NGHIEN CL/U DAC DIEM LAM SANG, CAN LAM SANG VA DANH GIA KET QUA DIEU TRI THONG D O N G MACH CANH XOANG HANG SAU CHAN THUONG SO MAT BANG CAN THIEP NOI MACH TAI BENH
VIEN TAI MUI HONG TRUNG UONG
Quach Thi C a n \ Pham Minh Thdng^
. • 'Sen/i vien Tai Miit Elgng Trung (Jang
~Khoa chan doin hinh inh benh vien Bach Mai
Thdng ddng mach cinh xoang hang sau chan thuang sg mat li mdt bie'n cht'fng mach miu thtfdng gap va rat nguy hiem. Ellen nay/ lrong Ilnh vtfc chuyen khoa Tai Miii Hgng chtfa cd nhieu nghien cifu md ti cic dac diem lam sang, can lim sing vi dinh gii ket qua dieu trj thdng dgng mach cinh xoang hang sau chin thuang. Muc tieu: nghien cifu dac diem lim sing, can lim sing va dinh gii kdt qui dieu tri thdng dgng mach xoang hang sau chifn thuang sg mat. Boi tugng va pbuang phap nghien cdu: hoi cifu 13 trUdng hop benh nhin duac chan doan vi dieu tri thdng dgng mach cinh xoang hang sau cha'n thtfang sg mat tai khoa cap cdu benh vien Tai MOI Hgng Trung tfdng td 6/2003 den 6/2009. Ket qua: tai ci benh nhin trong nhom nghien cdu deu cd chay miu d khe budm sang khi tham kham bang ndi soi qua dudng mill vi cd dudng vd d tang giifa nen sg tren phim chup dt Idp vl tinh mui xoang. Cd 1 tnfdng hgp benh nhan td vong trang khi can thiep ngi mach, 2 benh nhin mii thi luc sau khi can thiep, 11 benh nhin cdn lai cd kdt qua tdt sau khi can thiep. Ket luan: Benh nhan cd td'n thttang thdng dgng mach cinh xoang hang sau chan thuang thudng den vien vi ly do chay miu mui mudn, viec tidn hinh chup mach de cd chan doin xic djnh va can thiep ndi mach ngay sau dd li cin thie't vi dem lai kdt qui kha quan.
Tff khoa: thong dong mach canh xoang hang, chay mau mui sau chan thffdng
L D A T V A N D E
Tfl nhflng nam d i u cua t h d k'/ XXI sfl gia tang sd lfldng cua cac tai nan giao thdng lam tang ty le chan thfldng sp mat tren dja ban c l nfldc ta. Chay mau mui sau c h i n thflpng la mdt b i i n chflng r i t nang n l ma khoa c i p cflu benh vien Tai Mui Flpng Trung flpng thfldng tiep nhan tfl c l e chuyen khoa khac nhfl: ngoai than kinh, mat, rang ham mat.... Trong mpt vai nam trd lai day nhd sfl tien bd eua chuyen nganh c h i n d o l n hinh anh dac biet la chup c i t Idp vi tfnh (CT scan) cd tiem thud'c can quang va chup mach sd x o i n i n (Digital Subtraction Angiography) ma c l e thay thud'c chuyen khoa Tai Mui Hpng (TMH) chung tdi da phd'i hdp, c h i n doan x l c dinh v l d i i u trj dflpc n h i i u trfldng hpp tdn thfldng ddng mach canh (DMC) sau c h i n thfldng. Thdng DMC xdang hang
la mdt bien chflng thfldng gap va cd lien quan mat t h i i t tdi nhdm benh nhan (BN) cd tdn thifdng vd nen sp sau c h i n thfldng. Trdng nghien cflu nay chung tdi tien hanh hdi cflu md t l tflng ca thdng DMC xoang hang da dflpc chan d o l n x l c djnh nhd chup mach vdi muc tigu:
/ . A4d ta dac diem lam sang va can lam sang cua thong dgng mach canh xoang hang sau chan thuang sg mat.
