Tgp chl Tai Mui Hong Vi$t Nam - Volume (57-11). N°5 - Oct., 2012
DANH GIA KET QUA PHyC HOI SlTC NGHE CUA PHAU THUAT THAY THE XU-ONG B A N DAP BANG TRy GOM SINH
HQC TRONG BENH XOP XO TAI
Le Cong Dinh*
T O M TAT
Gom sinh hgc sdn xudt trong nu&c dugc irng dung ldm Iru ddn thay thi xuong bdn dgp trong dieu tri binh xdp xo tai Muc tieu Ddnh gid kit qud phuc hdi siic nghe cua Iru gdm vd so sdnh v&i kit qud ciia cdc logi h-u ddn khdc. Dot tugng vd phuang phdp nghiin cuu:
105 tai cua 80 binh nhdn xop xo tai dugc phdu thudt ldn ddu tien. Phuong phdp mo td, tiin Cliu, theo doi doc. Kit qud: sau thai gian 24 thdng PTA < 30 dB dgt 75,9%, ABG < 20 dB dgt 91,3 7%, khong co bien chicng diec ngng va Ihdi ghep. Ket lugn: Tru gom tien lgi su dung, kit qud phuc hoi siic nghe licang dmrng v&i cdc tru ddn nhgp ngogi, gid thanh thdp, CO the pho cap vd ting dung rgng rdi tren todn quoc.
Tit khod: xuang bdn dgp, tru gom sinh hgc
SUMMARY
EVALUATION OF HEARING RESULTS OBTAINED AFTER STAPEDECTOMY USING BIOCERAMIC STAPES PROSTHESIS IN PATIENTS WITH OTOSCLEROSIS
Bioceramic domestic production is used to replace the stapes in otosclerosis patients.
Objective: evaluation of hearing results after stapedectomy using bioceramic prosthesis and comparison with other types of stapes prosthesis. Methods: A descriptive prospective study consisting 105 ears of 80 patients underwent stapedectomy for the first time. Results:
75,9% of patients PTA < 30 dB obtained an socially-acceptable auditory acuity, 91,37%
ABG < 20 dB after 24 months. No complications sensorineural hearing loss and extrusion.
Conclusion: bioceramic prosthesis is comfortable to use, resulting in hearing recovery is equivalent to the types of imported, low cost and widely used for Vietnamese.
Keywords: stapes, bioceramic prosthesis
1 f>AT VAN f»F truyen am. Phuong phap dieu tri chii yeu la phau thuat thay the xuong bdn dap da bi Trong benh x6p x a tai (otosclerosis) tdn ^ ^ g ^ ^ bdng cac tru ddn am (prostiiesis) thuaiig hay gap nhat la d xop xo d bd tnidc ^ ^ ^^^^ ^61 sue nghe cho ngudi benh.
cua so bau dye va de dap gay xa ciing khdp j ^ ^ ^ ^y^^ g j ^ ^^ ^ ^ ^ ^ l^ai vat lieu duac su ban dap - tiln dinh tir do lam ban che di ^^^^g ^ ^ ^ ^ ^^ ^^ ^^^ ^^ ^ ^^^^^ ^^^
dpng hoac cd dinh xuang ban dap. Bieu (Xeflon), tiiep khong gi, Titan....Tuy nhien hien tren lam sang Id nghe kem till ddn ^^^ ^ ^ ^dn nay ciing co nhiing nhugc dilm ' Bo m6n TMH, Dai hoc Y Ha Npi.
Nh^ bai 1/10. Duyet in 10/10/2012
Tgp chl Tai MOi Hpng Vi$t Ngm -Volume (57-11). N°5 - Oct., 2012
nhu tinh ben vOng. cgng sinh licn kit vdi CO the vd d$c bi?t gid thdnh chua phii h^rp vdi da so b^nh nhdn Vi?t Nam. G6m sinh hpc Id mgt sdn pham du<?c nghien cuu vd sdn xuat bdi trudng dgi hgc Bdch khoa Hd Npi dd dugc img dyng ldm v§t li('u trong cdc chuyen ngdnh nhu Rdng Hdm M^t.
phliu thugt chinh hinh...L4n dau tifin chiing tdi nghien cuu sir dyng gom sinh hpc trong chuyen ngdnh Tai Mui Hgng dc tgo hinh ldm try dan thay the xuong bdn dgp trong dicu tn b?nh xop xa tai.
