Pathology of the Head and Neck

202 N. Gale · A. Cardesa · N. Zidar77.2.8 TracheopathiaOsteochondroplasticaTracheopathia osteochondroplastica (TO) is a rare,slowly progressing lesion, characterised by the presenceof cartilaginous and bony submucosal nodules projectinginto the lumen of the trachea, larynx and majorbronchi [148, 279, 295, 355]. Most cases are recognisedat autopsy, but may be also suspected due to problems ofendotracheal intubation [186].The aetiology and pathogenesis remain uncertain.Chronic infections, chemical and mechanical irritations,metabolic disorders, ecchondrosis, exostosis andmetaplasia of the elastic tissue are thought to be causalfactors [279, 295, 355, 356]. TO appears predominantlyin late adult life, but may be seen in childhood and earlyadult life [148, 295]. TO with minimal expressions mayoften be overlooked. Typical florid cases narrow the airwaysand cause a dry cough, dyspnoea, hoarseness andrecurrent infections [356]. Laryngobronchoscopic examinationis decisive for the diagnosis. Elevated, hard,whitish nodules bulge into the lumen with the appearanceof a stalactite cave. The posterior wall of the tracheais usually spared [186, 279]. An intralaryngeal locationof TO is very rare; as a rule it appears in the subglotticregion [355], exceptionally around the arytenoids [279].Histologically, submucosal nodules of cartilage andlamellar bone with marrow spaces are characteristicfindings, usually in relation to the underlying cartilage.Calcifications, ossifications and fatty marrow formationsmay be seen within the nodules [295]. Bone morphogeneticprotein-2 and transforming growth factorbeta, the potent inducers of new bone formation, havebeen recently detected in TO immunohistochemicallyand may have some decisive roles in the pathogenesis[356]. Surgical treatment has been recommended onlyin symptomatic patients [35, 186, 250].7.3 Inflammatory Lesions7.3.1 Acute Infections7.3.1.1 EpiglottitisAcute epiglottitis (AE), or more precisely termed supraglottitis[121, 331], is a potential risk of fatal airway obstructionin previously healthy persons. In the past, AEwas mainly a childhood disease caused by Haemophilusinfluenzae type B. Due to the introduction of an immunisationprogramme in the late 1980s, the diseasehas been steadily decreasing in children, but still has ahigh incidence in the adult population, more frequentlyin a form related to infections with pyogenic cocci [75,87, 231]. The most consistently found presenting symptomis severe pain on swallowing. In children, breathingdifficulties are often the predominant symptom.Other symptoms and signs are hoarseness, drooling, fever,tachycardia and toxic appearance [75, 87]. Reddishand evidently oedematous supraglottic area, includingtongue and pharyngeal structures, is observed. Oedematousswelling rarely spreads to the glottic region.Microscopic examination shows diffuse exudative inflammationwith fibrin, neutrophils and erythrocytesinvolving supraglottic structures. An early complaint ofdyspnoea may safely discriminate between patients requiringinvasive airway management with intubation andconservative treatment with close observation [150].7.3.1.2 LaryngotracheobronchitisLaryngotracheobronchitis (LTB), also known as subglotticlaryngitis, non-diphtheric croup, virus croup,spasmodic croup and fibrinous LTB, often occurs inchildren aged 1–3 years. Generally, LTB is of limitedduration, caused by influenza, parainfluenza or otherviruses. Prolonged infection by other pathogens maybe also involved [170]. The onset of the disease is moregradual compared with acute epiglottitis. When fullydeveloped, a croupy cough with inspiratory and expiratorystridor is present. Histologically, characteristicfibrinous laryngitis is observed with destruction of therespiratory epithelium. The mortality rate of the diseasehas remained low for many years [238, 353].7.3.1.3 DiphtheriaFortunately, laryngeal diphtheria is a matter of historynow in the developed world. Very exceptionally, an individualcase has been reported [137]. Histologically,dirty white, fibrinosuppurative membranes coveringthe laryngeal mucosa, accompanied by a foul smell, arecharacteristic of the disease [203].7.3.2 Chronic Infections7.3.2.1 TuberculosisLaryngeal tuberculosis (LT) was considered one of themost common diseases in the pre-antibiotic period, affectingthe larynx in 35 to 83% of patients with pulmonarytuberculosis [268, 390]. By the 1980s, the diseasehad become very rare in the developed world, owing tothe advent of antibiotic therapy, immunisation and improvedsocial and economic conditions. However, since1980, tuberculosis has again been showing a rising in-