Tap chi Tai Mui Hpng V i j t Nam - Volume (59-21) N°3- October. 2014
NGHIEN Ciru CHirc NANG TAI G I C A TRONG XEP NHI TOAN BO QUA THINH LlTC VA NHI LU'ONG
Kliiiu Him Thanh % Lirmg HSng Cliau**
TOM TAT
Muc tieu: Ddnh gia chuc nang tai giira cua xep nhT toan bo qua thinh luc vd nhi luong. Ddi tirffng vd phirffngphdp nghien citu: Nghien cuu quan sat mo Id cat ngang 48 tai cua 44 benh nhdn xep nhT todn bo tai benh vien Tai Mui Hong Trung Ifcfng trong thai gian til nam 2010 - 2012. Ket qud: Khodng each khi cSt daofABG) la 28,6 ± 11,39 dB, ABG a do 4 Id 33,2 ± 10,89 dB, cao han do 2,3 v&ip<0.01. ABG nhom gidn doan khop xuang Id 40.8 ±9,05 dB. NhT do gap nhieu nhdt la dang B vd C, v&i dp luc dinh trung binh Id Id -168.2 ± 93,33 daPa. Ket luan: Chuc nang nghe vd thong khi cua tai giiia gidm trong xep nhtlodn bo do tinh trang dp luc dm trong hom nhT, su co dinh he mang nhT xuang can hoac sugidn doan cdc khap xuang.
Tir khoa: Xep nhT todn bo, thinhluc, nhTluang SUMMARY
Objective: To analyze function of middle ear on total atelectasis by audiometry and tympanometry. Materials and medthod: Clinical observations M'ere made on 48 ears from 44 patients who had operated total atelectasis at The Vietnam National Hospital of Olorhinilaryngologyfi-om 2010 to 2012 Result: Air bone gap (ABG) on total atelectasis was 28,6 ± 11,39 dB, ABG at the f' grade was significantly more than the 2"' grade and 3'' grade with p<0,05. The lympanometiy presenting in most cases was type B or C, peak of volumne was -168,2 ± 95,53 daPa. Conclusion: Total atelectasis reflected the negative pressure of middle ear, the fixation of tympanum and ossicular or discontinued ossicular,
caused decreasing hearing and ventilation function.
Keywords: Total atelectasis, audiometry, tympanometry
1. DAT VAN BE dem tai giQa va su biln ddi ciu trie lop siji Xep nhi toan bo (XNTB) la tinh trang "fff, "^" ^'""' ° " ^ " '^^ ^^ '^"^ •*«"
mang nhi co 16m vao trong hom tai lam ' \k,Tu A • .•< , •- - .u- giam khoang tr6ng hom nhi, bao g6m ca , . > ™ ™ * ' ' ™ 8 '!™ f ' " ™'..*™ ^ p h k mang cang va mang chung [71. Gia "^J'" , ? ' " * T . ' ™ ' ^ ^ g . ' " ? " <^^^&
thuya XNTB la hau qua cua su giim ap '''."* ' ' t " ! , ' u ^'' ^-'^ ? T ™™
luc trong hom tai do rdi loan chuc nang voi " " " ^ " ^ , * " * ™° ' ' ° " ' ^ ' ''^' * " ^"^
giam thong khi hom nhi, r6i loan he th6ng *"."^ !'•? l ^ ™ ^' ^""' '^ *°'"^'^^'°™
• • g vol ty le 30%. Dieu tri XNTB trong giai doan muon gap nhieu kho khan, thuong
•Tnrimg DH Y Duoc Thai Binh that bai trong viec duy tri giai phau tai giiia,
**Benh vi|n TMHTW cai thien sue nghe do ton thuong he th6ng
Tap chi Tai Mui Hong Viet Nam -Volume (59-21). N°3- October, 2014 truyen am va khong thi hoi phuc bilu mo
niem mac co long chuyin [2].
Ton thuong cua XNTB gay anh huong chu yeu den chuc nang tai giiia, dac biet la chuc nang nghe va chuc nang thong khi.
Co nhieu phuang phap danh gia chirc nang tai giiia trong do, do thinh lire va nhT lugng dugc thuc hien khong qua phiic tap, co the trien khai dugc 6 nhieu dia phuang, cung cap nhiing thong tin co gia trj ve chuc nang nghe, chiic nang voi nhT, sir hien dien ciia dich trong hom tai va do di dong cua he mang nhT xuong con. Su dung noi soi ket hop voi tham do chiic nang tai giiia qua thinh luc va nhT lugng do giup danh gia tot nhiing ton thuang tai giua trong XNTB.
