Chronic laryngitis

Common chronic laryngitis is a superficial diffuse non-specific inflammation of the mucous membrane of the larynx with a long course and periodic exacerbations in the form of catarrhal inflammation. In most cases, common chronic laryngitis is combined with chronic inflammatory processes in the upper respiratory tract, covering both the nasopharyngeal spaces, as well as the trachea and bronchi.

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Causes of chronic laryngitis

The causes and pathogenesis of common chronic laryngitis are based on three factors:

1. individual predisposition to chronic inflammatory diseases of the upper respiratory tract, including individual anatomical features of the larynx structure;
2. risk factors (professional, domestic - smoking, alcoholism);
3. activation of opportunistic (vulgar) microbiota.

Common chronic laryngitis is more common in adult men, who are more often exposed to professional and domestic hazards. In childhood, common chronic laryngitis occurs mainly after 4 years, especially with frequently recurring adenoamygdalitis.

Banal polymorphic microbiota indicates non-specific inflammation in banal chronic laryngitis. Childhood infections (measles, whooping cough, diphtheria, as well as repeated tonsillitis and influenza infection) cause damage to the epithelium and lymphoid tissue of the larynx, which contributes to a decrease in local immunity and activation of saprophytic microbiota and increases the pathogenic effect of exogenous risk factors. An important role in the pathogenesis of banal chronic laryngitis is played by descending infection in chronic rhinosinusitis, adenoiditis, tonsillitis, periodontitis, dental caries, which are foci of pathogenic microbiota, often causing chronic inflammatory processes in the larynx. The same role can be played by ascending infection in chronic tracheobronchitis, pulmonary tuberculosis, purulent diseases of the bronchopulmonary system (bronchiectatic disease), asthma, which, along with infection of the larynx with sputum and pus, cause irritation of its mucous membrane with prolonged coughing attacks.

An important role in the development of common chronic laryngitis is played by impaired nasal breathing (rhinitis, polyps, curvature of the nasal septum), in which the patient is forced to constantly breathe through the mouth, which adversely affects the condition of the mucous membrane of the larynx (there is no humidification, warming and disinfection of the air). Particularly harmful to the condition of the larynx are impaired nasal breathing, unfavorable external climatic conditions (cold, heat, dryness, humidity, dustiness) and microclimatic conditions of human habitation and work.

The load on the larynx in people whose profession is related to the vocal function or work in a noisy industry is often the main risk factor for the development of banal chronic laryngitis.

Of great importance in the development of common chronic laryngitis are endogenous factors that cause a decrease in local immunity and trophism of the larynx, which, along with the pathogenetic effect of these factors on the larynx, potentiates the harmful effects of external risk factors, transforming them into active causes of common chronic laryngitis. Such endogenous factors may include chronic diseases of the digestive system, liver, cardiovascular and excretory systems, allergies, which often lead to circulatory, and therefore immune and trophic disorders of the mucous membrane of the upper respiratory tract. An important role in the development of common chronic laryngitis is played by endocrine disorders, in particular dysfunction of the thyroid and insular apparatus of the pancreas. Similar influences can be played by ischemic conditions caused by various reasons, vitamin deficiency, a number of common chronic infections (syphilis) and some specific diseases of the upper respiratory tract (ozena, scleroma, lupus, etc.).

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Chronic catarrhal laryngitis

In chronic catarrhal laryngitis, hyperemia of the mucous membrane is more of a congestive nature than of an inflammatory-paretic nature, characteristic of acute diffuse catarrhal laryngitis. Thickening of the mucous membrane occurs due to round-cell infiltration, and not serous impregnation. The flat epithelium on the vocal folds is thickened, on the back wall of the pharynx, the ciliated epithelium is replaced by stratified flat epithelium by metaplasia; the glands of the folds of the vestibule are enlarged and secrete more secretion. There is especially much sputum with a similar lesion of the trachea, which often manifests itself as a strong, sometimes spasmodic cough, increasing irritation and inflammation of the vocal folds. The blood vessels of the submucosal layer are dilated, their walls are thinned, due to which, with a strong cough, small-point submucosal hemorrhages occur. Around the vessels, foci of plasmacytic and round cell infiltration are noted.

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Chronic hypertrophic laryngitis

In chronic hypertrophic laryngitis, the epithelium and connective tissue of the submucosal layer hyperplasia; infiltration of the internal muscles of the larynx also occurs, most often the muscle fibers that form the basis of the true vocal folds, and proliferation of cells of the mucous glands and follicles of the ventricles of the larynx occurs.

