Head and Neck Pathology - SRS Flashcards
What are the two types of papillomas we covered?
Squamous papilloma
Schneiderian Papilloma
Squamous papillomas are more common than Schneiderian papillomas, and arise in the?
Squamous mucosa
Schneiderian papillomas are benign, but locally destructive neoplasms derived from embryonic schneiderian membrane like epithelium located in the sinonasal tract. What are the three types?
- Exophytic
- Inverted
- Oncocytic
Where in the nose do exophytic Schneiderian papillomas arise?
What cell type do they arise from?
Septal
Squamous
What part of the nose do the inverted schneiderian papillomas arise from?
What cell type?
Lateral
Squamous
What part of the the nose do oncocytotic papillomas arise on?
From what cell types?
Lateral
Cylindrical/columnar
What are three symptoms associated with schneiderian papillomas?
- epistaxis
- nasal obstruction
- asymptomatic mass
How often does the papilloma in the attached image develop invasive carcinoma?
Where does this papilloma arise?
Exophytic sinonasal papillomas arise on the septal nasal wall 90% of the time.
These rarely (almost never) develop invasive carcinoma
What infection is associated with the lesion shown below?
HPV in nearly 60% of cases
On histology of a papilloma removed from a patients nose you see a papillary structure with a fibrovascular core. What is this papilloma?
Exophytic Sinonasal Papilloma
(Septal, Squamous, Fungiform)
On histology of a papilloma removed from a patient you see the attached image, with nests of proliferating squamous epithelium, growing inward.
How many patients with this will develop invasive carcinoma within 5 years?
Where in the nose was this lesion likely excised from?
Inverted Sinonasal Papilloma occurs on the lateral nasal wall, near the middle turbinate most often.
5-10% develop invasive carcinoma within 5 years
What is the type of papilloma shown here?
Describe the characteristic features you see here.
Inverted sinonasal papilloma
Nests of proliferating squamous epithelium growing inward.
This papilloma was excised from the lateral wall near the middle turbinate. What type of papilloma are we looking at?
Is there an association with HPV?
Oncocytic Sinonasal Papilloma
(Cylindrical, Columnar)
No association with HPV
What is the recurrance rate of this tumor?
Do these invade?
25-35% recur
some may develop into invasive carcinoma
This small blue cell tumor was excised from the olfactory mucosa. You find neurosecretory (membrane bound) granules on EM. The patient presented with obstruction, epistaxis, anosmia and visual disturbances.
What tissue did this arise from?
What is the average age of onset?
What is the typical 5 year survival rate?
Olfactory Neuroblastoma (Esthesioneuroblastoma)
Arose from neuroectodermal olfactory cells
Average age of onset is bimodal - 15 and 50 yrs.
5 year survival rate is 40-90%
What are the three major divisions of the pharynx?
As you list them, say what types of epithelium you will find there.
- Nasopharynx
- 60% NK squamous*
- 40% Respiratory epithelium
- Oropharynx
- 100% NK squamous
- Laryngopharynx
- 100% NK squamous
What are the upper airway lympoid structures?
- Diffuse submucosal lymphoid aggregates
- Tonsils
- Palatine tonsils
- Adenoids
- Lingual
Identify the components of “Waldeyer’s Ring”
What is shown in the ring?
Lymph follicle
What are the palatine tonsils covered by?
Lingual?
Squamous epithlium for both
What are the adenoids covered by?
Ciliary columnar respiratory epithelium
The internal auditory canal can be obstructed by hypertrophic…
This leads to?
adenoidal tissue.
Leads to recurrent otitis media
If the tonsils obstruct the upper airway, what are some presentations you might see in a patient? 6
- Observed episodes of sleep apnea
- Snoring
- Difficult to arouse
- Daytime sleepiness
- Poor attention span
- Poor school performance
Pediatric patient presents with distinctive cough. Sputum culture reveals the tiny gram-negative coccobacilli in the attached image.
When you run PCR to confirm the diagnosis (or serology if thats your bag), what do you expect the diagnosis to be?
Describe the spread of this organsim.
Bordatella pertussis - whooping cough
Spread via respiratory droplets, maximal in catarrhal stage. Up to 80% secondary attack rate in households.