Miic tieu:
Ddnh gia chuc nang tai giira trong xep nhT todn bo qua thinh luc vd nhTluang.
2. DOI TU'ONG VA PHU^ONG PHAP NGHIEN C ^
2.1. Doi ttfong nghien ciru Nghien ciru 48 tai tren 44 benh nhan chin doan la XNTB dugc dieu tri tai benh vien Tai Miii Hgng Trung iTong trong thai gian tu thang 10/2010 din tiiang 10/2012.
Cac tai chon theo tieu chuan: noi soi co hinh anh mang nhT co keo ca mang cang va mang chiing vao trong hom nhT, co day du ket qua do thinh luc, nhT lugng.
2.2. Phu-ong phap nghien cihi Nghien cuu quan sat rao ta cit ngang.
Chgn mlu theo phuong phap lly mlu thuan tien.
Phan loai XNTB qua noi soi theo 4 do cua Sade (1981): Bd I: mang nhT co lom nhe, chua cham vao canh xu6ng xuong de.
Bp 2: mang nhT co lom cham canh xu6ng xuong de, khop de dap. Bp 3: mang nhT
lom, cham vao u nho, co the hut ra bang ong hut. Bp 4: mang nhT lom dinh vao u nho, chui vao cac ngach ciia tai giiia nhu ngach mat, ngach nhT, ha nhT, co the bong vay.
Cac tai deu dugc phau thuat nham chan doan phan biet do 3, do 4, xac dinh cac ton thuong xuong con chia lam 3 nhom. Nhom gidn doan kh&p xitang: co ton thuong mat canh xuong xuang de, mat mot phan xuong ban dap la gian doan khop de dap, ton thuong dau biia, xuang de lam gian doan khop bua de. Nhom khong gidn doan khop xirong: co ton thuang an mon xuang nhung khong anh huong toi khap, hoac cac ton thuong da anh huong toi khop nhung hinh thanh khop gia do to chiic xo, mang nhT dinh chat vao khop nhu an mon mom dau, an mon dau biia. Nhom khong co ton thu-ang xuffng con: khong co ton thuong xucmg con
Mo ta va doi chieu cac trieu chung ca nang, thinh lire do va nhT lugng do vdi cac giai doan ctia XNTB va ton thuong xuong con qua phau thuat cua cac tai theo cac thuat toan thong ke y hoc qua phan mem SPSS 16.0.
3. KET QUA
Bang 1: Phan b6 b^nh nhan theo tuoi va gioi
Nam NO' N
<16 5 1 6
16-30 3 10 13
31-45 5 10 15
>45 6 4 10
n 19 25 44
Do tuoi trung binh trong nghien cuu la 35 ± 14,2 tuoi. Benh nhan it nhat la 7 tuoi, cao nhat la 66 tuoi. Ty le nii trong mau la 56,8%, nam la 43,2%.
Tap chi Tai Mui Hong Viet Nam - Volume (59-21), N°3- October, 2014 Bang 2: Miic dp XNTB
0 9 xep N
%
O o 2 9 18,8
O o 3 16 33,3
O o 4 23 47,9
N 48 100
Tdng s6 benh nhan trong mlu nghien cuu la 44. Trong do, chiing toi nghien curu 48 tai xep nhT toan bg dugc phlu thuat. Ty le xep nhT a do 3 va dp 4 la 33,3% va 47,9%, khac biet vol do 2 co y nghTa thong ke voi p<0.05. Khong co tai xep do 1 trong nghien cihi.
Bang 3: Ton thuong xu'cng con trong cac giai doan xep nhT
0 9 xep
T6n thifcrng Kh6ng ton thu-ong Khdng gidn doan Gicin doan l<hap N
XNTB OS
2 9 0 0 9
0 6 3 12 2 2 16
Do 4 8 5 10 23
N
29 7 12 48
Do 2 cua XNTB khong co ton thuong xuong con. Dp 3 va 4 cua XNTB co ty le ton thuong xucmg con la 25,0% va 65,2%.
Su khac biet co y nghia thong ke voi p<0,05.
Trong XNTB, nghe kem va u tai trieu chung thuong gap nhit vcd ty le 93,2% va 84,1%. O dp 4, benh nhan d^n vien chu y6u vi nghe kem va u tai vod ty le 75,0%.
