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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
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
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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

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9780323188272
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
HEAD AND NECK PATHOLOGY, THIRD EDITION ISBN: 978-0-323-47916-5

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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
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Printed in China.
Last digit is the print number: 9 8 7 6 5 4 3 2 1

CONTENTS ■ C O N T R I B U TO R S vii
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
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
Brigham and Women’s Hospital and Harvard Medical School
Boston, Massachusetts, USA
v
CONTENTS ■ F O R E W O R D vii
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 ■ P R E FA C E vii
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 ■ A C K N O W L E D G M E N T S vii
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
■ Common
Acute rhinosinusitis is typically infectious, either viral
■ Nasal cavity and paranasal sinuses, often bilateral
(e.g., rhinovirus, adenovirus, respiratory syncytial virus,
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
■ Nasal discharge, watery in allergic and viral, mucopurulent in
result of an IgE-mediated reaction. Patients with allergic
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
■ Bacterial rhinosinusitis requires antibiotics, while viral infection is
setting.
treated supportively
By imaging, inflamed sinuses demonstrate opacification ■ 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
■ Surface epithelium may demonstrate squamous metaplasia,
with a bacterial etiology. There is often a component of
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,
CHAPTER 1 Non-Neoplastic Lesions of the Nasal Cavity, Paranasal Sinuses, and Nasopharynx 3
FIGURE 1.2
Chronic sinusitis is histologically character-
ized by a submucosal infiltrate of chronic
inflammatory cells including lymphocytes,
plasma cells, and eosinophils, which tend
to predominate in allergic sinusitis.
A B
FIGURE 1.3
Some cases of chronic sinusitis can demonstrate foci of surface epithelial squamous metaplasia (A). In addition, chronic sinusitis occasionally exhibits papillary
surface epithelial hyperplasia as a reactive change. When prominent, this finding can be confused with other lesions such as respiratory epithelial adenomatoid
hyperplasia or sinonasal papilloma (B).
asthma, aspirin intolerance, cystic fibrosis, diabetes mellitus, polyps are usually seen in younger patients (teenagers and
and other conditions. Inflammatory polyps are typically young adults), usually males, and are typically unilateral.
seen in adults (except for cystic fibrosis-associated polyps),
with no sex predilection. They involve the nasal cavity
(especially the lateral wall) and maxillary and ethmoid
sinuses and are usually bilateral (Fig. 1.4A). In addition to PATHOLOGIC FEATURES
the symptoms of the underlying condition (e.g., allergies),
sinonasal inflammatory polyps may cause nasal obstruc- GROSS FINDINGS
tion and pain. A subtype of inflammatory polyp known
as antrochoanal polyp arises from the maxillary antrum Inflammatory polyps are typically translucent and
and extends through the sinus ostia into the nasal cavity, mucoid in appearance (see Fig. 1.4A). Antrochoanal
nasopharynx, or oral cavity (see Fig. 1.4B). Antrochoanal polyps tend to be elongated with a stalk and fibrotic.
A B
FIGURE 1.4
The typical clinical appearance of inflammatory polyps is that of bilateral, multiple mucoid polypoid masses with a translucent appearance involving the nasal
cavity (A). The antrochoanal polyp is a subtype of inflammatory polyp arising from the maxillary antrum and protruding into the nasal cavity via a stalk (arrow)
through the nasal choana (B). (A, Courtesy of Dr. Douglas Reh.)
SINONASAL INFLAMMATORY POLYPS—DISEASE FACT SHEET SINONASAL POLYPS—PATHOLOGIC FEATURES
Definition Gross Findings

■ Polypoid growths of sinonasal mucosa that result primarily from ■ Translucent, glistening, and mucoid
submucosal edema ■ Antrochoanal polyps have a long stalk and are fibrotic
■ An allergic etiology is most common
Microscopic Findings
Incidence ■ Polypoid fragments of sinonasal mucosa with abundant stromal
■ Common edema
■ Nasal cavity and paranasal sinuses, often bilateral ■ Chronic inflammatory cell infiltrate with numerous eosinophils
■ Antrochoanal polyp is a subtype that arises from the maxillary ■ Epithelial basement membrane is usually hyalinized
antrum and protrudes through the sinus ostium, usually unilateral ■ Secondary changes including infarction, hemorrhage, and fibrin
deposition can be seen.

■ Antrochoanal polyps are less edematous, more fibrotic, fewer
Morbidity and Mortality
■ Usually minimal, although rarely may lead to bone erosion or eosinophils, and minimal basement membrane hyalinization.
remodeling
Pathologic Differential Diagnosis
■ Amyloidosis, hemangioma, lymphangioma, infections, respiratory
Sex and Age Distribution
■ Typically adults (except antrochoanal polyps in teenagers/young epithelial adenomatoid hamartoma, nasopharyngeal
adults and cystic fibrosis polyps in children) angiofibroma, sinonasal papilloma, embryonal
rhabdomyosarcoma
Clinical Features
■ Symptoms of underlying disease (e.g., rhinorrhea, nasal
stuffiness, headaches in allergic polyps)

■ Nasal obstruction and epistaxis MICROSCOPIC FINDINGS
Treatment and Prognosis The most prominent feature of a sinonasal inflammatory

■ Endoscopic removal polyp is submucosal edema beneath an intact respiratory
■ Treatment of underlying disease (e.g., nasal steroids for allergic epithelium (Fig. 1.5A). The subepithelial basement
polyps) membrane is typically hyalinized (see Fig. 1.5B). There
is usually a mild to moderate infiltrate of chronic inflam-
matory cells with a predominance of eosinophils (see
Fig. 1.5B). Scattered stellate or spindled fibroblasts are
seen, some of which may exhibit enlarged, hyperchromatic
nuclei (see Fig. 1.5C). Larger inflammatory polyps may
demonstrate prominent submucosal hemorrhage with fibrin
A B
C D
FIGURE 1.5
A sinonasal inflammatory polyp consists of a rounded proliferation of sinonasal mucosa with submucosal inflammation and edema (A). An inflammatory polyp
often has a hyalinized subepithelial basement membrane and an infiltrate of chronic inflammatory cells, especially eosinophils (B). Inflammatory sinonasal
polyps commonly demonstrate scattered atypical stromal myofibroblasts. When prominent, a mesenchymal neoplasm is a diagnostic consideration (C). In the
angiectatic or angiomatous variant of inflammatory polyp, there is abundant fibrin deposition (which can be mistaken for amyloid) as well as recanalizing vessels
(which can be mistaken for a vascular tumor) (D).
deposition or infarction, a pattern that has been referred which recanalizing vessels are prominent, a vascular or
to as “angiomatous” or “angiectatic” (see Fig. 1.5D). lymphatic neoplasm could be considered. Recognizing the
Antrochoanal polyps have a similar appearance but context of the vessels (i.e., with organizing fibrin within
tend to be more fibrotic and less edematous (Fig. 1.6A), a sinonasal polyp) is useful in avoiding this pitfall. The
have fewer eosinophils, and lack a hyalinized basement fibrous stroma and occasional nasopharyngeal location
membrane (see Fig. 1.6B). Bizarre stromal cells are more of antrochoanal polyps are somewhat reminiscent of
common in antrochoanal polyps than in inflammatory nasopharyngeal angiofibroma. In addition, both tumors,
polyps. typically as unilateral masses, arise in younger men.
Recognizing the dilated, “staghorn” appearance of the
vessels is important for diagnosing angiofibroma; the
vessels of antrochoanal polyp are typically small and
inconspicuous. In difficult cases, immunohistochemistry
for beta-catenin and androgen receptor may be used:
The diagnosis of sinonasal inflammatory polyp is usually the stromal cells of angiofibroma are positive for both,
straightforward. When there is prominent fibrin deposi- whereas antrochoanal polyps are negative. The atypi-
tion, amyloidosis is a consideration. True amyloid is cal stromal cells of sinonasal inflammatory polyps can,
positive with Congo red showing apple-green birefrin- in some cases, be alarming and raise the possibility
gence, in contrast to fibrin. In angiomatous polyps in of a sarcoma such as embryonal rhabdomyosarcoma.
A B
FIGURE 1.6
Antrochoanal polyp is a variant of inflammatory polyp that typically exhibits more prominent subepithelial fibrosis at low power (A). In contrast to the usual
inflammatory polyp, antrochoanal polyps have fewer eosinophils and lack a hyalinized basement membrane (B).
However, the atypical stromal cells of benign polyps

are singly and randomly distributed, do not aggregate PARANASAL SINUS MUCOCELE—DISEASE FACT SHEET
(e.g., no “cambium” layer characteristic of embryonal
Definition
rhabdomyosarcoma), are not mitotically active, and ■ Expansion of the paranasal sinus by mucin resulting from
are negative for desmin and myogenin. Respiratory obstruction of the outflow tract
epithelial adenomatoid hamartoma (REAH) tends to
show widely spaced glands, surrounded by a thick, Incidence
eosinophilic basement membrane, showing connections ■ Uncommon
of the invaginations to the surface. Finally, one must ■ Frontal and ethmoid sinuses most commonly affected
be sure to exclude the presence of another sinonasal

neoplasm such as sinonasal papilloma that are often
■ Can result in facial deformity, brain or orbit involvement if
seen in association with inflammatory polyps.
untreated

