Laryngeal tuberculosis: causes, symptoms, diagnosis, treatment

Laryngeal tuberculosis (laryngeal tuberculosis, respiratory tuberculosis) is a chronic infectious disease caused by mycobacteria of tuberculosis, which develops as a rule against the background of widespread tuberculosis of respiratory organs, hematogenous (lymphogenous) dissemination of extrapulmonary localization, or by contact (sputogically). Characterized by the development of cellular allergies, specific granulomas and polymorphic clinical picture.

Tuberculosis is known since ancient times. According to published data, pathological changes in the bones of the spine, characteristic of tuberculous lesions, were found on the skeleton during excavations under Heidelberg; the age of the find is attributed to the early period of the Stone Age (5000 BC). Among 10 skeletons of Egyptian mummies, referred to the XXVII century. BC. E., four had caries of the spine. As writes VL Einie, probably pulmonary tuberculosis was not found during excavations because in ancient times the insides, with the exception of the heart, were buried separately. The first convincing descriptions of the manifestations of pulmonary tuberculosis are found in the ancient peoples of the eastern countries. In ancient Greece doctors were familiar with the manifestations of tuberculosis, and Isocrates (390 BC) spoke of the contagiousness of this disease. In ancient Rome (1st-2nd century AD) Aretei, Galen, and others give a fairly complete description of the signs of pulmonary tuberculosis, which prevailed throughout many subsequent centuries. This information we find in the writings of Avicenna, Silvia, Frakastro and other outstanding doctors of the Middle Ages. In the Russian medical institutions of the second half of the XVII century.

Tuberculosis was called "dry disease" and "sorrow consumptive". However, during this period, the concept of tuberculosis was very superficial. Significant achievements in the teaching about tuberculosis were achieved in the XVIII-XIX centuries. In the field of pathological anatomy of this disease, when the main pathomorphological manifestations of it were discovered, however, although the infectiousness of this disease was already proved, its causative agent was still unknown. And in 1882, an outstanding German bacteriologist, one of the founders of modern microbiology, Robert Koch (1843-1910) reported the discovery of a pathogen of tuberculosis. In his report to the Berlin Physiological Society, the morphology of the MBT, the methods of their detection, etc., were characterized in detail. In Russia, by the middle of the 19th century, NI Pirogov described generalized forms of tuberculosis, acute miliary tuberculosis, tuberculosis of the lungs, bones and joints.

The stage of great importance was the discovery by the French scientist K. Geren in 1921-1926. Anti-tuberculosis preventive vaccination with the introduction of a weakened bovine MBT culture (BCG vaccine). A major role in the diagnosis of tuberculosis was played by the works of a major Austrian pathologist and pediatrician K. Pirke, who in 1907 opened a diagnostic skin test for tuberculosis (tuberculin diagnostics). These works, along with the discovery in 1895 of "X-rays" by the great German physicist V. K. Rentgen, made it possible to differentiate clinically different changes in the organs, especially in the lungs, the gastrointestinal tract, and the bones. However, progress in diagnosis and other areas of the problem of tuberculosis during the entire XIX century. They rested in the absence of etiological treatment. During the XIX century. And even in the second half the doctor had mainly hygiene-dietary methods of treating tuberculosis infection. Principles of sanatorium treatment were developed abroad (H. Brehmer) and in Russia (VA Manassein, GA Zakharin, VA Vorobyov, and others).

The basis in the newest direction of antibiotic therapy of tuberculosis was the theoretical considerations of II Mechnikov on the antagonism of microorganisms. In the years 1943-1944. S.Vaksman, A.Shats and E.Byozhi (S.Vaksman, A.Schtz, E.Vugie) have discovered streptomycin - a powerful antituberculous antibiotic. Subsequently, chemotherapeutic anti-tuberculosis drugs such as PASK, isoniazid, ftivazide, etc. Were synthesized. The surgical direction in the treatment of tuberculosis also developed.

ICD-10 code

А15.5 Tuberculosis of larynx, trachea and bronchi, confirmed bacteriologically and histologically.

Epidemiology of Laryngeal Tuberculosis

Approximately one third of the world's population is infected with mycobacteria tuberculosis. Over the past 5 years, the number of newly diagnosed TB patients with respiratory organs has increased by 52.1%, and the death rate among them - by 2.6 times. The most common complication of pulmonary tuberculosis is the development of tuberculosis of the larynx. It accounts for 50% of patients with pulmonary pathology, the share of tuberculosis of the oropharynx, nose and ear accounts for 1 to 3%. A low percentage of tuberculosis lesions of the oropharynx and nose are explained both by the peculiarities of the histological structure of the mucous membrane of these organons, and by the bactericidal secretion secreted by the mucous glands.

The main source of infection is a patient with tuberculosis, which secretes mycobacteria into the external environment, as well as cattle with tuberculosis. The main ways of infection are airborne, air-dust, less often - alimentary, hematogenous, lymphogenic and contact.

