Y HOC VI$T NAM THANG 5 - SO 1/2013
DANH GIA HIEU QUA CORTICOID TOAN THAN TRONG DIED TRj DIEC DOT NGOT TAI DENH VIEN TAI MUI HONG TRUNG UONG
Doan Thj Hong H o a * TOftA T A T
Nghien cuU hoi CIJ\J tren 127 tai benh co chan doan diec dot nggt, dieu tri tai benh vien Tai I^Qi Hong Trung liOng tir thang 01/2011 den thang 09/2011. Sau dieu tri, 70,9% BN du'dc dieu tii khdi dau vdi methylprednisolon 80mg/kg/ngay c6 miTc do cat thien thinh lut dang ke dSc biet d cac tan so 2000Hz va 40odHz ^ hdn so vdi nhuhg BN diing vdi lieu 40mg/ngay.
Td Ichoa: diec than kinh giac quan dot ngpt, thuoc, lieu phap corticoid
SUMMARY
EFFECT OF CORTICOID THERAPY ON RECOVERY OF IDIOPATHIC SUDDEN HEARING LOSS IN ENT
NATIONAL HOSPITAL A prospective study of 127 ears with diagnosis of sudden sensorineural hearing loss, treated at National Hospital of Otolaryngology, Jan 2011 to Sep 2011.
70,9% patients treated by methylprednisolon 80mg/kg/day had a higher recovery PTA especially at 2000Hz and 4000Hz as comparing with patients treated by methylprednisolon 40mg/day.
Keywords: Sudden sensonneural hearing loss, drugs, therapy, corrticoid.
L OAT VAN OE
Ngay nay, diec dot ngot van du'dc xem nhu"
la mot tinh trang cap ciTu Tai Mui Hpng, dd la nhii'ng diec tiep am tren 30 dB d ba tan so lien tiep xay ra trong 3 ngay [ 1 ] . Tan suat cd the len den 160 ngu'di /lOOOOO dan [2,3,4]. Da so diec dot ngof xay ra mpt ben va nguyen nhan chu'a rd rang nen chu'a ed phac do dieu tri dac hieu. Tuy nhien, corticoid toan than_dung ddn Ie hay phoi hdp vdi cac thudc khac van dddc col la phu'dng phap dieu tri cd hieu qua, du'dc ap dung pho bien d nhieu ndi tren the gidi.
6 Viet Nam noi ehung va benh vien Tai Mui Hgng Trung U'dng ndi rieng, viec dieu trj diec dot ngpt edn nhieu diem chu'a thdng nhat giu'a cac nh^ dieu tri trong viec ly'a chpn corticoid eung nhu' lieu diing sir dyng trong dieu trj. Vi vay, danh gia viec sir dung nhdm thuoc nay trong dieu trj, chung tdi tien hanh de tai "Danh gia hieu qua corticoid toan than vdi iieu lu'dng khac
* Benh vien TMH TW
Phan bien khoa hgc: PGS.TS. Pham Tran Anh
nhau trong dieu tri diec dot ngpt tai benh vien Tai MUI Hpng Trung l/dng"
II. DOI T U ^ N G VA PHUONG PHAP NGHIEN COU 1 . Doi t u ' d n g n g h i e n cufu: 110 benh an ciia 110 benh nhan (BN) vdi 127 tai benh, cd ehan doan diec dot ngpt, du'dc dieu trj tai khoa Tai Than Kinh - benh vien Tai Mui Hgng Trung U'dng tir thang 1/2011 den thang 9/2011. Nhu'ng benh nhan nay du'dc chi dinh corticoid toan than trong thdi gian dieu tri benh tai vien.
Phu'dng phap nghien ciru: mo ta, hoi ciru cat ngang.
III. KET QUA
3.1. i^gt so dac dii'm ve dich ti 3.1.1. Tudi va gidl tinh: Ju6\: trung binh 41+
17,3, ldn nhat la 72 tud'i va nho nhat la 11 tuoi.
