T a p c h i T a i M u i H o n g Vifet N a m - V o l u m e (59-21) N°3-October, 2014 ^ ^ _ _ ^ _
NOI SOI KHOET CHUM TIET CAN XOl THiEU DU*6NG XUYEN 6 N G TAI C H I N H HINH XU'OTVG CON
Nguyin Tdn Phong TOM TAT
Phdu thugt tiit can bdo ton diiu tri viim tai-xuong cham man tinh(viem tai giira man tinh nguy hiim dd hoc 16 nhOng nhugc diim cdn ban ve gidi quyit benh tich , dan luu sau phdu thudt vd chinh hinh xuong con. Muc tiiu: (1) Nghiin cuu dgc diim ngi soi, cdt lop vi tinh viem tai- xuang chUm man tinh(VTXC mt) khu tru sdo bdo- thugng nhi. (2) Ddnh gid hiiu qud phdu thudt ngi soi khoet chUm tiet cdn toi thiiu(KCTCTT) duang xuyen Sng tai Ddi tirffng vd phirong phdp: 45 binh nhdn ngi soi KCTCTT dudng xuyen ong tai , 3 7 trudng hgp chinh hinh xuang con bdng gom thuy tinh sinh hgc. Kit qud: VTXCmt nguyen nhdn tic tiii co keo chiim 55.2%,viem thugng nhT25% vd Cholesteatoma 19%. Chup CLVT CO 75% trudng hgp binh tich xam lan sdo bdo, sdo dgo. Kho tai sau mo sau 3 thdng 96%, thinh luc thu hep ABG 20dB trung binh cho moi tdn so. Kit luan: phdu thudt noi soi KCTC TTdudng xuyen Sng tai khong nhiing gidi quyet triet di(tiit cdn) binh tich viem md cdn tgo diiu kien thuan lgi cdn bdn cho chinh hinh xuang con dat hieu qud . Tir khoa: Khoet chum tiet cdn toi thieu (KCTCTT), Chinh hinh xuang con
SUMMARY
Transcanal endoscopic approach for minimum radical mastoidectomy(MRM) with ossculoplasty
OBJECTIVE: This study describes a transcanal endoscopic approach for MRMt with ossculoplasty and highlights ist advantages for removal limited Cholesteatoma in the tympanum and antrum. STUDY DESIGN:Retrospective review of surgical cases using a transcanal endoscopic approach for MRM. METHODS: The author's database of major otological procedures M'OS revie\i>ed to identify cases in which a transcanal approach for MRM M>as utilized to remove disease confined to the tympanum-antrum. Cases in which disease progressed into the mastoid, requiring a postauricular approach were excluded.
Patient demographics, ear pathology, surgical variables, postoperative variables, audiometric data and CT scan of temporal bone were recorded. Standard descriptive statistics were used to summarize demographic and clinical characteristics of study cases.Intraoperative video segment were recorded and edited to depict the operative technique.RESULTS: Transcanal antrotomy for MRM was performed on 45 patients Ossicular reconstruction was performed in 37 patients during initial surgery. Ceramic prothese was used in 77,8% of cases. No major complications occurred postoperatively. No patients had recurrent disease in the antrum. Closure of air-bone gap to within 20 dB occurred in 85% of cases. CONCLUSIONS: Transcanal antrotomy for MRM is a safe, efficacious, and minimally-invasive approach to remove disease from the middle ear and anPum. This approach allows for optimal exposure of the antrum and is less invasive than
Bo mon TMH E>ai hoc Y Ha Noi
Tap chi Tai MQi Hong Viet Nam - V o l u m e (59-21) N°3-October, 2014
postauricular and endaural approaches. With transcanal antrotomy, secon stage procedures can be cnmded in many cases resulting in reduced and improved quality of life.
