Patologia inflamatorie acuta laringo-traheala

1 Septembrie, 2010 - 23:00

Inflamatiile acute ale mucoasei laringiene au o etiologie polimorfa si un aspect simptomatic variabil in functie de topografia laringiana a inflamatiei si de agentul cauzator jogos casino online.

Inflamatiile mucoasei laringiene survin arareori izolat. Ele se integreaza intr-un context patologic inflamator mai larg, rino-faringo-laringo-traheo-bronsic.

Clasificarea laringitelor acute este, din aceasta cauza, foarte dificila. Exista multiple tentative de clasificare care difera de la scoala la scoala si de la autor la autor.

Clasificarea propusa si folosita de noi - si care raspunde nevoilor practicii cotidiene - este urmatoarea:

1. Laringitele acute ale copilului

Inflamatie acuta a mucoasei laringiene la copil - indiferent de cauza care o produce - ce are doua consecinte importante: tendinta la edem si tendinta la spasm (laringita striduloasa). Aceste doua efecte insumate - produc rapid la copil dispneea acuta, care are o manifestare clinica dramatica Bonus Fara Depunere

Dispneea apare foarte precoce in laringitele copilului si se explica prin aceea ca mucoasa laringiana este mult mai usor decolabila decat la adult. La aceasta se adauga ingustimea laringelui copilului, astfel incat, un edem difuz de 1 mm la nivelul coroanei laringiene ingusteaza lumenul laringelui
infantil cu 75%, in timp ce acelasi edem, la un laringe adult, determina o ingustare a acestuia cu maximum 25%.

Etiologia laringitelor acute ale copilului: frecventa maxima a laringitelor acute la copil este intre 1 si 6 ani; cauza obisnuita este infectia mono sau polimicrobiana.

Etiologia virala (influenzae, parainfluenzae, microvirus, APC virus) este implicata din ce in ce mai des. Inflamatia virala pregateste terenul pentru suprainfectia microbiana, mai ales la copiii cu sistem imunitar depresat;
laxitatea spatiului submucos si receptivitatea crescuta la infectii a copilului constituie factori favorizanti.

Manifestarea clinica a laringo-traheitelor determina si clasificarea acestor entitati nozologice in trei mari categorii:

a) Laringitele acute simple ale copilului

b) Laringitele acute dispneizante ale copilului (sufocante)

- Laringita striduloasa
- Laringita supraglotica
- Laringita subglotica

c) Laringitele acute ale bolilor contagioase

Laringita acuta simpla a copilului are o manifestare clinica de tip cataral (raguseala, tuse iritativa, fara dispnee) iar laringoscopia releva congestie difuza a coroanei laringiene, corzi vocale congestionate si usor ingrosate, starea generala neafectata;

Laringitele acute sufocante ale copilului sunt intens dispneizante, au o evolutie dramatica, constituie urgente O.R.L. si necesita interventii terapeutice extrem de rapide;

Laringita striduloasa (falsul crup difteric). In aceasta forma clinica intalnim o inflamatie intensa insotita de un edem moale situate la coroana laringiana si in hipofaringe. Sufocarea este produsa de spasmul laringian (glotic) indus si intretinut de inflamatia intensa.

Suferinta apare sub forma de criza, brusc, in plina noapte, manifestandu-se prin sufocare, respiratie sacadata, zgomotoasa, siflanta, voce ragusita, stinsa, tuse latratoare si tiraj suprasternal. Criza poate ceda spontan in 20-30', insa este repetabila.

Laringita supraglotica este determinata de obicei de o agresiune virala la nivelul cailor aeriene superioare. Se caracterizeaza prin congestie, inflamatie si edem, localizate pe marginea libera si pe fata laringiana a epiglotei care se tumefiaza, obstruand filiera respiratorie.

Debutul se manifesta in cursul evolutiei unei viroze respiratorii. Se instaleaza progresiv si relativ rapid dispneea, care reprezinta simptomul dominant al bolii. Dispneea este acompaniata de tiraj suprasternal si cornaj.

Copilul este agitat, anxios, cu voce voalata (infundata). Examenul laringoscopic indirect este dificil din cauza dispneei si a agitatiei copilului. Laringofibroscopia arata o epiglota ingrosata, tumefiata,
albicioasa, cu un edem alb, moale, difuz, care cuprinde fata laringiana si marginea libera a epiglotei.