The risk of developing tuberculosis is high in:

• persons without a fixed place of residence (homeless people, refugees, immigrants);
• persons who have been freed from their places by deprivation of liberty
• patients of narcological and psychiatric institutions;
• persons professions related to direct close communication with people;
• patients with various concomitant diseases (diabetes mellitus, peptic ulcer of the stomach and duodenum, HIV-infected or AIDS patients);
• persons receiving radiotherapy, long-term treatment with glucocorticoids, transferred exudative pleurisy; women in the postpartum period;
• patients with burdened heredity: in particular: in the presence of human leukocyte antigen, the risk of tuberculosis increases 1.5-3.5 times.

The peak incidence falls on the age of 25-35 years with a fairly high incidence in the range of 18-55 years. The ratio of men and women among patients with tuberculosis of the larynx is 2.5 / 1.

Screening

Tuberculin diagnostics (mass and individual) are used to screen the disease, a diagnostic test to determine the specific sensitization of the organism to mycobacteria of tuberculosis.

Fluorography for the population should be carried out at least 1 time in 2 years.

Endoscopic examination of ENT organs with mandatory microlaringoscopy should be performed by all patients with tuberculosis, especially those suffering from open bacillary forms of pulmonary tuberculosis.

Classification of tuberculosis of the larynx

In accordance with the localization and prevalence of the process in the larynx:

• monochordite;
• bihordite;
• defeat of vestibular folds:
• defeat of the epiglottis;
• defeat of the inter-head space;
• defeat of the throat of the ventricles;
• defeat of arytenoid cartilages;
• defeat of the podogolosovogo space.

In accordance with the phase of the tuberculosis process:

• infiltration;
• ulceration;
• decay;
• compaction;
• scarring.

By the presence of bacterial excretion:

• with the isolation of mycobacterium tuberculosis (MBT +);
• without isolation of mycobacteria tuberculosis (MBT-).

Causes of Laryngeal Tuberculosis

The causative agents of tuberculosis of the larynx are considered acid-fast mycobacteria discovered by R. Koh in 1882. There are several types of mycobacteria tuberculosis (human species, intermediate and bovine). The causative agents of tuberculosis in humans are most often (80-85% of cases) are mycobacterium tuberculosis of the human type. Mycobacteria of intermediate and bovine type cause tuberculosis in humans, respectively, in 10 and 15% of cases.

Mycobacteria are considered aerobic, but they can also be facultative anaerobes. Mycobacteria are immobile, do not form endospores, conidia and capsules. They are very resistant to the effects of various environmental factors. Under the influence of antibacterial substances, mycobacteria can acquire drug resistance. Cultures of such mycobacteria are ultrafine (filtering), persist for a long time in the body and support antituberculous immunity. In case of weakening of immunity, the described forms of the pathogen can again be transformed into typical ones and cause the activation of a specific tuberculous process. In addition, other manifestations of the variability of mycobacteria include the development of resistance to anti-tuberculosis drugs.

Sources of infection. The most important of them is a sick person, and all its secretions can serve as a source of infection. The most important is the sputum of a patient with pulmonary tuberculosis and upper respiratory tract, dried up in dust and spreading in the atmosphere (Koch-Kornet theory). According to Flügge, the main source of infection is an airborne infection that spreads when coughing, talking sneezing. The source of infection can be cattle: the infection is transmitted through the milk of sick animals with tuberculosis.

The entrance gates of infection in humans can be skin, mucous membrane and epithelium of the lung alveoli. The place of entry of the MBT can be lymphadenoid tissue of the pharynx, eye conjunctiva, the mucous membrane of the genital organs. Tuberculosis infection spreads lymphogenous and hematogenous, as well as per continuitatem.

The drug resistance of MBT is due to the wide use of chemotherapeutic drugs. Already in 1961, 60% of MBT strains were resistant to streptomycin, 66% to phtivazide, and 32% to PASC. The emergence of stable forms of MBT is due to more or less prolonged exposure to sub-bacteriostatic doses of the drug. Currently, the resistance of MBT to the relevant specific drugs is significantly reduced due to their combined use with synthetic antituberculous drugs, immunomodulators, vitamin therapy and rationally selected food additives.

Pathogenesis is complex and depends on the variety of conditions in which the pathogen and organism interact. Infection does not always cause the development of the tuberculosis process. VA Manasein in the pathogenesis of tuberculosis attached great importance to the general resistance of the organism. This situation attracted the attention of phthisiatricians to the study of the reactivity of the organism, allergy and immunity, which deepened the knowledge of the theory of tuberculosis and allowed us to assert that it would seem that a previously fatal tuberculosis disease would be curable. The leading role in the emergence of tuberculosis is played by unfavorable living conditions and also by a decrease in the body's resistance. There is evidence of a hereditary predisposition to the disease. In the development of tuberculosis, the primary and secondary periods are isolated. Primary tuberculosis is characterized by high sensitivity of tissues to MBT and their toxins. During this period, the primary focus (primary affect) may appear at the site of infection, in response to which, in connection with the sensitization of the body, a specific process develops along the lymphatic vessels and lymph nodes with the formation of the primary complex, most often in the lungs and hilar lymph nodes. During the formation of foci of primary tuberculosis, bacteremia is observed, which can lead to lymphogenous and hematogenic dissemination with the formation of tuberculous foci in various organs - the lungs, upper respiratory tract, bones, kidneys, etc. Bacteremia leads to an increase in the body's immune activity.

