Tap chl Tai MQI Hpng Viet Nam - Volume (57-12). N'e - Dec, 2012
CHAN DOAN NGUYEN NHAN VIEM TAI If DICH
Dodn Thi Hdng Hoa*TOM TAT
Vilm tai ir dich la su tdn Igi dich trong cdc hoc lai giira. Nd cd thi xdy ra a mgi lua tuoi, nhtmg thirong gdp nhdt a tre nho dudi 7 tuoi Cd nhiiu yiu Id gdy ra, thudng do rdi logn chirc ndng vol hay cd thi do vilm mgn hay nhiem khudn.
Vilm lai ir dich ggi Id Ihu phdt hay trilu chirng Id tinh Irgng d dich trong tai giiia, bilu hiln nhu mgt trong nhiing ddu hilu cua mdt blnh nguyen khdc. Chdn dodn ban ddu VT it dich dgc bill d ngudi ldn Id xdc dinh nguyen nhdn. Muc dich cita nghiln ciru ndy Id hi thing hoa nhirng nguyin nhdn co thi gdy u dich tai giiia.
Tir khda : vilm tai u dich Ihir phdt, tai giira SUMMARY
Abstract : Ptitis media with effusion (OME) is fluid that persists in the middle ear space. It occurs in all age groups, and most frequently is fi-om the newborn to age 7. The cause is multifactorial. OME often results from Eustachian tube dysfunction or can the result of chronic inflammation or microbial infection.
OME called "symptomatic or secondary" is defined by one of the signs of the underlying disease. Initial managent of OME in adult consiste of identifying the cause.
The aim ofthe report is to systematize the underlying causes of OME "secondary ".
Key words : secoruiary otitis media with effusion, middle ear.
1. D4iT V A N D E
Viem tai giira (VTG) li dich dupe dinh nghia la su ir dich trong cic hdc tai giita phia sau ming tai khdng thiing, khdng cd cic tridu chiing viem cip. Diy li mpt bpnh ll? rit thudng gap d tre em vdi tin suit mic benh cd fliS dat tdi 5-20% (Bluestpne,1995 et Narcy,1996) (2), gin liSn vdi cic dpt viem mui hpng. Ngoai ra cd nhieu bpnh ly khac nhu cac benh ly cua co quan lan cin tai hay cac bpnh viem die hipu vi khdng die hipu cd the biiu hita khdi diu dudi
•Bftihvi^nTMHTW Nhin bai 1/11. DuyStm 15/11/2012
hinh fllii viem tai li dich. Cd the gpi day li the viem tai ir dich thii phit hay trieu chirng. Trong cic trudng hpp nay neu khdng ehi y, de bd sdt nhilng bpnh nguyta, doi khi giy nhiing hau qua ning ni.
Chiing tdi tgm dinh nghia Viem tai li dich thur phit hay trieu chiing li tinh trang li dich trong tai giiia, bieu hipn nhu mpt trong nhihig trieu chirng cua mpt benh nguyta khic. T^ khea Tai Than kinh, bgnh vita Tai Mfli Hpng tnmg upng, nhiiu benh nhan dupe giri dta dieu tri vdi ly do VT li dich, sau khi hdi vi tham kham ky chimg tdi phit hien nhiiu bpnh canh khic nhau.
Tap chl Tai MQI Hpng VI j t Nam - Volume (57-12). N'e - Dec, 2012
Chinh vi v$y, ttieo chung tdi xur 1;? ban diu cua VTG li djch li xic djnh nguySn nhin.
Di giup cic nhi lim sing trinh bd sdt chin doin, chiing tdi co ging hp thong hda cic nguyen nhin cd the gip trong VTG li djch qua phin tich 35 tru&ng hpp VT li djch tripu chiing.
2. D<)I TUONG VA PHUONG P H A P
NGHI6N Ciru
Nghita ciiu hii ciiu 30 trudng hpp viem lai li djch "tripu chiing" gip t?i khoa Tai Thin kinh bpnh vipn Tai Mfli Hpng trung uong tii thing 9/2009 den thing 9/2012.
