Chronic laryngitis

Banal chronic laryngitis is a superficial diffuse nonspecific inflammation of the laryngeal mucosa with a prolonged course and periodic exacerbations in the form of catarrhal inflammation. In most cases, banal chronic laryngitis is combined with chronic inflammatory processes in the upper respiratory tract, encompassing both nasopharyngeal spaces, both the trachea and bronchi.

[1], [2], [3],

Causes of chronic laryngitis

The causes and pathogenesis of banal 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 structure of the larynx;
2. risk factors (professional, household - smoking, alcoholism);
3. activation of a conditionally pathogenic (vulgar) microbiota.

Banal chronic laryngitis is more common in adult men, who are more likely to experience occupational and domestic hazards. In childhood, banal chronic laryngitis occurs mainly after 4 years, especially with frequent adenohydalgalitis.

The banal polymorphic microbiota indicates a nonspecific inflammation in a common chronic laryngitis. Infantile infections (measles, whooping cough, diphtheria, as well as repeated angina and influenza infection) cause lesion of the epithelium and lymphoid tissue of the larynx, which helps to reduce local immunity and activate saprophyte microbiota and increase the pathogenic effect of exogenous risk factors. An important role in the pathogenesis of banal chronic laryngitis is played by a 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 play an ascending infection in chronic tracheobronchitis, pulmonary tuberculosis, purulent diseases of the bronchopulmonary system (bronchiectatic disease), asthma, which, along with infection of the larynx with phlegm and pus, causes irritation of its mucous membrane with prolonged coughing attacks.

An important role in the emergence of banal chronic laryngitis is the violation of nasal breathing (rhinitis, polyps, curvature of the septum of the nose), 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 moisturizing, heating and disinfection of air). Particularly harmful to the state of the larynx is the disruption of nasal breathing, unfavorable external climatic conditions (cold, heat, dryness, humidity, dustiness) and microclimatic conditions of human habitation and labor.

Load on the larynx in persons whose profession is associated with voice function or work in noisy production, is often the main risk factor for the occurrence of banal chronic laryngitis.

Important role in the emergence of banal chronic laryngitis is played by endogenous factors causing 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 influence of external risk factors, transforming them into active causes of the occurrence of banal chronic laryngitis. Such endogenous factors can be attributed to chronic diseases of the digestive system, liver, cardiovascular and excretory systems, allergies, which often lead to circulatory, hence, immune and trophic disorders of the mucous membrane of the upper respiratory tract. An important role in the occurrence of banal chronic laryngitis is played by endocrine disorders, in particular, dysfunction of the thyroid and insular apparatus of the pancreas. Similar effects may be played by ischemic conditions due to various causes, avitaminosis, a number of common chronic infections (syphilis) and certain specific diseases of the upper respiratory tract (ozona, scleroma, lupus, etc.).

[4], [5], [6], [7]

Chronic catarrhal laryngitis

With chronic catarrhal laryngitis, hyperemia of the mucous membrane is more stagnant than inflammatory-paretic, characteristic of acute diffuse catarrhal laryngitis. Thickening of the mucous membrane occurs due to round-cell infiltration, rather than serous sepiration. The flat epithelium on the vocal folds is thickened, on the posterior wall of the pharynx the ciliated epithelium is replaced by metaplasia with multilayered flat epithelium; The gland folds of the vestibule are enlarged and secrete more secretions. Especially a lot of sputum occurs with a similar tracheal injury, which is often manifested by a strong, sometimes convulsive cough, which increases irritation and inflammation of the vocal folds. The blood vessels of the submucosal layer are dilated, their wall is thinned, because of which, with a strong cough, small-spot submucosal hemorrhages develop. Around the vessels there are foci of plasma-cell and circular cell infiltration.

