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Head and Neck Pathology

Head
[Congenital/malformations/inflammation acute;chronic/tumours]

Oral cavity
o HSV1 cold sores very common, lips ; nose, single lesions/diffuse form ->
acute herpetic gingivostomatitis. Children/adults. Infection direct contact
(per os) neurotropism (basal ganglia of CNXII dormancy)
Predispositions exposure to cold, sunlight, wind, before menstruation,
stress,allergic reactions
Clinically local redness, swelling, pain
Morphology vesicles (small bullous), serous fluid crusts
o Angular cheilitis common, adults, M=F
Risks xerostomia, cigarette, Fe defit anemia, vitB defit, malab
syndromes, Zn defit, impaired IS (DownS, HIV, DM, cancer), lip
anomalies, dental prosthesis
Etiology candida, G+ bacteria (Staph), mechanical injury (skin
maceration elderly pts w toothlessness
Clinical pain, erythema, fissures, erosioness, crusts, atrophy
o Aphthous ulcers = Canker sore
Very common
Etiology unknown (dysreg of IS?), children/teens
Gross single/multiple, erosioness /ulcerations, erythema around
ulcerations
Clinical painful lesion, secondary infection purulent inflamm, self-
limit 7days/ persistent form, recurrent lesion // OR non-infective lesion!
o Oral candidiasis = thrush
o Opportunistic infection
AIDS, DM, neutropenia (leukemia, aplastic anemia), iatrogenic
infection long term Ab therapy
o Clinical angular cheilitis, painful, yellowish-gray superf membs,
erythematous background
Upper airways (nasal cav, nasopharynx, sinuses, larynx, throat)
o Throat pharyngitis/tonsillitis
V common, children/adults
Etiology viruses (rhino, echo, adeno, influ), bac (secondary! ; b-hemo
strep, staph), fungi (candida ; long term Ab therapy)
Opportunistic infection neutropenia, immunodefit processes
congenital/acquired), DM
Head and Neck Pathology
Clinical acute rapid onset sore throat, fever, malaise, headache,
cervical LN enlarged
Swelling and red colour of mucosa
Enlarged tonsils
Suppurative exudate pseudomembs (bact infec)
Abcesses of tonsillar crypts (bac infec)
Consequences Rheumatic fever, glomerulonephritis
Morphology exudative inflamm, reactive lymphoid hyperplasia
(follicular tonsillitis)
o Rhinitis
Acute/chronic
Etiology viral (common cold ; adenovirus, echo, rhino), bacterial
(secondary infection), allergic (hay fever ; plant [pollens, fungi, animal
allergen, dust mites)
Clinical runny nose (serous/suppurative exudate), weakness,
headache, dyspnea, fever
Morphology thick, edematous mucosa, deep pink/red, serous muco
purulent exudate
o Nasal polyps
39-year-old woman has been bothered by headache, facial pressure, nasal obstruction with
discharge, and diminished taste sensation for the past 6 months. On physical examination there is
discomfort on palpation over her left maxillary sinus. No oral lesions are noted. Rhinoscopy shows
nasal erythema, marked edema, and purulent discharge
Complication of infalammatory nasal polyp = nasopharyngeal carcinoma
Polypous overgrowths of the mucosa reaching even 3-4 cm, as a result of
repeated inflamm process (either infectious or allergic in nature)
Polyps are composed of hyperplastic, frequently chronically inflamed
and swollen mucosa w hyperplastic glands

Focal protrusion of the nasal mucosa, single/multiple, unilat/bilat


Clinical various degree of obliteration of nasal cavity, dyspnea,
headache, weakness
Morphology polypoid masses edema and congestion, soft
consistency, smooth surface, white/translucent, neutrophils,
lymphocytes, eosinophils, plasma cells
o Sinusitis
Maxillary frontal, ethmoid, sphenoid sinus
Head and Neck Pathology
Etiology
1. Acute acute/chronic rhinitis, periapical infection, trauma
2. Chronic Kartagener syndrome (bronchiectasis, situs invertus,
sinusitis) ; defective ciliary action // CF (mucoviscidosis)
Consequences intracranial septic thrombophlebitis, cerebral abcess
MENINGITIS, infalmm into orbit, osteomyelitis
Clinical
1. Acute maxillary sinusitis MOST common ; adults ; pulsating,
severe headache supraorbital area ; nasal cav obliteration ;
purulent/mucoso-purulent exudate ; fever
2. Acute frontal sinusitis very common, adults, headache frontal
area, tenderness, fever
3. Ethmoid frontal sinusitis very common, adults, headache (frontal
area), tenderness, fever
4. Ethmoid sinusitis most COMMON in children, malaise, swelling
of the eyelid(s), headache, fever
o Laryngitis
Etiology infection (viral, bacterial), allergic, reactive due to chemical
insult eg Tobacco smoke CHRONIC LARYNGITIS EXPOSURE TO
TOBACCO SMOKE!
Children/adults
Clinical acute/chronic, hoarseness aphony, dyspnea, stridor
Morphology mucosal congestion, edema, exudation,
erosion/ulcerations, inflamm cells accumulation, PUS, TB!!
GRANULOMAS!!
o Vocal cord polyps = reactive nodules
Non-neoplastic
Not precancerous change
Etiology chronic damage tobacco, voice work (singers)
Location true vocal cords
Clinical hoarseness
Morphology small, smooth, round; sessile/lith stalk, squamous
epithelium (keratotic/dysplastic), myxoid conntiss, chronic infalmm
o Laryngeal squamous papilloma

