TCNCYH Phg trUdng 80 (38) - 2012
PHAN LOAI TdN THUONG VA DANH GIA K^T QUA Dl6U TRj MANG DiNH MEP TRUOC DAY THANH TAI BENH VIEN TAI
MUI HONG TRUNG UONG
Hoang Dinh Ngyc, Quach Th[ Can B$nh vi$n Tai (\AQi Hgng Trung W&ng
Ming dinh mip Irw&c diy thanh li tin thuxmg hiim gip trin lim sing. Nghiin cim dw&c tiin hinh nhim phin loai tin thwang vi dinh gii kit qui diiu trj cua ming dinh mip truxirc diy thanh. Kit qui cho thiy hinh anh tin thuxmg trong khoing 35-50% dd dii diy thanh (tuxyng img v&i dd II cua phin lo^i Cohen}
chiim da sd (70,59%,) Kit qui diiu trj: Khdng cd binh nhin khd th& sau phau thu^t 2 tuin. Sau 2 tuan khdng cdn b$nh nhin khin tiing mux: dd ning. chi cdn 6 binh nhin khin tling muc dd vira. Sau 10 tuin chi cdn 3 binh nhin khin tling muc dd vua.Sau 10 tuin cho88,2%o binh nhin cd ket quHdt vi mit hlntj thii hqc vdi hlnh anh ton thuxyng day thanh dw&i 5%.
Tu khoa: mang dinh mep trudc day thanh I. OAT
V A NDt
Ming dinh mep tnjdc diy thanh la mpt to chue xa sgo duyc phu bdi myt lap bilu md gai ' khong su-ng hba nil lien hai day thanh. BOnh cd t h l do nhilu nguyen nhin gay nOn nhu:
bim sinh, sau chin thuang, nhiOm triing die hiOu. Song du vdi nguyOn nhan nao thi hiOn nay viOc dieu trj bOnh mang dinh thanh quan van la mpt thach thuc khong nho doi vdi cic thiy thulc Tai MOi Hpng. C6 nhieu phuang phap dilu trj khic nhau nhung lya chpn nao vin con la dau hoi bdi vl cho din nay chua ed phuang phap nao dgt duye kit qua nhu mong dyi. Sy tii phit rit hay xay ra do to chuc sgo phat triln sau phau thugt tich dinh.
Nghien edu tren 34 bOnh nhin duyc chin doan xic d]nh ming dinh mOp tni'dc diy thanh tgi bOnh viOn Tai MQi Hpng TW cb 17 bgnh nhin Nam 17 BN NO-. Khan tilng l i triOu Chung gOp d tit ca cic bgnh nhan. Trong do khan tilng muc dp vifa la 76,47%, mO-c dp ngng la 17,64% v i muc dp nhg l i 5,88%. Trigu Chung khd thd nhg chi-ggp d 7 bOnh nhan.
Phin logi t i n thuang mang dinh mep trudc diy thanh theo Cohen v i Men & Nicolas cO y nghTa trong theo doi tiln triln v i danh gia kit qua dieu trj. Hign nay phuang phap soi treo cit ming dinh kit hyp ap Mytomycin tai ehl da budc d i u dem Igi kit qua kha quan.
Chung tdi nghiOn euu de tai nay vdi myc tieu:
1. Phin logi t i n thuang eua mang dinh mOp trudc diy thanh
2. Dinh gii kit qua dilu tq ming dinh mep trudc diy thanh
II. £)6l TU'O'NG v A PHU'aNG PHAP
1. Doi tuyng nghien cuu: gom 34 bgnh nhin duye ehin doan xic djnh mang dinh mOp tnj'dc diy thanh tgi Bgnh vign Tai MOI Hpng Trung uang tir thing 5 nam 2006 din thing 8 nim 2009.
-TiOu chuin lya chpn:
+ Bgnh nhan duyc chin doan xie djnh ming dinh mOp tofdc d i y thanh qua npi sol
+ Cd bOnh i n day du, ghi chip r5 rang
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T C N C Y H P h y trUdng 80 ( 3 8 ) - 2012
- Tieu c h u i n loai tru':
+ Bgnh nhan co them cac ton t h u a n g sgo hgp tgi cac vj tri khac cua d u d n g t h d n h u hg thanh mon, khi quan, tien dinh thanh quan...
