NGOAI K H 0 A S 6 D A C BIET 1,2,3/2012
KET QUA PHAU THUAT NOI THAN KINH VII VA ONG TUYEN MANG TAI B A N G KY THUAT VI PHAU TAI BENH VIEN VIET DlifC
TOM TAT
Bat van de: Ton thu'dng than kinh VII va ong tuyen nu'dc bot mang tai (Stenon) thu'dng gap trong benh canh vet thu'dng ham mat phiic tap, tdn thu'dng da dang, hay phoi hdp vdi nhieu chan thu'dng khac. Neu khdng dydc chan doan va dieu tri Itjp thdi, ac ton thydng nay cd the de iai nhieu bien chii'ng va di chu'ng nang ne. Tai benh vien Viet Diic da trien khai ky thuat vi phau de xii tri cac ton thu'dng nay. Day ia mot trong nhii'ng phu'dng phap tdi u'u va bu'dc dau mang iai
\&t qua kha quan.
Bdi t&dng va phu'dng phap nghien c&u:
27 benh nhan dydc phau thuat ndi TK VII va dng Stenon tir 10/2004 den 12/2010. Tat ca cac benh nhan deu du'dc tham kham, danh gia day dii toan dien tru'dc mo, trong mo. Phau thuat va tiieo doi ket qua sau mo it nhat 12 thang.
Ket qua: Cd 24 nam, 3 nu', tuoi tCr 19 den 52. Ve nguyen nhan: 62.96% do TNGT va 37.14% do TNSH. Cd tdi 66.7% so BN cd gay xuWng mat va 59.3% cd chan thypng phdi hdp, tii CTSN, CT ngyc den gay nhieu xypng ... 19 BN CO VT mot hoac nhieu nhanh ciia TK VII va 12 8N cd VT ong Stenon, Tat ca cac BN du'dc mo sdm trong 48h dau trong dd 92.6% tru'dc 24h.
Theo doi sau md tii 12 den 66 thang. Ve ket qua 88% cac nhanh TK du'dc khau ndi vi phau phuc ti5l chiic nang gan nhu' ben lanh va 100% so dng Stenon khau ndi lien thi dau khdng cd bien chiing va di chiTng.
Kel luan: Cac ton thu'dng TK VII va ong Stenon neu phat hien va xii ly mudn cd the gay ra cac bien chu'ng, di chiing nang ne ve chiic nang, tham my. Ndi lai TK VII va dng tuyen bang Icy thuat vi phau cho phep phuc hoi cau true giai phau, chiic nang than kinh va dng tuyen mdt each toi u'u. Chan doan Y.is tri sdm cac ton
* Khoa Phdu thudt Tgo hinh - Hdm m^t, B?nh vi$n Vi?i Dire
Dao Van Giang*, Nguyin Hong Ha*
thu'dng TK va dng tuyen mang tai, su" phdi hop chat che nhieu chuyen l<hoa se mang iai ket qua tdt nhat
SUMMARY
Results of microsurgical treatment of injuries to the facial nerve and parotid duct at Viet Due Hospital Introduction: Failure to promptly diagnose and treat injuries to the facial nerve (FN) and parotid duct (PD) can result in significant functional and aesthetic sequelae. This paper reports the results of microsurgical treatment of such injuries at Viet Due Hospital.
Material and method: Twenty seven patients with complex injuries to the soft tissues (CIST) of the cheek area underwent microsurgical repair for damage to the FN and PD from 10/2004 to 12/2010. There was a minimum of 12 months follow up after surgery.
Results: The subjects comprised 24 male and 3 female patients between 19 and 62 years of age. Traffic accidents accounted for 59.3% of injuries with the remainder sustained during activities of daily life. Concurrent facial fractures were present in 66.7% of patients and 59.3%
had injuries in other parts of the body including the brain and chest. Damage to the FN and PD were present in 19 and 12 patients respectively.
