Adenoid Hyperplasia
(Adenoides)
The upper portion of the nasopharyngeal wall contains the third, or pharyngeal, tonsil which is made up of pale or red masses separated by vertical clefts. As a result of repeated inflammations in the nose and pharynx, this tonsil often hypertrophies, obstructing the openings of the choa-nae and Eustachian tubes and filling up a large part of the nasopharynx.
Children’s infectious diseases, such as measles, scarlet lever, influenza and diphtheria, sometimes stimulate the rapid growth of adenoids. This hyperplasia is most frequently met with in children at the age of three to eight or ten years, but it may also occur in the first year of life and after puberty, when adenoids normally tend to disappear.
Symptoms. The symptoms produced by adenoids are primarily those of nasal obstruction and continuous rhinitis which does not respond to ordinary conservative treatment. In consequence of nasal obstruction, children with adenoids sleep with their mouths open, and most of them keep it half-open when awake, which flattens their nasolabial fold and makes their facial expression apathetic and dull. Constant mouth breathing causes the hard palate to become high-arched and narrow, i.e. there forms the so-called “Gothic” palate. Hyperplasia of the pharyngeal tonsil is often accompanied by a similar enlargement of other lymphanic structures, above- all, the faucial tonsils, in which case nasal obstruction becomes even more severe. This type of mouth breathing adversely affects the child’s constitution, particularly, the shape of its chest. That is why children with adenoids look physically weak as well as mentally retarded. They have various nervous disorders, primarily nocturnal enuresis, which ought to be regarded as a reflex neurosis. They often complain of headache and inability to concentrate.
The folds and depressions of adenoids may harbour a numerous collection of bacteria, which are responsible for frequently recurring and acute inflammations of the nasopharynx. Adenoid hyperplasia which interferes with middle ear ventilation, may cause a gradual loss of hearing or repeated inflammations in the middle ear. Owing to nasal obstruction on the side of the choanae, the child speaks with a nasal twang (rhinolalia clausa).
Diagnosis. Apart from the symptoms described above, the diagnosis is based on rhinoscopy, primarily postnasal mirror examination, which will offer a direct view of the nasopharynx filled with adenoid hyperplasias hanging from the roof and obstructing the choanae to a greater or lesser extent. Posterior rhinoscopy is often impossible in children, in which case the finger must be used to palpate the nasopharynx. This is an easy method of detecting adenoids, as well as of determining whether they are of pasty or less soft consistency.
Finger Palpation of Nasopharynx
Treatment. In the majority of cases, adenoids are treated surgically. Indications for adenoidectomy should be sought for not so much in the size of the adenoids, as in the constitutional disturbances they are likely to cause, such as constant and stubborn rhinitis, which resists conservative treatment, and repeated inflammations of the middle ear.
Position of Pa-tiettt in Adenoidectomy
The operation is usually performed in the morning when the stomach is empty by means of different types of adenotomes available in five sizes to fit the size of the nasopharynx.
The child patient is wrapped in a sheet and firmly held by the assistant, who jams its legs between his own and keeps its head in position with one hand and its chest and arms with the other. At operation the child should not be allowed to fidget or tilt back its head. After the tongue has been pushed down with a spatula, the adenotome is slipped into the nasopharynx, behind the soft palate, set strictly along the mid-line and pressed to the nasopharyngeal roof, somewhat to the front. The adenoids are then cut off with a quick jerk from front to rear along the roof and jiosteriorwall of the nasopharynx, and withdrawn. Tags oll exuberant tissue overhanging the nasopharynx are clipped off with a con-chotome. Bleeding is usually scanty and easily controllable.
Contraindications and postoperative care in adenoidectomy. After the operation the child is directed to clear the! nose of blood by blowing it gently through one nostril at a time and to gargle the mouth with hydrogen peroxide solution. Next, the child has its nose packed with cotton wool until bleeding has ceased, is put in bed and encouraged] to lie quietly for two or three hours.
If hemorrhage ensues the blood should not be swallowed j but spat out into a basin.
The aftercare may be taken over by the parents who! must be instructed to keep the child in bed for two or three! days, give it cool and liquid meals and clean its room with I a wet cloth. These measures are aimed at prevention of 1 hemorrhage and infection of the open wound in the child’si nasopharynx. With normal body temperature and good general condition the child may go to school on the sixth or seventh day after the operation.
The operation is soon followed by the complete restoration of nasal breathing and hearing and later by improvements in the child’s physical and mental development.
Despite the removal of adenoids measures for promoting a sound constitution in children should not be neglected.
Following adenoidectomy, some children are given breathing exercises to promote nasal respiration.
If there are serious contraindications for surgical removal of adenoids, X-ray therapy may be of assistance.
Hypertrophy of Faucial Tonsils
Hypertrophy of the faucial tonsils similar to that of the pharyngeal tonsil is more common in children. In this condition, the tonsils are markedly enlarged and protrude beyond the faucial pillars (Fig. 74) or are in contact in the mid-line. Hypertrophied tonsils in children usually have no inflammatory signs. In time, these “physiologically” hypertrophied tonsils shrink to their normal size. This involution may be delayed, in which case comparatively large tonsils will be found in an adult patient.
Tonsillotomy
Treatment. Health promotion is the primary measure which includes a hygienic regimen, adequate nourishment, rest in child health centres, etc. In children suffering from marked hypertrophy of the faucial tonsils which interfere with speech, breathing and the passage of food, tonsillectomy must be resorted to, the redundant tissue protruding into the nasopharyngeal space being removed with a ton-sillotome.
Foreign Bodies in the Pharynx
Foreign bodies enter the pharynx not only through the mouth, which is the most common route, but also through the nose as well as the larynx and esophagus. Foreign bodies that lodge in the pharynx, like fish bones, fruit stones, grains, and the like, usually enter during a meal. Among other foreign bodies found in the pharynx are fragments of .dentures, coins, small toys and other objects children put in the mouth at play, as well as nails, drawing-pins, pins and buttons held in the teeth by adults at work, particularly shoe-makers and tailors.
The danger of foreign bodies slipping in with food through the mouth is greater in cases of toothless jaws with dentures which shut off the feel of the hard palate. In addition, foreign bodies often lodge in the pharynx at meals owing to a sudden cough, laughter, sneezing and talking which distract attention from chewing. Foreign bodies which become wedged in the pharynx are usually sharp and catch in the faucial mucosa, tonsils, faucial pillars or lodge at the entrance to the esophagus or larynx. Large and smooth foreign bodies more frequently pass down to the esophageal entrance or become stuck in the esophagus itself.
Foreign bodies are less likely to lodge in the nasopharynx. They may be broken-off pieces of instruments entering through the nose, remnants of food and sometimes pinworms belched out of the stomach. Sometimes live creatures, such as leeches, enter the nasopharynx through drinking filthy water from swamps and irrigation ditches.
