Professional Documents
Culture Documents
ADRIANA NEAGO
Universitatea de Medicin i Farmacie
Trgu Mure
CAIET DE CURS
OTORINOLARINGOLOGIE
ANUL V
MEDICIN GENERAL
Trgu Mure
2013
1
CURS nr 1
OTOLOGIE
INTRODUCERE
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1.ANATOMIA I FIZIOLOGIA
URECHII EXTERNE
Urechea extern este constituit
din pavilionul auricular i conductul
auditiv extern.
Conductul auditiv msoar la adult
aproximativ 2,5 cm
Inervaia senzitiv a urechii
externe N.auricular (din plexul
cervical) i ale
N.auriculotemporal(V3) .
Pri ale conductului auditiv sunt
inervate de ramura aricular a N.vag
N.facial (somatosenzitiv) .
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FIZIOLOGIE
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URECHEA MEDIE
trei pri :
- cavitatea timpanic
- sistemul de caviti pneumatice (celulele
mastoidiene)
-trompa lui Eustachio
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MEMBRANA TIMPANIC
Membrana timpanic- dou zone , pars tensa i pars flacida
Pars tensa
Stratul extern epidermic- epiteliu pavimentos pluristratificat
cu suprafa neted , care n mod normal reflect lumina ;
vine in continuarea conductului auditiv extern
Stratul intern mucos (Stratum mucosum) : epiteliu
pavimentos unistratificat ; ctre cavitatea timpanic
Stratul mijlociu :
dou straturi de fibre conjunctive
- extern cu un traiect radiar al fibrelor (stratum radiatum)
- intern cu traiect circular (stratum circulare) .
Fibrele se adun la marginea timpanului n inelul
fibrocartilaginos , care fixeaz membrana timpanic n anul
inelar al conductului auditiv osos .
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MEMBRANA TIMPANIC
Pars flacida (membrana lui
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CAVITATEA TIMPANIC
trei etaje :
Mezotimpanul :
fereastra rotund, fereastra oval cu scria i
promontoriul (proeminena dat de primul tur
de spir al melcului)
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CAVITATEA TIMPANIC
Epitimpanul ( Atica, recesul epitimpanic): este
etajul situat superior de membrana timpanic
- limita ntre epi- i mezotimpan - Partea
timpanic a N. Facial- formeaz la nivelul
peretelui medial al cavitii timpanice
- se afl marea parte a oscioarelor auriculare
mpreun cu ligamentele lor i unele cute
mucoase.
- acesta poate fi sediul unor inflamaii
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CAVITATEA TIMPANIC
Hipotimpanul( recesul hipotimpanic): este
situat inferior de membrana timpanic. Se
nvecineaz bulbului venei jugulare, i
prezint nite celule(celulele timpanice), care
comunic cu sistemul celulelor mastoidiene .
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OSCIOARELE AURICULARE
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OSCIOARELE AURICULARE
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OSCIOARELE AURICULARE
Nicovala este articulat cu capul
ciocanului.Acesta din urm mpreun cu
corpul nicovalei sunt situate n epitimpan.
Apofiza lung a nicovalei se articuleaz cu osul
scriei.
Platina scriei este angajat mobil prin
ligamentului inelar elastic n nia ferestrei
ovale i realizeaz comunicarea cu spaiul
perilimfei.
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OSCIOARELE AURICULARE
Scria este format din capul i gtul scriei,
braele scriei i platina scriei. Platina
scriei este angajat mobil prin ligamentul
inelar elastic n nia ferestrei ovale i
realizeaz comunicarea cu spaiul perilimfei.
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Vascularizaie i inervaie
a.carotide externe, - a.meningean medie,
a.faringean ascendent, a.maxilar i
a.stilomastoidian.
Inervaia senzitiv - n.timpanic, ramura a
n.glosofaringean.
Otalgie de iradiere, care poate rezulta n procesele
faringiene.
Parasimpatic- n.glosofaringean,
cu partea simpatic a plexului carotidian intern i cu
n.trigemen.
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cptuite de mucoas
au raport direct cu cavitatea timpanic
sunt aerisite n acest fel prin cavitatea
timpanic i trompa lui Eustachio.
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URECHEA INTERN
Urechea intern
- se afl n stnca temporalului
- se compune din canale comunicante
care poart denumirea de labirint
1. Labirintul membranos
2. Labirintul osos
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Labirintul
Labirintulmembranos
membranos
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LABIRINTUL OSOS
dintr-un sistem de canale semicirculare, din
cohlee i vestibul.
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COHLEEA
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Organul Corti
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Organul CORTI
celule senzoriale i de
susinere
Celule interne- celule ale
auzului ce realizeaz
transformarea informaiilor
acustice n semnale neurale
Celule externe-Stereocilii
sunt fixai de membrana
tectoria
legtura cu n. cohlear se
realizeaz prin fibre eferente.
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Funcia Cohleei
dou funcii mecanice :
1. Analiza frecvenei-anumite frecvene sunt
orientate ctre anumite fibre nervoase n
funcie de localizare(tonotopie)
2. Amplificarea biomecanic- unde cu
amplitudini sczute sunt transformate spre
amplitudini crescute cu ajutorul
amplificatorului cohlear.
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AMPLIFICAREA I TRANSDUCIA
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NERVUL ACUSTICOVESTIBULAR
prsete trunchiul cerebral ca un trunchi nervos
comun;
din punct de vedere funcional : n.vestibular i
n.cohlear
N.vestibular formeaz la acest nivel ggl.vestibular
Scarpa, de unde iau natere prelungirile periferice: n.
utriculoampullaris, n. saccularis, n.ampullaris
posterior.
Ganglionul cohlear (ggl.spinale cohleae) ns, n
mediolul cohleei.
N.vestibulocohlear parcurge meatul acustic intern
mpreun cu N facial
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Localizarea sunetului
Imaginea sunetului
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SISTEMUL VESTIBULAR
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Ampula i Macula
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Sistemul vestibular
central
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FUNCIILE VESTIBULARE
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Reflexul vestibulospinal(VSR)
Meninerea poziiei capului, statica, precum i
mersul n ortostatism
reflexul vestibulocervical.
Motilitatea spinal este reglat de reflexe
declanate proprioceptiv, vizual i vestibular.
Mersul n ortostatism este posibil cu dou
sisteme funcionale. Dac cele dou sisteme
ar fi afectate, ortostatismul i micrile ar fi
tulburate.
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NERVUL FACIAL
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NERVUL FACIAL
6 segmente
I Intracranial
II. Intrameatal
III. Labirintic
IV.Timpanic
V. Mastoidian
VI. Parotidian
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CURS nr 2
OTOLOGIE
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OTHEMATOMUL
Colecie sero-hematic
Simpt: tensiune local
Ex clinic: formaiune
ovoid,dur-fluctuent,
roie-violacee
- Dg. puncie aspirativ
- Tratam.: incizie, drenaj,
pansament compresiv
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PERICONDRITA URECHII
Infecia pericondrului
cartilajului
Etiologie: otite externe,
traumatisme, arsuri, operaii
Simptome: durere, febr,
Ex ORL: tumefierelocal,
edem, tegument de culoare
roie, cald
Tratament: antiinflamator
local i general, comprese
locale cu Rivanol
Tratament chirurgical la
nevoie
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OTOMICOZA
Etiologie: aspergillus
Simptomatologie: durere,
senzaie de plnitudine
auricular, corp strin n ureche
Examen clinic: mas rotund, de
aspect vtuit, negricioas
Tratament. Ungv ent antimicotic
local, aspiraie auricular, soluii
antimicotice
PIMAFUCIN, PIMAFUCORT,
CLOTRIMAZOL
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Etiologie. ngroare
progresiv a CAE, cicatrici
vicioase
Simptome. Hipoacuzie de
transmisie
Tratament: audiometrie
prealabil
Tratam chirurgical- incizie,
dilatator CAE
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Etiologie: tulburare de
dezvoltare CAE
Simptome: Excrescene ale
CAE, localizate pe peretele
postero-superior a CAE
Tratament: chirurgical pe cale
endaural
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TUMORI BENIGNE.
