Throat tuberculosis

The infection of the pharynx with tuberculosis infection is a relatively rare phenomenon that occurs in most cases with a severe, far-reaching process in the lungs and larynx, accompanied by a sharp weakening of the general and local resistance of the organism. There are some reports of primary tuberculosis of the pharynx, the primary affect of which is localized, as a rule, in the palatine tonsils. In addition, there are reports that tonsils can develop latent forms of tuberculosis without any external clinical manifestations. So, T. Gorbea et al. (1964) reported that in 3-5% of tonsils removed for various reasons, a latent form of tuberculosis is found.

Epidemiology of tuberculosis of the pharynx

MBT more often enter the body through the upper respiratory tract, less often through the gastrointestinal tract and damaged skin. The main source of infection is the sick people who release the MBT, as well as sick animals, mainly cattle, camels, goats, sheep, pigs, dogs, cats, chickens. MBT can be contained in milk, dairy products, less often in meat of sick animals and birds.

[1], [2], [3], [4], [5], [6], [7], [8]

The cause of pharyngeal tuberculosis

MBT - acid-fast mycobacteria of several species - human, bovine, avian, etc. The most frequent causative agent of tuberculosis in humans are the human type MBT. These are thin, straight or slightly curved sticks 1-10 microns long, 0.2-0.6 microns wide, homogeneous or granular with slightly rounded ends, very resistant to environmental factors.

Pathogenesis is complex and depends on the variety of conditions in which the causative agent of infection and the organism interacts. Penetration of the MBT does not always cause the development of the tuberculosis process. The leading role in the emergence of tuberculosis is played by unfavorable living conditions, as well as a decrease in the body's resistance. There is evidence of a hereditary predisposition to the disease. In the development of tuberculosis, primary and secondary periods are isolated, which occur in conditions of different reactivity of the organism. Primary tuberculosis is characterized by high sensitivity of tissues to the MBT and their toxins, as well as the formation of the primary tuberculosis complex (most often in the intrathoracic, basal lymph nodes), which can serve as a source of hematogenous dissemination of the MBT with the onset of a secondary period of tuberculosis, in which primarily the lungs are affected , and then other organs and tissues, including the lymphadenoid apparatus of the pharynx and larynx and surrounding tissues.

Pathological anatomy

Pathomorphologically, tuberculosis of the pharynx is manifested by the formation of infiltrates and ulceration. In the palatine tonsils, tuberculomas are located both in the follicles, and in perifolikulyarnyh tissues and under the mucous membrane.

Symptoms of pharyngeal tuberculosis

Tuberculosis of the pharynx depend on the stage of development of the process and its localization. In acute forms, severe pain occurs both spontaneously and when swallowed. Subacute ulcerative process and chronic forms are also accompanied by a pain syndrome, which, however, can vary in intensity, depending on the involvement of the sensory nerves innervating the pharynx in the process. If the process is localized in the lateral wall of the pharynx, the pain usually radiates into the ear. Another characteristic symptom for tuberculosis of the pharynx is abundant salivation.

The clinical picture of tuberculosis of the pharynx is clinically manifested in two forms - acute (miliary) and chronic (infiltrative-ulcerative), to which tuberculous lupus of the pharynx can also be attributed.

The acute (miliary) form of tuberculosis of the pharynx, or Isambreth's disease, is extremely rare, more often in individuals 20-40 years of age. Occurs when MBT is spreading lymphogenically or hematogenously.

At the very beginning, the endoscopic picture resembles the one seen in acute catarrhal pharyngitis: the mucosa in the soft palate, palatine arch and tonsils is hyperemic and swollen. Soon, against a background of hyperemic mucous membrane, rashes appear in the form of miliary tubercles (granulomas) of a grayish-yellowish color the size of a pinhead. Eruption is usually accompanied by a significant increase in body temperature. The presence of these rashes in the soft palate does not always indicate a common miliary tuberculosis, although it may serve as an early indication of it. The process continues by ulceration of the rashes and their fusion with the formation of more or less extensive ulcerous surfaces of irregular shape with slightly raised edges and a grayish bottom. Soon ulcers are covered with a granulation tissue, at the beginning of a bright pink, then acquiring a pale shade. The process can spread up and down, hitting the nasopharynx, auditory tube, nasal cavity, larynx. Deep ulceration can occur in the tongue, as well as on the posterior wall of the pharynx, reaching the periosteum of the cervical vertebrae. A sharp violation of swallowing due to severe pain in the throat, damage to the soft palate, destruction of the palatine arches, pronounced edema of the throat part of the pharynx and loss of motor function of the lower throat compressors cause the inability to feed naturally, which leads the patient to an extreme degree of cachexia, and only emergency measures for the establishment of various methods of nutrition, begun from the very beginning of the disease, prevent a fatal outcome, which in other cases may occur 2 months or less from the onset of the disease.