What are the phases of the sickness caused by the attached organism?
Pertussis
- Catarrhal phase
- paroxysmal phase
- convalescent phase
Pertussis is most transmissable in the catarrhal phase. What are the symptoms you see in this stage? What does it very much look like?
- Indistinguishable from common upper respiratory infections.
- Nasal congestion, rhinorrhea, and sneezing
Stage 2 of pertussis infection involves paroxysms of intense coughing with posttussive vomiting and flushing common copresentations. Why do patients get the distinctive whoop?
What patients do not get the whoop? What do they get instead?
- 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
What is stage 3 of pertussis? Describe briefly
Convalescent phase with chronic cough that may last for weeks
Ron Weasley presents to your office with the shown lobulated hypervascularized mass growing into the nasal fossa. History is significant for unilateral nasal obstruction, epistaxis and swelling of the eye, face and cheek.
What is this?
What people is this disease almost exclusive to?
Nasopharyngeal Angiofibroma (NA)
Almost esclusively in young males (often redheads)
Ron Weasly asks about the origin and course of the nasopharyngeal angiofibroma you diagnosed him with. What do you tell him?
Originates in the Posterolateral wall fibromuscular stroma
Benign, but 10-20% are locally aggressive and 9% are fatal
Ron Weasley further inquires about the treatment and prognosis for his NA. You tell him that?
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
What is the specimen shown in the attached image?
This is the nasopharyngeal angiofibroma you removed from Ron Weasely.
Nasopharyngeal carcinoma has what three histopathological types?
What cellular types are each of these associated with?
- Keratinizing - squamous cell carcinoma (SqCC)
- Nonkeratinizing - squamous cell carcinoma
- Undifferentiated/basaloid carcinoma, with lymphoid component*
What are the viral associations with nasopharyngeal carcinoma?
Other associations?
What geographical regions is it common in?
- EBV-Related
- environment associations diet (nitrosamines), smoking
- Africa - in children
- Asia in adults
An undifferentiated nasopharyngeal carcinoma may also be called?
Lymphoepithelioma
Nasopharyngeal carcinoma is frequently unresectable at diagnosis. How often do you see metastasis in this tumor?
What is the treatment?
What is the 5 year survival rate?
Mets in 70%
Tx with radiotherapy
5yr survival is 60%
This histology sample was taken from an HIV+ man from south China. Metastases were identified and the primary lesion was unresectable. What is this cancer?
Nasopharyngeal carcinoma
The histology is representative of biopsies from lesions in the mediastinum, head and neck of the patient. Based on the lesion locations you do a gene analysis and find the patient has a BRD4/BRD3-NUT fusion gene mutation.
What is the median survival for a patient with this presentation?
What is this and what does it look a lot like?
NUT midline carcinoma, similar appearance to nasopharyngeal and squamous cell carcinoma.
This is highly aggressive with a median survival of only 7 months. Terrible prognosis.
This patient has beefy red tonsils. What have they got?
acute pharyngitis
What does this patient have?
Acute tonsillitis
Most episodes of the attached examples are due to viral infections. What are 4 common culprits?
What is one bacterial agent that may present this way?
- Adenovirus (ds-DNA)
- HSV
- EBV
- Cytomegalovirus
Bacterial example is streptococcus
It is winter-early springtime, and a 5-15 year old patient comes in complaining of sore throat and fever. You see petechiae on the palate, and note strawberry tongue along with an erythematous pharynx. They have tender anterior cervical lymph nodes, and the tonsils are enlarged with patchy exudate.
Diagnosis?
What are four things you specifically won’t see if a bacterial infection?
Group A streptococcus
bacterial infection will be absent…
- cough
- coryza
- hoarseness
- conjunctivitis
What are the key aspects of the clinical presentation of Group A strep?
- age 5-15
- sore throat and fever
- strawberry tongue
- tender anterior cervical lymph nodes
- tonsilitis
- headache
- nausea
- vomiting
- abdominal pain
This filamentous, anaerobic gram-negative rod was cultured from a peritonsillar abcess of a patient with jugular vein thrombophlebitis. What is this syndrome called?
