Tgp chi Tai Mui Hong Vi$t Nam - Volume (60-25). N°1- Februaty, 2015
DANH GIA K&J QUA P H A U THUAT N Q I SOI CO Sir DUNG DINH VI LAY BO K H O I U MUI XOANG
LeMinh Ky, VQ Hdng Tudn, Bui Thi Anh, Hodng VU Giang, Pham vdn Hitu, Vu Trircmg Phong, Tdng Xuan Thdng,
Nguyin Quang Trung, Vo Thanh Quang.
SUMMARY
Objective: To report our experience with endonasal endoscopic surgery of benign tumors and tumor-like conditions ofthe nose and paranasalsinuses. Methods: The medical records of 45 patients with tumors and tumor-like conditions, who had undergone endoscopic surgery for removal oftheir lesions between 2013 and 2014, were studied.
Results: The study included a total of 45 patients. Out of these patients, there were 12 wilh inverted papilloma, 5 Juvenile nasopharyngealangiofibroma, 2 fibro-osseous lesions, 2 olfactory neuroblastoma, two schwannoma.... Follow-up assessment included endoscopy and yearly CT scans. These were managed endoscopically. There wereno major complication encountered in this study, one meningitis have been treated Conclusion:
Benign tumors and tumor-like conditions of the nose and paranasal sinuses can be managed with endonasal endoscopicsurgery with minimal morbidity.
1. DAT VAN ©E
Khdi u miii xoang la mdt bdnh thudng gap cua benh ly mui xoang. Benh cd thd gap d mgi lua mdi, bao gdm cdc the u khac nhau Idnh tinh ciing nhu dc tinh.
Trudc day phdu thudt khoi a miii xoang chii yeu dugc thuc hien bdng dudng ngodi, tuy vay khoang 2 thap ky gdn ddy, phdu thuat NSMX da dugc iing dung trong phau thuat khdi u nhd cac tidn bg ve ndi soi, chan doan hinh dnh...
Tuy vdy, phdu thuat ndi soi miii xoang vdn cdn nhung han ehd, khdng cd dugc mdt phdu trudng toan didn va cd chieu sdu, khdng dinh vi dugc chinh xdc cac moc giai phdu quan trgng, de xdy ra bidn chiing nguy hidm nhu tdn thuong sdn sg, 6 mit, than kinh thi, ddng mach cdnh.
Su ra ddi ciia he thdng hudng din hinh B?nh vien Tai Mui Hong TW
Nhan bai 10/10/2014. Duyet in 20/10/2014)
anh dinh vi ba chidu (IGNS hay IGS), va bat ddu dugc su dung trong ITnh vuc phau thudt ndi soi mui xoang tai My vao nhiing nam cudi cua thdp nidn 90 vd nhiing nam ddu cua thdp nien 2000, la mdt budc tien ldn, da giup khac phuc dupe nhiing han che cua phdu thuat ndi soi miii xoang, lam cho cudc md trd ndn an toan va triet dd hon;
giup dinh vi va tranh ldm tdn thuong cac cau tnic quan trpng nhu xuong gidy, d mat, san sg, thdn kinh thi, dpng mach canh trong.
Tai Viet Nam, vide iing dung phau thudt ngi soi mui xoang Idy khdi u mui xoangchi mdi bdt ddu dugc iing dung trong nhung nam gdn day va dd cd nhung ket qua nhdt dinh nhu : Idy hdt khdi u, ty Id tai phat gidm. Tuy nhien trong nhirng trudng hop khi khdi u phat tridn lan rdng, chen i'p vao cdc cau tnic quan trgng cua hdc miii, nen sg gay nhidu khd khan cho phdu thuat cd khi khdng dam bdo lay hdt khdi u, ngugc lai c6
60
Tap chi Tai MOi Hgng Viet Nam - Volume (60-25). N°1- February, 2015
thd phdi ngung phdu thudt dd ddm bdo an todn cho bdnh nhdn. He thdng IGS se khde phuc dugc nhiing khd khan ndy.
