RESPIRATORY SYSTEM - Main Pathologies

APARELHO
RESPIRATÓRIO
RESPIRATORY
SYSTEM
INFO
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Acute Laryngitis(1,2)
Acute inflammation of the larynx.
Catarrhal laryngitis is more frequently observed in adults, being, in general, of viral
origin and associated to the infection of
the upper airways. The excessive use of the
voice, allergic reactions and inhaling irritating substances (tobacco) may cause acute
or permanent (chronic) laryngitis. Acute
epiglottitis is due to a larynx inflammation
above the glottis, usually in children; it is
caused by type B Haemophylus influenzae.
Subglottis laryngitis is the larynx viral inflammation under the glottis.
The commonest symptoms are hoarseness
of voice (dysphonia), dry cough and pain in
the throat. Children with acute epiglottitis
present with fever and general malaise.
Child may prefer to remain seated as the
position makes breathing (airflow) easier.
Odynophagia (pain during swallowing)
may also be seen in some patients. Subglottic laryngitis affects younger children,
and presents with dry cough and a characteristic inspiratory sound (stridor), produced due to airway narrowing.
Diagnosis is based on clinical examination.
Sputum culture may help in identification
of the causative agent. Sometimes, an indirect laryngoscopy is necessary, although
it is normally contraindicated in acute epiglottitis.
 The conventional treatment consists of
avoiding the use of irritating substances,
resting the voice and administration of
anti-inflammatory agents.
 In acute epiglottitis and subglottic laryngitis, hospital admission and intravenous
antibiotics are used; in severe cases, orotracheal intubation or tracheostomy may
be required.
Acute Respiratory Distress
Syndrome(3)
Rapidly evolving acute respiratory insufficiency, associated with the appearance of
bilateral infiltrates, in the chest x-ray and
with PaO2/FiO2≤200 that cannot be explained by left heart dysfunction. The most
common cause is sepsis, but it may also be
observed in thoracic trauma, bronchial aspiration, toxin inhalation, opiate consumption, etc. It is caused by an increase in the
permeability of the alveolo-capillary membrane, consequent to dysfunction of type
II pneumocytes, decrease in the surfactant
surface and alveolar collapse. Chronic inflammation may lead to onset of fibrosis.
The most frequent symptoms are tachypnea (increase of respiratory frequency) and
dyspnea associated with symptoms related
to the underlying cause.
It is defined by the clinical picture, the thorax x-ray and the gas analysis (oxygen and
carbon dioxide) in the peripheral blood,
which shows mainly an important decrease
of the partial pressure of oxygen in the
blood (hypoxemia).
 Treatment of the triggering cause.
 Specific treatment consists of administering oxygen; the mainstay of supportive
management of ARDS is invasive positive
pressure ventilation.
Allergic Bronchopulmonary
Aspergillosis(4,5)
Pulmonary disorder caused by an allergic
reaction to Aspergillus fumigatus (heat resistant fungus that resides in moist areas or
decomposing materials, and also in houses). The pathogenesis is related to genetic
predisposition; inhaled conidia A. fumigatus
persist and germinate into hyphae, release
antigens that compromise the mucociliary
clearance, stimulate and breach the airway
epithelial barrier, and lead to inflammation. Destructive lesions, bronchiectasis,
fibrosis and lung retraction are observed.
The majority of patients present with
low-grade fever, wheezing and bronchial
hyper- reactivity (mimics asthma), hemoptysis, or productive cough. Expectoration of
brownish black mucus plugs is characteristic. On the thorax x-ray, there are transitory and recurring infiltrates that look like
pneumonias or atelectasis.
It is based on clinical and laboratorial criteria (Rosenberg-Patterson criteria): asthma,
increase in the number of eosinophils and
IgE levels in the blood, presence of specific
(IgE and IgG) anti-Aspergillus antibodies,
skin hypersensitivity tests and history of
pulmonary transitory infiltrates in the thorax x-ray.
 The key treatment is corticoids.
 Bronchodilators are only useful for controlling the symptoms.
Asbestosis(6,7)
Pulmonary condition secondary to inhalation of asbestos. Asbestos is used mainly in
manufacturing breaks and as insulation in
plumbing and boilers. It is a fibrotic process
limited to the walls of alveoli immediately
around the bronchioles in the early stages;
as it progresses, it covers adjacent areas and
becomes diffuse.
It arises after prolonged exposure to asbestos. The most common symptoms are an
insidious onset of dyspnea, cough and production of sputum. Patients have a greater
risk of lung and pleural cancer.
It is based on the clinical findings and the
history of exposure. Examination shows
findings of interstitial fibrosis (end-inspiratory crackles). Chest x-ray shows reticulolinear opacities, mainly in the lower zones.
Pleural fibrosis may be seen on CT. Pulmonary function tests show a predominantly
restrictive pattern. Occasionally, fiber optic
bronchoscopy and bronchoalveolar lavage
may demonstrate asbestos fibers.
 There is no known effective treatment.
 The patients should be followed periodically due to the greater risk of lung and
pleural cancer.
