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Sindrom mediastinal

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    Sindromul

    mediastinal

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    DefniieSindromul mediastinal este realizat deansamblul maniestrilor clinicesecundare unei aeciuni mediastinale.

    2

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    Rapel anatomic

    3

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    Rapel anatomic

    5

    Crosa aortiei i ramuri

    VCS i tributareTraheea

    Tiroida

    Esofag

    uct toracic

    !n "frenic# vag# laringeurecurent

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    Rapel anatomic

    $

    Timus

    Tiroida# paratiroide

    esut adipos

    %gl& limfatici

    'rtera mamar( intern(

    "Cel& %erminale)

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    Rapel anatomic

    *

    Cord# pericard

    'orta ascendent(

    Trunchi 'P

    Vv& pulmonare

    VCS# v& '+igos

    Traheea# bron ii principale%gl& limfatici hilari

    !n& vag i frenic

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    Rapel anatomic

    ,

    'orta descendenta

    Esofag

    uct toracic

    V& '+igos# hemia+igos

    !n "vag# lan simpatic)

    %gl& limfatici paravertebrali

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    Etiologie Tumori primitive (benigne/maligne) sau secundare (CaP) Adenopatii benigne sau maligne

    Boli inflamatorii (mediastinite acute/cronice)

    Alte afec iuni:

    Anevrism aort

    Megaesofag, diverticuli esofagieni

    Pneumomediastin

    ernii mediastinale

    -

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    Maniestri clinice

    !pecifice afec iunii

    "atorate compresiei/inva#iei structurilor $nvecinate

    !d% paraneopla#ice

    .

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    Simptome uncionale1. Durerile:

    Mediastinale & profunde, retrosternale, cu iradiere ascendent, sediufi', sunt mai mult permanente dect paro'istice, rebele la tratamentul

    obinuit*

    "e tip nevralgicnevralgie frenic (sugerata, mai ales, de pre#en+a unui sugi+ recidivant irebel)

    nevralgie cervico&braial (dureri la nivelul membrelor superioare)

    intercostal (unilateral, iradia# $n semicentura sau $n band)*

    -soase & persistente, de mare intensitate, accentuate nocturn%

    ..

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    Simptome uncionale2. Dispneea:

    Paro'istic, pseudoasmatic, apare la efort*

    Permanent, accentuat $ns de efort, mai mult cucaracter inspirator, $nso+it de corna. i tira.%

    !e $nso+ete, adesea, de alte simptome respiratorii:stridor inspirator i e'pirator

    ee#ing (martor al unei steno#e bronice)tuse seac, rebel la tratament, uneori cu caracter ltrtor itimbru metalic sau bitonal

    .2

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    Simptome uncionale3. Disfonia:

    !emn de compresiune a nv. laringeu recurent:voce cu caracter bitonal

    4. Disfagia:

    a !nceput intermitent

    "niial disagie pentru alimentele solide apoi #ipentru lic$ide% se agraveaz progresiv &i devinepermanent.

    .3

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    Simptome uncionale5. Simptome datorate stazei venoase:

    Cefalee

    Tinnitus

    0pista'is

    !omnolen

    Tulburri vi#uale

    .4

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    E'amen fzic1. Semne de compresie venoas: Sd. VCS a( )ianoz caracteristic% defnit prin dou elemente:localizat sau preponderen la a% g*t &i poriunea

    superioar a toracelui+agravat prin eort &i tuse+

    b( Edem , dur% r godeu% cu aceea&i topografe cacianoza -edem !n pelerin(+

    c( )irculaie venoas colateral% localizat !n regiuneatoracic superioar% asimetric% cu turgescentvenelor /ugulare.

    .5

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    .$

    sd. de Ven Cav Superioar

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    .*

    sd. de Ven Cav Superioar

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    .,

    sd. de Ven Cav Superioar

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    E'amen fzic2. Semne de compresie nervoas:

    n% laringeu recurent& disfonie, tuse ltrtoare

    n% frenic 1 sugi , parali#ia emidiafragm: dispnee,scderea amplitudinii mi crilor resp%, ascensiuneaemidiafragmului (decelat la e'%clinic23')

    n% vagi 1 taicardie, TA

    n% pneumogastrici& sialoree, tuse, dispnee astmatiform

    lan simpatic & sd% Claude Bernard orner / sd% Pourfourdu Petit

    .-

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    2

    sd. Claude Bernard Horner

    sd. Pourfour du Petit

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    E'amen fzic3. Semne de afectare arterial:pulsa ii suprasternale i supraclaviculare

    & dilatare vascular & deplasare vase

    suflu sistolic $n 4Ao/ 4P 1 compresie

    puls absent/diminuat

    ani#osfigmie & compresie subclavie unilateral

    2.

