Rekürren laringeal sinirin anatomik seyri ve tiroid cerrahisindeki komşu yapılar ile ı̇lişkisi
The anatomy and associatons with the neighbouring structures of the recurrent laryngeal nerve
Yazar: EREN YILMAZ
Danışman: DOÇ. DR. BORA BAŞARAN
İstanbul Üniversitesi / Tıp Fakültesi / Kulak Burun Boğaz ve Baş-Boyun Cerrahisi Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2017
Konu: Kulak Burun ve Boğaz = Otorhinolaryngology (Ear-Nose-Throat)
Dizin: Anatomi = Anatomy ; Cerrahi-kulak-burun-boğaz = Surgery-otorhinolaryngologic ; Laringeal sinirler = Laryngeal nerves ; Tiroid bezi = Thyroid gland ; Tiroid hastalıkları = Thyroid diseases ; Tiroidektomi = Thyroidectomy

Özet:
Amaç: Türkiye toplumunda rekürren laringeal sinirin komşu yapılar ile anatomik ilişkisini
araştırmak ve bu yapılar ile rekürren sinirin ilişkisini tanımlamak
Gereç ve Yöntem: Ocak 2013 ile Aralık 2016 tarihleri arasında kliniğimizde tiroidektomi operasyonu yapılan 91 hasta araştırmaya dahil edildi. Kocher'in kolye insizyonu ile operasyona başlandı, tüm vakalarda rekürren laringeal sinir bulundu ve çevredeki anatomik yapılar ile ilişkisi not edildi. Veriler SPSS 21.0 kullanılarak ki-kare test ile analiz edildi p<0.05 değeri anlamlı kabul edildi.
Bulgular: 91 hastanın cinsiyet dağılımı Erkek/Kadın: 27/64 tür. Hastaların en küçüğü 14, en büyüğü 85 yaşındadır ve yaş ortalaması 50.2 dir. Toplam 75 adet sağ, 76 adet de sol taraf olmak üzere 151 adet tiroid lobektomi yapıldı. Bir hastada sağ tarafta non-rekürren laringeal sinir görüldü; bu olgu çıkartıldığında kalan 150 tiroid lobektomi materyalinin 40'ında (%26.7) sinirin trakeösefagial oluğun anteriorundan, 93'ünde (%62) içinden, 17'sinde (%11.3) ise posteriorundan geçtiği izlendi. Sinir-Berry ligamenti ilişkisi değerlendirildiğinde; 114 lobektomide (%76) sinir Berry ligamentinin dış-yanında seyrederken, 36'sında (%24) ligamentin içine girdiği görüldü. Lobektomilerin 29'unda (%19.3) sinir inferior tiroid arterin önünden, 17'sinde (%11.3) dallarının arasından, 104'ünde (%69.4) ise arkasından geçtiği izlendi. Sekiz lobektomide (%5.3) sinirin inferior faringeal konstriktör kasın içine girdiği, 142'sinde (%94.7) ise kas liflerinin hemen altından larinkse girdiği bulundu. Rekürren laringeal sinirin larinkse girmeden dallanması toplam 9 sinirde görüldü (%6). İlgili anatomik yapılar ile sinir arasındaki ilişkinin her iki tarafta anlamlı bir farklılık oluşturmadığı saptandı. (Trakeösefagial oluk (p=.892), Berry ligamenti (p=.635), Inferior tiroid arter (p=.312), Inferior faringeal konstriktör kas (p=.444), Ekstralaringeal dal(p=.762))
Sonuç: Rekürren laringeal sinir anatomisi oldukça farklı varyasyonlar gösterebilmektedir. Rekürren laringeal sinir hasarından kaçınmak için, anatomik varyasyon oranının çok yüksek olduğu inferior tiroid arter ve Berry ligamenti hizasında sinir dikkatli bir şekilde diseke edilerek, takip edilmelidir.

Anahtar Kelimeler: Rekürren laringeal sinir, tiroid, tiroidektomi

Abstract:
Aim: Researching and defining the anatomic relation of the recurrent laryngeal nerve with the adjoining structures in Turkish population. Materials and Methods: 91 patients who undergone thyroidectomy in our clinic between January 2013 and December 2016 were included. Operations were started with Kocher's incision. Recurrent laryngeal nerve was found, and the anatomic associations with the neighboring structures were noted. The data were analyzed by using SPSS 21.0 with chi square test, and the results were found statistically meaningful with a p value < 0.05. Results: Men / Women ratio of this population of 91 patients is 27/64. The youngest of the patients is 14 years old and the oldest is 86 years old with the average of 50.2. A total of 151 thyroid lobectomies were performed, of which 75 was right and 76 was left sided. In one patient non-recurrent laryngeal nerve was observed, and when this patient was excluded in 40 (%26.7) of the remaining 150 thyroid lobectomy material the nerve was found anterior to the tracheo-osephageal groove, in 93 (%62) patients in the groove, and in 17 (%11.3) patients posterior to groove. When the position between the nerve and the Berry ligament observed, in 114 (%76) lobectomies the nerve was lateral to the ligament, and in 36 (%24) patients the nerve was found penetrating into the ligament. In 29 (%19.3) lobectomies the nerve was found passing anterior to the inferior thyroid artery, in 17 (%11.3) between the divisions of the artery, in 104 (%69.4) patients posterior to the artery. In 8 (%5.3) lobectomies the nerve was found penetrating inferior constrictor pharyngeal muscle, in 142 (%94.7) patients was found entering the larynx just below the muscle fibers. In 9 patients (%6) the recurrent laryngeal nerve divided before entering larynx. There was no significant difference in relationship between the nerve and the associated anatomic structures for each side found. (Trache-osephageal groove (p=.892), Berry ligament (p=.635), Inferior thyroid artery (p=.312), Inferior pharyngeal constrictor muscle (p=.444), extralaryngeal division(p=.762)) Conclusion: A great variation can be seen in recurrent laryngeal nerve anatomy. In order to avoid recurrent laryngeal nerve damage the nerve must be dissected, and followed very carefully at the level of the inferior thyroid artery and Berry ligament where the variations can be seen at most.

Keywords: recurrent laryngeal nerve, thyroid, thyroidectomy