Thermann M, Feltkamp M, Elies W, Windhorst T
Klinik für Allgemein- und Thoraxchirurgie, Städtische Kliniken Bielefeld-Mitte.
Chirurg. 1998 Sep;69(9):951-6. doi: 10.1007/s001040050520.
In the period of 1 January 1990 to 31 December 1996 the thyroidectomy cases we performed were immediately followed by vocal cord evaluation using a flexible bronchoscope while the patient was still on the operating table. If an obvious cord paralysis was discovered, an exploration of the recurrent laryngeal nerve, to the level of the larynx, was performed. If the nerve was found to be intact, no further measures were taken. A severed nerve underwent suture repair. If an otolaryngologist diagnosed a vocal cord paralysis 1-5 days after surgery, a reoperation was recommended except in the cases where postoperative bronchoscopy had shown an easily mobile cord or the recurrent nerve was completely dissected during the operation. Within this 7-year period, we performed 3492 thyroidectomy operations. The diagnosis of subsequent unilateral postoperative vocal cord paralysis occurred in 48 cases. In 33 of these cases the status of the nerve in the surgical field was known: 4 patients had an intact nerve proved by complete dissection during thyroidectomy, in two patients the lesions of the nerve were detected intraoperatively (1 transsection, 1 partial resection), and 27 cases were followed by reoperation. Of the 33 patients mentioned above, in 19 instances the recurrent laryngeal nerve was found to be intact; 3 displayed signs of local trauma, and 11 were found to be severed with total discontinuity. Those patients with an intact nerve, or local nerve trauma only, went on to develop normal function within 6 months in 20 (91%) of 22 cases. Of the 11 with a severed nerve, 8 showed "autoparalysis" with good voice within 4-8 months, after suture repair in 10 cases. The patient with partial resection had no repair of the nerve. If immediate postoperative evaluation showed mobility of the vocal cords but a paralysis was detected later by an otolaryngologist and repeat intervention was not done, vocal cord function was spontaneously restored in 9 of 11 patients. Four patients refused reoperation. From 1990 to 1991, the recurrent laryngeal nerve was not always dissected during our thyroidectomy operations. However, this was done routinely from 1991 to 1996. Routine intraoperative dissection of the vocal cord nerve reduced the rate of postoperative cord paralysis from 2.0% to 1.2%. It also reduced the frequency of intraoperative nerve injury with total discontinuity from 0.58% to 0.23%.
在1990年1月1日至1996年12月31日期间，我们对接受甲状腺切除术的患者，在其仍处于手术台上时，立即使用可弯曲支气管镜进行声带评估。如果发现明显的声带麻痹，则对喉返神经进行探查，直至喉部水平。如果发现神经完好无损，则不再采取进一步措施。对于切断的神经进行缝合修复。如果耳鼻喉科医生在术后1 - 5天诊断出声带麻痹，除了术后支气管镜检查显示声带易于活动或术中已完全解剖喉返神经的情况外，建议再次手术。在这7年期间，我们共进行了3492例甲状腺切除术。术后发生单侧声带麻痹的诊断有48例。在其中33例中，手术视野中神经的状况已知：4例患者在甲状腺切除术中通过完全解剖证明神经完好无损，2例患者术中检测到神经损伤（1例横断，1例部分切除），27例进行了再次手术。在上述33例患者中，19例喉返神经完好无损；3例有局部创伤迹象，11例神经被切断且完全中断。那些神经完好无损或仅有局部神经创伤的患者，22例中有20例（91%）在6个月内恢复正常功能。在11例神经被切断的患者中，10例进行缝合修复后，8例在4 - 8个月内出现“自行麻痹”且声音良好。部分切除的患者未进行神经修复。如果术后立即评估显示声带活动，但后来耳鼻喉科医生检测到麻痹且未进行再次干预，11例患者中有9例声带功能自发恢复。4例患者拒绝再次手术。1990年至1991年期间，我们在甲状腺切除术中并非总是解剖喉返神经。然而，1991年至1996年期间常规进行此项操作。术中常规解剖声带神经使术后声带麻痹率从2.0%降至1.2%。它还将术中神经完全中断损伤的频率从0.58%降至0.23%。