Laryngeal squamous cell carcinoma - large, fungating neoplasm that has the typical
appearance of a laryngeal squamous cell carcinoma. The most common risk factor is smoking, although chronic
Head and Neck Pathology
alcohol abuse also plays a role; some patients harbor human papillomavirus sequences. Invasive cancers arise from
squamous epithelial dysplasias. . Squamous cell carcinomas arise in the buccal mucosa and are invasive.

Benign
True vocal cords
Adults single nodule
CHILDREN multiple (juvenile laryngeal papillomatosis)
1. Recurrent, HPV6,11, no malignant transformation, spont
regression at puberty
Tumors of the larynx may be reactive proliferations or neoplastic growths. The
laryngeal nodule is a
common abnormality formed as a reactive process to excessive use; as such it may
be found in singers and is called a singers nodule. These nodules are solitary,
produce hoarseness, and histologically reveal a polyp consisting of fibrosis, dilated
vascular spaces, and myxomatous degeneration of
the stroma. Reactive nodules (vocal cord polyps, or singers nodules) occur most
often in men who are heavy smokers or who strain their vocal cords. The nodules
are generally only a few millimeters in size and have a fibrovascular core covered by
hyperplastic and hyperkeratotic squamous epithelium. They are not premalignant.

Croup is an acute laryngotracheobronchitis that most often occurs in children and


produces airway narrowing with inspiratory stridor.
Epiglottitis is an acute inflammatory process that may cause airway obstruction.

Laryngeal neoplasms may be either benign or malignant. Squamous papillomas are


benign neoplasms that occur in two clinical forms. One form is typically solitary and
occurs in adults (solitary squamous papilloma), while the other form is multiple and
occurs in children (juvenile papillomatosis). The latter form is associated with human
papillomavirus (HPV) and may recur locally after excision. Squamous papillomatosis
usually first appears in childhood; if it is extensive, it can produce airway
obstruction.

Malignant neoplasms of the larynx are most often squamous cell carcinomas.
Squamous cell carcinomas of the pharynx and larynx form irregular, ulcerating
masses, are more common in smokers, but generally are seen in individuals older
than this patient.

Clinical hoarseness, hemoptysis (ulceration!)


Gross soft, small (1cm dia), polypoid nodule, pale pink, irreg surface
Histology squamous epi, central fibrovascular cores
o Irritation fibroma / traumatic fibroma and focal fibrous hyperplasia =
submucosal mass of fibrous conntiss stroma on buccal mucosa along bite
lines or gingiva
Buccal mucosa
Single nodule
Benign
Head and Neck Pathology
o Pyognenic granuloma
Polypoid mass
Gingiva
Young pts
Pregnancy tumor
o Giant cell epulis
Gingiva
Young pts
Chronic inflamm
Histology fibroangiomatous stroma + multinucleated giant cells +
inflammatory cells
o Schneiderian papilloma
Tumour composed of overgrown squamous epithelium
HPV 6,11
Forms :
1. Exophytic
2. Inverted may have locally aggressive behaviour despite being
benign lesion (high recurrence rate), may sometimes harbour a
focus of cancer
Head and Neck Pathology

3. cylindrical
o Naropharyngeal carcinoma
Assoc w EBV!!!, and to a lesser extent heredity, nitrozamines and
smoking,
Incidence of subtypes varies with geography
Rare in most pops, but common in a few well defined pops incl. natives
of southern China, SEAsia (adults), the Arctic and MEast/NAfrica (in
Africa cancer of children)
Tx radiotherapy esp of poorly differentiated cases
Patterns
1. keratinizing squamous cell carcinomas
o microscopicqlly evident keratinization
o 25% of all nasopharyngeal carcinomas
o M>F, 4-6 decade
o Weaker assoc w EBV compared to other two
o Invasive carcinoma demonstrating obvious squamous
differentiation as intercellular bridges and keratinization

