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LM SNG, NGUYN NHN V KT QU IU TRBNH VIM TUYN GIP CP M TR EM

Study of clinical characteristics, causes and result of the treatment for acute,suppurative in children

Nguyn Th Hon, Nguyn Th phng, Nguyn Th Hng

Bnh Vin Nhi Trung ng

Trng khoa Ni tit - Chuyn ho - Di truyn, BnhVin Nhi Trung ng.a ch :15A ng 119 Ty sn, ng a H ni.Hng dn bo v thnh cng 11 Cao hc, 3 BSCK II v 1BS ni tr.40 cng trnh nghin cu khoa hc ng : Tp ch Nhi khoa,Tp ch Ri lon chuyn ho v Ni tit, Tp ch Ri londi truyn Nht Bn, Tp Ch NCKH ca c...

TS Nguyn Thi Hon Hng nghin cu: (1) Ni tit: i tho ng v bin

chng. Bnh suy gip bm sinh v pht hin sm bnh ticng ng. Nguyn nhn gy dy th v chuyn gii tr em. iu tr chm ln trong ln yn vHC Turner.(2) Chuyn ho: RLCH Mucopolysaccharidosis, Ci xng khng Vitamin D trem, to xng bt ton.(3) Cc bnh v di truyn: Bnh thn kinh c ph bin tr em nh bnhteo c Duchenne, bnh thoi ho c tu tr em. ti khoa hc:(1) Sng lc s sinh bnh suy gip tr em .(2) S dng k thut phn t xcnh t bin gene trong 2 bnh thn kinh c di truyn ph bin Teo c Duchenne v thoi ho ctu.

SummaryAcute, suppurative thyroiditis is a defect of the thyroid gland caused by bacteria. The

disease is usually encounted in adults, rarely in children. For the last years, Department ofEndocrinology Metabolism Genetics , NHP treated some patients with recurrent acute,suppurative thyroiditis. Consequently, the subjective of the research is to study clinicalcharacteristics, causes and result of the treatment for acute, suppurative in children.We carried the study of 66 cases of acute, suppurative thyroiditis aged from 41 days to 15years, comprising 17 males and 23 females in a period 1997-2003. The study showed thatthe majority of the patients had inflammation symptoms, thyroiditis and neck pain inhyperextension. Inflammation of the left lobe of thyroid gland was seen in 85.71%.Patients who had recurrent thyroiditis (more than 1 time) occupied 74.29%. Throatendoscopy found pyriform sinus fistula on the left side in 89.28%. Combination of

antibiotics (Tarceforksym and Amikacin) and aspiration/drainage had a good result. Afterinflammation period, operation was done to remove pyriform sinus fistula in 57.98% ofpatients or to close fistula.

I.t vn

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Vim tuyn gip (VTG) cp m l tnh trng bnh l tn thng nhu m tuyngip do vi khun thng thng gy nn vi cc biu hin cp tnh nh st, sng nng au TG, vim hng, kh nut, ging khn (11).

Mc d VTG cp m khng gp nhiu so vi VTG do cc nguyn nhn khc nhVTG bn cp De Quervain, VTG mn tnh Hashimoto, nhng rt hay ti pht (2,4,7,8).

VTG cp m tr em khng nhiu nhng hu ht u b ti pht nhiu ln. Theobo co nm 1979 ca Takai gp 13 tr b VTG cp m u tm thy c l r hnh qu l thy tri tuyn gip. l l do chnh lm VTG cp m rt hay ti pht.