Keyword: minimum radical mastoidectomy (MRM), ossculoplasty
1. DAT VAN DE
Tnrdc day, muc dich kho tai la can ban dii vdi phlu thuat tai xuong chiim. Nhung hien nay, phau thuat tai phai mang lai hieu qua phuc hdi siic nghe chii khong chi dimg lai d van de khd tai.Tuy nhien, tren thuc te benh nhan viem tai dii dieu kien cho chinh hinh tai giiia la rat it, nhieu trudng hgp chay tai dai dang mac du dugc dieu tri ngi khoa tich cue. Nguyen nhan chay tai la do viem day ruem mac khu tni trong cac ngan thugng nhi, sao dao, sao bao. Ben canh do, cau tnic ciia niem mac hom tai vdi niem mac sao bao khac nhau. Niem mac sao bao la niem mac trao doi khi khong co chiic nang van chuyen dich. Vi the, viem tai khu tni d thugng nhi, sao dao, sao bao kho dan luu dac biet la loai viem tai Cholesteatoma. Cho den nay ngudi ta van chi dinh loai ky thuat khoet chiim tiet can bao tdn vdi loai viem tai nay. Tuy nhien, phau thuat nay co mot nhugc diem can ban thudng tac dudng dan luu sau phau thuat do hoc mo bi dong kin. Thuc te co kha nhieu trudng hgp viem tai phat hoc mo chiim sau phau thuat do thong khi kem giiia hoc mo chiim vdi hom tai dac biet khi benh nhan cd tac voi nhi. 6 viem nay chang nhung pha hiiy he thong xuong con dugc tao hinh ma con cd the gay cac bien chiing nguy hiem khac nhu liet day VII, viem me nhT hay viem mang nao hoac bien chiing nhe va thudng gap ban la viem tai giira mang nhi dong kin. Chinh vi lihung ly do nay ma chiing tdi nghien ciiu tim con dudng p h i u thuat tiep can 6 viem sao bao- thugng nhi n g i n nhit va dan luu tuyet d i i
ra ong tai tao dieu kien thuan lgi cho phau thuat chinh hinh xuong con.
Muc tieu nghien ciiu:
1 Nghien cuu dgc diem 1dm sdng, ngi soi, cdt lop vi tinh viim tai xuong chum man tinh benh tich khu tru sdo bdo- thuong nhi
2. Ddnh gid hieu qud phdu thudt ngi soi khoet chUm tiet cdn toi thieu(MRM) duon xuyen ong tai ket hgp tgo hinh xuang con hang gom thuy tinh sinh hgc di dieu tri loai viem tai xuong chUm khu tru neu tren 2. DOI TU'ONG VA PHU^OT^G PHAP NGHIEN Cl5tJ
2.1. Doi tirgng nghien ciru:
45 benh nhan dugc phau thuat ngi soi khoet chiim tiet can tdi thieu(MRM) dudng xuyen ong tai ket hgp tao hinh xuong con bang gom thuy tinh sinh hgc
Tieu chuan lira chgn:
Viem tai xuong chiim man tinh khu tni Tlii CO keo thugng nhi khi day tiii xam lan sao dao, sao bao
Cholesteatoma tiii lan tir thugng nhi vao sao dao, sao bao
Viem thugng nhi lan den sao dao, sao bao
2.2. Phuotig phap nghien cuu:
Nghien ciiu mo ta timg tnidng hgp co can thiep
2.2.1. Tien trinh nghien cihi:
a. Kham lam sang.
b. Ngi soi danh gia tinh trang mang nhi, hom nhi qua Id thiing mang nhT.
Tap chi Tai Mui Hgng Viet Nam - Volume (59-21). N°3- October, 2014 c. Do thinh lire danh gia loai diec va
khoang each dudng xuong- dudng khi(ABG).
d. Chup cit lop \i tinh Chup CLVT vdi hai binh dien diing ngang (CORONAL) va nim ngang (AXIAL). Cac lat cit mong bang hoac dudi 1 mm nham danh gia vi tri, kich thudc ton thuang xuong chiim va cac xuong con.
Tien trinh phau thuat:
- Dat ong thong khi mang nhT
-Tiem thim va rach da ing tai hinh"
qua dao"
-Boc tach vat da boc Id thanh sau ong tai
-Khoan md tir thugng nhi din sao bao -Ha tudng day VII (Canall wall down) -Hoa hoc md vdi ong tai lam mot -Lam sach benh tich hoc md - Chinh hinh xuong con
Va mang nhi va ghep da hoc md
Hinh3 Tru gom hinh c^nh hoa thay bua - de Hinh 4 : Va nhi, gh6p da h6c m6 chum vS tao hinh hom nhi nhd
Tap chi Tai Mui Hong Via Nam - Volume (59-21) N°3- October, 2014 3. KET QUA
Bang 1. Phan loai bSnh ly viSm tai Loai
n
%
Cholesteatoma
9 18,8
Tiii
CO
keo 25 56.2
Viem thuang
nhi 11 25 Bang 1 cho thay ty le viem xuong chum khu tni hinh thanh tir tiii co keo co so lugng nhieu nhat.
Bang 2. Ton thuang xuang con (39 trudng hap) Loai
n
%
Co dinh 11 26
Gidn doan mot xuong
19 48,6
Hai xuong 9 25,4 Ton thuong xuong chiim tren chup cat lap vi tinh thudng chi khu tni trong pham vi thugng nhi, sao dao va sao bao, phin xuong chiim cdn lai dac nga. Tren chup cat lop vi tinh co din 34/45tnidng hgp(
chiem75%) benh tich da lan vao sao dao va sao bao.
