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Phân Tích Lâm Sàng Và X
Phân Tích Lâm Sàng Và X
H Ch Minh * Tp 14 * Ph bn ca S 1 * 2010
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TM TT
M u: U nguyn bo men l loi u do rng thng gp Vit Nam. Vic chn on trc m quyt nh cch thc iu tr v tin lng. Mc tiu: Kho st mt s c im lm sng v X-quang ca u nguyn bo men tng kh nng chn on chnh xc u nguyn bo men trc m. Phng php: Thit k nghin cu ct ngang m t v phn tch, qua hi cu 52 trng hp u nguyn bo men ti Bnh Vin Rng Hm Mt Trung ng nm 2007 v 2008. Kt qu: U nguyn bo men chim 30,8% cc u xng hm, v 6,6% cc tn thng hc ming c gii phu bnh. U thng gp nht t 20 n 40 tui (46,2%). T l nam/n l 1,1/1. a s u xy ra xng hm di (90,4%), nht l cnh ngang vng rng sau v gc hm (71,2%). L do khin bnh nhn i khm nhiu nht l sng mt (94,2%). Phng xng-bin dng mt l triu chng lm sng ph bin (96,2%) v u thng c kch thc ln hn 5 cm (80,8%). Trn phim X-quang ton cnh, hnh nh thu quang ch yu l dng nhiu hc (75%), dng mt hc t gp hn (23,1%). T l tiu ngt chn rng l 59,6%, nhiu nht ngi di 20 tui (91,7%) (p<0,05). 36,5% u c rng ngm, thng gp trong u dng mt hc (66,7%) v ngi di 20 tui (75%) (p<0,05). U dng mt hc cng c c im ph bin vng sau ca hm di, hy xng nhiu v gy tiu ngt chn rng nh u dng nhiu hc (p>0,05). Kt lun: Cn kt hp phn tch lm sng vi X quang thu thp nhiu thng tin c th gip cho chn on trc m chnh xc hn, nht l i vi u dng mt hc. T kha: U nguyn bo men, chn on trc m, c im lm sng v X-quang ca u nguyn bo men, xng hm di, cnh ngang vng rng sau v gc hm.
ABSTRACT
A CLINICAL AND RADIOGRAPHIC ANALYSIS OF AMELOBLASTOMA Phan Huynh An, Tran Cong Chanh , Huynh Anh Lan, Nguyen Thi Hong * Y Hoc TP. Ho Chi Minh * Vol. 14 - Suuplement of No 1- 2010: 274- 281 Background: Ameloblastoma is a common odontogenic tumor of the jaws in Vietnam. The preoperative diagnosis determines the treatment method and prognosis. Objectives: To investigate the clinical and radiographic features of ameloblastoma and to increase the possibilities of the accurate preoperative diagnosis. Method: A cross-sectional retrospective study was conducted on 52 new cases of ameloblastoma treated in the National Odonto-Stomatology Hospital in 2007 and 2008. Results: The ameloblastoma prevalence was 30.8% among all tumors of the jaws, 6.6% among all biopsy cases of the oral cavity. Ameloblastoma was mostly found between 20 and 40 years old (46.2%). The male/ female ratio was 1.1/1.This lesion occurred predominantly in mandible (90.4%), the angle and molar-ramus areas were the most common sites. The chief complaint was swelling (94.2%). Enlarged bone and deformation of the face were typical symptoms (96.2%). The tumor size was often larger than 5 cm diameter (80.8%). On panoramic
* Bnh vin Rng Hm Mt Trung ng a ch lin h: BS. Phan Huynh Anh ** Khoa Rng Hm Mt - i hc Y Dc Tp.HCM T: 0979173933 Email: anrhm03@gmail.com
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radiographs, multilocular appearance (75%) was more often observed than unilocular appearance (23.1%). Root resorption occurred in 59.6%, predominantly in patients younger than 20 years old (91.7%) (p<0.05). Impacted tooth was in 26.5%, more frequently associated with unilocular pattern (66.7%) and in patients younger than 20 years old (75%) (p<0.05). The common site usually in the posterior region of the mandible and radiographic features (much bone destruction, root resorption) of