[8], [9], [10], [11], [12], [13],

Chronic hypertrophic laryngitis

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

By hyperplasia means an excessive increase in the number of structural elements of tissues by their excess neoplasm. Hyperplasia, underlying hypertrophy, manifests itself in the multiplication of cells and the formation of new tissue structures. With rapidly occurring hyperplastic processes, a decrease in the volume of the multiplying cellular elements is often observed. As Strukov notes (1958), under hyperplastic processes in the narrow sense only those that are associated with the hypertrophy of tissues or organs are understood when it comes to the functional identity of the newly formed and the previous ("uterine") tissues. However, in pathology, all the multiplication of cells is often called the term "hyperplasia". For the propagation of cells in a broad sense, the term proliferation is also used. As a universal morphogenetic process, hyperplasia underlies all processes of pathological neoplasm of tissues (chronic inflammation, regeneration, tumors, etc.). In structurally complex organs, such as, for example, the larynx, the hyperplastic process can concern not only one single homogeneous tissue, but all other tissue elements that make up the morphological basis of this organ as a whole. Strictly speaking, this is the case for chronic hyperplastic laryngitis, when not only the epithelial cells of the ciliated epithelium but also the flat multilayered cells are exposed to proliferation, the cellular elements of the mucous glands, the connective tissue, etc. Hence the variety of forms of chronic hypertrophic laryngitis - from "singing nodules "To prolapse of the mucous membrane of the ventricles of the larynx and retention cysts.

The thickening of the vocal folds with chronic hypertrophic laryngitis is continuous, uniform along the entire length, then they acquire a spindle shape with a rounded free margin, or limited, in the form of separate nodules, tubercles or somewhat larger dense whitish formations (laryngitis chronica nodosa). Thus, the more massive thickening formed by the proliferation of the flat epithelium is sometimes formed in the region of the vocal fold in the vocal appendage of the arytenoid cartilage, where they have the appearance of a mushroom-like elevation on one side with a "kissing" depression in the opposite voice storage or symmetrically located contact ulcers. Much more often, the pachydermia occur on the back wall of the larynx and in the inter-bicarp space, where they acquire a hulled surface of grayish color - pachydermia diffusa. In the same place, hyperplasia of the mucosa in the form of a pillow 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 cushions of the mucous membrane that extend beyond the ventricles and cover up the vocal folds. Hyperplasia can also develop in the underlayment space, forming rollers parallel to the vocal folds (laryngitis chronica subglotica hyperplastica). In persons whose professions are associated with the stress of the voice (singers, teachers, actors), symmetrically arranged cone-shaped nodules, which are based on a thickened epithelium and elastic tissue, are often formed on the vocal folds, approximately in the middle, the so-called singing knots.

In chronic atrophic laryngitis, occurring less frequently than chronic hypertrophic laryngitis, metaplasia of the cylindrical ciliate epithelium is observed in flat keratinizing; capillaries, mucous glands and inner-throat muscles are atrophied, and interstitial connective tissue is sclerized, which causes the vocal folds to thin out, and the secret of mucous glands dries quickly and covers them with dry crusts.

[14], [15], [16], [17]

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.

[18], [19]

Causes of chronic atrophic laryngitis

By atrophy is understood a pathological process characterized by a decrease in volume and size, as well as by qualitative changes in the cells, tissues and organs, which usually arise during various diseases or as a consequence of them, differing from hypoplasia and hypogenesis (pathological atrophy) to varying degrees. In contrast to the latter, distinguish physiological (age) atrophy, due to natural aging of tissues, organs and the body as a whole and their hypofunction. An important role in the onset of physiological atrophy is played by the withering of the endocrine system, which is largely reflected in hormone-dependent organs such as the larynx, the organs of hearing and sight. Pathological atrophy differs from the physiological atrophy both from the causes of origin and from certain qualitative features, for example, the more rapid withering of the specific function of the organ or tissue in pathological atrophy. At the heart of any kind of atrophy is the predominance of dissimilation processes over assimilation processes. Depending on the causes of atrophy, distinguish:

1. tropho-neurotic atrophy;
2. functional atrophy;
3. hormonal atrophy;
4. alimentary atrophy;
5. professional atrophy arising from the harmful effects of physical, chemical and mechanical factors.

