XXXVIII

CHRONIC GRANULAR PHARYNGITIS

RAYMOND H. MARCOTTE, M.D.

NASHUA, N. H.

This study of chronic pharyngitis will be limited to that of the

oropharynx. The nasopharynx and the hypopharynx vary in an-
atomical and histological structure from it. The former is lined with
ciliated epithelium, forms the bed of the adenoids, and presents the
pharyngeal opening of the eustachian tubes; the latter presents the
orifices of the larynx and esophagus. These two are subject to dis-
eases that differ in character from those affecting the midpharynx
proper. Here the mucous membrane consists of squamous epithe-
lium and numerous mucous glands and lymph nodes which may
become hypertrophied and infected. This membrane is highly vas-
cularized and enervated. It has the double duty of transmitting air
and food and is subjected to infections and trauma by way of the
mouth as well as from the nose and nasopharynx.
Diseases of the tonsils, neoplasms, acute infections of the
pharynx, tuberculosis, and syphilitic pharyngitis are eliminated from
this study.
PATHOLOGY

Chronic granular pharyngitis is characterized by an alteration

in the mucous membrane of the pharynx involving the mucous glands
and the lymph follicles. The initial stage of hyperemia is followed
by an inflammatory change in the connective tissue and the hyper-
plasia of the lymphoid follicles. The granulations are largely made
up of masses of lymphoid cells, grouped around the mouths of the
ducts of the mucous glands; they vary in size and number in differ-
ent persons. The epithelium becomes thickened in some places and
atrophied in others.

Schenck! states that the histologic section of tissue from the

pharynges of over 100 patients presenting chronic pharyngitis in-
variably presented evidence of hyperplasia of the lymph nodules and
chronic inflammation. These histopathologic changes were common
to all types of chronic pharyngitis regardless of the variations in
systemic complications.

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
 CHRONIC GRANULAR PHARYNGITIS 407

ETIOLOGY

In chronic pharyngitis search should be diligently made for

some local or general cause, and better results will be obtained if
we are good diagnosticians than if we merely apply local remedies."
Among the various etiological factors of chronic granular pharyngi-
tis, the one most commonly stated is that of postnasal discharge
emanating from the accessory nasal sinuses. While this is undoubt-
edly a factor in a number of such cases, there are numerous other
causes. Lejeune," Schenck,' and Lillie" do not believe that chronic
pharyngitis is always due to constant bathing of inflammatory ma-
terial from the sinuses above or the lung below, and Lillie states that
his "observations have led him to believe that the most frequent
cause of pharyngeal complaints for which patients seek advice is
referable to the pharynx itself."

There are undoubtedly many patients presenting granular

pharyngitis which follows relatively closely upon an operation for
the removal of tonsils or adenoids, or both. Here it appears as if
nature were compensating for and replacing these areas of lymphoid
tissue which the original surgery has removed. Mouth breathers,
from whatever cause, usually nasal obstruction, frequently present
a pharyngeal wall studded with hypertrophied lymphoid follicles
which is probably due to dryness resulting from the inspired air's
absorbing moisture from the pharyngeal mucosa, dilatation of capil-
laries, and local inflammation."

Exposure to dust and irritating gases accounts for a certain

number of cases of chronic pharyngitis in those connected with such
occupations as stone cutting and cigarette manufacture and those in
the asbestos industry." Here the chronic pharyngitis is probably due
to recurrent acute attacks. Among the noninfectious irritants, to-
bacco smoke is a common source of irritation to the pharynxes of
certain individuals. This can be demonstrated by observing an irri-
tated pharynx, accompanied by a cough, subside after smoking is
eliminated. Johnson' states that dental caries is always a consider-
able factor.
Some general systemic diseases such as constipation, rheumatism,
hepatic cirrhosis, and cardiac affections may predispose to chronic
pharyngitis, due either to the accompanying toxicity or to disturb-
ances in the circulation. There is a group of patients, with otherwise
negative findings, whose symptoms and pharyngeal appearance sug-
gest dietary errors, faulty metabolism, or endocrine dyscrasias. On
the other hand the pharyngitis of allergy is described by Hansels as

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
408 RAYMOND H. MARCOTTE

a diffuse redness and edema; rarely are there any granulations present
unless complications exist.

