Pulm Path 6: Upper Airways, Ear and Neck (Singh) Flashcards
Which 3 viruses are the major cause of infectious rhinitis?
- Adenoviruses
- Rhinoviruses
- Echoviruses
The upper airways (i.e., nose, nasopharynx and sinuses) are lined by what type of epithelium?
Respiratory-type epithelium
Allergic rhinitis is an example of what type of hypersensitivity rxn?
Type 1 - immediate
Which 2 bacteria are most likely to be superimposed on infectious rhinitis?
- S. pneumoniae
- H. influenzae
How does the nasal discharge differ grossly if rhinitis purely viral or has a superimposed bacterial infection?
- Viral will have clear nasal discharge
- Bacteria will cause thick, purulent, sometimes suppurative discharge
Rhinitis/sinusitis characterized by marked mucosal edema, redness, and mucus secretion accompanied by a leukocytic infiltrate with prominent eosinophils describes what?
Allergic rhinitis
Edematous nasal mucosa w/ loose stroma, often harboring hyperplastic or cystic mucous glands w/ a variety of infiltrates including neutrophils, eosinophils, plasma cells, and occasional cluster of lymphocytes is characteristic of what?
Nasal polyps
What is the cause of nasal polyps?
Recurrent attacks of rhinitis
Maxillary sinusitis occasionally arises from extension of an infection from where?
Periapical infection through bony floor of the sinus (oral flora)
Obstruction and impairment of sinus drainage in sinusitis may lead to what 2 gross findings?
- Empyema = impounded suppurative exudate
- Mucocele = accumulation of mucus secretions
Which patients are at higher risk for particularly severe forms of chronic sinusitis and by which type of organisms?
- Diabetics
- Fungi (i.e., Mucormycosis)
Kartagener Syndrome is characterized by what triad and the sx’s are all caused by what?
- Bronchiectasis
- Situs inversus
- Sinusitis (less common)
- All sx’s due to defective ciliary action
What are 2 possible complications which may arise due to spread of infection associated with chronic sinusitis?
- Speading into the orbit or penetrating surrounding bone –> osteomyelitis
- Spreading into cranial vault –> septic thrombophlebitis of a dural venous sinus
What are 3 frequent complications which may arise from chronic sinusitis of the ethmoid sinus?
- Preseptal cellulitis
- Orbital cellulitis
- Subperiosteal abscess
What are 3 conditions which can produce necrotizing ulcerating lesions of the nose and upper respiratory tract?
- Acute fungal infections (i.e., Mucormycosis)
- Granulomatosis w/ polyangiitis (Wegener)
- Extranodal NK/T-cell lymphoma, nasal-type
Which sex, ethnicities, and age group is most frequently affected by extranodal NK/T-cell lymphomas?
- Males in the 5th-6th decade
- Most common in those of Asian or Latin American descent
Extranodal NK/T-cell lymphomas are related to which virus?
EBV
What are 3 systemic signs/sx’s related to lymphomas?
- Fever
- Night sweats
- Weight loss
Acute invasive sinusitis requires what prompt treatment?
Emergent IV antifungal therapy to prevent extension into brain or sepsis
Which bacteria are most commonly found superimposed on pharyngitis/tonsilitis of viral origin?
- β-hemolytic strep = most common
- S. aureus
How are the hyphae formed by Mucormycetes distinct from Aspergillus hyphae?
Form nonseptate hyphae of variable width w/ frequent right-angle branching
Involvement of which other organ system may develop in pt with rhinocerebral mucormycosis and what is seen?
- Lungs
- Lesions of combined hemorrhagic pneumonia w/ vascular thrombi and distal infarctions
Which sinus is most often involved in obstruction of outflow in sinusitis leading to a mucocele?
Frontal sinus
Proliferating masses of hyphae due to Aspergillus frequently form what?
“Fungus balls” = mycetoma
Describe the presentation of granulomatosis with polyangiitis in the sinus tract.
