Damage to the recurrent nerve. Branches of the vagus nerve in the thoracic and abdominal parts n

Main function The recurrent laryngeal nerve serves as the process of innervation of the laryngeal muscles, as well as the vocal cords, along with providing them motor activity, and in addition, sensitivity of the mucous membrane. Damage nerve endings may cause malfunction speech apparatus generally. Systems may also suffer due to 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 laryngeal paresis, is diagnosed on the left side as a result of the following factors:

Previous surgical manipulation of the thyroid gland.
Previous surgical manipulation of the respiratory system.
Previous surgical manipulation in the area of the great vessels.
Viral and infectious diseases.
Vascular aneurysm.
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 lesions are usually explained anatomical features the position of nerve endings that may be injured due to surgery. Congenital ligament paralysis can be found in children.

Inflammation of nerve endings

Against the background of 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 potassium or calcium deficiency in the body.

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

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

Symptoms of damage to this nerve

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

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

If the recurrent nerve was not cut during surgery, speech can be restored within two weeks. Against the background of partial transection 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 They are pale in color, and the fingers and toes are cold; in addition, a person may experience a feeling of fear. Trying to perform any physical activity only leads to a worsening of the condition. Three days later vocal cords may take an intermediate position and form a small gap, then breathing returns to normal. But nevertheless, during any movements, the symptoms of hypoxia return.

Cough, along with constant 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 consultation with an otolaryngologist. In addition, you will need an examination by specialists such as a neurologist, neurosurgeon, pulmonologist, thoracic surgeon and endocrinologist. Diagnostic tests Against the background of laryngeal paresis, the following are performed:

Conducting an 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.
During laryngoscopy, the vocal cords are in a midline position. During a conversation, the glottis does not increase in size.
Carrying out phonetography.
Performing electromyography of the laryngeal muscles.
Carrying out biochemical research blood.

As part of additional diagnostic procedures, it may be necessary to perform computed tomography and ultrasound. It would not be superfluous for the patient to undergo X-rays of the brain, 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 breathing problems. These include:

Laryngospasms.
Blockage of blood vessels.
The appearance 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 attacks of suffocation, first of all, emergency care is provided, after which diagnostics are carried out and the necessary treatment method is selected.

Classification of symptoms for this disease

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

The development of unilateral palsy 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, the patient cannot talk for a long time, and while eating, he may choke, feeling the presence of foreign object in the larynx.
Bilateral paresis is accompanied by difficulty breathing and attacks of hypoxia.
A condition that simulates paresis is formed against the background of unilateral damage to the laryngeal nerve. In this case, a reflex spasm of the vocal fold may be observed on the opposite side. The patient has difficulty breathing, cannot clear his throat, and chokes on food while eating.

Reflex spasms can develop due to a deficiency of calcium in the blood; a similar condition is often found in people who suffer from thyroid diseases.

What is the treatment for recurrent laryngeal nerve?

Pathology treatment methods

Paresis of the laryngeal nerve is not considered a separate disease, so its treatment begins, first of all, with eliminating the main causes that cause this pathology. As a result of the growth cancerous tumors the patient requires surgical removal of such tumors. An 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. This operation is carried out under local or general anesthesia. In this case, a special cannula and tube are inserted into the trachea, which is fixed using a Chassignac hook.

Drug therapy

Drug 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, medications are prescribed that accelerate the resorption of bruises.

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

Against the background of long-term impairment of vocal functions, atrophy may occur along with pathology in the functioning of the laryngeal muscles. In addition, fibrosis of the cricoarytenoid joint may develop, which will interfere with the restoration of speech.

Performing surgical laryngoplasty

If conservative treatment is ineffective, as well as against the background of bilateral paresis of the recurrent nerve, patients are prescribed reconstructive surgery to restore respiratory functions. Surgical intervention is not recommended in old age, and in addition, in the presence of malignant thyroid tumors 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 bends 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.

With aortic aneurysms, compression of the left recurrent nerve by the aneurysmal sac and loss of its conductivity are observed.

The right recurrent nerve departs slightly higher than the left at the level of the right subclavian artery, also bends 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 close to the posterior surface of the lateral lobes of the thyroid gland. Therefore, when performing a strumectomy, special care is required when isolating the tumor so as not to damage the n. recurrens and not get voice function disorders.

On its way n. recurrens gives branches:

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

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

3. Rami tracheales - tracheal branches - also originate in the area of the sulcus oesophagotrachealis and branch 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 at the level of the cricoid cartilage is divided into two branches - 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 it 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 interscalene fissure.

The second segment of the artery within the interscalene fissure.

