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Oparzenia, intubacja i radioterapia najczęstszymi przyczynami wewnętrznych urazów krtani

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Wewnętrzny uraz krtani może być spowodowany intubacją lub niektórymi zabiegami medycznymi, np. laryngoskopią, obecnością ciała obcego w krtani, a także oparzeniem i radioterapią. Objawy i leczenie wewnętrznych urazów krtani uzależnione są od rozległości i rodzaju uszkodzenia.

Urazy wewnętrzne krtani, podobnie jak zewnętrzne, mogą być groźne dla życia i zdrowia pacjenta. Stąd w przypadku objawów uszkodzenia krtani, konieczna jest konsultacja z lekarzem.

Urazy krtani spowodowane oparzeniem

Wewnętrzne oparzenia krtani mogą być skutkiem działania drażniących dymów lub gazów, a także gorącej pary lub zachłyśnięcia się wrzątkiem bądź żrącym płynem. W tych przypadkach objawy dotyczą: chrypki, kaszlu, duszności (obrzęk krtani nasilający się w ciągu pierwszych 6-12 godzin), odynofagii (ból odczuwany podczas przełykania), dysfagii (zaburzenia połykania), uczucia palenia, pieczenia. Dochodzi wówczas do przekrwienia nagłośni, obrzęku i ubytku błony śluzowej.

W przypadkach oparzeń krtani konieczna jest natychmiastowa hospitalizacja. Specjalista ocenia uraz, a także gardło i dolny przełyk. W postawieniu diagnozy wykorzystywana jest laryngoskopia pośrednia, bezpośrednia oraz fiberoskopia. Leczenie oparzenia krtani zwykle obejmuje farmakoterapię – stosuje się glikortykosteroidy dożylne, antybiotyki, leki przeciwbólowe. W poważniejszych przypadkach konieczne może być wykonanie tracheostomii.

Odczyn popromienny krtani

Wewnętrzny uraz krtani może być również spowodowany działaniem radioterapii. Wczesny odczyn popromienny pojawia się w 2.-3. tygodniu leczenia promieniami jonizującymi, natomiast późny może rozwinąć się nawet po wielu latach od radioterapii. Odczyny popromienne w krtani manifestują się występowaniem chrypki, zaburzeniami oddychania, silnym bólem w okolicy krtani, trudnościami w połykaniu.

Reakcje popromienne wymagają odpowiedniego nawodnienia, zastosowania diety półpłynnej, leków przeciwbólowych i przeciwobrzękowych, antybiotyków (w przypadku infekcji bakteryjnej). Ciężkie odczyny popromienne wymagają natomiast przerwania napromieniania i zastosowania glikortykosteroidów, antybiotyków, leków przeciwgrzybiczych. Niekiedy konieczne jest wdrożenie żywienia pozajelitowego i wykonanie tracheotomii.

Uszkodzenia jatrogenne – pointubacyjne

Najczęstszą przyczyną urazu pointubacyjnego jest niedostateczne zwiotczenie pacjenta podczas intubacji lub zbyt duża średnica rurki intubacyjnej. Uraz może wywołać także twarda prowadnica, wielokrotna lub przedłużona intubacja bądź zbyt wysokie ciśnienie w mankiecie uszczelniającym rurki.

Uszkodzenia jatrogenne podzielone są na dwa rodzaje: wczesne i późne. Rozpoznanie urazu przeprowadza się na podstawie badania laryngologicznego i wywiadu.

Wczesne uszkodzenie jatrogenne krtani

Pojawia się bezpośrednio po usunięciu rurki intubacyjnej. Obserwuje się wówczas szybko postępującą dysfonię (wielopostaciowe zaburzenie głosu), kaszel, krwioplucie, ból krtani i szyi. Przyczynami tych objawów najczęściej są: krwiak przestrzeni Reinkego fałdu głosowego, uszkodzenie błony śluzowej krtani, rozerwanie fałdu głosowego, obrzęk okolicy podgłośniowej, zwichnięcie stawu pierścienno-nalewkowego i niedowład nerwów krtaniowych dolnych.

Postępowanie w przypadku wczesnych urazów pointubacyjnych uzależnione jest o rodzaju urazu – niektóre z nich nie wymagają leczenia i ustępują samoistnie (np. krwiaki, powierzchowne uszkodzenie błony śluzowej, niedowład nerwów), natomiast rozdarcie fałdu głosowego lub zwichnięcie chrząstki nalewkowej wymaga postępowania chirurgicznego.

Późny pointubacyjny uraz krtani

Występuje zazwyczaj od 2 do 8 tygodni po intubacji. Ten rodzaj urazu jest następstwem przedłużonej intubacji i manifestuje się dysfonią lub dusznością. W wyniku wywierania ucisku przez rurkę intubacyjną na przyśrodkową powierzchnię chrząstki nalewkowej, staw pierścienno-nalewkowy, tylny odcinek szpary głośni, okolicę międzynalewkową i okolicę podgłośniową, dochodzi do zaburzenia perfuzji włośniczkowej błony śluzowej. Prowadzi to do owrzodzenia i zapalenia chrzęstnej oraz miejscowej martwicy nabłonka. Następstwem odczynu zapalnego na martwicę nabłonka jest powstanie ziarniny, a jej powikłaniem może być ziarniniak pointubacyjny, który lokalizuje się na wyrostku głosowym chrząstki nalewkowej. Leczenie zachowawcze urazów późnych polega na rehabilitacji foniatrycznej i/lub podaniu inhibitorów pompy protonowej, a także na iniekcjach toksyny botulinowej. W przypadku niepowodzenia leczenia wdraża się chirurgię polegającą na mikrochirurgicznym usunięciu ziarniniaka, najczęściej przy użyciu lasera.

Przedłużona intubacja może również prowadzić do zwężenia okolicy podgłośniowej i zrostów w tylnym odcinku szpary głośni. Wówczas wymagane jest postępowanie chirurgiczne na drodze endoskopowej z użyciem lasera lub wycięcia zwężonego fragmentu i zespolenia „koniec do końca” z dojścia zewnętrznego.

Źródło: mp.pl, „Otolaryngologia praktyczna. Podręcznik dla studentów i lekarzy”, tom 2, 2005, str. 129-130

 

Przeczytaj także: Zewnętrzny uraz krtani to bezpośrednie zagrożenie życia. Jak przebiega ocena urazu i leczenie?

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