GS.BS.

MIRCEAIFRIM

vrtN sl VI.¢N HAN LAM Y KHOA RUMANI

? ~ "

ATLAS GIAI PHAU NGUOI

Phii'n npi t~ng

NgUiJi djch: BS. Nguyen Kim Loc

... ",I' ?

NHAXUAT BANY HQC

HA N(n - 2004

Mircea Ifrim

Member of the Medical Science Academy

Human Anatomy Atlas

Viscera

Coordina itor:

Mircea Ifrim

Colaborators:

Chen Feng Ifrirn, Adrian Maghiar, Traian Maghiar,

I Acad. Gh. Niculescu I

Reviewers:

Prof. Dr. Cezar Niculescu, Prof. Dr. Dumilru Dragoi, Prof. Dr. Mocanu Gh. Illustrations by E. Palrascuta

Translation into English - L.M.Roller

Ifrim, Mircea

Human Anatomy Atlas/Mircea Ifrim - Arad: Servo - Sal, 1999. 3 vol.; i l.; 34cm.

ISBN 973 - 9442-03-X

VoLlI - 199-9 - 272 p. Bibliogr. - ISBN 973-9442-04-8 611 (081)

ldi tua

Cuon Atlas giai phau nguoi rna cac ban dang earn tren tay c6 n9i dung M C?P chu yeu t6i cac tarig (co quan). Tac phfim dude xuat ban bang tieng Anh va la cong trinh ddu tien th uoc th~ loai nay cua nganh CUi phau hoc Rumani.

"Atlas gili phau ngudi" truce het Ia su ke thua va phat tri~n tli tudng cua nha glai ph au hQC vi dai Francisc Josef Rainer, cha de cua nganh Giai phau h9C Rumani. Ngn tang b.i tu6ng khoa h9C cua Rainer bat nguon tit each nhin nhan cau true theo chuc nang: moi diu true giai phau deu duoc nghien cuu va giai thich dua trElTI co sd chuc nang cua chung.

Ben ca nh do, "Atlas gLli phau nguoi" can dong thoi th~ hien mot quan niem co ban khac cua y h9C hien dai, D6 chfnh la quan niern Him sang.ICu6n sach khong di vao mo ta cac cau true giai phau vai nhiing chi bet ruom ra vo b6. Nguoc Iai, no t?P trung trinh bay cac cau tr-ue Day trong moi tucng quan vdi y nghia lam sang cua chung thea phuong phap di nh khu, nharn phat huy tdi mac t6i da tmh hiru dung ciia giai phau hoc d6i voi thuc hanh y hoc,

Vdi noi dung kien thirc sau rong va hinh anh m inh hO{1 lam sang phong phil, cu6n sach nay thuc sl.;i da vuct qua khuon kh6 cua mot cuon Atlas giiH phiiu hoc thong thirong.

Thanh cong cua cuon sach b~t nguon til s\1 ket hop giita quan niem dinh khu lam sang vdi nhimg ky thuat nghien cuu mdi nhat ve cau true hinh thai (chup dt 16p vi tinh, ghi hlnh cong hudng til, chup nhap nhay quet ldp, nQi soi). SJ.,t ket hop fly phari anh qua trinh vua ke thua nhirng gia tri khoa hoo truyen th5ng duoc thie't l?p bai Francisc Josef Rainer, vua khong ngung tiep can nhung kha m pha mdi nhat cua y hoc hien dai,

Vdi mot phuong phap tiep can hoan toan mdi, thoat him khoi 16i me t3. chi tie't ru'dm ra d~ chi' tap trung vao nhirng khai niern co ban nhat, co y nghia lam sang quan trong, cuon "Atlas giai phau nguoi" da dat toi mot su thong tnoang hie'm tha'y trong mot linh vue von rat cu thg la giai p hau h9C. Cu5n sach chuyen khao nay, vi the, IS. su phan ~nh xung dang cua mot nganh khoa hoc giai phau nien dai, tuong xung vdi nhirng doi hoi cua ki nguyen moi dang bit dau.

Tac gil cua cufin "Atlas gi3i phau nguoi" la mQt nha gi3.j phau hoc co uy tin, vdi tai nang va nhitng cong hien da duoc biet den tren toan the gidi, va hien dang giil cac chuc vu Chu tich cua A.B.I - Uy ban Nghien cuu Hoa Ky, T6ng Giarn d5c cua Vien Ti~u su The gidi 6 Cambridge v .. v .. Cong trinh nay cu a ong duoc danh gia la ill(lt dong gop c6 gia tri cua nga nh Giai phau hoc Rumani cho giai phau hoc toan the gidi, N6 cung dbng thai 18. su ke't tinh cua qua trinh ke thua c6 phat huy nhung gin tri khoa h9C va t inh than cua GS Rainer, mOt nguci luon h uong cuoc dCii minh thea theo cau cham ng6n: " Ngu'i'Ji thay vi dai la nguoi t hay dao tao nen nhung the' h(i hoc tro xuat siic hon chinh ban than minh",

VI~N S1 GS. BS. NICOLAE CAJAL Chrl tjch Vifn Him lam Y khoa Rumani

3

Ldi n6idau

Cuori sach Atlas giai phau hoc, xuat ban bang tie-ng Anh La m{lt tal lieu e6 noi dung vuot qua k h uon kh6 cua giai p hau h9C kinh d1~n. Mot mat, chung toi nhan manh tai nhung chi t iet giai p hau co tum quan trong lam sang, va mat khac chung tui t ri nh bay nhung ung dung noi-rigoai khoa co ban dua trcri nhung hieu biet sau sac v& diu true giai phau,

GiAi. phfl. u cua cd th~ song co mi)t val tro quan trong, khdi d&u bdi quan n iern ella Ciao Sll Francisc Rainer eho r:lng: "Giai phau hoc 13. mot khoa hoc cua co thS song". Cling trong hoi canh nay rna giai phau hoc X quang, sang Iap bdi Eugen Flavu, mot cuu sinh vien xuat ,,:ftc t.ruoc dllY ella Giao su Francisc Rainer, aa chiern duoc vi trf uu the.

Do do. sach Atlas nay se co fch doi vdi sinh vien ella die tr uong dai h9C y khoa, va ca. doi voi nhfrng bite sy a cac ngan h chuyen khoa khac nua. Vdi cudn sach nay, ho co sYm m{lt tai li¢l.l ho an hao ve giai phau hoc Lam sang rat huu ieh trong thuc hanh hang n gay.

1'6i mong dog, trong boi canh nhu v~y, duoc bay to long b iet on cua toi doi vdi nhung nguoi th{iy vi dai da dao tao tui trong rihieu narn: Vien sl Stefan Milcu, Vien si 1. Ffigrfisanu, Vl~n 81 Theodor Rurghelc, GS, TS. V.Papilian, GS. TS. Th. Riga, GS. TS. F. Craciun, Vien si B. Menkes, GS.TS. Z.lagnov, GS. TS. RRobaeki, GS. TS. 1. Chiricula ,

Dong thoi, t6i xin cam en rat nhieu Vien S1 N. Cajal va Vien S1 V.Voiculeseu vi 81:1 qu an tam n6ng nhiet vi s1)' giup dB than thiet cua cac Vi~n Sl trong toan b9 qua trinh nghe ngh iep cua toi.

T6i mong mufin ducc bay to long biet en tdi nhimg d6ng nghiep cua t61 Iii. cac GS. TS.

Cezar Nieuleseu, GS. TS. Dumitru Dragci vi GS. TS. Gheorghe Mocanu, vi aft giup da t6i co hieu qua d~ hoan thanh cuon sach Atlas nay.

Cub'j cung nhung khong he kern phan 18n lao, toi xin bay to long kinh trorig sau s~c nhat t(ji Vien sl Gheorghe Niculeseu, rna tui e6 han hanh dliQc cqng tac gin gui va suot ddi Vien S1 aa giimh eho toi tinh ban chan thanh.

GS.BS.MIRCEAIFRIM

Vi~n si Vi¢n Han lam Y khoa

5

LiJi iua 3

[.di noi d6u '" 5

Chtidng 1. Diiu va cS 9

l'dJ diiu 11

Vung mui 12

C{,C h6c mui 15

Nhirng xoang canh mui 21

Hoc mieng 23

'I'ien dmh h6c mieng 24

liac mieng chinh thuc 25

Nhimg vung nong cua hOC rnieng va cua mat 28

Nen (san) hoc miang 31

] .irdi va vung htBi 32

H$ thong tuyen nuoc bot cua hoe mi$ng " 38

Vorn mieng " " 41

Cfic thanh phan phu thuoc cua hOC mieng " 49

Vung hAu 55

Hau (Hong) 55

Vung duoi ham va vung mang tai " " 65

Vung dUdi ham " 65

Vung mang tai 66

Vung thanh quan 67

Thanh quan 67

Vung tuyen giap . khi quan· thuc quan 81

Tuyen giap 81

Khi quan doan c6 87

ThJ.,1C quan dean c6 89

Chuong 2: Ngu'c 91

Thanh nguc 93

Vung vu (vung tuyen vu) 95

Khoang nguc 97

Mang ph6i 97

Phe quan g6c 101

Ph6i 103

Cily phe' quan 108

Trung that 116

Trung that trudc 116

Vung tim-mung ngoai tim 127

Trung that sau 146

Chu'dng 3. Bung .. ~ 155

Mb dAu 157

Gidi han va cac thanh cua bung 157

6 bung 162

7

Phuc mac (Mang bung) 162

T{ing treo ket mac trang ngang 179

Vung da day ; 179

Vung tit trang-tuy tang 189

Vung gan 196

Vung lach 216

T:'ing d lioi mac treo ket trang ngang 218

Hong trang va h6i trang (Hong-h6i trang) 219

Dai trang (Ruot gift) 226

Khoang sau phuc mac 214

Cac tuyen tlurong than 247

Than 2,18

Nieu quan 262

Cac mach mau 6 khoang sau phuc mac 265

H~ thong bach huyet sau phuc n1<~C cua 6 bung 267

Chuoi than kinh giao cam that lung 269

Darn r6i tang (Dam rOI dunng) 270

Chuoug d. Ch::ji.u hong 273

1\.10 c.t:iu 275

Phuc 1l1(lC chau hong 276

]:;:'ll'lg quang 282

Cite co quan sinh dye trong ella nam gidi 285

Tinh hoan 287

Mao t.inh 288

Ong tinh 290

Gng phong tinh 291

Tuye'n tieo liet 292

Cac hong tinh (Cac tuyen bong) 295

Nieu dao nam gi.Gi 295

Cite co quan sinh due trong cua nil gioi 299

Vung am dao 299

Vung tii cung ~04

Vung voi ti't cung-buong trung 312

Nieu dao nil gioi 319

Day chau ~21

Cae bQ phan sinh due ngoai cua nu gidi 332

Cac br) pharr sinh due ngoai cua nam gidi 335

Clnrong 5. MQt so ung dung lam sang n9i-ngo~i khoa 341

1-"19t 80 ung dung noi-ngoai khoa 343

Chirong 6. Nhirng khai niem vii giai ph.1u in vivo va nQi soi 363

Nhimg khai niem v& giai phau in vivo va 09i soi 365

Kham lam sang cac tang trong khoang than 365

Hinh chieu die tang trong 6 nguo lim thanh ngiro 365

Hinh chicu cac tang trong 6 bung len thanh bung 372

Kharn cac tang trong khoang than b~ng dung cu 382

Tai li~u tham khao chon IQc 399

8

Ddu va c{/

Ma d,au

Phon 1;.1'0[1 ci'1,n thur, nglidi bao gO'lll hai thanh phfin: cldu 1<:ephahH:~um) va cti' (('cn'i;1" 1 , glOl han phan each giua hai [)h~n nit)' la m¢t du~ng vong. b:lt dau till:! c:hdm. I'l{;oa.i (iniou>, dtS[Jng oilY keo dbi saug hai ben doe theo du'Cl'ng I!h.im tren, tdi mom C'hiim, C'h~j' vblig qua mom nay Wi phra duoi ong tai ngoai. r3i t!9i bo sau ~ua nganh l.jn ~ntong ham dual thl d6i hllang di tiEIP xuiln g dudi doc b~) nil}' cl~ tal goc xlilfl'!/l ham riWI! i.g!wirJr!), [,&i Lien ra phis trudc doc rhoo bi:l dudi cua :'::1,.rOl:lg m'iy [Ill u. cam tgnaUtion). il clay ch.tUllg giai han a hai b~n !:!{llJ p,lm l.I khep kin ~'Gtlg giOi han gilts dli.u vil CD-

XIronI) cu6'n mili glfra [ru<:i'1[J ~OOIft !JlO'a)

c ua can x U:Clng ((c, 0 cl§.y d:.tCllll!1 nil y t rimg v6i gioJ,i han du(Ji ella no' tinh mach duh.

N h C'rn g en quan tao nen p h~ n d~,u "u.a ''b(lo m~; thu nMn (Jfic cha'l~1 (Rainer) tire Ia. phan tren cung CUJ! M tiE!m hoa va h6 ha'p, dl1Qc S9i tell kMng th~t chinh x-ii.t· 1iJ cite "tt;lng" (hcac "Cd quan") I. J\rhunj{ nha giai pIlAu c6 gqi cite thsmh phan cua h. th6ng tiEiou hoa va hO hltp nAm d trong long n~nte va t~ l:n;mg la "'t:;mg", "j nhtn tha'y ehung cCa viii! bong mu~t (nhay nbnt), im u'dt, ,.it. ['Jam crotlg mOt 6 chanh rnac (fi mll ng ph5'i hO~i: ph € m ~:II; I (~ ttl an g ngoa i t.i t11 hose n.go~ i tam Il'I~C. 6 m,ang b\lng hO$C phuc mac), m~ til d6 chung cO th~ d~ dilng dun ra ])~oaj uaQc

XUUfloj coon mlli tren Dung (Jl.lftJ1lg ~(lan ~ curg) Xlrof1!] cutin mJi tnm ~XJJOt'Ig I<OOn !riml Xoartg birom

Rllinh mOJ sau N~p VOl-khofu cai L'o "aU cila ~Ol tal (\fQi nh~

H;,t!'lh nna n half fVA)

Ngad-i h~u

GO' \101 tai (\llJi llhil Cung tI6t cr~1

XLltfng ,utln mu I d!Mi (XUUJII~ x(l~n ova)

KhAu cal :i'..lK1n9 li\n~u ~I cU'I'Ig)

Man JoIhtUJ cai ---=----.:..:.:::::._~n~~~:!!!!"~¢1! [khifu cal mi:m) -----~,.~IJ;.~~

r~n (linh mil,ffig ----UK:.i.

Trv trarrc mlln kh~1J cat (cung !maw cilj.lll~) ------~

Han~ nMn (amklal'l)

kh~u cal. .

Tru seu man khi3u ctli

(ClJng khau cai-i'>.au}

n~n (1100 mi~l1~

Hong~~ng Hau, Illa'I"Jh sail (ltl<i. mh g«lJ hr;mgll Sun 1tial1!1lhi~t .

lnAp thanh mon) Klloa""ig thanh Qu!in

Co Ulm· U'OI (',,0 c.:tm-rnon 9 / Ngf1ch INln i'anl'l nMn

Hinh 1: Thiet do dUing dqc: gi'lla d'u va c6

Duong gi,.ui han d'ljCli CUl vllng eG, pMn each c6' va n1'Nc. lit. mQt du(jng b~t u:h.ltlr dinh mom gal cUw do't song l:a' thL't 7, keo dai sang hm ben. tell mOm cung cac xU'dng vai, roi dO] hl.idng di ra tnroc va vae trong; doc theo b?J tntoc cua hai xlfClng don> tili b(s trcn

• "Ti\'rogI d[cn Iii danrl philp ~ ~ n~ Lalin ·~I~c.mf, ~O n'llI'iTOI e nlJl'Ig I ~ eac b~ ph ~11 ho~c Ci:I quan t{onQ c.O!hEi: Q ~:l' ~"G 'ill ~ lrinh b~ ~ ngu6n ~1ic ~O a tUl' "WI5~!Ual' XIoIi!Ii' ~ hj~ tu" ~flh n-gi1 cO nghTll ,~, nh!ln. !:Ibn ~, tren, lim, mOl ~ii" ~,4 ~t>; nhkin .. i>b ph~ n, cd qUllJ1 Mm Uol'l-;! jon D n D '.f~ vii ~ bl,mg .. tid Ihall h mae bat! ~, ,,~m Qr:. ~ nhtlng crill; chlh Illn, T,,~ nh[~A. n~./ly nay ngh~ cUlllir I'\~y dll9C mh.r~nQ (I~ chi cB rlllll~u I:l~ p~n, CC! qLN!1'I kM-c !l;h6ng 0: iwng lang nglfc va & b"I11i!. nilit mOi. rni~n9, tHlu; eli utlll ~cn III "viscera" &al'le 'ti~ng \I~t 13 ''\!"!f lio~c "M quart",

11

(goi lD. dua phu t.ang ra ngoai) chi qua mdt dUdng rach ddn gian, du sau d§ lam thung toa n b(i chieu day cua cae thanh gidi han cac 6 n6i tren, Thuat ngli "tang" ducc dung d~ chI cac b(i phan eua h~ thong tieu hoa va h6 hap a phan tren cua than th€ (d§.u va e6) la khong chtnh X{lC, vi chiing kh6ng narn 6 trong mQt 6 thanh mac, do d6 chung kh6ng ducc bao boc bdi mot mung thanh mac b6ng m uot va :lm, tuy nhicn cac "tang" nay nam ('j nhimg vi trf. rna d~ toi duoc chung thi p h ai p hau tieh, cAt cliung ra khoi vung co th4 chua chung,

Cac "tang" J phan tren cua than nguci nay deu narn 6 pnan giib (vung true dung d9C giua cua than nguoi), ca trong hai phan cua phan tren than ngudi, tuc la 6 d<iu V3. 6 vu ng truoe cua e6, nhung vung nay se mang ten cua ph an t.uong ung.

Nhu the', d dau, ngay giua mat, co vung nuii, tao neri bdi mdt xucng ben ngoai va hai hoc rnui a trong sau, phia duoi vung hoc m ui 13. vung mieng vdi cac moi tri'm va duoi. va oung cdm. (h inh 1).

d vu ng truce cua c6 lien tiep c6 cac oung dudi cdm, uung xlidng mong, vung iUY{;JL gidp va tnuig SI,W nhdn (toan bQ cac vu.ng nay hop t.han n vu ng thanh quan), roi t.{jj vung khi qua n, na m trong he sau cua hiS' t.irih mach canh, keo dai tdi t~n khuyet trnh mach ctinli (incisurajugularis) (xem t~p 1),

Gi6i han hai ben cua cac tang (co quan) thuoc duong ticu hoa-ho hap, d trong vung co truce 13. hai ducng th£ng dung, thea quy ude, vach tit cac khop uc-don tdi bCl duoi ella xuong ham d udi.

Tuy nhien, dean dau cua h~ thong tieu hoa con e6 cac cd quan doi (co hai co quan doi xung), do do chung phai nfl.m d hai ben cua dlidng gura, D6 la nhtrng doi tuyen nuoc bot ldn: doi tuyen dudi ham va doi tuyen rnang tai, nhfmg tuyen nay mang ten cua cac vung tuong -(jng. Cae tuyen dlioi ham n,\m d phfa duai xlidng ham dUdi, 6 hai ben cua vung duo) dim, con cae tuycn mang tai thi nAm d phia duoi o'ng tai ngoai, giua cd ue~don-chum va b2:J sau eua 'nganh lcn xu'dng ham duoi. Giua vung mang tai

12

va vung mieng la vung co d.n, 6 lop nong ciia vung nay co mflu nho ra trudc (rnau truce) cua tuyen nude bot mang tai cung v8i ong bai xuat ciia tuyen goi 13. 6ng Stenon (doc thea tieng Vi~t la xte-nong).

Vung mUi (Regio nasalis)

Vung mui c6 nhurig gidi han sau day: phia tren IS. mbt duong thing narn ngang di qua die'm goc miii (nasion) Os. di~m g?P nhau giua duorig khop mui-tran va mat ph~ng dung doc giua); ben duCri la mot duong thang nAm ngang di qua die"m dlioi miii (la dinh cua gee hop bdi bd dudi cua vach mui vdi moi t ren); a hai ben la hai ranhLiep n6i nhau: riinh. miii-nui va riinh. miii-mi mat,

Vung mui e6 hinh tht; nhu m9t hinh thap vdi ba mat ben va rn(it day (gQi 18. tluip miii), Canh truce, We la song miii (dorsum nasi), di til' goc rnui, We 1:\ die'm g6c miii (nasion) tdi dau mui eon g91 13. tlinh. miii, Song mui nam a giil'a hai mat truce-ben cua thap mui; hal mat nay trai cheoh sang hai ben tOi cac ranh mui-rna va mui-rnf mat, hai ranh nay l ai ehfnh Iii ha i canh ben cua thap miii, Mat ben thu ba cua thap mfii Ia mat sau, d sau, va hen tiep voi cac hoe mui. Day ella thap m iii chinh la hai lo miii (nares), ngan each vdi nhau bdi bd duoi cua vach mui.

Mill e6 be mat ben ngoai phu bai da, va be m(it ben trong phu bdi da-niern mac lien tiep voi niern mac h6 hap ella cac hoe mui. Nam trong bi'! day, giua hai be m:}t ben ngai va ben trong nay 13. cac lop khfic eua vung mlii:

lOp rno lien ket-md dliO} da lop cd va

khung xuOng-sl,m.

Mui nh6 ra trui.k so vai m(tt, c6 hinh thi'i va kieh thudc rat thay drSi. Phan duoi

cua cac mat trudcben cua mui di d9ng duoc, tao thanh canli miii (alae nasi). Tu dinh. miii di ra phia sau c6 mot nep da, Vach mui va nhung bo tu do cua cac canh rmii gioi han hai 16 miii (nares), phan i'J ben ngoai nhat cua 16 miii goi Ii nhirng die'm canh. miii.

Chieu cao cua mui duoc tfrih tit diim goc miii (nasion) toi die'~ dzt{Ji miii ; va chieu r9ng cua mui la khoang each giua hai ddm ctinh. maio Ty so gitra chieu eao va chieu rong ella miii goi la chi so~ mui, Phan bo cua chi so miri tren toan cau mang tfnh chat thfch nghi va thea luat Thomson Buxton thi chi s6 nay tang len tu cac vung lanh toi cac vung am (hinh 1-6).

Cau true: d phan tren cua mui, lop da mong va de di d9ng, nhirng i'J phari dudi mui, da trd nsn day hen va dinh hou VaG cac lop d sau. Da duoc cung cap b6i nhieu mach mau va chua nhieu tuyen ba nhdn. a phan tren, da de tach khoi cac lop sau; nhung d nua dudi fhi da dinh chat vao cac cau true sun-sci i'J lop sau hen.

• Lap m6 lien kef-mil duOi da morig, chi eo chu yeu b phan tren cao cua vung mui, nhung hau nhu kh6ng eo d khu vue cac canh. miii va dinh. miii.

• Lop en do cac co bam da m$e tao nen, va baa g6m cac co dudi day:

- ca kieu hiinh (hoac ca tluip cua mili), bam VaG sun ben cua canh mui va vao xuang miii (as nasale, cung goi 1a xuang song mili) r6i di tdi va bam t~n VaG da a vung nflm giua hai cung long may.

- ca miii (musculus nasalis) bao gem hai phan: pluin ngang (pars transversa) hoac co ngang miii va phii.n canh. miii hoac co nd miii, Phii.n ngang cua ed mui di hi ldp can d song rnui va bam t$-n vao mat sau cua da a ranh mlii-ma. Ph6n canh mui cua ed mui thi b§.t ngu6n hi mQ.t sau cua ranh mili-ma va Mn ham t$.n vao lop sau eua da d b(j du'oi cua hai 16 mui (nares).

, Cae cO bam da m,'lI con dl1(,le 9<;>i ia cae co net mi).t

- co nang moi tren va canh. miii (m. levator labii superioris alaeque nasi) bam nguyen uy vao mat hen mom tran cua xucng ham tren va vao mom miri cua xuong tran (tuc mom is mat trong cua xuong trim) r6i toa xufing bam t$-n vao 16p sau cua da d canh mui va moi tren.

- co ha otich. nuii (m. myrtiformiei" xuat ph at tu hO' co la cua xuong ham tren va tit h6 nanh r6i den ham t~n VaG lop sau cua da a phan vach mui di d9ng (hinh 5).

• Khung xuang-sun: Vung mfii duoc nang dB bi'Ji mQt khung xucng-sun.

* Phan xuong cua khung h9P bdi mom tran cua xuong ham tren, cac xuong mfn", gal rnui truce va mom khau cal cua xuong ham tren, hai mom xuong nay gidi han 16 hirih qua Ie (tuc la 16 trudc cua hoc mui xuong).

Luc nen cua d(>ng tao nhai ttl nhimg rang a phia tr udc cua cac ham truyen doe thea hai mom tran cua xucng ham tren, len tdi oom. SQ (calvaria), tao nen mdt khu vue xuong dac goi la tru khang h,1C miii-tran . Nhirng luc nen tu cac rang ham dau tien truyen doc theo cac du'dng luc duoi ;5 mAt eua cac tru go rna, roi cung hoi t1.,1 vao cac tru mui-tran noi treri, T6ng luc nen n6i tren duoc truyen qua cac tru rntii-tran Wi xuong tran va cac xuong mfii, tao nen mQt tru khang luc tran-sang trudc cua xuong SQ, do xudng sang va duong khop lien-tran hop thanh, Nhu vay, phan t.rudc cua cac h6c mui duoc dong khung bdi hai tru khang luc, cac tru nay bao v$ eho ph fin trudc cua cac hoc mui va dang thai dung lam khung xucng nang dB cho m ui.

Cac xuong rmii (cung goi la: xuong mui chinh thuc) 13. hai manh xuong dlllc hinh b6n canh, tie'p khop vdi nhau a tren duong giua, tao nen mi?t vom, hai bo ben eua vom nay L;d tl,ia tren bo truoc eua cac mom tran xlidng ham tr€m, va b phia tren thi vom tiep khOp voi gai mui cua xu'dng tran_ a tren

, Co h{l vilch mOi (m. myrtiformis) con dl1(,lC djeh la cO la

• XUdng mOi (os nasa/e) con 9<;>i la xlfang 56ng moi ho;te xlfong mui ehinh thliG.

13

dU6ng gnra ve phfa sau, vom ella hai xuong m ui tiep khdp voi truinn dl1ng thling cua xucng sang, do d6 vorn nay tang cuong eho he thong nang da d giira hai h6e mui (tuc 18. mdnh dung thling xuong sang va xuang lei. mia5). Ed truce cua mom khau cai cua xuong ham tren co tac dung nang da cho bd sau ella cac 16 mui trudc cua h5c miii xuong va vach rnfij cling bam VaG gai rnui cua XU{1ng ham tren.

* Ni'ra ben dudi cua khung xuong sun cua filii chi h9P bdi cac sun, baa gam: cac sun ben cua miii (cartilago nasi lateralisi, 18. hai rrianh sun hirih tam giac, nam d hai ben dUdng gii1a thuoc ve hai mat truce-ben ella t.hap mii i, xen vao giua xuong mui va canh. miii (alae nasi) 6 mlii ben (hinh 2).

. Sun. cdnh. miii ldn (cartilago alaris major) Iii sun doi, nam d phfa duoi sun ben cua mui, hinh m6ng ngua, gioi han phftn truce nguai cua cac l6 mui, Sun canh mui Idn e6 hai nganh, nganh trong tham gia vao phan di d9ng cua vach mui, va nganh ngoai t9-0 nen khung cua canh ruui (hinh 3, 4).

Khoarrg trfing gifia nhimg sun k~ tren cua mui ducc b6 sung bbi cac cau tao rnang xo, trong be day ella cac rnang nay co th@ co mot so' hrong khOng co dinh nhfmg mieng sun nho goi la sun ph.u, s~n crinh miii nhd, sun vitng va sun. luai cay. Mang xo narn xen giua cac sun lien tiep vdi mang xirong hoac mang sun? 6 xung quanh.

Stj tiep giap giua phan xuong va sun ding tham gia VaG hinh thai cua mfii.

• Lap duai niem mac: b bd cac 10 rniii, da phil be mat ben ngoai cua mui quat sau vao trong cac hoc mfii, va tci nnrc b(j dudi cua nhung suti ben ella miii thi da tiep n5i vci niern mac h6 hap cua h6c mfii, Phan da d day (d b€ m$.t ben trong cua mili) dinh chi,lt vao mang Sl,tn (ngo9-i st,m) , do do neu bi m\ln nhQt b vung nay thi rat dau,

, XUC!ng 1.3 mia (vomer) con goi Iii xuong {lfOi cay.

• Mi:mg x\Jong, mt.mg sun con dIMc gQi Iii ngo;;ti clit va ngo;;ti sun, Iii m6 lien kel bao boc 0 ben ngoai cac cJu truc xU'crng va sun.

14

Hoc mui: Be mat ben ngoai cua vung mui a ca hai beh se tiep n6i vao phia trong va ra sau vdi be m$.t ben trong cua phan n~m d phia truce cua cac h6"e mui. Be m?t ben trong cua dean truoc-duci cac hoc mui diroc phu hOi da, co hinh mot ang voi chieu dai khoang 15 mm (goi Iii iien. dinh miii). Thanh ben ngcai cua tien dinh tuong irng voi canh miii va thanh ben trong chinh la urich miii (septum nasi). L6 dudi cua tien dinh chfnh 13. cac 16 rnui. L6 trim cua tien dinh narn d muc duoc goi la th€m miii (limen nasi), tuc 13. rnuc d d6 lop da phu be m$.t cua tien dinh tiep neli voi lop niern mac h6 hap; themrnui c6 hinh cu a mot khe hmh tam giac. d phan truce cua nhung 16 m iii, sat hai ben dinh rnfii, thi b6 dudi cua cac canh mfii hoi quat ra phia sau giGi han m9t khoang nho d ben trong gQi la ngtich. dinli miii. Trong ldp da cua phan dirdi cac tien dinh rnui, co cac tuyen ba nhcn va nhiing long rung {v ibrisae) , cac long nay dai ra va trd nen cung hon thea tu6i.

Hai canh miii c6 tac dung d~y kh6ng khf tdi niern mac khuu giac, neu khong co tac dong' cua canh mtii thi cam thu kh uu giac se hi giam,

D~ kham phan t.rtrdc cua cac hoc mui, nguiri ta su dung phuong phap soi miii va soi hOc miii tit phia truttc.

M~ch mall va day thdn k inh vimg rnii i D(mg mqch. cua vung miri g6m c6:

. dt;ng mach. s({ng miii, la mgt nhanh t$,n cua d(lng mach mat, d{mg mach nay la nhanh ben cua duy nh:rt cua d9ng mach canh trong, D{mg mach song mui phan bo eho vung g6e mui, s5ng mui va tiep noi voi di)ng macb goc (mat) 13. nhanh t£).n cua d(ing macli miit, d(lng m~ch nay doi khi cling tach ra mgt nhanh cho s5ng mlii, dinh mlii va m(lt nhimh cho vom I~.

- d{Jng m{lch crinh miii: la nhanh cua G9ng m:;lch mi,it.

Tinh mgch thu th~p mau ella vung miii 13. tlnh m(lch canh mlli va finh m(lch goc (milt), ca. hai deu Ia nhanh cua (inh m(lch mg.t. H~ thong tinh m:;J.ch mi,it tie'p

niSi d vung goc trong cua miit vdi tinh. mach. md! tren, tinh mach nay se d6 van xoang tinh. mach. hang d trong hQp s9, do d6 neu nan mun nhot con non (chua thanh mu) d vung mui thi co th~ d§.n tOi hau qua viern tmh mach b uyet khoi d xoang finh mach hang, day 1f1 milt tirih trang Him sang nang.

Mo.cl» bo.ch. huyet (bocb mgch) cua vung mtri duoc phan thanh cac nhorn sau:

- nh6m tren: thu nhan bach huyet rBi d6 van cac hach bach huye't d vung tren tuyen mang tai va cac nach truck tai;

- nh6rn giua: thu nhan bach huyet d~ d6 vao cac hach bach h uyet dudi tuyen mang tai:

- nhorn duoi: thu nhan bach huye't d~ d§.n ve rihom hach dudi ham.

Than kinh VI;;n dpng duoc tach ra ttt cac nnanh cua day than kinh mat,

Than kinh cam gisic duoc dam bi'w bqi day than kinh tam thoa, thong qua nhirng nrianh:

- than kinh dudi-rong roc (miii ngoai), 13. m9t nharih tQ.n cua day than kinh muimi, day than kinh nay lai Iii nhanh t$.n cua day than kinh mat: nhanh dudi-rong roc chi phci cam giac 0 vung goc mui.

- day than kinh dudi 6 mit, Iii nhanh tan en a day than kinh ham tren: day thin kirih dudi 6 mat chi pho'i cam giac cho phan ben ngcai cua vung mui;

- nhanh mui ngoai (day thfin kinh canh m iii), Iii mot nhanh cua day than kinh sang truttc (day than kinh rriui trong); than kinh nay lai 1a nhanh tan cua day than kinh mu i-rni, m¢t nhanh t?n cua day than kinh mit. Sau khi tach ra khOi day than kinh sang truce, thi nhanh mfii ngoai di len mat ngoai cna xuong miii tdi ch6 xuong nay tiep khop vdi cac S1,1n cua miri, vudt qua gidi han nay va tie'p tuc di d duoi da cho tdi tan dinh mui. Nhanh 'thrin kinh mui ngoai nay chi phoi cam giac a ph an trudc-duoi cua mui,

Phia sau cua thap mui la eac hoc mui_

Cae hoc mui (Cavum nasi)

Hac mui hinh thanh mot h~ thong dudng him co rihieu ngach, narn d phan trung tam cua khoi xuong mat, va duoc phan thanh hai 1l11a bdi mQt vach d chinh giua (xern t?P I).

Cac hoc mui thong vdi cac hoc hoi goi 13. cac xoang canh. miii (sinus paranasales) hoac xoang hdi cua mat: d6 Iii. cac xoang iran, xoang ham, xoang buam, va xoang sang. Ve phia truck, cac hoc mui (xuong) rno ra ngoai bang hai 16 goi la cac 16 miii truce. v« phi a sau, cac hac rnui (xucng) thong YOl pnan hong-mid (con goi la tyhdu)7 bdi hai 10 goi la cac [0 miii sau, Cac h6'c mui la co quan d~ ngui: vi vi tri cao cua chung, cac hoc mtii Iii. phan tren cung cua dlldng h6 hap.

M6i ho'c rmii co bon thanb, do la: thanh ben ngaai khong deu d~n va thanh ben trang, thanh tren va thanh dudi; ba thanh sau nay e6 cau true don gian hon,

* Thanh ben trong cua hai h6'e mui 1a m9t khung xuong-sun chung cho ca hai hoc mui nen con goi Ia utich. miii (septum nasi), vach miii h9P bi'li manh dung th&ng cua xuong sang (0 phan tren), xucng la mia hoac xucng luih cay Cd phan sau va duci) va vach sun (0 phan truce),

Veich miii duoc phu bdi niern mac df! tach khoi nen xucng-sun. Cach bo sau cua 16 miii truoc 1,5cm, doi khi c6 th~ thay mot 16 nho cua co quan. Jacobson con g9l lit cd quan lei mia-mili (organum vomeronasal), Iii mot ang nho di tich phoi thai, duoc 16t bdi niern mac tren m{lt chieu dai khoang

7 Trang lai li(lu Giai phau hoc ti6ng Vii!I tr110C day. hr;mg cung dLl<;lC gQi Ill. hAu. Vi hau thonq veti ba co quan khac nhau b ph fa tnmc, la h6c mili, h6c m;~ng va Ihanh qulm. nEm aLlde phfln bl~t thanh ba pnan: ty-hau (phan rnui), khAu-hIlu (phan mi~ng) va Ihanh-hau (phan thanh quan), Neu sa d\,ng ng6n ngl! thong IhLlong thi e6 thi! gQi ba phan d6 Ian Ill<;ll 103 h9n9- mili. hQng-m;~ng va hQng-thanh quan. Trang tai Ii~u nay chUng t6i SU d\,ng ca hal danh philp n6i tr6n. Ngoai ra Iy,-hliu. kh'u-hau. thanh-hau con dLl<;le g<;>1 103 tluJgng - hr;mg (epipharynx). trung-h<;mg (mesopharynx) Yil h(l-hQng (hypopharynx) (xem IMm ehu thieh 14).

15

vai milimat. a phan dudi cua vach mui, trong lap niern mac e6 mot ''ve't mach", la mot vung rat giau mach mau, va thucng la noi xay ra chay mau cam (chay mau miii).

* Thanh tren cua moi hcc mui can goi Ii trdn. hoc miii, la mQt mang dai thea chieu truoc-sau, va eong 15m huong xuong phia dirdi, chi' r9ng khoang vai milirnet. Tran Me: miii k~ tit phia truce ra phra sau h9P boi: cac xuang miii (can goi la xucng song mili) , gai miii cua xucrig triin, mdnh ngang cua xU:dng sang (con gQi la mdnh sang: lamina cribosa) va than xudng bU:dm. Tdl.n hoc mui ngan each h6e mui vdi h9P S~J, va lil phari xucng d~ gay va nhat cua so-mat, vi manh sang rat mongo

* Thanh dudi can goi l a n~n (hoac scm) cua hoc mui, cung c6 hinh th~ rihu mQt ma ng, nhung mang nay rong han va ngan hen so vdi trtin cua hcc mui, SCm hoc miii ngan each cac h6c mui voi hOc mieng . Ba phan t.u t.rude cua san h6c mui hinh thanh boi mom khdu ctii cua xuang ham tren, con mot phan tU sau Ii.! mdnh ngang cua xucng khdu cai, Niern mac phil nen h6c mui che kin mot 6ng nho goi Ia ong rang czla (ductus incisivus) hoac ong kha'u cai triatc,

* Thanh ben ngoai cua cac hoc mui h9P thanh bCii mat trong cua cac xuong ham tren va ctinlt trong cua mom chan budm, hai xucrig nay tiep khdp lfin luot vdi:

xuang l¢ (os Iacrimale);

mdnh dltng th&ng cua xuang kha'u cai; cdc kh6i ben cua xuans; sang (con gqi til me cung xuang sang);

xuong cucn mut dudi (concha nasalis inferior) con g9i la xur1ng xotiri duai.

Xuang sang 18. yeu to chinh hinh thanh nen thanh ben ngoai cua h6c rnui, vi vay xuong nay la dUQc coi Ia "xuorig ehinh cua mu i" (Guerran). Cac xuong tham gia vao thanh ben ngoai cua hoc mili gioi h~n hai 6ng va mqt 10:

. Gng mui-l¢ ho~e {fng l¢-ty' (canalis naso-lacrimalis), ang nay gioi h/im Ci phia ngoai bCii xudng ham tren, xudng 1~ va mom

16

l¢ cua xuang cuon miii duoi; d phia trong hOi chfnh xuong cu6n mui dudi: 6ng miri-Ie la duong thong giua hoc mat vdi hoc miri, qua 6ng nay nude mat se db vao ngrich miii du:di.

- Gng khcl.u cai ldn hoac ong khdu cai sau, nam giua xuong ham tren va xuong khtiu cai; 6ng nay ngan each hoan toan voi hoc mui va chi c6 15 mb ra 0 vern khiu cai:

- L6 budm·khdu cdi tforamen sphenopalatinum) gidi han bdi mot khuyet cling ten va xuang budm; qua 16 nay, h6- chan bu:dm·khdu ctii thong vdi hcc rnui, va cung qua 16 nay rna b6 mach-than kinh chinh cua hoc mui eli vao hac mui, do d6 16 buornkhiu cai dU<;IC coi Ia "ron" cua hoc mui, 8

Cac xddng cufin mid (ho~e xu'dng xoa n): Thanh ben ngoai cua cac hoc mui kh6ng pharig rna go ghe do co cac xucng cu6n. Thuc ra day chi la cac la xucng, cong 16i v~ phia long cua h6e mui, va c6 chieu dai thea hudng trudc-sau.

XU(Jng cuon miii duai hoiic xudng xoiin. duai (concha nasalis inferior) Iii mQt xuong rieng biet, va la xuong dai nhat trong sO' cac xuong cuon: xuong cuon dudi narn bAe ngang qua 16 cua xoang ham, che kin phan dUoi cua 15 nay, va tie'p khop voi gd cuon cua cac xucng ham tren va xuong khau cai, va tiep khdp vni ea xuong 1$.

Cae xuong euo'n (xoiin) tren va giita (concha nasalis superior et media) kh6ng phai la cac xuong rierig rna la cac bi? phan eua xUdng sang. Bo tren eua cac xuong cu6n nay dinh VaG kh6i ben cua xirong sang (hoac me cung xUdng sang).

Xuang cuon giiia hinh thanh nhu mQt mom hinh vo-van nho vao phfa trang, tai gfin sat vdi vach miri, va do d6 phan ehia hoc mui ra thanh hai tAng: Uing tren, la uung khitu guic (regio olfactoria) va Hing dudi la vimg h6 Mip (regio respiratoria). Xuong cuon g iira keo dai ra truoc va ra sau,

8 "R6n": la thu~t ngil' chi nO'i cae m<jlch mau va day than kinh t,jlp trung M di vao va di ra khoi m¢t co quan. vi d~ r6n phoi, r5n lach.

VUQt qua d ben t.ren cac xoang sang ra phia truce vii. ra phia sau, d~ khop voi mao sang (hcac go cuon tren) cua xuong ham tren va x uorig khau cai, Xuong cuon tren nho hen, nhung eo hinh th€! giong vdi xucng cuon giQa; co th~ con co mot xlidng eu6n thu tu hoac xutnu; won tren ciing (xudng cuon Santorini). Phia t reri cac xuong cuon 13 'lung trcn cuon (hoac ngtich. buarn-stingv; phfa truoo cua ngach nay co [6 eua xoang buitm mo vao hoe rnui. M6i xuong cuon cung vdi th anh ngoai ella hoc rmii a phan tuong ling, gidi h;:.n mQt khoang goi 13. ngiicli miii (meatus nasi).

Nhirng' nguch rnji i

Ng d.ch. mu~ tren (meatus nasi

superior) chi 13. mot khoang nho, narn (j p han sau cua hoc rriui, trong ngach miri trcn thay c6 2 hoac 3 16 nho cua cac a{ brio sang sau (cellulae posteriors) md vao ngach mui nay.

Ng6ch mur gii)a (meatus nasi medius): a thanh ben ngcai cua ngach nay co nhieu cau tao:

- B9t sang (bulla ethmoidalis) bao gom m9t te bao sang hinh t6 chim en, thanh treri cua te' bao sang nay la mQt la xuong thuoc ve xuong xoan giua:

- MQt hcac nhieu 16 nho cua nhfing te bao sang truoc va giira md ra d ben dudi va phfa trudo cua bot sang (vao mot ranh d phia sau cua bong nay);

- Nh.t ngci.eh miii gii1a hoac 16 th6ng giua nh ung ngach mui:

- Mom moe, lit mot la xuong c6 hinh mfit 1\101 guorn cong, t.u tach ra di vito oung de mut (agger nasi) - mQt vung 16i len khac cung do mot te bao sang tao rien - mom m6c vUQt qua lli cua xoang ham, rbi tiep vdi xuong cuon duoi d phia dudi, va vdi xuong khau cai d phfa sau;

Khe ban nguY9t (hiatus semilunaris) hnac riinh. moe-bot, narn d giua hot sang va mom moe;

- pMu sang ho(ic rfng tran-mili lien tiep v6i khc ban nguy$t, Mt eheo khoi ben

xuong sang; day lit mot "6ng th6ng nh6 len" cao tren d6 hinh thanh xuong CUOn gifia.

Ngtieh. miii duoi (meatus nasi inferior): d ph§.n trudc cua b6 tren cua ngach nay c6 16 dudi cua ong miii-l~ md vao ngach,

LEi cua xoang ham bi ehe Hlp d phia duoi bdi mom ham cua xucng cuon duoi: xoang ham md vao ngach mui giira,

NH~m mac mlii: Niern mac phu thanh ben ngoai cua hoc rnui dinh chat vdi Idp ngoai c6t (mang xucng, eot-m~c) cua cac xuong, va duoc goi la niern mac ngoai cot. Niern mac nay phu be mat cac xuong va 16i ra d~ luon sau vao trong rihung xoang canh. hoc miii va nhi1ng tit bao sang (goi chung Ia cac xoang hoi). Rieng xoang ham thi kh6ng nlru vay, vi niern mac mui ehe lap hai 16 eua xoang, va chi de' cho xoang thong vdi h6c mui d phia sau va phia tren boi mot 18 narn d phfa tren mom moe. Cac 10 cua tat ca cac xoang hoi deu md van ngach mui giua Ia do chung c6 cung mQt ngu6n g6c phoi thai voi h6c miii tuong ling, ttl ngu6n gac phci thai chung nay ve sau moi co s1;1 ph an ly khac nhau. Ve mat dinh khu, thanh ben ngoai cua hf)c mui c6 the' phan chia thanh ba vung khac nhau: vung d phia truce phang nhan, vung 0 phia sau c6 cac ngach vi c6 nhling xuong cudn va vung tren Ia vung khuu giac,

Cac mach mau va day th:1n kinh (hinh 6)

D9ng moeh. chinh cung eap mau eho hoc mui 18. nh anh tan cua r1(ing mach. ham tren, goi Ia d¢ng mach. bUdm-khdu cai, va nhung nguBn phv la nhung nhanh clla a(ing macli milt va d¢ng mach. rruit:

* D¢ng mach. bUdm-khciu cat

(a. sphaenopaiatina) ehui qua Z6 bUCJmkhdu cai (dU9C coi nhtr "ron" cua h6c mui) d~ thoat ra kh6i h6' dudi-tluii duong, rBi phan chia thanh nhieu nhanh goi iii cdc d(Jng mach. miii sau, miii ngoai, va miii trong (aa. nasales posteriores, lateroles et septi).

- fJ¢ng mach. miii trang (con g9i 18. di)ng mr;tch vaeh mili) se tach ra nhung nhanh mlii tren va ngoai d~ phan phoi cho vung eua xlldng cuon tren, r6i di chech vach mlii

17

d~ Wi gan ii'ng rang czta thi nBi tiep vdi d9ng mach khl'i'u cai xucng, d9ng mach nay di ngang qua man khftu cai (hoac khilu cai mem)" tit phia truce ra phia sau,

- Nhiing d(mg mach. miii ngoai, doi khi hop nhat t.hanh m9t than chung, phan be cac nhanh cho cac xuong cuon mui va cho cac ngach rriui duoi va giua.

* Nhi1ng nguon d¢ng macn phu. baa gom:

- nhtirig d(jng mach. sang truce va sau (aa. ethmoidales anterior et posterior), deu la nb a nh cua d(mg mach mat; nhung d9ng mach sang nay cung cap mall cho vung k h uu gihc va eho n iern mac cua vung trudc xuorig cu on, cirng nhu: cho xoang tran:

- a(jng mach. duai-uach. miii, la mot nhanh cua dong mach mat; phan nh anh d vung truoc-dudi cua vach mui,

"Vet mach" la mot vung nho niern mac nam d phan dudi-truoc cua vach rmii, d day cac d(Jng mach da meS til 6 tren noi tiep vdi nhau. Hall het nhung truong hop chay mall cam (chay mali rnui) nang thuong xay ra d phia sau cua "vet mach" va mali chay ra la tir dong mach mui trong.