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    E'amen fzic4. Semne de compresie duct toracic:revrsate pleurale bilaterale (ciloase)5 cilotora'

    !d% Menetrier 5 ipereste#ie perete abdominal i mb%sup% stng, pleure#ie bilateral, ascit i edeme gambiere

    22

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    E'amen fzic5. lte semne clinice utile:matitate la percu ia claviculelor

    cre terea ariei matit ii mediastinale e'amenul tiroideipre#en a adenopatiilor superficialeepato&splenomegaliaemfi#em subcutanatdegete ipocratice, -AP

    23

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    DiagnosticRadiografa incidena antero,posterioar #i profl

    24

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    Diagnostic0ranzitul baritat esoagian

    25

    Compresie

    e0trinsec(

    iverticul

    esofagian

    Cancer

    esofagian

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    Diagnostic ,)0Cu substan a de contrast 6 P0T&CTMetoda de elec ie pentru mediastinul antero&superior i mi.lociu

    Poate gida punc ia transtoracic

    2$

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    Diagnostic, "RM73M mai pu in utili#at $n diagnosticul afec iunilor mediastinale

    Avanta.: nu foloses te sc iodate, nu iradia#

    "e elec ie pentru diagnosticul tumorilor neurogene

    2*

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    Diagnostic1iopsietransbron#ic

    endoesoagian g$idat ecoendoscopic

    transtoracic g$idat )0

    mediastinoscopie)ervicala

    Suclavicular

    toracoscopie -laterotoracic inerior(

    2,

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    0umori mediastinale

    primare8% Cisturi: tiroide, bronogene, enterogene, pleuro&pericardice, teratodermoide

    9% Tumori endocrine: timus, gu retrosternala, adenoameparatiroidiene, seminoame

    % Tumori neurogene: neurofibroame, neurinoame,ganglioneurinoame, neuroblastoame

    ;% Tumori me#odermice: lipoame, fibroame, condroame,emangioame, sarcoame

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    Chiste pleuro1pericardiceAnomalii de delimitare celomic a cavit iipericardice

    Forma iuni chistice cu perete sub ire, delimitat de celule mezoteliale, pline cu lichidseros limpede!lbui

    Cel mai frecvent localizate anterior, "nun!hiul cardiofrenic #dr$st!.%

    Frecvent asimptomatice

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    Chiste pleuro1pericardice

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    Chiste pleuro1pericardice

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    Chiste bronhogene3 1 $ din totalul forma & chistice mediastinale

    ocali+ate frecvent subcarinal sau paratraheal

    orma iuni chistice# ovoidale# delimitate de epiteliu ciliar pot

    con ine lichid seros galben sau brun# dar i mucus# cartila6# +one

    de calcific(ri

    Comunic( cu arborele traheobron ic

    Clinic7 Wheezing, dispnee, infec ii pulmonare recurente ns

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    Chist bronhogen

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    Chiste teratodermoideisembrioame cu structur( diferit( de cea a forma iunilormediastinale

    ocali+ate 8n mediastinul anterior

    orma iuni chistice/solide# sferice/ovoidale# moi/dure

    9enigne/ maligne ".513)

    'simptomatice p:n( la pubertate# ulterior fen& compresive#

    complica ii "infec ie# ruptur()# maligni+are

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    Teratom mediastinal

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    3,

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    Timoamele2 dintre t& primitive mediastinale

    ocali+ate 8n mediastinul anterior i superior

    9enigne/ maligne "315)# solide/chistice

    ;7

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    4

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    Timomul1 sd& asociate &ndocrine' tireoto(icoz, hipercalcemie, b. Addison,

    panhipopituitarism

    Autoimune' polimiozit, )*, sd. S+o!ren, &S, PA-,sarcoidoz, S), colit ulcerativ, tiroidit Hashimoto

    Hematolo!ice' hipo!amma!lobulinemie, anemie

    aplastic, pancitopenie, poli!lobulie, deficit de limfocite

    /euro0musculare' *1, distrofia miotonic, miozit

    -enal' sd. nefrotic, 1/

    2AHP

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    Timom 1 diagnostic

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    %u a substernal(.51 2 dintre t& primitive mediastinale

    ocali+at( 8n mediastinul anterior i superior .

    retrotraheal i posterolateral de esofagPoate fi e0tensia tiroidei cervicale sau proliferare ectopic(

    intratoracic(

    !ormo/hipo/mai rar hipertiroidie

    Complica ii7 fenomene compresive# hemoragie "tablou acut

    sever)# maligni+are "relativ frecvent)

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    %u a substernal(1

    diagnostic

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    %u a substernal(1diagnostic

