Recurrent nerve injury. Branches of the vagus nerve in the thoracic and abdominal parts n

main function recurrent laryngeal nerve is the process of innervation of the laryngeal muscles, as well as the vocal cords, along with providing them motor activity, and in addition, the sensitivity of the mucous membrane. Damage nerve endings can cause disruption speech apparatus generally. Systems can also suffer from such damage.

Laryngeal nerve dysfunction: clinical manifestations and causes of the disease

Often, damage to the recurrent laryngeal nerve, which in medicine is called neuropathic paresis of the larynx, is diagnosed on the left side as a result of the following factors:

Transferred surgical manipulation on the thyroid gland.
Transferred surgical manipulation on the organs of the respiratory system.
Transferred surgical manipulation in the region of the main vessels.
Viral and infectious diseases.
Vascular aneurysms.
The presence of oncological tumors of the throat or lungs.

Other causes of paresis of the recurrent laryngeal nerve can also be various mechanical injuries along with lymphadenitis, diffuse goiter, toxic neuritis, diphtheria, tuberculosis and diabetes mellitus. Left-sided lesion is usually explained anatomical features positions of nerve endings that can be injured due to surgery. Congenital paralysis of the ligaments can be found in children.

Inflammation of nerve endings

Against the background of the pathology of the recurrent laryngeal nerve, the nerve endings become inflamed, which occurs as a result of certain transferred viral and infectious diseases. The reason may be chemical poisoning along with diabetes mellitus, thyrotoxicosis and deficiency of potassium or calcium in the body.

Central paresis can also occur against the background of damage to brain stem cells, which is caused by cancerous tumors. Another reason may be atherosclerotic vascular disease, and in addition, botulism, neurosyphilis, poliomyelitis, hemorrhage, stroke and severe skull trauma. In the presence of cortical neuropathic paresis, bilateral nerve damage is observed.

As part of surgical operations in the larynx region, the left recurrent laryngeal nerve can be inadvertently damaged by some instrument. Excessive pressure with a napkin during operations, squeezing suture material, resulting hematomas can also damage the laryngeal nerve. Among other things, there may be a response to anesthetics or disinfectant solutions.

Symptoms of damage to this nerve

The main symptoms resulting from damage to the recurrent laryngeal nerve include the following manifestations:

Features of the state of patients against the background of damage to the recurrent laryngeal nerve

In the event that the recurrent nerve was not cut during the operation, then speech can be restored in two weeks. Against the background of partial intersection of the right recurrent laryngeal nerve recovery period usually takes up to six months. Symptoms of numbness of the epiglottis disappear within three days.

Surgery on both lobes thyroid gland can lead to bilateral nerve paresis. In this case, it can form as a result of which a person will not be able to breathe on his own. In such situations, it may be necessary to apply a tracheostomy - an artificial opening in the neck.

Against the background of bilateral paresis of the recurrent nerve, the patient is constantly in a sitting position, and skin have a pale color, and the fingers and toes are cold, in addition, a person may experience a feeling of fear. Attempting to perform any physical activity only worsens the condition. Three days later vocal cords can take an intermediate position and form a small gap, then breathing normalizes. But nevertheless, during any movements, the symptoms of hypoxia return.

Cough along with permanent damage to the mucous membranes of the larynx can lead to the development of inflammatory diseases such as laryngitis, tracheitis and aspiration pneumonia.

Methods for diagnosing the disease

The anatomy of the recurrent laryngeal nerve is unique. It will be possible to accurately determine the damage only after consulting an otolaryngologist. In addition, you will need an examination by specialists such as a neurologist, neurosurgeon, pulmonologist, thoracic surgeon and endocrinologist. Diagnostic examinations against the background of paresis of the larynx, the following are performed:

Examination of the patient's larynx, as well as taking an anamnesis.
Performance computed tomography.
X-ray of the larynx in direct and lateral projection.
As part of the laryngoscopy, the vocal cords are in the middle position. During a conversation, the increase in the glottis does not occur.
Carrying out phonetography.
Performing electromyography of the muscles of the larynx.
Holding biochemical research blood.

As part of additional diagnostic procedures, it may be necessary to perform computed tomography and ultrasound. It will not be superfluous for the patient to undergo an x-ray of the brain, organs of the respiratory system, thyroid gland, heart and esophagus.

Differentiation of paresis from other diseases

It is extremely important to be able to differentiate paresis of the laryngeal nerve from other diseases that also cause respiratory failure. These include:

Laryngospasms.
Blockage of blood vessels.
The occurrence of a stroke.
Development of multiple system atrophy.
Attacks of bronchial asthma.
development of myocardial infarction.

Against the background of bilateral paresis, as well as in severe conditions in patients and asthma attacks, first of all, emergency care is provided, after which a diagnosis is carried out and the necessary method of therapy is selected.

Classification of symptoms in this disease

Based on the results of diagnostic measures, and in addition, examination of patients, all the symptoms of damage to the recurrent nerve are divided into the following conditions:

The development of unilateral paralysis of the left recurrent nerve manifests itself in the form of severe hoarseness, dry cough, shortness of breath when talking and after physical exertion. In addition, while the patient cannot talk for a long time, and directly during the meal he may choke, feeling the presence foreign object in the throat.
Bilateral paresis is accompanied by shortness of breath and bouts of hypoxia.
A condition that mimics paresis is formed against the background of unilateral damage to the nerve of the larynx. In this case, a reflex spasm of the vocal fold can be observed on the opposite side. The patient has difficulty breathing, he cannot cough up, and chokes on food while eating.

