Throat examination

Study of the pharynx includes a number of procedures aimed at identifying both local and manifestations of common diseases and pathological conditions caused by violation of the innervation of the oral and pharyngeal organs. If a neurological disorder is detected, for example, deviation of the tongue, a decrease in taste sensitivity, a paresis of the soft palate, etc., the patient must be examined by a neurologist. Examination of a patient with a pharynx disease includes the collection of an anamnesis, an external examination of the anterior and lateral surfaces of the neck and sepation, an internal examination, an x-ray and in some cases a bacterio- and mycological examination.

Anamnesis

Interrogation of a patient with a pharynx disease is carried out according to the traditional scheme. To clarify the complaints, a number of questions are asked concerning the functions of the functions discussed above. In particular, they clarify the state of the swallowing function, whether the patient does not have puffs, food and liquids enter the nose, if there is a biting of the tongue, whether there are signs of a violation of the taste and other types of sensitivity of the oral cavity, etc. At the same time, functions of other sense organs.

Clarify the timing and sequence of the appearance of pathological signs, their dynamics, possible, according to the patient, the reasons. Pay attention to the timbre of the voice, the construction of speech, facial expressions, the presence of involuntary swallowing movements, whether the patient's forced situation and other peculiarities in his behavior are observed. These abnormalities can indicate both inflammatory and neurogenic diseases of the pharynx, which have arisen acutely or gradually, associated with any particular cause indicated by the patient, or "spontaneously," gradually.

When collecting an anamnesis of life, it is found out whether the patient has not suffered any diseases or injuries with the defeat of the peripheral or central nervous system, whether he is under the supervision of a neurologist, whether the information about a possible birth trauma has not been imprinted, etc. Find out the nature of work activity, and household hazards, the state of marital status, the presence of stressful situations. The information obtained during the collection of the anamnesis is subjected to careful analysis by comparing complaints and their dynamics with objective signs of the disease.

Examination of a patient who complains of TS or other signs of pharyngeal disease begins with a face examination, since his facial expressions can be reflected in his facial expressions due to a disease of the oral cavity, pharynx and esophagus. In addition, when examining a person, a number of signs can be identified that indicate the presence of a "lesion at a distance": the asymmetry of the eye slits, the smoothness of the nasolabial fold, the hyperemia of one half of the face, anisocoria, exophthalmos, strabismus,

Particular attention is paid to the lips. Pale lips testify to the presence of anemia, cyanosis - a lack of breathing, a grayish-blue color - about developing asphyxia. In severe toxic infections on the lips, there are often dark brown crusts, fused with the lip of the lips. Small vesicular eruptions on the lips in combination with general toxic symptoms or signs of irritation of the meninges may indicate the presence of a viral disease (influenza, cerebrospinal epidemic meningitis). In some women during menstruation, there are specific changes in the border of the lips, resembling herpetic eruptions. Ulceration and cracks in the corners of the mouth ("seizures") appearing in children older than 2 years, characterized by severe pain and persistence of the flow, indicate the presence of highly virulent streptococcal infection. On the lip rim, primary syphilis can appear as a hard chancre characterized by a red round or oval ulcer without clear boundaries of a densely-cartilaginous consistency with a zone of hyperemia around. This ulcer and accompanying regional lymphadenitis are characterized by their painlessness (unlike vulgar infection). With congenital syphilis in the corners of the mouth, linear radial scars of the skin can be observed. Lip augmentation (macrogelia) is observed with lymphostasis or with congenital forms of idiocy.

If the innervation of mimic muscles is impaired, one can observe the asymmetry of the corners of the mouth with the omission of one of them on the side of muscle weakness. Here, in the corner of the mouth, one can observe the accumulation of a certain amount of saliva and the phenomenon of maceration of the skin.

