Chronic pharyngitis

Chronic pharyngitis is a group of diseases of the mucous membrane of the pharynx and diffusely located mucous glands and lymphadenoid granules in it. Depending on the depth of damage to the elements of the mucous membrane, its prevalence, it can be defined as diffuse, limited, catarrhal, granular, hypertrophic, atrophic and combined.

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What causes chronic pharyngitis?

Chronic pharyngitis is caused by a variety of bacteria that nest in the crypts and parenchyma of the lymphadenoid formations of the nasopharynx and pharynx, activated after an adenovirus infection, which sharply weakens local tissue immunity.

Pathogenesis of chronic pharyngitis

The pathogenesis of chronic pharyngitis largely depends on the causes of the disease and a number of contributing factors. The causes of chronic pharyngitis can be local and general. The most common local causes that play an important pathogenetic role in the development of chronic pharyngitis include chronic rhinitis and sinusitis, chronic adenoiditis and tonsillitis. General causes and contributing factors include metabolic diseases, constitutional predisposition to diseases of the mucous membrane of the upper respiratory tract and the lymphadenoid apparatus of the pharynx, hemodynamic disorders in the upper respiratory tract (congestion leading to hypoxia and hyponutria of their structures) caused by corresponding diseases of the cardiovascular system, liver, kidneys, and lungs. In hazardous production conditions, sharp temperature fluctuations, dry hot air, atmospheric dustiness (cement, clay in porcelain production, flour in the milling industry), and vapors of various substances with free radicals, pronounced oxidizing, alkalizing, and certain toxic properties play a major role in the damage to the tissues of the upper respiratory tract. Household hazards (smoking, abuse of strong alcoholic beverages, especially surrogates, consumption of spicy hot dishes) play a major role in the development of chronic diseases of the upper respiratory tract and, in particular, chronic pharyngitis.

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Diffuse catarrhal chronic pharyngitis

In reality, this chronic pharyngitis is a total catarrhal inflammation of the pharynx, including the mucous membrane of the nasopharynx, often the auditory tube and especially the excretory ducts of the anterior paranasal sinuses. Chronic pharyngitis is more common in childhood due to the more significant development of the lymphadenoid apparatus - the nest of chronic infection, and less common in adults, in whom this apparatus is significantly atrophied.

In the pathogenesis of the disease, an important role is played by infection of the nasal cavity and impaired nasal breathing, which excludes the protective functions of the nasal mucosa from the act of breathing and causes contact of the air entering the respiratory tract with the mucous membrane of the pharynx. Oral breathing is a significant aphysiological factor that negatively affects many tissue processes in the pharynx, ultimately leading to disturbances in local metabolism, hypoxia, drying out of the protective layer of mucus containing biologically active substances that protect the mucous membranes of the pharynx from harmful atmospheric factors, and finally, all this taken together leads to a violation of cellular homeostasis and a deficiency of local immunity. All these factors, acting on different sprouts of the mucous membrane, lead to various pathomorphological changes, reflected in the clinical names of various forms of pharyngitis.

Symptoms of chronic pharyngitis

Symptoms of chronic pharyngitis are based on the patient's complaints, his general and local objective condition. Subjective signs of chronic diffuse catarrhal pharyngitis outside of exacerbation are absent in children, in adults they are manifested by moderate complaints of a sore throat, viscous, difficult to expectorate secretions, increased gag reflex with crust accumulation, cough. Patients often resort to gargling at night. In the morning hours, the above symptoms are more pronounced.

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How to recognize chronic pharyngitis?

During pharyngoscopy, against the background of general not very bright hyperemia of the mucous membrane on the back wall of the pharynx, soft palate, viscous mucous deposits are determined, which are difficult to remove with tweezers. In the cold season, hyperemia of the mucous membrane increases, the amount of mucous secretions increases, and they become more liquid.

When the pharynx is infected with adenoviruses or bacteria (their own opportunistic microbiota), the mucous discharge becomes mucopurulent and the inflammation acquires clinical signs of acute or subacute bacterial diffuse pharyngitis. Headache, subfebrile body temperature and all signs of moderate intoxication appear.

