CHNG MT T TH KCH PHT LNH TNH

(Benign paroxysmal positional vertigo: BPPV) BS. H Vnh Phc, TS. Cao Phi Phong Ngy 17 thng 12 nm 2009 GII THIU Chng mt t th gm c: 1. Chng mt t th trung ng 2. Chng mt t th kch pht lnh tnh (BPPV): - ng bn khuyn sau(Posterior-canal benign paroxysmal positional vertigo). - ng bn khuyn ngang(Horizontal-canal benign paroxysmal positional vertigo: canalolithiasis type, Horizontal-canal benign paroxysmal positional vertigo: cupulolithiasis type) - ng bn khuyn trc(Anterior canal benign paroxysmal positional vertigo). NH NGHA BPPV BPPV c c im gy cn chng mt ngn khi thay i t th u, nguyn nhn l do s di chuyn c hc ca si tai (otoconia) t soan nang (utricle) vo trong ng bn khuyn. Hu ht bnh nhn chng mt khi nm xung, xoay u qua phi hay tri trn gi hay khi cui xung, nhn ln (top shelf vertigo). C th c ri lon thng bng, quay cung trong u (lightheadedness) hay bp bnh vi gi n c ngy sau cn BPPV. c trng ca BPPV: Triu chng khi pht ngm ngm (1-40 giy) Thi gian ko di triu chng thng t hn 1 pht Nystagmus nh ln hay xoay Triu chng gim i khi lp li kch thch. Chng mt m khng c phi hp vi ic tai hay tai, bn cht v hi (lnh tnh), kt hp vi cm gic xoay trn v chng mt tr nn nng hn khi thay i v tr u. Khi triu chng BPPV tip tc tn ti, bnh nhn thng s chp nhn ngn nga bng cch trnh t th gy ra chng mt. Hu qu c th dn n ri lon chc nng c ct sng, gim chc nng tin nh hay c hai. Dch t hc BPPV Nguyn nhn thng gp nht ca ri lon tin nh ngoi bin, chim t 17 n 20% bnh nhn chng mt, thng gp la tui t 50-70, mc d c th gp trong bt c nhm tui no, v gp 2 ln n, 50% chng mt ngi gi, 85% chng mt t th, t l mc bnh gia tng theo tui.

CC GI THUYT SINH L BNH BPPV

Nm 1962, Harold Schuknecht, MD, xut ra gi thuyt cupulolithiasis hay cn gi l si i tai (heavy cupula); mnh v si tai dnh vo i tai gii thch cho bnh chng mt t th kch pht lnh tnh. (Hnh 1)

Hnh 1: M t Canalithiasis ca ng bn khuyn sau v Cupulolithiasis ng bn khuyn ngang.

Nm 1979, Hall, Ruby v McCure cng b gi thuyt ca ng v canalithiasis (si ng tai hay si ng bn khuyn). ng ngh rng triu chng ca bnh chng mt t th kch pht lnh tnh ph hp hn vi s di chuyn t do ca si ng bn khuyn (canaliths) trong ng bn khuyn sau hn l s bm dnh vo cupula. (Hnh 1) NGUYN NHN Nguyn nhn thng gp nht ngi di 50 tui l sau chn thng, Migrain. ngi gi hu ht nguyn nhn thng do s thoi ha h thng tin nh tai trong. Vim tai do virut nh: vim tin nh, bnh Mnere. Nguyn nhn khc sau phu thut tai Hn mt na trng hp khng tm thy nguyn nhn CHN ON Da vo bnh s vi cn chng mt ngn xy ra khi thay i t th. Khm lm sng tt c cc du hiu lm sng bnh th ng ngoi tr nghim php Dix-Hallpike dng tnh.

NGHIM PHP DIX-HALLPIKE: Thc hin NP Dix-Hallpike, u tin cho bnh nhn ngi thng, thy thuc gii thch cho bnh nhn nghim php c th gy chng mt (xem video).

