Rinolalia. Neurological disorders of the pharynx
Diphtheria croup
Tonsil diphtheria
Parotitis.
Orchiepididymitis
Herpes zoster.
Streptococcal impetigo.
Dühring's herpeptiform dermatosis.
Pemphigus.
Herpes simplex.
19. A 10-year-old patient suffered from mumps the day before, after which pain appeared in the right half of the scrotum with irradiation to the groin area, an increase in the right half of the scrotum, scrotal hyperemia, an increase in body temperature up to 38 ° C. The testicle on the right is large, dense-elastic, sharply painful. The scrotum is hyperemic and edematous. Left testicle at the bottom of the scrotum, painless. What is the most likely diagnosis?
Testicular torsion.
Testicular tumor.
Acute dropsy of the testicle.
The twist of the Morgagni hydatids.
20. A 4-year-old child was examined by a local pediatrician. Complaints of pain when chewing, opening the mouth, headache, fever up to 38.9 ° C. In the parotid areas salivary glands the swelling is contoured, moderately painful on palpation, the skin over the swelling is not changed. On examination of the oropharynx, the opening of the Stenon's duct is hyperemic. What is the most likely diagnosis in this case?
Cervical lymphadenitis.
Sialoadenitis.
Diphtheria of the tonsils.
Infectious mononucleosis.
21. A 12-year-old patient fell ill acutely with an increase in T to 37.8 ° C, a slight sore throat, malaise. When viewed in the pharynx, cyanotic hyperemia, on the tonsils islets of white-gray plaque, which are difficult to remove with a staple with bleeding of the underlying tonsil tissue when trying to remove them. Submandibular lymph nodes are slightly painful. To diagnose:
Infectious mononucleosis
Follicular tonsillitis
Angina Simanovsky-Rauchfus
Fungal sore throat
22. A 1.5-year-old patient fell ill with an increase in T up to 37.5 ° C, a rough cough. By the end of the day, the voice hoarse, the cough intensified, acquired the character of "barking". By the 3rd day of illness, the condition worsened: there was noisy, frequent breathing with stretching of the pliable areas of the chest. The voice became aphonic, the cough was silent, the pulse was paradoxical. The skin is cold, sticky, moist, acrocyanosis is expressed. Make a clinical diagnosis.
Retropharyngeal abscess
False croup
Foreign body of the larynx
Laryngeal papillomatosis
23. A 9-year-old patient with tonsil diphtheria on the 11th day of illness developed a nasal voice, liquid food poured out of the nose, the soft palate was limited in mobility, cyanotic hyperemia in the pharynx, no plaque on the tonsils.
What is the reason for the defeat of the nasopharynx in the patient?
Retropharyngeal abscess
Paratonsillar abscess
Diphtheria croup
Adenoids
24. A 4-year-old patient was admitted to the infectious diseases department with a diagnosis of “filmy sore throat.” By the 3rd day of hospital stay, the condition improved, there was a positive dynamics of changes in the pharynx. laboratory research necessary for a definitive diagnosis?
, (Moscow)
Paresis of the soft palate, after adenotomy and tonsillectomy for the treatment of paresis.
The most common operations in otorhinolaryngology are adenotomy and tonsillectomy. According to the literature, the share of tonsillectomies among other otorhinolaryngological interventions is 20-75%, and adenotomies are 6.5-40.9%. Despite this, in the extensively studied literature, we find relatively few works comprehensively illuminating the topic we have touched upon.
Transient and persistent paresis of the cranial nerves - at the level of nuclei, fibers, nerve endings - including those innervating the soft palate, are referred to in the literature as a rare complication.
Paresis of the soft palate is clinically characterized by a violation of its important functions with the development of dysphagia, accompanied by the flow of liquid food into the nasopharynx and nasal cavity. Speech acquires a nasal nasal tone, since the sound resonates in the nasopharynx, not closed by the palatine curtain. Unilateral lesion is manifested by the hanging of the soft palate on the side of the lesion, immobility or lagging behind on this side during phonation. The uvula deviates to the healthy side. The pharyngeal and palatal reflexes decrease or drop out on the affected side. The defeat of sensitive fibers leads to anesthesia of the mucous membrane of the soft palate, pharynx.
