- Sinuses, paranasal:
- nonspecific chronic sinusitis:
- without eosinophilia
- with eosinophilia (and negative AFS features...negative fungal stain)
- mycetoma: sinus or possible sinus-extrusion debris is mycetoma until proven otherwise; d-Pas stain
may not stain dead organisms...advised to do silver stains (silver has far less false
negative). On H&E, one might see pigmented filaments that are dematiaceous fungi [L11-14262].
- eosinophilia of tissue: do fungus stain to find intranasal or sinus allergic fungal problem, if present.
- allergic mucin: this is the tip off to look for more scant fungal elements than if one saw actual mycetoma debris & help DX allergic fungal sinusitis (AFS5), & it is layered mucus with sheets of eosinophils and Charcot-Leyden
- fungal sinusitis (see GMS note above) categories (possibly an immunocompetent patient6):
- fungus ball [L10-13954].
- allergic fungal sinusitis (AFS): compatible clin. HX and other findings; allergic mucin findings (above); positive fungal stain &/or culture without evidence of fungal invasion[L12-3523].
- chronic erosive (noninvasive) fungal sinusitis.
- invasive fungal sinusitis
- Nasal, turbinates: partial endoscopic turbinoplasty removes turbinate mucosa and my remove some anterior nasophaygeal lymphoid tissue, particularly at rim of eustachian tube opening (Gerlach’s tonsil).
- Tonsils & adenoids & sleep apnea:
- watch out for asymetry, surface papillary lesions, or erosions
- facial dermatology specimens: these could include minor salivary gland tissue which might be abnormal...maybe chronically inflammed [S10-7625].
- lip problems:
- cheilitis can be underlain and/or complicated by actinic changes, dryness, "lip biting", recurrent HSV, etc. [S10-11632].
- benign mucosal papule: stroma-dominant exophytic nodule or papule [S13-943].
- geographic tongue biopsy: always search for candida so as to rule it out; it has atrophy of the filiform papillae & usually has spongiosis and intraepithelial polys with spongiosis (benign migratory glossitis) [S11-7328]; seen in 1-2% of adults and about 5-20% of psoriatics7.
- Greenspan "Focus Score": lower lip minor salivary gland is most easily biopsied in
effort to diagnose Sjogren's syndrome (SS) & has been found to have changes comparable to the larger glands [lacrimal...although lacrimal may have diagnostic score earlier (more sensitive findings4), the submandibular & the parotid); beware of over-diagnosing secondary
inflammation rather than an autoimmune pattern (duct dilation, extravasated saliva, and extravascular polys
indicate secondary). We have only dealt with minor salivary gland specimens.
- two goals:
- avoid using glandular tissue complicated by other injury as suggested by ductule dilation, extravasation, and extravaxcular polys
- render precise grading of inflammatory intensity using the details, below.
- gland variability: You could find significant variability & want to express the situation as an intensity "no lighter than"...don't express it in terms just of the worst possible section of the gland. Also, in a series of stepcut H&E sections, it can be shocking to see the size get large enough to be a "focus" in only one of the stepcut sections (HP13-1633)!
- scoring method & rules:
- grade lymphoplasmacytic inflammatory cellularity first:
- grade 0 = no lymphocytic or plasma cells at all.
- grade 1 = slight lymphocytic or plasma cell infiltrate.
- grade 2 = moderate lymphocytic or plasma cells but no "focus" or nidus of 50 grouped lymphocyte & plasma cells at rate equal to 1 "focus" per 4 square mm area of gland. Be sure to study every stepcut frame!
- grade 3 = as intense as, but not moreso than, 1 "focus"/4 sq. mm.
- grade 4 = more intense than1 "focus"/4 sq. mm.
- then issue a "focus score" on those that are grade 4: that "focus score" is your expression of how many clusters of 50 or more are in a 4 square mm. area of grade 4 inflammation.
- evaluation examples: S10-2533, "chronic sialadenitis, grade 2-3, Greenspan "focus score" less than one (1)"; S97-6197, grade 4; S97-6179, grade 4; S98-4930, grade 0; S99-1333, grade 4; S00-11372, grade 4; HP13-1633, attempt to extrapolate from a minor gland of only 2 square mm.
- other pointers:
- sialadenitis of less intensity is nonspecific: 20% of patients with rheumatoid arthritis show some sialadenitis & one source found 40% to have a "focus score" between 1-3; a group of 10 Sjorgren's cases all had grades 2-4, 60% being 4 (an old study1 in the 1960s...we are going to be faced with diagnoses earlier in the disease course in the USA).
- sialosclerosis: moderate to marked fibrosis in absence of significant inflammatory cellularity correlates with scleroderma or some other systemic sclerosis...maybe even IgG4 sclerosis.
- serology: Sjorgren's tends to have speckled pattern ANA positivity with ENA screen positive for SSA & SSB & polyclonal elevation of serum IgG with hypergammaglobulinemia. Presence of SSA and SSB in asymptomatic persons identifies a group at increased risk of SS.
- lichen planus: a lot of nonspecific chronic stomatitis
looks "lichenoid". The oral lesions should look clinically like LP,
lichenoid inflammation should be discerned on biopsy, and the direct fluorescent
staining of the biopsy should match the diagnosis.
- bone changes: you may get such as a stapes bone specimen & should look for any evidence of Paget's disease of bone vs. simple otosclerosis (the latter shows articular-end "blue mantles of Manasse"...a sort of osteocartilaginous, hematoxalinophylic knobby enlargement [L09-7595]).
- vertigo: there are no histological changes with benign paroxysmal positional vertigo (BPPV...bppv maneuverolder patients) which may easily respond to the Epley maneuver (video of "how to").
- cholesteatoma: usually originates from a ruptured eardrum, looks histologically like an epidermal inclusion cyst, often carries intracystic infection, can rarely burrow internally to the point of contact with the dura & "point" further to form a brain abscess & even more rarely result in death (FA11-7 a 36 y/o who ignored a bad headache about 3 days & was found dead).
- labyrinthitis: HERE.
- Chisholm DM & Mason K., "Labial salivary gland biopsy in Sjorgren's disease", J. Clin. Path. 21:656-660, 1968.
- Greenspan JS, et. al., "The histopathology of Sjorgren's syndrome in labial salivary gland biopsies", Oral Surgery 37(2):217-229, Feb. 1974.
- Batsakis JG, Tumors of the Head and Neck 2nd Ed., page 105, 1979, 573 pages (EBS).
- K P Xu; S Katagiri; T Takeuchi; K Tsubota, "Biopsy of labial salivary glands and lacrimal glands in the diagnosis of Sjögren's syndrome",The Journal of rheumatology, vol 23, Jan.1996.
- Allergic fungal sinusitis HERE.
- McKee, Calonje, & Granter, Pathology of The Skin... Two volumes, 3rd Ed. 2005.
(posted 20 April 2005; latest addition 18 September 2013)