NASAL AND SINONASAL LESIONS
 INFLAMMATORY, GRANULOMATOUS AND INFECTIOUS DISEASES
1.) Acute infections of upper respiratory tract - are among the most
common human diseases
-common cold (acute rhinitis) -clinical symptoms include congestion of nasal
mucosa accompanied by watery discharge, sore throat, mild increase in
temperature
pathogenesis: is usually caused by rhinoviruses, parainfluenza and influenza
viruses, etc
clinical course: the infection is self-limited, usually lasting for about a week
-common complication include bacterial upper respiratory tract infection
-in minority of cases- common cold may be complicated by
-bacterial otitis media
-or bacterial sinusitis
- acute pharyngitis - manifests itself as sore throat
-morphologic changes are mild-mucosal edema, hyperemia, exudate
-more severe forms of pharyngitis are associated with tonsillitis or acute
pharyngotonsillitis
-marked hyperemia, larger amounts of exudate
pathogenesis:
most often caused by beta-hemolytic streptoccoci and
adenovirous infections
acute pharyngitis may be also a component of infectious mononucleosis (caused
by EB-virus )
-acute suppurative sinusitis- bacterial inflammatory disease characterized
by mucosal edema, inflammatory infiltrate (with abundant eosinophilic leuko in
allergic types), and hyperplasia of mucous producing glands
2.) Chronic infections of upper respiratory tract
 -chronic rhinitis- chronic inflammation of the nasal cavity- repeated
nonspecific chronic bacterial infections may have a form of hyperplastic
rhinitis- possible obstruction of airways
or of atrophic chronic rhinitis-associated with strong odor from the
respiratory tract (ozena)
 chronic paranasal sinusitis - infiltration of accessory air sinuses (maxillary,
ethmoid, frontal)
-common complication of acute and chronic rhinitis that results from the
obstruction of the nasal openings caused by infiltration and edema of the nasal
mucosa
-chronic inflammatory and allergic nasal polyps -repeated attacks of acute
rhinitis may result in the development of inflammatory nasal polypspseudotumors composed of edematous stroma, abundant inflammatory cells,
including neutrophils, eosinophils, lymphocytes and plasma cells, eosinophils are
more numerous in allergic nasal polyps
-nasal polyp may cause nasal obstructionnasal polyps are soft, edematous, semitranslucent polypoid masses affecting
nasal cavity, usually associated with acute and chronic rhinitis and sinusitis
-antrochoanal polyps- between 3 to 6% of all patients with nasal
inflammatory polyps have the antral-choanal variety
-It is usually solitary, nasal obstruction and epistaxis are the major
symptoms
Choanal polyps are defined as paranasal sinus polyps that pass through
sinus ostia and protrude into the boundary between nasal cavity and
nasopharynx, called choana
-rare inflammatory polyps arising in the mucosa of maxillary sinus (antrum
Highmori), it protrudes into posterior nasal cavity, can easily become
traumatized- ulceration, bleeding, neovascularization- may mimic hemangioma,
hemangiopericytoma, juvenile angiofibroma, etc.
 Most choanal polyps originate in the maxillary sinus. With enlargement the
antrochoanal polyp protrudes through the middle meatus into the nasal
cavity between middle turbinate and lateral wall of the nasal cavity. Even
posterior extension moves polyp into the nasopharynx, very large polyps
may present as oropharyngeal mass.