Immunity in tuberculosis according to modern ideas depends on the presence in the body of live MBT, as well as on the functions of immunocompetent cells; cellular immunity acts as a leading link in the formation of resistance to tuberculosis infection.

Pathogenesis of tuberculosis of the larynx

Tuberculosis of the larynx is considered a secondary disease. The most frequent source of damage is the larynx. Ways of infection of the larynx are different: hematogenous, lymphogenic, contact (sputogenic).

The emergence of tuberculosis of the larynx is associated with a number of unfavorable factors, both general and local. Among the factors include the reduced reactivity of the organism. Among the local factors, topographic and anatomical features of the larynx should be considered. Its location is such that sputum from the bronchi and trachea, falling into the larynx, can be delayed for a long time and inter-percutaneous space, guttural ventricles, causing superficial maceration on the layer of the mucous membrane of the larynx, loosening and slushing of the epithelium. Thus, mycobacteria through the damaged (and even intact) epithelium penetrate into the closed lymphatic space of the subepithelial layer of the vocal folds and the inter-head space and cause a specific tubercular process there. In addition, the local predisposing factors include chronic inflammatory processes in the larynx.

The development of tuberculosis of the larynx takes place in 3 stages:

• formation of infiltrate;
• ulcer formation;
• cartilage damage.

Infiltration leads to a thickening of the mucous membrane of the larynx, the appearance of tubercles similar to the papilloma, and then tuberculoma is formed, followed by ulceration. Attachment of secondary infection is accompanied by involvement of the perichondrium and cartilage in the process, may cause laryngeal stenosis.

Primary tuberculosis of the larynx is rare, it is often secondary to the primary localization of infection in the lungs with involvement of the intrathoracic lymph nodes. Often tuberculosis of the larynx is accompanied by tuberculosis of the trachea and bronchi, tuberculous pleurisy and tuberculosis of other localization (tuberculosis of the nose, pharynx, palatine tonsils, bone, articular, cutaneous tuberculosis). Secondary tuberculosis of the larynx, along with tuberculosis of the trachea and bronchi, is the most frequent and formidable complication of pulmonary tuberculosis. The incidence of tuberculosis of the larynx and the severity of the clinical course is directly dependent on the duration and form of the disease. According to A.Ruedi, tuberculosis of the larynx occurs in approximately 10% of patients with the initial form of pulmonary tuberculosis, in 30% of persons with long-term course of the process and in 70% of cases with autopsy of those who died from pulmonary tuberculosis. Laryngeal tuberculosis is more common in patients with exudative, open and active forms of pulmonary tuberculosis and less frequently in productive forms. Sometimes, with primary pulmonary tuberculosis or with chronic inactivated, previously not recognized foci of tuberculosis, the first signs of a common tuberculosis infection may be symptoms of laryngeal lesions, which gives rise to an appropriate examination of the patient and the identification of either the primary focus or the activation of dormant tuberculosis infection. Significantly more often tuberculosis of the larynx is sick in men aged 20-40 years. In women, tuberculosis of the larynx is more common during pregnancy or a short time after childbirth. Children get sick less often, and at the age of less than 10 years - very rarely.

Usually in the clinical course between tuberculosis of the larynx and pulmonary tuberculosis there is a certain parallelism, which is manifested by the same exudative or productive phenomena. However, in a number of cases, such parallelism is not observed: either tuberculosis of the larynx is exacerbated and pulmonary tuberculosis is reduced, or vice versa. In many patients there is no correlation between the amount of infected sputum secreted from the pulmonary focus and the frequency or form of tuberculous lesion of the larynx. This fact testifies either to the presence or absence of an individual predisposition of a patient with pulmonary tuberculosis to the disease of laryngeal tuberculosis. Probably, we are talking about the quality of the so-called local immunity either in the active state or suppressed by some external harmful factors. For example, it has been proved that pulmonary tuberculosis, secondary and primary tuberculosis of the larynx are mainly affected by smokers, alcoholics and persons whose occupations are associated with the presence of harmful agents in the inhaled air, which reduce the resistance of the mucous membrane of the upper respiratory tract and lungs to infection.

