颈深神经或副神经整复舌下神经临床效果初探

目的:探讨舌下神经离断后应用颈深神经或副神经显微吻合重建的临床效果。方法:回顾性分析2例因副神经节瘤手术的患者,术中舌下神经离断,及时解剖颈深神经1支或副神经胸锁乳突肌支,与舌下神经远心端作外膜吻合,术后应用激素及神经营养药物治疗,并辅以早期功能锻炼。结果:术后1～2个月,2例患者舌体功能获得部分恢复,但病变侧舌体仍有轻微萎缩,患者自觉舌体活动能力逐渐增强。结论:以颈深神经分支或副神经分支整复舌下神经,可以成为舌下神经损伤后功能整复的方法。     

喉返神经成形术的研究及进展

简述声带麻痹后喉返神经成形术的实验研究及进展概况。包括喉返神经断端吻合术,膈神经移植术,迷走神经与喉返神经吻合术及舌下神经袢喉返神经吻合术。一些研究者的实验结果有待进一步评价,距离临床应用还有不小差距。     

舌下神经-面神经侧端吻合术治疗小脑脑桥角肿瘤术后面瘫

摘要：目的探讨舌下神经-面神经侧端吻合术治疗小脑脑桥角肿瘤术后面瘫的效果。方法6例小脑脑桥角肿瘤切除术后面瘫患者均行舌下神经-面神经侧端吻合术。所有患者术后每3个月随访1次,评估House Brackmann(H B)分级和舌下神经功能。结果术后1年H B III级2例,H B Ⅳ级3例, H B V级1例。静态面部张力4例患者在吻合术后6个月改善明显,1例患者在吻合术后 9个月改善,1例患者在吻合术后1年改善。所有患者均未出现术侧舌肌瘫痪萎缩,发音和吞咽功能均正常。结论舌下神经-面神经侧端吻合术可改善小脑脑桥角肿瘤切除术后面瘫患者的面部张力和面肌功能,借助神经监护可尽量减小对舌肌功能的影响。     

喉神经修复治疗外伤性声带麻痹的远期疗效分析

目的探讨各种神经修复术式治疗外伤性喉返神经损伤的远期疗效。方法外伤性喉返神经损伤致声带麻痹患者153例,单侧138例、双侧15例,病程从损伤即刻至3年不等。行喉返神经减压术31例、颈袢喉返神经吻合术102例、喉返神经端端吻合术9例、膈神经移植及部分病例联合应用神经肌蒂植入术11例。手术前后以喉镜、嗓音评估及声学分析、肌电图检查等评价手术效果。结果①单侧声带麻痹患者:病程3个月内19例、3月以上1例经喉返神经减压术恢复了不同程度的声带内收及外展功能;3个月以内3例、3个月以上4例患者经喉返神经减压及喉返神经端端吻合后均未恢复声带运动;颈袢喉返神经吻合组78例发声时声带突有明显内收运动,24例无明显内收运动;但上述3种术式除喉返神经端端吻合1例、颈袢喉返神经吻合3例外,其余患者发声时声带均处于正中位,声门闭合良好,后联合裂隙不明显,97%(134/138)嗓音恢复正常。②双侧声带麻痹患者:行神经减压4例7侧,有4例5侧恢复运动,均拔除气管套管;行膈神经移植术的11例中,恢复明显吸气性声带外展功能6例6侧,幅度达2~8mm;轻度外展2例2侧,幅度1~2mm,但声门裂隙达6~12mm,此8例均顺利拔管,发声时声带均有一定幅度的内收。2例2侧膈神经移植术后声带仍固定,1例1侧吸气性声带内收,未能拔管。一侧膈神经移植而另一侧肌蒂埋植的4例中,肌蒂埋植侧仅1例声带轻微外展。总拔管率80%(12/15)。膈神经移植手术前后发声无明显变化,神经减压术后发声明显好转。③各种神经修复术的神经再支配得到神经肌电图检查的证实,随访一年以上各项指标无明显退步。结论①喉返神经减压术、颈袢喉返神经吻合术、膈神经移植术能很好地恢复喉的生理功能;②喉神经修复术式的选择应根据病程、神经损伤程度、类型及侧别而定。     

