Head and Neck Pathology THIRD EDITION A Volume in the Series Foundations in Diagnostic Pathology Lester D.R. Thompson, MD Consultant Pathologist Department of Pathology Southern California Permanente Medical Group Woodland Hills, California Justin A. Bishop, MD Associate Professor and Director of Head and Neck Pathology Department of Pathology UT Southwestern Medical Center Dallas, Texas Series Editor John R. Goldblum, MD, FCAP, FASCP, FACG Chair, Department of Anatomic Pathology Professor of Pathology Cleveland Clinic Lerner College of Medicine Cleveland, Ohio Other books in this series Busam: Dermatopathology, 2e 9780323261913 Folpe and Inwards: Bone and Soft Tissue Pathology 9780443066887 Hsi: Hematopathology, 3e 9780323479134 Iacobuzio-Donahue and Montgomery: Gastrointestinal and Liver Pathology, 2e 9781437709254 Marchevsky, Abdul-Karim, and Balzer: Intraoperative Consultation 9781455748235 Nucci and Oliva: Gynecologic Pathology 9780443069208 O’Malley, Pinder, and Mulligan: Breast Pathology, 2e 9781437717570 Prayson: Neuropathology, 2e 9781437709490 Procop and Pritt: Pathology of Infectious Diseases 9781437707625 Zhou and Magi-Galluzzi: Genitourinary Pathology, 2e 9780323188272 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 HEAD AND NECK PATHOLOGY, THIRD EDITION ISBN: 978-0-323-47916-5 Copyright © 2019 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted in 2013, 2006. Library of Congress Cataloging-in-Publication Data Names: Thompson, Lester D. R., editor. | Bishop, Justin A., editor. Title: Head and neck pathology / [edited by] Lester D.R. Thompson, Justin A. Bishop. Other titles: Head and neck pathology (Thompson) | Foundations in diagnostic pathology. Description: Third edition. | Philadelphia, PA : Elsevier, [2019] | Series: Foundations of diagnostic pathology | Includes bibliographical references and index. Identifiers: LCCN 2017051700 | ISBN 9780323479165 (hardcover : alk. paper) Subjects: | MESH: Head and Neck Neoplasms | Head–pathology | Neck–pathology Classification: LCC RC936 | NLM WE 707 | DDC 616.99/491–dc23 LC record available at https://lccn.loc.gov/2017051700 Executive Content Strategist: Michael Houston Senior Content Development Manager: Kathryn DeFrancesco Publishing Services Manager: Patricia Tannian Senior Project Manager: Sharon Corell Book Designer: Patrick Ferguson Printed in China. Last digit is the print number: 9 8 7 6 5 4 3 2 1 CONTENTS ■ CONTRIBUTORSvii Justin A. Bishop, MD Lester D.R. Thompson, MD Associate Professor and Director of Head and Neck Consultant Pathologist Pathology Department of Pathology Department of Pathology Southern California Permanente UT Southwestern Medical Center Medical Group Dallas, Texas, USA Woodland Hills, California, USA Diana Bell, MD James S. Lewis, Jr., MD Associate Professor Professor Head and Neck Section Department of Pathology, Microbiology, and Immunology University of Texas Vanderbilt University Medical Center Departments of Pathology and Head and Neck Surgery Nashville, Tennessee, USA MD Anderson Cancer Center Houston, Texas, USA Austin McCuiston, MD Resident Physician Rebecca D. Chernock, MD Department of Pathology Associate Professor The Johns Hopkins Hospital Department of Pathology and Immunology Baltimore, Maryland, USA Washington University School of Medicine St. Louis, Missouri, USA Susan Müller, DMD, MS Professor Emeritus Simion I. Chiosea, MD Emory University School of Medicine Associate Professor of Pathology Atlanta, Georgia, USA Department of Pathology University of Pittsburgh Medical Center Brenda L. Nelson, DDS, MS Presbyterian Hospital Head Pittsburgh, Pennsylvania, USA Department of Anatomic Pathology Naval Medical Center, San Diego Uta Flucke, MD, PhD San Diego, California, USA Consultant Pathologist Department of Pathology Mary S. Richardson, MD, DDS Radboud University Medical Centre Professor Nijmegen, The Netherlands Department of Pathology and Laboratory Medicine Medical University of South Carolina Vickie Y. Jo, MD Charleston, South Carolina, USA Assistant Professor Department of Pathology Brigham and Women’s Hospital and Harvard Medical School Boston, Massachusetts, USA v CONTENTS ■ FOREWORDvii The study and practice of anatomic pathology are both have formal training in this area. As such, a comprehen- exciting and somewhat overwhelming, as surgical pathol- sive reference such as this has great practical value in ogy (and