Foreign bodies may produce different symptoms depending on their individual features. In the case of a sharp foreign body wedged in the mucous membrane, the patient will complain of a more or less severe pricking pain, particularly marked on swallowing. In other cases, a foreign body may produce mucosal inflammation with signs of hyperemia, swelling and increased secretion, which in turncause coughing, choking and sometim.es vomiting. Should a large foreign body become lodged in the lower pharynx, at the laryngeal entrance, this may produce sudden symptoms of asphyxia.
Treatment. Following location of the foreign body by a thorough and consecutive examination of all parts of the pharynx, it is extracted by aid of a straight or angular forceps with the blades in close contact. The patient is sometimes distressed by scratches and sores left by the removed foreign body which simulate the latter. Aftercare consists of mildly antiseptic gargles and a bland diet.
ACUTE INFLAMMATIONS OF THE PHARYNX
Inflammation of the_pharyngeal_mucosa may be acute orTiEronTc.
“Acute pharyngitis (pharyngitis acuta). Acute inflammations of the pharyngeal mucosa rarely occur of themselves, and are commonly provoked by a dqwnward xtension of acute catarrh ojhenose and nasopharynx. Acute pharyngitis mayp Qucedifferent subjective symptoms in the throat, such as dryness, slight pain or tension, sore throat, etc. Physical examination reveals hyperemia of the mucous membrane, which iff places is covered with mucopurulent secretion. Individual follicles exhibit as red granules on Jthe retropharyngeal mucosa. The uvula is red, swollen and slightly edematous. Body temperature is either normal or slightly elevated, and bodily discomfort is mild. Acute pharyngitis frequently foreshadows or accompanies tonsillitis.
Treatment. This is similar to that of tonsillitis, namely, rest in bed, a bland diet of warm and liquid or semi-liquid food, administration of salicylic and sulfonamide drugs, application of a hot compress to the neck and use of the following antiseptic gargles:
Rp. Dec. radicis Althaeae 400.0
Natrii benzoici 6.0
Glycerini 10.0
T-rae Opii benzoici 3.0
MDS. Gargle
Rp. Kalii hypennanganici 1.0
DS. Two or three crystals in a glass of water for a gargle
The gargle should be warmed a little beforehand and the head tilted back to let the liquid irrigate the farthest portions of the pharynx, na Foll icular Tonsillitis Catarrhal, Lacunar an Tonsillitis is a generalized infectious disease with inflammation of the pharyngeal lymphoid structures, above all the faucial tonsils, and with swelling of the regional lymphatic glands.
The inflammation in the pharynx presents a wide variety of morbid symptoms owing to the presence in the pharyngeal mucosa of adenoid tissue which may be wholly or partly involved in the process. The inflammation may be diffuse and superficial when it affects the surface of the tonsils and their crypts, or it primarily involves adenoid tissue, tonsillar parenchyma, with the follicles embedded in it.
The cause of tonsillitis is invasion by streptococci and, less frequently, by staphylocci and pneumococci, while the predisposing factors are thermic, chemical and mechanical irritations of the mucosal receptors of the fauces and tonsils in the presence of a diminished body resistance. The infection may be introduced by external factors or be activated by an increased virulence of the germs permanently inhabiting the tonsillar crypts, mouth and pharynx. The source of infection may be a suppuration in the nose and paranasal sinuses or dental caries.
Tonsillitis often develops as a grave constitutional disease, which is evidenced by frequent complications in such organs, as the heart, joints and kidneys, as well as by the fact that the local signs in the fauces are often preceded by severe malaise with fever, headache and rheumatic pain.
Tonsillitis may occur in the catarrhal, lacunar and follicular forms depending on its severity and on the presence or absence, as well as the character and location, of a patchy membrane on the faucial tonsils.
Catarrhal tonsillitis. The patient first complains of dry-ild JUneuufas 111 the throat and later of moderate throat pain on swallowing. The temperature is usually subfebrile, whereas in children a high-grade fever is more common, and vomiting is one of the early symptoms. Headache and feebleness are frequent. The disease continues three to four days. In mild cases, examination of the pharynx reveals slightly swollen and red tonsils whose surface is coated with a yellowish mucoid secretion. In severe cases, there is punctate hemorrhage on the mucosa as well as edema of the uvula and faucial pillars. The lymph nodes below the mandibular angle are swollen and tender.
Catarrhal tonsillitis is nearly always present with many acute infectious diseases. In scarlet fever, it takes a peculiar course. At the onset, the inflammatory redness is sharply outlined in the centre of the soft palate, whereas in unaccompanied tonsillitis the tonsillar mucosa is most affected. Within a day or two, the bright and limited redness caused by catarrhal tonsillitis present in scarlet fever disappears, and hyperemia extends over a wider area invading the tonsils and the posterior wall of the pharynx.
The characteristic skin rash of scarlet fever appears after the first 23 or 24 hours. In measles, hyperemia of the fauces is of spotted character and appears on the second or third day after the onset of the disease as part of general enanthema.
In lacunar tonsillitis the general symptoms are more pronounced. The constitutional disturbance is more severe than in catarrhal tonsillitis, while pain felt on swallowing and headache are worse. There is a marked fever which in children rises as high as
Follicular tonsillitis. This condition is another form of the same infectious disease occurring independently or concomitant with lacunar tonsillitis. The red and swollen mucosa of both tonsils becomes the site of eruption of a considerable number of round and slightly prominent yellow or yellowish-white nodules the size of a pin-head, which are suppurated tonsillar follicles. This disease differs from other forms of tonsillitis with patches in that the suppurated follicles are of uniform size and regular shape, and are confined to the free area of the tonsils. In the process of suppuration, the yellowish-white follicles gradually grow in size and burst into the pharyngeal space. Evacuation of their contents into the connective tissue bed of the tonsil may produce a peritonsillar abscess.
The onset of follicular tonsillitis is. often sudden, accompanied by a chill, a rapid rise in temperature to
Follicular tonsillitis may attack the pharyngeal and lingual tonsils simultaneously. Though its course is severe this disease usually ends in complete recovery in five to seven days’ time.
Tonsillitis is liable to produce a number of complications of a local and general character.
The former refer to peritonsillar abscesses and acute otitis media, the latter—to cardiac and articular rheumatism, renal diseases and sepsis.
Diagnosis. This disease is not difficult to recognise. In diagnosing lacunar tonsillitis particular care should be takeot to mistake it for diphtheria. The difference between them will be discussed in the section on diphtheria.
In tonsillar syphilis, there is very little malaise, moderate pain on swallowing, and a very slight fever. The faucial pillars and tonsils are bright red and covered with greyish-white round papules which are also found on the mucosa of the cheeks, gums and tongue. Numerous swollen and solid lymph nodes can be felt under the mandible and on the neck. The diagnosis of tonsillar syphilis is verified by general examination and Wassermann’s test.