All patients underwent microsurgical repair within 48 hours of the accident with 92.6% receiving treatment within 24 hours. Follow up ranged from 12 to 66 months after surgery. In patients treated for FN damage, 88% regained near complete function. In patients treated for PD damage, 100% regained full function and no complications were observed.
Conclusion: CIST of the cheek area along 385
DAI HOI HOI NGOAI KHOA VN LAN T H Q Xll VA HOI NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
with damage to FN and PD are often diagnosed and treated late so patients are usually left with severe physiological and aesthetic sequelae.
Microsurgery is the best method to achieve complete recovery of the FN and PD. The combination of high awareness and muitidiscipiinary collaboration when managing cheel< injuries optimises outcomes for FN and PD damage.
I. OAT V A N OE
Cac vet thuong (VT) ham mat ldn kem theo tdn thuong cac thanh phan quan trpng d sau nhu vd xuong, than kinh Vll (TK VII), dng tuyen mang tai (dng Stenon) dupe coi la vet thuong phan mem phiic tap (VTPMPT).
Trong nhieu trudng hop cac tdn thuong mach mau, TK, dng tuyen thudng bi bd sdt va chi dupe phat hien d giai doan mudn khi da gay ra cac bien chimg. [1-13]
De cd dupe su phuc hdi chiic nang tdi da cua than kinh va dng tuyen va tranh cac bien chung, dieu quan trpng la phai phat hien chan doan sdm de cd the sira chOa khau ndi tdn thuong ngay thi dau bang ky thuat vi phau.
[7.8,10]
Tai BV Viet Dire da trien khai phau thuat ndi iai than kinh Vll va dng Stenon bang ky thuat vi phau. Tac gia mudn thdng bao ket qua dieu trj dang tdn thuang nay trong thdi gian tir 2004 din 2010.
II. oo'l TUONG VA PHUONG PHAP 2.1. Doi tu'ffng: Cac BN duoc chan doan va phau thuat sdm cac tdn thuong toan bd hoac nhanh ciia than kinh Vll hoac dng Stenon, tir 10/2004 din 12/2010. BN dupe theo ddi ket qua sau md it nhat 12 thang.
Tat ca cac BN deu dupe tham kham toan dien lam cac xet nghiem can thiet trudc md... Ky thuat vi phau dupe ap dung cho tat ca cac phau thuat ndi TK va dng Stenon.
386
2.2. Phirong phap:
2.2.1 Tham khdm binh nhan Kham lam sang cac benh nhan cd vk thuong mat viing ma, xac dinh tdn thuong than kinh VII hoac neu benh nhan hdn me se dupe kiem tra danh gia trong md nham phat hien tdn thuang TK hoac dng tuyen Stenon.
2.2.2. Khau noi TK trurc tiep:
Khau ndi true tiep dudi kinh vi phlu nSu 2 dau TK sac gon, khdng dap nat mat doan, bang chi prolene 8/0, 9/0. Nhiing tdn thuang d phia trudc co can tuang img vdi dudng ke dpc di qua gdc mat ngoai khdng can khau n6i vi theo nhieu tac gia tir day di vao trung tam ciia mat, TK sau chan thuong tu tai tao gSn nhu mdt each tu nhien. [3, 5, 10]
2.2.3. Khau noi ong Stenon:
Sau khi d§ xac dinh dupe dau trung t3m va ngoai vi, 2 phan dau dng se dupe phau tich rdi khdi td chirc xung quanh sao cho khi rap ndi 2 dau khdng bi cang. Khau ndi dudi kinh phdng dai, tren kim ludn hoac catheter tTnh mach bang chi prolene 8/0, 9/0 miii rdi.
2.3. Theo d^i danh gia sau mo:
Tat ca BN dupe hen kham lai sau 3 tuan, 6 tuan, 3, 6 thang, 1 nam, 2 nam... theo doi su phuc hdi day TK VII, qua trinh lanh VT va cac bien chimg di chiing.
