T?p chl Tai MQi Hong Vi$t Nam -Volume (57-8). N°2 - March. 2012 V I E M TAI DINH: PHAN LOAI VA X C T R I
Cao Minh Thdnh*
T6M TAT
Myc tieu: danh gid ket qud ph§u thuat viem tai dinh theo loai vd miic dp. Thiet ke nghiSn cihi: tien curu, phdn tich ket qud tru6c vd sau di^u tri. B^nh nhan: 45 b$nh nhan dugc chan doan viem tai dinh. Can thi?p: phau thu^t t^o hinh tu6fng thut^ng nhi, tao hinh hom nhT va ddt 6ng thong khi c6 hodc khong ket h(?p v6i phSu thudt tao hinh xuong con. Ket qua; viin\ tai dinh khu tna chiem ty \i 75,5%(34/45), viem toan bo chilm 24,5%(II/4S) vdi (p = 0,009 - x2 = 6,76).Ty I? t6n thucmg xuong con Id 35,6%(I6/45).PTA trudc vd sau ph5u thudt tucmg ilng Id 46,5 ± 15,5 dB vd 34,6 ± 13,2 dB vdi (p = 0,00001 - F statistic = 222), siic nghe sau phau thual tdng 11,7 dB. Ket luan: phau thudt viem tai dinh dem lai ket qud cdi thi$n sue nghe khd tot, gidm cdm gidc kho diiu cho b$nh nhdn.
Tir kh6a: viem tai dinh SUMMERY
Adhesive otitis media: classifications and treatments
Objective: To access results surgery of adhesive otitis media following classified and gradings system. Study design: Prospective, analysis of preoperative and postoperative results. Patients: we studied 45 cases with Adhesive otitis media.
Intervention: Reconstruction wall of epitympanum, insertion of ventilation tubes with and without ossicular tympanoplasty. Results: the prevalent of local adhesive occupied 75,5%(34/45) and total adhesive was 24,5%(l 1/45) (p = 0,009 - x2 = 6,76). Ossicular erosion was 35,6%(16/45). The patient's preoperative and postoperative pure-tonc- aveiage were 46,5 ± 15,5 dB and 34,6 ± 13,2 dB, respectively(p = 0,00001 - F statistic
= 222), hearing result improved 11,7 dB postoperative. Conclusions: adhesive surgery improved symtoms and hearing results.
Keywords: Adhesive otitis media I. BAT VAN 8 E
Viem tai dinh (adhesive), xep nhT (Atelectasis) da duac cdc tac gid nghien cftu nhu Sade vd Berco ndm 1976, Avraham nam 1979, Sadi ndm 1979, Nakano nam 1993 vd dugc chia Idm 5 muc do. Tuy nhien su phan chia nay thucmg ndm chung gi&a 2 lo^i xep nhT (Atelectasis) vd vi6m tai dinh (Adhesive).
Trong phdn lo^i cua Sade ndm 1979 thi xep nhT dugc chia lam 5 loai, trong do 3 loai dau la xep nhi, nhung lo?i thii jb va thii nam lai ghi rit r6 Id viim tai K h (Adhesive). Nhtmg Manner nam
2003 thi chia ro 2 loai Id xep nhT vd viem tai dinh rieng biet. Tdt cd cdc tdc gid diu thdng nhdt rdng viem tai dinh Id mdng nhi dinh vdo u nhd hoac xuong con (adhere, adherent, adhesive) nghia Id c6 su Ii6n kit chdc chdn giOa mdng nhT vd cdc c^u true tren, do do mang nhi khdng di dpng vd khdng tdch khdi vi tri dd dinh khi ldm nghi?m phdp Valsava hodc bom vdi. Cdn x?p nhi la su tilp xuc (touch) gi&a mdng nhi vdi y nhd hodc xuong con vd khdng cd tao lien kit vdi vi tri md mdng nhi tilp xiic. Do vay ma mdng nhi cdn rung dpng vd trd l^i vi tri binh thudng khi ldm nghiem phdp Valsava
Tgp chl Tai Mui Hging Vi$t Nam -Volume (57-8). N"2 - March. 2012 hodc bom hai vdi nhT. VI cdch dieu trj
khdc nhau giOa x?p nhi vd viem tai dinh, vi ydy phdn loji phdi diing vd tiSu chuin chdn dodn rd rdng de xii tri cho ngudi b?nh d(it hi?u qud nhk. Vi vdy de Idi ndy nghien ciiu vdi myc tieu
Ddnh gid kit qud phiu thuf I vilm tai dinh theo logi vd mirc dg b^nh ly.
