Pathology of Nasopharynx, Sinuses and Salivary Glands
allergic rhinitis = dt total allergen load, IgE response, early and late phase responses, s/sx: edema, redness, mucus initiall, mucosa turns white when chronic, marked by leukocytic infiltration (eosinophils)
infectious rhinitis = the common cold, usu viral etio: adenoviruses, echoviruses and rhinoviruses, initial acute phases involved thickened, red mucosa, changes may extend to pharynx->pharyngotonsillitis, secondary bacterial infx increases inflam rxn and exudate
chronic rhinitis = superficial desquamation or ulceration of mucosal epithelium dt recurrent acute rhinitis, roughened surface, decreased cilia activity, allergic or microbial plus bacterial, nasal polyps can form
vasomotor rhinitis = w/migraine,
the pro-inflammatory triad: asthma, polyps, aspirin sensitivity
acute = up to 4 weeks, subacute = 4-12 weeks, chronic = over 12 weeks of s/sx
nasal polyps = focal protrusion of mucosa 3-4cm usu max, etio: recurrent rhinitis or spontaneous, not infx but may ulcerate & become secondarily infx, may encroach on airway, rich in eosinophils
acute sinusitis = usu preceded by acute or chronic rhinitis, occ etio: peri-apical dental infx, common etio: impaired drainage dt inflam edema of mucosa, Dr Miller says viruses are the most common cause (90-95%), Dr Thom says fungi (95%) dt chronic Abx use. Suspect bacterial if s/sx persist past a week or two and increase in severity. Bacterial more febrile but not diagnostic. Fungal infx plus uncontrolled diabetes->beware murcormycosis.
chronic sinusitis = can permanently change sinus wall when drainage malfx, defective cilia and mixed flora, complications: can spread to orbit (opthalmitis, peri-orbital cellulitis), bone, brain (encephalitis, meningitis, septic thrombophlebitis of dural veins) ->can be lethal
rhinosunisitis = nose and paranasal sinus inflam
fungal infx = dangerous in sinus, murocrmycosis esp in diabetic, blackening/necrosis of face, assoc w/ Wegener's granuloomatosis and T-cell lymphome, ulceration and secondary bact infx complicates tx-->necrotizing lesions of nose & uppper airways = formerly assoc w/ lymphoma, often fatal dt dissemination esp into cranial vault
lymphoma = neoplasm from lymphoctyes forming tumors in lymph nodes, variable prognosis depending on type
tumors: nasopharyngeal angiofibroma, sinonasal papillomas (think HPV), plasmacytomas, olf neuroblastomas, nasopharyngeal carcinomas, adenomas...
nasopharyngeal angiofibroma = benign, vascular, oft in adolescent males, friable
sinonasal papilloma = benign neoplasm, squamous or columnar epithelium in 3 forms: septal (commonest), inverted (most imp), cylindrical. HPV 6 & 11 suspect (EBV?)
inverted papilloma = aggressive locally but benign, invades epithelium instead of sticking out, bad in orbit of cranial vault, may develop into carcinoma (very rare)
plasmacytoma = in lymphoid structures near nose/sinuses, polypoid tumors may protrude into cavities, covered by intact mucosa, rarely progress to multiple myeloma
olfactory neuroblastoma = very uncommon and highly malignant tumor, from neuroendocrine cells in olf mucosa, small round cells like neuroblasts, oft in lobular nests and encircled by vascularized CT, superior & lateral locations, highly metastatic, Tx: surgery, radiation, chemo->50-70% 5 yr survival
nasopharyngeal carcinoma = malignant, distinctive geographic distribution, close to lymph tissue, assoc w/ EBV infx (HPV?), one of the patterns: keratinizing squamous, nonkeratinizing squamous, undifferentiated squamous (worst) w/ abundant non-neoplastic lymphocytic infiltrate, common in parts of Africa, most frequent childhood cancer in US, common in adults in southern China but not in kids why?? can occur in nasopharynx, tonsils, post. tongue or upper airway. Tx: radiotherapy w/ 50-70% 3 year survival rate, cant remove cancer because it spreads through lymphatics. Radiotherapy best for undiff, not so good for keratinizing.
