Phlegmonous pharyngitis exhibits a still higher grade of inflammation. It involves the submucous structures as well as the mucous membrane, including at times the fibrous sheaths of the muscles. It may, in addition, involve the palate, the tonsils, the base of the tongue, and contiguous structures. Suppuration is common, usually circumscribed, but not infrequently diffuse in patients of enfeebled constitution.
One variety of the disease is essentially a deep-seated pharyngitis; and this form almost always progresses to suppuration (suppurative pharyngitis). The process becomes then, not infrequently, a diffuse suppurative inflammation of the subpharyngeal connective tissue, extending sometimes downward along the oesophagus, into which the pus may be discharged by spontaneous rupture, with a result of permanent stricture from irregular cicatrization. Sometimes the suppurative process extends anteriorly beneath the cervical fascia, and the pus may gravitate so as to occlude the air-passages, partly or completely, by direct pressure; or in other instances the entrance of the larynx may become blocked by the tumefaction of the pharynx. When phlegmonous pharyngitis is of traumatic origin, there will be more or less destruction of the mucous membrane according to the nature of the injury, whether accidental or designed, whether due to burn, scald, inhalation of hot air or steam, or to deglutition of alkaline, acid, or other corrosive substances. In these cases the morbid process is rarely confined to the pharynx, but the larynx, the oesophagus, and even the stomach, are liable to be involved. If regurgitation of hot air or of caustic fluids takes place through the nasal passages, the injury will of course involve those regions.
Ulcerative pharyngitis is a low form of inflammation present in sore throat, probably dependent upon septicæmia. The tonsils are somewhat congested and swollen, and one or more white superficial ulcers form on their surface, or on the palate, or on the pharynx. These ulcers are generally round or oval, and vary greatly in size. When two or more ulcers exist, they exhibit no tendency to confluence. Healing takes place rapidly, usually without leaving any traces of the lesion.
Membranous pharyngitis, or herpes of the pharynx, is one of the infrequent phenomena of a not uncommon sore throat, which exhibits at first a collection of small vesicles the size of millet-seeds or larger, isolated here and there or clustered in groups on the palate and uvula, less frequently on the tonsils. Herpes of the mouth and lips sometimes coexists. These vesicles are surrounded by inflammatory areolæ. Their contents are more or less turbid. In rare instances they disappear without trace after a day or two. Usually they soon undergo rupture, sometimes within a few hours, so that small ulcers are left, which almost immediately become covered with a grayish-white exudation. A number of patches will coalesce, forming limited sheets of false membrane not unlike those of diphtheria. The disease is usually confined to one side of the throat, the corresponding submaxillary or cervical glands being affected moderately when at all involved. The tonsil is swollen, and the mucous membrane of the palate and the palatine folds is congested and often tumefied. There is an abnormal secretion of viscid, ropy, turbid mucus. In a few days the ulcers heal beneath the exudation, which becomes disintegrated and detached, the inflammatory process subsiding by gradual resolution. Sometimes the ulcers cicatrize without previous deposit of false membrane. Occasionally there are at longer or shorter intervals successive crops of vesicles, which may or may not undergo ulceration.
Gangrenous pharyngitis may supervene upon any form of pharyngitis, but in the majority of instances its malignant character is inevitable from the outset; so that some authors have even restricted the term gangrenous to a form of sore throat characterized by primitive gangrene of the pharyngeal mucous membrane originating independently of any other malady. Whether an idiopathic disease, or whether it follows scarlatina, measles, small-pox, dysentery, or enteric fever, it is associated with that depraved condition of the system denominated typhoid. At times it occurs in tuberculous phthisis. The initial manifestations may be simply those of intense inflammation. The tongue is covered with a dark creamy, pultaceous deposit consisting of broken-down epithelium, pus-cells, bacteria, and molecular débris, while similar masses are occasionally seen upon other mucous surfaces of the mouth and throat. The tonsils, palate, and pharynx are livid and swollen, and sometimes oedematous. At an early period the tonsils, the palatine folds, and the posterior wall of the pharynx become covered with dark, ashy-colored ulcers with excavated edges. Sometimes these spots are black from the first, and appear slightly elevated. These soon slough out with more or less of the surrounding tissues, and the ulcers left are covered with sanious, ichorous, fetid secretion. In some instances a delicate pseudo-membrane has been found in the bed of the ulcer after death (Mackenzie). The destructive process rapidly extends—sometimes to the oesophagus in one direction or to the nares in the other. The larynx is less frequently implicated; should it be attacked, oedema is liable to occur. Occasionally the process is limited to the tonsil, and there is no pharyngitis at all. Erosion of the blood-vessels may give rise to fatal hemorrhage. In those instances where the gangrene is circumscribed there are found, post-mortem, depressed oval or circular patches from one-twentieth to one-half an inch in diameter, varying in color from dark gray to absolute black. The edges are of a brownish color and are perpendicular. The bundles of muscular fibre are laid bare by destruction of the mucous membrane and submucous connective tissue, but as a rule escape implication of their substance. Similar patches have been noted in the epiglottis and the upper part of the larynx as well as in the mouth and pharynx—in some cases, indeed, in the trachea, the lungs, the oesophagus, the stomach, and the intestines.
