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Respiratory II Exam 1 > Head and Neck Pathology (2)- Gomez > Flashcards

Head and Neck Pathology (2)- Gomez Flashcards

1
Q

Squamous Papillomas

A

(verruca vulgaris/wart of nasal vestibule)
Arises in squamous mucosa
More common than sinonasal (Schneiderian) tumors

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2
Q

Schneiderian Papillomas

A

Benign neoplasms (but locally destructive)
Derived from embryologic Schneiderian membrane-like epithelium
Located in sinonasal tract (nasal Schneiderian mucosa)
Three Types
Exophytic (septal, squamous) ~50-60%
Inverted (lateral, squamous) ~40-50%
Oncocytic (lateral, cylindrical/columnar) ~5-10%
Symptoms: epistaxis, nasal obstruction, asymptomatic mass

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3
Q

Exophytic Sinonasal Papilloma

A

(Septal, Squamous, Fungiform)

Occurs on septal nasal wall (less than 10% lateral)
20 – 50 yr; 4-10M:1F
HPV 6/11 in ~60%
Recurrence: ~25% if not completely excised
Rarely (almost never) develops invasive carcinoma

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4
Q

Inverted Sinonasal Papilloma

A

Occurs on lateral nasal wall near middle turbinate or sinus
40 – 70 yr; 2-5M:1F
HPV 6/11 in ~40%
Recurrence: 15% even with aggressive surgery
5-10% develop invasive carcinoma within 5 years

Nests of proliferating squamous epithelium grow inward
Downward - Inverted

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5
Q

Oncocytic Sinonasal Papilloma

(Cylindrical, Columnar)

A

Occur on Lateral nasal wall near middle turbinate
>50 yr; 1M:1F
HPV Association: None
Recurrence: 25-35% (even after aggressive surgery)
Some may develop invasive carcinoma
Oncocyte = abundant bright pink cytoplasm (from mitochondria in this tumor)

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6
Q

Olfactory Neuroblastoma

A

(Esthesioneuroblastoma)

Arises from neuroectodermal olfactory cells in olfactory mucosa
Neurosecretory (membrane bound) granules by EM,
Numerous IHC markers may be positive (NSE, SYP, CgA, CD56 [NCAM])
Average age onset bimodal- 15 and 50 years of age (Range 3-90)
Often extensive polypoid mass, obstruction, epistaxis, anosmia, visual disturbance
Rx- surgery, radiation and chemotherapy
5-year Survival 40-90%, varying biologic activity

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7
Q

Pharynx – Three Major Divisions

A

Mucosae

Nasopharynx
60% NK squamous*
40% Respiratory epithelium

Oropharynx
100% NK squamous

Laryngopharynx
100% NK squamous

*NK = “non-keratinizing”
= no cornified layer

Misnomer -All squamous epithelium makes keratin

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8
Q

larynx

A

it is not part of the laryngopharynx). The larynx is covered variably by respiratory and squamous mucosae.

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9
Q

Upper “Airway” Lymphoid Structures

A

Exposure/surveillance environmental antigens
Diffuse submucosal lymphoid aggregates (nasal cavity)
Tonsils
Palatine tonsils - covered by squamous epithelium
Lingual tonsils - covered by squamous epithelium
Adenoids (pharyngeal tonsil) - covered by respiratory epithelium

Waldeyer’s “tonsillar” ring

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10
Q

Nasopharynx

A

Airway between nasal cavity (anterior-superior) and oro- & laryngopharynx (inferior)
Subject to same infectious & inflammatory (e.g., allergic) conditions that affect nasal mucosa

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11
Q

Obstruction of the internal auditory canal by hypertrophic adenoidal tissue
leads to

A

recurrent otitis media

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12
Q

Obstruction in upper airway

leads to

A

sleep apnea

Observed episodes of sleep apnea
Snoring	 
Difficult to arouse 
Daytime sleepiness 
Poor attention span
Poor school performance
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13
Q