[1], [2], [3], [4], [5], [6]

Inspection of the oral cavity

When examining the oral cavity draw attention to the smell from the mouth. Experienced clinicians say that it is possible to diagnose not only the lip rim, but also the smell from the mouth. So, the putrid smell could testify about tooth caries, periodontitis, alveolar pyorrhea, ozene, decaying cancer of the tongue, pharynx, palatine tonsils; Sugary-sweet odor or odor of acetone is characteristic for diabetics. Intolerable nauseating odor of exhaled air can indicate throat pharynx, bronchiectasis, nome, gangrene of the lung. Garlic smell most often indicates intoxication with phosphorus-containing substances; this odor from the mouth appears when the patient is injected with neosalvarsan. The smell of ammonia is pathogens for uremia, and the smell of aldehyde is for alcoholic intoxication. Different odors from the mouth may appear with the use of some preparations containing lead, iodine, mercury, arsenic, etc., which are excreted with saliva. There are also the so-called essential oral kakosmia, observed in clinically healthy individuals, as well as smells caused by gastrointestinal diseases. Unpleasant odor from the mouth should be differentiated from the unpleasant odor from the nose.

Language examination

In the old days, internist doctors said: language - "the mirror of the stomach." Indeed, the shape of the tongue, the structure of its surface, the nature of the movements, etc., may indicate the presence of various pathological conditions in the body. Therefore, a doctor's request to show a language is not just a formality, but a step in diagnosis, an important test in establishing a number of significant symptoms.

When examining the patient's tongue, ask him to stick it out as much as possible. When sticking out the tongue, important signs can be identified. Thus, in severe toxic infectious conditions, patients are not able to stick their tongue out of the teeth, but if they succeed, the tongue does not protrude completely and often fibrillates (local wormlike movements) or trembles. The latter is observed with alcoholic or mercury intoxication, generalized paralysis or deep sclerotic changes in the brain stem structures. The defeat of the nucleus of the sublingual nerve or a hundred-way pathway (hemorrhage, cerebral infarction, tumors of the corresponding localization) causes the deviation of the tongue when it protrudes to the sore side, because the lingual muscles of the healthy side push the tongue toward the paralyzed muscles. With phlegmons of the root of the tongue or with the abscessing inflammation of the paratonsillar space, the protrusion of the tongue is extremely difficult and painful. It should be borne in mind that incomplete protrusion of the tongue may be due to a variety of anatomical causes, for example, its short frenum. In this case, there are certain defects in articulation, for example lisp.

The size of the tongue, its volume also have an important diagnostic value. The increase in volume (macroglossia) may be due to its damage to the tumor, lymphangioma, hemangioma, inflammatory process, myxedema. The cause of microglossia can be atrophy of the tongue with lesions of the sublingual nerve, dorsal air, generalized paralysis in polyneuritis, and so on.

Congenital malformations of the tongue include its hypo- and aplasia, its fusion with the surrounding tissues, splitting (lingua bifida), double tongue (lingua duplex), the absence of a bridle, etc. The most common abnormally large language, the reason for which is the excessive development of its muscular tissue. In some cases, the tongue reaches a size that does not fit in the mouth; such people go with their tongues sticking out, hanging over the lower lip.

Congenital anomalies of the tongue include the so-called folded tongue. At the same time, the language is slightly enlarged, but remains soft; On its surface near the passing but middle line of the furrow are seen divergent furrows, similar to the furrows of the skin of the scrotum (lingua scrotalis). To innate defects of the tongue should be attributed and the non-opening of the blind hole of it, which sometimes serves as an entrance gate for infection, causing abscesses of the root of the tongue, phlegmon of surrounding tissues.

