《耳鼻喉科教学课件：Disease of the Larynx and Laryngopharynx》由会员分享，可在线阅读，更多相关《耳鼻喉科教学课件：Disease of the Larynx and Laryngopharynx（109页珍藏版）》请在金锄头文库上搜索。
1、AcuteepiglottisAcutelaryngotracheobranchitisinchildrenChroniclaryngitisVocalfoldpolypsVocalfoldnodulesLeukoplakiaoflarynxLaryngealpapillomasLaryngealcancerSquamouscellcarcinomaofpharynx(cancerofhypopharynx)Crown Prince Frederick of GermanyHoarseness Most common symptom Small irregularities in the vo
2、cal fold result in voice changes Changes of voice in patients with chronic hoarseness from tobacco and alcohol can be difficult to appreciatePatients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluationMalignant lesions can appear as friable, fung
3、ating, ulcerative masses or be as subtle as changes in mucosal colorVideostrobe laryngoscopy may be needed to follow up these subtler lesions infection? Carcinoma?He as evaluated by Sir Makenzie of London, the inventor of the direct laryngoscopeGood neck exam looking for cervical lymphadenopathy and
4、 broadening of the laryngeal prominence is requiredThe base of the tongue should be palpated for masses as welllaryngeal crepitus Restricted may be a sign of post cricoid or retropharyngeal invasionOther symptoms include:DysphagiaHemoptysisThroat painEar painAirway compromiseAspirationNeck massFrede
5、ricks lesion was biopsied and thought to be cancerHe refused laryngectomy and later died in 1888Frederick was succeeded by Kaiser Wilhelm II, who along with Otto von Bismark militarized the German Empire and led them into WW ICould an Otolaryngologist have prevented WW I?11,000 new cases of laryngea
6、l cancer per year in the U.S.Accounts for 25% of head and neck cancer and 1% of all cancersOne-third of these patients eventually die of their diseaseMost prevalent in the 6th and 7th decades of life4:1 male predilectionDownward shift from 15:1 post WWIIDue to increasing public acceptance of female
7、smokingMore prevalent among lower socioeconomic class, in which it is diagnosed at more advanced stagesProlonged use of tobacco and excessive alcohol use primary risk factorsThe two substances together have a synergistic effect on laryngeal tissues90% of patients with laryngeal cancer have a history
8、 of bothHuman Papilloma Virus 16 &18Chronic Gastric RefluxOccupational exposuresAsbestos mustard gaspetroleum products other risk factors.Prior history of head and neck irradiationGlottic Cancer: 59%Supraglottic Cancer: 40%Subglottic Cancer: 1%Most subglottic masses are extension from glottic carcin
9、omas85-95% of laryngeal tumors are squamous cell carcinomaHistologic type linked to tobacco and alcohol abuseCharacterized by epithelial nests surrounded by inflammatory stromaKeratin Pearls are pathognomonicVerrucous CarcinomaFibrosarcomaChondrosarcomaMinor salivary carcinomaAdenocarcinomaOat cell
10、carcinomaGiant cell and Spindle cell carcinomaThyroid cartilage cricoid hyoid epiglotticcricothyroid ligament epiglotticThyroid Arytenoidscorniculate, cuneiformcricoidsagittal viewcoronal viewSupraglottic tumors more aggressive:Direct extension into pre-epiglottic spaceLymph node metastasisDirect ex
11、tension into lateral hypopharnyx, glossoepiglottic fold, and tongue baseGlottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainageThey tend to metastasize after they have invaded adjacent structures with better drainageExtend superiorly into ventricular walls or
12、 inferiorly into subglottic spaceCan cause vocal cord fixationTrue subglottic tumors are uncommonGlottic spread to the subglottic space is a sign of poor prognosisIncreases chance of bilateral disease and mediastinal extensionInvasion of the subglottic space associated with high incidence of stomal
13、reoccurrence following total laryngectomy (TL)Biopsy is required for diagnosisPerformed in OR with patient under anesthesiaOther benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegners granulomatosisO
14、ther potential modalities:Direct laryngoscopyBronchoscopyEsophagoscopyChest X-rayCT or MRILiver function tests with or without USPET ?( Positron emission tomography)TXTXMinimum requirements to assess primary Minimum requirements to assess primary tumor cannot be mettumor cannot be metT0T0No evidence
