Tap ChfTai MGi Hpng Vidt Nam - Volume (57-9). N°3 - July. 2012
CAP NHAT NHU"NG QUAN DIEM M d i VE CHAN DOAN VA DIEU TRI VIEM MUI XOANG
Le Cdng Dinh*
1. DA r \ AN Dft
Viem mui xoang (VMX) \k b^nh ihutTiig gap trong chuyen khoa Tai Mui Hgng. Fy I? m3c b^nh tgi M\ khoang 15%, tai DOrc khoang 8%. tai Singapore khoang 13%. Tai Vi?t Nam udc tinh khoang 15%
dan so mSc b^nh nay. Ngay nay b^nh c6 xu hucmg gia t ^ g do qua trinh do thi hod, cong nghiOp hoa, 6 nhiem moi trucmg \k bien doi khi hau. Do dSc diem dai dang keo dai nen VMX man tinh duqc xep vao danh muc cac benh man tinh nhu hen, cao huyet ap...VMX anh huong rat 1cm toi siic khoe va chat lucmg cupc song cua ngucri b?nh.
Cho den nay sinh benh hoc con nhieu van de chua sang to. Dieu tri con gap nhieu kho khan do ty le that bai va tai phat cao. Gan day Hoi mui xoang Chau Au va Nhat Ban da dua ra huong dan moi dd thong nhat v^
chan doan va dieu tri VMX.
2. NQI DUNG
2.1. Phan loai va tieu chuan chan doan viem mui xoang
- Thuat ngu viem mui xoang Cho den nay thuat ngu: viim miii xoang da dugc thong nhat tren toan the gioi. Di§u nay do nhung dac diSm chung v§ giai phau, sinh ly cua mili va xoang. Do la:
+ MQi va xoang deu thong voi nhau qua
* Khoa Tai MQi Hgng - Banh vi^n Bach Mai NhSn Mi 15/5. Duyet in 25/5/2012
cac lo thong ty nhien
f Niem mac mui v^ xoang ciing loai \k licn liep v6i nhau
-"- Thu(Tng viem mui truoc sau do den viem xoang, hi^m khi viem xoang ma khong CO viem mui.
i Cac tri?u chung cua viem xoang bieu hi?n trpi 6 mui nhu ng^t mui, chay mui.
- Phan loai viem miji xoang
Hpi mui xoang Chau Au dua vao thai gian dien bien b?nh da thong nhat phan lam 2 loai: viem miii xoang cap va man tinh [2].
+ Viem mui xoang cap: cac trieu chung ngat mui, chay miii, ho...keo dai tren 10 ngay va het trong vong 12 tuan.
+ Viem mui xoang man tinh: cac trieu chumg keo dai tren 12 tuan
Trieu chung co nSng:
2 tri?u chiing chinh: ngat miii \ a chay mui 2 tri?u ehung phu: dau dau va giam hoSc mat ngui
Tieu chuan chan doan: co it nhat 2 tri?u chirng trong do phai co 1 trieu chung chinh.
Npi soi mui: khe mui giira co mu ho^c phu ne niem mac ho^c polip mui.
Va/ hoac: CLVT mui xoang cd ma phiic hpp lo ngdch hay mo cac xoang.
2.2. Danh gia mvc d$ nang cua viem mui xoang
Hpi mui xoang Chau Au [2] da dua ra
£0
Tap chf Tai MQi Hong Vi6t Nam - Volume (57-9). N°3 - July, 2012
thang diem danh gia miic dp nang cua viem mui xoang thong qua cac tri$u chiing anh huong den chat lupng cupc song eiia b?nh nhan bSng thuac thang diem VAS (Visual Analog Scale) tir miic dp khong dkn rdt kh6 chiu.
Chia lam 3 miic dp:
Miic dp nhe: V A S < 3 Miic dp vira : VAS > 3 - 7 Mu:cdpnang: V A S > 7 - 1 0 2.3. Nguyen nhan viem mui xoang
2.3.1. Cdc nguyin nhdn kinh diin Theo Parsons [1] viem mui xoang do cac nhom nguyen nhan chinh nhu sau:
+ Sau cam ciim + Diiing
+ Hpi chiing trao ngupc da day - thuc quan
+ Hit phai eac chdt kich thich (bui, khoi thuoc la, hoa chit...)
+ BSt thucmg \h giai phau nhu: veo lech vach ngan, bong hoi cuon giiia, qua phat mom moc, bong sang, VA qua phat, cac khoi u vom mui hpng...
+ Benh toan than: suy giam miln dich, r6i loan chiic nang long chuydn, benh xa nang (cystic fibrosis)...
