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An introduction to head and neck pathology (view source)

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Cytopathology of the head and neck is dealt with in a separate article called ''[[head and neck cytopathology]]''.
Cytopathology of the head and neck is dealt with in a separate article called ''[[head and neck cytopathology]]''.
=Anatomy=
[[Image:Blausen_0872_UpperRespiratorySystem.png|thumb|Head and neck anatomy (BruceBlaus/WC).]]
*Oropharynx - includes: tonsil, tonsillar pillar, base of tongue, soft palate.<ref>URL: [https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/what-is-oral-cavity-cancer.html https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/what-is-oral-cavity-cancer.html]. Accessed on: 1 April 2021.</ref><ref>URL: [http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/throat-cancer/oropharyngeal-cancer/soft-palate-cancer/ http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/throat-cancer/oropharyngeal-cancer/soft-palate-cancer/]. Accessed on: 15 November 2016.</ref>
*Oral cavity - includes floor of mouth, bucca, anterior 2/3 of tongue,<ref>URL: [http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/tongue-cancer/ http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/tongue-cancer/]. Accessed on: 15 November 2016.</ref> lips, [[hard palate]], upper & lower alveolar ridge, retromolar trigone.<ref>URL: [http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/oromandibular-cancer/ http://www.headandneckcancerguide.org/teens/cancer-basics/explore-cancer-types/oral-cancers/oromandibular-cancer/]. Accessed on: 15 November 2016.</ref>
*Laryngopharynx.
*Nasopharynx.


=Clinical=
=Clinical=
Common lesions:<ref name=Ref_PBoD780>{{Ref PBoD|780}}</ref>
Common lesions:<ref name=Ref_PBoD780>{{Ref PBoD|780}}</ref>
*Leukoplakia.
*[[Leukoplakia]].
**Homogeneous.
**Homogeneous.
**Non-homogeneous.
**Non-homogeneous.
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:''[[Hairy leukoplakia]] is dealt with in a separate section''.
:''[[Hairy leukoplakia]] is dealt with in a separate section''.
:''The typical [[benign leukoplakia]] is dealt with in a separate section''.
:''The typical [[benign leukoplakia]] is dealt with in a separate section''.
 
{{Main|Leukoplakia}}
===General===
*Non-specific clinical finding - may be benign ''or'' malignant.
*Associated with tobacco use.<ref name=pmid11336117>{{Cite journal  | last1 = Bánóczy | first1 = J. | last2 = Gintner | first2 = Z. | last3 = Dombi | first3 = C. | title = Tobacco use and oral leukoplakia. | journal = J Dent Educ | volume = 65 | issue = 4 | pages = 322-7 | month = Apr | year = 2001 | doi =  | PMID = 11336117 }}</ref>
 
Risk of malignancy:
*In twos series ~13% were associated with an invasive lesion.<ref name=pmid19953947>{{Cite journal  | last1 = Lan | first1 = AX. | last2 = Guan | first2 = XB. | last3 = Sun | first3 = Z. | title = [Analysis of risk factors for carcinogenesis of oral leukoplakia]. | journal = Zhonghua Kou Qiang Yi Xue Za Zhi | volume = 44 | issue = 6 | pages = 327-31 | month = Jun | year = 2009 | doi =  | PMID = 19953947 }}</ref><ref name=pmid16545712>{{Cite journal  | last1 = Lee | first1 = JJ. | last2 = Hung | first2 = HC. | last3 = Cheng | first3 = SJ. | last4 = Chen | first4 = YJ. | last5 = Chiang | first5 = CP. | last6 = Liu | first6 = BY. | last7 = Jeng | first7 = JH. | last8 = Chang | first8 = HH. | last9 = Kuo | first9 = YS. | title = Carcinoma and dysplasia in oral leukoplakias in Taiwan: prevalence and risk factors. | journal = Oral Surg Oral Med Oral Pathol Oral Radiol Endod | volume = 101 | issue = 4 | pages = 472-80 | month = Apr | year = 2006 | doi = 10.1016/j.tripleo.2005.07.024 | PMID = 16545712 }}</ref>
*Non-homogenous leukoplakia has a greater risk of malignancy than homogenous.<ref name=pmid16545712/>
*Location matters - floor of mouth and ventral tongue lesions higher risk for malignancy.<ref name=pmid7548621>{{Cite journal  | last1 = Sciubba | first1 = JJ. | title = Oral leukoplakia. | journal = Crit Rev Oral Biol Med | volume = 6 | issue = 2 | pages = 147-60 | month =  | year = 1995 | doi =  | PMID = 7548621 | URL = http://cro.sagepub.com/content/6/2/147.long }}</ref>
 
===Gross===
*White lesion - may be subdivided:
**Non-homogenous.
**Homogenous.
 
