During a reoperative central neck dissection for recurrent papillary thyroid carcinoma, the surgeon encounters dense fibrosis around the right recurrent laryngeal nerve. Intraoperative neural monitoring (IONM) shows loss of signal on the right side after dissection. What is the most appropriate immediate action?

• A Stop dissection on the affected side, assess nerve integrity visually, and consider aborting further dissection on that side ✓
• B Complete the dissection on the contralateral side to ensure adequate oncologic clearance
• C Administer intravenous methylprednisolone and continue the dissection
• D Transect the nerve deliberately to ensure complete tumor resection and perform immediate neurorrhaphy

Explanation

Loss of IONM signal during reoperative central neck dissection indicates potential recurrent laryngeal nerve injury. The correct response is to stop dissection on that side, visually assess the nerve for integrity, and weigh the oncologic benefit of further dissection against the risk of bilateral vocal cord paralysis. Completing contralateral dissection risks bilateral RLN injury and airway catastrophe. Steroids have no proven role in acute intraoperative nerve injury. Deliberate nerve sacrifice is reserved for cases where the nerve is directly invaded by tumor and cannot be preserved, not for traction or thermal injury.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.