Prognosis is usually favourable, but it is rather common that recovery from tonsillitis, however severe, is followed by grave constitutional complications, like rheumatoid arthritis, rheumatic endocarditis, nephritis or septicopyemia. The forecast, therefore, should be made with caution, particularly in cases of recurrent tonsillitis followed by complications.
In all cases of more or less severe tonsillitis, blood tests should be performed since this condition may be a symptom of a serious disease of the blood, leukemia, etc.
Treatment. The patient is advised to take to bed, as a prophylactic measure against complications, is prescribed a diet of thin gruel and given acetylsalicylic acid (aspirin) with caffeine orally.
Rp. Aspirini 0.5
Coneini natrio-benzoici 0.1
M. f. pulv.
D. t. d. N. 10
S. One powder dose two or three times daily
Small children are given a solution of sodium salicylate. Mildly antiseptic gargles, like boric acid, sodium benzoate and other solutions, are used for throat irrigation.
Rp. Hydrogenii hyperoxydati 3% medic. 100.0
DS. One or two tablespoonfuls in a glass of
a water for a gargle
Rp. Acidi borici 25.0
DS. One teaspoonful in a glass of warm boiled water
for a gargle Rp. Gramicidini 2.0 D. t. d. N.
S. The contents of one ampule dissolved in a glass of water for a gargle
Rp. Natrii benzoici 25.0 DS.
Half a teaspoonful in a glass of water for a gargle
Children are given plenty of warm drinks. A hot compress on the neck, preferably soaked in a solution of one-third of alcohol to two-thirds of water, is effective as well as steam inhalations from a hot 2% baking soda solution and administration of laxatives. The condition of the heart and kidneys should be watched, in the case of the latter—by analysis of urine. The hot compress will help diminish infiltration and congestion in the pathologically changed organ, viz., in the tonsils, after which the morbid process will speedily resolve, and pain will be alleviated.
The streptococcic nature of tonsillar infection is an indication for the use of streptocide and other sulfonamide drugs as well as penicillin by intramuscular injection, and biomycin and terramycin in tablet form. Streptocide, sulfathiazole and sulfadimezin are given for a few days in 0.3 to
Prophylaxis. The prevention of tonsillitis is based on general rules for strengthening the body and enabling it to resist various harmful external influences.
These rules are as follows:
Observance of sanitary and technical regulations in
industry, selection by fitness for a particular job, registra tion and regular examination and treatment of persons susceptible to tonsillitis; more hygienic living conditions, personal hygiene and body hardening; treatment of diseases conducive to tonsillitis, such as chronic tonsillar hypertrophy, purulent highmoritis, adenoid hyperplasia, dental caries, etc., which affect the upper respiratory tract.
Although tonsillitis infection is not highly contagious, it is advisable to isolate the patient with tonsillitis and provide him with individual eating and other utensils. Healthy persons, children in particular since they are especially susceptible to the disease, should avoid contact with the patient. Acute inflammation is not always restricted to the tonsils, but may often involve the entire lymph-adenoid tissue of the pharynx; yet lesion of individual tonsils may have peculiar clinical symptoms of its own.
Acute pharyngeal tonsillitis. This condition commonly occurs in children, particularly in cases of hypertrophy of the pharyngeal tonsil, and is called acute adenoiditis or retronasal tonsillitis (angina retronasalis). The symptoms are fever, a general feeling of weakness, and signs of rhinitis. The troublesome smarting sensation in the nasopharynx is accompanied by cough and otalgia. The cervical lymph nodes are often swollen and tender.
Treatment is the same as that for acute rhinitis.
Acute lingua tonsillitis. This condition is much rarer. Its general symptoms are similar to those of other types of tonsillitis: local pain on swallowing, marked tenderness at the base of the tongue on pressure with a spatula, a bright red and swollen lingual tonsil, sometimes covered with yellowy dots or coated all over as in lacunar tonsillitis.
Treatment. This is similar to that applied to inflamed faucial tonsils. Ulcero-membranous angina (Vincent’s angina). This disease causes ulceration of the mucosa of the soft palate and tonsils, less commonly of the gums, retropharyngeal wall and cheeks. It is due to the symbiosis of a fusiform bacillus and an oral spirochete which usually resides in a low virulent state within the folds of the oral mucosa.
The condition is marked by superficial necrotic patches of a yellowish-white colour on the mucosa of the tonsils and soft palate. These necrotic patches quickly merge to form superficial and sometimes deeper ulcers on the mucosa, which are not very painful but often produce bad breath and salivation. The temperature is usually subfe-brile or normal with little constitutional change. The regional lymphatic glands are swollen and tender.
The normal duration of the disease is about a week, but it may linger for a few weeks and longer.
Ulcero-membranous angina occurs either sporadically or in epidemics. When observing an outbreak of this disease in
N. P. Simanovsky, the first Russian to have written a treatise on this subject, in 1890 described a similar epidemic of ulcero-membranous angina in St.
According to earlier evidence of Russian physicians, namely, Filatov and others, ulceration of the oral cavity and pharynx occurs with ulcerative stomatitis. Thus, the identity of ulcero-membranous angina with ulceration of the oral mucosa had been proved clinically long before Vincent discovered the pathogen of this disease in 1898.
Diagnosis. The diagnosis is verified by a laboratory investigation of smears taken from the ulcer contents, which reveals both fusiform bacilli and spirochete. Sometimes, external evidence is insufficient for differentiation of ulcero-membranous angina from diphtheria, syphilis or cancer.
Treatment. In mild cases,
Agranulocytic angina (angina agranulocytotica). This condition is usually marked by a sudden fever, sometimes accompanied by chills and sore throat. Examination of the throat will reveal a markedly swollen mucosa covered with necrotic patches of a dirty grey colour. Deep ulcers form later which are not confined to the tonsils but spread all over the pharynx, oral cavity and larynx. Constitutional disturbance is grave, and fever is of the septic type.
The blood picture in such cases will nearly always reveal a drastic decrease and sometimes nearly complete absence of granular leukocytes, or granulocytes, from the blood. The number of white cells in the blood drops from between 6,000 and 7,000 to 500 per cu mm and less. In the absence of blood-test evidence this disease may be mistaken for diphtheria and ulcero-membranous angina.
This exceedingly grave disease is comparatively rare, and the precipitating causes are still unknown. It lasts four to five days or up to several weeks and if untreated frequently proves fatal.
Treatment. This is by blood transfusion, X-ray irradiation of the bone marrow, drug therapy to speed up leukocytosis and with pentoxyl given in
Tonsillitis in Infectious Mononucleosis and Listeriosis
(Angina monocitotica et listerellosa)
Infectious mononucleosis is basically a sporadic disease, though, less frequently, it may occur in epidemics confined to a small community or family. The clinical picture of this condition was first described by N. F. Filatov in 1885 as glandular fever characterized by swollen lymph nodes and distinctive changes in the blood.
