Acta Oto-Laryngologica

ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage:

The Influence Of Cigarette Smoke On The Pharyngeal Mucosa Z. Radsel & V. Kambc To cite this article: Z. Radsel & V. Kambc (1978) The Influence Of Cigarette Smoke On The Pharyngeal Mucosa, Acta Oto-Laryngologica, 85:1-6, 128-134, DOI: 10.3109/00016487809121433 To link to this article:

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Date: 14 April 2016, At: 17:55

Acta Otolaryngol85: 128-134, 1978


Z. RadSel and V. Kambii: From ENT Clinic, University ofljubljana, Ljubljana, Yugoslavia

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(Received February 22, 1977)

Ahstrnct. The influence of cigarette smoke on the pharyngeal mucosa was investigated in a clinical study and in an experiment on animals. Histologic reports were evaluated according to the KambiE-Lenart classification of hyperplastic aberrations of the throat mucosa. A close dependence of the degree of hyperplasia and the number of cigarettes smoked was revealed. The more cigarettes the patients smoked every day, the more evident were changes on the mucosa. more clearly manifested in male than in female smokers. It was observed that the changes related to the hyperplasia atypica were more evident the longer the patients smoked. They were also more intense the younger the smokers were when they started smoking. In the experiment on animals, a number of factors with additionally noxious influence on the pharyngeal mucosa were excluded. A great interdependence was observed between the number of daily inhaled cigarettes and the changes on the pharyngeal mucosa.

Various pathological changes on the pharyngeal mucosa and the number of malignancies in this region are on the increase. Frequent occurrences of disease in the upper respiratory tract are associated with an altered way of life and a high standard of living, and industrialization. Smoking today stands accused as a significant factor in the incidence of specific diseases. According to the reports of the WHO, 80% of all cancers are caused by exogenous agents, or these agents contribute, at least to some extent, to the incidence of cancer (Silverberg & Holleb, 1973). Kambir & Lenart (1968, 1971) believe that endogenous factors, i.e. hormones, prepare favourable group for This research has been sponsored by the Slovene Research Association.

the activity of the exogenous agents and are involved in the increased risk of cancer of the larynx. Research has been conducted to determine the effect of cigarette smoke on the laryngeal mucosa in humans and in experimental animals. We wanted to see whether the increased number of cigarettes smoked daily might lead to changes in the pharyngeal mucosa. These changes were evaluated by the Kambic-Lenart classification of hyperplastic aberrations in the mucous membrane of the throat (Fig. 1). The authors divide hyperplastic changes into three grades-simple, abnormal, and atypical hyperplasia. Hyperplasia simplex and hyperplasia abnormalis represent mainly the hyperplastic process on the epithelium of the laryngeal mucosa which normally does not turn malignant. In a simple hyperplasia, the epithelium thickens on account of the prickle cell layer. The basal layer remains unchanged. In subepithelial tissues very few immunocompetent cells are observed. In abnormal hyperplasia, the epithelium thickens on account of the basalification. Basal cells extend to the middle of the epithelium; thc- are no pathologic mitoses or atypias anywhere. Subepithelial tissue contains more immiinocompetent cells. In the atypical hyperplasia, cells of the entire hyperplastic epithelium have the shape of basal cells. Nuclei are hyperchromatic and slightly polymorphic; here and there partially atypical mitoses appear. The subepithe-

Influence of cigarette smoke on the pharyngeal mucosa

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Fig. 1 . The KambiE-Lenart classification of hyperplastic changes on laryngeal rnucosa: 0, Normal epithelium; 1 ,


hyperplasia simplex; 2, hyperplasia abnormalis; 3 , hyperplasia atypica; 4a, Ca in situ; 4b, Ca invasivum.

