Lecture number 16. Acute inflammatory diseases of the pharynx

1. Acute pharyngitis

Acute pharyngitis is an acute inflammation of the mucous membrane of all parts of the pharynx. This disease is more often concomitant with respiratory infections of viral and microbial etiology (influenza, adenovirus, coccal).

The patient complains of a feeling of soreness or pain in the pharynx, perspiration, dryness, hoarseness, and on examination there is hyperemia of the mucosa of all parts of the pharynx, accumulation of viscous mucus on the back wall, sometimes of a hemorrhagic nature.

General symptoms - weakness, fever, discomfort - are due to the underlying disease. For the treatment of acute pharyngitis, oil-balsamic drops in the nose are recommended, a mixture in equal amounts of sea buckthorn, vaseline and menthol oils 3-5 times a day, warm alkaline inhalations, lubrication of the pharyngeal mucosa with Lugol's solution on glycerin, analgesics, aspirin are prescribed orally.

Differential diagnosis of acute pharyngitis is carried out with diphtheria, scarlet fever, measles, rubella and other infectious diseases.

In acute pharyngitis, it is recommended to take a swab from the pharynx for corynobacteria, and if necessary, the patient is hospitalized in an infectious diseases hospital.

2. Angina

Angina is an acute inflammation of the palatine tonsils and the mucous membrane of the pharynx.

Angina according to clinical data and pharyngoscopic picture is divided into catarrhal, follicular, lacunar, ulcerative-membranous and necrotic.

Angina is a common nonspecific infectious-allergic disease of predominantly streptococcal etiology, in which local inflammatory changes are most pronounced in the lymphadenoid tissue of the pharynx, most often in the palatine tonsils and regional lymph nodes.

Manifested clinically in the form of catarrhal, follicular and lacunar tonsillitis.

Nonspecific angina

Nonspecific angina - catarrhal, when only the mucous membrane of the tonsils is affected, follicular - purulent damage to the follicles, lacunar - pus accumulates in the lacunae. It is usually caused by group A streptococcus.

However, there is pneumococcal tonsillitis, staphylococcal tonsillitis and tonsillitis, in the etiology of which lies a mixed coccal flora. A variety of this angina is alimentary angina, caused by epidemic streptococcus. The microbe is introduced, as a rule, in case of violation of the cooking technology by unscrupulous workers.

Catarrhal angina affects the mucous membrane of the tonsils and arches, while hyperemia of these parts of the pharynx is noted, but there are no raids.

The patient notes pain when swallowing, burning in the pharynx. Has a bacterial or viral etiology. The temperature is subfebrile, fever is less common.

Regional lymph nodes may be moderately enlarged. The disease lasts 3-5 days. Treatment - rinsing with soda, sage, lubricating the tonsils with iodine-glycerin, ingestion of aspirin.

Catarrhal angina must be distinguished from acute pharyngitis, in which the entire mucous membrane of the pharynx is affected, especially its posterior wall.

Follicular and lacunar tonsillitis are caused by the same pathogens and are similar both in clinical course and in the general reaction of the body and possible complications. The difference lies in the different form of raids on the tonsils.

With follicular angina, suppuration of the follicles occurs, and dead white blood cells shine through the mucous membrane. With lacunar angina, inflammation begins with lacunae, where pus accumulates, then protruding from the lacunae to the surface of the tonsils.

After 1-2 days, raids spread over the entire surface of the tonsils, and it is no longer possible to distinguish between two types of tonsillitis. Patients feel severe pain when swallowing, discomfort in the throat, refuse food.

The cervical lymph nodes are sharply enlarged, the temperature rises to 39 and even 40 ° C.

On the 2nd - 3rd day, a differential diagnosis is made with diphtheria. Already at the first examination, the patient must take a smear on a diphtheria bacillus, try to remove plaque with a cotton brush.

If the plaque is removed, this speaks in favor of angina vulgaris, if it is difficult to remove, and bleeding erosion remains in its place, this is most likely diphtheria.

In case of doubt, it is necessary to introduce antidiphtheria serum.

