Actinomycosis of the pharynx

Actinomycosis of the pharynx is a chronic infectious disease of man and animals, caused by the introduction into the pharynx of actinomycetes (radiant fungal parasites).

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Epidemiology and causes of actinomycosis of the pharynx

Actinomycetes are widespread in nature; their main habitat is soil and plants. By structure, actinomycetes are similar to bacteria, but form long branching filaments resembling a mycelium. Some species of actinomycetes are pathogenic for humans and animals, among which there are both aerobes and anaerobes. In humans, actinomycosis is relatively rare. Men suffer from this disease 3-4 times more often. Observations of different authors do not give grounds to consider actinomycosis as a professional disease of persons of agricultural labor, although in a number of cases the disease arises from the introduction into the body of an actinomycete freely living in the environment surrounding it in an exogenous way.

[5], [6], [7], [8], [9], [10], [11], [12]

Pathogenesis and pathological anatomy

The main pathway of infection is the endogenous pathway, in which the disease is caused by parasites that have acquired parasites, which inhabit the oral cavity and the gastrointestinal tract. A specific infectious granuloma develops around the parasite that has entered the tissue, which, along with the disintegration in its central part, is characterized by the formation of fibrous connective tissue in the granulation tissue. As a result, a pathomorphological element specific for actinomycosis - an actinomycotic nodule - drusa is formed, which is characterized by the presence of so-called xantom cells, that is, cells of connective tissue, saturated with small droplets of cholesterol-ester, giving the cells accumulating yellow (xanthomous) color. Actinomycetes can spread in the body by contact, lymphogenous, hematogenous pathways and often settle in loose connective tissue.

Symptoms of actinomycosis of the pharynx

The incubation period averages 2-3 weeks after the introduction of the actinomycete. Cases of prolonged, even long-term incubation are not uncommon. The general condition of the patient in the initial stage of the disease varies little. Body temperature is subfebrile. With long-term current forms of actinomycosis, body temperature can be maintained at a normal level.

Actinomycosis can affect all organs and tissues, but the maxillofacial region (5%) is more often affected. This is explained by the fact that pathogenic species of actinomycete are permanent inhabitants of the oral cavity. As noted by DP Grinev and RI Baranova (1976), they are found in dental plaque, pathologically altered gingival pockets, root canals with dead pulp. Most often, the patient is treated to a dentist with complaints about the presence of infiltrates and fistulas in the maxillofacial area, from which pus is found, containing a large number of drusen. Infiltrates are not very painful, immovable, soldered to surrounding tissues.

The initial period of this disease often goes unnoticed, as it is not accompanied by painful sensations and proceeds without a rise in body temperature. Often the first symptom of developing actinomycosis in the maxillofacial region is the impossibility of free opening of the mouth, caused by the inflammatory contracture of the temporomandibular joint and the parts of the masticatory muscles adjacent to the focus (the de Cervin symptom). This is due to the fact that a significant part of the pathogen is introduced into the mucous membrane covering the incompletely erupted lower 8th tooth, as well as to the radical tissues of the molars with the dead pulp (the importance of timely sanation of teeth, removal of roots, treatment of periodontitis!). Defeat of actinomycete can spread to the chewing muscle, which is also the cause of trismus. With the transition of the process to the inner surface of the mandible, trisus sharply increases, difficulty in swallowing, severe soreness with pressure on the tongue, restriction of its mobility, hence - chewing and moving the food lump in the oral cavity, violation of articulation.

Further development of the process is characterized by development in the region of the angle and in the posterior parts of the body of the lower jaw, and in the oral localization of the process - on the alveolar process, the inner surface of the cheek, in the tongue, etc., a significant (woody) density of the bluish infiltrate, which does not have clear boundaries. Gradually, individual parts of the infiltrate rise in the form of "swellings" over the surrounding tissues (skin or mucous membrane), in which foci of softening resemble small abscesses. The occurrence of such formation in the palatal arch or in the peritonsillar region can simulate the sluggish current peritonsillar abscess. The skin above the infiltrate gathers into the fold, blushes, and in some places becomes reddish-cyanotic, which is characteristic of the actinomycosis infiltrate in the stage immediately preceding the fistula formation. Further thinning and rupturing of the skin leads to the formation of a fistula, through which a small amount of lean pus is released. Simultaneously with the melting of tissues and the periphery of the softening foci, the sclerosing process takes place, as a result of which characteristic roll-like folds with several fistulous passages form on the skin. Often, in the surrounding tissues, as a result of secondary infection, bacterial abscesses and phlegmons that require surgical intervention develop, which, however, is only symptomatic, since emptying of the abscess does not lead to the elimination of the inflammatory process: the infiltrate does not completely disappear and after several days increases again, and the entire actinomycotic process is resumed.

