개의 후두 내전신경 절단과 직접 신경이식이 성대의 외전운동에 미치는 영향

Abstract

[한글]

양측 성대마비의 치료는 영구 기관절개술, 성재절제술, 피열연골절제술, 피열연골고정술 등이 있으나 이 술식들들은 정상구조를 제거해야 하므로 결과가 만족스럽지 못한 경우가 많으며 영구 기관 절재술 또한 일생동안 술후 처치를 받아야 하는 불편함이있다. 따라서 이러한 여러문제점을 개선하고 정상에 가까운 기능 회북을 위한 보존적 수술방법 개발의 필요성이 절실히 요망되어 왔다.

이에 저자는 양측 반회신겨잉 마비되었을 경우에 내전신경을 절단하거나 절단된 내전신경의 근위부를 후윤상피열근에 이식하는 술식이 성대의 외전을 유지할 수 있는지 여부를 알아보고자 본 견구를 시행하였다. 실험동물은 사람의 후두와 유사한 특성을 가진 개를

사용하였으며 개의 반회신경을 절단하여 성대를 마비시킨 다음 신경재식을 유도하기 위하여 단단 문합만 시행한 대조군과 단단 문합술과 내전신경을 절단한 다음 이를 결찰한 군, 단단 문합술과 내전신경을 절단한 다음 신경의 근위부를 후윤상피열근에 이식한 군을 대상으로 하여 수술 후 3개월 이상 경과한 후에 성대의 외전운동 여부 및 빚정상적인 운동 유무와 후윤상피열근의 형태학적 변화를 관찰하여 다음과 같은 결과를 얻었다.

1. 반회신경을 절단한 후 단단문합술만 한 대조군에서는 수술 3개월 후 평상호흡 및 심호흡시 성대의 외전이 없었으며 흡기시 공동운동 (synkinesis)으로 인한 비정상적인 내방융기를 보여 오히려 흡기시 성문의 크기가 감소하였다. 따라서 반회신경 간의 문합술은 신경재식이 잘 되었다 허다라도 양측 성대마비시 외전운동의 개선을 위한 술식으로는 부적합하였다.

2. 단단문합술 후 내전신경을 절단한 군과 내전신경을 이식한 군에서는 ㅗㅇ 7마리 중 한 마리를 제외하고는 내방융기 등의 비정상적인 운동이 없었으며 평상호흡 및 심호흡시 성대의 외전이 있었다.

3. 외전시 성대가 이루는 각도는 대조군에서는 심호흡시에 평상호흡시 보다 의의있게 감소하였으며 내전신경 절단군 및 내전신경 이식군에서는 평상호흡시 보다 심호흡시에 각도가 증가함을 보였다. 절단군 및 이시국ㄴ 사이에서는 두 술식간의 외전 정도의 차이가

없었다.

4. 정상 후윤상피열근은 Ⅰ형의 근섬유가 51%, Ⅱ형의 근섬유가 49$의 구성을 보였으며 대조군, 내전신경을 절단한 군, 내전신경을 이식한 군에서는 재군집현상을 보여 신경재식이 일어났음을 알 수 있었다. 신경재식 후에는 Ⅱ형 근섬유가 다소 증가함을 보였으나

정상근과의 구성의 차이는 5%미만으로 호흡시의 외전기능에는 영향이 없을 것으로 생각되었다.

이상의 결괄로 미루어 볼 때 내전신경을 절단하거나 후윤상피열근에 이식하는 수술방법이 공동운동을 방지함으로써 성대의 외전에 효과적이라고 사료되었다. 따라서 이 방법이 양측 성대마비의 치료방법의 하나로응용될 수 있으리라 생가되며 앞으로 선택적인 문합을 통하여 외전운동 뿐만 아니라 내전운동의 회복도 동시에 도모할 수 있는 술식의 개발도 기대할 수 있다고 생각된다.

The Effect of Selective Section and Direct Nerve Implant of Laryngeal Adductor

Nerve on Vocal Cord Abduction

Eun Chang Choi

Department of Medical Science, The Graduae school, Yonsei University

(Directed by Professor Won Pyo Hong. M.D.)