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Treatment of diffuse catarrhal chronic pharyngitis

Treatment of chronic diffuse catarrhal pharyngitis consists primarily of eliminating the underlying cause of the disease - chronic sinusitis or chronic adenoiditis, as well as pathologically altered remnants of the palatine tonsils, if any have remained after their removal in the past. In the event of an exacerbation of the inflammatory process, the same treatment is used as for acute catarrhal pharyngitis.

Hypertrophic chronic pharyngitis

Chronic hypertrophic pharyngitis most often serves as the next stage of development of chronic diffuse catarrhal pharyngitis, caused by the reasons described above. Most often, hypertrophy of lymphadenoid formations of the pharynx is interpreted as a compensatory (protective) reaction that increases the volume of local cellular immunity structures.

Symptoms of chronic pharyngitis

Clinically, chronic hypertrophic pharyngitis is considered as adenopharyngitis caused and maintained by the same rhinosinus or adenoid chronic infection. Long-term, over many months and years, contact of the mucous membrane of the pharynx with mucopurulent secretions containing decay products of blood cells, mucus and interstitial tissue, which have toxic-allergic properties in relation to the mucous membrane, leads not only to hypertrophy of the superficial tissues of the pharynx, but also the underlying muscular and interstitial tissue, due to which the nasopharyngeal cavity appears narrowed, the mucous membrane thickened, the nasopharyngeal openings "buried" in edematous and hypertrophied tissue. These changes negatively affect the function of the auditory tube, therefore many people suffering from chronic hypertrophic pharyngitis also complain of hearing loss.

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How to recognize hypertrophic chronic pharyngitis?

During pharyngoscopy, the mucous membrane of the pharynx, soft palate, and palatine arches is hyperemic, covered with thin mucopurulent discharge flowing from the nasopharynx, the palatine arches and lateral ridges of the pharynx are thickened, under the discharge a hyperemic mucous membrane is determined, which after some time in certain small areas begins to turn pale and thin, which, in essence, marks the transition to the next stage of chronic pharyngitis - atrophic. On the way to this stage, so-called granular chronic pharyngitis occurs in half of the patients, which is widespread in atrophic pharyngitis.

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Granular chronic pharyngitis

Granular chronic pharyngitis is manifested by hypertrophy of lymphoid granules covering the back wall of the pharynx. The process of hypertrophy of granules begins with a change in the mucopurulent secretions flowing down the back wall of the pharynx; with further development of the process, they become viscous, dense, drying into crusts that are difficult to remove. At this stage, the mucous membrane of the back wall of the pharynx turns pale, and the granules increase in size and turn red. These granules form small islands of lymphoid tissue on the back wall of the pharynx, which, in essence, are analogs of infected granules of the palatine tonsils, only in a dispersed state, and cause the same local and general pathological phenomena as chronic tonsillitis.

On the lateral walls of the pharynx, behind the posterior arches of the soft palate, the follicles unite into lateral lymphoid folds of the pharynx, which also become infected and hypertrophied, creating the impression of additional posterior palatine arches. Their inflammation and hypertrophy are defined as lateral pharyngitis, which is, in fact, only one of the signs of chronic hypertrophic pharyngitis.

Mucopurulent discharges flowing down the back wall of the pharynx reach the laryngeal part of the pharynx and, in particular, the interarytenoid space. Here they macerate the mucous membrane of the entrance to the larynx, have the same pathological effect on it as on the rest of the mucous membrane of the pharynx, drying out, turning into crusts and irritating the nerve endings of the superior laryngeal nerve, provoking a cough and causing hoarseness of the voice.

Later, chronic pharyngitis progresses to a stage with pronounced tissue dystrophic processes.

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Chronic epipharyngitis

Chronic epipharyngitis, being the cause of acute and chronic inflammatory processes in the lower parts of the pharynx, can occur as an independent disease, having adenoid vegetations as a "feeding" source of infection (chronic adenoiditis), or be caused by a chronic rhinosinus infection. The mucous membrane of the nasopharynx, unlike the mucous membrane of the pharynx, is covered with respiratory epithelium, which is more sensitive to infectious agents and always reacts more strongly to infection than the multilayered (flat) epithelium covering the mucous membrane of the oropharynx.

