非返性喉返神经损伤的预防

目的 探讨非返性喉返神经的临床意义。方法 复习4例非返性喉返神经的临床资料并结合相关文献，了解非返性喉返神经的变异类型及甲状腺手术中应注意的事项。结果 湘雅医院2156例甲状腺手术中暴露喉返神经共719条，4例被确认具有非返性喉返神经，占0．56％。其中右侧和左侧各2例。3例因首次手术后声嘶再次手术时证实为非返性喉返神经，1例于首次手术中发现。其中3例为同时伴有返支和非返支的喉返神经，且2支均在入喉前2cm处汇合。另外1例为不伴有返支的右侧非返性喉返神经。结论 非返性喉返神经属少见变异，在甲状腺手术中容易损伤。充分认识非返性喉返神经及变异类型，有助于预防甲状腺手术时喉返神经损伤。     

右侧非返性喉返神经一例

由于非返性喉返神经是临床罕见的解剖异常,在施行甲状腺切除术中,如不采取预先显露或解剖喉返神经极易造成损伤.我们近年来曾分别遇到左侧非返性喉返神经[1]和右侧非返性喉返神经患者各1例.现将后者报告如下.     

喉不返神经报道

喉返神经损伤是甲状腺手术最常见的并发症。导致喉返神经损伤的原因很多,除手术医师对颈部解剖特别是甲状腺周围血管、神经解剖关系不熟悉外,喉不返神经的存在也是出现这一并发症不可忽视的重要因素。喉不返神经是一种罕见的解剖变异,Bowde报道尸体解剖中发现喉不返神经发生率为1%-2%,临床资料中其右侧的发生率是0.3%-1.6%,左侧为0.04%。     

甲状腺手术中无喉返神经的识别

喉下神经无返回支是罕见的畸形，右侧发生率０．３％～０．４％，左侧更少见。甲状腺手术中损伤喉下神经的机会较高，所以，需要识别喉下神经无返回支的变异。该文报道甲状腺手术中无喉返神经２例，阐述了其胚胎学，并讨论了识别的方法。喉返神经由第６鳃弓发生而来。第４鳃弓在右侧形成锁骨下动脉，左侧形成主动脉弓。喉返神经在右侧绕过锁骨下动脉，在左侧绕过主动脉弓。右侧喉返神经的畸形常伴锁骨下动脉的异常；而左侧喉返神经的畸形，则主动脉弓及动脉韧带必然出现在相反位置（出现在右侧）。所以，左侧喉返神经的畸形是极罕见的。术前…     

甲状腺手术喉返神经损伤的神经修复治疗

目的探讨甲状腺手术所致喉返神经损伤的神经修复治疗。方法选取2008年10月～2013年4月收治的甲状腺术后喉返神经损伤患者4l例,行喉返神经减压术23例,行喉返神经端端吻合术11例,行颈袢主支喉返神经吻合术7例。结果喉返神经减压组17例、喉返神经端端吻合组6例及颈袢主支喉返神经吻合组2例,于术后半年内麻痹声带恢复内收及外展运动;吸气时外展幅度基本对称;发音时声带内收于正中位,双侧声带长度及体积对称,声门闭合无裂隙。喉返神经减压组患者声带黏膜波及声带振动恢复了对称性。喉返神经端端吻合组及颈袢主支喉返神经吻合组患者声带黏膜波、声带振动基本对称。喉返神经减压组患者声音均恢复正常。喉返神经端端吻合组8例、颈袢主支喉返神经神经吻合组4患者声音恢复正常;喉返神经端端吻合组3例、颈袢主支喉返神经吻合组3患者声嘶明显改善。结论神经修复治疗甲状腺手术所致喉返神经损伤疗效确切,以神经减压术效果最佳。     