Infection of the larynx occurs either in the ascending way, in which the infection penetrates the mucous membrane from the sputum secreted from the pulmonary focus, or, more often, by the hematogenous way. Hematogenous desmination is observed with closed and miliary forms of tuberculosis. The presence of banal laryngitis promotes the introduction of MW in the mucous membrane of the larynx. It is established that the lesions of the larynx are more often on the same side as the primary focus in the lungs. This is because the infection of the larynx occurred lymphogenically from the lymph nodes of the trachea and bronchi of the same side. Another explanation for homolateral lesion of the larynx is the action of the ciliary epithelium, which "delivers" the infection from its "side" to the same side to the larynx. This explanation confirms the channel mechanism of local homolateral lesion of the larynx either in the area of the "posterior commissure", in the intercellular space or monolaterally, while in the hematogenous pathway the foci of tuberculosis infection may appear randomly over the whole surface of the larynx, capturing its vestibule.

Pathological anatomy. From the point of view of the clinical-anatomical principle of classification, pathological changes in tuberculosis of the larynx are subdivided into chronic ilefiltrative, acute miliary form and lupus of the larynx. In chronic infiltrative form, microscopic examination reveals subepithelial infiltrates that transform into diffuse ones, which, spreading to the surface of the mucosa and undergoing caseous decay, turn into ulcers surrounded by granulomatous formations, which also contain characteristic tuberculous nodules. The mucous membrane appears thickened due to edema and proliferation of the connective tissue membrane. With the productive form of tuberculosis, a fibrous process predominates with local infiltrates covered with a normal mucosal species and a slow progressive course. With the exudative form of tuberculosis of the larynx, diffuse ulcers, covered with gray-dirty deposits and edematousness of surrounding tissues, are revealed. This form of tuberculosis evolves much faster than productive tuberculosis, and the spreading of the larynx into the depth of the walls and the attachment of secondary infection causes the onset of chondroperichondritis and inflammation of the scapular arm joints.

In some cases, there is destruction of the epiglottis, the remains of which have the appearance of a deformed and edematous stump. The edges of ulcers are elevated and surrounded by nodular infiltrates.

The miliary form of tuberculosis of the larynx is much less common than the two presented above and is characterized by diffusely disseminated small nodular infiltrates, reddish-gray edema of the mucous membrane that cover the entire surface of the mucous membrane of the larynx and often spreads on the mucous membrane of the pharynx. These nodules quickly ulcerate, representing sores that are at different stages of development.

Lupus is a kind of tuberculosis of the larynx and is microscopically manifested by changes similar to the initial pathomorphological manifestations in the common tuberculosis of the larynx. Lupus infiltrates are encapsulated and symmetrically located (laryngitis circumscripta), characterized by polymorphism, in which close to fresh nodular infiltrates can detect ulcers and even their superficial cicatricial changes, surrounded by a dense connective tissue. These changes are observed most often along the edge of the epiglottis, the contour of which has the appearance of a notch and is often completely destroyed.

Symptoms of Laryngeal Tuberculosis

A characteristic complaint of patients with tuberculosis of the larynx is hoarseness of the voice, expressed to some extent, pain in the larynx. When the process is localized in the podgolospace, respiratory failure develops.

With indirect laryngoscopy of the early manifestation of tuberculosis of the vocal folds, the mobility of one or both of the vocal folds is characteristic, but there is never complete immobility. The mucosa of the larynx is hyperemic. Hyperemia is caused by subepithelial eruptions of tubercle bumps. As the process progresses, the number of tubercles increases, and they begin to lift the epithelium, and the hyperemia of the mucosa becomes thickened (infiltrated). Infiltrates ulcerate, erosion and ulcers are formed on the fold, imitating a "contact ulcer," which acquires a lenticular shape: the bottom acquires a pale gray color.

The tuberculous process in the larynx can begin with the defeat of the inter-head space. The initial manifestations of tuberculosis in this area, as well as in cases of the destruction of true vocal folds, are represented by limited areas of hyperemia and infiltration followed by ulceration, the appearance of a gray-dirty color of the mucous membrane.

The tubercular focus in the guttural ventricles, progressing, extends to the lower surface of the vestibular fold, and then to the voice surface. This is the so-called "crawling" of the infiltrate into the crease. Tubercular lesions of the vestibular folds are characterized by one-sidedness, as well as partiality of the lesion. There is a process of blurred hyperemia of individual segments of the vestibular folds, followed by a slight infiltration of all or part of the vestibular fold. The latter in this case almost completely covers the vocal folds. The process ends with ulceration followed by scarring. Very rarely (3% of cases) the tubercular process affects the podogolospace. This determines infiltrates, which can ulcerate.

Early manifestations of epiglottis tuberculosis: infiltration of the submucosal layer at the junction of the laryngeal and lingual surfaces, or in the border of the epiglottis and vestibular folds. Extremely rarely tubercular process affects the petal of the epiglottis and the arytenoid cartilages. Consequently, with tuberculosis of the larynx, there is a mosaic, polymorphic clinical picture.

