c r e a t i n g a n e w e x t e r n a l auditory c a n a l . Objectives: To e x a m i n e the possibility a n d t h e o u t c o m e of the posterior transantro - attic a p p r o a c h for surgical correction of the atretic external auditory c a n a l as w e l l as to correct the m a l f o r m a t i o n of t h e ossicles c h a i n . Method: Prospective d e s c r i p t i v e study of 1 8 easees C.A.A p e r f o r m e d w i t h the posterior transmastoid approach for creation of a n e w e x t e r n a l ear canal.
Results: F o l l o w i n g t h e i n i t i a l surgery w i t h this t e c h n i q u e , good resul was o b t a i n e d in 14 eases. 4 eases w e r e unsuccessful w i t h stenosis of t h e n e w l y f o r m e d c a n a l , w i c h required revision surgery in one eases.
Conclusion: Transantro - attic posterior a p p r o a c h for surgery of C.A.A is a safe t e c h n i q u e w h i c h provides a large enough f i e l d for surgical c o r r e c t i o n of t h e atretic external auditory canal a n d of t h e osseular chain m a l f o r m a t i o n
Keywords: cogenital Aural Atresia, transantro - attic approach, ossiculoplasty
NGHIEN CL/U DAC DIEM LAM SANG CUA XEP N H T
Luong Hong Chau Benh vien Tai Mui Hong Trung dang
Xep nhl la hdu qud hay bien chdng cua viem tai d dich khdng ddde dieu tri, hay dieu tri that bai. Xep nhl nguy hiem vi nd tiem an nguy cd gdy viem tai cd bien chdng nguy hiem. Muc tieu: nghien cdu ddc diem lam sdng cua xep nhl. Dd'i tugng va phuang phap nghien cdu: md td, tien cdu, thdc hien tren 60 benh nhan.
Ke't qua: u tai: 86,7 %; nghe kem: 81,7 %; nghe vang trong tai: 53,3%; dau tai: 31,7%; khdng chay mu tai.
Khdm ndi soi Id phddng phdp chinh: xep nhl todn bo: 56,7 %; xep nhl khu tru hay tui co keo: 43,3%. Ket luan: trieu chdng chinh cua xep nhl la u tai, nghe kem. Noi soi cd gid tri de chan dodn va theo ddi xep nhl.
Tlf khoa: xep nhT, viem tai U djeh
I O A T V A N F)F '^^'- ^ ° ^^ '^'^^ ^^'^ ^ ^ P '^^'^ ^*^' '•'^ '^ ^''^ ' ^ ' ^ °''°
[ 3 ] . C d ehe h i n h t h a n h x e p n h l : m a n g n h l tao vdi Xep n h l ddoc d i n h nghTa la sd l d m cua m a n e ,^ ^i,- u . - . • - » - . . i , - „ . ,
•^ 5 ^ " ° 6 xdong t h a n h sau o n g tai m p t goe rpng hdn eae goc n h l vao trong h d m tai l a m g i i m k h o i n g t r d n g eua i u - A U- * - .J ,^- - . . . < , i ~ i - > p - „ „ u „ ° ° 6 5 k h a e d p h i a t r e n , d d d i va trdde. D i e u nay l a m eho h d m n h l [2, 3 ] . X e p n h l ed t h e x a y ra d toan b d u-> ' ^ u- » ji, - - - . / . < , . . - ,
•^ ' • p h a n sau eua m a n g nhi trd n e n y e u trdde sd tae m a n g nhT hoac d m d t p h i n cua m a n g n h l . N e u -,- ' - i , i u- -^ » -- * • -• k^
o 1^ 6 d p n g c u a a p ldc khi q u y e n t r o n g o n g tai ngoai. A p xep nhl ehi xay ra d mdt p h i n mane nhl thi dUde , , - . ^ - u u_ i u- . - u- - i <
^ / . K 5 ldc nay trd nen manh hdn khi sd can bang ap Ide goi la xep nhl khu trd hay edn goi la tui eo kec •-, u- . • - i u- -' i u- - J ... J
" '^ r 5- <=" gida hdm tai va khi quyen khong eon ddde duy tn [4]. Xep nhT khu tru thUdng x l y ra d mane chung -, . , --• i u-. - ' -• u- i:^-~
