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

Chondroperichondritis of the larynx is an inflammation of the perichondrium and cartilage of the larynx skeleton, caused either by the diseases described above (laryngeal angina, acute laryngoblochitis, submucosal laryngeal abcession), or resulting from traumatic damage to the larynx with disruption of the integrity of the mucosa and perichondrium and secondary infection, or as a result ulceration of the mucous membrane in diseases such as syphilis, tuberculosis, etc.

Classification of larynx chondroperichondritis

1. Primary chondroperichondritis of the larynx:
   1. traumatic;
   2. caused by a 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.

The cause of chondroperichondritis of the larynx. Streptococci, staphylococci, pneumococci and microorganisms of specific infections (MBT, pale treponema, influenza viruses, etc.) are the causative agents of chronic lon- gerodontodontitis of the larynx.

Pathological anatomy and pathogenesis. Pathological changes in the cartilages of the larynx 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 introduction only by some infiltration and proliferation of connective tissue cells, while the inner layers providing vascularization and growth of the cartilages of the larynx are less resistant to infection. When an inflammation of the perichondrium occurs between these layers, on the one hand, a layer of pus appears on the cartilage, which separates the perichondrium from the cartilage, which deprives it of trophic and immunoprotective influence of the perichondrium and, as a consequence, leads to cartilage necrosis and sequestration (chondritis). Thus, mainly hyaline cartilages that are not supplied with vessels are affected, but are fed through the vascular system of the perichondrium.

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

In most cases, the chondroperionditis of the larynx covers only one cartilage of the larynx (anatomical, cricoid and thyroid, and rarely cartilage of the epiglottis). When the thyroid and cartilaginous lesions are affected, the inflammatory process can spread to the outer perichondrium, which is manifested by swelling on the front surface of the neck, often by flushing of the skin and by the progression of the disease-purulent fistula on its surface. Depending on the localization of the subservient abscess, internal and external perichondritis is distinguished.

To eliminate the inflammatory process, as a rule, a different degree of cicatricial stenosis of the larynx is formed. It should be noted that the development of an inflammatory infiltrate of the perichondrium does not always end with an abscess; in this case the process passes into sclerosing perichondritis, which is manifested by the thickening of the perichondrium.

According to BM Mlechin (1958), in the first place in the frequency of lesion is an arytenoid cartilage, then cricoid, less often thyroid, and the epiglottis is rarely affected. With the primary chondroperionditis of the larynx, the abscess can reach a large size, especially with inflammation of the outer perichondrium, since the skin, unlike the mucous membrane covering the internal perichondrium, long prevents the pus breakout outside and formation of the fistula. Secondary chondroperionditis of the larynx is deprived of this obstacle, therefore, with them abscesses do not reach a large value and early break through into the laryngeal lumen.

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

When the external chondroperionditis of the larynx is marked by moderate pain during swallowing, phonation and coughing, pain in the region of the anterior part of the neck when the head turns. With the increase in the clinical picture, these pains intensify and radiate into the ear. There is pain in palpation of the larynx. In the region of the formed abscess, fluctuation is determined. In the place of the greatest thinning of the skin, a cyanotic yellowish spot is formed, then the abscess, if not timely opened, breaks itself out 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.

Sharply harder are the acute internal chondroperionditis of the larynx. They are characterized by a rapid increase in signs of stenosis of the larynx: breathing becomes noisy, stridorous, frequent; the phenomenon of hypoxia is growing so rapidly that it is necessary to produce a tracheotomy sometimes at the patient's bedside. Characteristic features of this form of chondroperionditis of the larynx is not so much the hoarseness and weakness of the voice as the change in its timbre beyond recognition, especially in the chondroperionditis of the larynx of the arytenoid cartilages with the involvement of the scapular folds in the inflammatory process. Breakthrough pus in the lumen of the larynx brings relief only if the bulk of the contents of the abscess is ejected outward as a result of coughing. If, however, the emptying of the abscess occurred during sleep, there is a risk of aspiration pneumonia or even asphyxia as a result of spasm of the larynx.

Endoscopic picture with internal chondroperionditis of the larynx is extremely diverse and depends on the localization of the pathological process. The mucous membrane is hyperemic, bulging in the form of a spherical formation or in the form of round infiltrates, smoothing out the contours of the affected cartilage. Perichondritic abscesses on the inner surface of the thyroid cartilage protrude the mucosa into the larynx and cause it to narrow. Sometimes an intraortital fistula is seen, more often in the area of the anterior commissure (often using the terms "front" and "back commissure", paying tribute to tradition, in fact in the larynx there is one commissure located in the corner of the thyroid cartilage, the word commissure stands for fusion, there is no anatomical formation in the larynx, the concept of "posterior commissure" is incorrect, since the arytenoid cartilages there are anatomically not connected and between them there is a significant distance that varies during phonation and breathing, It is not characteristic of true commissures).