A multitude of procedures such as cordectomy, arytennoidectomy and arytenoidopexy

have been attempted to ameliorate the problems of bilateral vocal cord paralysis.

Theese methods have partially improved airway symptoms in many patients, while

others have been left with permanant tracheostomy and marginal airway due to

incomplete resuction or senosis. For these reasons, investigators have continuesd

to design operative procedures which might be more physiologic and less

destructive.

The purpose of this study is to know whether selective section or direct implant

of adductor branch of recurrent nerve is possiable or not as a treatment of

bilateral vocal cord paralysis. To this purpose, laryngeal reinnervation procedures

were performed in 10 adult mongrel dogs. Two dogs were used as control, four

animals had selective section of adductor branch an the other four had implant

procedure in which adductor nerve was routed to the posterior cricoarytenoid

muscle. Three months after reinnervation procedures. telelaryngoscopy with

television monitoring, videolaryngography, nerve stimulation test and histochemical

examinations were used to obtain and evaluate data. Results of the study include

the following:

1. Telelaryngoscopy 3 months following reinnervation revealed no abduction during

quiet and deep respiration in control group. Furthermore glottic chink was markedly

decreased due to synkinetic medial bulging of the vocal cord. So neurorhaphy at the

trunk of recurrent nerve was ineffective as a treatment of bilateral vocal cord

paralysis.

2. In experimental group, bocal cord was noted to be abdcted during quiet and

deep respiration except one dog which adductor branch was thought to be avulsed

from the PCA muscle.

3. In control group, angulation of the vocal cord during deep inspiration was

even more decreased than during quiet one. In experimental groups, angle of the

vocal cord was increased during deep inspiration.

4. Reinnervated muscle Showed fiber type grouping. The composition of normal PCA

muscle was type Ⅰ fiber(51%) and type Ⅱ fiber(49%). Type Ⅱ muscle was slightly

increased after reinnervation.

This results suggest that selective section or direct implant of adductor branch

may be effective surgical procedure in some cases with bilateral vocal cord

paralysis. Much more research needs tobe done to improve upon existing techniques

designed to restore both adductive and abductive laryngeal function.

[영문]

A multitude of procedures such as cordectomy, arytennoidectomy and arytenoidopexy have been attempted to ameliorate the problems of bilateral vocal cord paralysis.

Theese methods have partially improved airway symptoms in many patients, while others have been left with permanant tracheostomy and marginal airway due to incomplete resuction or senosis. For these reasons, investigators have continuesd to design operative procedures which might be more physiologic and less destructive.

The purpose of this study is to know whether selective section or direct implant of adductor branch of recurrent nerve is possiable or not as a treatment of bilateral vocal cord paralysis. To this purpose, laryngeal reinnervation procedures

were performed in 10 adult mongrel dogs. Two dogs were used as control, four animals had selective section of adductor branch an the other four had implant procedure in which adductor nerve was routed to the posterior cricoarytenoid muscle. Three months after reinnervation procedures. telelaryngoscopy with television monitoring, videolaryngography, nerve stimulation test and histochemical examinations were used to obtain and evaluate data. Results of the study include the following:

1. Telelaryngoscopy 3 months following reinnervation revealed no abduction during quiet and deep respiration in control group. Furthermore glottic chink was markedly decreased due to synkinetic medial bulging of the vocal cord. So neurorhaphy at the trunk of recurrent nerve was ineffective as a treatment of bilateral vocal cord paralysis.

2. In experimental group, bocal cord was noted to be abdcted during quiet and deep respiration except one dog which adductor branch was thought to be avulsed from the PCA muscle.

3. In control group, angulation of the vocal cord during deep inspiration was even more decreased than during quiet one. In experimental groups, angle of the vocal cord was increased during deep inspiration.

4. Reinnervated muscle Showed fiber type grouping. The composition of normal PCA muscle was type Ⅰ fiber(51%) and type Ⅱ fiber(49%). Type Ⅱ muscle was slightly increased after reinnervation.

This results suggest that selective section or direct implant of adductor branch may be effective surgical procedure in some cases with bilateral vocal cord paralysis. Much more research needs tobe done to improve upon existing techniques designed to restore both adductive and abductive laryngeal function.