ACUTE INFLAMMATORY DISEASES OF THE PHARYNX

The pharynx occupies a certain anatomical-topographic position (the crossing of the

respiratory and food-transporting tracts). It performs a number of the functions important
for the organism. There are:
a) participation of the pharynx in the act of eating (sucking and swallowing),
whose disruption results in a lacking vitality of newborns and inflicts much suffering on
adults;
b) accomplishment of breathing, as during the nasal and mouth breathings the air
enters the deep respiratory passages through the pharynx;
c) formation of voice and speech (the resonance function), whose disruption causes a
pronounced rhinolalia;
d) determination of taste owing to the receptors located in the pharyngeal areas
adjacent to the tongue;
e) the protective function. Fulfillment of the last function takes place with participation
of the mechanical protection (regurgitation) made for by a high sensitivity of the mucous
membrane to foreign objects which are not food (a reduced sensitivity in old persons
increases frequency of revealing foreign bodies in their oesophagus) owing to the
sympathetic and parasympathctic innervation (the 10th and 9ft pairs), and a pronounced
activity to the repair because of a good blood supply and presence of the salivary lysozyme
(a rapid healing of wounds). The specific protection is of paramount importance here; it is
performed by the function of the tonsillar apparatus of the pharynx based on the lymphoid
and reticular tissues which are closely interrelated with the epithelium.

Human pharynx is diveded inti three parts:

