颈部迷走神经副节瘤术中的神经保护和功能修复

目的:探讨颈部迷走神经副节瘤的临床解剖特点、术中保护神经或神经离断后修复的方法。方法:6例颈部迷走神经副节瘤患者,肿瘤均包裹迷走神经干并在手术解剖中离断。在迷走神经离断后行断端吻合术(3例)或颈深神经(2例)、舌下神经(1例)移植术。术后行糖皮质激素、营养神经药物治疗及发声、吞咽功能锻炼。结果:2例副节瘤术后复发患者,术前吞咽呛咳明显,术后吞咽呛咳消失;4例术后吞咽呛咳,6～12个月明显减轻。5例术后声嘶,6～12个月明显改善;1例术后12个月声嘶仍明显。术后3个月纤维喉镜检查,残端吻合术(3例)及舌下神经移植术患者(1例)术侧声带内侧约1/2于发声时有颤动;颈深神经移植者(2例)1例有颤动,1例动度不明显。结论:颈部迷走神经副节瘤术中仔细甄别迷走神经纤维并加以最大限度保护,可以明显减少术后声嘶或吞咽呛咳。迷走神经干离断后的神经断端吻合、颈深神经或舌下神经移植均可能改善声带动度,从而有助于改善声嘶。     

胸锁乳突肌的神经分布

鑑于头颈外科手术日益增多,术中常涉及胸琐乳突肌及进入该肌之副神经和颈丛神经,为此,作者解剖了50例100侧标本,所得结论如下:胸锁乳突肌之神经可来自颈丛,可来自副神经外支,也可来自以上二神经的吻合支,其中双测完全对称的仅10％。来自颈丛的占86％,其中44％来自C_2和C_2前支组成的第二颈袢,28％来自C_3前支,3％来自C_3和C_4的神经袢,2％来自C_1神经泮。副神经外交经颈内静脉前或后到达胸锁乳突肌前缘,可单独一支,也可分成二、三支或更多小支进入胸锁乳突肌。关于副神经外支与颈丛的吻合文:1883年Maubrae提出副神经外支与C_3或C_2的分支吻合形成一弓,由此发出神经纤维到胸锁乳突肌。根据该氏的理论,作者发现Maubrae弓有三种类型。第一类,占51％,又可分五型:Ⅰa型,副神经外支与颈丛的一支吻合,     

颈部Ⅱ～Ⅳ区副神经和耳大神经及颈横神经临床解剖学研究

目的 研究颈部Ⅱ～Ⅳ区副神经和颈丛耳大、颈横神经解剖标志,为颈部Ⅱ～Ⅳ区功能性颈淋巴结清扫术提供临床解剖资料.方法 在42例(56侧)Ⅱ～Ⅳ区颈淋巴结清扫术中,重点观测副神经、颈丛耳大神经和颈横神经的行程、分布以及与周围毗邻结构关系.结果 副神经进入胸锁乳突肌点距乳突尖的距离(4.93±0.75)cm:其穿出胸锁乳突肌后缘点均位于耳大神经出肌点上方,两者出肌点的距离(1.04±0.59)cm;副神经出肌点到锁骨中点距离(8.09±0.65)cm.颈丛耳大神经穿出胸锁乳突肌后缘后在下颌角水平分支,出肌点与分支点的距离(6.37±0.73)cm:耳大神经出肌点到锁骨中点距离(7.67±1.00)cm,耳大神经与前方颈外静脉在同一层面,大多数病例中两者几乎平行,两者距离(1.02±0.61)cm.颈横神经于耳大神经下方穿出胸锁乳突肌后缘后近水平在其浅面并于颈外静脉深面向前,其分支点变异较大,分支后呈扇形向前分布颈侧.颈部左右侧各测量数据差异无统计学意义.结论 深入了解副神经和颈丛耳大神经、颈横神经临床解剖资料,功能性颈清扫时保留其功能是可行的.     