Pertussis / Whooping Cough - cause, vaccine

A

Bordetella pertussis
Extremely small gram-negative coccobacilli
Spread via respiratory droplets
Maximal in catarrhal stage (earliest stage)
secondary attack rate up to 80% in households
Vaccine - DTaP (diphtheria/tetanus/acellular pertussis)
Tdap (tetanus toxoid, low dose diphtheria toxoid and acellular pertussis) booster
Attaches to pharygneal and tracheal surfaces
Dx - Nasopharyngeal swab for culture & PCR or serology

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14
Q

Whooping Cough/Pertussis Stages

A

Stage 1 - Catarrhal phase
Indistinguishable from common upper respiratory infections.
Nasal congestion, rhinorrhea, and sneezing
Pertussis is most infectious when patients are in the catarrhal phase

Stage 2 - Paroxysmal phase
Paroxysms of intense coughing
Posttussive vomiting and turning red are common
Coughing occasionally followed by a loud whoop as inspired air goes through a still partially closed airway
Infants younger than 6 months do not have the characteristic whoop but may have apneic episodes

Stage 3 - Convalescent phase
Chronic cough which may last for weeks

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15
Q

Nasopharyngeal Angiofibroma (NA)

A

Epidemiology: RARE –
Occurs almost exclusively in young males (often redheads)***
onset 10-20 years (rare > 30); “Juvenile NA”
Symptoms: Unilateral nasal obstruction and epistaxis
can also include swelling of face, eye, cheek
Clinical Behavior: Posterolateral wall fibromuscular stroma origin
Benign, but 10-20% are locally aggressive and 9% are fatal
Tumor cells have androgen receptors and may resolve with age

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16
Q 
Nasopharyngeal Angiofibroma (NA)
 treatment and prognosis
A

Treatment: Surgery, hemorrhagic complications not uncommon
- requires pre-op arteriogram with pre-surgical embolization

Prognosis: Excellent after removal; local recurrence rate of 5-25%
Prognosis depends on extent of resectability

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17
Q

Nasopharyngeal Carcinoma subtipes and epidemiology

A

Three histopathologic types
Keratinizing - squamous cell carcinoma (SqCC)
Nonkeratinizing - squamous cell carcinoma
Undifferentiated/basaloid carcinoma, with lymphoid component*

Epidemiology
	EBV-related (+EBER-1)**
 	environment associations
		diet (nitrosamines), smoking
**	Africa: Common in children (not adults) 
**	S. China: Common in adults (not children)
	USA: Rare
Clinical Course
	Freq. unresectable at diagnosis 
		[+metastases in 70%]
	Treat with radiotherapy
	Five year survival (after Rx) 60%
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18
Q

NUT Midline Carcinoma

A

Mostly mediastinum (35% head and neck
Any age or sex
Highly aggressive (median survival 7 mo.)
Appearance similar to nasopharyngeal and squamous cell carcinoma
BRD4/BRD3-NUT fusion gene (inhibitors being developed)

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19
Q

Pharynx – Oropharynx

A

Not really part of airway; represents
posterior portion of oral cavity

Acute tonsillitis, acute pharyngitis: “beefy red”

Most of these are due to Adenovirus (some HSV, EBV, cytomegalovirus, some bacterial- Streptococcal)

20
Q

Group A Streptococcus (GAS)Typical Clinical Features

A

age 5-15 yrs
winter-early spring
Sore throat + fever

Strawberry tongue (red swollen), petechiae on palate, erythematous pharynx
Absence of cough, coryza, hoarseness, conjunctivitis
(these suggest a virus)

Tender anterior cervical lymph nodes
Tonsils are enlarged , erythematous and have patchy exudate (follicular tonsillitis)

21
Q

Fusobacterium necrophorum

A

~10% acute pharyngitis cases
>20% in recurring cases and in peritonsillar abscesses
May cause associated abscesses especially peritonsillar abscesses
–Jugular vein with thrombophlebitis (Lemierre syndrome)
– Thrombi break off and seed to different sites

(Filamentous, anaerobic, Gram-negative rod)

22
Q

Corynebacterium diphtheriae

A

strains carrying tox gene cause diphtheria
Gene encoded within a lysogenic bacteriophage

Diphtheria
Sudden onset of exudative pharyngitis that gets much worse over 3 days or so
Production of pseudomembrane

23
Q

Viral Pharyngitis

A

Rhinoviruses (~20%) - Indirect pharyngitis. Grow in nasal mucous membranes and causes swelling of membranes in the area and pharynx.