喉返神经在迷走神经颈段定位及临床应用的实验研究

目的 :探讨喉返神经在迷走神经颈段的位置及应用神经端侧吻合术修复喉返神经损伤的效果。方法 :SD大鼠 2 0只 ,采用剥离法 ( 10只 )及乙酰胆碱酯酶组织化学染色法 ( 10只 )确定喉返神经在迷走神经中的位置 ;将 60只SD大鼠分为 3组 :实验组 :切断右侧喉返神经 ,将其远断段与迷走神经颈段喉返束端侧吻合 ;对照组 :切断右侧喉返神经后立即行神经端端吻合。正常组不做处理。术后 1、3个月利用纤维喉镜及神经肌电图观察声带活动及神经再生情况。结果 :喉返束位于迷走神经前内侧 ,单独成束 ,直径为总干的 1/ 4。术后 1个月实验组与对照组纤维喉镜及神经肌电图检查结果差异有显著性意义 ( P <0 .0 5 )。术后 3个月两组检查结果差异无显著性意义 (P >0 .0 5 )。结论 :喉返神经在迷走神经中的准确定位 ,为手术操作提供了重要的解剖标志 ;神经端侧吻合术效果与神经端端吻合术相似 ,为喉返神经修复术提供了一种新的手术方法     

舌下神经喉移植的初步研究

当前对单侧声带麻痹的治疗主要采用声带内移术 ,但这一手术的局限性在于仅使声带固定正中位 ,而不能活动。最理想的治疗方法是通过神经再支配 ,恢复声带的正常生理功能。有人使用颈丛 -喉返神经吻合术 ,术后发音有明显改善 ,但声带的内收运动仍嫌不足。由于舌下神经与颈丛相比具有更多轴突 ,人类舌下神经大约有 92 0 0个轴突 ,在远侧端分成 5束 ,因此更有可能恢复杓状软骨的运动 ;此外舌下神经具有更为满意的生理活动性 ,这种活动性表现在吞咽与讲话时使声带内收 ,而在吸气时则使声门开放。这为舌下神经 -喉返神经吻合术提供了生理学基础。…     

迷走神经劈开术治疗大鼠声带麻痹的实验研究

目的:探讨劈开颈段迷走神经中喉返神经支修复大鼠声带麻痹的手术方法和手术效果。方法:首先运用剥离法及乙酰胆碱酯酶组织化学染色方法确定喉返神经支在颈部迷走神经中的位置,将60只SD大鼠被分为3组,实验组为迷走神经劈开术吻合组,切断右侧喉返神经,将其远断段与劈开的颈段迷走神经的喉返支吻合。对照组为喉返神经端端吻合组,切断右侧喉返神经后立即行神经吻合。正常组不做处理。术后3个月利用纤维喉镜及神经肌电图观察声带活动及神经再生情况。结果:喉返神经束位于颈段迷走神经前内侧,单独成束,直径为总干的1/4。术后3个月2种手术方法效果差异无统计学意义(P>0.05)。结论:对喉返神经在迷走神经中准确定位,为手术操作提供了重要的解剖标志。迷走神经劈开术为喉返神经修复术提供一种新的手术方法。     