Theo bo co ti Khoa Ni tit - Bnh vin Nhi trung ng trong 10 nm (1981-1990) c 36 trng hp chn on l VTG cp m (3). Tuy nhin trong nghin cu ny,nguyn nhn gy bnh VTG cha c phn loi nn VTG cp m cn xp chung trong

bnh cnh ca VTG.Ngy nay vi phng php thm d hin i gip cho vic chn on bnh

nguyn, bnh sinh VTG ni chung v VTG cp m ni ring. K thut chc ht tuyngip bng kim nh khng nhng xt nghim t bo hc m cn nui cy, phn lp

vi khun trong trng hp nghi ng VTG cp m do vi khun. Siu m TG c vai trquan trng trong chn on VTG m da vo m ECHO khng ng nht v c trng m trong TG (9, 12). Ni soi h hng l xt nghim cn thit trong VTG cp m xc nh ng r bm sinh lin quan ti TG, c bit l r xoang l (14).

gip cc bc s Nhi khoa c kinh nghim trong chn on, iu tr v phng tipht cho nhng bnh nhn VTG cp m, chng ti tin hnh nghin cu vi mc ch:Nghin cu lm sng, nguyn nhn v nhn xt kt qu iu tr VTG cp m tr em.

II.i tng v phng php nghin cu1.i tng NC: 66 bnh nhn c chn on VTG cp m t 41 ngy n 15 tui.

Tiu chun chn la:- Triu chng lm sng: St, sng nng au vng TG, trn siu m tuyngip to hn bnh thng (theo tui) v t chc TG c xc nh c m, xtnghim t bo hc VTG cp m gm c t bo vim v t bo tuyn gip.- Xt nghim: Cng thc mu, tc lng mu, chc ht TG lm t bo hc,

phn lp vi khun v lm khng sinh ti BV N hi T.Siu m tuyn gip, T4 v TSH c lm ti BV Ni tit.

Ni soi h hng xc nh ng r xoang l c tin hnh khi bnh nhn htvim m TG ti BV Tai Mi Hng T.

Tiu chun loi tr l vim/abces vng c xung quanh TG, abces ng di li, u nanggip bi nhim, u tuyn gip c phn ng vim, vim TG do nguyn nhn khc.- iu tr :

- Ni khoa: C 3 phc iu tr ni khoa khi cha c khng sinh : (A)Chloramphenicol 30mg/kg/24gi trong12-14 ngy, (B) Cloxaxilin 100mg/kg/24gi +Amikacint 3mg/kg/24gi trong 12-14 ngy, (C) Tarceforksym 100mg/kg/24gi +Amikacin 3mg/kg/24gi trong 12-14 ngy. Khi c kt qu khng sinh th iu tr theokhng sinh .

- Ngoi khoa: Chch tho m nu TG c abces.

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Hoc m bc tch ng r v ly ht ng r hoc m ct ng r v tht yxoang l khi ng r qu phc tp ti BV TMH T.2. Phng php nghin cu:- Nhm tin cu: gm 35 bnh nhn iu tr t 1/2002 n 8/2003- Nhm hi cu: gm 31 bnh nhn iu tr t 1/1997 n 12/2001 ti Khoa NT-CH-

DT, BV Nhi T.Cc s liu c x l theo phng php thng k Y hc.

III.Kt qu nghin cuBng 1: Phn b bnh nhn theo tui v gii

TuiGii

41 ngy -5 tuin %

6 - 10 tuin %

11 - 15 tuin %

Tngn %

Nam 17 25.76 11 16,67 2 3,03 30 5.46

N 23 34,85 10 15.15 3 4,54 36 54,54

Tng 40 60,61 21 31,82 5 7,57 66 100

a s bnh nhi VTG la tui di 10 tui chim 92,42%T l nam/n l 1,2/1

Bng 2: Thi gian t lc khi bnh n khi vo vin vi abces TGAbces TG

Thi gianKhng abcesn %

C abcesn %

Tngn %

< 7 ngy 4 11,43 1 2,86 5 14,29

7 ngy 5 14,29 25 71,43 30 85,71Tng 9 25,7

126 74,2

935 100

- a s bnh nhn n vin mun 7 ngy: 30/35 bnh nhn chim t l cao85,71%.

- 26/35 (74,29%) trng hp VTG cp m vo vin c bin chng abces.