Tinli mach. deu di kern theo cac d9ng rriach cung ten. Chung tao thanh hai mang luoi: m9t mang luci nang (; trong niern mac va mot marig sau 6 trong cot-m?c (ngoai cot). Nhirng tlnh mach trong xuong chay thiing tdi "ron" elm hoc mui, va la nguon chay mall trong phau thuat d.t xuong cuon. Mau tinh mach cua hBe mui mfit phan dU:Qe din Iuu qua nhung tinh. mach. miii sau VaG dam roi tinh. mach chan budm, mdt phan qua nhtrng tinli mack miii tren tdi xoang tinli mach. hang, con mot phan nho qua nhung ti~li tinh mach d~ d6 VaG tinli mach. mi,it.

Mach bach huyet (bach mach) tao nen nhung ~~ng luoi phong phd niim' 0 trang niem m~c mlii, va cling gio'ng nhu cac tinh m~ch, chung dftn lu:u b~ch huyet thea ba hudng: tai nhung h:;tch b~ch huye't sali-

o Mim kh5u r;{Ji. ho~r; kh§u cai m6m, tronQ mOt s6 tai lieu tien g Vi~t truoe day' con 99i la man hall. Trang tai li~u n~y chung toi chi dich la man kh~u cai hal[ic kh~u eai mem vi thea tieng Latin th] chi c6 hai tLt -palatum molle", "velum palatinum" de chi phan nay, va l;:Ii thU~1 nglJ'. lieng Anh va tieng PhBp cung 18 n hlr;lt la soft palate v~ voile du palais ,

18

hau, tdi cac hach c6 sau, va m9t phan nh6 hen tai cac hach bach huyet duoi-ham.

Than kinh gine quan (khitu giiic) dU<;lc darn bao bdi day than kinh khuu giac, bao gam nhieu sci xuat ph at tit vung khuu giac cua niem mac miri, va qp h9P tren met dien tfch khoang 2 centimet vueSng, d mat tren cua xuong cu6n tren va (; phtin va~h mui ngang vdi muc do, Day than kinh khu:u guic Ia nhirng b6 soi t.ruc cua cac te baa cua niern mac khuu, cac te bao khuu giac nay nam rai rae, xen Ibn giira nhfrng te' baa nang da cua lop niern mac. Nhirng te bao khuu giac Iudng cue se tiep xuc thong qua cac kh8p than kinh (sinap) voi nhirng te' bao mii-ni (hoac mil su) cua hanh khuu bdi sci true cua chung, sau khi nhung 5Qi true nay da chui qua nhirng 16 cu a manh ngang xUdng sang, Til day nhung xung than kinh khuu giac se true tiep di tdi vung khuu nao, kheSng qua mfrt trarn trung gian nao nua, va do d6 duong dan truyen khuu giac chi bao g6m co hai noron.

Than kinh eam gicic duoc dam bao bdi nhiing nhanh tan cung cua day than kinh bUdm-kha'u cai, mot nhanh cua day than kinh ham tren, day nay lai la n hanh thu hai ella day than kinh tam thoa. Ngu6i ta phfin biet cac day than kinh miii tren. (nn. nasales superiores) tai phan nhanh chi ph6i cam giac d phiin niem mac phu cac xuong cuon gi iia va dudi, day than kinh mili-khtIu cai (n. naso-palatinus) thi chi ph6i cam giac (; vach mui, va nhtrng nhanh cua nhung day thiin kinh khfiu cai tru'dc va giiia thi chi phdi cam giac d nen hoc miri. Ngoai ra, co m9t nh6m nhung sci than kinh thuc vat. n~m trong day thin kinh budrnkhtiu cai, chung xuat ph at til hach. chan buiirn-kha'u cai hoac hach bUdm-kha'u cdi. Nhiing soi than ki~h thuc vat k~ tren di tdi hach budm-khau cai Iii nhung SQi tach ra ttt mQt day th:in kinh, gQi 13. day than kinh Vidien (dQe Ia vi-dieng), n:lm trong ong chan bU:om, thOng qua re giao cam eua dam r61. than kinh quanh aQng mg,ch eanh trang, va ttl' cae day than kinh aa thong qua day than kinh m(it va ddy than kinh thi~t.hau.

Day than kinh mili trong ho$,eday thAn kinh sang tru:de, la nhanh eua day tM.n kinh mlit chi ph6i cam giae d vimg 16 mili va phfin tru:de eua mlii.

~~s:;~~}jl-- Sun ~r'ItI mO· m (Wl1gC'~i)

Sl,In ca nh miii n ha

H~nh 2. Cae sun da mui (nhin tu phfa ben ngoai)

Wlflh n~ar.g x~ ~g (~nhsanQ)

XO<¥lg bumn

Mann trong mom CfiSif'l bl.WJn

Mllh nam ng:aI'lQ i'\U'OOg khau cai

Or"ll}rtng rua

Hinh 3. Cat syn eua mm (nhin HI phi~. b~r1 trong)

19

G1ii mul tNCrc

Longmoi

Sun c.an.h m Ut Idri (trT,I trOngl" Sl,m dlnh mWi Ian lil'1,l ng(}a~

Sun'of:'lenmDI lvach giiffi mui)

Minh 4. C.ae SVIA ICI1.~ rnai (nhln tU' ben d'lJdi}

Xoong mui (lI,lJo:ng seing m D1

Mum:en wong - ............ --~........!_...J hamW:n

'l~I.Ii~~-'"'7'L ~ Co oar¥;! iMi trim

.... a E<:1ntl mOl

SI,IrI ~n cUi! mlli

(;1} mUI, pl1an og9fB ~oo nQfl'lQ mill!)

Ca m(ji, phan eann miJJ (co I'iOmOi)

Sun caoh mu. ltrn (rru !rorJg)

s~ vach mill (0'11 Gh lilCra m un) H,nh 5. Thap mUli (khlJJ'ng, xl1ijngl~s~ n vi cae c a)

20

~~--- rtdu tnl~l (jU:Oi gal '----- Khau cal xuung (kh~1J cai G~)

Nhfmg xoang canh mui (SiI'iIJS paranas,aies)1Q

.'llh ilng .ronng c~nh mrl~ lli nhilng xoang hrti phu thu9c vao cac h6, mu], vlchLi.ng phat ~in'" t: if I:UC hoc n111i va CUl1g nhl),l1 l;;hOng k hl u:r cac hnc rnui, :..fhung xoang card. IUlh phan b6· thunh b6n nh6no: cae xoang sang, xnang tran, xnang bUCJm, vit xoang hllm; C:.1C xoang nil)" Lhu:Ctng hay bi nlllem khufin 1~11 tu hOC J\l11i vAC! vil g3}' ra benh "if'm xoang ..

I, XmmiJ canh mai: I~ thu~1 ngiI ell; chung cae 1'1& I'!~m. 0 iHIFIQ kh6i XUOIl!jjl m ~ I. ch Li"fl kh El ng khj. 'oi~ lI~u lh~ ~'ll ~ill cac h.6~ mtll CO mat 56 ~en gOI ~1'1jk III XDEI~ MI, XMng 1'I1I~1. Cole ;0;0<1 n(l n ii~' d11l;lC goi Ie n thee I~I'I cua ~Yllng eIlifa cae ~oan'il do

Cae re baa san'D

(Sinus ethmoidalls seu labyrinthu~ e1hmolda~is)

• • ,t;

(Xoang sang ho~c me cung sang,

ca.c ~€ hac sill'lg VO'] so: hlQng tit 8 difn, 10 t€ ban, binh thanh ni~t h¢ thong ngoe IlICach. nam rrong be tli1ycua hm kh6l biil1 ,xmmg sang. Nhung til! bao sang !.leu m~ thOIl g v!!i phia hen tl'on~ va.O cae ngich m~lll tl'~n va gida, ngtfr;le. itl] v€ phla ben ngoili chung dU:Qc ngan caeh hoan loan veri CQC h[")I: m~t. boi mdnh. hac mdt eu~ xu"(dng sang. Cae te buo 51'tng lien quan: ve phia trin ~i mling nao cimg va nao (I.l~n co th~' dAn t6i

II XO ,mil :fimg ~c ~~ boo dl'l9:! ~ ;:I'ic xllsng Clilnh m Ui hQ~e };1lI"rtg hdi n&m a LrO:>119 JlIJdillij ~Mg; TU:i. 1IIn.I~n. '~1 c_a.c ~DEmQ ~ ~ ng bao ..&n r~t nlll e u h.5G nho, n'!lO mo!N h o.c ~LltIC 91;)1 1;'1 l6 Wio $an'tl. ~ I'B ~o ~8ng c:!(!ll nam. lJ trong l1ill kI'lOI b~ n cU;) :!:.Wng ~,ang. lam chn e~dllt6i • uti ng n,Bl' c6 d LI true r~i plilCK Iii' bQI nlliiiu Me. n 9 8~h nhb, ~p n:g p 1II1'1[r~ t'6::. n~h 1'10 d~c !lei t6n I~ m~ CUll!! sang.

21

cac bien churig a mung nao va nao khi bi viern), ve phia ngoai vdi hai hoc mat, ve phia sau voi xoang budrn, va ve phia duoi vci xoang ham, cac te bao sang d phia truce con lien quan ve phia t.ren vdi xaang tr an, xoang nay co th~ duoc coi la mot te' bao sang-triin. ldn:

Xoang tran (Sinus frontalis)

La hoc hoi co hinh thap ba mat va mgt day, xoang tran xuat hien trong giai dean tre em va co rmrc d(l phat tri~n thay d6i. Thanh trudc cua xoang day, va tuong ung vdi vurig long may; thanh sau cua xoang mong hon, lien quan vdi mang nao va qua eric ldp mang nao lien quan vdi thuy trari cua dai niio (qtc trutic eua ban edu dai niio), Thanh trong cua xoang trim la otich. gian-xoang, ngan each hai xoang tran d hai ben vdi nhau, hai xoang nay baa gio cling kh6ng bang nhau ve kich thudc; thanh dudi duoc xcm la day cua cac xoang trim va hen quan vdi hoc m:it va xuong sang. Xoang trari thong vdi ngach mui gil1a bdi i{ng trtinmiii, orig nay co 16 rnd VaG phiu eua ngtich. miii giiai nam (j cue tren cua khe ban nguy¢t. C6 th~ lam thu thuat thong xoang tran bang each dua 6ng thong qua ngach mui giua,

Xoang buam (Sinus sphenoidalis)

Cac xoang budm nam (j hai mra ben cua than xuong budm, hal xoang hal hen diroc nga n each Val nhau bdi mQt vach rat mongo Cac xoang budm lien quan: ve phfa trsn vdi h6' yen (sella turcica), trong h6 co chua tuye'n yen (con goi la tuyen ha nao), ve phia sau vdi mijt doc, ve phia ngoai vdi cac xoang tinh. mach. hang, trong xoang tinh mach nay con chua d(lng mach canh trong, va cac day thAn kinh S9 s6 III, IV, V" va VI, con ve phia dudi thi xoang budm lien

22

quan vdi hau (hong), Thanh truce cua xoang budrn nhin VaG phan hdu-mili (con goi la iy'-hdu), va co mQt 16 nho md thong VaG phan nay cua hau, nhung 16 bi lap bdi m9t marig ngan niem mac, va bi khtii xuang cu6n giiJa che khuat tEim nhin. Xoang budrn co th~ co kfeh thudc nhc, trung binh, hoac IOn; trong truong hop xaang Ian thi co th~ se thong vdi cdc ngtich. narn trong M day cua canli lan xudng buom, trong nen cua mom chan buam, hoac thong vdi 6ng th.i gidc, hoi;ic vdi xoang ham, cung nhu voi ngach d mom nen eua xuang cham.

Xoang ham

(Sinus maxillaris seu antrum Highmori ) ( Xoang ham hoac hang Highmor)

Xoang ham la mQt hoc nam trorig th an ella xuang ham tren, nhung thanh cua xoang c6 th~ chi la nhG:ng tam xuong mong. Hinh th~ cua xoang cling gi5ng vdi hinh th~ cua than xircng ham tren, tuc Ia hinh t.hap co bon mat ben (deu goi Ia thanh xoang) vrri mot day huang VaG phia trong.

Thanh trudc tucng ling vrri h6~ nanh va Iii thanh phftu thuat, vi duong VaG xoang la dUdng qua riinh. lai-nui 12, phan dirdi cua thanh nay e6 dam r5i huyet rang tren bih cheo qua. Thanh sau va ngoai (hoac thanh dudi-thai duong) lien quan vdi h6' chan bUdm-khfi'u cdi, trong be day cua thanh nay c6 day thdn kinh huy¢t rang sou (hoac day than kinh rang sau) di VaG d~ chia nhanh tdi cac huyet rang. Thanh tren (con goi Ia thanh is mat) la nin 0' miit , t.ren thanh nay co riinh. dum 6' m&t chay til SHU ra trudc, r6i tie'p We vdi 6ng duoi 6' mdt. Ranh dudi 6 mat lam thanh mot gd xudng 16i vao him trong xoang. Thanh trong cua xoang tuc la day thap, tucng ung voi thanh ngoai cua cac ngdch. miii giiia va duci, co mQt 16 r9ng goi Iii 16 xaang ham (hiatus). a ngach mui giua, 16 xoang ham co mom moc di ngang

12 Ri!lnh l(Ji-mll: ranh t';lO nan bdi m¢t ban (ban ngoa;) 1,1, mat trong ma va ben kia (ben trong) la l<;li phu ba huy~t riling (ba dlftli) cua xlfang ham Iran.

qua va ph an ldn 16 hi lap kin bi'li niem mac, 6 ngach mui dudi, 16 xoang ham bi bit kin bdi mom ham cua xustng cu6'n duai, nhurig vi trf nay chinh la diiim ducc chon d~ choc xoang ham. Ed trudc cua xoang ham tuong ling vdi 6ng mili-le. Bd dudi cua xoang lien quan voi r& cua hai rang ham Ion dau tien va rang ham be thu hai, do do xoang hay bi <\nh huong bdi nhfrng be nh vg rang. Brnh thuorig xoang ham chua khong khL Hinh the' va kich thucc cua xoang kha thay d6'i. Xoang nho voi the' tich dudi 8 centimet kh5i co th~ 13. binh thudng hoac do hau qua cua qua trlnh nhiern khuan man tinh. Xoang Ian vci th~ ttch Vllt;1t qua 15 cent.imet kh6i co tht} thong vui cac ngach: ve phia tren ngach narn trong be day cua nganh. len xuttru; h.am. tren, ve phia ngoai ngach narn trong xlidng go rna, vg phia dudi n~m trong be day cua b(! huy~t rung cua vom khftu cai, va ve phia sau-t ren cling co the; co ngach narn '.j ph an t.ren cua xuong khdu ctii,

Hoc mi~ngi3 (Cavum oris)

1I6c mieng hoac rmerrg (tU tieng By LQ.p: stoma = m6m) la bQ phan dau tien, hoac doa n d mat cua dudng tieu hoa, Nho cau true cua mierig, nen bQ phan nay co chuc nang la hoan tharih giai dean d1l.u cua qua trinh tieu hoa, va ki~m soat eMit Iuong cua thuc an b?ing cac heat d9ng: nhai, tharn nude bet, va nuot kh6i thuc an; cung nhu vf}.y, vi co cac thanh gidi h a n h5c mieng va cac cd quan chua dung a ben trong, rna am thanh ph at ra tit thanh quan se dl1Qc tao t.hanh lCii noi ph at ra r6 ring va co thJ hi~u duoc (hinh 7).

H5c mierig cau tao nsn bdi mot khung xuong vdi hai xuong ham, die cau trtic phftn mem se dllQC phan b5 a nong hdn ho~c sau hdn so vdi khung xudng nay, d~ cung t:;to nen cae thanh eua h6c mi~ng.

" H6c mii;mg co the con gOi la 6 mi~ng

Cae tnanh a nfrng ella mieng ch inh 18. cac vung nong cua mat, baa g6m: cac moi, dm va vung co don.

Nmrng thanh 0 sau ella rmeng: phia tren va trong tao nen vung khdu ctii (con g9i la vorn mieng): phia duoi tao nen nin (hoiu: san) mieng ; vdi a giua Ia llidi va hai ben Ia cac vung cua cac tuyen nude bot dudi ham va dudi ludi.

v« phfa san-ben, hdc m ieng lien quan voi hai vung Ian can: oiing dudi-thai duong va uiing chan buam-ham, hai vung nay chua nhirng thanh phari mach mau va than kinh Iii nguon cung cap rnau va chi ph6i th:ln kinh eho ph:1n ldn hoc mieng.

H6c mieng mo ra phia truoc bdi khe mieng (rima oris), khi cac moi giu yen d tu the' b6t dQng, thi khe nay chi 18. met khe rfit hep, vdi chieu narn ngang tit 4-5 cm, gidi han bdi cac bd tu do ella cac moi tren va d~oi. H6c mieng thong ve phfa sau vdi hdu (hr;mgj14 bdi met 10 md thudng xuyen, g9i 18. ti€n dinh hdu hoac hong-mieng (eo h6.umieng, hoac eo hong)", eo c6 hinh cua mot cung vdi chidu cong 10m nhin xuong phia dudi va ra sau , dude gioi han: d phia tren bdi man khdu ctii (con gal la khdu ctii milm) , d hai ben bdi cac nep khdu ctii-ludi (con gui 1ft cac tru truce cua man khdu aii), va 0 phfa dudi hoi noi tiep n5i giua hai phan day va than cua ludi.

Khi hai cung rang (ham rang) t.ren va dudi khep lai sat vdi nhau, thi h5c mieng chi con Iii. mot khoang ao, vdi khci ludi chiern h€t phan trung tam ella mieng, Nguoc Iai, hoc mieng chi' tra thanh mdt khoang that s1,i khi no chua cac th€ tfch chfit ran, chat long, hoac hoi khi, hoac khi

14 Hau cung 99i la ht;mg hai hi nay coi nhtr dong nghTa. la (JOlin th(( hai CLla 6ng lieu hca n~m xen gilla mi~ng va thuc quan, Til h9ng dlJdc dung phB thong hen (viem hQng, riau hQng), nhltng trong nhllng thuat- ngll kep bao gam hai hoac ba 10' Ihi hiiu va hgng c6 th~ du ng thay d'5i cho nhau. (vi d\l Ir.-hau, eo-hl;mg. ung thl! h{l-h(>ng, am;dan hau. cO nang hau, Cd Mit htlu, co vc)i-Mu ... ), Trong tai li<1ou nay Ill' Hau va H9ngdlJqc dung thay cho nhau va la dong nghTa.

" Eo hong-m;~ng Iii Ib thong gilla hoc mi~ng va phan mi~ng clla h;!iu (hr;>ng-m;~ng ho.jlc khBu- haul, Trong mQt so tai li~u Gilli phr.u h9C 10 nay l1uc;:lc 99i Iii eo-hQng. Trong lai li~u nay chung toi chi sit d~ng hai thu~t ngli' eo h"mg-mi~ng ho,?c eo IlBu-milmg va 103 dong nghia.

23

,...._~- TFJ,i SOlIJ man kh~lJ cal (CUr'lg kh~u ci!IJ.fJ~ul ,..,....--- H.:mh nhan [amidan] kh&U cai • ~--- Tn!llnl!t1r. man kh~u ca! ~cl.lng khau c8!-100i)

---. .... I-r---- M~1 !fen ~IJ~ 0 lfng 100)

b-f+--~ t.t~t dLl'di ludi r:--:.'#---- l,J dtrCt Ji.IUi

lQi

'I~¥- __ - Mtli diJ'6:i

~~--IR~nh mJi-~m ~"""';=!::1-~--

C1Jng ral'ly Iren ~h1ml ramg tffin) ---.oJIiI~ Kh6u cl i xm;:rp!;I (kh6 U dli ccmgl-~-..,

Man rrn~u cai (~h~u cai m~m) .- __ ~~~~_ TI~IJ It'll ~t ~ IIJOi giil) ~---

Mep (11'l5l, mi~tl9I----~

E~lKif1lg (eo.hau) ---~

H::illl! IUIJj--~~~+ CUrlg ra ng dIJa ~Mm rkJ1g d Ln'n) --~~~n;.

h.ftJi n;LI:. ra .sUUI no(ic: khi chuy~n dieh hai n(i m rA ug de h xa nha u ra (M .nll~ ng): khoarig each g!ua hai h~lll1rang khi .rni~ng: hii ron g co the Wi 4-5 em, khi do khoa.tJ.g dch giila de bd t~ do ("u~ die r~ ng ~if;.ll dol di~tl nhau a had ham tr&n va dU'ffi.

Haj I::ung ri'ing (ham rAng) va d:o~n mieng (b{j 1W:Wl ror~g) eua I:ii~: x1fdng ham phil n chia hoc mi~ng ra lam hai phan:

- Ph:1n nitm ij pol-ria ngoai de h.am. rA.ng ~91 l~ tien dinh mifng;

- Ph:!1n ltii.m ~ ben treng de ham ra~[]g duqt: gq1 1i'1 Me miqng chtn.li ~h tk.

H ai phan niiy €;'un hOc mil;ng tMngvcl:i uhau qua de khe gill:3i eac rrLng vh qUJ'l T1J.Q-t. khounlJ: tr6ng dUllg thang, n!.m " ph:ia sau ~:u..'3 die' riin!l; htnn cum c~\n~ goi la khodn.g .sa!,,- ni,n/ci hru~~, khoDne: ni:ly v~n tro'ng ngay ca khi lui ham ding khep l~i "!"(li nhau,

24

Tierl dinh hoc m~~n,g (Ves~ibulum oris)

Khi h.oc mi.~ng a tu' the khcp, thi tH~n diIlhmi~ng chi ]~ .m~)t It houngao co hmh m6n!; ngua mil.. chieu oong 16m hUQllg ra sau, du.;lc gUlj han 0 giua mQt bin (phia truac-n.gosli) lil m5i vo. mil. v.il benki~ (pMfI sau-trong) 13. eat cung rang {ham rang) va. bet huy?t ra.nt; eua Cae Mtung ham co lQi che phUl~.

V(li chill] I:~O bllU'.Ig binh tu 4-5 em, t'i.~n dinhmi~ng gidi han bbi Cae Lui cimg. 40 neil cue ranh eua pllllt tibt dinh ~r~fl va d rJ!ii (ho~(! crm g~ i ) A !! om U 111, al nh mif ug

,~ Ctt;'g ta~ g h{l~G h'+m ra n9 ¥~, Q¢ hu~t r!ill:;! cUs cae )twlIIg ham ~6 1;);. P hO d~ gal;!~ ch u ng III 1<11"9 ffinQi"iOi

tren ua dudi). M6i ranh cua tien dinh lai duoc phan thanh hai nua-ranh, nua-riinli phai ua trai, b6i m9t nep hinh liem gQi la hiini moi (frenulum labii superioris et inferioris: hiim moi tren. va dztdi).

6 ph ia rna cua tien dinh rnieng, ngang voi rrurc rang ham tren th u hai c6 16 rnd vao mieng cua (/ng Stenon, tuc Iii ang bai xuat ella tuyen nude bot mang tai (papilla parotidea: nlui tuyen truing tai).

Tien dirih mieng thong vdi h6e mieng ehinh thuc d khoang sau-rang ham, gidi han sau cua khoarig nay la mQt nep, narn trorig be day ella nep 18. day chiing chan buitrn-Iiam ; hirdng thang dung, khi ha to mieng thi nhin thay nep nay d phfa trong cua h6' V?t.

Hoc mi~ng chinh thuc (Cavum oris proprium)

La phan sau cua rmeng, narn d phia sau-trorig ella cac cung riing-lai; hoc mieng chinh thuc hinh bau due, hoi det thea chieu tren-dudi, ph~n sau rong hon phan truce: kieh thuoc cua hoc mierig chinh thuc cung 11\ kich t.hudc cac chien cua cac cung rang (ham rang), tuc la: duong bnh truce sau: 7,5 em, dudng kieh thd.ng dung: 2,5 em, va dttCing kinh ngang: 4-5 em do knoang gifra ma t nh ai cua hai rang ham Ion euoi cung d hai ben, va 18. 2,5 em neu do khoang g iua hai rang ham be a hai ben.

HSc mieng ehfnh thuc gioi han d phia tren boi obm khdu cui xuang c6 niern m ac phu, niem mac nay tiep tuc ra phia sau d~ phu khung co-mac cua man kha'u cai (khdu cai mem) (hinh 7 -9).

Ve phia trudc-ben, h6e mieng ehinh t huc duoc gioi han bdi cung rang va hdi bd xuong co IQ1 ehe phu cua cac xuong ham (tuc bd huy~t rang cua cae xudng ham tren

va du:Oi)17. d phia sau, hoc rmeng chfnh thuc thu nho dan chisu ngang ve phia eo hong-mieng va narn sau giira cac bo truoe cua hai ngann len cua xuong ham dudi, 16i vao trong h6c mieng khi rnieng ha to, va thanh dung thing ella tien dinh hau, phan nay cua h6c mieng chinh thuc nttm giiia hai oung chan budm-kluiu. ctii d hai ben, do d6 c6 th~ vao duoc vung chan bztdm-khdu cdi d dean nay bang dudng m ieng.

Gi01 b an dudi cua h6c mierig chtnh thtrc Ia nen mieng (hoac scm mieng). Phin giua cua nen mieng la ludi, Iudi 16i len thanh m9t kh6i Ion vao trong h6c rrrierrg chfrih thuc, va cung vdi cung rang-lei d hai ben gioi han cac ranh goi la riinli huy¢t·lztiji.

Riinh: huy¢t-IztiJi (2J m6i ben) la m9t khoarig hinh tam giac keo dai, voi di'nh 6 phta sau gidi han bdi b21 loi-huyet rang narn 2J phia ngoai cua day Iudi. Ph an truce cua riinli huy¢t-lztiji co u cua tuyen nude bot duoi Iuai nho len, u nay 6 phia sau tiep sat vdi mfiu nho ra trudc cua tuyen nude bot duoi ham, cung vdi 6ng bai xuat cua tuyen nay goi li't (j'ng Wharton (doc thea am Vi¢t 18. Oac-tong). Nhfrng u 16i ella cac 'tuyen dudi Iudi tao nen I,l dztdi luiti, doi khi 13. hai u hinh mao ga, nen goi la mao dltai luiti,

6 tren ducng giua, c6 ham ludi (frenulum linguae), khoang 1 ern phia sau ch6 bam cua ham nay co rnQt u nho goi 1a CI,lC tuyin nuac bot, d g1ua dinh cua cue nay co 16 rna vao mieng cua 6ng Wharton (ductus sub mandibularis: on.g dum ham), hoi lech ra ngoai cua 10 ong Wharton co 16 cua (jng bai xua't ehinh cua tuyen duoi Iudi, goi la ong Rivinus. Tuyen nude bot duoi ludi con co nhieu ong bai xuat phu (til 10-12 ong) cling md th~ng vao ranh huyet-ludi, va chi co th~ nhin tha'y khi soi kinh ph6ng dai.

1T Cac rll.ng cua hai ham phat Iriolln W Irang cac h6 gQi III cac huy€!1 r!'lng, " cac bo duoi va Iren cua die Xl1dng ham Iren va duoi 111dng (fng, Cac ba nay ctJqc gQi Iii. M l1uy~t rang. c6 niem m<:lc mi~ng phd g<;>i Iii. I~i. £)4 cha de hinh dung. m9t so sach giao kho8 lieng ViE;!t 99i t~p h<;lp cae rang va cac ba huyiH rang c6 l<;Ii phu nhu 'lay la cung rang IQi.

25

Ni ern mae mi~ng: Toan b9 hac mieng dVQC lat Mu dan b6i niern mac, niern mac nay chi' khong phu phan varih cua cac rang.

Tuy thea tung vung trong h'ac rrrieng, riiern mac m ieng rat khac biet va c6 cau true thich nghi vdi nhimg giai doan tient ieu hoa khac nhau cua khoi thuc an.

BAt dau tU 10 mierig (khe mi~ng) 6 noi tiep noi giira da va niern mac tren cac moi, Diem mac misng tie'p tuc phu be mat trong cua cac rnoi va rna, va chua dung nhieu tuyen nuoc bot nudc-rihay " (e6 ca te bao ti.ct nude bot loang va t8 bao tiet nude nhay), rat nho, n~m rai rae trong dng biJu mo. Can phn i n6i rAng cac tuyen nho nay aUQc phan ba t$_p trung d$,e bi$t 0 nhirng vung c6 hoat d¢ng chile nang manh hon, vi du cac tuyen 6 vung rang ham cua tien dinh.

Khi tu mat trong eua moi va rna quat len phu b(j huyet rang cua cac xucrig ham, thi niern mac mieng lai thich nghi voi mot chirc nang mrri, d6 la chiu sue ep. Do vay, ni ern mac 6 day trd nen day hon, dai ben hon, kern long leo hon va giau rna soi han, trd thanh mot mang soi-nhay, va duoo goi Ia lai. Lai phu lien tuc ttt mat tien dinh (mat truoc-ngoai) cua cac bd h uyet ding sang mat ludi (mat sau trong) cua cac b(j nay, lutin qua cac khe giua cac ding, va tao nen mQt bao chac chiin 6 xung qu a nh c6 cua cac ding, bao nay phu chom m¢t chut len phan c6 rang giai phau, 6 phan lei phu chorn len c6 ding nay, hinh thanh mQt ttii cung oong quanh rang, tui cung nay nang, rna trong be day IJ?,i co chua dean vong trim cua day chdng huy¢t·rang; do d6 binh thuong giua niern mac (IQi) va M m$,t cac r{mg thvc sJ.! kh6ng tie'p xuc voi nhau.

,. Tuyen nLrOC bot co ca hai loai Ie bao tiet ruroc bot loang va tiet ntIOC nhtly. con cuoc 99i Itl tuyen pha ho~c tuyen hon hop.

26

6 phfa m$,t h101 (mat sau-trcng) cua bd huyet rang cua cac xucng ham, thi 19i kh6ng c6 cling tinh chat gi5ng nhau giua ham tren va ham duci.

o xuong ham tren, niern mac phu toan bi) be m~t cua vorn khau cai giu nguyen tinh chat soi-nhay vdi chuc nang cua no nhu khi trinh bay d phan 1<;Ji. 6 day thuc an duoc t$,p trung lai va tao nen khai (cue) thuc an trirdc khi nuot, N goai ra, ij phan sau va giua cua vorn khau cui xudng, thi trong ldp sau ella niern mac mierig co nhieu mo tuyen.

Tuy nhien, niem mac dan dan mat bet tinh chat xo (S<;Ii) kJ til: gidi han sau cua vorn khau cai xucng, d~ trd tharih m ot niern mac dai ch£c nhung mern mai hdn, co co chat cua tuyen. Niern mac nay phu len be mat cua nhfrng tru cua man khfiu cai (velum palatinum) vai nhieu t uyen nuec bot rai rae d ben trong.

Phan l<;Ii phu mat Iudi (mat sau-trong) cua bd huyet rang 6 xucng ham dirci thi nhanh chong mat tinh chat xo (sci) va chuyen thanh niem mac cua vung dudi lirdi va cua luci; riiem m:;J.C nay lat phan tren cua nen mieng, Nie m rn ac cua vung durii ludi nay va phan quat len mat duoi Ivai cua no rat mong va mern mai, nhung tuong do'i dai chac, Do do co th~ so sanh vdi niem mac cua moi va rna duoc,

Kh6ng dung lai voi phan niern mac phu mat tren cua ludi, 6 day chung toi chi nhan 'manh rang cau true cua phan n iern mac 6 m:}t tren cua 1118i kh6ng nhtrng phai thfeh nghi vdi sv van d{mg cua Ivai, rna ea voi chirc nang nern cua ludi nira.

l'Ihoallg haiti ~~h(la ng hong 111) SilU marl khiu ct.i IClJng ~h:au .'-">,-" .. ", . ..._

Nep h.au·tharm Hann nMn kMu cal----l:-~~_~;'" j anndan kh ~\J cal) TI"\l trv>Jc]Dan I{hau cfjj ---';;--t----,~ ..... (tlJlllllo;h~u ciii-IuCi)

r

,-_,.,,;.;...~- C(f chan mrom Ir"Octg D.fo~+-~- NgEmn len xumg fiam d~

-. r-~---- Ct.;JmiH ~::---~- M~c to3.u-rool ~mac hQl"9"mtit)

£Iil'lh ILroi -----'

Hlnh S .. HIOC: mh~~nl,g {nhin lli' phla trsn, cat ngang dau thea

m¢t m~t phang nam ngi3ng qua nganh len xutm9 ham dum va bo phan tr€m)

Cr;r thai dl1C1ng _,.,. .... ~~

Mom tI'I~n blfflm _....:;p,--+~+---'~~~~.

".:;-'--;,...,~~- Ctl chtifi bt!tlrn ngoai ~~irI"-....flj~,*"""I--- Co chan worn lro ng --'!---:'!'-- Co clul

Hllnh 9. H,ck ml~ng: d,le cCi nhai (Ifliet do dung ngang)

27

Nhfmg vung nong eua hoe mi~ng va cua m~t

Cac moi va vung moi

Cac m6i hi mot I09-i th anh di dong cua mierig. co chuc nang k hep kin h6c mieng 6 phfa truce tdi rmrc do cAn thiet. M6i m6i la mot nep co-mac di d9'ng duoc: nep tren hoae moi tren, va nep dudi hoac mci dudi; hai m61 tiep xuc sat voi nhau d bd narn ngang t1,1 do ella chung, tao thanh khe mieng (rima oris). Cac diiu cua hai moi gap nhau i!J phia hai ben tao nen hai mep (hinh 7).

Hi nh th~ ngoa i cua rno i: M6i moi co mot phan (bEf mat) nang d be'n ngoai, phil b6i da, va mot ph An (mat) sau a ben trong mie ng, phu bdi niern mac, hai phan nay lien tiep vdi nhau d hCl tu do cua moi.

Moi tren. nam d ben dudi tluip miii, phia dudi diilm diati miii la di@m narn d day (nen) cua urich miii. Moi tren gidi han a hai ben bdi hai ranh, nam 6 phfa sau cac canh mu i, In cac riinli miii-nui, xufing phia duoi hon d ngang muc moi tren thi ranh nay mang ten la riinli miii-moi-nui.

6 m~t nong cua moi tren, t.ren duong gii1a, eo mot rji nh dung doc, di tit day vach mui xudrig phfa duoi, goi ten la rtinli duai miii hoac riinli nluiri trung (philtrum), ranh nay tan het a gioi h an cua phan rrioi phu boi niern mac.

Bd tlj do cua rnfri c6 rnau do h6ng cua niern mac, chung t6 lOp dudi niem mac d day co nhieu mao mach mau. 6 phiin giUa cua moi treri, ngay 6 d§.u duoi cua riinh. nhan trung eo ell giua (In mot m§:u cua moi nh6 ra truce).

Niern mac cu a moi tren a dean tucng ling voi eae rang cll'a va rang nanh, se quat len d~ phli bd huy~t rang' clla xuong ha~ tren, t~l.O thanh ill9t tui cung, ho?c ranh {ren cua tit'n dinh' mi¢ng (ho$.c fornix uestibuli superior: vom tien dinh mi¢ng tren). Ranh nay chia m6i thanh hai mia

28

trai va phai b6i mot nep giua doc, hinh Iiem goi la ham moi (frenulum labii superioris ", ham moi tren), ranh nay tiep noi phan sau cua moi vdi 1<;11.

Moi dum trong da s6 truong hop narn hoi triut ra sau han so vdi moi tren, d m~t ngoai, nang, rnoi dudi ke lien vdi uung cdm d bEm dudi, gioi han giira m6i dirdi va vung cAm 1a riinh. m6i-c&m; d hai ben t.hi moi dudi dut;ie gidi han bai phan keo dai xuong duoi ella riinh. miii-mbi-ma.Viing t.iep n6i da-niern mac cua moi dudi (pars inter media: vimg trung gian) e6 hinh cu a mQt ducng cong deu dan, hoi 16m len tren. Mat sau cua moi duoi (pars mucosa: pluin. niera mac) phli hdi n iern mae rnieng, niern mac til moi dudi quat len phu cung rang 19i d dean tuong i1:ng vdi cac rang cua va rang nanh, tao nen riinh. duai cua titn dinh. mi~ng (hoac fornix vestibuli inferior: uom. tit'n dinh mieng duai).

Cling gifing nh u ij moi tren, a mat sau cua moi duoi, tren duong giua co mot nep goi la ham moi dum (frenulum labii inferioris). Ham cua hai moi trcn va dudi chinh la moe ducng giua ella hoc m ieng.

Cau trite cua mOl: Cac moi dude cau tao bdi 5 Idp mo Ian luQ't k~ tit nong tai sau la: ldp da, lap m6 lien ket·ma duni cia, lop co, lap dudi niem m ac, va lop bi~u rno riiern mac va tuyen.

* Da: da b vung moi day, grau nang long va tuyen ba nhdn; d lap sau co rn ang luoi mach bach huyet kha mau.

* Ma lien ket-mo durJi da: lop nay thieu d nhirng eh6 c6 cd bam da bam vao da: tuy uhien, a vung ducng gifia va a viing mep tht eo h&n ca mot n6t nho that su Iii mo lien

ke't sci. . . .

* Cdc co cua moi: bao gam cac cd oong moi hoac con goi Iii ca khep moi va phuc hop nhung co bam da m(tt a quanh mierig, cac co nay t$,n het d ldp sau eua da vung moi, voi eae sQi bit eheo nhau, chung t{lO nen 6 hai ben, phfa sau eae mep moi ben mOt not (cl;lC) lien ket Sau mep. Nhung Cd nay xep lam hai lop nong va sau: bao g6m: cd go ma ldn va nho, cd nanh, cd nang m6i

trim va canli miii nang va sdu, cc tam gidc mal du/ti, va ca ouoru; dm. 6 ldp sau nhat la co mut. () tn~ so sinh, trong be day cua cac rnoi , co cac b6 soi co narn thea huang sautrudc, tao ncn ca ep moi (hoac co Klein),

Trang be sau duoi cac lop ed co mot lop nhung tuyen nhay day di;te, do la nhimg t uycn (nude bot) cua moi.

., Lop niem. mac e6 bi4u mo lilt t:ing phu d b€ mat va dfnh chat vdi lop co 6 ben duoi trong cac vung cua bo tv do cua hai moi. 6 duoi ldp b ieu rna co mang hrdi mach bach huyct kh6ng lien h$ vdi mang ludi mach b •. ich huyet 6 ma t ngoai (dudi da) cua m01.

Mach mau va day thtin kinh cua moi Cdc a(jng moen ehinh cua hai moi, dung dau la cac a(Jng mach. uanh. (moi) tren va duai. deu 13. nhung nhanh cua hai d(mg mach. nuit . Cac d¢ng mach. oanh. tren. va (lllOi chui qua lop co va tea nhimh vao be mat sau cua hai moi, i'J vung gan cac bo tv: do cua moi. 0 day cac d9ng mach vanh i'J hai ben noi tiep voi nhau. Ngu6n d(>ng mach thu hai cu a moi IiI cac nhanh moi cua d(>ng mach duai 6' milt di tai moi tren va nhanh mE)1 cua aQng mach. cdm di tili moi d udi.

NhU:ng day than kinh v¢n aqng cua moi bat nguon tu nhirng nha nh cua ddy than hinh. mtit, eon day than kinh earn giac deu lil nhanh cua day than kinh tam thoa, va d~c biet la nh arih cua ddy thdn kinh ham tren (day than kinh s6 Vz)IU thOng qua nluinh. dudi 6' milt d6i voi rnoi t.ren va ddy than kinh ham duai (day thfin kinh so V3) thong qua nluinli ciim doi vdi moi dudi,

Cam va vunq cam

C6:m tao nen mot u nho d giila va dU:Bi eua phfln tnloc·du:8i cua m:;lt (t~p 1)_ Vung

,0 Than kmh so Vi, ho:;'c so V,: each viet ngan g<;ln ten cac nhanh cua day than kinh lam thoa. Than kinh tarn thoa 1<'1 day thal1 kinh s9 dt19c danh so tha V (narn). chia ra ba nhanh cung Ion. do d6 viet g(;)O elk nhanh Ii! V,. V2, V3 Ian 11I9t d~ chi GaG nhanh Iha nhat (than kinh mal). Ihil hai (than kinh ham tren) va Ihl! ba (than kinh ham dt1eJi).

earn duoc gidi han ve phi a tren VOl rnoi duoi bdi riinh. moi-cdm va phia dudi gidi han vdi vung e5 bci bCi dudi phan truce ella tluin. xuong ham dU:ui_ Ciim. c6 hmh thS ben ngoai nhu mot cu (g<;>l Ia gnathion ::: 16i c6m), l6i dim eong 16i v~ phia trudc cil thea chieu dung doc lftn chieu na m ngang. Lo'i ciim ducc phu bdi da day va dinh vdi xucng ben dudi, 6 mat sau va tren vung ducng giua, da giau nang long va tuyen ba nhrln, d day co cac b6 cua cac co bam true tiep van da teo bam da cd, cd nang c&m20, va cd tam giac moi).

Vung dim tren toan b(> dien tieh cua no tuong ling vdi vung dude goi la "vurig cam" (vung "cam" cua m~t la nhung vung rna phan b6 mach va thin kinh 1a khorig dang k~-tac gia). Hai vung earn hai ben, mOl vung d~u hinh tam giac rna dinh narn 6 phia t.ren, ngang muc V01 noi tie"p noi giua da va niern mac cua moi dudi,

Mil va vung rna (Regia buccalls)

Cac ma tao nen hai t.hanh ben cua hOc mieng . N6i chung, rna tao rien vung truncben cua mat hoac uiing nui.

Vung rna co nhitng gici han sau day: phia tren 13 bd dud! 6' miit, phia dudi la biJ duai xuttng ham dU:ui, phia t.rudc Ia riinli miii-mii va m<)t ducng tie'p tuc ranh nay di xuong phia duoi qua hai mep (cua mierig), phia sau la bd truck ella co can, bd nay 13. gidi han giua hai vung rna va vung co c:1n_ Vung rna lai bao g6rn hai phan nho hon: phan tren la oung dudi 0' mift bao v~ cho b6 mach-tluin. kinh d!ldi 0' mat va phan dudi la vung mieng tao nen t hanri ben th~ t su cua 6 m ieng va thong thucng hay duoc g9i 13. viing rna, thu~t ngu nay da tro nen thong d\lng.

Hinh thf! ngoai: Vung rna 13. m(>t hinh b6n e~nh dai thea chieu dung dQc, vung rna

2<J Co nang c~m con dl1o;1C gol 18 cO chOm (au.

29

co d!)ng mach. va tinh. mach. miit di cheo qua va co 6ng Stenon di ngang, chia thanh hai phan tren va d udi.

:via c6 hai mat: mat ngoai hoac m~t da, va mat trong hoac rn?t mierig. rn$.t da r¢ng hun so vdi mat mieng.

Mi;it ngoai cua nui, tv do va d~ di d¢ng a phan trung tam, nh ung a phan chu vi thi dinh vdi ldp xucng thuoc vg mat ngoai cua cac xuong ham tren va xuong ham duoi.

Miit trong eua rna, phu boi niern mac m ieng, tao ncn thanh ngoai cua tiiin dinh. mieng: 6 mat nay, ngang rmrc vdi c6 ding ha m tren thu hai c6 16 rnb van m ieng cua OILg Stenon, xung quanh 16 nay co rai rae nhi$u t.uyeri n udc bot cua niern mac rna con goi 1a tuyitn rang ham.

Cau true: Tu nfmg VaG sau, rna dUQC cau t10 b6i nam ldp ke tiep nhau nhu duoi day, kh6ng k~ lop marig xuong (c6t mac) rna cac phan mern cua rna bam van 6 phia t.ren va phia dudi.

* Lap da: nit mong va rihan rihui d phan t.ren , nhurig tr6 nen day hen 6 phan dudi va 6 phan nay c6 b¢ rau day, d rn at sau cua da c6 mfit Iuai mach bach huyet kha mau.

* Lap mo lien klt-md dudi da: phong phu hen 6 phan sau cua vu n.g, l6t m~t sau cua da, lop nay 0 nhirng nguoi map beo va d tn~ em co th~ chua nhieu mo. Trang ldp rna lien ket- rna co mot cue rna trcn goi Iii Cl:"C md Bichat (d9C theo tieng Viet: Bi-8a) nam 6 pha n tr en-sau cua vung rna. Kh6i rna c6 th~ lan xa ra phia ben ngoai vao lop co miit, va ra phia trudc VaG gan cd thai duang va bd truce cuu co din, rei Ian tdi cac khoang rna lien ket-md cua cac h6' duai-thtii duang va h6' thai duang; va lap day khoang tr6ng 6 trong cac h6 nay. Do d6, thong qua kh6i luong rna nhung khoang tr6ng trong cac hfj" noi tren thong thudng voi nhau va vai vung rna.

'" Cac cd cua miit, h9i tv ve phia cac nut cd sau mep, cac cd nay x<ip xep thanh hai lap kh6ng lien tl).C. Lap nong tit tren xu6ng duoi co nhling Cd sau day: cae Cd go rna. Ian va be, cd nang nong moi tren va canh miii,

30

cd cuai, ca bam da cd va ca tam gidc mot dudi. LClp sau chu yeu tao nen bi'li ca miit, ca nanh, ca n~ng stu: moi tren va eanh. miii va co vuong cam.

* Khodng gian co: 13. nhiing khoang each narn giira cac co, d§ gia nh cho die mach rnau, day than kinh va 6ng Stenon di qua. Cac dgng mach va tfnh mach m a t di thea ducng cheo goc qua vung rna, nam i':J giua bo truce-dedi cua cd ciin va goc trong cua mdt. Trong trucng hop c6 cac hach. bach. huytt rna va hach. cd mut thi cac hach nay se narn doc theo dudng di cua cac d¢ng mach va tinh mach mat.

Ong Stenon di ngang qua nih sau cua vung rna, huang di narn tren mgt duong thang vach tit dai tai tai ctinh. miii cung ben, va tren duong nay eo th@ so n<in thay 6ng. Tdi bo truce ca can thi ong Stenon vong qua bo nay, di vao trong M vong truce gan co thoi duimg; lien quan vdi cw rru) Bichat va chui qua co mut d~ rei eu6i cling md van tien. dinh. mieng hoi mot 15 0 ngang rmrc c6 rang ham tren thit hai.

* Lap kh6ng lien tuc nhftng tuytn nude bot: nam CJ mat sau cua niern mac rna, ldp nay dinh vdi mat sau cua ca mut. Trong lap nay cua n iem mac co marig ludi mach bach huyet kha mau.

Lop xuong 6 phan tren cua rna 1a tha nh rna cua xucng ham tren. (tao nsn vung duoi ;5 mat), i':J day co 16 cu a ong dl1di d milt, trong d6 co b6 mach-than. kinh duai 6' mdt. Lap xuong 6 phan ben duoi cua rna do ph an ngoai cua than xl./(/ng ham dudi tao tha nh , b day c6 [6 cam voi b6 mach. tluin. kinh cam n~rn trong d6.