Asbestosis
Lung
Fiber
Scar
Bronchi
Pleural
lining
Alveoli
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Asthma(8,9)
Chronic inflammatory disease of the airways, characterised by reversible limitation
of the air flow and recurring episodes of
bronchial spasm. An inflammatory mechanism, with predominant involvement of
mast cells and immunoglobulin E, together
with an alteration of the neural control of
the airways (sympathetic and parasympathetic play an important role in the pathogenesis). There is an exaggerated bronchial
response to multiple stimuli (bronchial hyper-reactivity), that precedes and predicts
the development of asthma. Etiological and
triggering factors include genetic predisposition, allergens (acarus, pets’ epithelium –
cats and dogs, pollens and fungi), physical
exercise, irritating gases, viral infections
and drugs like acetylsalicylic acid and other
non-steroid anti-inflammatory agents.
Typical symptoms are: dyspnea (shortness
of breath), wheezing (with a characteristic
sound, like a whistle, made by the air passing through the narrowed airways) and
cough.
A temporal relationship between the appearance of the symptoms and the inciting
factor is usually apparent.
Wheeze is a distinctive, if non-specific,
finding in the physical exam. Diagnosis is
confirmed by spirometry; reversibility of
obstruction of the air flow, after administration of a bronchodilator, is characteristic.
 The mainstay of treatment is administration of bronchodilators (beta blockers) and
anti-inflammatory agents (corticosteroids,
leukotriene inhibitors, mast cell stabilizers).
 Acute episodes are managed with
inhaled bronchodilators and injectable/
inhaled steroids. Severe episodes require
hospitalization.
 Other agents that are used in the treatment of chronic asthma include: disodium
cromoglycate, nedocromil and theophyllines.
Symptoms
Normal bronchiole
Hyper-responsive lower airway
Hyperinflated lung
Asthmatic bronchiole
Cough
Hissing
Chest
tightness
Atelectasis(10,11)
Collapse of a peripheral, segment or lobar
region of the lung or of the entire lung,
caused by an airway obstruction. It is not
a pathology in itself, but is the consequence
of a pulmonary or bronchial disorder, such
as intraluminal bronchial obstruction (foreign body, mucus plugs, mass lesions) or
extraluminal obstruction (pneumothorax,
pleural effusion). After a bronchial obstruction, blood absorbs the peripheral alveolar
gas and the consequent lung retraction
causes the alveolar air content to disappear after a few hours. Atelectasis results
in development of a left to right shunt, with
attendant hypoxemia.
Symptoms depend on the etiology, speed
of development and the extent of the atelectasis. An acute bronchial occlusion
with massive collapse causes pain in the
affected side, dyspnea and tachycardia.
There may be a concomitant pulmonary
infection, usually with fever. Atelectasis
that develops slowly may be completely
asymptomatic or else causing only mild
symptoms.
The diagnosis is suspected on the basis of
signs and the clinical setting. Radiology
confirms the diagnosis: Chest x-ray shows
homogenous parenchymal density (segment, lobar or pulmonary), decrease of
the volume of the affected hemithorax and
displacement of neighboring structures
(heart, mediastinum and diaphragm, etc.)
to the affected side. It is important to look
for the cause of atelectasis. This may require
thoracic axial computerized tomography
(CT) and fiber optic bronchoscopy/biopsy.
 The treatment depends on the etiology
of the atelectasis.
 Treatment is based on repositioning
and suctioning of respiratory secretions,
percussion therapy, incentive spirometry,
or intermittent positive pressure ventilation.
 In some cases, bronchoscopic suctioning and fiberoptic bronchoscopy for extraction of foreign body or mucus plug may be
necessary.
Bronchiectasis(12,13)
It is a chronic pulmonary condition characterized by persistent cough, excessive sputum production and recurrent chest infections. There is an abnormal and irreversible
bronchial dilatation in one or more lobes,
secondary to the destruction of the elastic
and muscular components of the bronchial
wall. It is associated with impairment of
mucociliary clearance, leading to bacterial
colonization and infection. Most causes are
post-infective (pneumonia, tuberculosis);
other etiologies include immune defects,
connective tissue disorders, allergic bronchopulmonary aspergillosis, cystic fibrosis,
obstruction or foreign body aspiration or
inhalation and asthma.
The most frequent complications are massive hemoptysis, recurrent pneumonia
(affecting the parenchyma around the affected bronchus), empyema and lung abscess, respiratory failure and cor pulmonale.
Chest x-ray may give characteristic images,
however, it is non-specific. Diagnosis is confirmed by high resolution axial computerized tomography (HRCT) of the chest.
 Treatment is targeted at elimination of
the bronchial obstruction, improving clearance of secretions (physiotherapy and postural draining) and treating the respiratory
infections.
 According to the etiology and severity,
bronchodilators and oxygen therapy may
be necessary. Steroids are not recommended unless there is concomitant asthma or
COPD.
 All patients must receive annual influenza and 5-yearly pneumococcal vaccination.
Upper lobe:
Cystic Fibrosis
Tuberculosis
Central:
Cystic Fibrosis
ABPA
Congenital
Tracheobronchomegaly
Bronchiectasis
Normal bronchi
Lower lobe:
Childhood Infection
Aspirations
Immunodeficiency
Outer wall
Mucus
Cilia
Destruction
of wall
Increased
mucus
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Bronchiolitis(14,15)
A fibrotic disease of the respiratory bronchioles. In constrictive bronchiolitis, the
fibrotic lesion develops external (peribronchiolar) to the airway lumen, leading
to constriction of the airway in a concentric
manner and eventual obliteration of the
lumen. In proliferative bronchiolitis, lesion
develops internally and fills the lumen with
an inflammatory polypoid lesion or buds of
granulation tissue. Multiple etiological factors are known, such as: exposure to tobacco or toxic gases, viral infections (more frequent in children under the age of 3 years
old), post-pulmonary or cardiopulmonary
transplant. Many cases are idiopathic.