2. Banb gia ket qua dieu tri tbong dgng mach canh xoang bang sau chan thuang sg mat bang can thiep ngi macb.
II. DOI TUONG vA PHUONG
P H A PNGHIEN CL/U
1. Dd'i tffdng nghign cffu
Gdm 1 3 BN c h l y mau mui sau c h i n thfldng sp
mat dflpc c h i n d o l n xac djnh cd thdng DMC xoang hang bang ky thuat chup mach sd x o i nen va dupe dieu tr] can thiep ndi mach ngay sau dd.
2. Phffdng phap nghien cffu Hoi cflu md t l tflng ca.
Thdi gian nghien cflu: 6/2003 den 6/2009.
Dia d i i m nghien cflu: khoa c i p cflu benh vien Tai Mui Hpng trung fldng va khoa C h i n doan hinh I n h benh vien Bach Mai.
III. KETQUA .
1. Dich te hoc lam sang
Tudi va gidi: Trong sd 1 3 BN cd 1 2 BN nam va 1 BN nfl vdi tudi t h i p n h i t I I 23 tudi cao n h i t la 40 tudi. D i n g lull y la cd 10/1 3 BN dfldi 25 tudi.
Nguygn nhan gay cha'n thfldng: C l 1 3 BN d i u bi c h i n thfldng so mat dn tai nan giao thdng.
Thdi gian xuat hien chay mau mui sau cha'n thffdng: la khoang thdi gian tinh tfl khi benh nhan bj c h i n thfldng cho tdi khi benh nhan nhap vien vl ly do c h l y m l u mui. Cd 5 benh nhan nhap vien vdi trieu chflng chay m l u mui sau c h i n thfldng vdi thdi gian dfldi 1 t h i n g , cdn tren 1
2.2.2. Trieu ehifng thj giic
thing cd 8 benh nhan. Ihdi gian x u i t hien c h l y m l u mui sau c h i n thfldng t h i p n h i t la sau 7 ngay, cac n h i t I I sau 4 thang.
2. Trieu chffng lam sang 2.1. Trieu chdng ca nang
Bang 1. Trieu chdng ca nang Trieu chflng cd nang
Dau d i u Chay mau mui G i l m hdac m i t thj Iflc
Nghe t h i y tieng thdi troi era tai ( u tai)
Tan suat 13/13 13/13 4/13 4/13 Nhan xet: chiy miu mui vi dau diu li 2 trieu ehifng trung thinh nha't ciia nhdm BN nghien ct'fu.
2.2 Trieu chdng tbUc the
2.2.1.Trieu chdng thtfc the qua tbim khim ngi sol:
T i t c l 13 BN trong nhdm nghien cflu deu cd c h l y mau tfl khe bfldm sang dfldi tham kham bang ndi soi qua dfldng m u i . Khdng cd trfldng hpp nao c h l y m l u tfl khe gifla hoac d c l e vj trf khac cua hoc mui.
Trieu chffng thj giac T i n suit
Bang 2.
M a t thj Iffc 1 ben 2 bgn
2/1 3 2/1 3
Trieu chdng thi giac Giam thj Iffc 1 bgn 2 bgn
2/1 3 0/1 3
Ldi m i t 4/13
Phu kg't mac 4/1*3
... • - • •! •'•
Sup mi 1/13
Nhan xet: cd 4 tnfdng hgp cd trieu ehdng ve thj giac trong dd cd 2 trtfdng hgp mat thj ldc hoin toan mgt ben mat pbii vi 2 trtfdng bgp mit cdn phin biet dugc sing tdi d mit phai.
2.2.3. Cac trieu chdng khic
Cd benh nhan da dflpc p h i u thuat c h i n thfldng sp nad trfldc khi den vidn vdi di chflng la y i u nfla ngfldi ben phai.
2.3. Trieu chdng can lam sang / 2.3.1 Mifc do thieu miu:
Biing 3. Miic dg tbieu mau
Mffc do thig'u mau Khdng t h i i u m l u Nhe
vera Nang
Sdca 2 2 6 3
(%) (15,4) (15,4) (46,1) (23,1)
Nhin xet: da sd BN cd bieu hien thieu miu vifa va nang qua xet nghiem cdng thifc miu.