- CHIST SEBACEU- pe antitragus sau lobul
- FIBROAME- cheloid
- NEVII- pigmentari sau vasculari
- Condiloame: -rdcina helixului
- CONDROFIBROAME- PAPILOAME
- HEMANGIOAME
- OSTEOAME
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CONDILOM AURICULAR
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Diagnostic diferenial:
Diskeratoza
Degerturi
Eczema
Psoriazis
Nodul nedureros
Lupus
Sifilis
Othematom
Tratament: chirurgical- extirparea tumorii reconstrucie pavilion
auricularradioterapie
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CURS nr 3
OTOLOGIE
36
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CLASIFICARE
1. TRAUMATISMELE DIRECTE
TRAUMATISMELE TIMPANICE PRIN CORPI STRINI
ARSURA TIMPANULUI
TRAUMATISMELE PRESIONALE- BLASTUL,
BAROTRAUMATISMELE, BANGUL SUPERSONIC
TRAUMATISMUL ACUSTIC ACUT
TRAUMATISMELE ELECTRICE
2. TRAUAMTISMELE INDIRECTE ALE URECHII
TRAUMATISME. ASOCIATE
FRACTURI. LABIRINTICE
FRACTURI. EXTRALABIRINTICE
3. LEZIUNILE LANULUI OSICULAR
COMOIA LABIRINTIC
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Arsura timpanului
Simptomatologie:
Durere intens
CAE cu pete marmorate
Membran timpanic hiperemic, turgescent
Perforaie timpanal larg antero-inferioar
Tratament:
Pansamente endaurale
Trat antibiotic
MIRINGOPLASTIE la 6 luni dup oprirea supuraiei
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BAROTRAUMATISMELE
Creterea brusc a presiunii n mediul ambiant
Aplicarea unei palme peste ureche
Proba Valsalva dificil de realizat
Simptomatologie:
Congestia timpanal- epitimpan
Congestia difuz cu retracia timpanului
Hemotimpan
Ruptur timpanal liniar
Afectarea lanului osicular
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BAROTRAUMATISMELE
Surditate prin compresie- unilateral
Surditate prin decompresie- bilateral, progresiv, curb
orizontal
BAROTRAUMATISMELE LA AVIATORI
Barotraumatismul acut- otalgie, acufene, vertij
Barotraumatismul subacut- otalgie vag, pasager
Barotraumatismul cronic- HT pe frecvene joase, apoi mixt
Ex clinic: MT ngroat retractat, orizontalizarea mnerului
ciocanului, durere intens, unilateral, vertij, acufene,
perforaie larg
Tratament: i
gienic- toaleta CAE
Miringoplastie
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BLASTUL
Deplasare unei mase de aer prin explozie, deflagraie
Se produc leziuni degenerative la nivelul labirintului prin hemoragie
sau comoii ale urechii interne
BANGUL SUPERSONIC
Energie sonic 130-145 dB, durat scurt
Modificri hidrodinamice pe fondul unei cohleei fragile
Simptomatologie:
ureche nfundat
Surditate cu vertij asociat
Leziuni labirintice degenerative
HP pe frecvene nalte
Tratament:
vasodilatatoare
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TRAUMATISMUL ELECTRIC
prin electrocutare
SE PRODUC:
- leziuni primare directe asupra membranei
timpanice
- leziuni secundare tardive
Hipoacuzie neurosenzorial sau mixt
Perforaii timpanale
Fenomene asociate: necroza osoas, tulburri
psihice, atingere cerebral atrofia limbii, paralizie
facial, complicaii oculare
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COMOIA LABIRINTIC
manifestri labirintice postraumatice n absena unei
fracturi
Lezarea ireversibil a elementelor neurosenzorialefereastra oval i primul tur de spir al cohleei
Simptomatologie:
Hipoacuzie
Acufene
Otalgie nevralgic
Hipoacuzie neurosenzorial de tip degenerativ pe
frecvenele nalte i apoi cele joase
Tratamentul: implant de tranzistori cu rol stimulator
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CURS nr 4
OTOLOGIE
44
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CATAR TUBO-TIMPANIC
ETIOLOGIE:
Apare la copii sub 4 ani
Alterarea funciei trompei lui Eustachio
determin inflamaii cronice ale mucoasei casei
medii
Cauze: rinofaringite, adenoidite acute i cronice,
hipertrofii ale cornetelor inferioare, polipi, tumori
benigne i maligne, afeciuni sinusale, aspectul
anatomic al trompei- orizontal,palatul ogival,
malformaii coanale, postraumaticpostadenoidectomie- bride cicatriciale, alergii,
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CATAR TUBO-TIMPANIC
Simptomatologie:
3 stadii:
- obstrucia tubar simpl
- obstrucie tubar cu transudat n casa medie
- organizare plastic cu sechele funcionale
Clinic:
1. obstrucie auricular
2. autofonie- intensitate variabil, se amelioreaz la
nghiit, cscat, suflat de nas
3. zgomote auriculare de tonalitate joas
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CATAR TUBO-TIMPANIC
Examen clinic:
Hiperemia discret a mnerului ciocanului i a
membranei Shrapnell
Aspiraie timpanului, mulat pe lanul osicular
Orizontalizarea mnerului ciocanului
Culoare albicios-cenuie
Lichid mobil n casa medie- bule de lichid
ngroarea secreiilor- stabilirea nivelului de
lichid- glue ear
Examen rinofaringe i rinoscopie anterioar
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CATAR TUBO-TIMPANIC
Diagnostic:
Permeabilitatea trompei E.- manevra Valsalva,
i Toynbee
Cateterizarea trompei- cu sonda Itard
Examen radiologic
Timpanograma: curb aplatizat, sau
negativizarea curbelor
Audiometrie: hipoacuzie de transmisie
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CATAR TUBO-TIMPANIC
TRATAMENT:
nlturarea cauzelor rinofaringiene
Acumulare de lichi: drenaj transtimpanal- diabolo
Antiinflamatorii
Dezobstruante nazale
Aerosoli
Mucolitice
Cortizon
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Este frecvent
Poate trece neobservat
Ex otologic- ESENIAL
Orice stare febril a sugarului necesit
consult otologic
este bilateral
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MIRINGITA ACUT
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OTOMASTOIDITA SUGARULUI
Etiopatologie:
infecie nazal i rinofaringian
Igiena deficitar general
prematuritatea
Conformaia trompei lui Eustachio
Anatomia patologic:
Inflamaia cu afectarea tuturor esuturilor urechii medii
Forme clinice: manifest i latent
Tablou clinic n forma manifest
Febr 39-40
Agitaie
Insomnie
Tulburri de digestie
Scdere ponderal
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OTOMASTOIDITA SUGARULUI
Examen clinic n forma manifest
Secreii nazale
Durere la apsarea tragusului
Hiperemia difuz a MT
Bombarea acesteia
Pavilion mpins nainte i n jos
Timpanotomie- secreie purulent
Voalarea mastoidei
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OTOMASTOIDITA SUGARULUI
FORMA LATENT
Apare la copiii distrofici
Apare sub forma unei stri de toxicoz: sindrom
nervos, sindrom digestiv, deshidratare
Ex clinic local:
- semne puin zgomotoase
- cderea peretelui post-sup a CAE
- voalarea mastoidei pe RTG
EVOLUIA:
Complicaii endocraniene
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OTOMASTOIDITA SUGARULUI
TRATAMENT
Drenaj precoce
Combaterea infeciilor asociate
TIMPANOTOMIE
Antibioterapie
Dezobstruante nazale
ANTROMASTOIDECTOMIA
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MASTOIDIT ACUT
EXTERIORIZAT
Topirea septurilor mastoidiene i formarea
flegmonului endomastoidian
Abces subperiostal superior
Abces retroauricular postero-superior
subperiostal
Otomastoidita temporal
Abces substernocleidomastoidian BEZOLD
Otomastoidita occipital
Otomastoidita jugodigastric
Petrozita sau petroaticita
SINDROMUL GRADENIGO- Otit medie
supurat , cefalee intens, paralizia
oculomotorului extern
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Examen otoscopic
Ex audiometric
RTG sau CT mastoidian
Dup tipul de leziune
Natura leziunilor timpanale
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TRATAMENTUL COLESTEATOMULUI
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OTOREEA TUBAR
SIMPTOMATOLOGIE
- otoree mucoas, intermitent
- surditate de transmisie moderat 10-15 dB
EXAMEN OBIECTIV:
- perforaie antero-inferioar
- sediu marginal
- margini bine delimitate
- prin perforaie se vede mucoasa cavit timp
hiperemic, congestionat
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OTOREEA TUBAR
EVOLUIE I PROGNOSTIC:
- otoree rebel la tratament
- nlturarea cauzelor de vecintate
COMPLICAII:
- otita extern- iritaia CAE
TRATAMENT: curativ i simptomatic
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ATICITELE
Caracteristici:
1. Localizare atical
2. Debut i origine obscure
3. Fr antecedente auriculare semnificative
4. Evoluia lent a unui colesteatom primitiv
Anatomia patologic:
perforaie marginal la nivelul membranei
Shrapnell
Perforaie mic cu leziuni osoase
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ATICITELE
EX CLINIC LA DEBUT
Hipoacuzie uoar rmne mult timp nemodificat
Cefalee occipital
Secreii auriculare minime
Evoluie silenioas, lent
Secreie clar ,fetid
CAE normal
PERFORAIE LA NIVELUL MEMBRANEI SHRAPNELL
Extragere de lamele de colesteatom din atic
Manevra Valsalva negativ- blocaj atical
Palparea mastoidei negativ
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ATICITELE
EX. CLINIC IN PERIOADA DE OTOREE:
Hipoacuzie net
lezarea lanului osicular
CAE normal
Lamele de colesteatom n atic
Mucoas granulat, hiperemic
CLASIFICAREA ATICITELOR:
1. Anterioare cu perforaie mic
2. Posterioare cu perforaii largi, retromaleare
3. Polipoase
4. Colesteatomatoase
5. Perforaii asociate
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ATICITELE
Forme complicate:
1. dureroas
2. vertiginoas
3. complicat cu paralizie de facial
Evoluia:
Supuraie continu,cu complicaii endocraniene
Prognostic:
Afectarea auzului, complicaii endocraniene
Tratament: chirugical- antroaticotomie,
antromastoidectomie
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67
CURS nr 5
OTOLOGIE
68
COMPLICAIILE SUPURAIILOR
AURICULARE
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OTITA EXTERN
ADENITA RETROAURICULAR
OSTEOPERIOSTITA, ABCESUL I FISTULA
RETROAURICULAR
FISTULA GELLE
CERVICALE
INTRAOSOASE
ENDOCRANIENE
GENERALE
SEPTICEMIA KORNER
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1. COHLEARIZAREA
Modaliti de afectare cohlear:
1. spontan- prin afectare inflamatorie
concomitent sau sec unei acutizri
2. hemoragia intracohlera
3. perilimfatic- scurgere de perilimf
4. postototoxic- prin adm de antibiotic local
5. fibrozarea sau osificarea cohleei
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3. LABIRINTITELE
Definiie: atingerea urechii interne de ctre un
proces infecios
Clasficare:
Seroas acut
bacteriene
Supurat acut
Supurat cronic
Fibroas i osifiant
virale
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3.1.4.LABIRINTITA FIBROAS I
OSIFIANT
Este stadiul final al unei labirintite
Se produce esut fibros care oblitereaz
labirintul , apoi se produc osificri calcificri
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4. PETROZITA
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6. MENINGITA OTOGEN
Definiie: inflamaia meningelui i invazia bacterian n
l.c.r
Etiologie: streptococ pneumoniae, Haemofilus,
Pneumococ, Neisseria meningitidis
Patogenie:
focar inflamator cronic sau supracut
mastoidianpropagare directa meningelui
Hematogen
limfaticinfecii rinofaringiene, sau otice
Soluii de continuitate
iatrogene
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6. MENINGITA OTOGEN
Simptomatologie
Debut: brusc, febr, cefalee , vrsturi, convulsii
Perioada de stare:
- sindrom infecios: febr, indisponibilitate, stare
de ru
- Sindrom meningean: cefalee intes n casc sau
frontoparietal, fotofobie, vrsturi, bradicardie
Redoarea cefei
Otorea, otalgia, hipoacuzia- pot lipsi
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6. MENINGITA OTOGEN
Diagnosticul pozitiv:
- semnele meningitei
. Semnele inflamatorii acute, subacute sau cronice
auriculare sau mastoidiene
- examenradiologic- Proces inflamtor mastoidian- osteite
- puncia lombar pozitiv!!!
- aspectul LCR.: hipertensiv, tulbure, presiune peste
200mmHg, leucocitoz> 100oleuc/mm3, neutrofilie,
proteinorahie>1g/l, glicorahie< 0,34 g/l, germeni patogeni
prezeni
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6. MENINGITA OTOGEN
Tratamentul
Examen direct negativ
antibioterapie masiv : CEFTRIAXON, CEFOTAXIM, AMOXICILIN, CEFTAMIL
Examen direct pozitiv:
- gram pozitiv: AMOXICILIN
- gram neg.: AMOXICILIN, CEFTRIAXON, CEFOTAXIM
- coci gram poz.: se asoc VANCOMICINA
- bacili gram neg: CEFTRIAXON, CEFOTAXIME
Corticoterapie , Manitol
CEFTRIAXON- 70-100mg/kg.c/zi 1-2x/zi
CEFOTAXIM 200/300 mg/kg.c zi 4x/zi
AMOXICILIN 200mg/kgc/zi 4-6x/zi
VANCOMICINA 40-60 mg/kg.c/zi 4x/zi
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6. MENINGITA OTOGEN
TRATAMENT CHIRURGICAL- EVIDARE PETRO-MASTOIDIANdrenaj larg
OTITELE ACUTE
- NU ESTE INDICAT
- MASTOIDITELE EXTERIORIZATE- INDICAT
- EVOLUIE FAVORABIL SUB TRATAMENT MEDICAMTEMPORIZARE
EVOLUIE NEFAVORABIL- INDICAT CHIAR DAC TIMPANUL
ESTE NORMALIZAT CA ASPECT
OTITE CRONICE
- EVOLUIE NEFAVORABIL- INDICAT
- EVOLUIE FAVORABIL- TEMPORIZARE
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7. ABCESUL CEREBRAL
Definiie: colecie purulent localizat i
nconjurat de o zon de encefalit
Cauze: O.M. S. Acut i cronic, O.M
colesteatomatoas, Otomastoidita cronic
Patogenie:
- extindere direct de la UM prin tegmen tympani,
sinus cavernos
- cale venoas retrograd- tromboflebite
LOCALIZARE LOB TEMPORAL, ABCESE MULTIPLE
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7. ABCESUL CEREBRAL
Stadii evolutive:
1. Stadiul iniial- cerebrita iniial- febr, cefalee,
scderea capacitii de concentrare, st gen alterat
2. Stadiul de localizare- cerebrita tardiv- HIC
tranzitoriu, atacuri epileptiforme, simp precedente
3. Stadiul de abces manifest- febr, cefalee, redoare de
ceaf, crize epileptice, alterarea strii de contien
4. Stadiul terminal- obnubilare, torpoare, com, resp
Cheyne- Stokes
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7. ABCESUL CEREBRAL
Forme clinice:
Hipoacuzie discret
Halucinaii auditive
Tulburri de miros
Tulburri de vedere
Neuropatii craniene III,IV
Tulburri de vorbire
2. ABCES CEREBELOS
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7. ABCESUL CEREBRAL
DIAGNOSTICUL POZITIV
- ex laborator: leucocitoz, PCR poz, LCR : leucocitoz, proteine crescute,
presiune crescut
- ex RTG i CT i RMN: zon hipodens, sau hipercaptant cu substan de
contrast
DIAGNOSTICUL DIFERENIAL:
- abcesul extradural
- tromboflebita de sinus lateral
- meningita otogen
- labirintitele
- vestibulopatii
- scleroza n plci
- tu. cerebrale
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7. ABCESUL CEREBRAL
TRATAMENT MEDICAMENTOS
- antibioterapie masiv , Corticoterapie
- se adm n forme de cerebrit, abcese mici, sau
multiple, sau unde se contraindic chirurgia
TRATAMENT CHIRURGICAL
- echipe mixte cu neurochirurgia
- abord al abcesului+ evidare petromastoidian
n acelai timp operator
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82
CURS nr 6
OTOLOGIE
83
SINDROAME VESTIBULARE I
HIPOACUZII
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SINDROAME VESTIBULARE
Def: Totalitatea manifestrilor cauzate de afectarea sistemului
vestibular.
