I NGHIEN CLAJ KHOA HOC
NHAN XET BAN OAU VE PHAU THUAT DIEU TRI
• • •
VQ SAN HOC MAT
Nguyin Dire Tlidnh', Nguyen Quoc Anh', Nguyen Minh Anh', Bui Dao Qudn', Phgm Trgng Van", Vo Vdn Duac",
TOM TAT
\ 'a sdn hdc mdt fl'SHM) dang ti-a thdnh mpt vdn de trong xu tri didn thuang mdt tgi Viet Nam. Benh nhdn (BN) bi chdn thuong den khdm vi Idm mat gdy anh huang thdm mi hogc song thi gdy rranggi trong sinh hogt.
Muc tieu: Danh gia ket qua phdu thudt phuc hdi sdn hdc mdt cho cdc BN VSHMvoi cdc logi mirc dp tdn thuong khde nhau.
Ddi tirong va phirong phap: 12 ti-uanghap bi VSHMvoi mirc dp khde nhau. da dugc phdu thudt su dung luoi titan hay tdm Xledpore. Nghien ciru thu nghiem lam sdng khdng ddi chimg. Ket qua: Nghien cini cho thdy ludi titan phu hgp vdi nhung VSHM rpng (Dp 3). tivngkhi tdm Medpore cd the dp dung vdi nhimg tdn thuong nhe (Dp 1 hay 2). Hien tugng ddy luoi Medpore hay cam gidc di vat hdc mdt xudt hien a 3 BN.
Chi cd 1 BNcdn Idy vd thay tdm Medpore vd theo doi Idu ddi do song thi tdng len sau phdu thudt. 2 BNxudt hien hien tugng ddy tdm Medpore.
Ket luan: VSHM co the phdu thudt vai ket qua thdnh cdng cao. Dv gidc hai mdt vd thdm mi dugc cai thien. Tuy nhien chi dinh cdn cdn cu theo mirc dp tdn thuong de de ra cdc phuong phdp thich hgp.
Tir khoa: Viysdn hdc mdt. Idm mdt.
I. DAT VAN DE
Thuat ngii VSHM (blow out fracture) dupc de ra
•\ao nam 1957 nham md ta tinh trang tang ap lire thu}
tinh trong hdc mit ga} nen \ d xuong [1. 2]. NTiiing nam 1970. hien tugng sa ket td chirc hdc mit xudng xoang ham da dugc lam rd nhd sir ra ddi cua chup cat ldp CT scan [3(jer]. Koomneer la ngudi diu tien tha}
ring. \ i mang xuong bi sa xudng xoang nen da ga} di lech cac cau tnic mang hen ca dinh \ ao [ 1].
Dua \ao hinh anh chup CT scan. VSHM dugc chia lam ba mirc dp: Dp 1 - Xuong san hdc mit khdng hen tuc: Dp 2 - Vd nho cd manh xorong; Dp 3 - Di lech toan bp san hdc mit cimg \ di cac td chuc dinh vao nd.
'KItoa Chdn thircnig, Benh vien Mdt Tningumig
"Bo mon Mdt, Dgi hoc Ykhoa Ha Noi '"Benh xien da khoa Quang Tn
Cac tae gia deu quan niem nen phau thuat sdm 2 tuan dau sau chan thuang mac dii mat cdn phii ne ha}' chua xuat hien cac dau hieu nhu 1dm mat ha}' song thi de tranh hien tugng xo hoa td chirc [3. 4].
0 Viet Nam, phau thuat na} chua dugc chu y mdt each dimg miic do BN it, chan thuang toan than rat nang va thieu ngu} en lieu phuc hdi san hdc mat. Chiing tdi da cd giai doan su dung sun suan de phuc hdi san hdc mat nhung ket qua khdng tdt nen khdng lam nghien cuu theo hudng na}.
Ba nam gin day (2008 - 2010). phau thuat nav dugc lam thudng xuyen hon tai Benh \ien Mit Trung uang nhd da cd tam Medpore do bac sy Ne^^mann (Orbis) cung cap \ a ludi titan. Nghien ciiu nav nham muc dich danh gia ket qua phau thuat tren mdt nhdm tuong ddi ldn BN \ di cac loai mirc do tdn thuang khac nhau de nit ra ket luan ve y n^hia cua phau thuat \ di cac BN Viet Nam (dac
30 I Nhan khoa Viet Nam (Sd20 - 2010)
NGHIEN CUtJ KHOA HOC
diem la den mudn va nang).
