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SINDROMUL MEDIASTINAL
Dr. Anca Mihailescu
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Cuprins
Delimitarea mediastinului si acompartimentelor sale
Semnele si simptomele SM Explorarea functionala si paraclinica a SM
Patologie mediastinala
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MEDIASTIN- DELIMITARE
Inferior diafragm
Superior apertura toracica superioara
Lateral
pleure Anterior stern
Posterior - coloana vertebrala
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MEDIASTIN - CONTINUT
Cord
Ao, AP, VCS, VCI
Vase limfatice, ggl
Trahee, bronhii principale
Esofag
Nervii vagi, laringei recurenti, frenici, ic, lanturilesimpatice
Timus
Tesut conjunctiv
Ty, Pty ectopice
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SINDROM
SINDROM = semne + simptome careapar adesea impreuna in diferite boli
cu etiologii diferite- tumorale
- vasculare
- infectioase
- inflamatorii
- de dezvoltare
- traumatice
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Mediastinul superior
Trahee
Esofag superior
Timus
Arc aortic
N X N frenici
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Mediastinul anterosuperior
Tesut gras
Ganglioni limfatici
Tiroida ectopica Timus
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Mediastinul mijlociu
Cord
Aorta ascendenta
VCS, VCI, vvbrahiocefalice
Vase pulmonare
N frenici Ganglioni
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Mediastinul posterior
Esofag
Canal toracic
Vv azygos,hemiazygos
Aorta descendenta
Nn vagi, intercostali
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SIMPTOME
Dispnee, tuse, disfonie
Durere
Disfagie, sughit, varsatura
Sincopa
Cefalee, ameteli, somnolenta, tulburaride vedere
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DISPNEE
Compresie extrinseca a traheei
Obstructie bronsica
Iritatia n X Pareza de CV stg
Limitarea miscarilor resp durere
Pareza de frenic Tamponada pericardica
Revarsat lichidian pleural
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TUSEA
Chintoasa
Latratoare compresii traheobronsice
Bitonala pareza laringeu recurent
Afona distructii de CV
Surda Hemoptoica staza, T br, ruptura de Ao
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DISFONIA
>2-3 sapt semnal
Sdr Ortner
- fonastenie
- afonie
- raguseala - diplofonie
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DUREREA TORACICA
Nespecifica
Nevralgica frenica
- ic
- cervicobrahiala
Terebranta
osteita sternala
Pseudoanginoasa
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SIMPTOME DIGESTIVE
Disfagia compresie, obstructie,inflamatie
Sughit- iritatie frenica
Varsatura - +vag, afectiuni esofagiene
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SEMNE MAJORE
Cianoza
Edem
Circulatie colaterala
Sb mica, Sp mare
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SEMNE (I, P)
Anizocorie, sdr Claude Bernard Horner
Retractii - mediastinita retractila, atelectazie
Bombari anevrism Ao
Adenopatii, splenomegalie Puncte Valleix
Emfizem sc
Anizosfigmie
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SEMNE (P, A)
Matitate interscapulovertebral- sternala superioara
- rotunjita deasupra cordului- baza toracelui
- segmentara
Obstructie localizata/ abolirea MV
SS parasternal stg
S Hamman
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Rg pulmonara (f,p)
Masa mediastinala vs sdr mediastinal
Largirea mediastinului
Rx :Pulsatilitate
Rata cresterii masei mediastinale
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CT
De rutina in SM
Dg cert de anevrism Ao, lipomatoza
mediastinala, grasime pericardica Localizare, extindere, invazie, circulatia
colaterala
Semne indirecte de malignitate (invazie, meta)
Ghidaj
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RMN
Afectare nervoasa, vasculara
Leziuni apropiate de apertura
superioara
Invazie diafragmatica
CI la substanta de contrast (alergie, IR)
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ECO
Chist vs solid
Ghidaj biopsie
Copii
Leziuni E/periE (ecoendoscopie)
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ESOFAGOGRAFIA SI EDS
Afectiuni intrinseci E (diverticuli, cesofagian)
Compresie extrinseca
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SCINTIGRAFIE
I 131, I 123 Tiroida
Ga 67- limfom
I-metilbenzilguanina
feocromocitom
Selenometionina PTy
Tc pertechnetat chiste neuroenterice(mucoasa gastrica)
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INVESTIGATII INVAZIVE
Bronhoscopie spalare (BAL), periaj, biopsie
Toracotomie
VATS biopsie pleurala/ pulmonara
Mediastinoscopie (suprasternal) nu Ap Ao-pulm, paratraheali stg
Mediastinotomie parasternal
Biopsia medulara Biopsia excizionala
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MANIFESTARI ASOCIATE
Hipoglicemie mezoteliom, teratom,fibrosarcom
Sdr Cushing
Hipercalcemie T Pty
Simptome neurologice T neurogene
Miastenia gravis - timom
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EPIDEMIOLOGIE
Adulti frecvent AS
Copii frecvent P
Simptome ~ malignitate
Leziuni maligne mai frecvente la copii
Lf in crestere
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PATOLOGIE MEDIASTINALA
Acuta/ cronica
Tumorala/netumorala (hernii, chiste,infectioasa, inflamatorie, traumatica)
M superior/anterior/ mijlociu/ posterior
/difuz
Frecventa/rara
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AFECTIUNI MEDIASTINALE
frecvente rare
Anterosuperior TimomLimfomT germinale
Leziuni vasculareT mezenchimale
T endocrine