- Necrotizing granulomas of the upper or lower respiratory tract or both
- Necrotizing or granulomatous vasculitis affecting small-to-medium sized vessels
- Can lead to ulceration, necrosis, or perforation of the septum
Enlarged, reddened tonsils (due to reactive lymphoid hyperplasia) dotted by pinpoints of exudate emanting from tonsillar crypts is known as what?
Follicular tonsillitis
Nasopharyngeal angiofibroma is a benign tumor found almost exclusively in whom?
Also associated with what GI disorder?
- Adolescent males who are most often fair-skinned and red headed
- Association w/ FAP
Nasopharyngeal angiofibroma arises from which layer of tissue and in which location?
Fibrovascular stroma of the posterolateral wall of the ROOF of the nasal cavity
What is the treatment of choice for nasopharyngeal angiofibroma?
Surgical removal
Sinonasal (Schneiderian) Papilloma most often occurs in which sex and age group?
Adult males between the ages 30-60 yo
What are the 3 forms the lesions of Sinonasal (Schneiderian) Papilloma occur as; which is most common?
- Exophytic = most common
- Endophytic (inverted)
- Cylindrical
Which form of Sinonasal (Schneiderian) Papilloma is uniquely aggressive and in a minority of cases may progress to malignancy?
Endophytic (Inverted) form
The exophytic and endophytic forms of Sinonasal (Schneiderian) Papilloma are associated with what virus?
HPV (types 6 and 11)
What 2 locations are endophytic sinonasal papillomas found in?
- Nose
- Paranasal sinuses
What are the 2 benign (but potentially locally aggressive) tumors of the nose, sinuses, and nasopharynx?
- Nasopharyngeal angiogibroma
- Sinonasal (Schneiderian) papilloma
What are potential serious complications which may arise from a Sinonasal (Schneiderian) Papilloma?
- Invasion of the orbit or cranial vault
- Malignant transformation
Olfactory neuroblastomas arise from which cells and in which location?
Neuroectodermal olfactory cells present within the mucosa, particularly the superior aspect of the nasal cavity
What is the characteristic histology of Olfactory Neuroblastomas?
- Small, blue, round cell neoplasms
- Nests and lobules of well-circumscribed cells separated by fibrovascular stroma
What specific immunohistochemical markers are expressed by Olfactory Neuroblastomas?
- Neuron-specific enolase
- Synaptophysin
- CD56
- Chromogranin
What is unique about the age distribution of Olfactory Neuroblastomas; patients present with what signs/sx’s?
- Bimodal distribution = peaks at 15 yo and 50 yo
- Present w/ nasal obstruction and/or epistaxis
Olfactory neuroblastomas may penetrate through the cribriform plate and produce what characteristic appearance on imaging?
“Dumb-bell” shaped
Where to NUT (midline) carcinomas occur?
- Nasopharynx
- Salivary gland
- Midline structures in thorax or abdomen
NUT (midline) carcinomas are often mistaken for what malignany?
SCC
What is the typical course and prognosis of NUT (midline) carcinoma?
- Extremely aggressive
- Most patients survive for <1 year following dx
NUT (midline) carcinomas are associated with translocations involving what 2 proteins?
NUT and BRD4
What are the 3 patterns of Nasopharyngeal Carcinoma which may be seen?
- Keratinizing SCC’s
- Nonkeratinizing SCC’s
- Undifferentiated/basaloid carcinomas w/ abundant lymphocytic infiltrate (formerly lymphoepithelioma)
What are the 3 factors which influence the origin of Nasopharyngeal Carcinomas?
- Age
- Hereditary
- Infection with EBV
Nasopharyngeal carcinoma is the most frequent childhood cancer where?
Africa
Nasopharyngeal carcinoma is very common in adults where?
SE China
Which dietary and enviornemental factors are associated with Nasopharyngeal Carcinoma?
- Diets high in nitrosamines, such as fermented foods and salted fish
- Smoking and chemical fumes
What is seen histologically with the undifferentiated/basaloid type of nasopharyngeal carcinoma (i.e., cell types and characteristics)?