II. DOI TUgfNG VA PHUONG PHAP NGHIEN CUU 12 BN bi VSHM sau chan thuang mit dugc tham kham va danh gia tdn thuang.
Thdm khdm vdphdn logi ton thuong:
BN dugc danh gia thi Irrc va kham nhan cau de phat hien cac tdn thuang mat do chan thuang phdi hgp. Van nhan len tren dugc danh gia bang each do khoang each tir bd mi dudi den ria dudi giac mac khi nhin len tren. Ldm mat dugc danh gia bang thude do do ldi Hertel. Cac ket qua trade va sau md dugc ghi vao file Excel va phan tich.
Cdch thirc phdu thudt:
Cac BN cd chi dinh phau thuat deu dugc gay me ndi khi quan.
Gay te dudi da bd xung bang thude lidocaine pha adrenaline 1/10 000 de lam co mach.
Rach ket mac cimg do dudi phdi hgp md gdc ngoai mi dudi hay rach each bd mi dudi 1mm.
Cam mau.
Rach mang xuong bang dao dien. Diing dung eu tach mang xuong va bdc Id tdn thuong xuong thanh dudi hdc mat,
Diing panh Farabeuf tach va ven md hdc mat bi sa len tren.
Do dien khuyet xuong bang bia vd khuan.
Dat tam Goretex ha}' ludi titan cd phu Goretex phuc hdi san hdc mat va bat vit cd dinh.
Khau phuc hdi mang xuong.
Khau ddng vet md (neu qua dudng ket mac ciing dd dudi, can khau cd dinh nhanh da} chang mi ngoai de tranh lat mi sau md).
BN dugc diing khang sinh toan than nhung
khdng dugc dimg corticoid x 7 nga} sau md.
Theo ddi sau mo:
BN dugc xuat vien nga}' thii hai sau md va dupc kham lai sau 2 - 3 tuan le. Khi kham lai. BN dugc do do ldi va danh gia van nhan theo each tuong tu tnrdc khi phau thuat.
III. KET QUA
Phdn bo benh nhdn theo tuoi vd gidi:
Cac BN deu o lira tudi tre 19 - 40 tudi \ a da sd la nam gidi phan bd theo ti le: Nii/ Nam (2/12).
Nguyin nhdn chdn thuong:
Cac BN deu bi ehan thuang ham mat ha}' chan thuang sg nao nang. 1 BN da bi ga} xuong mat Le Fort ni. Tai nan giao thdng la ngm en chinh ga} VSHM.
Phdn logi ton thuong:
Cac BN dugc phau thuat deu thude nhdm vd san do II va III theo ti le (8/4). 2 BN vd san mirc do III cd sa nhan cau xudng xoang ham.
Thdi gian phdu thudt:
12 BN deu dugc xir tri rat mudn (2 - 12) thang sau chan thuong do thdi gian hdi phuc cac tdn thuong sp nao hay ham mat nang di kem.
Kit qud phdu thudt:
5 BN ban dau khdng duge phan loai dung va phau thuat sir dung tam Medpore. 7 BN cd VSHM rdng cd sir dung ludi titan vdi ket qua tdt (ldm mat giam va van nhan len tren cai thien).
1. Dp ldi: Hien tugng 16m mat giam dang ke d tat ca 12 BN 2 tuan dau sau md. Dp ldi mat tang 1 - 3mm. Tuy nhien a 3 BN cd hien tugng da}' tam Medpore cd hien tugng ldm mat tai phat.
2. Vdn nhdn len tren:
6
NGHIEN CLrtJ KHOA HOC
D E HL VSHM do 2
A. B va C: Truoe md (chay mdu xoang hdm. C). D va E: Sau md 3. Cac bien chung sau md: Hien tupng day tim Medpore xuit
hien a 3 12 BN nhung chi co 1 BN phai thay t i m phuc hoi san khac.