Symptoms are non-specific and include
cough and shortness of breath (dyspnea).
The chest x-ray may show hyperinflation; HRCT shows a mosaic pattern and
may show fibrosis in late stages. Biopsy
is required for classification and definitive
diagnosis.
 Treatment is symptomatic; corticosteroids, bronchodilators and oxygen are
utilized. Occasionally other immune-suppressants may be required (cyclosporine).
Chronic Obstructive
Pulmonary Disease (COPD) (16,17)
It is a disease characterized by irreversible
or partially reversible airflow obstruction.
Chronic bronchitis is characterized by the
presence of cough and sputum for more
than 3 months in an year, during two or
more consecutive years. Pulmonary emphysema is characterized by abnormal
and permanent increase of the air spaces
besides the terminal bronchiole, secondary
to destruction of alveolar walls. The restriction of the expiratory airflow is caused by
inflammation or fibrosis and destruction
of the alveolar architecture. The main risk
factor for COPD is smoking; it impairs ciliary mobility, inhibits macrophage function,
produces hypertrophy and glandular hyperplasia and acute bronchoconstriction.
Other risk factors include exposure to noxious gases, pollutants, and chronic respiratory infections.
Symptoms appear around middle age, in
individuals who have a history of smoking
for several years. Typically, patients present
with chronic cough, which may be productive (mucopurulent sputum), and shortness of breath (dyspnea). Exacerbations
are caused by respiratory infections. In
advanced conditions, dyspnea is observed
at rest or upon minimal effort. Symptoms
and signs of right heart failure may appear
(ankle swelling, bluish color of the skin –
cyanosis, and hepatomegaly).
Constrictive
bronchiolitis
Mucus
Inflammed
bronchiole wall
Normal
bronchiole
Diagnosis is suspected on the basis of
clinical presentation. Chest x-ray shows
emphysematous changes (hyperinflated
lung fields, depressed diaphragm) or nonspecific changes. In severe stage, right
heart enlargement may be seen. Diagnosis
is confirmed by the demonstrating a nonreversible obstruction of the airflow, on
spirometry.
Chonic bronchitis
Inflammation and
structural changes
 Smoking must be discontinued and
exposure to other etiological agents should
be minimized.
 Exercise is advised for all patients, as
per clinical condition.
 Pharmacological treatment consists of
bronchodilators; inhaled steroids are recommended for exacerbations.
 In the causes of exacerbation by respiratory infection, antibiotics may be useful.
 Anti-flu and anti-pneumococcal vaccines
are necessary.
 In patients with severe disease, oxygen
is recommended for several hours a day.
Normal
Increased mucus
Bronchiole
Bronchus
Emphysema
Bronchiole
Destruction and
enlargement of air spaces
Alveoli
Chylothorax(18)
Accumulation of lymph, rich in long chain
fatty acids (chyle), in the pleural cavity. Usually, it is caused by the rupture of
the thoracic duct or one of its tributaries.
The most frequent causes are tumors and
trauma.
Symptoms are similar to other pleural effusions. Large collections of lymphatic fluid
are also associated with symptoms of malnutrition due to loss of proteins and long
chain fatty acids.
Pleural tap shows a milky fluid, which
doesn’t become clear after centrifugation.
Diagnosis is confirmed by demonstrating
triglycerides > 110 mg/dl or by the presence of chylomicrons in the pleural fluid.
 If the cause is traumatic, pleural fluid
is drained; surgical ligation of the thoracic
duct may be required.
 Supplementation of diet with middle
chain fatty acids (parenteral feeding or oral
feeding) may be needed.
 If it is secondary to neoplasia, chemotherapy or radiotherapy may be effective.
Idiopathic Pulmonary
Fibrosis(19,20,21)
Disease of unknown etiology, characterized
by presence of scar tissue within the lungs.
Cigarette smoking is strongly associated
with IPF. Pathogenesis involves injury to the
alveolar epithelium, followed by a burst of
pro-inflammatory and fibroproliferative
mediators that promote formation of fibrotic tissue.
It is most frequently observed in patients
between the ages of 50 and 70. The initial
symptoms are non-productive cough and
dyspnea on exertion. Pulmonary auscultation reveals early inspiratory crackles.
Chest x-ray shows bilateral reticular markings that are dominant in the lower zones.
HRCT chest shows subpleural honeycombing (palisades of small, round translucencies), traction bronchiectasis and thickened
interlobular septae. Biopsy is the gold
standard; BAL fluid analysis, and biopsy
may be required to exclude other diagnosis.
 Corticosteroids and other immunesuppressants are used in carefully selected
patients.
 Pulmonary transplant may be indicated
in severe cases.
 Supportive measures, like supplemental oxygen, are used as indicated.
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Larynx Cancer(22,23)
It is the most common cancer of head and
neck region. The most frequent type is the
squamous cell carcinoma; the majority
originate in the glottis. It is more frequent
in men and is related to smoking and heavy
alcohol consumption.
