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EF LUCR. DR.

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

Sistemul auditiv extern- responsabil de recepia


undelor i traducerea lor n impulsuri neuronale
Sistemul auditiv central-responsabil de
prelucrarea avansat a informaiilor acustice; el
recunoate direcia i intensitatea undelor sonore
Sistemul vestibular central-realizeaz legtura
ntre organul vestibular i efectorii orientrii n
spaiu i ai echilibrului

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SEGMENTELE SISTEMULUI AUDITIV EXTERN

Sistemul auditiv periferic se mparte n 3


segmente:
Urechea extern(Auris externa)-format din
pavilionul auricular i conductul auditiv extern
Urechea medie(Auris media)-format din
membrana timpanic, lanul osicular , muchi i
sistemul pneumatic al osului temporal
Urechea intern(Auris interna)- nglobat n stnca
temporalului, este format din labirintul
membranos i cohlee

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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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Relaii anatomo-topografice ale urechii externe

Ventral de conductul osos i cartlaginos se afl


articulaia temporo-mandibular
Antero-inferior, conductul auditiv cartilaginos
intr n raport cu parotida
Dorsal , peretele posterior al conductului osos
formeaz parial peretele anterior al mastoidei
Cranial , urechea extern intr n raport cu
M.temporal i cu pars squamosa a osului
temporal.

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FIZIOLOGIE

Pavilionul auricular i conductul auditiv extern


transform unde
Datorit formei pavilionului auricular, undele
sonore se lovesc n unghiuri diferite;n acest
fel se creaz dou ci diferite de
transmitere:una direct(prin cavum conchae)
i una indirect (prin helix i antehelix).
Urechea extern are i rolul de protecie

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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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STRUCTURA MEMBRANEI TIMPANICE

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MEMBRANA TIMPANIC
Pars flacida (membrana lui

Shrapnell) se afl superior de


plica malleares .
La examinarea cu otoscopul,
ea nu poate fi mereu bine
vizualizat i se poate continua
n peretele superior al
conductului auditiv .
La microscopie se observ
lipsa stratului fibros la acest
nivel.

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ELEMENTELE ANATOMICE ALE MEMBRANEI


TIMPANICE

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SISTEM AUDITIV EXTERN

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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- EPITIMPANUL


- Comunic prin partea extern a aticii cu antrul
mastoidian i cu sistemul de celule
pneumatice ale procesului mastoidian.
- La nivelul antrului se afl o proeminen
osoas dat de structura canalului
semicircular lateral
- Peretele superior(tegmen timpani) este
reprezentat de o lam osoas subire, care
desparte epitimpanul de fosa cranian
mijlocie.
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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

cele mai mici oase ale omului


prezint multiple caracteristici speciale
nutriia lor este asigurat doar prin periost
Oscioarele sunt unite prin ligamente i muchi
(M.tensor tympani si M.scriei) .

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OSCIOARELE AURICULARE

Ciocanul se ancoreaz cu mnerul de


membrana timpanic; n centrul acesteia osul
formeaz o nfundare , aa numitul umbo,
care este un reper anatomic important pe
membrana timpanic.

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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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Musculatura cavitii timpanice


M.stapedius (m.scriei): se inser pe gtul
scriei i este situat ntr-un canal osos, paralel
de partea mastoidian a n.facial, de care este
n acelai timp inervat.
M.tensor tympani (m.ciocanului): se afl paralel
de trompa lui Eustachio i este inervat de
ctre n.trigemen. Se inser pe gtul ciocanului.
reflexul stapedian ndeplinete o funcie de
aprare n urechea intern.

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RAPORTURILE TOPOGRAFICE ALE CAVITII TIMPANICE:

peretele lateral: format de ctre membrana timpanic i


conductul auditiv osos
peretele medial: cohleea
peretele inferior: bulbul venei jugulare
peretele superior: dura fosei craniene mijlocii
peretele anterior: a.carotida intern
peretele posterior: partea mastoidian a n.facial
nervul Chorda tympani, - din N.facial; ea trimite ramuri
gustative ctre cele dou treimi anterioare ale limbii.

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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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SISTEMUL CELULELOR MASTOIDIENE

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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TROMPA LUI EUSTACHIO


legtura cavitii timpanice cu
rinofaringele
se deschide sub forma unei plnii posterior
de coane
Funciile trompei sunt:
1. asigurarea aerisirii cavitii timpanice i
a sistemului celulelor pneumatice
2. echilibrarea presiunii gazoase ntre
cavitatea timpanic i exterior,
3. drenajul cavitilor urechii medii
precum
4. mpiedicarea migrrii agenilor
infecioi.

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Trompa lui Eustachio


Funcia :
- forele de deschidere, reprezentate de
tonusul muscular, presiunea urechii medii,
elasticitatea cartilajului
- de forele de nchidere, cum ar fi presiunea
esutului, starea de tensiune

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Fiziologia urechii medii


Fucia principal este ajustarea impedanei .
Datorit impedanei acustice diferite a aerului
i lichidului(diferena de rezisten) fa de
undele sonore
urechea medie are rolul de a minima pe ct
posibil acest deficit de transmitere.
Reechilibrarea presiunea atmosferic, ce se
afl ntr-o modificare permanent datorit
diferitelor condiii meteorologice i a variaiior
de altitudine.
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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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Diferenierea funciilor cohleei


Funcia macromecanic(n compartimentul
lichidian)
Undele, ce se propag de la platina scriei spre
perilimf produc unde saltatorii la nivelul membranei
bazilare.
Fenomenul d posibilitatea unei analize pasive a
frecvenei i tonotipiei(adic impresia unei frecvene
anumite n zone diferite ale membranei bazilare i
astfel corespondena la o anumit fibr nervoase)
Funcia micromecanic(n compartimentul celular)

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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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SISTEMUL AUDITIV CENTRAL

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FUNCIILE SISTEMULUI AUDITIV CENTRAL

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

funciile principale enumerm:


Fixaia unui orizont optic, cu scopul orientrii
n spaiu n cazul unor micri rapide ale
capului; pentru ndeplinirea acestei funcii
sistemul vestibular acioneaz mpreun cu cel
optic.
Meninerea staticii i echilibrului, realizat
prin interaciunea cu sistemul proprioceptiv
motor

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Reflexul vestibuloocular (VOR)


Nucleii vestibulari trimit eferene importante ctre
nucleii motori ai muchilor oculari.
Aparatul vestibular acioneaz n mod reflex asupra
micrii i poziiei ochilor- rol n orientarea n spaiu
La micrile rapide ale capului
Nucleii vestibulari i primesc feed-backul pentru
reglaj fin prin receptori retinieni, aceast situaie
nefiind valabil i la ntuneric.
Legturile polisinaptice ntre cei doi nuclei vestibulari
i legturile ctre cerebel.

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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

Nervul facial descrie un traiect complicat,


traversnd stnca temporalului, urechea
medie i glanda parotid

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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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TRAUMATISMELE URECHII EXTERNE

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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TRAUMATISMELE URECHII EXTERNE


DEGERTURILE PAVILIONULUI
Stadiul I- dermatita edematoas- arsur, neptur,
anestezie local, local- culoare alb
Stadiul II- dermatita buloas flictenular
Stadiul III-gangrena uscat- coloraia brun a
tegumentelor
Stadiul IV- gangrena umed- escare infiltrative,
edematoase, fetide

Tratament: calmarea durerilor, nclzire treptat,


administrarea de vitamine, vasodilatatoare locale
i generale

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TRAUMATISMELE URECHII EXTERNE


ARSURILE PAVILIONARE
Ex clinic: jen dureroas, hiperemia difuz
Stadiul I- flictene, eritem
Stadiul II- leziuni profunde,fr flictene,
epiderm cenuiu
Stadiul III- leziune cu suprafa nchis
Tratament: curire, ndeprtatrea crustelor,
dezinfectante locale, ungvente epitelizante

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TRAUMATISMELE CONDUCTULUI AUDITIV


EXTERN
TRAUMATISMUL DIRECT
Intereseaz prile moi sau scheletul cartilaginos
Se produc: grataj , manipulare incorect a instrumentelor
Simptome: durere, singerare, decolarea tegumentului
Tratament: local dezinfectante, suprevegherea plgii
FRACTURA CAE
Producere: cdere pe menton, fr ale bazei craniului
Simptome:
- bombarea conductului, ngustarea acestuia
- durere n articulaia temporo-mandibular
Tratament: reducerea fracturii, fixare cu me endaural,
imobilizarea mandibulei

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DOPUL DE CERUMEN I DOPUL EPIDERMIC


DOPUL DE CERUMEN
Hipersecreia gld ceruminoase
Simptome: hipoacuzie, prurit,
acufene cu timbru grav, autofonie
Dg. pozitiv.: otoscopie- culoare
maronie
Tratament: spltur auricular sub
control vizual
DOPUL EPIDERMIC
Inflamaii cronice ale CAE
Simptome: idem Dop cerumen
Ex clinic: culoare albicioas,
consisten dur

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FURUNCULUL CONDUCTULUI AUDIT EXTERN


Infecie cu Stafilococ
Localizare: poriunii
cartilaginoase a CAE
F favorizani: surmenaj, diabet,
hipovitaminoza
Simptome: febr, durere local,
trismus, hipoacuzie uoar
Ex. Local: tumefierea difuz, apoi
localizat a CAE, tumefacie roie
Diagnostic diferenial : Otita ext
ern eczematoas, otita ext ern
difuz, otite medii supurat
Tratament: mee locale cu
Rivanol, sau ungv Tetraciclin,
trament antibiotic OXACILINA
i tratament antiinflmator

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OTITA EXTERN DIFUZ


Inflamaia difuz a CAE
Etiologie: otite supurate cr., eczeme,
furuncule, iritaii mecanice, corpi
strini
Simptome: durere, febr, mncrime
intens, tensiune local
Ex clinic: tumefierea difuz a CAE,
concentric, eroziuni epiteliale ,
secreie seroas, apoi purulent,
pielea ngroat, timpan greu vizibil
Tratament: sol alcool boricat 4%, sau
Sol Rivanol 1%, sau sol Betadin,
antiinflamatorii locale i generale

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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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ECZEMA CONDUCTULUI AUDITIV EXTERN

Etiologie: iritaii prelungite,


substane iritante, otoree cronic
Simptome: prurit intens,
Ex ORL: descuamare epitelial,
scuame apoase, transparente
Complicaie: eczema pavilionului
auricular, atrezia de conduct
Tratament: alimentaie lactovegetarian, vitamine,
desensibilizri, ndeprtarea
factorilor declanatori

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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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STENOZA DE CONDUCT AUDITIV EXTERN

Etiologie. ngroare
progresiv a CAE, cicatrici
vicioase
Simptome. Hipoacuzie de
transmisie
Tratament: audiometrie
prealabil
Tratam chirurgical- incizie,
dilatator CAE

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EXOSTOZELE CONDUCTULUI AUDITIV EXTERN

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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ERIZIPELUL URECHII EXTERNE

Etiologie: infecie streptococic


Simptomatologie: febr, frison, alterarea strii
generale, semne de septicemie,
Examen clinic. Tumefierea pailionului
auricular i a CAE

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ZONA ZOSTER AURICULAR

Etiologie: viral- virus herpes zoster


Simptome: arsur local, durere
Ex clinic: vezicule, extinse pe pavilionul auricular,
spre conductul auditiv extern, i spre fa
Tratament. Antiviral local i general

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TUMORILE URECHII EXTERNE

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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34

TUMORI MALIGNE ALE URECHII EXTERNE


Etiologie: traumatisme, expunere la soare
Anatomie patologic: vegetante, ulceroase, ulcerovegetante, infiltrative
Extindere:
grd I- ulceraie mic, fr afect . Cartilajului
Grd II- invazia cartilajului
Grd III- invadarea urechii externe i ggl
Grd IV- metastaze
Diagnostic histopatologic: :
epiteliom spinocelular, bazocelular, sarcom

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EPITELIOM AL PAVILIONULUI AURICULAR

Diagnostic diferenial:
Diskeratoza
Degerturi
Eczema
Psoriazis
Nodul nedureros
Lupus
Sifilis
Othematom
Tratament: chirurgical- extirparea tumorii reconstrucie pavilion
auricularradioterapie

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35

CURS nr 3
OTOLOGIE

36

TRAUMATISMELE URECHII MEDII

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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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37

TRAUMATISMELE TIMPANICE PRIN CORPI


STRINI
Simptomatologie: durere, hemoragie
subepitelial
Perforarea membranei timpanice cu
dizlocarea lanului osicular, fenomene
vertiginoase
Ex. ORL: PERFORAIE MEZOTIMPANAL
Tratament: aspiraie, pansament uscat
endaural, aplicare de pansament
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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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38

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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39

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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TRATUMATISMUL ACUSTIC ACUT


Expunere la zgomot puternic pe o perioad de
timp 2 ore-7 zile
Hipoacuzie neurosenzorial pe frecvenele
nalte cu anco la 4000 Hz.
Fenomen de epuizare nervoas
Tratament:
Vasodilatoare
Vitamine

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40

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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TRAUMATISMELE INDIRECTE ALE URECHII


TRAUMATISMELE ASOCIATE
- impact mastoidian
- temporo-parietal
- occipital
- occipito-parietal
fracturi longitudinale- TIMPAN I CASA MEDIE AFECTATE,
N FACIAL INTEGRU
fracturi transverse- C.A.I. , VESTIBUL, COHLEE PERETE
INTERN AL CASEI MEDII, N .FACIAL, FR AFECTAREA
TIMPANULUI
fracturi oblice

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41

FRACTURI LABIRINTICE I EXTRALABIRINTICE


FR LABIRINTICE: fr. Ale labirintului osos, fr. Ale stncii cu respectarea
labirintului osos, comoia labirintic
FR. EXTRALABIRINTICE: fr. Ale casei medii, fr ale vrfului stncii,
mastoidiene, CAE
Simptomatologie:
- perforaie timpanal
- otoragie
- licvoree
- Surditate
- tulburri de echilibru
Paralizie de N. V, VI, VII
Tratament: conservativ,sau chirurgical
echpe mixte

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LEZIUNILE POSTRAUMATICE ALE SISTEMULUI


TIMPANO-OSICULAR
Simptomatologie:
HT care se transform n HM sau HP
Acufene
Tulburri vestibulare
Localizare: artic incudo-stapedian, apofiza descendent a nicovalei,
artic stapedo-vestibular
Diagnosticul clinic:
Timpanometrie, reflex stapedian
Audiograme
Deschiderea casei medii n scop dg.
Tratament:
CHIRURGICAL- reconstrucii de lan osicular, MT.