Etiology. Recent clinical and bacteriological studies suggest that this disease is caused by a virus, Some authorities believe that infectious mononucleosis is a form of listeriosis caused by bacteria of the genus Listeria (Liste-rella monocitogenes). This conjecture seems reasonable in view of the similarity that exists between the clinical symp- toms of infectious mononucleosis and listeriosis. In the former case, the disease runs a milder course with fewer of the grave complications fairly common to listeriosis. _ The clinical picture and course. Infectious mononucleosis occurs mainly in young people between 10 and 30 years °f age and is caused by droplet infection. The disease has various, sometimes light, clinical forms. In typical, more frequent, cases, the onset is marked by rigor, headache and a high fever of 39° to
Tonsillitis in infectious mononucleosis usually appears on the third or fourth day in a broad variety of forms. It may be catarrhal, lacunar, and quasi-membranous resembling diphtheria, as the patches spread over the faucial pillars, uvula and soft palate. More severe cases may develop into the ulcero-necrotic form with deep ulceration in the body of the tonsil coated with a greyish-green membrane and foul odour from the mouth. These changes in the pharynx cause excruciating pain and considerable enlargement of lymph nodes.
Diagnosis. This is based on an examination of the blood which makes it possible to differentiate this condition from leukemia, agranulocytosis, tularemia and brucellosis. The blood picture shows a moderale leukocytosis (15,000-20,000 with a predominance of mononuclear cells, which may number 50 to 90 per cent of the total leukocytes. The red cell count is usually normal.
The disease lasts two or three weeks, then the fever gradually subsides, local symptoms of tonsillitis disappear, pain ceases, the spleen shrinks to its normal size and the swollen lymph nodes gradually diminish to become impalpable. However, the blood condition rises to normal more slowly.should be avoided. Septic angina (alimentary toxic aleukia). The onset of this disease is marked by a sudden fever of 39° to
The anginal stage is not the onset of the disease and follows food intoxication that has been in progress for one to three weeks without any significant signs.
The disease is caused by cereal food such as millet, wheat, rye, barley, buckwheat, and oats, that had been left out in the field during the winter.
Ingestion of this grain, in particular millet, will cause a bitter taste and a burning sensation in the mouth, pharynx, esophagus and stomach, as well as numbness in the tongue. These symptoms are often accompanied by nausea, vomiting, and headache. Further consumption of this food, however, does not cause a recurrence of these sensations since the body seems to become immune.
Yet in other cases, the absorption of this food for only two or three weeks is followed by headache, prostration and weakness. Punctate hemorrhage looking like flea bites appears on the skin. Already at this early period of septic angina, blood analysis will reveal a progressive reduction in the leukocyte count, viz., onset of the period of leukopenia.
Should consumption of this winter-spoiled graiot be discontinued, and treatment not be started immediately, then within one, two or three weeks there will be a sudden onset of septic anginal syndrome. The whitish or yellowish-brown membrane which appears on the tonsils marks the onset of necrosis which soon, in fact in 24 hours, causes deep ulcers that bleed readily. This ulceration commonly affects not only the tonsils which soon collapse completely but other aggregations of lymphadenoid tissue as well, and may extend to the palatine, pharyngeal and esophageal mucosa and, sometimes, to that of the oral cavity.
Withdrawal of toxic products from food at the initial period of the disease, prior to the onset of anginal symp-tomps, may often bring recovery, especially if the total amount of toxic food eaten has been moderate.
Advanced septic angina is frequently fatal.
Medical aid for this condition essentially consists in an early diagnosis of septic angina in the leukopenic stage, a mass examination of inhabitants of districts where winter-spoiled grain was used for food and an indispensable analysis of blood to detect leukopenia.
Treatment. At the first signs of the disease, toxic products should be immediately withdrawn from food, and lavage of the stomach undertaken. The patient is then given large doses of magnesium sulfate or sodium sulfate to cleanse the stomach of toxic food residue. The diet must be nourishing and rich in proteins and vitamins, and drink must be given in plenty to help expel toxins from the body. Local treatment, apart from the use of gargles, and anesthetic ointments, is by sprinkling the ulcerated surfaces with streptocide or sulfadimezin powders twice daily.
Intramuscular penicillin injections and pentoxyl have been used with success. Hemorrhage can be checked by blood transfusion in 200-300 ml doses and by intravenous injections of calcium chloride. Cardiac failure may be helped by administration of camphor, caffeine and strychnine.
Prophylaxis. The basic means of control of septic angina is prophylaxis by timely and careful harvesting of all cereals and by making the public understand how dangerous it is to use winter-spoiled cereals for food. The chemical nature of the poison responsible has not yet been established, and only its heat resistance is obvious, since neither cooking, nor boiling or any other culinary treatment of winter-spoiled grain can reduce its toxicity.
Peritonsillar Abscess or Quinsy
(Angina phlegmonosa, s. peritonsillitis abscendens)
The peritonsillar abscess is a fairly common sequel to chronic tonsillitis and, more frequently, to acute tonsillitis. The infection penetrates from the depth of a tonsil crypt into the connective tissue bed of the tonsil causing an inflammatory process which leads to the formation of an abscess.
Symptoms. The commonest complaint in quinsy is a spontaneously growing pain. The patient who has just recovered from tonsillitis again feels pain on swallowing, mostly unilateral and has a rising fever.
Half of the soft palate becomes markedly red and increasingly swollen, gradually hiding the tonsil and pushing the edematous uvula to the opposite side (coloured Table III, Fig. 2). The pain is more severe than in lacunar or (a) anterosuperior peritonsillar abscess, (b) posterior peritonsillar abscess Line indicates site of incision follicular tonsillitis, and is felt even when the patient is motionless.
Peritonsillar Abscess
It becomes a sharp shooting pain, frequently radiates to the ear and increases on swallowing, coughing, or any movement. The mouth is opened with pain and difficulty and the patient inclines his head towards the sore side. The regional lymphatic glands on the affected side are often swollen and tender. The almost complete immobility of the soft palate makes the voice muffled and the swallowing of food difficult or even impossible.
The abscess forms in the connective tissue bed of the tonsil, commonly above and before or behind the tonsil. It may also develop in connective tissue at the lower pole of the tonsil and anteriorly to it.
In the event of an anterosuperior abscess the most marked redness is in the soft palate and the anterior faucial pillar. An abscess behind the tonsil is identified by an oval-shaped and extremely tender swelling and redness in the posterior pillar, with the soft palate and the anterior pillar showing no marked changes. The abscess comes to a head in five to seven days. Its progress is accompanied by a characteristic throbbing pain and increased infiltration with softening in a particular place. Frequently the abscess ruptures through the anterior pillar or drains above through the tonsil. The opening of the abscess between the anterior pillar and the edge of the tonsillar capsula is often inadequate for its full evacuation and should therefore be enlarged to assist recovery.
Diagnosis. Identification of quinsy involves no special difficulties. Peritonsillar abscess is commonly preceded by tonsillitis where unilateral redness in the fauces gradually expands, while swelling and increasing pain with a high-grade fever serve as another pointer to the genuine cause of the condition.
