Nghien cuu dac di6m lam sang, thinh luc, nhi d6 va kgt qua dat 6ng thong khi trong viem tai tiSt dich tre em
Clinical Features, Audiogram, Tympanogram and Results of Tympanostomy Tubes in the Children Suffering from Persistent Otitis Media with EITusion
LeCoiig Dinh*, 'Bd man Tai A hi i Hong Trirdng Dai Hoc. Y HaNgi.
Mai V The'" **Benh vien Tai Mui Hong Trung irang
Viem tai tiet djch la benh thudng gap d tr^ em. Muc tieu: Md ta d i e diem lam s i n g , thinh hoc v i danh gia ket qua dat dng thdng khi. Ddi tUOng & phUOng p h i p nghien cdu: l i 87 tai cua 45 tre viem tai tiet dich cd chi dmh dat dng thdng khi. Nghien cdu tien cdu md t i tUng ca. Ketgud: nhdm < 6 tudi gap nhieu nhat (75,6%), phan ldn bi viem 2 tai (93,4%). Cic tneu chUng thudng gap: Ngat mui (84,4%), chiy mui (82,2%), nghe kem (42,2%), ii tai (24,4%). Hinh anh qua ndi soi tai: m i n g nhi co Idm (48,3%), binh thudng (34,5%), day due (59,8%), mau vang mat ong (29,8%), ed bdng khi (10,4%). Nhi dd p h i n g gap nhieu nhat (66,7%), sau do la nhi do hinh ddi (31%). Thinh lUc dd: nghe kem truyen i m vdi PTA > 20 dB chiem 90,9%, VA l i benh phdi hop hay gap nhat: 68,8%. Phau thuat d i t OTK 1 hoac 2 ben tai phdi hop nao VA, eat amidan. Thdi gian theo ddi 4 t h i n g , hau het cic trUdng hap sUc nghe t i n g , tai khd, OTK cdn tren mang nhi. Cac bien chUng hay gap l i ' chay tai, tut va t i c OTK, Ket ludn: Cac trieu chUng cua VTTD tham lang va khd phat hien. Noi soi tai v i do nhi lUOng la bien phap rat cd gia tri de chan doan. D i t OTK mang nhi giup phyc hdi sUc nghe va tai lap lai chUe n i n g tai gida.
TLT/thocJ; Viem tai tiet dich, dng thdng khi
S u m m a r y
Otitis media with effusion (OME) is a common disease in children. Objective: To study clinical, audiometry and results of tympanostomy tubes. Materials & methods- Descriptive and prospective study on 87 ears of 45 children with OME. Results' The most common age group was < 6 years of age The most infections w/ere in both ears (taking up 93.4%) Common symptoms were nasal obstruction (accounting for 84 4%), running nose (82.2%), hearing loss (42.2%) and tinnitus (24.4%). Otoscopic examination was as follows: eardrum retracted (amounting to 48.3%), normal (34.5%), opaque (59.8%), honey-colored (29.8%) and bubbles (10.4%). Tympanograme type B was the most (66.7%) and type C was 31%. Audiogram was conductive hearing loss > 20 dB in 90.9%, Adenoide vegetation is the most common coordinate (68.8%) Tympanostomy tube insertion was on one or both sides associated with adenoidectomy and tonsillectomy. The results after 4 months of follow-up showed that the most common cases were dry ear, hearing improvement, tubes on the eardrum. Common complications were otorrhea, extrusion and obstruction. Conlusions: Symptoms in OME are silent and difficult to detect.
Otoscopy and tympanograme are valuable measures for diagnosis. Tympanostomy tube insertion helps hearing improvement and reconstructs the function of the middle ear.
Keywords. Otitis media witli effusion, tympanostomy tubes.
