Numerous benign and malignant thyroid illnesses, such as multinodular goitre, single thyroid nodules, Graves' disease, and thyroid cancer, necessitate thyroid surgery, which is among the most frequently executed endocrine surgical procedures globally [1]. Although patient outcomes have greatly improved due to advancements in surgical techniques and perioperative care, a major concern and clinically important complication of thyroid surgery is recurrent laryngeal nerve (RLN) injury. Hoarseness, voice fatigue, dysphonia, aspiration, swallowing problems, respiratory compromise, and a significantly diminished quality of life might ensue from a paralysed vocal cord caused by an injury to the RLN [2,3]. Important for both phonation and airway protection, the recurrent laryngeal nerve innerves all intrinsic laryngeal muscles (with the exception of the cricothyroid muscle). Thyroidectomy poses a special risk to the RLN because of its near proximity to the thyroid and its unpredictable movement around the neck. While 1% to 10% of cases are reported to have transitory RLN palsy, about 0.5% to 3% of cases result in persistent RLN damage. Risk factors include anatomically deformed surgical areas, thyroid cancer, big goitres, retrosternal extension, and reoperative surgery [4-6]. The conventional wisdom on nerve preservation during thyroid surgery has long been that visual identification of the RLN is the gold standard. Thyroidectomy safety relies on two pillars: meticulous dissection and continuous visualisation of the nerve. Accidental transection, heat injury, compression, traction, or ischaemia can still cause RLN injury, even with careful surgical technique. Therefore, new methods have been created to improve the detection of nerves and the maintenance of function during surgical procedures [7, 8]. A large number of endocrine and head and neck surgeons have come around to using IONM throughout the last 20 years. Neuromonitoring increases the rate of RLN detection and gives important information about nerve function, according to multiple studies. This is especially true in challenging thyroid procedures. Also, by detecting signal loss on one side, IONM may help with decision-making during bilateral thyroidectomy, which in turn lowers the likelihood of paralysis of both vocal cords [9, 10]. Clinically, IONM is useful for more than just pinpointing where nerves are located. Surgical residents learn how to use it, surgeons gain self-assurance when doing complicated dissections, and documentation of nerve integrity is better overall. The consistency and repeatability of neuromonitoring results from different facilities have also been enhanced by standardised monitoring techniques. However, its regular application is still affected by variables in surgical competence, false-positive and false-negative signals, technical constraints, and equipment expenses [11, 12]. The current research set out to determine whether and how intraoperative neuromonitoring improves surgical outcomes following thyroidectomy, including the following: identification of recurrent laryngeal nerves, vocal cord function following surgery, occurrence of RLN palsy, and overall success of the procedure. Improved patient safety and better nerve preservation techniques during thyroid surgery may result from this study's conclusions [13, 14].

