Tehran University Medical Journal
مجله دانشکده پزشکی، دانشگاه علوم پزشکی تهران
Tehran Univ Med J
Medical Sciences
http://tumj.tums.ac.ir
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1683-1764
1735-7322
10.18869/acadpub.tumj
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jalali
1390
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gregorian
2011
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69
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online
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fulltext
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آترزی کوآن: تجربه 13 ساله و بررسی متون: گزارش کوتاه
The choanal atresia: 13- year experience and a review of the literature: brief report
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<p style="text-align: justify text-indent: 7.95pt direction: rtl unicode-bidi: embed" class="MsoNormal"><span style="font-size: 10pt">آترزی کوآن </span><span style="font-size: 10pt">(Choanal atresia)</span><span style="font-size: 10pt"> <span lang="FA">که ابتدا توسط دکتر </span></span><span style="font-size: 10pt">Roeder</span><span style="font-size: 10pt"> در سال 1755 معرفی شد، باریک شدن یا انسداد
دهانه خلفی حفره بینی است. این بیماری میتواند مادرزادی یا اکتسابی رخ دهد. اغلب
مبتلایان به این بیماری مونث هستند. موارد مادرزادی ممکن است ایزوله بوده یا همراه
با ناهنجاریهای دیگری نظیر همراهی سندرم </span><span style="font-size: 10pt">CHARGE</span><span style="font-size: 10pt"> باشند که این موارد حدود 50-20% از موارد مادرزادی را تشکیل میدهند. آترزی کوان
میتواند یکطرفه یا دوطرفه باشد؛ با وجود اینکه موارد دوطرفه جدیتر بوده و
نیازمند درمان اورژانس هستند، موارد یکطرفه شایعتر بوده و اکثرا سمت راست را
درگیر مینمایند. آترزی کوان میتواند منشا استخوانی، غشایی یا مختلط داشته باشد.
در حال حاضر درمان قطعی آترزی کوان، درمان جراحی است. در حال حاضر، سه روش جراحی
ترانس پالاتال، ترانس سپتال و ترانس نازال (بهوسیله آندوسکوپ) ارجح هستند. در این
پژوهش پرونده تمامی بیمارانی که از سال 1376 تا سال 1388 به بیمارستان امیراعلم
مراجعه نمودهاند مطالعه شد. با جستجو در بخش بایگانی بیمارستان امیراعلم 54 بیمار
مورد آترزی کوان که در این بیمارستان تحت عمل جراحی قرار گرفتند یافت شد. سن این
بیماران از دو تا 29 سال متغیر و میانگین و میانه سن بیماران بهترتیب 4/12 و 12
سال بود. نسبت دختر به پسر دو به یک بوده و نسبت موارد یکطرفه به دوطرفه 1 :9/1 محاسبه
شد. از بین موارد یکطرفه 19 مورد سمت راست بودند. 40 مورد مختلط، 13 مورد استخوانی
بودند و یک مورد نیز غشایی مشاهده شد. پنج بیمار از طریق ترانس پالاتال و بقیه
موارد تحت روش آندوسکوپیک بدون استنت جراحی شدند. 80% موارد با علایمی از انسداد
بینی مراجعه کرده که در بین آنها 18% موارد دوطرفه و با سیانوز همراه بوده است و 64%
موارد نیز رینوره داشتند. میانگین بیماران ما 4/12 سال محاسبه شد که نسبت به
مطالعات دیگر کمی بالاتر است و این مسئله میتواند ناشی از مراجعه دیرهنگام و عدم
آگاهی بیماران از علایم و کمبود مراکز بهداشتی در سطح کشور باشد. روش ترانس
پالاتال بیشترین روش مورد استفاده تا اواخر دهه 80 بوده است. این روش بهعلت
توانایی ایجاد ورودی ابتدایی بزرگتر دسترسی مناسبتری را فراهم میکند. اما در دو
دهه اخیر روش ترانس نازال ارجح بوده است. در این روش با استفاده از آندوسکوپ میتوان
مکان دقیق رزکسیون را تعیین و امنیت جراحی را افزایش داد. استفاده از استنت در
جراحی آترزی کوان هنوز مورد بحث است. بعضی نویسندگان عقیده دارند استنت مانع تنگی
مجدد میشود در حالیکه بعضی دیگر به افزایش ریسک عفونت و اسکار با استفاده از استنت
معتقدند. با توجه به موارد ذکر شده بررسیهای بیشتر در زمینه آترزی کوان، بهترین
روشهای جراحی و تکنیکهایی جهت تشخیص زودرس آن ضروری بهنظر میرسد.</span></p>
<p style="text-align: justify">Choanal atresia was first described by Roeder in 1755.1 Choanal atresia is the narrowing or obstruction of the posterior nasal fossa. This anomaly could be congenital or acquired. Most patients are female.2 Choanal atresia might be isolated or associated with other anomalies like CHARGE syndrome and 20-50% of congenital cases have this company.3 Choanal atresia could be unilateral or bilateral while bilateral cases are emergent surgical conditions, unilateral cases are more frequent and mostly right-sided. Choanal atresia may be osseous, membranous or mixed.2 The definite treatment for choanal atresia is surgery and transpalatal, transseptal and transnasal (with endoscope) are the three preferable approaches.3 The medical records of fifty-four patients diagnosed with choanal atresia and admitted in Amiralam university hospital during the years 1998 to 2010 were evaluated. The patients were 2 to 29 years old with a mean and median age of 12.4 and 12, respectively. Female to male ratio was 2:1 and unilateral to bilateral involvement ratio was 1.9:1. Among unilateral cases, 19 cases had right-sided involvement. Forty cases had mixed, 13 had osseous, and one of them had membranous choanal atresia. Five patients had undergone transplatal surgery and the rest had their choanal atresia repaired by endoscopic approach. 80% of the cases had revisited for symptoms of nasal obstruction among which 18% had bilateral obstruction and presented with cyanosis and 64% had rhinorrhea. In comparison to similar studies, our patients had a higher mean age. This could be due to late referral, the patients' unfamiliarity with the symptoms and inadequacy of specialized treatment centers. Transpalatal approach was the most common surgical approach till late 80s as it provided better access due to the provision of a wider opening. Providing direct access to the surgical field and causing the least trauma to the site, endoscopic approach has been the most preferable option during the last two decades. In this approach, the exact site of resection can be determined and surgical safety will be increased.4 Use of stents in the surgery of choanal atresia is still controversial. Some authors believe in the prevention of recurrence with stents while some think about higher probability of infection and scar.5 Regarding the mentioned issues above, more research is needed to find the best surgical approaches and techniques for the early detection and treatment of choanal atresia.</p>
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http://tumj.tums.ac.ir/browse.php?a_code=A-10-25-217&slc_lang=fa&sid=1
Naraghi
M
محسن
نراقی