In the genesis of paresis of the soft palate after adenotomies and tonsillectomies, a number of factors are important: impregnation with an anesthetic or direct trauma to the nerve with a needle during anesthesia; blockage or damage to the nerve with a needle during deep injections, rough manipulations; paresis that lasts for several hours is due to a nerve blockade, prolonged or persistent - mechanical damage. The possibility of such damage is associated with the anatomical proximity of the tonsils to the parapharyngeal space, in the posterior parts of which the glossopharyngeal, vagus, accessory, hypoglossal cranial nerves and the border sympathetic trunk pass, and in the retropharyngeal space - the facial one. Possible direct trauma to the nerve by the instrument or compression of the nerve by hematoma, wound discharge and edematous tissues, in the subsequent involvement of the nerves in the cicatricial process. Damage (injury) to the anatomical structures adjacent to the nasal part of the pharynx can lead to paresis of the soft palate, since muscles and their tendons involved in its movement are injured. Paresis of the soft palate can also be caused by damage to the cranial nerves that innervate the soft palate at the level of their nuclei by the type of bulbar syndrome as a result of the penetration of infection into the medulla oblongata from the nasopharynx by the hematogenous route or through the perineural spaces, or decompensation of organic pathology of the brain such as tonsillogenic vasculitis ...
We treated 9 children with paresis of the soft palate after operations on the lymphoid-pharyngeal ring (after adenotomy - 7, after tonsillectomy - 2). In the complex of treatment, means were used that ensure the improvement or restoration of metabolic processes and the regeneration of nervous tissue:
Biogenic simulators: aloe extract, FIBS, humisol, apilak
Vasodilators: a nicotinic acid, dibazol
Means that improve vascular microcirculation: trental, cavinton, stugeron
Means that improve the conductivity of nerve tissue: proserin, galantamine
Antihistamines and hyposensitizing drugs
Means that normalize the functional state nervous system - glycine, novo-passite.
These groups of drugs are used in combination with physiotherapy (endonasal electrophoresis with dalargin, galvanization with novocaine in the submandibular region, bioelectrostimulation of paralyzed muscles, neck massage).
In 6 children, it was possible to restore the function of the soft palate, the treatment of three children continues.
Description:
Paralysis of the larynx (laryngeal paresis) is a disorder of motor function in the form of a complete absence of voluntary movements due to a violation of the innervation of the corresponding muscles. Laryngeal paresis - a decrease in the strength and (or) the amplitude of voluntary movements due to a violation of the innervation of the corresponding muscles; implies a temporary, up to 12 months, impaired mobility of one or both halves of the larynx.
Causes of paresis (paralysis) of the larynx:
Laryngeal paralysis is a polyetiologic disease. It can be caused by the compressed structures innervating it or the involvement of nerves in the pathological process that develops in these organs, their traumatic injury, including during surgical interventions on the neck, chest or skull.
The main causes of peripheral laryngeal paralysis are:
medical injury during surgery on the neck and chest;
compression of the nerve trunk throughout due to a tumor or metastatic process in the neck and chest, tracheal or esophageal diverticulum, or infiltration in trauma and inflammatory processes, with an increase in the size of the heart and aortic arch (Fallot's tetrad), mitral defect, ventricular hypertrophy, dilatation pulmonary artery); inflammatory, toxic or metabolic genesis (viral, toxic (poisoning with barbiturates, organophosphates and alkaloids), hypocalcemic, hypokalemic, diabetic, thyrotoxic).
The most common cause of paralysis is pathology thyroid gland and medical trauma during operations on it. With primary intervention, the complication rate is 3%, with repeated intervention - 9%; with surgical treatment - 5.7%. 2.1% of patients are diagnosed at the preoperative stage.
Symptoms of paresis (paralysis) of the larynx:
Paralysis of the larynx is characterized by immobility of one or both halves of the larynx. Violation of innervation entails serious morphological and functional changes - the respiratory, protective and voice-forming functions of the larynx suffer.
Paralysis of central genesis is characterized by impaired mobility of the tongue and soft palate, changes in articulation.
The main complaints with unilateral paralysis of the larynx:
aspirated hoarseness of varying severity; that increases with voice load;
choking;
pain and foreign body sensation on the affected side.
With bilateral paralysis of the larynx, the clinical symptoms of its stenosis come to the fore.