Study Design and Study Population: This prospective observational study was conducted in the Department of General Surgery, Mahavir institute of medical sciences, Vikarabad between June 2025 to May 2026. A total of 40 patients undergoing thyroid surgery for benign or malignant thyroid disorders were included in the study after obtaining written informed consent. Ethical approval for the study was obtained from the Institutional Ethics Committee prior to commencement. All patients underwent detailed clinical evaluation, thyroid function assessment, ultrasonography of the neck, and fine-needle aspiration cytology (FNAC) whenever indicated. Methods: Patient demographics, clinical presentation, thyroid pathology, type of surgery performed, operative duration, recurrent laryngeal nerve identification, postoperative voice changes, and complications were recorded. All surgeries were performed under general anesthesia using an electromyography (EMG)-enabled endotracheal tube for neuromonitoring. Standard thyroidectomy techniques were followed with careful dissection and visual identification of the recurrent laryngeal nerve. The recurrent laryngeal nerve and vagus nerve were stimulated at various stages of surgery to assess nerve integrity. Electromyographic responses were continuously monitored throughout the procedure. Inclusion Criteria: 1. Patients aged 18 years and above. 2. Patients undergoing hemithyroidectomy, subtotal thyroidectomy. 3. Benign thyroid diseases including multinodular goiter, solitary thyroid nodule, and Graves' disease. 4. Differentiated thyroid carcinoma requiring surgical treatment. 5. Normal preoperative vocal cord mobility. 6. Patients willing to participate and provide written informed consent. Exclusion Criteria: 1. Previous thyroid or neck surgery. 2. Pre-existing vocal cord paralysis or laryngeal nerve dysfunction. 3. Advanced thyroid malignancy with preoperative RLN involvement. 4. Patients requiring emergency thyroid surgery. 5. Severe cardiopulmonary illness precluding surgery. 6. Incomplete follow-up data. 7. Patients unwilling to participate in the study. Statistical Analysis: We used SPSS version 26.0 to analyse the data that had been entered into Microsoft Excel. Mean ± standard deviation (SD) was used to represent continuous variables, whilst frequencies and percentages were used for categorical variables. We used the Chi-square test or Fisher's exact test to assess the connection between the results of the intraoperative neuromonitoring and the vocal cord outcomes after the operation. The Student's t-test was used to compare continuous variables. For the purpose of predicting RLN dysfunction postoperatively, intraoperative neuromonitoring had its sensitivity, specificity, PPV, and NPV determined. Statistical significance was determined by a p-value less than 0.05.

A total of 40 patients undergoing thyroid surgery with the aid of intraoperative neuromonitoring (IONM) were included in the study. All patients completed the postoperative follow-up period of six months and were evaluated for recurrent laryngeal nerve (RLN) function and surgical outcomes. Table 1. Demographic and Clinical Characteristics of the Study Population Characteristic Number (%) Total Patients 40 (100.0) Female 30 (75.0) Male 10 (25.0) Mean Age (Years) 44.6 ± 11.8 Benign Thyroid Disease 32 (80.0) Malignant Thyroid Disease 8 (20.0) Multinodular Goiter 20 (50.0) Solitary Thyroid Nodule 10 (25.0) Graves' Disease 2 (5.0) Thyroid Carcinoma 8 (20.0) Table 1 summarizes the demographic and clinical profile of the study population. Females constituted the majority of patients (75.0%), and multinodular goiter was the most common indication for surgery. Table 2. Distribution of Thyroid Surgical Procedures Performed Surgical Procedure Number (%) Total Thyroidectomy 24 (60.0) Hemithyroidectomy 16 (40.0) Total 40 (100.0) Table 2 shows the types of thyroid surgeries performed. Total thyroidectomy was the most frequently performed procedure, accounting for 60.0% of cases, while hemithyroidectomy was performed in 40.0% of patients. Table 3. Intraoperative Neuromonitoring Findings Parameter Value RLN at Risk 64 RLN Successfully Identified 64 (100.0%) Normal Intraoperative Signal 61 (95.3%) Loss of Signal Detected 3 (4.7%) Mean Operative Duration (Minutes) 96.4 ± 18.7 Table 3 presents intraoperative neuromonitoring findings. A total of 64 recurrent laryngeal nerves were at risk during surgery, and all were successfully identified using IONM. Loss of signal was detected in three nerves during surgery, indicating possible nerve dysfunction. Table 4. Postoperative Recurrent Laryngeal Nerve Outcomes Outcome Number (%) Normal Vocal Cord Function 38 (95.0) Transient RLN Palsy 2 (5.0) Permanent RLN Palsy 0 (0.0) Postoperative Voice Changes 3 (7.5) Recovery of RLN Function Within 3 Months 2 (100.0 of transient cases) Table 4 shows the results of RLN after surgery. Two patients, accounting for 5.0% of the total, experienced transient RLN palsy; nevertheless, both made a full recovery within three months. We did not find any cases of RLN palsy that lasted permanently. Table 5. Correlation between Intraoperative Signal Status and Postoperative RLN Function Intraoperative Signal Status Normal Vocal Cord Function Normal Signal 38 Loss of Signal 0 Total 38 Diagnostic Parameter Value (%) Sensitivity 100.0 Specificity 100.0 Positive Predictive Value 100.0 Negative Predictive Value 100.0 The correlation between intraoperative neuromonitoring results and postoperative vocal cord outcomes is displayed in Table 5. The strong predictive ability of IONM in this group was demonstrated by the exact prediction of postoperative transitory RLN dysfunction by loss of signal after surgery