Ti6u chuin l\ra chpn En li nhOng tru&ng hpp di dupe chin doin vi dieu trj viSm tai u! djch, khi vio vipn phit hi&i bpnh nguyen khic giy ra tinh tr?ng li djch tai gifla ciia BN.
3. K^TQUA
Bpnh nhin chu yiu li ngudi Idn lua tuii t i 16 den 75 mii. Tiy flieo b ^ nguyen mi tripu chimg lim sing rat da d ^ g ngoii tri^u chimg li djch tai giiia.
Khai thic tiin sir, b#nh cinh lam sing vi cic tripu chiing khdng diin hlnh cua viem tai ir djch, chung tdi phit hi$n duprc nhihig cic bpnh sau:
Bing 1 - Viem tai i> djch trieu chiing vdl cic b^nh nguyin khic nhau Benh nguyin
Kvdm
U n^n sp (meninglome)
Khdi u nguyfin phit trong HN (papllome. adenoma, neurlnome
Dj dang mach, phlnh mgch canh trong trong hdm nhT Gii u viim n^n sp
Lao tai
VTG nim
Wegener
Leucose HIV
Tudi 18-62
46,53
25-50
50,75
50,76
16-52
16,72
18
63 24
Trliu chiing lim sing i> dich TG cd thi c i 2 b6n, vdm bit thudng (sui hay phdng), dau diu
i> djch TG 1 bin, nhin ddi hay chdng mit con.
Cr djch, dit dng TK, dng dio thil sdm, Bn iudn cd cim giic bit thudng trong tai (dau nhdl, u tai) hay xuit hl$n Nit mit ir djch dip theo nhjp mach, ddi khi cd chiy miu tai
Cr djch, dit dng dio thil dudi dp luc kim li$t hiu hpng hay net ludi, +/- dii dudng Chiy tai dai ding sau dit dng TK hay dio thil ing sdm, dau nhdi tai, HC m i nhT m$t Chiy tai kim viim ming nhT, niim mac hdm nhT, dau nhiic tai v i ngiia trpng tai VT l i dich t i i phit. m i nhT hda, miu ling CRP ting cao, Viim ciu thin
VT li dich 2 bin, thl4u miu, mit mdi Chiy tai kio dii sau dit ing, viim hdm nhT
Sica 8
3
3
2
3
6
2
1
1 1
Tgp chl Tai MOi HQng Vi$t Nam - Volume (57-12). N°6 - Dec, 2012
DS phat hiSn c^c b?nh nguyfin n^y, cSc nhS lam sang nSn chu y tim cAc tri?u chiing khong dien hinh ciia viem tai u dich nhu dau dau, chong m$t, chdy tai Ic^o d^ sau dat ong, li?t day than kinh sp, li tai theo nhjp dg.p---Cac xet nglii^m mau, chyp cSt lop va CO the tien hanh sinh thiet giup ich cho chan doan b^nh nguyen. Dudi day la mpt so b?nh dn vd hinh dnh minh hpa.
K vdm : BN nam 51 tuoi, vao vi?n \6i tri?u chung viem tai li djch 2 ben tien trien tir 8 thdng kem theo u gid nang 6 trdn vom.
Chup MRI vd sinh thi^t khang dinh K vom.
U mdng nao: BN n& 48 tuoi, dd duac chdn doan VT ijr dich phdi, trich rach mdng tai vd dat 6ng TK 2 ldn each luc vdo vien 1 ndm, 6ng tu ddo thai rdt nhanh. Vao vien ldn nay vi u tai , thinh thodng dau dau va mdt nhin doi. Kham tai, mang tai x?p, % trudc duoi co khdi ph6ng bdt thucmg.
Chvp MRI thdy u mang nao ldn d goc cau tieu ndo.
Papilome tai giua
BN nii 41 tuoi vdo vi?n vi ii tai vd dau nhijrc tai Fdi dupe chan doan viem tai li dich vd trich rach mang nhi, sau trich rach BN van kho chyi trong tai, vdo vi?n thay mdng tai kin ddy hcd x?p voi nghe kem hon hpp. Dupe phau thuat md hom nhi tham do, thdy to chiic viem siii chiem todn bp phan ti^n vd ha nhi, ldy thu gidi phau benh phdt hien papilome tai giua. Sau phdu thuat benh nhan tu ch6i khong dieu tri ve nhd, sau 5 nam dSn xudt hien kh6i papilome vdi nang hoa khSng lo chilm toan bp xuong thai duong phai.