Mijlociu Chiste bronhogeneT limfoide
Chiste pericardice
Chiste gastro
Posterior T neurogene Leziuni vasculareT mezenchimale
Leziuni limfoide
Hernie Bochdalek
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PNEUMOMEDIASTIN
Durere in inspir, dispnee, disfonie
Crepitatii sc
Context clinic
posttraumatic/ barotrauma/ruptura esofagiana
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MEDIASTINITA ACUTA
Perforatie esofagiana Sdr. Boerhaave
- prognostic prost
- durere brusca, febra- Rx - pneumomediastin, hidroptx- tranzit baritat- TCTrat: chirurgical+Ab
Post sternotomie (in I sapt, < 1%, Mo 15%) Perforatia traheobronsica Prin contiguitate
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Esofagograma cu gastrografin Sdr.Boerhaave
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MEDIASTINITA CRONICA SIFIBROZA MEDIASTINALA
Sdr de VCS
Peric constrictiva
Obstructie de AP Obstructie
traheobronsica
Evolutie lenta
CT, Rx, angiografie
Culturi -
Histoplasmoza
Mycobacterii
Candida Iradiere
Metisergida
B autoimune
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PATOLOGIE TUMORALA
Ap metastatice si din Lf cea maifrecventa cauza de masa mediast
Mediastin A si M 70% simptomatici (local/ general)
LH LMNH
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GUSA PLONJANTA
10% din masele mediastinale
20% M
Simptome apar si in formele B
Rx, CT +/- scinti
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MEDIASTIN ANTEROSUPERIOR
T timica , HT timica
Teratom (B, M), seminom
Limfom
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TUMORI TIMICE
B/M
Mediastin AS
Cea mai frecventa T mediast primara
Decada 5-6, B=F, unilat Sdr paraneo
- miastenia gravis
- hipoglobulinemie
- aplazie eritrocitara
HT timica decade 1-2
Asociaza miastenia gravis, HTy, ICSR, acromegalie
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TUMORI GERMINATIVE
Seminom voluminos, ant, stg, HCG
Teratom benign fete, voluminos, resturi
ectodemice
Teratom malign meta, creste repede
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MEDIASTIN MIJLOCIU
Adenopatii - LH, neo bronsic, sin
- infectii (tbc)
- sarcoidoza Chist pericardic
Chist bronhogen
Anevrism Ao Hernia Morgagni
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SARCOIDOZA
B granulomatoasa necazeoasa
Ap simetrice hilare/ mediastinale
Asimpt/simpt: astenie, tuse, dispnee,eritem nodos, uveita
Dg: biopsie cutanata/ ggl
Evolutie stationara/ remisie/progresiva
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HERNIA MORGAGNI
3 M: medial, mature, minuscule
Femeie, obeza, de virsta medie
Mal formarea septului transvers
dr>stg
+/- defecte pericardice
Dispnee, tuse, simpt dig sup nespec
Complicatii: incarcerare
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MEDIASTIN POSTERIOR
T neurogene (schwanom, neurofibrom,feocromocitom)
Anevrism Ao desc Diverticuli E (Zenker, epifrenici, interbronsici)
Carcinom esofagian
Hernii (de alunecare, paraesofagiana, Bogdaleck) Hematopoeza extramedulara
Pseudochist pancreatic
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ANEVRISM DE AORTA
Crosa SVCS + pusatii si expansiunesuprasternala
Crosa si Ao asc comprima laringeulrecurent + osteita sternala
Ao desc disfagie + nevralgie ic + osteitavertebrala
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HERNIA HIATALA
Cea mai frecventa
Nivel hidroaeric posterior de cord, de
obicei pe stg.
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HERNIA BOGDALECK
- 3B : baby, back (posterolateral), big
- stg>dr
- Lipsa de inchidere a faldului pleuroperitoneal
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SINDROMUL DE VCS
Dispnee, cefalee, obstructie nazala, tulburare deconstienta, coma
Edem, cianoza, circulatie colaterala, stridor, edem
papilar
Compresie
Invazie
Tromboza
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SINDROMUL DE VCS
C pulmonar, LH, meta
Fibroza mediastinala
Anevrism de Ao
Histoplasmoza, TBC, lues T benigne
Tromboza (cateter venos central, pacemaker)
CT sediul/ mec obstructiei RMN vizualizeaza direct fluxul sangvin
Venografie circulatia colaterala
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Venografie - sdr VCS
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Anatomia VCS si a venelormediastinului
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SINDROM MEDIASTINAL
Dispnee
Durere toracica
Disfagie Disfonie
Edem in pelerina
Cianoza in pelerina
Circulatie colaterala
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Timom
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LIMFOM
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pneumomediastin
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HH
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ti
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timom
timom
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timom
Rest timic
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Rest timic
pneumomediastin
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pneumomediastin
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Meta melanom
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Meta melanom
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Fibroza de iradiere
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limfom
G l j t
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Gusa plonjanta
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T neurogena
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Anevrism de aorta descendenta