các phẫu thuật thông thường tai mũi họng

PGS L E VA N L0I CAC p h Au THUAT THONG THlidNG TAI MUI HONG ■ TAP I PHAN TAI C A C P H A U T H U A T TH O N G T H l/d N G TA I - M UI - H O N G TAP P(iS LE VAN LOI cAc p h A u t h u A t ■ t h o n g t h i /o n g TAI - MUI - HONG ■ TAP I PHAN TAI (Tai ban kin tlu'thai co sifa clula) NHA XUAT BAN Y HOC HA NO I - 2002 LOI NOI DAU Tii nganh chuyen khoa TAI MUI HONG dupe lap, nganh da dao tao nhieu the he bac si chuyen khoa va da khoa qua nhieu tai lieu bai giang ve benh hoc chuyen khoa, nhung cho toi hien nay, chua co mot tai lieu in an chinh thuc nao ve phau thuat chuyen khoa TMH Cuon sach "CAC P h A u THUAT THONG THUONG TAI MUI HONG" doi mong dupe dong gop phan nao cho cong cuoc xay dung nganh chuyen khoa TMH Viet Nam cua chung ta Cuon "CAC PHAU THUAT THONG THUONG TAI MUI HONG" gom tap: - Tap I : Cac phau thuat tai - Tap II: Phau thuat hong, thuc quan - Tap H i: Cac phau thuat mui xoang Chu yeu de dung cho giang day chuyen khoa, nham dao tao nhung bac si chuyen khoa cua nganh Cuon sach bao gom nhung bai giang ve ky thuat va phau thuat mang tinh chat co’ ban va kinh dien doi voi nhung benh thong thuo’ng ma mot nguoi thay thuoc chuyen khoa TMH thudng hay gap va co trach nhiem giai quyet Cuon sach co the dung cho cac sinh vien y khoa di thuc tap, ho co the tim thay o’ day nhung diem co’ ban dieu tn phau thuat cac benh thong thuo’ng TMH Sach nav cung giup ich phan nao cac thay thuoc da khoa de tham khao su phoi hop dieu tri noi khoa vdi dieu tri ngoai khoa mot so benh TMH thucmg gap- Dac biet cac thay thuoc chuyen khoa ve Mat, Rang H a n Mat, Than kinh cung co the tham khao them sach dieu tri xu ly mot so benh cua chuyen khoa minh co lien quan vdi TMH Sach tap trung de cap nhung ky thuat va phau thuat chinh va kinh dien, da duoc chinh thuc quv dinh chuong trinh giang day dao tao Co the co mot so phuong phap ky thuat mdi hoac sang kien mdi doi, nhat la nhung thap ky cuoi cua the ky XX nay, vdi nhip tang lien rat manh me cua khoa hoc ky thuat noi chung va nganh Y noi rieng, udc mong sau nhung van de mdi se duoc bo sung vao chuong trinh giang day Cuon sach chu nhieu ve mat ky thuat, khong di sau nhSc lai giai phau hoc Khong mo ta dung cu phuong tien phau thuat, khong noi nhieu den cac che tien phau va hau phau chung cho ngoai khoa Day la quyen sach dau tien ve phau thuat TMH bang tieng Viet, nen ve mat tii ngu co the co mot so' chua duoc hoan chinh Dac biet cac danh tu ten ngudi, chung toi de nguyen ven khong phien am sang tieng Viet nham ton danh tinh va goc tich ten ngudi Mot so tieu de chuong muc va ky thuat quan trong, chung toi co ghi chu them tieng Anh - Phap, de tien cho cac ban muon tham khao them tai lieu ngoai ngu Ngoai viec sap xep chuong muc trinh bay tranh ve cho tdi noi dung va tu ngu, co the phan nao phai siia them va doi mdi, tran mong duoc su gop y xay dung chan tinh cua cac dong nghiep va ban doc Ha Noi, 20-10-1997 T a c gia Chuong I I MOT SO NGUYEN TAC CHUNG TRONG cAc PHAU THUAT TAI - XUONG CHUM Cac phau thuat ve Tai doi da lau nam tu the ky XIX nhung nam he thong cac phau thuat