Muc tieu nghien cuu:
Ddnh gia ket qud phyc hdi siic nghe cua phau thuat thay the xuong ban dgp bdng try gdm sinh hpc.
So sdnh vdi ket qud cua cdc loai try dan khdc dang sir dung hien nay.
2. 0 0 1 TU'ONG VA PHlTOfNG PHAP NGHIEN c u t ]
2.L Doi tugng nghien ciru
La 105 tai ciia 80 benh nhdn dupe chan doan xdp xo tai qua lam sdng, npi soi, do thinh luc, chup CLVT xuong thdi duong.
Cdc benh nhdn dd dupe giai thich vd dong y tham gia nghien cuu. Tat cd cdc tai diu dugic phau thuat lan ddu tien tai b^nh vi?n TMH TW va Bgch Mai. Co 105 tai theo d5i sau mo dugc 6 thdng, 95 tai theo doi 12 thdng va 58 tai theo ddi 24 thdng.
2.2. Phirong phap nghien cvu Phuang phap nghien cuu md td timg ca CO can thiep vd theo doi dgc
2.2.1. Phuang tifn nghien cuu - Try gom dugc tao hinh tii phdi g6m
sinh hgc do trudng dgi hgc Bdch Khoa Ha Ngi sdn xuat (dd du<;c Bg Y te cap ph6p sii dyng). Hlnh ddng vd kfch thudc theo mlu try dSn xuong dong chiing cua Vi?n Tai J.Hough (My) [7] cy thi: chilu ddi 3.2 mm, dudng kfnh tryc 0,6mm. phan tiep khdp vdi ngdnh xuong xuong de hinh 6 chdo c6 dudng kfnh Imm.
- Kinh hicn vi phau thugt, bp vi phau xuong bdn dgp vd thudc do Palmer.
2.2.2. Ddnh gid phgc hoi sue nghe. Cic chi so vd cdch ddnh gid dya theo bdn hudng dan cua Uy ban thfnh hpc vd tien dinh My [2].
- Chi so PTA Id trung binh cua ngudng nghe dudng khi d 4 tdn sd: 500, 1000,2000
\a 4000 Hz. PTA sau md dgt muc < 30 dB Id thanh cdng.
- Chi sd ABG (Air Bone Gap) Id hieu so ciia trung binh ngudng nghe dudng khi vd dudng xuang d 4 tan so tren d cung mpt Ian do.
ABG sau m6: 0-10 dB: rdt tdt; 11-20 dB: t6t; 21-30 dB: Uung binh; > 30 dB: thdt bai. ABG < 20 dB la thanh cdng.
- Thay ddi ngudng nghe dudng xuong.
Danh gid d 3 tin sd 1000. 2000 vd 4000 Hz.
Gidi hgn cho phep ± 10 dB, nlu < -10 dB la cd bien chiing nghe kem tiep am sau md.
2.2.3. Phuang phdp xir ly sS ligu - Xu ly bdng phdn mim SPSS 16.0 - Su dung cdc thu^t todn Z test, T test ghep cdp, ANOVA test dl kilm djnh, so sanh danh gid cdc ket qud thu dupfc, p<
0,05 dugfc coi la s\r khac biet cd y nghia thdng ke.
Tap chl Tai MOI Hpng Vi^t Nam - Volume (57-11) N°5 - Ocl,, 2012
3. KET QUA
^ ^ ^ ^ ^ ^ Tan sd PTA ( d B r " " " - - - - ^ Tnracmo Sau 6 thang Sau 12 thang Sau 24 thang
500H2 60,86 ± 9.71 24,48 ±10,18 23,95 ±8,11 24,40 ± 8,58
1000Hz 58,29 ± 0,91 22,19 ±9,75 21,58 ±8,41 22,33 ± 8.54
2000Hz 52,57 ±3,15 23,48 ± 0,21 22,79 ± 9,75 23,97 ± 0,50
4000Hz 50,38 ±5,85 29,71 ±5,99 28,79 ±4,69 28,97 ±4,04
Nhdn xet:
- Ngudng nghe dudng khi cua tung tan so sau ml diu nhd hon trudc m6 (p < 0,01) - Trong ciing mdt tdn sd tai cac thdi diem sau ml 6, 12, 24 thang ngudng nghe khong CO su khdc biet (p > 0,05)
Bdng 2. Tmng binh dudng khi (PTA) d 4 tdn so trudc va sau m l PTA
(dB) 0-30 31-50 51-70 7 1 - 90
N Gia tri TB
Tt-ic fnx n 0 38 57 10 105
%
0 36,19 54,28 9,53 100 55,52
Sau 6thang n 81 20 4 0 105
%
77,10 19,00 3,90 0 100 24,96
Sau 12 thang n 74 21 0 0 95
%
77,90 22,10 0 0 100 24,27
Sau 24thang n 44 14 0 0 58
%
75,90 24,10 0 0 100 24,91
Nhgn xet:
- 67/105 tai (63,81%) trudc mo mat siic nghe miic dp trung binh va nang (PTA >50 dB).
