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Larynx
Normal Anatomy
and
Histology
Normal Anatomy
and
Histology
Normal Anatomy
and
Histology
Laryngeal Epithelium
Squamous Epithelium
10
Seromucinous Glands
11
12
Seromucinous Glands
13
Oncocytic Transformation of
Seromucinous Epithelium
14
15
Chondroid Metaplasia
16
Non-neoplastic
Lesions of the
Larynx
17
Tuberculosis
18
Granulomatou
s
Inflammation
19
Fungal Infections
3Histolplasmo
sis
3Coccidiomyc
osis
3Cryptococcos
is
3Blastomycosi
s
20
Other
Granulomatou
s Diseases
3Leprosy
3Tertiary
Syphilis
3Sarcoidosis
3Crohns
disease
3Wegeners
21
granulomatosis
Acute Epiglottitis
3Haemophylus influenzae type B
3Reddened, markedly
edematous supraglottic
structures
3Edema with marked infiltrate of
neutrophyls with or without
microabscess formation
22
Diphtheria
23
Diphtheri
a
24
27
Edematous-Myxoid Type
3 Submucosal
accumulation of
pale blue to pink
material admixed
with sparsely
cellular and
variably
vascularized
stroma
28
Vascular-Hyaline Type
3 Dilated
submucosal
vascular spaces and
deposition of
dense
eosinophilic fibrinlike material
29
Laryngocele
3Abnormal dilatation of the saccule
(appendix of the ventricle) containing
air and maintaining an open
communication with laryngeal lumen
3Men >women
3Bilateral - 25%
3Hoarseness, lateral neck mass,
dyspnea, dysphagia, laryngopyocele
31(pain)
Laryngocele: Types
3Internal:
laryngocele confined to the
intrinsic larynx
3External:
dilated sac projects upward and
laterally
3Combined
32
Laryngocele: Etiology
3Acquired:
increased
intralaryngeal
pressure
(glassblowers,
musicians, weight lifters)
3Congenital
3SCC in 15% of cases
33
Laryngocele
Laryngocele
3Respiratory
epithelial- lined
(ciliated,
columnar) cyst
with a fibrous wall
3Squamous
metaplasia
3Oncocytic
metaplasia
35
Laryngocele:
Differential
Diagnosis
3Branchial cleft
cyst
3Oncocytic
papillary
cystadenoma
3Laryngeal cysts
36
3Ulcerated,
polypoid, nodular,
or fungating mass
with a beefy red to
tan-white
appearance, up to
3 cm in diameter
38
40
41
3Infectious diseases
3SCC
3Spindle cell carcinoma
3Vascular neoplasms: lobular
capillary
hemangioma,
angiosarcoma,
Kaposis
sarcoma
Laryngeal Amyloidosis
3Extracellular accumulation of
fibrillar proteins
3Systemic or localized
3Primary or secondary
3Men > women, in the 5th and 6th
decades
3Polypoid mass (glottis and
supraglottis) or diffuse mucosal
swelling (subglottis)
42
3Hoarseness
Laryngeal Amyloidosis
3 Extracellular,
eosinophilic,
amorphous material
deposited randomly
throughout
submucosa;
depositions around or
within the walls
3 Disappearance of
the seromucous
glands,
3 Mixed chronic
43
inflammatory
Laryngeal Amyloidosis
Subglottic Stenosis
3Congenital or acquired
3Rare; acquired > congenital
3Progressive respiratory difficulty,
stridor, dyspnea, air hunger,
hoarseness, abnormal cry,
aphonia, dysphagia
3Etiology: trauma, neoplasms,
infectious or autoimmune diseases,
45idiopathic
Subglottic Stenosis
3Narrowing of the endolaryngeal
diameter with mucosal or submucosal
mass or bulging
3Histologic picture depends on the cause
3Idiopathic stenosis: submucosal fibrous
proliferation with associated non-specific
chronic inflammation
3Differential diagnosis: infectious
diseases, Wegeners granulomatosis,
46collagen vascular diseases, neoplasms
Idiopathic
Subglottic
Stenosis
47
Terminology of Epithelial
Changes
3Leukoplakia:
white lesion on a mucosal membrane
(clinical)
3Erythroplakia:
red lesion on a mucosal membrane (clinical)
3Hyperplasia:
thickening of epithelial surface as a result
of an absolute increase in the number of
cells.