Reflex spasms can develop due to calcium deficiency in the blood, a condition often found in people who suffer from thyroid disease.

What is the treatment for recurrent laryngeal nerve?

Pathology treatment methods

Paresis of the laryngeal nerve is not considered a separate disease, therefore, its treatment begins, first of all, with the elimination of the main causes that cause this pathology. As a result of the growth cancerous tumors the patient requires surgical removal of such neoplasms. And the enlarged thyroid gland is subject to mandatory resection.

Emergency care is required for patients with bilateral paresis, otherwise asphyxia may occur. In such situations, a tracheostomy is performed for the patient. Such an operation is carried out under local or general anesthesia. In this case, a special cannula and a tube are inserted into the trachea, which is fixed with a Chassignac hook.

Medical therapy

Medical treatment paresis of the recurrent laryngeal nerve includes taking antibiotics along with hormonal drugs, neuroprotectors and B vitamins. In the event that there is an extensive hematoma, agents are prescribed that accelerate the resorption of bruises.

Reflexology is carried out by acting on sensitive points that are located on the surface of the skin. This therapy restores nervous system, accelerating regeneration damaged tissue. Voice and vocal function is normalized due to special classes with a phoniatrist.

Against the background of a long-term violation of voice functions, atrophy can occur along with the pathology of the functioning of the muscles of the larynx. In addition, fibrosis of the cricoarytenoid joint may form, which will interfere with the restoration of speech.

Surgical laryngoplasty

With the ineffectiveness of conservative treatment, as well as against the background of bilateral paresis of the recurrent nerve, patients are prescribed a reconstructive operation to restore respiratory functions. Surgical intervention is not recommended in the elderly, and in addition, in the presence of malignant tumors of the thyroid gland or severe systemic pathologies.

N. recurrens - recurrent nerve - is a branch vagus nerve, predominantly motor, innervates the muscles of the vocal cords. When it is violated, the phenomena of aphonia are observed - loss of voice due to paralysis of one of the vocal cords. The position of the right and left recurrent nerves is somewhat different.

The left recurrent nerve departs from the vagus nerve at the level of the aortic arch and immediately goes around this arch from front to back, located on its lower, posterior semicircle. Then the nerve rises up and lies in the groove between the trachea and the left edge of the esophagus - sulcus oesophagotrachealis sinister.

In aortic aneurysms, there is compression of the left recurrent nerve by the aneurysmal sac and loss of its conduction.

The right recurrent nerve departs slightly higher than the left one at the level of the right subclavian artery, also flexes it from front to back and, like the left recurrent nerve, is located in the right esophageal-tracheal groove, sulcus oesophagotrachealis dexter.

The recurrent nerve is closely adjacent to the posterior surface of the lateral lobes of the thyroid gland. Therefore, during strumectomy, special care is required when isolating the tumor so as not to damage n. recurrens and do not get disruption of the voice function.

On its way n. recurrens gives branches:

1. Rami cardiacici inferiores - the lower cardiac branches - go down and enter the cardiac plexus.

2. Rami oesophagei - esophageal branches - depart in the region of sulcus oesophagotrachealis and enter the lateral surface of the esophagus.

3. Rami tracheales - tracheal branches - also depart in the region of sulcus oesophagotrachealis and branch out in the wall of the trachea.

4. N. laryngeus inferior - the lower laryngeal nerve - the final branch of the recurrent nerve, lies medially from the lateral lobe of the thyroid gland and is divided into two branches at the level of the cricoid cartilage - anterior and posterior. The anterior innervates m. vocalis. (m. thyreoarytaenoideus interims), m. thyreoarytaenoideus externus, m. cricoarytaenoideus lateralis, etc.

The posterior branch innervates m. cricoarytaenoideus posterior.

Topography of the subclavian artery.

Subclavian artery, a. subclavia, on the right departs from the innominate artery, a. anonyma, and to the left - from the aortic arch, arcus aortae, conditionally it is divided into three segments.

The first segment from the beginning of the artery to the interstitial fissure.

The second segment of the artery within the interstitial fissure.

The third segment - at the exit from the interstitial gap to the outer edge of the 1st rib, where a already begins. axillaris.

The middle segment lies on the 1st rib, on which an imprint remains from the artery - the groove of the subclavian artery, sulcus a. subclaviae.

In general, the artery has the shape of an arc. In the first segment, it goes up, in the second it lies horizontally, and in the third it follows obliquely downwards.

A. subclavia gives off five branches: three in the first segment and one each in the second and third segments.

Branches of the first segment:

1. A. vertebralis - the vertebral artery - departs with a thick trunk from the upper semicircle of the subclavian artery, goes up within the trigonum scalenovertebrale and goes into the foramen transversarium of the VI cervical vertebra.