Treatment. This depends on the stage of inflammation. In the beginning, at the stage of infiltration, it may be possible to abort the process by adequate sulfonamide therapy in a total dose of 3 to
The patient should be given a diet of warm liquid or gruel. Severe pain may be relieved by aspirin (with caffeine) given in
The ripe abscess may often be opened with a blunt probe or bent forceps via the supratonsillar fossa upon rupturingthe tonsillar capsule. Incision of an anterior peritonsillar abscess is made in the anterior faucial pillar, 1 to
Opening of Anterosuperior Peritonsillar Abscess Through Supratonsillar Fossa
Among the complications of quinsy is hemorrhage due to pus corroding the walls of the pharyngeal vessels, deep cervical phlegmons, edema of the larynx, and sepsis.
Prophylaxis. Oral hygiene is extremely important as well as the treatment of chronic tonsillitis, dental caries and suppurations in the paranasal sinuses. Frequent recurrence of peritonsillar abscesses necessitates tonsillectomy, i.e. complete excision of the tonsils three or four weeks after recovery from quinsy.
Where indicated, however, the presence of a peritonsillar abscess is no obstacle to removal of the faucial tonsils which, in particular, is a prophylactic against recurrent abscess formation.
Lingual Tonsil Abscess (periamygdalitis abscendens lin-gualis). Inflammations or injuries of the lingual tonsil may cause phlegmons at the base of the tongue similar to phlegmons in the faucial tonsils. In this condition, there is always severe malaise, high-grade fever, headache, acute pain on swallowing and speaking. At first, the base of the tongue grows red, swollen and edematous. The edema may sometimes encroach on the entrance to the larynx and epiglottis and threaten death by suffocation. The abscess may develop towards a side of the neck causing tender swelling and redness in the floor of the oral cavity or at the mandibular angle.
Treatment. This condition is treated in the same way as the peritonsillar abscess.
Retropharyngeal abscess (abscessus retropharyngeal). This abscess is most commonly encountered in emaciated and weak infants and young children. It arises owing to suppuration of the lymph nodes lying on the posterior pharyngeal wall in front of the spinal column, in the so-called retropharyngeal space. The infection enters here through lymphatic channels from the nasal cavity, sometimes after the ordinary common cold, or from the oral cavity through fissures and abrasion caused by improper care of the mouth in babies. In children aged above five or six years retropharyngeal abscesses are rare because by this age the prespinal lymph nodes have usually atrophied.
Symptoms. In small children the abscess causes a high fever of up to 39-
Treatment. Incision of the abscess is indicated as soon as the diagnosis is made, in order to avoid spontaneous rupture with the danger of suffocation by pus suddenly filling the larynx, especially in sleep, or pneumonia due to pus aspiration into the lower respiratory tract.
A small incision is made in the abscess with a scalpel bound with an adhesive plaster
Infiltrative abscesses must not be opened on the pharyngeal side as there is a danger of secondary infection and formation of a fistula. They are treated by punctures and suction followed by infusion of 5 to 10 ml of iodoform emulsion or streptomycin solution.
Faucial Diphtheria
(Diphtheria faucium)
Diphtheria is an acute contagious disease caused by Loeffler’s bacillus, whose clinical signs occur between the second and seventh day of infection. The disease is communicated either by direct contact wheii the patient sprays sputum particles in cough, sneezing and talking, or by indirect contact through objects he has handled. Infection may also be transmitted by recovered and healthy diphtheria carriers. The disease most commonly affects the fauces and tonsils, and primarily occurs in children aged between two and six years.
In breast-fed babies and adults faucial diphtheria is a comparatively rare phenomenon.
The clinical picture and severity of the disease varies, and it is, therefore, subdivided into the localized, diffuse^ toxic and hemorrhagic forms.
The mild forms, such as localized diphtheria, may be similar to lacunar or follicular tonsillitis, the only difference being in body temperature, which is subfebrile and in adults may often be normal. This condition is characterized by the formation of a greyish or greyish-white patchy membrane on the moderately swollen and congested surface of the tonsils and a slight constitutional disturbance. Pain in the throat is not severe. The submandibular lymph nodes are only swollen slightly, and the disease may disappear within three or four days. Usually the individual spots on the tonsils soon merge to form whitish, greyish-white or, less frequently, yellowish islands which grow into compact, adherent crusts. The latter may not only occupy the free surface of the tonsil, but, in the so-called diffuse form, may invade the faucial pillars and soft palate and often rise above the surface of the mucosa. In the event of the membrane being stripped off the tonsil bleeding will ensue.
The severe forms, otherwise known as toxic, cause a much graver constitutional disturbance with a nigh fever of 39-
In the hemorrhagic form of diphtheria, there is hemorrhage in the mucous membranes and on the skin, while the membranous patches become saturated with blood.
In the toxic form, where edema of cellular tissue spreads down to the clavicle and below, as well as in the hemorrhagic form, it is not always possible to save the life of a child patient. In the diffuse form without edema of the cervical cellular tissue, recovery is certain, if serum treatment was started in time.
It is essential to distinguish the localized diffuse form of diphtheria from lacunar tonsillitis, especially when the latter causes extensive membrane formation. To facilitate differentiation between faucial diphtheria and tonsillitis we have drawn up a table listing the characteristic symptoms of both diseases (see page 206). In this scheme each symptom taken separately is not pathognomonic of either disease, whereas judgement based on the sum total of symptoms available may help diagnosis in obscure cases.
A high fever without obvious bodily discomfort is more common in tonsillitis, while a moderate fever of over 37 to
In tonsillitis, the membranous patches are more superficial and can easily be removed, whereas in diphtheria the thicker membranes rise above the mucosal surface and are difficult to remove. Tonsillitis membranes rarely extend beyond the limits of the free tonsil surface. Where possible a throat swab should be taken to ascertain the presence of diphtheria bacilli.
Treatment. When verifying the diagnosis and in uncertain cases, an antidiphtheric serum should be given immediately without waiting for the bacteriologist’s report.
The serum is usually warmed and injected intramuscularly. In the localized form of faucial diphtheria the serum dose is 5,000-8,000 a.u. (antitoxic units).
In the diffuse form, the initial dose is 10,000-
In the hemorrhagic form, the single dose is equal to 40,000-
Babies under one year and between one and two years of age are given a quarter-dose and half-a-dose respectively.
To prevent anaphylactic phenomena, Bezredka’s method is recommended whereby 1 ml of serum is injected one or two hours before administration of the full therapeutical dose.
Today, a dialysed, that is protein-free and ferment-processed, serum known as diaferm possessing antitoxin in an extremely high concentration is used for injection of large doses of antitoxin. The seroreaction touched off by this serum is the least possible.
Local treatment for older children consists in antiseptic gargles of dilute boric acid, borax or hydrogen peroxide.
