TRI U NHU MUI XOANG VA ITNG DUNG PHAU THUAT NOI SOI Difiu NGHIEN ctru DAC DIEM LAM SANG, CAN LAM SANG

Tap chi Tai IVIOi Hong Viet Nam - Volume (59-20). N°2- April, 2014

NGHIEN c t r u DAC DIEM LAM SANG, CAN LAM SANG VA ITNG DUNG PHAU THUAT NOI SOI

Difiu TRI U NHU MUI XOANG

Vo Thanh Quang', LeMinh Ky', Nguyin Quang Trung", Nguyin Nhat Linh', Ha Minh Loi'vd c$ng su.

Tom tat: U nhu la logi u hay gap nhdt trong cdc logi u ldnh tinh aia mBi xoang. Hien nay, phdu thugt la bien phdp diiu trf duy nhdt. Viec img dung^ noi soi vdo diiu tri phdu thudt cdn chua co nhiiu nghien cuu di xdy dung chi dinh, chdng chi dinh ciing nhu quy trinh thuc Men. MifC tieu: Mo td dgc diim ldm sdng, can ldm sdng cua u nhu mui xoang (UNMX) vd ddnh gid tinh img dung cua phdu thugt noi sol trong diiu tri. Bdl tuang va phutmg phdp nghien ciiu: 50 benh nhdn duac chdn dodn xdc dinh UNMX vd dieu Iri

bang phdu thugt noi sol tgi Benh vien Tai MUi Hong Tlf tit 3/2012 - 12/2013. Ket qui:

Tudi trung blnh: 49,82 ± 14,01, nam/nU = 1/1, trieu chung hay ggp Id nggt mfii (90%) vd chdy mm nhdy (84%), hlnh thdi qua khdm noi sol: dgng chiim nho: 62%, dgng qud ddu:

26%, gidng polyp: 12%. Tren phim CLVT, tin thucmg chu yiu la ophite hap 16 ngdch, xoang hdm vd xoang sdng truac (diu Id 70%). Mo benh hoc: UNBN 66%, u nhu thuang 34%. Biin chiing trong mi: 4% chdy mdu, 2% tin thucmg S mit. Kit qud PTNS tdt aglai dogn 1 la 90%, a giai dogn 2 Id 65,5%. Ty le tdi phdt 36.4% a glal dogn 3. Ket luan: Tdn thuong tren CLVT nhiiu han tin thucmg phdt Men trong PTNS. PTNS u nhit gn todn, it biin chimg. Ty le tdi phdt thdp han so voi phdu thugt duomg ngodi.

Summary: Sinonasal Papilloma is the most common in benign neoplasms of the sinonasal tract. Surgery Is only method to treatment for smonasal papilloma. Application endoscopic surgery to removal of sinonasal papilloma benign neoplasms of the sinonasal tract are now being successfully with endoscopic sinus instrumentation. Indication, contraindication as well as process of application endoscopic surgery to removal of sinonasal papilloma benign neoplasms of the sinonasal are not consensus. Purpose:

Describe clinical endoscopic examination and CT scans of sinonasal papillomas features and evaluation on results of application endoscopic surgery treatment of sinonasal papillomas. Patients and methods: We studied 50 cases sinonasal papillomas and treated with endoscopic surgery to removal of sinonasal papilloma In National ENT Hospital from March 2012 to December 2013. Results: Mean age: 49,82 ± 14,01; male/female rate = 1/1. Common symptoms are nasal obstruction (90%>) and mucus running nose (84%), specific lesion 88 %, liked polyp 12 %. On CT Scan: Extend maxillary ostium (62%), focal hyperostosis (60%), opacification of middle meatus, maxillary sinus, anterior ethmoid sinus with the same hight rate (70%)). Histopathology: 66% Inverted papilloma, squamous papilloma.