2. Truncus thyreocervicalis - thyroid trunk - departs from the anterior semicircle a. subclavia is more lateral from the previous one and soon divides into its terminal branches:

a) a. thyreoidea inferior - lower thyroid artery - goes up, crosses m. scalenus anterior and, passing behind the common carotid artery, approaches the posterior surface of the lateral lobe of the thyroid gland, where it enters with its branches, rami glandulares;

b) a. cervicalis ascendens - ascending cervical artery - goes up, located outward from n. phrenicus-and behind v. jugularis interna, and reaches the base of the skull;

c) a. cervicalis superficialis - superficial cervical artery - goes in the transverse direction above the clavicle within the fossa supraclavicularis, lying on the scalene muscles and the brachial plexus;

d) a. transversa scapulae - the transverse artery of the scapula - goes in the transverse direction along the clavicle and, having reached the incisura scapulae, spreads over the lig. transversum scapulae and branches within m. infraspinatus.

3. A. mammaria interna - the internal mammary artery - departs from the lower semicircle of the subclavian artery and goes down behind the subclavian vein to supply the mammary gland.

Branches of the second segment:

4. Truncus costocervicalis - costocervical trunk - departs from the posterior semicircle of the subclavian artery, goes up and soon divides into its final branches:

a) a. cervicalis profunda - deep cervical artery - goes back and penetrates between the 1st rib and the transverse process of the 7th cervical vertebra to back region neck, where it branches within the muscles located here;

b) a. intercostalis suprema - the superior intercostal artery - goes around the neck of the first rib and goes to the first intercostal space, which supplies blood. Often gives a branch for the second intercostal space.

Branches of the third segment:

5. A. transversa colli - the transverse artery of the neck - departs from the upper semicircle of the subclavian artery, penetrates between the trunks of the brachial plexus, goes in the transverse direction above the clavicle and at its outer end is divided into its two terminal branches:

a) ramus ascendens - ascending branch - goes up along the muscle that lifts the scapula, m. levator scapulae;

b) ramus descendens - descending branch - descends along the vertebral edge of the scapula, margo vertebralis scapulae, between the rhomboid and posterior superior dentate muscles and branches both in the rhomboid muscles and in m. supraspinatus. It is important for the development of roundabout blood circulation in the upper limb.

Usually, sore throat, ear and cough are associated with infectious diseases of the upper respiratory tract: tonsillitis, tonsillitis, SARS, otitis media. In this case, the pain sensation in the first days of the disease increases, and later, after the appointment of adequate treatment, it subsides and does not reappear. Inflammatory diseases of the upper respiratory tract are accompanied by general weakness, headache and fever.

About the neurogenic nature of the disease

If these symptoms all together or individually occur suddenly and recur periodically in the form of seizures, not accompanied by fever and general malaise, it is worth thinking about the neurogenic nature of the phenomenon. Regardless of the type, the diagnosis of neuralgia is made only after the exclusion of all possible somatic diseases with similar symptoms. Therefore, those who suspect that they have neuralgia should consult an ENT doctor and a dentist before visiting a neurologist.

If we are talking about neuralgia, then let's first study the structure of the so-called vagus nerve (see picture)

1 - dorsal nucleus of the vagus nerve; 2 - the core of a single path; 3 - core spinal tract trigeminal nerve; 4 - double core; 5 - cranial root of the accessory nerve; 6 - vagus nerve; 7 - jugular opening; 8 - top node vagus nerve; 9 - the lower node of the vagus nerve; 10 - pharyngeal branches of the vagus nerve; 11 - connecting branch of the vagus nerve to the sinus branch of the glossopharyngeal nerve; 12 - pharyngeal plexus; 13 - upper laryngeal nerve; 14 - internal branch of the superior laryngeal nerve; 15 - outer branch superior laryngeal nerve; 16 - the upper cardiac branch of the vagus nerve; 17 - lower cardiac branch of the vagus nerve; 18 - left recurrent laryngeal nerve; 19 - trachea; 20 - cricoid muscle; 21 - lower constrictor of the pharynx; 22 - middle constrictor of the pharynx; 23 - stylo-pharyngeal muscle; 24 - upper constrictor of the pharynx; 25 - palatopharyngeal muscle; 26 - muscle that raises the palatine curtain, 27 - auditory tube; 28 - ear branch of the vagus nerve; 29 - meningeal branch of the vagus nerve; 30 - glossopharyngeal nerve

Neuralgia of the superior laryngeal nerve

The recurrent laryngeal nerve is one of the terminal branches of the vagus nerve (the X pair of cranial nerves). It provides sensation and controls the contraction of the muscles of the lateral stack of the pharynx, soft palate and the cricothyroid muscle of the larynx.

With damage to the recurrent laryngeal nerve, a typical for neuralgia occurs pain syndrome: present-like, very strong pain occurs with irritation of the trigger zones in the pharynx or tonsils, extending into the throat. In addition, the attack is accompanied by a dry cough and severe autonomic symptoms up to loss of consciousness.

Cough, change in heart rate and impaired consciousness are associated with irritation of the vagus nerve. Neuralgia of the recurrent laryngeal nerve outside the attack is not accompanied by a violation of swallowing and sound production. The appearance of these symptoms indicates the progression pathological changes and the transition of neuralgia to the stage of neuritis.

Neuralgia of the glossopharyngeal nerve

Glossopharyngeal nerve- The IX cranial nerve provides sensation to the root and posterior third of the tongue, the mucous membrane of the middle ear and eustachian tube(connecting the ear cavity and pharynx), and the muscles of the pharynx. It is also involved in the innervation of the carotid sinus, an important reflexogenic zone that is located along the carotid artery and is involved in the regulation blood pressure and cardiac activity.

