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Common Infections of the Pharynx and Fauces
COMMON INFECTIONS OF THE PHARYNX AND FAUCES HARRY
P. SCHENCK, M.D., F.A.C.S. ~
IT is appropriate that we first consider a few abnormalities of the lymph tissue because this tissue is the Achilles' heel of the anatomic structures of the pharynx and fauces. While it is true that infection must first breach the mucous membrane in order to reach the lymphatic tissue, nevertheless it is in the lymphatic structures that infection becomes perpetuated, from them infection spreads to other portions of the respiratory tract and other parts ·of the body, and they are the site of the most impressive pathologic change. Waldeyer's ring is composed of the pharyngeal, lingual, faucial and tubal tonsils as well as the innumerable lymph follicles incorporated throughout the pharyngeal walls. The pharynx and fauces therefore possess very nearly all of the lymph tissue of Waldeyer's ring. From the clinical viewpoint the fauces may be considered to be part of the pharynx; it merely serves to separate the oropharynx from the oral cavity. Neither acute nor chronic infections are strictly limited to individual units of Waldeyer's ring but because of the profusion of intercommunicating lymph channels they readily induce similar if lesser alterations in other parts of the ring. ACUTE INFLAMMATION OF THE LYMPHATIC STRUCTURES OF THE PHARYNX AND FAUCES
Acute inflammation is always generalized to some degree but the major involvement is confined to the pharyngeal tonsil (adenoid), the faucial tonsils and the lateral pharyngeal bands or the lingual tonsils. CASE I.-The first patient is a girl, twelve years of age. Her first symptoms appeared two days ago with a dry throat which soon became painful on swallowing. Within the first twenty-four hours she had two chills and her temperature reached 104.2 F. This was followed by marked malaise, headache, pain in the limbs, anorexia and otalgia. Her voice became mufHed and she expectorated tenacious, ropy mucus. Her tongue is coated, her breath fetid and the cervical glands are swollen, painful and tender. The entire pharynx is red and granular, and the tonsils are swollen to several times their normal size and are extremely hyperemic. Many tonsillar crypts contain plugs of yellow debris which in sonle areas spreads out to form a soft, yellow-white, adherent, friable membrane. Brushing of such a membranous area produces no bleeding. Slight pressure upon the anterior pillar of either tonsil expresses fluid pus from the crypts. Not only are the lateral pharyngeal bands red and swollen but the pharyngeal tonsil shows changes similar to those in the faucial tonsils when inspected by means of a postrhinoscopic mirror. 0
~ Professor of Ot~laryngology, University of Pennsylvania Medical School; Chief, Otolaryngological Service, Hospital of the University of Pennsylvania, Philadelphia.
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It is obvious that this patient is suffering an attack of acute lacunar tonsillitis. Other than to rule out diphtheria, the examination of smears will be of little diagnostic importance since hemolytic strepto· cocci will be found to predominate in overwhelming numbers in cultures and smears. The admixture of staphylococci, pneumococci and other bacteria is of little significance. Although with conservative treatment the majority of infections of the pharynx run a benign and self-limiting course, this patient is pre· sented in order that we may discuss some complications of this potentially dangerous disease as well as a few aspects of therapy. Aside from acute streptococcic laryngotracheitis, acute middle ear infections and mastoiditis, the commonest complications resulting from the spread of the infection into contiguous structures are periton.. sillar abscess, retropharyngeal abscess, abscess of the cervical glands and abscess of the pharyngomaxillary space. Dire consequences follow the dissemination of the infection by blood and lymph channels. Thus, acute infections of the pharynx appear to have been the direct precipitating factor in some instances of arthritis, rheumatic fever, chorea, acute serofibrinous pericarditis,] albuminuria,2 acute glomerulonephritis 3 and hematogenous peritonitis. 4 Clinicians are agreed that treatment should b'e begun at the earliest possible moment. Rest in bed is imperative to minimize the ·complications which we have outlined. The pain is controlled by 5 grain doses of salicylates or phenacetin every three hours and these may be reinforced by small doses of the barbiturates. The application of 50 per cent solution of silver nitrate to the crypt-bearing surfaces of the faucial tonsils appears to have great value whether chemotherapy is being employed or not. Care of course must be observed to apply the silver nitrate solution only upon the involved areas and especially to prevent material on the applicator from dropping into the laryngeal structures. Silver nitrate applied to the pharyngeal wall itself is of little or no value. Throat irrigations every two or three hours should be as hot as can be borne and at least 2 quarts of normal saline and sodium bicarbonate solution should be used for each irrigation. Steam inhalations of compound tincture of benzoin, one teaspoonful (4 ce.) to a container of water kept boiling at the bedside, relieve the annoying dryness of the mucous membranes. The local use of sulfonamides is of doubtful value. Sulfathiazole or sulfadiazine powder may be blown upon the inflamed areas with a powder blower but systemic use is of far more value. Systemic therapy is reserved for severe infections. Because of its lesser toxicity, sulfadiazine is preferred. Adults are given an average dose of 15 grains (1 gm.) every four hours until the fever and symptoms subside. The dose is then gradually reduced until the drug is withdrawn. A
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teaspoonful (4 gm.) of sodium bicarbonate with each dose of sulfadiazine alkalinizes the urine and minimizes the precipitation. of crystals in the urinary tract. Sufficient fluids must be given to obtain a minimum output of 1000 cc. of urine in twenty-four hours. In children the drug is eliminated more rapidly so that a relatively higher dose of 1 % grains (0..1 gm.) per pound of body weight per day is advisable. All sulfonamide therapy should be controlled by white blood cell count and urinalysis before and during the course of treatment. The appearance of hematuria, leukopenia, skin rashes, mental confusion, headache, nausea or vomiting requires the immediate with·drawal of the drug. Since the drug itself may produce hyperpyrexia, withdrawal is indicated when fever does not subside within forty-eight hours or upon the appearance of a high fever after the fifth day of medication. For overwhelming infections large doses of penicillin parenterally (100,000 units every hour) are used concurrently with the sulfonamide. Intramuscular administration of pencillin is far more effective than oral use or lozenges, but the latter may be used where expense is not a factor. . CHRONIC TONSILLAR AND ADENOID INFECTIONS
These infections are usually unaccompanied by local symptoms. Vague burning, scratchiness or soreness of the throat with a feeling of a foreign body may be noted but the patient is usually unaware of the abnormal changes. Primarily, the infection is centered in the lymph follicles of Waldeyer's ring and these show hyperplasia and chronic inflammation when examined histologically. Abnormal appearance of the lymph follicles, per se, is not adequate evidence that chronic infection is present or that systemic disease must result. Hodgkin's disease and blood dyscrasias produce not only general manifestations but alterations in lymphatic structures as well. Aller.gic children may present marked changes in the structures of Waldeyer's ring due to the edema and eosinophilic infiltration of allergy. Biopsy specimens of such follicles would identify the nature of the change and assure prompt allergic investigation and treatrnent. Patients with obscure conditions attributable to focal infection often exhibit no demonstrable focus other than chronic pharyngeal or tonsillar infection. The constant presence of enlarged nodes in the superficial cervical chain is significant. Drainage from the ethmoidal and sphenoidal sinuses or secretions from the lower respiratory tract, driven upward by forceful coughing, frequently infect and reinfect the lymph tissue of the pharynx. When other foci are missing, the frequency with which chronic infection of the pharynx is observed in individuals with presenting symptoms of rheumatism, chorea, arthritis, myositis, nephrosis, neuritis or chronic myocardial diseases appears to be more than mere coincidence. Whether the pharyngeal
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changes are primary or secondary is sometimes debatable. That they may be primary is suggested by the frequent observation that symptoms which disappear after tonsillectomy often return as the extratonsillar tissue in turn becomes infected and hyperplastic, that exacerbations of chronic systemic manifestations commonly follow or coincide with acute infection in the pharynx; and that infection and hyperplasia of pharyngeal lymph follicles may occur without apparent involvement of the faucial tonsils. CASE II.-This young lady is now 18 years of age and a student. Ten years ago she was seized with a febrile illness which continued unabated for seven months. There was severe anemia. Prostration and the appearance of cardiac murmurs made the prognosis doubtful. Her tonsils and adenoids had been removed at the age of 5 years. Much residual tonsillar tissue remained at the base of each fossa and the pharyngeal follicles were red, projecting from the surface and peppered with yellow-white pinpoint areas. At that time the chemotherapeutic drugs \vere not in use. As usual, all local therapy was ineffective. The tonsil remnants \vere removed and later the pharyngeal follicles were electrocoagulated very cautiously because a febrile response accompanied each treatment. Eventually the patient became afebrile and the cardiac murmurs disappeared. As you can see, she is a perfectly normal and healthy young lady today.
