甲状腺手术所致喉上神经损伤的临床表现（附3例报道）

目的：探讨甲装腺手术后喉上神经（ＳＬＮ）损伤。方法：报告３例ＳＬＮ损伤病例，分析有关ＳＬＮ解剖结构、损伤原因、临床症状及避免的方法。结果：３例均在术后３天～２周内自愈。结论：强调在甲状腺手术中应同样重视ＳＬＮ和喉近神经（ＲＬＮ），避免损伤。     

慢性化脓性中耳炎相关的面神经麻痹

目的：探讨影响慢性化脓性中耳炎相关的面神经麻痹发生的因素。方法：回顾分析29例慢性化脓性中耳炎相关的面神经麻痹的病例资料。结果：650例慢性化脓性中耳炎中相关的面神经麻痹发病率为4．46％，术前8例（1．23％）为慢性化脓性中耳炎并发症，其中5例为胆脂瘤型，耳流脓史平均20．5年；术中12例（1．85％）为乳突根治术中损伤面神经所致。其中6例为胆脂瘤型中耳炎，6例为骨疡型中耳炎，损伤部位8例在面神经水平段，4例在锥曲段；术后9例（1．38％）为面神经水肿或炎症反应所致。结论：慢性胆脂瘤型中耳炎病程较长，面神经解剖标志不清，医师术中操作不当是导致面神经麻痹发生的因素。     

甲状腺良性病变手术与喉返神经损伤

目的探讨甲状腺良性病变的手术致喉返神经(recurent laryngeal nerve，RLN)损伤的主要相关因素。方法回顾分析586例甲状腺良性病变的手术资料，探讨RLN损伤与手术方式、RLN在手术中是否预先分离保护的关系。结果586例手术病人发生RLN损伤者为34例，占5.80％，其中以甲状腺次全切除术RLN受损率最高，占88.24％(30／34)；术中明确预先解剖出RLN并予以保护者，术后暂时声带麻痹的发生率为0．91％，无永久性声带麻痹。结论甲状腺次全切除术RLN损伤率最高，可能与缝合残体时RLN被误伤有关。术中先行游离RLN并予以保护，缝合甲状腺残体时，应尽量在食管沟平面以上注意保留后包膜的完整是减少医源性RLN损伤的重要措施。     

甲状腺良性病变手术与喉返神经损伤

目的 探讨甲状腺良性病变的手术致喉返神经(recurrent laryngeal nerve,RLN)损伤的主要相关因素。方法回顾分析586例甲状腺良性病变的手术资料,探讨RLN损伤与手术方式、RLN在手术中是否预先分离保护的关系。结果586例手术病人发生RLN损伤者为34例,占5.80％,其中以甲状腺次全切除术RLN受损率最高,占88.24％(30/34);术中明确预先解剖出RLN并予以保护者,术后暂时声带麻痹的发生率为0.91％,无永久性声带麻痹。结论 甲状腺次全切除术RLN损伤率最高,可能与缝合殁体时RLN被误伤有关。术中先行游离RLN并予以保护,缝合甲状腺残体时,应尽量在食管沟平面以上注意保留后包膜的完整是减少医源性RLN损伤的重要措施。     

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     

甲状腺疾病再手术的相关因素探讨

目的：探讨甲状腺疾病再手术的原因、手术并发症及其预防。方法：回顾性分析43例（13例良性病变，30例恶性病变）因甲状腺疾病而再手术的病例，尤其注意其手术并发症的发生，并与同期261例甲状腺恶性疾病首次手术的并发症进行比较。结果：43例均治愈，30例恶性病变的并发症（喉返神经的损伤）发生率为20％，较初次手术者高（P＜0．01）。结论：初次手术方式选择和病理因素是甲状腺疾病再手术的重要原因。甲状腺再次手术时喉返神经损伤的机会明显增加，术中解剖并保护好喉返神经是避免其损伤的关键。甲状腺再手术时的手术风险比初次手术时大，应尽可能予以避免。     

