Tap chl Tai Mui Hpng Viet Nam - Volume (58-15). N 3- May, 2013
M O T s o DAC BIEM DICH TE HOC LAM SANG AP XE VtfNG CO
Le Vdn Sau*, TongXudn Thdng**, Dodn Thf Hdng hoa**
TOM T A T
Qud trinh nhiim khudn, lam mu ciia cdc khoang to chuc liin kit vitng co, do nhieu nguyin nhdn gdy ra. thudng nang, nguy hiem din tinh mgng nguoi benh Muc tieu: 1) Mo td cdc yeu to dich te hgc 2) phdn tich cdc yeu to dich te hoc liin quan dp xe vitng co. Doi tugng , PPNC: Nghien cuu timg ca qua 60 truong hgp dp xe viing co do nhieu nguyen nhdn khdc nhau.Dugc chdn dodn lam sang, noi soi. CT scan, vd diiu tri tai Benh vien TMHTW, 2007-2009. Ket qua: Gap 7 logi dp xe Nguyen nhdn dp xe vitng cS.
Do chdn thuang 30%, rd boi nhiem 28,3%, viem mui hgng 20%, do rdng mieng 6.7%.
khong xdc dinh 15%, su khdc biet co y nghia thong ke (p<0,005). Tuoi mac lao dgng> 15 den - 60 tu6i( 63,3 %). Nam 75% NQ 25%. Binh nhdn den tic cdc dia phuang quanh Hd ngi 75%, gap 3 lan tai Hd ngi. Cdc benh ly lien quan:ddi duong (13,3 %), khdc biet vai lao phoi, vd cdc binh ly liin quan khdc, p<0,005. Binh nhdn din vien nhieu hon vdo miia xudn vd he 28-30%. Thai gian den vien sau 5- 7 ngdy ( 70%), sau 8 ngdy cUng co 13,3 %, su khdc biet voi p<0,001. Ket luan: Ap xe vitng co do chdn thuong 30%, ro boi nhiem 28,3%, viem mui hgng 20%, do rdng mieng 6.7%
Tir khoa: Ap xe vung co. Dich ti hgc.
SUMMARY
The abscess and infections of the neck space are mortal denger and to have many causes common. Ojective : The descriptions and discussions on thefortors epidemiologies of the abces of neck space infection . Materials and Methods: Case study of 60 patients of the abscess and infection of the neck space, at Hospital ENT central (2007-2009).
Diagnostic clinical, endoscopic, CT scan, and the treatments. Results and discussions .There are 7 formes abscess. The causes are trauma( 30%). fistules congenital (28,3%), pharyngeal infections (20%), dental (6.7%), (p<0,005). Ages from 16 to 60 years (63,3 %). Man 75% woman 25%. The patiens of the suburbs of Hanoi is 75%. The deseases ofdiabete is 13,3 % and different these orther (p<0,005). The hospitalisation in the Spring autumn and Summer is from 28 to 30%. The times incubate from 5 to 7 days is 70%, and after 8 days is 13.3 % (p<0.001). Conclusion: There are 7formes abscess;
Man 75% trauma(30%), diabete( 13,3 %).
Key words: Abscess of the neck space. Epidemiology.
I. D A T V A N D E ^ ^ ^^ ^"^^ ^^^ khoang to chiic lien ket, do Ap xe vung co do viem nhiem, phii ne. nhieu nguyen nhan gdy ra. Qua trinh nhiem khudn do thuang nang, nguy hiem den ca
* BV. tinh Thanh Hda tinh mang nguoi benh. 6 mii thuang lan
**BV. TMHTW Nhan bat 25.2. Duygt m 15.3
Tap chl Tai MQi Hgng Vi^t Nam - Volume (58-15) N°3 - May, 2013
rpng theo cdc khoang do ciia to chiic lien kit va CO s\r ph6i hgp ciia vi khuan di khi vd ky khi. Cdc nguyen nhan, co the Id duong ro bdm sinh vung c6 ( xoang Ie,gidp luoi, ro tuyen mang tai, ...), cdc viem nhiem trung tir VA, amydan, rdng mi?ng, biin chiing do di vdt hgng thuc qudn...