+ BOnh n h i n hogc n g u d i nha khdng dong y tham gia nghiOn c d u
2. P h u a n g phap nghien CLPU Nghien euu hoi cuu md ta tung ca cd can Ihigp 3. Cac b u d c tien hanh
3.1. Hoi bOnh s u . tien s u
3.2. Kham lam sang danh g i i IriOu chung ca nang
3.3. Npi soi danh g i i ton t h u a n g 3.4. Can thiOp b i n g p h u a n g p h i p soi treo c i t mang dinh mep t r u d c k i t h y p i p Mitomycin tgi chd
3.5. X u iy sd ligu
Danh g i i k i t qua dieu trj qua kham npi soi sau p h l u thugt 2 t u i n va 10 t u i n
Cac dtp ligu thu d u y c dien theo m i u bOnh an cd s i n
S l liOu d u y e x u ly b i n g p h i n mem t h i n g ke y hgc Epi info 6.04
3.6. Mpt s l phan logi d u y c i p dyng trong nghien ciKu:
- Trong nghien c u u ed s u dyng p h i n logi cua Cohen, bgnh mang dinh thanh quan d u y c
chia t h i n h 4 dp n h u sau [3]:
DO 1, mang dinh dudi 35% thanh mon khdng phoi hyp vdi t i n thuang d i y dinh d hg thanh mon Dp 2: mang dinh t u 35 d i n 50% thanh m6n, ton t h u a n g l i m p l m i n g mbng hoOc cd dp day trung binh cd t h l kOm h o i c khdng vdi l l n t h u a n g day dinh hg thanh mdn
DO 3: Mang smh l u 50 d i n 70% thanh mdn, ton t h u a n g c6 hinh thai day d phia trudc mdng d phia sau cd the di kem vdi ton t h u a n g day dinh d hg Ihanh mdn.
DO 4. Mang dinh lii' 75 d i n 90% thanh mdn. t i n I h u a n g day toan bp va lien tyc vdi d i y thanh 2 ben gay khd khan trong viOc xac dinh b d t y do cua 2 day thanh, hg thanh mdn t h u d n g bj hep kem theo ton t h u a n g x a lan rpng xuong phia d u d i
- Trong nghien cuu cd s u dyng phan loai theo % dp dai ton t h u a n g day thanh cua Men v i Nicolas [6]:
T i n t h u a n g < 2 5 % chieu dai day thanh Ton t h u a n g 25 - 5 0 % c h i l u dai day thanh T i n t h u a n g > 50% chieu dai day thanh III. K E T Q U A
1. Hinh thai ton t h u a n g
1.1. Mu'C dp ton t h u o n g day thanh theo phan dp Cohen
Bang 1 . Mu'c d y ton t h u a n g day thanh theo phan do cua Cohen
n
%
Qp 1 5 14,7
Op II 22
64,7
C9III 7
20,6
061V 0 0
long so 34
100
Ton thuang d m u c dp II chiem mot ty le cao n h i t eo 22/34 t r u d n g hop.1.2. Ty Ig t i n t h u a n g day thanh theo phan loai cua Men va Nicolas
TCNCYH Phg trUdng 80 (SB) - 2012
Mire dg t6n
< 25%
25 - 50%
> 50%
Tong thifcng
B i n g 2. , Ty 1? t6i 1 thu'O'ng ddy n 3 24 7 34
thanh
%
8,8 70,6 20,6 100
Ty 10 tin Ihuang diy thanh duyc tinh theo ty s6 quy ra % gida dO dii diy thanh bi ton thuang v i dO dii cua diy thanh. Kit qua cho thiy cd 24/34 BN tin thuang diy thanh d trong khoang 25-50% chllm ty Ig cao nhit.
2. Danh giO k i t qua dieu trj 2.1 Mii'c dO khd thd sau phiu thuOt
Sau phlu thuOt 2 tuin khdng edn bOnh nhin khb thd 2.2. Thay dii muc dO khin tilng sau phiu thuOt
Bang 3. Muc dy khan t i l n g sau phau thuat
Muc dO khin Tnjdc
phau thuOt
Sau phau thuOt 2 tuin
Sau phlu thugt ID tuin
Nhe Vira NJng Tong so
N 2 26 6 34
%
5,9 76,5 17,6 100
n 28
6 0 34
%
82,4 17,6 0 100
n 31 3 0 34
%
91,2 8,8 0 100 Sau 2 tuin khbng con bOnh nhan khin tilng muc dO n$ng, chi con 6 bgnh nhan khin tieng muc dO vua. Sau 10 tuin chf cdn 3 bOnh nhSn khin tilng mire dO vCfa.