ad modum Ryan et al. (1955), by the number of cigarettes they smoked per day. The first group consisted of those who smoked up to 9 cigarettes per day. In the second group they smoked 10 to 15, in the third 16 to 20, in the fourth 21, to 34, and in the fifth, more than 35. In addition, there was a control METHODS group of non-smokers. For the inhalation of cigarette smoke in Fourty-six male and 36 female patients have been surveyed. They suffered chronic ton- animals, a special method was developed, sillitis and underwent tonsillectomy. The pa- based on the flow of air and cigarette smoke. tients were mostly young people, aged 24, on We used a special apparatus which enabled a average, except for 3 who were 16 and one constant apportionment of gases and the flow who was over 50. Their occupations ranged of the mixture through the container. This procedure made a longer exposure to the cigarette from farm and factory workers to clerks. In 41 patients, tonsils were removed be- smoke possible. The apparatus consisted of a cause of frequent purulent tonsillitis. Besides glass cylinder and a cover with a rubber recurrent purulent tonsillitis 32 patients washer on its brim and three openings through suffered pain in the throat, a sense of dis- which the blend of air and cigarette smoke comfort and of having a foreign body in the entered, and gases from the box were repharynx during phases of the disease. Three leased. The third opening was used for patients had peritonsillar abscesses, one had measuring the temperature, moisture, CO, polyarthritis, one had kidney inflammation, and CO in the box. Cigarettes burned in a special Raucher Vulkan’s device which pulsed and one alopecia areata. After the removal of tonsils, a piece of a mixture of air and the smoke of three cithe mucosa from the left and right frontal garettes into the box through a rubber tube. palatine arch was removed for histologic ex- Gases were pumped from the box by a water amination. The operation was in no way more pump connected to the water network. 42 complicated by this additional procedure, nor male mice of the Albany breed, 4 months old, did the patient suffer any injury, since the were used in this experiment. The mice were tissue taken was that which is normally re- divided into five groups of 7 and a control moved in tonsillectomy. group which was not exposed to cigarette The patients were divided into five groups, smoke. The smoke of three cigarettes was in-

lial tissue is full of immunocompetent cells, which is significant for this aberration. By experimenting on animals we wanted to confirm, accept, or refute our investigations in humans.

Actcr Otolarvnpl85

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2. Rads'el und V . Kambic'

Fig. 2. Pharyngeal mucosa in human: Hyperplasia simplex. HE, x255.

Fig. 3. Pharyngeal mucosa in human: Hyperplasia abnormalis. HE, ~ 2 5 5

Fig. 4 . Pharyngeal mucosa in hu-

man: Hyperplasia atypica. HE, x210.

Influence of cigarette smoke on the pharyngeal mucosa

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Table I. Relationship between the degree of hyperplasia and the number of cigarettes smoked daily Number of cigarettes


Hyperpl. simplex

0 9 15 20 34 40

3 0 0 0 0 0

11 4 2 1 0 1

Hyperpl. abnormalis I

Hyperpl. atypica 0 4 3 4 6 5


10 9 8 3

haled by the mice once to five times per day, five times a week, during 10 weeks. The mice were sacrificed immediately after the last exposure. In one mouse from each group, femoral vein was incised, blood for the COHb test was examined, and the pharyngeal mucosa was examined microscopically RESULTS In checking the first group of patients, we observed that 4 patients had signs of simple hyperplasia (Fig. 2), 7 patients showed abnormal hyperplasia (Fig. 3 ) , and 4 the atypical one (Fig. 4). In the second group, 2 patients had a simple, 10 the abnormal, and 3 the atypical hyperplasia. In the third group the simple hyperplasia was diagnosed in one patient, the abnormal in 9, and the atypical in 6. In the fourth group, 8 patients showed the abnormal, 6 the atypical hyperplasia. In the fifth group one patient showed the simple stage of hyperplasia, 3 the abnormal, and 5 the atypical one. In 3 patients from the control group, the pharyngeal mucosa was healthy. A simple hyperplasia was observed in 11 patients of this group and only in one patient was the abnormal stage ofhyperplasiadiagnosed (Table I). The experimental mice were regularly Table 11. Relative weight increase in mice Group ... Increase ...

