curs respirator
DESCRIPTION
panduriTRANSCRIPT
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SINDROAME MEDIASTINALE
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MEDIASTIN (anatomie)
Mediastin – regiunea dintre cele doua pleure, limitata anterior de stern si posterior de coloana vertebrala
superior –inel toracic osos superior
inferior – diafragm
anterior – stern
posterior – corpi vertebrali, grilaj costal
lateral – fata mediastinala a pleurei
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Clasificare anatomica
Mediastin anterior (MA) – anterior – stern
posterior – pericard, aorta
ascedenta, trunchi branhiocefalic
Continut timusganglioni mediastinali anteriori extensii substernale ale tiroidei, paratiroidei artere si vene mamare interne
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Clasificare anatomica
Patologie timom, hiperplazia timusului limfoame tumori germinativemase tiroidiene tumori mezenhimaleHernia prin foramen Morgagni
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Mediastin mijlociu (MM)
Continut cord, pericard crosa aortei, aorta ascendenta vene cave, artere si vene branhiocefalice nervi frenic, vag artere si vene pulmonare traheea si bronhiile principale, ganglioni adiacenti
Clasificare anatomica
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Clasificare anatomicaPatologie
metastaze ganglionare adenopatii granulomatoase chiste pleuropericardice, bronhogenice formatiuni de origine vasculare
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Clasificare anatomica
Mediastin posterior (MP) - anterior – pericard, trahee - posterior – coloana vertebrala
Continutaorta descendenta toracicavene azygos, hemiazygosesofagganglioni mediastinali posteriori lanturi nervoase simpatice duct toracic
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Patologie tumori neurogene chiste gastroentericeboli esofagienehernia prin foramen Bochdalek
Clasificare anatomica
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SEMIOLOGIA SINDROAMELOR MEDIASTINALE
- 40% cazuri simptomatice
- 60% diagnostic radiologic intamplator
- formatiune mediastinala depistata radiologic
asimptomatic – 90% este benigna
simptomatic – 50% este benigna
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tuse, durere toracica, dispnee
Tuse uscata, recurenta, caracter iritativ, apare in accese rar productiva – sanguinolenta, cu lichid clarnu se remite la antibiotice!produsa de iritarea vagului prin adenopatii, formatiuni tumorale
Simptome locale
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Dispnee
•cvasiconstanta, precoce datorata compresiei CAS sau/si reflex (iritare n. vag, n. recurent)
•nelegata in general de efort, se coreleaza cu amplitudinea respiratiei
prin compresie – dispnee inspiratorie, cu cornaj si tiraj supra- si substernal, stridor
reflexa - accese astmatiforme (iritare n. vag)
- sufocanta secundar parezei de coarda vocala stanga (iritare n. recurent)
Simptome locale
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Compresia hilului drept prin cancer pulmonar
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Durere toracica
nelegata de efort, ci de miscarile respiratorii
agravata de tuse, flexia/extensia capului, palparea coastelor
difuzaviolenta, nevralgica iradiata pe un traiect nervosde tip frenic – puncte dureroase parasternal si la varful coastei X (punct Gueneau) intre capetele de insertiensternal si clavicular ale m. SCM cervicobranhiala – din regiunea cervicala – axiala – sub epitrohlee – mana de tip intercostal – puncte dureroase parasternal, pe linia axilara medie, paravertebral de tip anginos – prin compresia plexurilor nervoase cardiace
Simptome locale
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Simptome de extindere regionala
Disfonie – compresia n. recurent cu pareza corzii vocale stangi
Raguseala, vocea bitonalaDigestive - sughit rebel – iritare n. frenic - disfagie – compresie esofag - varsaturi – insotind accesele de tuse, prin iritarea n.
