VIETNAM MEDICAL JOURNAL N°1 - OCTOBER - 2017 , Dao Hinh Tuan (2011). NhiTng bien doi ve khi
mau, xet nghiem sinh hoa, huyet hgc d benh nhan viem phdi nang tai khoa ho hap benh vien Nhi Tmng L/cJng nam 2010. Y hoc thu'c hanh, 5(765), 73-75._
, Nguyen Duy Bo, Nguyen Thj Yen (2013), lien guan giuS lam sang, Sp02 va khf mau dgng mach
d tre 1-12 diang suy ho hap do viem phoi tai benh vien Nhl Trung U'dng, Dai hoc Y Ha Noi.
, Usen S, Webert M (2001), "Clinical signs of hypoxemia in children with acute lower respiratory infection: indicators of oxygen therapy", int j Tuberc Lung Die; 5(6):505-10.
LAO TAI: HINH THAI LAM SANG vA NHU'NG TIEN BO TRONG CHAN D O A N HIEN NAY
Tdn Cdng Cuomg**, Hoang Thi Phuwng*, Doan Thi Hong Hoa**, Nguyin Van Himg*, Nguyin ViSt Nhung*, Nguyin Thi T6 Uyen** fioan Hdng Anh**.
Tir khoa: Lao tai, hinh thai lam sang, xet nghiSm VI khuan tien tien
SUMMARY
TUBERCULOSIS OTITIS MEDIA, CLINIC PRESENTATIONS AND ADVANCED BACTERIOLOGICAL EXAMINAHON The tuberculous otitis media (TOM) is a rare gjctra- pulmonary localization which is accounted for 0.{M%
to 0,9% of CSOM in developed countries. In recent years, TB patients has an increasing trend, including TOM patients specially m the developing countries, Vietnam ranked 15/30 highest T8 burden countries and ranked 14/27 MDR-TB burden countries. The study describes a retrospective series of 31 cases which suggest a new perspective in diagnostic by revealing sample collections for histopathology and bacteriology. In literature, it used to present as tlie triad: pain- free ear discharge, multiple perforations of tympanic membrane and penpheral facial palsy. Ttie.
clinical features of TOM changed over the years. The' new clinical pattern of TOM should be recognized by clinicians.Our study releaved average of 30 years old with the range of ages from 16 months to 65 years.
Based on the analysis of the cases, it is suggested that TOM should be entertained as a possible diagnosis in patients with atypical OM. There are many similarities existing between TOM and pulmonary tuberculosis.
Firstly, the dinical presentation of TOM today is polymorphic, which can be acute or sub-acute or chronic form. Secondly, they are both the respitory tuberculosis. In this regard, whenever a TOM is diagnosised, lung CT scan is recommended, even when routine chest radiograph is considered normal.
The third, TOM can develop into adhesif OM with hearing loss even after anti-tuberculosis therapy.
There should be a close cooperation between the otologistes and the pneumologistes, early diagnosis ans search for other TB sites. To Impove TOM diagnosis, the samples need to be taken maximum amount to perform histopathology. Beside, the technique of incubation and ECA lavage fluid collection need to be conducted to perform Xpert MTB/RIF and BACTEC.
Key words: tuberculous otitis media, dinic presentations and advanced baeteriological examination.
