Acute inflammatory diseases of the larynx and trachea often occur as a manifestation of acute inflammatory diseases of the upper respiratory tract... The reason may be the most diverse flora - bacterial, fungal, viral, mixed.

4.4.1. Acute catarrhal laryngitis

Acute catarrhal laryngitis (laryngitis) - acute inflammationlaryngeal mucosa.

As an independent disease, acute catarrhal laryngitis occurs as a result of the activation of the saprophytic flora in the larynx under the influence exogenous and endogenous factors. Among exogenous factors such as hypothermia, irritation of the mucous membrane with nicotine and alcohol, exposure to occupational hazards (dust, gases, etc.), prolonged loud conversation in the cold, the use of very cold or very hot food play a role. Endogenous factors - decreased immune reactivity, diseases of the gastrointestinal tract, allergic reactions, age-related atrophy of the mucous membrane. Acute catarrhal laryngitis often occurs during puberty when the voice mutates.

Etiology. Among the various etiological factors in the emergence of acute laryngitis, the bacterial flora plays a role - p-hemolytic streptococcus, pneumococcus, viral infections; influenza A and B viruses, parainfluenza, coronavirus, rhinovirus, mushrooms. Mixed flora is common.

Pathomorphology. Pathological changes are reduced to circulatory disorders, hyperemia, small cell infiltration and serous saturation of the laryngeal mucosa. When inflammation spreads to the vestibule of the larynx, the vocal folds can be covered by edematous, infiltrated vestibular folds. When the subglottic region is involved in the process, a clinical picture of a false croup (subglottic laryngitis) arises.

Clinic. It is characterized by the appearance of hoarseness, perspiration, discomfort and a foreign body in the throat. Body temperature is more often normal, less often it rises to subfebrile numbers. Violations of the voice-forming function are expressed in the form of varying degrees of dysphonia. Sometimes the patient is worried about a dry cough, which is further accompanied by expectoration of sputum.

Diagnostics. It does not present any particular difficulties, since it is based on pathognomonic signs: acute appearance of hoarseness, often associated with a specific reason (cold food, SARS, colds, speech load, etc.); a characteristic laryngoscopic picture - more or less pronounced hyperemia of the mucous membrane of the entire larynx or only vocal folds, thickening, swelling and incomplete closure of the vocal folds; no temperature reaction if there is no respiratory infection. Acute laryngitis should also include those cases when there is only marginal hyperemia of the vocal folds, since this limited

the process, as well as spilled, tends to turn into a chronic

In childhood, laryngitis must be differentiated from the common form of diphtheria. Pathological changes in this case will be characterized by the development of fibrinous inflammation with the formation of dirty gray films intimately associated with the underlying tissues.

Erysipelas of the mucous membrane of the larynx differs from the catarrhal process by a clear delineation of the boundaries and simultaneous damage to the skin of the face.

Treatment. With timely and adequate treatment, the disease ends within 10-14 days, its continuation for more than 3 weeks most often indicates a transition to a chronic form. The most important and necessary therapeutic measure is the observance of the voice mode (silence mode) until acute inflammation subsides. Failure to comply with the sparing voice regime will not only delay recovery, but will also contribute to the transition of the process into a chronic form. Reception of spicy, salty food, alcoholic beverages, smoking, alcohol is not recommended. Drug therapy is mainly local in nature. Effective are alkaline-oil inhalations, irrigation of the mucous membrane with combined preparations containing anti-inflammatory components (Bioparox, IRS-19, etc.), infusion of medicinal mixtures of corticosteroid, antihistamines and antibiotics into the larynx for 7-10 days. Effective mixtures for infusion into the larynx, consisting of 1% menthol oil, hydrocortisone emulsion with the addition of a few drops of 0.1% solution of epinephrine hydrochloride. In the room where the patient is, it is desirable to maintain high humidity.

For streptococcal and pneumococcal infections, accompanied by an increase in body temperature, intoxication, general antibiotic therapy is prescribed - drugs of the penicillin series (phenoxymethylpenicillin 0.5 g 4-6 times a day, ampicillin 500 mg 4 times a day) or macro-leads ( for example, erythromycin 500 mg 4 times a day).

The prognosis is favorable with appropriate treatment and adherence to the vocal regime.

4.4.2. Infiltrative laryngitis

Infiltrative laryngitis (laryngitis inflltrativa) - acute inflammation of the larynx, in which the process is not limited tozyme, but spreads to deep-lying tissues. The process may involve the muscular apparatus, ligaments, nad-x Rashnitsa.

Etiology. The etiological factor is a bacterial infection that penetrates the tissue of the larynx during trauma or after an infectious disease. A decrease in local and general resistance is a predisposing factor in the etiology of infiltrative laryngitis. The inflammatory process can proceed in the form of a limited or diffuse form.

Clinic. Depends on the extent and extent of the process. When the form is poured, the entire mucous membrane of the larynx is involved in the inflammatory process, with limited areas of the larynx - the intercranial space, vestibule, epiglottis, sub-voice cavity. The patient complains of pain, aggravated by swallowing, severe dysphonia, high body temperature, and feeling unwell. Cough with expectoration of thick mucopurulent sputum is possible. Against the background of these symptoms, there is a violation of respiratory function. Regional lymph nodes are dense and painful on palpation.

With irrational therapy or highly virulent infection, acute infiltrative laryngitis can turn into a purulent form - phlegmonous laryngitis { laryngitis phlegmonosa). At the same time, pain symptoms increase sharply, body temperature rises, worsens general state, difficulty breathing, up to asphyxia. With indirect laryngoscopy, an infiltrate is found, where a limited abscess can be seen through the thinned mucous membrane, which is confirmation of the formation of an abscess. Laryngeal abscess can be the final stage of infiltrative laryngitis and occurs mainly on the lingual surface of the epiglottis or in the area of ​​one of the arytenoid cartilages.

Treatment. As a rule, it is carried out in a hospital setting. Prescribe antibiotic therapy at the maximum dosage for a given age, antihistamines, mucolytics, and, if necessary, short-term corticosteroid therapy. Emergency surgery is indicated in cases where an abscess is diagnosed. After local anesthesia with a guttural knife, an abscess (or infiltrate) is opened. At the same time, massive antibiotic therapy, antihistamine therapy, corticosteroid drugs, detoxification and transfusion therapy are prescribed. It is also necessary to prescribe analgesics.

Usually, the process is quickly stopped. During the entire disease, you need to carefully monitor the state of the lumen of the larynx and not wait for the moment of asphyxia.

In the presence of a spilled phlegmon with spread to the soft tissues of the neck, external incisions are made, always with wide drainage of purulent cavities.

It is important to constantly monitor your breathing function; whensigns of acute growing stenosis require urgentnaya tracheostomy.

4.4.3. Sublining laryngitis (false croup)

Sublining laryngitis -laryngitis subglottica(subchordal laryngitis- laryngitis subchordalis, false croup -false croup) - acute laryngitis with a predominant localization of the process insub-voice cavity. It is observed in children usually under the age of 5-8 years, which is associated with the structural features of the podvocal cavity: loose tissue under the vocal folds in young children is highly developed and easily reacts to irritation with edema. The development of stenosis is also facilitated by the narrowness of the larynx in children, the lability of the nervous and vascular reflexes. When the child is in a horizontal position, due to blood flow, the edema increases, so the deterioration is more pronounced at night.

Clinic. The disease usually begins with inflammation of the upper respiratory tract, nasal congestion and discharge, low-grade fever, and cough. The general condition of the child during the day is quite satisfactory. At night, an attack of suffocation suddenly begins, a barking cough, cyanosis of the skin. Dyspnea is predominantly inspiratory, accompanied by retraction of the soft tissues of the jugular fossa, supra- and subclavian spaces, and the epigastric region. A similar state lasts from several minutes to half an hour, after which profuse sweating appears, breathing is normalized, the child falls asleep. Such conditions can be repeated after 2-3 days.

Laryngoscopic picture subglottic laryngitis is presented in the form of a roller-like symmetric swelling, hyperemia of the mucous membrane of the subglossal space. These ridges protrude from under the vocal folds, significantly narrowing the lumen of the larynx and thus making breathing difficult.

Diagnostics. It is necessary to differentiate from true diphtheria croup. The term "false croup" indicates that the disease is contrasted with true croup, i.e. diphtheria of the larynx, which has similar symptoms. However, with lining laryngitis, the disease is paroxysmal in nature - a satisfactory condition during the day changes with difficulty breathing and an increase in body temperature at night. The voice with diphtheria is hoarse, with subglottic laryngitis it is not changed. In diphtheria, there is no barking cough, which is characteristic of false croup. With lining laryngitis, there is no significant increase

of regional lymph nodes, in the pharynx and larynx there are no films characteristic of diphtheria. Nevertheless, it is always necessary to conduct bacteriological examination of swabs from the pharynx, larynx and nose for diphtheria bacillus.

Treatment. It is aimed at eliminating the inflammatory process and restoring breathing. Inhalation of a mixture of decongestants is effective - 5% ephedrine solution, 0.1% adrenaline solution, 0.1% atropine solution, 1% diphenhydramine solution, hydrocortisone 25 mg and chymopsin. Antibiotic therapy is required, which is prescribed at the maximum dose for a given age, antihistamine therapy, sedatives. Also shown is the appointment of hydrocortisone at the rate of 2-4 mg / kg of the child's body weight. Drinking plenty of water is beneficial - tea, milk, mineral alkaline waters; distracting procedures - foot baths, mustard plasters.

You can try to stop a choking attack by quickly touching the back of the pharynx with a spatula, thereby causing a gag reflex.

In the case when the above measures are powerless, andsuffocation becomes threatening, it is necessary to resort tonasotracheal intubation for 2-4 days, and if necessarya tracheostomy is shown.

4.4.4. Laryngeal sore throat

Laryngeal sore throat (angina laryngea), or submucous laringit (laryngitis submucosa) is an acute infectious disease withdamage to the lymphadenoid tissue of the larynx, located in the ventricles of the larynx, in the thickness of the mucous membranetangential folds, at the bottom of the pear-shaped pocket, as well as in the lingual surface of the epiglottis. It is relatively rare and can pass under the guise of acute laryngitis.

Etiology. The etiological factors causing the inflammatory process are diverse bacterial, fungal and viral flora. The penetration of the pathogen into the mucous membrane can occur by airborne droplets or alimentary. Hypothermia and trauma to the larynx also play a role in the etiology.

Clinic. In many ways it is similar to the manifestations of tonsillitis of the palatine tonsils. Sore throat worries, aggravated by swallowing and turning the neck. Dysphonia, difficulty in breathing are possible. Body temperature with laryngeal angina is high, up to 39 ° C, the pulse is quickened. On palpation, regional lymph nodes are painful and enlarged.

With laryngoscopy, hyperemia and infiltration of the laryngeal mucosa are determined, sometimes narrowing the lumen

rice. 4.10. Epiglottis abscess.

respiratory tract, individual follicles with punctate purulent deposits. With a protracted course, an abscess may form on the lingual surface of the epiglottis, scooplary laryngeal fold and other places of accumulation of lymphadenoid tissue (Fig. 4.10).

Diagnostics. Indirect laryngoscopy with appropriate anamnestic and clinical data allows the correct diagnosis to be established. Laryngeal angina should be differentiated from diphtheria, which may have a similar course.

Treatment. Includes antibiotics wide range actions (augmentin, amoxiclav, cefazolin, kefzol, etc.), antihistamine agents (tavegil, fenkarol, peritol, claritin, etc.), mucolytics, analgesics, antipyretics. If there are signs of respiratory failure, short-term corticosteroid therapy is added to the treatment for 2-3 days. With significant stenosis, an emergency tracheotomy is indicated.

4.4.5. Laryngeal edema

Laryngeal edema (oedema laryngea) - rapidly developing vazomotor-allergic process in the mucous membrane of the larynx,narrowing its lumen.

Etiology. The causes of acute laryngeal edema can be:

1) inflammatory processes of the larynx (subglottic laryngitis, acute laryngotracheobronchitis, chondroperichondritis and

acute infectious diseases (diphtheria, measles, scarlet fever, flu, etc.);

laryngeal tumors (benign, malignant);

laryngeal injury (mechanical, chemical);

allergic diseases;

pathological processes of organs adjacent to the larynx and trachea (tumors of the mediastinum, esophagus, thyroid gland, pharyngeal abscess, phlegmon of the neck, etc.).

Clinic. Narrowing of the lumen of the larynx and trachea can develop with lightning speed (foreign body, spasm), acutely (infectious

diseases, allergic processes, etc.) and chronically (against the background of a tumor). The clinical picture depends on the degree * of narrowing of the lumen of the larynx and the speed of its development. What would be- | the faster the stenosis develops, the more dangerous it is. With inflammatory! etiology of edema worries sore throat, aggravated by! swallowing, foreign body sensation, voice change. Ras- | the spread of edema on the arytenoid mucosa! cartilage, scooplary laryngeal folds and subglottic band- [causes acute stenosis of the larynx, causing severe! a picture of suffocation threatening the patient's life (see section! 4.6.1).

Laryngoscopic examination determines the swelling of the mucous membrane of the affected larynx in the form of! watery or gelatinous swelling. Epiglottis with! this is sharply thickened, there may be elements of hyperemia, the process! extends to the region of the arytenoid cartilage. Voice- | vaya gap with edema of the mucous membrane is sharply narrowed, in! subglottic cavity edema looks like a bilateral pillow - | co-shaped protrusion.

It is characteristic that with an inflammatory etiology of edema on - | reactive phenomena of varying severity, hyperemia and injection of vessels of the mucous membrane are observed! loci, with non-inflammatory - hyperemia is usually absent - | blows.

Diagnostics. Usually not difficult. Difficulty breathing in varying degrees, the characteristic laryngoscopic picture allows you to correctly identify the disease.] It is more difficult to find out the cause of the edema. In some cases, hyperemic, edematous mucous membrane closes the tumor, foreign body, etc. in the larynx. Along with indirect laryngoscopy, bronchoscopy, "" radiography of the larynx chest and other studies.

Treatment. It is carried out in a hospital setting and is aimed primarily at restoring external respiration. Depending on the severity of clinical manifestations, conservative and surgical methods of treatment are used.

Conservative methods are indicated for compensated and subcompensated stages of airway narrowing and include prescriptions: 1) parenteral broad-spectrum antibiotics (cephalosporins, semi-synthetic penicillins, macrolides, etc.); 2) antihistamines (2 ml of pipolfen intramuscularly; tavegil, etc.); 3) corticosteroid therapy (prednisone - up to 120 mg intramuscularly). Recommended intramuscular injection of 10 ml of 10% solution of calcium gluconate, intravenous - 20 ml of 40% glucose solution simultaneously with 5 ml of ascorbic acid.

If the edema is severe and there is no positive

dynamics, the dose of administered corticosteroid drugs can be increased. A faster effect is provided by intravenous administration of 200 ml of isotonic sodium chloride solution with the addition of 90 mg of prednisolone, 2 ml of pipolfen, 10 ml of 10% calcium chloride solution, 2 ml of lasix.

The lack of effect from conservative treatment, the appearance of decompensated stenosis requires immediate tracheo-stomata. In case of asphyxiation, an emergency conicotomy is performed,

and then, after the restoration of external respiration,- tracheo-stomy.

4.4.6. Acute tracheitis

Acute tracheitis (tracheitis acuta) - acute inflammation of the mucous membrane of the lower respiratory tract (trachea and bronchi). In isolation, it is rare, in most cases, acute tracheitis is combined with inflammatory changes in the upper respiratory tract - the nose, pharynx and larynx.

Etiology. The cause of acute tracheitis is infections, the causative agents of which are saprophytic in the respiratory tract and are activated under the influence of various exogenous factors; viral infections, exposure to adverse climatic conditions, hypothermia, occupational hazards, etc.

Most often, when examining the discharge of the trachea, the bacterial flora is found - Staphylococcus aureus, H. in- fluenzae, Streptococcus pneumoniae, Moraxella catarrhalis and etc.

Pathomorphology. Morphological changes in the trachea are characterized by hyperemia of the mucous membrane, edema, focal or diffuse infiltration of the mucous membrane, blood filling and expansion of the blood vessels of the mucous membrane.

Clinic. A typical clinical sign of tracheitis is a paroxysmal cough, especially at night. At the beginning of the disease, the cough is dry, then sputum of a mucopurulent nature, sometimes streaked with blood, joins. After a coughing fit, different severity of pain in the chest and larynx is noted. The voice sometimes loses its sonority and becomes hoarse. In some cases, sub-febrile body temperature, weakness, and malaise are observed.

Diagnostics. The diagnosis is established on the basis of the results of laryngotracheoscopy, anamnesis, patient complaints, mic-

robiological examination of sputum, radiography of the lung.