vag
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febra – infectioasa – mediastinita acuta, suprainfectarea tumorilor mediastinale, neoplazica
inapetenta, astenie tahicardie – gusa tiroidizata sindroama endocrine paraneoplazice
sdr. carcinoid – (cefalee, flush, palpitatii, HTA, diaree) – in bolile timusului
constipatie, varsaturi, hipercalcemie, hiperfosfatemie – in tumori paratiroidiene
Simptome generale
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Inspectie cianoza - initial intermitenta (la efort), ulterior permanenta - secundara stazei venoase la nivelul capului, gatului,
torace edem hemicorp superior - semn tardiv, de certitudine
- poate apare mai precoce pe fata dorsala a mainii
sdr. Vena cava superioara – edem + circulatie colaterala cu derivarea sangelui din sistemul cav superior in cel inferior prin venele azygos, mamare interne, intercostale si epigastrice
EXAMEN CLINIC
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Circulatie colaterala in gusa plonjanta
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SCS dimineata si seara
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Cancer pulmonar care da sindrom de cava superioara
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sdr. Claude bernard Horner – mioza +enolftamie + ingustarea fantei palpebrale
- prin pareza simpaticului cervical semn Roque – inegalitate pupilara prin midriaza (iritare
simpatic) + miozii (iritare vag) retractie costala C XI-XII posterior (semn Broadbent) – in
mediastinopericardite
+ fixitatea socului apexian si retractia sistolica apexiana (semn Skoda)
EXAMEN CLINIC
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retractia sau bombarea unui hemitorace – atelectazii masive, pleurezii
pulsatii ample ale aortei in furculita sternala – anevrism de aorta
circulatie venoasa discreta – telangiectazii la baza torace, ISV, laterotorcic f. evidenta – retea venoasa toracoabdominala/brahiala
EXAMEN CLINIC
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EXAMEN CLINICPalpare freamate arteriale – compresia arterei pulmonare diferente puls membre superioare – patologia crosei aortei
Percutie matitate in spatiu ISV – adenopatii traheobronsice matitate manubriu – gusa intratoracica
Auscultatie semne de compresie bronsica – pectorilocvie afona, suflu cavitar semne de atelectazie – silentiu respirator, suflu amforic cord – sufluri sistolice in anevrism aorta, compresii vasculare
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1. Metastaze ganglionare2. Tumori neurogenice – 25%3. Bolile timusului – 20%4. Chiste – 15% - bronhogenice, pleuropericardice, dermoide5. Tumori germinative – 15%6. Limfoame – 10%
Dg. de excludere se face in aceasta ordine La copii loc I – tumori neuronale (40%)
loc II – limfom (25%)
ETIOLOGIA SDR. MEDIASTINALE
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1. Radiografia pulmonara – PA, profil drept/stang
- dimensiune, sediu, natura formatiunii, examen comparativ si evolutie
- Raporturi anatomice, legatura cu hilurile
2. Ecografia – utila pentru formatiunile situate anterior si superior in mediastin
(timom, gusa tiroidiana, chist pericardic)
ALGORITM DE INVESTIGARE
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3. Tomografia computerizata (TC) – cea mai valoroasa tehnica imagistica
- utila pentru mase mediastinale imprecis delimitate prin metode radiologice conventionale, mai ales originea formatiunii mediastinale
- diferentiaza tumorile benigne si chistele lichidiene de alte procese
4. Mediastinscopia si mediastinotonomia anterioara – ptr. MA sau MM
ALGORITM DE INVESTIGARE
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5. Rezonanta magnetica nucleara (RMN) – avantaj fata de TC doar cand mediastinoscopia sau toracotomia sunt riscante
6. Biopsia dirijata tomografic/fluoroscopic – biopsie aspirativa cu analiza aspectului celular
-multe tumori mediastinale au o buna corelare citologie-histologie → pt. dg. inaintea radio- sau chimioterapiei formatiunii inoperabile
