甲状腺乳头状癌累及喉返神经的处理方法

Management of recurrent laryngeal nerve involved in papillary thyroid carcinoma

目的探讨甲状腺乳头状癌累及喉返神经的处理方法。方法根据42例甲状腺乳头状癌侵犯喉返神经情况分为包绕、黏连、压迫3组,术中根据喉返神经与肿瘤的关系结合术前声带运动情况综合考虑是否保留喉返神经。包绕组无论声带活动情况如何,喉返神经均予切除。黏连组如伴完全声带麻痹,切除喉返神经;否则喉返神经予以保留。压迫组喉返神经均予保留。观察所有患者声带术后活动情况、评估疗效。结果 42例患者中甲状腺全切除23例,次全切除术19例,随访1年术后均未复发。包绕组患者均行喉返神经切除,术后声带完全麻痹;粘连组中,3例声带完全麻痹者切除喉返神经、术后声带完全麻痹,9例术前不完全声带麻痹均予以保留喉返神经,2例术后出现声带完全麻痹,3例声带不完全麻痹,4例声带运动恢复正常;压迫组无声带完全麻痹,完整保留喉返神经,术后声带运动均恢复正常。结论对甲状腺乳头状癌侵犯喉返神经的处理,应结合术前声带运动情况及术中喉返神经与肿瘤关系采取不同的处理方法。

Objective To discuss the treatment principle of recurrent laryngeal nerve involvement in papillary thyroid carcinoma. Methods According to the degree of nerve involvement found during operation, 42 patients suffering from papillary thyroid carcinoma with recurrent laryngeal nerve involvement were divided into 3 groups, i. e., circumvolution group （n = 11 ）, adhesion group （n = 19） and compression group （n = 12 ）. Intra-operative preservation of the involved recurrent laryngeal nerve was determined based on both the degree of nerve involvement and preoperative vocal cord movement. The recurrent laryngeal nerves in all the cases of the circumvolution group were resected regardless of the vocal cord movement. In the adhesion group, the nerves were also resected in those with preoperative complete vocal cord paralysis and preserved in those with incomplete vocal cord paralysis or normal vocal cord movement. The nerves in all the cases of the compression group were preserved. The postoperative vocal cord movement in all the cases was observed, and the therapeutic effect was evaluated. Results Of all the 42 patients, total thyroidectomy was performed in 23 and subtotal thyroidectomy in 19. All of them were followed up for one year without recurrence. Postoperative complete vocal cord paralysis was observed in all the 11 cases of the circumvolution group with intraoperative nerve resection. In the adhesion group, postoperative complete vocal cord paralysis occurred in 3 cases with preoperative complete vocal cord paralysis and intraoperative nerve resection. In 9 cases of the adhesion group with preoperative incomplete vocal cord paralysis and intraoperative nerve preservation, postoperative complete and incomplete vocal cord paralysis occurred in 2 and 3 cases respectively, and vocal cord movement returned to normal in 4. Vocal cord movement returned to normal in all the cases of the compression group. Conclusion The recurrent laryngeal nerve involved in papillary thyroid carcinoma should be managed comprehensively according to relationship between tumor and nerve combining the preoperative vocal cordmovement.