■ Any age or sex
Clinical Features
These are benign lesions. Treatment includes endoscopic ■ Nasal obstruction, headaches, visual disturbances, proptosis
■ Radiographs show expanded sinus with bone erosion and

surgery in addition to treatment of the underlying medical
sclerosis and rarely invasion of the orbit or cranial cavity
cause (e.g., nasal steroids for allergic polyps).
Treatment and Prognosis
■ Surgical excision
■ PARANASAL SINUS MUCOCELE ■ Treatment of underlying cause (usually chronic sinusitis)
Mucoceles of the paranasal sinus result from obstruction

of the sinus outflow tract with subsequent expansion of
the sinus with mucin.
(ostium or duct), most commonly chronic sinusitis, but
also occasionally trauma, neoplasms, or other causes.
The obstruction leads to expansion of the involved sinus,
CLINICAL FEATURES
usually frontal or ethmoid (Fig. 1.7A). Mucoceles can
produce alarming clinical and radiographic features,
Sinus mucoceles can occur in any age or sex. They result including facial deformity, headaches, visual disturbances,
from any disease that obstructs the sinus outflow tract proptosis, bone erosion and sclerosis, and rarely, invasion
A B
FIGURE 1.7
This computed tomography scan demonstrates a sphenoid sinus mucocele, with expansion of the sinus with secretions and thinning and remodeling of the
surrounding bones (A). This T2-weighted magnetic resonance imaging scan shows a fluid-filled mucocele involving the brain (B).
MICROSCOPIC FINDINGS
PARANASAL SINUS MUCOCELE—PATHOLOGIC FEATURES
The microscopic features of mucoceles are typically
Gross Findings underwhelming (particularly in the setting that is suspi-
■ Abundant mucin, otherwise nonspecific cious for malignancy) and closely mimic normal sinonasal
tissue. The sinonasal tissue sometimes has an attenuated
Microscopic Findings appearance resembling a cyst lining (Fig. 1.8A and B).
■ Very nonspecific
Epithelial squamous metaplasia, fibrosis, a rim of reactive
■ Sinonasal mucosa with inflammation, sometimes attenuation,
squamous metaplasia, scarring, reactive bone, or cholesterol

bone, or cholesterol granuloma formation can also be
granulomas seen. Because of their nonspecific nature, a definitive
diagnosis cannot be made on histologic grounds without
Pathologic Differential Diagnosis clinical or radiographic input.
■ Normal sinonasal mucosa, inflammatory polyps, unsampled
neoplasm leading to obstruction
The main diagnostic consideration is normal sinonasal

of the orbit or cranial cavity (see Fig. 1.7B). Given these tissue. Clinical and radiographic correlation is needed to
dramatic symptoms and radiographic features, a neoplastic make the distinction. Sinonasal polyps or a salivary gland
process is often suspected clinically. mucocele may also be in the differential. An unsampled
neoplasm may be the cause of the obstruction leading to
a mucocele.
PATHOLOGIC FEATURES
GROSS FINDINGS
Abundant mucin is generally apparent grossly or Sinus mucoceles are treated by surgical excision. The
reported intraoperatively (if suction has removed all of underlying cause of the obstruction (e.g., chronic sinusitis)
the contents). should also be addressed. The prognosis is excellent.
A B
FIGURE 1.8
Histologically, paranasal sinus mucoceles have a nonspecific appearance, consisting of attenuated strips of relatively normal appearing sinonasal mucosa.
Radiographic correlation is needed to make the diagnosis of mucocele (A). In this example of an aggressive mucocele, normal-appearing sinonasal epithelium
is seen in brain tissue (B).
neutrophils, Charcot-Leyden crystals, fibrin, and desqua-

■ ALLERGIC FUNGAL SINUSITIS
mated epithelial cells (Figs. 1.9 and 1.10). The various
components of allergic mucin are typically arranged in
Allergic fungal sinusitis (AFS) is a relatively common a laminated fashion, creating a striated or “tigroid”
condition believed to represent an allergic reaction to appearance (see Fig. 1.9). Fungal elements are usually
antigens from fungi (most commonly Aspergillus species) not apparent on routine histology. The background
that have colonized the sinonasal tract.
CLINICAL FEATURES ALLERGIC FUNGAL SINUSITIS—DISEASE FACT SHEET
Definition
AFS most often affects children and young adults, with ■ A noninvasive form of fungal sinusitis resulting from an allergic
no sex predilection. Affected patients present with nasal reaction to colonizing fungal antigens
discharge along with allergic-type symptoms such as nasal
Incidence and Location
stuffiness, facial pressure, and fullness. Patients are often
■ More common in warmer climates such as southern and
observed to have firm, viscous, foul-smelling mucin within
southwestern United States
their affected sinuses. In addition, patients typically
exhibit peripheral eosinophilia and elevated serum IgE Morbidity and Mortality
levels. In severe cases, patients uncommonly may exhibit ■ Typically minimal, although rarely patients may demonstrate
facial asymmetry with bone destruction. facial asymmetry and bone destruction

■ Typically children or young adults, no sex predilection
PATHOLOGIC FEATURES
Clinical Features
■ Nasal discharge, allergic-type symptoms
GROSS FINDINGS ■ Elevated serum IgE levels and peripheral eosinophilia
■ Sinus contents with firm, rubbery, foul-smelling mucus
Grossly, the secretions of AFS are firm, thick, and

rubbery and have the quality of putty or peanut butter. Treatment and Prognosis
■ Evacuation of tenacious mucus
■ Intranasal steroids
MICROSCOPIC FINDINGS ■ Some patients benefit from fungal allergic desensitization
■ Long-term therapy may be needed to control relapses

The microscopic hallmark of AFS is so-called allergic
mucin: inspissated mucin that is admixed with eosinophils,
FIGURE 1.9
The diagnostic histologic finding is allergic
mucin, which is composed of inflam-
matory cells (particularly eosinophils),
Charcot-Leyden crystals, desquamated
epithelial cells, and other debris. A
lamellated (“tigroid”) appearance is classic
for allergic mucin. Stains for fungi (in
this case, Gomori methenamine silver)
highlight fungal hyphae in a subset of
allergic fungal sinusitis cases. The hyphae
are often degenerated and distorted, as
seen here (inset).
FIGURE 1.10
Charcot-Leyden crystals are seen as long
needlelike and bipyramidal-shaped crystals
in this case of allergic fungal sinusitis.
sinonasal mucosa exhibits edema and chronic inflamma-

tion with frequent eosinophils.
The histologic appearance of AFS may resemble non-

specific rhinosinusitis or sinonasal polyps, but the
ANCILLARY STUDIES
characteristic presence of allergic mucin is diagnostic for
AFS. The allergic mucin of AFS may be confused with
Special stains for fungi (Gomori methenamine silver [GMS] another form of noninvasive fungal sinusitis known as
and periodic acid–Schiff [PAS]) reveal scattered fungal mycetoma or fungus ball. However, in mycetoma the
hyphae within the allergic mucin in about half of cases. debris is composed entirely of matted fungal hyphae in
These fungal elements are often scarce and may have an far greater numbers than what is seen in AFS. Mycetomas
unusual, degenerated appearance (see Fig. 1.9, inset). may calcify or show conidia (fungal fruiting bodies)
(Fig. 1.11A). Finally, AFS must be distinguished from