 Sphenochoanal polyp develops in the sphenoid sinus and protrudes through
sphenoid ostium into the nasal cavity
 rhinoscleroma- is an uncommon chronic infection of ther upper respiratory
tract- endemic in eastern Europe (Poland), the Middle East, Central Africa,
and Latin America
-it its caused by Klepsiella rhinoscleromatis
morphology: rhinoscleroma affects the mucous membranes of the nasal cavity
and later may extend to nasopharynx and larynx, it presents with polypoid
mucosal lesions caused by accumulation of foamy macrophages (Miculizc cells)
filled with bacteria and lymphoplasmacytic infiltration in nasal mucosa- result in
formation of polypoid masses and ulcerations-the overlaying epithelium may be intact, or squamous metaplasia and
pseudopitheliomatous hyperplasia is seen
 fungal sinusitis- noninvasive fungal sinusitis exists in the form of
mycetoma- most commonly caused by aspergillus- these organisms
normally occur on the mucosal surfaces of nasal cavity and paranasal
sinuses but rarely cause disease
-in patients with chronic sinusitis and poor drainage of paranasal sinusesaspergilli may proliferate and produce aspergilloma
-invasive fungal sinusitis- affects immunosupressed or immunocompromized
patients, those with severe debilityting metabolic and neoplastic diseases
 Wegener´s granulomatosis- is a rare disease that affects respiratory tract,
lungs and kidneys
-the clinical presentation is characterized by large sinonasal mucosal non-healing
ulcerations, and extensive necroses
-septal perforation, and edema, with mucosal swelling can be seen
-these clinical features have been reffered to as lethal midline granuloma
-lesions of the nasal and paranasal mucosa are the most common and the
most characteristic of the disease
-in upper respiratory tract- there are lesions characterized by
necrotizing destructive granulomas- associated with severe vasculitis
pathogenesis: is a form of necrotizing allergic vasculitis
-in most patients (85-95%) have a positive test for ANCA antibodies
(antineutrophil cytoplasmic antibodies)
TUMORS OF NASAL CAVITY AND PARANANASAL SINUSES
-introduction- carcinomas of nasal cavity and paranasal sinuses account for
0.2 to 0.8% of all malignant neoplasms and aprox. 3% of tumors of head and neck
etiology: occupational exposure to wood dust is known as a risk factor
Benign tumors:
- scheiderian papilloma-the most common benign tumor of the mucosa of nasal and paranasal cavities
(schneiderian membrane)
-histologically composed of exyphytic papillary protrusions made up of
fibrovascular stromal papillae covered by benign stratified squamous
epithelium
-common manifestation - is epistaxis (bleeding from the nasal mucosa) and/or
obstruction- removed surgically
-inverted papilloma -is a variant of schneiderian papilloma in which the
epitheliumprolifeates into the underlaying stroma- endophytic growth pattern
-has slightly more common local recurrences
 malignant tumors
rare, they include a wide spectrum of tumors with variable clinical outcomes
more common include squamous cell carcinoma, lymphoma and plasmocytoma
squamous cell carcinoma- located in nasal vestibule or at mucocutaneus
junction of the septum
clinical symptoms- nasal fullness, obstruction, epistaxis, pain, paresthesia,
persistent and non-healing mucosal ulceration, etc.
-clinical course is indolent, lymph node meta occur in less than 10%
SCC of paranasal sinuses more aggressive (the most common- maxillary sinus)
- SCC is classified to keratinizing, nonkeratinizing, papillary and
verrucous types- warty, papillary subtype with better clinical
outcome- no metastases, rarely recur
 Sinonasal adenocarcinoma- these are glandular malignancies arising from
the glands of respiratory mucosa
- Two main categories include intestinal type adenocarcinoma -similar
to colorectal adenocarcinoma histologically, causal relationship of
wood dust with development of ca has been demonstrated,
aggressive tumor with frequent local recurrence (50%), less
commonly LN meta, distant meta are rare
- Non-intestinal type adenocarcinoma-low grade and high grade
lesions
 Lymphoepithelial carcinoma- is a poorly differentiated SCC or
undifferentiated ca accompanied by heavy lymphoid infiltrate, strong
associatiation with EBV infection
 Small cell carcinoma- histologically similar to pulmory ca, common mitoses
and necroses, poor prognosis
Most carcinomas of the nasal cavity and paranasal sinuses are locally aggressive,
they grow readily to adjacent structures
 Olphactory neuroblastoma- malignant neuroectodermal tumor that
originates from olphactory membrane of the sinonasal tract
Treatment- safe surgical margins
 Extranodal T/NK lymphoma of nasal type- is characterized by diffuse
lymphoid infitrate causing destruction of mucosa, poor prognosis
Lethal midline granuloma
-this term was originally applied to a group of diseases characterized by severe
destructive ulcerations in the middle of the face including the nasal cavity
-most of the cases of LMG (if Wegener and rare fungal infections were
excluded)
represents sinonasal T-cell lymphoma of type
microscopically: characterized by diffuse infiltration composed of atypical
lymphoid tumor cells accompanied by extensive tissue necroses and ulcerations
of the surface of the mucosa (caused by angiodestructive growth of this type of
lymphoma)

Extramedullary plasmocytoma- is slowly growing mass lesion composed of
mature IgG producing neoplastic plasma cells
Prognosis is good, only 20% develop multiple myeloma
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