Hyperplasia is understood as an excessive increase in the number of structural elements of tissues by their excessive neoplasm. Hyperplasia, which underlies hypertrophy, manifests itself in cell proliferation and the formation of new tissue structures. In rapidly occurring hyperplastic processes, a decrease in the volume of the proliferating cellular elements themselves is often observed. As A. Strukov (1958) notes, hyperplastic processes in the narrow sense are understood only as those associated with hypertrophy of tissues or organs, when it comes to the functional identity of newly formed and previous ("uterine") tissues. However, in pathology, any cell proliferation is often designated by the term "hyperplasia". The term proliferation is also used for cell proliferation in the broad sense. As a universal morphogenetic process, hyperplasia underlies all processes of pathological tissue neoplasm (chronic inflammation, regeneration, tumors, etc.). In structurally complex organs, such as the larynx, the hyperplastic process may affect not only one homogeneous tissue, but also all other tissue elements that make up the morphological basis of the organ as a whole. In fact, this is the case with chronic hyperplastic laryngitis, when not only the epithelial cells of the ciliated epithelium, but also the squamous multilayered epithelium, cellular elements of the mucous glands, connective tissue, etc. are subject to proliferation. This is the reason for such a variety of forms of chronic hypertrophic laryngitis - from "singer's nodules" to prolapse of the mucous membrane of the laryngeal ventricles and retention cysts.

Thickening of the vocal folds in chronic hypertrophic laryngitis can be continuous, uniform along the entire length, then they acquire a spindle-shaped form with a rounded free edge, or limited, in the form of separate nodules, tubercles or somewhat larger dense whitish formations (laryngitis chronica nodosa). Thus, more massive thickenings, formed by proliferation of squamous epithelium, sometimes form in the area of the vocal fold at the vocal process of the arytenoid cartilage, where they look like a mushroom-shaped elevation on one side with a "kissing" depression on the opposite vocal fold or symmetrically located contact ulcers. Much more often, pachydermia occurs on the back wall of the larynx and in the interarytenoid space, where they acquire a bumpy surface of a grayish color - pachydermia diffusa. In the same place, hyperplasia of the mucous membrane in the form of a cushion with a smooth red surface (laryngitis chronica posterior hyperplastica) can be observed. The hyperplastic process can develop in the ventricles of the larynx and lead to the formation of folds or ridges of the mucous membrane that extend beyond the ventricles and cover the vocal folds. Hyperplasia can also develop in the subglottic space, forming ridges parallel to the vocal folds (laryngitis chronica subglotica hyperplastica). In people whose professions are associated with vocal strain (singers, teachers, actors), symmetrically located cone-shaped nodules often appear on the vocal folds, approximately in the middle, the basis of which is thickened epithelium and elastic tissue - the so-called singer's nodules.

In chronic atrophic laryngitis, which is less common than chronic hypertrophic laryngitis, metaplasia of the columnar ciliated epithelium into squamous keratinized epithelium is observed; capillaries, mucous glands, and intralaryngeal muscles atrophy, and the interstitial connective tissue undergoes sclerosis, due to which the vocal folds become thinner, and the secretion of the mucous glands quickly dries out and covers them with dry crusts.

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Chronic atrophic laryngitis

Chronic atrophic laryngitis is much less common; more often it occurs in the form of a subatrophic process in the mucous membrane of the larynx, combined with systemic subatrophy of the mucous membrane of the upper respiratory tract.

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Causes of chronic atrophic laryngitis

Atrophy is a pathological process characterized by a decrease in volume and size, as well as qualitative changes in cells, tissues and organs expressed to varying degrees, usually occurring during various diseases or as a consequence thereof, thus differing from hypoplasia and hypogenesis (pathological atrophy). In contrast to the latter, a distinction is made between physiological (age-related) atrophy caused by the natural aging of tissues, organs and the organism as a whole and their hypofunction. An important role in the occurrence of physiological atrophy is played by the withering of the endocrine system, which largely affects such hormone-dependent organs as the larynx, hearing and vision organs. Pathological atrophy differs from physiological atrophy both in the causes of occurrence and in some qualitative features, for example, a more rapid withering of the specific function of an organ or tissue in pathological atrophy. Any type of atrophy is based on the predominance of dissimilation processes over assimilation processes. Depending on the causes of atrophy, a distinction is made between:

1. trophoneurotic atrophy;
2. functional atrophy;
3. hormonal atrophy;
4. alimentary atrophy;
5. professional atrophy resulting from the harmful effects of physical, chemical and mechanical factors.

In otolaryngology, there are many examples of the latter (occupational anosmia, hearing loss, atrophic rhinitis, pharyngitis and laryngitis, etc.). To the above-listed forms of atrophy, we should also add atrophy caused by the consequences of an acute or chronic infection, both banal and specific. However, this type of atrophy is also accompanied by pathological changes in tissues and organs, characterized by complete destruction or replacement of specific tissues with fibrous tissue. As for chronic atrophic laryngitis specifically, all of the above-listed types of causes can participate in its pathogenesis to one degree or another, causing atrophy not only of the epithelium of the mucous membrane itself, but also of all its other elements (trophic and sensitive nerve endings, blood and lymphatic vessels, connective tissue layer, etc.). On this basis, chronic atrophic laryngitis should be recognized as a systemic disease that requires an analytical approach for its study, as well as for the development of etiotropic and pathogenetic treatment.

