Tgp chl Tai MDi Hpng Vi?t Nann - Volunne (57-8). N°2 - March. 2012
6. Lim J.Y., Kim K.M., Choi E.C., et 7. Murat T., Cagatay O., Kursal V., al: Current clinical propensity of Asli S.Y., Mehmet K.: Laryngeal laryngeal tuberculosis: review of 60 involvemct in patients with active cases. Eur Arch Otorhinolaryngol, 2006, pulmonary tuberculosis. Eur Arch 263 (9), pp.838-842. Otorhinolaryngol. 2007, pp.405-407.
LV'A CHQN DirdNG PHAU THUAT KHOI U H 6 N HQIP TUYEN NU'dC BQT KHOANG BEN HQNG
Ll Minh Ky*, Nguyin Quang Trung*
T 6 M TAT
U hin h(7p tuyen nude bpt khoang ben hong ci nguin gic tir tuyen mang tai hojc xuit phat tir cdc tuyen nude bpt lac cho. Myc tieu: nhSm tim hiiu dac diim lam sang, ch§n dodn hinh anh trong l^a chpn dudng phau thuat hieu qua cac khii u nay. Doi tuQug vii phirong phdp nghien ciru: 12 l^enh nhan duoc chan doan va phau thuat u khoang quanh hpng, vol ket qud gidi phau benh sau mo la u hon hop tuyen nuoc hot, tai B?nh vi?n tai miii hpng trung uong tu thdng 12 -2008 den thang 2-2011. Phuong phdp nghien cuu tien cuu, mo ta tung truong hpp. Ket qua: Nghien ciru ciia chiing toi gom 5 nam va 7 nii, dp tuoi trung binh la 36,6; benh nhan tre tuoi nhat la 20 tuoi benh nhan ldn tuii nhdt la 69 tuoi. Trieu chimg phat hien benh thudng gdp nhat la khoi sung viing hpng mi^ng, ddy man hdu vd amidan vdo trong (100%). Cd 3 tnrdng hpp khoi u khd Ion, cue tren ciia khdi u lan len tan vim mQi hong. Khii u cd kich thuoc 3-6 cm Id gap vdi ty le nhiiu nhdt chiim 58,3%, khii u cd kich thudc >6 cm gap vdi ty le 25%. Tren hinh dnh chup cit lop vi tinh va MRI cho thdy khdi xuat phdt tir thiiy sdu tuyen mang tai trong 10 trudng hop, cd 2 trudng hpp khii u phdt sinh tir tuyen nude hot lac chd. Dudng mi dudi hdm dupe thuc hien cho 11 trudng hpp, cd 2 trudng hpp phdi mo dudng md tuyin mang tai md ring, khing cd trudng hpp ndo dupe mi qua dudng mieng. Theo dii cho din nay co I trudng hpp khii u tai phdt sau phdu thudt bdng dudng dudi ham (chiim 8 %). Ket lu?n:Khii u hpn hop tuyin nude bot khoang ben hpng cd triiu chirng ISm sdng khd kin ddo, chup cdt ldp vi tinh vd MRI cd vai trd xdc dinh nguon gic phdt sinh khoi u, phau thuat bdng dudng dudi hdm an toan, it tai bien. Dudng phdu thudt hiyin mang tai md ring dupe dung cho cac khii u dfnh liin mit khii vdi thuy sau tuyen mang tai.
Tir khia: U hon hpp tuyin nude bpt, khoang ben hong SUMMARY
The choice of surgical approach for pleomorphic adenoma of parapharyngeal space
Pleomorphic adenoma of parapharyngeal space derivated from deep lobe of parotid or ectopic salivary gland. Objective: To find out clinical and imagery characteristics in determining the surgical approach for pleomorphic adenoma of
* BV Tai MQi Hpng trung uong
" BO m6n Tai MDi Hpng Oai hpc Y Hd Npi Nhdn bdi 15-4-2012, duy$t in 26-4-2012
T9P chl Tai MQI Hpng Vi^t Nam -Volume (57-8). N"2 - March. 2012
parapharyngeal space. Patients and method: 12 patients with pleomorphic adenoma of parapharyngeal space, diagnosed and operated at ENT Hospital from Dec 2008 to Feb 2011. This was prospective and descriptive study. Results: There were 5 males and 7 females in our study, the average age was 36,6 years old. The most common symptoms was a lump in oropharynx that pushed laterally the tonsils. The dimension the most frequent was from 3 to 6 cm (58.3%), 25% of tumors was superior to 6 cm. Based on CT and MRI. we stated that 10 tumors derivated from deep lobe of parotid and 2 from ectopic salivary gland. Transcervico-submandibulary approach was performed in 11 cases, the parotidectomy extend approach in 2 cases, no case with endobuccal approach.
