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Preoperative laryngoscopy
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Preoperative smoking cessation
Fiberoptic intubation
Topical corticosteroids
Use of a zero-profile plate instead of a cage with plating system
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Patients undergoing anterior cervical discectomy and fusion (ACDF) after thyroidectomy or for a revision ACDF on the contralateral side require preoperative laryngoscope evaluation with ENT to evaluate for vocal cord paralysis. The recurrent laryngeal nerve (RLN) is at risk during the Smith-Robinson approach for an ACDF as the nerve runs between the trachea and esophagus and can be compressed between retractors and the inflated endotracheal tube. The incidence of RLN injury is reported to be between 2.3-24.2%. Asymptomatic unilateral RLN are twice as common as symptomatic RLN injuries. Symptoms of unilateral RLN injury include hoarseness, dysphonia, and dysphagia. Bilateral RLN injury can result in dysphagia and complete airway obstruction. Therefore, patients undergoing repeat anterior neck surgery or a revision ACDF should undergo preoperative laryngeal screening to evaluate for RLN injury. Curry et al. reviewed 23 patients who underwent preoperative laryngoscope examination and subsequent ACDF between 2004-2010. They found 4 out of the 23 patients exhibiting significant findings on the laryngoscopy evaluation, with 2 patients being asymptomatic and 2 experiencing chronic hoarseness. Therefore, they concluded that 17.3% of patients undergoing preoperative laryngoscope evaluation before a revision ACDF had significant findings affecting the decision-making regarding the laterality of the approach for the revision ACDF. Paniello et al. reviewed 50 laryngeal examinations on 47 patients who had previously undergone an anterior cervical approach. They found laryngeal abnormalities in 26% of examinations, including paralysis in 11 cases (22%), resulting in a recommendation to perform the cervical approach through the affected side. Paniello et al. concluded that preoperative laryngeal screening is a simple and effective method for reducing the risk of bilateral vocal cord paralysis. Incorrect Answers:Answer 2: Smoking is associated with an increased risk of dysphagia, reoperation, and wound infection following ACDF, but is not a risk factor for bilateral recurrent laryngeal nerve paralysis. Answer 3: Fiberoptic intubation is indicated in the setting of cervical spine instability or injury, and would not have reduced this patient's risk for postoperative acute respiratory distress Answer 4: Topical corticosteroid use has been shown to decrease the risk of postoperative anterior neck pain and dysphagia, but does not decrease the risk of recurrent laryngeal nerve injury Answer 5: The use of a zero-profile plate would not impact this patient’s risk of developing a recurrent laryngeal nerve palsy and has not been shown to significantly reduce postoperative dysphagia in patients undergoing an ACDF. The use of a zero-profile plate instead of the cage with a plating system is associated with an increased operative time, which may increase the risk for recurrent laryngeal nerve injury.
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