With diffuse chondroperiondonitis 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 sequestrants. With laryngoscopy, sequestrants are identified as whitish cartilaginous fragments of various shapes with thinned, chipped edges exposed to purulent fusion. The danger of sequestration lies in their actual transformation into foreign bodies, the consequences of which are unpredictable.

Cases of convalescence in diffuse gangrenous chondroperionditis of the larynx result in a cicatrical process and failure of its walls, which subsequently causes a laryngeal stenosis syndrome, manifested by chronic hypoxia and the consequences to which this condition leads.

Hypoxia, or oxygen starvation, is a general pathological condition of the body that occurs when the body's tissues are not adequately supplied with oxygen or disrupted its utilization. Hypoxia develops when the oxygen content in the inhaled air is insufficient, for example, when it rises to a height (hypoxic hypoxia) as a result of a disturbance in external respiration, for example, in diseases of the lungs and respiratory tract (respiratory hypoxia), circulatory disorders (circulatory hypoxia), blood diseases (anemia ) and some poisonings, for example, carbon monoxide, nitrates or with methemoglobinemia (hemic hypoxia), with tissue respiration disorders (cyanide poisoning), and certain tissue metabolism disorders tissue hypoxia). In case of hypoxia, compensatory adaptive reactions occur that are aimed at restoring oxygen consumption by tissues (dyspnea, tachycardia, an increase in the minute volume of blood circulation and blood flow velocity, an increase in the number of red blood cells due to their release from the depot and an increase in the content of hemoglobin in them). When deepening the state of hypoxia, when compensatory reactions are not able to ensure normal oxygen consumption of tissues, their energy starvation occurs, in which the cerebral cortex and the brain nerve centers are primarily affected. Deep hypoxia leads to the dying of the body. Chronic hypoxia is manifested by increased fatigue, shortness of breath and palpitations with insignificant physical exertion, decreased ability to work. Such patients are exhausted, pale with cyanotic coloring of the border of the lips, eyes are sunken, the mental state is depressed, sleep is restless, shallow, accompanied by nightmarish dreams.

Diagnosis of chondroperionditis of the larynx. Primary perichondritis practically does not differentiate from septic edematous laryngitis and phlegmon of the larynx, the appearance on the mucous membrane of ulcers facilitates the diagnosis of chondroperionditis of the larynx. Edema of the anterior surface of the neck, the presence of purulent fistula and sequestrants are reliable signs of this disease. Diagnosis is supplemented by a severe clinical picture, asphyxiation and acute hypoxia. An important differential diagnostic help, along with direct laryngoscopy, is the radiographic examination of the larynx, in which its inflammatory edema, as well as non-inflammatory edema, can be easily differentiated from traumatic and tumor lesions. Apply the method of tomography and lateral projection, in which the zones of destruction of the cartilages of the larynx are identified and the dynamics of pathoanatomical changes in chondroperionditis of the larynx are evaluated.

Differential diagnosis with chondroperionditis of the larynx is carried out with tuberculosis, syphilis, laryngeal cancer, especially in those cases when a secondary inflammatory process (superinfection) occurs in these diseases. In the presence of external fistula, the larynx chondroperionditis is differentiated from actinomycosis.

Treatment of chondroperionditis of the larynx in the debut stage is carried out with massive doses of broad-spectrum antibiotics in combination with hydrocortisone, antihistamines and anti-edematous treatment. If abscess and sequestration occur, surgical treatment is performed using an external or endoscopic method, the purpose of which is to open the abscess (phlegmon) and remove cartilaginous sequesters. In many cases, before the main surgical intervention, an inferior tracheotomy is produced to give endotracheal anesthesia, preventing pus flow into the trachea, and those significant difficulties in endolaryngeal surgery performed in the absence of general anesthesia. Surgical intervention produces extremely sparing. With external access, try not to damage the internal perichondrium of the larynx, and vice versa, with the endolaryngeal approach - the outer perichondrium. With curettage, whose purpose is to remove non-viable parts of the cartilaginous tissue, try not to damage the cartilage, which has a normal appearance and especially those that provide the lumbar and respiratory function of the larynx. After opening the abscess and emptying it with suction, an antibiotic powder mixed with sulfanilamide is injected into the formed cavity.

The prognosis is more favorable in case of chondroperiondonitis of the larynx with a slow development of the inflammatory process, and even in more acute forms, if an early adequate treatment is undertaken. With the common forms of chondroperionditis of the larynx, the prognosis is cautious and even doubtful. In some cases, with immunodeficiency states (AIDS, leukemia, weakening of the organism with a long chronic infectious disease), the outlook is often pessimistic. The prognosis for voice and respiratory function is always cautious, because even timely and correct treatment with chondroperionditis of the larynx never in this respect leads to satisfactory results.

[1], [2], [3]