The severity of clinical symptoms and morphofunctional changes in the larynx with paralysis depends on the position of the paralyzed vocal fold and the duration of the disease. Distinguish between median, paramedian, intermediate and lateral position of the vocal folds.
In the case of unilateral paralysis of the larynx, the clinical picture is most striking with the lateral position of the paralyzed vocal fold. With a median, symptoms may be absent, and the diagnosis is made by chance during a dispensary examination. Such paralysis of the larynx is 30%. Aphonia is characteristic of bilateral lesions with lateral fixation of the vocal folds. Respiratory failure develops as a hyperventilation syndrome, possibly a violation of the dividing function of the larynx, especially in the form of choking on liquid food. With bilateral paralysis with a paramedian, intermediate position of the vocal folds, respiratory dysfunction is noted up to third-degree laryngeal stenosis, requiring immediate surgical treatment... It should be remembered that in bilateral lesions, the better the patient's voice, the worse the respiratory function.
The severity of clinical symptoms also depends on the duration of the disease. In the first days, there is a violation of the dividing function of the larynx, shortness of breath, significant hoarseness, a sensation of a foreign body in the throat, sometimes. Later on, on the 4-10th day and at a later date, improvement occurs due to partial compensation for the lost functions. However, in the absence of therapy, the severity clinical manifestations may increase over time due to the development of atrophic processes in the muscles of the larynx, which worsen the closure of the vocal folds.
Treatment of paresis (paralysis) of the larynx:
Etiopathogenetic and symptomatic therapy is performed. Treatment begins with the elimination of the cause of the immobility of half of the larynx, for example, nerve decompression; detoxification and desensitizing therapy in case of damage to the nerve trunk of an inflammatory, toxic, infectious or traumatic nature.
Laryngeal paralysis treatments
Etiopathogenetic treatment
Nerve decompression
Removal of tumor, scar, removal of inflammation in the damaged area
Detoxification therapy (desensitizing, decongestant and antibiotic therapy)
Improvement of nerve conduction and prevention of neurodystrophic processes (triphosphadenine, vitamin complexes, acupuncture)
Improving synaptic conduction (neostigmine methyl sulfate)
Simulation of regeneration in the damaged area (electrophoresis and medical-therapeutic blockade of neostigmine with methyl sulfate, pyridoxine, hydrocortisone)
Stimulation of nervous and muscle activity, reflexogenic zones
Arytenoid mobilization
Surgical methods (laryngeal reinnervation, laryngotracheoplasty)
Symptomatic treatment
Electrical stimulation of the nerves and muscles of the larynx
Acupuncture
Phonopedics
Surgical methods (thyro-, laryngoplasty, implant surgery, tracheostomy)
Treatment goals
The goal of treatment is to restore the mobility of the elements of the larynx or to compensate for the lost functions (breathing, swallowing and voice).
Indications for hospitalization
In addition to those cases when surgical treatment is planned, it is advisable to hospitalize the patient in the early stages of the disease for a course of restorative and stimulating therapy.
Drug-free treatment
The use of physiotherapeutic treatment is effective - electrophoresis with neostigmine methyl sulfate on the larynx, electrostimulation of the larynx muscles.
External methods are used to directly influence the muscles of the larynx and nerve trunks, electrostimulation of reflexogenic zones with diadynamic currents, endolaryngeal electrostimulation of muscles with galvanic and faradic currents, as well as anti-inflammatory therapy.
Respiratory gymnastics and phonopelia are of great importance. The latter is used at all stages of treatment and at any time of the disease, for any etiology.
Drug treatment
Thus, with neurogenic paralysis of the vocal fold, regardless of the etiology of the disease, treatment is immediately initiated aimed at stimulating the regeneration of nerves on the affected side, as well as the cross and residual innervation of the larynx. Medicines are used that improve nervous, synaptic conduction and microcirculation, slowing down neurodystrophic processes in the muscles.
Surgery
Surgical methods for unilateral laryngeal paralysis:
reinnervation of the larynx;
thyroplasty;
implant surgery.
Surgical reinnervation of the larynx is performed by neuro-, myo-, neuromuscular plastics. A wide variety of clinical manifestations of laryngeal paralysis, the dependence of the results of intervention on the duration of denernation, the degree of internal muscles of the larynx, the presence of concomitant pathology of the arytenoid cartilage, various individual characteristics of regeneration nerve fibers, the presence of sykinesias and poorly predictable perversion of the innervation of the larynx with the formation of scars in the operation area limit the application of the technique in clinical practice.