- Trung binh PTA sau md 6, 12, 24 thdng khong co su khac biet vd deu nho hon trudc ml (p < 0,05). PTA < 30 dB sau 6 thdng: 81/105 tai (77,1%), sau 12 thang: 74/95 tai (77,9%), sau 24 thang: 44/58 tai (75,9%).
Bang 3. Trung blnh ABG trudc va sau mo ABG (dB)
0 - 1 0 11-20 21-30 31-60 N GB tri TB
Tnr&c m6 n 0 0 17 83 105
%
0 0 16,20 83,80 100 38,95Sau 6 th.ng n 56 38 9 2 105
%
53,30 36,20 8,60 1,90 100 11.64
Sau 12 t h i n g n 51 36 8 0 95
%
53,70 37,89 8.41 0 100 11,31
Sau 24 t h i n g n 31 22 5 0 58
%
53,44 37,93 8,63 0 100 11,33
Tap chl Tai MOI Hpng Vi$t Nam - Volume (57-11). N°5 - Oct., 2012
Nh^n xet:
Gii trj Irung binh ciia ABG sau mo l?i cic IhM diem 6, 12, 24 tli4ng Idiong c6 su ]<hac bi?t v^ deu nh6 hon [ru6c mo (p < 0,01)
- ABG d?t mile r4t toi sau 6 tiidng: 56/105 tai (53,3%), sau 12 thdng: 51/95 tai (53,7%), sau 24 thdng: 31/58 tai (.si.44%). ABG < 20 dB sau 6 thdng: 94/105 tai (89,5%), sau 12 thang: 87/95 tai (91,59%), sau 24 thdng: 53/58 tai (91,37%).
Bdng 4, Thay d6i ngu&ng nghe 6\rirng xuong sau mfi
Hi^usiOX (dB)
<-10 -10-.-HO
N
Sau 6 n 4 101 105
hdng
%
3.80 96,20 100
Sau 12 thdng n 1 94 95
%
2,10 97,90 100
Sau 24 thdng n 2 56 58
%
3,40 96,60 100 Nhgn \cv.
- Da so cdc tai khong cd sy thay doi ngudng nghe dudng xuong sau mo.
- Co 4/105 tai (3,8%) sau 6 thang, 1/95 tai (2.1%) sau 12 thdng vd 2/58 tai (3,4%) sau 24 thdng c6 hieu so nguong nghe dudng xuong < -10 dB.
4. BAN LUAN
4.1. Ket qua phuc hoi sire nghe - Ddnh gid theo tung tdn so ciia dudng khi. Ket qua bang 1 cho thay ngudng nghe dudng khi d tiing tdn s6 500, 1000, 2000 vd 4000 Hz d tdt ca cac thdi dilm 6, 12. 24 thang deu tuong duong nhau vd nhd ban trudc mo. Dieu nay cho thay siic nghe dd duoc phyc hoi sau mo vd ket qua on dinh sau thdi gian theo ddi 24 thdng. Tuy nhien sir phuc hdi d cac tan sd khdng hoan toan gidng nhau. Cy the d thdi diem theo ddi dai nhat (24 thang) ngudng nghe d tan sd 500, 1000 va 2000Hz diu nhd hon d tdn so 4000H. Dieu ndy chung to try gim dd phyc hdi sue nghe d cdc tan so tram va tnmg tdt
hon tdn so cao. Nghien ciiu nay cung phu hgrp vdi kit qud cua Dost [3] khi sii dung try dan bdng Titanium.
- Ddnh gid theo chi sd PTA. Ket qua d bdng 2 cho thay PTA sau md d cdc thdi diem 6, 12, 24 thdng khdng c6 su khdc biet
\'a deu nhd ban trudc md. Theo Uy ban thinh lyc vd tien dinh My vdi miic PTA <
30 dB thi b?nh nhan co the hod nhgp vdi xd hpi md khong can cdc bi?n phap trp thinh.