2. nonkeratizing squamous cell carcinomas AKA lymphoepithelioma,


Rigaud and Schmincke types of lymphoepithelioma (purely of
epithelial origin! Lymphocytes present are not neoplastic!)
o differentiated
o squamous differentiation
o most common subtype 60%! Most frequent paediatric type
of NPC -esp in NAfrica (accounts for 10-20% of NPCs)
o 12% of nasopharyngeal carcinoma
Head and Neck Pathology
o High incidence in China, SEAsia, NAfria and Arctic
o M>F, 4-6 decade
o Strong assoc w EBV also nitrosamines and smoking
o Usually prominent non-neoplastic lymphocytoplasmatic
infiltrate accompanying the tumour
o Tumour cells have moderate eosinophilic to amphophilic
cytoplasm, round nuclei, prominent eosinophilic nucleoli,
vesicular chromatin
o Syncytial arrangement of cohesive cells w indistinct cell
margins (Regaud pattern) or diffuse cellular infiltrate of
non-cohesive cells (Rchminke pattern) resembling NHL
(growth patterns have no clinical significance)

3. undifferentiated carcinomas (abundant non-neoplastic,


lymphocytic infiltrate)

Tumours of upper airways


1. Benign
a. Epithelial inverted papilloma
i. Locally aggressive, increased rate of recurrence, HPV infection
b. Mesenchymal nasopharyngeal angiofibroma
i. Adolescent males
ii. Bleeding (MASSIVE!)
Head and Neck Pathology
iii. Highly vascular fibroid tissue
2. Malignant
a. Squamous cell carcinoma Carcinoma of the oral cavity accounts for approximately 5%
of all human malignancies. More than 90% of oral carcinomas are of the squamous cell type;
precursor lesions
include leukoplakia (dysplastic leukoplakia) and erythroplasia, with transformation rates of
approximately 15 and 50%, respectively. Oral carcinoma is more common in males. Smoking,
tobacco chewing, chronic irritation, heat exposure, and irradiation are all thought to
contribute to carcinogenesis. The lower lip is the most common site, followed by the floor of
the mouth, the anterior tongue, the palate, and the posterior tongue. Prognosis varies
according to site but is best for lesions of the lip and worst for lesions in the floor of the
mouth.
b. Lymphoepithelioma
c. Olfactory neuroblastomas
i. Rare tumour growing from neuroendocrine cells in olfactory epithelium
ii. Nests or sheets of uniform small cells with scant cytoplasm, round nuclei
w indistinct nuclear mem and punctuate chromatin, no/indistinct
nucleoli
iii. NSE, Chr, CD56
iv. Varying biologic activity and survival rate from indolent growth to very
aggressive tumour
v. HIGH RECURRENCE RATE
vi. Due to location usually upper part nasal cav in proximity to orbitae and
cranial cavity excision may prove difficult

d. MUCOSAL MELANOMA

Ear

1. Acute otitis
a. Infants/ children,adults Rare
b. Middle ear + mastoid
c. Etiology
Head and Neck Pathology
i. Viral serous exudate
ii. Bacterial pus (streptococci)
d. Clinical pain, tenderness, headache, fever, decreased appetite, transient
deafness
e. Increased risk of recurrence
f. Recurrent acute otitis chronic otitis
2. Chronic otitis
a. Repeated acute otitis with failure of resolution
b. Etiology bacterial pseudomonas aeruginosa (DM destructive necrotizing
otitis media), staph aureus, fungi, mixed flora
c. Clinical attacks of symptoms typical for acute otitis (exacerbation)
d. Complications perforation of ear drum, involvement of
ossicles/labyrinth/mastoid space, purulent .. ??
Cholesteatoma
Non-neoplastic tumour in the middle ear
Morphology cyst, small 1-4cm dia), fibrous wall, keratinizing squamous epithelium,
cholesterol crystals, chronic inflamm (multinucleated giant cells)
Slow enlargement
Erosion if ossicles, labyrinth, skull, soft tiss
Can mimic primary brain
Otosclerosis
Abnormal fibrosis/ calcifications, bone deposition in the middle ear about the rim of
the oval window immobilisation of the footplate of the stapes
Unilat/bilat
Younger pts (30-40y)
Familial condition (AD!)
Slow progression
Clinical hearing loss