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Symptoms of atrophic laryngitis

In the pronounced clinical and pathological form, there is significant dryness of the mucous membrane, acquiring a reddish-gray tint, the vocal folds are hyperemic, covered with dry crusts of a yellow or greenish-dirty color, tightly fused with the underlying surface. After rejection, small hemorrhages and damage to the epithelial cover remain in their place. In general, the laryngeal cavity appears expanded, with a thinned mucous membrane, through which small tortuous blood vessels shine through. A similar picture is observed in the mucous membrane of the pharynx. Such patients constantly cough, make attempts to remove crusts from the larynx using characteristic vocal sounds; their voice is constantly hoarse, quickly tires. In dry rooms, these phenomena intensify and, on the contrary, weaken in a humid environment.

Diagnosis of atrophic laryngitis

The diagnosis is established on the basis of the anamnesis (long-term course, presence of bad habits and corresponding occupational hazards, chronic foci of infection nearby and at a distance, etc.), complaints of the patient, and a characteristic endoscopic picture. The variety of morphological disorders of only one banal chronic inflammatory processes in the larynx, not counting those that occur with infectious and specific diseases, makes the diagnosis of chronic laryngitis a very responsible process, since many of the above-mentioned diseases are considered precancerous, the degeneration of which into malignant neoplasms, including even sarcoma, is not such a rare phenomenon, which was especially clearly demonstrated by official statistics at the end of the 20th century. When determining the nature of a particular chronic laryngeal disease, it should be borne in mind that chronic hypertrophic laryngitis almost always accompanies a particular malignant process or specific laryngeal disease and often masks the latter until both reach their destructive forms. Therefore, in all cases of dysphonia and the presence of "plus tissue", such a patient should be referred for consultation to an ENT oncologist, where he will undergo a special examination, including a biopsy.

In doubtful cases, especially in hyperplastic chronic laryngitis, an X-ray examination of the patient is mandatory. Thus, in chronic hypertrophic laryngitis, the use of frontal tomography of the larynx allows visualizing the following changes: 1) thickening of the vocal or vestibular folds; thickening of the ventricular fold; 2) its prolapse, as well as other changes without detecting defects in the internal walls and anatomical formations of the larynx.

An important differential diagnostic sign, testifying in favor of the benign nature of the process, is the symmetry of morphological changes in the larynx, while malignant neoplasms are always unilateral. If chronic hypertrophic laryngitis manifests itself as a unilateral "inflammatory process", then an X-ray examination of the patient and a biopsy of suspicious "plus tissues" are always necessary. Banal chronic laryngitis is differentiated from primary infiltrative tuberculosis of the larynx, tertiary syphilis and benign and malignant tumors, scleroma and papillomatosis of the larynx. In children, chronic hypertrophic laryngitis is differentiated from papillomatosis and undetected foreign tissues of the larynx. Chronic atrophic laryngitis is differentiated from primary ozena of the larynx. Myogenic dysfunctions of the larynx, which often occur with banal chronic laryngitis, should be differentiated from neurogenic paralysis of the internal muscles of the larynx, which are characterized by specific symptoms.

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Symptoms of chronic laryngitis

Complaints of patients with banal chronic laryngitis do not differ in any significant features and depend solely on the emerging pathological anatomical changes, as well as on the degree of vocal load and professional need for the vocal apparatus. Almost all patients complain of hoarseness of the voice, rapid fatigue, sore throat, often dryness and constant cough.

The degree of voice dysfunction may vary from mild hoarseness, which occurs after a night's sleep and during the working day, slightly disturbing the patient and only reappearing in the evening, to severe constant hoarseness. Constant dysphonia occurs in cases where banal chronic laryngitis and other chronic diseases of the larynx are accompanied by organic changes in the vocal folds and other anatomical formations, especially in proliferative-keratotic processes. Dysphonia can significantly worsen under unfavorable weather conditions, during endocrine changes in women (menopause, menstruation, pregnancy, during exacerbation of the main inflammatory process in the larynx).

For professionals, even minor dysphonia is a factor of mental stress, aggravating the phonatory qualities of the vocal function, often radically changing their social status and worsening their quality of life.

Disturbances in the sensitivity of the larynx (scratching, itching, burning, sensation of a foreign body or accumulated sputum or, on the contrary, dryness) force the patient to constantly cough, make attempts to remove the "interfering" object by closing the vocal folds and vocal effort, lead to further fatigue of the vocal function, and sometimes to spastic contractures of the vocal muscles. Often these sensations contribute to the development of cancerophobia and other psychoneurotic conditions in patients.

The cough is caused by irritation of the tactile receptors of the larynx, and with abundant sputum - chronic inflammation of the mucous membrane of the trachea and bronchi. The cough is more pronounced in the morning, especially in smokers and workers whose professions are associated with hazardous production (founders, chemists, welders, battery workers, etc.).

Of great importance in establishing the form of banal chronic laryngitis is a laryngoscopic examination of the larynx, both with indirect and direct laryngoscopy, including microlaryngoscopy, which makes it possible to examine those parts of the larynx that are not visualized using a conventional directoscope.