•^ 5 r 5 5 nUa do sd roi loan chdc nang eua voi nhi. Dong hode gde p h i n td sau tren eua mang eang do ,i^. , •- - i , , w^ t • - - u--
° '^ 5 ^ 5 " " thdi, sd giam ap Ide trong hom tai eung gay hieu nhdng tinh chat dae trdng eua eae vi tri nay. ,, .-• i i .. i ,_ i u- •-. .--^ . - - .-
" 6 ^ . ^ ' |">y. ^ ^ g i,^i l^g^ lij^ Iddng khi gida tang tren va tang Xep nhT tien trien qua nhieu giai doan va dUde dddi hdm tai qua eo nhT, thddng nhT. Hau qua la ghi nhan la hau q u i cua mdt viem tai tiet djeh vdi phan mang ehung vd gde p h i n td sau tren eua sU rdi loan ehdc nang cua vdi nhT tao ra dp ldc am mang eang la chju n h i l u tae dpng hdn e l . Khi ldp trong tai gida va hut mang nhT ve phia trong eua xd sdi eua mang nhT bj mdng va ma't d i , mang hdm tai. Theo Richard Maw A. va Rachel Bawen, eang eung trd nen ye'u nhd mang ehung va bj Idm
Viee phdt hien ra eac giai doan d i u cua xep nhl rd't khd khan vi theo Sade chi ed 1 0 - 20% ed nhdng bieu hien d tai [3]. Vi xep nhl cd the ket thuc b i n g hinh thanh cholesteatoma vdi ty le 30%
theo Magnan va Bremond [4]. Do vay viee chan dodn va theo ddi cde giai doan eua xep nhT la rat c i n thiet n h i m ngdn ngda ddde bien chdng cc the x l y ra.
Hien nay 6 nddc ta ehda ed edng trinh nao nghien edu d l y du ve xep nhT. Vi vay, ehung tdi tien hanh de tai vdi muc tieu:
Nghien cdu dae diem lam sang cua benh xep nhl.
II. DOI TUONG vA PHUONG
PHAPNGHIEN CUu
1. Doi tupng nghien ciifu
60 benh nhan ddde ehan doan la xep nhT ddde dieu trj tai Khoa Tai va Khoa Tai t h i n kinh, Benh vien Tai Mui Hpng Trung ddng, trong thdi gian td thdng 9/2005 den thdng 11/2009.
2. Tieu chuan Ida chpn benh nhan
- Ca ndng: u tai tieng u khdng lien tue, tieng tram. Nghe kem: ed the da xua't hien td nhieu thdng tham ehi n h i l u nam. Thinh ldc ngay eang gidm, mde dp nang hay nhe tu'/ thupc vao d6 eua xep nhl. Dau tai: ed the ed hoac khdng. Khi ndi cam gide tieng vang trong tai.
- Khdm tai: la phddng phap duy nha't ehan dodn xep nhl tren lam sang, gdm" eac bUdc td thdp den eao vd ddde ehan doan xep nhl.
3. Tieu chuan loai trii: benh nhan khdng du cdc tieu chuan tren. Benh nhan khdng ddng y tham gia nghien cdu.
4. Phuong phap nghien cii'u
- Phddng phdp nghien cdu md t l , tien edu.
- Phddng tien: khdm thdng thddng, kham b i n g otoscope ed speculum Siegle, bang dng npi
soi 0° vd b i n g kinh hien vi trong lue phau thuat n h i m phat hien mang nhT bi thay ddi v l mau s l e , dp rung dpng, sd dinh eua mang nhT vdo cae thdnh phan ben trong hdm tai.
Npi soi 0°giup ta ddnh gia chinh xae tinh trang eua mang nhT: mdng hdn so vdi binh thddng, ldm eham vao hay dinh vdo eae thdnh p h i n ben trong hdm tai, dd di dpng eua mdng nhT khi lam nghiem phdp Valsalva, d6i khi ed the tha'y ddde sd gian doan xddng eon (mang nhT dinh trdc tiep vao ehdm xddng ban dap md khdng thay eanh xudng xddng de). Dae biet vdi dng ndi soi 30° ed the eho phep ta quan sat ddde d l y vdi xep nhT khu tru phan mang ehung dd HI ma dddi phddng tien thdng thddng khong the quan sat ddde. Qua tham khdm lam sang xae djnh mdc dp eua xep nhT [6].