ngoai khoa chung Cuoi the ky XIX nhd su hoat dong phat trien manh cua chuyen khoa Tai Mui Hong, cac phau thuat tai duo’c chinh thuc neu voi nhu cau nham chu yeu giai quyet nhung tai nan, viem nhiem nang cua tai, dac biet nhung bien chung so nao nguy hiem Tu sau the gio'i dai chien thu hai, su doi cua khang sinh di cung voi su- phat trien manh me cua cac phuo’ng tien kham va dinh benh da gio’i han han nhung loai phau thuat ke tren va cho phep phau thuat tai di sau vao giai quyet nhung chi tiet nho cua tai bi viem bi chan thuong, va dac biet di nhieu ho’n niia vao cac phau thuat mang tinh chu’c nang cua tai (phau thuat mo diec) va vao cac phau thuat mang tinh tham my cua tai (phau thuat tao hinh tai ngoai) Ngoai cho phep phau thuat tai mo’ rong pham vi di vao cac phau thuat phoi hop Tai Than kinh, Tai - So nao Mac du voi su phat trien va doi mdi manh me cua cac phau thuat tai ca ve kv thuat va phuo’ng tien rat khac nhau, nhung tuu trung nguo1! thay thuoc mo tai van phai luon luon tuan thu mot so nguven tac chung co1 ban khong the thieu duo’c: 1- Phai hieu biet that ky giai chi tiet cua nhung no phan tai quan lien quan phau kinh va so nao, co nhu vay mdi phau cua tai, dac biet co chuc nang chu chot thuat giua tai vcfi than khong pham nhung sai sot ky thuat dang tiec co the xay 2- Thay thuoc chuyen phau thuat tai can phai qua nhung dot thao tac thuc hanh tren mo hinh xac ngudi va xac dong vat, nhu vay de bao dam tinh an toan chinh xac nhung phau thuat chinh thuc tren ngudi benh 3- Phai co chon loc ky chi dinh phau thuat va cung can co tinh toan ky lua chon phuomg phap ky thuat se ap dung, nhu vay de bao dam ket qua tot nhat cho phau thuat 4- Benh nhan can duoc chuan bi that tot day du moi mat trudc phau thuat: Ve mat toan than: danh gia sue khoe chung, sue chiu dimg, gay te hay gay me Ve mat tai cho: - Danh gia cac chuc nang cua tai trudc mo la dieu quan (khong the thieu duoc dac biet phau thuat chuc nang): • De co co sd khoa hoc danh gia ket qua phau thuat ve mat chuc nang • De co co sd phap ly giai thich nhung thac mac (neu co) cua benh nhan sau phau thuat - Danh gia cac benh tich d tai cung la van de quan trong: • De huv dong dung cu phuo’ng tien can thiet Hinh 181: Kho kh&n gap phai tinh mach ben qua phong loi ap sat ong tai: - hoac tam cat b o xuang ong tai de c o cho di vao tui noi djch (xuang se gan lai cho cu bang tissucol) - hoac bo vd xuang bo c lo tinh mach ben ven no ve phia sau de c o cho di vao Ngau bien lam thung ban khuyen sau: tinh mach ben qua phong loi (hinh 181) hoac tai khoi tai me dao nam qua lui ve phia sau sat gan tinh mach Ngau bien se lam tai hu hong va diec hoan toan: day la mot ngau bien can phai het sue tranh vi no lam mat muc dich ket qua cua phau thuat Du chua han la da hoan toan hong tai trong, thay thuoc can tranh khong duo’c hut vao lo thung, bit lo thiing bang mot manh to chuc lien ket, roi tiep tuc phau thuat Ngau bien lam rach thung m ang nao: khong nguy hai, can khau lai bang chi to1, hoac neu lo rach to thi va bit lai bang mot manh ghep can co thai duong duo’c dan chat tai cho bang keo dinh