Clasificare:
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- acufene
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- sindromul Meniere
- sindromul Lermoyez
- boala Meniere
- labirintita acut seroas sau supurat
-posttraumatic (comoia labirintic, fractura
labirintic, ruptura ferestrelor, trauma sonor)
- postoperator
- toxic
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- vertij
- acufene
- NU exist hipoacuzie
Semne:
- nistagmus
- de iritaie vagal
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- NU exist acufene
- NU exist hipoacuzie
Semne:
- de iritaie vagal
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- tumori cerebeloase
- leuconevraxita
- anevrism bulbar
- insuficien vertebro- bazilar
- kinetoze
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- ameeal( NU vertij)
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SINDROMUL MENIERE
Def: Sindromul Meniere sau hidropsul
endolimfatic se caracterizeaz prin crize
paroxistice de sindrom vestibular periferic,
repetitive, determinate de perturbri n dinamica
endolimfei prin disfuncia valvei utriculoendolimfatice.
- reprezint circa 90% din sindroamele vestibulare
periferice
- crizele scad n timp ca intensitate i frecven
-de obicei este unilateral, dar se poate bilateraliza
n timp.
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SINDROMUL MENIERE
Simptome:
- fonofobie
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SINDROMUL MENIERE
Semne:
- nistagmus
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SINDROMUL MENIERE
Forme clinice
forma clasic complet cohleovestibular
sindromul Lermoyez( hidrops endolimfatic
paradoxal atipic)
catastrofa otolitic(cdere brusc troncular de
scurt durat)
hidrops endolimfatic cohlear( doar fenomene
auditive)
hidrops endolimfatic vestibular( doar fenomene
vestibulare)
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BOALA MENIERE
- afeciune caracterizat printr-o criz
vestibular de tip periferic, unic, foarte
intens, nsoit de o hipoacuzie de percepie
profund, definitiv, cauzat de o hemoragie
intralabirintic cu hemolabirint i ulterior
labirintofibroz
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90
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NEVRITA DE VESTIBULAR
Def : afeciune inflamatorie a nervului
vestibular i/sau a ganglionului Scarpa, de
etiologie viral( vasculit vasa nervorum) sau
idiopatic( spasm, tromboz, embolie,
hemoragie pe vasa nervorum).
Este un sindrom vestibular radicular pur,
aprnd mai frecvent ntre 30-60 ani, rar n
copilrie.
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SIMPTOME
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SCHWANNOMUL DE VESTIBULAR
Def : este o tumor benign a tecii Schwann a
nervului vestibular, cea mai frecvent tumor
de unghi pontocerebelos, cu evoluie lent,
afectnd mai ales femeile cu vrsta ntre 35-40
ani.
Este un sindrom vestibular, radicular atipic, cu
hipoacuzie de percepie.
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SCHWANNOMUL DE VESTIBULAR
Evolueaz n trei faze:
faza otologic (simptomatologie insignifiant, unilateral, lent
progresiv) - acufene, senzaie de plenitudine aural,
hipoacuzie de percepie lent progresiv, n ani, unilateral; se
poate manifesta i ca surditate brusc instalat( prin compresie
pe artera labirintic), vertij foarte rar( paradoxal)
faza neurologic (afectare polineural)
- nerv V - hipo/areflexie corneean, hipoestezie hemifacial,
parestezii, hemicranie, semnul Hitselberger pozitiv ( lipsa
percepiei dureroase n zona Ramsey Hunt);
- nerv VII - foarte rezistent, tardiv apar parez, paralizie,
hipoestezie n zona Ramsey Hunt
- nerv VII Wrisberg
- nerv VIII
faza de hipertensiune intracranian
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SURDITATEA DE PERCEPIE
I.COHLEAR:
1) afeciuni congenitale
- hiperbilirubinemia
- traume intrapartum
- sifilis congenital
- medicaia teratogen
- hipotiroidie
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- comoia cohlear
- fistula labirintic
- ruptura fenestral
- trauma sonor
- boala chesonierilor
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- labirintita
- sifilis,TBC
4) ototoxic
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SURDITATEA DE PERCEPIE
II. NEURAL:
inflamatorie - nevrita gripal,varicela-zooster,rujeola,
urlian,sifilis,meningoencefalita
tumoral - schwannom de vestibular, de cohlear,
tumor UPC, CAI(osteom, colesteatom, meningiom)
toxic - saturnism,alcoolism,arsenicul,anestezicele
metabolic - DZ, mixedem, hipervitaminoza D
idiopatic - degenerativ i neuropatic demielinizant
presbiacuzia
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SURDITATEA DE PERCEPIE
III. CENTRAL
- granulomatoza Wegener
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SURDITATE DE TRANSMISIE
1.Prin blocaj meatal
- agenezie meatal, stenoza meatului
congenital
- stenoza meatal complet, cicatriceal
sechelar posttraumatic sau postotitic(dop
cerumen,epidermic, corp strin meatal, otita
extern, tumori meatale, exostoza, osteom
CAE)
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SURDITATE DE TRANSMISIE
2. Prin lezare miringian
a)Blocaj miringian
- otita fibroadeziv
- otita adeziv
- ruptura miringian
- perforaia miringian
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SURDITATE DE TRANSMISIE
3. Prin lezare osiculo- cavotimpanic
a) Blocaj osicular
- posttraumatic
- postotitic
- malformativ
d) Sdr. de laxitate articular i / sau osicular(Escat): posttraumatic/
malformativ/ postotitic+ osteomalacia apofizei descendente a
nicovalei/ arcului stapedian n osteogenesis imperfecta
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SURDITATE DE TRANSMISIE
4. Prin disfuncie tubar
- blocaj tubar
- otita adeziv
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SURDITATE DE TRANSMISIE
5. Prin blocaj fenestral (FO sau FR)
- otosclerotic
- malformativ
- timpanosclerotic
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SURDITATEA DE TRANSMISIE
6. Altele
- anevrism de ACI
- procidena dural
- odontom cavotimpanic
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SURDITATEA DE TRANSMISIE
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99
CURS nr 7
OTOLOGIE
100
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DEFINIIE
HIPOACUZIE NEUROSENZORIAL COHLER
unilateral
Minim 30 Db
Produs brusc
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ETIOLOGIE
1. VASCULAR2. TRAUMATIC- comoia Urechii interne, complic aii
chirurgicale, fracturi ale stncii temporale
3. NEOPLAZIC- neurinom de acustic
4. NEUROLOGIC-scleroza multipl
5. INFECIOAS- meningita meningococic, oreion,
herpes zoster, rujeol, rubeol, sifilis
6. AUTOIMUN- - lupus
7. TOXIC- aminoglicozide i diuretice
8. METABOLIC- dezechilibre hidroelectrolitice,
hormonale, hiperlipidemie
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SPASMUL
TROMBOTIC
EMBOLIC- FIBRILAIA ATRIAL
HEMORAGIC- HTA, coagulopatii
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DIAGNOSTICUL POZITIV
1. Anamneza: debut brusc, uni sau bilateral, la persoane
cu comorbiditi
2. Simptomatologie:
- hipoacuzie de percepie de 30 dB
- acufene
- cefalee, gruri, vrsturi
- plenitudine auricular
- fonofobia
3. Examen clinic:
- otoscopie- fr modifcri patologice
- cruste n CAE- otite gripale
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DIAGNOSTICUL POZITIV
Ex paraclinic:
Acumetria instrumental
WEBER lat spre Urechea sntoas
RINNE pozitiv
SCHWABACH- prescurtat sub 15 sec.
Audiometria tonal- HP. Minim 30 Db.curb plat
descendent, pe frecvenele nalte
Impedanzmetria- curb tip A, reflex stapedian ipsilateral
variabil i contralateral pozitiv
Probe supraliminare- SISI>70 %
Electrocohlearografia- leziune Cohlear
Imagistica- CT, RMN-uneoriafeciune otic asociat
Ex. Lab-glicemie, lipidogram,teste tiroidiene,
coagulogram
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DIAGNOSTIC DIFERENIAL
AFECTAREA COHLEAR
- boli genetice sau congenitale
- boli infecto-contagioase- O.M. Ser ac., O.M. Sup. Cr
acut., infecii virale, labirintita
- toxice
- imune
-traumatice- comoia cohlear, rupturi ale ferestrei
Sindromul Meniere
AFECIUNI ALE NRVULUI COHLEAR
- infecioase- Nevrita cohlear
- Tumori- Neurinom de acustic, tumori de unghi pontocerebelos
Toxice
metabolice
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TRATAMENTUL
PATOGENIC
- spasm- vasodilatoare
-tromb- anticoagulante
Embolic- vasodilatatoare
Hemoragic- hipotensoare, diuretice
ETIOLOGIC
-Infecioas- trat. Antibiotic
- Vascular- vasodilatatoare periferice sau centrale,
oxigenoterapie hiperbar, , Dextran, Papaverin,
Pentoxifilin
- Imun- coticoterapiein doz 1mg-kg.corp
- Traumatic- ruptura membr. labirintice- dg intraoperator
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TRATAMENTUL DE URGEN
GLUCOZA 5%, RINGER
HHS 75-150 mg
Vasodilatatoare- Hydergin, Pentoxifilin,
Sermion
Neuroroborante- Piracetam
Anticoagulate- Heparin 5000 Ui
La terminarea perfuziei: 1f. Ederen
Vit B1 i B6
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OTOSCLEROZA
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DEFINIIE
Osteopatie primitiv
Localizare: capsula labirintic
Proces de osificare capsular
Focarul evolueaz n 3 stadii
1- congestiv- dilatarea capilarelor, apar
osteoclaste
2- osteospongioza- osul devine spongios prin
creterea resorbiei osoase, apariia
osteoclastelor i reducerea osteoblastelor
3- otoscleroza- apare os compact, osteoblaste
puine
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ETIOLOGIE
Rasa alb
Femei- factor endocrin
Vrsta 20-50 ani
Predispoziia familiar
Variaii ale metabolismului osos
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SIMPTOMATOLOGIE
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EXAMEN CLINIC
OTOSCOPIA:
triada Hohngren: CAE uscat, fr cear
absena reflexelor
Timpan- aspect i mobilitate pstrat, sm
Schwarze- n cadranul postero-inferior apar
pete rozate, circulare, in form de semilun
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EXAMEN PARACLINIC
TRIADA BEZOLD
WEBER- spre urechea bolnav
RINNE- negativ
SCHWABACH- prelungit
Proba Bonier- pozitiv cu diapazon de 128 Hz
Audiometria tonal- H.T cu cdere osoas pe 2 KHz- ancoa
Carhardt
H.M.- H.P
Impedanzmetria- timpanogram tip As,
Reflex stapedian- NEGATIV, POZITIV CONTROLATERAL
Reflex stapedian controlateral negativ- FIXARE
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TRATAMENT
CHIRURGICAL
1- Mobilizarea direct i indirectSTAPEDOLIZA
2- STAPEDOTOMIE
3- STAPEDECTOMIE
4- CRUROTOMIE ANTERIOAR
PROTEZ PISTON-TEFLON
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109
CURS nr 8
RINOLOGIE
110
RINOLOGIE
ANATOMIA, FIZIOLOGIA NASULUI I A
SINUSURILOR PARANAZALE
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OASELE FEEI
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PIRAMIDA NAZALA
oase nazale
cartilajele triunghiulare
cartilajele alare
columela nasi
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FOSELE NAZALE
vestibulul nazal
limen nasi
apertura piriformis
septul nazal
coane
cornetele nazale
meatele nazale
orificiile de deschidere ale
sinusurilor paranazale
ductului nazo-lacrimal.