In chronic hypertrophic laryngitis, diffuse hyperemia of the mucous membrane is often observed, which is most pronounced in the area of the vocal folds, while the mucous membrane is covered in places with viscous mucous secretion. In chronic hypertrophic laryngitis, the vocal folds are diffusely thickened, edematous with uneven edges. In the interarytenoid space, papillary proliferation of the mucous membrane or pachydermia is observed, which is clearly visible with mirror laryngoscopy only in the Killian position. This pachydermia prevents the vocal folds from closing completely, which affects the phonatory function of the larynx: the voice becomes rough, rattling, and quickly tires. In some cases, pronounced hyperplasia of the vestibular folds is also noted, which, with indirect laryngoscopy, cover the vocal folds, the examination of which in this case is possible only with direct laryngoscopy. During phonation, these hypertrophied folds come into contact with each other and, under the influence of exhaled air, give the voice a characteristic, almost pitch-less, rough sound, which is sometimes used by pop singers, such as the great American singer Moon Armstrong. In rare cases, hyperplasia of the mucous membrane in the subglottic space occurs, which takes the form of two elongated and thickened ridges located on either side of the larynx, as if duplicating the vocal folds located above them and protruding from behind them, narrowing the lumen of the larynx. Exacerbation of the inflammatory process in this area or the occurrence of superinfection can lead to pronounced edema of the subglottic space and threatening suffocation.

Two forms of chronic hypertrophic laryngitis deserve special attention - these are contact ulcers and prolapse of the laryngeal ventricle (a paired formation located on the lateral wall of the larynx between the vestibular fold and the vocal fold).

Contact ulcer of the larynx

Named by American authors Ch. Jackson and Lederer, it is nothing more than local symmetrically located pachydermia, formed on the mucous membrane covering the vocal processes of the arytenoid cartilages. Often the rest of the larynx has a normal appearance, although in essence these pachydermia indicate the presence of chronic hypertrophic laryngitis. Contact ulcers owe their origin to excessive vocal efforts in weakened individuals with a poorly developed subepithelial layer (N. Costinescu).

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Laryngeal ventricular prolapse

In fact, we are talking about excessive proliferation of the mucous membrane covering one of the ventricles of the larynx, which prolapses into the lumen of the larynx and can partially or completely cover the corresponding vocal fold. This hyperplastic formation is red in color, often has an edematous appearance and can be mistaken for a tumor of the larynx. Often, prolapse of the ventricles of the larynx is combined with a cyst of the ventricular fold, which occurs as a result of proliferation of the epithelium of the mucous gland and blockage of its excretory duct. However, such laryngeal cysts occur rarely; much more often, phoniatrists and ENT specialists in a wide profile encounter the so-called false cyst of the vocal fold, in which in most cases a defect in the form of a contact ulcer is formed symmetrically on the opposite fold. Often, false cysts are visually mistaken for polypous formations of the vocal folds, the distinctive feature of which is a lighter shade, which in terms of color intensity occupies an intermediate position between a false cyst and the so-called fusiform edema of the vocal folds. The described volumetric formations significantly disrupt the function of the vocal folds, preventing their complete closure, which is clearly visualized using the stroboscopy method.

Polypous formations that arise on the vocal folds are morphologically related to the so-called mixts, consisting of fibrous and angiomatous tissues. Depending on the ratio of these morphologically different structures, these formations are called fibromas, angiofibromas, and angiomas. As noted by D.M. Thomasin (2002), the red or angiomatous type of polyp can be a manifestation of "congenital pathological processes", and its color depends on the fact that the fibrinous exudate envelops the angiomatous elements, giving them a dark red hue.

Mucous retention cysts occur in both adults and children. In appearance, they are "yellowish humps that arise under the mucous membrane and deform the free edge of the vocal fold." Morphologically, these formations are true cystic cavities located in the stroma of the mucous gland. The cyst develops as a result of blockage of the excretory duct of the gland under the influence of a chronic proliferative inflammatory process. The cavity of the gland is filled with secretion, and its walls undergo proliferation (proliferation of mucous and intercalated cells, thickening and increase in the size of the cyst wall). Unilateral and bilateral cysts, as well as polyps, prevent complete closure of the vocal folds and disrupt the phonatory function of the larynx.

