LAUSR

Editor We congratulate Sitges-Serra et al.1 on their comprehensive article about the possibility of avoiding staged thyroidectomy in most cases of signal loss. The guidelines of the American Academy of Otolaryngology Head and Neck Surgery suggest intraoperative nerve monitoring adoption in revision surgery, in the setting of pre-existing recurrent laryngeal nerve (RLN) paralysis, and in bilateral thyroid procedures to prevent two-sided vocal cord palsy2. In our opinion, prevention of bilateral RLN palsy should be considered the main reason to utilize nerve stimulation during thyroid surgery. We agree with the authors that staged thyroidectomy is frustrating for the patient; however, even if extremely rare, a possible tracheostomy may be much more frustrating. Consequently, when a loss of signal occurs after resection of the first lobe in planned bilateral thyroidectomy, we strongly advise postponing excision of the contralateral side3. Certainly, benign disease cannot dictate completion thyroid surgery on the uninjured contralateral side in case of loss of signal on the first side of resection. The risk of bilateral vocal fold paralysis would be an unjustified complication related to non-neoplastic disease. The authors stated that ‘if the voice remains normal and postoperative laryngoscopy shows good cord mobility, patients may see no convincing reason why the operation was not completed’. In our opinion, the option of two-stage surgery must be shared with patients who are informed preoperatively about the advantages and disadvantages of intraoperative nerve monitoring and potential surgical complications when intraoperative nerve monitoring data are not considered. Most of our patients agree with this concept and understand the clear benefit in deciding on a twostep approach in case of loss of signal on the initially operated side. Finally, several international organizations are advocating for preoperative and postoperative laryngeal examination in all patients undergoing thyroid surgery as preoperative diagnosis of asymptomatic vocal cord paresis and paralysis can be of benefit to both physician and patient 4,5.