Õ“°“√§—¥®¡Ÿ° (Nasal Obstruction)

π“π“ “√– § ≈‘ π‘ °

Õ“°“√§¥®¡— °Ÿ (Nasal Obstruction) Õ“°“√§—¥®¡Ÿ°‡ªìπÕ“°“√∑’Ëæ∫‰¥â∫àÕ¬„π‡«™ªØ‘∫—µ‘ ´÷ËßÕ“®‡ªìπÕ“°“√∑’Ëæ∫‰¥âµ“¡ª°µ‘ (´÷Ëßæ∫‡ªìπ à«ππâÕ¬ ‰¥â·°à Õ“°“√§—¥®¡Ÿ°∑’Ë‡°‘¥®“°°“√∑’Ë®¡Ÿ°∑”ß“π ≈—∫¢â“ß°—πµ“¡∏√√¡™“µ‘ ∑’Ë‡√’¬°«à“ nasal À√◊Õ turbinate cycle À√◊ÕÕ“°“√§—¥®¡Ÿ°∑’Ë‡°‘¥®“°°“√‡ª≈’Ë¬π∑à“∑“ß ‡™àπ πÕπµ–·§ß·≈â«§—¥®¡Ÿ°¢â“ß∑’ËπÕπ∑—∫Õ¬Ÿà ‡¡◊ËÕµ–·§ß‰ªÕ’°¥â“πÀπ÷Ëß ¥â“π∑’Ë‡§¬§—¥®–°≈—∫‚≈àß¢÷Èπ ´÷Ëß‡°‘¥®“°·√ß¥÷ß¥Ÿ¥¢Õß‚≈°) À√◊Õ‡°‘¥®“°‚√§¢Õß®¡Ÿ°À≈“¬Ê ™π‘¥ (´÷Ëßæ∫‡ªìπ à«π¡“°) ·≈– ‡ªìπÕ“°“√∑’Ëæ∫∫àÕ¬Õ’°Õ“°“√Àπ÷Ëß∑’Ëπ”ºŸâªÉ«¬¡“À“·æ∑¬å ‡π◊ËÕß®“°¡—°∑”„ÀâºŸâªÉ«¬√”§“≠ ·≈– ∑π∑ÿ°¢å∑√¡“π ·≈–¡’§ÿ≥¿“æ™’«‘µ·¬à≈ß „πª√–‡∑» À√—∞Õ‡¡√‘°“‰¥â‡§¬¡’ºŸâª√–‡¡‘π«à“¡’§à“„™â ®à“¬„π°“√√—°…“Õ“°“√§—¥®¡Ÿ° Ÿß∂÷ß 5 æ—π≈â“π‡À√’¬≠ À√—∞µàÕªï ·≈–¡’§à“„™â®à“¬ Ÿß∂÷ß 60 ≈â“π ‡À√’¬≠ À√—∞µàÕªï „π°“√∑”°“√ºà“µ—¥√—°…“Õ“°“√§—¥®¡Ÿ°1.

§”®”°¥§«“¡— Õ“°“√§¥®¡— °‡ªŸ πÕ“°“√∑ì º’Ë ªŸâ «¬√É Ÿâ °À√÷ Õ‡¢◊ “„®«â “≈¡À√à ÕÕ“°“»∑◊ º’Ë “π‡¢à “À√â ÕÕÕ°®“°®¡◊ °Ÿ πâÕ¬°«à“ª°µ‘ ‚¥¬∑’Ë¡’≈¡À√◊ÕÕ“°“»∑’Ëºà“π‡¢â“À√◊ÕÕÕ°®“°®¡Ÿ°πâÕ¬®√‘ß (objective restriction of nasal cavity airflow) ‡π◊ËÕß®“°¡’§«“¡º‘¥ª°µ‘¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ° À√◊Õ¡’ª√‘¡“≥πÈ”¡Ÿ°‡æ‘Ë¡¡“° ¢÷Èπ2 °“√∑’Ë‡¬◊ËÕ∫ÿ®¡Ÿ° “¡“√∂√—∫√ŸâÕ“°“»∑’Ëºà“π‡¢â“À√◊ÕÕÕ°®“°®¡Ÿ° ‡™◊ËÕ«à“ºà“π∑“ßµ—«√—∫√Ÿâ —¡º— ·≈–Õÿ≥À¿Ÿ¡‘ (tactile and thermoreceptors) ∑’ËÕ¬Ÿà„π nasal vestibule ·≈–‡¬◊ËÕ∫ÿ®¡Ÿ° ´÷Ëß §«“¡‰«¢Õßµ—«√—∫√Ÿâ¥—ß°≈à“«®–πâÕ¬≈ß‡√◊ËÕ¬Ê ®“°¥â“πÀπâ“‰ª¥â“πÀ≈—ß ‡ âπª√– “∑∑’Ë√—∫√ŸâÕ“°“»

ª“√¬– Õ“»π–‡ π æ.∫., √Õß»“ µ√“®“√¬ å “¢“‚√§®¡°·≈–‚√§¿Ÿ ¡Ÿ ·æ‘ â ¿“§«™“‚ µ‘ π“ °‘ ≈“√ß´‘ «å ∑¬“‘ §≥–·æ∑¬»“ µ√»å √‘ √“™æ¬“∫“≈‘ ¡À“«∑¬“≈‘ ¬¡À— ¥≈‘

§≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 235 ∑’Ëºà“π‡¢â“À√◊ÕÕÕ°®“°®¡Ÿ° §◊Õ ª√– “∑ ¡Õß§Ÿà∑’Ë 5 Õ“°“»„ÀâÕÿàπ·≈–™◊Èπ¢÷ÈππâÕ¬°«à“§πª°µ‘, ºŸâªÉ«¬‚√§ (ophthalmic and maxillary branch of trigeminal ®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ™π‘¥ƒ¥Ÿ°“≈∑’ËÕ¬ŸàπÕ°ƒ¥Ÿ°“≈À√◊Õ nerve). ‰¡à¡’Õ“°“√ (asymptomatic seasonal allergic rhinitis), ºªŸâ «¬‚√§®¡É °ÕŸ °‡ ∫¿— Ÿ¡‘·æâ™π‘¥‡ªìπµ≈Õ¥ªï º≈°√–∑∫∑“ß§≈‘π‘°¢ÕßÕ“°“√§—¥®¡Ÿ° (perennial allergic rhinitis)8 · ¥ß«à“‡¡◊ËÕ®¡Ÿ°¡’ ‡π◊ËÕß®“°®¡Ÿ°‡ªìπÕ«—¬«–∑’ËÕ¬Ÿà à«πµâπ¢Õß §«“¡ “¡“√∂„π°“√ª√—∫Õ“°“»„ÀâÕÿàπ·≈–™◊ÈπµË” ®–¡’ √–∫∫∑“ß‡¥‘πÀ“¬„® Õ“°“√§—¥®¡Ÿ°®÷ß¡’º≈µàÕ∑“ß ‚Õ°“ ‡°‘¥°“√Õ—°‡ ∫‡√◊ÈÕ√—ß¢Õß∑“ß‡¥‘πÀ“¬„® à«π ‡¥‘πÀ“¬„® à«π≈à“ß‚¥¬‡©æ“–À≈Õ¥≈¡·≈–ªÕ¥ ≈à“ß‰¥â¡“°¢÷Èπ πÕ°®“°π—Èπ°“√»÷°…“π’È‰¥âæ∫§«“¡ πÕ°®“°π—ÈπÕ“°“√§—¥®¡Ÿ° Õ“®∑”„Àâ‡°‘¥Õ“°“√πÕπ —¡æ—π∏å√–À«à“ß§«“¡ “¡“√∂¢Õß®¡Ÿ°„π°“√ª√—∫ °√π·≈–/À√Õ¿“«–À¬◊ ¥À“¬„®¢≥–À≈ÿ ∫‰¥— 3â ‡¡Õº◊Ë ªŸâ «¬É Õ“°“»„ÀÕâ π·≈–™ÿà π¢◊È π°÷È ∫§«“¡√— π·√ß¢Õß‚√§Àÿ ¥¥◊ «¬â §—¥®¡Ÿ°¡“°∑”„ÀâµâÕßÀ“¬„®∑“ßª“° Õ“®∑”„ÀâºŸâ °≈à“«§◊Õ¬‘Ëß§«“¡ “¡“√∂¢Õß®¡Ÿ°„π°“√ª√—∫Õ“°“» ªÉ«¬¡’Õ“°“√‡®Á∫§Õ‡√◊ÈÕ√—ß, §Õ·Àâß À√◊Õ√–§“¬§Õ‰¥â „ÀâÕÿàπ·≈–™◊ÈππâÕ¬≈ß‡æ’¬ß„¥ ®–æ∫«à“¡’§«“¡√ÿπ·√ß ßà“¬. ¢Õß‚√§À◊¥¡“°¢÷Èπ‡∑à“π—Èπ8 · ¥ß∂÷ß§«“¡ ”§—≠¢Õß º≈°√–∑∫¢ÕßÕ“°“√§—¥®¡Ÿ°µàÕ√–∫∫µà“ßÊ ¡’ ®¡Ÿ°µàÕ√–∫∫∑“ß‡¥‘πÀ“¬„® à«π≈à“ß. ¥ßπ— ’È ºŸâªÉ«¬∑’Ë¡’‚√§ªÕ¥ Õ“°“√§—¥®¡Ÿ° Õ“®∑”„Àâ¡’ °“√‡æ‘Ë¡¢÷Èπ¢Õß pulmonary resistance, ¡’°“√≈¥≈ß 1. √–∫∫∑“ß‡¥‘πÀ“¬„® ¢Õß compliance ¢ÕßªÕ¥, √–¥—∫ÕÕ°´‘‡®π„π‡≈◊Õ¥

