Resp Ii - Unit I

Front 1

Squamous Papilloma

Back 1

verruca vulgaris/wart of nasal vestibule

Front 2

Sinonasal (Schneiderian) Papillomas *3 types*

Back 2

Uncommon, Benign neoplasms (but locally destructive)

1. Exophytic (septal,squamous) ~50-60%

2. Inverted (lateral,squamous) ~40-50%

3. Oncocytic (lateral,cylindrical/columnar) ~5-10%

Front 3

Exophytic Sinonasal Papilloma (Septal, Squamous, Fungiform)

Back 3

- Occurs on septal nasal wall

- Rarely (almost never) develops into invasive carcinoma

- Looks like fingers off the septum

Front 4

Inverted Sinonasal Papilloma

Back 4

- Occurs on lateral nasal wall near middle turbinate

- 5-10% develop invasive carcinoma within 5 years

Front 5

Oncocytic Sinonasal Papilloma (Cylindrical, Columnar)

Back 5

- Occur on Lateral nasal wall near middle turbinate

- No assx w/ HPV

- Oncocyte = abundant bright pink cytoplasm (from mitochondria in this tumor)

Front 6

Olfactory Neuroblastoma (Esthesioneuroblastoma)

Back 6

- Arises from neuroectodermal olfactory cells in olfactory mucosa

- Average age onset bimodal- 15 and 50 y/o

- 5-year Survival = 40-90%

- obstructive

- Superior nasal concha, upperseptum, roof of nose, cribriform plate, ethmoidsinus

- "Small blue cell" tumor

Front 7

Three Major Divisions of the pharynx

Back 7

1. Nasopharynx (*NK)

2. Oropharynx

3. Laryngopharynx

*NK = “non-keratinizing” (no cornified layer)

Front 8

Lymphoid structures in the Upper “Airway”

Back 8

- "Waldeyer'sring" (left) - which includes Palatine tonsils

- Lymphocytes in the lamina propria (Submucosal dense lymphoid aggregates)

Front 9

What will obstruction of the internal auditory canal in the Nasopharynx cause?

What about in the upper airway?

Back 9

Recurrent otitis media --> hypertrophicadenoidal tissue --> Obstruction ofthe internal auditory canal

Obstruction inupper airway --> Sleep apnea

Front 10

Nasopharyngeal Angiofibroma (NA)

Back 10

- Epidemiology = rare

- Occurs almost exclusively in young males (often redheads)

- onset 10-20 years (rare>30); “Juvenile NA”

- Sx = epistaxis

- Clinical Behavior: Posterolateral wall fibromuscular stroma origin

- Benign, but 10-20% are locally aggressive and 9% are fatal

- Tx = surgery

- Prognosis = Excellent after removal

Front 11

Nasopharyngeal Carcinoma

*3 histo subtypes*

Back 11

- Epidemiology = EBV-related

- Africa: Common in children (not adults)

- China: Common in adults (not children)

- Rare in U.S.

- Freq. unresectable at diagnosis, Five year survival (after Rx) 60%

1. Keratinizing - squamous cell carcinoma (SqCC)

2. Nonkeratinizing- squamous cell carcinoma3. Undifferentiated/basaloid carcinoma,with lymphoid component*

Front 12

What is "Pharynx –Oropharynx". What occurs here?

Back 12

Not really part of airway; represents posterior portion of oral cavity

- this is where Acute Pharyngitis “Beefy Red” & Acute Tonsillitis hits . In either, think Adenovirus [ds-DNA]. Viral infections by far most common cause of AP

Front 13

Group A Streptococcus (GAS)

Back 13

- 10-20% of pharyngitis ages 5-15 yrs

- Rare in adults

- Incidence peaks winter-early spring

- Sore throat + fever

- Absence of cough, coryza, hoarseness, conjunctivitis •(these suggest a virus)

- Tender anterior cervical lymph nodes

- Tonsils are enlarged, erythematous and have patchy exudate (follicular tonsillitis)

Front 14

Fusobacterium necrophorum

Back 14

- ~10% of acute pharyngitis cases

- >20% in recurring cases and in peritonsillarabscesses

- Jugularvein with thrombophlebitis (Lemierre syndrome)

Front 15

Corynebacterium diphtheriae

Back 15

- Only strains carrying toxgenecausediphtheria

- Gene encodedwithin a lysogenic bacteriophage

- Diphtheria

- Productionof pseudomembrane

Front 16

ViralPharyngitis

Back 16

- Rhinoviruses(~20%) - Indirectpharyngitis.

- Adenoviruses - Cancause pharyngoconjunctivalfever (fever,sore throat, conjunctivitis).

- EBV - Infectious mononucleosis mainlyin 15-25 yr-oldage group, Monospottest for heterophile antibodies.

- HSV types I and 2- Gingivitis, stomatitis and pharyngitis, vesicles inpharyngeal mucosa

- Influenza - Pharyngitis

- Parainfluenza andcoronaviruses- pharyngitis aspart of common cold syndrome

- Enteroviruses(certain coxsackieand echovirus)-pharyngitis secondaryto upper GI infection and then dissemination

- CMV &HIV – Mononucleosis-typeillness

Front 17

How to vocal cords move during phonation?

