42-year-old female with Graves disease is scheduled for a total thyroidectomy in February of 2024. Post-operatively has significant stridor and a flexible fiberoptic laryngoscopy confirms bilateral vocal cord paralysis. She is intubated and monitored for a couple of days, treated with steroids. They attempt to extubate day 5, however continues to have bilat paralysis. She is reintubated and they schedule a tracheotomy. That is done approximately 3 days later. She is discharged after 18 days of admission.
Post admission, PC continues to have difficulty speaking and swallowing while getting home care. Required trach compressor and multiple follow-up visits. PC as of last month states that her paralysis is unilateral now, 6-month post-op. Still unknown if this is permanent, however according to PC, the ENT was not optimistic about full recovery.
I have included the original operative report and laryngoscopy procedure note as photos for your initial review.
The physician in question is a general surgeon. Obviously, we seek a general surgeon who performs total thyroidectomies regularly and could speak to any deviations/recognized comps, etc.
We appreciate your time and opinions in advance. If you require any further information, please feel free to reach out.
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Do you believe there might have been medical error?
Bilateral recurrent nerve injury is a well known and feared complication of total thyroidectomy. While nerve injuries during thyroidectomy can occur, there are available mitigation strategies that are widely available. The use of intraoperative nerve monitoring has become very widely used to prevent BILATERAL RLN injury. While the use on nerve monitoring has never been shown to prevent a single side injury, its use , when use properly can prevent bilateral injury in that if the surgeon loses signal on one side they do not go to the other side to put that nerve at risk. Especially in a case of benign disease such as graves disease
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
the use of nerve monitoring can prevent BILATERAL injuries by identifying an unilateral injury and the stopping the operator from going to the other side and putting the contralateral nerve at risk
What makes you a good expert for this case?
50% of my practice has been thyroid/parathyroid since 2006 with approximately 75 open neck cases per year
How often do you encounter cases similar to this one in your practice?
Graves disease is more frequently treated with non operative methods these days ( radioactive iodine, RAI), but still see 5-7 cases per year that require total or subtotal thyroidectomy
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