Tgp chl Tai MQi Hong Vigt Nam - Volume (57-11). N°5 - Oct.. 2012
KY THU^T M 6 6 C TAI
TRONG PHAU THUAT CAY OC TAI DIEN TITDA KENH
Le Tran Quang Minh * Nguyin Thi ^gpc Dung*, Phgm Nggc Chdt**
TOM TAT Muc tieu: Mo td, ddnh gid kit qud ky thugt ma vdo 6c tai
Doi tirgrng vd phuang phdp nghien cuu: Nghien cuu mo td timg ca co can thiep. 52 binh nhdn dugc phdu thugt cdy oc tai diin tit v&i ky thugt m& oc tai &phia tru&c dual ga cira sd trdn, 02 binh nhdn di dgng 6c tai duac ddt diin cue thdng ddc biit.
Ket qud- bdn lu$n: Ky thudt m& oc tai a phia tru&c du&i ga cira so trdn dgt ty le thdnh cong 100% (52 binh nhdn), dgt dugc toan bg 24 kenh cua diin ctfc, tdt cd co ddp img thdn kinh, dung vi tri thang nht, kliong co ton thuang ben trong oc tai (do tr& khdng thdp sau dgt diin cue), khong co tai bien trong vd sau mo.
Ket lu^n: Thi ma dc tai quan trgng nhdt, viec xdc dinh cica so trdn Id mdc gidi phdu chinh. Ky thugt m& vdo dc tai & vi tri tru&c du&i g& cua so trdn da dugc chung tdi thtrc hiin thdnh cong & 52 ca (100%). todn bg diin cue dugc ddt hit vao 6c tai, khong ghi nhdn tdn thuang ben trong 6c tai Ddi v&i tru&ng hgp bdt thu&ng GPH oc tai, cdn nghien cuu ky CT Scan de co ky thudt cdy 6c tai diin tii phii hap. Ky thudt ndy dam bdo yiu cdu vira ma chinh xdc vdo thang nhi vira khong gdy ton thuang ben trong 6c tai
Tic khoa: Oc tai diin tit, di dgng 6c tai, ga cua so trdn.
SUMMARY
COCHLEOSTOMY TECHNIQUE IN COCHLEAR IMPLANT SURGERY Le Tran Quang Minh *, Nguyen Thi Ngoc Dung*, Pham Ngoc Chat**
Objective: Descript and ascess the cochleostomy technique results.
Method: Descriptive case study. 52 patients had cochlear implant with the antero- inferior round window niche cochleostomy technique, 2 patients have cochlear deformities who were implanted the straight electrode.
Results and Discussion: The antero-inferior round window niche cochleostomy technique has the 100% result (in 52 patients). The electrodes are completely inside cochlear with 24 channels which have nervous reflex and accurate scala tympany (low impedance), no complications.
Conclusions: Cochleostomy is the most important step. Round window niche is chiefly anatomy landmark. The antero-inferior round window niche cochleostomy technique was done successfully in 100% of cases. The electrodes were completely inside cochlear. In cochlear deformity, it was checked carefully on CT Scan in order to get the appropriate cochlear implantation. This technique makes sure the exact scala tympany implantation without cochlear damage.
Keywords: Cochlear implant, cochlear deformity, round window niche.
* BV Tai Mui Hong- TP H6 Chi Minh.
** Bp mon Tai Mui Hpng- D^i Hoc Y Dirge TP H6 Chi Minh.
Nh$n bai 5/10. Duyft in 15/10/2012.
Tgp cht Tai MQi Hpng Vi$t Nam - Volume (57-11). N°5 - Oct., 2012
1. DATVAN0fe
Phau thuat cay 6c tai di?n tii U mpt phau thuat tai nang cao tucmg doi phijrc tgp vdi nhieu thi kh^c nhau trong phau thu^t. K^ tir 1961. WiHam House d3 gi6i thi^u v£k chuan hda cdc thi chinh cua phau thu^t cay oc tai di^n tir bao gom: mo xuoiig chum, mo hom nhi sau qua iigEich mat. md 6c tai vd d^t di?n c\rc. Trong cdc thi chinh cua phau thu^t, ihi mo oc tai Id thi quan trpng nhat, quyet djnh s\r thdnh cong hay that bgi cua phau thuat.
Tren the gidi hipn nay. van cdn nhieu quan diem khdc nhau vc vi tri md 6c tai nhung t^ru trung, cdc tdc gid van dang CO gdng gidi quyet van de lam the ndo vira phdi ma dupe 6c tai vira phai tranh nguy CO ton thucmg ben trong 6c tai.