salivary gland review: parotid, submandibular, sublingual. subject to bact & viral infx, TB, sjogren's (dry mouth, parotid), sarcoidosis (noncaseating granuloma), alcoholism, tumors (usu non-neoplastic)
muculitz syndrome = combo of salivary and lacrimal gland enlargment (usu painless) with xerostomia. erio: leukemia, lymphoma, sarcoidosis, other granulomatous dz.
xerostomia = dry mouth, etio: radiation therapy, sjogrens, sialadenitis
sjogren syndrome = autoimmune disorder, dry mouth, eyes, ct probs
sialadenitis = inflam of salivary gland, viral = mumps, autoimmune->sjogren's
mucoceles = cyst-like, filled with mucin, lined by granulation or fibrous CT, common dt trauma, often on lower lip, blue hue, in babies/toddlers and elders (notes say inflam of salivary glands but there are none in lower lip)
sialolithiasis = calculi in salivary ducts, usu calcium phosphate stones, usu in submandibular and minor, may be painful and swell esp w/ eating, etio: dehydration chronic, may have superinfx, if gram negative infx then necrosis of abscess possible
neoplasms = notes are contradictory about occurence but many begin in parotid, etio unclear, risk: radiation. Apparently unrelated: alc, tobacco, stones, trauma. Slight female predominance except for Warthin tumors.
pleomorphic adenoma = most common benign tumor of salivary gland, parotid most, histologically diverse: myxoid, hylaine, chondroid, osseous, usu round in shape with well-demarcated borders, appear encapsulated. slow growing, 4% recurrence with parotidectomy but 25% if part of gland is left.
Warthin tumor = second most common benign, more in males, smokers have 8x risk, usu in 50-70's, restricted to parotid, aka papillary cystadenoma lympomatosum.
mucoepidermoid carcinoma = most common malignant, variable mixtures of squamous, mucus-secreting and intermediate cells, mainly in parotids, up to 8cmD, lacks capsule and infiltrative at margin, pale gray/white on transection with small mucin-containing cysts, range of prognosis depending on grade
adenoid cystic carcinoma (an adenocarcinoma) = uncommon but unique, often in minor salivary glands incl in palate, poorer prognosis than parotid location, second most common malignant, appears as small poorly encapsulated infiltrative lesions, gray/pink in color, cells in tubular, solid of cribriform patterns, spaces between cells filled with hyaline material, usu slow growing, relentless nad unpredictable, recurrent, 50% disseminate widely, survival rate 60-70% at 4 yeasr but drops to 15% at 15 years
actinic cell tumor = cells resemble serous acinar cells, rare, mostly in parotid, sometime bilateral or multicentrac, small discrete encapsulated lesoins
dentigerous cysts = cyst originating in crown of un-erupted tooth as result of separation odf dental follical, impacted 3rd molar, rare neoplastic transformation
odontogenic keratocyst = possibly aggressive, most in ages 10-40, males, posterior mandible, well defined uniloculour or multilocular radiolucencies, recurrence 60%, eval for nevoid basal cell carcinoma syndrome (Gorlin syndrome)
odontoma = scrambled tooth, classic example of hamartoma, extensive enamel and dentin, usu from epithelial cell line
ameloblastoma = perhaps most clinically significant dental tumor, resembles developing tooth, cystic, slow growing and locally invasive, seldom metastasize, sometimes considered benign
temporomandibular joint dysfunction (TMJ) = common among tooth grinders (bruxors), more after whiplash, oft assoc w/ malocclusion, s/sx: clicking, popping, limited opening, deviation of mandible, pain.
otitis media = in humans more dt eustacian tube evolved when we were 4 legged, angled wrong for 2 legged. enlarged adenoids can impinge on tube, allergies (smoke, food) cause swelling, cleft palate and deviated septum also risks all dt decreased drainage
bullous myringitis = dt Mycoplasma pneumoniae, bullae on TM, M. pneumo also most common cause of atypical pneumonia