耳鼻咽喉頭頸外科學(xué)：喉癌

1、喉 癌（Carcinoma of larynx）概述(outline)Epidemiology: 1-5% of all carcinoma15-20% of head and neck cancers80% in 50-70 year-old age groupA high incidence in men and smokersA high incidence in north-east China病因(etiology)No definite causes known, possible risk factors1. 吸煙(tobacco use)飲酒(alcohol)2. 化學(xué)因素（c

2、hemical factors)空氣污染(air pollution) 生產(chǎn)性粉塵、廢氣3. 病毒感染（HPV）4. 癌前期病變(precancerous lesions)5. 性激素及其受體(hormone, receptor)6. Radiation7、微量元素 Zn Se病理(Pathology) 鱗狀細(xì)胞癌占95%左右，且多為分化好的級(jí)。Squamous cell carcinoma 95%(usually moderately to well differentiated),Adenocarcinoma very rare, 2%Sarcoma, extremely rare, ma

3、inly in young分型（Classification）聲門區(qū)癌：glottic, the commonest type (60-70%)聲門上型: supraglottic, mainly on the epiglottis, next common (30-40%)聲門下型: subglottic, rare, less than 5%癥狀和體征(symptoms and signs)聲嘶(hoarseness)，呼吸困難（dyspnea)，咽喉疼痛(sore throat and dysphagia)，咳嗽（cough), 咽喉異物感(a feeling of something

4、foreign in the throat)痰血臨床特點(diǎn)（Clinical features）Glottic carcinoma: Usually unilateral true cord,Early hoarsenessCord fixation and laryngeal obstruction in late cancersNo neck node metastasis in early tumorsPrognosis is much betterSupraglottic carcinoma: More aggressive than the glottic carcinomaMetas

5、tasis earlier and readily (35%)Readily invades the preepiglottic space, but rarely involves the true cords, rarely with early hoarsenessAsymptomatic until a large tumor causes painful dysphagia, dyspnea and a metastatic neck node Prognosis is worse than glottic carcinomaSubglottic carcinoma:Hard to

6、find in early stageMay be subglottic extension of glottic cancerOften seen initially as airway obstruction with stridor in late stageEarly metastasis to paratracheal nodes and direct spread to the thyroid glandPrognosis is the worst in three type頸淋巴轉(zhuǎn)移(cervical metastases )淋巴圖喉癌的三種類型(three types of l

7、aryngeal carcinoma)診斷(diagnosis)1、癥狀（symptoms)：聲嘶(hoarseness)，呼吸困難（dyspnea)，咽喉疼痛(sore throat and dysphagea)，咳嗽（cough ) 尤其是40歲以上男性。2、頸部視診與觸診 (palpation in neck)、 喉外形 頸部淋巴結(jié)3、喉鏡檢查(indirect laryngoscopy fibre laryngoscopy) 喉部有無(wú)腫塊、潰 瘍、結(jié)節(jié)、雙聲帶和披裂運(yùn)動(dòng)情況、聲帶與室?guī)欠駥?duì)稱、喉室是否空虛。 特別要注意會(huì)厭喉面、前聯(lián)合、喉室及聲門下區(qū)影象學(xué)檢查： 頸側(cè)位照片 喉CT掃

8、描或MRI 活檢：(biopsy) 確定腫瘤性質(zhì) 是診斷的依據(jù)鑒別診斷(differentiate diagnosis)喉結(jié)核(tuberculosis of larynx)：主要癥狀為聲嘶與劇烈喉痛。 檢查見喉部粘膜蒼白水腫，有 淺潰瘍和分泌物，多患有肺結(jié)核。 確診靠病理學(xué)檢查。喉乳頭狀瘤(papilloma of larynx)： 癥狀：聲嘶，病程長(zhǎng)。 成人者多為單個(gè)帶蒂，且發(fā)展慢。 兒童則多為多發(fā)、復(fù)發(fā)、發(fā)展較快。 腫瘤呈乳頭狀突起、聲帶運(yùn)動(dòng)好（病 變僅在粘膜層。） 多次復(fù)發(fā)的成人喉乳頭狀瘤要警惕癌變圖X3、P9治療(treatment)：原發(fā)灶以手術(shù)、放療為主，可單獨(dú)或聯(lián)合使用。（體積1cm者單獨(dú)放療，尤其是聲帶癌。轉(zhuǎn)移灶（頸淋巴）：對(duì)放療不敏感，主要是手術(shù)。手術(shù)治療(surgical therapy)： 原則為根除病灶、保留或重建喉功能1、部分喉切除術(shù)（partial laryngectomy) 喉顯微CO2激光手術(shù) 喉裂開聲帶切除術(shù) 垂直部分切除術(shù) 額前部分切除術(shù) 聲門上水平部分切除術(shù) 水平垂直部分喉切除術(shù) 近全喉切除術(shù)2、全喉切除術(shù)（total laryngectomy)3、頸淋巴清掃術(shù)(neck dissection)放