Nasal cavity, paranasal sinuses, nasopharynx

Last revised 20 March 2008

Copyright (c) 2004-2008, PathologyOutlines.com, Inc.

Home Page

Printer Friendly Version

Bold and underlined topics are hypertext links and may open a new window

 

 

Table of contents

Primary references, normal anatomy, normal histology

Inflammatory/infectious lesions: allergic fungal sinusitis, allergic rhinitis, Aspergillus, chronic rhinitis, cholesterol granuloma, Churg-Strauss syndrome, eosinophilic angiocentric fibrosis, fungal ball, fungal disease, granulomatous lesions, idiopathic midline destructive disease, infectious rhinitis, Kartagener syndrome, leprosy, mucocele, Mucor, myospherulosis, nasal polyps, necrotizing sialometaplasia, pertussis, pharyngitis, rhinoscleroma, rhinosporidiosis, sinusitis, sarcoidosis, steroid injections, tuberculosis, Wegener’s granulomatosis

Nasopharyngeal carcinoma: general, keratinizing squamous cell, nonkeratinizing-differentiated, undifferentiated, papillary adenocarcinoma

Sinonasal carcinoma: general, adenocarcinoma-general, low grade adenocarcinoma, intestinal adenocarcinoma, cylindrical (transitional), small cell, squamous cell, undifferentiated (anaplastic)

Hematologic conditions: lymphoma-general, angiotropic lymphoma, diffuse large B cell lymphoma, follicular lymphoma, lymphoid hyperplasia, lymphomatoid granulomatosis, mantle cell lymphoma, NK/T cell lymphoma, peripheral T cell lymphoma, plasmacytoma

Other tumors: ameloblastoma, aneurysmal bone cyst, angiomyolipoma, angiosarcoma, astrocytoma, carcinoid, chondrosarcoma, chordoma, cocaine related, craniopharyngioma, dermoid cyst, desmoplastic small round cell tumor, fibroinflammatory proliferation, fibroma, fibromatosis, fibroosseous lesions, fibrosarcoma, follicular dendritic cell, gangliocytic paraganglioma, giant cell reparative granuloma, giant cell tumor, glial heterotopia, glomus, hemangiopericytoma-sinonasal type, leiomyoma, lobular capillary hemangioma, malignant fibrous histiocytoma, malignant peripheral nerve sheath tumor, Masson’s tumor, melanoma, meningioma, myxoma, nasal chondromesenchymal hamartoma, nasopharyngeal angiofibroma, neurofibroma, nodular fasciitis, nonsecretory cyst, olfactory neuroblastoma, osteochondromyxoma, osteoma, papilloma, paraganglioma, pituitary adenoma, pleomorphic adenoma, psammomatoid ossifying fibroma, respiratory epithelial adenomatoid hamartoma, rhabdomyoma, rhabdomyosarcoma, Rosai-Dorfman disease, salivary gland anlage tumor, salivary gland tumors-general, schwannoma, solitary fibrous tumor, teratoid carcinosarcoma, teratoma, Warthin’s

Miscellaneous: TNM staging, post-chemotherapy atypia, grossing, features to report

 

Primary references

top

 

AJCC Cancer Staging Manual (6th Ed)

American Journal of Surgical Pathology (AJSP), Jan 1998 to Aug 2004

Archives of Pathology and Laboratory Medicine (Archives), Jan 1998 to Aug 2004

Human Pathology (Hum Path), Jan 1998 to July 2004

Modern Pathology (Mod Path), Jan 1998 to July 2004

Rosai, J:  Ackerman’s Surgical Pathology (9th Ed); Mosby-Year Book, Inc., 2004

Sternberg, S: Diagnostic Surgical Pathology (4th Ed); Lippincott Williams & Wilkins, 2004

Journal search terms: nose, nasal, paranasal, sinus, nasopharynx

 

Please refer to these primary references for more detailed discussions and photographs

 

Normal anatomy

top

Nasal cavity, paranasal sinuses and nasopharynx form functional unit

 

Nasal cavity

top

Divided into olfactory region (superior nasal turbinates and opposed septum) and respiratory region (rest of cavity)

Nasal chambers are on either side of median plane formed by nasal septum

Bounded above by cribriform plate; bounded laterally by turbinates

Bulla ethmoidalis: elevation on lateral wall of middle meatus, site of opening of middle ethmoid meatus

