Chondroperichondritis of the larynx: causes, symptoms, diagnosis, treatment

Chondroperichondritis of the larynx is an inflammation of the perichondrium and cartilages of the laryngeal skeleton, caused either by the diseases described above (laryngeal tonsillitis, acute laryngobronchitis, submucous laryngeal abscess), or resulting from traumatic injury to the larynx with damage to the mucous membrane and perichondrium and secondary infection, or as a result of ulceration of the mucous membrane in diseases such as syphilis, tuberculosis, etc.

Classification of chondroperichondritis of the larynx

1. Primary chondroperichondritis of the larynx:
   1. traumatic;
   2. arising as a result of latent infection;
   3. metastatic as complications of common infections (typhus and typhoid fever, influenza, pneumonia, postpartum sepsis, etc.).
2. Secondary chondroperichondritis of the larynx:
   1. complications of common acute laryngitis;
   2. complications of common chronic laryngitis;
   3. complications of specific diseases of the larynx.

Cause of laryngeal chondroperichondritis. Streptococci, staphylococci, pneumococci and microorganisms of specific infections (MBT, pale treponema, influenza viruses, etc.) are considered as causative agents of chronic laryngeal chondroperichonditis.

Pathological anatomy and pathogenesis. Pathological changes in the laryngeal cartilages are determined by different resistance to infection of the outer and inner layers of the perichondrium. The outer layers are more resistant to infection and react to its penetration only with some infiltration and proliferation of connective tissue cells, while the inner layers, which provide vascularization and growth of the laryngeal cartilages, are less resistant to infection. When inflammation of the perichondrium occurs, a layer of pus appears between these layers, on the one hand, and the cartilage, which separates the perichondrium from the cartilage, which deprives it of the trophic and immune-protective effect of the perichondrium and, as a result, leads to cartilage necrosis and sequestration (chondritis). Thus, mainly hyaline cartilages are affected, which are not supplied with vessels, but are nourished through the vascular system of the perichondrium.

In metastatic infections, the inflammatory process can begin as osteomyelitis in the area of cartilage ossification islands, forming, as Liicher showed, multiple inflammatory foci.

In most cases, chondroperichonditis of the larynx affects only one of the laryngeal cartilages (arytenoid, cricoid and thyroid, less often - the epiglottis cartilage). When the thyroid and cricoid cartilage are affected, the inflammatory process can spread to the outer perichondrium, which is manifested by swelling on the anterior surface of the neck, often hyperemia of the skin and, as the disease progresses, purulent fistulas on its surface. Depending on the localization of the subperichondrium abscess, internal and external perichondritis are distinguished.

After the inflammatory process is eliminated, cicatricial stenosis of the larynx of varying degrees usually develops. It should be noted that the development of an inflammatory infiltrate of the perichondrium does not always end in an abscess; in this case, the process turns into sclerosing perichondritis, which is manifested by thickening of the perichondrium.

According to B.M. Mlechin (1958), the arytenoid cartilage is the most frequently affected, then the cricoid, less often the thyroid, and the epiglottis is extremely rarely affected. In primary chondroperichonditis of the larynx, the abscess can reach large sizes, especially with inflammation of the outer perichondrium, since the skin, unlike the mucous membrane covering the inner perichondrium, prevents the breakthrough of pus to the outside and the formation of a fistula for a long time. Secondary chondroperichonditis of the larynx is deprived of this obstacle, therefore, with them, abscesses do not reach a large size and break through into the lumen of the larynx early.

Symptoms and clinical course of chondroperichonditis of the larynx. Primary chondroperichonditis of the larynx is acute, accompanied by high body temperature (39-40°C), chills, inspiratory dyspnea, general severe condition, pronounced inflammatory phenomena in the blood. Secondary chondroperichonditis of the larynx is less acute and, as a rule, sluggish; in specific infections, it is characterized by corresponding symptoms and pathological changes.

In external chondroperichonditis of the larynx, moderate pain is observed when swallowing, phonating and coughing, pain in the anterior neck when turning the head. As the clinical picture worsens, these pains intensify and radiate to the ear. Pain appears when palpating the larynx. Fluctuation is determined in the area of the formed abscess. In the place of the greatest thinning of the skin, a bluish then yellowish spot is formed, then the abscess, if it is not opened in time, breaks through on its own with the formation of a purulent fistula. This leads to an improvement in the general condition of the patient, a decrease in body temperature and recovery.

Acute internal chondroperichonditis of the larynx is much more severe. It is characterized by a rapid increase in signs of laryngeal stenosis: breathing becomes noisy, stridor, frequent; hypoxia increases so rapidly that it is sometimes necessary to perform a tracheotomy at the patient's bedside. The characteristic signs of this form of chondroperichonditis of the larynx are not so much hoarseness and weakness of the voice, as a change in its timbre beyond recognition, especially with chondroperichonditis of the larynx of the arytenoid cartilages with involvement of the aryepiglottic folds in the inflammatory process. A breakthrough of pus into the lumen of the larynx brings relief only if the bulk of the abscess contents is expelled as a result of coughing. If the abscess is emptied during sleep, then there is a risk of aspiration pneumonia or even asphyxia as a result of laryngeal spasm.

