Primary tuberculosis of the larynx is rare, it is often secondary to the primary localization of infection in the lungs, which occurs with the involvement of the intrathoracic lymph nodes. Tuberculosis of the larynx occurs in approximately 10% of patients with the initial form of pulmonary tuberculosis, in 30% of persons with a long course of this infection and in 70% of cases with the autopsy of those who died from it. Tuberculosis of the larynx affects children less often, and at the age of less than 10 years - very rarely. The disease is more common in smokers and drunkards, as well as in people whose profession is associated with the presence in the inspired air of harmful agents that reduce the resistance of the mucosa of the upper respiratory tract and lungs to tuberculosis infection.
Infection of the larynx occurs in two ways: by the channel route, when the infection penetrates the larynx mucosa from the pulmonary focus, and more often - by the hematogenous way. The presence of chronic banal laryngitis (for example, a smoker's laryngitis, or chronic professional laryngitis in tobacco, mining, and asbestos industry workers) promotes the introduction of a tubercle bacillus into the mucous membrane of the larynx.
Pathological anatomy of laryngeal tuberculosis. Morphological changes in tuberculosis of the larynx are divided into chronic infiltrative, acute miliary form and lupus of the larynx.
The chronic infiltrative form is caused by the appearance under the mucous membrane of subepithelial infiltrates that extend to the surface of the mucosa, where they merge, undergo caseous decomposition and turn into ulcers. The further pathomorphological process can proceed in two forms - productive and exudative. In the first case, a fibrous process predominates with local infiltrates covered with normal mucosa, and characterized by a slowly progressive course. In the second case, diffuse ulcers are formed, covered with gray-dirty deposits with edema of surrounding tissues. The edges of ulcers are elevated and surrounded by nodular infiltrates.
The exudative form evolves much faster than the productive form, the ulcers spread to the depth of the larynx walls, and the attachment of the secondary infection causes the occurrence of chondroperichondritis and inflammation of the scaly joints. In some cases, there is a destruction of the epiglottis, the remains of which are represented as a deformed and edematous stump.
Lupus is a type of tuberculosis of the larynx and is manifested by changes similar to the initial pathomorphological manifestations in the common tuberculosis of the larynx. Lupus infiltrates are encapsulated and symmetrically located, characterized by polymorphism, in which near the fresh nodular infiltrates it is possible to 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 is represented in the form of notches and is often completely destroyed.
Symptoms and clinical course are determined by the clinical and pathological form of tuberculosis of the larynx.
The chronic infiltrative form is more common than other forms. At the initial stage, the inflammation develops slowly and asymptomatically; The general condition of the patient does not suffer much, there may be an evening subfebrile condition. Gradually, the patient has a foreign body sensation in the throat, a growing pain in phonation, by the evening - hoarse voice, which soon becomes permanent and steadily increases. The patient is worried about a constant dry cough.
At the initial stage, the endoscopic picture is similar to the changes that occur with exacerbation of chronic catarrhal laryngitis. The difference lies in the long, almost non-stopping flow, the ineffectiveness of conventional remedies, the progression of dysphonia, which soon becomes very pronounced up to aphonia. The appearance of ulcers on the epiglottis, aryepiglottic folds, periendritis of the arytenoid and cricoid cartilage causes difficulty and soreness in swallowing. Swallowing movements are accompanied by the irradiation of pain in the ear, corresponding to the affected side of the larynx. Disturbance of breathing due to the gradual adaptation of the organism to the gradual development of stenosis and to slowly increasing hypoxia occurs only with an extreme degree of stenosis of the larynx.
An indirect sign of tuberculosis of the larynx can be the pallor of the mucous membrane of the soft palate and the threshold of the larynx. In the inter-cerebral space, infiltration similar to pachidermy can be seen. It is this infiltration that prevents the complete convergence of vocal appendages of the arytenoid cartilages, causing dysphonia phenomena (1).
Endoscopic picture of some forms of tuberculosis of the larynx:
- Infiltration of vocal folds and inter-head space.
- Tuberculosis monochorditis.
- Ulcerative infiltrative form.
- Miliary tuberculosis.
Often a tuberculous infection affects the vocal folds, one of which develops a specific monochordite. The affected vocal fold appears swollen with a thickened free margin (2). One-sided lesion of the vocal fold without destructive changes can take a long time, while the opposite vocal fold can remain intact.