■ NASAL GLIAL HETEROTOPIA
acute or chronic forms of invasive fungal sinusitis, in
which fungal elements invade stroma with frequent
involvement of vessels (see Fig. 1.11B). Nasal glial heterotopia is a benign condition resulting
from the failure of the developing frontal lobe to com-
pletely retract into the cranial cavity during fetal develop-
ment. Because it is not a neoplasm, the historical term
“nasal glioma” should not be used.
Treatment includes removal of the mucus as a means to

restore mucociliary function. Intranasal steroids are
CLINICAL FEATURES
frequently used. Fungal desensitization may also be used
as a treatment option. There does not appear to be a role
for antifungal agents. Prognosis is good, although long- Nasal glial heterotopia usually affects infants, although
term therapy may be needed to control relapses in some it can occasionally be encountered in older patients.
patients. There is no predilection for either sex. Glial heterotopia
presents as a firm nodule that can be extranasal (60%)
on the bridge or side of the nose, intranasal within the
nasal cavity (30%), or both intranasal and extranasal
ALLERGIC FUNGAL SINUSITIS—PATHOLOGIC FEATURES (10%). Patients often have nasal obstruction and
infants may show difficulty feeding as a result of the
Gross Findings mass. By radiology, there is no connection to the
■ Thick, viscous mucin that may resemble putty or peanut butter
intracranial cavity, a crucial feature that distinguishes
glial heterotopia from an encephalocele (Fig. 1.12A
■ Allergic mucin: a striated mixture of mucin, inflammatory cells,
and B).
Charcot-Leyden crystals, and other debris
■ Fungal hyphae seen in approximately half of cases with special
stains
■ Fungi often scarce and have a degenerated appearance PATHOLOGIC FEATURES
■ Nonspecific rhinosinusitis, sinonasal polyp, mycetoma (fungus
GROSS FINDINGS
ball), invasive fungal sinusitis (acute or chronic)
Well-circumscribed nodule of firm soft tissue, 1 to
3 cm in size, with a glistening cut surface.
A B
FIGURE 1.11
Mycetoma (fungus ball) is a form of noninvasive fungal sinusitis consisting of a matted collection of degenerating fungal hyphae growing within the sinus, with
no tissue invasion (A). In contrast, fulminant invasive fungal sinusitis is characterized by invasion of tissues with necrosis and a limited inflammatory reaction
(B).
A B
FIGURE 1.12
Computed tomography scan of extranasal glial heterotopia (arrow) without a connection to the cranial cavity (A). In contrast, this encephalocele involving the
nasal cavity has a clear connection to the cranial cavity (arrow) (B).
A B
FIGURE 1.13
Nasal glial heterotopia manifests as fibrotic glial tissue in the sinonasal submucosa (A). At high power the glial tissue consists of scattered astrocytes in a pink,
fibrillary background (B). Immunostaining for glial fibrillary acidic protein confirms the glial nature of the tissue (inset).
MICROSCOPIC FINDINGS ANCILLARY STUDIES

Heterotopic glial tissue resembles gliotic brain tissue, with
astrocytes admixed with eosinophilic fibrillary glial tissue Nasal glial heterotopia can be confirmed immunohis-
underlying skin or sinonasal mucosa (Fig. 1.13A and B). tochemically by positivity for the glial markers glial
Neurons are only rarely seen, whereas dura and meninges fibrillary acidic protein (GFAP) (see Fig. 1.13B), S100
are not present. The glial tissue may be obscured by fibrosis, protein, and the newly introduced nuclear marker
necessitating immunohistochemical confirmation. OLIG2.
favors an encephalocele, but these features are often lost,

NASAL GLIAL HETEROTOPIA—DISEASE FACT SHEET especially in long-standing lesions. Ultimately, the distinc-
tion requires clinical and radiographic input (see
Definition
Fig. 1.12B).
■ Developmentally displaced glial tissue in the sinonasal tract
without a connection to the cranial cavity
Incidence PROGNOSIS AND THERAPY

■ Uncommon
■ Extranasal (bridge or side of nose) in 60%, intranasal in 30%,
and mixed in 10% Glial heterotopia is treated with simple excision. The
prognosis is excellent following complete removal of the
glial tissue.
■ Minimal, although can result in difficulty feeding for some infants

■ Usually infants
■ RHINOSCLEROMA
■ No sex predilection
Clinical Features Rhinoscleroma is a rare, chronic infectious disease

■ Nasal mass, often resulting in obstruction caused by Klebsiella rhinoscleromatis, a gram-negative
coccobacillus bacterium, that affects the nasal cavity
Treatment and Prognosis and nasopharynx.
■ Excellent prognosis after complete excision
CLINICAL FEATURES
Rhinoscleroma most often affects young adults in

NASAL GLIAL HETEROTOPIA—PATHOLOGIC FEATURES
their second and third decades. There is a slight female
predominance. It is endemic to certain parts of South
Gross Findings America, Central America, Africa, India, and Indonesia,
■ Small circumscribed firm nodule with a glistening cut surface but is rare in North America. Rhinoscleroma affects the
nasal cavity and nasopharynx, and there are three distinct
Microscopic Findings clinical stages. The rhinitic or exudative stage is
■ Astrocytes in a glial fibrillary matrix characterized by a foul-smelling mucopurulent nasal
■ Neurons only rarely present, leptomeninges are absent
discharge with nasal obstruction and erythema. With
■ May be fibrotic, obscuring the glial nature of the lesion
progression of the disease after months or years without
Ancillary Studies treatment, the florid or proliferative stage is marked by
■ Glial tissue positive for GFAP, S100 protein, OLIG2
mucosal thickening by numerous small masses and
subsequent nasal obstruction (Fig. 1.14). Finally, long-
Pathologic Differential Diagnosis term rhinoscleroma is known as the fibrotic or cicatrical
■ Nonspecific fibrosis in sinonasal polyp, encephalocele stage and is characterized by marked scarring and nasal
stenosis. Rhinoscleroma can result in marked facial
deformities, particularly in the latter stages of the
disease.
PATHOLOGIC FEATURES
Heterotopic glial tissue can be misdiagnosed as nonspecific
fibrosis in a sinonasal polyp, a distinction that can be GROSS FINDINGS
easily addressed by immunohistochemistry for glial
markers. Another diagnostic consideration is encepha- The gross pathologic appearance varies based on the
locele. The distinction is not trivial, because an clinical disease stage. The rhinitic/exudative stage has a
encephalocele, by definition, means that there is a patent nonspecific appearance, whereas the florid/proliferative
connection with the cranial cavity, which puts the stage produces friable nasal polyps. Finally, the fibrotic/
patient at risk for meningitis. The presence of dura/ cicatrical stage is characterized by densely fibrotic
leptomeninges or well-organized glial tissue with neurons tissues.
RHINOSCLEROMA—DISEASE FACT SHEET
Definition
■ Infectious disease caused by Klebsiella rhinoscleromatis, a
gram-negative coccobacillus bacterium
Incidence and Location

■ Rare
■ Endemic in parts of South America, Central America, Africa, India,
and Indonesia

■ Can cause marked facial deformity and nasal stenosis

■ Second and third decades
■ Slight female predilection
Clinical Features
■ Three clinical stages: rhinitic (exudative) with abundant
foul-smelling mucopurulent secretions; florid (proliferative) with

numerous small friable nodules causing obstruction and
deformity; and fibrotic (cicatrical) with marked scarring and
stenosis

■ Long-term antibiotics and possibly surgical débridement
■ High relapse rates necessitate long-term follow-up

FIGURE 1.14
A clinical photograph of a 42-year-old man with rhinoscleroma presenting as
several years of progressive nasal ulceration, along with palatal perforation,
yielding marked nasal and mid-facial distortion. (Courtesy of Dr. R. Carlos.)
MICROSCOPIC FINDINGS RHINOSCLEROMA—PATHOLOGIC FEATURES
Rhinoscleroma is most often biopsied in the florid Gross Findings

stage, where the submucosa is expanded by an inflam- ■ Nonspecific, or friable polyps, or dense sclerosis
matory infiltrate including lymphocytes, plasma cells,

neutrophils, and histiocytes. As in any disease with Microscopic Findings
abundant plasma cells, Russell bodies—large cytoplasmic ■ Marked chronic inflammation with lymphocytes, plasma cells,
inclusions composed of immunoglobulin—are frequent. neutrophils, and histiocytes in the sinonasal submucosa
■ The diagnostic finding is the “Mikulicz cell”—large histiocytes with
The diagnostic microscopic finding is the presence of clear, vacuolated cytoplasm
“Mikulicz cells”—large histiocytes with abundant, clear,
vacuolated cytoplasm (Fig. 1.15). As rhinoscleroma Ancillary Studies
progresses, lesions become increasingly fibrotic and less ■ Warthin-Starry stain highlights the rod-shaped organisms within
inflammatory. the Mikulicz cells