The commonest symptom is progressive
dysphonia. Occasionally patients may
present with abnormal sensation in the
throat, dyspnea.
Diagnosis is suspected on the basis of
symptoms. Laryngoscopy is performed to
visualize the lesion and biopsy the lesion.
Histopathology (biopsy sample) is used for
delineating type of cancer.
 Tumor size and extent is used for making treatment decisions.
 In an early stage, the treatment consists
of surgery or radiotherapy. When the vocal
cords are compromised, radiotherapy is
usually preferable, since it preserves voice.
 Advanced stages require partial or total
excision of the larynx (partial or total laryngectomy) with radiotherapy.
Lung Cancer(24,25,26,27)
It is the commonest cause of cancer related
deaths, worldwide. The commonest types
are: small cell carcinoma, adenocarcinoma,
squamous cell carcinoma and large cell carcinoma. Tobacco smoking is thought to be
responsible for the majority of cases of lung
cancer; the strongest association is with the
squamous cell and small cell types. Among
non-smokers, the most frequent is adenocarcinoma. Five year survival after diagnosis is under 50% in case of localized disease,
and under 25% if it is disseminated.
Patients may remain asymptomatic for
months. The commonest symptoms are:
persistent cough, chest pain (especially if
tumor involves the pleura), fatigue, loss of
appetite or weight loss; recurrent pneumonia; secondary to bronchial obstruction and
atelectasis; swelling of neck and face; hemoptysis. When neighboring structures are
involved by tumor extension, it may cause
tracheal obstruction, dysphagia, dysphonia (by compression of the recurrent laryngeal nerve), paralysis of the phrenic nerve,
superior vena cava syndrome may also be
seen. Blood-borne metastasis and paraneoplastic syndromes are common.
Chest x-ray and sputum test are rarely diagnostic. Diagnosis is established by means
of tissue biopsy (fibre optic bronchoscopy).
The extension of the disease is evaluated
by radiological investigations including:
computerized axial tomography, MRI, bone
scan, mediastinoscopy, etc.
 Treatment is based on the stage of the
disease, specific type of cancer cells, location in the lungs, metastatic spread and the
general health of the patient.
 Various modalities are used including
surgery, radiotherapy and chemotherapy.
The basis for the treatment of small cells
cancer is chemotherapy.
 In small cell cancer, the first line of
treatment is chemotherapy, while surgery
is recommended for non-small cell cancers.
Nasal Polyp(28,29)
Benign lesion arising from the nasal mucosa. It is related to an inflammatory or an
allergic process. Nasal polyps are mostly bilateral. Samnter’s Triad consists of nasal polyposis, asthma, and aspirin hypersensitivity.
Presents with nasal obstruction, rhinorrhea
(watery nasal discharge), and post nasal
drip. Decrease in sense of smell and taste
is common.
Rhinoscopy shows multiple polypoid masses, most frequently arising from the middle
meatus. CT scan may be useful if surgery is
planned.
 Medical treatment includes decongestants, antihistaminics and topical corticosteroids.
 Surgical therapy is reserved for cases
refractory to medical treatment.
Obstructive Sleep Apnea(30)
It is a sleep disorder characterized by occurrence of apnea or hypopnea, repeatedly
during sleep, leading to disruption of the
sleep architecture. Apneas are characterized by the cessation of airflow for more
than 10 s; hypopnea (in adults) is characterized by a reduction in nasal pressure by
at least 30% of baseline for a duration of
at least 10 s, accompanied by oxygen desaturation ≥ 4%. It is commonest in middle
aged, obese men. In most cases, there is a
functional impairment of the upper airway
dilator muscle. Sleep fragmentation and
chronic sleep deprivation lead to excessive
daytime sleepiness.
Excessive sleepiness during the day and
loud snoring at night are the commonest
symptoms. Other symptoms include decrease in attention and memory, headache,
irritability and sexual dysfunction. OSA is
associated with cardiovascular complications; it increases the risk of hypertension,
arrhythmias, heart failure, and stroke.
It is confirmed by polysomnography, which
consists in registering different physiological parameters during the sleep-vigil cycle.
The relation between the number of apneas
and hypoapneas and the total minutes of
sleep generate the apnea-hypoapnea index. Values over 10 are considered pathological.
 If the condition is mild, measures like
weight reduction, avoiding alcohol and
sedatives and the use of intra-oral devices
may be useful.
 Continuous positive airway pressure
(CPAP) ventilation is the primary treatment for patients with OSA. Very severe
cases that don’t respond to treatment may
require surgical correction (uvulopalatopharyngoplasty, maxillomandibular surgery and, rarely, tracheostomy).
Normal breathing during sleep
Obstructive Sleep Apnea
Soft
palate
Tongue
Uvula
Blocked
airway
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Pleural Effusion(31,32)
Abnormal accumulation of fluid in the pleural space. It may be:
- Transudate: when it is produced by an
increase in osmotic gradient across the
pleural capillaries, e.g. by a decrease of
plasmatic oncotic pressure.
- Exudate: when it is produced by an increase in the permeability of the capillary
or by a decrease in the lymphatic drainage.
The most frequent causes of transudative
effusion are: cardiac insufficiency, cirrhosis,
nephrotic syndrome and rarely, myxedema.
