recurrent laryngeal nerve injury
Introduction
Introduction to recurrent laryngeal nerve injury Intestinal recurrent nerve injury (injuryofrecurrentnerve) has sputum in different positions on the vocal cords, mostly due to neck trauma and accidental injury during surgery, such as thyroid surgery, especially reoperation, causing recurrent laryngeal nerve injury is more common. Others such as neck injuries, gunshot wounds, penetrating injuries, knife cuts, etc. can cause the nerve to be injured. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific population Mode of infection: non-infectious Complications: laryngeal trauma
Cause
Causes of recurrent laryngeal nerve injury
Neck trauma (25%):
Neck trauma can be divided into open and closed injuries. The former is caused by war wounds, work injuries or other accidents. The nerve can be injured, such as a bullet wound, a penetrating injury, or a knife cut.
Surgical injury (30%):
Such as thyroid surgery, especially re-operation, the accidental injury factors are: (1) direct surgical injury: bleeding during surgery, because the recurrent laryngeal nerve and blood vessels, in the hemostasis, the nerve may be clamped together with the blood vessels, This is the most important cause of damage to the nerves.
Other factors (30%):
1. Familiarity with neck dissection or abnormal nerve position is difficult to grasp: the recurrent laryngeal nerve is sometimes attached to the posterior membrane of the thyroid gland or partially surrounded by glandular tissue. When there is inflammatory scar tissue nearby, separation, hemostasis, suturing Easy to accidentally hurt the nerves.
2, there is no routine habit of exploring the recurrent laryngeal nerve during surgery, sometimes encounter suspicious tissue, not traced, so it is easy to accidentally hurt the nerve.
3. The nerve is excessively pulled, or the blood supply is insufficient after the nerve is exposed.
4, postoperative edema or hematoma compression of the recurrent laryngeal nerve, or postoperative scar tissue contraction compression of the recurrent laryngeal nerve.
5, patients with thyroid surgery again, due to scar tissue contraction, anatomical landmarks are unclear, difficult to separate, more likely to nerve damage.
Prevention
Recurrent laryngeal nerve injury prevention
Thyroid surgery must prevent accidental injury to the recurrent laryngeal nerve.
1, routine exposure of the recurrent laryngeal nerve
It can reduce the rate of recurrent laryngeal nerve injury. Lahey describes the normal method of exposing the recurrent laryngeal nerve: the recurrent laryngeal nerve can be under the thyroid artery, in the middle or inside of the branch, and sometimes on the lateral side (the right recurrent laryngeal nerve is laterally More)) If the thyroid is pulled outward, the inferior thyroid artery is in a state of tension. At this time, the nerve is seen across the artery. If the thyroid is pulled near the inside of the artery, the nerve is not affected, and the lower thyroid artery is separated. It can be seen that the nerve should be protected.
2, avoid large bundle ligation of the thyroid
Ligation of the thyroid gland in time, should be as close as possible to the gland, avoid large bundle ligation, a large part of the resection of a leaf, easy to stop bleeding after resection, for easy bleeding, rather for total leaf resection, the subtotal for hyperthyroidism should be done, it is best not to Most of the bilateral symmetry is removed, and one leaf is completely cut, and the other side is mostly or half cut.
3. The inferior thyroid artery is an important marker of exposed nerves.
First, the anatomy is started from the lower part of the artery, and the nerve is inserted into the throat, and then the glandular tissue at the outer part of the annular cartilage is separated. The position where the nerve enters the throat is the most vulnerable part, and it is also the most prone to bleeding. Special attention must be paid when stopping bleeding.
4, to avoid bilateral laryngeal nerve injury
In order to avoid bilateral recurrent laryngeal nerve injury, Kratz first exposed one side of the recurrent laryngeal nerve after resection of the bilateral thyroid gland. After removing one side of the thyroid gland, the laryngoscope and electrostimulator were used to observe the movement of the vocal cords. If there is no movement on the side of the vocal cords. , the contralateral thyroid can not be removed.
5, monitoring the recurrent laryngeal nerve
Folisherg and Linhalm used an electromyography test on 15 patients undergoing thyroid surgery, inserting the electrode into the ring membrane and the tip at the laryngeal muscle to monitor the recurrent laryngeal nerve.
6. Observing the inferior thyroid artery with a surgical microscope. The artery has a branch to supply the blood circulation of the lower thyroid gland. The pulsation of the artery can be seen from the connective tissue. The recurrent laryngeal nerve is close to the inner side of the artery, laterally or through the branch of the artery. The small blood vessels close to the nerve can be ligated. Because the recurrent laryngeal nerve is very thin, Kratz uses a 3V facial nerve stimulator to identify the recurrent laryngeal nerve under the operation microscopic magnifying glass and hanging laryngoscope. This method is superior and can protect the laryngeal gyrus. The nerves are not damaged.
Complication
Recurrent laryngeal nerve injury Complications, laryngeal traumatic paralysis
Bilateral recurrent laryngeal nerve injury can be complicated by dyspnea.
Symptom
Symptoms of recurrent laryngeal nerve injury Common symptoms Laryngeal muscle weakness, cough, hoarseness, difficulty breathing
1, unilateral recurrent laryngeal nerve injury (unilateral recurrent laryngeal nerve spasm):
It is the abductor muscle of the one side and the tendon of the adductor muscle, but the nerve on the larynx is still normal, so the ring muscle can still maintain the function of abduction and adduction.
The hoarseness and vocal weakness are the only symptoms of the unilateral recurrent laryngeal nerve. The vocal cords in the healthy side can exceed the midline when they are vocalized in the future, and the sound is improved when the vocal cords are in contact with the affected side. This kind of sputum does not cause breathing difficulties. The cough is weak and the degree of hoarseness is the same. Some patients with unilateral recurrent laryngeal nerve injury, only mild hoarseness and vocal weakness, are easily missed.
2, bilateral recurrent laryngeal nerve injury ( bilateral recurrent laryngeal nerve spasm):
Most of them are caused by extensive thyroid surgery and bilateral recurrent laryngeal nerves.
There is a brief history of hoarseness after bilateral recurrent laryngeal nerve injury. Cough is weak. Because the bilateral vocal cords are near the midline, they cannot be abducted during inhalation, and the sound is not affected, but there are severe breathing difficulties.
Examine
Examination of recurrent laryngeal nerve injury
Laryngoscope and fiber laryngoscopy, the unilateral injury can be seen in the occipital vocal cord in the paramedian position, in the lower plane, the sacral cartilage is tilted forward, and is located in front of the healthy side, the vocal cord on the affected side is fixed when deep inhalation When bilaterally injured, the vocal cords are in the midline position, the sacral shape is disgusting, the sacral cartilage on both sides is tilted forward, and the nailfold muscle is slack. When the inhalation and vocalization are deep, the vocal cords on both sides are stagnant.
Diagnosis
Diagnosis and diagnosis of recurrent laryngeal nerve injury
1. History: history of neck trauma or history of thyroid surgery.
2, clinical manifestations: unilateral recurrent laryngeal nerve injury, only the sound is weak and the vocal folds due to the compensation of the vocal cords on the healthy side, the vocalization can return to normal. Therefore, many unilateral injuries have not been diagnosed, but the symptoms and laryngoscopy can be Confirmed diagnosis. Bilateral recurrent laryngeal nerve injury can not be abducted due to bilateral vocal cords, and there is a healthy search for dyspnea.
3. Auxiliary examination and diagnosis.