Choanae: posterior opening of nasal cavity, communicates with nasopharynx

Columella: anterior extreme nasal septum

Nares: anterior openings of nasal cavity

Vestibule: slight dilation inside anterior aperture of nostril, bounded laterally by ala and lateral crus of greater alar cartilage and medially by medial crus of greater alar cartilage; lined by skin containing hair and sebaceous glands

Lateral wall: contains superior, middle and inferior nasal turbinates (conchae); below each is corresponding nasal passage or meatus

Sphenoethmoidal recess: above superior turbinate, site of opening of sphenoidal sinus

Turbinates (concha): comprise lateral walls of each nasal cavity

 

Superior meatus: along upper border of middle turbinate, site of opening of posterior ethmoid meatus

Middle meatus: below and lateral to middle turbinate

Drawings: lateral wall of nasal cavity #1, #2 after removal of conchae, cartilages of nose-side view, from below, bone and cartilage of septum

 

Nasopharynx

top

Respiratory passage above and behind the soft palate

Part of pharynx, which also includes oropharynx and hypopharynx

Begins anteriorly at posterior turbinates and extends along plane of airway to the level of the free border of the soft palate

Anterior wall is perforated by posterior nares (choanae)

Posterior wall is also its roof, as well as the posterior base of skull; extends inferiorly to level of free border of soft palate where oropharynx begins

Lateral wall contains ostium of eustachian tube, surrounded by mucosa covered cartilaginous prominence; ostium is anterior to pharyngeal recess (fossa of Rosenmuller)

Gross image: regions of pharynx

 

Paranasal sinuses

top

Diverticula of nasal cavity that extend into neighboring bones

Ethmoid sinuses: between the orbits; well developed at birth

Frontal sinuses: most anterior, above the orbits; small/rudimentary at birth; develop through puberty

Maxillary sinuses: under the cheeks; small/rudimentary at birth; develop rapidly during childhood until permanent teeth develop

Sphenoid sinuses: most posterior at base of brain; small/rudimentary at birth; develop rapidly during childhood until permanent teeth develop

Ohngren’s line: connects medial canthus of eye to angle of mandible; used to divide maxillary sinus into anteroinferior portion (infrastructure), associated with good prognosis for carcinomas, and superoposterior portion (suprastructure), with a poor prognosis for carcinomas

 

Normal histology

top

Nasal cavity

Lined by stratified squamous and respiratory type pseudostratified columnar epithelium, separated by transitional epithelium in some places

Respiratory mucosa (also called Schneiderian membrane) may contain goblet cells; may undergo squamous metaplasia

Superior third of nasal septum, superior turbinate and cribriform plate are covered with thinner olfactory mucosa, usually patchy in adults, which has neuroendocrine features

Seromucinous glands (resembling salivary glands) are present in submucosa, numerous near eustachian tube opening of nasopharynx, may undergo oncocytic metaplasia with increasing age

Normally no lymphoid tissue

 

Nasopharynx

top

Lined by stratified squamous epithelium (inferior anterior and posterior walls and anterior lateral walls) and respiratory type epithelium (around nasal choanae and roof of posterior wall); remaining areas have mixtures of squamous and respiratory or intermediate epithelium (also called transitional although it does not resemble urothelium ultrastructurally)

Intermediate epithelium is usually concentrated as a wavy ring at junction of nasopharynx and oropharynx

Seromucinous glands may undergo oncocytic metaplasia, and rarely form a mass or obstruct eustachian tube

Abundant lymphoid tissue present, particularly at rim of eustachian tube opening (Gerlach’s tonsil); functionally equivalent to that of GI tract or mucosal-associated lymphoid tissue (MALT)

 

Paranasal sinuses

top

Mucosa is continuous with nasal cavity and identical (respiratory type epithelium), but thinner and with fewer goblet cells and seromucinous glands

Normally no lymphoid tissue

 

 

Inflammatory/infectious lesions

Allergic fungal sinusitis

top

Due to Aspergillus, Curvularia lunata or Fontana-Masson positive dematiaceous fungi (Drechslera, Bipolaris, Exoserohilium)

