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Bs. DNG MINH PHNG Chuyn Khoa I RHM

BNH NHIM TRNG RHM

MC CH: Gii thiu mt s bnh nhim trng ca rng hm mt. YU CU: Hc vin lit k c cc bnh nhim trng rng hm mt. I.BNH VIM NHIM NGUYN NHN DO RNG: a s cc bnh nhim trng vng hm mt l do rng b su sau tin trin thnh ty thi hoc vim quanh chp cp tnh hay mn tnh, khi c m chp rng n thot ra theo ba ng: ng ty, mng nha chu, xng rng trng hp ny m c th vo n xng hm. V vy trng hp vim nha chu hoc tai bin mc rng khn m cng c th vo mng xng ri xuyn qua xng vo phm mm gy ra nhim trng m t bo lng lo hoc vim ct ty. i vi cc rng sa v chn rng ngn nn t khi gy ra vim m t bo lng lo. I.I.Vim m t bo [Cellulitis]: M t bo l loi m lin kt lng lo, nu b vim n lan ta m mm ch khng gii hn nh abces. Vim c th t ti ch hay lan ta khp m t bo vng mt. Nguyn nhn thng do rng b ty thi v su hoc chn thng to nn cc sang thng quanh chp gc rng nh u ht, abces, u nang hoc do vim quanh thn rng lc mc rng khn, vim nha chu, sang chn. Khng c loi vi trng c bit no gy ra vim m t bo m l tt c loi vi trng thng gp trong ming nh t cu, lin cu, xon trng, vi trng k kh. M t bo b vim khi b m xm nhp trc tip, hoc do c t ca vi khun, hoc do nhim trng lan truyn qua ng bch huyt. C th phn ra vim m t bo t v lan ta. I.I.1.Vim m t bo t: Thng gp nht c cc th bnh cp tnh, bn cp, mn tnh v hoi th. I.I.1.a.Vim cp tnh: +Vim c huyt thanh: [vim m t bo mng] l giai on u tin ca vim m t bo t, c ri lon tun hon [co mch, gin mch] v thot huyt thanh. Triu chng lm sng: -Triu chng ton thn khng r rng. -Triu chng ti ch: sng che lp cc rnh v lm trn mt, mt sng nhiu hay t ty v tr rng nguyn nhn v c tnh loi vi khun, da cng bng, s hi nng, t, khng au lm, khng in du ngn tay. Chn on: Trang 1

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Bs. DNG MINH PHNG Chuyn Khoa I RHM

-Xc nh: da vo tin s bnh c rng au -Phn bit: vim do inh ru, sang chn do d vt xuyn qua nim mc, vim xng hm, vim hch Tin trin: khi sau vi ngy nu rng nguyn nhn c iu tr hoc tin sang giai on c m. iu tr: cha ni nha bo tn rng hoc nh rng nguyn nhn ty th trng bnh nhn v tng trng hp c th. +Vim ty [phlegmon] c m: [vim m t bo ty] khi bnh tin trin n giai on ny cc triu chng ton thn v ti ch th hin r rng hn. Triu chng: -Ton thn: st cao, mch nhanh, nhc u [m bt u gom t li th bt st]. -Ti ch: mt sng ty, da , s nng, au nhiu lin tc, khng h ming rng c, hi th hi. i vi hm di khi rng nguyn nhn cng v pha sau tnh trng cng kht hm [trismus] cng nng, au mt n mt ng ung thuc cng khng lm th trng suy sp. Lc u kh thy du hiu chuyn sng biu hin s t m. Chn on: -Xc nh: da trn tin s c rng au, v tr khi sng ty c lin quan n rng nguyn nhn. -Phn bit: hm di c th lm vi vim ty vng sn ming do tt ng nc bt Wharton, nang nhi c m, vim hch di hm. hm trn vng rng nanh vim lan n mi mt di c th nhm vi vim ti l. Tin trin: khi m thot ra ngoi qua da hoc nim mc trong ming to thnh l d bnh s nhng nu rng nguyn nhn khng c cha s ti pht tin n giai on mn tnh. Nu th trng bnh nhn suy sp hoc c t vi trng mnh s gy ra nhng bin chng nng hn nh nhim trng mu, vim lan ta, vim ct ty iu tr: Phi hp iu tr ton thn v ti ch. Dng khng sinh liu cao nn dng khng sinh c loi khng sinh hu hiu, ch nng cao th trng. Gii quyt rng nguyn nhn, i vi trng hp ti pht nn nh cng sm cng tt. Sau khi nh mc d mt phn m thot ra ngoi theo rng mt phn m vn cn ng li cho nn phi rch tho m, nu bnh tin trin sang vng ln cn phi tip tc rch abces dn lu m. Khi bnh ko di hoc khng thuyn gim ch n cc nguyn nhn nh u ht, vim ct ty hm, do rng bn cnh rng nguyn nhn cng b ty cht hoc nhng nguyn nhn gy suy nhc c th. I.I.1.b. Vim bn cp: Xy ra khi c tnh vi trng yu nhim trng tin trin chm do c th c thi gian khng. C hai loi: Trang 2