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238 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 °—Èπ™àÕß®¡Ÿ°§¥, §«“¡º‘¥ª°µ‘∫√‘‡«≥≈‘Èπ®¡Ÿ° (nasal 2. °“√ª√–‡¡‘π‚¥¬„™â‡§√◊ËÕß¡◊Õ„π°“√ valve), √Ÿ∫√‘‡«≥À≈—ß‚æ√ß®¡Ÿ°µ—π (choanal atresia). µ√«®«—¥ (objective measures) ¡—°„™â∑—Èß„πß“π 3. ‡ªìπ§«“¡√Ÿâ ÷°¢ÕßºŸâªÉ«¬∑’Ë¡’Õ“°“»ºà“π‡¢â“ §≈‘π‘°·≈–ß“π«‘®—¬ ‡™àπ peak nasal inspiratory À√◊ÕÕÕ°®“°®¡Ÿ°πâÕ¬≈ß ∑—ÈßÊ ∑’Ë‰¡à¡’Õ“°“»∑’Ëºà“π flow (PNIF), rhinomanometry (RMM), acoustic ‡¢â“À√◊ÕÕÕ°®“°®¡Ÿ°πâÕ¬≈ß®√‘ß ‡™àπ ‚√§®¡Ÿ°Õ—°‡ ∫ rhinometry (ARM) ´÷Ëß‡À¡◊Õπ°—∫°“√ª√–‡¡‘π ‡À’Ë¬«ΩÉÕ, ºπ—ß°—Èπ™àÕß®¡Ÿ°∑–≈ÿ, ºŸâªÉ«¬À≈—ßºà“µ—¥®¡Ÿ° ‚¥¬„™â§«“¡√Ÿâ ÷°¢ÕßºŸâªÉ«¬§◊Õ ¡’ª√–‚¬™πå„π°“√ ·≈–/À√◊Õ‰´π— . ª√–‡¡‘π«à“ºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°À√◊Õ‰¡à ∂â“¡’ ‡ªìπ ¡“°πâÕ¬‡æ’¬ß„¥ ·≈– “¡“√∂„™âµ‘¥µ“¡º≈°“√√—°…“ °“√ª√–‡¡πº‘ ªŸâ «¬∑É ¡’Ë Õ“°“√§’ ¥®¡— °∑“ß§≈Ÿ π‘ °‘ Õ“°“√§—¥®¡Ÿ°‰¥â. °“√ª√–‡¡‘πÕ“°“√§—¥®¡Ÿ° ª√–°Õ∫¥â«¬°“√ °“√ª√–‡¡‘πÕ“°“√§—¥®¡Ÿ°ª√–°Õ∫¥â«¬°“√ ª√–‡¡π‚¥¬„™‘ §«“¡√â Ÿâ °¢Õßº÷ ªŸâ «¬É (subjective mea- ´—°ª√–«—µ‘ °“√µ√«®√à“ß°“¬ ·≈–°“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡ sures) ·≈–„™â‡§√◊ËÕß¡◊Õ„π°“√µ√«®«—¥ (objective (¿“æ∑’Ë 1). measures) ´÷Ëß°“√ª√–‡¡‘π‚¥¬„™â§«“¡√Ÿâ ÷°¢Õß ºŸâªÉ«¬π—Èπ ·µ°µà“ß°—π‰¥â¡“° ‡π◊ËÕß®“°Õ“°“√§—¥®¡Ÿ° 1) °“√´—°ª√–«—µ ‘ ª√–°Õ∫¥â«¬ ¢÷ÈπÕ¬Ÿà°—∫À≈“¬ªí®®—¬ ‡™àπ µ—«√—∫√Ÿâ§«“¡¥—π (pressure -§—¥®¡Ÿ°‡ªìπ¢â“ß„¥ ¢â“ß‡¥’¬« À√◊Õ 2 ¢â“ß receptors), Õÿ≥À¿Ÿ¡‘ (thermal receptors) ·≈– ‡ªìπ‡∑à“Ê °—π À√◊Õ‡ªìπ¢â“ß„¥¢â“ßÀπ÷Ëß¡“°°«à“ §«“¡‡®Á∫ª«¥„π®¡Ÿ° (pain receptors) À√◊Õ “√§—¥ ≈—°…≥–¢ÕßÕ“°“√§—¥®¡Ÿ° ‡ªìπÊ À“¬Ê À√◊Õ‡ªìπ À≈—Ëß„π®¡Ÿ°13 ¥—ßπ—Èπ°“√ª√–‡¡‘πÕ“°“√§—¥®¡Ÿ°‚¥¬ µ≈Õ¥‡«≈“ ‡ªìπ‡∑à“‡¥‘¡ À√◊Õ‡ªìπ¡“°¢÷Èπ‡√◊ËÕ¬Ê. „™â§«“¡√Ÿâ ÷°¢ÕßºŸâªÉ«¬ ®÷ß‰¡à§àÕ¬¡’§«“¡ —¡æ—π∏å°—∫ ■ Õ“°“√§—¥®¡Ÿ°∑’Ë‡ªìπµ≈Õ¥‡«≈“ ·µà °“√ª√–‡¡‘π‚¥¬„™â‡§√◊ËÕß¡◊Õ„π°“√µ√«®«—¥. ‡ªìπ¡“°‡æ’¬ß¢â“ß‡¥’¬« ·≈–‰¡à‡ªìπ‡æ‘Ë¡¢÷Èπ ¡—°‡°‘¥ 1. °“√ª√–‡¡π‚¥¬„™‘ §«“¡√â Ÿâ °¢Õßº÷ ªŸâ «¬É ®“°‚§√ß √â“ß∑’Ëº‘¥ª°µ‘ ‡™àπ ºπ—ß°—Èπ™àÕß®¡Ÿ°§¥ (subjective measures) ‰¥â·°à °“√„™â visual analog À√◊Õ‡°‘¥®“°‡π◊ÈÕßÕ°„π™àÕß®¡Ÿ°∑’Ë¡’¢π“¥§ß∑’Ë (‰¡à‚µ scale (VAS) ‡™àπ µ’‡ âπ 0-10 ‚¥¬ 0 = ‰¡à¡’Õ“°“√ ‡æ‘Ë¡¢÷Èπ), choanal atresia À√◊Õ¡’ ‘Ëß·ª≈°ª≈Õ¡„π §—¥®¡Ÿ°, 10 = §—¥®¡Ÿ°¡“° ·≈â«„ÀâºŸâªÉ«¬¢’¥≈ß∫π ®¡Ÿ°‡¥Á° Õ¬à“ß‰√°Áµ“¡ ºŸâªÉ«¬∑’Ë¡’æ¬“∏‘ ¿“æ¥—ß°≈à“«

‡ âπ‡æ◊ËÕ∫Õ°§«“¡√ÿπ·√ß¢ÕßÕ“°“√§—¥®¡Ÿ°. Õ“®¡’Õ“°“√§—¥®¡Ÿ°∑’Ë‡ªìπÊ À“¬Ê ‰¥â®“° nasal ○○○○○○○○○○ ○○○○○○○ cycle. 0 10 ■ Õ“°“√§—¥®¡Ÿ°∑’Ë‡ªìπ¡“°¢÷Èπ‡√◊ËÕ¬Ê (‰¡à§—¥®¡Ÿ°) (§—¥®¡Ÿ°¡“°) ·≈–‡ªìπ¢â“ß‡¥’¬« ¡—°‡°‘¥®“°‡π◊ÈÕßÕ°„π™àÕß®¡Ÿ° ∑’Ë¡’¢π“¥‚µ¢÷Èπ‡√◊ËÕ¬Ê ‚¥¬‡©æ“–‡π◊ÈÕßÕ°√â“¬À√◊Õ À√◊Õ°“√„™â§–·ππ (symptom score) ‡™àπ √‘¥ ’¥«ß®¡Ÿ°™π‘¥ antrochoanal polyp. 0 = ‰¡à§—¥®¡Ÿ°, 1 = §—¥®¡Ÿ°‡≈Á°πâÕ¬, 2 = §—¥®¡Ÿ° ■ Õ“°“√§—¥®¡Ÿ°∑’Ë‡ªìπÊ À“¬Ê ·≈–‡ªìπ ª“π°≈“ß, 3 = §¥®¡— °¡“°Ÿ °“√„™ â VAS ·≈– symp- ∑—Èß 2 ¢â“ß ¡—°‡°‘¥®“°‚√§®¡Ÿ°Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic tom score π’È ¡’ª√–‚¬™πå„π°“√ª√–‡¡‘π«à“ºŸâªÉ«¬¡’ rhinitis) ´÷ËßÕ“®‡°‘¥®“°‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ À√◊Õ Õ“°“√§—¥®¡Ÿ°À√◊Õ‰¡à ∂â“¡’ ‡ªìπ¡“°πâÕ¬‡æ’¬ß„¥ ‚√§®¡Ÿ°Õ—°‡ ∫™π‘¥‰¡à·æâ, alar collapse. ·≈– “¡“√∂„™âµ‘¥µ“¡º≈°“√√—°…“Õ“°“√§—¥®¡Ÿ°‰¥â ■ Õ“°“√§—¥®¡Ÿ°∑’Ë‡ªìπ¡“°¢÷Èπ‡√◊ËÕ¬Ê ¥«¬.â ·≈–‡ªìπ∑—Èß 2 ¢â“ß ¡—°‡°‘¥®“°‡π◊ÈÕßÕ°„π™àÕß®¡Ÿ°

