Thyroid Surgery — Nerve Injury and Intraoperative Decision-Making

During thyroid surgery, injury to the recurrent laryngeal nerve (RLN) results in vocal cord paralysis in the paramedian position. Which muscle is responsible for this characteristic positioning?

A 52-year-old man from Delhi undergoes left total thyroidectomy for papillary thyroid carcinoma. During mobilization of the left lobe, the surgeon observes the left recurrent laryngeal nerve (RLN) is intimately involved with tumor. Careful dissection is attempted, but the nerve cannot be separated from the tumor without risk of transection. The tumor is adherent to approximately 2 cm of the nerve. What is the most appropriate intraoperative decision?

A 52-year-old man from Mumbai undergoes right total thyroidectomy for multinodular goiter with compressive symptoms. During careful dissection of the right lobe, the surgeon identifies the right superior laryngeal nerve (SLN) and notes it is running a variant course—crossing the superior pole vessels at a distance of only 2 mm from the thyroid capsule. The nerve appears healthy with no tumor involvement. What is the most appropriate next step?

A 52-year-old woman undergoes total thyroidectomy for papillary thyroid carcinoma. Intraoperatively, the surgeon notices hoarseness of voice immediately after ligation of the superior thyroid vessels on the left side. The patient is extubated without difficulty and breathing is normal, but voice changes persist. Which investigation is most appropriate to confirm the diagnosis and assess the extent of nerve injury?

During total thyroidectomy in a 48-year-old man for multinodular goiter, the surgeon observes loss of the "light reflex" on the left side during intraoperative neuromonitoring (IONM). The patient is still under general anesthesia. What is the most appropriate next investigation to assess the functional status of the left recurrent laryngeal nerve before completing the right side of the surgery?