unilocular tumors were similar to multilocular tumors (p>0.05). Conclusion: Clinical observations combined with radiographic analysis are recommended to lead to a nearly correct preoperative diagnosis, especially for unilocular ameloblastomas. Keywords: Ameloblastoma, preoperative diagnosis, clinical and radiographic features of ameloblastoma. Mandible, angle and molar-ramus areas. Bnh vin Rng Hm Mt Trung ng t T VN 01/01/2007 n 31/12/2008. U nguyn bo men l loi u do rng thng xy ra vng hm mt v kh pht hin sm(0,0). Mc d lnh tnh, him khi ha c v di cn, nhng u c tnh cht xm ln ti ch ph hy khng gii hn, gy bin dng vng hm mt, v kh nng ti pht cao(0,0). Vic chn on trc m quyt nh hng x tr v nh hng n tin lng. Nu u c dng thu quang nhiu hc in hnh th thng chn on trc m l u nguyn bo men v iu tr m rng trnh ti pht, nhng nu u c dng thu quang mt hc th thng phn vn hoc chn on nhm l nang v khng c k hoch m rng. V vy, chng ti tin hnh kho st phn tch mt s c im lm sng v hnh nh X-quang ca u nguyn bo men nhm cc mc tiu sau: M t cc c im lm sng ca u nguyn bo men v t l, tui, gii tnh, v tr, thi gian pht hin, l do n khm v triu chng lm sng ph bin. M t cc c im X-quang ca u nguyn bo men v dng u, kch thc u, tiu ngt chn rng v rng ngm. Phn tch s lin quan gia cc c im lm sng vi X-quang nhm lm tng kh nng chn on u nguyn bo men v nht l u nghuyn bo men dng mt hc.
Tiu chun loi tr: khng c chn on gii phu bnh, kt qu gii phu bnh khng phi l u nguyn bo men, u nguyn bo men kt hp vi u khc, u nguyn bo men ti pht. Thit k nghin cu: ct ngang, m t v phn tch. Thu thp d liu: (1) Ghi nhn cc ca xng hm v hc ming c chn on gii phu bnh. (2) Ghi nhn nhng d kin lm sng v cn lm sng, chn on v iu tr t cc h s bnh n. (3) c phim ton cnh kho st tn thng xng hm, do 2 Bc s c (ch s Kappa = 0,85). X l d liu: nhp v x l d liu bng phn mm SPSS 16.0. Phn tch s lin quan bng php kim Chi bnh phng, lin quan c ngha khi p < 0,05.
KT QU V BN LUN Lm sng
Trong nm 2007 v 2008 ti Bnh vin Rng Hm Mt Trung ng, c 783 ca tn thng hc ming c sinh thit v chn on xc nh bng gii phu bnh, trong s ny c 169 ca l u xng hm. Nh vy, t l u nguyn bo men trong tng s cc u xng hm (khng k nang) l 30,8%, v trong cc tn thng hc ming l 6,6%. Bng 1. U nguyn bo men phn b theo tui v gii tnh
Tu i Nam S % N S % T ng S % Gi tr p
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0,297
c im X-quang
1,9 % 23,1 % 75 %
U thng gp nht t 20 tui n 40 tui (46,2%) (bng 1). Tui trung bnh l 32,9 tui, nh nht l 11 tui, v ln nht l 66 tui. L do n khm thng gp nht l sng mt, chim 94,2%. Cc l do khc l au, lung lay rng, nh rng khng lnh. a s pht hin v iu tr di 1 nm (57,7%) v t 1 nm n 2 nm (32,7%). Tr hn, c 9,6% c chn on u sau 3 nm n 10 nm. Thi gian pht hin trung bnh l 14,4 thng (2 thng). Bng 2. V tr u nguyn bo men
V tr Hm trn C m Cnh ngang hm d i (vng rng sau) Cnh ngang v gc hm Gc hm v cnh ln Cnh ngang, gc hm v cnh ln N u rng hm d i T ng c ng S ca 5 2 3 32 7 2 1 52 T l % 9,6 3,8 5,9 61,5 13,5 3,8 1,9 100,0
Biu 1: Phn b cc dng u nguyn bo men Phn loi 52 ca u nguyn bo men da trn X-quang (biu 1) nh sau: Dng nhiu hc: 39 ca (75%), l dng ph bin nht. Dng mt hc: 12 ca (23,1%). Dng ngoi xng (nu rng): 1 ca (1,9%), khng hy xng. nh gi kch thc u trn phim ghi nhn 10 ca (19,2%) di 5 cm, 29 ca (55,8%) c kch thc t 5 cm n 10 cm, v 13 ca (25%) c u ln hn 10 cm. a s u biu hin hnh nh thu quang c ng vin cn quang un ln (76,9%). Tiu ngt chn rng kh ph bin (59,6%). Rng ngm gp trong 19 ca (36,5%), ch yu rng s 8 (94,7%).
