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.     

喉肌电活动实时监测喉返神经在再次甲状腺手术中的应用

目的探讨实时监测技术对预防喉返神经损伤的意义及应用价值。方法对55例再次甲状腺手术患者在全麻手术中使用喉返神经探测仪进行实时喉返神经监测（IONM）,术中分离显露喉返神经,并以神经刺激探针探测证实喉返神经在甲状腺后段行程及功能状态以保护其免受损伤,评估患者术后喉返神经损伤和声带功能恢复情况。结果共探测喉返神经107条,均成功显露。4例术前已证实有单侧声带麻痹的患者,术中探查该侧喉返神经证实3例被离断,另有1例被结扎,经松解后喉返神经肌电信号恢复,术后声带功能恢复。2例（3.64%）完整显露喉返神经的病例,手术结束前肌电信号消失,术后出现暂时性声带麻痹,均于2个月内恢复。结论使用喉返神经探测仪利于显露和保护喉返神经,有助于发现导致喉返神经损伤的原因并能较好地预测术后声带功能恢复的情况,减少医源性喉返神经损伤发生率,值得在再次甲状腺手术中推广。     

延期神经吻合术重建声带内收和外展功能的实验研究

为探讨延期喉内收及外展肌神经再支配术的时机，选用１５只杂种犬为研究对象，在喉返神经切断后４，６，８，１０及１２个月，分别行膈神经与右喉返神经吻合，并切断内收肌支后，选择性支配右环杓后肌，颈袢主支与喉返神经的内收肌支吻合选择性支配喉内收肌。采用喉镜、神经肌电检查、肌收缩力测定及组织化学检查发现，失神经１０个月内行神经再支配声带可恢复不同程度的内收和外展，同时间声带内收幅度较外展明显，失神经病程越短，内收和外展恢复越好，且在６个月以内行环杓后肌的神经再支配及８个月内行喉内收肌神经再支配效果较好。认为，延期喉内收及外展肌神经再支配术应在喉返神经损伤１０个月内进行     

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。     

术中神经监测技术在复杂甲状腺手术中的应用

目的 探讨应用术中神经监测技术（intra operative neuromonitoring,IONM）,以减少复杂甲状腺手术喉返神经损伤。方法 吉林大学中日联谊医院甲状腺外科2009年3~7月对132例复杂甲状腺手术病人,共186支高风险喉返神经行术中神经监测。在甲状腺切除前后分别探测迷走神经及喉返神经肌电信号。甲状腺手术前后常规检查声带活动度。结果 除术前声带麻痹4例,余182支喉返神经均可在甲状腺切除后测得明显肌电信号,未发生缝合切口前神经肌电信号消失,提示神经电传导功能良好。精确检出非返性喉返神经2例。结论 术中喉返神经监测使喉返神经显露更加便捷,更加确切,并可验证喉返神经功能完整性。在高风险、复杂甲状腺术中应用神经监测是降低喉返神经损伤率的一种重要辅助措施。     

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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,造成不同程度的声音嘶哑、误吸和呛咳等症状,影响病人的生活质量。传统的治疗方法如声带注射术、甲状软骨成形术和杓状软骨内收术等虽能改善发音,但这种声音缺乏音调、音量的调节功能,且远期疗效不满意。声带麻痹的最佳治疗方法是通过神经修复手术恢复麻痹喉的生理性功能。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、神经肌蒂埋植术或神经植入术、舌下神经转位术及喉神经修复联合声带内移术等。早期减压效果最佳,颈袢喉返神经吻合等神经修复术也能有效地恢复喉的发音功能。损伤病程长者宜采用神经修复联合声带内移手术。喉神经修复术式的选择应根据病程、神经损伤的部位、程度、类型而定。     

