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ENT Pathologies – Tuesday, September 26, 2006

Normal Nasal Defences

Squamous epithelium with hairs and sebaceous glands (secrete sebum)
Columnar, respiratory epithelium; cilia (carries particles back up to pharynx)
Mucous
Sinuses – makes head lighter, has sebum, has IgA
~ if there is obstruction ANYWHERE between these sinuses, you will have pathology
~ chronic sinusitis, rhinitis – why are these ppl so pre-disposed to these infections?
Maybe there is underlying issues in sinuses and their drainage

Rhinitis
Lots of causes: allergies, viruses, etc
Infectious  typically viral
~ it infects epithelial cells and they become necrotic (it dies and initiates an immune
response  leukocytes, etc)
~ if bacterial infection – get neutrophils
~ if viral infection – lymphocytes
~ get increased vascularity  increase transudate and exudates  get viral snot
exudates leaking thru epithelial wall, has viral particles and necrotic cells)
~ discharge (snot)  has lots of viral particles which can lead to secondary bacterial
infection
~ white colour – lymphocytic infiltration due to viral infection, TCM – cold
~ yellow green – secondary bacterial infection, TCM – wind heat (yellow is pus
from the neutrophils fighting bacterial infection)
Allergic – IgE mediated immune reaction with an early-phase and late-phase response
~ lots of eosinophils in blood and nasal discharge
Chronic – long lasting rhinitis – can do damage to nasal mucosa

Sinusitis
Inflammation of paranasal sinuses often by extension of nasal cavity or dental infection
Typically preceded by rhinitis (acute or chronic)  causes edema and obstructs sinuses
and get secondary infection
~ or infection traveled to sinus from nose (thru nasopharynx)
Key factor – obstruction of tube(s) that connect sinuses to each other and to the
nasopharynx
Maxillary tooth infection  communicate to maxillary sinus = another source of
infection
Trigeminal nerve – sensation of face (3 branches), so same nerve innervates ear,
maxillary sinus, and tooth
 ~ for children, they are not able to distinguish as well which sensations are what, so
they may say they have earache when they have a tooth coming in
Dangerous! Uncomfortable and the infection can get bad enough to infect bone, which
means it can lead to septic shock or meningitis

Wegener Granulomatosis
Usually consists of a triad:
~ 1) vasculitis causing necrosis of lung and upper airway
~ 2) necrosis of granuloma of upper and lower respiratory tract
~ 3) glomerulitis causing necrosis
Very serious, without treatment, 80% patients die in 1 year
No causative agent identified
Often seen antineutrophilic cytoplasmic antibodies

Squamous Papilloma
Wart, HPV
Benign mucosal neoplasm of nose and sinuses
Associated with HPV 6 and 11
Usually warts grow on septum  exophytic growth
Cause obstruction! Can’t clear nose
Inverted  endophytic growth, very locally aggressive because of inward growth
~ risk of orbital or cranial invasion  BAD

Disorders of Nasal Cavity

Hemangioma = vascular tumour
~ accumulation of capillaries, can happen anywhere in the body
~ capillary – most important type
~ unencapsulated aggregates of closely packed, thin-walled capillaries covered with
epithelium
~ bright red  blue, level with skin or slightly elevated
~ tends to regress
~ risk: very thin walled and if broken, may loose a fair amount of blood because the
coagulation and blood clotting process needs to happen with ALL the capillaries, not just
one
Cavernous – greatly distended, loosely organized vascular channels
~ have thin, collagenized walls
~ happen most in cerebellum, pons, and subcortical regions
Pyogenic – rapidly growing nodule attached by a stalk
~ bleeds easily and often ulcerated
~ extensive edema with inflammatory infiltrate, especially if ulcerated

Neoplasia of Nasal Cavity

Olfactory Neuroblastoma – tumour on olfactory nerve
~ highly malignant tumor made of small round cells of neuroendocrine origin
Nasopharyngeal Carcinoma
~ squamous cell carcinoma of nose
~ associated with EBV infection (epstein barr virus)
~ keratinizing and non-keratinizing types
~ undifferentiated type  most common and most associated with EBV
~ EBV infects B lymphocytes which causes proliferation of reactive T lymphocytes
causes atypical lymphocytosis, seen in peripheral blood, and enlarged lymph nodes

Pharyngitis/Tonsillitis
Concomitants of viral or bacterial URTI (upper respiratory tract infection)
Can move into trachea and get chest cough
More serious when infection is by beta-hemolytic Streptococcus (Strep throat)  risk of
sequelae (“something that comes next”)  rheumatic fever (Strep throat so severe
that the antibodies react against own heart and can have valvular concerns or GN –
glomerulonephritis)
~ Strep – very red, very painful, fever, and see other systemic signs of infection
~ hyperemia and exudates
~ neutrophils will produce cytokines that will cause fever
~ remember that as an ND if your px tests positive for Strep, it is your obligation to
recommend antibiotic tx because it can be so severe
~ severe in infants, children, immunocompromised, diabetics
Weaker immune = higher risk
Commonly see lymphadenopathy – tonsillary, superficial cervical