Treatment. The patient needs to provide warm, moist air in the room. Expectorants (licorice root, mukaltin, glycyram, etc.) and antitussives (libek-sin, tusuprex, sinupret, broncholitin, etc.) drugs, mucolytic drugs (acetylcysteine, fluimucil, bromhex-sin), antihistamines (suprastin pipolfen, claritin, etc.), paracetamol. Simultaneous administration of expectorants and antitussives should be avoided. The use of mustard plasters on the chest, foot baths has a good effect.

With an increase in body temperature in order to prevent a descending infection, antibiotic therapy is recommended (oxacillin, augmentin, amoxiclav, cefazolin, etc.).

Forecast. With rational and timely therapy, the prognosis is favorable. Recovery occurs within 2-3 weeks, but sometimes a protracted course is observed and the disease can become chronic. Sometimes tracheitis is complicated by a descending infection - bronchopneumonia, pneumonia.

4.5. Chronic inflammatory diseases larynx

Chronic inflammatory disease of the mucous membrane and submucosa of the larynx and trachea occurs under the influence of the same reasons as acute: the impact of unfavorable domestic, occupational, climatic, constitutional and anatomical factors. Sometimes an inflammatory disease from the very beginning acquires a chronic course, for example, in diseases of the cardiovascular and pulmonary systems.

There are the following forms of chronic inflammation of the larynx: catarrhal, atrophic, hyperplastic; diffuseny or limited, subglottic laryngitis and pachydermalarynx.

4.5.1. Chronic catarrhal laryngitis

Chronic catarrhal laryngitis (laryngitis chronica catar- rhalis) - chronic inflammation of the larynx mucosa. This is the most frequent and most light form chronic inflammation. The main etiological role in this pathology is played by a prolonged load on the vocal apparatus (singers, lecturers, teachers, etc.). Impact is also important

unfavorable exogenous factors - climatic, occupational, etc.

Clinic. The most common signs are hoarseness, disorder of the voice-forming function of the larynx, fatigue, and a change in the timbre of the voice. Depending on the severity of the disease, the feeling of perspiration, dryness, sensation of a foreign body in the larynx, and cough are also disturbed. There is a smoker's cough, which occurs against the background of prolonged smoking and is characterized by a constant, rare, mild cough.

At laryngoscopy moderate hyperemia, edema of the mucous membrane of the larynx, more pronounced in the area of ​​the vocal folds, against this background, pronounced injection of the vessels of the mucous membrane are determined.

Diagnostics. It is not difficult and is based on the characteristic clinical picture, history and data of indirect laryngoscopy.

Treatment. It is necessary to eliminate the effect of the etiological factor, it is recommended to observe a gentle voice mode (exclude loud and prolonged speech). Treatment is mostly local. During the period of exacerbation, it is effective to infuse a solution of antibiotics with a suspension of hydrocortisone into the larynx: 4 ml of isotonic sodium chloride solution with the addition of 150,000 U of penicillin, 250,000 U of streptomycin, 30 mg of hydrocortisone. This composition is poured into the larynx 1 - 1.5 ml 2 times a day. The same composition can be used for inhalation. The course of treatment is carried out within 10 days.

With local use of drugs, antibiotics can be changed after planting for flora and detecting antibiotic sensitivity. Hydrocortisone can also be excluded from the composition, and chymopsin or flu-imupil, which has a secretolytic and mucolytic effect, can be added.

The appointment of aerosols for irrigation of the laryngeal mucosa with combined preparations, which include an antibiotic, an analgesic, an antiseptic (Bioparox, IRS-19), has a beneficial effect. The use of oil and alkaline-oil inhalations must be limited, since these drugs have a negative effect on the ciliated epithelium, inhibiting and completely stopping its function.

A large role in the treatment of chronic catarrhal laryngitis belongs to climatotherapy in a dry sea coast.

The prognosis is relatively favorable with proper therapy, which is repeated periodically. Otherwise, a transition to a hyperplastic or atrophic form is possible.

4.5.2. Chronic hyperplastic laryngitis

Chronic hyperplastic (hypertrophic) laryngitis

(laryngitis chronica hyperplastica) is characterized by limitedor diffuse hyperplasia of the laryngeal mucosa. There are the following types of hyperplasia of the laryngeal mucosa:

singer's nodules (singing nodules);

pachydermia of the larynx;

chronic lining laryngitis;

prolapse, or prolapse, of the ventricle of the larynx.

Clinic. The main complaint of the patient is varying degrees of persistent hoarseness, voice fatigue, sometimes aphonia. With exacerbations, the patient is worried about perspiration, a feeling of a foreign body when swallowing, a rare cough with mucous discharge.

Diagnostics. Indirect laryngoscopy and stroboscopy can detect limited or diffuse hyperplasia of the mucous membrane, the presence of thick mucus both in the intercranial and in other parts of the larynx.

In the diffuse form of the hyperplastic process, the mucous membrane is thickened, pasty, hyperemic; the edges of the vocal folds are thickened and deformed throughout, which prevents them from closing completely.

With a limited form (singing nodules), the mucous membrane of the larynx is pink without any significant changes; on the border between the anterior and middle thirds of the vocal folds, there are symmetrical formations in the form of connective tissue outgrowths (nodules) on a wide base with a diameter of 1-2 mm. These nodules prevent the glottis from closing completely, resulting in a hoarse voice (Figure 4.11).

With pachydermia of the larynx, the mucous membrane is thickened in the inter-scalp space, on its surface there are limited epidermal outgrowths that outwardly resemble a small tuberosity, granulations are localized in the posterior third of the vocal folds and the inter-head space. In the lumen of the larynx there is a scanty viscous discharge, crusts may form in places.

Prolapse (prolapse) of the ventricle of the larynx occurs as a result of prolonged overstrain of the voice and inflammation of the mucous membrane of the ventricle. With forced exhalation, phonation, coughing, the hypertrophied mucous membrane protrudes from the ventricle of the larynx and partially covers the vocal folds, preventing the glottis from closing completely, causing a hoarse voice.

Chronic lining laryngitis with indirect

Rice. 4.11. Limited form of hyperplastic laryngitis (singing nodules).

my laryngoscopy resembles a picture of a false croup. In this case, there is a hypertrophy of the mucous membrane of the sub-vocal cavity, narrowing the glottis. Anamnesis and endoscopic microlaryngoscopy can help clarify the diagnosis.

Differential diagnosis. Limited forms of hyperplastic laryngitis must be differentiated from specific infectious granulomas, as well as from neoplasms. Appropriate serologic tests and biopsy followed by histological examination help in the diagnosis. Clinical experience shows that specific infiltrates do not have symmetrical localization, as in hyperplastic processes.

Treatment. It is necessary to eliminate the impact of harmful exogenous factors and the mandatory observance of a gentle voice mode. During periods of exacerbation, treatment is carried out as in acute catarrhal laryngitis.

With hyperplasia of the mucous membrane, the affected areas of the larynx are extinguished every other day with 5-10% silver nitrate solution for 2 weeks. Significant limited hyperplasia of the mucous membrane is an indication for its endolaryngeal removal with subsequent histological examination of the biopsy specimen. The operation is performed using local application anesthesia with 10% lidocaine solution, 2% cocaine solution, 2% solution di- cain. Currently, such interventions produce with using endoscopic endolaryngeal methods.

4.5.3. Chronic atrophic laryngitis

Chronic atrophic laryngitis (laryngitis chronica atro­ phied) characterized by dystrophy of the mucous membrane of the larynx with its paleness, thinning, the formation of a viscous secretion and dry crusts.

Isolated disease is rare. The cause of the development of atrophic laryngitis is most often atrophic rhinopharyngitis. Environmental conditions, occupational hazards, diseases of the gastrointestinal

tract, the absence of normal nasal breathing also contribute to the development of atrophy of the laryngeal mucosa.

Clinic and diagnostics. The leading complaint in atrophic laryngitis is a feeling of dryness, perspiration, a foreign body in the larynx, and varying degrees of severity of dysphonia. When coughing up, there may be streaks of blood in the sputum due to a violation of the integrity of the epithelium of the mucous membrane at the time of the cough shock.

With laryngoscopy, the mucous membrane is thinned, smooth, shiny, in places covered with viscous mucus and crusts. The vocal folds are somewhat thinned. During phonation, they do not close completely, leaving an oval-shaped gap, in the lumen of which there may also be crusts.

Treatment. Rational therapy involves eliminating the cause of the disease. It is necessary to exclude smoking, the use of irritating food, a gentle voice mode should be observed. Of the drugs, agents are prescribed that contribute to the liquefaction of sputum, its easy expectoration: irrigation of the pharynx and inhalation of isotonic sodium chloride solution (200 ml) with the addition of 5 drops of 5% alcohol solution of iodine. The procedures are carried out 2 times a day, using 30-50 ml of solution per session, for long courses for 5-6 weeks. Inhalation of 1-2% menthol oil is periodically prescribed. This solution can be infused into the larynx daily for 10 days. To enhance the activity of the glandular apparatus of the mucous membrane, a 30% solution of potassium iodide is prescribed, 8 drops 3 times a day by mouth for 2 weeks (before the appointment, it is necessary to find out the tolerance of iodine).

With an atrophic process simultaneously in the larynx and nasopharynx, submucous infiltration into the lateral parts of the posterior wall of the pharynx with a solution of novocaine and aloe (1 ml of 1% solution of novocaine with the addition of 1 ml of aloe) gives a good effect. The composition is injected under the mucous membrane of the pharynx, 2 ml in each side at the same time. The injections are repeated at intervals of 5-7 days, a total of 7-8 procedures.

4.6. Acute and chronic stenosis of the larynx and trachea

Laryngeal stenosis andtrachea is expressed in the narrowing of their lumen,which prevents the passage of air into the underlyingrespiratory tract, leading to severe external disordersbreathing up to asphyxia.

The general phenomena in stenosis of the larynx and trachea are practically the same, the therapeutic measures are also similar. Therefore, it is advisable to consider laryngeal and tracheal stenoses together. Acute or chronic laryngeal stenosis - not

a separate nosological unit, but a symptom complex of any disease of the upper respiratory tract and adjacent areas. This complex of symptoms is rapidly developing, accompanied by severe violations of the vital functions of the respiratory and cardiovascular systems, requiring emergency assistance. Delay in its provision can lead to the death of the patient.

4.6.1. Acute laryngeal stenosis and tracheitis

Acute stenosis of the larynx is more common than stenosis of the trachea. This is due to the more complex anatomical and functional structure of the larynx, a more developed vasculature and under the mucous tissue. Acute narrowing of the airways in the larynx and trachea immediately causes severe disruption of all basic life support functions, up to their complete shutdown and death of the patient. Acute stenosis occurs suddenly or in a relatively short period of time, which, unlike chronic stenosis, does not allow the body to develop adaptive mechanisms.

The main clinical factors subject to immediate medical evaluation in acute laryngeal stenosis are:

the degree of insufficiency of external respiration;

the body's response to oxygen starvation.

With stenosis of the larynx and trachea, adjusternye(compensatory and protective) and pathological mechanismwe. Both are based on hypoxia and hypercapnia, which disrupt the trophism of tissues, including cerebral and nervous, which excites the chemoreceptors of the blood vessels of the upper respiratory tract and lungs. This irritation is concentrated in the corresponding parts of the central nervous system, and as a response, the body's reserves are mobilized.

Adaptive mechanisms have fewer opportunities to form during the acute development of stenosis, which can lead to oppression up to complete paralysis of one or another vital function.

Adaptive reactions include:

respiratory;

hemodynamic (vascular);

blood;

fabric.

Respiratory are manifested by shortness of breath, which leads to increased pulmonary ventilation; in particular, happens deepen-

lengthening or quickening of breathing, attraction of additional muscles - back, shoulder girdle, neck to the execution of the respiratory act.

TO hemodynamic compensatory reactions include tachycardia, increased vascular tone, which increases the minute volume of blood by 4-5 times, accelerates blood flow, increases blood pressure, and removes blood from the depot. All this enhances the nutrition of the brain and vital organs, thereby reducing oxygen deficiency, improves the elimination of toxins that have arisen in connection with stenosis of the larynx.

Blood and tissue adaptive reactions are the mobilization of erythrocytes from the spleen, an increase in vascular permeability and the ability of hemoglobin to be completely saturated with oxygen, and an increase in erythropoiesis. The ability of the tissue to absorb oxygen from the blood increases, a partial transition to the anaerobic type of metabolism in cells is noted.

All these mechanisms can, to a certain extent, reduce hypoxemia (lack of oxygen in the blood), hypoxia (in tissues), as well as hypercapnia (an increase in the content of CO 2 in the blood). Lack of pulmonary ventilation can be compensated for provided that a minimum volume of air enters the lung, which is individual for each patient. An increase in stenosis, and therefore hypoxia under these conditions, leads to the progression of pathological reactions, the mechanical function of the left ventricle of the heart is disturbed, hypertension appears in the small circle, the respiratory center is depleted, and gas exchange is sharply disturbed. Metabolic acidosis occurs, the partial pressure of oxygen falls, oxidative processes decrease, hypoxia and hypercapnia are not compensated.

Etiology. Etiological factors of acute stenosis of the larynx and trachea can be endogenous and exogenous. Among the first local inflammatory diseases - edema of the larynx and trachea, lining laryngitis, acute laryngotracheobron-chit, chondroperichondritis of the larynx, laryngeal angina. Non-inflammatory processes - tumors, allergic reactions, etc. General diseases of the body - acute infectious diseases (measles, diphtheria, scarlet fever), diseases of the heart, blood vessels, kidneys, endocrine diseases. Among the latter, the most common are foreign bodies, trauma to the larynx and trachea, condition after bronchoscopy, intubation.

Clinic. The main symptom of acute stenosis of the larynx and trachea is shortness of breath, noisy tense breathing. Depending on the degree of narrowing of the airways, on examination, there is a depression of the supraclavicular fossae, retraction of the intercostal spaces, and a violation of the rhythm of breathing. These signs are associated with an increase in negative pressure in the mediastinum during inspiration. It should be noted that with stenosis on

at the level of the larynx, shortness of breath is inspiratory in nature, the voice is usually changed, and with narrowing of the trachea, expiratory shortness of breath is observed, the voice is not changed. A patient with severe stenosis develops a feeling of fear, motor excitement (he rushes about, strives to run), face hyperemia, sweating, cardiac activity, secretory and motor function of the gastrointestinal tract, urinary function of the kidneys are disturbed. If the stenosis continues, there is an increase in pulse rate, cyanosis of the lips, nose and nails. This is due to the accumulation of CO2 in the body. There are 4 stages of airway stenosis:

I - stage of compensation; II - stage of subcompensation;

Decompensation stage;

Stage of asphyxia (terminal stage).

In the stage of compensation, due to a decrease in oxygen tension in the blood, the activity of the respiratory center increases, and at the same time, an increase in the content of CO2 in the blood can directly irritate the cells of the respiratory center, which is manifested by a decrease and deepening of respiratory excursions, shortening or loss of pauses between inhalation and exhalation, and a decrease in the number of pulse beats. The glottis is 6-7 mm wide. At rest, there is no shortage of breath, shortness of breath appears when walking and exercising.

In the stage of subcompensation, the phenomena of hypoxia deepen, and the working capacity of the respiratory center weakens. Already at rest, inspiratory dyspnea appears (breathing is difficult) with the inclusion of auxiliary muscles in the act of breathing. At the same time, there is a retraction of the intercostal spaces, soft tissues of the jugular, supra- and subclavian fossae, swelling (flutter) of the wings of the nose, stridor (breathing noise), pallor of the skin, restlessness of the patient. The glottis is 4-5 mm wide.

In the stage of decompensation, the stridor is even more pronounced, the tension of the respiratory muscles becomes maximum. Breathing is frequent and shallow, the patient takes a forced semi-sitting position, with his hands he tries to hold on to the headboard or other object. The larynx makes maximum excursions. The face acquires a pale cyanotic color, a feeling of fear, cold clammy sweat, cyanosis of the lips, tip of the nose, distal (nail) phalanges appear, the pulse becomes frequent. The glottis is 2-3 mm wide.

In the stage of asphyxia with acute stenosis of the larynx, breathing is intermittent, like Cheyne-Stokes, gradually pauses between respiratory cycles increase and stop altogether. The glottis width is 1 mm. There is a sharp drop in cardiac activity, the pulse is frequent, threadlike,

blood pressure is not determined, skin pale gray due to spasm of small arteries, pupils dilate. In severe cases, there is loss of consciousness, exophthalmos, involuntary urination, defecation and death comes quickly.

Diagnostics. Based on the described symptoms, data of indirect laryngoscopy, tracheobronchoscopy. It is necessary to find out the causes and location of the narrowing. There are a number of clinical signs to distinguish between laryngeal and tracheal stenosis. In laryngeal stenosis, it is mostly difficult to inhale, i.e. shortness of breath is inspiratory in nature, and with tracheal - exhalation (expiratory type of shortness of breath). The presence of an obstruction in breathing in the larynx causes hoarseness, while with constriction in the trachea, the voice remains clear. Differentiation of acute stenosis follows from laryngospasm, bronchial asthma, uremia.