In the otorhinolaryngology, there are many examples of the latter (professional anosmia, deafness, atrophic rhinitis, pharyngitis and laryngitis, etc.). To the above forms of atrophy should be added and atrophy, caused by the effects of acute or chronic infection, both banal and specific. However, this type of atrophy is accompanied by pathoanatomical changes in tissues and organs, characterized by complete destruction or replacement of specific fibrous tissues. With regard specifically to chronic atrophic laryngitis, in its pathogenesis to any extent, can participate all of the above listed types of causes that cause atrophy, not only the epithelium of the mucous membrane, but all its other elements (trophic and sensitive nerve endings, blood and lymphatic vessels, connective-tissue interlayer, etc.). On this basis, chronic atrophic laryngitis as a systemic disease requiring an analytical approach for its study, as well as for the development of etiotropic and pathogenetic treatment, should be recognized.

[20]

Symptoms of atrophic laryngitis

At the expressed clinical and pathoanatomical form the considerable dryness of the mucous membrane acquiring a reddish-gray shade is noted, the vocal folds are hyperemic, covered with dry crusts of yellow or greenish-dirty color, densely welded to the underlying surface. After rejection, small hemorrhages and epithelial cover damage remain in their place. In general, the larynx cavity appears enlarged, with a thin mucous membrane, through which small convoluted blood vessels appear 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 with the help of characteristic voice sounds; their voice is constantly hoarse, quickly tired. In dry rooms, these phenomena intensify and, on the contrary, weaken in a humid environment.

Diagnosis of atrophic laryngitis

Diagnosis is established on the basis of anamnesis (long-term course, the presence of harmful habits and the corresponding occupational hazards, chronic foci of infection in the neighborhood and at a distance, etc.), patient complaints, a characteristic endoscopic picture. The variety of morphological disturbances of only one common chronic inflammatory process in the larynx, apart from those that arise in infectious and specific diseases, makes the diagnosis of chronic laryngitis a very important process, since many of the diseases noted above are regarded as precancerous, the degeneration of which into malignant neoplasms, including even sarcoma, are not so rare a phenomenon that was especially clearly demonstrated by official statistics in tse XX century. When determining the nature of a chronic disease of the larynx, it should be borne in mind that almost always chronic hypertrophic laryngitis accompanies a particular malignant process or a specific disease of the larynx and often masks the latter until both the first and second do not reach their destructive forms. Therefore, in all cases of dysphonia and the presence of "plus-tissue" such a patient should be referred for advice to the ENT oncologist, where he will undergo a special examination, including a biopsy.

In doubtful cases, especially with 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 us to visualize the following changes: 1) thickening of the vocal or vestibular folds, thickening of the ventricular fold; 2) its prolapse, and also other changes without detection of defects of internal walls and anatomic formations of the larynx.

An important differential diagnostic indication, which is indicative of the good quality of the process, is the symmetry of the morphological changes in the larynx, while the malignant neoplasms are always one-sided. If chronic hypertrophic laryngitis is manifested by a one-sided "inflammatory process," a radiographic examination of the patient and a biopsy of suspicious "plus-tissues" are always necessary. Differentiate the banal chronic laryngitis from the 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 undiagnosed foreign tissues of the larynx. Chronic atrophic laryngitis is differentiated from the primary larynx of the larynx. Myogenic dysfunctions of the larynx, often associated with common chronic laryngitis, should be differentiated from the neurogenic paralysis of the internal muscles of the larynx, which are characterized by specific symptoms.

[21], [22], [23]

Symptoms of chronic laryngitis

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

The degree of voice dysfunction can vary from a slight hoarse arising after a night's sleep and during a working dm a little disturbing patient and only in the evening reappearing until a pronounced hoarseness is expressed. 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 of it, especially in proliferative-keratotic processes. Dysphonia can be significantly aggravated in unfavorable weather conditions, during endocrine changes in women (menopause, menstruation, pregnancy, with an exacerbation of the main inflammatory process in the larynx).

For professionals, even a slight dysphonia is a factor of mental stress, exacerbating the flashmaking qualities of the voice function, often at the root of changing their social status and worsening their quality of life.

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

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. Cough is more pronounced in the morning hours, especially in smokers and workers whose occupations are associated with harmful production (foundry workers, chemists, welders, battery holders, etc.).