BENH HQC VlfeM TAI DINH Thir nh^t Id do tdng sinh Idp tc bdo simg d vj tri mdng nhT bj Idm vdo Irong. Idp te bdo bieu md vdy diy hon binh thudng. Ldp sgi bj phCi ne, cd tinh trang cdc te bdo b^ich cau xdm nhdp ddc bi?t Id tc bdo lympho vd Plasmocyte[7].
Ldp gi&a cua bieu md tdng Acid Schiff trong tudn hodn i^i cho- xuat hi?n to chiic hat. Dudi kinh hien vi dipn tii mdng nhi trong viem tai dinh chl cdn Idp bieu bi mdng nhi, khdng cd Idp sgi vd khdng cd Idp bieu md thay vdo dd Id ldp to chiic lien kit dinh vdo xugng con hodc thdnh trong hdm nhl.[2][5]
Thir hai la sy ton tai yeu to trung mo: trong nghien ciiu ciia Ruah vd cpng su, tien hdnh so sdnh md b?nh hpc xucmg thdi duang ciia lai binh thudng vdi viem tai giOa till djch vd viem tai gi&a mii. Hp phdt hipn ra cd sy tdn Ipi ciia yeu Id cd nguon gdc tir Irung mo d mdng cdng vd gdc 1/4 sau tren ciia mdng nhi, d nh&ng mau bpnh pham 2 Ihdng tudi, tai giOa binh ihudng, mau bpnh phdm 4 Ihdng tudi viem tai tilt djch, 10 Ihdng tudi vdi viem li mii tai giOa. Hp cho rdng sy chdm tre trong hap Ihu vd cdc dnh hudng khdc ciia ylu td trung md cd the Id nguyen nhdn Idm cho Idp sgi chun ciia mdng nhi phdt triln khdng hodn chinh. Sy phdt trien hodn chinh cua ldp sgi chun d mdng cdng vd gdc 1/4 sau trSn dugc tim thdy d benh phdm 5 ngdy ludi. Trong U benh pham xuang thdi duang bj viem tai giOa li mil chi tim thay
I bpnh phim cd sy phdt triln hodn chinh Idp sgi chun, Irong 13 b$nh phim xuang thdi duong cd viSm tai tilt djch thi khdng tim dugc mau ndo cd Idp sgi chun phdt triln hodn chinh [6]. Tdc gid kll lu^n ring sy chdm tre Irong phdt trien hodn chinh Idp sgi chun Id ylu to nguy ca Idm Idng ly Ip phdt triln tiii co k^o vd xpp nhi. Chinh do sy viim nhiem ldm kfo ddi sy l^n 1^1 ciia ylu Id Irung md Irong lai gifta, vd ylu tl ndy sS Idm chdm • hodc Idm gidn do?n qud trinh phdt Irien hodn chinh Idp sgi chun mdng nhT.[7]
Thir ba Id do ciu true niem mac hdm nhi: gdc sau Itin cd khuynh hudng hinh thdnh tiii co k^o nhieu han cac vi tri khdc d mdng cdng. Diiu ndy cung lucmg linp vdi cdu tnic niem mac khdc nhau d phdn trudc vd phan sau ciia hdm nhi.