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Bs. DNG MINH PHNG Chuyn Khoa I RHM

-Loi mt abces: sau giai on vim c huyt thanh, da sng c khi thm tm, s hi nng, khi sng c ranh gii r trn, gia mm chung quanh cng c du hiu chuyn sng, lung lay c cm gic vng sng dnh vo xng. H ming hn ch khi rng nguyn nhn l rng hm nm gn c nhai. Khm trong ming ngch hnh lang y ln, nim mc cng bng, rng nguyn nhn au t hoc va c nh vi hm. Khng iu tr tt s v m to l d lm su da v dnh vo xng. -Loi nhiu abces: cng xut hin sau vim c huyt thanh nhng v tr vng gc hm v c, thm d thy abces rt nng v da chung quanh khng x cng khi sng s au, mm, dn dn c du hiu chuyn sng sau v m ra ngoi da, sau xut hin abces vng ln cn ri li v m. C trng hp rng nguyn nhn nh m vn tip tc xut hin abces l do vim lan t ni ny n ni khc duy tr nhng ng d. iu tr sm, rch dn lu tt s trnh trng hp ny. I.I.1.c. Vim mn tnh: Xut hin sau vim cp hoc bn cp. Vng vim khng xp hn m gom li di da bng ngn tay trn khng au ranh gii r, di ng c nhng c cm gic dnh vo xng, mu bnh thng. Sau mt thi gian c l d da, phn bit vi vim hch lao l khng dnh vo xng v to nhiu ng d lu lnh [cn xt nghim lao t, m sinh thit bch]. iu tr rng nguyn nhn, rch abces ng trong ming trnh so, nu d m lu phi no ng d, bm ra, t dn lu. I.I.1.d.Vim hoi th: y l tnh trng trung gian gia vim t v vim lan ta, m hi thi c hi tp trung trong mt khoang ca m t bo lng lo v c nhng mnh vn ca t chc b hoi t. Triu chng: st cao, mt mi ton thn, khi sng mt s lo so. Tin trin: iu tr khng kp thi hoc khng y bnh s thnh lan ta. iu tr: rch tht su, tht rng dn lu tt km khng sinh, nng cao th trng. I.I.2.Vim m t bo lan ta: L th vim c tnh cht lan rng khng gii hn ng thi hoi t lan rng cc t chc b vim, c im nhng ngy u khng c m, m khng gom t ngay m s loi ra cng vi m hoi t. Bnh thng gp sau khi vim khp rng cp tnh, vim ti nha chu hoc sau khi nh rng kh, thnh thong gp sau khi gy xng hm hoc vim ct ty hm. Triu chng: Trang 3

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Bs. DNG MINH PHNG Chuyn Khoa I RHM

Nhng ngy u triu chng ton thn rt nng rt run, st cao, mch nhanh, m sng, kh th, nn, tiu chy. Khi sng ty v tr ca vng vim, bnh nhn c th cht sau ngy th 2 hoc th 3 v nhim c ton thn. Nu qua khi m gom t sau ngy th 5 hoc th 6, sau thot ra da do da b thng v hoi t hoc sau khi rch, m ra cng nhng t chc b hoi t. Nu lnh bnh phi cn thi gian kh lu v li nhiu di chng nng nh vim tc tnh mch, vim khp ln cn Chn on phn bit vi vim ct ty, vim m t bo t. iu tr: ch yu bng phu thut rch rng v nhiu ni dn lu, nh ngay rng nguyn nhn, nng cao th trng km phi hp khng sinh liu cao. I.II. Vim xng hm [osteomyelitis]: Xng hm b vim do ba nguyn nhn: nguyn nhn do rng thng gp nht v vi trng theo ng ty xm nhp vo gia xng ni khng c mng xng v bch huyt bo v, do ng mu [vim ct ty] v t gp hn l do s tip cn nh trong vim nha chu, vim quanh rng trong khi mc rng khn, vim m t bo v xng hm c mng xng dy che ch rt tt. Ngoi cc bnh ton thn hoc gy hm cng l yu t thun li. Bnh thng gp hm di v ng mch rng di nm rt gn chp rng [rng 8 rng 5] v li l ng mch tn cng do d b nh hng ca cc nhim trng chp gc v nhim trng d lan rng, khc vi hm trn cc ng mch phong ph hn v khng phi l tn cng nn vi trng kh tp trung v d b tiu dit, nhng nu xng hm trn b vim th rt nng c th lan nhanh chng n cc xng s v xng mt li nhng tn thng vnh vin. Khng c vi trng c hiu m thng l phi hp nhiu loi vi trng. Triu chng: St cao n lnh mt l, au nhc rng d di lan ta khp xng hm, vng m sng to da hng, s cm thy xng dy u thm v au, trong ming c nhiu rng lung lay c triu chng ca vim khp rng, c th b cng hm. Tin trin: Sau m thot ra ngoi theo l d da hoc nim mc, lc ny tng trng c v tt hn nhng ngay c khi rng nguyn nhn c nh khi sng vn khng thuyn gim. Dng thm chm i theo ng d cm thy ming xng cht bn trong rung rinh v ch khi n c rt ra bnh mi thuyn gim. iu tr: -Nh rng nguyn nhn nhng khng nh cc rng ln cn d c lung lay, cho khng sinh sm nhiu v lu, phi hp an thn v bi b th trng. -Rch abces trnh tnh trng to thnh l d. -Theo di ly xng cht ra khi n hon ton tch khi xng lnh. Trang 4