Khong CO benh nhan nao it tai hay dau tai don thuin. Tat ca benh nhan dju thiy nghe kem.
Nghe kem dan tniyln gap nhiju nhit a xjp nhi toan bo voi ty le 75,0%. Nghe kem hon hop, tiep nhan gap voi ty le hiong ung la
12,5% va 4,2%. Su khac biet co y nghia th6ng ke voi p<0,05.
ABC**"'" 1 I (dB)
20.0 -l
10.0 -i
[!!:
^ 10.00 J .
Bleu do 1: So sdnh ABG trong cac giai doan XNTB
ABG 6 XNTB la 28,6 ± 11,39 dB, ABG xep nhi toan bo dp 2, 3, 4 tuong ung la 24,3 ± 9,62 dB; 24,5 ± 10,98 dB; 33,2 ± 10,89 dB. Sir khac nhau giiia ABG dp 4 vdi dp 2 va dp 3 CO y nghia thong ke voi p<0,05.
60,0 50,0 - 40,0 30,0 20,0 10,0 -
,0
[]
51,i500 40,83J3
Khong ton Khong gian Gian doan thu-OTtg doan khop Khop Bieu d6 3: Doi chi^u thinh lye vdi tinh chat ton
thuong xuang con
Tap Chi Tai Mui Hong Vi^t Nam - Volume (59-21). N°3- October, 2014
Trong xep nhi toan bg, ABG cua t6n thuong gian doan khop la 40,8 ± 9,05 dB, cao hon so voi ABG cvia t6n thuong khong gian doan khop la 23,9 ± 6,05 dB va ABG cOa xep nhi khong ton thuong xucmg la 24,7 ± 9,59 dB. Sir khac biet ABG giiia XNTB CO gian doan khop voi XNTB khong ton thuong xuong, XNTB t6n thuong xuong nhung tao khop gia co y nghia thong ke voi p<0,05.
Nhi do dang B va C chidm ty le lin lup-t la 45,5% va 39,4%. Nhom nhi d6 co dinh ap luc am (B va C) va dinh binh thuong (A, As va Ad) khac biet co y nghia th6ng kS vdi p<0,05. The tich 6ng tai ngoai cua XNTB la 2,0 ±1,21 ml. Dp thdng thuan cua XNTB la 0,344 ± 0,2866 ml. Ap luc dmh cua XNTB la -168,2 ± 95,53 daPa.
sJ,200 -
ml
1,00 -:
,800 -I
,600 H ,400 -j ,200 -j
,00 -L
- -I
• • 2796
^ , 1 1 0 0 ' 1
Bp2 DO 3
Bieu d6 3: So sanh d6 thong thuSn trong cdc giai doan XNTB
Dp thong thuan cua XNTB giam din theo dp 2, 3, 4 lin luot la 0,454 ± 0,3134 ml, 0,373 ± 0,2839 ml, 0,280 ± 0,2738 ml.
Su khac biet khong co y nghia thong ke voi p>0,05.
4. BAN LUAN
4.1, Dac diem lam sang ciia xep nhi toan b9
Tuoi trung binh cua nhom benh nhan nghien cuu ciia chung toi la 35 tu6i- K^t qua nay ciing tuong ung voi cac kit qua cua Dao Trung Diing [2] la 33,5 tu6i. K6t qua nay phii hop voi benh sinh cua XNTB la mot benh ly man tinh, keo dai do tac dong tir viing voi nhT mot each tir tu..
Benh nhan den kham mugn, XN do 3 va 4 CO ty le 81,2%. 6 xep nhT do 3, 4 mang nhT da dinh vao mat trong hom nhT lam giam sue nghe va de dga nguy co bidn chung. Trong thuc hanh lam sang, viec kiem soat six lom vao ciia mang nhT cao cac ngach mat va ngach nhT d^ phan biet giua XNTB do 3 va do 4 gap nhilu kho khan.