Neck
Congenital anomalies
o 1. Branchial cyst = lymphoepithelial
Unilat/bilat
Origin remnants of the branchial arches, development salivary gland
inclusions within cervical LNs
Slow enlargement
Head and Neck Pathology
Gross cyst dia 2-5cm
Morphology fibrous wall, squamous/pseudostratified columnar
epithelium, lymphocytic infiltrate lymphatic tiss, cystic content is
clear and watery/muinous
BRONCHIAL CYSTS ARE LATERALLY Branchial cleft cysts, which arise from
remnants of the branchial (pharyngeal) apparatus, may contain lymphoid tissue A 25-
year-old woman is concerned about a lump on the left side of her neck that has remained the same
size for the past year. Physical examination shows a painless, movable, 3-cm nodule beneath the skin
of the left lateral neck just above the level of the thyroid cartilage. There are no other remarkable
findings. Fine-needle aspiration of the mass is performed. Her physician is less than impressed by the
pathology report, which notes, Granular and keratinaceous cellular debris. Fortunately, she has
saved her Robbins pathology textbook from medical school. She consults the head and neck chapter
to arrive at a diagnosis, using the data from the report. There are several types of cysts that
occur in and around the oral cavity.
Branchial cysts, also known as lymphoepithelial cysts, may be remnants of an
embryonic branchial arch or a salivary gland inclusion in a cervical lymph node. They
are distinguished from thyroglossal duct cysts by their lateral location, the absence
of thyroid tissue, and their abundant lymphoid tissue. Occult thyroid carcinoma,
often a papillary carcinoma, may manifest as a metastasis to a node in the neck, but
the microscopic pattern is that of a carcinoma. About 5% of squamous cell
carcinomas of the head and neck initially manifest as a nodal metastasis, without an
obvious primary site. This patient is quite young for such an event, however.
o 2. Thyroglossal tract cysts (MOVES WHEN SWALLOWING)
A 56-year-old woman has noticed an enlarging lump on the right side of her neck for the past 7
months. On physical examination, there is a 3-cm nodule in the right upper neck, medial to the
sternocleidomastoid muscle and lateral to the trachea at the angle of the mandible. CT scan shows a
circumscribed, solid mass adjacent to the carotid bifurcation. Microscopic examination of the
excised mass shows nests of round cells with pink, granular cytoplasm. Tests for
immunohistochemical markers chromogranin and S-100 are positive. Electron microscopy shows
neurosecretory granules in the tumor cell cytoplasm. The tumor recurs 1 year later and is again
excised. A thyroglossal duct (tract) cyst is a developmental abnormality that arises from elements
of the embryonic thyroglossal duct extending from the foramen cecum of the tongue down to the
thyroid gland. One or more remnants of this tract may enlarge to produce a cystic mass. Although
lymphoid tissue often surrounds these cysts, malignant transformation does not occur

Middle line of the neck


Cystic dilation of remnants of developmental tract of the thyroid (base
of the tongue anterior wall of the trachea)
Younger pts
Gross dia 1-4cm
Morphology fibrous all (remnants of thyroid)
Squamous epithelium/ pseudostratified columnar epithelium
Malignant transformation squamous cell carcinoma (RARE)
Risk of recurrency RARE
o Localised unde the tongue p, composed of fibrous wall
Tumours
Head and Neck Pathology
Salivary glands
The heterotopic salivary tissue heterotopia is common in the LNs near the parotid gland
but is much less frequent in the submaxillary region and in other upper cervical nodes
Extranodal salivary gland heterotopias pitu gland1, middle ear2, external auditory
canal3, cerebellopontine angle4, mandible5, oropharynx6, cervical superior7, thyroid
capsule8, lower anterolteral neck9
Inflammation / Tumours

1. Sialadenitis (inflammation of salivary gland)


Acute blocked outflow of saliva due to dehydration, drugs [phenothiazines],
surgery; bacterial/viral [mumps!], infection)
Chronic obstructive sialolithiasis esp. submandibular gland/ non-obstructive,
bacterial, autoimmune
a. Etiology infection
i. Viral mumps/ epidemic phrotitis
1. Children
2. Unilat/bilat
3. Swelling/enlargement of the parotid
4. Adults pancreas, testes infertility
5. Main complication encephalitis
ii. Bacterial with/without stones
1. Stone formation sialolithiasis
2. Unilat
3. Submandibular
4. Nonspecific purulent inflamm (abcesses!!)
5. Acute/chronic fibrous atrophy
b. Clinical enlarged and painful glands
autoimmune sjogren syndrome xerostomia = dry mouth,
keratoconjunctivitis sicca, xerophtalmia
- lymphocytic infiltration of salivary and lacrimal glands
-frequently arthritis, vaginal dryness
-may be 1 or 2 to several systemic autoimm Ds RA, SLE, scleroderma,
1 biliary cirrhosis
c. Clinical gland enlargement, pain, purulent discharge

Mucocele cystic space filled w saliva (obstructed minor salivary gland) Mucoceles, which
typically occur on or near the lips due to a ruptured minor salivary gland, consist of a cyst filled with
mucous material. They lack an epithelial lining.
Head and Neck Pathology
A 95-year-old man, had local trauma, has noted swelling of his lower lip for the past month. On examination,
there is a fluctuant, 1-cm nodule with a blue, translucent hue just beneath the oral mucosa on the inside of
his lip. The lesion is excised, and on microscopic examination shows granulation tissue.
a mucocele of a minor salivary gland, which is most often the result of local trauma in the very
young and very old. There is either rupture or blockage of a salivary gland duct.