■ Rosai-Dorfman disease, infections (atypical mycobacteria, leprosy,
ANCILLARY STUDIES syphilis), granulomatosis with polyangiitis, clear cell epithelial

neoplasms
A Warthin-Starry stain highlights rod-shaped Klebsiella

organisms within the Mikulicz cells (see Fig. 1.15).
(Fig. 1.16). Moreover, although Mikulicz cells are positive

for CD68, they are negative for S100 protein. In some
cases of rhinoscleroma, the Mikulicz cells can be so
Rhinoscleroma can mimic Rosai-Dorfman disease; prominent that the lesion may be mistaken as a clear
however, in rhinoscleroma emperipolesis is not observed cell epithelial neoplasm such as mucoepidermoid
FIGURE 1.15
In the florid phase of rhinoscleroma, there
are numerous “Mikulicz cells”—large
histiocytes with abundant, clear, vacuolated
cytoplasm. These cells are positive for
rod-shaped bacteria on Warthin-Starry
staining (inset).
FIGURE 1.16
Rosai-Dorfman disease may affect the sino-
nasal tract and can mimic rhinoscleroma.
The diagnostic feature of Rosai-Dorfman
disease is emperipolesis—large histiocytes
with intracytoplasmic lymphocytes. These
histiocytes are positive for S100 protein
by immunohistochemistry (inset).
carcinoma or myoepithelioma. This can be resolved by

immunohistochemistry for CD68 (positive in rhinoscle-
roma) and cytokeratin (negative), as well as positive
Warthin-Starry staining. Other infections (atypical Long-term systemic antibiotics are indicated for rhino-
mycobacteria, leprosy, and syphilis) may result in granu- scleroma. Surgical débridement may be needed to correct
lomata. Giant cells and granulomas may be seen in stenotic nasal passages. Rhinoscleroma generally shows
granulomatosis with polyangiitis (GPA) (Wegener), but a good response to antibiotics, but high relapse rates
vasculitis is not seen in rhinoscleroma. necessitate long-term follow-up.
inflammation, similar to nonspecific inflammatory polyps.

■ RHINOSPORIDIOSIS
The diagnostic finding is the presence of numerous cysts
(sporangia) of variable sizes (Fig. 1.17). Larger cysts (up
Rhinosporidiosis is a chronic zoonotic infection caused to 300 µm) contain numerous endospores (see Fig. 1.17).
by the eukaryotic organism Rhinosporidium seeberi. The cysts are present in the stroma but may uncommonly
also involve the epithelium. On occasion, rupture of cysts
can induce an acute stromal inflammatory infiltrate.
CLINICAL FEATURES
Rhinosporidiosis is typically localized to the sinonasal

tract and conjunctiva but is rarely encountered in other RHINOSPORIDIOSIS—DISEASE FACT SHEET
anatomic sites like larynx, trachea, esophagus, genital
Definition
tract, and others. It is rare in North America, but it is
■ Zoonotic infection caused by the eukaryotic organism
endemic in parts of India and Sri Lanka. Patients of any
Rhinosporidium seeberi
age can be affected, but it is most commonly encountered
in patients in their third and fourth decades. There is a Incidence and Location
slight male predominance in patients with nasal disease. ■ Rare in North America but endemic in parts of India and Sri
Patients with sinonasal disease complain of nasal obstruc- Lanka

tion, rhinorrhea, and nosebleeds. ■ Affects the mucous membranes of the sinonasal tract and less
commonly conjunctiva, upper airway, genital tract, and other sites

■ Typically minimal
PATHOLOGIC FEATURES
GROSS FINDINGS ■ Slight male predominance
■ Any age, most common in third and fourth decades
Rhinosporidiosis typically manifests as friable nasal

polyps or masses, classically described as strawberry-like Clinical Features
■ Nonspecific: rhinorrhea, nosebleeds, obstruction
in appearance.
MICROSCOPIC FINDINGS ■ Surgical
■ Excellent prognosis
Rhinosporidiosis microscopically appears as polypoid
fragments of edematous sinonasal mucosa with chronic
A B
FIGURE 1.17
Rhinosporidiosis is an infection that exhibits presence of numerous scattered cysts (sporangia) of variable sizes (A). Larger cysts (up to 300 µm) contain
numerous endospores (B).
term Wegener granulomatosis is still widely used, many

RHINOSPORIDIOSIS—PATHOLOGIC FEATURES organizations (e.g., American College of Rheumatology,
the European League against Rheumatism, and the
Gross Findings
American Society of Nephrology) recommend avoiding
■ Friable polyps or masses
it due to a trend against eponyms.
■ Variably sized cysts up to 300 µm, predominantly subepithelial
■ The largest cysts contain small endospores
■ Background nonspecific chronic inflammation and edema, acute

CLINICAL FEATURES
inflammation if cysts rupture
GPA tends to affect middle-aged adults, with a slight male
Ancillary Studies
predominance. GPA classically affects the head and neck
■ GMS and PAS highlight organisms, though usually not needed
(especially sinonasal tract), lung, and kidney, but it can
for diagnosis
be localized to only one or two of these areas. Affected
Pathologic Differential Diagnosis patients complain of nasal discharge, nasal obstruction,
■ Oncocytic sinonasal papilloma, coccidiomycosis nosebleeds, and pain. On clinical examination, patients
have a nasal septum ulcer with crusting, which can
GMS, Gomori methenamine silver; PAS, periodic acid–Schiff. sometimes progress to perforation and collapse of the nasal
cartilages (Fig. 1.18A). Respiratory disease manifests as
hemoptysis, lung infiltrates, or cavitary masses, whereas
renal disease results in glomerulonephritis.
ANCILLARY STUDIES
Special studies are not generally needed as the cysts are PATHOLOGIC FEATURES
typically numerous and visible on routine stains, but
microorganisms can be highlighted with PAS and GMS GROSS FINDINGS
stains.
The gross appearance is often a nonspecific appearing
ulcer.
MICROSCOPIC FEATURES
The oncocytic type of sinonasal papilloma exhibits The histologic triad of GPA is biocollagenolytic
numerous intraepithelial microcysts that can be confused (necrobiotic) necrosis, granulomatous inflammation, and
with the cysts of rhinosporidiosis. However, in oncocytic vasculitis. “Biocollagenolytic” or “necrobiotic” necrosis
sinonasal papilloma the microcysts are confined to the refers to zones of geographic basophilic necrosis with
epithelium. The cysts of rhinosporidiosis can be confused granular, cellular debris (see Fig. 1.18B). The granulo-
with the spherules of Coccidioides immitis, but these matous inflammation of GPA is typically poorly formed,
spherules are much smaller (up to 60 µm) and accom- sometimes simply consisting of scattered giant cells (see
panied by a granulomatous inflammatory infiltrate. Fig. 1.18C). Vasculitis of small to medium-sized vessels
is the most specific finding but is often focal or absent.
Unfortunately, most patients with GPA have biopsies
that show nonspecific acute and chronic inflammation
with eosinophils and sometimes neutrophilic microab-
scesses, and multiple biopsies may be required to establish
Rhinosporidiosis is treated by complete surgical excision. a pathologic diagnosis.
Antibiotics are not effective. The prognosis is excellent,
with only occasional recurrences. The disease is not
infectious to other individuals.
ANCILLARY STUDIES
Elastic stains may be helpful by highlighting vessels that

■ GRANULOMATOSIS WITH POLYANGIITIS
are involved by vasculitis (see Fig. 1.18D). Special stains
for microorganisms are negative. Patients with GPA have
Granulomatosis with polyangiitis (GPA) is a systemic positive serum cytoplasmic antineurtrophil cytoplasmic
immune complex vasculitis of unknown etiology that antibodies (c-ANCA) and proteinase 3 (PR3) antibodies
often affects the sinonasal tract. Although the synonymous in approximately 80% of cases (Fig. 1.19).
A B
C D
FIGURE 1.18
Granulomatosis with polyangiitis clinically presents as nasal erythema, crusting, ulcer, and perforation (A). Histologically a classic feature of granulomatosis with
polyangiitis is “biocollagenolytic necrosis” (or “necrobiosis”), which is basophilic necrosis with nuclear debris (B). The granulomas of granulomatosis with
polyangiitis are typically not well formed and may consist simply of giant cells (C). An elastic stain can highlight foci of vasculitis (D). (A, Courtesy of Dr. Douglas
Reh.)
FIGURE 1.19
In granulomatosis with polyangiitis, giant
cells may be present (upper left), but
well-formed granulomas are absent. Note
the vessel wall in the lower right, with
destruction by the inflammatory process in
an example of vasculitis. Inset: A c-ANCA
shows a granular cytoplasmic pattern in a
case of granulomatosis with polyangiitis.
GRANULOMATOSIS WITH POLYANGIITIS—DISEASE GRANULOMATOSIS WITH POLYANGIITIS—