control 4.4

1 3.9

2 2.2

3 3.2

4 1.6




Table 111. COHb in mice blood COHb Group



0 20 20 28 34 31


2 3 4 5

weighed and the relative weight increase was. measured. Their weight diminished when the daily number of the inhaled cigarettes increased. The highest relative weight increase was observed in the mice of the control group (Table 11). No COHb in blood was found in animals of the control group. The COHb level increased with the number of exposures to the cigarette smoke up to 34% as in heavy smokers (Table 111). Autopsy of the mice revealed no macroscopic pathologic changes on the pharyngeal mucosa. The mucous membrane was pale pink and moist. In one mouse from groups 2, 3, 4 and 5 , an atelectasis of lungs was observed. In 2 mice from group 4, changes in the lungs were observed which were histologically diagnosed as abscesses. Microscopic examination revealed that the thickness of the epithelium had decreased on account of the prickle cell layer, when the number of exposures increased. With the increased number of inhalations the number of mitoses increased. These were measured in ten fields of view (Table IV). The following observations were made in separate groups: 1st group= a simple hyperplasia was observed in 2 mice, atypical in one, abnormal in 4 2nd group=simple hyperplasia was seen in 2, abnormal in 4 mice, atypical in one 3rd group= simple hyperplasia developed three times, abnormal and atypical twice each 4th group= simple hyperplasia was seen in one mouse, abnormal in 4, atypical in 2 Acrri Orolaryngol85

Z . Raa’iel and V . Kambii:

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Fig. 5. Pharyngeal mucosa ii mouse: Normal epithelium. HE X255.

Pharyngeal mucosa in mouse: llasia simplex. HE, x255.

Pharyngeal mucosa in mouse: lsia abnormalis. HE, ~ 2 5 5 . Acta Otolaryyngol85

Influence of cigarette smoke on the pharyngeal mucosa Table IV. Number of mitoses in different groups (measured in tenfields of view) Group

Number of mitoses

Control 1 2 3 4 5

9.28 9.28 14.28 13.71 13.57 19.00

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5th group= abnormal hyperplasia developed in 3 mice, atypical in 4. Five mice in the control group had a healthy mucosa, and 2 showed symptoms of simple hyperplasia (Figs. 5-7). DISCUSSION In spite of the obvious influence of the cigarette smoke on the incidence of malignancies in the pharynx, it is impossible to establish its effect accurately. We are of the opinion that alcohol and hygienic and dietetic factors (Rothman & Keller, 1972; Schmidt & DeLint, 1972) are also associated with the occurrence of cancer in this region. It is very difficult to determine the effect of separate agents. Differences in their degree of risk render the evaluation of the effect of these factors even more complex. Besides, the number of the cigarettes smoked each day is not constant, all smokers do not inhale in the same way, nor exhale the same composition of gases. In the experiment on animals these factors were not considered, and consequently only the effect of the cigarette smoke on the pharyngeal mucosa could be investigated. The basic prerequisite for the experiment on animals was the production of a human model of smoking, though it was not possible to develop an ideal one. In smokers, solid particles of the cigarette smoke are arranged differently, the bulk of them remaining in the nose (Dalhamn et al., 1968). In humans, lungs are the most exposed


region; in animals, fewer particles enter the lungs. Almost any method of supplying cigarette smoke to animals is unnatural and, even with the best technical equipment, the dose of cigarette smoke which the animal receives cannot be exactly established (Armitage et al., 1974). We have proved, however, that cigarette smoke has a harmful effect on the pharyngeal mucosa of mice. The greater was the number of cigarettes inhaled, the more severe were the changes on the mucous membrane (r=0.70, a=0.001). With the increase in daily number inhaled cigarettes, the number of mitoses rose (r=0.50, a=O.OOl), the epithelium grew thinner on account of the prickle cell layer and the basal layer grew. In the experiment on animals, a number of factors having an additionally noxious effect in humans, were eliminated, and consequently, our observations show only the influence of the cigarette smoke. We have to consider the fact that exposures were of short duration, that the animals were sacrificed immediately after the experiment, and that the corneous mucosa of the pharynx in mice is less prone to the harmful effect of smoking than is so in humans. However, there is evidence that even in animals the cigarette smoke does affect the pharyngeal mucosa. CONCLUSION In our research into the dependency between the degree of hyperplasia and the number of Table V. Relationship between the degree of hyperplasia and the number of cigarettes inhaled daily in mice Number of cigarettes

