Tgp chl Tai Mui Hpng Vi6t Nam - Volume (57-11). N°5 - Oct., 2012
LVA CHQN Dl/dNG VAO PHAU THUAT U KHOANG BEN HQNG QUA t)6l CHIEU LAM SANG ~ CT SCAN VA MO BfNH HQC
Nguyin Dmh Phuc*, TSngXudn Thdng*, DdBdHung*
T6M TAT
U khoang quanh hgng (parapharyngeal space tumor- PPS) la nhitng khdi u ldnh tinh hay dc linh. phdt sinh vd phdt trien & khoang quanh hgng [4.6]. CT, MRI, chup mgch ddnh gid chinh xdc vi tri u Mo henh hgc chdn dodn hdn chdt u. Mgc tieu : Doi chieu ddc diim ldm sdng vcri ion thuong tren CLVT va mo hinh hgc cda khoi u khodng ben hgng de chi dfnh du&ng vdo phdu thugt phii hgp. Doi tu^ng vd PPNC: Gom 53 binh nhdn dugc chdn dodn vd dieu tri " khoang quanh hgng. Mo td timg ca. can thiip, tien ciiu. Ket qud vd bdn ludn: Vi iri u dung so vai sau phdu thugt: CLIH^ 100% . Ranh gi&i u tren CLVT: 4/lOBN (40%) u dc tinh ranh gi&i khong rd, 41/43BN (95 35%) u ldnh ranh gi&i ro. Du&ng phdu thudt- U tru&c trdm: Cd ben 22/3IBN (70.97%), c6 mgt 3/31 (9.68%). Usau trdm: CS ben 13/! :'BN {~6 47%). U sau hgng: Cd ben 2/5 (40%), trong hgng 1/5BN(20%). Kit lugn: U dc tinh 10/53 (18.8% ) , ldnh tinh 43/53 (81.2%), phdu thugt vai du&ng vdo co bin, hodc du&ng phoi hgp co - mat. Duong sau hgng chi dp dung cho u a khodng sau hgng TU khod- U khodng ben hgng, Duong vdo phdu thugt.
SUMMARY
Parapharyngeal space (PPS) are the belignant or malignant tumors and identified, namely those of salivary origin, neurogenic tumors and paragangliomas. Objective The clinical were analysed and comparisized with CT and anatomopathological data of 53 patiens PPS Materials and methode : A retrospective of 53 patients from Central
Otorhinolaryngology Hospital M'ho were diagnosed as PPS and undem'ent excision from 2005 to January 2010. Results : the malignant tumors 10/53 - 18.8%, the belignant tumors 43/53 - 81,2% The commonest surgical approach was transcervical, and combined transcervical-transoral. The approach of the pre-styloid space was transcervical 22/3 IBN (70.97%), and Iranscervico - facial 3/31 (9.68%). The post-styloid was transcervical 13/17BN (76 47%). The post pharyngeal was transcervical 2/5 (40%) and transoral 1/5BN(20%). Conclusion: The malignant tumors 10/53 (18,8% ) , the belignant tumors 43/53 ( 81,2%). Histopathological examination verified that the origin of these tumors was most frequently salivary or neurogenic. The commonest surgical approach was transcervical,..
Key Words: Parapharyngeal tumors. The surgical approach.