FACT SHEET PATHOLOGIC FEATURES
Definition Gross Findings

■ Immune complex–mediated small vessel vasculitis of unknown ■ Nasal ulcer with crusting and/or perforation
etiology
Incidence ■ Classic histologic triad: biocollagenolytic necrosis (necrobiosis),
■ Uncommon vasculitis, and granulomatous inflammation

■ Affects the head and neck (especially sinonasal tract), respiratory ■ Granulomas tend to be poorly formed and often consist simply
tract, and/or kidneys of giant cells

■ It is uncommon to see all three classic findings in a biopsy, with
Morbidity and Mortality vasculitis being the least common

■ Sinonasal disease can result in significant facial
deformities Ancillary Studies

■ Renal and pulmonary disease can be life-threatening ■ Vessels with vasculitis can be highlighted by elastic stains
■ Presence of serum c-ANCA and PR3 autoantibodies are quite
Sex and Age Distribution specific

■ Middle-aged adults, with a slight male predominance
Clinical Features ■ Infectious rhinosinusitis, cocaine use, Churg-Strauss disease,
■ Nasal disease results in nasal obstruction, pain, epistaxis, septal NK-/T-cell lymphoma, nasal type
ulcer, and possibly perforation and deformity

■ Systemic corticosteroids and/or cyclophosphamide
■ Prognosis depends on extent of disease
GPA is treated with immunosuppressive agents such as

corticosteroids or cyclophosphamide. The prognosis of
GPA depends on the extent of disease. Localized disease
DIFFERENTIAL DIAGNOSIS has a good prognosis, but relapses are common. However,
renal and pulmonary disease can be life-threatening.
The differential diagnosis includes infectious granuloma-

tous rhinosinusitis (e.g., chronic fungal sinusitis). Infec-
■ SINONASAL HAMARTOMAS
tious granulomatous disease tends to produce granulomas
that are better developed than those seen in GPA. Special
stains for microorganisms (e.g., GMS, AFB) are helpful in The sinonasal hamartomas consist of three lesions: REAH,
addressing this possibility. Churg-Strauss disease shows seromucinous hamartoma (SH), and chondromesenchymal
granulomatosis and vasculitis and is an allergic reaction, hamartoma (CMH). Despite the “hamartoma” terminol-
showing asthma and tissue and peripheral eosinophilia, ogy, there is evidence to suggest that each of these lesions
and may even have elevated ANCA titers. Another con- is actually a benign neoplasm.
sideration is lymphomas in general but the NK-/T-cell
lymphoma, nasal type specifically. This malignancy often
exhibits vascular involvement resulting in large zones of
necrosis, and the inflammatory infiltrate can be deceptively
CLINICAL FEATURES
mixed and, at times, not obviously malignant. Neverthe-
less, on close inspection, overtly malignant lymphoma cells
with marked nuclear atypia and a high mitotic rate can be All three hamartomas are rare. REAH and SH have a
found in NK-/T-cell lymphoma. In addition, NK-/T-cell similar clinical profile: they tend to arise in adults with
lymphoma lacks granulomatous inflammation and is posi- a slight male predominance and have a predilection for
tive for Epstein-Barr virus (EBV) by in situ hybridization the posterior nasal septum (Fig. 1.20). REAH and SH
for EBV-encoded small nuclear RNA (EBER). Finally, present as unilateral polyps that cause nasal obstruc-
cocaine abuse can result in nasal ulcers and perforation. tion or epistaxis. In contrast, CMH arises most often in
The histopathologic features of cocaine abuse are typi- infants as a slow-growing, expansile lesion within the
cally nonspecific, but occasionally polarizable material paranasal sinuses, nasal cavity, and/or orbit that can be
from talc or other material used to “cut” cocaine can be locally aggressive. CMH has a strong association with the
identified. pleuropulmonary blastoma tumor predisposition disorder.
or edematous stroma (see Fig. 1.21B), usually showing

PATHOLOGIC FEATURES
a prominent and thickened basement membrane. SH
consists of a dense proliferation of variably sized sub-
GROSS FINDINGS mucosal seromucinous glands lined by a single layer of
cuboidal cells (Fig. 1.22A). In both REAH and SH, the
REAH and SH have the appearance of a nasal polyp.
CMH is firm and white.
SINONASAL HAMARTOMAS—DISEASE FACT SHEET
MICROSCOPIC FINDINGS Definition

■ Benign proliferations of epithelium (REAH and SH) or stroma
REAH consists of downward-growing proliferations (CMH)
of branching glands originating from the surface epithe-
lium (Fig. 1.21A). The glands are lined by a pseudostrati- Incidence
fied ciliated epithelium and are surrounded by a hyalinized ■ All three are rare
■ REAH and SH most frequently occur on the posterior nasal
septum
■ CMH involves the paranasal sinuses, nasal cavity, or orbit

■ REAH and SH are localized lesions
■ CMH may be locally aggressive

■ REAH and SH involve middle-aged patients with a male
predominance
■ CMH usually affects infants with a male predominance
Clinical Features
■ REAH and SH present with unilateral nasal obstruction, bleeding,
and polyps
■ CMH presents as nasal obstruction or a mass

■ Excellent prognosis
FIGURE 1.20 CMH, Chondromesenchymal hamartoma; REAH, respiratory epithelial

Respiratory epithelial adenomatoid hamartoma and seromucinous hamartoma adenomatoid hamartoma; SH, seromucinous hamartoma.
have a similar radiographic appearance—a polypoid mass of the posterior
nasal septum (arrow).
A B
FIGURE 1.21
Respiratory epithelial adenomatoid hamartoma consists of a polypoid mass with a downward growth of surface epithelium (A). The glands are ciliated, pseu-
dostratified, and often surrounded by a thick basement membrane (B).
A B
FIGURE 1.22
Seromucinous hamartoma consists of an increased number of normal-appearing seromucinous glands in the submucosa (A). Some examples of seromucinous
hamartoma have areas that closely resemble respiratory epithelial adenomatoid hamartoma (left), suggesting these lesions are closely related (B).
FIGURE 1.23
Chondromesenchymal hamartoma dem-
onstrates scattered, ill-defined nodules of
variably mature cartilage in the sinonasal
submucosa.
glands can be dilated and lined by flattened, atrophic mature or immature, and the islands are typically sur-
epithelium. REAH and SH are both frequently rounded by a cellular fibrous stroma, often with atypical
accompanied by chronic inflammation with edema cells and even mitoses. Bony trabeculae, fat, or entrapped
and inflammatory polyps. In is not uncommon to see glands may also be seen.
lesions with hybrid features of both REAH and SH,
suggesting that the lesions exist at ends of a spectrum
ANCILLARY STUDIES
(see Fig. 1.22B).
CMH consists of irregular nodules of cartilage or
chondromyxoid stroma haphazardly arranged in the The role for immunohistochemistry in the diagnosis of
sinonasal submucosa (Fig. 1.23). The cartilage may be sinonasal hamartomas is limited. The glands of REAH are
A B
FIGURE 1.24
Low-grade nonintestinal sinonasal adenocarcinoma has fused, complex, back-to-back seromucinous glands without intervening stroma (A). In contrast, seromucinous
hamartomas have stroma between the seromucinous glands (B).
usually surrounded by basal cells that are positive for p63,

p40, and CK903, but SH typically lacks surrounded basal SINONASAL HAMARTOMAS—PATHOLOGIC FEATURES
or myoepithelial cells. Patients with CMH usually harbor
Gross Findings
germline or somatic mutations of DICER1 as part of the ■ REAH and SH appear as an edematous nasal polyp
pleuropulmonary blastoma tumor predisposition disorder; ■ CMH is a firm tan-white mass
CMH can be the presenting lesion of this syndrome.
■ REAH—downward proliferation of surface epithelial glands lined
DIFFERENTIAL DIAGNOSIS by pseudostratified ciliated epithelium
■ SH—proliferation of small seromucinous submucosal glands lined
by eosinophilic cuboidal epithelium