Produces “allergic mucin” (lamellated collection of inspissated inflammatory debris with numerous eosinophils and Charcot-Leyden crystals) and fungal hyphae

Mucin may require curettage to remove, may recur

May cause bony erosion due to pressure remodeling, but usually not invasive

Affects immunocompetent patients ages 20-49 years with chronic allergy, asthma, nasal polyps or sinusitis

May be due to tenacious mucin that traps normally nonpathogenic, low-virulence fungal organisms

Diagnosis initially missed in half of cases

Treatment: surgical removal, low-dose corticosteroids, possibly immunotherapy for underlying allergy

Gross: green, brown or black mucin with consistency of clay; gray-brown, laminated, gelatinous or translucent cut surface

Micro: mucosal edema, marked eosinophilic infiltrate, allergic mucin in 92%, eosinophils may have degenerative changes of smudged, elongated or basophilic nuclei; also plasma cells and lymphocytes; rare noninvasive fungal hyphae (often found only with GMS stain), rare neutrophils

Micro images: 1-allergic mucin (arrows) with fungus; 2-allergic mucin (arrows) without fungus; 3-fungi with sparse and fractured hyphae

References: Hum Path 2004;35:474

 

Allergic rhinitis

top

Also called hay fever

Due to exposure to plant pollens, fungi, dust mites, animal allergens

Affects 20% of US population

IgE mediated

Endoscopic images: swollen pale turbinates with thick secretions

Micro: mucous secretions have neutrophils and prominent eosinophils

 

Aspergillus

top

Causes fungus balls (see below) in nasal antrum of immunocompetent patients with minimal inflammatory response, microabscesses or multinucleated giant cells

Also causes invasive aspergillosis, regardless of immune status, with extension into retroorbital region, cranium or parapharyngeal space; often fatal

Also causes allergic fungal sinusitis (see above)

Micro: septate hyphae that branch at 45 degrees

DD of invasive fungal infections: Zygomycetes, Pseudallescheria boydii, Paecilomyces, Alternaria, Cladosporium trichoides, Fusarium

 

Chronic rhinitis

top

Sequel to acute rhinitis (symptoms lasting 6 weeks or less), with development of secondary bacterial infection

Associated with deviated septum or nasal polyps; also ulceration and infection extending into sinuses

Endoscopic images: pale turbinates and dry secretions in smoker

 

Cholesterol granuloma

top

Rare in nasal cavity or sinuses; usually associated with chronic middle ear disease

May be a reaction to hemorrhage

Treatment: excision

Case reports: maxillary sinus lesion of 38 year old man (Archives 2002;126:217)

Micro: foreign body giant cells surrounding empty, needle shaped spaces (cholesterol clefts representing cholesterol crystals that have dissolved due to alcohol in staining process), chronic inflammatory infiltrate, hemosiderin laden macrophages, dilated lymphatics

Micro images: 1-cholesterol clefts in cholesterol granuloma; 2-foreign-body giant cells surround cholesterol clefts; 3-foreign-body giant cell with asteroid body; also hemosiderin laden macrophages and chronic inflammatory infiltrate

 

Churg-Strauss syndrome

top

2/3 have nasal polyps or mucosal crusting

Micro: discrete necrotizing granulomas with numerous eosinophils, often forming microabscesses

DD: Wegener’s granulomatosis

 

Eosinophilic angiocentric fibrosis

top

Very rare; unknown cause

May be mucosal counterpart of granuloma faciale

Involves any portion of upper respiratory tract, often nasal septum and sinus mucosa

Usually women, mean age 44 years

Case reports: 45 year old man with no history of allergic disease (Archives 2004;128:90)

Treatment: corticosteroids, resection

Micro: thick collagen bundles, perivascular onion-skin fibrosis with eosinophil-rich inflammatory infiltrate; no granulomas, no necrosis, no vasculitis

Micro images: 1-vessels with concentric fibrosis and scattered eosinophils; 2-onionskin fibrosis without vascular wall destruction (trichrome stain)

DD: granuloma faciale (inflammatory vascular reaction with facial papules, neutrophilic and eosinophilic infiltrate, vasculitis with fibrinoid material in vessel walls)

 

Fungal ball

top

Also called mycetoma, chronic noninvasive fungal sinusitis

Usually immunocompetent patients, often prior history of sinus disease, trauma or foreign body