The third segment is at the exit from the interscalene fissure to the outer edge of the first rib, where a already begins. axillaris.

The middle segment lies on the first 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 is directed upward, in the second it lies horizontally and in the third it follows obliquely downwards.

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

Branches of the first segment:

1. A. vertebralis - vertebral artery - arises 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 – thyrocervical trunk – extends from the anterior semicircle a. subclavia is 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 general 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 upward, located outward from n. phrenicus-and behind v. jugularis interna, and reaches the base of the skull;

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

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

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

Branches of the second segment:

4. Truncus costocervicalis - costocervical trunk - departs from the posterior semicircle of the subclavian artery, goes upward and soon divides into its terminal 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 on posterior region neck, where it branches within the muscles located here;

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

Branches of the third segment:

5. A. transversa colli - transverse artery of the neck - departs from the upper semicircle of the subclavian artery, penetrates between the trunks of the brachial plexus, runs transversely above the collarbone and at its outer end divides 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 serratus muscles and branches both in the rhomboid muscles and in m. supraspinatus. It is important for the development of roundabout circulation in the upper limb.

Usually, a sore throat, earache and cough are associated with infectious diseases of the ENT organs: tonsillitis, sore throat, ARVI, otitis media. In this case, the pain increases in the first days of the disease, and later, after adequate treatment is prescribed, it subsides and does not reappear. Inflammatory diseases of the ENT organs are accompanied by general weakness, headache and fever.

About the neurogenic nature of the disease

If these symptoms, together or individually, appear suddenly and are repeated periodically in the form of attacks, not accompanied by an increase in body temperature 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 excluding 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 - nucleus of the solitary tract; 3 - core spinal tract trigeminal nerve; 4 - double core; 5 - cranial root of the accessory nerve; 6 - vagus nerve; 7 - jugular foramen; 8 - top knot vagus nerve; 9 - 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 - superior laryngeal nerve; 14 - internal branch of the superior laryngeal nerve; 15 - outer branch superior laryngeal nerve; 16 - superior cardiac branch of the vagus nerve; 17 - lower cardiac branch of the vagus nerve; 18 - left recurrent laryngeal nerve; 19 - trachea; 20 - cricothyroid muscle; 21 - lower pharyngeal constrictor; 22 - middle pharyngeal constrictor; 23 - stylopharyngeal muscle; 24 - superior pharyngeal constrictor; 25 - palatopharyngeal muscle; 26 - muscle that lifts the velum palatine, 27 - auditory tube; 28 - auricular 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 (X pair of cranial nerves). It provides sensation and controls contraction of the muscles of the lateral pharynx, soft palate and cricothyroid muscle of the larynx.

When the recurrent laryngeal nerve is damaged, typical neuralgia occurs. pain syndrome: present-like, very strong pain occurs when the trigger zones in the pharynx or tonsils are irritated, radiating into the throat. In addition, the attack is accompanied by a dry cough and severe vegetative symptoms up to loss of consciousness.

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

Neuralgia of the glossopharyngeal nerve

Glossopharyngeal nerve– The IX pair of cranial nerves provides sensitivity 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, which 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 attacks of pain typical of this disease: strong, burning, paroxysmal in the area of 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 nerve, so when it is irritated, autonomic symptoms similar to recurrent neuralgia.

Cord tympani neuralgia

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

Cord tympani neuralgia (deep facial neuralgia) with pain in the external ear canal, radiating to the throat and root of the tongue, the attack is often accompanied by drooling and paresthesia in the form of a sore throat, which provokes a cough.

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

Neuralgia of the ear ganglion

The auricular ganglion is adjacent to the mandibular nerve from the inside at 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 tympanic membrane, velum palatine and salivary gland.

The main symptom of neuralgia ear node is an acute paroxysmal superficial pain in front auricle and in temporal region. Painful sensations may spread to the lower jaw, upper third neck and deep into the ear canal area. 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 lower jaw.

Neuralgia of the submandibular and sublingual node

The submandibular node is adjacent to the same 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 chorda tympani 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 sharply intensifies and becomes burning. The duration of the attack is from several minutes to an hour, during which time there is also excessive salivation or dry mouth. The symptoms of neuralgia of the hypoglossal ganglion are similar to those described; the attack is provoked by overeating.

Laryngeal nerve: structural and functional features

The article will tell you what the recurrent nerve is, what its function is, 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, let's look at its features.

A little 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 “recurrent” fully characterizes its course in the human body after leaving the cranium. There is one branch of the vagus nerve on 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 large arteries, it creates a loop around them, and only then returns to the neck, to the larynx.

