JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N°3/2011
Nghien cuu nguyen nhan va danh gia ban dau cac phuo^ng phap dieu tri ngoai khoa ch§n thuong thanh - khi quan
Investigation the causes and primary evaluation the result of surgical management of laryngotracheal trauma
Quach Thj CSn', Vo Thanh Quang', 'Benh vien Tai MHi Hong Trung uang Le Thanh Thai^ -Bo mon Tai Mui Hong Dai hoc Y Hue
T o m t a t
Muc tieu: nghien cdu nguyen nhan va danh gia ban dau cac phuong phap dieu tri rigoai khoa chan thUPng thanh khf quan. PhUPng phap nghien cdu: hoi cdu 23 benh nhan chan thUPng dupc dieu trj ngoai khoa tai Benh vien Tai Mui Hpng Trung UPng va Benh vien Trung UPng Hue, trong thdi gian t d t h i n g 6/2008 den t h i n g 6/2010. Ket qua: Nguyen nhan hang dau la tai nan giao thdng, ke den la tU td, tai nan lao dpng.
Loai ton thuong giai phau benh tUPng dUPng nhau gida chan thUPng kin va hd. PhUPng phap phau thuat chu yeu la md tham do phue hoi cau true dPn thuan chiem ti le 6 1 % va la phUPng phap duy nhat d nhom chan thUPng hd. Vj tri cau true phue hoi dPn thuan chu yeu la sun giap va mang giap - mong. So ngay dieu tri trung binh la 13,5 ngay. Ti le benh nhan co the tU thd dupc chi chiem 65% sau lan dieu tri dau tien, so benh nhan con dat ong hoac deo canul deu nam d nhom chan thUPng kin.Ti le benh nhan co giong noi nhU binh thudng chi dat 35%.
Ket luan: tai nan giao thong la nguyen nhan chu yeu cua chan thUPng thanh khf quan. Ti le chan thUPng thanh khf quan kfn va hd la nhu nhau. Md tham do phue hoi cau true dPn thuan la phUPng phap dieu tri ngoai khoa chu yeu. Sau dieu tri benh nhan phue hoi gipng noi hoan toan dat ty le thap.
TCf khoa: chan thuong thanh q u i n .
Summary
Objective: to investigate the causes and primary evaluate the surgical management of laryngotracheal trauma. Method: a retrospective study on 23 patients with laryngotracheal trauma underwent larygotraeheal surgery in National ENT Hospital and Hue Central Hospital from 6/2008 to 6/2010. Results:
The main causes were traffic accidents, suicide and occupational accidents. The number and proportion were equal between blunt trauma and open trauma. The main method of operation was simply reconstruction with 6 1 % . Thyroid cartilage and thyrohyoid membrane were essential injury site. The average time of hospitalization was 13.5 days. Only 65% patients could breath by themselves after the first treatment. The proportion of patients with normal voice was only 35%.
Conclusion: The main causes were traffic accidents. The main method of operation was simply reconstruction. The proportion of patients with normal voice post treatment was low.
Keywords: laryngotracheal trauma.
Phan bifn khoa hpc: TS. DOANTHI THANH HA
I.Oatvande
Chan thdong thanh-khf q u i n ft gap tren lam sang, tuy v i y day la loai chan thdong ed ti le tdvong cao, ehi xep sau chan thdong sp n i o trong cic chan thdong vung dau mat co. D i e biet ti le di chdng cao ve thd va p h i t am. Vi vay, viec dieu trj nham lam giim ti le t d vong va di chdng cho den thdi diem hien tai van la van de mang tfnh thdi sd doi vdi cic nha l i m sang. Do tfnh chat phdc tap ve phdong dien giii phau, chdc n i n g cung nhu co che ton thdong, thi van de dieu trj chan thuong thanh khf q u i n cung rat phdc tap. Moi loai ton thuong ed mot phdong p h i p dieu trj rieng biet, nhung khdng cd phdong p h i p nao la toi du cho mpi loai ton thdong, ma ngay c i cho mot loai ton thuong doi khi cung cd nhieu phdong p h i p dieu trj khic nhau.