Gross: grumous, friable, gray-brown-black material, often with clotted blood

Micro: tightly packed extramucosal hyphae, usually in maxillary antrum; no/minimal host response, no allergic mucin or tissue invasion; usually due to Aspergillus (hyphae with septation and branching at 45 degree angles, no spores)

 

Fungal disease

top

Includes sinusitis (acute fulminant, chronic invasive), mycetoma, saprophytic infestation (fungal spores on mucous crusts of respiratory passages) and allergic fungal sinusitis

 

Granulomatous lesions

top

May develop post-steroid injection with amorphous foreign material

Cholesterol granulomas in paranasal sinuses are rare

Also due to fungal infections, myospherulosis, tuberculosis, Wegener’s granulomatosis

 

Idiopathic midline destructive disease

top

Diagnosis of exclusion

Gross: usually perforated nasal septum, perforated palate, erosion of antral bone or ulceration of skin overlying nose or antrum

Micro: acute and chronic inflammatory cells with variable necrosis; may have multinucleated giant cells or granulomas; no atypical lymphocytes, no fibrinoid necrosis of vessels, no prominent eosinophils

DD: Wegener’s granulomatosis (different clinical findings)

 

Infectious rhinitis

top

Also called “common cold”

Due to adenovirus, echovirus and rhinoviruses

Symptoms: catarrhal discharge, thick, edematous, erythematous nasal mucosa; enlarged turbinates

May cause pharyngotonsillitis; may have secondary bacterial infection

 

Kartagener syndrome

top

Situs inversus, bronchiectasis and sinusitis, due to defective ciliary action

 

Leprosy

top

Affects nasal mucosa in 95% of patients; may be initial manifestation of disease

Usually affects nasal septum and inferior turbinate

Micro: early - plasma cells with lesser numbers of histiocytes and lymphocytes; later - broad sheets of histiocytes with foam cells; well formed granulomas of tuberculous type are uncommon

Positive stains: acid fast stains

 

Mucocele

top

Also called pseudocyst

Complication of chronic sinusitis due to outflow obstruction

May destroy contiguous bones and resemble a neoplasm

2/3 in frontal sinus; also anterior ethmoid sinus

Micro: inflammatory cells and mucin lift epithelium of sinus and periosteum away from underlying bone; epithelium may undergo squamous metaplasia; extravasation of mucin into lamina propria with muciphages

 

Mucor

top

Relatively common life-threatening fungal infection, associated with diabetic ketoacidosis, poor glycemic control or immunosuppression

Spreads rapidly across nerves and tissue planes to blood vessels of orbit and brain, causes thrombosis, hemorrhage and infarction

Member of phylum Zygomycota, class Zygomycetes, order Mucorales; found in high-organic matter and soil

Mortality rate of 48%

Case reports: 29 year old man post bone marrow transplant with psychosis and gingival lesion (Archives 2000;124:883)

Micro: broad nonseptate hyphae branching at 90 degrees, accompanied by numerous neutrophils and histiocytes within granulation tissue

Micro images: fungal hyphae in vessel lumen that infiltrate vessel wall;  asexual structures (very rare in tissue)

 

Myospherulosis

top

Iatrogenic lipogranuloma after hemostatic packing of nasal cavity or paranasal sinuses with petrolatum based ointment and gauze

Resembles subcutaneous disease of East Africa

Micro: large tissue spaces with saclike structures containing brown spherules resembling Prototheca but actually clumped red blood

cells

Negative stains: GMS

 

Nasal polyps

top

Common; not neoplastic, but may fill entire nasal cavity or extend into cranial cavity or orbit

In children, must rule out cystic fibrosis

Often recur due to persistence of causative factors

Endoscopic images: gelatinous polyp #1#2#3large polyp extending into oropharynx

Micro: edematous lamina propria with variable inflammatory infiltrate including eosinophils; subtypes include angiectatic (angiomatous), cystic, edematous, fibrous, glandular

 

Angiectatic polyps

top

Extensive vascular proliferation and ectasia with pseudoamyloid deposition that simulates malignancy

Due to marked reactive and reparative changes

May cause life threatening epistaxis, facial deformity or bone erosion and remodeling

Gross: gelatinous, semitranslucent masses with smooth, blue-gray glistening surface