* BV Tai IVIui Hong trung uang

** Bp mon Tai Mui Hpng, DHYHN Nhjn Mi 20/3. Duyet in 30/3/2014 54

Tgp chi Tai l^ui Hong Vigt Nam - Volume (59-20). N°2- April, 2014

1. D^T VAN DE

U nhli miii xoang (UNMX) dugc Ward va Billroth mfi ta ldn dau tien nam 1854 vd la lo^ u cd nguon gdc bifiu mfi hay gap nhat trong cac khdi u ldnh tinh miii xoang, (ty lfi tir 0,5-4%). Nam 2005, Td chuc y tfi tiie gidi da chinh thiic chia UNMX thdnh 3 nhdm md bfinh hgc: u nhd thudng, u nhu ddo ngugc (UNDN) va u nhu tfi bdo lorn ua axit, trong dd hai loai sau cd the tien trien thanh ac tinh. Phuang phap difiu tri chu yeu hi?n nay vdn la phdu thuat, nhung do UNMX cd thfi xam lan ra xung quanh nen viec kifim soat bfinh tich UNMX vdn cdn nhifiu khd khan.

Trudc ddy, phdu thudt UNMX chi dugc thuc hien theo dudng ngoai (dudng md canh miii vd lot gang tdng mat giiia) dfi cit mdt phdn hay toan bp phdn giiia xuong hdm. Tir nhiing nam 1990, phdu thuat nfii soi dugc Stammberger vd Wigand sir dun^

dfi difiu tri UNMX, tir dd da ddn thay thfi cho cac phdu thuat duoiig ngoai cfi dien.

6 Viet nam trudc nam 2000, cdc bfinh nhdn UNMX dfiu dugc md bang phdu thuat dudng ngodi nhung ty lfi tai phat cdn kha cao, ddc biet la rdt khd theo doi, danh gia miic dd tdi phat va xii ly tai phat sau md.

Tir sau nam 2000 dfin nay, tai Khoa Miii Xoang Bfinh vien Tai Miii Hgng Trung uong dd budc ddu dp dung phau thudt ngi soi dfi difiu tri bfinh UNMX vd thu dugc kfit qua kha quan. Bao cao kfit qua ban ddu cua vi?c irng dung phdu thuat ndy da dugc tac gid Vfi Thanh Quang trinh bay tai Hpi nghi Tai Mui Hpng cdc nudc ASEAN ldn thu X t^ Bali - Indonesia. Tuy nhien vdi sfi lugng b?nh nhdn va kinh nghiem cdn it, chua thfi cd dupc nhimg kfit ludn vung chac. Chinh vi v^y, hifin nay tai Viet Nam cdn ton tai 2 quan diem difiu tri UNMX bdng phau thudt

ndi soi va bdng phlu thudt kinh difin theo dudng ngodi. Dfi dung hda hai ludng quan difim trfin, da sd cac tdc gid dfiu cho rang nfin ap dung phfii hgp cd hai phuong phap.

Vi su khdng thfing nhdt trfin, ddng thdi cimg vdi lgi ich md benh nhan cd thfi dat dugc khi su dung phau thudt npi soi voi khd nang ldy u rdng rai chiing tdi dfi xuat nhifim vu nay nhdm sdm cd dugc nhirng kfit ludn cdn thifit, tao difiu kien cho vific dp dung va trien khai phdu thudt ndi soi difiu tri UNMX.

Muc tieu nghien cihi:

1. Mo td dac diim ldm sdng, can ldm sdng cua UNMX.

2. Ung dung phdu thugt ndi soi trong diiu tri UNMX vd ddnh gid kit qud cda phdu thugt.

2. D 6 I TU^ONG V A PHU'aNG PHAP NGHIEN cifV.

2.1. Doi tugng nghien ciiu.

50 bfinh nhan dupc chdn dodn xac dinh qua Idm sang va xet nghifim gidi phau benh la UNMX, dugc difiu tn bang phdu thuat nfii soi va theo ddi sau md tai BV Tai Mui Hpng Trung uong tCr thang 3/2012 dfin 12/2013.

* Tiiu chudn lua chon:

- Cd mfi bfinh hgc xdc chdn la UNMX theo phdn loai cua TCTYTTG 2005.

