喉神经修复治疗外伤性声带麻痹的远期疗效分析

A Study of the Effect of Recurrent Laryngeal Nerve Prosthesis on Laryngeal Paralysis

目的 探讨各种神经修复术式治疗外伤性喉返神经损伤的远期疗效。方法 外伤性喉返神经损伤致声带麻痹患者153例，单侧138例、双侧15例，病程从损伤即刻至3年不等。行喉返神经减压术31例、颈袢喉返神经吻合术102例、喉返神经端端吻合术9例、膈神经移植及部分病例联合应用神经肌蒂植入术11例。手术前后以喉镜、嗓音评估及声学分析、肌电图检查等评价手术效果。结果 ①单侧声带麻痹患者：病程3个月内19例、3月以上1例经喉返神经减压术恢复了不同程度的声带内收及外展功能；3个月以内3例、3个月以上4例患者经喉返神经减压及喉返神经端端吻合后均未恢复声带运动；颈袢喉返神经吻合组78例发声时声带突有明显内收运动。24例无明显内收运动；但上述3种术式除喉返神经端端吻合1例、颈袢喉返神经吻合3例外，其余患者发声时声带均处于正中位，声门闭合良好，后联合裂隙不明显，97％（134／138）嗓音恢复正常。②双侧声带麻痹患者：行神经减压4例7侧，有4例5侧恢复运动，均拔除气管套管；行膈神经移植术的11例中，恢复明显吸气性声带外展功能6例6侧，幅度达2—8mm；轻度外展2例2侧，幅度1～2mm，但声门裂隙达6—12mm，此8例均顺利拔管，发声时声带均有一定幅度的内收。2例2侧膈神经移植术后声带仍固定，1例1侧吸气性声带内收，未能拔管。一侧膈神经移植而另一侧肌蒂埋植的4例中，肌蒂埋植侧仅1例声带轻微外展。总拔管率80％（12／15）。膈神经移植手术前后发声无明显变化，神经减压术后发声明显好转。③各种神经修复术的神经再支配得到神经肌电图检查的证实，随访一年以上各项指标无明显退步。结论 ①喉返神经减压术、颈袢喉返神经吻合术、膈神经移植术能很好地恢复喉的生理功能；②喉神经修复术式的选择应根据病程、神经损伤程度、类型及侧别而定。

Objective To study long - term therapeutic effect of recurrent laryngeal neurve（RLN） prosthesis on its lesions in humans. Mothods （1）153 patients with traumatic RLNs paralysis were studied, including 138 cases with unilateral vocal cord paralysis（ UVCP） and 15 cases with bilateral vocal cord paralysis（BVCP）.The course of injury varied from the onset of occurrence to 3 years. In 31 cases, RLNs were decompressed. In 102 cases, RLNs were anastomosed to ansa cervicalis. In 9 cases, RLNs were anastomosed end to end. In 11 cases, the 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. （2）Pretreatment and post - treatment, therapeutic efficacy were examined by laryngoscope, voice evaluation and voice acoustics parameter analysis and examination of laryngeal electromyography（LEMG）. Results （1）in these cases with UVCP, abductory and adductory motion of the glottis were observed in 20 decompressed RLNs, including 19 cases whose course were shorter than 3 months and 1 case whose course was longer than 3 months. The vocal cords motion was not observed in cases whose RLNs were anastomosed end to end. In 102 cases whose RLNs were anastomosed to ansa cervicalis,and adductory motion of the glottis was observed in 78 cases. 97% （134/138） cases had normal voice back. （2）In these cases with BVCP,4 patients showed the motion of the glottis on 5 sides while 4 patients had the nerve- decompressed on 7 sides, achieving sufficient airway without a tracheotomy. Sufficient inspiratory abductory motion of the glottis was noted on 6 sides of 6 patients on the reinnervated sides by the phrenic nerve. The vocal cord abductory excursion varied from 2 mm to 8 mm. The glottic chink increased to 6 mm to 12 mm during inspiration after surgery. 2 patients＇ vocal cord were immovable and trachea-tube could not be removed. In one side of 4 patients treated with nerve muscle- pedicle（NMP） technique, only slight abductory motion could be recorded. （3）The reinnervating of the RLNs was approved by LEMG in these patients whose RLNs were restored. For one year follow - up, the resutls maintained unchanged. Conclusion （1） Nerve decompression and anatomosing RLN to ansa cervicalis and phrenic nerve graft raise satisfactory laryngeal function. （2）The nerve prosthesis techniques should be choosn according to the occurrence course , the degrees, types and positions of RLN injuries.