跨面部面神经吻合术

当面神经干缺失而不能直接吻合或作神经移植时，可行跨面部面神经吻合术治疗。作者于1968年首次为15岁女孩岩骨肉瘤切除后以健侧面神经颊支近端与自体胖神经（长20cm）吻合，经颇区皮下隧道与患侧茎乳孔处的面神经平远端吻合，l年后EMG检查口轮匝肌、鼻肌及下唇方肌有动作电位。以后不断改进术式，亦认为面神经下支（颈面支）为最粗，故将胖神经（20cm）与健侧面神经颈面支近端吻合，经上述隧道与患侧面神经干吻合4例，3倒无轴京再生而失败，其中1例4年后行Ⅶ－Ⅷ吻合重建及另1例2年后将患侧丢下神经颈障支近端与患者面神经颈面支远端吻合…     

甲状腺手术喉返神经损伤的神经修复治疗

目的探讨甲状腺手术所致喉返神经损伤的神经修复治疗。方法选取2008年10月～2013年4月收治的甲状腺术后喉返神经损伤患者4l例,行喉返神经减压术23例,行喉返神经端端吻合术11例,行颈袢主支喉返神经吻合术7例。结果喉返神经减压组17例、喉返神经端端吻合组6例及颈袢主支喉返神经吻合组2例,于术后半年内麻痹声带恢复内收及外展运动;吸气时外展幅度基本对称;发音时声带内收于正中位,双侧声带长度及体积对称,声门闭合无裂隙。喉返神经减压组患者声带黏膜波及声带振动恢复了对称性。喉返神经端端吻合组及颈袢主支喉返神经吻合组患者声带黏膜波、声带振动基本对称。喉返神经减压组患者声音均恢复正常。喉返神经端端吻合组8例、颈袢主支喉返神经神经吻合组4患者声音恢复正常;喉返神经端端吻合组3例、颈袢主支喉返神经吻合组3患者声嘶明显改善。结论神经修复治疗甲状腺手术所致喉返神经损伤疗效确切,以神经减压术效果最佳。     

颞骨岩部胆脂瘤切除术及面神经保护和修复

目的分析总结颞骨岩部胆脂瘤的外科治疗、术中面神经功能的保护及修复方法及疗效。方法回顾性分析解放军总医院2000年1月至2012年12月79例手术治疗的颞骨岩部胆脂瘤病例,按House-Brackmann法对面神经功能进行分级,根据术中探查所见,依据面神经损伤的部位和范围分别采用面神经减压、吻合、耳大神经移植、面神经-舌下神经吻合术等方法进行修复;随诊1年以上,资料齐全的48例患者,根据手术前后面神经功能的分级进行比较,分析治疗效果。结果 79例岩部胆脂瘤患者经过手术切除病灶,术中发现面神经受累部位以迷路段最为多见。面神经损伤修复方法:面神经减压48例(60.76%);面神经端端吻合5例(6.33%);面神经改道吻合3例(3.80%);耳大神经移植修复面神经3例(3.80%);面神经舌下神经吻合10例(12.66%)。剩余10例术中面神经未处理。随访1年以上,资料完整的48例患者预后:面神经减压:29例,术前面神经功能Ⅰ级13例,Ⅱ级1例,Ⅲ级7例,Ⅳ级2例,Ⅴ级4例,Ⅵ级2例;术后Ⅰ级22例,Ⅱ级2例,Ⅲ级1例,Ⅳ级3例,Ⅴ级1例。端端吻合:4例;术前Ⅰ级1例,Ⅴ级3例;术后Ⅱ级1例,Ⅲ级3例。改道吻合:3例;术前Ⅴ级1例,Ⅵ级2例;术后:Ⅲ级2例,Ⅳ级1例。耳大神经移植:2例;术前均为Ⅴ级;术后:Ⅳ级1例,Ⅴ级1例。面神经舌下神经吻合术:7例;术前Ⅴ级4例,Ⅵ级3例;术后:Ⅲ级1例,Ⅳ级4例,Ⅴ级2例。3例术中未处理面神经病例,面神经功能无变化。结论颞骨岩部胆脂瘤术中需仔细保护面神经,发现面神经损伤后应及时修复,依据损伤程度和范围的不同,采取不同的修复方式可以使患者获得较好的预后效果。     

