Faculty of Medicine

Medical Education-
Damietta University

Level 1
Semester II
Module 4A
 Diseases of
upper
respiratory tract
BY:
Dr Hazem Abdullah
 Instructor information
• Contact: Pathology Department.

• Official email: drhazem_abdullah@yahoo.com

• Mobile (optional): 01146710982

• Academic hours: any time

……………day: 00:00-00:00 AM
…………...day: 00:00-00:00 AM
Lecture Outline
•Allergic sino-nasal polyp.

•Rhinoscleroma.

• Diseases of nasopharynx.

•Diseases of tonsils.

•Diseases of larynx
Learning Outcomes
• Define & describe inflammatory nasal polyps and
mention its complications.
• Define, mention cause, describe & mention the
complications of rhinoscleroma.
• Recognize pathologic aspect of nasopharyngeal
diseases (nasopharyngitis – adenoids).
• Recognize pathologic aspect of tonsillar diseases
(diphtheria, acute & chronic tonsillitis)
• Recognize pathologic aspect of laryngitis.
 Case Scenario
A young lady complains of nasal obstruction. ENT
examination shows a polypoid lesion in the nasal
cavity and paranasal sinuses. Biopsy examination
shows edematous stroma with numerous
eosinophils.
A.What is the diagnosis?

B.Is this lesion precancerous or not?

C.What are the expected complications?

UPPER RESPIRATORY
TRACT
 Nose & Paranasal Sinuses
A- Inflammation

Rhinitis: inflammation of nasal mucosa.

Sinusitis: inflammation of mucosa of paranasal sinuses.
Nasopharyngitis: inflammation of nasopharynx.
Tonsillitis: inflammation of the tonsils.
Laryngitis: inflammation of the larynx.
Rhinoscleroma: A destructive infective granuloma of upper
respiratory tract primarily in the nose caused by Klebsiella
Rhinoscleromatis. It is endemic in Egypt.

Adenoids: Inflammatory hyperplasia of lymphoid tissue in the

posterior wall of nasopharynx, usually in children.

Inflammatory Nasal Polyp: finger like projection arising from

the mucosa of the nose and paranasal sinuses due to
inflammatory process.
A- Acute Rhinitis and Sinusitis

(1) Common cold (Acute coryza):

• Pathology: Acute catarrhal inflammation

caused by rhinoviruses with few neutrophils
until 2ry bacterial infection supervenes, their
number increases.
Fate:

1) Subsides after few days.

2) 2ry bacterial infection (suppurative inflammation).

3) Spread of infection to middle ear (otitis media), lower

respiratory tract (bronchitis, bronchopneumonia).

4) Chronicity especially in sinusitis (common in maxillary

sinus due to upward direction of drainage leading to
mucocele & empyema).
(2) Atopic (Allergic) rhinitis and sinusitis:

• Acute allergic inflammation (numerous eosinophils

and hypertrophic mucous glands).

• Repeated attacks of allergic inflammation with

chronicity leads to thickening of the mucous

membrane with formation of Allergic Nasal Polyp

B- Chronic Rhinitis and Sinusitis

1) Chronic Non-specific Inflammation:

1- Chronic Hypertrophic Rhinitis and sinusitis:

*follows acute inflammation which fails to resolve.

*common in maxillary sinus.

N/E:

The mucous membrane is thickened, opaque,

may be granular or polypoid, and covered by mucous or

purulent exudate.

• M/E:
• Epithelium: hyperplasia or squamous
metaplasia.

• Subepithelium: proliferated mucous glands &

chronic inflammatory cells
Eosinophil
Complications:

- Narrowing of nasal cavity due to thickened mucous

membrane.

- Nasal polyps may cause obstruction.

- Squamous cell carcinoma on top of squamous

metaplasia.
2- Chronic Atrophic Rhinitis (Ozena):
• characterized by atrophy of nasal mucosa with foul
smelling, and anosmia
• It is rare
• commoner in females than males.
Causes:
1- End stage of chronic hypertrophic inflammation (ischemic
changes).

2- Primary due to infection with klebsiella ozanae.