Treatment. It is carried out depending on the cause and stage of acute stenosis. With compensated and subcompensated stages, it is possible to use drug treatment in a hospital setting. For laryngeal edema, dehydration therapy, antihistamines, corticosteroids are used. With inflammatory processes in the larynx, massive antibiotic therapy, anti-inflammatory drugs are prescribed. In diphtheria, for example, it is necessary to administer a specific antidiphtheria serum.

The most effective conduct drug destroying, the scheme of which is set out in the relevant sections on the treatment of laryngeal edema.

With decompensated stage of stenosis urgently needed naya tracheostomy, and in the stage of asphyxia, a conicotomy is urgently performed, and then a tracheostomy.

It should be noted that with appropriate indicationsthe doctor is obliged to perform these operations in almost anyconditions and without delay.

In relation to the isthmus thyroid gland depending on the level of the incision are distinguished upper tracheostomy -above the isthmus of the thyroid gland (Fig.4.12), lower below itand the middle through the isthmus, with its preliminary dissection anddressing. It should be noted that this division is conditional due tovarious options for the location of the isthmus of the thyroid gland in relation to the trachea. Separation depending on the level of incision of the tracheal rings is more acceptable. At the toptracheostomy cut 2-3 rings, with an average 3-4 rings andat the bottom 4-5 rings.

The upper tracheostomy technique is as follows. The position of the patient is usually supine, a roller must be placed under the shoulders in order to protrude the larynx and facilitate orientation.

Rice. 4.12. Tracheostomy.

a - midline skin incision and dilution of the wound edges; b - exposure of rings

trachea; c - dissection of the tracheal rings.

Sometimes, with rapidly developing asphyxia, the operation is performed in a semi-sitting or sitting position. Local anesthesia - 1% novocaine solution mixed with 0.1% adrenaline solution (1 drop per 5 ml). The hyoid bone, the lower notch of the thyroid and the cricoid cartilage are probed. For orientation, you can use a brilliant green color

Rice. 4.12. Continuation.

d - the formation of a tracheostomy.

mark the midline and level of the cricoid cartilage. A layer-by-layer incision of the skin and subcutaneous tissue is made from the lower edge of the thyroid cartilage by 4-6 cm, vertically downwards strictly along the midline. The superficial plate of the cervical fascia is dissected, under which a white line is found - the junction of the sternohyoid muscles. The latter is incised and the muscles are gently separated in a blunt way. After that, a part of the cricoid cartilage and the isthmus of the thyroid gland, which is dark red in color and soft to the touch, are observed. Then an incision is made in the capsule of the gland that fixes the isthmus, the latter is displaced downward and held with a blunt hook. After that, the fascia-covered tracheal rings become visible. Opening the trachea requires careful hemostasis. To fix the larynx, the excursions of which are significantly pronounced during asphyxia, a sharp hook is injected into the thyroid-hyoid membrane. To avoid severe cough a few drops of 2-3% dicaine solution are injected into the trachea. 2-3 rings of the trachea are opened with a pointed scalpel. The scalpel must not be pushed too deeply so as not to injure the posterior, cartilageless wall of the trachea and the anterior wall of the esophagus adjacent to it. The size of the incision should correspond to the size of the tracheotomy tube. To form a tracheostomy, the skin in the circumference of the wound on the neck is separated from the underlying tissues and sutured with four silk threads to the perichondrium of the dissected tracheal rings. The edges of the tracheostomy are pushed apart with a Trousseau expander and a tracheotomy tube is inserted. The latter is fixed with a gauze bandage around the neck.

In some cases, in pediatric practice, with stenosis caused by diphtheria of the larynx and trachea, naso (oro) is used

tracheal intubation with a flexible synthetic tube. Intubation is performed under the control of direct laryngoscopy, its duration should not exceed 3 days. If a longer period of intubation is required, a tracheostomy is performed, since a prolonged stay of the endotracheal tube in the larynx causes ischemia of the mucous membrane of the wall, followed by ulceration, scarring and persistent stenosis of the organ.

4.6.2. Chronic stenosis of the larynx and trachea

Chronic stenosis of the larynx and trachea- long-term and irreversible narrowing of the airway lumen, causing a number of severe complications from other organs and systems. Persistent morphological changes in the larynx and trachea or in the areas adjacent to them usually develop slowly over a long time.

The causes of chronic stenosis of the larynx and trachea are varied. The most common are:

surgical interventions and injuries during laryngotracheal operations, prolonged tracheal intubation (over 5 days);

benign and malignant tumors larynx and trachea;

traumatic laryngitis, chondroperichondritis;

thermal and chemical burns of the larynx;

prolonged stay of a foreign body in the larynx and trachea;

dysfunction of the lower laryngeal nerves as a result of toxic neuritis, after stumectomy, with compression by a tumor, etc.;

congenital defects, scar membranes of the larynx;

specific diseases of the upper respiratory tract (tuberculosis, scleroma, syphilis, etc.).

Often in practice, the development of chronic stenosis of the larynx is associated with the fact that tracheostomy is performed with a gross violation of the operation technique: instead of the second or third tracheal ring, the first is cut. In this case, the tracheotomy tube touches the lower edge of the cricoid cartilage, which always quickly causes chondroperichondritis, followed by severe stenosis of the larynx.

Prolonged wearing of a tracheotomy tube and incorrect fitting can also cause chronic stenosis.

Clinic. Depends on the degree of airway narrowing and the cause of the stenosis. However, a slow and gradual increase in stenosis gives time for the development of the adaptive mechanisms of the body, which allows even under conditions

insufficiency of external respiration to support life support functions. Chronic stenosis of the larynx and trachea has a negative effect on the entire body, especially for children, which is associated with oxygen deficiency and changes in reflex influences emanating from receptors located in the upper respiratory tract. Violation of external respiration leads to sputum retention and frequent recurrent bronchitis and pneumonia, which ultimately leads to the development chronic pneumonia with bronchiectasis. With a long course of chronic stenosis, changes in the cardiovascular system join these complications.

Diagnostics. Based on typical complaints, anamnesis. The study of the larynx to determine the nature and localization of stenosis is performed by means of indirect and direct laryngoscopy. Diagnostic capabilities have significantly expanded in recent years thanks to the use of bronchoscopy and endoscopic methods, which allow determining the level of damage, its prevalence, the thickness of the scars, the appearance of the pathological process, the width of the glottis.

Treatment. Small cicatricial changes that do not interfere with breathing do not require special treatment. Cicatricial changes that cause persistent stenosis require appropriate treatment.

Under certain indications, dilation (bougienage) of the larynx is sometimes used with bougie increasing in diameter and special dilators for 5-7 months. With a tendency to narrowing and ineffectiveness of prolonged dilation, the airway lumen is restored surgically. Surgical plastic interventions in the upper respiratory tract are performed, as a rule, in an open way and represent various options for laryngopharyngotra-cheofissure. These surgical interventions are complex and multi-stage in nature.

4.7. Diseases of the nervous apparatus of the larynx

Among the diseases of the nervous apparatus of the larynx are distinguished:

sensitive;

movement disorders.

Depending on the localization of the main process, disorders of the innervation of the larynx can be of central or peripheral origin, and by nature - functional or organic.

4.7.1. Sensory disorders

Sensory disorders of the larynx can be caused by central (cortical) and peripheral causes. Central disorders, caused, as a rule, by a violation of the ratio of the processes of excitation and inhibition in the cerebral cortex, are bilateral in nature. At the heart of the naru-; Neuropsychiatric diseases (hysteria, neurasthenia, functional neuroses, etc.) lie in the sensory innervation of the larynx. Hysteria, according to I.P. Pavlov, is the result of a breakdown of the highest nervous activity in people with lack of teamwork signaling systems, expressed in the predominance of the activity of the first signaling system and subcortex over the activity of the second signaling system. In light-hearted persons, a dysfunction of the larynx, which arose under the influence of a nervous shock, fright, can be fixed, and these disorders take on a long-term nature. Sensory impairment manifests itself hypesthesia(decreased sensitivity) of various severity, up to anesthesia, or hyperesthesia(increased sensitivity) and paresthesia(perverted sensitivity).

Hypesthesia or anesthesia The larynx is more often observed with traumatic injuries of the larynx or superior laryngeal nerve, with surgical interventions on the organs of the neck, with diphtheria, with anaerobic infection. A decrease in the sensitivity of the larynx usually causes minor subjective sensations in the form of perspiration, awkwardness in the throat, and dysphonia. However, against the background of a decrease in the sensitivity of the reflexogenic zones of the larynx, there is a danger of pieces of food and liquid entering the respiratory tract and, as a consequence, the development of aspiration pneumonia, impaired external respiration, up to asphyxia.

Hyperesthesia can be of varying severity and is accompanied by a painful sensation when breathing and talking, often there is a need to cough up mucus. With hyperesthesia, it is difficult to inspect the oropharynx and larynx due to a pronounced gag reflex.

Paresthesia is expressed by a wide variety of sensations in the form of tingling, burning, sensation of a foreign body in the larynx, spasm, etc.

Diagnostics. Based on anamnesis data, patient complaints and laryngoscopic picture. In diagnostics, a method for assessing the sensitivity of the larynx during probing can be applied: touching the mucous membrane of the laryngopharyngeal wall with a probe with cotton wool causes an appropriate response. Along with this, it is necessary to consult a neuropathologist, psychotherapist.

Treatment. It is carried out together with a neurologist. By-

since disorders of the central nervous system are the basis of sensitivity disorders, therapeutic measures are aimed at eliminating them. Prescribe sedative therapy, pine baths, vitamin therapy, spa treatment. In some cases, novocaine blockade is effective both in the area of ​​nerve nodes and along the pathways. From physiotherapeutic agents for peripheral lesions, intra- and extra-laryngeal galvanization, acupuncture, homeopathic remedies are prescribed.

4.7.2. Movement disorders

Movement disorders of the larynx are manifested in the form of partial (paresis) or complete (paralysis) loss of its functions. Such disorders can occur as a result of an inflammatory and regenerative process in the muscles of the larynx and in the laryngeal nerves. They may be central and peripheral origin. Distinguish myogenic and neuro-gene paresis and paralysis.

♦ Central paralysis of the larynx

Paralysis of central (cortical) origin develops in traumatic brain injury, intracranial hemorrhage, multiple sclerosis, syphilis, etc.; can be one- or two-sided. Paralysis of central origin is more often associated with damage to the medulla oblongata and is combined with paralysis of the soft palate.

Clinic. It is characterized by speech disorders, sometimes breathing disorders and seizures. Movement disorders of central origin often develop in the last stage of severe brain disorders, for which it is difficult to count on a cure.

Diagnostics. Based on the characteristic symptoms of the underlying disease. With indirect laryngoscopy, there is a violation of the mobility of one or both halves of the larynx.

Treatment. Aimed at eliminating the underlying disease. Local disorders in the form of difficulty breathing sometimes require surgical intervention (produce a tracheostomy). In some cases, it is possible to use physiotherapy in the form of electrophoresis of drugs and electrical stimulation of the muscles of the larynx. Climatic and phonopedic treatment has a beneficial effect.

♦ Peripheral paralysis of the larynx

Peripheral paralysis of the larynx, as a rule, is unilateral and is caused by a violation of the innervation of the muscles by the laryngeal, mainly recurrent, nerves, which is explained

the topography of these nerves, the proximity to many organs of the neck and chest cavity, diseases of which can cause dysfunction of the nerve.

Paralysis of the muscles innervated by the recurrent laryngeal nerves is most often caused by tumors of the esophagus or mediastinum, enlarged parabronchial and mediastinal lymph nodes, syphilis, cicatricial changes in the apex of the lung. Recurrent nerve damage can also be caused by an aortic arch aneurysm for the left nerve and an aneurysm of the right subclavian artery for the right recurrent laryngeal nerve, as well as surgical interventions. The left recurrent laryngeal nerve is most commonly affected. In diphtheria neuritis, paralysis of the larynx is accompanied by paralysis of the soft palate.

Clinic. Hoarseness and weakness of the voice of varying severity are characteristic functional symptoms of laryngeal paralysis. With bilateral lesions of the recurrent laryngeal nerves, breathing is impaired, while the voice remains sonorous. In childhood, choking occurs after eating, associated with the loss of the protective reflex of the larynx.

With laryngoscopy, characteristic disorders of the mobility of the arytenoid cartilage and vocal folds are determined, depending on the degree of movement disorders. In the initial stage of unilateral paresis of the muscles innervated by the recurrent laryngeal nerve, the vocal fold is somewhat shortened, but retains limited mobility, moving away from the midline during inspiration. In the next stage, the vocal fold on the side of the lesion becomes motionless and is fixed in the middle position, occupies the so-called cadaveric position. Subsequently, compensation appears from the side of the opposite vocal fold, which extends beyond the midline and approaches the vocal fold of the opposite side, which retains a sonorous voice with slight hoarseness.

Diagnostics. If the innervation of the larynx is disturbed, it is necessary to identify the cause of the disease. X-ray examination and computed tomography of the chest organs are performed. To exclude syphilitic neuritis, it is necessary to examine the blood according to Wasserman. Paralysis of the vocal fold, accompanied by spontaneous rotatory nystagmus on one side, indicates damage to the nuclei of the medulla oblongata.

Treatment. With motor paralysis of the larynx, first of all, the underlying disease is treated. With paralysis of inflammatory etiology, anti-inflammatory therapy, physiotherapy procedures are performed. With toxic neuritis, for example, with syphilis, special

physical therapy. Persistent disorders of mobility of the larynx caused by tumors or cicatricial processes are treated promptly. Effective plastic surgery- removal of one vocal fold, excision of the vocal folds, etc.

♦ Myopathic paralysis

Myopathic paralysis is caused by damage to the muscles of the larynx. In this case, the constrictors of the larynx are mainly affected. The most common paralysis of the vocal muscle. With bilateral paralysis of these muscles during phonation, an oval-shaped gap is formed between the folds (Fig. 4.13, a). Paralysis of the transverse arytenoid muscle is laryngoscopically characterized by the formation of a triangular space in the posterior third of the glottis due to the fact that, with paralysis of this muscle, the bodies of the arytenoid cartilages do not approach completely along the midline (Fig. 4.13, b). The defeat of the lateral cricoid muscles leads to the fact that the glottis takes the shape of a rhombus.

Diagnostics. Based on anamnesis data and a laryngoscopic picture.

Treatment. It is aimed at eliminating the cause that caused the paralysis of the laryngeal muscles. Physiotherapeutic procedures (electrotherapy), acupuncture, food and voice mode are used locally. To increase the tone of the muscles of the larynx, faradization and vibration massage have an effect. A good effect is given by phonopedic treatment, in which, with the help of special sound and breathing exercises, the speech and respiratory functions of the larynx are restored or improved.

Rice. 4.13. Movement disorders of the larynx.

Laryngospasm

Convulsive narrowing of the glottis, in which almost all the muscles of the larynx are involved - laryngospasm, occurs more often in childhood. The cause of laryngospasm is hypocalcemia, a lack of vitamin D, while the calcium content in the blood decreases to 1.4-1.7 mmol / l instead of the normal 2.4-2.8 mmol / l. Laryngospasm can be hysteroid in nature.

Clinic. Laryngospasm usually occurs suddenly after a severe cough, fright. Initially, there is a noisy, uneven long breath, followed by intermittent shallow breathing. The child's head is thrown back, the eyes are wide open, the neck muscles are tense, the skin is cyanotic. Cramps of the limbs and facial muscles may appear. After 10-20 s, the respiratory reflex is restored. In rare cases, the attack ends in death due to cardiac arrest. Due to increased muscular excitability, the production of surgical interventions - adenotomy, opening of the pharyngeal abscess, etc., in such children is associated with dangerous complications.

Diagnostics. Spasm of the glottis is recognized on the basis of the clinic of the attack and the absence of any changes in the larynx in the interictal period. At the time of an attack, with direct laryngoscopy, one can see a collapsed epiglottis, arypiglottic folds converge along the midline, arytenoid cartilages are drawn together and turned out.

Treatment. Laryngospasm can be eliminated by any strong stimulus of the trigeminal nerve - an injection, pinch, pressure on the root of the tongue with a spatula, spraying the face cold water etc. With prolonged spasm it is favorable intravenous administration 0.5% novocaine solution.

In threatening cases, one should resort to tracheotomy or conicotomy.

In the post-attack period, general strengthening therapy, calcium and vitamin D preparations, stay in the fresh air are prescribed. With age (usually by 5 years), these phenomena are eliminated.