Of the four types of thyroplasty for paralysis of the larynx, the first (medial displacement of the vocal fold) and the second (lateral displacement of the vocal fold) are used. In thyroplasty of the first type, in addition to medializing the naked fold, the arytenoid cartilage is displaced laterally and fixed with sutures using a window in the plate of the thyroid cartilage. The advantage of this method is the ability to change the position of the vocal fold not only in the horizontal but also in the vertical plane. The use of this technique is limited when fixing the arytenoid cartilage and on the side of the paralysis.
The most common method of medializing the vocal fold for unilateral laryngeal paralysis is implantation surgery. Its effectiveness depends on the properties of the implanted material and the method of its introduction. The implant must have good absorption tolerance, fine dispersion, allowing easy insertion; to have a hypoallergenic composition, did not cause a pronounced productive tissue reaction and did not have carcinogenic properties. Teflon, collagen, auto fat and other methods of injecting material into the paralyzed are used as an implant. vocal fold under anesthesia with direct microlaryngoscopy, under local anesthesia, endolaryngeal and percutaneous. G, F. Ivanchenko (1955) developed a method of endolaryngeal fragmentary Teflon-collagen plasty: Teflon paste is injected into the deep layers, which forms the basis for subsequent plastics of the outer layers.
Among the complications of implant surgery are:
sharp.
the formation of granulomas.
migration of Teflon paste into the soft tissues of the neck and the thyroid gland.
Further management
Treatment of paralysis of the larynx is staged, consistent. In addition to medication, physiotherapy and surgical treatment, patients are shown long-term sessions with a phonopedist, the purpose of which is to form correct phonation breathing and voice leading, to correct the violation of the laryngeal dividing function. Patients with bilateral paralysis should be observed with an examination frequency of 1 time in 3 or 6 months, depending on the clinic of respiratory failure.
Patients with paralysis of the larynx are shown a consultation with a phoniatrist to determine the possibilities of rehabilitation of the lost functions of the larynx, restoration of voice and breathing as early as possible.
The period of incapacity for work is 21 days. With bilateral paralysis of the larynx, the ability to work of patients is sharply limited. With one-sided (in the case of a voice profession), it is possible to limit the ability to work. However, if the voice function is restored, these restrictions may be removed.
At the heart of the adequate functioning of the pharynx are the most complex mutually consistent nervous processes, the slightest violation of which leads to disorganization of food and airway functions at this level. Located at the "crossroads" of the respiratory and alimentary tract, richly supplied with blood and lymphatic vessels, innervated by V, IX, X and XI cranial nerves and sympathetic fibers, replete with mucous glands and lymphadenoid tissue, the pharynx is one of the most sensitive organ to various pathogenic factors. Among the numerous diseases to which the pharynx is susceptible, its neurological disorders are not uncommon, arising both with inflammatory and traumatic lesions of its peripheral nerves, and with numerous diseases of the stem and overlying centers, which provide integral regulation of physiological (reflex and voluntary) and trophic functions of the pharynx.
Neurogenic disorders of the pharynx cannot be considered in isolation from similar disorders of the esophagus and larynx, since these anatomical formations represent a single functional system that receives nervous regulation from common centers and nerves.
Classification of neurogenic pharyngeal dysfunctions
Dysphagia, aphagia syndrome:
- neurogenic dysphagia;
- painful dysphagia;
- mechanical dysphagia (this form is included in the classification in order to reflect all types of dysfunction of swallowing).
Sensitive Disorder Syndrome:
- paresthesia of the pharynx;
- hyperesthesia of the pharynx;
- glossopharyngeal neuralgia.
Syndromes of involuntary motor reactions of the pharynx:
- tonic spasm of the pharynx;
- clonic spasm of the pharynx;
- pharyngeal myoclonus.