Bng 3: Mi lin quan gia tnh cht ti pht vi abces TGTi pht

Abces

Khng ti pht

n %

C ti pht

n %

Tng

n %Khng abces 7 20,00 2 5,71 9 25,71

Abces 2 5,71 24 68,58

26 74,29

Tng 9 25,71 26 74,29

35 100

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- C bnh nhn b ti pht t 4 n 7 ln.- 24/26 bnh nhn abces TG b ti pht cao chim 92,31%.

Bng 4: Triu chng lm sng ca VTG cp m

S bnh nhnTriu chng

Tng smc

Tng sBN nghincu

T l %

St+ Khng st+ Nh 3705 ->


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T l 36,11% 63.89% 100%23/36 (63,89%) trng hp thy trong lng TG c m bt mu ECHO khng ng

u v c trng m, cn li 36,11% (13/36) trng hp ch thy xc nh l th tch TGto hn bnh thng

26/28 trng hp kim tra T4 v TSH trong gii hn bnh thng.

Bng 7: Kt qu ni soi h hngKt qu ni soi c ng r khng c ng r Tng s

S bnh nhn 28 3 31

T l 90,32% 9,68% 100%28/ 31 bnh nhn (90,32%) thy c ng r xoang l, 25/28 trng hp ng

r bn tri l ch yu: 89,29% , khng c bnh nhn no b r 2 bn, c 5 chu phi soi liln th 2 mi tm c ng r

3/31 bnh nhn (9,68%) khng c ng r c 3 bnh nhn ny u ch c soi 1ln.

Bng 8. Mi lin quan gia s ln ti pht VTG m vi ng rTi pht

R xoang lKhng ti phtn %

C ti phtn %

Tngn %

Khng c ng r 3 9,68 0 0 3 9,68

C ng r 5 16,13 23 74,19 28 90,32Tng 8 25,81 23 74,19 31 100

3 bnh nhn soi h hng khng c ng r xoang l th cng u cha ti phtBnh nhn b VTG ti pht ch yu nhng trng hp soi h hng xc nh c

ng r xoang l chim 74,19% (23/31) bnh nhn. C 5 bnh nhn c ng r nhngcha b ti pht ln no chim 16,13%. Nh vy, l r xoang l l nguyn nhn dn nVTG m ti pht nhiu ln (vi 2 = 5,74;P0,05. So snh hiu qu iu tr gia phc A v C, s khc nhauc ngha thng k vi 2 (A-C) = 8,47; P


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* iu tr ngoi khoa: Bnh nhn phi chch tho mVTG chim t l cao 80% (28/35) iu tr ni khoa thnh cng gip bnh nhn khng phi chch tho m ch c 7/35

bnh nhn chim 20%. Trong s 28 bnh nhn soi h hng xc nh c ng r xoang l m c 19

bnh nhn ti BV TMH T: M bc tch ly ng r c tin hng 11 bnhnhn (57,89%); m tht y xoang l c tin hnh trn 8 bnh nhn(42,11%).

IVBn lunQua nghin cu 66 bnh nhn, chng ti thy VTG cp m gp tt c mi la

tui t 41 ngy n 15 tui. Mc d cha c ti liu no ni v VTG cp m gp s sinhnhng thc t chng ti iu tr bnh nhn 41 ngy vim ton b tuyn gip. Tui haygp l 5 tui tr xung chim 60,61% (40/66) bnh nhn (Bng 1). Nghin cu ca LMinh K v nang v r mang vng c bn cho thy tr di 5 tui hay mc nhim trng

tai mi hng l yu t thun li kch thch biu m cn st li ca ng r bm sinh vngtai mi hng ch tit gy tch t v nhim khun (1). La tui hay gp VTG cp m di5 tui l mt gi u tin v nguyn nhn c th lin quan ti vn d tt bm sinh.

