七氟烷吸入麻醉在儿童喉乳头状瘤手术中的应用

目的通过将七氟烷吸入诱导麻醉应用于儿童喉乳头状瘤手术中,对比使用肌松剂的静脉诱导麻醉,以寻求一种儿童喉乳头状瘤手术的安全有效的麻醉方法。方法美国麻醉师协会（ASA）分级为Ⅰ～Ⅲ级的30例患儿,在全麻插管下行喉乳头状瘤手术,随机分配至A、B两组,A组患儿吸入七氟烷麻醉诱导后插管,手术全程只使用1%～4%的七氟烷吸入,并复合0.05mg/kg维库溴铵,维持理想的麻醉深度,整个手术过程中不用其他镇静药。B组予氯胺酮2mg/kg,咪唑安定0.1mg/kg,维库溴铵0.1mg/kg,异丙酚2mg/kg静注诱导插管,术中以丙泊酚2～4mg/（kg.h）-1泵入维持麻醉。结果A组患儿诱导时间长于B组患儿,但拔管时间显著短于B组患儿（P〈0.05）;术后两组恶心、呕吐发生率相比无显著差异（P〉0.05）;术后A组躁动发生率较B组稍高（P〉0.05）。结论采用七氟烷吸入麻醉诱导,可减少气管插管的风险,提高麻醉手术的安全性,缩短拔管时间。在困难气道的处理方面与使用肌松剂的静脉快速诱导相比具有优越性,七氟烷吸入诱导麻醉应用于儿童喉乳头状瘤手术是一种安全有效的麻醉方法。     

术中喉返神经监测系统在甲状腺开放手术中的应用

目的总结使用喉返神经监测系统在甲状腺开放手术全过程中,对喉返神经的监测、保护,以及使用体会与注意事项。方法①21例患者中甲状腺恶性肿瘤5例、良性肿瘤9例,甲状腺功能亢进症7例。②喉返神经监测系统主要由监测仪主机、喉返神经刺激探测针、专用接触声带的肌电图（electromyography,EMG）气管插管、接地传导回路电极针、抗干扰探头等组成。③手术采用三步法,首先显露颈迷走神经干检测仪器,再解剖、保护喉返神经,之后切除甲状腺组织。结果全部21例患者,术侧喉返神经均清晰显示,从甲状腺下级血管至入喉处。术后患者发音清晰,无饮水呛咳。结论甲状腺开放手术中,应用＂喉返神经监测系统＂,可使喉返神经在手术全过程中得到切实保护,避免损伤发生。     

甲状腺手术中喉返神经监测技术的优化与解读

喉返神经损伤是甲状腺手术常见并发症,严重影响患者生活质量,是困扰外科医师的技术问题。术中神经监测不仅可以定位和鉴别喉返神经、查找损伤点、发现导致损伤的步骤、预测术后声带功能,而且可以阐明喉返神经损伤的机制。     

甲状腺术中喉返神经监测技术的标准化

目的在甲状腺手术中缺少术中神经监测(intra operative neuromonitoring,IONM)的标准化操作可导致结果变异性强,这些结果可产生错误信息并增加喉返神经损伤的危险性。因此有必要进行IONM操作的标准化。方法本研究共招募了289例进行过甲状腺切除术的患者(435根神经有危险),均由一位外科医师实施手术。每例患者均由同一位麻醉师使用EMG气管导管进行插管。每例患者均进行标准化IONM操作。该操作包括术前和术后对声带运动进行录像监测、保证电极在正确位置、喉返神经剥离前后刺激迷走神经并记录EMG信号,并摄像记录暴露的喉返神经。结果5例患者出现IONM波形异常,是由于电极错位所致,这一问题被立刻监测到。监测到1例患者在手术较早阶段出现非喉返神经损伤。甲状腺剥离时18例患者的神经失去了EMG信号,使用我们的标准化IONM操作后神经损伤的原因得以清楚阐明。结论标准化IONM操作不仅在消除错误的IONM结果方面有用且有帮助,而且有助于阐明喉返神经损伤的机制。在确定外科手术的缺陷并提高外科手术技巧后,本研究显著降低了神经麻痹的发生率。     