Benh lai ndng them tren nhung ngu6i c6 benh tilu duong, tim mach, huyet dp cao, lao,...Tien lugng cung phy thugc them vdo tuoi, giai doan, thcri gian den vi?n. De tai
" M O T S O D A C D I E M D I C H Tfi HOC
LAM SANG AP XE VUNG CO GAP TAI B.V. TAI MUI HONG TRUNG UONG NAM 2007- 2009", voi muc tieu: \)M6 td mot so yiu to dich te hgc 2) Phdn tich cdc yeu to dich ti hgc liin quan qua 60 dp xe
vimg CO. 2
i. DOI TirONG VA PHirONG PHAP NGHIEN ClTU.
1.1. Gom 60 benh nhan dug-c chdn dodn va dieu tri tai benh vien TMHTU* tu 2007-2009.
1.2. Nghien ciiu ngang mo td tung truong hgp, tien cuu.
1.3. Chdn doan lam sdng, khai thdc cdc yeu to djch tl hgc. Chup CT voi cdc lat cat ngang, dung ngang, dung hinh dung dgc. Tat cd deu duoc dieu tri.
dan luu dp xe vd gidi quyet nguyen nhdn dong thai hoac o thi sau.
1.4. Su dung thong ke hgc theo chuong trinh Epinfo 6.0, dh tinh p.
2. KET QUA.
2.1. Phan loai cac apxe vung co qua 60 benh nhan
Bdng 1. Phdn logi cdc apxe viing co qua 6 b$nh nhan
1 2 3 4 5 6 7
Vi tri dp xe Ap xe do r6 xoang 16 Ap xe cgnh c6 do ti6c x u o n g
Ap xe Amydan Ap xe toa lan vunq cd Ap xe tttdnh sau honq Ap xe tuy^n mang tai
Ap xe hgch c6 N
N n 17 16 11 07 05 02 02 60
%
28,3 26,7 18,3 11,6 8,3 3,3 3,3 100%
Gdp nhieu dp xe do ro xoang le (28,3%),vd bien chung cua di vdt th\rc quan (26,7%), sau do la bien chiing ciia ap xe amydan (11,6%).
Phan bo theo tuoi
Bdng 2 Phdn b6 theo tu6i T U O I
L o ^ i dp xe Ap xe do ro xoang 13
n=17 Ap xe cgnh c6 do h6c xirong
n=16 Ap xe Amydan
n=11 Ap xe toa lan
vung c6 n=7 Ap xe thdnh
sau hpng n=5 Ap xe tuy^n
mang tai n=2 Ap xe hgch c6
n=2 N = 6 0
<15
2 5
1 3.3
8,3
1,7
8 ( l 3 , 3 16- <60
15 5 8 4 2
2 2 38
25 8,3
13,4 6,7
3,3
3,3
3,3
63,3
> 60
6 3 3 2
14 10
5 5 3,3
23,4
24
Tgp chi Tai MQi Hpng Vi$t Nam - Volume (58-15) N°3 - May, 2013
Tuoi hay gg-p a nhom 16-60 tuoi (63,3%), 2 nhom duoi 15 va tren 60 chi gap khoang 14%.
2.3. Phan bo theo gidi Bang 4. Phdn b6 theo gIP'i
GiM Loai dp xe Ap xe do r6 xoang IS n=17 Ap xe canh c6 do hoc xuong n=16 Ap xe Amydan
n=11 Ap xe toa lan vCing CO n=7 Ap xe thdnh sau hong n=5 Ap xe tuyen mang tai n=2 Ap xe hach c6
n=2 N = 6 0
Nam n 12 16 4 7 2 2 2 45
20
%
26,7 6,7 11,7 3,3 3,3 3,3 75
NC n 6
7
3
15 8,3
%
11,7
5
25
Gioi nam gap nhieu hon vd gdp 3 lan nil.
2.4. Phan bo theo dia dir Bang 5. Phdn bo theo Cta du Dia d u
n
%
HSnOi 15 25
T!nh khac 45 75
N 60 100
Benh nhan den cac dia phuong quanh Hd ngi gap nhieu hon va gap 3 Idn hon tai Ha ngi.
2.5. Phan bo theo mua Bang 6. Phdn bo theo mua Miia
n
%
XuSn (2,3,4) 18 30
HS (5,6,7)
17 28,3
Thu (8,9,10)
12 20
Oong (11,12,1)
13 21,7
N 60 100
Benh nhdn den viSn nhieu hon vao mua xuan va he 28-30%.