Kd tir khi he thdng hudng dan hinh anh IGS dugrc dua vdo sii dung tai Bdnh vidn Tai Mui Hgng TW, chung tdi da tung budc ling dung vdo cdc phdu thuat cdn thidt.
Chinh vi v^y, van dd chi djnh, chdng chi dinh, quy trinh phdu thudt, quy trinh van hdnh may an todn, chinh xac cdn duoc nghien ciiu.
Chung tdi tidn hdnh de tai: "Nghien cwu lfng dung h$ thdng dinh vi khong gian ba chieu trong phau thug.t ndi soi cat bo khoi u mui xoang", vdi muc tieu Ddnh gid kit qud budc ddu, tai biin, biin chung cita phdu thudt tren.
2. ©6l TU*ONG VA PHUONG PHAP NGHIEN CUtJ
2.1. Doi tuong nghien cuu
Gdm 45 benh nhdn dugc chdn dodn u miii xoang dupc didu tri phdu thu|tt ngi soi dudi hudng dan ciia hd thong dinh vj khdng gian ba chidu.
- Nghien ciiu dugc tien hanh tai Benh vien Tai Miii Hgng Trung uong
- Thdi gian tii thdng 12/2013 ddn thdng 10/2014
2.2. Tieu chudn l^a chgn
Benh nhan dugc chdn doan u mui xoang, dupc chup CLVT tai Benh vidn Tai Miii Hgng Trung uong, bao gdm:
U lanh tinh: u xo mach vdm mui hgng, u nhii miii xoang, u nhdy xoang...
U dc tinh miii xoang: img thu bidu md vdy, ung thu bieu md tuyen, u nguydn bdo than kinh khuu gidc...
Phuong phap didu tri Id phdu thudt NSMX dudi s\i hudng ddn cua hd thdng dinh vi khdng gian ba chidu IGS.
- Benh nhan tu nguydn tham gia nghien ciiu
2.2.2. Tieu chudn logi trie
- Khdi u lan rdng vao ndi sg, d mdt, hd chan budm hdm.
- Bdnh nhan chdng chi dinh phau thudt.
2.3. PHU'OfNG PHAP NGHIEN CUtJ 2.3.1. Thiet ki nghien cuu
Thidt ke md ta tiing ca cd can thiep vd theo ddi ldm sang.
2.3.2. Phmmg tiin nghiin ciru Benh an nghidn cihi
Trang thiet bi khdm nOi soi: gdm bd ndi soi Karl- Stortz, camera, ddy dan sang vd optic 4mm cdc gdc dp 0 do, 70 do.
Phim vd dia CD ky thudt sd CT scaner trudc md: phim dugc chup bang may ky thudt sd MSCT 16 do day lat cat 0,7mm, kdt qud luu vao dia CD de cai dat trong luc md
He thdng dinh vi khdng gian ba chidu: he thdng dinh vi quang hge cua hang BrainLAB. Tdn ggi ciia may Id Kolibri navigation system cranial/ENT version 2.6, Id he thong IGS thd he mdi vdi uu didm;
gpn nhe, thdi gian Idp dat, dang ky may nhanh, giao dien phan mdm thugc he didu hanh Windows de sir dung. May cd the sii dung chung cho ca phau thudt ngoai thdn kinh vd phau thudt mui xoang. Mdy cho phep xoay ddu bdnh nhdn trong luc md md khdng bi sai lech kdt qua.
* Chudn hi & ddng ky tuang tdc benh nhdn phdu thudt vdi IGS:
Tdt cd cdc bdnh nhdn ddu dupc gay me ndi khi qudn.
Gan vdng deo dau cd 3 qud cdu dinh vi ldn trdn bdnh nhan.