内镜辅助经下颌下入路腮腺深叶多形性腺瘤切除术

摘要：目的探讨内镜辅助经下颌下入路切除腮腺深叶多形性腺瘤的可行性及疗效。方法采用内镜辅助经下颌下入路切除腮腺深叶多形性腺瘤7例,其中男2例,女5例,年龄36～65岁,平均年龄47岁。主要症状是吞咽异物感5例,咀嚼不适感2例;主要体征为发现患侧咽侧壁、软腭部膨隆6例,另1例无明显阳性体征。结果本组7例手术均在1.5～2.5 h内顺利完成,肿瘤获得完全切除,切口甲级愈合。且无腮腺区肿胀、声嘶、呛咳、呼吸及吞咽困难、伸舌偏斜发生,其中1例术后2 d出现患侧口角歪斜,约1个月后完全恢复。术后病理均为多形性腺瘤。随访时间6～38个月,平均为20个月。结论内镜辅助经下颌下入路可以完全、彻底切除腮腺深叶多形性腺瘤,既能保留面神经功能,又有助于同时保护颈部重要血管、神经,值得临床推广应用。     

听神经瘤手术同期实施面神经端端吻合

听神经瘤术中切断面神经常属不可避免,对于面神经复活来说,直接进行面神经端端吻合术其结果优于其他任何类型神经吻合术。自乳突部位将面神经改道,再行端端吻合术可于听神经瘤术中同期完成。作者自1977年10月至1990年10月为19例患者行听神经原发肿瘤切除,术中因肿瘤累及面神经而有意切断,少数则无意损伤致面神经离断,随即实施面神经端端吻合术。随访超过18个月,16例进行面神经功能检查,House分级达Ⅳ级以上。避免了进行二期较大范围的神经吻合术,且不致因Ⅶ、Ⅻ颅神经吻合而导致Ⅻ颅神经缺损。作者建议在切除听神经瘤对面神经切断的处理缺乏训练     

单侧喉返神经损伤神经修复术式探讨

目的　探讨 5种神经修复术治疗单侧喉返神经损伤声带麻痹的疗效。方法　 1993年 1月～ 2 0 0 1年 4月治疗外伤性单侧喉返神经损伤声带麻痹 38例 ,病程从损伤即刻至 2年不等。资料完整者 35例 ,其中行神经减压术 8例、颈襻主支喉返神经吻合术 16例、喉返神经端端吻合术 6例、颈襻神经肌蒂埋植术 3例、颈襻神经植入术 2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　病程 4个月内神经减压 5例恢复了正常的声带内收及外展功能 ,4个月以内 1例、以上2例及颈襻主支吻合组、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 ,满意地恢复声带的肌张力、肌体积、声带振动对称性及正常黏膜波 ,声门闭合良好 ,嗓音恢复正常。颈襻神经肌蒂埋植术及颈襻神经植入术均能改善声嘶 ,但无恢复正常病例。结论　①单侧喉返神经损伤神经修复治疗以神经减压效果最佳 ;②颈襻主支吻合术、喉返神经端端吻合术也能有效地恢复喉的发音功能 ;③喉神经修复术式选择应根据病程、神经损伤程度、类型而定     

Glomus vagale: Paraganglioma of the vagus nerve

Review of the experience of a single institution with a rare tumor may give inadequate and biased information. In an effort to better understand issues related to diagnosis and subsequent management of paraganglioma of the vagus nerve, review of the experience at two university medical centers was undertaken. A review of the records of all patients with a diagnosis of vagal paraganglioma at the University of Pittsburgh and the Eastern Virginia Medical School was undertaken. Presenting signs and symptoms, treatment, and subsequent outcome were assessed. Data on 19 patients with vagal paraganglioma were available. The most common initial finding was a neck mass. Forty-seven percent (9/19) had vocal cord paralysis at presentation. Angiography was beneficial in helping to make the diagnosis and in identifying synchronous tumors. History of familial paraganglioma was present in 47% (9/19). Multiple paragangliomas were diagnosed in 53% (10/19) cases in our study. Of the patients with familial vagal paraganglioma, 89% (8/9) had multiple paraganglioma. All patients treated with surgery had postoperative vocal cord paralysis. Elective management of patients with bilateral vagal paraganglioma is a special dilemma. Radiation therapy of selected “operable” patients may be indicated because of the potential for bilateral vocal cord paralysis in these patients and its attendant sequela.     