7. Toracotomia minima
8. Scintigrama tiroidiana
9. Arteriografii selective.
ALGORITM DE INVESTIGARE
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1. Anevrism de aorta2. Bolile timusului3. Mase tiroidiene/paratiroidiene4. Adenomopatii mediastinale anterioare5. Chiste6. Tumori germinale7. Hernia prin foramen Morgagni
PATOLOGIA MEDIASTINULUI
ANTERIOR
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ascendenta, crosa – sifilis, ATS simptome locale sau prin compresie (n. recurent, bronsii, VCS) masa pulsatila ± suflu sistolic in furculita sternala Rx – dilatarea ± calcificarea aortei ecocardiografia – dilatarea aortei ≥ 40 mm, pereti grosi
aortografia - pentru interventiile chirurgicale TC cu substanta de contrast – demonstreaza originea vasculara NU proceduri invazive de dg (biopsie aspirativa,
mediastinoscopia)
Anevrism de aorta
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Timomul cea mai frecventa tumora din MA 20% din tumorile mediastinale incidenta maxima 40-60 ani, rar la copii tumorile benigne – asimptomatice → dg. radiologic
intamplator tumorile maligne (25%) – durere toracica, dispnee
invazive prin extensie directa, metastaze rar, tardiv (oase bazin) diferentierea cu tumorile benigne – doar chirurgical
Bolile timusului
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asociat cu sdr. paraneoplazice: miastenia gravis (40% timoame asociaza miastenia, 10% miastenie asociaza
timom) agammaglobulinemia anemia plastica pura LES, b. Whipple, b. Cushing
Dg.: - radiografie pulmonara – opacitate omogena, neregulata, uni/bilaterala - se vede bine polul superior pe incidenta PA - TC - biopsie aspirativa
Tratament: - ablatie chirurgicala si a tesaturilor din jur
Bolile timusului
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Bolile timusuluiHiperplazia de timus
apare dupa 20 ani; mai frecvent la barbati respecta structura timusului: prezinta foliculi
germinativi 50% din cazuri – durere, dispnee asocierea cu sdr. miastenic/anemie plastica →
suspiciune mare de boala timusdg. pozitiv: - radiografia pulmonara – formatiune bine
delimitata la nivelul vaselor mari, fara calcificari
- ecografie, TC
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Dg. Diferential cu timomul: prednison 0,5 mg/kg 10-14 zile
formatiunea se reduce formatiunea nu se reduce
Hiperplazie timus Timom
punctie biopsie dirijata TC sau prin toracotomie
Tratament: - rezectie subtotala
Bolile timusului
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Gusa plonjanta (intratoracica)
frecventa la femei > 20 aniporneste din polul inferior sau istm si se extinde in MA,
anterior de traheemultinodulara, hiperfunctionala asimptomatica sau cu dispnee + stridor, tuse, durere toracica
Mase tiroidiene
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CT gat – gusa plonjanta
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CT torace – gusa plonjanta
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Mase tiroidiene dg. radiologic formatiune opaca
bine delimitata inferior prost delimitata superior
scintigrama tiroidiana: iodocaptare crescuta (examen negativ nu exclude dg.)
Tratament: - urmarire – asimptomatic, scintigrama pozitiva
- chirurgical – simptomatic (15% se malignizeaza)
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Clasificarea topografica a ganglionilor mediastinali (McLound & Meyer 1982)
- corespunde aspectului de pe radiografia toracica si TC- de sus in jos: - ganglioni mamari interni (bilaterali)
- ganglioni paratraheali (in dreapta)
- ganglioni paraaortici
- ganglioni din fereastra aortopulmonara
(in stanga)
- ganglioni hilari si interbronsici (bilaterali)
- ganglioni mediastinali posteriori
(paravertebral bilateral)
- ganglioni paracardiaci (bilaterali)
Adenopatii mediastinale anterioare
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limita superioara a dimensiunii normale a ggl. – 10 mm ggl. din zona subcarinala, paratraheali si hilari sunt mai mari
decat in alte zone apar frecvent peste 30 ani apar in
limfoame – limfom Hodgkin, limfom limfocitic adenomopatii bilaterale, asimetrice, contur policiclic
neoplasm bronsic, mamar, gastric, pancreas TBC
Dg. pozitiv: biopsie
Adenopatii mediastinale anterioare
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se dezvolta in partea superioara a mediastinului se pot
deschide in bronsii → vomicapericard, pleura → revarsate lichidiene
infecta → durere, febradevin simptomatice cand apar complicatii (40%)
Chiste bronsice si enterice
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Chiste bronsice si enterice
Diagnostic:Radiologic – formatiune opaca PA -medial, unde pleaca
vasele mariEcografic – formatiune transsonica, omogena TC – formatiune cu perete fin, omogena, fara calcificariBiopsie ghidata TC (contraindicat in chist hidatic)
Tratament: chirurgical la cei simptomatici punctie aspirativa – daca creste brusc si da compresie
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Benigne (80% din tumorile germinale) teratom chist dermoidMaligne seminom coriocarcinom
Se dezvolta din tesutul embrionar cu origine in fantele brahiale
Tumori germinale
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Tumori germinaleTeratomul frecvent la adolescent sau adult barbat contine derivati:
ecto (piele, par, unghii)- endo (fibre musculare, tesut grasos) mezodermici (epiteliu bronsic sau diferentiat)
incapsulata, bine delimitata, creste lent → 5-6 cm la momentul dg.