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42

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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43

CURS nr 4
OTOLOGIE

44

OTITELE MEDII ACUTE I CRONICE

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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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45

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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46

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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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47

CATAR TUBO-TIMPANIC
TRATAMENT:
nlturarea cauzelor rinofaringiene
Acumulare de lichi: drenaj transtimpanal- diabolo
Antiinflamatorii
Dezobstruante nazale
Aerosoli
Mucolitice
Cortizon

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SINDROM DE TUB BEANT


Definiie: imposibilitatea de nchidere a trompei
Simptomatologie: zgomot aerian la inspiraie,
hipoacuzie, acufene
Examen clinic: timpan aspect de drapel care
flutur la fiecare micare respiratorie
Tratament:
- insuflaie de acid boric sau acid saliciliccontracia reflex a trompei
- cauterizarea electric a orif faringian
- injectare de teflon

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48

OTITA MEDIE ACUT

TROMPA LUI EUSTACHIO

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OTITA MEDIE ACUT


CLASIFICARE :
1. OTITE MEDII ACUTE MICROBIENE- Otita
medie acut congestiv sau supurat
2. OTITE MEDII ACUTE NEMICROBIENE- Otita
seroas

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49

OTITA MEDIE ACUT MICROBIAN


Etiologie: produs de Pneumococ,
Haemophilus, Stafilococ
Anatomie patologic:
1. Faza congestiv: inflamaie cataralfaz
supurat cu colecii pururlentedrenaj
spontan- perforaie sau chirurgicalparacentez
2. Supuraie persistentcronicizare
3. Osteit cu mastoidit

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OTITA MEDIE ACUT MICROBIAN


Cauze favorizante:
1. Disfuncia tubar
2. Infeciile rinofaringiene
3. infecii virale sisteice- rujeola, grip,
varicel
4. traumatismul extern al timpanuluiperforaie de timpan

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50

OTITA MEDIE ACUT MICROBIAN


Simptomatologie:
- febr, durere, autofonie, hipoacuzie,
acufene cu timbru grav
Examen otoscopic:
- faza congestiv: desen vascular intens
al mnerului ciocanului, sau a MT
posterior i post-superior
- faza cataral- timpan retractat, reflex
luminos absent, orizontalizarea
mnerului ciocanului, mobilitate redus
a MT
Examen funcional: triada BEZOLD , HT.
Mederat, VS redus

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OTITA MEDIE ACUT SUPURAT

Definiie: proces supurativ la nivelul mucoasei


tutror compartimentelor urechii medii
Anatomo-patologic: hiperplazia mucoasei
urechii medii

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51

OTITA MEDIE ACUT SUPURAT


SIMPTOMATOLOGIE:
- n funcie de stadiu evolutiv al unei otite
medii congestive sau catarale
- otalgie: brusc, pulsatil, iradiere spre
arcada dentar
- febr 39-40
FAZA PREPERFORATIV
FAZA PERFORATIV

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OTITA MEDIE ACUT SUPURAT- faza


preperforativ

Ex clinic: hiperemia difuz a MT- roie intens


Vascularizaia intens a mnerului ciocanului
Congestia trece de inelul timpanal
Refle luminos ters
Suprafaa MT devine mat
Uneori dureri la apsarea mastoidei- reacie
mastoidian
Hipoacuzie de transmisie, acufene, ameeliiritarea labirintului
Febr, astenie, leucocitoz, tahicardie

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52

OTITA MEDIE ACUT SUPURAT- faza


preperforativ

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OTITA MEDIE ACUT SUPURAT- faza


postperforativ
ESTE OTIT MEDIE SUPURAT ACUT
PERFORAIE SPONTAN SAU PROVOCAT
Ex clinic:
puroi n CAE- sero-sangvinolent sau purulent,
sau galben-verzui, NU MIROASE
Timpan congestionat, perforaie
mezotimpanal, margini neregulate

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53

OTITA MEDIE ACUT SUPURAT- faza


postperforativ

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OTITA MEDIE SUPURAT ACUT

Evoluie: 10-14 zile de tratament corect


cedeaz supuraia
La nc 7-10 zile vindecare
COMPLICAII:
- meningite
. labirintite
- mastoidite
- cronicizare

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54

OTITA MEDIE SUPURAT ACUT


FORME ANATOMO-CLINICE:
1. DUP CRITERIU EVOLUTIV: forme supracute,
subacute
2. DUP ASPECTUL PERFORAIEI
- mezotimpanal
- membrana Shrapnell- post. sup- Troeltsh sau
antero-superioar- Prussak
3. DUP NATURA AGENTULUI PATOGEN
- pneumococ mucos
- stafilococ
- enterococ

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OTITA MEDIE SUPURAT ACUT


Diagnostic diferenial:
1. otita extern difuz
2. miringita
3. zona zoster auricular
4. O.M sup cronic n faza renclzit
Tratament:
- calmarea durerii- antialgice
- trat antiinflamator
- trat. antibiotic conform antibiogramei
- dezobstruante nazale
Evoluie: 10 -14 zile- vindecare, sau persistena
perforaiei cu risc de recidive i cronicizare

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55

OTITA MEDIE A SUGARULUI

Este frecvent
Poate trece neobservat
Ex otologic- ESENIAL
Orice stare febril a sugarului necesit
consult otologic
este bilateral

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OTITA MEDIE DIN BOLI INFECTO-CONTAGIOASE


COMPLICAII ALE BOLILOR INFECTO-CONTAGIOASE
1. SCARLATINA- 2 forme: timpurie- n primele 2-3 zile
ale bolii, necrozant
2. RUJEOLA 3. GRIPAL- flictene pe suprafaa timpanului, hemoragii
timpanale
4. ERIZIPELATOAS- placarde veziculare n CAE i pe
suprafaa timpanului
5. TUSE CONVULSIV
6. PAROTIDITA EPIDEMIC- asociat cu hipoacuzie de
tip neurosenzorial, prin afectarea cohleei

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56

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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57

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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58

OTOMASTOIDITA SUGARULUI
TRATAMENT
Drenaj precoce
Combaterea infeciilor asociate
TIMPANOTOMIE
Antibioterapie
Dezobstruante nazale
ANTROMASTOIDECTOMIA

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OTOMASTOIDITA ACUT SUPURAT


Etiopatogenia: proces supurativ al casei medii care
se transmite spre mastoid prin aditus ad antrum
Forme clinice: acut neexteriorizat acut latent,
acut exteriorizat, otomastoidita sugarului
Anatomia patologic
Faza iniial: hiperemia difuz a MT, ngroarea
mucoasei, secreii seropurulente
Faza a doua: invadarea osului mastoidian,
empiem mastoidian, ngroare osoas,
exteriorizare

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59

OTOMASTOIDITA ACUT SUPURAT


Examen fizic:
Durere la palparea mastoidei
Timpan intens congestionat, bombat
Perforaie timpanal prin care se scurge puroi
pulsatil
Fistula GELLE- fistul a CAE , ptoz a peretelui
posterosuperior a CAE
Hipoacuzie de transmisie
Voalarea mastoidei

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OTOMASTOIDITA ACUT SUPURAT


Forme clinice
SUPRACUT- prinderea simultan a UM i a
mastoidei
SUBACUT- cefalee, otoree purulent
APARENT PRIMITIV- modificri minime ale MT
i majore ale mastoidei
Complicaii:
Meningita otogen
Paralizia N FACIAL
Abcese peridurale
labirintita

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60

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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OTITA MEDIE CRONIC


Definiie: proces inflamator cronic al casei medii i
mastoidei
Agenii patogeni: polimicrobian
Anatomia patologic:
1. Leziuni ale timpanului: perforaii timpanalemezotimpanale sau epitimpanale, respectiv n
pars tensa sau pars flaccida- membrana
Shrapnell, margini libere sau aderente
2. Leziuni mucoase: infiltrate celulare i formare de
microchiste, polipi granulaii
3. Leziuni osoase: tromboze vasculare la nivelul
lanului osicularnecroze osoase... Osteita

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61

OTITA MEDIE SUPURAT CRONIC

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OTITA MEDIE SUPURAT COLESTEATOMATOAS


Perforaie marginal a MT, cu henierea epiteliului CAE

SKIN IN THE WRONG PLACE


Clasificare: colesteatom n sac herniar, colesteatom
extensiv
Atica- punct de plecare, invadarea membranei Shrapnell
Antrul mastoidian- posibilitate de extindere spre
mastoid
Lezarea lanului osicular de procesele osteitice
Casa medie- leziuni extinse ale canalului facial
Extindere spre canalul facialului sau canal semicircular

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62

SEMNE CLINICE ALE


COLESTEATOMULUI

Otoree purulent fetid


Evoluia continu a otoreei
Otoree insensibil la tratament local i general
Otoragie
Polipi n casa medie sau granulaii, lamele de
colesteatom dispuse concentric
Hipoacuzie de transmisie HP sau HM.
Acufene- ureche nfundat
Paralizia facial
Perioade de renclzire
Complicaii endocraniene

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DIAGNOSTICUL POZITIV AL COLESTEATOMULUI

Examen otoscopic
Ex audiometric
RTG sau CT mastoidian
Dup tipul de leziune
Natura leziunilor timpanale

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63

TRATAMENTUL COLESTEATOMULUI

TRATAMENT CURATIV: - suprimarea cauzei


care l-a produs
TRATAMENT SIMPTOMATIC- dezinfectante
nazale i rinofaringiene, soluii locale
antiseptice
TRATAMENT CHIRURGICALANTROMASTOIDECTOMIA LRGIT tehnic
nchis sau deschis

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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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64

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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65

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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66

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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OTOMASTOIDITA CRONIC SUPURAT


Anatomie patologic:
Proces osteitic, asociat cu un proces supurat
Cuprinde toate cavitile UM
Simptomatologie:
I. Mastoidita cr. simpl
1. forma comun- sm clinice reduse, otoree, durere la
palparea mastoidei
2. forma fistulizant- forma Gelle- fistula atico-timpanic,
prbuirea CAE perete postero-superior
II. Mastoidita cronic renclzit
complicaii grave endocraniene, labirintite, petrozite,
abcese, paralizie de N. Facial.

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67

CURS nr 5
OTOLOGIE

68

COMPLICAIILE SUPURAIILOR
AURICULARE

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CLASIFICAREA COMPLICAIILOR SUPURAIILOR AURICULARE


EXTERNE

OTITA EXTERN
ADENITA RETROAURICULAR
OSTEOPERIOSTITA, ABCESUL I FISTULA
RETROAURICULAR
FISTULA GELLE

CERVICALE

Teaca m SCM- pseudoBezold


Teaca m digastric post- otomastoidita jugodigastric
Moulet
Teaca m. Trapez, splenius- otomastoidita occipital

INTRAOSOASE

OSTEITA SCUAMEI TEMPORALULUI


OTOMASTOIDITA TEMPORO-ZIGOMATIC
PARALIZIA N FACIAL
FISTULIZAREA COHLEEI- COHLEARIZARE
LABIRINTITA
PETROZITA ANTERIOAR I POSTERIOAR
PETROAPICITA- SIND GRADENIGO

ENDOCRANIENE

TROMBOFLEBITA DE SINUS LATERAL


MENINGITA
ABCESUL EXTRADURAL, SUBDURAL, CEREBRAL
CEREBELOS
HI BENIGN POSTOTITIC

GENERALE

SEPTICEMIA KORNER

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69

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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2. PARALIZIA NERVULUI FACIAL


Etiopatogenie:
Se datoreaz nevritei sau ischemiei la nivelul vasa nervosum
prin tromboze sau vasculite
Complicaie a O.M. COLESTEATOMATOASE- erodarea pereilor
canalului Fallope
Ex. Clinic:- paralizie facial periferic
Tratament:
O.M SUP.ACUTA i P.F.- antibioterapie i mirigotomie larg
OTOMASTOIDITA ACUT- antromastoidectomie sau
antrotomie
OTOMASTOIDITA CRONIC- asanarea focarului infecios,
evidare timpano-mastoidian

