Nasal, oral and pharyngeal diseases: Pathology review

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Case Study0:00–0:54

While in the ENT Clinic, two people present with trouble breathing through the nose and have frequent nose bleeds. One of them is a 25 year old individual named Andrew, and the other one is an 18 year old individual named Sarah.
Andrew says the problems appeared gradually and feels like something is stuck in the nose. Andrew also has a history of aspirin allergy.
On examination, everything seems normal, except for a decrease in the sense of smell. Sarah, on the other hand, has noted these problems ever since childhood.
Sarah also mentioned that the symptoms get worse during the spring or proximity to flowers. On examination, presentation is nasal congestion and red, itchy, swollen eyes with frequent bouts of sneezing.
Blood tests were normal in both individuals.Now, from what we can gather, both have some type of nasal, oral, or pharyngeal disease.

Anatomy0:54–1:48

But first, a bit of anatomy. The nasopharynx is an open chamber located below the base of the skull and behind the nasal cavity.
The nasopharynx contains structures like the adenoids, also known as the pharyngeal tonsils; the Waldeyer's tonsillar ring, which is a ring-like arrangement of lymphoid tissue in both the nasopharynx and oropharynx; the Rosenmüller fossa, which is part of the lateral recess of the nasopharynx and a common site of nasopharyngeal cancers; and the eustachian tube orifices.
Now, the nasopharynx connects the nasal cavity and oropharynx, which is posterior to the oral cavity that contains structures like the salivary glands, soft and hard palate, tongue, and tonsils.
Ok, so we can begin with nasal polyps. Now, remember that a nasal polyp is a clump of epithelial cells that undergo hyperplasia and form a growth of tissue along the lining of the nasal cavity.

Nasal Polyps1:48–3:52

This is most often caused by seasonal allergies, recurrent infections, frequent asthma exacerbations, chronic sinusitis, or acetyl-salicylic acid and nonsteroidal anti-inflammatory drug sensitivity.
There are some genetic causes too; that’s high yield. Remember that it’s associated with cystic fibrosis and primary ciliary dyskinesia.
You also need to know that usually, nasal polyps form in the ethmoid or maxillary sinuses and are typically non-cancerous.
As polyps enlarge, they often obstruct the airflow as well as the mucus drainage, allowing pathogens to linger in the sinuses and cause recurrent infections.
For symptoms, know that this leads to progressive nose breathing difficulties, nose foreign body sensation, the loss of the sense of smell, or anosmia, and bouts of fevers and headaches due to infections.
In young infants, it can cause hypoxia, which gives a bluish tinge to their skin color, called cyanosis. This specifically happens in infants because they are obligate nose breathers, meaning they really prefer breathing through their nose.
If bilateral obstruction occurs, a period of cyanosis occurs, then the infant cries and breathes through the mouth, resolving the cyanosis.
So on the exam, look for an infant with periodic bouts of cyanosis, resolved by crying. Now, regarding diagnosis, all you need to recall is that nasal endoscopy or CT can help diagnose nasal polyps, and determine the size, location, and number.
The treatment is to shrink them using nasal steroids, which work by decreasing the inflammation and swelling of the polyp.
Those unresponsive to steroids are removed by endoscopic sinus surgery. Next, let’s look at rhinitis, which is irritation and inflammation of the mucous membrane inside the nose.
It can be caused by things like viral or bacterial infections, irritants, and more commonly, allergens. Allergic rhinitis is also called hay fever, and it’s typically caused by hay, dust, pollen, animal dander, or mold spores.

Rhinitis3:52–5:57

A high yield concept to remember is that allergic rhinitis is a type 1 hypersensitivity reaction, which is a type of allergic reaction that starts with exposure to an environmental allergen and is characterized by immunoglobulin E antibody production and mast cell degranulation releasing mediators; like bradykinin and histamine that causes inflammation.
This leads to excess fluid build up in the nasopharynx and facial tissue, causing symptoms. Remember the typical clinical picture usually consists of nasal congestion, red, itchy, swollen eyes with frequent bouts of sneezing, and in some cases, nose bleeding.
These symptoms can begin just minutes after exposure to the allergen and can persist for weeks at a time. Ok, so the most common way to diagnose allergic rhinitis is through skin testing.
One type of skin testing is called the patch test, where allergens are applied to small patches and stuck onto the skin.
If the skin under a particular patch becomes irritated, it suggests an allergy to that substance. Blood tests might show elevated immunoglobulin E antibody and eosinophil levels, but this is not always reliable.
Also, remember that allergic rhinitis may be part of the atopic triad, which also includes atopic dermatitis and asthma.
In terms of treatment, the best option is to simply avoid the triggering allergen if possible. Also, remember that if the individual is symptomatic, antihistamine medications like Chlorpheniramine and Terfenadine can be used to suppress the effect of mast cell degranulation.Let’s now discuss sinusitis or rhinosinusitis, which is the inflammation of the mucosal lining of the nasal cavity and paranasal sinuses, especially of the maxillary sinuses.
It can be caused by either viruses, or bacteria like Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis.
It can also be caused by fungi like Aspergillus fumigatus, but a high yield fact to remember is that fungal sinusitis usually occurs in immunosuppressed people and it can present with a high-grade fever and dark necrotic ulcers on the face.