So far, I recurrent after surgery with transcervico-submandibulary approach.
Conclusion: CT and MRI had an important role in indentifying the origin of tumors.
Surgery with transcervico-submandibulary approach was safe, efficace, least complications. Surgery with transcervico-submandibulary approach was used in case of the bloc of tumors and deep lobe of parotid.
Keywords: parapharyngea tumor l.DATVANDf,
U khoang ben hpng \k nh&ng khoi u ph^t sinh tur nhihig thinh phkn trong khoang ben hpng ho3c nhihig khoi u phat sinh ben ngoai nhung xam l^n vao khoang nay.
U hon hpp tuyen nu6c bpt khoang ben hpng co nguon goc tu tuyen mang tai hoac xudt phat tir cdc tuyen nu6c bpt lac cho. No chilm khoang 26 den 43 % cac khoi u khoang ben hpng. Hai loai khdi u khac thucmg gap khac la u than kinh {chiem khoang 17-25%) va u c?in hach (chi6m khoang 10-15%) [3].
U hon hpp ciia tuyen nu6c bpt nSm 6 khoang ben hpng, la mpl vj tri khd d^t biet doi voi loai kh6i u nay, da d$t ra nhieu vin dk ve chdn dodn, chan dodn phan bi?t va van de lyra ducmg phau thuat, each thuc phau thuat...
Ngay nay CT scanner vd MRI Id nhiJng x^t nghiSm chdn dodn hinh dnh rat CO gid tri trong chan doin cdc khoi u khoang ben hpng noi chung vd u hon hpp tuySn nuoc bpt n6i rieng, cdc x6t nghi?m nay giiip danh gid vi tri phat sinh u, phdn
ndo cho biit dupe bdn chat kh6i u, vd gop phdn chpn t\ra ducmg phSu thuat.
Do vgy, chiing toi tiln hdnh dl tai N^hiSn curu lua chpn du6ng phau thuat dieu tri khoi u hon hpp tuyen nuoc bpt khoang ben hpng nhdm tim hilu ddc diem ldm sdng, chan doan hinh anh trong l\ra chpn duong phau thuat hi$u qud cdc khoi u nay.
2. D 6 I TirONG VA PHlTONG PHAP NGHIEN c u t !
2.1. Doi t u ^ g nghien cihi
Nghien cuu gom 12 b^nh nhan dupe chan dodn va phau thuat u khoang quanh hpng, v6i ket qua gidi phau b?nh sau mo Id u hon hpp tuyen nude bpt, tai B?nh vi?n tai mui hpng trung uong tir thdng 12 -2008 din thang 2-2011.
2.1.1. Tieu chuin /(ra chpn
- B^nh nhan dupe chdn dodn xdc djnh Id khoi u khoang quanh hpng tren lam san^ vd tren chup cdt I6p vi tinh dd dupe dieu tri phau thudt tgi b?nh vi?n Tai Mui Hpng trung uong.
76
Tgp chl Tai MDi Hgng Vi#t Nam - Volume (57-8). N°2 - March. 2012 - Benh nhdn dupe lam xet nghiem
mo b?nh hpc khii u sau mi, kit qud Id u hon hpp tuyin nude bpt.
2.1.2. Tilu chuan logt trir
- Khing dupe chyp phim cdt Idp vi tinh hodc MRI trudc phau thu(it.
- Dupe chdn dodn xac djnh Id khoi u khoang quanh hpng nhung khdng dupe diiu tri phau thudt vi nhOng ly do khdc nhau nhu: hcnh nhan tit choi phSu thuat, benh nhan khong cd chi djnh phlu thuat cimg nhu khin^ dupe ldm xit nghipm mi b^nh hpc khdi u sau phau thuat.
2.2. Phuong phdp nghien ciru 2.2.1. Thiit ki nghiln cuu: Tiin ciru, mi td timg trudng hpp.
2.2.2. Tiln hdnh nghien cuu - Ddnh gia vi tri cua khoi u so vdi hodnh trdm, dua tren lam sdng, chup cdt ldp vi tinh, nhan dinh khi phau thuat.
- Ldy mau khoi u lam chdn dodn mi benh hpc
- Thu thdp cdc dir lieu ve cdch thuc phau thudt
3.2. Tri^u chirng thvc the Bdng 1. Phdn bo tri^u chdng thu'c thi
2.2.3: Xi: ly so llfu; Sau khi thu thdp si li?u dupe day du cdc thing tin theo b^nh dn mlu, so lipu dupe xii ly bdng phan mem SPSS 16.0 vd sir dyng cdc test thong ke.