It is important to point out that only one' or two follicles should be treated by electrocoagulation at one sitting and there should be an interval of ten days to two weeks between each sitting. I am convinced that the recovery of this patient was due to control of her pharyngeal infection. Should her symptoms reappear one would suspect either a new focus or a recurrence of infection in Waldeyer~s ring. Deafness is an important result of chronic infection of the pharynx. Drastic hearing loss may reach tragic proportions unless early intervention occurs in the case of children. The discovery that irradiation affects the germinal follicles of the lymph tissue of the pharynx and eustachian tubes has resulted in the restoration of hearing in many subjects of school age. CASE III.-This boy of 8 years now has normal hearing. Two years ago he was listless and unable to compete with his schoolmates either in sports or in studies. He was examined by a school physician because his teacher suspected a hearing loss which had gone unnoticed by his family. Audiometer examination revealed a bilateral hearing loss of 37 decibels per cent in the speech range in the right ear and 39 decibels per cent in the left ear. Following the application of radium to the nasopharynx there was a gradual improvement in his hearing until six months later the hearing was normal in both ears and has remained within normal lirpits until today.
Irradiation of the nasopharynx with radium or radon is effective only in the treatment of conductive deafness due to obstruction of the pharyngeal end of the eustachian tube by lymphoid tissue. It is of no value in other forms of deafness. As developed by Crowe and Bord-
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ley5 the technic is safe and effective. A series of three irradiations are spaced two weeks apart. The dose is calculated at 25,000 milligram seconds for the standard monel Army applicator or 17,000 millicurie seconds for the stainless steel radon gas applicator made by the Kelly Clinic. The applicators are simply inserted along ~he floor of the nostril into the nasopharynx in close proximity to the eustachian orifice and permitted to remain for the calculated period of time. Adults have not shown great improvement with this form of therapy, the satisfactory results having been obtained almost exclusively in children. Formerly the removal of chronically diseased adenoids and tonsils was the sole means of combating chronic involvement of Waldeyer's ring. Irradiation and the meticulous use of electrocoagulation now permit positive intervention in the case of extratonsillar lymphoid tissue. VINCENT'S ANGINA OR FUSOSPIROCHETAL PHARYNGITIS
Vincent's angina is characterized by areas of inflammation in the pharynx which first ulcerqte and later become covered with a pseudomembrane. The lesions are the site of symbiotic growth of a fusiform bacillus and a characteristic spirochete, and the appearance of stained smears varies widely. Thus from lesions in the soft tissues of the pharynx or fauces there is a predominance of spirilla forms while from gingival lesions the rod forms predominate. v
IV.-This patient is presented because he has had ulceration due to Vincent's organisms in an unusual location, namely in the pharyngeal tonsil or adenoid. He is 18 years old. Two weeks ago he noticed a vague discomfort upon swallowing and a foul-smelling discharge from both nostrils. There was only slight nasal obstruction. Later there were occasional twinges of pain in either ear. He was referred to the clinic because of a constant temperature ranging from 100 to 100.8 F. and the suspicion that he was suffering from an acute sinus infection. Both the clinical and the x-ray examinations however indicated that the sinuses were entirely normal. His tonsils were surgically absent but there were swollen nodes in the superficial cervical chain under the angle of either jaw. While there was some edema of the soft palate, the oropharynx was only slightly injected. Examination with a nasopharyngoscope revealed the adenoid tissues to be ulcerated and covered with false membrane. Examination of smears from the ulcerated areas revealed numerous spirilla of Vincent and some rod forms. His treatment was complicated by the fact that he was known to exhibit sen.. sitization phenomena when receiving penicillin or sulfadiazine. Five per cent neoarsphenamine in glycerine was therefore used locally. The drug was applied with a cotton wound applicator passed through one nostril while its position was noted through a nasopharyngoscope passed through the opposite nostril. Applications were made three times a day. The local treatment was begun five days ago and two days later his temperature became normal and has remained so. Inspection of the adenoid tissue through the nasoscope shows almost complete disappearance of the lesions. CASE
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Vincent's angina is usually confined to one tonsil or to one side of the pharynx but it tends to spread widely and death from sepsis and secondary infection has been known to occur in untreated· cases. The lualignant or recurrent forms associated with leukemia are almost invariably fatal. The gradual onset with dryness and soreness in the region of the lesion is followed by pain on swallowing, otalgia and swelling of the cervical nodes. Mental lassitude and depression accompany the fever, although the temperature rarely exceeds 100° to 102°F. The breath has a characteristically foul odor and the patient usually.complains of a disagreeable taste. Demonstration of the two organisms in smears stained by Gram's method confirms the diagnosis. Differentiation is made from diphtheria by the successful culture of Klebs-Loeffier bacilli, from syphilis by the history 'and a positive Wassermann reaction, from tuberculosis by the presence of associated lesions elsewhere and from malignancy by biopsy examination. The effectiveness of neoarsphenamine solutions in glycerine in the treatment of the lesions of Vincenfs angina depends upon the application of the drug to every accessible crevice. In intractable cases neo.. ar~phenamine should be used intravenously. Frequent irrigation of the infected areas should also be carried out. For this purpose sodium perborate (2 teaspoonfuls to a glass of water) is probably the best drug although hydrogen peroxide solution is a good substitute. Penicillin has been found to be the most effective drug for the management of Vincent's infections. Usually both local and parenteral administration is required in malignant cases. The lesions are sprayed with a solution containing 250 to 500 units of the drug, preferably at three-hour intervals. During the waking hours about 100,000 units of penicillin are administered .in the form of gum or lozenges. Ten slowly dissolving lozenges, each containing 10,000 units of penicillin, are used during the day at two-hour intervals. If necessary, parenteral penicillin should be used in addition and at times the sulfonamides may be useful in combating secondary infection. With penicillin therapy, however, the patient is usually free of pain and discomfort in forty-eight hours, the smears become negative in forty-eight to 120 hours and the ulcers heal in five to seven days. RETROPHARYNGEAL ABSCESS V.-This little girl is 5 years old and has been ill for five days. Two weeks ago she had a severe upper respiratory infection. As she lies in her crib she holds her head in extension and there is an inspiratory and an expiratory stridor. The latter is more marked when she sleeps. She is pallid and restless. Her present temperature is 104.5° F. The cervical lymph nodes On both sides of the neck are swollen but the greater swelling is on the left side. Because of the nasal obstroction, difficult respiration, position of the head, fever and the swollen cervical glands we suspect she has a retropharyngeal abscess. The posterior wall of the pharynx is seen to be congested and bulging forward. CASE
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The mass is soft, tender and is fluctuant when palpated. The x-ray film shows an increased space between the pharynx and the vertebrae. If there were a fluid level in the abscess cavity air bubbles might show above the fluid level but no fluid level shows here.
