KHAO SAT TINH TRANG DI ifNG Of BENH NHI VIEM TAI G I C A T I E T DICH
Nguyen 77it Ngpc lyung', Nguyen Dirih Chuang"
TOMTAT
Dpt van de: Gan day co nhim cong trinh nghien cuu tren thegiM nhan thay co su lien quan giiea mem tai giiea tiei djch (VTGTD) vd cac binh di ieng.
Muc tieu nghien cOu: Khao sat ti le tinh trang dj iing (TTDlX) d nhieng binh nhi VTGTD, ti le thanh phan bach coil trong djch tai giiea, tit do khao sat sie lien quan giiea TTDlSva VTGTD.
Doi tugng - phuang phap nghiin ciiu: Nghiin cieu mo id cat ngang tren 33 binh nhi duoc chah doan VTGTD tai binh vien Nhi Dong 2 tie thdng 09/2014 deh thdng 04/2015.
Kei qua: Ti le henh nhan VTGTD co TTDlf chirni 39,4% trong do biHt hien cua VMDlt (33,3%) hoac co bieu Men chdm, me day, hen phe quan (6,1%). Ti le bach cau da nhan trung tinh (BCDNTT) trong dich tai giiea CO tile cao rihcA chian 48,34%; bach caU da nhan di toan (BCDNAT) thi chiem 3,29%. Ti liBCDNAT trong dUh tai giua b binh nhi co TTDltcao han so vai binh nhi khong co TiDlX(p < 0,05) vd khong co sie khac biet vtti IS BCDNTT trong dich tai giiia a hai nhom. benh nhi co TTDlXvd nhom binh nhi khong co TTDlX(p > 0,05).
Kei luam Di ung la yeu to thuan lai gay ra nhieng benh ly viem nhiem a vimg mui hong, anh huimg den diitc nang voi nhi vd tai giiia. Do do nhieng binh nhan co bieu hien dj img can duac fa'lm tra tai di'phdt hiin vd dieu tris&m tinh trang viem taigiHa.
Tie khoa: viem tai giiia tiei djch, tinh trang di img, bach cau da nhan di toan.
ABTRACT
THE RELATIONSHIP BETWEEN ATOPIC DISEASE AND OTTTIS MEDIA WTTH EFFUSION Nguyen I h i Ngoc Dung, Nguyen Dinh Chuang*Y Hoc TP. Ho Chi Minh * Vol. 20 - No 1 - 2016:12 -17
Backgrmmd: Many studies over many years have determined a correlation between atopic diseases and otitis media with effusion (OME).
Objective: To determine the incidence cf atopy associated with OME, the white blood cell amiposition of middle ear fluid; and to identify if there is the relationship between atopic diseases and otitis media with effusion.
Methods: A cross - sectional study was performed on 33 patients with OME in Children's Hospital No.2 from 09/2014 to 04/2015.
Results: VJe found allergic rhinitis in 33.3%, asthma in 6.1%, eczema in 6.1%, urticarial in 6.1% of children with OME. Neutrophils had the highest percentage of WBC count in MET at 48.34%, whereas the proportion cf eosinophils was 3.29%. There was a higher percentage of et^inophih in atopic patients with OME compared with that seen in nonatopic patients (P < 0.05), but there is no significant difference in percentage of neutrophils betiveen atopic patients with OME and nonatopic patients (P > 0.05).
