甲状腺乳头状癌累及喉返神经的处理方法

 目的探讨甲状腺乳头状癌累及喉返神经的处理方法。方法根据42例甲状腺乳头状癌侵犯喉返神经情况分为包绕、黏连、压迫3组,术中根据喉返神经与肿瘤的关系结合术前声带运动情况综合考虑是否保留喉返神经。包绕组无论声带活动情况如何,喉返神经均予切除。黏连组如伴完全声带麻痹,切除喉返神经;否则喉返神经予以保留。压迫组喉返神经均予保留。观察所有患者声带术后活动情况、评估疗效。结果42例患者中甲状腺全切除23例,次全切除术19例,随访1年术后均未复发。包绕组患者均行喉返神经切除,术后声带完全麻痹;粘连组中,3例声带完全麻痹者切除喉返神经、术后声带完全麻痹,9例术前不完全声带麻痹均予以保留喉返神经,2例术后出现声带完全麻痹,3例声带不完全麻痹,4例声带运动恢复正常;压迫组无声带完全麻痹,完整保留喉返神经,术后声带运动均恢复正常。结论对甲状腺乳头状癌侵犯喉返神经的处理,应结合术前声带运动情况及术中喉返神经与肿瘤关系采取不同的处理方法。     

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。     

肌电检查声带麻痹220例分析

本文分析220例声带麻痹的肌电检查结果:220例中,30例为联合性麻痹,占13.6％;187例为喉返神经麻痹,占85.0％;2例一侧喉返神经麻痹,另一侧联合性麻痹:剩下1例为喉上神经麻痹。14例双侧麻痹中(28侧中)有3侧属于完全麻痹(ⅡA型),占10.70％;205例单侧麻痹中,完全麻痹者22例,占10.70％。联合性或喉返神经完全麻痹,声带可分别居中间位,旁正中位或正中位;联合性部分麻痹声带可居正中位或旁正中位。提示:肌电检查对确定麻痹的程度,鉴别联合性与喉返神经麻痹和喉上神经麻痹是不可缺少的手段。特发性麻痹可能与病毒感染有关。     

痉挛性发音障碍与声带麻痹的关系

目的 探索痉挛性发音障碍与声带麻痹发病关系。方法 用肌电图仪测定喉内肌电位，用电视闪光放大喉镜录像观察声带运动状态，将声带麻痹程度分为轻、中、重三度。结果１９８３￣１９９４年１２月中遇到轻、中、重声带麻醉１３００例，在１３００例中伴有痉挛性发音障碍者５例；其中重度和中度声带麻痹者各１例，轻度者３例。结论 通过５例的观察，发现声带麻痹的进行或治愈过程中皆可出现痉挛性发音障碍，考虑此５例为喉周围神经器     

痉挛性发音障碍与声带麻痹的关系

目的探索痉挛性发音障碍（ｓｐａｓｍｏｄｉｃｄｙｓｐｈｏｎｉａ）与声带麻痹发病关系。方法用肌电图仪测定喉内肌电位，用电视闪光放大喉镜录像观察声带运动状态，将声带麻痹程度分为轻、中、重三度。结果１９８３～１９９４年１２年中遇到轻、中、重声带麻痹１３００例，在１３００例中伴有痉挛性发音障碍者５例；其中重度和中度声带麻痹者各１例，轻度者３例。结论通过５例的观察，发现声带麻痹的进行或治愈过程中皆可出现痉挛性发音障碍，考虑此５例为喉周围神经器质性病变所引起。     

颈神经袢移植用于单侧声带麻痹的功能性评价

治疗单侧声带麻痹的方法较多,但评价颈神经袢移植后喉功能结果的客观研究很少。本实验以6只狗为模型,切断一侧喉返神经并立即与颈神经袢的胸骨甲状腺支吻合,5～6个月后测量发声功效及声学参数,并作电视喉镜、电视喉动态镜、诱发肌电图及神经传导速度观测。另用8只狗作对照组,观察正常电刺激、声带发音和模拟单侧喉返神经麻痹时的各指标。两侧声带肌、喉返神经、颈神经袢、神经袢-喉返神经吻合部位均作组织学检查。实     