tissucol 165 PH U O NG PHAP ROI SIEU A M H U Y M E D A O C U A A R S L A N (Ultrasound labyrinthectom y) Nguyen t£c, noi dung, chi dinh Day la phucmg phap Arslan de xirdng, co tinh hien dai so vdi phircmg phap Portmann, dcm gian hem va ket qua nhieu hem Noi dung chu yeu la due md xuong chum roi chieu roi huy diet me dao b&ng nhung tia sieu am, dong thdi van bao ton duoc siic nghe Chi dinh trong: Hoi chiing Meniere va giai quyet nhung chong m at ton tai sau phau thuat md me dao xuong Ky thuat Gay me hoac gay te trudng hop Thi m ot: due md xuong chum: md bao dao la chinh va xac dinh vanh ban khuyen ngoai la tam Thi hai: boc lo ro vanh ban khuyen ngoai: dung mui khoan nho mai mong ldp vo xuong bao quanh vanh ban khuyen, cho tdi vanh hien ro dudi mot giai mau xanh xam Trong mai, chu y luon tudi nude, lam lanh 166 Hinh 182: Roi sieu am vao g oc wen cua vdng ban khuyen ngoai dau mui khoan (tranh gay nong lam ton thuong day VII va day VIII) Thi ba: roi sieu am vao me dao (hinh 182-183) Nguyen tac la roi tap trung true tiep vao vong ban khuyen va khong di chech hudng Tia roi voi cucmg tang dan tu 12 roi toi 22 watts/cm va voi chu ky 800.000 Hertz Tia roi duoc tap trung va dan vao mot ong dan dai 8cm rong 0,5cm (khong de tia tan xung quanh co the hai toi phan oc tai) Han che tac dung di xuyen cua tia, khong sau qua 2cm (tranh di qua vao nao) Trong roi benh nhan phai tinh de theo doi cac dong mat (neu benh nhan gay me, phai doi de tinh h4n) Hinh 183: Roi sieu am, hir&ng di cua tia roi tranh oc tai va day VIII Dong mat se xuat hien 30-60 giay, sau bat dau roi, thuong danh ve tai benh, 7-10 phut thi het Thay thuoc se chuyen huong roi ve phia cac vanh 167 ban khuyen tren, lai gay dong mlit 5-10 phut cho toi het dong mat Trong roi, nhung dong mat kieu kich thich thuo’ng co kem theo chong mat va doi co non Trung binh thai gian roi sieu am la 25-30 phut, chu y dau o'ng roi phai luon luon duoc tuoi nude mat, khong cho nhiet len qua 38° se gay hai cho day VII Hau phau Nhu d phau thuat md ciia so Chu y cho khang sinh va cho thuoc chong chong mat buon non Tai bien, ngau bien Liet day VII co kha nang xay ra, nhung co the tranh duoc neu lam dung ky thuat M ot so' ta c gia roi sieu am di dudng tron g ong tai n goai di qua m an g nhi, roi true tiep va o vu n g u nho va nhu vay kha nang tai bien co nh ieu hon cho day VII PHU ONG PHAP TIEM PHONG B g H ACH T H A N KINH N G OI S A O (Stellate ganglion b lock) Nguyen tkc, noi dung, tac dung Dung novocain hoac xylocain 0,5% tiem phong be vao hach ngoi nham cat dut tam thdi luong than kinh giao cam chi huy vung dau cd, chu yeu tac dung che ngu nhung roi loan van mach vung dau co 168 Chi dinh Trong benh M eniere de danh gia tac dung cua sir ckt giao cam va tam thdi che ngu nhung com chong mat va non cap tinh Trong benh Bell: liet hoan toan cap tinh day VII (khong tai) va moi bi vong ba Hoi chung thieu nang tuan hoan tai trong, vi du: hoi chung Lermoyez, diec dot ngot tai trong, u tai dot ngot cap tinh Dieu tri m ot -so' trudng hop viem mui man teo det va tri mui Ky thuat Lam theo phucmg phap Mac Intosh - Ostlere (1955) Benh nhan nam ngua gay tua tren goi, dau ngua nhieu de lo nguc vung cd va Sat khuan sach vung cd don uc Thi mot: xac dinh diem choc kim Hinh 184: Phong be hach Dot song co C7: Dinh cua mang phoi; Noi dam kim phong be Tren mot dudng ngang d cao cach xa 3-4cm bd phia tren cho tan cung cua xuong don vdi xucmg hom uc, sat canh ong quan Dung ngon tay trai rd tim dong mach canh goc, tay phai cam mot kim dai 5cm dam kim thang vao sau, giua 169 Hinh 185: S o cat ngang vung co Day hach giao cam cd: D0ng mach canh trong: Khi quan: Day hoi phuc:5 Thuc quan:6 Dot song C7:7 DQng mach c(u song dong mach va quan (hinh 185) Kim se phai di len phia tren cua dinh mang phoi, roi di vao sau toi cham vao dot song co C7 Tren dudng di, kim co the xuyen vao mot goc cua tuven giap Neu dam kim d me trai cd, kim se di sat vao thuc quan - Khi da cham vao dot cd C7, se rut kim 0,5-lcm (hinh 185) Dau kim luc da nam khoang binh dien cua he day giao cam cd, nam d phia trudc cua can trudc cot song Thi hai: tiem te phong be - Dau tien thu hut bom tiem de kiem tra khong choc kim vao mang phoi hoac choc kim vao mach mau 170 - Borm 5ml dung dich novocain hoac xylocain 0,5% (khong pha adrenalin) - Rut them kim 1cm phia ngoai roi tiem tiep nua 5ml dung dich gay te Khoi luang va diem tiem du de phong be mot vung trudc, sau va xung quanh day hach than kinh giao cam Doi cho xuat hien hoi chung Claude Bernard - Horner (co dong tu, m it lom xuong, mi m&t xa xuong) chung minh phong be da cong Tai bien, ngau bien - Tran mang phoi - Tiem vao dong mach, cot song - Thiing thuc quan - Tiem vao day than kinh hoi quy - Tiem vao day than kinh co hoanh Ba tai bien tren co kha nang nguy hiem tinh mang Do phuong phap phong be chi nen chi dinh that can thiet ma thoi 171 TAI LIEU THAM KHAO Abreges: Urgences chirurgicales Cap cuu ngoai khoa B Chiche et P Moulle Berteause Nha xuat ban Y hoc Ha Noi 1992 Abrege d ’ ORL de l’ enfant G Cotin et M Bodard Masson editeur Paris New York 1983 Abrege d ’ ORL a l'usage de l’ etudiant par M Portmann Masson editeur Paris 1982 Atlas operatii na ukhe V.K Liuko - V.M Marchenko Edition Edorovia Kiev Russia 1989 Bai giang benh hoc Tai Mui Hong Tap I va II Giao su Tran Hiru Tiroc 1969 Chirurgie cervico faciale et ORL par M Aubry - P Piaoux - G Jost Masson et compagnie editeurs Paris 1966 La chirurgie d ’ urgence en hopital de district: B Sankarana-A.Vasun Organisation mondiale de la sante - Geneva 1990 Current therapy in ORL, head and neck surgery by G A Gates Mosby company ed Toronto London 1986 Diseases o f the Ear by S.R Mawson E Arnold ed London 1974 Diseases o f the ear, nose anf throat by A.G Likhachov Edition Moscova 1986 Encyclopedic m edico chirurgicale ORL Paris 1976 & 1982 Gerkhi Ligu Atlasas (Atlas o f laryngeal diseases) By V Uloza Vilnius Lithuanic 1986 172 Luyen m6 Tai Mui Hong Emtrainement chirurgical en ORL Bs Pham Kim dich Nha xuat ban Y hoc - Ha Noi 1974 Ma quan - Bs Nguyen Van Due Nha xuat ban Y hoc - Ha Noi 1974 Oto-Laryngology Vol I.II.III by M Paparella - D Shumrick Saunders co editor Philadelphia London Toronto 1980 