TTT BD CB Y T BM SKRM I.III. Vim xoang hm do rng:

Bs. DNG MINH PHNG Chuyn Khoa I RHM

L vim nim mc xoang nhng khng tn thng xng, nguyn do im thp nht ca nn xoang nm gn chp rng 4,5,6 trng hp xoang ln th t rng 3 n rng 7,8. Nn xoang c khi xung rt thp nm gia hai chn rng nn nhng rng nhim trng chp, u nang, rng ngm nhim trng d gy vim xoang, ngoi ra vim ct ty hoc tai nn lc nh rng lm chn rng b y vo xoang, gy xng hm trn lm mu ng trong xoang cng l nhng nguyn nhn gy vim xoang hm. Triu chng: Ngi ngy ngt st, mi mt, mt ng. Nhn bn ngoi hi sng vng xoang tng ng, n vo au, trn film X quang xoang b m bn vim do hin din m vim hoc do tch t cht dch trong xoang, au tc na mt m lan n mi mt di au ngy cng tng cho n khi m hi thi thot ra c t l mi pha bn au th ngi nh hn. Nu m khng thot ra c, mt thi gian sau s vim xoang trn, vim xng hm, hoc bin chng mt [vim dy thn kinh th gic, vim mng mt], vim tc tnh mch xoang hoc to l d ra da. iu tr: -Nu xoang mi b vim th nh rng nguyn nhn c th lnh bnh. -Chn rng lt vo xoang th tm cch li ra nu khng c phi c m xoang v no nim mc xoang tn sinh. II.BNH VIM NHIM NGUYN NHN KHNG DO RNG: II.I.inh nht: L nhim khun lm tiu hy t chc chn lng do t cn khun vng [staphylocoque Dor] xm nhp qua nhng vt try xc da, nu xut hin mt nht l mi th rt nguy him v c nhiu mch mu nn c th bng pht sng ty d di nu chch nn ci ngi cn non, th hin vi cc triu chng ton thn v ti ch nguy kch c th dn n t vong v vim tc tnh mch xoang. Triu chng: -Ton thn: bnh nhn au nhc st tng cao, mch nh yu, kh th. -Ti ch: lc u ni ln mt mn nh, cng lan rng sau bt u hoi t gia lan dn lm da c mu trng. Da hoi t v c m vng chy ra, gia c mt ngi mu vng xanh. Tin trin: n ngy th 8-9 ngi theo nc m tri ra ngoi, lc ny bt bnh da lin dn c mu tm. iu tr: cc inh nht mt cm chch nn ch dng khng sinh liu cao, chm nng, theo di bo v cn thn trnh ng dp. Trng hp bng pht mt ty cng bng lan n mi mt phi a ngay vo hi sc cp cu. Trang 5

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Bs. DNG MINH PHNG Chuyn Khoa I RHM