Niem mac d phia trudc ciia hdm nhi chu yeu Id niem m^c che nhdy gid ting long chuyen, Idp te bdo che nhdy d phia uudc thi diy vd dirge bao phd d tren bdi ldp djch nhdy.Phdn sau ciia hdm nhi thi chu yeu Id te bdo bieu md vay, khdng cd ll bdo Idng, ddy cd the Id nguyen nhan gay li dpng cdc chil xudt tiet trong qua trinh viem [I]. Chinh li dpng chit xuit tilt trong qud uinh viem ndy gdi thich t^ sao trong viem tai tilt djch 1^ tjp trung nhieu men lieu Protein, ddc bipt Id men lieu collagene (Collagenase). Sy tdp Irung nhieu cdc men tieu Protein trong hdm nhi cd the Id nguyen nhan gdy phd huy Idp sgi collagen ciia mdng nhi, ldm gidm siic cdng cua mdng nhi. Sy phdt hipn ndy dugc chiing minh Irong nghien cihi ciia Ruah vd cpng sy, trong dd Idp sgi cua mdng cdng bj phd huy trong viem tai giOa ir mil nhieu hon so vdi viem tai tiet djch. Bdi vi trong viem tai giita ir mil Ihl hoat chit tnmg gian hod hpc vd cdc enzym trong djch mii tdng cao hem so vdi djch trong viem tai tilt djch. [6]
82
Tap chi Tai Mui Hpng Vi$t Nam - Voiume (57-8). N°2 - March. 2012 Thtir tur la roi lo^n chirc nSng v6i
nhT: d^c bi^t 1^ tac v6i nhT 1 p h ^ , sS ldm ap l\rc trong hom nhT dm tinh. Do ap lyre am tinh nen mang nhT luon luon bj k^o cang vao trong, do quA trinh nay k^o dai ciing lam cho lop sai cua m ^ g nhT suy ySu va giam tinh d ^ hdi. Ngoai ra khi ap luc am trong hom nhT k^o d^i s6 dSn d^n hi^n tut^ng thodt djch tii I6ng mach vac khoang gian bdo, gdy ix dong djch.
Do do ldm cho long m^ch gidn rpng d ^ den hi§n tuong cdc te bao bach c^u xuySn m^ch thodt ra ngodi, bdt dau qud trinh hoat hod viem vd gidi ph6ng cdc chdt trung gian hod hgc chua cdc men tieu Protein va Collagen ldm ton thucmg lop bi6u mo vd I6p s<?i cua mang nhT.
Qud trinh ndy k^o dai thi lop sgi mdng nhi s6 bi tieu hoan todn, 16p bieu mo m$t trong mang nhT bi ton thuong do d6 khi ti^p xuc voi be mdt khac se tao nen to chuc lien k^t, sgi xo vd dinh chac vao vi tri md no tiep xuc.
fiinh nghTa: viem tai dinh la tinh trang mdng nhT dinh vdo xuong con (vao nhimg vi tri xuong con ma binh thudng khong bao gio mang nhT dtnh vao d6) vd thdnh trong hom nhT, do lop sgi cua mdng nhT bi phd huy. Ld hdu qud ciia qud trinh viem keo ddi trong h6m nhT va roi loan chuc ndng voi nhT lam ton thuang lap bi6u mo vd tieu huy lop sgi mdng nhT, ldm mang nhT mdt tinh dinh hinh va tinh dan hoi do vay hom nhT bi thu hep mgt phdn hay todn bg boi mdng nhT dinh ch^t vao xuong con vd thdnh trong hom nhi.
Mang nhT khong di dgng khi lam nghi?m phap Valsava.
PHAN LO4I
Hi^n nay co nhi6u each phan loai khac nhau, xip viem tai dinh (VTD) vdo xep nhT khdng phii hgp, de nhdm lan, vd
dinh theo trrieu chirng th\rc the vd cdch xir trf Id phii hgp nhal.
Viem tai dinh chia ldm 2 toai: loai khu tni vd toan bg
Viem tai dinh khu tni co the if mdng chiing hodc mdng cdng. Viem tai dinh todn bg Id b$nh tfch cd d mdng chimg vd mdng cdng.
* Viem tai d!nh khu tru
Viem tai dinh khu tni 6 mdng chiing: chia ldm 5 do:
- Dp I: mang nhT I5m nhung chua dinh vdo co xuong biia.
- DO II: mdng nhT lom dinh vdo co xuong bua, co the tieu 1 phdn tu6rng thugng nhT, phan mdng nhT dinh xdc dinh rS.
- Dg III: mdng nhT lom dinh vdo co vd chom xuang biia, tuong thugng nhT hi tieu huy 1 phan hay todn bg.
Xac dinh ro vi tn' mdng nhT dinh.