Gross images: marked hemorrhage and spongiform change (arrows); translucent, glistening appearance of typical inflammatory nasal polyp (asterisk)

Micro: dilated thin walled vessels in pools of eosinophilic material, associated with patchy necrosis and atypical spindle cells; associated with choanal polyps arising in paranasal sinuses and protruding into nasopharynx

Micro images: (1) proliferation of thin walled vascular channels;  (2) thin walled vessels embedded in amorphous material (asterisks) or surrounded by amorphous material (arrows);  (3) atypical stromal cells (arrows) and fibrin thrombi (right side-asterisk);  (4) vascular channels lined by large hyperchromatic endothelial cells; also atypical stromal cells

EM images: poorly formed vascular channel with endothelial cells resting on granular and amorphous material composed of red blood cells and intact and degenerated platelets

DD: angiofibroma, hemangioma

References: Archives 2000;124:406

 

Antrochoanal polyp

top

4-6% of nasal polyps

Frequently occur in childhood

90% solitary

Arise from wall of maxillary antrum, extending through large primary or secondary maxillary ostium into nasal cavity

May pass into choanae or nasopharynx

Gross: long narrow stalk with firm, fibrous body

Gross images: long polyp extending from maxillary sinus into nasopharynx

Micro: thin surface mucosa with no thickened basement membrane; stroma with stellate cells, less edema and fewer glands than inflammatory polyp; may have prominent dilated vessels with thrombosis or infarct; prominent eosinophils in only 20%

Micro images: thin surface epithelium, edematous stroma with prominent dilated vessels and minimal inflammation #1#2#3

 

Atypical stromal cells

top

Common; have prominent cytoplasm, enlarged hyperchromatic nuclei resembling “radiation fibroblasts” or sarcoma

More common in younger patients or those with prominent fibrous stroma

No increased cellularity, no prominent vasculature, no mitotic figures

Resemble polyp on low power

 

Cystic fibrosis polyp

top

Must rule out cystic fibrosis in any child with nasal polyps

Present in 20% with cystic fibrosis

May arise up to 12 years before clinical diagnosis; rarely is initial manifestation of disease in adults

Micro: similar to inflammatory polyps, but no basement membrane thickening, no submucosal hyalinization, no/rare stromal eosinophils; may have large cystic glands with inspissated mucin in lumina; mucous glands, cysts and mucous contain predominantly acid mucin

Positive stains: purple-blue mucin with combined Alcian blue PAS stain (vs. red for inflammatory polyp)

 

Inflammatory polyp

top

Most common type of nasal polyp

Due to recurrent attacks of rhinitis (allergic, inflammatory)

Most people with polyps are NOT atopic; only 0.5% with atopy develop polyps

Usually ages 30 years or older (rarely < age 20 years)

Often recurs after surgery

Often associated with asthma, chronic rhinitis, aspirin intolerance (14%)

Gross: usually multiple and bilateral and involve nasal cavity and paranasal sinuses; have translucent, moist or edematous cut surface (opaque areas may represent papilloma); broad base of attachment is present; usually not destructive

Gross images: inflammatory polyps

Micro: respiratory epithelium, often with squamous metaplasia, edematous and loose stroma with hyperplastic mucous glands, inflammatory infiltrate (lymphocytes, plasma cells, eosinophils, neutrophils, mast cells); mucosa may be ulcerated or infected; basal membrane may be thickened; may have “bizarre” stromal cells (large and pleomorphic) due to reactive changes; may have prominent glandular component

Micro images: respiratory mucosa with edematous stroma with numerous eosinophils and plasma cells

Virtual slides: respiratory epithelium overlying edematous stroma with eosinophils and plasma cells 

DD: papilloma

 

Necrotizing sialometaplasia

top

Benign process that resembles squamous cell carcinoma or mucoepidermoid carcinoma

Occurs after surgery on nose or sinuses

Micro: necrosis of seromucinous glands with secondary squamous metaplasia and reactive atypia

Micro images: various images

 

Pertussis

top

Possibly life-threatening nasopharyngeal infection caused by Bordetella pertussis

Causes progressive, repetitive paroxysmal coughing, mild systemic complaints and lymphocytosis