15、 of primary tumorNo evidence of primary tumorTisTisCarcinoma in situCarcinoma in situT1T1Tumor limited to one subsite of supraglottis with normal vocal Tumor limited to one subsite of supraglottis with normal vocal cord mobility cord mobility T2T2Tumor involves mucosa of more than one adjacent subsi
16、te of Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform mucosa of base of the tongue, vallecul
17、a, medial wall of piriform sinus) without fixation sinus) without fixation T3T3Tumor limited to larynx with vocal cord fixation and or invades Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, preepiglottic tissue, any of the following: postcrico
18、id area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) inner cortex) T4T4a aTumor invades through the thyroid cartilage and/or invades Tumor invades through the thyroid cartilage and
19、/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) thyroid, or esoph
20、agus) T4T4b bTumor invades prevertebral space, encases carotid artery, or Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures invades mediastinal structures T1T1Tumor limited to the vocal cord (s) (may involve anterior or Tumor limited to the vocal cord (s) (m
21、ay involve anterior or posterior commissure) with normal mobilty posterior commissure) with normal mobilty T1aT1aTumor limited to one vocal cord Tumor limited to one vocal cord T1bT1bTumor involves both vocal cords Tumor involves both vocal cords T2T2Tumor extends to supraglottis and/or subglottis,
22、and/or with Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility impaired vocal cord mobility T3T3Tumor limited to the larynx with vocal cord fixation and/or Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyro
23、id cartilage invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) erosion (e.g. inner cortex) T4aT4aTumor invades through the thyroid cartilage, and/or invades Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft t
24、issues of the tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus muscles, thyroid, or esophagus T4bT4bTumor invades prevertebral space, encas
25、es carotid artery, or Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures invades mediastinal structures T1T1Tumor limited to the subglottis Tumor limited to the subglottis T2T2Tumor extends to vocal cord (s) with normal or Tumor extends to vocal cord (s) with
26、 normal or impaired mobility impaired mobility T3T3Tumor limited the larynx with vocal cord fixation Tumor limited the larynx with vocal cord fixation T4aT4aTumor invades cricoid or thyroid cartilage and/or Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond larynx (e.g. trachea
27、, soft tissues invades tissues beyond larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) tongue, strap muscles, thyroid, or esophagus) T4bT4bTumor invades prevertebra
28、l space, encases carotid Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures artery, or invades mediastinal structures N0N0No cervical lymph nodes positive No cervical lymph nodes positive N1N1Single ipsilateral lymph node 3cm Single ipsilateral lymph node 3cm
29、 N2aN2aSingle ipsilateral node 3cm and Single ipsilateral node 3cm and 6cm 6cm N2bN2bMultiple ipsilateral lymph nodes, each Multiple ipsilateral lymph nodes, each 6cm 6cmN2cN2cBilateral or contralateral lymph nodes, Bilateral or contralateral lymph nodes, each 6cm each 6cm N3N3Single or multiple lym
30、ph nodes 6cm Single or multiple lymph nodes 6cm M0M0 No distant metastasesNo distant metastasesM1M1 Distant metastases presentDistant metastases present0 0TisTisN0N0M0M0I IT1T1N0N0M0M0II IIT2T2N0N0M0M0IIIIIIT3T3N0N0M0M0T1-3T1-3N1N1M0M0IVAIVAT4aT4aN0-2N0-2M0M0T1-4aT1-4aN2N2M0M0IVBIVBT4bT4bAny NAny NM
31、0M0Any TAny TN3N3M0M0IVCIVCAny TAny TAny NAny NM1M1Premalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesionCO2 laser can be used to accomplish this but makes accurate review of margins difficultEarly stage (T1 and T2) can be treated with radiotherapy or sur