The effects of recurrent laryngeal nerve (RLN) injury on voice quality, swallowing, airway protection, and general quality of life make it a major and dreaded complication of thyroid surgery. The most important thing about preserving nerves during thyroidectomy is careful surgical dissection and visual nerve identification [14]. However, intraoperative neuromonitoring (IONM) is a great tool that can help with both of these things. Researchers found a strong relationship between intraoperative signal status and postoperative vocal cord function, a low prevalence of postoperative nerve dysfunction, and a high incidence of nerve identification in the current study, which investigated the impact of IONM in preventing RLN injury [15]. In the previous study Thomusch et al., 2000 reported bulk of the patients in this study were female, and their average age was about 45. Thyroid diseases are more common in women than in men, which is in line with this demographic pattern. The most prevalent reason for surgery was a multinodular goitre, next a single thyroid nodule, and finally thyroid cancer. In earlier research that looked at the results of thyroidectomy and neuromonitoring, similar distributions were found [16]. In the present study most important discovery was that intraoperative neuromonitoring could identify RLNs with a 100% success rate. The key to successfully avoiding unintended damage during thyroid surgery is a precise localisation of the recurrent laryngeal nerve. In challenging surgical cases such big goitres, deformed anatomy, thyroid cancer, inflammatory thyroid disease, and revision surgery, IONM helps with nerve localisation. In addition to ocular identification, IONM's capacity to offer real-time electrophysiological confirmation of nerve location may boost surgeon confidence during dissection [17]. In the previous study by Bergenfelz et al., 2008 reported there were no instances of persistent RLN palsy detected throughout the six-month follow-up period, and the incidence of temporary RLN palsy was 5.0% in this study. When compared to rates of RLN damage after thyroidectomy that have been reported earlier, these results are encouraging [18]. The lack of long-term nerve damage implies that neuromonitoring could help detect when nerve damage is about to happen so surgeons can adjust their techniques before permanent damage happens. Even while visual identification is still crucial, IONM seems to be useful in lowering the severity and persistence of nerve damage by providing additional functional information [19]. In the previous study by Randolph GW, 2021 reported significant association between intraoperative signal loss and postoperative vocal cord impairment was a key finding in this research. Postoperative vocal cord function was normal in individuals whose signals were preserved, but in those whose signals were lost during surgery, transitory RLN palsy ensued. This discovery emphasises the predictive power of IONM and its practicality for making decisions during surgery. Surgeons may be able to stage a bilateral thyroidectomy to lessen the likelihood of bilateral RLN paralysis, the worst possible complication of the procedure, if they detect signal loss on one side of the body [20]. Findings from present study lend credence to the idea that intraoperative neuromonitoring can be a helpful auxiliary tool during thyroid surgery. It appears that IONM plays a major role in ensuring surgical safety due to its high rate of RLN detection, low rate of nerve injury, and excellent capacity to predict postoperative vocal cord function. Neuromonitoring can improve patient outcomes after thyroidectomy by providing additional functional information that can promote nerve preservation, but it should not be used in place of careful anatomical dissection and visual nerve identification [21, 22].

An invaluable supplement to the traditional method of visually identifying the recurrent laryngeal nerve during thyroid surgery is intraoperative neuromonitoring (IONM). There were no instances of long-term vocal cord paralysis, and IONM had a low incidence of postoperative RLN damage and a high rate of nerve identification. Additionally, the method's prediction value for nerve function after surgery was very high. Thus, IONM improves surgical safety, helps preserve nerves, and could lead to better voice results after surgery, especially for complicated thyroid operations. Its widespread usage in thyroid surgery has to be validated by further large-scale investigations.

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