Cac rnac h mau va thiin kinh cu a rna Vung rna chu yeu duoc nuoi dudng boi diJng mach. va tinli mach. mat, va thu yeu bdi nhirng nhanh cua a!)ng mqch thai dUdng, cua d(mg mq.ch ham trong va Clla dr';ng mg,ch mdt. Nhilng nh{inh d9ng rnl;lch a vung rna tiep noi vai nhau t~o nEm vung nor titp gilia hai h¢ d¢ng m(Lch canh trong va canh ngoai.

Vung (co) c~n

Vimg (co) ciin lien tiep voi uiuig nui d phia sau, va Ia vung d phia sau cung trong stl nhung vung nang cu a mat.

Vung (ca) cdn gidi han bdi cac bd cua co ciin rna no mang ten: gioi han trudc cua vung chinh 13. bd truoc cua cd can, bd nay hoi chech len t.ren va ra tr udc, gioi han duoi cua vung tucng ung vdi bd dual cua ch6 bam ciia cd cdn vao xuang ham dUd£, Gioi han tren cua vu ng la cung tiip va gioi han sau cua vung la bd sau cua ngdnh len xuong ham duoi, bd nay ctmg dong thoi 19. guri h a n trudc cua vung mang tai.

Val nhirng gidi han nhu tren, vung (co) ciin c6 hinh th@' cua rnQt hinh beln canh dai theo chieu dung doc, giong vdi vung rna lien tiep vdi no ng ay a phia truoc.

K~ tU nang toi sau, vung (co) crin cau. tao boi: da va cac bQ phan cua da, mo lien ket·ma dudi da, can cd ciin, va co cdn,

Da ij vung nay dai hen, c6 h$ thong long to cung (rau) , va htoi mach bach huyet thu rih an bach huyet dJ db' VB cac hach. oung mang tai.

Ben trong da la lop rna lien ket-rnd dudi da, chua it nhieu mo rna, di trong lOp nay co nnung thanh phan sau day:

· ct(ing mach. ngang miit, chay song song Val cung tiep va d dudi cung nay 1 em.

· r/ng Stenon, chay tit sau ra truce, di kern boi rruiu. nhO rti truce cua tuyen nude bot mang tai; d6i khi mau nay nam co 1Q_p k hoi tuyen va duoc coi nhu m9t tuytn mang tai ph.u . ()ng Stenon narn tren mfit duong thang ke til did tai tdi canh mui cung ben, va co th5 sa nan thay duoc.

· cac soi t;\in cirng toa rong cua cac nluinli thai duang-miit va nhiinh. co'-m¢t clla day than kinh m(it. Cae nhanh th§n kinh nay di qua vung cd dn va phan b6 cho cae cd bam da mrJ,t.

Can (co) c6.n phu mat ngoai cua co va dinh chat vao co, lam cho vung (ca) cdn l a mot vung day.

Bd truoc cua can (co) cdn la cho bam cua mac cd mut, 18. cd bam da mat duy nhat co mac, va lil. chO bam eho cac b6 sau cua co cuoi, la co nam d vung gift a cua rna. Bo sau cua can (co) cdn b. cho barn cua can co" nong, can nay khong phai 18. gi khac rna chi ia Hi. nang cua mac cua vu ng mang tai. VB phfa tren, can (cc) can. lien tiep vdi m(tc thai duong, Ong bai xuat va mdu nhO ra truac cua tuyen nude bot mang tai, di ra phia trudc, nam a trong mac (ca) ciin, rna d phan nay nay thi mac tach ra lam hai lao

Ca cr'in hXp d§.y uung (co) edn va dinh chat VaG ldp mang xircng cua xuong ham dudi la chO bam cua co can, chi rieng d phfa tren thi co nay roi khoi xuong ham dudi dg bam VaG mom tiip eua xuang go nui (hinh 9).

Nen (San) hoc mi~ng

Ntn mieng (hoac san mi¢ng) la khoang narn d giua vong cung 10m cu a than xuong ham duai a phia trudc, va chieu 16i ra truce cua xuong m6ng a phfa sau, gidi han tren cua nen rnieng 18. niem m\1C mieng , va gidi han dudi la Idp da dudi xucng m6ng. Hai cd ham-mr5ng d hai ben dan voi nhau tran dudng giua goi la duang dan giiia, tao nen mot hodnh co mieng (diaphragma oris), va phan chia vung nen rnieng thanh hai phan: phdn tren-ham m6ng va ph6n duoi-hiim m6ng (hinh 9).

Phdn tren-ham m6ng nam d phan giua cua nen mieng Ia oung dudi llidi, se dUQc rna ta cung voi luiti.

Phiin. duai-ham. m6ng cua nen mieng h9P thanh hoi ba doi co:

1. Cd luim-mong bam vao toan b9 chieu dai cua dUdng hdm-m6ng (linea mylohyoidea) cua xudng ham dudi. Tii day, cd hdm-m6ng di xu6ng ve phia mi;i.t truOc than xildng m6ng va VB phia dtiOng giila, d day hai cd ham m6ng hai ben lien ket vdi

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nhau tao nen duang dan giila21 di duong khdp giua cam tai xuong m6ng, Nhu vay, hai cit ho.m-mong tao nen mfit hoanh. ca. co t.ac dung nang da hai cd cclm-m6ng va luiti a vung ducng giua va cac tuytn nuac bot dUdi luai 2! phfa ben ngcai han. Cac cd hammong dU<;Jc chi phdi bdi day thtin. kinh tam thoa ; thong qua nhanh thu ba cua no la day th.dn kinh ham duai (V,J, t.ir day nay tach ra nluinli co luim-mong, 6 phia tren hai co ham m6ng la hai ca ciim-mong,

2. Co ciim-mong (Iil co doi) di tit cu clim dusti CUll. gai ci'im xuang ham dudi tdi mat tr udc xudrig m6ng va duoc chi ph6i bdi day than kinh ha thiet", nhirng soi van dQng cua day than kinh nay x uat phat tit dean tu,Y s6ng cd c., C2.

:3. Bung truac cua cd hai than2:J bam vao riinh. cd hai than (con gQi Ia h6 co nhi than) 6 bd dirdi cua xucng ham dudi, tit day, bung tr udc cua co hai than di ra phia sau, tiep theo b('Ji mot gall trung gian, gan nay duoc niu vao xucng m6ng boi mQt dai gan hinh yang thong 19n9, Co hai than cung dude chi phoi boi day tluin. kinh ca harn-rnong . Ca hai than Uli0C che phu a ldp nang bdi cd ham da co' va da. Cil ba cd cua vung tren m6ng rna ta 6 t.ren deu la cac co ha ham (ha xuong ham duoi) va nang xuong mong,

Ph/in. dudi ham-mong tuong ung vdi vung tren m6ng con dude goi la tam gieic truce eua co'. Trong phan nay ngudi ta phan biet m(Jt vung giua hoar: uung dudi c!im, nam a giua cac bung trudc cua hai co hai than d hai ben, va hai vung d ben ngoai, nam giua bung truce va bung sau cua m6i co hai than a m6i ben, thr tao nen hai vimg duai ham, hinh

21 DUlmg dan giU'a: la len g<;>1 m¢t s6 d u tao do cac co doi xCtng, cung len, a sal hal bfln dvong gilta. eo cac th<'l sci dan ket vOi nhau t<:,o nen mol dVong IhoiJng jj ehinh gilta, co khi g;6ng nhlI mot gan dai, chae. Vi dl,l ve duong dan gilra nhu vay thay 0 giCta hai ca Ilfim-m6ng a nen mieng, hoae giiia hai co nimg h~u man a ph,;n day ch!iu, a thanh sau ella hAlf (hong),

n Day thfirJ k;nh ha thiet: trong it saeh tie'ng Vi$t con goi Iii Ihan kinh (fal h? thief, lil doi day than kinh so 56 XU, ehu yEiu chi ph6i van dong cae cd ella 11IDi va m¢t 56 cd eua vilng Iren mongo

2J eel hal than cOng goi la ca nhi than, loai ea eo hinh the d!lc biel 1;'3 co hal bung eel n61 tlap vdi nhau bai m¢t gan a gilia.

:i2

tam giac, se duoc mo ta d trong chuang n6i ve tuyen. nuac bot duai ham,

Luai va vung IUdi

Luiii la mot e6 quan cau tao bai co va mac, bJ mat ludi duoc phu bdi niern m ac day, va deiy lUdi (hoac cu6ng ludi) dinh lien vdi nen rnieng, hinh thanh mot vung d giua cua ph/in. tren. ham-mong cua nen. mieng, Niern mac p hu mat tren 1uai c6 chua co quan vi gitic, la hi? phan cam nhan giac quan nern, va 1:l noi phat sinh ph an X? tiet tdi cac tuyen nude bot phu thuoc hoc mierig (hirih 9-12).

Phan truce cua ludi la phan t1._1 do, c6 kh a nang ch uyen dong rilt d@ dang, Phari nay cua luai, chiern toan bQ phan khoang rn ieng n:lm i'l ben dirdi vorn khau cai xUdng, va gidi han (j hai ben va phia tr udc hi'li cac eung rang lei tren va duoi,

Khi ngam mieng, thi Iudi lap day Me mieng chinh tluic va bien hoc nay th anh mot khoang ao. 6 nhimg ngudi bi thieu rang, thi Iudi con c6 xu huang chui VaG d, nhung khoarig trong do thieu rang do.

Ludi Ia mot co quan phu cua duorig 'tieu hoa vi nho nhimg gai llldi nguoi ta cam nhan duoc nhfing vi co ban va darih gia dUQC chat lucng cua thuc an. Ludi cung tham gia vao cac hoat dgng rmit (hut vao), gill thuc an trong mieng, va phan phoi t.huc an VaG khoang giua mat nhai cua cac rang,. Ludi gop phan tao nen kh61 (cue) thuc an, diy n6 v~ phfa sau tdi hdu (hong) VaG hie nuot. Luoi con la mot co quan tao ICJi n6i va hoan thien am thanh phat ra tit thanh quan,

Hinh th€ ngo al: Ludi co hinh bau due vdi true dai truoc-sau, hoi det theo chieu tren-dirdi, vdi mQt dinh hUang ra trudc, Luai c6 hai m~t, hai bo, illQt di'nh21, va mgt day (hotitc radix linguae: riI fudi).

24 f){nh /Ifili 103 dau phfa trllde, thlJ nho, mong, hai nhon eua IUDI, ngon ngii dan gian gqi oinh 11IDi la eMu /wi. Day /wl lil philn sau cung eua IUDi, riing, day, ng6n ngli dan gian hay goi lil cu6ng /Ifili.

Mtit tren. hoac lung llifii (dorsum linguae) det theo chieu ngang va eong 16i theo mat phfing dung doc. Giua mot phan ba sau va hai phan ba trirdc cua mat tren co mot ranh hin h chua V goi la V luiii (sulcus terminalis: riinli t¢n), ma ra phia truce, (j dinh cua V ludi co mot h6 nho goi la l(~ tit iforamen caecum), day la di@m g(i.p nhau cua ba m am phoi thai cua ludi, va dong t.hoi cling 18. di~m phat sinh tuye'n girip 6 gia i doan phfii thai (hirih 10).

L6 (it d ngiroi IOn co th~ th~ hien nhu: mot h6 16m nong hoac sau, Nhung khi 16 nay giu nguyen tmh chat phoi thai thi se 18. mot 6ng thong tit L/J (it toi t~n eo tuy{tn giap .

Ph an m~t t ren hrdi a phia trudc V luiii, con goi 13. pluin. mieng ella luoi, narn ngang, c6 mot ranh chay doc theo chieu trirdc sau 0 chinh gifia, nen goi la rtinh. giiia (sulcus medianus). 6 hai ben cua rarih nay niern m ac IUdi co nhirng 16i rat nho goi la cac gai lu:ai~>' then kfch thirdc Ion dan va so lucng nho drln, cac gai nay duoc goi In gai chi, gai lii, gai ruim. va gai doi; Cac gai dai, hoac gal co rtinh. bao quanh, chi c6 9 toi 11 cai, cfmg xap xep then hinh chu V b ngay phia tr udc ranh. tan; trong cac gai adi nay va cac gai ruirn, gai Id co nhung rui ui gidc, tuc la GtC co quan nha n cam (receptor)" vi giac, trong khi cac gai chi thi giu chuc nang co hoc.

PhAn mat tren ludi d phfa sau V Iudi, con gqi Iii pluin. luiu, dung doc, co dij.c di~ill iii noi t<~p hop ella rat nhieu cac nang bach. h{JYet. bo trf khorig deu, toan bO duoc goi la

;C Cec gai Ivoi co 4 loa, 99i lil gai hinh chi (nho nhl1 so: chi). gai 1;3. gai hinh ntim va gai hinh rial. De cho gon, trong tai li~u nay se chi dung cac W: g</J en], gai I". gal norm va gai rial. Gai luoi con goi la ntiu l/.fa, (nhu dai, nhi.! nam, nhu la, nhu chl).

zs Co quan nhan cam: lil nhlfng cau true co chirc nang d~e bi~t lil thu nhan cac kich thich W ben ngoai ho\lc ben trong co Ill",. va thu6c nh;eu bim chat khac nhau (giac quan. cam giac. Ihay dOi ve huyet ap. v€l eac khi trong maul. rEii dan Iruyen vao he thong than kinh de xU' Iy. Ngay nay cae tai li$u tieng Anh. Philp va co the nhieu thu tieng khac giii nguyen W receptor de chi nhiing cau true nay (Iham chi la cae eau true phan tLi a mang te b~lO de tiep nhiln cac phfm tLi ben ngoai nhl! hormon cling dlfoe 99; la receptor). Do do chung toi dung h3i thullt ngil thay dbi cho nhau: receplor ho~c co quan nh~n cam.

hanh. nhdn lu:Bi hoac amidan luai": Gidi han sau-dudi cua ph in sau nay cua ludi co ba nitp luiti-thanli thi¢t28, trong d6 c6 mot nep giiia (plica glossoepiglotticae media: nep luoi-thanli thi?t giita) va hai nep ben (plicae glossoepiglotticae laterales: nep luBi, thanh thi?t ben), deu noi ludi vci sun thanh thiet, va giira ba nep nay co hai 16m nho goi la cac thung liing thanh thiet (valleculae epiglotticae).

Mat dudi cua hidi kern phang han so vdi mat tren, va d tren ducng giua c6 mot nep goi Iii ham luBi (frenulum linguae), ham ludi n6i m$.t dudi ludi vdi riinli huy?t-luBi va c6 tac dung han che cac d(Jng tac cua dinh Iuai.

o hai ben cua day ham Judi c6 hai C\1C nho n6i len do la cac CIfC duoi fum, tren dinh cua mM cue co mot 16 mo cua dng Wharton; ben ngoai nua' co 16 md cua cac ong bai Xllat chfnh cua cac tuyen nuoc bot duci hrdi (eng Bartholin), xa hdn ra phfa ngoai thi eo hai \1 tuyen nude bot dudi ludi, vdi 16 mo cua nhirng eng tiet phu nho hon (ong Rivinus, khoang 5-10 eng).

Song song vdi ham hrdi, d mat dudi ludi mBi ben co mot vet mau xanh cua tinh. mach. luai sou, gidi han d phia ben ngoai bbi illQt mao nhi) hoac mot nep lorn nho goi Ia nep ren (plica [imbriatai, chay song song vdi bO hrdi,

Hai b& ben cua ludi tron va nhan, lien quan voi miit luiti cua cac rang. D9C thea phan sau cua cac bd nay c6 cac 16 rub ra ngoai cua cac tuyen nhay Weber.

Dinh luili (apex linguae) det thea chieu tren-duoi, Iii. phan di dOng nhat cua ludi, Ve phia dinh ludi, con co mot doi tuyen nude

21Hanh nnen la W dieh W amydan (nghfa tieng Phap) de chl cae Call true mo Iypmpho it nhieu t~p trung. ndi sinh san ra eae te bao Iympho. Trong tsi li~ll nay 5e dung hai tll nay thay the cho nhau va Iii dong nghl~

1. Thanh Ihi~1 (Epiglottis) la ten goi m¢t sun a phfa trEm eung eua lhanh quim hinh giong cai IlIOi, co chue nang d~y kin thanh quan trong d¢ng tac nuOt. do do trong cae tili lieu tieng Viet eo hai c,kh goi: sun lhanh lhi~t. SI,Jn nAp thanh qUiJn. Tuy nhiim. theo danh phap quoc Ie thi epiglolliis eo nghfa la tren thanh mono

33

bot th uoc ]09i tuyen pha, goi Iii tuy6t Blan.din-Nuhri:

fJay (cuong) luiti la phan ludi dinh vdi khung xuong va Ia noi hoi tu ella nhfing co tham gia vao cau tao cua ludi; phia ben va dudi cua day llidi la noi die mach mali va thrin kinh di vao luiii.

Khung xu'dng-scji ella lu'oi: Ludi nhu mo tit 6 ph an trcn kh6ng co khung xuang rieng; tuy nhien, vi hrdi duoc tao nen chu yE'{u bdi n hieu co, trong so d6 co cac co chi na m iJ hen trong ludi (noi t.ai) , nhung 19.i c6 nhieu co di toi ludi til ben ngoa i (ngoai Jai), nhc) cac co nay rna ludi co th~ chuyen dong dit de dang, nen co thd mo tii khung xuang ij giap vdi Iudi , HI cho bam cua nhung co ngoa i Iai, va mfit khung s~ti cho nhung co nci tai bam. Khung xuang cua ludi baa gom xudrig m6ng va mom tram cua xuong thai duong: con khung soi cua ludi baa gom murig mong-luai, bam VaG bd tren cua xuong mong, d phan giua hai sitng nho cua xuong nay, nurn d duoi niern mac phu mat treri cua Iu:di, va vao odch. luiti. Veieh lU:di Ia m ot ma nh sdi hlnh liem, dung doc 6 trong mi)t pharig dung giua cua ludi, day cua cdch. htdi dinh vdi mang mong-Luai va than :alOng mong ; eon dinli cua urich huang ra phia tr udc ve ph fa dinh. lztdi. Cac co ham Vila khung xuong sqi nay d~ cau tao nen hr(Ji (hi nh 11).

Cac co cua hidi: Luiri Ia m(Jt khci thit, rtQng tfnh cua ludi la d9ng tac phoi hop cua 17 co, trong do 16 co ]h nhung co n:lm ij hai ben aoi xung vdi nhau, va kh6ng baa gii:J thicu, cac co nay tao thanh 7 doi, va 2 co ]13; c6 mot co khi co khi kh6ng goi 1ft ca hanli nhfin-ludi (amidan-Izt(ji) (hlnh 12, 16, 17).

A) Citc co tit ben ngoai di tiJi htoi (ngoq.i lai)

* Cd elim-ludi (m. genioglossus) Ia cd doi, nAm doi xling, tSlo nen toan b9 ph§.n truOc·duoi cua ph§.n Ivai di d/?ng ella Iuai. Co b£t dAu tit phia trUde bdi mQt gan bam v1lo mom clim tren eua gai cdm ij m;'!.t sau than xUdng ham duoi; tit day cae b6 cd toa len trcn va ra sau thanh hlnh qu~t, v6'i nhling s9i cd c6 ehieu hUdng khac nhau, tl,lO cho ]uai co nhung dOng Hie thay d6i. Nhung

34

b6 sci co tren cung tao thanh ducng' hinh eung cong ra truoc, di toi t$.n dinh. luiti va d€n bam tan vao can ella ludi. Nhiing b6 soi co duoi cung thi hau nhir narn ngang tir trUoe ra sau, Wi bam VaG b(! tren. xuang mong , va VaG mang mong-luoi, ktl ca vao sun thanh thiet, Nhimg' b6 sci trung gian d giira hai 101:1i k~ treri, thi day d(tc, chay chech tdi ph An sau ella Ivai.

D¢ng ttic: Khi nhirng sci tron cung co, thi keo dirih ludi xuorig phfa sau ph in duong khdp giua ella cAm. Nhung soi trung gian (; gifra co co, thi ep Ivai xueng ncn m ieng, con khi cac soi dtrdi cung co t hi keo xuong m6ng len tren hoac dua dtnh Iuai ra ngcai m ieng.

* Co tram lztdi (m, styloglossus) cung hl co a6i, bl1t diu hoi mot gan nho a phia sau bam vao mum tram xlLdng thai duong, til day cac b6 soi co toa ra hirih quat toi vung day va phan sau ella ludi, Co di tit mom tram toi ph an ben cua than luiti.

Nhirng soi a treri cung cua ca tram-luoi t9-0 ncn bCI cua Iuai, suet tu day t6i dinl: ludi, c6 mQt nh6m b6 sci co huang vao phia duong giira va bam t~n van odch. luoi, con mot nh6rn 16 sci co khac thi t9-0 nen phan ben cua phlin sau ludi,

Nhirng sci co d dudi cung bit cheo d phfa trudc vdi cac soi ch inh ella ca sitngIUcJi, r6i vdi phan chinh, tile phan day hrdi ella ca dutti-luiii, tie'p rue di vao phia trong cua co nay d~ bAt ch eo voi cac soi ella co luai duci va tdi dlnh. wDi thi b~t ch eo voi cac soi ella co tram-luiti ben doi dien,

D¢ng ttic: Khi mot co trn m-ludi co thi keo ludi ra phia sau, lim tren va ve ph ia ella ed eo; neu ca hai ed co dong thdi. thl chung keo Ivai len tren va ra sau, ve phi a man kha'u cai.

* Cd dztai-lztdi (m. hypoglossus) la cd doi, hinh ehu nh$,t, nitm 6 hai ben ella day lztdi, ben tren xztdng m6ng. Co bao g6m hai phlin, khac nhau tuy theo vi tri bam vao xudng m6ng. Phan sitng-Iudi bam vao toan bi? ehieu dai cua bd trim sung tan xztdng m6ng va pMn tiep giap ella sitng nhd xztdng mongo

L:i lit c\iallJoi ____'~~r:--\j+t---~ ... ~ Ran h ~~n tr.\ir~ hinh cht! V) dl1lIL~ Gal (f1lj(NhU rlai) GSlia [llhirli3j--q,::

Gl1l nOli (lIhu nOn) -- ..... -...;;..,......::...._-

Khe: Ihllnll mtln (tnarm rn1:m) Nep 1ha.nh amlday Ihanh NEip lien diM (da~ lhM1h 3m 1J18-----f"!f.I ~ rMV ihar.f1 am lrtml

NCp Ilbeu-lhanh lIli~t IPr.h.nap thanh mOl'll Ngacn hlnh qua Ie

Syn ltianl'llhlet (nap 1hanh mlrl) ti~T1II1ffi..th.oliih lN~t Wi ~hoac nyool)

Th1Jr']1lung th.anh!.hie{ --:::t=.==~b~.~~'

Mep Iuffl.-lhanh lh~ giCia -,,!OO,---.....,... ......... -- Hanh r.MIl um ~amidan J~)

,....,--~_=___:t_I~:_;__- [Jay k.rCii tcuoilg I~~

Hgnh Ilhan h.llJU ctIl

[am' dan koolJ cai}

___,.-~ Tru tl'\Jdc rna'l kMU C<ll

l cwng kh&u cai- JJJai)

~r--=""-!i::""""""i-- I<huy~l gll1fl pheu ~--'-,*",,-- Cu s~nSiun!l lII;.iH ..... ...,..;,-..- eu SLm ct1~i11

Hinh 1,0. Lu'Oi (phan nam ngang \!13 phan dang Lh~mg) va .0 t'hanh quan trim (l6 vio tll,anh qUiA)

-----V~ch IIlOi ('IIam yiO'a ''.[(11)

Mfll dLtlll_-.:-

TIi!!n dinh mi(!ng __ -":~..r-

Hinh 111. LLf6li va nen hoc ml,;ng (thi€t do d(mg d9C gil1a)

35

ccr khiu ~1·II,JIOi -~---~ C(1lrrun-l~ ---~~- .....

Hqnh rtMn kh~u cai (amidan kMll aail .,..._-~ GO' IrIlm-mOng

n~----- ell'lrarn-MIJ ,..-&.~~--~- Co: kM: hau wen M loo-hau

c:a earn-Iva ~-___..

CCI carn-rrtt:.l1g -~- ....

Gel mong'~Jd ...I'

Ga trilm-morl!} --~----

"'~ng giap-mOflg _~~ _,;

CO'gl~p-mbng ~- __ ~ _ _..

Miiiflh !lim 1Tai GUo! S\ln 9 ia,p Co nha niliir~, bOo thiN;l, I:l6 chech

Hinh 12. CalC cd cum ! urBi

Cue duallurn~_~--=....1'::"""':'

6ng~i~al~nl~- ~~~~

~C_~_

aia tuy€n dum Caea"~lmrn---~~~.

~---:=----- rUytll nli~ bQ! doo lurn ......_-~--~-- 6~1 tJa I ~u1it cua tuyo&h dV(ll nam ~--....:;:.~~---- Tuy€in nutm:: bot durn ham

36

Phdn aay-ludi thi bam VaG than xuong mong ; vao bCi lorn cua eh6 barn ella ca c&mlliiii va VaG phia tren eha bam cua ca hamtruing d xuong ham dudi. Tli nhling nguyen u.y nay, ca hai phan cua ca dudi·lllai, each nhau bdi mot khnang t rorig; di chech len tren, ra truoc, va VaG trong, tdi phan ben ngoai cua ludi, Hai ph An nay duoc lien ket vdi nhau boi nhirng b6 tren ella co tramluiJi rna chung bth cheo, r6i Ch0Y tiep tdi dinh. luiJi va tai otich. luai.

D¢ng lac: co duci-luai keo ludi xuong dudi, Co nay Ia d6ng van voi co c&m·luai, va voi co iram-luai d mot rmrc do nhat dinh. ~eu ca hai co hai b~n cling co thi hai co durJi-llldi keo Iudi ra ngoai mierig.

* Co khilu cai-ludi (m.palatoglossus) la co doi, tao nen tru truoc cua miln khilu cai (eo mieng- hong). Co khdu cai-luai chay trr tren xu6ng dudi va VaG trong, tdi phan ben cua day luci, 0 day cac sci cua co nay tr9n tin vdi cac h6 soi cua cao co tram-ludi, Iuiul,tai va hanh. nluin-luiii,

Doru; tee: tham gia vao dQng tac nang dflY JUdi, lam gia m kfch thudc ella eo hcngmi?ng.

* Ca luinh. nhan-luiii hoac amidan-ludi (m. amygdaloglossus) duoc cac tac gia Phap ncu len nhu mot co khi e6 khi khong. Khi co thi n6 duoc rna ta Iii mot b6 co nho bam VaG can hau, can nay eli tie'p Vr2 phia m?t sau ella hanh. nhiln khdu ciii, Til day, co h.anh. nhtui-ludi di xuong duci tdi day luiti, va vao phia trong d.§ dan voi eel cung ten d ben d6i dien:

DQng tac: hai co cung eo thi nang day luiii len tren ve phia uom khdu cai.

,. Ca luiu-luai (m.phcryngoglosssus) t.huc ra chi la nhirrig b6 tren cung cua co khil luiu. tren , cae b6 co nay chay xu6ng dudi va ra trtrdc d dudi ca duai-Luiti, r6i tron l§.n voi nhung b6 s<;li eua cae cO khae ella llidi.

EJ(ing tac: keo ludi ra sau va hdi len phia tren

B) Ccic ea ndm d trong lltdi (n(ji toi) * Co luisi dllai (m. longitudinalis inferior '" co d9C duci): tao nen phan duoi ella ludi; eel nay a phi a sau thi nam giua ca eiim-luai va co duai-luoi, con d phia truce thi n~m giua ca trtim-luiii va cd cdm-luBi.

tJ(mg tdc: keo dinh ludi ra sau va xuong duoi, lam cho Iudi ng:ln lai va uon ludi eong len tren.

'" Ca IUdi tren. (m. longitudinalis superior =: cd doc tren) nim ngay d ben dudi lop niern mac va ldp can cua mat tren hrdi: co chay doc til aay luiti tdi dinh ludi va bam vao dinh. IUiji.

fJ(jng tac: nang dinh ludi len cao va keo ludi sang ben ve phia co co.

'" Cd ngang (m. transversus linguae =: ca ngang luai), bao g6m nhtrng b6 soi co chay theo chieu ngang cua ludi, do d6 la mot CO l€~, narn a ben duoi cua co doc tren ciia luiii. Cae b6 soi eo bam VaG m?t ben cua udch. lUdi va VaG mat sau cua lap uijm cua niem. mqc phu b6 ludi,

fJ{jng tdc: co ngang luih co se thu nho chieu ngang ella Ivai va do do lam tang chieu dai cua ludi, hoac uon ludi eong thanh hinh mang d9C.

>I< Cc dung doc (m. uerticalis linguae =: ca dung doc luiii) xuat phat til mat sau ella can luai, r6i den bam vao lop duai niem. mac ella m¢.t dudi luiii,

fJ(jng tac: lam det lum theo chieu tren-dudi. Cae mach ma u va day than kinh cua hiO'i (hinh 16 va 17)

fJ(jng mach: Iudi kha giau mach mau nuoi dudng, chu ye'u 18. cac nhanh cua d{jng mack IlliJi va thir ye'u Iii cac u(jng mach. khdu cai len va r1{jng mach. hdu len (nhanh cua a{jng mach. ctinh. ngoili).

C6 hai vung hinh tam giac qua d6 c6 th~ vao duqc tOi a{jng mqch htiJi, trong hai viing nay, di_)ng m~eh Ivai chi bi ehe khuat hOi cd mong-luiJi va tuye'n nUde bQt dum hilm.

Tam giac Beclard c6 nhung qmh HI.: sung Ian xuong m6ng, bd sau cua cd m6ng-

37

ludi va bung sau cua co hal than, trong tam gif1C nay, dorig mach Ivai b5.t cheo day tluin kinh h.a-thiet:

Tam gidc Pirogaff, c6 nhirng canh sau d:1y: gan trung gian cua co hai than, be sau cua cO luim-numg ; va day thtin kinh hathiet, Trong thuc te, neu gap trudng hop chay mau 6 at d ludi, th i nguoi ta ua that than cua d¢ng mach. cdnh. ngoai hon la thAt fieng dong mach Iudi.

Tinh. mach: 'I'rcn dean dftu thl tInh mach Iudi di kern dong mach ludi; nhung sau d6 thi rdi xu dong mach va chay ra phia ngoai,xuat hi~n cung vdi day thlln kinh halhi¢t (j khoang giua co mong-ludi va bd sau cua co ham-mongo Tinh mach luai nhan cac rink mach. Lurig luoi, tinh. mach. lltdi stiu , va tinli macli duiti ludi d6 VaG nhu nhung nhanh ben, rai di vao ph ia trong tdi co trtim-mong va de; vao iinh. mach. canh. trong hoac true tiep, hoac qua m9t than chung vdi hai ti nh mach khac goi la than tinli mach. guip-luai-miit.

Mach. bach. huyet: cac mach bach huyet cua vung Ivai vg mi,it dinh khu c6 th~ chi a ra 13m ba nh6m chinh:

1. Nh6m mach bach hu yet day Ivai va b(1 Iliai, de; vao hach. dltai-Cd hai than; cac mach bach huyet sau cua ludi cling d6 VaG hach nay.

2. Nh6m mach bach huyet xuat phat til phan lung cua ludi nam d phia trudc V lliai (sulcus termi.nali.s linguae) thl de; vg cac hach na m d ca n h than tinh. mach. giap-luoinuit, Bach huyet d phan ndng thuoc b(j cua nhung vung nay thi t.huong hay db vif cac hach. duai ham hen.

3. Cac mach bach huyet d vung dinh Ivai t hi hoi tv. ve cac hacii dudi eam, tU day bach huyet se dude dAn tai ehu6i hach. tinh. mach canh. trudc, va d6 vao trong nh6m hach. vai-m6ng.

Sa db nay c6 th~ thay d6i, nhat Ia khi cac mach bach huyet xufft phat til vu ng na m 6 g<'\n giua bd cua ludi.

Nhilng day than kinh v¢u dOng cua ludi hAu het deu Iii nhanh cua day tluiri kinh

38

ha-thiet (day thdn kinh SQ sf/XII), day than kinh nay chia thanh mot so ldn nhirng nhanh cho m6i b6 cua cac co Ivai. each ph an bo than kinh nay cling nhu so luong IOn cac co cua IUdi la Iy do lam eho Ivai c6 d¢ng tac rfit da dang. Trang so nhiing day than kinh khac, thi chi' c6 day than kinh thi?t hau chi phoi van d¢ng cho co khtiu cai-luai.

Day tluui kinh cam giac: cam grac cua ludi dVQc chi phSi bdi ba day than kinh khac nhau: thtin. kinh tam thoa, thong qua day than kinh lltdi nhan cam giac 6 dean truce V Ivai; tluiti kink thi~t-hau nha n cam giac d ph§.n sau hrfii, tru mot khu vl.je rfit nho canh-thanh. thi?t 6 giira, do day thiin. kinh phi/~ui nhan cam giac, thong qua nhanh cua n6 la ddy than kinh thanh qudn. trsn,

Than kinh giac quan (V! giac) d hai phan ba truce cua Ivai duoc dam bao bdi day thung nhi (nhanh cua day than kinh trung giari Wrisberg, hoac day than kinh VII'), di tdi no'i tiep vci day than kinh lUdi d~ Wi ludi,

MQt phAn ba sau cua Iuai thi vi giac do day than kinh thiet-tuiu va than hinh ph,"vj dam nhiern,

H~ thong tuyen nUO'e bot ella hoe mi~ng

C6 rat nh ieu tuyen nude bot d6 chat che tiet cua chung vao trong ho~ mierig. Cae tuyen nay dli9C phan bi~t tha nh hai 10Q.i: cac tuyen 16n va tuyen nho.

Nh Gng t.uyen nlioc bot Ion: la nh iing dDi tuyen n§.m doi xung d hai ben, thea thu tl.j vi trf tit phfa sau ra phi a trudc c6: tuyen mang tai, tuyen. duai ham va tuyer: dUdi luiJi (hinh 13).

Hai d6i tuyeri dudi ham va dudi Ivai thuoc ve vung n€n mieng ; trong khi d6i tuyen mang tai narn trong so nhung thanh phan cua khoang canh-luiu,

Nh ung t uyfin mroc bot nho cua nrem mac rm e ng: Niem mac mieng thuong xuyen <'im uot nho nhung tuyen nude bot nho tiet nude bot nude (long) va nhay VaG h6c mieng. Cac tuyen nho nay cung duoc phan biet thanh ba nh6m thea di nh khu:

1. Cae tuyer: m6i-ma: narn d trong rn9t lop mo lien ke't mong duoi co hoac ngay ben dudi niern mac, lam cho niern mac 16i vito trong va e6 ve nhu c6 nhieu nu m. Cac tuyer: moi-ma nay tf,tp trung vdi sO' luong nhieu hen 6 xung quanh [0 mieng va d phan giua cua tien. dinh. mieng ; 6 day chung h9P thanh nhling tuye'n riing ham b xung quanh 16 cu a i/ng Stenon.

2. Cric tuyen khi£u cai: narn d trong Idp rno mong dudi niern rriac va trong ldp niern mac phu be mat man khdu cai d vung canh dirong giua: 0 vorn khau cai xuong, lap rna chua tuyen nude bot dinh ch$.t VaG lc'Jp niem m ac vi: cot-mac, d vung hai ben dudng giua thi tuyen mau hen, 0 man khriu cai, lap rna chua tuyen nude bot giarn dan be day, tr6 nen mong d phan rnang: ldp mo chua tuyen nucc bot nay phil toan bQ vung kh&u cai va ti~u thi¢t29

3. Cdc tuytn luiii, d§. ducc trtnh bay, narn a sau duoi niern mac cua vung ludi d sau V ludi, sau hon ca lap cac nang bach. h.uyet: 6 cac bCi [uBi thi e6 nh6rn nhung tuyen nArn ngay trong lop niern mac, su6t tu V ludi tdi dinh. ittiii. Mat dudi cua dinh lui'Ji e6 doi tuyen nude bot goi la tuyen Blandin-Nuhn voi kich thudc khoang 10-15 mm, riarn sau trong 16p co va d6 ra hoc mi¢ng bing cac ang bai xu at nho (cac tuyen nay 1a nhirng tuycn pha, nucc-nhay). a day ludi co tuyen nude Ebner.

Vung du'di lU'Bi va tuyen nu'dc bQl dttCIi hJ6i

Trong khoang giua r1riy ludi (cuifng luai), xudng ham dltdi, niern rn~c n~n

,. Ti{;u til!¢! 103 mol mom nho nh6 ra khoi phan giiJa ella bo sau mim kllifu cal. r!g6n ngiJ dar! gian g<)' la flIm gao

mieng, va phan dudi n€n mieng n5i 1en mot \1, tao thanh khoang (vung) dirdi ludi, Trong khoang nay c6 chua tuyen. ruatc bot dudi ludi vdi ang bai xUllt ella no, mdu nM ra truoc cua tuyen nude bot dudi ham di kern bdi 6>ng bai xuat cua tuyen nay (6ng Wharton), b6 mach-than kinh ella Iudi (g6m aijng mach, tinli mach. luiii, va day tluin kinh lU:di vdi cac hach. ttiuc v(it phu thuoc) va day than kinh ha-thiet (day thfin kinh S9 so XII).

Vung tao nen phan tren-ham-mong (tuc phan tren) cua nen mieng la mot vung hirih lang tru tam giac duoc gidi han bdi: mat ngoai cua day luai (cu6ng ludi) d phfa trong, mat trong cua xucng ham dudi a phfa ngoai, va co ham-mong d phia dudi-ngoai. a mat trong ella xucng ham dudi thuoe vu n g nay co mot hO' nho la hi;' duai-luai, narn d ngay phia treri cua eo ca ham-mong (go xuong di co harn-rnong bam vao). Hai eo ham-mung la m9t hoanh co cua nen mierig, ngan each vung dudi ludi vdi tam gitic duoic&:m a phia trudc, vdi phan truoc ella oung dudi-ham d khoang giua, nhung hai vung nay (dudi-Iudi va dirdi-ham) thOng thuong tv: do voi nhau b phfa sau ella bd sau ed ham-mongo a phia treri, ph an tren cua n{!n mieng duoc ehe phil bdi niern mac mieng, di tu bi'J huy¢t rang ella xuong ham dudi toi day luiti. Thanh nay (tuc la niern mac mieng) lien tuc vdi thanh tren cua vung dudi ham.

Vung du&i-luai chua dung nhilng thanh phan sau day: tuytn nude bot dum [uJi, milu nh» ra truce ciia tuye'n nude bot dum ham di kern voi {/ng Wharton, cac day thrin kinh lui'Ji va thdn kinh ha-thiet, dqng mach, tinh. mach. lui'Ji va cac mach bach huyet.

* Tuyen nude bot duai luiti chiern khoang ldn nhat cua vung, day 1a mot t~p hejp nhling dam tuyen nha, to an bQ t~o n€m m9t kh6i n(tng khoimg 6-8 g, voi ehieu dai lil. 25-30 mm, ehieu cao lil 11-15 mm, va ehieu day Ja 5-6 mm_ Tuye'n nude b9t dU:di ludi duqc bao b9c bdi mQt la rna lien ket-xd, m9t phan (phan duejj-trong) duqe phll b6i m9t la mong mo mO. Tuyen e6 hai rn$.t, hai b6 va hai d:iu hoi;ie e\le (hinh 13).

39

- M¢t trong cua tuyen, phimg, lien quan vdi co c6m-htdi va co ciim-rnong , tuyer, nude bot va hai co nay each nhau mot khe, di qua khe nay e6 cac thanh phan sau: day than kinh Luisi, cac d{jng mach. va tinh. mach. duai luai, dean cudi cua day than kinh ha-thiet (XII) va 6'ng bai xuat cua tuyen nude bot dudi ham ({{ng Wharton)_

- Mi;it duai-ngoai cua tuyen, 16i, nam gon trong ha duoi ludi a rn at trong xucng ham duoi, ngay tren cd ham-mongo

- BiJ dudi cua tuyen, morig va 16i, lach sau VaG trong g6e giua co luim-mong, co ciim-mong va co cdm-ludi; viern ta:y n€n mieng e6 th~ ph at sinh 0 trong khe nay, D6i k hi, vung dudi lttEh c6 th~ th6ng thuong vdi vung dudi ham qua khe giila nhiing b6 tach rdi khoi nhau cua cd hiun-mong, vi co nay chl duoc phu boi mot la morig m6 lien ke't c6 nhieu 10 t.hun g.

Dng bai xuat cua tuyen dudi ludi c6 mot ong chinh (ductus lingualis major) con co ten la {/ng Bartholin, 6ng nay di kern vdi ang bai xuat cua tuyen dudi ham (tuc Ia (/ng Wharton, rno vao mieng 0 dinh cua eve dudi ludi), va rna vao 6 rnieng bai 16 narn d phi a ngoai cue dudi luoi, tuyen dudi luai con e6 nhieu ong bai xuat phu, nho, rna vao rsnh huyet-ludi boi nhieu 16 nho ni'irn tren ducng thang doc theo true dai cua If dudi luei.

* Mdu nho ra trudc eua tuytn nudc bot dudi ham: muc dQ lOn nho thay d6i vi miiu nay keo dai c6 th~ toi sat cue truoc cua tuyen dudi ludi, hoac kh6ng vuot qua mfit phan ba sau cua tuyen nay. Du trong tinh huang dinn khu nao, thi ngiroi ta cling nhan thay mou nh6 ra trudc cua tuyen dudi ham dt1u duoc ket noi chat che voi bi:! dudi cua tuyen dudi lu'm bdi mot 15. rna lien ket-xd nho, cung vdi cac mach mau va day than kinh.

'" Ong Wharton: di VaG vung dudi lUdi tn3n m9t chit1u dai tU 30-40 mm, va nAm d trong khe a giua tuyen dudi h.:idi va day ludi (cuong Iudi), chi d duai lOp niem mlilc phu nen rni~ng c6 vai milimet, va d phia tren cua m6.'u nh6 ra trude cua tuyen duoi ham_

'" Day than kinh ludi: la mQt day th{in kinh cam gi3.c va giac quan (v~ giac), va la

40

mot trong nhfrng nhanh cua day than ntnn. ham dr..tdi (13)' Day than kinh htdi di VaG vung dudi Iuai, biit cheo ang Wharton tU ngoai VaG trong va ttl' dudi len tren , d trong khe giua tuyen duoi ludi va mau nh6 ra truce cua tuyen duoi ham, d day day than kinh tach ra mot nhanh quan trong cho tuyen nude bot duoi ludi, Sau d6 day tluin. kinh ludi di vao khe giiia day ludi va tuyen duoi ludi, rbi di tiep ve phia dinh Iudi o~ t~n cung 0 d6.

'" Day tluin. kinh hgAhi¢t (than kinh SQ so'XII): vong qua bo tr udc cua co mong-luiii r6i di sau VaG phan dudi cua vung dudi ludi, dE'! tci gan thanh trong cua vung nay va chia thanh hai b6 nhanh d:~ chui vao be day cua ludi qua nhung khe giua cac b6 cua cd ciim-luoi. Giiia hai day than kinh h(1-thi¢t va thdn kinh luiti, c6 nhieu nhanh noi tiep hinh cung (cong).

* D¢ng mach. ludi: chay dQC a ben can h ca mong-ludi, r6i d phia ben ngoai ca cdmludi cho toi dinh ludi.

* Cdc mach. bach. huytt: trong vung duoi ludi c6 rihieu mach bach huyet to thu th~p bach huyet; tu cac biJ huy¢t rung cua xuong ham duoi, tU nism mac n{n mieng , tU dirih. lr..toi, va bit htdi cung ben, d~ d:6 vao cac hach. bach. huyet dudi ham. Trong trucng hop ung thir tuyen duoi ham, thi c6 th~ phat hien thay mQt hai hach bach huye] cua vung duci ludi bi sung to.

C6 th~ di vao vung nen mieng bang nhiing ducng VaG phau thuat nhu sau:

- Duong dUCJi, b§.ng each rach thanh da d giira bit dr..tdi cua xUdng ham duoi va xudng m6ng;

- Duong tren, di qua mieng bing each rach 1CJp niem. m(Jc d nin mieng; hoac 6 giua tuyin dudi lr..toi va xudng ham dudi, hoi).c d giila tuyln dudi" htiJi va m¢t dtidi ludi (duCing VaG d:~ Wi ong Wharton);

- Dudng truoc: d:i qua tam giac dUdicdm_ Dudng r~ch da c6 th~ th\1C hi¢n tren dudng giua ho~c d b€m ngoai han, dQc bd truoc eua b¥ng trudc cua co hai than. NElu can thi c6 th~ d.t rbi cd nay khoi xuong ham duoi.

- C6 mot dudng tr udc VaG ne'n mLfng, m6 rQng nhung it khi rllic;lc sl't dung, la d.t xuong ham dudi d cit hai ben dlidng giua, hoac a ch8 n6i giua hai phan n~m ngang va phan dung cua xuong ham dudi.

Vern rni~ng (Tran hoc mi$ng)

Hoc mieng duoc gidi han ve phia tren"au bih mot thanh cong 16m xuong dudi tao nen ou ng kha'u cui (vorn khau cai, vorn m ieng), Thanh nay ke can ve phia tren va tniac vdi cac hOc miii, ve phfa ben vdi vimg lai-riing (vurig x1idng ham tren) va cac xoang ham, ve phia tn§n va sau vdi phon luiu-miii (con gqi la ty'-hdu) va cac ubi tai (hoac u~i nhi), ve phia ben va sau vdi tharih ben cua hau, va ve phia dudi 13 hOc mieng cung vrri uitng hanh. nluin. (amidan).

Mat trensau cua vung khtlu cai tuong ung vdi cac hoc miii, vdi cac xoang ham (mat tren vorn khiu cai 18. mot phan nen cua cac xoang nay), va vdi ph:in hong-mid (ty'-hriu); mat dudi cua vung khau cai nhin true tiep vAG hoc mieng ; va tao nen com. mieng .

Vung khau cai bao g6m hai phan ro r¢t: phari truce, hau nhir n~m ngang, la ph an xucng, va eo' dinh, gqi la vern khtlu cai, hoac kha'u cui cung (palatum durumi, hoi[tc kha'u cui xuitng; phan sau narn chech W tren xuong dudi va ra sau, gin nhu thRng citing, mern, co cau tao co-mac va di dQng duoc, goi la man khilu cai hoac khilu cai mern. (palatum mollei.

Co th~ quan sat va kharn xet vung khau cai thong qua hOc mieng, qua cac hoe miii va qua phan hong-miii (ty'-hdu). Cach kharn xet thu an l<;1i nhat la kharn qua du'dng h6c mierig. Kham vung khflu cai nham phat hi~n n hung thay d6i vi'! hinh th§ cua vom kh5u cai, vclm c6 lien t~c hay bi dut quang, vom c6 vet nut ho$.e 18 thung kh6ng, dung ng6n tay sd n:in vao vom khflu Cal co th~

phat hien dude nhitng ch8 day len, khdi u , hoac m9t tieh tv nao do. Co thif kham mat trEm-sau cua man kha'u cdi (khdu ctii mem), b~ng each dua ngon tay qua h6c mierig VaG t~n hiu (hong).