喉返神经术中监测的原理与应用

喉返神经损伤是甲状腺手术最严重的并发症,导致患者生活质量下降甚至危及生命。如何规避喉返神经损伤是外科医师一直探索的课题。甲状腺手术中常规识别喉返神经是喉返神经保护的＂金标准＂。但即使外科操作标准化,     

显露喉返神经在甲状腺手术中的意义

目的:探讨显露喉返神经在甲状腺手术中的意义。方法:回顾性分析我科收治的共332例甲状腺手术患者的资料,全部患者均在全身麻醉下进行,术中均解剖术侧喉返神经。单侧腺叶切除131例,双侧次全切除138例,单侧腺叶切除加对侧腺叶次全切除51例,双侧甲状腺全切术12例。结果:手术过程中共533条喉返神经主干均得到很好的显露,术后共4例(0.75%)出现声嘶,无麻醉插管引起,均为单侧声带固定,行激素、营养神经药物等治疗,均在3个月内恢复,无永久性损伤。结论:在行甲状腺手术时,结合运用多种解剖喉返神经的方法,能够有效避免喉返神经的损伤。     

甲状腺手术中常规解剖喉返神经的临床价值

目的探讨甲状腺手术中常规解剖喉返神经对防止其损伤的临床价值。方法回顾性分析5344例甲状腺手术患者在全身麻醉下行手术治疗的临床资料,术中解剖喉返神经548例(解剖组),未解剖喉返神经4796例(未解剖组);比较两组术中喉返神经损伤的发生率有无差异。结果解剖组喉返神经损伤12例,发生率为2.2%;未解剖组喉返神经损伤512例,发生率为10.7%。两组喉返神经损伤率差异具有统计学意义(P0.01)。结论甲状腺手术中常规解剖喉返神经能有效防止其损伤。     

甲状腺手术解剖喉返神经对其损伤的预防作用

目的：探讨甲状腺手术中解剖喉返神经对预防喉返神经损伤的作用。方法：回顾性分析我科1993年1月～2005年5月手术治疗的甲状腺病变患者517例，解剖喉返神经组（解剖组）163例187侧，未解剖喉返神经组（未解剖组）354例438侧。未解剖组按常规甲状腺手术保护喉返神经行走区的神经。解剖组于甲状腺下极下方离气管食管间沟0～1cm处先找到喉返神经，顺其向上解剖；或先找到喉返神经入喉处，顺其向下解剖。边解剖喉返神经边切除甲状腺病变，解剖长度视甲状腺病变而定。结果：解剖组喉返神经部分解剖123侧，全程解剖64侧，除2例甲状腺癌已侵犯喉返神经术前已有声带麻痹外，无一例发生医源性喉返神经损伤。未解剖组发生喉返神经损伤3例3侧，喉返神经损伤发生率为0．7％，明显高于解剖组，差异有统计学意义（P〈0．01）。结论：甲状腺手术中解剖喉返神经对喉返神经损伤有预防作用。解剖喉返神经的长度视病变大小及部位而定。远离气管食管间沟的良性病变可不解剖喉返神经。     

无肌 松药全麻下实施鼻内镜手术的临床观察

目的探讨无肌松药（muscle loose medicine，NMB）全麻下鼻内镜手术的安全性和有效性。方法根据美国麻醉师协会（ASA）分级标准选择ASAⅠ～Ⅱ级择期行鼻内镜手术患者160例随机分为A、B两组，每组80例，均以瑞芬太尼、丙泊酚及氯化琥珀胆碱静脉快诱导，气管插管后A组以瑞芬太尼和丙泊酚维持麻醉，B组以瑞芬太尼、丙？白酚和维库溴铵维持麻醉。记录两组患者T1～T6各观察时点心率（HR）、平均动脉压（MAP）、血氧饱和度（SpO2）、呼末二氧化碳分压（EtCO2）、术中体动次数、麻醉苏醒时间、拔管时间、有无不良反应及并发症。结果两组患者T1～T4各观察时点HR、MAP、SpO2变化无明显差别（P〉0．05），术中无体动反应；T5、T6时点A组麻醉苏醒时间和拔管时间明显短于B组（P〈0．01），B组麻醉苏醒后，低氧血症、分泌物增多、心动过缓发生率明显高于A组（P〈0．01）。结论瑞芬太尼一丙泊酚无肌松药全麻下实施鼻内镜手术效果肯定，麻醉苏醒和呼吸功能以及保护性反射恢复早，避免了肌松药及其拈抗药的不良反应。     