nu da invazie, da compresie → tuse dispnee, durere epiteliu diferentiat activ → secretie enzime → liza
intratumorala, inflamatie → cresterea dimensiunii, febra, hemoragie
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Tumori germinale
Diagnostic: Radiologic – formatiune ovalara, omogena, cu calcificari
in interior Ecografie – caracter neomogen, formatiuni ecogene cu
con de umbra
TratamentToracotomie minima
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Chist dermoid
contine doar componente ectodermice (eoiderma + anexe)
Tratament: - chirurgical – indicatii: - simptome - complicatii: infectie, hemoragie - dimensiuni mari – risc de malignizare (20%, mai ales la barbati)
Tumori germinale
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Seminom mai frecvent la barbati > 20 aniSimptome
locale: durere, tuse generale: mereu – febra, alterarea starii generale
Diagnostic: biologic: - gonadotrofine corionice normale
- Ag CAE – rar crescut
- fosfataza alcalina placentara – negativ
radiologic: - masa rotunda/ovalara, neregulata, prost delimitata, fara calcificari
TC: absenta capsulei, caracter invazivbiopsie aspirativa – dg. de certitudine
Tumori germinale
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Tratament: foarte radiosensibila chirurgical ± radioterapiemetastaze: iradiere + polichimioterapie secventiala (oncovin +
cisplatin + bleomicina)
Rata de supravietuire – 80-90%
Tumori germinale
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Tumori germinaleCoricarcinom mai frecvent la barbatiginecomastie bilateralabiologic: - gonadotrofino corionice - ↑↑ (15 x normal)
- Ag CAE prezent
- fosfataza alcalina placentara - ↑↑ (dg. diferential de seminom)
Tratament: chirurgical + polichimioterapie (insensibil la radioterapie)
Rata de supravietuire – aprox. 1 an
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Foramen Morgagni – mici defecte triunghiulare in diafragm, intre fibre musculare, cu originea pe xifoid si coasta VII
herniaza continutul abdominal in MA, de obicei pe dreapta
Diagnostic: - radiologic, TC
Tratament – reparare chirurgicala a defectului
Hernia prin foramen Morgagni
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PATOLOGIA MEDIASTINULUI
MIJLOCIU
1. Adenomopatii mediastinale mijlocii
2. Chiste (pleuro) pericardice
3. Chiste bronhogenice
4. Anomalii vasculare – anevrism de aorta
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Inflamatorii granulomatoase: TBC sarcoidoza – bilaterale, simetrice, cu respectarea distantei
mediastin-hil
Metastatice – 90% din tumorile din MM sunt maligne limfom – b. Hodgkin (forma scleroza nodulara) – bilaterale,
asimetrice neoplasme: bronsic, mamar, gastrointestinal, prostata, rinichi
Adenomopatii mediastinale mijlocii
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Limfom
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apar peste 30-40 ani asimptomatice – descoperit radiologic (diametru 4-6 cm) localizare: - cel mai frecvent – anterior in unghiul cardiofrenic
drept si in unghiul cardiofrenic stang, hil contin lichid clar
Dg. pozitiv: - Radiologic – masa omogena, bine delimitata,
nepulsatila, fara calcificari
- Ecografie cardiaca
- Biopsie aspirativa – lichid clar, acelular
Dg. diferential: anevrism cord, hernie hiatala
Tratament: - chirurgical doar daca sunt simptomatice
Chiste (pleuro) pericardice
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apar peste 20 ani paratraheal/adiacent carinei traheale se proiecteaza in portiunea posterioara MM asimptomatic in absenta complicatiilor – infectie (tuse, expectoratie
purulenta, nivel hidroaeric)
Diagnostic: - radiologic: - camp pulmonar mijlociu – chist 0,5-3 cm, neomogen
- NU se fac bronhografie, scintigrama
Tratament: chirurgical
4.