甲状腺良性病变手术喉返神经损伤的预防

目的探讨甲状腺良性病变手术致喉返神经损伤的预防措施。方法回顾分析1999年1月～20072月378例甲状腺良性病变手术临床资料。结果378例中出现喉返神经麻痹2例,占0.53%,经药物治疗均可恢复,无永久性喉返神经麻痹、失声、呼吸困难病例。结论甲状腺良性病变手术喉返神经损伤与手术方式、术中操作密切相关,只要遵循手术操作规程,采用囊内结扎法,提高手术技巧,是预防喉返神经损伤的有效措施。     

合并骨质疏松颈椎病后路减压术颈5神经损伤的MEP监测研究

目的 评估应用经颅电刺激运动诱发电位行术中脊髓监测在预测颈椎后路减压术后部分节段运动麻痹的价值。方法64例患者，男47例、女17例，平均年龄64岁，合并骨质疏松，在本中心行经颅电刺激运动诱发电位术中脊髓监测下颈椎后路减压术。经颅电刺激经针型电极进行传送，胸髓及双侧三角肌、肱二头肌、肱三头肌的诱发电位被完整记录。结果 术中诱发电位在57例患者的上述 所有肌群被成功记录，在其余的7例患者中诱发电位未被完整记录。在57例患者中无一例出现诱发电位波幅的明显降低。所有患者的临床症状在术后均有明显的改善；然而,有3例患者出现短暂的术后颈5神经。结论 在经颅电刺激运动诱发电位的监测中无异常出现，即使在合并有短暂的术后颈5神经麻痹的患者。这些结果提示颈椎后路减压手术后颈5神经麻痹与术中神经根或者脊髓的 损伤无明显的关联,虽然其确切的机制尚不清楚。术者应清楚颈椎后路减压手术后颈5神经麻痹是 一可能的并发症，即使术中无明显的神经损伤。     

延髓型重症肌无力喉肌电指标变化的临床价值

目的探讨延髓型重症肌无力患者电视胸腔镜下胸腺扩大切除术（video-assisted thoracoscopic extended thymectomy,VATET）后喉肌电指标测定的临床价值。方法回顾分析2002年6月～2011年7月我科36例延髓型重症肌无力（延髓型组）行VATET的临床资料,对术前后喉肌电指标进行分析,选取同期36例健康受试者作为对照组。结果延髓型组术前喉内肌肌电振幅（210．68±75．42）μV,较对照组（309．40±55．33）μV明显缩窄（t=6．332,P=0．000）;时程（7．68±0．57）ms较对照（5．42±0．34）mB明显延长（t=-20．431,P=0．000）;募集相最大电位（1132．18±467．19）μV较对照组（1675．00±532．85）μV明显缩窄（t=4．596,P=0．000）,术后2组比较仅时程有明显差异（t=6．375,P=0．000）。延髓型组喉内肌群术后肌电振幅（312．91±69．43）μV,较术前（210．68±75．42）μV明显变宽（t=-5．983,P=0．000）;术后时程（6．19±0．64）m8较术前（7．68±0．57）m8明显缩短（t=10．431,P=0．000）;术后募集相最大电位（1557．67±521．45）斗V较术前（1132．18±467．1）μV明显变宽（t=-3．646,P=0．000）;喉外肌仅肌电振幅差异显著[（139．36±74．26）μV vs．（102．75±63．22）μV,t=-2．252,P=0．027]。术后喉肌电图正常的患者疗效有效率89．3％（25／28）,喉肌电图异常的患者疗效有效率37．5％（3／8）,2组比较有统计学差异（χ2=6．891,P=0．009）。结论延髓型重症肌无力患者肌电指标异常,VATET可有效改善各项指标,缓解相关的临床症状。     