These concepts designate symptom complexes, which are based on disorders of the swallowing and alimentary functions of the pharynx and esophagus. According to F. Magendi's concept, the act of swallowing is divided into 3 phases - oral voluntary, pharyngeal involuntary fast and esophageal involuntary slow. Swallowing and alimentary processes normally cannot be arbitrarily interrupted in the second and third phases, however, they can be disturbed in any of these phases by various pathological processes - inflammatory, traumatic (including foreign bodies of the pharynx), tumor, neurogenic, including lesions of pyramidal, extrapyramidal and bulbar structures. Difficulty swallowing (dysphagia) or its complete impossibility (aphagia) can occur in most diseases of the oral cavity, pharynx and esophagus, in some cases, and in diseases of the larynx.
Paralysis of the soft palate can be unilateral and bilateral. With unilateral paralysis, functional disturbances are insignificant, but visible disturbances are clearly revealed, especially during the pronunciation of the sound "A", in which only the healthy half of the soft palate contracts. In a calm state, the uvula is rejected in the healthy direction by the thrust of the muscles that have retained their function (m. Azygos); this phenomenon sharply increases during phonation. With central lesions, unilateral paralysis of the soft palate is rarely isolated, in most cases it is accompanied by alternating paralysis, in particular, the laryngeal hemiplegia of the same name and rarely paralysis of other cranial nerves.
Often, unilateral paralysis of the soft palate occurs with central lesions, manifested in initial stage hemorrhagic stroke or softening of the brain. However, the most common cause of soft palate hemiplegia is the lesion of the glossopharyngeal nerve with herpes zoster, which is second only to herpes zoster n. facialis and is often associated with it. In this viral disease, one-sided paralysis of the soft palate occurs after herpetic eruptions on the soft palate and lasts for about 5 days, then disappears without a trace.
Bilateral paralysis of the soft palate is manifested by open nasal, nasal reflux of liquid food, especially when upright position body, inability to suck, which is especially detrimental to the nutrition of infants. With mesopharyngoscopy, the soft palate appears to be sluggishly hanging to the root of the tongue, floating during respiratory movements, remaining motionless when pronouncing the sounds "A" and "E". When the head is tilted backward, the soft palate passively, under the influence of gravity, deviates towards the posterior pharyngeal wall, when the head is tilted forward, towards the oral cavity. All types of sensitivity for paralysis of the soft palate are absent.
The cause of bilateral paralysis of the soft palate in most cases is diphtheria toxin, which has a high neurotrophicity (diphtheria polyneuritis); less often, these paralysis occur with botulism, rabies and tetany due to impaired calcium metabolism. Diphtheria paralysis of the soft palate usually occurs with insufficient treatment of this disease or with unrecognized pharyngeal diphtheria. As a rule, these paralysis appear from the 8th day to 1 month after the disease. Dysphagia syndrome sharply increases with damage to the nerve fibers innervating the lower constrictor of the pharynx. Often, after pharyngeal diphtheria, combined paralysis of the soft palate and the ciliary muscle of the eye is observed, which makes it possible to establish a retrospective diagnosis of diphtheria, mistaken for pharyngitis vulgaris or sore throat. Treatment of diphtheria paralysis of the soft palate is carried out with anti-diphtheria serum for 10-15 days, strychnine preparations, B vitamins, etc.
Central paralysis of the soft palate caused by damage to the brain stem is combined with alternating paralysis (bulbar paralysis). The causes of these lesions may be syphilis, cerebral apoplexy, syringobulbia, brain stem tumors, etc. Paralysis of the soft palate is also observed in pseudobulbar paralysis caused by damage to the supranuclear pathways.
Paralysis of the soft palate can occur during a hysterical seizure, which usually manifests itself in other symptoms of hysterical neurosis. Usually, with such paralysis, the voice becomes nasal, but there is no nasal reflux of the swallowed fluid. The manifestations of hysterical neurosis are extremely varied and outwardly can simulate various diseases, but most often they mimic neurological and mental illness... Neurological symptoms include paralysis, rifling, and disorders of various severity and prevalence. pain sensitivity and coordination of movements, hyperkinesis, tremors of the limbs and contractions of facial muscles, various speech disorders, spasms of the pharynx and esophagus. The peculiarity of neurological disorders in hysterical neurosis is that they are not accompanied by other disorders common for neurological disorders of organic origin. So, with hysterical paralysis or spasms of the pharynx or larynx, there are no changes in reflexes, trophic disorders, dysfunctions pelvic organs, spontaneous motor vestibular reactions (spontaneous nystagmus, miss symptom, etc.). Sensory disorders in hysteria do not correspond to the zones of anatomical innervation, but are limited to the zones of "stockings", "gloves", "socks".