2.6. Thdi gian mac benh Bang 7. ThP-i gian mSc b$nh
n
%
Ngiiy
diu
2-4 n g i y
10 16,7
5-7 ng4y
42
>7 ngdy 8 70,0 13,3
N
60 100
Th6i gian den vien thuang la mugn sau 5- 7 ngdy (70%), sau 8 ngdy cung co 13,3%, su khac biet vai p<0,001.
2.7. Nguyen nhan gay ra dp xe Bdng 8 NguySn nhdn gdy ra dp xe
n
%
Do rang 4 6,7
Vi6m mCi hong 12 20
Chan thuong
18 30
Ro, bpi nhiem
17 28,3
Khong rONN 9 15
N 60 100
Cac nguyen nhan thuong gap la chdn thuang ro boi nhiem, sau do Id viem miii hgng va do rang, su khac biet co y nghia thdng ke (p<0,005)
2.8. Benh ly toan than lien quan Bang 9. Benh ly todn thdn lien quan
n
%
dufrng 8 13,3
Huyit ap cao 2
Co ung thtr TMH 1
Lao ph6i 2
Dung nhi^u rifiyu, thu6c la
19 31,7
Tam than 1
N
60 100
Dai duong gap 13,3 % co su khac biet voi lao ph6i, vd cdc benh ly lien quan khdc, p<0,005.
4. BAN LUAN
4.1. Cac loai dp xe viing co.
Chiing toi nhdn thay rang dp xe vung c6 CO thi gap o nhieu the loai, trong do dp xe do cdc dong ro bam sinh la thang gap
Tap chl Tai MCi Hong Vi#t Nam - Volume (58-15). N°3 - May, 2013
nhlt 17/ 60 truong hgip chiem 28,3%
(100% la r6 xoang le, con cdc dufmg r6 cung mang I, r6 cung mang 11 khong gap).
Trong ro bam sinh Chiang toi cung thay ring loai ro khong c6 lo rd thodt ra ngodi bi ap xe la 100%. Sau ro xoang le chijng toi gap cac ap xe canh co do hoc xirong c6n khu tni gap 16/60 truong h(?p chiem ty le 26,7% tong cac ap xe ciia vung co, trong cac loai di vat gay ra dp xe quanh th^c quan chung toi thay ring 96% la cdc loai dj vat CO nguon goc tir xuong cac loai dgng vat gay ra. Ket qua nghien ciru cua chiing toi cung phii hqtp voi ket qua cua mot s6 tdc gia khdc nhu: Vii Tnmg Kien 96,3% la dj vat gay dp xe thuc quan co co ngu6n g6c dong vat [5]. Tiep theo dp xe canh thuc qudn CO, chiem hang thu 3 la dp xe quanh Amydan gap 11/60 cdc truong hop chiSm 18,3%, dp xe do viem tod lan 6 viing co gap 7/60 cdc truong hgp chiem 11,6% va dp xe thdnh sau hgng it gap hon co 5/ 60 cdc tru- ong hgp chi6m 8,3%. Cu6i cung dii it nhu- ng vdn CO the gap la dp xe tuySn mang tai va dp xe hach 2/60 cac truong hgp dju chiem 3,3%. Nhu vay dp xe vung c6 co th^
gap 6 nhieu the loai, trong nghien ciiu cua chiing toi gap 7 loai dp xe vung c6.
4,2. Tuoi
Chiing toi nhan thdy dp xe vung cd co the gap a moi nhom tuoi song gjp nhiju nhat 6 nhom tu6i truong thdnh (iCr > 15 den - 60 tu6i) gdp 38/60 cdc truong hgp chi^m 63,3%. Sau do la a nhom tu6i cao > 60 tu6i gap 14/60 cdc truong hgp chi^m 23,3%, con tre em la 8/ 60 cdc truong hgp chiSm 113,3%. Trong nghien ciiu nay chiing toi
gdp tuoi thap nhat Id 16 thang tu6i hi' dp xe c ^ h CO do hoc xuong con khu tni vd tu6i cao nhat la 80 tuoi bi dp xe tod lan vCing CO. Trong nghien ciiu cua chiing toi nhom tu6i > 15 den < 60 c6 ty 1^ bi dp xe vilng c6 cao nhdt (63,3%) day Id liia tu6i lao dgng sung sue nhat Id nguon nhan luc chinh cho gia dinh vd xa hgi. Tuoi trung binh cdc ap xe vung CO trong nghien ciiu ciia chung toi Id 35,3 tu5i. Tuong tu nhu cua mgt s6 tac gid khdc nhu Linh The Cong tu6i tir 15 - 60 chiem 65,7% vd tuoi trung binh Id 41,3 tu6i [2]. Tom lai dp xe vung c6 gSp 6 moi liia tuoi cao nhat la a liia tuoi lao dgng.
