Immunohistochemical and genetic analysis of respiratory epithelial adenomatoid hamartomas and seromucinous hamartomas: are they precursor lesions to sinonasal low-grade tubulopapillary adenocarcinomas?

Respiratory epithelial adenomatoid hamartoma (REAH) and seromucinous hamartoma (SH) are rare tumor-like lesions of the nasal cavity, paranasal sinuses, and nasopharynx. The pathogenesis of REAH/SH is still unclear. Neoplastic proliferation, chronic mechanical irritation, inflammation, or possible embryological tissue misplacement are speculated as possible mechanisms of their development. Low-grade tubulopapillary adenocarcinoma (LGTA) is a rare variant of nonsalivary, nonintestinal type sinonasal adenocarcinoma. The aim of this study was to evaluate the immunohistochemical and genetic profiles of 10 cases of REAH/SH, with serous, mucinous, and respiratory components evaluated separately and to compare these findings with the features of 9 cases of LGTA. All cases of REAH/SH and LGTA were analyzed immunohistochemically with a cocktail of mucin antigens (MUC1, MUC2, MUC4, MUC5AC, MUC6) and with epithelial (CK7, CK20, CDX2, SATB2) and myoepithelial markers (S100 protein, p63, SOX10). The next-generation sequencing assay was performed using FusionPlex Solid Tumor Kit (ArcherDx) in 10 cases of REAH/SH, and the EGFR-ZNF267 gene fusion was detected in 1 of them. Two female REAH/SH cases were assessed for the presence of clonality. Using the human androgen receptor assay, 1 case was proved to be clonal. The serous component of REAH/SH was positive for CK7/MUC1 and SOX10 similarly to LGTA. Although REAH/SH and LGTA are histopathologically and clinically separate entities, the overlap in their morphological and immunohistochemical profiles suggests that REAH/SH might be a precursor lesion of LGTA.

Effect of a dairy diet on nasopharyngeal mucus secretion.

OBJECTIVES/HYPOTHESIS: To examine the effects of dairy versus nondairy diets on self-reported levels of nasopharyngeal mucus secretion. STUDY DESIGN: Prospective, randomized, double-blinded controlled study. METHODS: Twenty-six men and 82 consecutive women over the age of 15 years attending the otolaryngology department at East and North Hertfordshire NHS Trust who reported experiencing increased levels of nasopharyngeal mucus secretions were selected for a double-blinded trial of dairy versus dairy-free dietary supplementation for the last 4 days of a 6-day dairy-free diet. Main outcome measures were comparisons of mean daily reporting of subjective levels of nasopharyngeal secretions by linear scoring (1-100) and by an ordinal scale of 1 to 4. On each day, t tests were used to compare differences. RESULTS: There was a significant reduction in the reported linear secretion score seen from day 1 to 4 in nondairy (t[53] = 4.39, P < .01) and in dairy (t[53] = 3.94, P < .01) arms. There was a significant increase in secretion score days 4 to 7 in the dairy arm (t[53] = -2.56, P = .01), and a continued but nonsignificant reduction in the nondiary arm (t[53] = 1.54, P = .13, with an overall significant reduction between day 1 and 7 in the nondairy arm (t[53] = 4.79, P < .00). In the ordinal secretion scale, both dairy arm (t[53] = 2.754, P < .01) and nondiary arm (t[53] = 5.52, P < .01) scores decreased significantly from days 1 to 4. There was a significant decrease in scores from days 1 to 7 in the nondairy group (t[53] = 5.12, P < .01). CONCLUSIONS: In this blinded trial, a dairy-free diet was associated with a significant reduction in self-reported levels of nasopharyngeal secretions in adults who previously complained of persistent nasopharyngeal mucus hypersecretion. LEVEL OF EVIDENCE: 1b Laryngoscope, 129:13-17, 2019.

Expression and clinical significance of LRRC4 in benign and malignant nasopharyngeal diseases.

The aim of this study was to investigate the expression of LRRC4 in nasopharyngeal carcinomas, nasopharyngeal precancerous lesions, and nasopharyngitis as well as the clinical significance of LRRC4. Fifty patients with nasopharyngeal carcinoma were selected as study subjects; 28 patients with chronic nasopharyngitis and 22 patients with nasopharyngeal precancerous lesions served as controls. Immunohistochemical analysis was used to study protein expression of LRRC4; the relation between LRRC4 expression and the clinical stage and histopathological features of nasopharyngeal carcinoma was also analyzed. The LRRC4 expression manifested itself as yellow staining in the cytoplasm or nucleus. LRRC4 was strongly expressed in nasopharyngeal epithelial tissues of patients with chronic nasopharyngitis and in nasopharyngeal precancerous lesions; the rates of positive results were 82.1 and 81.8%, respectively. LRRC4 was weakly expressed in nasopharyngeal carcinoma tissues, at a rate of 10% positive results (P< 0.001); there was no significant difference in the expression of LRRC4 among different clinical stages and pathological grades. Therefore, disappearance of LRRC4 expression is a major feature of nasopharyngeal carcinoma.

