Chapter 16: Pulmonary Pathology of Head/Neck and Pulmonary Radiographic Correlations (Singh)

Question 1

Infectious Rhinitis/Sinusitis

What are 4 causes of Viral (R/C/A/E) and 2 causes of Bacterial (SP/HI) rhinitis/sinusitis?

Answer 1

Viral: rhinovirus, coronavirus, adenovirus, echovirus
- clear rhinorrhea

Bacterial: Strep. pneumoniae, H. influenzae
- thick, purulent nasal secretions

leads to either 2nd infection or chronic rhinitis/sinusitis, which can then become inflammatory nasal polyps

Question 2

Inflammatory Sinonasal Polyps

Answer 2

• develop due to chronic rhinitis/sinusitis (constant aggravation)
• causes edema in the stroma with large quantities of eosinophilic infiltrates

Question 3

Allergic Fungal Sinusitis

Answer 3

• occurs due to hypersensitivity to fungal organisms like Aspergillus that colonizes the sinus tract
• see allergic mucin with high levels of eosinophils and fungal hypae that can lead to formation of mycetoma (fungal ball)

Question 4

Acute Invasive Fungal Sinusitis

Who does it occur in and what species is most commonly implicated?

Answer 4

• typically seen in DIABETIC or Immunosuppressed pts. often due to ZYGOMYCOSIS species like Mucor
• requires IV antifungal therapy to prevent extension into brain or sepsis (treat aggressively)
• invades into wall and can get into brain or blood vessels

Question 5

Granulomatosis with Polyangiitis (GPA)

Answer 5

• seen in middle-aged adults and can affect nasal passages, leading to ulceration/necrosis/perforation of the septum
• can also affect lungs and kidneys

Histo: granulomatous inflammation with classic necrobiotic necrosis (BLUE color)

Question 6

What are 2 benign tumors (NA/SP) and 4 malignant tumors (ON/NMC/NC/ENCL) of the head and neck?

Answer 6

Benign: nasopharyngeal angiofibroma and sinonasal (Schneiderian) papilloma

Malignant: olfactory neuroblastoma, NUT midline carcinoma, and EBV-malignancies (nasopharyngeal carcinoma and extranodal NK/T cell lymphoma)

Question 7

Nasopharyngeal Angiofibroma

Who does it occur in, what is its histology, and what condition is it associated with?

Answer 7

• nasopharyngeal polypoid mass occurring in YOUNG MEN; benign but can recur and bleed

Histo: vascular fibrous core lined by benign epithelium

• spindle cell proliferation
• looks like penile erectile tissue
• associated with Familial Adenomatous Polyposis (FAP) –> caused by APC mutation and causes the development of numerous colon polyps in childhood

Question 8

Sinonasal Papilloma

Who does it occur in, what are its two growth types, and which one is worse?

Answer 8

• occurs in middle-aged MEN more than women
• 3 types: exophytic (external tree), endophytic (internal growth), and oncocytic (type of cell)
• endophytic subtypes have HIGH rate of recurrence, with a minority of cases progressing to malignancy (inc. rate of recurrence w/inc. risk of malignancy)

Question 9

Olfactory Neuroblastoma

What is it and what does it histologically look like, where does it come from, and what patients does it affect?

Answer 9

• small round blue cell tumor that creates ROSETTEs on histological imaging; looks like “dumb-bell”-shaped tumor on CT (penetrates through cribiform plate)
• arises from neuroectoderm in the superior nasal passage
• has BIOMODAL distribution, affecting adolescent and middle-aged patients

Question 10

Nasopharyngeal Carcinoma

What is it, where does it typically present, and what two patient populations does it commonly affect?

Answer 10

• essentially squamous carcinoma that is either keratinizing or non-keratinizing, or basophilic with lymphoid tissue (associated with EBV)
• arises in nasopharynx but mainly presents in the NECK as LN METASTASIS
• commonly occurs in Southeast Asian adults (ingestion of smoked fish w/nitrosamines, EBV) and young African children (EBV)
• can stain for EBER-1

Question 11

Extranodal NK/T Cell Lymphoma

What is it, who does it occur in, and what symptoms does it present with?

Answer 11

• EBV-related tumor that can cause necrotic destruction of the paranasal sinuses
  
  • biopsy shows NECROSIS (EBER stain)
• occurs in middle-aged Asian and Latin American pts.
  symptoms: fever, night sweats, weight loss (systemic signs of lymphoma)

Question 12

What are Vocal Cord nodules?

Answer 12

• also called “Singer’s nodules” because they usually occur in pts. that use their voice frequently; expansion of soft tissue underlying the vocal fold (soft and translucent)
• not malignant and is NOT a neoplasm; shows edema and loose stroma under benign squamous epithelium

Question 13

What is Laryngeal Squamous Papilloma?

Answer 13

• benign squamous NEOPLASM with a papillary appearance and is strongly associated with HPV 6/11
• has grossly, friable papillary masses and shows benign/mildly atypical squamous epithelium with multiple papillae
• either solitary or in association with recurrent respiratory papillomatosis

Question 14

What is Recurrent Respiratory Papillomatosis?

Answer 14

• occurs in children and adolescents typically
• associated with HPV 6/11 and is acquired at birth, through vaginal delivery, being first born, or being born to mothers < 20 yo
• can spread down the trachea and diffusely involve the lungs, but malignant progress is seen in < 1%

Question 15

Laryngeal Carcinoma

What is it, who is it commonly seen in, and what 3 things does it have strong associations with?