3- Endocrinal disturbances.
• N/E:
mucous membrane is dry, pale grey, smooth &
covered by dried exudate in the form of crusts.
It has offensive odor.
• M/E:
- Atrophy of the mucosa and glands
- Fibrosis of submucosa with scanty
chronic inflammatory cells.
• Complications:
- Widening of the nose (fibrosis).
- Anosmia (loss of smell, due to atrophy of nerve
endings)
 Inflammatory Nasal Polyps

• Definition: finger like projections arising from the

mucosa of the nose and paranasal sinuses due to
inflammatory process.

• Causes:
1. Chronic hypertrophic rhinitis and sinusitis.
2. Repeated attacks of allergic rhinitis and
sinusitis.
N/E:
Site: On the middle turbinate bones & within the
maxillary sinus.
Size: Variable sizes.
Shape: Pedunculated (may be sessile).
Surface: Smooth and shiny surface (opaque with
squamous metaplasia).

Consistency: Soft in consistency (gelatinous).

Colour: Pink or gray (mucoid).
Number: Multiple and bilateral.
M/E:

1- Covering epithelium:
- Hypeplastic pseudostratified ciliated.

- Squamous metaplasia is common.

2- Core of connective tissue with:

Edema.

Hyperplastic mucous glands, some cystic.

Mixed acute & chronic Inflammatory cells.

If eosinophils predominate; the polyps are allergic.

Complications:

Nasal obstruction.

Epistaxis.
2) Chronic Specific inflammation (Granuloma)

• Tuberculosis

• leprosy

• Syphilis

• Rhinoscleroma may involve and destroy the

nasal structures.
 Rhinoscleroma
• A destructive infective granuloma of
upper respiratory tract

• primarily in the nose

• caused by Klebsiella
Rhinoscleromatis.

• It is endemic in Egypt.
• N/E:
1) The primary site is the nose:
- It is enlarged & hard.
- Mucous membrane is thick, granular & a nodular
stage or single large mass.

2) Extend to upper lip, nasal sinuses, naso- or

oropharynx, larynx and trachea with soft
tissue destruction
• M/E:

- Surface epithelium: hyperplasia or squamous

metaplasia.
- Subepithelium:
a- Mickulicz cells (hydropic degeneration of
macrophages).
b- Russel bodies (hyaline change of plasma
cells).
c- Lymphocytes and plasma cells.
d- Granulation tissue ending in fibrosis.
• Complications:
- Nasal obstruction.
- Nasal deformity
- Epistaxis.
- Spread of inflammation to upper lip, nasal
sinuses, naso- or oro-pharynx
(pharyngoscleroma), larynx (laryngoscleroma) &
trachea.
- Ulceration and 2ry bacterial infection.
- Squamous cell carcinoma.
 Nasopharynx
A- Inflammation (Nasopharyngitis)

(1) Acute Nasopharyngitis:

- It is the most common cause of sore throat
- Causes: Viral or Bacterial.
- Pathology: Acute catarrhal, mucopurulent, or
purulent inflammation.

(2) Chronic Nasopharyngitis:

- It follows acute Nasopharyngitis.
- Pathology: hypertrophic inflammation which passes to
atrophic one (pharyngitis sicca).
dryness of nasopharynx due to dried up mucous leading to irritation
(3) Adenoids:

Definition: Inflammatory hyperplasia

of lymphoid tissue in the posterior

wall of nasopharynx

usually in children.

Cause: it follows rhinitis,

nasopharyngitis, tonsillitis.
- Adenoid Facies:
* Narrow nasal openings.
* Open mouth.
* Short upper lip.
* Protruding central upper
incisors.
* Absent nasolabial fold.
* Fibrosis and atrophy occurs
after puberty
N/E:
Swelling in the nasopharynx
which reachs maximum size
at 3 years of age producing
obstruction and mouth
breathing.
M/E:
hyperplasia of the lymphoid tissue with
chronic non-specific inflammation.

Complications:
- Nasal obstruction and mouth
breathing.

- 2ry infection with spread to middle

ear (otitis media) or down the
respiratory tract).
Tonsils Common tonsilitis is non specific

I- Inflammation

A- Acute Inflammations:

(1) Diphtheria: Acute Specific

- Acute infectious fever caused by

corynebacterium diphtheriae, in unimmunised
children between 2-5y
- Method of infection: droplet infection.

- Pathology:
via exotoxin:

1- Locally: pseudomembranous inflammation.

2- Reach distant organs via blood →→Acute toxemia

3- The draining cervical L.Ns and spleen show

lymphoid hyperplasia and focal necrosis.

