Pathology of Upper & Lower

Respiratory Tract
Dr. Ni Wayan Winarti, Sp.PA
Anatomical Pathology Department
Faculty of Medicine, Udayana University
2014
 Subtopics
Upper Respiratory Tract
– Inflammatory ds
– Tumors

Lower Respiratory Tract

– Obstructive vs restrictive
pulmonary ds
– Pneumonia
– Tumors
– Diseases of pleura
 Pathology of
Upper Respiratory Tract

• Inflammation • Tumors
– Nose and paranasal sinuses
• Infectious rhinitis
• Allergic rhinitis
• Nasal polyps
• Chronic rhinitis
• Sinusitis
– Pharynx and related part
• Pharyngitis
• Tonsilitis
– Larynx
• Laryngitis
• Reactive nodules
– Nose, sinuses and
nasopharynx
• Nasopharyngeal
Angiofibroma
• Sinonasal (Schneiderian)
Papilloma
• Nasopharyngeal
Carcinoma
– Larynx
• Squamous papilloma
and papillomatosis
• Carcinoma of the larynx
 Infectious Rhinitis
• Synonym: “common cold,”
• Caused by one or more viruses adenoviruses, echoviruses,
and rhinoviruses.
• Clinically characterized by profuse catarrhal discharge
• Gross morphology:
– the nasal mucosa is thickened, edematous, and red
– the nasal cavities are narrowed
– the turbinates are enlarged
• Self limiting
• Secondary bacterial infection  mucopurulent or suppurative
exudate
 Allergic Rhinitis
• Synonym: hay fever
• Initiated by hypersensitivity reactions (type I)
to allergens (plant pollens, fungi, animal
allergens, and dust mites)
• Morphology:
– marked mucosal edema, redness, and mucus
secretion
– Microscopy: leukocytic infiltration (>>eosinophils)
 Nasal Polyp
• Is protrusions of
nasal mucosa due
to recurrent attacks
of rhinitis
 Nasal Polyp
• Microscopy:
– edematous mucosa,
infiltrated with a variety
of inflammatory cells
(neutrophils,
eosinophils, plasma
cells, lymphocytes)
– harboring hyperplastic
or cystic mucous glands
– Mucosal epithelium
intact or ulcerated
 Sinusitis
• Is a sequel to repeated attacks of acute rhinitis, either
microbial or allergic in origin, with the eventual
development of superimposed bacterial infection.
• Predisposition: deviated nasal septum or nasal polyps
• Microscopy:
– superficial desquamation or ulceration of the mucosal
epithelium
– Infiltration of neutrophils, lymphocytes, and plasma cells
subjacent to the epithelium.
 Pharyngitis and tonsilitis
• Are frequent in the usual viral upper respiratory infections
(rhinoviruses, echoviruses, adenoviruses, respiratory syncytial
viruses and influenza virus).
• Bacterial infections may be superimposed (β-hemolytic
streptococci, Staphylococcus aureus or other pathogens)
• Morphology:
– reddening and slight edema of the mucosa
– mucosa may be covered by an exudative membrane (pseudo-
membrane)
– nasopalatine and palatine tonsils may be enlarged and covered by
exudate.
• A typical form: follicular tonsillitis
 Laryngitis
• May cause by allergic, viral, bacterial, or chemical insult
• Associated with:
– generalized upper respiratory tract infection
– heavy exposure to environmental toxins such as tobacco smoke
– gastroesophageal reflux due to the irritating effect of gastric
contents.
– systemic infections, such as tuberculosis and diphtheria
• Most are self-limited, but may be serious, especially in
infancy or childhood  laryngeal obstruction
• In heavy smokers, predisposes to squamous epithelial
metaplasia  carcinoma
• Laryngoepiglottitis
– caused by respiratory syncitial virus, Haemophilus
influenzae, or β-hemolytic streptococci
– in infants and young children may induce sudden
swelling of the epiglottis and vocal cords  lethal
• Croup (laryngotracheobronchitis in children)
– the inflammatory narrowing of the airway
produces the inspiratory stridor
 Reactive Nodules
(Vocal Cord Nodules and Polyps)
• Sometimes develop in heavy smokers or in individuals who
impose great strain on their vocal cords (singers' nodules)
• These nodules are smooth, rounded, sessile or pedunculated
excrescences, generally only a few millimeters in the greatest
dimension, located usually on the true vocal cords
• Microscopy:
– Covered by squamous epithelium that may become keratotic,
hyperplastic, or even slightly dysplastic
– The core is a loose myxoid connective tissue that may be variably
fibrotic or punctuated by numerous vascular channels
– The mucosa may undergo ulceration
 Nasopharyngeal angiofibroma
• A highly vascular tumor  may bleed
profusely
• Benign
• Occurs almost exclusively in adolescent males
Sinonasal (Schneiderian) Papilloma
• Benign neoplasms
• Composed of squamous or columnar epithelium
• Associated with HPV types 6 and 11
• Occur in three forms:
– exophytic (most common),
– inverted (most important biologically)
• locally aggressive
• high rate of recurrence  invasion of the orbit or cranial vault;
carcinoma may also develop
– Cylindrical
 Nasopharyngeal carcinoma
• Associated with EBV infection
• Three morphologic types
– keratinizing squamous cell carcinomas
– nonkeratinizing squamous cell carcinomas
– undifferentiated carcinomas (lymphoepithelioma)
 Squamous Papilloma and Papillomatosis
• Benign neoplasms
• Usually located on the true vocal cords
• Soft, raspberry-like excrescences (rarely >1 cm)
• Microscopy:
– multiple slender, finger-like projections supported by central fibrovascular cores
– covered by an orderly stratified squamous epithelium.
– trauma may lead to ulceration
• It usually single in adults, often multiple in children (juvenile laryngeal
papillomatosis)
• The lesions are caused by HPV types 6 and 11
• Frequently recur
• Cancerous transformation is rare
 Carcinoma of the Larynx
• Sequence in carcinogenesis: hyperplasia  atypical
hyperplasia  dysplasia  carcinoma in situ  to
invasive carcinoma
• Macroscopically,
– smooth, white or reddened focal thickenings, sometimes
roughened by keratosis
– irregular verrucous or ulcerated white-pink lesions
• Related to tobacco smoke, alcohol, nutritional
factors, exposure to asbestos, irradiation, and
infection with HPV
 Pathology of
Lower Respiratory Tract

