膈神经替代喉返神经修复治疗双侧声带麻痹

Reinnervation of the posterior cricoarytenoid muscle by the phrenic nerve for bilateral vocal cord paralysis in humans

目的 探讨膈神经喉返神经吻合和内收肌支环杓后肌植入术 (膈神经手术 )治疗双侧喉返神经损伤声带麻痹的有效性、可行性。方法 第二军医大学长海医院耳鼻咽喉科 1999年 8月～2 0 0 1年 7月治疗外伤性双侧喉返神经损伤声带麻痹 6例。病程 1周～ 18个月 ,一侧作膈神经手术 ,而另一侧作颈袢肌蒂环杓后肌植入术。手术前后电子喉镜、频闪喉镜观察声门大小、声带运动、振动情况 ,嗓音声学参数分析 ,喉肌电图检查评价手术效果。结果 术后 2～ 3周检查发现 4例声门较术前增大 2～ 3mm ,但声带固定不动 ,2例无明显改善。术后 6个月 5例膈神经修复侧均恢复了较大幅度的吸气性声带外展功能 ,外展幅度可达 3～ 5mm ,而肌蒂植入侧仅轻微外展或固定不动 ,幅度均在 1mm以内。此 5例均顺利拔管 ,并能承受较大强度的体力活动 ,1例仍在随访中。术后 4个月 6例肌电图检查显示膈神经修复侧自发、诱发电位均明显大于肌蒂植入侧 ,自发电活动与肋间肌基本同步 ,而较肌蒂植入侧延迟 10 0～ 2 0 0ms。声音估价显示 3例声嘶术后较术前好转 ,2例无变化。术后半年肺功能均恢复正常。结论 膈神经喉返神经吻合内收肌支环杓后肌植入术安全可行 ,较颈袢肌蒂植入术更能有效地恢复声带吸气性外展运动 。

Objective To reestablish the respiratory abduction of the paralyzed vocal cord through reinnervation of the posterior cricoarytenoid(PCA) muscle by the phrenic nerve in humans Methods In six cases with bilateral recurrent laryngeal nerve paralysis, the phrenic nerve was anastomosed to the anterior branch of recurrent laryngeal nerve,while the adductor branch of recurrent laryngeal nerve was severed and its proximal end was implanted into the PCA muscle belly in one side, for the other side nerve muscle pedicle technique was used All cases had been subjected to preoperative and postoperative video laryngoscopy, stroboscopy, electromyography, voice recording and acoustic analysis Results Among the 6 patients,it is observed in five cases′ phrenic nerve reinnervation side the inspiratory abducent motion evidently recovered,and the abducent range was from 3 to 5 mm, While only slight abductent motion or no motion could be recorded on the other side reinnervated with nerve muscle pedicle technique, and the vocal cord excursion on this side was less than 1 mm in all cases It is because the glottis is broad enough for the patients to have daily activities without short of breath, so all of them were decannulated postoperatively The reinnervated PCA muscle by the phrenic nerve showed typical inspiratory high frequency discharge with 100 200 ms delay as compared with the other side, indicating the phrenic motoneuron pattern No long term diaphragmatic paralysis and lesion of respiratory function was found All cases′ voice was not weakened, and no aspiration occurred Conclusion The phrenic reinnervation is feasible clinically for treating vocal cord paralysis, and it is found to be more effective for restoring inspiratory abducent function than the nerve muscle pedicle technique