Purpose: To determine if intra-operative neural monitoring (IONM) is effective in lowering the rate of recurrent laryngeal nerve (RLN) injury, when selectively applied in thyroidectomy for certain diagnoses which carry a higher risk of nerve injury. Methods: A retrospective study of 175 patients (262 nerves at risk) undergoing 'high-risk' thyroidectomy, namely those for carcinoma, Graves' disease, re-operations and retrosternal goitres, was performed using data extracted from the public

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... s electronic system. RLN palsy rates of those with IONM used or with visual identification of nerve alone (VA) were compared. RLN palsies were confirmed on flexible laryngoscopy. Results: In the VA group, the rate of endoscopically confirmed temporary and permanent RLN palsy were 1.3% and 4.5%, respectively. There were no endoscopically confirmed RLN palsy in the IONM group. IONM use was associated with significantly less endoscopically confirmed RLN palsies (0 vs. 9, P=0.012). Permanent RLN palsies diagnosed either clinically and endoscopically were both significantly less in the IONM group (0 vs. 7, P=0.044). There was no significant reduction in the number of RLN palsy with the use of IONM in each highrisk subgroup. Conclusion: In this study focusing on high-risk thyroidectomy, IONM has been shown to significantly reduce the permanent RLN palsy rate. The selective use of IONM presents a potential approach to demonstrate the beneficial effect of IONM in avoiding RLN injuries.