• Obstructive vs restrictive pulmonary diseases

• Pulmonary infections
• Tumors
• Pleura
 Obstructive pulmonary diseases
• characterized by an increase in resistance to
airflow due to partial or complete obstruction
at any level, from the trachea and larger bronchi
to the terminal and respiratory bronchioles
• 4 major forms
– Asthma
– Chronic bronchitis
– Emphysema
– Bronchiectasis
 Asthma
• Chronic inflammatory disorder of the airways
– causes recurrent episodes of wheezing, breathlessness,
chest tightness, and cough
– particularly at night and/or in the early morning
– usually associated with widespread but variable
bronchoconstriction and airflow limitation
– at least partly reversible, either spontaneously or with
treatment.
• Asthma may be categorized into
– atopic  type I IgE-mediated hypersensitivity reaction
• usually begins in childhood
• triggered by environmental allergens, such as dusts, pollens, roach or animal
dander, and foods
• a positive family history is common
• a skin test results in an immediate wheal-and-flare reaction
• evidence of allergen sensitization by serum radioallergosorbent tests (called
RAST)  identify IgE specific

– non-atopic
• Usually trigered by respiratory infections due to viruses (e.g., rhinovirus,
parainfluenza virus), environmental exposure to irritants (e.g., smoke,
fumes), cold air, stress, and exercise
• Underlying condition: hyperirritability due to chronic inflammation
 COPD
• Emphysema
– a condition of the lung characterized by
irreversible enlargement of the airspaces distal to
the terminal bronchiole, accompanied by
destruction of their walls without obvious fibrosis
• Chronic bronchitis
– persistent cough with sputum production for at
least 3 months in at least 2 consecutive years, in
the absence of any other identifiable cause
 Emphysema
• Tobacco smoking and other pollutant lead to imbalance between
proteases and antiproteases enzyme
Chronic bronchitis
Emphysema and Chronic Bronchitis
 Bronchiectasis
• Bronchiectasis is a disease characterized by permanent
dilation of bronchi and bronchioles caused by destruction of
the muscle and elastic tissue, resulting from or associated
with chronic necrotizing infections.
• Some predisposing factors:
– Congenital or hereditary conditions
– Postinfectious conditions
– Bronchial obstruction
– Other: rheumatoid arthritis, SLE, IBD and post-transplantation
Disorders Associated with Airflow Obstruction: The Spectrum
of Chronic Obstructive Pulmonary Disease
 Restrictive diseases
• Characterized by reduced expansion of lung
parenchyma and decreased total lung capacity
• Restrictive defects occur in two general
conditions:
– chest wall disorders (e.g., neuromuscular diseases such
as poliomyelitis, severe obesity, pleural diseases, and
kyphoscoliosis)
– chronic interstitial and infiltrative diseases, such as
pneumoconioses and interstitial fibrosis of unknown
etiology
 Atelectasis
• Atelectasis refers either to incomplete expansion of
the lungs (neonatal atelectasis) or to the collapse of
previously inflated lung, producing areas of relatively
airless pulmonary parenchyma
• Acquired atelectasis (in adults):
– resorption (or obstruction)
– Compression
– contraction atelectasis
