Tu laringe

15/12/2012
João Flávio Nogueira, MD
Fortaleza, Brasil
• Discutir a anatomia básica da laringe
• Entender seu funcionamento e principais
doenças
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• Evitar aspiração de líquidos/comida nos
pulmões
• Proteger via aérea de conteúdo abdominal
– Refluxo
– Vômitos
– Pressão intra-abdominal
• Fonação
The original use of the larynx was to keep us alive through breakfast. Its main function
is stop solids and liquids from entering the trachea and choking us to death. Its
secondary functions are to bear down, phonation and speech. The larynx of humans
and great apes in infancy is higher in the neck so that they can breathe and suckle at the
same time. In humans it descends before the age of two.
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• Hyaline cartilage
• Largest
• Encloses the larynx
anteriorly and laterally
• Two alae
• Ossification
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 Hyaline cartilage
 Directly below the thyroid
cartilage
 Stongest
 Shape: Signet ring
 Lamina – flat portion
 Only complete annular
support of the larynx
 Articulates w/ Inferior
cornu of the thyroid
cartilage
• Fibroelastic cartilage
• Leaf-shaped structure
• Petiole – small narrow
portion of the glottis
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•
•
•
•
Mostly hyaline cartilage
Smaller in size
Responsible for opening and closing of the larynx
Shape: pyramidal
• Anterior
– Vocal process receives the
attachement of
the mobile end of
each VC
• Lateral
– Muscular process
• Articulation
– Cricoarytenoid
joint
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• Fibroelastic
• Cartilages of Santorini
• Small cartilages above the arytenoid and in
the aryepiglottic folds
• Firboelastic cartilages
• Cartilages of Wrisberg
• Elongated pieces of
small yellow elastic
cartilage in the
aryepiglottic folds
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• Composed of cartilage:
– Cricoid Cartilage – Greek Name meaning ‘ring like’
– Thyroid Cartilage – Greek Name meaning ‘Sheild
like’
– A pair of Arytenoids
– Epiglottis
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Laryngeal Anatomy
anatomy.uams.edu/anatomyhtml/atlas_html/rsa3p2.html
1. Hyoid bone
2. Thyroid cartilage
3. Cricoid cartilage
4. Tracheal cartilages
www.bartleby.com/107/
illus952.html
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Larynx
www.ling.yale.edu:16080/ling120/Larynx/Larynx_side.gif
Cricoid
anatomy.uams.edu/.../atlas_html/rsa3p6.html
1.
Anterior arch
2.
Posterior
lamina
3.
Articular facet
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Thyroid Cartilage
/www.yorku.ca/earmstro/journey/images/thyroid.gif
ARYTENOIDS
homepages.wmich.edu/~gunderwo/intro_voice.htm
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1. Thyroid prominence
2. Cricothyroid ligament
3. Arytenoid cartilage
4. Corniculate cartilage
5. Vocal ligament
6. Vestibular fold
7. Cricoid cartilage
8. Articular facet for inferior
cornu of thyroid cartilage
anatomy.uams.edu/anatomyhtml/graphics/rsa3p8.gif
1.
Epiglottis
2.
Arytenoid cartilage
3.
Corniculate cartilage
4.
Aryepiglottic fold
anatomy.uams.edu/anatomyhtml/graphics/rsa3p10.gif
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The thyroid rests superiorly on the cricoid and attaches posterior-laterally at the
cricoid’s inferior articulator facets. This attachment (the cricothyroid joint)
hinges the cricoid and thyroid allowing their anterior sides to adduct, changing
vocal fold length.