Exudative effusion usually appears in the
context of pleuropulmonary infections,
cancer, pulmonary thromboembolism,
pancreatitis, collagen diseases, etc.
Purulent pleural collection, with high leucocyte content or presence of microbes is
termed empyema.
Small effusions are asymptomatic. The
common symptoms include a pleuritic
chest pain, dyspnea and dry nonproductive
cough. Symptoms of underlying etiologies
will be apparent, e.g. fever in patients with
an infectious disease.
Chest x-ray and the ultrasound are useful
for determining the location and volume
of the effusion. Thoracocentesis (pleural
tap) and examination of the pleural fluid is
necessary to ascertain the etiology. In some
cases a thoracoscopic pleural biopsy may be
necessary.
 The primary cause should be treated.
 Large fluid collections and empyemas
require placement of a pleural drain. In cases where there is loculation of fluid, intrapleural instillation of fibrinolytics (through
the draining tube) may be done to facilitate
the exit of pus. Another procedure is the
decortication, which implies a thoracotomy
with complete removal of existing pus.
 Pleurodesis consists of applying an
irritant (talc, tetracycline, bleomycin) between the two pleural layers (parietal and
visceral) aiming to cause an inflammatory
reaction that results in the fusion of both
layers. It is used in the symptomatic treatment of recurrent significant effusions of a
malignant etiology.
Pneumonia(33,34)
Infectious process of the pulmonary parenchyma. Microorganisms invade the lung via
aspiration of colonizers from the oropharynx, via blood from a non-pulmonary focus,
or by contiguous spread from a neighboring
structure. A failure in the defense mechanisms (ciliary movement, mucus secretion,
immune response, etc.) or a very high load
of microorganisms predispose to infection.
In adults, the commonest etiological agents
are Streptococcus pneumoniae, Staphylococcus aureus, Legionella and Haemophilus
influenza and various viruses. Mycoplasma
pneumoniae is a frequent cause of pneumonia in older children and young adults.
Alcohol consumption, smoking, diabetes,
cardiac insufficiency and COPD are predisposing factors. Children, the elderly and
individuals with alterations in the immune
system are more prone to develop pneumonia. Pneumonia is classified as community
acquired (CAP; develops within or after 72
hours of hospital discharge), or nosocomial
(occurs in patients hospitalized due to other
pathology).
The typical presentation consists of an
acute fever, chills, productive cough and
pleuritic chest pain, with high leukocyte
count in the peripheral blood. Atypical
pneumonia presents subacutely with fever,
headache, myalgia (muscle pain), arthralgia (joint pain) and dry cough. The nosocomial pneumonias may be masked by the
underlying disease; it must be suspected in
patients with fever and new radiological
infiltrates.
Diagnosis is based on clinical history, examination and radiological investigations.
The etiological diagnosis can only be confirmed by sputum’s exam, blood culture
and bronchoscopy. In general, invasive
procedures are not used regularly, since in a
high percentage of CAP the responsible microorganisms are common and treatment is
empirical.
 It is based on antibiotics and supportive
measures.
 The choice of the antibiotic depends
on the type of pneumonia (CAP or nosocomial), the type of presentation (typical
or atypical), the presence of risk factors for
unusual microorganisms (elderly, COPD,
severe types of presentation). Antimicrobial choice may be modified by culture and
sensitivity reports.
 Patients with severe disease require
hospitalization and may need aggressive
support measures including invasive ventilation.
Pneumonitis by
Hypersensitivity(35,36)
Immunologically mediated group of conditions which follow repeated exposure
to different antigens. Usually, it is seen as
an occupational disease in cattle breeders,
farmers, wood workers, pigeon breeders,
etc. Exposure to the antigen (fungi, bacteria, animal or plants products) causes
an exaggerated inflammatory response,
which, when chronic, evolves to pulmonary
fibrosis.
May occur in an acute, subacute or chronic
form. In the acute type, patient presents
with fever, chills, dyspnea, cough and
myalgia, which disappear a few days after the exposure is discontinued. Tachypnea, tachycardia, and bibasilar inspiratory
crackles are usually present. The chronic
type is secondary to prolonged exposure,
and presents with cough, dyspnea, weight
loss; there may be symptoms of pulmonary
hypertension.
Normal
Pneumonia
Windpipe (trachea)
Lung
Bronchiole
Bronchus
Air sacs (alveoli)
Fluid in
air sacs
It is based on high index of suspicion.
Physical examination shows non-specific
findings; chest x-ray shows ground glass
opacities in acute cases and increased reticular shadows/honeycombing in the chronic
cases. Bronchoscopy and bronchoalvelolar
lavage is also useful.
 Identifying and eliminating the causal
agent is fundamental.
 Milder cases usually resolve on their
own following discontinuation of exposure.
 Severe ones require treatment with corticosteroids.
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Pneumothorax(37)
Air or gas accumulation in the pleural cavity. It causes the separation of the parietal
and visceral layers, leading to compression and collapse of the pulmonary parenchyma. It may be: - traumatic (open
or closed trauma); - spontaneous, in thin,
young males (rupture of apical bubbles) or in
patients with COPD; - hypertensive, when
by a valvular mechanism, air penetrates in
the pleural space during inspiration and it
is retained during expiration; - catamenial,
in young women, related to menstruation.