Bang 3 Phyc hoi thinh lye Tan s6(Hz)
ABGTrudc mo ABGSau mo
500 47,5 24,6
1000 43,2 26.2
2000 41,1 22,3 Bang 3 cho thay phuc hdi sue nghe hTing binh la 20dB d ba tin s6 500, 1000,2000Hz .
Bang 4. Ti 1$ khd tai sau mo Thdi
gian n
%
<3 thang
30 67
3-6 thdng
9 20
6 thSng- 1 nSm
4 9
>1 nam
2 4
Bang 4 cho thay kho hoc mo sau phlu thuat dudi 3 thang chiem ti le cao nhit, chi CO 2 trudng hgp kho sau Inam.
4. BAN LUAN
1. Day la phau thuat co the giai quyit triet de benh tich lai an toan dii vdi VTXC mt khu tni:
a. Vi phau thuat di qua ong tai nen no vao thang benh tich khdi thuy d thugng nhT bang con dudng ngan nhat.
b. Do sir dung ky thuat ha tudng day VII(canall wall down ) cai tien phau thuat da loai hoan toan 6 viem ra khoi hom tai, de hoc md hoa cung ong tai lam mot.
^. Do ngan chan dugc cac nguyen nhan gay bien chung tac voi, hinh thanh tiii CO keo va cholesteatoma tai phat,vi vay nd tao dieu kien an toan cho chinh hinh chudi xuong con.
d. Dudng vao phau thuat khong di qua tam giac nguy hiem (Mang nao-tTnh mach ben-day VII) da bi thu hep tren mot xuong chiim dac nga nhu cac ky thuat tiet can bao ton di dudng sau tai van lam 2. Ton thuang giai phau do phau thuat rat it vi sao bao nam each thanh ong tai khoang 3-4 mm tren xuong chiim dac nga nen con dudng xuyen ong tai(transcanal) la ngin nhat dan den sao bao,do do no dat dugc nguyen ly.- ton thuang gidi phdu it nhdt md hiiu qud toi da .
3. Phau thuat ngi soi KCTCTT xuyen ong tai da dat dugc ca hai muc dich : thii nhat giai quyet triet de(tiet can) benh tich Cholesteatoma vi nd loai bo hoan toan 6 viem xuong va hoa hoc mo vdi ong tai lam mot. Thii hai tach rdi d viem khoi khu vuc chinh hinh xuong con nen no cho phep tao
Tap chi Tai Miii Hong Viet Nam - Volume (59-21). N°3- October, 2014 hinh xuong con de phuc hoi chiic nang
nghe ngay cung mot lan phau thuat, 3. KET LUAN
Phau thuat npi soi KCTC TT duong xuyen 5ng tai ( Ky thuat Phong) co th6 giai quyit triet dl benh tich tao dieu kien an toan la loai bo 6 viem, thong khi tai giiia dl phau thuat chinh hinh xuong con dat hieu qua phuc hoi chirc nang nghe
Phlu thuat npi soi KCTCTT xuyen Ing tai tao con duong dan luu ngan va hop ly nhSt cho hic ml KCTCTT. Vi thuc tl no khong con hIc mo chiim niia,h6c mo da hoa vao ong tai lam mot
Phlu thuat noi soi KCTCTT xuyen Ing tai dong gop them mot phau thuat mdi cho chuyen nganh phau thuat npi soi chiic nang tai (Funtional Endoscopic Ear Surgery: FEES)
TAI LIEU THAM KHAO 1. Nguyin Tan Phong ( 2005) Phlu thuat
npi soi chinh hinh tai giira. Hoi nghi
nghanh TMH toan quic 11/2005 Ha npi.
2. Nguyin Tan Phong (2009) Phlu thuat Npi soi chuc nang Tai. Nha xuat ban Y hpc Ha npi
3. Holt JJ (2008), Transcanal antrotomy.
Nov:118{ll):2036-9. Doi: 10.1097/
MLG.
4.Tarabichi M (2005), Endoscopic management of Cholesteatoma: Long- term results.Jun;122(6):874-81 5. Tarabichi M, Nogueira JF, Marchioni D,
Presulti L, Pothier DD, Ayache S (2013), Transcanal endoscopic management of cholesteatoma. Apr; 46(2):107-30. Doi:
10.1016/i.otc.2012.10.001. Epub 2012 Dec 20.
5. Kakehata S, Watanabe T, Ito T, Kubota T, Furukawa T( 2014) - Extension of indications for transcanal endoscopic ear surgery using an ultrasonic bone ctirette for cholesteatomas. Jan; 35(1): 101-7.
doi: 10.1096/MAO.
