An introduction to head and neck pathology
This article is an introduction to head and neck pathology. Most of head and neck pathology is squamous cell carcinoma and its variants.
The thyroid gland is dealt with in its own article, as is pathology of the salivary gland.
Cytopathology of the head and neck is dealt with in a separate article called head and neck cytopathology.
Clinical
Common lesions:[1]
- Leukoplakia.
- Homogeneous.
- Non-homogeneous.
- Erythroplakia - more worrisome for cancer than leukoplakia.
Leukoplakia
- Hairy leukoplakia is dealt with in a separate section.
- The typical benign leukoplakia is dealt with in a separate section.
General
- Non-specific clinical finding - may be benign or malignant.
- Associated with tobacco use.[2]
Risk of malignancy:
- In twos series ~13% were associated with an invasive lesion.[3][4]
- Non-homogenous leukoplakia has a greater risk of malignancy than homogenous.[4]
- Location matters - floor of mouth and ventral tongue lesions higher risk for malignancy.[5]
Gross
- White lesion - may be subdivided:
- Non-homogenous.
- Homogenous.
Microscopic
Features:[1]
- Often associated with epithelial thickening (hyperkeratosis, acanthosis).
DDx:
- Food debris.
- Oral candidiasis.
- Lichen planus.
- Benign alveolar ridge keratosis (oral lichen simplex chronicus).[6]
- Squamous cell carcinoma of the head and neck.
- Others - see Dermatopathology#Leukoplakia.
Erythroplakia
General
- Non-specific clinical finding - may be benign or malignant.
- Strong association with non-keratinizing squamous lesions (invasive and dysplastic).
Microscopic
Features:[1]
- Unidentified red lesion.
- Often erosion.
Overview
Cysts
- Rathke cleft cyst - nasal cavity.
- Thyroglossal duct cyst - midline, neck.
- Branchial cleft cyst - lateral neck.
Larynx
Oral
Main article: Oral pathology
Infectious:
Other:
Vascular:
Pigmentation:
- Focal:
- Diffuse
Nasal cavity/nose
- Rhinoscleroma.
- Nasal glial heterotopia.[7]
Benign cystic lesions
- Cytology dealt with in Head and neck cytopathology.
Cystic lesions - overview
Lateral cystic lesions:
Medial cystic lesions:
Lateral & medial lesions:
- Epidermoid cyst.
- Cystic squamous cell carcinoma.
Rathke cleft cyst
- Main article: Rathke cleft cyst
- Arises from intermediate lobe - embryonic remnant.
- Benign cystic lesion without calcification.
- Related to craniopharyngioma.
Thyroglossal duct cyst
Main article: Thyroglossal duct cyst
Branchial cleft cyst
- AKA branchial cleft remnant.
Main article: Branchial cleft cyst
Benign lymphoepithelial lesion
- AKA benign lymphoepithelial cyst
Main article: Benign lymphoepithelial lesion
Other benign
Vocal cord nodule
Main article: Vocal cord nodule
Squamous papilloma
- Caruncle lesion is dealt with in papilloma of the caruncle.
- The lesion in the esophagus is dealt with in squamous papilloma of the esophagus.
Main article: Squamous papilloma
Pemphigus vulgaris
Main article: Pemphigus vulgaris
- AKA pemphigus.
- Should not be confused with bullous pemphigoid (which is less serious).
Pyogenic granuloma
Main article: Lobular capillary hemangioma
Plummer-Vinson syndrome
Triad:[9]
- Iron-deficiency anemia.
- Glossitis.
- Esophageal dysphagia (usually related to webs).
Rhinoscleroma
Main article: Rhinoscleroma
Neoplasms
Odontogenic tumours and cysts
Main article: Odontogenic tumours and cysts
This is a rather large topic and dealt with in a separate article.
It includes:
- Keratocystic odontogenic tumour.
- Radicular cyst.
- Dentigerous cyst.
- Ameloblastoma.
- Adenomatoid odontogenic tumour.
- Ameloblastic fibroma.
- Odontogenic myxoma.
Pharyngeal/nasopharyngeal specimens
- Specimens may be challenging to interpret as there is normally an abundance of lymphoid cells.
- Malignant tissue can look benign.[10]
- May be difficult to differentiate from other malignancies.
Histology
- Upper airway distant from areas with friction: respiratory type epithelium.
Work-up of negative H&E Bx differs by site:
- Sunnybrook:[11]
- LMWK (CAM5.2).
- pankeratin (AE1/AE3).
- UHN.
- Nothing.