Vung khflu cai, nhin chung, cong 16m theo ca hai chieu, va e6 dUdng vien la bit huy~t rang, hinh cung, cua x1iong ham tren, vern huang xu6ng dudi va ra truce; chieu trudc-sau cua vom la 7-9 em, chieu nay thay dEh tu)' theo kfeh thudc cua phan man khdu ctii (kh6u aii mtm), VI man khdu ctii co thif ng an, trung binh, hol),e dai, Chieu cao trung binh cua vorn khau cai 1a 1,5 cm. C6 nhung truorig hdp vom cong nhieu va hep, trong cac trucng hop khac vorn thap hem va c6 th~ trai r¢ng t.harih det (dac bi~t la d nhirng nguoi bi mat mQt ph an hoac toan b¢ rang).

o tre em, man khdu cai (khdu cai me'm) dai hen, va doi khi co th§ giu nguyen nhu vay den tu6'i tru'dng thanh, lam cho nguoi d6 khi n6i co giong mui, Man khdu ctii c6 th~ rung dQng trong giae ngu sau; khi ngu sau, ham dudi co th@ gian va nguoi ngu hit kh6ng khi qua ca miii va ruieng he md lam eho man khdu ctii rung d¢ng giita hai lU6ng kh6ng khi, tao nen cac am goi la tie'ng ngay (hinh 14, 15)_

Vung khftu cai cau tao bdl b6n lop rna:

- niern mac phu be mat ben dudi cua vern co biiu mo thuoc ki~u t.ieu hoa (bi~u me lat tang);

- lOp tuyen d dudi niern mac khflu cai;

- lop xuong cua khau cai cung lien

tiep ra phfa sau vdi lop co-mac cua khilu cai mem;

- ldp niern mac phu be mat ben tren cua vorn khau cai (trong d6 co m(lt phan la nen cac hoc rmii) la bi&u rna te bao tru co long thuoc ki§u h6 hap.

41

Bi.IJJfIg dSl!'l tilAu cSl Cactl.LY~ n ~ nooc bt;lt)

kh~1Jlcal .

TiJien 1'11 ... '& b~t maflg 1j3! n~1I thi~ l ~ l!15i IliiI~

(}gng mOildn khfilJ r-~i ItIn

Kh~1ll cili ~mm!J [kh6u clli clIngl O<1y Ihail kinh kt1~iIJ ca~ Itm

Dong Illi3.Ch k n~1J cai ~M

Me n kh:iiu rili (IkhofuJ cal mEi m 1

Hinh ,~. 'Kh§ u d i .:nfGn gl (k hau ca,i] cltilg}1 va kh~!.JI cai IrillI'm {rna n kh ~u ca~) (8~n tm i: lap nang; Ben phii: lap sa.l!)

Cl1I1g r.3nglren. [h::i m f~flg Mn)

Ca f1a~ij rna n kh~lI aai

CIJ knll M!J 1100 (bb ml~r,}-hSlJ)

CO' t.hil~ cai·MLI Co klla1J cai Iu:d

Han F1 nilan If'IAu CSi (arr.i[fa"1 khau c,F)

- T~ lh~ OLrOi g81 Va Iil hl~ tl~~ gli]a II;Iall

Gan. 00 cang man 1dl~!J di I f) IlfI:ng d!an ~d;iy ~qan9} d'lM buom-Mm

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Co Mm-loo

~y 'LflJi ~CUOIlJ 1tIll)

. '" '

H~nh 15. Kh iUIJ cail ;utc'i19 va ma n kha u ca~, 'lung 1h~l'Ih n'fian (cac err cu a 'JJ ung k na LI cail)

42

Co CI{ . -con -chum

-.., .

09ng IfI(l.Ch hiilnh r31<in ~fI'lJ ctl i, CIl1r~-Iurn

D~ It-lll kiflh lutl, haet. dut1 t'lSm llnan klt'Jh thlfC "~~l OIJ9.Mi ~U~, CU3 ~~n (nuOc oot) dtrol flam, rocam-'lllftlj l'

Tinh m~cl1 c8nh ngoai

~a hal th;1ifl (nh! ltlan), bl)ngl1ll1c ~~-HO tJOng m~ch ~1 [Jay Ihan kllm hi;l.,lhi~1 (XII)

t)Qng m<,!cIl O"c··rlOl"t-chCim (lual t~o killl'l di 'DQrig m-?cf1 can tI ~I Dong m~ch IVOi

G[Jmbng"~ ElQr,g m,c~ giap Lrerl

)Wang ham d!.Kli EI~ng macfJ GLI'l7llufii, cClMm-mory

CClMm-mang

Cc gilip-mOng

Xuong milng

--- Gel iJc-mong tlk.clm-mo~l

1~~~+4-+- C~w~~g

Minh 1'I.)'V~ng dtMi iuai va VlJJng tren rn6ng

(day th~n kinh h~~thi~l than kinh-ILIOi, co dOOi Itltti, d¢ng m~ch dum hiB. -lien qu.an)

CI1 Gha n toU¢n'1lrong

Co- Lr~ m-IIM, day 1r.a""J kinh tMW-hllu

Oi:IU;JIY'I.mong Co hili the n Inti! !han) bl,lflg !;.aIJ

- C(l~m-fL1riJ, dQnylll~ch dLTO'i/!Jui I'

0'

ErQr:.y mach IT'I~~ £long mam cenh ngo;;;1 Day lruolnll ha-th~ (tffin cOO cal) Cn_lr11ln-hal.i, va day d1ar,g Iram-mD~

£tQnIl rna::;h ciil"lh ti'Or19 Co khlL hau gi Lffi, ~g rnacn 1!IUi

XJ.IOTHJ mOO!)

Hinh 11, Vung duUi lLt"ai: lien qlJJan m~'ch • ~h,'nr kinh

(bQc: I~ d~rlg rnaeh 'ilIa; va day than kinh luUi ban9 each cat b~n9 sau oua or] hai tMn)

43

Khiu cal cling ho~c khc1u cal xlfdng (Palatum durum)

Niern mac mierig lilt (phil) mat dudi cua oom khdu cai: d b21 huyet ding cua xuorig ham tren thi niern mac nay day, dinh chat via ldp mang xuang (c6t~m~c). d hai phrin ba truac cua vorn kh§:u cai va d cac b21 cua vern, tren mat n iern mac thay c6 3·7 nep narn ngarig, mau do-xarn. 0 mot ph an ba sau, thi niern mac nay nhan, va c6 nhieu 16 cua cac tuyen nude hot nho,

6 hai phan ba truoc, c6 th~ phan biet dUQc m(\t vet cua duorig giua; con 6 m(\t ph an ba sau thi vet nay tao nen dudng dan cua khau cai, dircng nay th~ hien hOi mot vet nho cao nhu mQt mao, hoac nguoc lai, boi mot vet 15m nhu mot ranh. Ranh nay d phia tr udc t~n het d phia sau cua khe giita cac rang cua giua ella ham tren, 16i mot h5 nho hinh qua Ie, hoac doi khi bdi mQt diJm nho cao, goi Ii eu kha'u cai, tudng i1ng vdi 16 rang elta. H6 hinh qua Ie hoac cu khdu cai noi tren IS. V! trf cua 6'ng Jacobson, mot di tich cua duong thong thuong mui-rnieng nguyen thuy. 0 noi nay co mot b6 rna lien ket chui sau vao ong khdu cdi truce va cung co cho duong dan giua, 6 phia sau, thi duong dan giira tan cung d tiiu thi¢t (htiJi gil).

Lop tuyen cua niem mac phu vorn kh au cai trai rQng ra hai ben cua ducng giira dudi dang hai dai song song, day khoang 2~ 3 m m, keo dai tai tan khfiu cai mern. Lap tuyen nay kh6ng th~ tach ra kbOi ldp dudi niern mac duoc vi chung dinh chat vdi phAn sau cua kip duoi niern mac,

Khung xucng cua kh:1u cai (khau cai xucng) duoc tang cuong d chu vi bdi biJ huy¢t rang clla xUClng ham tri'm, hinh cung, 13. mQt vom eong 15m thea ca. hai chi€u ngang va truac-sau. Kh~u cai xlidng h9P boi mom khdu cai cua xudng ham tren 0 hai phin ba trude, mam nay tiep kMp v6i bCli mom ndm ngang cua xudng kha'u aii, t~o nen mQt phin ba sau cua khfru cai xUdng.

44

Vorn khau cai xucng nhan b phan sau, nhung go ghe d phan tr udc, vi co nhimg u nho xep song song va d5ng tam. Vorn co hai duimg kh6p thang goc vdi nhau: mQt du2Ing khop truoc-sau n~m tren ducng gitra , gQi la duimg khdp giila kha'u cai, va mot dUdng khop chay theo chieu ngang. Hai duong khdp nay t{LO tharih hinh chir thap la nhimg duong tiep khdp giua cac xudng tao nen khfrU cai xuong.

Hoi b phla sau cua ducng khdp ngang, c6 cac {rng khdu cdi phu. sau rub vao 16 kha.'u ctii be (foramen palatinum minor), 16 nay narn 0 ngang voi muc xuong ham euBi cung va b glln M huy¢t rang; 16 kh§u cai be th6ng len phia tren nd r(jng din nhu hinh mot pheu md VaG trong ho' chan budm·khdu cai.

Ed sau cua vorn kh&u cai xuong hoi 15m ra truce, tren duong giua cua bd nay c6 mot mau xuong 1M ra sau goi la gai mtii sau (spina nasalis posterior). 6 ea hai ben, bo sau cua khau cai xuong deu tan h~t 6 dAu cua mom chan budm, Canh trong cua mom chan buorn c6 mQt mftu 10i narn ngang va huang ra phfa ngoai goi la moe ciui mom cluiri blldm_ Xung quanh 16 chinh c6 th~ thay nhieu 16 phu, 6 cil hai ben, b;1t diu tit bo tru'dc cua 16 kha'u cai c6 mQt ranh nho chay doc ra phia truric theo bo cua vern khau cai xuung, nni vern nay lien tiep vdi bd huy~t rang tren; cac df)ng mach. va day tluin. kinh khdu cai chay d trong rfirih nho nay. 6 ben canh cua ranh nbO nay con thay cac h6 nho phan each nhau, dOl khi bdi nhirng mao nhon trong d6 chua cac tuyen nude bot nho, Mang xuong (cct-rnac) phu vorn kh§u cai xuorig kha phat tri~n va dinh chat vdi xucng 0 tren duung giua. Lop eBtmac cung dfnh vdi n iern mac va kho boc khoi lap xuong, nhat la vi be mat xucng go ghe. Lop cot-mac nay eo m(\t y nghia thuc ti~n trong nhung phiiu thuat d vom kh&u cai, eil ve m$t mb dUdng vao t~m thOi d~ tOi hOc mui, Hin ve mi;i.t ph:iu thu$.t t~o hlnh cho tre em bi tat hd ham e'ch (palatoschisis). Lap tre~ cung clla kh§u Cal xuOng tU'dng i1ng vai nen h6e mui va 1a lop niem mg,c mili.

Cac mach rria u va da-y th~n kinh cu a vu ng khiiu cui

* Vii phia mieng, vorn khau Cal xuong rhjQ,c nuoi dudng chu yeu bdi d9ng mach. kluiu cai xuong ; la mot dt}ng mach rieng, va t hu yeu boi nhanh. iuich. miii cu a dong mach

blldm-khdu cdi. .-

- D(;nf1, nuich. kh6u cai xu(j'ng (hoac d¢ng 1n,9ch k~au cai sau) la mQt dQng mach cua vurn k hau cai xuong, tach ra tit df)ng mach. ham trong: d trong ho~ duai-thai duong, sau do di qua 6ng khdu ctii Ion, v uot qua l6i irustc cua 16 kha'u cai va tiep tuc di trong ranb nh6 ('I bd cua vorn khau cai da noi tdi 6 trcn. tit trong ranh nay dorig mach tach ra nhung nhanh ben van phia trong va ra phia ngoili; nhirng nhanh ben nho nay se phun chia t.hanh cac nhanh n ho han mia noi tiep vdi nhau t hanh cac cung d6n~ mach d b2J h uyet. rang cua vom kh:lU cai, '

Vi chung ta da biet ra ducng di cua dorig mach chirih cua vom khftu Cal xuong, neri trong phau t huat, khi rach manh niern mac dinh dung dJ bit kin ~9t ch6 khuyet cua xuong t hi phai bat dflu dUCJng rach 6 phta truce cua rang ham eu6i cung.

- Cu6ng d9ng mach thu hai cua vnm k hau cai xuong la d()ng mach. miii trong , mot nhanh cua d(Jng mach. budm-kh6u cai, tit htle mui, ch ui qua is rang cue: (l6 khdu cai truce), d~ vao h6c mieng va ph an b6 Cl phan trudc cua vo m khau cai, dong thci n6i ticp vdi dQng mach kh&u Cal xuong.

* Ctic tin]: mach. deu di kern dr;mg mach cung ten, din mau d6 vao ddm. ro'i tinh. mach. chan buom. va vao cac finh mach cua niern mac m.ui: cac tinh mach chi din mau ve cac tlnh mach cua hEi~ va cua tuyen ha nh n ha n cue ky thu yeu,

* Cac mach. bach. huylt chay ve phia cac luich. bach. huyet eo'sau va cac luich. sau hau,

.. Gae day than kinh la nhanh cua day than kinh ham tren (V2). Nhung day thrin kinh khdu cui trurk va gifta (thoat ra ttl' lti kha'u cai ldn), di a ben cf!.nh cae d9ng m::,tch Vil phan chia thanh nhung cl).m nhanh nha phan b6 van trong niem mf;l,e, chung n&m a giua nhung Cl,lID tuyen nUdc b9t nh6; mQt

vai soi t,h§.n kinh di ra phia sau ve phia man khau cui; vung chi ph5i cua day tluin. kinh khriu ctii truce va giiia la hai phan ba sau cua vorn khflu cai xuong, ttfdng ling voi cac rang ham nho va ldn. N guon chi phoi than kinh thu hai la day than kinh miiikhr'i'u cai, day nay chui qua 16 rang cila va phan b6 cac nhanh vao riiern mac cua phan truce vern khau cai vdi gidi han sau 18. mot

ducng ngang n6i giua hai rang nanh, '

, L6 !iing cua, bi ehe khuat bai nlui rang cua, narn tren duong giua, d phia sau cac ding cua giua khoang 1 em; a phan durri th i 16 nay nha, nhung len phta tren thi tach thanh hai nganh hop thanh chu: "V" hoac ehu "Y" di chech ra'sau va len tren, d~ ~d van nen hai h6c miii, 6 ngay hai ben cua urich miii. DJ thuc hien dung dong tic gay te, phai choc kim vao sa u trung 10 khoang 5 mrn, thea huang sang song vdi true cua rang cua giira.

Lii khdu cai ian narn d each bd sau cu a khau cai xirong 5 mm vg phfa truce, a each moe eua canli trong mom chan budm 1 em v~ phia trtrdc, va each bit huy¢t rang 1 ern ve phfa t.r0ng. Tren ~i;it phing dung ngang (mat phang tran), 16 nay ngang rmrc khe giua rang ham IOn thu hai va rang khdn.

Ong khdu cai di chech xuong phia dudi v~ ra t~-Ude. D~ thuc hien gay te t6t, kh6ng can phai choc kim vao trong bng, rna chi phong be' vung Iii khdu cai tan la du dac biet Ia phong be vung truce cua 16 nay,' ,

Khfi'u cal mem hoac man kho1u cal (Palatum melle)

Khdu ctii mem. 18. mot rnanh co-can n&m giua, h9!_1-g-mil.i" (ty.-ha~) va hong-mieng (khdu-hau). Khau eai me'm co ehile nang ngan each giua hai ph§n mlii va mi¢ng eua hQng trong hie nuot, va lam thay d5i am phat ra. Khdu eai m€m dinh van bCl sau cua khfiu erii xudng va lien tiep ve phia sau voi W!u thi¢t (lu:iJi ga). Ve phi a dUoi, khftu cai mem lifm ket voi day lu:iJi va thanh hriu (h9ng) bdi hai bo cd hinh cung, g9i 1a eung

45

hha'u cai-luai (arcus palatoglossus) hoac tru truce va cung khdu ctii-luiu (arcus palatopharyngeus) hoac tru sau eua khfi'u cai mem , nAm gifia hai tru nay co hanh. nluin khiiu cai (amidan kha'u ctii). Kh~u cai mern duoc cau t1!O bdi can, co, va niem mac,

Can khdu ctii mem. Ia mot Ia soi lien tiep voi khtlu cai xuang 6 phfa truce va dinh vao bo sau clla phan nay, d phia hai ben thi kh:lu Cal mern dtrih vao moe chan buam (hamulus pterygoideus: moe & dau duai ca nh trong cua mom chan buom). Can soi nay hlnh tam giac, m:).t tren cua manh dm soi nay c6 mot s6 co bam vao, va tU day cac co di len tdi nen S9 (cd nang man kha'u cai va cd cang man khdu cai), hoac tU mat dudi ella can kh~u cai mern di xudng day II/di vii th anh hau (co khiiu ceii-hti1i va cd kha'u cai-hau). Ngoai ra, d phan giira c6 nhirng b6 co nho, xuat phat tit gai miii sau di tdi dirih cua tie'u thift (goi Ia ca til/u tliiet hoac JUdi ga).

Cac cd cua khfru d.i mern

* Ca nang man khfiu ciii (m. levator oeli palatiniy, con goi 1;3. cd clavvi tai trong, nam ('j phan sau-ben cua 16 mui sau, co c6 nguyen uy til:

- m()t gan nho bam vao dien g6 ghe cua mat duoi cua xudng thai duang, d phia truck ngoai so vdi 16 dudi cua ong clf}ng mach. etinh;

- mom boc cua pluin. nlii cua xircng thai duorig, mom nay tao nen ph an tren cua baa dorig mach canh:

m9t s6 soi co bam vao mat dudi cua phan sun ella ubi tai (voi nlii).

Tu nhung nguyen uy nay, cd nang man khtfu cai di xu6ng phia dudi cua voi tai, vi vay co chi bih cheo phan trong cua voi tai d mire ctinh. ngoai eua mom chan bucm, roi den bam vao mat tren cua can khau cai nlt~m, b£t chea d dUdng giua voi cd cung ten 6 ben doi di~n. Cd nang man khtfu ceii t?O nen mQt nep niem m:;tc n6i eao len d thanh ben ella hqng-mrli.

46

fJ¢ng tac: nang man khfru cai len cao, va c6 dong tac phu la lam gifin r9ng 16 hau ella voi tal.

* Ca ciing man khfiu cdi (m_ tensor oeli palatini). can goi la ca da-ooi tai ngoai, nam d phia ben ngoai so voi cann trong cua mom chan budm; so VOl uoi tai, va so vdi co nang man khdu ctii. Co bam nguyen uy tu: hrJ thuytn cua mom chan buam, Iii. ngoai cua sur; obi tai, va phan xuong cua uoi tai d giua la bdu due va 18 gal buom:" k~ ca d mat trong cua gai busrm, Cac b6 cua ca cang man khJu ctii tit nhung nguyen uy noi tren di xu6ng giua co chan buom. trong va co nang man khdu cai, vong qua va duoc ket n6i VaG moe chan buam, r6i vunt qua cM bam cua cd mut df tdi bam tan vao can eua man khdu ctii, van die n tfch ~.iim d phia sau mao khd'u cai, va vao' nuinh. ndm ngang cua xuong khtlu cai. Giua gan co cang man khiu cai va moe chan buam (hamulus pterygoideus) c6 mot tui thanh mqc nho.

Dong tac: cang phan truric cua man khau cai trong dQng tac nu6t, dong thoi md r(mg voi tai.

* Ca kha'u eai-hau hoac hriu-uoi tai tm. palatopharyngeus, m. pharyngoetaphylinus): xuat phat tit mat duci cua can man khdu cai, til dAu trong cua sun VOL tai, va til moe chan budm, cung vdi nhung sci cua cd khit hau iren, Cd khau cai-hau tao nen be day cua tru sau man khdu cai (hoac arcus palatopharyngeus: cung kha'u caihau), 6 phan duoi cung cua cd, pha n Ion cac soi co di van va tan he't d ldp duoi nie m m ac cua phjin durti hau,

DQng tee: nang hau len cao, hoi!.c keo man khau cai xu6ng dudi; thu riho 16 cua eo hong-mieng (isthmus faucium).

* Cd khtlu ctii-luai (m. palatoglossus); biit dau til mat dudi giiia ella can man khdu cai, rai di toi phAn ben ngoai eua day llidi (eu6ng luai), t~o nen tr{l trU:dc da man khdu crii (ho$e arcus palatoglossus: cung kha.'u cai-luiii).

30 Ul giJi but'Jm con dU'9C cac tac gia Phap 9<;>; fa /0 iron M.

fli)ng tac: nhu co khau cai - hau.

* Co tieu thi¢t hodc lU:di gd (m. uvulae): bit cHiu til gai miii sau va t$.n het a trong ti6u t hiet.

T6m d.t o¢ng tac cua nhirng cd ding va co ruing man khii'u ciii, chung ta can nhd rAng. co thu nhat. lam ding phan truoc cua man khau cai, trong dQng tac nuot, len toi mat phang ngang voi moe chan buom, trong kh i co t hu hai cung cang man khfiu cai, nhurig chi c6 th~ nang man nay len tdi ngang muc cua nhling co chan budm, va nhir V:\Y co dua man khilu cai tdi ap van t.hanh sa u cua hall (hong). Cil hai co k§ tl'en deu 1:'1. nhirng co lam giii n uoi tai. Voi vi t.ri cu a chung, hai co nay bao quanh ooi t ai., ctt cang man luu: d p hia truoc voi , va co nang man hrill d phia sau voi, Ca hai co cung co tac dung rna rQng voi tai, va nhu vay lam thfmg khf hom. nlii,

Ni ern mac cu a man kJuiu cai: mot phan cling gi6ng n hu nism mac a khdu cdi xuang Tuy nhien, niern mac a man khri'u ctii morrg hen, kern dmh hun, va ngan each vdi lOp tuyen bdi mot ldp rna lien ket dudi nicm mac.

Vung h.anh. nhsin. kh6.'u cui hoac vu ng amidan kh6.'u cui (regio tonsillaris): narn d gidi han giua hoc mieng va h§.u (hong), tham gill. diu tao nen eo hong-mieng (co luiu-mifng). Vung harih nhan khftu cai bao gam m6i ben mot h6 goi la ha' hanh. nluin. (fossae tonsilares) va hai hanli nh/in hluiu cai hoac amidan kha'u ctii (tonsillae palatinae) narn gon trong hai h6 cung ten. R6' hanh nluin. hinh vorn nhon Ia do d phia tren thi hai tru trudc va sau'cua man khdu ali sat v6i nhau, nhung a dudi thi tach xa nhau.

Trl,l trU:dc, con gQi 13. cung kha'u ccii-lU:Bi (arcus palatoglossus) la do Cd khdu ccii-lu:Bi lui vilo phia trong t:;to thanh m9t nep c6 niem mQ-c che phu. TTl; (rU:dc bit dau tU g& n day cua tilu thi?t, di Wi thanh ben cua hau (hQng), r6i di xu6ng dudi Wi bd ben cua day htiJi d~ t~n het a day. Tn; sau ho<'\.e cung khdu cai-hau (arcus palatopharyngeus) cling la mQt nep cd-niem ml;le nhu

tru truce, nhung 1M van phia trong hen va bam VaG thanh ben ella hau: nep nay e6 hinh tam giac hudng chech ve phia duci, ra ngoai va ra sau, va dUQC phu boi niern mac cua hau, Thanh ben ngoai cua h6' hanli nhiu: dude tao nen bdi co khit hau tren, can luiu, va ~at 'hiem khi co d. co hanh. nluinlu:oi tham gia (khi co cd nay). 6 phia ngoai hon nua, la co tram-luisi va ca irtim-luui, hai co nay nam b trong khoang canh-luiu, Day cua h6 hanh nhan a phta dudi, tuong ling vdi nrtp luin-thanh. thiet ben. Thanh ben ngcai CUll. h6 harih nhan con hop boi d. can n(ii·hau. Hanh nhan kh&u cai (amidan khau 'c3.i) nam d nth tren CUll. hO' hanh nhan d§. mo tit d tren.

Hanh. nhan khri'u cai (arnidan khau cai): cau tao boi mot khfii cac nang bacli huytt, nam (r be mat thanh ben cua hau, trong uung hanh. nhtin, Hanh nhan khAu cai hinh qua bau due, hoi dai thea ch ieu tren-duoi, va det thea chieu trong-ngoai. Mat trong cua hanh nha n hoi 16i hoac phfing, nhan vi c6 niern m ac hiiu phu, nhung tren mat nay thay c6 nhiing 10 (18 den 20 16) la mierig cua nhling hoc an sau vao trong hanh nhan, M$t ngoai cua han h nhan khau cai e6 mot ldp rna lien ket bao boc t9-0 nen boo hg.nh· nh/in. (lid banh. nhdn), rat kho tach rdi khoi nhu mo ben trong. Giila hai phan ba tren cua bao hanh nhan vci thanh cua hi'l u co mQt lop b6c tach ducc vi la lop mo lien ke't long leo, goi la khodng quanh-hanh. nhsin, duoc urig durig trong phflu thuat ciit hanh. nhan kha'u cai; tuy nhien ap xe cung c6 th§ hinh thanh trong khoang quanh hanh nhan nay va dUQC gQi khong dung la viern tay hanh nhan. Mi)t phan ba dudi cua bao hanh. nluin. thi dinh voi cac co cua thanh hau va la vung d~ di tdi dUQc cuong3! chinh cua h?nh nhan (hinh 15).

Cljc tren cua h\wh nhan kh:lu cai, cach vdi kh:lu cai xudng boi h6' tren·h(;mh nhdn, 1a di tich cua ranh cung mang thli hai a thdi ky bao thai.

31 Cu6ng: la thu~t ngLt Gi;.\i phau hc;>c hay dung M chi tifJp hQp cae thilnh phan nubi dU'3ng (m<:,c milu. m<:,ch bach huyEit). day than kinh. va thanh phan chLi'c n~ng (vi d\,j phs quiln, ong mM) laP trung I<:,i t1e di vaa va di ra khoi cO quan hai).c t<:,ng.

47

Ba sau cua h a nh rihan ngan each vdi tru sau cua man khau cai boi mot ranh c6

ch'ieu sau thay d6i. .

Cue dudi cu a hanh nhan thong thuong na m (1 each ni/p luiti-thanh. thiet ben 2 ern ve phia t.reri, va tach rei khoi nhung mo lympho 6 xung quanh.

C6 th~ quan sit hanh nhan khau cai rat de dang bAng each nhln qua hoc rrrieng. Khi ha r9ng m ieng va keo Ivai ra truce, an luiri xuorig thap vii ra truce bang mot de ludi, thi se trong thay ro hanh nhan khau cui narn giii:a hai tru cua man khliu ctii, voi kich th uoc to hoac nho: hanh rih an eo kich t.hirdc ldn hon 6 tn~ em va bi teo nho kh i oen tu6i gia. Co th,§ kharn hanh nhan bang ng6n tay hoac dung cu dua qua hoc mieng .

Kharn hanh nhan khtiu cai qua duong' mat rat kh6 khan vi bi can tro bai nganh. ten xuong ham diati. Ne'u bing an manh dau ng6n tay vao cac lop rna mern narn d ben dudi goc ham, thi co th~ cam nhan ducc hanh nhan khau cai neu bi phi dai th~t to; tuy nhicn, vi%e kham se di'i dang hon nhieu neu d ua ng6n tay vao oung hanh. nhtin, rihimg rt9ng tac nay phai rat kheo leo.

Vitng hanh. nluin: lien quan ve phia trcn vdi man khilu cai, nen khi vung hanh nhari bi tfch mu thi mu d& Ian Wi man kh au cai, v~ phia truce duni voi day luin, nen ung thu hanh nhan hay Ian tdi day hroi, ve phfa dudi vdi uung duiii ham, nen viem tay d khodng quanh- hanh. nhdn thi eo th~ Inn toi vimg dua: ham,

Mi;it ben ngoai cua vung hanh nhan lien quan qua tb anh hau vdi khoang canh. hfw (hoac khoang "luirn-luui"), chua d.§y mo lien ket va rna rna, vui trong khoi rna nay eo cac co trtim-Luiti va co trtim-mong . nhii:ng a(jng mach. hau ten, a¢ng mqch m[jt, d¢ng m~ch eanh trong va canh ngoai, (inh mr;tch canh tronr.r. vii cae day than kinh thi¢t-hau, phe: vi, than kinh phl/2 va thiln kink hr;t-thi¢t. Ph;1n Ion cac m(lch mau va day than kinh nay deu n:1.m hdi d phia sau.ngoai so voi

" Day than kinh phu (fl. accesorius) lil day than kinh 59 s6 IX, cae tac gia Philp 99i day than kinh nay la day than kinh gai song.

48

dien d6i chieu cua hanh nluiri kha'u ctii len thanh cua hau, D¢ng mach. ctinh. trong narn each hanh nhan khau cai khoang 1,5 em d phia ngoai va phia sau (doi khi ct:9ng mach nay narn sat vdi hanh nhan va chi each nhau bdi thanh cua hau), digu nay bAt buoc ph Au thuat vien phai nit than trong khi thuc hien cac phau thuat b vimg h.anh. nluin . D¢ng mach. mot e6 khi di cong len tdi giap czzc duai cua hanh nhan k hau cai, do do cung can than trong d€ tranh gay chiiy mau do tan thuong d9ng mach nay. Trang so nhfrng day than kinh vua k~ a trcn, th i day than kinh tliiet-Iuiu. narn rat gan thanh cua hau, do d6 curig Ia thanh phan d~ bi t6'n thuong trong cac thu thuat a vung hanh nhan.

Cac maoh rrrau va day than kinh cua ha nh nh an

. Cac d9ng mach bitt ngu6n tU dong mach. luiii, d¢ng mach. hau len, va d¢ng mach. miit, cac o9ng mach cua hanh nhan deu toi hanh nhan tU mat ben ngoai (goi 18. ron lianh. nluin], DQng mach quan trong nhat Iii d¢ng macli kha'u cai len (a. palatine ascendens) (Ia nhanh cua d¢ng mach. mi;it), d¢ng mach. kha'u ctii len tach ra mot nha nh (ramus tonsillaris: nhrinh hanh nhan), doi khi kha to gay ra chay m au <3 at trong phau thuat dt hanh nhan khau cai.

- Cac t1nh mach tao thanh mOt hroi cac tInh mach nho d be mat cua hanh nhan, va mau tinh mach duoc thu nh$.n vao cac ttrih mach cua hau,

. Mach bach huyet: hoi tv vii cac hach mach huyet duci ham, riam d vung quanh gee xuong ha m duoi, va ve cac hach c6 sau (nodi lymphatici jugulodigastriei : nhoni hacli bach. huylt tinh. mach. canh-ca hai than). Trang truong hop bi viem nhiern, thi eac h!;J,ch nay sung to va eo th~ sd nftn thiy, doi khi ehung h9P thiinh m9t kh6i to, dau d duai goc ham.

- Cae day than kinh hinh thanh a b~ mat cua hanh nhan khflU cai mot luai sdi nho voi cUc' Sc;li taeh ra tu cae day 'than kink lUdi (mot nhanh nho cua day than kinh tam thoa: V~), va than kinh thi¢t-hriu (so IX).

Car: mac h mau va day thiln kinh eua khdu ca i xuo'ng va man kh~u ca i

- Cac d¢ng mach cua uom. khdu ctii xuitng va cua mem khri'u cai xuat p hat tU d()ng n!(Jd~ m(it (a.paIatina ascendens: d¢ng nuich. ktuiu cai len) va tli dean cuoi cua r1~)ng moen ham trong (a. palatina descendens: dong mach. hhdu cai xu6ng), cac dQng mach nay eho cac rihanh tuorig ling 18. d\)ng mach. khdu cai Ian (a. palatina major) va n hung dQng mach. kh(iu ctii be (aa. palatinae minoresi, p ha n nhanh 6 trong h6 chfm buorn-hurn.

, - Cac tinh m ach tao nen nhung dam roi do V{I.() cac thfm tinh mach 16n hon va dAn m a u del vao dam rrl2 tinli mach chan buitm va vao cac tinli mach. cua hd~,

- Cac mach bach huyet din luu bach h uyet cua vung toi nh6m hach tren cua cJuu1i hach. bach huyet co'sau ..

- Cac day than ki nh cam giac la nhanh ella day than kinh mili-kha'u ceii (cac nhanh nay mung ten la nn. pnlatini major, medius et minores: cac ddy tJHin kinh khilu ceii ldn, trung binh. va nho), tat ca di tdi vung khftu cit qua 6ng khtlu ctii triatc va (teu thuoc ve khu vue chi phoi cua day tluin. kinh ham tren (VJ. Ngcai ra, vung khau cai con duoc ehi, ph61 bdi cac 5Qi cam giac cua hai d§y than kinh thi¢t-hllu va phe-o], Cac day than k inh van d(mg thi xuat phat tU day tluin. kinh ham dudi (Vo) (cac nha nh van d9ng nay gQi ten Ia n. tensoris oeli palatini: thiin kinh co ding 111(1n khdu cai), tu day thsin. kinh. thi¢t-hau vii. day thdn kinh phI/vi, Ifin lliqt co ng uon goc tit nhung day tluin. kinh uuit vA hr;Ahiijt (day tluin. kinh ha-thiet chi

chi phoi rieng m9t co luai-ooi tai)_' .

Cac thanh phan phu thuc}c cua hoe mi~ng

LQi (Gingivae)

La phan niem. mQ.c mieng dfnh vao cotm\lc cua cac xuong ham tren. va ham duai,

ehe phu biJ huy~t rang cua cac xuong nay d ca hai mat ti~n dinh va mat mieng (mat hrdi). Loi phu d hai m~t nay lien t iep vdi nhau qua khe giua nhung rang, va xung quanh co rang thi tao thanh mot vong nhan (vorig tron c6 b~ day), tang cucng cho rang ducc giu vung hon VaG cac huy¢t rang, d5ng thci cung vdi ldp cot-mQc riing-huyet rang hinh thanh mot lien ket dim h6i, phai tach ra trudc, khi mudn nh6 mot rang nao do. LQi bam chae VaG ldp cot-m:;tc (mang xuong) cua cac xucng ham, do d6 khi choc kim phong be novacain d l{,1i rat dau.

Cae rang (Dentes)

La cac cau true rari earn van trong cac huy?t rang 6 bd cac xuong ham tren va duoi; rang c6 chuc nang nhai va ca chuc nang tao Idi n6i. Cac rang xe'p tharih hai hang tren va dudi, tao nen cac cung rang. Khi ngarn mieng, cung ham tren. (cung rang tren) thuong vuot qua ra trudc so vci cung ham duai (cung rang duoi), tao thanh cai gQi Ia "kiJu dn rieng" (kiJu d.n ca thg) hoac kie'u hhep rang. a loai nguoi, rang chi t~laY co mQt lfin (goi la ki~u moe rang hai hir~), qua trinh nay bit diiu tit khoang 6 tuoi rudi va ket thuc vao khoang 14 tdi 15 tuoi, Tuy nhien, rang ham Ian thu ba con goi 13 rang khan (dens sapientiae) thi moe

, ' .

muon hon,

M,?c rang: Loin moe ding thu nhat co 20 rang rung sam, con goi Ia rang sita (dentes decidui lactei: rang sua rl,mg 86m) bao gam: 8 rang cita, 4 rang nanh, va 8 riing ham sita33; ding ham sua cuoi cung moe d chb cua nhung rang ham nho trong

"_GiO'a s6 Ilf(;mg va tan goi cua cac rllng sO'a va rang vTnh vien e6 met di~m ~an nC:i ro de k~6i nham Ian: a nquoi Ibn tr~ng 56 cac rang Vlnh vien tren moi nua ham c6 2 rllng ham be (premolars) va 3 rang ham Ion (molars), con a tre em tronq thai ky moe rllng sua thl mOi ntta ham cbl c6 hai rang ham. Cho nan khong noi r6 dU<;Jc Iii rang ham be ncac Ibn. T.uy nhi~n a_day tac gia 9<,>i Iii rl'ing ham Ion (molars) v~ them "!nh ngLl "5.l1a". do d6 chung toi dich cae hi'd6 la rlmg hilm sila IfJa nMt va (fill fJai.

49

Uin t hay ri'ing hoac Ian moe rang uinh. vien. 'I'hoi k y mQC rang siia b&t dAu tU 6 thang tdi :)6 tha ng tubi. Dau ticn la moe cac rang cue: giU:a (thimg thu 6-9), r6i den cac rang cUa hen (thririg thu 9·18), r6i den cac rang ham thu nMIt (tharig thir 22-26), r6i den cac rdng nanh (thu ng thu 28-34) va cuoi cung li-l eric rang ham thu: hai (thang thu 32·36) (hinh 18. 25).

Cac rang vlnh uien (dentes permanents) xuat hien sau khi cac rang sua rung di, r~ cua cac rang sua bi t.ieu dan dudi ap luc cua cac rang vinh vien dang moe len (trit tntCing h9P cac rang ham Zan vinh vi!§n, vi cac rang nay khnng co trong thiti ki' rang sua). o day, thu tu moe rang (moe rang virih viJn va rung rang sua) 1a rihu sau: rang ham len thti nh/it (giira 5 va 7 tu6i), cac rang cU:a gii1a (gifra 6 va 8 tuoi), cac rang cU:a ben (giira 8 va 9 tuoi), cac rang nanli (gitia 10 va 12 tuoi), cac rang ham be (gifra 11 va 12 tu6i) va rang ham Zan thu: hai (giua 12 va 14 tuoi), Rang ham Zan thu: ba (gqi IiI "rang khan") la rang moe euoi cling giua 19 va 30 tu6i. N6i chung, die dng th uoc ham dual mQC trudc so voi rang ham tren, each nhau W 2·4 thang.

Nhung rang vinh. vitn, VOL s6 luong la 32 sf bao gorn: 8 rang clla, 4 rang nanh, 8 rang ham be va 12 rang ham lan, ph an bo giong nhau ij hai ham tren va dudi.

Trang t.huc hanh rang-rnieng, nguiri ta dung "cfing thuc rang" d~ de'm va nhan biet cac rang, eang th uc nay trinh bay so' cua cac rang tuong ling, lay mfic la duong giira cua moi cung rang, do d6 cong thuc rang se nhu sau:

87654321 12345678 87654321 12345678

Hoac don gian hon

2 123 2 123

50

Hinh th~ chung: Thong thuorig, moi rang bao g6m ba phan: oanh. ding, c6' rang va rJ rang (hoac chan rang) (hinh 21,22).

Yanh. rang (corona denlis) IS. phan nhin thay duoc trong mierig, mall trang riga. C6 th~ phan biet trim vanh cua m6i rang: mot mat ngoai huang ve phfa ben dinh mieng (facies labialis sioe buccaZis: miit moi va ma).14, mot mij.t trong huang ve ph fa luoi hoac phia vom m ieng (facies lingualis sioe palatina: rruit luiti hoiic khii'u ctii), cac mi;tt tiep giap vdi nhirng rang ben ca nh tr en cling mot cung rang thi goi la miit titp giap (facies contactus) - tuy thea cac rang khac nhau , cac mat tiep giap se la cac miit ben doi vdi rang clla va rang nanh, sf La nui! triatc va sau doi vdi rang ham be va ian - ngoai ra cac rang ham be Vii Idn thi con e6 mot miit nhai (facies masticataria) rat hiet hoa, Tren mi,it nhai cua cac rang nay, co cac mim lui goi la cac cu rang (tubercula dentis), cac cu nay giu vai tro tham gin vao di)ng tac nghien thuc an.

co' rang (collum dentis) noi tiep giua uanh. rang va rJ rang va nam ngang rmrc b(j rang cua lai.

Re rang (radix dentis) lA phan co dirih van huyet rang, each vci thanh cua huyet rang hai lOp cot-mac riing·huy¢t ding. C6 rang va r~ rang mall vang rihat. Co rang chi c6 m(>t r~, e6 rang nhieu r~, m6i r~ tan cung hoi mot dinh. re rang (apex radicis dentis).

Hinh th~ r ie ng (hinh 23, 24), Nhiing rang czta (dentes incisiui) hinh nhu ludi seng, det thea chieu truoc-sau. Rang cua bam

, Ve rnat thuat ngii noi ve hllong cac mat eua vanh ri'ing can phan bi~t nhU sau: cac rang cua va rMg nanh co hai mat hU'ong ra truce hoac ra ng08i. Illdng ttng v(ji mat !rong ra rnoi va rna (n<'m con diroc goi ta m;)t mai va mal. m91 mat huang ra seu hoac vao trong thi nhin ve phia Illili hoac vom mienq (nen (fUClc goi la m~t Ilf(ji hoac kh§u cai), con die m~t ri'ing qiap vo; nhau thi deu 99i la m4it lii§p giap; 0 rang ella va rang nanh thi la cac mat ben. eon a rano ham Ihi 1.3 mi'it tnroc va

sau. Rieng cac ri'i~g ham co m4i1 nh~i. .

Ring mmh 8Ga

Clic rung hlIm b€ Irfln Rang nam (hamllrel1

!Riii'l9 Mm11f!n d iJ{(j Ifnl hill "i-m5~-- RjllJ,;lll1am 1m. dOO ItHl 00 (rang ~)

IEBI~s~'_-- ilng rangl duOi tOO!! ham dL1{n)

dU(h tlnJi1ng- lhJ:ng thang. tl.'Qng khi ding ella ham tren lh,r{rng: ]uji ch~h r'a trude.

Cite rt:ing nard! (dentes CGllil:li) (;[) vanh rung khoe hen Vil loj ra phia m.oj. Re r9ing nanh hirrh tn:l. khaoe thU'Clng hoi cbc·ch rn ngCl3i.

Cne riMg ham be (d.!>nlcs pr?m.tllan!8~ rRn,g ~ru'ue-hum}c6 d~c diem I;i! (j ln~t nhai nl hai ~u rli'1f1 (wQt etl d phia ticn dinh mi~n~ va mQt ell d phta h1EIj bo~c phi.;;J kh;~u

eai)3~, hai eu rang .nay ngan each nhau kh6ng hoan Wan boi ml}t; rillll1 ntlm ng:.lng_ R~ eua cae rang ham be t-hi ngAn, thllimg t.:u ml}t re mijc dll dr)i khi ran.g ham be lhu nhat co re che. dol.

Ca,c rdng ham hin (a.erl-t,(1S matures: rong ~ulm) co d~c di!~m, In mf;!lt nhai 00 to 3 drl1 5

IS Ve m~H 91?i tan cim ru m'ng ~. lI~ll1h .. i QUa eac r~ng h~m, ~em I~i chu Ulict-I ... ii Citch goi L{Jn eac m~1 cua v~mfl r.llllll C e hu 'Morei'! 33 cu6i 11'1'1"'9 34

51

ICU' rang, ca.ccu rltay 00 "ai trn dung k~ u'otig dong tar ngh.ien thirc i:i 11 •• Vimn CUB. eae rang ham ian tren (0: 'bani lren) hlnh thni hn~,c hinh khrn. ba.u due, vlli m(it nhai r:6 b6'n cu (ha i C'U Cd phla rn a.. va hai CD 0 phitl lLtffi ho~c phis kh;liu cai). phan each nhau bi1j ffil)t ranh. Vilinh cua nhl1ng rnng hutn Wn ihJCli (0 hitm dU'di) th.uong hrnh kh6i vuonp;, Ion hchl va thUClnl{ eo s,o' h4Jil1J! crJ th tta (gQi La C!t CambellO so l'oi nhung ran g ha m Lo1''1 tfen tuo n g u.ng-.

Rd'lg hiun ian thK ba «(im g!)] Iii "ran,g kh{jn~ - de,7.s :;emitnw; sil.Je sapienticu), la rtlng- kem phat t.ri~n nh.i(t vil cO khj kh6nR ed,

Cae rrirlfl ham U/,. lren r;o bll.rc (hai re a pMa rna va m?o;l n!, d phiakh:iu cai) troD'! khl cac nlog ham liIn dl1(l:i chi co hai l:e (mQ1I: l'~ [rutile- vii liI¢t re saul, rrue c:1ila ca,c rang ham ian hal c:he'ch :ra pUla sau ..

Hinh 21. CiI,1;) rang (r~ng ella: 1-2; rang nanh: 3; 18 ng ham be: 4-5; rangl ham lem 6-1-8)

Cdc rang rl!ug smu (tuc 1a ning ,~~a) co vanh l'[ng miiou hoi xanh, v.a nbC. hem, rIDe tuy rlmg J~i Un1C1:ng h}ng hrm.

Ca.e rang duqt.: b6 td thilnh mQt Mng cong gqi Jh cung: ran;. cae J[I~t LLe_p gi<i[J sat voi nhau. Nhllng ~ ngang mllc 00 rang, thi gina nhimg Ttitngd canh nhau co kne 8'la-tl rting (spatial inlf!rderzlaria.- Mloang gian n'i~). Cae rang ham nbc. va ham ldn tren co hudng dl~ng cilng, h"ong khi va.nh clla cac rang Mml lon dU{1rj lM hdi che'ch \Ie phfa trong; t(re La phj'~1 hClC mi,~ng ehtnh thue,

CMng riing (Ten (arcus den ~ahs

superior) Mnh b'u due {hinh elip). co.n l:!1Jl1i rang duJi (r.Ln:u.'l' deMalis litfcrlor) thl hlrih parabol, vni nhi~u bie'n th~ khii.c nhau it nhi.$u.

Ki{l!~ cdn (ki~u tie'p :u'ic) duqc gQl la, I'dong" ho~c "khdp", Trang v~ tri dong th.i de rS.ng eua hllm trell thuCing v'UQt ra phla

l ruck: 11C1n so vCii rCmg <:ltJ. han' dltdi, .:hang WIl (~;'lc l'img rua dud ~ ll1Qt chut

C.1U true cua d~c ~'ilJ1ilg (hlnh 26. 27): 11 br-n twug ['nbi dlllg en m(}t hoc gci Jil hOc r(r!l~ (UHlllm rI"rllio'), 110(1(.: hoc ~u; 1'6 ng" h6'C' llity rhnn g vCsi mot ho~~(' nhi~u dilR d rar!..g ho;iC Ijnp, clutn rang teonati» rodicis (ir~'lI.iS). (,;It- 'Jtl g OilY deu co 1(; filO I'll n~oJ"li (j dinh 1.'Uti c,i.r I.-e n."H'Ill [lin'amell apices de" ti«: M dh~h f r(:' n'; rrg]_

Hri,- 111)' rart;1i vii cac rj;lg "e rr:ll.g chua d:\\ rno lien kiJ't memo mau rio nhat, giau mac-h mil U 'i.'il n hang sm than kino cnm ~i'-[t" ,h,o;ic g(li 10. ruJ'~ ni'U! (puipl/_ d~~n,tis).

Bi'to xu ng quanh wj' rilng-li:! m!)t. ch:'h ~iilng v 6i ",uLlng gt;li 1;J ngo. rUlig (subfllantia:

Cblj r'l t'0': eMf' riga), chfi't Hay maL1 vitng nh~~t. n1n hen vii giau mu.6i kholl ng hen, 00 ",ji xucug.