Chronic epipharyngitis in the first stage manifests itself as chronic catarrhal inflammation of the mucous membrane, which is hyperemic and covered with mucopurulent discharge. The patient complains of dryness and a sensation of a foreign body behind the soft palate, especially in the morning. These sensations arise as a result of the formation of dry crusts in the nasopharynx during the night, which are difficult to remove even with considerable effort from the patient. Instillation of alkaline or oil drops into the nose helps to soften and remove them. Very often, chronic epipharyngitis provokes headaches of deep localization, reminiscent of those in chronic inflammation of the posterior paranasal sinuses.

In the second stage, the mucous membrane thickens, especially in the area of the tubal tonsils, due to which the nasopharyngeal cavity appears narrowed and filled with mucopurulent discharge flowing down the back wall of the pharynx. Inflammation of the pharyngeal tonsils and chronic tubootitis in chronic epipharyngitis is a common phenomenon, aggravating the clinical picture of the general disease with hearing loss, pain in the nasopharynx, and periodic exacerbations of chronic adenoiditis. This stage of chronic epipharyngitis is usually combined with chronic hypertrophic rhinitis.

The third stage of chronic epipharyngitis is characterized by the growth of atrophic phenomena, which occur after many years and are most often observed in old people, as well as in workers in harmful professions, in people of vocal professions, in young people with debility syndrome, in the pre-tuberculosis stage, after scarlet fever and diphtheria. However, chronic epipharyngitis can occur primarily, as a constitutional disease. The mucous membrane in the atrophy stage appears pale, flat, covered with dry crusts, resembling crusts in ozena in appearance, but differing from them in the absence of a specific odor.

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Chronic smoker's pharyngitis

Chronic smoker's pharyngitis occurs in people who started smoking early and continue this harmful habit practically throughout their entire lives. Tobacco smoking (nicotinism) is one of the most common types of household drug addiction caused by the body's nicotine dependence. When smoking, dry distillation of tobacco occurs with the formation of a significant amount of various products: nicotine, hydrogen sulfide, acetic, formic, hydrocyanic and butyric acids, pyridine, carbon monoxide, etc. These substances are toxins by their chemical composition, naturally, they are foreign to the body and when they enter it, they cause harm to it, affecting various organs and systems.

Smoking tobacco is not a physiological need of the body. As L.V. Brusilovsky (1960) notes, it is rather a pathological act, caused first by imitation, and then with further smoking chronically destroying the body. Without going into details of the harm that nicotine causes to the body, we will only note that its negative impact concerns almost all vital organs and systems (the central nervous system, cardiovascular system, endocrine and bronchopulmonary systems, the reproductive system, the gastrointestinal tract, liver, kidneys, pancreas, interstitial tissue), while all types of metabolism, the adaptive-trophic function of the autonomic nervous system, immunity are disrupted to one degree or another, dystrophic processes occur in the upper respiratory tract, pharynx, esophagus, etc.

Nicotine acts directly on the mucous membrane of the mouth, nose, pharynx, larynx, exerting a pronounced damaging effect on it. Teeth are usually covered with a specific yellow plaque and are quickly affected by caries. Smoking often causes salivation and bad breath. In pipe smokers, irritation of the lips by the mouthpiece often causes cancer of the lower lip. Smokers often suffer from various diseases of the mucous membrane of the oral cavity. Damage to the pharynx by nicotine is manifested by pronounced hyperemia and dryness of the mucous membrane (smoker's pharynx), which provokes a constant cough and viscous gray discharge in the form of difficult to cough up sputum, especially in the morning. Stopping smoking normalizes the mucous membrane of the pharynx within 3-4 weeks.

Nicotine directly affects the mucous membrane of the esophagus, stomach and intestines, as a result of which chronic catarrhal inflammation of these organs develops in these individuals, and stomach ulcers or even cancer may develop in individuals who are especially sensitive to nicotine. According to a number of researchers, prolonged inhalation of tobacco smoke causes destructive changes in the spinal cord and peripheral nervous system in experimental animals. In workers employed for many years in the tobacco industry, in addition to damage to the respiratory and digestive tract, a neurological complex develops that resembles tabes dorsalis (according to A. Strumpell, "nicotine tabes").

