Лазерное воздействие осуществляется посредством монохроматического красного света и гелий-неонового лазера. Облучаются слизистая оболочка носа, задней стенки глотки и небные миндалины (при интенсивности излучения 2,65 мВт/см, время экспозиции — от 2 до 8 минут). Курс состоит из 5-7 ежедневных облучений, проводимых 2 раза в год.
Для профилактики рецидивирующих инфекций верхних дыхательных путей, в том числе частых рецидивов ангин, показано применение рибомунила. Препарат стимулирует специфический (гуморальный и клеточный) и неспецифический иммунитет, поскольку активными действующими веществами его являются бактериальные рибосомы и протеогликаны мембранной части Kledsiella pneumoniae. Препарат выпускается для приема внутрь, для ингаляций и для инъекций. Лечение проводится курсом: 3 таблетки утром натощак, один прием в сутки. Рибомунил назначают ежедневно, в первые 4 дня недели в течение 3 недель; затем — в первые четыре дня каждого месяца в последующие 5 месяцев.
8. Контроль результатов усвоения темы:
-тесты исходного (претест) и итогового (посттест) уровня знаний;
-ситуационные задачи;
9. Методические рекомендации студентам по выполнению программы самоподготовки:
9.1. Ознакомьтесь с целями практического занятия и самоподготовки;
9.2. Восстановите приобретенные на предыдущих курсах и ранее изученным темам знания;
9.3. Усвойте основные понятия и положения, касающиеся темы занятия;
9.4. Уясните, как следует пользоваться средствами решения поставленных задач;
9.5. Обратите внимание на возможные ошибки при постановке дифференциального диагноза;
9.6. Проанализируйте проделанную работу, выполните контрольные задания.
Angina (quinsy) is severe general infectious disease affecting the lymphoid tissue associated with the mucosa, with local phenomena in the form of an acute inflammation of one or more components limfadenoid pharyngeal ring, usually the tonsils. Although the term "angina" (from the Latin ango - compress, choke) is not accurate (acute inflammation of the tonsils rarely accompanied by suffocation), it is widely distributed among health workers and the public and can be used on an equal footing with the more precise term - "quinsy" .
There are primary and secondary acute tonsillitis. Acute primary tonsillitis is acute disease, whose clinical picture leading link are symptoms of the tonsils. Depending on the morphological changes distinguish certain forms of primary acute tonsillitis, the main of which are katarrhal, gap, follicular, pseudomembranous angina.
Acute tonsillitis is a secondary lesion in the tonsils of acute infectious diseases (mainly in diphtheria, scarlet fever, tularemia, typhoid fever), and diseases of the blood system (mainly in infectious mononucleosis, agranulocytosis, septic angina, leukemia).
Epidemiology. Infection with angina occurs via droplets. The source of infection - the patient, household items. Enhanced selection of an infectious agent occurs when coughing, sneezing, with one event that stands up to 106000 of microbial cells. Infection is possible, and from healthy carriers - in transport, classrooms, auditoriums, dormitories, barracks, etc. In large groups the likelihood of angina above. The incidence of these increases over 2-8 weeks from the time they update, ie "Beginners" group is 2-3 times more often than the "old-timers" sick angina. SARS disease contributes substantially to the allocation of streptococcus in the external environment when you cough, sneeze, talk.
Etiology and pathogenesis. For the occurrence of angina is not enough carriers of pathogenic microorganisms. Should be at the same time the presence of all three causes of any inflammation: a microorganism, reducing the overall resistance of the body, reducing the local resistance of tissue or organ.
Clarification of the etiology of angina is the most important factor determining treatment policy and preventive measures. The causative angina may be bacteria, viruses, spirochetes, fungi. Among the most frequent bacterial agents is the hemolytic streptococcus, rarely - Staphylococcus aureus, or a combination thereof. In organized groups of bacterial pathogens of angina can be pneumococcus, meningococcus, influenza bacillus, typhoid, klebsiella. Very rarely can cause angina anthrax bacillus, anaerobic type of Clostridium. The reason for viral sore throats more often than others may be adenoviruses (types 1-9), of Coxsackie enterovirus, herpes virus, and spirochetal (Vincent's angina) - oral spirochete in conjunction with spindle-shaped bacterium.