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70

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. LABIRINTITELE BACTERIENE


ETIPATOGENIE:
- Complicaie rar a O.M. Sau Otomastoiditelor
produse de Pneumococ, Streptococ, sau
Haemophilus
- Complicaie frecvent a OM. Cu pseudomonas,
Proteus, E. Colli
- Complicaiile Postoperatorii- evidri
petromastoidiene
- Complicaia postraumatic- fracturi temporale
- Secundare unor meningite, abcese extradurale,
petrozite

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71

3.1.1. LABIRINTITA ACUT SEROAS


SE PRODUCE PRIN: fistule la nivelul ferestrei ovale sau rotunde i
infectarea labirintului
Clinic:
Acufene nalte
HP sau mixt
Greuri, vrsturi, paloare
Vertij rotator
Nistagmus orizontal sau orizontal rotator
Ex obiectiv:
Sm. de otit sau otomastoidit
Sindrom vestibular periferic: nistagmus orizontal rotator la urechea
bolnav, secusa rapid spre urechea bolnav
Romberg pozitiv
Proba rotatorie i nu caloric datorit perforaiei

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3.1.1. LABIRINTITA ACUT SEROAS


Diagnostic. Pozitiv
Apariia brusc a vertijului
Nistagmus
Romberg invers nistagmusului
Schimbarea probei Weber din transmisie n percepie
Diagnostic. Diferenial:
Labirintita acut supurat
Alte sindroame vestibulare
Meningita
Abcesul cerebelos

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72

3.1.1. LABIRINTITA ACUT SEROAS


Prognostic:
Hipoacuzie definitiv
Dispariia fenomenelor vestibulare la 2-3 spt.
Forme clinice:
Circumscrise:- labirintului, vestibular- sm vest i HP,
cohlear- HPfr sm vestibulare
Postoperator- la 5-12 zile dup chirurgia mastoidei
Precoce: 2-3 zile dup otomastoidit sau otit
Tardive: 7-30 zile
Tratament: timpanotomie sau antromastoidectomie,
antibiotice, repaus, sedative

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3.1.2. LABIRINTITA ACUT SUPURAT


Etiologie:
otitei- prin fereastra rotund
Otomastoidit, colesteatom- eroziunea labirintului
Cale sanguin
Ex. Clinic:
Vertij sever
Nistagmus spre urechea bolnav
Romberg pozitiv
Pierderea auzului
Greuri, vrsturi
Evoluia: paralizie facial. Menigit
Tratament: antibioterapie masiv, repaus, antiemetice,
antivertiginoase

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73

3.1.3.LABIRINTITA SUPURAT CRONIC


Este secundar unui proces cronic supurati mastoidian
Ex clinic:
Uneori asimptomatic
OMS cr. Otoree intes
Cefalee, dureri mastoidiene
Vertij la micri brute ale capului
HT HM SAU COFOZ
Sm fistulei:
CSL- buclei- nistagmus spre partea sntoas
- ant de ampul- nistagmus spre urechea bolnav
CSP- nistagmus vertical
CSS- nistagmus orizontal spre urechea sntoas
Tratament: mastoidectomie, eradicarea colesteatomului,nchiderea
fistulei cu fascie sau pericondru

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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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74

3.2 . LABIRINTITA VIRAL


Apare n cursul infeciilor virale: zona zoster,
parotidita epidemic, grip
Propagare pe cale sanguin
Ex. Clinic: HP, vertij , nistagmus intens ,
echilibru susinut prin mec vizuale
Tratament: antivirale, sedative, antiemetice,
antivertiginoase

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4. PETROZITA

Definiie: afectarea inflamatorie a celulelor mastoidiene


Clasificare:
- anterioar- postotitic
- posterioar- postmastoidectomie
- petraopicita
Simptomatologie:
- supuraie abundent
- Acufene
- Alterarea strii generale
- leucocitoz
- sindrom Gradenigo: nevralgie trigeminal, parez de nerv VI.abducens i otoree
Dg pozitiv:
Otoree
Hipoacuzie
Diplopie
Nevralgie trigeminal
Tratament: antibiotice, evidare petromastoidian

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75

5. TROBOFLEBITA DE SINUS LATERAL


Etiopatogenie
Otomastoidita colesteatomatoas
Otomastoiditele supraacute
Postraumatic
Modalitai de extindere:
Continuitate
Cale venoas- vasele de la baza casei medii
Limfatic
Efracia peretelui venos
Toxinele din urechea medie

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5. TROBOFLEBITA DE SINUS LATERAL


Bacteriologie
proteus, streptococ, stafilococ
La copii- Haemofilus, pneumococ, piocianic, stafilococ
Anatomie-patologic
Mastoidita acut- infeciedistrugerea septurilor osoase
periflebitaperiflebita supurat
Contactul prelungit al ag patogen cu peretele
venoserodarea peretelui vascularextindere spre sinusul
transverssau sagitalvena jugular intern
Trombul datorit infiltrrii sale
bacterienetrombolizmetastaze septice- emboli care
determin septicemia cu semnale clince

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76

5. TROBOFLEBITA DE SINUS LATERAL


Diagnostic pozitiv
- Febr
- Frisoane
- Sensibilitate la palparea venei emisare mastoidiene
- Pe marg. ant a m SCM cordon dureros
- Peteii
- Hemocultur pozitiv
- Hematurie
- Albuminurie
- CT- absena substan osoas la nivelul sinusului sigmoid
- Angiografia
Diagnostic diferenial:
- Abcesul cerebral, extradural, meningita, af infecioase, TBC, pneumonie
viral

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5. TROBOFLEBITA DE SINUS LATERAL


TRATAMENT MEDICAMENTOS
- antibiotice ce strbat bariera hemato-encefalic
- antiedematoase
- anticonvulsivante
- monitorizare
TRATAMENT CHIRURGICAL
- Mastoidectomie lrgit
- Puncionarea sinusului lateral
- Ligatura venei jugulare interne
- Asocierea tratamentului antibiotic i anticoagulant

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77

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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78

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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79

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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80

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:

1. ABCES DE LOB TEMPORAL

Hipoacuzie discret
Halucinaii auditive
Tulburri de miros
Tulburri de vedere
Neuropatii craniene III,IV
Tulburri de vorbire

2. ABCES CEREBELOS

Nistagmus spontan pe partea lezat


Nistagmus provocat- poziie, lumin,
fix punct
Tremor
Ataxie
Dismetrie

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81

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:

- sindrom vestibular periferic ( armonic - toate deviaiile sunt


de aceeai parte cu secusa lent a nistagmusului)

- sindrom vestibular radicular (armonic)

- sindrom vestibular central( disarmonic - deviaiile sunt


variabile)

- sindrom vestibular mixt postrahianestezic

- manifestri vestibulare n afeciuni generale

- manifestri vestibulare reflexe

- tulburri vestibulare isterice.

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84

SINDROM VESTIBULAR PERIFERIC


Simptome: - vertij (halucinaii de micare
rotatorie)

- acufene

- hipoacuzie (auz fluctuant, senzaie de


plenitudine aural)
Semne: - nistagmus (orizontal rotator, scade la
fixarea privirii)

- de iritaie vagal (vrsturi,bradicardie,


transpiraii,paloare)

- imposibilitatea meninerii echilibrului

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AFECIUNI CU SINDROM VESTIBULAR PERIFERIC

- sindromul Meniere
- sindromul Lermoyez
- boala Meniere
- labirintita acut seroas sau supurat
-posttraumatic (comoia labirintic, fractura
labirintic, ruptura ferestrelor, trauma sonor)

- postoperator

- toxic

- vertij paroxistic poziional benign Barrany

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85

SINDROM VESTIBULAR RADICULAR


Simptome:

- vertij

- acufene

- NU exist hipoacuzie
Semne:

- nistagmus

- deviaii segmentare i tronculare de partea


opus nistagmusului(de partea secusei lente)

- de iritaie vagal

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AFECIUNI CU SINDROM VESTIBULAR RADICULAR

a) sindroame radiculare pure


- nevrita viral (gripal, urlian, rujeolic, zooster)
- sindrom radicular toxic: saturnism, alcool,
tabagism,arsenic, CO
- sindrom radicular metabolic: DZ, mixedem,
avitaminoze
- sindrom radicular idiopatic
b) sindroame radiculare atipice
- tumori de CAI (schwannom de vestibular,
meningiom, astrocitom)
- colesteatom petro- apical
- arahnoidita de unghi ponto- crebelos

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SINDROM VESTIBULAR CENTRAL


Simptome:

- vertij ( stare vertiginoas, rar n crize)

- NU exist acufene

- NU exist hipoacuzie
Semne:

- ale afeciunii cerebrale ce a generat i


sindromul vestibular

- de iritaie vagal

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AFECIUNI CU SINDROM VESTIBULAR CENTRAL

- tumori cerebeloase
- leuconevraxita
- anevrism bulbar
- insuficien vertebro- bazilar
- kinetoze

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ALTE SINDROAME VESTIBULARE


4. Sindrom vestibular mixt postrahianestezic:

- sdr.vestibular este bilateral, mixt,foarte intens

- tulburrile de echilibru sunt de durat

- surditate bilateral, profund.


5. Manifestri vestibulare n afeciuni general:

- ameeal( NU vertij)

- apar n distonia neurovegetativ, anemii, HTA, DZ,


deshidratri, sedative, ebrietate.
6. Manifestri vestibulare reflexe

- n apendicit, anexit, duodenit, colecistit, ulcer


duodenal
7. Tulburri vestibulare isterice

- surditate isteric, acufene,tulburri vestibulare


isterice

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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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88

SINDROMUL MENIERE

Simptome:

- vertij n crize repetitive cu durata de minuteore, cu frecven i intensitate variabil, cu


perioade de remisiune; criza poate fi precedat
de o aur

- hipoacuzie de tip percepie, poate fi


fluctuant- iniial cu afectarea frecvenelor grave

- senzaie de plenitudine aural

- acufene nepulsatile, continue sau


intermitente

- fonofobie

- iritaie vagal: grea, anxietate

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SINDROMUL MENIERE
Semne:

- nistagmus

- tulburri de echilibru(deviaii segmentare


i tronculare de partea secusei rapide a
nistagmusului)

- de iritaie vagal: vom, paloare,


bradicardie, transpiraie

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89

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

VERTIJUL PAROXISTIC POZIIONAL BENIGN


Def :Boal caracterizat prin criz de vertij periferic aprut
ntr-o anumit poziie a capului, avnd la origine cupulo
litiaza( otolii desprini din macula utricular degenerat
prin mecanism traumatic, infecios sau vascular cad pe
cupula CSP pe care o excit).
Este singura variant de sindrom vestibular periferic fr
hipoacuzie.

- ntr-o anumit poziie a capului apar nistagmusul i


vertijul

- nistagmusul este rotator spre urechea pe care st


aplecat bolnavul, are laten, variaz ca direcie n funcie
de poziia globilor oculari, obosete

- vertijul apare n crize scurte, tranzitorii, crete n


intensitate i dispare n circa 40 sec.

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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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91

SIMPTOME

- criz vestibular foarte puternic ce dureaz chiar


i 48 ore, unic, unilateral, care se remite complet n
cteva sptmni
- acufene
- iritaie vagal
- NU apare hipoacuzie
Semne:
- nistagmus orizontal, rotator, ce scade la fixarea
privirii, i mrete amplitudinea la orientarea privirii
ctre componenta rapid i invers
- de iritaie vagal: paloare, bradicardie, transpiraii,
vrsturi
- deviaii segmentare i tronculare de partea opus
nistagmusului(sdr. vestibular armonic)

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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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92

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

- compresie a trunchiului cerebral, a cerebelului,


cu hidrocefalie

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SURDITATEA DE PERCEPIE
I.COHLEAR:
1) afeciuni congenitale

- hiperbilirubinemia

- traume intrapartum

- boli genetice: surditate neurosenzorial profund


congenital, surditate neurosenzorial congenital
progresiv de tip familial

- rubeola n primele 6 luni de sarcin

- sifilis congenital

- rujeola n primele 6 luni de sarcin

- medicaia teratogen

- hipotiroidie

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93

SURDITATEA DE PERCEPIE- COHLEAR


2) traumatic

- comoia cohlear

- fistula labirintic

- ruptura fenestral

- fractura de stnc, craniobaz

- trauma sonor

- boala chesonierilor

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SURDITATEA DE PERCEPIE- COHLEAR


3) inflamatorie

- cohlearizarea- complicaie n supuraiile UM

- labirintita

- sifilis,TBC
4) ototoxic

- aminoglicozide, diuretice de ans, salicilai,


chimioterapice
5) idiopatic

- surditate de percepie brusc instalat, idiopatic


6) genopatii

- otoscleroza cohlear Manasse


7) presbiacuzia

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94

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

- este o hipoacuzie neurosenzorial uoar,


bilateral, cu predominen unilateral

IV. AFECTARE OTIC N BOLI SISTEMICE

- boala autoimun a urechii

- granulomatoza Wegener

- periarterita nodoas, histiocitoza X,


leucemia

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95

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

- timpan cicatricial calcar, fibros, hialin

- otita seroas acut/ cronic(mucocel cavotimpanic,


timpan albastru idiopatic)

- hemotimpan, licvortimpan, serotimpan

- otita fibroadeziv

- otita adeziv

- blocaj cu lamel osoas malformativ retrotimpanal


Belluci
b) Miringoliz

- ruptura miringian

- perforaia miringian

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96

SURDITATE DE TRANSMISIE
3. Prin lezare osiculo- cavotimpanic
a) Blocaj osicular

- sdr. ciocanului fixat Goodhill

- blocaj incudo- malear posttraumatic, congenital,


timpanosclerotic

- sdr. de anchiloz stapedo- vestibular - genetic(otoscleroza,


osteogenesis imperfecta) i timpanosclerotic
b) Boala Paget( osteitis deformans)
c) Sdr. de ntrerupere 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

