title: Vagal nerve monitoring in surgery of the skull base: a comparison of efficacy of three techniques.
abstract: OBJECTIVE
  To compare three techniques of monitoring the vagal nerve during skull base surgery using laryngeal electromyography (EMG).
  
  
  METHODS
  Prospective comparison.
  
  
  METHODS
  California Ear Institute at Stanford, tertiary referral center.
  
  
  METHODS
  Seventeen consecutive patients undergoing lateral skull base surgery potentially placing the vagal nerve at risk.
  
  
  METHODS
  Each patient was simultaneously monitored intraoperatively with three separate EMG techniques: 1) endolaryngeal surface electrodes mounted on an endotracheal tube (ETT) (Xomed Surgical Products, Inc., Jacksonville, FL); 2) endoscopically placed endolaryngeal thyroarytenoid intramuscular hookwire electrodes; and 3) percutaneously placed cricothyroid intramuscular hookwire electrodes.
  
  
  METHODS
  Sensitivity, reliability, response magnitude, incidence of false-positive responses, and complications were recorded. Preoperative and postoperative vagal nerve function was noted.
  
  
  RESULTS
  The study was completed in 13 patients. The endolaryngeal intramuscular electrode technique responded at the lowest current stimulus (mean, 0.073 mA) with the highest average magnitude response. It responded in 100% of patients. The percutaneous intramuscular technique was similarly sensitive (mean stimulus, 0.089 mA) with a large average magnitude response but was much less reliable (responded in 69.2% of patients). The Xomed ETT was less sensitive (mean stimulus, 0.120 mA), had the lowest average magnitude response, and demonstrated medium reliability (responded in 76.9% of patients). The ETT exhibited the lowest incidence of spontaneous false-positive EMG activity. No complications were noted, and vagal nerve function was not compromised in any patient.
  
  
  CONCLUSIONS
  Although the Xomed ETT exhibited ease of placement and a low false-positive response rate, it demonstrated lowest sensitivity compared with electrodes placed intramuscularly. The percutaneous intramuscular electrode technique was the least reliable, likely related to blind insertion, making it a less-desirable technique. Because of its highest relative sensitivity and reliability, the endolaryngeal intramuscular electrode technique of vagal monitoring is best supported by this study.
authors.affiliation: California Ear Institute at Stanford, Division of Otolaryngology, Stanford University Medical Center, Palo Alto 94304-1608, USA.
authors.forename: L E
authors.initials: LE
authors.lastname: Jackson
authors.forename: J B
authors.initials: JB
authors.lastname: Roberson
mesh_terms: D000328:Adult; D000368:Aged; D004566:Electrodes; D004576:Electromyography / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D020704:Laryngoscopes; D007828:Laryngoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D009431:Neural Conduction; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D019291:Skull Base / Q000294:innervation* / Q000601:surgery*; D016019:Survival Analysis; D014630:Vagus Nerve / Q000502:physiology*