手术治疗单侧喉返神经麻痹的甲状腺肿瘤

目的分析术前单侧喉返神经麻痹的甲状腺肿瘤患者的临床、病理特点,探讨合理处理受侵喉返神经的方法。方法回顾分析2004年5月～2008年12月收治的2174例甲状腺肿瘤患者的临床资料,其中19例术前诊断单侧喉返神经麻痹,包括结节性甲状腺肿2例,甲状腺恶性肿瘤17例。13例行根治性切除手术,包括双侧甲状腺切除＋颈淋巴结清除术12例,双侧甲状腺切除＋全喉切除术1例,其中6例保留喉返神经,1例切除受侵段神经后予以吻合,另6例切除病变神经;4例行姑息性切除,患侧喉返神经均切除;2例结节性甲状腺肿患者行双侧甲状腺全切除术,喉返神经保护。结果19例患者均无围手术期死亡病例。淋巴结转移者10例。19例均获随访,时间平均64（37～91）月。2例结节性甲状腺肿和6例甲状腺癌术中保留喉返神经者,术后声音改善明显,另1例健侧代偿。6例切除神经者和4例姑息性手术切除喉返神经者术后声音无改善。结论术中探明喉返神经受肿瘤侵犯程度,尽可能保留神经,可以改善患者生活质量,取得较满意治疗效果。     

甲状腺手术致喉返神经损伤的修复

目的探讨甲状腺手术致喉返神经损伤的修复时机及预后,进一步提高修复效果。方法对１２例甲状腺手术致喉返神经损伤者采用了不同术式及不同时机神经修复或再支配术,其中即刻手术６例,延期手术６例;喉返神经直接吻合５例,膈神经与喉返神经远侧断端吻合选择性支配环杓后肌,同时颈袢分支胸骨舌骨肌支与喉内收肌支吻合选择性支配喉内收肌１例,颈袢主支与喉返神经内收肌支吻合３例,颈袢胸骨甲状肌蒂植入左环杓后肌３例。结果术后随访６个月以上。即刻手术较延期手术效果好,选择性神经修复术较喉返神经直接吻合好,且延期手术１２个月以上效果较差。结论甲状腺手术致喉返神经损伤应尽早修复,最晚不超过１年。     

甲状腺手术时喉返神经损伤的神经修复治疗

目的探讨甲状腺手术喉返神经损伤神经修复治疗。方法对病程 2年以内甲状腺手术喉返神经损伤声带麻痹 4 2例患者行单侧损伤神经减压 8例、颈袢喉返神经吻合 2 1例、喉返神经端端吻合 6例 ,双侧损伤膈神经移植联合术 7例 (一侧膈神经移植 ,另一侧行神经减压 2例、神经肌蒂植入术 5例 )。手术前后喉镜、嗓音声学参数、肌电图检查等评价手术效果。结果单侧损伤神经减压组病程 4个月内 5例恢复了正常的声带运动功能 ,4个月以内 1例、4个月以上 2例及颈袢吻合组、喉返神经端端吻合组则未恢复声带运动 ,但上述 3种术式均能使喉内收肌获有效的再神经支配 ,发音时声门闭合良好 ,嗓音恢复正常。双侧损伤膈神经移植术侧恢复明显吸气性声带外展功能 6例 ;其中2例对侧神经减压恢复了正常的声带运动功能 ,4例对侧肌蒂埋植术仅 2例轻微外展 ,获肌电图检查的证实 ,这些患者均顺利拔管。 1例双侧均无外展。结论甲状腺手术喉返神经损伤以神经减压效果最佳 ;颈袢吻合也能有效地恢复喉的发音功能 ;膈神经移植术治疗双侧损伤较肌蒂植入术效果更满意 ;喉神经修复术式选择应根据病程、神经损伤程度、类型而定。     

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。     

甲状腺手术中喉返神经损伤修复术要点与技巧

喉返神经损伤引起的声带麻痹是甲状腺手术常见的严重并发症之一,以单侧多见。单侧声带麻痹的主要症状为不同程度的声音嘶哑、误吸和呛咳等,严重影响病人的生活质量。目前单侧声带麻痹最理想的治疗方式为喉返神经修复手术,方法包括喉返神经探查减压术、喉返神经端端吻合术、颈袢喉返神经吻合术、游离神经移植术、神经肌蒂埋植或神经植入术等。其中,以颈袢-喉返神经吻合术效果最佳。若能把握好手术适应证且遵循一些手术技巧,术后可使98%以上的病人恢复正常或接近正常的嗓音功能。     