- otita seroas, otoreea tubar, mucocel


cavotimpanic, timpan albastru idiopatic

- blocaj tubar

- otita adeziv

- sindromul tubei beante

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97

SURDITATE DE TRANSMISIE
5. Prin blocaj fenestral (FO sau FR)

- otosclerotic

- malformativ

- timpanosclerotic

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SURDITATEA DE TRANSMISIE
6. Altele

- colesteatom primitiv cu timpan intact,


heterotopii(choristom)= esut normal, dar ectopic: choristom de
gland salivar

- flebectazia de golf jugular

- anevrism de ACI

- procidena dural

- cilindromul membranei timpanice

- tumora glomic jugular

- alte tumori de UM - carcinom, rabdomiosarcom

- osteom al niei ovale

- odontom cavotimpanic

- neurofibromul solitar al cavotimpanului

- adenocoristom salivar intracavotimpanic

- granulomatoza Wegener, sarcoidoza, LES, mielomul multiplu,


leucemia, tumora cu mieloplaxe

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98

SURDITATEA DE TRANSMISIE

7. Leziuni otomastoidiene- otomastoidita


8. Traumatisme miringo- osiculo- cavotimpanice i sechelele lor
- otoragia
- otolicvoreea
- barotia
- serotimpan
- hemotimpan
- licvortimpan
- ruptura miringian
- perforaia miringian posttraumatic
- traumatism lan osicular
- fracturi cavotimpan
- ruptura FO, FR
9. Boli sechelare postotitice
- distrucii sechelare cicatriceale postotitice
- hiper- metaplastice = timpanoscleroza

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99

CURS nr 7
OTOLOGIE

100

SURDITATEA BRUSC INSTALAT

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DEFINIIE
HIPOACUZIE NEUROSENZORIAL COHLER
unilateral
Minim 30 Db
Produs brusc

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101

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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MECANISM PATOGENIC INCRIMINAT

SPASMUL
TROMBOTIC
EMBOLIC- FIBRILAIA ATRIAL
HEMORAGIC- HTA, coagulopatii

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102

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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103

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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104

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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105

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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106

ETIOLOGIE

Rasa alb
Femei- factor endocrin
Vrsta 20-50 ani
Predispoziia familiar
Variaii ale metabolismului osos

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SIMPTOMATOLOGIE

HIPOACUZIE DE TRANSMISIE UNILATERAL


- apare insidios
- frecvene grave
- influienat de starea de oboseal
PARACUZIA WILLIS- ameliorarea audiiei n mediul
zgomotos
PARACUZIA WEBER- autofonia
ACUFENE
VERTIJ
PLENITUDINE AURICULAR

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107

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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108

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

Maxilarul- lateral prin procesul


zigomatic cu osul zigomatic,
- cranial se continu cu osul
nazal procesul frontal se unete cu
osul frontal.
Osul zigomatic - se continu cu osul
frontal printr-un proces omonim, iar
spre dorsal se continu cu arcul
zigomatic

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111

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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112

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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113

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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114

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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115

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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116

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 venoas nazal


v.facial
v.retromandibular
v. jugular intern.

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117

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

Procesul uncinat - structur osoas situat la


nivelul peretelui lateral al foselor nazale
ntre marginea posterioar a procesului
uncinat i prima celul etmoidal- Bulla
etmoidalis se evideniaz un alt element al
complexului osteomeatal-Hiatusul semilunar
Cavitatea dintre procesul uncinat, bula
etmoidal i lamina papiracea a etmoidului
este descris ca infundibulul etmoidal

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119

Evaluarea imagistic a foselor nazale

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Examinarea endoscopic nazal

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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

Concha bullosa unic stng.

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121

ELEMENTE DE PATOLOGIE
Concha bullosa dubl dreapt.

cb

cb

ci
s

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Structura mucoasei respiratorii

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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122

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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Inervaia mucoasei nazale respiratorii

Inervaia senzitiv - N. Trigemen


inervaiei vegetative - ganglionul
pterigopalatin
fibrele parasimpatice realizeaz vasodilataie
i cresc secreia glandelor nazale
Fibrele simpatice- scad secreia gladular.

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123

Structura mucoasei olfactorie

cptuete regiunea olfactorie- partea


antero-cranial a septului
Mucoasa olfactorie acoper o arie de civa
cmp, pe care se afl ntre 10-20 milioane de
celule senzoriale bipolare

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Structura mucoasei olfactorie


Axonii- Fila olfactoria, ce se ntinde endocranian prin
lama ciuruit a etmoidului, formnd n.olfactivFibrele ajung la bulbul olfactiv-primul centru olfactiv,
care este legat de cortexul olfactiv prin tractul
olfactiv
Cortexul olfactiv- al doilea centru olfactiv - rolul n
percepia mirosurilor i asocierea acestora cu alte
impresii senzoriale.
legturi ctre centrele olfactive teriare- hipocampul,
regiunea insular anterioar, formaiunea
reticular- funcii polisenzoriale asociative.

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124

FIZIOLOGIA I IMUNOLOGIA NAZAL


Funcia de respiraie nazal
Funcia de nclzirea a aerului
Funcia de aprare a mucoasei nazale
Rolul n fonaie
Rolul n olfacie

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FUNCIA DE RESPIRAIE NAZAL


- inspir - flux laminar- se transform ntrun flux turbulent- intensificnd contactul
cu mucoasa nazal- nclzirea, purificarea
i umidifierea aerului inspirat.
Ciclul nazal - fosele nazale se ngusteaz
i se mresc alternativ.
- reaciile vasculare ale sinusoidelor, din
zona cornetelor inferioare- supuse unui
control autonom prin sistemul nervos
vegetativ - produc ngroarea alternant a
mucoasei nazale

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125

FUNCIA DE NCLZIREA A AERULUI

Aclimatizarea aerului inspirat- prin nclzire i


umidificare, la nivelul foselor nazale.
Fluxul turbulent - contact este mbuntit
ntre mucoasa nazal i aerul inspirat
Umidifierea este asigurat de secreiile
celulelor fuziforme i vaselor din lamina
proprie.

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FUNCIA DE NCLZIREA A AERULUI


Controlul termic este supus sistemului vascular nazal,
i mai ales sinusoidelor
partea anterioar a foselor nazale este o temperatur
mai sczut fa de cea posterioar;
aerul inspirat este nclzit treptat, pe cnd n expir se
produce un condens al particulelor de aer, acesta
recptndu-i umiditatea
25oC la nivelul rinofaringelui.
Tulburrile funciei de aclimatizare
fiziologic cu vrsta,
patologic- datorit unor inflamaii locale,
sau datorit unor operaii cu rezecii extinse de
mucoas nazal.

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126

FUNCIA DE APRARE A MUCOASEI NAZALE

Mecanismele nespecifice de aprare


- Aprarea mecanic- aparatul mucociliar cilii epiteliului respirator interpui ntre dou
straturi de mucus, unul bazal mai puin vscos i
altul superficial cu vscozitate crescut
- Aprarea celular- granulocitele
neutrofile, monocitele, macrofagele, precum i
celulele natural killers- rol n aprarea mucoasei
mpotriva infeciilor virale.

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FUNCIA DE APRARE A MUCOASEI NAZALE


Mecanismele specifice de aprare
- mucoasa nazal propriu-zis i esutul limfoepitelial al
inelului Waldeyer.
Mecanismul umoral de aprare-IgA;celulele, IgM i mai rar IgG.
Ig. eliberate sunt preluate de celulele glandulare, iar dup ce le
este asociat la acest nivel o component secretorie, ele sunt
din nou eliberate sub form de aa numiii anticorpi secretori.
Mecanismul de aprare celular-mastocitele, macrofagele,
leucocitele polimorfonucleare(neutrofile, bazofile, eozinofile),
limfocitele i celulele dendritice Langerhans

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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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131

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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132

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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133

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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134

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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135

SIMPTOMATOLOGIA N FRACTURILE NAZALE


Semne generale:
Paloare facial
Lipotimie
Pierderea contienei
Respiraie superficial
Bradicardie
Semne locale :
Obstrucie nazal uni sau bilateral
Hematom septal
Deplasarea nasului
Epistaxis
Cefalee
Durere local

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EXAMEN CLINIC ORL


Fracturi nchise
Deformarea piramidei nazale
Crepitaie osoas
Mobilitatea fragmentelor deviate
Prezena hematomului septal sau a epistaxisului
Fracturi deschise
Studierea fracturii
Statusul pielii i a esuturilor moi
Palparea osoas i a punctelor dureroase
Examinarea planeului orbitar

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136

TRATAMENTUL FRACTURILOR NAZALE


Intervenia precoce:
fixarea i reducia fracturii
Tratamentul plgilor asociate
Evacuarea hematomul septal
Oprirea hemoragiei nazale
Intervenia tardiv:
La 3-4 zile sau 10-12 zile

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Tratamentul fracturilor nazale


Fr. fr deplasasare- calmante, compres local,
supraveghere
Sept nazal: repoziie i tamponament nazal
Oase nazale: nfundare unilateral, bilateral i
deviaiile piramidei nazale( pensa Walsham)
Fr. cominutive: refacerea piedestalului septal+
tamponament nazal bilateral+contena extern
Fr. nazo-etmoido-orbitare: repoziia oaselor nazale+
cantopexia intern+repararea cilor
lacrimale+nchiderea breei meningo-etmoidale

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137

ngrijirea postoperatorie i evoluia

La 48-72 ore apare: edem, echimoz,


tumefierea dermului
Tratament: antibiotice, antiinflamatoare,
antialgice
Scoaterea meelor nazale la 72 ore
Suportul septal la 5-6 zile
Contenia extern la 14 zile

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TRAUMATISMELE SINUSURILOR PARANAZALE

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

TRAUMATISMELE SINUSURILOR PARANAZALE

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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TRAUMATISMELE SINUSURILOR PARANAZALE


III.Localizare:
1. Fr. ale sinususului frontal
2. Fr. ale sinususului maxilar:
arcada zigomatic
os malar
asociat arcad i malar
3. Fr. ale maxilarului superior:
1. fr. izolat a peretelui orbitar
2. fr. malarului i a peretelui orbitar
3. fr.incomplete: perete anterior sinus maxilar, creast alveolar,
tuberozitatea maxilarului, bolt palatin
4. fr complete: orizontale- LE Forte I, II, III.
verticale: medio-sagital, latero-sagital
combinate
cominutive

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139

TRAUMATISMELE SINUSULUI FRONTAL


Fracturile simple
Localizare:
peretele anterior
peretele posterior i lama ciuruit a
etmoidului
Fracturile fronto-bazale
Fracturi ale peretelui posterior sau lamei
ciuruite cu leziunea durei mater

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FRACTURILE SIMPLE

Tratament
Refacerea peretelui sinusal
Toaleta sinusal
Tamponament nazal

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140

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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141

Fracturile fronto-bazale
Tratament
Chirurgical
Echip mixta cu neurochirurgul
ngrijiri postoperatorii n serviciul ATI

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TRAUMATISMELE SINUSULUI MAXILAR


Clasificare:
Fr. izolat a arcadei zigomatice- trismus i tulb.
de masticaie
Fr. malarului
Fr. asociat a arcadei i malarului
Fr. asociat a malarului i planeului orbitar
Fr. izolat a planeului orbitar

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142

FRACTURILE MAXILARULUI SUPERIOR

Clasificare
Fracturi incomplete:
Fr.peretelui anterior al sinusului maxilar
Fr. crestei alveolare
Fr. tuberozitii alveolare
Fr. bolii palatine

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FRACTURILE MAXILARULUI SUPERIOR


Fracturi complete:
Fr inferioar- Le Fort I- apertura piriform- fosa canintuberozitatea maxilarului- apofiza pterigoid
Fr. Mijlocie- Le Fort II- oase nazale- apof asc a maxilaruluiperete inferior orbitar- perete int si inferior orbitardespictura sfenomaxilar- perete ant a sin. Maxilar
Fr. Superioar- Le Fort III- rdcina nasului- apof asc a
max.- perete int i podeaua orbitei- apof pterigoid- arcada
zigomatic... DISJUNCIE CRANIOFACIAL NALT
Fr. Combinate
Fr cominutive

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143

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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146

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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147

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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148

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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149

DIAGNOSTICUL DEFERENIAL AL ERIZIPELULUI


1. LUPUSUL ERITEMATOS
- Forma comun a LE cutanat
- afectarea feei- FLUTURE- extidere spre brbie, frunte
i nas
2. DERMATITA ALERGIC DE CONTACT
- contact cu produse cosmetice i de uz personal
- expunere la polen
- masca facial cu edem i eritem intens facial- contact
cu un alergen
3. ANGIOEDEMUL
- inflamaia facial , mai ales pleope i buze

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TRATAMENTUL ERIZIPELULUI

PENICILIN iv.
Antiseptice locale

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150

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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151

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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SIMPTOMELE CLINICE ALE RINITELOR ACUTE


Incubaia 3-7 zile
Stare general: cefalee, febr, dureri musculare
Local:
- nas iritat
- strnuturi
- discomfort nazal i epifaringian
- congestia mucoasei nazale
- secreii seroase
- obstrucie nazal
- uneori hiposmie

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152

STADIILE CLINICE ALE RINITEI ACUTE VIRALE

I. STADIUL USCAT
II. STADIUL CATARAL- secreia mucoas nazal,
obstrucie nazal, inflamaia mucoasei nazale
mai ales la nivelul cornetelor

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COMPLICAIILE RINITEI ACUTE VIRALE


CRS
RINOFARINGITE
FARINGITE
SINUSITE

ESUT LIMFATIC
ADENOIDITE
AMIGDALEITE

CRI
RINITA
ACUT
VIRAL

LIMFADENITE

LARINGITE
TRAHEITE

BRONITE

ALTELE
GASTROENTERITE

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153

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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154

RINOFARINGITA COPILULUI
COMPLICAII
cronicizare
Suprainfecie bacterian

locale
regionale

generale

Otita- disfuncie tubar


Otita medie congestiv acut
Otita seromucoas
Sinusita acut i cronic
Angine
Laringita
traheobronit

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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155

MECANISMUL FIZIOPATOLOGIC GENERAL AL


RINITELOR
Edem i rinoree apoas- prin pierderea
plasmatic rndotelial
Celulele endoteliale markeri de chemoretracie
i adeziune.....direcioneaz traficul de leucocite
Epiteliul cu glande seroase u celule caliciforme
contribuie la rspunsul antimicrobian prin Ig A
secretor, mucina polizaharidic i compoziia
ionic a fluidelor nazale
Procese vasomotorii conduse de SNC pe cale
nervilor autonomi

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RINITELE CRONICE SPECIFICE


Apar secundar infeciilor: sifilis, tuberculoza,
difterie, rinosclerom, mucormicoza, lepra
TUBERCULOZA
Afectare nazal rar
Clinic: ulceraie septal, afectare tegumentarulceraii sau necroze
Deficite funcionale mari
Diagnosticul poz.: anamnez, ex histopat,
depistarea inf primare pulmonare
Tratament: antituberculostatice

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156

RINITE CRONICE SPECIFICE 2.


