Effectiveness of intraoperative nerve monitoring in reducing rates of recurrent laryngeal nerve injury in aerodigestive and cardiovascular pediatric surgery

Infographic · Apr 2025 · 1 min read

In brief

Retrospective study of 426 pediatric procedures shows intraoperative nerve monitoring reduces vocal fold impairment by 44% compared to no monitoring (11.4% vs 20.2%). Protection is even stronger in children with pre-existing vocal fold issues (68.6% risk reduction), with bilateral paralysis 14× less likely when monitoring is used.

Intraoperative nerve monitoring reduced vocal fold impairment by 44% in pediatric aerodigestive/cardiovascular surgery (11.4% vs 20.2%, NNT=12)
Children with pre-existing vocal fold impairment benefit most from monitoring (69% risk reduction, NNT=3)
Bilateral vocal fold impairment was 14× more likely without monitoring (5.6% vs 0.3%)
Increasing IONM use correlated with decreasing injury rates year-over-year across 426 procedures
IONM should be standard for cervicothoracic/cardiothoracic cases, especially with baseline vocal fold dysfunction

Written by the GCMD Library team from the infographic.

Shawn Izadi MD, MPH, Megan Z. Chiu MD, Donna C. Koo MD, Jay Meisner MD, Somala Mohammed MD, Farokh R. Demehri MD, Jason Smithers MD, Carlos Munoz MD, Sukgi Choi MD, Benjamin Zendejas MD

Objective: To investigate the effectiveness of intraoperative nerve monitoring at decreasing vocal fold movement impairment in children undergoing at-risk procedures.

Background: Children undergoing aerodigestive or cardiovascular procedures are at risk for recurrent laryngeal nerve injury, leading to vocal fold movement impairment. Although intraoperative nerve monitoring has been shown to decrease recurrent laryngeal nerve injury in adults, there is paucity of data in children.

Methods: This was a retrospective, single-center cohort study of children who underwent airway, esophageal, or great vessel surgery between 2018 and 2023. Vocal fold movement impairment was evaluated with pre- and postoperative awake flexible fiberoptic laryngoscopy. Vocal fold movement impairment rates and associated characteristics were compared between those with and without intraoperative nerve monitoring.

Results: Among 387 children undergoing 426 at-risk procedures, intraoperative nerve monitoring was used in 72.1% (n = 307) of procedures. Intraoperative nerve monitoring significantly reduced postoperative vocal fold movement impairment compared with those without (11.4% vs 20.2%, P = .019, 43.6% relative risk reduction, number needed to treat: 12). In children with a pre-existing vocal fold movement impairment (n = 79, 18.5%), intraoperative nerve monitoring provided enhanced protection (vocal fold movement impairment 7.8% with intraoperative nerve monitoring compared with 25% without, P = .046, 68.6% relative risk reduction, number needed to treat: 3). Bilateral vocal fold movement impairment was 14 times more likely without intraoperative nerve monitoring (1.8% overall, 0.3% with intraoperative nerve monitoring, 5.6% without; 95% confidence interval 1.6–123.2; P = .006). Increasing intraoperative nerve monitoring use correlated with decreasing vocal fold movement impairment rates year over year (P = .046). Multivariable logistic regression demonstrated intraoperative nerve monitoring to remain significantly associated with reduced risk of vocal fold movement impairment (odds ratio, 0.48; 95% confidence interval, 0.26–0.85; P = .013).

Conclusion: Intraoperative nerve monitoring in children seems effective at decreasing recurrent laryngeal nerve injury and consequently vocal fold movement impairment. Intraoperative nerve monitoring should be considered in children undergoing cervicothoracic or cardiothoracic procedures, especially in those with preoperative vocal fold movement impairment.