Conclusion: Allergy plays a role as a risk factor for nose and throat inflammation, may also involve both Eustachian tube dysfunction and middle ear pressure dysregulation. Therefore, patients with atopic diseases should be evaluated and treated for otitis media in the early phase
' DH Y Khoa Pham Ngoc Thach " Dai hoc Y duac TPHCM
Tac gia lien lac: BS.Nguyen Dinh Chuong, DT: 0903638316, Email: [email protected]
Y Hpc TP. Ho Chi Minh * Tap 20 * So 1 * 2016 Nghien ciru Y hpc
Key words: otitis media with effusion, atopic disease, D A T V A N DE
Di ling la tinh trgng qua man voi khang nguyen qua trung gian IgE the hien a nhieu benh khac nhau. Theo (hong ke, ty le mac benh di ling dung thii nam trong cac benh man tinh a moi Ilia tuoi va diing thti ba o liia tuoi dum 18 tuoi. Gan day, nhieu nghien curu cho thay co sir lien quan giua duong ho hap tren va duong ho hap duoi trong benh dj ling. Su tuong tac giiia nhimg dap ling than kinh, mien dich, di ling voi tinh trang dap ling viem la nen tang cho mo hinh duong tha thong nhal va tai giua la mot phan cua duong ho hap (7). Ve mat mo h<?c, niem mac tai giua duoc lot boi bieu mo tni gia tang CO long chuy&i va ciing giohg nhu bieu mo duong ho hap tren va duoi. Nhiing thay doi ve mat mo hoc cua niem m?c tai giiia d benh nhan dj ling giohg voi su thay doi niem mac phe'quan khi bi hen.
O tie em, viem tai gjiia tiet dich (VTGTD) co the dien ra am tham ma khong gay ba't ky kho chju nao cho tie, viec chan doan dua tren khai thac benh su va tham kham lam sang, liuea thu nghiem khach quan do vay thieu diinh xac va rat de bo sot benh. Nea khong dugc dieii tri Ihich hpp, tre co the bi ii tai, nghe kem va nhieu bien chiing nguy hietn khac.
Tren thirc te^ tre em mac benh viem mui di ling (VMDU) kha nhiSa nhixng viec kham va dieu tri cho cac be thuong chi dupe bac si tap trung d viec giam trieu chiing tai mui ma chua quan tam nhieu d o i benh ly tai giiia 6 nhiing diia tre nay. D^ tim hieu moi tuong quan giiia benh di ting va VTGTD o tre em nham xay dung phac do dieu tri thich hpp, chiing toi hea hanh de tai nghien ciiu: "Khao sat tinh trang dj ling 6 benh nhi viem tai giiia tiet dich".
Muc tieu nghien cmi
Xac djnh ti le TTOU 6 benh nhi VTGTD.
Khao sat ti le cua thanh ph&i bach cau trong dich tai giiia 6 benh nhi VTGTD.
allergy, eosinophils.
Khao sat su lien quan giiia TTDU" va VTGTD.
DOIIX/ONG-rHLfONGPHAPNGEDtNCDtJ Nghien ciiu tiai ciiu, mo ta dt ngang tren 33 benh nhi dupe chaai doan VTGTD tai benh vien Nhi Dong 2 tii thang 09/2014 den thing 04/2015, CO chi djnh trich rach nhi, dat caig thong nhi voi chah doan VTGTD bang cac tri?u chiing ngjie kem, u tai, cam giac day nang tai, noi soi tai va nhi lupng do.
Cha me dong y cho tre tham gia vao 16 nghien ciiu.
Phuang phap thu thS^p so lieu
Khai thac va thu th^p thong tin theo benh an nghien ciiu mau.
Kham noi soi tai mui hong: danh gia su thay doi ciia mang nhi va cac benh ly di kem vimg mui hong.
Do nhi lupng do, thinh luc do.
Lay dich tai gjiia va xet nghiem te bao hpc dich tai giua
- Dat bong gon co t&n adrenaline 1:1000 len mang nhi de han che chay mau khi trich rach mang nhi. Dimg OTig htit c6 he thong thu nhan dich (dung ciJ Juhn Tym Taps) dua vao horn nhi qua 16 rach mang nhi de hiit dich tir horn nhi.
- B&ih phain dupe pha loang trong 1ml dung dich nap mau, lac deu trong 30 giay va duoc dua toi phong xet nghiem trong 30 phiit.
- Djch dupe chia lam 2 phan: mpt phan dupe xet nghiem dem ti le te bao bach cau trong djch tai giiia bang he th6hg xet nghiem huye't hoc ADVIA 2120i, mpt phan dupe quay ly tam te' bao, phe't lame va quan sat te bao bang kinh hien vi.