people.umass.edu/jkingstn/ling414/figure%202.19%20arytenoid%20movement%20f05.jpg
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Composition of the Larynx (Con’t)
• Composed of Muscle:
–Extrinsic Laryngeal Muscles
–Intrinsic Laryngeal Muscles
Extrinsic Muscle
TWO Groups of Extrinsic Muscles:
• Suprahyoids – Attach to points above the Hyoid
(Jaw, Skull and Tongue) when they contract they
raise or elevate the Larynx eg Swallowing
• Infrahyoids – Attach to points below the Hyoid
(one connects to the thyroid, however the others
connect to the sternum and the scapula) when
they contract they lower or depress the Larynx
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www.sloan-studios.com/pm/teachingtools.htm
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Intrinsic Muscles
•
•
•
•
Adductors – vocal folds are together
Abductors – vocal folds apart
Tensors - Stiffen
Relaxors - Relax
Adductors
• Lateral Cricoarytenoids
• Interarytenoids
–Transverse Arytenoids
–Oblique Arytenoids
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A
d
d
u
c
t
o
r
s
A
d
d
u
c
t
o
r
s
artemis.austincollege.edu/acad/music/wcrannell/vocalped/images/larynx1.gif
artemis.austincollege.edu/acad/music/wcrannell/vocalped/images/larynx1.gif
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137.222.110.150/calnet/H+N/image/deep%20muscles%20of%20larynx-lateral%20view.jpg
Abductors
• Posterior Cricoarytenoids
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Vocal Folds
• Muscle
–External Thyroarytenoids – inserts into the
muscular process on the Arytenoids and the Thyroid notch (shorten and
adduct)
–Internal Thyroarytenoids – inserts into the
vocal process on the Arytenoids and the Thyroid Notch (shortens and
stiffens), act antagonistically to the Cricothyroids
• Membrane
137.222.110.150/calnet/H+N/image/deep%20muscles%20of%20larynx-lateral%20view.jpg
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Membranes
• False Vocal Folds – Ventricular folds
• Laryngeal Ventricle
• Conus Elasticus (interconnects the thyroid, cricoid and arytenoids
cartilages)
• Lamina propria (mucosal cover of the vocalis muscle)
– can vibrate independently of the vocalis muscle
• Vocal Ligament – the thread like collagenous fibers of
the deep layer of the lamina propria
Relaxors and Tensors
• External Thyroarytenoid – Relaxor, shortens
and adducts
• Internal Thyroarytenoid – Tensor, shortens
and stiffens
• Cricothyroid Muscles – Tensor, lengthens and
stiffens
Pitch is determined by Relaxors and Tensors
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www.kolumbus.fi/msts/larynx/larynx.htm
Fundamental Frequency
Phonation is made up of a fundamental
frequency or Fo (the number of times the folds
open and close per second-CPS) and harmonic
multiples of the Fo (two times the Fo, three
times, four times etc.) that fall in intensity
(volume) in an inverse relationship as the
harmonics rise in frequency or as the pitch
rises the volume falls.
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Fundamental Frequency
10
9
8
7
6
5
4
3
INTENSITY
2
1
(VOLUME)
100
200
300
400
500
600
700
800
900 1000
FREQUENCY
(PITCH)
Pitch
• Fundamental frequency (average: baby 500Hz, children 250-400Hz
men 125Hz women 200Hz) is primarily affected by applying
more or less longitudinal tension to the VF
using:
• Cricothyroids
• Tension in the vocalis muscle
OR
• Adjustments in vertical tension – depressing or elevating the
Larynx via suprahyiod and infrahyoid muscles
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Vocal Fold Tension, Elasticity and
Movement
•
•
•
•
•
Thicker or thinner
Shorter or longer
Open or close
Intermediate positions
Stiff or elastic
Movement:
Bronx Cheer or Raspberry– “the sound is that or air escaping in rapid bursts, not the
sound of the lips moving” – Borden and Harris. Aerodynamic forces acting on the
elastic body of the lips
ADMET – Aero Dynamic Myo-Elastic Theory
Glottal vibration is the result or refers to interaction
between aero-dynamic forces and vocal fold
muscular action.
• Sub-Glottal Pressure
• Bernoulli Effect – set vocal folds into vibration due to the elasticity of the
folds (elastic recoil – the force which restores any elastic body back to its resting
place)
• Muscular Force – Muscles act to bring the folds together so they
can vibrate, and muscles regulate their thickness and tension to alter
fundamental frequency. Folds are FULLY or PARTIALLY ADDUCTED for
phonation
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Bernoulli Effect
• An increase in velocity results in a drop in the
pressure exerted by the molecules of moving
gas or liquid, the pressure drops being
perpendicular the direction of the flow
Schematic showing the Bernoulli Effect. The arrows indicate movement of pressure. As the air
moves through a narrowing, inside pressure drops and outside pressure increases pulling the sides
inward.
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Glottal Cycle
• Vertical Phase Difference – vocal folds open at
the bottom first. As top part opens bottom
part closes. Wave like motion
www.phon.ox.ac.uk/~jcoleman/phonation.htm
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Chest (Modal Register)
•
•
•
•
Low fundamental frequency
Vocalis muscle activity
Folds are thick and short
Low stiffness
Falsetto Register
•
•
•
•
•
Longer and thinner folds
Stiff folds
Small amplitude of vibration
Incomplete closure of the folds
Shutter like appearance – Vibrate more like strings
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Vocal Onset
• How we bring the folds together:
– Attack
– Breathy
– Vocal Fry
– Partial adduction – Whispering or falsetto register
(Note: Folds come together FULLY but without force
for Modal register)
Pitch
• Lies in the stiffness of the folds resulting from
lengthening and contraction of the
thyroarytenoids, especially the vocalis portion
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Tumores de laringe
Fatores de risco
• Tabaco
– Cigarros de enrolar
– Marijuana
• Álcool
• Refluxo GE
• HPV
TABACO
ALCOOL
CA
LARINGE
AG.QUIMICOS
POLUIÇÃO
GENÉTICA?
