颈部迷走神经副节瘤术中的神经保护和功能修复

Protection and functional repair of vagus nerve during the operation of cervical vagal paraganglioma

目的:探讨颈部迷走神经副节瘤的临床解剖特点、术中保护神经或神经离断后修复的方法。方法:6例颈部迷走神经副节瘤患者,肿瘤均包裹迷走神经干并在手术解剖中离断。在迷走神经离断后行断端吻合术(3例)或颈深神经(2例)、舌下神经(1例)移植术。术后行糖皮质激素、营养神经药物治疗及发声、吞咽功能锻炼。结果:2例副节瘤术后复发患者,术前吞咽呛咳明显,术后吞咽呛咳消失;4例术后吞咽呛咳,6～12个月明显减轻。5例术后声嘶,6～12个月明显改善;1例术后12个月声嘶仍明显。术后3个月纤维喉镜检查,残端吻合术(3例)及舌下神经移植术患者(1例)术侧声带内侧约1/2于发声时有颤动;颈深神经移植者(2例)1例有颤动,1例动度不明显。结论:颈部迷走神经副节瘤术中仔细甄别迷走神经纤维并加以最大限度保护,可以明显减少术后声嘶或吞咽呛咳。迷走神经干离断后的神经断端吻合、颈深神经或舌下神经移植均可能改善声带动度,从而有助于改善声嘶。

Objective：To explore the clinical anatomy and the methods to protect or reconstruct the continuity and function of vagus nerve during the operation of cervical vagal paraganglioma.Method：Six cases of vagal paraganglioma were reviewed.All tumors were identified to wrap the cervical vagus nerve stem and excised during surgery.The operative modality was to trace the vagus nerve stem inside the tumor as far as possible,to reconstruct the continuity by way of vagus nerve anastamosis（3/6） or alternatively,other motor nerve transplantation（3/6）.Postoperative treatment included steroid,neurotrophic medication and voice and swallowing rehabilitation.Result：Two cases of the recurrent paraganglioma experienced aspiration during swallowing preoperatively and no aspiration after surgery.Choking was gradually reduced in four recurrent cases half to one year postoperatively.Hoarseness was improved in five cases（5/6） half to one year postoperatively,while one case remained prolonged obvious hoarseness.Three months postoperatively,the vocal cord fibrillation at the tumor-related side was observed during pronunciation in the end-to-end anastamosis cases（3/6）,sublingual nerve-transplanted case（1/6） and deep cervical nerve-transplanted cases（1/6） under fiberoptic laryngoscope,and the mobility was even more obvious at the time of half an year postoperatively.While in another deep cervical nerve-transplanted case（1/6）,the vocal cord demonstrated no obvious fibrillation.Conclusion：To carefully identify and preserve the vagus nerve fibers as much as possible during the operation of cervical vagal paraganglioma could significantly eliminate postoperative hoarseness and aspiration.End-to-end anastamosis,deep cervical nerve or sublingual nerve transplantation to resume the continuity of vagus nerve may improve the mobility of vocal cord thus the quality of voice and swallowing.