Treatment of follicular and lacunar tonsillitis consists in rinsing the pharynx, a cervical semi-alcohol compress, prescribing analgesics, desensitizers (diphenhydramine, suprastin, tavegil), and broad-spectrum antibiotics intramuscularly. Patients are recommended a sparing diet.

Angina, caused by adenoviruses, proceeds in the form of diffuse acute pharyngitis, although it can also be accompanied by raids on the tonsils. Typical for adenovirus infection is a widespread lesion of the lymph nodes and a very frequent combination with conjunctivitis.

This is especially true for adenovirus type 3, which causes pharyngoconjunctival fever. A similar picture is given by the influenza virus, but in 10-12% of cases it can be combined with streptococcal tonsillitis.

Acute inflammation of the tonsils of another localization. Angina of the lingual tonsil has characteristic symptoms - pain in the region of the deep pharynx, which increases sharply when you try to protrude the tongue.

The diagnosis is made by indirect laryngoscopy using a laryngeal mirror.

Angina of the nasopharyngeal tonsil. Pain is localized in the nasopharynx, a thick mucous discharge is released from the nose, an acute runny nose is noted. With posterior rhinoscopy, an edematous tonsil of a cyanotic color is visible, sometimes with raids, thick mucus flows down the back of the pharynx.

Angina as a syndrome of common infectious diseases

Angina with scarlet fever can proceed in different ways. Most often it is angina catarrhal and lacunar.

In the classic course of scarlet fever, there is a characteristic redness of the soft palate in the circumference of the pharynx, which does not extend beyond the soft palate, swelling of the cervical lymphatic glands and a whitish thick coating on the tongue, followed by its cleansing when the tongue takes on a bright color.

To make a diagnosis, it is necessary to take into account all the symptoms of the disease, especially the scarlatinal rash in the region of the mastoid process and flexor surfaces of the extremities.

There are severe forms of scarlet fever, occurring in the form of:

1) pseudomembranous angina with the formation of a fibrinous exudate widespread on the mucous membrane of the tonsils, pharynx, nasopharynx and even cheeks in the form of a thick grayish film tightly soldered to the underlying tissue. There is a bright hyperemia of the pharyngeal circumference, a rash appears already on the first day of the disease. The prognosis of this form of scarlet fever is unfavorable;

2) ulcerative necrotic angina, characterized by the appearance of grayish spots on the mucous membrane, quickly turning into ulcers. There may be deep ulceration with the formation of persistent defects of the soft palate. Lateral cervical lymph nodes are affected by extensive inflammation;

3) gangrenous tonsillitis, which is rare. The process begins with the appearance of a dirty gray plaque on the tonsils, followed by deep tissue destruction up to the carotid arteries.

Angina with diphtheria can occur in various clinical forms. With diphtheria, plaques go beyond the arches. For angina, the pathognomonic is the strict border of the distribution of raids within the tonsils. If raids spread beyond the arches, the doctor must question the diagnosis of nonspecific tonsillitis. There is a simple diagnostic test. The plaque is removed from the tonsil with a spatula and dissolved in a glass of cold water.

If the water becomes cloudy, the plaque dissolves, then it is a sore throat. If the water remains clear, and plaque particles have surfaced, then this is diphtheria.

Angina with measles proceeds under the mask of catarrh in the prodromal period and during the rash.

In the second case, the diagnosis of measles does not cause difficulties; in the prodromal period, it is necessary to monitor the appearance of measles enanthema in the form of red spots on the mucous membrane of the hard palate, as well as Filatov-Koplik spots on the inner surface of the cheeks at the opening of the Stenon's duct. The course of sore throat with rubella measles is similar to measles.

Angina with influenza proceeds in the same way as catarrhal, however, diffuse hyperemia captures the tonsils, arches, tongue, back wall of the pharynx.

Erysipelas is a serious disease that often occurs along with facial erysipelas. It starts with a high temperature and is accompanied by severe pain when swallowing. The mucosa is colored bright red with sharply defined reddening borders, it seems varnished due to edema.

Angina with tularemia begins acutely - with chills, general weakness, reddening of the face, enlargement of the spleen.

For differential diagnosis, it is important to establish contact with rodents (water rats, house mice and gray voles) or blood-sucking insects (mosquitoes, horseflies, ticks).