电子喉镜吞咽功能检查在声带麻痹定位诊断中的应用

目的 探讨电子喉镜吞咽功能检查在声带麻痹定位诊断中的应用价值。方法 以15例单侧声带麻痹患者为例,应用电子喉镜对此组患者进行吞咽功能检查,其中左侧声带麻痹10例,右侧声带麻痹5例,发病期5d～10个月。以迷走神经神经节为界,将病变部位分为迷走神经神经节或以上部位的高位病变、迷走神经神经节以下部位的低位病变,其中高位病变4例,低位病变4例,部位不明7例。结果 高位病变组的4例患者,吞咽糊状食物时全部有食物残留于病变侧梨状窝;低位病变组的4例患者,吞咽糊状食物时3例梨状窝无食物残留,仅1例患者同侧梨状窝有食物残留,但是该例患者在同时进行的食管镜检查中发现食管中段癌;7例损伤部位不明的患者中,2例同侧梨状窝有食物残留,5例梨状窝无食物残留。结论 电子喉镜下对单侧声带麻痹患者进行吞咽功能检查,根据病变侧梨状窝有无食物残留可以初步判定喉返神经损伤的部位是在迷走神经节以上或以下部位。     

Cricothyroid approximation for voice and swallowing rehabilitation of high vagal paralysis secondary to skull base neoplasms

This study documents the speech and swallowing outcomes of isolated ipsilateral cricothyroid approximation (aka tensioning thyroplasty; Type IV thyroplasty) for the treatment of high vagal paralysis (combined superior laryngeal nerve and recurrent laryngeal nerve paralysis). This is a pilot study of five cases with high vagal paralysis consequent to skull base neoplasms. Unilateral cricothyroid tensioning sutures were used. In all cases, vocal fold tensioning and vertical realignment of lax vocal folds were achieved. A partial, but acceptable medialization of vocal cord position was achieved. In all cases, aspiration was minimized and normal swallow function was restored by 6 weeks. The voice outcome was excellent in four cases and acceptable in one. Cricothyroid approximation restores vocal fold tension; in addition, it restores vertical vocal fold position and partially restores horizontal vocal fold position. Good voice and swallowing outcomes have been achieved. The procedure is quick, safe, and convenient when combined with a skull-base excision procedure. Further evaluation is merited.     

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。     

Artificial reflex arc: A potential solution for chronic aspiration. III: Stimulation of implanted cervical skin as a functional graft triggering glottic closure in the canine

Stroke often impairs the ability of the vocal cords to close during deglutition, resulting in aspiration. The current study is a further advance on the application of the concept of an artificial reflex arc during swallowing. The second and third cervical branches were bilaterally isolated in four dogs and baseline sensory nerve traffic was detected via tripolar perineural electrodes. Cervical skin pressure-induced suprathreshold signals were used to trigger vocal cord contraction via bipolar electrodes passed around the recurrent laryngeal nerves. Skin subtended by the cervical nerves was implanted over the lateral aspect of the pyriform sinuses for 1 week. After reexploration, glottic closure was verified on videotape as surges in sensory nerve traffic were induced by mechanical stimulation of the pharynx. The possibility of artifactual stimulation was ruled out by lack of electrode motion during pharyngeal stimulation, spontaneous firing in the sensory nerve during light anesthesia, and sensory frequency differing from ambient 60-Hz noise. This article introduces the concept of autogenous functional graft as a basis for afferent information in electronic systems for dynamic rehabilitation of swallowing disorders.     

Resection of cervical vagal schwannoma via a post-auricular approach

Cervical vagal schwannomas are extremely rare and gross total resection is the standard treatment modality. However, because the conventional cervical approach leaves an incision scar in a visible area, other approaches need to be developed for young women who want the postoperative scar to be invisible. A 28-year-old female underwent complete resection of a 4x4 cm tumor in her right upper neck via a post-auricular approach using an inverted V-shaped incision along the post-auricular sulcus and hairline. The tumor was a schwannoma originating from the right cervical vagus nerve. Postoperatively, right vocal cord paralysis developed despite careful dissection but completely recovered within 6 months after surgery. The patient was satisfied with an invisible external scar which was hidden by her auricle and hair. A cervical vagal schwannoma can be successfully removed by making an incision in a potentially invisible area.     