- Large epithelial cells w/ oval or round vesicular nuclei
- Prominent nucleoli, and indistinct cell borders in a SYNCYTIUM-like array
- Admixed w/ abundant lymphocytes (predominantly T cells)
What may be detected via in-situ hybridization or immunohistochemistry in the malignant epithelial cells of nasopharyngeal carcinoma?
- EBV encoded RNA’s such as EBER-1
- Proteins such as LMP-1
How do nasopharyngeal carcinomas typically present; most often metastases where?
- Nasal obstruction
- Epistaxis
- Majority of cases present in the neck (cervical LN metastasis)
What is the standard tx for nasopharyngeal carcinoma and which variant is the most/least sensitive to tx?
- Radiotherapy is standard tx
- Undifferentiated carcinoma is the most radiosensitive = best prognosis
- Keratinizing SCC is the least radiosensitive = worse prognosis
Laryngoepiglottitis in children is most often due to what 3 underlying organisms?
- Respiratory syncytial virus
- Haemophilus influenza
- β-hemolytic streptococci
Why is laryngoepiglottitis more serious in childre/infants?
Smaller airways; sudden swelling of epiglottis and vocal cords may cause obstruction –> medical emergency
Laryngotracheobronchitis (aka croup) is often seen in whom and with what sign/sx?
- Children
- Inflammatory narrowing of airway –> inspiratory stridor
Reactive nodules of the vocal cords are most often seen in whom?
- Smokers
- Pts who impose great strain on their vocal cords (i.e., Singers)
How do singers nodules differ from polyps in terms of distribution?
- Singers nodules = bilateral
- Polyps = unilateral
Reactive nodules (vocal cord nodules and polyps) are covered with what histologically and what is seen at their core?
- Covered by squamous epithelium that may become kerotic, hyperplastic, or slightly dysplastic
- Core composed of loose myxoid CT
Reactive nodules of the vocal cords will present with what signs/sx’s?
Risk of malignancy?
- Change in voice + hoarsness
- Virtually never give rise to cancer
What is seen on histologic examination of laryngeal squamous papillomas (i.e., morphology, cell types, and core)?
- Multiple slender, finger-like projections
- Supported by central fibrovascular core
- Covered by stratified squamous epithelium
Laryngeal squamous papillomas are caused by what?
HPV types 6 and 11
Laryngeal squamous papillomas are usually single lesions in whom?
Multiple lesions in?
- Single lesions in adults
- Multiple lesions in children –> Juvenile laryngeal papillomatosis
Chance of malignancy w/ laryngeal squamous papillomas and typical course?
- Benign and do NOT become malignant
- Often spontaneously regress at puberty, but some affect pt’s endure numerous surgeries before this occurs
Recurrent respiratory papillomatosis typically occurs in whom and is associated with what?
- Children and adolescents
- Associated w/ HPV 6 and 11; thought to be acquired during birth
Recurrent respiratory papillomatosis may diffusely involve what?
Lungs
Laryngeal carcinoma is most often what type of carcinoma and seen in whom?
- SCC
- Men >60 yo who smoke
What is the hyperplasia-dysplasia-carcinoma sequence seen in laryngeal carcinomas?
Hyperplasia –> atypical hyperplasia –> dysplasia –> carcinoma in situ –> invasive carcinoma
The likelihood of the development of an overt laryngeal carcinoma is directly proportional to what?
Grade of dysplasia when the lesion is first seen
What are the risk factors for laryngeal carcinoma?
- Smoking
- Alcohol
- HPV infection
- Asbestos
- Irradiation
Where may laryngeal carcinomas arise and how does this fit with the terms intrinsic and extrinsic?
- Usually on the vocal cords
- May also arise on epiglottis or aryepiglottic folds or in pyriform sinuses
- Those confined in larynx proper = intrinsic; those arising or extending outside the larynx = extrinsic
Laryngeal carcinomas begin as in situ lesions which later have what gross appearance on the mucosal surface?