- Do IV: mdng nhT lom dinh vao c6 vd chdm xuong bua, khop biia de, tuong thugng nhT mdt phan 16n hodc todn bg. Chom vd co xuong xuong biia co the bi an mon hodc gidn doan, xuon^ de co the bi dn mon hoac mat phan than. Co the co sir tich tu bilu bi nhung khi ldy sach van xdc dinh dugc phan mang nhT dinh.
- Dg V: nhu do IV + khong xdc dinh dugc phan mdng nht dinh.
Vidm tai dinh khu tni a mdng cdng: chia lam 3 dg
- Dg I: mdng nhT dinh vdo ngdnh xuong xuong de, ldm nghiSm phdp Valsava mdng nhT khong di dgng vd khdng tdch rcri khoi vi tri dinh.
- Dg II: mang nhT dinh vao ngdnh xudng xuong de, khdp de dap (chdm
Tgp chl Tai MDi Hpng Vi$t Nam - Volume (57-8). N°2 - March. 2012 xuong de mat) vd \i nhd. Mdng nhT
khdng di dgng khi Idm nghidm phdp Valsava.
- Dg IH: mdng nhT dfnh vdo ngdnh xu6ng xuong de, kh6p de d^p (ho$c chdm xuang bdn d^p), gdn co bdn d^p,
\f nhd. cOra s6 trdn ho$c dfnh todn bO vdo thdnh trong hdm nhT. Ngdnh xuong xuong de mSt, xuang bdn d^p cdn (cd thi bj ton thuong 1 ph4n).
* Viem tai dfnh todn b^
Viem tai dfnh todn b$ Id tinh tr^ng mdng nhT dinh vdo h$ th6ng xuong con
(binh thudng mdng nhT khdng dfnh vdo cdc vj tri dd cua h§ th6ng xuong con) d cd mdng chiing vd mdng cdng. Chia Idm 2 d§
- DO I: mdng nhT dfnh if mdng chiing vd dfnh khu tni ir gdc 1/4 sau trSn mdng cdng vdo ngdnh xu6ng xuong de, vd xuong bdn d^p. Xuong de cd thi cdn ho$c m^t, xucmg bdn dgp cdn nguydn v^n,
- DO II: cdc do vidm tai dinh mdng nhT khu tni 6 mdng chiing + viSm tai dinh khu tni dO II hodc dO III ir mdng cdng.
Anh 3.1 Viem tai dtnh todn bO dO I Mdt tudng thugng nhT, mdng nhT dinh vdo khdp bOa de vd thdn xirong de, dinh vdo ngdnh xudng xuong de vd khdp de - dgp 2. D 6 I TirONG vA PHl/OfNG P H A P NGHIEN Ctru
2.1. Doi tiring nghien cihi
Benh nhan dugc chin dodn viem tai dinh tir 2007-2011.
Tieu chuan chgn b?nh nhdn : +NOi soi: Chdn dodn viem tai dfnh khu
tni ho^c todn bO.
+Do sue nghe don am: tnrdc vd sau phlu thu^t.
+Phau thuEit: tao hinh tudng thugng nhT, ho|u: tao hinh hdm nhT, tgo hinh xuong con.
Anh 3.2 Vidm tai dfnh todn bO dd II Mdt tudng thugng nhT, mdt xucmg de, mdng nhT dinh vdo cd vd chdm xi/ang bOa, dinh vdo chdm vd gdn co bdn d^p, dinh vdo g nhd vd ci>a s6 trdn
+NOi soi tai ddnh gid sau phau thu$t - Ti6u chu4n logi tni:
+Viem tai dinh khu trii thugng nh!: do 1&2.
+Khdng du cdc tieu chudn tren.
2.2. Phinmg phdp nghidn cihi - Md hinh nghidn cuu: th\rc nghiem lam
sdng.
- Phuong tiOn nghien ciiu
+ NOisoiopticl.9 vd4.0mmloai30^
O".
+ Mdy do thinh l\rc SD50 ciia Diic.
84
Tap chi Tai Mui Hpng Vi$t Nam - Volume (57-8). N°2 - March. 2012 + Kinh hien vi phau thudt. Khoan vi
phlu, bd d\mg cu phau thuat tai.
- Chat liOu nghidn ciiu: mdng syn va s\m binh tai, xuong con thay the bdng g6m sinh hgc, dng thdng khi.