颈动脉体瘤的个体化序贯治疗应用评价

目的探讨颈动脉体瘤的个体化序贯治疗。方法回顾性分析1999年1月～2009年7月诊治的23例(29侧)颈动脉体瘤患者,其中单侧颈动脉体瘤17例,双侧6例;经确诊后采用术前Matas试验-BOT试验-手术的序贯治疗方式。手术方法包括瘤体剥脱、瘤体与颈外动脉同时切除、颈内动脉切除后颈外动脉与颈内动脉远心端吻合或颈内动脉自体血管重建及颈内动脉单纯结扎。结果患者术前Matas试验结果:能持续按压阻断30 min无特殊不适者1周内17侧、2周内26侧、4周内29侧。其中2例女性患者在通过Matas训练后,于术前行BOT试验检测时出现阳性反应。所有患者颈动脉体瘤11侧肿瘤切除后动脉完好,5侧肿瘤切除同时结扎颈外动脉,6侧肿瘤切除后行颈内动脉破损直接修补,2侧肿瘤行颈外动脉与颈内动脉对端吻合,3侧肿瘤取大隐静脉及1侧取颈外静脉行颈总,颈内动脉搭桥,1侧单纯结扎颈内动脉。术后患者出现局灶性脑梗塞1例,Horner综合征5例,迷走神经麻痹6例,舌下神经麻痹3例,面神经麻痹2例,副神经麻痹1例。采用静脉重建的颈内动脉术后3～6个月复查彩超均见重建血管通畅。结论术前Matas试验-BOT试验-手术的序贯治疗方式能有效促进大脑侧枝循环建立;该序贯治疗对术中颈动脉重建是否需要采用转流手术方式提供准确依据,术中颈动脉破裂后单纯颈动脉修补及颈外动脉与颈内动脉端端吻合均不需要行颈动脉转流;仅行大隐静脉搭桥重建颈内动脉时才需要转流手术。颈动脉体瘤的个体化序贯治疗不仅避免了不转流导致造成脑缺血而产生偏瘫、昏迷等严重并发症,而且减少了盲目使用转流管所带来的血管损伤、血栓形成等风险及相关材料的浪费。     

手术治疗面神经鞘瘤

目的：探讨诊断面神经鞘瘤的方法、手术治疗该病的效果及修复面神经功能的途径。方法：入住本院的面神经鞘瘤患者11例，在确诊前全部误诊为他病，确诊后，对6例中耳乳突腔面神经鞘瘤患者行神经移植，其中5例应用耳大神经移植，1例行干热骨骼肌桥接；对2例中耳乳突腔-颅内面神经鞘瘤的患者，1例行舌下神经移植（舌下神经攀植入舌下神经），1例直接将舌下神经襻植入面神经远端；其余患者面瘫时间较长，已不能恢复面神经功能，仅1例行阔筋膜口轮匝肌悬吊术，其他放弃面神经功能的重建。结果：3例未行面神经功能重建的患者，遗留完全面瘫；6例中耳乳突腔面神经鞘瘤的患者，面神经功能恢复分别为（Brakmann House功能分级）功能2级3例、3级2例、未恢复1例；2例舌下神经以及攀支重建面神经的患者，功能2级1例、3级1例。结论：面神经鞘瘤的临床症状多种多样，应进行系统检查排除误诊。术中为了完整切除肿瘤，可采用面神经改道吻合术、面神经移植等方法，在断端套用静脉血管给予保护，予以耳脑胶进行粘合。另外，干热骨骼肌的桥接在临床上应该推广使用。     

54例下颌下腺肿物切除手术的临床分析

目的探讨下颌下腺肿物切除的手术要点及临床疗效。方法对2011年1月～2014年1月本院收治的54例下颌下腺区肿物的患者行下颌下腺腺体及肿物切除术,对于病理回报为恶性肿瘤的患者同期行Ⅰ、Ⅱ、Ⅲ区淋巴结清扫术。术后随访12～24个月,观察治疗效果。结果54例患者均完整切除下颌下腺腺体及肿物,其中面神经下颌缘支暂时性损伤2例,感染1例,术后病理回报淋巴结转移2例,无舌下神经、舌神经损伤病例,无复发病例。结论下颌下腺区肿物切除术中,神经分支的保护,层次清楚的局部解剖和严密止血是保证手术成功的关键。     