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∑—Èß 2 ¢â“ß∑’Ë¡’¢π“¥‚µ¢÷Èπ‡√◊ËÕ¬Ê ‡™àπ √‘¥ ’¥«ß®¡Ÿ° À«—¥¡—°®–„ ´÷Ëß®–µà“ß®“°‚√§‰´π— Õ—°‡ ∫ À√◊Õ À√◊Õ‡°‘¥®“°‡¬◊ËÕ∫ÿ®¡Ÿ°∫«¡¡“°¢÷Èπ‡√◊ËÕ¬Ê ‡™àπ ®¡Ÿ° ®¡Ÿ°Õ—°‡ ∫®“°°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ ´÷Ëß®–¢âπ¡’ Õ°‡ ∫®“°°“√„™— ¬“À¥À≈Õ¥‡≈â Õ¥‡ª◊ πª√–®”ì (rhini- ’‡À≈◊ÕßÀ√◊Õ‡¢’¬«), ¡’‡≈◊Õ¥°”‡¥“‰À≈ À√◊Õ¡’πÈ”¡Ÿ° tis medicamentosa) À√◊Õ‡¬◊ËÕ∫ÿ®¡Ÿ°∑’Ë¡’°“√Àπ“µ—« ªπ‡≈◊Õ¥À√◊Õ‰¡à (Õ“®π÷°∂÷ß‡π◊ÈÕßÕ°„π™àÕß®¡Ÿ°), ¡’ ¢÷Èπ À≈—ß®“°¡’°“√Õ—°‡ ∫‡√◊ÈÕ√—ß‡ªìπ√–¬–‡«≈“π“π Õ“°“√ª«¥®¡Ÿ°√à«¡¥â«¬À√◊Õ‰¡à, ¡’°“√√—∫°≈‘ËππâÕ¬≈ß (hypertrophic change of nasal mucosa). À√◊Õ‰¡à. - √–¬–‡«≈“∑’Ë¡’Õ“°“√§—¥®¡Ÿ°. -¡’Õ“°“√º‘¥ª°µ‘∑“ßµ“ À≈Õ¥≈¡ (ÀÕ∫ - ‘Ëß„¥∑’Ë∑”„ÀâÕ“°“√§—¥®¡Ÿ°¡“°¢÷ÈπÀ√◊Õ À◊¥) §Õ À√◊ÕÀŸ√à«¡¥â«¬À√◊Õ‰¡à ‡™àπ §—π ‡§◊Õßµ“, πÕ¬≈ßâ ( “√°Õ¿à ¡Ÿ ·æ‘ ,â Ωπ,ÿÉ §«π,— Õ“°“»∑‡ª≈’Ë ¬π·ª≈ß’Ë · ∫µ“, πÈ”µ“‰À≈, µ“¡—«, ‡ÀÁπ¿“æ´âÕπ,‰Õ, ÀÕ∫, ¡—°°√–µÿâπ„ÀâºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫‡√◊ÈÕ√—ß¡’Õ“°“√§—¥ ‡®Á∫§Õ, §Õ·Àâß, √–§“¬§Õ, ¡’πÈ”¡Ÿ°≈ß§Õ, πÕπ°√π ®¡Ÿ°¡“°¢÷Èπ‰¥â). À√◊Õ¡’ÀŸÕ◊ÈÕ, ‡ ’¬ß¥—ß„πÀŸ, ‡«’¬π»’√…– ∫â“πÀ¡ÿπ. -¡§«“¡º’ ¥ª°µ‘ ¢Õß®¡‘ °ÕŸ πÊ◊Ë √«¡¥à «¬À√â Õ◊ - ª√–«—µ‘°“√„™â¬“ ´÷Ëß∑”„Àâ‡°‘¥Õ“°“√ ‰¡à ‡™àπ Õ“°“√§—π, ®“¡, πÈ”¡Ÿ°‰À≈ (Õ“®π÷°∂÷ß‚√§ §¥®¡— °‰¥Ÿ â‡™πà ¬“≈¥§«“¡¥π,— ¬“√°…“Õ“°“√´— ¡‡»√÷ “,â ®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâÀ√◊Õ‚√§À«—¥), ’À√◊Õ≈—°…≥–¢Õß ¬“√—°…“‚√§®‘µ‡¿∑, ¬“À¥À≈Õ¥‡≈◊Õ¥™π‘¥À¬Õ¥ πÈ”¡Ÿ° (πÈ”¡Ÿ°„πºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ À√◊Õ‚√§ À√◊Õæàπ®¡Ÿ° (‡™àπ ephedrine/ phenylephrine,

240 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 oxymetazoline). π’Èπ“πÊ Õ“®∑”„Àâ‡°‘¥√Õ¬¬àπ¢Õßº‘«Àπ—ß µ“¡·π« - ª√–«—µ‘°“√‡®Á∫ªÉ«¬„π§√Õ∫§√—« (‡™àπ ¢«“ß¢Õß —π®¡Ÿ°‰¥â ‡√’¬° allergic nasal lines. ª√–«—µ‘‚√§¿Ÿ¡‘·æâÀ√◊Õ«—≥‚√§). ■ ∂â“∫√‘‡«≥ —π®¡Ÿ° (nasal bridge) -ºªŸâ «¬ É ∫∫Ÿ À√ÿ ’ËÀ√Õ¥◊ ¡ ◊Ë √“√ÿ «¡¥à «¬À√â Õ‰¡◊ .à ·§∫¡“° ·≈–ºŸâªÉ«¬¡’ª√–«—µ‘‰¥â√—∫°“√∑” rhinoplas- -ºªŸâ «¬‰¥É √â ∫Õ— ∫ÿµ— ‡Àµ‘ ÿÀ√Õ°“√º◊ “µà ¥∫√— ‡«≥‘ ty ¡“°àÕπ Õ“®‡°‘¥®“°°“√µ—¥°√–¥Ÿ°ÕÕ° (osteoto- ®¡Ÿ° ·≈–/À√◊Õ‰´π— ¡“°àÕπÀ√◊Õ‰¡à (Õ“®‡°‘¥ adhe- mies) ´ß®–∑”„À÷Ë ‚æ√ß®¡â °·§∫≈ßŸ ¡Õ“°“√§’ ¥®¡— °‰¥Ÿ .â sions, nasal stenosis, septal perforation). ■ ∫√‘‡«≥ª≈“¬®¡Ÿ° ∂â“µ°¡“°‰ª (tip -ºªŸâ «¬µÉ ß§√√¿—È À√å Õ‰¡◊ à(„π°√≥º’ À≠Ÿâ ß‘ Õ“® ptosis) Õ“®∑”„Àâ≈¡À“¬„®∑’Ë‡¢â“‰ª ‡ª≈’Ë¬π∑‘»∑“ß ‡°‘¥ rhinitis of pregnancy). ‰ª∑“ß¥â“π∫π¡“°¢÷Èπ ¡’≈¡À“¬„®ºà“π∫√‘‡«≥µÕπ °≈“ß ·≈–µÕπ≈à“ß¢Õß®¡Ÿ°πâÕ¬≈ß Õ“®∑”„ÀâºŸâªÉ«¬ 2) °“√µ√«®√à“ß°“¬ ‚¥¬‡©æ“–µ√«®®¡Ÿ° √Ÿâ ÷°¡’Õ“°“√§—¥®¡Ÿ°‰¥â „π°√≥’π’È ∂â“¬°ª≈“¬®¡Ÿ°¢÷Èπ ·≈–°“√µ√«®ÀŸÀ√◊Õ§Õ√à«¡¥â«¬ °“√µ√«®®¡Ÿ°§«√ ®–∑”„ÀâÕ“°“√§—¥®¡Ÿ°¢ÕßºŸâªÉ«¬¥’¢÷Èπ. ‡√‘Ë¡®“°®¡Ÿ° à«ππÕ° ‡¢â“‰ªÀ“Õ«—¬«–µà“ßÊ ¿“¬„π ■ §«√„Àºâ ªŸâ «¬À“¬„®‡¢É “â ·≈–ÕÕ°‡∫“Ê ®¡Ÿ° ∑—Èß à«π∑’Ë‡ªìπ°√–¥Ÿ° ·≈–‡π◊ÈÕ‡¬◊ËÕÕàÕπ¿“¬„π. ·≈–·√ßÊ ·≈– —ß‡°µ§«“¡·¢Áß·√ß¢Õß upper ·≈– °“√µ√«®™àÕß®¡Ÿ°∑“ß¥â“πÀπâ“ (anterior rhi- lower lateral cartilage ∂â“¢≥–À“¬„®‡¢â“ ¡’°“√ noscopy) “¡“√∂∑”‰¥â‚¥¬„™â nasal speculum ¬ÿ∫µ—«¢Õß lower lateral cartilage (alar collapse) ·≈–·À≈àß°”‡π‘¥· ß À√◊Õ„™â otoscope ·≈– ear · ¥ß«à“æ¬“∏‘ ¿“æ¥—ß°≈à“«∫√‘‡«≥ nasal valve speculum ∑’Ë¡’¢π“¥„À≠à∑’Ë ÿ¥ ∑’Ë„ à‡¢â“‰ª„π‚æ√ß ∑”„ÀâºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°‰¥â. ®¡Ÿ°‰¥â (‚¥¬‡©æ“–„π‡¥Á°) «‘∏’π’È “¡“√∂µ√«®À“ ■ ºªŸâ «¬∑É ¡’Ë Õ’ ∫ÿµ— ‡Àµ‘ ∑ÿ”„À°√–¥â °®¡Ÿ °ÀŸ °— æ¬“∏‘ ¿“æ∑’Ë∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°∫√‘‡«≥ anteri- Õ“®‰ª°¥∫√‘‡«≥ nasal valve ∑”„Àâ∫√‘‡«≥π’È·§∫ or nare, vestibule, nasal valve, ºπ—ß°—Èπ™àÕß®¡Ÿ°, ‡°‘¥Õ“°“√§—¥®¡Ÿ°‰¥â. ‡¬◊ËÕ∫ÿ®¡Ÿ°, ‡∑Õ√å∫‘‡π∑Õ—π≈à“ß ·≈–Õ—π°≈“ß‰¥â. ■ °“√°√–·∑°∫√‘‡«≥°√–¥Ÿ°ÕàÕπ à«π °“√µ√«®™àÕß®¡Ÿ°∑“ß¥â“πÀ≈—ß (posterior ∫π (upper lateral nasal cartilage) Õ“®∑”„Àâ rhinoscopy) ‚¥¬„™°√–®° ”À√â ∫ — Õß¥à ‚æ√ßÀ≈Ÿ ß®¡— °Ÿ ºπ—ß°—Èπ™àÕß®¡Ÿ°§¥ ∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°‰¥â. (nasopharynx) ·≈–·À≈àß°”‡π‘¥· ß “¡“√∂¥Ÿ °“√µ√«®¢—Èπµâπ∑’Ëßà“¬∑’Ë ÿ¥ ‡æ◊ËÕ¬◊π¬—π«à“ºŸâªÉ«¬ æ¬“∏‘ ¿“æ∑’Ë∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°∫√‘‡«≥‚æ√ß ¡’Õ“°“√§—¥®¡Ÿ°®√‘ßÀ√◊Õ‰¡à ·≈–§—¥®¡Ÿ°¢â“ß„¥¡“° ®¡Ÿ°¥â“πÀ≈—ß (‡™àπ posterior septal deviation), °«à“°—π ·≈–Õ“°“√§—¥®¡Ÿ°‡ªìπ¡“°πâÕ¬‡æ’¬ß„¥ §◊Õ √Ÿ®¡Ÿ°¥â“πÀ≈—ß (choana) (‡™àπ choanal atresia, an- „™â‰¡â°¥≈‘Èπ∑’Ë‡ªìπ‚≈À–¡—π«“« ·≈–„À¡à «“ß√Õ‰«â„µâ trochoanal polyp), nasopharynx (‡™àπ adenoid √Ÿ®¡Ÿ°¢ÕßºŸâªÉ«¬ ‚¥¬„ÀâÀà“ß®“°√Ÿ®¡Ÿ°∑—Èß 2 ¢â“ß ‡ªìπ hypertrophy „π‡¥°Á ·≈– nasopharyngeal lymphoid √–¬–‡∑à“Ê °—π ·≈–„ÀâºŸâªÉ«¬À“¬„® ‡¢â“-ÕÕ° Õ¬à“ß hypertrophy „πºŸâ„À≠à). ∏√√¡¥“ (¿“æ∑’Ë 2) ‚¥¬∑’Ëªî¥ª“° ®– “¡“√∂¡Õß ‡ÀÁπ‰ÕπÈ”∑’ËÕÕ°¡“¢≥–ºŸâªÉ«¬À“¬„®ÕÕ° ‡ªìπ«ß - ®¡Ÿ° à«ππÕ° Õ¬Ÿà∫π‰¡â°¥≈‘Èππ—Èπ ´÷Ëß “¡“√∂‡ª√’¬∫‡∑’¬∫¢π“¥ ■ ºªŸâ «¬‚√§®¡É °ÕŸ °‡ ∫¿— ¡Ÿ ·æ‘ â∑ ¡’Ë Õ“°“√’ √–À«à“ß¢â“ß´â“¬·≈–¢â“ß¢«“Õ¬à“ß§√à“«Ê ‰¥â (rhino- §—¥·≈–§—π®¡Ÿ° Õ“®¢¬’È ·≈–‡ ¬ª≈“¬®¡Ÿ°∫àÕ¬Ê hygrometry) ¢â“ß∑’Ë¡’«ß‰ÕπÈ”‡≈Á°°«à“ ®–‡ªìπ¢â“ß∑’Ë ≈—°…≥–‡™àππ’È‡√’¬°«à“ çallergic saluteé °“√∑”‡™àπ §—¥®¡Ÿ°¡“°°«à“ ∂â“‰¡à‡ÀÁπ«ß‰ÕπÈ”‡≈¬ · ¥ß«à“®¡Ÿ°

§≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 241 ¿“æ∑’Ë 2. °“√∑¥ Õ∫Õ“°“√§—¥®¡Ÿ°‚¥¬„™â‰¡â°¥≈‘Èπ (rhinohygrometry).

¢“ßπâ πÕ—È ¥µÿπ‚¥¬ ¡∫— √≥Ÿ å (complete nasal obstruc- valve π’È‰¥â™—¥‡®π.14 tion) ºŸâªÉ«¬∑’Ë¡’Õ“°“√§—¥®¡Ÿ°‡æ’¬ß¢â“ß‡¥’¬« ®–‡ÀÁπ °“√∑” Cottle maneuver ‡ªìπ°“√∑¥ Õ∫ §«“¡·µ°µà“ß√–À«à“ß«ß¢Õß‰ÕπÈ”∑’ËÕÕ°¡“®“°√Ÿ®¡Ÿ° §«“¡º‘¥ª°µ‘∫√‘‡«≥ nasal valve π’È ‚¥¬°“√¥÷ß·°â¡ 2 ¢â“ß‰¥â™—¥‡®π ∂â“‰¡àµà“ß°—π¡“° Õ“®√Õ¥Ÿ«à“ «ß ‰ª∑“ß¥â“π¢â“ß (¿“æ∑’Ë 3 °) ´÷Ëß®–¥÷ß upper lateral ‰ÕπÈ”¢â“ß‰Àπ®–À“¬‰ª°àÕπ · ¥ß«à“¢â“ßπ—Èπ ¡’ cartilage ÕÕ°®“°ºπ—ß°—Èπ™àÕß®¡Ÿ° ∑”„Àâ∫√‘‡«≥ Õ“°“√§—¥®¡Ÿ°¡“°°«à“ «‘∏’π’È¡’ª√–‚¬™πå¡“° ‚¥¬ nasal valve °«â“ß¡“°¢÷Èπ (¿“æ∑’Ë 3 ¢ ·≈– §) Õ’° ‡©æ“–„π°“√ª√–‡¡πÕ“°“√§‘ ¥®¡— °Ÿ „πºªŸâ «¬‡¥É °‡≈Á °Ê,Á «‘∏’∑’Ë∑”‰¥âßà“¬ §◊Õ„™â‰¡âæ—π ”≈’‡¢’Ë¬ upper lateral ºŸâªÉ«¬∑’Ë¡’§«“¡æ‘°“√∑“ß ¡Õß À√◊ÕºŸâªÉ«¬∑’ËÀ¡¥ µ‘ cartilage ÕÕ°‰ª∑“ß¥â“π¢â“ß®“°¿“¬„π™àÕß®¡Ÿ° ´÷Ëß‰¡à “¡“√∂∫Õ°‰¥â«à“¡’Õ“°“√§—¥®¡Ÿ°À√◊Õ‰¡à. (¿“æ∑’Ë 4) ·≈–∂“¡ºŸâªÉ«¬«à“ À≈—ß¥÷ß·°â¡ À√◊Õ‡¢’Ë¬ - ‚Àπ°·°â¡ (maxilla area) ∂â“‡§“– upper lateral cartilage ·≈â« Õ“°“√§—¥®¡Ÿ°¥’¢÷ÈπÀ√◊Õ À√◊Õ°¥‡®Á∫ Õ“®π÷°∂÷ß‰´π— Õ—°‡ ∫ ∂â“¡’Õ“°“√™“ ‰¡à ∂â“¥’¢÷Èπ · ¥ß«à“æ¬“∏‘ ¿“æ∫√‘‡«≥ nasal valve Õ“®π÷°∂÷ß‡π◊ÈÕßÕ°„π™àÕß®¡Ÿ° ·≈–/À√◊Õ maxillary π’È ∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ° Õ¬à“ß‰√°Áµ“¡ ∂â“ºŸâªÉ«¬¡’ sinus. æ—ßº◊¥ (synechiae) ∫√‘‡«≥ nasal valve Õ“®„Àâº≈ - ≈‘Èπ®¡Ÿ° (nasal valve) ‡ªìπ∫√‘‡«≥ false negative ‰¥â. ∑’Ë·§∫∑’Ë ÿ¥¢Õß®¡Ÿ° æ¬“∏‘ ¿“æ∫√‘‡«≥π’È ®÷ß∑”„Àâ °“√„™â external nasal dilators ‡™àπ ‡∑ª ºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°¡“° ‡™àπ ºπ—ß°—Èπ™àÕß®¡Ÿ°∑’Ë ∑’Ëªî¥∫√‘‡«≥¥â“ππÕ°¢Õß®¡Ÿ°∫√‘‡«≥ nasal valve §¥∫√‘‡«≥π’È¡“° À√◊ÕºŸâªÉ«¬∑’Ë‰¥â√—∫°“√ºà“µ—¥ rhino- ®–™à«¬∑”„Àâ∫√‘‡«≥¢Õß nasal valve °«â“ß¢÷Èπ‰¥â plasty Õ“®∑”„Àâ∫√‘‡«≥π’ÈÕàÕπ·Õ‰¥âßà“¬ °“√µ√«® ‚¥¬∑”„Àâ upper lateral nasal cartilage ‡§≈◊ËÕπ‰ª ∫√‘‡«≥π’È®÷ßµâÕß√–¡—¥√–«—ß ‰¡à‰ª∑”„Àâ∫√‘‡«≥π’Èº‘¥ ∑“ß¥â“π¢â“ß (lateral) ¡“°¢÷Èπ. √Ÿª√à“ß‰ª ¢≥–„ à‡§√◊ËÕß¡◊Õ ‡™àπ nasal speculum πÕ°®“°π—Èπ ºŸâªÉ«¬∑’Ë¡’§«“¡µ÷ßµ—«¢Õß À√◊Õ otoscope ‡¢â“‰ªµ√«® à«π„À≠à°“√¬°ª≈“¬ °≈“¡‡πâ Õ∫√◊È ‡«≥„∫Àπ‘ “≈¥≈ßâ ®“°°“√∑¡’Ë Õ“¬’ ¡“°¢ÿ π÷È ®¡°¢Ÿ π∑“ß¥÷È “π∫πâ ®– “¡“√∂∑”„À‡Àâ π∫√Á ‡«≥‘ nasal À√◊Õ°≈â“¡‡π◊ÈÕ„∫Àπâ“‡ªìπÕ—¡æ“µ Õ“®∑”„Àâ°≈â“¡‡π◊ÈÕ

