Tap chi Tai Mui Hpng Vijt Nam - Volume (58-15). N°3 - May, 2013
KET QUA DIEU TRI CAC AP XE VUNG CO NHAN XET QUA 56 BENH NHAN
Nguyen Binh Phuc*, Le Van Sau**
Le Cong Binh ***, Qudch Thf Can *
T O M TAT
Qud trinh nhiim khudn, lam mu ciia cdc khoang to chuc lien ket vitng co, do nhieu nguyen nhdn gdy ra, thuang ngng, nguy hiem din tinh mgng nguoi benh M^c tieu: 1)M6 td mot so phuang phdp dieu tri da dp dung 2) Ddnh gid ket qud dieu tri dp xe vung co. Boi tuijmg , PPNC: Nghien ciru timg ca qua 56/60 truong hgp dp xe viing co do nhieu nguyin nhdn khdc nhauDugc chdn dodn Idm sdng, ngi soi, CT scan, vd dieu tri tai Benh vien TMHTW, 2007-2009. Ket qud: Gap 7 logi dp xe vd cd 2 biin chung: kho tha.frdn mu trung thdt. Phdi phau thuat 100% cdc truong hgp tir trich ddn luu dan thudn, mo cgnh co. vdphoi hgp vai cdc thu thuat khdc di dieu tri nguyen nhan (noi soi lay di vat v.v...). Ket hgp vai diiu tri ngi khoa, hoi sue. di phong cdc biin chung. thay bdng. rua vit mo bdng Betadinia, nuac oxygia va Idy to chuc hogi tir. Diing khdng sinh phoi hgp co tdc dung vai cd vi khudn - ua khi vd ky khi do la: betalactamin + Metronidazole (92,8%). Diiu tri ho trg: kiem sodt tot duong tha de phdng kho tha, cung cdp dinh duong qua dat sonde dg ddy hoac md thong da ddy, bdi phu nude dien gidi thdng bdng kiem toan. Thai gian cdn de ra vien trung binh Id 11.62 %>. Kit lugn: Co 1/56 truong hgp phdi phoi hgp dieu tri ngogi khoa long nguc. Kit qud lot 83,9%. Tien trien chgm, vd thay doi phuang thuc ngi khoa 14,3%.
Tu- khoa: Dieu tri dp xe vitng co.
SUMMARY
The abscess and infections of the neck space are mortal denger and to have many causes common. Ojective : The descriptions and discussions on thefortors epidemiologies of the abscess of neck space infection . Materials and Methods: Case study of 60 patients of the abscess and infection of the neck space, at Hospital ENT central (2007-2009).
Diagnostic clinical, endoscopic, CT scan, and the treatments. Results and discussions:There are 7 formes abscess, and two complications(dyspnie.mediastinitite).
Cervicotomise and draina is 100% and medical traitements (betalactamin + Metronidazole (92,8%) , and causal traitements The 11,62 %. Conclusion: There are 1/56 cafor draina mediastina. The resultats is good(83,9%).and moderate( 14,3%).
Keyword: The resultats and traitements of abscess of the neck space.
1. D A T V A N D E khudn do thuong nang, nguy hiem den cd
; , J J • - ! , • « u- " tinh mang nguoi benh. 6 mu thuang Ian Ap xe vung CO do viem nhiem, phu ne, , , . , , . . i , . i-rpng theo cdc khoang do cua to chirc lien ket va CO su phoi hgp cua vi khudn di khi vd ky khi. Cac nguyen nhdn, c6 the la