32、gery alone, both offer the 85-95% cure rate.Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomesRadiotherapy is given for 6-7 weeks, avoids surgical risks but has own complicationsXRT complications include:MucositisOdynophagiaLaryngeal edemaXerost
33、omiaStricture and fibrosisRadionecrosisHypothyroidismAdvanced stage lesions often receive surgery with adjuvant radiationMost T3 and T4 lesions require a total laryngectomySome small T3 and lesser sized tumors can be treated with partial larygectomyAdjuvant radiation is started within 6 weeks of sur
34、gery and with once daily protocols lasts 6-7 weeksIndications for post-op radiation include: T4 primary, bone/cartilage invasion, extension into neck soft tissue, perineural invasion, vascular invasion, multiple positive nodes, nodal extracapsular extension, margins50%No tongue base disease past cir
35、cumvallate papillaeApex of pyriform sinus not invlovedResection of true vocal cords, supraglottis, thyroid cartilageLeave arytenoids and cricoid ring intactHalf of patients remain dependent on tracheostomyIndications:T3 or T4 unfit for partialExtensive involvement of thyroid and cricoid cartilagesIn
36、vasion of neck soft tissuesTongue base involvement beyond circumvallate papillaeTracheostomal prosthesisElectrolarynxPure esophageal speechInaccurate stagingInfectionVoice alterationsSwallowing difficultiesLoss of taste and smellFistulaTracheostomy dependenceInjury to cranial nerves: VII, IX, X, XI,
37、 XIIStroke or carotid “blowout”HypothyroidismRadiation induced fibrosis5 year survival5 year survivalStage IStage I95%95%Stage IIStage II85-90%85-90%Stage IIIStage III70-80%70-80%Stage IVStage IV50-60%50-60%After initial treatment patients are followed at 4-6 week intervals. After first year decreas
38、es to every 2 months. Third and fourth year every three months, with annual visits after thatPatients considered cured after being disease free for five yearsMost laryngeal cancers reoccur in the first two yearsDespite advances in detection and treatment options the five year survival has not improv
39、ed much over the last thirty yearsThe pyriform sinus is the most common site for hypopharyngeal cancer (65-75%). Cancer may extend from here into the subglottis, thyroid cartilage, postcricoid region, or cricoarytenoid joint. Three of every four patients presenting with hypopharyngeal cancer at this
40、 subsite may have regional metastasis with apical primaries, resulting in a poorer prognosis. Laryngeal carcinoma Etiology: tobacco and excessive alcohol use primary Human Papilloma Virus 16 &18Chronic Gastric RefluxOccupational exposuresPresentationHoarseness, Dysphagia,Hemoptysis,Throat pain, Ear
41、pain, Airway compromise, Aspiration,Neck massappear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal colorLaryngeal carcinoma DiagnosisHistoryEndoscopyBiopsy Treatment OperationRadiotherapy Chemotherapy A life-threatening infectionAcute epiglottitis in the Children Acut
42、e epiglottitis in the Adult Acute epiglottitis in the Children Organismsnontype B H. influenzae( in vaccinated children)Streptococcus pyogenes, S. pneumoniae S. aureus. Diagnosis history and clinical findingsLateral soft tissue radiographs “thumb sign” a dilated hypopharynx.Occasionally, supraglotti
43、c region appears hazy In severe cases, treatment should not be delayed to obtain radiographs Differentiating Diagnosis laryngotracheitis is not always easy, but it is of paramount importance The signs and symptoms Signs A toxic appearance is involved, with the child assuming an upright sitting posit
44、ion with the chin up and mouth open, bracing themself on the hands (the tripod position). Patients often have difficulty in handling their secretions. Speech is limited due to pain. Stridor is a late finding and signals nearly complete airway obstruction. Symptoms Severe throat pain Fever Irritabili
45、ty and respiratory distress that are rapidly progressive Muffled voice How is acute epiglottitis managed?arrangements for airway endoscopy in the operating room All anxiety-provoking maneuvers should be avoided. endotracheal intubation, and appropriate staff should be prepared to perform a tracheoto
