1/12/2011

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Granulomatous disease in
Head & Neck
By u . ..+..a
.av.. .-a +.. .ur.
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Granuloma
Lesion produced by defensive immunopathologic
process
Formation of granuloma : Langerhan giant cell
(multinucleated giant cell) surrounding with
lymphocyte ,Eosinophil around with fibroblastic
proliferation
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Giant cell
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Granulomatous disease
Often infectious caused
Nonhealing ulcerative lesion mucosal tumor or mass
in head & neck
Biopsy to rule out neoplastic disease
Pathologist often report granulation tissue with
acute & chronic inflammation
Investigation begin with history : fever night sweats
,weight loss, loss of appetite, malaise ,arthralgia
,systemic disease , immunocompromised&recent
travel to developing countries
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Cause of Granulomatous disease
Infection : bacteria,fungal ,parasite
Neoplastic disorder
Inflammatory disease of unknown
ethiology
Autoimmune /vasculitis disease
Trauma
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Bacterial infections
Tuberculosis & nontuberculous mycobacteria
Cat-Scratch disease & Bacillary Angiomatosis
Brucellosis
Rhinoscleroma
Leprosy
Actinomycosis & Nocardia
Syphilis
Tularemia
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Tuberculosis
Mycobacterium organism Mycobacterium
tuberculosis
80% of cases were pulmonary
Men,poor, inner city nonwhite, HIV
&immunosuppressed
Transmiited by inhalation of airborne droplet
Rare in Head & neck
6-8 wks after exposure can spread to systemic&
regional LN
most common is cervical lymphadenopathy
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Tuberculosis
Nodes: multiple,matted,Bilateral,firm& generally
not tender ,frequently involve posterior triangle&
supraclavicu;ar nodes
98 % PPD+ve if cervical lymphadenitis but PPD ve
unlikely tuberculosis
1%Laryngeal symptom: Hoarseness,diffuse
edema,hypertrophic mucosa involve posterior 1/3 of larynx ,
arytenoid>TVC>epigolltis>FVC, nodular or ulcerative lesion
(confused with carcinoma)
Otologic involvement: thicked hyperemic spots onTM
coalescence & multiple perforations with painless drain & thin
watery d/c
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Tuberculosis
if pyogenic bacterial superinfection: d/c thick & cheesy c
increase granulation tissue
Mastoiditis: absence of bony destruction & sclerosis because
of acute process
Middle ear: granulation tissue c erosion of ossicle
Nasal involvement: obstruction,rhinorrhea,mucosal
granuloma, septal perforation
Oropharynx : oral ulceration,tonsillitis,sialdenitis
Diagnosis : AFB,culture,FNA, Biopsy : caseating
granuloma,CXR,PPD > 15mm,>10 in high
prevalence,> 5mm in HIV or low immune
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Laryngeal tuberculosis
Otologic TB
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Tuberculous oral cavity
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Tuberculosis
U/s : necrotic caseating &suppuration
low echogenic mass c nonhomogeneity
CT : multiloculated low-density nodal mass with enhancing rims &
normal fascial planes ,wall of nodl mass thicker than malignant
disease
Treatment :
- Respiratory isolation in pulmonary & laryngeal involvement
- Antituberculous drug,
- LN excision in Fluctuant or chronically draining nodes avoid
I&D if nontuberculous invlvement
- mastoidectomy in mastoiditis
- Anti HIV
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Nontuberculous mycobacterium
Less virulent than Mycobaterium tuerculosis
Less responsive to standard anti TB drug
Repeated positive cultured more significant than
single C/S
Route of transmission from soil to mouth ,respiratory
tract,eye
Incubation period >= 5 years on average Most
common pathogen: Mycobacterium aviumcomlex &
Mycobacterium Kansansii
most commonly cause cervical lymphdenopathy
than tuberculous
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Nontuberculous mycobacterium
MAC: most common causes in human disease
- Typically pulmonary& result in osteomyelitis
,peritonitis,dissemnateddisease in severe
immunocompromised, superficial lymphadenitis in
children
M.Kansasii : pulmonary as well as disseminated