Ket qua ve dieu tri tdn thuang TK: dupe danh gia dua vao su phuc hdi chuc nang cua cac nhanh TK dupe khau ndi. Thuc hien qua tham kham, chup anh, quay phim va so sanh khudn mat d trang thai tmh, trang thai ddng, su ddng van. Danh gia trang thai tinh dira tren sir can ddi ciia: mat, ranh mui ma, goc mep.Trang thai ddng dua tren kha nang thuc hien cac dgng tac: nhan tran, nham mat, ha mieng, nhe rang va chum mdi. Cac chi so tren dupe danh gia theo thang didm chitc nang TK mat Sunnybrook. ( Sunnybrook Facial Grading System: SFGS). Cac xet
NGOAI KHOA SO D*iC BIET 1,2,3/2012
nghiem dien chdn ca va dien thta kinh cung duoc thiic hien dS theo dai qua trinh h6i phuc cua TK sau noi.
Ket qua ve dieu tri t6n thuang 6ng tuygn dupe danh gia la T6t: VT lijn thi diu, khong bien chiing. Kha : co hien tugng do nuoc bpt nhung liSn VT khong de lai di chiing. Kem:
do nuoc bpt keo dai, seo co keo, anh huong den tham my.
Chup 5ng tuyen mang tai (Sialographie):
Chup kiem tra sau mo xac dinh su thong suot ciia ong tuyen.
III. KET QUA VA BAN LUAN
Tit thang 10/2004-12/2010 chiing toi da
tien hanh phau thuat som ngay sau tai nan, phoi hop da chuyen khoa nSu cin cho 27 BN VTPMPT CO t5n thuong TK Vll va 6ng Stenon.
Bang sau cho thay tom tit s6 lieu cac nguyen nhan ca che tdn thuang, tu6i, thai gian tir khi bi tai nan den khi duac m6, cac loai ton thuang, phuang phap phau thuat, vo ha xucmg mat va cac chin thuang phoi hop khac neu co.
Tuoi cua cac BN tir 19 dSn 62 tudi, trung binh la 38. Co 24 nam, 3 nu. Cac ti le vl giai tinh, tuoi tac phii hop voi cac thong ke vS tinh hinh chjn thuang ham mat. [2]
TT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Tuoi
49 30 31 35 25 23 45 37 45 42 47 38 20 40 37 43 33 58 62 19 39 24
i T
38 28 7 23
7 10 15 14 6 17 15 23 7 18
2 8 20 13 5 10 16 15
Ton t h u o n g TK V I I , Stenon
StBT 7mT StCT
7m, MTT 7f,z,b, StABT, MTT
7f, MTT StBT
7m, MTT 7b,m, StAT, MTT
StCT StBT
7m, MTT 7, MTP
StAT, MTT
7rr
7z,b, MTP StBP
7f, MTT 7f,z,b, StBT
7f,z,b, MTT 7f,z,b, MTT 7m MTP
Not Vi PhSu
no!
ko noi ko noi 7z,qhep 7b, ko7f St
ko noi noi noi + qhep 7b, St
noi noi St
ko ko noi noi no!
no!
ko noi noi 7z.b, ko 7f
noi Noi
CTPH
SN12 XGl X G l , SN14
XGl
SNIO
CS, SN7 CTNK, SN6
CTSN14 XGl XGl
SN12
387
BAI Hpi HOI NGOAI KHOA VN LAN THll Xll VA HOI NGHI KHOA HOC NGOAI KHOA TOAN QUOC U N XIV
23 24 25 26 27
36 23 48 50 40
12 8 6 10 11
7 f,z,b StBP StBT
7f 7b
7 f,z,b MTT Noi Noi Noi Noi Noi
CTNK.SNIO
XGl
Chu thich: AT: thdi gian tir luc tai nan den khi phau thuat
TK: 7f: frontal: nhanh tran. z: zygoma: go ma, b: buccal; mieng, m: mandibular:
ham dudi.
St: Stenon, A, B, C phan doan giai phau.A: ton thuong sau co can, B: doan cac3n, C trudc CO cin. T: Trai, P: Phai. MT: Mang tai.