Tgp chi Tai Mui Hong Viet Nam - Volume (60-25). N''1 - February, 2015
Camera phdt ra tia hdng ngoai se dupfc dat d phia trdn ddu ciia bdnh nhdn, hudng camera ve phia 3 qud cdu dinh vi tren trdn bdnh nhan cho ddn khi thdng tin trdn man hinh ciia mdy bao dat yeu cdu.
Dang ky tuong tdc benh nhdn vdi phuong phdp quet be mat da: diing dung cu phdt ra tia laser mdu dd (Z touch laser pointer) nhdn mit vd giii lidn tuc, chidu ldn mdt sd vung tren tran vd mdt cua benh nhdn cho ddn khi may bdo dat yeu cdu, dung cu nay ddng thdi phdt ra tia hdng ngoai vd dugc camera ghi nhdn vd dua vdo he thdng IGS dl tmh toan.
Kiem tra do chinh xdc cua he thdng bdng dung cu thdm dd dugc mac dinh sdn bang each cham vao cac mde giai phdu ben ngodi nhu chdp miii, nhdn trung, xuong chinh miii, va ben trong h5c miii ddi vdi cdc moc giai phau hdng dinh nhu vach ngdn, cung ciia mui sau. Ddi chieu trdn mdn hinh may dinh vi ba chidu dd xdc nhan dg chinh xdc. Khi dat yeu cdu se tien hanh phau thuat.
Cdc qud cdu dinh vi cdn dugc gan trdn bdt ky mdt dung cu nao cdn sir dung trong liic md, nhu dng hiit, que tham dd, pince.
Moi ldn chi dupc sii dung mdt dung cu dugc dang ky tuong tdc kem vdi dung cu thdm dd duoc mac dinh sdn. Neu mudn thay ddi dung cu khac thi dang ky tuong tdc Iai, rieng dung cu tham dd dugc mac dinh sdn thi khdng cdn dang ky hrong tac. Thdng thudng chi can dung cu tham dd dugc mac djnh sdn vd them mdt hay hai dung cu khde dugc dang ky dinh vi them nhu dng hiit, cay tham dd.
2.3.6 Xir ly so lieu
Cac kdt qud thu nghien ciiu thu dugc dugc xii ly bdng cdc thuat todn thdng ke dua trdn phan mem SPSS 16.0
3. KE:T QUA NGHIEN CtTU VA BAN LUAN 3.1. D^c diem ve tuoi, gidi:
Bang 3.1. Ph3n bd li>a tuoi cua nhom nghifen ci>u Lira tuoi
<5 5-14 15-39 40-60
> 60 tuoi T6ng so
S6 lu'o'nq 1 3 9 27
5 45
Piian trSm 2%
6%
20%
50%
11%
100%
Da sd cdc trudng hgp nam trong liia tudi tir 40 den 60 tudi, trong dd chi cd I trudng hgp dudi 5 tudi vd 5 trudng hgp trdn 60 tudi. Bdnh nhan ldn tudi nhat Id 82 tudi vdi khdi u nhay xodng trdn sang, benh nhan nhd tudi nhdt Id 1 mdi vdi khdi u than kinh (shwanoma) cua xoang sdng.
3.2. Tridu chirng ca nang cua khdi u mui xoang
Bang 3.2. Phdn b6 trigu chdng co ndng Tri$u chiJng co"
nanq Nqat tdc mOi Chay mOi Chay mdu mOi Bau nhi>c ddu Gidm thi lu'c Mat, qiam nqi>i Diu hi#u thin Itinh
S6 tru'&ng hpp
43 42 39 31 5 30 0
Ty IS (%) 95%
93%
86%
68%
11%
66%
0%
Trieu chiing quan trgng nhdt trong cac 62
Tap chi Tai Mui Hpng Vi$t N a m - V o l u m e (60-25). N 1 - February, 2015
khdi u mui xoang Id ngEit tac mui, chidm da sd trudng hop. ben canh dd tridu chiing chky mdu miii cac miic dp khde nhau ciing chiem ty Id quan trpng ( 86 %). Ddy Id hidu chiing nghi ngd khdi u miii xoang khi bdnh nhdn ddn khdm. Trieu chiing giam, mdt ngui ciing la mot trieu chiing kha quan trgng, chidm 66%. Khdng cd trudng hgp nao cd tridu chiing ve than kinh khu tni, do nhiing trudng hgp ndy thudng ndng, khdng cd chi dinh phau thuat.
