Tap ciu THONG TIN Y DlfOC Sd thdng 8 ndm 2010
NGHIEN CUU UNG DUNG NOI SOI TRONG CHAN DOAN VA DIEU TRI BENH
VIEM MUI XOANG CO Dl HINH KHE GIUA TAI BENH VIEN DA KHOA BINH PHUOC Nguyen Minh Quang', Nguyen Van TUdng",
Nguyen Minh Tho", Nguyen Thi Hang"' TOM TAT
Muc tieu: ting dung ky thuat ndi soi trong chan doan va dieu tri benh viem mui xoang man tinh (VMXMT) cd di hinh khe giiia va bddc dau danh gia ket qua phau thuat. Ddi tUdng va phUOng phap: nghien ciiu tien ciiu vdi 53 benh nhan dddc chan doan xac dinh viem mui xoang cd di hinh khe giiia, phau thuat ndi soi chdc nang mui xoang (FESS) va theo ddi sau phau thuat tai Benh vien Da khoa tinh Binh Phddc td thang 11/2008 den 2/2010. Ket qua:
benh nhan cd polyp: 88,7%, di hinh vach ngan (32,1%), di hinh mom mdc (28,3%>); di hinh cudn gida (17%), di hinh cudn dddi (9,4%). Ket luan: chan doan xac dinh va danh gia kit qua phau thuat dda vao cac trieu chdng thdc thi qua ndi soi hoc mui.
SUMMARY
Application of endoscopic method in diagnosis and treatment of the rhino-sinusitis having deformity of middle meatus at Binh Phuoc hospital
Objectives: to apply the endoscopic method to diagnose and treat the chronic rhino-sinusitis having middle meatus abnormal. The first step to evaluate the results of treatment by functional endonasal sinus surgery (FESS) in the diseases having deformity of middle meatus. Methods: a prospective study was performed on 53 patients who were diagnosed to ha ve allergic rhinitis sinus between the slots, FESS and monitored after surgery in Binh Phuoc provincial general hospital from November 2008 to February 2010.
Results: patients with polyps: 88.7%), septal deformities: 32.1%, hook tip deformities: 28.3%), middle turbinate deformities: 17%, inferior turbinate deformities: 9.4%. Conclusions: the diagnostic evaluation and determination of surgical outcomes based on physical symptoms through nasal endoscopy.
I. OAT VAN OE
Benh VMXMT la benh thudng gap trong Tai Mui Hgng (TMH), benh khd dieu trj triet de va hay tai phat. Mot trong nhu'ng nguyen nhan gop phan gay benh viem xoang la nhu'ng di hinh vung khe gida (Concha bullosa, thoai hoa mom mdc - bdng sang, veo vach ngan, te bao agger Nasi qua phat,...) la nhu'ng nguyen nhan lam cho vung phdc hdp Id ngach (PHLN) trd nen chat hep va lam can trd dich trong xoang ra mui va la nguyen nhan gdp phan lam benh viem xoang phat sinh va phat then. Dieu tri bang phau thuat npi sdi mui xoang la mdt phUdng phap tdi Uu dugc cac nha TMH lua chgn khi phUdng phap dieu tri ndi khoa that bai. Viec nghien cdu cac di hinh vung khe gida da trd thanh cac van de thdi sU dUdc cac nha TMH quan tam nghien cdu. Xuat phat td nhdng van de tren, chung tdi nghien cdu de tai vdi muc tieu: dng dung ky thuat ndi soi trong chan doan - dieu tri benh VMXMT cd di
hinh khe gida va budc dau danh gia ket qua phau thuat.
II. OOI TlTONG VA PHl/ONG PHAP 1. Ddi tUOng
* Mau nghien cdu
53 benh nhan (BN) dUdc cha'n doan xac dinh viem mui xoang cd di hinh khe gida, phau thuat ndi soi chdc nang mui xoang va theo ddi sau phau thuat tai Benh vien Da khoa tinh Binh PhUdc trong thdi gian td thang 11/2008 va dddc theo ddi den thang 02/2010.
* Tieu chuan Ida chgn
NgUdi Viet Nam tud'i td 16 trd len.