'rhis child is in danger of suffocation because of the great size of the swelling and also because of the possibility of extension of the edenla to the larynx. If we delay so that spontaneous rupture occurs she may suffocate by the aspiration of blood and pus. Delay may also permit the spread of infection to the pharyngomaxillary space, down the carotid sheath and to the posterior mediastinum. . At this stage of her infection we. are faced with a real emergency and we will therefore incise the abscess and evacuate the pus at once. We need no anesthesia. The child is being wrapped in a sheet and placed on this table in a head-low position with the head extended over the edge of the table. I am now testing this large suction tip to make certain that it is functioning properly. The incision is made at the point of greatest fluctuation and is about an inch in length. A gush of pus fills the throat and oral cavity and the importance of the suction tip is now apparent. It immediately removes the secretions before they can be aspirated and cause respiratory obstruction. As I dilate the wound with a hemostat there is a further gush of pus. The child is now breathing comfortably and is out of danger for the present. Such acute forms of retropharyngeal abscess follow suppuration of the retropharyngeal lymph nodes· and occur almost exclusively in in.. fants and children. Adults are rarely afflicted because the retropharyn.. geal lymph nodes generally atrophy before adult life is reached. The sulfonamides or antibiotics are rarely helpful because the abscess is usually well advanced before the patient comes under observation and only surgical drainage can be effective. Some abscesses might be prevented by early chemotherapy before actual pus is present. Since the retropharyngeal lymph nodes receive lymph drainage .from the nose and sinuses, the upper portion of the nasopharynx, the eustachian tube and the tympanum, attention to and control of these primary sources of infection is the best prophylaxis. PERITONSILLAR, ABSCESS CASE VI.-This man is 23 years of age and has a peritonsillar abscess. The initial localized infection in the right faucial tonsil probably extended through the capsule and has gone on to abscess formation and there is now a collection of pus in the connective tissue of the bed of the faucial tonsil. He has had four similar attacks in the past three years and he must now be impressed with the importance of tonsillectomy in a few months to forestall future attacks. The first throat discomfort occurred four days ago and since that time he has had constant pain on the right side of his throat and in the right ear. The act of swallowing is now difficult and painful and he is able to open his mouth only 3 fraction of an inch. His voice is characteristically mufHed as he tries to answer
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questions. As he attempts to swallow water from this glass the fluid regurgitates into his nose. His temperature ranges from 101 to 103 F. Headaches and pain in his back and limbs add to his discomforts. He has had no bowel movement for ' three days and has no desire for food. 0
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It is with great difficulty that we open the patient's mouth with a metal tongue depressor so that the fauces may be inspected. Th~ right tonsil is red, pushed downward, forward and mesially and the soft palate and uvula are red and edematous, and pushed to the left. The tongue is coated and there is marked fetor of the breath. The patient bends his head to the affected side and holds it there. There are several tender, palpable nodes beneath the angle of the right jaw. Incision of such an abscess before suppuration has localized merely results in prolonging the course. We know that the abscess is attempting to rupture by pointing because definite fluctuation can be felt. Drainage of the pus, which we know to be present, should be established at once. We will not use anesthesia because the tension of the swelling has rendered the superficial tissues relatively insensitive. If anesthesia is used it should be limited to topical applications of such anesthetic solutions as 20 per cent cocaine hydrochloride or pontocaine. It is extremely dangerous to use local anesthetics by injection because of the resulting spread of infection and the frequency with which pulmonary abscess follows such attempts. General anesthesia is equally if not more dangerous because of sudden asphyxia and the facility with which aspiration occurs. A straight bistoury is selected and the blade wrapped with several turns of adhesive fape about 1 em. from the tip. This prevents going too deeply and yet permits a stab incision to be made followed by a quick slash downward. I will now incise the abscess at its point of greatest prominence and where' it is- soft on palpation. There is a gush of thick yellow pus mixed with blood and free bleeding follows. More pus appears as a curved Kelly hemostat is inserted between the wound margins and they are separated. The patient's expression indicates the degree of relief obtained. The bleeding will continue for a few minutes but will subside spontaneously. The incision may be separated with a hemostat within twelve to twenty-four hours if we suspect that drainage is incomplete. A sulfonamide or penicillin will abort most infections leading to such abscesses provided that treatment is begun within twenty-four to forty-eight hours after the first symptoms are noted, but incision and drainage alone are effective once fluctuation occurs. Once pus is present, chemotherapy merely prolongs the course and the infection becomes active as soon as chemotherapy is withdrawn. After drainage is established, chemotherapy is unnecessary but may serve a useful purpose in facilitating healing and shortening the period of convalescence.
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DIPHTHERIA
The most frequent primary site of diphtheria or Klebs-LoefBer bacil.. Ius infection is the pharynx. Primary infections, however, may occur in the nose or larynx and later extend to the pharynx and fauces. It has been shown statistically that chronic foci of infection in the oropharynx and nasopharynx will increase the slisc:eptibility of an individual to diphtheria. 6 At onset the illness is most frequently ascribed to "ton· sillitis" and occasionally the anterior pillar has actually been incised in an effort to drain a nonexistent peritonsillar abscess. CASE VII.-The patient before us now is a man 22 years of age. Five weeks ago he noticed a slight sore throat which increased in severity until he consulted a physician three days after the onset. A smear and cultures were taken and t\venty-four hours later (four days after the first symptoms were noted) a diagnosis of Klebs-Loeffier infection was made. He was immediately given adequate doses of antitoxin. Recovery from his .infection was prompt. Yesterday he experienced some speech difficulty. When he was examined in the clinic it was found that the uvula and the median raphe of the palate deviated to the right or norma] side. If you will now elicit his gag reflex by using a tongue depressor you will note that the posterior wall of the pharynx makes a rapid movement to the right and then partly disappears under the right posterior ar.ch and lateral ligament. No other palsies have been found. This man shows a postdiphtheritic, unilateral paresis of the pharyngeal constrictors. He will probably recover from the paresis in a matter of weeks and should now be reassured of the outcome.