4.8. Larynx and trachea injuries

Injuries to the larynx and trachea, depending on the damaging factor, can be mechanical, thermal, radiation and chemical. There are also open and closed injuries.

In peacetime, injuries to the larynx and trachea are relatively rare.

♦ Open injuries

Open trauma, or injury, of the larynx and trachea, as a rule, are of a combined nature, they damage not only the larynx itself, but also the organs of the neck, face, chest. Distinguish between cut, stab and gunshot wounds. Cut wounds are caused by damage from various cutting tools. Most often they are applied with a knife or razor for the purpose of murder or suicide (suicide). According to the level of location of the incision, there are: 1) wounds located under the hyoid bone, when the thyroid-lingual membrane is cut; 2) injuries to the sub-voice area. In the first case, due to the contraction of the cut muscles of the neck, the wound, as a rule, gapes wide, so that the larynx and part of the pharynx can be examined through it. With such wounds, the epiglottis always moves upward, breathing and voice are preserved, but speech is absent with a gaping wound, since the larynx is disconnected from the articulatory apparatus. If, in this case, the edges of the wound are moved, thereby closing its lumen, then speech is restored. When food is swallowed, it comes out through the wound.

Clinic. The general condition of the patient is greatly disturbed. Blood pressure drops, pulse quickens, body temperature rises. When the thyroid gland is injured, significant bleeding occurs. Consciousness, depending on the degree and nature of the injury, can be retained or confused. When injured carotid arteries death comes immediately. However, the carotid arteries are rarely crossed in suicidal wounds; suicides strongly throw their head backward, protruding their neck, while the arteries are displaced posteriorly.

Diagnostics is not difficult. It is necessary to determine the level of the location of the wound. Examination through the wound and probing allows you to determine the state of the cartilaginous skeleton of the larynx, the presence of edema, hemorrhage.

Treatment surgical, includes stopping bleeding, ensuring adequate breathing, replenishing blood loss and primary wound care. Particular attention should be paid to respiratory function. As a rule, a tracheostomy is performed, preferably a lower one.

If the wound is located in the area of ​​the thyroid-hyoid membrane, the wound should be sutured in layers with the obligatory suturing of the larynx to the hyoid bone with chrome-plated catgut. Before suturing the wound, it is necessary to stop the bleeding in the most careful way by bandaging or suturing the vessels. To relieve tension and ensure

convergence of the edges of the wound, the patient's head is tilted anteriorly during suturing. If necessary, for a complete revision, the wound should be widely dissected. If the mucous membrane of the larynx is damaged, its possible suturing, the formation of a laryngostomy and the introduction of a T-shaped tube are performed. In order to prevent infection, the patient's nutrition is provided with the help of a gastric tube inserted through the nose or mouth. At the same time, anti-inflammatory and restorative treatment is prescribed, including the introduction of massive doses of antibiotics, antihistamines, detoxification drugs, hemostatics, and anti-shock therapy.

■ Gunshot injuries of the larynx and trachea. These injuries are rarely isolated. More often they are combined with injuries of the pharynx, esophagus, thyroid gland, vessels and nerves of the neck, spine, spinal cord and brain.

Gunshot wounds of the larynx and trachea are divided into end-to-end,blindandtangents (tangential).

With a through wound, as a rule, there are two holes - an entrance and an exit. It should be borne in mind that the inlet rarely coincides with the course of the wound canal, the site of damage to the larynx and the outlet, since the skin and the tissues on the neck are easily displaced.

In blind wounds, a shrapnel or bullet gets stuck in the larynx or in the soft tissues of the neck. Once in the hollow organs - the larynx, trachea, esophagus, they can be swallowed, spit out or aspirated into the bronchus.

With tangential (tangential) wounds, the soft tissues of the neck are affected without violating the integrity of the mucous membrane of the larynx, trachea, esophagus.

Clinic. Depends on the depth, degree, type and forward force of the wounding projectile. The severity of the injury may not correspond to the size and strength of the wounding projectile, since the concomitant contusion of the organ, violation of the integrity of the skeleton, hematoma and edema of the inner lining aggravate the patient's condition.

The wounded is often unconscious, shock is often observed, as the vagus nerve is injured and the sympathetic trunk and, in addition, when large vessels are injured, a large blood loss occurs. An almost constant symptom is difficulty breathing due to injury and compression of the airways by edema and hematoma. Emphysema occurs when the wound hole is small and quickly sticks together. Swallowing is always impaired and accompanied by severe pain; food, entering the respiratory tract, contributes to the onset of cough and the development of inflammatory complications in the lung.

,...■,.■■■. ■ . ■■■ ■ . ■ 309

Diagnostics. Based on history and examination data. Neck wound for the most part it can be wide, with torn edges, with significant loss of tissue and the presence of foreign bodies - metal fragments, pieces of tissue, powder particles in the wound, etc. When injured at a close distance, the edges of the wound are burned, there is hemorrhage around it. In some wounded, soft tissue emphysema is determined, which indicates the penetration of the wound into the cavity of the larynx or trachea. Hemoptysis can also testify to this.

Laryngoscopy (direct and indirect) in a wounded person is often practically impossible due to severe pain, inability to open the mouth, fractures of the jaw, hyoid bone, etc. In the following days, with laryngoscopy, it is necessary to determine the state of the region of the vestibule of the larynx, glottis and subglottic cavity. Reveal hematomas, ruptures of the mucous membrane, damage to the cartilage of the larynx, the width of the glottis.

Informative in the diagnosis of the X-ray method of research, computed tomography data, with which you can determine the state of the skeleton of the larynx, trachea, the presence and localization foreign bodies.

Treatment. In case of gunshot wounds, it includes two groups of measures: 1) restoration of breathing, stopping bleeding, primary treatment of the wound, combating shock; 2) anti-inflammatory, desensitizing, restorative therapy, tetanus (possibly others) vaccination.

To restore breathing and prevent further impairment of respiratory function, as a rule, a tracheotomy is performed with the formation of a tracheostomy.

Bleeding is stopped by the imposition of ligatures on the vessels in the wound, and if large vessels are damaged, the external carotid artery is ligated.

The fight against pain shock includes the introduction of narcotic analgesics, transfusion therapy, transfusion of blood of the same group, cardiac drugs.

Primary surgical treatment of a wound, in addition to stopping bleeding, includes gentle excision of crushed soft tissues, removal of foreign bodies. In case of extensive damage to the larynx, a laryngostomy should be formed with the introduction of a T-tube. After emergency measures, it is necessary to administer tetanus toxoid according to the scheme (if serum was not previously administered before the operation).

The second group of measures includes the appointment of broad spectrum antibiotics, antihistamines, dehydration and corticosteroid therapy. The patients are fed through the nasoesophageal tube. When introducing the probe, one should beware of getting it into the respiratory tract, which is determined by the occurrence of coughing, difficulty in breathing. "■>

♦ Closed injuries

Closed injuries of the larynx and trachea occur when various foreign bodies, metal objects, etc. get into the laryngeal cavity and the podvocal cavity or with a blunt impact from the outside, falling onto the larynx. Often, the laryngeal mucosa is injured by a laryngoscope or an endotracheal tube during anesthesia. Abrasion, hemorrhage, violation of the integrity of the mucous membrane are found at the site of damage. Sometimes edema appears at the site of the wound and around it, which can spread, and then it poses a threat to life. If an infection enters the wound site, a purulent infiltration may appear, the possibility of developing phlegmon and chondroperichondritis of the larynx is not excluded.

With prolonged or rough exposure to the endotracheal tube on the mucous membrane, in some cases, the so-called endotracheal granuloma is formed. Its most common location is the free edge of the vocal fold, since in this place the tube is most closely in contact with the mucous membrane.

Clinic. With a closed injury of the mucous membrane of the larynx and trachea by a foreign body, a sharp pain occurs, which increases with swallowing. Swelling and tissue infiltration develops around the wound, which can lead to breathing difficulties. Because of the sharp pain sensations, the patient cannot swallow saliva, take food. The accession of a secondary infection is characterized by the appearance of pain on palpation of the neck, increased pain when swallowing, and an increase in body temperature.

With external blunt trauma, there is swelling of the soft tissues of the larynx outside and edema of the mucous membrane more often in its vestibular section.

Diagnostics. Based on anamnesis data and objective research methods. With a laryngoscopic examination, you can see edema, hematoma, infiltration or abscess at the site of injury. In the pear-shaped pocket or in the fossa of the epiglottis on the side of the lesion, saliva can accumulate in the form of a lake. Radiography in frontal and lateral projections, as well as with the use of contrast agents, allows in some cases to detect a foreign body, to determine the level of possible fracture of the cartilage of the larynx.

Treatment. The tactics of patient management depends on the examination of the patient, the nature and area of ​​damage to the mucous membrane, the state of the airway lumen, the width of the glottis, etc. In the presence of an abscess, it is necessary to open it with a laryngeal (hidden) scalpel after preliminary application anesthesia. When expressed

breathing disorders (stenosis II- III degree), an emergency tracheostomy is necessary.

In edematous forms, to eliminate stenosis, drug destenosis is prescribed (corticosteroid, anti-histamine, dehydration drugs).

In all cases of closed injuries of the larynx occurring against the background of a secondary infection, antibacterial therapy, antihistamines and detoxification agents are required.

Inflammation of the mucous membrane of the posterior pharyngeal wall - pharyngitis- can be acute and chronic.
Acute pharyngitis - Acute inflammation of the mucous membrane rarely occurs as an independent disease. More often it is a consequence of a respiratory viral infection or the result of the spread of bacterial flora from the nasal cavity, tonsils or carious teeth.

Causes, contributing to the development of pharyngitis, there may be the following:

General or local hypothermia;

Irritation of the mucous membrane by secretions flowing from the paranasal sinuses;

exposure to harmful impurities in the air - dust, gases, tobacco smoke;

Acute infectious diseases;

Diseases internal organs- kidneys, blood, gastrointestinal tract, etc.

Clinical manifestations acute pharyngitis are as follows:

Dryness, soreness, rawness in the throat;

Moderate soreness when swallowing;

Irradiation of pain in the ear;

Hearing loss - "stuffy" ears, clicking in the ears when the process spreads into the nasopharynx and mouth auditory tubes;

Mild signs of intoxication, sub febrile temperature.

With oropharyngoscopy noted:

Hyperemia and moderate swelling of the posterior pharyngeal wall;

Thickened hyperemic follicles, edematous lateral ridges;

Mucopurulent discharge on the back of the pharynx in the presence of a bacterial pathogen.
Pronounced forms acute pharyngitis is accompanied by regional lymphadenitis.

Treatment acute pharyngitis includes:

Rehabilitation of foci of infection in the nasal cavity, nasopharynx,
oral cavity, tonsils;

Elimination of irritating factors;

Gentle diet;

Plentiful warm drink;

Warm-moist inhalation with the addition of essential oils, soda;

Irrigation of the back wall with warm disinfectant solutions: furacillin, chlorophyllipt, hexoral, povidone iodine, herbal decoctions;

Aerosol preparations: Kameton, Ingalipt, Proposol, IRS19;

Oroseptics for absorption in the oral cavity "Faringosept", "Septolete", "Strepsils", "Lariprokt", "Lariplus", etc.

Lubrication of the posterior pharyngeal wall oil solutions, Lugol's solution;

Antiviral agents: interferon, remantadine, etc.
Prophylaxis consists in carrying out the following activities:

Hardening procedures;

Restoration of nasal breathing;

Eliminate irritating factors.
Chronic pharyngitis depending on the nature

the inflammatory process is divided into catarrhal(simple), hypertrophic(granular and lateral) and atrophic and combined(mixed). Causes development chronic pharyngitis:

External irritating factors;

The presence of foci of infection in the area of ​​the nose, paranasal sinuses, oral cavity and tonsils;

Disruption of metabolic processes (diathesis in children, diabetes in adults, etc.);

Stagnant phenomena with a disease of internal organs.
Subjective signs the various forms of pharyngitis are largely identical:

Dryness, burning, itching in the throat

Soreness with an empty throat;

Feeling of a foreign body;

Irradiation of pain in the ears;

Accumulation of viscous mucous discharge, especially
in the morning.

Chronic pharyngitis diagnosis is placed mainly on the basis of pharyngoscopy data:

- with catarrhal form there is hyperemia of the mucous membrane, its thickening, increased vascular pattern;

- with hypertrophic form- on the swollen and hyperemic mucous membrane of the posterior pharyngeal wall, individual red grains (granules) are visible, an increase and swelling of the lateral ridges;

- with atrophic form the mucous membrane is dry, thinned, shiny, pale, sometimes covered with viscous mucus or crusts.

Treatment depends on the form and stage of the disease and, above all, should be aimed at eliminating the causes of the disease.

Local treatment consists in the appointment of irrigation, inhalation, atomization and lubrication with drugs corresponding to the form of the disease. With atrophic pharyngitis use alkaline and oil preparations. With hypertrophic pharyngitis the mucous membrane is treated with 1-5% solution of collargol, protargol or lapis, novocaine blockade. With severe hypertrophy, use cryotherapy(freezing) onto granules and side rollers.

The result of treatment with these methods often does not satisfy the doctor and the patient. In recent years, a new method for the treatment of acute and chronic pharyngitis has appeared, which consists in the use of vaccines, which are lysates of pathogens of the upper respiratory tract. Such a drug is Imudon, which is produced in France and is widely used to treat diseases of the oral cavity and pharynx. The drug is available in tablets for absorption in the mouth. Imudon has a local effect on the mucous membrane, as a result of which phagocytic activity increases, the amount of secretory immunoglobulin A, and the content of lysozyme in saliva increases. The maximum effect in the treatment of this drug in the form of monotherapy and in combination with other drugs is obtained in acute and chronic catarrhal and hypertrophic pharyngitis. The successful use of Imudon for specific prevention and treatment of inflammatory diseases of the oral cavity plays an essential role in the prevention of diseases of the pharynx. Studies have shown that the use of Imudon in the treatment of frequently ill children leads to an increase in the content of interferon in saliva, a decrease in the number of exacerbations of diseases and a decrease in the need for prescribing anti-material therapy.

Acute tonsillitis (tonsillitis) is a common infectious-allergic disease with an inflammatory process in the lymphoid tissue of the tonsils. Inflammation can also occur in other accumulations of pharyngeal lymphoid tissue - lingual, pharyngeal, tubular tonsils, in the lateral ridges. To define these diseases, the term is used - angina, (from the Latin. Anqo - to squeeze, choke), known from ancient times. In the Russian medical literature, you can find the definition of angina as "throat toad". The disease mainly affects children of preschool and school age, as well as adults under the age of 40. There are marked seasonal increases in the incidence in the spring and autumn.

There are several classification schemes for sore throats. They are distinguished by etiology, pathogenesis, clinical course.

Among the various microbial pathogens, the main etiological role belongs beta-hemolytic streptococcus, which is found according to different authors from 50 to 80% of cases. The second most frequent causative agent of sore throats can be considered Staphylococcus aureus. Diseases caused by green streptococcus. In addition, the causative agent of sore throat can be adenoviruses, rods, spirochetes, fungi and dr.

Penetration of an exogenous pathogen may occur by airborne droplets, alimentary and by direct contact with a patient or a bacillus carrier. More often, the disease occurs due to autoinfection with microbes or viruses that normally grow on the mucous membrane of the pharynx. It is possible that an endogenous infection can spread from carious teeth, a pathological focus in the paranasal sinuses, etc. In addition, angina can occur as a relapse of a chronic process.

According to classification by I. B. Soldatova(1975) acute tonsillitis (tonsillitis) are divided into two groups: primary and secondary,

TO primary(commonplace) tonsillitis include - catarrhal, follicular, lacunar, phlegmonous tonsillitis.

Secondary(specific) tonsillitis caused by a specific specific pathogen. They can be a sign of an infectious disease (pharyngeal diphtheria, ulcerative necrotizing tonsillitis, syphilitic, herpetic, fungal) or blood diseases.

Primary (commonplace) tonsillitis

Catarrhal tonsillitis- the mildest form of the disease, which has the following Clinical signs;

A burning sensation, dryness, sore throat;

Soreness when swallowing is mild;

Subfebrile temperature;

Moderate intoxication;

Increased regional lymph nodes;
The duration of the disease is 3-5 days.
With pharyngoscopy is determined by:

Spilled hyperemia of the tonsils and palatine arches;

Slight enlargement of the tonsils;

In places, a film of mucopurulent exudate is determined.

Follicular tonsillitis has the following features:

Acute onset with an increase in temperature to 38-39 °;

Strong pain in the throat when swallowing;

Irradiation of pain in the ear;

Intoxication is expressed, especially in children, - decreased appetite, vomiting, confusion, the phenomenon of meningism;

Significant hematological changes - neutrophilic leukocytosis, stab shift, accelerated ESR;

Enlargement and tenderness of regional lymph nodes.