3. KfiT QUA VA BAN L U ^ N 3.1. Tudi v4 gidi tinh
Trong nhdm b$nh nhan nghien cim ci 5 nam vd 7 nO, di mii trung binh Id 36,6; bpnh nhdn tri tuoi nhat Id 20 tuoi binh nhdn ldn tuoi nhit Id 69 tuii. Trong so 12 b$nh nhan ci 5 nam vd 7 nO
Theo nghien cuu ciia Nguyin Dinh Phuc[l] tuii trung binh 43,3, nhom tuii ttr 18-60 chiim 87%, Pham Bich Dao[2]
lira tuii tit 21-60 chiim 73.08%. Ty le nam vd nO- trong nghien cuu cua chiing tii Id 5/7. Trong nghiin cua ciia Nguyen Dinh Phuc[l], nam chiim 44,5%, nu 55.5%. Do s6 lupng nghien cim nho nen chua ndi lin duoc ty li chinh xdc vi gidi tinh, tuy nhien ty le gidi tinh dua tren cde nghien ciru tren cho thdy khing ci sir khdc biet giGa nam vd nir.
~ ~ ^ - _ ^ _ ^ ^ Wtrlu
Tti^u Chung thuc thi ~~~~~-—~...,,__^
Sd thiy khii u sau gdc hdm
£dy phong trg trudc amidan vd mdn hdu H ^ T h i n g trg sau amidan vd amidan
^ d n g dd ddy amidan vd cdc trg amidan pdy phong thdnh bdn hpng lan ldn vdm mQi hpng pdy phing lan dpc theo thdnh bdn ha hpng gdy khd thd
N
3 12 0 0 3 1
%
25 100 0 0 25 8,3
Tgp chl Tai MQI Hpng Vl^t Nam - Volume (57-8). N"2 - March. 2012 (100%). C6 3 truing hpp kh6i u khd I6n, Trong cdc tru^g hpp nghien curu,
th6i gian xuat hi^n tri^u chung tdn ddu tien rat kh6 xdc djnh do tri^u chung phdt hi?n b?nh thu6ng khong r6 rdng. Pensak [6] trong nghifin cuu tr6n 123 b$nh nhdn u khoang bfin hpng cho rdng phdn \6n cdc kh6i u ldnh tfnh diu khdng c6 tri$u chung, da s6 dupe chdn dodn m$t cdch tinh cb liic di khdm b^nh
Ngupc l^i chiing toi ghi nh§n nuot vu6ng trong, vd dau lan len tai trong 3 trudng hpp. Theo Carrau [4], nhChig dau hi?u ndy xudt hi?n trong khodng 6% cdc trucmg hpp. Chiing toi khong phdt hi?n trudng hpp ndo c6 tri?u chiing cumg hdm hodc li^t m$t trong nh6m bSnh nhan nghien curu.
Tri?u chung phdt hi?n b$nh thu6fng gdp nhal Id khoi sung vung hpng mi?ng, day mdn hau vd amidan vdo trong
c\rc tren ciia khoi u lan len tan v6m mui hpng.
Theo Carrau [4], vi^c khdm vimg CO kit hpp v(Vi stf bdng ngon tay vdo khoi u trong hpng, khfing mang l^i nhilu d& ki§n cho vi$c xdc djnh nguon g6c tuyin mang tai ciia kh6i u, trong so 14 trudng hpp u khoang b6n hpng xudt phdt tir tuyin mang tai, chi c6 2 trudng hpp c6 the sd thay dupe khi khdm vimg co.
Th§t vHy, so vdi cde khoi u sau trdm sS c6 nhieu tri^u chiing lam sdng gpi 1? nhu cdc tri?u chiing do di ddy m^ch mdu. dau, li^t thdn kinh...cdc tri^u chiing ciia khoi u hon hpp tuyen nude bpt thudng ngheo nan, mo ho , thdm chi khong cd tri^u chiing. Chdn dodn ldm sdng thudng mupn khi khoi u dd phdt trien ldn.
