TNG TiT M HI BN TAY

(PALMAR HYPERHYDROSIS)

I CNG
Tng tit qu mc p ng sinh l ca c th Nguyn nhn - Th pht: tn thng TKTW (h i, tuyn yn) hay ngoi vi (m ri c); ni tit (cng gip, mn kinh, u ty thng thn); bnh mn tnh (lao, tiu ng, lymphoma) - Nguyn pht: cha r, cng giao cm, di truyn (25-50%)

I CNG (tt)
c im - Khp c th hoc khu tr (bn tay, bn chn) - i xng - Tng t (cn tng tit), t ngt - Yu t kch thch: thi tit, tm l, TK... - CLS: bnh thng Khng gy hi v sc khe Vng lun qun tm l XH hiu qu ngh nghip

SINH L BI TiT M HI

Phn ng

Phn cun

Si giao cm cholinergic

SINH L BI TiT M HI (tt)

Bt: phn cun MH s khai (in gii huyt tng, khng protein) ti hp thu phn ng MH: Na+ 5mEq/l; ure v K+ m c. Tng tit Na+ 60mEq/l tit aldosterol ti hp thu mui. TTMH: ko di khng mt Na+ Kch thch bi tit m hi: - Kch thch giao cm: si giao cm cholinergic - Ngoi ra: epinerphrin v norepi. (thng thn) TKTV: nhy vi kch thch, d t hot ng ti a (10 ln) hn TK gai sng (100 ln)

Xung ng TK theo si trc, lan truyn n synap

SYNAP

V myelin bo v si trc v cho php dn truyn tn hiu in

Cht trung gian dn truyn TK

Tin synap

Kch hot th th hu synap (neuron TK tip theo hoc tb ch)

Tn hiu in c dn truyn theo si trc

Thn tb TK khi ng kh cc mng t bo v gi tn hiu in

CHT TRUNG GIAN THN KINH

Norepinephrin: neuron hu hch GC; tr tuyn MH, c dng lng, mt s MM Acetylcholin: - Neuron tin hch GC v GC - Hch GC v GC - Neuron hu hch GC - Neuron hu hch giao cm n tuyn MH... c ch cholinergic tit MH v nhiu tc ng khc

TRNG LC GC v GC
Trng lc GC v GC: hot ng lin tc mc cn bng ca h GC v GC Trng lc GC: gip MM co nh Dmax Hot ng ca h tim mch chu nh hng ch yu ca epi v norepi t thng thn hn h GC hy GC n tim mch, h tim mch vn hng trn mc trung bnh Hy GC hay i GC tng c kh nng ti lp cn bng sau 1 thi gian (ct GC n tim ch 160l/p sau 6 thng, 120l/p)

NHY CM SAU HY GC hay GC

gii phng cht trung gian TK t tin synap tng s th th hu synap t bo hiu ng (thi gian di) phn ng ca c quan ch vi cht trung gian TK ngoi sinh Sau ct GC ngc phng thch acetylcholin neuron hu hch n tuyn MH s th th acetylcholin tuyn MH tit MH ma, xy ra ngy 3-5 sau PT.

GiI PHU H GIAO CM

Trung khu ty GC: 1 nhn di sng bn cht xm, t on ty C8 TL1-2 Cung phn x GC: 4 neuron (gai sng: 3 neuron) - Hng tm: n sng sau ty (TK gai sng) - Trung gian, sng sau sng trc - Ly tm, 2 neuron (TK gai sng 1 neuron) N tin hch: sng trc hch ngoi vi N hu hch: hch ngoi vi c quan ch 1 N tin hch to synap vi nhiu N hu hch m rng, khuch i tn hiu d t hiu qu hot ng ti a

Cung phn x gai sng: 3 neuron

Xung ng hng ln n v no nhn cm cm gic au

Cht trng Cht xm

Sng sau tu sng

Hch r TK

Thn tb neuron cm gic Neuron cm gic

Th th cgic (da)

Knh trung tm

Neuron trung gian

Neuron vn ng Sng trc tu sng Thn tb neuron Vn ng Hiu ng ch (c)

Cung phn x giao cm: 4 neuron

GiI PHU H GIAO CM (tt)

Hch GC ngoi vi: cnh sng, trc sng, trc tng, ni thnh Hch cnh sng: xp 2 hng, 2 bn CS, ni nhau bi nhnh gian hch chui GC t nn s - xng ct, 4 on: c, ngc, TL, cng ct Nhnh gian hch gm si tin v hu hch (ly tm) v cm gic tng (hng tm) Nhnh thng ni trng: ch c on trung khu ty GC, si trc neuron tin hch, c myelin r trc TK gian sn tn cng hch cnh sng