T O M TaT
Viem_^tai ^giij'a do lao la mot ton thu'dng khu tru ngoai phdi hiem gap, chiem khdang 0,04 den 0,9% d cae nUdc phat trien. Trong vai nam gan day, b^nh lao ed xu hUcJng gia tang trd lai trong _dd cd VTG do lao dae biet d eae nude dang phat tnen. Viet nam hien van la nude c6 ganh nSng benh lao^cao, dii'ng thir i s trong so 30 nude ed tinh hinh dieh te lao cao nhat tren toan cau, va dufng thir 14/27 nu'de co ganh nang ve lao da khang thuoc. Nghien ciru hoi culi mo ta 31 ea lao tai vdl mong mudn ehia xe kinh nghiem trong viec la^ benh pham de chan doan lao tai. Kinli dien, lao tai bieu hien vdi tam chiTnp: chay mii tai Widng dau, mang tai thiing nhieu lo va liet mat. Vdi thdi gian, benh canh lam sang ciia lao tai co nhieu thay ddi. Cac nlia lam sang nen cap nhat nhiJng trieu chirtig mdi eua lao tai. Nghien cirij ciia chimg toi nhan thay lao tai c6j:he gap 6 moi lira tu^di tir 16 thang den 65 tuoi vdi tudi trung binh la 30 tudi. Benh canh lam sang ciia lao tai ngay nay rat da dang, nen khi gap tru'dng hcJp VTG khong dieu hinh trUdc ten phai nghi ngd lao tai. Cd nhieu SLT tu'dng ddng giiJa lao tai va lao phoi ve bieu hien lam sang va Hen tnen. Thir nhat, hinh thai lam sang ciia lao tai ngay nay rat da dang, co the bieu hien dirtJi cap, ban cap va man tinh. thu' hai, lao tai va lao phdi deu la lao cua du'dng ho hap nen khi chan doan lao tai nSn chup cat Idp phdi de tim them khu tru tdn thudng ngay ca khi Xquang phoi co ve binh thu'dng. Thu" ba, sau dieu tn lao tai mot sd trudng hdp chuyen viem tai day; dinh. Can eo sy ket hcJp chat clie vdi nha ho hap^de^chan doan sdm va tim eac tdn thUcJng khac. Oe chan doan lao tai, eac nha chuyen khoa nen chit y each lay benhj)ham. Khi lam mo benh hoc, phai lay toi da benh pham mdi co the tim tliay viing tdn thUOng lao, va khi lay mil lam vi khuin hoc nhU^^ BACTEC va Xpert de tang do tap trung eiia vi khuan phai ii va lay d|ch tai,
*Benh vien Phdi 71/
**Benh viin Tai Mui Hong Tif Chju trach nhiem chinh: Tdn Cong Cu'cfng Email: Drtoncuongent@gmail Ngay nhan bai: 27.7.2017 Ngay phan bien khoa hgc: 20.9,2017 Ngay duyet bai: 28.9.2017 230
TAP CHi Y HOC VIET NAM TAP 4S9 - THANG 10 - SO 1 - 2017 I.DiftTVANDE
Hien nay, benh lao la mdt van de cd ban ve su'c khoe cdng dong tren toan rau, u'dc tinh nam 2015 ed khoang 10.4 trieu ca mac lao mdi.
Day la nguyen nhan hang dau gay tu" vong do cac benh truyen nhiem (vdi khoang 1,8 trieu ngu'di chet/nam), tnang dd phan Idn sd ngu'di chet gap d cae nu'de cd thu nhap thap va trung binh [1]. Theo Bao cao ciia To chu'c Y te The gidi (TCYTTG) nam 2015, Viet nam hien van la nu'de CO ganh nang benh lao cao, dirng thir 15 trong 30 nu'de cd tinh hinh dich te lao cao nhat tren toan cau. Dien bien benh lao ngay cang trd nen phii'c tap, tru'dc day 85% cae tdn thu'dng lao thu'dng bleu hien d phdi, tuy nhien vdi su" gia tang dan sd va su' lam dung khang sinh, lao ngoai phdi gap nhieu hdn vdi eae hinh thai da dang. Bang chu'ng ehinh de chan doan lao la tim dirde vi khuan lao, nhutig ddi vdi lao ngoai phoi, lu'dng vi khuan ngheo nan va du'dc coi la lao khdng lay, chan doan khd khan de bd qua.
Lao tat hay VTG do lao la mdt tdn thu'dng khu tru ngoai phdi tu'dng doi hiem gap. Kinh dien, lao tai tier piiat rat hiem va chii yeu gap d em. I^o tai thu'dng thir phat sau lao phdi, bieu hien du'di hinh thai VTG man vdi tam c h i ^ g : chay tai khdng dau, mang tai thiing nhieu id thiing va liet mat ngoai bien sdm. Vdi thdi gian, hinh thai lam sang cua lao tai cd nhieu thay doi, chan doan gap nhieu khd khan. Tuy nhien trong nhu'ng nam gan day, cac ky thuat xetjnghiem vl khuan lao da cd nhOlng cai tien dang ke nhU IGRA, he thdng cay t y ddng BACTEC va ky thuat sinh hpc phan tir nliu" xet nghiem Xpert, Main da gdp phan nang eao chan doan sdm va ehinh xac benh lao.