Tir tinh trang neu tren vd thuc te chua CO de tai nao bao cdo ve van de nay, chung toi tien hanh thuc hien de tai nghien cuu voi muc dich xdc dinh vi tri ma 6c tai chinh xdc, gop phdn nang cao ty le thdnh cong ciia phau thuat.
2. DOI TU'gfNG VA FHU'CNG FRAP NGHIEN CUtJ
2.1. Doi tugng nghien cihi
• Tieu chuan lira chpn benh nhan 54 b?nh nhan diec ndng vd sdu cd 2 tai dupfc khdm, chan doan va phau thuat tai Benh vien Tai Mui Hpng thanh pho H6 Chi Minh tir thang 9 nam 2009 d^n thdng 12 nam 2011.
Tieu chuan l\ra chpn benh nhan:
Benh nhan > hoac bdng 12 thang Diec tiep nhan ndng den diec ddc 2 tai Chirc nang than kinh thinh gidc binh thuotig
Phdt trien tam sinh ly binh thucmg, co ky nang n6i vd giao ti§p t6t. Doi vai tre em thi cha m? phdi sdn sang phoi hpp huan luy?n cho tr6 cdc ky n5ng nghe, n6i sau cay dipn oc tai.
Khong cdi thipn thinh li^c khi deo bat ky logi mdy trpr thinh ndo
Khong c6 bpnh ly npi khoa chong chi djnh phau thudt
Kh6ng c6 bat thu6ng gidi phau hpc viing tai trong (khdo sdt tren CT Scan vd MRI)
Tieu chuan logi trir
Bpnh nhan khong dii cac tieu chuan tren 2.2. Phirong ph^p nghien cihi: Nghien cuu mo ta timg ca co can thipp.
Cdc bpnh nhdn dupfC khai thac bpnh su, do thinh l\rc ddnh gid muc dp nghe kem, chyp CT xuong thai duang danh gid tinh trang 6c tai, chup MRI.
Bpnh nhan con duprc khdm danh gid tinh trgng phdt trien tam than, npi soi tai vd vom danh gia V.A (d6i voi tre em).
Bpnh nhan phai duprc ngo V.A vd chung ngira viem mang nao mu truac khi phdu thudt 3 thdng.
Phau thuat duac th^rc hipn voi duong rach da each ranh sau tai 1cm, tir tren xuong duoi song song vcri rSnh sau tai vd CO dp ddi tir 3-4 cm. Boc tach cot mac du de tiep can vi tri se khoan giuang dat bp phan tiep nhan trong. Khi tiep cgn mdt ngoai xuang chiim, cac thao tac ma vao xuang chum, mo ngach m^t, tgo giudng, dgt dien cue duprc th\rc hipn tuang tu phuong phap m6 kinh dien. Rieng thi ma 6c tai se dupe thuc hipn theo ky thugt mo 6c tai 16 nho.
Tgp cht Tai MOi Hpng Vi$t Nam - Volume (57-11). N°5 - Oct., 2012
3. K E T Q U A N G H I E N ClfU VA BAN LU.^N: T6ng s6 54 bpnh nhan.
Gi*i: Nam 53,7%. N u 46,3%. Nam nhieu han nir nhung khong ddng ke.
Tuoi phau thuat
<2tu6i: 16(29,6%) 2-5 tu6i: 30 (55,6%) 6-15tu6i:6(ll,l%)
>15tu6i:2(3,7%)
Dp tu6i pho bien nhat: 2-5 tu6i (55,6%).
Theo Niparko chi so tuoi phdu thuat rat quan trpng vi:
Cho thay vai tro ciia viec phat hien diec som 6 tre em.
Cay som a tu6i cdng nho, ket qua phdt trien ngon ngii cang tot hon -> hpi nhap som (2)(4).
56%
b
Biiu di 1: Ti ll phdn bo tuoi phdu thudt Dia phirong
Mijn BSc: 19 (35,2%).
Mijn Tnmg: 10 (18,5%).
Mi6n Nam: 25 (46,3%) trong do co 15 (27,8%) benh nhan a TP H6 Chi Minh.
Phan b6 kha din du BV Tai MOi Hong cr TP H6 Chi Minh, mien Nam co nhieu hon nhung khong dang k l do Men nay, BV Tai Mui Hong TP H6 Chi Minh la BV chinh thuc hien phau thuat cay 6c tai dien tft a VN.
