Výsledky dekompresí a suturporaněného vratného nervu

Results of Decompressions and Sutures of an Injured Recurrent Laryngeal Nerve

The authors summarize the results of decompressions and sutures of the recurrentlaryngeal nerve injured during strumectomy in 21 patients (30 recurrent nerves used to bridge thedefect between stumps of the recurrent nerve without tension), 4 times they made an anastomosisof the distal stump of the recurrent nerve with the r. descendens of the n. hypoglossi, in one instanceanastomosis of the recurrent nerve with the vagus (its distal cervical portion was resected onaccount of a neurinoma propagating into Hashimoto’s goitre) and in one instance they sutured thevagus using an autograft.The authors’ experience is based on 807 thyroidectomies, where they visualize as a matter of routinethe recurrent nerve. Two decompressions and two successful peroperative sutures of the recurrentnerve 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’sligament. 7 times at the site of crossing of the recurrent with the lower thyroid artery, 4 timescaudally from the crossing of the n. recurrens with the lower thyroid artery and 4 times the nervewas 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. EMGexamination correlated with the clinical finding.The results of decompression and sutures of the recurrent nerve were very satisfactory in earlyrevisions, 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 restoredperfectly. In two instances only the adduction movement of the vocal cord was restored and theocclusion 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 threetimes to improved mobility of the vocal cord by cca one third and to improvement of the voice. Inone instance this late decompression was not successful.The results of early sutures of the recurrent nerve were very good. Ten times there was partialadjustment of the adduction of the vocal cord, the phonation closure improved and there wassignificant improvement of the voice. In one instance the suture failed (it may have been howeverassociated strain on the nerve at another site). In one instance the authors did not evaluate theeffect of laterofixation of the ipsilateral vocal cord which the patient refused to eliminate. Bilateralsuture 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 beforedecannulation was four months (range three weeks to one year). The prerequisite of decannulationwas an adequate width of the intermembraneous rima. In two patients the lumen of the larynx wasenlarged 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 earlymicrosurgical revision of the injured recurrent nerve, preferably during operation or on the firstday after surgery, but not laster than after seven days. Early suture of the recurrent nerve isconsidered the method of choice. If the surgeon visualized and saved the recurrent nerve duringsurgery, possible paresis of the vocal cord improves as a rule spontaneously and revision is thereforenot necessary.Phoniatric reeducation and possible phonosurgical surgery of the larynx are part of patient care ininjuries of the recurrent nerve.

Key words:
recurrent laryngeal nerve, injury, regeneration, suture of the nerve, thyroid gland,strumectomy.