2.
a. Blocked outflow from the salivary duct (mucous retention) or rupture of the
duct (mucous extravasation cyst)
b. May be partially lined w epithelial cells, w chronic inflamm infiltrate
(granulation tiss) in the wall
Clinical local swelling (lump) or even polyp *RANULA mucocele in the

floor of the mouth in sublingual region

3. Tumours of the salivary glands

a. Benign (adenomas) peak incidence in 5-7th dec, malignant ones in later


age (w some exceptions)
Head and Neck Pathology
i. Pleomorphic adenoma = mixed tumour (50%) MOST COMMON
TUMOUR OF THE PAROTID
Pleomorphic adenoma is the most common tumor of the parotid gland. These tumors are
rarely malignant, although they can be locally invasive

1. Benign
2. Parotid (60-85% ; 15-30% of it being malignant),
submandibular 10% of which 40% is malignant, sublingual and
other glands 5-25% of which 50-90% being malignant, minor,
salivary glands
3. F>M
4. Clinical single solitary nodule, swelling of the parotid, mobile
nodule, 2-4-6-10cm dia, painless, slow growth, encapsulated
5. Morphology epithelial (ductal) and mesenchymal
proliferation, myoepithelial cells, mesenchymal metaplasia
(chondroid-cartilaginous, myxoid, hyaline, bone, fat, tiss),
fibrous capsule, satelitary nodules, no pleomorphism,
decreased mitotic activity
Recurrency is COMMON (25% if tumour was only
enucleated)
Malignant transformation RARE (carcinoma-ex-pleomorphic
adenoma, malignant mixed tumour) risk is increasing w
time (10% after 15y)

ii. Warthin tumour (5-10%) Papillary cystadenoma lymphomatosum,


lymphadenoma
Warthins tumors occur mainly in the lower regions of the parotid
gland, especially near the angle of the mandible, and on rare occasion
may be bilateral. They are completely benign neoplasms. The pattern is
highly characteristic of an epithelial surface lining of acidophilic cells
that overlay benign lymphoid tissue elements, including germinal
centers // Warthins tumor (papillary cystadenoma lymphomatosum),
which histologically reveals cleftlike spaces lined by oncocytic
epithelial cells overlying a stroma with a dense lymphocytic infiltrate. The epithelial cells are oncocytic
because their pink cytoplasm is packed with mitochondria. The epithelial portion probably arises from early
Head and Neck Pathology
duct cells that become entrapped within developing parotid lymph nodes during embryogenesis. syndrome.
Warthin tumors are uncommon and indolent, although they may be bilateral or multicentric.

Warthin tumor is the second most common salivary


gland tumor, and it almost always arises within the parotid gland. These tumors tend to be slow growing.
Microscopically there are spaces lined by a double layer of superficial columnar and basal cuboidal epithelial cells
that are surrounding a lymphoid stroma.

1. Benign, M>F but in recent years statistics show inced women


prob due to no. of smoking women, peak @ 6-7 decade life
1. Almost always arising in Parotid, Solitary/multifocal (10%),
Unilat/bilat (10%) ; in rare cases arising in nearby LNs
2. DOES NOT TRANSFORM INTO MALIGNANCY, RARE (2%)
RECURRENCE
3. Increased risk in smokers!! Strong assoc w smoking!!
4. Clinical nodule (round, oval), 2-5 cm dia, elastic, painless
5. Morphology multicystic, papillae

6. Micro: double layer of neoplastic epithelial cells (outer


columnar layer with underlying cuboidal) resting on a dense
lymphoid stroma sometimes bearing germinal centres
-cystic spaces have papillary protrusion
-cells of the tumour have abundant finely granular eosinophilic
cytoplasm (oncocytic apprearance) becos they are stuffed w
mitochondria
-nuclei are rel small, uniform, w/out polymorphism or atypia
Head and Neck Pathology

ii. Oncotoma (1%)


iii. Other adenomas (5-10%)
1. Basal cell adenoma
2. Canalicular adenoma
iv. Ductal papillomas
v. Basal cell and canalicular adenomas
vi. Benign lymphoepithelial lesion (Mikulicz disease)
1. Benign bilat enlargement of salivary and lacrimal glands caused
by some other disease
Mikulicz syndrome symptoms like Mikulocz disease
but the condition is 2 to other Ds : Sjogren
syndrome, tbc, sarcoidosis, lymphoma
b. malignant
i. mucoepidermoid carcinoma 15% MOST COMMON MALIGNANT
TUMOUR OF SALIVARY GLANDS may be present also at other sites
bronchial wall, lacrimal glands
1. middle aged 35-65y pts, may be also children
Head and Neck Pathology
2. >50% cases have fused MECT1-MAML2 gene result of
chromosomal translocation 1119
3. Very malignant, 40-60% arising in parotid gland w/wout facial
n. CNV involvement, 10% in minor salivary glands around oral
cavity particularly the palate, radiation induced (younger pts)
4. Clinical nodule 8cm dia, initially painless swelling of salivary
gland or fixed tumour, encapsulated
5. Morphology mixture of squamous/mucous-secreting
cells/intermediate cells ; small cysts; various degree of
maturity (low, intermediate, high grade) ; squamous
component increased malignancy!! ; aggressive growth,
invasion..
6. Micro : cords, sheets and clusters of cells of the tumour 3
subpopulations resembling
Squamous cells (epidermoid)
Mucinous cells (muco)
Intermediate cells (basal-to-epidermoid appearance)
Degree of polymorphism and atypia variable
Low grade tumours usually more mucinous
component and lots of cysts
High grade tumours more squamous component
and solid structure