Pearly gray, wrinkles plaques, ultimately ulcerating and fungating
Laryngeal carcinoma most often manifests clinically with what signs/sx’s?
- Persistent hoarsness
- Dysphagia
- Dysphonia
3 most common bacteria responsible for acute otitis media?
- Streptococcus pneumoniae
- Moraxella catarrhalis
- H. influenza
*SMH*
What are the most common causative agents of chronic otitis media?
- Pseudomona aeruginosa
- Staphylococcus aureus
- Some fungi
Otits media in the diabetic pt is most often caused by which organism and what serious complication may arise?
- P. aeruginosa
- Is especially aggressive and spreads widely, causing destructive necrotizing otitis media
What are cholesteatomas; and what are they associated with?
- Non-neoplastic, CYSTIC lesions lined by benign squamous epithelium w/ trapped keratin debris and sometimes spicules of cholesterol
- Associated w/ chronic otitis media
The reactive nature of cholesteatomas may lead to what complications?
- Erode into the ossicles, the labyringht, adjacent bone, or surrounding soft tissue
- May produce visible neck masses
What is the primary complication of Otosclerosis?
Conductive hearing loss
Otosclerosis is due to abnormal bony deposition where?
Stapedial footplate anchoring it to the oval window
What is the inheritance pattern of Otosclerosis?
Familial, autosomal dominant w/ variable penetrance
Branchial cysts are thought to arise from what remnant and are most commonly observed in whom?
- Second branchial arch
- Young adults btw ages 20-40 yo
Where are branchial cysts most often anatomically?
Upper lateral aspect of neck along the SCM
What is the histology of branchial cysts?
Simple cyst lined by stratified squamous or respiratory epithelium w/ surrounding fibrous tissue +/- lymphoid tissue w/ prominent germinal centers
Thyroglossal duct cysts arise from what?
- Remenant nests of tissue from thyroid migration
- Origin at base of tongue (foramen cecum) to its definitive midline location in anterior neck
What type of epithelium are thyroglossal duct cysts lined with when located near base of tongue vs. lower locations in anterior neck?
- Base of tongue –> stratified squamous epithelium
- Lower –> pseudostratified columnar epithelium
Paragangliomas (carotid body tumors) are most commonly found where and form what?
- Adrenal medulla —> pheochromocytomas
- Extra-adrenal occuring in the head and neck region
What is the origin of paragangliomas (carotid body tumors)?
Neural crest
Paragangliomas (carotid body tumors) typically develop in what 2 locations and differ how?
- Paravertebral paraganglia –> sympathetic connections and are chromaffin-positive, stain for catecholamines
- Paraganglia related to great vessels of the head and neck (i.e., carotid bodies) –> parasympathetic innervation and infrequently release catecholamines
Carotid body tumors are chiefly composed of what histologically and are surrounded by?
- Nests (zellballen) of round to oval chief cells (neuroectodermal in origin)
- Surrounded by delicate VASCULAR septae
Which 5 neuroendocrine cell markers do the chief cells of carotid body tumors stain strongly for?
- Chromogranin
- Synaptophysin
- Neuro-specifc enolase
- CD56
- CD57
What supporting network of cells is seen in carotid body tumors and what do they stain for?
- Spindle-shaped stromal cells, called sustentacular cells
- Positive for S-100
What is the growth of carotid body tumors like and when are they most often seen?
- Slow-growing and painless masses
- Usually arising in the fifth and sixth decades
Carotid body tumors may arise how and how does the pattern differ based on the underlying cause?
- Sporadically
- Autosomal dominant assoc. w/ MEN-2 –> often multiple and b/l
How aggressive are carotid body tumors, where do they metastasize and what is the prognosis?
- Frequently recur after incomplete resection
- May metastasize to regional LN’s and distant sites
- 50% are fatal due to infiltrative growth (histology CANNOT tell!)