Further development of the disease is manifested by the development of infiltrates and their ulceration; The edges of the vocal folds acquire a serrated appearance, an ulcer is formed in the intercellular space, surrounded by infiltrates. These changes are characteristic of the exudative form of tuberculosis of the larynx, while the productive form is manifested by limited infiltrates that protrude into the laryngeal lumen in the form of a single tuberculoma (3, 4). The degree of disturbance of the mobility of the vocal folds depends on the damage to the internal muscles of the larynx, secondary arthritis of the pericuminal plexus joints, infiltrative and productive phenomena.
With the further development of the tuberculosis process, perichondritis affects the entire skeleton of the larynx, infiltrates and purulent-caseous decay of pre-laryngeal tissues form with the formation of external fistulas, through which a cartilaginous tissue and prominent sequestrants can be probed with a button probe. During this period the patient experiences the strongest spontaneous pain in the larynx, sharply increasing at night and not decreasing not only under the influence of analgesics, but also narcotic drugs. At the same time, the pulmonary process is aggravated. The resulting hemoptysis can be not only pulmonary but also guttural. Often, with the artery of a large arterial vessel, patients die from profuse pulmonary or guttural bleeding.
An acute miliary form of tuberculosis of the larynx arises from the hematogenous path and is caused by seeding of the larynx and often pharynx. The disease progresses rapidly, the body temperature rises to 102-104°F, the general condition is sharply worsened, marked dysphonia, reaching a complete loss of the 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 failure.
When laryngoscopy on the pale and swollen mucosa, there are many ubiquitous, scattered, miliary rashes the size of a pinhead of gray color surrounded by a pink corolla. In the initial period, these rashes are isolated from each other, then merge and undergo caseous decay, leaving after themselves superficial ulcers that are at different stages of development - from fresh rashes to scars. (5). Similar changes occur on the mucosa of the pharynx. At the same time, regional adenopathy develops, characterized by severe pain syndrome, often with caseous decomposition of affected nodes, fistula formation, subsequent calcification, and scarring.
The diagnosis of tuberculosis of the larynx does not cause difficulties and is based both on the endoscopic picture and on the signs of the primary disease, that is, on the symptoms of pulmonary tuberculosis. With a miliary form in the initial period, the tuberculosis process can be mistaken for herpetic pharyngolaryngitis or the postgrippos pharymon beginning with the larynx.
From secondary syphilis, this form differs in temperature reaction, dysphagia, severe pain syndrome and swelling of surrounding tissues. Chronic tuberculosis of the larynx in the initial stage can be confused with banal laryngitis.
With each unilateral lesion of the larynx, an asymmetric inflammatory process, especially in the presence of pulmonary tuberculosis, tuberculosis of the larynx should be suspected. Despite the fact that the infiltrates in the inter-cerebral space - a phenomenon typical of tuberculosis of the larynx, yet they can be mistaken for banal pachydermia. Ulceration in this area can not be detected, therefore, for indirect laryngoscopy, different positions (Killian, Turk) or direct laryngoscopy should be used. Infiltrates in other places of the larynx should be differentiated from tertiary syphilis or carcinoma.
In the diagnosis of laryngeal tuberculosis, one of the main methods is radiography.
Radiographs for some forms of laryngeal tuberculosis:
- Moderate thickening of the left ventricular fold and a decrease in the size of the ventricle (tuberculosis of the larynx, which arose during the development of pulmonary tuberculosis).
- Tuberculosis epiglottis, laryngeal edema (profile shot).
- The ulcerative form of tuberculosis of the throat-pharynx.
- Tomography of the larynx with diffuse tuberculous lesion of the epiglottis, edema of mucous membrane, thickening of vocal and vestibular folds, reduction of the laryngeal cavity.
- The ulcerous form of tuberculosis of the larynx with massive edema and multiple ulceration in the overlying and lining spaces.
- X-ray picture of the patient (5), which visualizes mixed bilateral fibro-exudative changes in the lungs.
The prognosis for tuberculosis of the larynx depends on the degree of severity of the main pathological process, its form, and stage, timeliness and completeness of treatment, the general state of the organism. In neglected cases, the prognosis may be unfavorable with respect to the functions of the larynx (respiratory and voice-forming) and the general condition of the patient (disability, disability, cachexia, death).
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. The main goal of the otorhinolaryngological manual is to systematically laryngoscopy for the early diagnosis of laryngeal involvement by tuberculosis infection, to prevent superinfection and to take emergency measures for acute stenosis of the larynx and laryngeal bleeding.