Gidl tinh: Nam chiem 67 BN, niJ chiem 60 ca 3.1.2. Thdi han trung binh td khi bl benh den khi din viin diiu trp. 14,3 ± 5,6 (ngay), sdm nhat la sau 1 ngay, mugn nhat ia sau 6 tuan
3.1.3. Hinh thai thinh idc do thu dddc:
loai A va B hay gap nhat Bang 1: Cac darig thinh lyc do Hinh thai thinh
lire Loai A (doc len) Loai B (nam nqanq) Loai C (doc xuong) Loai D (bien thien) Loai E (diec sau)
So ca 35 36 28 18 10
Ti le % 27,6 28,3 22,0 11,2 7.5 3.1.4. I^dc do giam nghe {(\\Sa theo phan loai ciia WHO)
Bang 2: Mire do nghe kem MLTC do giam thinh
lu'c Nghe kem nhe Nqhe kem trunq binh Nqhe kem nanq Diec sau
So ca 20 35 32 40
Ti le % 15,7 27.6 22 31,5 f = 8,59; p = 0,035
Y HOC VIET HAM THAHG 5-S6 1/2013
3.2. Khao sat v l | c sii' dung corticoid toan t h a n _ vdi nhu'ng benh nhan co chan doan diec dot ngot du'dc sir dung corticoid toan than, tat ca nhu'ng
benh nhan nay dUdc chi dinh methylprednisolon khdi dau theo du'dng tTnh mach. Ty I? BN dung methylprednisolon theo du'dng tinh mach vdi cac mire lieu khac nhau du'dc the hien trong bang 1.
Bang J ; Viec sir dunq cac corticoid vdi cac mire lieu khac nhau tronq dieu trj Ueu dung corticoid
khcfi dau MP 80mq/nqay MP 40mq/nqav
So tai benh (n) 90
Ty I? (Vo) 70,9 % 29,1'!
Thcfi gian dieu trj (ngay) 10,3 ±3,0 10,9 ± 3,2 Nhan xet: 100% Bn du'dc chi dinh corticoid toan than du'dc diing methylprednisolon. Khong co BN nao trong mau nghien ciru du'dc chl dinh corticoid khac.
Ty le BN diing methylprednisolon tinh mach vdi lieu SOmg/ngay la 70,9 %, trong do, 21,9% BN du'dc diing methylprednisolon tinh mach vdi lieu 40mg/ngay. Thdi gian dieu tri trung binh ciia 2 nhom BN tren lan lu'dt la 10,3 ± 3,0 va 10,9 ± 3,2 ngay. Tat ca BN dieu tri bang corticoid toan than tren 10 ngay deu dUOc giam lieu trirdc khi ngirng dieu tri.
Nhu vay, ty le BN dUdc chi dinh corticoid du'dng toan than vdi mire lieu cao hdn chiem ty le Idn hdn.
3.3. Danh gia hieu qua dieu trj bang corticoid toan t h a n d cac mij'c Ifeu IUdng Bang 4: Ty le cai thien va miic do hoi phue thinh lire
Thuoc dieu tri Methylprednisolon 40mq/nqay Methylprednisolon
80mq/nqay
Co hoi phue So tai benh
(n) 20 63
T y l e
(%)
54,1 % 70,0 %
Z ±2,95
Khong hoi phue So tai benh
(n) 17 27 p = 0,086
T y l e (°/oj 45,9 % 30,0 %
MLTC do phue hoi thinh lire (dB)
i D l D 15,4 24,0 ± 21,6
p = 0,013 Nhan xet: Trong nhdm BN du'dc dieu tr; khdi dau bang methylprednisolon vdi iieu 80mg/ngay CO 70,0% hoi phue thinh lu'c, cao hdn so vdi nhdm BN diing methylprednisolon 40mg/ngay va khong diing corticoid. Mire dp hdi phue thinh ly'c d nhom BN nay cung cao so vdi nhdm BN diing methylprednisolon 40 mg/ngay (p = 0,013).