3Pseudoepitheliomatous hyperplasia:
malignan reactive or reparative overgrowth
48exuberant
Terminology of Epithelial
Changes
3Keratosis:
presence of keratin on an epithelial
surface
3Parakeratosis:
presence of nuclei in the keratin layer
3Dyskeratosis:
abnormal keratinization of epithelial
cells
3Ulceration:
erosion or loss of surface epithelium
anoth
49 3Metaplasia:
er
Terminology of
Epithelial
Changes
3 Koilocytosis:
viral
cytoplasmic vacuolization
(HPV)
suggestive of effect
3 Dysplasia or atypia:
abnormal maturation and cellular aberrations
3 Carcinoma in situ:
full thickness epithelial dysplastic change
with an intact basement membrane.
3 Superficially (microscopically) invasive
SCC: SCC in which there is violation of the
basement membrane with invasion into the
50 underlying stroma.
Hyperplastic
Epithelial
Changes
3Reactive or reparative benign process,
reflecting the epithelial response to a
stimulus or an injury
3Men > women
3Occurs anywhere, but mainly along
the true vocal cords
3Hoarseness
3Etiology: smoking, ETOH, voice abuse,
chronic inflammation
51
Hyperplastic
Epithelial
Changes
3Flat, papillary, or verrucoid lesion with a
white (leukoplakic) or red (erythroplakic)
appearance
3Small or diffuse
3Thickening of epithelial surface as a result
of an absolute increase in the number of
cells
3Presence of superficial keratin layer
(keratosis) or nuclei in the superficial
52
keratin layer (parakeratosis)
Hyperplastic
Epithelial
Changes
3Presence of keratohyaline granules
in the granulosa cell layer
3Presence of koilocytosis
3Presence of cytologic atypia
3Presence of dyskeratosis
3Differential diagnosis:
contact ulcer, verruca vulgaris,
verrucous carcinoma, welldifferentiated
conventional
SCC
53
Keratosis with
Epithelial Hyperplasia
w/o Dysplasia
54
55
56
Dysplastic
Epithelial
Changes
3Men > women
3Occurs anywhere, but mainly
along the anterior portion of the
true vocal cords, 25% bilateral
3Hoarsen
ess
3Etiology:
smoking,
ETOH,
chronic
57
Dysplastic
Epithelial
Changes
58
Dysplastic Epithelial
Changes:
Grading
3Mild:
lower 1/3 of the thickness of
epithelium
3Moderate:
lower 2/3 of the thickness of
epithelium
3Severe:
from 2/3 to almost complete thickness
59
Dysplastic
Epithelial
Changes
61
Keratosis with
Moderate
Dysplasia
62
63
Benign Neoplasms of
the Larynx
64
Laryngeal Papilloma
3Benign, exophytic neoplastic growth
composed of branching fronds of
squamous epithelium with
fibrovascular cores
3The most common benign
laryngeal neoplasm
3No sex predilection
3Changes in phonation, dyspnea,
cough, dysphagia, stridor
653HPV types 6 and 11
Laryngeal Papilloma
3Juvenile type:
multiple lesions with extensive
growth and rapid recurrence, may
remit spontaneously or persist into
old age
3Adult type:
more often single, recurs less
often, less likely to spread
66
67
68
Laryngeal Papilloma
3Absence of
stromal
invasion
3Certain
degree of
cellular atypia
3Koilocytic
changes
69
Laryngeal Granular
Cell Tumor
3Men > women
3Hoarseness
3Along the posterior aspect of
true vocal cord ( but also in
supraglotic and infraglotic
areas)
79
Granular
3Solitary,
polypoid,
sessile,
papillary, or
cystic lesion,
measuring up
to
3.0
71 cm in
Cell Tumor
Granular
3 Poorly
circumscribed
subepithelial lesion
with syncytial,
trabecular, or
nested growth
pattern
3 Round to polygonal
cells with round to
vesicular nuclei and
coarsely granular
cytoplasm. Poorly
defined cell borders.
