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Safety analysis of vagal nerve stimulation for continuous nerve monitoring during thyroid surgery


  • Colin Friedrich and Christoph Ulmer contributed equally.



Intraoperative neuromonitoring (IONM) facilitates recurrent laryngeal nerve (RLN) identification, but various studies affirm virtually unchanged postoperative RLN palsy rates. Several authors meanwhile suggest continuous intraoperative neuromonitoring (CIONM) via vagal nerve stimulation (VNS) to improve RLN protection. However, knowledge of side effects of electrical VNS derives mainly from its therapeutic applications in the fields of neurology and psychiatry. The presented study was conducted to further evaluate the safety of CIONM and identify possible VNS related side effects.

Study Design:

Prospective nonrandomized controlled trail.


Forty patients scheduled for thyroid or parathyroid surgery were enrolled in the trail. The intervention group consisted of 22 patients receiving VNS for CIONM. Eighteen patients were operated on with routine IONM. To assess VNS-induced effects on the autonomic nervous system (ANS), heart rate variability analysis (HRVA) was applied. Serum cytokine levels of tumor necrosis factor (TNF)-α were monitored to evaluate immunomodulatory effects of VNS.


HRVA revealed significantly increased vagal activity during CIONM. This parasympathetic predominance was not countered by the sympathetic nervous system. Despite a significant increase of vagal tone, no hemodynamic events occurred; in fact, no significant changes in median heart rate or in median arterial blood pressure were detected. Even though anti-inflammatory effects of VNS have been reported, no attenuation of cytokine release of TNF-α was measured.


VNS for CIONM resulted in increased vagal activity assessable via HRVA. The increased parasympathetic tone affected neither hemodynamics nor levels of the proinflammatory cytokine TNF-α. VNS for CIONM appears safe with the applied settings. Laryngoscope, 2012