CTPH: Chan thuang phdi hop: CTSN, CTNK, XG: gay xuong chi Ve nguyen nhan: 62.96% do TNGT va
37.14% do TNSH chu yeu la do chem bang dao hoac kiem. Viec tang cudng dpi mu bao hi8m trong giao thdng cd the gdp phan lam giam ti le cac thuong tat nang ne nay.
Trong sd 27 BN cd 15 BN (55.56%) cd tdn thuong TK phdi hpp vdi dng Stenon hoac tuydn mang tai, 8 BN VT dng Stenon va chi cd 4 BN cd VT TK VII don thudn. Ta thdy rang cac tdn thuong TK VII va dng tuyen rat hay phdi hpp tren ciing mdt BN. Do dd can tham kham toan dien ti mi cac VTPMPT viing ma. Neu cd tdn thuong tuyen mang tai hoac dng thi can kiem tra ky de phat hien tdn thuong TK VII va ngupc lai.
Trong sd 19 BN cd VT TK, 13 BN dupe khau noi vi phau toan bo cac nhanh hoSc mot phan. 6 BN khdng dupe khau ndi bao gdm: 3 nhanh ham dudi, 2 nhanh tran, 1 TK VII dut d trong tuyen. Tat ca cac BN khdng ndi TK deu de lai di chiing liet d viing nhanh dd chi phdi. Khdng cd hien tuong ty tai lap phuc hdi lai chuc nang van ddng. Nguyen nhan khdng ndi chii yeu la do VT qua dap nat nen khdng tim thay 2 dau TK.
Trong 13 BN ndi TK vi phau, tdng sd 27 nhanh hi tdn thuong bao gdm 8 nhanh tran, 7 go ma, 9 mieng va 3 nhanh ham dudi. Cd 25 388
nhanh TK da dupe khau ndi, vdi ket qud 22 nhanh (88%) phuc hdi chirc nang van dgng gan nhu ben ddi dien, mac dii cd hien tuong ddng van muc dp nhe. Cac nhanh khdng noi la 3 nhanh tran, do khdng tim dupe. 2 nhanh khdng hdi phuc m^c du cd dupe ndi cung la 2 nhanh tran. Cd the do nhanh tran kich thudc nhd nhat trong sd cac nhanh, viec tim thay va khau ndi la rat khd khan nen ket qua dieu tri khdng cao.
Khi danh gia theo thang diem Sunnybrook (SFGS) ca 13 BN dupe khau ndi TK deu cd sd diem cao tir 79 den 98. Co 5 BN dupe ndi het toan bd cac nhanh TK bi dut dat di8m tir 96 dgn 98 tren 100 cua thang diem chung td sy phuc hdi la gan nhu binh thudng.
Trong nhdm 12 BN VT dng Stenon, 11 BN dupe khau ndi vi phlu ngay thi dau cimg vdi cac tdn thuong TK hay v5 xuong ho^c CTPH khac. ikt ca cac trudng hpp khau n6i vi phau deu cho ket qua tdt, VT lien seo thi dau, khdng cd hien tuong dd nude bpt sau md. Theo doi sau 12 thang, kdt hpp chup ong tuyen ngupc ddng cilng khdng thdy cd hi?n tuong tic hay bien chung gi khac.
Tdn thuong dng can dupe nghi ngd khi cd VT cit ngang qua dudtig chuin dich binh
NGOAI KHOA SO DAC B l i T 1,2,3/2012
tai - mdi tren hay khi cd bieu hien liet nhanh mieng TK VII vi hai thanh ph^n nay cd lien quan giai phau chat che. Ndu viec tim kiSm dau xa khd khan ta cd the ludn catheter nhd vao Id dng trong mieng di ngupc ddng ve phia tuyen de xac dinh dau xa. Mdt khi diu xa da tim thay viec tim dau gin hay d i u tmng tam trong cac VT s i c gpn la kha dg dang, bang each keo hai mep VT vao nhau va tim theo hudng dau dd da dua vao tir d i u xa.