- Cac hinh thai lam di dang hoc mui: polyp mui, qua phat niem mac mom mdc, qua phat cudn mui, di hinh vach ngan mui, cac viem xoang tang san man tinh cd polyp mui ket hdp, cac xd dinh trong hoc mui do nhieu nguyen nhan (chan thUdng, hau qua ciia cac phau thuat trUdc dd,...).
' TS.BS., "BSCK2, '"BSCKI., BV Da khoa tinh Binh PhUdc
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Tap chi THONG TIN YDlfOC S3thdng8ndm 2010
- Tieu chuan can lam sang: co hinh anh md cac hoc xoang mat tren phim X-quang (Blondeau, Hirtz) hoac phim CT Scan (Coronal, Axial).
* Teu chuan loai trd
- Khong du cac dieu kien nhU da neu trong tieu chuan Ida chgn.
- Cac BN phau thuat ddn thuan xoang co dien, chinh hinh mui ddn thuan khong cd viem xoang.
- BN phau thuat cap cdu dd cac bien chdng cua viem xoang, do chan thUdng.
- Khong cd du phim X-quang (Blondeau, Hiztz, CT Scan).
2. Phu'dng phap nghien cu'u
* Thiet ke nghien cu'u: nghien cdu tien cdu
* Cac bu'dc tien hanh:
- Kham noi soi va chan doan hinh anh: may va dung cu phau thuat ndi soi cua hang Wofl.
- Phau thuat, cham sdc va theo ddi: sau mo, ngay khi ra vien, mdi 3 thang (hoac mdi khi cd cam giac khd chiu ve mui xoang) tai kham.
* Danh gia kit qua phau thuat: dUa vao cac dau hieu thUc the de danh gia:
- Tot: hoc md sach. Niem mac hong deu, nhan, mao mach tan tao. Vung PHLN, Id xoang ham va xoang sang thdng thoang, khdng bi dinh tac, dan lUu tdt.
- Kha: hoc mo cd xuat tiet nhay. Niem mac xd hda day, mau trang nhat, it mach mau.
PHLN va vung md xoang sang, Id thdng xoang ham thong thoang, khdng bj dinh tac.
- Trung binh: hoc md cd mu nhay dac, niem mac phii ne, nhieu chd viem dd, de chay mau, cd tai phat polyp nhd rai rac nhUng khdng gay tac cac dudng dan lUu.
- Kem: hdc mui cd nhieu mu nhay dac, tai phat polyp mui xoang. Viing PHLN va 16 xoang ham bi dinh hoac bi pdlyp tai phat bit kin gay can trd dan lUu.
*Xu'lyso lieu: bang phan mem Epi Info 6.04.
III. KET QUA
Qua nghien cdu 53 trddng hdp BN VMXMT cd di hinh khe gida, chiing tdi thu dUdc ket gua nhU sau:
1. Cac hinh thai di hinh khe gitfa Bang 1: Cac dang di hinh mui (n=53) Cac dang di hinh mui SL TL%
Di hinh vach ngan 17 32,1 Di hinh cuon dUdi 5 9,4 Dj hinh cuon giLTa 9 17,0 Di hinh mom mdc 15 28,3
Polyp 47 88,7
Ty le BN cd polyp chiem ty le cao nhat (88,7%).
Ty le BN cd dj hinh cudn dUdi chiem 9,4%.
2. Chan doan hinh anh
17 trUdng hdp viem xdang ham 1 ben (32,07%) va 33 trUdng hdp viem xdang ham 2 ben (62,26%).
Hinh anh md xoang sang hai ben chiem ty le cao nhat (71,7%). Hinh anh xoang sang binh thUdng chiem ty le thap nhat (3,8%).
Hinh anh md xoang sang mot ben cd 13 trUdng hdp (24,5%).
Theo ket qua tren, chi cd 29 trUdng hdp BN dUdc chup phim CT.Scan, chiem ty le 54,7%
tdng so BN. Hinh anh viem xoang sang va xoang ham ca hai ben chiem ty le cao nhat (48,3%). Tac nghen toan bp hoc mui chiem 6,9%. Viem xoang ham + polyp trong xoang mot ben chiem 10,3%.
