DISORDERS & NEOPLASMS OF THE
UPPER RESPIRATORY TRACT
Prof. Dr. Gamze YURDAKAN ÖZYARDIMCI
• The nasal cavity, paranasal sinuses, and nasopharynx form a functional unity
• The two main types of epithelia lining these structures
→stratified squamous and respiratory-type pseudostratified columnar
• Organized lymphoid tissue is present throughout the nasopharynx
→Waldeyer ring
the pharyngeal tonsil = the adenoid,
lymphoid cells are abundant in the rim of the eustachian tube opening
=Gerlach tonsil.
4/5/2024
2
ACUTE INFECTIONS
1.COMMON COLD
• Acute infections of the upper respiratory tract = “common cold”
→most common afflictions of humans
• The clinical features are:
nasal congestion accompanied by watery discharge
sneezing
scratchy, dry sore throat and
a slight increase in temperature
• Most occur in the fall and winter
• are self-limiting →usually lasting for 1 week or less
4/5/2024
3
• The most common pathogens
rhinoviruses, coronaviruses,
respiratory syncytial viruses,
parainfluenza
influenza viruses,
adenoviruses,
enteroviruses, and
sometimes even group A β-hemolytic streptococci have been implicated
• may be complicated by the development of bacterial otitis media or sinusitis
• infections of the upper respiratory tract may produce signs and symptoms
localized to the pharynx, epiglottis, or larynx.
4/5/2024
4
2. ACUTE PHARYNGITIS
• manifesting as a sore throat, may be caused by a host of agents.
• Mild pharyngitis with minimal physical findings frequently accompanies a
cold and is the most common form of pharyngitis
• More severe forms with tonsillitis, with marked hyperemia and exudates,
occur with
→β-hemolytic streptococcal and adenovirus infections
• Streptococcal tonsillitis is important to recognize and treat early, because
of the associated potential
For development of peritonsillar abscesses or
for progression to poststreptococcal glomerulonephritis and
acute rheumatic fever
4/5/2024
5
3.ACUTE BACTERIAL EPIGLOTTITIS
• predominantly affecting young children
• an infection of the epiglottis caused by H. influenzae,
• major findings →pain and airway obstruction
• The onset is abrupt
• Failure to appreciate the need to maintain an open airway for a child with this
condition can have fatal consequences.
• The advent of vaccination against H. influenzae has greatly decreased the
incidence of this disease
4/5/2024
6
3.ACUTE LARYNGITIS
• can result from
inhalation of irritants or
by allergic reactions
by agents that produce the common cold
• Tuberculous laryngitis →almost always a consequence of protracted active tbc
during which infected sputum is coughed up
• Diphtheritic laryngitis →has become uncommon because of the widespread
immunization of young children against diphtheria toxin.
Corynebacterium diphtheriae implants on the mucosa of the upper airways
→elaborates a powerful exotoxin
→causes necrosis of the mucosal epithelium
→dense fibrinopurulent exudate →create the classic superficial, dirty-gray
pseudomembrane of diphtheria
4/5/2024
7
The major hazards of this infection
1. Sloughing and aspiration of the pseudomembrane
→causing obstruction of major airways and
2. Absorption of bacterial exotoxins
→ producing myocarditis,
peripheral neuropathy, or
other tissue injury
4/5/2024
8
• laryngotracheobronchitis= croup,
parainfluenza virus is the most common cause in children
respiratory syncytial virus also may precipitate this condition
self-limited
frightening inspiratory stridor and harsh, persistent cough.
In occasional cases, the laryngeal inflammatory reaction may narrow the airway
sufficiently → result in respiratory failure.
• Viral infections in the upper-respiratory tract predispose the patient to
secondary bacterial infection, particularly by staphylococci, streptococci, and H.
influenzae.
4/5/2024
9
INFLAMMATORY CONDITIONS
1.NASAL POLYPS
• not true neoplasms →associated with inflammation, allergy, or mucoviscidosis
• appear as soft exophytic masses that extend laterally from the mucosa into the
anterior part of the middle meatus.