3.3. Dac diem vi tri ton thuorng xam ldn tren CLVT mui xoang
Bang 3 3. Vj tri tSn thuong xam lan tr6n CLVT
3.4. Dac diem giai phdu b^nh ly:
Bang 3.4. Phan b6 khoi u mQI xoang theo giai phau b#nh
T6n thu'Ong xSm lan Cdc thanh xoang XifO'ng k h I u cdi Xdm lln 6 mit Chdn b u a m Ho Chan bu'6'm hdm An mdn t r i n xoang sdng Xdm l l n n0i sp
So iLTOnq
46 1 3 5 2 3 0
T y i *
%
100%
2%
6%
1 1 % 4 % 6%
0%
Da sd cdc trudng hop khdi u lanh tinh ciing nhu dc tinh deu cd xdm ldn, phd hiiy cac thanh xoang trdn, sang,budm, ham d cdc miic dg khac nhau. Cd 3 trudng hgp khdi u xdm ldn d mdt, nhiing trudng hap nay chiing tdi phau thuat ket hgp dudng ngoai, trong dd cd 1 trudng hpp phdi khoet bd nhdn cdu. Trdn sdng bi an mdn trong 3 trudng hgp, tuy nhidn trdn phim chup cdng hudng tir, khdng cd ddu hidu lan vdo mdng ndo-nao. Trong thdi gian tdi, chung tdi se phdi hgp vdi ngoai thdn kinh dd phau thuat trong nhung trudng hpp ndy.
Giai p h l u benh
U nhd mQi xoang
U nhay
Trdn Trdn-sdng Trdn-sdng-buam Sdng Bu'6'm U x o mach VMH U shwanoma
U d c tinh
Carcinoma te bdo chuyen t i l p
Carcinoma vay sCpng hda
K bieu m5 khdng bl$t hda
Carcinoma t u y l n bi$t hda vua K t u y l n nang U hdc td dc tinh K nguyen bao TK U x o smh xu-ong Gia u do n i m xoang bipdm Gia u do viem dfnh 6 m i t
So lupng
12 2 4 1 2 1 5 2 4
1
1
1
1 1 2 2 2 1
Phan tram 28%
4 % 8%
2%
4 % 2%
1 1 % 4 % 8%
2 %
2%
2%
2 % 2%
4 % 4 % 4 % 2 %
Trong sd 45 bdnh nhdn, cd 12 trudng hgp u nhii miii xoang, u nhii thd ddo ngugc gdm 10 bdnh nhan chidm 22 %. U nhay miii xoang cd 10 trudng hgp chidm 22%, trong dd cd 1 trudng hgp u nhay xoang tran dan thudn. Khdi u dc tinh mui xoang chidm 11 trudng hgp, nhung cd den 4 trudng hgp ung thu bidu md dang nhii.
Kuhn [4] bdo cao trong 75 trudng hgp phau thuat khdi u mui xoang, trong dd cd 53 u Idnh tinh vd 22 u ac tinh, trong dd cd
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Tgp chi Tai Mui Hgng Vigt Nam - Volume (60-25). N°1- February, 2015
28 u nhu ddo ngugc, chi cd 2 trudng hgp ung thu bidu md nhu.
Trong bdo cao ciia Singhal [7] trong sd 92 trudng hgp khdi u miii xoang dupc phau thudt thi u nhu miii xoang chiem nhidu nhdt 28 ca, sau dd la u nhdy (14 ca), u xo mach 6 cas.