disease c skin lesion as erythema
nodosum,erythema multiforme
M.Scrofulaceum: exists in soil, water &
contaminated foodstuffs
- Cause lymphadenitis in children < 6 year commonly at
preauricular,submandibular,anterior cervical c slowly enlarge
& draining tract
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Nontuberculous mycobacterium
Diagnosis :
- Culture for 2 wks & wks inidentifiedspecies
,biopsy,PCR,AFB
- 50% PPD +ve
Treatment :
Excisional biopsy in scrofula
unacceptable in fluctuant lesion,severe skin
necrosis,close to facial n. or critical structure
resolve without treatment but scarring
contraindicated in I&D
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Mycobacterium - scrofula,
AFB stain
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Leprosy (Hansens disease)
Tropical climates c Mycobacterium leprae
Vector - Human nasal droplets or by soil to open
lepromatous ulcer, breast milk
Cutaneous transmission : require prolong contact
Manifestation : Hypopigmented or erythematous
macules,tuberculoid skin lesion & nerve involvement c muscle
wasting and anesthesia, anesthetic plague,mucosal ulcerated
nodules in mouth & nose,keratitis, laryngeal ulceration,
lymphadenopathy, hyposmia, eyebrow& eye lash loss,nasal
collapse,facial n. paralysis
peripheral neuropathy : impair perception of fine touch,temp
& pain lead to recurrent trauma & ulceration to extremities
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Leprosy (Hansens disease)
Tuberculoidform - Widespread peripheral
nerve involvement with pain, muscle atrophy
Lepromatous form - cutaneous with
hypopigmentedconcave macules
Sx: nasal congestion, epistaxis, hoarseness
due to mucosal nodules - cartilage collapse,
saddle deformity,
Diagnosis - bx & clinically
Treatment - Dapsone,
- clofazimine & rifampicin , minocycline in
dapsone resistance
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Leprosy
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Cat scratch disease
Bartonella hensalae (rickettial)
Gram neg. nonacid fast bacilli in Warthin Starry
silver stain
Reservoir in 50% of cat
self-limited
Inoculation 3-14 days after exposure
Manifestation:
50 % usually children c head&neck masses
Tender regional adenopathy(axillary,cervical,submand) c
mild fever
Cutaneous lesion at site of inoculation by cat scratch or bites:
erythematous papule or pustule
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Cat scratch disease
Protean symtom: low grade fever abdominal
pain,headache,malaise
Complication :uncommon in liver spleen& bone
marrow
Diagnosis: Hx of cat exposure ,primary inoculation
site,regional lymphadenopathy
- Histology: intracellular bacilli in warthin Starry silverstain
- Excisional biopsy: suppurative &necrotizing
granulomatous lymphaenitis c stellate microabscess
Treatment: supportive,I&D,azithromcin may be
speed recovery but not useful in lymphadenopathy
1-2month
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Bacillary angiomatsis
Bartonella hensalae, Bartonella quintana
Cat /louse exposure, HIV, immunocomproised,
poverty,Homeless
Predominantly in young adult
Manifestation: Cut. papules,subcut. nodules or indurated
hypopigmental plague or masses,lesion frquently bleed easily,
involve mucous memb. of nose ,oral
cavity,pharynx,larynx,bronchiconjunctiva bone & CNS
Peliosis nepatica : visceral involvement
Diagnosis: vascular (lobular capillary)proliferation
with leomorphic gram neg. acilli in Warthin Starry
silver stain or H&E stain 22
Bacillary angiomatsis
Treatment of choice : Erythromycin
Alternative treatment:
doxycycline,clindamycin,Azithromycin
Untreated : progressive disease & fetal
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Actinomycosis
Anaerobic or microaerohilic gram-positive
Actinomyces species
A. israelli : most common in human disease
follow by dental manipulation,trauma,gingival
infection
Palpable mass is most common head&neck finding
50% cervicofacial infection
(60% visible sinus tr. ,40% lymphadenoathy)
Common dental,sinus,perimandibular disease with
pain & fever prominent
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Actinomycosis
Progessive syptoms often present for months before
diagnosis
purplish discoloration of overlying skin
Diagnosis:
sulfur granules on micro from bx; characteristic
bacterial growth pattern
Culture: thioglycollate broth in CO2 atmosphere