甲状腺术中喉返神经损伤原因及预防

喉返神经损伤是甲状腺手术的严重并发症之一。我院从1998年1月-2004年4月共实施各类甲状腺手术986例次,发生喉返神经损伤5例,占同期手术的0.5%,现总结报道如下。1资料和方法1.1一般资料。5例均为女性,年龄19-53岁,均为单侧损伤,其中左侧3例,右侧2例。损伤性质:切断4例,结扎1例。损伤部位:甲状腺下动脉与喉返神经交叉处4例,环甲关     

非返性喉返神经的临床所见及文献回顾

目的　探讨非返性喉返神经（non recurrent laryngeal nerve,NRLN）的变异规律及保护的方法。方法 对我院近3年来的4例NRLN病例总结及对国内学者1995年 至今报道的NRLN病例进行回顾性分析。结果　NRLN的临床平均发生率为0.35%,以右侧居多（96.36%）,均伴有右侧锁骨下动脉解剖变异;NRLN的损伤率高达11.82%,自2007年以来NRLN的损伤率显著降低（5.20%）;NRLN的变异类型以II型为主,其中IIA型多于IIB型。结论　NRLN是一少见变异、同时伴有高损伤率,但是通过规范的神经解剖、辅助检查及术中神经检测可以有效发现并避免神经损伤。     

良性甲状腺疾病继发喉返神经麻痹

甲状腺疾病引起的喉返神经麻痹，多数为甲状腺肿恶变所致。该作者治疗3例继发于甲状腺良性肿块的喉返神经麻痹患者，其中男性2例，女性1例，年龄为67、69及73岁。均因声嘶就诊。检查均见甲状腺肿大伴声带固定。3例均行甲状腺次全切除，并于术中仔细辨认和保护喉返神经。术中发现3例甲状腺肿块均压迫甚至牵拉喉返神经。组织学检查3例均为给节性甲状腺肿块伴有出血，未见恶性证据。3例中有2例术后6个月、1例术后7个月声带运动恢复正常。认为良性甲状腺疾病所致的声带麻痹应尽早地施行甲状腺次全切除，解除神经受压，术后绝大多数均能在4～6个…     

喉返神经减压术

目的探讨喉返神经减压治疗因甲状腺手术和甲状腺肿物压迫所致喉返神经功能障碍的疗效.方法2002年10月-2005年6月间,行喉返神经减压术治疗单侧喉返神经麻痹9例,声门闭合不全4例.包括甲状腺良性肿物切除术后喉返神经麻痹7例,均为普通外科术后.其中6例神经缝扎,1例神经瘢痕粘连,同时对其中2例行Ⅰ型甲状软骨成形术;甲状腺腺瘤1例和结节性甲状腺肿并喉返神经麻痹1例,均行甲状腺肿物切除喉返神经减压.声门闭合不全的4例中,结节性甲状腺肿3例、桥本甲状腺炎1例分别行甲状腺肿物切除或腺叶部分切除,电子喉镜观察手术前、后声带动度变化,评价手术效果.结果5例神经被结扎和1例神经粘连者于3个月内行减压术,术后1周～3个月声带动度恢复,发声满意;1例神经被结扎于术后4个月行减压术者,随访1年声带动度未见恢复.甲状腺腺瘤和结节性甲状腺肿并喉返神经麻痹患者减压术后3个月内声带动度完全恢复,声门闭合不全并结节性甲状腺肿和桥本甲状腺炎者,术后1周内声门缝隙消失、声嘶消失.结论对于因甲状腺手术所致的喉返神经麻痹,应尽快行喉返神经探查和减压术;声音嘶哑较严重者,可考虑同时行Ⅰ型甲状软骨成形术,以短时间内改善患者发声状况,提高患者生活质量;对于甲状腺肿物合并喉返神经麻痹或声门闭合不良者,应积极行手术探查,行喉返神经减压.     

