Возвратный гортанный нерв может иметь множество анатомических вариантов при экстраларингеальном расположении, что нередко приводит к смене техники оперативного вмешательства в каждом конкретном случае. В статье описаны два клинических наблюдения выявления невозвращающегося возвратного гортанного нерва и дополнительных коллатеральных анастомозирующих структур возвратного гортанного нерва. Невозвращающий-ся возвратный гортанный нерв, по данным последних исследований, встречается в общей популяции несколько чаще (до 4,8%), чем может предположить практикующий хирург-эндокринолог. Выявление невозвращающегося возвратного гортанного нерва перед операцией является важным объектом исследований. По данным многих авторов, парезы гортани при невозвращающемся возвратном гортанном нерве увеличиваются в разы по сравнению с возвращающимся гортанным нервом. Функциональное и клиническое значение анастомозирующих структур возвратного гортанного нерва до сих пор остается неизвестным. Визуализация их во время операции -редкое явление. Это приводит к их неизбежному повреждению. Таким образом, альтернативой теории тракционных повреждений возвратного гортанного нерва мы видим повреждение его нестандартных анатомических вариантов и анастомозирующих структур. В связи с редкостью выявления таких вариантов экстраларингеального расположения возвратного гортанного нерва считаем целесообразным поделиться собственным опытом. Ключевые слова: невозвращающийся возвратный гортанный нерв, анастомоз Галена, симпатическая анастомозирующая ветвь нижнего гортанного нерва, клиническое наблюдение.The recurrent laryngeal nerve can have a variety of options in extralaryngeal position, which often changes the technique of surgical intervention in each specific case. Below there are two clinical observations of the non-recurrent laryngeal nerve and additional collateral anastomosing structures of the recurrent laryngeal nerve. The non-recurrent laryngeal nerve, according to the recent research, is found in the general population somewhat more often (up to 4.8%) than the practicing surgeon may suggest. The identification of a non-recurrent laryngeal nerve before surgery is an important object of research. According to many authors, the cord palsy in the non-recurrent laryngeal nerve increases many times compared with the recurrent laryngeal nerve. The functional and clinical significance of the anastomosing structures of the recurrent laryngeal nerve is still unknown. To visualize them during surgery is a rare phenomenon, which ultimately leads to their damage. Thus, an alternative to the theory of traction damage of the recurrent laryngeal nerve is the damage to its non-standard anatomical variants and anastomosing structures. Taking into account that such an option of extralaryngeal location of the recurrent laryngeal nerve is so rare, we consider it appropriate to share our own experience.

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Hypoparathyroidism is the most common complication after surgery on the thyroid gland. All authors confirm the fact that the main cause of hypoparathyroidism is a violation of the blood supply of parathyroid glands, as well as their damage or even accidental removal during surgery. Having analyzed the real cases, and based on our own experience, we came to the conclusion that in order to prevent complications, we will need to study the types of blood supply of the parathyroid glands in details. To this end, we have performed 46 unilateral microdissections and X-ray angiography studies of the arterial supply at 23 organocomplexes of the neck. 42 upper and 43 lower parathyroid glands were detected. It has been established that the main feeding vessel of parathyroid glands is the inferior thyroid artery (type I). The association of glands with the inferior thyroid artery was revealed in 71.8% of cases. A mixed variant of blood supply (simultaneously from the superior and inferior thyroid arteries) was revealed in 14.1% cases (type II). Only 10.6% of the gland were fed isolated from the superior thyroid artery (type III). In addition, in 8.7% cases in the preparations there was no inferior thyroid artery. In 3.5% cases, the connections of the lower parathyroid glands with the thyroid arteries were not reliably detected. Most probably, their feeding was provided at the expense of small collaterals from surrounding organs (type VI).

BACKGROUND. Current trends of «fast track surgery» give rise to development of new safe techniques of the thyroid and parathyroid surgery, the purpose of which is to minimize the level of postoperative complications, such as vocal cord palsy, hypoparathyroidism, bleeding. In this regard, it is important for the endocrine surgeon to save «dry operating field», which contributes to the clear visualization of such «thin» structures as the recurrent laryngeal nerve, the external branch of the superior laryngeal nerve and the parathyroid glands. Therefore, the key issue of this surgery is to understand the anatomical and topographic features of the blood supply to the internal neck organs (a complex of neck organs consisting of the thyroid and parathyroid glands, larynx, trachea, esophagus).AIM. To determine the main sources of arterial blood supply of the internal neck organs and their anatomical, topographic features.MATERIALS AND METHODS. The computed tomography protocols of cervical branches of brachiocephalic arteries were analysed in the study. The thickness of the reconstructed sections in the axial, frontal and sagittal planes was 0.35±0.05 mm. The fact of blood supply was confirmed by the anatomical close of the arterial structure to the internal organ and the presence of intramural arterial branches.RESULTS. The course of all cervical branches of the subclavian and common carotid artery was traced among 42 patients. It is noted, that only the inferior, superior thyroid arteries and thyroid ima artery supply internal neck organs with the blood. At the same time, the superior thyroid artery was visualized in all angiograms. However, the inferior thyroid artery was absent in 2.4% of cases. The thyroid ima artery was rarely detected (in 4.8% of patients). In 73.2% of cases, the inferior thyroid artery was detected high at the upper third level of the thyroid lobe and then had a descending course. In 23.2% of cases, the artery was formed at the middle third level of the thyroid lobe and was directed horizontally to the gland. Only in 3.6% of cases, the ascending course was determined in the vessel. The inferior thyroid artery was located on the posterior surface of the thyroid lobe, where it formed glandular branches. On the contrary, the branches of the superior thyroid artery were located mainly along the anterolateral surface of the thyroid gland. The average thickness of the inferior thyroid artery was 2.1±0.5 mm, and the superior thyroid artery was 1.6± 0.7 mm.CONCLUSION. According to the study, arterial blood supply to the internal neck organs is provided mainly by the inferior and superior thyroid arteries. At the same time, the trunk of the inferior thyroid artery is larger than the superior thyroid artery (p=0.032). The inferior thyroid artery forms branches along the posterior surface of the thyroid lobe and from a topographic point of view it is the main source of blood supply to the parathyroid glands. In most cases, the inferior thyroid artery has a descending course, is directed along the posterior surface of the thyroid gland and forms an X-shaped intersection with the recurrent laryngeal nerve.