Neuralgia of the glossopharyngeal nerve is manifested by bouts of pain typical of this disease: severe, burning, paroxysmal in the base of the tongue, palate and tonsils, radiating to the ear. The glossopharyngeal nerve has common nuclei and is partially in contact with the vagus, therefore, when it is irritated, autonomic symptoms similar to neuralgia of the recurrent nerve.

tympanic neuralgia

The drum string contains the terminal fibers of the facial, intermediate. lingual (trigeminal) and facial nerve. It provides middle ear sensitivity, auditory tube and taste buds in the anterior two-thirds of the tongue.

Neuralgia of the tympanic string (deep neuralgia of the face) with pain in the external ear canal, extending to the throat and the root of the tongue, the attack is often accompanied by salivation and paresthesia in the form of a sore throat, which provokes a cough.

This syndrome is often secondary, the causes of pain may be compression of the nerve by the tumor or irritation as a result of inflammatory process in the region of the mastoid process and the petrous part temporal bone. When similar symptoms necessarily carried out full examination in order to identify organic cause diseases.

Neuralgia of the ear node

The ear node is adjacent from the inside to the mandibular nerve at the point of its exit from the cranial cavity. In addition to the main trunk of the third branch of the trigeminal, it is associated with the auriculotemporal nerve and a branch of the middle meningeal plexus. It provides sensitive and autonomic innervation muscles that strain the eardrum, palatine curtain and salivary gland.

The main symptom of neuralgia ear node is an acute paroxysmal superficial pain in front auricle and in temporal region. Pain may radiate to the lower jaw, upper third neck and deep into the ear canal. The attack is accompanied by ear congestion and hypersecretion of the salivary glands on the affected side.

Neuralgia of the ear node occurs as a reaction to chronic inflammation in nearby anatomical structures: pharynx, tonsils, paranasal sinuses and teeth and bones mandible.

Neuralgia of the submandibular and sublingual node

The submandibular node is adjacent to the same name salivary gland located under the muscles and mucous membrane of the floor of the mouth. It is formed by the sensory branches of the lingual nerve, the autonomic branches of the tympanic string and sympathetic plexus external carotid artery.

With neuralgia of the submandibular node, there is a constant It's a dull pain in the submandibular region, which during an attack increases sharply and becomes burning. The duration of the attack is from several minutes to an hour, at which time there is also excessive salivation or dry mouth. Symptoms of neuralgia of the hypoglossal node are similar to those described, the attack is provoked by overeating.

Laryngeal nerve: structural and functional features

The article will describe what the recurrent nerve is, what is its function, signs of its damage and diseases accompanied by its dysfunction.

The laryngeal nerve plays important role in the life of every person, as it innervates the muscles of the larynx, thereby participating in sound production. Next, consider its features.

A bit about anatomy

The laryngeal nerve is a branch of the X pair of cranial nerves. It contains both motor and sensory fibers. Its name is the vagus nerve, which gives branches to the heart, larynx and voice apparatus mammals, as well as to other visceral units of the body.

The name "return" fully characterizes its course in the human body after leaving the cranium. One branch of the vagus nerve approaches each side of the neck, but their route is similar. Interestingly, after leaving the cranial cavity, the recurrent nerve first runs to chest, where, bypassing the large arteries, creates a loop around them, and only then returns to the neck, to the larynx.

For some, such a route may seem meaningless, since until it returns to the larynx, it does not perform any function. In fact, this nerve is the best evidence of human evolution (more details in the video).

It turned out that in fish this nerve innervates the last three pairs of gills, passing to them under the corresponding branchial arteries. Such a route is quite natural and the shortest for them. In the course of evolution, mammals acquired a neck that was previously absent in fish, and the body acquired a large size.

This factor also contributed to the elongation of blood vessels and nerve trunks, and the appearance, at first glance, of their illogical routes. Perhaps the extra few centimeters of the loop of this nerve in humans have no functional significance, but represent great value for scientists.

Attention! Just as in humans, this nerve runs an extra ten centimeters, in a giraffe the same nerve runs an extra four meters.

functional significance

In addition to the actual motor fibers as part of the recurrent nerve, going to the muscles of the larynx, providing a voice-forming function, it also gives branches to the esophagus, trachea and heart. These branches provide innervation of the mucous and muscular membranes of the esophagus, trachea, respectively.

The superior and inferior laryngeal nerves carry out mixed innervation of the heart through the formation of nerve plexuses. The composition of the latter includes sensory and parasympathetic fibers.

Clinical Significance

Especially the significance of this nerve is felt when its function falls out.

When this might happen:

Intraoperative nerve injury. In this case, the most important surgical interventions on the thyroid and parathyroid glands, and vascular bundle. The proximity of the topographic location of these organs internal secretion and the occurrence of the laryngeal nerves predisposes to increased risk their damage.
malignant process. Damage to the nerve along its length by metastases or by the tumor itself in the process of its growth can occur, for example, in cancer of the larynx or thyroid gland.
Cardiac pathology. Some defects, accompanied by a significant increase in the size of the heart chambers, especially the atria, can cause pathologies such as paralysis of the laryngeal nerve. Such heart defects include tetralogy of Fallot, severe mitral stenosis.
infectious process. In this case, there is neuralgia of the superior laryngeal nerve, or neuritis. The most common etiologies are viruses.
Other causes of mechanical compression. These include a hematoma formed during an injury, as well as inflammatory infiltrate in the neck area. Hypertrophy or hyperplasia of the thyroid tissue is common cause especially in endemic areas for iodine deficiency.