颈段食管吻合口狭窄的手术治疗

目的探索颈段食管吻合口狭窄的手术方法及疗效。方法回顾9例颈段食管吻合口狭窄患者的治疗经过,其中,因腐蚀伤行结肠食管吻合者5例,因食管癌行胃食管吻合者3例,1例为颈部恶性淋巴瘤放射治疗后颈部食管狭窄,局部成形术后再狭窄。手术方法包括吻合口局部成形术6例,胸锁乳突肌骨膜瓣修复1例,结肠和空肠食管重建各1例。结果患者均一期愈合,吞咽功能完全恢复者7例,二次术后吞咽功能基本恢复者2例。随访1～3年吞咽功能恢复稳定。无新发喉返神经麻痹或胸腹腔并发症。结论颈段食管吻合口狭窄扩张治疗失败者宜行手术治疗。     

颈淋巴清扫术中副神经定位的临床研究

目的探讨副神经行程及与周围毗邻结构关系。方法选取2002年7月—2005年5月行颈淋巴清扫且进行术中副神经测量的病例136例(共163侧),根据术前有无颈部手术史分为2组。行颈淋巴清扫的同时测量记录副神经出肌点与耳大神经出肌点、锁骨中点、胸锁关节距离;副神经入斜方肌点与锁骨中点距离。结果副神经出肌点均于耳大神经出肌点上方穿出,无手术史组二者距离(x-±s,下同)为(0.61±0.35)cm,男女差异无统计学意义(P>0.05),与有手术史组(0.95±0.63)cm相比,则差异有统计学意义(P<0.05)。88.2%(112/127)均在耳大神经上方1.0 cm之内穿出,11.8%(15/127)在1.0~2.0 cm之间穿出。67.7%(86/127)副神经在入斜方肌前接受颈丛来的神经交通支。副神经出肌点到胸锁关节距离及锁骨中点距离男女性别上差异均有统计学意义(P<0.05),但与有无手术史无关。副神经入斜方肌点到锁骨中点距离为(4.96±0.78)cm,在有无手术史及男女性别上差异均无统计学意义(P>0.05)。结论无颈部手术史者以副神经出肌点-耳大神经距离及副神经入斜方肌点-锁骨中点距离均可准确定位寻找副神经。对有颈部手术史者及耳大神经损伤者可联合运用副神经出肌点到胸锁关节及锁骨中点距离或副神经入斜方肌点-锁骨中点距离定位寻找副神经。     

Treatment of a proximal accessory nerve injury with nerve transfer

OBJECTIVE AND HYPOTHESIS: This study presents a case report of a patient who sustained an iatrogenic proximal accessory nerve injury that was treated with a medial pectoral to accessory nerve transfer. STUDY DESIGN: Case study. MATERIALS AND METHODS: Chart of one patient who was treated with a medial pectoral to accessory nerve transfer was reviewed. RESULTS: Five months after excision of a branchial cyst that resulted in a very proximal injury to the accessory nerve, this patient underwent a medial pectoral to accessory nerve transfer. At final follow-up, 3 years after surgery, the patient had full abduction overhead with some residual shoulder/scapular discomfort and mild scapular winging. CONCLUSION: The medial pectoral to accessory nerve transfer provides a viable surgical option with good reinnervation of the trapezius muscle in patients with a proximal accessory nerve injury where standard nerve repair or graft techniques are not feasible.     

