Bronchadenitis

BRONCHADENITIS, inflammatory lesion of the lymph glands of the mediastinum—the so-called bronchial glands (see). This lesion, acute or chronic, non-specific or tuberculous, occurs mainly in childhood. Non-tuberculous bronchadenitis (bronchoadenitis simplex) occurs in a number of infectious diseases accompanied by lesions of the respiratory tract: a) particularly frequently in whooping cough, measles, influenza, and less frequently in typhoid or in the presence of bronchitis, especially bronchopneumonia, both during the acute phase of the disease and after the primary disease; b) in pneumonia; c) in acute and chronic diseases of the nasopharynx, hypertrophy of the tonsils and adenoid vegetations, despite the absence of anatomical connection with tracheo-bronchial diseases; d) in stagnant catarrhs of the respiratory tract in cardiac patients; e) in congenital syphilis in early childhood. In the overwhelming majority of cases (70% of all B., Maslov), the etiology of B. is tuberculous (pathological anatomy of B.—see Lymphadenitis).- Pathogenesis. The localization of the tuberculous process in the tracheo-bronchial glands is almost obligatory in every case of tuberculosis in children (Kflss, Albrecht, Gohn—in more than 95% of all cases of tuberculosis; Marfan, Comby—in almost 100%). This frequency of localization of the tuberculous process in the bronchial glands is currently associated with the doctrine of the predominantly aerogenous method of infection with tuberculosis, according to which the tuberculous agent is retained in the lung tissue, forming a primary lesion (Gohn's primary nodule), from which bacilli move to the regional lymph glands (primary complex of Ranke); from there, the bronchial glands of higher groups are affected by lymphogenous means. According to others, tuberculous B. is primary and occurs hematogenously (Baumgarten, Kisel, Calmette). All, however, agree that the tracheo-bronchial glands are the most frequent localization of the process in childhood. The intensity and extent of glandular lesions in children can many times exceed the degree of spread of the primary pulmonary focus. The primary focus in its fresh state, representing a small pneumonic infiltrate, cannot be recognized; only when it passes into induration or calcification is it sometimes accessible to X-rays; meanwhile, the significantly affected bronchial glands can be recognized clinically and radiologically much earlier. Therefore, great importance is attached to the clinic and symptomatology of B. Clinic. The frequent, almost usual, lesion of the bronchial glands in tuberculosis in children makes it probable that in every tuberculous-infected child (presence of a positive tuberculin test) the process is localized in the bronchial glands. This gives some basis in cases of hidden (latent) tuberculosis, in the absence of clinically recognizable localization, to attribute the entire complex of subjective and objective data in the child to the clinical manifestations of tuberculous B. The diagnosis of B., which is often made, is usually based on individual signs of physical examination of the chest and on questionable X-ray data, especially unclear shadows of Julius'ob, in the presence of a number of general symptoms: subfebrile temperature, weight loss, weakness, etc. Meanwhile, with a critical assessment of all the symptomatology, taking into account anatomotopographic data, in comparison with X-ray and clinical data, and the latter with autopsy data, there is little basis for such widespread diagnosis, and reliable recognition of B. is possible in a much more limited number of children. The clearest clinical symptoms of B. are given by early childhood, in which there is a significant lesion of the glands (entire groups, fusing together, form a nodular mass the size of a pigeon's egg or larger), which, compared with the small size of the chest, gives favorable anatomical ratios for clinical recognition. For the same reason, at this age the symptoms of compression of neighboring organs by the affected glands are more pronounced, namely: 1. Dilatation of the veins of the neck and upper part of the chest, more on the right side (from compression of the superior vena cava by the right paratracheal glands). Compression of the superior vena cava leads to bulging of the jugular veins, cyanosis, edema of the face, neck, and arms. 2. The most characteristic symptom, especially in early childhood, is expiratory dyspnea (noisy breathing) and a sonorous, two-tone (toux bi-tonale) cough, explained by the pressure of the affected glands on the trachea and large bronchi. In older childhood, the sonorous cough often has a whooping cough-like character. 3. In some cases, especially in early childhood, a severe stenotic symptom complex may develop: severe dyspnea, cyanosis, stagnation in the veins of the chest, neck, head, bulging eyes, dilatation of the pupils. The intensity of these symptoms often changes. They are sometimes observed for months and may disappear due to the subsequent calcification or shrinking of the glands. 4. More rare symptoms are: dysphagia, tachy- or bradycardia (compression of the vagus nerve), chronic inspiratory dyspnea and hoarseness (compression of the recurrent nerve), anisocoria (compression of the sympathetic nerve). In addition to the size of the glands and their corresponding localization, peradenitic processes also play a large role in the mechanism of compression symptoms. Favorable anatomotopographic conditions make the percussion phenomena more pronounced in B. in early childhood, compared with older childhood: 1. Dullness over the upper part of the sternum and at the edges of the sternum (Filatov's symptom) is noted with a significant lesion of the glands of the right tracheo-bronchial angle (it is necessary to exclude enlargement of the thyroid gland, the presence of mediastinal tumors, heart diseases). 