3. KET QUA
Ddc diem trudc phau thudt Bang 3.1. Trl$u chiing thyc th^
• Ky thugt: tao hinh tudng thugng nhT, tgo hinh hdm nhT ho^c tao hinh xuong con dudng trong 6ng tai.
• Ddnh gid ket qud
+Ngi soi tai: ddnh gid mdng nhT, tudng thugng nhT.
^ ^ ^ ' Lo?iVTD T6n t h u v n g ^ ^ ^
xuxyng con ^ " ^ ^ Khdng
C6 N
Khu tni Thucng nhT n 12
0 12
%
100,0 0,0 100,0
Mdng cdng n 15
7 22
%
68,2 31,8 100,0
ToSn bO
n 2 9 11
%
18,2 81,8 100,0 Nhan xet
Ty le viem tai dinh khu tni d thugng nhT khdng tdn thuong xuong con chidm ty Id 100%.
Ty Id viem tai dinh khu tni mang cang khdng tdn thuong xuong con chidm 68,2%, cd tdn thuong xuong con chidm 31,8%. Su khac biet khdng cd y nghTa thdng kd vdi p = 0,22 (x2= 1,47).
Vidm tai dinh todn bd ty Id khong tdn thuong xuong con chiem 18,2% thdp hon so vdi ty Id tdn thuang xuong con chidm 81,8%.
Ty Id vidm tai dinh khu tni chidm 75,5% (34/45), ty Id vidm tai dinh todn bO chidm 24,5% (11/45). Su khdc bidt cd y nghia Ihdng kd vdi p
= 0,009 ((x2 = 6,76).
Phan logi phau thuat Bdng 3.2. Ty 1$ phdu thudt theo logi vidm tai dinh
^ ^ t ^ / viem tai dinh
Cich phau thu^t ^ ^ ^ ^ Tgo hlnh Ihirp'ng nhT Tgo hinh hdm nhT Tgo hinh xirang con D$l ong thdng khf
Thugng nhi
12 0 0 0
Ming dng
0 22
7 22
Toin b^
11 11 9 11
n
23 33 16 33
'/.
61,1 73,3 35,6 73,3
T9P chi Tai MDi Hpng Vi$t Nam -Volume (57-8). N°2 - March. 2012 Nhan xet
Vidm thugng nhT khu tni khdng cd trudng hgp ndo t6n thuang xucmg con, ty 1? ddt ong thdng khf 0,0%, tgo hinh hdm nhT chilm 0,0%, tgo hinh tudng thugng nhT chilm 100%.
Trong vidm lai dfnh khu tni d mdng cdng ty 1^ tgo hinh hdm nhT chiem 100%, d$t Ing thdng khf (OTK) chilm 100%. Ty 1^ tgo hinh xuong con chilm 40,9%, khdng tgo hinh xuong con chilm 59,1%. Sv khdc bi?t khdng cd y nghia thing kd vdi p = 0.76 ({x2 = 0,09).
Ty 1? tgo hinh xuang con trong viem tai dfnh chilm 35,6%, ty I?
tgo hinh tudng thugng nhT chidm 51,1%, tgo hinh hdm nhT chilm 73,3%, ddt OTK chilm 73,3%. Sv khdc bi?t cd y nghTa thong kd vdi p
= 0,049 ((x2 = 6,03).
Stic nghe trudc vd sau phSu thu§t PTA trudc phau thugt Id 46,5 (SD=15,5) dB sau phau thugt Id 34,6 (13,2) dB. Sv khdc bi?! cd y nghTa thong kd vdi p = 0,00001 (F statistic = 222) tdng 11,7 dB.
ABG trudc phau thugt 39,7 (SD=11,3) dB, sau phSu thu^t Id 27,8 (SD=10,5) dB. Sy khdc biOt cd y nghTa thdng kd vdi p = 0,00001 (F statistic = 226). ABG tdng 11,8 dB.