Expression of GRIN2A in benign and malignant nasopharyngeal diseases and its clinical significance.

The gene glutamate receptor, ionotropic, N-methyl D-aspartate 2A (GRIN2A) is associated with development and neuron viability, and our previous studies showed it to be substantially methylated in nasopharyngeal carcinoma, indicating a link to this disease. The aim of this work was to investigate GRIN2A expression and its clinical significance in nasopharyngeal carcinoma, in contrast to nasopharyngitis and nasopharyngeal precancerous lesions. Fifty patients with nasopharyngeal carcinoma were selected as study subjects, while 28 chronic nasopharyngitis patients and 22 individuals with nasopharyngeal precancerous lesions were used as controls. Immunohistochemical analysis was used to study GRIN2A protein expression, and its relationship with nasopharyngeal carcinoma clinical stage and histopathological features were assessed. GRIN2A appeared as yellow staining in the cytoplasm or nucleus. It was strongly expressed in the nasopharyngeal epithelial tissues of patients with chronic nasopharyngitis and in nasopharyngeal precancerous lesions, the proportions of GRIN2A-positive cells being 82.1 and 72.7%, respectively. However, it was weakly expressed in nasopharyngeal carcinoma tissues, with 28.0% of cells testing positive (P < 0.001). No significant difference in the expression of GRIN2A was observed between different clinical stages and pathological grades. We conclude that weak GRIN2A expression is a major feature of nasopharyngeal carcinoma.

Melanotic oncocytic metaplasia of the nasopharynx: a case report with a focus on immunohistochemical analyses and literature review.

Melanotic oncocytic metaplasia (MOM) of the nasopharynx is an extremely rare lesion, with only 21 cases reported in English literature to date. MOM typically occurs near the Eustachian tube opening in Asian men in their 60 s to 70 s. Here, we present a case of MOM in a 57-year-old Japanese man who is a heavy smoker. The patient did not have complaints; MOM was diagnosed incidentally as 4 flat elevated lesions with brown to black discoloration, ranging from 2 to 3 mm in maximal diameter, were found in the right torus tubarius. On suspecting melanoma, the largest lesion was biopsied. Microscopic examination identified both oncocytic metaplasia and melanin pigmentation of the epithelium in the same gland. Upon immunohistochemical examination, melanocytes displayed reactivity for 3 out of 4 melanocytic markers; immunopositivity for S-100 protein, Melan-A, and MITF and immunonegativity for HMB-45 was observed. Normal melanocytes in the nearby surface respiratory epithelium displayed the same pattern of immunoreactivity. Immunopositivity for S-100 protein and immunonegativity for HMB-45 have been previously reported in MOM. Reduction of stimulation of melanocytes in a longstanding lesion like MOM may explain the immunonegativity for HMB-45. S-100 protein, in conjunction with more specific marker for melanocytes, Melan-A or MITF, could prove the definite presence of melanocytes in this case of MOM. As it has been shown by previous reports that MOM pursues a benign course, it will be sufficient to follow up the patients regularly for the remaining 3 lesions.

Melanotic oncocytic metaplasia of the nasopharynx.

We report a rare case of melanotic oncocytic metaplasia of the nasopharynx in a 63-year-old man, presenting as several black nodules up to several millimeters at the nasopharynx. It is a benign mimicker of malignant melanoma.

Inflammatory pseudotumor in head and neck.