1. xoay u bnh nhn sang bn t 30 n 45 (hnh 2 A)

Hnh 2 A: Dix-Hallpike (Photo: Christine Kenney)

2. Bnh nhn m mt nhn thng vo mt hay trn thy thuc, sau thy thuc gi u cho bnh nhn nm nga nhanh xung trong 2 giy, c dui nh ra sau v thp hn mt gng khm t 20 n 30 ( Hnh 2B)

Hnh 2B: Nghim php Dix-Hallpike (Photo: Christine Kenney )

Sau khong 2 n 20 giy xut hin git nhn cu xoay nh ln hay git ngang, c th ko di t 20 n 40 giy. Git nhn cu thay i hng khi bnh nhn ngi thng ln. Nu git nhn cu khng xy ra cho bnh nhn ngi ln 30 giy sau lp li xoay u sang i bn. Da vo git nhn cu phn loi tn thng ng bn khuyn: 1. ng bn khuyn sau: nh ln hay xoay theo kim ng h ( Upbeating or Torsion) 2. ng bn khuyn tr c: nh xung c hay khng xoay theo kim ng h (Downbeating with/wo Torsion) 3. ng bn khuyn ngang: ngang (Horizont) Knh Frenzel (Frenzel Goggles) hay video Frenzel goggles c th lm test DixHallpike nhy hn. Dng thng gp nht ca BPPV: ng bn khuyn sau (95%) ngang (3%) trc (2%). . CHNG MT T TH KCH PHT LNH TNH NG BN KHUYN SAU *Thng gp ng bn khuyn sau (95%) *Git nhn cu nh ln hay xoay theo kim ng h *Git nhn cu xoay pha nhanh hng v tai thp nht *Tim n vi giy *Thi gian gii hn < 20 giy *Chiu git ngc li khi tr v t th ngi thng *Triu chng gim khi lp li kch thch . IU TR Vi quan im si tai di chuyn trong ng bn khuyn khi thay i v tri u v c th a tr li soan nang, y chng s c phn hy. iu tr ti nh v ng bn khuyn (Canal Repositioning Treatment (CRT)) bng nghim php Epley Hiu qu ng bn khuyn trc v sau do canalithiasis. C th thc hin ngay sau khi chn on. Thay i t th u lin tip nh v li cc mnh v si tai.

NGHIM PHP EPLEY John Epley bo co nm 1992, bao gm di chuyn u trong bn t th lin tip, mi t th ngng li khong 30 giy, ti pht sau iu tr khong 30%/nm, lp li iu tr ln 2 c th cn thit, dng thuc chng nn trc nu cn thit. Khi thc hin ch cc triu chng xy ra nh: yu, t, ri lon th gic c th do chn p ng mch sng nn, nu ko di c th do t qu (xem video)

1. Cho bnh nhn nm nga nhanh xung trong 2 giy, c dui nh ra sau v thp hn mt gng khm t 20 n 30 ( Hnh 3.A)

Hnh: 3.A (Photo: Christine Kenney) 2.Xoay u bnh nhn sang tri 90 , gia t th trong mt pht (hnh 3.B).

Hnh: 3.B (Photo: Christine Kenney )

4. K n bo bnh nhn xoay ngi tip sang tri vung gc vi mt ging u vn xoay theo, gia t th trong mt pht (hnh 3.C).

Hnh: 3.C (Photo: Christine Kenney ) 4. T t cho bnh nhn ngi dy (hnh 3D).

Hnh: 3.D (Photo: Christine Kenney ) Bin chng CRP 1. tht bi 25% 2. ti pht 13% trong 6 thng 3. tc dng ph bun nn nn ngt tot m hi
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4. chng mt xu hn do si tai ri vo ng bn khuyn ngang. (Trng hp nn i c th dng promethazine(phenergan) tnh mch, si tai di chuyn n ng bn khuyn ngang thc hin nghim php Bar-b-que) Chng ch nh CRP Bnh tim khng n nh, hp ng mch cnh mc nng, bnh l ct sng c, cn thong thiu mu no hay thiu mu no ang tin trin v c thai trn 24 tun HNG DN BNH NHN SAU KHI TP - i khong 10 pht sau nghim php phng cn chng mt ngn do si tr li. - Ng nm nghing gc 45 .