242 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 dilator naris (´÷Ëß§Õ¬ªÑÕß°—π nasal valve collapse zoline) ´÷Ëß™à«¬≈¥°“√∫«¡¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ° (¿“æ∑’Ë 6) ¢≥–À“¬„®‡¢â“) ‰¡à∑”ß“π ∑”„Àâ¡’ nasal valve ∂â“Õ“°“√§—¥®¡Ÿ°¥’¢÷Èπ À≈—ßæàπ¬“À¥À≈Õ¥‡≈◊Õ¥ collapse √–À«à“ßÀ“¬„®‡¢â“‰¥â ¥—ßπ—Èπ§«√µ√«®°“√ ¥—ß°≈à“« · ¥ß«à“Õ“°“√§—¥®¡Ÿ°π—Èππà“®–‡°‘¥®“° ∑”ß“π¢Õß°≈â“¡‡π◊ÈÕ∫√‘‡«≥„∫Àπâ“¥â«¬«à“¡’ª√– “∑ °“√Õ—°‡ ∫¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ°15 ∂â“Õ“°“√§—¥®¡Ÿ°‰¡à¥’¢÷Èπ ¡Õß§Ÿà∑’Ë 7 ‡ªìπÕ—¡æ“µÀ√◊Õ‰¡à. À≈—ßæàπ¬“À¥À≈Õ¥‡≈◊Õ¥¥—ß°≈à“« · ¥ß«à“Õ“°“√§—¥ - ºπ—ß°—Èπ™àÕß®¡Ÿ° µ√«®¥Ÿ«à“¡’°“√ ®¡Ÿ°π—Èππà“®–‡°‘¥®“°§«“¡º‘¥ª°µ‘¢Õß‚§√ß √â“ß¢Õß §¥ßÕ À√◊Õ∫‘¥À√◊Õ‰¡à (¿“æ∑’Ë 5) ´÷Ëß¡—°®–∑”„Àâ ®¡Ÿ° ‡™àπ ∫√‘‡«≥ nasal valve ·§∫16, ºπ—ß°—Èπ™àÕß ºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°¢â“ß∑’Ë™àÕß®¡Ÿ°·§∫®“°ºπ—ß°—Èπ ®¡Ÿ°§¥ À√◊Õ°√–¥Ÿ°‡∑Õ√å∫‘‡π∑Õ—π≈à“ß‚µ·≈–¬◊Ëπ‡¢â“ ™àÕß®¡Ÿ°§¥ ·µàºŸâªÉ«¬∫“ß√“¬Õ“®¡’Õ“°“√§—¥®¡Ÿ° ¡“„π‚æ√ß®¡Ÿ°, ¡’‡π◊ÈÕßÕ°„π‚æ√ß®¡Ÿ° πÕ°®“°π—Èπ ¢â“ß∑’Ë™àÕß®¡Ÿ°°«â“ß°«à“‰¥â ®“°‡∑Õ√å∫‘‡π∑Õ—π≈à“ß ‡¡◊ËÕ‡¬◊ËÕ∫ÿ®¡Ÿ°¬ÿ∫∫«¡·≈â« §«√µ√«®„Àâ‡ÀÁπæ¬“∏‘- ¢Õß¢“ß∑â °«’Ë “ß°«â “¡à °“√Àπ“µ’ «¢— π¡“÷È (compensatory ¿“æ¿“¬„π™àÕß®¡Ÿ° (∂â“¡’) ‡™àπ √‘¥ ’¥«ß®¡Ÿ°, turbinate hypertrophy). ºπ—ß°—Èπ™àÕß®¡Ÿ° à«πÀ≈—ß§¥ (posterior septal de- - ‡¬Õ∫◊Ë ®¡ÿ°Ÿ §«√®–µ√«®°Õπà ·≈–À≈ß— viation), ‡π◊ÈÕßÕ°„π‚æ√ß®¡Ÿ° (¿“æ∑’Ë 7) Õ¬à“ß‰√ æπ¬“À¥À≈Õ¥‡≈à Õ¥◊ (‡™πà ephedrine À√Õ◊ oxymeta- °Áµ“¡ ‚√§¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ°∫“ß‚√§ À≈—ßæàπ¬“À¥ °

¿“æ∑ ’Ë 3. °“√∑” Cottle maneuver (°) ·≈– ¿“æ„π‚æ√ß®¡Ÿ°¢â“ß¢«“∫√‘‡«≥ nasal valve °àÕπ (¢) ·≈–À≈—ß∑” Cottle maneuver (§) (IT = inferior turbinate).

§≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 243 À≈Õ¥‡≈◊Õ¥·≈â« Õ“°“√Õ“®‰¡à¥’¢÷Èπ‰¥â ‡™àπ rhinitis ‡¬Õ∫◊Ë µ“∫«¡Õÿ °‡ ∫À√— Õ‰¡◊ à‡æ√“–æ¬“∏ ¿“æ¢Õß®¡‘ °Ÿ medicamentosa, diffuse nasal polyposis. Õ“®·æ√à°√–®“¬¡“∑“ßµ“‰¥â ∂â“æ∫√Õ¬§≈È”„µâ¢Õ∫ ≈—°…≥–¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ°∑’Ë∫«¡ Õ“®™à«¬∫Õ° µ“≈à“ß (allergic shiners) ´÷Ëß‡°‘¥®“°°“√§—Ëß¢Õß ∂÷ß “‡Àµÿ¢ÕßÕ“°“√§—¥®¡Ÿ°‰¥â ‡™àπ ‡≈◊Õ¥¥” ®“°°“√§—¥®¡Ÿ°‡√◊ÈÕ√—ß ™à«¬∫àß∫Õ°«à“ºŸâªÉ«¬ -∂â“°“√∫«¡π—Èπ‡°‘¥®“°°“√¢¬“¬µ—«¢Õß Õ“®‡ªìπ‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ. À≈Õ¥‡≈◊Õ¥ ‡¬◊ËÕ∫ÿ®¡Ÿ°∑’Ë∫«¡ ¡—°¡’ ’·¥ß§≈È” À√◊Õ -ºŸâªÉ«¬∑’Ë¡’Õ“°“√§—¥®¡Ÿ°µ—Èß·µàÕ“¬ÿ ÕÕ° ’πÈ”‡ß‘π®“°°“√∑’Ë‡≈◊Õ¥¡“§—Ëß. ¬ßπ— Õ¬â ·≈–‡ªπÕ¬ì π“πŸà ∑”„Àµâ ÕßÀ“¬„®∑“ßª“°‡ ¡Õâ -∂â“°“√∫«¡π—Èπ ‡°‘¥®“°°“√∑’Ë¡’¢Õß‡À≈« Õ“®∑”„Àâ°“√‡®√‘≠‡µ‘∫‚µ¢Õß°√–¥Ÿ°„∫Àπâ“·≈–øíπ ‰À≈ÕÕ°¡“ – ¡Õ¬„π‡¬Ÿà Õ∫◊Ë ®¡ÿ°¡“°Ÿ ‡¬Õ∫◊Ë ®¡ÿ°∑Ÿ ∫«¡’Ë º‘¥ª°µ‘ ∑’Ë‡√’¬°«à“ long-face syndrome §◊Õ„∫Àπâ“ ¡—°¡’ ’´’¥ ¡Õß¥Ÿ≈—°…≥–‡À¡◊ÕπÕÿâ¡πÈ”‰«â. à«π≈à“ß®–¬“«°«à“ª°µ‘ ‡π◊ËÕß®“°µâÕßÕâ“ª“°À“¬„® -∂“°“√∫«¡πâ π—È ‡°¥®“°°“√µ‘ ¥‡™‘ ÕÕ◊È °‡ ∫— µ≈Õ¥‡«≈“ ‡æ¥“πª“°®–·§∫·≈–‚§âß Ÿß (Gothic ‡¬◊ËÕ∫ÿ®¡Ÿ°∑’Ë∫«¡¡—°¡’ ’·¥ß®—¥ ·≈–Õ“®‡ÀÁπ®ÿ¥‡≈◊Õ¥ arch) ‡«≈“¬‘È¡®–¡Õß‡ÀÁπ à«π¢Õß‡Àß◊Õ°∑’ËÕ¬Ÿà‡Àπ◊Õ ÕÕ°‡≈Á°Ê °√–®“¬Õ¬Ÿà∑—Ë«‰ª. øíπ∫π‰¥â¡“° ‡√’¬°«à“ gummy smile. πÕ°®“°π—Èπ °“√µÕ∫ πÕß¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ° µàÕ¬“À¥À≈Õ¥‡≈◊Õ¥ Õ“®™à«¬∫Õ° “‡Àµÿ¢ÕßÕ“°“√ 3) °“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡ ‡™àπ §—¥®¡Ÿ°‰¥â∫â“ß ‡™àπ °“√∫«¡¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ°®“°°“√ 3.1) °“√ àÕß°≈âÕßµ√«® ∑—Èß°“√„™â ¢¬“¬µ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥π—Èπ ®–¬ÿ∫µ—«‰¥â‡√Á«°«à“°“√ °≈Õß™πâ ¥·¢‘ ßÁ (rigid nasal endoscope) ·≈– ∫«¡®“°°“√Õ—°‡ ∫µ‘¥‡™◊ÈÕ À≈—ßæàπ¬“À¥À≈Õ¥‡≈◊Õ¥. ™π‘¥ÕàÕπ (flexible nasal endoscope) °“√ - °√–¥Ÿ°‡∑Õ√å∫‘‡π∑ °√–¥Ÿ°‡∑Õ√å- Õß°≈à Õßµ√«®â ¡¢’ Õ¥â §’ Õ “¡“√∂µ√«®À“æ¬“∏◊ ¿“æ‘ ∫‘‡π∑Õ—π°≈“ß∑’Ë¡’ air cell ‡¢â“¡“ (concha bullosa) ∑’Ë∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°‰¥â™—¥‡®π ‚¥¬‡©æ“–„π ∑’Ë¡’¢π“¥„À≠à¡“° Õ“®‡ªìπ “‡Àµÿ∑’Ë∑”„ÀâºŸâªÉ«¬ µ”·Àπß∑à ‰¡’Ë “¡“√∂µ√«®‰¥à ¥â «¬µ“‡ª≈â “à ®“°°“√∑” ¡’Õ“°“√§—¥®¡Ÿ°‰¥â, °√–¥Ÿ°‡∑Õ√å∫‘‡π∑Õ—π≈à“ß ∑’Ë¡’‡¬◊ËÕ anterior ·≈– posterior rhinoscopy ‡™àπ ™àÕß ∫ÿ∑’ËÀπ“µ—« À√◊Õ¡’°√–¥Ÿ°¬◊Ëπ‡¢â“¡“„π‚æ√ß®¡Ÿ°¡“° ®¡Ÿ°µÕπ°≈“ß, middle meatus ·≈–Õ“®™à«¬„π º‘¥ª°µ‘ ‡ªìπ “‡Àµÿ∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°‰¥â ºŸâªÉ«¬ °“√µ—¥™‘Èπ‡π◊ÈÕ„π°√≥’µâÕß°“√º≈∑“ßæ¬“∏‘«‘∑¬“ ∑’Ë‰¥â√—∫°“√µ—¥°√–¥Ÿ°‡∑Õ√å∫‘‡π∑Õ—π≈à“ßÀ√◊ÕÕ—π°≈“ß ¬◊π¬—π À√◊Õπ”‡Õ“‡¬◊ËÕ∫ÿ¢Õß®¡Ÿ° À√◊Õ “√§—¥À≈—Ëß ‡™àπ ÕÕ°¡“°‡°‘π‰ª Õ“®¡’Õ“°“√§—¥®¡Ÿ°‰¥â®“° empty πÈ”¡°À√Ÿ ÕÀπÕß‰ª∑”°“√‡æ“–‡™◊ Õ¥◊È «¬â °“√ Õß°≈à Õßâ nose syndrome (¡’°“√ Ÿ≠‡ ’¬ receptor ∑’Ë√—∫ µ√«®¡’ª√–‚¬™πå„π°“√ª√–‡¡‘π«à“ºŸâªÉ«¬¡’Õ“°“√ §«“¡√Ÿâ ÷°«à“Õ“°“»‰À≈ºà“π‡¢â“-ÕÕ°®“°®¡Ÿ°). §—¥®¡Ÿ°À√◊Õ‰¡à ∂â“¡’ ‡ªìπ¡“°À√◊ÕπâÕ¬‡æ’¬ß„¥ ·≈– “¡“√∂„™âµ‘¥µ“¡º≈¢Õß°“√√—°…“Õ“°“√§—¥®¡Ÿ°‰¥â - °“√µ√«®Õ◊ËπÊ ‡™àπ ¥«¬.â - °“√∑æ∫π’Ë È”¢ßÕ¬— „πÀŸà ™Ÿ π°≈“ßÕ“®—È 3.2) °“√∂à“¬¿“æ√—ß ’‰´π— ™π‘¥ ‡°‘¥®“° chronic nasopharyngeal inflammation, plain radiography ¡—°„™âµ√«®«à“¡’‰´π— Õ—°‡ ∫ adenoid hypertrophy À√◊Õ°âÕπ‡π◊ÈÕ∑’ËÕÿ¥√Ÿ‡ªî¥¢Õß √à«¡¥â«¬À√◊Õ‰¡à πÕ°®“°π—Èπ “¡“√∂‡ÀÁπ≈—°…≥– ∑àÕ¬Ÿ ‡µ‡™’¬π„π nasopharynx. ¢Õßºπ—ß°—Èπ™àÕß®¡Ÿ° ·≈–‡∑Õ√å∫‘‡π∑Õ—π≈à“ß‰¥â π‘¬¡ - πÕ°®“°π—Èπ §«√µ√«®µ“¥â«¬«à“¡’ „™∑â “à Caldwellûs view (‡æÕ¥◊Ë æ¬“∏Ÿ ¿“æ¢Õß‘ frontal Àπ—ßµ“µ°, µ“‚ªπ, §«“¡º‘¥ª°µ‘„π°“√°≈Õ°µ“, ·≈– ethmoid sinus) ·≈–∑à“ Watersû view (‡æ◊ËÕ

244 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 ¿“æ∑ ’Ë 4.∫√‘‡«≥ nasal valve ¢Õß‚æ√ß®¡Ÿ°¢â“ß¢«“°àÕπ (°) ·≈–À≈—ß (¢) °“√„™â‰¡âæ—π ”≈’¥—π lower end of upper lateral nasal cartilage ‰ª∑“ß¥â“π¢â“ß (IT = inferior turbinate).

¿“æ∑ ’Ë 5. ¿“æ„π‚æ√ß®¡Ÿ°¢â“ß¢«“ (°) ·≈–´â“¬ (¢) · ¥ß„Àâ‡ÀÁπ«à“¡’ºπ—ß°—Èπ™àÕß®¡Ÿ°§¥‰ª∑“ß¥â“π´â“¬ (IT = inferior turbinate).

¥Ÿæ¬“∏‘ ¿“æ¢Õß maxillary sinus) ¢âÕ¥’¢Õß«‘∏’π’È§◊Õ ºπ—ß°—Èπ™àÕß®¡Ÿ°§¥, nasal bone fracture, choanal ‡§√◊ËÕß∂à“¬¿“æ√—ß ’™π‘¥π’È¡’Õ¬Ÿà∑—Ë«‰ª ·≈–√“§“∂Ÿ°. atresia, ‰´π— Õ—°‡ ∫, concha bullosa ¢âÕ¥’¢Õß«‘∏’ 3.3) Film lateral nasal bone π’È§◊Õ “¡“√∂‡ÀÁπæ¬“∏‘ ¿“æ∑’Ë∑”„Àâ‡°‘¥Õ“°“√§—¥ ”À√—∫™à«¬«‘π‘®©—¬°“√À—°¢Õß°√–¥Ÿ°®¡Ÿ° (nasal ®¡Ÿ°„π‚æ√ß®¡Ÿ°, ‚æ√ßÀ≈—ß®¡Ÿ° ·≈–‰´π— ‰¥â ·≈– bone) „π°√≥’∑’ËºŸâªÉ«¬¡’Õÿ∫—µ‘‡Àµÿ∫√‘‡«≥ —π®¡Ÿ°. “¡“√∂∫Õ°¢Õ∫‡¢µ (extension) ¢Õßæ¬“∏ ¿“æπ‘ π—È 3.4) °“√∂à“¬¿“æ√—ß ’‚¥¬„™â«‘∏’ ‚¥¬ “¡“√∂„Àâ¢âÕ¡Ÿ≈„π·π«πÕπ (axial plane) ·≈– computerized tomography (CT) „™â«‘π‘®©—¬ „π·π«µ—Èß (coronal plane) ·≈–· ¥ß¢Õ∫‡¢µ¢Õß

§≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 245 ¿“æ∑ ’Ë 6. ¿“æ„π‚æ√ß®¡Ÿ°¢â“ß´â“¬·≈–¢«“°àÕπ (°) ·≈–À≈—ß (¢) æàπ¬“À¥À≈Õ¥‡≈◊Õ¥ (3% ephedrine) ‡¢â“‰ª„π‚æ√ß®¡Ÿ° (IT = inferior turbinate).

¿“æ∑ ’Ë 7. ¿“æ„π‚æ√ß®¡Ÿ°¢â“ß´â“¬ · ¥ß„Àâ‡ÀÁπ‡π◊ÈÕßÕ°™π‘¥ inverted papilloma „π®¡Ÿ°¢â“ß´â“¬æ√âÕ¡¡’ ‡≈◊Õ¥ÕÕ° (IT = inferior turbinate).