In small children, the mouth is kept clean by spraying or syringing it with the same solutions or 2 % baking soda solution.
The most serious complications of diphtheria are lesions of the cardiovascular system (myocarditis) and symptoms of nephrosis. Therefore, all diphtheria patients should be strictly confined to bed and given cardiac stimulants, such as caffeine, camphor, strychnine, etc., as indicated
clinically.
Injection of serum is sometimes followed in 7 to 12 days by the onset of serum sickness marked by urticarial rashes, fever and pain in the joints.
The itching is relieved with hot baths, administration of calcium chloride, orally or by intravenous injection, while pain in the joints is allayed with hot-water bottles and hot compresses.
In some cases, three to four weeks after recovery, there is temporary paralysis of the soft palate when liquid food enters the nose and the voice acquires a nasal quality.
Mild forms of such paralysis remit spontaneously, whereas more severe forms are given, where possible, electrical treatment, as well as arsenic and strychnine drugs orally, in T-rae Strychni form in doses of as many drops as the child’s years twice or three times daily.
Prophylaxis and nursing care. The patient with diphtheria should be immediately isolated, preferably in a hospital.
If hospitalization is delayed, even for a few hours, the patient should be given the first injection of antidiphthe-ritic serum on the spot, since early serum administration is essential for its efficacy.
Anyone having had contact with diphtheria patients must have throat swabs taken for bacteriological examination. They must be isolated and may only leave quarantine seven or ten days later provided all’clinical symptoms of diphtheria are absent and the bacteriological tests are negative.
Following his hospitalization, the patient’s flat should be disinfected.
It should be borne in mind that diphtheria bacilli may be discharged not only by active carriers but also by convalescents, who are thus a danger to the community. Their condition is known as the bacilli-carrier state.
Eradication of the bacilli-carrier state is a major problem of diphtheria control. The development of this condition largely depends on the extent of the child’s debility following a severe illness as well as on the pathological condition in the nose, pharynx and tonsils, whose treatment must be part of the complex measures against the bacilli-carrier state. Immediate destruction of the bacilli is produced by local, intramuscular or combined administration of antibiotics. The nasal cavity is sprayed with a mixture of penicillin and streptomycin, preferably in the aerosol form, whereas levomycetin, biomycin, tetracycline and erythromycin are given orally in three
Since there is no reliable protection against diphtheria carriers, they must be isolated; in the case of children they may not attend school, etc., and should be kept in the open-air as long as possible, until they are bacilli-free. Antiseptic gargles are also helpful.
The child may be considered free of the bacilli-carrier state only when this has been proved by three examinations of nasal and throat swabs taken consecutively at intervals of a few days.
Diphtheria patients may be discharged from hospital a week after the disappearance of clinical symptoms if the bacteriological tests have proved negative. It is extremely important that information about diphtheria and the measures necessary for its prevention be made widely known among the general public. The ancillary personnel must be taught the rules governing the care of a diphtheria patient; persons in charge of the patient should wash their hands in mercury bichloride solution, 1 : 1,000, after any contact with him. No one should be permitted to sit on the patient’s bed, visitors should not be admitted, nor should the patient’s utensils be taken from the ward or room. Gauze and cotton wool used to cleanse the patient’s nose and mouth must be burned immediately.
The patient’s temperature and pulse rate must be carefully watched because weakened heart activity is the most dangerous symptom in diphtheria. The diet consists of liquid or gruel-like meals of milk, broth, butter and jelly sufficient in vitamins, especially, vitamin C, which may be given in ascorbic acid drugs.
CHRONIC INFLAMMATIONS OF THE PHARYNX
Chronic tonsillitis (tonsillitis chronica). Chronic inflammation of the faucial tonsils, or chronic tonsillitis, is a frequent disease caused by repeated attacks of acute tonsillitis in the adult. The morbid process is confined to the tonsillar crypts or may primarily affect the tonsillar parenchyma.
The squamous epithelium of the crypts comes off in scales to form fetid caseous masses plugging the crypts and containing numerous bacteria and leukocytes. Owing to the expansion of the crypts the tonsils appear porous and spongy, and the faucial pillars often adhere to the free surface of the tonsils. The crypts become a most convini-ent place for the retention and propagation of virulent streptococci and staphylococci whose vital activity keeps up the inflammatory process in the tonsils. In unfavourable conditions, like chilling or reduced body resistance, etc., these bacteria may cause exacerbations, such as acute tonsillitis, peritonsillar abscess and a number of general complications, for example, infectious polyarthritis, rheumatic heart, nephritis, etc.
Patients with chronic tonsillitis often complain of discomfort in the tonsillar area, pain on swallowing and, sometimes, of bad breath. There may often be the sensation of a foreign body in the throat and reflex otalgia caused by the pressure of an increased caseous plug. In cases of frequent exacerbations of chronic tonsillitis, the regional lymph glands, both submandibular and cervical, are swol len and tender. Some patients, however, are not conscious of the disease at all.
Irrigation of Tonsil Crypts (1) tonsil crypts, (2) irrigation cannula
The patient’s history will indicate frequent recurrence of tonsillitis, peritonsillar abscesses, or complications in the form of constitutional diseases immediately consequent upon tonsillitis. Chronic tonsillitis may produce a prolonged slight fever setting in at night for five or six months and longer as well as a constitutional disturbance manifest in apathy, inability to work, headache, etc.
Consideration of complaints and anamnestic data is not enough for a final judgement; careful examination of both tonsils is necessary to verify the diagnosis.
Treatment. This may be conservative or surgical. The former is by painting the tonsillar crypts with a 5% solution of iodine tincture, trichloracetic acid, 1% Lugol solution or 1-3% silver nitrate solution. If carried out regularly, this procedure frequently causes the tonsils to shrink and stops plug formation. Similar results may be obtained by regular irrigation of the tonsillar crypts with 4% boric acid or penicillin solution, etc. (Fig. 80). Good results are also obtained sometimes by dissection of the tonsillar crypts with a galvanocauter or a blunt-pointed curved knife followed by removal of tissue tags with a conchotome.
Complete excision of the tonsils is indicated in a frequently recurring peritonsillar abscess and tonsillitis, especially when the latter is liable to cause such complications as rheumatic heart, nephritis, etc. This operation, known as tonsillectomy, comprises the complete enucleation of the tonsils in their capsules. Iearly all cases, tonsillectomy is a reliable method to prevent relapses of tonsillitis.
The operation is made under local anesthesia at an impatient clinic. This operation is contraindicated in subjects with a hemopoietic disease or poor blood clotting.
Instruments Used in Tonsillectomy
(1) grasping forceps to engage tonsil; (2) elevator for separation tonsil; (3) tonsil snare
Immediately after the operation, the patient should be carefully watched, because of the likelihood of postoperative hemorrhages. The patient is forbidden to swallow and instructed to spit saliva into a basin or towel. The patient should refrain from taking food, at least for the first 8 to 12 hours after the operation.