Nhieu truong hgp cin sir dung optic 30'~' hoac qua phlu thuat de danh gia. Ci do 2 ciia XNTB chiing toi khong gap truong hgp nao ton thuang xuong con. Ton thuong xuong con gap 6 do 3 va 4 vai ty le tuong ung la 25% va 65,2%. Canh xu6ng xuong de bi an mon trong tat ca cac truang hgp ton thuong xuong con, tuy nhien chi co 66,7% truang hgp nay co gian doan khop de dap. Trong 5 truong hgp con lai, mac du xucmg de bi an mon mat mom d$u nhung t6 chiic xo phat trien tao thanh khop gia. Su an mon xuang de co the giai thich do mang nhT ep chat vao mach nuoi ch^y dgc canh xuong xuang de, gay thieu duong mach tao phan ling viem xuong. Ket qua cua chiing toi Cling phu hgp voi nghien cuu ciia Luang Hong Chau [I] voi ty le t6n thuong xuang con do 3 va 4 la 14,3% va 46,7%.
Trieu chung co nang ph6 bien cua XNTB la nghe kem va u tai voi ty le 93,2%
Tap chi Tai Mui Hong Viet Nam-Volume (59-21), N°3-October. 2014
^a 84,1%. 100% benh nhan XNTB dp 4 co bieu hien nghe kem. Nghe kem va u tai bieu hien ro vao giai doan cuoi ciia benh.
Nghe kem thuong xuat hien 6 dp 2 cua XNTB tro di, do mang nhi cham vao canh xuong xuong de lam giam boat dong don bay cua xuong biia de. Tuy nhien, dao dong don bay nay dong gop it ve mat am hoc, benh nhan thuong nghe kem it, de bo qua.
Khi mang nhi da cham dinh vao u nho hay cac thanh phan khac cua mat trong hom tai, ty le dien tich rung dong hieu qua ciia mang nhi so vdi ciia so bau due giam di ro ret nen benh nhan nghe kem nhieu hon. Do do, nhimg benh nhan nghe kem don thuin thuong den vien khi benh tich da tuong d6i nang
Chiing toi gap nghe kem dan truyin nhieu nhat vol ty le la 75,0%. Di6u nay chung minh nhung ton thuong gap trong xep nhi chu yeu la ton thuong 6 tai giiia.
Chiic nang nghe giam vdi ABG la 28,6 ± 11,39 dB, nho hon miic 30 dB co y nghia th6ng ke. ABG ciia XNTB co thS len toi 25 dB trong truong hop khoang trdng phi'a ngoai cila so iron vin con dupe thong khi.
Khi mang nhi xep dinh vao vimg cua sS iron, vai tro bao ve ciia mang nhi va khoang khi tai giiia toi rung dong cua ciia so tron mit, ABG co thj len toi 40 - 50 dB.
Chiic nang nghe ciia tai giiia o dp 4 giam CO y nghia thdng kS so voi dp 2 va 3 vdi ABG o dp 2, 3, 4 tuong ling la la 24,3 ± 9,62 dB, 24,5 ± 10,98 dB va 33,2 ± 1(),89 dB. ABG theo cac giai doan cua chiing toi cao hon nghien ciiu Borgstein [4] voi do 2, 3. 4 tuong ling la 11,8 ± 10,4 dB, 21.3 ± 12,0 dB, 12,1 ± 9,0 dB. Su thay d6i vi thinh luc giiia cac giai doan frong nghien
ciiu ciia chiing toi khac voi James [6] trong do ABG a dp 4 cao hon dp 2 va dp 3 voi p<0,01. ABG 6 dp 4 Ion hon 30dB co y nghia th6ng ke. Theo Carrillo [5], ABG cao hon 30dB lam tang nguy co gian doan xuong con tir 2,54% len 32,97%. Co thS nhiing ton thuong lam gian doan khop xucmg anh huong lam co su giam nghe ro ret d dp 4 XNTB.
Chiic nang nghe tai giira cua nhom XNTB CO gian doan khop giam co y nghia thong ke so vdi nhom ton thuong xuong khong gian doan khop va nhom khong t6n thuong xuong con vcri ABG la 40,8 ± 9,05 dB. Nhu vay, ton thuang am hpc nhiSu nhit trpng XNTB la nhiing t6n thuong co lam gian doan khop.