Treatment: surgical debridement+
aqeous Penicillin G IV for 2-6 wks then oral penicillin
3-6 months
allergic to penicillintetracycline
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Actinomycosis
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Rhinoscleroma
Klebsiella rhinoscleromatis ; gram neg. bacteria
Central America and Eastern Europe
Usually involve nose & paranasal sinus :
Prolonged purulent rhinorrhea followed by
granulomas in the upper airway which coalesce and lead to
sclerosis of the nose,
larynx, and tracheobronchial tree, ear.orbit
3 stages
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Rhinoscleroma
1. Catarrhal: purulent rhinorrhea, larynx;
hoarseness,interarytenoiditis,hyperemia,vocal fold edema
2. Granulomatous(Flarid): nasal mucosa granuloma&
hyperemia : epistaxis,nasal obstruction,anosmia,nasal mass
3. Fibrotic: nasal,laryngeal & trachebrocheal tree stenosis->
airway obstruction
Diagnosis:
- Hx of travel to endemic area
- Honey-comb color crusting in the nose c prolong rhinorrhea
- Histopathology: Mikulicz cells(multinucleated macrophages
with clear foamy cytoplasm)during flarid stage in gram or
Warthin Starry stain
Treatment : long-term tetracyclin or ciprofloxacin,
Sx: larygeal obstruction
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Rhinoscleroma
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Brucellosis
( mediteranean fever,Malta fever)
Brucella spp. aerobic gram neg. coccobacilli
Harbor in cattle, pig, goat, bison
Aquire infection from product of harbors or
occupational exposure
Enter lymphatic & replicated intracellular /regional
LN in reticuloendothelial system then cause
noncaseating granuloma in the involve tissue
Manifestation:
weakness,sweating,chills,headache,backache,
arthralgia, fever commonly peak in afternoon
Diagnosis: Hx of exposure,serumtiters
Treatment of choice : Doxycycline&rifampicin 30
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Syphilis
Treponema pallidum, increased incidence
Primary stage - painless chancre lips, tonsil, tongue
Secondary stage - disseminated mucocutaneous
white macules/papules, acute rhinitis,
laryngopharyngitis,OM, alopecia
Tertiary - gummatous as erosive granulomatous
- Severe organ damage perticulary in CNS & cardiovascular
Congenital form by transplacental
Lesion :nasoseptal perf, saddle deform, hard palate
laryngeal nodules and ulcers
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Syphilis
Otosyphilis : SNHL;congenital or tertiary,fluctuating
tinnitus,Hennebert sign +ve
Congenital - Hutchinsons teeth: nothched,lack
enamel& underdevelop
Diagnosis- Darkfield microscopy,
VDRL(sensitivity but not specific)TPHA,
FTA ABS : high specific
Treatment: penicillin or tetracycline,
Otosyphilis &neurosyhilis ; long-term IV penicillin
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Syphilis
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Tularemia
Rare disease , rabbit fever
Caused by Gram negative pleomorphic
rod : Francisella tulrensis
Reservoir important in human disease :
ticks,rabbits & deer trasmission by bited
Direct inoculation by contamination of
wound or arthropod bites
Incubation period 3-5 days
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Tularemia
Manifestration: severe illness c
fever,chill,malaise,headache,myalgia may
be photophobia,decrease VA ,regional
lymphadenpathy
Oropharyngeal tularemia in 1 % : exudative
pharyngitis with lymphaenopathy
Diagnosis : serum agglutination test to
detect antibodies
Treatment : Streptomycin,gentamicin
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Fungal infections
Histoplasmosis
Blastomycosis
Cocidiodomycosis
Rhinosporidiosis
Cryptococcosis
Candidiasis
Aspergillosis & phycomycosis
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Histoplasmosis
Histolplasma capsulatum
Airborne transmission most commonly in Ohio &
Mississipi River valleys
organism in soil enriched with bird chicken & bat
excrement
primary & chronic infection in pulmonary infection
or fibrosing mediastinitis or mediastinal
granulomatosis : mediastinal LN enlarge &coalesce
may invade or compress nearby structures
progressive disseminated infection in extreme of
age & immunocompromisedhost
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Histoplasmosis
Head & neck mucosal site involve in 25 % of
