sinonasal pathology

Two main etiologies (categories) of skin of nose pathology

UV and inflammation

Three pathologies (presentations) of skin of nose UV etiology

• solar keratosis

• Basal cell carcinoma

• Squamous cell carcinoma

Three pathologies (presentations) of skin of nose inflammatory etiology

• lupus erythematosus

• Rosacea

• Rhinophyma

Six pathologies (findings) of the nose, nasopharynx, paranasal sinuses

• rhinitis

• Nasal polyps

• Epistaxis and anosmia (bleed and smell)

• Maxillary sinus

• Benign tumors of nose and paranasal sinuses

• Malignant tumors of paranasal sinuses and nasopharynx

Four pathologies (findings) of oropharynx

• viral and bacterial infections

• Reactive lymphoid hyperplasia

• Acute and chronic tonsillitis

• Ludwig angina

Five pathologies (findings) of larynx

• laryngitis

• Allergic and toxic damage

• Reactive nodules

• Begign

• Malignant

Solar (actinic) keratosis

• UV skin nose sun damage

• Scaly plaques

• Either stable, regress or progress to SCC

Basal cell carcinoma

• UV skin nose

• Loss of function mutation PTCH1

• slow grow, rarely metastasize, fairly good outcome

  • 40% pts develop another w/in 5 years

• Local excision for treatment

Lupus erythematosus

• inflam nose of skin

• Autoimmune, systemic (SLE) and UV can exacerbate

• Discoid rash: erythematosus raised patches w adherent keratotic scaling and follicular plugging

• Butterfly aka malar rash: fixed erythema, flat or raised, over malar eminences (cheekbone, over nose bridge to cheekbone), photosensitive

Rosacea

• inflam skin of nose

• Chronic vascular and follicular dilation of nose and cheeks: telegiectasis (small, micro vessel)

• Female predilection

• Four stages:

  • Pre: flushing

  • Mild: persistent erythema and telangiectasia

  • Moderate: pustules and papules

  • Severe: rhinophyma

Rhinophyma

• inflam of skin of nose

• Form of severe rosacea but can be isolated as well

  • In isolation more common in men 12-30: 1

  • Hypertrophy, follicular dilation, hyperplasia of sebaceous glands

  • Increased vascularity

Rhinitis

• nose, nasopharynx, paranasal sinuses

• Inflam nasal cavity

  • Infectious rhinitis = common cold

    • Excessive nasal discharge

  • Allergic rhinitis

  • Chronic rhinitis

    • Allergic or microbial due to polyps or deviated septum (physical obstruction; hold pathogens)

Nasal polyps

• nose, nasopharynx, paranasal sinuses

• Does not tell etiology but often rhinosinusitis

• Smooth, semi-transparent, ovoid masses

• Histopathology: immense edema, scattered chronic inflam cell

Histopathology shows mainly plasma cells

Nasal polyp non-allergy

Histopathology shows eosinophils

Allergic nasal polyp

Epistaxis

• nose, nasopharynx, paranasal sinuses

• Nosebleeds, highly vascular nasal submucosa

• Many etiologies: granulomatosis with polyangitis (Wegener granulomatosis), hemangioma, HHT (hereditary hemorrhagic telangiectasia)

Anosmia

• nose, nasopharynx, paranasal sinuses

• Loss of smell

• Two etiologies (causes): obstructive and sensorineural

Obstructive anosmia pathologies

• rhinitis

• Sinusitis

• Nasal polyps

• Tumors

Sensorineural anosmia pathologies:

• trauma

• Tumors

Nerves do not respond

Acute maxillary sinusitis

• nose, nasopharynx, paranasal sinuses

• Thickened, acute, inflamed sinus membranes

• Preceded by acute or chronic rhinitis

• Can result from periapical infection

• Drainage cannot occur due to inflam edema

  • Ostia: openings to/in between sinuses that allow drainage

• Can have secondary bacterial infections

• Serve infections can involve ethmoid and frontal sinuses and meninges of brain

Chronic maxillary sinusitis

• nose, nasopharynx, paranasal sinuses

• Recurring or lasting longer than 3 mo

• Cause: failure of acute inflamed sinus to drain

• Could be mistaken for painful, accessed tooth

• Can be caused by fungal infection: mucormycosis: not seen in healthy so becomes emergency situation

  • Other factors: cigs, allergies, deviated nasal septum

Benign tumors

• nose and paranasal sinuses

• Four types:

  • Squamous papilloma: finger like projections HPV 6, 11

  • Fungi form and inverted papillomas: contains respiratory epithelium and possible malignancy

  • Hemangioma (vascular), hamartoma usually at septum, epitaxis

  • Nasopharyngeal angiofibroma: vascular tumor, exclusively in adolescent males and young males, mimics malignancy, epitaxis

Malignant

• nasopharynx:

  • Nasopharyngeal carcinoma

    • Caused: EBV

    • Prevalent in China, Southeast Asia and East Africa

    • Early metastasis, late detection

    • Clinical presentation: Nasal obstruction, Epistaxis, Cervical lymph node metastasis

• paranasal sinuses:

  • Squamous cell carcinoma: causes erosion, max sinus most often affected

Waldeyer’s ring

• Palatine tonsils (tonsils)

• Nasopharyngeal tonsils (adenoids)

• Lingual tonsils

• Tubal tonsils (Eustachian)

Oropharynx pathology

• viral and bacterial infections

• Reactive lymphoid hyperplasia (most common cause of tonsillitis enlargement)

• Mild pharyngitis (most common pharyngitis)

• Severe can accompany beta-hemolytic strep and adenovirus infection; “quinsy” peritonsillar abscess, acute rheumatic fever and post-strep glomerulonephritis

Diphtheria

• oropharynx

• Cause: corynebacterium diphtheria contact with infected person or carrier w droplets

• Farm animals, dairy

• Pseudomembrane on soft palate and pharynx resulting in obstructive asphyxia (breathing)

• Production of exotoxins: necrosis, affects heart and nerves

• Rare bc there is a vaccine

Larynx pathology

• acute laryngitis

• Diphtheria laryngitis: exotoxins, pseudomembrane

• Tuberculosis laryngitis

• Croup (laryngotracheobronchitis)

• angioedema type 1 hypersensitivity (vascular swelling)

• Acute toxic laryngitis: toxic fumes

• Chronic laryngitis: cigs, pre malignant

Allergic and toxic damage

Polyps

• on true vocal cords

• Chronic irritation

• Cause hoarseness

• Unilateral, smooth, round

• sessile (flat) OR pedunculated (mushroom)

Vocal cord nodules

• singers nodules affects true vocal cords

• Chronic irritation and strain

• Progressive hoarseness

• Bilateral lesions

• Treat w voice or speech therapy and behavior modification

Squamous papilloma of larynx

• cause: HPV

• True vocal cords Chronic

• Solitary in adults

• Multiple in children: respiratory papillomas, HPV 6, 11, can extend down, regress at puberty

Laryngeal carcinoma

• usually squamous cell carcinoma

• Cig smokers (also HPV, alcohol, asbestos)

• Males 7:1

• Persistent hoarseness

• Best prognosis: true vocal cords

• Worst: supraglottis metastasize to cervical lymph nodes

• Treat: surgery and/or radiation

• 1/3 mortality rate due to distant Mets