特发性声带麻痹患者喉返神经及环杓后肌形态学观察

发布时间：2019-07-03 12:51

【摘要】：目的：观测特发性声带麻痹的喉返神经、环杓后肌和运动终板的组织形态学改变,旨在探讨特发性声带麻痹是否存在喉返神经修复的组织学基础。材料及方法：2014年2月至2015年2月期间我科收治特发性声带麻痹17例纳入本研究。纳入标准为不明原因的声带麻痹,排除颅底、颈部、胸部、纵膈肿瘤、脑部病变等致病可能,且接受6个月以上营养神经等保守治疗后声音无改善或不明显,自愿接受患侧杓状软骨内收联合喉返神经修复术。根据病程分为三个组：①0.5-1年组(男3例、女3例、年龄42.0±19.96岁),②1-2年组(男1例、女4例、年龄50.60±14.67岁),③2年组(男3例、女3例、年龄35.33±11.37岁)。正常喉返神经及环杓后肌(取自喉癌行全喉切除患者)作为正常对照组。取受损侧喉返神经(11例)行甲苯胺兰染色,光镜观察喉返神经干并作有髓神经纤维计数,电镜观察喉返神经超微形态结构变化。受损侧环杓后肌(17例)行Masson三色染色,用Image Pro Plus图像分析系统分析肌纤维相对截面积和胶原纤维相对截面积两个指标。环杓后肌(10例)行乙酰胆碱酯酶染色,观测运动终板的数量变化及形态结构改变。采用SPSS 18.0软件进行实验数据统计分析,P0.05为差异有统计学意义。结果：1、特发性声带麻痹的喉返神经组织学及超微结构变化光镜下显示随着病程的延长,喉返神经有髓神经纤维数逐渐减少：透射电镜观测到以厚髓神经纤维(神经纤维直径较大)减少为主,喉返神经脱髓鞘程度随病程的延长呈逐渐加重趋势,表现为髓鞘肿胀空泡化、细胞器密集、髓鞘板层松解脱落和大量Bungner带分布。但有2个病例例外,病例1的病程虽很短,仅为0.5年,但喉返神经严重脱髓鞘,有髓神经纤维大量减少；而病例6的病程虽长达4年,光镜和电镜所见喉返神经脱髓鞘现象较轻,存在大量厚髓神经纤维和薄髓神经纤维。提示特发性声带麻痹的神经损伤程度与病程有一定关系,病程越长病变越重,但存在很大个体差异。2、特发性声带麻痹环杓后肌形态学观察随着病程的延长,特发性声带麻痹环杓后肌的肌纤维截面积逐渐减小,而胶原纤维面积逐渐增加。肌肉／胶原截面积的比率逐渐下降,0.5-1年组比正常对照组下降75.14%,1-2年组比0.5-1年组下降52.68%,2年组比1-2年组下降18.63%。特发性声带麻痹各组环杓后肌的肌肉相对截面积和胶原相对截面积与正常对照组比较差异均有统计学意义(P均0.05),0.5-1年组与1-2年组及2年组比较差异均具有统计学意义(P均0.05),而2年组和1-2年组之间比较差异无统计意义。相同病程亚组的特发性声带麻痹环杓后肌与课题组前期创伤性声带麻痹环杓后肌的研究数据进行比较,二者各亚组之间的差异均无统计学意义(P均0.05)。但特发性声带麻痹组有的病例尽管病程长达10年,但环杓后肌萎缩纤维化并不严重,而有的病例病程虽然只有1.5年,但肌肉萎缩却非常明显,提示特发性声带麻痹环杓后肌萎缩纤维化程度总体随病程延长而加重,但也存在个体差异。3、特发性声带麻痹环杓后肌运动终板形态学观察病程2年内的环杓后肌尚存在大量运动终板,运动终板结构清晰、在肌肉中部形成运动终板带,与肌纤维几近垂直,形态接近正常,尤其以0.5-1年内运动终板形态结构完整,1-2年内虽有一定数目的运动终板,但形状不规则,表现为固缩变小,边缘不清。而病程超过2年的病例,环杓后肌运动终板非常明显减少,在残存的萎缩的肌纤维表面存在零星散在的少量运动终板。结论：随着特发性声带麻痹病程的延长,喉返神经脱髓鞘程度逐渐加重、有髓神经纤维数目逐渐减少,直径缩小,形态不规则；环杓后肌萎缩纤维化逐渐加重,纤维结缔组织逐渐增生；运动终板数目逐渐减少,且形态越为异常。但少数病例并不符合这种规律,存在很大的个体差异。病程1-2年是喉返神经干、环杓后肌和运动终板组织形态超微结构改变最明显的阶段,病程小于2年神经、肌肉及运动终板形态相对较好,提示在此期间行喉返神经修复具有组织学基础,但个体差异大,需结合肌电图等其它指标综合判断。
[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.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R767.4

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