* BV. TMH TW duong ro bam sinh vung co (xoang le,giap
**BV. tinh Thanh H6a.
1dm mil cua cdc khoang to chiic lien ket, do nhieu nguyen nhan gdy ra. Qud trinh nhiem
* * * B V . Bach Mai
NhSn bai 25.2. DuySt in 15.3.2013
Tap chi Tai Mui Hpng Viet Nam - Volume (58-15) N°3 - May, 2013
luoi, ro tuyin mang tai...), cac viem nhilm trimg tir VA, amydan, rSng mifng, bien chiing do di vat hpng thuc qu4n... Bgnh lai nang them tren nhttng nguiri c6 benh tieu dutmg, tim mach, huylt dp cao, lao,...Tien lugng cung phu thugc them vdo tuoi, giai doan, thcri gian den vien. ph tdi "Kel qui diiu trj cdc dp xe vung co nhan xet qua 56 bfnh nhan gfp tfi bvlmhiw tic nam 2007- 2009", voi muc tieu: \)Md Id mpt s6 phucmg phdp diiu Iri da dp dun^ 2) Ddnh gid kit qud diiu tri dp xe viing cd hay gap . 2. D 6 | Tl/ONG VA PHUONG PHAP NGHIEN CiltJ.
2.1. G6m 56 benh nhan dugc chan doan va diiu tri tai benh vien TMHTLT tir 2007- 2009.
2.2. Nghien ciiu ngang mo ta timg truong hop, tien cim.
2.3. Chin doan lam sang, khai thac cac yeu t6 dich tl hgc. Chup CT voi cac lat cat ngang, dung ngang, dung hinh dimg dgc. Tat ca deu dugc dieu tri, dan liru ap xe va giai quyet nguyen nhan dong thoi hoac a thi sau. Sii dung thong ke hgc theo chuong trinh Epinfo 6.0, de tinh p.
3. KET QUA 3.1. Dac diem chung.
3.1.1. Phan bo 56 dp xe viing co da dieu Iri
Bang 1. Phdn bo cdc lo^i dp xe TT
1 2 3 4 6
Vi tri dp xe Ap xe do rO xoang 16 Ap xe canh c6 do h6c xu-ong
Ap xe Amydan Ap xe toa Ian vung c6 Ap xe thdnh sau hpng
N
N n 17 16 11 07 05 56
30,3
%
28,6 19,9 12,3 8,9 100%
Gap nhilu dp xe do rd xoang le (30,3%),v4 bien chiitng cua dj v$t th\rc quan (28,6%), sau do Id bien chimg cua dp xe amydan (19,9%).
3.1.2. Phdn bo theo tuoi: Nhom tuoi lao dgng gdp nhieu nhat (63,3%)
3.1.3. Phdn bo Iheo gidi: Nam gdp 75 %.
3.1.4. C(fc Ai«i cAihig : Kho tho phdi mo khi qudn 3 BN (5,4 %), Trdn mu trung thit 1 BN (1,8%). Nhu vay chi co 4 Bn bi biin chiing (7,2%).
3.2. Ket qua diiu trj
Bang 2. Cdc p h i u thudt iJd thg-c hi$n.
Phuong phdp Mff canh cb ddn luu mu vd trlch thdo mu d o n thu4n M o canh c6 ddn luu mu + Soi true ti^p tim rp xoang 16 M o canh co ddn luu mu + Soi tn,j'C tiep lay di vdt M a canh co ddn luu mij + Mo l<hl quan + Soi tn/c ti^p iSy dj v$t
N
N 20 17 16 3 56
%
35,7
30,3
28,6 1
5,4 100 Phai ddn luu mu qua rao c?iih co, va trich dan luu 100%.
Bdng 3. Cdc phu'Ong phdp diJu tri Ii6 trp.
P h u o n g phdp B $ l sond dg ddy M d thdng dg ddy M p khi qudn
K4t hop di4u tri tieu dudng Oi4u th n j i khoa t h u * n g qui, sau m o cgnh co dan luu
N
N 16 4 3 8 25 56
%
28,6 7,1 5,4 14,2
44,7
100
Tgp chl Tai MQi Hong Vi$t Nam -Volume (58-15) N°3-May.2013
Phdi mo thong da ddy (7,1%%), Mo khi qudn 5,4%.