2.3.2. Hinh inh tdn thtfang nen sg tren phim CT scan:
Bang 4. Hinb anh tdn thuang nen sg tren phim CT scan
Vj trf tdn thflOng tai n i n sp Tang gifla Tang trfldc va t i n g gifla Tang sau va tang gifla
Tan suit 13/13 8/13 1/13
Nhin xet: tren phim CT scan, 100%o BN cd dtfdng vd a ting gida nen sg vdi cic die trUng sau vd cac thanh ctia xoang bUdm: 13/13 BN, vd cinh nhd xtfOng btfdm: 7/13 BN,vd dinh xtfong di: 8/13 BN
dai da sd la BN nam (1 2/1 3 BN), chl cd 1 BN nfl.
2.3.3. Vj tri tdn thttang DMC tren phim chup mach sd xoi nen:
C l 13 benh nhan deu du'dc chup mach va phat hien tdn thflOng thdng DMC - xoang hang sau c h i n thfldng sp mat.
3. Ket qua dieu trj
T i t c l 13 BN d i u dflpc can thiep npi mach sau khi cd c h i n doan xac djnh thdng DMC xoang hang nhd vao chup he mach c i n h xoa n i n . Cd 4 BN dfldc nut Id thdng bang coil, 5 BN dflpc nut Id thdng b l n g bdng. 1 BN tfl vong do vd ddng mach trong khi can thiep mach. Trong sd 12 BN cdn lai chung tdi theo ddi cd 1 trfldng hdp thdng DMC xoang hang tai phat va 1 trfldng hdp m i t thj Iflc mpt ben sau khi nut maeh.
IV. BAN LUAN
Ton thflpng thdng DMC - xdang hang la mdt b i i n chflng thfldng gap [ 1 , 2] va nguy hiem sau c h i n thfldng sp mat. Trong nghien cflu cua chung tdi, e l 1 3 BN d i u cd nguyen nhan c h i n thflpng sp mat la hau qua cua tai nan giao thdng vdi dp tudi cdn rat tre, 10/13 BN dfldi 25 tudi. Trong dd tuyet
Trong nghien cflu nay toan bd 1 3 BN deu nhap vien vdi ly do c h l y mau mui. Tinh c h i t cua chly m l u mui la x l y ra dot ngdt, c h l y r i t dfl dpi, sau dd tfl e l m va t i i p h l t , trieu chflng nay cung dfldc md ta tfldng tfl d c i c nghien cflu k h l c 13,4]. Phln Idn BN (9/13 ca) cd tlnh trang c h l y m l u vdi sd Ifldng nhieu gay ra hdi chflng thieu mau vfla va nang khi nhap vien. C h l y m l u mui cung chfnh la ly do nhap vien cua BN. Vdi nhflng BN chay m l u mui vdi tfnh c h i t nhfl tren, chung tdi cho tie'n hanh chup CT scan mui xoang va n i n sp de d i n h g i l cd tdn thfldng d nen sp hay khdng, dac biet I I ten thfldng d vung xoang bfldm. Khi vd tui gia phinh tao ddng c h l y manh vao xoang hang hoac vao xoang bfldm gay chay m l u mui tflng dot va tai p h l t . Mflc dp c h l y m l u nang hay nhe tuy thupc vao tflng BN vdi c l e t h i c h i n thflOng nang nhe khac nhau va c l e mflc dd ten thfldng mach mau khac nhau.