3 Variable degree of
72 cellular pleomorphism
Cell Tumor
S-100 Protein
Immunostain
73
Pseudoepitheliomatous
hyperplasia
74
Granular
Cell Tumor
3 Cytoplasmic granules:
PAS/d +, Alcian blue pH 2.5 +, trichrome +
(red)
3 Angulate bodies:
needle shaped, PAS + bodies in the
interstitial cells
3 Tumor cells:
S-100+, NSE +
3 Interstitial cells with angulate bodies:
S-100 - and myelin protein +
3 EM:
membrane bound autophagic vacuoles
75
containing mitochondria, RER, myelin,
Malignant Granular
Cell Tumor
3Rare ( 1% of all GCT)
3Do not occur in
newborns 3Size > 4
cm
3Increased
cellularity,
pleomorphism,
necrosis,
prominent nucleoli, spindle
shaped
cells
and
>
2
mitoses/10
vessel
76
HPF
s
Chordoma
3Uncommon
3Males >
females
3Dyspnea,
strydor, and
hoarseness
3May originates from epiglottis,
cricoid, arytenoid, or thyroid
cartilages
77
Chordoma
3Lobulated,
normally
looking
chondrocytes
3Absence of
pleomorphism
, binucleated
chondrocytes,
or mitotic
activity
78
Rhabdomyoma
3Benign tumor of striated muscle
3Adult type:
3less common
3Males > females; > 40 y/o
3Hoarseness, dyspnea
3Well-defined, lobulated, red-brown
mass, up to 5 cm in diameter
79
Rhabdomyoma: Adult
Type
3 Large polygonal to
round cells with
abundant deeply
eosinophylic cyroplasm
and one or two
periphery placed
vesicular nuclei
3 Nucleoli,
cytoplasmic
vacuolization
3 Cross-striation
3 Absent mitoses
3 Abundant
80cytoplasmic
glycogen (diastase
Rhabdomyoma: Fetal
Type
3Very rare
3Male children < 3 y/o
3Posterior auricular subcutaneous
tissue > nasopharynx, parotis, neck
3Solitary, well to moderately
circumscribed nodule, 1-8 cm in
size, gray to pink mucoid
appearance
81
Rhabdomyoma: Fetal
Type
3 Spindle cells and
immature muscle
fibers with in a
myxoid stroma
3 Cross-striation
rarely discernible.
Mature muscle
fibers can be
seen in the
periphery
3 Absence of mitoses,
82 necrosis, and
significant
Malignant
Laryngeal
Neoplasms
83
In Situ Squamous
Cell
Carcinoma
84
In Situ Squamous
Cell
Carcinoma
3 Dysplastic process
involves the entire
thickness of the
epithelium
3 Loss of cellular
maturation and
polarity
3 Increase of
nuclear/cytoplaslic
ratio
3 Normal and
85abnormal mitoses
Microinvasive or Superficially
Invasive Squamous Cell
Carcinoma
3 Nests of malignant
cells that have
penetrated the
basement membrane
and invaded
superficially into the
submucosa
3 Capable of
metastasizing
3 Development from
carcinoma in situ or
from epithelium with
86no evidence of CIS
Invasive Squamous
Cell Carcinoma
88
Supraglottic
Squamous Cell
Carcinoma
32540% of laryngeal SCC
3Epiglottis (base), false vocal cords
3Changes in the quality of voice,
dysphagia, odonophagia, hoarseness,
hemoptisis, dyspnea
3Marginal carcinomas (suprahyoid
epiglottis, aryepiglottic folds); remain
quiescent for longer period and present at
more advanced stage
89
Supraglottic
Squamous Cell
Carcinoma
3Ulcerated, flat,
exophytic, or papillary
3Tend to be
nonkeratinizing 3In situ
component 3Mitoses
and necrosis
90
Supraglottic
Squamous Cell
Carcinoma
3Large, tanwhite
neoplasm in
the right
supraglottis,
extending
upward toward
epiglottis
91
Supraglottic
Squamous Cell
Carcinoma
92
Glottic SCC
3Early: irregular area of mucosal
thickening
3Advanced: exophytic,
fungatic, endophytic,
ulcerated mass
3More commonly keratinizing,
well to moderately
differentiated
3In
situ component
93
Glottic SCC
94
Glottic SCC
95
Glottic SCC
96
Subglottic SCC
98
Transglottic SCC
3Involves both glottic and
supraglottic structures
3Represents advanced tumor
3Nodal metastases and extranodal
spread
3Overall 5-year survival rate <
40%
100