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

In chronic hypertrophic laryngitis, the diffuse hyperemia of the mucous membrane is often observed, which is most pronounced in the area of the vocal folds, with the mucous membrane sometimes covered with a viscous mucus secret. In chronic hypertrophic laryngitis, the vocal folds are diffusely thickened and edematous with uneven edges. In the intercellular space there is papilliform proliferation of the mucous membrane or pachidermy, which, with mirror laryngoscopy, is well visible only in the position of Killian. This pachydermia prevents the full closure of the vocal folds, which causes the laryngeal function of the larynx to suffer: the voice becomes rasping, rattling, rapidly fatiguing. In some cases, marked hyperplasia of the folds of the vestibule, which with indirect laryngoscopy cover the vocal folds, the examination of which in this case is possible only with direct laryngoscopy. During the phonation, these hypertrophic folds touch each other and, under the influence of the exhaled air, give the voice a characteristic almost tone-free rough sound, which is sometimes used by variety singers, for example the great American singer Lun Armstrong. In rare cases, there is hyperplasia of the mucosa in the underlayment space, which takes the form of elongated and thickened ridges located on both sides of the larynx, duplicating the vocal folds above them and protruding because of them, narrowing the laryngeal lumen. The aggravation of the inflammatory process in this area or the occurrence of superinfection can lead to a pronounced edema of the lining space and a threatening suffocation.

Two forms of chronic hypertrophic laryngitis deserve special attention: a contact ulcer and prolapse of the ventricle of the larynx (paired formation located on the lateral wall of the larynx between the fold of the vestibule and the vocal fold).

Contact larynx ulcer

Called this way by the American authors Ch.Jackson and Lederer, there is nothing else than a local symmetrically arranged pachidermy 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 pachiderma testify to the presence of chronic hypertrophic laryngitis. Contact ulcers due to their origin of excessive voice effort in persons weakened with a poorly developed subepithelial layer (N.Costinescu).

[24], [25], [26], [27], [28], [29], [30]

Prolapse of the ventricle of the larynx

In fact, we are talking about excessive proliferation of the mucous membrane covering one of the ventricles of the larynx, which prolapses into the laryngeal lumen and can partially or completely cover up the corresponding vocal fold. This hyperplastic formation differs in red, often has a swollen appearance and can be mistaken for a laryngeal tumor. Often, the prolapse of the ventricles of the larynx is combined with the ventricular fold of the cyst that results from the proliferation of the epithelium of the mucous gland and the obstruction of its excretory duct. However, such cysts of the larynx are rare, much more often phoniatrists and ENT specialists of a wide profile meet with 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 taken for polyposis formation of vocal folds, the distinguishing feature of which is a lighter shade, which is of an intermediate position between the false cyst and the so-called spindle edema of the vocal folds. The described volumetric formations essentially violate the function of the vocal folds, preventing them from completely closing, which is visually visualized by the method of stroboscopy.

Polyposal lesions arising on the vocal folds morphologically belong to the so-called micro-mixes, consisting of fibrous and angiomatous tissues. Depending on the ratio of these morphologically different structures, these formations are called fibroids, angiofibromas and angiomas. As D.M. Tomassin (2002), a red or angiomatous type of polyp, may be a manifestation of "congenital pathological processes," and its color depends on the fact that fibrinous exudate envelops the angiomatous elements, giving them a dark red hue.

Mucous retention cysts are found in both adults and children. In appearance they are "yellowish humpbacks that appear 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 plugging the excretory duct of the gland under the influence of a chronic proliferative inflammatory process. The cavity of the gland is filled with a secret, and its walls undergo proliferation (multiplication of mucous and intercalary cells, thickening and increase in the size of the cyst wall). One-sided and bilateral cysts, as well as polyps, prevent the complete closure of the vocal folds and disrupt the laryngeal function of the larynx.

Great importance in the emergence of the above pathological conditions of the vocal folds in chronic hypertrophic laryngitis, a number of authors attach to the so-called Reinke space, which forms part of the voice fold. The bottom of the Reinke space forms a layer of fascia that covers the vocal muscle, which thickens towards the free edge of the vocal fold and is woven into the vocal cords, which in turn in the caudal direction transforms into an elastic cone and a cricoid ligament ensuring the attachment of the vocal fold to the process of the cricoid cartilage . The ceiling of the Reinke space forms a thin layer of flat epithelium, lying on a strong basal membrane covering the fascia of the vocal muscle. According to 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 the preservation in an optimal state structures of the Reinke space during surgical interventions for the above-described pathological conditions of the vocal folds. 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 when there are phenomena of chronic laryngitis and a strong vocal tension of the laryngeal function. Occasionally, cystlike formations are formed in the Reinke space, which some authors treat as retention cysts that arise from the "lost" mucous glands, others - like the edema of this space. Dispute resolves the histological examination of the removed tissue. Often with prolonged ventilation, the endotracheal tube is the cause of the so-called intubation granuloma.