Diphtheritic infection of the pharynx follows an incubation period of two to four days. The gradual onset with sore throat, slight fever, chills and general malaise is soon followed by a red pharynx and pain and difficulty in swallowing. The most important symptom is profound prostration out of all proportion to the temperature elevation. With the appearance of a confluent, adherent membrane, dirty gray in color and with well defined margins, all that should be necessary for a conclusive diagnosis is bacteriological confirmation. Extensiop to the nostrils produces nasal obstruction, a sanguineous purulent discharge with foul odor and especially severe lymph node involvement. Involvement of the larynx produces first hoarseness, later a croupy cough and finally cyanosis and continuous dyspnea. Death may occur from laryngeal obstruction. The diagnosis can be confirmed only by the finding of Klebs-Loeffier bacilli in cultures grown on LoefHer's medium for at least eighteen hours. Early specific therapy, however, is justified on the basis of smears, prostration out of proportion to the fever and the presence of a dirty gray membrane in the throat. Attempts at removal of the adherent membrane leave a denudep, bleeding area and the residual membrane is apt to become yellow or black as accumulated coagulated blood forms beneath it. Enlarged, tender lymph nodes appear at the angle of the jaw and in the anterior cervical region. The temperature rarely
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exceeds 102 0 F. while the pulse rate ranges from 100 to 120 beats per minute. The Shick test is positive. While clinicians are alert to the incidence of diphtheritic infection in children, they are frequently loath to make an early diagnosis in adults although in the United States 10 per cent of the adult population are Shick positive and presumably susceptible to diphtheria. A differential diagnosis must be made between diphtheria, acute follicular tonsillitis, membranous pharyngitis, Vincent's angina, syphilis and keratoses. Acute follicular tonsillitis is most frequently confused with Klebs-LoefBer bacillus infection. In the former no diphtheria bacilli are found on culture and the temperature reaches the higher levels of 104 0 to 105 0 F.; the tonsils are injected and swollen, with exudate limited to the tonsil and its crypts. The removal of this exudate does not leave a bleeding surface. Cough is rarely present and then is not croupy in character. Paralytic Phenomena.-Paralytic phenomena appear in 10 per cent of patients acquiring diphtheria. in temperate climates. First appearing two or three weeks after the onset of infection, diphtheritic paralysis tends to be limited to the cranial nerves, but involvement of the extremities may predominate or both may be affected. The lower extremities are more often affected than the upper. Next most frequently attacked are the ocular nerves, especi,ally those distributed to the ciliary muscles. This produces paralysis of accommodation with preservation of the pupillary reflex. Inequality of the pupils, diplopia, strabismus and ptosis are not uncommon findings. As a rule, paralysis begins in and is limited to the uvula and the palatal muscles. It is first recognized by the appearance of nasal speech and the regurgitation of fluid through the nose. This is a flaccid paralysis; the insensitive soft palate and uvula do not move. Normally, the uvula moves in its midposition when the mouth is opened. In unilateral paralysis, the uvula or the median raphe of the palate deviate to the normal side; in bilateral paralysis, the uvula hangs in the midposition and does not move when the mouth is opened. If there is unilateral paresis of the pharyngeal constrictors, such as we have noted in the patient in Case VII, the posterior wall of the pharynx makes a rapid movement to the normal side and partly disappears under the posterior arch and lateral ligament of the normal side. Involvement of the bulbar nerves produces not only paralysis of the laryngeal and pharyngeal muscles but also either partial or complete anesthesia of the mucous membrane. Paralysis of one or both vocal cords or inability to close the glottis should be suspected with the appearance of aphonia, hoarseness or dysphagia. Death from aspiration pneumonia follows paralysis of the glottis. The prognosis is always poor when the bulbar nerves are involved. The facial muscles and tongue are rarely involved but when they are,
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the facial expression is lost and the tongue shows a variety of changes, chief among whicll are deviation from the midline, tremor, atrophy and impairment of taste sensation in the posterior third. More rarely, the neck muscles are involved and then the head falls helplessly npon the shoulders. The prognosis is grave when tachycardia due to paralysis of the vagus appears. Dyspnea follows involvement of the phrenic nerve, becoming especially severe when both phrenic nerves are paralyzed. Exodus follows paralysis of the vagus and of the phrenic nerves. The general polyneuritis of diphtheria simulates pseudotabes and may progress to complete paralysis of the lower extremities. Usually the lower extremities are first and most extensively involved, becoming paretic, ataxic, with loss of deep reflexes and steppage gait. Footdrop and impairment of all forms of sensation rapidly follow. Although the paralysis of the extremities appears later than that of the palatal and pharyngeal muscles it persists for weeks or months after the palatal and pharyngeal involvement has disappeared. Treatment.-The only specific remedy is diphtheria antitoxin. It is necessary to test the sensitivity of the patient before using the horse serum containing the antitoxin. If a wheal develops when a minute amount of serum is injeGted into the skin the patient is sensitive to horse serum and goat serum containing antitoxin must be used. Epinephrine in 1: 1000 solution should be at hand in case of severe reactions to serum, especially edema of the glottis with asphyxia. If the test dose produces no reaction, full therapeutic doses should follow. The doses may vary from 5000 units in mild infections to 50,000 units in severe infections or 100,000 units or more in malignant forms. While intramuscular injection into the upper gluteal region is the usual route, the intravenous route may be advisable in severe infection. The administration of antitoxin begun three to four days after the onset of throat symptoms is ineffectual in preventing paralysis because the diphtheria toxin becomes fixed in the nervous system early in the course of the disease and can then no longer be neutralized by antitoxin. Rest in bed is imperative for the minimization of heart involvement and also protects the peripheral nerves to some extent. The introduction of penicillin and other chemotherapeutic drugs has not eliminated the necessity of .administering adequate doses of antitoxin. Penicillin will not neutralize the toxin or affect the rate of clearance of th~ membrane but it do~es redu~~ the incidence of complications, especially clinical myocardial involvement. In sufficiently large doses, penicillin shortens the duration of both the convalescent and chronic diphtheria carrier states. Doses of 120,000 to 240,000 units of penicillin per day for twelve days are advisable in acute diphtheria while the treatment of the chronic diphtheria state requires a minimum of 240,000 units per day for twelve days.
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REFERENCES 1. Wilkins, F. A.: Clinic on Acute Serofibrinous Pericarditis Secondary to Acute
Pharyngitis. Proc. Staff Meet., Mayo Clin., 9:637 (Oct. 17) 1934. 2. Merle, E.: Pensons toujours aux infections pharyngees chez nos albuminuriques. J. med. fran~., 19:396 (Oct. 30) 1934. de Wesselow, o. L. V. S., Goadby, H. K., and Derry, D. C. L.: Tonsillitis and Albuminuria. Brit. M. J., 1:1065 (May 25) 1935. 3. Seegal, B. C. and Lyttle, J. D.: The Nature of the Preceding Infection in Acute Glomerulonephritis in Two New York Hospitals and in Four Southern Hospitals. J.A.M.A., 105:17 (July 6) 1935. .4. Felsen, ]. and Osofsky, A. G.: Pharyngogenic Hematogenous Streptococcic Peritonitis. Arch. Surg., 31 :437 (Sept.) 1935. 5. Bordley, J.. E.: The Use of -Radium in the Treatment of Conduction Deafness. Surg., Gynec. & Obst., 84:839 (April 15) 1947. 6. Norris, R. F., Kern, R. A., Schenck, H. P. and Silcox, L. E.: Diphtheria in the Tropics; a Report of 18 Cases Seen on a U. S. Hospital Ship. U. S. Nav. M. Bull., 42:518 (March). 1944.