大鼠失神经支配骨骼肌萎缩的实验研究

目的　观察大鼠失神经支配骨骼肌组织学、电生理及酶组织化学改变 ,探讨反映肌肉萎缩程度的指标。方法　选用SD大鼠 ,建立失神经支配腓肠肌模型 ,观察术后肌细胞直径及截面积 ,运动终板超微结构、纤颤电位波幅、Na 、K ATP酶及Ca2 ATP酶活性变化。结果　肌细胞直径及截面积随失神经支配时间延长呈进行性下降 ;运动终板 4周内改变不明显 ,16周后消失 ;纤颤电位波幅在 8周内维持在高水平 ,12周后呈进行性下降 ;Na 、K ATP酶活性随失神经支配时间延长呈进行性下降 ;Ca2 ATP酶活性在 8周内维持在较高水平 ,12周后明显下降。结论　肌细胞直径及截面积可作为反映肌肉萎缩的可靠形态学指标 ,纤颤电位波幅可作为潜在电生理指标 ;Na 、K ATP酶活性是可靠酶组织化学指标。     

Utility of the continuous intraoperative neuromonitoring in the prevention of the recurrent laryngeal nerve paralysis during thyroid surgery. A prospective observational study

BackgroundThe continuous intraoperative neuromonitoring (C-IONM) of the recurrent laryngeal nerve (RLN) could help reducing the incidence of nerve paralysis after thyroid surgery, in comparison with the mere anatomical visualization of the RLN. The objective is to assess the efficacy and utility of C-IONM as a predictive test for recurrent laryngeal nerve paralysis after thyroidectomy.MethodsA prospective observational study was performed in 248 patients who underwent thyroid surgery where C-IONM was applied, between September 2018 and December 2019, in a high-volume center. A previous and later laryngoscopy was performed, which allowed to evaluate the reliability of the C-IONM as a predictive test for recurrent paralysis. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) were studied.ResultsA total number of 171 thyroidectomies, 62 hemithyroidectomies, 15 totalization thyroidectomies and 27 thyroidectomy with cervical dissections were performed. Postoperative laryngoscopy was altered in 40 patients (16.12%). The SE, SP, PPV and NPV values ​​were 65%, 94.7%, 70.2% and 93.4% respectively.ConclusionsC-IONM is a safe technique that provides real-time information about anatomical and functional integrity of the RLN and can improve the results of thyroid surgery.     

Contribución de la neuroestimulación a la seguridad en la extubación traqueal tras tiroidectomía total. Estudio prospectivo con electrodos de aguja

Introduction and objectivesBilateral laryngeal paralysis cause serious respiratory complications. In thyroid surgery, neuromonitoring helps in identifying the recurrent laryngeal nerve, reports on its functioning at the end of surgery, supports decision making, and may reduce the risk of bilateral paralysis. Our objective was to estimate the influence of neuromonitoring in operative strategy and extubation safety in total thyroidectomy.MethodsA non-randomized prospective study was conducted on 210 patients undergoing total thyroidectomy (420 laryngeal nerves stimulated included). We collected qualitative neuromonitoring variables (presence or absence of final signal after stimulation of the vagus nerve), and postoperative indirect laryngoscopy (normal motility or paralysis), performed until 3rd day after the surgery.ResultsThe accuracy of the test was 99.5% (95% CI 98.3 to 99.9). The positive predictive value was 100% (95% CI 99.1 to 100), which showed the high ability of neuromonitoring to predict paralysis in case of loss of signal, and the negative predictive value was 99.5% (95% CI 98.3 to 99.9), which indicated its predictive capacity for normal motility when there is a normal signal.ConclusionsIn our group of patients, recurrent laryngeal nerve monitoring was useful in total thyroidectomy as it provided information on the prognosis of laryngeal motility, and helped in making decisions during surgery when there was signal loss. Due to the risk of serious respiratory complications due to bilateral recurrent laryngeal nerve paralysis, we opted for the performing of the 2-stage total thyroidectomy in case of signal loss in the first lobectomy. Thereby, neuromonitoring contributed to the safety of the airway in tracheal extubation, aiding in the prevention of a possible bilateral laryngeal paralysis.     