BACKGROUND: Inflammatory pseudotumor (IPT) is a tumefactive lesion characterized by fibroblastic proliferations and a prominent inflammatory component. It behaves as a locally benign or aggressive lesion, clinically and radiologically mimicking a neoplastic process. Numerous entities can be diagnosed as IPT, from reactive lesions to true neoplasms. The diagnosis of IPT requires further elaboration, and IPT should be distinguished from other similar entities such as inflammatory myofibroblastic tumor and IgG4-related sclerosing disease. CASE SUMMARY: We report two cases of IPT arising from the head and neck region. One occurred at the orbit and the other at the parapharyngeal space. Histologically, they showed aggregates of myofibroblasts and inflammatory cells. Immunohistochemically, the number of IgG4-positive cells was less than 40% of the number of IgG positive cells, and the myofibroblastic cells were negative for anaplastic lymphoma kinase. The diagnosis was IPT/not otherwise specified. One patient was treated by systemic administration of corticosteroid and had good response. The other, who was treated by local administration of corticosteroid, partially responded and is currently stable with limited disease. DISCUSSION: IPT has been reported to occur in various anatomical sites, most commonly in the lungs. The incidence in the head and neck area is extremely rare. Treatment of IPT is controversial and may involve corticosteroids or surgical resection, or both. Other chemotherapeutic agents and radiotherapy may be considered in steroid-resistant patients. The pathological subtype, safety of resection, and safety of corticosteroid use must be included in the decision-making process for treatment.

Neutrophil extracellular traps and bacterial biofilms in middle ear effusion of children with recurrent acute otitis media--a potential treatment target.

BACKGROUND: Bacteria persist within biofilms on the middle ear mucosa of children with recurrent and chronic otitis media however the mechanisms by which these develop remain to be elucidated. Biopsies can be difficult to obtain from children and their small size limits analysis. METHODS: In this study we aimed to investigate biofilm presence in middle ear effusion (MEE) from children with recurrent acute otitis media (rAOM) and to determine if these may represent infectious reservoirs similarly to those on the mucosa. We examined this through culture, viability staining and fluorescent in situ hybridisation (FISH) to determine bacterial species present. Most MEEs had live bacteria present using viability staining (32/36) and all effusions had bacteria present using the universal FISH probe (26/26). Of these, 70% contained 2 or more otopathogenic species. Extensive DNA stranding was also present. This DNA was largely host derived, representing neutrophil extracellular traps (NETs) within which live bacteria in biofilm formations were present. When treated with the recombinant human deoxyribonuclease 1, Dornase alfa, these strands were observed to fragment. CONCLUSIONS: Bacterial biofilms, composed of multiple live otopathogenic species can be demonstrated in the MEEs of children with rAOM and that these contain extensive DNA stranding from NETs. The NETs contribute to the viscosity of the effusion, potentially contributing to its failure to clear as well as biofilm development. Our data indicates that Dornase alfa can fragment these strands and may play a role in future chronic OM treatment.

[Extranodal Rosai-Dorfman disease of upper respiratory tract: a clinicopathologic study].

OBJECTIVE: To study the clinicopathologic features and differential diagnosis of extranodal Rosai-Dorfman disease (RDD) of the upper respiratory tract. METHODS: The clinical, pathologic and immunohistochemical features of 10 cases of RDD were evaluated. RESULTS: Among the 10 cases studied, there were 3 males and 7 females. The age of patients ranged from 20 to 61 years old (mean 38 years). The lesion arose in the nasal cavity (7 cases), nasopharynx (2 cases) or hard palate to trachea (1 case). Most of the patients presented with nasal obstruction, rhinorrhagia or tumor mass in the nasal/nasopharyngeal regions. CT scan often showed the presence of soft tissue lesion without bone destruction. Histologically, extranodal RDD was characterized by light-staining bands alternating with dark-staining bands. The light-staining bands were formed by aggregates of large round or polygonal histiocytes with emperipoiesis. The dark-staining bands were formed by abundant lymphoplasmacytic infiltrates. Immunohistochemical study showed that the histiocytes strongly expressed S-100 protein and partially expressed CD68. Six patients had no recurrence after surgical resection. CONCLUSIONS: Extranodal RDD of the upper respiratory tract is a rare disorder of histiocytic proliferation, which usually involves the nasal cavity and paranasal sinuses. RDD can easily mimic rhinoscleroma, mainly due to the overlapping morphologic appearance. Immunohistochemical study is helpful in the differential diagnosis.

Melanotic oncocytic metaplasia of the nasopharynx as a benign mimicker of malignant melanoma: a case report.

INTRODUCTION: Melanotic variant of oncocytic metaplasia of the nasopharynx is an extremely rare condition. CASE REPORT: A 73-year-old Japanese man presented with nasal congestion and chill. Nasoscopic examination revealed multiple black nodules around the bilateral torus tubarius. The nodules were biopsied to determine the histology. The clinical differential diagnosis was malignant melanoma or hemangioma. Microscopically, there were oncocytic plump cells with abundant brown pigmented granules showing glandular pattern. No significant atypia was found. The pigment was positive for Fontana-Masson staining, and negative for Berlin blue staining, showing that it was melanin pigment. Immunohistochemically, S100-positive HMB45-negative dendritic cells were also found. CONCLUSION: Such a pigmented variant of benign oncocytic lesion is very rare, and only 15 cases have been reported in the English literature. As a benign mimicker of malignant melanoma, melanocytic oncocytic metaplasia should be always taken into consideration in the clinical setting.