Worldwide causes 60 million severe cases and 1 million deaths annually

In US, 5000-7000 annual cases, deaths usually only in infants younger than 1 year

Outbreak in Wisconsin (USA) in 1993 with attack rates of 23% (ages 30-49 years) and 33% (ages 50+)

Vaccination widely given, but efficacy may wane 4 years after last dose

Diagnosis: culture requires 5-7 days, also PCR

Treatment: erythromycin (but some cases are resistant)

References: Archives 2002;126:173

 

Pharyngitis

top

Often secondary bacterial infection by Streptococcus pneumonia or Staphylococcus aureus

Severe infections occur in infants or adults with neutropenia, HIV, diabetes, antibiotics

Streptococcus pneumonia pharyngitis: treat with antibiotics to prevent subsequent glomerulonephritis or rheumatic fever

Viruses: rhinovirus, echovirus, adenovirus, respiratory syncytial virus, influenza

 

Rhinoscleroma

top

Also called scleroma

Rare; chronic granulomatous disease affecting nasal cavity (95-100%), nasopharynx (18-43%), larynx (15-40%), trachea (12%) or bronchi (2-7%) caused by Klebsiella rhinoscleromatis

Usually low socioeconomic environments of central/South America, Africa, Middle East, Philippines, India; rare in US (usually immigrants)

Most common in young adults

Initially nonspecific rhinitis, then purulent, fetid rhinorrhea with crusting; then granulomatous stage with blue-red granular nasal mucosa with intranasal rubbery nodules or polyps, epistaxis, anosmia, enlargement of uvula, anesthesia of soft palate, variable airway obstruction; finally sclerosis

Treatment: tetracycline or trim-sulfa, possibly steroids, surgery to correct scars or stenosis

Microbiology: MacConkey agar cultures are 50-60% sensitive; bacteria is gram negative, encapsulated, nonmotile diplobacillus, member of Enterobacteriaceae, not normal flora, infective via drops or contamination of material that is inhaled

Case reports: polypoid intranasal mass in 32 year old woman (Archives 2001;125:159)

Micro: initially inflamed granulation tissue; later hyperplastic mucosa with pseudoepitheliomatous squamous hyperplasia, granulomatous inflammation, foamy macrophages (Mikulicz cells containing bacteria) and plasma cells with Russell bodies; variable vasculitis and ulceration; late-fibrosis, lymphocytes and plasma cells but no Mikulicz cells

Micro images: 1-diffuse granulomatous inflammation; 2-vacuolated macrophages with bacilli (Mikulicz cells); 3-gram negative bacteria by gram stain

Positive stains: PAS, Giemsa, Steiner or Hotchkiss-McManus stains for gram negative bacteria

EM: large phagosomes containing bacilli and finely granular material (antibodies on bacterial surface and aggregates of bacterial mucopolysaccharides)

DD: Rosai-Dorfman disease, leprosy

 

Rhinosporidiosis

top

Caused by Rhinosporidium seeberi, traditionally thought to be a fungus, but actually an aquatic protistan parasite (J Clin Microbiol 1999;37:2750, Emerg Infect Dis 2000;6:273, Indian J Med Microbiol 2002;20:119)

Endemic in southern India, Sri Lanka and emigrants from this region (Diagn Pathol 2006;1:25, Singapore Med J 2004;45:224); rare indigenous cases in US (South Med J 1996;89:65)

Natural aquatic habitat, transmitted through traumatized epithelium, most commonly in nose and eye, also skin, ear, genitals and rectum

Risk factors: bathing or working in stagnant water

Rarely presents with disseminated skin disease (Indian J Dermatol Venereol Leprol 2007;73:185, Indian J Dermatol Venereol Leprol 2001;67:332)

Not transmitted person to person.