7. Prognosis and biology differs depending on grade


Head and Neck Pathology
a. Low grade tumour mostly locally malignant (invading
tissues, recurring after excision 15% with good prog
90% of 5y survival)
b. High grade tumours behaving like a classical cancer
with both local malignancy (invasion high recurrence
rate 30% and metastasizing 30% ; 50% of 5y survival)

ii. adenocarcinoma (NOS) 10%


iii. acinic cell carcinoma 5%
iv. adenoid cystic carcinoma 5% - THE MOST COMMON MALIGNANCY IN
SUBMANDIBULAR GLAND DISTANT MATES BONE, LIVER, BRAIN ;
METAS RECURRENCY CAN OCCUR
1. upto 50% cases minor salivary glands esp. palate
2. may arise in nose, sinuses, bronchi as well
3. very malignant
4. minor salivary glands (oral cavity)
5. clinical well differentiated and slow growing tumour,
painless/painful, may be unpredictable
6. gross small, poorly encapsulated, gray-pink nodule
7. morphology small, uniforn cells, tubular, solid, cribriform
pattern, hyaline material bundles
8. Micro : tubular, solid, or cribriform pattern similar to
cylindroma of skin
Small bland myoepithelial cells w scanty cytoplasm and dark
compact angular nuclei
Pseudoglandular spaces w PAS+ excess basement membrane
material
Head and Neck Pathology
Hyalinisation between cells may be present (excess of ECM of
basal mems)
Presence of pseudoglandular lumina, true glandular lumina and
perinuerial invasion is usually required for diagnosis
TENDENCY TO INVADE NERVES
The salivary glands give rise to a wide variety of tumors, the majority
of which are of epithelial origin and benign. Most tumors occur in
adults and have a slight female predominance. Approximately 75 to
85% occur in the parotids, 10 to 20% in the submandibular glands, and
the remainder in the minor glands. In the parotid the vast majority are
benign, whereas in the minor glands 35 to 50% are malignant.
Clinically, most tumors of the salivary glands present as palpable
masses, regardless of histologic type. The most common neoplasm of
the parotid gland is the pleomorphic adenoma (mixed tumor), which
histologically reveals epithelial structures embedded within a
mesenchyme-like stroma consisting of mucoid, myxoid, or chondroid
tissue. A malignant tumor may develop from a pleomorphic adenoma,
in which case it is called a carcinoma ex pleomorphic adenoma. The
second most common tumor is Warthins tumor (papillary
cystadenoma lymphomatosum), which histologically reveals cleftlike
spaces lined by oncocytic
epithelial cells overlying a stroma with a dense lymphocytic infiltrate. The epithelial cells are oncocytic
because their pink cytoplasm is packed with mitochondria.

Three malignant tumors of the salivary glands are mucoepidermoid carcinoma, adenoid cystic carcinoma,
and acinic cell carcinoma. Mucoepidermoid carcinomas consist of a mixture of squamous epithelial cells
and mucus-secreting cells. The mucus-secreting cells of a mucoepidermoid carcinoma can demonstrate
intracellular mucin with a special mucicarmine stain. Mucoepidermoid tumors are less common than
pleomorphic adenomas in major salivary glands. They may be high-grade and aggressive. Mucoepidermoid
carcinomas are infiltrative and form mucous cysts along with a population of squamoid cells.
A 60-year-old woman noticed an enlarging bump beneath her tongue for
the past year. She does not smoke or use alcohol. On physical examination,
there is a 2.5-cm, movable, submucosal mass arising in the minor salivary
glands on the buccal mucosa beneath the tongue on the right. Histologic
examination of the excised mass shows that it is malignant and locally
invasive. The tumor recurs within 1 year.
Mucoepidermoid carcinomas can arise in major and minor salivary glands. They account for most neoplasms that
arise within minor salivary glands, particularly malignant neoplasms. Low-grade mucoepidermoid carcinomas may be
invasive, but the prognosis is usually good, with a 5-year survival of 90%. High-grade mucoepidermoid carcinomas
can metastasize and have a 5-year survival of only 50%.

