耳鼻咽喉头颈外科学：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. 吸烟(tobacco use)饮酒(alcohol)2. 化学因素（c

2、hemical factors)空气污染(air pollution) 生产性粉尘、废气3. 病毒感染（HPV）4. 癌前期病变(precancerous lesions)5. 性激素及其受体(hormone, receptor)6. Radiation7、微量元素 Zn Se病理(Pathology) 鳞状细胞癌占95%左右，且多为分化好的级。Squamous cell carcinoma 95%(usually moderately to well differentiated),Adenocarcinoma very rare, 2%Sarcoma, extremely rare, ma

3、inly in young分型（Classification）声门区癌：glottic, the commonest type (60-70%)声门上型: supraglottic, mainly on the epiglottis, next common (30-40%)声门下型: subglottic, rare, less than 5%症状和体征(symptoms and signs)声嘶(hoarseness)，呼吸困难（dyspnea)，咽喉疼痛(sore throat and dysphagia)，咳嗽（cough), 咽喉异物感(a feeling of something

4、foreign in the throat)痰血临床特点（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颈淋巴转移(cervical metastases )淋巴图喉癌的三种类型(three types of l

7、aryngeal carcinoma)诊断(diagnosis)1、症状（symptoms)：声嘶(hoarseness)，呼吸困难（dyspnea)，咽喉疼痛(sore throat and dysphagea)，咳嗽（cough ) 尤其是40岁以上男性。2、颈部视诊与触诊 (palpation in neck)、 喉外形 颈部淋巴结3、喉镜检查(indirect laryngoscopy fibre laryngoscopy) 喉部有无肿块、溃 疡、结节、双声带和披裂运动情况、声带与室带是否对称、喉室是否空虚。 特别要注意会厌喉面、前联合、喉室及声门下区影象学检查： 颈侧位照片 喉CT扫

8、描或MRI 活检：(biopsy) 确定肿瘤性质 是诊断的依据鉴别诊断(differentiate diagnosis)喉结核(tuberculosis of larynx)：主要症状为声嘶与剧烈喉痛。 检查见喉部粘膜苍白水肿，有 浅溃疡和分泌物，多患有肺结核。 确诊靠病理学检查。喉乳头状瘤(papilloma of larynx)： 症状：声嘶，病程长。 成人者多为单个带蒂，且发展慢。 儿童则多为多发、复发、发展较快。 肿瘤呈乳头状突起、声带运动好（病 变仅在粘膜层。） 多次复发的成人喉乳头状瘤要警惕癌变图X3、P9治疗(treatment)：原发灶以手术、放疗为主，可单独或联合使用。（体积1cm者单独放疗，尤其是声带癌。转移灶（颈淋巴）：对放疗不敏感，主要是手术。手术治疗(surgical therapy)： 原则为根除病灶、保留或重建喉功能1、部分喉切除术（partial laryngectomy) 喉显微CO2激光手术 喉裂开声带切除术 垂直部分切除术 额前部分切除术 声门上水平部分切除术 水平垂直部分喉切除术 近全喉切除术2、全喉切除术（total laryngectomy)3、颈淋巴清扫术(neck dissection)放