显微外科修复尿道下裂术后尿道皮肤瘘

目的 探讨喉返神经修复手术治疗声带麻痹的效果及损伤的修复时机对预后的影响。方法 采用了不同术式及不同时机施行神经修复手术治疗声带麻痹１９例（单侧１４例，双侧５例０，其中即刻手术６例、延期手术１３例，喉返神经直接吻合５例、膈神经与喉返神经远侧断端吻凳时颈拦胸骨舌骨肌支与喉内收肌支吻合１例、颈袢主支与喉返神经内收肌支吻合８例、颈袢胸骨 肌蒂填植入左环杓后肌５例。结果 １９例均有不同神经再支配，且即刻手     

Bilateral recurrent laryngeal nerve paralysis in a child following a neurosurgical operation

We experienced a case of 7-year-old boy who developed bilateral recurrent laryngeal nerve paralysis following an elective neurosurgical operation under oxygen-nitrous oxide-isoflurane anesthesia. He underwent a removal of brain tumor in the supratentorial region on supine position. After the removal of the endotracheal tube in the intensive care unit, he developed marked respiratory effort and inspiratory stridor. A diagnosis of bilateral recurrent laryngeal nerve paralysis was made by a direct diagnostic laryngoscopy. The patient needed continuous care for his airway patency with tracheotomy tube in place, and his normal vocal cord mobility recovered on the 23 rd postoperative day. Common cause of recurrent nerve injury following general anesthesia is either the procedure of endotracheal intubation itself or trauma due to surgical manipulation. In the present case, an endotracheal tube, a transesophageal stethoscope and a nasogastric tube inserted into the narrow laryngeal space might have been a cause of this complication. Moreover, accidental extreme flexion of his neck which occurred during the surgery might also be an additional cause. This case suggests that recurrent laryngeal nerve paralysis due to anesthetic instruments around the larynx is a possible cause of complications during general anesthesia in pediatric patients.     

Swallowing disorders in unilateral recurrent laryngeal nerve paralysis

Swallowing difficulties in isolated recurrent laryngeal nerve paralysis are rarely reported in the literature, although it is frequently mentioned in lesions of both recurrent laryngeal and superior laryngeal nerves. The aim of this prospective study was to evaluate the incidence of aspiration in patients with unilateral recurrent laryngeal nerve paralysis after head and neck or thoracic surgery. Eighteen patients were included and evaluated within the first week and eleven two months postoperatively. Position, tone and tension of the vocal fold as well as assessment of the glottic axis, arytenoid position and mobility, laryngeal sensibility, status of the pyriform sinus and salivary stasis were studied. Swallowing evaluation was performed using flexible fiberoptic videolaryngoscopy during dry swallowing, thick cream and methylene blue liquid swallowing. Five patients had symptomatic aspiration, one silent aspiration and twelve patients had no aspiration. The type of regimen feeding used was classified as a normal, mixed, or blended diet. Added specific treatment performed was also described. We conclude that aspiration may occur in unilateral recurrent laryngeal nerve paralysis and have to be systematically evaluated after pneumomectomy, because adequate treatment can be proposed.     

Is dysphonia permanent or temporary after anterior cervical approach?

The rate, causes and prognosis of dysphonia after anterior cervical approach (ACA) were investigated in our clinical series. During a 10-year interval, 235 consecutive patients with cervical disc disease underwent surgical treatment using anterior approach. Retrospective chart reviews showed recurrent laryngeal nerve (RLN) injury in 3 (1.27%) patients. All three patients were men and only one patient had multilevel surgery. These patients had RLN injury after virgin surgery. Laryngoscopic examination demonstrated unilateral vocal cord paralysis in all patients who had postoperative dysphonia. No permanent dysphonia was observed in our series and patients recovered after a mean of 2 months (range 1–3 months) duration. Dysphonia after ACA was a rare complication in our clinical series. Pressure on RLN or retraction may result in temporary dysphonia.     

Recurrent laryngeal nerve paralysis: current knowledge and treatment

The aim of this report is to summarize current concepts in unilateral recurrent laryngeal nerve paralysis (URLNP). Important aspects of laryngeal phylogenesis, physiology and anatomy are reviewed. Recent advances in the neurophysiology of URNLP are discussed. Revised and updated principles of diagnosis and treatment are provided. Glottic configuration and prognosis vary according to the type of neural lesion (neurapraxia, axonotmesis or neurotmesis). Therapeutic indications depend on glottic configuration and prognosis. Treatment options include voice therapy, vocal fold augmentation by intrafold injection, medialization thyroplasty, arytenoid adduction, and laryngeal reinnervation. Each treatment option is summarized, and the results reported in the medical literature are reviewed.     