The diversity of morphological changes in chronic hypertrophic laryngitis was mentioned above. Here we note several more forms of this disease, the final differences between which can be established only with microlaringoscopy and histological examination. One such form is the so-called contact granuloma, which appears as a contact ulcer with prolonged traumatic contact of the vocal folds of either professional genesis, or as a complication of a prolonged inflammatory process.

Another not common form of chronic hypertrophic laryngitis is pseudomixoma of the larynx - a tumor, which can be based on the usual swelling of the tissue, turning it into a substance resembling mucus, but not containing mucin, which is a spindle-shaped infiltrate located on the vocal fold. Sometimes pseudomixom is bilateral with a developed network of blood vessels. Single papillomas (benign tumors from the cover epithelium, which has a characteristic kind of papillary overgrowth, protruding above the surface of the surrounding unchanged epithelium - exophytic growth, true papilloma 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 outgrowth, a gray or whitish hump of a dense consistency . All the above forms of chronic hypertrophic laryngitis require differentiation from the precancer of the larynx or its carcinoma.

Types of chronic laryngitis

Inflammatory phenomena with common chronic laryngitis are less pronounced and more prevalent than with acute catarrhal laryngitis. They develop mainly in the area of vocal folds and in the intercellular 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 in the elimination of risk factors that contribute to the emergence of this disease, which include harmful habits, profvrednosti, foci of infection in the upper respiratory tract. Essential is the diet that must be observed by patients (excluding hot and cold drinks, spicy foods, fatty and fried foods). In the diet of the patient should include fruits, vegetables, easily digestible food. For violations of the functions of the gastrointestinal tract, excretory and endocrine systems, such patients should be referred to the appropriate specialists.

Special treatment is divided into nonoperative and surgical (microsurgical). Non-surgical treatment is provided to persons suffering from chronic catarrhal laryngitis, chronic atrophic laryngitis and certain forms of chronic hypertrophic laryngitis, surgical - chronic hypertrophic laryngitis.

Therapeutic treatment of chronic laryngitis

According to many laryngologists, from the point of view of the use of medicines, chronic catarrhal laryngitis and chronic hypertrophic laryngitis differ little from each other. It is important to emphasize two features of 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, because behind the manifestations of chronic hypertrophic laryngitis can conceal precancerous conditions. In case of individual selection of medical measures (inhalations, installations, aerosol irrigation, etc.), one should keep in mind that both chronic catarrhal laryngitis and chronic hypertrophic laryngitis tend to exacerbate, in which dryness and the formation of a viscous, difficult to separate phlegm accumulating on 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 treatment of the patient and the nature of the prescribed drugs (softening, astringent, cauterizing). At exacerbations it is possible to use the same means, as at an acute catarrhal laryngitis. The funds used in the middle of the 20th century did not lose their healing value. So, 1% oil solution of menthol, chlorobutanol for inhalations, sea-buckthorn oil for infusions into the larynx, etc., belonged to softening and anti-inflammatory agents.

As an astringent and slightly cauterizing agents, 1-3% solution of collargol, 0.5% resorcinol solution for infusion into the larynx, 1-1.5 ml once a day, 0.25% solution of silver nitrate - infusion of 0.5 ml every other day for hypersecretion; solution of tannin with glycerin, 0.5% zinc sulfate solution (10 ml) in a mixture of ephedrine hydrochloride (0.2) for infusion into the larynx of 1 ml, etc. To dilute viscous sputum and larynxes formed in the larynx, a solution of chymotrypsin or trypsin ( 0.05-0.1%) for infusion into the larynx of 1.5-2 ml.