SYMPTOMATOLOGY

The most constant symptom is that of a sore throat, especially

when the patient is fatigued, a dry hacking cough, and occasional
hoarseness, probably due to the thick tenacious secretions which con-
sist of collections of mucus in clumps. Inspection reveals a diffuse
injection of the pharyngeal mucosa, and nodules of lymphoid tissue
distributed over the pharyngeal wall, varying in character and in
number with different individuals, and with the same individuals at
various times. At times these are markedly inflamed and occasionally
present crypts which may contain cheesy like collections; the inter-
vening membrane may be pale and even atrophied in appearance, or
dry and glazed. The blood vessels are usually enlarged. The mucous
glands and the lymph nodules are especially conspicuous behind the
posterior faucial pillars, because they are more closely grouped along
the lateral pharyngeal wall.
In diagnosing a granular pharyngitis a thorough inspection must
be conducted carefully and extensively in order to eliminate the
purely catarrhal type which may be due to sinus disease, and care
must be taken that some pathologic factor in the larynx or the post-
nasal space or even in the pulmonary system is not overlooked.

TREATMENT

That no specific therapy has as yet been accepted for this con-
dition is evidenced by the fact that so many varied measures are
adopted for its relief.

Probably the simplest treatment is that of normal saline nasal

and postnasal wash, once or twice a day. Shambaugh" recommends
this, stating that it will relieve the symptoms. Many authorities dis-
agree and do not find any relief of subjective symptoms nor change
in the pharyngeal appearance following either douches or gargles.
Eidinow'" has devised a quartz mercury vapor throat lamp with
which he reports encouraging results with chronic inflammatory
lesions of the pharynx and nasopharynx. He described the reaction
as that of initial hyperemia and vasodilatation, followed by absorp-
tion of the inflamed follicles.
Hindley-Smith'! recommends ultraviolet therapy with the cold
quartz lamp, reporting gratifying results in chronic pharyngitis.

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
 CHRONIC GRANULAR PHARYNGITIS 409

Eagle and Reeves'" report the successful treatment of nonencap-

sulated lymphoid tissue of the pharynx by roentgen ray radiation:
"We suggest such treatment in all patients with chronic symptoms
referable to hypertrophy and infected pharyngeal lymphoid tissue,
especially when other modes of treatment have failed to alleviate
those symptoms."
In April, 1937, Reeves" reported approximately 300 patients
who had received radiation therapy for chronic pharyngitis. He
described the reaction as characterized by congestion and swelling
of lymphatic nodules shortly after the treatment. Later the pharyn-
geal follicles lose their reddened granular appearance and are replaced
by fibrous tissue. He advises fractional doses of low voltage, in the
same manner as when treating chronic infections elsewhere in the
body.
Richards H states that in several instances he has found multiple
small doses of X-ray effective in this condition.
Gordon'? advises that vaccine therapy be employed to clear up
the local pharyngitis and to deal with the systemic complications
when present.
Electrocoagulation to the individual follicles has been recom-
mended by Schenck 16 and others.
Schenck.!" Carmack;" Lillie/ and various others favor local
caustics, such as silver nitrate and chromic acid. Some surgeons
recommend surgical removal under local anesthesia. All of these
therapeutic measures are variably successful. Nearly all authorities
recommend internal medication with iodine in some form or other,
either as Lugol's solution, potassium iodide, lipoiodine, or even syrup
of hydriodic acid. Lillie 4 reports satisfactory results with the inges-
tion of iodine in a tablet form given two to four times a day, the
duration of medication being governed by the amount of relief ex-
perienced by the patient.
During the past two years I have made a study of 29 patients
with symptoms of granular pharyngitis, all of whom presented the
typical nodules of hypertrophied lymphoid tissue distributed in vary-
ing amounts over the pharyngeal mucosa. All but one of these
patients had previously undergone tonsillectomy. The youngest pa-
tient was 11 years of age, the oldest was 67. Most of the patients
were between 15 and 40 years of age.
The treatment consisted of prescribing an aqueous solution of
iodine internally, and either cauterization with 50 per cent silver

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
410 RAYMOND H. MARCOTTE

nitrate solution or destruction by means of electrocoagulation. This

local treatment was applied to the larger nodules, care being taken
not to destroy surrounding or intervening mucous membrane.