Yeu to dao diic trong nghien ciiu De cuong dupe xet duyet boi Hoi Dong Y Diic cua Dai Hpc Y Dupe Thanh Pho Ho Chi Minh truoc khi hen hanh.
Nhi Khoa
Y Hoc TP. H o Chi M i n h * T a p 20 * So 1 * 2016 KET Q U A - BAN LUAN
Dac d i ^ LSm sang va c?n lam sang cua V T G T D
Chung toi nhan thay rang tre bi VTGTD co ti le cao nhat a nhom tre duoi 4 tuoi. Tuy nhien tre bj VTGTD CO bieu hien dj ling lai tap trung chu yeu 6 nhom tre tren 5 tuoi, chian ti le 76,9%.
Nghe kem la trieu chiing co nang thuong gap nhat d i i a n 81,8%. Day la mpt trong nhiing trieu chiing co nang de phat hien benh. Tuy nhien doi khi tre d&\ kham nhung khong co bieu hien ro ret 6 tai
Khong CO tmong hpp nao thay mang nhi phong, ti le mang nhi trung tmh d i i o n 56,2% va ti le mang nhi 16m chiSn 43,8%. Mang nhi co hinh anh bong khi va/hoae miic nuoc hoi chian 47,9%. Tat ca cac truong hpp deu mo hoac due trong do tinh t r ^ g m o chi&i 91,3%, tinh trang due chian 8,7%. mau trang m o chion 45,8%, mau vang ho phach chian 45,8%, mau trang due chion 8,4%.
Nhi lupng do dgng B la thuong g | p nhat chiem 83,3%.
Thth chat dich tai giSa
Chiing toi ghi nhan ti le (iianh djch chimi nhi«i nhat voi 56,3%, dich keo chian 35,4%, djch mu ehian 8,3%. Trong traig so 33 benh nhan, thi ti le VMDU" chian Im lupt trong cac loai dich tiianh dich, keo va mii la 35%, 36,4%, 0%. Ket qua nay kha tuong dong voi ket qua cua tac gia
Chul Kwon tiien 370 benh nhan bj VTGTD sau 2 tuan dieu tri khang sinh va tiep tue sau 2-3 Ihang iheo d6i(& Tac gia ^ n h | n thanh djch chian ti le cao nhat (50,2%), tiep theo la djch keo (34,9%) va djch mil (14,9%). Trong do, ti le VMDU' chiSn ti le trong cac loai dich la 40,3%, 27,9%, 25,5%.
Dong thoi, ong ciing ghi nhan ti le benh nhan VMDU* va hen trong nhom thanh djch cao hon so vol nhom dich keo. Theo tac gia, V M D U va hen CO xu huong it xay ra 6 nhom dich co dp nhot cao. Mat khac vi khuah dupe phan i^p a nhom djch mii cao hon la nhom thanh djch hay djch keo. Tir do ong ket luan VTGTD the thanh djch CO lien quan tori TTDU", trong khi VTGTD the djch mu c6 lien quan tinh trang nhiem trimg hon la dj ling.
Trong nghien ciiu nay, chung ^ i ghi nhan eo 8,3% truong hpp eo djch mu. Day la mot dang viem tai kha dac biet ma nhieii tac gja nhu Bade, Hurst,... ding m6 ta*. Dang nay tiiuong gap 6 nhung tre em bj viem im gjiia cajp Mi di tai lai tren n&i mpt VTGTD lam cho djch thuong xuyen ti dpng trong tai giira.
Thanh phan tebao b^ch cau trong dich tai giiia Chiing toi ghi n h | n ^ ' b a o bach cau da nhan tiling tinh (BCDNTT) chiSn uu the vcd ti le 48,34%, tiep Iheo la thanh phan Ijmipho bao chian ti le 24,01%, mono bao chietn 19,53%, bach cau da nhan ai kion (BCDNAK) chian 4,89%, bach cau da nhan ai toan (BCDNAT) diion 3,29%.
