图像引导下颈部切开术与喉返神经再支配治疗II区玻璃致颈部创伤：一例病例报告。

文献信息

中文摘要

背景： 血流动力学稳定的穿透性颈部创伤伴深部异物存留，即使计算机断层血管造影未发现主要血管损伤，也可能掩盖具有功能意义的神经损伤。在部分病例中，早期喉镜检查可提供决定性的功能证据，并有助于识别需要及时手术探查的隐匿性喉返神经损伤。
病例报告： 一名45岁女性因多块玻璃碎片导致穿透性颈部创伤，存在II区入口伤口以及跨越多个分区的深部经颈轨迹。她血流动力学稳定，无气道受损。计算机断层血管造影显示多个玻璃异物存留于深部颈部间隙，无对比剂外渗、假性动脉瘤或血肿。柔性喉镜显示左侧声带麻痹。鉴于深部异物存留、邻近关键结构以及喉镜证实的声带固定，实施了选择性探查性颈部切开术。取出40块玻璃碎片。术中在气管食管沟内发现左侧喉返神经横断。清创失活神经断端后，无法进行一期修复；在3倍手术放大镜下，使用颈袢上根进行直接神经再支配。术后过程平稳；患者于术后第5天出院。在12个月随访时，她表现出持续的功能性嗓音恢复，最大发声时间、声学参数和视频喉频闪镜检查结果均有改善。
结论： 在部分稳定的穿透性颈部创伤病例中，缺乏硬体征并不能排除具有重要功能意义的隐匿性神经损伤。伴有异物存留的深部伤口轨迹可能需要进行早期喉镜检查联合计算机断层血管造影——这种评估可以指导选择性探查，并在技术可行时实现及时的神经重建。

英文摘要

BACKGROUND Hemodynamically stable penetrating neck trauma with retained deep foreign bodies can conceal functionally significant neural injury despite absence of major vascular findings on computed tomography angiography. In selected cases, early laryngoscopy may provide decisive functional evidence and help identify occult recurrent laryngeal nerve injury requiring timely surgical exploration. CASE REPORT A 45-year-old woman presented with penetrating neck trauma caused by multiple glass fragments, with Zone II entry wounds and a deep transcervical trajectory across zones. She was hemodynamically stable, without airway compromise. Computed tomography angiography demonstrated multiple retained glass foreign bodies in deep cervical compartments, without contrast extravasation, pseudoaneurysm, or hematoma. Flexible laryngoscopy demonstrated left vocal fold paralysis. Given the deep retained foreign bodies, proximity to critical structures, and laryngoscopy-confirmed vocal fold immobility, selective exploratory cervicotomy was performed. Forty glass fragments were removed. Intraoperatively, left recurrent laryngeal nerve transection was identified within the tracheoesophageal groove. After debridement of nonviable nerve ends, primary repair was not feasible; direct reinnervation was performed using the superior root of the ansa cervicalis under 3× surgical loupe magnification. The postoperative course was uneventful; the patient was discharged on postoperative day 5. At the 12-month follow-up, she demonstrated sustained functional voice recovery, with improvements in maximum phonation time, acoustic parameters, and videolaryngostroboscopic findings. CONCLUSIONS In selected stable penetrating neck trauma cases, hard sign absence does not exclude functionally important occult neural injury. Deep wound trajectories associated with retained foreign bodies may warrant early laryngoscopy with computed tomography angiography-this assessment can guide selective exploration and enable timely nerve reconstruction when technically feasible.