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Original Investigation
From the American Head and Neck Society
December 2016

A Cost-Utility Analysis of Recurrent Laryngeal Nerve Monitoring in the Setting of Total Thyroidectomy

Author Affiliations
  • 1Department of Surgery, Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, North Carolina
  • 2Department of Otolaryngology–Head and Neck Surgery, Princess Margaret Hospital, Toronto, Ontario, Canada
JAMA Otolaryngol Head Neck Surg. 2016;142(12):1199-1205. doi:10.1001/jamaoto.2016.2860
Key Points

Question  Is intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve cost-effective for total thyroidectomy?

Findings  In this cost-utility analysis, visual identification is more cost-effective than IONM in nearly all cases, including most high-risk cases, for total thyroidectomy. In selected high-risk cases, IONM becomes cost-effective if a surgeon can use it to decrease nerve injury rate by at least 50.4% over visual identification alone.

Meaning  Visual identification alone is more cost-effective than IONM for most surgeons in the setting of total thyroidectomy.


Importance  Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is used as a tool to decrease the rate of nerve injury, although study findings are divergent on IONM efficacy. The cost-effectiveness of this approach to total thyroidectomy has not been well studied.

Objective  To determine whether IONM is a cost-effective intervention in the setting of total thyroidectomy.

Design and Setting  This study creates a decision-tree model of total thyroidectomy to analyze, from a societal perspective, the cost-effectiveness of universal IONM (ie, use in every case) vs selective IONM (ie, high-risk cases including reoperative cases, substernal or toxic goiters, and cases with known cancer) vs no IONM (visual identification only). Parameters for the model were derived from review of the literature, and deterministic and probabilistic analyses were performed to test the model’s robustness. All analyses were performed from the model; there were no human participants.

Interventions  Modeled total thyroidectomy with and without IONM of the RLN.

Main Outcomes and Measures  Cost-effectiveness of universal IONM vs selective IONM vs visual identification only of the RLN.

Results  Visual identification of the RLN led to a cost savings of $179.40 and $683.20 per patient, and an improvement of 0.001 and 0.004 quality-adjusted life-years, over selective IONM and universal IONM, respectively. Visual identification was the most cost-effective approach, despite variations in costs and utilities in both deterministic and probabilistic sensitivity analyses. In a 1-way sensitivity analysis, decreasing the probability of RLN injury with IONM made selective IONM more cost-effective. When the rate of RLN injury for visual identification was kept constant (at 3.86%), selective IONM became the most cost-effective approach when its RLN injury rate dropped below 1.9%. As the rate of RLN injury with IONM dropped below 50.4% of the visual identification RLN injury rate, selective IONM became the most cost-effective approach.

Conclusions and Relevance  Visual identification of the RLN is more cost-effective than any use of IONM. If a clinician can, with use of IONM, decrease the rate of RLN injury by 50.4% or more compared with visual identification, selective use of IONM in high-risk cases is most cost-effective.