Sinusitis5:57–8:19

Now, it might help you to know that the resulting inflammatory process causes increased edema and mucus production, which block the sinus ostium, and, consequently, the normal ventilation and drainage of the sinus.
Because of this, individuals will present with rhinorrhea or purulent nasal drainage in bacterial sinusitis or clear nasal drainage in viral sinusitis; nasal congestion,facial pain, especially when they lean forward, fever, and conjunctivitis.
As the edema and mucus production progresses, it can cause nasal blockage, hyposmia or loss of the sense of smell, as well as tenderness and erythema over the affected sinuses, which is a key clue.
As a particularity, infections in sphenoid or ethmoid sinuses may extend to the cavernous sinus and cause cavernous sinus syndrome, which is a condition characterized by multiple cranial nerve palsies.
Diagnosis is clinical, based on the presenting symptoms. Radiographs and secretion culture are not recommended for evaluation of routine acute sinusitis.
Treatment is supportive in case of viral rhinosinusitis. It can encompass adequate rest and hydration, warm facial packs, and steam inhalation.
Symptomatic medication might be needed as well, like analgesics and antipyretics for fever or intranasal corticosteroids for congestion.
In case of bacterial sinusitis, antibiotics like amoxicillin are added to therapy. As for fungal rhinosinusitis, surgical debridement of the necrotic tissue is often necessary, in addition to antifungal medications like amphotericin B.Next up is epistaxis or nose bleeding, which can be either anterior or posterior.
Anterior epistaxis originates from a plexus of vessels known as the Kiesselbach’s plexus, located at the anterior part of the nasal septum.
Posterior epistaxis originates in the posterior septum overlying the vomer bone, and it involves the spheno-palatine artery, a branch of the maxillary artery.

Epistaxis8:19–10:10

It might help to remember the most common causes of nose bleeding: trauma and drying of the nasal mucosa, and rarely, hypertension and coagulation disturbances.
Regarding symptoms, bleeding can occur in one or both nares, individuals might have local pain, and in rare instances, nosebleeds may drain posteriorly to cause hemoptysis or hematemesis.
Diagnosis is made clinically, using a nasal speculum and a bright headlamp or head mirror which can detect if the site is anterior or posterior.
However, if a question mentions the bleeding is severe or recurrent and no site is seen, fiberoptic endoscopy is necessary to see where the bleeding originates.
Treatment in anterior epistaxis consists of pinching the nasal alae together for at least 10 minutes while sitting upright.
If this fails, a cotton pledget with a vasoconstrictor like phenylephrine, a topical anesthetic like lidocaine, is inserted and the nose is pinched for 10 more minutes.
In cases of severe bleeding, the blood vessels can be cauterized with electrocautery or silver nitrate on an applicator stick.
For posterior bleeding that’s difficult to control, nasal balloons and posterior nasal packs are effective but very uncomfortable.
Sometimes, the internal maxillary artery and its branches must be ligated to control the bleeding.Before we move on, we need to discuss another cause of nose bleeding, which is nasopharyngeal angiofibroma.
It is a benign, but locally aggressive vascular tumor of the nasopharynx that arises from the tissue in the sphenopalatine foramen, an orifice which connects the nasal cavity with the pterygopalatine fossa.
It might also be useful to know that it mostly affects adolescent boys, and that it’s associated with mutations of the MEN1 gene, which causes multiple endocrine neoplasia type 1.