Chronic infiltrative-ulcer tuberculosis of the pharynx is the most common form of tuberculosis of the pharynx, which appears as a complication of clinically pronounced pulmonary tuberculosis of the "open" form. Usually, infection of the tissues of the pharynx occurs at the site of traumatization of its mucosa. Infection can also occur in the hematogenous or lymphogenous way, or per continuitalem from a tuberculous ulcer of the oral cavity or nasopharynx. The disease develops gradually and begins with complaints of the patient for progressive pain and discomfort when swallowing, the appearance of nasal congestion, a sense of interference in the nasopharynx, caused by a "disobedient" soft sky. As the disease develops against the background of a common tuberculosis infection, the increase in malaise, weakness, sweating, and a rise in body temperature above the subfebrile values is attributed to the exacerbation of the pulmonary process. Usually, with the above complaints, the patient turns to the ENT specialist, whose experience determines the timely setting of the correct diagnosis.

The pharyngoscopic picture depends on the severity of the process. At an early examination against the background of a pale pink mucous membrane, small (0.5-0.7 mm) round elevations (infiltrates) scattered in the posterior pharyngeal wall, in the soft palate, lingual tonsil, palatine arches and tonsils, tongue, gums . They are dense to the touch and as if embedded in the mucous membrane, painful when pressed. At a later examination (3-5 days later), in the place of many of the above infiltrates (tuberculosis), granulation ulcers with uneven slightly raised and pitted scalloped edges are identified. The bottom of ulcers not exceeding 1 cm in diameter is covered with a greyish-yellowish coating. The mucous membrane around the ulcers is pale, on this surface are determined many small infiltrates, which are at different stages of development from small yellowish formations to large ulcers. Adenony is a sign of constant any form of tuberculosis of the pharynx.

The infiltrative-ulcerative form of tuberculosis of the pharynx differs by a slow course and depends entirely on the state of the pulmonary process. With a favorable course of the latter phenomenon in the pharynx may end within 1-3 years, leaving behind more or less pronounced cicatricial deformities. It should be noted that the Russian literature described a rare form of tuberculosis of the pharynx called "sclerosing tuberculosis of the pharynx", which is characterized by diffuse compact infiltration of the entire pharynx without the presence of separate infiltrates described above. This infiltrate has a significant density, reaching in some places to the density of the cartilaginous tissue. The mucous membrane above it is weakly hyperemic. This form does not cause severe dysphagia and occurs with moderate clinical forms of pulmonary tuberculosis, often without isolation of the MBT and in their absence in sputum.

Differential diagnosis of tuberculosis of the pharynx

The diagnosis of pharynx tuberculosis in the presence of the main focus of infection in the lungs does not cause difficulties and is based not only on the data of pharyngoscopy, but also on the results of special research methods that are applied to phthisiatric patients. And the weight in setting the final diagnosis should differentiate tuberculosis of the pharynx from such diseases as Plout's angina-Vincent, the gum of the tertiary period of syphilis, the sluggish phlegmon of the pharynx, the malignant neoplasm.

[9], [10],

Larynx of the pharynx

Lupus erythematosus is a special form of tuberculosis, which is predicted as a secondary manifestation of lupus in the nose or oral cavity.

Symptoms of lupus in the throat

Unlike all other forms of tuberculosis characterized by ascending progression of the infection (lungs - bronchi - trachea - larynx - swallow of the nasopharynx), lupus, like syphilis, does this entire way in reverse order, starting at the nasal apertures, spreading through the nasopharynx and pharynx in the larynx. Currently, this way for lupus is an exceptional rarity, as it is stopped at the earliest stages of development with the help of hydrazide and vitamin D2 preparations.