Adenoid cystic carcinomas form tubular or cribriform patterns histologically and have a tendency to invade
along perineural spaces, especially the facial nerve. Acinic cell carcinomas contain glands with cleared or
vacuolated epithelial cells.
Head and Neck Pathology

9. increased invasion of perineural spaces


10.prognosis 5y survival about 70%, however dropped to 15%
after 15 years. They may disseminate even years after prompt
removal
v. malignant mixed tumor 3-5%
vi. squamous cell carcinoma 1%
vii. other carcinomas 2%
Numerous diseases result from bacterial infections of the oral cavity. A. israelii, a normal
inhabitant of the mouth, is a branched, filamentous gram-positive bacteria that may produce
an indurated (lumpy) jaw with multiple draining fistulas or abscesses. Small yellow colonies,
called sulfur granules, may be seen in the draining material.

Acute necrotizing ulcerative gingivitis (Vincents angina or trench mouth) is caused by two
symbiotic organisms, a fusiform bacillus and a spirochete (B. vincentii), the combination
being termed fusospirochetosis.

C. diphtheriae causes diphtheria, which is characterized by oral and pharyngeal


pseudomembranes and a peripheral lymphocytosis.
Rhinoscleroma, a chronic inflammation of the nose, is caused by K. rhinoscleromatis and
histologically is characterized by numerous foamy macrophages, called Mikulicz cells.

Ameloblastoma - Histologic sections from a 3-cm mass found in the mandible of a 55-year-
old female reveal a tumor consisting of nests of tumor cells that appear dark and crowded at
the periphery of the nests and loose in the center (similar to the stellate reticulum of a
developing tooth). Grossly, the lesions consist of multiple cysts filled with a thick, motor
oillike fluid.
Head and Neck Pathology
A rare tumor of the oral cavity (found most commonly in
the mandible) that is similar to the enamel organ of the
tooth is the ameloblastoma. This locally aggressive tumor
consists of nests of cells that at their periphery are similar
to ameloblasts and centrally are similar to the stellate
reticulum of the developing tooth. A similar lesion occurs in
the sella turcica and is called a craniopharyngioma. In
contrast, pleomorphic adenomas, mucoepidermoid
carcinomas, adenoid cystic carcinomas, and acinic cell
carcinomas are all tumors that originate in salivary glands.

DILATION OF COCHLEA DUCT AND SACCULE Mnires disease is an abnormality


that is characterized by periodic
episodes of vertigo that are often accompanied by nausea and vomiting, sensorineural
hearing loss, and tinnitus (ringing in the ears). These symptoms are related to hydropic
dilation of the endolymphatic system of the cochlea. Inflammation of the middle ear (otitis
media), which occurs most often in children, may be acute or chronic. If otitis media is
caused by viruses, there may be a serous exudate, but if it is produced by bacteria, there may
be a suppurative exudate. Acute suppurative otitis media is characterized by acute
suppurative inflammation (neutrophils), while chronic otitis media involves chronic
inflammation with granulation tissue. Chronic otitis media may cause perforation of the
eardrum or may lead to the formation of a cyst within the middle ear that is filled with
keratin, called a cholesteatoma. The name is somewhat of a misnomer, as cholesterol
deposits are not present. Otosclerosis, a common hereditary cause of bilateral conduction
hearing loss, is associated with formation of new spongy bone around the stapes and the oval
window. Patients present with progressive deafness. Tumors of the middle ear are quite rare,
but a neoplasm that arises from the paraganglia of the middle ear (the glomus jugulare or
glomus tympanicum) is called a chemodectoma. Other names for this tumor include
nonchromaffin paraganglioma and glomus jugulare tumor. This lesion is characterized
histologically by lobules of cells in a highly vascular stroma (zellballen). A similar tumor
that occurs in the neck
is called a carotid body tumor.

Retinoblastoma is the most common malignant tumor of the eye in children. Clinically,
retinoblastoma may produce a white pupil (leucoria). This is seen most often in young
children in the familial from of retinoblastoma, which is due to a deletion involving
chromosome 13. These familial cases of retinoblastoma are frequently multiple and bilateral,
although like all the sporadic, nonheritable tumors they can also be unifocal and unilateral.
Histologically, rosettes of various types are frequent (similar to neuroblastoma and
medulloblastoma). There is a good prognosis with early detection and treatment;
spontaneous regression can occur but is rare. Retinoblastoma belongs to a group of cancers
(osteosarcoma, Wilms tumor, meningioma, rhabdomyosarcoma, uveal melanoma) in which
the normal cancer suppressor gene (antioncogene) is inactivated or lost, with resultant
malignant
change. Retinoblastoma and osteosarcoma arise after loss of the same genetic locus
hereditary mutation in the q14 band of chromosome 13. In contrast, a blue sclera can be seen
Head and Neck Pathology
with osteogenesis imperfecta, while a yellow sclera is seen with jaundice. Lack of an iris
(aniridia) can sometimes be associated with Wilms tumor of the kidney, while a subluxed
lens can be found in individuals with either Marfans syndrome or homocystinuria.