I.DATVANDE space tumor- PPS) la nhirng kh6i u ldnh U khoang quanh hpng (parapharyngeal tinh hay dc tinh, phat sinh vd phat trien d khoang quanh hpng [4,6]. Khoang nay bao
• Dai hpc YH^ Npi g6m khoang sau hpng, khoang trudc tram Nhan b4i 10/9. Duyet in 20/9/2012
10
Tgp chl Tai MQi Hpng Vi^t Nam - Volume (57-11). N°5 - Oct, 2012
va khoang sau trdm.[3,7]. Khoi u khoang quanh hpng ggp kh6ng nhieu chi chiem 0.5% cac khoi u cua vimg dau co vd da so la u ldnh tinh [9,10]. Nhung v^ vi tri khu tni vd ngudn g6c phdt sinh kh6i u thi lgi phuc tap nen kho chan dodn, de bi nhdm lan. Khoang quanh hpng Id khoang cd cau tnic gidi phdu phiic tap lien quan vdi day sp, mach mau va than kinh do do nhirng khoi u khoang quanh hpng Id nhiJng khoi u kho thdm khdm tren lam sdng . Cdc trieu chiing la cac dau hieu muon ciia cdc co quan lan can khi md khoi u da kha to gay chen ep vd anh hudng den cdc cdu tnic mach mau, thdn kinh xung quanh [3,4,8], Chdn doan hmh dnh nhu CLVT, MRI , chup mach ... da giiip cho ddnh gid chinh xdc vi tri, s6 lupng, kich thudc, mure dp lan rpng cua kh6i u [4,6,10] Nghien ciiu dat ra muc tieu sau: Doi chieu dgc diem ldm sdng v&i tdn thuang tren CLVT vd md binh hgc cda khdi u khodng ben hgng di ddnh gid bdn chdt u tru&c phdu thugt 2. DOI TU'ONG VA PHU'ONG PHAP NGHIEN c(fV
Gdm 53 benh nhan duac chan dodn va di6u tri u khoang quanh hpng
Tieu chudn Iwa chon Benh nhan dugc chup CLVT khoang quanh hpng.
Benh nhan dugc ldm xet nghiem mo benh hoc lch6i u sau m6 Dugc phau thuat tai khoa kh6i u Benh vien Tai Miii Hpng Trung LTong..
Thiet ke nghien cmi: Mo td timg ca, can thiep, tien cuu.
3. KET QUA
3.1. Dirdng vao ph§u thudt lay kh^i u khoang ben hong qua doi chieu LS.
CLVT va MBH.
Bang 1: Dudng vdo phSu thu$ttheo vj tr( qua LS-CLVT-MBH
fil l
Tronq hpnq cabin Cgnh c6
C6m4it KhSc
N
Theo phan logi vi tri u ( LS-CLVT) Sau hpng 1 2 1 0 1 5
Sau tram 2 13 2 0 0 17
Trudc tram
2 22
3 3 1 31
N S 37 6 3 2 53 Nhdn xit:
Ty le cac dudng phdu thuat lay bo khoi u theo timg vi tri:
- Dudng c6 ben (transcervical) 37/53BN (69.81%), dudng canh c6 6/53BN (11.32%), dudng trong hpng 5/53BN (9.43%).
Vdi kh6i u khoang tnidc tram:
Dudng c6 ben 22/3IBN (70.97%).
Vdi kh6i u khoang sau tram: Dudng c6 ben 13/17BN (76.47%).
3.2. Doi chieu dirdrng vao phau thuat vifi CLVT va mo benh hoc.
Bang2 £>6i chieu du'6'ng vao phau CLVT va me benh hoc.
Chan Joan trSn CLVT
U lanh tinh
U hSn hop tuv^n nu6c bot U nang Schwannome U xo than kinh U mau - u cuOn cSnh Ul<hac Uactinh N
Tru'dc tram
10 12 0 0 2 2 5 31
Sau tram 1 1 5 2 2 2 4 17
huat vdl Sau hong 1 2 0 0 0 1 1 5
N 12 15 5 2 4 5 10 53
Tgp chl Tai MQi Hpng Vi$t Nam - Volume (57-11), N°5-Oct, 2012
• Nhgn xet:
- Khoang tnrdc tram: u nang 12/3IBN (38.71%). u hon hgp tuyen nude bpt
10/3IBN (32 26%). u dc linh 5/3IBN (16.13%)
- Khoang sau tram: u Idnh tinh c6 ngu6n goc than kinh 7/17BN (41.18%).
- Khoang sau hpng g$p kha da dgng: u nang 2/5BN (40%).
3.3. D^i chieu phau thuat \iVi hirdng xam lan cua khoi u tren CLVT
Bdng 3 €)Ai chi^u phdu thu^t vdi hudng xdm Idn cua kh6i u trfin CLVT tlu-dng phSu
\ , ^ t h u S t x a m l^n \ ,
xam lan
L6n trSn Xuong
dL/di vao trong Ra ngoai
O u d n g phSu thu$t Trong
hpng
0
1
4
0 C6 ben
11
3
33
10 C6 mat 1
0
2
1 Canh
c6 1
3
3
3 Khac
0
0
1
0 N
13
7
43
14
Nhdn xet:
Vdi nhimg trudng hgp khdi u xdm ldn len tren, vao trong va ra ngoai thi dudng phau thudt de ldy bd kh6i u van chii yeu Id dimg dudng c6 ben.