Bang 4. Cdc thu6c n0i khoa 6\ku tn h6 trg Phuang phdp
Khdng sinh nh6m Betalactam Metronidazon
Thu6c giam vi6m phu ne BO nub-c di^n giai
N=56 52 66 56 50
%=100 92,8
100 100 89,2 Phoi hgp khang sinh a 92,8 % cdc truong hgp.
Bang . Ngdy nim di^u tn trung binh . Phuang phdp
Tiy 2-4 ngdy TCr 5-7 ngdy Tu" 8-9 ngdy Tren 10 ngdy
Ngdy dieu tri trung binh = 11,62 N 8 18 10 19
%
16,1 32,2 17,8 33,9
Thoi gian cdn de ra vien trung binh Id 11,62%.
Bang 6. K^t qua dieu trj.
Phuang phdp Khoi hodn todn - t6t Tien tnen chdm - khd Chuyen vipn vi dp xe trung that
N 47 8 1
%
83,9 14,3 1,8 Chi cd 1/56 truong hgp phdijihoi hgp dieu tri ngoai khoa long nguc Ket qud tot 83,9%. Tien trien chdm , vd thay doi phuong thiic ngi khoa 14,3%
4, BAN LUAN 4.1. Bac diem chung.
Qua 2 nam 2007-2009 tai benh vien Tai mui hgng trung uong da co 60 benh nhdn voi 7 loai dp xe ( ngodi 2 loai it gap Id dp xe tuyen mang tai 2 Bn va 2 BN hach co). Do vay trong khuon kho mgt bdo cdo
nay de cap den 5 loai thuong gap nhieu hem (bdng 1) , da dugc dieu tri va phdu thuat.
Ap xe do cac duong ro bam sinh la thong gdp nhdt 17 truong hgp chiem 30,3%
(100% la ro xoang le, con cdc duong ro cung mang I, ro cung mang II it gap hon).
Trong ro bdm sinh chiing toi cQng thay rang loai ro khong co 16 ro thodt ra ngodi bi dp xe Id 100%. Ap xe canh co do hoc xuong con khu tni gap 16 truong hgp chiem ty le 28,6% , trong cac loai di vat gdy ra dp xe quanh thuc qudn chiing toi thdy rang 96% la cdc loai di vat co nguon goc tu xuong cdc loai dgng vat gay ra. Tiep theo dp xe canh thuc qudn co, chiem hang thii 3 la ap xe quanh Amydan gap 11 BN, dp xe do viem tod Ian 6 viing co gap 7 BN va dp xe thanh sau hgng it gap hon co 5 tru- ong hgp.
4.2. Ket qua dieu tri
4.2.1.Cdc phuang phdp phdu thuat da d- tegc dp dung
Trong nghien cuu nay chiing toi da nghien ciiu cac dp xe viing co nen tat ca cac truong hgp deu phai phdu thuat, co the phdu thuat trich thdo mil, c6 the ket hgp tim nguyen nhdn gay dp xe bang soi, co the giai quy^t bi8n chiing truoc (gidi phong duong tha) k^t hgp voi di^u tri ngi khoa hoi siic cap cuu vd phdu thuat.
Theo cdc tdc gid trong nuoc nhu [3,6]
Cling nhu cac tac gid nuoc ngoai [7,8,9]
vice phdu thuat mo rgng nham dan luu vd cdt Igc cac mo hoai tu la yeu to quan trgng trong dp xe viing co. Viec dieu tri som tich cue ngay tu dau (diing thai diem) se ngan chan dugc nhung bien chiing nguy hiem co the xdy ra. Phdu thuat nham ma rgng khu vuc t6n thuong, loai bo to chiic hoai tu tao dieu kien cho dan luu ra ngodi dugc tot nhat [10], phdu thuat con tao dieu kien cho
Tgp chl Tai MQi Hgng Vi$t Nam - Volume (58-15). N°3 - May, 2013
vk thuang chong hoi phyc. Trong nghien cuu ciia chiing toi co mo canh co dan luu + soi timg ro Id 17 trufrng hgp chiem 30,3%, mo canh c6 dan luu soi gdp dj vat Id 16 truong hgp chiem 26,8%.