Nasophar. Angiofibroma10:10–11:49

Now, although it is a benign tumor, it is locally invasive and can invade the nose, cheek, and orbit. Because it tends to grow in the back of the nasal cavity, the clinical picture usually consists of one-sided nasal obstruction associated with trouble breathing and profuse epistaxis.
On your test, a sign to look for in nasopharyngeal angiofibroma is the antral sign or Holman-Miller sign which is the forward bowing of the posterior wall maxilla.
Diagnosis is based on CT or MRI, which typically shows non-encapsulated soft tissue mass in the center of the sphenopalatine foramen, which is often widened, deforming the posterior wall of the maxillary antrum.
Now, your exams might offer “biopsy” as an answer choice, but a very high yield concept here is that this procedure is contraindicated because it might cause extensive bleeding, since the tumor is composed of blood vessels without a muscular coat.
On the other hand, the treatment is primarily surgical. The tumor is usually excised by external or endoscopic approach.
Now, nasopharyngeal carcinoma is the most common cancer originating in the nasopharynx. You’ll need to know that it originates in the epithelial cells lining the nasopharynx, and it’s usually located in the fossa of Rosenmüller.
Regarding causes, a high yield fact to know is that it’s often associated with Epstein-Barr virus infection. Ok, so individuals are initially asymptomatic.
Cervical lymphadenopathy is the first sign in many patients. When the tumor grows larger, it can cause epistaxis, nasal obstruction, and conductive hearing loss due to Eustachian tube obstruction, and the development of a middle ear effusion.

Nasopharyngeal Carcinoma11:49–13:00

Middle ear effusion refers to a build-up of fluid in the space behind the eardrum. Also, keep in mind that diagnosis is confirmed by indirect nasopharyngoscopy, CT or MRI scan of the head and neck, and endoscopic guided biopsy.
Another clue is a positive heterophile antibody test, which confirms Epstein-Barr infection. Nasopharyngeal carcinoma can be treated by surgery, chemotherapy, or radiotherapy.And another type of cancer pertaining to the pharynx is oropharyngeal carcinoma.
Unlike nasopharyngeal carcinoma, it is usually located in the soft palate, palatine tonsillar fossa and pillars, lateral and posterior pharyngeal wall, and base of the tongue.
The main causes are thought to be different too. In oropharyngeal carcinoma, tobacco, alcohol abuse and human papillomavirus infection are the main cause, and not Epstein-Barr virus infection.
As with nasopharyngeal carcinoma, the individual is initially asymptomatic with cervical lymphadenopathy as an early sign.
As the tumor grows, it can cause persistent sore throat, and dysphagia. These symptoms are easily overlooked, as they are unspecific.

Oropharyngeal Carcinoma 13:00–14:40

Because it can mimic a simple upper respiratory infection, on your exam, make sure you think of oropharyngeal carcinoma if you see any of the risk factors like a long history of smoking, drinking or HPV infection mentioned along with the previous sympto ms.
Ok so later in its evolution, the tumor can cause ulceration of the mucosa, oral pain, and weight loss due to the cancer using up a lot of the body’s nutrients and because it can cause difficulties feeding.
Diagnosis can begin with biopsy if the primary tumor has been detected, or with fine-needle aspiration cytology of enlarged lymph nodes.
Treatment regimens vary depending on the stage of the cancer but they usually consist of radiotherapy, chemoradiotherapy, and surgery which can be either curative or palliative.
Moving on, another high yield oral lesion is oral thrush, aka oral candidiasis, which is a fungal infection of the oral mucosa and the tongue.
Typically, oral thrush presents as a scrapable white plaque that looks like cottage cheese. This is caused by the yeast Candida albicans, which can be normally present in low numbers in the oral mucosa.
For your exams, some important risk factors for Candida overgrowth include recent antibiotic use; as well as immunosuppression induced by treatment with corticosteroids, chemotherapy, radiation therapy, and diseases like cancer, uncontrolled diabetes mellitus, or HIV infection.
Finally, another important risk factor for oral thrush is having a condition that causes xerostomia or dry mouth, such as Sjogren syndrome.

Oral Thrush14:40–15:54

For diagnosis of oral thrush, a sample of the lesion can be scraped off and then analyzed under a microscope, where the most high yield finding is the presence of pseudohyphae, which is when candida cells have an elongated shape that looks like long thin filaments.
Oral thrush is treated with nystatin oral suspension, by swishing it around the mouth and then swallowing or spitting it out.
Now, a very similar oral lesion is hairy leukoplakia, which is associated with the Epstein-Barr virus or EBV and typically appears in immunocompromised individuals, such as those with HIV or who received an organ transplant.
Now, hairy leukoplakia is a benign irregular white plaque with hairy appearance that most often appears on the lateral side of the tongue, but can also appear elsewhere in the mouth.
Now, the most important clue to help you distinguish it from oral thrush is that hairy leukoplakia can’t be scraped off.And another similar oral lesion is leukoplakia, which is also a white plaque that appears on mucous membranes, such as the mouth.