Trong nghien cflu cua chflng tdi, toan bd 13 BN nghien cflu d i u cd hinh I n h vd t i n g gifla nen sp tren hinh I n h CT scan mui xoang. Qua khao s i t hinh I n h CT scan mui xoang d 2 tfl the dflng
ngang va ngang cho t h i y 100% BN cd hinh I n h vd phflc tap cac tang cua sp mat. D i n g lflu y la tat c l nhflng benh nhan BN nay d i u cd hinh I n h tu m l u trcng xoang bfldm mdt ben hoac hai ben di kem vdi hinh I n h gay vd d tran, than hdac d t h i n h sau xcang bfldm, cung cc t h i cd hinh I n h vd c i n h nhd xfldng bfldm hoac dfldng vd d dinh xfldng d l . V l phflpng dien g i i i phau hpc xoang hang gdm 1 ddi d hai ben cua than xflang bfldm va d phfa trfldc cua hd' nao gifla, D M C trong bat ngudn tfl DMC chung d tam g i l c cd trfldc tfl dd di len tren vao hop sp qua d'ng DMC trong va Id r i c h trfldc. Tren dfldng di DMC trong di qua xflang d l va t h o l t ra d dinh xfldng d l va vao xoang tTnh mach (TM) hang . DMC trong t h o l t ra khdi xoang TM hang d mdm yen trfldc d tren c i n h nhd xfldng bfldm rdi chia ra c i c n h l n h tan. Nhfl vay Id r i c h trfldc va d'ng DMC I I nhflng md'c quan trpng cua hd nao gifla. Ld r i c h trfldc nam d gifla dinh xfldng d l , than xfldng bfldm v l p h l n n i n cua xfldng c h i m . C I c dfldng vd cua nen sp d t i n g gifla cd lien quan chat che tdi p h l n d l cua xfldng t h i i dfldng [4,5,6]. Trong nghien cflu nay cd 8/13 BN cd hinh I n h vd d dinh cua xfldng da. Dfldng vd eua t i n g gifla n i n sp chl ra nguy cd cao cho tdn thfldng D M . Nhfl vay c l n p h i i n h i n manh rang c h i n thfldng sp mat gay vd n i n sp d tang gifla ce nguy cd t i i m i n gay rach thanh DMC trong dan tdi thdng DMC xoang hang hoac c h l y m l u mui do vd cac thanh cua xoang bfldm. •
BN thfldng cd cac bieu hien lam sang nhfl chay mau mui, Idi m i t , phu k i t mac, g i l m thj Iflc... ma khdng tim t h i y tdn thfldng sp nad nao khlc sau c h i n thfldng thi can phai dflpc chup CT scan. N i u tren phim CT scan cd cac tdn thfldng nhfl da md t l d tren thi dd la cac d i u hieu r i t quan trpng gdi y cho c l e thay thudc lam sang nghT d i n thdng DMC xoang hang [4,5] .Dong thdi viec chup mach se dem tdi c h i n doan x l c djnh vj trf va kfch thfldc cua Id thdng [ 1 , 2, 4]. Quy trinh
can thiep ndi mach de nut tui phinh b l n g c i c loai vat lieu khac nhau dflpc tie'n hanh ngay sau khi BN cd c h i n d o l n xac dinh. T i t c l BN trong nghien cflu nay d i u diipc chup mach va can thiep tai Khoa c h i n d o l n hinh I n h - BV Bach Mai. Cac bien chflng ve mat chflc nang x l y ra phu thudc vao thdi gian bj c h i n thfldng d i n khi nut mach va kfch thfldc cua Id thdng. Cd 2 BN bj m i t thj Iflc hoan toan trfldc khi nut mach va dflpc nhap vien mudn sau c h i n thflpng 4 thang. Da so' BN dflpc nhap vien sau c h i n thfldng tren 1 t h i n g 8/13 BN.
Trong sd nhflng BN nay cd 2 BN m i t thj Iflc hoan tdan. Cdn d nhdm BN nhap vien trfldc 1 t h i n g sau c h i n thflpng, trieu chflng chfnh la c h l y mau mui va sau khi nut mach ty le hdi phuc chflc nang hoan toan la 100%. Nhfl vay c l e b i i n chflng m i t chflc nang ( m i t thj Iflc) x l y ra tren nhflng BN d i n vien mudn. Khi cd ludng thdng gifla ddng mach va tTnh mach dan tdi lam giam lflu lflpng mau tdi D M vdng mac kem theo I I hien tflpng tang I p Iflc trong tTnh mach mat dan tdi g i l m tfldi mau vdng mac, nhflng BN nhap vien mudn, tinh trang t h i i u m l u va loan dfldng d vdng mac cung se keo d i i dan tdi g i l m hoac m i t thj Iflc. Viec d i i u trj bao tdn chflc nang thj g i l c , ngan chan tinh trang vd va chay m l u d D M hoac c i c b i i n chflng thil^u mau nao dflpc t i i n hanh bang viec nut Id thdng vdi vat lieu la coil hoac bdng [ 1 , 2, 3]. Qua hdi cflu chung tdi ghi nhan dfldc 1 trudng hop BN tfl vong ngay trong khi can thiep nut mach vl m i t mau c i p do vd ddng mach. 2 BN cd t i i p h l t sau nut mach d i u dflpc bang coil do coil la vat lieu cd the phat t i n trong Idng mach va g l y ra t i i p h l t ludng thdng.
