良性甲状腺疾病继发喉返神经麻痹

甲状腺疾病引起的喉返神经麻痹，多数为甲状腺肿恶变所致。该作者治疗3例继发于甲状腺良性肿块的喉返神经麻痹患者，其中男性2例，女性1例，年龄为67、69及73岁。均因声嘶就诊。检查均见甲状腺肿大伴声带固定。3例均行甲状腺次全切除，并于术中仔细辨认和保护喉返神经。术中发现3例甲状腺肿块均压迫甚至牵拉喉返神经。组织学检查3例均为给节性甲状腺肿块伴有出血，未见恶性证据。3例中有2例术后6个月、1例术后7个月声带运动恢复正常。认为良性甲状腺疾病所致的声带麻痹应尽早地施行甲状腺次全切除，解除神经受压，术后绝大多数均能在4～6个…     

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。     

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.     

甲状腺外科手术操作与手术并发症的相关性

目的 了解甲状腺外科手术操作与手术并发症的相关性,探讨辨认及保护喉返神经、喉上神经外支、甲状旁腺的甲状腺切除术在治疗甲状腺肿物中的作用,以提高甲状腺肿物的手术治愈率,并减少手术并发症。方法 回顾分析甲状腺良性肿瘤或甲状腺癌患者152例临床资料,甲状腺切除采用"精细化被膜解剖"技术,术中辨认及保护喉返神经、喉上神经外支、甲状旁腺。结果 152例患者中,行喉返神经探查262侧,均成功辨认及保护;行喉上神经外支探查231侧,174例成功辨认(75.3%)。原位解剖保护甲状旁腺150例,行甲状旁腺移植术2例。术后发生单侧暂时性喉返神经麻痹1例,在术后3个月内恢复;无喉上神经外支功能障碍。术后发生暂时性甲状旁腺功能低下症13例,术后1周恢复9例, 4周后恢复3例, 5个月后恢复1例。无发生永久性甲状旁腺功能低下症、永久性喉返神经损伤和永久性喉上神经外支损伤病例。结论 术中辨认及保护喉返神经、喉上神经外支、甲状旁腺技术行甲状腺肿物切除术是安全的甲状腺手术操作,有效避免了永久性甲状旁腺功能低下症、喉返神经和喉上神经外支损伤并发症的发生。最大限度地保存了喉功能和甲状旁腺功能,提高了甲状腺肿物的手术治愈率。     

甲状腺手术中喉返神经损伤的探讨

探讨甲状腺手术中喉返神经损伤的原因和预防措施。分析了３６８例甲状腺手术，暂时性喉返神经麻痹３例（０．８２％），未发生一例永久性喉返神经麻痹。术中喉返神经是否暴露，采用具体情况区别对待方法，对大多数甲状腺良性病变（８９．１％），尽可能术中不暴露喉返神经，但对于较大的结节性甲状腺肿、甲状腺腺瘤和再次手术病例，术中应暴露喉返神经；甲状腺癌术中常规暴露喉返神经。作者认为，只要掌握手术操作要领，熟悉喉返神经解剖和变异，喉返神经损伤，特别是永久性损伤是完全可以预防的     

甲状腺术后声带运动正常而发音障碍机理的探讨

甲状腺摘除术后发音障碍７０例中，５８例为声带麻痹；１２例声带运动正常，但有声音嘶哑。用肌电图检查了１２例声带运动正常的喉内肌电位，发现一侧或双侧喉上神经轻度或完全麻痹者４例；一侧或双侧喉上和喉返神经轻度或完全麻痹者５例；一侧或双侧喉返神经麻痹者３例。以上三种类型麻痹是声带运动正常但嘶哑的原因，尤其是喉上神经麻痹是甲状腺术后发音障碍不可忽视的原因。     

困难甲状腺手术中喉返神经解剖的研究

目的：探讨困难甲状腺手术中喉返神经解剖的方法,以最大限度减少损伤,提高手术的安全性。方法：回顾性分析52例巨大结节性甲状腺肿、胸骨后结节性甲状腺肿、位于甲状腺下极的结节性甲状腺肿、甲状腺癌以及甲状旁腺肿瘤等困难甲状腺手术中喉返神经的解剖过程和方法,了解病变累及喉返神经的状况以及避免喉返神经损伤的措施。结果：52例患者中,除2例甲状腺癌一侧喉返神经受侵予以切除外,其余50例喉返神经均解剖成功。50例喉返神经解剖成功者中,3例喉返神经拉长者术后无声嘶,2例喉返神经局部压为扁平者术后也无声嘶,3例术后轻微声嘶者经营养神经治疗1~3个月后恢复正常。1例喉不返神经,2例胸骨劈开,2例术后行气管切开。术后无并发症发生。结论：困难甲状腺手术中喉返神经的解剖大多需要游离腺叶和肿瘤并将其翻向内前上方,再以气管食管沟、甲状腺下动脉和（或）甲状软骨下角为标志进行解剖,实践证明该方法可行。     