LEPRA
Produs de Mycobacterium leprae
Rar
Incubaie: 3-5 ani
5 tipuri:
- tip tuberculoid
- Tip border-line tuberculoid
- Tip border-line
- Tip border-line lepromatos
- Tip lepromatos- cel mai frecvent

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RINITELE CRONICE SPECIFICE 3.


- Tip lepromatos- cel mai frecvent
- Afectarea mucoasei nazale i a cornetelor
nazale
- obstrucie nazal
- cruste urt mirositoare, ulceraii
- anestezia locoregionala- prin distrugerea n
senzitivi
- tegumente faciale ngroate, edeme,
hipertrofii ale buzelor i lobulilor auriculare
- lavaj salin, unguente locale, tratament
polimedicamentos

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157

RINITELE CRONICE SPECIFICE 4.

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 CRONICE SPECIFICE 5.


SIFILISUL NAZAL
sifilisul primar:
- Localizare- vestibul nazal
- Adenopatie satelit
- Edem perivascular i infiltrat limfoplasmocitar
- Leziuni ulcerative i necrozante
- Evoluie lent n 5 sptmini dup care apare rinoree apos
- Diagnostic poz.: poliadenopatie, rush cutanat, ex lab: VDRL
Sifilisul teriar:
Goma sifilitic cu perforaii septale, distrugerea scheletului
osos nazal
Determinri osoase, cardiovasculre, SNC
TRATAMENT: schema din bolile dermatovenerologice

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158

RINITELE CRONICE SPECIFICE 6.


ACTINOMICOZA
- Actinomycos Israeli- germen Gram +
- Apare dup traumatisme sau afeciuni dentare
- Zona afectat este roie i indurat
- Tratament: ablaie chirurgical i drenaj sinusal
DIFTERIA
- Cvasieradicat
- Clinic: rinoree serosangvinolent, cruste n vestibulul nazal
i regiunea buzei superioare, ulceraii n partea nateroar a
septului nazal
- Febr, stare general alterat
- Tratament: penicilinoterapie, cefalosporine sau Macrolide
- Antitoxina: cind se suspicioneaz leziuni faringiene

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RINITELE CRONICE SPECIFICE 7.


MUCORMICOZA
- Fungi din clasa Mucoracee
- Afectarea persoanelor cu imunitate deficitar- diabet
SIDA
- Clinic: rinoree, zone diseminate negricioase pe
mucoasa nazal, febr, cefalee
- Extindere spre regiunile vecine: orbit, sinus cavernos
- Diagnostic poz.: biopsie
- Tratament: debridri chirurgicale masive, tratament
antifungic- AMFOTERICINA B
- Prognostic: rezervat

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159

RINITELE VASOMOTORII

Clinic: rinoree seroas, strnuturi, congestie nazal


Rspuns la mediul ambiant
Pacienii nu au o component alergic a suferinei
Reacii alergice negative
Mecanismele imediate gen IgG nu au nici un rol
Tratament: spraz cu cortizon
Tratament chirurgical:
- turbinectomia LASER CO2
- LASER cu dioda pt conservarea funciei mucoasei
nazale
- RFA

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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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160

RINITE INDUSE DE FACTORI ANATOMICI


Mecanism: obstrucia nazal anantomic i
mecanic------ retenia secreiilor i inflamaia
mucoasei nazale
ATREZIA COANAL- uni sau bilateral
ADENOIDITA CRONIC HIPERTROFIC:stagnarea secreiilor i inflamaia mucoasei
nazale
DEVIAIILE SEPTULUI NAZAL:-obstrucie
nazal, blocaj ostio-meatal

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RINITE INDUSE DE FACTORI ANATOMICI 2.


HIPERTROFIA CORNETELOR NAZALE INFERIOARE
definiie: inflamaia cronic a mucoasei nazale
Pot fi:
. Difuze- Localizate- coada cornetului inferior, cap sau 1/3medie
Clinic:
- obstrucie nazal,
- obstrucia n bascul
Complicaii: sinusale, otice, faringiene
Tratament:
- medicamentos- ineficient de cele mai multe ori
- chirurgical: LASER, sau RFA, mucotomie, turbinoplastie,
rezecie endoscopic a zonei hipertrofiate

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161

RINITELE ATROFICE
Atrofia mucoasei nazale
Forme la virstnici: senzaie de obstrucie
nazal cu uscciunea mucoasei sau rinoree
apos necontrolabil

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RINITELE ATROFICE- OZENA

Klebsiella Ozenae- cruste fetide


Stafilococul aureus sau Proteus Mirabilis
metaplazia epiteliului ciliat i atrofia glandular
Cauze: deficit de Fe, vitam A., imunodeficien
Clinic: obstrucie nazal, cruste fetide
Diagnostic dif.: sifilis, lepra, tbc., granulomatoza
Wegener
Tratament: toaleta nazal cu soluii saline, ungv.,
Biseptol luni de zile
Tratament chirurgical: implant submucos de
cartilaj sau os

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162

ALGORITMUL TERAPEUTIC AL RINITELOR

EVITAREA
CAUZELOR

CORTICOIZI
TOPICI

EXAM. LA 1014 ZILE

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

Alergolog si ORL ist

Structural: polipi,
DS, Hipertrofia
cornetelor inf.

Medic ORL

Diverse:
hormonala,
medicamentoas

Corticoizi topici,
splturi saline

Tumori, sarcoidoz
gr Wegener

Specialist ORL trat


medicam si chir.

Medic ORL

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163

SINUZITELE ACUTE I CRONICE

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CLASIFICAREA RINOSINUZITELOR
CLASIFICARE

DURATA

ISTORIC- EX ORL

ASPECT SPECIFIC

ACUTE

PN LA 4 SPMNI

2 semne majore sau


1 semn miajor i 2
minore, sau rinoree
purulent

Febr, durere,
agravare simpt dup
5 zile, persist 10 zile

ACUTE RECIDIVANTE

4 SAU MAI MULTE


EPISOADE PE AN ,
FR COMPLICAII

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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164

SEMNE I SIMPTOME SUGESTIVE


MAJORE

MINORE

DURERE, PLENITUDINE FACIAL

CEFALEE

OBSTRUCIE NAZAL

FEBR
HALEN

RINOREE ANTERIOARSAU POSTERIOAR


OBOSEAL
HIPOSMIE SAU ANOSMIE

DURERI DENTARE
TUSE

FEBR

OTALGIE SAU PRESIUNE AURICULAR

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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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165

FIZIOPATOLOGIA SINUZITELOR ACUTE


INFLAMAII
INFECII

ALERGIE

EDEM AL MUCOASEI
NAZO-SINUSALE

OBSTRUCIE NAZAL

NCETINIREA MICRII I
CLEARENCE-ULUI MUCOCILIAR

HIPOXIE

TUTUTN

EXUDAT-TRANSUDAT

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BACTERIOLOGIA RINOSINUZITELOR ACUTE


Recoltarea corect a secreiilor : control
endoscopic din meatul mijlociu, meatul
superior sau recesul sfenoetmoidal
Recoltarea prin puncie cu aspiraie a
secreiilor
Germeni prezeni: Streptococus Pneumoniae,
Haemophilus influenzae, Moraxella catarhalis

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166

FLORA RINOSINUZITELOR ACUTE


FRECVENT NTLNII

FRECVENA REDUS

STREPTOCOCCUS PNEUMONIAE

STREPTOCOCI -HEMOLITICI
STAFILOCOC AUREUS

HAEMOPHILUS INFLUENZAE
KLEBSIELLA
MORAXELLA CATARHALLIS
ANAEROBI: FUSOBACTERII,
PEPTOSTREPTOCOCI, BACTEROIDES
VIRUSURI: CORONAVIRUSURI.
INFLUENZAE

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ASPECTE CLINICE I DE DIAGNOSTIC


TABLOUL CLINIC:
Debut relativ brusc, dup infecie viral
Durere sau senzaie de plenitudine la nivelul obrazului i frunii
Algiile dentare
Obstrucie nazal
Febr
Rinoree purulent apare mai trziu
EXAMEN ENDOSCOPIC: mucoas nazal edemaiat, hiperemic,
acoperit de secreii pururlente
Secreii n meatul mijlociu, blocaj meatal
EXAMENE COMPLEMENTAREE: RTG sinusuri, ex. CT sinusal, examen
gacteriologic din secreia nazal

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167

CLASIFICAREA RINOSINUZITELOR ACUTE


I. RINOSINUZITA ACUT MAXILAR RINOGEN
II.RINOSINUZITA ACUT MAXILAR
ODONTOGEN
III. RINOSINUZITA ACUT SECUNDAR
HEMOSINUSULUI
IV. RINOSINUZITA ACUT FRONTAL
V. RINOSINUZITA ACUT ETMOIDAL
VI. RINOSINUZITA ACUT SENOIDAL

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RINOSINUZITA ACUT MAXILAR RINOGEN

Cea mai frecvent


Apare dup rinita acut viral
Durere pulsatil
Cefalee
Rinoree purulent
Obstrucie nazal
Febr
Nrvralgii suborbitare
Ex clinic: durere la palparea fosei canine, secreie purulent
meatal, hiperemia mucoasei nazale, edem al mucoasei nazale,
hiperemia cornetului mijlociu i dedublarea acestuia
Diagnostic dif.:rinita purulent
RINOSINUZITA ACUT RECIDIVANT: episoade acute separate de
vindecri

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168

RINOSINUZITA ACUT MAXILAR


ODONTOGEN
ORIGINE: carie dentar sau lucrare
stomatologic
Caracteristici:
- este unilateral
- rinoree fetid
- dureri dentare
- RTG evideniaz afectarea dentar

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RINOSINUZITA ACUT SECUNDAR HEMOSINUSULUI

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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169

RINOSINUZITA ACUT FRONTAL


apare n cadrul pansinuzitelor
Incidena redus
Cauze: concha bullosa, blocaj ostio-meatal, tumori, polipi,
traumatisme, saun postoperator- rinoplastii
Clinic: obstrucie nazal, unilateral, durere orbitar
unilatral, rinoree purulent, fotofobie
Ex endoscopic: blocaj meatal prin: polipi, tmori, edem
RTG sinusal sau CT sinusal
Clasificare:
- blocat: dureri atroce, pulsatile, nu cedeaz la antialgice,
obstrucie nazal i nu rinoree
- recidivant: episoade repetate, este bilateral, pe fundal de
imunodeficien
- barotraumatic: durere i epistaxis
- postraumatic: suprainfecia unui hematom sinusal

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RINOSINUZITA ACUT ETMOIDAL


Simptomatologie: cefalee fronto-orbitar
pulsatil cu fotofobie
Examen clinic: edem palpebral, durere la
micarea globului ocular i la presiunea
unghiului intern al orbitei
Examen endoscopic: puroi n meatul mijlociu
RTG i CT sinusal- integritatea laminei
papiracee i a rinobazei
Tratament de urgen
Evoluie favorabil sub tratament
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170

RINOSINUZITA ACUT SFENOIDAL

izolate: sunt rare


factori favorizani: infecii de CRS, obstrucia
ostiumului sinusal sfenoidal
Simptomatologie:
- dureri oculare sau retrooculare, sau n
centrul capului
- rinoree posterioar
- tulburri de vedere
- secreii la nivelul recesului sfenoetmoidal
- congestie conjunctival i lcrimare
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TRATAMENTUL SINUZITELOR ACUTE


Principiu: drenaj i aerarea cavitilor sinusale
TRATAMENT MEDICAMENTOS
Vasoconstrictoare 7-10 zile
Corticoterapia topic
Corticoterapia parenteral sau p.o.
Tratament antibiotic conform antibiogramei
Amoxicilina sau Amoxi+ Acid clavuranic
Cefalosporine gen II i III
Macrolide: Claritromicina, Azitromicina..... Haemophilus
Chinolonele - de rezerv
Durata tratamentului: 8-14 zile

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171

TRATAMENTUL SINUZITELOR ACUTE


TRATAMENT CHIRURGICAL
- puncia i drenajul sinusului maxilar
- trepanopuncia sinusului frontal
. etmoidotomia
- sfenoidotomia
- luxarea cornetului mijlociu sub control
endoscopic

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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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172

RINOSINUZITELE CRONICE

SINUZITA CRONIC- evoluie mai lung de 3 luni


Simptomatologie: rinoree unilateral purulent,
posterioar, obstrucie nazal, iritaie faringianmai ales dimineaa, cefalee 3-4 ore dup trezire
Iritaie faringian
Laringite repetate

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CLASIFICARE

Rinosinuzite cronice rinogene: maxilar,


frontal, etmoidal, sfenoidal
Forme particulare ale rinosinuzitelor cronice:
1. rinosinuzitele copilului
2. manifestri sunusale n SIDA la copii
3. rinosinuzitele nozocomiale
Rinosinuzitele fungice
Rinosinuzitele polipoase

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173

RINOSINUZITELE CRONICE RINOGENE


Rinosinuzita cronic maxilar
Semne clinice variabile
Rinoree ant sau posterioar prezent
Obstrucie nazal
Tuse iritativ
Manifestri secundare: iridociclite, uveite
Ex endoscopic: congestia mucoasei, rinoree
meatal, edem al procesului uncinat, cornet
mijlociu dedublat- bureletul Kauffmann, concha
bullosa

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RINOSINUZITELE CRONICE RINOGENE 2.

