Recurrent Nerve/Ansa Cervicalis Nerve Anastomosis: A Treatment Alternative in Unilateral Recurrent Nerve Paralysis

Sectioning of the right recurrent nerve was done in 5 mongrel dogs under general anaesthesia. The distal stump was anastomosed with the ansa cervicalis nerve branch to the sternothyroid muscle. Three to 5 months later the vocal cord movements during light and very light anaesthesia were videorecorded. Under light anaesthesia contraction and medial bulging of the reinnervated right vocal cord occurred in 4 of the dogs. Under very light anaesthesia there was also some adduction of the right vocal cord in these 4 dogs. The right recurrent nerve was then sectioned proximally to the anastomosis and stimulated electrically. In all 5 dogs we observed that electrical stimulation produced a strong adduction of the right vocal cord. Histochemistry of the right vocal and posterior cricoarytenoid muscles showed that reinnervation had taken place. The study indicates that in cases of unilateral vocal cord paralysis an anastomosis between the ansa cervicalis and the recurrent nerve will result in improved phonatory function of the affected vocal cord.     

Update: Laryngeal Reinnervation for Unilateral Vocal Cord Paralysis With the Ansa Cervicalis

Eight patients underwent ansa cervicalis anastomosis to the adductor branch of the recurrent laryngeal nerve for unilateral vocal cord paralysis. They were followed long enough (at least 1 year) to determine if the procedure was successful. All cases have been subjected to preoperative and postoperative voice recording, acoustic analysis, and videolaryngoscopy. Some of them have been subjected to stroboscopy and electromyography (EMG). Data from these cases indicate that satisfactory phonatory quality may be achieved after the procedure. The reinnervated vocal cord neither abducted nor adducted, but it presented itself in midline for precise apposition with the normal cord. Synchronous mucosal waves in both vocal cords could be observed. EMG showed that the procedure produced satisfactory reinnervation of the adductory muscles. Therefore, the authors believe that the procedure could be proposed as an alternative to Teflon injection or thyroplasty in selected cases.     

颈袢主支吻合术治疗单侧声带麻痹的临床观察

采用颈袢主支与喉返神经内收肌支吻合术治疗单侧声带麻痹７例。结果表明，声音恢复满意，术后声学三参数频率微扰、振幅微扰及标化嗓音能量均明显减小，平均值均在正常范围之内；喉镜检查发现术侧声带均有不同程度的内移，其中３例恢复至正中位；喉肌电图显示，发育及喉括约活动时术侧喉内收肌恢复与健侧基本同步的密集型强放电，证明术侧喉内收肌获得颈袢主支有效的神经再支配。提示该术是治疗单侧声带麻痹一种理想方法。     

选择性喉返神经吻合术治疗喉麻痹的实验研究

目的 研究不同神经源分别支配受损喉返神经内收及外展肌支的神经肌电表现。方法 将实验组犬左喉返神经完全切断，再将其外展肌支及内收肌支分别同期与同侧膈神经支及颈袢胸舌肌支吻合，吻合术后6个月分别用神经电图仪、光镜、电镜及直达喉镜等方法全面检测甲杓肌与环杓后肌神经肌电活动情况，所得数据用统计学方法进行分析。结果 吻合术后6个月，喉内收及外展肌均出现动作电位波，其甲杓肌潜伏期与术前比较无差异，甲杓肌神经传导速度已恢复正常，环杓后肌神经传导速度稍慢。结论 选择性喉返神经吻合术最大限度地从生理及解剖上避免了吻合术后喉内肌的联带运动问题，达到了预期目的。     

Ansa Cervicalis Nerve: Review of the Topographic Anatomy and Morphology

In recent years, there has been a proliferation of techniques utilizing the ansa cervicalis nerve to reinnervate the paralyzed larynx. The anatomic course and morphology of the ansa cervicalis are complicated by the variable course and location along the great vessels of the neck, as well as the significant differences observed in the arrangement of its contributing roots and regional branching patterns. Herein, we review the surgical anatomic course of ansa cervicalis and its innervation of the muscles of the neck, and develop specific recommendations with respect to the use of this nerve in laryngeal reinnervation.     

