鼓室成形术病人面神经诱发肌电位反应与神经肌肉阻滞程度间的相关性

目的 探讨面神经诱发肌电位(EEMG)反应与神经肌肉阻滞(NMB)程度间的相关性.方法 拟行鼓室成形术病人40例,分为面神经暴露组(A组,n=16)和面神经非暴露组(B组,n=24),术中同步行面神经EEMG监测和外周NMB程度监测.不同NMB程度(0、25%、50%、75%、100%)时测定面神经EEMG刺激阈值和固定刺激强度下EEMG振幅.EEMG的刺激阈值和振幅与NMB程度间进行等级相关分析.结果 NMB≥75%时,4例病人未能诱发EEMG;A组和B组EEMG刺激阈值与NMB程度间的相关系数分别为0.38和0.26(P＜0.01),EEMG振幅与NMB程度间的相关系数分别为-0.66和-0.55(P＜0.01).在各个NMB水平,A组EEMG刺激阈值低于B组(P＜0.01);随着NMB程度的加深,EEMG刺激阈值逐渐增加,EEMG振幅逐渐降低(P＜0.05).结论 鼓室成形术病人面神经EEMG刺激阈值与NMB程度呈正相关,EEMG振幅与NMB程度呈负相关.     

Predictors and consequences of recurrent laryngeal nerve injury during open thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Project database analysis

BackgroundRecurrent laryngeal nerve (RLN) injury is a serious complication of thyroidectomy. The purpose of this study is to determine the predictors and consequences of RLN injury during thyroidectomy.MethodsA retrospective analysis was conducted using the ACS-NSQIP 2016–2017 main and thyroidectomy targeted procedure databases. Data was analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of RLN injury and morbidity/mortality.ResultsAge ≥65, black race, neoplastic indication, total or subtotal thyroidectomy, concurrent neck surgery, operation time > median, hypoalbuminemia, and anemia were associated with RLN injury. Use of intraoperative nerve monitoring was associated with decreased RLN injuries. RLN injury is a risk factor for overall morbidity, hypocalcemia, hematoma, pulmonary morbidity, readmission, reoperation, and length of stay > median.ConclusionSeveral predictors of RLN injury during thyroidectomy are identified, while use of intraoperative nerve monitoring was associated with a decreased risk of RLN injury. RLN injury is associated increased postoperative complications.     

Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy

BACKGROUND: Intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, or related central neck procedures can elucidate actual or potential mechanisms of recurrent laryngeal nerve (RLN) injury, especially visually intact nerves, which were previously unknown to the endocrine surgeon. STUDY DESIGN: In this prospective evaluation study, 373 patients underwent 380 consecutive thyroidectomy- or parathyroidectomy-related operations using intraoperative nerve monitoring, with 666 RLNs at risk. The success of visual and functional identification of the RLN, persistent loss of RLN function to nerve stimulation, the mechanism and location of RLN injury, and anatomy of the RLN or technical difficulties that appeared potentially risky for RLN injury were recorded. RESULTS: RLN was identified visually or functionally in 98.2% of nerves at risk. Initial intraoperative injury to the RLN occurred in 25 nerves at risk (3.75%). It was significantly more likely to be a visually intact RLN (n = 22; 3.3%) than a transected RLN (n = 3; 0.45%), p < 0.001. Paralysis persisted in 2 RLNs (0.3%). Visual misidentification accounted for only 1 RLN injury; the most common cause of injury resulted from traction to the anterior motor branch of a bifurcated RLN near the ligament of Berry (n = 7; 28%), then paratracheal lymph node dissection (n = 6; 24%), incorporating ligature (n = 4; 16%), and adherent cancer (n = 4; 16%). Fifty nerves at risk (7.5%) were identified as particularly at risk for injury, most notably those with anatomic variants (n = 26; 52%) and large or vascular thyroid lobes (n = 19; 38%). CONCLUSIONS: RLN injury during thyroidectomy or parathyroidectomy occurs intraoperatively significantly more often to a visually intact RLN than to a transected nerve. The anterior motor branch of an RLN bifurcating near the ligament of Berry is particularly at risk of traction injury.     