The surgical anatomy of the spinal accessory nerve and the internal branch of the superior laryngeal nerve

Injury to the spinal accessory nerve may occur during conservation neck dissection. In supraglottic laryngectomy preservation of the internal branch of the superior laryngeal nerve has largely been ignored. Cadaver dissection and diagrams are used to review the surgical anatomy of these two structures. Particularly important are the relationship of the spinal accessory nerve to the sternocleidomastoid muscle, its interaction with the cervical plexus, and its superficial path inferiorly. Landmarks for the identification of the internal branch of the superior laryngeal nerve are indicated, and technique for preservation is described. An intact accessory nerve can be efficiently preserved thereby eliminating the shoulder syndrome. Significant sparing of the internal branch of the superior laryngeal nerve can be routinely accomplished as an aid in minimizing postoperative aspiration.     

Facial nerve dysfunction after parotidectomy: the role of local factors

OBJECTIVES/HYPOTHESIS: The objective was to analyze the incidence and factors associated with facial nerve dysfunction after conservative parotidectomy with facial nerve dissection. STUDY DESIGN: A retrospective unicentric study in a tertiary care center with prospective record of studied factors. METHODS: Over a 10-year period, 131 patients with normal facial nerve function underwent a superficial or total conservative parotidectomy with nerve dissection performed by one surgeon for primary benign or malignant tumors. Facial nerve function was assessed on the first postoperative day and at 1 month and 6 months after the parotidectomy. Extent of surgery, histopathological findings, tumor size, close contact of tumor with facial nerve, and sex and age of the patient were reviewed. These variables were studied in a chi2 statistical univariate and stratified analysis to determine their association with postoperative facial nerve dysfunction. RESULTS: Incidence of postoperative facial nerve dysfunction was 42.7% on the first postoperative day, 30.7% at 1 month after the parotidectomy, and 0% at 6 months after the parotidectomy. The most common dysfunction was paresis in a single nerve branch (48.2%), in particular, the marginal mandibular branch. Total parotidectomy was associated with a significantly higher incidence of facial nerve dysfunction during the first postoperative period (60.5% at day 1 and 44.7% at month 1) than superficial parotidectomy (18.2% at day 1 and 10.9% at month 1) (P < .001). In patients with total parotidectomy, close contact of the tumor with the facial nerve was found to have statistical causal relation with facial nerve weakness. In patients with superficial parotidectomy, inflammatory conditions were found as factors that increased postoperative facial nerve dysfunction. CONCLUSION: In the study series of conservative parotidectomies with facial nerve dissection, only extent of surgery and particular local conditions of nerve dissection, especially the close contact of tumor with facial nerve and inflammatory conditions, were found to be associated with postoperative facial nerve dysfunction.     

Facial nerve in parotidectomy: a topographical analysis

OBJECTIVE: Establish normative data concerning parotidectomy and facial nerve dissection and determine the relationship between the length of the facial nerve dissected during parotidectomy and subsequent facial nerve paresis. STUDY DESIGN: Prospective mapping of facial nerve during parotidectomy and comparison with postoperative facial nerve function. METHODS: A prospective observational study of 78 patients who underwent 79 parotidectomy procedures. During each procedure, various topographical measurements were recorded. These measurements included the distance from the tragal pointer to the main trunk of the facial nerve, the distance to the pes anserinus, and length of each segmental branch dissected. In addition, a designation of the patient's tumor location was made by drawing a line from the ear canal to the nasal spine. Tumors above this line were designated anatomic zone A and those below the line were designated anatomic zone B. Finally, facial nerve function was quantified at a 1-week follow-up visit using the House-Brackmann Scale. RESULTS: The distance from the main trunk of the facial nerve to the tragal pointer was significantly (P < .000) less than the previously accepted standard of 1 cm. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected. Results of an independent t test and logistic regression (P = .01, both) indicated that patients with temporary facial nerve paresis had a significantly greater amount of nerve dissected than patients without temporary facial nerve paresis. Patients with short-term facial nerve dysfunction had significantly (P < .01) more total nerve dissected (136.73 mm vs. 94.73 mm) than patients without short-term facial nerve dysfunction. Patients with nerve dissection lengths at the third quartile (130.0 mm) were 3.8 times more likely to experience temporary facial nerve paresis than patients with nerve dissection lengths at the first quartile (64.5 mm). CONCLUSIONS: The axiom that the main trunk of the facial nerve is located 1 cm from the tragal pointer may need to be modified to less than 1 cm. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected. Facial nerve paresis after parotidectomy is associated with the length of the facial nerve dissected during the procedure. The greater the length of facial nerve dissected, the higher the chance of facial nerve paresis, albeit temporarily, in this particular series of patients.     