Trong nghin cu ny, chng ti nhn thy khng c s khc bit ng k gianam v n vi P>0,05. Nhng khc hn vi VTG cp m ngi ln. Qua nghin cu 42

bnh nhn c chn on VTG cp m ti Khoa ni tit, BV Bch Mai ca tc gi LTrung Th, th ch c 7 bnh nhn l nam m c ti 35 n chim t l rt ln 83,83%.

Nh vy ngi ln b mc VTG cp m c s khc nhau gia nam v n. S khc nhauv gii ca bnh VTG cp m ngi ln v tr em chng ti cha l gii c. Chngti ch c th kt lun l tr em gii tnh khng nh hng n VTG cp m. iu ny

ph hp vi cng b trn y vn (10).Mt s tc gi trong nc (6) v ngoi nc a ra kin rng VTG m lin quanti vim nhim ng tai mi hng, h hp, nhim trng vng u, mt, c. Thc t trongnghin cu ca chng ti, bnh nhn VTG cp m gp nhiu vo nhng thng ma h, tl mc bnh nhim trngTMH, ng h hp trn cng cao cc nc nhit i nhnc ta nhng khng phi l c th ring cho cc nhim trng h hp, tai mi hng. Hnna trn 35 bnh nhn tin cu ca chng ti ch c 2 trng hp c km theo nhimtrung h hp v tai mi hng.

Trong 26/ 35 bnh nhn tin cu c abces TG trc khi n vin chim 74,29%(Bng 2). Nh vy bin chng abces TG gp bnh nhn cp m l rt ln. Kt qu nycng ph hp vi nghin cu ca tc gi khc (7,8,9). Mc d cc tc gi ny cha a racon s c th nhng nhn nh rng bin chng abces l thng gp v ch nh chchrch m l cn thit. T l mc bin chng abces bnh nhi VTG m cho n nay chac tc gi no Vit Nam cng b.

Trong nghin cu ca chng ti, thi gian n vin mun sau 7 ngy l ch yuchim 85,72% (30/35). Trong 30 bnh nhn n iu tr mun th c ti 25 chu b mc

bin chng abces trc khi vo iu tr chim 71,43%. T l b abces TG nhm niu tr mun cao hn hn nhm n iu tr sm (Bng 2). Trong khi c 5 bnh nhn

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n vin sm trc 7 ngy th c 4 chu khng b abces. Ch c 1 chu 41 ngy tui nvin sm b abces. Trng hp ny chng ti ngh rng c th do tr qu nh tui, sc khng km nn mc d c iu tr sm nhng khng trnh khi bin chng. Nh vytheo chng ti, mt nguyn nhn b bin chng abces TG l do bnh nhn n vin iutr mun. V vy bnh nhn VTG cp m cn c iu tr sm theo mt phc hu

hiu hn ch bin chng abces TG v phi chch abces dn lu m di ngy.Qua khai thc tin s v bnh s 35 bnh nhn c khm trc tip, chng ti

thy t l bnh nhi b VTG ti pht rt cao 74,29% (26/35) bnh nhn. Trong khi ch c25,71% (9/35) bnh nhn hoc khng ti pht hoc tm thi cha ti, a s cc chu nymi vo vin ln u v cha c c hi ti pht c th do tui cn nh di 5 tui.

Nghin cu ny ca chng ti cng gn vi nghin cu ca Takai cho thy c 13 tr VTGcp m th c 13 tr u ti pht (13). Cc tc gi khc cng thng nht VTG cp m hayti pht v cho rng r xoang l l nguyn nhn gy ti pht nhiu ln nhng bnh nhnVTG cp m (10,11).