甲状腺手术喉返神经损伤原因分析

目的 探讨甲状腺手术暂时性喉返神经麻痹发生的原因及预防措施。方法 回顾性分析１５年间甲状腺手术后出现暂时性喉返神经麻痹１８例的临床资料。结果 所有病例术后均有声嘶,并经间接喉镜检查证实有单侧声带运动障碍,其中明确损伤原因的１５例：钳夹４例,缝结扎５例,牵拉２例,电灼１例,术中显露喉返神经术后出现喉返神经麻痹的３例;另有３例全麻病人损伤原因不明。结论 暂时性喉返神经损伤应引起临床上足够重视,损伤后至     

甲状腺手术单侧喉返神经损伤类型和临床表现分析

目的探讨甲状腺手术患者喉返神经不同损伤类型的临床表现。方法回顾性收集2015年1月~2018年6月于首都医科大学附属北京友谊医院普外科行甲状腺手术患者1687例,术中IONM证实单侧喉返神经损伤且随访86例,男性18例,女性68例,年龄14~78岁,平均年龄(48.66±13.01)岁;甲状腺癌68例,结节性甲状腺肿16例,桥本氏甲状腺炎2例。行双侧甲状腺全切术45例,甲状腺腺叶切除术41例。分析术后声音嘶哑、饮水呛咳恢复情况。结果86例患者中横断损伤占26.7%(23/86),非横断损伤占73.3%(63/86)。64%(55/86)的患者术后出现不同程度的声音嘶哑和(/或)饮水呛咳的症状,其中横断伤患者15例(65.2%),非横断伤患者40例(63.5%),两者比较差异无统计学意义(P>0.05)。结论单侧喉返神经损伤后,横断损伤与非横断损伤主要临床表现均可为声音嘶哑、饮水呛咳,也可无明显临床表现。在未使用IONM技术的情况下喉返神经损伤率可能被低估。     

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。     

甲状腺切除术显露喉返神经预防神经损伤的体会

喉返神经损伤是甲状腺切除术常见而严重的并发症.我院2000年1月～2003年5月甲状腺切除术中显露喉返神经126例,重点探讨显露喉返神经的方法及价值.     

腔镜甲状腺手术中喉返神经损伤预防

目的探讨腔镜甲状腺切除术中预防喉返神经损伤的方法。方法对2002年3月至2006年10月暨南大学附属第一医院采用胸乳入路施行腔镜甲状腺腺叶切除术的492例临床资料,及术中采用躲避喉返神经或解剖喉返神经技术进行分析。结果2例出现暂时性喉返神经损伤,无永久性喉返神经损伤。结论熟悉与甲状腺手术相关的解剖知识,掌握腔镜下组织结构清楚暴露和避免神经热损伤的手术技巧是预防喉返神经损伤的关键。     

Laryngeal reinnervation by ansa cervicalis nerve implantation for unilateral vocal cord paralysis in humans

BACKGROUND: Ansa cervicalis (AC)-recurrent laryngeal nerve anastomosis (RLN) is usually not desirable for correction of paralytic dysphonia when it is difficult to find a viable distal stump of the recurrent laryngeal nerve. Nerve implantation of the thyroarytenoid muscle with the ansa cervicalis is a simple alternative method. STUDY DESIGN: Ten patients with unilateral vocal cord paralysis were prospectively designed to receive nerve implantation. A minimum period of 12 months after onset of paralysis was allowed to elapse to permit possible spontaneous reinnervation or compensation. Patients were followed long enough (at least 2 years) to determine if the procedure was successful. All patients were subjected to preoperative and postoperative voice recording, acoustic analysis, and videolaryngoscopy. Some of them underwent laryngeal electromyography. RESULTS: Ten patients underwent nerve implantation of the thyroarytenoid muscles by using the ansa cervicalis, and 8 of 10 (80%) had improved phonatory quality. Laryngeal electromyography showed that the procedure produced satisfactory reinnervation of the thyroarytenoid muscle. CONCLUSIONS: Nerve implantation of the thyroarytenoid muscle by the anso cervicalis is a simple and efficient alternative to nerve transfer if dense scarring at the cricothyroid articulation and lack of a viable distal stump of the recurrent laryngeal nerve preclude the procedure of nerve transfer. But careful selection of the appropriate candidate seems to be the earliest prerequisite for a successful procedure.     

Long-term result of vocal cord paralysis after anterior cervical disectomy

Purpose

Anterior cervical disectomy and fusion (ACDF) is a highly effective and safe method for spinal cord and cervical root decompression. However, vocal cord paralysis (VCP) remains an important cause of postoperative morbidity. The true incidence and recovery course of postoperative VCP is still uncertain. This study is a report on VCP after ACDF to evaluate the incidence, recovery course, and possible risk factors.

Methods

From 2004 to 2008, 1,895 consecutive patients underwent ACDF in our hospital and were followed up for at least 3 years. All surgeons were well trained and used a right-sided exposure. Prolonged VCP, where patients suffered from postoperative VCP lasting more than 3 months, was recorded and analyzed.