Symptoms

Paralysis of the recurrent laryngeal nerve has a number of symptoms:

respiratory failure occurs due to the immobility of one or both vocal folds, which leads to a decrease in the lumen of the respiratory tract in relation to human needs;
hoarseness, which may varying degrees manifestations;
breath resounding in the distance;
aphonia (may occur as a result of a bilateral process).

All of the above criteria can be characterized by the concept of "recurrent laryngeal nerve symptom".

Thus, with paresis of the laryngeal nerve, all three functions of the larynx suffer - respiratory, sound-forming and protective. The price of a voice is most tangible when it is lost.

Important! Paralysis of the larynx is a complex condition that is one of the causes of stenosis of the upper respiratory tract due to a disorder in the motor function of the larynx in the form of a violation or total absence arbitrary movements muscles.

A carefully collected anamnesis of life and illness by a doctor will allow you to suspect the correct diagnosis. What factors from the biography are important to pay attention to when consulting with a doctor in order to help make an accurate diagnosis with your own hands:

were carried out in Lately or earlier surgical interventions on the organs of the neck (possibly, there is damage to the laryngeal nerve during operations on the neck);
the rate of onset of symptoms;
pathologies known to you from the cardiovascular system, the presence of heart murmurs previously established by the doctor;
symptoms suggesting a possible oncological process larynx - pain radiating to the ear, discomfort when swallowing up to dysphagia, etc.

Diagnostics

As mentioned above, when making a diagnosis, the doctor receives about 80% of the information from a patient's survey - his complaints, an anamnesis of life. For example, a person who works for a long time in a coatings factory has an increased risk of damage to the laryngeal nerve due to a malignant tumor of the larynx.

In the presence of inspiratory dyspnea (complicated breathing on inspiration) and hoarseness, laryngoscopy is an important diagnostic technique. With its help, you can see the actual vocal cords and the lumen of the glottis, and neoplasms of this area, if any.

Among other things, visualization of the immobile vocal cord in a unilateral process will tell which side the dysfunction is on - whether there was paresis of the left recurrent laryngeal nerve, or the right one.

To confirm the underlying cause, methods such as CT, MRI are used. Additional research methods help to clarify the preliminary diagnosis of the process, the growth of which is complicated by irritation of the vagus or recurrent laryngeal nerve.

Attention! If the patient has a severe respiratory failure, the necessary therapeutic support for such a patient is first carried out, and only later, after the condition is normalized, examinations are carried out.

For complete differential diagnosis using chest X-ray in two projections and laboratory research- clinical and biochemical analyzes blood at the first stage. Paresis of the recurrent laryngeal nerve and the treatment of this condition requires the exclusion of all other possible causes.

Treatment Methods

Undoubtedly, the first rule of effective therapy is etiotropic treatment, that is, aimed specifically at pathology, in combination with pathogenetic treatment. Exceptions are such conditions as acute bilateral paresis of the recurrent laryngeal nerve, and the treatment of which must be provided immediately.

Conditions that threaten the life and health of the patient always require urgent action. Often, in the absence of symptoms of acute respiratory failure, conservative treatment after paresis of the recurrent laryngeal nerves against the background of a previous strumectomy. But in this case, everything is quite individual.

Treatment after paresis of the recurrent laryngeal nerves and its prognosis depends on whether the paresis is temporary or permanent. In most cases, with temporary dysfunction of these nerves, antibiotic therapy a wide range and glucocorticosteroids in small doses.

Important! The instructions for these drugs will inform you about possible contraindications to their use. Be sure to read it.

In conclusion, it is important to say that the appearance of a sudden hoarseness of the voice always requires verification. Sometimes the cause can be a banal viral pharyngitis, but sometimes this symptom May be early sign hard process.

Neuralgia of the superior laryngeal nerve is manifested by severe pulsating, excruciating unilateral or bilateral paroxysmal (paroxysmal) pain, lasting for several seconds and localized in the larynx (usually at the level of the upper part thyroid cartilage or hyoid bone) and the angle of the lower jaw, radiating to the area of the eye, ear, chest and shoulder girdle and accompanied by hiccups, hypersalivation, coughing; neuralgia intensifies at night, is not stopped by analgesics. The provoking factors of neurological lumbago are swallowing, eating, yawning, coughing, blowing your nose, head movements. Trigger zones are not detected. Painful paroxysms are most often accompanied by strong cough, general weakness, often fainting. On the lateral surface of the neck, above the thyroid cartilage (the place where the laryngeal nerve passes through the thyroid membrane), a painful point is determined.

Known methods of treatment of this disease by novocaine blockades, alcoholization of the upper laryngeal nerve in the zone of the hyothyroid membrane; carbamazepine (or finlepsin) is also effective. In resistant cases resort to the intersection of the nerve.