C I c BN cdn lai deu bao tdn dfldc chflc nang va sinh boat binh thfldng sau khi can thiep.
V . K E T L U A N
Thdng DMC xoang hang la mdt b i i n chflng thfldng gap sau c h i n thflpng sp mat. Tu'/ thudc vao hfldng va vj trf cua tdn thflong ma BN cd c i c trieu chflng khac nhau nhfl c h l y mau mui, c l e
trieu chflng v l thi g i l c nhfl: Idi mat phu k i t mac, g i l m hoac mat thj Iflc. Chup CT scan mui xoang v l n i n sp chl ra c i c dfldng vd d tang gifla n i n sp r i t cd gia trj d l c i c t h l y thud'c l l m s i n g nghT tdi thdng DMC xoang hang sau c h i n thfldng. Chup mach va can thiep ndi mach nut Id thdng la mpt phfldng phap cd gia trj v l an toan trong chan d o l n va d i i u trj benh.
T A I LIEU THAM KHAO
1. Bui Van Giang, Pham Minh Thong, Pham Hong Dffc, Dff Dffc Chien, H. Deramond (2008),
" G i l trj cua phflpng p b l p nut mach trong d i i u trj thdng ddng mach c i n h xoang hang". Tap chf Y hpc Viet Nam, tap 265, sd 11, tr 73 - 79.
2. Pham Minh Thdng, Bui Van Giang (2003),
" D i i u trj thdng ddng mach canh xoang hang trflc t i i p bang phflong phap can thiep ndi m a c h " . Tap chf Y hpc thflc hanh, tap 459, sd 9, tr 54 - 56.
3. FabianT (1999). Posttraumatic carotid cavernous fistula: frequency analysis of the signs, symptoms and disability outcomes after angiographic embolization. / trauma; 1 8 : 4 1 - 45.
4. Fattahi TT (2003). Traumatic carotid cavernous fistula: pathophysiology and treatment. ) craniofac Sur; 1 4: 240 - 246.
5. Samii M (2002). Skull base trauma: diagnosis and management. Neuro Res ; 24: 147 - 156.
6. Wu Z (1999). Endovascular embolization of traumatic carotid cavernous fistulas. Chin Med J (Engl); 1 1 2 : 4 3 3 - 4 3 7 .
Summary
STUDY CLINICAL, PARACLINICAL FEATURES AND TREATMENT OF PATIENTS WITH TRAUMATIC CAROTID CAVERNOUS FISTULA AFTER CRANIOFACIAL TRAUMA
IN NATIONAL EAR NOSE THROAT HOSPITAL
Background: Traumatic carotid cavernous fistula (TCCF) is a rare and dangerous vascular complication of craniofacial trauma. At this time, otolaryngologists don't have any study about TCCF due to craniofacial trauma. Method: We performed a restospective analysis 13 of inpatients with TCCF after craniofacial trauma in intensive care unit of National Ear Nose Throat hospital bettwen 6/2003 and 6/2009. Results:
All of patients (13 patients) with TCCF have bleeding from sphenoid - eithmoidal recess under sinonasal endoscopy and have middle fossa fractures on CT scan of basilar skull. 1 patient died when performed embolization, 1 patient lost vision post embolization done, 11 patients have good result after treatment.
Conclusion: Patients with TCCF hospitalized due to late epistaxis after trauma, perform angiography to confirm diagnosis and managemnet by endovasular intervention are necessary and make a good result for patients.
Keywords: Traumatic carotid cavernous fistula, epistaxis post trauma