The duration of the disease is 5-7 days. With pharyngoscopy is determined by:

Severe hyperemia and infiltration of the soft palate and arches;

Increase and hyperemia of the tonsils, a bumpy surface in the first days of the disease;

Multiple yellowish-white dots 1-3 mm in size (purulent follicles) 3-4 days of illness.

Lacunar tonsillitis often more severe than follicular. Inflammation develops, as a rule, in both tonsils, however, on one side there may be a picture of follicular tonsillitis, and on the other - lacunar. This is explained by a deeper lesion of all lymphoid follicles. Superficial follicles give a picture of follicular sore throat. The follicles located in the depths of the amygdala fill the adjacent lacunae with their purulent contents. With an extensive process, pus comes out to the surface of the tonsil in the form of islands or drainage deposits.

Clinical signs lacunar tonsillitis are as follows:

Severe sore throat when swallowing food and saliva;

Irradiation of pain in the ear;

Chills, increased body temperature up to 39-40 °;

Weakness, weakness, sleep disturbance, headache;

Pain in the lower back, joints, in the region of the heart;

Severe hematological changes;

Significant enlargement and soreness of regional lymph nodes and spleen.
The duration of the disease is 10-12 days.

At pharyngoscopy determined:

Severe hyperemia and enlargement of the amygdala;

Yellowish-white deposits located at the mouths of the lacunae, which can be easily removed with a spatula;

Islets of purulent deposits, sometimes covering a significant surface of the amygdala.
Phlegmonous tonsillitis is relatively rare and is characterized by purulent fusion of tissue inside the amygdala - the formation of phlegmon.

Causes, contributing to the formation of the process can be the following:

Decrease in the body's immune forces;

Virulence of the pathogen;

Trauma to the tonsil by a foreign body or when performing medical procedures;

Development of adhesions deep in the amygdala with difficulty in the outflow of contents.

Clinical signs phlegmonous tonsillitis can be similar to the manifestations of lacunar tonsillitis, small abscesses can be almost asymptomatic. In more severe cases, there is an increase in pain on the one hand, difficulty in swallowing, deterioration of the general condition.

With pharyngoscopy is determined by:

An increase in one amygdala, hyperemia, tension;

Soreness when pressed with a spatula;

The presence of fluctuations with mature phlegmon.
Submandibular lymph nodes enlarged and painful on the affected side.

Treatment of primary (commonplace) tonsillitis should be etiotropic, complex - local and general. As a rule, treatment is carried out at home, and only in severe cases or under unfavorable social conditions, the patient is admitted to a hospital. To confirm the diagnosis and choose an adequate treatment, a bacteriological examination of the contents of the nose and pharynx is carried out. Treatment should include the following steps:

1. Treatment adherence diseases:

Strictly bed rest during the first days of the disease;

Sanitary and epidemic standards - isolation of the patient, individual means care and personal hygiene items;

Diet - a mechanically, thermally and chemically sparing diet, rich in vitamins, drinking plenty of fluids.

2. Local treatment:

- gargling with warm solutions of potassium permanganate, furacillin, gramicidin, sodium bicarbonate, chlorophyllipt, hexoral, iodine povidone, as well as decoctions of chamomile, sage, eucalyptus;

Treatment of the mucous membrane of the pharynx with aerosol preparations: "Cameton", "Eucalyptus", "Proposol", "Bioparox";

Application of oroseptics: "Faringosept", "Geksaliz", "Lari-plus", "Laripront", "Septolete", "Strepsils", "Anti-angin", etc .;

Lubrication of the pharyngeal mucosa with Lugol's solution, iodinol;

Aromatherapy: essential oils of eucalyptus, cedar, tea tree, lavender, grapefruit. 3. General treatment:

Sulfanilamide drugs are prescribed taking into account the severity of the course of the disease, usually at the initial stage;

Antihistamines are recommended due to the toxic-allergic nature of the disease (tavegil, suprastin, diazolin, fenkarol, etc.), antibiotic therapy is prescribed depending on the severity and stage of the disease: the use of antibiotics is not recommended for young people in the initial stage of the disease. V severe cases, in the stage of abscess formation or in case of damage to other organs are used semi-synthetic preparations of a wide spectrum of action(ampicillin, amoxicillin, amoxiclav, unazine), first generation cephalosporins(cephalexin, cephalothin, cephalosin), macrolides(erythromycin, rovamycin, rulid). Antibiotic treatment should be accompanied by the prophylaxis of dis bacterium for - the appointment of nystatin, levorin, diflucan. With the wrong choice of antibiotics and the timing of treatment, conditions are created for the transition of the process to a chronic one.

Anti-inflammatory drugs - paracetamol, acyl salicylic acid are prescribed for hyperthermia, and it is necessary to take them into account side effects;

Immunostimulating therapy is recommended in the form of the following drugs: thymus extract (vilosen, timoptin), pyrogenal, natural immunostimulants (ginseng, leuzea, chamomile, propolis, pantocrine, garlic). The use of a vaccine-type immunomodulator - the drug Imudon - gives positive results in the treatment of herpetic, fungal lesions of the oral cavity and pharynx, increases phagocytic activity and the level of lysozyme in saliva.

Physiotherapy procedures are prescribed after the removal of hyperthermia and the elimination of a purulent process with prolonged lymphadenitis: solux, UHF in the submandibular region, phonopharesis, magnetotherapy.

During treatment, it is necessary to monitor the condition of cardio-vascular system, conduct repeated studies of urine and blood. After suffering a disease, the patient should be under the supervision of a doctor for a month.

Prevention of acute tonsillitis should include:

Timely sanitation of foci of chronic infection;

Eliminating the reasons that make it difficult nasal breathing;

Elimination of irritating factors in the environment;

Correct mode work and rest, hardening procedures.

Persons who often suffer from angina are subject to dispensary observation.

Paratonsillitis in most cases, it is a complication of angina in patients with chronic tonsillitis and occurs as a result of the penetration of a virulent infection into the peri-mucosa tissue. The reasons for the development of paratonsillitis in most cases are a decrease in immunity and inadequate or early discontinued treatment of angina. The spread of the inflammatory process outside the tonsil capsule indicates the termination of its protective action, that is, the transition to the stage of decompensation.

Clinical manifestations of the disease:

Constant pain when swallowing, worse when trying to swallow saliva;

Irradiation of pain in the ear, teeth, aggravated to refusal of food and drink;

Emergence trism- spasm of the chewing muscles;

Slurred, nasal speech;

Forced position of the head (to one side), resulting from inflammation of the muscles of the pharynx, neck and cervical lymphadenitis;

Severe intoxication - headache, feeling of weakness, febrile temperature;

Significant hematological changes of an inflammatory nature.

Pharyngoscopy usually difficult due to trismus, on examination there is an unpleasant putrid odor from the mouth. A characteristic picture is the asymmetry of the soft palate due to the displacement of one of the tonsils to the midline. Depending on the location of the abscess in the peri-mucous tissue, an anteroposterior, antero-inferior, lateral and posterior peri-mucosa abscess are isolated. With anteroposterior paratonsillitis, there is a sharp swelling of the upper pole of the amygdala, which, together with the arches and the soft palate, is a spherical formation. In the area of ​​greatest protrusion, there is fluctuation.

During the course of the disease, there are two stages - infiltration and abscess formation. To resolve the issue of the presence of pus, a diagnostic puncture is performed.

Treatment paratonsillitis in infiltrative stage carried out according to the scheme recommended for acute tonsillitis. The complex nature of the treatment, the use of broad-spectrum antibiotics, the appointment of novocaine blockades can lead to a gradual attenuation of the inflammatory process and the patient's recovery.

When an abscess ripens you should not wait for it to empty itself spontaneously. An autopsy is desirable after spraying the pharyngeal mucosa with 10% lidocaine solution or 2% dicaine solution. The introduction of 2-3 ml of a 1% solution of novocaine into the area of ​​the masticatory muscles near the corner of the lower jaw relieves trismus and facilitates the manipulation. Lancing an abscess is often done through. supra-amygdala fossa or at the site of the greatest protrusion with a scalpel or forceps. In the following days, the edges of the wound are diluted, the cavity is washed with disinfectants.

To prevent possible relapses of the process and the development of complications, the patient is removed tonsils - tonsillectomy. Usually, the operation is performed one week after opening the paratonsillar abscess. In some cases, in the presence of chronic tonsillitis, complicated by paratonsillitis, as well as when other complications are detected, the entire purulent focus is removed entirely at any localization, which ensures a quick recovery of the patient.

Retropharyngeal abscess is a purulent inflammation of the lymph nodes and loose tissue between the pharyngeal fascia and the prevertebral fascia, which persist in children up to four years of age. At a young age, the disease occurs as a result of the introduction of infection into the pharyngeal space with acute rhinopharyngitis, sore throat, acute infectious diseases against a background of weakened immunity. In older children, trauma to the posterior pharyngeal wall is often the cause of a retropharyngeal abscess.

Clinical manifestations of the disease depend on the localization of the abscess, its size, the state of immunity, the age of the child. However, the disease is always difficult, and the leading symptoms are sore throat and difficulty breathing:

- at a high location abscess in the nasopharynx; there is difficulty in nasal breathing, nasal sound;

- in the middle position the abscess appears noisy stridorious breathing, snoring, the voice becomes hoarse;

- when lowering an abscess in the laryngopharynx, breathing becomes stenotic, with the participation of auxiliary muscles, cyanosis is noted, periodically suffocating attacks, forced position of the head with throwing back;

Sore throat, refusal to eat, anxiety and fever are characteristic of all types of localization of the process.

With pharyngoscopy there is hyperemia and swelling of a rounded shape on the posterior wall of the pharynx along the midline or occupying only one side. With a pronounced trismus in young children, a digital examination of the nasopharynx and oropharynx is performed, in which an infiltrate of dense consistency or fluctuating is found. Regional lymph nodes are significantly enlarged and painful.

Treatment. In the stage of infiltration, conservative treatment. If signs of abscess formation appear, it is necessary surgery- opening the abscess, which to prevent aspiration is carried out in a horizontal position with preliminary puncture and suction of pus. The incision is made in the place of the greatest protrusion, immediately after a deep breath, and the child's head is lowered down. After opening, the edges of the wound are re-diluted, the throat is irrigated with disinfectants, and antibacterial treatment is continued.

Secondary (specific) tonsillitis are signs of blood diseases or are caused by pathogens of infectious diseases.

Ulcerative membranous (necrotic) tonsillitis of Simanovsky-Vincent caused by the symbiosis of bacteria - fusiform sticks and spirochetes of the oral cavity, which are usually in a mildly virulent state in the folds of the oral mucosa. Factors predisposing to the development of the disease, are:

Decrease in general and local reactivity of the body;

Postponed infectious diseases;

The presence of carious teeth, gum disease.
Clinical manifestations, diseases are as follows:

Body temperature rises to subfebrile numbers or may remain normal;

There are no sore throats, there is a feeling of awkwardness, a foreign body when swallowing;

Putrid breath, increased salivation.
With pharyngoscopy pathological changes are found on one amygdala:

Greyish or yellowish bloom in the upper pole;

After the plaque is rejected, a deep ulcer is formed with uneven edges and a loose bottom.
Regional nodes are enlarged on the affected side,

moderately painful.

The duration of the disease is from 1 to 3 weeks.

Treatment ulcerative necrotizing tonsillitis is carried out in the infectious department of the hospital. Upon admission, a bacteriological examination is carried out to clarify the diagnosis.

Local treatment includes:

Cleansing ulcers from necrosis with 3% hydrogen peroxide solution;

Irrigation of the pharynx with a solution of potassium permanganate, furacilin;

Lubrication of ulcers with tincture of iodine, a mixture of 10% suspension of novarsenol in glycerin;

Primary stage syphilis in the throat can occur during oral sex, while there are the following clinical manifestations:

Slight pain when swallowing on the affected side;

On the surface of the amygdala, red erosion is determined, the ulcer or the amygdala takes on the appearance of acute tonsillitis;

The tissue of the almond is dense when felt;

There is a unilateral increase in lymphatic
nodes.

Secondary syphilis pharynx has the following characteristic features:

Spilled copper-red color of the mucous membrane, capturing the arches, soft and solid sky;

A papular rash of a round or oval shape, grayish-white;

Increased regional lymph nodes.
Tertiary syphilis manifests itself in the form of limited

a gummy tumor, which, after disintegration, forms a deep ulcer with smooth edges and a greasy bottom with further destruction of the surrounding tissues in the absence of treatment.

Treatment specific, locally prescribed rinsing with disinfectant solutions (see the section "Chronic specific diseases of the ENT organs").

Herpetic tonsillitis refers to diseases caused by adenoviruses. The causative agent of herpangina is the Coxsackie virus of group A. The disease is epidemic in nature, in summer and autumn and is highly contagious. Children are more likely to get sick, especially younger age.

Clinical manifestations the following:

Temperature rise up to 38 ~ 40 о С;

Sore throat when swallowing;

Headache, muscle pain in the abdomen;

Vomiting and loose stools are noted in young children.

In adults, the disease is milder.

With pharyngoscopy is determined by:

Hyperemia of the pharyngeal mucosa;

Small vesicles on a hyperemic base in the soft palate, uvula, palatine arches, sometimes on the back of the pharynx;

The formation of ulcers at the site of the opened bubbles on the 3-4th day of the disease.

Treatment is carried out at home and includes:

Isolation of the patient from others, compliance with the sanitary and hygienic regime;

Sparing diet, drinking plenty of vitamins;

Irrigation of the pharynx with solutions of potassium permanganate, furacilin, iodine povidone;

Treatment antiviral agents(interferon);

Anti-inflammatory therapy (paracetamol, nurofen, etc. .);

Detoxification therapy is indicated in young children in severe cases, and hospitalization is necessary.

Fungal tonsillitisv lately has become widespread in the following reasons:

Decreased immunity in the general population;

Insufficiency of the immune system in early children
age;

Postponed serious diseases that reduce the nonspecific defenses of the body and change the composition of the microflora of hollow organs;

Long-term use of drugs that suppress the body's defenses (antibiotics, corticosteroids, immunosuppressants).

In bacteriological examination fungal tonsillitis, pathogenic yeast-like fungi such as Candida are found.

Typical clinical manifestations the following:

Temperature rise is inconsistent;

Sore throat is minor, dryness, impaired taste;

The phenomena of general intoxication are poorly expressed.
With pharyngoscopy is determined by:

Enlargement and slight hyperemia of the tonsils, bright white, loose, cheesy plaque that can be easily removed without damaging the underlying tissue.
Regional lymph nodes are enlarged, painless.

Treatment is carried out as follows:

Cancellation of broad-spectrum antibiotics;

Irrigation of the pharynx with a solution of quinosol, iodinol, hexoral, povidone iodine;

Insufflation of nystatin, levorin;

Lubrication of the affected areas with 2% water or alcohol solutions of aniline paints - methylene blue and gentian violet, 5% silver nitrate solution;

Nystatin, levorin, diflucan orally in a dosage appropriate for age;

Large doses of vitamins C and B group;

Immunostimulating drugs, imudon;

Ultraviolet irradiation of the tonsils.

Angina with infectious mononucleosis characterized by the following signs;

Chills, fever up to 39 ~ 40 s C, headache
pain;

An increase in the palatine tonsils, a picture of lacunar, sometimes ulcerative-necrotic tonsillitis;

Increase and soreness of the cervical, submandibular lymph nodes;

Simultaneous enlargement of the liver and spleen;

In the study of blood, an increase in the number of mononuclear cells and a shift in the formula to the left.

Treatment patients are carried out in the infectious diseases department, where they are assigned:

Bed rest, food rich in vitamins;

- local treatment: rinsing with disinfectants and
astringents;

- general treatment: administration of antibiotics to eliminate secondary infection, corticosteroids.
Agranulocytic tonsillitis is one of the characteristic signs of agranulocytosis and has the following
clinical manifestations:

Chills, high temperature - up to 4СГС, general serious condition;

Severe sore throat, refusal to eat and drink;

A necrotic, dirty gray plaque that covers the mucous membrane of the pharynx and oral cavity;

Unpleasant putrid odor from the mouth;

The spread of the necrotic process deep into the tissues;

In the blood there is a pronounced leukopenia and a pronounced shift of the leukocyte formula to the right.

Treatment carried out in the hematology department:

Bed rest, gentle diet;

Thorough care of the oral cavity;

Prescription of corticosteroids, pentoxil, vitamin therapy;

Bone marrow transplantation;

Fight against secondary infection.

Chronic tonsillitis. This diagnosis means chronic inflammation of the tonsils, which is more common than inflammation of all the other tonsils combined. The disease usually affects school-age children from 12 to 15% and adults up to 40 years old - from 4 to 10%. This pathology is based on an infectious-allergic process, which manifests itself as repeated sore throats and causes damage to many organs and systems. Therefore, knowledge of the symptoms of the disease, its timely detection and rational treatment will help prevent the occurrence of complications in patients and the need for surgery.