3. Danh gia kit qua sau FESS
Bang 2: Cac loai phau thuat noi soi mui
xoang (n=53) ^ ^ ^ ^ Phau thuat SL TL %
Cat polyp ddn thuan 2 3,8 Cat polyp, cat mom mdc 17 32,1 Cat polyp, cat mom mdc, chinh 4 7 5
hinh vach ngan
Cat polyp, md ham - sang 39 73,6 Cat polyp, md ham - sang - budm 4 7,5 Md ham - sang - budm 12 | 22,6
Phau thuat cat polyp md ham sang nhieu nhat chiem ty le 73,6%.
4. Theo ddi bien chd'ng sau mo
Bang 3: Theo ddi biin chdng sau md 1 tuan (n=53)
Bien chdng SL TL %
Chay mau 2 3,8
Nhiem khuan 1 1,9
Tu mau ket mac 1 1,9
Ton thUdng than kinh thi giac 0 0 Ton thUdnq manq nao 0 0 2 trUdng hdp chay mau kec dai (3,8%).
Bang 4: Tinh trang niem mac mui qua_ kham noi soi sau mdi 3 thang phau thuat (n-41J
Tinh trang niem mac qua npi soi SL TL%
Binh thUdng 27 65,8
Phu ne, tiet dich 4 9,8
Nhay, mil 2 4,9
Tac 16 thong xoang ham 3 7,3 Tac 16 thong xoang sang 2 4,9 Dinh cuon mui qiua vao vach ngan 3 7,3 30
Tap chi THONG TIN Y DUOC Sdthdng8ndm 2010
Kiem tra lai (trong 2 thang dau moi tuan rda ho md mui xoang 1 lan) chi cd 41 trddng hgp BN den tai kham theo tich hen, trong dd ket qua thu du'dc cho thay cd 27 BN (65,8%) niem mac binh thu'dng.
Bang 5: Danh gia ket qua sau phau thuat Ket qua phau
thuat SL TL % P
Tot 14 26,4
Kha 23 43,4
Trung binh 15 28,3 p<0,05
Kem 1 1,9 P<0,01
Tonq 53 100
Ty le tot va kha chiem 69,8%.
IV. BAN LUAN
Qua nghien cdu 53 BN dugc chan doan xac dinh VMXMT cd di hinh khe gida, dddc FESS va theo ddi hau phau tai Benh vien Da khoa tinh Binh Phudc td thang 11 nam 2008 den het thang 02 nam 2010, chung tdi nhan thay:
1. Trieu chd'ng thUc the cua BN VMXMT co di hinh khe gi&a
Vach ngan cd mao vach ngan, gai vach ngan chiem ty le 32,01% trong tdng so BN.
Trong khi dd Vu Van Minh (43,8%) [5], Pham Kien Hdu (54,0%) [3], cd le do so lUdng benh nhan nghien cdu khdng gidng nhau nen cd sU sai so nhat dinh.
Dj hinh cuon dUdi (9,4%) va dj hinh cudn gida (17%) cd anh hudng tdi vung khe gida, so vdi Vu Van Minh la 8,8% [5]. Khi hda xUdng cucn giua (concha bullosa) gay can trd vung phdc hdp Id ngach, cd the gay dinh gida hai niem mac cua vung phdc hdp Id ngach va dan tdi tac nghen cac Id thdng xoang. Theo Parson D.S. [9], nhu'ng benh nhan cd cdncha bullosa cang Idn thi cang hay kem theo nhu'ng dau hieu cua viem mui xoang.
Mom mdc la mot phan cau true cua vung phdc hdp Id ngach cd lien guan trUc tiep den sU theng thoang cua dUdng dan lUu xoang.
Chung toi gap 15/53 benh nhan cd di hinh mom mdc (chiem ty le 28,3%). Theo ket qua nghien cdu cua Nghiem Thj Thu Ha (18,2%) [2], Vd Thanh Quang (12,7%) [6], Vu Van Minh (27,6%) [5], Theo Parson D.S va cdng sU [9] tinh trang qua phat mom mdc khdng co hoi khi dung thudc co mach la mdt trong nhu'ng
nguyen nhan gay tac nghen vung phdc hdp Id ngach dan tdi viem mui xoang.