甲状腺手术中喉返神经显露的意义

目的阐明甲状腺手术中显露喉返神经（recurrent laryngeal nerve,RLN）的优点。方法在452例不同类型的甲状腺手术中显露喉返神经,手术前后喉镜检查声带运动情况。结果共显露喉返神经748根,暂时性喉返神经损伤14例（占1．88％）,永久性损伤2例（占0．27％）。结论甲状腺手术中显露喉返神经可有效防止其损伤并有利于手术疗效。     

甲状腺手术中喉返神经的保护

目的：探讨甲状腺手术中保护喉返神经的方法。方法：术前经B超证实36例甲状腺疾病患者病变部位、范围及性质，术中依靠一些解剖标志寻找和识别喉返神经并加以保护。结果：36例患者术后32例无声带并发症，4例术后声嘶，随访3～6个月，2～6个月声嘶恢复正常。结论：手术中解剖喉返神经必须遵循规范化操作原则，首先在甲状腺下极甲状腺下动脉周围寻找喉返神经，若有困难可在喉返神经入喉处，亦可在颈动脉鞘迷走神经附近寻找。     

甲状腺外科手术中喉返神经的解剖

目的：探讨甲状腺外科手术中喉返神经的解剖特点和方法。方法：回顾性分析56例甲状腺疾病患者在手术中解剖的63条喉返神经的有关资料：结果：48条喉返神经入喉前分成前、后两支．占喉返神经总数的76．19％。29条(46．03％)喉返神经位于甲状腺下动脉的深部．19条(30．56％)喉返神经位于甲状腺下动脉的浅面．8侧(12．70％)甲状腺下动脉分叉．神经穿行其间．7侧(11．11％)术中未发现甲状腺下动脉：术后喉返神经暂时麻痹1例,永久麻痹1例。结论：充分掌握喉返神经的解剖特点．术中正确辨认并安全地解剖喉返神经是避免喉返神经损伤的关键。     

甲状腺癌右侧喉不返神经与颈交感神经交通1例报道

目的 总结1例少见的甲状腺癌术中发现右侧喉不返神经和颈交感神经交通并汇合后入喉患者的病例资料,以引起临床医生的重视.方法 分析1例30岁女性体检发现甲状腺结节,术前细针穿刺细胞学结果考虑甲状腺乳头状癌,在全麻下行手术治疗,术中探查发现该患者右侧喉不返神经和颈交感神经交通并汇合后入喉,术中给予精细解剖,喉返神经完整,手术...     

喉返神经的解剖显露在甲状腺手术中的价值

目的 探讨甲状腺手术喉返神经（RLN）的解剖特点和方法，以减少神经的损伤。方法 回顾分析2000年1月-2005年10月256例甲状腺手术的临床资料，常规显露RLN201例（211条），不显露RLN55例，并对RLN解剖特点、损伤情况和预防进行分析。结果 显露RLN者暂时性损伤率为1．00％（2／201），无永久性损伤；未显露者暂时性损伤率为7．27％（4／55），永久性损损伤率为3．64％（2／55），两组暂时性损伤率之间和永久性损伤率之间经统计学处理差异均有统计学意义（P〈0．05）。“非返性喉下神经”发生率为0．95％（2／211）；67．30％（142／211）RLN在入喉前有分支，59．24％（125／211）的RLN位于甲状腺下动脉的深面，30．81％（65／211）位于动脉的浅面，5．68％（12／211）穿行于动脉的分叉处，4．27％（9／211）与动脉无关。结论 RLN的行程过程中解剖关系较为复杂；甲状腺手术中有计划显露RLN可以预防其损伤。     

Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk.