A number of authors attach great importance to the so-called Reinke's space, which is part of the vocal fold, in the occurrence of the above-described pathological conditions of the vocal folds in chronic hypertrophic laryngitis. The bottom of the Reinke's space forms a layer of fascia covering the vocal muscle, which thickens in the direction of the free edge of the vocal fold and is woven into the vocal cord, which, in turn, in the caudal direction passes into an elastic cone and a cricoid ligament, which ensures the attachment of the vocal fold to the process of the cricoid cartilage. The ceiling of the Reinke's space forms a thin layer of squamous epithelium lying on a strong basement membrane covering the fascia of the vocal muscle. According to the data of special phoniatric, stroboscopic and model studies, it was established that the Reinke space plays an important role in fine voice modulation, which is an important acoustic mechanism that enriches the timbre of the singing voice and gives it a unique individuality, therefore, one of the principles of modern laryngeal microsurgery is to preserve the structures of the Reinke space in an optimal state during surgical interventions for the pathological conditions of the vocal folds described above. One of the pathological manifestations of chronic hypertrophic laryngitis is edema of the tissues that make up the Reinke space (Reinke's edema), which occurs in the presence of chronic laryngitis and severe vocal strain of the phonatory function of the larynx. Occasionally, cyst-like formations are formed in the Reinke space, which some authors interpret as retention cysts arising from "lost" mucous glands, while others - as edema of this space. The dispute is resolved by histological examination of the removed tissue. Often, with prolonged mechanical ventilation, the intubation tube is the cause of the so-called intubation granuloma.

The diversity of morphological changes in chronic hypertrophic laryngitis has been discussed above. Here we will note several more forms of this disease, the final differences between which can only be established by microlaryngoscopy and histological examination. One of these forms is the so-called contact granuloma, which, like a contact ulcer, occurs during prolonged traumatic contact of the vocal folds, either of professional genesis or as a complication of a long-term inflammatory process.

Another rare special form of chronic hypertrophic laryngitis is pseudomyxoma of the larynx - a tumor that may be based on normal tissue edema with its transformation into a substance resembling mucus, but not containing mucin, which is a spindle-shaped infiltrate located on the vocal fold. Sometimes pseudomyxoma is bilateral with a developed network of blood vessels. Solitary papillomas (benign tumors of the integumentary epithelium, which have a characteristic appearance of papillary growths protruding above the surface of the surrounding unchanged epithelium - exophytic growth; true papillomas can be difficult to distinguish from papillary growths of inflammatory origin, including productive manifestations of syphilis, gonorrhea, tuberculosis) with hyperkeratosis, occurring exclusively in adult men, having the form of a single growth, a tubercle of gray or whitish color of dense consistency. All the above forms of chronic hypertrophic laryngitis require differentiation from precancer of the larynx or its carcinoma.

Types of chronic laryngitis

Inflammatory phenomena in banal chronic laryngitis are less pronounced and widespread than in acute catarrhal laryngitis. They develop mainly in the area of the vocal folds and in the interarytenoid space. According to the predominant nature of the inflammatory process, chronic catarrhal laryngitis, chronic hypertrophic laryngitis and chronic atrophic laryngitis are distinguished.

Treatment of chronic laryngitis

Treatment of chronic laryngitis consists primarily of eliminating risk factors that contribute to the development of this disease, which include bad habits, occupational hazards, and foci of infection in the upper respiratory tract. The diet that patients must follow is of great importance (excluding hot and cold drinks, spicy foods, fatty and fried foods). The patient's diet should include fruits, vegetables, and easily digestible foods. In case of disorders of the gastrointestinal tract, excretory and endocrine systems, such patients should be referred to the appropriate specialists.

Special treatment is divided into non-surgical and surgical (microsurgical). Non-surgical treatment is for people suffering from chronic catarrhal laryngitis, chronic atrophic laryngitis and some forms of chronic hypertrophic laryngitis, surgical treatment is for chronic hypertrophic laryngitis.

Therapeutic treatment of chronic laryngitis

According to many laryngologists, in terms of the use of drugs, chronic catarrhal laryngitis and chronic hypertrophic laryngitis differ little from each other. It is important to emphasize two features of the treatment of these forms of the disease: treatment should be strictly individual, taking into account the patient's sensitivity to the drugs used and the effect obtained; treatment should not activate proliferative processes, since precancerous conditions may be hidden behind the manifestations of chronic hypertrophic laryngitis. When individually selecting treatment measures (inhalations, instillations, aerosol irrigations, etc.), it should be borne in mind that both chronic catarrhal laryngitis and chronic hypertrophic laryngitis have a tendency to exacerbations, in which dryness and the formation of viscous, difficult to separate sputum accumulating on the vocal folds can be replaced by increased secretion of mucus (activation of the mucous glands) and exudation (the result of activation of the inflammatory process in the mucous membrane). These changes determine the tactics of treating the patient and the nature of the prescribed drugs (emollients, astringents, cauterizing). During exacerbations, you can use the same means as for acute catarrhal laryngitis. The remedies used in the middle of the 20th century have not lost their healing value. Thus, 1% oil solution of menthol, chlorobutanol for inhalation, sea buckthorn oil for infusion into the larynx, etc. were classified as emollients and anti-inflammatory agents.

The following were used as astringents and slightly cauterizing agents: 1-3% collargol solution, 0.5% resorcinol solution for infusion into the larynx at 1-1.5 ml once a day, 0.25% silver nitrate solution - infusion of 0.5 ml every other day in case of hypersecretion; tannin solution with glycerin, 0.5% zinc sulfate solution (10 ml) in a mixture of ephedrine hydrochloride (0.2) for infusion into the larynx at 1 ml, etc. To liquefy viscous sputum and crusts formed in the larynx, a solution of chymotrypsin or trypsin (0.05-0.1%) was used for infusion into the larynx at 1.5-2 ml.