一种喉返神经入喉处的变异探讨

目的 分析报告一种喉返神经入喉处的变异.方法 1998年1月至2008年12月共有3078例患者行显露喉返神经的甲状腺手术,其中男性683例,女性2395例.为了避免误伤喉返神经,共显露了4241根甲状腺段的喉返神经.总结报告其中一种变异喉返神经的变异情况.结果 发现入喉处变异的喉返神经44根(1.0%,44/4241),其变异情况是喉返神经主干或其分支在远离环甲关节后方处人喉,入喉处距环甲关节后方的距离超过5 mm.根据术中发现可将上述入喉处变异的神经分为4种类型:Ⅰ型,变异的喉返神经无分支,主干直接走行至远离环甲关节后方的环甲肌下方入喉,该型共35根(79.6%,35/44);Ⅱ型,变异神经先发出2根分支,1根分支仍走行至环甲关节附近入喉,另1根分支走行至远离环甲关节后方的环甲肌下方入喉,该型有5根(11.4%,5/44);Ⅲ型,变异神经先发出2根分支,2根分支共同走行至远离环甲关节后方的环甲肌下方入喉,该型共3根(6.8%,3/44);Ⅳ型,变异神经先发出3根分支,其中最外侧1根分支走行至远离环甲关节后方的环甲肌下方入喉,该型共1根(2.2%,1/44).术中误伤变异神经4根(9.1%,4/44).结论 对外科医生来说,有必要了解尽可能多的喉返神经变异情况,以期尽可能地降低喉返神经误伤的发生率.     

喉返神经分段解剖在腔镜甲状腺切除中的应用

目的：探讨在经乳晕入路腔镜甲状腺切除术中,根据甲状腺切除方式的不同选择喉返神经分段解剖方法来降低喉返神经损伤的价值。方法在47例良性甲状腺疾病患者经乳晕入路腔镜手术中,根据甲状腺切除方式不同分段解剖喉返神经,观察患者术后发声、术中出血量、手术时间、术后手足口周麻木或手足抽搐、术后住院天数等指标。结果所有患者手术均获成功,手术平均时间105（85~195）min,平均出血量25（5~115）ml,平均住院时间4.5（3~7）d,术后均无声音低沉或嘶哑、无饮水呛咳、术后创面无大出血,术后第1天诉双手及口周轻微麻木1例,未经治疗第2天上述症状自行消失。随访3个月~1年均无不适。结论经乳晕腔镜甲状腺良性疾病切除术中,根据甲状腺切除方式不同选择喉返神经分段解剖的方法可降低喉返神经损伤的发生率。     

腔镜甲状腺切除术中喉返神经的显露

目的探讨腔镜甲状腺切除术中喉返神经的显露技巧,避免因显露而造成的喉返神经医源性损伤。方法2011年4月～2012年4月,行胸乳晕人路腔镜下甲状腺切除术17例。于乳腺前皮下置入troear,注入CO2（压力6mmHg）建立操作空间,用超声刀显露喉返神经。结果17例均顺利完成喉返神经显露,其中7例行腔镜双侧甲状腺腺叶手术（6例双侧叶结节和1例甲状腺癌）,5例行一侧甲状腺叶切除术（一侧腺叶多发结节）,5例行一侧腺叶次全切除术。喉返神经主干位于甲状腺下动脉之前、之后和动脉分叉之间的比例分别为17．6％（3／17）、47．1％（8／17）和35．3％（6／17）,术后未见声音嘶哑等发生。结论尽管甲状腺下动脉与喉返神经的关系不固定,应用甲状腺囊外解剖和上翻技术,在切除腺体的同时可以显露喉返神经,减少喉返神经损伤。     

Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model

Background

Advanced bipolar and ultrasonic energy have demonstrated reduction of operating time and blood loss in thyroidectomy. However, these devices generate heat and thermal dispersion that may damage adjacent structures such as the recurrent laryngeal nerve (RLN). This study was designed to evaluate the safety profile of the Harmonic Focus+^® (HF+) device through the evaluation of thermal injury to the RLN using different algorithms of distance and time with state of the art technology.

甲状腺手术中喉返神经损伤的预防及处理

目的:探讨避免喉返神经损伤及损伤后的处理办法。方法:回顾分析539例甲状腺手术,比较甲状腺全切除和次全切除术、暴露与非暴露神经的损伤率,探讨神经断离一期修复的疗效。结果:共发生喉返神经损伤19例,在甲状腺全切除术(单侧或双侧)中,暴露与非暴露神经的损伤率分别为3.5%和19.3%,有显著差异。甲状腺全切除时神经损伤率高于次全切除术。另外,损伤神经行一期修复者其声带恢复效果较为肯定。结论:对于甲状腺全切除手术,常规暴露喉返神经利大于弊,能及时发现神经断离并作一期修复,术后能尽早恢复功能。     

Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy

Background

The role of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery is still debatable. The aim of this meta-analysis was to evaluate the potential improvement of IONM versus RLN visualization alone (VA) in reducing the incidence of vocal cord palsy.