 Nasopharynx (above soft palate)
 Orhopharynx (below soft palate but above the upper end of epiglottis)
 Hypopharynx (below the end of epiglottis)
There are 6 tonsils in the pharynx (3 – in orhopharynx, 3 – in nasopharynx):
 Two palatine glands
 Two glands of auditory tubes
 One pharyngeal gland
 One lingual gland.
They all form the pharyngeal lymphoid ring (described at first by N.I. Pirogov). This
pharyngeal ring is not just an accumulation of the lymph tissue but a peculiar organ with
its own structure (the parenchyma and stroma).
Its stroma is represented by a capsule separating the tonsils from the muscles of the
pharynx. The parenchyma which consists of the reticular tissue with lymph follicles having
rounded centres of lymphocyte multiplication. The inner surface of the palatine tonsil that
faces the pharynx is not smooth but jagged with ramified depressions, so-called lacunae,
lined with the epithelium differs by its structure from the epithelium in the oral cavity by the
fact that epithelial cells here alternate with lymphoid ones, thereby forming a so-called
lymphoepithelioid tissue. Owing to the lacunae, the total area of the contact between the
tonsil and the environment significantly increases.
The pharyngeal ring is participant of MALT-system (Mucosal Assosiated Limphoid
Tissue) that unites all limphoid structures situated on the border between environment and
internal environment. It provides the contact between antigen and lymphocyte. This fact
and a close functional relationship between the epithelium and lymphocytes (that is much
alike structural relations of the lymphocytes and epithelium in the thymus) that determine
the main protective functions of the tonsillar apparatus. They are as follows:
a) participation in the cellular immunity. The oral cavity in the newborn is sterile but
during 24 hours there is appearance of some microbial flora in the cavities of the mouth
and pharynx with resultant production of lymphocytes in the lymph follicles of the
palatine tonsils. Migrating through the lacunal epithelium, these lymphocytes reach a
lacuna where they take part in phagocyte reactions killing microbes or eliminating their
pathogenic properties and leaving antigenic ones with resultant production of natural
vaccines that induce formation of corresponding antibodies in the organism (the tonsils are
"a natural laboratory of vaccines");
b) participation in the humoral immunity. There is a constant formation of antibodies in
the tonsils from B lymphocytes in response to the antigenic stimulus by their
transformation into plasma cells; these antibodies include secretory immunoglobulin A
and serum globulins A, M and G that take part in the general systemic immunity;
c) fulfillment of informative-immunological functions. Owing to its immediate
proximity to the environment the tonsillar apparatus of the pharynx ensures receiving of
information by the immunocompetent organs (the thymus, spleen, reticuloendothelial
system) about a state of the bacterial background This information goes by two ways:
nervous (the tonsils have rich sympathetic and parasympathetic innervation) and
humoral (migration of T lymphocytes from the lacunae back to the tonsil and later to the
thymus for providing this organ of immunity with concrete information thanks to
which the thymus gives orders to other immunocompetent organs for their
corresponding responses);
 d) participation of the lymphoid ring in the virus-induced immunity. Experience of
the past has shown that passion for an operation of removal of the palatine tonsils,
particularly at childhood in the United States of America, resulted in an epidemic of
poliomyelitis in this country, persons after tonsillectomy falling ill with this disease much
more frequently and having the most severe forms. It has been also noticed that the persons
whose tonsils were removed are more subject to viral respiratory diseases. The study of
these facts has shown that lymphocytes of the tonsillar apparatus of the pharynx produce
interferon whose action lies in the basis of the virus-induced immunity.
We clearly see active participation of pharyngeal lymphoid ring in pathological processes,
because the lymphoid tissue is one of the first tissues that contacts and starts to fight
against the microflora. Most frequently, this process involves the palatine tonsils, and
their acute "inflammation is termed angina (Greek ancho and Latin angere, meaning
"I squeeze"). It is possible to come across another term in the literature - "acute tonsillitis"
(V.F. Undrits), but it is better to call it "angina", as it clearly shows that this process is
acute, because the word "tonsillitis" is more characteristic of a chronic inflammation of
the palatine tonsils.
The morbidity rate of angina depends upon the seasonal prevalence (the autumn-
winter and winter-spring periods) and residence (the urban population suffers more
frequently than the rural one). The geographical position (the northern or southern
latitudes) does not play any part, but the southerners who come to the northern regions fall ill
more frequently that the aboriginal population.
The etiological factor of anginae are microorganisms, particularly the beta-hemolytic
streptococcus of group A .
Thus, angina is an infectious disease with different kinds of transmission of the
infection. The ways of transmission:
a) the droplet way;
b) a direct contact, or use of the same household goods that a patient uses;
c) the alimentary way (when eating food stuffs which contain streptococci:
cakes, chicken and duck eggs, etc.).
 Contamination with an infection may be exogenous, as described above, and
endogenous, when in the presence of an infection in the oral cavity (dental caries) and on
the tonsils (chronic tonsillitis) and the resultant sensitization of the organism any
permitting factor (superinfection. supercooling) may cause angina.
Since the palatine tonsils have structural barrier formations, it is possible to describe
a scheme of their disturbances in the course of the development of the anginal process by
V.I. Voyachek. Thus,
 the epithelium in the lining of the lacunae is the 1st barrier and its affection
manifests itself in the form of catarrhal angina;
 the 2nd barrier consists of the subepithelial reticular tissue: its lesion is interpreted
as lacunal angina;
 the 3rd barrier is made up of lymph follicles whose affection results in follicular
angina;
 lesion of the 4th barrier - a friable connective tissue of the stroma - produces
phlegmonous angina;
 and affection of the 5to (histohaematic) barrier develops metatonsillar
complications (sepsis, rheumatism, nephritis, etc.).
The classification of of angina diseases. It distinguishes the following forms:
I - primary acute tonsillitis (catarrhal, lacunal, follicular anginae) with
 local (phlegmonous angina, lymphadenitis, paratonsillitis, parapharyngiris) and
 general complications (tonsillogenous sepsis, nephritis, rheumatism, etc.).
II - affection of the tonsils in general diseases (angina in blood diseases, general
infections, mononucleosis, scarlet fever, diphtheria); and, finally,
III - peculiar forms of angina (fusospirochetal or ulceromembranous angina, known
abroad as Vincent's angina).
Common people and some doctors have an incorrect notion about angina as an "easy"
disease. Sometimes the course of angina is very severe, therefore its clinical manifestations
depend, first of all, upon the form of the disease and reactivity of the organism in each patient.
Angina manifests itself with its local and general signs.
The typical general signs are as follows:
 1. Rise in the body temperature to febrile values (38-39°C).
2. The patient feels jaded, suffers from a chill or chilling.
3. A headache.
4. Unpleasant musculoarticular sensations.
5. Loss of appetite and sleep.
Local signs are as follows:
1. Pains in the throat on swallowing (at first on one side, and later on the both sides).
2. Swelling of the regional lymph nodes.
3. Appearance of some foul smell from the mouth.
Blood reveals leukocytosis, accelerated ESR, presence of the acute phase indices: C-
reactive protein, glycoproteins, seromucoid, sialic acids. All these signs are less
pronounced in catarrhal angina and increase in the lacunal and follicular ones.
The results of pharyngoscopy:
- a bright hyperemia of the palatine tonsils and no changes in the colour of other parts of
the faucial and pharyngeal regions indicate catarrhal angina;
- if there are whitish or greyish irregular patches in the crypts which are easily removed, it
is lacunal angina;
- in follicular angina, it is possible to see white and yellow-white rounded points under the
mucosa (inflamed lymph follicles), and they cannot be removed.