In the case of nodular formations, along with other medicinal means (infusion of menthol oil solutions into the larynx, lubrication with a 2% solution of silver nitrate), blowing various powdered substances into the larynx was used, for example:

• Rp.: Aluminis 1,0
• Amyli Tritici 10.0 MX pulv. subtil.

• Rp.: Tannini
• Amyli tritici aa 5.0 M. G. pulv. subtil.

For electrophoresis in the larynx area, the following medications were used: 2% calcium chloride solution, 0.25% zinc sulfate solution, 1% potassium iodide solution, 0.1 lidase (64 U) per procedure for “singer’s nodules”, etc.

Chronic atrophic laryngitis is usually part of a general systemic dystrophic process that has developed in the upper respiratory tract, so isolated treatment of the larynx alone without taking into account and treating other ENT organs is ineffective. As for the tactics of treatment for chronic atrophic laryngitis and the means used, in a certain sense they are the complete opposite of the methods used for chronic catarrhal laryngitis and chronic hypertrophic laryngitis. If astringents, cauterizing agents and means that prevent proliferative (hyperplastic) processes and, as a consequence, hypersecretion and hyperkeratosis are used in the treatment of the latter, then in the treatment of chronic atrophic laryngitis all measures are aimed at stimulating the natural factors of the "vital activity" of the mucous membrane of the larynx.

Medicines for chronic laryngitis

Medicines used in chronic atrophic laryngitis should facilitate the liquefaction of viscous mucus containing high concentrations of mucopolysaccharides (mucin), which form viscous aqueous solutions and dry into dense crusts, facilitate the separation of crusts, moisten the mucous membrane of the larynx and, if possible, stimulate the proliferation of its "uterine" cellular elements and the function of its glands. For this purpose, warm moist inhalations of alkaline mineral waters are used, as well as inhalations of medicines.

The use of the above-mentioned means, which were used and are partially used at present, is mainly symptomatic and is aimed at the pathogenesis of the disease in an indirect, not always clearly established way. For example, the use of astringents and cauterizing agents in some forms of chronic hypertrophic laryngitis cannot be called pathogenetic and especially etiotropic treatment, since these means are aimed only at reducing the severity of the symptoms of the disease, but not at the primary mechanisms that cause the proliferation of cellular elements of the mucous membrane, goblet cells, connective tissue, etc. In this sense, some methods of treatment for chronic atrophic laryngitis are closer to pathogenetic treatment, since they are to one degree or another aimed at stimulating natural reparative processes by activating stimulating effects aimed at replicating the morphological elements of organs and tissues. Activation of these effects in chronic atrophic laryngitis can be achieved only with complex treatment, when the applied means have a multidirectional effect, the sum of the effects of which, and often their mutual potentiation, approaches the natural harmony of those physiological processes that participate in ensuring the trophic and morphological homeostasis of tissue or organ. The effectiveness of such treatment increases many times over if it is possible to establish the cause of atrophy and eliminate it, otherwise a kind of dynamic balance is established between reparative and destructive processes, in which the "victory" will ultimately always be on the side of the latter.

It is impossible to say with certainty that modern therapy of so-called banal chronic diseases of the larynx has achieved significant success, it can only be asserted that this direction in acute laryngitis is one of the most urgent, especially in the context of urgent environmental problems facing humanity, and that this direction conceals great potential scientific opportunities. Nevertheless, today it is possible to offer a number of modern methods and drugs to the practicing physician, which in combination with traditional means can be used in the treatment of so-called banal chronic laryngitis.

The tendency of chronic non-atrophic laryngitis to proliferative processes causes in some cases a certain differentiation of methods in the treatment of some of their forms. Thus, in case of exacerbation of chronic catarrhal laryngitis caused by the activation of saprophytic microbiota (ARI, adenovirus infection, general and local hypothermia, etc.), the use of the composite drug Strepsils is indicated, which has an antiseptic and local anesthetic effect. Usually a spray dispenser is used (1 bottle contains 20 ml of solution). When using a spray for the treatment of exacerbation of chronic catarrhal laryngitis, it is necessary to direct the stream - the dose during inhalation into the laryngopharynx, simulating stridor breathing (contraction of the vocal folds). In this case, most of the dose settles on the vocal folds and the walls of the larynx.

In case of frequent exacerbations of chronic catarrhal laryngitis, and in some cases chronic hypertrophic laryngitis, the use of Broncho-Munal (for children Broncho-Munal BP) is indicated. It contains a lyophilized lysate of bacteria that most often cause respiratory tract infections (Str. pneumoniae, Str. Viridans, Str. Pyogenes, Staph. aureus, Moraxella catarrarhalis, Haemophylus influenzae, KI. pneumoniae, Kl. ozaenae). The drug has an immunomodulatory effect: it stimulates macrophages, increases the number of circulating T-lymphocytes and IgA, IgG and IgM antibodies (including on the mucous membrane of the respiratory tract), stimulates the body's natural defense mechanisms against respiratory infections, and reduces the frequency and severity of respiratory diseases.