Vdi nhihig khoi u xam lan xuong dudi xucmg mdng thi dudng egnh c6 vd dudng c6 ben dugc dimg vdi ty Ip tuong duang nhau 3/7BN (42.86%).
3.4. Doi chieu dvdng vdo phau thuat vdi chan dodn mo b^nh hpc.
Bdng 4: K^t qud chdn dodn t6 bdc hpc kh6i u tru'dc m6
U d i U lanh tinh
U ac tinh N
n 31
4 35
%
88 57 11.43 100
Nh§n xll ;
- C6 35 bpnh nhan du(?c lAm u do tru6c phau lhu?it: 31/35BN (88.57%) lanh tinh, 4/35BN (11.43%) lade tinh.
Bang 5. K^t qua mO b^nh hpc t<hAi u sau m6
Me benh hpc
U i a n h tinh
U h6n hpp tuy^n nu-dc bot U nang U t^ bap Schwann U xa thAn l<inh U mau- u cudn canh U k h a c u a c t i n h
n 12 15 5 2 4 5 10
%
22,64 28.30 9.43 3.77 7.55 9.43 18 87
N
43
10
Nhgn xel:
- U lanh 43/53BN (81.13%) trong do u nang 15/43BN (34.88%), u hon h(;ip tuyin niiac bgt 12/43BN (27.91%).
- U ac tinh 10/53BN (18.87%).
Bang 6: 06i chi^u t4 bao hpc tn/dc md vdi m6 bgnh hpc sau m6
\ ^ MS benh
\ v ^ hpc T g bao h p c \ ^
Ac tinh Lanh tinh
N
Ac tinh
3 6 9
Lanh tinh
1 25 26
N
4 31 35
Nh^nxel:
Tgp chl Tai MQi Hpng Vi$t Nam - Volume (57-11). N°5- Oct., 2012
Trong 35 benh nhan dugc Idm xk bdo hoc kh6i u tnrdc m6 co 4/35BN (11.43%) khoi u ket luan Id ac tinh trudc m6 thi 3/4BN (75%) ket qud sau m6 diing Id u dc tinh.
- Cd 31/35BN (88.57%) dugc khdng dinh Id u ldnh tinh tnrdc m6 thi 25/31 BN (80.65%) dung vdi ket qua mo b^nli hpc kh6i u sau mo.
Bang 7: Doi chieu dudng phSu thu$t vdi ban chat m6 b0nh hpc
Dudng Ban \ ^ ch^t u \ Tinh ch^t u
Lanh tinh
Ac tinh N
Ou'dng p h i u thuat Trong
hpng 4
1
5 Co ben 31
6
37 C6 mat 3
0
3 Canh
c6 5
1
6 Khac
0
2
2 N
43
10
53
Nhdn xet:
Dudng phau thuat lay u theo dudng mo CO ben dugc sir dung nhieu nhdt cho
cd kh6i u ldnh tinh 31/43BN (72.09%) va kh6i u ac tinh 6/lOBN (60%).
4. BAN LUAN
4.1. D5i chieu hirdng xam lan ciia khoi u qua phau thuat vdi CLVT
Vdi nhihig trudng hgp khoi u xdm ldn len tren, vao trong va ra ngoai thi dudng phdu thuat de lay bo khdi u vdn chu yeu la diing dudng c6 ben.
- Vdi nhihig kh6i •• xdm ldn xu6ng dudi xuong mdng thi dudng canh c6 va dudng c6 ben dugc dimg vdi ty le tuang duong nhau 3/7BN (42.86%).
- Theo Khafif A, Segev Y, Kaplan
DM, Gil Z [7] tren 47 benh nhan u khoang quanh hpng thi 40% trong s6 do dugc phdu thugt theo dudng co ben. Khi so sdnh ehiing t6i thay c6 sir khdc nhau ve ty I? sir dyng ducmg mo co ben su khdc nhau ndy c6 y nghTa th6ng ke (p<0.05).
Theo Olsen KD [8] qua nghien cmi 44 benh nhdn co u khoang quanh hpng dudng phau thuat co ben (transcervical) dugc diing nhieu nhat 35/44BN. Theo Ulku CH, Uyar Y, Arbag H [10] qua th6ng ke sau 10 ndm phau thuat lay bo kh6i u khoang ben hpng thi co nhieu dudng phau thuat dugc sir dung nhung dudng c6 ben la hay su dung nhat.