甲状腺乳头状癌颈部淋巴结转移规律及影响因素分析

目的：探讨甲状腺乳头状癌颈部淋巴结转移规律及其相关影响因素,为甲状腺乳头状癌颈部淋巴结清扫术提供一定的临床依据。方法：回顾性分析314例甲状腺乳头状癌患者的临床资料。314例患者中,行甲状腺腺叶峡部切除、中央区淋巴结清扫术79例,甲状腺全切、中央区淋巴结清扫术173例,甲状腺全切、中央区淋巴结清扫术、侧颈部改良根治性颈部淋巴结清扫术62例。手术中清扫出淋巴结1～55个,其中阳性淋巴结0～14个。结果：314例患者中经病理证实共有168例（53．50％）患者有淋巴结转移,其中中央区淋巴结转移159例（50．64％）,中央区＋侧颈转移淋巴结55例（17．52％）,单纯侧颈淋巴结转移9例（2．87％）。患者年龄、肿瘤直径、甲状腺被膜受侵犯、临床分期是甲状腺乳头状癌颈部淋巴结转移的影响因素（P〈0．05）。结论：甲状腺乳头状癌患者最常发生中央区淋巴结转移,应常规进行中央区淋巴结清扫术。     

颈袢主支与喉返神经内收肌支吻合术治疗喉麻痹的实验研究

建立单侧喉麻痹模型，实验组作颈袢主支与喉返神经（ＲＬＮ）内收肌支吻合术，对照组不作神经修复术。６个月后行喉镜、肌电图、组织化学检查及肌收缩力测定，证实实验组动物声带内收肌获得有效的再神经支配，声带内收为颈袢主支支配的结果。对照组无再神经支配征象。提示颈袢主支与ＲＬＮ内收肌支吻合术治疗单侧喉麻痹是一较为理想的手术方法。     

甲状腺外科手术中喉返神经的解剖

目的：探讨甲状腺外科手术中喉返神经的解剖特点和方法。方法：回顾性分析56例甲状腺疾病患者在手术中解剖的63条喉返神经的有关资料：结果：48条喉返神经入喉前分成前、后两支．占喉返神经总数的76．19％。29条(46．03％)喉返神经位于甲状腺下动脉的深部．19条(30．56％)喉返神经位于甲状腺下动脉的浅面．8侧(12．70％)甲状腺下动脉分叉．神经穿行其间．7侧(11．11％)术中未发现甲状腺下动脉：术后喉返神经暂时麻痹1例,永久麻痹1例。结论：充分掌握喉返神经的解剖特点．术中正确辨认并安全地解剖喉返神经是避免喉返神经损伤的关键。     

甲状腺手术中冷冻切片检查的价值

目的：研究甲状腺手术中冷冻切片检查的准确性及其对决定手术方式的指导意义。方法：对1057例甲状腺结节患者进行回顾性分析。根据是否行冷冻切片检查将患者分为冷冻切片检查组（FS组）和非冷冻切片检查组（NFS组）。结果：FS组共750例,其中冷冻切片检查诊断良性病变626例,恶性117例,冷冻切片检查不能明确者7例;常规病理检查诊断良性病变623例,恶性127例。117例冷冻切片报告为恶性的患者均得到常规病理检查确认。无假阳性,假阴性5例,真阳性117例,真阴性621例。术中冷冻切片检查的敏感性为95．9％,特异性为100．0％,确诊率为98．4％,不符合率为1．6％。NFS组共307例,术前临床诊断均为良性病变,术后常规病理检查良性病变277例,恶性30例,临床诊断和病理诊断不符合率为9．77％。两组不符合率经二项分布检验,差异有统计学意义（P〈0．01）,即FS组的不符合率明显低于NFS组的不符合率。结论：术中冷冻切片检查可以明确多数甲状腺结节的性质,对决定甲状腺手术中甲状腺的切除范围有一定价值。     

Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy

OBJECTIVE: To compare the incidence of postoperative vocal cord paresis or paralysis in a cohort of patients who underwent thyroidectomy with and without continuous recurrent laryngeal nerve (RLN) monitoring by a single senior surgeon. We hypothesize that continuous RLN monitoring reduces the rate of nerve injury during thyroidectomy DESIGN: Retrospective medical chart review. SETTING: Academic tertiary care medical center. PATIENTS: A total of 684 patients (1043 nerves at risk) who underwent thyroid surgery under general anesthesia. MAIN OUTCOME MEASURE: Incidence of vocal cord paresis or paralysis in patients who underwent thyroid surgery with continuous RLN monitoring vs those undergoing surgery without continuous RLN monitoring. RESULTS: The incidence of unexpected unilateral vocal cord paresis based on RLNs at risk was 2.09% (n = 14) in the monitored group and 2.96% (n = 11) in the unmonitored group. This difference was not statistically significant. The incidence of unexpected complete unilateral vocal cord paralysis was 1.6% in each group. Two of the 5 paralyses in the unmonitored group and 7 of the 11 paralyses in the monitored group had complete resolution. CONCLUSIONS: Monitoring of the RLN does not appear to reduce the incidence of postoperative temporary or permanent complete vocal cord paralysis. There appeared to be a slightly lower rate of postoperative paresis with RLN monitoring, but this difference was not statistically significant.     