Case reports: Case of the Week #97

Treatment: surgical excision, may recur; no effective medical treatment

Gross: hyperplastic, polypoid, red, granular masses of nasal cavity; yellow pinhead spots represent mature sporangia; superficial mucus is common

Micro: large (100 to 450 microns), thick walled sporangia with 1000+ endospores, each 6-10 microns, accompanied by a mixed inflammatory infiltrate; may not be present in all sections and may need additional sampling for diagnosis

Micro images: image #1#2#3

Positive stains: GMS, PAS

DD: myospherulosis (large tissue spaces with saclike structures containing brown spherules that resemble Prototheca but are actually clumped red blood cells, GMS negative), Coccidiodes immitis (smaller spherules: 30-60 microns, smaller endospores: 2-5 microns), often arthroconidia and hyphae

 

Sinusitis

Acute sinusitis

top

Often preceded by acute or chronic rhinitis

Usually self limited or well controlled with supportive treatment

 

Acute invasive fungal sinusitis (fulminant invasive fungal sinusitis)

top

Often seen in immunocompromised or diabetic patients, often ocular involvement or intracranial extension, associated with progressive disease and death

Treatment: vigorous systemic antifungal therapy

Micro: vascular invasion by fungi is present and may cause thrombi; also neutrophils, eosinophils, tissue necrosis and hemorrhage

 

Chronic sinusitis

top

Mixed bacterial flora, develops after acute sinusitis

May produce osteomyelitis of orbit or thrombophlebitis of dural venous sinus

Most commonly in maxillary sinus, and preceded by periapical infection from floor of sinus

May need biopsy for accurate diagnosis

Noninvasive fungal disease is often Aspergillus

Treatment: surgery to control disease may be necessary

Gross: edematous mucosa which blocks drainage and may cause empyema of sinus

Micro: glandular hyperplasia, squamous metaplasia, basement membrane thickening, inflammatory cells including eosinophils, edema; bone may show thickening and remodeling with osteoblastic rimming and fibrosis of bone marrow spaces; presence of allergic mucin (lamellated collection of inspissated inflammatory debris) suggests fungal organisms

 

Chronic noninvasive fungal sinusitis

top

Also called indolent fungal sinusitis

Associated with diabetes, immunocompromise or endemic areas (Sudan, Saudi Arabia)

Micro: fungi with surrounding foreign body inflammatory response or granulomas and tissue invasion; no vascular invasion by definition

 

Sarcoidosis

top

5% of patients have upper airway involvement, usually in nasal septum or inferior turbinate

Micro: granulomas without caseous necrosis

DD: tuberculosis

 

Steroid injections

top

Micro: granulomas with amorphous area (residual injected substance) surrounded by palisading histiocytes

 

Tuberculosis

top

Rare; usually associated with cervical lymphadenopathy

Usually isolated infection and not secondary spread from pulmonary infection

Diagnosis: culture or PCR

Gross: ulcerated or polypoid lesion of nasal septum or inferior turbinate; variable septal perforation

Micro: poorly formed granulomas, usually no necrosis; organisms rare

 

Wegener’s granulomatosis

top

Rapidly progressive condition involving nasal cavity, lungs and kidney

Biopsies of 5 mm or more improve diagnostic yield

Note: lymphocyte rich biopsies are unlikely to be Wegener’s and more likely represent lymphoma

Diagnostic for Wegener’s: granulomatous inflammation, necrosis and vasculitis, in addition to clinical involvement of lung or kidney; OR two of three microscopic features and lung and kidney involvement

Probable: two of three microscopic features and (lung or kidney involvement) but not both

Suggestive: one of three microscopic features and lung and kidney involvement

Suspicious: one of three microscopic features and (lung or kidney involvement) but not both

Nonspecific: no microscopic features, either lung or kidney involvement

Gross: early disease usually lacks destruction of cartilage or bone

Micro: leukocytoclastic vasculitis of arterioles, small arteries and veins with geographic necrosis surrounded by palisading histiocytes, variable poorly formed granulomas with minimal lymphocytes; variable giant cells; granulomas and giant cells are distant from vessels or adjacent/within vessel wall; also epithelial ulcers; vessel may be obliterated by inflammatory cells and thrombus and be difficult to identify without elastic stain; all stages of vasculitis are present (acute: neutrophils with fibrinoid necrosis; chronic/healed: narrowed or obliterated lumina with concentric rims of perivascular collagen); usually no significant lymphoid infiltrate

Positive stains: elastic stains to identify badly damaged vessels

Negative stains: EBV

DD: Churg-Strauss syndrome, NK/T cell lymphoma, idiopathic midline destructive disease, tuberculosis, lymphoma, eosinophilic angiocentric fibrosis, cocaine-related lesions, systemic lupus erythematosus, necrotizing vasculitis from other causes