Chinh vi vay chung tdi mudn md ta cae trieu chu'ng lam sang cua lao tai hien nay va trinh bay mot sd tien bd ve xet nghiem lao trong chan doan va dieu trj qua 31 tru'dng hdp lao tai.
II. D 6 | TirpNG Mk PHU'aNG PHAP NGHIEN CCTU - Nghien edu hdi ciJu tren 31 tru'dng hdp nghi ngd la VTG do lao vao kham va chan doan sd bp tai khoa Tai -Tai than kinh ciia benh vien Tai Mui Hpng TU* va du'dc chuyen den benh vien phdi tmng u'dng de ciian doan xac djnh va dieu tri theo phac do lao trong gia doan tiy 2011 den nay.
- Cac dd lieu nghien ciTu gdm; tien su", bieu hien lam sang, can lam sang, cac xet nghiem chan doan tiiy thupc vao benh j i h a n ed chay tai hay khdng. Cac xet nghien chan doan lao gdrn cae xet nghiem gian tiep (Mantoux, IGRA, md benh hpc) va cac xet nghiem trdc tiep (BACTEC, PCR lao va dac biet la Xpert).
- De tim du'dc tdn thu'dng lao, ehiing tdi nhan thay ky thuat lay benh pham la rat quan trong.
Tiiy theo tiTng giai doan, trdde nam 2013, lao tai du'dc chan doan chii yeu nhd md benh hpc.Gan day tuy theo tiTng tru'dng hdp benh nhan cd chay tai hay khdng chung tdi cdn tien hanh them xet nghiem tim vi khuan lao bang nudi cay BACTEC, khueeh dai gene Xpert va ca IGRAs.
Kinh nghiem eho thay, tru'dc tru'dng hdp VTG khdng dien hinh de tim du'dc td'n thu'dng lao, khi phau thuat phai lay tdi da eae benh pham de lam md benh hoc va trong tru'dng hdp benh nhan cd chay tai ky thuat ii va lay chat rij^a dieh tai de iam tang dd tap trung vi khuan khi tien hanh xet nghiem Xpert va nudi cay BACTEC mdi cd the tim du'dc bang chu'ng vi khuan hoc.
- Sau khi chan doan VTG do lao, nen tien hanh chup eat Idp phdi de tim tdn thu'dng phon hdp.
- Thdi gian theo ddi trung binh la 2 nam, it nhat tir 9 thang den 6 nam, ket qua dieu tri dddc danh gia tinh trang toan than va tinh trang gial phau, chii'c nang cua tai.
IM. KET QUA NGHIEN CCrU
1. Tudi va gidi: Tuoi trung binh la 30, nhd nhat la 16 thang, Idn nhat la 65 tudi, vdi 7 tre em. Benh thu'dng gap d nd.
G\6/\
2 9 %
^
2. Thd^ gian du'dc chin doan: tiiy theo trieu ehdng ciia benh nhan cd ram rd hay khdng va tiiy theo kinh nghiem ciia thay thude ma thdi han chan doan (x> the keo dai tiT 1 thang den 6 nam.
Thd*! h^n chan d o a n
• Trw6c 3 t h a n g
^ M TCr 3 d e n 6 t h ^ n g s Til- 7 t h a n g d e n 6
VIETNAM MEDICAL JOURNAL N''1 - OCTOBER - 2017 3. Yeu to dich te: Khai thac tien sir rat
quan trpng
- Gia dinh cd ngu'di mac lao (cu hay mdi hoat dpng): 8 ea (26%)
- Tiep xuc nghe nghiep (y ta hay giao vien): 6 ca (19%)
- Benh nhan cd thdi gian nam vien de dieu trj hay cham sdc ngu'di nha: 7 ca (23%)
4. BSnh canh lam sing: Cap tinh vdi trieu chirng dau du' dpi hay hdi ehimg me nhT mat xuat
hien nhanh ehdng khien benh nhan va thay thuoc tien hanh chan doan ngay: 8/30 ca (26%). Ban tap hay man tfn: hau het benh nhan du'dc dieu tri viii dil loai khang sinh, nhuTig benh khdng khoi van tien trien dai dang: 23/30 ca ^74%)