甲状腺外科无喉返神经损伤的可能性

目的探讨甲状腺外科手术喉返神经(recurrenlaryngealnerve,RLN)零损伤的可能性。方法回顾性分析我科2001年3月～2005年3月659例甲状腺疾病的手术方式、术后RLN损伤、甲状旁腺功能低下、术后出血和术后复发等并发症的发生。术中常规解剖RLN,保护并勿过度解剖甲状旁腺及其供应的血管。结果甲状腺一侧腺叶加对侧腺叶部分切除376例、甲状腺一侧腺叶加峡部切除87例、甲状腺双侧腺叶次全切除76例、甲状腺全切除73例、颈部低位领式切口入路切除胸骨后结节性甲状腺肿47例。术后无一例发生RLN损伤。术后暂时性低钙血症发生率为1.67%(11/659)。无永久性低钙血症。术后出血需再手术止血和术后伤口血肿的发生率分别为0.60%(4/659)和0.45%(3/659)。甲状腺功能低下和术后复发的发生率分别为0.45%(3/659)和0.15%(1/659),无切口感染。结论甲状腺外科手术中熟悉RLN的解剖知识,常规紧贴甲状腺被膜外分离并全程解剖RLN及其分支可避免RLN的损伤。     

Value of recurrent laryngeal nerve monitoring in the operative strategy during total thyroidectomy and parathyroidectomy

ObjectiveThe purpose of this study was to assess the role of recurrent laryngeal nerve (RLN) monitoring in the operative strategy during total thyroidectomy and parathyroidectomy. Due to the risk of serious respiratory complications of bilateral recurrent nerve paralysis, two-stage surgery may be considered in the case on negative stimulation of the first side.Patients and methodsThis prospective study was conducted in 100 consecutive patients between May 2007 and March 2011. Translaryngeal monitoring was performed. When stimulation of the RLN on the first side dissected was negative, dissection of the other side was deferred to avoid the risk of bilateral RLN paralysis.ResultsThe main surgical indications were thyroid carcinoma (34%), Graves’ disease (27%), multinodular goitre (27%) and parathyroid hyperplasia (9%) with seven cases of redo surgery. Four RLN identified on the first side gave a negative response to stimulation and surgery to the other side was therefore deferred. Transient unilateral RLN paralysis was observed in these four patients and two cases of RLN paralysis were observed among patients with positive RLN stimulation. Among the 96 contralateral RLNs tested, two were not visualized (one case of transient RLN paralysis, one case of permanent RLN paralysis), two gave a negative response to stimulation (two cases of permanent RLN paralysis) and 92 gave a positive response to stimulation (nine cases of transient RLN paralysis, including two cases associated with transient paralysis of the first side, and one case of permanent RLN paralysis). The incidence of RLN paralysis by nerve was 9.6% for transient RLN paralysis and 2% for permanent (unilateral) RLN paralysis.ConclusionWhen bilateral RLN dissection is planned, RLN monitoring is particularly useful to limit the risk of bilateral RLN paralysis. Two-stage thyroidectomy, following functional recovery of the damaged RLN, can therefore be proposed. The risk of bilateral RLN paralysis was avoided in four patients, while transient bilateral RLN paralysis was observed in two patients despite positive stimulation.     

改良Miccoli术中喉返神经的显露及损伤预防

目的：探讨甲状腺改良Miccoli术中解剖显露喉返神经的方法及预防喉返神经损伤的临床意义。方法：回顾性分析218例行甲状腺改良Miccoli术患者的资料，均在内镜直视下寻找喉返神经并进一步显露直至人喉处，行甲状腺次全切或腺叶全切除。结果：218例患者手术均获成功，无中转开放手术。术中均成功显露颈段喉返神经并保护之。术中、术后病理证实结节性甲状腺肿185例，甲状腺腺瘤8例，甲状腺乳头状微小癌25例。2例甲状腺乳头状微小癌及1例有鼻咽癌放疗史的患者，术后出现暂时性声嘶，3个月内声带活动恢复正常。结论：甲状腺改良Miccoli术中解剖显露喉返神经是该手术顺利进行的关键，是预防喉返神经损伤的有效方法。     