Causes the development of a chronic inflammatory process in the palatine tonsils are as follows:

Change in the reactivity of the body;

Difficulty in nasal breathing due to curvature of the nasal septum, hypertrophy of the turbinates, enlargement of the adenoids;

Chronic focal infection (sinuitis, adenoiditis, carious teeth), which is the source of the pathogen and contributes to the occurrence of relapses of tonsillitis;

Postponed childhood infections, repeated respiratory viral diseases, infections of the gastrointestinal tract, which reduce the body's resistance;

The presence of deep lacunae in the tonsils, creating favorable conditions for the development of virulent microflora;

Assimilation of foreign protein, microflora toxins and tissue breakdown products in lacunae, contributing to local and general allergization of the body;

Extensive lymphatic and circulatory pathways, leading to the spread of infection and the development of complications of an infectious-allergic nature.
Chronic tonsillitis should be attributed to the actual infectious diseases, caused for the most part by autoinfection. According to the latest data
foreign and domestic publications in the etiology of chronic tonsillitis takes the leading place beta-hemolytic staphylococcus aureus group A- in children 30%, in
adults 10-15%, then Staphylococcus aureus, hemolytic staphylococcus, anaerobes, adenoviruses, herpes virus, chlamydia and toxoplasma.

The variety of local and general signs of chronic tonsillitis and their relationship with other organs made it necessary to systematize these data. There are several classifications of chronic tonsillitis. Currently received the most widespread recognition classification by I. B. Soldier(1975), dividing chronic tonsillitis into specific(syphilis, tuberculosis, scleroma) and nonspecific, which in turn is divisible by compensated and decompensated form. According to the well-known classification of B.S. Preobrazhensky, a simple form of chronic tonsillitis and a toxic-allergic form are distinguished.

The reason for staging diagnosis chronic tonsillitis are frequent sore throats in history, local pathological signs and general toxic-allergic phenomena. It is advisable to evaluate the objective signs of chronic inflammation of the palatine tonsils no earlier than 2-3 weeks after the exacerbation of the disease.

Compensated form of chronic tonsillitis characterized by the following features: Patient complaints:

Sore throat in the morning, dryness, tingling;

Feeling awkward or foreign when swallowing;

Bad breath;

An indication of a history of tonsillitis.

Pharyngoscopy data (local signs) inflammatory process in the pharynx:

Changes in the arches - hyperemia, roller-like thickening and swelling of the edges of the anterior and posterior arches;

Adhesions of the palatine arches with the tonsils as a result of repeated tonsillitis;

Uneven coloration of the tonsils, their looseness, pronounced lacunar pattern;

The presence of purulent-caseous plugs in the depths of the lacunae or liquid creamy pus, which are detected by pressing with a spatula at the base of the anterior palatine arch;

Hypertrophy of the palatine tonsils in chronic tonsillitis, which occurs mainly in children;

The increase and soreness of regional lymph nodes in the submandibular region and along the anterior edge of the sterno-mastoid muscle is a characteristic symptom of the disease.

The presence of 2-3 of the listed signs provides a basis for the diagnosis. With a compensated form of the disease in the period between angina, the general condition is not disturbed, there are no signs of intoxication and allergization of the body.

Decompensated form chronic tonsillitis is characterized by the above local characteristics pathological process in the tonsils, the presence of exacerbations 2-4 times a year, as well as common manifestations of decompensation:

The appearance of low-grade fever in the evenings;

Increased fatigue, decreased performance;

Periodic pain in the joints, in the heart;

Functional disorders of the nervous, urinary and other systems;

Availability, especially during periods of exacerbation, diseases associated with chronic tonsillitis- having a common etiological factor and mutual
action on each other. Such diseases of an infectious and allergic nature include: acute and

chronic tonsillogenic sepsis, rheumatism, infectious arthritis, diseases of the heart, urinary system, meninges and other organs and systems.

Local complications that occur in the pharynx against the background of repeated sore throats are evidence of decompensation of the inflammatory process in the pharynx, these include: paratonsillitis, retropharyngeal abscess.

Accompanying illnesses do not have a single etiological and pathogenetic basis with chronic tonsillitis, the connection is carried out through general and local reactivity. An example of such diseases can be: hypertension, hyperthyroidism, diabetes mellitus, etc.

Treatment of chronic tonsillitis. due to the form of the disease: with compensated form held conservative treatment, at decompensated form recommended surgery- tonsillectomy- complete removal of the tonsils.

Conservative treatment chronic tonsillitis should be complex - local and general. It should be preceded by the sanitation of foci of infection in the oral cavity, nasal cavity and paranasal sinuses.

Local treatment includes the following activities:

1. Washing the lacunae of the tonsils and rinsing with antiseptic solutions (furacillin, iodinol, dioxidin, quinosol, octenisept, ektericide, chlorhexidine, etc.)
course of 10-15 procedures. Washing lacunae with interferon stimulates the immunological properties of the tonsils.

2. Extinguishing the lacunae of the tonsils with Lugol's solution or 30% alcohol tincture propolis.

3. Introduction to Lacunae of antiseptic ointments and pastes on a paraffinobalsamic basis.

4. Intra-amygdala novocaine blockade.

5. The introduction of antibiotics and antiseptic drugs in accordance with the sensitivity of the flora.

6. The use of local immunostimulating drugs: levamisole, dimexide, splenin, IRS 19, ribomunil, Imudon, etc.

7. Reception of oroseptics: pharyngosept, hexalysis, laryplus, neoangin, septolet, etc.

8. Treatment with the apparatus "Tonsilor", which combines ultrasound effect on the tonsils, aspiration of pathological contents from the lacunae and pockets of the tonsils and irrigation antiseptic solutions... The course of treatment consists of 5 sessions every other day.

9. Physiotherapeutic methods of treatment: ultraviolet irradiation, phonophoresis of lidase, vitamins, UHF, laser therapy, magnetotherapy.

10. Aromatherapy: essential oils of eucalyptus, cedar, tea tree, lavender, grapefruit, etc.

General therapy for chronic tonsillitis is carried out as follows:

1. Antibiotic therapy is used for exacerbation of chronic tonsillitis after determining the sensitivity of microflora. Antibiotic treatment should be accompanied by the prevention of dysbiosis.

2. Anti-inflammatory therapy is prescribed for an acute process with a hyperergic reaction (paracetamol, aspirin, etc.)

3. Antihistamines are prescribed to prevent complications of an infectious and allergic nature.

4. Immunostimulating therapy should be carried out both during an exacerbation and outside it. Thymus gland extract preparations are prescribed: thymalin, timoptin, vilosen, tim-uvocal; immunocorrectors of microbial origin; natural immunostimulants: ginseng,
echinocea, propolis, pantocrinum, chamomile, etc.

5. Antioxidants, whose role is to improve metabolism, work of enzyme systems, increase immunity: rutin-containing complexes, vitamins of groups A, E, C, trace elements - Zn, Mg, Si, Fe, Ca.

The treatment described above is carried out 2-3 times a year, more often in the autumn-spring period, and gives a high therapeutic effect.

The criterion for the effectiveness of treatment is an:

1. Disappearance of pus and pathological contents in the tonsils.

2. Reduction of hyperemia and infiltration of the palatine arches and tonsils.

3. Reduction and disappearance of regional lymph nodes.

In the absence of these results or the occurrence of exacerbations of the disease, it is indicated tonsillectomy.

Decompensated form treatment chronic tonsillitis is carried out surgically with complete removal of the tonsils along with the adjacent capsule.

Contraindication for tonsillectomy is an:

Severe cardiovascular insufficiency;

Chronic renal failure

Diseases of the blood;

Severe diabetes mellitus;

High degree of hypertension with possible development
hypertensive crises, etc.

In such cases, semi-surgical methods of treatment are used. (cryotherapy- freezing the tissue of the tonsil) or conservative treatment.

Preparing for surgery held in outpatient and includes:

Remediation of foci of infection;

Blood test for coagulability, content
platelets, prothrombin index;

Blood pressure measurement;

Examination of internal organs.

The operation is performed on an empty stomach under local anesthesia using a special set of instruments.

Most frequent complication tonsillectomy is bleeding from the amygdala region.

Patient care in the postoperative period the nurse should do the following: - lay the patient on the right side on a low pillow;

prohibit getting up, actively moving in bed and talking;

Place a diaper under the cheek and ask the patient not to swallow, but to spit out saliva;

Observe the patient's condition and the color of saliva for two hours;

Tell your doctor if you have bleeding if necessary;

Give a few sips of cold liquid in the afternoon;

Feed the patient a liquid or pureed, cool beggar for 5 days after surgery;

Irrigate the throat several times a day with aseptic solutions.

Prophylaxis chronic tonsillitis is as follows:

Combating environmental pollution;

Improving the hygienic conditions of work and life;

Improving the socio-economic standard of living of the population;

Active identification of persons suffering from chronic tonsillitis and the implementation of dispensary supervision over them;

Timely isolation of patients and the appointment of adequate treatment;

Individual prevention consists in the rehabilitation of foci of infection and increasing the body's resistance to the harmful effects of the external environment.
Clinical examination patients with chronic tonsillitis

is an effective method of improving the health of the population. Main goals dispensaries in otorhinolaryngology are as follows:

Timely identification of patients with chronic and often recurrent diseases;

Systematic monitoring of them and active treatment;

Identification of the causes of this disease, and the implementation of recreational activities;

Evaluation of the results of the work done.

There are three stages of clinical examination:

Stage 1 - registering - includes the identification of persons subject to clinical examination, drawing up a plan of treatment and prophylactic measures and dynamic observation. Selection of patients is carried out by the passive method when patients seek medical help and by the active method in the process of carrying out preventive
inspections. The first stage of dispensary is coming to an end preparation of medical documentation and preparation specific individual plan medical professionals
lactic activities.

Stage 2 - execution- requires long-term observation. At the same time, measures are needed to improve the health literacy of the population, systematic about
follow-up of patients and implementation of preventive courses of treatment. In chronic tonsillitis, it is advisable to conduct such courses in spring and autumn, which corresponds to periods of exacerbation.

Stage 3 - quality and efficiency assessment dispensary observation. The results of the examination of patients and the courses of treatment carried out are reflected at the end of the year in
epicrisis. The disappearance of signs of chronic tonsillitis and exacerbations of the disease within two years are the basis for removing the patient from the dispensary
accounting in a compensated form of chronic tonsillitis. If there is no effect from the measures taken, the patient is sent for surgical treatment.

To assess the effectiveness of the organization of work, indicators of the quality of medical examination are determined.

22.11.2017

Chronic illnesses throat and larynx (ENT)

Chronic diseases of the upper respiratory tract include: laryngitis, pharyngitis, tonsillitis. Laryngitis is a nonspecific inflammation of the larynx mucosa.

The reasons for the development of diseases are very diverse. Laryngitis has the following causes:

• bacterial infection;
• frequent acute course of laryngitis;
• dry dirty air;
• smoking;
• overvoltage vocal cords.

For example, the main symptom of laryngitis is a barking cough. There is also a complete or partial loss of voice, dry and sore throat, hoarseness.

Types of chronic ENT disease - laryngitis

There are three forms of chronic laryngitis:

• catarrhal;
• hyperplastic;
• atrophic.

In the catarrhal form, hyperemia of the laryngeal mucosa is observed, a small space is formed between the ligaments. The hyperplastic form develops if the treatment of laryngitis was not timely. At this stage, the cells of the laryngeal mucosa begin to grow rapidly. They can be localized throughout the larynx or in some of its parts. Since the glands perform their function poorly, the entire larynx is covered with viscous mucus.

What does laryngitis look like inside

The most recent and dangerous form is an atrophic form characterized by constant hoarseness, dryness, frequent and prolonged cough, sputum production with blood clots. A complication of chronic laryngitis can be stenosing laryngitis (false croup). It manifests itself in the form of respiratory failure due to laryngeal edema, usually at night. Stenoses are acute and chronic. Acute develop in a very short period of time. They are very dangerous in both children and adults, so you need to immediately provide first aid and call an ambulance. Chronic stenoses develop for a very long time and have a more persistent character.

Laryngitis treatment is complex, that is, both medications and therapeutic procedures are used. One of the most common methods is inhalation.

Each form of chronic laryngitis has its own characteristics of treatment. So with a catarrhal form, anti-inflammatory drugs are used. Steroids and antibiotics are prescribed for hyperplastic form. And with an atrophic form of laryngitis, it is recommended:

• anti-inflammatory;
• steroid;
• antibiotics;
• physiotherapy procedures (thermal inhalation, electrophoresis, UHF).

Preventive methods include airway sanitation and the necessary voice mode.

Pharyngitis

Chronic pharyngitis is a chronic inflammation of the pharyngeal mucosa. It develops as a result frequent illnesses pharyngitis, proceeding in an acute form, infections of the throat and larynx, irritation of the laryngeal mucosa by chemicals.

The same reason can be chronic diseases ear, throat and nose, chronic diseases of gastritis, pancreatitis, DZhVP, ARVI, reduced immunity, bad habits(smoking and alcohol).

Types of chronic pharyngitis:

• simple;
• catarrhal (the patient feels a constant sore throat, dryness, sore throat);
• subatrophic (there is a diffuse proliferation of lymphoid tissue, dryness in the throat is also noted, viscous mucus appears on the back of the throat);
• hypertrophic (sclerosis of the mucous membrane occurs, while crusts are formed, which are very difficult to separate; a dry, debilitating cough appears).

The main symptoms may be nasal and auditory congestion, a feeling of a foreign body in the throat, constant swallowing of a viscous secretion, a hoarse voice, redness of the mucous membrane. Treatment is aimed at eliminating irritating factors. You should stop smoking and alcohol, spicy, salty and acidic foods. A plentiful warm drink is necessary.

Gargle regularly with herbal decoctions that contain antiseptic and anti-inflammatory substances, throat lubrication and inhalation. In addition to local treatment, general treatment is also necessary. Antibiotics are prescribed antibacterial drugs, pain relievers. Treatment is much effective when using UHF, ultrasound. After the provided therapy, a course of drugs that improve immunity is prescribed.

Tonsillitis

Tonsillitis is a disease that affects the palatine and pharyngeal tonsils, often caused by a viral infection. The development of chronic tonsillitis is facilitated by frequent tonsillitis, acute respiratory viral infections, also untreated diseases of the oral cavity (caries, periodontal disease), sinusitis, sinusitis. The disease can take two forms.

With tonsillitis, the tonsils swell

The first form is expressed in frequently recurring tonsillitis, and the second is an inflammatory process in the tonsils, which is very sluggish. In this case, the patient feels:

• malaise;
• nervousness;
• irritability;
• lethargy;
• rapid fatigue;
• headache;
• in the evening, subfebrile body temperature is possible;
• joint pain;
• sore throat and sore throat;
• cough in the morning;
• there may be an unpleasant odor from the mouth.

Chronic tonsillitis

Chronic tonsillitis can cause changes in the immune system, possible failures in the work of the heart and kidneys. Specific symptoms include:

• swollen lymph nodes;
• enlargement of the palatine and pharyngeal tonsils;
• pain in the submandibular and parotid lymph nodes.

There are two types of treatment:

• conservative;
• surgical.

Conservative treatment includes bed rest, a gentle diet, plenty of fluids, tonsil debridement, antibacterial and antiseptic therapy, antimicrobial therapy, broad-spectrum antibiotics (for severe disease), inhalations and immunostimulants.

Surgical intervention is used if the patient suffers from angina up to four times a year. At the same time, in the gaps there is purulent formations, the performance of internal organs and systems deteriorates.

Prevention of chronic diseases

For the prevention of chronic diseases of the upper respiratory tract, doctors recommend:

• proper nutrition;
• keep your home and workplace clean;
• timely treatment of teeth, gums, sinusitis.

During an epidemic of influenza and SARS, drink vitamins. When what first symptoms appear, it is necessary to consult a therapist and an otolaryngologist.

Everyone in his life had to meet with various diseases of the ENT organs, most often there are viral or bacterial infections in the form of ARVI, flu or tonsillitis. But there are a number of other pathologies, the symptoms of which need to be known in order to diagnose the disease in time.

The structure of the pharynx and larynx

To understand the essence of the disease, one should have a minimal understanding of the structure of the larynx and pharynx.

Regarding the pharynx, it consists of three sections:

• upper, nasopharynx;
• oropharynx, middle section;
• hypopharynx, lower section.

The larynx, an organ that has multiple functions. The larynx is a conduit for food to the digestive tube, and it is also responsible for the flow of air into the trachea and lungs. In addition, the vocal cords are located in the larynx, thanks to which a person has the ability to make sounds.