- Dugc chup cdt ldp vi tinh miii xoang theo dung tieu chuan.

- U nhli giai doan 1, II, III theo phan loai cua Krouse.

* Tiiu chudn logi trir:

- Khi khdi u xdm ldn nen sp, d mat, md mfim d mat... (dua trfin phim CLVT).

Tap chi Tai Mui Hgng Viet Nam - Volume (59-20). N"'2- April, 2014

- UNMX cd ung thu hoa (theo kfit qua giai phdu bfinh).

- Cd chdng chi dinh gay me do cd tifin su bfinh ly toan thdn.

2.2. Phuung phap nghien ciru.

Nghifin ciiu thfing kfi md ta timg truong hgp cd can thiep.

2.3. Cach thirc tien hanh.

* BN dugc chgn vao nghien ciiu theo tifiu chuan nfiu d trfin dugc danh gid vi tri xuat phat va do lan rpng ciia khdi u, tir do dua ra chi dinh phdu thuat ngi soi phii hgp theo 4 budc cua PTNS lay UNMX nhu sau:

+ Budc 1: Lay u trong hdc mui.

+ Budc 2: Lay u d khe giira bao gdm ca phiic hgp 16 ngdch.

+ Budc 3: Cat phan giiia xuang ham va lay u trong xoang ham.

+ Budc 4: Lay u trong xoang trdn hay xoang buom.

* Chi dinh loai phau thuat:

+ Phau thuat loai 1: thuc hien budc 1 d tren va cat phan niem mac xung quanh. Chi dinh vdi khfii u giai doan I.

+ Phau thuat loai 2: Thuc hifin budc 1 va 2 (md rgng Id thdng xoang ham, md sang trudc vd ngach tran). Chi dinh vdi khfii u giai doan 11.

+ Phau thuat loai 3: Thuc hifin ca 4 budc tren (PTNS tifit can + cat phdn gitra xuong ham). Chi dinh vdi khfii u giai doan III.

* Sau thdi gian hdu phlu, cac BN dugc theo ddi sau md tCr 3-12 thang dfi danh gia theo 3 miic dp;

+ Tdt: Hdc mo sach, nifim mac phuc hdi tdt.

+ Kha; Hdc mfi cd vifim mirc do nhe, khdng gay bit tic PHLN.

+ Kem: Hoc md vifim nhifiu, cd mii nhdy hoac mii dac, bit tac PHLN, tai phdt u.

3. KET QUA.

3.1. Dac dilm Iam sang UNMX.

3.1.1. Tudivdgi&L

50 BN trong nhdm nghien cuu cd 26 nam va 24 nil, vdi do tudi tu 4 - 74 tufii, trung binh la 49,82 ± 14,01. Phan chia cac nhdm tudi va gidi the Men trong bdng 3.1.

Bdng 3.1. Phdn bd theo tudi vd giai

Nhom tudi

< 2 0 21 - 4 0 41 - 6 0

> 6 0 Tdng

Nam n 2 5 13 6 26

%

4,0 10,0 26,0 12,0 52,0

na

n 0 6 14

4 24

%

0,0 12.0 28,0 8,0 48,0

T6ng n 2 11 27 10 50

%

4,0 22,0 54,0 20.0 100

Nhdn xet Nhdm tudi 41-60 chifim ti le cao nhdt (54%), it gap UNMX d nhdm tufii trfi em (4%). Khdng cd su khac biet vfi gidi bi UNMX trong nghifin ciiu nay.

3.1.2. Trieu chimg Cff ndng.

I rg rg. (^,

Ngat Chay Chay Giam Dau m u i i mui mau khu-u nhu'c ben nhay mui giac vung

Bieu do 3.1. Trieu chung c o nSng

Tap chl Tai MOi Hong VIM Nam - Volume (59-20). N°2-April, 2014

Trieu chiing co nang chu ydu la ngat mui 1 cliay mau mui (26%) va giam khiiu giac ben (chiam 9(),0%) va chay mui nhay (22%). Dau nhiic vung mat chi co 6 9 BN, (chiem 84%). tt gap hon la trieu chiing chigm 18%.