5. Tai tdn thu'dng: bieu hien d 2 tai: 7 ca (23%); 1 tai: 24 ea (77%).
6. Trieu ehdng ed nang: da dang co the phdi hdp nhieu trieu chu'ng
I
21Tri?u chii'ng cff nang
• • I
C h i y tai L i ^ t m g t Su'ngsau tai Vet mo khong lien
7. TriSu ehdng thu'c the: cd nhieu hinh thai khac nhau bieu hien hai ton thu'dng chinh ciia lao la ny hat va dieh ri viem, mang tai cd the
- Khdng thiing nhT, nhu'ng day ddi khi cd d dpng vay xuat tiet: 8 ca (29%)
- Thung nhT vdi nhieu hinh thai: nhd vdi niem mac hdm nhT viem nhdt, thiing nhieu lo hay thiing rdng sat xu'dng: 14 ca (45%)
• Nu hat viem siii nhdt mau dng tai ngoai iioac vet nio khong lien: 9 ca (29%) tidt so hinh inh mang tai ve lao taj_
8. Xet nghiSm can lim sing - Thinh ItTc do: du'dc tien hanh tren 30 ca, trong dd 1 ca 16 thang khdng do thinh liTc do.
Cd the gap eac loai nghe kem khac nhau, trong 30 ca vdi 37 tai benh ehiing tdi nhan thay: diee hoan toan: 5/37 tai (14%), diee hon hdp: 2 1 / 37 tai (57%) va diee dan truyen: 11/37 tai (29%).
Mu'e dp diee va loai diee khdng phu thude vao thdi gian mac benh
- Xet nghiem mau thu'dng qui
+ thieu mau nhe: 7 / 3 1 ca (23%) + mau lang tang miTc dp nhe hay viTa: 8 ca - Phan u'ng Mantoux: hien nay khdng lam - Xet nghiem IGRA: viTa bat dau lam, 3 ca du'dng tinh
- Xet nghiem HIV thu'dng qui: 100% ea am t'nh.
- Xquang long ngiTc: thu'dng qui cd 7/31 ca (23%) cd nghi ngd lao phdi
9. Chup cit Idp xddng thai dddng: txQw'i^
benh nhan vert 38 tai benh, gap 3 hinh thai sau;
TAP CHi Y HOC VigT NAM TAP 459 • THANG 10 - SO 1 - 2017 + Md toan bd xu'dng chum va hdm nhT vdi
xu'dng chum thdng bao, cac vach ngan nguyen ven, thu'dng gap nhat vdi 31 tai benh.
+ Md toan bp xu'dng chum va hdm nht nhu'ng vd xu'dng chum kem thdng bao (4 tai)
+ Viem hoai tuf xu'dng chum ed the kem theo manh xu'dng chet la 3 tai.
10. Cac xet nghiem chan doan: tiiy theo tiTng thdi ky, chj'n doan lao tai cd the diTa vao:
Test chan doan Md benh hoc lao Md benh hpc va xet nghiem
vi khuan hoc Xet nqhiem vl khuan hpc
So benh nhan 8 15 8 11. Scanner phoi: phat hien 12/22 ea cd ton thu'dng phdi hdp mac du tren Xquang phoi binh thu'dng.
12. Cac lao khac phdi hdp: ngoai lao phoi, cd the gap lao hach, lao mang nao, lao tinh hoan...
13. Theo ddi sau dieu tri:
- liet mat: 3/6 ca phuc hoi hoan toan - 14/31 ca: mang tai dinh toan bo hay mdt plian ngay ca khi mang tai thung lam anh hu'dng (Jen SLTC nghe,
Hinh anh viSm tai dinh di didhg sau 0eu tri IV. BAN LUAN
Tdn thu'dng lao xu'dng thai du'dng du'dc md ta lan dau tien vao the ky XVIII bdi Jean Louis Petit, va den nam 1883 Esche phan lap ddde vi Wiuan lao tiT dieh tai ngay sau khi R. Koch phat hien ra vl khuan lao. Khoang nam 1885, Habermann tim thay ton thu'dng nu hat lao trong niem mac hdm nhT. Dau hieu lam sang ciia lao tai du'dc Wilde md ta lan dau tien nam 1853 vdl tam chung chay tai khdng dau, mang tai cd nhieu lo thung va ny hat nhdt mau trong cac hdc tai giiiia. T^n suat cua lao tai thay ddi theo thdi gian va tiTng qudc gia. Vao dau the ky XX, lao tai chiem 3-5% trong cac viem tai giu'a man mil d
ngu'di tdn va viec phat hien khang sinh chong lao dan dan ra ddi giiip eho dieu tn lao ed hieu qua rd ret, ehi sd nay giam di mdt each rd ret chi edn 0,04-0,9% d cac nu'de phat trien. Tuy nhien trong nhiJng nam gan day, benh lao dae biet la eac the lao ngoai phoi cd xu hu'dng gia tang trd lai cimg vdi su" xuat hien cua cac ehiing vi khuan da khang va sieu khang thude da va dang xay ra d cac nu'de dang phat trien. Viee phat hien va kiem scat lao ngay cang trd nen khd khan. Hien nay, cac bao cao ve viem tai giij'a do lao rat ngheo nan, chii yeu ve eae ea lam sang vdl cae dau hieu rat phong phu.