Laringita acuta subglotica a copilului are aceeasi etiologie virala ca si precedenta. Edemul inflamator viral se localizeaza insa sub corzile vocale (subglotic) - obstruand lumenul traheal.

Debutul este brusc, starea generala este intens afectata, evolutia este rapida si grava. Se insoteste de complicatii bronho-pulmonare (laringo-traheo-bronsita acuta sau laringo-traheo-mediastinita acuta).

In prezenta acestor complicatii este necesara intubarea copilului sau traheostomia si aspirarea permanenta a secretiilor. Daca aceste manevre terapeutice nu se instituie la timp, moartea survine in cateva minute.

Diagnosticul diferential al dispneei copilului este pe cat de dificil, pe atat de important. Dispneea acuta provocata de o laringita subglotica trebuie diferentiata de:

- Dispneea supralaringiana (hipofaringiana);
- Dispneea sublaringiana (din adenopatiile traheo-bronsice, din bronhopneumopatii);
- Dispneea cardiaca, sau de alte cauze.

Toate formele de laringita acuta a copilului au nevoie de un tratament instituit rapid - in timp util - bazat pe urmatoarele principii:
- observare permanenta a copilului - oxigenoterapie;
- aerosoli cu corticoizi si vasoconstrictoare - corticoterapie pe cale generala;
- administrare de mucolitice - antibioterapie - antialergice;
- intubatie sau traheostomie;
- aspirarea continua a secretiilor laringo-traheo-bronsice.

Laringitele acute din bolile contagioase. Bolile contagioase care se complica frecvent cu laringo-traheite sunt: gripa, rujeola, rubeola, scarlatina si, cu totul exceptional astazi, difteria.

Laringitele acute - ale copilului din cursul febrelor eruptive se manifesta clinic printr-o simptomatologie de tip cataral.

Tratamentul lor este cel al bolii de fond. in ceea ce priveste Laringita difterica, crupul difteric, de culoare cenusiu-albicioasa obstrueaza rapid lumenul laringian, producand asfixia.

Tratamentul crupului difteric este o mare urgenta, necesitand traheostomie, inlaturarea prin aspiratie a falselor membrane si intubatie prelungita pentru asigurarea respiratiei.

2. Laringitele si laringo-traheitele adultului

Formele cele mai intalnite in practica sunt:

- Laringita catarala;
- Edemul laringian acut;
- Laringita flegmonoasa;
- Laringo-traheita acuta cu pericondrita;
- Laringitele acute ale unor boli generale (Laringita acuta gutoasa, Laringita acuta reumatismala)

Laringita catarala este produsa de o inflamatie acuta banala a mucoasei laringiene.

Este mai frecventa la indivizi cu teren imunologic modificat (neuroartritici, persoane care lucreaza la temperaturi scazute, in umiditate, praf, fum), persoane care au profesii in care isi solicita laringele (avocati, cantareti).

Este de multe ori secundara unei suferinte rino-sinusale sau rino- faringiene.

Agentul patogen poate fi viral sau bacterian.

Simptome:

- voce voalata sau ragusita;
- tuse seaca, iritativa;
- dureri laringiene sub forma de intepaturi.

La laringoscopie indirecta, laringele apare intens congestionat, corzile vocale sunt si ele congestionate si tumefiate (miopatie submucoasa).

Tratamentul:

- repaus profesional intr-o camera curatata, bine aerisita;
- suprimarea fumatului;
- comprese calde pe gat, bauturi caldute;
- repaus vocal;
- calmante ale tusei;
- antiinflamatorii;
- inhalatii sau aerosoli cu corticoizi (pentru efectul calmant local).

Edemul laringian acut, in manualele mai vechi, este descris ca ”edem glotic”, dar, glota fiind un spatiu virtual, situat intre corzile vocale, nu poate face obiectul localizarii edemului.

Acesta intereseaza mucoasa si peretii laringieni din jurul spatiului glotic deci, consideram ca denumirea de ”edem laringian acut” este mai potrivita cu locul si natura suferintei.