REAH may be confused with sinonasal inflammatory ■ CMH—irregular proliferation of variably mature cartilage nodules
polyps, although glandular proliferation not commonly in the sinonasal submucosa with fibrotic stroma
seen in polyps. Inverted sinonasal papilloma also
exhibits downward growth of surface epithelium, but Pathologic Differential Diagnosis
the epithelium of inverted sinonasal papilloma tends to ■ REAH: sinonasal inflammatory polyp, inverted sinonasal
be squamous or squamoid, thickened, and infiltrated by papilloma, biphenotypic sinonasal sarcoma

■ SH: low-grade nonintestinal sinonasal adenocarcinoma
neutrophils with microabscesses. Biphenotypic sinonasal ■ CMH: chondromyxoid fibroma, chondroma
sarcoma shows invaginations of the surface epithelium
reminiscent of REAH, but the cellular stromal spindle cell CMH, Chondromesenchymal hamartoma; REAH, respiratory epithelial
component and mixed neural and myogenic differentiation adenomatoid hamartoma; SH, seromucinous hamartoma.
is unique. REAH and especially SH can be confused

with a low-grade nonintestinal sinonasal adenocarcinoma.
Although low-grade nonintestinal sinonasal adenocarci-
noma is composed of similar-appearing small glands, it
is architecturally more complex, with fused glands and
papillary structures (Fig. 1.24A). Importantly, the glands
of SH and REAH, while proliferative, are also surrounded
by intervening stroma (see Fig. 1.24B). The absence of
basal/myoepithelial cells is not useful in the diagnostic All sinonasal hamartomas are treated with surgical exci-
distinction. sion, and the prognosis for each is excellent with recur-
CMH is more likely to be confused with a mesenchymal rences being uncommon.
process such as chondromyxoid fibroma or chondroma.
The young age of the patient and haphazard distribution
of the cartilaginous nodules are more in keeping with SUGGESTED READINGS
CMH. Moreover, chondromyxoid fibroma typically lacks The complete Suggested Readings list is available online at
well-formed hyaline cartilage. ExpertConsult.com.
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He went on to tell me about a question of property concerning two
golden heads. There is a mountain called Popa (5000 feet high) standing
right in the middle of the plain. We could see it from the back of the house. It
is an extinct volcano and is the home of two of the most important Nats in all
Burmah. They have lived on Popa ever since about 380 A.D. They were
brother and sister, and used to have a festival held on this mountain every
year in their honour.
About the middle of the eighteenth century one of the kings of Ava—
Bodawpaya—presented to the Popa villagers two golden heads, intended to
represent these Nats. At that time Popa village, for some reason, was a
separate jurisdiction outside the jurisdiction of the Pagan governor. What
happened was that these heads were kept in the Royal Treasury at Pagan for
safety, and taken up to Popa every year for the festival and brought back
again. Subsequently, Popa came under the jurisdiction of the Pagan
governor. Then apparently the Pagan people began to think that these heads
really belonged to them, and they were kept in Pagan until the annexation in
1886. After this, our Government, thinking they were very valuable relics
which ought to be preserved, sent them down to the Bernard Free Library in
Rangoon, where they have been lodged ever since.
Some time ago the Popa villagers sent in a petition that they might be
allowed to have their heads back, as they wanted them for the festival.
Investigations were started and about a month before my visit Mr Cooper
had been up to Popa and there dictated a written guarantee, signed by the
principal men of the village (the Lugyis, as they are called), that they would
undertake the responsibility of looking after these heads if they were given
back to them. Then Mr Cooper came to Pagan and had a meeting of the
Pagan Lugyis, asking them to sign a written repudiation of claim, and that's
where the matter rested.
I asked Mr Cooper to tell me the story of these famous Nats, in whose

honour a coconut is hung up in houses in this part of Burmah just as
regularly as we do for the tomtits at home, so that they can eat when they
like, and here is the story in his own words as he told it to me at Pagan.
These Nats have a good many names, but their proper names are
Natindaw and Shwemetyna, and they used to live in a place up the river
called Tagaung, a thousand years ago. Natindaw, the man, was a blacksmith.
He was very strong indeed—so strong that the King of Tagaung was afraid
of him and gave orders that he should be arrested. The man (he had not
become a Nat then) was afraid and ran away, but his sister remained and the
king married her. After some time the king thought of Natindaw again and
believed that although in exile he might be doing something to stir up
rebellion. So the king offered Natindaw an appointment at the Court, and
when Natindaw came he had him seized by guards and bound to a champak
tree near the palace. Then the King had the tree set on fire, and Natindaw
proceeded to burn up. Just at that moment the queen (Natindaw's sister)
came out of the palace and saw her brother being burnt. She rushed into the
fire and tried to save him, and failing, decided to share his fate.
The king then tried to pull her out by her back hair but was too late, and
both the brother and sister were utterly consumed except their heads. That
finished them as human beings, but they became Nats and lived up another
champak tree at Tagaung, and there, because they had been so shockingly
treated, they made up for it after death. They used to pounce on everyone
who passed underneath—cattle and people. At last the king had the tree with
the brother and sister on it cut down, and it floated down the river and
eventually stranded at Pagan. Well, the King of Pagan, who was at that time
Thurligyaung, had a dream the night before that something very wonderful
would come to Pagan the next day by river. In the morning he went down to
the bank and there he found the tree with the human heads of Natindaw and
Shwemetyna sitting on it, and they told him who they were and how badly
they had been treated. The king became very frightened and said he would
build them a place to live in on Popa. So they thanked him and he built them
Natsin, a little sort of hut on Popa, and there they have lived ever since.
Every year the kings of Pagan used to go in state and offer sacrifice to
Natindaw and Shwemetyna of the flesh of white bullocks and white goats,
and the Popa Nat story is still going on because of the latest development
about the golden heads.
It is a Burmese saying that no one can point in any direction at Pagan in

which there is not a pagoda, and on many of them in the mornings I saw
vultures—great bare-necked creatures—thriving apparently on barrenness.
Lack of water is the great trouble to the villages. The average rainfall in
this dry zone (which extends roughly from south of the Magwe district to
north of Mandalay) is fifteen to twenty inches.
Tenacious of life, these Thaton villagers of Pagan and Nyaungoo, led

into captivity by King Naurata, whose zeal as a religious reformer had been
fired by one of their own priests, survived their conquerors. They became,
nine hundred years ago, slaves attached to the pagodas, and under a ban of
separation, if not of dishonour, they have kept unmixed the blood of their
ancestors, are the only Burmese forming anything like a caste, and still
include some direct descendants of their famous king.
In the villages there is some weaving and dyeing of cloth, and quite a
large industry in the making of lacquer bowls and boxes.
It was not far to walk from the Circuit House to one of the villages,—
across the dry baked, brick-strewn earth, past great groves of cactus and
through the tall bamboo fence that surrounds the village itself. I passed a
couple of carts with primitive solid wheels, and under some trees in the
middle of the collection of thatched huts with their floors raised some feet
above the ground, a huge cauldron was sending up clouds of steam. Some
women were boiling dye for colouring cloth. This was Mukolo village. I
called at the house of U Tha Shein, one of the chief lacquer makers, and he
took me about to different huts to see the various stages of the work.
First, a "shell" is made of finely-plaited bamboo; this is covered with a

black pigment and "softened" when dry by turning it on a primitive lathe and
rubbing it with a piece of sand-stone. Then the red lacquer is put upon the
black box with the fingers, which stroke and smear it round very carefully.
In Burmese the red colour is called Hinthabada, from a stone I was told they
buy in Mandalay. The bowls now red are set to dry in the sun, and next are
placed in a hole in the ground for five days,—all as careful a process as that
of making the wine of Cos described in Sturge Moore's Vinedresser.
When they are exhumed after hardening, a pattern is finally engraved or

scratched on the lacquer with a steel point and a little gold inlaid on the more
expensive bowls.
I was going from house to house to see the different stages of the work,
when I heard a pitiful wailing and came upon the saddest sight I had yet seen
on my journey. The front of a thatched hut was quite open. A mangy yellow
pariah dog was skulking underneath, and some children were huddled silent
upon the steps leading up to the platform floor. There lay a little boy dead,
and his mother and grandmother were sorrowing for him. The grandmother
seemed to be wrinkled all over. Her back was like a withered apple. She
moaned and wailed, and tears poured from her eyes. "Oh! my grandson," she
cried—"where shall I go and search for you again?"
She was squatting beside the little corpse and pinching its cheeks and
moving its jaws up and down. "You have gone away to any place you like—
you have left me alone without thinking of me—I cannot feel tired of crying
for you."
And a Burman told me that the child had died of fever, and that the
father had gone to buy something for the funeral. He added, "The young
woman will never say anything—she will only weep for the children. It is
the old woman only that will say something."
CHAPTER V
MANDALAY
Christmas morning at Mandalay was bright, crisp and cold, with just that
bracing "snap" in the air that makes everyone feel glad to be in warm
clothes. On such a day the traveller feels a sense of security about the people
at home—they must be comfortable in London when it is so jolly at
Mandalay!
I was drawn by some Chinese characters over a small archway in

