甲状腺手术中喉返神经显露的处理方式探讨

Management of recurrent laryngeal nerve exposure in thyroid surgery

目的探讨甲状腺手术中喉返神经显露的方法。方法回顾性分析耳鼻喉头颈外科2010—2016年收治的甲状腺手术患者907例,其中甲状腺瘤38例,结节性甲状腺肿290例,桥本氏甲状腺炎36例,透明变梁状肿瘤1例,甲状腺肉瘤1例,甲状腺淋巴瘤4例,甲状腺髓样癌1例,甲状腺鳞状细胞癌2例,甲状腺癌534例,均在全麻下手术,同时解剖术侧喉返神经。观察患者术前术后发音情况,术后声音嘶哑,且电子喉镜检查确定存在声带麻痹,可判定为喉返神经损伤。结果手术过程中均显露喉返神经,除肿瘤累及喉返神经无法保留外,术后共10例出现单侧声带固定或活动减弱,其中2例为喉返神经端端吻合患者,6例为二次或三次手术。经带状肌内侧或外侧入路,于瘢痕区寻找喉返神经,2例为甲状腺乳头状癌初次手术患者。行营养神经、激素治疗及禁声休息后均于6个月内恢复,无永久性损伤。结论甲状腺手术中精细化被膜解剖、依据肿物位置选择不同入路可更好的显露喉返神经,有效减少神经损伤。

Objective To study the necessity and significance of recurrent laryngeal nerve exposure during thyroid surgery. Methods A retrospective analysis was performed on 907 cases of thyroid surgery patients,who were admitted from2010 to 2016 in otolaryngology and head and neck surgery,including 38 cases of thyroid adenoma,290 cases of nodular goiter,36 cases of Hashimoto＇ s thyroiditis,1 case of transparent trabecular tumor,1 case of thyroid sarcoma,4 cases of thyroid lymphoma,1 case of thyroid medullary carcinoma,2 cases of thyroid squamous cell carcinoma,and 534 cases of thyroid carcinoma. All patients were operated under general anesthesia and the recurrent laryngeal nerve was dissected. Postoperative pronunciation and postoperative hoarseness were observed,and electronic laryngoscopy was performed to determine the existence of vocal cord paralysis,which can be identified as a sign of laryngeal recurrent nerve injury. Results Recurrent laryngeal nerve was exposed in all patients during surgery except in patients with a neoplasm involving the recurrent laryngeal nerve. Postoperatively,10 cases appeared unilateral vocal cord fixation or weakened mobility. Nerve nutrition,hormone therapy and gag rest were performed and all patients recovered within six months after treatment without permanent damage. Conclusion Fine dissection of the tunica adventitia and selection of different approaches according to the location of the tumor can better expose the recurrent laryngeal nerve and effectively reduce nerve injury.