甲状腺手术单侧喉返神经损伤的颈袢神经修复治疗

目的 探讨颈袢主支喉返神经吻合术治疗甲状腺手术引起的喉返神经损伤单侧声带麻痹的远期疗效.方法 对1990年10月至2010年1月因甲状腺手术致单侧声带麻痹的325例患者施行颈袢主支喉返神经吻合术,对其疗效进行回顾性分析.结果 动态喉镜随访发现术后声门闭合程度、声带边缘直线性、患侧声带位置、声带振动的对称性和规律性与术前相比有明显改善(P＜0.01),嗓音功能评价的各种主客观参数(GRBAS评分、基频微扰,振幅微扰,噪谐比,最长发声时间)术后与术前比较,均有显著改善(P ＜0.01);93.5％ (304/325)的患者嗓音恢复正常,有效率达98.8％(321/325).术后喉肌电图检查证实麻痹侧喉肌获得充分的神经再支配.结论 颈袢主支喉返神经吻合术治疗后甲状腺手术单侧喉返神经损伤声带麻痹患者嗓音功能可恢复正常,远期疗效非常满意.     

甲状腺肿瘤手术喉返神经损伤的研究

作者对１５５７例甲状腺肿瘤手术后喉返神经损伤的原因及预防措施进行了分析。本组喉返神经麻痹发生率，良、恶性肿瘤分别为２．３％和９．８％；首次与再次手术分别为３．９％和１０．５％。作者提倡术中暴露喉返神经，但对于双侧肿瘤、巨大肿瘤及甲状腺癌侵犯神经者应按其具体情况区别对待。作者提出了暴露喉返神经的三个解剖标志，以及神经损伤的预防和处理措施。     

喉返神经显露在甲状腺手术中的临床应用

目的 探讨甲状腺手术中如何降低喉返神经损伤的发生率和预防措施.方法 回顾分析我院手术治疗267例甲状腺手术肿瘤病例,术中常规显露喉返神经.结果 267例甲状腺手术喉返神经损伤发生率为0.38%.结论 甲状腺手术中为避免喉返神经损伤,应熟悉喉返神经的解剖和变异,掌握喉返神经的解剖方法 ,常规显露喉返神经是降低喉返神经发生率的有效方法 .     

甲状腺手术中喉不返神经的手术操作技巧

目的了解喉不返神经解剖特点和变异,总结甲状腺手术中发现喉不返神经的方法和预防损伤的经验。方法分析5例甲状腺手术中发现的喉不返神经患者的临床资料,分析喉不返神经手术操作技巧。结果经手术证实本组5例喉不返神经均位于右侧,术中有3例切断了喉不返神经,2例出现了声音嘶哑,1例神经吻合后声音无明显变化。结论甲状腺手术中在颈动脉鞘和喉之间,除外甲状腺中静脉之外的任何横行索状结构均不能首先切断,需显露喉返神经后再作处理;甲状腺手术中如探查喉返神经缺如,均需显露颈段迷走神经,以寻找是否存在喉不返神经。     

甲状腺手术中显露喉返神经的意义

目的　探讨甲状腺手术中喉返神经显露的方法和利弊。方法　对 2148 例甲状腺切除术患者分两组进行前瞻性研究,其中术中显露喉返神经936例,不显露喉返神经1212例。结果　显露喉返神经术式者喉返神经损伤2例,损伤率为0 21%。不显露喉返神经术式者喉返神经损伤5例,损伤率为0 41%。两者之间差异有统计学意义(P<0 05)。结论　甲状腺全切除术中显露喉返神经可以降低喉返神经损伤的发生率。术中应先在甲状腺下动脉周围寻找喉返神经,然后在喉返神经入喉处或颈动脉鞘迷走神经附近寻找喉返神经。     

显露喉返神经在甲状腺手术中的临床意义

目的 探讨甲状腺手术中常规显露喉返神经对于减少其损伤的临床意义.方法 770例全麻下行甲状腺手术患者,解剖显露喉返神经430例,未解剖显露喉返神经340例.比较两组患者神经损伤的发生率.结果 显露神经组430例中2例（0.47％）出现暂时性声音嘶哑,无永久性喉返神经损伤.未显露组340例中有8例（2.35％）出现喉返神经损伤,其中6例为暂时性损伤,2例为神经永久性损伤.组间比较差异有统计学意义（P＜0.05）.结论 甲状腺手术时显露喉返神经可明显降低喉返神经损伤的发生率.     

