發(fā)布時間：2019-07-03 12:51

【摘要】：目的：觀測特發(fā)性聲帶麻痹的喉返神經(jīng)、環(huán)杓后肌和運動終板的組織形態(tài)學改變,旨在探討特發(fā)性聲帶麻痹是否存在喉返神經(jīng)修復的組織學基礎(chǔ)。材料及方法：2014年2月至2015年2月期間我科收治特發(fā)性聲帶麻痹17例納入本研究。納入標準為不明原因的聲帶麻痹,排除顱底、頸部、胸部、縱膈腫瘤、腦部病變等致病可能,且接受6個月以上營養(yǎng)神經(jīng)等保守治療后聲音無改善或不明顯,自愿接受患側(cè)杓狀軟骨內(nèi)收聯(lián)合喉返神經(jīng)修復術(shù)。根據(jù)病程分為三個組：①0.5-1年組(男3例、女3例、年齡42.0±19.96歲),②1-2年組(男1例、女4例、年齡50.60±14.67歲),③2年組(男3例、女3例、年齡35.33±11.37歲)。正常喉返神經(jīng)及環(huán)杓后肌(取自喉癌行全喉切除患者)作為正常對照組。取受損側(cè)喉返神經(jīng)(11例)行甲苯胺蘭染色,光鏡觀察喉返神經(jīng)干并作有髓神經(jīng)纖維計數(shù),電鏡觀察喉返神經(jīng)超微形態(tài)結(jié)構(gòu)變化。受損側(cè)環(huán)杓后肌(17例)行Masson三色染色,用Image Pro Plus圖像分析系統(tǒng)分析肌纖維相對截面積和膠原纖維相對截面積兩個指標。環(huán)杓后肌(10例)行乙酰膽堿酯酶染色,觀測運動終板的數(shù)量變化及形態(tài)結(jié)構(gòu)改變。采用SPSS 18.0軟件進行實驗數(shù)據(jù)統(tǒng)計分析,P0.05為差異有統(tǒng)計學意義。結(jié)果：1、特發(fā)性聲帶麻痹的喉返神經(jīng)組織學及超微結(jié)構(gòu)變化光鏡下顯示隨著病程的延長,喉返神經(jīng)有髓神經(jīng)纖維數(shù)逐漸減少：透射電鏡觀測到以厚髓神經(jīng)纖維(神經(jīng)纖維直徑較大)減少為主,喉返神經(jīng)脫髓鞘程度隨病程的延長呈逐漸加重趨勢,表現(xiàn)為髓鞘腫脹空泡化、細胞器密集、髓鞘板層松解脫落和大量Bungner帶分布。但有2個病例例外,病例1的病程雖很短,僅為0.5年,但喉返神經(jīng)嚴重脫髓鞘,有髓神經(jīng)纖維大量減少；而病例6的病程雖長達4年,光鏡和電鏡所見喉返神經(jīng)脫髓鞘現(xiàn)象較輕,存在大量厚髓神經(jīng)纖維和薄髓神經(jīng)纖維。提示特發(fā)性聲帶麻痹的神經(jīng)損傷程度與病程有一定關(guān)系,病程越長病變越重,但存在很大個體差異。2、特發(fā)性聲帶麻痹環(huán)杓后肌形態(tài)學觀察隨著病程的延長,特發(fā)性聲帶麻痹環(huán)杓后肌的肌纖維截面積逐漸減小,而膠原纖維面積逐漸增加。肌肉／膠原截面積的比率逐漸下降,0.5-1年組比正常對照組下降75.14%,1-2年組比0.5-1年組下降52.68%,2年組比1-2年組下降18.63%。特發(fā)性聲帶麻痹各組環(huán)杓后肌的肌肉相對截面積和膠原相對截面積與正常對照組比較差異均有統(tǒng)計學意義(P均0.05),0.5-1年組與1-2年組及2年組比較差異均具有統(tǒng)計學意義(P均0.05),而2年組和1-2年組之間比較差異無統(tǒng)計意義。相同病程亞組的特發(fā)性聲帶麻痹環(huán)杓后肌與課題組前期創(chuàng)傷性聲帶麻痹環(huán)杓后肌的研究數(shù)據(jù)進行比較,二者各亞組之間的差異均無統(tǒng)計學意義(P均0.05)。但特發(fā)性聲帶麻痹組有的病例盡管病程長達10年,但環(huán)杓后肌萎縮纖維化并不嚴重,而有的病例病程雖然只有1.5年,但肌肉萎縮卻非常明顯,提示特發(fā)性聲帶麻痹環(huán)杓后肌萎縮纖維化程度總體隨病程延長而加重,但也存在個體差異。3、特發(fā)性聲帶麻痹環(huán)杓后肌運動終板形態(tài)學觀察病程2年內(nèi)的環(huán)杓后肌尚存在大量運動終板,運動終板結(jié)構(gòu)清晰、在肌肉中部形成運動終板帶,與肌纖維幾近垂直,形態(tài)接近正常,尤其以0.5-1年內(nèi)運動終板形態(tài)結(jié)構(gòu)完整,1-2年內(nèi)雖有一定數(shù)目的運動終板,但形狀不規(guī)則,表現(xiàn)為固縮變小,邊緣不清。而病程超過2年的病例,環(huán)杓后肌運動終板非常明顯減少,在殘存的萎縮的肌纖維表面存在零星散在的少量運動終板。結(jié)論：隨著特發(fā)性聲帶麻痹病程的延長,喉返神經(jīng)脫髓鞘程度逐漸加重、有髓神經(jīng)纖維數(shù)目逐漸減少,直徑縮小,形態(tài)不規(guī)則；環(huán)杓后肌萎縮纖維化逐漸加重,纖維結(jié)締組織逐漸增生；運動終板數(shù)目逐漸減少,且形態(tài)越為異常。但少數(shù)病例并不符合這種規(guī)律,存在很大的個體差異。病程1-2年是喉返神經(jīng)干、環(huán)杓后肌和運動終板組織形態(tài)超微結(jié)構(gòu)改變最明顯的階段,病程小于2年神經(jīng)、肌肉及運動終板形態(tài)相對較好,提示在此期間行喉返神經(jīng)修復具有組織學基礎(chǔ),但個體差異大,需結(jié)合肌電圖等其它指標綜合判斷。
[Abstract]:Objective: To observe the changes of the morphological changes of the recurrent laryngeal nerve, the posterior muscle and the motor end plate of the idiopathic vocal cord paralysis. The purpose of this study is to explore the histological basis of the repair of recurrent laryngeal nerve in idiopathic vocal cord paralysis. Materials and Methods:17 cases of idiopathic vocal cord paralysis were included in the study from February 2014 to February 2015. The inclusion of the standard for vocal cord paralysis with unknown causes, excluding the possible causes such as the skull base, the neck, the chest, the mediastinal tumor, the brain pathological changes, and the like, and has no improvement or no obvious sound after the conservative treatment such as the vegetative nerve and the like is accepted for more than 6 months, Voluntary acceptance of the combined