Khi VT dap nat cd the tiem ngupc ddng xanh metylen de chan doan tdn thucmg dng tuyen.
[7,8,11-13]
Neu khdng dupe phat hien va khau ndi ngay thi dau thi cac VT dng tuyen nude bpt thudng gay cac bien chung. Trong y van chiing tdi nhan thay cd rat nhieu cac bao cao ve cac ve cac bien chimg mudn nhu sialocele, nang, ap xe, dd nude bpt ra da. Va cung cd rat nhieu phucmg phap dieu tri cac bien chung bang phau thuat: din luu vao mi?ng, that dau trung tam, cat bd tuyen, hay cic bien phap khdng phau thuat nhu: bang ep, nhin an, nudi dudng bang tTnh mach, thudc ire che tiet nude bot, Botox, [6-13]
Ve lam sang chiing tdi nhan thay kich thudc ciia cac nhanh TK Vll vao khoang 0,7 - 2mm. Cdn dudng kinh ngoai dng Stenon ciing chi khoang 2-3 mm nhung thyc chat dudng kinh trong nhd hon nhieu. Viec sir dung kinh phdng dai tang dp chinh xac, cac dung cu tinh te, kim chi nhd lam giam chan thirong da lam tang ti le tbanh cdng cua khau noi. Mdi day viec sir dung ghep tmh mach trong nhiing trudng hop mat doan dng Stenon hoac TK cho cac ket qua rat kha quan. Cho d i n nay, hau het cac tac gia deu dfing y r i n g khau ndi bang ky thuat vi phau thuat la phuong phap tdi uu. [3-8, 10]
Ve chan thuong phdi hpp: 59.3% cd CTPH. tir gay nhidu xucmg din CTSN, CT nguc...Theo kinh dien nhidu khi ngudi ta uu tien giai quylt cac CTPH trudc khi giai quylt din cac CTHM. Do dd khdng it VTPMPT chi dupe khau da djnh hudng, cim mau thi dau. Cac tdn thuong dng tuyin, TK thudng bi bd sdt hoac de lai sua chiia thi hai. Kit qua rat nhieu bien chung va di chung cung nhu keo dai thdi gian dieu tri va sd lan phiu thuat. Trong sd BN cua chung tdi mac dii qua nua cd CTPH nhung tat ca deu dupe md sdm trudc 48h tinh tir khi bi tai nan, trong do 92.6% dupe md trudc 24h. Su phdi hpp giira cac chuyen khoa giup cho kit qua phau thuat tdt nhat.
IV. KiT LUAN
Cac VTPMPT vimg ma thudng kem theo tdn thuong TK VII va dng Stenon . Viec bd sdt cac tdn thuong nay gay ra cac bien chung, di chung nang ne chiic nang, tham my.
Dua vao ket qua phiu thuat sdm cac tdn thuong tren cho 27 BN va tham khao y van, chung tdi nhan thiy: TK Vll va dng Stenon phuc hdi tdt sau khi ndi lai bang ky thuat vi phau.
Chan doan xir tri sdm cac tdn thuong TK va dng tuyen mang tai, sy canh giac trudc cac viet thuong ham mat vimg tuyen mang tai, su phdi hpp chat che nhieu chuyen khoa:
sp nao, ham mat tao hinh, gay me hdi sue,...
se mang lai ket qua phau thuat tdt nhat
TAI LIEU THAM K H A O
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DAI HOI HOI NGOAI KHOA VN LAN THlf Xll VA HOI NGHj KHOA HOC NGOAI KHOA TOAN QUOC L A N XIV
Nguyen Tai Son, Nghien ciru dieu tri Het day than kinh mat (VII) bang ghep ca thon tu do CO noi mach mdu vd thdn kinh. Luan an tiln sy y hoc - Vien nghien cu'u khoa hpc Y- Duac lam sang 108. 2003.
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Nahlieli, Traumatic injuries lo the parotid
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364-7.
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