In the initial period, the mucous membrane of the pharynx appears thickened in the form of papillary growths of dark red color. In the period of maturity, lupomas (lupoplastic nodules), agglomerated into separate "colonies", having a grayish-yellow color, undergo erosion, merge, forming ulcers with fuzzy contours that spread like a creeping ulcer. The bottom of the ulcer is dry (unlike caseous tuberculous ulcers), the surrounding ulcer is a mucous membrane of cyanotic color. Usually, lupus is located on the soft palate, tongue, very rarely on the palatine arches and tonsils. Reaching the nasopharynx, the posterior surface of the opener, the posterior surface of the tongue, the area of entry into the nasopharyngeal opening of the auditory tube are affected. The ulcer, spreading into the lumen of the auditory tube, and then scarring, deforms it, right up to the obliteration of the lumen. In the laryngopharynx, only the epiglottis is affected.

Despite quite pronounced pathomorphological lesions of the pharynx in case of lupus, regional lymphadenitis is not detected, the general condition of the patient remains good, and he treats his illness with indifference.

The disease developed slowly and for a long time, for 10-20 years. During this time there are repeated relapses, old ulcers are scarring, new ones appear. The process of scarring causes syenosis and deformities of the pharynx, similar to those that develop with tuberculosis infection.

In rare cases, severe bacterial dissolution occurs, manifested by a septic state.

Differential diagnosis of lupus with syphilis and pharynx scleroma is extremely difficult. To make the final diagnosis, they often resort to a study of a smear, a biopsy or inoculation of a pathological material with a guinea pig to obtain a clinical picture of the diagnosed disease.

Larvoid tuberculosis of the pharynx

In foreign literature, this name refers to tuberculosis of palatine tonsils in situ, that is, cases where only one palatine tonsil and only other lymphadenoid formations of the pharynx, in particular lingual and pharyngeal, are affected by tuberculous lesions. The cause of this form of tuberculosis of the pharynx is the fact of "saprophytic" vegetation in the parenchyma of these tonsils of the MBT, which under certain favorable circumstances for it is activated and causes damage to the tissues in which it lives. This kind of tuberculosis of the larynx can be secondary in people with an open form of tuberculosis, and primary in children. Clinically, the laryngeal tuberculosis of the pharynx manifests itself as a banal hypertrophy of the tonsils without any subjective and objective signs of vulgar infection, and only the results of bacteriological and histological studies make it possible to establish the true cause of the hypertrophic process. However, the latent and almost without obvious signs of chronic inflammation the disease has long been neglected by both the patient and the doctor. However, there are some signs that you can suspect the presence of a patient with laryngeal tuberculosis of the pharynx. These are repeated angina with regional adenopathy, pallor of the mucous membrane of the soft palate and the presence of established tuberculosis infection at a distance, most often - pulmonary tuberculosis in the stage of decay of lung tissue.

In case of unjustified vulgar infection of hypertrophies of palatine tonsils, which are characterized by pallor, presence of widespread adenopathy, exciting not only regional but also axillary lymph nodes, poor health, weakness, subfebrile condition, excessive sweating, etc., it is necessary to assume the presence of tuberculosis infection, conduct an appropriate in-depth TB examination of the patient .

The otorhinolaryngologist should keep in mind that bacillary tonsillar hypertrophies often simulate chronic tonsillitis, and periodically appearing as it were, "exacerbations" often move a physician to tonsillectomy. This practice often leads to severe consequences in the form of tuberculous meningitis, non-healing tuberculosis ulcers in the field of palatine niches. Therefore, always with the hypertrophy of the tonsils and the presence of signs that allow suspect latent current laryngeal tuberculosis of the pharynx, before the final diagnosis of chronic (decompensated) tonsillitis, the patient should conduct a thorough phthisiatric examination. Detection of laryngeal tuberculosis of the pharynx does not exclude, but on the contrary, involves the removal of a specific foci of infection (tonsillectomy), which, however, should be performed after preliminary preparation and in the absence of any purulent inclusions in the palatine tonsils. It is advisable before the operation to clear the crypts from caseous masses (washing, vacuum suction), conduct immunocorrective and restorative treatment, streptomycin therapy and vitaminization of the body.

The operation itself should be performed by an experienced surgeon, in a gentle manner. After the operation, it is advisable to prescribe broad-spectrum antibiotics, as well as desensitizing drugs, calcium glucose, vitamin C in increased dosage.