Trong nghien ciru nay muc PTA < 30 dB sau 6 thang dat 77.1%, sau 12 thang dgt 77.9% va sau 24 thdng dgt 75,9%. Day la ket qua ban dau rat dang khich le bdi trudc nghien cuu ndy cd rat nhilu bgnh nhan sau md siic nghe khong tdng va phdi deo mdy irg thinh hd trgf.
- Ddnh gid theo chi sd ABG. Kit qua bang 3 cho thay ABG dgt miic rat tdt sau 6 thang Id 53,3%, sau 12 thang Id 53,7% va sau 12 thdng Id 53,44%. So sdnh vdi cac loai try dan khdc cho thay. Brujin dung tru Teflon [1] vd Massey dimg try Titanium [6]
dgt 71%. McGee [7] dung xuong ddi dong
Tgp chl Tai MDi Hpng Vigt Nam -Volume (57-11) N^S- Oct., 2012
chung lam try ddn dat 88,5%. Ty le ABG d miic rdt tit trong nghien cuu nay thdp hon cdc nghidn ciiu khac dieu nay dugc giai thich bdi phan ldn cdc tai trudc ml diu mdt sue nghe d muc trung binh va nang (67/105 tai: 63,81%). Nen tuy PTA da cai thi?n sau mo mpt phan nhung ABG van khong thi dong lgi hoan toan. Hon niia kit qua ciing phu thugc nhiSu vdo kinh nghiem vd miic do thdnh thao ciia phau thuat vien bdi day la loai phdu thuat khd.
Ty le ABG < 20 dB miic dugc coi la thdnh cdng sau 6 thang la 89,5%, sau 12 thdng Id 91,59% va sau 24 thdng la 91,37%.
Ket qua ndy tuong duong vdi ty le 91% ciia Dost su dung try Titanium [3] va 86% ciia Gerard khi diing try dan Teflon [4].
- Danh gid qua thay doi ngudng nghe dudng xuong. Do thuc hien cgy lay de dgp md vao me nhT nen chung toi ciing nghien cuu tac dgng ciia phau thugt doi vdi tai trong qua thay doi dudng xuong. Ket qua bang 4 cho thay cd 4 tai (3,8%) sau 6 thang, 1 tai (2,1%) sau 12 thang vd 2 tai (3,4%) sau 24 thang co hieu so nguong nghe dudng xuong < -lOdB. Day Id so tai dugc coi Id c6 bien chiing nghe kem tiep am sau mo. Tuy nhien ton thuong chi d miic dp nhe, khdng co tai nao bi bien chiing nghe kem tiep am nang vd diec dgc.Ty le ndy theo Glasscock [5] la 0,6%, theo McGee [7] la 3% qua theo doi 5 nam. Mgt so kinh nghiem de hgn che tdn thuang tai trong do la diing dng hiit rat nho va khong hiit true tiep vdo cua sd bdu due, khong dugc hiit ngoai dich, thuc hien cam mau tot khdng de chdy vdo tien dinh.
4.2. So sanh vdi cac lo^i tni dan khac - Kit qua phuc hoi siic nghe. Qua theo
doi do sue nghe tai cdc thdi dilm sau ml 6, 12 va 24 thang. Kit qua cho thay siic nghe deu phuc hoi tot vd In djnh. Ty le thdnh cong ciia try gom tuong duong vdi cac cdc loai try khac nhu Teflon, Titan, xuong dong chiing nhu dd bdn ludn d tren.
- Chat Ii?u. Gom sinh hgc c6 cau tnic hod hpc giong vdi xuang ngudi nen co dac diem nhu cpng sinh va lien ket tot vdi co the song. Qua theo doi khong thdy trudnghgp nao c6 biln chiing thai gh^p.
Phoi gom mem xop bdi vay co the d8 ddng che tac theo kich thudc tuy y, nhanh chong.
Try gom kh6ng gay
nen hieu iing Actefact (nhieu hinh) khi chup CLVT hay MRI de kiem tra. Doi vdi cac try bang Teflon, Titan, Vang...mac du miic dp dung nap vdi ca the song khd cao tuy nhien ciing co mgt ty le gay phdn ung tao u hgt xung quanh tru ddn Idm dnh hudng den viec truyen am. Nghien curu cua Glasscock [5] diing try Teflon co 1,3% thdt bai do u hat tao xung quanh try dan tu do dnh hudng den dan truyen am thanh. Trong nghien cuu nay co 1 trudng hgp phai mo lai do try gom lech true. Khi md hom nhT kiem tra chiing toi nhan thay xung quanh tru gom CO nhieu mach mau bo tdi. Dieu nay cho thay tinh cpng sinh va lien ket cua try gom vdi niem mac tai giua kha tdt.