disseminated case : lips gingiva tongue pharynx &
larynx
Symptom : cough, dyspnea, dysphagia
,odynophagia, sore throat , painful
mastication,hoarseness,gingival irritation,formation
of esophagopulmonary fistula, post obstruction
pneumonia & bronchiectasis
Lesion : firm slowly enlarging painful ulcers with
heaped up edge or verrucous appearance &
sometime mimic carcinoma or tuberculosis
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Histoplasmosis
Diagnosis : serology ,histology by Grocott
silver or Wright giemsa stain ,swab c/s
Treatment : Itraconazole is Tx of choice,
Amphotericin B in immunocompromised &
life threatening disease
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Blastomycosis
Blastomyces dermatitidis
Inhaled the conidia of the organisms
Asymptomatic to acute pneumonitis &
disseminated by Hematogenous involve skin
bones genitourinary system
Rare in direct inoculation
Triad : cutaneous lesion(verrucous or
ulcerative) ,pulmonary involvement&
constitutional symptom
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Blastomycosis
Oropharyngeal & laryngeal involvement less
common than hitoplasmosis
Diagnosis : sputum culture ,microscopic skin
scraping or biopsy
Treatment of choice is Itraconazole
Amphotericin B in immunocompromised or
CNS involvement
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Coccidiodomycosis
Coccidioides immitis
Transmission by inhalation of the arthroconidia of
organism that live in the soil in dry desert climates
reproductionin lung then common hematogenous
dissemination
systemic disease approximately 0.5 %
commonly involve skin first seen as nodules or
erosions granulomatous skin lesion subcut. abscess
& can form draining sinus
Head & neck manifestration is rare
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Coccidiodomycosis
mucous memb of thyroid eye trachea
temporal bones facial skeleton & larynx
Diagnosis : Histology, serology &skin test
culture(2-5days)
Treatment : fluconazole ,Itraconazole &
Amphotericin B in severe disease or azole
failure
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Paracoccidiodomycosis
South American blastomycosis
rare in healthy adults but treat to
immunocompromised
Paracoccidiodes brasiliensis
Head & neck manifestration common
involvement of oral mucosa & larynx also
involve
- granulomatous appearance or ulcerated
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Paracoccidiodomycosis
Diagnosis : organism in biosy ,histologically :
suppurative granulomas with lymphocytes
,epithelioid cell & giant cells
Treatment : Azole agent ,Amphotericin B
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Candidiasis
immune-suppression, prolonged use of
broadspectrumATB
candida esophagitis :
Sx: severe odynophagia, dysphagia,
laryngitis, angular cheilitis
Typically white pseudomembrane in oral
cavity or oral pharynx
Dx: swab and micro with culture
Tx: with nystatin, systemic antifungals for
persistent or invasive disease
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Candidiasis Candidiasis Candidiasis Candidiasis
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Rhinosporidiosis
Rhinosporidium seeberi
prominent in southern India & Sri Lanka
An infection of nasal ,palatal or conjuctival
mucous membrane
strawberry lesion Indolent,painless,warty
excrescences : erythematous friable &
polypoid
Treatment : excision
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Rhinosporidiosis Rhinosporidiosis Rhinosporidiosis Rhinosporidiosis
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Cryptococosis
Cryotococcus neoforman
predisposing factor in immunosuppression
primary infection in lungs & CNS
although in eye prostate & skin
Rare in Head & neck : gingivitis , sinusitis , sialdenitis,
thyroi
ditis , nasopharyngitis , laryngitis, hearing loss &
lymphadenitis
Diagnosis : serology & direct microscopic exam
Treatment : amphotericin B or Azole antifungal
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Parasitic infections
Leishmaniasis
Myiasis
Toxoplasmosis
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Leishmaniasis
Leishmania species
Transmission by sandfly bites
multiply in macrophges & capillary
endothelial cells before disseminated
Two predominant forms :
- Viseral leishmaniasis
- Cutaneous leishmaniasis
Lesion results in cell-mediated immune