Gi tr p
D ng Ngoi xng M th c Nhi u h c Kch th c < 5cm 5-10cm > 10cm Tiu ngt chn rng Khng
0,534 0 (0,0) 4 (33,3) 8 (66,7) 0 (0,0) 5 (20,8) 19 (79,2) 1 (6,2) 3 (18,8) 12 (75,0) 0,261 2 (16,7) 6 (50,0) 4 (33,3) 3 (12,5) 13 (54,2) 8 (33,3) 5 (31,2) 10 (62,5) 1 (6,3) 0,036 1 (8,3) 12 (50,0) 8 (50,0)
a s u xy ra hm di (90,4%) (bng 2) v c triu chng phng xng-bin dng mt (96,2%) (bng 3).
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Gi tr p Tu i < 20 20-40 > 40 Gi i tnh Nam N V tr u Hm trn Hm d i Th i gian pht hi n < 1 nm 1 nm Tri u ch ng Sng m t au T mi Rng lung lay Kch th c u < 5cm 5-10cm > 10cm Tiu ngt chn rng Rng ng m
0,534
D ng Ngoi xng M th c Nhi u h c Kch th c <5cm 5-10cm >10cm Tiu ngt chn rng Khng C Rng ng m Khng C
0,000 0 (0,0) 2 (40,0) 3 (60,0) 0 (0,0) 10 (21,7) 36 (78,3) 1 (100,0) 0 (0,0) 0 (0,0) 0,007 4 (80,0) 1 (20,0) 0 (0,0) 5 (100,0) 0 (0,0) 5 (100,0) 0 (0,0) 6 (13,0) 27 (58,7) 13 (28,3) 15 (32,6) 31 (67,4) 27 (58,7) 19 (41,3) 0 (0,0) 1 (100,0) 0 (0,0) 0,007 1 (100,0) 0 (0,0) 0,142 1 (100,0) 0 (0,0)
0,462 0,04
D ng Ngoi xng M th c Nhi u h c Gi tr P Kch th c < 5cm 5-10cm > 10cm Gi tr P Tiu ngt chn rng Khng C Gi tr P
Cc im X-quang ca u khng khc bit c ngha gia nam v n (p>0,05). Lin quan c ngha (p<0,05) c tm thy gia tui bnh nhn vi tiu ngt chn rng, rng ngm trong u (bng 4), gia v tr u vi dng u v kch thc u trn phim X-quang, vi tiu ngt chn rng (bng 5), gia triu chng rng lung lay vi s tiu ngt chn rng (bng 6). Rng ngm thng gp trong u dng mt hc hn u dng nhiu hc (p<0,05) (bng 7).