3.1.3. Triiu chung thifc thi (khdm qua noi soi).

Bang 3,2, Hinh thai ktioi u qua noi soi

Hlnti tiiai

n

%

Chum hho 31 62,0

L¥

_{Qua dau}

13 26,0

a

Giong polyp

6 12,0

Hinh thai difin hinh la khfii u cd dang chum nho d 31 BN chifim 62%, dang qud ddu d 13 BN chiem 26%. Dang khdng dien hinh Id hinh thdi giong polyp chi cd 6 BN chifim 12%.

3.2. Dac diem can lam sang.

3,2.1. Vi tri cdc xoang tdn thwong tren phim CLVT.

Bang 3.3. Vj trl cSc xoang ton thu'ang tren phim CLVT Vi tri xam

l i n n

%

H6C mOi 10 20,0

PHLN 35 70,0

Xoang ham

35 70,0

sang tru'dc 35 70,0

sang sau 15 30,0

Xoang bu'dm 8 16,0

Xoang tran

6 12,0

Noi so.

ngoai xoang 0 0,0

Tfin thuong chii yeu d phiic hop Id ngdch va xoang lan can nhu xoang ham vd sang tnrdc (dfiu chifim 70%), it gap u xdm lan len xoang tran hay xoang budm.

3.2.2. Chan dodn giai dogn UNMX theo Krouse.

Bi^u do 3 2 Chan doan giai doan UNMX theo Krouse

Da sd bfinh nhan dfin d giai doan som (giai doan 1 va 2) vdi ti lfi 78%.

3.2.3. Kit qud mo binh hgc Ket qud mo benh hgc cua 50 BN cho thdy UNDN chifim da sfi vdi 33 ca (66%), con u nhli thudng chi cd d 17 ca (34%), khdng gap BN cd UNDN kfit hgp vdi ung ihu ciing nhu u nhii tfi bao ldn ua axit.

3,3. iTng dung phau thuat ngi soi trong dieu tri UNMX va danh gia ket qua cua phau thuat.

3.3.1. Logi phau thugt ngi soi

Tap chl Tai Mui Hong Viet Nam - Volume (59-20). N°2-April, 2014

Bieu do 3.3. Loai ph§u thu|t ndi soi Chiing tdi thuc hifin ca 3 loai PTNS, trong dd loai 2 chifim nhifiu nhat vdi ty le 58%, loai 3 Id phdu thuat cd cat phan giiia xuong hdm chifim 22%.

3.3.2. Biin chitng, di chirng trong vd sau phdu thugt

Bang 3 4. Bidn chdng, di chii'ng trong va sau phau thuat

Bi4n chi>ng, di chu'ng Chay mau

Tu mau 6 mat Bign chu'ng l<hac (Giam thi IU'C, Song ttii. Do DNT, Seo dinh, Thung vach ngan..)

Khong c6 bign chiing n 2 1

0

47

%

4 2

0,0

94 Bien chiing trong md hay gap nhat la chdy mau chifim ty lfi 4%, tu mau d mat chifim 2%, khfing gap bifin chiing ndng khdc ve mat hay ndi sg.

3.3.3. Ket qua phdu thugt theo phdn logi PTNS

Bang 3 5. Ket qua ph§u thuat theo phan loai PTNS

PTNS Kit qua PT

Tat Kha Kem

PTNS loaii n 9 1 0

%

90 10 0,0

PTNS loai 2 n 19

7 3

%

65,6 24,1 10,4

PTNS ioai 3 n 5 2 4

%

45,5 18,2 36,3

Phlu thuilt loai 1 va 2 cho ket qua t6t hon loai 3. Ty le dat kk qua t6t ciia phlu thu^t loai 1 va 2 chilm ty le cao, tuong ilng la 90% va 65,5%