P. SCHENCK, M.D., F.A.C.S. ~
IT is appropriate that we first consider a few abnormalities of the lymph tissue because this tissue is the Achilles' heel of the anatomic structures of the pharynx and fauces. While it is true that infection must first breach the mucous membrane in order to reach the lymphatic tissue, nevertheless it is in the lymphatic structures that infection becomes perpetuated, from them infection spreads to other portions of the respiratory tract and other parts ·of the body, and they are the site of the most impressive pathologic change. Waldeyer's ring is composed of the pharyngeal, lingual, faucial and tubal tonsils as well as the innumerable lymph follicles incorporated throughout the pharyngeal walls. The pharynx and fauces therefore possess very nearly all of the lymph tissue of Waldeyer's ring. From the clinical viewpoint the fauces may be considered to be part of the pharynx; it merely serves to separate the oropharynx from the oral cavity. Neither acute nor chronic infections are strictly limited to individual units of Waldeyer's ring but because of the profusion of intercommunicating lymph channels they readily induce similar if lesser alterations in other parts of the ring. ACUTE INFLAMMATION OF THE LYMPHATIC STRUCTURES OF THE PHARYNX AND FAUCES
Acute inflammation is always generalized to some degree but the major involvement is confined to the pharyngeal tonsil (adenoid), the faucial tonsils and the lateral pharyngeal bands or the lingual tonsils. CASE I.-The first patient is a girl, twelve years of age. Her first symptoms appeared two days ago with a dry throat which soon became painful on swallowing. Within the first twenty-four hours she had two chills and her temperature reached 104.2 F. This was followed by marked malaise, headache, pain in the limbs, anorexia and otalgia. Her voice became mufHed and she expectorated tenacious, ropy mucus. Her tongue is coated, her breath fetid and the cervical glands are swollen, painful and tender. The entire pharynx is red and granular, and the tonsils are swollen to several times their normal size and are extremely hyperemic. Many tonsillar crypts contain plugs of yellow debris which in sonle areas spreads out to form a soft, yellow-white, adherent, friable membrane. Brushing of such a membranous area produces no bleeding. Slight pressure upon the anterior pillar of either tonsil expresses fluid pus from the crypts. Not only are the lateral pharyngeal bands red and swollen but the pharyngeal tonsil shows changes similar to those in the faucial tonsils when inspected by means of a postrhinoscopic mirror. 0
~ Professor of Ot~laryngology, University of Pennsylvania Medical School; Chief, Otolaryngological Service, Hospital of the University of Pennsylvania, Philadelphia.
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COMMON INFECTIONS OF THE PHARYNX AND FAUCES
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It is obvious that this patient is suffering an attack of acute lacunar tonsillitis. Other than to rule out diphtheria, the examination of smears will be of little diagnostic importance since hemolytic strepto· cocci will be found to predominate in overwhelming numbers in cultures and smears. The admixture of staphylococci, pneumococci and other bacteria is of little significance. Although with conservative treatment the majority of infections of the pharynx run a benign and self-limiting course, this patient is pre· sented in order that we may discuss some complications of this potentially dangerous disease as well as a few aspects of therapy. Aside from acute streptococcic laryngotracheitis, acute middle ear infections and mastoiditis, the commonest complications resulting from the spread of the infection into contiguous structures are periton.. sillar abscess, retropharyngeal abscess, abscess of the cervical glands and abscess of the pharyngomaxillary space. Dire consequences follow the dissemination of the infection by blood and lymph channels. Thus, acute infections of the pharynx appear to have been the direct precipitating factor in some instances of arthritis, rheumatic fever, chorea, acute serofibrinous pericarditis,] albuminuria,2 acute glomerulonephritis 3 and hematogenous peritonitis. 4 Clinicians are agreed that treatment should b'e begun at the earliest possible moment. Rest in bed is imperative to minimize the ·complications which we have outlined. The pain is controlled by 5 grain doses of salicylates or phenacetin every three hours and these may be reinforced by small doses of the barbiturates. The application of 50 per cent solution of silver nitrate to the crypt-bearing surfaces of the faucial tonsils appears to have great value whether chemotherapy is being employed or not. Care of course must be observed to apply the silver nitrate solution only upon the involved areas and especially to prevent material on the applicator from dropping into the laryngeal structures. Silver nitrate applied to the pharyngeal wall itself is of little or no value. Throat irrigations every two or three hours should be as hot as can be borne and at least 2 quarts of normal saline and sodium bicarbonate solution should be used for each irrigation. Steam inhalations of compound tincture of benzoin, one teaspoonful (4 ce.) to a container of water kept boiling at the bedside, relieve the annoying dryness of the mucous membranes. The local use of sulfonamides is of doubtful value. Sulfathiazole or sulfadiazine powder may be blown upon the inflamed areas with a powder blower but systemic use is of far more value. Systemic therapy is reserved for severe infections. Because of its lesser toxicity, sulfadiazine is preferred. Adults are given an average dose of 15 grains (1 gm.) every four hours until the fever and symptoms subside. The dose is then gradually reduced until the drug is withdrawn. A
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HARRY P. SCHENCK
teaspoonful (4 gm.) of sodium bicarbonate with each dose of sulfadiazine alkalinizes the urine and minimizes the precipitation. of crystals in the urinary tract. Sufficient fluids must be given to obtain a minimum output of 1000 cc. of urine in twenty-four hours. In children the drug is eliminated more rapidly so that a relatively higher dose of 1 % grains (0..1 gm.) per pound of body weight per day is advisable. All sulfonamide therapy should be controlled by white blood cell count and urinalysis before and during the course of treatment. The appearance of hematuria, leukopenia, skin rashes, mental confusion, headache, nausea or vomiting requires the immediate with·drawal of the drug. Since the drug itself may produce hyperpyrexia, withdrawal is indicated when fever does not subside within forty-eight hours or upon the appearance of a high fever after the fifth day of medication. For overwhelming infections large doses of penicillin parenterally (100,000 units every hour) are used concurrently with the sulfonamide. Intramuscular administration of pencillin is far more effective than oral use or lozenges, but the latter may be used where expense is not a factor. . CHRONIC TONSILLAR AND ADENOID INFECTIONS
These infections are usually unaccompanied by local symptoms. Vague burning, scratchiness or soreness of the throat with a feeling of a foreign body may be noted but the patient is usually unaware of the abnormal changes. Primarily, the infection is centered in the lymph follicles of Waldeyer's ring and these show hyperplasia and chronic inflammation when examined histologically. Abnormal appearance of the lymph follicles, per se, is not adequate evidence that chronic infection is present or that systemic disease must result. Hodgkin's disease and blood dyscrasias produce not only general manifestations but alterations in lymphatic structures as well. Aller.gic children may present marked changes in the structures of Waldeyer's ring due to the edema and eosinophilic infiltration of allergy. Biopsy specimens of such follicles would identify the nature of the change and assure prompt allergic investigation and treatrnent. Patients with obscure conditions attributable to focal infection often exhibit no demonstrable focus other than chronic pharyngeal or tonsillar infection. The constant presence of enlarged nodes in the superficial cervical chain is significant. Drainage from the ethmoidal and sphenoidal sinuses or secretions from the lower respiratory tract, driven upward by forceful coughing, frequently infect and reinfect the lymph tissue of the pharynx. When other foci are missing, the frequency with which chronic infection of the pharynx is observed in individuals with presenting symptoms of rheumatism, chorea, arthritis, myositis, nephrosis, neuritis or chronic myocardial diseases appears to be more than mere coincidence. Whether the pharyngeal
COMMQN INFECTIONS OF THE PHARYNX AND FAUCES
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changes are primary or secondary is sometimes debatable. That they may be primary is suggested by the frequent observation that symptoms which disappear after tonsillectomy often return as the extratonsillar tissue in turn becomes infected and hyperplastic, that exacerbations of chronic systemic manifestations commonly follow or coincide with acute infection in the pharynx; and that infection and hyperplasia of pharyngeal lymph follicles may occur without apparent involvement of the faucial tonsils. CASE II.-This young lady is now 18 years of age and a student. Ten years ago she was seized with a febrile illness which continued unabated for seven months. There was severe anemia. Prostration and the appearance of cardiac murmurs made the prognosis doubtful. Her tonsils and adenoids had been removed at the age of 5 years. Much residual tonsillar tissue remained at the base of each fossa and the pharyngeal follicles were red, projecting from the surface and peppered with yellow-white pinpoint areas. At that time the chemotherapeutic drugs \vere not in use. As usual, all local therapy was ineffective. The tonsil remnants \vere removed and later the pharyngeal follicles were electrocoagulated very cautiously because a febrile response accompanied each treatment. Eventually the patient became afebrile and the cardiac murmurs disappeared. As you can see, she is a perfectly normal and healthy young lady today.