46、my. spontaneous ventilation should be maintained The intubated child should be transferred to the ICU. laryngoscopy to obtain swab cultures from the epiglottisappropriate intravenous antibiotic therapy a second- or third-generation cephalosporin cefuroxime, cefotaxime, or ceftriaxoneAmpicillin/ sulb
47、actam trimethoprim/sulfamethoxazole Chloramphenicol Symptom fever, sore throat, a muffled voice, dysphagia, and odynophagia. longer than that seen in children (usually more than 24 hours)Signswollen, bright-red epiglottis swollen epiglottis and dilated hypopharynx on a lateral neck radiograph infect
48、ious etiology Haemophilus group A streptococcus. The clinical course appears less severe Conservative measures include oxygenation, humidification, hydration, corticosteroids, and intravenous antibiotics Acute laryngotracheobronchitis (LTB), or croupViral laryngotracheitis is the most common larynge
49、al inflammatory disorder of childhood. Organisms parainfluenza virus respiratory syncytial virus influenza rubeola Adenoviruses Mycoplasma pneumoniae history viral upper respiratory infection with rhinitis, cough, and low-grade feversymptoms hoarseness, dyspnea, stridor, and a barking cough characte
50、ristic cough gives its common name, croupairway obstruction is caused by laryngotracheitis, the stridor is characteristically inspiratory, or biphasic. diagnosis based on the history,examination of the larynx erythematous and edematous mucosa with normal vocal fold mobility(although not necessary) R
51、adiographs, reveal a narrowing of the subglottic lumen, the “steeple sign,”How is LTB managed?Most cases are alleviated by simple home methods, such as humidification most severe cases cause acute airway obstructionHydration, Humidificationsupplemental oxygen, fluids,nebulized racemic epinephrineThe
52、 use of oral and/or intramuscular glucocorticoids ( dexamethasone) Antipyretics, decongestants, Artificial airway support (eg, intubation) is necessary in a relatively small proportion of patientsSecondary bacterial infection high temperature spikes and exudative, purulent drainageRadiographicallyth
53、e lumen of the upper airway will appear narrowed, shaggy, and irregularOrganisms Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, Moraxella catarrhalis,hemolytic streptococciAntibiotic therapy is indicated . How is chronic laryngitis treated?general inflammation of the larynx
54、 smoking, voice abuse, or laryngopharyngeal reflux symptoms chronic hoarseness, chronic cough, throat irritation, frequent throat clearing, and globus sensation. The voice usually improves if the irritating factors are discontinued. This may involve smoking cessation or voice rest. H2 blockers and p
55、roton pump inhibitors are highly effective in treatment. In addition resting their voice, sleeping with the head of the bed elevated, and waiting 3-4 hours after eating before going to bed. Polyps asymmetric and appear soft and smooth on one or both vocal folds vocal nodules usually pairedsmall and
56、discrete located in the 1/3 the distance from the anterior commissure.Contact granulomas found on the vocal processes of the arytenoid cartilage.Vocal fold cysts mucous retention or epidermoid cysts located in the superficial layer of lamina propria at the middle third of the vocal fold in the media
57、l and superior aspectWhat are the treatment options for vocal fold nodules?Vocal fold nodules often arise as a result of excessive laryngeal use. Voice therapy is a highly effective method of treatment. In rare cases in which voice therapy does not give satisfactory results, surgical removal of nodu
58、les may improve the voice. Generally, surgery will not resolve the hoarseness completely, and it is rarely indicated because vocal coaching is usually curative. How is a laryngeal polyp treated?A laryngeal polyp is a single benign lesion of the larynx. Voice therapy is recommended before and after s
59、urgery and could be the only required treatment. Laryngeal polyps can be removed with a standard cold knife, which is preferable, or with a carbon dioxide laser. Microflap technique is used to preserve the mucosal cover and the underlying vocal ligament, when possible. Normal voice usually returns a