OBJECTIVES/HYPOTHESIS: Recurrent laryngeal nerve palsy (RLNP) is a major obstacle in thyroid and parathyroid surgery. Therefore, methods that reduce the number of temporary and, especially, permanent recurrent laryngeal nerve palsies are of great interest. One promising way to ensure the integrity of the recurrent laryngeal nerve (RLN) is to identify the nerve always. The first question raised in the present study was whether RLN preparation reduces the number of recurrent laryngeal nerve palsies or whether it introduces additional risks. Second, from former cases we know that the absence of postoperative hoarseness does not exclude RLNP, nor does postoperative hoarseness exclusively imply RLNP. Besides, misdiagnosis is not uncommon. Therefore, preoperative and postoperative laryngoscopic examination was given attention. STUDY DESIGN: Patients were investigated 1 to 7 days before and 3 to 7 days after surgery. When an RLNP was identified, patients were followed up in a 2-week rhythm the first few times and every 6 to 8 weeks thereafter until RLNP resolved or it was considered permanent after 2 years. METHODS: We prospectively investigated 608 surgical patients with 1080 nerves at risk. Because different diseases might have different rates of postoperative RLNP, we analyzed benign thyroid disease (680 nerves at risk), thyroid malignoma (321 nerves at risk), and hyperparathyroidism (79 nerves at risk) separately. Patients undergoing primary surgery (no prior thyroid surgery) and secondary interventions (there were one or more thyroid operations before this intervention) were evaluated separately. RESULTS: We found 3.4%, 7.2%, and 2.5% of temporary recurrent laryngeal nerve palsies per nerve in the benign thyroid disease, thyroid malignoma, and hyperparathyroidism groups, respectively. The prevalence of recurrent laryngeal nerve palsies in these groups was 0.3%, 1.2%, and 0%, respectively. Conforming with other studies, the total number of recurrent laryngeal nerve palsies (temporary and permanent) was not increased compared with cases with no RLN preparation, whereas the number of permanent recurrent laryngeal nerve palsies was markedly reduced. An RLN was always identifiable. Astonishingly, the restitution of an RLNP was up to 2 years in duration; however, most restitutions occurred within the first 6 months. Thirty cases of hoarseness appeared or were intensified after surgery and were not caused by RLNP. Eleven cases of postoperative RLNP had no detectable hoarseness. CONCLUSIONS: Besides indirect laryngoscopy, videostroboscopy should be performed in all cases with no evident bilateral normal laryngeal function or normal voice. Otherwise, the incidence of false-positive or false-negative diagnosis of RLNP is likely to be increased.     

困难甲状腺手术中喉返神经解剖的研究

目的：探讨困难甲状腺手术中喉返神经解剖的方法,以最大限度减少损伤,提高手术的安全性。方法：回顾性分析52例巨大结节性甲状腺肿、胸骨后结节性甲状腺肿、位于甲状腺下极的结节性甲状腺肿、甲状腺癌以及甲状旁腺肿瘤等困难甲状腺手术中喉返神经的解剖过程和方法,了解病变累及喉返神经的状况以及避免喉返神经损伤的措施。结果：52例患者中,除2例甲状腺癌一侧喉返神经受侵予以切除外,其余50例喉返神经均解剖成功。50例喉返神经解剖成功者中,3例喉返神经拉长者术后无声嘶,2例喉返神经局部压为扁平者术后也无声嘶,3例术后轻微声嘶者经营养神经治疗1~3个月后恢复正常。1例喉不返神经,2例胸骨劈开,2例术后行气管切开。术后无并发症发生。结论：困难甲状腺手术中喉返神经的解剖大多需要游离腺叶和肿瘤并将其翻向内前上方,再以气管食管沟、甲状腺下动脉和（或）甲状软骨下角为标志进行解剖,实践证明该方法可行。     

Laryngeal nerve monitoring and minimally invasive thyroid surgery: complementary technologies

