双侧喉返神经损伤神经修复治疗术式探讨

Comparison of Different Procedures of Posterior Cricoarytenoid Muscle Reinnervation for Bilateral Vocal Cord Paralysis

目的探讨三种神经修复术式治疗双侧喉返神经损伤声带麻痹的效果。方法对28例双侧喉返神经损伤声带麻痹患者行喉返神经减压术（8例）、膈神经移植术（11例11侧）、神经肌蒂移植术（9例）。治疗前后以喉镜、嗓音主观评估及嗓音声学分析、喉肌电图检查等评价手术效果，随访1年以上。结果①神经减压术8例13侧有6例10侧声带恢复生理性内收及外展运动，外展幅度2—8mm，声门裂隙6—12mm，顺利拔管；2例双侧声带仍固定无法拔管。②膈神经移植11例11侧中8侧术后恢复声带外展功能，幅度达2．8mm，声门裂隙6．12mm，发声时声带均有一定幅度的内收，此8例均顺利拔管；2侧声带仍固定、1侧吸气时声带反而内收，此3例均未能拔管。③神经肌蒂移植术9例9侧仅1侧吸气时声带轻度外展，声门开大为4mm，发声时声带内移，拔管后不能行较大强度的体力活动。④除6例神经减压术后发声恢复正常外，其余手术前后发声无明显变化。⑤术后12个月膈神经移植、神经减压术侧自发电位波形、诱发电位均明显大于神经肌蒂移植术侧，而前两者差异无统计学意义。结论喉返神经减压术、膈神经移植术较神经肌蒂移植术能更有效地恢复声带吸气性外展运动，神经减压术还能恢复正常发声功能。

Objective To compare the results of 3 different procedures of posterior cricoarytenoid （PCA） muscle reirmerration for bilateral vocal cord paralysis（BVCP） in humans. Methods The present study included 28 patients. In 8 cases, recurrent laryngeal nerve（RLN） decompression was used. In 11 cases, phrenic nerve was anastomosed to anterior branch of RLN and the adductor branch of RLN was cut and its proximal end was implanted into the PCA muscle. In the other 9 cases, nerve muscle - pedicle（NMP） technique was used. Therapeutic effect was appraised by laryngoscope and strobe - laryngoscope and voice evaluation and voice acoustics parameter analysis of pretreatment and post - treatment. Results ①Abductory and adductory motion of the vocal cords in 10 sides of 6 patients were observed in the nerve - decompressed 13 sides of 8 patients and the vocal cord abductory excursion varied from 1 mm to 8 mm. The glottic chink increased to 6 mm to 12 mm during inspiration after surgery. There were 6 patients achieving sufficient airway without a tracheotomy, in 2 patients vocal cords were iminovable and tracheatube can not be removed off. ②Large and good inspiratory abductory motion of the glottis in 11 sides were observed on the reinnervated sides by the phrenic nerve and the vocal cord abductory excursion varied from lmm to 8mm. The glottic chink increased to 6 mm to 12 mm during inspiration after surgery. There were 8 patients achieving sufficient airway without a tracheotomy, but in 2 sides, vocal cords were immovable and adductory was observed in 1 side vocal cord during inspiration. These three patients＇ tracheatube can not be removed off. ③In 9 sides of 9 patients who received NMP technique, only slight abductory motion could be recorded in 1 case who achieved enough airway and the golttic chink was only 4 ram. ④Physiological phonafion was found in 6 patients for nerve- decompression, the others unchanged. 0 Both spontaneous and evoked electromyography were recorded on the reinnervated PCA muscles for phrenic nerve graft and nerve decompression. The amplitude of spontaneous and evoked electromyography was not significandy different between these two procedures, but they were signiilcandy greater than NMP technique respectively. Conclusion Phrenic nerve graft and nerve decompression resnlte more satisfactory vocal cord abductory motion than NMP technique. Nerve decompression can restore physiological phonation.