Great importance is attached to the color of the tongue. For example, it is generally accepted that "coated" language indicates a disease of the stomach. With scarlet fever, the tongue is initially coated with a white coating, then after 2-3 days desquamation of the surface layer occurs, and the tongue acquires a bright red color ("crimson" tongue). For the glossitis Ponter, a harbinger of malignant anemia, the bright red color of the tongue with the "lacquered" surface and strong spontaneous pains that intensify when eating, especially hot and spicy, are characteristic. Pale tongue is observed in primary and severe secondary anemia; yellow tongue, mainly on the lower surface, - with jaundice, black villous ("hairy" tongue) - in heavy smokers or in cachex patients. There are many other diseases and pathological conditions, in which changes in the shape, color, movements and sensitivity of the tongue are observed. Thus, the syndrome of glossolgia (glossodynia), manifested by burning, tingling, tingling, numbness, etc., accompanied by excessive salivation, the cause of which, at times, it is difficult to establish. Often this syndrome is accompanied by paresthesia in other parts of the oral cavity (lips, cheeks, palate), in the pharynx and esophagus. Diseases of the tongue are united under the common name "glossitis"; among them there are gummy, sclerosing, Mallerian, desquamative (geofacific), scarlet fever and other forms of glossitis. Diseases of the tongue are the subject of attention of the dentist, while the lingual tonsil belongs to the competence of the otorhinolaryngologist. Often, the examination of the pharynx is impeded by active resistance of the tongue, sometimes insurmountable ("unruly tongue", as well as a pronounced pharyngeal reflex).

To examine the pharynx and oral cavity, the examinee should open his mouth wide, not sticking out his tongue. The doctor inserts a spatula into the oral cavity and with its entire plane (and not the end!) Presses the tongue against the bottom of the mouth with slight pressure and pushes it somewhat forward. The spatula rest on the front 2/3 of the tongue, not reaching the V-shaped papillary formation, which prevents the appearance of the pharyngeal reflex. The tongue is pressed downwards so that the posterior wall of the pharynx, up to the edge of the epiglottis, the root of the tongue, the side walls of the pharynx, the palatine arches and other anatomical formations of the pharynx were well visible. With a "submissive" language and a low pharyngeal reflex, it will be possible to examine the initial sections of the laryngopharynx, the edge of the epiglottis, parts of the cherpalodnagortan folds and almost completely lingual tonsil. When examining the pharynx, the subject is asked to say "a" for 3-4 seconds, during which the MyaN rises, and the upper part of the posterior pharyngeal wall becomes visible. One assesses temporarily the degree of mobility and symmetry of the soft palate. A pharyngeal reflex is evaluated by touching with a spatula to the posterior pharyngeal wall.

When examining the pharynxes pay attention to the color of the mucosa, its humidity, the presence of lymphadenoid granules on the back wall. The normal mucous membrane is pale pink with a characteristic moist luster (unlike the "dry" mucosa, which is distinguished by "lacquered" gloss). Through the normal mucosa of the posterior pharyngeal wall, the vessels are not transparent, there are no whitish spots characteristic of atrophy, there are no erosions, papules hypertrophied with halos of follicle hyperemia and other pathological inclusions. Assess the condition of the lateral ridges, teeth, gums. The ENT specialist should be able to distinguish the normal condition of the gums from the pathological (periodontal disease, periodontitis, gingivitis ), to reveal obvious diseases of the teeth, as foci of focal infection.

Especially careful examination is subjected to palatine tonsils. Assess their magnitude, color, density, lacuna content, adhesion to surrounding tissues. Normally, the amygdala easily "dislocates" from its niche with a trowel pressing on the base of the anterior palatal arch. With cicatricial changes that fix the amygdala in its niche, this does not happen. Use a finger or a spatula to determine the density of the tonsils. Normally, the amygdala is soft, when squeezed from it, a whitish liquid secret is released, sometimes a small amount of detritus. In chronic inflammation, the tonsils are dense, immobile, soldered to surrounding tissues, of which a large number of caseous masses or pus with an unpleasant putrefactive odor are released.

Inspection of the nasopharynx is carried out either with the help of an endoscope (direct epipharyngoscopy), or with a nasopharyngeal mirror (mirror epipharyngoskonia).

Inspection of the laryngopharynx is performed with the help of a laryngeal mirror (indirect hypopharyngoscopy) or with a special mirror-directing (direct hypopharyngoscopy), as will be discussed in more detail in the chapter on the study of the larynx.