Chiste bronhogenice
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1. Tumori neurogene
2. Boli esofagiene
3. Hernia prin foramen Bochdalek
PATOLOGIA MEDIASTINULUI
POSTERIOR
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Tumori neurogene
cea mai comuna tumora primara mediastinala (21% din formatiunile mediastinale la adult, 40% la copil)
deriva din trunchiul nervos simpatic paravertebral si nervii spinali
20% tumori maligne
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Clasificare dupa tesutul neural de origine
Tumori derivate din nervii periferici
1. Neurofibrom
2. Neurofibrosarcom
3. Neurilemom (shwanom)
B. Tumori dertivate din ganglionii simpatici
1. Ganglioneurom (neurinom)
2. Neuroblastom
3. Simpaticoblastom
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C. Tumori derivate din celule paraganglionare
1. Feocromocitom
2. Paragangliom (chemodectom)
Clasificare dupa tesutul neural de origine
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Tumori neurogene la adult – majoritatea tumorilor sunt benigne si
asimptomatice la copil – 50% sunt maligne si simptomatice
Radiologic – formatiuni opace paravertebrale unilaterale
Neurofibromul tumora benigna incomplet capsulata 15% se maligniaza; 25% se asociaza neurofibromatozei
Recklinghausen poate avea dimensiuni mari → compresii nervoase/pe
structuri adiacente
Tratament: - chirurgical
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Neurosarcom frecvent la tineri, copii tumora maligna → invadeaza, erodeaza → durere toracica
Radiologic: - masa omogena, neregulata
Tratament: - chirurgical
Neurilemom – cea mai frecventa tumora neuronala- mai ales la adult (30-40 ani)- bine delimitata, creste lent- in general asimptomatic cu durere nevralgicaTratament: - chirurgical
Tumori neurogene
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Neurinom – dezvoltata pe traiectul n. spinal sau n.vagDg. pozitiv: - biopsie
Neuroblastom – a 3-a neoplazie la copil (90%)- durere, semne generale (greata, varsaturi, febra)- metastaza f. repedeTratament: - chirurgical; poate involua sau transforma in tumora
benigna
Simpaticoblastom – f. agresiv, invazie locala- metastazeaza rar
Tumori neurogene
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Tumori benigne: leiomiom, fibrom, lipom
Tumori maligne: carcinom
Chiste gastroenterice - tapetate cu mucoasa esofagiana, gastrica
- adiacente esofagului la orice nivel in MP
- dg. pozitiv: tranzit baritat
- tratament: - chirurgical
Diverticul Zenker - esofagul superior
- frecvent are nivel hidroaeric
- dg. pozitiv: tranzit baritat
- tratament: - chirurgical
Hernia hiatala: - radiologic
Boli esofagiene
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cea mai frecventa hernie diafragmaticade obicei defectul este posterolateral pe stg. apare frecvent la copil
Dg. pozitiv: TC
Tratament: - chirurgical doar la cei simptomatici
Hernia prin foramen Bochdalek
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MEDIASTINITA ACUTA
Etiologieperforarea esofagului secundar neoplasm esofagina sau bronsic
invaziv sternotomie mediana in chirurgia cardiacaperforarea esofagului prin corpi straini, sclerozare varice
esofagiene, arme sdr. Mallory-Weiss chirurgia glandei tiroide – infectie propagata pretraheal fizic: radioterapie rar: extensie directa a infectiei din tesut adiacent (plaman, pleura,
pericard)
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MEDIASTINITA ACUTA