cytopathology) have become increasingly the day-to-day practice of any surgical pathologist. The complex and sophisticated. It is simply not possible for list of contributors, as usual, includes some of the most any individual to master all of the skills and knowledge renowned pathologists in this area, all of whom have required to perform the daily tasks at the highest level. significant expertise as practicing pathologists, researchers, Simply being able to make a correct diagnosis is chal- and renowned educators on this topic. Each chapter is lenging enough, but the standard of care has far surpassed organized in an easy-to-follow manner, the writing is merely providing an accurate diagnosis. Pathologists are concise, tables are practical, and the photomicrographs now asked to provide huge amounts of ancillary informa- are of high quality. There are thorough discussions pertain- tion, both diagnostic and prognostic, often on small ing to the handling of biopsy and resection specimens amounts of tissue, a task that can be daunting even to as well as frozen sections, which can be notoriously the most experienced surgical pathologists. challenging in this field. Although large general surgical pathology textbooks The book is organized into 29 chapters, including remain useful resources, by necessity they cannot possibly separate chapters that provide thorough overviews of cover many of the aspects that diagnostic pathologists non-neoplastic, benign, and malignant neoplasms of the need to know and include in their daily surgical pathology larynx, hypopharynx, trachea, nasal cavity, nasopharynx, reports. As such, the concept behind Foundations in paranasal sinuses, oral cavity, oropharynx, salivary glands, Diagnostic Pathology was born. This series is designated ear and temporal bone, gnathic bones, and neck. Similarly, to cover the major areas of surgical pathology, and each chapters describing the non-neoplastic, benign, and volume is focused on one major topic. The goal of every malignant neoplasms of the thyroid gland, parathyroid book in this series is to provide the essential information gland, and paraganglia system are included. that any pathologist, whether general or subspecialized, I am truly grateful to Dr. Thompson and Dr. Bishop in training or in practice, would find useful in the evalu- as well as to all of the contributors who put forth tre- ation of virtually any type of specimen encountered. mendous effort to allow this book to come to fruition. Dr. Lester Thompson and Dr. Justin Bishop, both It is yet another outstanding edition in the Foundations renowned and highly prolific head and neck pathologists, in Diagnostic Pathology series, and I sincerely hope you have edited an outstanding state-of-the-art book on the enjoy this comprehensive textbook and find it useful in essentials of head and neck pathology. In fact, this area your everyday practice of head and neck pathology. is one of the most common topics encountered by any surgical pathologist, but very few pathologists actually John R. Goldblum, MD vii CONTENTS ■ PREFACEvii There is an axiom in computing called Moore’s law that It is the aim of this edition to highlight several of the states the computing speed of processors doubles every new diagnostic entities within the anatomic confines of 2 years while the cost halves. However, if you actually the larynx, sinonasal tract, ear and temporal bone, salivary read the fine print, it is the number of transistors in an gland, oral, oropharynx, nasopharynx, gnathic, and neck average computer that would double every 2 years—a regions. Clearly, the unlimited nature of the internet with corollary if you will. Thus, the average CPU in a computer countless webpages of information cannot be contained now has 904 million transistors, which clearly contributes within a single book without requiring a forklift to move to the overall speed, even though perhaps the “law” has it around. Thus, the reader is encouraged to use this book slowed down. as a starting point to make a meaningful diagnosis of the How does this apply to pathology and medicine? Well, most common and frequent diagnoses that may beset a it seems that there is a tremendous increase in the number busy surgical pathologist in daily practice, while using the of discoveries, new entities being carved out of old ones, references and other materials to lead to greater