A tension pneumothorax is a medical emergency due to rising intrathoracic pressure
from progressive air accumulation in the
pleural cavity.
The clinical presentation depends on the
patient’s ventilatory reserve and the degree of lung collapse. Common symptoms
include back pain, dyspnea, dry cough,
sweating, tachycardia and pallor. In patients with tension pneumothorax, cyanosis and shock are common.
It is confirmed by a chest x-ray. For visualizing small pneumothorax (< 15% area of
hemithorax), CT scan may be required.
 Therapeutic options include bed rest, oxygen supplementation, manual aspiration,
chest tube drainage, and thoracoscopic and
surgical interventions. Small spontaneous
pneumothoraxes without ventilatory compromise require only rest and observation.
 Those associated with respiratory compromise require thoracic draining.
 To avoid relapses, surgical treatment
(by resection of bullae) is helpful in selected patients only.
 Tension Pneumothorax is considered
an emergency that requires immediate
administration of oxygen and insertion a
high caliber needle in the 2nd intercostal
space. The air exit confirms the diagnosis
and should remain open until a permanent
draining tube is placed.
Pulmonary Hypertension(38)
Condition characterized by elevated pulmonary arterial pressure (pulmonary artery
pressure > 25 mmHg during rest or over 30
mmHg during exercise) and secondary right
ventricular failure. Primary pulmonary hypertension is not very frequent and its
cause is unknown. Secondary pulmonary
hypertension is more frequent and is often
the consequence of chronic respiratory or
cardiovascular diseases which are associated with low oxygen level in the blood (hypoxemia). The most frequent cause is COPD.
Other causes for secondary pulmonary hypertension are: congenital heart diseases,
portal hypertension, human immunodeficiency virus (HIV) infection, drugs, chronic
exposure to great heights, etc. Hypoxemia
induces the constriction of pulmonary vessels (to maintain the gas-exchange equilibrium), which lead to change in the vascular
wall and thrombosis. Cor pulmonale is the
increase in size of the right ventricle secondary to chronic pulmonary hypertension.
In primary pulmonary hypertension, the
most frequent symptom is progressive dyspnea, which may occur after several years
of onset of disease. Fatigue, weakness, as
well as thoracic pain, are also observed;
syncope and hemoptysis may occur. In
secondary pulmonary hypertension, the
symptoms overlap with those of the primary disease process.
Physical examination shows signs of right
ventricular insufficiency (engorged jugular
veins; hepatomegaly, peripheral edema).
Electrocardiographic features of right ventricular and atrial enlargement are seen.
Cardiac catheterization is useful to directly
measure the pulmonary artery pressure, as
well as to rule out other secondary causes.
 Primary pulmonary hypertension is a progressive disease for which there is no cure.
 Oxygen supplementation is essential
for all patients with arterial hypoxemia.
 Pulmonary transplantation is prescribed
for patients with severe right cardiac insufficiency, who do not respond to treatment.
 Vasodilators, which act on pulmonary
circulation, diuretics to reduce fluid retention, and anticoagulants are used. Medications include calcium channel blockers, prostanoids, endothelin receptor antagonists
and phosphodiesterase type-5 inhibitors.
 urgical thrombo-endarterectomy is the
primary surgical therapy for selected patients with thromboembolic obstruction of
the proximal pulmonary arteries.
 Pulmonary transplant is prescribed for
patients with severe right cardiac insufficiency, who do not respond to treatment.
Pulmonary Hypertension
Constriction of pulmonary arteries
Normal heart
Aorta
Left atrium
Pulmonary
arteries (to lungs)
Pulmonary veins
(from lungs)
Right atrium
Enlarged right ventricle
Right ventricle
Left ventricle
Lungs
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Pulmonary
Thromboembolism (PTE)(39,40)
Pulmonary vessel obstruction by one or
several emboli. Emboli, in most cases, are
fragments of thrombi (clots), which travel
through the blood until they obstruct a
smaller caliber vessel. The most common
source of emboli is thrombosed lower limbs
veins or those of the pelvis (deep venous
thrombosis). Emboli of fat, amniotic fluid,
bone marrow or tumor fragments may also
lodge in the pulmonary vasculature. The
risk factors for venous thrombosis and pulmonary thromboembolism are: prolonged
immobilization, pregnancy, recently diagnosed cancer, oral contraceptives and states
of hypercoagulability. When the pulmonary
blood flow is acutely interrupted, it creates
a shunt (left to right) and leads to hypoxemia. Obstruction of large vessel or obstruction of multiple smaller vessels leads
to strain on the right heart and increase in
pressures.
Dyspnea (a sensation of shortness of
breath) and tachypnea (increase of respiratory frequency) of sudden onset are frequent. Acute embolism may present with
dizziness, fainting, palpitations and even
syncope. The presence of cyanosis (bluish
color of the skin), or syncope (sudden loss
of consciousness) indicate massive embolism. In a large proportion of cases, signs
of deep venous thrombosis of the leg(s)
are evident. Pulmonary hypertension, if
severe, is followed by acute respiratory
insufficiency, right ventricular insufficiency
and even death.