甲状腺手术中喉返神经的保护

目的:通过分析甲状腺手术引起喉返神经损伤的原因,探讨手术中保护喉返神经的措施。方法:回顾性分析手术治疗的189例甲状腺肿瘤患者的临床资料,对于甲状腺单纯肿瘤剜除或甲状腺部分切除,术中不显露喉返神经;对于甲状腺腺叶切除、甲状腺癌根治术或甲状腺再次手术,术中均显露喉返神经,于环甲关节后下方约0.5cm处(即喉返神经入喉处)寻找喉返神经。结果:5例患者术后出现单侧的喉返神经损伤,其中暂时性损伤1例;长期性损伤4例,其中3例术中未显露喉返神经,1例术中显露喉返神经颈段全程。4例长期性损伤患者继续随访3~6个月,有3例患者声带功能逐渐恢复,1例术中未显露喉返神经患者声带仍然固定。结论:甲状腺手术中是否显露喉返神经应以肿瘤大小及手术方式而异,但不强求全程显露喉返神经。于环甲关节后下方约0.5cm处较易找到喉返神经,视野清晰,手术更安全可靠。     

甲状腺手术中显露喉返神经的安全性探讨

目的 探讨甲状腺手术中显露喉返神经对术后并发症的影响.方法 对397例甲状腺切除术患者分两组进行回顾性分析,其中显露喉返神经210例,不显露187例.比较两组术后喉返神经损伤和低钙血症发生情况.结果 显露组喉返神经损伤率低于不显露组,差异有统计学意义(P<0.05);甲状腺功能亢进的患者喉返神经损伤率高于甲状腺功能正常和甲状腺功能减退者,差异有统计学意义(P<0.05);显露组暂时性低钙血症的发生率高于不显露组,差异有统计学意义(P<0.05);显露组永久性并发症发生率低于不显露组,差异有统计学意义(P<0.05).结论 甲状腺手术中全程显露喉返神经可减少其损伤,并可降低永久性并发症的发生率.     

甲状腺手术中显露喉返神经以避免喉返神经损伤的临床意义

目的探讨甲状腺手术中显露喉返神经(RLN)对预防RLN损伤的临床意义。方法回顾性分析2006年9月至2011年8月期间我院行甲状腺全切除术和次全切除术1 723例患者的临床资料,其中行显露RLN术式914例,共显露RLN 1 203条;行不显露RLN术式809例,共行1 013侧甲状腺腺叶切除手术。比较术后RLN损伤情况及术后6个月声带恢复情况。结果显露组与不显露组RLN损伤发生率分别为0.91%(11/1 203)和2.07%(21/1 013),2组比较差异有统计学意义(P<0.05)。术后随访6个月,显露组与不显露组分别有0例和13例(61.9%,13/21)永久性RLN损伤,2组比较差异有统计学意义(P<0.01)。结论在甲状腺全切除和次全切除术中,显露并注意保护RLN能最大程度地避免RLN损伤,尤其是永久性RLN损伤。     

甲状腺术中喉返神经解剖显露的临床意义

目的 探讨甲状腺术中喉返神经(RLN)的解剖特点及探查方法,以减少神经损伤.方法 回顾性分析327例甲状腺手术的临床资料.常规显露RLN 242例(293条),不显露RLN 85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1.65%(4/242),无永久性损伤;未显露者暂时性损伤率为8.23%(7/85),永久性损损伤率为2.35%(2/85),两组暂时性损伤率之间和永久性损伤率之间差异均有统计学意义(P＜0.05).67.23%(197/293)的RLN在入喉前分为前后两支,61.09%(179/293)的RLN位于甲状腺下动脉的深面,31.39%(92/293)位于动脉的浅面,4.09%(12/293)穿行于动脉的分叉处,4.13%(10/293)与动脉无关,"非返性喉下神经"的发生率为0.68%(2/293).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地显露RLN可以预防其损伤.     

Recurrent laryngeal nerve injury in thyroid surgery: a review

Recurrent laryngeal nerve palsy (RLNP) is an important and potentially catastrophic complication of thyroid surgery. Permanent RLNP occurs in 0.3–3% of cases, with transient palsies in 5–8%. A literature review and analysis of recent data regarding RLNP in thyroid surgery was performed, with particular focus on the identification of high‐risk patients, the role of intraoperative identification and dissection of the nerve, and the role of intraoperative neuromonitoring (IONM) and optimal perioperative nerve assessment. In conjunction with the review, data from the Monash University/Alfred Hospital Endocrine Surgery Unit between January 2007 and October 2011 were retrospectively analysed, including 3736 consecutive nerves at risk (NAR). The current literature and our data confirm that patients undergoing re‐operative thyroid surgery and thyroid surgery for malignancies are at increased risk of RLNP. Intraoperative visualization and capsular dissection of the RLN remain the gold standard for intraoperative care during thyroid surgery for reducing RLNP risk. IONM should not be used as the sole mechanism for identifying and preserving the nerve, although it can be used to aid in the identification and dissection of the nerve, and may aid in nerve protection in high‐risk cases including cancer surgery and re‐operative surgery.     