Tgp chl Tai MOi Hpng Vi$t Nam - Volume (57-12). N°6 - Dec. 2Q12
Lao tai: b?nh nhan n& 30 tuoi, c6 tien sir n4m hpng sau cdt Amidan tir 5 ndm trudc. Sau khi di^u trj khdi nAm hpng 1 thdng, xuat hi^n ii tai, nghe k^m dupe ch4n dodn Id VT li djch vd d$t 6ng thdng khf, 2 tuiin sau ong t\r ddo thai ke tir dd BN ludn khd ch\ii trong tai, dupe dimg khdng sinh lien tyc . trung binh 1 - 2 ihdng diing 10 ngdy khdng sinh, gan luc vdo vifn xual hifn nhflng con dau nhdi tai. luc dAu Ihua sau tdng dan, vdo vifn dieu trj.
4. B A N L U ^
Viem tai li dich d^c tnmg bdi sy ton t^i dich, thudng la thanh djch hay nhdy trong hfic ciia tai giira. 6 tre em, viem tai li djch thudng xdy ra sau giai d o ^ viem tai giiia cdp khi v6i nhi khong dupe dan luu hodn chinh (2,3). Trdi lai d ngudi ldn, cd nhieu nguyen nhdn khdc nhau gay ra tinh tr?uig li dich tai giiia. Vifc dieu tri phdi luon nghi ngd, dac bift la nhihig trudng hpp viem tai li dich npt ben. Trifu chiing chinh cdm gidc ddy tai vd dnh hudng din sue nghe. Bfnh
nhdn thudng phdn ndn cd tieng Idch tdch hay cd nude trong tai, cdm gidc nhu cd dj v$t trong 6ng tai ngodi hay dau tai nh^ lan tda. Ddi khi cd the cd cdm gidc mix thdng bdng khdng rd rdng. R6i Ipan chiic ndng vdi dupe coi Id ylu t6 chii ylu trong bfnh sinh cOa vi6m tai li djch. Binh thudng, vdi nhT cd 3 chiic ndng sinh ly chii ylu : cdn bdng dp lyc gifla tai gifla vd tai ngodi, loai bd cdc chat tilt qua vdm mfli hpng vd bdo vf tai gifla trdnh cdc vi khuAn vd trdnh thay doi dp lyc d vdm mfli hpng. 0 tr^g thdi binh thudng, vdi nhi ludn ddng, chi md trong thdi gian r^t ngdn vdi timg thdi dilm.
Thdi gian md vdi trong mpt ngdy khong vupt qud 4 phiit vdi ludng khdng khi Iran qua vdi khong qud 1 ml (tuong img vdi 1/10 thi tich hdm nhi) (3). Cd nhilu nguyen nhan gay roi Ipan chirc ndng vol dupe sdp xep tir A// tac voi den viem thu phdt. Ly thuyet bjt tdc vdi nhi vd ly thuylt viem Id 2 ly thuylt chinh trong bfnh sinh ciia viem tai u djch.
*Ly thuyet bjt tdc voi nh! kinh dien dupe A Politzer dua ra giai thfch bjt tdc voi gdy gidm dp trong hdm nhi vdi mang tai co kdo vd tiet djch qua cdc mao m^ch niem m^c. Tfic CO hpc ciia vdi cd thi tii trong ra hay tu ngoai vdo. Tfic ben trong cd thi do sy bat thudng ve hinh thi cua Idng 6ng hay thdnh 6ng. Thuong g&p lo^ nay la viSm do nhiim khuan hay dj iing. Tdc tir ngoai vao cd thi do 6p tir ngodi vdo Idng vdi ldm hep vdi nhu khoi u hay qud phdt ciia td chiic lympho. Tren lam sdng, tfic vdi cd the gdp cdc tinh huong sau :
- Ton thucmg ngiQfin phdt tgi voi nhi:
hiem thay trong y vdn thi gidi, chu ylu do khd chdn dodn sdm vi hgn chl cdc thdm do
Tgp chl Tai MQi Hpng Vi$t Nam - Volume (57-12). N°6 - Dec, 2012
d vung ndy. Tuy nhien chiing tdi gdp trudng hpp papilome, adenome tai gifla bieu hifn viSm tai ir djch dai ddng. Tren thi gidi cd mpt vdi tdc gid md td trudng hpp melanome vdi nguyen phdt bilu hifn VT li dich dai ddng dupe dieu trj bdng d$t ong thdng khi qua mdng nhi phoi hpp vdi diec h5n hpp vd lift m^t khdng hodn todn thii phdt. Ngodi ra chiing tdi cdn gdp VT li dich d bfnh nhan dpng mach cdnh trong Igc dudng hay tiii phinh dpng mach cdnh trong ndm bit tdc todn bp tien nhT.