4.3. Gioi tinh
Chiing toi nhan thay rang ty le nam gap nhieu hon nu la 3/1 trong do nam 75% va ai 25%>. Theo mgt s6 tdc gia khdc nghien ciiu 1 trong cac loai dp xe a vimg co ty le nam/ni?
id; Linh The Cuong nghien ciiu ap xe toa lan viing co gap nam la 57,1% nii42,9%[2], theo Simkeopich nghien cuu viem tdy ap xe quanh Amydan nam 74,29% , nft la 25,71%
[6], theo VQ Tnmg Kien nghien ciru ve bien chiing cua di vat thuc qudn thi nam 60,6%, nu 39,4% [3],
4.4. Dja dv
Nguoi o tinh ngodi Ha ngi chijm 75%, Hd Ngi chi chiSm 25%. theo Simkeopich nghien cuu ve viem tdy va dp xe quanh Amydan thi benh nhan trong Ha Noi 62,86%, con tinh khac la 37,4% [6]. Nhimg theo Vii Trung Kien nghien ciiu ve dp xe c ^ cd do h6c vd cdc bien chiing thi ty le b?nh nhan a Hd Ngi chiem 23,9% [4].Theo chiing toi trong cdc dp xe vimg co deu la
26
Tgp chl Tai Mui Hong Vi6t Nam - Volume (58-15). N°3 - May, 2013
benh nang cap cuu nen cdc tuyen chuyen len tuyen cao nhdt nhieu Id di6u dl hieu vi CO nhung dp xe vimg c6 (dp xe ro) da tai di tdi lai nhieu lan, hon nua tuyen TW Id noi CO cdc phuong tien hien dai nhat vd dgi ngu thdy thuoc chuyen sau nhdt.
4.5. Theo thang (mua).
Chiing toi thdy cdc dp xe a viing co gdp rai rac khap cdc mua trong nam nhng nhieu hon vdo miia xuan (30%) va miia he (28,3%). Theo mgt so tdc gid trong vd ngoai nuoc khdc khi nghien ciiu mgt trong cdc dp xe vung CO do la: Simkeopich gdp nhieu vao cdc thdng cuoi he, ddu thu [6], Vii Trung Kien lai gap vao cdc thdng cuoi dong va ddu xudn (dip t8t) [11], theo Boding thong gap vao cdc thdng cuoi xudn [3], con Chaikhounia, Aland thi thdy benh hay gap vao cdc thdng nghi he ciia tre em [7]
4.6. Thoi gian tir khi co trieu chung dau tien den khi nhap vien
Ngdy dau tien nhdn vien phong gap mgt truong hgp nao Nhap vien vdo ngdy thu 2 den ngay thii 4 sau khi co trieu chiing ddu tien co 42/ 60 cdc truong hop chiem 70%. Theo Simkeopich, Le Sy Lan trong viem tdy vd dp xe quanh Amydan Id 20%
vd 25,75 % [6]. Theo Vu Trung Kien trong bien chiing di vdt thuc quan Id 17% [3].
Theo Kieff thi benh nhdn nhap vien trong ngdy ddu la 5% vd ngdy thii 2 - 3 Id 75%
[10]. Nhu vay so benh nhan nh$p vien cua cdc nuoc Chau au Id ngugc hdn voi chiing ta dieu ndy chiing to benh nhdn cua chiing ta con chu quan khong, hieu ro ve benh ndy, CO thoi quen eo chiu dung va tu dieu
tri lai nha khi dau qud sung tdy 1dm md nhieu vd benh nguy kich moi den benh vi?n dieu tri. Ap xe vung co Id mgt cdp curu co the nguy hiem den tinh mang nhung su chii quan thieu hieu biet cua nguoi ddn ve benh nay la mgt dieu kho c6 the chap nhan.