response to organism in targeted tissue
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Cutaneous Leishmaniasis
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Leishmaniasis
Characteristic : papules that progress to ulceration
& encrustation
Espundia : initial lesion on extremities with blood
borne spread to oral cavitiy & oropharynx
months or years later progressive inflammation &
destruction of soft tissue of mouth & nose
Diagnosis : biosy ; intracellular organism in
microscopic exam stain Donovan bodies
Treatment : pentavalent antimonial compound,
sodium stibogluconate & meglumaine antimonate
& liposamal amphotericin B ; other antifungal agent
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Toxoplasmosis
Toxoplasma gondii
Ingestion of oocyst-containing cat feces or poorly
cooked infected lamp or pork
most patients are asymptomatics
clinically can be primary or secondary due to
reactivation with immunosupression congenital or
ocular
Primary : painless adenoathy , particulary cervical
,pharyngitis , rash,fever,fatigue& hepatosleenomegaly ;
multiple organ involvement include CNS in immunocomromise
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Toxoplasmosis
Congenital : primary infection during
pregnancy
- chorioretinitis, hearing loss and/or developmental
delay
Diagnosis : IgMor 4 folds increase in Ig G
acute phase
Treatment of choice : Pyrimethamine plus
trisulfapyrimidines
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Myiasis
Infestation with maggots from larvae of screw
worm or bot fly
Deposit patients skin when mosquito ingest blood
meal
nonfuruncular or furuncular ; pustular lesion with
central breathing pores
Usual sites are nasopharynx in former form & skin in
latter form
Diagnosis : microscopic examination
Treatment : surgical removal ; excision & curettage
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Neoplastic disorder
Langerhans cell Histiocytosis
(Histiocyosis X,LCH)
Fibrous histiocytoma
Pyogenic granuloma
Repartive granuloma
Necrotizing sialometaplasia
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Langerhans cell Histiocytosis
(LCH,Histiocytosis X)
Disorder of proliferation of mononuclear
phagocytic cell
LCH lesion : granulomatous contain
histiocytes,eosinophils & lymphocyte may be with
giant cells ,neutrophils & plasma cell
early stages : dominated Histiocyte &Langerhans
cell
mature stage : necrosis, phagocytosis
& ultimately xanthomatous changes with fibrosis
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Langerhans cell Histiocytosis
(LCH,Histiocytosis X)
Incidence 4/1,000,000 / year with median age
male > female
Etiology : unclear +/- genetic predisposing
Mortality rate approximately 20 %
Grouped into various subsets
- Hand Schuller-Christian disease
- Letterer-Siwe disease
- Eosinophilic granuloma
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Hand Schuller-Christian
disease
Chronic disseminated form
polyostotic form of eosiniphilic granuloma
Occur in post infancy,children,young adult
Triad : 10 % of case
- Skull lesion,exophthalmos,diabetes insipidus
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Letterer-Siwe disease
Disseminated form
infants,children>3yrs or younger
Extraskeletal involvement
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Eosinophilic granuloma
localized form
children & young adult
Osteolytic lesion in one or several bones
predilection for frontal & temporal bones
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Langerhans cell Histiocytosis
(LCH,Histiocytosis X)
Manifestation : common in bone (flat bone>long
bone) skin& lung lesion
Very common in Head & neck
most common in Head & neck is skull lesion
Temporal bone lesion : persistent otitis media c
dermatitis of EAC or external ear
Dental symptom: mandibular involvement less
often in maxilla ; painful swelling mandible or
gingiva c cervical adenopathy
Skin involvement : disseminated form as seborrheic
rash often involve skull & post auricular areas
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Langerhans cell Histiocytosis
(LCH,Histiocytosis X)
Diabetic insipidus: hypothalamic or pituitary
involvement
other organ: liver ,spleen,CNS,LN
Diagnosis: electron microscope
- Birbeck granules(pediatric),X-granules,Langerhans bodies
- Radiography: punch out ,lucencies of medullary bone with no