+ Hinh dang ciia try dan. Cdc loai try ddn hien nay duac thiet ke co moc de kep vdo nganh xu6ng xuong de. iJu diem la tao ra su ket noi khd chdc chan gida nganh xuong xuong de va try dan. Tuy nhien moc bugc ndy da lam han che cung cap mdu cho phdn xuang ngay tai cho vd dudi cho bupc
Tgp chl Tai MOi Hgng Vi^t Nam - Volume (57-11). N°5 - Oct., 2012
mdc tir d6 gay nen hi?n tupng thieu dudng
\a tieu ngdnh xuong xuong de. Theo Glasscock [5] c6 22,3% sau ml th^t bgi Id do nguyen nhan ndy. Trong nghien cuu nay try gom d phan tiep khdp vdi ngdnh xuong xucmg dc dupe thiet ke theo hinh o coi de m6m dgu ngdnh xuong xuong de khdp vdo, khdc phyc nhugc diem khdng bi bugc kgp lam hgn chl ty Ig tieu ngdnh xuong xuong de sau mo. Qua theo ddi 24 thdng chiing toi khong gdp trudng hgrp ndo that bgi do nguyen nhan ndy.
+ Gia thdnh ciia try dan. Cdc logi try Titan. Platin. Teflon... phdi nhdp khdu vd CO gia thanh khd cao khoang 6 - 8 tri^u VND. Trong khi do try gom dugc che tdc tir phoi gdm y sinh san xudt trong nude, ddy la nguon nguyen lieu sdn c6 vd chu dgng. Hien nay try gom co gid thdnh khoang 1 trieu VND, dieu nay kha phii hgp vdi dieu kien kinh te ciia nhieu benh nhdn.
5. KET LUAN
Qua theo doi cdc trudng hgp su dung gom sinh hpc lam try dan thay the xuong bdn dgp chung tdi nhdn thdy:
- Ket qua phyc hoi siic nghe tgi thdi diem theo dfli Idu nhdt la 24 thdng:
Ngudng nghe theo dudng khi d 4 tan so 500, 1000, 2000 vd 4000Hz diu dugc hdi phuc. PTA < 30 dB dgt ty 1? 44/58 tai (75,9%), ABG < 20 dB dgt ty 1? 53/58 tai (91,37%). Khong co trudng h^p nao biln chiing diec tiep dm ndng.
Try gom sinh hgc cd tinh dung ngp tot, ket qua on dinh va tuang duong vdi cdc try dan khdc. Do dut^c che tdc tir nguyen
li?u sdn xu4t trong nude nen try gom rdt ti?n lgi sii dyng, gid thdnh phii hprp bdi v^y c6 thi phi cgp vd iing dyng rpng rdi tren todn quoc.
TAI L I $ U T H A M KHAO 1. Bruijn A., Tange R., Wouter. A
(2001), Efficacy of evaluation of audiometric results after stapes surgery in otosclerosis. Otolaryngology - Head and NeckSurgery, 124, 76-89.
2. Commitee on Hearing and Equilibrium guidelines for the evaluation of results of conductive hearing loss, (1995), Otolaryngology Head and Neck Surgery, 113.186-187.
3. Dost P., Janhn K., (2005), A prospective evaluation of the Essen Titanium stapes prosthesis, Clin Otolaryngo Allie Sci, Feb, 30(1) 21-24.
4. Gerard J.M., SerT\- P, Gesdorff M.
(2008), Outcome and lack of prognostic factors in stapes surgery. Otology &
Neurotology, 29, 290- 294.
5. Glasscock M.. Storper 1., Haynes D. (1995), Twenty- five years of experience with stapedectomy. Laryngoscope, September, 105,899-903.
6. Massey B. L. Kennedy R. J., Shehon C.
(2005), Stapedectomy outcomes:
Titanium versus wire prosthesis, Laryngoscope, Feb, 115(2), 249-252.
7. McGee M. (2002), Homograft microlathed femur prosthesis m stapedectomy, ENT Journa/, March, 81(3)1-13.