246 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 ‰´π— ∑’Ë‡ªìπ°√–¥Ÿ°‰¥â¥’ ¢âÕ‡ ’¬§◊Õ¬—ß‰¡à “¡“√∂∫Õ° ºŸâªÉ«¬Õ¬Ÿà„π∑à“π—Ëß À“¬„®ÕÕ°‡µÁ¡∑’Ë ·≈â«„™âÀπâ“°“° ∂÷ß≈—°…≥–¢Õßæ¬“∏‘ ¿“æ (histological nature) §√Õ∫®¡Ÿ° ªî¥ª“° ·≈â«„ÀâºŸâªÉ«¬ Ÿ¥À“¬„®‡¢â“∑“ß ¢Õßæ¬“∏‘ ¿“æ∑’Ë∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°‰¥â ·≈– ®¡Ÿ°ºà“π‡§√◊ËÕß‡µÁ¡·√ß·≈–‡√Á« ÿ¥ «—¥ª√‘¡“µ√Õ“°“» ‡§√◊ËÕß∂à“¬¿“æ™π‘¥π’È Õ“®¡’‡©æ“–∫“ß∑’Ë ·≈–§à“„™â ∑’ËÀ“¬„®‡¢â“‚æ√ß®¡Ÿ° ∑”„Àâ∂Ÿ°µâÕß 3 §√—Èß ·≈â«„™â ®à“¬„π°“√µ√«®¬—ß¡’√“§“·æßÕ¬Ÿà. §à“∑’Ë¡“°∑’Ë ÿ¥‡ªìπ§à“ PNIF ¡’¢âÕ¥’§◊Õ §àÕπ¢â“ß 3.5) °“√∂“¬¿“æ‚¥¬„™à §≈â π·¡◊Ë ‡À≈à °Á –¥«° ”À√—∫ºŸâªÉ«¬„π°“√«—¥ “¡“√∂π”æ°µ‘¥µ—« (magnetic resonance imaging : MRI) ‡ªìπ ‰ª«—¥∑’Ë∫â“π‰¥â, „™âßà“¬, ‡§√◊ËÕß¡◊Õ√“§“‰¡à·æß, „™â °“√∂à“¬¿“æ‚¥¬„™â§≈◊Ëπ·¡à‡À≈Á°·∑π√—ß ’ ¢âÕ¥’§◊Õ ‡«≈“„π°“√µ√«® —Èπ. ¢âÕ‡ ’¬§◊Õ‡ªìπ°“√«—¥ª√‘¡“µ√ ∑”„ÀâºŸâªÉ«¬‰¡àµâÕß —¡º— °—∫√—ß ’ ·≈–„Àâ√“¬≈–‡Õ’¬¥ Õ“°“»∑’ËÀ“¬„®‡¢â“ºà“π®¡Ÿ°∑—Èß 2 ¢â“ß ‰¡à “¡“√∂ ‡°’Ë¬«°—∫‡π◊ÈÕ‡¬◊ËÕÕàÕπ (soft tissue) ‰¥â¥’ ‡™àπ “¡“√∂ «—¥·¬°∑’≈–¢â“ß, ‰¡à “¡“√∂∫Õ°®ÿ¥Õÿ¥°—Èπ„π™àÕß®¡Ÿ° ·¬°√–À«à“ß¢Õß‡À≈« ·≈–‡π◊ÈÕßÕ°∑’Ë∑”„Àâ‡°‘¥Õ“°“√ ‰¥â«à“Õ¬Ÿà∫√‘‡«≥„¥, ∂â“ºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°¡“°®π §—¥®¡Ÿ°‰¥â, „™â«‘π‘®©—¬ glioma À√◊Õ encephalocele À“¬„®‰¡à‰¥â‡≈¬ (complete nasal obstruction) ∑’Ë∑”„Àâ‡°‘¥Õ“°“√§—¥®¡Ÿ°‰¥â ¢âÕ‡ ’¬§◊Õ„™â¥Ÿ à«π∑’Ë‡ªìπ ®–«—¥‰¡à‰¥â ·≈–°“√∑’ËºŸâªÉ«¬µâÕßÀ“¬„®‡¢â“‡√Á«·≈–·√ß °√–¥Ÿ°‰¡à‰¥â ·≈–‡§√◊ËÕß∂à“¬¿“æ§≈◊Ëπ·¡à‡À≈Á°π’È Õ“® Õ“®∑”„Àâ‡°‘¥ nasal valve collapse ∑”„Àâº≈ ¡’‡©æ“–∫“ß∑’Ë ·≈–§à“„™â®à“¬„π°“√µ√«®¡’√“§“·æß. ∑’Ë‰¥â‰¡à∂Ÿ°µâÕßπ—° ·≈–‰¡à‰¥â· ¥ß∂÷ß°“√À“¬„® °“√∂à“¬¿“æ√—ß ’‰´π— ™π‘¥ plain radio- ‡¢â“-ÕÕ°„π¿“«–ª°µ‘¢ÕßºŸâªÉ«¬ πÕ°®“°π—Èπ º≈∑’Ë graphy, °“√∂à“¬¿“æ√—ß ’‚¥¬„™â«‘∏’ CT ·≈–°“√ «—¥‰¥âÕ“®¡’§«“¡·µ°µà“ß°—π‰¥â¡“° ‡π◊ËÕß®“°ºŸâªÉ«¬ ∂à“¬¿“æ‚¥¬„™â§≈◊Ëπ·¡à‡À≈Á° ¡’ª√–‚¬™πå„π°“√ µâÕß„™â·√ß„π°“√ Ÿ¥ ®÷ßµâÕßÕ“»—¬§«“¡√à«¡¡◊Õ„π ª√–‡¡‘π«à“ºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°À√◊Õ‰¡à ·µà‰¡à§àÕ¬¡’ °“√µ√«®®“°ºŸâªÉ«¬ ·≈–Õ“»—¬§”·π–π”∑’Ë∂Ÿ°µâÕß®“° ª√–‚¬™π„π°“√ª√–‡¡å π§«“¡√‘ π·√ß¢ÕßÕ“°“√§ÿ ¥®¡— °Ÿ ºŸâ∑¥ Õ∫20 ·≈–°“√«‘π‘®©—¬À“ “‡Àµÿ¢ÕßÕ“°“√§—¥®¡Ÿ° √«¡∑—Èß 3.8) Rhinomanometry (RMM) °“√µ‘¥µ“¡º≈¢Õß°“√√—°…“Õ“°“√§—¥®¡Ÿ°¡“°π—°. ‡ªìπ°“√«—¥§«“¡¥—π¿“¬„π™àÕß®¡Ÿ° ·≈–ª√‘¡“µ√ 3.6) Rhinohygrometry ‡ªìπ°“√ Õ“°“»∑’Ëºà“π‡¢â“ÕÕ°®“°®¡Ÿ° ·≈â«π”¡“§”π«≥À“ ª√–‡¡‘π§«“¡√ÿπ·√ß¢ÕßÕ“°“√§—¥®¡Ÿ° ‚¥¬„™â‡§√◊ËÕß §à“§«“¡µâ“π∑“π¢ÕßÕ“°“»∑’ËÀ“¬„®ºà“π∑“ß®¡Ÿ° ¡◊Õµ√«®«—¥«‘∏’·√°17 (¿“æ∑’Ë 2) ‚¥¬„ÀâºŸâªÉ«¬À“¬„® (nasal airway resistance: NAR)21 ™π¥∑‘ π’Ë ¬¡„™‘ â §Õ◊ ≈ß∫π°√–®° ·≈–«—¥‡ âπºà“»Ÿπ¬å°≈“ß¢Õß«ß‰ÕπÈ”∑’Ë active anterior rhinomanometry22 §◊Õ„ÀâºŸâªÉ«¬ °√–∑∫≈ß∫π°√–®°π—Èπ ·≈â«π”¡“‡ª√’¬∫‡∑’¬∫ À“¬„®‡Õß·≈â««—¥. √–À«à“ß¢â“ß¢«“ ·≈–¢â“ß´â“¬18 ´÷Ëß™à«¬∫Õ°§«“¡‚≈àß ¢Õß®¡Ÿ°Õ¬à“ß§√à“«Ê (‰¡à‰¥â∫Õ°∂÷ß§à“§«“¡µâ“π∑“π §«“¡·µ°µà“ß¢Õß§«“¡¥—π∑’Ë√Ÿ®¡Ÿ°∑“ß¥â“π ¢ÕßÕ“°“»¿“¬„π®¡Ÿ°) ¢âÕ¥’§◊Õßà“¬·≈–√«¥‡√Á« „π NAR = Àπâ“ ·≈–„π‚æ√ßÀ≈—ß®¡Ÿ° °“√∑”,„™â‡§√◊ËÕß¡◊Õ∑’ËÀ“‰¥âßà“¬ √“§“‰¡à·æß ·≈– Õ“°“»∑’Ëºà“π‡¢â“-ÕÕ°®“°®¡Ÿ° “¡“√∂µ√«®®¡Ÿ°∑—Èß 2 ¢â“ß‰¥âæ√âÕ¡°—π. 3.7) Peak nasal inspiratory flow ‚¥¬ºŸâªÉ«¬∑’Ë¡’§à“ NAR Ÿß°«à“§à“ª°µ‘ · ¥ß«à“ (PNIF) «—¥‚¥¬„™â nasal peak flow meter ´÷Ëß‡ªìπ ¡’Õ“°“√§—¥®¡Ÿ°®√‘ß ª√–‚¬™πå¢Õß‡§√◊ËÕß¡◊Õπ’È §◊Õ ‡§√◊ËÕß¡◊Õ∑’Ë¥—¥·ª≈ß¡“®“° peak flow meter ∑’Ë 1) ™«¬¬à π¬◊ π«— “¡à Õ“°“√§’ ¥®¡— °®√Ÿ ß‘ ·≈–ª√–‡¡π‘ „™â„πºŸâªÉ«¬‚√§À◊¥19 «‘∏’«—¥§à“ PNIF ∑”‰¥â‚¥¬„Àâ §«“¡¡“°-πâÕ¬¢ÕßÕ“°“√§—¥®¡Ÿ°‰¥â.

§≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 247 ¿“æ∑’Ë 8. ¿“æ· ¥ß°√“ø (rhinogram) ∑’Ë‰¥â®“° acoustic rhinometry °àÕπ (°√“ø‡ âπ≈à“ß) ·≈–À≈—ß (°√“ø‡ âπ ∫π) °“√æàπ¬“À¥À≈Õ¥‡≈◊Õ¥ (3% ephedrine) ‡¢â“‰ª„π‚æ√ß®¡Ÿ° ·°ππÕπ§◊Õ √–¬–∑“ß®“°√Ÿ®¡Ÿ° ∑“ß¥â“πÀπâ“ ·°πµ—Èß§◊Õ æ◊Èπ∑’Ë¿“§µ—¥¢«“ß¢Õß‚æ√ß®¡Ÿ° (cross-sectional area) √Õ¬À¬—°·√° (°) ‡ªìπµ”·Àπàß¢Õß nasal valve ·≈–¡—°®–‡ªìπæ◊Èπ∑’Ë¿“§µ—¥¢«“ß∑’ËπâÕ¬∑’Ë ÿ¥ (minimal cross-sectional area) ¢Õß‚æ√ß®¡Ÿ° √Õ¬À¬—°∑’Ë Õß (¢) ‡ªìπµ”·Àπàß¢Õß à«πÀπâ“¢Õß‡∑Õ√å∫‘‡π∑Õ—π≈à“ß À√◊Õ Õ—π°≈“ß √Õ¬À¬—°∑’Ë “¡ (§) ‡ªìπµ”·Àπàß¢Õß à«π°≈“ß À√◊Õ à«πÀ≈—ß¢Õß‡∑Õ√å∫‘‡π∑Õ—π°≈“ß

2) ™à«¬·¬°«à“Õ“°“√§—¥®¡Ÿ°π—Èπ¡’ “‡Àµÿ¡“ À√◊Õ¡’ºπ—ß°—Èπ™àÕß®¡Ÿ°∑–≈ÿ ®–«—¥‰¡à‰¥â, µâÕß„™â‡§√◊ËÕß ®“°‡¬◊ËÕ∫ÿ®¡Ÿ°∫«¡ (§à“ NAR °àÕπ·≈–À≈—ß°“√„™â¬“ ¡◊Õ´÷Ëß¡’√“§“·æß ·≈–µâÕßÕ“»—¬‡®â“Àπâ“∑’Ë´÷Ëß‰¥â√—∫ À¥À≈Õ¥‡≈◊Õ¥®–·µ°µà“ß°—πÕ¬à“ß™—¥‡®π) À√◊Õ®“° °“√Ωñ°Ωπ¡“∑”°“√«—¥, µâÕßÕ“»—¬§«“¡√à«¡¡◊Õ¢Õß ‚§√ß √â“ß∑’Ëº‘¥ª°µ‘ (‡™àπ ºπ—ß°—Èπ™àÕß®¡Ÿ°§¥ À√◊Õ¡’ ºŸâªÉ«¬æÕ ¡§«√„π°“√«—¥, ‰¡à “¡“√∂«—¥§à“ NAR °âÕπÕÿ¥µ—π‚æ√ß®¡Ÿ° ‡™àπ √‘¥ ’¥«ß®¡Ÿ° À√◊Õ‡π◊ÈÕßÕ°) √«¡∑—Èß¢â“ß´â“¬·≈–¢«“ (total NAR) ‰¥â‚¥¬µ√ß (§à“ NAR °àÕπ·≈–À≈—ß°“√„™â¬“À¥À≈Õ¥‡≈◊Õ¥®– ‡æ√“–µâÕß«—¥ NAR ∑’≈–¢â“ß ·≈â«π”¡“§”π«≥À“§à“ ‰¡à·µ°µà“ß°—π¡“°π—°). total NAR, ‰¡à “¡“√∂∫Õ°®ÿ¥Õÿ¥°—Èπ„π™àÕß®¡Ÿ°‰¥â 3) ™à«¬„π°“√µ‘¥µ“¡º≈°“√√—°…“Õ“°“√§—¥ «à“Õ¬Ÿà∫√‘‡«≥„¥. ®¡Ÿ° ‰¡à«à“®–„™â¬“ À√◊Õ∑”°“√ºà“µ—¥√—°…“. 3.9) Acoustic rhinometry (ARM) ¢âÕ‡ ’¬ §◊Õ ∂â“ºŸâªÉ«¬¡’Õ“°“√§—¥®¡Ÿ°¡“°®π ‡ªìπ°“√«—¥æ◊Èπ∑’Ë¿“§µ—¥¢«“ß¢Õß‚æ√ß®¡Ÿ° (cross- À“¬„®‰¡à‰¥â‡≈¬ (complete nasal obstruction) sectional area : CSA) „π√–¥—∫§«“¡≈÷°µà“ßÊ °—π

248 §≈‘π‘° ªï∑’Ë 29 ©∫—∫∑’Ë 4 ‡¡…“¬π 2556 ‡¡◊ËÕ«—¥®“°√Ÿ®¡Ÿ°∑“ß¥â“πÀπâ“‡¢â“‰ª‚¥¬Õ“»—¬°“√ „πª®®í ∫ÿπ¡— §’ ”·π–π”„π°“√«¥∑— ß—È RMM –∑âÕπ°≈—∫¢Õß§≈◊Ëπ‡ ’¬ß23 ´÷Ëßπ”¡“ √â“ß‡ªìπ°√“ø ·≈– ARM25 ‡æ◊ËÕ„Àâ‡ªìπ¡“µ√∞“π‡¥’¬«°—π„π°“√ (rhinogram)24 ´÷Ëß “¡“√∂∫Õ°µ”·Àπàß∑’Ë‚æ√ß®¡Ÿ° ∑¥ Õ∫·≈–°“√·ª√º≈ ·≈–≈¥§«“¡·µ°µà“ß∑’ËÕ“® ·§∫∑’Ë ÿ¥‰¥â (minimal cross-sectional area : ‡°‘¥¢÷Èπ‰¥â®“°°“√«—¥∑—Èß 2 «‘∏’π’È. MCA) (¿“æ∑’Ë 8). ¢âÕ¥’¢Õß ARM §◊Õ “¡“√∂∫Õ°®ÿ¥ °“√√—°…“Õ“°“√§—¥®¡Ÿ° Õÿ¥°—Èπ„π™àÕß®¡Ÿ°‰¥â«à“Õ¬Ÿà∫√‘‡«≥„¥ ≈÷°‡¢â“‰ª„π®¡Ÿ° °“√√—°…“Õ“°“√§—¥®¡Ÿ° ‡√‘Ë¡µ—Èß·µàÕ∏‘∫“¬„Àâ ‡ªìπ√–¬–∑“ß‡∑à“„¥ ·≈–∑”„Àâ¡’Õ“°“√§—¥®¡Ÿ°¡“° ºŸâªÉ«¬∑√“∫∂÷ß “‡Àµÿ¢ÕßÕ“°“√§—¥®¡Ÿ°«à“‡°‘¥®“° πâÕ¬‡æ’¬ß„¥ (¡’ CSA ¡“°πâÕ¬‡æ’¬ß„¥), „™â‡«≈“„π Õ–‰√∫â“ß ·≈–®–µâÕß√—°…“¥â«¬«‘∏’„¥ [‡™àπ „™â¬“À√◊Õ °“√µ√«® —Èπ (πâÕ¬°«à“ RMM), Õ“»—¬§«“¡√à«¡¡◊Õ °“√ºà“µ—¥ (À√◊Õ√à«¡°—∫°“√©“¬· ß À√◊Õ°“√„Àâ¬“ ¢ÕßºŸâªÉ«¬„π°“√µ√«®πâÕ¬, “¡“√∂∫Õ°ª√‘¡“µ√ ‡§¡’∫”∫—¥ „π°√≥’Õ“°“√§—¥®¡Ÿ°‡°‘¥®“°‡π◊ÈÕßÕ°)] ¢Õß‚æ√ß®¡Ÿ°‰¥â‚¥¬„™â°“√§”π«≥§à“ CSA ¢Õß∑ÿ° ´÷Ëß¢÷ÈπÕ¬Ÿà°—∫ “‡Àµÿ¢ÕßÕ“°“√§—¥®¡Ÿ° Õ“°“√§—¥®¡Ÿ° ®ÿ¥„π‚æ√ß®¡Ÿ° ¢âÕ‡ ’¬§◊Õ ∂â“ºŸâªÉ«¬¡’ºπ—ß°—Èπ™àÕß ®–À“¬¢“¥À√◊Õ‰¡à À√◊Õ¡’‚Õ°“ °≈—∫¡“‡ªìπ´È”Õ’° ®¡Ÿ°∑–≈ÿ ®–«—¥‰¡à‰¥â, µâÕß„™â‡§√◊ËÕß¡◊Õ´÷Ëß¡’√“§“·æß ·≈–„π°√≥∑’ ‰¡’Ë À“¬¢“¥à À√Õ¡◊ ‚Õ°“ °≈’ ∫¡“‡ª— π´ì È”Õ°’ ·≈–µâÕßÕ“»—¬‡®â“Àπâ“∑’Ë´÷Ëß‰¥â√—∫°“√Ωñ°Ωπ¡“∑” ºªŸâ «¬§«√ªØÉ ∫‘ µ— µ‘ «Õ¬— “ß‰√à ‡æÕ≈¥Õ“°“√°≈◊Ë ∫‡ª— π´ì È” °“√«¥.— ππ.—È

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