Actinomycosis of the pharynx

Actinomycosis of the pharynx is a chronic infectious disease of humans and animals caused by the introduction of actinomycetes (parasitic ray fungi) into the pharynx.

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Epidemiology and causes of actinomycosis of the pharynx

Actinomycetes are widespread in nature; their main habitat is soil and plants. Actinomycetes are similar in structure to bacteria, but form long branching threads resembling mycelium. Some types of actinomycetes are pathogenic for humans and animals, including both aerobes and anaerobes. Actinomycosis is relatively rare in humans. Men suffer from this disease 3-4 times more often. Observations by various authors do not provide grounds to consider actinomycosis as an occupational disease of agricultural workers, although in some cases the disease occurs as a result of the exogenous introduction of an actinomycete that lives freely in the environment into the body.

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Pathogenesis and pathological anatomy

The main route of infection is the endogenous route, in which the disease is caused by a pathogen that has acquired parasitic properties and inhabits the oral cavity and gastrointestinal tract. A specific infectious granuloma develops around the parasite that has penetrated the tissue, which is characterized, along with decay in its central part, by the formation of fibrous connective tissue in the granulation tissue. As a result, a pathomorphological element specific to actinomycosis is formed - an actinomycotic nodule - druse, which is characterized by the presence of so-called xanthomatous cells, i.e. connective tissue cells saturated with small droplets of cholesterol esters, which impart a yellow (xanthomatous) color to the cells that accumulate them. Actinomycetes can spread in the body by contact, lymphogenous, hematogenous routes and most often settle in loose connective tissue.

Symptoms of actinomycosis of the pharynx

The incubation period averages 2-3 weeks from the moment of actinomycete introduction. Cases of long, even multi-year incubation are not uncommon. The general condition of the patient at the initial stage of the disease changes little. The body temperature is subfebrile. In long-term forms of actinomycosis, the body temperature may remain at a normal level.

Actinomycosis can affect all organs and tissues, but the maxillofacial region is most often affected (5%). This is explained by the fact that pathogenic species of actinomycetes are permanent inhabitants of the oral cavity. As noted by D.P. Grinev and R.I. Baranova (1976), they are found in dental plaque, pathologically altered gingival pockets, root canals with dead pulp. Most often, a patient comes to the dentist with complaints of infiltrates and fistulas in the maxillofacial region, from which pus containing a large number of druses is released. Infiltrates are slightly painful, immobile, fused with surrounding tissues.

The initial period of this disease often goes unnoticed, as it is not accompanied by pain and proceeds without an increase in body temperature. Often the first symptom of developing actinomycosis of the maxillofacial region is the inability to freely open the mouth, caused by inflammatory contracture of the temporomandibular joint and parts of the masticatory muscles adjacent to the lesion (de Quervain's symptom). This is explained by the fact that a significant part of the pathogen penetrates the mucous membrane covering the incompletely erupted lower 8th tooth, as well as the root tissues of molars with dead pulp (the importance of timely dental sanitation, root removal, periodontitis treatment!). The defeat of the actinomycete can spread to the masticatory muscle, which is also the cause of trismus. When the process moves to the inner surface of the lower jaw branch, trismus increases sharply, difficulty and painful swallowing, sharp pain when pressing on the tongue, limitation of its mobility, and therefore, chewing and movement of the food bolus in the oral cavity, and impaired articulation appear.

Further development of the process is characterized by the development in the area of the angle and in the posterior parts of the body of the lower jaw, and in the oral localization of the process - on the alveolar process, the inner surface of the cheek, in the area of the tongue, etc., of a significant (woody) density of the cyanotic infiltrate, which has no clear boundaries. Gradually, individual areas of the infiltrate rise in the form of "swellings" above the surrounding tissues (skin or mucous membrane), in which foci of softening are revealed, resembling small abscesses. The occurrence of such a formation in the area of the palatine arch or in the peritonsillar area can simulate a sluggish peritonsillar abscess. The skin above the infiltrate gathers into a fold, turns red, and in some places becomes reddish-cyanotic, which is characteristic of an actinomycotic infiltrate at the stage immediately preceding the formation of a fistula. Further thinning and rupture of the skin lead to the formation of a fistula, through which a small amount of viscous pus is released. Simultaneously with the melting of tissues on the periphery of the foci of softening, the process of sclerosis occurs, as a result of which characteristic roller-shaped folds with several fistulous passages are formed on the skin. Often, as a result of secondary infection, bacterial abscesses and phlegmons develop in the surrounding tissues, requiring surgical intervention, which, however, is only symptomatic treatment, since emptying the abscess does not lead to the elimination of the inflammatory process: the infiltrate does not completely disappear and after a few days increases again, and the entire actinomycotic process is resumed.