It is important to point out that only one' or two follicles should be treated by electrocoagulation at one sitting and there should be an interval of ten days to two weeks between each sitting. I am convinced that the recovery of this patient was due to control of her pharyngeal infection. Should her symptoms reappear one would suspect either a new focus or a recurrence of infection in Waldeyer~s ring. Deafness is an important result of chronic infection of the pharynx. Drastic hearing loss may reach tragic proportions unless early intervention occurs in the case of children. The discovery that irradiation affects the germinal follicles of the lymph tissue of the pharynx and eustachian tubes has resulted in the restoration of hearing in many subjects of school age. CASE III.-This boy of 8 years now has normal hearing. Two years ago he was listless and unable to compete with his schoolmates either in sports or in studies. He was examined by a school physician because his teacher suspected a hearing loss which had gone unnoticed by his family. Audiometer examination revealed a bilateral hearing loss of 37 decibels per cent in the speech range in the right ear and 39 decibels per cent in the left ear. Following the application of radium to the nasopharynx there was a gradual improvement in his hearing until six months later the hearing was normal in both ears and has remained within normal lirpits until today.
Irradiation of the nasopharynx with radium or radon is effective only in the treatment of conductive deafness due to obstruction of the pharyngeal end of the eustachian tube by lymphoid tissue. It is of no value in other forms of deafness. As developed by Crowe and Bord-
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HARRY P. SCHENCK
ley5 the technic is safe and effective. A series of three irradiations are spaced two weeks apart. The dose is calculated at 25,000 milligram seconds for the standard monel Army applicator or 17,000 millicurie seconds for the stainless steel radon gas applicator made by the Kelly Clinic. The applicators are simply inserted along ~he floor of the nostril into the nasopharynx in close proximity to the eustachian orifice and permitted to remain for the calculated period of time. Adults have not shown great improvement with this form of therapy, the satisfactory results having been obtained almost exclusively in children. Formerly the removal of chronically diseased adenoids and tonsils was the sole means of combating chronic involvement of Waldeyer's ring. Irradiation and the meticulous use of electrocoagulation now permit positive intervention in the case of extratonsillar lymphoid tissue. VINCENT'S ANGINA OR FUSOSPIROCHETAL PHARYNGITIS
Vincent's angina is characterized by areas of inflammation in the pharynx which first ulcerqte and later become covered with a pseudomembrane. The lesions are the site of symbiotic growth of a fusiform bacillus and a characteristic spirochete, and the appearance of stained smears varies widely. Thus from lesions in the soft tissues of the pharynx or fauces there is a predominance of spirilla forms while from gingival lesions the rod forms predominate. v
IV.-This patient is presented because he has had ulceration due to Vincent's organisms in an unusual location, namely in the pharyngeal tonsil or adenoid. He is 18 years old. Two weeks ago he noticed a vague discomfort upon swallowing and a foul-smelling discharge from both nostrils. There was only slight nasal obstruction. Later there were occasional twinges of pain in either ear. He was referred to the clinic because of a constant temperature ranging from 100 to 100.8 F. and the suspicion that he was suffering from an acute sinus infection. Both the clinical and the x-ray examinations however indicated that the sinuses were entirely normal. His tonsils were surgically absent but there were swollen nodes in the superficial cervical chain under the angle of either jaw. While there was some edema of the soft palate, the oropharynx was only slightly injected. Examination with a nasopharyngoscope revealed the adenoid tissues to be ulcerated and covered with false membrane. Examination of smears from the ulcerated areas revealed numerous spirilla of Vincent and some rod forms. His treatment was complicated by the fact that he was known to exhibit sen.. sitization phenomena when receiving penicillin or sulfadiazine. Five per cent neoarsphenamine in glycerine was therefore used locally. The drug was applied with a cotton wound applicator passed through one nostril while its position was noted through a nasopharyngoscope passed through the opposite nostril. Applications were made three times a day. The local treatment was begun five days ago and two days later his temperature became normal and has remained so. Inspection of the adenoid tissue through the nasoscope shows almost complete disappearance of the lesions. CASE
0
0
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COMMON INFECl'IONS OF THE PHARYNX AND FAUCES
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Vincent's angina is usually confined to one tonsil or to one side of the pharynx but it tends to spread widely and death from sepsis and secondary infection has been known to occur in untreated· cases. The lualignant or recurrent forms associated with leukemia are almost invariably fatal. The gradual onset with dryness and soreness in the region of the lesion is followed by pain on swallowing, otalgia and swelling of the cervical nodes. Mental lassitude and depression accompany the fever, although the temperature rarely exceeds 100° to 102°F. The breath has a characteristically foul odor and the patient usually.complains of a disagreeable taste. Demonstration of the two organisms in smears stained by Gram's method confirms the diagnosis. Differentiation is made from diphtheria by the successful culture of Klebs-Loeffier bacilli, from syphilis by the history 'and a positive Wassermann reaction, from tuberculosis by the presence of associated lesions elsewhere and from malignancy by biopsy examination. The effectiveness of neoarsphenamine solutions in glycerine in the treatment of the lesions of Vincenfs angina depends upon the application of the drug to every accessible crevice. In intractable cases neo.. ar~phenamine should be used intravenously. Frequent irrigation of the infected areas should also be carried out. For this purpose sodium perborate (2 teaspoonfuls to a glass of water) is probably the best drug although hydrogen peroxide solution is a good substitute. Penicillin has been found to be the most effective drug for the management of Vincent's infections. Usually both local and parenteral administration is required in malignant cases. The lesions are sprayed with a solution containing 250 to 500 units of the drug, preferably at three-hour intervals. During the waking hours about 100,000 units of penicillin are administered .in the form of gum or lozenges. Ten slowly dissolving lozenges, each containing 10,000 units of penicillin, are used during the day at two-hour intervals. If necessary, parenteral penicillin should be used in addition and at times the sulfonamides may be useful in combating secondary infection. With penicillin therapy, however, the patient is usually free of pain and discomfort in forty-eight hours, the smears become negative in forty-eight to 120 hours and the ulcers heal in five to seven days. RETROPHARYNGEAL ABSCESS V.-This little girl is 5 years old and has been ill for five days. Two weeks ago she had a severe upper respiratory infection. As she lies in her crib she holds her head in extension and there is an inspiratory and an expiratory stridor. The latter is more marked when she sleeps. She is pallid and restless. Her present temperature is 104.5° F. The cervical lymph nodes On both sides of the neck are swollen but the greater swelling is on the left side. Because of the nasal obstroction, difficult respiration, position of the head, fever and the swollen cervical glands we suspect she has a retropharyngeal abscess. The posterior wall of the pharynx is seen to be congested and bulging forward. CASE
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HARRY P. SCHENCK
The mass is soft, tender and is fluctuant when palpated. The x-ray film shows an increased space between the pharynx and the vertebrae. If there were a fluid level in the abscess cavity air bubbles might show above the fluid level but no fluid level shows here.