3.3.4. Tdi phdt theo giai Soifn u (theo Krouse).

Bang 3.6. Ty le tai phat theo giai doan u

Giai doan Giai doan 1 Giai doan 2 Giai doan 3

Sd ca tai phat

0 3 4

n 10 29 11

%

0 10,3 36,4 Ty lfi tdi phdt d nhdm bfinh nhdn hi bfinh giai doan 3 Id cao nhat, chifim t)* lfi 36,4%, d giai doan 2 la 10,3%, d giai doan 1 Id 0%

4. BAN LUAN

4.1. Dac diem Iam sang UNMX.

Khac vdi u nhii thanh qudn, UNMX chu yeu gap d tudi trung nifin. 50 BN ciia chiing tdi cd tudi trung binh Id 49,82 ± 14,01, vdi nhdm tudi > 60 chifim toi 74%.

Ket qua nay phu hgp vdi nghien ciiu cua cac tdc gia khdc nhu Luong Tudn Thanh 63,6%, Nghiem Thi Thu Ha 69,4%, Pham Thai Qudc Bim 70%, Nguyfin Ba Klioa 70%, Nguyfin Quang Trung 61,4%, Gustafson 53,8%, Pelause 55,8 %. Vfi gidi, chung tdi thay ti le nam/nir ~ 1/1. Nghifim Thi Thu Ha la 1,25/1, Nguyfin Quang Trung la 1,6/1. Sham, Minovi, Yoon la 2/1.

Ti le nay cdn cao hon niia d mdt sd thong ke khac nhu cua Luang Tudn Thanh la 2,75/1, cua Pham Thai Qufic Bim la 7/1, ciia Lombardi la 3,7/1. Theo tdng kfit so lieu ldn tir da trung tdm thi ty le nam/nfl dua raid 3:1.

Vfi trifiu chiing ca nang, hay gdp Id ngat mui mdt bfin (90,0%) va chay mui nhay mu cung bfin ngat miii (84%i), tuang

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Tgp chi Tai MQi Hong Viet Nam - Volume (59-20). N°2- April. 2014

tv nhu cua cac tdc gid khdc: Nghiem Thi Thu Ha: 88,9% ngat mui, 69,4% chdy miii nhay, Luong Tuan Thdnh 96,7% ngat mui, 73,3% chdy miii nhdy, Nguyfin Quang Trung: 98,5% ngat miii. 87,1% chdy miii nhay,... va cao han ciia cdc tac gid nudc ngodi vfi trifiu chiing ngat miii nhu cua Bielamowicz la 71%, Pelause: 71,4%, Minovi 70,1%, Kristensen 82%... Cac trifiu chiing nay khfing phdi la ddu hieu dac trung cua bfinh UNMX va ciing la cdc trifiu chdng ciia vifim miii xoang — polyp miii thdi^ thudng, trir 1 diem dang chii y la tat cd cac tri^u chung chi xay ra d 1 bfin hfic mui. It gap hon cd chay mau miii (26%).

Ddy la dau hieu dang luu y lam benh nhan lo lang va di khdm voi dac difim Id cd the chay tu nhifin hay khi xi mui manh. Da sd bi chdy mdu mui d mdt bfin vdi sd lugng it vd thuong tu cam. Khi g^p nhirng bfinh nhdn nhu vdy (cd u hfic mui ma xuat hifin chay mau miii) thi can chan dodn loai trir ung thu mui xoang. Tii nhung nghien ciiu ndy, vdn de dat ra la ddi vdi cac trudng hop UNDN ma cd ddu hifiu chay mau miii kem theo thi cdn dugc sinh thifit u lam gidi phdu bfinh d^ loai trir cdc tdn thuong ac tinh di kem va nhifiu khi BN can dugc sinh thiet nhifiu ldn moi cho kfit qud duong tinh. Nhu vay UNMX cd cac dac diem dau hifiu co ndng tuong tu nhu bfinh cdnh ciia khfii u hdc mui khdc va khdng cd trifiu chiing co ndng dac hifiu rifing bifit.