Inflammations of the Throat

Laryngitis
~ manifestation of allergic, viral, bacterial or chemical injury
~ most common result of nonspecific infection or tobacco exposure
~ inflammation and edema of vocal cords = hoarseness
~ if in children, often caused by Heomophilus influenzae (which causes mucosal
congestion, edema, and airway obstruction)
~ related to croup (acute laryngotracheobronchitis – acute inflammation of larynx,
trachea, and epiglottis and can be life threatening in infants)
~ often viral infection
Epiglottitis
~ medical emergency in young children/infants
~ infection of epiglottitis and larynx w H. influenza or beta-hemolytic streptococci
~ it is more serious for children b/c the throat is smaller in children, so when epiglottis
swells and can block trachea and obstruct breathing
~ be careful with the tongue depressor b/c if it touches epiglottis, the irritation can
cause further inflammation
~ if suspect: SEND TO EMERGENCY ASAP
~ sxs: loss of appetite, hard to breathe

Growths of Throat
Vocal cord polyps and nodules
~ due to frequent irritation to vocal cords  acute inflammation
 ~ if source of irritation is constant, move into chronic inflammation (simultaneous
inflammation, irritation, and attempt of resolution)
~ end up with hyperkeratinization, hyperplasia, fibrous tissue
~ rarely develop to CA
~ nodules  bilateral, clump
~ polyps  unilateral, singular
~ smooth, rounded, pedunculated fibrous tissue covered by squamous epithelium
~ if cancerous – irregular, not smooth
~ can have laryngeal papilloma – benign neoplasm located on true vocal cords
~ can undergo malignant change in adults

Normal Ear Defenses

Cerumen – ear wax!
Cilia – epithelium of ear, to help move things away from tympanic membrane
Tympanic Membrane – protects middle ear and transmits sounds
Eustachian Tube

Otitis Externa
“swimmer’s ear” – often fungal infection of external auditory canal
Risks: swimming, scratching ear, irritants, ear plugs (especially re-use)
Focal infection – feruncle, can communicate into cranium
Diffuse involvement – whole ear canal, more likely with fungal infection

Otitis Media
Acute  secondary to nasopharyngeal infection
~ after URTI
~ inflammation in middle ear
~ most common causes are viral: s. pneumonia, Haemophilus influenza
~ very common in children
~ complications can lead to meningitis
Chronic  due to repeated bouts of acute infection
~ pseudomonas aeruginosa, S. aureus, fungus
~ potential for rupture of tympanic membrane (pressure from obstruction), mastoiditis,
brain abscess, otosclerosis (scarring of ossicles in middle ear – will decrease hearing)
~ get back into cycle of attempt to heal with re-infection
With effusion = glue ear
~ sterile mucoid fluid in middle ear
~ may be caused by edema (from allergies), or structural reasons
~ reducing dairy might help, remove food allergies
~ breast feeding – good for development anatomically of head and neck, as well as
nutritional values

Disorder of the Middle Ear

Cholesteatoma
~ cystic lesions 1-4cm in diameter
~ Cholesteatomas are epidermal inclusion cysts of the middle ear or mastoid process
~ keratinizing squamous epithelium – expansion causes damage
~ filled with debris, sometimes with cholesterol
~ often extends to mastoid process
~ although, neoplastic, it can have same effect as slow-growing benign tumour
Otosclerosis – uncoupling of bone resorption vs formation (no longer balanced)
~ bone deposition can happen around oval window so lose vibration of stapes against
oval window
~ ankylosis of foot plate of stapes to window
~ slowly progressive hearing loss
~ tends to be bilateral, often due to chronic ear infections
~ can also be genetic (autosomal dominant)

Disorders of Inner Ear

Meniere’s disease – distension of cochlear duct by excess fluid, irritates auditory nerve
~ vestibular membrane bulges into vestibular cavity
~ see tinnitus, vertigo, nausea, vomiting
Schwannoma – acoustic neuroma
~ well-circumscribed masses stuck to peripheral nerves, cranial nerves, spinal nerve roots
~ causes unilateral hearing loss
~ often involves cranial nerve #8 – between cerebellum and pons
~ benign, slow growing encapsulated tumour from Schwann cells

Oral Cavity Pathology

Mouth exams are important!
Mouth is common place for infection
Check mucosal health – reflection of GI tract and nutrition (vitamin and mineral status)
Teeth decay – bone structure in body, nutritional status with relation to bone health
TCM – tongue diagnosis
Hygiene
Halitosis – bad breath (physiological and metabolic state)

Normal Defenses of Mouth

Mucosa
Flora
Secretory IgA and Lymphocytes
Saliva – digestive and immune functions

Manifestations of Systemic Disease

Hairy Leukoplakia – describes irregular white mucosal patches
~ hyperkeratosis, usually due to secondary chronic irritation
~ usually benign, but can be carcinoma in situ or dysplasia
Oral Candidiases – local white, membranous lesion caused by Candida albicans
~ aka thrush or moniliasis
~ mucosal hyperemia and inflammation
~ usually in debilitated infants and children, immunocompromised patients, and diabetics
HIV common risk for both
Mucosal Inflammation
Apthous stomatitis – canker sores
~ Single multiple shallow ulcerations on mucosa, thin exudates, erythematous ring
~ Mononuclear infiltrate
~ Not the same as herpes – viral, vesicles
~ In TCM – mouth is linked to ST (chronic canker sores is heat in ST)

Cancerous and Precancerous Lesions

Leukoplakia – white plaque
~ Precancerous
~ Atypia, hyperkeratosis
~ Squamous Cell Carcinoma
~ Most common place in head and neck