Answer 15

• squamous carcinoma; has ulcerated lesion with rolled edges and keratin pearls on histology
• most commonly seen in > 60 yo MALES
• has strong associations with: SMOKING, ALCOHOL, and HPV INFECTIONS (especially in young adults)

Question 16

What 3 organisms are commonly responsible for Otitis Media (S/M/H) and what organism is responsible for Chronic Otitis media in diabetics?

Answer 16

OM: Strep. pneumoniae, Moraxella catarrhalis, H. influenzae

OM in D: Pseudomonas aeruginosa

Question 17

What is a Cholesteatoma?

Answer 17

• cystic lesion that arises in chronic otitis media (“Ear Zit”); lined by benign squamous epithelium with trapped keratin debris
• is a REACTIVE process (NOT NEOPLASM) but can enlarge and erode adjacent bone

Question 18

What is Otosclerosis?

Answer 18

• abnormal inherited AD bony deposition typically at the stapedial footplate
• causes CONDUCTIVE HEARING LOSS

prosthetic implants can help recover hearing

Question 19

Brachial Cysts

Who does it occur in, where does it arise from, and what does it look like histologically?

Answer 19

• occurs in young adults as a lump anterior to sternocleidomastoid muscle on neck
• frequently arises from 2nd brachial arch

Histo: simple cyst lined by stratified squamous/respiratory epithelium with surrounding fibrous tissue
- US shows simple cyst

Question 20

Thyroglossal Duct Cysts

Where does it occur and what does it look like histologically?

Answer 20

• remnant nests of tissue from thyroid migration, with cystic change that can occur around the tongue, hyoid bone, or thyroid cartilage

Histo: has respiratory lining with thyroid follicles (filled with pink colloid)

Question 21

Carotid Body Tumor

What is it, where does it arise from, and what does it look like histologically and on imaging?

Answer 21

• tumors of neural crest origin arising from autonomic paraganglia that can arise sporadically or in association with MEN 2
  
  • 15-40% will be malignant (histo cannot tell)
  • metastasis or local invasion

Histo: nest of cells (ZELLBALLEN) that has S-100 staining

Imaging: shows “Lyre Sign”

Question 22

What is the name for the pattern that Bronchiopneumonia produces on imaging?

Answer 22

“Tree-in-bud”

• see vessels peripherally with small “buds” coming off of them

Question 23

What is the name of the pattern that Lobar Pneumonia can produce on imaging?

What is it called when it has massive consolidation and what does it look like?

What do abscesses in Lobar pneumonia look like on imaging?

Answer 23

• see consolidation in the lobe
• if massive consolidation takes place, can see “Bulging Fissure” sign, which is a dark underline to the bottom of the consolidation
• abscesses will have air-fluid levels in them

Question 24

What are 3 organisms that are likely to cause a Lobar Pneumonia (SP/SA/GN) and what 3 organisms are likely to cause abscess formation (KP/SA/A)

Answer 24

lobar = Strep pneumo, Staph aureus, gram (-)s

abscess = Klebsiella pneumo, Staph aureus, anaerobes

Question 25

What does bronchiectasis look like on imaging?

What are 4 conditions bronchiectasis can be seen with (CF/ABPA/TB/PCD)

Answer 25

• has abnormal, persistent widening of airways into the peripheral lung fields
• seen in cystic fibrosis, allergic bronchopulmonary aspergillosis, TB, and primary ciliary dyskinesia

would see situs inversus with PCD

Question 26

What is the “Batwing” pattern and what 4 complications is it seen in? (PE/VP/HP/II)

What is the “Reverse Batwing” pattern and what 3 complications is it seen in? (IPF/ILD/S)

Answer 26

• whitening from medial to peripheral lung fields
  
  • seen with PE, viral pnemonias
  • hypersensitivity pneumonitis, inhalation injury

anything favoring PROXIMAL vascular/airways

• darkened middle lungs with peripheral white
  
  • seen with idiopathic pulmonary fibrosis
  • also with other ILDs and sarcoidosis

anything favoring PERIPHERAL involvement, like FIBROSIS (sarcoidosis follows LYMPHATICS)

Question 27

What is the most common cause of diffuse bilateral “white-out” on pulmonary imaging?

Answer 27

ARDS (Acute Respiratory Distress Syndrome)

Question 28

What is the difference in appearance of calcifications due to Histoplasmosis and Hamartomas?

Answer 28

Histo: either diffuse or laminated calcifications
- these patterns are seen with OLDER granulomas

Hamar: can produce a “coin lesion” similar to Histo, but can also be lobulated, giving it a POPCORN calcification

Question 29

What does Mucinous Adenocarcinoma and Adenocarcinoma in situ look like on pulmonary imaging?

Answer 29

MA = can look like pneumonia and be bilateral
- breaks the rules of what you would expect

AIS = can also look like pneumonia and be bilateral, but has a HAZE to it (hasn’t invaded yet)
- has a GROUND GLASS appearance

Question 30

What do Invasive Adenocarcinomas and Squamous Carcinomas look like on pulmonary imaging?

Answer 30

IA = has BUBBLE LUCENCIES in mass (small little spaces in tumor mass)

SC = massive CAVITATION in mass (big mass lesion with central necrosis)

Question 31

What does a “Wedge-Shape” pulmonary image signify?

What are two cancers that can have this pattern on imaging?

Answer 31

• can be RESORPTION atelectasis or infarct
• resorption atelectasis can be causes due to mucus, aspirates, tumors (anything that blocks the airway)
• Squamous Carcinoma and Carcinoid Tumor (Collar Button mass), if growing endobronchially, can cause this pattern