2. Dullness in the interscapular area (according to Biedert, at the height of II-III, according to Schlossmann, Marian, from III to V thoracic vertebrae) depends more on the presence of perifocal changes than on the lesion of the glands themselves (Finckelstein). The listed percussion changes are possible only with a significant lesion of the glands and cannot be considered frequent (Zabel). 3. The more tested and reliable is the phenomenon of Koranyi-de la Camp; dullness over the spinous processes of V-VII thoracic vertebrae; with quiet percussion from bottom to top, dullness in the area of IV-VI vertebrae indicates a lesion of the bifurcation glands, I-IV vertebrae—a lesion of the tracheo-bronchial glands. And this symptom has not acquired a finally established and reliable value. Among the auscultatory phenomena, the symptom of d'Espine is encountered—bronchophony on the spine between the VII cervical and IV-V thoracic vertebrae, when listening to a loud voice and cry and when listening to whispering (chuchotement). This symptom is given great importance in preschool and school age (Redeker, Medovikov); however, many deny its reliability and reliability (Kleinschmidt, Wiese). Among other auscultatory data, tracheal breathing in the area of I-IV thoracic vertebrae and the appearance of venous noise on the sternum with the head thrown back (Smith), as is believed, are not specific and not constant. The symptom of Petruschky—pain on pressure on the spinous processes of II-VII thoracic vertebrae—is also considered rare. The listed symptoms without X-rays are insufficient for the diagnosis of B. But even the evaluation of X-ray data of fluoroscopy and radiographs requires a very critical approach, especially regarding the etiology of the lesion. The presence of the median shadow of the heart, large vessels, trachea and main bronchi in frontal fluoroscopy and radiographs hides the shadow of the bifurcation glands and most groups of glands on the left side. Therefore, fluoroscopy should be performed in frontal and various oblique positions and each time supplemented with radiographs [see separate table (p. 287-288), fig. 2-4]. The right paratracheal glands are most accessible to X-rays, which, due to their topography with their significant lesion (tuberculosis), give an arched expansion to the right of the upper part of the median shadow. The right bronchopulmonary glands give clear changes in the right hilus, the left ones are less accessible to X-rays. The evaluation of the shadows of the hilus requires great caution: the presence of an enhanced pattern of the right hilus is not sufficient for diagnosis—spots and streaks can be obtained when using very soft tubes. Clear outlines of the affected glands on the radiograph are present in case of caseation of the glands with calcification or an indurative process; in fresh lesion of the glands and in the presence of perifocal changes, the shadows are less defined. The presence of perifocal changes of the glands of the right hilus gives significant shadows, indicating a highly active state of the tuberculous process (see Tuberculosis). Collateral changes of the hilus glands can also occur in non-specific adenitis, therefore all the above is not exclusively characteristic of tuberculous B., for the diagnosis of which it is necessary to take into account the entire clinical picture, with the mandatory use of tuberculin tests (Pirquet, Mantoux). Diagnosis. The diagnosis of B. is very difficult. Often a significant tuberculous lesion of the intrathoracic lymph glands gives very meager clinical and radiological data.

On the other hand, it is necessary to keep in mind other lesions localized and sometimes originating from the glands of the mediastinum: lymphogranulomatosis, lymphosarcomatosis, metastases of tumors, mediastinitis, etc. The almost obligatory participation of bronchial glands in every tuberculous disease in a child always makes this localization diagnosis probable, but such a diagnosis, without clear clinical and X-ray data, is purely speculative. Rare cases of extrapulmonary localization of the primary complex in cases of death from accidental causes sometimes confirm the complete unfoundedness of such a diagnosis. In the absence of clear local clinical and X-ray data and in the presence of a number of general symptoms, such as subfebrile temperature, anemia, malnutrition, with a positive Pirquet reaction, the usual diagnosis of B. cannot always be confirmed anatomically [tuberculous intoxication (Kisel), hidden tbc (Engel)].--The prognosis for non-tuberculous B. depends on the underlying disease of the respiratory tract. An unfavorable transition to suppuration with breakthrough into neighboring organs is rare (see above). In tuberculous B., the prognosis depends on the consideration of the overall clinical picture and the involvement of other organs. Even at the very earliest age, with clear clinical and X-ray data, clinical recovery may occur. Most often, with a sharply expressed clinical picture of tuberculous B., especially in early childhood, behind the clinical manifestations of gland involvement, there follows the picture of development of the pulmonary process, the picture of hematogenous dissemination in other organs or miliary tbc. The breakthrough of a caseous gland into neighboring organs is rare and always leads to a catastrophe.-The treatment of tuberculous B. reduces to the treatment of tbc in general (see Tuberculosis, treatment); nutrition, helio- and aero-therapy should be placed in the first place. As for the treatment of B. by special physical methods, along with the quartz lamp, X-ray therapy and treatment with radium (Nobecourt) are available. Regarding the use of the latter two methods, great caution is necessary. Their application is still little studied and represents a double-edged weapon (Kleinschmidt, Bacmeister). The treatment of non-tuberculous B. reduces to the treatment of the underlying disease and the application of a general strengthening regimen and physical methods of treatment.