The larynx functions as a movement apparatus that has cartilage connected to the ligaments and joints of the muscles. At the beginning of the organ is the epiglottis, the function of which is to create a valve between the trachea and the pharynx. At the moment of swallowing food, the epiglottis blocks the entrance to the trachea, so that food enters the esophagus, and not into the respiratory system.

What are the pathologies of ENT organs

According to their course, diseases are classified into: chronic and acute. In the case of an acute course of the disease, the symptoms develop instantly, they are pronounced. Pathology is more difficult to tolerate than in a chronic course, but recovery occurs faster, on average in 7-10 days.

Chronic pathologies arise against the background of a constant, untreated inflammatory process. In other words, the acute form becomes chronic without proper treatment. In this case, the symptoms do not appear so rapidly, the process is sluggish, but complete recovery does not occur. At the slightest provoking factors, for example, hypothermia or ingestion of a virus, a relapse of a chronic disease occurs. As a result of a constant infectious focus, human immunity is weakened, because of this it is not difficult for a virus or bacteria to penetrate.

Diseases of the pharynx, as well as the larynx:

• epiglottitis;
• pharyngitis;
• tonsillitis;
• laryngitis;
• rhinopharyngitis;
• adenoids;
• laryngeal cancer.

Epiglottitis

Diseases of the larynx include inflammation of the epiglottis (epiglottitis). The cause of the inflammatory process is the ingress of bacteria into the epiglottis by airborne droplets. Most often, the epiglottis affects the hemophilus influenza and becomes the cause of the inflammatory process. The bacterium can not only cause epiglottis disease, but is also the causative agent of meningitis, pneumonia, pyelonephritis and other pathologies. In addition to hemophilus influenza, the following can cause inflammation of the epiglottis:

• streptococci;
• pneumococci;
• candida fungus;
• burns or foreign body ingress into the epiglottis.

The symptoms of the disease develop rapidly, among the main ones are:

• difficult breathing with a whistle. Edema occurs in the epiglottis, which leads to a partial overlap of the larynx and trachea, which complicates the possibility of normal air flow;
• pain when swallowing, difficulty swallowing food with a feeling that something is in the larynx;
• redness of the throat, pain in him;
• fever and fever;
• general weakness, malaise and anxiety.

Epiglottitis occurs more often in children aged 2 to 12 years, mostly in boys. The main danger posed by inflammation of the epiglottis is the possibility of suffocation, therefore, at the first symptoms of the disease, you should immediately consult a doctor. There are acute and chronic inflammations of the epiglottis. If an acute form of pathology has developed, the child should be urgently taken to the hospital, transportation should be done in a sitting position.

Treatment consists of antibiotic therapy and maintenance of the upper airway. If the life-threatening symptoms cannot be stopped, a tracheotomy is performed.

Nasopharyngitis

Inflammation of the nasopharynx, which occurs by the infection of the throat and nose with a virus, is called rhinopharyngitis. Symptoms of nasopharyngeal inflammation:

• nasal congestion, as a result, difficulty breathing;
• acute sore throat, burning sensation;
• difficulty swallowing;
• nasty voice;
• temperature increase.

Children are more difficult to tolerate the inflammatory process in the nasopharynx than adults. Often, the focus of inflammation from the nasopharynx spreads to auricle, that leads to acute pain in the ear. Also, when the infection descends into the lower respiratory tract, the symptoms are accompanied by a cough, hoarseness.

On average, the course of nasopharyngeal disease lasts up to seven days, with correct treatment, the chronic form of rhinopharyngitis does not take. The therapy is designed to eliminate painful symptoms. If the infection is caused by a bacterium, antibacterial drugs are prescribed, in the case of a viral infection, anti-inflammatory drugs are prescribed. It is also necessary to rinse the nose with special solutions and take antipyretic drugs if necessary.

Laryngeal diseases include acute and chronic laryngitis. Acute form pathology, rarely develops in isolation, more often laryngitis becomes a consequence of a respiratory disease. In addition, acute laryngitis can develop as a result of:

• hypothermia;
• with a long stay in a dusty room;
• as a result allergic reaction for chemical agents;
• the result of smoking and drinking alcoholic beverages;
• professional overload of the vocal cords (teachers, actors, singers).

Symptoms of such a disease of the larynx as laryngitis are characterized by:

Acute laryngitis with voice rest and the necessary treatment disappears within 7-10 days. If the doctor's recommendations regarding treatment are not followed, the symptoms of the disease do not go away, and the laryngitis itself becomes chronic. When laryngitis is recommended:

• alkaline inhalation;
• voice peace;
• warm drink;
• antitussive drugs;
• antiviral and immunomodulatory agents;
• antihistamines for severe swelling;
• gargling;
• hot foot baths, to drain blood from the larynx and reduce its swelling, etc.

Pharyngitis

Diseases of the pharynx are most often expressed in the form of pharyngitis. This infectious pathology often develops against the background of a viral or bacterial lesion of the upper respiratory tract. Isolated pharyngitis occurs as a result of direct exposure to the pharyngeal mucosa of the irritant. For example, when talking for a long time in cold air, eating too cold or, conversely, hot food, as well as smoking and drinking alcohol.

The symptoms of pharyngitis are as follows:

• sore throat;
• pain when swallowing saliva;
• feeling of abrasion;
• pain in the ear when swallowing.

Visually, the mucous membrane of the pharynx is hyperemic, in places an accumulation of purulent secretions can be observed, the tonsils are enlarged and covered with a whitish coating. It is important to differentiate acute pharyngitis from catarrhal sore throat. Treatment is mainly local in nature:

• gargling;
• inhalation;
• compresses on the neck area;
• absorbable sore throat lozenges.

Chronic pharyngitis develops from acute, as well as against the background of chronic tonsillitis, sinusitis, dental caries, etc.

Diseases of the pharynx can be expressed as a sore throat. Inflammation of the lymphoid tissue of the tonsils is called sore throat or tonsillitis. Like other diseases of the pharynx, tonsillitis can be acute or chronic. Pathology in children is especially frequent and acute.

The cause of the development of tonsillitis is viruses and bacteria, mainly the following: staphylococcus, streptococcus, pneumococcus, fungi of the genus Candida, anaerobes, adenoviruses, influenza viruses.

Secondary tonsillitis develops against the background of other acute infectious processes, for example, measles, diphtheria or tuberculosis. Symptoms of sore throat begin acutely, they are similar to pharyngitis, but have certain differences. The tonsils greatly increase in volume, are painful to the touch, depending on the form of tonsillitis, are covered with a purulent coating or their lacunae are filled with purulent contents. Cervical lymph nodes are enlarged and may be painful when pressed. The body temperature rises to 38-39 degrees. There is pain in the throat when swallowing and itching.

The classification of tonsillitis is quite extensive, the following forms are distinguished:

• catarrhal - superficial damage to the tonsils occurs. the temperature rises slightly, within 37-37.5 degrees. Mild intoxication;
• lacunar, the tonsils are covered with a yellowish-white coating, the content of purulent secretion is observed in the lacunae. The inflammatory process does not extend beyond the lymphoid tissue;
• follicular, tonsils are bright scarlet, edematous, suppurating follicles in the form of whitish-yellowish formations are diagnosed;
• phlegmonous form, often a complication of the previous types of tonsillitis. Not only the tonsils are affected, but also the peri-tonsil tissue. The pathology proceeds acutely, with sharp pain, more often an abscess occurs on one side. Regarding the treatment, opening of the purulent sac and further antibiotic therapy is required.

Treatment is mainly medication, antibacterial and local effects on the pharyngeal mucosa. In cases where the pathology becomes chronic, systematically recurrent tonsillitis or the presence of an abscess are indications for the removal of the tonsils. Surgical excision of lymphoid tissue is used in extreme cases if drug therapy does not bring the desired results.

Adenoid vegetation

Adenoids are hypertrophy of the nasopharyngeal tonsil that occurs in the nasopharynx. Most often diagnosed in childhood from 2 to 12 years. As a result of the proliferation of adenoid vegetation, nasal breathing is blocked and vomiting of the voice occurs, with prolonged presence of adenoids, hearing impairment occurs. Hypertrophy of the nasopharyngeal tonsil has three stages, the second and third are not amenable to drug treatment and requires surgical intervention- adenotomy.

Foreign bodies in the larynx or pharynx

The reason for the ingress of a foreign body into the pharynx is most often inattention or haste when eating. Children without parental supervision may try to swallow various small objects, such as toy parts.

Such situations can be extremely dangerous, it all depends on the shape and size. foreign object... If an object enters the larynx and partially blocks its lumen, there is a danger of suffocation. Symptoms of a person choking on are:

This situation requires urgent medical care to the victim. Emergency assistance should be provided immediately, otherwise there is a great risk of suffocation.

Cancer of the pharynx or larynx

Diseases of the pharynx can be different, but cancer is the most terrible and certainly life-threatening. A malignant formation in the pharynx or larynx, in the early stages, may not manifest itself in any way, which leads to late diagnosis and, accordingly, the appointment of therapy is untimely. Symptoms of a tumor in the larynx are:

• persistent foreign body sensation in the larynx;
• desire to cough up, interfering object;
• hemoptysis;
• constant pain in the pharyngeal area;
• difficulty breathing when the tumor reaches a large size;
• dysphonia and even aphonia, with the localization of education near the vocal cords;
• general weakness and disability;
• lack of appetite;
• weight loss.

Oncological diseases are extremely life-threatening and have a disappointing prognosis. Treatment for cancer of the larynx is prescribed depending on the stage of the pathology. The main method is surgery and removal of the malignant formation. Radiation and chemotherapy are also used. Appointments of one or another method of treatment are purely individual.

Each disease, regardless of the complexity of the course, requires attention. You should not self-medicate and even more so establish a diagnosis for yourself. Pathology can be much more complicated than you think. Timely diagnosis and fulfillment of all doctor's prescriptions allows you to achieve complete recovery and the absence of complications.

site

MILITARY-MEDICAL ACADEMY

Department of Otolaryngology Ex. No. _____

"APPROVED"

VrID of the Head of the Department of Otorhinolaryngology

Colonel of the Medical Service

M. GOVORUN

"____" ______________ 2003

Lecturer at the Department of Otolaryngology

Candidate of Medical Sciences

Major of the medical service D. Pyshny

LECTURE number 18

on otolaryngology

on the topic: “Diseases of the pharynx. Abscesses of the pharynx "

For students of the faculty of the leading medical staff

Discussed and approved at a meeting of the department

protocol No. ______

"___" __________ 2003

Clarified (supplemented):

«___» ______________ _____________

Inflammatory diseases of the pharynx.

Abscesses of the pharynx.

Literature

Otolaryngology / Ed. I.B. Soldatov and V.R. Hoffman.- SPb., 2000.- 472 p .: ill.

Elantsev B.V. Operative otorhinolaryngology. -Alma-Ata, 1959, 520 p.

Soldatov I.B. Lectures on otorhinolaryngology. - M., 1990, 287 p.

Tarasov D.I., Minkovsky A.Kh., Nazarova G.F. Ambulance and emergency care in otorhinolaryngology. - M., 1977, 248s.

Shuster M.A. Emergency care in otorhinolaryngology. - M. 1989, 304 p.

Diseases of the pharynx

Inflammatory diseases of the pharynx

Sore throats

Angina- acute inflammation of the lymphadenoid tissue of the pharynx (tonsils), which is considered a common infectious disease. Sore throats can be difficult and give a variety of complications. Quinsy of the palatine tonsils are more common. Their clinical picture is well known. These sore throats are differentiated from diphtheria, scarlet fever, specific tonsillitis and lesions of the tonsils in general infectious, systemic and oncological diseases, which is very important for the appointment of adequate emergency therapy.

Angina of the pharyngeal tonsil(acute adenoiditis). This disease is typical for childhood... It occurs more often simultaneously with acute respiratory viral diseases (ARVI) or tonsillitis, and in these cases it usually remains unrecognized. Adenoiditis is accompanied by the same changes in the general condition as sore throat. Its main clinical signs are a sudden violation of free nasal breathing or its deterioration, if it was not normal before, a runny nose, a feeling of stuffiness in the ears. There may be coughing and sore throat. Examination reveals hyperemia of the posterior pharyngeal wall, flowing down mucopurulent discharge. The pharyngeal tonsil increases, swells, hyperemia of its surface appears, sometimes plaque. By the time of the maximum development of the disease, lasting 5-6 days, changes in regional lymph nodes are usually noted.

Adenoiditis should be differentiated primarily from the pharyngeal abscess and diphtheria. It must be remembered that measles, rubella, scarlet fever and whooping cough can begin with the onset of symptoms of acute adenoiditis, and if a headache joins, then meningitis or poliomyelitis.

Angina of the lingual tonsil... This type of sore throat is much less common than its other forms. Patients complain of pain in the area of ​​the root of the tongue or in the throat, as well as when swallowing, protruding the tongue is painful. The lingual tonsil turns red and swells, plaques may appear on its surface. At the time of the pharyngoscopy, pain is felt when the spatula is pressed against the back of the tongue. General violations the same as with other tonsillitis.

If the inflammation of the lingual tonsil takes on a phlegmonous character, then the disease proceeds more severely with a high body temperature and the spread of edematous-inflammatory changes to the external parts of the larynx, primarily to the epiglottis. The lymph nodes of the neck enlarge and become painful. In this case, the disease must be differentiated from inflammation of the cyst and ectopic thyroid tissue in the area of ​​the tongue root.

Treatment. With the development of any sore throat, which is an acute infectious disease that can cause serious complications, treatment should be started immediately. Prescribe orally antibiotics of the penicillin series (for intolerance - macrolides), food should be gentle, you need plenty of drink, vitamins. In severe angina, strict bed rest and intensive parenteral antibiotic therapy, primarily penicillin in combination with desensitizing drugs, are prescribed. If necessary, use broad-spectrum antibiotics (cephalosporins, aminoglycosides, fluoroquinolones, metrogil).

As for local treatment, it depends on the localization of the inflammation. With adenoiditis, vasoconstrictor nasal drops (naphthyzin, galazolin,), protorgol are necessarily prescribed. For tonsillitis of the palatine and lingual tonsils - warm bandages or compress on the neck, rinsing with a 2% solution of hydrochloric acid or sodium bicarbonate, a solution of furacilin (1: 4000), etc.

Sore throat ulcerative membranous (Simanovsky). The causative agents of ulcerative membranous sore throat are the spindle-shaped bacillus and the spirochete of the oral cavity in symbiosis. After a short phase of catarrhal sore throat, superficial, easily removable whitish-yellowish plaques form on the tonsils. Less commonly, such plaques also appear in the oral cavity and pharynx. Ulcers, usually superficial, but sometimes deeper, remain at the site of rejected plaques. Regional lymph nodes on the affected side are enlarged. Painful sensations are not strong. Body temperature is normal or subfebrile. There may be bad breath associated with necrotic changes in the bottom of the ulcers. When assessing the clinical picture, it should be borne in mind that occasionally there is a lacunar form of the disease, similar to a common sore throat, as well as bilateral lesions of the tonsils.

The diagnosis is established on the basis of the detection of fusospirillary symbiosis in smears from the surface of the tonsils (removed films, prints from the bottom of ulcers). Filmy ulcerative sore throat should be differentiated from diphtheria, tonsil lesions in diseases of the hematopoietic organs, and malignant tumors.

For treatment, rinse with hydrogen peroxide (1-2 tablespoons per glass of water), a solution of rivanol (1: 1000), furacilin (1: 3000), potassium permanganate (1: 2000) and lubrication 5% alcohol solution iodine, 50% sugar solution, 10% salicylic acid solution diluted in equal parts of glycerin and alcohol, 5% formalin solution. If clinical signs of a secondary infection appear, antibiotics are prescribed.

Angina with infectious mononucleosis. This is a common disease of viral etiology, starting acutely with a high body temperature (up to 40 ° C) and usually sore throat. In most patients, there is a lesion of the tonsils, which significantly increase in size. Often, the third and fourth tonsils also enlarge, which can lead to difficulty breathing. On the surface of the amygdala, plaques of various nature and color are formed, sometimes of a lumpy-cheesy appearance, usually easily removable. A putrid odor from the mouth appears. The pain syndrome is not clearly expressed. The cervical lymph nodes of all groups are enlarged, as well as the spleen and sometimes lymph nodes in other areas of the body, which become painful.

The diagnosis is made on the basis of the results of a blood test, however, in the first 3-5 days, there may be no characteristic changes in the blood. Later, as a rule, moderate leukocytosis, sometimes up to 20-30 l0 9 / l, neutropenia with the presence of a nuclear shift to the left and severe mononucleosis are revealed. At the same time, there is a slight increase in the number of lymphocytes and monocytes, the presence of plasma cells, varied in size and structure, with the appearance of a kind of mononuclear cells. A high relative (up to 90%) and absolute mononucleosis with typical mononuclear cells at the height of the disease determines the diagnosis of this disease. It is differentiated from banal tonsillitis, diphtheria, acute leukemia.