4. BAN LUAN
Ty !? vidm tai dinh khu tni chilm 75,5%(34/45), ty !0 vidm tai dinh todn bO chilm 24,5%(ll/45). Syr khdc bi^t cd y nghTa thdng kd vdi p = 0,009 ((x2 = 6,76). Nhu vdy chung ta thudng gdp vidm tai dfnh khu tni hon Id todn bO,
trong vidm tai dinh khu tni thi ty 1^ thdnh cdng ciia phau thugt cao han viem tai dfnh todn bO (bdng 3.1). Trong viem tai dfnh khu tni thi gdp d mdng cdng nhilu hom mdng chiing, ty 1? tin thuong xuong con trong vidm tai dfnh khu trii d mdng cdng chilm 40,9% (7/22) (bdng 3.1), gdp tin thuong gidn dogn xucmg de 100%.
Vidm tai dfnh todn bg chilm 24,4%(ll/45), trong vidm tai dinh tadn bO thi thudng gdp cd ton thuong xuong con phii hgp vdi ty 1? 81,8%.
Trong vidm khu tni d thugmg nhT thi chii ylu gdp dO IV, chi cd 3 trudng hgp dO III. khdng cd trudng hgp ndo cd tin thuong xuong con kdm theo. Do dd phau thugt khdng can thiet ddt OTK vd tgo hinh xuong con. Ty 1^ tao hinh hdm nhT chiem 73.3% (33/45) (bdng 3.2) gdp trong vidm tai dinh todn bg vd thd khu tni d mdng cdng. Trong nghidn ciiu ndy chi gdp I trudng hgp vidm tai dinh todn bg dO II. sau phau thugt 6 thdng mdng nhT dinh lgi vdo thdnh trong hdm nhT d phia trudc trdn vd phfa sau mdnh s^n d$t tren y nhd, mdc dii siic nghe ciia b^nh nhan van tdng. Ty If ddt OTK mdng nhT trong phau thugt tgo hlnh hdm nhT la 100%, dd can bdng dp Ivc trong hdm nhT vd ben ngodi, hgn che s\r dinh lgi mdng nhT vdo thdnh trong hdm nht sau phau .thugt. Tgo hinh xuong con chilm 35,6%
(16/45) (bang 3.2) chi gdp trong viem tai dinh todn bO vd thd mdng cdng, xuong con tgo hinh Id xucmg de chiem 100%, khdng cd trudng hgp ndo tdn thuang xuong bdn dgp.
PTA' vd ABG sau phau thudt tdng 11,7 vd 11,8 dB. Trong trudng hgp vidm tai dinh cd ton thuong xucmg con thi siic nghe cung khdng gidm nhidu, \i thudng Id mdng nhT dinh vdo chdm xuong ban dgp do v$y rung dgng chuydn vdo tai trong thudng khdng bj gidn doan ma chi
T9P chl Tai MQi Hgng Vi§t Nann - Voiume (57-8). N°2 - l\/1arcti. 2012 hi han che. Vi vgy neu trong trudng hi?p
viem tgi dinli loan b6 dp II, n^u b?nh nhan khong c6 gi Icho chiu, kh^m khong thay CO Cholesteatoma thi khong nen phau thugt.
TAI LIEU THAM KHAO
1. Djalilian HR et.al (2000), "The atelectatic ear". Otolaryngology & Head and Neck Surgery, Lippincott William&
Wilkins Inc, pp.369-374.
2. Hartwein J el.al (1990),
"Elektronenaptische Utersachungen zur Koliagcnfaslerstruktur des manschlichcn Trommelfellis bein AdhasivprozeP", Lryngol Rhinol Otol(59). pp.333-336.
3. Manner AL (2003), "Adhesive Otitis Media", A pocket guide to the Ear.
Thieme-Stugalt- Newyork, pp. 68-70
4. Manner AL (2003), "Atelectasis and Retraction Pockets", A pocket guide to the Ear. Thieme-Stugalt- Newyork, pp.
67-68
5. Pau HW (1995), "Middle Ear Retraction the Role of Predamaged Tympanic Membranes", Int J Pediar Otolaryngol (SuppI 32), pp.S163-S166.
6. Ruah C ct.al (1992), "Mechanism of retraction pockets formation in the Pediatric Tympanic Membrane", Arch Otolaryngol Head Neck Surgery (118), pp.1298-1305.
7. Sadi J et.al (1981), "Atelectasis, Retraction pockets and Cholesteatoma"
Acta Otolaryngol (92), Hinari, pp.501- 512.