Angina with tularemia in most cases occurs when infected by the alimentary route - when drinking water, food after an incubation period of 6-8 days in an infected patient.

Another differential diagnostic sign is the formation of buboes - packets of lymph nodes in the neck, sometimes reaching the size of a chicken egg.

Lymph nodes may suppurate. The picture of the pharynx may resemble catarrhal or more often membranous angina, erroneously diagnosed as diphtheria.

Angina with blood diseases

Monocytic tonsillitis (infectious mononucleosis or Filatov's disease) can clinically proceed in a variety of ways - from catarrhal to ulcerative necrotic. The etiology of this disease has not been fully elucidated. Clinically: an increase in the liver and spleen (hepatolienal syndrome), the presence of compacted and painful to the touch lymph nodes (cervical, occipital, submandibular, axillary and inguinal, and even polylymphadenitis).

A pathognomonic symptom is the appearance in the peripheral blood of atypical mononuclear cells.

Agranulocytic angina is associated with the complete or almost complete disappearance of granulocytes in the peripheral blood with the preservation of monocytes and lymphocytes against the background of severe leukopenia. The etiology of the disease has not been elucidated, it is considered polyetiological. The disease is associated with the immoderate and uncontrolled use of drugs such as analgin, pyramidon, antipyrine, phenacytin, sulfonamides, antibiotics, chloramphenicol, Enap.

The clinical picture is usually severe and consists of symptoms of acute sepsis and necrotic tonsillitis, since the microbes that inhabit the pharynx belong to the opportunistic flora and, when the leukocyte protection is turned off and other adverse circumstances, they become pathogenic and penetrate into the tissues and blood. The disease is severe, with high fever, stomatitis, gingivitis, esophagitis. The liver is enlarged. The diagnosis is made on the basis of a blood test: leukopenia is sharp, below 1000 leukocytes per 1 mm³ blood, absence of granulocytes. The prognosis is serious due to the development of sepsis, laryngeal edema, necrosis of the tissues of the pharynx with severe bleeding. Treatment consists of fighting a secondary infection - prescribing antibiotics, vitamins, throat care (rinsing, lubricating, irrigating with antiseptic, astringent, balsamic solutions), intravenous transfusion of leukocyte mass. The prognosis for this disease is quite serious.

Alimentary-toxic aleukia is characterized by the fact that, unlike agranulocytosis, when only granulocytes (neutrophils, eosinophils) disappear from the peripheral blood, the disappearance concerns all forms of leukocytes. The disease is associated with the ingestion of a special fungus that multiplies in overwintered cereals left unharvested in the fields and contains a very toxic substance - poin, even a very small amount of which leads to contact lesions in the form of tissue necrosis, hemorrhagic ulcers affecting the entire gastrointestinal tract , and even getting feces on the buttocks causes their ulceration.

The poison is heat-stable, so the heat treatment of flour (cooking baked goods, bread) does not reduce its toxicity.

From the side of the pharynx, necrotic sore throat is pronounced, when the tonsils look like gray dirty rags, and a sharp, nauseating smell is released from the mouth.

The number of leukocytes in the peripheral blood is up to 1000 or less, while granular leukocytes are completely absent. Characterized by high fever, the appearance of a hemorrhagic rash. Treatment at an early stage consists of gastric lavage, enemas, the appointment of a laxative, a sparing diet, intravenous infusions of saline with vitamins, hormones, glucose, blood transfusion, leukocyte mass.

In the stage of angina and necrosis, antibiotics are prescribed. With sharp clinical manifestations of the disease, the prognosis is unfavorable.

Angina in acute leukemia occur with varying degrees of severity, depending on the stage of leukemia. The onset of angina (usually catarrhal) proceeds relatively favorably, begins against the background of apparent well-being, and only a blood test allows us to suspect acute leukemia at this early stage of the disease, which once again proves the mandatory blood test for angina.

Sore throats with developed leukemia, when the number of blood leukocytes reaches 20 or more, and the number of red blood cells drops to 000-1 million, sore throat is extremely severe in the form of an ulcerative-necrotic and gangrenous form with high fever and severe general condition. Nosebleeds, hemorrhages in organs and tissues, and enlargement of all lymph nodes occur. The prognosis is unfavorable, patients die within 2-1 years. Treatment of sore throat is symptomatic, local, antibiotics and vitamins are prescribed less often.