One of the most common eyelid lesions is the chalazion, a chronic


inflammatory reaction to lipid released into the tissue from the eyelids sebaceous glands of
Meibom or Zeis. Characteristic histologic features of this lesion include a
chronic inflammatory reaction with giant cells that surround empty spaces where the lipid
vacuoles from the sebaceous glands had been located. Because the major clinical disorder to
be differentiated from chalazia is sebaceous carcinoma, ophthalmologists biopsy recurrent
lesions suspected of being chalazia to rule out sebaceous carcinoma.
Hordeolums (styes) are acute staphylococcal infections of the eyelash follicles (external
hordeolum) or the Meibomian glands (internal hordeolum).
Xanthelasmas (yellow plaques on the skin) histologically reveal aggregates of foamy
macrophages within the dermis. Hydrocystomas are one type of cyst that may affect the
eyelid and may be lined by apocrine or eccrine cells.

Two cysts that occur in the neck are the branchial cleft cyst (usually located in the
anterolateral part of the neck) and the thyroglossal duct cyst (usually located in the anterior
part of the neck). Each of these cysts may histologically reveal a lining
composed of squamous epithelium or pseudostratified columnar epithelium.
Branchial cleft cysts, which arise from remnants of the branchial (pharyngeal)
apparatus, may contain lymphoid tissue, while thyroglossal duct cysts may move up and
down as the patient swallows. A 25-year-old woman is concerned about a lump on the left side of her
neck that has remained the same size for the past year. Physical examination shows a painless, movable, 3-
cm nodule beneath the skin of the left lateral neck just above the level of the thyroid cartilage. There are
no other remarkable findings. Fine-needle aspiration of the mass is performed. Her physician is less than
impressed by the pathology report, which notes, Granular and keratinaceous cellular debris. Fortunately,
she has saved her Robbins pathology textbook from medical school. She consults the head and neck
chapter to arrive at a diagnosis, using the data from the report. There are several types of cysts that
occur in and around the oral cavity. The most common type is the radicular cyst. These
cysts result from chronic inflammation of the tooth apex. Histologic sections reveal chronic
inflammation of the tooth apex with epithelialization of periapical granulation tissue. Other
types of oral cysts include follicular cysts (which arise from the epithelium of the tooth
follicle), odontogenic keratocysts (which consist of keratinized squamous epithelium), and
inclusion (fissural) cysts (which are fluid-filled cysts lined by squamous or respiratory
epithelial cells). Follicular cysts are called dentigerous cysts because the associated tooth is
unerupted, while odontogenic keratocysts are important because they may recur and act
aggressively. These keratocysts may also be associated
with basal cell carcinomas of the skin.
Head and Neck Pathology
Increased pressure with inflammation in the sinus can erode into adjacent bone, causing
osteomyelitis. A mucocele filled with nonpurulent secretions is more likely to occur in
frontal and ethmoid sinuses. Sinusitis is not a risk factor for malignancy. Nasopharyngeal
carcinomas are related to Epstein-Barr virus (EBV) infection. T-cell lymphomas typically
occur in men and are EBV positive. Papillomas most often occur in men and have an
exophytic growth pattern, but those that are endophytic aggressively extend into adjacent
soft tissue and bone, making removal difficult.

Recurrent respiratory papillomatosis is caused by human papillomavirus types 6 and 11.


These lesions frequently recur after excision. They may regress after puberty.
Laryngeal papillomas arising in adulthood are usually solitary and do not recur.

There is no effective antiviral therapy for human papillomavirus. Although the lesions can
arise throughout the airways, they are benign and do not become malignant.
The occurrence of the lesions is not related to the use of the voice, as is a laryngeal nodule,
which is quite small. This is not a congenital condition and is not part of a syndrome.

Non- Hodgkin lymphomas are found in adjacent cervical lymph nodes or in the Waldeyer
ring of lymphoid tissue.

A primitive neuroectodermal tumor, also known as an olfactory neuroblastoma, is a small,


round, blue cell tumor of childhood; it is likely to arise in the nasopharyngeal region.

In some parts of the world, the chewing of betel nut is a risk factor for oral cancer.

- The most common cause for dry mouth (xerostomia)


and dry eyes (xerophthalmia) is a medication effect.
Anticholinergics such as trihexyphenidyl to treat the
parkinsonian tremor can be implicated, as well as
antidepressants, antipsychotics, and antihistaminics.
- Sialadenitis is more common in older individuals, and
individuals receiving therapy for schizophrenia with
typical antipsychotics such as haloperidol can have
reduced salivary secretions, which promotes stasis
and infection. Most neuroleptic drugs are dopamine
receptor blockers, but they have extrapyramidal and
anticholinergic side effects. The dry mouth, coupled
with dehydration, favors inspissation of salivary gland
secretions and stone formation to block ducts and
increase the risk of inflammation and infection. S.
aureus is the most likely organism to cause infection
with suppurative inflammation. Epstein