Ch:'Il ngil b phgn ['I~ n1n g d:U\1~ phil Mn 11 ~.!\);t' hm mQt ldp m6 ){uc:lng mong, m iUJ n:iu-V;Hl.g nh:p .. , gtJL Ia. CClfH~r! ~ (}{mlenl~m ,.;rt'l.' ,<;lJ.bslanliu O$se.a:: cement h(l~c chlii _nMHg), lOp ;.:udn~ n;'ly ke't n8'j vai oot·m(lt' riinf{-h I.QI~l ((mf! bdi 1111)1. h~ thong nhu:ng sf,h tlW keo {g9i la ~(Ji Sho.'rpe),)_

N'ga rl'lng d phfin vanh rill1g 'thi Ul1Qc bao I'Qc. bd] me" "iiJ~!f (substan tiu (ldatl~f1nr,jna), ]9 mqt chit m~u tl'fing, bong, en I he coi !i~1 IQ<;J.I rna ni.n cling nhKt t.wng cd the, hau nhu chi diu t.r,to l:1L1i de mnE;i khoi~ ng va nglim hoi apn tit til u<)c lcai phosphaL 1\..1en rQ}lg d[]'c,jc c:a'u LljI:o bbi nhung ct (~11 vi r;:9 i til t r~1 I'll. I? f! '-0 ng. trl.} men ran ~ h:Wnh bng tl'l.l dai, sou mat. ~1itm th5 n.g gOc VOl ue m ~j.t C il,n, ua fI h nirzg va ket nol v(!i nhau bJi m{lt chat ~;1n "'Co dinh hinb.

H ~ ~ ~)~®~®

~, '\J \ -f'~ V ef

a b abc

Cae; tJ1ng nanh ~crl'll(J nalll be

~~@ ~nl>~

a

bed ~

Cat:: rang ham Ian. tren

"w b ~

a

cae rang Mm Irtn dUOi

Hinh 23. Cic mijt cU.a ring

a "

R¥!g ~r11lha!T!) ~IJlIj

Hinh 24. Cae mij,t ella rang

53

B9 may nang do va eo dj nh cac ding (parodontium: cdu true canh. rang) baa g6rn bon yeu to sau day:

1. M6 quanh rl rang hoac nha chu (periodontium) hop bdi rna hen ket baa xung quanh n:; rang, narn d khoang giua r~ rang va t harih cua huy?t rang. Cac sci tao kco ket neli r~ fang vao thanh cua huyet rang rnang tinh dim hOi, do d6 lam gHlrn sue ep tat dong t6i rang trong hie nhai, can nhlfng thuc an ran. o gdn m ieng cua huyet rang. cac S9i tao keo cua rno quanh chan fling narn toa ra xung quanh nhu nan hoa banh xe , hoi ucn cong ve phia bl'l mat cua ra rig, g<;ri 13. day chdng coru; rang (ligamentum circular dentisi, day ching nay gop phan ket n6i lei voi c6 rang. 0 phfa duoi huyet rang, nhimg s0i cua ma quanh rt rang c6 huang chech hon, va d dlnh re rang thi cac soi nay tao thanh mot phuc h0P cac 50i doc va toa ra hinh nan hoa, goi 13. day chling dinh rl (ligamentum apicalei,

2. Loi: (da rna ta d phan tren),

3_ BiJ huy¢t rang va huy?t rang: cac huyet rang hoac [) chan rang la nhling hoc narn 6 b(j huy¢t rang (con goi la mom huy¢t rang) cua cac xuang ham tren va duai, trong do c6 r~ rang earn vao. Xurmg (j huyet rang Iucn thay d6i, phu thuoc vao cac yeu to co hoc tac d(mg tdi huyet rang,

4_ Chat cement: hoac con gQi la xuong quanh rl rang (xuong quanh chan rang) duoc ket n5i v8i c6-t mq.c riing-huy¢t rang bdi cac eoi Shnrpey .

Mach mau va day than kinh cua cac ding

* Cac d(Jng mach. nuoi dudng cac rang xuat phat til df)ng macn huy~t rang duoi (a. aloeolaris inferior) va cac rlQng mach. huy~t rang tren (aa. alueolaree euperiores anteriores et a. aloeolaris superior posterior: cac rlrjng mach. huy¢t rang irentruce va tren-sau); tat ca cac dQng mach

54

nay d~u la nhanh cap mot hoac cap hai cua dQng mach ham trong. Sau khi di qua 6'ng rang du:di cua xuong ham dudi, va nhung 6ug nha cuo. xudng ham tren, nhiing dong mach n6i tre n n6i tiep vdi nhau rat phong phu, roi tach ra cho m6i rang mQt hoac nhieu nluinli rang err. dentales), Trude khi chui vao l6 dinh. ril rang, nhimg nha nh rang nay lai tach ra nhling nhanh rat nhc di tOi lr;ii va cot mqc rang-huy¢t rang, r6i mdi ehui vao {/ng rf rang (aug chan rang) d~ trd thanh mao mach d trong tuy rang.

* Cdc tinh. mach. di kern cac d¢ng mach tuorig ling.

* Mach. bach. huye't: Mi.n bach huyet tU cac rang cua ham tren tdi nh6m giua va ngoai cua chu6i hach. bach. huye't duoi ham, trong khi bach huyet tU nhung rang cua ham dudi thi duoc dan v~ nh6m tren cua ctic hach. cd'sau_

* Day than hinh: 1a than kinh cam giac, thuQc vung chi phoi cam giac cua cac nha nh cua day than kinh tam thoa. Cung rang tren e6 C§.C nhanh di tdi cua day than kinh ham trEm (Vz); cac nhanh nay t1;1.0 nen dam ral: rang, tit d6 phan cac nhanh eho xuong, 191 va rang trr. gingiuales et dentales supericres: cac nluinh. loi va rang tren). Cung rang duai rihan cac nhanh cua day than kinh rang duai (la ffi9t nhanh cua day than kinh ham dUdi, Y3), day than kinh rang duci n~m trong mot 6ng cung ten 6 trong xucng ham dudi, ding tao nen dam r6i ding, tii d6 tach ra cac s<;l1 thin k inh cho lei va cho rang trr. gingivales et dentales inferiores: nhcinh lai va rang dudi)_ Tat d. nhling nhanh nay sau khi di trong 6ng ri'i rang thi vao tuy rang va tao nen mot ludi sci rat phong phu,

Vimh rang ~ .

'R~fang (ch.'ln rang,

, ... ". ,

Cement

lwCfr'.g r~ r,an!illilo~c ~JJCIl¥.;! onan rfingj'

~;r,.....- 6n9 ri\ rail!)

(6~ cl1an I'liing ~

Rerang {ch~n r~ngl

Hinh 26, Ciu trolc chung CUB rang (lhiet do CIOn 9 dQ!C)

'Vung h'u (ho~,c vi:mg hQn,g)

Hau (HQng) (Pharynx)

us» '(hQ~c Iwng) )0 m'9t I:el quan Es do hni. duoog hli hlip (1'11 miU tho.ng xuong thanli quo rl) _va tJeU holl (ti.t m~n~ !Cu.ring autr: t]U{il'1) bat cheo nhau; do do c6 ten gQ1. 1<.'1 : ng.n 'W h/i..IJ" (oga tlf h9ng) , Hall eo hinh the nhu r.Ili)t pheu co-mae, nAm a phra tl"U(lC cor sifng cri. v.a keo dai tr~J) mc;.t khoang dl} 15 em, tu r~ilt s~ lJ1i ngung mOe bd ulliii CUIi ~WI nhdn thanA quiin., tucug ifng vdi bb (htdi elia dot s6ng ,e:6 th,J 13 (C,,) a ngUdil(ln, h[l(l~ clot s.6ng di 4. ( C'I) Cd t~ so !'llnh, oot SOl1g d~ 7 (C~) l! uglloi gilL Nhiilng moe nay LI!OY (bJi theo s'v chuy~n d¢ng CUll h:iu treng khmi.n~ giln b~ng chi'l!u cao t.-Ua m¢t ,dot scing.

HaL phan ha tL'~n cua hiu n~m lJ ddu, phfil sau cua vbng (lung cua. XiJ(lng lu"ill'l allm; con IUQtphiin ba dU:(f,'i cua ha\l lai Ii~ m i1 r:d:mg (:0, lien quan vai. th.anh qudn ~a I il~n h3P v,f.ji. tlz!le qi~&i'!_

c5 rang

.,.~ri-rtIPJi.....:::f:"''-:'''''·~'_- Men r$l!l

....... -- Ng3I ra.l'll) iF---M(I[: ruy

rang (6 ~ang) Cement (lJ.ICII'Ig m rang,

ooac XI/I1Iilg Gllan rilll;l) ~-- 01'19 re rtJng

(6ng d'lan rang}

T-Ul,u thong ra phia l:.1·u(le; Q m,Q~ phdn bill. t,!!'tm \'di eac htf.e mfii. th~ng qua cae M mo.r sau, iI mQt ph.!n ba giua voi hoc mifng., qua eo hf_mg.mi~ng (.w hdu·mi(;ng) {aditus bI1CC()pltiJrytlgel~; Mz 1";0:0 ffll-i!ng--ht1uJ: va. a ml.}t phlln ba du:<.1i thl thOn~ vdi thank qudl1' qua t{, phluAhanh. thiN (ad£Ws larjincis; lJ j)ao lha:llh qUGu., ho~,c M U,a.nh quat! trtll)SI,( philn ehiacac pnin ella hfiu theo dinh khu d trong !lung clmg phl;l. thu('n:,: ~aQ nhung vi t.r! i.b{mg th1,..JClng !lay; \fung trim CU3 hju. gQoi lit thrt(j'1,g.h~ltfJ (epipharynx) ho~c ly'.h&'u (rhiltophn.1Jmx) h.oij.c hong-mill (p,czrs na8.o1i... phar:yngi.~: pfu!i.n m iU cua hiiu). vilnS giua 13 t.n,J.ng·h&u (meeopha.ryrt.rJ hu;),c kh.iu-hdu. (oroplw.rynx) ho~c 111!ng-mifne (pan; or-alis ph.al'jmgis: pfr_6n mi-~,zg CUR hellt) , VQ ~'iing duoi g~i lit h~h~,m.g (!tYJJopllnryru;) ho!)c thanh.lulu (laryngopharynx), hm}.{: fu;mg·lhalth q.ud.rl (pa.rs larYfl/fea pharyngis: pldin tha.,nh, QU&ll tau h&U) (hiinb 2g-34).~G

Hinh ,tbi nga.8:1t va Iii,!u QlI.lOP: Hlt.ll (J() mQt m~l sa.u, hai Hl$t hlm .. ro~t cue I.reb vb mQt cIfe dum.

1Il Va clan h phil p Gi~1 pi'l!u hr,1C t'lti !!I!jji ten c.Ilt: phon Gila ~u hCo~1) h.Qt1!1. :<'illft tt.em r.::ic dui thld1 "7 .... a 14

55

* Mat sau hau g§.n nhu det va lien tiep 6 hai hen voi cac mat ben, hop vdi hai mat nay thanh cac goc gan tron. Mi).t sau cua hau tuong ung vdi c¢t song co', vdi tluin. va mom ngang cua 6 dot song ctf tren cung, dltQe phu 6 phfa truce bai mgt lop co tao ncn bdi cac co (rude song (mm. rectus colli et rectus capitis: cd thiing co' ua cd thiiru; dau) va bdi mru: trudc song. Ngoai ra, mat sau hau con lien quan voi chu6i than kinh !-[lan earn co".

Giua hriu, narn d phia truce, va cac ca truac s6ng va m{lc truce song, nam (j phia sau, 1:\ khoang sau-luiti (spatium retrophary ngeum), Khoang nay chua rno lien ket long leo va hal hach bach huyet (goi Ia cac hach. sau-Iuiu), nhirng hach bach h uyet. nay n han cac mach bach huyet tit tuven. yen (tuyen ha nao), tit hanh. nhdn hctu (amidan hau) , til ooi tai (voi nhi) va tit cac hoc miii,

Nhirng hach bach huyet nay rat d~ bi vi em nhiern (viern tay hach sau hau),

Khoang sau hdu baa dam cho hau chuyt§n dong duoc so voi cot s6ng.

Thong qua thanh sau h§.u c6 th~ kham xet cac dot song c6 tr€m cung, hoac chich rach [) vie m tay sau h au, hoac choc hut ap xe lanh xuat hien thu ph at do b~nh Pott d cQ! song c6 (lao cot song co).

* 0 hai ben, thi doari d:au cua hau lien quan d hai ben vci cac tuyer: nude bot mang tai; con doan. cd' cua hau thi lien quan vdi uurig ca ilc-dbn-chflm; vung nay co th~ phan chin thanh hai vung, mot d tren va mot d duoi, bbi mot mat phang nitm ngang di qua bd t reri cua sur: guip .

- 6 trong vung ben tren, thi lien quan voi t.harih ben cua hau co nhung thanh ph,)n sau day: nguyen uy cua cac dQng nU;1Ch ctinli trong va ngoai, cac di)ng mach. guip tren, hdu len, luoi, tinh. mach. canh. trong: phia dudi hen thi co than tinh. mach. guip-luiti-nuit: chay d phfa trim va phia trong cua than tinh mach nay la day thdn hinh hr;L-thiid, day th§.n kinh nay b:1t cheo

56

phia ngoai cua cac dong mach canh trong va canh ngoa i, beach 5- 20 mm phia t.ren cua ch6 chia doi cua di)ng mach. canh g6C (con goi Iii d¢ng mach. cdnh. chung), thuong nhat itt (j ngay phia tren nguyen uy cua d¢ng mach. ludi. Trim mat ben cua thanh hau co day than kinh phe:uj di tir tren xu6'ng dudi kern thea b6i nharih than kinh tim tren. cua day nay.

- 0 trong vung ben duoi, thi tharih ben cua h3u lien quan vdi a¢ng mach. ciinli gac (canh chung), tinli mach. cdnh. trong va day thrin kinh phe' vi, vdi phan sau thuy ben cua tuyin guip (giap tr ang) va cuong mach cua tuyen nay, vdi quai cua day tluin kinh ha-thiet (XII) eli kern thea tinli mach. canh. trong.

Trong khol me lien ket narn 6 khoang canh. hau (spatium parapharyngeum) co cac cd tram eli qua (cac co bam nguyen uy 6 mom tram cua xuong thai duang goi chung la cac co tram), cac co nay cung voi mac cua chung tao nen mdt vach dung ngang (goi la canli cua hau - Thoma Ionescuj", vach nay chia khoang canh hau ra lam hai oung truac-tram va oung sou-tram,

Vung truitc-trani thong thucng true tiep vdi uung mang tai; con vung san-tram thi c6 df)ng mach. cdnh. trong, tinh. mach. ctinh. trong , day than kinh ph&:uj (X), than kinh pliu. (XI), thi¢t-hdu (IX), va chu6i giao cam ca' di qua; tat ea cac thanh phan vita ducc k§, mdi dAu d€u n6.m 6 phfa sau cua d¢ng mach. ctinh. trong; nh ung sau do, day tluin. kinh phu. chay ra phia ngoai dg Wi cd ucdon-chum va co thang ; day than kinh thiethdu eli chech xucng phia duoi, d~ toi phia hau va day Iudi; day thiin. kinh ha-thie: co ducng eli tuong tu nhu day than kinh thiethau, nhurig xuong thap hon, Iach qua giua tinh mach canh trong va dong mach canh trong va di VaG vung dudi Ivai. 0 vung nay cling c6 n hung hach. (bach. h uy&t) c6' sau,

37 Canh cua hau dU'<;lc cae lac gi;l Viel va Phap goi la hoimh trtlm.

Ca ci'lan buaffi ngoa I

. r..1Ct11 Irnm

Da.y chang lram-mOnQ

CO' tram-mtmg cc Chan butml !mrrg -CO' hal tMn (ntJi l'nan), buflg sau ~

Cd tr~m-11lIli

B6m~ng-hau ....... 80hiJjJ1rr~l1~ B61i,Wi·MIJ

BIJ SJ.,In-ldu (al

eo sU'rig-hiiu ll»

Ccr khiil. Mu 9 Aia

'''hmw!;; bill (endopharYllx; n(li hdu) ~nznmJ phaJ'Y'il?lS: hoc hriufRl; dUde chia til fu.h aa ~'un:g (ho(jc dng), dltqC gr;.i "ten gQi cur [h('o tang do thOng "oj cd quan nao trn~l~ ba co quan la mUI, mi~n~ ... a thanh quan,

.. H:tLll;lillg roll,1 rnj~fl9 ~'.l! m,li, 1<\ r;o QUlin ruog. MI'I 00 n~' dung be 11 tron"l 11'1 m9' '~hQ:!."!l lr;Srig. 00 ttL€ gQi h:' 1rKS:;, t, (tt&:II),'€Il:;i' INk mO,. 6 !?ljE)ngl. MHfnlOlihito;;> mOl 9D l::Ji Uu ILifllJ ... iN ,hi 9~ lEI i:hOolng h.§(.1

• Ty,.hau (thl.tqng.hrJn.!J. hprzg·mlii) (prJrs nasalt» pharyngis); keQ dai lu l'I.e'n. :t:Q tCi'i mut' ngang vo.m h.hlu l'di. tlffn so tno n~n thanh tren ella b~u n~)) I:ung il~(Ir.· gqi I.a l1bm hdu (furli . ix pharyngi6). H.Qng-mui (..'6 chh1:u cao khoiing 5 em, chi.eu ngllng 4. em, va I:hieu tnt(1c-suu. 2 em. Ve phfa dutli. h9ng-mj)j th8ng vdi h9ng"m'~llg (!~hdu.hdll) (paTs arahs p,har-yngis), vi! puia tl'Uc}C th()ng v6i cac hoc milt boi de M i'1l.UL SOtL Cac u mil; SQ.l.i La hai l5 hinh bflu d\lc 1:0 tr\lC ian hu:lIng theo chieu wen due)). c~k la miii sau

57

CIJ' kh~u eilj·hall----El~ng ~rn canh trong --

Da~ lhfui ilIIn l'''HI''JI~1 (X!l)

Day iIWI k.n~ ~h~ ~tha~ ~ir. ~ g~;1 ~XI)

Da~ Ih~m krr,h IlEnh quail tren --D~~ IMn ~ iI'Ih ph~·~i (dm;m d rd)

Co flM phliu ell' nharHflh~\l sau [)il~ 1htlrl klnh lnanh qUB.fI i:llliri T U'fon g.lp llhUl'" om I

fIiIiln hWiu cai (loihalJ cl.i manll

P'ha h~u mOl Iu!!I (P~11 dtl'ng Ir.a~g)

SlIlIlhiMl h Ihie! ~map Iham rn&nl

Il.Jep halJ!4ha.n1l1h~1

~~!'Ihi"flqlliiril Tihh 1i!aG1

canh irOflig

90ng! m:!th ~anl'l g60: (cann cl'rungl

Dil~ ,han kTin 1h~n [JIj.3rl cfLIC'i (qu~ rtgiJ~)

~ioi h;.tn d ~Jhi~J hl!1!l 1l1:l:0ili hih cae rii1~]~ rnui· h6u, " phia ben trong boi b21 sau cua !.la.ch '''Hi!. CI phta tren b.i1i IMn J;.ltt:mg bwm. 'i.'a" & phi n ("hid; bo-i m (j n k hellt cat.

TIl iiJL h l.1·e [J ell 11, h;i U hoo}!: [lom lid u tforni» pfuu:vn.gis) ~~J) nen b2di tMin XlMng blic1m v:~ miJm, rJdn xUclng chi/m; vern hliu d{;t: lit tre.n N:m3"ng dum va 1'3 sou; lien tiR3P voi thunb say cua hU:!"l, tnanh sau cua h~u a d O!P1 nay nam (I p Ii fa tntCrc dily eh6ng dui'lJ1 .d{i!. r-rmg r.ntdc c~la dot d(}i va ~!!dn cU:;J. eMI tr~'c, Thanh tren cua flt/ng-mui 00 mQt c1:!tm mo JYIl'l.pho tdl dai, goi la hard~ 'lhan hau Luschka (ho~c amidnn ldiu) itonsil!« ph. a ryngr:u J.

Hanh .nh~n h~ LJI~ mgt cd quurI lympho, rnnu vi! n g (,J m{i.t dQ memo hop hoi 7-8 thuy nho. kh6ng di~u nhm.l,ng,fin each nhau hoi I1hilln.~ ranh, gOi ~,a khe (ho~c hoc) h~nh

58

11M." {cr,y'pta rt tonsma Nts) T M~t t tong u h il ng khe n.'ty nkm !r~n r.'iU(1l1g giCfa, sau hem ea, va t~ll he't bili mqt tLii Lhli:i ti t dl1[jc ~~i 1::.~!li hau (burul pharyngea). Nhung khe khitc ciia hanhnban haH eCm.g h'Qi t1;l ve t1.~i h:lu nay, H{~m.h nhar.o hau dai kho~nl'l 3 em, va kich 'thltdc tang len dfil1 Wi 16 tuJi, sal] dO till 1 ~ iM'O (U,n. Kl:d h ruzn rzhdn lui u bi pM d!;l.i rhitae no$n srH v~m h,mg'ID. Do ht;lnh ~,thlin h&~ c{~ nhi~u rnaeh ml1U nuOl d1.r8ng, nen Hi tham kham Mng .t1gim tay m~ S~) nln vao o:·Cl.ng di gayt'3 chay IllAu.Hq.nh nh6.n hiiu cfin.g IiI m~t hQ p!-J{ll1. eGa. vcm.g bl,U:h hll}'f!·~ Waldl!~r (atmg Wnldeyer)~.

~ e_',iJ; 1I&m f'<ing lh Lfiln!J nail ~ I tt),e". Ih"';'1 "!:ICI !i~"~ Philp I~ r.6 VA, {~~!Jetatlofl acfenoid~: s.ui 1110 Ivrnpooj.

.J Von 9 bijlm h!!'/91 W.aIireYll'r. (My\; ra pIl~1 !119i la vOn Q m 0. iymptJQ' auanh h91"1,"" do Walde\,er mO t~ 'CI~u 1,~,

Co htl11l1an {nhi bur.g sa~

Day o~n!l trflm-rnong ---~----l:II4'WJl

l--~-- OdY lhan kiflh mat (V"I C:'~---- Cd ha~ Ulan (nhi than), by!lg ssu

...... w-__,...."""'--'-'f--~-- Day than Wl')l1 n'il~iet (XII~ ~~......__~-- O~ Ihiin kinh pnu (~n t.)nIT gai) (XII ~;.---- Cd iJo.d~n-{)hUm +i+,..;-----Trnh m~d:t canh 1flJ119 \..,W-fl----~- Ckly Ii'lan ~fnj; ph'·",r !4F~----- 00'l9 m~h canh gO(; Mn'h chung) .......,,¥L.ff.i~-----lMn giao- cam (chubr giall cam cd,

:.6ioi.,__----- El¢n!l mach glaP dliffi 1io9''----=~---- Dill' th.~ n kinh QU~. ngm;re

Hinh 3(1. IHau (hQ-ng). ba d01 day tDanl'kinh sy d'U'lJi cung, (X, )n, XII) ~a th~n gill'lO cam '(thUIOi, '9Ii,1I0 cam c6) (Nhfn fir phia sal!)

('j phia tl'LrUC cua hont: nhdn hila. ~tt}i khi co [he du'IY trL~[' c{;r: dam r:k bao bi~u mo, lLI. eh uch ella dill1 iIJy.?"n :.,ell rl·8~·ye.n rlw,\'. {)ng lli\y s.e trCl thanh rut Ra.tMtt!, va durn teb~to bi&l,m8 con Iai duVlC w,li 1:':1 'l.I.n~n )'en JlIl,U hoac t!Jyii~ yen lu;mg.

o L'Q'11 Julu. thitn ;xudng budm va mom n~n :Wong cham dut;lt:: boo bol m¢L Ufp !_;,otm~t" (rnang ,x1,JCJng) day tron~ db cO th~phat ;;mh tl xo hong-mui.

Thanh b~ncim hl?ng·mui c6 i/J hau cda tnt led fQ$f.ium plw,rynxaeum tubae auditiuae) !lid "'flO h~.lI. Li) l1ilY n&m 0 phin ::.<11.1 elm da.u sau );:U(lng C{.lJ.i;'t m·at dddi I em. v~ o phi~ U@lt cun man hdt.! 1 em, thong qua V(l}, 'OJ (con g~i Hi, ~'b~ nhi), hau thOng v iii nr,m rui. va "01 tui cung· l~ thtdng Ian tran 1,hi~m khu~n tit bong l~:'n lai giila. Phia bil sau to hJu cua Llbr: In,l co m,Qt ~

niem mac do S~Ul uoi tui 16i v 30 U·on); hAu BQl HI go ['bi ~ai (torrlS ~ub(Jrius), til gb "oi tai 'ci'l meat n~p niem 1'li~C di };uong phta dl:IC!J. rangoai, till phta mil,tl khE)U c~H gqi lit ni1p ubi-'uiu (pUC(1 8aJpingopha~m,glm,J; n!lm rrong nep nay Hi. 00 v',i·hd!l. Phis. sau eun ntip o,roi.·hall. eo ~'i1 }(j v6i ts.i Cil m¢t hi)' ~9i la hotf Ro.senmEWe-r ho(l.(" ngd.ch Mh~ {T~cessus lJharyn.gis), L5 hii.u cua viii tai co In1C1ng lam [_'ho c6 I;h~ tbii.m kharn. de d.1.ng bhng each d\.ta m.{iL lIng tMm qua ngacll mui dud] dil drty 'lao 10 v~)i ta]. Ni'~m mae bao quanh [0 hill elia .... ·oi wi ctl.ng co nhilng khcii ml) lyrnpno t¥o thimh lu;mli nhan rJoi hoac amidan vbi Gerl.(}.ch (iollsilla tubaria).

Thanh dudi cua lamJ.g-mui (tY..fUlU) chi hinh thanh trong d{mg tac T'mOt, khi mim khri'u C(U dUCjCllung len tiip XUI: vCli thanh sau h~u. va up ch*t v ao gil hose go~ Passavant (t~1O nen kh.L. eu kllit hdl( tren. eo).

59

V:ilcti rOlli IlJ9ch 18 mfal -----\-'t-1IT~N1 -:-1.r;-IL~"" C.ac wJmg cufJl'I mOl (lWUIIg ~(lan mUil---,....-~&::-___j

I~III, glcrn. dum

.. H.:"I----OOv cMrtg butirr"hilm ~r---l!"if~-- CI1 ch;"n btrom ngo&i

Co chan blJ'Cfm lfong --~

eft Ila! than (r'l1~ tMn), byng sau --_"'_'IMI

Hirth 31. Hau (hqng){mat ben trong, nhin tu phfs, sa,u)

C~ r h~~lIh rlh{m kJui" ctii; lu;mh rlhan L)Oi. h~lJI11 uhrin l!.lfJi \.'R Ju;mh ,:l.hO/1 hi'iu.. t~o nl'll viJ/lg b(;N~h huy~l WCl~d€ye}',

. Khci'u-Mht flnmg-hong, !t-I}ng"miifng) (po ".": lJ ra] i!" phary nei 15; phdlt mi~ nB eu tl flo fl): 1..>0 gicli h~1'I tri}n HI. man khrlll. ctii; khi t'l"l:'l n nfl)' J LflQC: nail glen rauc nitm l'lgaflg, va girh han duoi h\ ml}t l!n~lt phfl.ng n~m ngang di II Ll<1 rita n :ill(1:l1g mong, JHSI duQng kinh ClW 111,J:rt~- m i9Dl ~ del.! diii khoang <I em. Khr'i fl-htiu \'c pMa tl'lrilc thang r{ing riii vai Ilb'c tni~llg IW3 N) hrmg'miq-tlg ris,hrnu:1 10 urium t: ['0 nay ghJi han CI phfa h'en 'hoi ('ung rU:dl,Mi errl cdi. bao g.sm bai ufI. tn./de CUll mew !thrIll 001 va d pIlla chlCti be;i 1tr(jj. Tru sew cua man }dr.i/u erii di checb tit lren x uiJIll,: dudi Vi1 ra sau td thanh hen i.:ua b!u,

no

t"~ sau t:on duqc gQi ln, ,-'ung }duj,"u c<ii.h&l~ (arcI palalopluuJlngr:t),

G.iiJli hai tru tnWc vii MU eua man kh5u r:::i.l,thimh ben ella I'diu hi.nh thlmh ITti' hg,n..h nhan, t,rung (1'6 chilo hcuzfl llhrin khdr; caf. (a rn ida I! kh6u, cdi). Qua thanh hau. hanh nhan kh~u c-§Ii lien quun 1/01 eac thanh phltn £lim tl'ong khfJar!11 c~nll hou,

-* T'u.mh-hau (h",-hQng, hrptg,-thanh qudn.) (pars laryfl:gen phurY'lgis: phlin. thant: qlujn ('ua hau): n~n1 b giim hu i rn~t pbfing nA.m ngnng. m~t d:i (lUll tluirl :xfldup mcing va m(iL di qua g:i(Ji han diJdi ella. thanh quan d muc Srln nlufl'1, l)o~l1 nay can 5 em, Phia truiic cua thanhhau ro cae thanh p ha 11; lhanh ~hi~t (nap InafLh 11101'1), day tlh1~. h rp!h ith6-n hdjj, c::k r~ @p htfJi·

*'~--- H~nh ",hlill hall lam.dan Mu. VA.} f.:!---~-' ce '1(1\ lsi (gg vdI nhij

-1IIi::- ..... --- LO Mu om vol tai

..... '"rIIi:---- Ngaoo h1lu (h6 Ros.erunu1ler)

trI1I'; -- 'Nri? vOl..ruii.!

1'IIlI'- -- Mali I-;I'I~u cii Iktiau cai .)

~ -- H"tnh i'lllafIld.:!1.I c:!ii j a mlllaol'J'!'l.I cai)

iIIIIfi'j~I---- Trv sau man ki'l~u Iii.. (W1'19 1ol1liu caf.~J

~w=--- Gai !iill (ohU dili) ~!V-~-- 5~ thanh ttI~ CooP lhanh milo)

fhrmh thiN. vol. d.c IIHmg liing lhanrh tMft: p~dfl sau-dndi eua nht1ng thanh ph~n nay 1:\ 1~ vao ~u~c J.O au:~rnh quan ~rlR ho¢e ld

'ao Ow.nh qudn (adif,us klry·.'~gis). 16 niLy [:ti{ii ha Llboi ,de S~J.tl pJri-u, khe gmn. S!,m pheu, cae ne'p jJhJu-t~ulnh thi,r.; (j hai ben 10 trim thanh qulin l~ hei ugad' kilth (IUa U :"in ~;iu vao Juri m.M ben eua thanh qu:1.n, tren thitnh elm cae ng:~ch Llay <:6 mQt nep uiem m~l~ t~o nen do ddiS t!uil'2 kitlh thant:

CjIVali trru (g9i III ~ep Hyra), ID(jot nep ,l1uy nh,:-tt tl"Oll!,!; cd th~ t~o nen do diy th:ln kinh, Thanh sau cua thanh-hjiu tU:Ol1g aug vdi lhiin eua die d:6t ;;[,ng e6 Ca - C, •.

Co'u true 'ci..a thanh h,4n: t.hanh n:iu. co Illem mac lat m~t trong (tunica rnuCQ.'fa:

Mp Iw!m m~c). uiero. m~~ t:hu~c ki~u b]~11 m6 l.-lt Uing. rien.g ph'n ha.u·mi:li (t:,'(.h,;iu). [hi niern mac thuQ.c: kiiu b]~u m.5 tn,;J 'co

long cbQY~T.i (n.i~m mac h6 h:ip). nhung uilng lae (fmc eo nhung cho Ii b,i,e;u mt) hit d.ng. Trong Wp nie.rn l'Il~U: eo [lhung t,uye-i7 Jt&'u (glandulae pltaryngeae) a l1ong, vii t.hU~li: kiJu ~u;}'kn pha a "ban h(;In~·mui. thuoc l>.i'u tuyen uho.y 0 phAn bc.mg-miq.ng va hl?ng·tha.nh quan, 'Tronll: niern m<Jc eimg co cae ;~a-I:j.g lymp'lo.

Ben Guili lOp niem mac Iii m{lt ldp mo i'iln Mt (tela submru!t)s!! pluU'yngi.s: (6p duai·nihn m"c MIlL lCJp m6 lien .kS-1. nay trd nen mau, dai Mn. giu'ng nhu Mi}t 1a 8(}i x~ eh ~c:, nen dd'Qe gQl h'l cdn hd u _ Cii 11 h a. u pMt tri'n hon iI phan ben du\li. con (j ndi c:fi.n ham val) m~t ngoa] n~n 89 tMcfin t1.\O thanh HlQt phuong ti~n rd.ng dC! I.lho h!u, g(}l 13. m~C' hal.i.·n.fr" (fascia ph.aryngo· bassilaris), G day, l''i.i3ng din h~u '4ton{!n tb.anh hall. vi k'h6ng 06 Cd a phon nay.

61

Ice "~LI ell!! w~11e11'1'<'11 Ci16nJ rna, tr.~~ro-... __ .-.

D~g III~ kt,'j~' len --.l.....-I-~,.."L GD'tioll'lg ",.a~ l~hIW tal --~~dilll

~1r:it'tt!tl~-rTif--- T1!I'J tnl~ (1Wl gal U::P'31IW~~~~--- Ttl' ~"II ffiiln KM'J ~I ~GiII kh~u~MJ.I)

D~g 1'111WI h';!1PI nhHn -~~~~7'-i!s ",~~~==:...;:_ _

., C~· kt-r. hiI ... Ir~"

1\1i~~+---IAI:m1t du 910'l1

I-linh '33,. 1hanh be:n eua Mu (h,?,ngl) (vung hi\l,nh nhan)

Lin: l'U cuu h.au; UI(J eel tl[lnl{·a m !I~'{"ulw·i~) ('119 him (1);(,",c chia ["3. inm hai nhom: nh6m cd h'dl ilau VI, nhrirn nJ fl(U~g lui~ rhrnh 28. 30. 31).

A. Cuc C(1' k'? it 'tfi U~ HI. ba Cd del, COI.l~ vrw phia trong. 0 phi:fl sau, c:k cu nay dtiu d;1I1 1,16; eel n(1n do] di~n CHen dUdng gilia t :~() nen chtiJng do '1. gl ito C'u a hri pj f rop he pllaryngia); r:~lC W kl"iit h~u ch6ng len. nhau nh'Lt kieu nu'ij ngui, nt-ning l~p ngurlc, tire Iii C(l l_,!Mt hfl u d .. roi chom len mOt phoin I;d khit hall gill:) \Oil cd nay h:ri. chiHn lfm m90t phbn ("0 khi t htlll tl'en,

- L'cJ kh i~ hdu trcH (tn. c:rmlS~ridor

pha ryrigis superior): bam ngu)'en uj til': 11l1a h['n dut'h ciia LCi sau CU8I md~h ~rong na:lm t4uju rntJrn {pars p~el'ygopho7J'l!g€(J: ')() r:fdm b!irim·h6u), dn)' cMng chan o!MmII ami' m plw plery.'/lo/11 a rtdih ular i 1:;: duxlng

'.'J r'I_

arm ",hdn bl/dm_-hiim) .0 phan !'11m giira mom chan la/om '\l~ biJ h !O'l~l nl.lig CUll lI.udn,g IInm. ar.tai (par« buccophar.wigCc,," 66 m.i~ltg-hJ_",), dflll san ella gd c(/ ham mOrl]! {;ua xuctng hum du'oi (pClrs n'j.ylo{Jhary}tJJt~: b6 ~Ulm rnOrJg.h&u.), va d~y luui (par!.> t:I(l5 .. ~oph(i~~ynge(1: M (ltm·huu. bo nay con dl(~.k: coi 10. moL ee ricng S9i l:tt ca hdl1.-luiii). Tit cae nguyen uy k~ tren, cae bo eo n6i chun.g l1eut411 bEit lJ dUClng MU J!i'i1:n CUll. thanh sau btu: ClU: b~ trcn cung thi rfi len LIen vii ra aau, th.eo rn'9t.mQt duong eong viI dtin bam !laO eu hdu a mom nill rr.ilmg chiiIn, lM lai m,Qt khcang tn':ing khOn.g CQ Cd a ngay duuii m~t ngnai rtJn ,'-19. Khi co 1lhiJ 'u:iu trefi 00 5C dong: kin ph;)[1 h90g·mui tl"Qng d:Ql1'[ tac nu6t. b~ng each t~lo nen iil?t \L Mi d thanh SEl.U hau (g9i J~ gOI PaSSG van t), gO! mil)' tid hl)l maJl khii'll raj c'Ong dr1J1:Jg t.hai t'hlQC n~ng COD lE:n Jo;J,i nuot.

Lo hall eua ..vI lal Co;;ang marl kl~u tai

~Q m adt khju cai len

Tru I~C man 'kh~1J cal l co khaLJ dli-lilUi)

[J Q ng mach t1l,ml'l nhan (amidan k~1J eli)

Co Ira-malllili

Olly Ih~n kinn IIlI$l·halJ jlX)

CO'mOng~t.rrn Day CM~ tram-m{)ng

. - CO" nang man J;~u Gai

- Go w-hilu

Tm, sau man k.hall dli (00 "'hau cai.fliul llnh m ach hi(lllt'l n Min (IlrrVrJafl khiiu. cai)

CO' k1'l11 tIau lr~n

'-dIl1il1'~~1t----- err kM Mu wO'a

1 •• ~M~ __ ~+---- CulmmNiu

~"~_~";"""~If---- Sun ltl3nh !hlel (nap ltianh ITlIlIl)

Sl,Ingl<ip-

Hinh 34. M~t bin lrong ha.u· C8'C CeI' CUI tx"hau va hiu-hau (NI-llrl trim Ihiet d~ d~n9 dQc. (fa cal b6 h~nh nMrI k.i1au ,cai )

Iiun 1110 Lhbng thrf(1.ng glua hong- mCtL v~ hqnjl-ml~ng dliQc d';ng k.In,

- CrJ Mnf Jill u gi Ilu (m.. CQn,~rrichir jJh,a:\'P]l~ls Ill ... dius]; eo nguyen Illy ttl: lli1 "au ,~ittli! DC- JCu'drtg nu:mg (pars dWII elmphoryn{.;e-a; b6 .~~m·}/['Ilt) va a 00 h'en ~~r:tf1g {lin ('us xuung nay tpars cera ~nph(J I'yrrgpn:

IJa ~irfi$"'.&II}. Til nguyen uy. cO nay tDfI than h hi uh qLI~lt di t'l) phffl. snu "I.,a bflln tij[l vno iliklng do» lliLio d thanh SElU CU.9 hliu. I ren m<jL nun ell iell dh i cua dt((;llg nay.

- Crt kliit krill diiJi {~n. constrictor pizar.w,gis Ilitcri.(Jr-J: con g\ii Ifi co tllall.h lpHHI -hd r.l, bam nguyen uy tren mgt. go r-he.o cua m rJ_f 'If,:mit v~ CI ~lIng duai etta S[ln giap (por.~ lllympharJ)1g(~[J: bo giOp.kdrl)_ CI m'4I bE>n eua VQt1!_i ,'1{11'l nhtfJ1 (pars cricophary~!J,"t'tl: M nhnn-nau). v~ a ml)t ngofii cua vong SLut kM qUdtl tren c:-U.ng (pars

imr:hrJopharynj{ca: 06 kM Quall-h6'ul; t'L:r nhung nguyen uy n<'LY, cc di \fang ra pMa mat sau h6u .".ii tf}n h€;t tr&n cJuon~ (hm gilta CU:I m~t_ nay. tren gill hel ch16u dM etta rhtbng ,nay,

- Crt n(l,nh J1ht'in ·lr.tfJi (rn, amy~r:i.a/{pglossw;} Ia cokhi c6khi khong, khi C1i LM eel n ay di tu beo (uoJ ;WJ elHl hfJ,u1i 12hdrl khri"u cai tal hd Mn euu 111(1].

Dong tac: khi cH.e I?Cf khLl hnu en, thj co Ui.c d\lJ),g ciay kh(j"} thuc an tu- trtm x!..l6ng altdi.

B- Ca£' ca n.an,g h,du (h.o~lr. cac 0:0 dQc),: deu xu tf t ph at til £no} t ngo v i eua Flir: 89', r Cii di :!u6ng dudi, thultng h~.t chao vat cite Sql eua cne C'(J kilU hdu,. roi barn tf,tn vao nhung S1.,1n thaI1D QUDn va V3(1 call hail_

63

ClIMm..mOO;'!

T~n lowX Ixi!} dl!Oi Iltd' C'\Q ~i xulit bJ~iin tmtti'C: bQll cU\'l i'18J1'1 ~CI h\,~n Inni Ih:in), . J!1Q • Co cam QOi £I0rlg m~eh kill linhn;ach ~ eel cam·meng - __ -J~

C0'1rtIm-1!.roo ----

CII h3uHrion; Da~' than kinh lIa·thi¢t 11..11) -- =---' CamOOg·I~l Co h.:Ji Ihtwl ~iili Ihm~ bm.g InMrc

~~-- TUY!!n ~ooUc 0011 m~ ~I r-~~-- ~'cArl. lIl~wcan ltln ..an) IIfH1m@~mifl

~:i,J~~~:-~:-:-i!:l:T-- tXltg mach mat

~~----co~~~ HHI---Da1 TK. 1\1, m.' lhanh q~fm trm

Mi:i'~---- ~ng "111m, ~11 1I1~cl1 gl~p 11M

Hinh 35. Cae tuyen nl~c bQI: dlldi ham, dU'di IIIlffi va mangl tai (Iiell quan)

- Ct! tram ·ha~t lm, s~yl(JplH:uJngcrN3); h;; In nt::tlyQ.n uy lr mom l"am x!Mng thai dttdnp. 1'6i di x.uo'ng dudi, I fidl "~U) khe giiJa 1::14.' ('(1 ilhfr flci1l trJI1 va gii1u d~ de'n bam t{l,n vuu bil tr-r-n'.·"l bCi sau cua 5~1Z giap,

C(J Ijui'r,~ cri~ .. h(ju, (m.pl1.lnto-

l~ha,.yng('u~J: )luEit ph~i t t(f thanh sau h{.u vii til h21 sa U ('U:I St-!iZ giap d~ 11] tfll ha m t~n V;lO C(~lJ Mli"/u ('ui (mJm) , L.ren dui.lng giua, (t .;;t;:i,y. dJC .... ~L cd dan Lin voi du:: s<;Ii CUfl co d:mg tel' botl dOl dio?u.

- C[J ~.f}r.har( tm. 8alpmgopharynge!~s): xun1 phat eLi m;;tt duCii eua s{m ubi tal vi?! cling nhu eCl khau cai-hau di sau \·8.0 t.I'01"lg I hunh b~11 Cl'lH h.~u

J)r:h~g ide: Cae cd rtnng !lli!~ CO chue narig ken h{ilD l~n l rong d9ng tac nuot. tl:to thuan Jqj rho rae r.rl knif nilu d&y kh6i tbue ~ln xuc;ng phiDi dudi.

Thanh eo eua I.b~I.1]h hau CI pMZl ben ngoiti .Ju'Q'c pbu biri. m¢t ].(:lp mo lien ket (g'9i h'l "t,o ngDai no*c rLO lien ke"t cua h~u"), Lop 010 lien kEtt nay ,n~m xen vaOo giiila ball viJ nhimg ec quan tJ ben canh, Ui.m tho hau. ~huye'n dQ,ng clU"~j'r de dfm~.

M~ch miiUY3 dliiiy thtin ldnh cua hiu

to D9ng mocb: Hau Chlt,lc 1111lOi (I,uang ehu yliu bl~i oQ,n_.g n1~cll, hclu len ta. pharyng~a a seen-dens) , la rn (~t,.., h anh be t1 c uao d:(}ng

1I1Qc1l cu nh. ngoai, va t hir yeu bci nhung nh a n h cua d()ng mach. khClu cai len. cua u(Jn{i I1IQch fJ!idm~khdu cai va cua d(mg mach. uidian. (la nhirng nhanh cua d(ing mach. ham ngoai).

* Tlnli mach: 6 lop duoi n iern mac va lop 110 lien bit cua hau c6 nhung dam r6i t inli nuic]: thu rihan rnau d4 dan luu vao t inh. macli ctinh. trong va phan nao vao eac dam /"61 tinli moen chan buam,

* Mach. mach. huyet: dan hru bach huyet ve cac hacb sau luiu. va hacli c6 stiu. (nhom dudi).

... Day iluin. kinh: cac co duoc van dQng boi eric nhanh cua dam r6i luiu. (plexus phwyngeus) narn 6 vung ben cu a co khit lulu giii:a va tao nen boi cac nhanh cua hai day tluin. kinh thiet-luiu. va phe:vt.

Dam rtli than ki nh nay cung chua nhung soi them kinh th uc v(It den tu hach. ;.;iao cam ed tren de' chi phoi ldp niern mac, va eli theo nhung sci than kinh tit hach c6 t ren can co nhirrig sci den tit day tluin kinh tarn thoa .

Vung du'ai ham va vunq mang tai

Vung dU'oi ham Tuyen dU'oi ham (Glandula submandibularis)

(j ph fin nong, uurig drtdi ham duoc gidi han d phan trcn bdi bil duai cua xuong ham duai. va 6 ph a n dudi boi cac bung truttc va tll!ng sau cua ca hoi than, tao thanh mot vu n g hi n h tam giac, Vung durii ham chua dung tuver: nude bot dlLdi ham la chu ye'u, i.uyen nay duoc bao quanh b6i mot m ac lien ket. III m0t tha nh p h a n cua nuu: c6' nang," mac nay gidi han vung cua tuyen.

q Mac cO' la cac 1.3 me lien keto bao bee hoac che phil cac cc, va CaG co quan a co, va k€t neii cac co va cac co quan nay voi nhau. Tuy theo vi tri, ngLIoi ta phan bi$t ca mac CO la mac cO

Vung dti(ji ham c6 ba thanh:

~ Thanh t.ren-rigoai: la m¢t trong cua xuang ham dudi, phan nam a ben dudi cu a gil ca ham-mongo

- Thanh dudi-rigoai: tao nen b6i m(lc eo' nang, cd bam da c6', va da phu ben ngoai cu ng,

. Thanh trong: tao nen bdi cd hammong , co mong-luai, co tram-luiti va cd tram-mongo

Tuyen dtioi ham: kh6ng chi' nam gon trong gidi han cua vung tam giac n6i treri . o bo sau cua ca luim-rnong , giua co nay vA co mong-ludi c6 mot khe qua d6 vung cluoi ham thong thuong vdi uiuig dUdi~lrtai, day cfrng la nci rna ma.'u nho ra truce eua luytn dudi ham cung vdi 6ng Wharton (ductus eubmandibularis: 6ng tuytn duai ham) di vao oung duai·ludi, Trong vung nay, tuyen dirdi ham lien quan vdi dAu sau ella tuyen duci hid], tao nen mot khfli tuyen chung. Ong bai xu/it. cua tuyen dudi ham di qua phia mat trong cua tuye:n nude bot dudi IILifi va rnd vao riinli huy¢t~luai bdi mot 16 6 di'nh cua C1JC duai-ludi (papilla sublingualis: nhii duai iuai) (hinh 35).

Ca c rnach mau va day thin kinh cua vimg dtioi ham

* D(mg mach: tuyen duoi ham duoc nuai du6ng boi nhling nhanh cua d(Jng mach. miit va d¢ng mach. luiii.

* Tinh. mach: di kern d9ng mach cung ten, va thu mau d~ d6 VEl tinh. macli cdnh. trorig .

* Mach. bach. huyit: bach huyet cua vung duoi ham del vao cac hach. bach. huyitt duai ham.