Merchant Street to turn up a narrow passage between high walls, which led
me to a modern square brick joss-house. There were several Chinese about
and I got to understand that the temple was especially for all people who
were sick or ill, and I went through the very ancient method of obtaining
diagnosis and prescription.
BURMESE PRIEST AND HIS BETEL BOX.
An English-speaking Chinaman told me that this temple was "the church

of Doctor Wah Ho Sen Too," who lived, he added, more than a thousand
years ago, and had apparently anticipated the advantages of Rontgen rays.
The American who is watching in Ceylon the formation of pearls without
opening of oysters, is yet far behind Doctor Wah Ho Sen Too, to whom all
bodies are as glass. The stout Chinaman grew quite eloquent in praise of this
great physician, explaining with graphic gestures how he had been able to
see through every part of all of us, and follow the career of whatever entered
our mouths.
In front of the round incense-bowl upon an altar, before large

benevolent-looking figures, was a cylindrical box containing one hundred
slips of bamboo of equal length (if any reader offers to show me all this at
Rotherhithe or Wapping, I shall not dispute with him but gladly avail myself
of his kindness). I was directed to shake the box and draw out at random one
of the bamboo slips. This had upon it, in Chinese characters, a number and
some words, and I was told that my number was fourteen. Upon the left-
hand wall of the temple were serried rows of one hundred sets of small
printed reddish-yellow papers. I was taken to number fourteen set and
bidden to tear off the top one, and this was Doctor Wah Ho Sen Too's
prescription.
I have not yet had that prescription made up; to the present day I prefer
the ailment, but I asked the English-speaking Chinaman what the medicine
was like, and he told me that it was white and that I could get it at Mandalay.
When he was in South America Waterton slept with one foot out of his
hammock to see what it was like to be sucked by a vampire, but I am of
opinion there are some things in life we may safely reject on trust, declining
taste of sample.
I went from the joss-house of Merchant Street to the Aindaw Pagoda,

about the middle of the western edge of the city, a handsome mass, blazing
with the brightness of recent gilding. From "hti" to base it was entirely gilt,
except for the circle of coloured glass balls which sparkled like a carcanet of
jewels near the summit. Outside the gate of the Aindaw Pagoda, where some
Burmans were playing a gambling game, a notice in five languages—
English, Burmese, Hindostani, Hindi and Chinese, announced, "Riding, shoe
and umbrella-wearing disallowed."
The Queen's Golden Monastery at the south-west corner of the town is a

finer specimen of gilded work, built in elaborately-carved teak, with a great
number of small square panels about it of figure subjects as well as
decorative shapes and patterns. Glass also has been largely introduced in
elaborate surface decoration at the Golden Monastery, not in the tiny tessarae
of Western mosaic but in larger facets, giving from the slight differences of
angle in the setting, bright broken lights almost barbaric in their richness. No
one seems to know where all the coloured and stained glass that is so
skilfully used in Burmese temples came from—whether it was imported or
made in the country.
The priests were returning to the monastery with bowls full of food from
their daily morning rounds, but there were very few people about at all, and
the place was almost given up that day to a batch of merry children, who
came gambolling round me, some of them pretending to be paralysed
beggars with quaking limbs.
It was very different at the Maha Myat Muni, the Arrakan Pagoda, which
was thronged with people like a hive of bees. This pagoda includes a vast
pile of buildings and enshrines one of the most revered images of Buddha, a
colossal brass figure seated in a shrine both gorgeous and elaborate, with
seven roofs overhead. Of shrines honoured to-day in Burmah the Arrakan
Pagoda is more frequented than any except the Shwe Dagon at Rangoon, and
is approached through a long series of colonnades gilded, frescoed, and
decorated with rich carving and mosaic work. They are lined with stalls of
metal-workers, sellers of incense, candles, violet lotus flowers, jewels,
sandalwood mementoes, and souvenirs innumerable, among which the most
fascinating to the stranger are grotesque toy figures, with fantastic movable
limbs, which would make an easy fortune at a London toy-shop, and before
long will doubtless be exported and gradually lose their exotic charm.
Passing through this Vanity Fair I at last reached the shrine, and in the
dim interior light I climbed up behind the great figure and followed the
custom of native pilgrims in seeking to "gain merit" by placing a gold-leaf
upon it with my own fingers. At all hours of every day human thumbs and
fingers are pressing gold-leaf upon that figure of Gautama. Outside in the
sunlight white egrets strutted about the grounds, and close by was a tank
where sacred turtles wallowed under a thick green scum. A swarm of rice-
sellers besought me to buy food for the turtles, and their uncomfortable
persistence was, of course, not lessened by patronage. The overfed animals
declined to show their heads, leaving the kites and crows to batten on the
tiny balls of cooked rice.
Now close to this turtle-tank and still within the precincts of the temple
was a large structure, evidently very much older than the rest of the
buildings—a vast cubical mass of red brick with an inner passage, square in
plan, round a central core of apparently solid masonry. Against one side of
this inner mountain of brick-work was the lower half of a colossal figure,
also in red brick, and cut off at the same level as the general mass of the
building. Whether the whole had ever been completed or whether at some
time the upper half had been removed, I could not tell. It was as if the
absence of head and shoulders cast a spell of death, which surrounded it with
a silence no voice ventured to dissipate, and with the noise and hubbub
outside nothing could have more strikingly contrasted than the impressive
quiet of this deserted sanctuary.
That Christmas afternoon, as already told, I left Mandalay on my way to

Bhamo, returning afterwards for a longer stay.
Far away, beyond Fort Dufferin on the other side of the city, rises
Mandalay Hill which I climbed several times for the sake of the wonderful
view. In the bright dazzle of a sunlight that made all things pale and
fairylike, I passed along wide roads ending in tender peeps of pale amethyst
mountains. I crossed the wide moat of Fort Dufferin, with its double border
of lotus, by one of the five wooden bridges and, traversing the enclosure,
came out again through the red-brick crenelated walls by a wide gateway,
and re-crossed the moat to climb the steep path by huge smooth boulders in
the afternoon heat. It was as if they had saved up all the warmth of noon to
give it out again with radiating force. At first the way lies between low
rough walls, on which at short intervals charred and blackened posts stand
whispering, "We know what it is to be burned"—"We know what it is to be
burned." They were fired at the same time as the temple at the top of the hill
over twenty years ago; but the great standing wooden figure of Buddha, then
knocked down, has been set up again, though still mutilated, for the huge
hand that formerly pointed down to the city lies among bricks and rubble.
The Queen's Golden Monastery and the Arrakan Pagoda were hidden
somewhere far away among the trees to the south of the city. Below, I could
see the square enclosure of Fort Dufferin, with its mile-long sides, in which
stands King Thebaw's palace and gardens, temples and pavilions, and I could
see the parallel lines of the city roadways. Mandalay is laid out on the
American plan, with wide, tree-shaded roads at right angles to each other.
Nearer to the hill and somewhat to the left lay the celebrated Kuthodaw or
four hundred and fifty pagodas, whereunder are housed Buddhist scriptures
engraved upon four hundred slabs of stone. The white plaster takes at sunset
a rosy hue, and in the distance the little plot resembles some trim flower-bed
where the blossoms have gone to sleep.
BURMESE MOTHER AND CHILD.
One of the loveliest things about Mandalay is the moat of Fort Dufferin.
In the evening afterglow I stopped at the south-west corner, where a boy was
throwing stones at a grey snake, and watched the silhouette of walls and
watch-towers against a vivid sky of red and amber and the reflections in the
water among the lotus leaves. Each side of the Fort is a straight mile long,
and the moat, which is a hundred yards across, has a wide space all along the
middle of the waterway quite clear of lotus. But moat and walls are both
most beautiful of all at sunrise. The red bricks then glow softly with warm
colour, and against their reflection the flat lotus leaves appear as pale hyaline
dashes.
Within, upon the level greensward, you may find to-day a wooden horse
—not such a large one as Minerva helped the Greeks to build before the
walls of Troy, nor yet that more realistic modern one I have seen in the great
hall, the old "Salone" of Verona—but a horse for gymnastic exercises of
Indian native regiments of Sikhs and Punjabis. Strange barracks those
soldiers have, for they sleep in what were formerly monasteries with halls of
carved and painted pillars.
I was asking the whereabouts of the only Burmese native regiment and
found it just outside Fort Dufferin, in "lines" specially built. It is a regiment
of sappers and miners. On New Year's Day Captain Forster, their
commanding officer, put a company of these Burmans through their paces
for me. In appearance they are not unlike Gourkhas, sturdy and about the
same height, and like the Gourkha they carry a knife of special shape, a
square-ended weapon good for jungle work.
King Thebaw's palace stands, of course, within the "Fort," which was
built to protect it. It is neither very old nor very interesting, and the most
impressive part is the large audience hall. The columns towards the entrance
are gilded, but on each side the two nearest the throne are, like the walls,
blood-red in colour, and the daylight filtering through casts blue gleams
upon them. It was not here, however, that the king was taken prisoner, but in
a garden pavilion a little distance from it with a veranda, and according to a
brass plate let into the wall below:—
"King Thebaw sat at this opening with his two queens