46%
19% I
M I £ N B A C M I ^ N M I ^ N N A M TRUNG
Biiu do 2: Ti li phdn bo theo dia phuang
Loai diec
Tniac ng6n ngii (Diec bam sinh): 51 (94,4%)
Sau ng6n ngii (Diec mac phdi): 3 (5,6%)
Diec truac ngon ngu (Diec bam sinh) chiem ty le 94,4%, nhu vdy dai da s6 la cac benh nhi. 3 ca diec sau ngon ngir deu xay ra sau viem mang nao. Nhu vay trong nghien curu cua chung toi, viem mang nao la nguyen nhan thucmg nhat gay diec tai trong sau sinh cung nhu tdc gia Berke (3).
• Oi£C MAC PHAI
• Di£CMAC PHAl
Bieu do 3: Ti li phdn bo phdn logi diec Thioh lire do
50 ca (92,6%) diSc ddc.
04 ca (7,4%) diSc sau 90-100 dB.
Hau het cac benh nhan deu diec rat nang, kh6ng the nghe duoc bang may trp thinh.
C T Scan, M R I
52 ca (96,3%) CT Scan co hinh dang, vi
Tgp cht Tai MOi Hpng Vi$t Nam - Volume (57-11). N''5 - Oct., 2012
tri oc tai trong gi6i hgn binh thu6ng.
02 ca (3,7%) CT Scan c6 logn sdn tai trong 2 ben.
54 ca (100%) c6 ket qua MRI binh thu6ng. kh6ng thay cdc ton thucmg ho$c u day than kinh VIII.
CT Scan c6 vai tr6 d$c bipt quan trpng de ddnh gid \'i tri. hinh dgng oc tai, xdc djnh lru6c cac moc (iiai phau can thiet dc CO the mo oc lai. D^c bipt doi vai tru^g h(7p di chumg viem mdng ndo, oc tai sc dan bj cot h6a. do vgy can chyp CT Scan it nhat trong I thdng tru6c mo de ddnh gid chinh xdc oc tai (1 )(4).
Ben phau thuat Ben (P): 37/54 (68.5%) Ben(T): 10/54(18,5%) 2 ben: 7/54 (13%)
Chung t6i thuc hipn da so a ben (P) vi neu trong truang hop xuong chiim va 6c tai 2 ben binh thuomg, chiing toi s€
thirc hien ben tay thuan de benh nhan de thdo lap mdy.
Gan day chung t6i phau thuat 7 ca 6 2 ben (khi benh nhdn co dieu kipn kinh te). Viec cay 6c tai dien tu 2 ben giup benh nhan nghe vd djnh hucmg dm thanh t6t hon (4)(6).
Phau thuat
Hien nay tren the gioi co 3 phuang phap mo vdo 6c tai ddt dipn c\rc:
1. Dgt qua mdng cua so tron.
2. Khoan mo rpng go cira so tron, sau do dgt qua mang cua so tron.
3. Khoan ma 6c tai lo nho a phia truoc duoi go cira s6 tron.
Nhung noi chung co the chia thdnh 2 phuang phdp: dgt qua mang cira so tron vd ddt qua lo khoan ma 6c tai, moi
phuang phdp c6 im vd nhup^c diem rieng. (8)(9)
Chung t6i lh\rc hipn ma 6c tai theo ky thugt md 6c tai lo nho theo da so cdc tac gid tren the gi(M (Nghien cim ciia Oliver Adunka vd cpng s\r) (7). Ngodi ra, Robert J.S. Briggs, Michael Tykocinski trong mpt nghien cihi dd nhdn thay kh6ng co t6n thucmg dang ke trong 6c tai 6 cd 2 phuang phdp ddt dipn cyc qua mdng cira s6 tr6n vd qua m6 6c lai a phia truoc duoi g6 cua s6 trdn. (1)
Trong 52 ca (96,3%) c6 hinh dgng, vj tri 6c tai trong gidn han binh thuong tren CT Scan, chiing t6i ddt dien cue theo ky thugt nay thdnh c6ng (100%).
02 ca (3,7%) CO di dgng 6c tai 2 ben tren CI Scan, chung toi khong the xac dinh cira so tron va g6 cira so tron nen kh6ng the d^t dipn cue theo 1 trong 3 cdch kinh dien tren. E)6i voi 2 truong hpp ndy, chung t6i phdi th\ic hien ddt dien cue ddc bipt. Ddy la loai dien cyc thdng ciii^
bao g6m 24 kenh, c6 chieu dai khodng 10mm. 01 ca chiing t6i ddt vdo 23 kenh, ca con lgi chi dat dupe 12 kenh nhimg deu CO dap img thdn kinh t6t.