Lemierre syndrome
What is this bacterium?
It is part of the pharyngeal normal flora, what can turn it pathogenic?
What are two possible sequelae to be aware of with this organism?
Potent endotoxin production turns fusobacterium necrophorum pathogenic.
- Lemierre syndrome
- Thrombi breaking off and seeding to different sites.
What makes this bacteria pathogenic?
What is a hallmark of this disease on physical exam?
Corynebacterium diphtheriae
Tox gene
production of pseudomembrane
What are 5 viral causes of pharyngitis?
- Rhinovirus
- Adenovirus
- EBV
- HSV
- Influenza
Rhinoviruses cause what type of pharyngitis?
Indirect
Adenoviruses grow in the pharyngeal mucosa and can cause what?
Pharyngoconjunctival fever
EBV causes infectious mononucleosis in 15-25 yr old age group. What are some components of the presentation?
What does a monospot test detect?
- pharyngitis
- tonsillitis
- lymphadenitis
- hepatosplenomegaly
Monospot test for heterophile antibodies
HSV types 1 and 2 may be found in gingivitis, stomatitis and pharyngitis existing in vesicles in pharyngeal mucosa and causing pain as the nerve endings are affected. How are these organisms spread in the body?
Via transport into ganglia then centrifugal migration via sensory/autonomic nerves
What is this?
What is the main cause?
What are some other causes?
Epiglottitis - AKA laryngoepiglottitis
Main cause is H. influenza type b
RSV
B-hemolytic strep
This can be caused by infections, chemical reaction or traumatic agents. What is the danger in this condition?
Epiglottitis can involve complete blockage of the airway leading to suffocation and death.
If you meet a child patient who has acute laryngitis, what should enter your mind?
Holy shit, in kids this can lead to life threatening laryngoepiglottitis
Croup/laryngotracheitis/laryngotracheobronchitis mainly affects the larynx and trachea, occasionally the bronchi.
What is this the most common cause of?
What is this associated with?
What causes it?
Common cause of inspiratory stridor in kids
seal-like barking
caused mainly by parainfluenza (paramyxovirus)
What was the pathogenesis of the organism that caused the finding shown in the attached image of a patient with a seal bark cough?
Croup - image shows “steeple sign”
- •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
Your patient is a middle aged female with a history of smoking and a husky, low pitched weak voice. You see the soft gelatinous translucent expansion of the cord surfaces shown on the left. (The image at right is a normal vocal cord for comparison).
What is this called?
In addition to smoking, what is another risk factor?
Reinke Edema (Polypoid Corditis)
Can also occur with heavy recurrent voice strain
What does this presentation typically occur after?
Vocal cord nodules and polyps typically occur following sustained injury caused by…
- heavy smoking
- heavy recurrent voice strain (singer’s nodules)
Taylor swift presents to your office complaining of throat pain while singing. You take a look and see the attached lesion which you remove and stain. What do you tell Taylor about her chances of this becoming cancerous?
Where did you probably find the nodule located at?
Vocal cord nodules virtually never give rise to cancer.
The classic location is the junction anterior and middle third of cord.
What is this benign neoplasm called?
Which image is likely from and adult, and which likely from a child?
Vocal cord Papilloma - single nodule in the left photo. Adults tend to get singles.
Vocal cord papillomatosis - multiple papules are the typical presentation in children
What virus is associated with the pictured lesion?
How often does this become malignant?
HPV types 6/11
Rarely becomes malignant
What is the most consistent symptom of squamous cell carcinoma of the larynx?
What is it strongly associated with (risk factors)?
Prolonged hoarseness (> 6 wks) earliest, most consistent symptom
- Heavy smoking (>50 pack years)
- Ethanol abuse/dependence
Your patient presents with CC of difficulty swallowing, and shortness of breath. On physical exam you find palpable cervical lymph nodes and note the patient’s voice is hoarse. They report that the hoarseness has been present for quite some time. Months maybe.
What is the most likely diagnosis here?
What history items are critical in coming to your diagnosis?
Why are the cervical lymph nodes palpable?
Squamous cell carcinoma of the larynx
Flesh out history of smoking and etoh.