2.3. So sanh k i t qua nyi soi trudc va sau phau thugt Bang 4. So sanh k i t qua nyi soi trudc va sau phau thugt MLPC dp ton thu'O'ng tinh
theo % chieu dai day thanh
<5%
5-20%
>20%
T6ng s6
Tru'o'c phau thu$t n 0 3 , 31 34
%
0 8,8 91,2
100
Sau phau thuat 2 tuan n 29 5 0 34
%
85,3 14,7 0 100
Sau
n 30
4 0 34
phau thuit 10tuan
%
88,2
11,8
0
100
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T C N C Y H Phy trUdng 80 (3B) - 2012
Sau 2 t u i n khdng cdn bgnh n h i n cd t i n thuang day thanh > 2 0 % chieu d i i . Sau 10 tuan p h i u thugt cb 88,2% BN ed miPC dp ton thuang chi d u d i 5% chieu dai day thanh
I V B A N L U A N
Danh gia hinh thai ton t h u a n g theo p h i n
• logi cua Cohen va theo p h i n logi cua Men v i Nicolas
Trong nghlOn c u u nay ehu yeu chiing tOi ggp ton thuang d dp II (64,71 % ) , khdng ed bOnh nhan nao t i n thuang d dO IV trong nghiOn cuu.
Cac t i c gia n u d e ngoai t h u d n g ed nhung phac dd x u tri thong nhat cho ea 4 dO eua bgnh, nen c i c nghien c u u cua hp t h u d n g cd ca 4 dp phan logi trong nhdm nghien e u u . Tuy nhien d n u d e ta n h u n g bOnh nhan ed ton thuang dp ill dp IV ( t h u d n g ed kem theo xa sgo phoi h y p d cac viing khae nhau cua thanh quan) thudng d u y c x d 1^ theo phac do d i l u tn sgo hgp ciia thanh quan, do vay it khi cb mgt trong nghien ciru. Theo p h i n logi cua Cohen thi dp dai ton t h u a n g chu y l u rai vao dp II.
Tuy nhien trong qua trinh nghien c u u chung toi nhgn t h i y phan logi cua Cohen ed lyi diem trong viec danh g i i t h u a n g ton va anh h u d n g cua no den hinh thai trong cac t i n t h u a n g ngng d thanh quan [3]. Theo p h i n logi n i y dp I ( t u c la mue dp nhb n h i t ) da eb the cb c i c ton thuang den 3 5 % thanh m o n khong p h i i h y p vdi t i n t h u a n g d i y dinh d hg thanh m6n ( t o n thuang la mdt mang mbng d a n t h u i n ) . Trong khi tren binh dign chue nang, cac ton t h u a n g nhu t h l cb gay r l i loan ngng hogc lam m i t chde nang phat am eOa thanh quan. ThOm vao dd tren binh dign theo ddi k i t qua dieu tri i p dyng p h i n logi eua Cohen d l l vdi bOnh n h i n CO ton t h u a n g d dp I se khOng danh gia d u y e ket qua dieu tri va thee doi sau m l . Do vgy i p dyng phuang p h i p nghien c u u m d i nhat cua cac t i c gia Men S va Nicolas R [5,6] chiing tbi
d u a them p h i n logi t i n t h u a n g tinh theo % dp d i i eua day thanh bi dinh. C i c h phan logi nay dgc bigt cb tac dyng tot trong vigc theo ddi k i t qua dieu trj. Chi can thay doi 1 % dp d i i day thanh bj ton t h u a n g cd d u y c ghi nh^n va dieu chinh kjp thd'i trong cac Ian tai k h i m . K i t qua cho thay cd 24/34 bgnh n h i n ton t h u a n g day thanh d trong khoang 25 - 5 0 % chiem ty Ig cao n h i t .
Thay doi ve miPC dp khd thd va khan t i l n g sau p h i u thugt. T r u d c p h i u thugt chi cd 7 bOnh nhan khd Ihd dp I (71,4 %) va 2 bgnh nhan ed thd dO 11(28,6%). Sau p h i u thugt 2 t u i n khdng cdn bOnh nhan khd t h d . Ket qua nghien euu cua Chung tdi r i t phii h y p vdi k i t qua nghien euu eua cac lac gia Colon RT,Nicolas R [4,6].