Nhu vdy. viec xdc dinh chinh xac ga cira so tron co y nghTa quan trpng quyet dinh thanh cong ciia phau thuat. Trong truong hprp di dgng bat thuong, c6t hoa 6c tai ho$c viem nhiem gay c6t hoa oc tai thur phat (nhu sau viem mdng nao), phdi ddnh gid ky CT Scan moi chup tru6c khi tien hdrih phau thugt.
Thoi gian ndm vifn sau phau thuat
• < 7 ngdy: 3 (5,6%) 7-10 ngdy: 42 (77,6%)
> 10 ngdy: 9 (16,8%)
Tgp chi Tai Mui Hgng Vi$t Nam - Volume (57-11). N°5 - Oct, 2012
> 10 Ngay i m 17%
7-10 Ngay • • • • • • • • 78%
< 7 Ngay I 6%
0 70 4n AO RO 100
Bieu do 4: Ti li phdn bo thai gian ndm vien sau phdu thudt
Da so cdc benh nhdn xudt vipn trong khodng 7-10 ngay sau mo, khi vet m6 ldnh on dinh.
Tai bien
Kh6ng CO tai bien trong phau thudt.
Kh6ng chdy mdu vd tu mdu sau phdu thudt.
Vet m6 kh6, lien da sau 1 tudn: 54 ca (100%).
KETLUyVN
Trong cdc thi chinh cua phdu thugt, thi m a 6c tai dat dien cue la thi quan trpng nhdt, quy6t dinh su thdnh c6ng hay that bai cua phdu thudt. Trong do viec xac dinh cira s6 tron la m6c gidi phau chinh yeu giiip ma vdo 6c tai diing vi tri.
Ky thugt m o vdo 6c tai 6 vi tri truoc duoi go ciia s6 tron da dupe chiing toi thuc hien thdnh c6ng a 52 ca (100%). Toan bp dien cyc dupe ddt hh vao 6c tai, kh6ng ghi nhgn t6n thuang ben trong 6c tai qua cac test kiem tra ddp ling thdn kinh vd do trd khdng sau m6.
D6i vdi tnrdng hpp bdt thudng GPH 6c tai, cdn nghiSn cuu ky CT Scan de cd ky thudt cay 6c tai dien tu phii hpp.
Trong trudng hop he tai binh thudng ve vi tri vd hinh dgng, ky thuat ndy ddm bdo yeu cdu vira md chinh xdc vao thang nhi vira kh6ng gay t6n thuong ben trong 6c tai.
TAI LI$U THAM KHAO 1. Briggs RJ, Tykocinski M, Stidham K,
Roberson JB (2005). Cochleostomy site:
implications for electrode placement and hearing preservation. Acta Otolaryngol.
2005Aug;125(8):870-6.
2. Deborah L. Tucci, John K. Niparko (2005). Medical and Surgical Aspects of Cochlear Implantation. In: John K.
Niparko. Cochlear Implants Principles and Practices, Lippincott Williams and Wilkins, Philadelphia, pp 189- 221.
3. Jamie Berke (2010). Cause of Hearing Loss.
About.com Guide.
4. John K. Niparko (2005). Assessment of Cochlear Implant Candidacy. In: John K.
Niparko. Cochlear Implants Principles and Practices, Lippincott Williams and Wilkins, Philadelphia,ppl73-I77.
5. Joseph B. Robertson (2005). Cochlear implant Surgery: Minimally invasive technique. Operative techniques in Otolaryngology- Head and Neck Surgery.
Vol 16, Issue 2, pp 74-77.
6. Mack KF, Heermann R, Issing PR, Lenarz T, Schwab B (2006). Four year's experience with the minimally invasive surgical approach in cochlear implant surgery.
Minim Invasive Ther Alied Techno!., vol 15, Issue 3, pp 187-192.
7. Oliver F. Adunka, MD; Craig A. Buchman, MD (2007) Scala Tympani Cochleostomy I:
Results Laiyngoscope, 117:2187-2194, 2007.
8. Omid Majdani, Theodore Schuman (2010).
Time of cochlear implant surgery in academic settings. Otolaryngol Head Neck S-wrg.; 142(2); pp 254-259.
9. Richard C, Fayad JN, Doherty J, Linthicum FH (2012) Round window versus cochleostomy technique in cochlear implantation: histologic findings. Otol Neurotoi 2012 Sep; 33(7):1181-7.