Laryngeal neoplasms
Main article: Laryngeal carcinoma
These are dealt with in a separate article.
Human papillomavirus-associated head and neck squamous cell carcinoma
- Abbreviated HPV-HNSCC.
Sinonasal undifferentiated carcinoma
- Abbreviated SNUC.
Main article: Sinonasal undifferentiated carcinoma
Nasopharyngeal carcinoma
- Abbreviated NPC.
Main article: Nasopharyngeal carcinoma
Squamous lesions
- Premalignant lesions
- Mild dysplasia.
- Low risk of progression to invasive lesions.
- Moderate dysplasia.
- Severe dysplasia/carcinoma in situ (CIS).
- Histologically severe dysplasia and CIS cannot be differentiated reliably; ergo, there can be considered the same thing.
- Severe dysplasia is not a necessary intermediate for cancer, i.e. invasive squamous cell carcinoma may be present with moderate dysplasia.
- Mild dysplasia.
- Invasive squamous cell carcinoma (SCC).
- "Microinvasive" squamous cell carcinoma - term should be avoided as there is no concenus on what it means.
- There are several subtypes of SCC.
Squamous dysplasia of the head and neck
Main article: Squamous dysplasia of the head and neck
Squamous cell carcinoma of the head and neck
Main article: Squamous cell carcinoma of the head and neck
Small cell anaplastic carcinoma
- Rare.
DDx:
- Metastatic small cell carcinoma of the lung.
Granular cell tumour
Main article: Granular cell tumour
Olfactory neuroblastoma
- See also: neuroblastoma.
- AKA esthesioneuroblastoma.
Main article: Olfactory neuroblastoma
Craniopharyngioma
Main article: Craniopharyngioma
- Cystic lesion +/- calcifications +/-squamous nests.
- Related to Rathke cleft cyst.
Nasopharyngeal angiofibroma
- See also: Angiofibroma.
- AKA juvenile nasopharyngeal angiofibroma.
General
- Classically adolescent males with recurrent nose bleeds.
Microscopic
Features:[12]
- Fibroblastic cells with plump (near cuboidal) nuclei.
- Fibrous stroma.
- Abundant capillaries.
Images:
Nasal polyps
Overview
DDx (benign - multiple):[13]
- Autoimmune/idiopathic:
- Asthma.
- Allergic rhinitis.
- Churg-Strauss syndrome (AKA allergic granulomatous angiitis).
- Features: asthma, eosinophilia, granulomatous inflammation, necrotizing systemic vasculitis, and necrotizing glomerulonephritis.[14]
- 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 carcinomas.
- Sarcomas.
- Hemangioma.
- Schneiderian papilloma.
- Other.
Memory devices:
- GAIT = Genetic, Allergic/idiopathic, Infectious, Tumours.
- Allergic causes As - allergic, asthma, allergic granulomatous angiitis (Churg-Strauss syndrome), nonallergic rhinitis with eosinophilia.
Epidemiology
- More commonly assoc. with nonallergic conditions.[13]
Treatment
- Recurrent polyps: functional endoscopic sinus surgery (FESS).
Inflammatory polyps with neutrophils
General
- Histologic findings are non-specific; DDx includes:[15]
- Cystic fibrosis.
- Primary ciliary dyskinesia syndrome.
- Young syndrome
Microscopic
Features:
- Neutrophil predominant.
- Edema.
- +/-Mucus-impaction (dilated glands with mucus).
- Suggestive of cystic fibrosis.[16]
Sign out
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.
Allergic nasal polyp
General
- People with allergies.
- Same type of polyps seen in those without allergies.[17]
Gross
- Polypoid mass - several millimetres to centimetres in size.
- Translucent.[citation needed]
Microscopic
Features:[18]
- Normal respiratory epithelium.
- Stroma with:
- Edema.
- Eosinophils.
- +/-Other inflammatory cells (plasma cells, lymphocytes, neutrophils).
DDx:
- Inflammatory nasal polyp with abundant neutrophils.
- Vasculitis.
Sign out
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.
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.
Tonsillar lymphangiomatous polyp
Microscopic
Features:[19]
- Polyp with lymph channels.
Schneiderian papilloma
General
- Lumpers vs. splitters debate about whether it is one entity or three.[21]
- Inverted (Schneiderian) - most common ~60-65%.
- Fungiform (Schneiderian) - less common ~30-35%.
- Oncocytic (Schneiderian) - least common ~5%.
Inverted
- AKA inverted papilloma.[22]
- Usually lateral wall (as the septum as little soft tissue to grow into).[21]
- May transform to carcinoma.