> Mu'c dp hoi phue thinh lu'c d tu'ng t a n so Bang 5: Mdc do cai thien thinh lu'c d tiTng tan so
Tan so 250 Hz 500 Hz 1000 Hz 2000 Hz 4000 Hz 8000 Hz PTA
Methylprednisolon 40mg/ngay
15,1 ± 19.8 19,7 ± 20,1 18,0 ± 19,6 11,4 ± 15,0 7,2 ± 13,6 8,9 ± 12,7 14,1 ± 15,4
Methylprednisolon SOmq/nqay
23.3 ± 26,4 27,3 ± 24,7 24,0 ± 24,0 24,6 ± 25,8 20,0 ± 22,6 15.8 ± 20,4 23,g ± 21,6
P p = 0,09 p = 0,14 n = 0,19 p = 0,01 p = 0,01 p = 0,18 p = 0,02 Nhan xet: Mire dp cai thien thi'nh ILTC la khong co SLT khac biet giQ^ 2 nhdm BN d cae tan so 250 Hz, 500 Hz, 1000 Hz va 8000 Hz. Trong khi dd, nhu'ng BN diing methylprednisolon 80mg/ngay eo mire do cai thien thinh lu'c tdt hdn nhom BN diing corticoid vdi lieu 40mg/ngay d eac tan so 2000 Hz va 4000 Hz. SU khac biet nay la co y nghia thong ke. Ngoai ra, miic dd cai thien thinh life do trung binh ddn am (PTA) d nhom BN diing corticoid 80mg/ngay cung tot hdn, SLT khac biet nay eo y nghTa thong ke (p < 0,05).
IV. BAN LUAN
Trong mau nghien ciru, vdi 127 tai benh ciia nhifng BN cd chan doan diec dot ngpt dupe dieu
tri tai benh vien Tai Mui Hpng Trung Lfdng bang methylprednisolon toan than, 70,9% BN diTdc ehi
Y HQC VigT NAM THANG 5 - SO 1/2013 djnh vdi lieu 80mg/ngay va 2 9 , 1 % du'dc chi dinh
vdi lieu 40mg/kg.
Thdi gian dieu trj trung binh d 2 nhdm BN la khoang 10 ngay. Ngoai ra, tat ca BN dung thuoc tren 10 ngay deu du'dc giam lieu tru'dc khi ngu'ng thuoc. Oieu nay la phii hdp vdi nguyen tac sir dung corticoid dai ngay nham muc dfch giam cae TDKMM ciia thuoc.
Corticoid la thudc du'dc chi djnh lieu diing dira tren can nang BN chir khdng phai la tuoi hay gidi tinh BN. Tuy nhien, nghien cifu hoi ciTu benh an, chung toi khdng thu thap du'dc thdng tin can nang BN trong benh an hoi ciru, do dd, khong the cd du'dc su" danh gia chinh xac mire lieu corticoid tfnh theo kg can nang ciia BN du'dc diing trong nghien ciTu nay. Tuy nhien, cung cd the thay viec lira chpn lieu dung thudc cijng du'dc eac bae sy di/a tren tu6"i va gidi tfnh ciia BN. BN nam va ed dd tud'i 15 - 55 tuoi du'dc u'u tien chi dinh corticoid toan than vdi lieu eao hdn. Day la mpt thdi quen trong ke ddn cua cac nha dieu tr;
ma chu'a cd mdt nghien ciru nao khuyen cao vdi each sir dung corticoid nay,
Tien sir benh, dang thfnh lu'c do, cac trieu chu'ng ed nang di kem khdng anh hu'dng den viec li/a chpn lieu diing corticoid toan than.
Tuy nhien, mire dp nghe kem ed anh hu'dng den viec li/a chpn lieu diing corticoid toan than.
Lieu cao hdn (80mg/ngay) dddc ehi dinh ehii yeu eho nhu'ng BN cd tinh trang giam thfnh li/c nang hoae diec sau. Mire lieu nay it du'pc ehi djnh hdn vdi nhii'ng BN giam thfnh li/e nhe va vira.