Hu ht l do chnh bnh nhn vo vin iu tr khng phi v st m v triu

chng sng to vng trc c , dng khng sinh thng thng v h st tuyn trckhng c kt qu. Triu chng vim ti ch TG gp 100% bnh nhn (66/66) (Bng 3).Kt qu ny ph hp vi nghin cu ca cc tc gi khc (4,6,7,8,10) v VTG cp m tr em. Chng ti khm trc tip trn 35 bnh nhn tin cu thy a s l vim thy triTG chim 85,71% (30/35), bn phi rt t gp chim 11,43% (4/35), c 2 bn c s l2,86% (1/35). VTG cp m gp ch yu thy bn tri trng hp vi d tt r xoang lcng ch yu gp bn c tri cng cng c nhn nh ca cc tc gi r xoang l lnguyn nhn VTG cp m (12,13,14). Theo chng ti, v t l VTG thy tri qu cao nnc th xem y nh l mt gi VTG cp m phn bit trn lm sng vi cc nguynnhn vim vng c bn khc nh vim c c n chm, vim gip mng, vim hch.

Trong nghin cu ny chng ti gp 100% (35/35) bnh nhn c au khi nga c. Triuchng nga c au, gp c khng au cng c cc tc gi m t. c bit Wilkins chorng nga c au v gp c khng au l triu chng c gi tr chn on phn bitVTG cp m vi cc vim vng c do cc nguyn nhn khc. Triu chng nutau/nghn, khn ging, kh th, khc m gp cc t l khc nhau do TG chn p vothc qun, thanh qun/kh qun, hay do abces v vo thc qun.

Trong nghin cu ny, 36 bnh nhn c lm xt nghim t bo hc th c 22trng hp c kt lun l VTG cp hay VTG c m v 14 trng hp c kt lun lt chc vim cp hay vim m m cha khng nh l VTG . Trong trng hp ny cnkt hp vi siu m chn on xc nh. Khi tin hnh siu m 36 bnh nhn, 23trng hp (63,89%) xc nh c m. Kt qu ny gn trng vi xt nghim t bo hcchn on l VTG m (22 bnh nhn). c bit c gi tr l 14 trng hp xt nghim t

bo ch l t chc vim m hay vim cp m cha xc nh l t chc l TG th ktqu siu m tr li l th tch TG to hn bnh thng. Siu m ngoi tuyn gip ngoixc nh th tch TG to hn bnh thng cn xc nh TG c m hay cha da vom ECHO, s khng ng nht hay c trng m trong TG(16,18,27,37,38,4244,52). T nhn xt trn y, theo chng ti cn s dng c 2 phng

php ny chn on bnh VTG cp m s lm tng tin cy ca chn on. Tuy

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nhin, cho n nay Vit Nam cha c ti liu no cng b v gi tr chn on ca haiphng php ny i VTG cp m.

Cng nh cc bnh nhim vi khun khc, VTG cp m bnh nhim khun thngthng, do vy phn ng chng ca c th l bch cu tng cao v s lng. Trongnghin cu ny, 51/61 (83,61%) bnh nhn c bch cu tng 10 000/mm3 tr ln, 16,39%

c bch cu cao trn 20 000 /mm3. BCNTT tng gp 36/61 trng hp chim 59,02%.a s bnh nhn n trong giai on abces (26/35) nn ngoi tng BCNTT, c thcn huy ng mt s i thc bo v monoxit n dn xc vi khun, v vy BCNTTkhng tng cao trong mt s trng hp. VSS tng cao tuyt i trong c 2 gi. Kt qu

bch cu tng v VSS cao ph hp vi y vn.(4,6,10,11).Chng ti tin hnh ly mu bnh nhn VTG cp m kim tra chc nng TG

v thy rng 26/28 (92,86%) bnh nhn c nng FT4 hoc T4 hon ton bnh thng.Ch c 1 trng hp T4 tng nh 158,4 nmol/L (bnh thng 50-150 nmol/L) v 1 trnghp FT4 gim nh 7,6 pmol/L (bnh thng 9-25 pmol/L). Cng tng t nh vy, TSHhon ton bnh thng 26/28 (92,86%) bnh nhn. Mt trng hp TSH l 8,4 Mu/ml

v mt trng hp TSH l 0,56 Mu/ml. Nh vy c th kt lun l khng c s bin iv hormon TG bnh nhn VTG cp m. iu ny cng ph hp vi kt lun ca cc tcgi khc (6,7,10,11).