Vi vdy, mdc dii hiem gdp cdc khoi u nguyen phat ciia vdi nhT nhung phdi ludn ludn tim kilm, trudc benh cdnh viem tai ii djch tai phdt cua ngudi ldn. Chan dodn rdi loan chiic ndng vdi "vd can" khdng nen dat ra qua nhanh sau khi kham tai vd miii hong.
- Ton thucmg tu ngodi vdo voi nhT: kinh dien, viem tai li dich thudng I ben cd the Id trieu chiing diln hinh vd ban dau ciia ung thu vdm mui hpng. Tuy nhien phai tren ldm sang phai cdnh gidc khi khoi u cd xu hudng lan tod dudi niem mac vdi su xdm nhiem sau, trong khi npi soi niem mac dudng hd hdp cd ve binh thudng hay trudng hpp viem tai li dich 2 ben vdi bieu hifn nhu u nang tran vdm (khdi « dudi niem mac).
Theo chiing tdi, trieu chirng dau ddu dai ding vdi ii djch tai gifla d ngudi ldn phai chii y din u cdc khdi u vung kin ddo ndy vd chup MRI nin so dl trdnh bd xdt.
Ngoai ra, trong y van cdc khdi u d dinh xuong da hay hd dudi thai ducmg lan tran vao viing vdi nhi ciing bieu hifn ban ddu Id viem tai li dich va nghe kem. Thdi han phdt
hifn ra khoi u thudng mupn, khoang tCr 1 den 10 nfim vdi trung binh sau 3,5 ndm ke tir khi ed cdc trifu chirng viem tai li dich ban d4u (1,4). Trong nghien ciiu cua chiing tdi, trong cdc khoi u nen sp xdm lan vdo viing vdi nhT thi u mdng ndo Id hay gap nhat, cdc bfnh nhan thudng dupe ddt ong thdng khi, nhung 6ng bi ddo thdi sdm, khi khoi u bdt dau lap Id trong hdm nhT, nghi ngd chup cdt ldp xuong thdi ducmg mdi phdt hifn. Hdi ciiu tien sir, BN thudng cd cac trifu chiing than kinh phdi hpp nhu md mdt hay nhin ddi, rdi logn chirc nang ddy thdn kinh tam thoa hay chdng mgt con hay dau ddu.