The tubercular process in the oropharynx manifests itself as hyperemia, infiltration and ulceration of the anterior (rarely posterior) arches, tonsils, soft palate and tongue. On the mucosa, a large number of yellowish-gray nodules-tuberculoma is detected. In this case, palpated enlarged (up to the size of the plum) submandibular lymph nodes, solid in the consistency of the surface and deep lymph nodes of the neck.

The tubercular process in the nose can be localized both on the threshold of the nose (the inner surface of the wings of the nose) and in the cartilaginous part of the nasal septum, and also in the region of the anterior ends of the lower and middle nasal concha. As a rule, one half of the nose is affected. Clinical forms of tuberculosis of the nose: infiltrative-diffuse, limited (tuberculosis), ulcerative (superficial and deep with perichondritis).

For tubercular otitis characterized by multiple perforations of the tympanic membrane, which, merging, lead to its rapid disintegration; abundant discharge with a sharp putrefactive odor. In this case, often involved in the process of bone, with the formation of sequesters and the development of paresis or paralysis of the facial nerve.

Chronic infiltrative form occurs more often than other forms. At the initial stage, a specific inflammation develops slowly and asymptomatically; the general condition of the patient does not suffer much, there may be an evening subfebrile condition. As the desmination of MBT progresses from the pulmonary focus of infection, the body temperature rises, chills arise. Gradually, the patient has a foreign body sensation in the throat, intensifying soreness in phonation, towards evening - the hoarseness of the voice, which soon becomes permanent and steadily increases. The patient is disturbed by a constant dry cough, caused both by the sensation of a foreign body in the larynx, and by the developing pathological process in her and in the lungs. Often these phenomena are ignored by both the patient and the treating physician, since the initial morphological changes in the larynx are very similar to the exacerbation of chronic catarrhal laryngitis observed in the patient for a long time. However, atypical for exacerbation of chronic catarrhal laryngitis is the progression of the expression of aphonia, which soon becomes very pronounced, up to complete aphonia. The appearance of ulcers on the epiglottis, cherpalodnagortane folds, periendritis of arytenoid and cricoid cartilage supplements the patient's complaints of difficulty and soreness when swallowing. The swallowing movements are also accompanied by the irradiation of pain in the ear, corresponding to the side of the larynx lesion. Often even swallowing saliva causes painful pains, and patients refuse food, which is why they develop cacexia very quickly. Violation of the inhibitory function of the larynx due to the defeat of the epiglottis and the muscles that pull together the arytenoid cartilages, leads to the entry of fluid in the lower respiratory tract and the development of bronchopneumonia. Infringement of breath in view of gradual development of a stenosis and adaptation of an organism to gradually accruing hypoxia arises only at an extreme degree of stenosis of a larynx, however a dyspnea and a tachycardia at physical activities arise and at a moderate stenosis of a larynx. Progression of laryngeal stenosis is an indication for a preventive tracheotomy, as obstructive phenomena can suddenly reach a critical condition in which a tracheotomy has to be done in great haste without thorough preparation for it.

Endoscopic picture of the larynx with this form of tuberculosis varies depending on the localization and prevalence of the lesion, which in turn depends on the form of tuberculosis - exudative or productive. In the initial stage, the changes that occur in the larynx are barely noticeable and hardly differ from the manifestations of banal laryngitis. Indirect signs of tuberculosis of the larynx may be the pallor of the mucous membrane of the soft palate and the threshold of the larynx, and in the intercostal space one can notice a nipple infiltration similar to the pachydermia. It is this infiltration that prevents the complete convergence of vocal appendices of the arytenoid cartilages, causing the phenomena of dysphonia.

Another place of frequent development of the tuberculosis process is the vocal folds, one of which develops a specific monochordite, which is not difficult to detect. The affected vocal fold appears swollen with a thickened free margin. Such a frequently occurring monolateral localization of tuberculosis infection can last for a long time, even during the entire main tuberculosis process, until it is completed inclusively, and the opposite fold can remain practically in a normal state.

The further development of tuberculosis of the larynx is determined by the dynamics of the clinical course of the main tuberculosis process. When it progresses and the protective properties of the body decrease, a specific inflammatory process in the larynx progresses: the infiltrates increase and ulcerate, the edges of the vocal folds acquire a jagged appearance. With indirect laryngoscopy, only a part of the ulcer is seen in the inter-punctate space, surrounded by infiltrates of irregular shape, similar to a thickened cock's crest. Similar infiltrative phenomena are observed on the vocal fold, in the lining space, and more rarely on the epiglottis. The latter has the form of a thickened stationary shaft, covered with ulcers and groinlike infiltrates, covering the vestibule of the larynx. Sometimes the swelling of the epiglottis of the reddish-gray color hides these changes. These changes are characteristic for exudative form of tuberculosis of the larynx, while the productive form is manifested by limited lesions of the circumscripta type that protrude into the laryngeal lumen in the form of a single tuberculoma. The severity of mobility disorders in the vocal folds depends on the degree of involvement of the internal muscles of the larynx, secondary arthritis of the pericuminal plexus joints, infiltrative and productive phenomena. In rare cases, infiltration of the mucous membrane of the ventricle is observed, which covers the appropriate voice scraping.