Angina with infectious granulomas and specific pathogens

Tuberculosis of the pharynx can occur in two forms - acute and chronic. In the acute form, hyperemia is characteristic with a thickening of the mucous membrane of the arches, soft palate, tongue, resembling a sore throat, body temperature can reach 38 ° C and above. There are sharp pains when swallowing, the appearance of gray tubercles on the mucous membrane, then their ulceration. A characteristic anamnesis, the presence of other forms of tuberculosis help in the diagnosis.

Of the chronic forms of tuberculosis, it is more often ulcerative, developing from infiltrations, often proceeding without symptoms. The edges of the ulcer are raised above the surface, the bottom is covered with a gray coating, after its removal, juicy granulations are found. Most often, ulcers are observed on the back of the pharynx. The course of processes in the pharynx depends on many reasons: the general condition of the patient, his nutrition, regimen, social conditions, timely and correct treatment.

In acute miliary form of tuberculosis, the prognosis is unfavorable, the process develops very quickly with a fatal outcome in 2-3 months.

The treatment of tuberculosis of the pharynx, as well as its other forms, has become relatively successful after the advent of streptomycin, which is administered intramuscularly at 1 g per day for an average of 3 weeks. R-therapy sometimes gives good results.

Syphilis of the throat. Primary syphilis most often affects the palatine tonsils. Hard chancre is usually painless.

Usually, on a red limited background of the upper part of the tonsils, a solid infiltrate is formed, then erosion, turning into an ulcer, its surface has a cartilaginous density. There are enlarged cervical lymph nodes on the side of the lesion, painless on palpation.

Primary syphilis develops slowly, over weeks, usually on one tonsil.

The condition of patients with secondary angina worsens, fever, sharp pains appear. If syphilis is suspected, it is imperative to carry out the Wasserman reaction.

Secondary syphilis appears 2-6 months after infection in the form of erythema, papules. Erythema in the pharynx captures the soft palate, arches, tonsils, lips, surface of the cheeks, tongue. The diagnosis of syphilis at this stage is difficult until the appearance of papules from a lentil grain to a bean, their surface is covered with a touch of greasy sheen, the circumference is hyperemic.

Most often, papules are localized on the surface of the tonsils and on the arches.

The tertiary period of syphilis manifests itself in the form of gumma, which usually occurs several years after the onset of the disease. More often, gummas are formed on the back of the pharynx and soft palate. First, limited infiltration appears against the background of bright hyperemia of the pharyngeal mucosa. Complaints during this period may be absent.

With a further course, paresis of the soft palate occurs, food enters the nose. The course of tertiary syphilis is very variable, depending on the localization and rate of development of gumma, which can affect the bone walls of the facial skull, tongue, main vessels of the neck, causing profuse bleeding, grows into the middle ear.

If syphilis is suspected, a consultation with a venereologist is required to clarify the diagnosis and prescribe rational treatment.

Fusospirochetosis. The etiological factor is the symbiosis of the spindle-shaped rod and spirochete in the oral cavity. A characteristic manifestation of the disease is the appearance of erosions on the surface of the palatine tonsils, covered with a grayish, easily removable coating.

In the initial stage of the disease, there are no subjective sensations, the ulcer progresses, and only after 2-3 weeks there are mild pains when swallowing, regional lymph nodes on the side of the lesion may increase.

During pharyngoscopy during this period, a deep ulcer of the tonsil is found, covered with a gray fetid plaque, easily removed. General symptoms are usually not expressed.

In differential diagnosis, it is necessary to exclude diphtheria, syphilis, tonsil cancer, blood diseases, for which a blood test, Wasserman reaction, and a diphtheria bacillus smear are done.

Rarely, pharyngitis and stomatitis join the defeat of the tonsils, then the course of the disease becomes severe.

Treatment consists in the use of rinsing with hydrogen peroxide, a 10% solution of berthollet salt, potassium permanganate. However, the best treatment is a plentiful lubrication of the ulcer with a 10% solution of copper sulphate 2 times a day.