Paresis and paralysis in hysteria cover muscle groups involved in the performance of some arbitrary purposeful motor act, for example, chewing, swallowing, sucking, closing the eyes, movements of the internal muscles of the larynx. So, hysterical glossoplegia, which arises under the influence of negative emotions in persons suffering from neurasthenia, leads to a violation of the active movements of the tongue, its participation in the acts of chewing and swallowing. In this case, an arbitrary slow movement of the tongue is possible, but the patient cannot stick his tongue out of the mouth. The resulting decrease in the sensitivity of the mucous membrane of the tongue, pharynx, and the entrance to the larynx aggravates dysphagia, often leading to aphagia.
Diagnosis of functional dysphagia of hysteroid genesis does not cause difficulties due to the remitting (repetitive) nature and rapid disappearance after taking sedatives and tranquilizers. With true dysphagia of organic genesis, the diagnosis is based on signs of a causal (underlying) disease. Such diseases can include banal inflammatory processes with vivid symptoms, specific processes, neoplasms, damage, developmental anomalies.
Pharyngeal paralysis is characterized by impaired swallowing, especially of dense food. They do not arise in isolation, but are combined with paralysis of the soft palate and esophagus, and in some cases with paralysis of the laryngeal muscles that widen the glottis. In these cases, the gastric tube is always adjacent to the tracheotomy tube for feeding. The causes of such paralysis are most often diphtheria neuritis of the glossopharyngeal and other nerves involved in the innervation of the pharynx, larynx and esophagus, as well as severe forms of typhus, encephalitis of various etiologies, bulbar poliomyelitis, tetany, barbiturate poisoning and drugs... Functional disorders are explained by the paralysis of the constrictors of the pharynx and the muscles that lift it and the larynx during the act of swallowing, which is determined by palpation of the larynx and during mesopharyngoscopy (examination of the pharynx during the pharynx can be carried out provided that the subject before the pharynx squeezes a plug or other object between the molars, size which allows endoscopy). This technique is necessary due to the fact that a person cannot take a sip if his jaw is not clenched.
Pharyngeal paralysis can be unilateral in case of unilateral damage to the glossopharyngeal nerve and motor fibers vagus nerve... This type of pharyngeal hemiplegia is usually associated with unilateral paralysis of the soft palate, but does not involve the larynx. This picture can be observed either with insufficient cerebral circulation, or after a viral infection. With herpes zoster, unilateral pharyngeal paralysis is usually associated with the same paralysis of the soft palate and facial muscles of the same etiology. Hypoesthesia of the pharyngeal mucosa is also noted on the affected side. Glossopharyngeal nerve palsy is manifested by the accumulation of saliva in the piriform sinuses.
X-ray examination with contrasting reveals asynchronous movements of the epiglottis and pharyngeal compressors during swallowing and accumulation of contrast agent in the fossa of the epiglottis and especially in the piriform sinus on the affected side.
The occurrence of bulbar laryngopharyngeal paralysis is explained by the commonality of their innervation apparatus, the proximity of the nuclei of the glossopharyngeal nerve and the vagus nerve and the efferent fibers of these nuclei. These disorders will be described in more detail in the section on neurogenic functional disorders of the larynx.
Painful dysphagia occurs during inflammatory processes in the oral cavity, pharynx, esophagus, larynx and in the tissues surrounding these organs, with foreign bodies of the pharynx and esophagus, injuries of these organs, inflammatory complications, disintegrating infectious granulomas (except for syphilis), tumors, etc. The most painful tuberculous ulcers, disintegrating malignant tumors are less painful and syphilitic lesions of the walls of the alimentary tract are least painful. Painful dysphagia in inflammatory processes in the oral cavity, paramandibular space is often accompanied by contracture of the temporomandibular joint or reflex trismus. Somewhat less often, painful dysphagia has a neurogenic nature, for example, with neuralgia of the trigeminal, glossopharyngeal and superior laryngeal nerves, as well as with various hysterical neuroses manifested by prosopalgia, paralysis, paresis and hyperkinesis in the chewing and swallowing-alimentary complex.