60、fter treatment. Leukoplakia (precancerous lesions) a characteristic white lesion on the vocal foldexhibit thickening of the epithelial layerabnormal keratinization of the superficial layerssolitary or multifocal. benign and malignant Histologically, most of these lesions are benign, but there is tho
61、ught to be an approximately 3% risk of malignancy for leukoplakia of the vocal foldLaryngeal papillomatosis affects mucous membranse of the larynx characterized by multiple and recurrent squamous papillomatamay more prevalent in children and less common in individuals over 30 years of age.causing ho
62、arseness some degree of respiratory obstruction,particularly in chidren .which is associated with human papilloma virus (HPV) types 6 and 11. Papillomatosis in childrenPapillomatosis in AdultHow is laryngeal papillomatosis transmitted?Transmission is multifactorial. Fifty percent of mothers have a h
63、istory of active or prior HPV infection. The risk of transmission is 1 in 400. Cesarean section is not recommended for mothers with either active or latent infection because transmission has occurred despite cesarean section. gross inspectionappear in a multinodular pattern sessile or exophytic.Hist
64、ologicallypapillary projections and hypervascular fibroconnective tissus covered by hyperplastic squamous epithelium that shows maturation.Cellular atypia is the rule rather than the exceptionHistologic differentiation from early carcinoma may sometimes be difficult.What triad is associated with lar
65、yngeal papillomatosis?Firstborn child: primigravid mothers are more likely to have a prolonged second stage of labor, which increases the risk for infection Teenage mother Vaginal delivery How are laryngeal papillomas treated?spontaneous remissions can occurMultiple surgical resections, often with a
66、 laser, are required. cidofovir (intraoperative injections), indole 3-carbinol/diindolylmethane, acyclovir, and interferon- are under investigation. DistinguishcharacteristicbetweenlaryngotracheitisandsupraglottitisDistinguishcharacteristicbetweennodularandpolypsLeukoplakiaaretheprecancerouslesionsW
67、hattriadisassociatedwithlaryngealpapillomatosis?Malignant Tumors of the Larynx and Hypopharynx. Cummings- Otolaryngology- Head and Neck Surgery. 4th ed., Mosby, 2005.Malignant Laryngeal Lesions. Lawani- Current Diagnosis and Treatment in Otolaryngology- Head and Neck Surgery. McGraw-Hill and Lange,
68、2004.Neck. Moore- Essential Clinical Anatomy. 2nd ed., Lippincott, 2002.Head and Neck. Rohen- Color Atlas of Anatomy. 5th ed., Lippincott, 2002.Surgery for Supraglottic Cancer. Myers- Operative Otolaryngology Head and Neck Surgery Vol. 1. 1st ed., Saunders, 1997.Surgery for Glottic Carcinoma. Myers-
69、 Operative Otolaryngology Head and Neck Surgery Vol. 1. 1st ed., Saunders, 1997.The Larynx. Lore and Medina- An Atlas of Head and Neck Surgery. 4th ed., Elsevier, 2005.Hinerman, R, Morris, C, et al. Surgery and Postoperative Radiotherapy for Squamous Cell Carcinoma of the Larynx and Pharynx. Am J Cl
70、in Oncol. 2006; 29(6): 613-621.Huang, D, Johnson, C, et al. Postoperative Radiotherapy in Head and Neck Carcinoma with Extracapsular Lymph Node extension and/or Positive Resection Margins: a Comparative Study. Int J Radiat Oncol Biol Phy. 1992; 23:737-742.Bernier, J, Domenge, C, et al. Postoperative
71、 Irradiation with or without Concomitant Chemotherapy for Locally Advanced Head and Neck Cancer. N Engl J Med. 2004; 350: 1945-1952.Sessions, D, Lenox, J, et al. Supraglottic Laryngeal Cancer: Analysis of Treatment Results. Laryngoscope. 2005; 115: 1402-1410.Wolf, GT. The Department of Veterans Affa
72、irs Laryngeal Cancer Study Group. Induction Chemotherapy Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. New England Journal of Medicine. 1991; 324: 1685-90.Lefebre J, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx Preservation in Pyriform Sinus Cancer: Preliminary Results of a European Organization for Research and Treatment of Cancer Phase III Trial. Journal of the National Cancer Institute. Jul 1996. 88(13): 890-899.Grants Atlas 10th ed. CD-ROM