Uteropharyngeal abscess

In publications on the complications of tuberculosis infection, many cases of "cold" retrofaringual abscesses of tuberculous etiology are described, the sources of which can be:

1. infected with tuberculosis nasopharyngeal tonsil;
2. Pott's disease, manifested suboccipital or cervical spinal tuberculosis.

Most often, a pharyngeal tuberculous abscess occurs with Pott's disease. This abscess of the vagal space develops very slowly, without any inflammatory manifestations (hence the name "cold" abscess). Out of the zagochlorous space, pus diffuses into the mediastinum, affecting the pleura and pericardium, sometimes the vessels through the arthrosis of their walls.

The clinical picture is characterized by painful sensations in the cervical spine, restriction of mobility in it, and with pharyngoscopy, it is as if the swelling of the posterior pharyngeal wall covered by a normal mucosa. With his careful palpation, the index finger does not seem to have a purulent sac, the symptom of the fluctuation is not determined. Signs of the actual pharyngeal tuberculous abscess in the absence of acute inflammatory phenomena are rather scanty. Sometimes the patients have a sensation of foreign body pharynx and some discomfort when swallowing. A violent reaction occurs when pus breaks into the mediastinum with the appearance of mediastinitis, pleurisy or pericarditis, which, along with possible bleeding from the main vessels of the mediastinum, lead to rapid death.

With a clear diagnosis of tuberculous pharyngeal abscess, both tonsillogenic and in Pott's disease, it must be emptied by puncture under the cover of streptomycin in combination with broad-spectrum antibiotics.

The diagnosis is preliminary based on the presence of a "cold" abscess on the posterior wall of the pharynx, the final one - based on the result of an X-ray examination, in which the distinctive bone lesions of the cervical vertebrae are revealed.

Differential diagnosis is carried out with benign retrofaringealnymi tumors, banal retrofaringealnymi abscesses, with an aneurysm of the aorta, which manifests itself as a pulsating lump on the back of the pharynx slightly laterally. In the presence of a pulsating tumor, puncture is categorically contraindicated.

The prognosis is determined by possible complications, the activity of bone spinal tuberculosis, the general resistance of the body and the quality of the treatment. For life with timely opening of the abscess and its healing, the prognosis is favorable.

Lupus treatment is carried out with the help of antibiotics, UV, cauterization of foci by physical and chemical methods. The use of vitamin D2 gives a very positive result, but requires monitoring of the lungs and kidneys.

When treating the "cold" pharyngeal abscess after its opening, it is first necessary to immobilize the cervical spine for a period of up to 3 months. Of antibiotics, streptomycin (3 r / week) and isoniazid (10 μg / kg body weight) for 3 months are prescribed. Then the dose is reduced by half and injected continuously for 1 year, as is customary in the treatment of bone tuberculosis. If a certain effect is not achieved with streptomycin, then it is replaced by PASK.

Treatment of pharyngeal tuberculosis

Treatment of tuberculosis of the pharynx is carried out in special phthisiatric institutions and sanatoriums and, as a rule, is combined with general anti-tuberculosis treatment of its various forms (pulmonary, visceral, bone). The main means of treating patients with any form of tuberculosis are antibiotics of anti-tuberculosis action - aminoglycosides (kanamycin, streptomycin) and ansamycins (rifabutin, rifamycin, rifampicin). In recent years, biologically active additives have been recommended for poverty from a series of vetons, as well as vitamins and vitamin-like products (retinoids, glycopenthides). Great importance is attached to high-grade easily assimilated food, climatotherapy, etc.

Treatment of pharyngeal tuberculosis is carried out against a background of general specific treatment and includes the following measures: relief of pain syndrome (local spraying with anesthetic solutions - 2% cocaine hydrochloride or dicaine solution, alcohol solution of tannin and anestezin); irradiation with small doses (20-25 g) - analgesic and antidisfagic action; with severe pain - alcoholization of the upper laryngeal nerve. The use of streptomycin, as a rule, by the end of the first week removes the pain syndrome and stops the development of the granulomatous-ulcerative process in the pharynx.

Ulcers treated with 5-10% lactic acid solution; designate tubular UFO. In fibrotic hypertrophic forms of tuberculosis of the pharynx, galvanocaustic and diathermocoagulation are used. According to Gorbea (1984), local x-ray therapy (from 50 to 100 g per session, for a total of 10 sessions with repetition after 1 week) gives good results in the fight against a widespread ulcerative process.