Bieu hien lam sang eiia lao tai du'dc md ta lan dau tien vao nam 1853 eho den nay rat da dang.
Theo y van, lao tai thu'dng bi mdt ben, nam trong benh canh VTG man tinh mil du'dc dac tru'ng bdi chay mil tai khdng dau, khdng dap utig vdi dieu trj khang sinh thdng thu'dng, d benh nhan cd nhiem khuan lao rd ret mang tai ed nhieu lo thiing, t d chiTc hat viem day dae, hoai tir xu'dng va hach tru'dc tai. 6 giai doan sdm, ed the thay mang tai cd nhieu lo thiing, nhu'ng sau dd nd ket lai thanh id thiing rdng kem theo td chiTe hat nhdt mau. Ngoai ra mang tai cd the day len va mat cac moc glal phau, dieh ri viem trong tai cd the rat dae va ddi khi nham lan vdi cac can keratin nhiim khuan eiia cholesteatome. Cac bien chii'ng mudn cd the gap nhu" liet mat, viem me nhT, rd sau tai, ap xe du'di mang xu'dng, viem dinh xu'dng da va xam lan vao trong so. Liet mat do lao tai chiem khoang 16% d ngu'di Idn va 35% d tre em. Ton thu'dng phoi thu'dng phdi hdp lao tai chlem tiT 50 den 94% (2,3).
Qua 31 tru'dng hdp lao tai, chiing tdi nhan thay hinh thai lam sang ciia lao tai rat da dang, cd nhieu diem tu'dng ddng vdl lao phdi. J h e o nghien ciTu ciia Magnan tai giu^ gidng phdi thu nhd ve phat sinh nguon gde, cau true va he thdng mien djch,
- Tru'dc tien, lao tai cd the xay ra vdi benh canh lam sang cap tinh, ban cap hoac man ti'nh, phai nghi ngd lao tai trong cac tru'dng hdp viem tai cd cac trieu chiTng khac thu'dng nhu' dau nhiTc tai, ii tai tieng cao, nghe kem, chay tai keo dai khdng dap iTng vdl dieu tn ^ thdng thu'dng.Trieu chiTng cap tinh thu'dng bleu hien dudi hinh thai dau nhiTc, siil xuat tiet trong dng tai va mang nhT kem theo trieu chiTng me nhT mSt xuat hien nhanh (diee hon hdp thien ve tiep nhan cd the kem theo Net mat). Ban cap hoac man ed the bleu hien cu'dng tu viing xu'dng chbm, dau nhdi trong tai, ii tai tieng cao hay nghe kem hoac chay tai keo dai mac dii dieu trj
VIETNAM MEDICAL JOURNAL N°1 - OCTOBER • 2017 ndi khoa tieh cde ngay ca dung cac thude nhdm
quinolone hoac phau thuat.
- Trieu chii'ng cd nang chii yeu khien ngu'di benh den kham thay ddi tiiy theo lu'a tudi va tiiy thu'de vao timg benh nhan. O ngu'di Idn, trieu ehiTng khdi dau thu'dng gap nhat la ii tai tieng eao, dau nhdi trong tai, hoac nghe kem. 6 tre em, thu'dng chay tai keo dai hay suTig sau tai, hoac quay khde khdng len can.