===Microscopic===
Features:<ref name=Ref_PBoD780>{{Ref PBoD|780}}</ref>
*Often associated with epithelial thickening ([[hyperkeratosis]], [[acanthosis]]).
 
DDx:
*Food debris.
*[[Oral candidiasis]].
*[[Lichen planus]].
*[[Benign alveolar ridge keratosis]] (oral [[lichen simplex chronicus]]).<ref name=pmid18158926>{{Cite journal  | last1 = Natarajan | first1 = E. | last2 = Woo | first2 = SB. | title = Benign alveolar ridge keratosis (oral lichen simplex chronicus): A distinct clinicopathologic entity. | journal = J Am Acad Dermatol | volume = 58 | issue = 1 | pages = 151-7 | month = Jan | year = 2008 | doi = 10.1016/j.jaad.2007.07.011 | PMID = 18158926 }}</ref>
*[[Squamous cell carcinoma of the head and neck]].
*Others - see ''[[Dermatopathology#Leukoplakia]]''.


==Erythroplakia==
==Erythroplakia==
===General===
===General===
*Non-specific clinical finding - may be benign or malignant.
*Non-specific clinical finding - may be benign or [[malignant]].
*Strong association with non-keratinizing squamous lesions (invasive and dysplastic).
*Strong association with non-keratinizing squamous lesions (invasive and dysplastic).


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===Cystic lesions - overview===
===Cystic lesions - overview===
Lateral cystic lesions:
Lateral cystic lesions:
*[[Brachial cleft cyst]].
*[[Branchial cleft cyst]].
*[[Cystic hygroma]].
*[[Cystic hygroma]].


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Work-up of negative H&E Bx differs by site:
Work-up of negative H&E Bx differs by site:
*Sunnybrook:<ref>S. Raphael. December 2008.</ref>
*One large hospital:
**[[LMWK]] ([[CAM5.2]]).  
**LMWK (CAM5.2).  
**[[pankeratin]] ([[AE1/AE3]]).
**Pankeratin ([[AE1/AE3]]).
*UHN.
*Another large hospital:
**Nothing.
**Nothing.


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:See also: ''[[Angiofibroma]]''.
:See also: ''[[Angiofibroma]]''.
*[[AKA]] ''juvenile nasopharyngeal angiofibroma''.
*[[AKA]] ''juvenile nasopharyngeal angiofibroma''.
===General===
{{Main|Nasopharyngeal angiofibroma}}
*Classically adolescent males with recurrent nose bleeds.
 
===Microscopic===
Features:<ref name=Ref_Klatt144>{{Ref Klatt|144}}</ref>
*Fibroblastic cells with plump (near cuboidal) nuclei.
*Fibrous stroma.
*Abundant capillaries.


Images:
==Biphenotypic sinonasal sarcoma==
*[http://commons.wikimedia.org/wiki/File:Nasopharyngeal_angiofibroma_-_intermed_mag.jpg Nasopharyngeal angiofibroma - intermed. mag. (WC)].
*[[AKA]] ''low grade sinonasal sarcoma with neural and myogenic features''.
*[http://commons.wikimedia.org/wiki/File:Nasopharyngeal_angiofibroma_-_2_-_high_mag.jpg Nasopharyngeal angiofibroma - high mag. (WC)].
{{Main|Biphenotypic sinonasal sarcoma}}


