耳鼻喉科醫師執行之甲狀腺手術術前超音波及術中喉返神經監測研究

Otolaryngologist Performed Pre-operative Ultrasound and Intra-operative Recurrent Laryngeal Nerve Monitoring in Thyroid Surgery

吳伯軒(Po-Hsuan Wu) ； 廖立人(Li-Jen Liao) ； 鄭博文(Po-Wen Cheng) ； 羅武嘉(Wu-Chia Lo)

《台灣耳鼻喉頭頸外科雜誌》 54卷3期 (2019/09) Pp. 142-148

https://doi.org/10.6286/jtohns.201909_54(3).142

摘要

背景：近年來有越來越多甲狀腺腫瘤的病人被轉介給耳鼻喉頭頸外科醫師執行超音波檢查，如何在第一線執行超音波檢查時分辨甲狀腺腫瘤的良惡性成為耳鼻喉頭頸外科醫師的重要技能。喉返神經麻痺是甲狀腺手術術後常見且嚴重的併發症之一。雖然術中神經監測系統被認為能降低喉返神經在手術中受損的機會，然而實際成效仍具爭議性，故特此提出討論。方法：回溯性分析2008年至2012年在亞東醫院耳鼻喉頭頸外科接受甲狀腺手術之病人，共有101名納入此研究，這些病人手術前皆有進行超音波檢查，病人的年齡、性別、甲狀腺結節超音波檢查結果、手術方式、病理診斷、是否使用神經監測儀及術後喉返神經是否麻痺均納入分析比較。結果：最終病理報告顯示有54名病人為良性甲狀腺疾患，44名為甲狀腺癌。總共執行了124次甲狀腺葉切除手術。術前超音波評估的部分，結節邊緣（margin）、超音波回音性（echogenicity）、鈣化（calcifcation）及淋巴結腫大（lymphadenopaty）在良性及惡性甲狀腺結節之間有顯著的差異（p＜0.005）。在良性甲狀腺疾患的病人中，無論有無使用術中神經監測儀均無出現喉返神經麻痺的情况。然而，在甲狀腺癌的病人之中，術中有使用神經監測儀與未使用神經監測儀的喉返神經麻痺出現機率有顯著的差異（分别為3%及25%；p=0.022）。此外，是否執行頸部淋巴廓清術及有無頸部淋巴結轉移是永久性副甲狀腺功能低下的危險因子。結論：術前超音波檢查對於醫師區分良性或惡性甲狀腺結節是有幫助的。針對甲狀腺癌的病人，術中神經監測儀對於降低術後喉返神經麻痺的發生是有幫助的。

關鍵字

otolaryngologist ； ultrasound ； thyroid surgery ； recurrent laryngeal nerve monitor（耳鼻喉科醫師 ； 超音波 ； 甲狀腺手術 ； 喉返神經監測儀）

並列摘要

BACKGROUND: In recent years, there are increasingly more patients with thyroid nodules referred to otolaryngologist-head and neck surgeon for ultrasound (US) examination. US, as a first-line examination modality, has been used to differentiate between benign thyroid nodules and malignant ones. The usage of US has become an important ability for otolaryngologist-head and neck surgeons. Recurrent laryngeal nerve (RLN) palsy is one of the most common and serious complication after thyroid surgery. Intraoperative neuromonitoring (IONM) has been proposed to reduce risk of RLN palsy. However, the reduction of frequency in RLN injury remains controversial. METHODS: One hundred and one patients who underwent thyroid surgery at Far Eastern Memorial Hospital between 2008 and 2012 were consecutively enrolled and reviewed. All the patients received pre-operative US exam. Age, gender, US characteristics, operative techniques, final diagnosis, IONM use, and RLN palsy were analyzed. RESULTS: The final pathological reports showed that 54 patients were having benign thyroid disease and the other 44 patients were having thyroid cancers. Totally, 124 thyroid lobectomies were performed. Under pre-operative US evaluation, there were significant differences (p-values ＜ 0.005) in margins, echogenicity, calcification, and lymphadenopathy between benign and malignant thyroid nodules. The RLN palsy rate between thyroid cancer patients who had IONM used and those who had not was significant different (3% and 25 %, respectively; p = 0.022). Additionally, neck dissection and neck metastasis were risk factors of permanent hypoparathyroidism. CONCLUSIONS: Pre-operative US exam is helpful in differentiating benign and malignant thyroid nodules. In thyroid cancer patients, IONM is useful in decreasing the rate of RLN palsy.

並列關鍵字

otolaryngologist ； ultrasound ； thyroid surgery ； recurrent laryngeal nerve monitor