功能性颈清扫术在复发性鳃裂畸形治疗中的应用

目的:探讨功能性颈清扫术在复发性鳃裂畸形治疗中的应用。方法:回顾性分析我科采用功能性颈清扫术治疗复发性鳃裂畸形(瘘管和囊肿)患者15例的资料。结果:13例切口一期愈合,2例二期愈合,1例术后饮水呛咳,1个月后自行恢复,1例术后遗留Horner综合征。随访2个月～6年,除2例失访外,无一例复发。结论:功能性颈清扫术对于多次复发的第二、第三鳃裂畸形(瘘管和囊肿)是一种安全有效的治疗手段。     

择区性颈清扫术治疗下咽鳞状细胞癌颈部淋巴结转移的术式探讨

目的:探讨择区性颈清扫术(SND)治疗下咽鳞状细胞癌颈部淋巴结转移的手术范围。方法:回顾性分析接受SND的26例下咽癌患者,其中11例cN0患者,15例cN+患者。本组共有51侧的SND,其中34侧为选择性SND,17侧为治疗性SND。结果:发现隐匿性颈淋巴结转移6例(55%),颈淋巴结转移均限制在Ⅱ区和Ⅲ区内。cN+患者均证实有颈淋巴结转移,其中Ⅱ区转移占66.7%,Ⅲ区转移占86.7%,Ⅳ区转移占46.7%,Ⅴ区转移占20.0%,另外Ⅰ区仅1例发现转移(6.7%)。随访发现区域复发4例,均为cN+患者,且均未见Ⅰ区复发。结论:cN0下咽癌患者SND(Ⅱ～Ⅲ)清扫有一定的临床意义,尚需进一步验证;cN+患者Ⅰ区清扫尚无必要,SND(Ⅱ～Ⅴ)配合术后放疗能取得满意的疗效。     

择区性颈清扫术在临床N0舌鳞状细胞癌治疗中的应用

目的比较择区性颈清扫术(selective neck dissection，SND)与经典性或改良性颈清扫术(radical neck dissection，RND)在治疗舌鳞状细胞癌颈淋巴结临床阴性(cN0)患者中的效果。方法将1998年1月-2002年12月之间采用肩胛舌骨肌上颈清扫术(Ⅰ～Ⅲ区)14例及Ⅰ～Ⅳ区清扫19例(SND组)共33例与1980年1月-1997年12月之间112例采用经典性或改良性颈清扫术(RND组)的病例，根据T分期、综合治疗方式和淋巴结病理情况进行随机配对分析。Kaplan—Meier方法计算复发率和颈部淋巴结复发或生存趋势。结果RND组5年颈部复发率为9．1％(3例)，SND组5年同侧颈部复发率12．1％(4例)；两组的5年生存率分别是78．8％和82．9％(分别为26例和28例)。Ⅰ-Ⅲ区清扫组5年颈部复发率为21．2％(3例)，清扫野外复发率为14．3％(2例)；Ⅰ-Ⅳ区清扫组5年同侧颈部复发率5．3％(1例)，清扫野外复发率为0。结论与经典性或改良性颈清扫术相比，择区性颈清扫术并不影响cN0舌癌患者的肿瘤治疗效果，术式以Ⅰ～Ⅳ区清扫为适宜。     

选择性颈清扫术在复发性第二三鳃裂瘘管术中的应用

由于鳃裂瘘管与颈部重要神经、血管关系密切,手术切除不彻底,易造成反复感染.对于复发者,常规手术方法更难治愈.我们采用选择性颈清扫术,整块切除病变组织,保留颈内动静脉、神经、胸锁乳突肌, 治疗8例复发性第二、三鳃器瘘管患者,术后随访2～10年,无一例复发,总结如下.     