Treatment is mainly symptomatic; rinse the throat with a solution of furacilin (1: 4000) 4-6 times a day. When signs of secondary infection appear, antibiotics are prescribed.

Angina with agranulocytosis. Currently, agranulocytosis develops most often as a result of taking cytostatics, salicylates and some other drugs.

The disease usually begins acutely, and the body temperature quickly rises to 40 ° C, chills and sore throat are noted. On the palatine tonsils and surrounding areas, dirty gray plaques with necrotizing-gangrenous decay are formed, which often spread to the posterior wall of the oropharynx, the inner surface of the cheeks, and in more severe cases occur in the larynx or the initial part of the esophagus. Sometimes there is a strong odor from the mouth. Occasionally, the tonsils are completely necrotic. In the study of blood, leukopenia is found up to 1 10 9 / l and below, a sharp decrease in the number of neutrophils, eosinophils and basophils up to their absence with a simultaneous increase in the percentage of lymphocytes and monocytes.

It should be differentiated from diphtheria, Simanovsky's tonsillitis, tonsil lesions in blood diseases.

Treatment consists of intensive antibiotic therapy (semisynthetic penicillins), the appointment of corticosteroid drugs, pentoxil, B vitamins, nicotinic acid. In severe cases, a leukocyte mass is transfused.

Diphtheria

Patients with diphtheria need emergency care due to the possibility of developing severe general complications or stenosis in the case of laryngeal localization of the lesion. Even if you suspect diphtheria, the patient must be immediately hospitalized in the infectious diseases department. In recent years, adults have suffered from diphtheria no less and more severely than children.

The most common diphtheria of the pharynx. It should be remembered that mild forms of pharyngeal diphtheria can proceed under the guise of lacunar or even catarrhal sore throat at low or normal (in adults) body temperature. Plaques on the surface of the hyperemic tonsil are at first tender, filmy, whitish, easily removable, but soon they take on a characteristic appearance:

go beyond the amygdala, become dense, thick, grayish or yellowish. Plaques are difficult to remove, leaving an eroded surface.

With the spread of diphtheria, the violation of the general condition of the patient is more pronounced, filmy overlays are also found in the pharynx, nasopharynx, sometimes in the nose, while disturbances in nasal breathing and nasal discharge are noted. However, the spread of the process downward occurs more often with the development of true croup. There is also a swelling of the subcutaneous fatty tissue of the neck.

The toxic form of diphtheria begins as a common acute infectious disease, occurring with a sharp increase in body temperature, headache, and sometimes vomiting. A characteristic feature is the early appearance of edema in the throat and soft tissues of the neck. Cervical lymph nodes are also enlarged and painful. The face is pale, pasty, there are nasal discharge, odor from the mouth, cracks on the lips, and nasal sound. Paresis develops in the later stages of the disease. The hemorrhagic form is rare and very difficult.

The diagnosis in typical cases can be established by the clinical picture, in the rest, which make up the majority, bacteriological confirmation is necessary. The best is the study of the removed plaques and films, in their absence, smears are made from the surface of the tonsils and from the nose (or from the larynx with laryngeal localization). Material from the pharynx is taken on an empty stomach, and before that you should not gargle. Sometimes a diphtheria bacillus is detected immediately on the basis of only a smear bacterioscopy.

Diphtheria of the throat and pharynx area should be differentiated from banal tonsillitis, phlegmonous tonsillitis, thrush, Simanovsky's tonsillitis, necrotic tonsillitis, including scarlet fever; the hemorrhagic form must be distinguished from lesions of the pharynx region associated with diseases of the hematopoietic organs.

Laryngeal diphtheria (croup) occurs as an isolated lesion mainly in toddlers and is rare. More often the larynx is affected in the common form of diphtheria (descending croup). In the beginning, catarrhal laryngitis develops with a violation of the voice and a barking cough. Body temperature becomes subfebrile. In the future, the patient's general condition worsens, aphonia develops, the cough becomes silent and there are signs of difficulty in breathing - an inspiratory stridor with retraction of the "compliant" places of the chest. With increased stenosis, the patient is restless, the skin is covered with cold sweat, pale or cyanotic, the pulse is rapid or arrhythmic. Then the stage of asphyxia gradually begins.

Plaques appear first within the vestibule of the larynx, then in the area of ​​the glottis, which is the main cause of stenosis. Filmy whitish-yellowish or grayish bloom, but in milder forms of laryngeal diphtheria, they may not appear at all.

The diagnosis must be confirmed bacteriologically, which is not always possible. Laryngeal diphtheria should be differentiated from false croup, laryngitis and laryngo-tracheitis of viral etiology, foreign bodies, tumors localized at the level of the vocal folds and below, a pharyngeal abscess.

Diphtheria of the nose as an independent form is very rare, mainly in young children. In some patients, only the clinical picture of catarrhal rhinitis is revealed. Typical films, after rejection or removal of which erosions remain, are not always formed. In most patients, the lesion of the nose is unilateral, which makes it easier to establish a diagnosis, which must be confirmed by the results of a microbiological study. Diphtheria of the nose should be differentiated from foreign bodies, purulent rhinosinuitis, tumors, syphilis, tuberculosis.

Features of diphtheria of the respiratory tract in adults. The disease often proceeds in a severe toxic form with the development of croup descending into the trachea and bronchi. At the same time, in the initial period, it can be worn out and masked by other manifestations of diphtheria, its complications or pathological processes in the internal organs, which complicates the timely establishment of a diagnosis. With croup in patients with a toxic form of diphtheria, especially with descending croup with the involvement of the trachea (and bronchi), tracheostomy is shown in the early stages, and intubation is inappropriate.

Treatment. If any form of diphtheria is detected, and even only if there is a suspicion of the presence of this disease, it is necessary to immediately begin treatment - the introduction of anti-diphtheria serum. In severe forms, multiple injections are made until the plaque regresses. Serum is injected according to the Bezredki method: first, 0.1 ml of serum is injected subcutaneously, 0.2 ml after 30 minutes, and after another 1-1.5 hours - the rest of the dose. With a localized mild form, a single injection of 10,000-30,000 ME is sufficient, with a common one - 40,000 ME, with a toxic form - up to 80,000 ME, with diphtheria descending croup in children - 20,000-30,000 ME of serum. For children under 2 years of age, the dose is reduced by 1.5-2 times.

Patients with croup require oxygen therapy and correction of the acid-base state. It is advisable to administer parenteral corticosteroid hormones (taking into account the patient's age) and prescribe sedatives, and in connection with frequent complications of pneumonia, antibiotics. If there is stenosis of the larynx and within the next hours after the start of treatment with anti-diphtheria serum there is no positive effect, then intubation or tracheostomy is necessary.

Tuberculosis (pharynx, tongue root)

Patients with widespread, mainly exudative-ulcerative, tuberculosis of the upper respiratory tract may require emergency care due to severe sore throat, dysphagia, and sometimes laryngeal stenosis. The defeat of the upper respiratory tract is always secondary to the tuberculous process in the lungs, but the latter is not always diagnosed in a timely manner.

Fresh, recently developed tuberculosis of the mucous membranes is characterized by hyperemia, infiltration, and often swelling of the affected sections, as a result of which the vascular pattern disappears. The resulting ulcers are superficial, with jagged edges; their bottom is covered with a thin layer of purulent discharge, whitish-grayish color. Ulcers are small at first, but soon their area increases; merging, they capture large areas. In other cases, the destruction of the affected areas occurs with the formation of defects in the tonsils, uvula or epiglottis. With damage to the larynx, the voice deteriorates up to aphonia. The condition of patients is moderate or severe, body temperature is high, ESR is increased, there is leukocytosis with an increase in the number of stab neutrophils; the patient notices weight loss.

The diagnosis is made on the basis of the clinical picture and the detection of a tuberculous process in the lungs (X-ray). In ulcerative forms, a good non-traumatic way of rapid diagnosis is a cytological examination of a scraping or an imprint from the surface of the ulcer. In case of a negative result and an unclear clinical picture, a biopsy is performed.

Tuberculosis (mainly exudative ulcerative) of the pharynx and pharynx area should be differentiated from acute banal sore throats and Simanovsky's tonsillitis, erysipelas, agranulocytic tonsillitis. Tuberculosis of the larynx, which is in the same form, must be distinguished from influenza submucous septic laryngitis and abscesses of the larynx, herpes, trauma, erysipelas, acute isolated pemphigus, lesions in diseases of the hematopoietic organs.

The goal of emergency care is to eliminate or at least reduce pain. For this, intradermal blockade is performed with a 0.25% solution of novocaine. Local anesthetic measures consist in anesthesia of the mucous membrane using spraying or lubrication with 2% dicaine solution (10% cocaine solution) with adrenaline. After that, the ulcerative surface is lubricated with an anesthetic mixture of Zobin (0.1 g of menthol, 3 g of anestezin, 10 g of tannin and ethyl alcohol rectified) or Voznesensky (0.5 g of menthol, 1 g of formalin, 5 g of anestezin, 30 ml of distilled water) ... Before eating, you can gargle with a 5% solution of novocaine.

At the same time, general anti-tuberculosis treatment begins: streptomycin (1 g / day), viomycin (1 g / day), rifampicin (0.5 g / day) intramuscularly; inside give isoniazid (0.3 g 2 times a day) or protion-mid (0.5 g 2 times a day), etc. It is necessary to prescribe at least two drugs of different groups.

Abscesses of the pharynx.

Paratonsillitis, paratonsillar abscess

Paratonsillitis of the palatine tonsils. Paratonsillitis is an inflammation of the tissue surrounding the amygdala, which occurs in most cases due to the penetration of the infection beyond its capsule and with complications of angina. Often this inflammation ends with abscess formation. Occasionally, paratonsillitis can have a traumatic, odontogenic (posterior teeth) or otogenic origin with an intact amygdala or be the result of a hematogenous drift of pathogens in infectious diseases.

In its development, the process goes through the stages of exudative-infiltrative, abscess formation and involution. Depending on where the zone of the most intense inflammation is located, anterosuperior, anteroinferior, posterior (retrotonsillar) and external (lateral) paratonsillitis (abscesses) are distinguished. The most common anterior-superior (supratonsillar) abscesses. Sometimes they can develop on both sides. Tonsillar phlegmonous process in the periaminal tissue can develop during sore throat or shortly after.

Paratonsillitis (abscesses) are usually accompanied by fever, chills, general intoxication, severe sore throat, usually radiating to the ear or teeth. Some patients, due to pain, do not eat and do not swallow saliva that flows out of their mouths, do not sleep. In addition, they may develop dysphagia with the throwing of food or liquid into the nasopharynx and nasal cavity. A characteristic symptom is trismus, which makes it very difficult to examine the oral cavity and pharynx; odor from the mouth, a forced position of the head with a tilt forward and to the sore side are also often noted. Submandibular lymph nodes enlarge and become painful on palpation. ESR and leukocytosis usually increase.

With pharyngoscopy in a patient with paratonsillitis, it is usually revealed that the most pronounced inflammatory changes are localized near the amygdala. The latter is enlarged and displaced, pushing back the inflamed, sometimes edematous uvula. The process also involves the soft palate, the mobility of which is therefore impaired. With antero-upper paratonsillitis, the amygdala, displaced downward and posteriorly, can be covered by the anterior arch.

Posterior paratonsillar abscess develops near the posterior palatine arch or directly in it. It becomes inflamed, thickens, sometimes swells, becoming almost vitreous. These changes to one degree or another extend to the adjacent part of the soft palate and uvula. Regional lymph nodes swell and become painful, the corresponding arytenoid cartilage often swells, there is dysphagia, trismus may be less pronounced.

Lower paratonsillitis is rare. An abscess of this localization is accompanied by severe pain when swallowing and protruding the tongue, radiating into the ear. The most pronounced inflammatory changes are observed at the base of the palatine-lingual arch and in the groove separating the palatine tonsil from the root of the tongue and the lingual tonsil. The adjacent part of the tongue is sharply painful when pressed with a spatula and is hyperemic. Inflammatory swelling with or without edema extends to the anterior surface of the epiglottis.

The most dangerous external paratonsillar abscess, in which suppuration occurs lateral to the amygdala, the abscess cavity lies deep and difficult to access, more often than in other forms, respiratory decompensation occurs. However, he, like lower paratonsillitis, is rare. The amygdala and the surrounding soft tissues are relatively little changed, but the amygdala bulges inward. There is pain on palpation of the neck from the corresponding side, the forced position of the head and trismus, regional cervical lymphadenitis develops.

Paratonsillitis should be differentiated from phlegmonous processes that occur in diseases of the blood, diphtheria, scarlet fever, erysipelas of the pharynx, abscess of the lingual tonsil, phlegmon of the tongue and the floor of the mouth, tumors. With maturation and a favorable course, a paratonsillar abscess on the 3-5th day can open up on its own, although the disease is often delayed.

According to VD Dragomiretsky (1982), complications of paratonsillitis are observed in 2% of patients. These are purulent lymphadenitis, perepharyngitis, mediastinitis, sepsis, parotitis, phlegmon of the floor of the mouth, thrombophlebitis, nephritis, pyelitis, heart disease, etc. Antibiotic therapy is indicated for all paratonsillitis. It is advisable to prescribe semisynthetic penicillins, as well as various combinations of broad-spectrum antibiotics, Metrogyl ..

Certain features are characterized by paratonsillitis in children who suffer from them, although rarely, starting from infancy. The smaller the child, the more severe the disease can be: with a high body temperature, leukocytosis and an increase in ESR, accompanied by toxicosis, diarrhea and difficulty breathing. Complications, on the other hand, develop rarely and usually proceed favorably.

When a patient with paratonsillitis is admitted to the hospital, treatment tactics should be immediately determined. With the primary onset of paratonsillitis without signs of abscess formation, as well as with the development of the disease in young children, drug treatment is indicated. Antibiotics for such patients are prescribed in the maximum age-related doses.

Conservative treatment is advisable only in the early stages of the disease. In addition to antibiotics, analgin, vitamins C and B group, calcium chloride, antihistamines (diphenhydramine, tavegil, suprastin) are prescribed ..

The main method of treating paratonsillitis and mandatory paratonsillar abscesses is their opening. In the most common anteroposterior form of paratonsillitis, the abscess is opened through the upper part of the lingual (anterior) arch.

The incision should be long enough (wide), but not deeper than 5 mm. To a great depth, it is permissible to move only bluntly with the help of a forceps in the direction of the tonsil capsule. For posterior abscesses, the incision should be made vertically along the palatopharyngeal arch, and for anteropharyngeal abscesses, through lower part palatine-lingual arch, after which it is necessary to bluntly penetrate outwards and downwards by 1 cm or pass through the lower pole of the tonsil.

Typical opening of anteroposterior abscesses is usually performed either at the point where the pus is visible, or in the middle of the distance between the edge of the base of the uvula and the posterior tooth of the upper jaw on the affected side, or at the intersection of this line with the vertical drawn along the palatine-lingual arch. To prevent vascular injury, it is recommended to wrap the scalpel blade at a distance of 1 cm from the tip with several layers of adhesive plaster or a gauze strip soaked in furacilin solution (used for tamponade of the nasal cavity). Only the mucous membrane should be cut, and deeper to move in a blunt way. Getting into an abscess during its opening is determined by the sudden cessation of tissue resistance to the movement of the forceps.

When opening the posterior abscesses, a vertical incision is made behind the amygdala in the place of the greatest protrusion, but first you need to make sure that there is no arterial pulsation in this area. The scalpel tip should not point to the posterolateral side.

Incision is usually performed under surface anesthesia, carried out by lubrication with a 3% solution of dicaine, which, however, is ineffective, therefore it is advisable to premedicate with promedol beforehand. Reduces pain when opening an abscess submucosal administration of a solution of novocaine or lidocaine. After opening the abscess, the course into it must be expanded, pushing the branches of the inserted forceps to the sides. In the same way, the hole made is expanded in cases where no pus is obtained as a result of the incision.

A radical method of treating paratonsillitis and paratonsillar abscesses is abscessstonsillectomy, which is performed with a history of frequent tonsillitis or repeated development of paratonsillitis, poor drainage of the opened abscess, when its course is prolonged, if bleeding occurs due to incision or spontaneously as a result of arthrosis of other vascular tonsils, [Nazarova GF, 1977, etc.]. Tonsillectomy is indicated for all lateral (external) abscesses. After the incision has already been made, tonsillectomy is necessary if there is no positive dynamics during the day after that, if abundant discharge of pus continues from the incision, or if the fistula from the abscess is not eliminated. A contraindication to abscessstonsillectomy is a terminal or very serious condition of the patient with abrupt changes in the parenchymal organs, thrombosis of the cerebral vessels, diffuse meningitis.