Hinh 1: Hinh anh cac tebao BCDNTT (N), BCDNAT (E), Lympho bao (L), Mono bao (W trong dich tai giiia (hinh trdi) vd hinh anh 15 tebao BCDNAT (mui tin) trong dich tai giQa (hinh phai) a QT x80.
Y Hpc TP. Ho Chi Minh * T3p 20 * So 1 * 2016 Nghien cihi Y hpc
Palva cho rang xet nghiem te'bao hpc djch tai giiia va te bao trong cac mau sinh thiet tao nen mpt biie tranh toan canh qua trinh mien djch sinh hpc dang dien ra chinh xac hon.
BCDNAT va di ling ciing dupe xem la nhung yeii to ket hpp trong sinh berth hpc va m6 hpc cua VTGTD. Nam 1973 Miglets dimg co phan huong kich thich niem mac tai giiia va ong ghi nhan su xuat hien nhieu te bao bach cau da nhan bao gom luon BCDNTT va BCDNAT trong niem mac tai giiia.
LIEN QUAN G I 0 A TTDU" V A VTGTD MotsobieuhienJTDlt&benhnhi VTGTD
Trong mau nghien ciiu a i a chiing toi, ti le benh nhi co bieu hien VMDU chiem 33,3%, tiep theo la hen va viem da co dja chie'm 6,1%, bieu hien TTDU' (eo it nhat mot trong cac benh tren) la 39,4%.
Su khac nhau ve ti le cac benh di ling ciia nhieu nghien cihi da duoc cac tac gia giai thich la do cac nguyen nhan:
- Nghien ciiu dua tren bang tra loi cau hoi tu cha me benh nhi, do do ket qua co dp tin cay thap.
- Sai lech do nho lai (recall bias).
- Sai lech do gioi thieu benh nhan (referreil bias): Nhung nghien ciiu thuong dupe thuc hien tai cac trung tam ve benh dj ling va/hoac viem tai gjira nen ti le cac benh di ling cao hon trong cong dong.
Khong nhat quan trong ehpn mau va phuong phap nghien ciiu®.
Co dhe* eiia benh di ling dong vai tro trong VTGTD van eon nhieu ban cai. Bluestone dua ra gia thuyet "Vai tro cua benh dj ling trong benh nguyen va sinh benh hpc ciia VTGTD" eo the do mpt hoac cac co che sau®;
- Niem mac tai giua hoat dpng nhu mot ca quan dich cua phan ling dj ling
- Niem mac voi nhi bj viem ne do cac phan img di ling lam tac voi gay viem tai giiia
- Di ling lam viem tac mui
- Hien tuong tac miii, tac voi nhi tao ra ap luc am trong tai giiia, se tao ra luc hiit keo vi khuah, djch tiet tir vom mui hong vao tai giua.
Ngay nay, mpt so' tac gia cho rang tai giiia dupe xem la mot thanh phan trong he duong Iho th6hg nhat bao gom hong miii, tai giiia va vol nhi. Ve co ban, qua trinh VMDU" se lam phii ne va tac nghen voi nhi t?o ap l\rc am trong tai giiia va can tro qua trmh thong khi horn nhi. Khi voi nhi mo ihoang qua se hiit nhiing chat tiet chua vi khuan va sieu vi tir hpng miii vao tai giiia. Do vay, roi loan chiic nang voi nhi khi VMDU" se gay nhiing ton thuong niem mac horn nhim. Sau do, voi nhi se bj dong lai va nhiing hoa chat trung gian do phan ling di ling tai hoc miii va niem mac da day, lam tang tmh tham niem mac mang nhay, do do nhiing chat tiet chiia vi khuan se tir hpng miii chay vao horn nhi. Cuoi cimg, cac yeii to' siie cang be mat (surfactant) trong voi nhi se bj thay dSi trong phan ling dj ling gay nen r6i loan chiic nang thanh thai ciia voi nhi. Do do, nhieu nghien ciiu khac da chiing minh m6i lien quan giiia VMDU va VTGTD la do roi loan chiic nang voi nhi thii phat sau phan ling di ling 6 miii. Hon th^ niia, nguoi ta con chiing minh nhiing dj nguyen duong ho ha'p co lien quan deh khoi phat VTGTD trong khi viem da ca dia va viem ket mac di ling thi khong.