Hon nfra thai gian den vien mugn gan nhu phdi phau thuat ciing gay nen ton kem cho benh nhan ve ngan sach ciing nhu thai gian dieu tri. Vi vay mgi nguai dan can co nhan thiic diing ve benh nay va can thiet di kham vd dieu tri som khi moi co cac dau hieu dau tien ciia benh.
4.7. Nguyen nhan gay ap xe
Chiing toi nhdn thay ap xe vung co gap sau mgt chan thuong o thuc qudn vd hgng Id nhigu nhdt 30% trong do 26,7% Id do di vdt thuc qudn con 3,3% Id do chdn thuong o hgng do di vdt vd do dat ong ngi khi quan. Trong nghien cmi ciia chiing toi khong gap truong hgp nao chan thuong tu ngoai vao vung co gay dp xe nhu mpt so tac gid da mo ta [3,4,5,7]. Nguyen nhdn do duong ro xoang le diing sau chan thuang thuc qudn va hgng la 28,3% trong cdc dang ro 6 CO chiing toi chi gap ro xoang le, loai khong CO 16 ro ra ngoai da, con cac duong ro cung mang I, II hoac ro Amidan, ro thuc qudn chiing toi khong gap mgt truong hgp nao [1]. Cdc viem miii hgng cap hoac dgi cap ciia viem man tinh ciing Id mgt nguyen nhdn trong nghien cihi cua chiing toi chiem din 20% gay ra cdc dp xe o vimg co. Theo nghien cuu cua Knipping nguyen nhan gay ra viem tdy vd dp xe quanh Amydan Id 56%
[7], con cua chiing toi dp xe quanh Amydan do viem mui hgng co den 90,9%. So sanh
Tap chl Tai MQi Hpng Vi$t Nam - Volume (58-15). N°3 - May, 2013
vai mgt s6 tac gid khdc chiing toi thay nguyen nhdn dp xe c6 do nhiem tning ciia rang mi?ng gdp 6,67% chii yeu trong dp xe toa lan viing c6 (57%), giong nhu:
Mohamedi 1 vd CS [10], Tran SJ? Tan [5], Simkeopich [6] khac v6\ Linh Thk Cueing khong gap ca nao dp xe tod Lan do rang [2]. Trong nghien cuu cua chimg toi khong gap mgt truong hgp nao; sau cdt Amydan, chan thuang tCr ngoai vdo hodc tuyen truyen gay ra dp xe viing co. Khac voi Linh Thk Cuong va Nguyen Huu Khoi [2,4].
Khong'xac dinh dugc nguyen nhdn (duong vdo) ciia dp xe vimg co chung toi gap la 9/
60 cdc truong hgp chiem 15% tuong tu nhu nghien cuu ciia Bruce vd cgng su [9]. Nhu vay nguyen nhan gay ra dp xe o co chii yeu hay gap la chan thuang viing co gay rdch thuc qudn vd hgng, sau do den cdc dong ro, viem mQi hgng vd rdng. Ngoai ra van con 15% khong xdc dinh dugc nguyen nhan.
4.8. Benh toan than phoi hgp co lien quan toi yeu to nguyen nhan
Trong nghien cuu cua chiing toi co dSn 8/ 60 cdc truong hgp chiem 13,3% mdc benh dai duong can phdi di§u trj kk hgp.