Recurrent laryngeal nerve palsy after anterior cervical spine surgery: the impact of endotracheal tube cuff deflation, reinflation, and pressure adjustment

BACKGROUND: Vocal fold immobility (paresis or paralysis) from recurrent laryngeal nerve injury remains an important cause of morbidity after anterior cervical spine surgery. A maneuver involving endotracheal tube (ETT) cuff manipulation has been proposed to reduce its incidence. This study is a randomized, prospective, double-blind investigation to test the hypothesis that ETT cuff manipulation reduces the incidence of postoperative vocal fold immobility after anterior cervical spine surgery. METHODS: One hundred patients scheduled to undergo anterior cervical spine surgery were randomly assigned to one of two groups. After inducing general endotracheal anesthesia, patients in the intervention group had their ETT cuff pressures maintained at 20 mmHg or less. After placement of self-retaining retractors, the ETT cuff was deflated for 5 s and then reinflated. Patients in the control group had no further manipulation of their ETT once the cuff was inflated after intubation. Cuff pressures in both groups were recorded before skin incision (baseline) and after placement of self-retaining retractors (peak). Patients' vocal fold motion was evaluated by indirect laryngoscopy performed preoperatively and postoperatively. The examination was videotaped and reviewed by a blinded otolaryngologist. Postoperative vocal fold motion was graded as normal, paretic, or paralyzed. RESULTS: Complete data were available in 94 patients. The incidence of vocal fold paralysis was 3.2% (95% confidence interval, 0.7-9.4%). Cuff manipulation decreased ETT cuff pressure but did not reduce the incidence of vocal fold immobility (15.4% vs. 14.5%). CONCLUSION: Endotracheal tube cuff deflation/reinflation and pressure adjustment do not reduce the incidence of vocal fold immobility in anterior cervical spine surgery.     

A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy

HYPOTHESIS: Recurrent laryngeal nerve paralysis after thyroidectomy can be unrecognized without routine laryngoscopy, and patients have a good potential for recovery during follow-up. DESIGN: A prospective evaluation of vocal cord function before and after thyroidectomy. Periodic vocal cord assessment was performed until recovery of cord function. Persistent cord palsy for longer than 12 months after the operation was regarded as permanent. SETTING: A university hospital with about 150 thyroid operations performed by 1 surgical team per year. PATIENTS: From January 1, 1995, to April 30, 1998, 500 consecutive patients (84 males and 416 females) with documented normal cord function at the ipsilateral side of the thyroidectomy were studied. MAIN OUTCOME MEASURES: Vocal cord paralysis after thyroidectomy. RESULTS: There were 213 unilateral and 287 bilateral procedures, with 787 nerves at risk of injury. Thirty-three patients (6.6%) developed postoperative unilateral cord paralysis, and 5 (1.0%) had recognizable nerve damage during the operations. Complete recovery of vocal cord function was documented in 26 (93%) of 28 patients. The incidence of temporary and permanent cord palsy was 5.2% and 1.4% (3.3% and 0.9% of nerves at risk), respectively. Among factors analyzed, surgery for malignant neoplasm and recurrent substernal goiter was associated with an increased risk of permanent nerve palsy. Primary operations for benign goiter were associated with a 5.3% and 0.3% incidence (3.4% and 0.2% of nerves at risk) of transient and permanent nerve palsy, respectively. CONCLUSIONS: Unrecognized recurrent laryngeal nerve palsy occurred after thyroidectomy. Thyroid surgery for malignant neoplasms and recurrent substernal goiter was associated with an increased risk of permanent recurrent nerve damage. Postoperative vocal cord dysfunction recovered in most patients without documented nerve damage.