=Nasal polyps=
=Nasal polyps=
==Overview==
{{Main|Nasal polyps}}
DDx (benign - multiple):<ref name=emedicine994274>URL: [http://emedicine.medscape.com/article/994274-overview http://emedicine.medscape.com/article/994274-overview]. Accessed on: 16 March 2011.</ref>
*Autoimmune/idiopathic:
**Asthma.
**Allergic rhinitis.
**[[Churg-Strauss syndrome]] (AKA ''allergic granulomatous angiitis'').
***Features: [[asthma]], eosinophilia, granulomatous inflammation, necrotizing systemic [[vasculitis]], and necrotizing glomerulonephritis.<ref name=emedicine333492>[http://emedicine.medscape.com/article/333492-overview http://emedicine.medscape.com/article/333492-overview]</ref>
**Nonallergic rhinitis with eosinophilia syndrome (NARES).
*Infectious:
**Fungal infection (with allergic component - ''AFS'' = allergic fungal sinusitis).
**Chronic rhinosinusitis.
*Genetic:
**Primary ciliary dyskinesia.
**[[Cystic fibrosis]].
*Associations:
**Alcohol intolerance ~ 50%.
**Aspirin intolerance - upto ~ 25%.
*Tumours:
**Juvenile [[nasopharyngeal angiofibroma]] - young males.
**[[Nasopharyngeal carcinoma]]s.
**[[Sarcoma]]s.
**[[Hemangioma]].
**[[Schneiderian papilloma]].
**Other.
 
Memory devices:
*''GAIT'' = '''G'''enetic, '''A'''llergic/idiopathic, '''I'''nfectious, '''T'''umours.
*Allergic causes '''A'''s - '''a'''llergic, '''a'''sthma, '''a'''llergic granulomatous angiitis (Churg-Strauss syndrome), non'''a'''llergic rhinitis with eosinophilia.
 
===Epidemiology===
*More commonly assoc. with nonallergic conditions.<ref name=emedicine994274/>
 
===Treatment===
*Recurrent polyps: functional endoscopic sinus surgery (FESS).
 
==Inflammatory polyps with neutrophils==
===General===
*Histologic findings are non-specific; DDx includes:<ref name=emedicine994274dx>URL: [http://emedicine.medscape.com/article/994274-diagnosis http://emedicine.medscape.com/article/994274-diagnosis]. Accessed on: 16 March 2011.</ref>
**[[Cystic fibrosis]].
**Primary ciliary dyskinesia syndrome.
**Young syndrome
 
===Microscopic===
Features:
*Neutrophil predominant.
*Edema.
*+/-Mucus-impaction (dilated glands with mucus).
**Suggestive of cystic fibrosis.<ref name=pmid15554502>{{cite journal |author=Beju D, Meek WD, Kramer JC |title=The ultrastructure of the nasal polyps in patients with and without cystic fibrosis |journal=J. Submicrosc. Cytol. Pathol. |volume=36 |issue=2 |pages=155–65 |year=2004 |month=April |pmid=15554502 |doi= |url=}}</ref>
 
===Sign out===
<pre>
A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils.
- Negative for malignancy.
 
B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils and fragments of bone.
- Negative for malignancy.
</pre>
 
==Allergic nasal polyp==
===General===
*People with allergies.
**Same type of polyps seen in those without allergies.<ref name=pmid8441521>{{Cite journal  | last1 = Davidsson | first1 = A. | last2 = Hellquist | first2 = HB. | title = The so-called 'allergic' nasal polyp. | journal = ORL J Otorhinolaryngol Relat Spec | volume = 55 | issue = 1 | pages = 30-5 | month =  | year = 1993 | doi =  | PMID = 8441521 }}</ref>
 
===Gross===
*Polypoid mass - several millimetres to centimetres in size.
**Translucent.{{fact}}
 
===Microscopic===
Features:<ref>{{Ref Klatt|144}}</ref>
*Normal respiratory epithelium.
*Stroma with:
**Edema.
**Eosinophils.
**+/-Other inflammatory cells (plasma cells, lymphocytes, neutrophils).
 
DDx:
*Inflammatory nasal polyp with abundant neutrophils.
*[[Vasculitis]].
**[[Wegener's granulomatosis]].
**[[Churg-Strauss syndrome]].
 
===Sign out===
<pre>
A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils.
- Negative for malignancy.
 
B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils and fragments of bone.
- Negative for malignancy.
</pre>
 
 
<pre>
A. NASAL SINUS TISSUE, RIGHT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS.
- NEGATIVE FOR MALIGNANCY.
 
