Respiratory Pathology PDF

DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Upper Respiratory tract Anatomy: Nose Paranasal sinuses Pharynx Tonsills Larynx Histology: Pseudostratified columnar ciliated epithelium with goblet cells (Respiratory Epitheliu...

DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Upper Respiratory tract Anatomy: Nose Paranasal sinuses Pharynx Tonsills Larynx Histology: Pseudostratified columnar ciliated epithelium with goblet cells (Respiratory Epithelium) Stratified squamous Non-keratinized (Vocal Cords & openings) Rhinitis Definition: inflammation of the nasal mucosa. Usually accompanied by sinusitis. A) Acute rhinitis Acute Catarrhal Rhinitis Acute Allergic (Common cold) Rhinitis Etiology -Cause: -Cause: Rhinovirus+2ry Bacterial inhalation of certain infection antigens (as pollens, -PF: animal allergens,dust Exposure to cold mites) -PF: Atopy,TypeI Hypersensitivity 1  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Pathology Gross Gross Early: Mucous membrane is Marked mucosal edema, red, hot, Swollen and dry. redness, and mucus Then: watery mucoid secretion discharge and may be purulent. (If 2ry infected) Microscopic Microscopic Submucosa: Congested Submucosa: BVs, edema and mild Congested BV, neutrophilic infiltrate. marked edema, allergic inflam. rich Mucous cells swollen, in eosinophils rounded and may rupture. Complications Spread of infection causing Nasal Polyp formation sinusitis, pharyngitis, {repeatedattacks adenoids,laryngitis, otitis (chronicity) of allergic media,bronchitis, rhinitis & sinusitis bronchopneumonia B) Chronic rhinitis : NB: ❖ Chronic Non-Specific rhinitis + Exposure to dry heat or chemical fumes. Etiology: Nasal obstruction Mucus accumulation Damage the cilia (nasal polyps, deviated nasal septum , adenoid , Tumors ) Chronic sinusitis Retentin of bacteria a source of continous infection + &chronic infection 2  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Types: a) Simple (Non-thickened mucosa): The submucosa shows chronic inflammatory cells, endarteritis & fibrosis. b) Hypertrophic: Mucosa is thickened & polypoid. c) Atrophic Definition ▪ Rare chronic non-specific rhinitis. Common in female Etiology: The pathogenesis is unclear. The suspected causes are: 1-Ischemic changes due to endarteritis in chronic nonspecific rhinitis 2-endocrinal disturbance 3-Infection with Klebsiella ozaenae bacteria. Pathology: Atrophy of: Nasal mucosa: Thin & covered by crust of dried discharge which have offensive odor. Nasal bones: causing widening of the nasal cavity (Roomy Nose). Nerve endings: causing anosmia (loss of smell). ❖ Chronic Specific rhinitis (Rhinoscleroma) Definition: Granulomatous inflammation of URT. NB: - Common (endemic) in Egypt ✓ Young and middle-aged adults ✓ Slightly more common in Females Etiology: CO: klebsiella rhinoscleromatis (Gram –ve bacilli) Pathology: Site: Nose is the most common site (Rhinoscleroma), but pharynx 3  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA (pharyngioscleroma), larynx (laryngioscleroma) & upper trachea maybe also affected. Stages: Catarrhal Granulomatous (proliferative) Fibrotic Gross Picture: Single or multiple hard nodules. ( Filling the nasal cavity & may extend to upper lip, sinuses, pharynx, larynx & upper trachea.) Nasal deformity (Hebra nose). Microscopic Picture: The covering nasal mucosa may show squamous metaplasia The submucosa is densely infiltrated with inflammatory cells (Granuloma) & shows progressive fibrosis. The inflammatory cells of scleroma : 1) Mikulicz cells: These are the pathognomonic cells. They are macrophages with hydropic degeneration. The cells are large sharply outlined with foamy cytoplasm and small central or eccentric nuclei (foamy macrophages). 