De danh g i i ket q u i dieu trj ngoai khoa benh ly chan thuong thanh - khi q u i n trong giai doan hien nay. Chung toi thdc hien de tai n i y nham cac muc tieu sau:
1. Nghien cdu nguyen nhdn chan thuang thanh qudn;
2. Ddnh gid ban ddu ket qud dieu tri ngoai khoa chan thuang thanh qudn.
2. Doi tuang va phdong phap nghien cdu 2.7. Doi tuang nghien cdu
Bao gom tat ea benh nhan bj chan thdong thanh khi q u i n ddpc dieu tri bang phuong phip ngoai khoa tai Benh vien Tai Mui Hpng TW va Benh vien TW Hue trong thdi gian t d thing 6/2008 den thing 6/2010. Nhd viy, trong nghien cdu nay chung tdi khdng chpn nhdng benh nhan chin thdong thanh - khf quin ehi di/pc dieu trj npi khoa.
2.2. Phuang phip nghien cdu
Sd dung phdong phip nghien edu md ta tdng ea ed can thiep.
3. Ket qua nghien cuTu
3.1. Nguyen nhan chan thuang thanh quin 3.1.1. Nguyen nhdn
Nguyen nhin gay chan thdong thanh quin chiem ti le chu yeu la tai nan giao thdng vdi ti le 43,5%, do tutd chiem ti le 21,7%, tiep den la tai nan lao dpng (17,4%) va tai nan sinh boat (17,4%).
3.1.2. Phdn bo nguyen nhdn gdy benh theo Ida tuoi
Bang 1. Phin bo nguyen nhin g i y chan thdong theo Ida tuoi
^ ^ ^ Nguyen nhan
Lda tuoi ^ " ^ " ^ ^ 1 6 - 2 5
2 6 - 3 5 36r-45 4 6 - 5 5 Tong so
Tai nan lao dpng
2 2
4
Tai nan giao thong
5 4
1 10
T u t d
2 2 1 5
Tai nan sinh hoat
2 1
1 4
Tong so
7 9 4 3 23
Lda tuoi gap chan thdong nhieu nhat I i Ida tuoi t d 26 - 35 phin bo d tat ea cic nguyen nhan, gap nhieu nhat d nhdm nguyen nhan do tai nan giao thdng, Ida tuoi ke tiep I i Ida tuoi td 16 - 25.
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N 3/2011
3.1.3. Ton thuang gidi phau benh
Loai chan thdong g i i i phau benh xap xi nhau d hai nhdm. Chan thdong kin cd 13 benh n h i n chiem ti le 56,2% edn chan thdOng hd cd 10 benh nhan chiem ti Ie43,8%.
3.2. Dinh gii ban dau ket qui dieu trj
3.2.1. Cdc phuang phdp phau thudt dd dUpc tien hdnh
Bang 2. Cic phdPng p h i p phau thuat
~ ~—--^^___^ Loai chan thUPng
PhUPng phap phau thuat ~^____^
Phau thuat chinh hlnh va dat nong
Phau thuat phue hoi don
thuan
Phue hoi khf quan Phue hoi sun giap
Phue hoi mang giap-mong Phue hoi mang giap - mong Khau mang giap - nhan Khau mang giap - nhan Oay sun nhan ve dung vj trf Phau thuat npi soi
Tong so
Kfn
6 1 2
1 3 13
Hd
1 3 3 2 1
10
Tong so
6
14
3 23
Tile (%)
26
61
13 100
Phdong phap phau thuat chu yeu la md t h i m do phue hoi cau true don thuan, la phdong phap duy nhat d nhdm chan thdong hd. Cac phdong p h i p phue hoi don thuan tuy thuoc vao vj tri ton thdPng va sd ket hpp ton thdOng, phdOng p h i p md phue hoi sun g i i p chiem so Idpng nhieu nhat, ke tiep la phue hoi mang g i i p - m d n g .
3.2.2. Songdy dieu trj trung binh
So ngay dieu trj trung binh la 13,5 ngay.
3.2.3. Ket qud ddnh gid chdc ndng thd
Bang 3. Tmh trang thd cua benh nhan sau lan nam vien dau tien
Tmh trang thd
Chan thuong kfn Chan thuong hd Tong so
Tile
Thd thong qua dudng t u nhien
5 10 15 65%
Con deo canul hoac ong nong
8
8 35%
Tong so
13 10 23 100%
Ti le benh nhin ed the t u thd bing dddng td nhien ehi dat 65%, toan bd benh nhin d nhdm chan thdong hd deu t d thd ddpc, nhdng benh nhan edn phii deo ong hoac deo canul deu d nhdm chan thuong kin.
3.2.4. Ket qud ddnh gid chdc ndng phdt dm
Bang 4. Tmh trang p h i t am cua benh nhin sau lan nam vien dau tien
Tmh trang noi Chan thuong kin Chan thuong hd Tong so
Tile
Noi trong 3 4 7 35%
Con deo ong 8
8 35%
Khan tieng 2 6 8 30%
Tong so 13 10 23 100%
Tmh trang cd ddpc chdc ning noi nhd binh thddng ehi chiem 1/3 so trddng hpp.