'rhis child is in danger of suffocation because of the great size of the swelling and also because of the possibility of extension of the edenla to the larynx. If we delay so that spontaneous rupture occurs she may suffocate by the aspiration of blood and pus. Delay may also permit the spread of infection to the pharyngomaxillary space, down the carotid sheath and to the posterior mediastinum. . At this stage of her infection we. are faced with a real emergency and we will therefore incise the abscess and evacuate the pus at once. We need no anesthesia. The child is being wrapped in a sheet and placed on this table in a head-low position with the head extended over the edge of the table. I am now testing this large suction tip to make certain that it is functioning properly. The incision is made at the point of greatest fluctuation and is about an inch in length. A gush of pus fills the throat and oral cavity and the importance of the suction tip is now apparent. It immediately removes the secretions before they can be aspirated and cause respiratory obstruction. As I dilate the wound with a hemostat there is a further gush of pus. The child is now breathing comfortably and is out of danger for the present. Such acute forms of retropharyngeal abscess follow suppuration of the retropharyngeal lymph nodes· and occur almost exclusively in in.. fants and children. Adults are rarely afflicted because the retropharyn.. geal lymph nodes generally atrophy before adult life is reached. The sulfonamides or antibiotics are rarely helpful because the abscess is usually well advanced before the patient comes under observation and only surgical drainage can be effective. Some abscesses might be prevented by early chemotherapy before actual pus is present. Since the retropharyngeal lymph nodes receive lymph drainage .from the nose and sinuses, the upper portion of the nasopharynx, the eustachian tube and the tympanum, attention to and control of these primary sources of infection is the best prophylaxis. PERITONSILLAR, ABSCESS CASE VI.-This man is 23 years of age and has a peritonsillar abscess. The initial localized infection in the right faucial tonsil probably extended through the capsule and has gone on to abscess formation and there is now a collection of pus in the connective tissue of the bed of the faucial tonsil. He has had four similar attacks in the past three years and he must now be impressed with the importance of tonsillectomy in a few months to forestall future attacks. The first throat discomfort occurred four days ago and since that time he has had constant pain on the right side of his throat and in the right ear. The act of swallowing is now difficult and painful and he is able to open his mouth only 3 fraction of an inch. His voice is characteristically mufHed as he tries to answer
COMMON INFECTIONS OF THE PHARYNX AND FAUCES
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questions. As he attempts to swallow water from this glass the fluid regurgitates into his nose. His temperature ranges from 101 to 103 F. Headaches and pain in his back and limbs add to his discomforts. He has had no bowel movement for ' three days and has no desire for food. 0
0
It is with great difficulty that we open the patient's mouth with a metal tongue depressor so that the fauces may be inspected. Th~ right tonsil is red, pushed downward, forward and mesially and the soft palate and uvula are red and edematous, and pushed to the left. The tongue is coated and there is marked fetor of the breath. The patient bends his head to the affected side and holds it there. There are several tender, palpable nodes beneath the angle of the right jaw. Incision of such an abscess before suppuration has localized merely results in prolonging the course. We know that the abscess is attempting to rupture by pointing because definite fluctuation can be felt. Drainage of the pus, which we know to be present, should be established at once. We will not use anesthesia because the tension of the swelling has rendered the superficial tissues relatively insensitive. If anesthesia is used it should be limited to topical applications of such anesthetic solutions as 20 per cent cocaine hydrochloride or pontocaine. It is extremely dangerous to use local anesthetics by injection because of the resulting spread of infection and the frequency with which pulmonary abscess follows such attempts. General anesthesia is equally if not more dangerous because of sudden asphyxia and the facility with which aspiration occurs. A straight bistoury is selected and the blade wrapped with several turns of adhesive fape about 1 em. from the tip. This prevents going too deeply and yet permits a stab incision to be made followed by a quick slash downward. I will now incise the abscess at its point of greatest prominence and where' it is- soft on palpation. There is a gush of thick yellow pus mixed with blood and free bleeding follows. More pus appears as a curved Kelly hemostat is inserted between the wound margins and they are separated. The patient's expression indicates the degree of relief obtained. The bleeding will continue for a few minutes but will subside spontaneously. The incision may be separated with a hemostat within twelve to twenty-four hours if we suspect that drainage is incomplete. A sulfonamide or penicillin will abort most infections leading to such abscesses provided that treatment is begun within twenty-four to forty-eight hours after the first symptoms are noted, but incision and drainage alone are effective once fluctuation occurs. Once pus is present, chemotherapy merely prolongs the course and the infection becomes active as soon as chemotherapy is withdrawn. After drainage is established, chemotherapy is unnecessary but may serve a useful purpose in facilitating healing and shortening the period of convalescence.
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HARRY P. SCHENCK
DIPHTHERIA
The most frequent primary site of diphtheria or Klebs-LoefBer bacil.. Ius infection is the pharynx. Primary infections, however, may occur in the nose or larynx and later extend to the pharynx and fauces. It has been shown statistically that chronic foci of infection in the oropharynx and nasopharynx will increase the slisc:eptibility of an individual to diphtheria. 6 At onset the illness is most frequently ascribed to "ton· sillitis" and occasionally the anterior pillar has actually been incised in an effort to drain a nonexistent peritonsillar abscess. CASE VII.-The patient before us now is a man 22 years of age. Five weeks ago he noticed a slight sore throat which increased in severity until he consulted a physician three days after the onset. A smear and cultures were taken and t\venty-four hours later (four days after the first symptoms were noted) a diagnosis of Klebs-Loeffier infection was made. He was immediately given adequate doses of antitoxin. Recovery from his .infection was prompt. Yesterday he experienced some speech difficulty. When he was examined in the clinic it was found that the uvula and the median raphe of the palate deviated to the right or norma] side. If you will now elicit his gag reflex by using a tongue depressor you will note that the posterior wall of the pharynx makes a rapid movement to the right and then partly disappears under the right posterior ar.ch and lateral ligament. No other palsies have been found. This man shows a postdiphtheritic, unilateral paresis of the pharyngeal constrictors. He will probably recover from the paresis in a matter of weeks and should now be reassured of the outcome.