Chiing tdi gdp hinh thdi dien hinh ciia UNMX la 88%, bao gfim dang chiun nho (62%) vd dang qud ddu (26%), tuong duong nghien cdu cua cac tdc gid khac nhu Nguyfin Quang Trung: 88,6%, Nghifim Thi Thu Hd: 75%, Luong Tudn Thanh: 70%.

Cdn lai mdt sd it (12%) cd hinh thai u khdng difin hinh (gifing polyp). Vi vay ma cdc bdc sT lam sang can luu y dfi phdn bifit

giua cac benh ly cd polyp miii mdt bfin (nhu polyp Killian hay vifim xoang man tinh cd polyp mui chi d 1 ben) vdi benh Iy UNMX cd hinh thdi khong difin hinh nay.

Khi cd nhimg ban khoan thi can tien hanh sinh thifit dfi cd chdn dodn xdc dinh rdi tir dd dua ra phuang an dieu tri thich hgp.

4.2. Dac diem cdn Iam sang

Bdng 3.3 cho thay cac tdn thuang tap trung chii yfiu d vung trung tdm mui xoang (bao gdm phiic hgp Id ngdch, xoang hdm vd xoang sang trudc) vdi mdi loai chiem tdi 70%. Nguyen nhdn la do da sfi khfii u cd vi tri xudt phdt tir vdch miii xoang nen chiing thudng gay ra su tac nghen ddng ddn luu cua vung xoang hdm vd sdng trudc, ho^c do khdi 11 tir vdch mui xoang xdm ldn vao vimg xoang ham va sang trudc. Cac tdn thuong it gap hon bao gdm vi tri sang sau chifim 30%, xoang buom 16%, xoang tran 12%. Nhu vay cd the ndi rang UNMX it khi xdm ldn ra sau (sang sau, xoang buom) cung nhu ra trudc (xoang tran) ma thudng tap trung chu yfiu la vung trung tdm (xoang ham vd sang trudc). Day cung Id nhdn dinh ciia da sd cdc tac gid khac nhu Nghifim Thi Thu Ha, Nguyfin Quang Trung, Krouse, Lawson....

Da sd benh nhan den kham vd difiu tri d giai doan sdm (1 va 2), chiem 78%. Ket qua nay cung gan gidng vdi kfit qua trong nghifin cim gan day cua Nguyfin Quang Trung, Cannady, cdn cac nghien ciiu trudc day ciia Luong Tudn Thanh (2004) vd Nghifim Thi Thu Ha (2009) thi gap chu yfiu d giai doan mudn hon, chimg td y thiic cua BN vfi vific can di kham bfinh sdm da dugc ndng cao.

Ket qua md bfinh hgc cd 34 % Id u nhii thudng vd 66% Id UNDN (khdng pdp u nhu tfi bdo ldn ua axit). So sdnh vdi ket qua cua

Tap chi Tai Mui Hgng Viet Nam - Volume (59-20). N°2- April, 2014

cac tac gia khdc vfi UNDN, Luong Tuan Thanh gap 80%, Nghifim thi Thu Ha gap 72,7%, Nguyfin Quang Trung gap 57,1%.

Barnes tong ket 728 trudi^ hgp cua 5 tdc gia cho ty lfi la UNDN chiem 62%, u nhu thudng 32%, u nhii te bao ldn ua axit chifim 6%. Nhu vay cd the ndi UNDN chifim da sd trong cac UNMX.

4.3. tTng dung phdu thuat ndi soi trong dieu tri XJNMX va danh gia kfit qua cua phau thuat.

BN ciia chiing toi chu yfiu dugc phdu thuat loai 1 vd 2 (78%). Cdn vdi cac BN dfin kham ma cd khfii u d giai doan 3, chiing tdi ap dung quan difim phdu thuat npi soi rdng rai nhu md sdng trudc, sang sau, cat phdn giiia xucmg ham ket hgp vdi md rdng xoang tran va/hoac xoang budm dfi dam bao lay hfit bfinh tich u, kifim sodt toan bg hdc mo. Quan diem nay cua chiing tdi Cling gidng nhu cua Nguyfin Quang Trung, Lawson, Nicolai, Kraft, Lombardi...