* Diy than kinh: t.uyan duoi ham duoc chi phoi bdi thdn. kinh ph6 giao cam lit nhirng soi cua day thitng nlii (chordo tympani) (l a nhanh cua diiy than kinh trung gian hoac day thin kinh s5 VII'), thitng nhi di Wi n5i tiep voi day thiin. kinh

n6ng, mac cel gi[ra va mac c6 sau Co tal lieu Giai phau h9C con gOi cac m<:lc co nay la cs» co.

65

luai, day nay tach cac nhanh di vao cac hach. than kinh duoi ham, 6 day cac sci than kinh ph6 giao cam trtroc hach di tit nb an n udc bot tren se tiep xuc, qua cac k hdp thin kinh (sinap), vdi cac soi sau hach, va cac h ach nay di toa nhanh VaG cac pha n cua nhu rna tuyen dt§ chi phoi tuyen che tiet rrudc bot,

Cac soi than kinh giao cam thi Mn tuyen mrcc bot dudi ham thong qua cae dam r6i iluin. kinh quanh d(jng mach. mat va dt;ng mach. luiti, cac soi than kinh nay di thea rtha nh tuyen dudi ham cua cac dorig much m~t va Iudi d~ VEW trang tuyen,

Trong vung duci ham e6 cac dt;ng mach. mtit, dQng mach. luiii, tinh. mach. mat, tinh. mach. Luisi va day tluin kinh hQ.-thiijt (XII) di qua.

Vung mang tai Tuyen mang tai (Glandula parotis)

Vurig mang tai co nhung gioi han nhu sau: phia truce la bd sau cua xucng ham duiti (bi::J sau cua nganh len va goc xudng ham dudi): phia tren 13. ong tai ngoai; phia sau la xudng chum va ca uc-don-chiim; phfa dudi Iil. mot dUdng thimg quy Uoe tiep tuc til bo duoi cua xuong hum dudi toi di§m duong nay g~p ca tic-don-chiim,

Vung mang tai chua tuy€n nude bot cung ten, la tuyen Ion nhat trong so nhirng tuyen nude bot phu thuoc hoc mi~ng. Tuyen. mang tai ducc boc trang mi;lt bao (vo) sci xo goi la mqc mang tai (parotid fascia), cung 18 mac khep kin vung mang tai.

Vung mang tai: co hinh thoi-binh hanh vdi true lon hudng thea chieu dung doc, bon tharih va hai day.

- Thanh ngoai la da, vdi mfLc mang tai nang nam 6 ben dudi, mac nay Iieri tie'p 6 vung ml).t vdi mac mang tai-cdn, va a vung cO vrii mac ca uc-don-ch.iirn. Iii mot b9 phan cua mqLc co' nang;

66

• Day truoc-tren la ong tai ngoai (k@ cit phan xucng va phan sun);

-Th anh sau 1a thanh co, tao nen bai cd uc-don-chiini va bung sau cua ca hai than;

-Day dudi duoc tao nen bdi mot tam mo lien ke't, goi la udch. sai xo gian tuyen, vi vach nay ngan each vimg mang tai kh6i uurig dudi ham;

-Thanh trudc Ia thanh xucng-co vi t00 nen bdi b(j sau ngonh. zen xutmg ham duoi va bd sau cua ca can va co chan buam trong;

- Thanh trong lien quan vdi hau, duoc tao nen bdi can mom tram, can nay bao quanh b6 coday chang bam vao mom tram xuang thai duang ( goi la b6 Riolan: bao gom cac ca trtim-luiu, trtim-mong , va cac day chiing tram-ham va trtim-mongv. M:iu nh6 cua tuyeri mang tai di qua din tram nay M 19t VaG khoang canli luiu. (hoac khoang ben hau), a day rnau nha cua tuyen lien quan vci thanh ben cua hau va khoang sau-trtim .

Tuyen mang tai: duoc bao boc trong mQt mac, qua mac nay tuyen co rihfrng lien quan cling giong voi lien quan cua vung mang tai. Tuyen mang tai c6 hai rruiu. nhi) (hinh 35):

- Milu nh6 ra truce hoac goi la milu nh6 nuit, di qua mi;it ngoai cua co crin va tiep tuc b6i dean ngoai tuyen cua ang bai xU<lt goi la rYng Stenon .

. Ma'u nM vao trong hoac mdu n.h6 luiu ong hili xu/it cua tuyen nude bot mang t.a i di ngang d mat ngnai cd ciin, roi ngang qua ca mut va rna VaG ranh. treri cua tilin dinh hOc mieng bai mot 10 narn a ngang muc c6 rang ham be tren thu hai.

Cae mach mau va day th§.n kinh cua vilng mang tai

* D(mg mach. nuoi tuyen mang tai Iii. nhfmh mang tai cua dQngmc;tch ctinh. ngoai va nhtmg nhanh tach ra tit chS pha n doi t~n cung cua dong mach nay d trong bg day cua tuyen, ngoai ra con co nhung nharih cua dQng macli thai duong nang va cua

d()ng mach. ham tren, cung la hai nhanh cung cua d9ng mach canh ngoai,

* Tinli mach: la cac t'irih mach di kern d9ng mach cung ten.

* Mr;u:h buch. huyitt: bach huyet ella t uyen mang tai duoc dftn luu ve cac luich. mang tai nang va stu: (trong tuyen), r6i tir dCiY l ai d6 V:'l0 nhf:lng hoch. bacli huyit co' thuoc nh6m SQ,

* Day thiln kinh: trong tuyen mang tai c6 day tiuin. kink truit di qua, day thfln kinh nay toa r9ng' tharih nhirng nluinh. thai diasng-mat va c//-m¢t d ngay trong tuyen, hai uha nh lOn nay n6i ti€!p vci nhfing n ha nh ella dam. n3'i thiin. kinh co' nang va nha nh cua day thdn kinh tai-thtii diamg,

Thdn kinh phs» giao cam chi ph6i tuyen co ngu6n gac tit nluiti nuac bot dudi narn d trong h.anh. niio, 'I'u trong nao di ra cac soi thrin kinh ph6 giao cam nay qua day tluin. kinli Jacobson con goi 1:\ day tluin. kinh nlii tai (n. tympanicus) va qua day thdn kinh eta nang be d~ toi hach. iai (can g9i la hach. Arnold), hach nay na m d g§.n va dinh vdi day thdn kinh ham dudi (YJ) , til day than kinh ham dudi thong qua day thdn kinh-tai tluii duang va nhanh noi tiep cua no vdi day thdn kink mat, cac sci than kinh pho giao cam di Vf!O tuyen mang tai d~ chi phoi heat dong che tiet. Cac sci trudc hach va sau hach cua pho giao cam t.iep xiic voi nhau qua cac khop thAn kinh (sinap) d t.rong hac]: tai.

Thein kinh giao cam chi phoi tuyen m ang tai thi xuat phat tit chu6i giao earn ci/. Cac sQi trudc hach va sau hach cua thftn kirih giao cam nay tiep xuc vdi nhau qua nhirng sinap d trong hach. giao cam c{j'tren, 1'6i til day, cac soi sau hach se thea cac dam ra'i quanh cdc d(mg mach. cdnh; r5i quanh d()ng mach. th.ai duoru; nang va ham trang va quanh cac nh:1nh til cac dong mach nay toi tuyen mang tai d~ chi phoi tuyen.

J\' goa ira, trong vung m ang tai can co mot loat thanh phan duoc liet ke dudi day: d(Jng mach. ctinh. ngoai, tinh. mach. ciinh. ngoai, day than kinh rruit (VII), cac day than kinh tai-thai dUdng, day than kinh tai

Ian. va nhling hach. bach. huyet mang tai nang va stiu,

Vung thanh quan (Regia laryngica)

Vung thanh qutin gioi han ben tren b6i bd tren. s~n guip va ben duoi bdi biJ duci sun nhan; va VB p hta hai ben thi lien quan voi tuye'n guip (giap trang).

Thanh quan (Larynx)

Thanh quiin la cd quan phat am, narn d hen duoi xuang mong , va duoc n,6i vdi xudng nay bdi mang mong-guip ; thanh quan nam ngay phia tren vorig eun khi qudn thu nhat va duec n6i vdi vong nay boi mang nhd.n-khi quan, Phia sau thanh quan la heiu (h9ng) (pars laryngica pharyngis: ph6.n thanh qiuin. eua heiu), va VB phia truce thi thanh quan duoc che phu boi co uc-giap va cd gicip-m6ng, nhirng co nay thuoe ve h~ thong nhung cd thang, cang giua biJ tren. xuang uc va ba dudi xlidng ham dudi, va eii bdi co brim da cd va da.

Bo tren ella suri gicip, khi dau d tu the binh thuong, thi narn ngang mire vdi bO tren cua dot soOng c6' thu 5 (Co), can bo dudi s1;ln nhan thi n~m ngang muc vdi bo dudi cua dot song cd thir 6 (C6). Do do, thanh quan d nguci 16n tuong ung voi chieu cao cua hai dot song ci/ CS-c6. Tuy nhien, vi trf nay thay d6i tuy thea tu6i.

Khi dau d tu th€! ng:lng, thi thanh quan xuong tha'p va bo dudi cua n6 co th~ 6 ngang muc bo tren ella dot so'ng c6' 7 (C7). d(ie biet la d nguoi gia.

V] tri cua thanh quan thay dai tuy thea tu6i va theo gidi. (5 ph6i thai va tre so sinh thanh quan narn ngang muc than cac dot s6'ng c6 3 va 4 (C3-C4), can 6 ngudi gia thi

67

Day Chili~ gi.ap-mO.I1(l-----J Sun [hilc

Lap r,iem 1'1'10' cOa lhUflQ ---- ... ~~ lUng lha n hthi~t

Cli~l,lnc~lliIGli sun elmg - -~...cI~

N~p ti~n oLnh -~

Ti~n ufnh th@nh qlJan -~-!i'"~!],"

mp th.anh am (day ~h811h am) CO'tMriham CI)' nh;3ll-ijJfleu

OOy d1~ng nh~ili;ip

Tuyen glltlp (lhu ~ !lEG 1r3~ --

-- ...... H~+---- Ti~i'I dnh I~Jlh quan 'i'i---- Slrrig lren (slrfl9 rntJIlg) san gi;'lp

Calien ~l1elJ Ilgatlfl

....... +-f~~J:'-~fi--- NOI"I churl JI'III~';""'~-- GLI nhan.pneu Sl'l\i

~K"r.u"

H~ntJ 36. Mijt ben '~rong ella thanh qllaJn (n!'lin tU phla saul

tha n h quan <F ngang mllc de dot s6ng c5 C,;.C.

Do llhun~ moi liel, ket giai phau" rna btlt cd Ch~lY~11 d~ng nao x.1y ra glua min m iilng VA ca hn~nh. d~u co anh hlldng Uit thuj dOl vi lri ella tu~ tluznh-hJd quan. ~hung chI.Ly~'n dQng CUE! c{H SOltg (cu1 va 11g-da dAu) (teu Jam tha.v dS] chi.eu dai cua (~llg t ha.I!~p.-khi qluln ttl 1() teli 30%, Tronztu the' nhmngu,a. thanh qusn V9 khf quan se cao hon Illot flU:1l hoar: tha.m chi mat ehieu COlO cua rtirt fiGltg ci th~n.h {Juan' ehuy~n dQrllo! theo Chle!U d(ITi.g dec, di ChlJ3·4'n len. eao k ln ng~j£l Mm. khi nuOt, va khs phirt nh1i:ng am cao: va di di.uy,en K1.iI:Jng thflp khi phat eft(_; n L'I"I th.'(p V9. Hi cui eMu.

Kith I..hLtdc t.:u.a th.ann qu;i.n l:iing thay d6'i eheo moL gidi vh thea tung ciL th~, Vllo hie I"l'!loi sinh thanh Cluan r[tk~m phi!;t tri en, nhuug to rlfi n ]fin eho tdi 3 tudi, vs tit dfi bat dau phat trie:n: thanh quan phat

u-i~n rti't nh an h Q bl'e em n a i vao tuoi d~y thi. ]{1ch th U(lC trun g binh la: :3 5· 500 1'.1 m chi eu eao, :=:.5·43 m m ell]€ u nga n g., ... :t 25·.36 In m chi eu tru:oc S all.

'1'lmnlt qudn. la mQcC(i qu an 1'5ng, .r:AU t:,w btit .m~Jt khung SI,lD, ciLe khdp gil],a cite S\lU, cac cia;!.' chang. de mans dan hoi k~l n6i ca.e sun Va] nhau, va mot M th6ng co v~ n d{)ng, eac rnaeh rnau vlL dity than kin h (hlnh 36· 59),

Kbung S-'\!i" cira thanh quan: bae g6m bn sun 1 e vii hni S~I n do i,

* S~m gidp (cartilngo thyro.~d€o): la 91,]f'I to nhat eua. rhanh quan. co th~ nhln thh nO'i eao len v~ sCI ~1:i~1 th;§"'y qua da vung ciS trudc, S\:1n giap eo hai manh ben piuii [}ti trl'ii (familia tiextr« e~ ;'jinis~.m). HEm Hep val nhau (r phia tnil'k, trw th.anh mtll. gilt: khcang mi' (8 nam giljl~), niCs ra phJ~ sau, d~ n ticcn ci~.(l g6c ~.l ii y (;0 t he ~a nil n thJfy qua da; phan .. n.h& 1"lhie1ll nhJ(t 1.'3 tn1~e nay

TMn XIJ~ m{rng _

I).~y cMi1g mOr.Q-fhallh fni~l -- __ ~'!rDey dnar.g glap-mortg

1f:hi5i mer (d~m rOO) ciJa thanh quio D~~ r;h~1'I!J yi;3p"tlianh !hiM I ou6~ $"UI'I lnanh 1J1iN hooc ClJong iI~ thanh mOn) .

Day ch:Jng l~l "tnh Day 'f.la nil ~m (day cnartg Ihanh Am)

Coo g lap-pheu C::I nh~n-'9~p

O:ty G~!J IlIlAI't-giap

----Day r.h;!l1g Y~n9 khi' quSn. ~

cac luy€n IIltl q uan

- S\ln Ihanh 1hi~!

-~,..,__--- Mang giap-mong

~ SUng tren S1,Jn giilp mat'ti

s~ philtu

.----- rJa~ d1ang nttan·Mu ?'iII'-r'---- [jao (manh] sun nh~n

f.r----- -- lOp "!ern m'1C cna ilal.! ~hQng)

Hinlh 3,1. M~t be1n 'trang c{"athanh qu~n (Nhin til phia b~f11rai)

con (lul,Il: !;9i 1:1. {I tluwh qud II (pl"OffiUhmtiCl tn!yn~ical ho;}C' ql.ui ufo it&unf~ (h1n.1J ;-t1:'/--1 II.

o clfiu [ren eva goe ti€p nil! gnltl hai m~:1nh phiii \.! 'tral con lM."y khuyet giap 'n_;11 (ill r:lSI1I'U thyrcQidea cra1taii.'1: hhll)'J'i ~Hip pJlla rich::). Tit bo snu elia de mann nl'n di tic(p }Em pMa tr€m co mOi hen m9t .~I!l]g mont: s~m t;icip (cornu hyoiderun t·orldu.gii thYl"eoi'.(l~i)u> va (ti t,i~;p Ku6ng phl:J. lhtdi co m5i ben mqt si'tng n.h.dn s~.r.n gjdp tCOrlU/ crico.ideuml, tl'&n moi ~.dt1,g lilian ct~ll co m{lt. dien khClP. di~1i kh(tp

'" Ph~n Ire.1'I dlllQ ~u~ c'\'f'Itl gnta. h,,] m~nh ,;>1'181 viJ ir.li olis 81,10 "".lp a:<l m~' I\huy~l. !I~I Iii ~hLJ)lo!l giilp IMfI, pnAn na:i oM r a pf1iOl IntO:: nl'lieu nh~t.. 19m Ul.'mh m.'l~, 'II. Ilgil'fIIl H!~ phU'ti_ng g,o. I~ qui! MO Ao~m. cen n!;le.r. rlgU'dh 11;010 \fl~1 rhl VIII ohilm la Mu ~i ~U Irong IU' '{l h8U ~,,; "nung ngmti moll \.till A!liam I'll ... I" t(U'<Ic tlLla ,0 reI

J SUl19 trlOi1rJ liB stl'n g rth J n !IV!'! glilj;l g),n sal lEi 11 itrql I" iLll1g lr8r~ _, a ~(mg rJiJOI

l~hr1n, d~ tiep vEli cac di~n Uillllg ung elm sl,tl1 nhJn.

MlLt sau-trong cua Sl,'IfI gi6p kh6ng nhung ch~ g1l3] h~n Uurnh r(l.lJin. nhl1ng con om la"y cA. th;j11n ben CUll hilu, (h~ng). lam cho gHi:1i\ nhung /Jtanh Mn cua S\lO ~iE1P va rbanh ben ella hau hin.h thitnh (1 moj bEm m9t h6 gl?i ta Tanh thfWh-h4u bo*e n!!cieh hilm qua Ie (J'€ce.qJUlS 1) irlformI;S). lhuQc "T~ vung #umh·hdu (hc.;m,g-thaJth q,.,mu).

... Sun nMn (cariit.ug() criaoidea): co Mnh gi611,g mot Chl.lc nhlin cO m~t, vei phtin rui]t nh~n iJ pMa sau. M{it nh~n ]i, m¢t man-h, hlnh g~n (1 htt han canh vdi ,tr\lc dili theo hu:img trerHh,roi gqi III ban. h(J~C man~ SUfi nM-n (lomiila Cftl"tUagiruB cricoidae). 0 b~ tren CUI'! ban s~n fl-h6n co hat di~lt khr1p pldu d6 kMp vlli. d]l~n kMp tudnS ung a day eiia eRe .q~m phit~ (hinh 45-,1n

69

* Sun thanh thiet hoac s~n n6p thanh mon. (carlilago epiglottidis): giong hinh mot 1ft cay, vdi ph/in bd tu do rong, h udng len trcn. va phan cuiing 1& (petiolus epiglottidis: curing thanh th iet) a phia dudi: euollg sun. thanh thiet nay khi soi thanh qu a n n hi n thay nhu mot ell goi la eu thanh th.iet. (tuberculu» epiglottidis). Cuong sun. thanh th.iet ket noi voi mat sau cua goc sun giap 6 ngay phfa trcn ehb bam cua cac day th anli am (hi nh 36, 37, 44).

C:1.e hd t1;i do cua su n thanh thiat b~1O nen phan truce cua l6 thanh quati tren. (aditus laryngis: IJ vao thanh qudn], S1,1n thanh quan co vai tro day kin IJ thanh quan tren khi nuot, do do lam cho cac chat d ich va khoi thuc an bat buoc bi dfly vao Iuiu va th.u»: qua.n, Be mat sun thanh th ict c6 mot so ho 15m, d6 la eM chua cac tuycn nhay.

* Sun ph!u (cartilago arytenoidea): la sun d6i, co hinh thap vdi ba mat ben va mot cUIY. M(it ben trong va nuit sau ella sun ph6u nhan, kha« voi miit ben ngoai go ghe. D(lY (basis) sun pheu co dien. khdp nhdn (facies articuloris cricoidea) d~ tiep khdp voi dien tuorig ung a bo tren cua ban sl}n nluin, O;,'Iy cung eo hai mom: mot 0 phia t rude In chb bam cho day thanh am nen goi lit mom thanh am (processus vocal is), va mot mom huang ra phia sau-ngoai lit ehb bam cua cac co cua thanh quan, nen goi Iii. nuim co (processus muscularis). Dinh cua sun pht;u heJi nga ra sau va tie'p k hdp vdi su n sitng (hinh 42-47).

~hCi k.hdp giua cac sun. ph€u vdi sun. nluin, rn a cac sl}n pMu, dudi tao d9ng cua cac co, co th~ phdi hop 81;i ch uyen d9ng cua cac day thanh am va toan bl) chuyen dong cua thanh quan.

"" Ctic sun. sling (cartilago eornieulata): hoac sun. Santorini, lit sun dOl, nho, hinh trim, n&m d dinh cua cac sl}n ph€u, tao nen

70

hai cu (tuberculum corniculatum: eu s~n sitng) d hai bd cua khe giari-pheu:

* Cdc sun. chem (eartilago cu neiformis'i can goi Iii. suri Wrisberg, cu ng la sun doi, nho, na m (j b€m ngoai sun sung, trong cac nep phlu-thanh thi¢t, va cung tao thanh nhling cil (tuberculum cuneiforme: cu sun. chem), c6 th~ nhin thay khi sal thanh quan.

Trong b& day ella day cluing mong-guip bEm, cung eo hai SV11 rAt nho (kieh thuoc chi bllng hat gao) goi Ia s~n thoc (hinh 36, 48, 50,51).

Be} may day chAng ella thanh qu an:

Ph an tru'dc cua xuttng m6ng va cua suri guip cung nhu ella s~n nhan ket noi VOl nhau bdi cac mang soi XCi, cac ma ng nay eo dirih khung sun cua tlianh. quan vdi xuong mongo Xucng nay 1:;'1i duoc eo dinh vao ne'n S9 bai nhling day chling trtim-mong va cac co cua ludi. Nhirng mang soi xd noi treri, duoo tang cuong bdi nhung day chang, d6ng thdi cung Iii. duong vao ella nhirng phau thuat d thanh quan d~ toi cac vung khac nhau cua co quan nay (hinh 36, 37, 48, 55, 57).

B9 may day chang ke't noi thanh qua n vdi nhirng bo phan Ian e$n bao gam: mang mong-gitip, mango mong-thanh. thiet, cac day chling luiii-thanh. thiet, luiu-thanli thiet, guip-thanli thiet, va day chling hoac mang nhtin-khi qtuin,

* Mung mong-gidp (membrana

hyothyreoidea), trai tU xudng mong tdi bit tren. va cac eung mong (sung tren) cua sun giap. Ph an giua cua mang duoc tang cuon g bdi day ehdng mong-guip giiai (ligamentum hyothyreoideum medium), con 6 hai bd sau ngoai cua rnang thi eo cac day chling monggiap ben (ligamentum hyothyreoideum lateralei tang cudng, trong be day cua hai day chAng nay eo chua hai sun th6c (cartilago triticea).

Do thanh quan dU<;Jc ke't n6i chat cM voi xuorig mong, nen thanh quan cling tham gia vao su cb uyan dQng cling vrri xciong nay.

Ph An ben ngnai cua mang mong-giap co nhirng 16 d~ cho cac d¢ng mach. va tinh. IIL(Lch thank qudn tren. va nhanh. trong (ramus internusi cua day than kinh thank LJllc11I tren. (n. laryngeus superior) chui VaG thanh qua n,

" Miing mong-thanli thi~t (membrana hyoepiglotticcu: lien ket mat truce cua sun. ihanh. thi~~t vui bd lreti cua xudng mongo Phfa dudi mang m6ng-thanh thiet, giira sun. thank th iet v:\ nuuig m6ng-gicip co khoi rna (d~m InJ: COl1Jl1S adiposum) cua thanh quan, Mang mong-thanh thiet khOng lien tuc; mang nay gidi han cung voi nuuig mong-giap 6 phia truce. sun thanh thi~t d phia sau, va Bl}n giap iJ phia duoi mot khoang goi la khoang monggiap-th.anh. thiet,

'" Day chang luisi-thanh. th.iet (lig. glossoepiglotticumi nfii day lU:di vdi sun. thanh thiet, dgi niern I11?C len thanh cac ncp: co ba day chang luoi-thanh thiet 1s. mot. day giua va hai day ben; cac nep niern mt.1e do chung tao th a nh cling mang cung ten: m<)t nitp luai-thanh. thiet giiia va hai 116) hAlj-thanh th.iet ben, giua ba nep Iil hai h6 16m gqi 12. cac thung lung thanh thiet,

* Day chang gicip-thanh thiet (Zig. thvreoepiglotticurns: tao tharih mot khop gluH sun. thanh thift va goc sl,ln giap; day chang nay nAm d ben dudi cua day ch6.ng morus-thnnh. thiet, ket n6i cuoru; sun. thanh tliiet vdi mat sau cua khuyet guip tren (k h uyet a gi ira bo tren sun giap).

* Dtiy chang nhdn-khi qutin. (lig. cricot.racheale): cang giua bd dudi cua sl,ln nluin. vii oong sun khi quan. tren cung.

* Day cluing tie'n dinh. tlig, uestibulare): tham gia vao cau tao cua cae nep tie'n dinh,

* Cdc day thanh am (lig. vocate): 18. cac day chang dut;lc cau tao bci 1110 soi-chun, 6 phia truce, cac day chang nay bam VaG goc slj-n thanh qiuin qua mot cau true dim h6i (macula (lava; vet vang), i'J phfa sau thi cac day ching nay bam vao mom thanh rim cua day sun. phiu.

* Mang X(/ -chun cua thanh qusin (membrana [ibroelasiica laryngis): la mot mang kha day, narn C! dudi lop niern mac cua thanh quan. Co th~ ph an biet m a ng nay hai phin k hac nhau: phan trim va phan dudi,

1. Phdn tren. cua mang xa-chun: la rn a ng doi, doi xung nhau, nim 6 hai ben phai va trai, mbi ben la mot mang hinh bon canh (membrana quadrangularis: mang bOn canli), bit diu d phia tren tit cac nip phlu-thanh thi¢t r6i di xuong dudi tdi t~n het b:lng each t.ron Hin vdi cac day chling thanh-thiit, Ve phia tr udc, rnang bon carih bam vao sun thanh thiet va ve phfa sau th i bam VaG rruit truce ngoai sun pheu. Mang bon canh tao cho tit'n dinli thanh qtuin co hinh n6n C\1t vei day Ian mC! len tren.

2. Phan diroi cua m ang xo-chun: goi lit non chun (conus elasticus), tuong urig veri khodng dudi-thanli mon. va la 1119t thanh ph An lien ket-chun quan trong cua thanh quan; d phia dudi, non chun barn vao rung va bd ben ban cua slj-n nluin, tit day non di len tren d§ bam ve phi a truce van mat sau cua g6c slj-n giiip 0 0,5 em dudi khuyrtt gid.p tren, va ve phia sau bam VaG mom thanh am cua sun pheu. Nhu vay, bd tren. tu do, eua n6n chun cang giua g6c sun giap va mom thanh am cua sun pheu tao thanh cac day thanh am. Dean trudc cua non chun, nam giua bd dudi cua sun giap va cung cua sun nhan dU9C gqi la phdn trj do cua non chun (pars libera coni elastici) hoac day chling nluin-guip (lig. cricothyreoideum), Hinh th~ cua non chun thay d5i mM khi thank mon. rnd ra,

71

Cae khop cua thanh quan (hinh 45-47)

* Khttp nhtin-phlu (articulatio cricoarytenoideay: la mot khdp aijng vdi su tham gia cua cac dien khop 6 day cua cac s~n phiiu (facies articularie cricoidea) va cac dien khop 0 biJ tren cua ban s~n nhdn (facies articularis erytenoideai, day la nhirrig khdp a§.y au, vci met mung heat dich va mgt bao khop e6 cac day chang tang cuong 6 phia trong, Cac khOp nay c6 th§ thuc hien duoc cac dQng tac trirot suri pheu theo chieu ngang va xoay sun pheu quanh true dung doc, Eoi nhii'ng dorig tao nay, sun pheu dua mom thanh am va do d6 cac day thanh am lai gin nhau hoac ra xa nhau. Nhung dorig tile khep va m6 (giang) nay la bAt bunc d6i vdi chuc nang cua thanh quan (phat am va the). Tat ca nhii'ng co narn ben trong ella thanh quan tac aijng true tie'p tdi hai khop nay.

* Kh.dp nluin-gid.p (articulatio cricoth.yreoidea) la hai khop dOng, phang, narn tiep khop giii'a sung nhdn (sung dudi) cua sun. giap vdi mat ben cua s{in nhan ([iacies articularis thyreoidea: dien khap giap), hai sun duoc ket n6i voi nhau boi mot bao khop, vdi ba day charig: beri ngoai, sau, va tr udc tang cuong.

Nho khrrp nay rna s~n gidp e6 th§ truct treri sun nhan vdi bien dQ nho, va e6 th~ xoay qua nh mot true nam ngang di qua en hai khdp doi xung nhau, do d6 lam ding cac day thanh am.

BAng each nang cung s{in nhdn lim cao, thi phan trcn cua ban sun nhan voi cac sun pheu n&rn tren ci6 (hai - sun nay tiep khdp vdi nhau) se bi nga ra phia sau, lam cho cac day thanli am cang ra, Nguoc lai, neu cung sun nhdn ducc keo ha xuong thap, thi nhung di.£m bam cua cac day thanh am se

72

lai g§.n nhau hen va lam eho cac day nay trung Iai.

Cac ed cua thanh qu an (hinh 50-52, 54,58)

* Co nhdn-giap (m. cricothyreoideus): di til ba duai va sitng nhan (sung nho) cua s{in giap tdi bCi tren cua cung sun. nluin, Co c6 d(ing tac nang cung sun nhan len cao, lam eho ban s~n nhan nga ra sau hoac cac ban eua sun giap ngs. ra phfa trudc, ke't qua ella d9ng tac nay 13 lam ding cac day thanh am. Co duoe tao nen bdi hai b6: b6 truce, goi la b6 th!tng va b6 sau goi la b6 ch.ech. hoac b6 cheo,

* Ca nhdn-phJu sau (m. cricoarytenoideus posterior): di tu mat sau cua ban s~n nhrln toi mom co eua sun. pheu. D9ng tac ella co la keo mom co sun pheu ra phia sau, Lim eho sun nay di chuyen thea chieu ngang, va til d6 rna rong khe thanh mon (rima glottidis), vi cac nep thanh am (tuc la die day thanh am) hi keo ra phia ngoai: day la ca ma thanh mon (Cd giang nep thanh am) duy nhat ella thanh quan. Trong trvdng hop co nay bi li~t, thi day thanh am 6 cung ben se kh6ng th~ di chuyen ra phia ngoai dUCiC.

* Co nhan-phifu ben em. cricoarytenoideus lateral is): di tU mat ben cua cung s~n nhan tdi mom co cua aay s~n phiu. Co' co tac dung keo mom ca s{ln phiu ra phi a truce, va do do khep khe thanh mon (rima glottidis), lam trung cac ddy thanh tim, Co nhan pheu hen la co md thanh mon (gir;.ng ni[p thanh am). Khi hai co hai ben cung eo thi hai sun phiu sat Iai g§.n nhau hon.

Sl1ngmorl!) (simg tr~fII)

~I'lu~giaplli!" ~tJn.J~~t IJ~ Sl.,Ing

Sbrng nh~n k,4!""""""- tS'iiiliQ d!.Wil giap dI.0i (kooye1 ,d~di ~~ giap) Hinh 39. Syn gila, (nhtn ~cr ph{a ~nITrc)

S~mong twngtr;erJ]

MArihbell 3l,1l'i giap

Sil'l1g ntla., ~W11g diJOl),

~-- Cu 91i!p lren {~U ~ &:In giap) DL:IdrIg die" (w" c.:hSch)

sl,Ingi.ap Hlnh ,4tSyn gliap' f.J nil g~o~

L- eu glilp dlWi

roo duUi :s~n glap)

H~1'I1h 4(1" Sl;in shlp' a If1Slm 'g:idi

Mom 00

l\. t.tiIm thanh am [j.i~n ~.I1Up ~(jj ban SUIl nhan $) Mom 0(1

Hlnh 42. S~n pheu {m~l di'~f1 khOp, ho~c day)

D~k~'o'd! tt.8nSUrlnh3n

Hkdl~3! e. 8 ~In ph ellJ (~t tm ng)

Di~n kMp '1al SI.iI1II1lM.n

-Ban (~~ ~"hl s'\!I'lIlMn

Hlinh 45. CaJc Ii ~ 11 iph.O:u: ,cae k njp n h~:n~ph~u (n hih tir phJa,lruoc)

Cl!OO~ s~ n 1haT1h IliIi~t

tfin h 44, s~ III anhlh ii~t ho~c rna p ths'nh m,DI

73

BEn! (hi:i~ mAnhl s\!n n!t<ll\

IJ~I'I k.h(;p vt'lI S~I"I giap

~o---- L6i sun ph&!

Moo hlnh G\JI'ig --~rl=.~--

HO hlflh lam gJ$.(

Mom ccr -~W~;~~..--- t.m thann a.m

~U[l ~ .. ~" suo' plleu

... ~ . I~

Clan tho~t;. nian ) HO b~il rau

sul'l flh~n 'SIJfI plrifiru

IJ~ khcrp,v(ij ;$ijilQiap

,..;.:,~- £)Tlln Sl,In pMu M~mih8JntJ ~m 5\ln p;11~1J

'H~rdl ~,G. Cae k,hop nhani"]pheu {nhin tCr phfa saul

GUflg iUI'I Mia" I--~- Syn nhAn

Hinh 47. Kh~ nhan.!ph..eu

(nhin t.u phla ben I1Qoal)

Thuog lOng !.hartn Ihi~ ~--~"JI.Il.~ svn th:a!lh lhi.~! In!p ttm"'" man) ~---t~J.,.,J:!I,'"

!l:rh"-~!rP---- Nep luf1l-ttJanhllliE!t glO:.aJ ~--- Mal'lfl giap-mtmg

lJf .".-- SClng 100 WJl'1Ig m6rtg

'IIIIIII_~'~

+---- Sl,II1 tMoJ;

SUI"! cMm ----'-IIIt--!I'-Sun sUn!) ~---t~:_;

S\ln pMu --...",.._~~

l:ttl~'iif--- Mang bi'in Q,lilh

'I'i--- Si1ng rOOn!;l (SLrrtgJ tren) s~n g,l~p

74

* Cc gitip-pheu tm. thyreoaryte-

noideuev": Di trr mat trong cua dean dudi g()C s{m gidp toi rruit ben ngoai sun pheu. Co duoc tao n en boi hai b6: b6 ngoai (pars lutcralis) va b6 trong (pars medialis), Hai co hai ben e6 tac dung lam hep khe thanh rnon, bfing each b20 hai suri pheu lai g:in n hau (b6 ngoai) va dieu chinh sue cang cua cac day thanh am (b6 trong), lam cang hoac Hun trung cac nep thanh am (day thanh (1m): do do h ai co nay dude goi la ca thanh am (dac b iet Iii b6 trong).

'" Co lien pheu (m. arytenouleusv: bao g6m hai h6, b6 ngang (pars transversa), di til mat scu: va mom co cua sun pheu m9t ben sang hen etoi dien, va b6 chen (pars obliqua), eli til mom ca clla mot sun pheu tdi dink cua sun phcu ben doi dien, Cac co nay lam hep lihe thanli mon. (rima glottidis), va lam hep p han n ao Ii] thanh qiuin. tren (aditus laryngis: 1/; van thank quan).

* Of gitip-tluinli thi?t (m. tliyreoepiglotticus); di tU goc s\ln giap tdi b(j ben cua s(Jn thanh thiet va tdi mang bon canh, Co c6 tac d ung d6ng IS thanh qudn tren. bfing each keo sun thanh thret (nap thanh quan) xuong dudi va ra sau. Hai co giap-thanli thiN e6 vai tro bao v~ d~ kh6ng cho di v~t rei vao thanh quan theo co ehe pha n xa:

Cite co cua thanh quan, nhin to an b9, thuc hien d1.Ne cac chuc nang sau day: bao v~ khorig eho cac dj vat rei van ducng h6 hap theo co ehe phan xa, khep nhi) hoac mb rfmg hlu: thanh mon. va lam cang hoac trung cac nel) thanli am (day thanh am), biing each nay, thanh quan e6 th~ phat ra mgt loat cac am vdi tan so khac nhau va nhu vay thanh quan d6ng thoi la mot co quan phat am.

44 Co thanh am la len 9<;>i be, !rong Gua co giap-pheu (duoi). vi b6 trang nay nam sal va cung vbi de day r;ht,ng giap-pheu lao nE'I1 cae; day thanh am (Iheo cae lac gia PMp). Day Ght.ng giap-pheu cung voi be lrong Cd giap pheu dl1(lc phu boi niem mac thi gQi lil n{ip thanh am.

Khoang thanh quan (cavum laryngis); khoang thanh quan co hinh th6 nhu mQt d6ng h6 cat nen e6 th4' phan hiet ba phan (hoac tang); pho'in tren (tang tren) goi la tluanu; thanh qtuin. (epilarynx) hoac khodng tren. thanh rnon , hoac tien. dinh. thanh qudn (vestibulum laryngis), keo dai tii lo thanh . qiuin. tren. toi ngang nep tien dinh. (j phfa duoi. Phtln giiia (tung giua) narn giua khoang phia tren Ia cac nep tieti dinli va phia dudi Iii. cac ni/p thanh am (day thanh am), phan nay duoc goi la trung-thanh qudn (mesolarynx) hoac ihanh-thtit (ventriculus laryngis)45. Khoang tU cac ne'p thanh am tdi bo dudi cua Sl,ln nhrfn la thuoc phan dudi (tUng dudi) va dl1qe goi la hathanh quan. (hypolarynx) ho:}.c hhoting dlidi thanh mon. (cavum infraglotticum laryngiev.

* Ph§.n tren (epilarynx: thli(jng thanh quan) can goi Ia tien. dinh, c6 gidi han tren la [0 thanh qiuin. tren (aditus laryngis: 16 van thanh quan), 10 nay hudng ra phia sau va len tren, Chu vi cua 16 thanh quan tren. (16 vao thanh quan) phan truoc la bd cua slIn thanli thist, hai ben 18 hai niip pMuthanh thi?t (plicae aryepiglotticae), hai nep nay di tu phia trudc ra phia sau, chech til tre n xuong dudi va van trong, do d6 hal nep sat lai gan nhau va d khoang giua diu sau cua hai nep hinh tha nh khuyet ginn phiu (incisura interorytenoidea), Trong be day cua m6i nep pheu-t.hanh thiet c6 m9t S\J.n nho: sun. chem. Wrisberg, va d dffu sau cua moi nep thi co suri sung Santorini, L6 thanh quan tren (10 vao thanh quan) mo r9ng khi tM binh thl1dng, nhung trong hie nudt thi 1& bi bit kin b(ji sun thanh thiet va day ludi, eon thanh quan duoc keo len ph ia tren. 0 phi a ngoai cua cac nep pMu-thanh

.5 Thanh thai con dl1Qc g<:>i ta bu6ng Ihanh (juan, thuc ra la hai ngach b hal ben thong voi lang gili'a cua khoang thanh quitn boi mot khe, khe nay nam gilta nep win dinh va nep thanh am b mOi ben (We la gilta day thanh am gia 0 tren va day thanh am Ih~1 (] duoi)

75

thiet, mern mac thanh quan lien tiep vdi n iern mac cua hau, hinh thanh d moi ben mot ranh huong ve phia [0 tren. cua thuc qiuin, goi 1a ngtich. hinh qua le (recessus piriformis). Thanh thi¢t (n6.p thanh quan) dUQC noi vdi day luai nam a phfa truoc-tren b6'i ba nep niem mac d6 la hai nep luitithanh thiet ben va mot nep luai-thanh. thi~t giila (hi nh ;~6, 37, 53, 54,57,59).

Niern mac phu tien. dinh thanh qutin. la thlH}C ki@u Iat tAng, vdi mot ldp duoi niern mac phong phil mo lien ket thua, rna trong tnfdng hop bi viern se thi gay ra phu ne thanh mon, tuy goi the nhung phil ne la a phia tr6n thanh mon.

Khi vi mot 1.9 do nao d6 (be nh huyet t hanh. benh bach hau thanh quan v.v.) rna xa y ra phu thanh mfm, thi ve giai phau berih , cac nep bi sung to len, IS thanh qiuin. tren. (16 VaG thanh quan) bi thu nho lai dang k~ va ben n nhan se kh6 thd, doi khi khorig tho duoc va bi dc th6. Neu kh6ng can t h iap cap cuu bttng Mt ong n9i khi qua n hoac mo khi quan thi ben h rihan c6 nguy cd bi tV vong do ngat thd.

* Thanh tlui; (bu6ng thanh quan) (mesolarynx: trung thanh quan) tuong ung vci dean cua khoang thanh quan narn gifia Ilep tidn dinh d phia t ren va nep thanh am (day thanh am) d phia duoi. Giua hai nep nay, c6 m9t ngach phat tri~n ra ph.ia ngoai goi la ngtich. thanh quan. (recessus laryngis) [con gqi 10. ngrich (bu6ng) Morgagni]. Hai IU'P ti.tn dinh gici han b giira chung mot khe goi Ia khe tien. dinli (rima uestibuli), va gi iia hai nep thanh. am (day thanh am) la khe thanli rruin. (rima glottidis, cung gQi la thanh. mon)_ Nhu the, phan giua thanh quari thong vdi phan tren (tien dinh) qua khe t ien dinh va thong vdi ph~n dudi (k hoang durii thanh men) qua khe thanh mo n (hinh 54, 57).

Cae nep thanh thd-t la m?>t doi nep niem m<;l.c b5.t diu d phia truoc tit di~m bam cua

76

s~m thanh thi¢t VaG g6c s~n giap , va trai ra theo chieu narn ngang. Trong be day cua hai nep nay co mot so sci co bam VaG m(>t day chang (ligamentum ventriculare: day chang thanh that). Hai nep nay con QUI/C goi la day thanh am giti, Mang bon canh ti;tn het d muc cua cac nep nay.

6 phia duci cua cac nep thanh-thsit Iii. bf may thanh am chinh thuc (cac day thanh am chinh thuc) , chung tao nen thanh mono Be? may thanh am la hai nip thanh am (labia vocals hoac plicae oocoless, gici han d hai ben khe thanh man hoac thanh mOn. Trong be day cua cac nep thanh am e6 cac cd thanh dm (m. vocalis), bam vao ddy thanh am (hoac day chang thanh am), day nay nam b bd tv do ella mbi nep thanh am, va cung Ia bd tren cua cac non ch.un (hinh 56).

Cac nep thanh am bam d phia tr udc vao goc $(in guip , ngay 6 dudi eh6 bam cua s(in thanh thi~t, con ve phia sau thi bam vao mom thanh q,m ella day Slim pheu.

Nhu vay, khe thanh mon. (hoac thanh mon) dUQc phan biet thanh hai phan: phan truce gQi la phfln gian mang (pars intermembranacea) va ph:in sau la phdn gian sl,tn (pars intercartilagineas.

* Phan dudi thanh men cua khoang thanh quan g9i Ia khoang duai thanh mon (cavum infraglotticum) hoac h.a-thonh. quan (hypolarynx) narn trong dean sl,tn nhr1n cua thanh quan, va duoc gioi han i'J phia trudc va ben tren b6i cung sl,tn nluin. va non ch.un, gidi han phfa sau va phia ngoai b6i ban 8(in nhr1n va phan ben eua sun nay, ve phf a dudi thi khoang dirdi thanh mon thong vci khi quan_ Non chun bam vao bo tren cua cung sl,tn nluin, raj tir d6 di len tdi bd duoi S(W giap; phan giua cua n6n nay tao nsn day chling nluin-guip , con gQi Ia phdn tlJ do cI1a non chun (pars Libera coni elastici); phan con lai cua non chun di len t6i t<itn cac day thanh am va tf,in het d day. Trong

Syn lfiIaoo thi~ (~p lhaflh mflnl Sl.Jil1gnho xut'lngm6ng StIIig Ion .xl1i:mg mODY

t#'4iJl-- MIilng gia~moflg

"JIr.:-!:~-llay chotlng

g ~-thaflh lhi,~

Mal.ll.hLt'a UlOlnll thai.

[la~ ohang ---'!.&-.!IIIo::lf,-, nh~n-giap

Hlnh 49. Day Ichang rnhh·rgl,ap va maillai giap-m6n!31 (nhirl to' ph[a lmoe)

XUl1flij m6ng CO' p11~u-ll'l~lf'Ih Ihl~t Sun dl~m S~IR sCl'ng

eu Sl,JIl chem

SCmil mbng

($Crng Ir~n) SJ,ln !)Iap

SLrngM~n

(sung dllili) sun 9 I3p

Hi nh5'O. Cae CD tIla ~h an h qua n (nhln tu phia saul

~nll\anh I h[~lln3~ lmanh moT.)

ClI 1hanh lhl~1 [eli n~p tMntl mOil)

S~np~J Sl,In giap

CO I iEfI pi'l6u n gang

HJnh :51.. Thanh quan m~t b~11I trong (nhin W phia sau)

khLl;l n~ ni'UI1 gl\t~ non ('hun va cac mQnh b.}n .. qm gfcip co ca nidp-pltiu.. Nlem mac r hanh qunn dmh I:h~'t "'~I{I m~t trung Cl~<l flor! chun . nism mac nb.y r.huQr. ki~u 1'15 M.ip loi.{[1 m6 lr~ ('6 long rhuye~l). tru ij phf1n rN~lI 'hnnh Qm; iJ phfint:J~y ni€!m mac ph~ ~ t hi!'h ngh i v 6i b'i.c dung keo c~ng eel hllf. tW!Lt,; hJC phil t ti m va tho,. nen duqc phil. bdi MCIJ m6 (.cit t&'lg,

• Cae ml!lch. mitu '!.'a da.y than kinh Cu.,l. tbanh quan

.. Cdc d(mg mr;ze·/l cun thanh Quan cteu l~ nhanh cua cae a(jng mc,u.:h gi6p f,I'Prl \'2 d(mg 11i. \lCh giap dlfdi,

.fJ(mg mad: thanh qua'l tren (a, lar),~Hea crcniaUs) ·tach ra t(t dqmg' mt,u:.h gicip ~ren Ct

CO' pl"l&i"tll'3nh tI"Ii~l

_ Mnm CCl S!;I" p'hSu •.•.. .....

r" ang g~mon 9

Do ~BFI phE!u cJU10 Co I~n p~u ngang

CcIgiap- 1hanh thl~1

CI:!I'I!r'!~npi"lel,JMn

Dayc;h~ng

rIM an·kr,1 q uan

Co I1h~tl-p~1J 800 DI~ t.hO'p 'IICi sun giap (([i~1l kI1O'p giilp ciJa SI,:ijJ lIIt1ln)

CO' nMn.-glap

teal ~an~}

Hi nh 52. Cae cd (:uJa th.mh qua n {nhin c~~c-h lu phia Mn}

s~ n 1hanl1lhi~t (na.p 1haflh mtln)

X~m~ng D~ cha ng tier! di nh -tJac~ !MalilQ hi nh bOO can h Tier! di nh thallh qua,n - ~-ft-""""'---iR."I.\ IKhe 00tl dinh S~n 'GaD Day th£lnh ~m ~dfl¥ chang iMilh a ITiJ

KM tria nl"J rt1'Qm ,lfian.tJ mo n I t)9~ rn~oh. lil1h m{!ch Qi~p 1m n

Kil(l<lI')!J durCri lhanh !'POn ~nl'lr.:an

ng,l ng rnuc ha tren sun gdip. fl('li1 g mach rh auh qu au ln~m b[.t cheo r~hcinh trong eua tlay thda kinh I}Hlrih [P:1.<1n (ren i ehui qua man.!J rn{j'~if·gif1p "u to~ nhanh l"I.u6i dUOllg: p han liii:n dinh thanh quan, D~ng much tl1L'U1 h q u ii n t.:rfm t;C'I tin h r]1 ach cung te u e'li J,i~m. f)Qf'I~ mach gi.ip tr&n cu.ng tach nl nhanh g'!.)i la a(ing m~C'h f"th611.·glcip. tesi n\lCI1 IhtCing phjin dlfnj eua thanh qnan, Dr)ng In acl? thMih q !Uln durJi (0:. laryngf':(J

XI1!J'ng'mQII9 \

'l"ha nil thai (b~-,611g th.anh Qual'll

. Sun giap

Khrlquan

!HI n h 53. Thanh quan, th~ et It! C; d](mg n-gang

(n hin hI pt1 fa seu ~

rIM cllnh !haM quan

CI1 ph~!,IHh.mh t'hi ~1 D:I glap.mbng

r;atldal~~:) ]f] mi}t nhanh nho cua d6ng mach. gia.p dt/tli. dixuong fj ph.La~au 1.1~ hen ella khdp nhan-gidp, r6l tach en nhung nhanh eho nhUl'l~ ed (j: phial! sau thanh qu~m va eho lCIp niern mac CliLli thn n h quau.