功能性颈清扫术式治疗复发性第二及第三四鳃裂瘘管或囊肿16例

我科2001—05—2011-08对16例复发性第二及第三、四鳃裂瘘管（或囊肿）患者行功能性颈清扫术治疗,效果较好,报告如下。     

舌癌的择区性颈清扫术

舌游动部分鳞状细胞癌较易发生颈淋巴转移，据报道约有30％的初诊病例临床检查即可发现转移的肿大淋巴结。虽然如此，但也有不少病例，即使是晚期的T4病变，临床检查也未触及肿大淋巴结(cNO)。触及肿大淋巴结做传统的或功能性的颈淋巴清除当无异议，但对cNO病例的治疗处理仍有不同意见。     

择区性颈清扫术后颈内静脉的功能评价

目的:通过彩色多普勒超声检查,评价头颈部恶性肿瘤患者行择区性颈清扫术后颈内静脉(IJV)的功能。方法:行单侧或双侧择区性颈清扫术的下咽、喉鳞状细胞癌患者40例(共76侧IJV),按手术清扫范围大小将76侧IJV分为2组:A组行Ⅱ、Ⅲ区清扫(39侧);B组行Ⅱ～Ⅳ区和Ⅱ～Ⅴ区清扫(37侧)。所有患者在术前和术后1、3个月超声检查IJV有无血栓形成、呼气流量、呼气内径,呼气和捏鼻鼓气时的面积及流速,将结果进行统计分析。结果:①术前及术后76侧IJV均无血栓形成;②术后1、3个月IJV的通畅率分别为85.5%和96.1%,A、B组比较均差异无统计学意义(均P>0.05);③A、B组术后1个月除捏鼻鼓气时流速外,其余各项指标与术前比较均差异有统计学意义(均P<0.05);术后3个月除呼气时面积外,其余各项指标与术前比较均差异有统计学意义(均P<0.05);A、B组术后1、3个月比较,除呼气流速外,其余各指标比较均差异有统计学意义(均P<0.05);④不同手术清扫范围对IJV各指标的影响均差异无统计学意义(均P>0.05)。结论:①择区性颈清扫术后IJV均无血栓形成,说明术中细致操作、运用正确的手术技巧及采用恰当的术后处理可以避免IJV血栓形成;②IJV各项指标在择区性颈清扫术后早期有变化,但在术后3个月时多数指标有所恢复,呼气流量可以恢复至术前水平,说明术后较长时间IJV能恢复正常回流功能。     

择区性颈清扫和改良性颈清扫术后肩功能的评估及比较

目的评估及比较择区性颈清扫术（selective neck dissection,SND）和改良性颈清扫术（modified neck dissection,MND）术后患者的肩功能,为颈清扫术式的选择提供参考依据。方法采用自制的肩功能评价系统对在我院行单侧颈清扫头颈癌患者35例进行肩功能评价,其中SND19例,MND16例。肩功能评价于术后6个月～1年进行,采用主观指标和客观指标结合的方法进行评价;其中问卷调查内容8项,涉及颈清扫侧颈部皮肤感觉改变、肩部及上肢活动状况及其对生活和工作的影响程度;肩功能客观指标包括健侧和患侧耸肩的高度,上肢前举、侧举角度的差值。数据分析采用SPSS10.0统计软件包,等级资料和连续资料的比较均采用非参数秩和检验。结果35例均能完成肩功能评价,问卷调查完成时间为（4.5±3.1）分钟,全部评价完成时间为（7.4±3.5）分钟。问卷调查量表内部一致性检验克朗巴赫系数α=0.904,重测信度分析相关系数r均〉0.75。主观指标中,MND组的颈部疼痛,麻木感,僵硬感,高处取物、日常生活与工作所受影响较SND组严重,P均〈0.05。客观指标中,MND组术后颈清扫侧耸肩、上肢前举及侧举等肩周活动所受影响较SND组严重,P均〈0.05。结论自制的肩功能评价系统具有较高的效度和信度,值得推广。择区性颈清扫术对患者术侧肩部活动功能和肩颈部感觉的影响明显轻于改良性颈清扫术,合理采用择区性颈清扫术能提高头颈部癌患者的生活质量。     