The diagnosis is suspected on the basis of
symptoms in the context of the clinical setting (presence of risk factors). Pulmonary
perfusion scintigraphy allows visualization
of pulmonary areas with reduced blood
flow. It is performed in conjunction with
pulmonary ventilation scintigraphy (V/Q
scan to look for mismatch, which is diagnostic). CT scan, contrast spiral CT and
determination of D-dimers in blood may
be useful. D-dimer has a good negativepredictive value, especially in setting of low
clinical suspicion. The gold standard for diagnosis is pulmonary angiography.
 The treatment of suspected PTE is anticoagulation with heparin. Either regular
or low molecular weight heparin may be
used.
 In acute cases with significant hemodynamic compromise, and in patients in
whom > 50% of pulmonary perfusion is
compromised, it is recommended to start
treatment with intravenous fibrinolytics.
 After the acute period, treatment with
oral anticoagulants should be continued
for 3 to 6 months.
 In patients with recurring embolism or
irreversible risk factors, life-long treatment
with anticoagulants may be required.
 In cases where anticoagulation is contraindicated, inferior vena cava filters or
embolectomy may be necessary.
Rhinitis(41,42)
Inflammation of the mucus membrane
that covers the nasal pits. It is defined as
the presence of at least one of the following: congestion, rhinorrhea, sneezing, nasal itching, and nasal obstruction. It may
be due to viral infections (coryza), allergy,
parasympathetic hyper-functioning (vasomotor rhinitis), associated with pregnancy,
dry environment and contamination.
Common symptoms are rhinorrhea (watery
nasal discharge) and decrease in sense of
smell; these may be associated with other
flu-like symptoms. Allergic rhinitis may
be due to a large variety of allergens and
presents with repetitive sneezing, rhinorrhea, nasal obstruction and nasal or ocular
itching. Vasomotor rhinitis is triggered by
temperature change, irritative agents, hypothyroidism and oral contraceptives. Repeated episode of acute rhinitis can lead to
a hypertrophic chronic rhinitis, with increase
in the size of the inferior turbinate. Dry
rhinitis presents as lesions with crusting and
signs of bleeding. Ozena is a type of atrophic
rhinitis that presents with smelly crusts and
anosmia (absence of sense of smell).
Usually, a detailed history and clinical exam
is enough. Rhinoscopy for visualization of
the nasal cavity and the turbinates is performed.
 The following medications are commonly utilized: decongestants, anti-inflammatories and anti-pyretics.
 In allergic rhinitis, besides avoiding
contact with the allergen, decongestants
(antihistamines) and topical corticosteroids
are useful.
 Vasomotor rhinitis may require vidian
nerve neurectomy or cryosurgery.
 Inferior turbinate surgery may be indicated in hypertrophic chronic rhinitis.
 Dry rhinitis requires abundant hydration.
Sarcoidosis(43)
Multisystem granulomatous disease of unknown cause, characterized by the formation of noncaseous epithelioid cell granulomas. It involves the respiratory system in
> 90% of cases, usually the hilar and mediastinal nodes, and, less frequently, the lung
tissue. There is an exaggerated response of
the cellular immunity leading to formation
of granulomas. The inflammation and coalescence of granulomas alters pulmonary
architecture, causes fibrosis, cyst formation,
bronchiolitis and bronchiectasis.
Pulmonary involvement is frequently
asymptomatic or presents with dyspnea
and dry cough. Enlargement of the thoracic
lymph nodes is frequent. Nasal mucosal
membranes may be involved. Laryngeal
granulomas may cause dysphonia. Other
affected organs are: skin (pernio lupus,
erythema nodosum); eyes (uveitis, choroiditis), liver, nervous system, bone marrow,
spleen, nervous system, heart, endocrine
system and reproductive organs.
Diagnosis is confirmed by histopathology,
which shows granulomas in the tissue biopsy. However, biopsy may not be possible
in many cases and diagnosis is suspected on
the basis of the clinico-radiological picture.
CT scans of chest are commonly utilized for
diagnosis and staging of the disease. The
most accessible areas for biopsy are the
bronchial tree or the lung (transbronchial
biopsy). Blood tests that help in diagnosis
include raised serum ACE levels and hypercalcaemia.
 A third of the cases may remit spontaneously after 1 or 2 years, one third show
signs of progression and the rest remains
stable.
 In severe disease or in patients with
significant extra-pulmonary involvement,
treatment with corticosteroids and other
immunosuppressants is recommended.
 Airway disease is treated symptomatically; corticosteroids (oral/inhaled) are
used for clinically significant disease.
Systemic Involvement in Sarcoidosis
Brain complications
Eye problems
(burning, itching
tearing or pain)
Salivary glands
Lupus pernio (painful skin sores on the
face) and skin lesions on back, arms,
neck, face and scalp
Enlarged lymph nodes
in chest near windpipe
and lungs
Enlarged lymph nodes
in neck and chest
Heart complications
Scarring and
granulomas
in lung
Granulomas
(Inflamed lumps)
in lungs
Liver enlargement
Spleen enlargement
Erthema nodosum (itchy
and painful rashes) on the
lower legs and ankles
RESPIRATORY SYSTEM - Main Pathologies
DESCRIPTION
SYMPTOMS
DIAGNOSIS
TREATMENT
Silicosis(44,45)
Pulmonary pathology caused by silica dust
inhalation (e.g. in quartzquarry workers).