Back 17

Front 18

Anatomy of the Laryngopharynx/Hypopharynx& Larynx

Back 18

Front 19

Discuss Acute Laryngitis

Back 19

Front 20

Croup/ Laryngotracheitis / Laryngotracheobronchitis

Back 20

• MC cause of inspiratory stridor (laryngealor supraglottic obstruction)in children

• Oftenassociated with seal-like barking

• Cause - Mainlyparainfluenza (paramyxovirus)

• Steeple sign – subglottic narrowing

• Pathogenesis = Infx via aerosol into nasopharynxand spread to larynx and trachea•Edemaand inflammation in subglottic larynx and trachea around cricoid cartilage –airway narrowing. May haveendothelialdamage and loss of ciliaryfunction. Fibrinous exudate may beformed andaddto airway occlusion•Edemaof vocal cords can cause hoarseness

• Treatment = Supportivewith short termsteroids to reduceinflammation.

Front 21

Reinke Edema (PolypoidCorditis)

Back 21

Middle-aged females who are heavy smokers --> Develop husky low-pitched weak voices

Front 22

Vocal Cord NodulesandPolyps

Back 22

- Pathogenesis:Reaction to injury of vocal cord

- Classic location at junctionanterior and middle third of cord

- Occurs following sustainedinjury causedby Heavy smoking Heavy, recurrent voice strain (singer’snodules)“Theyvirtually never give rise to cancers”

Front 23

VocalCord Papilloma and Papillomatosis

Back 23

- Papillomas: Benignneoplasms locatedon true vocal cords

- Usuallysinglein adults, but can be recurrent

- Multiple in children (juvenile laryngeal papillomatosis)

- Causedby HPVtypes 6/11

Front 24

SquamousCell Carcinoma of Larynx

Back 24

- ClinicalFindingsProlongedhoarseness (>6 wks) earliest,most consistent Sx

- Epidemiology= ~90%have a prolonged and significant history of Heavy smoking,>20 years (> 50 pack yrs) + Ethanol abuse/dependence

Front 25

Squamous Cell Carcinoma of Larynx

(Premalignant Changesand InvasiveCarcinoma)

Back 25

Front 26

Location of Laryngeal Carcinoma

Back 26

Anatomic locations

1. Glotticcarcinoma:involvesthe true vocal folds 50-60%oflaryngeal carcinomas

2. Supraglotticcarcinoma: confinedto the supraglotticarea (free border of the laryngeal epiglottis, false vocal folds and laryngealventricles) 30-40%oflaryngeal carcinomas Discovered later– early tumors do not causehoarsenessHigher stage tumors at diagnosis- 2/3StageIIIor IV

3. Subglottic carcinoma:extendor arise more than 10mmbelow the free marginofthe true vocal fold up to the inferior border of the cricoid cartilage. <5%of laryngeal carcinomas

4. Transglotticcarcinoma:cross the ventricle from the supraglotticarea to involve the true and false vocal folds or involve the glottis andextend subglotticallymore than 10mm orboth. Glottictumors:5 yrsurvival ~65% Supraglottictumors:5 yrsurvival ~45%

Front 27

Squamous Cell Carcinoma Larynx - Survival by Stage

Back 27

Front 28

Anatomy of the Ear

Back 28

Front 29

External Ear and Otic (Aural) Canal

Back 29

Otitis Externa

•Marked tendernessafter gentletractionof pinna

•Peak age between 7-12

•Physical Findings: erythema,swelling, moist debris +/-pus

•Etiology: Traumatized ear canal• excessive use cotton-tip swabs• retained contaminated water“Swimmer’sEar”

•Bacterial -90%

• PseudomonasSp 38 - 50%

• StaphylococcusSp

• Gram-negativerods

• Fungal 10%

•Aspergillus

• Candida

Neoplasms = Simplyskin tumors; i.e. squamous and basal cell carcinoma

Front 30

Middle Ear Anatomy

Back 30

Middle ear is linedby thin “non-keratinizing” stratified squamous epithelium

Front 31

Middle Ear Inflammatory Disorders - Acute OtitisMedia

Back 31

Tympanic membraneopacity, bulging , erythema, effusion and decreased motility

Front 32

Middle Ear Inflammatory Disorders - Chronic Otitis Mediaand Cysts

Back 32

ChronicOtitis Media: when Eustachian tube becomesblocked repeatedlyCauses:Recurrent otitis media (> 3/6 mo; 4/yr) with adenoid hypertrophy

Bacterialagents: Pseudomonasaeruginosa, S. aureusLong-termsequellae:Perforationtympanic membrane, scarring, mastoiditis and bone erosion, cysts; conductive hearing loss common

Middle ear cysts (0.5 - 3 cm) Two types of cyst lining

1.Squamous epithelium (cholesteatoma):large amounts of keratin produced

2.Metaplastic columnar epithelium: mucin-secreting

Front 33

Cholesteatoma

Back 33

Squamous epitheliumtrappedwithin thetemporal bone(middle earor mastoid)

Front 34

Otosclerosis

Back 34

Bony overgrowth --> severe conductive hearingloss

Front 35

Neck- Branchial Cleft Defects

Back 35

Front 36

Neck - ThyroglossalDuct Cysts

Back 36

Cystin midlinelocationAnyage (usually<40)

Front 37

Neck- Carotid Body Tumor

Back 37

- Prototypeof parasympathetictumor --> With↓pO2 carotid bodyreleasesneurotransmitters that↑ ventilatory rate

- Bruit on auscultation duetoobstruction and turbulent flow