recurrent laryngeal nerve repair in the affected side of the cartilage. According to the course of course, three groups were divided into three groups:1-1-year-old (3 males,3 females, 42.0-19.96 years),1-2 years (1 male,4 females, 50.60-14.67 years), and 2-year-old (3 males and 3 females, and 35.33 to 11.37 years). The normal laryngeal nerve and the posterior muscle of the ring (taken from the total laryngectomy of the laryngeal carcinoma) were used as the normal control group. The recurrent laryngeal nerve (11 cases) was stained with toluidine blue, the recurrent laryngeal nerve was observed by light microscope and the nerve fiber was counted, and the micromorphological structure of the recurrent laryngeal nerve was observed by electron microscope. The relative cross-sectional area of the muscle fibers and the relative cross-sectional area of the collagen fibers were analyzed by image Pro Plus image analysis. The changes of the number and the morphological structure of the motor endplates were observed by B-choline esterase staining in the posterior muscle of the ring (10 cases). The statistical analysis of experimental data was performed with SPSS 18.0 software, and the difference was statistically significant. Results:1. The histological and ultrastructural changes of the recurrent laryngeal nerve of the idiopathic vocal cord paralysis showed that the number of the nerve fibers in the recurrent laryngeal nerve gradually decreased with the prolongation of the course of the disease. The degree of defibrination of the recurrent laryngeal nerve is gradually increasing with the prolongation of the course of the disease, which is characterized by the swelling and vacuolation of the pulp, the dense organelles, the release of the lamina of the pulp and the distribution of a large number of Bungner belts. However, there were 2 cases with the exception, the course of the case 1 was very short, only 0.5 year, but the recurrent laryngeal nerve was severely defibrinated, and the myelinated nerve fiber was greatly reduced; while the course of the case 6 was 4 years, the phenomenon of the recurrent laryngeal nerve was lighter in light and electron microscope. There are a large number of thick and thin myelinated nerve fibers. It is suggested that the degree of the nerve injury of the idiopathic vocal cord paralysis is related to the course of the disease. The longer the course of the disease, the more the lesion is, but there is a great individual difference. The cross-sectional area of the muscle fibers of the posterior muscle of the idiopathic vocal cord paralysis is gradually reduced, and the area of the collagen fiber is gradually increased. The ratio of the cross-sectional area of the muscle/ collagen gradually decreased, the group of the 0.5-1 year group decreased by 75.14% compared with the normal control group, the group decreased by 52.68% in the 1-2 year group compared with the normal control group, and the 2-year group decreased by 18.63% over the 1-2 year group. The relative cross-sectional area of the muscle and the relative cross-sectional area of the muscle in the patients with idiopathic vocal cord paralysis were significantly different from those in the normal control