甲状腺手术后声嘶的临床分析

对甲状腺术后声嘶８６例临床资料进行分析。结果示８６例中声带麻痹３７例，其中喉返神经受损３１例，喉上神经受损４例，同侧喉上，喉返神经联合性损伤２例；声嘶原因不明４９便。认为，甲状腺手术时易损伤喉返、喉上神经而引起噪音改变，原因不明的声嘶也不能排除该神经的损伤，只是程度较轻未引起声带麻痹。喉神经的损伤与甲状腺肿物的大小无密切关系，但与甲状腺肿物的性质及手术的次数有关。术后３个月内积极治疗并辅以坚持发声     

突发声带麻痹为首发症状的甲状腺恶性肿瘤

目的：探讨以突发声带麻痹为首发症状的甲状腺恶性肿瘤的临床特点,分析诊断、治疗过程中的注意点,避免漏诊、误诊。方法：对我科1999年2月-2003年2月收洽的5例以突发声带麻痹为首发症状的甲状腺恶性肿瘤患者的临床资料进行回顾性分析。结果：5例病理检查均证实为甲状腺乳头状腺癌,4例侵犯一侧喉返神经致声带麻痹,术中分离喉返神经后行患侧腺叶切除,其中3例术后6个月内恢复正常的声带外展及内收功能,1例对侧声带代偿,声音嘶哑好转;1例肿瘤先侵犯右侧喉返神经致声带麻痹,1年后肿瘤侵入喉内引起双侧环杓关节固定,声音嘶哑加重,出现呼吸困难,先行患侧腺叶切除加半喉切除,术后3个月复发,又行全喉切除,随访2年无复发。结论：对于突发声带麻痹,同侧甲状腺占位,排除其他部位病变者,建议手术探查甲状腺,术中暴露喉返神经并加以保护,术中快速冷冻切片,根据病理检查结果决定手术范围。     

微创伤激光手术治疗双侧声带麻痹

双侧声带麻痹多由甲状腺手术损伤喉返神经所致，其发生率约为2％，由于麻痹声带固定于中位或务中位，患者常因呼吸困难需要手术治疗，而喉外手术团导致严重的发音困难或失音已被喉内手术所取代。该作者于1983～1994年间采用COZ激光喉内声带究切除术治疗双侧声带麻痹患者84例，年龄8～82岁，平均602岁，男女比例l：4。66例进行1期手术，其中左侧声带突切除37例，右侧声带突切除26例，双侧声带突切除3M。18例进行I期手术，其中行对侧声带突切除10例，构状软骨全切或次全切除8例。巨期手术患者H次手术的平均间隔时间为5个月者12例，平均间隔…     

支撑喉镜下CO2激光辅助一侧声带黏膜下切除术治疗双侧声带麻痹

双侧声带麻痹常见于甲状腺手术损伤双侧喉返神经和颈部外伤，声带固定于正中位或旁正中位，可引起呼吸困难．以吸气时为重．常需要手术改善呼吸。CO2激光应用于临床后．学者们已将其用于杓状软骨切除术或声带切除术，术中基本不出血，手术操作大大简化。支撑喉镜下CO2激光辅助一侧声带黏膜下切除术治疗双侧声带麻痹已取得了良好效果。     

Investigation of the mechanism of hoarseness after thyroidectomy

Electromyography of the intrinsic laryngeal muscles and laryngeal function measurements were performed on 34 patients with hoarseness after thyroidectomy. It is believed that mild laryngeal nerve paralysis might not give rise to disturbances in vocal cord movement. Causes of hoarseness after thyroidectomy could be mild recurrent superior laryngeal or combined nerve paralysis. During recovery, the vocal cord moved from paramedian position to middle position. Normal vocal cord movements did not mean complete recovery from paralysis, since electromyogram still showed abnormal potentials. It is suggested that vocal cord paralysis be divided into three types: severe, moderate and mild.     