0 3 6 9 12 15



Hyperpl. simplex 2 2 2 3


Hyperpl. abnormalis

4 4 2 4 3

Hyperpl. atypica

1 1

2 2 4 Actn Ofolaryngol85

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Z . RadSel and V . Karnbi?

cigarettes smoked daily, the following conclusions were reached. The greater was the number of cigarettes smoked, the greater were the changes on the pharyngeal mucosa (r=0.75, a=0.001). The earlier the age when smoking started, the greater the changes that occurred (r=0.51, a= 0.001). Our studies indicate that in male smokers, smoking the same number of cigarettes daily, the changes that fall into the atypical hyperplasia category were more frequent than in women. x2 test for evaluating the relationship between the variables has proved significant at the 0.01 level. Differences in the degree of hyperplasia show that there are endogenous agents to be considered, as has already been pointed out by Kambit et al. (1973).

ZUSAMMENFASSUNG Der EinfluS des Zigarettenrauches auf die Rachenschleimhaut wurde in einem klinischen Experiment und im Tierversuch untersucht. Die histologischen Resultate wurden nach der Klassifikation von Kambii: und Lenart fur die hyperplastischen Aberrationen an der Kehlkopfschleimhaut gegliedert. Die Autoren haben einen groSen Zusammenhang zwischen dem Schweregrad der Hyperplasie und der Zahl taglich gerauchter Zigaretten gefunden. Je mehr Zigaretten die Patienten taglich rauchten, um so groRer waren die Veranderungen an der Rachenschleimhaut, ausgepragter beim Mann als bei der Frau. Der Grad der Hyperplasie war auch von der Zeit abhangig; je langer die Patienten rauchten, desto mehr atypische Hyperplasien wurden in den histologischen F'raparaten gefunden. Im Tierversuch konnten einige zusatzliche schadliche Faktoren fur die Rachenschleirn-

Actu Otolaryngol85

haut ausgeschieden werden. Auch bei den Mausen fanden die Autoren einen groRen Zusammenhang zwischen der Zahl der taglich inhalierten Zigaretten und dem Schweregrad der Hyperplasie der Rachenschleimhaut .

REFERENCES Armitage, A. K., Houseman, T. H., Turner, M. D. & Wilson, D. A. 1974. The evaluation of a machine for introducing tobacco smoke into the lungs of anaesthetised animals during spontaneous respiration. Q J Exp Physiol59, 43. Dalhamn, T., Edfords, M. L. & Rylander, R. 1968. Retention of cigarette smoke components in human lungs. Arch Environ Health 17, 746. KambiE, V. & Lenart, I. 1968. Untersuchungen iiber die Wirkung von Testosteron auf die Kehlkopfschleimhaut des Hundes. H N O 11, 327. - 1971. Notre classification des hyperplasies de l'epithelium du larynx au point de vue pronostic. J Fr Otorhinolaryngol 20, 1145. KambiE, V . , Lenart, I., Lenart, V. & RadSel, Z. 1973. Beitrag zur Frage der Reversibilitat bzw. Irreversibilitat von Gewebsveranderungen, die bei Hunden nach der i.m. Verabreichung von Testosteron an der laryngealen Schleimhaut auftreten. H NO 21, 300. Rothman, K. & Keller, A. 1972. The effect of joint exposure to alcohol and tobacco on risk of cancer of the mouth and pharynx. J Chron Dis 25, 71 1. Ryan, R. F., McDonald, J . R. & Devine, K. D. 1955. The pathologic effect of smoking on the larynx. Am J Pathol60, 472. Silverberg, E. & Holleb, A. I. 1973. Cancer statistics 1973. CA: Cancer J for clinicians 23, 2. Schmidt, W. & DeLint, J. 1972. Causes of death of alcoholics. Q J stud Alcohol 38, 171. Z . RadSel, M.D. OforinolaringoloSka klinika KliniEni center Zaloika 2 61000 Ljubljana Yugoslavia

The influence of cigarette smoke on the pharyngeal mucosa.

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