Etiologia este diversa:

- a frigore (pe fondul unui surmenaj, efort si suprasolicitare locala, umezeala si frig);
- traumatica;
- infectioasa;
- secundara unei cauze regionale (rino-sinuzita, rino-faringita);
- secundara unei cauze generate (gripa, tiroidita acuta, boli eruptive, substante chimice);
- cauze circulatorii sau renale (cardiopatii decompensate, nefrite);
- neurohormonala (alergii, tulburari endocrine, tulburari metabolice).

Simptomatologia este datorata edemului care apare brusc si se extinde rapid, sediul sau fiind in regiunea supra si subglotica: dispnee; cornaj; senzatie de durere si tensiune la nivelul laringelui si la baza gatului; bolnav anxios, agitat, are sete de aer; vocea ramane nemodificata.

Examenul obiectiv:

- tiraj inspirator suprasternal;
- cracment laringian absent, palparea laringelui este dureroasa;
- laringoscopia indirecta evidentiaza supra sau subglotic un edem rosu (daca este de cauza infectioasa) sau alb (daca este alergic)

Tratament:

- Daca dispneea este foarte intensa, se impune trahectomia;
- Daca dispneea este moderata, se va incerca intai asa-numita ”trahectomie alba” (medicamentoasa) care consta din perfuzii cu HHC 200-300mg, la care se asociaza calciu, vitamina C si antibioterapie parenterala;
- De asemenea, se administreaza antiinflamatorii, antihistaminice, sedative; se va restrange aportul de sare.

Laringita flegmonoasa (abcesul laringian) este foarte rar intalnita in zilele noastre. Se dezvolta dintr-o laringita edematoasa suprainfectata. Germeni virulenti (stafilococ, anaerobi) determina la inceput o celulita supurata difuza (stadiul flegmonos); mai tarziu, prin localizarea infectiei, apar colectii purulente bine izolate (stadiul de abces).

Simptomatologie: tulburari respiratorii intense, la care se adauga sindromul infectios toxico-septic; tumefactia gatului in regiunea laringiana; cracment laringian absent (semnul Moure), palparea laringelui fiind extrem de dureroasa; examenul laringoscopic evidentiaza abcesul si localizarea lui.

Tratamentul este de urgenta:

- Trahectomie;
- Antibioterapie pe cale generala;
- Corticoterapie;
- Deschiderea pe cale endoscopica a colectiilor purulente si aspirarea continutului.

Laringita acuta cu pericondrita este secundara unui traumatism laringian
care se suprainfecteaza cu streptococ sau stafilococ. Uneori poate surveni si in cadrul unor boli infectioase generate.

Infectia se propaga prin contiguitate de la mucoasa la cartilajul tiroid sau, mai rar, la cartilajul aritenoid; depasind limitele acestor cartilaje, procesul inflamator trece la zonele celulare cervicale. Examenul
endoscopic evidentiaza o inflamatie ingustata a comisurii anterioare.

Tratamentul consta in antibioterapie si corticoterapie, oxigenoterapie, supraveghere permanenta si, la nevoie, traheotomie.

Laringitele din unele boli generale

a) Laringita reumatismala. Localizarea, la nivelul articulatiilor cartilajelor laringiene a reumatismului poliarticular acut, este mai rara. Se manifesta prin artrita crico-aritenoidiana, monocordita (miozita
corzii vocate) sau artrita crico-tiroidiana.

Simptomatologie:

- simptomele generate sunt cele ale reumatismului Sokolski-Bouillaud;
- durerea in timpul fonatiei (in cordita reumatismala);
- tumefactia regiunii aritenoidiene (in artrita cricoaritenoidiana);
- afonie (in artrita crico-tiroidiana);
- tratamentul antireumatic este eficace.

b) Laringita gutoasa se caracterizeaza printr-o congestie moderata, difuza, partiala a mucoasei laringiene, mai ales in regiunea aritenoidiana.

Articulatia crico-aritenoidiana prezinta fenomene de artrita. Afectiunea retrocedeaza la tratamentul antigutos sau spontan, o data cu disparitia atacului gutos.

(Prof. Dr. Dorin Sarafoleanu - Clinica ORL si Chirurgie Cervico-faciala ”Sf. Maria”, Bucuresti)

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Sunteti de acord cu modificarea examenului de rezidentiat propusa de ministrul Sanatatii?
Da
25%
Nu
75%
Total voturi: 4