B. NASAL SINUS TISSUE, LEFT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS AND FRAGMENTS OF BONE.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
==Tonsillar lymphangiomatous polyp==
===Microscopic===
Features:<ref>http://www.nature.com/modpathol/journal/v13/n10/full/3880208a.html</ref>
*Polyp with lymph channels.
 
==Schneiderian papilloma==
*[[AKA]] ''Schneiderian polyp''.
*[[AKA]] ''sinonasal papilloma''.<ref>URL: [http://emedicine.medscape.com/article/862677-overview http://emedicine.medscape.com/article/862677-overview]. Accessed on: 19 November 2011.</ref>
===General===
*Lumpers vs. splitters debate about whether it is one entity or three.<ref name=pmid11904343>{{cite journal |author=Barnes L |title=Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck |journal=Mod. Pathol. |volume=15 |issue=3 |pages=279–97 |year=2002 |month=March |pmid=11904343 |doi=10.1038/modpathol.3880524 |url=http://www.nature.com/modpathol/journal/v15/n3/full/3880524a.html}}</ref>
 
[http://www.nature.com/modpathol/journal/v15/n3/fig_tab/3880524t1.html#figure-title Subclassification]:<ref name=pmid11904343/>
*Inverted (Schneiderian) - most common ~60-65%.
*Fungiform (Schneiderian) - less common ~30-35%.
*Oncocytic (Schneiderian) - least common ~5%.
====Inverted====
*[[AKA]] ''[[inverted papilloma]]''.<ref name=pmid8189990>{{Cite journal  | last1 = Vrabec | first1 = DP. | title = The inverted Schneiderian papilloma: a 25-year study. | journal = Laryngoscope | volume = 104 | issue = 5 Pt 1 | pages = 582-605 | month = May | year = 1994 | doi =  | PMID = 8189990 }}</ref>
*Usually lateral wall (as the septum as little soft tissue to grow into).<ref name=pmid11904343/>
*May transform to carcinoma.
 
====Fungiform====
*[[AKA]] exophytic papilloma, [[AKA]] septal papilloma.<ref name=pmid11904343/>
*Low risk of malignant transformation.
 
====Oncocytic====
*[[AKA]] ''cylindrical cell papilloma''.<ref>{{Cite journal  | last1 = Bravo Domínguez | first1 = O. | last2 = Vela Cortina | first2 = M. | last3 = Ramírez Ruiz | first3 = RD. | last4 = Ros Vergara | first4 = A. | last5 = Dinarés Jaumeandreu | first5 = D. | last6 = Encina Ruiz | first6 = L. | last7 = Arias Cuchí | first7 = G. | last8 = Ardíaca Bosch | first8 = MC. | last9 = Cánovas Robles | first9 = E. | title = [Oncocytic schneiderian papilloma. A case report]. | journal = An Otorrinolaringol Ibero Am | volume = 32 | issue = 2 | pages = 115-23 | month =  | year = 2005 | doi =  | PMID = 15929584 }}</ref>
*Lateral nasal wall.<ref name=pmid11904343/>
 
===Microscopic===
====Inverted Schneiderian papilloma====
Features:<ref name=pmid11904343/>
*Well-demarcated epithelial islands in the stroma.
*Squamous +/-surface keratinization ''or'' respiratory type epithelium (with cilia).
*+/-Neutrophils.
*+/-Goblet cells.
 
Notes:
*May mimic invasive SCC.
 
Images:
*[http://path.upmc.edu/cases/case32.html Inverted papilloma & verrucous carcinoma (upmc.edu)].
*[http://commons.wikimedia.org/wiki/File:Sinonasal_papilloma_-_very_low_mag.jpg Schneiderian papilloma - very low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Sinonasal_papilloma_-_cropped_-_very_high_mag.jpg Schneiderian papilloma - very high mag. (WC)].
 
====Fungiform Schneiderian papilloma====
Features:
*Exophytic growth pattern - '''key feature'''.
 
====Oncocytic Schneiderian papilloma====
Features:
*Oncocytes - '''key feature'''.
*Exophytic or endophytic growth pattern.


=See also=
=See also=
Michael
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