Isolated nasopharyngeal aspergillosis caused by A flavus and associated with oxalosis.

We report a case of isolated nasopharyngeal aspergillosis in a 52-year-old woman with Hashimoto's thyroiditis. We found the nasopharyngeal lesion incidentally while evaluating bilateral cervical lymphadenopathy, which we had discovered during a routine follow-up examination pursuant to the patient's thyroid problem. Biopsy analysis of the nasopharyngeal lesion revealed the presence of a mycelium made up of septate hyphae and associated oxalosis. Mycologic examination confirmed that Aspergillus flavus was the responsible pathogen. No systemic involvement or involvement of other head and neck sites was found. The patient had been exposed to a considerable amount of dust during the construction of her house, and this may have been the precipitating factor in the development of her infection. We treated the patient with a 4-week course of itraconazole. At the end of therapy, she exhibited no evidence of A flavus on physical and mycologic examinations.

Melanotic oncocytic metaplasia of the nasopharynx: a report of seven cases and review of the literature.

We describe seven cases of melanotic oncocytic metaplasia of the nasopharynx and review five other cases in the literature. It is usually a small, brown to black lesion that occurs around the Eustachian tube opening, where abundant seromucinous glands and lymphoid tissue are present. Multiple or bilateral lesions are sometimes seen. All 12 reported cases are of Asian origin. Melanotic oncocytic metaplasia occurs predominantly in men (male:female=11:1), with a mean age of 68 years. Simple excisional biopsy appears to be curative. Microscopically, melanotic oncocytic metaplasia is a combination of oncocytic metaplasia of the epithelium of the gland and melanin pigmentation in its cytoplasm. Fontana-Masson staining and immunohistochemical staining of S-100 protein revealed numerous melanocytes with conspicuous dendrites in the glands and stroma, which probably transfer melanin to adjacent glands. The exact pathogenesis of melanotic oncocytic metaplasia is unknown, but we postulate that the lesion could be related to the oncocytic metaplasia of the seromucinous glands around the Eustachian tube, which is followed by the local production and/or acquisition of the melanin pigment, under the influence of certain neuropeptides in the vicinity. The recognition of melanotic oncocytic metaplasia is of clinical importance, as it may be misdiagnosed as a malignancy to the unwary.

Reflux of nasopharyngeal content into middle ear through the eustachian tube.

Whether nasopharyngeal content passes into the middle ear in patients without any head and neck pathology during the recovery phase of anesthesia is shown with an objective and prospective method. Thirty-eight patients, 21 female and 17 male, aged between 17 and 76, were included in the study. During the recovery phase of general anesthesia, 10 ml of 5 mCi Tc-99m-MAA was administered intranasally to the patients with a 10-F catheter. A manometer-adapted cuffed intubation tube was placed in the nasal passage so that the cuff was located at the choana. The pressure changes reflecting to the nasopharynx were recorded. The patients were extubated 10 min after the radionuclide was applied. The scintigraphic evaluation was done at the end of the 1st hour of the application of radionuclide. Transmission and emission views were taken with a gamma camera. Passage of nasopharyngeal content into the middle ear via the eustachian tube was not a statistically significant observation. The mean value of maximum pressure reflecting from the nasopharynx did not differ significantly between patients. Our study does not support the hypothesis that nasopharyngeal content passes directly through the eustachian tube into the middle ear and causes deleterious effects.

Component analysis and growth process of nasopharyngeal calculus as revealed by Fourier transform infrared (FT-IR) spectroscopy.

A quite rare case of nasopharyngeal calculus in a woman in her twenties associated with the nasal discharge of pseudomonas infection was reported. As the substance was irregularly large in size, we extracted it partially by piecemeal resection using forceps and also by cracking technique using the holmium yttrium-aluminum-garnet (YAG) laser, under saline irrigation and stereotactic microscopic navigator (SMN) system under endoscopic observation. The substance was firmly fixed to the pharyngeal tonsil bed. The final extract was a small piece of singly folded bandage, which is probably the focal background for calculus formation. In a cross section of calculus specimen removed during surgery, Fourier transform infrared (FT-IR) analysis revealed that a) signal ratio of methylene group (organic substance) to amide I (protein) was 21.6% at the nasal cavity side, gradually decreased toward nasal mucous membrane showing approximate 50%, b) signal ratio of amide I to P04(3-) (inorganic substance) ranged between 17.7% and 26.7% at the different sites and inside the calculus, the protein content was approximate 1/5 of the inorganic substance, and c) signal ratio of the methylene group to amide I at the nasal cavity site showed that their contents were almost equal. The quantity of the organic substance was estimated at approximate 1/2 quantity of the protein at both the central part and the part contacted with the mucous membrane. From these results, it seems that throughout the course of calculus growth, both inorganic substance and protein remain almost constant inside the calculus, while organic substance is released from the internal part of the calculus being probably formed at an early stage.