The pathomorphological manifestations of actinomycosis in the oral cavity are not fundamentally different from those of skin lesions, but the oropharyngeal process causes immeasurably greater suffering to the patient, since we are talking about damage to the mucous membrane of the oral cavity, tongue, pharynx, which is rich in sensitive nerves, and, in addition, very mobile organs that play an important physiological role in ensuring the function of both breathing and chewing and digestion.

Actinomycosis of the tongue is the most painful for the patient, often being the source of further progression of the process in the direction of the pharynx and esophagus. One or more dense infiltrates appear in the thickness of the tongue, giving it rigidity and depriving it of mobility and the ability to arbitrarily change shape (for example, to fold into a tube). Very quickly, a softening zone with thinning of the mucous membrane and formation of a fistula appears in the thickness of the infiltrate. The treatment tactics in this case consist of surgical opening of the abscess in the softening phase before its opening, but this does not lead to rapid healing, which is observed with a vulgar abscess or phlegmon of the tongue: the process ends with slow scarring, and often with secondary bacterial complications.

Primary actinomycosis of the pharynx does not occur, but is a consequence of either actinomycosis of the maxillofacial region or actinomycosis of the tongue. Localization of the infiltrate on the back wall of the pharynx, soft palate and palatine arches is a rare phenomenon, but when it occurs, depending on the structure of the anatomical formation on which this infiltrate arose, the clinical picture appears different. For example, when infiltrates occur on the back wall of the pharynx, the pathogen can penetrate into the deep parts of the pharynx and cause not only damage to soft tissues, but, reaching the vertebral bodies, can also cause damage to bone tissue; or, penetrating into the laryngeal part of the pharynx, spread to the walls of the esophagus or vestibule of the larynx, causing corresponding destructive lesions here.

In actinomycosis, in addition to the local process, metastatic lesions of the brain, lungs, abdominal organs are possible, and with a long course of the disease, the development of amyloidosis of internal organs - a form of protein dystrophy, in which an abnormal protein - amyloid - is deposited (or formed) in organs and tissues.

How to recognize actinomycosis of the pharynx?

The diagnosis is established on the basis of typical clinical data (woody cyanotic infiltrate, formation of softening swellings in it, thinning of the skin and formation of a fistula on each swelling that secretes viscous pus). The final diagnosis is established on the basis of microscopic examination of the purulent contents, in which drusen typical of actinomycosis are found. Diagnostic skin-allergic reaction with actinolysate, biopsy are also used. Other research methods are determined by the form and anatomical localization of the pathological process (Dopplerography of parenchymatous organs, radiography of bone formations, CT and MRI).

Treatment of actinomycosis of the pharynx

Treatment of actinomycosis of the pharynx is usually complex. It includes surgical methods, methods of increasing specific immunity by using actinolysate or other non-specific immunomodulators, stimulating and restorative therapy. In complex treatment, iodine preparations (potassium iodide), antibiotics of the penicillin group (benzylpenicillin, phenoxymethylpentane), antimicrobial agents in combinations (co-trimoxazole), tetracyclines (doxycycline, metacycline), desensitizing drugs, physiotherapeutic methods, including local X-ray therapy, diathermocoagulation, galvanocautery are used. The scope and nature of surgical intervention in actinomycosis depend on the form of the disease, the localization of its foci and the resulting life-threatening secondary purulent and septic complications.

How to prevent actinomycosis of the pharynx?

Prevention consists of oral cavity sanitation, elimination of foci of purulent infection, and increasing the body's resistance. Of particular importance for the prevention of actinomycosis is the use of respirators when performing "dusty" agricultural work in haylofts, elevators, etc.

What is the prognosis for actinomycosis of the pharynx?

The prognosis for life with actinomycosis of the maxillofacial localization is, as a rule, favorable. The prognosis becomes serious when infiltrates occur in the area of the entrance to the larynx, in the vicinity of the main blood vessels, when vital internal organs are affected.