- Tieu chuan phan dp xep nhT: theo Tos vd Poulsen da nghien edu, phdn ehia xep nhT cue bp, ehi d mang ehung thanh 4 dp:
4- Dd 1: tdi eo keo nhd d thddng nhT, day tui ehda dinh vao xdong bua.
-I- Dp II: tui eo keo ed day tui tie'p xue vdi ed xddng bua .
-t- Dd 111: tui eo keo an sau vao phia sau tddng thddng nhT, b i t d i u ed tdn thdong xdong.
-^• Dp IV: tdi eo keo an sau vao phia sau tUdng thddng nhi an mdn tddng thddng nhT va tdn thddng xddng bda ed the e l xddng de. Loai nay la cholesteatoma thddng nhT.
Neu xep nhT x l y ra d toan bp mang nhT. Theo phdn loai cua Sade j . nam 1976, cd 4 mde dd eua xep nhl toan bp:
-I- Dp I: mang nhT bj ldm vao trong gidng nhd ta ep mdng nhT b i n g soi tai bdm nen eua Siegle.
Gd vanh khdng Id rd. Ci dp nay khdng ed trieu chdng CO nang va khdng can d i l u trj.
4- Dp II: mang nhT ldm sau eham hoac dinh
ednh xudng xddng de, ed the an ddt ngdnh nay. 6 mde dp eo ldm nay ldp sdi mang nhi mat di. Ap ldc dm trong hdm nhl cd the la ngudn gde tieu huy mo sdi eua mdng nhT va chudi xddng ccn.
-1- Dp III: mdng nhT chain nhdng ehda dinh vao U nhd, ed t h i tdeh mdng nhT ra khdi u nhd b i n g speculum Siegle. Ldp sdi eua mang nhT khong edn nda. Dat dng thdng khi ed the d-da p h i n dinh vao u nhd trd v l vj tri binh thddng.
-I- Dp IV: mang nhT dinh vao u nhd, mang nhT chui sau vao cac ngdc ngach trong hdm nhT:
ngach mat, ngach nhT va ha nhT va hinh thanh viem tai dinh (I'otite adhesive). Cd the quan sat ddde ldp sdng hod bong ra d tui eo keo hode td ehdc cholesteatoma. Giai doan nay nha't thie't p h l i ddde phau t h u | t . Cung vdi hien tddng an ldm vao hdm tai, mang nhT bong vay ngay eang tang the hien viem ldp bieu md vd hinh thanh cholesteatoma tui. Cholesteatoma phd huy eae vach ngan gida eae ngan co Idm eua mang nhf, phd huy eanh xudng xddng de, ehdm va gpng xUOng ban dap. Sd phd buy nay manh me nha't khi ldp Sdi mang nhT mat di va hien tddng viem tren b l mat mang nhT.
III. KETQUA
1. Dae diem chung
- Tudi va gidi tinh: Tudi trung b i n h mac benh 30,1 ± 14,6 t u d i . Nam: 5 8 % va nd: 42%.
-. Phan b d t h e o vdng dja dd: benh nhan nong thdn ehiem ty le 65%, benh nhan d thdnh thj chiem iy le 35%.
2. Trieu chdng lam sang
2.1. Trieu chdng ca nang: tren cung 1 benh nhan cd the gap 2 hoac nhieu trieu chdng
Bang 1. Trieu chdng ca nang Tong sd
u tai Nghe kem Dau tai
Nghe vang trong Cha'y mu tai
tai
N = 60 52 49 19 32 0
(%) (86,7) (81,7) (31,7) (53,3) (0)
Nhan xet: trieu chdng nghe kem va u tai la 2 trieu chdng thddng gap nhd't chiem ty le 81,7% vd 56,7%.
2.2. Trieu chdng thUc the d mang nhT if - T'y- le xep nhT todn bd ehiem 56,7% trong nhdm nghien edu eua chdng tdi. Trong dd, gap ehu yeu
la dp III vd IV vdi ty le la 41,2 va 4 4 , 1 % .
- Ty le xep nhl khu trd ehiem 4 3 , 3 % , trong dd, dp 1 vd III ehiem ty le 7,7 va 11,5% , dp 11 va IV vdi ty le 46,2 va 34,6%.