Theo mdt so bao cao (1,4 ), ty Id tai phat sau phdu thudt u nhii dao ngugc thay ddi tir 17-20%, vide ling dung ndi soi vdi cac loai dng gdc nhin khde nhau 6a gjup phdu thudt tri?t dd hon, tuy nhien vdi hd trg cua he thdng dinh vi cang giup phau thudt vidn lay bd khdi u triet dd hon vd an todn hon.
3.5. Ket qua phau thuat noi soi co su dung dinh vi
Bdng 3.5. Phu'ong phap p h l u thuSt
Bang 3.6. D u d n g phdu thu^t:
P h u v n g phap p h l u thudt Md xoang trdn, sang, bifdm d i n lu'u u n h l v C i t u don t h u l n C i t xoang sdng C i t xoang bupm C i t xoang sdng-budm C i t p h i n trong xupng hdm trdn
C i t todn bd xuong ham trdn S6 lu'O'ng
11 7 1 3 9 13 1
P h i n tram 24%
15%
2%
6%
20%
28%
2%
Ddi vdi hau hdt cdc u nhdy miii xoang, chiing toi chii ydu tien hanh md din luu rpng vdo hdc mu khdi u nhdy, khdng nhdt thidt phai lay het vd bao u nhdy.
Cat phdn trong xucmg ham trdn 13 ca, da sd dugc thuc hidn qua dudng ngi soi ddi vdi u nhii dao ngupc, chung tdi diuc hien bang dudng ngoai cho cdc khdi u ac tinh.
Cd mdt trudng hpp khdi n khd Ian rdng, ddn xucmg khdu cdi, chiing tdi phdi tien hdnh phdu thudt dudng ngodi phdi hgp cat bd toan bd xuong ham trdn.
Dud'ng phau thu|it Npi soi don UiUein
Ph6i hop
Jaques
Caldwel Luc hay Rouge Danker Canh mui Canh mui m d rgng
8 6 lirg'ng
37 1 2 4 1
Phdn trdm '82%
18%
Da sd bdnh nhdn dugc phau thudt bang ngi soi don thudn, tuy nhidn cd 10 bdnh nhan cdn phdi hgp vdi dudng phdu thudt dudng ngodi. Vide md dudng ngoai chu yeu tien hdnh ddi vdi cac khdi u dc tinh Ian rdng, cdn Idy bd rdng rai, kd cd phdn xucmg nghi tham nhidm u, ngay ca trong nhirng trudng hpp nay, chiing tdi nhdn thdy vai trd cua dinh vi cung rdt quan trgng, giiip phdu thuat vidn kiem soat tdt cdc tdn thuong sat ndn sp, xoang budm, nhdt Id cdc ton thuang cd Ian ddn d mat, day than kinh thi gidc
Trong nghidn ciiu Luong Amber [1]
(My), trong sd 57 ca u dc tinh miii xoang dupc phau thudt bang dudng ndi soi, cd 6 ca can phai phdi hpp vdi dudng ngoai.
Bang 3.7. Ty l§ Idy h§t kh6i u
Ty le l i y h i t khoi u 80-100%
70-80%
60-70%
S6 ll^pnq 40
3 2
T } l | 88,9%
6,7%
4,4%
Chiing tdi ddnh gid ty Id Idy hdt khoi u trong phdu thuat bdng cdch kiem tra dudi he thdng dinh vi vd ngi soi, neu ddu dd dinh vi cd the di cham ddn toan bd bd chu vi ciia khdi u, kidm tra dudi ndi soi khdng cdn khdi u thi cd thd xem nhu Idy hdt hr 90-100%.