Oto-Laryngology - Textbook o f D Deweese - W Sauders Third edition Mosby co: ed Saint Louis 1968 Tai Mui Hong thuc hanh Tap I, II, III Giao su V o Tan Nha xuSt ban Y hoc - Ha Noi 1974-1976 Traite de technique chirurgicale ORL et cervicofaciale M Portmann et Y Guerrier Masson ed Paris New York 1986 Traite de technique operatoire OR: Vol I, II G Portmann Masson ed Paris 1962 173 MUC LUC LCJI NOI DAU CHITONG I I Mot so nguyen tac chung cac phau thuat tai xuong chum II Chuan bi phuong tien dung cu cac phau thuat tai - xuang chum CHUONG II CAC PHAU THUAT TAI NGOAl I Vanh tai qua vfinh 18 II Trai tai tach doi 19 III Khong co trai tai 20 IV Vanh tai qua to 22 V Vanh tai bi sut 23 VI Chit hep ong tai ngoai 24 VII Cac ro balm sinh vung truoc tai 26 VIII Nu thit thua truoc vanh tai 27 IX 28 U mau vanh tai - Viem sun vanh tai CHUONG III CAC THU THUAT Cl MANG NHI I Trich rach mang nhi 30 II Choc hut mang nh! - Bom thuoc qua mang nhi 32 III M o thong hom nhi va mang nhi kieu co dinh 33 IV Polyp ong tai 36 CHUONG IV CAC PHAU THUAT TAI XUONG CHUM I Cac m oc giai phau can nhd 39 II Phau thuat md khoet chum don thuan (mastoidectomy) 44 III Ky thuat ma khoet chum mot so the lam sang dac biet 50 174 IV Phau thuat khoet r6ng da chum 55 - Khoet r6ng da chum toan phan 56 - Phuong phap Hautant khoet r6ng cac da chum 66 - Khoet r6ng da chum ban phan 68 CHUONG V PHAU THUAT CAC BIEN CHUNG CUA VIEM TAI XUONG CHUM I Viem tac tinh mach ben tai 71 II Ap xe dai nao tai 75 III Ap xe tieu nao tai 77 IV Viem mang nao tai 80 CHUONG VI CAC PHAU THUAT TAO HINH MANG NHI HOM NHI (TYMPANOPLASTIES) I Cac ky thuat lay vat lieu va ghep mang nhi, hom nhi 90 - Ky thuat Wullstein I 99 - Ky thuat Wullstein II 104 - Ky thuat Wullstein III 106 - Ky thuat Wullstein IV 108 - Ky thuat Wullstein V 109 II Phau thuat tao hinh mang nhi hom nhi cac chan 111 thuong mang nhi tieu cot - V o rach mang nhi 112 - Tu mau chan thuong hom nhi kem nghe kem 113 - Trat khop chan thuong cua he thong tieu cot 16 - Gay vo toan bo khoi tieu cot chan thuong 119 - Nhung benh tich hom nhi tieu cot kem liet mat 123 - Nhung ngau bi[...]... T2-CPTTT 15 Chuong II CAC PHAU THUAT TAI NGOAI Nguyen tkc chi dinh Cac phau thuat a tai ngoai chu yeu nham giai quvet cac veo lech, cac di tat, di hinh thuong gap cua vanh tai va ong tai ngoai nhu: vanh tai qua venh, vanh tai bi sut, khong co trai tai hoac trai tai bi xe doi, nu thit thua trudc vanh tai, duong ro vung re tai, seo hep cua o'ng tai v.v Cac di tat, di hinh cua tai ngoai co nguyen nhan hoac... cua ong tai (hinh 32) Thi bon: khau da ong tai: dung chi loai nho khau ep tung mui da lat vao thanh cua ong tai mai tai tao, cac dau day chi di xuyen qua to chuc sau tai va buoc vao da vung sau tai K e t thuc: cuoi cung dat mot ong cao su tao sure nong to cua ortg tai mdi tai tao Sau 10 ngay cat chi Phucmg phap Osenat - Ramadier Ap dung cho trudng hap chit hep sau ca cura ong tai va trong ong tai Gay... quanh tai 0 moi diem, duong tiem se cheo nhau vai huong bao quanh lay tai va tiem ca lop nong lin lop sau, tong cong khoang 10-12ml thuoc tiem la du tai Vo cam o' vung ong