Transglottic SCC
101
103
105
Heterologous Elements
106
Verrucous Carcinoma
3Highly differentiated variant of SCC with
focally destructive, but not metastatic
capabilities
decad
3Men >ofwomen,
6th carcinomas
31-3%
all laryngeal
th
es > sinonasal
7
3Oral
cavity > nasal fossa
tract, nasopharynx
3Larynx: hoarseness
3In the larynx most common in the
glottic area
3Potential
etiologic factors: tobacco,
109
viruses
Verrucous Carcinoma
3 Tan or white, warty, fungating, or exophytic,
firm to hard mass, attached by a broad base
3 Squamous cell proliferation:
./ uniform cells without dysplastic features and
mitoses
./ marked surface keratinization
./ broad or bulbous rete pegs with pushing,
NOT infiltrative margin
./ Dysplastic features limited and confined to
basal sone
3 Mixed chronic immflammarory cell
110
infiltrate
Verrucous Carcinoma
3 Tan or white,
warty,
fungating, or
exophytic, firm
to hard mass,
attached by a
broad base
111
Verrucous Carcinoma
112
Verrucous Carcinoma
3 Squamous cell
proliferation:
./ uniform cells without
dysplastic features and
mitoses
./ marked surface
keratinization
./ broad or bulbous rete pegs
with pushing, NOT
infiltrative margin
./ Dysplastic features limited
and confined to basal
zone
113
3 Mixed chronic
Verrucous Carcinoma
3Differential diagnosis:
./ Keratotic squamous papilloma
./ Reactive keratosis and epithelial
hyperplasia
./ Pseudoepitheliomatous hyperplasia
./ Verruca vulgaris
./ Keratoacantoma
./ Conventional SCC
114
Verrucous Carcinoma
3Metastasis in regional lymph nodes
are rare, and distant metastases do
not occur
3Excellent prognosis after complete
surgical removal
3Anaplastic transformation may result in
distant metastases
3Adequate biopsy material with a good
epithelial- stromal interface is critical for
115the interpretation
129
Basaloid SCC:
Differential
Diagnosis
3Adenoid cystic carcinoma
3Neuroendocrine carcinoma
3Adenosquamous carcinoma
3Spindle cell carcinoma
122
Adenosquamou
s
Carcinoma
Adenosquamou
s
Carcinoma
Adenosquamou
s
Carcinoma
126
Adenosquamou
s
Carcinoma
Neuroendocrine
Carcinoma:
Classification
3Carcinoid
(well differentiated)
3Atypical carcinoid
(moderately differentiated)
3Small (oat) cell
carcinoma
(poorly differentiated)
128
Neuroendocrine Carcinoma
3Submucosal
nodular
or
polypoid
mass with tanwhite appearance and up
to 4 cm in diameter
3Surface ulceration may
present in moderately or
well-differentiated
neuroendocrine
carcinoma
129
Carcinoid
3 Organoid or
trabecular growth
pattern with
fibtovascular
stroma
3 Glands or
squamous
differentiation can
be seen
3 Absence of
130
surface
Carcinoid
3 Uniform cells with
centrally located
round nuclei,
vesicular
chromatin, and
eosinophilic
cytoplasm
3 Absence of
pleomorphism,
mitoses,
necroses
131
3 Low
Carcinoid
3
Histochemistr
y: PAS/d +
mucin,
argyrophilia
3 IHC:
Cytokeratin +,
Chromogranin +, NSE
+, synaptophysin +
3 EM:
neurosecretory
132
granules, cellular
Atypical Carcinoid
3 Organoid, trabecular,
cribriform, or solid
gowth pattern
3 Mild to marked
cellular
pleomorphism
3 Nucleoli may be
prominent 3 Mitoses and
focal necrosis 3 Variable
nuclear:cytoplasmic
ratio
3 Surface ulceration
133
and
lymphovascular
Chondrosarcoma
3Rare
3Males >Females, 4th - 7th
decades
3Cricoid > thyroid cartilage
> arytenoid
3Smooth, lobulated, hard
submucosal mass larger than 2
cm
136
Chondrosarcom
a (high
grade)
3 Lobulated
hypercellular tumor
with
hyperchromatic,
pleomorphic nuclei
and prominent
nucleoli
3 Binucleate or
multinucleated
cells
3 Mitoses: usually
uncommon
137
Synovial Sarcoma
138
Synovial Sarcoma
139
Synovial Sarcoma
140