OBJECTIVE: To determine the feasibility of the combined use of laryngeal nerve monitoring and minimally invasive thyroid surgery. DESIGN: Prospective, nonrandomized analysis of single-surgeon experience. SETTING: Academic institution. PATIENTS: Consecutive series of patients undergoing both minimally invasive thyroid surgery and laryngeal nerve monitoring. MAIN OUTCOME MEASURES: Incision length and incidence of temporary or permanent laryngeal nerve injury. RESULTS: Two hundred eighty-three patients underwent thyroid surgery at the Medical College of Georgia, Augusta, between January 2004 and November 2006. Some type of minimal-access approach (endoscopic or nonendoscopic) was used in 137 cases (48.4%) in which general anesthesia was administered. Laryngeal nerve monitoring was performed in 73 (53.3%) of these 137 cases, although the proportion of cases in which it was performed increased significantly from 8.7% (2 of 23 cases) in 2004 to 95.2% (58 of 61 cases) in 2006 (P < .001). There were no cases of permanent nerve injury. The incidence of temporary recurrent laryngeal nerve paresis was 4.3% (4 of 92 nerves at risk) in the cases in which laryngeal nerve monitoring was used and 6.0% (5 of 84 nerves at risk) in the cases in which the nerve was visually identified without use of a monitor. This difference failed to reach statistical significance (P = .73), which may reflect an insufficient sample size. CONCLUSION: Monitoring of the laryngeal nerves is feasible in minimal-access thyroid surgery and may serve as a meaningful adjunct to the visual identification of nerves.     

甲状腺手术中的喉返神经显露

目的 探讨甲状腺手术中喉返神经显露对避免损伤喉返神经的作用。方法 回顾性分析150例甲状腺手术患者的临床资料，其中甲状腺瘤125例，术中均顺利显露同侧喉返神经；甲状腺癌25例，其中仅10例能显露喉返神经。结果 随访6个月～4年，甲状腺瘤术后声带麻痹(单侧)5例，其余120例术后声带运动良好，发声正常。甲状腺癌15例术后并发声带麻痹，10例声带运动正常。结论 甲状腺腺叶切除术中，常规显露喉返神经能减少喉返神经的损伤。对显露过长的喉返神经，术中应利用游离筋膜覆盖，以免术后瘢痕形成压迫喉返神经致声带麻痹。     

Thyroid surgery in children and adolescents: A series of 65 cases

ObjectivesTo describe the specificities and complications of thyroid surgery in children and adolescents.Material and methodsThis retrospective study was based on 64 patients under the age of 18 who underwent thyroid surgery between January 2004 and March 2012, with two operations in one case. The following data were analysed: anatomical variants of the recurrent laryngeal nerve, postoperative recurrent laryngeal nerve paralysis rate, postoperative hypoparathyroidism rate, and histological results.ResultsTwo cases of right non-recurrent inferior laryngeal nerve were observed (2.2% of the 93 recurrent laryngeal nerves dissected). One case of persistent left recurrent laryngeal nerve paralysis was observed (1.1%) despite intraoperative recurrent laryngeal nerve monitoring. Eight cases of immediate postoperative hypocalcaemia were observed (23.5% of the 34 total thyroidectomies) and permanent hypocalcaemia was observed in 5 cases (14.7%) with a significantly lower immediate postoperative serum calcium than in the case of transient hypocalcaemia (P = 0.035). Among the 11 patients operated for familial medullary thyroid carcinoma (MTC), 36.3% presented one or more sites of C-cell carcinoma. Among the 32 patients operated for thyroid nodule, 6.3% presented papillary adenocarcinoma. Histological results were benign in all other cases.ConclusionsThyroid surgery in children and adolescents is part of global multidisciplinary management of thyroid disorders in children. Recurrent laryngeal nerve paralysis is a rare complication, but may occur despite the use of intraoperative recurrent laryngeal nerve monitoring. Permanent hypoparathyroidism is the most common complication and is correlated with immediate postoperative serum calcium. Systematic prophylactic total thyroidectomy in patients with a RET proto-oncogene mutation allowed early diagnosis of MTC in one-third of cases. In view of the low rate of malignant nodules in our series, the malignant thyroid nodule rates reported in children in the literature may be overestimated.