II.II. Bnh NOMA hoc CANCRUM ORIS [Cam Tu M] L bnh lot hoi t xng hm v phn mm vng hm mt. Nguyn nhn khng r, khng c vi trng c hiu, thng xut hin sau nhng bnh gy suy nhc nng nh thng hn, kit l, st pht ban, nht l tr sau khi ln si km tnh trng v sinh rng ming km. Triu chng: -Ton thn: sau khi ht si bt u b st cao tr li, ton thn mt mi, xanh xao, mch nhanh, th trng chung rt km, c bit l hi th hi, chy nhiu nc bt. -Ti ch: bt u l vt lot nu lan nhanh n cc m ln cn, lot ra da sau hoi t thng mi, m v xng tr ra, qu trnh din ra ch 1-2 ngy nhanh nh nga chy, rng lung lay ri rng nhiu rng mt ln. Tin trin: khng iu tr dn n t vong sau 5-7 ngy do nhim trng huyt hoc bin chng phi. iu tr mun xng hm hoi t li di chng v chc nng v thm m. iu tr: ch yu dng khng sinh Penicillin liu cao, nng cao th trng bng vitamin B1, C, truyn huyt thanh ngt, tr tim, cht dinh dng km vi v sinh rng ming bng nc mui bm ra nhiu ln. Nu c rng lung lay v xng hoi t th ly ra sau lm phu thut to hnh. II.III. Vim tuyn nc bt: Trong ming c nhiu tuyn nc bt, c tuyn nh ri rc trong ming nh vm ming, nim mc m, nim mc mi, c tuyn ln nh tuyn mang tai, di li, di hm, nhng thng gp nht l vim tuyn nc bt mang tai. Nguyn nhn do c s gim tit nc bt lm nhng vi trng thng thng nh Streptococus, Staphylococus, Pheumococus d xm nhp theo ng ng tuyn, t khi theo ng mu. Triu chng: +Vim c m: bt u tuyn sng to, st tng cao nhanh chng, mch nhanh, ngi m mt. Ti ch c y du hiu ca vim, au t nhin c th lan n c v thi dng, gim thnh gic, h ming kh, l ng Stenon cng , cm gic kh hng v tuyn khng bi tit na, n vo da vng tuyn c in du ngn tay v c m chy ra l ng tuyn nc bt. +Vim hot t: ch gp trong trng hp suy kit, ngi mt l kh th, ti ch da tm thng lot c nhiu t chc b hoi t, trong tuyn c kh s thy lo so, c nhiu m chy ra t ng Stenon. Tin trin: khng iu tr tuyn cng sng to, d m ra da khong ngy th 5,6 sau bnh lui dn, sau mt thi gian t nhin ht d, tuyn b x cng. Trong vim hoi t s dn n lit dy thn kinh mt. Trang 6

TTT BD CB Y T BM SKRM Chn on phn bit:

Bs. DNG MINH PHNG Chuyn Khoa I RHM

-Nu vim tuyn c hai bn: phn bit vi quai b [bnh ly thnh dch, mau khi, c th c bin chng vim dch hon hoc bung trng, xt nghim mu men amiloaza tng]. -Vim tuyn mt bn: phn bit vi vim cnh cao xng hm di [tin s bnh v rng, n vo xng thy au, c tn thng xng trn film]: vi vim xng chm [tin s bnh v tai]; vi vim hch gc hm [v tr thp hn, s vo mi au khng au t nhin, khng c m l Stenon]. iu tr: nn m bng cch n tay vo tuyn 4-5 pht/ngy chm lnh ngy th 2-3 bm ra thng ng Stenon cho thuc tng bi tit nc bt nh Pilocacpin vitamin v khng sinh nng cao th trng v trnh bi nhim Trong th bnh hoi t cn rch rng v sm, ng rch cong i t di tai xung gc hm v i theo b di xng hm di, nu cn rch nhiu ng th rch ngang song song dy thn kinh mt v ng Stenon, ri dng kp nong thot m. Ti liu tham kho: Lester W.BURET, D.D.S. , M. D. , Oral Medicine Diagnosis Treatment J.B. LIPPINCOTT Company copyright, 1946 Trng i Hc Y Khoa B Mn Rng Hm Mt, Rng Hm Mt Tp II. Nh Xut Bn Y Hc, 1971

CU HI LNG GI 1/Vim m t bo t xut hin tr em. 2/M t bo l loi m lin kt chc ch. 3/T cu trng thng gp trong VMTB. 4/VMTB c th do nhiu nguyn nhn 5/VMTB t c 3 th bnh. 6/VMTB mng l th bnh c thot huyt thanh 7/VMTB giai on u khi khm li du n ngn tay. 8/Trismus l tnh trng cng kht hm. S S S S S S S S Trang 7

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Bs. DNG MINH PHNG Chuyn Khoa I RHM S S S S S S S S S S S S

9/Phlegmon l tnh trng VMTB bt u c t m 10/Khi m thot ra ngoi qua l d l sp lnh bnh. 11/Abces khi khm c du hiu sng v. 12/VMTB bn cp thng xut hin abces. 13/VMTB hoi th thng c mi hi v hi. 14/VMTB lan ta c triu chng rt nng nhng ngy u 15/Vim xng hm thng xut hin hm di. 16/Vim xng xy ra hm trn th rt nguy him 17/Vim xoang hm thng km theo vim xng hm. 18/inh nht l tnh trng vim nhim khng do rng 19/NOMA rt thng gp cc thnh ph ln. 20/Tuyn nc bt d b vim khi c xon khun.

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