In the early postoperative period, the patient is given a cool and bland diet of milk, broth, jelly, and half-liquid gruels. Naturally, the diet should contain vitamins in plenty.
Chronic pharyngitis (pharyngitis chronica). Chronic diseases of the pharyngeal mucosa occur in the catarrhal, hypertrophic and atrophic forms. Their etiology may be of local and systemic character. The former refers to chronic rhinitis, suppuration in a paranasal sinus, chronic tonsillitis, etc. The latter refers to metabolic disturbances and stasis in the venous system in diseases of the heart, lungs, liver and kidneys.
Another important cause is unfavourable climate and occupational hazards presented by dry air, drastic temperature changes and dirty surroundings found in various industries, such as cement plants, porcelain factories, flour mills, etc. Vapour and gases in the chemical industry as well as the constant abuse of tobacco and alcohol may have a pernicious effect on the pharyngeal mucosa.
Symptoms. In the atrophic form of chronic pharyngitis, there is a sensation of tickling, scratchiness and dryness in the throat. In the hypertrophic form, the basic complaint is one of a large accumulation in the nasopharynx ot tenacious mucous secretion which causes much coughing and expectoration, especially in the morning, when it may be accompanied by retching and sometimes vomiting.
In the hypertrophic form, the mucosa is red and thickened, and the posterior pharyngeal wall is covered with a sticky mucopurulent secretion which trickles down through the nasopharynx. In the atrophic form, however, the mucosa is dry and glazed as though covered with a thin film of varnish. Sometimes, it is covered with a viscid, almost dry mucus or crusts which are hard to remove even if a medication has been applied.
The lymphoid structures of the mucosa often respond to chronic irritation with a marked hyperplasia of individual follicles exhibited as red granules scattered over the posterior pharyngeal wall and symptomatic of granular pharyngitis. Sometimes there is hypertrophy of adenoid tissue embedded in the lateral pharyngeal folds, which in this case are seen as prominent bright-red and thick bands behind the posterior faucial pillars. This condition is known as lateral pharyngitis.
Treatment. The first essential is to eliminate the basic cause of the condition.
Local treatment of the mucosa comprises the removal of the adherent secretion and alleviation of irritation by frequent throat irrigations with warm alkaline solutions of baking soda, borax and weak, 0.5-1%, saline solutions. For their prescriptions see the section on atrophic rhinitis.
The following gargles are also recommended:
Rp. Natrii benzoici
Natrii biborici
Natrii bicarbonici aa
DS. Half a teaspoonful in a glass of warm water for a gargle
Rp. Natrii benzoici 3.0
T-rae Opii simplicis gtt. XX
Aq. Amygdalarum amararum 2.0
Glycerini 10.0
Aq. Menthae 50.0
Aq. destill. 200.0
MDS. To be used as a warm gargle three or four times daily, or bicarmint is prescribed in one or two lozenges in half a glass of water for a gargle
In the event of copious secretion, mildly antiseptic and styptic gargles are used two or three times daily. For this a tablespoonful of camomile or a teaspoonful of sage leaves, which have a stronger styptic effect, are steeped in a glass of boiling water. The tea thus prepared is strained and used as a gargle while being warm. Warm irrigation has a soothing effect on the mucosa and keeps down hypersensitivity and unpleasant sensations in the throat.
The porous and hypertrophied mucosa is shrunk by painting it with l%-2%-3%-5% silver nitrate solution once in every two or three days. In the atrophic form, 1% iodine-gly-cerol or 1 % menthol solution in liquid petrolatum are used after a preliminary application of alkaline gargles.
Pharyngomycosis (pharyngomycosis benigna s. leptothri-cia).
This disease is marked by hornification of the squamous epithelium of adenoid tissue. There are white or creamy plaques or thorn-like excrescences found on the unchanged tonsillar surface as well as on the lateral folds of the posterior pharyngeal wall and at the base of the tongue. These pointed or round, as though calcareous, excrescences markedly protruding above the mucosal surface are firmly adherent to their beds. The thorns harbour numerous organisms of the fungus Leptothrix buccalis.
Symptoms- Leptothrix lesions are usually symptomless and are detected only by chance or when they cause a slight pricking sensation. Though this condition is stubborn and resists treatment, it entails no serious complications. Pharyngomycosis is very often mistaken for lacunar tonsillitis.
Treatment. This has been of little effect so far. The common methods are electric cauterization or regular application to the excrescences of 5% iodine tincture, the use of alkaline gargles with an addition of five drops of iodine in a glass of water, as well as oral iodine in doses of five drops repeated for two or three weeks. Frequently the lesions heal of their own accord.
BENIGN TUMOURS OF THE PHARYNX
Benign pharyngeal tumours which grow as pedunculated papillomas and fibromas from the pillars or soft palate are not dangerous.
Treatment. The tumour is removed by surgery.
Nasopharyngeal fibroma. The nasopharyngeal fibroma is a special type of tumour which occurs almost exclusively in males between the age of 8 to 13 years and in full puberty, i.e. from 20 to 25 years, when the tumour, if still present, begins to shrink.
The essential element of a nasopharyngeal fibroma is
dense connective tissue containing a great number of elastic fibres and blood capillaries. The tumour is histologically benign, but for its clinical course marked as it is by irresistible growth and destruction of the surrounding tissue, postoperative relapses and frequent copious hemorrhages endangering the patient’s life, it may sooner be classified as a malignant neoplasm.
Symptoms. The initial clinical symptom is unilateral nasal obstruction. After four to six months full nasal obstruction occurs as well as more or less marked complications in the ear. In advanced cases with a rapid growth of the tumour it causes the eye, as well as the soft and hard palates to bulge, swells out the nose, etc. Repeated nasal hemorrhages at the very onset of the disease weaken the patient and aggravate his condition still further.
Diagnosis. The tumour is recognized easily. Anterior rhinoscopy usually reveals a red, smooth tumour filling one side of the nose and bleeding readily on probing. When examining the pharynx, a swelling in the soft palate with the edge of a pink, smooth tumour often showing from behind it can be seen. The tumour differs from a choanal polyp by its greater density and broad area of attachment.
Treatment. The treatment is by surgery. The operation is rather difficult because of the deep position of the tumour, its firm adherence to the basal tissue and severe hemorrhage. Small tumours located in the nasopharynx are removed via the nose or mouth.
Ieglected cases where the tumour invades the zygomatic area and paranasal sinuses the removal is performed only after a preliminary operation has been undertaken to provide access to the tumour proper. This access may be obtained through the antrum of Highmore with complete removal of the lateral nasal wall. Recently surgical diathermy has been successfully used to remove the tumour. Radiotherapy, particularly X-rays, is sometimes also effective.
MALIGNANT TUMOURS OF THE PHARYNX Cancer of the nasopharynx. This disease is frequently met with after 40 years of age, in younger subjects it is far less requent. The symptoms of malignant nasopharyngeal tumours should be sought in the progress of the tumour and the functional disturbances attending this progress, particular attention being paid to the initial stages of their development.
