Head & Neck Pathology

Head & Neck Pathology / ©2010 Mark Tuttle
Disease / Signs & Symptoms / Pathogenesis / Histology
Normal Tooth Anatomy / Symptoms
-  Redness
-  Edema
-  Bleeding
-  Loss of soft tissue adaptation to teeth
Incidence
-  Severe in adolescents
-  But can occur in any age / Caries (tooth decay)
-  Focal degradation of tooth struct caused by mineral dissolution by acid metabolic end products from oral bacteria fermenting sugars.
-  Prevention
o Fluorides make the enamel resistant to degradation by bacterial acids by forming fluoroapatite
Gingivitis
-  Cause: lack of proper oral hygiene
-  Accumulation of dental plaque
o Normal oral flora
o Salivary protein
o Desquamated epithelial cells
-  Calculus formation
o Calcified plaque / Periodontitis
-  Inflammation of the periodontal ligament, cementum and alveolar bone
-  Can lead to teeth loss
-  Causative organisms
o Actinobacillus
o Actinomycetes
-  Can cause:
o Infective endocarditis
o Pulnary abscess
o Brain abscess
/ -  Enamel - acellular tissue
-  Dentin - cellular with tubules
-  Periodontal ligament attach the tooth to jaw
Inflammatory/Reactive Lesiosn
Pyogenic Granuloma / -  Common in pregnancy
-  Looks like granuloma tissue / -  Erythematous, hemorrhagic, and exophytic mass arising from the gingival mucosa / Aphthous ulcers
(canker sores) / -  Painful
-  Cause unknown / -  Single ulceration with an erythematous halo surrounding a yellowish fibrinopurulent membrane.
Glossitis
(Not true inflammation, but atrophy) / -  B12 deficiency
-  Other vitamin deficiencies
-  Sprue
-  Secondary inflammation can occur / Herpes Simplex Virus / -  HSV-1 (most common)
-  HSV-2 (can occur)
-  Vesicular lesions
-  Recurrent / Candida (thrush) / -  Pseudomembranous candidiasis
-  Immunosuppression is a risk factor
-  Diabetes
-  AIDS
Oral Manifestatiosn of Some Systemic Diseases
Scarlet Fever / Fiery red tongue with prominent papillae (raspberry tongue); white-coated tongue through which hyperemic papillae project (strawberry tongue)
Measles / Spotty enanthema in the oral cavity often precedes the skin rash; ulcerations on the buccal mucosa about Stensen duct produce Koplik spots
Mononucleosis / Acute pharyngitis and tonsillitis that may cause coating with a gray-white exudative membrane; enlargement of lymph nn in the neck, palatal petechiae
Diptheria / Characteristic dirty white, fibrinosuppurative, tough, inflammatory membrane over the tonsils and retropharynx
HIV / Predisposition to opportunistic oral infections, particularly herpesvirus, Candida, and other fungi; oral lesions of Kaposi sarcoma and hairy leukoplakia
Hematologic Disorders
Pancytopenia / (agranulocytosis, aplastic anemia) Severe oral infxn: gingivitis, pharyngitis, tonsillitis, may extend to produce cellulitis of the neck (Ludwig angina)
Leukemia / With depletion of functioning neutrophils, oral lesions may appear like those in pancytopenia
Monocytic Leukemia / Leukemic infiltration and enlargement of the gingivae, often with accompanying peridontitis
Dermatologic Conditions
Lichen planus / Reticulate, lacelike, white keratotic lesions that rarely become builous and ulcerated; seen in more than 50% of patients with cutaneous lichen planus; rarely, is the sole manifestation
Pemphigus / Vesicles and bullae prone to rupture, leaving hyperemic erosions covered with exudates.
Bullous pemphigoid / Oral lesions resemble macroscopically those of pemphigus but can be differentiated histologically
Erythema multiforme / Maculopapular, vesciulobullous eruption that sometimes follows an infection elsewhere, ingestion of drugs, development of cancer, or a collagen vascular disease; when it involves the lips and oral mucosa, it is referred to as Stevens-Johnson syndrome
Miscellaneous
Melanocytic Pigmentation / May appear in Addison disease, hemochromatosis, fibrosis dysplasia of bone (Albright syndrome), and Peutz-Jagher syndrome (gastrointestinal polyposis)
Phenytoin / (Dilantin) Striking fibrous enlargement of the gingivae
Pregnancy / A friable, red, pyogenic granuloma protruding from the gingiva (“pregnancy tumor”)
Rendu-Osler-Weber syndrome / Autosomal dominant disorder with multiple congenital aneurysmal telangiectasis beneath mucosal surfaces of the oral cavity and lips
Tumors
Leukoplakia / -  Thickening of the epithelium
-  Pre-cancerous / -  smooth and thin with well-demarcated borders. / -  diffuse and thick / -  irregular with a granular surface / -  diffuse and corrugated.
Histology is variable:
Squamous cell carcinoma
-  Smoking
-  Alcohol
-  HPV / A.  The typical clinical progression of oral cancer.
B.  The histologic progression of squamous epithelium from normal, to hyperkeratosis, to mild/moderate dysplasia, to severe dysplasia, to cancer.