The endoscopic picture of internal chondroperichonditis of the larynx is extremely diverse and depends on the localization of the pathological process. The mucous membrane is hyperemic, protruding in the form of a spherical formation or in the form of rounded infiltrates that smooth out the contours of the affected cartilages. Perichondritic abscesses on the inner surface of the thyroid cartilage protrude the mucous membrane into the larynx and cause its narrowing. Sometimes an intralaryngeal fistula is visible, most often in the area of the anterior commissure (the terms “anterior” and “posterior commissure” are often used, paying tribute to tradition, but in fact there is one commissure in the larynx, located in the corner of the thyroid cartilage; the word commissure means fusion, connection, there are no other such anatomical formations in the larynx; the concept of “posterior commissure” is incorrect, since the arytenoid cartilages located there are not anatomically connected and there is a significant distance between them that changes during phonation and breathing, which is completely uncharacteristic of true commissures).

In diffuse chondroperichonditis of the larynx, the general condition of the patient becomes extremely severe and can be aggravated by sepsis, general hypoxia, and cartilage necrosis with the formation of sequesters. During laryngoscopy, sequesters are detected as whitish cartilaginous fragments of various shapes with thinned, chipped edges that are subject to purulent melting. The danger of sequesters is their actual transformation into foreign bodies, the consequences of which are unpredictable.

Cases of recovery from diffuse gangrenous chondroperichonditis of the larynx end with a cicatricial process and collapse of its walls, which subsequently causes laryngeal stenosis syndrome, manifested by chronic hypoxia and the consequences that this condition leads to.

Hypoxia, or oxygen starvation, is a general pathological condition of the body that occurs when there is insufficient oxygen supply to the body's tissues or when its utilization is impaired. Hypoxia develops when there is insufficient oxygen content in the inhaled air, for example when ascending to a height (hypoxic hypoxia) as a result of external respiration disorders, for example in diseases of the lungs and respiratory tract (respiratory hypoxia), in circulatory disorders (circulatory hypoxia), in blood diseases (anemia) and some poisonings, for example carbon monoxide, nitrates or methemoglobinemia (hemic hypoxia), in tissue respiration disorders (cyanide poisoning) and some tissue metabolism disorders (tissue hypoxia). In hypoxia, compensatory adaptive reactions occur, aimed at restoring oxygen consumption by tissues (shortness of breath, tachycardia, increased minute volume of blood circulation and blood flow velocity, an increase in the number of erythrocytes in the blood due to their release from the depot and an increase in the hemoglobin content in them, etc.). With a deepening state of hypoxia, when compensatory reactions are unable to ensure normal oxygen consumption by tissues, their energy starvation occurs, in which the cerebral cortex and brain nerve centers suffer first of all. Deep hypoxia leads to the death of the organism. Chronic hypoxia is manifested by increased fatigue, shortness of breath and palpitations with minor physical exertion, decreased ability to work. Such patients are exhausted, pale with a cyanotic coloring of the border of the lips, sunken eyes, depressed mental state, restless, shallow sleep, accompanied by nightmares.

Diagnosis of chondroperichonditis of the larynx. Primary perichondritis is practically not differentiated from septic edematous laryngitis and phlegmon of the larynx, the appearance of ulcers on the mucous membrane facilitates the diagnosis of chondroperichonditis of the larynx. Edema of the anterior surface of the neck, the presence of purulent fistulas and sequesters are reliable signs of this disease. Diagnostics is supplemented by a severe clinical picture, symptoms of suffocation and acute hypoxia. An important differential diagnostic aid, along with direct laryngoscopy, is an X-ray examination of the larynx, in which inflammatory edema, as well as non-inflammatory edema, are quite easily differentiated from traumatic and tumor lesions. The tomography method and lateral projection are used, which reveal zones of destruction of the laryngeal cartilages and assess the dynamics of pathological changes in chondroperichonditis of the larynx.

Differential diagnostics for chondroperichonditis of the larynx are carried out with tuberculosis, syphilis, laryngeal cancer, especially in cases where a secondary inflammatory process (superinfection) occurs with these diseases. In the presence of external fistulas, chondroperichonditis of the larynx is differentiated from actinomycosis.

Treatment of laryngeal chondroperichonditis at the debut stage is carried out with massive doses of broad-spectrum antibiotics in combination with hydrocortisone, antihistamines and decongestant treatment. In the event of an abscess and sequesters, surgical treatment is carried out using an external or endoscopic method, the purpose of which is to open the abscess (phlegmon) and remove the cartilaginous sequesters. In many cases, before the main surgical intervention, a lower tracheotomy is performed to give endotracheal anesthesia, prevent pus from flowing into the trachea and those significant difficulties with endolaryngeal surgery, performed in the absence of general anesthesia. Surgical intervention is performed extremely sparingly. With external access, they try not to damage the internal perichondrium of the larynx, and vice versa, with the endolaryngeal approach - the external perichondrium. During curettage, the purpose of which is to remove non-viable parts of cartilaginous tissue, they try not to damage cartilages that have a normal appearance, especially those that provide the phonatory and respiratory function of the larynx. After opening the abscess and emptying it with suction, antibiotic powder mixed with sulfanilamide is introduced into the resulting cavity.

The prognosis is more favorable for chondroperichonditis of the larynx with a slow development of the inflammatory process, and even for more acute forms, if early adequate treatment is undertaken. In common forms of chondroperichonditis of the larynx, the prognosis is cautious and even questionable. In some cases, with immunodeficiency states (AIDS, leukemia, weakening of the body by a long-term chronic infectious disease), the prognosis is often pessimistic. The prognosis for the vocal and respiratory function is always cautious, since even timely and correct treatment for chondroperichonditis of the larynx never leads to satisfactory results in this regard.

[ 1 ], [ 2 ], [ 3 ]