择区性颈清扫术治疗63例下咽鳞状细胞癌的颈淋巴转移

目的 分析下咽鳞状细胞癌(简称鳞癌)患者颈部淋巴转移规律,评价择区性颈清扫术(selective neck dissection,SND)在下咽癌颈淋巴转移治疗中的效果.方法 回顾性分析1990年1月至2004年12月在北京大学第一医院接受颈清扫术的下咽鳞癌患者63例,其中cN0患者17例,cN+46例.单侧SND共计15例;双侧SND共计22例;改良性颈清扫术(modified radical neck dissections,MRND)共计16例;一侧行经典性颈清扫术(radical neck dissections,RND)或MRND,另一侧行SND共计10例.随访48例(76.2%),随访时间范围为24～143个月,随访中位时间为41个月.结果 颈清扫术后发现淋巴结病理阴性(pN0)22例,淋巴结病理阳性(pN+)41例.95侧清扫标本中共发现106枚阳性淋巴结,其在颈部的分布如下:Ⅰ区0%,Ⅱ区47.2%(50/106),Ⅲ区33.0%(35/106),Ⅳ区11.3%(12/106),Ⅴ区2.8%(3/106),Ⅵ区5.7%(6/106).值得注意的是,无论是cNO还是cN+下咽癌患者,对侧颈部都可出现淋巴转移和复发.在随访的48例中,共有18例(21例次)复发.颈清扫术后淋巴结复发主要分布在Ⅱ区和Ⅲ区(19例次).根据Kaplan-Meier方法计算3年生存率,pN0患者为58.1%,pN1患者为44.9%,pN2患者为41.1%.Cox同归分析:N分级是影响预后最重要的因素,pN1的危险比为1.7,pN2的危险比为2.2.结论 淋巴转移是下咽鳞癌最重要的预后因素.恰当的选择双侧SND,可以取得较满意效果,同时减少患者形态和功能的损伤.     

颈清扫术历史与相关名词的演变

非常遗憾，到目前为止，我们还不知道究竟是谁最早介绍了颈清扫术(颈廓清术)，因为早在Crile之前，就有关于根治性颈清扫术的零星报道。     

Resection of recurrent branchial cleft deformity using selective neck dissection technique

ObjectivesThis study explores application of selective neck dissection technique in recurrent second, third, and fourth branchial cleft deformities.MethodsA total of 19 cases of recurrent second, third, and fourth branchial cleft deformities were treated using the selective neck dissection technique, during which the sternocleidomastoid muscle, cervical anterior muscle, and carotid sheath were contoured. The lesion above the prevertebral fascia was then resected en bloc. Finally, the opening of the internal fistula was ligated and sutured using the purse-string approach.ResultsPatients in this study had no injures to their internal carotid artery, jugular vein, vagus nerve, accessory nerve, hypoglossal nerve, or recurrent laryngeal nerve. There were also no complications such as poor wound healing. The patients were monitored for 7–73 months and showed no recurrences.ConclusionsUsing selective neck dissection to treat second, third, and fourth branchial cleft deformities resulted in en bloc lesion resections and reduced the chance of recurrence. Contouring the sternocleidomastoid muscle, strap muscle, and carotid sheath is key to the surgical procedure, as it leads to en bloc lesion resection while retaining the recurrent laryngeal nerve and carotid sheath.     