The cervical lymph nodes are metastases, these are present in 10-20% of patients at the time of their initial diagnosis.
Identify the stages shown in the attached image of squamous cell carcinoma.
From left to right
- hyperplasia
- hyperkeratosis
- dysplasia
- carcinoma in situ
- Cancer
Identify, lesion and sections indicated by arrows
Squamous cell carcinoma of the larynx
Top right: dysplastic squamous epithelium
Bottom Left: Invasive low-grade SCC
In order of occurance, what are the four top locations of laryngeal carcinoma?
- Glottic Carcinoma
- Supraglottic carcinoma
- subglottic carcinoma
- transglottic carcinoma
What does glottic carcinoma involve?
True vocal folds
What does a supraglottic carcinoma involve?
False vocal folds and laryngeal ventricles
What are the survival rates for glottic and supraglottic carcinomas respectively?
Glottic 5 year survival is ~65%
Supraglottic tumor 5 year survival is ~45%
Location and extent of carcinoma in the larynx is important for staging.
What are intrinsic and extrinsic carcinomas?
Intrinsic is confined to the larynx
Extrinsic extends beyond
What type of squamous cell carcinoma of the larynx is this?
Transglottic carcinoma - crosses the ventricle from the supraglottic area to involve the true AND false vocal folds. Alternately can involve the glottis and extend subglottically more than 10 mm. Or both
In order to take the edge off the impending PCM exam Michael goes swimming a ton. He ends up getting the presentation shown in the attached image. What the hell is going on with him?
What is the etiology? 3
Otitis externa (severe case)
- Traumatized ear canal
- excessive use cotton-tip swabs
- retained contaminated water “Swimmer’s Ear”
What is this?
What are organisms that can be involved in this?
Otitis externa (mild)
•Bacterial - 90%
•Pseudomonas Sp 38 - 50%
- Staphylococcus Sp
- Gram-negative rods
• Fungal 10%
- Aspergillus
- Candida
What type of epithelium lines the middle ear?
“non-keratinizing” stratified squamous epithelium
What are the three most common causative organisms for this presentation?
Acute otitis media
- S. pneumoniae
- H. Influenza
- Moraxella catarrhalis
This presentation is associated with two other infection sites. What are they?
What population in this the most frequent specific diagnosis?
Associated with bacterial conjunctivitis and concurrent URI.
Most frequent specific diagnosis in febrile children.
This child has chronic otitis media, a condition that presents due to repeated blockage of the eustachian tube due to recurrent otitis media and adenoid hypertrophy.
What bacterial agents are responsible for this?
What is a major possibly consequence of this?
What is the specific presentation indicated by the green arrows?
P. Aeruginosa and S. aureus
Conductive hearing loss is common as a result
mastoiditis is shown in the picture.
In chronic otitis media patients cysts may develop in the middle ear. There are two types. what are they?
- Cholesteatoma
- Metaplastic columnar epithelium: mucin secreting
What is shown here?
What is it a complication of?
Cholesteatoma
Complication from chronic otitis media
The image shows a stapes that has over calcified and attached to the oval window. What is the etiology of this condition?
What is the name of the condition?
Describe the pathological process at work.
Otosclerosis
Autosomal dominant condition with variable penetrance. More than 50% have a family history of otosclerosis.
Callus of bone accumulates as the footplate of the stapes and rim of oval window. The progressive ankylosis/immobilization worsens over decades and produces severe conductive hearing loss.
What does this guy have?
Branchial cleft defect derived cyst. Will be found on the lateral neck.
What does this patient have?
Thyroglossal duct cyst. Will be found midline.
This tissue sample was taken from a midline cyst. What is it?
Thyroglossal duct cyst
This is a tumor removed from a patients carotid body. What is this tumor a prototype of?
You might hear a bruit on auscultation due to obstruction and turbulent flow.
What are the 4 distinct paraganglionic tumor syndromes?
Prototype of a parasympathetic tumor.
1. MEN types 2a and 2b
2. Von hippel-lindau syndrome
3. neurofibromatosis type 1
- familial forms with succinate dehydrogenase complex mutations
What percent of carotid body tumors are benign?
90% benign, of the 10% that are not, 50% fatal due to infiltrative growth.