Pliiin bien khoa hoc: TS DOAN THAXH HA
no
TAP CHl Y DU'O'C L A M S A N G 10. Tap 8 - S o 2/2013
I . D a t v a n d e
Viem tai tiet dich (VTTD) la t i n h trang d dich trong hdm tai vdi mang tai khdng t h i i n g . Day l i benh kha t h u d n g gap d tr^ e m liifa tudi mau giao va hoc dudng. Tai Viet Nam theo t h d n g ke cua Nguyen Thi Hoai An [1] cd k h o i n g 8,8% tr^ bi benh n i y . Benh g i y ra suy giam sUc nghe, tU d d anh hudng rat Idn den qua trinh phat trien n g d n ngCf va ket q u i hoc tap. Neu khdng dUOc xU tri kip t h d i cd the tien trien thanh xep nhi, tui co keo, cholesteatome...tU do inh hudng den ehUc nang cua tai v i sUc kho^ cua tre. Tren l i m sang benh hay bi bd sdt do c i c trieu chifng kin dao t h a m l i n g v i tre em khdng nhan biet dddc. Ngay nay cd rat nhieu p h u o n g tien hien dai nhu npi soi, do t h i n h luc, nhi luang de chi'n doan benh. Cac viem nhiem d m u i hong n h u VA, viem mui hong,, gay ra rdi loan chUe nang vdi nhi tU do tao ra ap luc i m t r o n g hdm tai d d n g vai trd quan trong trong ca che benh sinh benh. Do v i y viec giai quyet cac d viem ke can d d n g thdi tao ra su c i n b i n g i p luc v i thdng khi hdm tai la muc tieu chinh trong dieu trj. D i t dng t h o n g khi mang nhi n h i m can bang ap luc va dan luu djch t r o n g h d m tai tU d d giup c i i thien sdc nghe, han che cac bien chUng va di chUng.
Tim hieu ve VTTD ed y nghTa thUc tien, giup cho eic bac sy cd them kinh nghiem trong chan d o i n va dieu trj. Do v i y m a d e tai duoc tien h i n h nham muc tieu:
Mo td ddc diem Idm sdng, thinh lUc vd nhi do cua viim tai tiet dich tre em
Ddnh gid ket qud ddt dng thong khi mdng nhi
2.Dditilcrng va phUcrng phap nghien cdu 2.1. Doi tdang nghien cdu: La 87 tai ciia 45 tre viem tai tiet djch ed chi djnh dat dng t h d n g khi mang nhi tai benh vien Tai Mui Hong TW trong thdi gian 3/2012-10/2012
Tieu chuan lua chpn:
- Viem tai tiet djch 1 hoac c i 2 ben tai khong dap Ung vdi dieu trj npi khoa.
- Cd ket qua ndi soi tai, d o nhi lupng v i do thinh Idc trudc v i sau m d .
- Bd me ciia BN ddtJc g i i i thich v i d d n g y cho BN tham gia nghien cCfu.
2.2. Phddng phap nghien cdu. Nghien cdu mo ti tdng trddng hap co can thiep.
- C i c tieu ehl nghien cUu: tuoi, gidi, trieu chdng ca nang, hinh anh ndi soi m i n g nhi, thinh luc d d , nhi do, phuong p h i p phau t h u i t va tinh trang cua tai, dng t h d n g khi.
- Phuang tien nghien cUu: May ndi soi Karl- Storz, m i y do thinh luc, nhi luong, kinh hien vi phau thuat va dng t h d n g khi (OTK) loai Grommet.
- Qui trinh nghien cdu. Trude m d : hdi benh, noi soi tai, do nhi luang, do thinh luc cho tre ldn v i hop t i e tdt. Tien h i n h phau thuat dat dng thdng khi; ed the phdi hop nao VA va cat Amidan neu cd chi dinh.
Sau m d : dieu tri ndi khoa, tai kham ndi soi tai danh gia tinh trang dng thong khi tai thdi diem 2 tuan, 2 t h i n g va 4 t h i n g .
- N h i p v i xU ly sd lieu theo chUOng trinh p h i n mem thdng ke y hoc SPSS 16.0.
3. Ket qua
J . 7. Dac diem chung
Tudi v i gidi: nhdm tudi gap nhieu n h i t l i < 6 tudi ed 34/45 BN (75,6%). Nhdm tudi gap it nhi't l i 11-15 tudi cd 2/45 BN (4,4%). Tudi trung binh l i 4,69
± 2,43. BN nhd nhi't la 12 t h i n g v i ldn nhat la 12 tudi. Cd 26 tre g i i chiem 57,8% v i 19 tre nam chiem 42,2%.