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。     

喉返神经麻痹的粘膜波动及杓状软骨活动调查

本实验应用德国产Ｗｏｌｆ－５０１２型喉动态镜、Ｗｏｌｆ－５３７０型彩色摄像机、日本产ＮＶ－６３３盒带式录像机、ＫＶ－１９ＦＸ．ＩＭＴ彩色监示器及丹麦产ＤＩＳＡ－１５００型肌电图仪，对４６例间接喉镜下单侧声带固定于某一位置的患者进行粘膜波动、杓状软骨活动及喉内肌电位检查。结果发现：４６例均为单侧喉返神经麻痹，其中完全麻痹１２例占２６．０９％，部分麻痹３４例占７３．９１％。１２例完全麻痹中粘膜波动消失者５例占４１．６７％；３４例部分麻痹中粘膜波动消失者３例占８．８２％。经统计学检验，两者差异有显著性（Ｐ＜０．０５）．因此．单侧喉返神经麻痹的粘膜波动消失与麻痹程度有一定关系，完全麻痹中粘膜波动消失者多，部分麻痹中粘顺波动消失者少，但完全麻痹中也有粘膜波动存在者。１２例喉返神经完全麻痹中构状软骨固定者２例占１６．６７％，３４例部分麻痹中构软骨固定６例占１７．６５％，经统计学检验，差异无显著性（Ｐ＞０．０５）。因此，单侧喉返神经完全麻痹和部分麻痹均可致杓状软骨固定。     

Functional Restoration for Recurrent Laryngeal Paralysis: An Experimental Study

The purpose of this investigation was to exclude abductor disturbance and to maintain phonation during recurrent laryngeal nerve paralysis through a new surgical design. This new method consists of implantation of the ansa hypoglossi and sternothyroid muscle pedicle which has been shown to provide sufficient abductor function in a recent publication, and the selective severance of the abductor branch after neurorrhaphy of the recurrent laryngeal which is shown to be a sufficient adductor function in another study. The recovery of sufficient abductor function during inspiration and dyspnea was 67% and 89% of adductor function with phonation. However, after cutting an adductor nerve branch of the recurrent laryngeal nerve in cases of insufficient abduction, the vocal cord on the operated-on side regained abduction during inspiration. The effect of the ansa hypoglossi and sternothyroid muscle pedicle is also discussed.     

咬肌神经-面神经吻合治疗面瘫的解剖学研究

目的通过对咬肌神经与面神经进行显微解剖学研究,为咬肌神经-面神经吻合治疗面瘫提供解剖学依据与安全有效的操作方法。方法对20例(左右两侧,共40侧)湿性头颅标本面神经和咬肌神经及周围毗邻结构进行详细的显微解剖学研究,总结咬肌神经的分段与定位标志并分别对咬肌神经与面神经各段的走行、分支、长度及横径进行观察与测量。结果咬肌神经恒定出现于颞下颌前三角(由颧弓下缘、下颌颈前缘、咬肌浅层后缘围成)内,且距离下颌骨髁突颈前缘8.52±1.35mm～9.00±1.58mm,距离颧弓外侧面深度为15.20±1.07mm～15.73±1.28mm;根据临床应用特点,咬肌神经可分为三段,分别为M1段(自卵圆孔至颧弓下缘)、M2段(自颧弓下缘至发出第一分支处)、M3段(自发出第一分支处至咬肌神经主干末端);咬肌神经M2段中点横径为1.12±0.18mm～1.18±0.18mm,面神经各分支中点横径在1.00±0.15 mm～1.39±0.23mm之间。结论咬肌神经M2段长度适宜且横径与面神经各分支横径相匹配,咬肌神经-面神经吻合术治疗面瘫具有解剖学上的可行性。同时咬肌神经解剖位置恒定,在颞下颌前三角内可安全有效地进行解剖,该三角是术中定位咬肌神经的可靠标志。     

甲状腺手术中的喉返神经显露

目的 探讨甲状腺手术中喉返神经显露对避免损伤喉返神经的作用。方法 回顾性分析150例甲状腺手术患者的临床资料，其中甲状腺瘤125例，术中均顺利显露同侧喉返神经；甲状腺癌25例，其中仅10例能显露喉返神经。结果 随访6个月～4年，甲状腺瘤术后声带麻痹(单侧)5例，其余120例术后声带运动良好，发声正常。甲状腺癌15例术后并发声带麻痹，10例声带运动正常。结论 甲状腺腺叶切除术中，常规显露喉返神经能减少喉返神经的损伤。对显露过长的喉返神经，术中应利用游离筋膜覆盖，以免术后瘢痕形成压迫喉返神经致声带麻痹。     