Trong dd ,ve mgt chirc nang thd cua thanh quan,phiu thuat tach dinh day thanh cd s u dyng mytomicin C cho ket qua h i u nhu tuyOt doi va ngay lap t u c . C i n phai ndi thOm v l mdc 2 t u i n va 10 tuan sau khi p h i u thuat. Theo ly t h u y l t ve sinh ly ciia qua trinh phye hoi thuang t i n . Q u a trinh nay lien quan den ca tai tgo b i l u mo v i to chuc hinh thanh sgo x a . Nd bao gom 3 thi chinh: ViOm - Hinh t h i n h to chuc hgt - L i n g dpng cac e h i t nOn ngoai t l bao va s y bu d i p Igi. Neu s u tang sinh, bii d i p d to chuc lien k i t d c i c mue dp v u a phai, Idp bieu mo cd dii thdi gian d l phyc hoi che phu p h i n bieu mb bj m i t , to chue x a se khong v u y t q u i ra khoi Idp bieu mb gai, vet t h u a n g se d u y e phyc hoi t u a n g doi hoan ehlnh.
D u d i t i c dyng cua Mitomycoin C qua trinh hinh thanh t l chuc s a sgo non tgi mep trudc v i qua trinh t i i tgo bieu md phu len be mgt ton t h u a n g day thanh la dinh h u d n g cho s y phat trien v i hfnh thanh cua to chuc x a cung v i co keo sau nay d u y c hoan t i t trong thdi gian 10 - 14 n g i y N h u vgy la d i i vdi ton t h u a n g mang dinh thanh quan tai p h i t sau p h i u thuOt t i c h dinh, sau 2 t u i n ta cd the quan sat d u y e hinh
TCNCYH Phy trUdng 80 (38) - 2012 thii tuang dii I n dinh eua hinh th^ tin thuang sau niy nlu khdng cd can thiOp gl thOm.
Cdn dii vdi mlc 10 tuan sau phiu thuOt, thi diy l i thdi gian m i dudi tic dyng cua Mitomycin C tin thuang ming dinh thanh quin I n djnh Qui trinh bilu mb phu d i hoin t i l . Sgo xa d bd ly do diy thanh da hlnh thinh hoOc khdng cb khi nSng phit triln rOng han.
Do vOy thdi gian theo ddi sau dilu trj chf cin din muc 10 tuin l i d u .
Kit qua nghiOn cuu cua chiing lOi phii hyp vdi nghiOn cyu ciia cac tic g i i trong db triOu ehung khd thd phyc hll nhanh han do v l mOt hlnh thii tin thuang I n djnh sdm. Du'di tic dyng cua Mitomycin C ,viOe q u i trinh hoin thinh bilu m6 hba v i I n djnh t l chdc xa sgo dudi bieu mO d thanh quan diln ra trong khoang 10 tuin, Irong khi qui trinh bilu mb hda dien ra trong khoang 2 tuan do vOy triOu chung khd thd dgi diOn cho sy phye hoi ve hinh thai dai t h l thudng on dinh sau 2 tuin, edn triOu chung khin tieng, dgi diOn cho sy phyc hoi ve hinh thii vi thl thudng phai sau 10 tuin mdi bilu hign ro. Vi vgy ed t h l ndi la nhd eb Mitomycin C ma qui trinh dieu trj cung nhu theo doi tin thuang bOnh ming dinh thanh quan trd nen dO ding han rit nhilu.
+ So sinh kit qua nOi soi trudc v i sau phlu thugt
Topdc phiu thuOt cb 31 bOnh nhin cb mue dO dinh Idn han 20% chilu dii thanh mdn
Sau phiu thugt 2 tuin cb 29 bgnh nhan cd ton thuang < 5% thanh mdn
Sau phau thuOt 10 tuin ed 30 bOnh nhin cb tin thuang < 5% thanh mbn
Theo Rabats R. v i Kim [9], dudi tic dyng cua Mitomycin C, vigc hoan thinh q u i trinh bilu md hba v i I n djnh to chuc xa sgo dudi bilu me d thanh quan dien ra trong khoing 10 tuin. Qui trinh bilu mb hba chf diln ra trong
2 tuin, do vOy sy phyc hIi ve hinh thii dgi thl thudng I n djnh sau 2 tuin, cdn sy phyc hIi v l hlnh thii vi t h l diln ra trong vbng 10 tuin mdi bilu hiOn r6. Kit qui thim kham dinh g i i sy biln d i i cua hlnh thii diy thanh sau dilu trj cOng phin anh quy luOt niy. Kit qui nghiOn cu'u cua chiing tbi cOng pbu hyp vdi cie nghiOn edu cua Cohen, Cotton, Nicolas [3,4,6]. Trong db hiu hit cic bOnh nhin dlu cb mifc dO I n djnh hinh thii thanh mdn sau 2 tuin phiu thuOt.