Adenoviruses –> pharyngoconjunctival fever

EBV - Infectious mononucleosis - Monospot test for heterophile antibodies

HSV types I and 2 - Gingivitis, stomatitis and pharyngitis, vesicles

Influenza - Pharyngitis is a common component

Parainfluenza and coronaviruses

Enteroviruses (certain coxsackie and echovirus)

CMV and HIV- mononucleosis-type illness

24
Q

Laryngopharynx

A

=Hypopharynx & Larynx

Laryngopharynx & true vocal cords have squamous epithelium, most everything else covered by respiratory epithelium

25
Q

Epiglottitis = Laryngoepiglottitis

A

Swelling of epiglottis secondary to infections (most common), chemical, and traumatic agents
Complete blockage of the airway may occur (suffocation and death)
Airflow resistance increases
H. influenzae type b main cause prior to Hib vaccine where most patients were young (~2 yr) children
Pleomorphic Gram negative coccobacilli that colonize upper airways (predominantly encapsulated variants)
Also causes pneumonia, sinusitis, otitis media, meningitis, cellulitis
Also caused by RSV & β-hemolytic strep
Nowadays more common in adults (3M:1F), but pretty rare

26
Q

Acute Laryngitis defn, symptoms, common causes

A

Definition: Laryngitis < 3 weeks

Symptoms
Hoarseness (gradual onset, progressive)
Decreased vocal volume
Painful speech

Common Causes
Infections
Vocal overuse: Acute – loud yelling
Vocal overuse: Subacute – lecturing Heavy smoking (acute)
Direct trauma

Uncommon Causes
Acute allergic reactions
Acid reflux from the stomach (GERD)

27
Q

Infectious acute laryngitis

A

Clinical Course: abrupt onset, self-limited, less than 3 wk duration
Age of Onset: 3 – 5 yrs* & 18–40 yrs
Symptoms: progressive hoarseness (aphonia)
often concurrent upper respiratory tract infection (URI)
Laryngoscopy: vocal cords swollen and red
Etiology
Viruses > 90% cases: Rhinoviruses, Parainfluenza, RSV, Adenoviruses
Bacteria causes: H. influenzae, S. pneumonia

*In children may lead to life-threatening laryngoepiglottitis!

28
Q

Croup / Laryngotracheitis / Laryngotracheobronchitis

A

inspiratory stridor

seal-like barking

mainly parainfluenza

Steeple sign- subglottic narrowing, absent in about half the kids

Pathogenesis
Infection via aerosol into nasopharynx and spread to larynx and trachea
Edema and inflammation in subglottic larynx and trachea around cricoid cartilage – airway narrowing. May have endothelial damage and loss of ciliary function. Fibrinous exudate may be formed and add to airway occlusion
Edema of vocal cords can cause hoarseness
Treatment
Supportive with short term steroids to reduce inflammation

29
Q

Reinke Edema (Polypoid Corditis)

A

Usually occurs in middle-aged females who are heavy smokers
Can also occur with heavy, recurrent voice strain
Develop husky low-pitched weak voices

Soft, gelatinous translucent expansion of cord surfaces caused by edema and expansion of Reinke space (lamina propria of vocal mucosa)

30
Q

Vocal Cord Nodules and Polyps

A

Pathogenesis: Reaction to injury of vocal cord

Hyperkeratosis
Increased myxoid stroma
Classic location at* junction anterior and middle third of cord*
Nodules - bilateral, small (~2-3 mm)
Polyp - unilateral, larger (~4-8mm)
Occurs following * sustained injury caused by
Heavy smoking
Heavy, recurrent voice strain (**singer’s nodules)
“They virtually never give rise to cancers”