Rinosinuzita cronic frontal


Asociere cu sin etmoidal
Rinoree purulent posterioar unilateral
Obstrucie nazal
Tulburri olfactive
Semne la distan
Endoscopie nazal: blocaj meatal mijlociu
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174

RINOSINUZITELE CRONICE RINOGENE 3.

Rinosinuzita etmoidal cronic


Asociat cu alte forme de sinuzite
Simptomatologie: cefalee matinal, durere n
rdcina nasului, obstrucie nazal, fr
rinoree
Ex endoscopic: blocaj meatal mijlociu

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RINOSINUZITELE CRONICE RINOGENE 4.

Rinosinuzitele sfenoidale cronice


Cefalee retroorbitar median
Hemaj
Rinoree posterioar
Blocaj al recesului sfeno-etmoidal
Dureri nevralgice la nivelul maxilarului
superior

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175

TRATAMENTUL RINOSINUZITELOR CRONICE


TRATAMENT MEDICAMENTOS
Antibiotice
- cel puin 3-4 sptmni
- conform antibiogramei
antiinflamatorcorticoterapie
decongestionante nazale
Lavaj cu soluii saline

TRATAMENT CHIRURGICAL

chirurgia cornetului mijlociu


Polipectomie
Septoplastia
Etmoidectomia limitat
infundibulotomie
Tratament medical 3 luni corect
efectuat
Conceptul funcional
Drenajul sinusului sfenoidal
Puncia spltur sinusala
Tehnicile chirurgicale Draf I, II, III

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FORME PARTICULARE ALE RINOSINUZITELOR


FACTORI FAVORIZANI:
- infecii ale CRS
- alergia
- poluarea
- obstacole anatomice
- corpii stini
- deficit de drenaj al secreiilor

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176

RINOSINUZITA ACUT A COPILULUI


vrsta mai mic de 5 ani
simprome: febr, rinoree purulent, obstrucie nazal, edem
palpebral
3 forme de evoluie: abces palpebral, abces subperiostal,
flegmon periorbital

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TRATAMENTUL RINOSINUZITELOR ETMOIDALE


ACUTE

MEDICAMENTOS LOCAL I GENERAL


CHIRURGICAL

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177

DIAGNOSTICUL DIFERENIAL AL SINUZITELOR


N FUNCIE DE OBSTRUCIA NAZAL

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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DIAGNOSTIC DIFERENIAL N FUNCIE DE TIPUL


DE RINOREE
RINOREE

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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178

ALGORITM DE DIAGNOSTIC AL RINOSINUZITELOR LA


COPII
2-6 ANI

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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179

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RINOSINUZITELE ALERGOFUNGICE

CLINIC: rinosinuzit cronic i alergie


polipoza nazal
Ex bacteriologic i histopatologic
Se asociaz cu polipoza nazal
Prezena mucinei alergice
Ex CT

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180

RINOSINUZITELE CRONICE POLIPOASE

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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RINOSINUZITELE CRONICE POLIPOASE


Anamneza- antecedente alergice, hipereactivitate
nazal: strnut, mincrime nazal, strnut
Examen clinic i endoscopic: aspectul mucoasei nazale,
prezena polipilor, cruste
Clasificarea polipozei nazale:
GRD I polipi edematoi meatali mijlocii
GRD II polipi edematoi marg inf a cornetului mijl.
GRD III polipi edematoo sau fibroi la nivelul marg sup
a cornetului mijlociu
GRD IV polipi edematoi sau fibroi ce ocup toat fosa
nazal

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181

RINOSINUZITELE CRONICE POLIPOASE


Examinri
complementare:
Ex bacteriologic i
micologic
Ex citologic
Ex alergologic
Ex pneumologic
CT sinusal

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RINOSINUZITA CRONIC POLIPOAS


TRATAMENT MEDICAMENTOS
- CORTICOTERAPIA PREDNISON sau Medrol de 16 mg.10-12 zile
- cure de 3x pe an
- Antihistaminice
- toaleta nazal- splturi nazale
- spray-uri cu cortizon NASONEX, AVAMZS, BIORINIL
TRATAMENT CHIRURGICAL
- polipectomia LASER CO2
- eliberarea meatului mijlociu i orif de deschidere sinusale
- drenaj larg
- se asociaz cu cel medicamentos
EVOLUIE: posibilitate de refacere

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182

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

Limfom non Hodgkin


Plasmocitom
Midline granuloma

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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184

TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 1.
Nu pun probleme de diagnostic
Clinic se manifest ca procesele inflamatorii

5 sindroame de diagnostic de certitudine

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SINDROAMELE DE CERTITUDINE
sindroame

Fose nazale

Sinus maxilar Etmoid

Frontal

Nazo-sinusal

Orbitar

Buco-dentar

Neurologic
frontal

Facial

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185

TUMORILE BENIGNE ALE NASULUI I SINUSURILOR 2.


1.

PAPILOAMELE FOSELOR NAZALE I


SINUSURILOR
Pot fi izolate sau intereseaz ambele zone
Pot fi confundate cu polipii
Recidiveaz
Clinic: epistaxisuri repetate, obstrucie nazal, rinoree
Examen endoscopic nazal: formaiuni tumorale
vegetante, sesile, sngernde
Tratament: chirurgical
Diagn Pozitiv: histopatologic

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TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 3.
2. ADENOAMELE
Provin din gld sero-mucoase ale mucoasei nazale
Se gsesc pe sept sau cornete
Ex clinic endoscopic: formaiuni bine delimitate, gri-roz
Diagnostic: CT i endoscopie+ ex histopatologic
Tratament chirurgical
3. FIBROAMELE
Provin din periost
Localiz. pe peretele lat al fosei nazale
Aderente de os
Diagnostic: ex endoscopic + ex histopatologic
Tratam chirurgical

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186

TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 4.
4. MIXOMUL I GLIOMUL
Se pot confunda cu polipii
Apar rar la nivelul foselor nazale
Ex endoscopic+ ex .histopatologic+ CT
Tratam . Chirurgical cu atenie
5. OSTEOMUL
Osteom frontal cel mai frecvent ntlnit
Fr semne clinice importante
CEFALEE
Tratament chirurgical
Diagnostic: CT+extirparea tu + ex histopat.

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TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 5.
6. SCHWANOAMELE I NEUROFIBROAMELE
5%
Clinic: epistaxis, obstrucie nazal
Ex endoscopic: formaiune tumor roie, crnoas
Diagnostic pozitiv. Ex endoscopic+ CT+ex
histopatologic
7. CONDROAMELE
Localizare n partea anterioar a septului nazal
Ex endoscopic: mucoas nazal normal
Tratament chirurgical

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187

TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 6.
8.HEMANGIOAME I ANGIOFIBROAME
Epistaxis recidivant
Se asociaz cu boala Osler Rendu

Se pot extinde endosinusal


Diagnostic : ex endoscopic+ CT+ex histopatologic, angiografie
Tratament. Embolizare+ abord endoscopic+electrocoagulare

9. HEMANGIOENDOTELIOM
Tumor rar

10. HEMANGIOPERICITOM
Clinic: tumor gri roiatic, moale
Pseudopolipoid
Diplopie, ptoz, palparea unei tumori intraorbitare

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TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 7.
ANGIOFIBROMUL NAZO-FARINGIAN
Tumor mare hipervascularizat
Sex masculin
Agresivgitate mare
Ex clinic: tu. Mare, bine delimitat roie, consisten ferm, polilobulat
Extindere:
sfenoidal i endocranian
Fosa pterigomaxilar
Endoorbitar
Regiunea infratemporal
Regiunea zigomatic
Fosa nazal opus
Cavum
!!!!! SINGERARE LA ATINGERE
!!!!! Tratament chirurgical riscant
!!!!! EMBOLIZARE SELACTIV
Evoluie favorabil dup tratament chirurgical i hormonal

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188

TUMORILE BENIGNE ALE NASULUI I


SINUSURILOR 8.
PAPILOM INVERTIT
Tumor benign cu potenial de transformare
Clinic: mas polipoid, tumoral n meatul mijlociu
EXAMEN HISTOPATOLOGIC
Tratament chirurgical+ control endoscopic periodic
!!!!se poate asocia cu carcinom scuamos

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TUMORILE MALIGNE NAZO-SINUSALE


5 SINDROAME:
Sindrom nazo-sinusal: obstrucie nazal, rinoree
purulent, epistaxis recidivant, hiposmie, unilaterale
Sindrom orbitar: diplopie- m drp intern, scderea acuitii
vizuale, exoftalmie, edem periorbitar, lcrimare
Sindrom buco-dentar- ulceraii dentare i gingivale,
fistule, afectarea palatului dur i moale, trismus
Sindrom facial: edem dureri, nevralgie, parestezii
Sindrom neurologic. Complicaii infecioase- meningite,
empiem, deficit de atenie, HIC

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189

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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190

TUMORILE MALIGNE NAZO-SINUSALE


Clasificarea TNM

T1- tumor limitat la mucoasa antral, fr leziune osoas


T2- tumor care erodeaz osul inclusiv palatul dur
T3- tumor care invadeaz : sinus maxilar, planeul orbitar,
peretele orbitar i planeul orbitei, sinus etmoidal
T4 invadeaz: lama ciuruit a etmoidului, etmoid posterior, sinus
sfenoidal, nazofaringe, fosa pterigomaxilar, vl palatin, baza de
craniu
N0- fr ggl patologici
N1- 1 ggl metastatic omolateral sub 3 cm
N2a- 1 ggl. Metast omolateral 3-6 cm
N2b- mai muli ggl. Metast omolat
N2c- metast bilat maxim 6 cm.
N3- metast peste 6 cm

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TUMORILE MALIGNE NAZO-SINUSALE


Clasificare dup localizare:

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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191

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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192

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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193

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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Carcinom neuro-endocrin cutanat


Tumor rar
Este de origine neuroendodermic
Apare la vrstnici
Apare ca un nodul cutanat
violaceu
Ex histopat+
imunohistochimie pozitiv,
citocheratina pozitiv
Metastazeaz rapid

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194

MALADIA BOWEN

carcinom in situ cu evoluie spre carcinom


epidermoid invaziv
Leziune unic bine delimitat, roiatic
Se poate confunda cu cheratoza solar
Diagnostic i excizie rapid .......VINDECARE

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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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197

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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198

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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TIPURI DE ALERGENE CARE


DETERMIN RINITELE ALERGICE
Praful de cas
Acarienii se hrnesc cu epitelii umane
descuamate din saltele, pene, pturi
Alergenii se gsesc n fecalele acarienilor
Expunerea se face n timpul nopii prin
inhalaresau percutan
Polenurile
Purtate de vnt
Transportate de insecte

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199

TIPURI DE ALERGENE CARE


DETERMIN RINITELE ALERGICE
Fungii
Drojdii, mucegaiuri- creterea lor este favorizat
de cldur i umiditate
Insecte- gndacii de buctrie
Animale domestice i peridomestice
Pisic, cine, cal, pr de iepure
Ageni ocupaionali
Anhidride, sruri de platin, Nichel, crom,petii,
crustacee, nitrii, formaldehid, fum de igar,
contraceptive i alte medicamente

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MECANISME
I. SENSIBILIZARE
II. RSPUNS ALERGIC- faza precoce i tardive

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200

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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MECANISME- FAZA PRECOCE


Apare la cteva minute la expunere
Clinic: strnut, prurit, rinoree
Cei mai importani mediatori eliberai sunt:
histamina, prostraglandina D2- vasodilataie i
crete permeabilitatea vascular,
leucotrienele- produc vasodilataie, scade
clearencul mucociliar

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201

MECANISME- FAZA TARDIV

apare la 4-6 ore de la provocarea cu alergen


este consecina unui mecanism inflamator
Clinic: obstrucie nazal
Rol_ eozinofilele prezente n mucoasa nazal ct i
n secreia nazal
HIPERREACTIVITATEA NAZAL- exagerarea
rspunsului nazal la stimuli nespecifici i iritani,
Hipereactivitatea nazal nespecific- consecina
infeciei nazale bacteriene sau virale

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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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202

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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203

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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204

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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205

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

Msuri de control al mediului


Terapie farmacologic
Imunoterapia specific cu alergene
Chirurgia adjuvant(n cazuri atent
selecionate)

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206

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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207

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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208

GENERALITI

Tulburrile respiratorii de somn(SDB)se


asociaz cu anumite condiii speciale cum ar fi:
snoringul primar
sindromul de rezisten al cii respiratorii
superioare (UARS)
sindromul de apnee-hipopnee obstructiv de
somn(OSAHS)
apneea central
astmul
afeciunile pulmonare cronice(COPD)

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ELEMENTE CE POT DETERMINA COLAPSUL


CILOR RESPIRATORII N TIMPUL SOMNULUI

Activitatea musculaturii dilatatorie a cii


faringiene
Presiunea negativ generat n timpul inspirului
care se opune activitii muchilor dilatatori
Anatomia structural a cilor respiratorii

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209

ACTIVITATEA MUSCULATURII DILATATORIE


A CII FARINGIENE

Regiunea cilor respiratorii superioare situat ntre palatul


moale i hipofaringe, nu dispune de elemente cartilaginoase
sau osoase de susinere, motiv pentru care n cursul
somnului exist potenial real de colaps al acestor structuri.