Results

In this retrospective study, 9 of the 1,895 patients (0.47 %) documented prolonged VCP lasting over 3 months. Six of the nine patients had total recovery within 9 months. Only three patients (0.16 %) still had symptoms even after 3 years postoperatively. All symptoms of VCP, except hoarseness, could be improved. After matching with 36 non-VCP patients, no differences with regard to longer operative or anesthesia time, shorter neck, obesity, and prevertebral edema. All cases of prolonged course of postoperative VCP occurred in patients who underwent exposure at the C67 level.

Conclusion

In our study, only 0.47 % documented prolonged postoperative VCP, while most patients recovered within 9 months. However, if symptoms last longer, there could be almost permanent VCP (0.16 %). In our study, choking and dysphagia subsided mostly within 6 months, but hoarseness remained. The exposure of the C67 level obviously was a risk factor for postoperative VCP.     

自体颈丛神经移植修复喉返神经缺损18例报告

目的 探讨采用自体颈丛神经移植一期或延迟一期修复喉返神经缺损的手术方法及其疗效.方法 18例声音嘶哑的甲状腺癌患者(包括6例肿瘤侵犯喉返神经患者,3例瘢痕包裹及线结缝扎喉返神经的患者及9例喉返神经离断患者)在行甲状腺癌根治性切除手术后,选用术中保留的颈丛神经深支或浅支移植修复喉返神经.治疗前后以喉镜、嗓音主观评估等评价手术效果.结果 全部患者均得到3个月至2年的随访(平均8个月),其中16例患者声带不同程度的恢复了外展运动,2例声带未恢复运动,声带外展运动恢复率为88.9%(16/18).结论 自体颈丛神经移植一期或延迟一期修复喉返神经缺损术式简便易行,能有效地恢复声带外展运动,成功率高.     

Vocal cord paralysis, synkinesis and vocal fold motion impairment

Felix Semon's 'laws' of vocal cord paralysis were conceived over a century ago, based on the simple concept that abductor function of the recurrent laryngeal nerve was more vulnerable than adductor function. It is now clear that the neuromuscular pathology of laryngeal innervation is much more complex. Whether the nerve has been cut, crushed, stretched, cauterized or otherwise injured, it is seldom completely transected. There might be no detectable vocal cord movement at laryngoscopy, yet, electromyography usually shows at least some activity because of incomplete denervation and/or developing synkinesis. Electrical silence hardly ever persists forever. Disordered vocal fold movement following nerve injury appears to depend on laryngeal synkinesis with disorganized neuromuscular function caused by misdirected regeneration and aberrant reinnervation, sometimes by adjacent nerves. The severity of the injury, abnormal random reinnervation, scar tissue formation and nerve growth-stimulating and inhibiting factors influence the final position of the vocal fold. For a better understanding of neurolaryngological disorders it is no longer sufficient to think merely in terms of 'vocal cord paralysis'.     

A functional evaluation of ansa cervicalis nerve transfer for unilateral vocal cord paralysis: future directions for laryngeal reinnervation

There are a variety of methods for treating unilateral vocal cord paralysis, but to date there are few objective studies that evaluate the functional results of nerve transfer from the ansa cervicalis. Six dogs underwent unilateral recurrent laryngeal nerve section with immediate reanastamosis to the sternothyroid branch of the ansa cervicalis. After 5 to 6 months, measurements of vocal efficiency and acoustic parameters, videolaryngoscopy, videostroboscopy, and evoked electromyography were performed. Identical measurements were made in eight control dogs during normal electrically induced phonation and a simulated unilateral recurrent laryngeal nerve paralysis. Histologic analysis of both vocalis muscles, recurrent laryngeal nerves, ansa cervicalis, and the ansa-recurrent laryngeal nerve anastamosis site was performed. Evidence of reinnervation was found in all of the animals that underwent nerve transfer. The vocal efficiency and acoustic quality after ansa cervicalis nerve transfer were dependent on the degree of electrical stimulation from the transferred nerve to the reinnervated cord during phonation. In the absence of electrical stimulation to the nerve transfer, physiologic vocal cord motion could not be elicited from the reinnervated cord.     

Autologous fat injection laryngoplasty for unilateral vocal fold paralysis

Background: Fat injection laryngoplasty has been used at the Sydney Voice Clinic for selected cases of unilateral vocal fold paralysis since 1989. Methods: Forty‐five consecutive cases deemed suitable for treatment by this technique are presented in this paper. Results: Mean follow up for this group of patients was 33 months. Over the period of follow up, 39 of the 45 patients achieved normal or near normal voice, with four patients requiring additional surgical intervention. Conclusion: Fat injection laryngoplasty is a quick, simple, inexpensive and reliable procedure, with few complications and good long‐term results in suitable selected cases of unilateral vocal fold paralysis.