A rare case of bilateral vagus nerve schwanomatosis

Schwanomatosis is the third most common form of neurofibromatosis. Schwanomatosis affecting the vagus nerve is particularly rare. In this report, we describe an extremely rare case bilateral vagus nerve schwanomatosis in a 45-year-old male patient. The patient initially presented with bilateral neck tumors and hoarseness arising after thoracic surgery. We performed left neck surgery in order to diagnose and resect the remaining tumors followed by laryngeal framework surgery to improve vocal cord closure and symptoms of hoarseness. Voice recovery was successfully achieved after surgery. An appropriate diagnosis and surgical tumor resection followed by phonosurgery improved patient quality of life in this rare case.     

Rare case of the cervical vagal neurinoma

Neurinoma is the most common tumor of the neurogenic origin. Primary location in the neck with the vagal nerve as a source is very rare clinical situation (less than 100 cases published in the literature). The authors would like to present a case of 35 old men with vagal neurinoma. Main symptoms included painless neck tumor found on palpation. Differential diagnosis included the pedicled cyst and metastatic neck mass. The ultrasound picture was unclear. The intraoperative findings suggested the tumor arising from the vagal nerve. In first day after the surgery hoarseness appeared with paresis of the right vocal cord in the examination. The final histological evaluation revealed neurinoma.     

Endoscopic laryngeal patterns in vagus nerve stimulation therapy for drug-resistant epilepsy

In 30 % of patients with epilepsy seizure control cannot be achieved with medications. When medical therapy is not effective, and epilepsy surgery cannot be performed, vagus nerve stimulator (VNS) implantation is a therapeutic option. Laryngeal patterns in vagus nerve stimulation have not been extensively studied yet. The objective was to evaluate laryngeal patterns in a cohort of patients affected by drug-resistant epilepsy after implantation and activation of a vagus nerve stimulation therapy device. 14 consecutive patients underwent a systematic otolaryngologic examination between 6 months and 5 years after implantation and activation of a vagus nerve stimulation therapy device. All patients underwent fiberoptic endoscopic evaluation, which was recorded on a portable device allowing a convenient slow-motion analysis of laryngeal patterns. All recordings were blindly evaluated by two of the authors. We observed three different laryngeal patterns. Four patients showed left vocal cord palsy at the baseline and during vagus nerve stimulation; seven showed left vocal cord palsy at the baseline and left vocal cord adduction during vagus nerve stimulation; and three patients showed a symmetric pattern at the baseline and constant left vocal cord adduction during vagus nerve stimulation. These laryngeal findings are here described for the first time in the literature and can be only partially explained by existing knowledge of laryngeal muscles and vagus nerve physiology. This might represent a new starting point for studies concerning laryngeal physiology and phonation, while the vagus nerve stimulation therapy could act as a new and ethical experimental model for human laryngeal physiology.     

Long-term results with a simple surgical treatment of bilateral vocal cord paralysis

Since 1979, we have treated patients suffering from bilateral vocal cord paralysis with laterofixation of one vocal cord, a simple and comparatively atraumatic method. To evaluate the long-term results of this method of laterofixation, 11 consecutive patients were examined at least 5 years postoperatively regarding breathing capacity, voice function, and swallowing ability. Breathing capacity was assessed by determination of orolaryngeal (upper) airway resistance and spirometry. Voice function was judged by two listening panels. Swallowing ability was studied by barium contrast radiography. Postoperative improvement of breathing capacity was, in most cases, found to be long lasting. Furthermore, there was no deterioration of voice function, nor were there aspiration problems during the postoperative follow-up period. We suggest this method of laterofixation as the treatment of choice in patients suffering from breathing difficulties due to bilateral vocal cord paralysis.