Titdi chat dich tai giUa va TTDlt
Ti le thanh djch, djch keo, dich mii trong benh nhi VMDU" la 35%, 36,4%, 0%.
Ti le thanh djch, djch keo, djch mii h-ong benh nhi hen, cham, me day deu lah lupt la 5%, 9,1%, 0%.
Ti le BCDNTT vd BCDNAT trong dich tai giiia a benh nhi VTGTD co TTDlX vd khong co TTDU
Ti le BCDNAT trong dich tai giira 6 nhom co TTDU" cao hon so voi nhom khong co T T D U va su khac biet nay co y nghia thong ke. Ket qua nay phii hpp v6i nhiing nghien ciiu truoc do cho rang tai giiia ciing tham gia vao phan ling dj ling pha muon Th2. Wright va cong su® ding ghi
Nhi Khoa
nhan su tang IL-5 va major basic protein (protein trong cac hat cua BCDNAT) a niem mac tai giua tren benh nhan VTGTD so voi nhom ehiing.
Ngoai ra. Hurst va Vengeis ciing bao cao tang nong dp ECP (eosinophilic eationic protein - protein dupe tiet ra tix BCDNAT) a nhiing benh nhan VTGTD co dj ling so voi khong eo TTDU".
LOy HP.N va cong su® ciing ghi nhan nong dp BCDNAT, te bao lympho T, IL-4 mRNA trong djch tai gjiia, VA va voi nhi cao hon o nhom VTGTD CO TTDU" so voi nhom khong eo TTDU*.
Dong thin nong dp BCDNTT va IFN-y mRNA trong cac vi tri tren 6 nhom VTGTD eo TTDU thap hon so voi nhom khong co TTDU". Do do, cac tac gia cho rang phan ling dj ling 6 nhung nguoi CO benh dj ling va VTGTD khong chi xay ra don thuan 6 tai giiia ma con 6 2 ben voi nhi va hpng miii. Qua trionh viem nay xay ra ciing giong nhu 6 nhiing co quan khac trong he h6 hap.
Tuy nhien, trong nghien eiiu cua chiing toi thi kh6ng co su khac biet ti le BCDNTT trong djch tai giiia a nhiing benh nhan VTGTD co TTDU va khong co TTDU".
Cho toi nay, nguoi ta chua thay ro rang vai tro cua BCDNTT trong benh tai giiia. Ngucri ta cho rang BCDNTT thuong hien dien 6 betih nhan VTGTD mii. Nhung trong n ^ e n ciiu cua Hurst va Venge'S tM cac tac gia ghi nhan BCDNTT dupe boat hoa nhieu ngay ca VTGTD giai doan man. Ong ghi nhan a nhiing benh nhan co TTDU" co tang nong dp MPO (myeloperoxidase - glycoprotein dupe tiet ra tii BCDNTT) va ECP trong dich tai giira, mac dii nhiing benh nhan nay khong co tinh trang nhiem trimg cap nhung o nhiing b | n h nhan viem tai giiia mii thi co tang ca 2 hoa chat trung gian tren nhimg tang khong tuong xiing voi MPO nhieu hon. D i ^ dang luu y I^ trong viem tai giiia mu khong Ihay su ho^t dong cua duong bao (mast cell). Trong pha mupn aia dap ting di ling qua trung gjan IgE ciing ghi nhan su hoat dpng cua bach cau da nhan trung tinh va cac yeu to" hoa huong dpng bach cau da nhan trung tinh 6 m6 da va mui, dac biet la IL-8 (nhu hinh minh
hpa). Cac yeu t6'nay xuat hien 6 ca benh nhan co benh dj ling va khong co benh dj ling. Do do dj ling CO the dong gop vao su tang nong dp cua MPO. Do v^y su tang hoat dpng ciia ci BCDNAT va BCDNTT deu la nhirng tiianh phan kh6ng the thieii trong djch tai giiia.