Clinical analysis of hoarseness after thyroidectomy]

The present paper reports 86 cases of hoarseness after thyroidectomy. In 37 cases, glottic paralysis was confirmed. Among them the injury of recurrent laryngeal nerve were 89.91% (33/37). In 33(36 side) cases of recurrent laryngeal nerve paralysis, left injury was 20 and right was 16. Referring to the literature author consider that: 1. the recurrent laryngeal nerve was injured easy by thyroidectomy because that thyroid gland was located closely with recurrent laryngeal nerve in neck; 2. recurrent laryngeal nerve injury after thyroidectomy was related to the character of thyroid gland tumor and times of operations; 3. incidence of superior laryngeal nerve injure in thyroidectomy was rare; 4. following up 16 cases of glottic paralysis, most of all (13/16) hoarseness was improved with the health side vocal cords overcompensation.     

喉返神经减压术

目的探讨喉返神经减压治疗因甲状腺手术和甲状腺肿物压迫所致喉返神经功能障碍的疗效.方法2002年10月-2005年6月间,行喉返神经减压术治疗单侧喉返神经麻痹9例,声门闭合不全4例.包括甲状腺良性肿物切除术后喉返神经麻痹7例,均为普通外科术后.其中6例神经缝扎,1例神经瘢痕粘连,同时对其中2例行Ⅰ型甲状软骨成形术;甲状腺腺瘤1例和结节性甲状腺肿并喉返神经麻痹1例,均行甲状腺肿物切除喉返神经减压.声门闭合不全的4例中,结节性甲状腺肿3例、桥本甲状腺炎1例分别行甲状腺肿物切除或腺叶部分切除,电子喉镜观察手术前、后声带动度变化,评价手术效果.结果5例神经被结扎和1例神经粘连者于3个月内行减压术,术后1周～3个月声带动度恢复,发声满意;1例神经被结扎于术后4个月行减压术者,随访1年声带动度未见恢复.甲状腺腺瘤和结节性甲状腺肿并喉返神经麻痹患者减压术后3个月内声带动度完全恢复,声门闭合不全并结节性甲状腺肿和桥本甲状腺炎者,术后1周内声门缝隙消失、声嘶消失.结论对于因甲状腺手术所致的喉返神经麻痹,应尽快行喉返神经探查和减压术;声音嘶哑较严重者,可考虑同时行Ⅰ型甲状软骨成形术,以短时间内改善患者发声状况,提高患者生活质量;对于甲状腺肿物合并喉返神经麻痹或声门闭合不良者,应积极行手术探查,行喉返神经减压.     

以声嘶为首发症状的甲状腺良性肿物治疗经验

目的：探讨以声嘶为首发症状的甲状腺良性结节的手术疗效。方法：12例以声嘶为首发症状就诊的甲状腺良性结节患者,行同侧甲状腺次全切除加喉返神经解剖术,比较术前、术后患者纤维喉镜检查、嗓音分析结果,分析声带活动及声音质量,对术前、术后患者的基频微扰、振幅微扰及嗓音障碍严重程度指数进行统计分析。结果：12例患者术后声嘶明显好转,声带恢复活动。术后1个月患者基频微扰、振幅微扰及嗓音障碍严重程度指数与术前比较均差异有统计学意义（均P〈0.01）。结论：甲状腺良性结节可导致声带麻痹及声嘶,早期诊断及积极手术探查能有效改善患者的声音质量。     