4. Ban luan
4.1. Nguyen nhan chan thuang thanh quin
Trong nghien cdu niy, nguyen nhin gay chan thdong thanh quin chiem ti le chu yeu la tai nan giao thong, td td, tiep den la tai nan lao dpng, tai nan sinh hoat. Tai nan giao thong cung la nguyen nhin hang dau trong nghien cdu eua da so t i c g i i trong nddc cung nhd d nddc ngoai [5,6,8,9,10]. Theo mot so tic gii nude ngoai chan thuong thanh quin ed the gap d mpi Ida tuoi, trong nghien edu cua chung tdi Ida tuoi gap chan thdong nhieu nhat la Ida tuoi td 26 - 35, phin bo d tat c i cic nguyen nhan, gap nhieu nhat d nhdm nguyen nhan do tai nan giao thdng, Ida tuoi ke tiep Ii Ida tuoi td 16 - 25. Ket q u i niy cung phiJ hpp vdi ket qui eua cic tie g i i Viet Nam khic nhd nghien edu cua Nguyen Ngpe Lan [1] v i Tran Phan Chung Thuy [3].
Loai chan thdong giii phau benh xap xi nhau d hai nhdm, chan thuong thanh quin kin chiem 56,2% so benh nhan nghien cdu edn chan thdong thanh quin hd chiem 43,8% so benh nhin nghien edu. Tuy chan thdong kin ed trpi hPn chut ft nhdng sd trpi hon cua chan thdPng kfn khong nhieu, ed le do trong nghien cdu niy chi gom nhdng benh nhin phau thuat, ti le can thiep phau thuat it hon so vdi chan thdong hd. Ket qui nay cung phu hpp ket q u i eua cic t i c g i i khic.
4.2. Dinh gii ket qui dieu trj
Phuang p h i p phau thuat chu yeu la m d t h i m dd va phue hoi cau true ddn thuan chiem ti le 61% v i la
phdong phip duy nhat d nhdm chan thdong hd. Cd the giii thich la do ti le benh nhin chan thuong hd cao I i nhdng trddng hpp benh nhin td td bang cich cat CO bang dao, vi viy viec phue hoi ma khdng can dat nong I i du mang lai hieu qui. Ben canh do, ti le nhdng trddng hpp ton thdong don thuan sun giap cung cao, ma phdOng phip phau thuat don thuan ehi la md bde Ip sun giip va phue hoi lai sun giip cung du cd ddpc ket q u i . Ket q u i nay cung phu hpp vdi ket q u i eua da so cic t i c g i i khic, sun giip ldn nhat, nhd ra nhat d vung eo nen la sun bj tie dpng nhieu nhat eua Idc giy chan thuong. Trong nghien cdli niy chung tdi thay phdong phip md phue hoi sun giip chiem so Idpng nhieu nhat, tiep den la phue hoi mang giip - mdng. Dieu nay ed the giii thich I i ton thdong don thuan sun giip va ton thdOng ddt mang giip - mdng do t u td chiem so Idpng nhieu, ke tiep cung la ton thuong phoi hpp sun giip v i ming giip - mdng. Muc dich chfnh la tao sU on djnh cau true khung thanh - khf quin va sp phu kfn niem mac. Ket q u i niy cung phu hpp vdi ket q u i eua da so cic t i c g i i trong nude va nddc ngoii khac. So ngay dieu tri trung binh cua chung tdi la 13,5 ngay. Ket q u i niy cung phu hpp vdi ket q u i eua cung t i c g i i . Nhdng benh nhan phii dat ong nong I i nhdng trddng hpp ed so ngiy nim vien thudng keo dai. Ti le benh nhin ed the td thd bang di/dng td nhien chi dat 65%, toan bp benh nhin d nhdm chan thdOng hd deu td thd duac, nhdng benh nhin edn phii deo ong hoac deo canul deu d nhdm chan thdong kin. Theo chung tdi
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N 3/2011
CO le trong nhdng trddng hpp chan thdPng kfn do ton thuong phdc tap g i y bien dang nhieu khung thanh - khf quan, cung cd the do trong chan thdong kfn viec dda ra ehi djnh toi du de benh nhan cd the t d thd ddpc van con khd, tham chi gay tam ly do dd do tfnh phdc tap cua benh ly chan thdong thanh khf q u i n . Ket q u i eCia chung toi cao hon ket q u i cCia t i e gia Tran Phan Chung Thuy [3], nhdng thap hon so vdi ket q u i eua cic t i e g i i nddc ngoai, nhd nghien edu eua t i c g i i Marko Juutilainen [5] thi toan bp 33 benh nhin ed the thd nhd binh thddng, tuy nhien t i c g i i cd thdi gian theo doi tren 3 nam, can thiep phau thuat thddng sdm trong vdng 24 gid, die biet t i e gia d i sd dung mot phdong tien eo djnh ma theo nhieu nghien edu la phdong p h i p tot nhat hien nay cho viec CO djnh khung thanh - khf quan, do la he thong nep - vft miniplates ma hien tai d Viet Nam ehua cd.