Intraoperative Electrophysiologic Monitoring of the Recurrent Laryngeal Nerve

Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve was performed with a commercially available device consisting of an endotracheal tube with integrated stainless-steel-wire surface EMG electrodes positioned at the level of the true vocal cords. Forty-two recurrent laryngeal nerves were successfully monitored with this system in 31 patients undergoing thyroidectomy or parathyroidectomy. In all cases, evoked EMG responses were elicited by direct electrical recurrent laryngeal nerve stimulation. Stimulus thresholds for evoked responses ranged from 0.2 to 0.6 mA (mean 0.3 mA) for the 37 nerves with preoperative ipsilateral normal vocal cord mobility. Mechanically evoked potentials with acoustic signals were also detected during the surgical procedures related to recurrent laryngeal nerve manipulation. It may be concluded that surface electrode monitoring of the recurrent laryngeal nerve with this system provides a simplified, noninvasive technique that is as sensitive as monitoring with intramuscular laryngeal electrodes.     

Hunt综合征合并喉返神经损伤1例报告

Ramsay Hunt综合征是水痘-带状疱疹病毒(Varicella-zoster virus,VZV)引起的以侵犯面神经为主的疾病,临床主要表现为耳部疱疹、疼痛和/或面瘫,还可以出现耳鸣、听力减退、眩晕、恶心、呕吐等症状.病毒可以侵犯Ⅴ～Ⅷ颅神经而引起多发性神经炎,因此少数患者可出现其它颅神经症状[1].现将一例合并声音嘶哑的Hunt综合征报告如下.     

Objective Measures of Laryngeal Function After Reinnervation of the Anterior and Posterior Recurrent Laryngeal Nerve Branches

Previous research indicates that separate reinnervation of the anterior and posterior branches of the recurrent laryngeal nerve (RLN) can provide purposeful motion of the larynx, even after transplantation. This canine study was undertaken to better determine the results of RLN reinnervation after nerve transection distal to its bifurcation. This approximates ideal conditions for transplantation, because potential rejection and nerve branch mismatch are eliminated. Eight months after nerve repair, video, electromyographic, mechanical, and histologic data were collected on four canines. Results show return of appropriate motion without synkinesis, including purposeful abduction on endotracheal tube occlusion. Abductory function was weaker on the reinnervated side, but adduction was equal or stronger on the reinnervated vocal cord. These results indicate that this method of RLN reinnervation produces consistent, strong physiologic motion in the denervated larynx.     

Autologous Transplantation of Fascia Into the Vocal Fold as a Treatment for Recurrent Nerve Paralysis

Objectives To apply the technique of autologous transplantation of fascia graft into the vocal fold for glottal insufficiency due to recurrent nerve paralysis and to evaluate the results in eight patients who underwent the procedure. Study Design Technical modifications were made in transplantation of the temporal fascia into the paralyzed vocal fold. Eight patients underwent the surgery, and their phonatory function was examined preoperatively and postoperatively. Methods The following surgical techniques were applied to prevent the falling‐off of the graft: 1) a roll‐shaped fascia graft was prepared before the transplantation and 2) a pocket was made within the lamina propria mucosa using a newly devised special elevator. The maximum phonation time and airflow rate during sustained phonation (in four cases) were measured, and perceptual evaluation of voice quality was made using the GRBAS scale by speech pathologists before and after the surgery. Results All the cases showed no evidence of falling‐off of the graft. Elongation of the maximum phonation time and improvement in voice quality were obtained in all cases postoperatively. Conclusion The method proved to be useful for the treatment of glottal insufficiency due to recurrent nerve paralysis.     

Asymmetry of the Laryngeal Reflex Responses to Superior Laryngeal Nerve Stimulation Unrelated to the Length of the Recurrent Nerves in the Porcine Model

Electrical stimulation of the superior laryngeal nerve (SLN) can elicit reflex responses in the cricothyroid (CT) and thyroarytenoid (TA) muscles. We made bilateral recordings of the responses evoked in these muscles in piglets by the stimulation of either the right or the left superior laryngeal nerve (SLN). The stimulus intensity was gradually increased to study the ?persistence? of the responses. We observed a direct, ipsilateral response in the CT muscle, and reflex, ipsilateral and crossed responses in both CT and TA muscles. The ipsilateral or contralateral responses obtained in TA muscles, following stimulation of the left SLN, were significantly delayed in comparison with those evoked by stimulation of the right SLN. This delay cannot be explained by the difference in length between the right and the left recurrent laryngeal nerves, but rather by an asymmetry in the sensory afferent pathway. The functional significance of this observation remains to be determined.