2) Plasma cells 3)Russel bodies: They are plasma cells with hyaline degeneration. They appear round or oval with bright red cytoplasm. Some cells show a pyknotic eccentric nucleus, others are anuclear. 4) Lymphocytes 4  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Complications Nasal deformity Nasal obstruction Epistaxis (Bleeding) & 2ry bacterial infection. Nasal Polyps (Allergic) Etiology: Repeated attacks of allergic rhinitis and sinusitis. Pathology: ▪ Gross Picture: Multiple soft pink polyps, projecting from the mucosa of the nose and sinuses. Often bilateral. Vary in size, in severe cases, may completely fill the nasal cavity ▪ Microscopic Picture: 1-Covering Epithelium: Respiratory epithelium with thick BM & Squamous metaplasia 2- Connective tissue Core: Congested BV, oedema, many eosinophils, lymphoplasma cells & proliferated mucous glands 5  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Complications: ▪ Nasal obstruction (This predisposes to infection leading to chronic rhinitis and sinusitis.) ▪ Epistaxis (Bleeing) Sinusitis Definition: This is inflammation of the mucosa of the paranasal sinuses. Commonly associated with rhinitis Acute Sinusitis: Acute Catarrhal & Allergic (In association with similar types of acute rhinitis) Chronic Sinusitis: Etiology: 1- A complication of repeated attacks of acute rhinitis and sinusitis 2- Spread of infection from an infected tooth (mainly maxillary sinus). Pathology: A) Chronic Non Allergic: - The mucosa: Respiratory epithelium may show sq metaplasia The submucosa: Chronic inflammatory cells, edema, endarteritis& fibrosis. B) Nasal Sinus Polyps (Allergic): Same as nasal polyps C) Mucocele and Empyema of the maxillary sinus: Obstruction of sinus ostium due to ch sinusitis Retention of mucous discharge (mucocele) Secondary infection Accumulation of pus inside the sinus (empyema). ▪ 6  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Tumors of Nose & Sinuses A)Sinonasal Papilloma: Definition: A benign neoplasm arising from the sinonasal mucosa. Etiology : May be caused by HPV 6 & 11 Pathology: Composed of squamous or columnar epithelium. The lesion occur in two forms: -Exophytic -Endophytic (inverted) 7  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Exophytic Enophytic (inverted) Pharyngitis Definition: inflammation of the pharyngeal mucosa “sore throat “ Acute Pharyngitis: Etiology: Commonly streptococcus hemolyticus infection. Pathology: Catarrhal or suppurative inflammation. catarrhal Suppurative Complications: Spread of infection: may lead to o Adenoids, laryngitis, otitis media, bronchitis, pneumonia o Cellulitis of neck o Retropharyngeal abscess Autoimmune (Hypersensitivity) : o Rheumatic fever o Glomerulonephritis Chronicity 8  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Chronic Pharyngitis: 1- Nonspecific following acute pharyngitis 2- Specific as scleroma (pharyngioscleroma). Tonsilitis Definition: inflammation and swelling of the tonsils (palatine tonsils). A)Acute Tonsillitis Etiology: - CO: Bacterial infection; most common streptococcus hemolyticus -MOT: Both inhalation & ingestion Pathology:3 types( stages) 1-Catarrhal Tonsillitis: Enlarged, swollen tonsils with hyperemic mucosa & covered by mucous. 2- Follicular (suppurative) Tonsillitis: Remarkably enlarged tonsils. Lymphoid follicles show pus which appears at the tonsillar crypts 9  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA 3-Membrarous Tonsillitis: In severe cases mucosal necrosis & exudate form a yellow membrane covering the tonsils. NB: Microscopic Picture: As general Complications: 1-Spread: a) Direct: o Peritonsillar abscess (Quinzy) o Otitis media. o Pharyngitis, Laryngitis, bronchitis... b) Lymphatic: leads to cervical lymphadenitis. c) Blood: leads to bacteremia, toxemia. 