Fungiform
Oncocytic
Microscopic
Inverted Schneiderian papilloma
Features:[21]
- 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:
- Inverted papilloma & verrucous carcinoma (upmc.edu).
- Schneiderian papilloma - very low mag. (WC).
- 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
References
- ↑ 1.0 1.1 1.2 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 780. ISBN 0-7216-0187-1.
- ↑ Bánóczy, J.; Gintner, Z.; Dombi, C. (Apr 2001). "Tobacco use and oral leukoplakia.". J Dent Educ 65 (4): 322-7. PMID 11336117.
- ↑ Lan, AX.; Guan, XB.; Sun, Z. (Jun 2009). "[Analysis of risk factors for carcinogenesis of oral leukoplakia].". Zhonghua Kou Qiang Yi Xue Za Zhi 44 (6): 327-31. PMID 19953947.
- ↑ 4.0 4.1 Lee, JJ.; Hung, HC.; Cheng, SJ.; Chen, YJ.; Chiang, CP.; Liu, BY.; Jeng, JH.; Chang, HH. et al. (Apr 2006). "Carcinoma and dysplasia in oral leukoplakias in Taiwan: prevalence and risk factors.". Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101 (4): 472-80. doi:10.1016/j.tripleo.2005.07.024. PMID 16545712.
- ↑ Sciubba, JJ. (1995). "Oral leukoplakia.". Crit Rev Oral Biol Med 6 (2): 147-60. PMID 7548621.
- ↑ Natarajan, E.; Woo, SB. (Jan 2008). "Benign alveolar ridge keratosis (oral lichen simplex chronicus): A distinct clinicopathologic entity.". J Am Acad Dermatol 58 (1): 151-7. doi:10.1016/j.jaad.2007.07.011. PMID 18158926.
- ↑ Penner, CR.; Thompson, L. (Dec 2003). "Nasal glial heterotopia: a clinicopathologic and immunophenotypic analysis of 10 cases with a review of the literature.". Ann Diagn Pathol 7 (6): 354-9. PMID 15018118.
- ↑ Baglin, AC. (Aug 2011). "[Vascular tumors and pseudotumors. Pyogenic granuloma (lobular capillary hemangioma)].". Ann Pathol 31 (4): 266-70. doi:10.1016/j.annpat.2011.05.014. PMID 21839350.
- ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 776. ISBN 0-7216-0187-1.
- ↑ S. Raphael. December 2008.
- ↑ S. Raphael. December 2008.
- ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 144. ISBN 978-1416002741.
- ↑ 13.0 13.1 URL: http://emedicine.medscape.com/article/994274-overview. Accessed on: 16 March 2011.
- ↑ http://emedicine.medscape.com/article/333492-overview
- ↑ URL: http://emedicine.medscape.com/article/994274-diagnosis. Accessed on: 16 March 2011.
- ↑ Beju D, Meek WD, Kramer JC (April 2004). "The ultrastructure of the nasal polyps in patients with and without cystic fibrosis". J. Submicrosc. Cytol. Pathol. 36 (2): 155–65. PMID 15554502.
- ↑ Davidsson, A.; Hellquist, HB. (1993). "The so-called 'allergic' nasal polyp.". ORL J Otorhinolaryngol Relat Spec 55 (1): 30-5. PMID 8441521.
- ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 144. ISBN 978-1416002741.
- ↑ http://www.nature.com/modpathol/journal/v13/n10/full/3880208a.html
- ↑ URL: http://emedicine.medscape.com/article/862677-overview. Accessed on: 19 November 2011.
- ↑ 21.0 21.1 21.2 21.3 21.4 21.5 Barnes L (March 2002). "Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck". Mod. Pathol. 15 (3): 279–97. doi:10.1038/modpathol.3880524. PMID 11904343. http://www.nature.com/modpathol/journal/v15/n3/full/3880524a.html.
- ↑ Vrabec, DP. (May 1994). "The inverted Schneiderian papilloma: a 25-year study.". Laryngoscope 104 (5 Pt 1): 582-605. PMID 8189990.
- ↑ Bravo Domínguez, O.; Vela Cortina, M.; Ramírez Ruiz, RD.; Ros Vergara, A.; Dinarés Jaumeandreu, D.; Encina Ruiz, L.; Arias Cuchí, G.; Ardíaca Bosch, MC. et al. (2005). "[Oncocytic schneiderian papilloma. A case report].". An Otorrinolaringol Ibero Am 32 (2): 115-23. PMID 15929584.