The probable cause of neuralgia of the superior laryngeal nerve is compression of its internal branch when it passes through the thyroid-hyoid membrane. Also, according to Z.Kh. Shafieva and Kh.A. Alimetova (Department of Otorhinolaryngology, Kazan State medical university) one of the causes of neuropathy of the upper laryngeal nerve is cervical osteochondrosis. Pathological impulses from osteochondrosis-affected cervical vertebral motor segments (PDS) form in the zone of their innervation a symptom complex of myopically, expressed in tension and contraction of muscles, ligaments, fascia, the appearance of painful muscle seals in them, displacement of organs from their physiological position.

The above authors examined and treated 28 patients with neuropathy of the superior laryngeal nerve aged 32 to 76 years. Their disease duration ranged from 5 to 22 years. During this time, they consulted and were treated by various specialists (endocrinologist, neuropathologist, otorhinolaryngologist, therapist, psychiatrist, etc.), more often unsuccessfully, and then again looked for "their" doctor. The ineffectiveness of the treatment was the reason for the development of secondary neurosis in them up to hospitalization in a psycho-neurological hospital. The examination included examination of the pharynx and larynx, palpation of the organs and muscles of the neck, radiography and electromyography, and consultation with a neurologist. With endopharyngeal digital examination 4 patients had a painful band at the level of the hyoid bone in the projection of the stylohyoid and posterior belly of the digastric muscles. Indirect laryngoscopy in all 28 patients revealed narrowing of the pear-shaped pocket on the side of the lesion and lagging of the corresponding half of the larynx during phonation. There were no signs of inflammation in the pharynx and larynx. Palpation in all patients revealed a sharp reduction in the thyroid-hyoid distance on the side of manifestation of neuropathy of the upper laryngeal nerve. At the same time, the hyoid bone assumed an oblique position, which indicated the side receiving predominant pain impulses from the affected cervical SMS. In 10 patients, the most painful point was in the projection of the upper horn of the thyroid cartilage, in the rest - posterior to it, in the thyroid-hyoid space. Electromyography using surface (skin) electrodes confirmed the excess tone of the anterior muscles of the larynx and neck by 2-2.5 times compared with the norm. X-ray examination also confirmed the presence of osteochondrosis cervical spine. expressiveness clinical manifestations osteochondrosis did not always correspond to the severity of radiological findings in the PDS. The clinical manifestations of the disease are more influenced by the degree of compression of the nerve trunks at the exit from the intervertebral foramina and inflammatory changes around them. The condition of the patients was regarded as secondary neuropathy of the superior laryngeal nerve against the background of cervical osteochondrosis. The pathogenesis of neuropathy of the superior laryngeal nerve probably consists of 2 points: 1 - compression of the nerve at the site of its passage into the larynx through the thyroid-hyoid membrane; 2 - infringement of the nerve in the gap between the upper edge of the thyroid cartilage and the hyoid bone.

The treatment plan included sedative therapy, massage of the cervical-collar zone, post-isometric relaxation (PIR) of the anterior muscles of the larynx of the neck and the thyroid-hyoid membrane, novocaine blockade and puncture analgesia of painful muscle indurations (PMU, triggers). After 8-10 sessions of PIR, the condition of the patients improved, in 17 patients the local pain disappeared, in the rest it decreased. After 1 year, 2 patients reappeared pain of the same nature, the rest of the patients remission lasted from 2 to 5 years.

Analyzing the above, the authors came to the conclusion that osteochondrosis of the cervical spine and the asymmetric cervical muscular-fascial pathology caused by it can be the cause of neuropathy of the upper laryngeal nerve, which is confirmed by clinical, radiological and electrophysiological research methods.

Recurrent neuralgia

ICD-10 code: G52.2

Neuralgia of the superior laryngeal nerve- one of the local syndromes of the head and facial pain associated with damage to one nerve, such as trigeminal or occipital neuralgia.

A) Symptoms and clinic of neuralgia of the superior laryngeal nerve. Episodic stabbing pain, usually unilateral, radiating to upper part thyroid cartilage, angle of the mandible and lower part ear. When pressing on the larynx, patients experience pain in the region of the greater horn of the hyoid bone or the thyroid-hyoid membrane.

b) Causes and mechanisms of development. The cause of neuralgia is unclear, but may be related to viral infection, previous trauma (or surgery) or nerve injury associated with the anatomical features of this area (for example, the hyoid bone).

The disease is observed in people aged 40-70 years. The trigger zone is located in the pear-shaped pocket and is irritated when swallowing, during a conversation, and when coughing.

V) Treatment of neuralgia of the superior laryngeal nerve. For the treatment of neuralgia, repeated blockades of the upper laryngeal nerve are performed. Solution local anesthetic inserted between big horn hyoid bone and superior horn of the thyroid cartilage. Treatment with carbamazepine also helps.

Infiltration anesthesia of the superior laryngeal nerve:
1 - vagus nerve; 2 - superior laryngeal nerve;
2a - internal branch; 2b - outer branch.

The main function of the recurrent nerve is the innervation of the muscles of the larynx and vocal cords, ensuring their motor activity and sensitivity of the mucous membranes. Damage to the nerve endings causes a malfunction of the speech apparatus, organs of the respiratory system.