Polyp d hoc mui (88,7%) la do niem mac tai cho thoai hda thanh polyp hoac niem mac d trong xoang ham, xoang sang thoai hda. Gida cac tac gia trong va ngoai nddc cdn cd nhieu khac biet, theo Nghiem Thj Thu Ha [2] la 45,5%, Chd Ngpc Binh [1] 39,1%, Dao Xuan Tue [7]
53,5%, Pham Kien Hdu [3] 24%. SU khac nhau nay cd the la do sU Ida chgn BN cho tdng de tii cua mdi tac gia vdi muc dich khac nhau.
2. Trieu chd'ng X-quang
Viem xoang ham ddn thuan 1 ben chiem ty le 32,07%. Vdi Nghiem Thj Thu Hi [2] la 42,4%. Viem xoang ham ddn thuan 2 ben chiem ty le 62,26%, so vdi Chd Ngoc Binh [1]
la 82,3%. Chup phim X-quang la mdt tham do re tien, de thu'c hien d bat ky cd sd y te nio.
Neu mudn biet chinh xac vj tri, mdc dp ton thUdng cua niem mac, tinh trang cic Id thdng mui xoang vi cac cau tao giai phau bat thudng vung pheu sang va phdc he id ngach thi chung ta phai chup phim CT Scan. Chung tdi cd 29/53 (54,7%) BN chup phim CT Scan, Nghiem Thj Thu Ha [2] cd 11/33 (33,3%) BN chup phim CT Scan. Theo Parsens D.S. va cdng su" [7], benh sd cd gia trj chan doin la 50%, trieu chdng thUc the qua npi soi li 25%
vi phim X-quang la 25% cdn lai.
3. PhUdng phap FESS
La ky thuat md td trUdc ra sau. Qua nghien cdu 53 trUdng hdp, chung tdi thay: thUdng hay gap nhat li benh ly viem xoang him vi xoang sang 2 ben cd polyp gap nhieu nhat (73,6%), cd polyp trong hoc mui cung vdi mom mdc qui phat gap it hdn (32,1%), cd polyp ddn thuan trong hoc mui gap it nhat (3,8%).
Trong VMXMT cd thoii hda cuon gida hoac polyp d khe gida, cat polyp trUdc sau dd mdi lay tiep den mom mdc, bdng sing, md rpng id dan lUu xoang him, nao sing trddc vi sau.
Cuon gida thoai hda qua phat thudng be vio trong hoac cat dau cudn gida, neu theai hda nhieu cd the cat bin phan td trUdc ra sau nhu'ng van phai giu" lai phan gdc cuon giua.
Kinh nghiem niy cung dUdc Vd Thanh Quang de cap [6], Tuy nhien, Parsons D.S. va cpng sU [9] khuyen khdng nen cat cuon giua du la ban phan neu nd chUa thoai hda han thanh polyp.
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Tap ciu THOXG TIX Y DCOC Sd thdng 8 nam 2010
Ooi vdi cac VMXMT co poiyp, chung tdi phan lam 2 loai: cac polyp do thoai hda niem mac khe gida hoac td trong xoang ham ra hay cac polyp ddn dgc (polyp Killian) thudng la cac polyp cd cudng, cd chan ggn, rat mong, mau trang due, khdng cd mach mau. Dung kim nhd luon sat chan bam cat ggn chan va dUa ra qua cda mui trudc hoac sau, sau dd cd the dot chan bam cua polyp bang may dot ludng cut.
Vdi cac polyp dd thoai hda niem mac mui, dac biet la cucn giQa thdai hda, thudng cd chan rat rdng, nhieu mach mau, chan bam cd khi khong xac dinh ro hay moc thanh tdng chum khi cat rat gay chay mau va ton thUdng nhieu niem mac lanh xung quanh. Vdi nhu'ng trUdng hdp nay nen cat tdng phan va cam mau ky bang thudc co mach dat tai chd.
4. Danh gia kit qua FESS trong dieu tri VMXMT co di hinh khe giua
Theo Stammberger H. va cdng sU [10], Vd Thanh Quang [6], Nguyen Thi Quynh Lan [4]
danh gia ket qua sau md chu yeu dua vao sU cai thien cua cac trieu chdng cd nang (dau dau, nghet mui, chay mui) ket hdp vdi thee ddi tinh trang tai phat sau md va hinh anh cai thien tren phim X-quang.
