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Erna Sulistyowati Bagian Patologi PPD Unisma

I. The Upper Respiratory Tract & Ear :

Upper resp tract infections Epiglottitis Wegeners granulomatosis Allergic reactions Paranasal & aural polyps Nasal & aural papillomas Laryngeal papillomatosis Squamous cell carcinomas Lethal midline granuloma Otitis media Otosclerosis

II. The Lung

. Bronchial asthma . Pulmonary edema

. Pneumonia
. Emphysema . COPD

. Pulmonary embolism
. Diffuse alveolar damage . Hyaline mambrane disease

. Atelectasis
. Pneumothorax . Pleural effusion

. Pneumoconiosis
. Sarcoidosis . Bronchogenic carcinoma . Mesothelioma



Viral nasal cavity & paranasal sinuses = common cold - mucosa edematous - infilt acute/ chronic inflamatory cells (2nd inf bacterial : increase in neutrophils) - excess fluid production

LARYNGOTRACHEOBRONCHITIS Cx : influenza virus, respiratory syncytial virus,rhinovirus


- viral airway obstruction

- Corynebacterium diphtheriae pseudomembrane in pharynx

Candidosis Epiglotitis

Acute Epiglotitis

Wegeners granulomatosis
- unknown cause - involves : URT, lungs, kidneys - characterized : vasculitis, granulomatous inflamation rhinorrhea, sinusitis, & malaise histol : necrotizing granulomas, multinucleated giant cells, chronic vasculitis.

- edema, eosinophilic infiltration - rhinorrhea and stuffy nose - larynx may be narrowed

INFLAMATORY POLYPS of the nasal cavity & paranasal sinuses

- represent polypoid areas of edema & inflamation, with eosinophilic infiltrate.

Ex : infection or allergy

Nasal Polyps

Other benign conditions :

Blockage of the outflow of the paranasal sinuses can lead to a MUCOCELE LARYNGEAL CYST arises similarly through the obstruction of the draining duct of mucous glands of the larynx resulting in hoarseness LARYNGEAL NODULE or SINGERS NODE is related to chronic trauma of the vocal cords. This nodules vary in histologic appearance depending on their stage of development from edema through fibrosis.


Benign Squamous Papilloma (BSP) nasal cavity &

paranasal sinuses o Inverted papilloma : is a polypoid growth has invagination of squamous epithel lateral nasal wall & paranasal sinuses, HPV is implicated o Laryngeal papillomatosis : consists of BSP, seen most often in children, at times obstruct the larynx o Nasopharyngeal Juvenile Angiofibroma

- profound epistaxis complicates the picture

- may destroy adjacent structures Histol : BSP consist of fibrous tissue & blood vessels

B. MALIGNANT 1. Squamous Cell Carcinoma (SCC) is the most common

- may occur on the nose, nasal cavity, nasopharynx, and larynx - association with smoking NASOPHARYNGEAL Ca (NPC)

Anaplastic NPC

- squamous origin - China >>, EBV related - often become evident owing to metastases Obstructions late in the course of the disease

Transtional Cell Ca Lymphoepithelioma : poorly diff. SCC from URT area which
has metastasized to a regional lymph nodes LARYNGEAL SCC - in smokers hoarseness -on true vocalcords & anterior commissure

Histol : leukoplakia to thickening, nodularity, ulceration & infiltration

2. Lethal Midline Granuloma ( Polymorphic reticulosis ) is characterized by respiratory tract ulcerating & necrotizing lesions 3. Extramedullary plasmacytomas
URT : the nasal cavity, nasopharynx, paranasal sinuses histol : plasma cell proliferation
eventually develop multiple myeloma

4. Olfactory neuroblastoma/ Esthesioneuroblastoma - is derived from the olfactory mucosa

- produces a polypoid mass - neural crest origin - histol : variable appearance - present with rhinorrhea, epistaxis, obstruction of the nasal passages - recurrences & metastases are common


Otitis externa bacterial inflamation

Pseudomonas aeruginosa destructive

Otitis media (Acute = OMA ; chronic = OMC ; purulenta = OMP)

- in the middle ear, usually related to blockage to the eustachian tube - cx : H. influenzae, Strep. Pyogenes, Strep. pneumoniae - pain, erythema, bulging of the tympanic membrane ruptur ear drainage

is a process of bone resorption & replacement by fibrous tissue, which is later replace by immature bone - autosomal dominant abnormality - causes hearing loss in the young & middle aged

A. BENIGN * Squamous papilloma * Schwannoma ( n. VIII = acoustic neurinoma )
- hearing loss, vertigo & ringing in the ears - Tx : surgical removal

* Meningioma pressure effect * Chemodectomas = Nonchromaffin paragangliomas,

Glomus jugulare tumor - n. VIII hearing loss



- of the external ear related sun exposure - of the auditory canal are agressive


CONGENITAL DISORDERS * Benign pulmonary cyst
- in the peripheral lung, < 5cm, lined by respiratory epithelium

- no symptoms, occasionally become infected

* Pulmonary sequestrations
a portion of lung receives a blood supply directly from the aorta & has no connection to the rest of the lung

- intrapulmonary : a mass of tissue in a lower lobe,

which may become infected

- extrapulmonary : is found outside the lung

above/below diagphragm, in the mediastinum

* Cystic adenomatoid malformation * Esophageal atresia * 1-antitrypsin deficiency