喉返神经麻痹与气管内插管

在外科喉返神经麻痹一般见于甲状腺手术后,头颈部以外的手术极少发生这种合并症。作者观察4例气管内插管后没有任何其它明显原因而发生的喉返神经麻痹病例,并结合尸体解剖研究证实了气管内插管可引起喉返神经麻痹的见解。作者在尸体标本上解剖出喉返神经,然后作     

Laryngeal mask anesthesia with intraoperative laryngoscopy for identification of the recurrent laryngeal nerve during thyroidectomy

OBJECTIVES/HYPOTHESIS: A critical step in thyroidectomy involves definitive identification of the recurrent laryngeal nerve (RLN). Using the laryngeal mask airway, identification of the RLN can be facilitated by stimulation of the nerve while monitoring vocal cord movement with a fiberoptic laryngoscope. We present this technique as an effective and safe means to identify the RLN during thyroid surgery, with significant advantages over existing techniques in appropriately selected patients. STUDY DESIGN: Retrospective case series. METHODS: We performed thyroidectomy on 8 patients (13 RLN identifications) in which laryngeal mask airway anesthesia with fiberoptic laryngoscopy was used to identify the RLN. Results are reviewed with regard to postoperative vocal cord function, as well as intraoperative and postoperative courses with laryngeal mask airway anesthesia. RESULTS: In all 13 cases in which the RLN was sought, it was definitively identified by witnessing brisk vocal cord movement on a video screen with stimulation of the RLN. No patient had postoperative vocal cord paresis or paralysis. Overall recovery from laryngeal mask airway anesthesia was uneventful and had advantages when compared with general anesthesia with endotracheal intubation. CONCLUSIONS: Laryngeal mask airway anesthesia with intraoperative fiberoptic laryngoscopy to identify the RLN is effective and safe in carefully selected patients. Advantages include decreased postoperative throat discomfort, absence of coughing during emergence from anesthesia, and elimination of the possibility of vocal cord mobility impairment secondary to RLN ischemia from the endotracheal tube balloon. In addition, this technique is applicable in operations besides thyroid surgery, in which definitive identification of the RLN is indicated.     

Evidence for recurrent laryngeal nerve contribution in motor innervation of the human cricopharyngeal muscle.

OBJECTIVE: To study the functional motor nerve supply of the upper esophageal sphincter in humans. STUDY DESIGN: Intraoperative electromyographic study. METHODS: The contribution of the recurrent laryngeal nerve and the pharyngeal plexus in the motor nerve innervation of the cricopharyngeal muscle and the inferior pharyngeal constrictor muscle was examined intraoperatively. RESULTS: Electromyography showed that there is a considerable overlap in the innervation of the cricopharyngeal muscle and the inferior pharyngeal constrictor muscle. The recurrent laryngeal nerve functionally contributes to the motor innervation of the cricopharyngeal muscle in all patients and contributes to the motor innervation of the inferior pharyngeal constrictor muscle in most patients. The pharyngeal plexus functionally contributes to the motor innervation of the inferior pharyngeal constrictor muscle but does not always contribute to the motor innervation of the cricopharyngeal muscle. CONCLUSIONS: This is the first report which provides evidence that the recurrent laryngeal nerve functionally contributes to the motor innervation of the cricopharyngeal and inferior pharyngeal constrictor muscle. Furthermore, this study shows that intraoperative electromyography in humans is a feasible method to analyze the physiology of the motor innervation of the upper esophageal sphincter.     