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Anatomia – subdivisão
Source: AJCC Cancer Staging Manual, 6th Ed (2002)
Tumores de laringe
Epidemiologia
• Ca mais comum de cabeça e pescoço (excluindo pele)
• Homens = 4 : 1
• > 90% carcinoma epidermóide
• Variações de prevalência ao redor do mundo
Incidência por local
Supraglótico
40%
Glótico
59%
Subglótico
1%
American Cancer Society: Cancer Facts and Figures 2008. Atlanta, Ga: American Cancer Society, 2008.
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Cancer supraglótico
•
•
Predominância de lesões em epiglote, falsas pregas vocais e prega
ariepiglótica
Extensão para valéculas, base da lingua, seio piriformee tireóide
• “silencioso”; dor de garganta, disfagia, otalgia reflexa, tu no
pescoço
Cancer glótico
• Mais comum: 59-65%
• ROUQUIDÃO, estridor ou dispnéia
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Cancer subglótico
• Raro
(1%)
• Estridor, dispnéia
Tumores de laringe
Quadro clínico
• Sinais e sintomas
– ROUQUIDÃO, disfagia, hemoptíase, dispnéia, aspiração
– Dor de garganta
– Otalgia reflexa (ramo do N. Vago = sugere estágio avançado)
– CA Glótico = ROUQUIDÃO = diagnóstico precoce
– CA Supraglótico = diagnóstico tardio
• Tu volumosos ao diagnóstico
• Provável comprometimento de linfonódios regionais
• Emagrecimento
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Tu de laringe
Quadro clínico
• Exame físico
– Exame completo de cabeça e pescoço
• Palpação de linfonódios; restrição do crepitar laringeo
– Qualidade da voz
• Soprosa = paralisia de prega vocal
• Abafada = lesão supraglótica
– Laringoscopia
• Indireta com espelho de laringe
• Videolaringoscopia
• Notar: bordos, cor, vibração, mobilidade da prega vocal, e lesões.
Tumores de laringe
Diagnóstico diferencial
•
•
•
•
Laringite crônica
Doenças granulomatosas (TB, sarcoidose)
Papilomatose juvenil
Linfoma
Rotina
1) Videoendoscopia
2) Exames de imagem
3) Biópsia e histologia
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Tu de laringe
Laringoscopia indireta
• A imagem do laringe é refletida
no espelho no orofaringe; a
técnica permite uma visão
indireta das pregas vocais.
Tu de laringe
Videolaringoscopia
NEOPLASIAS
Rouquidão permanente sem
períodos de normalização !
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Tu de laringe
Imagem
• CT ou MRI
– Avaliar estruturas adjacentes: espaço pré-epiglótico ou paraepiglótico
– Erosão da cartilagem tireoidea
– Linfonódios cervicais comprometidos
Tu de laringe
Biópsia e histologia
• Microlaringoscopia direta com biópsia
• Histologia:
– CARCINOMA EPIDERMÓIDE (>90%)
• Histo normal  hiperplasia  displasia  ca in situ 
ca invasivo
• Tabaco + alcool
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Tu de laringe
Biópsia e histologia
• Histologia (outros tumores):
– Glândula salivares
• Carcinoma adenocístico
• Carcinoma mucoepidermóide
– Sarcomas (condrosarcoma)
– Diversos: linfoma, metastáses
Tu laringe – estadiamento (TNM)
•
• Supraglottis
Subglottis
Glottis
– Tis: CA in-situ
––
–
–
–
–
–
–
–
–
––
Tis:
CA
Tis:limited
CAin-situ
in-situ
T1:
to subsite of supraglots
T1:
limited
totosubglottis
T1:
limited
cord;
w/normal cord
mobility
extends
to vocal
with
T2:
invade
mucosa
ofcord
>two
1 subsite
T1a:
one cord;
T1b:
cordsof
supraglottis,
glottis,
or outside of
normal
or impaired
mobility
T2: extends
to supraglottis,
supraglottis
of cord
the
T3:
limited
tow/out
larynxfixation
w/vocal
and/or
subglottis,
and/or
larynx
fixation
w/impaired cord mobility
T3: limited to larynx w/vocal cord
T4a:
invades
orw/vocal
thyroid
T3: limited
tocricoid
larynx
cord
fixation
and/or
invades
postcricoid
cartilage,
and/orinvades
invades
tissues
fixation
and/or
area,
pre-epiglottic
tissues,