腮腺良性肿瘤切除术中腮腺导管和面神经颊支解剖关系的观察

目的观察研究腮腺导管与面神经颊支的解剖关系,为术中用腮腺导管作为面神经探查标记物提供解剖依据。方法在腮腺良性肿瘤切除术中观察和测量42例患者的腮腺导管和面神经颊支的解剖关系,包括深浅、成角和距离关系。结果在深浅关系上,颊支位于腮腺导管浅面占69.05%（29/42）,同层面占14.29%（6/42）,深面占16.67%（7/42）。从二者走形角度上,基本平行占76.19%（32/42）,明显成角的占23.81%（10/42）。以出腮腺处测量距离来看,上颊支位于腮腺导管上0.2~1.0 cm,平均（0.61±0.13）cm;下颊支位于导管下0.2~1.5 cm,平均（0.77±0.27）cm。结论腮腺导管与面神经上下颊支解剖关系相对恒定,可以用于腮腺肿瘤术中寻找解剖面神经的标志物。     

腮腺良性肿瘤手术中面神经颈支的解剖

目的探讨应用面神经颈支为向导显露面神经并完成腮腺良性肿瘤切除的可行性和安全性。方法收治腮腺良性肿瘤87例,分别应用以面神经总干、颊支、下颔缘支和颈支为向导的方法显露出面神经,完成腮腺肿瘤切除,并观察术后面神经的功能情况。结果应用面神经总干、颊支、下颔缘支和颈支显露面神经的病例分别为10、8、28、41例,术后出现的面神经损伤率依次为30％、37．5％、46,4％、24．3％,其中应用下颔缘支和颈支的方法术后面神经损伤几率的比较,P〈0.05,有显著差异性。结论应用面神经颈支为向导显露面神经总干及其他分支的方法,方便可行,优于通过下颔缘支的方法。     

How do the cervical plexus and the spinal accessory nerve contribute to the innervation of the trapezius muscle? As seen from within using Sihler's stain

OBJECTIVE: To determine how the spinal accessory nerve and the trapezius branches of the cervical plexus contribute to the innervation of each of the 3 parts of the trapezius muscle. Special emphasis was placed on the nerve supply of the clinically most important descending part of the muscle. DESIGN: Anatomical analysis of the distribution of the cervical plexus and spinal accessory nerve branches in the human trapezius muscle. MATERIALS: Twenty-two trapezius muscles from 11 perfusion-fixed human cadavers ranging in age from 66 to 92 years (mean, 81.7 years). INTERVENTIONS: The specimens were dissected free and macerated, decalcified, and stained according to Sihler's technique for about 6 weeks. The translucent, stained muscles were then backlit, and the findings were documented photographically and by schematic drawings. RESULTS: In all 22 muscles, the innervation of each of the 3 parts of the trapezius muscle was seen. In all muscles investigated, the nerve supply to the descending part of the muscle consisted of a single fine branch of the spinal accessory nerve, whereas the transverse and ascending parts were innervated by both the spinal accessory nerve and the trapezius branches of the cervical plexus. CONCLUSION: Our results, especially those involving the descending part of the trapezius muscle, may help to minimize the rate of unexpected trapezius muscle paresis after surgery of the neck.     

Schwannoma of the accessory phrenic nerve

Otolaryngologists are frequently confronted with the management of cervical tumors. Neurogenic tumors concern, especially, the cranial, sympathetic, or peripheral nerve sheathes. These tumors are benign and grow slowly. The involvement of the cervical part of the phrenic nerve is exceptional, and only 2 cases are reported in the literature. We describe the first case of a cervical schwannoma involving the accessory phrenic nerve. The anatomy and function of the accessory phrenic nerve are reviewed.