With the further development of the tuberculosis process, the resulting perichondritis affects the entire skeleton of the larynx, infiltrates and purulent-caseous decomposition of the pregarthular tissues form with the formation of external fistulas, through which the cartilaginous tissue is probed by a probe probe, fragments of sequestrants are isolated. During this period the patient experiences the strongest spontaneous pain in the larynx, sharply increasing at night and not falling not only under the influence of conventional analgesics, but also morphine, promedol and other opiates. At the same time, the process in the lungs also worsens. The resulting hemoptysis can be not only pulmonary, but also guttural. Often, patients die from profuse pulmonary or guttural bleeding in the artery of a large artery.

Acute miliary form of tuberculosis of the larynx arises by hematogenous way and is caused by seeding of the MBT of the larynx and often pharynx. The disease progresses rapidly, body temperature rises to 39-40 ° C, the general condition is poor, marked dysphonia, reaching a complete loss of voice function within a few days. At the same time, there is a violation of the swallowing function, accompanied by a painful pain syndrome, an extremely painful paroxysmal cough, drooling, paralysis of the soft palate, increasing respiratory obstruction.

When laryngoscopy on the pale and swollen mucous membrane, there are many scattered ubiquitous miliary eruptions as large as a pinhead, gray in color, surrounded by a pink corolla. In the initial period, these rashes are isolated from each other, then merge, forming a continuous inflammatory surface, and undergo caseous decay, leaving behind surface ulcers that are at different stages of development - from fresh rashes to scars. Similar changes appear on the mucous membrane of the pharynx. With the same form of tuberculosis of the larynx, adenopathy of laryngeal laryngeal nodes develops, characterized by severe pain syndrome, often with their caseous decay, fistula formation and subsequent calcification and scarring. Several forms of acute miliary tuberculosis of the larynx are described: acute, supra-acute, subacute.

The superficial form is characterized by a very rapid development of the inflammatory process, leading the patient within 1-2 weeks to death. It is characterized by diffuse ulceration of the mucous membrane, abscess formation and development of phlegmon of the larynx, with extremely severe pain and obstructive syndrome, severe intoxication, rapid decay of the cartilage of the larynx and surrounding tissues, the appearance of arrosion bleeding. With this form, all existing treatments are ineffective. The subacute form evolves slowly, within a few months, characterized by seeding of the mucous membrane with nodular formations that are at different stages of development.

Luprial larynx, as a rule, is a descending process, the primary focus of which is either in the region of the external nose, or in the region of the nasal cavity, nasopharynx and pharynx. According to Albrecht's statistical data, laryngeal lupus occurs in 10% of patients with these forms of primary lupus. Primary larynx of the larynx is rare. The most common lupus is the epiglottis and scapular folds. Men are sick in middle age, somewhat more often - women.

Features of clinical manifestations. Syndrome of general intoxication can be of different severity. It is based on the multiplication of bacteria, their dissemination and the action of tuberculosis toxin. By the severity of local changes, it is possible to identify limited foci (small forms) of lesions, common changes without destruction, including the defeat of several organs, a progressive destructive process. In former times, forms such as tuberculous caseous pneumonia, miliary tuberculosis and tuberculous meningitis, as well as generalized forms of tuberculosis with multiple lesions of various organs, were often encountered. And although in our time these forms of tuberculosis are much less common, the problem of primary and secondary tuberculosis remains relevant, especially for closed groups.

Secondary tuberculosis takes a long time, wavy, with a change in periods of exacerbation and fading. Local manifestations of primary tuberculosis (for example, larynx, bronchi, pharynx and other ENT organs) are detected mainly in unvaccinated children, in children and adolescents with the phenomena of immunosuppressive and immunodeficient conditions. In elderly and elderly people, symptoms of tuberculosis are observed against the background of signs of age-related changes in various organs and systems (primarily in the upper respiratory tract and bronchopulmonary system), as well as concomitant diseases.

Negatively affect the clinical course of tuberculosis pregnancy, especially early, and postpartum period. However, mothers with tuberculosis are born full-fledged, practically healthy children. They are usually not infected, and they need to be vaccinated with BCG.

Diagnosis of laryngeal tuberculosis

Physical examination

Anamnesis. Particular attention should be paid to:

• the time of appearance and duration of causeless violation of the voice function (hoarseness), not amenable to the standard methods of treatment:
• contacts with patients with tuberculosis, the patient's belonging to the groups at risk:
• in young people (up to 30 years) it is necessary to clarify whether they were vaccinated and revaccinated against tuberculosis:
• peculiarities of the profession and occupational hazards, harmful habits;
• transferred diseases of the larynx and lungs.

Laboratory research

In clinical blood analysis, typical changes include moderate leukocytosis with a left shift and anemia.