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ch yu vng rng sau. Nhn nh ny nht qun cc nghin cu(9). Nhiu tc gi ghi nhn xng hm di thng b nht (hn 80%)(3,4,6,10); v thng phn sau ca xng hm (6175%)(6,11,12), c th l vng rng sau hm di-gc hm(1,3,4) v thng lin quan cnh ln(11,12). U hm di ph bin dng nhiu hc (78,3%), thng ln hn 5cm (87%) v d gy tiu ngt chn rng (67,4%) hn u hm trn (p<0,05). U nguyn bo men ngoi vi (ngoi xng) khi pht trong m nu rng, him gp, chim khong 2-10% cc u nguyn bo men v c tui trung bnh l 52,1 tui(9,11). Nghin cu ny ch gp 1 ca (1,9%) nu rng vng rng sau hm di nhng khng hy xng hm, trn mt bnh nhn n 51 tui.
V tr u nguyn bo men
a s u xy ra xng hm di (90,4%), c bit cnh ngang vng rng sau, gc hm v cnh ln (84,7%). T l u hm trn l 9,6%, cng
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chng rt ph bin trong u nguyn bo men ngi tr. a s (71%) cc trng hp b tiu ngt chn rng c triu chng lm sng rng lung lay. y c th l l do bnh nhn i nh rng, cho nn nha s cn phi thn trng cnh gic chp phim pht hin u xng hm trc khi nh rng lung lay khng c nguyn nhn nhim trng r rng.
Rng ngm
T l rng ngm trong u l 36,5%. S lng rng ngm c th thay i nhng thng t 1 n 2 rng, hu ht l rng s 8. Rng ngm gp trong 66,7% cc u dng mt hc, nhng ch gp trong 28,2% cc u dng nhiu hc (p<0,05). Kt qu ny ph hp vi y vn v t l rng ngm trong u nguyn bo men dng mt hc (52-100%) cao hn dng nhiu hc (15-40%)(8). iu ny c th hiu do u nguyn bo men c th xut pht t nang thn rng(6,9). Nghin cu tm thy s lin quan c ngha gia tui bnh nhn vi s hin din rng ngm (p<0,05). T l rng ngm trong u l 75% nhm di 20 tui, gim cn 37,5% trong nhm 20-40 tui v ch gp 6,3% trong nhm trn 40 tui. C th do u xy ra sm nn nh hng n s mc rng, nht l nhng rng mc tr. Kt qu ny cng gi u nguyn bo men ngi tr c th lin quan vi mt nang thn rng trc .
Kch thc u Thc t, a s bnh nhn n khm v sng vng mt (94,2%), nhng khi u hy xng rt nhiu. 80,8% u ln hn 5 cm, mc d lnh tnh v thng c pht hin di 2 nm. Tiu ngt chn rng Tiu ngt chn rng l mt c im ph bin ca u nguyn bo men(12). Nghin cu ny ghi nhn t l 59,6%. S tiu ngt c th xy ra theo nhiu hng v nhiu dng khc nhau, nhng dng dao ct kh in hnh. Mt nghin cu trc y ghi nhn tiu ngt chn rng chim 81% trong 32 ca u nguyn bo men, 55% trong 20 ca nang thn rng, v 18% trong 33 ca nang nhim trng(12). Nh vy, s tiu ngt chn rng khng phi lun lun thy trong u nguyn bo men, nhng s xut hin ca n l mt gi c gi tr trong chn on, nht l khi c hnh nh dng dao ct. Tiu ngt chn rng xy ra n 91,7% ngi di 20 tui, nhng ch gp 50% ngi ln. C th do u xut hin sm, trong lc rng vnh vin mi to v ang mc, thm ch rng cha ng chp, nn tiu ngt chn rng l triu
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KT LUN
U nguyn bo men l loi u do rng thng gp Vit Nam. U ph bin ngi tr v xng hm di, thng gy phng xng v bin dng mt, biu hin hnh nh X-quang thu quang dng nhiu hc, c th dng mt hc. Thng c s lin quan gia mt s yu t lm sng nh tui, v tr u vi mt s c im Xquang nh dng u, kch thc u, tiu ngt chn rng, rng ngm trong u. S phi hp gia cc yu t lm sng v X-quang c nhiu thng tin c th gip chn on trc m chnh xc hn v quyt nh iu tr ng, nht l i vi u dng mt hc.
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