Among the exogenous factors determining is of paramount importance infectious agent that penetrates through the epithelium of the inner surface of the tonsils, their lacunae. In the mechanism of development of angina also have the value of such harmful environmental factors and working environment as dust, fumes, drops in air temperature. Significant role in the pathogenesis of angina is common and local hypothermia; certain place is given power-factor protein monotonous diet deficient in vitamins C and B predisposes to the development of angina. Predisposing factor may be small injury tonsils foreign body (hairs of a toothbrush, small fish bone), a spatula in determining the content of lacunae of tonsils. A very important role in the pathogenesis of angina is a violation of nasal breathing. Sometimes surgery is the nose is provocative moment for its occurrence. All this - and microbial agents and predisposing circumstances, opposes such an endogenous factor, as the state of reactivity of the organism, the severity of its protective forces. In healthy individuals nonspecific and specific protective factors hinder the manifestation of pathogenic agents of angina.
In the pathogenesis of angina and its complications play a role neuro-reflex mechanisms. This is according to research local otolaryngologist on the structural and functional characteristics of the receptor apparatus of the tonsils and their reflex relationship with some internal organs, particularly the heart (tonzillokardialny reflex).
Clinical picture.
Catarrhal sore throat is characterized primarily superficial lesions of the tonsils and are often preceded by a deeper their defeat. The prodrome lasts from several hours to 2-4 days. The disease begins abruptly with a feeling of dryness, a tickle in my throat, general malaise, headache, pain in joints and muscles. Soon there is a pain in the throat, increasing swallowing. Perhaps it was radiating to the ear. The body temperature rises slightly, but there may be chills. Seen from the palatine tonsils hyperemic, edematous. Lymph nodes at the corner of the lower jaw enlarged and slightly painful on palpation. Changes in the blood are absent or insignificant. Children of all phenomena is more pronounced, including temperature reaction. The disease lasts 1-2 days, after which the phenomenon of inflammation in the throat or tonsillitis subside passes into another form. Weather favorable.
Lacunary tonsillitis begins with a sharp rise in temperature to 39-40 "C, accompanied by chills, significant malaise, sore throat, heart, joints, headache. Perhaps the delay of his chair. Often noted increased salivation. In children, vomiting often occurs. When pharyngoscope - sharp hyperemia of the tonsils, swelling and infiltration. Lacunas expanded in them - a yellowish-white fibropurulent content, formed on the surface of the tonsils soft plaque in the shape of small lesions or film. Plaque can cover the whole amygdala, but not beyond its limits, dull and rises above the surface of the tonsils. It is porous, friable and relatively easily removed from the surface of the tonsils, leaving a bleeding defect. Regional lymph nodes were enlarged, and palpation of their sharply painful. In the blood - leukocytosis up to 1,2 -2,0 h104 h104, neutrophilic left shift, ESR 40-50 mm / hour. The urine may appear traces of protein, sometimes - erythrocytes.
Lacunary angina usually lasts 5-7 days. During her stormy. Signs are growing rapidly and as quickly subsided. During the clinical manifestations of angina subsided starts cleaning tonsils from air raids. The temperature is reduced analytically. Swelling of the regional (zachelyustnyh) lymph nodes is kept longer than other symptoms - up to 10-12 days.
Tonsillitis is characterized by a primary lesion of the parenchyma of the tonsils of follicular apparatus. Just as lacunary, tonsillitis begins with a sudden chill fever to 40 ° C, severe pain in the throat. It is expressed toxic symptoms, patients concerned abrupt weakness, headache, pain in the heart, joints and muscles. Sometimes observed phenomena dyspepsia, oliguria. Tonsils giperemirovanny sharply edematous. Through the epithelium of translucent festering follicles in the form of whitish-yellowish formations the size of a pinhead. The surface of the tonsils, in the figurative expression of NP Simanovsky, takes the form of "starry sky". Pronounced regionarny limfadenid. Changes in blood and urine are similar to those in Lacunary angina. These forms of sore throats are inherently represent different stages of one process. Isolation is their being based on the predominance of certain symptoms.