    !cintigrama cu iod radioactiv

    identific esutul tiroidian

    captant%

    0'ist i gu necaptant

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    Tumori neurogene

    9

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    Tumori neurogene

    9enigne

    !eurinom "sch>anom)1celmai frecvent

    !eurofibrom

    %anglioneurom

    ;aligne

    Sch>anom malign

    !eurofibrosarcom

    !euroblastom "copii)

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    Tumori mediastinaleme#encimale

    9enigneipom

    ibroame

    Condroame

    'ngiolipom?emangiom# limfangiom

    ;aligneiposarcom

    eiomiosarcom

    Condrosarcom

    @abdomiosarcoma?emangiosarcom

    Sub . din t& mediastinale primare

    ocali+ate in mediastinul anterior i inferior

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    'denopatiile mediastinaleBeni!ne'

    3nfec ii' BC, pneumonie, antra(

    3nflamatorii' sarcoidoza

    *ali!ne'

    imfoame

    *etastaze !an!lionare 0 cancer BP

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    TBC mediastinal

    Primoinfec ia pulmonar la copii, f. rar la adul i

    Pot atin!e dimensiuni tumorale cu complica ii severe#obstruc ie bron ic, perfora ii, diseminare pulmonar%

    )ia!nostic'

    &(amen bacteriolo!ic

    3)- la tuberculina

    Bronhoscopie

    -(' adenopatii hilare i paratrahele, mai frecvent unilaterale,asimetrice, cu contur imprecis #periadenit%

    Biopsie' folicul tuberculos

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    52

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    !arcoido#a

    Boal !ranulomatoas, multisistemic, etiolo!ieincert

    *ai ales femei, 45065 ani

    Afectare pulmonar' 758

    Adenopatia hilar simetric, cu contur net policiclic reprezintleziunea precoce caracteristic

    Fibroza pulmonar #std. vansate% *anifestri e(trapulmonare' cutanate, adenopatii

    superf., HS me!alie, oculare, neurolo!ice, cardiace

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    54

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    !arcoido#a & diagnostic

    -adiolo!ic 9 aspect caracteristic: evolu ie stadial

    ava+ bronhoalveolar' alveolit limfocitar

    &(amen histopatolo!ic' !ranulom sarcoid

    0 lez cutanate

    0 !!l. superf mediastinali

    est ;

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    5$

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    @imfomul mediastinal

    60=58 limfom mediastinal primitiv

    658 dintre b. cu limfom Hod!>in au afectaremediastinal

    Clinic'

    Semne !enerale' astenie, subfebrafebra #Pel0&bstein%,scadere ponderala

    Adenopatii superficiale

    Hepatosplenome!alie

    Paloare, purpur, pete ii, echimoze

    3nfec ii recurente

    @imfomul mediastinal

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    @imfomul mediastinal&diagnostic

    *odificri H1, medulo!ram

    Biopsie !an!lionar 0 dia!n de certitudine

    3ma!istic 9 stadializare, e(tensie -adio!rafia' opacitate mediastinala centrala, voluminoasa cu

    mar!ini festonate, in mai ales mediastin anterior si mi+lociu

    C' mase tumorale !an!lionare neiodofile #zone nodularedistinctebloc adenopatic%, care , pot comprimadeplasa traheea,bron iile, vasele

    3-*' mai sensibil pentru identificarea adenopatiilor din fereastraaorto0pulmonara

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    5-

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    Pneumomediastin"emfi+em mediastinal)

    Cauz

    0 Spontan

    0 Secundar'

    ruptur postinterven ional esofa!traheearborebron ic

    pneumoperitoneu pneumotora(

    mediastinite acute

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    Pneumomediastin"emfi+em mediastinal)

    Clinic

    )urere retrosternal brutal, intens

    use, dispnee, disfa!ie

    &mfizem subcutanat0 crepita ii subcutanate

    Semnul Hamman? crepita ii particulare care se auscultaprecordial, se modific cu pozi ia i sunt ritmate de btile cardiace

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    Pneumomediastin"emfi+em mediatinal)

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    ;ediastinita acut(

    Cauze'

    0 complica ie a &)S sau chirur!iei esofa!iene

    0 posttraumatic0 poststernotomie

    0 postin!estie de caustice

    0 perfora ii neoplazice "n mediastin0 Sd. Boerhaave

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    ;ediastinita acut(

    Clinic

    )urere retrosternal intens

    Febr, stare septic

    )isfa!ie

    2dinofa!ie

    orticolis

    use, dispnee, cianoz #dc. e interesat traheea%

    &mfizem subcutanat

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    ;ediastinita acut(

    )ia!nstic'