• Cae lr.llh mt;lch cua thanh quan bao !:l,Om. tinh. mf)ch thank lj!lml ircn. di\ vao tinh mwh glap hen va n,.h m~fr:h thon ~l qutin. alirJi do vao dzl.l'fl. 1'6i trnh m ach

hly.~in giap. .

31,ln cr.mn _"""'I;---"-,.,, " 51,f'L S(mg ....;Jiol- ... _~

S\II1 ~h"nlllt'ii$1 ...... __ '.,-tmlp mann m(rJf

XLI'lllll meng

Thung ~"'!J --t,-~FI II!.:lnhUr.l~

Ni'p phbu-lk.:Inh Ihe\ ~ Dh c~~ mtrtg.-ig~p Nap 1i&I d'm

Simg m~ ISlJng Wn)Sl,lngiap SqnsLmg

Ba1Jen oon {ma.tl~ sun ['IMn

SUIl nban

KheganpM~

(KIM Ill(!" ~UfI plJe.1J) m.yGl1~Ug nnart'pMbi :;au

Oa.~ chang nha~p:sau

MM, ro ~ p'.JJ M&Dth(lM

am s.,n phi!:u

.... P4II~r- C~·,IJ!ar~ Eft I~~ ,;h~f\111m:l ! -.11 '

Hlnln 5,5.11111'1'" q;u:jl'l: rnillngl m61l,!-gi:iJj:l (nhTn tcr phra s.au)

KI1~yeiI giap tre~ Ik"tl~ IJffi SU1I91r.p) Hiln'h '56. Cae d,~y tllalflh am

N~p!lMuIhan'n 111~'

KtI~ 100' l~rn a t'l'Bnh quail OOy ~MnQ giaf}-'!!IOOg Day ,hang ~lh3J1h Ih'~ Sl,lnglilp Nep 1'4n dir.h Than1, Lrlit (tIufmg 'lJ1anh quin I D.a}! Ch/ing ntJa'fl-gl~p

~nlhanl'ltWil {flap !!'Iann m(rJ.f

Day chang gitq>In:rJi !:hi$!

N~ pM u-lMnh Ihilll

CIi ~Un o:b.en"I

Cusun sUng

r~n (F.nt! Ih~ qu;\n

C(I n~n pl1eu ng~

Jt~~~lJ~N~P t!1t111h am

81!n min ~n(tJ\lII'.IiI~~1"!!.'l dlJtri ~iIi'1h IIlOfI

lOp niem m9l= nv.rc qUM Co nn~nr;Musau

Ktte \h~-khl qu~n Co n\1~n ·rJu

Day than htn tMnt'l quarl tr~n

CiA sID T-~~~_ sCmg

Cua; Gallen

Sum nhhl (SlJIlQ dU~) sun gltlp

Tu~~n giaj;l

Cacluy4r. • d!ngi~tr{llliJ

Bilng 1l1~ 9iJlp~ OO~1h~"'jnh I:IfJ~l"Ig~

Syn manh lhi~ lnap !hom qu;!n) --------,"""'",.._ Cu iMi'ml'l irii!l (eu n~p Ihanh {lueln!----"!F-.",x;., ...

N~p phe-u-Ihanl'l 'Inlet

___ -+-~ N~p lien (Ill'll ....... "'------ l1~n (finn l:Ilanh QiJan

..... '-Ir-'-- Ne p Ihanh am \d~1 tiianh am)

H1n" 59. Ui ... .10 thanh quan po thanA quih~b'En)

H" -0 • ~ h~

d'ltl '0. Cae dayt an

kinh coa ,thanh quan

79

* Mach bach. huyet cua tharih quan rlt«}c chia ra lam hai nhorn: nhom tren va nh6m duoi. 6 phan tre n thanh quan, cac muc-h bach huyet thea ducng d:i cua dong mach thanh quan tren va ad ve cac hach. df sou. narn d g:in cho phdn cloi eua d¢ng mach. canh. g6c. Bach huyet (j phan durii thanh qu.in tr-uce tien duoc dan ve cac hach. truitc thanh quiin, 1'6i tit day rndi duoc dAn ve cliuoi h.ach. co' stiu, d(i.e hiet la bach huyet (} doan tren sun nhan: trong khi bach huyet d doa n dudi sun nhan, thi chay theo cac mach di cung day than kinh thanh quan. dutti. de Wi chu/;i hrich. truac hhi quan: Tat ca n hirng mach bach huyet cua thanh quan euoi cung deu db vc nhung hach ben duoi cua clI1u3i co'sdu.

* Cac day than kinh cua thanh quan (hi nh 58) l a day than kin.h thanh qudn tren (». laryngeu« cranialisi va than kinh. thanh. qiui n duoi (n. laryngeu.s caudalin), ca hai deu co n hfm g soi thAn kinh van dong va cam giac,

Day than hinlt thanh qudn tren la mot rihanh ella day than kinh phe'vi (X). Day tha n kinh thanh quan tren di Wi gAn sung j{jn xuong murig thi chia ra hai nh anh: nluinh. trong va nluinli ngoai. Nharih ngoai chi phoi cho co thanh quiin-tuiu va cd nluin/{idp . Nhanh trong chui qua mang m6nggirlp, r[)i chay 6 duoi ldp niern mac cua ngdch. liinli qua le va chi phai niern mac phu sun thanh th iet va niern mac thanh qua n tdi ben duci cac nep thanh am (day thanh am).

Day than kinh thanh. qutiti duai la n ha nh cu ng cua day than kinh qtuit nguac, Day than kinh thanh quan duoi di cung riling mach. thanh quan. dudi tdi thanh sau clW. thanh quan 6 ngang mue khifp nhdngiap. Nhung nhanh v$n d9ng cua th§n kinh nilY chi phoi toan bQ cuc cd CUll. thanh qwin, tru cO nh6n-giap (vi co nay da dUQc chi phai b6i nhanh ngoai CUll. day tMn kinh thanh qWln tren). Nhung nhanh cam giue cua than kinh thanh quan dlioi chi phai niem mw: len tdi t$.n phfa tren eua khe thanh mon. va xu6ng phfa duoi toi t$n ngang mue t.·(Hlg 8!Ut khi qudn thu 2 ho(j.e thu 3.

80

6 doan tren thanh quan, vung chi phci cua hai day than kinh thanh quan tren va dudi xen ke vdi nhau.

Thurn kh arn thanh qui.'tn: So nAn thanh quan bing dau cac ngon tay doi voi ph an thanh quan 6 tren duorig giira, va nan thanh quan d giira hai n gon cai va ngun tro doi vdi mat ben cua thanh quan, Tha m kharn nhu v(ty ph ai dU9C thuc hien mot each kien nhan va h~ thong, nharn phat hieri nhung yeu to giai phau khac nha u co th~ cam nhan duoc bang bien phap nay.

N &m 6 gidi han tren CUll. viing duai mong , xuong nay chi 16i len chut it, nh ung co th~ so nan th ay diroc. Tiep then xudng m6ng 0 tren duong giira e6 mot h610m nang eao khoang 2 em tuorig ung voi mang monggidp , rai tci khuyet guip ir eri 15i nhat, va goc sun. guip , 16i thanh quan hay qua U'1O Adam dudi nira IQ.i c6 mot 16m thir hai WOng ling vdi mang nluin-giap , va dudi cung la cung sun nluin. 6 hai ben, c6 th§ nan thay silng lan cua xuong rnorrg, va thap hen mot chut e6 thg so t.hay cac sitng m6ng (sung tren) cua sun giap va manli ben cua sun nay, bi che phu mot phan boi cac thuy ben tuye~n giap (G. Portman).

Tluirn khrim cac hacti bach. huyc't e6 y nghia dac biif!t, nhit la trong cac truorig hop ung thu thanh quan, nharn phat hien di can toi h ach. Nhfrng hach. truttc thanh qudn, chu6i hach. tinh-dong mach. ctinh, chu6i b.ach. gai deu c6 th.i so nan th ay neu bi sung. Trorig thuc te, can quan tam d?c biet tdi chuoi tinh-tlong macb canh. vi hay co di can Ian Wi nhat. Sd nan chuoi h ach nay bing diu ngon tay, an sau vao vun.g d¢ng mach. cdnii tit phia bCi tr udc va bo sau co lie-don-chum. C6 mot kg thuat lam cho each kham nay d~ thuc hien han li't: d~ b¢nh nhan ng6i tren ghe diu, th1y thuoc dung 6 phfa sau; baa b¢nh nhan cui dilu ra trude, Sd nAn chuoi h1;lch nhtr au rna tii d t1'€m voi ngon tay gap cang ll;li.

Soi thanh quim: Trang khuon kh6 ca.ch tham kham nay, chung tai chi noi toi vi~c quan sat eac chuy§n dQng eua eac ni/p thanh am (day thanh am) va ella slf.n phiiu. Phai quan sat ca trong hie b~nh nhan phat

am Ibn hie thd. D€ dat muc dich cI6, bao berih nhan phat cac am "i" hoac "a", r6i sau cI6 hit sau vao, BAng each nay chung ta se co duoc cac da Iieu lien quan Wi ba nhorn cd thuc hien cac chuc nang sinh Iy cua th anh quan (cac cd ciing day thanh am, va lehep thanh man hoat dorig khi phat am, va co ma thanh man hoat cI¢ng khi tho) dong thoi cilng darih gia ducc chuc nang cua hai khdp nhdn-phtu.

Bang each k ha m xet noi tren, chung ta co th~ nhin th ay hinh anh cua b9 may thanh am rih u sau:

- Trong khi benh nhan thCJ nhe nhang thi die nep thanh am (day thanh am) hoi d each xa nhau (giang), va do d6 khe thanh man co hinh tam giac can, day huang ra sau (nhm thiiy day d phan dudi guong soi thanh quan),

- Trong hIc b~nh nhan hit VaG that sau, thi d. hai suri phiu deu lui each xa nhau, keo theo chung hai day thanh am (nep thanh arn.), do d6 day cua tam giac thanh mo n tang kich thudc va thanh mon trd tha nh hinh nam canh,

- Trang luc phat am thi cac day thanh am narn song song va hai s~n phiu sat lai gAn nhau; khe thanh man c6 kich thlloc chieu ngang nho nhat. T'ren thuc te, thi trong luc phat am cac ne'p thanh am (day thanh am) rung, lai gAn va tach xa nhau voi t5c di? nhanh; ht..ng mat thuong thi khong th~ nhin thay nh iing rieng tung chuyen dong nay, n htrng thay cIllQC chuyen d()ng t6ng hop- cua chung Ia hinh anh cIa- mo til. d t ren.

Vi hian tuong' sinh ly cua h6n hcp cac hinh anh, nhftng dao dorig VUQt qua tAn so 10 chu kyfgiay khOng th& nhan tha'y bang' mat thucrig dircc, nhung hinh anh nay co th~ thay duoc nho hieu qua hoat ngh iem, neu SU: dy.ng mot nguon anh sang phat t ha nh nhip, di€u chinh d mot ti'in so thich hdp. Bing each kharn duoi den hoat nghiern, vdi tfin so va bien di) thay d6i, va trong dieu kien thanh man khep, thi co th€ pha t hien duc;lc cac benh ve philt am d ngay giai dOSin chue nang.

Vung tuyen giapkhi quan - thirc quan

La vu ng n:1rn d truce va gnta c6, bao gam tuyt{n giap tguip trang), khi qiuin. va doan c6 cua th.uc quan: Vung guip-hhi-tliuc qutin cung thuoc ve vung dudi-mong ; va co mot khung sci XCI tao nen bdi mac eo' nang vdi co ham da c6, va mac cO' giiia.

v« m~t trinh bay, uung guip trang co th€ phan cach ro r$t vdi oung hhl-th.uc quan: Vung giap trang co hinh th€ la hai tam giac nam d hai ben duong giua, deu lien quan ve phia trong vdi khi quan, ve phia tren-ngoai vdi bung tren eua ca oaimong; va ve phia dudi- ngoai vci cd zie-aiJnmongo Tuyen giap tr8.i dai tir mot phan ba giua cua s~n gidp ve phia tren, xllong tdi tan oong s~n khi quan. thu 5 hoac thu 6, tuong ung vdi cac aot song co' 5 din cd 7 (C&-C7) ve phia dudi. Vung hhi-tliuc quan. hinh chfi nhat, gidi han d phia tren b(;l sun. nhdn, ,j phia dudi brri khuyet tinli mach. cdnli cua bCJ tren xucng ltc, va d hai ben bdi hai du:ong th§.ng noi giua cac khdp uc-dtm vci bo ngoai cua eam.

Tuyen giap

La m9t co quan le, d phu nu phat triJn hon so vdi d nam gidi, lam cho c6 c6 hinh tron deu dari hdn va to hen. Tuyen giap hinh chu H gom co hai thuy ben, hAu nhu bang nhau, hinh thap ba mat (vdi mot cue nhon 0 trim va mot cue to d duoi coi nhu day thap), Hai thuy ben cua tuyen noi vdi nhau d giQa bang mqt eo trung gian. Ngoai ra, con c6 m9t mom tluip (goi la thap Lalouette), thap nay khi co thi xuat phat tu eo tuyin hoac thuy ben trtii, r6i di len tren tdi phfaxl/rlng m6ng (hinh 60).

Eo tuye'n g lap: eo tuyen giap nam b phia truoc hai vong S!.tn khi qudn tren cung, doi khi c6 th~ nAm cao d phia tren

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sun nhan. Vi lien quan giua eo tuyen giap voi khi qu an, nen thu th uat mb khi quan co hai ki~u: ki~u tren-eo va ki~u duoi-eo. Eo tuyen giap narn each khuyitt tinh. mach. eanh cua xlAlng IIc tit 2,5 den 3 em yg phfa tren, va day la mot mac quan trong dl.n p ha i biet khi lam thu thuat mb khf quan. Ve phia trirdc, eo tuyen giap dude che phu biJi cac co uc-guip , cac m(LC co' nang va mr;zc c(/giila, co bam da c6', va da.

Cac t.huy bim tuyen giap: cac thuy ben tuyeri giap IiI hai khoi tuyen dai thea chieu treri dudi, vdi ba mat ben la miit ca (tuc mat truoc-ngoai), miit thanh-khi qtuin. (t.uc mat trong) va miit mach. truiu (tUc mat sau); m6i thuy ben e6 mot cue tren nho hen va mOt cue duai to dude eoi Iii day.

* M(1t trudc-ngoai: lien quan qua rnQt lap me) lien ket md vdi co uc-guip, co IIc donm6ng va ca vai-m6ng, cac co nay a£\u diroc baa boc bili can c6' giiai (fascia colli media).

* Miit sau [rang: hEm quan vdi vong s~n khi qutin thu n hfit, vdi sun. nhrin, va s~n guip, () phia sau, m a t nay di qua ra sau khi qu.an , lai g&n thuc quan, va lien quan voi cac tha nh pha n n5.m trong khe giua thuy ben t uyen giap va thuc quan la ddy tiuin. kinh thanh qusin dudi va chu6i hach bach

huyi/l khi qutin, . .

* M(1t sau cua thuy ben tuyen giap lien q uan vdi bo mach. th/in kinh c6', d~c biet Ia vci d¢ng mach. canh. gor: (dinh chung).

* Cue tren ella thuy ben hoi nhon, la vi trf iJ do, a(Jng macli gitip tren, nhanh eua ddng mach. ctinh. ngoai, ehui qua bao tuyen giap d~ van trong tuyen va tea ra cac nha nh, chu yeu la (1 mit t.rudc-ngoai cua thuy ben cua tuyen. Dong mach giap trim co tinh mach cung ten va cac nhanh cua day tiuiri kinh thanh quan tren di kern. Nluinli ngo_ai ella day than kinh nay (goi la nhanh nhan~giap) oi chech tit tren xuong duoi 6 tren mQ,t eua thuy ben tuyen giap d~ l6i cd nhan-gid.p.

* evc dum clla thuy ben, binh thlidng nitrn cAch 1,5-2 cm d phia tren xlidng zIC (incisurajugularis: khuyet tinh rn1i1.ch dnh).

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Mang lien ket bao bon tuyen giap bao gam:

- Bao trong chinh thuc (bao rieng cua tuyen giap), la illQt lap mo lien ket sui xo dinh chat voi nhu mf tuyen;

- Bao ngoai quanh tuyen giap, xuat phat tU mac c{/ giila.

Bao quanh tuyen giap (baa xd hoac baa ngoai): khac vdi bao trong chinh tluic (bao trong rieng) cua tuyen giap, bao ngoai quanh. tuyin bao boc than tuyen, va df nh vdi baa trang. Bao ngoai quanh tuye'n la met la mo lien ket soi xo, ve phia sau-trong thi bao nay dai bgn hun eon tren cac phan con lai chi la rna lien ket rfft thua, bao ngaai quanh tuytn do mo lien ket 18. tit nhieu ngu6n goc khac nhau dong di,i.e 1:,11. Baa ngoai quanh tuyen; tren thuc te, 13. slj noi tiep giua cac rnang lien ket d each nhau duci day:

- ve phia truce, la ill~C bao cd uc-giap, mac nay Cling chi 1a m9t che cua m(Lc co' giila;

- ve phia ngoai va phfa sau, la baa mach tluin kinh cua b6 t'inh-a(Jng macli cdnh; .

- baa di)ng mach. ciinh. (vagina carotica);

- ve phia trong, bao ngoci quanh tuyer;

guip 13. nhirng Iii. mo lien ket bao quanh thuc quan va khi quan, va cung 1a mot ph fin cua bao tang, Bao ngoai quanh tUYe11 giap con duoc tang cuong bci mo quanh mach mau cua 4-5 cu6ng mach. ella tuyen. Niirn sat vdi phan quanh khf-thuc quan cua baa ngoai tuyen g iap c6 nhirng Iii. rna lien ket dong d$.c lai doc duong di cu a cac day thiin. kinh qu¢t ng uac , day than kinh nay di d ph fa ngoai bao tuyen gia p, narn giila khi quan va thuc quan, D~ van duoc tdi day thtln kinh quat ngucc, t.ren dean day than kinh nay d phan giua va tren cua c6, thi se phai pha vd bao ngoai tuyen giap va mo khoang gian-bao cua tuyen (khoang giua bao ngoai quanh tuyen va baa trong rieng cua tuye'n). Nhigu la sQi xd truoc song di kern d. a(jng mt;Lch giap dudi va vong tuyen giap ella chu6i thdn kinh giaa cam_ a vi trl d,c 1a rno lien ket nay n&rn sat nhau, thi chung t~o nen rn9t rnfmg duy nhit bang each dinh lign voi nhau, va tang eudng cho bao xd ella tuyen. DQc thea nhung cau truc

nay, nhung ch:i't dich tlch [L,I h(l~c ap xe Ct khonng gian-bao tuy~~in giap co th.§: Ian h'an XlU)'ng tdi tan phhl1 [['Em tnmg th5t, vau elm!; ("(/ br)(.· UUJIlg-o(jt. 50i:tg iliA vito i1'l9'C (r'!Nc srjil_rl va khnaug tr!(()c song.

. ve phi.'!. tren, ban )tgoiii QrJ.anh tUjlE'n fJ.1fr(1 Wip I: ~IC ,ai Um t[Ji. xl/ong mang va hoi m ";10 xm:1ng; nay.

• (S phra (h1f(~ I cua eo "'3 eve dU!'di th!Jj hell tt.~)·e-n g13p, ban Luyan gjap (lH~t 1-'li d~ bUll vong- qurmh en t uye'n vii (:£ie lhu~y ben, qll; ncn m~t t.ci~ ciwg. hh nily bam vao khi Qua n (.~ phi:! sau. V3 tr~n tan vai ph~n con 11;11 ~·uQ. 1." rno if{!fl kif tn£fie·khi. qudn_ Lri tnh lien !';'el duai-eo tuyengiap th~ hi~n nhu m~lt 1:.1 mo dung ugang duy nhitT kri!o dili t6i 1(111 t mng thal va dude m(H so tac gin g~] J1 11'1 gi6p-ng~9i tdm m,?c_ 6 gii;ia bao npmii quu ~lh luyi"/" giap va beo lrcmg O'i.Vt ;'W (hao flf'O!:(') la Hwang qt..umh W)'ei. Sldp bu:}c khoUJ111 luyei1 guip. khoang nay, luy co cae 111~ch m3U I'ti qua. nhUng th~t slj HI. m9t tap Me tach ll"Ong phIlU thu~i, tu:,' nh.iCn. b phia t niuc. '11M3 dU!9l vaphl3 sau-ngcal thl de boc tach hnn. Dilu 111.5'1 cuu r:hJd:ng vito d~ tei khoimg bOc tach eun tuyen .Ia die eo U"c· giiip, vi (:Ij nay dfnh v& bav quanh IUyt!I'l. ~iriJ1 {;h~t ehe hdn so vdi. phau cl3n lai cua mClc L·ri gtila" Xac dhlh ch.u,!!: hai cd ac·f!idp vi\ di vao chJ!jc m~t slrl.l cua ehling, v-oililp mo hen kel.- phu thu~c, se diAn chung v:lo Wi Mwong quani: trly2tl giaJJ. Ngoai fa, bao qw:mh tUYelt giap con klh no] ch~t ehe vm

lap du ngoiii cua khi qU<ln va. tlrH,h: quan vu

n'li bao m,~R:h COO c6~, Tl'Em m¢ot. thiet d5 ., n~nJ'lg '(;0. toan b<) nhunglr3p ma lien kr;t. mll

ta i1 tr6n the Oten ra nh 1I' mOot 16. me. lien klt I narn ngang, d~ df) m~t 'f;i':/ tae gia m6 ta nhung r·;:iu true nay nhu mi}t Lh\tc th€ rieng birt, !:fIJi Iii. ("on dj' figrm~', tI{lc l~p dOl vl1i 1& giii'a eua m{lI: 1:6 (m(l'1: ect gUla.).

Ve phia b&!L tfflng va pni81 san, tM kJwrmg Qucm.h t'UY.!?jl. gi,ap d~n din thu h~p, "[I mat h:in do bUll Quanh tllyen va ba.o ,.UmMo cU:3 t.uy€in dlnh hen 'Iti'i nllJlU. t.~o· nen nl9t Iii rm) lien I!:£t cluy nh:l·L. Ii nAy dfnh lufm d vclt Cdp an /Lgooi t:ua thanh !Juan vlI. khi qld.n_ La rn6 li@1l kct m\y thl,tc s'4 tr:a LhanJ] 1T1J()t b¢ m.ay nang do,ket n6'l tomn b{l

kho'i tuyen va dlC bao cu.:!!. uo V'di ~~n ""h6n va khi quan. Do do, ii da.;Jo' vi~c b6c tuyen trong bao (ni,li-bao) thM s'-cl Iii. khong 'Ch.6 t hue hi~fI dU\I C i va d'; tach vim khoa 1lR /fia.n bf.W ~l,y'n 18 hanh lil;'ng ng-uy hiim.

'fuyen c~i.n giap (tr=llll.g) lien quan rna,t tbte't vdi tuyi'n g~6p_ Cac luyen C~1'l girijJ ~J'~ng lill nhung tuyen nhO. thong thL~dng c6 so 111Qng b bon tuyen, moi hen. co hai, m9t tuy~n trcn va m¢;t. tuy€n rllfdi.

Cac lUytn q:iu giri.f.J lr;ull;" l@l [lei] co nit nhiell. biO-n t.hG glai phllu hoc,

f){)i Juyen dudi co the nam ho(ir; d gan t:rp:: aridi cua cee 01 uy ben lr.!)'en gi6p, trong goc hQop bo] tllyln girip va th ~tc quun. hQ~c 11~m. 0 trong be day cua bao ~uyeiL gidp, ~ khu vue ben trone hef.n, gim nn] d()ng mach, glap dltfJi ehui vao tuyen. Ddi tUj'€n C(i.R giap tr{ll'lg r.ren. khi n1 m d ng:~ n g In UC C'U a mi)t tntbc-ngoi:ii SI .. m nhdn, I;.hi du:~c C9i la .j t'i tri eao (Sil .... elrs); nhl1ng dlc tuy{!n nay thuol"lg hoy d vitrl thi{p hdn. ngang mirle eu.a 'lJonlj ,,;~n kM qUOit thu hai, 'I..'i trl nay dl1~jc g·~;n 1.:1 vt tri bert trong (Crisoli). .Rat hie'm tI'uClng hem. tuyen c6 tb~ c6 vi td n?i·b(T.O ho~c n,Qi.tuyfJi. D~ r6 th~ gill I~j cae tuy@il Carl gia.p Ir{tlll1. trong ph~u tl)j1,.I.~t c~t Luyan giap gan tcan b9, n~tfdi ta phai ehi?ta 1'8. d{nlS mg.ch gidp t,.tn va eb_] lh~t: chun lee :ricn~ nhanh ~nlik-ng(J(li CUll d~ng mf.lCh n~s,

, .

I' •

I~ \ II

I ' •

,II

•

.. ,

Cac tuyrtn qin guip irang thuong hay duoc nuoi dudng Mi cac nhanh cua c!i}ng mach. gitip duai rihat; mbi tigu dQng mach nuoi tuyen dgu la mot dong mach ti).n, khong c6 ngudn nai tiep nao bu Iai khi hi that. Nhu v$-y khi t.hat cac d9ng mach cua tuyen giap, co th~ gay ra tinh trang tuyen c~n giap trarig bi cat sinh ly do thieu cap m au; khi cat thuy ben tuyen giap toan b() 6 ngoai bao quanh tuyi>.'n thi cfing c6 thi dftn tal hau qua nhu tren, do do, khi phau thu at phai giG .lai mot "tuong' nhu mo d phia sau (m9t ldp mong nhu mo d phan sau thuy ben tuyeri giap) d~ bao v~ nhirng nluinb. iuyer: cu a dong mach giap dudi, doi tuyer; cf.in gitip trang duoi, va day thrin kinh thanh quiin duoi.

::-.reu nhung thanh phan noi tren bi t6'n thirong, thi se Min tdi bien chung sau mb la chung co cang cd, bien chung nay co th~ tr anh dliqc bang each chi thAt rieng nhtinh. trudc-ngoai cua dong mach giap tren va chua lai nluinli sau.

Cac mach ma u va day th§.n kinh cua tuyen giap

Tuye'n girip la mot co quan rat phong phu mach mau, Kich thuoc cua tuyen giap thay dbi tuy thea luong mau duoc cung cap, trong tr uorig hop huyet ap -(j phan dftu-c6 tang len thi tuyen. giap co th~ nhan duoc mot lucng rriau thira du, rna no se gui trd lai tim, xoang ctinh. et~ tham gia vao co che' digu hoa hru luong mau nay. Moi d(>ng mach trong bon a(jng mach. gidp deu co mot kich thudc long mach ngang voi mot d(jng macli quay. Nhung dong mach giap cung cap cho tuyen giap mQt luong mau b5.ng vdi lucng mau rna cac dQng mach. niio cung cap cho nao,

Tuyen giap c6 nam cuong mach: (j mOl ben co hai cu6ng ben va chi rieng m¢t cuang duai,

* Cae d§ng mocb

1. D(jng mr;tch gicip tren tach ra tit m~t tn10c cua d(jng m{Lch canh ngoai d cach phia tri'!D clla chb phan doi cua di)ng mr;tch canh gar: 5 cm. Mdi d~u d(ing m~ch giap tren di ngang d trang vitng tam gicic ai)ng

84

mach. canh, roi Wi gi'in tuyen giap va tan het bing each chia ra hai nhanh cling d qtc tren cua thuy ben tuyln gidp.

Trang oung tam guic d(jng mach. ciinh, dQng mach giap tren lien quan ve phia ngoai vdi cac lOp co mac va da che phil vung nay, va v~ phia trang thi d9ng mach ap vao thanh quan; (j tren mat ngoai cua thanh quan d(>ng mach di kern vci day than kinh thanh qtuin. trent

o doan gin tuyen giap (can-tuyen), d(>ng mach giap tren co tinn mach cling ten di kern cling voi nhdnh ngoai cua day tluin. kinh thanh qudn tren, tat ca h9P thanh cu6ng mach. than kinh tren. cua tuyen giap: cu6ng nay lien quan: d phia ngoai vdi cd ucgitip va bung tren. cua cd vai-m6ng; d phia trong vdi mang gidp-mong va sun. guip; d phia truoc vdi bd sau cua cd gicip-m6ng; va d phia sau voib6 tLnh-c!(mg mach. ciinh,

Dong vmach giap tren tach ra nhimg nhanh ben sau day: nluinh. dudi-mong di toi cac co dirdi-rnong, nhanh giira cd uc-donchum, ai)ng mach. thanh qtuin tren. chui qua mang gidp-mong cling v{Ji day thin kinh cung ten va phan nhanh cha thanh cua thanh quan, va nhcinh nhdn-girip n6i tiep vdi nhanh cling ten ben doi dien.

Nhi1ng nhanh cling cua d(>ng mach giap tren iii;

- Nhanh. trong ; tiep tue huang di cua dQng mach chmh, di thAng dung - xuong phia dirdi, d9C theo thuy ben tuyen gicip va t~n cung b5.ng each n6i tiep vdi nhanh cung ten ben etai di~n, tao thanh nor tie'p tren-eo (tuyen giap):

- Nhcinh sau, chay d9C thea mJli_t sau thuy ben tuy{n gidp va n6i tiep vdi nhanh sau cua di)ng mach. gitip dliai cung ben;

- Nhcinh ngoai, ton nhanh d mat trucengoai cua thuy ben tuyen giap;

Dong m?ch giap trE!D nuoi dlidng hai ph~n ba tren cua tuyen giap va m(>t ph~n cua eo tuyen giap, cung voi thanh cua thanh quan.

2. Di)ng m{Lch gicip duai, trong h~u het cac trlidng hQp tach ra nhli m9t nhanh ben

cua than d¢ng mach. giap-co', rat hiern t.ruong hop Q(jng mach nay tach ra tq:ic tiep hi d¢ng mach dudi don. D(jng mach giap duoi cling c6 thJ tao nen m(jt than chung voi bat cu nha nh ben nao cua d(jng mach dudi don"', Ve mat ngoai khoa thi dang ehu y Ht truung hop Q(jng mach giap dudi tach t.u' d(ing mach. duai don cung mot than chung vdi r1¢ng mach. dot song. Nguoi ta du thay co 6% s6 truong hop, d dean goc cua than chung cua d(ing mach. gidp dudi vdi r1(jng milch dot song hinh thanh ID9t non d¢ng mach:

Duong di cua Qi}ng mach giap dudi dune chia ra lam ba doan.

- Dean diu 1a dean dang doc, dQng mach duoc phu boi mac trl10c song va rno md, va di qua giua bo mach. thdn kinh co'va a(ing much. d6t s6ng (d phia trudc-ngoai), r5i tao thanh doan cang thu nhat duditrong, d phia dudi cu d¢ng mach. canh. rna dong mach giap duoi khOng bao gid tdi gftn vi n6 di each xa cu dong mach. ctinh. tU 1 den 3 ern, trung binh 1a 1,5 ern.

- Doan thli hai la doan narn ngang, dong mach giap duoi tao nen m¢t dean cong thli hai ra phfa trudc, va bit cheo mi;it sau cua d¢ng macli cdnh. g6c va ma.t truce cua d¢ng mach. dot song. Tuy nhien trong 12% s6 trudng hop a ben trai va 3,5% so truong hop d bEm phai, di}ng mach giap dual bit cheo phfa sau dong mach dot song, tuy thea cae bien th~ ve nguyen uy cua d¢ng macli giap duoi va tuy theo mac dot song dudi cung (C, hoac Co) co [6 ngang rna dQng mach. dot song chui vao. Trang doan nay, dong mach giap dudi dfnh vdi mt;tc c6' sau va quai thdn kinh giao cam va lien quan gin voi hach. giao cam co' giiia. o dily, d¢ng mach tach ra nharih cho chu6i giao cam e6. Dieu nay giai thieh tai sao khi th:lt d¢ng mach giap dudi c6 th€ gay ra nhung t6n thlidng {j ehuOi than kinh giao cam co'.

" Cae tae gia Phap mo til mot nhanh eua r:J~ng m?ch dlldl rJon, gOI Iii than glap-nl1! cd-val Iii dO<,ln dong m~ch chung, tit d6 xuat phil! 4 nhann cung, rna m9t trang s6 nhimh nay la r1C1ng mi;lch giap duoi

- Tdi bd trong cua dong mach. canh goc, thi d{>ng mach giap dudi Iai tao nen doan cong thu ba, 16m len phia tren, va sau d6 thi hoac di}ng mach giap dudi phan nhanh cung, trong 70% s5 truorig hop, hoac di them 3·4 cm nita nhu mot than Q9ng mach. (j doan thli ba nay, d¢ng mach giap dudi tach ra nhanh ben cho tuyen c¢n giap trang, va c6 lien quan vdi day than kinh 'quiit nguoc. Dong mach bao gid cfing bat cheo day th~n kinh {j bd sau cua tuyen giap. Bien th~ sau day hay gij.p hon: day than kinh qu¢t nguqc phiii bi\t cheo d phia truce than dqng mach giap duoi chu kh6ng bit chao nhanh cung cua n6; con day than kinh quiit ngufJc trai thi nam a phia trong hen va bit cheo phia sau dQng mach giap dudi a phan ba trong cua n6. Dean thu hai va thu ba cua d9ng mach giap dudi baa gid cung lien quan voi m~t sau-dudi cua thuy ben tuyen. guip va dean thu ba cua d9ng mach nay Ia dean narn trong bao cua tuyen (noi-bao).

D9ng mach giap dudi tach cac nhanh chokhiquan,hau,vath¢cquan,khinhung nhanh nay kh6ng xuat phat tU mot trong nhirng nhcinh ciing cua d9ng mach giap dudi.

Nhiing nhanh cung cua dQng mach giap dudi gom co:

- Nluinli sau eli len tren theo ba sau cua thuy ben tuytn gitip tao thanh noi tiep doc a bo nay;

- Nhcinh trong vong qua c¢c dum cua thuy ben tuye'n giap ; va di len tren doc theo mat trong cua thuy ben, tao thanh cung n81 tiep dudi-eo, hiem thay, Khi c6 cung nay, thi cung ducc hlnh thanh bdi m¢t nhcinh trudc-trong cua d(ing mach giap duoi, di doc bd dudi cua eo tuyen guip .

- Nhcinh ngoai toa nhanh nuoi dufmg cho mr;it trude-ngadi eua thuy ben tuyen giap;

- Nh6.nh sau, tiep tl,lc huang di cua than dQng mt;lch gicip dUdi, chGlY dQc m(jt trang cua thuy ben tuyen giap, n~m gift a thuy nay va khi qui'm, tren dUdng di tach ra cac nhfmh cho tuyen. Cac nhanh cung cua d¢ng m!;lch giap duoi vita mo til. d tren cung ea"p

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mau cho mra duoi ella cao thuy ben tuyen giap va noi tiep vdi nhau d trong nhu mo tuyen va voi nhanh cung cua di)ng mach. guip iren, Rieng phan eo tuyen thi nam b vi trf "giao di~m" giua bon dQng mach giap, nhung chi co it nhanh noi tiep narn ngang giua chung d day, vi vay c6 th§ cit eo tuyen giap rna khong sQ chay rnau nhieu.

3. V¢ng mach. giiip giiJa hoac af}ng macli gtap duai cung (af)ng mach. Neubauer) 18 met ti~u dQng mach khi c6 khi kh6ng (co trong 10% s6 truong hop); khi co, thi d9ng mach nay tach ra tit than d¢ng macli tay-ddu hoac true tiep tu quai af}ng mach. ehll, va di len tren a trong lei mt) lien kit giap-ngoai tam mac tdi eo tuyen giap, va khi co afjng macn guip giila nay thi mQt trong hai ar5ng mach. gitip dztdi Iai thuong khorig co. Trong thu thuat md khi quan qua eo hoac duoi eo phai tranh cat phai d9ng mach giap giua neu thay c6.

* Tinh. mach: ve s6 luong, tinh. mach giap giita c6 th~ thieu, co th4 chi c6 ~Qt, hoac nh ieu: nhung iuon luon Ia t'inh mach ngan, xuat phat tit m¢t ngoai cua thuy ben tuyitn gieip, 1'6i di qua phia truck cua dfjng mach. canli goc va d6 true tiep vao tinli mach. canh. trong , va khOng di kern vdi dong mach ·nao cua tuyen giap,

Tinh. mach. guip duai phat sinh tit nhieu r~, r6i di xuorig phia dudi d trong la mo lien kef gidp-ngo(Ji tam mac d~ tdi d6 vao g6c tinli mach. dudi don-ctinh. trong hoac vao tinli mach. tay-d6.u trai.

* Mocti va hq,eh b qch. huye't cua tuyen giap va tuyen c~n giap trang: bach huyet tlr cac phan ben ngoai va tren-sau ~ua cac thuy ben tuye'n guip duoc thu nhan vao nhimg than bach huyet47 chay theo cac cu6ng m(Jch than kinh gidp tren va d6 vao cae hqch co" BaU (ni"im d phia trong tinh m~eh canh trong). B~ch huyet tU phan trudc va ph&n tren cua thuy ben kJ ca tit eo, dUQc thu nh~n vao m9t than ben trang, than nay khi di qua mlilt trlidc cua tuyen giap co th§ b! ngAt Quang bi'li rn9t Val h{J,ch

.7 Than b~ch huyet I~ nhiing m~ch b~ch huyet lon, thu nh~n nhieu nh~mh nho han n6 va thuong do v~o h~ch biilCh huy6t

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cd n6ng (narn d giua, truce thanh quan). Trri gifra tuyen giap va sun nhjin thi cac than nay hop vdi cac mach bach huyet cua phan tren thanh quan va cung d6 vao ch uti hacli tinh. macli cdnh. trong .

Tit phan dudi cua thuy ben va tit eo tuyen giap, cac mach bSICh huyet co mot nh6m di ra phia ngoai (nh6m ngoai) va m9t nhom vao trong (nh6m trong). Nh6m ngoai di kern theo tinh. mach. guip giiJa va dlin bach huyet ve cac hach ben dudi cua chu6i dl sau (narn i'l phi a trong tmh mach canh trong). Nhom trong thi d6 vao 5-6 hach trung gian (tn/ac va canli khi quan), narn doc tren duorig di cua day than kink quiit nguoc va day than kink phl-v[; Cac hach nay cung nhan bSICh huyet tit phan sau va duoi cua thanh quan va ttl phan tren cua khi quan, d~ cuoi cung db' ve chuoi hach e6 sau (phia trong t1nh mach canh trong). Cac mach bach huyet thuQc nh6m ben trong co th~ co duang di khac (kh6ng d6 vao chuoi hach tinh mach canh trong), ttrc la d6 vao cac hach. bach. huyet trung tMit sau, r6i tit day d6 vao than bach. huye't ph@' quan-trung that.

MQt bien th& thu na m la nhirng mach bach huyet tu tuyen giap d6 vao chu6i hacb bacb huyef sau hau.

* Cdc day thcin kinh cua tuyen giap: tuyen giap ducc chi phffi bdi cac soi than kinh giao cam (ciS) khong vo myelin di theo cac mach rnau va bdi nhimg day than kinh thanh quan tren va duoi. Day than kink thanh quan. dudi lien quan voi df)ng mach. gidp duai (nhu aa dUQc rna ta ij phil:n trim), phai dtroc chu y tranh kh6ng cham tdi day than kinb nay trong phftu thuat cit tuyen giap, vi day than kinh nay neu bi t6n thuClng se gay ra 1'oi lo~n phat am. Do d6, trong tntCJng hc;lP ph8.i thit mQt so nhanh cua cu{/ng m{;wh duai eua tuyen giap thi phai he't suc tranh khOng d4 cac nhanh cua day thiin kinh thanh quan duai b! to'n thudng_

Khi quan doan c6

Khi quan. tiep lien vdi thanh. qtuin. vi khi quan la m(>t phan cua dudng h6 hap dudi, 6 nguoi Idn, khi quan bat diu a ngang mire khoang giua cac dot song cd thu 6 va thu 7 (C6-C7), nhung d6i chieu nay cimg thay d6i it nhieu thea tu6i. Khi quan tan het d cho no chia doi thanh hai phi/ qtuir: g6c. Vi tri chia doi nay tudng irng vdi dot song nguc thrr 4 va thu 5.

Ve mat dinh khu, khi quan duoc phan ra lam hai doan: doati co' (pars cervicalis tracheae) va doan nguc (pars thoracalis tracheae).

d ngudi ldn, khi quan. doan. co'dai 5-7 em, chiem khoang mot mia t6ng chieu dai cua cit khf quan. 6 tre em, khi quan dean c6 ng an hon, chi 4-6 ern. Yang Sl,ln khi qtuin. thu nhat 6 ngang muc do't song c5 6 hoac 7, th arn chi ngang muc dot song nguc thu nhat (theo Corning-Hafferl). Khi quan doan c6 bat d§.u tit bCi dudi S(in nhrin, co mang XCi ket noi vdi sun nay, va t$.n he't d muc m~t pharig nam ngang di qua bCI tren cua ctin. xucng ue. Trang doan nay, khi quan nam treri dudng giua cua c6, nhung hui l~ch sang phai khi di dan xu6ng phia nguc, ucn thea tu the cua c(it song, tuc la di chech xuorig dudi va ra sau,

* Lien quan quan trong nhat cua khi qu a n doan nguc la vdi lei mo lien ket truockhi qudn. Day la mot la rna lii'm ket mau (day dac) che phil m(it truce-ben cua khi quan. Tuy nhien, c6 th€ tach ms:j.t sau cua la mo lien ket nay ra khoi mi;'it truce khf quan d~ di van khoting trudc-kbi qtuin; khoa ng nay thong xu6'ng Wi t~n trung that va la m(>t ldp boc tach phau thuM ly tudng: cung e6 th~ thl;lc hi¢n n(>i soi trung that b:lng d.ch di theo lop boc tach nay. Yi~c xac dinh lOp b6e tach nttm giua lei ma lien kit lrILde khi quan va khi quan lam cho thil

thuat md khi quan tra thanh khong chay mau. M~t truce cua fa me lien ket trucc-hhi qudn lien quan vdi tat ca cac tharih phan co, tang va 'mach-than kinh cua vung dr.tdimong, rna la mo lien ke't nay c6 th~ bao v~ trong thu thuat boc lQ khf quan,

'" yg phfa truck, thong qua hi ma lien ktt trr.trJe-khi quan; khi quan doan c5 him quan: jj muc cac vong sun d:&u tien (vong thu 2, 3, 4) vdi eo tuyen guip , vdi lti ma lien ket gidp-ngoai tam m(te, rna trong b~ day c6 chua cac hach bach huy€t (goi la chubi hach. trILac khi quan, nhan cac mach bach huyet to' cac hach thanh quan, va cac mach bach huye] til eo tuyen giap), v6i cac tinli mach. giap ; vdi than tinh. macli tay-dau khi than nay di VU\Jt qua len tren can xuang uc, va doi khi vdi a(mg mach. guip giiia (dqng milch Neubauer) khi co d:Qng mach nay.

'" yg phia ngoai, khi quan doan c6 lien quan vci nhfrng mach mau Ion cua c6 d moi ben; dqng mach. ciinh. goc hoi lui ra sau hon so voi khi quan va bi ddy ra phia ngoai hOi thuy ben tuyen giap,

Trang khe nam giua a(jng mach. cdnh. goc, thuc qudn, va khi qtuin, c6 d9ng macli guip duai di qua va phan chia thanh cac nhanh cung d phta dudi cue dudi cua thuy ben tuyin guip, Day than kinh quijt nguac phai n~m d phia sau hon, d trong khoang gioi han a giua khf quan, thuc quan, va cQt s6ng, trong khi day than kinh qu(it ngILr;c trai n~m d phia truce hen, trong goc h9P bdi mat ben thuc quan va mat sau khi quan. Ca hai day than kinh qu~t nguoc deu bAt cheo d(>ng mach giap dudi cung ben.

Tat c3. cac thanh phan k~ tren d~u du</c che phil a phia truce bai lop co-mac va da. o ngang muc slfn nhdn (C6), khi quan can lien quan vdi l6 tren. eua thue quiin,

'" yg phfa sau, qua th\1c quan, khi quan lien quan voi C9t song co'; khi quan ket noi voi th1;!c quan bCli rna s~i chun va cae sQi cd

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(goi la cac day chdng khi-thljC quan). Ca hai ta ng nay dgu duoc bao boc chung trong mot 18. mo h€m ke't (goi Ia mg,c hoac baa tr.tng Monteiro), bao nay xuat phat tu mat ngoai n€n SQ, bao phu luiu, tao thanh lOp ao ngoai cua luiu, rai tiep tuc bao boc khi quan va thuc quan va eli xuong Wi t~n trung that,

Cau true cua khi qu an: Khi quan co hinh th~ nhu mot ong hinh tru, nhirng mot phan tu' sau cua ong thi det, Khi quan duoc diu tao hdi:

- Ldp niem. mac a trong cung. Niern mac nay lien tiep voi niern mac cua thanh quan 6 ph ia tren, va phu bdi biilu mn tru tiing c6 long chuye"'n. Ben duoi III lop duai niem m(1c;

- Lop giira la lap co-eun, hop bdi 16-20 vong sun kh6ng afty du (vi thieu d mot ph an tu sau, n€m moi vong sun that ra 180 hinh m6ng ngua): cac vcng sun nay hoi det thea chiifu ngang 6 dean khi quan c5 va thea chieu doc 6 doan khf quan nguc; vong su n thu nhat U~c biet day hen cac vong kh ac. Cac vong sun ket n6i vdi nhau bdi cac day cluing chun (marig chun), lien tisp voi lop truing sl!n (ngog,i sl!n) cua cac vong. Hai dAu sau cua mJi vong sun duoc n6'i vdi nhau bdi mot mang cd hop bdi nhirng s(ji co iran nam ngang;

- Lop ngoai cung la m9t mang sai xa chun, phu b m~t ngoai cac vorig sun va ket noi churig vdi nhau (goi la day cluing vong) dong t.hoi phu tiep ca ma t sau cua khi quan (ph an co), toan bo h9P tha nh lop ao ngoai cua khi qu an.

Cac mach mau va day than kinh cua khi quan

* f)(jng mach.: cac dong mach cua khi quan aO{l.n c6 blch ra tit a(mg mg,eh giap JUdi cung nhu tu d(jng mg,ch, giap gii.ta (khi c6 d(jng m;;:tch nay).

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* Tinh. mach: cae tinh mach nii'tm ngang trong khoang giua cac vcng SI,m cua khi quan, va db ve cac tinh. mach. gitip va vao ludi tinli mach. quanh thl/c qudn.