beyond
thespace,
larynx
paraglottic
space,and/or
and/or
minor
paraglottic
minor
thyroid
cartilage
erosion
cartilage
erosion space,
T4b: invades
prevertebral
T4a:
thyroid
cartilage
encases
carotid
artery,
or invades
T4a:invades
invades
thyroid
cartilage
and/or
beyond
mediastinal
structures
and/or tissues
tissues
beyondlarynx
larynx
T4b:
space,
T4b:invades
invadesprevertebral
prevertebral
encases carotid artery, or invades
space, encases carotid artery, or
mediastinal structures
invades mediastinal structures
Source: AJCC Cancer Staging Manual, 6th Ed (2002)
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Estadiamento
• Subglottis
– Tis: CA in-situ
– T1: limited to subglottis
– T2: extends to vocal cord with
normal or impaired mobility
– T3: limited to larynx w/vocal cord
fixation
– T4a: invades cricoid or thyroid
cartilage, and/or invades tissues
beyond the larynx
– T4b: invades prevertebral space,
encases carotid artery, or invades
mediastinal structures
• Nodes
– N0: no regional node mets
– N1: single ipsilateral node, ≤ 3 cm
– N2a: single ipsilateral node, > 3 cm,
≤ 6 cm
– N2b: multiple ipsilateral nodes, ≤ 6
cm
– N2c: bilateral or contralateral
nodes, ≤ 6 cm
– N3: node > 6 cm
• Mets
– Mx: unknown
– M0: no distant mets
– M1: distant mets
Source: AJCC Cancer Staging Manual, 6th Ed (2002)
Tu de laringe
Drenagem de linfonódios
Tu supraglótico
Tu
subglótico
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Estadiamento agrupado
Estágio 0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
T3
N0
M0
T1-3
N1
M0
T4a
N0-1
M0
T1-4a
N2
M0
T4b
any N
M0
any T
N3
M0
any T
any N
M1
III
IVA
IVB
Stage IVC
Inicial
Avançado
Tu de laringe
Tratamento – Opções:
• Cirurgia
–
–
–
–
Microlaringocirurgia
Hemilaringectomia fronto-lateral (vertical)
Hemilaringectomia supraglótica (horizontal)
Laringectomia total
• Radiaterapia
A considerar
• Quimioterapia
1) Local e tipo do tumor
2) Invasão adjacente
3) Metástases
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Tu de laringe
Tratamento – Estágios I/II
• Alternativas possíveis:
5-anos sobrevida:
– Microcirurgia com laser (transoral)
Estágio I = 90%
– Hemilaringectomias
Estágio II= 70%
– Radioterapia
• Resultados similares entre cirurgia x radioterapia
• Recomendação atual: radioterapia inicial e cirurgia reservada
para recorrências locais (??)
Mendenhall WM et al., Cancer. 2004 May 1;100(9)
Complicações da radioterapia
•
•
•
•
•
•
•
Disgeusia (=dor de garganta)
Mucosite
Dermatites
Xerostomia
Fibrose superficial
Fistulas
Hipotireoidismo
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Tu de laringe
Tratamento – Estágios III/IV
1) Quimioterapia
2) Radioterapia x Laringectomia total
3) Laringectomia total ou Radioterapia posop
Department of Veterans Affairs Laryngeal Cancer Study Group, N Engl J Med 1991;324:1685-90.
Treatment – Advanced Stage
(III/IV) – RTOG 91-11 Study
Concurrent
chemoXRT
Induction chemo
 XRT
XRT alone
2 yrs
5 yrs
2 yrs
5 yrs
2 yrs
5 yrs
Dz Free
SurvivalA
61%
36%
52%
38%
44%
27%
Overall
SurvivalB
74%
54%
76%
55%
75%
56%
Distant
metsC
8%
12%
9%
15%
16%
22%
therapy  significant decreased in dz free survival
compared to XRT
alone (P =0.02 compared w/induction, P = 0.06 compared
w/conccurent Tx)
Forastiere AA et al, N Engl J Med 2003;349:2091-8.
BNo significant difference
CDifference only significant comparing concurrent
chemoXRT vs XRT alone.
AChemo
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Tu de laringe
Reabilitação posop
Métodos:
A) Escrita
B) Fala esofageana
C) Eletrolaringe
D) Valvula traqueoesofágica
Eletrolaringe
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Válvula traqueo-esofágica
Vida sem laringe ?
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Dúvidas?
45