Hnh 4: Hng dn sau khi iu tr. - Trong ngy c gng gi u thng, khng c i ht tc, nh rng, tp th dc i hi di chuyn u. Cn thn khi co ru, nh thuc mt, gi u. - t nht 1 tun trnh xoay u v bn kch thch k 2 gi khi ng. -Trnh nm ng bn kch thch khng nga ln hay cui xung qu. -Mt tun sau iu tr, t xoay u sang bn gy chng mt. HNG DN IU TR BPPV TI NH NGHIM PHP EPLEY TI NH (HOME EPLEY MANEUVER) c khuyn co cho nhng bnh nhn c chn on r, bi t p c hiu qu hn do lp li mi m trong mt tun. Minh ha bi tp Epley ti nh. (xem video)

1. Xoay u sang tri 45 sau nm xung. (Hnh 4A)

Hnh: 4A 2. Nm u vn gi 45 duy tr t th ny 30 giy (hnh: 4B)

Hnh: 4B

3. Xoay u sang phi 90 , gi t th ny 30 giy. (Hnh: 4C)

Hnh: 4C

4. Ln ngi tip sang phi t th lng vung gc vi ging, gi t th 30 giy. (Hnh: 4D)

Hnh: 4D

5. Ngi dy. (Hnh: 4E)

Hnh: 4E BRANDT-DAROFF EXERCISES c khuyn co nhng bnh nhn c khi c tn thng v tr ng bn khuyn khng r bnh nhn BPPV. T l thnh cng 95% trng hp(xem video)

1. Bt u ngi t th thng (Hnh: 5A)

Hnh:5A

2. Ri di chuyn sang t th 2, u nhn ln trn u 45 , gi t th ny 30 giy. (Hnh: 5B)

Hnh: 5B

3.Sau ngi dy t th thng (Hnh: 5C)

Hnh: 5C
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4.K n lm ngc li t th 2, gi t th ny trong 30 giy. (Hnh: 5D)

Hnh: 5D

5.Kt thc, ngi dy t th thng. (Hnh: 5E)

Hnh: 5E Thi gian tp nn c thc hin trong 2-3 tun, mt ngy tp 3 ln.(xem video) CC TH CHNG MT T TH KCH PHP LNH TNH KHNG IN HNH ng bn khuyn trc, ng bn khuyn ngang, cupulolithiasis, vestibulolithiasis, multicanal patterns

Hnh: 6 Cc th BPPV

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CHNG MT T TH KCH PHT LNH TNH NG BN KHUYN TRC 1. Him 2% 2. Git nhn cu nh xung/xoay chiu kim ng h cho tai i bn trong NP. Dix-Hallpike (Down-beating /torsional). NP Dix- Hallpike kch thch ng bn khuyn trc tai i bn, nu xy ra chng mt khi nghing u bn phi, vn c th tai bn tri, c th kch thch c khi nghing u sang bn v khi u t th treo. Si tai di chuyn ng bn khuyn trc rt him , thng na sau ng bn khuyn trc, c th do bin chng NP. Epley. 3. NP. Epley c hiu qu ng bn khuyn trc v sau do canalithiasis. CHNG MT T TH KCH PHT LNH TNH NG NGANG 1. Hu ht BPPV khng in hnh 2. 3-9% trng hp 3. Hu qu NP. Epley 4. Git nhn cu ngang n thun (Horizontal purely nystagmus) 5. Cupulolithiasis nhiu hn canalithiasis 6. iu tr: Modified Epley / lampert maneuver.
BPPV tai tri

30 giy

30 giy

NP. Epley sa i

TI LIU THAM KHO 1. Brny R. Diagnose von Krankheitserschernungen in Bereiche des Otolithenapparates. Acta Otolaryngol (Stockh) 1921; 2: 434-7 2. Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979; 8(2): 15. 3.Parnes LS, McClure JA. Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Laryngoscope 1992; 102 (9): 988-92. 4. Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969; 90: 765.
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5.Schuknecht HF, Ruby RR. Cupulolithiasis. Adv Otorhinolaryngol 1973;20:434. 6. Epley JM. Human experience with canalith repositioning maneuvers. Ann N Y Acad Sci 2001;942:179-91;20: 434 7. Dix MR, Hallpike CS. Pathology, symptomatology and diagnosis of certain disorders of the vestibular system. Proc R Soc Med 1952; 45: 341. 8. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106: 484-5 9. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107: 399-404. 10. Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 2000;126: 617-22. 11. Timothy C. Hain. Benign paroxysmal positional vertigo. May 2008.22

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