Tuy vdy trong mgt sd trudng hpp, khdi u lan rgng, nam d cdc vi tri nguy hidm nhu lan vao ddng mach cdnh trong-xoang budm, lan sdu vdo dinh d mdt, trdn xoang budm, ffiih
Tap chi Tai IVIui Hgng Vi6t Nam -Volume (60-25). N°1- February. 2015
mach xoang hang..,khdi u ac tinh thdm nhiem sdu vung tran vdm... chiing tdi khdng thd idy dugrc toan bd khdi u.
Trong nghidn ciiu cua Hwan-Jung Roh tren 24 bdnh nhdn cd khdi u dc tinh miii xoang, cd 19 trudng hgp lay dugc het khdi u, trong dd cd 3 trudng hap phdi hop vdi dudng ngoai. Cd 5 trudng hgp khdng Idy dugc todn bd khdi u.
Tuy nhien trong nghien ciiu nay chung tdi khdng ldm sinh thiet tiic thi vimg ria khdi u do nhung khd khdn vd didu kien he thdng gidi phau bdnh ly cung nhu vd didu kien kinh te d VN.
Bang 3.8.Bi^n chung do phdu thuat:
Bien chi>nq Chay mdu Tu mdu Biln chCrnq mit Chay dich ndo tOv Vidm mdng ndo
S6 lupnq 1 1 0 0 1
Phin tram 2%
2%
0%
0%
2%
Trong cdc trudng hpp nghidn ciiu, chiing tdi chi gap 3 trudng hgp cd bidn chiing, trong dd cd 1 trudng hgp vidm mang nao mii sau md. Day Id trudng hgp khdi u dn man trdn sdng, dinh sdt vdo mang nao. Chung tdi khdng gap trudng hgp ndo bien chiing chay dich nao tiiy sau md.
4 .KET LU^N
Vdi kdt qud ban ddu, chiing tdi nhdn thay phau thuat ndi soi mui xoang cd su dimg dinh vi trong didu tri cac benh ly khdi u miii xoang la mdt budc tidn bd quan trgng trong phau thudt dieu tri khdi u miii xoang, giiip phdu thudt vien cd thd lay triet de khdi u hon, tranh dugc cac tai bidn, bien chung do phdu thudt.
TAI LIEU THAM KHAO 1. Amber Luong, M.D., Ph.D.,1 Martin J.
Citardj, M.D.,1 and Pete S. Bafra. M.D.2 Management of sinonasal malignant neoplasms: Defining the role of endoscopy. Am J Rhinol Allergy 24- 150-155 2010
2. Cummings (1998), "Neoplasmes ofthe nasal cavity", otolaryngology- head and neck surgery, pp. 95-98.
3. Hwan-Jung Roh, M.D., Ph.D.,Pete S.
Batra, M.D.,Martm J. Citardi, M.D.,Joung Lee, M.D.,§ William E.
Bolger, M.D-,and Donald C. Lanza, M.D.Endoscopic Resection ofSinonasal Malignancies: A Preliminary Report.
American Joumal of Rhinology 18, 239-246, 2004
4. Kuhn, Uta M;Mann, Wolf J;Amedee, Ronald GEndonasal Approach for Nasal and Paranasal Sinus Tumor RemovalORL : Journal for Oto - Rhino - Laryngology and Its Related Specialties;
Nov/Dec 2001; 63, 6; ProQuest Central, pg. 366.
5. Neumann A.M, Passquale-Niebles (1999), "Image-guided transnasal endoscopic surgery of the paranasal sinuses and anterior skull base", American Journal of Rhinology. 13, pp.
449-454.
6. Palmer JN , Kennedy DW (2005),
"Historical perspective on image-guided sinus surgery", Otolaryngol Clin North
^m. 38(3), pp. 419-428.
7. Surinder K Singhal, Nitin M Nagarkar, Arjun DassEndoscopic Removal of Tumors of Noseand Paranasal Sinuses:
Our Experience.C/m/cfl/ Rhinology: An International Journal, January-April 2011:4(l):27-37.
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