With the help of palpation, hidden from the eye pathological conditions or abnormalities of pharyngeal development can be revealed. For example, this technique can reveal a giant cervical process, which is usually palpated at the border of the posterior margin of the tonsil and the lateral wall of the pharynx; when pressing on the process, the patient may feel pain. Palpation of cervical processes is bimanual: with palpation on the left, the second finger of the left hand is inserted into the oral cavity and palpated the pharyngeal side wall in the above area; At the same time, the fingers of the right hand are pressed externally at the angle of the lower jaw, trying to penetrate the submandibular fossa in the projection of the exit of the facial nerve.

Palpation of palatine tonsils can reveal their scarring, concrements, as well as pulsating large vessels and aneurysms, which is especially important for planned surgical interventions in this area (removal of tonsils, cervical processes, enlarged monotonzillectomy in tumors of the amygdala, opening of the peritonsillar abscess, etc.). With the aid of a buttoned probe penetrate into the lacunae, investigate their depth, content, establish the presence of a supramaxel fossa, etc. By palpation, the condition of the nasopharynx, its walls, as well as the reflex activity of the pharynx and the state of the lingual tonsil are determined.

Neck Examination

Particular attention should be paid to the examination and palpation of the anterior and lateral surfaces of the neck, supraclavicular and jugular pits. Examine the thyroid gland, superficial and deep cervical lymph nodes, the projection zone of large cervical vessels. If necessary, a phonendoscope is used to listen to vascular noise in the region of the projection of the common carotid artery. These noises can occur in pathological conditions of the arteries (aneurysm, stenosis, swelling, etc.) and often simulate ear noise. Differentiate them from true ear noise can be a way of squeezing the common carotid artery.

Palpation of the neck is carried out mainly to determine the condition of the lymph nodes and thyroid gland. Palpation of the lymph nodes of the neck is carried out simultaneously with both hands with slightly inclined forward head of the subject, starting from the submandibular lymph nodes; then move to the palpation of the regional for palatine tonsils lymph nodes located along the anterior edge of the sternocleidomastoid muscle, then palpate the deep lymph nodes of the neck along the posterior margin of this muscle, the supraclavicular and posterior cervical lymph nodes; the latter can be involved in the process with metastatic nasopharyngeal tumors. When palpation of the thyroid gland determine its magnitude, consistency, macrostructure of the structure. When palpation of the jugular fossa and an arbitrary throat of water, it is sometimes possible to reveal a portion of the thyroid gland that is upstroke dystopic behind the handle of the sternum.

Research of pharyngeal functions is carried out in several directions. First of all, its mobility, symmetry and quality of resonant abilities in phonation, as well as its swallowing function with the help of a drink of water, are evaluated; while paying attention to its patency for the liquid. If the swallowing function of the pharynx is disturbed, the swallowing act is performed with effort and forced movements in the neck and trunk, may be accompanied by pain; with the paresis of the muscles of the soft palate, the liquid enters the nose, with the paresis of the muscles that protect the larynx during the swallowing act, the liquid enters the larynx. As a result of the reverse peristaltic movement of the esophagus, the liquid and contents of the food lump after the pharynx can again return to the oral cavity, etc.

The change in the timbre of the voice occurs with various functional disturbances and organic processes both in the innervation and in the articulatory apparatus. Thus, open nasal arises when the soft palate paralyzes, its defects, the hardness of the sky; closed nasal congestion is observed with obstruction of the nasopharynx ( adenoids, choanal polyps, atresia of the khohans, nasopharyngeal tumors, etc.) Changes in the tone of the voice are observed with abscesses and tumors of the pharynx, dysarthria - with defects in the tongue (impossibility of normal pronunciation of sounds t, d, c, e, p ) or lips (b, n, c, a, y).

When examining the oral cavity and pharynx, a study of taste sensitivity is carried out simultaneously .