Erysipelatous pharyngitis is usually an extension of erysipelas from the facial integument, which may take place by the lips and mucous membrane of the mouth, by the nasal fossæ, by the Eustachian tube from the tympanum and external ear, or by the nasal fossæ from the conjunctiva and eyelids through the lachrymal duct. When the disease begins in the pharynx the order of communication may be reversed. The pathological processes are the same as in cutaneous erysipelas. The mucous membrane of the pharynx will be diffusely red or purplish and shiny. Sometimes little bullæ are formed and become ruptured, leaving a patch of softened whitish-yellow tissue, which is sometimes torn from the surface beneath by the act of coughing or of deglutition. The inability to swallow is not due to swelling of the tissues, but to actual paresis of the muscles, probably from interstitial infiltration, but perhaps from implication of their substance. The cervical and submaxillary glands are rarely involved. Erysipelatous pharyngitis usually terminates by resolution, desquamation of the greater part of the epithelium of the mucous membrane often taking place; but it may be followed by abscess or by gangrene. Extension may take place to the larynx, and oedema may follow.
Exanthematous pharyngitis accompanies some cases of cutaneous exanthemata. The pharyngitis of small-pox is occasioned by an eruption upon the mucous membrane similar to that which appears on the skin. Often in advance of the cutaneous eruption it occupies the inside of the cheeks, the palate, uvula, and pharynx; sometimes the larynx as well. Maturation occurs more rapidly than upon the skin, and there is more or less purulent infiltration of the submucous connective tissues. Ulceration of the larynx or trachea may ensue so severe in character as to cause fatal termination by the local lesion.
In measles an eruption similar to the cutaneous manifestation occupies the air-tract from nostril to bronchi rather than the food-passages. The Eustachian tubes may be involved, and the inflammation is sometimes propagated along the lachrymal duct. The throat may be affected a day or two before the external integument. Small red points the size of a millet-seed or larger appear on the palate, the tonsils, the posterior palatine folds, and the wall of the pharynx. These disappear in a few days, though sometimes in bad cases fibrinous exudation may accumulate. In other instances abscess or ulceration takes place, chiefly in the larynx.
The pharyngitis of scarlatina develops a day or two prior to the cutaneous eruption, the mucous membrane of the palate, tonsils, and pharynx being deeply congested, uniformly or in patches, with slight papulous elevations here and there. In the course of a day or two an opalescent or milky deposit, consisting chiefly of detached epithelium and viscid mucus, is observed on the swollen palate and tonsils. In the anginose variety the hue of the inflamed structures is more dusky. There is a pseudo-membranous deposit of a dirty-white, ash, or even yellow color. It is not limited to the tonsils, but accumulates rather on the palate, palatine folds, and posterior wall of the pharynx. The mucous membrane beneath the patches is often ulcerated, and sometimes gangrenous. There is much greater tumefaction of all the parts than in simple scarlatina, the enlargement of the cervical and submaxillary glands and the infiltration of contiguous connective tissue being so great in some instances as to prevent the mouth from being opened. A viscid and turbid secretion accumulates in the mouth. The nasal secretions sometimes desiccate into firm crusts. Suppuration may occur. Sometimes otitis media results from extension along the Eustachian tube, and sometimes suppuration of the membrana tympani, suppurative external otitis, or disease of the internal ear with extension to the cerebrum. In malignant cases all the processes are aggravated. Ulceration or gangrene soon ensues, the pseudo-membranous deposit being dark, almost black, from extravasated blood. Oedema of the uvula and soft palate is liable to occur, and if the larynx be involved there may be oedema of the epiglottis and ary-epiglottic folds.
SYMPTOMATOLOGY.—Simple pharyngitis very often gives rise to but little discomfort. There is usually more or less heat and dryness in the parts, especially at first. There is some dysphagia, principally from pain in swallowing, but in part from actual debility in the muscles of deglutition. Hoarseness is not usual, and cough is infrequent if there be no elongation of the uvula. Speech may be embarrassed by difficulty of articulation. There is usually some febrile movement, with acceleration of pulse and respiration. Some cases exhibit more intense inflammatory action, with a corresponding aggravation of the constitutional symptoms. The skin becomes markedly heated, the body-temperature rises to 101° F. or higher, the pulse reaching 100-120, in some instances 140, beats per minute, even in the adult.