    0 biolo!ic' leucocitoz marcat, sd. 3nflamator

    0 radiolo!ic' r!irea umbrei mediastinale

    Pneumomediastin

    -evarsat pleural #ma stan!% Hidropneumotora(

    0 C

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    ;ediastinita acut( 1@0

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    ;ediastinita cronic(

    Cauze

    0 BC

    0 Histoplasmoz

    0 Silicoza

    0 Fibroza mediastinal idiopatic

    ? proces fibros de etiolo!ie necunoscut care infiltreaz

    spa iile con+unctive mediastinale comprim@nd VCS, tributare,esofa!, bron ii mari

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    Vrsta 20- 40 ani

    Clinic:

    - iniial asimptomatic- Frecvent Sd. VCS

    - Tuse

    - Dispnee

    - Hemoptiie

    ibro+a mediastinal( idiopatic(

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    Fibroza mediastinal

    idiopatic

    F/29 with SVC Syndrome by Histoplasmosis

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    ibro+a mediastinal( idiopatic(

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    ernii mediastinale

    ernii congenitale: lipsa de fu#iune a componentelordiafragmului $n timpul de#voltrii embrionare

    Bocdale: mediastinul posterior

    Morgani: mediastin anterior (ernierea omentului iorganelor abd la nivelul ungiului cardiofrenic drept)

    ernii dobndite:

    ernia iatal& retrocardiac, mediastinul mi.lociu

    Postraumatic

    *.

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    *2

    Hernia BochdalekHernia Morgani

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    "iverticul esofagian4orma iune saculara protru#iva la nivelul organelortubulare

    Congenital/dobanditi, de pulsiune/trac iune

    Pot fi locali#ati: faringo&esofagian (ener), esofagmi.lociu, epifrenic

    Clinic:"isfagie, durere retrosternal

    3egurgita ii!ialoree

    alen fetid

    *3

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    Anevrismul aortic

    5 dilatare patologica a lumenului normal aortic interesand unulsau mai multe segmente, avand un diametru de cel putin 9 orifata de diametrul normal al unui anumit segment aortic%

    "escriere anevrism:

    &@ocali#are (aorta abdominala, aorta toracica,toracoabdominal)

    &"imensiune

    &Morfologie (fusiform sau sacular)

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    Pre#entare clinicMa.oritatea sunt asimptomatice

    "urere :2@ocali#are: retrosternal/interscapulovertebral ( anevrism

    intratoracic)

    2 7radierea& depinde de e'tensia anevrismului si fenomenelecompresive nervoase

    2Caracter: apsare, sfredelire

    2"urata: ore, uneori ciar #ile

    2Modificarea caracter:2u se modific cu micrile

    2Poate fi amelioarat de anumite po#iii (de e'emplu cu picioareleusor ridicate)

    DDDDD -rice durere nou aparut sau accentuat sugerea#

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    Pre#entare clinic

    0fecte compresive locale (sd mediastinal):2!indrom de vena cava superioar

    2Tuse, ee#ing, dispnee ( simptomele pot fi dependente depo#itie), pneumonii recurente& comresie tracee sau broniiprincipale

    2"isfagie 1 compresie esofag

    2"isfonie 1 compresie laringeu recurent!imptome date de complicatii: embolii sistemice, ruptura,disectie de aorta, simptome datorate regurgitarii aortice(anevrism ao% ascendenta)

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    0'amen obiectiv!emne de aterosclero#a sistemic/ boli de tesut con.unctiv

    Anevrism aorta ascendent:

    & pulsaii ale aortei $n furculia sternal& impuls sistolic palpabil in spaiul 9& intercostal drept

    & mrirea matitatii retrosternale

    & #g% 9 intrit in focarul aortic (clangor aortic)

    & suflu de regurgitare aortic

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    0'amen obiectivAnevrism de cros aotic:

    & "isfonie

    &Asimetrie de puls la mb% superioare prin compresiaarterei subclavie stg%

    & Traceal tug (miscari sincrone ale traeei cu pulsatiileaortei)

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    "iagnostic3adiografie toracica: marirea umbrei mediastinale,largirea butonului aortic sau deviere traceala de lalinia mediana

    0TT: nu poate vi#uali#a portiunea distala a aorteiascendente

    0T0: poate vi#uali#a toata aorta toracica

    CT/M37aortografie

    !d -rtner

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    !d% -rtner(sd% cardio&vocal)

    ,

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    "e re inut

    !d% mediastinal 5 Triada clasic simptomatic(dispnee2disfonie2disfagie) 6 sd% EC!

    0tiologia cea mai frecvent e dat de tumori

    adult: limfoame, determ sec CaP, ciste i t% neurogene

    copil: t% neurogene, limfom, teratoame

    Simptomatolo!ia clasic doar "n stadii avansate

    "iagnostic: imagistic 6 istopatologic


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