摘要
双侧喉返神经(RLN)麻痹常由颈部手术、外伤、肿瘤等引起。麻痹声带位于旁中位，常引起严重的呼吸困难，甚至窒息。临床上对此类病人需行气管切开、杓状软骨切除或声带外移固定术，导致其长期带气管套管生活，且丧失发音功能。因此，能否通过恢复环杓后肌(PCAM)的神经支配而使声带恢复主动性外展，从而解决呼吸困难，成为近几十年来喉科领域内令人关注的课题。
对RLN麻痹应选择性地恢复喉肌功能，已为多数学者所接受。近年来国内外多选用膈神经(PN)与RLN吻合，并切断RLN内收肌支来选择性支配环杓后肌。但该术式同时存在如下问题：切断一侧PN后将导致同侧膈肌麻痹，故不能用于双侧喉返神经麻痹。如能够既恢复PCAM的神经支配，又不牺牲PN，不损害膈肌的功能，则是一种较理想的手术，这可通过近年来发展起来的神经端侧吻合技术来实现。
应用神经端侧吻合技术来重建PCAM的功能，国内外尚未见报道。本实验的目的是：在建立RLN单侧麻痹模型上，研究RLN-PN端侧吻合术重建PCAM功能的可行性及疗效，并将RLN-PN端侧
郑州大学2002年硕士毕业论文 神经端侧吻合术重建环构后肌功能的实验研究
吻合术与 RLNPN端端吻合术和 RLN端端吻合术做一比较，以
探讨双侧RLN麻痹的手术治疗方式。
方法：手术采用WIStar大鼠，分成RLNFN端侧吻合组（A
组人RLNIN端端吻合组旧组），RLN端端吻合组瞩组）和
不吻合组（D组人 每组15只动物。在手术显微镜下分离并切断
右侧hN建立大鼠右侧RLN麻痹模型。对各吻合组动物，暴露
RLN在喉内分支处，切断其内收肌支。对A组动物，暴露右侧颈
根部 PN，在其内侧面开窗，将 RLN远侧断端修剪成 45‘斜面后，
吻合于PN开窗处；对B组动物，在胸廓入口处切断PN，返转后
引向气管食管沟与RLN远侧断端吻合；C组动物，亘接将RLN
端端吻合；D组动物，将切断后的RLN两断端结扎。术后当时行
喉镜检查以证实右侧声带固定于旁中位。术后饲养到二个月时再
行纤维喉镜检查，以观察右侧声带外展恢复情况，并行双侧PCAM
肌电图检查，得出术侧与健侧诱发动作电位潜伏期和峰值的恢复
率。上述检查后取下所有动物的双侧PCAM，固定后常规病理切
片观察肌肉萎缩情况，术侧与健侧相比，得出其恢复率。
结果：术后2个月时门）纤维喉镜检查发现右侧声带运动恢
复情况，C组效果最好，D组全部未恢复。A组、B组与C组相
比，差异均有显著性中＜0刀5人A组与B组相比，差异无显著性
中叩刀5）；Q）P＊AM肌电图检查显示，各吻合组均可记录到术”
侧PCAM自发及诱发肌电活动，不吻合组显示为纤颤波。诱发动
作电位潜伏期与峰值的恢复率，C组结果最好，A组、B组与C
组相比，差异均有显著性0叩刀5人A组与B组相比，差异无显
著性0功刀5人（3组织学检查发现，不吻合组＊＊AM肌纤维萎
2
郑州大学20肥年硕士毕业论文 神经端侧吻合术重建环构后肌功能的实验研究
缩明显，肌细胞间隙明显增宽，且有大量结缔组织；各吻合组PCAM
肌纤维萎缩不明显。显微镜下计数每高倍视野下肌纤维数目显示
C组己恢复正常，A组、B组恢复较差，A组、B组与C组相比，
差异有显著性0＜0刀5人A组与B组相比，差异无显著性中＞0刀5人
结论：（）RLNPN端侧吻合术的效果同RLNPN端端吻合
术，可用于双侧RLN麻痹的治疗。
u）RLN端端吻合术的效果优于RLNIN端端、端侧
吻合术。
Bilateral paralysis of the recurrent laryngeal nerve (RLN), most often caused by cervical operation, trauma and tumor, brings the vocal cords to a fixed paramedian position that results in a severe impairment of respiration. Relief of the inspiratory dyspnea is currently obtained either by tracheostomy or by surgical procedures such as arytenoidectorry or arytenoidopexy. Those patients, however, pay for the respiratory improvement both with the discomfort of a permanent tracheostomy and with the losing of the phonatory function. So, a more convenient approach to rehabilitation of bilateral paralysis of the larynx seems to be that aimed at reestablishing the inspiratory opening of the glottis through reinnervation of the posterior cricoarytenoid muscles (PC AM).
Many researchers agree that it should selectively restore the function of laryngeal muscles. The operation method, suturing the phrenic nerve(PN) to the distal stump of the RLN after intralaryngeal
sectioning of its adductor branch, was widely adopted in this area. But it can't be used to bilateral paralysis of RLN. The ideal method is to obtain reinnervation of the PCA muscles and intact phrenic nerve. It can be obtained by end-to-side neurorrhaphy technique.
There was no same report about reconstructing the function of PCAM by end -to- side neurorrhaphy. The aim of this research is to study the feasibility and effect of RLN-PN end-to-side neurorrhaphy, compared with RLN-PN end-to-end neurorrhaphy and RLN anastomosis, in order to find a rational operation for bilateral paralysis of the RLN.
Methods: Sixty rats were divided into four groups at random: RLN-PN end-to-side neurorrhaphy (Group A ), RLN-PN end-to-end neurorrhaphy (Group B ), RLN anastomosis (Group C),Control group(Group D),every group has 15 rats. Under the operative microscope, the right RLNs were separated and cut to prepare the model of unilateral paralysis of RLN. To every anastomotic group, the RLNs were dissected distally to its terminal branches, where the adductor-abductor sorting out occurs. Then the adductor branches were cut. To Group A, after exposing the right PN at cervical part, a window was opened at the PN epineurium, then suture the distal RLN (45?angle bevel) to the window .To Group B, the right PNs were cut at the entrance of thorax, the distal end of PNs were reversed and sutured to the distal end of RLNs end-to-end. To Group C, the RLNs were sutured directly. To control group, the RLNs were severed and ligated.
After operation, all the rats were examined by fiberolaryngoscope to confirm that the right RLNs were fixed at paramedian position. After 2 months, the recovery of abduction was investigated and recorded by fiberolaryngoscope. Then, the electromyogram of bilateral PCAMs were examined by electromyograph, obtained the recovery ratio of induced active potential latency and peak value. After these examinations, the PCAMS were resected, fixed and stained to evaluate the musle atrophy, obtained recovery
Results: (l)Two months after operation, fiberolaryngoscope was used to examine the recovery of right vocal cords' movement, showing that Group C was the best, Group D was the worst .There were significant differences between Group A, Group B and Group C (P<0.05 ). There were no significant difference between Group A and Group B (P>0.05). (2)Three anastomostic group can record spontaneous and induced myoelectric activity. Group D could only record fibrillation potential. The recovery ratio of latency and peak value showed that Group C was the best. There were significant difference beween Group A, Group B and Group C (p<0.05) There were no significant difference between Group A and Group B(P>0.05). (3)Histological examination showed that there were apparent myoatrophy among Control group. The tap between muscle fibers became wide and connective tissues proliferated. Under the microscope, computing the fiber mumbers in each high power field showed that Group C had recovered to normality. There were
significant differences between Group A, Group B and
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