So sanh vdi kfit qua cua mot sfi tac gid khac vfi giai doan I - 2 - 3 ldn lugt iihu sau:

Nguyen Quang Trung: 40% 26,7%

33,3%, Nghiem Thi Thu Ha: 11,1%

19,4%-69,5%.

Vfi bifin chiing, di chiing trong va sau md, cd 2/50 BN (4%) cd bifin chiing chdy mau tir nhanh ddng mach sang trudc, xudt hien khi chung tfii tien hdnh ldy u d phdn sau ngach tran va da dugc xii ly bdng ddng difin ludng cue. Ngoai ra cdn cd I BN (2%) bi tdn thucmg xuang gidy gay tu mau d mdt sau md. Ngoai ra, khdng gap cdc bifin chiing nang nhu la dd dich nao tuy, song thi, giam thi luc... Cd thfi kfit ludn PTNS difiu tn UNMX kha la an todn, vdi ti le khfing cd bifin chiing la 94%. Ty lfi bifin chiing phy thupc vdo miic do lan rgng cua khoi u, sd lan thuc hien phdu thudt, dung cu, trang thifit bi cting nhu kinh nghiem cua

phdu thuat vifin. Chiing toi it gap bien chiing Id do khdi UNMX xudt phat chd yfiu tu vach miii xoang, da sd lan vdo sang trudc va/hoac xoang ham, it khi xam ldn vdo xoang trdn hay xoang budm nen viec kifim sodt PTNS cung dfi dang hon.

Danh gia kfit qua phau thuat theo phdn loai PTNS: Sd lieu trong bang 3.5 cho thdy kfit qud phau thudt se cd ty le tdt cao han d nhiing BN dugc dp dung PTNS loai 1 va loai 2. Nguyfin nhdn la do PTNS loai 1 va loai 2 dugc chi dinh cho nhiing trudng hgp u cdn tuong ddi khu tru d vi tri xuat phdt hay miic dp xam ldn it hon (khoi UNMX cdn d giai doan 1 vd giai doan 2). Day cilng la nhdn dinh cua da sd cdc tdc gid khac.

Kinh nghifim cua chiing tdi, vdi PTNS loai 1 cdn ldy rgng nifim mac tai vj tri u xuat phat (thudng d vdch ngan va/hoSc cufin mui). Vdi PTNS lo^ 2 cdn md rdng vimg phirc hgp lo ngach dfi tao mot hfic mfi rpng, nhdt la can phai lay dugc het cdc vach ngan giua cac tfi bao sang dfi ddm bdo dan luu tdt han ciing nhu de kifim soat tdi phdt sau md dugc dfi dang. Cdn ddi vdi PTNS loai 3 thi luu y cdn phdi cdt bd phdn giiia xuong ham vi vi tri u xudt phat la tCr cac thanh cua xoang ham. Nfiu thuc hifin dupc nhu vdy se lam giam ty le tai phdt mfit cdch ddng kfi.

Sd lieu trong bang 3.6 cho thdy, cdng phdu thuat d giai doan mufin, ty le tai phdt cdng cao. Ddy ciing la nhdn dirih cua da sfi cac tac gia trong nudc va trfin the gidi.

Thuc vdy, d giai doan 1 va 2, chi dinh PTNS dfi difiu tri UNMX la rdt rd rang vd dat hifiu qud cao. Cdn d giai doan 3 thi vi^c su dung PTNS don thudn hay phdi hgp vdi duong ngoai kinh difin cdn can cii vdo tinh trang cu thfi cua BN (qua tham khdm tai cho va cdc tham dd can lam sang). Viec xir

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Tap chi Tai Mui Hgng Viet Nam - Volume (59-20). N^a- April, 2014

Iy khdi u tai phat tuy thudc vao vific BN den kham lai sdm hay mugn. Nfiu BN den kham sdm, u mdi tai phat (cdn nhd), chiing tdi tifin hdnh bdm lay u qua ndi soi vd chi can gdy te tai cho. Cdn d6i vdi cac trudng hgp BN dfin kham mugn, u da tdi phat ldn thi bdt budc phdi chup lai phim CLVT dfi ddnh gia tdn thuang ciing nhu tinh trang cdu tnic cdc xoang ldn cdn, tir dd mdi cd ca sd de quyet dinh PTNS l^i don thuan hay phfii hgp vdi duong ngodi.