甲状腺手术显露喉返神经保留甲状腺动脉

目的探讨显露喉返神经及保留甲状腺动脉手术方法对预防喉返神经损伤及甲状旁腺功能低下的临床价值。方法回顾分析247例甲状腺手术患者,55例行甲状腺全切及次全切除术,192例行甲状腺部分切除术。术中均保留甲状腺上、下动脉,常规显露喉返神经,术前及术后均行电子喉镜检查,血钙及甲状旁腺素检测。结果247例患者,术后均无声嘶症状出现,无术后出血并发症发生,均无手足抽搐及麻木症状出现,术后检测血钙及甲状旁腺素均在正常范围,术后电子喉镜显示无声带麻痹。随访4～36个月,所有患者均未发生永久性甲状旁腺功能低下及声带麻痹症状。结论术中显露喉返神经及保留甲状腺动脉可以避免喉返神经损伤,保全甲状旁腺功能,值得在甲状腺手术方法上推广。     

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。     

甲状腺手术中喉返神经损伤的探讨

探讨甲状腺手术中喉返神经损伤的原因和预防措施。分析了３６８例甲状腺手术,暂时性喉返神经麻痹３例,未发生一例永久性喉返神经麻痹。术中喉返神经是否暴露,采用具体情况区别对待方法,对大多数甲状腺良性病变,尽可能术中不暴露喉返神经,但对于较大的结节性甲状腺肿,甲状腺腺瘤和再次手术病例,术中应暴露喉返神经;甲状腺癌术中常规暴露喉返神经。     

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.     

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。     

甲状腺手术喉返神经损伤危险因素及应对策略

目的探讨甲状腺手术出现喉返神经损伤的危险因素及避免损伤的方法。方法回顾性分析1902例甲状腺患者,按手术科别、性别、麻醉方法、病变性质、术中是否常规解剖喉返神经、手术次数及手术范围分组,观察喉返神经损伤率,进行单因素分析及多因素回归分析。结果喉返神经总损伤率为1.84%。单因素分析显示,在甲状腺恶性病变患者、多次手术及甲状腺广泛性手术中喉返神经损伤率升高有统计学意义(χ2分别为1.096、1.893、1.467,P<0.05)。在甲状腺广泛性手术中,术中显露喉返神经可有效降低喉返神经损伤率(χ2=1.758,P<0.05);而在保守性手术中,术中是否显露喉返神经,喉返神经损伤率的差异无统计学意义(χ2=0.638,P>0.05)。Logistic回归分析显示,多次手术及甲状腺广泛性手术是喉返神经损伤的重要危险因素。结论对于病变范围较小的甲状腺良性肿瘤,术中不显露喉返神经、保留部分甲状腺背侧组织是安全可靠的。而对于广泛性甲状腺切除手术,术中应常规解剖喉返神经。     

Completion thyroidectomy: is timing important for transcervical and remote access approaches?

Completion thyroidectomy (CT) is employed after lobectomy when histopathological results mandates total removal of the gland as in case of well differentiated thyroid carcinoma (DTC). It is also employed as a second stage thyroid surgery when unfavorable events occur as in recurrent laryngeal nerve injury or when the surgeon finds out the case is beyond his/her expertise in an attempt to protect the contralateral side and allowing time for recovery or for an expert surgeon to help.     

The recurrent laryngeal nerve in relation to the inferior constrictor muscle of the pharynx

The point of penetration of the recurrent laryngeal nerve into the larynx is recognized as the most frequent site of injury to the nerve during surgical procedures of the thyroid gland. The anatomical relationships of 25 right and left recurrent laryngeal nerves in 25 anatomical blocks from formalin-fixed human corpses have been studied. In 34 cases (68%), the recurrent laryngeal nerve penetrated into the larynx below the lower fibers of the inferior constrictor muscle of the pharynx (type 1 of penetration). In the remaining 16 cases (32%), the nerve crossed through those muscle fibers to penetrate into the larynx (type 2 of penetration). The thyroid gland was found to involve the recurrent laryngeal nerve at the penetration point into the larynx in 19 of 50 cases (38%).     