甲状腺术前选择性喉镜检查替代常规喉镜检查可行性分析

目的 探讨甲状腺手术病人术前选择性喉镜检查替代常规喉镜检查的可行性。方法 回顾性分析2018年1—12月北京协和医院收治的行术前喉镜检查的1906例甲状腺手术病人的临床资料,分析术前声带麻痹的影响因素。结果 仅18例（0.9%）病人发现术前声带麻痹。多因素分析表明,术前声音嘶哑（OR=19.094,95%CI 6.270~58.146,P<0.001）、结节位于后被膜（OR=27.976,95%CI 2.995~261.368,P=0.003）、既往有颈部手术史（OR=12.032,95%CI 2.058~261.368,P=0.006）为甲状腺术前声带麻痹的独立危险因素。术前有619例（32.5%）病人至少具备1个独立危险因素,其术前声带麻痹的发生率为2.9%（18/619）。如以选择性喉镜替代常规喉镜,1287例（67.5%）病人不必行术前喉镜检查,同时未遗漏术前声带麻痹的病人。结论 甲状腺手术病人术前声带麻痹的发生率较低,可选择性针对有独立危险因素的病人行术前喉镜检查。     

Arteria lusoria identified on preoperative CT and nonrecurrent inferior laryngeal nerve during thyroidectomy: a retrospective study

BACKGROUND: To evaluate surgical identification of nonrecurrence of the inferior laryngeal nerve (NRILN) during thyroidectomy in patients with an aberrant subclavian artery (a. lusoria) as seen on CT. MATERIAL AND METHODS: The medical files of patients treated by thyroidectomy between January 1998-December 2000 (n = 583) were retrospectively reviewed for preoperative and postoperative mobility of the vocal cords and perioperative identification of NRILN. The available preoperative CT studies (n = 163) were reviewed for presence of a. lusoria. RESULTS: In five patients, the CT study revealed an a. lusoria (3.16%). In one of five of these patients, an NRILN was surgically detected; the overall detection rate of NRILN was 0.21%. In one of four patients with nonidentification of this nerve during surgery, immediate unilateral and permanent vocal cord paralysis were present after surgery. No permanent vocal cord paralysis occurred in any of the other patients. CONCLUSION: The identification of a. lusoria should alert the radiologist and surgeon that a NRILN is present, allowing an anticipating surgical technique, reducing the risk of neural injury.     

Unilateral vocal cord paralysis following endotracheal intubation

The present report describes a case of postoperative paralysis of the left recurrent laryngeal nerve in a patient undergoing surgery at a site far from the anatomic course of the nerve. Possible aetiological factors, symptoms, management and prophylaxis are discussed.     

甲状腺手术区解剖的外科应用

目的寻求甲状腺手术中对喉上神经和喉返神经提供定位和保护的应用解剖标志。方法解剖100具(200侧)颈部尸体标本,在甲状腺手术区对喉上神经和喉返神经及其分支进行定位观测。结果①喉上神经在咽上缩肌外面分为两支内支与喉上动脉伴行穿甲状舌骨膜入喉;外支伴随甲状腺上动脉后内方下行。②右喉返神经在甲状腺下动脉之前、之后、在动脉分支之间以及神经与血管相互夹持穿过者分别为48条(48%)、24条(24%)、14条(14%)、14条(14%),左喉返神经则分别为15条(15%)、57条(57%)、15条(15%)及13条(13%)。③117条(58.5%)喉返神经在甲状腺下极平面以上平均(9.9±7.3)mm,19条(9.5%)在甲状腺下极平面,64条(32%)在其平面以下平均(8.5±5.6)mm。④喉返神经前支入喉处距甲状软骨下角尖端平均(7.4±3.7)mm,其中72侧(36%)在其前平均(1.6±0.8)mm,58侧(29%)在其后平均(1.8±0.5)mm,70侧(35%)在其正下方入喉。后支入喉处距甲状软骨下角尖端平均(7.3±3.2)mm,16侧(8%)在其前平均(1.7±0.9)mm,134侧(67%)在其后平均(1.8±1.2)mm,50侧(25%)在其正下方入喉。结论在甲状腺手术中,结扎甲状腺上动脉要紧靠甲状腺侧叶上极;结扎甲状腺下动脉需仔细分离、单独结扎,以免损伤喉返神经或其分支而发生并发症。     