Catarrhal angina
Follicular angina

Lacunal angina
If the infection invades the paratonsillar fatty tissue, it causes development of a
paratonsillar abscess (phlegmonous angina); this abscess is most frequently localized in
the area of the upper tonsillar pole. With respect to the tonsil, the abscess may be anterior,
posterior and lateral. It is usually unilateral, but sometimes both the tonsils may be involved.
As a rule, this process develops 4-5 days after the onset of angina, when its signs are
accompanied with nasal speech, difficult opening of the mouth (trismus) and
hypersalivarion, as the patient is not able to swallow the saliva. Pains in the throat increase,
the patient is imable to sleep and eat, his body temperature is high (39-40°C).
 Visual examination reveals some swelling of the regional lymph nodes and
asymmetry of the fauces caused by protrusion of the palatine tonsil with an oedema of the
uvula and arches. Sometimes it is possible to see a yellowish point in the centre of the
protrusion.
In children up to 5 years of age, angina may be complicated with a retropharyngeal
abscess because of the peculiar structure of the retropharyngeal space and presence of the
lymphoid tissue there. In this case, the general signs of angina are accompanied with
presence of some protrusion to the right or left of the median pharyngeal line; when it
descends into the hypopharynx, this protrusion may occupy the median line and hamper
breathing and swallowing. If the abscess is not opened, it may descend to the mediastinum
during its next stage and cause mediastinitis.

Retropharyngeal abscess
TREATMENT of ANGINAE is as follows:
 the patient should be isolated from the surrounding persons,
 follow a bed regimen, have a rest,
 abundant drinking, food (with restricted amounts of salt, spicy and dairy
produce, but a lot of vitamins, particularly vitamin C), a tea with a lemon.
 As far as antibiotics are concerned, it is better to use the penicillin line, to which
the ß-hemolytic streptococcus is highly sensitive and has no habituation.
  Salycilates, aspirin for prevention of rheumatism, and calcium gluconate are to be
administered too.
 It is obligatory to make analyses of the blood and urine at the end of the disease
in order not to miss any possible complications.
 Local gargling with warm antiseptic solutions and hot compresses on the neck are
also indicated.
In case of a paratonsillar abscess, there is its opening followed by intensive therapy
together with dehydration measures and desintoxication. Sometimes it is recommended
not to evacuate the pus by making an incision, but immediately perform
abscessotonsillectomy, because presence of peritonsillitis demonstrates an absolute
disruption of the tonsillar function (tonsillectomy during an acute period).
If the infection invades the
paratonsillar fatty tissue, it causes
development of a paratonsillar
abscess; this abscess is most
frequently localized in the area of
the upper tonsillar pole. With respect
to the tonsil, the abscess may be
anterior, posterior and lateral.