Iodine has been generally recommended and I have secured

almost uniformly good results with it. Since it is well known that
iodine lowers the basal metabolic rate in hyperthyroidism, these pa-
tients were all subjected to a basal metabolism test before therapeutic
measures were instituted. I was seeking to determine the possibility
of a disturbance in iodine or thyroid metabolism as an etiological or
concurrent factor in this condition. (See Table 1.)

Twenty-six of these patients studied had a basal metabolism

rate of between +7 and --10 per cent. One patient with a rate of
+ 11 was a middle-aged female with mild symptoms of thyrotoxi-
cosis, her rate being reduced to -11 per cent while undergoing treat-
ment. Two young adults with rates of -16 per cent also complained
of symptoms of hypogonadism; these two patients received small
doses of iodine and were referred to an internist for further endocrine
therapy following an improvement of their throat symptoms. One
young woman, 18 years of age, with an especially large amount of
pharyngeal lymphoid tissue which did not respond to the above
treatment is now undergoing X-ray radiation. As the treatment is
not completed, results cannot yet be ascertained.

Although this series is too small to be conclusive I can find no

evidence that disturbed iodine metabolism plays any part with granu-
lar pharyngitis, as a basal metabolic rate between 10 and -10 is +
considered normal. In order to supplement this study I spent a few
days in a well-known endocrine clinic where I was informed that
the patients, either with hyperthyroidism or hypothyroidism, did not
complain of pharyngeal symptoms as such. I had the occasion to
examine several of the patients and found no more pharyngeal path-
ology than one would expect in any similar group in any office or
clinic.

The favorable results from iodine therapy are probably empiri-

cal, possibly biochemical, and do not serve to readjust a disturbed
iodine metabolism.

SUMMARY

1. The basal metabolic rate of patients with granular pharyn-

gitis in a series of 29 cases was within normal range in all but 3 cases,
and these presented complicating endocrine disturbances.

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
 CHRONIC GRANULAR PHARYNGITIS 411

2. Patients with hyperthyroidism or hypothyroidism, as a group,

did not complain of pharyngeal symptoms more than did any control
group.
3. Symptoms of granular pharyngitis are improved by local
treatment and internal iodine therapy.
215 MAIN ST.