1-antitrypsin deficiency
- is a biochemical deficiency of a protease inhibitor - The phenotype PiZZ has markedly seru level of hepatic origin enzyme, may result in panacinar emphysema

The Lung
are ingeniously constructed to carry out their cardinal function, the exchange of gases between inspired air and the blood Alveolar wall : - capillary endothelium - basement membrane (yellow) - alveolar epithelium : -Type I pneumocyte - Type II pneumocyte - alveolar macrophages - pores of Kohn

BRONCHITIS a. Acute bronchitis
- usually a viral URT infection, - bacterial superinfection may be present

b. Chronic bronchitis
- chronic cough productive sputum due to excessive mucus production - histol : hyperplasia of the mucous glangs, mucous cells - is due to chronic irritation or infection, especially from smoking

The patient has repeated episodes of bronchospasm with expiratory wheezing & cough. Alergic (extrinsic) : - 50% of cases of asthma - begins in young adult, history of allergic rhinitis, elevated Ig E levels -antigens presipitating : pollens, animal dander, molds
b. Nonallergic (intrinsic) - no identifiable offending antigen, Ig E levels are normal - starts in later adulthood c. Occupational asthma ( dusts, gases, fumes) d. Exercise, Viral Infection, aspirin ingestion may induce asthma attacks

- bronchospasm occurs with edema of bronchial & bronchiolar walls

- thick mucus production e. Continuing attack which can lead to death is Status asthmaticus


is an irreversible dilatation of bronchi & bronchioles with an accompaniying infection marked by sputum production. Ex : damaging acute infection bronchial obstruction ( foreign object, tumor, mucus ) congenital/ hereditary conditions : congenital bronchiectasis cystic fibrosis, immune deficiency immotile cilia

asymptomatic, or may have : cough, foul-smelling sputum production,

fever, recurrent pulmonary infection gross : the lower lobes are usually involved, bronchi & bronchioles are dilated & extend nearly to the visceral pleura, contain mucopurulent material

histol : ulcerated mucosa, acute/ chronic inflammation in the wall

destruction & fibrosis of the smooth muscle & elastic tissue Tx : supportive & antibiotics

Kartagener syndrome

Situs inversus There is a defect in ciliary motility, associated with structural abnormalities of cilia.
Males : tend to be infertile, owing to ineffective

mobility of the sperm tail.

Inherited autosomal recessive



BRONCHIOLITIS OBLITERANS-ORGANIZING PNEUMONIA ( BOOP) -occurs as a result of several insult such as : viral and bacterial infections

diffuse interstitial pneumonia

autoimmune disease, graft-versus-host reaction in bone marrow transpl.

inhaled toxins & extrinsic allergies

- clinically : cough & dyspnea with or without fever & wheezing bronchioles are narrowed & inflamed,

contain a plug of fibrous tissue within the lumen

- Tx : Steroids is helpful

3. Gangguan vaskuler paru

Kongesti & edema paru Adult Respiratory Distress Syndrome = ARDS (Diffuse Alveolar Damage) NRDS (Newborn Resp. Distress Syndrome) Emboli, perdarahan, dan infark Hypertensi pulmonal and sklerosis vaskular

Pulmonary congestion & Edema

Pulmonary embolism, hemorrhage & infarction Occlusions of the pulmonary arteries by blood clot are almost always embolic in origin. Large vessel in situ thromboses are rare, develop only in the presence of : * pulmonary hypertension * pulmonary atherosclerosis * heart failure Pulmonary emboli thrombi in the deep veins of the leg ( >95%) Total occlusion in the great vessels fatal sudden death

Pulmonary infarct : macroscopic

Pulmonary infarct : histology

Hipertensi &sklerosis vaskuler paru


adult respiratory distress syndrome

diffuse alveolar damage

shock lung acute alveolar injury

traumatic wet lung

Terjadi akibat cedera akut pada alveolus. : cedera sel transudasi cairan kedlm alveolus&edema paru, fibrin menutupi epitel yg rusak.


newborn respiratory distress syndrome penyakit membran hialin

Terjadi akibat kurangnya pembentukan surfaktan paru oleh pneumosit tipe II, paru gagal mengembang, alveolus kolaps, cedera epitel fibrin


: a syndrome caused by diffuse alveolar capillary damage. Characterized clinically : The rapid onset of severe life-threatening respiratory insufficiency Cyanosis Severe arterial hypoxemia : * that is refractory to oxygen therapy * that may progress to extrapulmonary multisystem organ failure.


Morphology ARDS
Acute edematous stage :
* lungs are heavy, firm, red,and boggy * congestion, interstitial & intra-alveolar edema, and inflamation * fibrin deposition = alveolar hyaline membranes

Resolution : is unusual Organization of the fibrin exudate, with resultant

intra-alveolar fibrosis :

* proliferation of interstitial cells & deposition of collagen

thickening of the alveolar septa ensues

Superimposed bronchopneumonia fatal cases


Histologic feature of ARDS :

Clinical course ARDS

Usually hospitalized Profound dyspnea & tachypnea Cyanosis, Hypoxemia, & respiratory failure, X-ray : diffuse bilateral infiltrates. If unresponsive to O2 therapy respiratory acidosis THERAPY : * difficult, frequently fatal * Oxygen toxicity high concentrations of O2 * resorption of the edema fluid * reexpansion of ateletatic area.