- Khi phat hien viem tai cd dau hieu khdng dien hinh, khai thac tien sd ban than^va gia dinh rat quan trpng ed the hu'dng den chan doan lao tai va tim eae tdn thu'dng lao khac nhd lao phoi, lao hach... Tien sir gia dinh cd ngu'di mac lao dang hoat ddng hay da cd thdi gian dieu tr| lao tir lau. Co gia dinh cd 3 ngu'di mac lao eae thdi diem khac nhau, nhu' bd mac lao hach each day 30 nam, em trai mac lao mang phdi tiT 7 nam tru'dc va nay benh nhan mac lao tai. Hoac ed tru'dng hdp, bd benh nhan luc nhd cd dieu tn lao hach, tre 6 tudi lai mac lao tai. Phai chang yeu to gen ddng mdt ph3n trong nguy cd ngu'di mac lao - gen cam nhiem. Tuy nhien khai thac tien siJT tiep xiic nguon lay dang hoat dpng can phai chii y de tranh lay ian edng ddng cung nhu" la hieu qua dieu tri. Nguon lay ed the lien quan den nghe nghiep nhu'y ta, giao vien hoac ngay trong gia dinh.Cd tru'dng hdp me viTa dieu tri lao phdi vdl BK du'dng tinh, tre 5 tudi lai lao tai cung ed BK du'dng tfnh.
- TriSu ehdng thdc the rat phong phii bleu hien dudi hai dang ton thu'dng chi'nh la nu hat va djch ri viem. Nd cd the ton thu'dng d dng tai ngoai vdi hinh thai siii nhdt mau xuat tiet hoac mang tai day khdng thiing, cd djch ri viem dinh hay vay khd bam tren mang tai, hoac mang tai thiing vdi hinh hanh nu hat viem trang mem mac hdm nhT. Ngoal ra, mang tai cd the cd nhieu lo thiing nhu' hinh anh kinh dien hoac thiing rdng xu'dng bua Id tran vdi niem mac lidm nhT viem.
TTieo ddi tien trien ciia mang tai khi chu'a chan doan lao tai chung tdi nhan thay hinh anh mang tai ban dau giong nhu' viem tai giife cap, cd the ed not phdng tren mang tai nhu'ng sau do mang tai day phdng, dat dng thdng khi khd khan^ hoac dat du'dc ong thdng khi nhutig mang tai van day hoac chay tai qua ong keo dai bieu hien niem mac hom nhT van dang viem. Bieu hien lam sang cd the 2 ben chiem 7 / 3 1 ea (chiem 23%), tuy nhien phan ldn gap 1 ben.
- Vi khuan lao la vi khuan hieu khf va vi hieu khi, nd thu'dng cay vao vimg phan ap dxy cao nhd dinh phoi. Do viy lao tai chu yeu gap d nhu'ng benh nhan cd xu'dng chum thong b^o va
hinh anh chup cat Idp xu'dng thai dddng doi khi gdi y den lao tai Od la hinh anh md toan bp tiiong bao xu'dng chum va hdm nhT hoac tham tn' viem hoai tu'xu'dng chiim xay ra tren benh nhan viem tai giu'a khdng dap utig vdi khang sinh thdng thu'dng. Ddng thdi khi phat hien lao tai nen chyp cat idp phdi ngay ea khi ehyp Xquang phdi ed ve binh thu'dng de tim cac tdn thu'dng phdi hdp. Nghien ciTu chung tdi thay cd 12/22 ca cd ton thu'dng phoi phdi hdp tren CT scan phoi, ehu yeu Ja viem hach ron phoi hay tdn thu'dng tham nhiem dinh phoi. Ngoai ra lao tai cd the nam trong benh canh lao rai rac vdi eac lao khac nhiT lao hach, lao tmh hoan hay lao mang nao day vcli liet mat 2 ben d ngudi gia suy giam mien djch.
- Bang ehdng chinh de chan doan lao la tim dddc vl khuan lao, nhutig ddi vdi lao tai lu'dng vi khuan ngheo nan nen xet nghiem vi khuan thu'dng am tinh. Theo cac nghien ciiti, ky thuat nhudm soi try'c tiep tim AFB (Acid Fast Bacilli) qua dich tai thu'dng am tinh, nudi cay thdng thu'dng ddi hdi mat It nhat 4 tuan vi khuan mdi moc, va ti le vi khuan lao du'dng tinh trong dich tai tru'dc day ehi chiem 5 den 35%.