Complications
A- Suffocation Respiratory Failure

B- Acute Toxemia:
I - Respiratory system:
- Asphyxia. Suffocation
- Aspiration bronchopnemonia.
- Otitis media.
2- Degenerations : (cloudy swelling , fatty
change and necrosis of parenchymatous
organs.
In myocardium causing heart failure
3- Zenker's deg. of muscles. And diaphragm and intercostal
muscles causing respiratory failure
4- C. V.S.:
- Acute heart failure (toxic myocarditis).
- Shock.
5- Nervous system:
- Temporary nerve paralysis of extra ocular
muscles, palate, larynx, muscles of
respiration, ..... etc.
- Peripheral neuritis (axonopathy).
Curable
6- Epistaxis. Imp

Most severe complication is heart failure

 (2) Acute tonsillitis
- Common in children
- Streptococcus pyogens.
Pathology: Bilateral affection passing in
stages but may stop at any of them:
1- Acute catarrhal tonsillitis.
2- Acute follicular tonsillitis: acute
suppurative inflammation and the pus
appears in the mouths of crypts.
Severe inflammation
3- Pseudomembranous tonsillitis: the
purulent exudate covers the surface of
tonsils with a yellow membrane.
- Cervical lymphadenitis.
Complications

1- Spread of infection:
a- Direct:

- Acute parenchymatous tonsillitis.

liquifactive degeneration around tonsils due to
- Peritonsillar abscess"Quinsy“ suppurative inflammation

- Ludwig's angina (neck cellulitis).

- Mediastinal or retro-pharyngeal abscess

- Acute pharyngitis, acute inflammation of the respT.and otitis m.

b- Lymphatic: cervical lymph nodes (suppurative
lymphadenitis)

c- Blood: Septicemia and pyemia.

2- Allergic diseases:

- Rheumatic fever. - Post streptococcal G.N.

3- Chronicity: act as septic focus.

 B- Chronic Inflammations:
(1) Non-specific
- Causes: follows acute
- N/E: Both tonsils show multiple abscesses due to fibrous
closure of mouths of crypts. In later stages the tonsils
decrease in size due to fibrosis.
- Complications:
- Act as septic focus. - Lead to septicemia or pyemia.

(2) Specific: T.B., syphilis

 Larynx
I- Inflammation (Laryngitis)
A- Acute laryngitis:
Causes:
- Infective: mostly viral
- Non infective: Excessive or faulty use of vocal cords,
tobacco smoke, and atmospheric pollution
Pathology:
- Acute catarrhal which may pass to muco-purulent, or
purulent inflammation.
B- Chronic Laryngitis:
* Chronic non-specific laryngitis:
Causes:
- Following acute laryngitis.
- Smoking and atmospheric pollution
- Chronic alcoholism.
- Excessive or faulty use of vocal cords.
Pathology: Hypertrophic inflammation with granularity or small
polypoid formation (singer's nodes) on vocal cords it passes to
chronic atrophic inflammation
Complication: Leukoplakia (Precancerous) Viable to turn into squamous cell
carcinoma

* Chronic specific laryngitis:

T. B., Leprosy & Laryngoscleroma.
 Questions
The followings are
complications of diphtheria
except:
A. Asphyxia
B. Peripheral neuritis
C. Systemic pyaemia
D. Toxic myocarditis with acute heart failure
E. Aspiration bronchopneumonia
 Rhinitis means:
A. Inflammation of the larynx.

B. Inflammation of pleura.

C. Inflammation of nasal cavity.

D. Inflammation of lung tissue.

E. Inflammation of nasopharynx.
 An allergic complication of
acute streptococcal tonsillitis
is:
A. Rheumatic fever
B. Peritonsillar abscess
C. Otitis media
D. Acute pharyngitis
E. Suppurative lymphadenitis
 Define

• Coryza. Common cold

• Ozena. Chronic atrophic Rhinitis

One of the followings is not a
complication of chronic
hypertrophic rhinitis :
• Nasal obstruction.

• Dilatation of nasal cavity.

• Malignancy.

• Thickening of nasal mucosa.

 References for further
reading

• Robbin’s pathologic basis of disease

• Harsh Mohan textbook of pathology

• Special pathology book of pathology

department – Mansoura University
THANK YOU