suroundind sclerotic lesion
Treatment : depend on extention of disease
- Eosinophilic granuloma : surical excision
- Radiation therapy: recurrences or inaccesible lesion
- Systemic chemotherapy : systemic disease
- Corticosteroid to proven effective chemotherapeutic agent
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Fibrous histiocytoma
painless mass lesion
sun-exposed skin,orbital tissue
Head & neck : upper aerodigestive tract,salivary
gland deep layer of scalp& face
Age 1-70 years, M:F= 2.5: 1
Most common symptom : nasal
obstruction,epistaxis,dysphagia,dyspnea
Lesion : slow-growing nodules ,1/3 of tumors are
multiple & metachronous
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Fibrous histiocytoma
Histopathoogy: biphasic cell population of
fibroblasts & histiocytes with spindle-shaped cells c
elongednuclei in storiform(cartwheel) pattern
Rare metastasis
Treatment:
local excision c clear margins
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Pyogenic granuloma
Polypoidor lobular capillary hemangioma on skin
& mucosal surfaces,
Benign lesion ,painless c bleed intermittently
Etiology unknown may be hormonal factor
female > male
most common sites: finger, lip, face, nasal
cavity(60% septum : epistaxis),tongue
Gingiva in pregnancy granuloma gravidarum :
regressive when delivery
Treatment: surgical excision
- Incomplete resection lead to recurrence 68
Pyogenic granuloma
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Reparative granuloma
Etiology unknown secondary to local trauma
Peripheral form : sessile or pedunculated
mucosa-coverd reddish or bluish mass from gingiva
or alveolar mucosa
Central form: endosteal usually anterior to 1 st
molar
Radiography: lytic expansile ,unilocular cavity
with well demarcated nonsclerotic margins c intact
bony cortex
Treatment: curettage
70
Necrotizing Sialometaplasia
Self-limited reactive inflammatory process of
salivary gland
metaplastic epithelial cells lining small salivary
gland with preservation of lobular architecture
Most often in oral cavity(often mstaken with oral
carcinoma) frequently junction of hard&soft palate
Lesion: deep-seated & sharply demarcated ulcer
but nonuclerated swelling
Spontaneous resolution for weeks to months
More common in smoker
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Necrotizing Sialometaplasia
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Inflammatory disease of
unknown etiology
Sarcoidosis
Idiopathic Midline Destructive disease
73
Sarcoidosis
Multiorgan disorder with a variable clinical picture
Etiology is unknown, genetic predisposition
Typically strikes young adult < 40 yrs
female > male
Noncaseating granulomas in the afflicted areas
Often deposit in lungs & intrathoracic LN
30-60% asymptomatic & common incidental
discovered by radiography
Acute c sudden onset : spontaneous remission
within 2 yrs
74
Sarcoidosis
chronic sarcoidosis : gradual onset c organ specific
symptoms & symptomatic relapse
organ specific : 90 % pulmonary involvement :
dry cough ,dyspnea , chest pain,hilar adenopaty,
1/3 of pts have constitutional symptoms :
- Weight loss,night sweats ,fatigue, myalgia, low grade fever,skin rash
,visual change ,nervous system symptom
- generalized adenopathy 25-50 % of cases
- subcutaneous nodule Darrier Rousey
Pathognomonic of laryngeal sarcoid : diffusely
enlarged pale-pink,turban- like epiglottis
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Sarcoidosis
Head & neck manifestration 10-15 %
- 50 % cervical adenopathy
- yellow subcut. nodules or polyps may deposit in upper respiratory
tract & usually supraglottic larynxdysphonia dyspnea or dysphagi
Sinonasal lesion: nasal obstruction, edema ,
epistaxis, crusting& thick d/c, nasal mass, saddle
nose , epiphora ,anosmia
Orbital lesion15-25 % : orbital masses, lacrimal
swelling& uveitis
Parotid involvement about 6 % : parotid swelling with or
without facial palsy
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Sarcoidosis
Heerfordt disease or uveoparotidfever :
parotitis, uveitis ,facial paralysis & fever
Lupus pernio : purplish rash or bluish discoloration of
nose,cheeck,lips or ears : poor prognostic sign
Otologic involvement is rare
- Middle ear : ET tube involvement
- SNHL : meningeal inflammation
Oropharynx: tonsilar hypertrophy : OSA,UAOs
Granulomatous lesion in pharynx & esophagus