Nhi d6 gap nhiSu nhit la dang B va C CO ty le la 52,1% va 35,4%. Co r6i loan chiic nang voi nhi trong XNTB, bi8u hien nhi lugng co ap luc dinh giam, trung binh la -168,2 ± 95,53 daPa. He mang nhi xuong con trong XNTB kem di dpng, bifa hien do thong thuan thip, trung binh la 0,344±0,2866 ml. Theo Nguyin Tin Phong [3] , nhi do CO dinh lech vl ben am chimg to CO hien tuong tac voi, dinh tu chiing to CO dich keo trong hom nhi, dinh ha thip, giam do thong thuan chiing to co Men tupng CO dinh xuong con. Cac dang nhi di pho bien tren diu la dang nhi d6 tarn biln, thi Men diy du ban chit ciia XNTB, khi ma ap luc am do hien tuong tic vol dong vai tro chinh lam mang nhi xep vao hom nhi, dinh vao khop de dap, co xuong biia, u nho, lam CO dinh he mang nhi xuong con
Dp thong thuan tang dan tir dp 2, 3, 4 tuong ling la 0,454 ± 0,3134 ml, 0,373 ±
Tap chi Tai Mui Hong Viet Nam - V o l u m e (59-21). N°3- October, 2014
0,2839 ml va 0,280 ± 0,2738 ml. Do thong thuan do 4 giam nhieu hon do 3, the hien do Cling cua he mang nhT xuong con Ion ban. Co the do do 4, mang nhT dinh vao cac cau tnic ciia thanh trong hom tai, khong the hiit ra bang ong hut lam tang miic tra khang cua mang nhT xuang con. Ket qua nay phu hgp voi nhan dinh cua Luong Hong Chau trong cac benh ly viem tai giiia mang nhT dong kin, dg thong thuan co y nghTa nhat de chan doan va theo doi benh [1].
Chiing toi khong tim thay su khac biet ve do thong thuan va ap lire dinh ciia nhom khong CO ton thuong xuong, nhom ton thuong khong gian doan khop va nhom ton thuong gian dogn khdp. Nhu vay, cac ton thuong ve xuong con it anh huong tai su thay doi nhT lugng.
5. KET LUAN
Trieu chiing co nang pho bien ciia XNTB la nghe kem va u tai vai ty le 93,2% va 84,1%. 100% benh nhan XNTB do 4 CO nghe kem.
Thinh luc d6 dang nghe kem dan tmyen gap nhieu nhat voi ty le 75,0%
NhT d6 gap nhieu nhat la dang B va C co tyle la 52,1% va 35,4%.
Chiic nang nghe giam vai ABG la 28,6
± 11,39 dB, trong do do 4 nghe kem hon do 2 va 3
Chiic nang nghe tai giiia cua nhom XNTB CO gian doan khop giam so voi nhom t6n thuang xuong khong gian doan khap va nhom khong ton thuong xuong con vai ABG la 40,8 ± 9,05 dB.
Co r6i loan chiic nang thong khi tai giua trong XNTB, bieu hien nhT lugng co ap luc dinh giam, trung binh la -168,2 ±
95,53 daPa.
He mang nhT xuang con trong XNTB kem di dong, bieu hien do thong thuan thip la 0,344 ± 0,2866 ml, tang ty le thuan voi do xep.
TAI LIEU THAM KHAO 1. Luang Hong Chau (2010), "Nghien ciiu
bien dong ciia thinh lire va nhT lugng trong xep nhT', Y hoc Viet Nam, 367 (2), trang 6-9.
2. Dao Trung Diing (2007), Danh gia ket qua dieu tri xep nhT, Luan van tot nghiep Bac sy noi tni benh vien, Truong Dai hgc Y Ha Noi.
3. Nguyen Tan Phong (2000), "Nhiing hinh thai bien dong ciia nhT lugng do". Tap chi thong tin Y Dugc, so 8, trang 32 4. Borgstein J, Gerritsma TV, et al. (2007),
"The Erasmus atelectasis classification;
proposal of a new classification for atelectasis of the middle ear in children".
Laryngoscope, 117 (7), pp. 1255-9.
5. Carrillo RJC, Yang NW, and Abes GT (2007), "Probabilities of ossicular discontinuity in chronic suppurative otitis media using pure-tone audiometry", Otol Neurotol, 28 (8), pp. 1034-7.
6. James AL, Papsin BC, Trimble K, et al.
(2012), "Tympanic membrane retraction: An endoscopic evaluation of staging systems". Laryngoscope, 122 (5), pp. 1115-20.
7. Sade J, Avraham S, and Brown M (1981), "Atelectasis, retraction pockets and cholesteatoma". Acta Otolaryngol, 92 (5-6), pp. 501-12.
Cong trinh dugc thuc hien tai benh vien Tai Mui Hgng Trung U*ong tir thang 2/2012 d^n thang 10/2012, ngu6n kinh phi tu tiic.