全麻甲状腺手术中的喉返神经实时监控

目的评价术中实时监控技术在预防喉返神经医源性损伤中的实际意义和应用前景.方法自2002年11月至2005年5月在40例全麻甲状腺手术中对喉返神经功能进行术中实时监控.全部采用气管插管式电极,同步进行全麻与术中监控.在7例腺叶切除手术中主动探测解剖喉返神经,搜寻探测到喉返神经5例,其他类型的手术中均没有解剖暴露喉返神经.结果39例患者术后喉返神经功能保持完好,1例术中即发生左侧喉返神经麻痹.40例均满意记录到声带非同步性自发喉肌肌电图波,刺激显露和探测到的12例喉返神经,均能诱发喉肌同步肌电图反应波.最小刺激电流强度阈值为0.08～0.35 mA,平均最小电刺激阈值为0.25 mA,适宜刺激电流范围为0.2～1.0 mA.结论喉返神经术中实时监控技术具有灵敏度高、准确性强和稳定性好的特点,可以在术中提供神经受刺激的同步信息,起到早期预警的作用.该技术的应用可以减少医源性喉返神经损伤,预防严重并发症的发生.术中可以不用预先解剖喉返神经,提高手术安全性.     

Esophageal stethoscope. Another possible cause of vocal cord paralysis

Hoarseness after endotracheal intubation can result from compression of the anterior branch of the recurrent laryngeal nerve as it passes behind the thyroid cartilage to innervate the lateral cricoarytenoid muscle. This usually occurs when the cuff of the endotracheal tube lies in the larynx instead of the trachea. When a nasogastric tube is positioned in the midline, resultant postcricoid inflammation can result in vocal cord immobility. This may result from neuropraxia of the posterior branch of the recurrent laryngeal nerve that innervates the posterior cricoarytenoid and interarytenoid muscles, or inflammatory spasm of the interarytenoid muscles themselves. We present a case of vocal cord paralysis after general anesthesia that may have been caused by an esophageal stethoscope. The mechanism for vocal cord immobility could be similar to that of a midline nasogastric tube with resultant postcricoid inflammation. We describe measures that can be taken to prevent vocal cord paralysis after intubation of the larynx or esophagus.     

Nerve monitoring and stimulation during endoscopic neck surgery in the pig

OBJECTIVES: To determine the feasibility of recurrent laryngeal nerve monitoring and stimulation during endoscopic neck surgery in an animal model. STUDY DESIGN: Prospective, nonrandomized experimental investigation in a porcine model. METHODS: Bilateral recurrent laryngeal nerve monitoring and stimulation was accomplished during endoscopic neck surgery in five domestic pigs. Each pig was intubated with an electromyography endotracheal tube. Recurrent laryngeal nerve function was monitored throughout the endoscopic neck surgery with a nerve integrity monitor system. An endoscopic surgical pocket was created in the neck using blunt dissection followed by low-pressure carbon dioxide insufflation. Under direct endoscopic visualization, the trachea, thyroid gland, and associated vasculature were identified. The recurrent laryngeal nerve was identified on each side of the animal and was successfully stimulated with a monopolar stimulator probe. RESULTS: Ten of ten recurrent laryngeal nerves were successfully monitored and stimulated. No significant complications were encountered during the procedures. CONCLUSIONS: Recurrent laryngeal nerve monitoring and stimulation may be successfully accomplished during endoscopic neck surgery.     

Usefulness of neuromonitoring in thyroid surgery

INTRODUCTION: Identifying the recurrent laryngeal nerve is the gold standard for reducing injury in thyroidectomy. OBJECTIVE: To evaluate the usefulness of neuromonitoring in identifying the recurrent laryngeal nerve. METHODS: This was a study of 259 recurrent laryngeal nerves at risk during thyroidectomy performed with neuromonitoring (group A: 129 nerves) and without neuromonitoring (control group B: 130 nerves). RESULTS: The percentage of visually unidentified nerves was 18% in group A and 20% in group B, with no statistical difference. From the moment of non-identification, identification with neuromonitoring was achieved in group A in 100% of cases. The difference was statistically significant. The positive and negative predictive value of neuromonitoring was 100%. CONCLUSIONS: Neuromonitoring helps to identify the recurrent laryngeal nerve and increases the security of the surgeon in the technique. It is advisable to perform neuromonitoring routinely in thyroid surgery.     