M6 khi qudn + md dan luu + soi tim di vat 03 truong hgp chiem 5,3%.
Mo dan luu dan thuan ho^c trich thdo mii don thudn 21 truong hgp chilm 37,5%.
Cdc dp xe viing c6 Id phai phau thuat, can phdi dugc theo doi trich thdo mii diing, kjp thai dk dh phong cac bien chiing nguy hiem md chiing gay ra.
4.2. Cac hinh thirc dieu tri ho trg khac Nhimg truong hgp dp xe viing co thuang CO tinh trang todn than nhiem triing nhiem dgc nang, ban niia benh nhdn thuong den benh vien mugn md benh lai khong an, khong uong dugc tren co dia co mgt benh todn than can dieu tri. Nen benh nhdn bi dp xe vung co luon cdn dugc hoi Stic tit vd di^u tri h6 trg ban gom: kiem sodt duong tho, dinh duong tot dieu tri ngi khoa ket hgp.
Phai mo khi quan 3 truong hgp chiem 5,4%, chiing toi thay so benh nhan co bieu hien kho tho cao hon nhung sau khi gidi phong 6 dp xe thi tinh trang kho tho het.
Nhu vay viec theo doi sat duong tho Id rdt can thiet chi ma khi quan khi c6 chen ep gdy kho tho thanh quan tir dg i l .
Phai ddt ong thong mui da ddy gap 16/
56 truong hgp chiem 28,6%.
Phdi mo thong da ddy 4/56 chiem 7,1%.
Phoi hgp dieu tri ddi duong 8/56 chilm 14,3%.
Chiing toi nhan thdy benh nhdn phai ddt sonde da ddy va mo thong da ddy chiem
ty 1? 16n vi cung cap dinh duong tot rat can cho ng6i b?nh, trong khi ton thuong gay ap xe viing c6 deu phdn nhilu xudt phdt tu:
du^ng dn gay ra. Th6i han nit ong th6ng dji ddy tuy thugc vdo vi?c lien ciia vet rdch, thiing th^rc qudn, hgng vd quan trgng nhit Id viec day, Idnh cua ddy vet mo voi vi^c u6ng thir xanh methylene co con ro ra vlt mo khong. Vi?c thay bdng kiSm tra vd nia vet mo hdng ngdy bdng Bentadine dugc thuc hi?n thuong xuyen a tat cd benh nhan.
Cdn phdi chdm soc vet mo h^u phau nhdm tiep t\ic lay bo to chuc hoai tu, lam sach ho mo ddm bdo ddn luu, bom nia vet mo hang ngay.
4.3. Dieu tri ngi khoa
Dieu tri ngi khoa luon can thiet va tien hdnh truoc ciing nhu dong thoi voi dieu tri phdu thuat va cdc phucmg phdp dieu tri ho trg khdc.
4.4. Cac hinh thirc dieu tri ho tr^r khic Nhung trong hgp dp xe viing co thirong CO tinh trang toan than nhiem trung nhiem dgc nang, hon nira benh nhdn thong den benh vi?n mugn ma benh 1^ khong an, khong uon^ dugc tren co dia c6 mgt benh todn than can dieu tri. Nen b?nh nhan bj ap xe vung CO luon can dugc hoi siic tet va dieu tri ho trg ban gom: kiem soat duong tha, dinh duong tot dieu tri ngi khoa ket hgp.