3.3. Chup cdt Idp vi tinh vd cQng hudng tii-
Bdng 2. Kich thudc kh6i u tr6n chgp cdt Idp vi tinh ho^c phim MRI Kich thu&c cda khoi u
< 3cm
a 3cm 3 cm- 6cm
>6cm N
Al 2 7 3 12 Khoi u c6 kich thudc 3-6 cm Id gdp vdi ty I? nhilu nhat chiem 58,3%, tiep theo do Id khoi u cd kich thudc >6 cm g5p vdi ty I? 25%. Cd s\r khdc bi?l ve ty I? kich thudc ciia khoi u tren phim chyp CLVT. Khoi u cd kich thudc > 3cm Id gdp nhieu hon cd (83,3%).
Bdng 3. LI6n quan kh6i u v&\ tuy^n mang tai tr6n phim chgp cdt Idp hodc MRI Uin quan vdi tuyin mang tat
Lidn tiip vdi thOy sdu tuyin mang tai Ranh gidi ti vdi thOy sdu tgyin mang tai N
N 10 2 12
%
83 17 100
Tgp chi Tai MDI Hpng Vl#t Nam - V o l u m e (57-8). N°2 - March. 2012
Khoi u xudt phdt tir thiiy sau tuyin mang tai theo WHO chilm khoang 10%
khSi u tuyin mang tai, tuv nhien khoi u tir thuy sau phdt triln vl phia khoang ben hpng rdt hiim gdp, Andre [ 3 ] chi bao cdo 3 trong s6 37 trudng hpp (4%).
Chyp cdt Idp vi tinh va/hodc chyp MRI giup khdng dinh dupe chinh xac nguon goc khdi u td tuyin mang tai dua vao CO hodc khon^ co khodng mo md giiia khoi u vd tuyen mang tai. Som [7]
trong nghien ciiu dd nh^n thay 2/3 khoi u thuy sdu tuyin mang tai phdt trien vl khoang ben hpng, chi bieu hi?n vdi eo noi rat mdnh gi&a khdi u va tuyin mang tai, va nhan djnh rdng MRI giiip xdc dinh khoang mo md gi&a khoi u vd tuyin mang tai tot han chup cdt ldp vi tinh.
That v$y trong nghien cuu ciia chiing toi, nhd vao CT scan vd MRI, chiing toi co thi xdc dinh xudt phat tu thiiy sdu tuyin mang tai ciia kh6i u trong 10 trudng hop dua vao hinh dnh lien tuc cua khoi u vdi tuyen mang tai.
2 trudng hpp cdn lai Id khdi u hon hpp tuyin nude bpt td tuyin nude bpt lac cho. That vdy u hon hpp tuyen nude bpt d khodng trudc tram cd the xudt phat tir tuyin nude bpt lac cho trong qua trinh phdt trien phoi thai, tuy nhien theo 3.4. DiTOTig vao cua phau thu^t Bdng 4. Bud'ng vdo cua phdu thudt Idy kh6i u
Andre [3] nh&ng khoi u hon hpp ndy co the xuat phat tu phan hpng ciia thiiy sau tuyin mang tai vd mdt di sy lien he vdi tuyin khi khdi u phat triln.
Tuy nhien cdn phan biet vdi nhiing khoi u ciia tuyen nude bpt phy d niem mgc thdnh hpng, khong ndm trong nghien ciiu ciia chiing tdi, nh&ng khoi u ndy thudng ndm dudi niem mac viing khau cdi, gdp chii ylu d n& gidi, tuoi trung nien.
Som [7] trong nghien cihi tren 104 khoi u ben hpng da nhdn thay 19 ca (28,8%) c6 nguon goc tir tuyin mang tai, 10 cas (10,6%) cd ngu6n glc td tuyin nude bpt la.c cho. Trong khi d6 Carrau 14] trong sd 16 khli u tuyin nude bpt khoang ben hpng, nhan thdy 63% co nguon gdc tu tuyen nude bpt lac ch6, 37% CO nguon goc tu tuyen mang tai.
Chup MRI Id xet nghiem co tri nhdt, CO the ddnh gia su lien tuc cua khli u vdi tuyin mang tai, Som [7 ] nhan manh din su hien dien cua ldp mo md gi&a khoi u vdi CO xiet hpng vd giua khoi u vdi tuyen mang tai, tuy nhien doi khi su phan biet nay rat khd. Theo Carrau [ 4 ] co khoang 7 % khoi u cua tuyen nude bpt lac cho dupe chan dodn nhan la khoi u cua thiiy sau tuyen mang tai.