In connection with the fact that the pharynx in the anatomical and to a large extent functionally occupies a central position in the system of ENT organs, and its own structure is replete with diverse and extremely active and vital structures, the pathological states that arise in it are manifested not only by well-known local structural and functional disorders, but also various organic and functional disorders at a distance. On the other hand, her numerous connections with neighboring organs and regulatory centers of the nervous system, her dependence on blood supply systems, lymphopoiesis, lymph drainage, etc., often cause the occurrence of certain secondary functional or organic diseases of the pharynx, interpreted as "pharyngeal complications". The richness of the pharyngeal lymphoid apparatus, a protective tool, often turns into various kinds of diseases of this apparatus, both local and distant, for example, metastasis of purulent or teratogenic emboli. The combination in the throat of the three most important functions - the esophagus, the respiratory and the immune, significantly diversifies the phenomenology of its diseases, the abundance of which, on the one hand, increases the effectiveness of the probabilistic approach to the establishment of a specific diagnosis; on the other hand, in some cases, however, the occurrence of "cross-symptomatology" makes it difficult differential diagnosis of a number of its diseases.

Being at the "crossroads" of the respiratory and esophagus pathways, richly supplied with blood and lymphatic vessels, literally saturated with glandular and lymphadenoid tissues, the pharynx is one of the organs most sensitive to various pathogenic factors. Sometimes, referring to an ENT specialist with a complaint, for example, to a slight difficulty in swallowing or choking, a patient (often a doctor) does not suspect that this symptom may be a manifestation of any progressive disease of the brain or the beginning of the tumor process, but spontaneously the arisen "angina" can serve as the first sign of a blood disease.

The pharynx is an extremely mobile organ functioning in strict dependence on the nervous, endocrine and immune regulation of all functions. Malfunctions in any of these links of the integral regulatory system lead to trophic and functional disorders that entail secondary, tertiary, etc. Pathological changes of an organic nature. The latter, in turn, closing the vicious circle, aggravate the course of the disease, acquiring a systemic nature, often turning it into a chronically current process. Proceeding from what has been said, any, even the most banal disease of the pharynx, should be considered as a condition involving the whole complex of its constituent structures in the pathological process, ie, as a systemic pathological process requiring a comprehensive approach, both in diagnosis and treatment.

One should pay attention to one more aspect of the "pharynx" disease. It is with diseases of the pharynx and other other ENT organs that are functionally related to it that such a psychosocial condition of the patient as a quality of his life is significantly impaired. Acute diseases of the pharynx literally "cut off" a person from the social and domestic environment, and chronic ones, especially those associated with specific or occupational diseases, can dramatically change the fate of the patient, condemning him to suffering and loneliness.

An important place in the problem under consideration is the diagnosis and treatment of a particular disease. Diagnosis is facilitated by visual and instrumental access to the pharynx, but only if the pathological process is limited to its anatomical limits. However, many diseases of the pharynx have their origin far beyond these limits, and the pharynx acts as a secondary "instance", involved in the pathological process "by coercion," and then becomes the organ of the most vivid manifestations. Sometimes the distant hearth remains "in the shadows" for a long time, does not show itself, and the process in the throat is active and bright. In this case, the detection of the primary source is a difficult task, and only a systematic approach to any pathological process, including the elaboration of all possible variants of its causes, increases the likelihood of establishing the most complete diagnosis, in which all the components of this concept appear: etiology, pathogenesis and pathoanatomical changes .

Treatment for diseases of the pharynx has its own peculiarities. It includes non-operative, "semi-surgical" (without removing any of the anatomical formations of the pharynx or opening of the abscesses) and surgical (adenotomy, tonsillectomy, opening of the abscess, plastic surgery, oncosurgical interventions). Non-operative treatment of the pharynx includes the local and general use of numerous medicinal products of both plant origin and synthetic, as well as a number of physiotherapy techniques. Local treatment includes compresses, rinsing, inhalation, aerosol and lubricating applications, lavage of the lacunae of the tonsils, nasal installations. Physiotherapy methods include pharyngeal pharadization with various neurogenic diseases, UFOs, for example, in tuberculosis or sclerosis of the pharynx, radiation therapy with oncologic diseases of the pharynx, etc. Half-surgical interventions include galvanic caustic of palatine tonsils, dissection of lacunae, etc. A detailed description of the treatment methods is given in description of specific diseases of the pharynx.