group (P <0.05). The difference of the relative cross-sectional area and the relative cross-sectional area of the collagen in the control group was statistically significant (P <0.05), and the difference of the relative cross-sectional area of the muscle and the group of the 2-year group was statistically significant (P <0.05). There was no statistical significance between the 2-year group and the 1-2-year group. In the same course, the patients with idiopathic vocal cord paralysis were compared with the study data of the post-traumatic vocal cord paralysis of the post-traumatic vocal cord paralysis, and the difference between the two groups was not statistically significant (P <0.05). But in the idiopathic vocal cord paralysis group, although the course of the disease is up to 10 years, the amyotrophic fibrosis of the ring is not serious, and the course of the case is only 1.5 years, but the muscle atrophy is very obvious, It is suggested that the degree of amyotrophic fibrosis of the idiopathic vocal cord paralysis is increased with the prolongation of the course of the disease, but there are individual differences. In the middle part of the muscle, the motor endplate band is formed, and is nearly vertical to the muscle fiber, and the shape is close to normal. In particular, the structure of the motor endplate is complete during the period of 0.5 -1 year, but the shape is irregular, the shape is irregular, the expression is reduced, and the edge is not clear. In the case of more than 2 years of course, the motor end plates of the posterior muscle of the ring were significantly reduced, and a small amount of the moving end plates were scattered on the surface of the remaining atrophic muscle fibers. Conclusion: With the prolongation of the course of the idiopathic vocal cord paralysis, the degree of the defibrination of the recurrent laryngeal nerve is gradually increased, the number of the myelinated nerve fibers is gradually reduced, the diameter is reduced, the shape is irregular, the amyotrophic fibrosis of the ring is gradually increased, and the fibrous connective tissue gradually increases. The number of motor end plates is gradually reduced and the shape of the motor end plates is abnormal. But a few cases do not accord with this rule, there is a great individual difference. During the course of 1-2 years, the morphological ultrastructures of the recurrent laryngeal nerve, the posterior muscle of the ring and the end-plate of the motor endplate were changed to the most obvious stage, the course of the course was less than 2 years, the shape of the muscle and the motor endplate was relatively good, suggesting that the recurrent laryngeal nerve repair had a histological basis during this period, but the individual difference was large, And comprehensive judgment is required in combination with other indexes such as electromyography.
【學位授予單位】：第二軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R767.4

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8 岳兵;喉返神經(jīng)及其分支的應(yīng)用解剖學研究[D];吉林大學;2007年

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10 王東;甲狀腺術(shù)中神經(jīng)監(jiān)測肌電信號正常閾值的初步探討[D];青島大學;2012年

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