2.3 . Ddi chieu giai doan xep nhi vdi trieu chdng u tai, nghe kem
Bang 2. Ddi chieu giai doan xep nhl vdi trieu chdng u tai va nghe kem Trieu
Xep nhT Dp 1 Dp II Dp III Dd IV
ehu'ng U tai
n = 52 4 12 15 21
(%)
(100,0) (80,0) (88,2) (87,5)
Nghe n = 49
0 8 17 24
kem (%)
(0) (53,3) (100,0) (100,0)
U tai n =
i -1- Nghe kem
= 41 0 5 15 21
(%)
(0) (33,3) (88,2) (87,5)
Nhan xet:
- Xep nhl do I cd ty le u tai Id 100%o, khdng cd nghe kem.
- Xep nhl do tl cd ty le u tai la 80%, nghe kem la 53,3%.
- Xep nhl dep III va IV, nghe kem chie'm ty le 100%. Ty le sd benh nhdn vda cd u tai vda cd nghe kem d do III vd IV Id 88,2 va 87,5% cao han d do I va II Id 0% vd 33,3%. Sd khac biet nay cd y nghia thd'ng ke vdi p < 0,05.
IV. BAN LUAN
1. Tud'i va gidi: tud'i trung b i n h mac b e n h 30,1 ± 1 4,6 t u d i , ke't q u i eua ehung tdi phu hdp vdi nghien cdu eua cdc tde g i i khac. Theo tde g i i Sade va Bereo la 30,7 tudi [3]. Ty le mac b e n h d nam (58%) va nd (42%) la gan tddng ddong, sd khae b i e t k h c n g ed y nghTa.
2. Phan b d theo viing dja dU: ehung tdi nhan tha'y nhdm benh nhan sdng d ndng thdn ( 65%) e h i l m ty le eao hdn nhdm benh nhan sdng d thanh thj (35%), d i l u nay p h i n anh thdc trang viee cham sdc va dieu trj benh d ndng thdn cdn ehda ddde tdt. Benh nhan thi ehu quan, khdng td nhan biet v l benh, bde sy tuye'n dddi thi ehda ddoc cap nhat kie'n thdc, nen d i l u trj benh viem tai d djeh ehda triet de, de lai hau q u i ty le xep nhT cao.
3. T r i f u chiifng lam sang
3.1. Trieu chdng ca nang: tren eung 1 benh nhan ed the gap 2 hdae nhieu trieu chdng. Trieu chdng nghe kem va u tai la 2 trieu chdng-thddng gap nha't ehiem t'y; le 8 1 , 7 % va 86,7%; u tai tdng ddt, tieng t r i m va la mdt trong nhdng trieu chdng cd nang gay khd chju eho benh nhan. C i m giac nghe vang trong tai ehiem ty le 53,3 %; dau tai it gap hdn vdi ly le 31,7% va khdng phai la con dau nhdc thdc sd, ma ehi la e l m giac hdi nhdc hdae khd chju trong tai, khdng cd benh nhan nao ed
trieu chdng chay mu tai. Nhan xet nay eua ehung tdi phu hdp vdi ket qua nghien eCifu eua Le Hdng Anh [11.
3.2. Trieu chdng thUc the d mang nhJ Ty le xep nhT toan bp chiem 55,7% trong mdu nghien edu eua ehung tdi. Trong dd, gap ehu ye'u la dd 111 va IV vdi ty le la 41,2 va 4 4 , 1 % eao hon b i n dp I va II vdi ty le la 5,9 va 8,8%. Nhd vay, benh nhan den kham ehu yeu d giai doan mudn, giai doan da b i t d i u I n h hddng nhieu de'n sdc nghe va ed the hlnh thanh cholesteatoma. Ket q u i eua ehung toi phu hdp vdi k i t q u i eua Sade vd Bereo[3]: dp 111 va IV ed ty le la 37,5% va 28%;
d6 1 va 11 c d t y le 1 5 va 19,5% [3, 6].
Ty le xep nhl khu tru ehiem 43,3% trong nhdm nghien cdu eua ehung tdi. Trong dd, dp I va III ehiem ty le 7,7 va 11,5% tha'p hdn d6 N va IV vdi ty le 46,2 va 34,6%. K i t q u i eua ehung t6i tha'p hdn so vdi ket qua nghien edu eua Le Hdng Anh [1] vdi t'y- le: dp 11 va IV vdi ty le 2 8 % va . 6 0 % , d6 111 vdi ty le 12%, tde g i i khdng gap tui eo keo dp I .