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Clinic stare grava (prostratie, agitatie); febra, frisondurere toracica mare accentuata de miscarile respiratorii, extensia
gatului la palpare – durere ± crepitatii (emfizem subcutan)
MEDIASTINITA ACUTA
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MEDIASTINITA ACUTA
Paraclinicbiologic: probe inflamatorii ↑↑ radiologic: largire localizata/difuza a opacitatii mediastinale ± uneori pneumotorax, hidropneumotorax
TC – demonstreaza prezenta lichidului biopsie aspirativa – obligatorie pt. analiza lichidului patologic
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MEDIASTINITA ACUTA
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MEDIASTINITA ACUTA
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Tratament drenaj aspirativ toracotomie – in caz sever (ruptura esofagiana) antibioterapie
metronidazol 2 g/zi 10-14 zile penicilina 6-12 mil. UI/zi antistafilococice – oxaciclina, rocephin (1 g/zi)
MEDIASTINITA ACUTA
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MEDIASTINITA ACUTA
Mediastinita acuta dupa chirurgie cardiaca incidenta 0,4-5% se manifesta la 4-30 zile postoperator (de obicei la 14
zile)
Dg. pozitiv – biopsie aspirativaTratament – drenaj imediat, debridare, antiobioterapie Mortalitate > 20%
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Extreme ale inflamatiei cronice granulomatoase ale mediastinului
Faza I – ggl. mediastinali participa in infectii granulomatoase pulmonare TBC, silicoza, sarcoidoza, histoplasmoza asimptomatice → granuloame 4-10 cm
Faza II – transformare fibroasa idiopatic, postiradiere, std tardiv mediastinita gr. compresii → modificari degenerative corticoterapia ineficienta
MEDIASTINITA GRANULOMATOASA
SI FIBROASA
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Clinic sdr. de vena cava superioaradiverticuli de tractiune, tulburari de motilitate esofagiana,
disfagieobstructie traheala/pe bronsii mariobstructie pe arterele sau venele pulmonare proximale afectare nervoasa: - raguseala, paralizie diafragm, sdr. Horner
MEDIASTINITA GRANULOMATOASA
SI FIBROASA
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MEDIASTINITA GRANULOMATOASA
SI FIBROASARadiologicmediastinita granulomatoasa – masa localizata (aria paratraheala
dr.)mediastinita fibroasa – largire generalizata a portiunii superioare
TC – pentru anomalii neevidentiate radiologic
Tratament – specific – antibacilar
- amfotericina B – histoplasmoza
- cortizon – uneori pt. fibroza
- chirurgical – eficienta nedovedita
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Prezenta de gaz (aer) in interstitiu mediastinal
Cauze ruptura alveolara cu trecerea aerului in mediastinboala de cai aeriene + manevra (tuse, stranut, varsatura,
Valsava repetat, ventilatie mecanica) apare la asmatici cetoacidoze diabetice cu hiperventilatie si varsaturi incoercibileventilatie mecanica, decolari rapide
EMFIZEM MEDIASTINAL
(PNEUMOMEDIASTIN)
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Clinic asimptomatic/durere retrosternala severa agravata de respiratie,
deglutitie emfizem subcutan (crepitatii) in furculita sternala semn Hamman – zgomot sincron cu bataile cordului, in decubit
lateral (50%)
Dg. pozitiv: radiologic – pneumomediastin
Tratamentnu e necesar; aerul se resoarbe mai repede la inspir de concentratii
↑ O2 rar – decomprimarea chirurgicala a mediastinului prin
aspirare/toracotomie
EMFIZEM MEDIASTINAL (PNEUMOMEDIASTIN)
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