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ACTIVITATEA MUSCULATURII DILATATORIE


A CII FARINGIENE
Activitatea M. Genioglos este implicat n faza
inspiratorie a respiraiei impiedic prolapsul
limbii spre peretele posterior faringian
Activitatea M. Genioglos scade n timpul NREM i
descrete mai mult n tonus n REM .
Reduceri ale activitii muchiului tensor al vlului
palatin.
Modificarea tonusului n timpul somnului ridic
susceptibilitatea obstrurii cilor respiratorii .

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210

ACTIVITATEA MUSCULATURII DILATATORIE A


CII FARINGIENE

Reducerea substanial a tonusului muscular la


apariia unui sindrom de rezisten n calea
respiratori superioar sau la obstrucia complet a
acesteia.

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Presiunea negativ 1.

Efectul Venturi - accelerare a fluxului aerian ca


urmare a intrri aerului ntr-un spaiu limitat
Principiul Bernoulli arat c un vacum sau
existena unei presiuni negative determin
explozia aerului nafar

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211

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

Palatul moale devine elongat


Pilierului posterior n exces la nivelul faringelui
posterior
Amigdale mult mrite
esutul faringian voluminos
Retrognaia sau retractarea brbiei
efectul dilatator al muchilor faringieni i efectul
protruziv al M.Genioglos sunt inadecvate n
somn limba are tendina de a prolaba n calea
aerian, rezultnd vibraia palatului moale,
luetei i a esutului faringian

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212

Respiraia nazal
Este cea fiziologic
Dac nu exist cauze obiective, ea se realizeaz
n orice condiii

Valva nazal este esenial pentru ventilaia


nazal

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Respiraia nazal n timpul somnului 1.


Alae-nasi - acestea sunt intens activate
Obstrucia nazal produce o cretere a
rezistenei
nazalemodificarea
efectului
Bernoulli, producndu-se automat sforitul
Starea nasului n timpul somnului este
determinat de gradul de edemaiere al
mucoasei nazale, n special la nivelul cornetelor
Modificarea arhitecturii somnului-prin blocarea
receptorilor nazali

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213

Respiraia nazal n timpul somnului 2.


Existena unor modificri funcionale ale
faringelui obstrucia nazal - o blocare a
mecanismelor compensatorii determinnd
sforitul i apneea de somn
Persoanele cu un faringe stabil tolereaz bine o
obstrucie nazal
Rolul localizrii obstruciei nazale -obstacolul
produs n epifaringe

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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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214

Patologia ORL afeciuni laringiene


Reducerea tonusului muscular al abductorilor care n
asociere cu o funcie glotic insuficient poate determina
stridor.
Micrile anormale de la nivelul glotei
Afeciunile laringiene implicate:
edemul epiglotei
paralizia corzilor vocale
laringomalacia
colabarea plicilor ariepiglotice
atrezia traheal
leziunile intrinseci traheale
compresiile extrinseci
modificri la nivelul esutului traheal i laringian

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Patologia ORL- afeciuni nazale i sinusale

Deviaii ale septului nazal,


Hipertrofia cornetului inferior
Fracturi la nivelul septului nazal
Hematoame septale
Corpii strini nazali
Rinita cronic simpl
Rinita alergic
Rinosinusitele cronice
Polipoza nazal
Tumorile nazale i sinusale
Atrezia coanal

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215

Modificrile faciale i cervicale


Micrognaia
Anchiloza temporomandibular
Modificri distale ale
mucturii cu
proeminena incisivilor,
sau cu incisivi invertii
Retrognaia
Gtul scurt i gros
Poziia anormal a
hioidului

Clasificarea dup Angle


a.Neutralbi
b.Distalbi cu proeminena molarilor
c.Distalbi cu molari invertii
d. Medialbi

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Rolul otorinolaringologului

Consultant n centrele de somnologie


Cooperarea cu specialistul n somnologie
Contribuie major n managementul apneei de
somn
Identific procedurile terapeutice care pot
anticipa cel mai apropiat tratament al sleep
apneei
n direcionarea evalurii i n stabilirea
tratamentului

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216

Metodologia de examinare a patologiei ORL


la pacienii cu Sindrom de Apnee Obstructiv
de Somn

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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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217

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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218

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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219

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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220

Computertomografia 1.
Permite evaluarea structurilor complexului faringelaringe
Exist posibilitatea reconstruciilor volumetrice 3D

Diminuare pe seciune transversal a


nasofaringelui, orofaringelui i hipofaringelui

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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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221

RMN

Rolul pe care l are esutul grsos

parafaringian
din
regiunea
superioar a gtului la pacienii cu
OSAS

Nu se poate efectua n timpul


somnului

Evaluarea pacienilor nainte i


dup operaii de tipul UPPP,
rezecii ale bazei limbii, chirurgia
m. geniohioidian

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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222

Ecografia 2.
Limitele tehnicii echografice:
Nasofaringele nu poate fi examinat

Metoda este greu sau chiar imposibil de


efectuatla pacienii cu hipertrofia bazei limbii i
la pacienii la care lueta nu este vizibil( indicele
Mallampatti)

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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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223

Corelaia ntre valorile rinomanometrice i gradul


de obstrucie nazal
0 - 500 cm3/s.
35cm3/s.

500-700 cm3/s.

35cm3/s.

700- 870 cm3/s. 35cm3/s.

peste 870cm3/s. 35cm3/s.

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Cefalometria 1.

Cea mai eficient metod


Deviere a urmtorilor parametri:
- PAS- spaiul respirator posterior
- PM-PU-lungimea luetei
- MPH-distana ntre hioid i planul mandibulei
- Unghiul SNA - unghiul ntre sella turcica,nas
i regiunea supramentonier
- Unghiul SNB - unghiul ntre sella turcica,nas
i regiunea submentonier

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224

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

Scurtarea lungimii bazei


craniului
Scurtarea lungimii mijlocului
feei n partea superioar
Modificarea proporiei ntre
lungimea limbii i calea
respiratorie inferioar
Retrognaie
Retropoziia maxilarului
Alungirea accentuat a bolii
palatine
Reducerea oro i
hipofaringelui

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225

Modificri cefalometrice 2.

n retrognaie, rmn spaiu redus pentru limb,


hioidul proiectndu-se spre caudal
Odat cu nainterea n vrst se produce
alungirea luetei, iar hioidul este situat mai
profund

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Rolul metodelor de examinare n timpul


somnului
Localizarea obstrucieila nivelul regiunii velare
a faringelui
Precizarea locului obstruciei este dependent
de stadiul somnului
Un colaps continuu,urmat de presiuni critice
transform un pacient normal ntr-un sforitor
sau apneic

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226

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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Alte metode de examinare n timpul


somnului

Faringoscopia flexibil

Computertomografia sau cine CT

Metode de determinare ale presiunii n faringe

Cuantificarea zgomotului de sforit, a


intensitii acestuia i a severitii acestuia

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227

Faringoscopia flexibil n timpul


somnului
Asigur confort pacientului
Permite evaluarea real a
gradului de colabare a
structurilor
Risc anestezic la pacienii cu
SAOS
Propofol
0,5 2 mg./kg.corp

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Cunoaterea mecanismelor respiraiei nazale


fiziologic
Rolul faringelui n realizarea mecanismelor
compensatorii n situaia unei obstrucii nazale
Condiiile de apariie a snoringului i a
sindromului de apnee obstructiv de somn

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228

Evaluarea ORL a pacienilor cu OSAS i snoring

Investigaiile eseniale i de rutin: faringoscopia


flexibil, rinomanometria anterioar, cefalometria,
investigaiile din timpul somnului
Investigaii complementare:
Computertomografia, RMN-ul, Echografia

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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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229

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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231

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232

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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233

Histologia corzilor vocale

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Zonele topografice laringiene

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234

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

Sgm apical inf


drp
B. Lobar
inferioar drp.

Segm
paracardiac
Segm bazalepost , ant.,
lateral

traheea
B.Lobar sup stg

Segm infer.
LINGULA
superioar

ventral

b. Princip strg
culmen

apicodorsal

Segm apic inf stg


b.Lobara inf stg.
Segm bazale

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235

FIZIOLOGIA LARINGELUI
FUNCIA DE PROTECIE
FUNCIA RESPIRATORIE
FUNCIA DE FONAIE

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LARINGITELE ACUTE I CRONICE

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236

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

Infecioas- viral, bacterian, micotic


Alergic
Inhalatorie
Medicamentoas
Edemul neinflamator al laringelui

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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237

LARINGITA ACUT CATARAL

ETIOLOGIE:
- sex masculin
-abuzul vocal
- condiii climaterice
- infecii rinosinusale i faringiene
- traumatisme
Obstrucia cilor respiratorii superioare
Factori terapeutici

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LARINGITA ACUT CATARAL


Anatomia patologic:
- stadiul cataral- congestia c.v pareza c.v edemul c.v-rou,
bogat n fibrin
- stadiul de supuraie-secreiile muco-purulente i purulente
n comisura posterioar
Simptomatologie:
- debut brusc
- disfonie
- uscciunea gtului, jen laringian
- durere la nghiit i fonaie
- tuse seac iritativ
- dispnee
Stare general alterat cu febr- UNEORI

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238

LARINGITA ACUT CATARAL


Dg pozitiv:
Anamnez
Ex ORL: congestia difuz a
c.v,hipertrofic c.v., desen vascular
capilar paralel cu axul pricipal al c.v
Mobilitate redus a c.v
!!! LARINGOSCOPIA CU FIBRA OPTIC
SAU CU OPTIC DE 90 grd.

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LARINGITA ACUT CATARAL


EVOLUIE:
- remisie dup 10-14 zile
COMPLICAII:
- edemul laringian
- pericondrita
- Flegmonul perilaringian
- abcesul laringian
TRATAMENT:
- antiinflatoare nesteroidiane sau steroidiene
- Atmosfer umed
- antitusive: Codein phosfat, Paxeladine
- antihistaminice- origine alergic
- repaus vocal absolut
- eliminarea factorilor iritativi

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239

LARINGITA ACUT forme anatomo-clinice

Laringita acut edematoas


Laringita acut necrozant
Laringita gripal
Laringita herpetic zosterian
Laringita aftoas
Laringita din varicel
Laringita tific
Laringita din scarlatin
Laringita rujeolic i rubeolic
Laringita din tusea convulsiv
Laringita acut bacterian
Laringita acut difteric- CRUP DIFTERIC

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LARINGITA ACUT EDEMATOAS


Etiologie: primitiv, secundar altor afeciuni: alergii,
rinosinuzite
Ex ORL: edem pe faa lingual a epiglotei, pliri ariepiglotice
Dispnee de tip inspirator
Tuse iritativ
Durere laringian
Anxietate, disfagie
Febr
Ex endoscopic: edem rou- infecios, sau translucidalergic

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240

LARINGITA ACUT EDEMATOAS SUBGLOTIC


Apare la copilul mic
Simptomatologie: dispnee inspiratorie, tiraj,
cornaj, edem laringian
Stadializare:
- St. I- tuse uscat latrtoare, voce clar, tiraj
moderat
- St. II- dispnee inspiratorie, tiraj, febr modeart
- St. III- IR A, cianoz, agitaie, dispnee, tiraj,
- St IV.- stare gen. Alterat, asfixie

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LARINGITA ACUT EDEMATOAS


SUBGLOTIC
Examen clinic: anamneza, ex laringoscopicPERICULOS DE EFECTUAT, edx lab. Complet
Tratament: internare, supraveghere
permanent
Corticoterapie
Antibioterapie
Umidifierea aerului n camer
Restabilirea respiraiei: Traheostomie la
nevoie

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241

LARINGITA SUPRAGLOTIC- EPIGLOTITA

Etiologie: H. Influenzae
Simptomatologie:
- debut brusc
- Febr
- Dispnee i disfonie