For some, this route may seem pointless since it serves no function until it returns to the larynx. 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 gill arteries. This route is quite natural and the shortest for them. During evolution, mammals acquired a neck, which was previously absent in fish, and the body acquired large sizes.

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

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

Functional significance

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

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

Clinical significance

The importance of this nerve is especially felt when its function is lost.

When this might happen:

Intraoperative nerve damage. In this case, surgical interventions on the thyroid and parathyroid glands, and vascular bundle. Proximity of the topographic location of these organs internal secretion and the location 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 during its growth can occur, for example, with cancer of the larynx or thyroid gland.
Cardiac pathology. Some defects, accompanied by a significant increase in size of the heart chambers, especially the atria, can cause a pathology such as laryngeal nerve paralysis. Such heart defects include tetralogy of Fallot and severe mitral stenosis.
Infectious process. In this case, neuralgia of the superior laryngeal nerve, or neuritis, occurs. The most common etiology is viruses.
Other causes of mechanical compression. These include a hematoma formed during injury, as well as inflammatory infiltrate in the neck area. Hypertrophy or hyperplasia of thyroid tissue is common cause, especially in areas where iodine deficiency is endemic.

Symptoms

Recurrent laryngeal nerve palsy has a number of symptoms:

respiratory dysfunction occurs due to immobility of one or both vocal folds, which leads to a decrease in the lumen of the airways in relation to human needs;
hoarseness, which may be varying degrees manifestations;
an inhalation resounding from a distance;
aphonia (may occur as a consequence of a bilateral process).

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

Thus, with paresis of the laryngeal nerve, all three functions of the larynx are affected - respiratory, sound-producing and protective. The cost of a voice is most noticeable when it is lost.

Important! Laryngeal paralysis is a complex condition, which is one of the causes of stenosis of the upper respiratory tract due to a disorder of the motor function of the larynx in the form of a violation or complete absence voluntary movements muscles.

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

were carried out in Lately or earlier surgical interventions on the organs of the neck (there may be damage to the laryngeal nerve during neck surgery);
rate of onset of symptoms;
pathologies of the cardiovascular system known to you, the presence of a heart murmur previously diagnosed by a doctor;
symptoms indicating probable oncological process larynx – pain radiating to the ear, discomfort when swallowing up to dysphagia, etc.

Diagnostics

As already reported above, when making a diagnosis, the doctor receives about 80% of the information from a survey of the patient - his complaints, life history. For example, a person who works for a long time at a paints and paints factory has an increased risk of getting damage to the laryngeal nerve due to a malignant tumor of the larynx.

In the presence of inspiratory dyspnea (complicated breathing during 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 in 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.

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

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

For complete differential diagnosis use radiography of the chest organs in two projections and laboratory research– clinical and biochemical tests blood at the first stage. Paresis of the recurrent laryngeal nerve and treatment of this condition requires excluding all other possible causes.

Treatment methods

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

Conditions that threaten the life and health of the patient always require immediate action. Often, in the absence of symptoms of acute respiratory failure, a conservative treatment after paresis of the recurrent laryngeal nerves due to 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, in case of temporary dysfunction of these nerves, antibacterial therapy wide range and glucocorticosteroids in small doses.

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

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

Neuralgia of the superior laryngeal nerve is manifested by strong pulsating, painful unilateral or bilateral paroxysmal pain, lasting for several seconds and localized in the larynx (usually at the level of the upper part of the larynx). thyroid cartilage or hyoid bone) and the angle of the lower jaw, radiating to the eye, ear, chest and shoulder girdle and accompanied by hiccups, hypersalivation, cough; neuralgia intensifies at night and is not relieved by analgesics. Provoking factors for neurological lumbago are swallowing, eating, yawning, coughing, blowing the nose, and head movements. Trigger zones are not detected. Painful paroxysms are most often accompanied by severe 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.

There are known methods of treating this disease by means of novocaine blockades, alcoholization of the upper laryngeal nerve in the area of the hyothyroid membrane; Carbamazepine (or Finlepsin) is also effective. In resistant cases, they resort to cutting the nerve.