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SINUSURILE PARANAZALE
Sinusurile paranazale
-caviti aerate
- comunic cu fosele nazale
- se dreneaz cu predominan n
meatul mijlociu
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SINUSUL MAXILAR
medial cu fosele nazale
cranial cu orbita
posterior cu fosa pterigomaxilar,care
conine A. Maxilar ramuri din N. Trigemen i
ale sistemului nervos vegetativ.
inferior cu rdcinile dentare ale
premolarului i primului
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CELULELE ETMOIDALE
situate cranio-medial de sinusul maxilar
descriu un labirint format din celule
pneumatice, desprite prin perei osoi
subiri
se ntind ntre cornetul mijlociu i orbit, iar
posterior pn la sinusul sfenoidal.
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CELULELE ETMOIDALE
Delimitarea de orbit - lamina
orbitalis(lamina papiraceae)
Celulele etmoidale posterioare - raport
posterior cu N.optic
Cranial celulele etmoidale vin n raport cu
lama ciuruit a etmoidului ce realizeaz
delimitarea de fosa cerebral anterioar.
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SINUSUL FRONTAL
situat n osul frontal
peretele inferior- orbita.
dorsal - fosa cerebral
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SINUSUL SFENOIDAL
caviti pneumatice de form cubic situate
n corpul osului sfenoid
Cavitatea sinusului sfenoidal variaz de la un
pacient la altul,
dimensiuni 2-2,5cm. n profunzime i 2 cm.,
lime.
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SINUSUL SFENOIDAL
Sinusul sfenoidal are 5 perei, dup cum urmeaz:
1. Peretele anterior (nazal)- direcie puin oblic i napoi
3 regiuni: - segmentul etmoidal
- segmentul nazal,recesului sfenoetmoidal
- segmentul septal
2. Peretele posterior, corespunztor etajului posterior al
bazei craniului
3. Peretele superior,- etajelor anterior i mijlociu al bazei
craniului.
3 zone: zona olfactiv
zona optic
zona hipofizar- cu aua turceasc limitat
napoi de marginea anterioar a lamei patrulatere.
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SINUSUL SFENOIDAL
4. Peretele inferior,- bolta coanelor avnd 510mm grosime
5. Peretele extern, subire i uneori dehiscent, cuprinde:
sinusul cavernos
artera carotid intern
nervii fantei sfenoidale VI, III, IV
nervul oftalmic
canalul i nervul optic i artera oftalmic.
septul intersinusal care este o structur osoas
subire
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VASCULARIZAIA
Vascularizaia nasului
- a.facial, ramur din a.carotid extern
- a.oftalmic, ramur din a.carotid intern
Vascularizaia foselor nazale- a.carotide externe
- a.sfenopalatine, ramur din a maxilar
- aa. etmoidale anterioare i posterioare-din a
oftalmic- ACI
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Circulaia limfatic
a feei i a nasului dreneaz n limfonodulii
submandibulari
a foselor nazale dreneaz n nodulii
retrofaringieni i cervicali profunzi.
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Inervaia
senzitiv tegumentar, facial, se realizeaz prin
ramurile terminale ale n.trigemen- prin gurile
supraobital, infraorbital i mentonier.
Excepie- regiunea unghiului mandibular i a prii
inferioare a pavilionului auricular, inervate de n.
auricular mare.
motorie a musculaturii feei se realizeaz separat
pentru musculatura mimicii i cea masticatorie;
musculatura mimicii - n.facial,
musculatura masticaie- n.mandibularn.trigemen.
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118
UNITATEA OSTIO-MEATAL
procesul uncinat,
hiatusul semilunar
recesul frontalului
bula etmoidal
infundibulul etmoidalului
ostiumul de deschidere al sinusului maxilar.
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UNITATEA OSTIO-MEATAL
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119
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120
ELEMENTE DE PATOLOGIE
Deviaiile septului nazal:
- n plan vertical;
- n plan sagital.
S
- creste sau
- spine septale;
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ELEMENTE DE PATOLOGIE
Concha bullosa:
cm
cb
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121
ELEMENTE DE PATOLOGIE
Concha bullosa dubl dreapt.
cb
cb
ci
s
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Epiteliul
celule ciliate i neciliate, fuziforme
celule imunocompetente tip T-helper,
CD4-pozitive; mastocite, macrofage i
celule dendritice purttoare de MHC-II.
Lamina proprie
membrana bazal
sinusoide
glande productoare de secreii seroase
Ca celule imunocompetente
apar:Limfocite T CD-4 pozitive, CD-8
pozitive citotoxice, celule supresoare,
limfocite T CD4 i CD 8 negative, limfocite
B adulte, plasmocite, mastocite i
macrofage.
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MORFOLOGIA
MORFOLOGIAMUCOASEI
MUCOASEI NAZALE
NAZALE
Partea
Parteaantral
antralaafoselor
foselornazale
nazaleiiaapiramidei
piramideinazalenazale-epiteliu
epiteliu
pavimentos
pavimentoscheratinizat
cheratinizatpluristratificatpluristratificat partea
parteaanterioar
anterioaraafosei
foseinazale
nazale--limita
limitantre
ntreepiteliul
epiteliul
pavimentos
pavimentos cheratinizat
cheratinizatiicel
celnecheratinizat,
necheratinizat, precum
precumiintre
ntre
epiteliul
epiteliulcilindric
cilindricneciliat
neciliatiiepiteliul
epiteliulrespirator
respiratorcu
cucelule
celuleciliate
ciliate
epiteliul
epiteliul cilindric
cilindric ciliat
ciliat
mucoas
mucoasolfactiv,
olfactiv,fiind
fiindnumit
numitzona
zonaolfactivolfactiv- zona
zona
superioar
superioar aaseptului
septului iin
napropierea
apropierealamei
lameiciuruite
ciuruite
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127
ROLUL N FONAIE
multiple sisteme, anatomic individuale, care
se coordonez funcional pentru a asigura un
timbru vocal normal
aceste structuri sunt:glota, SNC, fosele
nazale, sinusurile paranazale, i pri din
rinofaringe
Rolul n articularea cuvintelor
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ROLUL N OLFACIE
Din punct de vedere funcional impresia olfactiv
este posibil n inspir
Etapele olfaciei nu sunt nc pe deplin elucidate.
Deoarece, ntre olfacie i simul gustativ exist o
strns legtur, este important ca din punct de
vedere clinic, s se fac o difereniere ntre
tulburrile celor dou simuri
n majoritatea situailor, pacienii pierd ambele
simuri, ns n 2/3 din cazuri pierderea olfaciei
este principala cauz.