Sau dieu tn, 70,0% BN dimg corticoid lieu eao hdn cd cai thien thfnh lu'c, trong khi do, ty le nay d nhdm BN diing corticoid toan than vdi lieu 40mg/ngay la 5 4 , 1 % . Tuy nhien, SLT khac biet nay khong cd y nghTa thong ke. Sy" cai thien eac trieu chu'ng cd nang di kem (nghe kem, ii tai, chong mat) cung khdng cd sy" khac biet giu'a cac nhom BN diing corticoid toan than vdi mire lieu khac nhau.
Mire dp giam thfnh Idc d tat ca cac tan sd la khdng cd su" khac biet giu'a 2 nhdm BN du'pc chi djnh corticoid vdi lieu khae nhau tru'dc dieu tn khong ed SLT khac biet. Sau dieu tn, nhdm BN dung methylprednisolon tTnh mach vdi lieu 80mg/ngay cd kha nang eai thien thinh Idc d eac tan so 2000 Hz va 4000 Hz tdt hdn so vdi nhdm BN diing vdi lieu 40mg/ngay. PTA d nhu'ng BN diing corticoid toan than vdi lieu cao hdn cung cai thien tot hdn mot cahes dang ke, dae biet d
2000H2 va 4000Hz la nhutig tan sd am kha quan trpng trong giao tiep ciia BN. Nhu' vay viec sir dyng corticoid toan than vdi lieu cao hPn mang lai ed hpi tot hPn cho BN trong viee cai thien thfnh ly'c, dac biet la d cac tan sd giao tiep quan trong.
Tuy nhien, do khong cd day dii thong tin ve can nang BN nen trong nghien eiru nay chu'a danh gia du'dc mdi tu'dng quan giii'a hieu qua dieu tn va lieu corticoid toan than tfnh theo kg can nang. Theo vien han lam khoa hpc Tai Mui Hpng va phau thuat dau co Hoa ky (AAO-HNS) nam 2012 [5], lieu khuyen cao sir dung methylprednisolon trong dieu tri diec dot ngot la Img/kg/ngay. Cd the vdi mire lieu can vdi nguSng nay, nhung d mire lieu cao hon se eo hieu qua tdt hPn so vdi lieu thap hdn so vdi lieu khuyen cao.
V. KET LUAN
Corticoid la thuoc da va dang dddc chap nhan la cd hieu qua va du'dc sir dyng rpng rai nhat de dieu tri diec dot ngot. Lieu lu'dng corticoid cung da dang, da so cac tac gia khuyen cao diing lieu 1 mg/kg can nang. Chung toi nhan thay BN diing lieu 80 mg methylprednisolon co hieu qua tot hdn dang ke so vdi lieu 40mg/ngay.
TAI LIEU THAM KHAO
1. Conlin A. E., Parnes L. S. (2007), 'Treatment of suijden sensorineural hearing loss: I. A systematic review", Arch Otolaryngol Head Neck Surg, 133(6), pp, 573-81
2 Conlin A. E., Parnes L. S. (2007), "Treatment of sudden sensorineural hearing loss: II, A Meta- analysis", Arch Otolaryngol Head Neck Surg, 133(6), pp. 582-6.
3 Labus ] . , Breil J., Stutzer H., Michel O.
(2010), "Meta-analysis for the effect of medical therapy vs. placebo on recovery of idiopathic sudden hearing loss", Laryngoscope, 120(9), pp, 1863-71.
4. Schreiber B. E., Agrup C , Haskard D. O., Luxon L. M. (2010), "Sudden sensorineural hearing loss", Lancet, 375(9721), pp, 1203-11.
5. Stachler R. J., Chandrasekhar S. S., Archer S. M., Rosenfeld R. M., Schwartz S. R., Barrs D. M., Brown S. R., Fife T. D., Ford P., Ganiats T. G., Hollingsworth D. B., Lewandowski C. A., Montano 3. 3., Saunders J. E., Tucci D. L., Valente M., Warren B. E., Yaremchuk K. L., Robertson P. 3. (2012),
"Clinical practice guideline: sudden hearing loss", Otolaryngol Head Neck Surg, 146(3 Suppl), pp.
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