2-Chronicity: Chronic nonspecific tonsillitis (Reapeted attacks) 3-Hypersensitivity reaction (Autoimmune): Rheumatic fever. Glomerulonephritis B) Chronic Tonsillitis 1) Chronic Non-specific tonsillitis Etoilogy: follow repeated attacks of acute tonsillitis. Pathological picture: Hyperplasia of lymphoid follicles causing enlargement of the tonsils Chronic inflammation (as general) Fibrosis and atrophy of the tonsils in the late stages 2) Chronic Specific tonsillitis : 1ry &2ry TB 10  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Adenoid Definition: Hyperplasia of the lymphoid tissue present at the posterior wall of the nasopharynx of infants and children due to chronic infection. Pathology: Gross Picture: Swollen adenoid tissue Microscopic Picture: hyperplastic lymphoid tissue Complications: 1- Nasopharyngeal Obstruction mouth breathing Adenoid face Adenoid Face ✓ Open mouth ✓ Short upper lip ✓ Protruding upper central incisors ✓ Narrow nasal openings ✓ Absent naso-labial folds 2- Spread: causing otitis media, bronchitis... -Diphteria Definition: Pseudo-membranous inflammation of the tonsils and throat Etiology: - CO: Corynbacterium diphtheria - MOT: Droplet infection - PF: Unimmunized children 2-5 Y Pathology: Site: upper respiratory tract (Mainly) rarely conjunctiva, nose, vulva, skin wound are affected. 11  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Pathological picture: 1) Pseudo-membranous inflammation Grossly: Mucosa is Red (Hyperemic), Swollen, Edematous & Covered with Grayish dirty adherent membrane Microscopic: Pseudomembrane: necrotic cells+ PLM. + Fibrin Submucosa: VD, Congestion of capillaries, Inflammatory edema , Acute inflammatory cells as: Neutrophils … (Acute inflammation) 2) Acute cervical lymphadenitis Complications: Local : Asphyxia Inflammatory edema + Diphtheritic membrane in larynx and trachea Systemic: Acute severe Toxemia o Acute heart failure (due to toxic myocarditis) o Paralysis of respiratory, laryngeal and extraocular muscles o Acute adrenal insufficiency due to adrenal necrosis & hemorrhage o Zenker's degeneration (hyaline necrosis of Skeletal muscles as rectus abdominis). o Cloudy swelling and focal necrosis of the liver. Tumors of Pharynx 1- Nasopharyngeal (Juvenile) , Angiofibroma Definition: An uncommon benign tumor arising from periosteum of nasopharynx. NB: Affects Young adolescent boys (peak 15 y). 12  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA NB: Evidence of hormonal dependency of angiofibroma: ✓ Tumor growth is associated with puberty in boys ✓ Tumor cells express AR and lack ER or PR ✓ Some reports that testosterone administration has produced clinical enlargement Pathology: Site : Root of nasal cavity & nasopharynx Gross picture: Non capsulated grayish pink mass projecting into the nasopharynx. Microscopic Picture: Angiofibroma (fibroma rich in capillaries) Complications: 1) Epistaxis 2) Obstruction 3) Extend into : cheek, maxillary antrum, orbit, rarely intra-cranially 4) Profuse bleeding during surgery 13  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Prognosis: (Regress after puberty) Surgical removal is the treatment of choice o Preoperative embolization to reduce hemorrhage during surgery o Preoperative anti-androgen therapy Radiotherapy or Chemotherapy If advanced or aggressive Recurrence: 20% Because of extensions specially intracranial Fatal: 9% Death caused by hemorrhage and intracranial extension 2- Nasopharyngeal Carcinoma Definition: 1ry malignant epithelial neoplasm arising from nasopharynx Etiology: Exact etiology is unknown but following are Predisposing factors: Age: bimodal age common in 2 age groups (2 peaks): -Young individuals; 15-25years. - Old individuals; 60-70 years. Gender : Males > females (ratio 2-3:1) PF (Irritations) : URT infections with EBV Pathology: Gross Picture: Raised ulcerated nodule (Malignant ulcer) NB: Nodule may be not ulcerated. Infiltrative fungating mass with Hemorrhage & necrosis