C.  The sites of the most common genetic alterations identified as important for cancer development.
Nose and sinuses
Rhinitis / -  Allergic
-  Viral
-  Chronic
-  Nasal polyps: hyperplastic glands w/inflammation / Sinusitis / Causes:
-  Rhinitis
-  Tooth infection / -  Organisms
o Usually bacteria
o Mucormycosis in diabetics
Nasopharynx
Inflammatory lesions / -  Pharyngitis/tonsillitis
o Viral: rhino, echo, adeno, RSV, influenza
-  Squamous papillomas
o HPV 6,11 (low risk)
o Benign, squamocolumnar epithelium / -  Nasopharyngeal cancer
o Common in Africa (children)
§ Asia à adults
o Rare in U.S.
o EBV found in tumor cells
o Origin affected by: heredity, age, EBV
o Infection
o Types:
§ Keratinizing SCC
§ Nonkeratinizing SCC
§ Undifferentiated cancer
§ All have á lymphocytes (non-neoplastic) / Microscopy
-  Squamous cells (keratinized or non-keratinized) embedded in lymphoid background
Treatment: Radiotherapy
-  50-70% 3-year survival
o Undifferentiated à most sensitive
o Keratinizing the à least sensitive
Larynx
Laryngitis / -  Usually as part of URI, tobacco smoke
-  Self-limited
-  Serious form: infants, H. influenzae, β-hemolytic, Strep.
o May lead to swelling of epiglottis (laryngoepiglottis), airway obstruction / Reactive Nodules/
Polyps
-  True vocal cords / -  Smokers
-  Strained vocal cords
o (“singer’s nodules”)
-  Nodules à bilateral
-  Polyps à unilateral
-  Progressive hoarseness
-  Not premalignant / Squamous Papillomas
-  True vocal cords / -  Adults: solitary
-  Children: often multiple, papillomatosis
-  Linked to HPV 6, 11
o Tend to recur
-  Micro: stratified squamous epithelium on fibrovascular papillary cores
-  Septal or inverted
o inverted forms recur
Carcinoma of the Larynx / -  Persistent hoarseness
-  Risk factor: Tobacco
-  Late clinical picture
o Dysphagia
o Pain
o Hemoptysis / Sequence:
1.  Hyperplasia
2.  Dysplasia
3.  Carcinoma in situ
4.  Invasive carcinoma / Squamous cell carcinoma
A.  Laryngeal carcinoma. Note the large, ulcerated, fungating lesion involving the vocal cord and piriform sinus.
B.  Histologic appearance of laryngeal squamous cell carcinoma. Note the atypical lining epithelium and invasive keratinizing cancer cells in the submucosa.
Salivary Glands
Sial Adenitis / Mumps (predominantly parotid)
-  RNA virus
-  In children: no sequelae
-  In adults:
o Pancreatitis, Orchitis / Bacterial
-  Staphylococcus aureus
-  Streptococcus vindaus
-  Can be caused by sialolithiasis (salivary duct stones) / Chronic
-  Autoimmume Sjögren syndrome
Benign / Malignant
Pleomorphic adenoma (50%) (mixed tumor)
-  Most common 90%
-  Commonly in parotid gland
-  Recurs
-  Mixture of epithelial cells and myxoid corrective tissue / Mucoepidermoid carcinoma (15%)
Warthin tumor (5% - 10%) / Adenocarcinoma (NOS) (10%)
Oncocytoma (1%) / Acinic cell carcinoma (5%)
Other adenomas (5% - 10%)
-  Basal cell adenoma
-  Canalicular adenoma / Adenoid cystic carcinoma (5%)
Malignant mixed tumor (3% - 5%)
Squamous cell carcinoma (1%)
Ductal papillomas / Other carcinomas (2%)
/ Pleomorphic adenocarcinoma
Slowly enlarging neoplasm in the parotid gland of many years duration. / Bisected, sharply circumscribed, yellow-white tumor can be seen surrounded by normal salivary gland tissue. / A well-demarcated tumor in the parotid gland / Low-power view showing a well-demarcated tumor with normal parotid acini below / High-power view: amorphous myxoid stroma resembling cartilage, with interspersed islands and strands of myoepithelium.
Warthin Tumor
-  Papillary cystadenoma lymphomatosum / -  Benign
-  Second most common salivary gland tumor
-  Virtually all arises in parotid gland
-  Males > females
-  40-60 year olds
-  Smokers / -  Gross: encapsulated masses with cystic spaces filled with secretion
-  Micro: papillary structures lined by double layer of oncocytic cells and a lymphoid stroma
-  EM: many mitochondria
-  Benign, low recurrence rate
Malignant Tumors
-  Mucoepidermoid carcinoma
-  Most common malignant salivary gland tumor / -  Majority in parotid, but also common in other salivary gg.
-  Behavior dependent on grade
-  5-year survival:
o low grade = 90%
o high grade = 50% / Micro: squamous, mucous, and intermediate cells with varying differentiation
-  Gross: large, poorly circumscribed, mucinous / Low-power view showing epithelial and lymphoid elements. Note the follicular germinal center beneath the epithelium. / Cystic spaces separate lobules of neoplastic epithelium consisting of a double layer of eosinophilic epithelial cells based on a reactive lymphoid stroma.
Mucoepidermoid carcinoma showing islands having squamous cells as well as clear cells containing mucin / Mucicarmine stains the mucin reddish-pink.