The course of parapharyngitis is more severe, when the infection invades the cervical
fatty tissue. It results in a bad general state accompanied with presence of some swelling
on the neck, sharply tender on palpation, and a protrusion of the lateral pharyngeal wall in
the hypopharynx. The treatment begins with an operation on the neck: an incision along
the internal end of the sternocleidomastoid muscle.
Anginae in blood diseases are the first sign of leukaemia, aleukia and agranulocytosis,
because a change in the differential blood count leads to a loss of the phagocyte activity
and an intensified activity of microbes in the oral cavity and tonsils. The course of this
angina is severe, often it is of a necrotic character. Blood analysis makes it possible to
diagnose the disease. It is treated at special haematological institutions.
Anginae in general infections. Angina is dangerous in diphtheria, as an inopportune
diagnosis is fraught with complications of diphtheria and the resultant lethal outcome.
Such anginae may be localized and generalized, and toxic or haemorrhagic by their
course.
Owing to its localization in the tonsils, Corinebacterium diphtheriae contributes to a
fibrinous inflammation with formation of films. Absorption of the toxoid into the blood
causes an imbibition oedema of the local tissues and those of the cervical fat; this toxoid
may penetrate to the myocardium and nervous tissue and, finally, an outcome of the
disease does not depend mainly upon the regression of angina, but the patient dies
because of its complications. Spreading of diphtheria in the pharynx may be of the
ascending (from the larynx) and descending (from the tonsil) types. It peculiarly differs in
its clinical picture and differential diagnosis from the common angina by such facts as:
 a pronounced intoxication,
 presence of an oedema (an oedema of the arches and uvula) involving the
cervical fatty tissue (degrees I – an oedema of half of the neck, II – an oedema to
the clavicle and III, an oedema below the clavicle),
 a smell from the mouth
 presence of grey patches on the tonsils which are removed with difficulty and
leave a bleeding surface. It is important that the patch may spread on the arches
and other parts of the pharynx.
Toxic diphtheria – swelling of Diphtheria of pharynx
cervical fatty tissue
The diagnosis is facilitated by a smear taken on the border of the patch and the intact
surface, then a native preparation is prepared from this smear (two hours later it reveals
Cotynebacteria diphtheriae) and. what is the most important here, the toxicity of this
bacterium is determined (during 2-3 days), therefore the antidiphtheritic therapy for such
patients is provided on the basis of the clinical picture even before the laboratory data are
ready: the patient is administered different doses of the serum and transported to the
infectious department in a special vehicle.
Angina in mononucleosis (monocytic angina) occurs in children and juveniles and is
more frequent among males. Its etiology is unknown; it may be a viral disease. It is
characterized by the following syndrome:
a) angina is more often necrotic;
b) an undulating fever during 2-3 weeks;
c) a spread adenopathy (both regional, axillary, ulnar, occipital and inguinal lymph nodes
are swollen);
d) the liver and spleen are enlarged; and, finally,
e) presence of a reduced amount of polynuclear cells and an increased number of
monocytes up to 40-60 % in the peripheral blood. The prognosis is favourable. The
treatment consists of antibiotics for preventing activity of the commonplace flora, a full diet,
vitamins, sedatives. A good effect is produced by corticosteroids that sharply reduce the
number of monocytes.

Vincent's angina. At first it was described by S.P. Botkin in St. Petersburg among poor
aborigines. Later it was studied in detail by N.F. Simanovsky and termed in Russia by his
name. It is caused in weakened persons by the symbiosis of the microbes (Spirocheta
buccalis and Bacillus fusiformis) living in the oral cavity. The clinical picture is characterized
by a unilateral process (appearance of an ulcer on the tonsil surrounded with normal edges),
the general state is not affected (the body temperature is normal or subfebrile). Ihe ulcer is
covered with some grey-dingy patch and may spread from the tonsils to other organs (the
arches, tongue, pharynx). There is swelling of the regional lymph nodes on the affected side
and presence of a foul smell from the mouth. The disease should be differentiated from
diphtheria, syphilis and palatine cancer. The prognosis is favourable.
 Vincent’s angina
Acute pharyngitis is a diffuse inflammation of the pharyngeal mucosa and granules
of the lymphoid tissue located in its submucosal layer. The disease is most
frequently caused by a viral infection (such as adenoviruses or other respiratory
viruses) when the local protective mechanisms of the pharynx are weakened owing
to abnormalities in the nasal breathing (deviation of the nasal septum, hypertrophic
rhinitis, nasal polyps, adenoids, etc.) and the patient has to breath through his
mouth. Supercooling and other environmental factors (dust, vapours, gases,
radionuclides) play their part too. It is clinically manifested by appearance of some
discomfort in the pharynx (sensations of tickling, burning, presence of a foreign
body, coughing), as well as pains in the process of swallowing (dysphagia). Unlike
cases with chronic pharyngitis, the pains may be felt both "on an empty swallow"
and during eating (swallowing of food). Pharyngoscopy may demonstrate a
general hyperemia of the mucous membrane on the posterior pharyngeal
wall, an increased secretion, small red inflamed granules of the tissue
lymphocytes, thickening of the lateral tori. The treatment consists of a diet that
does not irritate the pharynx (exclusion of spicy dishes, alcohol, too hot or cold
food, smoking), various gargles (solutions of calendula [Calendula officinalis L.],
inatricary \Matricaria L.], chlorophyllipt, ectericide), sucking of decamethoxin
under the tongue 4-5 times a day, painting of the pharynx with iodine glycerol,
inhalations of antibiotics, sodium thiosulfate, urea If the general state is affected
(elevation of the body temperature, weakness, intoxication), it is necessary to
administer oral antibiotics, sulfanilamides and interferon.

Acute pharyngitis – the redness of the posterior wall of pharynx

Acute pharyngitis - small red inflamed granules of the tissue lymphocytes,

thickening of the lateral tori