Most often, damage to the recurrent nerve (neuropathic paresis of the larynx) is diagnosed on the left side after undergoing surgical procedures on the thyroid gland, organs of the respiratory system, main vessels, with viral, infectious diseases, vascular aneurysms and oncological tumors of the throat, lungs. The causes can also be mechanical trauma, lymphadenitis, diffuse goiter, toxic neuritis, diphtheria, tuberculosis and diabetes. The left-sided lesion is explained by the anatomical features of the location of the nerve endings that are injured during the surgical intervention. It occurs congenital in children.

With neuritis of the recurrent nerve occurs against the background of a viral or infectious disease. The cause may be chemical poisoning, diabetes mellitus, deficiency of potassium and calcium in the body, thyrotoxicosis.

Central paresis of the recurrent laryngeal nerve occurs when brain stem cells are damaged caused by cancerous tumors, atherosclerotic vascular lesions, botulism, neurosyphilis, poliomyelitis, hemorrhage, stroke, severe trauma to the skull. With cortical neuropathic paresis, there is a bilateral lesion of the recurrent nerve.

During a surgical operation in the larynx area, the recurrent laryngeal nerve can be damaged by any instrument, excessive pressure with a napkin, squeezing of the suture material formed by a hematoma, exudate. There may be a reaction to disinfectant solutions or anesthetics.

The main symptoms of recurrent nerve injury include:

difficulties during the pronunciation of sounds: hoarseness of voice, lowering the timbre;
dysphagia - difficulty in swallowing food;
whistling, noisy inhalation of air;
loss of voice
suffocation with bilateral nerve damage;
dyspnea;
impaired mobility of the tongue, sensitivity of the soft palate;
numbness of the epiglottis, food enters the larynx;
tachycardia, increased blood pressure;
with bilateral paresis noisy breathing;
cough with cough gastric juice into the larynx;
respiratory disorders.

If the recurrent nerve was not cut during the operation, then speech is restored after 2 weeks. With partial crossing, the recovery period can take up to 6 months. The symptom of numbness of the epiglottis disappears within 3 days.

Surgery on both lobes of the thyroid gland can lead to bilateral paresis of the recurrent nerve. In this case, paralysis of the vocal cords occurs, the person cannot breathe on his own. In such cases, the imposition of a tracheostomy is required - this is an artificial opening in the neck.

With bilateral paresis of the recurrent nerve, the patient is constantly in a sitting position, the skin is pale, cyanotic, the fingers and toes are cold, the person experiences a feeling of fear. Any physical activity leads to deterioration. After 2–3 days, the vocal cords occupy an intermediate position, forming a gap, breathing normalizes, but during any movement, the symptoms of hypoxia return.

Cough, constant trauma to the mucous membranes of the larynx leads to the development of inflammatory diseases: laryngitis, tracheitis, aspiration pneumonia.

Diagnostic methods

It is possible to determine whether the recurrent laryngeal nerve is damaged after consulting an otolaryngologist, neuropathologist, neurosurgeon, pulmonologist, thoracic surgeon and endocrinologist. Diagnostic examinations for paresis of the larynx:

Examination of the patient's larynx and taking an anamnesis.
CT scan.
X-ray of the larynx in direct and lateral projection.
During laryngoscopy, the vocal cords are in the middle position. During the breathing of a conversation, the glottis does not increase.
Phonetography.
Electromyography of the muscles of the larynx.
Biochemical study of blood.

Additionally, CT, ultrasound, and radiography of the respiratory system, heart, thyroid gland, esophagus, and brain may be required.

It is important to differentiate paresis of the laryngeal recurrent nerve from other diseases, causing violation breathing:

laryngospasm;
blockage of blood vessels;
stroke;
multiple system atrophy;
an attack of bronchial asthma;
myocardial infarction.

With bilateral paresis, serious condition patient, asthma attacks, first provide emergency care, and then diagnose and select necessary methods therapy.

Classification of CAH symptoms

According to the results of diagnostic measures, examination of the patient, all symptoms of damage to the recurrent nerve can be divided into:

Unilateral paralysis of the left recurrent nerve of the larynx is manifested by severe hoarseness, dry cough, shortness of breath when talking and after physical exertion, the patient cannot talk for a long time, chokes while eating, feels the presence of a foreign object in the mouth.
Bilateral paresis is characterized by difficulty in breathing, bouts of hypoxia.
A condition that mimics paresis develops against the background of unilateral damage to the recurrent nerve. In this case, there is a reflex spasm of the vocal fold on the opposite side. It is difficult for the patient to breathe, he cannot cough up, choke on food while eating.

Reflex spasm can develop with a calcium deficiency in the blood, a condition often found in people suffering from thyroid disease.

Treatment Methods

Paresis of the laryngeal recurrent nerve is not separate disease Therefore, treatment begins with the elimination of the causes that caused the pathology. With the growth of cancerous tumors, surgical removal of the neoplasm is required. The enlarged thyroid gland is subject to resection.

Emergency care is required for bilateral paresis, otherwise asphyxia may occur. In such cases, the patient undergoes a tracheostomy. The operation is done under local or general anesthesia. A special cannula and tube are inserted into the trachea, which is fixed with a Chassignac hook.

Medical therapy includes antibiotics, hormonal drugs, neuroprotectors, vitamins of group B. In the presence of an extensive hematoma, agents are prescribed that accelerate the resorption of the bruise.