- Sd tai benh, Cd 42 BN bi benh c i 2 tai chiem ty le 93,4% v i 3 BN bj 1 ben tai (6,6%).
3.2 Tneu chdng candng
Bang 3.1: Cac trieu chufng ccr nang Tneu
chtrng 56 ca (n) Ty le (%)
Ngat mui 38 84,4
Chay mui 37 82,2
Nghe kem 19 42,2
Utai n 24,4
Ngu ngay 9 20
Cham noi
5 11,1
Lac dau 2 4,4
Nhan xet: Tren 1 BN co the co nhieu trieu chirng phoi hop. Ngat mui la trieu chCrng gap nhat (84,4%) sau do la chay mui (82,2%). Cac dau hieu ve tai: nghe kem (42,2%), u tai (24,4%). Ngu ngay, cham noi va hay lac dau chiem ty le thap.
3.3. Ket qua npi sol i« j
Bang 3.2. Hinh thai mang nht qua noi soi tai (N=87)
Hinh thai mang nhi Phong Lorn Binh thudng Tong so (N)
So ca (n)
15 42 30 87
Ty le (%)
17,2 48,3 34,5 100 Nhdn xet: Hinh t h i i mang n h i co Idm gap nhieu n h i t 48,3%. Sau d d l i binh t h u d n g (34,5%). M i n g nhi phdng gap it n h i t 17,2%,
Bang 3.3: Mau sic mang nhi (N=87) Mau sac mang nhi
Trong, co bong khi Day, due, mat non sang Mau vang mat ong Tong so (N)
Soca (n) 9 52 26 87
Ty le (%) 10,4 59,8 29,8 100 Nhan xet: Mang nhi day due, mat non sang gap nhieu nhi't (59,8%) sau d d la mau vang m i t ong (29,8%). M i n g nhi trong, cd bdng khi gap it n h i t (10,4%).
3.4. Hinh dang cua nht do
Bang 3.4. Hinh dang n h l d d (N=87) Hinh dang
Oinh nhon, lech am Hinh doi Phang Tong so (N)
So ca (n) 2 27 58 87
Ty le(%) 2,3 31,0 66,7 100 Nhan xet: Hinh thai nhi d5 p h i n g gap nhieu nhat (66,7%) sau do la hinh doi (31%). Nhi do dinh nhon, lech am chi co 2,3%.
3.5. Ket qui do thinh li/c
BSng 3.5: NgUdng nghe t r u n g binh ducrng jthf ( N = 3 3 )
Ngudng nghe DK (PTA) 0 - 2 0 d B
21 -39dB 2 40dB Tong so (N)
Soca (n) 3 18 12 33
Ty le(%) 9,1 54,5 36,4 100 Nhdn xet: Co 33/87 tai do di/gc thinh Itrc. Nhom PTA > 20 dB CO 30/33 tai chiem ty 90,9%, Nhom PTA < 20 dB gap it nhat veil 3/33 tai chiem ty le 9,1%.
3.6. Cac b e n h phdi h a p
Bang, 3,6. Cac benh phoi hop (N=45) Benh phoi hop
Viem VA, qua phat Viem VA + Viem A Viem mui di irng Viem mui xoang
So ca (n) 31 6 12 7
Ty le (%) 68,8 13,3%
26,6 15,5 Nhan xet. Tren 1 BN co the nhieu benh phoi hop, VA la benh hay gap nhat t r o n g d o 31/45 BN (68,8%) don thuan va 6/45 BN (13,3%) phoi h o p vdi viem A.
Co 12/45 BN (26,6%) viem m u i di urng va 7/45 BN (15,5%) viem m u i xoang phoi hgp.
3.7. Cac phuong phap phau thuat
Bang 3,7. Cac phi/ong phap phau thuat (N=45) Phuang phap
Dat OTK 2 ben Bat OTK 2 ben + Nao VA Dat OTK 2 ben + Nao VA + CSt A Dat OTK 1 ben don thuan Dat OTK 1 ben + NaoVA Dat OTK 1 ben +Nao VA+ CSt A Tdng so (N)
So ca (n) 7 30 5 1 1 1 45
Ty le (%) 15,6 66,6 11,2 2,2 2,2 2,2 100 Nhan xet: Dat OTK 2 ben + nao VA chiem ty le nhieu nhat 30/45 BN (66,6%) sau d o la dat OTK MN 2 ben d o n t h u a n co 7/45 BN (15,6%).