甲状腺全切除术适应证及并发症探讨

目的 探讨甲状腺全切术手术适应证的选择和并发症防治.方法 回顾2007年4月至2010年6月51例甲状腺全切除术资料.乳头状腺癌48例,滤泡状腺癌1例,髓样癌2例;其中2例合并甲状腺功能亢进,3例合并远处转移.男17例,女34例;年龄5～82岁,中位数50岁;45例为首次手术,6例因复发或转移二次手术.初次手术的45例中T1 17例,T2 13例,T3 7例,T4 8例;NO 31例,N1a 11例,N1b 3例;M1 2例.手术常规解剖甲状旁腺、喉返神经及喉上神经外支,清扫Ⅵ区淋巴组织,其中25例清除Ⅱ～Ⅳ区淋巴组织.8例术后给[3]Ⅰ治疗.结果 随访1～36个月,无死亡病例,2年生存率100.0%(15/15).病理显示多发癌灶占42.2%(19/45),颈淋巴转移率51.0%(26/51).术后永久性甲状旁腺功能低下率为3.9%(2/51),无永久性喉返神经及喉上神经麻痹.1例髓样癌术后1年对侧颈淋巴结转移,再手术后无复发.初次治疗的2例M1患者远处转移病灶缩小稳定.结论 甲状腺全切除是安全的手术方式,术中解剖喉返神经及甲状旁腺可有效防止并发症的发生.     

Nonrecurrent laryngeal nerves and their clinical significance

The anomalous position of a nonrecurrent laryngeal nerve predisposes the nerve to injury during thyroidectomy and to compression by a thyroid mass. We present three cases in which a seemingly benign thyroid mass traumatized a nonrecurrent laryngeal nerve resulting in either vocal cord paralysis or a vague pressure sensation over the larynx. Some of these patients feel as if they need to clear a foreign body and present with a chronic cough. Normally the nerve is protected from thyroid masses as it passes through the tracheoesophageal groove. In all three patients, surgical excision of the thyroid mass and release of the nerve resulted in recovery of the nerve and resolution of the symptoms. We have found that small, benign, or otherwise asymptomatic lesions of the thyroid gland have a greater tendency to cause vocal cord paralysis in patients with nonrecurrent laryngeal nerves. The surgeon must always be aware of the possibility of the presence of a nonrecurrent laryngeal nerve.     

Risk factors for permanent laryngeal nerve paralysis in patients with thyroid carcinoma.

OBJECTIVES: This study investigated the incidence of and risk factors for permanent recurrent laryngeal nerve paralysis for patients with thyroid malignancy. DESIGN: Retrospective chart review. SETTING: Tertiary oncology referral centre. PARTICIPANTS: Records of 290 consecutive patients treated between 1997 and 2001 were reviewed. All patients who have had one or more operations. Patients with preoperative recurrent laryngeal nerve paralysis and patients who underwent thyroidectomy in conjunction with laryngectomy were excluded. The incidence of postoperative permanent cord palsy was calculated in relation to the number of patients. MAIN OUTCOME MEASURES: Age, gender, thyroid functions, tumour localisations and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, differentiation, histological type, co-existence of lymphocytic thyroiditis, total number of dissected and metastatic nodes, type of surgery, the place of surgery and number of operations were the risk factors investigated for permanent recurrent laryngeal nerve paralysis. Univariate and multivariate analyses were performed. RESULTS: Permanent recurrent laryngeal nerve paralysis developed in 27 (9%) of 290 patients with thyroid carcinoma. Transient and permanent paralysis rates in total or subtotal thyroidectomy, completion thyroidectomy and neck dissection groups were 5/3%, 7/3% and 24/17% respectively. Cox regression analysis identified the type of surgery [adjusted relative risk (RR) = 2.1, 95% confidence interval (CI) = 1.1-4.0, P = 0.01], extrathyroidal soft tissue invasion (RR = 5.7, 95% CI = 2.0-15.7, P = 0.001) and number of metastatic nodes (RR = 1.6, 95% CI = 1.1-2.5 P = 0.01). CONCLUSIONS: The factors related with recurrent laryngeal nerve paralysis post-thyroid carcinoma surgery are linked to special features of the tumour and to the type of surgery.