5. KET L U ^ .

Qua phau thuat va theo doi 50 BN dugc chdn dodn xac djnh la UNMX, chiing tfii thdy tudi trung binh la 49,82 ± 14,01. Ti lfi nam/nG = 1/1. Trifiu chiing hay gap la ngat mui (90%) va chay miii nhay (84%).

Hinh thdi qua kham npi soi: dang chum nho; 62%, dgng qua dau: 26%, gidng polyp: 12%. Trfin phim CLVT, tfin thuong chu yfiu la d phdc hgp Id ngdch, xoang ham va xoang sang trudc (deu la 70%). Md bfinh hpc: UNDN 66%, u nhii thudng 34%. Bifin chiing: 4% cd chay mau, 2% cd tdn thuang d mdt. Kfit qud PTNS tot d giai doan 1 Id 90%, d giai doan 2 Id 65,5%. Ty le tai phdt 36.4 %d giai doan 3.

TAI LIEU THAM KHAO 1. Pham Thai Qudc Biiu (2000): Budc

ddu nhgn xet vi dich te hgc, ldm sdng vd phdu thudi Papillome ddo ngugc a hdc mui. Luan van chuyfin khoa II, Dai hgc Y Thdnli phd Hd Chi Minh. 1-75.

2. Nghiem Thi Thu Hd (2009): Budc ddu ddnh gid kit qud diiu tri u nhu mQi xoang bdng phdu thudt ngi soi tgi Binh vi?n Tai MUi Hgng TV. Ludn van bac sT chuyfin khoa cdp II. Dai hgc Y Ha Npi. 1-93.

3. Nguyen Ba Khoa (2006): Phdu thugt ngi soi diiu tri UNDN mui xoang.

Ludn dn chuyfin khoa cap II, Dai hgc Y TP Hfi Chi Minh. 1-79.

4. Vd Thanh Quang (2010): Phdu thudt lay phdn giita xuang hdm phdi hgp vdi ndi soi trong diiu tri papilloma ddo ngugc mm xoang vd vai trd kiem sodt ndi soi trong md. Tap chi Y dugc hgc Quan sir, sd 3. 158-163.

5. Luang Tudn Thanh (2004): 7?m hieu ddc diim ldm sdng, md binh hgc cua 30 trudng hgp u nhd mui xoang tgi Viin Tai MUi Hong trung uang. Ludn van thac sy y hoc. 1-64.

6. Nguyfin Quang Trung (2012): Nghiin cuu dgc diim ldm sdng, can ldm sdng, ddnh gid kit qud phdu thudt ngi soi vd yiu td nguy ca HPV u nhu mui xoang.

Ludn an tifin sT y hgc. 1-116.

7. Krouse J.H (2000): Development of a staging system for inverted papillomas.

Laryngoscope 110, 965-968.

8. Krouse J.H (2001): Endoscopic treatment of inverted papilloma: Safety and efficacy. American Joumal of Otolaryngology, 22, Number 2, 87-99.

9. Lombardi D et all (2011): Limitations and complications of endoscopic surgery for treatment for sinonasal inverted papilloma: a reassessment after 212 cases. Head & Neck. 33, p.

1154-1161.

10. Sham CL, Ann D King, Andrew van Haselt (2008): The roles and limitations of computed tomography in the preoperative assessment of sinonasal inverted papillomas. Am J Rhinol 22, 144-150

11. Kristensen S (1985), Nasal Schneiderian papillomas: a study of 83 cases, Clin. Otolaryngol. 10, p. 125-134.