fibrosis & stenosis
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Sarcoidosis Sarcoidosis Sarcoidosis Sarcoidosis
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Sarcoidosis
Diagnostic criteria include
1.compatible clinical & radiograph finding
2. Histologic finding of noncaseating granuloma
3. exclusion of other diseases with similar findings or
local reaction
Pathologic hallmark :
noncaseating epithliod granuloma
compact & demonstrates multinucleated giant
cells,lymphocytes & mononuclear phagocytic cells
wrapped by fibroblasts & mast cells
79
Sarcoidosis
Treatment : oral corticosteroids improve
pulmonary function & radiographic appearance
not change long-term progression
mild pulmonary disease : inhaled
corticosteroids or NSAIDs
Sinonasal symptom : saline irrigation, topical or
systemic steroids, surgery to relief nasal obstruction
or recurrent or chronic sinusitis
80
Idiopathic Midline Destructive
disease
Lethal midline granuloma
rare spectrum of lymphoproliferative
disorder
destruction of nose, paranasal sinus palate
& facial soft tissue
currently most case attributed to lymphoma
but not either frank lymphoma or
lymphoproliferative disorder
Treatment : Radiation therapy
81
Autoimmune /vasculitis disease
Wegeners granulomatosis
Relapsing Polychondritis
82
Wegeners granulomatosis
Idiopathic disease c immunologically mediated
male=female ,age 20-40yrs,exclusively affect white
population
Triad : Pulmonary ,Renal & Head&neck
manifestation(most common)
50% nose involvement : mild nasal obstruction, pain over
nasal dorsum,nasal collapse,foul smell rhinorrhea, epistaxis,
hyposmia, epiphora
Nasal exam: nasal crusting ,granulation tissue,mucosal
inflammation,nasal septum perforation,saddle nose
83
Wegeners granulomatosis
Otological involvement 19-38 % : otitis media c
effusion secondary to ET tube obstruction from
luminal grnulomat, NP inflammation,COM,SNHL
Oral cavity : rare deep ulcerated oropharyngeal
mucosa
Subglottic stenosis 9-16 %
Occular involvement is common ; may be only
manifestation : proptosis, diplopia, visual loss,
periorbital cellulitis
Diagnosis: serum ANCA & tissue biopsy
Treatment: Corticosteroid & immunosuppressive
agent
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Relapsing polychondritis
Rare immunologically mediated with many
otologic manifestation
Antibody to collagen type II
Affect to cartilargenous structure: ears, nose, joints,
tracheobronchial tree
Auricular exam in acute exacerbation: red swollen
& tender at external ear c sparing ear lobule
EAC & ET tube narrow or collapse
Nasal chondritis ,destruction & saddle nose
85
Relapsing polychondritis
50% laryngotracheal disease : dyspnea
,wheezing,hoarseness,tender over thyroid &
anterior tracheal cartilage
Tracheotomy if dynamic obstruction
Occular involvement: scleritis conjunctivitis
Treatment: no standardized effective
regimen
86
Trauma
Intubation granuloma
Teflon granuloma
87
Intubation granuloma
Involve the vocal process of arytenoids
Initial trauma contact ulcer granuloma
pedunculated polyp
Symptom : Hoarseness , Foreign body
sensation
Treatment : voice rest , surgery if indicated
88
Post intubation granuloma
89
Teflon granuloma
Teflon injection that treatment of
unilat. TVCP
Granulomatous reaction if infiltrted
surrounding tissue resection of
granuloma
increasing dysphonia or airway
obstruction
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Characteristics of granulomatous conditions
that commonly affect larynx
Tuberculosis Posterior third of larynx
Leprosy Supraglotic
Scleroderma Catarrhal stage; Mikuliczs cells
Actinomycosis Draining sinus ; sulfur granule
Syphilis Painless ulcers; positive syphilis serology
Candidiasis Leukoplakia-loke lesions; identifiable on Gram stain
Blastomycosis Painless ulcers; microabscesses
Histoplasmosis Anterior laryngeal involvement : pseudocarcinoma
Coccidiomycosis Painless abscesses; spores seen on histology
Sarcoidosis Supraglottic swelling ; nodules granulomas
Wegeners
granulomatosis
Subglottoc involvement; necrotizing vasculitis;
pulmonary and/or renal involvement
91
Reference
Byron J.Bailey Head & neck surgery
otolaryngology 5 th edition
Ballengers Otorhinolaryngology
Head& neck surgery 16
th
edition
Cummings Otolaryngology Head &
neck surgery 5 th edition
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