31
Q

Vocal Cord Papilloma and Papillomatosis

A

Papillomas: Benign neoplasms located on true vocal cords

Usually single in adults, but can be recurrent
Multiple in children (juvenile laryngeal papillomatosis)

Caused by HPV types 6/11

32
Q

Squamous Cell Carcinoma of Larynx

A 
Clinical Findings
Prolonged hoarseness (> 6 wks) earliest, most consistent symptom

dysphagia, palpable cervical lymph nodes

Epidemiology
: most heavy smoking (> 50 pack years)
Ethanol abuse/dependence

33
Q

Location of Laryngeal Carcinoma

A
  1. Glottic carcinoma: involves the true vocal folds
    50-60% of laryngeal carcinomas
  2. Supraglottic carcinoma: confined to the supraglottic area (free border of the laryngeal epiglottis, false vocal folds and laryngeal ventricles)
    30-40% of laryngeal carcinomas
    Discovered later– early tumors do not cause hoarseness
    Higher stage tumors at diagnosis - 2/3 Stage III or IV
  3. Subglottic carcinoma: extend or arise more than 10mm below the free margin of the true vocal fold up to the inferior border of the cricoid cartilage.
    less than 5% of laryngeal carcinomas
  4. Transglottic carcinoma: cross the ventricle from the supraglottic area to involve the true and false vocal folds or involve the glottis and extend subglottically more than 10 mm or both.Glottic tumors: 5 yr survival ~65%
    Supraglottic tumors: 5 yr survival ~45%
34
Q

Squamous Cell Carcinoma of the Larynx

- terminology of extent

A

Intrinsic - confined to larynx
Extrinsic - beyond the larynx

Transglottic carcinoma
- the large, ulcerated, fungating lesion involving the vocal cord and pyriform sinus.

35
Q

Otitis Externa

A

Marked tenderness after gentle traction of pinna
Peak age between 7-12
Physical Findings: erythema, swelling, moist debris +/-pus
Etiology: Traumatized ear canal
excessive use cotton-tip swabs
retained contaminated water “Swimmer’s Ear”
Bacterial - 90%
Pseudomonas Sp - many

Fungal- 10% (aspergillus, candida)

36
Q

ear neoplasms

A

Simply skin tumors; i.e. squamous and basal cell carcinoma

37
Q

Middle Ear Anatomy

A

lined by thin “non-keratinizing” stratified squamous epithelium

ossicles: malleus, incus, stapes

38
Q

Acute Otitis Media- what we’ll see

A

Tympanic membrane opacity, bulging , erythema, effusion and decreased motility

39
Q

Chronic Otitis Media: causes and sequellae

A

Bacterial agents: Pseudomonas aeruginosa, S. aureus
Long-term sequellae: Perforation tympanic membrane, scarring, mastoiditis and bone erosion, cysts; conductive hearing loss common ***

ear-o? Aer-o and aur-o

40
Q

Middle ear cysts

A

Two types of cyst lining

Squamous epithelium (cholesteatoma): large amounts keratin produced 
Metaplastic columnar epithelium: mucin-secreting
41
Q

Cholesteatoma

A

Squamous epithelium trapped within the temporal bone (middle ear or mastoid)

42
Q

Otosclerosis

A

Autosomal dominant, variable penetrance

Progressive ankylosis/immobilization over decades → severe conductive hearing loss

Pathologic process
Callus of bone accumulates at footplate of the stapes and rim of oval window

43
Q

Neck - Branchial Cleft Defects

A 
Sinus tracts
Fistulas
Cysts (lymphoepithelial cyst)
Circumscribed ~2 - 5 cm 
20-40 y.o.

*** Lateral neck

Most arise from 2nd branchial cleft

44
Q

Thyroglossal Duct Cysts

A

Cyst in midline location

usually lined by respiratory or squamous epithelium and usually has chronic inflammation and thyroid follicles in the wall

45
Q

Neck - Carotid Body Tumor

A

Prototype of parasympathetic tumor

Bruit on auscultation ***

Slow growing, painless mass, pulsatile
May metastasize to lymph nodes and distant

Respiratory II Exam 1 (12 decks)

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