Trong nghin cu ny, 42 bnh nhn c chc TG ly dch nui cy vi khun vc 24 bnh nhn nui cy vi khun c kt qu dng tnh chim 57,14%. Khi phn lp vikhun th Streptococcus chim t l cao nht 70,83% (14/24), sau l S.Aureus 12,50%(3/24), E.Coli 2/24 (8,33%), cc vi khun khc nh Enterococcus, K.oranoe ch gp 2/24(8,33%). Trong 17 bnh nhn VTG do lin cu, chng ti bt gp hu ht cc type , tanhuyt, c bit gp rt nhiu ln chng Viridan v Pneudomonac. Kt qu ny khng khc

bit so vi nhn nh ca cc tc gi khc (10,11) cho rng lin cu, t cu, ph cu l cc

vi khun thng gy VTG cp m.Trong nghin cu ny, 31 bnh nhn tin cu c soi h hng th 28 (90,32%)pht hin c ng r xoang l. T l tm thy ng r xoang l trong nhm ny thphn so vi nhm ca Takai, c 13 (100%) bnh nhn VTG cp m u tm thy ng r.Theo cc nh tai mi hng, nguyn nhn ln u soi cha tm c ng r c th dovim nhim cha n nh hoc do ng r phc tp kh pht hin. Trong s 28 bnhnhn soi tm thy ng r xoang l, chng ti thy c ti 25/28 (89,29%) bnh nhn rthy tri chim 89,29%. T l ng r xoang l bn tri ca cc tc gi dao ng t 80%n 97,4% (1,8,13 ). Cc chuyn gia tai mi hng cho rng ni soi h hng l mt thmd quan trng, c gi tr chn on xc nh ng r xoang l. Cn cc tc gi nghincu v VTG cp m th cho rng chnh r xoang l l nguyn nhn VTG cp m v lm

bnh ti phtt. Do vy, ni soi h hng cho bnh VTG cp m l cn thit.V iu tr, phc C (Tarceforksym/Aminkacin) t t l thnh cng cao

91,11% (17/18) bnh nhn v t ra c hiu qu hn phc A v B vi P


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vng c bn. Lun n tin s chuyn ngnh TMH2. L Huy Liu. 1994. Cc bnh vim tuyn gip- bnh ni tut, 161-165

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Cng 2000. Nhn xt 1 s bnh tuyn gip qua chn on t bo hc ti BVBch mai trong 10 nm 1990-1999. K yu cng trnh NCKH 10 nm 1990-1999, 44-51

6. Mai Th Trach, Nguyn Thy Kh. Vim tuyn gip. Ni tit hc i cng, 256-

2617. Fran H.N; Peter H.F. Acute, subacute Thyroiditis-Endocrine System and lected.

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children. Areview of 112 cases-Ann Oto Rhinol Laryngol, 100: 361-36510. Mark A.Sperling 1992. Thyroid Imaging. Pediatric Endocrinology-Second

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and treatment of Endocrine Disorders in childhood and Aldolescence- fourthedition, 503-60412. Singer P.A. 1996. Thyroiditis: Acute Subcute, and chronic. Med Cli North Am,

75-16113. Takai S; Akira M; Fumio et al 1981. A fistula from Pyriform sinus in recurrent

acute suppurative Thyroiditis. Am.J.Dis.child: 135-17814. Manch Y; Morrisseau M.P; Perrin A; Abpucaya J.P; Roulleau P. 1998. le fon du

sinus Piriforme dans le traitement chirurgical des fistules de la 4 emes pocheendobranchiate. Revne de Laryngologie, 105, 5: 491-494

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