Silica dust is the main element in sand;
exposure is frequent among miners, silicaceous rock and granite cutters, foundry
workers and potters. When inhaled, silica
initiates an inflammatory reaction that
leads to pulmonary tissue fibrosis. Silica exposure is classically associated with restrictive lung disease.
Usually, symptoms appear after 20 or
30 years of cumulative exposure to the
dust. The severity of disease varies from
simple or classic type - small lesions
(silicotic nodule) that can be observed
in the chest x-ray; may be asymptomatic or present with cough and mild
dyspnea; - to a severe disease - massive
progressive pulmonary fibrosis, which
appears when simple nodules converge, forming large masses of fibrotic
tissue; presents with severe dyspnea
and cough. Silica exposure is also associated with lung cancer, pulmonary
tuberculosis and COPD.
Diagnosis is based on establishing a history
of exposure and correlating the same with
clinical findings and radiological investigations (chest x-ray/ CT).
 The exposure to dust at work should
be minimized by measures such as wearing
proper masks.
 It is necessary to perform regular control chest x-rays for the exposed workers.
 Once fibrosis sets in, the process is irreversible.
 Treatment is symptomatic, aimed at alleviation of dyspnea.
Sinusitis(46,47)
Inflammation of the mucus membrane
that covers the nasal sinuses. Usually, it is
caused by the obstruction of a perinasal
sinus, which makes draining difficult and
favors super-infection. The obstruction
may be favored by deviation of the septum,
polyps, decreased immunity (diabetes) or
reduction of the mucociliary activity (contamination). The bacterial agents most
frequently implicated in acute sinusitis are
the Streptococcus pneumoniae, Hemophilus
influenzae and Moraxela catarrhalis. A majority of sinusitis, however, is attributable to
a viral etiology. In chronic sinusitis, anaerobic agents are also important etiological
agents. In children, the sinus most commonly affected is the ethmoid; in the adult,
it is the maxillary sinus.
Acute sinusitis presents with headache
(worsen with manoeuvres that increase
the intra-sinus pressure, such as lowering the head), purulent rhinorrhoea and
pain on pressure at sinus points. Other
symptoms include halitosis (bad breath),
fever and changes in the sense of smell. In
chronic sinusitis the symptoms are milder,
with rhinorrhoea, nasal respiratory insufficiency and a nasal voice (rhinolalia).
The history indicates the diagnosis, which
is confirmed by clinical examination and xray of the paranasal sinuses. CT scan may be
used to complement the x-ray. It may show
mucosal thickening, presence of inflammatory discharge and concomitant polyps.
 Acute cases are treated with antibiotics,
vasoconstrictor decongestive medications,
aiming to improve the ventilation of the
paranasal sinuses.
 Surgical treatment may be necessary
in chronic cases, or acute cases with inadequate or poor response to conventional
medical treatment.
Deviation of nasal septum
Different causes of Sinusitis
Nasal cicle
(mucociliary
clearance)
Mucociliary clearance
of frontal sinus
Ostiomeatal
complex
Orbit
Nasal polyposis
Polyp in middle meatus
Antral choanal polyp
obstructs ostium of
maxillary sinus
Ostiomeatal
obstruction
Mucociliary
clearance of
maxillary sinus
Nasal septum
Fluid collected
in sinus
Tonsilitis(48,49)
Inflammation of the tonsils, usually of bacterial etiology (streptococcus, staphylococcus), although it may also be viral. The incidence is higher in pre-school age, though
it affects the majority of the population
sometime during their life.
The patient presents with high fever, malaise, pain, difficulty in swallowing and ear
pain (reflex otalgia). A frequent complication is the peritonsillar abscess, a collection
of pus in the peritonsillar area, which leads
to uvular displacement. Systemic complications may appear after a streptococcal
infection (glomerulonephritis or rheumatic
fever).
Examination of the throat shows erythema
and congestion of the tonsils. There may be
pus points or a thin white membrane over
the tonsil. Collecting some pus or mucus
from the posterior part of the throat with a
swab allows isolation of the causative microorganism.
 Bacterial tonsillitis requires treatment
with antibiotics, painkillers and antipyretics.
 If there have been seven or more episodes of tonsillitis in a year, five or more in
the last two years or three or more in the
past three years, a surgical excision of the
tonsils may be recommended.
Vocal Cords Nodule(50,51)
Benign bilaterally symmetric swelling of
the true vocal folds (anterior and mid-third
of the folds). It is caused by chronic abuse
of the voice. It is more frequent in women.
It presents itself with dysphonia (hoarseness), episodic voice loss and vocal fatigue.
Diagnosis is established by vocal cord examination (indirect laryngoscopy) and
biopsy.
 The treatment starts with voice therapy; if it doesn’t improve, microsurgical
excision is performed. Other indications for
microsurgical treatment are: longstanding
nodule (failure of voice therapy) and suspicion of a primary lesion with a reactive
callus on the other vocal fold.
Vocal Cords Polyp(50,51)
This is a benign mass that develops on the
true vocal fold; mostly secondary to voice
abuse or vocal trauma. It is unilateral and
more common in males.
Usually, patients present with chronic dysphonia and vocal fatigue.
Indirect laryngoscopy biopsy.
 Surgical treatment with the excision
of the polyp. Lasers may be used for treatment.
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