ngoai thong thuo’ng cung b in g 3 - 4 mui tiem true tiep vao da ong tai, su dung (hinh 7) 2-3ml la du Hinh 7: Tiem te vo cam vung 6ng tai D ‘ IHOC THAI NGUYE N! A 17 I v Anh TAI QUA v e n h Day la mot loai di hinh bam sinh cua vanh tai. .. tuy trudng hap Thi m ot: rach da sau tai nhu trong phau thuat md khoet chum Rach xuong tan xuong boc tach cot mac t6i cua ong tai Toi vung cua ong tai dung cai boc tach nho tiep tuc boc cot mac lam boc lo ro toan bo doan chit hep cua cura o'ng tai Ckt bo het cho chit hep de tai tao mot ciia ong tai rong (hinh 33) Thi hai: tiep tuc boc tach di sau vao trong ong tai boc lo cac phan mem, cSt bo het to... cua trai tai binh thuang Hinh 17; khau tao hinh Khau ven cac bo1 o’ hai ben lai voi nhau de tao hinh mot trai tai tron va co do day theo y muon Phuong phap Converse Su dung mot vat da co chan cuong lay a mat sau vanh tai va mot vat da co chan cuong lay a da co phia sau tai (hinh 18, 19, 20) Hinh 18: boc vat da A cua mat sau vanh sun tai Vat nay quay xuong 180° se tao thanh mat trudc cua trai tai (nha... dinh vao quanh cua ong tai bang vai nut chi nho (hinh 34) Thi boh: khau lien hai mep da sau tai Dat mot bac trong ong tai Sau 3 tuan le, cat dut chan cuo'ng cua vat da va khau sua lai lan cuoi cung vet rach phia sau tai VII CAC RO BAM SINH VUNG TRUOC TAI Vi tri thong thuo’ng la o’ trudc re vanh tai hoac a truoc nap tai (hinh 35) Chi dinh cat bo duong ro khi co trieu chung viem nhiem sung dau va chay mu... o truoc n&p tai to bang hat ngo hoac hon, so' luong co the la mot hoac hai hoac nhieu hon, do di tich cua thoi ky bao thai phat trien tai ngoai (hinh 37) Giai quyet: tiem te tai ch6 Rach da quanh chan nu Hinh 3 7 27 thit theo hinh mui cam roi boc tach, cat loc toan bo nu xo - sun, sau do khau kin hai bo da IX U MA u VANH TAI - VIEM SUN VANH TAI Nguyen nhan do viem nhiem tii ngoai da vanh tai, nhung... ranh sau tai lam chuan Rach da theo hai duong cong: mot duong cong tren mat xuong chum, duong cong thu hai tren mat sau cua vanh tai, hai hinh cong nay deu quay nhin vao khe ranh sau tai va hinh thanh nhu hinh mui cam (hinh 9) Duong rach da tren xuong chum sau den cot mac, duong rach da tren vanh tai sau den sun Thi hai: loc bo manh da hinh mui cam giua hai duong rach Thi ba: rach dut sun vanh tai theo... rach da tren vanh tai Dung mot boc tach mong va nho, boc tach manh sun tach roi khoi cac to chuc mem & mat truac vanh tai Thi boh: boc tach va bo di manh sun co hinh mui cam rong hep it nhieu tuy theo huong cua chinh hinh Thi nam: khau lien hai mep da voi nhau bang chi lin va co dat vai soi cuffc dan luu a mep phia duoi tai Bang ep chat II TRAI TAI TACH DOI Di tat bam sinh hoac do tai nan (hinh 11)... di Ket qua tao mot ong tai thong toi m ang nhi Thi ba: tao mot lan da lat vao ho mo bao dam khong cho seo xa tai phat se chit hep trd lai Phau thuat vien c it loc mot vat da hinh chu nhat d phia sau tai vung chum, vat da co chan cuong (hinh 33) Vat da nay se duoc cuon tron lai va lat vao ong tai, mep phia ngoai 25 Hinh 33 Hinh 34 cua no se duoc khau co dinh vao quanh cua ong tai bang vai nut chi nho