- Chinh VI vay, tru'dc day chiing tdi chan doan lao tai chii yeu dy'a vao ket qua md benh hpc va theo ddi ket qua dieu tri. Tuy nhien viec lay benh pham la rat quan trpng vi ton thudng lao trong phdi la tdn thu'dng tham nhiim va gian doan, xac dinh du'dc viing sinh thiet ja yeu to thanh cdng. Kinh nghiem cho thay, detim du'dc tdn thu'dng lao trong viem tai pida, nha phau thuit phai lay tdi da benh phim de phan hch mdi CO the tim thay hinh anh lao. Trong nghien cii'u chiing toi cd 4 tru'dng hdp md sinh thiet 1 tham tri md 2 lan, khong tim thay ton thu'dng hoac trong 3 hoac 4 manh sinh thiet chi tim du'dc 1 vj tri ton thu'dng lao dien hinh.
- Gan day nhiitig cai tien ve mdi tru'dng nuoi cay, nhu' he thdng ty" ddng BACTEC vdi dp nhay cao va thdi gian ngan chi can 8 ngay vi khuan bat dau mpc. BACTEC cd 3 tien bd la cd the cay mau tim Mycobacterium, djnh danh du'dc Mycobacterium tuberculosis complex va lam khang sinh do. Benh nhan sau khi cd^ket qua mo Irenh hpc, de chan doan lao chae chan chung toi tien hanh nudi cay BACTEC, mau benh pham dieh tai ed mau cung sir dyng du'dc nen nhDtig benh nhan sau md tai van lam du'dc.
- Ngoal ra nhu'ng tien bd trong sinh hpc phan tiT dae biet la ky thuat khueeh dai gen du'dc ap dyng trong y hoe lam sang. Ky thuat tieu bleu la phan irng chuoi (PCR) xac djnh Mycobacterium tuberculosis complex da phat trien, ket qua thu
TAP CHi Y HOC VigT NAM TAP 459 • THANG 10 - SO 1 - 2017 du'dc nhanh nhu' ky thuat nhudm soi cd the trong
vong 24 den 48 gid sau khi nhan benh pham nhu'ng dd nhay va dp dac hieu eao. Tuy nhien, vdi thdi gian cac tac gia nhan thay dp nhay rat khac nhau giij'a cac phdng thi nghiem, ti le diTdng tinh gia kha cao thu'dng gap nhat la do nhiem cae manh DNA tir lan nhan len tru'dc (amplleon) qua cac hat mii ma cae ky thuat vien lam ban ra khi thao tac vdi cac DNA san pham chi trong vai phut. Nhu'ng DNA san pham nay rat de nhiem vi sd lu'dng rat ldn tdi 1012 phan tiT trong moi phan iitig, chi can nhiim mpt vai phan tir nhd cung dii gay du'dng tinh gia. Mdt van de I6n nij^ la cd ca am ti'nh gia, gay ra bdi sy* iTc che DNA polymenase va hien nay chu^ kiem soat du'dc SlT de che nay. Trong nghien eiTu eiia chung tdi chi cd 2 ca du'dc chan doan lao dy^
vao hinh anh lam sang vdi PCR lao va theo ddi ket qua dieu tri.
6 Viet nam, ngay 26/12/2011, Bd y te du'a ra quyet djnh trien khai ky thuat gene xpert chii yeu cho benh pham ddm ddi vdl nhu'ng tru'dng hdp nghi mac lao khdng thude hoac lao dong nlillm HIV va nhu'ng benh nhan lao AFB am tinh.
Vdi nhu cau cap thiet trong viec chan doan lao tai CLia cae nha Tai Mijl hpng, eac nha chuyen khoa ciia Benh vien phoi trung u'dng da sang tao sir dung phu'dng phap lay djch tai qua ii va rda djch tai liang nu'de muoi sinh ly nham tang dp tip trung cua vi khuan. Qui trinh ky thuat dam bao tranh lay cheo va benh pham du'dc chuyen ngay khoa vi sinh de xuT iy. Vdi ky thuat nay, da tim du'dc 11 ca lao tai cd chay djch tai vdl Xpert du'dng tinh, trong dd ed 1 ca lao tai khang Rilampieln ciia mdt dieu du'dng vien. Tuy nhien, nhiTng benh pham cd lan mau thu'dng khdng diing du'dc.