Dudng phau thu$t Budng dudi hdm
Budng PT tuyin mang tai md rOng Budng qua mi$ng
Budng cdt xuong hdm dudi
N 11 2 0 0 Trong so 12 b6nh nhdn nghit-n cdu
vdi sd lan phau thuat Id 13, chung tdi thuc hien dudng md dudi ham cho 11
trudng hpp, cd 2 trudng hpp phdi md dudng md tuyen mang tai md rpng, khdng cd trudng hpp nao dupe md qua
Tgp chi Tai MOI Hpng Vl$t Nam - Volume (57-8). N"2 - March. 2012 dudng mi^ng, hodc qua dudng cdt xuong
hdm dudi. Sau thdi gian theo dOi cho din nay, chung tdi n h ^ thdy c6 I trudng hpp khoi u tdi phdt sau phau thu§t bdng dudng dudi hdm (chilm 8 %).
Doi vdi u hSn hpp khoang bSn hpng, Andre [3] dd cho rdng dudng phdu thu^t xuyen mdn hdu qua dudng mi^ng Id du dl ldy khoi u, tuy nhi^n hi^n nay hdu hit cdc tdc gid diu cho rdng dudng phdu thudt ndy khdng ddm bdo, do phdu trudng h?p, nhilu nguy ca khdng kilm sodt dupe chdy mdu, hon n&a ty 1$ tdi phdt u cao, theo Goodwin [5], cd 25% tdi phdt u sau 5 ndm.
Da so trudng hpp ehiing tdi sd dyng dudng dudi hdm, vdi Ipi ich cua dudng phau thudt ndy Id kilm sodt dupe cdc mach mdu ldn, khdng cd nguy ca lam ton thuang day VII, s?o vlt mo kin ddo, tham my. Trong cdc trudng hpp ndy, chiing tdi khong cd trudng hpp ndo phdi cdt xuong hdm dudi d€ md rpng phdu trudng, mdc dau cd 2 trudng hpp kh6i u khd ldn. Carrau [4] cung cd chung nhdn dinh nay.
Dudng phau thuat md tuyin mang tai md rpng, chiing tdi chi thyc hi$n trong 2 trudng hpp, 1 trudng hpp khdng ldy hit dupe u qua dudng dudi hdm vd mpt trudng hpp mo lai do khoi u tdi phdt sau khi md bdng dudng dudi hdm.
Dudng phdu thudt nay phiic tgip hon, phdi phau tich ddy VII vd cd nguy ca lam tdn thuong ddy thdn kinh eao.
That vdy, doi vdi nh&ng khoi u hon hpp khoang ben hpng cd kich thudc ldn, nhdt Id khdi u dinh lien vdi thuy sdu tuyin mang tai, tren phim chyp cdt ldp, hodc MRI, thi nen chii dpng phSu thu^t bdng dudng tuyin mang tai md rpng, bdo tdn cac nhdnh day VII.
4. KtT LU^N
Khli u hon hpp tuyin nude bpt khoang bdn hpng cd tri$u chting lam sdng khd kfn ddo, chyp cdt \6p vi tinh vd MRI cd vai trd xdc djnh nguon goc phdt sinh khli u, phdu thudt bdng dudng dudi hdm an todn, it tai biln. Dudng phau thu^t tuyin mang tai md rpng dupe diing cho cdc kh6i u dinh liln mpt khoi vdi thdy sdu tuyin mang tai.
T A I L i f u THAM KHAO
1. Nguyen Dinh Phfic. NghiSn cdu ddc dilm ldm sdng khli u khoang bSn hpng.
Tgp chf nghiSn cdu y hpc, 2009, 63(4), tr 44-49.
2. Ph^m Bfch Ddo. Nghien ciiu ddc dilm Idm sdng vd md b^nh hpc cdc khoi u quanh hpng gdp tai Vi^n Tai Mui Hpng. Lugn vdn tdt nghiep Bdc sT npi tni.
Dgi hpc YHd Npi 1999.
3. Andre P; Laccourreye H; Haguet J F. Parapharyngea] nerve tumors. Ann Otolaryngol chir cervicofac, 1975, 92 (7- 8), 345-6
4. Carrau R.L; Myers E.N; JobnsoB J.T. Management of tumors arising in the parapharyngeal space. Laryngoscope.
1990,100:583-9
5. Goodwin W J ; Chandler J R Transoral excision of the lateral parapharyngeal space tumors presenting intraorally. Laiyngoscope. 1988,98:288-9 6. Pensak M L; Gluckman L;
Shumrick K A. Parapharyngeal space tumors: An algorithm for evaluation^ and management. Laryngoscope.
1994,104:1170-3
7. Som P M; Braun I F; Shapiro M D;
Reede D L. Curtin H D; Zimmemum R A. Tumors of par^haryngeal space and upper neck: MR imaging characteiistu^..
Radiology, 1987,164: 823-9