Theo bang 3.31 cho thdy phai mo khi qudn 3 truong hgp chiem 5,3%, chiing toi thdy s6 benh nhan co bieu hi$n kho tha cao hon nhung sau khi gidi phong 6 dp xe thi tinh t r ^ g kho tho hit. Nhu vay viec theo doi sdt duong tho la rdt cdn thilt chi md khi qudn khi co chen ep gay kho tha thanh qudn tu do II.
Phdi d$t 6ng th6ng mui d? ddy gap 16/
56 truong hgp chilm 28,6%.
Tgp chl Tai MQi Hgng Vi$t Nam - Volume (58-15). N ° 3 - May, 2013
Phai mo thdng da ddy 4 / 5 6 chilm 7,1%.
Phoi hgp dieu tri ddi duong 8 / 5 6 chilm 14,3%.
Chung toi nhdn thdy benh nhdn phdi dat sonde da day vd mo thong da day chiem ty le Ion vi cung cap dinh duong tot rat cdn cho ngai b^nh, trong khi ton thuong gay dp xe vung CO deu phan nhieu xuat phdt tii du- ong dn gdy ra. Th6i han nit 6ng thong da ddy tuy thugc vao vi$c lien ciia vet rdch, thiing thyc quan, hgng vd quan trgng nhdt la viec day, Idnh ciia ddy vet mo v6i viec uong thu xanh methylene c6 c6n ro ra vet mo khong.Viec thay bdng kiem tra va nia vet mo hdng ngay bdng Bentadine dugc thyc hien thu6ng xuyen o tat ca benh nhan, nham tiep tuc lay bo to chiic hoai tu, 1dm sach h6 mo ddm bdo ddn luu, bom rira v6t mo hang ngdy.
4.5. Bilu tri n$i khoa
Dieu tri ngi khoa luon cdn thiet vd tien hdnh truoc cung nhu dong thoi voi diiu tri phau thuat vd cdc phuong phdp dieu tri ho trg khdc.
Trong do thai gian khoi ra vien sau 2 - 4 ngdy Id 16,1%, sau 5 - 7 ngay id 32,1%, sau 8-10 ngay Id 17,8% va > 10 ngdy moi ra vien Id 33,4%.
Nhu vay thai gian phdi ndm diiu tri tai benh vien > 10 moi ra vien ciia dp xe vimg CO la cao nhdt dieu ndy cung hodn todn hgp ly vi tat cd cdc bSnh nhdn bi dp xe vimg co diu phdi trich, rach dan luu mu. Vi vay cdn CO thoi gian de ddn luu het 6 mu, lay het to chiic hogi tu, cdc co quan bi rdch, thung, lien, day vet trich day ddn timg duoi len.
So sdnh voi mgt so tdc gid khdc khi nghien cihi timg loai dp xe o viing co chiing toi cung thdy ket qud nay phu hgp voi cdc
tac gid khdc nhu:
Simkeopich, Le Huynh Mai khi nghien cuu ve viem tay vd ap xe quanh Amydan, thai gjan dieu tri trung binh ciia hg la 5 - 8 ngdy, vi hg nghien ciiu ca viem tdy vd dp xe nen phdi dimg khdng sinh truoc cho dgi tao 6 dp xe moi trich rach [6]. Hoac Vu Trung Kien khi nghien ciiu cdc bien chiing ciia hoc xuong thai gian dieu tri trung bmh la 21,4 ngdy [5].Trong nghien ciiru cua chiing toi co 1 benh nhan > 2 thang moi xuat vien vi b?nh nhdn tdm thdn bi dp xe canh co do hoc nen viec ket hgp dieu tri benh nhdn rat kho Nhu vay cdc dp xe viing co la mgt benh cdp cuu rdt nang thai gian dieu tri thuang keo ddi trung binh gan 2 tuan moi xuat vien d- ugc
4.6. Ket qua dieu tri
Ddp ling tot voi dieu tri 83,9%, dap ung chdm 8 truong hgp chiem 14,2% con phdi thay doi phuong an dieu tri co 1 tru- ong hgp chiem 1,7% do Id truong hgp lien quan den benh toan than cua benh nhdn Id tam than nen viec ket hgp dieu tri rdt kh6 khan: tir vlt m6, dinh duong, an sonde da day, nguoi nhd deu khong the phoi hgp cho tot dugc phdi keo dai > 2 thang benh nhdn moi xudt vien dugc.