Occult tumor (No grossly visible lesion) Microscopic Picture: 3 patterns 1) Keratinizing squamous cell carcinomas: resemble the usual well-differentiated S.C.C. 14  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA 2- Non-keratinizing squamous cell carcinomas: resemble the usual poorly differentiated S.C.C. 3- Undifferentiated carcinoma: Undifferentiated carcinomas commonly associated with dense lymphocytic infiltrate and is therefore sometimes termed "Lymphoepithelioma". It is composed of large epithelial cells with oval or round vesicular nuclei, prominent nucleoli, and indistinct cell borders mixed with the abundant, mature, normal appearing lymphocytes, predominantly T cells. 15  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Spread : direct & lymphatic (late by blood) Prognosis : Radiotherapy is the treatment of choice. Undifferentiated Ca…… most radiosensitive (No keratinization) Keratinizing S.C.C……… least radiosensitive Epistaxis Definition: Bleeding from the nose Causes: General: Hypertension Blood diseases (As hemophilia &purpra) Leukemia &Lymphoma Vit C or Vit K deficiency Fever Hot climate Local: a) Traumatic Trauma Foreign Body b) Inflammation: Rhinitis ,Nasal polyp, Rhinoscleroma c) Tumors: of nose , sinuses and nasopharynx Laryngitis Definition: Inflammation of the larynx. It causes hoarseness or complete loss of the voice because of irritation to the vocal folds (vocal cords) 16  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA A)Acute laryngitis Etiology: 1) Bacterial infection; commonly streptococcus hemolyticus. 2) Viral infection e.g. measles. 3) Chemical irritation e.g. inhalation of irritant gases as chlorine and fumes. 4) Mechanical irritation e.g. faulty excessive use of voice causing vocal cord irritation. Pathology: Catarrhal inflammation (swollen hyperemic mucosa showing excess mucous). B)Chronic laryngitis ❖ Chronic Non-specific laryngitis Etiology: chronic irritation with smoking or chronic faulty use of voice. Pathological picture: vocal cords show chronic inflammation Or laryngeal nodule Clinical Presentation: hoarseness of voice. ❖ Chronic Specific laryngitis Laryngioscleroma. Tuberculous laryngitis. Syphilitic laryngitis Larngyeal Nodule Definition: common lesion (Reactive nodules) in the middle 1/3 of the true vocal cord. Etiology: related to excessive use of the voice (Due to trauma) and occurs in singers (Singer's nodule) and teachers. NB: May be due to irritation by smoking 17  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Pathology: Site: Middle 1/3 of true vocal cord (Trauma) Gross Picture: Firm rounded nodule covered by mucosa. Microscopic Picture: Core of myxoid C.T with dilated BV, fibrosis and mild ch. Inflammatory infiltrate Covered by st sq, may become keratinized, hyperplastic or ulcerated NB: Clinical presentation: Hoarseness of voice. NB: Fate: No malignant transformation Tumors of larynx 1) Squamous Cell Papilloma 18  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA 2) Squamous Cell Carcinoma Definition : 1ry malignant epithelial neoplasm arising from the larynx. Etiology: Not Exactly known but following are P.Fs: Smoking. Alcohol, Exposure to asbestos, Irradiation, HPV(16,18) NB: Epiemology of SCC of larynx Not uncommon (2% of all cancers of men). Age: Above 40 Y Gender: Male < Females (7:1) Pathology: Gross Picture: Ulcerated, Fungating mass Sometimes is very small and may be hardly visible grossly. Microscopic Picture: S.C.C well to poorly differentiated 19  DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Site: Glottic , Supra-glottic, Infra-glottic. Spread: Direct and by lymphatics (to cervical nodes). Blood spread is late. 20 DR / AHMED SAEDA RESPIRATORY PATHOLOGY SAEDA Verrocous carcinoma Papillary well diff. SCC Superficially invasive “pushing margins” Never metastasize Very good prognosis 21