Laryngeal morbidity after intubation with or without neuromuscular block in thyroid surgery using recurrent laryngeal nerve monitoring

Objective

The avoidance of neuromuscular blocking agents (NMBA) for endotracheal intubation is associated with a higher incidence of laryngeal discomfort and lesions, but could impair effectiveness of intra operative recurrent laryngeal nerve monitoring (IONM).

Methods

In a retrospective quality assessment study over a period of 30 months, a collective that had been intubated without NMBA was compared with a group, which had received NMBA. Endolaryngeal EMG was accomplished with a MagStim^®-EMG-electrode.

Results

Out of the 127 patients with 224 nerves at risk (NAR; NMBA 102 NAR, no NMBA 122 NAR), more than 90% received a total intravenous anaesthesia with propofol, and 88% had remifentanil. Laryngeal side effects and damage scores did not differ significantly.

Conclusions

In this special setting of IONM and thyroid surgery, avoidance of NMBA for endotracheal intubation seems not to increase the incidence of laryngeal side effects and lesions. If endotracheal intubation without NMBA is required, the authors suggest a standardized approach using induction agents as propofol and remifentanil.     

Useful landmarks in arytenoid adduction and laryngeal reinnervation surgery

OBJECTIVE: Knowledge of the location of the muscular process of the arytenoid cartilage and the recurrent laryngeal nerve is essential to performing a successful arytenoid adduction and laryngeal reinnervation surgery. We describe external landmarks useful in locating these structures. STUDY DESIGN: Cadaveric laryngeal dissection. METHODS: Posterior laryngeal dissection was performed in 16 human larynges. The position of the muscular process of the arytenoid was measured bilaterally relative to the inferior and superior borders of the thyroid lamina. The recurrent laryngeal nerve was followed distally from slightly below the level of the cricothyroid joint to its genu where its vertical course changes to an oblique intralaryngeal course. RESULTS: The muscular process of the arytenoid was usually found halfway between the roots of the superior and inferior cornu of the thyroid lamina. The recurrent laryngeal nerve was found just deep to the cricothyroid joint and lateral to the posterior cricoarytenoid muscle. There were no other nerves in this area. CONCLUSIONS: This study finds that the superior and inferior borders of the thyroid lamina are useful intraoperative landmarks to locate the muscular process of the arytenoid. The cricothyroid joint provides a good starting point to locate the recurrent laryngeal nerve, which can be identified slightly deeper between it and the posterior cricoarytenoid muscle.     

Enucleation of vagal nerve schwannoma using intraoperative nerve monitoring

Vagal nerve schwannomas are rare, benign, neural sheath tumors. The treatment of enlarging or symptomatic vagal nerve schwannomas is surgical resection. Transecting the vagus nerve results in significant morbidity, and attempts at nerve preservation should be made whenever possible. We introduce a nerve-sparing technique using meticulous microsurgical dissection and intraoperative nerve monitoring for vagal schwannomas. A 61-year old patient presented with an enlarging 2-cm right vagal nerve schwannoma. She underwent resection via a transcervical approach. The patient was intubated with an electromyographic (EMG) endotracheal tube that allowed for monitoring of the recurrent laryngeal nerve intraoperatively. A microsurgical subcapsular dissection was performed after branches of the vagus nerve were identified using a nerve probe and preserved. At the conclusion of the resection the nerve was intact and stimulated along its entire course. Postoperatively, the patient had normal vagal nerve function. We introduced the role of intraoperative nerve monitoring using an EMG endotracheal tube for successful enucleation of vagal schwannomas. In conjunction with meticulous microsurgical dissection, nerve monitoring allows for successful preservation of the vagus nerve and decreased postoperative morbidity.