2.3.2. Cdc gid thuyet m&i vi nguyen nhan viim mui xoang mgn tinh
2.3.2.1. Biofilm
Dinh nghia: la mang ngoai bao Polysarcarit (Extracellular Polysaccharide Matrix) sinh ra bai vi khuan, bao quanh vi khuan, co vai tro bam dinh vao be mdt m6 chii.
- Dac diSm cua Biofilm
• Khang sinh tham nhap rat it qua mang biofilm
• Dai thye bao kho tieu di?t dupe vi khuan trong mang biofilm
• Vi khuan tang siic de khang voi khang sinh
• Cac khang sinh thong thudng va thuoc sat khuan it cd tac dung
- Cac vi khuan cd Biofilm trong viem mui xoang man tinh
Biofilm dupe phat hien bSng kinh hien vi dien tii quet (Scanning Electron Microscopy). Theo nghien ciiu cua Palmer [3] khoang 30% viem mui xoang man tinh cd Biofilm. Hai loai vi khuan cd Biofihn trong viem mui xoang man tinh dupe de cap nhiSu nhit la Staphy. aureus va Pseudomonas aeruginosa. Ket qua nghien Cliu con cho thiy Biofilm bam dmh tren be mat ciia niem mac mui xoang lam han ch6 hoac liet hoat dpng cua cac long chuyln tir do anh hudng tdi chiic nang sinh ly cua xoang.
2.3.2.2. Viem xuang
Quan dilm tnrdc kia cho rang viem xoang la viem niem mac. Tuy nhien cac nghien ciiu gSn day cho thdy khong chi c6 niem mac ma edn cd viem xucmg phdi hop.
Bang chiing la:
- Tren phim CLVT ngoai hinh anh md xoang cdn cd hinh anh vach xuong cua xoang day.
- Trong phlu thuSt npi soi thdy benh tich xuomg day, qua san, dac biet trong nhiing trudng hap tai phdt, mo lai.
- Nghien cOru cua Kennedy [4] cho thiy:
+ 70% VMX man tinh cd tdn thuang tieu xuong va tao xucmg. VMX man tinh
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Tap chf Tai MQi Hpng Vi6t Nam - Volume (57-9). N°3 - July, 2012
dupe xep vdo logi viem xuang tuy mgn tinh (chronic osteomyelitis).
+ Ton thuang viem xuang bdt dau tir rdt sdm trong qua trinh viem xoang. O giai dogn dau, ong Haver cua xuong gidn rpng, thdm nhiem cdc te bdo viem, sau dd Id qud trinh tgo xa (fibrosis).
+ Viem xuang phoi hgp vdi viem niem mgc ldm cho dieu trj vi6m xoang khd khdn vd kdo ddi.
2.4. Hvihig dan mdi ve dieu trj viem miii xoang
2.4.1. Hu&ng dan cda Hgi mdi xoang Chdu Au 121
Diiu tri viim mUi xoang mgn tinh khong CO polip
- Miic dp nhe (VAS < 3).
Dieu tri: nia miii nude mudi sinh ly ket hgp corticoid xit mui keo ddi. Neu sau 3 thdng that bai thi can ket hgp vdi khdng sinh nhdm Macrolide lieu thdp, keo dai.
- Miic dp vira va ndng (VAS > 3 - 10) Dieu tri phdi hgp:
+ Riia mui nude muoi sinh ly + Corticoid xit miii keo dai.
+ Khdng sinh nhdm Macrolide lilu thap, keo dai.
+ Neu sau 3 thdng thdt bgi thi phau thuat npi soi miii xoang, sau dd lgi tiep tuc dieu tri npi khoa vdi cac thudc tren.
Diiu tri viim mUi xoang mgn tinh co polip
- Miic dp nh? va vira: rira miii nude muoi sinh ly ket hgp corticoid xit mui keo ddi trong 3 thang. Nlu cdi thien thi tilp tuc diiu tri. NIU khdng cdi thien chyp CLVT vd phau thuat npi soi miii xoang. Sau phdu
thu^t tilp tyc nia mui, corticoid xjt mui vd khdng sinh Macrolide lieu thap keo ddi.
- Mirc dp n ^ g . Rtra mui nude muoi sinh ly vd corticoid theo dudng uong vdi nh&ng dgt ngdn; kit hgp corticoid xjt mui.
Sau 1 thdng neu cd kit qud tilp tyc diing corticoid xjt mui. Neu that bai chi dinh chyp CLVT vd phau thuat npi soi mui xoang. Sau phSu thugt tiep tyc sir dyng corticoid xjt mui va khdng sinh Macrolide lieu thap, keo ddi.
2.4.2. Hir&ng ddn cua Hgi mdi xoang Nhgt Bdn ve logi vd lieu lugng khang sinh Macrolide trong dieu trj VMX mgn tinh.
Cd 3 logi khdng sinh nhdm Macrolide dugc lya chgn dd la: Erythromycine (EM), Roxythromycine (RX) vd Clarithromycine (CAM)
EM: lieu cho ngucri ldn: 400-600 mg/ngay; cho tre em: I Omg/kg/ngay.