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128
CURS nr 9
RINOLOGIE
129
TRAUMATISMELE
NAZALE
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Clasificare
Leziuni traumatice nchise
Leziuni traumatice deschise
Fracturile nazale
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130
CONTUZIA NAZAL
Definiie: Leziune traumatic nchis
Anatomie patologic
albirea zonei..... Edem.....echimoz
Clasificare:
- superficial- afectarea prilor moi
- profunde afectarea prilor osteocartilaginoase
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CONTUZIA NAZAL
Simptomatologie:
- durere spontan
- tumefierea zonei
- paloarea feei
- epistaxis
- lipotimie
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CONTUZIA NAZAL
Diagnostic pozitiv:
examen clinic ORL
RTG occipito-mentonier i latero-lateral
Diagnostic diferenial- fr. Oaselor nazale
Tratament : antialgice, antiinflamatoare,
compres local, control ORL
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PLGILE NAZALE
Definiie: soluie de continuitate la nivelul
tegumentelor i mucoaasei nazale
Cauze: aciunea unor substane chimice
temp. nalte
electricitate
fore mecanice
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PLGILE NAZALE
CLASIFICARE
I. cu sau fr pierdere de substan
tegumentar
II. superficiale sau profunde cu sau fr
pierdere de substan tegumentar
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PLGILE NAZALE
Simptomatologie
- starea tegumentelor
- raportul cu orgaanele vecine
- profunzimea plgii
- rebord orbitar intern i suborbitar
Diagnostic pozitiv: ex clinic ORL, RTG
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PLGILE NAZALE
TRATAMENT
- curirea plgii
- anestezie local
- explorarea plgii
- tamponarea lsmbourilor
- excizia i refacerea esuturilor
- repoziionarea fragmentelor osoase
- sutura plgii
- tratament antiinfecios
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FRACTURILE NAZALE
CLASIFICARE
I. FR. FR DEPLASARE: uni sau bilaterale
II. FR. CU DEPLASARE:
1. Oasele nazale: oc lateral sau oc anteroposterior
2. Sept nazal:
tip Chevalet- linie de fractur oblic n jos i
napoi
tip Jarjavay- deplasarea septului fa de anul
vomerian
3. Fracturi nazo-labiale: fr. Osteo-cartilaginoase i
fr. ale etmoidului
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FRACTURI NAZO-LABIALE
Fracturile cadranului osos:
1. deplasare nafar fr modificarea ligamentului palpebral
intern
2. deplasarea nuntru cu lezarea ligam palpbral intern, a
sacului lacrimal i a canalelor lacrimale
Leziuni ale aparatului musculo-ligamentar:
1. telecantus- nafar
2. hipocantus- n jos
3. epicantus- deformarea unghiului
Leziuni ale cilor lacrimale
Leziuni ale tuturor elementelor osoase, ligamentare i a
cilor lacrimale
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FRACTURILE LA COPII
Etiologie: - n cursul sarcinii i al naterii
- n copilrie prin traumatisme
Clasificare:
- Fr. Submucopericondral a septului nazaltip LEMARIEZ
- nfundarea unilateral a osului propriu
nazal
- Fr. n carte deschis- antero-posterioar
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Clasificare
I. Gravitate :
1. Tr. uoare- fisuri, fracturi fr deplasare
2.Tr. grele fr. fr complic. septice i leziuni
cerebrale
3.Tr. f. grele- nfundarea masivului facial i
leziuni cerebrale
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138
II. Localizare:
1.Fr. ale etj. superior- reg. frontal, arcade
sprncenoase, rdcine nasului
2. Fr. ale etj mijlociu: nas, buza superioar, maxilarul
superior , os.malar, arcada zigomatic, etmoid i
sfenoid
3. Fr. ale etj. Inferior: mandibula
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FRACTURILE SIMPLE
Tratament
Refacerea peretelui sinusal
Toaleta sinusal
Tamponament nazal
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Fracturile fronto-bazale
Simptomatologie:
Com sau stare comatoas
Hemoragii extradurale ale sinusului sagital superior
Hemoragie prin lezarea a. Oftalmice sau maxilare
interne
Lezarea mucoasei nazale
Anosmie
Sindr. HIC prin lezarea N. II, III, IV, V, VI
lcr. nazal
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Fracturile fronto-bazale
Clasificare:
Tip I- fr. Fronto-bazale extensive
Tip II- fr. Fronto-bazale localizate- perete posterior,
etmoid, sfenoid
Tip III- fr. Fronto-bazal asociat cu disjuncia craniofacial- nfundarea masivului facial
Tip IV- fr. Fronto-bazal latero-orbital- recesul
lateral al sinusului frontal sau celule etmoido-frontale
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Fracturile fronto-bazale
Tratament
Chirurgical
Echip mixta cu neurochirurgul
ngrijiri postoperatorii n serviciul ATI
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Clasificare
Fracturi incomplete:
Fr.peretelui anterior al sinusului maxilar
Fr. crestei alveolare
Fr. tuberozitii alveolare
Fr. bolii palatine
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RINOREEA CEREBRO-SPINAL
ETIOLOGIE
1. Post-traumatic
Fr. bolt cranian
Fr Le Fort I, II, III
Fr. Izolate ale peretelui sin frontal, lamei ciuruite, fr
labirintice i timpano-labirintice
2. Postoperatorii
3. Iatrogen
4. Spontane
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RINOREEA CEREBRO-SPINAL
Diagnostic pozitiv
Scurgere lcr prin nas spontan sau dup compresia
VJ.- metoda Quenckenstedt
Diagnostic topografic- prin CT sau injectare de
substan radioopac n fosele nazale
Tratament chirurgical- echip mixt cu medicul
neurochirurg
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144
CURS nr 10
RINOLOGIE
145
RINOLOGIE
AFECIUNILE INFLAMATORII ALE
PRII EXTERNE A NASULUI I ALE
FEEI
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INTRODUCERE
Afeciinile inflamatorii
- origine bacterian- stafilococ, sau strptococ
- clasificare: foliculita i furunculul, erizipelul
- manifestate la nivelul pielii sau a dermului
- colaborare interdisciplinar cu dermatologul
. pot produce complicaii la distan
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SIMPTOMATOLOGIA FURUNCULULUI I AL
FOLICULITEI
SEMNE LOCALE
Inflamaia eritematoas a regiunii
Asociarea cu edem local
Inflamaia buzei superioare
Nu este afectat mucoasa nazala ci numai
epiteliul pavimentos cheratinizat
SEMNE GENERALE
Febra
Durere
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EXAMEN DE LABORATOR
VSH
GLICEMIE
HLG CU FORMULA LEUCOCITAR
EX. BACTERIOLOGIC DIN SECREIE
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TRATAMENTUL FOLICULITEI I AL
FURUNCULULUI
LOCAL
- ungvent cu antibiotic- Tetraciclina sau
Neomicin, Fluocinolon
- compres cu Rivanol
GENERAL
- antibioterapie po. sau iv.
- alimentaie bogat n lichide
- prevenirea complicaiilor
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COMPLICAIILE FURUNCULULUI I AL
FOLICULITEI
Extindere pe cale sanguin spre structurile
intracraniale
Extindere prin sistemul venos al nasului i al
buzei superioare via v oftalmic i v.
angular.... Sinus cavernos
Inflamaia unghiului intern al ochiului...
Susp. De tromboflebit a v angulare
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ERIZIPELUL NAZAL
Etiopatogenie
- streptococ hemolitic grup A
- stafilococul aureus
- germeni gram negativi
- klebsiella pneumoniae
- extindere specific pe piele i la nivelul
esutului subcutanat
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SIMPTOMELE ERIZIPELULUI
Este vorba de erizipelul feei
Debut:
. febr
- senzaie de tensiune i arsur la nivelul feei
- urmat rapid de eritem i inflamaie desprite prin
linie de demarcaie fa de esutul sntos
- nclzirea tegumentului
Semne generale:
- febr
- stare genral alterat
- extindere spre nas i pleoape- risc de complicaie
intracranian
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TRATAMENTUL ERIZIPELULUI
PENICILIN iv.
Antiseptice locale
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INFLAMAIILE CAVITII
NAZALE- RINITELE
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RINITELE ACUTE
EPIDEMIOLOGIE
- RCELALA
- nu exist imunitate dup infecie
ETIOPATOGENIA
- infecie viral produs de:
- rinovirusuri, coronavirusuri
- virus influenzae
- adenovirusuri
- inf transmis pe calea aerului prin picaturile de saliv
- factori favorizani: expunere la frig, scderea imunitii
perioada de incubaie: 3-7 zile
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RINITELE ACUTE
FIZIOPATOLOGIE
-perturbri locale ale epiteliului- ciliostaz
- mecanisme de aprare pasiv nespecific, activ i imunitate specific
APRARE SPECIFIC PASIV
- filtrarea aerului
- aparatul muco-ciliar
- eliberarea mediatorilor sau a enzimelor de ctre eozinofilele i neutrofilele din
epiteliu
APRAREA NESPECIFIC ACTIV
- se manifest prin vasodilataie i exudat plasmatic
- apar celule inflamatorii
- monocitale i macrofagele- rol n eliminarea detritusurilor celulare
-creterea produciei de mucus
- iritarea receptorilor nervoi din lamina proprie....... STRNUT I PRURIT NAZAL
RSPUNSUL IMUNITAR SPECIFIC I ACTIV
- este dat de limfocitele T
- rspunsul umoral este dat de Ig. A
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I. STADIUL USCAT
II. STADIUL CATARAL- secreia mucoas nazal,
obstrucie nazal, inflamaia mucoasei nazale
mai ales la nivelul cornetelor
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ESUT LIMFATIC
ADENOIDITE
AMIGDALEITE
CRI
RINITA
ACUT
VIRAL
LIMFADENITE
LARINGITE
TRAHEITE
BRONITE
ALTELE
GASTROENTERITE
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DIAGNOSTICUL POZITIV
ANAMNEZ
EX CLINIC ORL- hiperemia mucoasei nazale
- secreie mucoas sau
seromucoas
- obstrucie nazal
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RINOFARINGITA COPILULUI
Debut : brusc
febr 39-40 grd C
catar oculo-nazal- lcrimare, rinoree
tuse spasmodic- nocturn
hiperemia mucoasei nazale
Evoluie: vindecare n 5-7 zile
complicaii
Tratament: simptomatic, antitermice,
dezobstruante nazale, vitamine, ceaiuri
NU SE ADMINISTEREAZ ANTIBIOTICE!!!
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RINOFARINGITA COPILULUI
COMPLICAII
cronicizare
Suprainfecie bacterian
locale
regionale
generale
convulsii
diaree
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RINITELE CRONICE
CLASIFICARE
1. RINITE CRONICE SPECIFICE
2. RINITELE VASOMOTORII
3. RINITELE MEDICAMENTOASE
4. RINITE INDUSE DEFACTORI ANATOMICI
5. RINITELE ATROFICE
6. RINITELE CRONICE NESPECIFICE
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Rinoscleromul
Klebsiella Rhinoscleomatis
Granuloame pe sept sau cornete
Cruste urit mirositoare
Ex bact. i histopatologic:- bacili gram negativi
n celule Miculicz.
- Vindecri cu sinechii
- Tratament : Streptomicin i Tetraciclin
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RINITELE VASOMOTORII
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RINITELE MEDICAMENTOASE
administrarea ndelungat a unor
medicamente: antihipertensive, sedative,
hipnotice, neuroleptice
clinic: obstrucie nazal, uscciunea mucoasei
nazale
tratament: toalet nazal cu soluii saline, ap
de mare, uneori tratament RFA sau LASER
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RINITELE ATROFICE
Atrofia mucoasei nazale
Forme la virstnici: senzaie de obstrucie
nazal cu uscciunea mucoasei sau rinoree
apos necontrolabil
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EVITAREA
CAUZELOR
CORTICOIZI
TOPICI
REDUCIA
CORNETELOR
DECONG
NAZALE.
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MANAGEMENTUL RINITELOR
Istoric, ex ORL
Alergie: sezonier ,
peren
Infecie acuti
cronic
Corticsec
alergologoizi topici
Antibiotice ,
decongestionanate,
corticoizi topici
alergolog
Structural: polipi,
DS, Hipertrofia
cornetelor inf.
Medic ORL
Diverse:
hormonala,
medicamentoas
Corticoizi topici,
splturi saline
Tumori, sarcoidoz
gr Wegener
Medic ORL
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CLASIFICAREA RINOSINUZITELOR
CLASIFICARE
DURATA
ISTORIC- EX ORL
ASPECT SPECIFIC
ACUTE
PN LA 4 SPMNI
Febr, durere,
agravare simpt dup
5 zile, persist 10 zile
ACUTE RECIDIVANTE
IDEM
IDEM
SUBACUTE
4-12 SPTMNI
IDEM
Remisiune complet
dup tratament
medical
CRONICE
12 SPTMNI SAU
MAI MULT
IDEM
Durerea i presiunea
facial n absena
altor semne
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MINORE
CEFALEE
OBSTRUCIE NAZAL
FEBR
HALEN
DURERI DENTARE
TUSE
FEBR
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RINOSINUZITELE ACUTE
Debut brusc
Apar dup infecii virale ale CRS
Fiziopatologie: blocaj ostio-meatal, cu blocaj de
secreii n sinusuri,edem al mucoasei nazale i
sinusale
Acumulare de secreii n sinusuri, transformarea
germenilor saprofii n germeni patogeni......
Transformarea coninutului sinusal
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ALERGIE
EDEM AL MUCOASEI
NAZO-SINUSALE
OBSTRUCIE NAZAL
NCETINIREA MICRII I
CLEARENCE-ULUI MUCOCILIAR
HIPOXIE
TUTUTN
EXUDAT-TRANSUDAT
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FRECVENA REDUS
STREPTOCOCCUS PNEUMONIAE
STREPTOCOCI -HEMOLITICI
STAFILOCOC AUREUS
HAEMOPHILUS INFLUENZAE
KLEBSIELLA
MORAXELLA CATARHALLIS
ANAEROBI: FUSOBACTERII,
PEPTOSTREPTOCOCI, BACTEROIDES
VIRUSURI: CORONAVIRUSURI.
