Ve sdělení autoři shrnují patofyziologii poranění nervů, pojednávaj í o diagnostice lézívratného nervu, o indikaci jeho revize, včetně chirurgických poznámek, a o léčebných metodáchobrn hlasivek. Popisují výsledky dekompresí a sutur vratného nervu poraněného při strumektomiiu 21 nemocných (30 vratných nervů) a stehu bloudivého nervu po řezném ztrátovém poranění nakrku u jednoho pacienta. Průměrná doba sledování činila 2,6 roku s rozmezím 10 měsíců až 5 let.Dekomprimovali 17 nervů, 1krát užili fibrinové lepidlo u částečně přerušeného rekurentu a 13nervů autoři sešili.Zkušenosti autorů vycházejí z 807 tyroidektomií, při kterých rutinně vizualizují vratný nerv. Dvědekomprese a dvě úspěšné peroperační sutury rekurentu pocházejí z vlastního souboru operovaných nemocných, ostatní revize vratného nervu byly doporučeny z jiných pracovišť. Výsledky autoři objektivizovali laryngostroboskopickým vyšetřením a 7krát provedli elektromyografii hrtanových svalů. EMG vyšetření korelovalo s klinickým nálezem. Výsledky dekompresíi sutur vratného nervu byly velmi dobré u časných revizí, tj. do sedmi dnů od vzniku léze postrumektomii.

The authors summarize the results of decompressions and sutures of the recurrent laryngeal nerve injured during strumectomy in 21 patients (30 recurrent nerves used to bridge the defect between stumps of the recurrent nerve without tension), 4 times they made an anastomosis of the distal stump of the recurrent nerve with the r. descendens of the n. hypoglossi, in one instance anastomosis of the recurrent nerve with the vagus (its distal cervical portion was resected on account of a neurinoma propagating into Hashimoto’s goitre) and in one instance they sutured the vagus using an autograft. The authors’ experience is based on 807 thyroidectomies, where they visualize as a matter of routine the recurrent nerve. Two decompressions and two successful peroperative sutures of the recurrent nerve were made in the authors patients, the other revisions were referred from other departments. Twelve times the paresis of the vocal cord was unilateral. Ten times a bilateral lesion was involved, which called for urgent tracheotomy in nine patients due to severe inspiration dyspnoea with stridor. Only one female patient with bilateral paresis of the vocal cords was able to avoid tracheotomy. Localization of the nervous lesion regardless of the type of injury: 15 times the area of Berry’s ligament. 7 times at the site of crossing of the recurrent with the lower thyroid artery, 4 times caudally from the crossing of the n. recurrens with the lower thyroid artery and 4 times the nerve was compressed by a tough modular goitre. The autors expressed the results objectively by laryn- gostroboscopic examination and 7 times they used electromyography of the laryngeal muscles. EMG examination correlated with the clinical finding. The results of decompression and sutures of the recurrent nerve were very satisfactory in early revisions, i.e. within 7 days after development of the lesion following strumectomy. After early decompression in 11 patients the mobility of the vocal cord and phonation was restored perfectly. In two instances only the adduction movement of the vocal cord was restored and the occlusion of the intramembraneous rimae and voice improved. Decompression of the nerve com- pressed by the goitre (clinically manifested by paresis of the vocal cord for several months) led three times to improved mobility of the vocal cord by cca one third and to improvement of the voice. In one instance this late decompression was not successful. The results of early sutures of the recurrent nerve were very good. Ten times there was partial adjustment of the adduction of the vocal cord, the phonation closure improved and there was significant improvement of the voice. In one instance the suture failed (it may have been however associated strain on the nerve at another site). In one instance the authors did not evaluate the effect of laterofixation of the ipsilateral vocal cord which the patient refused to eliminate. Bilateral suture of the nerve three months after development of the lesion was not a success. All nine patients with bilateral paresis of the vocal cords were decannulated. The mean period before decannulation was four months (range three weeks to one year). The prerequisite of decannulation was an adequate width of the intermembraneous rima. In two patients the lumen of the larynx was enlarged by chordectomxy and in one patient by chordedectomy with arytenoidectomy and insertion of a spacer from the thyroid cartilage into the anterior commissure. The authors recommend laryngoscopic examination on the day after strumectomy and early microsurgical revision of the injured recurrent nerve, preferably during operation or on the first day after surgery, but not laster than after seven days. Early suture of the recurrent nerve is considered the method of choice. If the surgeon visualized and saved the recurrent nerve during surgery, possible paresis of the vocal cord improves as a rule spontaneously and revision is therefore not necessary. Phoniatric reeducation and possible phonosurgical surgery of the larynx are part of patient care in injuries of the recurrent nerve.

ORL klinika 3 LF UK a FNKV Praha

Results of decompressions and sutures of an injured recurrent laryngeal nerve

Výsledky dekompresí a sutur poraněného vratného nervu = Results of decompressions and sutures of an injured recurrent laryngeal nerve /

Lit: 25

Souhrn: eng