Selective neck dissection in the management of the clinically node-negative neck

OBJECTIVE: To evaluate the efficacy of the selective neck dissection (SND) in the management of the clinically node-negative neck. STUDY DESIGN: Case histories were evaluated retrospectively. METHODS: The results of 300 neck dissections performed on 210 patients were studied. RESULTS: The primary sites were oral cavity (91), oropharynx (30), hypopharynx (16), and larynx (73). Seventy-one necks (23%) were node positive on pathological examination. The number of positive nodes varied from 1 to 9 per side. Of necks with positive nodes, 17 (24%) had extracapsular spread. The median follow-up was 41 months. Recurrent disease developed in the dissected neck of 11 patients (4%). Two recurrences developed outside the dissected field. The incidence of regional recurrences was similar in patients in whom nodes were negative on histological examination (3%) when compared with patients with positive nodes without extracapsular spread (4%). In contrast, regional recurrence developed in 18% of necks with extracapsular spread. This observation was statistically significant. Patients having more than two metastatic lymph nodes had a higher incidence of recurrent disease than the patients with carcinoma limited to one or two nodes. Recurrence rate in the pathologically node positive (pN+) necks was comparable to recurrence in those pathologically node negative (pNO) necks in the patients who did not have irradiation. CONCLUSION: SND is effective for controlling neck disease and serves to detect patients who require adjuvant therapy.     

Radical neck dissection

Radical neck dissection was described in 1906, and the following half century saw it being increasingly accepted without any significant change. More recently a number of differing concepts have arisen. While the value of the original radical operation is established, the more recent modifications are not yet substantiated by proper trials.     

Bilateral recurrent laryngeal nerve palsy following blunt neck trauma

Blunt trauma neck to larynx is an uncommon injury that results in a wide spectrum of damage to endolaryngeal soft tissues as well as underlying cartilaginous skeleton leading to upper airway obstruction requiring emergency tracheostomy. A case report of blunt trauma neck anterior is presented who developed upper airway obstruction necessitating tracheostomy. Indirect Laryngoscopy and fibre optic examination identified vocal cord paralysis as primary cause of upper airway obstruction although X ray soft tissue neck and CT neck revealed fracture hyoid as well as hematoma surrounding the laryngeal frame work. Emergency tracheostomy was done and patient recovered uneventfully.     

Phrenic nerve paralysis following neck dissection

Summary One of the complications of neck dissection to control regional metastatic disease in cancer of the head and neck is phrenic nerve paralysis. The resulting elevation of the ipsilateral diaphragm can be diagnosed on a postoperative chest X-ray and confirmed by fluoroscopy. Symptoms can be respiratory, cardiac or gastrointestinal. In a retrospective study, unilateral phrenic nerve paralysis was observed in 14 (8%) of 176 consecutive neck dissections. None of the patients with postoperative phrenic nerve paralysis displayed severe symptoms, although a significantly higher number sustained atelectasis with or without pulmonary infiltrates to complicate the postoperative course.     

Surgical complications and recurrence after central neck dissection in cN0 papillary thyroid carcinoma

Objectives

To evaluate surgical complications and recurrence patterns after central neck dissection (CND) in papillary thyroid carcinoma (PTC).

Methods

A retrospective analysis was performed on 361 patients who underwent total thyroidectomy with or without CND for PTC from 2000 to 2007. Clinicopathological results and recurrence were stratified according to treatment modality.

Results

Incidence of occult central metastasis of PTC was 64.3%. With respect to surgical morbidities, the total thyroidectomy (TT) with CND group exhibited a significantly higher incidence of transient vocal fold paralysis (10.0% vs 3.4%, p = 0.029) and permanent hypocalcaemia (11.4% vs 4.5%, p = 0.041), and significantly prolonged mean operating time (195.8 min vs 153.0 min, p < 0.001) than the TT alone group. Analysis of the recurrence patterns revealed that level IV was most commonly involved in both groups. When the location of recurrence was categorised into central and lateral neck, the recurrence rate in the lateral neck was significantly higher than that in the central neck, regardless of initial CND.

Conclusions

CND was associated with permanent hypocalcaemia and transient vocal fold paralysis. The lateral neck was mainly involved in recurrence regardless of initial CND, suggesting the clinical benefit of CND may be small.