Duong mau cao 1dm cho vi khudn gay benh phat trien manh dong thai lam cho siic dh khdng ciia ngucri benh kem. Trong 8 truimg hgp ddi duong chiing toi thdy co din 5/ 7 truong hgp chilm 71,4% Id dp xe toa lan 6 vimg c6 dieu ndy da gidi thich ro vi sao khi ducmg mau cao, sire dh khang gidm thi s\r khoanh viing viem nhilm ciia co Xhh lai kem nhu vay. Trong cac ap xe viing c6 chiing toi gap benh nhdn u6ng nhieu rugu hoac hiit thu6c la 19 truong hgp chiem
31,7% trong do nhieu nhdt la dp xe quanh Amidan, tiep den Id dp xe canh co, dp xe do r6 vd dp xe tod lan a co. Ngodi ra chiing toi c6n g§p 2 trudng hgip cao huylt dp, 2 tr- uing hgp lao phoi kit hgp. Day cung la 1 b$nh ly 1dm gidm siic de khang vd de bj cac nhiem triing khdc do cung Id yiu t6 gay ra vi?c dieu Iri kto ddi vd cdn kit hgp vdi chuyen khoa phoi.Trong cdc b?nh ly toan thdn CO lien quan chiing toi c6n gdp 01 tr- uong hgp K lam cho viec chdn dodn co phan sai l?ch nen khi 6 dp xe qud to chen ep, gay kh6 tho nen nhdm voi K thanh quan ha hgng chuyen sang ung buou sau khi khai thdc ky CO tien su hoc vd co K ha hong cu nen khdm lam sang can than lai co tinh trang nhiem trimg nang, co diem dau choi ro, va chup CT Can moi phdt hi?n ra 6 ap xe. Vi vay kho tho do K thanh quan hay do dp xe canh co to qua chen ep gay kho tha rat de nhdm Ian. Khi do moi xac dinh ra o dp xe boi cung rat de nhdm lan khi ung thu lan rgng ra ngodi da lam loet hoai ti da co sun. Mgt truong hgp tam than lam cho chan thuang Ian rgng, ddt Sonde da day cho an, uong nhimg benh nhdn khong cgng tac nen qud trinh chdm soc dieu tri rat keo dai > 2 thdng moi xuat vien dugc
4 . Ket luan
Ap xe vung co gdp 7 loai. Nguyen nhdn ap xe vimg co do chdn thuang 30%
ro bgi nhilm 28,3%, viem mui hgng 20%
do rdng mieng 6.7%, khong xdc dinh 15%
su khdc biet co y nghia thdng ke (p<0,005).
Tu6i mdc : Nhom tu6i lao dgng> 15 dfin 60 tu6i 63,3 %. Gioi: Nam 75% NG 25%
Dia du: Benh nhan din cac dia phucmg 28
Tap chl Tai MQi Hong Vi^t Nam - Volume (58-15). N''3 - May, 2013
quanh Ha n6i gap nhieu hon (75%) vd gdp 3 lan hon tai Hd ngi. Cdc benh ly lien quan Id ddi ducmg gap 13,3 %, co su khac biet voi lao phoi, va cdc benh ly lien quan khdc , p<0,005. Benh nhdn den vi^n nhieu hon vdo mua xuan vd he 28-30%.Th6i gian din vien thudng la mugn sau 5- 7 ngay (70%), sau 8 ngay ciing co 13,3%, su khdc biet v6i p<0,001.
TAI LIEU THAM KHAO
1. Nguyen Hoai An, Nguyen Hodng Son, Nguyin T6 Uyen (1999), " Mgt s6 nhdn xet qua 50 ca do xoang le", Ngi sanTMHs6 2,trl5-22
2. Linh Thi Cuong (2001), Nghien cim dac diem lam sdng va dieu tri viem tay toa lan vimg co gap tai Vien TMH", Luan van thac sy Y hgc, Dai hgc Y Ha ngi.
3. Vu Trung Kien (1997), "Tuih hmh biin chiing di vat thuc quan tai Vien TMH TU" tir thang 1/1990-9/1997", Luan van thac sy Y hgc, Dai hgc Y Hd ngi.
4. Nguyin Hiiu Khoi (1997), " Viem tdy vimg CO toa lan va nhilm HIV", Ngi san TMH, vol!, p 10-16.
5. Sunkeopich (2006), "Cdc bieu hien lam sang vd ddnh gid ket qua dieu tri viem tdy va dp xe quanh Amidan gap tai BV.TM HTU tir 11/2005-11/2006", Luan van Thac sy Y hgc, Dai hgc Y Ha ngi.
6. Trdn Sy Tdn, Tran Thanh Phuoc (1984), Nhan 293 truong hgp rang khon tai bien" , Cong trinh nghien ciiu khoa hgc Y dugc 1984, Nxb Y hgc, tr 111.
7. A Lan D.(2008) "Deep neck infection", up date mar. 11-2008.
8. Asensio JA. Et al, (2001), "Penetrating eosophageal injuries -multicenter study of the American Association for the surgery of trauma" J. Traumalo, Feb, p i 12-120.
Bruce AS et al (1993), " Deep neck space infection". Head & neck surgery- Otolaryngology, vol I, p 738-753.
Mohamedi I, et al (1999), "Cervical necrosing facitis: 10 years experience", Intensivecare Med, 25 (8), p 829-834.
9.
10,