*Ly thuyet viem : niem mgc tai giua ddng vai trd chii yeu trong sinh ly cua tai gifla. Nd nhu mpt mdng ban thdm ma dp luc tung phan ciia mdi thdnh phan khi ludn cd xu hudng cdn bang. Ngay nay ngudi ta coi viem nhu Id yeu to nguyen nhdn chu ylu cua viem tai li dich. Khdi dau nhiing nam 90 nhd nhung tien bp eua sinh hpc phdn tir, ngudi ta thay ro nhiing te bao viem gap d niem mgc lan chat dich vd can vi khudn trong VT li dich. Hon nfla, phdn tich cac m§u djch thu dupe nhdn thay dd Id dich ri viem (vdi ti le glucoprotem ddng ke) va chii khdng phdi Id djch tilt. Tl bao viem dnh hudng tucmg tac vd tao cac chat trung gian mien djch ciJng nhu cac yeu td hod hudng dpng, interferon. Cac ch^t trung gian miln djch nhu histamine, prostaglandins, leucotrienes gdy gian mach vd tang tinh thdm mach. Chinh vi vgy, trong viem tai li dich d ngudi ldn ngoai cdc trudng hpp cd
Tgp chl Tai MQi Hpng Vi^t Nam -Volume (57-12). N°6- Dec, 2012
bfnh ly miii xoang hay dj ling di kdm, phdi chu y cdc bfnh ly viem d§c hifu d lai gifla (nhu lao hay u hgt Wegener, bfnh Sarcoidose), trong cdc bfnh bfnh mdu (leucose kinh hay c4p), bfnh ty miln, HIV, nam xam \kn trong tai gifla... Hdi bfnh, thdm khdm ti mi, phdt hifn cdc trifu chiing khdc thudng trong viem lai li djch nhu cd kem theo dilc tilp nh§n, chdy tai dai ddng vdi niSm mgc viSm...Nen ldm x^t nghifm mdu, mdu Idng, CRP... ddi khi phdi tiln hanh phau thu^t sinh thiet.Vifc chin dodn
diing bfnh nguygn vd diiu trj sdm sg lam thay dhi tiln triln ciia bfnh vd trdnh dupe cdc di chiing n$ng nl. Tuy nhien trong diiu kifn vl Labo nude ta, chin dodn bfnh nguySn ddi khi gdp nhilu khd khdn ddi hdi phdi ph6i hpp ciia nhilu chuyen khoa. Mot dilm chiing tdi mu6n nhin manh, tir v i ^ tai li djch Id m^t trifu chiing ban dau cua vifim gid u vimg nin sp (5) d$c bift d nhflng ngudi cd suy gidm mien djch, ddi dudng.
Hinh 1 : Hudng chdn dodn viem tai li djch d ngudi ldn Tien sir, thdm khdm LS
Cdch xuat hifn Trifu chiing : tai tai Vimg CO c^uan lan can Mirc dp tram trpng ciia Tr/ch Npi soi TMH
phyc hdi (sau VMH, dj iing, CT ^ lyc)
ndng, khdng phyc hdi
Viem tai ir djch Roi logn CN vdi
Labo Do thinh lyc do Do nhi lupng XNmau
MRI hay Scanner nen sp
Tdc voi ViSm D.hieu Man, tdi phdt ^ Tun nguyen nhdn -""^
RL thong khi TG
48
Tgp cht Tai MQi Hpng Vi$t Nam - Volume (57-12). N°6 - Dec, 2012
5, K^T L U ^
Hifn nay vifc chan dodn VT Or djch tuomg doi de nhung cdc nhd lam sdng n6n chii f ddng sau li djch trong tai giiia cdn in chiia rdt nhieu bfnh d$c bift Id d ngudi ldn.
Hdi va thdm khdm ddy du ti mi phdt hifn cdc trifu chiing nghi ngd kem theo nhu dau ddu, te bi mdt, sot, mft mdi...Id rit quan trpng trong vifc chin dodn bfnh nguyen.
Khdng nen nhanh chdng ddt chin dodn VT li djch 'S-d cdn" khi chi khdm tai va vdm miii hpng. Cdc nha lam sang nSn ghi nhd:
"Xu ly ban ddu ciia VTG u djch la xdc dinh nguyen nhdn"
TAI Lllf U THAM KHAO 1. Ayache D, Trabalzini F, Bordure P,et al
(2012). Serous otitis media revealing temporal en plaque meningioma. J.
Laryngol Otol 126(6): 619-24.
Bluestone. CD, Klein. JO (1995). Otitis media. Atelectasis and Eustachian tube dysfimction. Pediatr. Otolaryngology, No 1 : 388-563
Romanet Ph., Magnan J., Dubreuil Ch et al (2005). L'otite chronique. Soei6t6 Francaise d'Oto-rhino-Iaryngologie et de Chirurgie de la Face et du Cou, Editeur., 9-29
A. Tsxmoda, T. Sumi, S. Shirakura et al (2012). Otitis media with effusion and skull base lesion . J Neurol Surg B; 73 - A334
Wilson B. Chwang, Ruchika Jam, Ananth Narayan et al (2012).
Inflammatory Pseudotumor of the Nasopharynx and Skull Base Mimicking an Aggressive Neoplasm or Infection. Arch Otolaryngol Head Neck Surg 138(8):765-769.