RX; ngudi ldn 150mg/ngay, tre em 5 mg/kg/ngay
CAM: ngudi ldn 200 mg/ngdy, tre em:
5 mg/kg/ngdy.
2.4.3. Vi sao Macrolide dugc lifa chgn di diiu tri yMX mgn tinh
Theo Yukiko lino [5]:
+ Phd khdng khuan ciia Clarithromycine (CAM) cd tac dyng vai hau hit cdc logi vi khudn Gr (-), Gr (+) vd cdc vi khuan khong dien hinh.
+ CAM khdng chi cd tdc dyng khang khudn vd cdn cd t ^ dyng khdng viem, diiu bien mien djch. Nghien ciiu ndng do cac hod chat trung gian viem nhu Interleukin 6, Interleukin 8 trong dich mui cua benh nhan VMX mgn tinh cho thay cd sy giam mgt
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Tap chi Tai MOi Hpng Vi6t Nam - Volume (57-9). N°3 - July. 2012
each CO y nghia thdng ke trudc vd sau 3 thdng diiu trj vdi CAM. Dieu nay dd ldm giam phu ne, loang dich nhay, tdng tap hgp bach cdu trung tinh vd bdo v? long chuyen ciia niem mgc mui xoang.
+ Nghien cim thyc nghifm (in vitro) cho thay CAM cd tdc dyng pha vd cdu tnic mang Biofilm cua vi khudn.
2.4.4. Nhung tnc&ng hgp it ddp img v&i Macrolide liiu thdp, keo ddi vd bign phdp khdc phuc
- Logi Macrolide. Cdc nghien ciiu cho thdy chi ed cdc Macrolide vdng 14 nhu:
Erythromycine, Clarithromycine va Roxythromycine mdi cd cac tac dung tren.
Cdc Macrolide vdng 15 nhu Azitromycine, vong 16 nhu Rokitamycinc.chua co nghien ciiu.
- VMX kem theo viem mui di iing.
Trudng hgp nay ngodi corticoid xit miii + khang sinh Macrolide, diiu tri cdn ket hgp vdi thudc chdng di iing.
VMX cd hoac khong cd polip kem theo tang bach cau ai toan vd hen phe quan.
Tnrdng hgp nay it ddp ting vdi lieu phap Macrolide lilu thdp keo ddi vd phau thugt npi soi miii xoang. Corticoid cd tdc dyng tot trong trudng hgp nay.
- VMX CO tdc phiic hpp 16 ngdch, polip mui ldn, lan tod. Phdu thudt Id phuong phdp lira chpn ddu tien sau dd mdi dieu tri khdng sinh Macrolide vd corticoid xit mui.
- Dgt cdp cua VMX man tinh khi dang trong qud trinh diiu tri Macrolide lieu thap keo ddi. Trudng hgp ndy cdn phai phoi hgp vdi cac nhdm khang sinh khdc nhu Amoxycillin, Cephalosphorin...
3. K^T LUAN
Viem miii xoang do nhilu nguyen nhan phoi hgp.
- Viem vd nhiem triing Id 2 co chl chinh trong sinh benh hpc VMX man tinh. Trong do viem xuong vd Biofihn Id nhiing gid thuyet nguyen nhdn mdi.
- VMX man tinh can dieu tri lien tuc va keo dai trong do chii yeu Id dieu tri npi khoa vdi su ket hop ciia cac phuang phdp:
lam sgch mui, chdng viem, chdng nhiem trimg, nham phuc hdi chtic nang ddn luu, thong khi va bdo ve cua miii xoang
- Corticoid xit mui ket hpp vdi khang sinh nhdm Macrolide lieu thdp, keo ddi la xu hudng mdi trong dieu tri VMX man tinh hien nay.
TAI LIEU THAM KHAO 1. Parsons. D (1996) Chronic sinusitis: a
medical or surgical disease?
Otolaryngologic clinics of North America, Vol 8, No 1, pp: 1 - 9.
2. Fokkens.W, Lund.V, MuUol.J (2007) European position paper on rhinosinusitis and nasal polyps, Rhinology, Supplement 20, pp:l-50 3. Palmer.J (2011) Impact of bacterial
biofilm on cilia function and mucocilliary clerance, 14 th Intemation Rhinologic Society Congress Tokyo - Japan.
4. Kennedy.D (2011) The role of bone mflammation m persistent chronic rhinosinisitis, 14 di Intemation Rhinologic Society Congress ,Tokyo - Japan 5. Yukiko lino (2011) Effectiveness of
macrolide therapy for chronic rhinosinusitis, 14 th Intemation Rhinologic Society Congress, Tokyo -Japan
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