Nasalpolyp pathology


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Nasalpolyp pathology

  1. 1. Pathology of nasal polyp Dr T Balasubramanian
  2. 2. Introduction <ul><li>Macroscopically polyp appears to arise like a pedicled tissue from the nasal mucosa
  3. 3. Histopathologically these polyp can be very diverse ranging from simple inflammatory to bening / malignant neoplasm
  4. 4. Polyp due to chronic rhinosinusitis can be described as non granulomatous inflammatory tissue projecting from the nasal mucosa </li></ul>
  5. 5. Histology of normal sinonasal mucosa 1 <ul><li>Components of normal sinonasal mucosa can be categorized under two heads (Structural / Non structural) components
  6. 6. Structural components – Surface epithelium, basement membrane and submucosal tissue
  7. 7. Non structural components – Resident / Non resident cells of lymphoid / Myeloid origin </li></ul>
  8. 8. Histology of normal sinonasal mucosa Epithelium <ul><li>Anterior 2 cm of nasal cavity is lined by skin i.e. Keratinized stratified squamous epithelium with fibrocollagenous dermis and adnexal glands
  9. 9. The rest of the nasal cavity is lined by respiratory type of epithelium (Schneiderian membrane)
  10. 10. The lining mucosa of paranasal sinuses is rather thinn when compared to that of nasal cavity </li></ul>
  11. 11. Schnederian membrane <ul><li>Sinonasal mucosa is also known as Schnederian membrane
  12. 12. It is composed of 4 cell types – ciliated columnar / cuboidal cells, interspaced goblet cells, nonciliated columnar cells with microvilli and basal cells
  13. 13. The ratio of columnar : goblet cells is 5:1
  14. 14. Columnar epithelium contains tight junctions and rest on the basement membrane
  15. 15. Squamous metaplasia is common due to exposure </li></ul>
  16. 16. Point to remember Whitish fleshy nasal polyp indicates Squamous Metaplasia due to drying effects caused by Exposure to atmosphere
  17. 17. Basement membrane <ul><li>The basement membrane contains following collagen types (I, III, IV, V, VI, & VII)
  18. 18. Other constituents include: Heparan sulfate proteoglycan, laminin and Nidogen
  19. 19. The basement membrane is thin and delicate in the whole of nasal cavity except for inferior turbinate area. </li></ul>
  20. 20. Olfactory epithelium <ul><li>Responsible for the sense of smell
  21. 21. Lines superior turbinate, superior portion of nasal septum, roof of nasal cavity and medial portions of middle turbinate
  22. 22. This epithelium is also pseudostratified ciliated columnar containing bipolar olfactory cells, microvillar cells and supporting sustentacular cells </li></ul>
  23. 23. ! Note Due to aging / infections olfactory Epithelium could be replaced by Normal nasal mucosa
  24. 24. Submucosa <ul><li>Lies under the basement membrane
  25. 25. Overlies the cartilagenous / bony framework of nasal cavity
  26. 26. Contains loose fibrovascular connective tissue, seromucinous / minor salivary glands, blood vessels, nerves, myeloid and lymphoid cells
  27. 27. Blood vessels contains many av anastomosis
  28. 28. Blood vessels communicate with venous erectile tissue which are prominent over inferior turbinates </li></ul>
  29. 29. Non structural components <ul><li>Lymphoid tissue is the most important of these components
  30. 30. Components of lymphoid tissue include single lymphocytes scattered among the epithelial cells and lamina propria and NALT </li></ul>
  31. 31. NALT <ul><li>Acronym for Nasal associated lymphoid follicles
  32. 32. Similar to Payer's patch of intesting
  33. 33. Unencapsulated
  34. 34. Becomes enlarged during nasal infections </li></ul>
  35. 35. Lymphoid cells of nasal cavity <ul><li>T cells
  36. 36. B cells
  37. 37. Plasma cells
  38. 38. Natural Killer cells </li></ul>
  39. 39. Causes of nasal polyp <ul><li>Chronic rhinosinusitis (still not proved)
  40. 40. Samter's triad (Bronchial asthma, aspirin hypersensitivity and nasal polyposis)
  41. 41. Eosinophilic chronic rhinosinusitis including AFRS
  42. 42. Cystic fibrosis
  43. 43. Young's syndrome
  44. 44. Churg – Strauss disease </li></ul>
  45. 45. Macroscopic features <ul><li>Pale smooth shining and oedematous mass
  46. 46. Soft in consistency when compared to surrounding nasal mucosa
  47. 47. Long standing nasal polypi could be firm and whitish due to squamous metaplasia
  48. 48. Firmness of long standing nasal polypi could also be caused by fibrosis
  49. 49. Presence of surface ulceration on the polyp should arouse suspicion of other pathologies </li></ul>
  50. 50. TIP Presence of thick tenaceous secretions along with Nasal polypi is caused by eosinophilic mucous chronic rhinosinusitis
  51. 51. Microscopic feature of nasal polypi <ul><li>Structural changes involve lining epithelium, submucosa and rarely underlying bone / cartilage
  52. 52. Presence of inflammatory exudate
  53. 53. Lining mucosa is ciliated columnar epithelium. Basement membrane is thickened. The stroma contains lymphocytes </li></ul>
  54. 54. Histological classification <ul><li>Oedematous allergic nasal polypi
  55. 55. Chronic inflammatory nasal polypi
  56. 56. Seromucinous / glandular polypi </li></ul>
  57. 57. Oedematous allergic nasal polypi <ul><li>Commonest variety
  58. 58. Seen in pts with allergy
  59. 59. Lined by ciliated columnar epithelium
  60. 60. Ulceration of mucosa, mucositis, epithelial hyperplasia and squamous metaplasia may be seen
  61. 61. Basement membrane is thickened, submucosa is oedematous. Mucous retention cyst+
  62. 62. Eosinophils / plasmacells/ lymphocytes infiltrate+ </li></ul>
  63. 63. Allergic nasal polyp vs cystic fibrosis nasal polyp Allergic nasal polyp Nasal polyp due to cystic fibrosis Thick basement membrane Thin basement membrane Stroma contains predominat eosinophils Stroma contains predominantly neutrophils Mucous secretions thin Mucous secretion thick
  64. 64. Chronic inflammatory polyp <ul><li>Also known as fibroinflammatory polyp
  65. 65. This type is less common
  66. 66. May be caused when oedematous polypi are traumatized
  67. 67. Stroma may show secondary inflammatory change
  68. 68. Stroma may show myofibroblastic proliferation
  69. 69. Submucosal fibrosis +
  70. 70. Squamous metaplasia + </li></ul>
  71. 71. Seromucinous polypi <ul><li>Caused by hyperplasia of seromucinous glands
  72. 72. This type of nasal polyp is rare
  73. 73. This is a true neoplasm
  74. 74. Underlying bone remodelling can also be seen </li></ul>
  75. 75. Histology of A/C polyp <ul><li>Antral component is soft and cystic
  76. 76. Nasal and choanal components are solid
  77. 77. Lined by pseudostratified columnar epithelium
  78. 78. Basement membrane appears thinned out
  79. 79. Stroma shows evidence of myxoid degeneration
  80. 80. Inflammatory cells are few in number
  81. 81. Degenerative changes are common </li></ul>
  82. 82. Thank you