GiI PHU H GIAO CM (tt)

Nhnh thng ni xm: si trc neuron hu hch, khng myelin, rt ngn, kt ni vi TK gai sng tn cng c quan ch (tuyn, c trn...) Mt thng: khng phn bit c xm-trng Nhnh tng, nhnh MM: nhnh hu hch cnh sng, trc sng Mt s nhnh khng to synap hch cnh sng hay trc sng m to synap hch trc tng hay hi thnh

GP CHUI GC NGC
C nh bi mc ni ngc v l phi thnh Hch sao (ln nht, kt hp hch c di N1, ngay trc u XS1) + 10-12 hch Quai GC di n Vieussens (nhnh gian hch trn ca hch sao) Cc si tin hch t trung khu ty GC u, c u phi qua hch sao

 Tn thng hch sao Claude Bernard Horner: - Sp mi - Co ng t - Mt lm - Kh mt - Gim tit MH - da (gin mch) na mt v chi trn tng ng

GP CHUI GC NGC QUA NS

XS u tin thy c qua NS: XS s 2

iU TR
Ni khoa: - Tc nhn gy kh da ti ch: aluminum chloride hexahydrate + cn. Bt tin, hiu qu ch vi gi - Anticholinergic: nhiu td ph (kh mi, mt, b tiu...), tgian td ngn (bn hy nhanh) - Tm l liu php: tr tm l - Ion ho (iontophoresis): tr bn tay, bn chn. Ngm vo dung dch in gii, dng in cng thp gy sc cc tuyn m hi. Lm nhiu ln trong tun, ngh 1 2 tun lp li. Km hiu qu, t tin, nguy c bng, git in, d ng da (nga, ni ban , bng nc) - X vng nch: so co rt da

iU TR (tt)
Th thut: - Chch botulinum: ngn chn phng thch acetylcholin tin synap. Kh tay 6 8 thng. Rt au khi tim, yu lit c vn, hqu tm thi (tim 2 3 ln/nm) v dn (khng th), t tin - Hy giao cm ngc qua da: di s hng dn ca CT, C-arm). Dng phenol, ethanol 95 96%, nc mui sinh l un si hoc sng cao tn. V tr tim kh chnh xc, khng bit trc mc ph hy BC cao, hiu qu khng chc chn

iU TR (tt)
Phu thut: - PT m: cch tip cn phc tp, tn ph m nhiu, TBBC cao lm 1 bn, hin t dng. ng m trn xng n, ng nch, ng sau - PTNS: cch tip cn v x l tn thng n gin * M NKPQ, NKQ + bm hi * T th na nm na ngi * Cch thc: ct b 1 on (sympathectomy) ct t ngang (sympathicotomy) kp clip * Mc can thip: ct 2 3 4 * Phng tin: dao, t in, laser, harmonic... t 2 mc tiu: hiu qu tr + hn ch tng tit b tr t TBBC

KT QU
Hiu qu tr: 92-95% ht tng tit MHT 60-70% ht tng tit nch

TBBC: - oxy mu: 5-15%, tm thi, do ngng thng kh - TMMP: 0-2%, t b mch gian sn - TKMP: 0-5%, do thng phi (dnh phi) - Trn nh trp MP: ng ngc, him gp - Xp phi: 1%, TKMP, TDMP, tc PQ, cha n - TK di da: 3%, t khi - au, d cm: 5-15%, lng, mt trong cnh tay - Horner: 0-4%, sc nng, li ko (hch sao)

KT QU (tt)
Hu qu khng mong mun: - tit MH phn hi (ma): 10-40%, HP 3-5, 24 gi - Kh tay qu mc - tit MH b tr: quan im rt khc bit * 3-98%, trung bnh 60% * Thng bng-i-khoeo-gy * T khi theo tgian vnh vin * a s chp nhn, c khi bt mn * Cha c cch tr hiu qu * Cha c cch hn ch, ngn nga

TM LI
Khng gy hi n sc khe Mc tiu tr: i tay kh ro Phu thut: phng php ti u, c hiu qu lu di L 1 cuc m (khng phi tiu phu): TBBC Ch c hiu qu tr bn tay + nch, khng h qu chn Nguy c tit MH b tr