- Dudng phdu thuat c6 ben co rat nhieu uu diem: No mang lai mpt phlu trudng rpng khi can thiet co the keo len tren tgo thanh dudng c6 mat, keo len tren ra trudc tao thanh dudng c6 ben ket hgp vdi che xuong hdm dudi vd no co the giiip phau thugt vien co mpt phau trudng rpng de cd the nao vet hach vdi cac trudng hgp u dc tinh.
4.2. Doi chieu ban chat u qua phlu thuat voi mo benh hpc .
Dudng phau thugt Idy u theo dudng mo c6 ben dugc su dung nhieu nhat cho ca kh6i u ldnh tinh 31/43BN (72.09%) vd kh6i uactinh6/10BN(60%).
Theo Jonas T. Johnson [6] vdi kh6i u CO ngu6n g6c tit thuy sdu tuyen mang tai 6ng thudng diing dudng c6 mat, vdi khdi u khoang sau trdm chua lan tdi 16 canh ong thudng dimg dudng c6 ben. Vdi nhimg khdi u can hach lan tdi 16 cdnh 6ng dimg
13
Tgp chl Tai MOi Hpng Vi^t Nam - V o l u m e (57-11). N ° 5 - Oct.. 2012
dudng d c6 ket hgp vdi dudng sau tai sau dd cho phep md xuang chum vdi vipc lay di m6m chum de bpc Ip ho cdnh.
K £ T LU/^N
Vj tri u diing so \di sau phSu thugt:
CLVT 100%
Ranh gidi u tren CLVT: 4/1 OBN (40%) u dc tinh ranh gidi kh6ng ro. 4I/43BN (95.35%) u ldnh ranh gidi ro.
Dudng phau thugt:
- U trudc tram: Co ben 22/3IBN (70.97%). CO m$t 3/31 (9.68%).
- U sau tram: Co ben I3/I7BN (76.47%).
- U sau hpng: Co ben 2/5 (40%), trong hpng I/5BN(20%).
TAI L i f u THAM KHAO 1. Vu Duy Dung (2004). Nghien cim dgc
diem ldm sdng vd hinh dnh chdn dodn u khoang quanh hgng gap tgi binh vien Tai MUi Hgng Trung uang tic thdng 1- 1999 din thdng 12-2004, Luan van tdt nghiep bdc sy npi tni benh vien.
2. Pham Bich Dao (1999). Nghien ciru dgc diem ldm sdng vd mo binh hgc cdc khoi u quanh hgng gap tgi viin Tai Mui Hgng, Ludn vdn tot nghiep bdc sy npi tni benh vien.
3. Nguyen Dinh Phiic (2009). "Nghien ciiu ddc diem lam sang khdi u khoang ben hpng", Tgp chi nghien cuu y hgc, 63(4), Tr. 44-49.
4. Ahn JY, Kang SY, Lee CH, Yoon PH, Lee KS (2005). "Parapharyngeal brachial cleft cyst extending to the skull base: a lateral transzygomatic- transtemporal approach to the parapharyngeal space", Neurosurg Rev, 28(1), 73-76.
5. Bouilloud F, Jegoux F, Caze A (2008). "Parapharyngeal tumors:
diagnosis and treatment", Ann Otolaryngol Chir Cervicofac, 125(4), 181-187.
6. Johnson JT (1997). "Parapharyngeal space tumor", Operative Otolaryngology, 1(70), 656-666.
7. Khafif A, Segev Y, Kaplan DM, Gil Z (2005). "Surgical management of parapharyngeal space tumors: a 10-year review", Otolaryngol Head Neck Surg, 132(3), 401-406.
8. Olsen KD (1994). "Tumors and surgery of the parapharyngeal space", Laryngoscope, 104(5), 1-28.
9. Shahab R, Heliwell T, Jones AS (2005). "How we do it: a series of 114 primary parapharyngeal space neoplasms", Clin Otolaryngol, 30(4), 364-367.
10. Ulku CH, Uyar Y, Arbag H (2004).
'"Management of parapharyngeal space tumors",/rA/erfy, 97(5), 140-142.