Microscopic examination of sputum with color according to Tsiol Nilsen, or luminescent microscopy is considered the most informative.

Sputum culture on nutrient media is also used. The shortcomings of the culture method include the duration of the study (up to 4-8 weeks). Nevertheless, the method is quite reliable. In some cases, only with this method can detect mycobacterium tuberculosis.

Pathomorphological examination of biopsy specimens from the larynx, in which epithelioid, giant cells and other elements characteristic of tubercular inflammation, including foci of caseous disease, are determined.

Apply bone marrow, lymph node examination.

Instrumental research

To diagnose tuberculosis of the larynx, use microlaringoscopy, microlaringostroboscopy, bronchoscopy, biopsy, radiography and CT of the larynx and lungs.

It is necessary to conduct spirometry, spirography, which allow to determine the functional state of the lungs and to reveal the initial manifestations of respiratory failure due to the pathology of the larynx, trachea, and lungs.

Differential diagnosis of tuberculosis of the larynx

Differential diagnosis is carried out with:

• mycosis of the larynx;
• Wegener's granulomotosis;
• sarcoidosis;
• laryngeal cancer;
• syphilitic granulomas;
• lupus in the upper respiratory tract;
• contact ulcer;
• pachidermy;
• scleroma;
• chronic hyperplastic laryngitis.

For differential diagnosis, CT larynx is widely used. Identify signs characteristic of larynx tuberculosis: bilateral lesion, thickening of the epiglottis, intactness of the epiglottis and parapharyngeal spaces, even with extensive lesions of the larynx by the tuberculous process. Conversely, radiologically laryngeal cancer is one-sided, infiltrates adjacent areas: often the destruction of cartilage and extrarortal invasion of the tumor, metastasis in the regional lymph nodes. CT data should be confirmed by the results of a pathomorphological examination of biopsy specimens on the affected parts of the larynx.

Indications for consultation of other specialists

In the absence of the effect of the therapy as a result of the drug resistance of mycobacteria tuberculosis, consultations are needed.

Treatment of tuberculosis of the larynx

Objectives of treatment of larynx tuberculosis

The treatment is aimed at eliminating the clinical manifestations and laboratory signs of tuberculosis of the larynx and lungs, regression of radiologic signs of a specific process in the larynx and lungs, restoration of the voice and respiratory functions and the patients' ability to work.

Indications for hospitalization

Long (more than 3 weeks) hoarseness and pain in the throat when swallowing liquid and solid foods, not amenable to standard methods of treatment.

Presence of chronic hypertrophic laryngitis, "contact ulcer".

Non-drug treatment of tuberculosis of the larynx

From non-pharmacological methods of treatment recommend:

• gentle voice mode:
• sparing high-calorie food;
• balneological treatment.

Drug treatment of larynx tuberculosis

Treatment is selected individually, taking into account the sensitivity of mycobacteria tuberculosis to chemotherapy drugs. Treatment is carried out in specialized anti-tuberculosis institutions.

Highly effective drugs are isoniazid, rifampicin, pyrazinamide, ethambutol and streptomycin. Usually, not less than 3 drugs are prescribed taking into account the sensitivity of mycobacteria to them. For example, isoniazid, rifampicin, ethambutol for a long time (up to 6 months). Systemic therapy is combined with inhalation of anti-tuberculosis drugs (10% isoniazid solution).

Local application of ointment preparations with anesthetic to ulcer surfaces, cauterization of infiltrates and ulcers with a 30-40% solution of silver nitrate, make a Novocaine blockade of the upper laryngeal nerve or an intradermal Novocain blockade according to A.N. Ascension, Vagosimpathetic blockade on AB Vishnevsky.

Treatment of patients suffering from tuberculosis of the larynx is carried out in specialized phthisiatric clinics, in the staff of which there is an otorhinolaryngologist specializing in tuberculosis lesions of ENT organs. His task includes primary and systematic ENT examination of all patients entering and treating and participation in the medical process. The main goal of the "otorhinolaryngological" treatment is to cure the patient of laryngeal disease (as well as other ENT organs) and to prevent superinfection (perichondritis, phlegmon, "malignant" scar process) and to take emergency measures for asphyxia in acute laryngeal stenosis tracheotomy).

Treatment is divided into general, aimed at stopping the therapeutic means of the primary focus of tuberculosis infection, or its elimination by extirpation of the affected part of the lung tissue, and local, with the help of which they try to reduce or even prevent destructive changes in the larynx and their consequences. As for chronic cicatricial stenoses, depending on their degree, surgical treatment with laryngoplasty methods is also used.