The defeat of actinomycosis of the oral cavity with pathomorphological manifestations does not fundamentally differ from the skin lesions, however, the oropharyngeal process causes immeasurably great suffering for the patient, since it involves the defeat of the mucous membrane of the oral cavity, tongue, pharynx, which is rich in sensory nerves, besides very mobile organs that play an important physiological role in providing the function of both breathing, and chewing and eating.

The most painful for the patient is the actinomycosis of the tongue, which is often the source of further progress in the direction of the pharynx and esophagus. In the thickness of the tongue there is one or several dense infiltrates, giving it rigidity and depriving it of mobility and the ability to arbitrarily change the shape (for example, fold into a tube). Very quickly in the thickness of the infiltrate a softening zone with thinning of the mucous membrane and fistula formation occurs. Tactics treatment in this case consists in surgical dissection of the abscess in the softening phase before its opening, but this does not lead to a rapid healing, as observed with a vulgar abscess or phlegmon of the tongue: the process ends with a slow scarring, and often secondary bacterial complications.

Primary actinomycosis of the pharynx is not found, but is a consequence of either actinomycosis of the maxillofacial region or actinomycosis of the tongue. Localization of the infiltrate on the posterior wall of the pharynx, soft palate and palatine arches is a rare phenomenon, but when it occurs, depending on the structure of the anatomical formation on which this infiltrate arose, the clinical picture appears to be different. For example, if infiltrates occur on the posterior wall of the pharynx, the pathogen can penetrate into the deep sections of the pharynx and cause not only soft tissue damage, but, reaching the vertebral bodies, can also cause damage to the bone tissue; or, penetrating into the throat part of the pharynx, spread to the walls of the esophagus or the vestibule of the larynx, causing appropriate destructive lesions here.

With actinomycosis, in addition to the local process, a metastatic lesion of the brain, lungs, abdominal organs is possible, and in the long course of the disease - the development of amyloidosis of internal organs - the form of protein dystrophy, in which an abnormal protein - amyloid is deposited in organs and tissues.

How to recognize actinomycosis of the pharynx?

Diagnosis is established on the basis of typical clinical data (a woody bluish infiltrate, the formation of softening blisters in it, thinning of the skin and the formation of a fistula on each bloating). The final diagnosis is established on the basis of a microscopic examination of purulent contents, in which druses are typical for actinomycosis. Apply also a diagnostic skin-allergic reaction with actinolysate, a biopsy. Other methods of investigation are determined by the form and anatomical localization of the pathological process (dopplerography of parenchymal organs, radiography of bone formations, CT and MRI).

Treatment of pharyngeal actinomycosis

Treatment of actinomycosis of the pharynx, as a rule, is complex. It includes surgical methods, methods of increasing specific immunity by using actinolysate or other nonspecific immunomodulators, stimulating and restorative therapy. In complex treatment iodine preparations (potassium iodide), antibiotics of the penicillin group (benzylpenicillin, phenoxymethylnenicillin), antimicrobial agents in combinations (co-trimoxazole), tetracyclines (doxycycline, metacyclin), desensitizing drugs, physiotherapy methods, including topical X-ray therapy, diathermocoagulation, galvanocaustic. The volume and nature of surgical intervention with actinomycosis depends on the form of the disease, the localization of its foci and the resulting secondary and purulent and septic complications that are life-threatening.

How to prevent actinomycosis of the pharynx?

Prevention consists in the sanation of the oral cavity, removal of foci of purulent infection, increasing the body's resistance. A definite value for the prevention of actinomycosis is the use of respirators when performing "dusty" agricultural works on haylofts, elevators, etc.

What prognosis is the pharyngeal actinomycosis?

The prognosis for life with actinomycosis of maxillofacial localization is usually favorable. The prognosis becomes serious in the event of infiltrates in the area of the entrance to the larynx, next to the main blood vessels, with the defeat of vital internal organs.