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Occupational chronic pharyngitis

Professional chronic pharyngitis is observed in almost all workers in industries associated with emissions of dust particles and vapors of aggressive substances into the atmosphere. The first phase - catarrhal inflammation in a newcomer to production, lasts no more than 3-5 months, then comes the phase of the atrophic process with the formation of crusts and the occurrence of periodic nasal and pharyngeal bleeding from small vessels. Often, in the presence of idiosyncrasy to certain industrial hazards, workers develop so-called intolerance pharyngitis.

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Chronic pharyngitis of idiosyncratic genesis

Chronic pharyngitis of idiosyncratic genesis is characterized by diffuse reddening of the mucous membrane of the pharynx, sensations of dryness and burning, unpleasant sensations when swallowing. This chronic pharyngitis occurs several minutes after direct contact of the mucous membrane with a reactogenic substance (a drug, a certain spice or drink containing a particular preservative, etc.) or hematogenously by absorption of the substance through the upper respiratory tract or gastrointestinal tract. In this case, the reaction may occur in 10-15 minutes. Chronic pharyngitis of idiosyncratic genesis is classified as allergic or toxic. The most common type of toxic pharyngeal lesion is chronic pharyngitis of alcoholics, caused not so much by the local burning and dehydrating effect of strong alcoholic beverages, but by the presence of severe alcohol avitaminosis (A, B6, PP and C) in this category of patients.

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Senile chronic pharyngitis

Senile chronic pharyngitis caused by age-related involutional processes is one of the syndromes of systemic aging of the organism, which is a general biological pattern inherent in all living things. According to the definition of Yu.N.Dobrovolsky (1963), "Old age is the final stage of development of the aging process, the final period of ontogenesis, which precedes the completion of the life cycle - death." As a rule, senile chronic pharyngitis does not occur in a pronounced form during physiological aging, which should be understood as a naturally occurring and gradually developing process of age-related changes, accompanied by a decrease in the level (but not distortion!) of metabolism, a change in the adaptive capabilities of the organism, leading to a decrease in the tolerance of the organism to environmental factors, medications, etc., as well as the predominance of natural tissue decay over their reproduction. S.P.Botkin pointed out the need to distinguish between the concept of physiological aging and premature aging. This concept has received wide recognition from the leading figures of Russian biological science (I.I. Mechnikov, I.P. Pavlov, A.A. Bogomolets, A.V. Nagorny, etc.), who in their works were pioneers in the world science of old age. Premature aging should be classified as a pathological phenomenon that occurs as a result of the impact on the body of a number of damaging factors, the origin of which is due to either the individual's lifestyle, or acquired diseases, injuries, intoxications, or a hereditary predisposition to the acceleration of physiological aging processes. It is with premature (pathological) aging that characteristic signs of subatrophic and atrophic pharyngitis (rhinitis, laryngitis, esophagitis, tracheitis, etc.) are observed, which are part of the general morphological changes in all tissues of an aging organism.

A characteristic feature of involutional processes occurring in the mucous membrane of the upper respiratory tract is selective atrophy of the elements of the mucous membrane, in which the mucous glands retain their function, increasing their activity under the influence of nocturnal activation of the vagus nerve (complaints of elderly people about the abundance of mucus in the nose, pharynx, larynx at night), at the same time, atrophy of the ciliated epithelium, interstitial tissue, submucosal layer, and lymphoid elements occurs. In the daytime, the mucous membrane appears dry, pale with vessels visible through it. Granules on the back wall of the pharynx are absent, the palatine tonsils and lateral ridges are practically not determined. Due to atrophy of the muscular layers of the pharynx, soft palate, palatine arches, the pharynx and pharyngeal cavity are enlarged. Reflexes of sensory nerves are reduced or absent.

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Treatment of chronic pharyngitis

Treatment of chronic pharyngitis is determined by the clinical form of the pathological process and the stage at which this clinical form is located.