The probable cause of neuralgia of the superior laryngeal nerve is compression of its internal branch as it passes through the thyrohyoid 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 superior laryngeal nerve is cervical osteochondrosis. Pathological impulses from cervical vertebral motor segments (VMS) affected by osteochondrosis form in the zone of their innervation a symptom complex of myofixation, expressed in tension and contraction of muscles, ligaments, fascia, the appearance of painful muscle compactions 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 from 32 to 76 years. The duration of their disease ranged from 5 to 22 years. During this time, they consulted and were treated by various specialists (endocrinologist, neurologist, otorhinolaryngologist, therapist, psychiatrist, etc.), often without success, 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 and including hospitalization in a neuropsychiatric 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 In 4 patients, a painful cord was detected 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 a narrowing of the pyriform recess on the affected side and a lag in 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 thyrohyoid distance on the side of the manifestation of neuropathy of the superior laryngeal nerve. In this case, 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 superior horn of the thyroid cartilage, in the rest - posterior to it, in the thyrohyoid space. Electromyography using surface (cutaneous) electrodes confirmed that the tone of the anterior muscles of the larynx and neck was 2-2.5 times higher than normal. X-ray examination also confirmed the presence of osteochondrosis cervical spine 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 as they exit the intervertebral foramina and inflammatory changes around them. The patients' condition was assessed as secondary neuropathy of the superior laryngeal nerve due to cervical osteochondrosis. The pathogenesis of neuropathy of the superior laryngeal nerve probably consists of 2 points: 1 - compression of the nerve at the point where it passes into the larynx through the thyrohyoid membrane; 2 - pinched nerve in the space between the upper edge of the thyroid cartilage and the hyoid bone.

The treatment plan included sedative therapy, massage of the cervical-collar area, post-isometric relaxation (PIR) of the anterior laryngeal muscles of the neck and the thyrohyoid membrane, novocaine blockade and puncture analgesia of painful muscle tightness (PMU, triggers). After 8-10 sessions of PIR, the condition of the patients improved, in 17 patients local pain disappeared, in the rest it decreased. After 1 year, pain of the previous nature reappeared in 2 patients; in the remaining 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 asymmetrical cervical musculofascial pathology caused by it may 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 headache and facial pain associated with damage to one nerve, such as trigeminal or occipital neuralgia.

A) Symptoms and clinical picture of neuralgia of the superior laryngeal nerve. Episodic stabbing pain, usually unilateral, radiating to top part thyroid cartilage, angle of the mandible and bottom part ear. When pressing on the larynx, patients experience pain in the area of the greater horn of the hyoid bone or the thyrohyoid 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 the area (for example, the hyoid bone).

The disease occurs in people aged 40-70 years. The trigger zone is located in the pear-shaped pouch and is irritated when swallowing, talking, or coughing.

V) Treatment of neuralgia of the superior laryngeal nerve. To treat neuralgia, repeated blocks of the superior laryngeal nerve are performed. Solution local anesthetic introduced 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 - external branch.

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

Most often, damage to the recurrent nerve (neuropathic laryngeal paresis) is diagnosed on the left side after surgical manipulations on the thyroid gland, organs of the respiratory system, main vessels, for viral, infectious diseases, vascular aneurysms and oncological tumors of the throat and lungs. The causes may also be mechanical injuries, 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 surgery. Occurs congenital in children.

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

Central paresis of the recurrent laryngeal nerve occurs with damage to brain stem cells caused by cancerous tumors, atherosclerotic vascular lesions, botulism, neurosyphilis, poliomyelitis, hemorrhage, stroke, and severe skull trauma. With cortical neuropathic paresis, bilateral damage to the recurrent nerve is observed.

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

The main symptoms of damage to the recurrent nerve include:

difficulties during the pronunciation of sounds: hoarseness of voice, decreased timbre;
dysphagia – difficulty swallowing food;
whistling, noisy inhalation of air;
loss of voice;
suffocation with bilateral nerve damage;
dyspnea;
impaired tongue mobility, sensitivity of the soft palate;
numbness of the epiglottis, food enters the larynx;
tachycardia, increased blood pressure;
with bilateral paresis, noisy breathing;
cough with coughing 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 intersection, 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 recurrent nerve palsy. In this case, paralysis of the vocal cords occurs, the person cannot breathe on his own. In such cases, 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, and the person experiences a feeling of fear. Any physical activity leads to worsening of the condition. 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.

Coughing and constant injury to the mucous membranes of the larynx lead 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, neurologist, neurosurgeon, pulmonologist, thoracic surgeon and endocrinologist. Diagnostic examinations for laryngeal paresis:

Examination of the patient's larynx and collection of anamnesis.
CT scan.
X-ray of the larynx in frontal and lateral projection.
During laryngoscopy, the vocal cords are in the midline position. During breathing and conversation, the glottis does not increase.
Phonetography.
Electromyography of the laryngeal muscles.
Biochemical blood test.

