显露喉返神经的甲状腺手术后患者声音嘶哑原因分析

doi:10.3969/j.issn.1000-8535.2023.02.008

摘要/Abstract

摘要： 目的探讨暴露喉返神经的甲状腺手术后患者发生声音嘶哑的原因。方法选取于2019年1月—2020年12月间在我院接受甲状腺手术且在术中暴露喉返神经的患者,对出现术后声音嘶哑的19例患者进行为期12个月的临床随访,观察研究对象术后声音嘶哑的发生特点、持续时间并进行直接喉镜及颈部超声检查。结果发生声音嘶哑的19例患者中,5例存在术中喉返神经损伤情况,其余14例患者术中喉返神经暴露及保护良好。直接喉镜检查示,该14例患者中,4例存在声带充血水肿现象,1例发生勺状软骨半脱位。术后1周左右的超声检查显示,该14例患者中有11例存在不同程度的创腔内积液。结论虽常规暴露喉返神经减少了术后声嘶的发生率,但术中喉返神经损伤仍然是造成患者术后声嘶的原因之一。此外,术后创腔积液、麻醉插管导致的声带损伤及其他插管相关并发症等非直接手术因素也是造成这些患者术后声嘶的重要原因,应引起临床重视。

关键词: 甲状腺, 暴露喉返神经, 声音嘶哑

Abstract: Objective To explore the cause of hoarseness of voice in patients after thyroidectomy with recurrent laryngeal nerve exposure. Methods The patients from January 2019 to December 2020 underwent thyroidectomy with exposure of recurrent laryngeal nerve during operation were selected. There were 19 cases of hoarseness of voice after operation followed up for 12 months. Postoperative observations included the characteristics of the hoarseness of voice, duration, and direct laryngoscope neck ultrasonography. Results A total of 19 patients had voice hoarseness, only 5 of them had recurrent laryngeal nerve injury during operation, the other 14 patients had good exposure and protection of recurrent laryngeal nerve. Direct laryngoscope showed that 4 of 14 patients had vocal cord edema and 1 had subluxation of arytenoid cartilage. About 1 week after operation, ultrasound examination showed that 11 of 14 patients had varying degrees hydrops of wound cavity. Conclusions Although the routine exposure of recurrent laryngeal nerve reduces the incidence of postoperative hoarseness of voice, the injury of recurrent laryngeal nerve is still a cause of postoperative hoarseness of voice. In addition, non-operative direct factors, such as fluid accumulation in the operative field, vocal cord injury caused by anesthetic intubation and other intubation related complications, are also important reasons for postoperative hoarseness of voice in these patients, which we should pay more attention to.

Key words: thyroid, exposed recurrent laryngeal nerve, hoarseness of voice

韩贺, 范昕, 王德钱, 黄文康, 葛彦锋, 王莹. 显露喉返神经的甲状腺手术后患者声音嘶哑原因分析[J]. 广州医药, 2023, 54(2): 42-45.

HAN He, FAN Xin, WANG Deqian, HUANG Wenkang, GE Yanfeng, WANG Ying. Analysis of hoarseness of voice after thyroidectomy with recurrent laryngeal nerve exposure[J]. Guangzhou Medical Journal, 2023, 54(2): 42-45.

参考文献

[1] MORRIS L G, SIKORA A G, TOSTESON T D, et al. The increasing incidence of thyroid cancer: the influence of access to care[J]. Thyroid, 2013, 23(7): 885-91.
[2] TAKANO T. Natural history of thyroid cancer[Review][J]. Endocr J, 2017, 64(3):237-244.
[3] LAHEY F H, HOOVER W B. Injuries to the recurrent laryngeal nerve in thyroid operations: their management and avoidance[J]. Ann Surg, 1938, 108(4):545-562.
[4] AHMED M, AURANGZEB, ABBAS S, et al. Should we routinely expose recurrent laryngeal nerve(s) during thyroid surgery?[J]. J Coll Physicians Surg Pak, 2013, 23(3):186-189.
[5] YU W B, ZHANG N S. Protection and dissection of recurrent laryngeal nerve in salvage thyroid cancer surgery to patients with insufficient primary operation extent and suspicious residual tumor[J]. Asian Pac J Cancer Prev, 2015, 16(17):7457-7461.
[6] 罗舟, 吴菁菁, 章佳新, 等. 甲状腺术中依据右侧颈总动脉与喉返神经交叉点寻找右侧喉返神经的可行性[J]. 局解手术学杂志, 2021,30(11):983-987.
[7]GAMBARDELLA C, POLISTENA A, SANGUINETTI A, et al. Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill?[J]. Int J Surg, 2017, 41 (Suppl 1):S55-S59.
[8] LING X Y, SMOLL N R. A systematic review of variations of the recurrent laryngeal nerve[J]. Clin Anat, 2016, 29(1):104-110.
[9] 李治, 屈新才, 程波, 等. 甲状腺术后喉返神经损伤的原因分析与预防[J]. 中华普通外科杂志, 2008, 23(2):146-147.
[10] 李春华, 王朝晖, 陈锦, 等. 分化型甲状腺癌再手术的并发症预防[J]. 中华内分泌外科杂志, 2017, 11(4).
[11] 刘溦薇, 邓先兆, 樊友本, 等. 甲状腺术中喉返神经的损伤和预防[J]. 国际外科学杂志, 2015, 42(2): 122-126.
[12] 邵堂雷, 吴志浩, 丁昊, 等. 甲状腺术后迟发性出血的临床分析[J]. 中华普通外科杂志, 2012, 27(10): 841-842.
[13] 焦梦思, 范宁, 石玉琦, 等. 喉返神经入喉处的精细解剖学研究[J]. 中国临床解剖学杂志, 2021,39(6):642-645.
[14] 管小青, 顾书成, 吴骥, 等. 喉返神经损伤原因及预防[J]. 中华内分泌外科杂志, 2012, 6(6):401-403.
[15] HAYWARD N J, GRODSKI S, YEUNG M, et al. Recurrent laryngeal nerve injury in thyroid surgery: a review[J]. ANZ J Surg, 2013, 83(1-2):15-21.
[16] MOHAMED B, SALAH T, REEM A. Recurrent laryngeal nerve injury and hypoparathyroidism rates in reoperative thyroid surgery[J]. Turk J Surg, 2017, 33(1):14-17.
[17] CHIANG F Y, WANG L F, HUANG Y F, et al. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve[J]. Surgery, 2005, 137(3):342-347.
[18] JAENSSON M, OLOWSSON L U. Endotracheal tube size and sore throat following surgery: a randomized-controlled study[J]. Acta Anaesthesiol Scand, 2010, 54(2): 147.
[19] 王松祥, 黄黎明. 甲状腺术后声音嘶哑的原因分析及对策[J]. 浙江创伤外科, 2017(4): 697-698.
[20] 关军鹏, 王永乾, 王成, 等. 喉返神经探查在甲状腺手术中的应用[J]. 中国现代普通外科进展, 2020,23(12):957-959.
[21] 田文, 张浩. 甲状腺外科能量器械应用专家共识(2017版)[J]. 中国实用外科杂志, 2017,37(9):992-997.
[22] 汤和伟. 甲状腺手术中应用精细化被膜解剖法对预防喉返神经与甲状旁腺损伤的效果观察[J]. 航空航天医学杂志, 2021,32(10):1163-1164.