TAP CHl Y DUOC L A M S A N G 108 Tap 8 - S o 2/2013
3.8. Ket qui dat dng thong khi mang nhi
Bang 3.8: Tinh trang cua ong thong khi r > . ~ . ^ ^ T h d i gian
Tinh t r a n g ^ ^ ^ ^ Chaytaiquaong Day ra ngoai Tk6ng thong khi Kli6, thong, con tren mang nhi Tong so (N)
2 tuan 7 2 1 77
87
2thang 11
3 4 61
79 4 thang
9 7 0 49
65 Nhdn xet: OTK khd, t h d n g cdn tren mang nhi gap nhieu nhat: 77/87 tai sau 2 tuan (88,5%), 61/79 tai sau 2 t h i n g (77,2%) va 49/65 tai sau 4 t h i n g (75,3%), Tai chay djch, OTK bi day ra ngoai va tac dng thdng khi l i c i c bien chUng hay gap sau m d .
4. Ban luan
- D i e diem chung. Ket q u i cho thay benh thddng gap d c i 2 tai (93,4%), nhdm tudi < 6 gap nhieu nhat vdi ty le 75,6%, t r o n g do benh n h i n nhd tuoi nhat la 12 t h i n g . Ket qua n i y cung phu hap vdi nghien cdu cua c i c t i e g i i [1][4]. Oieu nay duac g i i i thich bdi d lUa tudi mau g i i o tre hay bi cac benh viem dudng hd hap tren n h u VA, Amidan, viem mui hong, viem mui xoang.... C i c benh nay da lam i n h hifdng den chUc nang vdi nhi tU do g i y ra VTTD.
- Ve trieu chUng eo n i n g . Cic bieu hien cua VTTD khong ram rp nhU viem tai giUa cap. 6 nhdm tre be, benh duoc p h i t hien khi bd me dua tre k h i m benh vi cac ly do d mui hong n h u ngat mui, c h i y miJi.Trong nghien cdu nay ( b i n g 3.1) 84,4% tre bieu hien ngat t i c mui, 82,2%) chay mui trong, nhay hoac mCi. d nhdm tre Idn cd the n h i n ra c i c dau hieu n h u nghe kem, u tai, tieng dc i c h , tieng vang trong tai.
Qua khai thac benh sCf cd 42,2%> ed bieu hien nghe kem, 24,4%» cd u tai hoac tieng keu t r o n g tai. 6 nhdm tre be trieu chUng nghe kem t h u d n g bieu hien gian tiep qua cac dau hieu n h u c h i m ndi, tre khdng t i p trung, thay ddi t i n h c i c h , khi goi khdng dap urng, ket qua hpc t i p sa sut...Theo Bluestone [4]
day la nhCfng dau hieu gai y de chan doan VTTD d tre em. Mot sd bieu hien chi diem k h i c cung hay
gap n h u tre hay lac dau, chi vao tai, ngu ngay,..NhU v i y la eae trieu chUng cua VTTD rat ngheo n i n , tham l i n g va khd phat hien.
- Ve trieu chUng thuc the. T h i m kham tai d tre em rat khd k h i n do d i e diem dng tai ngoai nhd, nhieu Idng va r i y tai. Khi t h i m kham tre khdc lam cho mang nhi dd nen cung rat khd d i n h gia, N g i y nay dng ndi soi cd dudng kinh nhd duoc i p dung de t i n g k h i n i n g chi'n d o i n chinh xac. Trong nghien cUu nay chung tdi sU dung dng ndi soi ed dUdng kinh 2,7mm de t h i m kham. Ket q u i b i n g 3.2 va 3.3 cho thay hinh t h i i m i n g nhi eo 1dm gap nhieu nhat (48,3%), sau dd la binh thudng (34,5%). Hinh thai m i n g nhi phdng gap it nhat (17.2%). Ve m i u sic mang nhT d i y due, mat ndn sang gap nhieu nhi't (59,8%) sau 36 l i m i u vang mat ong (29,8%). M i n g nhi trong, cd bdng khi gap it n h i t (10,4 %). Ket qua cua nghien cUu n i y cung phu hap vdi cua Nguyen Thi Hoai An [1] v i Do Thanh Chung [3]. Trong c i c dau hieu tren thi hinh anh m i n g nhi ed m i u m i t ong h o i c bdng khi trong hdm nhi la rat cd g i i tri chi'n doan xac dinh. Mdt sd tac g i i bao c i o tdn t h u o n g mang nhT cd mau xanh. D d T h i n h Chung [3]
gap 6/85 tai. Day la nhdng trUdng hop VTTD keo dai nen dich tU trong chuyen thanh xanh, nhay. Trong nghien cUu nay chung tdi khdng gap loai tdn thuang nay.