Critical course of the anterior laryngeal branch of the inferior laryngeal nerve

BACKGROUND: Although in the past few authors stated that the nerve penetrated the ligament of Berry, many new authors have not confirmed this assertion. Because of the clinical importance and indefiniteness of this subject, we aimed to present an anatomical study concerning the course of the inferior laryngeal nerve. METHOD: In 60 specimens, 102 sides were examined for this project, including 41 male and 19 female cadavers between the ages of 40 and 89 years at death. RESULTS: In two sides (one on the right and the other on the left), we found that the anterior (motor) laryngeal branch of the inferior laryngeal nerve penetrated the ligament unilaterally. The branch entered the ligament 5.6, 7.2 mm above its lower border and 3.3, 1.9 mm below its upper border. Distances from the entrance point of the branch to the trachea and thyroid were 9.5, 8.2 mm and 3.1, 2.2 mm, respectively. CONCLUSION: We found two anterior laryngeal branches penetrating the ligament of Berry. This subject is very important during the thyroid surgery, particularly during the division of the ligament for total lobectomy.     

巨大甲状腺肿瘤的外科治疗(83例效果分析)

目的总结H大甲状腺肿瘤外科治疗的疗效。方法回顾性分析83例巨大甲状腺肿瘤行外科治疗患者的临床资料,良性56例,恶性27例,肿瘤直径平均13（10～17）cm,行单纯手术切除82例,手术加辅助治疗1例。结果本组无手术死亡病例。83例均获随访,平均时间6年（6个月～10年）,56例良性肿瘤,无一例复发。27例恶性肿瘤中,1例术后15个月死亡,1例术后6年内死亡,3例8年内死于肿瘤复发或转移,其余均健在;5年生存率达96．3％（26／27）,10年生存率达81．3％（22／27）。结论外科手术切除治疗巨大甲状腺肿瘤是安全、有效的。     

Laryngeal examination in thyroid and parathyroid surgery: An American Head and Neck Society consensus statement

This American Head and Neck Society (AHNS) consensus statement discusses the techniques of laryngeal examination for patients undergoing thyroidectomy and parathyroidectomy. It is intended to help guide all clinicians who diagnose or manage adult patients with thyroid disease for whom surgery is indicated, contemplated, or has been performed. This consensus statement concludes that flexible transnasal laryngoscopy is the optimal laryngeal examination technique, with other techniques including laryngeal ultrasound and stroboscopy being useful in selected scenarios. © 2016 Wiley Periodicals, Inc. Head Neck 38: 811–819, 2016     

Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation

Extralaryngeal bifurcation and trifurcation of the recurrent laryngeal nerve (RLN) is not well described in anatomical texts. This significant anatomical variation is important because prevention of vocal cord paralysis requires preservation of all branches of the RLN. The aim of this study was to examine the prevalence of extralaryngeal bifurcation of the RLN seen during thyroid/parathyroid surgeries. All patients undergoing total thyroidectomy, hemithyroidectomy and parathyroidectomy (excluding all minimally invasive procedures) carried out by a single endocrine surgeon from November 2003 to December 2004 were included. Operative data obtained prospectively included the location of the nerve, number of branches and the distance in millimetres from the inferior border of the cricothyroid to the point of bifurcation. A total of 213 (right = 114, left = 99) RLN in 137 patients were studied. Seventy-seven (36%) nerves bifurcated or trifurcated before entry into the larynx. Bifurcations were more common on the right (43%) than on the left (28%) (P = 0.05). Trifurcations were seen in eight nerves, seven on the right and one on the left (P = 0.05). Bilaterally branched RLN were observed in 14 (18%) of 77 patients undergoing a bilateral procedure. One non-RLN was identified on the right. The median distance from the cricothyroid to the point of division was 18 mm on the right and 13 mm on the left. Extralaryngeal division of the RLN is a common anatomical variant occurring more frequently on the right. Unseen branches of the RLN are at risk of injury during surgery. Therefore, great care is required following presumed identification of the RLN to ensure that there are no other unidentified branches.