In nodular formations, along with other drugs (infusion of menthol oil solutions in the larynx, lubrication with a 2% silver nitrate solution), various powdery substances were injected into the larynx, 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 region, drugs such as 2% calcium chloride solution, 0.25% zinc sulfate solution, 1% potassium iodide solution, lidase 0.1 (64 U) for the procedure for "singing knots", etc. Were used for electrophoresis in the larynx region.

Chronic atrophic laryngitis is usually part of the overall systemic dystrophic process that has developed in the upper respiratory tract, so isolated treatment of only the larynx without consideration and treatment of other ENT organs is ineffective. As for the tactics of treatment for chronic atrophic laryngitis and the drugs used, in a sense they are the exact opposite of those used for chronic catarrhal laryngitis and chronic hypertrophic laryngitis. If in the treatment of the latter, astringent, cauterizing, and agents that prevent proliferative (hyperplastic) processes and, as a consequence, hypersecretion and hyperkeratosis, then in the treatment of chronic atrophic laryngitis, all activities are aimed at stimulating the natural factors of the "life" of the laryngeal mucosa.

Medications for chronic laryngitis

Drugs used in chronic atrophic laryngitis should facilitate the dilution of viscous mucus containing high concentrations of mucopolysaccharides (mucin), forming viscous aqueous solutions and drying into dense crusts, facilitate the separation of crusts, moisturize the mucous membrane of the larynx and, if possible, stimulate the proliferation of its " uterine "cellular elements and the function of the glands. To do this, apply warm moist inhalation of alkaline mineral waters, as well as inhalation of medicines.

The use of the aforementioned agents, which have been used and are partially applied at present, is mainly symptomatic and is aimed at the pathogenesis of the disease indirectly, not always clearly established. For example, the use of astringent and cauterizing agents in some forms of chronic hypertrophic laryngitis can in no way be called pathogenetic and especially etiotropic treatment, since these drugs are aimed only at reducing the severity of the symptoms of the disease, but not on the primary mechanisms responsible for the proliferation of cellular elements of the mucosa, goblet cells, connective tissue, etc. In this sense, some methods of treatment for chronic atrophic laryngitis are closer to pathogenetic cure iju as they more or less directed to the stimulation of natural reparative processes by activating stimulus effects aimed morphological elements on the replication of organs and tissues. Activation of these effects in chronic atrophic laryngitis can be achieved only with complex treatment, when the drugs used 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 are involved in providing trophic and morphological tissue homeostasis or organ. The effectiveness of such treatment is many times increased if it is possible to establish the cause of atrophy and eliminate it, otherwise it establishes a peculiar dynamic balance between reparative and destructive processes, in which the "victory" will ultimately be on the side of the latter.

It is impossible to say with certainty that modern therapy of the so-called common chronic diseases of the larynx has achieved significant success, one can only say that this direction in acute laryngitis is one of the most urgent, especially in the face of pressing environmental problems facing humanity, and that this trend is fraught with to themselves large potential scientific possibilities. Nevertheless, today it is possible to offer a practical doctor a number of modern methods and drugs that, in combination with traditional drugs, 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, with exacerbation of chronic catarrhal laryngitis caused by activation of saprophyte microbiota (acute respiratory disease, adenovirus infection, general and local hypothermia, etc.), the use of the composite drug Strepsils, which has antiseptic and local anesthetic effect, is shown. Usually, a spray dispenser is used (1 bottle contains 20 ml of solution). When using a spray for treatment of exacerbation of chronic catarrhal laryngitis, it is necessary to direct the jet-dose on inhalation to the laryngopharynx by simulating stridoroid respiration (reduction of vocal folds). In this case, most of the dose settles on the vocal folds and walls of the larynx.

With frequent exacerbations of chronic catarrhal laryngitis and, in some cases, chronic hypertrophic laryngitis, Broncho-Munal (for children Broncho-Munal BP) containing lyophilized lysate bacteria, most commonly causing 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 antibodies IgA, IgG and IgM (including on the mucous membrane of the respiratory tract), stimulates the natural mechanisms of protecting the body against infection of the respiratory system, reduces the incidence and severity of respiratory diseases.

The drug of choice can serve 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.); is also effective in exacerbations of the inflammatory nature of chronic hypertrophic laryngitis.