INFLUENZAE
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Apare dup:
traumatism direct sinusal
Barotraumatism sinusal
Epistaxis sever fr protecie de antibiotice
Examen clinic: sinuscopie......snge intrasinusal
Tratament: evacuare cu lavaj sinusal, tratament
antibiotic
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RINOSINUZITELE CRONICE
Definiie: infecii secundare obstruciei
ndelungate a complexului ostio-meatal
Etiologie: infecia viral proces inflamator al
CRS blocaj ostio-meatal retenia
secreiilor n cavitatea sinusaledem al
mucoasei utilizarea oxigenului de ctre
bacteriile i celulele inflamatorii dezvoltarea
anaerobiloragresiune asupra mucoasei,
prezena stazei meninerea infeciei
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RINOSINUZITELE CRONICE
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CLASIFICARE
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TRATAMENT CHIRURGICAL
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OBSTRUCIA NAZAL
ACUT
CRONIC
UNILATERAL
RINOSIN INFECIOAS
ODONTOGAN
TUMOR CU INFECIE
TU BENIGN SAU
MALIGN
RINOSIN INFECIOAS
MICOZA
SINUSALGRANULOMATOZ
A
CORP STRIN
BILATERAL
RINOSIN INF.
RINOSIN ALERGICE
RINOSIN. TOXIC
RINOSIN
MEDICAMENTOAS
RINOSIN INF.
RINOSIN ALERGIC
POLIPOZA NAZAL
INTOLERAN LA ASPIRIN
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ACUT
CRONIC
UNILATERAL
RINOSIN INFECIOAS
RINOLICVOREE
TU BENIGN SAU
MALIGN
RINOSIN INFECIOAS
MICOZA
RINOSIN POSTRAUMATIC
BILATERAL
RINOSIN INFECIOAS
RINOSIN INFECIOAS
RINOSIN ALERGIC
RINOSIN ALERGIC
RINOSIN MEDICAMNETOS
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0-2 ANI
UNILATERAL
BILATERAL
CLAR
PURULENT
DEV CONG. A
SEPTULUI
NAZAL
INFECIOAS
SAU
ALERGIC
ALERGIE
INF
BACTERIAN
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RINOSINUZITELE FUNGICE
CLASIFICARE:
- NEINVAZIVE- SAPROFITE, FUNGUS BALL
- INVAZIVE- FULMINANTE SAU CRONICE
Produse de : Aspergillus flavus, Mucor,
Tablou clinic: polimorf
Forma cut fulminant:
evoluie rapid
mucoperiostit a sinusurilor
Forma cronic- produs de Aspergillus
- aspect pseudotumoral
Diagnosticul pozitiv: ex clinic- edem palpebral, tumefacie jagal, necroz
tegumentar
ex CT
Ex HISTOPATOLOGIC
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RINOSINUZITELE ALERGOFUNGICE
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POLIPOZA NAZAL
ETIOLOGIE: multifactorial, teren alergic
Factor determinant: inflamaia cronic a
mucoasei nazale
Prezena eozinofilelor
Triada Widal: polipoza nazal, astm bronic,
intolerana la aspirin
Diagnosticul: anamnez, istoric, es clinic i
endoscopic nazal
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CURS nr 11
RINOLOGIE
183
RINOLOGIE
PATOLOGIA TUMORAL NAZOSINUSAL
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CLASIFICAREA TUMORILOR NAZO-SINUSALE
BENIGNE
MALIGNE
EPITELIALE
Adenom
Papilom
Adenom pleomorf
Adenom monomorf
Oncocitom
Carcinom epidermoid
Adenocarcinom
Carcinom ceu celule tranziionale
Carcinom adenoid chistic
Carcinom mucoepidermoid
NEUROECTODERMALE
Schwanom
Neurofibrom
Meningiom extracranian
Melanom malign
Estezioneuroblast
LIMFORETICULARE
VASCULARE
Hemangiom
Angiofibrom
Angiopericitom
Hemangiopericitom
OSOASE
Osteom
Fibrom osifiant
Displazie fibroas
Sarcom osteogenic
CARTILAGINOASE
Condrom
Condrosarcom
MUSCULARE
Leiomiom
Rabdomiom
Leiomiosarcom
Rabdomiosarcom
ORIGINE DENTAR
ALTELE
Ameloblastom
Chist odontogenic calcifiant
Tumora odontogenicepitelial
calcifiant
Cordom
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SINDROAMELE DE CERTITUDINE
sindroame
Fose nazale
Frontal
Nazo-sinusal
Orbitar
Buco-dentar
Neurologic
frontal
Facial
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9. HEMANGIOENDOTELIOM
Tumor rar
10. HEMANGIOPERICITOM
Clinic: tumor gri roiatic, moale
Pseudopolipoid
Diplopie, ptoz, palparea unei tumori intraorbitare
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MUCOCELELE
Formaiuni pseudochistice
Coninut lichidian
Acoperite de mucoasa sinusal
Apar cel mai frecvent n regiunea etmoidal i frontal
Fiziopatologie: blocaj de drenaj sinusal, polipoze nazale sau
intervenii chirurgicale endonazale
Simptomatologie:
- iniial: asimptomatic
- algiile faciale
- exteriorizare la nivelul tegumentelor feei, unghiul intern al
orbitei( exoftalmie, strabism)
- fenomene compresive cerebrale- cefalee, tulburri de
comportament, crize convulsive
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MUCOCELE
EXAMEN CLINIC: ex endoscopic
Ex. CT sau RMN
CONSULT INTERDISCIPLINAR
TRAMENT:
preventiv: tratatrea corect a focarelor infecto-inflamatorii
rinosinusale, evitarea manevrelor dure chirurgicale
chirurgical : marsupializarea cavitii mucocelului
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I. SUPRASTRUCTUR:
etmoid, poriunea
posterioar a maxilarului i
osului malar
II. MEZOSTRUCTUR:
sinus maxilar, fos nazal
III. INFRASTRUCTUR:
palat dur i creast alveolar
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RINOLOGIE
TUMORILE CUTANATE ALE NASULUI
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TUMORI BENIGNE
TUMORI EPIDERMICE
Keratoacantom- expunere prelungit la soare
Chist epitelial cheratinizat- leziuni
subtegumentare, chistice, mobile
TUMORI PILARE
TUMORI SEBACEE
TUMORI SUDORIPARE
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TUMORI
MALIGNE
Carcinoame(epitelioame)spinocelulare, bazocelulare,neuroendocrine, i Maladia Bowen
Factori de risc:
expunere la soare
Plgi cronice vechi
Imunodepresia
Vrsta medie: 50 ani
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CARCINOM
BAZOCELULAR
Vrsta medie: 50 ANI
Sex masculin
Aspect: formaiune tumoral perlat, izolat,
sau ulcerat cu fundul vegetant,
Forme clinice:
1. Carcinom bazocelular superficial- leziune
mare cu margini hiperpigmentate
2. Ulcus rodens- ulceraie cronic, infiltrat,
acoperit de cruste, apare mai ales n
anul nazo-genian
3. Carcinom bazocelular sclerodermiformzon infiltrat albicioas, aspect cicatricial
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CARCINOM SPINOCELULAR
Apare la vrstnici
Metastazeaz ggl regional
Apare pe o leucoplazie
Clinic: formaiune tu burjonat, cu
centru cheratozic, ulcereaz rapid, are
n profunzime un aspect vegetant
Ex histopatologic din piesa de exerez
chirurgical
Risc de metastaz:
- tu peste 2 cm
- localizare
- apariia pe cicatrici vechi sau
leucoplazii
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MALADIA BOWEN
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195
CURS nr 12
ALERGIILE
PATOLOGIA DE SOMN
196
ALERGIILE RINOSINUSALE
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DEFINIIE
Degenerarea edematoas a pituitarei, ca
rspuns al mucoasei nazale, mediat Ig E, la un
alergen din mediu
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CLASIFICARE
INTERMITENTE- simptome prezente mai puin
de 4 zile spt. i mai puin de 4 sptmni
PERSISTENTE- mai mult de 4 zile pe sptmin
mai mult de 4 spt.
UOAR- dac nu se asociaz cu : tulburri de
somn, perturbarea activitii cotidiene,
colare
MODERATE- SEVERE- dac apar
simptomatologia de mai sus
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FACTORI DE RISC
POLUARE- mai fecvent n mediul urban
- fumul de igar
EXPUNERE LA ALERGENI- expunerea precoce la alergene
din mediul exterior- polenuri sau din interior- pref
STATUSUL SOCIO-ECONOMIC
ZONE GEOGRAFICE- prevalena rinitelor variaz att ntre
graniele aceleiai tri, ct i ntre ri, diferenele fiind
dictate de potena diferit a alergenilori de sezonul de
polenizare
GRUP ETNIC
FACTOR GENETICI- rolul ereditii este sczut n expresia
clinic a atopiei
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ALERGENE
DEFINIIE: sunt antigene care induc i exprim
imunoreactive mediate de Ig E
CLASIFICARE:
complete- provin din plante, insecte, animale,
alimente, medicamente
incomplete- medicamente, ageni
ocupaionali
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MECANISME
I. SENSIBILIZARE
II. RSPUNS ALERGIC- faza precoce i tardive
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MECANISME-SENSIBILIZAREA
Mucoasa respiratorie este expus la cantitate de
ordinul nanogramelor de alergen
Numai o parte din persoanele expuse se
sensibilizeaz
Sensibilizarea alergic are o puternic
component genetic- tendina de a produce
nivele crescute de Ig E i un rspuns inflamator
tip Th2 mare la pacienii atopici
Atopia- particularitatea natural a unei persoane de
a dezvolta Ig E specifice ca rspuns la expunerea
la factori comuni de mediu
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DIAGNOSTICUL POZITIV
Anamneza
Examen fizic
Teste cutanate alergologice
Endoscopie rigid sau flexibil
Examen citologic al secreiei nazale
Teste de provocare nazal
CT
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ANAMNEZA
2 CATEGORII:
- SNEEZERS- strnut, mucus apos, rinoree
anterioar i posterioar, prurit nazal,
obstrucia nazal variabil, asociereaconjunctivitelor
- BLOCKERS- lipsa strnuturilor, mucus nazal
consistent, rinoree mai mult posterioar, fr
prurit nazal, obstrucie nazal sever,
simptome constante peste zi, care se
agraveaz noaptea
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ANAMNEZA
RINOREE- rinitele alergice sezoniere- rspuns bun
la antihistaminice
OBSTRUCIA- rinitele perene alergice sau
nonalergice
HIPOSMIA-ANOSMIA- rinita nonalergic
Rinitele alergice polenice- se accentueaz matinal
sau n zilele cu vnt i se amelioreaz n timpul
ploii prin depunerea particulelor
Persistena simptomatologiei tot timpul anului
etiologie nonalergic sau alergen peren
acarieni, gndaci, animale de companie.
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EXAMEN FIZIC
Inspecia nasului: escoriaii ale marginii libere (consecina
pruritului) sau salutul alergic al copiilor ( pliu cutanat orizontal
deasupra 1/3 inferioare a nasului)
Rinoscopia anterioar:
- coloraia mucoasei albastruie , palid( rinite alergice) sau
rou profund, noroios( nonalergice)
- tipul secreiei apoas(alergice) sau vscoase, galben
verzui(nonalergice)
- anomalii anatomice(pot ntreine o rinit) deviaii ale septului
nazal, creste septale,polipoza nazal, hipertrofia de cornete
- gradul de rspuns al edemului la decongestionant( exist un
edem simetric al cornetului inferior i creterea vascularizaiei
acestuia)
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EXAMEN CLINIC
Endoscopia: investigarea obstruciei nazale i a
drenajului posterior
Semne de conjunctivit eritem, chemozis,
prurit, lcrimare( diag.diferenial cu cearcnele
aa zise alergice produse prin staz venoas i
caracterizate prin edem palpebral i cianoz
periorbitar i care nu sunt specifice rinitei
alergice)
Se mai pot asocia eczema atopic i astmul
bronic.