The drug of choice may be Bronhalis-Hel, which has anti-inflammatory, antispasmodic, antitussive and expectorant properties. It is indicated not only for chronic catarrhal laryngitis and its exacerbations, but also for obstructive and inflammatory diseases of the upper respiratory tract (smoker's catarrh, chronic bronchitis, bronchial asthma, etc.); it is also effective for exacerbations of the inflammatory nature of chronic hypertrophic laryngitis.

For chronic laryngitis of any of the three forms, accompanying immunodeficiency states of any origin, manifested in the form of chronic, sluggish and recurrent infectious and inflammatory processes not only in the upper respiratory tract, but also in other localizations, Likopid is indicated - a semi-synthetic glycopeptide, which is the main structural fragment of the cell wall of all known bacteria and has a broad immunomodulatory effect.

In chronic atrophic laryngitis and their exacerbations, occurring in the form of acute catarrhal laryngitis, accompanied by the release of viscous, quickly drying sputum with the formation of crusts, it is necessary to prescribe secretolytics and stimulants of the motor function of the respiratory tract and mucociliary clearance. Among such drugs, Carbocisteine has proven itself well, possessing a mucolytic and expectorant property due to the activation of sialic transferase - an enzyme of goblet cells of the mucous membrane of the upper respiratory tract and bronchi. Along with the restoration of viscosity and elasticity of mucus secreted by these cells, the drug promotes the regeneration of the mucous membrane, normalizes its structure. In atrophic processes, it increases the replication of goblet cells, and in their excessive proliferation, it regulates their number. The drug also restores the secretion of immunologically active IgA, which provides specific protection (local immunity) of the mucous membrane, improves mucociliary clearance. It is important to note that the maximum concentration of the drug in the blood serum and in the mucous membrane of the respiratory tract is achieved 2 hours after taking it per os and lasts for 8 hours, so the drug is indicated for immediate use in all ENT diseases without exception, especially in acute and banal chronic laryngitis, infectious laryngitis and as a preventive measure for complications in preparation for direct laryngoscopy and bronchoscopy.

Another effective drug with mucoregulatory action is Flunfort (Carbocysteine lysine salt), produced in the form of syrup or granules for per os use. The drug normalizes the function of the respiratory glands: restores the physiological state of sialomucins and fucomucins, normalizes the rheological parameters (viscosity and elasticity) of the secretion of goblet cells and cells of the mucous glands regardless of their initial pathological state, accelerates the mucociliary transport function of the ciliated epithelium, facilitates the restoration of damaged ciliated epithelium. It is indicated for acute and chronic diseases of the respiratory tract and ENT organs, accompanied by secretion disorders (laryngitis, tracheitis, rhinitis, sinusitis, otitis media, bronchitis, bronchiectasis, etc.).

In severe exacerbations of common chronic laryngitis and its pyogenic complications, as well as for their prevention, antibiotics from the cephalosporin (Ceftriaxone, Tercef, Cefuroxime, Supero), macrolide (Azithromycin, Sumazid) and fluoroquinoline (Ofloxacin, Toriferide) groups are used.

In the pathogenesis of chronic atrophic laryngitis, local secondary nutritional deficiency, hypovitaminosis and tissue hypoxia play a significant negative role. To combat these factors that intensify the main pathological process, vitamins C, thiamine, riboflavin, folic, para-aminobenzoic, pantothenic acids, vitamins B1, B6, B12 and PP, glucose, ATP, sodium bromide with caffeine are recommended.

Surgical treatment of chronic laryngitis

Surgical treatment of chronic hypertrophic laryngitis is resorted to in cases where non-surgical treatment is obviously ineffective and it is necessary to remove a volumetric formation that interferes with the functions of the larynx and cannot be treated non-surgically (cyst, papilloma, fibroma, laryngeal ventricle prolapse, etc.). The development of endolaryngeal surgery began after the invention of indirect laryngoscopy by M. Garcia in 1854, and by the end of the 19th century many surgical instruments for endosurgical intervention on the larynx had been invented, which were adapted specifically for this method of endoscopy. However, an obstacle to the development of laryngeal endosurgery was the inconvenience associated with blood and mucus leaking into the trachea during attempts at more radical surgical intervention. The use of suction somewhat facilitated the surgeon's task, but not so much that it was possible to operate in a "dry field". With the invention of tracheal intubation for endotracheal administration of narcotic gas substances by the Scottish physician W. Macewen in 1880, the development of endolaryngeal surgery accelerated. In the 20th century, in connection with the development of fiber optics, video endoscopy and the improvement of microsurgical instruments, the method of endolaryngeal microsurgery emerged and reached perfection. For this purpose, Professor Oskar Kleinsasser of the University of Marburg, in collaboration with the firm "Karl Storz", developed and introduced into practice in most countries original models of laryngoscopes and a wide variety of surgical instruments, allowing for the most delicate surgical operations under high magnification using an operating microscope for virtually all types of the above-mentioned hyperplastic processes in the larynx.