Hairy Leukoplakia15:54–16:28

What’s really important to know is that, unlike oral thrush and hairy leukoplakia, leukoplakia is a precancerous lesion and can evolve into squamous cell carcinoma.
Risk factors for the development of oral leukoplakia include smoking or chewing tobacco, heavy alcohol consumption, and HIV infection.Finally, let’s go over some high yield diseases of the salivary glands.
The first one’s sialadenitis, which refers to inflammation of any of the salivary glands, but most often affects the major ones, which are the parotid, sublingual, and submandibular glands.

Leukoplakia16:28–16:56

Sialadenitis presents with pain, swelling, and decreased salivary production. Some high yield causes include bacterial or viral infection, autoimmune diseases like Sjogren syndrome, or salivary flow obstruction due to sialolithiasis or salivary stones.
Now, sialolithiasis can affect any of the salivary glands, but most cases involve the Wharton duct of the submandibular gland.
And that’s a high yield fact! Common causes of sialolithiasis include dehydration, bacterial infection, and salivary gland trauma or injury; and the most characteristic finding is sialadenitis associated with intermittent pain that’s worse before and during meals.

Sialadenitis 16:56–17:32

Treatment of sialolithiasis usually involves NSAIDs to manage the pain, as well as applying warm compresses, followed by gland massage, and sucking on sour candies to help salivary flow and promote stone expulsion.
More difficult stones may be removed surgically. Finally, let’s go over salivary gland tumors.
These are usually benign tumors and most often involve the parotid gland; however, keep in mind that most tumors that affect the submandibular gland are malignant, and that’s a high yield fact!

Sialolithiasis17:32–18:20

Now, all salivary gland tumors typically present as a lump or swelling that’s usually painless; but some key findings that should make you think of malignancy include pain, facial paralysis, or ulceration of the mucosa.
In any case, a tissue biopsy is often done to confirm the diagnosis. Now, the most common malignant salivary gland tumor is mucoepidermoid carcinoma.
What’s important to know is that, in histology, mucoepidermoid carcinoma is composed of both squamous cells and mucinous or mucus-secreting cells.
On the other hand, the most common salivary gland tumor overall is pleomorphic adenoma, which is a benign tumor that may sometimes become malignant.

Salivary Gland Tumors18:20–20:35

In histology, pleomorphic adenoma is very variable, but most cases are composed of epithelial and myoepithelial cells, mixed with a chondromyxoid stroma, meaning a connective tissue that’s made up of cartilage and mucus.
Finally, another high yield salivary gland tumor is Warthin tumor, which is a benign cystic tumor that typically affects smokers.
A key rule to remember is that 10% of cases are bilateral, meaning they affect a salivary gland pair on both sides, and 10% are multifocal, meaning they affect more than just one pair of salivary glands.
Now, Warthin tumor is also known as papillary cystadenoma lymphomatosum because of its unique histological appearance. Papillary refers to the fact that the epithelium layer folds into the salivary ducts, forming finger-like projections called papillae.
Cystadenoma refers to the fact that the ducts fill up with fluid, forming large cysts. Finally, lymphomatosum refers to the fact that the epithelium layer gets infiltrated by lymphocytes, which organize themselves into germinal centers.
All right, as a quick recap, let’s go over some nasal, oral, and pharyngeal diseases. A nasal polyp is an overgrowth of the epithelial cells that line the respiratory region, especially in the maxillary and ethmoidal sinuses.
Because the polyps obstruct the flow of air and mucus through the nasal cavity, they lead to symptoms like trouble breathing, anosmia, and bouts of fevers and headaches when infection develops.
Rhinitis is mostly commonly due to a type 1 hypersensitivity reaction but can also be caused by infections. There’s inflammation and fluid build up which leads to nasal congestion and red, itchy, swollen eyes with frequent bouts of sneezing, and in some cases, nose bleeding.
Rhinosinusitis is due to viral, bacterial, or fungal infections that cause inflammation of the mucosal lining of the nasal cavity and paranasal sinuses.