A special place among the primary acute tonsillitis is pseudomembranous angina, the clinical picture which was first described in 1890, NP Simanovsky. A few years later data were published plaut and Vincent on the strain of the disease - a symbiosis fusiform bacteria and spirochetes of oral cavity.
The disease usually develops in people with a sharp decrease in the body's defenses, suffering from hypovitaminosis C and group B, immunodeficiency, marasmus, intoxication, and is characterized by a predominance in the inflammatory process phenomena of necrosis. The defeat of the tonsils, usually unilateral. On their free surface appear easily removable grayish-yellow attacks, which are formed on the rejection maloboleznennye superficial ulcers with a gray bottom. Ulceration may extend beyond the tonsils at the soft palate, gums, back of the throat, down into the vestibular parts of the larynx. In some cases, necrotizing process may extend to the underlying tissues down to the periosteum. The disease occurs at a relatively good general condition, accompanied by halitosis, salivation, pain when chewing, swallowing. On the side of the lesion develops regionarny lymphadenitis. The body temperature rises to subfebrile digits. Changing the composition of the blood usually comes down to moderate leukocytosis, increased ESR.
The diagnosis is confirmed when in discharge of ulcers or film symbiosis fusiform bacteria and spirochetes of oral cavity. The fence material for research should be carried out laboratory loop on the slide. When taking a cotton swab can get a negative response because of the hygroscopicity of cotton wool and dries swab on the swab. Detection fuzospirohetoznogo symbiosis does not always allow regarded ulcerative-necrotic process in the throat as pseudomembranous angina. It should be borne in mind the possibility of acceding fuzospirohetoznogo symbiosis with other ulcerative processes, such as ulceration of the cancer, angina with leukemia, agranulocytosis, chlamydia, radiation pharyngitis. In 10% of pseudomembranous angina occurs in combination with diphtheria.
Differential diagnosis.
The above angina should be differentiated from influenza, acute respiratory viral disease, acute pharyngitis, measles, as well as with secondary acute tonsillitis, ie with a sore throat with infectious diseases such as diphtheria, scarlet fever, tularemia, typhoid fever, and diseases of the blood system - infectious mononucleosis, leukemia, and agranulocytosis. Differential diagnosis of angina, should always be mindful of the possible defeat of the pharynx at early infectious syphilis and tuberculosis. Differentiation is accomplished by comparing the clinical signs of disease and laboratory results. For the flu is characterized by pronounced intoxication, the incidence of the inflammatory process in the entire upper respiratory tract. In the blood - leukopenia. Acute respiratory viral disease occurs with pronounced symptoms of rhinitis, rhinorrhea. Body temperature usually does not reach the high figures are absent or mild toxic symptoms. With strep throat, which should not be confused with catarrhal sore throat, as little affected general condition. Spills hyperemia of the posterior pharyngeal wall usually does not extend to the palatine tonsils. Body temperature is usually normal. The defeat of the pharyngeal mucosa with measles noted in the prodromal period and during the eruption. For the differential diagnosis is essential for the appearance of the mucous membrane of cheek stain Filatov - Koplik, measles enanthema and skin rashes. Of particular relevance is the question of differential diagnosis of a banal angina and diphtheria. The most common diagnostic errors happen in localized diphtheria oropharynx - the most common form of diphtheria infection. Gap angina, complicated paratonzillitom paratonzillyarnym or abscess, it is necessary to differentiate from toxic diphtheria oropharynx, especially marfanovskoy form in which the defeat of one-sided. All types of angina, accompanied by the formation of raids, should be considered suspicious for diphtheria, especially if the attacks scarious and tend to spread. The diagnosis is confirmed by the bacteriological examination of smears taken from the lesion sites. In typical cases of lack