Chung tdi cung chia lam 4 mdc do, dd la:
tot, kha, trung binh va kem. Ket qua: tdt:
14/53 (26,4%), kha: 23/53 (43,4%), trung binh: 15/53 (28,3%), kem: 1/53 (1,9%). So vdi cac tac gia Vd Thanh Quang [6]: tot 18%, kha 53%, it ket qua 18%, khdng ket qua 11%.
Nguyen Thi Quynh Lan [4]: tot 71%, trung binh 27%, xau 2%. Nghien cdu cua Parson D.S [9]: tdt la 80%.
V. KET LUAN
Qua nghien cdu 53 trUdng hdp VMXMT cd di hinh khe gida dUdc kham va dieu tri bang phUdng phap FESS tai Benh vien Da khoa tinh Binh Phudc, chiing tdi rut ra mot so ket luan sau:
1, Ltng dung ky thuat noi soi trong chan doan va diiu tri viim mui xoang co di hinh khe mui gida
Can cd vao trieu chdng thut the:
- Di hinh vach ngan (32,1%), mom mdc (28,3%), cudn giCra (17%), cuon dddi (9,4%).
- Cd polyp trong hoc mui (88,7%).
2. Bu'dc dau danh gia kit qua FESS co dj hinh khe gida
- Cat polyp, md ham - sang: 73,6%.
- Md ham - sang - budm: 22,6%.
- Cat polyp, cat mom mdc, chinh hinh vach ngan hoac cat polyp, md ham - sang - budm: 7,5%.
- Cat polyp ddn thuan: 3,8%.
- Cat polyp, cat mom mdc: 32,1%.
- Ket qua phau thuat: tot (26,4%), kha (43,4%), trung binh (28,3%), kem (1,9%).
TAI LIEU THAM KHAO
1. ChCr Ngpc Binh: Budc dau danh gia ket qua phau thuat ndi soi mui xoang tai Benh vien Vet Nam-Cu Ba tU thang 7/1998 den thang 7/2001. Luan van chuyen khoa 2, Tn/dng Dai hoc Y Ha Ndi, 2001.
2. Nghiem Thj Thu Ha: Nghien ciru Ung dung ky thuat noi soi trong chan doan viem xoang ham man
tinh. Luan van thac si y hoc, Tn/dng Dai hoc Y Ha Noi, 2001.
3. Pham Kien Hutu: Phau thuat noi soi chUc nang mui xoang qua 213 trudng hdp mo tai Benh vien Nhan dan Gia Dinh. Luan an tien si, Dai hoc YDupc Tp. HCM, 2000.
4. Nguyen Thj Quynh Lan: Tong ket 2499 trudng hdp phau thuat noi soi tai Benh vien Tai MOI Hong
Tp. HCM. Noi san Hoi nghi Khoa hoc Ky thuat, Benh vien Tai Mui Hong Tp. HCM, 2006, tr.304-309.
5. Vu Van Minh: Nghien cUu dac diem lam sang di hinh hoc mui tren benh nhan viem da xoang man t'nh va de xuat phudng phap xU tri bang phau thuat noi soi. Luan van thac si Y hoc, Hoc vien Quan Y, Ha Noi, 2005.
6. Vo Thanh Quang: Nghien cUu chan doan va dieu tri viem da xoang man b'nh qua phau thuat npi soi chUc nang mui - xoang. Luan an tien si Y hoc,
Tn/dng Dai hoc Y Ha Npi, 2004.
7. £>ao Xuan Tue: Nhan xet 600 trudng hdp viem xoang tai Vien Tai Mui Hong. Luan van chuyen khoa 2, Tn/dng Dai hoc Y Ha Npi, 1980.
8. Messerklinger W.: Functional endoscopic sinus
surgery. Eur Arch Otorhinolaryngol, 1990, 247, pp.63-76.
9. Parsons D.S.: The OtoLaryngologic Clinics of
North Americaca. Pediatric Sinusitis W. B. Saunders Company A Division of Harcourt Brace 8t Company Philadelphia London Toronto Montreal Sydney Tokyp,1996, Vol.29. No. 1, pp. 1-219.
10. Stammberger H. et al: Endoscopic diagnosis and surgery ef the paranasal sinuses and antenor skull base. University Ear, Nose and Throat Hospital Craz, Australia, 1991, pp.53-59.~
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