A 34-year-old woman undergoes total thyroidectomy for papillary thyroid carcinoma (PTC). Intraoperative nerve monitoring (IONM) shows loss of signal in the right recurrent laryngeal nerve at the end of resection. She is extubated and found to have a normal voice. What is the most appropriate immediate next management step?
- A Immediate laryngoscopy to confirm cord mobility and plan re-exploration
- B Administer IV dexamethasone and arrange tracheostomy
- C Transcutaneous electrical nerve stimulation to restore signal
- D Continue observation; IONM loss of signal with intact voice suggests a neuropraxia likely to recover spontaneously ✓
Explanation
Loss of IONM signal (electromyographic silence) at the end of thyroid surgery with an intact postoperative voice indicates neuropraxia rather than nerve transection. In this scenario, the nerve is anatomically intact but is temporarily nonfunctional due to stretch or thermal injury; spontaneous recovery occurs in the majority within weeks to months. Re-exploration or tracheostomy is not indicated when the voice is normal. Laryngoscopy would confirm cord movement but the clinical finding of normal voice provides sufficient evidence and urgent intervention is unwarranted.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.