* Ctic mach. bach. huyet di qua cac m ang sci xo va d m6i ben deu d6 VaG chuoi hach nam doc cac day than kinh quiit nguac; (; phia duoi, cac hach nay lien tiep vdi cac hach. khi-phe' qiuin:

* Ctic day thrin kinh: khf quan chi a se ngu6n cung dip day than kinh cua thanh quan, tire la hai doi day than kinh thank qutin trsn va dudi.

- Day than kinh thanh qtuin. tren, chu ye'u la than kinh cam giac, xuat phat ti1 hach. dudi (hach r6i) cua day than kinh ph{}: ui, tir day di chech xu6ng dudi va ra truce, b~t chao cM phan doi cua dong mach. cdnli goc 6 ngang mac sung ldn. xuong m6ng (moe M gay te), rai phan chia tharih hai nha nh cung: nhanh trong va nhanh ngoai,

+ Nhtinh. trong (hoac nhanli tren) nam (; ben dudi ar')ng mach. thanh quan. tren, chui qua mang giap-mong va phan nhanh chi ph6i niern mac phan tren thanh quan, niern mac cua phan hdu d gAn, va day luai. Nhanh nay thuong hay noi tiep vdi day than kinh thanh qutin duoi (qu¢t nguqc) tao nen quai Galien.

+ Nluinh ngoai (hoac nhanli dudi) chay d phia ngoai, doc theo eh6 barn cua co khit luiu. duci, tach ra mot nhtinli u(i.n d¢ng cd nhdngidp ; chui qua mang nhjm-giap rai phan nhanh eho niern mac phan tien dinli thanh qtuin, ne'p thanh am, va oung duai thanh mtm, Ngoai ra, nhanh ngoai con duy tri trudng luc cua tat ca cac co cua thanh quan,

. Day than kinh thanh qutin. dudi (qui;it ngur;Jc) chu yeu lil day van uQng, tach ra tu day than kinh phe'-vf: day ben phai thi tU phia duai cua a¢ng mf,lch dudi don phai, day ben trai thi tit dudi quai d¢ng mr;zch

chilo Til nguyen uy nay, cac day than kinh thanh quan dirci di len phia tren, narn trong g6c khf-thuc quan, day ben phai thi di hdi chech con day ben trai thi di theo huang thing dung. Cac day than kirih thanh quan duoi deu di qua miit sau cua thuy ben tuyi'n guip , nhung lien quan vdi d9ng mach. thanh qudn duci khac nhau giua day thrin kinh ben phai va ben trai; sau d6 cac day than kinh nay di qua phia duoi ca khit hdu duci, rBi chui VaG trong thanh quan va cung cap nhanh cho tilt ca cac cd cua thanh quan (ngoai trrr co nhangiap) , dQng tac cua cac co nay la khep hoac rnd thanh mon, do do c6 vai tro phat am va tho. Day than kinh thanh qudn duoi con chi phoi niem mac d phan sau thanh quan va noi tiep vdi nhanh trong cua day than kinh thanh quan t ren, 'I'ren dudng di, day than kinh quat nguoc con tach ra nhi1ng nharih ben la than kinh tim gir1a, cac nluinh. khi quan, th.uc qulin, va luiu,

Thuc quan doan c6

Th uc qtuin la mot ong co-mac, noi v{ji hau (h9ng) d tren va vdi d(1 day d duoi. D\1a treri cac vung rna thuc quan di qua, c6 th~ pha n tha nh ba doan sau: doa n c6, doan nguc va do?n bung. (Chung toi se trinh bay chi tiEh hen ve su phan chi a cac doan cua thuc quan trong phan noi ve thuc quan doan nguc).

Doan co' cua th.uc quan. nam d lop sau nhat cua uitng dudi-mong ; phia sau khi quan dean Ccl. Dean Ccl cua thuc quan dai 5·6 em, b~t driu b ngang muc b(l dl1di sun. nhdn, each vdi eung rang duai 15·16 cm v.! phi a durri (narn ngang muc dol song co' thu 6), va t?n cung d ngang mac mat phang n&01 ngang di qua bd t.ren cua xlidng uc.

Thuc quan nam tren duong giua c6 nhung hoi l~ch sang trai. Bo trtii cua thuc quan vuot qua sang tn'li so vdi mi;it ben trdi cua khi qtuin; con b2J ph ai cua thucquan thi narn trong g6c nhi dien h9P bdi khi qtuin. va c¢t song cd.

Thuc quan cung vdi khf quan duoc baa boc bbi mot lop ao rn6 lien ket, tao nen rn(\t bao soi xd, lien tiep vdi baa eua luiu (ao lien ket baa quanh hau) va keo dai xuong trung that t6i tan ca hoanh, Baa rn6 lien ket nay chua dung ca day than kinh quiit ngurjc (nhanh cua day tluin. kinh ph{{ .. uj), nam trong goc giua khi va thuc quan,

Thuc quan doan cd lien quan: b phia truoc vdi thanh: sau cua kh£ quan, chi co mot phan rat hep g§n biJ triii, vuct sang trai hon so voi khi quan thi kh6ng d sau khi quan, Phia trudc cua phan thuc quan vudt sang ben trai so vdi khf quan nay lien quan voi nhling tharih phan: day than kinh quiit nguitc trdi, d(mg macli gidp dum trai, tinh mach cung ten di kern di;lng mach, ehu6i hach. bach. huyit nam doc day than kinh quiit nguoc, va m at sau cua thuy ben tuyin giap trdi. Phia sau, thuc quan lien quan voi mat trudc cua c¢t song co: ducc che phu bdi cac ca v a mq,c truoc song.

Ed trai thuc quan kh6ng bi khf quan che a ph fa trudc, la b2J d~ di vao d~ md thuc quan til ben ngoai, day la b2J phau thuat cua thuc quan.

Ed phai cua thuc quan nam ~n sau 2-3 mm trong goc hop bi'li khi quan va ci)t s6ng c6, hen quan d phia tren vdi day than kinh quiit ngur;tc pluii, vi day than kinh nay tit dudi di len dan dan lai giin b(j thuc qUEm, vdi d¢ng moch. guip duai phai va nhfmg nhanh cua dgng m ach nay, toa ra nhu nan quat d giua khi qutin va c¢t song co'.

Hai bd cua thuc quan c6 lien quan mat thiet v(ji chu6i giao cam co' (hq,ch giao cam

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cd giiia), vdi d¢ng mach. canh. goc, tinh. mach. cdnh. trong va day thiin. kink phe:v;.

Bo trai ella thuc quan a phan dudi cua ctl con lien quan voi 6ng nguc"

Cite mach mau va day thiin kinh cua t h uc qu an doan e6

Thuc quan doan e6 chil yeu ducc nuoi ducrig bdi cac d¢ng mach. gidp duai, thong qua cac nluinh. thl/c quan tren. cua dQng mach nay: cac tinh mach gom eo tinh. macli th.uc quiin. tren, dftn mau d6 VaG cac finh mach. guip tren, Bach. huye't ella thuc quan dean c6 thi 06 ve cac hacb: cd sau,

eric day than kinh chi phbi thuc quan doan c6 la nharih cua day than kink pkt-vi (X), th/in kinh thi~t-hdu (IX) va nhimg soi cu a than giao cam C6'49 •

•• 6ng dan bach huyet l6"n nhat trong co the. thu nhan h:iu het loan b¢ bach huyet Irong co the ,,11 dd vao m¢t tinh mach a nen co (pnan duoi cong cua cd).

4> Phan th~n kinh giao cam coS bao g6m 3 hach than kinh n6i vai nhau hoi nhung thUng (day than kinh cO to) Irung gian 99i . ch ung I;' IMn giao cem cd hoi;!ic chu6i giao cem cd.

90

Kh unf::" xuon g [:iuJ ngljc (os teolh 0 r,ru:: hillg P'lg~ie ;utOng) hQp bOl 12 dtj£ :ntfJn.g sllfln, 12 dol IfOJlg nglf~\ vii Xllclrzg UC, cae }arong nils gHJJ 'han ml)t khonng g9i Iii '10ng nguc". khoang !lay chua de t~g CUI. ng1Jc.

G i';1 ha 'n tro n eua ng d c 1a dot sO'P'!i;{ ng~(" thu l"I hil"t (Ir~n cunr;). doi .-c!lring slfiln thu n n at lh'~n eung), va khuyet ~l-en lie [im·iaunr .}I.'crllaris sternalis: klUlJ'ei Unit much (xiuh rl}a ~liO"'ng ltC:). esc xUdng mly hop thanh 16 tren eua Uing ncr/e ((2.pe~lCJ.ra rhnr(I~'is Cl't.una.iis: M ~ci"ng ~g¢C pM.a ,dou),

Cae h~oh b~ch hW~1 ~:sJru Than b~h nU'J'~t dU'di dol'! ph;)i

cae ~~h hac!'! Iitl~ ~irih mioh

Cae h~cJi b~di hil~'e:l dudi dol')

C~ o 'hOlm bach hu y,M !rung ~rn OOGIljnllDm il1ng tAm) ,

Cidi han dud] cUSJ nglilc d'liVc gqi lilt Eo dr,t(Ji erla' Mng nc~('! (apertura tlwra.cis casdali«: M lOng ngr,tc pMa. du6il. hQp bOi miii. lA', b(j d[Mi ella cae xuung sVC1!1 auai cung, d.iu t'I'U{lc cua :3 xu(in~ :nton Judi cung vill n:r.om nlla.ng ena dot song ngl/c th1l.'t 12.

Kh{)ans: l,ong ngt;1c I.!ha.a t:jlIlg (CflVUrJ"l.

L'iscerum tnorasis: khoang l5lj,.g n.g¢c t~ngt VUQt Qua nhimg giiri han tr51'l cu.a !6nll nIJtlc ~I:.l(}t~g vito dU:"r,JC rna t.ilI. Nhu vlJ.y. (i n~u.ng giai do~n. he h!p nao do, mung pfr..{jiO: Vll ph6~ vUQl b£u l~n tren SCI v(jj eae x~p:mg sU'dn ehu nha't, dinh mung phf/i 116 th~ Hhl coo t~i Hm nua chigl.l da.y ells xuitng don 0 phfa dU(n cUn~ v~:y, giOi h~}m d1.!oi cua Hoang long n~:\tc thu:a tang Ul. ttl)' then \I~

Co (/C'c!~!1-d'ltim

".,,,._ .• -..

C'.ac h;;lcb t&ach htiy€1 qm'lt ~ ~.i.t ... ~~ CO' ~ to

- C~ m~h ~ch hu~et!'lm ~ep H~dl b~h huye! giSI't-WOn.

Xoang doin &Cia 6ng {j~n sua __ ~

~T u~<€n VIJ (t~e;" sua) . . cae; j~u IhuV luy(ln I/U La'pnKl

Hinh 62. Cae tuyerll VU

,I

• I

\

J

Xucng sut1n lnu III tllan kinh, il6rtg m@ell,

. m~ 1i11 gfarl s(r,(m .

Xtl(i'l!l $lJ!CII1 thO' VII '-- Co ngvc be

Hllnh 63. Tu),'n vu - thie~ do d(mg dQc (mru trUc)

Num~ X.oil"fgl de n $CIa

CO' 9 Ian SJJOri ngoSiI Co gian surn trofIiJ

[r·t cua co boanh, co nay co thi len cao wi (J)n ngang mue Hwang g1:un ~ltiJn·t 4·5.

Thanb nsvc: chfnh thfrc Chl~r. cill] t~o hiJi nhun~ thanh philn snu dliy:, lOng n:glJc ){l1dng. dic~d' gian 8l1i1n ngoli.i, m{ll' Flgoal ngltc' (ngo~i·ng~c). pMio tiep tl}c l:im m(lC' ":0' n(J"R ifa3CJ.r~ colli supelficiaUs) ,di xlJong I1g1jC:. eac ea gicm BrIan ['rv'll? phiL bvi m(lC tmn£ ngp/c: (rl!J.i.ng¢c). Hiua mae nni-nguc

, KhDilrtg 9'11" .s~ GU ng .du!' ,.ac co jjOO .stfI'iw, d~~ d,;in kinh. ~~ng mach, tTnh maCll !J'~'1l ;!;IJ[JI'J Imn 9 rn9~ ~O; laM II~u con go, ~fI )",'10'1 SJftjIr, I 'Ji d\r eo;;I tloSon wQn. fitl'i 1Il6n klllh Wn ~1.i'o111 .)

va mang phoi con c6 lop rna lien klt duai thanh mc;ze (tela subserosa), la mo lien ket nay dm h chat vdi iii th.anh. eua mung pho'i, va cung vdi lei thanh. mang ph6'i khi bi vlem se g:ly ra chung oitim. day truing phffi.

6 th anh ngl,lc, e6 vung vu (vung tuyen

vii) 12. vung d?c biet dang quan tam ve mat lam sling (hinh 61-63)_

Vung vu (vung tuyen vu) (Regia mammae)

v« mat dinh khu, vu ng vii trci.i d9C treri dU(Jng thfmg dung qua difIm giua cac xuong don, tu ngang muc xuong surm thir 4 den xuring suon t.hu 7, va thee chieu ngang tu phfa trong ra phia ngoai tu audng canli xuang uc tal ducng ruich. trudc a m6i ben. Ve phia ngoai, tuyen vii cung thuong xuyen eo nuiu 16i uao uung nacho

Vung vii ve chieu sau tien tdi sSt mac cua co nguc to, nhu vay, vung vu duoe ngan each vdi cac xuang suan va cac khoang gian suitn bni nhfirig tharih phan gi2.i phau tao non thanh tr irdc cua h6' nacho

Co hai luyelL uu (tuyen sua). Tuy nhien dfJi khi e6 th~ gl~p cac t rudng hop tuyen uu thila (da vu) hoac chi' co mot, hoac thieu ca hai tuyen vu (t(it kh6ng vu).

Hirih th& cua vu nX't thay d6i, thong t.huong nhat la hinh ban cau, doi khi hinh qua 16, hinh dia hoac hinh tru.

RIch thiroc cua vu thay dai thea tu6i, ti nh t ra ng sinh IS (co thai, sau de) va theo tung ca nhan khac nhau. Trude tu6i d~y t hi , tuyen vu chua phat tri&n, tdi tu6i day thi. tuyen vu mci b at driu phat tri~n dfl.y dli hdn, va sau tu6i man kinh thi tuyen vii lai t hoai triEin (hirih 62).

o trung tam cua phan da phu tuyen vii, co nurn vu (papilla mammae) bao xung quanh b6i Quang vu. Quang vu Ia m(jt vung hinh tn'm bao quanh day num vu, co dl1dng ldnh tit 15-25 mm. Da trong vling Quang vu mong va mau do tim, tren m~t da c6 nhieu num loi nhO, gQi la cac cu cua qufing VU, die ell nay ttldng ung voi 15 mil eua

nhiing tuyen bii nhitn. hoi bi phi Q\J,i narn d dudi da.

Trong 'thoi ky c6 thai co mot s6 cu xuat hien a vung Quang vu, duoc mgt s6 tac gia coi la cac tuyen vti ph u, goi la cU Montgomery .

NAm a trung tam cua quang vu la num. ini, num vu 10. mot nurn 16i hinh tru eao tit 10-12 mm va co duong kinh to' 9-10 mm. Doi khi num vu khong 10i ra ngoai rna lai hin sau vao trong (goi la num uu hinh rO'n)_ B~ m~t cua rnim vu ga gh€, nhan nheo, co mau nau, slim han so vdi mau do tim ella quang vu. Dinl: ella num. uu. co khoang 15- 20 16, d6 la 16 rna ra ngcai cua cac 6ng ddn sila (ducti lactiferii. 6 dinh num vu da rat morig , dfnh chat vci cac rno ben duoi, va d mat sau cua da co mot 56 Sr;Ji cd trdn tao nen cd dudi Quang uu1, khi cac sci co nay co thi lam cho nurn vu dung th:1ng len.

Mo kien ket rna a vung vii duoc phan chia ra lam hai lop: mgt ldp nam 6 phi a truce tuyen vii (6 nong hem mo tuyen), lap nay phat tri~n hen, g6p phan tao nen hinh th~ ben ngoai cua tuyen: mot lop khac narn d sau, phi a sau tuyen vu (6 sau han mo tuyen), kern phat trien hen va goi In m6 mo sau tuyer: uu. Hai lop mo nay thong thuong vCli nhau qua su6t be day ella nhu rna tuyen vu.

Nhu mo tuyen vu thuoc ki~u tuyen 6ngnang. Nhung nh6rn nang tuyen lien kiit voi nhau thanh nhung ti{/u thuy tuyen, va nhieu ti~u thuy h9P thanh thuy tuyen. Moi nang tuyen bao gam m(lt mang day, kh6 nhan ra, tren do co mgt lop te bao hinh sao goi la te' baa cd-bie'u mo, co tac dung tieh cue dfiy sua ra ngoai, Cac tiiu qudn tuyen (ong din sua nho) duoc cau tao hOi mgt lop te bao co-bieu me va mgt hoac nhieu lop te bao hinh kh6i vuong hoac hirih tru. Cae ti~u thuy duoc b6 trf thea h inh nan hoa, m8i tifIu thuy co mgt ong dan sua mo ra ngoai bai mot 10 d dinh num ou; m6i 6ng trU'oc khi md ra ngoal deu c6 ffiQt do(}.n ngiin phinh to gQi la xoang ddn si"ta. Cac nang tuyen vu dU'qe bao quanh bai rna kien ke't ma, nftrn a phia trtioc va phia sau tuye'n (hinh 63).

4 Co hie gia gQi co dlltJi quang vii Iii cO nlim vii

95

Tuyen vu c6 nhieu miu nho, mot s5 mau khi co khi kh6ng nlnr mau nh6 dUCli xuorig don, xuong uc, va mftu nh6 duoi, nhurig e6 mot mtiu bao gio cung co la miu nho VaG ho nach (mfru nM nach) di qua bo duoi cua co nguc to.

Tuyen vii ducc bao boc trong mot 15. mac do rno k ien ket duoi da (hq. bi) bi¢t hoa tao thanh, mac nay co th& phan biet thanh hai phan 13 mac trudc uu va mac sau uu.

MC(.c sau uu duoc ngan each vdi mac cua ca nguc to boi mot lop mo lien ket long leo, lam cho tuyen vii di chuyen de dang so vdi lap co (lap mo lien kirt sau vu nay duoc goi la tui sau uti - Chassaignac).

MZlC sau vu ve phia tren duoc c5 dinh 'lao mac co nguc to, tham chi vao cat mac (mung xuong) cua xuong don, d6ng thoi cung noi voi mac truce vu tao thanh mot day chang treo that su cua tuyen vu. Neu day chang nay bi dfio, gian, thi se gay ra chung sa tuyen vu (vu xe), tinh trang nay bi&u hien bdi num vu bi 16m xucrrg, kern thea voi vu phi dai dau (chung dau vu),

Cac ruaob mau va diiy th~n kinh cu a v urig vu

* Cac d¢ng mach. xuat phat tu d¢ng macli vu trong , la m9t nhanh cua d¢ng mach. duai don (chu yeu nu6i dudng phan trong va tren cua tuyen), tit d(jng mach. vu ngoai (con goi la d¢ng mach. ngl/e ngoai) , rriot nhanh cua d¢ng mach. ruich. (chu yeu nuoi dudng ph fin ngoai tuyen), va til nhimg dQng mac]: gian suim thong qua nhirng nluinlt xien. (df[ nuoi dudng phan sau cua tuyen).

* Cac tlnh mach. chay thea hudng ngUQc l~i v6i cae di)ng m<;ich tttdng ung.

* Mqch bC,lch huyet (hinh 61): dU<;lc phan thanh ba nh6m: ngoai, trong va duai. Nhom m?-ch b;;tch huye't ngoai dfin bl,lch huyet tai nh6m ngljc cua ehuoi hr;wh nach; nh6m trong dlin bl,lch huyet ve cac hl,lch b1.1ch huyet n~m tren duong di cua dQng mqch vu trong; con nh6m dudi dftn b?ch huye't tOi cac hq,ch bg,ch huytt nach va duoi don.

96

Cac mach bach huyet cung hinh thanh mot luoi rumg va m9t ludi sdu . Luci nang bao g6m hai dam roi, dam ro'i bi va ha bi, cac dam rai mach bach huyet nay mau hem d vung Quang tni, Ludi boch. huye't stu: thi narn a giua va bao quanh cac tiilu thuy tuyt/n,

M1.1ch bach huyet di tU cac Judi nay c6 tht; phan ra lam hai dinmg ch inh va phu:

- Duimg chinli la duang ruich. va ngl/c trong (uu trong). Cac mach bach huyet di thuoc duimg ruicli d vung bo ngoai cua tuyen vu se di Yang qua bo duoi cua co ngVe to (doi khi di xuyen qua co nay) va trri cac hach bach huyet b ho nach (chuoi hoac nh6m hach. ruich'), chu yeu la nh6m hach. vu ngotsi (nhorn hach narn thea dQng mach vu ngotii hoac nguc ngoai), nhung cung co th~ tdi nh6m trung tam, nh6m hach. uai va nh6m dum don. Cae hach bach huyet nay chu yeu thu nhan bach huyet d phan tv ngoai cua tuyen vii. Tit cac hacl» nacti bach huyet se tiep tuc duoc dlin ve cac hach. bach. huyet tren don.

Nhung hach. uu trong hoac canh. rIc narn d9C tren duong' di cua dijng macli vu trong ; cac mach bach huyet d6 ve chu6i hach nay xuat phat tit lum bach. huyi?'t sau cua tuyen, chu yeu la thuoc nua trong, 1'51 tit cac hach vu trong bach huyet duoc din tdi nhilng hach narn d phia trong nhat cua vimg tren don, hoac duoc db true tiep VaG f/ng nguc (6 ben trai) hoac VaG ong bach. huyet phai 5 Cd ben phai).

- Duong ptu: la dUdng true t iep dan hach bach huyet tdi cac hach. tren. don (Mornard), bao gom nhung mach bach huyet di xuat ph at tit phan tren cua vung vu (vung vu duqc chia thanh bon 6 bbi hai du'dng thing dung va n~m ngang d.t nhau d num vu), d.c ml,lch nay de thing vao cac hq,ch bg,ch huye't tren don, hoi;ic nitm d tren ho~c b duoi vung xUdng don.

Dl1ang nach trung tam-ngoai (Gercta) la du'dng d&n b<;ich huyet tu m9t b€m vu

5 Trong lai li(lu nay. eng bach huy~t phai dllOC lac gia gOi bang len Ifnh m{,ch bi;lCh huyet Ion (gre_al lymphatic vein).

~;H1g ben deli d ie n, M tdi ca c hacl: neieh ben d(~;i d ien.

LhAJn;.; phu duoi, kern ph6 bien hdn, x u a t phat t ir pha n duoi cua vung vu va dan bnch huyet tdi cac hach nrirn d phan tren cuu co tluing bung:

j{() rang la each phan b6 cac vung bach huyet ella vu lam eho phftu th uat 'lien g?P k ho k hu n Ion, k h i p h ai d.t tuyen vu ea kh6i (torm bo) cung vrii to an bo nhung nh unj; h ach bach huyet thu nh an bach huyet cua vung. khi tuycn vu hi ung th u: viec nay doi k h i k horu; th~ thuc h ien duoc. Do d6 chan clean ung thu tuyen vu b&t bU9C p hn i duoc rlurc hien sdm nhat khi co th&, tile Ia vao gi<li doari rna nhfrng nh6m hach bach huyet con ch ua bi eli can tci, nhat la cac hach cua ("II lI()i L'U trong .

* Cac day than kinh cua tuyen vu xuat ph at t u eric day than kinh gian suim, cac (t{li d,\y than hinh. gian suitn til thir II tdi t hu VI, til cac nhanh. tren don cua dam r6i I luin. kinl: c6' va tit cac nluinli nguc cua dam r61 than hinh cdnh. tav . Cac sui thdn kinh til uc v(it t ht di theo C·{lC dOng 'rn?eh d~ tci t u v e n vu ,

Khoang ngl!c (0 ngl/c)6

6 nguc co giai han tren va dudi la hai 16 ng{iC' tren. va duiri ([6 tren va 16 dudi eua 111ng nguc), 0 phfa truce, ben thi 6 nglJ'c chil_iC gidi h a n bili xuflng UC, cac xudng suim. va cac cit gian suitn, con 0 phia sau thi boi ("(Jt SrJllg nguc: 6 ngu« la mot khuang chua t.a rig, trong et6 co rihieu t:~ng (co quan hcac t ha nh phan) k hac nhau (hinh 64, 65, va hinh 120).

Mot so cac tang trong 6 nguc duoc baa boc boi thanh mac (nhu ph6i va tim), con

I l. hoac khoang. hoac hoc III ba tLr Viet dung d1l dlch W tiEing Latinh cavum. co nghTa Iii m9t khoang Irong. co hoac kh6ng chCr" cae Ihanh phan 0 ben trong. Voi th6i quen trang ng6n ngCi glai philu'h<)c va y hoc, cae lac gia su- dung ba tit nay thay the nhau tuy thea hoan c;imh vi d .... h6c mi~ng. h6c miJi. khoallg hau. khoang thanh quan, {} ngi/C. 6 philc m'1c.

cac tang khac thi chi c6 mo Win ket duoithanh mg.c baa boc.

C6 hai thanh mac: mang phii'i (hoac pM/ mac) , baa bee quanh phoi, va truing ngoai tim (hoac ngoai tam mqc) baa boc quanh tim, do do tao nen ba 0"' thanh m{tc Ion. Cac cau true gi~b phau narn trong khoi mo lien ke!; dudi thanh m{tc n6i chung keo dai theo chicu doc tren-dudi, va mo lien ket tao nen a xung quanh cac cau true nay m9t ldp do lien ke!; (ao ngoaii, va cac day chdng. hoac t(ip trung thanh mo lien klt cua trung tlui: (lamina fibrosa mediastini: Lti s(Ji xit cua trung that), va mi) Win kel duai thanh mr;rc (tela subserosa: lap duai thanh mac), Iien quan ma t thiet voi thanh mac, 16p rna lien ket duoi thanh mac eon tao nen mqc noinguc va baa xa ngoai tam m(le.

?

Mitng phoi

(Phe mac)

Mang ph6'i (phe mac) Iii. thanh mqe bao boc quanh phoi.

Mtuu; ph6'i bao gam hai la: lti tang; bao boc true tiep xung quanh ph6i (dinh sat vao nhu mo ph6i), va fa thanh. 16t mat trong cua tiuinli nguc, sat vdi la rna lien ket goi Ia mac noi-nguc. La thanh va la tang cua rnii.ng ph6'i lien tiep vci nhau 0 vung ron ph(/i t:;1.0 nen mot thanh mac lien tuc, va gidi han a giua hai 13. mot khoang ao, toan toan kin, goi Iii. 6' mang ph{/i (hoac 0' phe' mqc).

Theo di nh khu, t.h] lei thanh. cu a marig ph6i (con goi la phi mac thanh) hao gam nhung 'lung sau day: doan L1 thanh phil mat ben cua C(]f song, cae xuang suitn. va cac khoang gian. suan, va mot phan xuang lie, doan nay duoc goi la mang pho'i suan-cot s6-ng (phe" mg.c suim-cot stIng) (pars eostvertebralis pleurae parietnlie: pluin. sudn-c(jl song eua phi mac thanli), donn la t.hji nh phu m$t t ren ed hoa.nh. duoc goi la mting ph6'i hoanh. (phi!' mac hoanl: (pars diagphramatica pleurae parietalis: phan ui hoanh cila phe'mq,e thanh), 001.ln 1:1 thanh

97

ITIrmg ph'l] che [lhu m:~ l b~l1 ella cae th~flh p\lilll nam i; VUI1g giUa eua 16nJ!! rLJ5~c (trung thJr), tuc Iii cae th;~nh ph~n nfun ghl11 hai pht)i (quod in m edio Jo!lat). dn:,tn n~y d'f(]t: r!Qi til mcmg pM/I' JI'WV: thir.'t (phf m~c ~rung rMti) (P(U't; mcdil16linaiia plcwYJe pandalis) ]l/lo,] rJ'rmr.: Ih~i'r cua pitt m~u~ Ikanh); trong rloi,l [I n;_\y phe m=_lt: chanh co m.Qt phiin g-iap ,,<~i miHig Ilgwil tim (n}fO(Il ~dm m~cI, che phu Lao I!:CI CUll. ngoai t<'ml mac, vii ngan c;ieh ph&n nay ella trung thal vdi esc l mimfJ pluJi thinh 6£-"8).

Lri ~h.dnh cu~ mfmg ph{/z khi chuy~n til' m~t llIIl~t nil.y cua tnanh ngl.jc sang m~t kMe thl ti\_l.o n~n m¢t goc. nh~ dii:n. ho*c i.lji clln,g. S'Ql lit irH citl11J phi m~c~_ T~il eli.n.O swlrt-tru.Jlg thiJt dtt~c t=;lO nen 00 phe' mac phu erie xUllIng $~((ln )~.t sang thanh pAt m~c trutu; tuci:l, .C.IU ciurg hoii 1'l h _ t '-,fmC OufJ' uti ~e t{lo nen do ph(f m(lC 110(1:11:" chuy~n ue'p thanh pM'" ml1c trung lJuH, va ,lu,: cimg S!IOtl-r;(JJ e6ilg' dU'~c eao nen khi phe m,c phil die .lHtdng liuon l$t len phil m~)t bel) ¢{!t sCint, d, dean ~ruug thilt, I Ii thimh mtmg plltJi 15 lien t11£;, nlni'ng lach vho khe giua

P h6i wi ~,.:!!ioii!!,~J.rIf""'- ~~ng m ~d1 ptlfl

o mang n~(}~i 11m (d ng[]~L lam macl ~~alig i1!Joal tim (n.g0\lllam mac)

C mill1!1. pI1~ j6 phe: mt(IC)

Urn thli'~r<1!

moo Irrn (m~rn iml ...... ,.-H;,.t ... - CO" hoanJJ ::~_;'-:__b:.'"""Nx1"__·· ThUy gan li11

O&\'l'lf"'!lOI-- Lacn (19) """'''''''''1+-- D~ d9~

"""'-.,,---;'1i\'W--'f'--- ~l tral'lQl ngillng ( et lrang ngangl

TIhh mam c;hli Iter!

Van ;.:kt!.,mll i6 dOng m~m (;h1J van hai l:!l (van mO ni\--:,,"rfjU---,-+:-':__'-;'-:-III4--I~~~S V.·m tillh maCh cbu

lui m~t ----i;.IH;,.r-;..;;o;;;;,_,., T a 'lriing -!T!i!:!H'-:~

pJr t mac lmrz.g .tll-(it (Ia i hfmhJ (j I,rung r-nt1 phJi CJlIi:it l=lli d~ liW:i tie'l:J \.(ij pM/ m9'C' pho'l Oil t=,mg-). con t~1U n~n dl'tJi c!aing ph{~t n~m i'j bGn dl.ieri ClHl. f:m.iiw phr~ va 1'017. ph{j'i, va );cn diii ~ u[ing t(rn m~ t tr~ co 'willi b: dflY eh ang nay co hirlh ram gille. nen d.uyc Waldej'(2r gqi Ii] 1'U!;h' t 1,,{'fJ ph t:i'i (rnesonetJ nwnlum ).

lU I h Il nh cu.a m~f1!9' ph~' I~t lIili 111Mi'll Ir 0 ng C~;!I 16i1(l n Q uc, tinl ~l tu mM 1hal"lh ntor1 3B.ng tMnh klliJ Il'li 1~Q Ihanh 1n91 !l~C nh! doo'\<n, c6 l"~ ~€t1,J hoac nQng. Cae g6c nhl dli;ln nay CllfI;!C dn:: 18;; Qi.li !"hap 9.;.1 Ib 'vi cunq, nhun" nhlmg lac glilAnh M'jl dung W 8!nug (rogng1 a& chi enOn~. TIJ~ nhioe., Umid ngll Ill\! C~Jlg ~Ilg fllU]', rnlI 0:.11; IIIJC 9 iii pn.l!p ~Lr d1Jn~ 1:11 1M iell ht.Ip hI:M_

B La Ih~ n h ",0 ~ m'\ng phOI p nu rrl Q L troll!! cae xLlDnQ ~Jdn .,;) t.llwn~ !JI<lf1 ~h" I~'I I~i J1~ F!·hli 1€-f1 ""~I Den dd3 'ruIIY Lh~il h9P [hann RaJ goc "hj dilln (h<li leU. ~U<lJ~')' m¢" 0 phr~ Irv~ o;TLil;ll; 99i !~ llil ~1J.n!;l ~-flUJi!.i fI'J.i. (nl'.iCu ,t;Jj lieu ~ h at gI;'l I~ J~i Cling St{(ln-,lrlJr19 (h§r Ino'cl'c) , ~t C:I 'P ,,'ill ~au "'," lron.gl ntMu tal li(tu kh.lC Wi l:iJ 'wi cunll :;tIrlIl-''rtillg JM! :sat', OhLIn!) Il"9f1g l~i liell najl t<,.c yB£J, '1j'~j la 991 h! Ill' een a S~'IJI(I-~j sO.n9

e~~ m~d1 -:..-lI~-==---,,--~r-"lIII~s::.G phoi phB_

TIflh mach -~~:------:--"'h chti Iffill

mil ~6ng IV,]tre thiJ \/1 (mam gail Trung t~t SaiJ

ChuOl1Mn kin h 91ao ?m ng\ffi £!ollg m~h chu ng!re ~d~rtg mach oM ru1'ing) prit trai

Phel mac lrun~ lM:I (Ia lhilnh mang . phOl, phan trurtIJ ItI~O nnh m~c'h CHC1n t tinh mi;looilmJll"In)

ltU,lc'luan aCta" IIIglJC

P~quiin g&: ~n~ptHil

P'h6i p~i HSnh d~f1$J rmc'n eM (09n.9 m~n ct11! len) .' S~nsmml

6ng n[JJ,lc

..... cae h\icb b;;to1llrtu~~t gian km ~1=f1~ quan Tilitin dMg ~cI:1 phOI

PI1~ ~ lruilg!hil !l!tlMnI1 mang phoi. ph an InJnQ ~) <, Mang ngMI lim (ngtlal ~m rnac]

Hinh 65. Thi~ do 'cat Ingang ngl'IC qua mtl'c dot s.ong ngl/C tna 6

Ui lhimh mafllg P~. p'11~11 6LrtFn-C~ !iOOg 6 ma~ pllrn

(0 pMi m~c)

00 SOI"!Q. ~". \Ie lhlrVlI (rOOm gail Ong ngl!(:

Tn.Jn9 Ihat seu

' ...

Tinh mach -+-,p""==:----~-~---j~~~:p_.,.~:-=----____::~~....L_14_ £lfln.g mild! G!11i rnQ~rr.

tbI t1(mJ (eM Ulll ~1)illlgl

TIrh m~ch 'th'Jc Quim

ph6i Fltlal

Phoi phSi

Ph6i tf~1

- T;m nhl li.!i

\Ian nl1·:Mllrni (van hili Ia. val'! rna nI)

6 !11<1Ftf} ph61 (0 phe mec', Tdmlhfit1ritJ

Tarn lhlllllMi

Phe lliiiIC tru~ tM1 tla 1I1imh rna ng ptuIi, pn:m !rung that) \ TOI cung Sutn-truD;l thiit ~.Qi cOn!!! hO~G ~llang svan·:rung !MIl Mq

Tmh mach ohu dum

Tiim nhi' pMi -....

\Jan btl It! jvan nhT-lhlt 'Pf,ai,) XLiang i!c

Trung Ihfil tnlflc

IPhOI phal

DOl s6ng nguc 1M VI II

Alill!! Irni

Tam flhitra

XOOitg :AAfn --,:~I''L ti'\Cr\l1

Tam n1i~h3i

I,.I&'__ W~ IMn k!".1

~::='.....;;::,",,:'J1,r.. hoam 1fSf

1-~~~JN~~T~~l~

rr-.::---:7.i.~ - Mang lrlln Ilm (ll1Ul1!lg IIlm ma~1

Till Gung 5uan--in.Jng th~l (nll «Qg oo~c X08IlIg !IJJrl·twng ildllM);;)

nmm~!:!l mmlkJn)

fel! I;li~ I MOOl!gj g-an ~1lI mach I;hu-lm.rc qy,jl'!

Tam nhilraJ

Va ~ ml-lJnlllal

[van h al la, ~·~n m~ nil

TInh mach phd' pna 1tlt=::~~~:;:~~

'ru i ~ung (:«Iatl9) g Ian. tiM rnRch d~I-lrifC q!JiI1 Ph6i phai - Tt"h ~d1 Chu QiJ(lj

T~m rftT rAl~i 6 mang pMl (0 pM m1C)

Hmlhitp~

Ph~ 1II<l~ trunglh 51 [11I1JIanh m~

~~!E!!!~~~;;;::=~~~~~~ pMI ~n tru-:g Ina·1)

To Ol1l1g >UrltHnmg lIciL

Trur.] 1h~1111JW (18 CUll!:! ooolexO<l,t;piLlCfll-llung thai tJuti:c)

1(11)

cac th~nh phan narn 6 trong trung tMit sau (n h u d¢mg mach. chil, th.uc quan, tinh. mach. dim), tao nen mi?t loat cac ttii cung nfia , nhir tui cung gian chii-th.uc quan. 6 phia ben tn'li do mang ph6i lach vao khe giua d9ng mach. chu nguc va th.uc qudn. tao nen, lui cung gian iinh. mach. don-th.uc qtuin d phia ben phai do mang ph6i lach VaG khe giua tinli mach. dan va th.uc quan tao nen, Hai tui cung nay l ai ducc noi v9i nhau bdi mi?t day charu; gian mang ph6i (Morozov), la m_()t tftffi mo lien,k€t sci xd, mau, va mung narn thea rn~t phang dung ngang.

6 vu ng la thanh cua mang ph6i phil nuit. suitn. cua tluinh: nguc l*t len phu m(it tren co hoanh; hinh thanh nen tui curig suitn-hoiinh., khi thd van sau thi ph6i chi Hin vao trong tui cling nay m9t p han, p han con 10-i thl. lii m9t tiii cung mang ph6'i don thuan.

6 thanh nguc trudc, phia sau xuong lie co m(lt vung kh6ng c6 mang ph6i che phu, vung nay giong hinh cua hai tam giac, vdi hai day mot huang len tren m9t huang xunng dudi, noi vdi nhau d dinh cua chung (duoc go i 1ft tam guic tuyen ue va tam guic tim).

Tam giac tren cung dUQc goi la dien. gian-pherruic tren, 0 tre em tuong ung vci tuyi/n ti«, va d nguoi Idn thi 0 vi tri nay co mot kh6i mo lien ket rna la di t.ich cua tu~en uc thodi trien.

Tam giac dudi cung dU9C goi la dien. gian-phi mac duai, c6 mang ngoai tim ingoai tam macy, marig nay n§.m sat vdi tharih t.rudc nguc, kh6ng bj che phu bai rna ng phiSi. Khi choc 6' mang ngoai tim (choc 6 ngoai tam mac) thi thuc hien trong dien nay se kho ng dung cham tOi 0- mung ph6'i.

6 vung dinh. ph6L (apex pulmonis), phia tren xuong suim thu nhat, phi m(lc trung tluit. (Ia tharih) lien tiep vdi phi m(tc suiJn-c(Jt song (cung Iii lit thanh) t~o nen mQt vom, gQi Iii. dinh mang phl)'i (cupula pleurae), che phll dinh pho'i ij ngay ben dUal.

Ve phia truoe, dinh mang pho'i vU9t len tren so vai xudng sI1dn thu nhat, doi khi vUQt len tr€m ca xlidng don; ve phia sau,

dinh mang ph6'i n~m ngang muc cua dot song nguc thu nhdt.

Dinh mang pho'i dinh vci m(lc nqi-ngljc bCii mf lien ket, tao nen cac day chang, tuy theo vi trf dune goi la day cluing SI1dn-mang pho'i, cQt song-mang ph6'i, c¢t song-sudnmang pho'i, phi!' quan va th.uc qutin-mang ph6i, h9P thanh mQt bi? may treo mang ph6'i thea quan niem cua Sebileau. Dlnh. truing pho'i cling ducc giu bdi bao lien kit cua cac mach rnau va day thin kinh d gfin canh, cimg nhu bdi mac cua cac cd btu: thang .

Dinh mang ph6i lien quan ve phia sau vdi diu sau va e6' ella xudng suon. thu nhiit ; cd cd' dai ; duoc che phu bOi mqc truce song, va than than kinh giao cam rna d day la hach. giao cam co'dI1di con goi la luich. sao; vg phia trudc-rigoai dlnh. truing ph6'i lien quan vdi cac ca b¢c thang ; doan sau co b$.c thang cua d(Jng mach dudi don, d¢ng mach. ngljc trong (vii trong), aOng macli gian suon. tren. cung Ia mot nhit.nh cua a¢ng mach. ehii va vdi day than kinh hoanh,

Phe quan goc (Bronchi prineipales)

Hai phi!' quan gdC phai va trai (bronchi principales dexter et sinister), ella hai ph6'i phai va trai, phat sinh tU ch6 chia doi cu a kM quiin, 0 ngang muc til: dia gian dot song nguc thu 4 den thu 69• Cac pM~ qudn goc di chech ve phia ron ph(J'i tuong ung, r6i se phan ra cac nhanh cho cac thuy ph6i, goi 1:), cac phi quiin. thuv ; phe quan thuy lai phfm thanh cac phit qtuin phdn thuy (hinh 69).

Cae phi quan. g6C deu co hudng di chech xuong' duoi va ra ngoai, h9P voi nhau mot goc khoang 70°. Ph€' quan goc phdi co huang d6c hOn, ngl'in hdn, to hon va hl11 huong ra truoc; eon phi!' quan g6c trrii thi

9 M¢t so tac gia cho dIng cho chia d6i cua khf quim thanh hai phs quan gO(; m\\m ngang moic dot song ngl/c thil 5 ho~c 6, e6 tlLiang h<;'p ngang mue d5t song ngl/c thill.

101

n~ m n gang hun, hoi uno JUQ:l1. g~6ng Moll i"hii' S hoa, dai hen va nho, han; pfli{ quan gli(' tra! rnoi d!u hoi cong [Om. len t:r~n va. r.a ngna i. om l[y C'lJ.ng di)ng 1n{lch chtl Q phia tren. b!ap d6 l;,lz eong 10m xu6ng: dl:t"{jj va vic trong t.udng ling v'di chieu cong lDi {]ua lim (xem them hi nb 75),

LO:p aongoai

ph.a quan Cao lfen cU<l11fl1i [Juan.

IHinh 69. CInA thia ,dol eli,a Ikhi qluan (Khlf quan va eac phf qu en hai ben dt:fc;1C mb 1heo chi(~u dQc)

Phi q ua,n soc c6 m ~t d:O:liln n g:lJ~ i P h6'i va m{lot tloQ!.n tr~ng ph6i (xem th'em htnh 32).

Cljong pita";, (radtx: p~dmrm.J.J.~) la ~p hQp toan b~ nhfingthanh phfin gin! pb~u ti}p rrung l~i d.~ Il.i \f,aO 'i19J Ifi ra It hM ]j h6.i I Q ron

,~'. M:;" .,. It ~ 'L ..!' ~ h~'

priul. '. Ol cuong p. or nao gam IDQt.·p l!.

q u,a. n gO(;> on un g If~ng m.pch v,it tEn-it mpc1l. pM'i. cAe d~~ nUJcft. tink ffi{lck ph.t 'quOit, cae day th'n kinh vA mach bach hu~t (xem ~h~~n hinh 71).

l.i~n quan cua phi"ljudn. giie vldii nhun.g tbiinh phtlll k.Mc dUl cu6ng pMi khne nhau 21 ben ph~d so vm d ben tra.i (xem HU!.m runh llS va 114).

102

Moi P'lt.qudn g6c lien. quan o~hia trubc 'Voi d~ng m.t;'icll p1&di tudng ~nc. nhu~g khi tCli gAn ron ph6i thi r.lVng rn~ch phdi phcii hoan toan njim d l'Ma trU(jc ella pili.' quail. g6c pluil" trnng khi .rl(;118 m{lch ph.d.€: trai lai n~m 0 ph:fa tru:8c·trEm pM' quan goc trdi. N.&m (l phfa trude va phia d.uro CU,81 eac phil qu(in gde lit hai tlnh m()ch phrii.. m9t Hnh mach nl!,I.1~. Q ben tdn. (~~nh !7tfiCn pl'lili fren} va hoi 1i?eb ra truoc 50 vdi tlnh maeh n~m i'I be n dddi (Unl~ mr,.eh pMt dwJi). en hai tlnh maoh ph~i d~u nam if uuoi dQDg mach ph6i tucng ii:ng: v~ phfa sau, de pM'lJ~TI' goc U~n q u an Vt"j L CRC d9l1g rrup:h phd q ud n. C\'ling v~y. Lrnrig C'u{inc ph6i, phi qUaIl g5c ('lon Ii.en quan voi de h.~ch b~t:h hUYE!t va vdi nhirng dtim ,.6i. th&n. kifln a!~tc v.jt m.tde va 8a~·.

]{a, btl", phf qua n gdc 1 i'en quan vt'li nhOng 00 quan v,a thanh phlin ll,goai curing phi}i b vimg tiffp gi:i! p VQ1 CHong p hSi nh U' sa u:

o ben trai.. quaz armg mflC~h chu b§,t dH~O ,(~ phla tren ,eua phe q.uarl goe trtii, y~ dgug Itu;u:'h chu ngrft.· th] eli xuong a ngay phii'tl sou cdaphi! quan na}', cung v61 day lhlia ki'flh pht.vf tr6i nim d 'bell ngos.i. .Phra t ren phil" q,ua.rl. g8c troi !;!',on co. day th6.n k.tl~l~ qu.(it ngU'?C trdi, dfty thAn kinh c.ay Emu khi tach ra .khol day thb. kinh pluf vi hi!] tITl lu.c)n qua dli{ji qU(Ii di;Jng n~Q.ch chu. d' l;!i q1U~ t di. 1 eon. tren tdi phis. eo', Phf a sa u eua pM' quan ,g& t rel i een c6 lh~ quan aOQ,TI ng~c.~ di tli! trllnc5 ~uong va !lam l~(I!,h qlH~ sang Mn 'U·ii so vOl bti t.l'ai eua kM qudn.

6 b~n phRi. tht quai ,afl}! fTtf;Lch adn bat cn~o phI q.uan. g{le p.hdi a phiiVl S8U va phia hen;. va day thrln k~nh phI ~4 phdi cung di xuong qua m~n sau cua phii' ql1~in goo pbii. (i phi'a t..ro.ng Q1IUI.i tinh m.f;i.ch don, Vg phi:'a tl"11& pM· qulin phdi liien quan vdi tinh. ,mf!.£h uk ,d ken v h day th~ n ~i rnh hodnh phdi. d.ay nay d] t1:i' c6 )(uong ng~C' 0 m*,t ~ngQ~d cu.a, ti nh m ~ch eh ii trSl1,

CAe m~c;h mnu va day t.h;in kin.h CUR pb~ quan

m,(l phe q LJ li~ dtt~c nu5i clttong' oG-i cae dpng Ul{l:ch J)ht q r«in. n. nhanh c i..a a(jng ffl(;,Wh chu ng(lc. Cae ~'ink m~ch phi qtui!1.