In chronic laryngitis of any of the three forms accompanying immunodeficient states of any origin, manifested as chronic, slow and recurrent infectious and inflammatory processes not only in the upper respiratory tract, but also in other localizations, Likopid, a semisynthetic glycopeptide, is the main structural fragment of the cell wall all known bacteria and has a wide immunomodulatory effect.

With chronic atrophic laryngitis and their exacerbations occurring in the form of acute catarrhal laryngitis, accompanied by the release of a viscous, rapidly drying sputum with the formation of crusts, it is necessary to prescribe secretions and stimulants of the motor function of the respiratory tract and mucociliary clearance. Among these drugs, carbocysteine proved to have a mucolytic and expectorant effect due to the activation of sialic transferase - the enzyme of goblet cells of the mucous membrane of the upper respiratory tract and bronchi. Along with the restoration of the viscosity and elasticity of the mucus secreted by these cells, the drug promotes the regeneration of the mucosa, normalizes its structure. When atrophic processes increase the replication of goblet cells, with their excessive proliferation - regulates their number. The drug also restores the secretion of immunologically active IgA, which provides specific protection (local immunity) of the mucosa, 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 ingestion of it per os and remains for 8 hours, so the drug is indicated for immediate use with all diseases of ENT organs without exception, especially in acute and banal chronic laryngitis, infectious laryngitis and as a prevention of complications in the preparation for direct laryngoscopy and bronchoscopy.

Another effective preparation of mucoregulatory action is Flunfort (Carbocysteine Lysine Salt), available in the form of a syrup or granulate for use per os. The drug normalizes the function of the glands of the respiratory tract: restores the physiological state of sialomucins and fucomucins, normalizes the rheological parameters (viscosity and elasticity) of the secretion of goblet cells and mucous gland cells irrespective of their initial pathological state, accelerates the mucociliary transport function of the ciliary epithelium, facilitates the restoration of damaged ciliary epithelium. It is indicated for acute and chronic diseases of the respiratory tract and ENT organs, accompanied by a violation of secretion (laryngitis, tracheitis, rhinitis, sinusitis, otitis media, bronchitis, bronchiectasis, etc.).

In severe exacerbations of banal chronic laryngitis and their complications of a pyogenic nature, as well as for their prevention, antibiotics from cephalosporins (Ceftriaxone, Tertsef, Cefuroxime, Supero), macrolides (Azithromycin, Sumazid) and fluoroquinolines (Ofloxacin, Toryferid) are used.

In the pathogenesis of chronic atrophic laryngitis, a significant negative role is played by local secondary nutritional insufficiency, hypovitaminosis and tissue hypoxia. Vitamin C, thiamine, riboflavin, folic, paraaminobenzoic, pantothenic acids, vitamins B1, B6, B12 and PP, glucose, ATP, sodium bromide and caffeine are recommended to combat these factors, which strengthen the main pathological process.

Surgical treatment of chronic laryngitis

Surgical treatment for chronic hypertrophic laryngitis is used in those cases when the ineffectiveness of non-operative treatment becomes obvious and it is necessary to eliminate any voluminous formation that is not subject to non-operative treatment (cyst, papilloma, fibroma, prolapse of the ventricle of the larynx, etc.) that prevents the functions of the larynx. The development of endolaryngeal surgery began after the invention in 1864. M. Garcia indirect laryngoscopy, and by the end of the XIX century. Many surgical instruments for endosurgical intervention on the larynx were invented, which were adapted precisely for this method of endoscopy. However, an obstacle to the development of endosurgery of the larynx was the inconvenience associated with the flow of blood and mucus into the trachea in attempts to more radical surgical intervention. The application of the suction somewhat facilitated the task of the surgeon, but not so much that it was possible to operate in a "dry field". With the invention in 1880 of the Scottish physician W. Macewen intubation of the trachea for the endotracheal administration of narcotic gas substances, the development of endolaryngeal surgery accelerated. In the XX century. In connection with the development of fiber optics, the method of video endoscopy and the improvement of microsurgical instruments, the method of endolaryngeal microsurgery emerged and reached perfection. To this end, Professor Marburg University Oscar Kleinszaser, in collaboration with the firm Karl Storz, developed and implemented in practice in most countries the original models of laryngoscopes and a variety of types of surgical instruments that allow under a large increase using an operating microscope to perform the finest surgical operations in almost all types of higher hyperplastic processes in the larynx.