Do viec can thiep mupn q u i 2 tuan lam cho to chdc xo seo phat trien lam i n h hddng den ket q u i dieu trj.
Ve d i n h g i i chdc ning p h i p am cua benh nhan sau dieu trj chung toi thay chi ed 35% benh nhin ed the noi nhd binh thddng. D i y la van de nan giii trong dieu trj chan thdong thanh - khf quin, die biet d Viet Nam, khi ma yeu cau ve chat Idpng gipng noi edn bj xem nhe do chfnh benh nhin, eiJng nhd do cic nha lam sang. Ket q u i nay cung thap hon nhieu so vdi ket q u i eua t i e gia Marko Juutilainen, ket q u i benh nhan noi tot dat den 61%, ly do ed le cung la nhdng ly do ma chung toi da de cap d tren [5].
5. Ket luan
Qua nghien edu 23 benh nhan ddpc dieu trj ngoai khoa, chung toi rut ra mot so ket luan nhdsau:
- Nguyen nhan gay chan thdong hang dau la tai nan giao thong, ke den la t d t d . Loai ton thdong g i i i phau benh la tdOng ddong nhau.
- PhdPng p h i p phau thuat chu yeu la md tham do phue hoi cau true don thuan chiem ti le 61 % va la phdong phap duy nhat 6 nhdm chan thdong hd.
Phue hoi tai tao cau true don thuan chu yeu la sun giap va mang g i i p mdng. So ngay dieu trj trung binh la 13,5 ngay.
Ti le benh n h i n ed the t d thd ddpc chi chiem 65%, so benh n h i n edn dat ong hoac deo canul deu nam d nhdm chan thdong kin. Ti le benh nhin cd gipng noi nhd binh thddng chi dat 35%.
Tai lieu tham khSo
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2. Le Thanh Thai, Pham Khanh Hoa (2010), "Budc dau danh gia cac phUPng phap dieu trj chan thUPng thanh - khf quan". Tap chf Y hpc Viet Nam, Tap 365, So 1, tr.45-49.
3. Tran Phan Chung Thuy, Tran Anh Bfeh, Ngo Thj Diem Trang (2006), "Nghien edu tinh hlnh chan thUPng thanh khf quan tai Khoa Tai Mui Hpng, Benh vien Chp Ray 2005-2006" Npi san hoi nghj khoa hpc ky thuat TPHCM 12-2006, tr.430-436.
4. Lee W.T., Eliashar R., Eliachar I. (2008), "Acute external laryngotracheal trauma: Diagnosis and management".
Ear, nose and throat Journal, USA, march 1, volume 85, issue 3, pp.179 (6).
5. Marko J., Juha V., Soraya R., (2008), "Laryngeal fractures:
clinical findings and considerations on suboptimal outcome". Acta Oto-Laryngologica, 128:213-218.
6. Primuharsa W., Mazita A.M., Marina M.B. (2009),
"Laryngotracheal disruption caused by blunt neck injury". The internet journal of head and neck surgery, volume 3, number 1.
7. Scott P.S. and Steven D.S. (1993), "Laryngeal Trauma", Head and Neck Surgery, Otolaryngology, pp.936-944.
8. Thevasagayam M.S. and Pracy P. (2005), "Laryngeal trauma: a systematic approach to management".
Trauma, 7, pp. 87-94.
9. Thomas L.K., Patricia A.G., Brad M., Greene J.S., Phillip K.P., and Mark H. (2004), "Strobovideolaryngology in the management of Acute Laryngeal Trauma", Journal of voice, 18(1), pp.130-137.
10. Yolanda D.H., Robert T.S. (2002), "Blunt trauma to the larynx and the trachea: Considerations for the Professional Voice User", Journal of Singing, 59(1), pp.41-47.