喉返神经修复术及非喉返神经修复术治疗声带麻痹

目的 探讨喉返神经修复术及非喉返神经修复术这两种不同术式治疗声带麻痹的疗效。方法 ①单侧声带麻痹21例, 其中采用喉返神经修复术(喉返神经减压术、颈袢神经与喉返神经吻合术、颈袢神经肌肉蒂环杓侧肌移植术)15例, 采用非喉返神经修复术(声带自体脂肪注射术、自体软骨Ⅰ型甲状软骨成形术)6例;②双侧声带麻痹16例, 其中采用喉返神经修复术(喉返神经减压术、颈袢神经肌肉蒂环杓后肌移植术)6例, 采用非喉返神经修复术(声带外移术、内镜下杓状软骨切除术)10例。治疗前后以电子喉镜、频闪喉镜、声音评估等评价手术疗效。结果 ①单侧喉返神经麻痹患者中喉返神经修复组15例, 术后术侧声带活动不同程度改善, 发音时声带突明显内收, 声带振动及黏膜波均恢复对称性, 声门闭合良好, 手术前后的最大声时为(5.51±1.05)s和(12.10±1.41)s, 差异有统计学意义(P<0.01);非喉返神经修复术术后声带均不同程度内移, 声嘶症状改善, 但声带均无运动, 手术前后的最大声时为(5.47±0.45)s和(11.83±1.47)s, 差异有统计学意义(P<0.01)。神经修复组和非神经修复组术后最大声时比较, 差异无显著性意义(P>0.05);②双侧喉返神经麻痹患者中喉返神经修复术6例中, 术后呼吸困难缓解及声带外展部分恢复4例;非神经修复术10例术后呼吸困难改善;神经修复组术后拔管率为66.7%, 非神经修复组术后拔管率为100%;Fisher精确概率法比较两组术后拔管率, 差异无统计学意义(P>0.05)。结论 对于单侧声带麻痹, 喉返神经修复术及非喉返神经修复术疗效相当, 前者的远期疗效更佳。对于双侧声带麻痹, 非喉返神经修复术疗效更佳, 但喉返神经修复术不影响患者的发音功能。选择喉返神经修复术或非喉返神经修复术治疗声带麻痹, 需要医师根据自身的专业知识及技能、患者的身体状况及需求, 作出慎重的决定, 以取得可靠的疗效。     

Evaluation and treatment of vocal cord paralysis

One hundred eighty-one patients with unilateral or bilateral vocal cord paralysis unrelated to laryngeal carcinoma or its therapy were studied. The orderly diagnostic profile used to delineate cause of the paralysis includes CBC, VDRL blood sugar profile, latex fixation and serum sampling for toxic heavy metals. The radiologic and endoscopic evaluation is done to completion unless contraindicated, to assess aspiration as well as to observe laryngopharyngeal structures which may cause the paralysis. This evaluative profile defined the etiology of cord paralysis in 80 percent of patients, despite exclusion of viral disease as a cause subsequent to upper respiratory infection. Blunt trauma and previous neck surgery each were responsible for 23 percent of the cases. Fifty-four patients had bilateral paralysis of which 22 were post thyroidectomy. Surgical repair for cord paralysis was symptomatic, and included 28 successful teflon injected cords. Recurrent laryngeal nerve decompression was successful in four of five operations and arytenoidectomy was performed in 39 patients.     

Laryngeal reinnervation for unilateral traumatic recurrent laryngeal nerve injuries]

OBJECTIVE: To investigate 5 procedures of laryngeal reinnervation for unilateral vocal cord paralysis induced by traumatic recurrent laryngeal nerve injury. METHODS: 35 cases were selected for our study, all patients had unilateral recurrent laryngeal nerve injury, including 8 for nerve decompression, 6 for end to end anastomosis of recurrent laryngeal nerve, 16 for main branch of ansa cervicalis anastomosis to recurrent laryngeal nerve, 3 for nerve muscular pedicle and 2 for nerve implantation. All cases have been subjected to preoperative and postoperative voice recording, acoustic analysis, videolaryngoscopy, strobscopy and electromyography. RESULTS: It is found the adductory and abductory motion of the vocal cord restored in 5 cases with less than 4 months course who received nerve decompression. Although functional motion of vocal cord was not seen in two patients who received nerve decompression with a course longer than 4 months and one less than 4 months, and in all cases who received ansa cervicalis anastomosis and end to end anastomosis of recurrent laryngeal nerve, these procedures resulted in medialization of vocal cord and the mass and tension of the reinnervated vocal cord may become much the same as the contralateral normal vocal cord, thus resuming symmetric vibration of the vocal cords and physiological phonation. Nerve muscular pedicle technique and nerve implantation enabled adductory muscles to be reinnervated, thus improving severe hoarseness, but they didn't restore normal voice. CONCLUSIONS: (1) Nerve decompression seems to be the best procedure in laryngeal reinnervation; (2) Main branch of ansa cervicalis technique raises satisfactory reinnervation of adductor muscles; (3) Selection of the laryngeal reinnervation protocols should depend on the course, severity and type of nerve injury.     

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。