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

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

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

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

Classification of CAH symptoms

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

Unilateral paralysis of the left recurrent laryngeal nerve 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, and feels the presence of a foreign object in the mouth.
Bilateral paresis is characterized by difficulty breathing and attacks of hypoxia.
A condition simulating paresis develops against the background of unilateral damage to the recurrent nerve. In this case, a reflex spasm of the vocal fold on the opposite side is observed. The patient has difficulty breathing, cannot cough, or choke on food while eating.

A reflex spasm can develop when there is a deficiency of calcium in the blood; this condition is often found in people suffering from thyroid diseases.

Treatment methods

Paresis of the laryngeal recurrent nerve is not separate disease, therefore, treatment begins with eliminating the causes of the pathology. When cancerous tumors grow, surgical removal of the tumor is required. An 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 performed under local or general anesthesia. A special cannula and tube are inserted into the trachea, which is fixed using a Chassignac hook.

Drug therapy includes taking antibiotics, hormonal drugs, neuroprotectors, B vitamins. In the presence of an extensive hematoma, medications are prescribed that accelerate the resorption of the bruise.

Reflexology is carried out by influencing sensitive points located on the surface of the skin. The treatment restores the functioning of the nervous system and accelerates the regeneration of damaged tissues. Voice and vocal function help to normalize special classes with a phoniologist.

Surgical laryngoplasty

If ineffective conservative therapy, bilateral recurrent nerve palsy is indicated reconstructive surgery to restore respiratory function. Surgical intervention is contraindicated in old age, with malignant tumors thyroid gland, the presence of severe systemic diseases.

The patient is carefully examined and the optimal treatment tactics are chosen. There are two ways to perform the operation: percutaneous and through the oral cavity. The volume of the vocal cords is increased by introducing 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. Laryngoplasty of the vocal tract allows you to partially or completely normalize speech, breathing, and increase the clearance of the vocal cords.

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

Weakness internal muscles larynx, associated with a violation of their innervation. Unilateral neuropathic laryngeal paresis is accompanied by hoarseness and impaired vocal function. Bilateral neuropathic paresis of the larynx leads to severe breathing disorders with the development of hypoxia and can cause asphyxia. Diagnostic measures for neuropathic laryngeal paresis 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 of eliminating the factor that caused damage to the nerves innervating the larynx, using neuroprotectors, and conducting phonopedic and vocal exercises during the recovery period.

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

Symptoms of neuropathic laryngeal paresis

Reduced mobility of the vocal cords with neuropathic laryngeal paresis leads to disturbances in voice formation (phonation) and respiratory function. Neuropathic paresis of the larynx is characterized by sequential involvement in pathological process internal laryngeal muscles: first, the function of the posterior crico-arytenoid muscle, which is responsible for widening the glottis and abducting the vocal folds, is impaired, then weakness and paralysis of the laryngeal adductors develop, which normally narrow the larynx and bring the vocal cords together. This phenomenon is called the Rosenbach-Semon law. In accordance with it, in neuropathic paresis of the larynx, due to the preserved performance of the adductors at the beginning of the disease, the vocal cord on the affected side occupies a median position, after some time the weakness of the adductors increases and the vocal cord moves to an intermediate position.

Unilateral neuropathic laryngeal paresis at the beginning is characterized by preservation of phonation due to the adjoining of the healthy vocal cord to the ligament occupying the middle position of the affected side. Breathing also remains normal; difficulty can be detected only with significant physical exertion. Further development neuropathic paresis of the larynx is accompanied by the involvement of the laryngeal adductors and the intermediate position of the vocal cord, due to which the glottis does not completely close during phonation. Hoarseness occurs. After a few months, patients with neuropathic laryngeal paresis develop compensatory hyperadduction of the vocal cord on the healthy side and it begins to fit more tightly to the paretic ligament. As a result, there is a restoration of the normal sound of the voice, but disturbances in vocal function in patients with neuropathic laryngeal paresis persist.

Bilateral neuropathic laryngeal paresis in initial period accompanied by severe respiratory disorders, including asphyxia. This is due to the fact that both vocal cords occupy a midline position and can close completely, preventing the passage of air into the Airways. Clinically, bilateral neuropathic laryngeal paresis manifests itself rarely noisy breathing with retraction of the supraclavicular fossa, epigastrium and intercostal spaces on inspiration and protrusion of them on exhalation. A patient with bilateral neuropathic paresis of the larynx is in a forced position, often sitting, resting his hands on the edge of the sofa. His facial expression reflects extreme fear; his skin is cyanotic in color. Even minor 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 the appearance of symptoms of hypoxia.

Diagnosis of neuropathic laryngeal paresis

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