V. K ^ T LUAN v l hinh thai ton thuong
Hinh inh tin thuang trong khoang 35 - 50% db dii diy thanh (tuang ung vdi dO II cua phin logi Cohen) chilm chu dgo (chilm ty 1$
70,59% bOnh nhin)
.Ton thuang day thanh d trong khoang 25 - 50% chilm ty 10 cao nhat (24/34 bgnh nhan)
Danh gia k i t qua dieu trj
KhOng cb bgnh nhan khd thd sau phlu thuOt 2 tuan.
Sau 2 tuin khong cbn bgnh nhin khan tilng muc dO ngng, chi cdn 6 bOnh nhin khin tilng muc dp vua. Sau 10 tuin ehi con 3 bgnh nhin khin tieng muc dO vua.
Sau 10 tuan cho 88,2% bOnh nhan eokit qua tot v l mOt hinh thii hpc vdi hinh anh ton thuang diy thanh dudi 5%
T A I LIEU THAM K H A O 1. Qyach Thj Can (2001). Tim hi^u nguyen nhin va danh g i i kit qua dieu trj s?o hgp thanh khi quan gOp tgi bOnh vien Tai MOi Hpng Tnjng Lfang, Lugn van tot nghiOp bacsT chuyen khoa eip II, Trudng DM Y Ha Npi.
2. Benjamin B, E.A Mair (1991), Congenital interarytenoid web, Arch Otolaryngol Head Neck Bur; 117(10)
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T C N C Y H Phy trudng 80 (38) - 2012
3. Cohen .SR (1985). Congenital glottic laryngeal web. Int J Pediatr Otorhinolaryngol.
web in children. Ann Otov Rhinol Lanrygol; 121 70(6): 1 1 2 5 - 1 1 2 7 .
6. Nicollas R, Triglia JM (2008), The anterior laryngeal webs, Otolaryngol Clin North A m . ; 4 1 ( 5 ) : 8 7 7 - 8 8 8
(94): 1 - 1 6
4. Cotton .RT et al (1995). Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the
single- stage approach. The Lanrygoscope; 7. Tae-im Kim et al (2004). Mitomycin C - 105(8): 8 1 8 - 8 2 1 . Induced reduction of keratocytes and fibroblast 5. Men S, Iklz AO, Topcu I, et al (2006), after photorefractive keratectomy Inverstigative CT and virtual endoscopy findings in congenital Ophthalmology and visual science, 45(9)
Summary
LESSIONS CLASSIFICATION AND EVALUATION ON THE TREATMENT RESULTS OF ANTERIOR LARYNGEAL WEBS AT NATIONAL ENT HOSPITAL
Anterior laryngeal webs is a rare lesion. The purpose of this study was to evaluate treatment results and lesions classifiaction anterior laryngeal webs. The results indicated that the lesion in range 30 - 50%, ofvoical cord length ( same as grade II according Cohen's classification) is major clinical feature(70,59%o).
No patient had dyspnea 2 weeks post-op. After 2 weeks. 6 patients had mild hoarses voice. After 10 weeks only 3 patients had mild hoarses voice. After 10 weeks 88 2% of patients had good results in terms of image morphology with vocal cord lesions less than 5%
Keyword: anterior laryngeal webs
DAC DI^M LAM SANG, MO BENH HpC U NANG VA RO GIAP LUOI
Le Minh Ky va cs Benh vien Tai Mui Hong Trung ucrng
U nang vi rd giip-iuai la benh ly bam sinh kha thuong g$p trong chuyen nganh Tai Mui Hong, chu yeu gap a tre em. Nghien cuv duvc thuc hien nhim lim hiiu cic die diim lim sing vi md benh hoc ciia u nang vi rd giip-iuai. Kit qui cho thiy tuii vio vien trung binh li 20,9. Benh nhin It tuoi nhit li 2 tuoi, nhiiu tuoi nhitii 72 tuoi. Tuii khai phit binh trung binh li 16,0. Phin lan unangcd kich thuictirl din 3cm (77,8%). Vj trl nang rd a viing mong-giip li hay gip nhat (78,8%). Co 37,9 % si tieu bin cd hinh anh biiu mo Idt 90,9% biiu md Idt li biiu mo tnj gii ting. Tu kit qui tren ta cd thi kit luan u nang va rd giip ludi chi yeu nim a vung ci giua, trieu chunglim sang da dang Md benh hpc cho thiy ldng ing rd vi nang giap-luai la cd lip bleu md Idt, chd yiu la biiu md tru gii ting.
Tir khoa: nang va ro giap lu'&i, bieu mo try gia tSng
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