3.3. Ddi chieu giai doan xep nhl vdi trieu chdng u tai va nghe kem
- Xep nhT dd 1 ed ty le u tai la 100%, khdng cd nghe kem, do mang nhT ehda bi dinh nhieu va xddng eon ehda h i bj I n h hddng van d i m b i o dd rung dpng va dan t r u y i n binh thddng.
- Xep nhT d6 H ed ty le u tai la 8 0 % , nghe kem la 53,3%. Nhd vay, d mde dd nay tdi eo keo hac xep nhT toan bd nhieu hdn da lam ed djnh xddng eon hoac tham ehi lam gian doan xddng ccn, nen nghe kem n h i l u hdn.
- Xep nhT dp III va IV, nghe kem chiem ty le 100%. T'/ le sd benh nhan vda ed u tai vda cd nghe kem d dd 111 va IV la 88,2 va 87,5% cao hdn d dd 1 va II la 0% va 33,3%. Sd khae biet nay ed y nghTa thdng ke vdi p < 0,05. Nhd vay xep nhT mde dp III va IV da 100% I n h hddng sd rung
ddng va d i n truyen am eua he thdng tai gida gay nghe kem d n h i l u mdc dp khae nhau, neu tdn thddng xddng eon thi nghe kem eang nang hdn.
V. KET LUAN
Td ke't q u i nghien edu cho phep rut ra nhdng ke't l u | n sau v l dae diem lam sang eua xep nhT : Giai doan sdm eua xep nhT, u tai la trieu chdng xuat hien sdm nhat khien benh nhan de'n kham.
Nghe kem la trieu chdng thd hai sau u tai, xua't hien d giai doan III va IV eua xep nhT. Benh nhan khdng dau tai, khong bj chay mu tai. K h i m n6i soi eho phep danh gia mu'c dd va theo ddi tien trien eua xep nhT: xep nhT khu tru hay xep nhT toan bp, ed bi tdn thddng xddng eon kem theo hay khdng. Xep nhT mde dd HI va IV ed tdn thddng xddng eon thi sdc nghe eang g i i m va tien Iddng eang nang, e i n p h l i phau t h u | t sdm. X?p nhT khdng ddde dieu trj se gay ra viem tai ed cholesteatoma la viem tai nguy hiem, vi luon tiem an nguy co gay bie'n chdng den sinh menh.
T A I
LIEU
T H A M K H A O1. Le Hdng Anh (2003), Nghien edu hinh thai lam sang va danh gia ke't q u i dieu tri viem thUdng nhT, Luan van tdt nghiep Bae sy Ndi tru, TrUdng Dai hpe Y Ha N p i .
2. Bluestone & Klein ( 2001). Otitis Media in Infants and Children. W.B. Saunders Company.
3. Sade J., Berco E. (1976), "Atelectasis and secretory otitis media", A n n . Otol. Rhinol.
Laryngol, vol 85, pp. 66 - 72.
4. Sade ). (1980), "Retraction pockets and attic cholesteatoma". Acta Otorhinolaryngol Belg; 34 (1): pp. 6 2 - 8 4 .
5. Sade J., Avraham S., Brown M. (1981),
"Atelectasis, retraction pockets and cholesteatoma".
Acta Otolaryngol, vol 92: pp. 501 - 51 2.
6. Tos M , Pousen G (1980), "Attic retractions following seereetory otitis. Acta Otolaryngol, Vol 89, Number 5, pp 479 - 486.
Summary
RESEARCH ON SIGNS AND SYiVIPTOiVIS OF ATELECTASIS
Atelectasis is a sequela or complication of otitis media with effusion. Atelectasis is dangerous because it can cause severe complications. Objective: to study signs and symptoms of atelectasis. Methods:
Description and prospective research was done on 60 patients w i t h atelectasis. Results: tinnitus: 86.7%, hearing loss: 81.7%, otalgia: 31.7%, no otorrhea. Endoscopy: total atelectasis: 56.7 %, partial atelectasis and retraction porket: 43.3 %. Conclusion: prevalent symptoms of atelectasis are tinnitus, hearing loss.
Endoscopy is usefull to diagnosis and follow up atelectasis.
Keywords: atelectasis, otitis media with effusion
