laringe - fisiokinesiterapia · laringe . supraglottica epiglottide/corda vocale falsa (e il...
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LARINGE
www.fisiokinesiterapia.biz
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SUPRAGLOTTICA epiglottide/corda vocale falsa (e il ventricolo)
GLOTTICA corda vocale vera e commissuraanteriore
SUB-GLOTTICA margine inf. corda vocale vera fino alla trachea
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SUPRAGLOTTICA 3a e 4a tasca branchiale
GLOTTICA 6a tasca branchiale
SUB-GLOTTICA 6a tasca branchiale
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CISTI E LARINGOCELE
INFIAMMAZIONE
Laringite cronica: abuso di voce, esposizione ad agenti chimici, fisici, tabacco, alcool
Epiglottite acuta: edema massivo del bambino
Tubercolosi, Granuloma laringeo, Granuloma da corpo estraneo, Malacoplachia, Artrosi delle articolazioni (crico-aritenoidea, crico-tiroidea)
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TUMORI E LESIONI
SIMIL-NEOPLASTICHE
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PAPILLOMATOSI LARINGEA
Singola o multiplaGiovanile (entro i 20 anni)
Adulto
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PAPILLOMATOSI LARINGEA
HPV 11, 6 (adulto:HPV neg)crescita papillare , acantotica di cellule ben diff
Trattamento: ormoni, farmaci, vaccini, laringectomia (in rari casi)
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Cheratosi ordinaria Iperplasia verrucosa
Iperplasia pseudoepiteliomatosaLeucoplachia
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CHERATOSI ORDINARIA
Area di epitelio malpighianocaratterizzata da abnorme orto-
o paracheratosi, senza proliferazione sottostante
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Proliferazione squamosa ipercheratosicapapillare, che appare come una placca biancastra sessile, simile al carcinoma verrucoso. Prevalente nella cavità orale
Iperplasia verrucosa
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IPERPLASIA PSEUDOEPITELIOMATOSA
Proliferazione reattiva dell’epitelio squamoso nella
profondità dello stroma sottostante. Associato a flogosi
croniche (TBC, funghi, ulcere), o a particolari tumori
(granular cell tumor)
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VERRUCA VOLGARE
Proliferazione squamosa benigna della mucosa laringea
caratterizzata da ipercheratosi, acantosi, papillomatosi,
coilocitosi, granuli cheratoialini.Rara nel laringe, più frequente
nel cavo orale
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LESIONIPRENEOPLASTICHE
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CHERATOSI
Origina da una irritazione cronica (fumo).
Predilige le corde vocali.
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DISPLASIALieve: lievi atipie nel 1/3 basale, scarse
mitosi, cheratosi e inf moderate
Moderata: atipie nei 2/3, normale maturazione e stratificazione
Severa: marcate anomalie nucleari, nucleoli prominenti, mitosi in tutti gli
strati, perdita di maturazione oltre i 2/3 dell’epitelio, rimangono alcuni aspetti
differenziativi
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FATTORI INFLUENZANTI LA PROGNOSI DELLA
DISPLASIA
Attività mitoticaFigure mitotiche abnormi
Livello di maturazionePleomorfismo nucleare
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Carcinoma in situ (CIS)•Lesione unica o periferica a Ca invasivo (75% dei Ca invasivo associato a CIS)
•Raucedine, arrossamento
•Atipie in tutti gli strati e mancanza di maturazione superficiale
•CIS non trattato a distanza di tempo diventa Ca invasivo
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CARCINOMA SQUAMOCELLULARE
Sopraglottico (30-35%)Glottico (60%)
Sottoglottico (< 5%)
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CARCINOMA SQUAMOCELLULARE
Sopraglottico (30-35%)
falsa corda con tendenza ad invadere il ventricolo;
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CARCINOMA SQUAMOCELLULARE
Glottico (60%)
tende a rimanere a lungo localizzato e poi a diffondere verso la commissura anteriore, la
corda opposta e la commissura posteriore
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CARCINOMA SQUAMOCELLULARE
Sottoglottico (< 5%)
corda vera con estensione sottoglottica> 1 cm, invasione laterale alla cartilagine
cricoide
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CARCINOMA SQUAMOCELLULARE
ASPETTI MACROSCOPICIEsofitico a placca
VerrucosoUlcerato
Di solito associato a displasia, ma può insorgere anche ex abrupto
(drop-down carcinoma)
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METASTASI
•Linfonodi loco-regionali
•polmone
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VARIANTI
•Ca verrucoso (HPV+)
•Small cell Ca
•Basaloid squamous Ca
•adenoCa
•Ca sarcomatoide
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COMPORTAMENTODEL CA DELLA GLOTTIDEGrazie al suo limitato circolo
linfatico, il ca della vera corda ha un’ottima prognosi(a 5aa)
T1: 50%T2: 20%T3: 20%
T4: <10%
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METASTASI LINFONODALI DEL CA DELLA GLOTTIDE
T1: 2%T2: 17%T3: 25%T4: 65%
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CA SOPRAGLOTTICO
Al momento della diagnosi da ¼a metà dei pazienti ha metastasi
linfonodali loco-regionali
CA SUB-GLOTTICOMetastasi linfonodali nel 20%
dei casi al momento della diagnosi
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DIMENSIONI DELLA NEOPLASIA
Tumori di dimensioni < 2 cm.: 14% di metastasi
Tumori di dimensioni > 2 cm.: 40% metastasi
(Mc. Gavran et al)
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FATTORI PROGNOSTICI IMPORTANTI
A- Relativi alla neoplasia
Grado di differenziazionePleomorfismo nucleare
Attività mitotica
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FATTORI PROGNOSTICI IMPORTANTI
B- Interazione ospite-neoplasiaPattern di invasione (gettoni
solidi, singole cellule)Invasione vascolareReazione flogistica
Stadio di infiltrazione(microinv., superf., profonda)
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FATTORI PROGNOSTICI IMPORTANTI
C-Margini di resezioneNeoplasia a > 5 mm. dal margine di resezione: 52% sopravv. (a 5 anni)
Neoplasia a 2mm.: 30%Neoplasia al margine di resezione:
28%(Futrell et all.)
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