 Pulmonary Infections
• Respiratory tract infections are more frequent
than infections of any other organ and account
for the largest number of workdays lost in the
general population.
• Causes:
– Bacterial
– Viral
– Mycoplasmal
– Fungal
 Pneumonia syndromes
• Community-acquired acute pneumonia
• Community-acquired atypical pneumonia
• Hospital-acquired pneumonia
• Aspiration pneumonia
• Chronic pneumonia
• Necrotizing pneumonia and lung abscess
• Pneumonia in the immunocompromised host
Community-acquired acute pneumonia
Community-acquired atypical pneumonia

• The term atypical denotes:

– the moderate amount of sputum
– no physical findings of consolidation
– only moderate elevation of white cell count
– lack of alveolar exudate
 Hospital-acquired pneumonia
• Is pulmonary infections acquired in the course of a
hospital stay
• Common in patients with severe underlying disease,
immunosuppression, prolonged antibiotic therapy, or
invasive access devices such as intravascular
catheters
• Often lifethreatening
• Gram-negative rods (Enterobacteriaceae and
Pseudomonas species) and S. aureus are the most
common isolates
 Aspiration pneumonia
• Occurs in markedly debilitated patients or those who
aspirate gastric contents either while unconscious or
during repeated vomiting
• Partly chemical (irritating effects of the gastric acid),
partly bacterial (from the oral flora)
• Often necrotizing  fulminant  death
 Chronic pneumonia
• Is most often a localized lesion in the
immunocompetent patient, with or without
regional lymph node involvement
• Typically, the inflammatory reaction is
granulomatous, and is caused by bacteria
(e.g., M. tuberculosis) or fungi (e.g.,
Histoplasma capsulatum)
 Lung abscess
• A local suppurative process within the lung,
characterized by necrosis of lung tissue
• Important factors involved:
– Oropharyngeal surgical procedures
– sinobronchial infections
– dental sepsis
– bronchiectasis
 Pneumonia in the Immunocompromised
Host
• The appearance of a pulmonary infiltrate, with or without
signs of infection in patients whose immunocompromised
patient
– Disease
– immunosuppressive therapy for organ transplants
– chemotherapy for tumors
– Irradiation
• Can be cause by a wide variety of opportunistic infectious
agents, many of which rarely cause infection in normal
hosts
• Mortality from these opportunistic infections is high
Causes of Pulmonary Infiltrates in
Immunocompromised Hosts
 Tumors
• A variety of benign and malignant tumors may
arise in the lung
– 90% to 95% are carcinomas
– about 5% are bronchial carcinoids
– 2% to 5% are mesenchymal and other
miscellaneous neoplasms
• Lung Carcinoma
– arise by a stepwise accumulation of genetic
abnormalities that transform benign bronchial
epithelium to neoplastic tissue
– well-known lung carcinogen:
• Tobacco Smoking
• Industrial hazards
• Air pollutant
• Classification
– Adenocarcinoma (males 37%, females 47%)
– Squamous cell carcinoma (males 32%, females
25%)
– Small cell carcinoma (males 14%, females 18%)
– Large cell carcinoma (males 18%, females 10%)
 Pathology of Pleura
• Pleural effusion
– Inflammatory
– Non inflammatory
• Pneumothorax
• Pleural tumors
– Solitary fibrous tumor
– Malignant mesothelioma
Thank You