2 BN cdn lai xuat hien ldm mat tro lai nhung khdng d^n kham lai.
Hien tugng di}' tam Medpore tha}' a nhiing BN khdng dugc bit \\X hoac khau chi cd dinh ha}' khdng dat tam phuc hdi san xudng dudi mang xuong.
Hien tugng da}' tam phuc hdi san khdng tha}- co a cac BN su dung lucri titan,
Hien tugng nhiem trimg sau md khdng cd. Tm nhien. 1 BN xuat hien da}' tam phuc hdi san da co ap xe chi khau mang xuong sau lan md tha}' tam Medpore lan 2.
H2. Hien tucmg day tdm Medpore mdt trdi
4. Cdc ddu hieu gdy khd chiu khde: Tat ca 12 BN deu cd cam giac nhu co di \ at hdc mit sau mo.
Tu} nhien hien tugng na} het dan theo thdi gian ( 3 - 6 thang). Hien tugng song thi tang len sau mo chi xuat hien a mgt (1 12) BN. BN na} da dugc dat tam Goretex lan 2, do lan 1 xuat hien da} tam phuc hoi san \k dimg keo sinh hpc de dan cd dinh. BN khdng lac a tu the nhin thang nhung xuat hien song thi khi nhin len ga}' khd chiu. Trieu chiing nay giam dan \ di \ an nhan Ien tren tdt hon sau 3 thang theo ddi cd bit mat benh khi Iam viec.
B
32 I Nhan khoa Viet Nam (Sd 20 - 2010)
NGHIEN CUU KHOA HOC
D E F H3. Hai trudng hop VSHM ndng (Dp 3) gdy di lech nhdn cdu xuong xoang hdm
(A, B vd E, F: Trude md; C vd E: Sau md) IV. B A N LUAN
VSHM ngay cang xuat hien nhieu do chan thuong, tai nan giao thdng tang. Gan day, phau thuat dugc ap dung do da cd chat lieu phuc hdi san hoc mat chat lugng tdt. Ban luan dugc tap trang vao phan loai ton thuang va phau thuat nhu sau:
1. Van de tham kham va chi dinh phau thuat rit quan trpng. Cac BN dugc phau thuat vi mat ldm nhieu hay han ehe van nhan. Chung tdi khdng ehi dinh mo vdi cac BN ldm mat nhe hay song tin tu het theo thdi gian.
2. Phau thuat phuc hdi san hdc mat cd tac dung tdt vdi cac BN VSHM do chan thuong, cai thien tham mi va van nhan. Nghien ciru cho thay, ket qua nay bi han che trong tradng hgp chan thuang da lau ngay, cd hien tugng xo hda va teo td chirc md hoe mat. Cac BN cua chimg tdi dugc phau thuat mudn, trang binh 2 thang sau chan thuang sau khi cac tdn thuong toan than khae da dn dinh. Tuy nhien, ket qua van cai thien. Song thi khdng dugc danh gia bang sa dd song thi nhung van nhan da cai thien dang ke sau mo.
Ve kl thuat, dudng rach da each bd mi dudi 2mm rat phii hgp va thuan lgi cho viec bdc Id tdn thuong. Neu BN cd co dia seo ldi cd the sir dung dudng rach ket mac cimg dd. Tuy nhien, can can than khi khau ket mac do hien tugng hinh thanh u nang ket mac hdc mat sau md. Tat ca cac BN deu dugc rach mang xuong va khau mang xuong sau khi phuc hoi san hoc mat.
Medpore
Tam Medpore la chat lieu sinh hgc nen cd kha nang dung nap tot. Td chirc mach mau va xo cd the xam nhap vao va tich hgp vdi td chirc cua CO the. Cd 3 loai Medpore tiiy theo do day. Chung tdi sir dung tam cd do day trang binh. Tuy nhien, chiing tdi nhan thay Medpore rat mem, mac dii da gap ddi. Khdng dugc ngam Medpore vao nudc vi lam cho chat lieu cang mem. Medpore chi phii hpp vdi cac tdn thuang xuong nhe (Dp 1). Cac tradng hgp vd san do 2 sir dung chat lieu nay deu that bai. Trade khi dat Medpore cd the sir dung bia vd khuan de xac dinh kich thude diing viing can phuc hoi. Tam Medpore qua ldn cd the gay ton thuang cac to chiic d dinh hoc mat. Khdng nen dimg keo dan sinh hgc vi cd the keo dan chay vao dinh hdc mat gay song thi keo dai sau md. De tranh tradng hgp day tam lat can dung vit xuong hay khau co dinh vdi chi prolene 5/0 va khau lai mang xuong can than sau mo.