Trong nghien curu cua chiing toi khong gap 1 truong hgp tii vong nao cd the y thiic ve benh ciia nguoi ddn phan ndo dugc nang cao, hon niia sir chdm soc y te da tot hon, viec chuyen benh nhdn len tuyen tren khong qud mugn, viec su dung khdng sinh thi he moi rdt co hieu qud. Tuy nhien dp xe canh CO Id 1 benh nang theo 1 so tdc gid nu- oc ngodi vdn con that bai trong dieu tri cao nhu; Tung Yiu va CS gap 15% thdt bai trong do da s6 bi tu vong [9], Mohamedi vd CS nghien ciiu 10 nam da gap 20 truong hgp viem hoai tu cdn vung co va that bai
Tap chl Tai MOi Hpng Vigt Nam - V o l u m e (58-15). N ° 3 - IVIay, 2013
15% [8]. d Vi?t Nam theo Linh Th6 Cuimg that bai la 17,1% [6], theo Vu Trung Kien thi bijn chimg ciia di vat thuc quan cdn cao, van con ty I? tit vong 14 0,6% [5], ty 1$
khoi benh ciia viem trung that chi dgt 38 % Vi vay ap xe viing co la 1 b$nh rat ntag CO ty 1$ thk bai, tir vong cao khong chi 6 nuoc ta ma a cdc nadc tren the gi6i.
5. KET LUAN
- Phai phau thuat 100% cac trutag hpp til trich dan liru don thuan, mo canh co , vk phoi hop voi cac thu thuat khac de dieu tri nguyen nhan ( npi spi lay di vat v.v...). Ket hop voi di^u tri npi khoa, hoi sire, de phong cac bi^n chimg. thay bang, rira vet mo bang Betadinia, nuac oxygia va lay to chirc hoai tir.
- Diing khang sinh phoi hop co tac dung voi ca vi khuan ua khi va ky khi do la: betalactamin + Metronidazole (92,8%).
- Dieu tri ho tro: kiem spat tpt ducmg tho de phong kho tho, cung cap dinh duong qua dat sonde da day hoac ma thong da day, boi phu nuac dien giai thang bang kiem toan.
- Thcri gian can de ra vien tnmg binh la 12 ngay.
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2. Linh Thi Cuimg (2001), " Nghien cim dac diem lam sang va dieu tri viem tiy
10.
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Nguyen Hihi Khoi (1997), " Viem tiy viing CO toa Ian vk nhiem HIV", Ngi sanTMH,voll,p 10-16.
Simkeopich (2006), "Cac biSu hiSn lam stag va danh gii kit qui diSu tii viem tay va ap xe quanh Amidan gap tai BV.TM HTLT tir 11/2005-11/2006", Luan van Thac sy Y hpc, Dai hoc Y Ha npi.
Tran Sy Tan, Tran Thanh Phuoc (1984), Nhan 293 truong hop rang khon tai bien" , Cong trinh nghien ciiu khoa hpc Y dupe 1984, Nxb Y hoc, tr H I .
A Lan D.(2008) Deep nect infectipn", up date mar. 11-2008.
Asensip J A. Et al, (2001), "Penetrating epspphageal injuries -multicenter study pf the American Association for the surgery of trauma" J. Traumalo, Feb,pll2-120.
Bruce AS et al (1993), " Deep neck space infection", Head & neck surgery- Otplaryngplpgy, vol 1, p 738- 753.
Mohamedi I, et al (1999), "Cervical necrosing facitis: 10 years experience", Intensivecare Med, 25 (8), p 829-834.