Below are some of the recommendations of O. Kleizasseer on the technique of microsurgical intervention on the larynx and the drawings attached to them.

The author recommends first of all to operate with two hands using two instruments. In most cases, combine tweezers with scissors or coagulator with suction. The tongs are intended only for fixing the object to be removed and in no case for tearing or biting the fabric. "Sticking", that is, ripping off the polyp or ripping off the Reinke's edema, is a serious surgical error, as it can cause trauma to the tissue that needs to be preserved, which can subsequently lead to voice disruption and the formation of unwanted scars. Therefore, the smooth cutting off of the tissue to be removed using sharp scissors or a special scalpel should become an unswervingly executed rule.

To maintain a gentle principle, which is the main principle for endolaryngeal microsurgery, especially on the vocal folds, O. Kleinszaser recommends beginning surgeons to have a clear idea of the fine anatomical structures of the larynx and to study in detail the main pathoanatomical changes for their differentiation from healthy tissues to be preserved. When interfering with the vocal fold, it is necessary to take into account the fact that the flat epithelium is not fixed to the underlying substrate just above the body of the vocal fold; in the rest part it is attached from above and from below to arched lines, dorsally to the vocal process, and ventrally to the anterior commissure. It is also necessary to take into account the structure of the Reinke space; so the defects of the epithelium of the vocal fold, which are formed after the removal of polyps, nodules and varicose nodules, should remain as small as possible so that they are quickly covered with a new epithelial cover, and the Reinke space is again closed. When removing small pathological formations, for example polyps, nodules and small cysts sticking to the epithelium, they should not be grasped near the 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 base.

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

When edema Reinke, as noted by O. Kleinszaser, sucking mucus, curettage and resection of the remains of the mucous membrane in most cases do not lead to the desired result. The author cautions against the often recommended method of "stripping", in which the strip of epithelium is simply torn off the voice folds with tweezers. In this pathological condition, the author recommends firstly to cut the tissue with scissors around the removed epithelial band, and only after that the removed "preparation" with the viscous edematous fluid held on it can be "pulled" entirely, without damaging the underlying tissues. The thick secret left on the voice fold is removed by suction. With a large edema Reinke in order to avoid excessive disruption of the voice function, it is recommended to perform only partial removal of pathological tissue at the first operation, and then to complete surgical treatment with another two similar surgical interventions at intervals of 5-6 weeks.

With far-reaching chronic hypertrophic laryngitis with a thickening of the vocal folds, it is advisable to excise narrow strips of the most thickened epithelial layer and inflamed submucosal tissue in order that in future it will be possible to remodel the shape of the vocal folds at the expense of the remaining epithelial layer.

When juvenile papillomas, it is advisable to apply the method of their diathermocoagulation with the suction of the destroyed papillomatous tissue. This method is the fastest, most gentle and almost bloodless, providing a satisfactory function of the vocal folds. Destruction is carried out by touching the microcoagulator to the most protruding part of the tissue being removed, while the current is set at a low level so that the tissue does not burn when coagulated, but becomes soft ("boiled") and white and easily removed without bleeding by sucking. This technique does not allow you to act on the current at 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.

With precancerous tissue changes and small carcinomas, an excisional biopsy is currently being carried out, and not only small biopsies are taken: the healthy-looking epithelium of the affected part of the vocal fold is cut and this part is cut off within the healthy tissue to its base and the en masse is removed . Keratoses, as well as pre-invasive and micro-invasive 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 be resected and it within the healthy tissues.

As O. Kleinszaser notes, endolaryngeal chondectomy in the clinic run by him is carried out only when the tumor is affected only by the superficial muscular layer. With a more significant lesion of the voice fold, the author recommends performing an operation from the external access, which provides a good overview and one-stage restoration of the voice fold and thus preserves the usefulness of the voice function.

In the last decade, significant advances have been made in laser laryngeal microsurgery (MS Pluzhnikov, W. Steiner, J. Werner and others) using a carbon dioxide laser (G. Jako).