-Ve ket q u i do nhTluang va thinh lUc + Do nhT luang. D i y la bien p h i p k h i c h quan de danh gia chdc nang tai giUa. Nghiem phap nay cd the thUc hien d nhUng tre be. Tuy nhien de han che sai sd thi can p h i i kham v i lam sach tai trudc khi tien h i n h thU nghiem. Ket qua bang 3.4 eho t h i y loai nhT dd p h i n g gap nhieu nhi't (66,7%) sau dd l i hinh ddi (31%). NhTdd dinh nhon, lech i m chi chiem ty le 2,3%. Ket q u i nay cung phu hop vdi n h i n xet cua LUang Hdng C h i u [2]: nhT do phang la dang nhT do t h u d n g g i p nhat trong viem tai giUa tiet dich.
+ Do thinh lUe. Chung tdi sU dung phuong phap do thinh lUe dan am de d i n h g i i sUc nghe. Trong nghien cUu nay chi cd 33 tai d nhUng tre Idn va hap t i c dUdc do thinh luc kiem tra sUc nghe. Ket q u i thu duoc ( b i n g 3.6) cho thay tdn thuong la nghe kem the dan truyen i m trong dd 30/33 tai chiem ty 90,9% sdc nghe g i i m > 20 dB. Cac nghien cUu cua
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Bluestone [4], Paparella [6] cung cho thi'y sdc nghe t r o n g VTTD giam tU 10-40 dB. Ket q u i n i y cho thay VTTD i n h hudng ri't Idn den sdc nghe cua tr^.
- C i c benh phdi hap. Ket q u i b i n g 3.6 cho thay VA la benh phdi hop hay gap nhat t r o n g d d 31/45 BN (68,8%) tdn thUong don thuan v i 6/45 BN (13,3%) phdi hop vdi viem Amidan. Day la c i c nguyen n h i n chinh g i y VTTD d tr^ em. C i c viem nhiem ke can khac n h u viem mui dj dng chiem ty le 26.6%, viem mui xoang chiem 15,5%. Cac benh n i y da g i y ra VTTD t h d n g qua eo che t i c vdi va lan truyen vi khuan tU mui hong len tai giUa qua vdi nhi.
- D i e u tri phau thuat,
+ Dat OTK m i n g nhi : la phau thuat dUOc lUa chon dau tien trong c i c trudng hap VTTD can can thiep. T i e d u n g cua OTK giup c i i thien nhanh cac trieu chUng d i e biet nha't l i sUe nghe, dan lUu dich hdm tai v i tai l i p lai chUe n i n g t h d n g khi hdm nhT.
Theo Hpi Tai Mui Hong Nhi khoa Hoa Ky va Canada [5], chi dinh dat OTK t r o n g c i c t r u d n g hop: VTTD dai dang, khong dap Ung vdi dieu t n npi khoa, t d n tai dich tai giCfa dai dang tren 3 t h i n g sau mdi d o t viem tai gida c i p , cd tren 7 dot viem tai giUa t r o n g 6 t h i n g , sUc nghe 2 tai deu g i i m tren 20 dB v i m i n g nhi xep, tui eo keo Trong nghien cUu nay chung tdi thUc hien dat OTK dudi g i y me toan than. Loai OTK sU dung l i loai Grommet t h u d n g lUu lai tren mang nhi trong thdi gian ngan (<1 n i m ) . Ket hop vdi g i i i quyet cac d viem ke can nhU nao VA d o n thuan (66,6%), nao VA + eat Amidan (11,2%). Cic nghien cUu [1][3][5] cung deu chi ra rang ben canh d i t dng t h o n g khi, thi viec nao VA, cat amidan se giup c i i thien nhanh tinh trang U dich trong hdm tai v i l i m g i i m ty le t i i p h i t VTTD.