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INVESTIGAII
Teste de evideniere a alergiei
- in vivo teste cutanate
- in vitro- nivelul Ig E specifice(mai puin
intereseaz nivelul total)
Examen citologic al secreiei nazale
- diferenierea rinitelor infecioase de cele alergice
- distincia ntre infecii virale i cele bacteriene
- monitorizarea evoluiei rinitei
- monitorizarea rspunsului la tratament
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INVESTIGAII
CT - neresponsivitate la tratament, rinit
unilateral, suspiciune de sinuzit
RMN n suspiciunea de sinuzit fungic
Teste de provocare nazal
Test de clearence mucociliar(mai ales n rinoree
cronic, abundent a copilului, cu infecii
respiratorii frecvente)
Determinarea oxidului nitric exhalat(diferenierea
rinitelor alergice de cele nonalergice, a rinitelor
de polipoza nazal i diskinezia ciliar primitiv)
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DIAGNOSTIC DIFERENIAL
Infecii acute sau conice
Anomalii structurale deviaia septului nazal,
atrezia coanal
Hipertrofia de cornete
Tumori nazale benigne sau maligne
Polipoza nazal
Defecte ciliare
Rinoreea cerebro- spinal
Sick building syndrom
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TRATAMENT
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TRATAMENT MEDICAMENTOS
Rinita intermitent
1. uoar
antihistaminic oral sau topic
decongestionant
nazal(mai puin de 10 zile, maxim bilunar)
2.moderat/sever
- antihistaminic oral sau topic
- antihistaminic oral cu decongestionant
- glucocorticosteroid intranazal
- cromon
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TRATAMENT MEDICAMENTOS
Rinita persistent
1. uoar
- antihistaminic oral sau intranazal
- antihistaminic oral cu decongestionant
- glucocorticosteroid intranazal
- cromon
2. moderat/sever
glucocorticosteroid intranazal
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TRATAMENT MEDICAMENTOS
a)responsiv continuarea tratamentului cu
scderea progresiv a dozelor
b)neresponsiv glucocorticosteroid oral sau
decongestionant nazal:
- dac rspunde continuare cu scderea
dozei
- dac nu rspunde se adaug un
antihistaminic sau anticolinergice sau
antihistaminic oral cu decongestionant
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PATOLOGIE RESPIRATORIE DE
SOMN
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GENERALITI
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Presiunea negativ 1.
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Presiunea negativ 2.
Presiunea negativ mai mare dect tensiunea
produs de muchii dilatatori ai cii respiratorii
calea aerian colabeaz
Micarea intens a coloanei de aer , viteza
produs prin obstruciile cii aeriene, determin
rezisten i induce vibraia n diferite puncte dea lungul cii aeriene superioare , cu rezonana
esuturilor la nivelul faringelui i producerea
zgomotului de sforit.
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Consideraii structurale
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Respiraia nazal
Este cea fiziologic
Dac nu exist cauze obiective, ea se realizeaz
n orice condiii
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Patologia ORL
modificri la nivelul naso i orofaringelui
adenoiditele cronice
stenoze
limfoame
papilomatoza
carcinoame
hipertrofia amigdalian
ngroarea palatului moale
lueta elongat
chisturile linguale
hipertrofia amigdalei linguale
macroglosia produs de
hemangioame i limfoame
papilomatoza
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Rolul otorinolaringologului
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Anamneza 1.
Vrsta pacientului
Sexul
Greutate
nlime
Oboseal i somnolen diurn
Sforit
Pauze respiratorii n timpul somnului perioade de
trezire cu insuficiena respiratorie
Disfuncii sexuale
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Anamneza 2.
Obinuina de somn :
Perioade regulate de
culcare i de trezire
Regim de exerciii regulate
Istoricul somnului pacienilor
Habitat normal
- timp regulat de culcare i
de sculare
- exerciiu fizic
- mediul de somn
- micile zgomote
- temperatura ambiental
- relaxarea naintea
somnului
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Metode de examinare
n perioada de veghe
- Faringoscopia flexibil
sau rigid
- Computertomografia
- RMN-ul
- Echografia
- Rinomanometria
anterioar
- Rntgencefalometria
n perioada somnului
- Videofluoroscopia
- Videoendoscopia
- Metode de msurare
ale presiunii
- Computertomografia
- Cuantificarea
sforitului i a
intensitii sale
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Faringoscopia flexibil 1.
Identificarea unor modificri anatomice la nivelul
faringelui( colabarea pereilor faringieni )
MANEVRA Mller
O prob funcional
Tehnica: inspir forat cu gura nchis i nasul
obturat
Evaluarea faringelui, a epiglotei, evaluarea
spaiului retrovelar, retrolingual i retroepiglotic
Datele se coreleaz cu rezultatele nregistrrilor
efectuate.
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Faringoscopia flexibil 2.
Nu necesit expunere la radiaii
Este o investigaie dinamic
Este util n evaluarea obstruciilor la nivel
retrovelar i retrolingual
Este uor de realizat pre i postoperator
Se poate face n poziie eznd
Se poate executa n somn sau stare de veghe
Nu este o manevr scump
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Dezavantajele
Faringoscopiei flexibile
Produce un anumit disconfort pacientului
Efectuarea unor msurtori reale nu este
posibil
Evaluarea depinde de experiena examinatorului
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Faringoscopia rigid
Evaluare subiectiv a
modificrilor oro i
hipofaringiene
Aprecierea
dimensiunilor istmului
buco-faringian
Optic rigid 0o sau 90o
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Computertomografia 1.
Permite evaluarea structurilor complexului faringelaringe
Exist posibilitatea reconstruciilor volumetrice 3D
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Computertomografia 2.
Colabri masive pe seciuni la nivelul regiunii
velare a faringelui.
Stenozri la dou sau trei niveluri
Sforit habitual fr OSAS- o reducere a
spaiului la nivelul hipofaringelui
OSAS - o stenozare la nivelul vlului palatin i o
reducere a regiunii velare a faringelui
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RMN
parafaringian
din
regiunea
superioar a gtului la pacienii cu
OSAS
costuri ridicate
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Ecografia 1.
Examinarea unor zone limitate
Se efectueaz n poziie eznd i necesit o
colaborare din partea pacientului
Interpretarea rezultatelor comparativ cu
nlimea, vrsta, greutatea, indicele BMI, starea
de veghe i valoarea indicelui AHI
Se poate urmri n ntregime dimensiunea i
volumul limbii
Compararea ntre volumul faringian i suprafaa
de seciune mijlocie a faringelui la pacienii
normali i la pacienii cu OSAS
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Ecografia 2.
Limitele tehnicii echografice:
Nasofaringele nu poate fi examinat
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Rinomanometria anterioar
O metod rapid i
neinvaziv de examinare
a seciunilor nazale
Relevana diagnostic
la pacienii cu snoring
habitual
Ofer date referitoare la
valoarea rezistenei
nazale i a fluxului nazal,
corelate cu gradul
modificrilor anatomice
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500-700 cm3/s.
35cm3/s.
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Cefalometria 1.
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Cefalometria 2.
PM-PU 37 3 mm
MPH 15,4 3mm
PAS
11 2 mm.
SNA
82 2 0
SNB
802 0
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Modificri cefalometrice 1.
Scurtarea PAS
Alungirea PM-PU
Alungirea MPH
Modificarea unghiurilor SNA i
SNB
Strmtorarea naso-faringelui
Limba mrit
Retropoziia limbii
Alungirea luetei
ngroarea suprafeei palatului
moale
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Modificri cefalometrice 2.
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Videofluoroscopia
Obstrucia iniial la
nivelul orofaringelui n
regiunea velar
Paralel cu ngustarea
faringelui se produce
deschiderea bucal
Videofluroscopia este
o metod special
utilizat mai ales n
scop stiinific
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Faringoscopia flexibil
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Stabilirea
Stabilirea locului
locului unde
unde se
se produce
produce obstrucia
obstrucia cii
cii
respiratorii
respiratorii n
n timpul
timpul somnului
somnului
Alegerea
Alegerea unei
unei terapii
terapii corecte
corecte favorabile
favorabile
pacienilor
pacienilor
Interesul
Interesul ORL-istului
ORL-istului n
n diagnosticarea
diagnosticarea ii
tratamentul
tratamentul SAOS
SAOS ii aa snoringului
snoringului
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CURS 13
LARINGOLOGIE
230
LARINGOLOGIE
ANATOMIA I FIZIOLOGIA
LARINGELUI
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SCHELETUL LARINGELUI
este format din cartilaje hialine, reprezentate
de cartilajul tiroid, cricoid i cartilajele
aritenoide, precum i cartilaje elastice, cum ar
fi epiglota i cartilajele accesorii, lipsite de
funcie, localizate pe vrfurile cartilajelor
aritenoide (cartilajul corniculat a lui Santorini,
cartilajul cuneiform a lui Wrisberg).
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Inervaia laringelui
Inervaia motorie i senzitiv a laringelui i traheei: nervul
laringian superior i nervul laringian inferior (n.recurent)N.VAG
N.laringian superior
- motor m.cricotiroidian anterior prin ramura sa extern,
inervaia senzitiv a mucoasei prii superioare a laringelui
precum i cea a regiunii corzilor vocale-prin ramura intern
N.recurent
- inervaia senzitiv a mucoasei laringiene (sub nivelul
glotei) i traheale
- inervaia ntregii musculaturi interne laringiene.
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Vascularizaia laringelui
Zonele glotic i supraglotic - a.laringian
superioar din a.carotid extern
Zona subglotic - a.laringian inferioar, prin
trunchiul tireocervical din a.subclavia
v.tiroidian superioar i drenat n v.jugular
intern
v.tiroidian inferioar i drenat n
v.brahiocefalic
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ANATOMIA TRAHEEII
C6-7...........T4-5- bifurcaia
traheal
10-13 cm lungime
12-20 inele traheale
Diametru 13-20 mm
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B. intermediar
B segm antintern
b. Lobar medie
segm postextern
BP DRP
Segm
paracardiac
Segm bazalepost , ant.,
lateral
traheea
B.Lobar sup stg
Segm infer.