Reflexology is carried out by acting on sensitive points located on the surface of the skin. Treatment restores the functioning of the nervous system, accelerates the regeneration of damaged tissues. Voice and vocal function help to normalize special classes with a doctor-phoniator.

Surgical laryngoplasty

With inefficiency conservative therapy, bilateral paresis of the recurrent nerve is indicated reconstructive operation to restore respiratory function. Surgery is contraindicated in the elderly malignant tumors thyroid gland, the presence of severe systemic diseases.

The patient is carefully examined and the optimal treatment tactics is chosen. There are two ways of carrying out the operation: percutaneous and through the oral cavity. The volume of the vocal cords is increased by the introduction of collagen or Teflon. The therapy is carried out under the control of laryngoscopy, the doctor can monitor the progress of the procedure on a computer monitor. Vocal laryngoplasty allows you to partially or completely normalize speech, breathing, increase the lumen of the vocal cords.

The laryngeal nerve is responsible for motor function larynx, vocal folds. Its damage leads to impaired speech, causes difficulty in breathing and swallowing food. Bilateral paresis can cause suffocation and death, so the disease requires urgent treatment. The prognosis of therapy is favorable.

Weakness internal muscles larynx associated with a violation of their innervation. Unilateral neuropathic paresis of the larynx is accompanied by hoarseness and impaired vocal function. Bilateral neuropathic paresis of the larynx leads to severe respiratory disorders with the development of hypoxia and can cause asphyxia. Diagnostic measures with neuropathic paresis of the larynx include x-ray examination larynx, esophagus, chest organs; CT scan of the larynx and mediastinum; MRI and CT of the brain; Ultrasound of the heart and thyroid gland. Treatment of neuropathic paresis of the larynx consists in the elimination of the factor that caused the damage to the nerves innervating the larynx, the use of neuroprotectors, and the conduct of phonopedic and vocal exercises in the recovery period.

Central neuropathic paresis of the larynx can be observed with damage to the brain stem (bulbar palsy), which is noted with tumors, neurosyphilis, poliomyelitis, botulism, syringomyelia, severe atherosclerosis of the cerebral vessels, hemorrhage in the brain stem with hemorrhagic stroke. Also, neuropathic paresis of the larynx of central origin is noted in pathological processes affecting the corresponding pathways and the cerebral cortex. Cortical neuropathic paresis of the larynx occurs with brain tumors, hemorrhagic and ischemic stroke, severe traumatic brain injury. It should be noted that cortical neuropathic paresis of the larynx is always bilateral in nature, due to incomplete decussation of the conductive neural pathways before they enter the brainstem.

Symptoms of neuropathic paresis of the larynx

Reduced mobility of the vocal cords in neuropathic paresis of the larynx leads to impaired voice formation (phonation) and respiratory function. Neuropathic paresis of the larynx is characterized by consistent involvement in pathological process internal laryngeal muscles: first, the function of the posterior cricoarytenoid muscle, which is responsible for expanding the glottis and abducting the vocal folds, is disturbed, then weakness and paralysis of the adductors of the larynx develop, which normally narrow the larynx and reduce the vocal cords. This phenomenon is called the Rosenbach-Semon law. In accordance with it, in case of neuropathic paresis of the larynx, due to the adductors working capacity that remained at the beginning of the disease, the vocal cord on the side of the lesion occupies a middle position, after some time the weakness of the adductors increases and the vocal cord passes into an intermediate position.

Unilateral neuropathic paresis of the larynx at the beginning is characterized by the preservation of phonation due to the adjoining of a healthy vocal cord to the cord of the affected side occupying the middle position. Breathing also remains normal, its difficulty can be detected only with significant physical exertion. Further development neuropathic paresis of the larynx is accompanied by the involvement of the adductors of the larynx and the intermediate position of the vocal cord, due to which there is no complete closure of the glottis during phonation. There is a hoarse voice. A few months later, in patients with neuropathic paresis of the larynx, compensatory hyperadduction of the vocal cord develops on the healthy side and it begins to fit more closely to the paretic ligament. As a result, there is a restoration of the normal sounding of the voice, however, violations of the vocal function in patients with neuropathic paresis of the larynx persist.

Bilateral neuropathic paresis of the larynx in initial period accompanied by severe respiratory disorders up to asphyxia. This is due to the fact that both vocal cords occupy a median position and can close completely, preventing the passage of air into the Airways. Clinically, bilateral neuropathic paresis of the larynx manifests itself as a rare noisy breathing with retraction of the supraclavicular fossae, epigastrium and intercostal spaces on inhalation and their protrusion on exhalation. A patient with bilateral neuropathic paresis of the larynx is in a forced position, more often sitting, resting his hands on the edge of the sofa. The expression of his face reflects extreme fright, the skin has a cyanotic color. Even a slight physical effort causes a sharp deterioration in the condition. After 2-3 days from the onset of clinical manifestations of neuropathic paresis of the larynx, the vocal cords take an intermediate position and a gap forms between them. Respiratory function improves, but any exercise stress leads to symptoms of hypoxia.

Diagnosis of neuropathic paresis of the larynx

The goal of diagnosing neuropathic paresis of the larynx is not only to establish a diagnosis, but also to identify the cause of the paresis. For this, the patient is referred for a consultation.