- Ket q u i phau t h u i t . Oe d i n h gia ket cua cua phau t h u i t chung toi tai k h i m cho benh n h i n tai c i c thdi diem 2 tuan, 2 t h i n g v i 4 t h i n g . Ket q u i ( b i n g 3.8) cho thay hau het cac trudng hap OTK khd.
Sau md bien chUng c h i y tai la hay gap nhat, trong nghien cUu n i y co 7/87 tai (8%) sau 2 tuan, 11/79 tai (13,9%) sau 2 t h i n g , 9/65 tai (13,8%) sau 4 t h i n g . Ty le c h i y tai cua c i c t i e gia Gray [5] va Paparella [6]
dao d d n g trong k h o i n g 15-25%. NhUng trUdng h o p nay da dUOC ve sinh, hut rda lam sach tai, nhd khang sinh, giam viem vao tai. Chung tdi cCing gap m d t sd
t r u d n g h o p d n g t h o n g khi bj day sdm ra ngoai va tic d n g t h d n g khi. NhCTng t r u d n g h o p nay da lay nut tic b i n g mdc hoac n h d tai cho m ^ m rdi lay. Trong t r u d n g h a p OTK bj day ra sdm m i t r o n g hdm tai cdn djch thi p h i i tien h i n h dat lai OTK. Chung tdi cung theo ddi t i n h trang cua m a n g n h i sau khi OTK day ra sau m o 6-8 t h i n g . Hau het cac trUdng h a p mang nhi deu t u lien kin. Cd 3 tai cd 16 t h u n g nhd, tuy nhien n h d n g trUdng h o p nay qua t h e o ddi mang nhi tu lien lai m i khdng can can thiep va nhi. Nghien ciJfu cua c i c t i c g i i [4][5] cung cho thay t y le thCing m i n g nhT tU 3-5%).
S. Ket luan
- V i e m tai tiet dich la benh t h d d n g gap 6 tre < 6 tudi, nguyen n h i n chinh la d o viem VA va cac nhiem khuan hd hap t r e n . C i c trieu chdng d tai thudng yen l i n g ngheo nan va k h d phat hien. Ndi soi la bien phap g i u p danh g i i t i n h trang mang nhT v i hdm tai.
D o nhT l u o n g la bien phap k h i c h quan, dan g i i n va cd do chinh x i c cao de chan doan xac dinh.
- Dat d n g t h d n g khi m i n g nhT giup c i i thien nhanh sUc nghe, dan lUu dich, can b^ng ap lUc vatai l i p lai ehUc n i n g t h d n g khi cua tai giOa. Cic bien chUng hay gap la: c h i y tai, t i c d n g , day dng sdm ra ngoai va t h u n g m i n g nhi.
T ai lieu t h a m khao
1 Nguyen Thi Hoai An (2006), "Viem tai giUa d dich d tre em", Nhd xuat bdn YHgc Hd Ndi, 33-41.
2, Luang Hdng C h i u (2009), "Die diem hinh thai nhi dd trong viem tai thanh dich". Tap chi Y hgc thdc hdnh. sow [697), 4-37.
J. Do Thanh Chung (1999), Nghien cdu ddc diem Idrr^
sdng vd kit qud dieu tri binh viem tai d dich tgi benh vien Tai Mui Hong trung uang, Luan van thac sy Y hpc, Dai hpc Y H i Noi.
4. Bluestone CD, Klein J.O (1988), "Otitis media in infants and children", Ped/afr/cOfo/afyngo/ogy,Von4,86-90 5. Gray, S, Lusk. R 'Tympanic membrane
tympanostomy tubes", Head and Neck Surgery Otolaryngology. Vol 4,2971-2977
6. Paparella M.M, Timothyl K.L, Goycoolea M.V (1991), Otitis media w i t h effusion, Otolaryngology, Vol 3,1337-1340.
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