Treatment of chronic diffuse catarrhal and hypertrophic pharyngitis, like any other disease, regardless of etiology and pathogenesis, should be comprehensive, if possible, etiotropic, in most cases pathogenetic and always symptomatic. Considering that the cause of chronic diffuse catarrhal pharyngitis in the overwhelming majority of cases are inflammatory diseases of the nasal cavity, all attention should be paid primarily to the sanitation of the nose and paranasal sinuses (elimination of purulent infection, elimination of the causes of impaired nasal breathing, sanitation of lymphadenoid formations and, above all, the pharyngeal tonsils). In addition, attention should be paid to the general condition of the body, to exclude diseases of other organs and systems, the presence of allergies, idiosyncrasies, some genetically determined dysmorphia of the nasal cavity, oral cavity and pharynx. These general provisions are also true for the treatment of other forms of chronic pharyngitis.

Treatment of chronic diffuse catarrhal pharyngitis should be carried out taking into account the presence of catarrhal inflammation caused by vulgar pathogenic microbiota nesting in the layers of the mucous membrane, the virulence of which is supported by impaired trophism and a decrease in local cellular and humoral immunity. Based on this, the etiotropic treatment of chronic pharyngitis should be aimed at identifying pathogenic microbiota and targeting it with appropriate bactericidal agents. This impact should be directed primarily at the pathogenic focus of infection and only secondarily at the mucous membrane of the pharynx. The most effective drug in this case is the macrolide Clarithromycin (Binoclar, Klabax, Claricin, Klacid, Fromilid), used per os. This drug is active against many intracellular microorganisms, gram-positive and gram-negative bacteria.

Of great importance in the treatment of chronic diffuse catarrhal pharyngitis are methods that increase the overall resistance of the body, the use of antiallergic, desensitizing and sedative drugs, drugs that normalize metabolic processes, vitamin therapy, replenishment of the deficiency of microelements that play a vital role in maintaining homeostasis of the body's mucous membrane.

Local treatment of chronic pharyngitis

Local treatment of chronic pharyngitis can only partially be considered pathogenetic, namely in those cases when immune, metabolic, trophic and reparative processes are stimulated on the mucous membrane of the pharynx with the help of medicinal and physiotherapeutic means. A full set of the indicated methods is given in the previous sections; an experienced doctor only needs to make up an adequate and effective composition of them, taking into account the individual characteristics of the whole organism and the local pathological process. Since diffuse catarrhal chronic pharyngitis and chronic hypertrophic pharyngitis are, in essence, combined phases of the same inflammatory process, the methods used for their treatment are practically identical, except that in hypertrophic pharyngitis they (the methods) are more radical and invasive. In chronic catarrhal and hypertrophic pharyngitis, astringent and anti-inflammatory agents are used to reduce exudation and swelling of the mucous membrane, and in the hypertrophic form of chronic pharyngitis, cauterizing agents are used (10% silver nitrate solution, crystalline trichloroacetic acid after anesthesia with 1% dicaine solution), applied to individual hypertrophied areas of lymphadenoid tissue (granules on the back wall of the pharynx, lateral ridges). However, one should be wary of excessive enthusiasm for cauterization of these foci of the outpost in the fight against infection and centers of trophic regulation of the mucous membrane, otherwise there is a risk of transferring chronic diffuse catarrhal pharyngitis and chronic hypertrophic pharyngitis to the stage of the atrophic process, which in most cases remains irreversible.

The drugs of choice for local treatment of chronic diffuse catarrhal pharyngitis and chronic hypertrophic pharyngitis include Burow's solution, resorcinol solution (0.25-0.5%), propolis alcohol solution (30%), eucalyptus tincture (10-15 drops per glass of water for rinsing 3 times a day), etc. The following are used as astringents and disinfectants: 0.5-1% iodine-glycerin solution (Lugol's solution), 1-2% silver nitrate solution, 2-3% protargol or collargol solution, tannin mixed with glycerin, menthol in peach oil, 0.5% zinc sulfate solution.

With timely, adequate and effective treatment, taking into account the elimination of foci of infection in the upper respiratory tract, sanitation (if necessary) of other organs and systems, elimination of household and professional hazards, compliance with the work and rest regime, personal hygiene and periodic spa treatment "on the waters", chronic pharyngitis in the vast majority of cases regresses and completely disappears within 2-3 months. However, despite the most intensive treatment, alcohol consumption and smoking nullify all the efforts of the doctor and the patient, while the effect achieved is temporary and insignificant, and chronic pharyngitis continues to progress, moving into the stage of chronic subatrophic and atrophic pharyngitis.