Methods

A literature search for studies comparing IONM versus VA during thyroidectomy was performed. Studies were reviewed for primary outcome measures: overall, transient, and permanent RLN palsy per nerve and per patients at risk; and for secondary outcome measures: operative time; overall, transient and permanent RLN palsy per nerve at low and high risk; and the results regarding assistance in RLN identification before visualization.

Results

Twenty studies comparing thyroidectomy with and without IONM were reviewed: three prospective, randomized trials, seven prospective trials, and ten retrospective, observational studies. Overall, 23,512 patients were included, with thyroidectomy performed using IONM compared with thyroidectomy by VA. The total number of nerves at risk was 35,513, with 24,038 nerves (67.7%) in the IONM group, compared with 11,475 nerves (32.3%) in the VA group. The rates of overall RLN palsy per nerve at risk were 3.47% in the IONM group and 3.67% in the VA group. The rates of transient RLN palsy per nerve at risk were 2.62% in the IONM group and 2.72% in the VA group. The rates of permanent RLN palsy per nerve at risk were 0.79% in the IONM group and 0.92% and in the VA group. None of these differences were statistically significant, and no other differences were found.

Conclusions

The current review with meta-analysis showed no statistically significant difference in the incidence of RLN palsy when using IONM versus VA during thyroidectomy. However, these results must be approached with caution, as they were mainly based on data coming from non–randomized observational studies. Further studies including high-quality multicenter, prospective, randomized trials based on strict criteria of standardization and subsequent clustered meta-analysis are required to verify the outcomes of interest.     

Course of the recurrent laryngeal nerve relative to the inferior thyroid artery and the suspensory ligament of Berry.

An awareness of the surgical anatomy and the possible dispositions of the recurrent laryngeal nerve (RLN) is very helpful in avoiding its injury during thyroidectomy. The relationship of the RLN to the inferior thyroid artery (ITA) and the suspensory ligament of Berry were studied in 172 patients undergoing thyroidectomy. One hundred and ninety one nerves were identified, 109 on the right and 82 on the left. Most nerves, both on the right (82.6%) as well as on the left (85.4%) ran either posterior or between the branches of the inferior thyroid artery. The majority of nerves were found within 3 mm from Berry's ligament. The relationship of the recurrent laryngeal nerve to the inferior artery and to the ligament of Berry does not follow a constant anatomical pattern. Nevertheless these structures have a quite close relationship to the nerve in the majority of cases.     

喉返神经隧道解剖法结合神经监测在腔镜甲状腺手术中的应用

目的:探讨喉返神经隧道解剖法结合神经监测在腔镜甲状腺手术中的应用价值。方法:回顾分析2014年11月至2018年12月施行的141例腔镜甲状腺手术,术中均采用喉返神经隧道解剖法结合神经监测技术。其中甲状腺良性结节93例,甲状腺恶性肿瘤48例;行单侧腺叶切除术52例,单侧甲状腺癌根治术44例,双侧甲状腺癌根治术4例,41例部分切除术。结果:140例手术顺利完成,1例因喉返神经横断伤转开放手术行神经对端吻合;术后9例(9/141,6.38%)暂时性神经麻痹,无永久性声音嘶哑患者。结论:腔镜甲状腺手术中采用喉返神经隧道解剖法结合神经监测技术可快速定位喉返神经,降低手术难度,提高手术安全性,利于腔镜甲状腺手术更好地在基层医院推广普及。     

NERVE STIMULATION IN THYROID SURGERY: IS IT REALLY USEFUL?

BACKGROUND: Monitoring of the recurrent laryngeal nerve (RLN) has been claimed in some studies to reduce rates of nerve injury during thyroid surgery compared with anatomical dissection and visual identification of the RLN alone, whereas other studies have found no benefit. Continuous monitoring with endotracheal electrodes is expensive whereas discontinuous monitoring by laryngeal palpation with nerve stimulation is a simple and inexpensive technique. This study aimed to assess the value of nerve stimulation with laryngeal palpation as a means of identifying and assessing the function of the RLN and external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery. METHODS: This was a prospective case series comprising 50 consecutive patients undergoing total thyroidectomy providing 100 RLN and 100 EBSLN for examination. All patients underwent preoperative and postoperative vocal cord and voice assessment by an independent ear, nose and throat surgeon, laryngeal examination at extubation and all were asked to complete a postoperative dysphagia score sheet. Dysphagia scores in the study group were compared with a control group (n = 20) undergoing total thyroidectomy without nerve stimulation. RESULTS: One hundred of 100 (100%) RLN were located without the use of the nerve stimulator. A negative twitch response occurred in seven (7%) RLN stimulated (two bilateral, three unilateral). Postoperative testing, however, only showed one true unilateral RLN palsy postoperatively (1%), which recovered in 7 weeks giving six false-positive and one true-positive results. Eighty-six of 100 (86%) EBSLN were located without the nerve stimulator. Thirteen of 100 (13%) EBSLN could not be identified and 1 of 100 (1%) was located with the use of the nerve stimulator. Fourteen per cent of EBSLN showed no cricothyroid twitch on EBSLN stimulation. Postoperative vocal function in these patients was normal. There were no instances of equipment malfunction. Dysphagia scores did not differ significantly between the study and control groups. CONCLUSION: Use of a nerve stimulator did not aid in anatomical dissection of the RLN and was useful in identifying only one EBSLN. Discontinuous nerve monitoring by stimulation during total thyroidectomy confers no obvious benefit for the experienced surgeon in nerve identification, functional testing or injury prevention.     

Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy

OBJECTIVE: To estimate the patterns of use of intraoperative recurrent laryngeal nerve (RLN)-monitoring devices during thyroid surgery by otolaryngologists in the United States. METHODS: A questionnaire was mailed to 1685 randomly selected otolaryngologists, representing approximately half of all otolaryngologists currently practicing in the United States. Topics covered included training history and current practice setting, use and characteristics of use of RLN monitoring during thyroid surgery, as well as history of RLN injury and/or subsequent lawsuits. chi(2) test was used to examine associations between monitor usage and dependent variables, and odds ratios calculated by logistic regression were used to refine the magnitude of these associations. RESULTS: A total of 685 (40.7%) of questionnaires were returned, and 81 percent (555) of respondents reported performing thyroidectomy. Of those, only 28.6 percent (159) reported using intraoperative monitoring for all cases. Respondents were 3.14 times more likely to currently use intraoperative monitoring if they used it during their training. Surgeons currently using intraoperative RLN monitoring during thyroidectomy were 41 percent less likely to report a history of permanent RLN injury. Further information about surgeon background and rationale for decisions regarding RLN monitor usage are discussed. CONCLUSIONS: Presently, the majority of otolaryngologists in the United States do not report regular usage of RLN monitoring in their practices. Surgeon background and training, more so than surgical volume, significantly influenced the use of intraoperative RLN monitoring.     

甲状腺手术中常规显露喉返神经的意义

目的 探讨甲状腺手术中常规显露喉返神经(RLN)对保护神经的作用.方法 回顾性分析2009年至2010年间连续实施的232例甲状腺切除手术患者的资料.手术均由同一组医师实施,方式为甲状腺腺叶切除或全切除术,术中常规显露喉返神经.结果 共行腺叶切除181例,甲状腺全切除51例.术中解剖喉返神经280根(98.9%).术后...     

甲状腺手术中常规显露喉返神经的意义

目的 探讨甲状腺手术中常规显露喉返神经(RLN)对保护神经的作用.方法 回顾性分析2009年至2010年间连续实施的232例甲状腺切除手术患者的资料.手术均由同一组医师实施,方式为甲状腺腺叶切除或全切除术,术中常规显露喉返神经.结果 共行腺叶切除181例,甲状腺全切除51例.术中解剖喉返神经280根(98.9%).术后10例患者(3.6%)出现声音嘶哑,其中7例术中证实了喉返神经的完整性,但声带检查出现患侧运动障碍,均在术后2个月内发音恢复正常.另外3例为术中离断性神经损伤并行即刻吻合者,在术后4个月内声音均恢复正常.结论 甲状腺手术中常规显露喉返神经是预防喉返神经永久性损伤的有效方法.     

完全乳晕入路腔镜甲状腺切除术

目的 探讨完全乳晕入路行腔镜甲状腺切除的可行性.方法 2005年4月至2008年9月,对28例美容要求较高的女性患者施行完全乳晕入路腔镜甲状腺切除手术,平均年龄22.5(18～38)岁,其中结节性甲状腺肿25例,原发甲状腺功能亢进2例,甲状腺微小乳头状癌1例.观察和取标本孔位于右侧乳晕内缘(10 mm),右侧乳晕外缘(5 mm)及左侧乳晕上缘(5 mm)为操作孔.观察总结28例患者的手术结果.结果 28例患者手术均成功,行甲状腺单叶腺体切除术5例、单叶次全切除术15例、双叶次全切除术3例、单叶近全切除+对侧叶次全切除术4例、单叶全切+中央区淋巴结清扫+对侧叶次全切除术l例.平均手术时间60.7 min(40～125 min),平均出血5.8 ml(2～15 ml),术后住院时间3.1 d(2～5 d).无甲状旁腺和喉返神经损伤等并发症出现.术后随访1～40个月无复发,全部患者均对切口美容效果表示满意.结论 完全乳晕入路腔镜甲状腺切除手术具有较佳美容效果,安全可行.     