- Oe chan doan va quyet dinh dieu trjjao tai, trudc tru'dng hdp viem tai giij'a khdng dien hinh lao tai phai dddc phan biet vdi VTG do nam, benh u hat Wegener, sarcoidos, benh md bao va cac tdn thu'dng u trong tai giSa nhu' Adenome, Sarcoma, papiloma va ca u tu'dng bao ddn ddc.
- Ve dieu t n , viem tai giu'a do lao it nhat phai dung thude lao 6 -9 thang vdi 2 thang tan edng va 6 thang duy tri. Hau het benh nhan chung tdi du'dc dieu trj 9 thang vdi 2 thang tan cdng vdi 4 thuoc va 7 thang duy tri (2 thude). Cd 1 tru'dng hdp lao tai khang thuoc benh nhan du'dc dieu U-j theo phac dd lao khang thuoc vdl 6 loai thuoc (kanamycin, prothionamid, pyrazlnamld, ofloxacin, ethambutol, cycloserln, nhu'ng benh nhan dl iTng pyrazlnamld vdi men gan tang cao du'dc dieu trj bang corticoid va thay bang
linezolld). Benh nhan ehi diing du'dc thude 8 thang theo phac dd lao khang thude.
- Hieu qua dieu tri khang djnh chan doan, ngiTng chay mu tai vdi niem mac hdm nhT het viem, tuy nhien du mang tai thiing hay khong thiing sau khi dieu tn khoang 40% viem tai chuyen sang giai doan dinh (t nhieu anh hu'dng den thinh lu'c eua benh nhan. Liet mat cd the xuat hien ngay khi bat dau diing thude lao, miTc dp phuc hoi tiiy theo thdi gian va miTc dp tdn thu'dng eiia day mat, neu liet nhe benh nhan ed the phyc hoi hoan toan tnang vdng 2-4 tuan. Trong 6 ca liet mat cd 3 tru'dng hdp de lai dl chiTng.
V. KET LUAN
Ngay nay benh lao ed xu hu'dng gia tang trd lai dae biet la lao ngoai phdi, trong do ed lao tai.
Tru'dc tien, ngu'di thay thuoc phai nghT den lao tai tru'dc eac VTG tien trien khdng dien hinh, khdng dap iitig vdi dieu trj npl khoa thu'dng qui.
Chup eat Idp xu'dng thai du'dng cd hinh anh gdi y vdi md toan bd thdng bao va tai gitTa xay ra d xu'dng chum thdng bao. Can cd sy* phdi hdp chat che giij'a nha chuyen khoa Tai Mui Hpng va Hd hap de tien hanh chan doan lao tai, tim cac bang chu'ng vl khuan de dieu trj sdm tranh eae di chu'ng dang tide. Hay coi lao tai nhu' lao phoi, chu y khi lay benh pham, neu tien hanh phau thuat nghi ngd cd lao, nen lay tdi da benh pham ed the de lam md benh hoe mdi tim du'dc ton thu'dng lao. Neu benh nhan cd chay tai, de tang them dp tap trung ciia vi khuan, ky thuat u va lay dich riTa tai la rat quan trong de lam gene Xperti va nudi cay BACTEC. 6 tre nhd nen lay mau lam xet nghiem IGRAs de chan doan kha nang nhiem lao va tinh trang mien dieh cua tre.
Oac biet khi phat hien lao tai can phai chup cat Idp phdi mac du Xquang thu'dng qui ed ve binh thu'dng vi lao tai va lao phoi deu la nhiem khuan ciia du'dng hd hap.
TAI LIEU THAIVI KHAO 1. WHO, Tuberculosis 2016
2. Dale OT, Clarke AR, Drysdale AJ (2011}.
Challenges encountered in th Otol. 125/7: 738-40 3. Eitan Yaniv, Philip Traub, Rene Conradie
(1986). Middle ear tuberculosis -a series of 24 patients, Intemational Journal of Pediatric Otorhinoiaryngoiogy. Voll2/l: 59-63.
4. Generoso T-Abes, Franco Loure L.B Abes and Joselito-S, Jamir (2011). The variable elinique presentation of tuberculosis otitis media and the importance of early detection. Oto-neurology. 32:
359-543.
5. P.Adhikari (2008). Tuberculous otitis media: a review of literature. The internet journal of Otorhinoiaryngoiogy. Volume 9, No 1.