under- new diagnostic tools to achieve even greater precision standing. Use the pertinent clinical, imaging, laboratory, in diagnostic terms and clinical prognostication. Even macroscopic, microscopic, histochemical, immunohisto- with this staggering volume of data, it must always be chemical, ultrastructural, and molecular results presented harnessed by a mind willing to synthesize all of the data herein to reach a meaningful, useful, and actionable points into a meaningful and actionable diagnosis that diagnosis. a clinician and patient alike can use to treat the disease and achieve the best outcome for the patient. Lester D.R. Thompson, MD, and Justin A. Bishop, MD ix CONTENTS ■ ACKNOWLEDGMENTSvii With the passage of time, transition and change are I dedicate my work on this book to my wonderful wife, inevitable. As such, death seems to become more a part Ashley, and our beautiful children, Riley and Avery. I of life than the inherent meaning that the word suggests. am very grateful for their willingness to sacrifice so much And so it seems that many of those who influence you of our time together for this and other projects. I thank the most reach death’s doorstep ahead of you, creating my parents, Debbie and Fred, my sister, Kristen, and my a vacuum and space in your heart that is never refilled. brother, Martin, for their unwavering support. I am also The guidance provided by a parent, especially in the appreciative of Dr. William Westra, my mentor at The early years, is an example of this type of powerful Johns Hopkins Hospital who took a chance on me and influence. taught me much of what I know. Finally, I thank Dr. From as early as I can remember, my mother, Frances Lester Thompson for generously inviting me to co-edit Avril Dawn Ansley Thompson (can you tell where I got the newest edition of this book. I have enjoyed working all of my names!), provided love, support, and encourage- with him immensely and look forward to our many future ment. She so wanted me to be happy, healthy, and wise. collaborations. With each success or failure, triumph or rejection, I was always able to count on my mother to say the right Justin A. Bishop, MD thing—or say nothing at all, but just hold me, whether physically or emotionally. Last year as we were chatting about my projects, books, lectures, and work, she very quietly said: “It’s great that you have a written legacy, but remember to work on your spiritual, social, and emotional legacy with the same devotion and vigor.” Those words rang loud and clear at my 25th wedding anniversary celebration the following weekend, a party she would have loved to attend, but couldn’t as she had died of complications of a ruptured thoracic aortic aneu- rysm. Taking her final words to heart, I find myself drawn to other pursuits, attempting to keep work in an ever shrinking box, including the time devoted to philanthropic endeavors with my wife, Pam, whose role in my life continues to grow and expand with each passing year. Although patently obvious, the responsibility for any errors, omissions, or deviation from current orthodoxy is mine alone! Lester D.R. Thompson, MD xi 1 Non-Neoplastic Lesions of the Nasal Cavity, Paranasal Sinuses, and Nasopharynx ■ Austin McCuiston ■ Justin A. Bishop ■ RHINOSINUSITIS PATHOLOGIC FEATURES Rhinosinusitis is defined simply as inflammation of the GROSS FINDINGS nasal cavity (rhinitis), paranasal sinuses (sinusitis), or both (rhinosinusitis). In general, the gross findings consist of fragments of soft tissue and bone with no specific changes. Inflam- matory polyps (as described later) may be encountered. CLINICAL FEATURES Rhinosinusitis is a common condition that can be caused RHINOSINUSITIS—DISEASE FACT SHEET by myriad etiologies, including allergies (most common), infections, aspirin intolerance, exposures to toxins or Definition medications, pregnancy, systemic diseases, among others. ■ Inflammation of the nasal passages, most commonly as the Rhinosinusitis can also be idiopathic, with no known result of allergies or infection cause. Regardless of etiology, patients share the symptoms of nasal obstruction and discharge. Incidence Acute rhinosinusitis is typically infectious, either viral ■ Common (e.g., rhinovirus, adenovirus, respiratory syncytial virus, ■ Nasal cavity and paranasal sinuses, often bilateral among others) or bacterial (Streptococcus pneumoniae, Morbidity and