Spontaneous proliferative lesions in the nasopharyngeal meatus of F344 rats.

Spontaneous proliferative lesions in the nasopharyngeal meatus were identified as the cause of death in 12 of 1,600 male and 5 of 1,600 female Fisher 344 (F344) rats used in 2-yr carcinogenicity studies; none of the lesions were considered treatment related. All the rats showed dyspnea, abdominal distension, and clinical deterioration. Gross features were characterized by simultaneous occurrence of conspicuous gaseous distension of the intestinal tract, especially in the ileum and cecum, and focal nodular lesions in the nasopharyngeal meatus. Histopathologically, the nasopharyngeal meatus was partially obstructed by the following proliferative lesions: 3 areas of hyperplasia of the ectopic sebaceous glands in the soft and hard palate, 4 areas of squamous metaplasia (SM) with massive hyperkeratosis, 5 squamous cell papillomas (SCPs), and 5 squamous cell carcinomas (SCCs). No pathological changes were found in the distended portion of the intestinal tract. Formalin-fixed, paraffin-embedded samples of the proliferative lesions from the nasopharyngeal meatus were examined for the presence of mutations in the c-H-ras and c-K-ras genes. In vitro amplification of DNA using a polymerase chain reaction was combined with a nonisotopic method for selective oligonucleotide hybridization. Two of the 4 SM lesions, 3 of the 5 SCPs, and 5 of the 5 SCCs contained 1-3 point mutations in the c-H-ras and/or c-K-ras gene. Immunohistochemically, overexpression of p53 protein was found in 1 area of SM with a dysplastic lesion and 2 SCCs. These findings indicate that detailed examination of the upper respiratory system, including the nasopharyngeal meatus, may be particularly helpful for identifying primary occult lesions in F344 rats that show only gut distension at necropsy in long-term toxicity studies. In addition, mutations of the ras genes may be an important step in the early stages of carcinogenesis in the rat nasopharyngeal meatus, whereas p53 mutations could occur relatively late.

[Expression of cytotoxic-granule-associated protein TIA-1 in nasal NK/T cell lymphomas and lymphoid hyperplasia].

OBJECTIVE: 27 cases of nasal NK/T cell lymphomas were studied for the expression of the cytotoxic-granule-associated protein TIA-1, its immunophenotype, genotype and Epstein-Barr virus infection status. METHODS: Immunohistochemical staining for TIA-1, CD3, CD56, CD45RO, CD8, CD20; polymerase chain reaction (PCR) for TCR gamma chain gene and immunoglobulin JH chain gene rearrangement analysis; in situ hybridization for EBER 1/2 and double staining for TIA-1, CD8 with EBER 1/2. 10 cases of lymphoid hyperplasia were used for comparison. RESULTS: (1) In the 27 cases of nasal NK/T cell lymphomas, most tumor cells expressed TIA-1, CD3, CD45RO and EBER 1/2; expression of CD56 was found in 26 cases; no CD8 or CD20 were detected in tumors cells of this series of cases. Double labelled staining showed that the TIA-1 positive tumor cells coexpress EBER 1/2. TCR gamma chain gene rearrangement was detected in only 1 of the 27 cases. (2) In the 10 cases of lymphoid hyperplasia of nasal pharynx, a small amount of TIA-1 positive cells were present in 8 cases and their distribution similar to that of CD8+ cells, in 4 of these cases a few EBER 1/2+ cells were detected, the number of CD45RO+ cells and CD20+ cells were similar in all 10 cases. Double labelled staining showed that the EBER 1/2+ cells did not coexpress TIA-1. CONCLUSION: A high percentage of these tumor cells express TIA-1 and correlate with that of CD56, CD3 epsilon, CD45RO and EBER1/2 in nasal NK/T cell lymphomas. It is suggested that expression of TIA-1 in this tumor may be related to the tumor origin and may also be responsible for its special biologic behavior.