• Bilaterality is the rule
•they can fill the entire nasal cavity
and even extend upward into the
cranial cavity
4/5/2024
10
• LM/ composed of a loose myxoid or hyaline stroma surrounding mucous glands
covered by respiratory epithelium, which often exhibits foci of squamous
metaplasia
infiltrated by lymphocytes, plasma cells, mast cells, neutrophils, and eosinophils
• Eosinophils are not restricted to the polyps having a presumed allergic
pathogenesis
4/5/2024
11
• From 6% to 10% of patients with mucoviscidosis =cystic fibrosis
→develop polyps in the nasal cavity and paranasal sinuses
• LM/ the polyps differ from the ordinary variety by
→the presence of large cystic glands with inspissated secretion in their lumina,
degranulation of mast cells,
preponderance of acid mucin,
lack of extensive infiltration by
eosinophils, and scanty submucosal
hyalinization.
4/5/2024
12
2.CHRONIC SINUSITIS
• The maxillary sinus is by far the most commonly involved site
• The disease is caused by various microbial organisms.
4/5/2024
13
• LM/ inflammatory infiltrate,
• edema,
• glandular hyperplasia,
• basement membrane thickening, and
• squamous metaplasia
•Eosinophils may also be present and
are occasionally numerous.
• The underlying bone may show thickening and remodeling, with prominent
osteoblastic rimming and fibrosis of the bone marrow spaces.
4/5/2024
14
3.MUCOCELE of the maxillary sinus represents a complication of chronic sinusitis
• the accumulation of inflammatory exudate and the mucin secreted by the
hyperplastic glands → lifts the epithelial lining of the sinus and the periosteum
away from the underlying bone.
• The process gradually expands the cavity and causes destruction of contiguous
bones
4/5/2024
15
4.MYCOTIC INFECTIONS of the upper respiratory tract are usually located in the
paranasal sinuses.
• Mucormycosis is one of the most frequent
• in association with poorly controlled diabetes mellitus
• in the immunocompromised population
• may result in the formation of noninvasive mycetomas/fungus balls or
• spread rapidly to involve orbit and brain
=“invasive fungal sinusitis”
•In mucormycosis, the organisms characteristically
invade blood vessels and cause thrombosis,
hemorrhage, and infarction.
4/5/2024
16
5.GRANULOMATOSIS WITH POLYANGIITIS= WEGENER GRANULOMATOSIS
• classic form is a rapidly progressive condition in which nasal involvement is
accompanied by pulmonary and renal disease
4/5/2024
17
LM/ a leukocytoclastic vasculitis
with geographic necrosis
surrounded by palisaded
histiocytes,
• lymphocyte-poor granulomatous
reaction, and
• epithelial ulceration is seen
4/5/2024
18
6.MYOSPHERULOSIS
• an iatrogenically induced granulomatous condition
• a form of lipogranuloma that develops after hemostatic packing with
petrolatum based ointments and gauze
• LM/ large tissue spaces containing saclike structures with brown “spherules”
resembling fungi → simply erythrocytes that have been altered and clumped
by the action of the petrolatum
4/5/2024
19
NEOPLASMS
1.SINONASAL (=SCHNEIDERIAN) PAPILLOMA
• benign neoplasms of the sinonasal respiratory mucosa =the schneiderian
membrane
• presenting with nasal congestion, nasal obstruction, and/or epistaxis
• Most cases are seen in adult men
• There are three distinct clinicopathologic subtypes:
exophytic =fungiform,
inverted, and
oncocytic
• are unilateral in the large majority of cases
4/5/2024
20
• LM/ composed of proliferating columnar and/or squamous epithelial c.
with an admixture of mucin-containing cells and
• numerous microcysts →typically filled with neutrophils =neutrophilic
microabscesses
4/5/2024
21
• Downward growth into the sinonasal
seromucous glands →results in the
inverted papillomas
• Atypia is mild to moderate, and there
is an orderly maturation pattern
4/5/2024
22
• oncocytic papilloma →are partially or entirely composed of swollen,
granular, eosinophilic cells with features of oncocytes
4/5/2024
23
• Sinonasal papillomas have a tendency to recur
• They also have a complex relationship with malignancy,most commonly
squamous cell carcinoma
• HPV 6/11 has been the type most often detected
• The treatment of sinonasal papillomas is surgical removal.