Luoi titan
Chiing tdi sir dung ludi titan de phuc hdi cac VSHM rdng (Do 3) hay cd khuyet xuong. Tam ludi dugc phu them manh Medpore de han che td chirc md sa them xudng xoang ham. Vit xuong dugc sir dung de eo dinh ludi vao bd hd mat. Can tach ki mang xuong de bat vit dugc de dang ban. Chung tdi da hut mau trong xoang ham qua tdn thuang xuong hoc mat rdng. Ludi titan dugc diing cho hai BN cd nhan cau sa xuong xoang dat ket qua tot.
NGHIEN CUtJ KHOA HOC
Phau thuat khdng gay bien chirng nghiem trgng. Hien tupng phu mi sau md rit hay gap, dac biet khi cd bit vit cd dinh hay diing ludi titan. Hien tupng nay hgt sau 2 tuin. Do vay cin luu y cim mau kl de tranh gay phii nk, tu mau hoc mit gay thieu mau thi thin kinh.
T A I L I E U THAM K H A O
1 HARRIS GJ, GARCIA GH, LOGANI SC, MURPHY ML, S H E T H BP, SETH AK: "Orbital Blow-out Fractiires: Correlation of Preoperative Computed Tomography and Postoperative Ocular Motility", Trans Am Ophthalmol Soc, 1998,96:329- 47, discussion 347-53.
2. GERBINO G, ROCCIA F, BIANCHI FA, ZAVATTERO E: "Surgical Management of Orbital Trapdoor Fractiire in a Pediatiic Population", J Oral Maxillofac Surg, 2010 Apr 8.
3. NAGASAO T, MIYAMOTO J, JIANG H,
V. KET LUAN
VSHM cd the phau thuat vdi ket qua thanh cdng cao. Thi giac hai mat va tham mi dugc cai thien. Tuy nhien. chi dinh can can cir theo mirc do tdn thuang de de ra cac phuang phap thich hop.
TAMAKIT KANEKO T "Interaction of H} draulic and Buckling Mechanisms in Blowout Fractiires", Ann Blast Surg, 20\0 Mar 11.
4. KIM YK, KIM JW: "Evaluation of Subcihary Incision Used m Blow Out Fractiire Treatment: Pretarsal Flattening After Lower Eyelid Surgery", Plast Reconstr Surg, 2010 Feb 3.
5. KIM S, KIM TK, KIM SH: "Clinico- radiologic findings of entrapped inferior oblique muscle in a fi-acture of the orbital floor", Korean J Ophthalmol, 2009 Sep, 23(3):224-7,
SUMMARY
PRELIMINARY EVALUATION ON ORBITAL BLOW OUT FRACTURE SURGERY EVVIETOAMESE PATIENTS
Objectives: Orbital blow out fracture is becoming a common challenge in clinical practice which requires surgery as patients complains of annoying double vision and cosmetic appearance
Methods: We report here 12 cases havingvariable degrees of orbital floor fracture who have underwent floor patching using titan mesh or Medpore plate.
Results: Preliminary evaluation shows that titan mesh use is effective in large bone defect (3^'^ degree) while Medpore sheet should be suitable for P' or 2^ degree of fracture. Enophthalmos has been reduced significantly so as double vision despite surgical intervention takes place late after trauma. However, Medpore sheet extrusion and foreign body sensation are encountered. Only one patient needs Medpore sheet replacement and long time follow up. Two padents have plate extrusion and do not come back.
Conclusion: Blow out fracture can be successfully fixed using bone patching.
Key words: orbital blow out fracture, enophthalmos. Titan mesh, Medpore plate.
Ldi cdm on
Chiing tdi xin cam on bac sy Newmann (ORBIS) da cung cap Medpore de phau thuat, cac dong nghiep da gui BN den kham va cac nhan vien khoa Chan thuang, BenJi vien Mat Trang uong da phoi hgp dieu tn va cham sde BN.
34 I Nhan khoa Viet Nam (Sd20 - 2010)
