Recurrent laryngeal nerve monitoring and postoperative airway complications following thyroid surgery: A multivariable national surgical quality improvement program analysis.

BACKGROUND: Recurrent laryngeal nerve injury during thyroid surgery can result in clinically significant airway compromise, particularly in patients with limited pulmonary reserve. Although intraoperative nerve monitoring is widely used to reduce nerve injury, its association with postoperative airway complications has not been well characterized. This study evaluates trends in intraoperative nerve monitoring and its relationship with postoperative airway compromise after thyroidectomy. METHODS: We performed a retrospective cohort study of adult patients who underwent thyroid surgery between 2018 and 2022 using the National Surgical Quality Improvement Program database. Patients were stratified by use of intraoperative nerve monitoring. The primary outcome was postoperative airway compromise, defined as prolonged ventilation (>48 hours postoperatively) and unplanned postoperative reintubation. Secondary outcomes included recurrent laryngeal nerve injury, neck hematoma, and pneumonia. Univariate and multivariate analyses were performed to identify factors independently associated with airway complications. RESULTS: A total of 33,211 patients were included; 23,757 (71.5%) underwent surgery with intraoperative nerve monitoring. On univariate analysis, patients undergoing intraoperative nerve monitoring had lower rates of postoperative airway compromise compared with those without monitoring (0.4% vs 0.6%, P = .048). Although individual airway events were infrequent and did not differ significantly between groups, intraoperative nerve monitoring was associated with a lower rate of recurrent laryngeal nerve injury (5.7% vs 6.5%, P < .001). On multivariable analysis, preoperative dyspnea, American Society of Anesthesiologists class III or higher, advanced tumor stage (T3-4), chronic obstructive pulmonary disease, older age, and longer operative time were independently associated with increased odds of postoperative airway compromise. After adjustment for patient, tumor, and operative factors, intraoperative nerve monitoring remained independently associated with decreased odds of postoperative airway compromise (odds ratio, 0.64; P = .04). In subgroup analysis of patients with American Society of Anesthesiologists class III or higher, recurrent laryngeal nerve monitoring was associated with lower adjusted odds of postoperative airway compromise (adjusted odds ratio, 0.68), consistent with findings in the overall cohort, though estimates were limited by low event rates. CONCLUSION: In this large national cohort, intraoperative recurrent laryngeal monitoring was independently associated with reduced postoperative airway complications after thyroidectomy. Airway risk was driven primarily by patient comorbidity, physiologic reserve, disease severity, and operative complexity. These findings suggest that recurrent laryngeal nerve monitoring may be of greatest benefit in high-risk surgical patients.