When treating patients with tuberculosis of the larynx, they use the same medications as for pulmonary tuberculosis (antibiotic treatment), however, it should be borne in mind that antibiotics used in tuberculosis have only bacteriostatic and not bactericidal action, therefore under unfavorable conditions (immunodeficiency, poor hygiene and climatic conditions, nutritional deficiencies, beriberi, domestic hazards, etc.), tuberculosis infection can recur. Therefore, a set of medical products must necessarily include hygienic and preventive measures aimed at fixing the achieved therapeutic effect and preventing recurrence of the disease. The antibiotics used in the treatment of patients with tuberculosis of the larynx include the above Streptomycin, kanamycin, Rifabutin, Rifamycin, Rifampicin, Cycloserin. Vitamins and vitamin-like drugs (Retinol, Ergocalciferol, etc.), glucocorticoids (Hydrocortisone, Dexamethasone, Methylprednisolone), synthetic antibacterial agents (aminosalicylic acid, Isoniazid, Metazide, Opiniziazid, Ftivazid, etc.), immunomodulators (Glutoxim) , macro- and microelements (calcium chloride, Pentavit), secretolytics and stimulators of motor function of the respiratory tract (Acetylcysteine, Bromhexin), hemopoiesis stimulants (Butylol, Hydroxocobalamin, Glutoxim, Glucon Iron lactate and other iron-containing drugs, leucogen, Lenograstim, Metiluratsil and other stimulants, "white" blood). When antibiotics are used, a combination of streptomycin and phtivazide is a good result, especially with miliary and infiltrative-ulcer forms of tuberculosis. It should be borne in mind that a number of antibiotics used in the treatment of patients with tuberculosis have an ototoxic effect (Streptomycin, Kanamycin, etc.). Their harmful effects on SPO do not occur often, but, having arisen, can lead to complete deafness. Usually ototoxic effect begins with a noise in the ears, therefore at the first appearance of this symptom it is necessary to interrupt the treatment with an antibiotic and send the patient to the ENT specialist. In such cases, prescribe B vitamins, drugs that improve microcirculation, hold 3-4 sessions of plasmapheresis and dehydration therapy, intravenously inject reopoliglyukin, reoglumane and other detoxification products.

Local treatment is symptomatic (aerosols with anesthetics, mucolytic agents, infusion into the larynx of menthol oil). In some cases, with significant proliferative processes, it is possible to use intra-oral microsurgical surgical interventions with galvanocaustics, diathermocoagulation, laser microsurgery. In severe pain syndrome with otodonia, in some clinics an upper laryngeal nerve is intersected on the side of that ear, into which the pain radiates.

Treatment of larynx of the larynx includes the use of vitamin D2 in combination with calcium preparations by the method proposed in 1943 by the British phthisiatrist C. Charpy: appoint three times a week for 15 mg of vitamin for 2-3 months, then 15 mg every 2 week for 3 months - either per os, or parenterally. Assign also daily calcium gluconate for 0.5 g parenterally or per os, milk up to 1 l / day. Food should be rich in proteins and carbohydrates; animal fats in the daily diet should not be more than 10 g. The patient should receive a lot of vegetables and fruits.

With pronounced infiltrative and ulcerative lesions of the larynx, PASK and streptomycin are added.

Surgical treatment of tuberculosis of the larynx

With the development of stenosis of the larynx, tracheostomy is indicated.

Further management

Patients with tuberculosis of the larynx need regular follow-up. Approximate terms of incapacity for tuberculosis of the larynx: from 10 months or more to the conclusion of VTEK (when there is a tendency to cure), or disability registration for patients of voice-speech professions.

Forecast

The prognosis depends on the duration of the disease, the severity of the tuberculosis process, the concomitant pathology of internal organs and bad habits.

The prognosis for tuberculosis of the larynx depends on many factors: the severity of the pathological process, its shape and stage, the timeliness and completeness of treatment, the general state of the body and, finally, the same factors related to the tuberculosis process in the lungs. In general, in modern "civilized" medical care conditions, the prognosis regarding the condition of both the larynx and other foci of tuberculosis infection is favorable. However, in neglected cases, it may be unfavorable for the functions of the larynx (respiratory and voice-forming) and the general condition of the patient (disability, disability, cachexia, death).

The prognosis for tuberculous lupus in the larynx is favorable, if the overall resistance of the body is high enough. However, local cicatricial complications, in which one resorts to methods of dilatation or microsurgical intervention, are not excluded. In immunodeficient conditions, tuberculous foci in other organs may occur, in which the prognosis becomes serious or even doubtful.

Prevention of tuberculosis of the larynx

Prevention of tuberculosis of the larynx is reduced to the prevention of pulmonary tuberculosis. It is accepted to distinguish between medical and social prevention.

Specific tuberculosis prophylaxis is carried out with a dry anti-tuberculosis vaccine for intradermal administration (BCG) and a dry anti-tuberculosis vaccine for sparing primary immunization (BCG-M). Primary vaccination is performed on the 3rd-7th day of the child's life. Children aged 7-14 years who have a negative reaction to the Mantoux test are subject to revaccination.

The next important point of prevention is the clinical examination of patients with tuberculosis, as well as the introduction of new methods of diagnosis and treatment.

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