Laryngeal mask anesthesia with intraoperative laryngoscopy for identification of the recurrent laryngeal nerve during thyroidectomy

OBJECTIVES/HYPOTHESIS: A critical step in thyroidectomy involves definitive identification of the recurrent laryngeal nerve (RLN). Using the laryngeal mask airway, identification of the RLN can be facilitated by stimulation of the nerve while monitoring vocal cord movement with a fiberoptic laryngoscope. We present this technique as an effective and safe means to identify the RLN during thyroid surgery, with significant advantages over existing techniques in appropriately selected patients. STUDY DESIGN: Retrospective case series. METHODS: We performed thyroidectomy on 8 patients (13 RLN identifications) in which laryngeal mask airway anesthesia with fiberoptic laryngoscopy was used to identify the RLN. Results are reviewed with regard to postoperative vocal cord function, as well as intraoperative and postoperative courses with laryngeal mask airway anesthesia. RESULTS: In all 13 cases in which the RLN was sought, it was definitively identified by witnessing brisk vocal cord movement on a video screen with stimulation of the RLN. No patient had postoperative vocal cord paresis or paralysis. Overall recovery from laryngeal mask airway anesthesia was uneventful and had advantages when compared with general anesthesia with endotracheal intubation. CONCLUSIONS: Laryngeal mask airway anesthesia with intraoperative fiberoptic laryngoscopy to identify the RLN is effective and safe in carefully selected patients. Advantages include decreased postoperative throat discomfort, absence of coughing during emergence from anesthesia, and elimination of the possibility of vocal cord mobility impairment secondary to RLN ischemia from the endotracheal tube balloon. In addition, this technique is applicable in operations besides thyroid surgery, in which definitive identification of the RLN is indicated.     

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。     

Intraoperative nerve monitoring reduces recurrent laryngeal nerve injury in geriatric patients undergoing thyroid surgery

Objective: This research was aimed to investigate whether the intraoperative nerve monitoring (IONM) can reduce the incidence of recurrent laryngeal nerve (RLN) injury in geriatric patients undergoing thyroid surgery.

Methods: This retrospective cohort study included 522 geriatric patients undergoing thyroid surgery between January 2013 and June 2016 in the Sun Yat-sen Memorial Hospital. Patients with IONM during the surgery (n?=?340) were compared with patients without IONM (n?=?212). RLN injury was verified by direct or indirect laryngoscope and relative factors for injury would be retrospectively analyzed.

Results: The use of IONM group showed significant reduction in both total and transient RLN injury incidence, when compared with that in control group (1.76 versus 4.72%, p?=?.01 and 1.32 versus 3.67%, p?=?.03, respectively). However, the permanent RLN injury incidence did not show difference between the two groups (p?=?.3).

Conclusions: Our finding showed the use of IONM resulted in significantly reduction in RLN injury incidence. The technology of IONM is safe and convenient to detect, track and monitor the complete function of RLN and to provide the guidance for the surgeons during the thyroid surgery in geriatric patients, who are at high risk of RLN injury.     

Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation in predicting postoperative nerve paralysis

Bilateral recurrent laryngeal nerve (RLN) paralysis after thyroidectomy is infrequent, but serious when it occurs. Intraoperative knowledge of the status of the nerve after dissection could potentially provide the surgeon with important decision-making information. The current study examines the sensitivity and specificity of intraoperative stimulation of the RLN during thyroid surgery for predicting postoperative RLN deficits. Eighty-one RLNs in 55 patients were identified to be at risk of injury during thyroidectomy or parathyroidectomy performed between January 1998 and February 2000. Intraoperative determination of RLN function was evaluated with a disposable nerve stimulator (Xomed, Jacksonville, Florida) set at 0.5 mA. Injury was assessed by palpating for a contraction of the posterior cricoarytenoid muscle while the stimulus was applied. Postoperative assessment of RLN integrity was determined by using indirect or direct laryngoscopy to visualize vocal fold mobility. Nine RLNs failed to elicit a posterior cricoarytenoid contraction after nerve stimulation, and 4 RLNs were determined to be deficient in the postoperative evaluation. The calculated sensitivity and specificity were 75% and 92.2% with a positive predictive value of 33.3% and negative predictive value of 98.6%. The RLN injury rate was 4.94%. We conclude that intraoperative RLN stimulation is a relatively safe and useful method of determining what RLN function will be after thyroid or parathyroid surgery.     

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.