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LARINGO-TRAHEO-BRONITA ACUT

Copil sub 5 ani


LARINGITA SEROFIBRINOAS, CRUP MEMBRANOS
Etiologie: viral, strptococ, stafilococ, pneumococ
Debut i evoluie lent
Simptome: sm de guturai, dispnee inspiratorie,
tiraj subcostal,facies anxios,edem inflator
pseudo-membrane aderente, sm de IRA

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242

LARINGITA STRIDULOAS- CRUP SPASMODIC


Virsta 3-4 ani
Acces paroxistic de dispnee laringian, stridor,
tuse seac manifest
NU S-A PUS N EVIDEN AGENT INFECIOS
Este secundar infeciilor rino-faringiene
Edem , eritem al mucoasei c.v n regiunea
subglotic
Episod de dispnee n timpul somnului
La trezire este asimptomatic
Atacul spasmodic poate recidiva 2-3 nopi dup
care dispare complet

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LARINGITELE CRONICE

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243

LARINGITELE CRONICE ROII


1.LARINGITA CATARAL
- congestia difuz a c.v, hipersecreie mucoas
- capilare paralele cu axul laringelui
2. LARINGITA PAHIDERMIC ROIE
- cordita unilateral
- cordita n insule
3. LARINGITA CRONIC PSEUDOMIXOMATOAS
- edemul Reinke
- laringita interaritenoidian
- ulcerul de contact

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ASPECTE ENDOSCOPICE ALE EDEMULUI


REINKE i ulcer de contact

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244

Laringitele cronice albe


LEUCOPLAZIA
- leziune albicioas plan
- mucoasa c.v este normal sau hipere
mic
- leziune precanceroas
PAHIDERMIA ALB SAU KERATOZA
- formaiune tu cu baz larg, bine delimitat, dur
la palpare, suprafa neregulat
PAPILOMUL CORNOS
- mas vegetant

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Laringite cronice albe

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245

Tratamentul laringitei cronice

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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Manifestri laringiene ale refluxului


gastro-esofagian
Definiie: refluarea sucului gastric n esofag n
absena regurgitrii i a vomei
Se mai numete GER
CLINIC: pirozis, disfonie i disfagie, tuse,
regurgitaii, nod n gt, flegm, dificulti de
nghire
Refluxul gastroesofagian- GERD
Reflux faringo-laringian- LPR
Reflux extraesofagian- EER

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246

Tratamentul refluxului gastroesofagian


1. Modificri de comporatment
2. Nexium, Zantac
3. chirurgical

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LARINGITE CRONICE SPECIFICE

Tuberculoza
Histoplasmoza
Blastomicoza
Actinomicoza
Candidoza
Sifilisul
Granulomatoza Wegener
Boala Hansen- lepra

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247

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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248

Hiperplazia simpl a epiteliului sau


Keratoza sau displazia redus (GRD.I).
- epiteliul ngroat n ntregime.
- Stratul celulelor bazale devine ondulat,
cteodat cu prelungiri adnci n strom
(acantoz).
- Diferenierea celular merge pn la formarea
de structuri keratinice intracelulare. - Nucleii se
extind n stratul keratinic (parakeratoz) i
keratina acoper n diferite grade leziunea
(hiperkeratoz).
- Displazia este localizat la nivelul poriunii
inferioare a treimii interne a epiteliului (stratul
bazal).

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Hiperplazia epiteliului plat cu prezena ici i colo de


atipii sau keratoza cu atipii sau displazia moderat
(GRD.II).
-dezorganizare precoce a procesului de maturare dar
care nu este foarte extins.
- Pierderea organizrii normale este limitat i niciodat
nu afecteaz toate straturile n acelai timp
-La nivelul celular exist atipii de tipul modificrilor
raportului nuclear/citoplasm, mitoze anormale
-modificri de tipul acantoz, parakeratoz,
hiperkeratoz.
-Displazia cuprinde dou treimi din epiteliu.

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249

Displazia grav sau carcinom in situ


(GRD.III)
-cea mai grav dezorganizare a epiteliului
scuamos, indicnd o displazie sever.
-Aici se ntlnesc frecvente mitoze i anomalii
celulare.

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SCHEMA LUI KLEINSASSER

epiteliu normal

hiperplazie simpl

carcinom in situ sau carcinom invaziv

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250

METODE DE DIAGNOSTIC

Laringoscopia indirect
Laringoscopia direct
Laringoscopia n suspensie
Videostroboscopia
Prelevare de biopsie- biopsie cu pensa
perpendicular pe leziune

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251

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252

TUMORILE BENIGNE I MALIGNE


ALE LARINGELUI

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CLASIFICARE
BENIGNE

MALIGNE

POLIP, NODULI, GRANULOM,


ULCER DE CONTACT

EPITELIALE MALIGNE

PAPILOMATOYA LARINGIAN[

NEUROENDOCRINE
CHISTURI ;I TUMORI
PSEUDOCHISTICE

TESUTURI MOI

TUMORI RARE> LIPOM,


CONDROM,
HEMANGIOMADENOM

OSOASE SI
CARTILAGINOASE

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253

POLIPUL CORZILOR VOCALE


Formaiune tumoral benign,
pediculatsau sesil
Localizare: 1/3 anterioar a c.v
Extensie pa fa anterioar i
superioar a c.v.
Etiologie- neclar
Clasificare: edematos, angiomatos
Dg. poz.: laringoscopie direct,
laringofibroscopia
Tratament chirurgical
Tratament de recuperare: foniatric

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254

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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255

NODULI VOCALI
Formaiuni pseudotumorale
Localizare: marginea anterioar
a c.v.
Leziune traumatic
Tratament foniatric

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Etapele biopsiei laringiene

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256

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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Alte tumori benigne


CONDROAMELE- origine la nivelul cricoidului
FIBROAMELE- tumor fibroas, benign dar
evolueaz spre malignitate
ADENOAMELE- localizate pe benzile vntriculare
ADNOMUL PLEOMORF
LIPOAMELE
HEMANGIOAMELE- tumor neted, bine
delimitat, roiatic, hemoragic
AMILOIDOZA
SARCOIDOZA

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257

TUMORILE MALIGNE LARINGIENE

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CLASIFICARE

Tumori epiteliale maligne: CARCINOAMELE


Tumori neuroendocrine
Tumori de esuturi moi- sarcoamele
Tumori osoase- condrom, condrosarcom,
osteosarcom

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258

CILE DE DISEMINARE ALE


CANCERULUI LARINGIAN
Diseminare local: epiglot, valecula
glosoepiglotic, spaiul preepiglotic, sinus
piriform
Diseminare limfatic- cc supragloticdisemineaz cel mai frecvent
Cc subglotic- metastazeaz mai rar

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FACTORI DE PREDICIE N CANCERUL


DE LARINGE

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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259

CRITERII GENERALE DE CLASIFICARE


TUMORAL LARINGIAN
T1- tumor limitat la ambele c.v.cuprinznd comisura
anterioar, mobilitate pstrat
T1a - tumor limitat la o c.v.
T1b- tu. Care cuprinde comisura i c.v contralateral
T2- tu.extins la spaiul supra i subglotic, cu afectarea
mobilitii c.v
T3- tu. limitat la laringe, mobilitate redus a c.v., invadarea
spaiului supraglotic, paraglotic, fr eroziunea
pericondrului
T4a- tu. Care invadeaz cartilajul tiroid, structurile
extralaringiene
T4b- tu. Care invadeaz spaiul prevertebral, strucutrile
mediastinale

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STADIALIZAREA ADENOPATIILOR

Nx- fr adenopatii regionale evaluabile


N0- fr adenop. Regionale
N1- aedn. Reg. Ipsilat. Sub 3 cm
N2a- aden.ipsilat.unic3-6 cm
N2b- aden.ipsilat.multiple niciunapeste 6 cm
N2c-aden.bilat mai mari de 6 cm

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260

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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261

IMAGINI ENDOSCOPICE SI
HISTOPATOLOGICE DE LARINGITE
CRONICE

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262

TUMORA VALECULARA

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TUMORA FARINGOLARINGIANA

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263

TUMORA LARINGIANA

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264

CURS nr 14
CORPII STRINI
FARINGOLOGIE

265

CORPII STRINI

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CORPII STRINI ESOFAGIENI

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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266

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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267

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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268

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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Corpii strini traheo-bronici

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269

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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270

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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271

PATOLOGIE INFLAMATORIE
FARINGIAN

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Anginele acute

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272

CLASIFICARE

1. ANGINE ACUTE NESPECIFICE


- ang. Cataral sau eritematoas
- ang. Eritemato-pultacee- folicular
- ang. Pseudomembranoas nedifteric
- amigdalita acut ulceroas
- uvulita
2. ADENOIDITA ACUT
3.AMIGDALITA LINGUAL ACUT
4. FARINGITA ACUT BANAL
5.AFECIUNI INFLAMATORII FARINGIENE VIRALE

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ANGINELE ACUTE NESPECIFICE


SINDROM ANGINOS - durere la nghiire cu
iradiere spre ureche, vorbire dureroas cu
caracter nazal, trismus, salivaie, halena fetid
Angina acut banal - orig viral
Angina eritemato-pultacee - bacteriene

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ANGINA ACUT BANAL


Apare n anotimpurile reci
Exudat faringian- evid. Virusului
Simptome: debut brusc, febr, dureri
de cap, frisoane, jen la deglutiie,
alterarea strii generale
Ex ORL: hiperemia intens a
faringelui, luetei, vlului palatin,
amigdale umflate.
!!!hiperemia localizat se transform
n hiperemie difuz
Evoluia: 3-4 zile, 7 zile

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ANGINA ACUT BANAL- TRATAMENT


Tratament general
- regim lichidian
- antitermice
Tratament local
- comprese umede
- antiseptice
- gargarisme

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ANGINA ACUT ERITEMATO-PULTACEE


Este de natur bacterian
Streptococ beta hemolitic grup A i grup B
Stafilococ, pneumococ, bacilul Friedlaender,
bacilul Pfeiffer
FORMA COMUN
- debut brusc, febr, 39-40, odinofagie, astenie
-ex cl ob: amigdale mrite n volum, roii, exudat
pultaceu care devine gri-glbui
- leucocitoz
Evoluie 5-7 zile

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ANGINA ACUT ERITEMATO-PULTACEE


FORMA GRAV:
Debut brutal, febr, rehialgii, odinofagie
Ex cl ORL: amigdale mrite n volum, depuzite
albicioase, edem al luetei, adenit
submandibular, limb sabural, oligurie
Evoluie: spre complicaii locale

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ANGINA ACUT ERITEMATOPULTACEE- TRATAMENT


PENICILIN 2X3 MUI i.v.
GENTAMICIN 2X80 mg i.v.
Metronidazol 2x500 mg i.v.

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UVULITA

Inflamaia acut a luetei


Senzaie de corp strin n gt
Debut n timpul mesei, sau efort de tuse
Ex cl ORL: lueta tumefiat. Edemaiat, atinge
baza limbii
Tratament: dezinfectante bucale,
corticoterapie, antibioterapie

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ANGINA ACUT MICOTIC

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ADENOIDITA ACUT SIMPL A


SUGARULUI
Debut brusc, convulsii, spasm glotic,
febr, polipnee, aritmie
Ex cl. ORL: rinit muco-purulent ,
secreii glbui pe peretele posterior
orofaringian, limfadenita
submandibular, otita reactiv
Complicaii: laringo-traheo-bronit,
bronhopneumonie, otita medie
supurat

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278

ADENOIDITA ACUT SIMPL A


COPILULUI
Debut brusc, febr, atare general alterat,
otalgie, respiraie bucal zgomotoas, voce
nazonat
Ex cl. ORL: hiperemie faringian, hiperemie
amigdalian, secreii purulente pe peretele
posterior faringian

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COMPLICAIILE SUPURATIVE ALE


AMIGDALITELOR

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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280

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

Nu are o precizare clinic bine definit


Angine repetate
Recidive repetate
Senzaii dureroase discrete, nepturi la
nghiire
Moleeal, dureri n articulaii
Senzaie de iritaie a faringelui
Miros neplcutn gur

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SIMPTOME OBIECTIVE

VOLUMUL AMIGDALELOR
FORMA AMIGDALELOR
ASPECTUL CRIPTELOR
PALPAREA GANGIONILOR SATELII

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COMPLICAIILE AMIGDALITEI CRONICE


Flegmon periamigdalian
Amigdalita ulceroas
Infecii ale cilor respiratorii superioare: tuse
amigdalian, laringite cronice, tulburri
pulmonare
Infecii ale esututlui limfatic
Tulburri digestive

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INFECIA DE FOCAR AMIGDALIAN

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TEORIA INFECIEI DE FOCAR


Discuie permanent
nchistarea cu lipsa de posibilitate de drenaj
Toxinele microbiene eliberate din focarul
infecios acioneaz asupra organismului

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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

Copii 3-6 ani


Limfatismul
Rinitele repetate
Adenoiditele
Bolile infecioase
Lipsa de igien , deficitele alimentare
Anemia

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Simptomatologie

Insuficiena respiratorie nazal


Respiraia bucal
Voce nazonat
Tulburri al funciei auditive
Cefalee
Tuse reflex
Subfebriliti
Faciesul adenoidian
Poliadenopatii
Bolta palatin ogival
Secreii purulente pe peretele posterior faringian
Afectarea amigdalelor palatine

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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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