Review20:35–25:06

Symptoms include rhinorrhea, conjunctivitis, nasal congestion, and hyposmia alongside tender and erythematous sinuses. Epistaxis can be either anterior or posterior, and it’s usually due to trauma and drying of the nasal mucosa, hypertension and coagulation disturbances.
Bleeding can occur in one or both nares, and it might associate local pain. Nasopharyngeal angiofibroma is a benign vascular tumor of the nasopharynx that arises in the sphenopalatine foramen.
It mostly affects adolescent boys and that is associated with MEN1. Symptoms include one-sided nasal obstruction, trouble breathing and profuse epistaxis.
The antral sign or Holman-Miller sign which is forward bowing of the posterior wall of the maxilla can be seen on CT scans.
Nasopharyngeal carcinoma, most commonly located in the fossa of Rosenmüller, is often associated with Epstein-Barr virus infection.
In many patients, the first sign is cervical lymphadenopathy, but as the tumor grows, other symptoms might include epistaxis, nasal obstruction, and conductive hearing loss.
On the other hand, oropharyngeal carcinoma is located either at the base of the tongue, soft palate, palatine tonsillar fossa and pillars, or lateral and posterior pharyngeal wall.
It is mainly caused by tobacco, alcohol abuse and human papillomavirus infection, and it leads to symptoms like cervical lymphadenopathy, sore throat, dysphagia, ulceration of the mucosa, and weight loss.
Another important oral lesion is oral thrush, which is a scrapable white plaque that’s caused by Candida albicans, and risk factors include recent antibiotic use, immunosuppression, and xerostomia.
Oral thrush shouldn’t be confused with hairy leukoplakia, which is an irregular white plaque with hairy appearance that can’t be scraped off, and is associated with the Epstein-Barr virus; as well as leukoplakia, which is a precancerous white plaque that can evolve into squamous cell carcinoma, and is associated with tobacco, alcohol, and HIV infection.
Sialadenitis refers to inflammation of the salivary glands due to infection; autoimmune diseases; or salivary flow obstruction due to sialolithiasis, which most often involves the Wharton duct of the submandibular gland, and presents with intermittent pain that’s worse before and during meals.
Finally, salivary gland tumors are usually benign tumors and most often involve the parotid gland; although most submandibular gland tumors are malignant.
All salivary gland tumors present as a painless lump or swelling; while malignant tumors may cause pain, facial paralysis, or ulceration.
The most common malignant tumor is mucoepidermoid carcinoma, which is composed of both squamous and mucinous cells. The most common salivary gland tumor overall is pleomorphic adenoma, which is benign but may become malignant, and is composed of epithelial and myoepithelial cells, mixed with a chondromyxoid stroma.
Finally, Warthin tumor aka papillary cystadenoma lymphomatosum is a benign cystic tumor that has germinal centers, and typically affects smokers.
Back to our cases. Andrew came in with progressive difficulties breathing through his nose, the sensation of a foreign body in his nostril, and anosmia.
History revealed acetylsalicylic acid sensitivity, whereas the clinical examination and blood tests were normal. His clinical picture’s highly suggestive of nasal polyps.
Nasal endoscopy or CT would confirm the diagnosis. Sarah said she had trouble breathing ever since she was a child, especially during the spring or when she’s surrounded by flowers.
On examination, she presents nasal congestion and red, itchy, swollen eyes with frequent bouts of sneezing. These symptoms, which appear in the context of allergen exposure, is suggestive of allergic rhinitis.
The diagnosis can be confirmed by skin testing. pleomorphic adenoma, which is benign, but may become malignant, and is composed of epithelial and Maya epithelial cells mixed with a chondromyxoid stroma.
Finally warthen tumor AKA papillary cystadenoma lymphomatosis. Mm is a benign cystic tumor that has germinal centers and typically affect smokers.
Back to work, Aces Andrew came in with Progressive difficulties breathing through his nose. The sensation of a foreign body in his nostril and anosmia history revealed acetylsalicylic acid sensitivity.

Summary25:06–25:55

Whereas the clinical examination and blood tests were normal his clinical pictures. Highly suggestive of nasal, polyps nasal endoscopy or CT would confirm the diagnosis.
Sarah said, she had trouble breathing ever since she was a child, especially during the spring, or when she's surrounded, by flowers on examination.
She presents nasal, congestion and red, itchy swollen eyes with frequent bouts of sneezing these symptoms which appear in the context of allergen.
Exposure is suggestive of allergic. Rhinitis.
The diagnosis can be confirmed by skin testing.
Nasal, oral and pharyngeal diseases: Video, Causes | Osmosis