Diphtheritic infection of the pharynx follows an incubation period of two to four days. The gradual onset with sore throat, slight fever, chills and general malaise is soon followed by a red pharynx and pain and difficulty in swallowing. The most important symptom is profound prostration out of all proportion to the temperature elevation. With the appearance of a confluent, adherent membrane, dirty gray in color and with well defined margins, all that should be necessary for a conclusive diagnosis is bacteriological confirmation. Extensiop to the nostrils produces nasal obstruction, a sanguineous purulent discharge with foul odor and especially severe lymph node involvement. Involvement of the larynx produces first hoarseness, later a croupy cough and finally cyanosis and continuous dyspnea. Death may occur from laryngeal obstruction. The diagnosis can be confirmed only by the finding of Klebs-Loeffier bacilli in cultures grown on LoefHer's medium for at least eighteen hours. Early specific therapy, however, is justified on the basis of smears, prostration out of proportion to the fever and the presence of a dirty gray membrane in the throat. Attempts at removal of the adherent membrane leave a denudep, bleeding area and the residual membrane is apt to become yellow or black as accumulated coagulated blood forms beneath it. Enlarged, tender lymph nodes appear at the angle of the jaw and in the anterior cervical region. The temperature rarely
COMMON INFECTIONS OF THE PHARYNX AND FAUCES
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exceeds 102 0 F. while the pulse rate ranges from 100 to 120 beats per minute. The Shick test is positive. While clinicians are alert to the incidence of diphtheritic infection in children, they are frequently loath to make an early diagnosis in adults although in the United States 10 per cent of the adult population are Shick positive and presumably susceptible to diphtheria. A differential diagnosis must be made between diphtheria, acute follicular tonsillitis, membranous pharyngitis, Vincent's angina, syphilis and keratoses. Acute follicular tonsillitis is most frequently confused with Klebs-LoefBer bacillus infection. In the former no diphtheria bacilli are found on culture and the temperature reaches the higher levels of 104 0 to 105 0 F.; the tonsils are injected and swollen, with exudate limited to the tonsil and its crypts. The removal of this exudate does not leave a bleeding surface. Cough is rarely present and then is not croupy in character. Paralytic Phenomena.-Paralytic phenomena appear in 10 per cent of patients acquiring diphtheria. in temperate climates. First appearing two or three weeks after the onset of infection, diphtheritic paralysis tends to be limited to the cranial nerves, but involvement of the extremities may predominate or both may be affected. The lower extremities are more often affected than the upper. Next most frequently attacked are the ocular nerves, especi,ally those distributed to the ciliary muscles. This produces paralysis of accommodation with preservation of the pupillary reflex. Inequality of the pupils, diplopia, strabismus and ptosis are not uncommon findings. As a rule, paralysis begins in and is limited to the uvula and the palatal muscles. It is first recognized by the appearance of nasal speech and the regurgitation of fluid through the nose. This is a flaccid paralysis; the insensitive soft palate and uvula do not move. Normally, the uvula moves in its midposition when the mouth is opened. In unilateral paralysis, the uvula or the median raphe of the palate deviate to the normal side; in bilateral paralysis, the uvula hangs in the midposition and does not move when the mouth is opened. If there is unilateral paresis of the pharyngeal constrictors, such as we have noted in the patient in Case VII, the posterior wall of the pharynx makes a rapid movement to the normal side and partly disappears under the posterior arch and lateral ligament of the normal side. Involvement of the bulbar nerves produces not only paralysis of the laryngeal and pharyngeal muscles but also either partial or complete anesthesia of the mucous membrane. Paralysis of one or both vocal cords or inability to close the glottis should be suspected with the appearance of aphonia, hoarseness or dysphagia. Death from aspiration pneumonia follows paralysis of the glottis. The prognosis is always poor when the bulbar nerves are involved. The facial muscles and tongue are rarely involved but when they are,
1366
HARRY P. SCHENCK
the facial expression is lost and the tongue shows a variety of changes, chief among whicll are deviation from the midline, tremor, atrophy and impairment of taste sensation in the posterior third. More rarely, the neck muscles are involved and then the head falls helplessly npon the shoulders. The prognosis is grave when tachycardia due to paralysis of the vagus appears. Dyspnea follows involvement of the phrenic nerve, becoming especially severe when both phrenic nerves are paralyzed. Exodus follows paralysis of the vagus and of the phrenic nerves. The general polyneuritis of diphtheria simulates pseudotabes and may progress to complete paralysis of the lower extremities. Usually the lower extremities are first and most extensively involved, becoming paretic, ataxic, with loss of deep reflexes and steppage gait. Footdrop and impairment of all forms of sensation rapidly follow. Although the paralysis of the extremities appears later than that of the palatal and pharyngeal muscles it persists for weeks or months after the palatal and pharyngeal involvement has disappeared. Treatment.-The only specific remedy is diphtheria antitoxin. It is necessary to test the sensitivity of the patient before using the horse serum containing the antitoxin. If a wheal develops when a minute amount of serum is injeGted into the skin the patient is sensitive to horse serum and goat serum containing antitoxin must be used. Epinephrine in 1: 1000 solution should be at hand in case of severe reactions to serum, especially edema of the glottis with asphyxia. If the test dose produces no reaction, full therapeutic doses should follow. The doses may vary from 5000 units in mild infections to 50,000 units in severe infections or 100,000 units or more in malignant forms. While intramuscular injection into the upper gluteal region is the usual route, the intravenous route may be advisable in severe infection. The administration of antitoxin begun three to four days after the onset of throat symptoms is ineffectual in preventing paralysis because the diphtheria toxin becomes fixed in the nervous system early in the course of the disease and can then no longer be neutralized by antitoxin. Rest in bed is imperative for the minimization of heart involvement and also protects the peripheral nerves to some extent. The introduction of penicillin and other chemotherapeutic drugs has not eliminated the necessity of .administering adequate doses of antitoxin. Penicillin will not neutralize the toxin or affect the rate of clearance of th~ membrane but it do~es redu~~ the incidence of complications, especially clinical myocardial involvement. In sufficiently large doses, penicillin shortens the duration of both the convalescent and chronic diphtheria carrier states. Doses of 120,000 to 240,000 units of penicillin per day for twelve days are advisable in acute diphtheria while the treatment of the chronic diphtheria state requires a minimum of 240,000 units per day for twelve days.
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REFERENCES 1. Wilkins, F. A.: Clinic on Acute Serofibrinous Pericarditis Secondary to Acute
Pharyngitis. Proc. Staff Meet., Mayo Clin., 9:637 (Oct. 17) 1934. 2. Merle, E.: Pensons toujours aux infections pharyngees chez nos albuminuriques. J. med. fran~., 19:396 (Oct. 30) 1934. de Wesselow, o. L. V. S., Goadby, H. K., and Derry, D. C. L.: Tonsillitis and Albuminuria. Brit. M. J., 1:1065 (May 25) 1935. 3. Seegal, B. C. and Lyttle, J. D.: The Nature of the Preceding Infection in Acute Glomerulonephritis in Two New York Hospitals and in Four Southern Hospitals. J.A.M.A., 105:17 (July 6) 1935. .4. Felsen, ]. and Osofsky, A. G.: Pharyngogenic Hematogenous Streptococcic Peritonitis. Arch. Surg., 31 :437 (Sept.) 1935. 5. Bordley, J.. E.: The Use of -Radium in the Treatment of Conduction Deafness. Surg., Gynec. & Obst., 84:839 (April 15) 1947. 6. Norris, R. F., Kern, R. A., Schenck, H. P. and Silcox, L. E.: Diphtheria in the Tropics; a Report of 18 Cases Seen on a U. S. Hospital Ship. U. S. Nav. M. Bull., 42:518 (March). 1944.