The beginning of ulcer healing is noted already on the third day, which, in turn, also serves as a differential diagnosis with syphilis, blood diseases. The prognosis for timely treatment is favorable.

Candidomycosis of the pharynx is caused by yeast-like fungi, often in debilitated patients or after uncontrolled intake of large doses of antibiotics that cause dysbacteriosis in the pharynx and digestive tract.

There are sore throats, fever, against the background of hyperemia of the mucous membrane of the pharynx, small white plaques appear with further extensive necrosis of the epithelium of the tonsils, arches, palate, posterior pharyngeal wall in the form of grayish plaques, after the removal of which erosion remains.

It is necessary to differentiate the disease with diphtheria, fusospirochetosis, lesions in blood diseases. The diagnosis is made on the basis of microscopy of smear materials with a coating of yeast-like fungi. Treatment involves the mandatory cancellation of all antibiotics, irrigation of the pharynx with a weak soda solution, lubrication of lesions with Lugol's solution on glycerin.

This disease must be distinguished from pharyngomycosis, in which sharp and hard spikes protruding to the surface are formed in the lacunae of the tonsils. Since there are no signs of inflammation of the surrounding tissues and subjective sensations, the disease may not be detected by the patient for a long time. Conservative treatment is ineffective. As a rule, it is necessary to remove the affected tonsils.

Paratonsillar abscess

Between the capsule of the tonsil and the pharyngeal fascia is paratonsillar tissue, and behind the pharyngeal fascia, laterally, is the fiber of the parapharyngeal space. These spaces are filled with fiber, the inflammation of which, and in the final stage - and abscess formation determine the clinic of the named disease. An abscess is most often caused by nonspecific flora as a result of a tonsillogenic spread of infection. The disease begins acutely, with the appearance of pain when swallowing, often on one side.

Usually, a paratonsillar abscess occurs after suffering a sore throat during the recovery period. When examining the pharynx, there is a sharp swelling and hyperemia of the tissues around the tonsil (arches, soft palate, uvula), protrusion of the tonsil from the niche, displacement to the midline.

An abscess is formed on average about 2 days. Common symptoms are weakness, fever, enlargement of the cervical lymph nodes on the side of the abscess. The classic triad of paratonsillar abscess was noted: profuse salivation, trismus of chewing muscles and open nasality (as a result of paralysis of the muscles of the palatine curtain).

Combined treatment of abscesses is prescribed: antibiotics intramuscularly, taking into account pain when swallowing and forced starvation, aspirin, analgesics, a half-alcohol compress on the side of the neck (on the side of the abscess), antihistamines.

Simultaneously, surgical treatment is carried out. There are abscesses anteroposterior (pus accumulates behind the anterior arch and soft palate near the upper pole of the tonsil), posterior (with accumulation of pus in the region of the posterior arch), external (accumulation of pus between the tonsil capsule and pharyngeal fascia). Anesthesia, as a rule, is local - lubrication of the mucous membrane with a 5% solution of cocaine or a 2% solution of dicaine. A napkin is wound around the scalpel in such a way that the tip protrudes no more than 2 mm, otherwise the main vessels of the carotid pool can be injured.

An incision is made with an anterior abscess strictly in the sagittal plane at the middle of the distance from the posterior molar to the tongue, then a blunt probe or hemostatic clamp (Holsted) is inserted into the incision and the edges of the incision are separated for better emptying of the abscess.

When the pus is removed, the patient's condition, as a rule, improves significantly. A day later, the edges of the incision are again bred with a clamp to remove the accumulated pus. In the same way, the posterior abscess is opened through the posterior arch. It is more difficult and dangerous to open an external abscess, which lies deeper and requires more caution due to the risk of injury to blood vessels. Help with this can be provided by a preliminary puncture with a syringe with a long needle, when, if pus is detected, the incision is made in the direction of the puncture. After any incision in the pharynx, furacilin is rinsed. Very rarely there is a retropharyngeal abscess - an accumulation of pus in the region of the posterior pharyngeal wall. In children, this is due to the presence of lymph nodes in the retropharyngeal space, in adults - as a continuation of the external paratonsillar abscess.

Authors: Drozdov A.A., Drozdova M.V.

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