腔镜甲状腺手术喉返神经的显露技巧

目的:探讨腔镜甲状腺手术中喉返神经的显露技巧。方法:回顾分析56例腔镜甲状腺近全/全切除术的临床资料,总结腔镜手术中喉返神经的显露入路及方法。结果:53例手术获得成功,3例因术中冰冻病理报告为甲状腺乳头状癌而中转开放行患侧颈部淋巴结改良清扫术。手术时间平均125.3 min,其中23例经腺体下极入路,20例经峡部向气管食管沟入路;13例经甲状软骨下角入路。术后住院期间及出院后3个月随访,患者均无声音嘶哑。结论:腔镜甲状腺手术中剖显喉返神经是安全、可行的,可避免喉返神经损伤。     

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。     

A Newly Identified Variation at the Entry of the Recurrent Laryngeal Nerve into the Larynx

ABSTRACT

Objectives: We aimed to highlight a new anatomical variation of the recurrent laryngeal nerve (RLN), and to emphasize its implications for thyroid surgery. Methods: A prospective study was carried out in a group of 3,078 consecutive thyroidectomies from 1998 to 2008. Total, near-total, subtotal, and partial thyroidectomy were performed for various thyroid diseases. The RLN was routinely identified and exposed in its entire course until the entry into the larynx. The postoperative complications of patients with different variations were compared. Results: 4,241 RLNs were successfully identified in all patients unilaterally or bilaterally. In addition to extralaryngeal branching and nonrecurrent laryngeal nerves, an unreported variation was identified in 44 RLNs (1.04%) at their entries into the larynx. The variation happened at the trunk or the branches of the RLN entering the larynx far from the posterior of cricothyroid joint, and the entry was higher than the superior cornu of the thyroid cartilage and the arch of the cricoid. The median distance from the entry to the posterior of cricothyroid joint was more than 5 mm. As the trunk or the branches had to travel along the lateral edge of the upper 1/3 of the thyroid before entering the larynx, the incidence of RLN palsy was higher than that in extralaryngeal branching variations (p < .05). Conclusion: This newly discovered variation of the RLN is more vulnerable to injury and should be brought to the attention of surgeons.     

Sensitivity and Specificity of Intraoperative Recurrent Laryngeal Nerve Stimulation Test for Predicting Vocal Cord Palsy after Thyroid Surgery

INTRODUCTION Recurrent laryngeal nerve (RLN) palsy after thyroidectomy, although infrequently encountered, can decrease quality of life. In addition to the hoarseness that occurs with unilateral RLN palsy, bilateral RLN palsy leads to dyspnea and often to life-threatening glottal obstruction. Therefore, intraoperative awareness of the nerve’s status is of great importance. This study examined the sensitivity and specificity of a palpation technique to detect contraction of the posterior cricoarytenoid muscle (PCA) through the posterior hypopharyngeal wall while the RLN was being stimulated with a disposable nerve stimulator during thyroid surgery (the laryngeal palpation test) to predict postoperative RLN deficits. Methods A total of 2197 RLNs in 1376 patients were identified to be at risk of injury during thyroidectomy performed between July 2003 and August 2004. Postoperative RLN integrity was assessed using direct laryngoscopy or laryngofiberoscopy to visualize vocal fold mobility. Results Altogether, 76 RLNs failed to elicit a PCA contraction in response to nerve stimulation, and 80 cases of temporary vocal cord palsy and 21 cases of permanent vocal cord palsy were recognized on postoperative evaluation. For postoperative vocal cord palsy, the sensitivity and specificity of the laryngeal palpation test were 69.3% and 99.7%, respectively, with a positive predictive value of 92.1% and negative predictive value of 98.5%. For permanent vocal cord palsy, the sensitivity and specificity were 85.7% and 97.3%, respectively, with a positive predictive value of 23.7% and negative predictive value of 99.8%. Conclusions The laryngeal palpation test is not a particularly useful method for predicting the level of RLN function after thyroidectomy. All patients must be examined postoperatively by direct laryngoscopy or laryngofiberoscopy to check vocal cord mobility. Even if there is no contraction of the PCA and we detect vocal cord palsy immediately after surgery, vocal cord palsy often recovers within 1 year when visual preservation of RLN is successful.