BIBLIOGRAPHY

1. Schenck, H. P.: Chronic Infections in the Pharynx-A Pathological Study.

Arch. Otolaryng., 24:299-318 (Sepr.) , 1936.
2. Hoople, G. D.: Non-Surgical Treatment of Diseases of Nose and Pharynx.
ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY, 48:73-80 (March), 1939.
3. Lejeune, F. E.: A Review of Available Literature on the Pharynx and
Pharyngeal Surgery. Laryngoscope, 49:1043-1063 (Nov.); 1939.
4. Lillie, H.!.: The Clinical Significance of Compensatory Granular Pharyn-
gitis. Arch. Otolaryng., 24:319-324 (Sept.}, 1936.
5. Negus, V. E.: Pharyngitis. Brit. Clin, j., 62:281 (July), 1933.
6. Thompson, S. S.: Diseases of Nose and Throat, 3rd Ed. D. Appleton &
Company.
7. Johnson, L.: Certain Considerations on Dysphagia Associated with Anemia.
ANNALS OF OTOLOGY, RHINOLOGY AND LARYNGOLOGY, 47:809-813 (Sept.}, 1938.
8. Hansel, French K.: Direct communication.
9. Shambaugh, G. E.: Year Book of Eye, Ear, Nose and Throat, 1936, p. 565.
10. Eidinow, A.: Treatment of Chronic Diseases of the Mouth and Pharynx
by Local Application of Ultra Violet Rays. Brit. M. J., 94-97 (July 15), 1933.
11. Hindley-Smith, j. D.: Clinical Observation on Chronic Pharyngitis and Its
Treatment by the Cold Quartz Lamp. Brit. J. Phys, Med., 9:210-213 (March),
1935.
12. Eagle, W. W., and Reeves, R. j.: The Treatment of Lymphoid Hypertro-
phies and Infection of the Pharynx and Nasopharynx by Irradiation. South. M.
].,29:159-163 (Feb.), 1936.
13. Reeves, R. j.. Am. j. Roentgenol., 37:510-512 (April), 1937.
14. Richards, 1.. G.: Treatment of Diseases of the Throat. j. A. M. A., 115:
501-506 (Aug. 17), 1940.
15. Gordon, A. K.: Systemic Infections and the Pharynx. Med. Press, London,
132:474-476 (Dec.), 1931.
16. Schenck, H. P.: Chronic Infections of the Pharynx. Pennsylvania M. j.,
41:578-581 (April), 1938.
17. Carmack, j. W.: The Conservative Treatment of the Nose, Throat and
Ear, The Pharynx. Tr. Am. Acad. Ophth., 375-381, 1934.

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
 ~
......
TABLE I N

SUMMARY OF BASAL METABOLIC RATES

Appearance of Pharynx,
Amount of Lymphoid
Initial Sex Age Symptoms B.M.R. Tissue

A. P. F. 67 Cough, fullness in throat, dysphagia -4 ++

A.G. M. 23 Dysphagia and dry cough +2 ++ :;tl
;:t.
J.c. F. 19 Tightness in throat and cough -4 ++
M.F.
s:0><
F. 17 Dysphagia, fullness in throat -9 +++
Z
E.W. F. 51 Frequent sore throats -7 ++ t:l

A.G. F. 19 Sore throat and cough -2 ++

?::
s:
;:t.
P.W. M. 22 Cough and dysphagia +8 +++ :;tl
K.G. F.
n
34 Dry cough and dysphagia -7 ++ Tonsils present 0
"'":I
B.M. F. 44 Cough, dysphagia +11 and-11 ++ "'":I
t'>:I
A.B. F. 36 Constant sore throat and cough +5 +++
E. B. F. 21 Recurrent sore throats -1 +++

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
R. S. M. 13 Cough and sore throat +4 ++
E.H. F. 38 Dysphagia and dry cough -6 ++
B.D. F. 16 (?) Dry cough and sore throat -10 +++ Undergoing X-ray
treatment
M.L. F. 17 Frequent sore throats and colds -3 +++
 TABLE I (CONTINUED)

Appearance of Pharynx,
Amount of Lymphoid
Initial Sex Age Symptoms B.M.R. Tissue

C. P. M. 14 Sore throat and frequent colds -4 ++ o

E. S. M. 43 Cough and dysphagia -2 ++ ::r:
:;tI
0
H.W. M. 38 Dry cough, fullness in throat +3 ++ Z
J. B. F. 18 Cough and sore throat -6 ++ o
-
o
:;tI
M. J. F. 22 Cough and sore throat -5 +++ ~
Dry cough and sore throat
Z
R.H. M. 25 -4 ++ c::
r-
S.M. M. 13 Frequent colds and sore throat +8 ++ ~
:;tI
Dry cough and dysphagia (hypogonadism) ~
L. G. F. 22 -16 ++ ::r:
~
A.J. F. 31 Colds and dry cough +2 ++ :;tI
><
K.B. F. 28 Dry cough and sore throat +3 ++ Z
C'l
E.W. M. 37 Fullness in throat and cough +1 +++ ""'i

M. 31 Dysphagia and cough -4

R. K. ++ -'-"

Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 24, 2015
R.P. M. 43 Frequent colds and sore throat -1 ++
C. P. M. 18 Cough and sore throat (hypogonadism) -16 ++

~
.....
CN