According to the primary site of origin the initial symptoms of the tumour may be associated with the following phenomena: (1) otalgia and hearing disorders due to tumour growth beside the Eustachian tube which occurs in six out of every ten cases; (2) nasal obstruction caused by tumour growth in the choanae; (3) neuralgia and paralysis when the tumour grows upwards and presses on the cra-nio-cerebral nerves. These symptoms are absent in some cases, and the first morbid signs, therefore, may be “lymphadenitis” in the neck and submandibular region caused by metastases into the nearest lymph nodes. Metastases into the cervical lymph nodes are especially early in lymphepithelial tumours.
At first, the patient complains of gradual obstruction of one and then of both sides of the nose. Blowing the nose expels secretion containing blood filaments and sometimes causes nasal hemorrhage or pyoichorous nasal discharge. The patient is usually late in resorting to medical aid. Examination of the nasopharynx by posterior rhinoscopy and palpation with the finger, which is quite indispensable in such cases, will reveal a large or small knobby mass which often disintegrates, bleeds on palpation and merges evenly into the surrounding tissue.
Early diagnosis and correct X-ray treatment of malignant nasopharyngeal tumours improve their outlook, formerly quite hopeless. Recovery may be facilitated by stimulation therapy with repeated blood transfusions in fractional doses, whereas the use of leukopenia-preventive drugs, such as pentoxyl, campolon, etc., permits an adequate dose of irradiation to be administered to cases which until recently were regarded as incurable.
Malignant tumours in the middle and lower pharynx. A malignant tumour in the form of a dense knobby infiltration, which very easily ulcerates due to its traumatic irritation by the passage of food, may develop on the soft palate, tonsils (Fig. 82), posterior and lateral walls of the pharynx or in its lower portions, namely, the pyriform sinuses. With the onset of ulceration in the tumour, it begins to ache, grows in size and interferes with the passage of food. There are early metastases to the nearest lymph glands in the neck and at the base of the skull.
Surgical removal of these tumours from healthy tissue is often belated and its outcome may, therefore, be unfavourable. New hope has been given by X-ray and radium or radio cobalt therapy after a preliminary ligation of the external carotid artery. This treatment sometimes arrests the growth of the tumour for a long time and so delays the fatal outcome.
Lymphosarcoma of the tonsils occurs more frequently than other kinds of pharyngeal sarcoma, and mostly in young people.
ACUTE LARYNGITIS
(Laryngitis acuta)
Acute laryngitis is most commonly found in acute catarrh of the upper respiratory tract. The disease is often associated with total or partial chilling of the body. It may also be caused by inhalation of acrid vapours, very dirty air, as well as by overexertion of the vocal cords, such as in prolonged and loud talking. Laryngeal inflammation may also be the result of highly contagious diseases, such as measles, scarlet fever and typhoid.
Course and symptoms. Laryngoscopy reveals diffuse hyperemia of the laryngeal mucosa, more or less markedly swollen and congested true vocal cords, and clots of viscid secretion. Phonation sometimes fails to produce complete approximation of the vocal cords due to paresis of the vocal muscles. According to the degree of the laryngeal lesion the voice becomes hoarse and rough with cough, dry at first and accompanied by a feeling of dryness and burning in the throat. The scanty sputum, which is hard to expectorate, gradually grows in quantity, whereupon it may be expectorated with ease producing a marked amelioration in the patient’s general condition.
The general feeling of illness is sometimes combined with headache and a slight fever. The disease commonly persists for only seven to ten days and passes quickly if treatment is adequate.
Treatment. The basic remedy is to remove the harmful factors which have provoked the onset of the disease. The patient must give his larynx complete rest by speaking as little as possible for five to ten days depending on the severity of the case. He is advised at first to inhale penicillin aerosols and then proceed with alkaline inhalations a few times daily and a hot compress on the neck.
The following prescriptions may also be recommended:
Rp. Cocaini hydrochlorici 0.1
Aq. Amygdalarum amararum 4.0
Glycerini puri 6.0
Aq. Menthae 50.0
Aq. destill. 150.0
MDS. For steam inhalation
If a vaporizer is not available, the following prescription may be used for inhalation:
Rp. Mentholi crystallisati 1.0 Spiritus vini rectificati 10.0
MDS. Ten to twenty drops in a glass of boiling water for steam inhalation
Febrifuges and narcotics, such as codeine powder, are given for fever and cough, and mixtures are used to promote expectoration.
Codeine or dionin may be used in drops or solution together with bromine drugs.
Id case of marked dryness of the mucosa and dry crusting, oily solutions are applied to the larynx, such as:
Frequent ventilation of the room and clean fresh air assist speedy recovery.
Prophylaxis. See section on prevention of diseases of the upper respiratory tract.
CHRONIC LARYNGITIS
(Laryngitis chronica)
Chronic laryngitis follows repeated acute attacks. Furthermore, chronic laryngeal inflammation may be due to irremovable factors which cause acute laryngeal catarrh present in habitual alcoholics and inveterate smokers. Occupational laryngeal catarrh is often met with among singers, teachers and people who work in dusty surroundings or are^ exposed to chemical hazards. Long-continued inflammations in the upper airways, such as chronic coryza, paranasal sinus suppuration, tonsillitis, pharyngitis, etc., as well as in the lower portions of the respiratory tract, such as tracheitis, purulent bronchitis, may cause a chronic inflammation of the larynx.
Symptoms. These are similar to those of acute laryngitis, though somewhat milder. At times, there is exacerbation and aggravation of the condition in the affected area. The patient complains of hoarseness which grows worse at
Rp. Sol Argenti nitrici 1-2-3% 10.0
MDS. For laryngeal painting Rp. Tannini 1.01
Glycerini 10.0
MDS. For laryngeal painting
Inhalation of alkaline vapours of baking soda and natrium benzoicum solutions are used, as well as iodine-glycerol given for atrophy and crusting.
Apart from painting the larynx with iodine-glycerol, infusions of an aqueous iodine-glycerol solution are also helpful, and their effect is somewhat milder. The formula of this solution is as follows:
Rp. Jodi puri 0.15
Kalii jodati 1.0
Aq. destill. Aq. Menthae a 100.0
Glycerini 10.0 MDS.
For laryngeal infusion
Inhalations are given a few times daily with special instruments described above. If these are not available, two or three glassfuls of boiling water should be poured into a basin and the steam inhaled through a make-shift paper tube for two or three minutes a few times daily. Penicillin is an effectual remedy against exacerbations of chronic laryngitis.
Prophylaxis. To ward off this disease, one should avoid’ a sudden exposure of the larynx to cold upon leaving a heated room, abstain from singing and loud talk in the frost after a hot bath as well as from continual straining of the voice in dry and dusty surroundings, particularly in the absence of nasal breathing.