4/5/2024
24
2.SINONASAL CARCINOMA
• an uncommon group of tumors
• An occupational groups known to be at an increased risk
→nickel refiners
Woodworkers
• more commonly in the vestibule and lateral wall
• paranasal sinuses →the ethmoid sinus, the sphenoid sinus, and the frontal
sinus.
• Intranasal tumors may extend into the medial wall of the antrum, ethmoid
sinuses, orbit, anterior skull bone, and upper lip.
4/5/2024
25
• LM/ Types of Sinonasal Carcinoma→
1.
Conventional (keratinizing) squamous cell carcinoma
→the most
common microscopic type →high-grade lesions, with varying degrees of
keratinization
4/5/2024
26
2. Nonkeratinizing squamous cell carcinoma =transitional=cylindrical;
Schneiderian carcinoma with scant cytoplasm imparting a basaloid
appearance, occasional keratin pearl formation
• Foci of intracellular mucin production may be present.
• With an undulating or ribbon-like growth pattern
4/5/2024
27
3. Verrucous carcinoma
4. Basaloid squamous cell carcinoma
5. Sarcomatoid carcinoma =spindle cell carcinoma
= carcinosarcoma
6. Adenocarcinomas
7. Small cell neuroendocrine carcinoma
8. Sinonasal undifferentiated (anaplastic) carcinoma (SNUC)
9.NUT midline carcinoma →The diagnosis has to be confirmed by
immunostaining with a NUT-specific antibody or by molecular techniques.
4/5/2024
28
• The recommended treatment
→ a combination of surgery and radiation therapy with or without chemotherapy
• The 5-year survival rates around 60%
• Relapse occurs almost always within 2 years after the initial treatment.
• As usual, the most important prognostic factor is tumor stage.
• Adenocarcinoma carries a slightly better prognosis than squamous cell
carcinoma,
• The prognosis of high-grade adenocarcinoma, SNUC, and NUT midline
carcinoma are extremely poor.
4/5/2024
29
3. ANGIOFIBROMA (NASOPHARYNGEAL ANGIOFIBROMA)
• almost exclusively in males between 10 and 25 years of age →strongly
suggests that this lesion is androgen dependent
• This neoplasm arises from a distinctive erectile-like fibrovascular stroma
located in the posterolateral wall of the roof of the nose
• Grossly/ a polypoid mass that bleeds severely on manipulation and biopsy
grow to occlude the involved nares completely
4/5/2024
30
• LM/composed of an intricate mixture of blood vessels and fibrous stroma
fibrous stroma varies from loose and edematous, with stellate fibroblasts and
numerous mast cells, to a dense, acellular, and highly collagenized tissue
• The vessels range from capillary size to venous size
•The large vessels may have an irregular
or incomplete smooth muscle coat,
but they lack elastic fibers
•Location of the tumor is very important
in differential diagnosis
•Some large angiofibromas regress after
puberty, especially after incomplete
surgical removal or radiation therapy.
4/5/2024
31
4.NASOPHARYNGEAL CARCINOMA
• rare neoplasm
• Squamous cell carcinoma of the nasopharynx is a leading cause of death for
large populations in Southeast Asia and, to less degree, in northern Africa
• The age–incidence curve is bimodal, with a peak occurring
between 15 and 25 years and
another between 60 and 69 years
• this tumor results from the combined action of
genetic predisposition,
environmental factors, and
the EBV
4/5/2024
32
• It has
(1) the strong epidemiologic links to EBV and
(2)the high frequency of this cancer among the Chinese →raises the
possibility of viral oncogenesis on a background of genetic susceptibility
• In some individuals, infection leads to transformation of the epithelial cells
→the EBV genome is found in virtually all nasopharyngeal carcinomas
• Nasopharyngeal carcinomas invade locally,
spread to cervical lymph nodes, and
then metastasize to distant sites.