LINGULA
superioar
ventral
b. Princip strg
culmen
apicodorsal
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FIZIOLOGIA LARINGELUI
FUNCIA DE PROTECIE
FUNCIA RESPIRATORIE
FUNCIA DE FONAIE
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DEFINIIE
Proces inflamator acut al mucoasei laringiene
Etiologie polimorf
Clinic: rgueal, odinofagie, odinofonie, disfagie,
tuse, dispnee, afonie, febr
Afeciuni benigne
Survin n contextul unui proces inflamator rinofaringo-laringian
Debut este brusc
Evoluie de 10 zile
Anamneza- instrument de diagnostic
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etiologie
clinic
anatomic
Anatomo-patologic
Dispneizant
Striduloas
hiperalgic
Supraglotic-epiglotita
Glotic
subglotic
Cataral
Edematoas
Flegmonoas
ulceronecrotic
Copil i adult
vrst
evoluie
Simpl, recidivant
Complicat
Forme severe
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ETIOLOGIE:
- sex masculin
-abuzul vocal
- condiii climaterice
- infecii rinosinusale i faringiene
- traumatisme
Obstrucia cilor respiratorii superioare
Factori terapeutici
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Etiologie: H. Influenzae
Simptomatologie:
- debut brusc
- Febr
- Dispnee i disfonie
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LARINGO-TRAHEO-BRONITA ACUT
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LARINGITELE CRONICE
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Evitarea fumatului
Terapia vocal
Diminuarea factorilor iritani i agravani
Hidratare corespunztoare
Tratamentul cu Vit A sol uleioas
Tratamentul chirurgical n formele hipertroficept. Dg. Histopat. i ndeprtrea leziunii
Tratamnetul cortizonic inhalator este discutabil
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Tuberculoza
Histoplasmoza
Blastomicoza
Actinomicoza
Candidoza
Sifilisul
Granulomatoza Wegener
Boala Hansen- lepra
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Tuberculoza laringian
Forma primitiv, sau forma secundar
unei tuberculoze pulmonare
Coesxist cu cc laringian
tendin de malignizare
Clinic: inflamaie cu aspect nodular
monocordal
Dg pozitiv: ex histopatologic- celule
Langhans
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Strile precanceroase
Alterarea morfologic a mucoasei laringiene
determinat de factori iritani locali
Laringitele cronice- modificri ale epiteliului c.v care
preced cancerul invaziv
Anatomopatologii- termen de displazie
Displazia = dezorganizri la nivelul straturilor celulare i
tulburri de maturaie la nivelul membranei bazale
Displazia= clinic/ hiperplazii-pahidermia, leucoplazia
= histopatologic
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epiteliu normal
hiperplazie simpl
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METODE DE DIAGNOSTIC
Laringoscopia indirect
Laringoscopia direct
Laringoscopia n suspensie
Videostroboscopia
Prelevare de biopsie- biopsie cu pensa
perpendicular pe leziune
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CLASIFICARE
BENIGNE
MALIGNE
EPITELIALE MALIGNE
PAPILOMATOYA LARINGIAN[
NEUROENDOCRINE
CHISTURI ;I TUMORI
PSEUDOCHISTICE
TESUTURI MOI
OSOASE SI
CARTILAGINOASE
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Chistul laringian
Localizare: pe benzile
ventriculare sau epiglot
Acumulare lichidian survenit
prin dilatare a gld. Seroase
Se pot retrage spontan
Tratament : laringoscopie n
suspensie i extirparea
firmaiunii- puncionare
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PAPILOMATOZA LARINGIAN
Este o afeciune benign cu
potenial de transformare
Produs de papiloma virus
Ex orl: formaiune exofitic
localizat pe suprefaa c.v.,
culoare roz-roiatic
Tratament: laringoscopia n
suspensie cu ablaia
formaiunii, vaporizare LASER
CO2, Interferon postoperator
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NODULI VOCALI
Formaiuni pseudotumorale
Localizare: marginea anterioar
a c.v.
Leziune traumatic
Tratament foniatric
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EDEMUL REINKE
Inflamaie difuz a c.v
Acumulare de material gelatinos
n spaiul Reinke
Determinat de fumat, abuz vocal
Tratament chirurgical
Evoluie favorabil
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CLASIFICARE
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Const n 2 etape:
1. n prognosticul i evoluia cc cilor aeriene superioare
2. evaluarea i ealonarea diverselor mijloace terapeutice
Factori de prognostic legai de tumor:
- prezena keratinei intracelular
-pleiomorfismul celular
- celule dispuse n insule
- aspectul mitozelor
- infliltratul peritumoral
Localizarea i dimensiunile tumorii
Factori legai de organism
Vrsta
Amploarea metastazelor
TNM
Starea de strs
comorbiditi
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STADIALIZAREA ADENOPATIILOR
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STADIALIZAREA TUMORAL I
GANGLIONAR
STADIUL 0- Tis N0 M0
STADIUL I T1 N0 M0
StAdiul II T2 N0 M0
STADIUL III T3 N0 M0 SAU T1-3 N1 M0
STADIUL IV T4 N0,N1 M0, orice T N2,3 M0
orice T orice N M1
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TRATAMENTUL CANCERULUI DE
LARINGE
T1-T2-IRADIEREA , sau cordectomie+ iradiere,
sau hemilaringectomie
Laringectomia total- de rezerv
LASER CO2
T3-T4- LARINGECTOMIE TOTAL CU
LIMFADENECTOMIE BILATERAL cu
radioterapie
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IMAGINI ENDOSCOPICE SI
HISTOPATOLOGICE DE LARINGITE
CRONICE
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TUMORA VALECULARA
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TUMORA FARINGOLARINGIANA
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TUMORA LARINGIANA
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CURS nr 14
CORPII STRINI
FARINGOLOGIE
265
CORPII STRINI
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Etiologie:
- corpi strini duri, tioi, ascuii- n
scop de suicid
- penetraii accidentale- produse
alimentare, piese dentare, obiceiuri
greite de alimentaie
- piese instrumentare
- provenien din stomac, trahee,
bronhii
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Cauze de producere
tahifagia
tulburri de sensibilitate bucal
afeciunile psihice
prezena protezelor dentare
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Simptomatologie
Simptome de debut:
-durere violent
- sialoree
- uneori apare afonia
- poziie forat
- durere retrosternal- corp strin la nivelul bifurcaiei
traheeii
- presiune profund n torace, regiunea cardiac i
epigastru- corp strini mai jos inclavai
- senzaie de corp strin
- dispnee- inclavare nalt
- disfagie pentru solide i apoi lichide
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Simptomatologie
Simptome tardive:
- perforaii esofagiene primare i secundare
- perforaia esofagului cervical: tumefiere n
regiunea carotidian, micri dureroase ale
gtului, laringe deviat spre partea sntoas,
emfizem subcutanat
- perforaiile esofagului mediastinal- semne de
mediastinite: durere toracic, dispnee, cianoz,
angor
- perforaiile esofagului terminal-semne clinice
ale abdomenului acut
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Diagnosticul
Fenomene clinice i anamnestice
Examen radiologic
Pasaj baritat este contraindicat n formele
acute
Esofagoscopia
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Tratamentul
Tratamentul
NU
NU SE
SE PROVOAC
PROVOAC VOMA,
VOMA, I
I MPINGEREA
MPINGEREA
CORPULUI
CORPULUI STRIN!!!
STRIN!!!
Extragerea
Extragerea pe
pe cale
cale natural
natural
Extragerea
prin
esfogasopie
Extragerea prin esfogasopie sub
sub controlul
controlul
vederii
vederii
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Etiologie
Apare la copii mici
La aduli: obiceiuri greite
Clasificare:
Alimentari- bob de fasole, smna de floarea
soarelui
Duri: metalici, os
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Simptomatologie
Tablou clinic dramatic
Faza de debut: acces de sufocare, cianoza perioral, tuse
intens, transpiraii, senzaie de fric, asfixie
Faza secundar:
- corpi strini mobili: durere retrosternal, tuse, zgomot de
clap la expir, zgomot de drapel
- corpii strini inclavai: sunt suportai bine de ctre bolnavi,
sm. De insuf respir reduse, fenomene de infecie prezente
Faza tardiv: tuse cu expectoraie abundent, apare
atelectazia, retracia peretelui toracic, imobilizarea
toracelui in respiraie, abolirea vibraiilor, matitate sau
submatitate
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Complicaii
PRECOCE: bronita simpl, abcesul pulmonar
TARDIVE: bronhoree cronic
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TRATAMENT
TRAHEOBRONHOSCOPIE CU EXTRAGEREA
CORPULUI STRIN
MOMENTUL INTERVENIEI!!!
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PATOLOGIE INFLAMATORIE
FARINGIAN
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Anginele acute
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CLASIFICARE
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UVULITA
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1. FLEGMONUL PERIAMIGDALIAN
2. ADENOFLEGMONUL RETROFARINGIAN
3.FLEGMONUL LATEROFARINGIAN
4. FLEGMONUL DIFUZ AL FARINGELUI
5.PERIAMIGDALITA LINGUAL FLEGMONOAS
ABCES EPIGLOTIC
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FLEGMONUL PERIAMIGDALIAN
Etiologie: imunitate sczut, frigul,
umezeala, extinderea procesului
infecios spre spaiul periamigdalian,
prin penetrarea capsulei
Ex cl ORL: tumefierea pilierului anterior
amigdlaia, bombarea vlului palati,
lueta mpins spre partea sntoas
Deschidere spontan n a 8-a zi
Trismus, febr,
Puncia de prob
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AMIGDALITA CRONIC
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ETIOLOGIE I PATOGENIE
Accese acute de amigdalite n copilrie
Factori:
- criptele amigdaliene
- legtura limfatic cu fosele nazale- explic
legtura cu patologia nazal
- respiraia bucal
- bolile infecioase
- cauzele de vecintate- vegetaiile adenoide
- rinite i sinuzite cronice
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ANATOMIA PATOLOGIC
Hipertrofia moale- proces de scleroz interlobar
i parenchimatoas
Hipertrofia dur
Amigdalita cr.atrofic
Amigdalita cronic criptic
Chisturile de retenie amigdalian
Litiaza amigdalian
Amigdalita cronic infectant se renclzete la
intervale regulate- d nfecia de focar
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SIMPTOMATOLOGIE
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SIMPTOME OBIECTIVE
VOLUMUL AMIGDALELOR
FORMA AMIGDALELOR
ASPECTUL CRIPTELOR
PALPAREA GANGIONILOR SATELII
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Diagnosticul
Anamneza
Amigdale mici ascunse n loje amigdaliene
Pilier anterior congestionat, lichid care se scurge
dinamigdale prin compresia acestora
Ganglioni satelii mrii n volum
Tuse seac dimineaa
Hipersensibilitate la frig
Senzaie de deglutiie dureroas
Senzaie de oboseal
Somnolen
Palpitaii periodice
Subfebriliti
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EXAMEN DE LABORATOR
Hemograma
VSH
ASLO
PCR
FIBRINOGEN
NU EXIST UN EX LABORATOR SPECIFIC AL
INFECIEI DE FOCAR
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VEGETAIILE ADENOIDE
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ETIOLOGIE
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Simptomatologie
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EXAMINAREA RINOFARINGELUI
Cornete nazale inferioare
congestionate
Mucoziti abundente
esutul rinofaringian mrit n
volum
Forma, consistena crescut
la adult
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OTOSCOPIA
Timpan aspirat
Refle luminos diminuat, cculoare mai roiatic
Apare HT. De gravitate medie
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FORME CLINICE
FORMA SUGARULUI
- sindrom de obstrucie nazal
- coriza muco-purulent
- tuse spasmodic
- infecii auriculare repetate
- Sindrom neurotoxic
FORMA ADULTULUI
- determin apariia otitelor adezive
- Formaiuni rinofaringiene mai dure, localizate
peritubar
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COMPLICAII
Depind de volumul i consistena esutului rinofaringian
1. rinite cronice muco-purulente
2. afeciuni sinuzale secundare
3. rceli dese
4. laringite repetate
5. traheite, bronite, broniolite
6. hipoacuzii de diferite grade
7. adenopatii cervicale i submaxilare
8. complicaii auriculare
9. complicaii oculare: conjunctivite, iridociclite,uveite
10. nefrite, reumatism
11. enurezis nocturn
12. Laringospasm
13. Tulburri de dezvoltare ale scheletului
14. Tulburri intelectuale, gastrointestinale, endocrine
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