Mortality Haemophilus influenzae, among others). Viral rhinosi- ■ Usually minimal, although rarely untreated bacterial sinusitis can nusitis results in a watery nasal discharge, whereas extend to the orbit or meninges bacterial disease results in a mucopurulent discharge, headache, and fever. Bacterial rhinosinusitis can occasion- Sex and Age Distribution ally be superimposed on viral disease. ■ Any age, no sex predilection Chronic rhinosinusitis (i.e., symptoms lasting longer than 12 weeks) is most often allergic in etiology as a Clinical Features result of an IgE-mediated reaction. Patients with allergic ■ Nasal discharge, watery in allergic and viral, mucopurulent in bacterial rhinosinusitis complain of a clear nasal discharge, sneez- ■ Allergic disease accompanied by itching and sneezing ing, and itching after exposure to the offending allergen. Clinical examination reveals sinonasal mucosa that is Treatment and Prognosis edematous, pale, and sometimes bluish in color. Inflam- ■ Allergic rhinosinusitis treated with antihistamines, nasal steroids, matory polyps, as described later, are often seen in this allergic desensitization setting. ■ Bacterial rhinosinusitis requires antibiotics, while viral infection is By imaging, inflamed sinuses demonstrate opacification treated supportively ■ Surgery is reserved for refractory, chronic disease and mucosal thickening (Fig. 1.1A). Air-fluid levels are classically identified in acute disease (see Fig. 1.1B). 1 2 HEAD AND NECK PATHOLOGY A B FIGURE 1.1 This computed tomography scan demon- strates radiographic features of both acute and chronic sinusitis. The left maxillary sinus demonstrates near complete opaci- fication (A), and air-fluid levels are noted (arrow) in the left ethmoid sinus (B). MICROSCOPIC FINDINGS RHINOSINUSITIS—PATHOLOGIC FEATURES Rhinosinusitis exhibits sinonasal mucosa with a Gross Findings submucosal inflammatory infiltrate. The inflammatory ■ Nonspecific cells are generally composed of lymphocytes, plasma cells, macrophages, and eosinophils, which predominate in Microscopic Findings allergic disease (Fig. 1.2). Acute rhinosinusitis is character- ■ Submucosal infiltrate of lymphocytes, plasma cells, neutrophils, ized by increased neutrophils, especially when associated eosinophils, often with edema with a bacterial etiology. There is often a component of ■ Surface epithelium may demonstrate squamous metaplasia, inflammation, or reactive papillary hyperplasia stromal edema, which leads to the development of inflam- matory polyps (described in detail in the next topic). Pathologic Differential Diagnosis The surface epithelium may also demonstrate changes, ■ Inflammatory polyps, sinonasal papilloma, adenocarcinoma including inflammation, squamous metaplasia (Fig. 1.3A), or reactive papillary hyperplasia (so-called papillary sinusitis) (see Fig. 1.3B). allergic sinusitis is treated with antihistamines, intranasal corticosteroids, and/or allergic desensitization. Patients with chronic rhinosinusitis refractory to medical therapy DIFFERENTIAL DIAGNOSIS may require endoscopic surgery. Rhinosinusitis is gener- ally not life-threatening, with the rare exception of The diagnosis of rhinosinusitis is usually not difficult. untreated bacterial infection that can lead to infection Many of the changes overlap with sinonasal inflammatory of the orbit or meninges. polyps, and the distinction between the two entities is not important. In cases with squamous metaplasia and/ or reactive papillary hyperplasia of the surface epithelium, sinonasal papilloma can enter the differential diagnosis. ■ SINONASAL INFLAMMATORY POLYPS Sinonasal papillomas have squamous or squamoid epithelium that is also thickened, proliferative with endophytic and/or exophytic growth, and infiltrated by Sinonasal inflammatory polyps are common non-neoplastic neutrophils with microabscesses. Rarely, adenocarcinoma masses of sinonasal tissue that essentially result from may enter the differential diagnosis when there is a edema within the submucosa. reactive proliferation of seromucinous glands. CLINICAL FEATURES PROGNOSIS AND THERAPY Inflammatory polyps are associated with many conditions. Acute viral rhinosinusitis is treated symptomatically, They are most often seen in the setting of allergic rhino- whereas bacterial disease requires antimicrobials. Chronic sinusitis but may also be seen in the setting of infections,