• tend to be radiosensitive
• 5-year survival rates of 50% are reported,
• Responses to immune checkpoint inhibitors →providing a new therapeutic
strategy for tumors that do not respond to conventional therapy.
4/5/2024
33
• Histologic variants
→ keratinizing squamous cell carcinoma,
nonkeratinizing squamous cell carcinoma,and
undifferentiated carcinoma →the most common and the one most
closely linked with EBV
•LM/characterized by large epithelial
cells with indistinct cell borders reflecting
“syncytial” growth prominent eosinophilic
nucleoli.
4/5/2024
34
• In nasopharyngeal carcinomas, the tumor cells are often accompanied by a
striking influx of T cells,
• which are believed to be responding to viral antigens
4/5/2024
35
5.LARYNGEAL TUMORS
• A variety of nonneoplastic, benign, and malignant neoplasms of epithelial and
mesenchymal origin may arise in the larynx
• the most common presenting feature is hoarseness
A.NONMALIGNANT LESIONS
• Vocal cord nodules =“polyps
-are smooth, hemispherical protrusions (usually <0.5 cm in diameter)
-located, most often, on the true vocal cords
-occur chiefly in heavy smokers or singers =singer’s nodes
→suggesting that they are the result of chronic irritation or over use.
• 4/5/2024
36
-composed of fibrous tissue and covered by stratified squamous mucosa
-can be ulcerated from contact trauma with the other vocal cord
4/5/2024
37
• Laryngeal papilloma or squamous papilloma of the larynx
-benign neoplasm, usually located on the true vocal cords,
-forms a soft, raspberry like excrescence rarely more than 1 cm in diameter
-Papillomas usually are single in adults but often are multiple in children, in
whom the condition is referred to as recurrent respiratory papillomatosis (RRP),
since they typically tend to recur after excision.
-caused by HPV types 6 and 11 and
-often spontaneously regress at puberty
-Cancerous transformation is rare
4/5/2024
38
LM/ consists of multiple slender, fingerlike projections supported by central
fibrovascular cores and covered by an orderly, typical, stratified squamous
epithelium
-When the papilloma is on the free edge of the vocal cord →trauma →lead to
ulceration
→ hemoptysis.
4/5/2024
39
B.CARCINOMA OF THE LARYNX
• only 2% of all cancers
• after 40 years of age
• more common in men than in women →M/F =7
• Environmental influences are very important in its causation→
nearly all cases occur in smokers,
alcohol and asbestos exposure also may play roles.
HPV sequences have been detected in about 15% of tumors
• manifests clinically with persistent hoarseness
• 95% are typical squamous cell carcinomas
4/5/2024
40
The tumor develops directly
• on the vocal cords →glottic
tumors in 60% to 75% of cases
• above the cords →supraglottic in
25% to 40% or
• below the cords →subglottic
<5%
4/5/2024
41
* glottic tumors are confined to the larynx
at diagnosis in about 90% of cases
→ interference with vocal cord mobility
→develop symptoms early in the course
of4/5/2024
disease
42
• Squamous cell carcinomas of the larynx begin as in situ lesions
→ later appear as pearly gray, wrinkled plaques on the mucosal surface
→ultimately ulcerating and fungating
4/5/2024
43
•.
4/5/2024
44
• The glottic tumors are usually keratinizing, well to moderately differentiated
squamous cell carcinomas.
• adjacent mucosa may demonstrate squamous cell hyperplasia with foci of
dysplasia, or even carcinoma in situ
4/5/2024
45
• The location of the tumor within the larynx has a significant bearing on
prognosis→
*the glottic region has a sparse lymphatic supply,
spread beyond the larynx is uncommon.
* the supraglottic larynx is rich in lymphatic spaces
→nearly 1/3 of these tumors metastasize to regional (cervical) LN
* subglottic tumors tend to remain clinically quiescent
→manifesting as advanced disease
4/5/2024
46
• Treatment: With surgery, radiation therapy, or combination
treatment, many patients can be cured, but about one-third die of
the disease.
• -The usual cause of death is
• widespread metastases
• cachexia,
• sometimes complicated by pulmonary infection
4/5/2024
47
4/5/2024
THANK YOU….
48