of bacteriological confirmation is not grounds for cancellation of the clinical diagnosis of diphtheria. While with atypical course of the disease, rare localizations of bacteriological confirmation is mandatory for the diagnosis of diphtheria. A sore throat of scarlet fever may be accompanied by various injuries to the throat of catarrhal necrotic. Very characteristic is scarlatinal enanthema appearing at the end of prodromal period, ie before scarlatinal exanthema. Enanthema manifest expression and dissemination of hyperemia, exciting tonsils, and the hard palate and has a sharp boundary. Edematous and hyperemic staphyle looks like crushed cranberries. Owing to the unusually bright hyperemia disease got its name from the Italian scarlatum - purple. Tonsils were congested, sharply increased their changes correspond to bluetongue or follicular angina. Day by day enanthema pharyngeal mucosa progresses. At the tonsils appear raids grayish-yellow color, they merge and can cover the entire amygdala. Incursions tightly welded to the surface of the tonsil, but not rise above it. Regional lymph nodes were enlarged, painful on palpation. Diagnosis, in addition to the typical enanthema throats, scarlet fever helps the typical person - the so-called "skarlatinovaya Mask described Filatov: her cheeks were congested, bright color, while the nasal - labial triangle pale. Angina with tularemia occurs when it tonsillar - bubonic form. In the first 2 days of the disease changes the tonsils are catarrhal, and from the third day - filmy or necrotic in nature. The tonsils were enlarged, raid looks like grayish-white islands rapidly converging and covering the entire surface of the tonsils. When necrotic lesion plaque has a dirty-gray color, clearly demarcated from the rest of the tissue and is below the level of healthy tissue. After sloughing exposes the deep, slowly healing ulcers. Lymph node involvement is not limited only to the regional inflammation, the process applies to closely-posterior cervical and submandibular nodes. They grow for 1-3 days, merge and form a bubo tularemia, whose size can vary from walnut size to a goose egg. Conglomerate lymph nodes are not fused with surrounding tissues, palpation, prone to melt. The process is usually unilateral, develops slowly and reaches its maximum at 4-5-th day of illness. Healing is slow - from 2-3 weeks to 3-6 months. Scarring fistula asynchronously, the formation of coarse ends colloid scar. In the midst of the disease expressed gepatolienal syndrome. In the blood - leukopenia, relative limfomonotsitoz, bilirubinemia, increased content of residual nitrogen, sugar. The diagnosis in typical cases is not difficult. Important finding in the smears of the areas of necrosis and content fistula Bacterium tularense. Anginal form of infectious mononucleosis. The prodrome begins with malaise, sleep disturbance, loss of appetite. The disease is characterized by a sharp rise in body temperature to 39-40oC, swelling and tenderness zachelyustnyh, cervical and occipital lymph nodes. Then, in the process involved axillary, abdominal and inguinal lymph nodes. At the height of lymphadenitis in 85-96% of patients observed changes in the pharynx, resembling angina or banal, or diphtheria, or fusospirochetal. In contrast, monocytic angina begins with a dramatic swelling of the mucous membrane of the pharynx and the elements limfadenoid ring, which leads to difficulty of nasal breathing, nasal, stuffy ears. In some cases, edema and infiltration of the tonsils reach significantly and cause shortness of breath. In monocytic angina attacks stick in the throat very hard - in a few weeks or even months. Difficulties in diagnosis are usually resolved in the study of blood: leukocytosis reaches 10-20x10 '/ l and above, with a predominance of mononuclear cells (60-80%). The disease lasts 3-4 weeks. First, regressing fever, sore throat, and then only after them - lymphadenitis. Weather favorable. Angina with agranulocytosis. The first clinical manifestations of agranulocytosis are fever, sore throat, stomatitis, and then astonished the gastro-intestinal tract. Increased body temperature to 39-40 ° C accompanied by chills, intoxication, severe general condition.
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