Badarial-Anttgaii
Hinh 1: Tac ddng ciia thi tang di img len hoat dong ciia BCDNTT trong djch tai giiea b BN VTGTD.
"Nguon: Hurst D.S., Venge P., 2002".
KETLUAN
Da so' cac benh nhi trong nghien ciiu ciia chiing toi la 6 nhom 0-4 tuoL
Benh nhan co TTDU" chi&n 39,4% cac truong hpp voi cac bieu hien eiia VMDU nhu nghet miii, ngiia mui, chay mui, hat hoi (33,3%) hoac CO bieu hien cham, me day, hen phe quein dupe xac dinh boi cac bac si chuyen khoa H6 Hap va DaUlu(6,l%).
Bach cau da nhan trung tinh eo ti Ve cao nhat chiem 4834%; trong khi do b?ch cau da nhan ai toan chi ehian 3,29%.
Ti le bach cau da nhan ai toan trong djch tai giiia 6 benh nhi co TTDU" cao hon so voi benh nhi khong co TTDU" (p < 0,05). Khong eo su khac biet ve ti le bach cau da nhan trung tinh trong djch tai giiia 6 hai nhom benh nhi co TTDU" va khong CO TTDU (p > 0,05).
Nhu vay dj ling la yeii to' thuan Ipi gay ra nhiing benh ly viem nhiem 6 vimg miii hpng, anh huong den ehiic nang voi nhi va tai giiia. Do do nhung benh nhan eo bieu hien di ling can dupe kiem tra tai de phat hien va dieu tri som finh trang viem tai giiia.
Chuyen De Sue Khoe Sinh San - Ba Me Tre Em
Y Hoc TP. Ho Chi Minh * T$p 20 * So 1 * 2016 Nghien ctru Y hoc TAI UEU THAM KHAO
1 Bernstein JM (1996), "Role ai alleigy in eustadiian tube blockage and otitiB media with effusion: a review", Ololaryngd Head Nerk Surg. 114(4), ( ^ 562-8.
2. Bluesbme CD and Doyle WJ (1988), "Anatomy and [ ^ j ^ o l o g y of eustachian tube and middle ear related to otitis media", ]Allergy Clin Immunol. 81(5 Pt 2), p p . 997-1003.
3 Gentile DA and Skoner DR (2014), "Allergy and Immunology", in Bluestone CD, Simons ]P, and Healy GB, Editors, Bluestone and Stool's: Pediatric Otolaryngology, People's Medical Publishing House, USA, pp. 127-132.
4 Hoist DS and Venge P (1996), "Levels of eosinophil caBonic protein and myeloperoxidase from diTonic middle ear effusion in patiarts with a l t e g y and/or acute infection', Otolaryngol Head N o t Surg. 114(4), pp. 531-44.
5 H m s t DS and Venge F (2000), "Evidence of eosinophil, neutrophil, and mast-cell mediators in the effusion of OME patients with and wittiout atopy". Allergy. 55p), pp, 435-41.
6 Kwon C et al. (2013), "AUetgie diseases in children wlfti otitis media wifli effusion', Int} Pediafr Otarhinolaryngpl. 77^), pp.
158-61.
7 Marple BF (2010), "ALergic rhinitis and inflammatory airway disease: interactions within the unified aiispats". Am ] Bhmol Allergy. 24(4), pp. 249-54.
8 Nguyen L H et al, (2004), "Similar allergic inflammation in the middle ear and the upper airway: evidence linking otahs media with effusion to the united airways concept', J Allergy Clin /mmH«o). 114p), pp. 11105.
9 Wright ED et al, (2000), "bicreased expression of major b a a c protem (MBP) and interleukin-5([L-5) in middle ear biopsy specunens from attune patients with pergstait otitis media wjtfi division', CMaryngpl Head Ned: Surg. 123(5), pp. 533-8.
Ngay nhan hai bao: 12/11/2015
Ngdy phan bien nhan xet bai bao: 16/11/2015 Ngdy bdi bao duac dang: 20/01/2016