Below we present a summary of some of O. Kleisasser’s recommendations on the technique of microsurgical intervention on the larynx and accompanying drawings.

The author recommends, first of all, to operate with two hands and two instruments. In most cases, forceps are combined with scissors or a coagulator with suction. Forceps are intended only for fixing the object to be removed and in no case for tearing or biting off tissue. "Stipping", i.e. tearing off a polyp or tearing off Reinke's edema, is a serious surgical error, since it can cause injury to the tissue that needs to be preserved, which can subsequently lead to voice impairment and the formation of unwanted scars. Therefore, smooth cutting of the tissue to be removed with sharp scissors or a special scalpel should become a strictly followed rule.

In order to adhere to the gentle principle, which is fundamental for endolaryngeal microsurgery, especially on the vocal folds, O. Kleinsasser recommends that novice surgeons have a clear idea of the fine anatomical structures of the larynx and study in detail the main pathological changes in order to differentiate them from healthy tissues that must be preserved. When intervening on the vocal fold, it is necessary to take into account the fact that the squamous epithelium is not fixed to the underlying substrate only above the body of the vocal fold; in the rest of the part, it is attached above and below to the arcuate lines, dorsally to the vocal process, and ventrally to the anterior commissure. The structure of the Reinke's space should also be taken into account; therefore, defects in the epithelium of the vocal fold that form after the removal of polyps, nodules, and varicose veins should remain as small as possible so that they are quickly covered with a new epithelial layer, and the Reinke's space closes again. When removing small pathological formations, such as polyps, nodules and small cysts adhering to the epithelium, they should not be grasped at the very base, but fixed with tweezers at the very edge of the fold of the mucous membrane, pulled to the middle of the glottis and cut off at their very base.

Large cysts located on the vocal fold, after longitudinal dissection of the mucous membrane covering them without damaging the cyst wall, are carefully enucleated with a miniature spoon entirely with the capsule.

In Reinke's edema, as O. Kleinsasser notes, suction of mucus, curettage and resection of the remnants of the mucous membrane in most cases do not lead to the desired result. The author warns against the often recommended method of "stripping", in which a strip of epithelium is simply torn off the vocal fold with tweezers. In this pathological condition, the author recommends first making a smooth cut with scissors in the tissue around the strip of epithelium to be removed, and only after that the removed "preparation" with the viscous edematous fluid clinging to it can be "pulled off" entirely, without damaging the underlying tissues. The thick secretion remaining on the vocal fold is removed with suction. In case of large Reinke's edema, in order to avoid excessive impairment of the vocal function, it is recommended to perform only partial removal of the pathological tissue during the first operation, and then, at intervals of 5-6 weeks, complete the surgical treatment with two more similar surgical interventions.

In advanced chronic hypertrophic laryngitis with thickening of the vocal folds, it is advisable to excise narrow strips of the thickest epithelial layer and inflamed submucosal tissue in order to provide the opportunity in the future to remodel the shape of the vocal folds at the expense of the remaining epithelial layer.

In case of juvenile papillomas, it is advisable to use the method of their diathermocoagulation with suction of the destroyed papillomatous tissue. This method is the fastest, most gentle and almost bloodless, ensuring satisfactory function of the vocal folds. Destruction is carried out by touching the microcoagulator to the most protruding part of the tissue to be removed, while the current strength is set at a low level so that the tissue is not burned during coagulation, but becomes soft ("boiled") and white and is easily removed without bleeding using suction. This technique does not allow the current to act on an unacceptable depth and ensures coagulation of only the layer that needs to be removed. Due to the small return of thermal energy, there is no large postoperative edema.

In precancerous tissue changes and small carcinomas, excisional biopsy is currently performed, as a rule, and not just small biopsies are taken: healthy-looking epithelium of the affected part of the vocal fold is incised and this part is separated within the healthy tissue to its very base and removed en masse. Keratoses, as well as pre-invasive and microinvasive carcinomas are usually removed without technical difficulties and without damaging the submucosal structures of the vocal folds. But when determining the penetration of the tumor into the depth of the vocal muscle, it should also be resected within the healthy tissues.

As O. Kleinsasser notes, endolaryngeal cordectomy in the clinic he heads is performed only when the tumor affects only the superficial muscle layer. In case of more significant damage to the vocal fold, the author recommends performing the operation from an external approach, which ensures a good overview and one-stage restoration of the vocal fold and thus preserves the fullness of the vocal function.

In the last decade, significant advances have been made in laser microsurgery of the larynx (M.S. Pluzhnikov, W. Steiner, J. Werner, etc.) using a carbon dioxide laser (G. Jako).