and the queen mother when he gave himself up to General
Prendergast on the 30th November, 1885."
I was talking one day with an army officer in a Calcutta hotel about
Burmah, and he told me how he himself had carried the British flag into
Mandalay with General Prendergast, and that it had been his lot to conduct
the Queen Sepaya (whom he declared does not deserve all that has been said
against her) to Rangoon, and he gave her the last present she received in
Burmah. She was smoking one of the giant cheroots of the country and he
gave her a box of matches.
I had never quite understood the annexation and that officer explained it
as follows:—"We knew the French were intriguing—that Monsieur Hass, the
French Ambassador at Rangoon, was working at the Court—and we got at
his papers and found he was just about to conclude a treaty with Thebaw.
The chance we seized was this—a difference between Thebaw and the
Bombay Burmah Trading Company. For their rights in forest-land in Upper
Burmah they paid a royalty on every log floated down. Now other people
were also floating logs down, and Thebaw claimed several lakhs of rupees
from the Bombay Burmah Company for royalties not paid. The Company
contended they had paid all royalties on their own logs, and that the unpaid
monies were due on other people's timber, and we seized the excuse and
took Mandalay in the nick of time, defeating the French plans."
The most noticeable feature of the Mandalay Bazaar is the supremacy of

the Burmese woman as shopkeeper. The vast block of the markets is newly
built and looks fresh and spick and span, though without anything about its
structure either beautiful or picturesque. It is like Smithfield and Covent
Garden rolled into one, and given over entirely to petticoat government. I am
told there are close upon 200,000 people in Mandalay, and those long
avenues of the great bazaar looked fully able to cope with their demands.
There is the meat-market, with smiling ladies cutting up masses of flesh; the
vegetable-market, with eager ladies weighing out beans and tamarinds; the
flour and seed-market, with loquacious ladies measuring out dal and rice-
flour and red chili and saffron powder; the plantain-market, with laughing
ladies like animated flowers decorating a whole street of bananas; the silk-
market, with dainty ladies with powdered faces enticing custom with deft
and abundant display of tissues and mercery,—and yet this does not tell one
half of the Mandalay Bazaar. I have not even mentioned the flower-market,
with piquant ladies—fully alive to the challenging beauty of their goods—
selling roses or lotus, with faces that express confident assurance of their
own superior charms.
Perhaps it is not hardness—perhaps it is merely some lack of

appreciation in me—but in spite of all that has been said or written in their
praise, I could not find those Burmese women as charming as the shop-girls
of London. I admit that they have a very smart way of twisting a little pink
flower into the right side of their hair, and although I have seen a great many
sleeping upon the decks of river steamers, I never heard one snore. Many
men find wives, I was told, in the Mandalay Bazaar, and they are said to
make excellent housekeepers. One perfectly charming little woman I did see,
the wife of an Eurasian engineer (or is not "Anglo-Indian" now the
prescribed word?), but she looked too much like a doll; and while a real doll
who was a bad housekeeper would be unsatisfactory enough, a good
housekeeper who looked like a doll would surely be intolerable.
Thinking of dolls brings me to the marionettes which still delight the

Burmese people. They have long since gone out of fashion in England,
"Punch and Judy" shows fighting hard to keep up old tradition; in Paris, the
"Guignol" of the side alleys of the Champs Elysees are nowadays chiefly
patronized by children, and you must go further East to find an adult
audience enjoying the antics of dolls. Marionettes had a vogue in ancient
Greece, and in Italy survived the fall of Rome. Even in Venice the last time I
went to the dolls' theatre I found the doors closed, but in Naples they flourish
still, and at the Teatro Petrilla in the sailors' quarter I have seen Rinaldo and
Orlando and all the swash-buckling courage of mediæval chivalry in
animated wood.
At Mandalay there is the same popular delight in doll drama, and one
evening I watched a mimic "pwe" for an hour. The story was another version
of that which I had already seen acted by living people. The showman had
set up his staging in a suitable position, with a wide and sloping open space
before it, and there was the same great gathering of young and old in the
open air, lying on low four-post bedsteads or squatting on mats, while
outside the limits of the audience stalls drove a thriving trade in cheroots and
edible dainties. How the people laughed and cackled with delight at the
antics of the dolls! These were manipulated with a marvellous dexterity, and
seemed none the less real because the showman's hands were often visible as
he jerked the strings. I walked up to the stage and stood at one end of it to
get the most grotesque view of the scene. A long, low partition screen ran
along the middle of the platform. Behind this, limp figures were hanging
ready for the "cues," and the big fat Burmese showman walked sideways up
and down, leaning over as he worked the dancing figures upon the stage.
The movements were a comic exaggeration of the formal and jerky actions
of the dance, but the clever manipulation of a prancing steed, a horse of
mettle with four most practical flamboyant legs, was even more amusing.
The parts of the dramatis personæ were spoken by several different

voices, and the absence of any attempt to hide the arms and hands of the
showman did not diminish the illusion, while it increased the general bizarre
character of the scene rather than otherwise, and was an excellent instance of
the fallacy of the saying—Summa ars est celare artem.
Blessed be the convention of strings! The success of a marionette show,

as of a government, is no more attained by a denial of the wire-puller's
existence than the beauty of a marble statue is enhanced by realistic
colouring.
CHAPTER VI
SOUTHERN INDIA, THE LAND OF HINDOO

TEMPLES
A long line of rocks and a white lighthouse in the midst of them—this is

the first sight of India as the traveller approaches Tuticorin, after the sea
journey from Colombo. He sees the sun glinting from windows of modern
buildings, the tall chimney of a factory and trailing pennons of "industrial"
smoke. Far to the left, hills faintly visible beyond the shore appear a little
darker than the long, low cloud above them. Then what had seemed to be
dark rocks become irregular masses of green trees. Colour follows form—
the buildings grow red and pink and white, and the pale shore-line a thread
of greenish-yellow. The sea near Tuticorin is very shallow, and the steamer
anchors at least four miles out, a launch crossing the thick yellow turbid
water to take passengers ashore. On nearer view the lighthouse proves to be
on a tree-clad spit or island, and to the left instead of the right of the harbour.
Near the jetty I saw large cotton-mills, and passed great crowds of ducks
(waiting to be shipped to Ceylon), which dappled the roadside as I made my
way to the terminus of the South Indian Railway. At first the train passes
through a flat sandy country with little grass, but covered with yellow
flowering cactus, low prickly shrubs and tall palmyra palms. The shiny
cactus and sharp-pointed aloe leaves seemed to reflect the bright blue of the
sky, and by contrast a long procession of small yellow-brown sheep looked
very dark.
Presently the ground changed to red earth and tillage. Then we passed
more aloes and bare sand and a few cotton-fields. A thin stream meandered
along the middle of a wide sandy bed, and a line of distant mountains, seen
faintly through the shimmery haze of heat, seemed all the while to grow
more lovely. Taking more colour as the day advanced they stretched along
the horizon like the flat drop-scene of a theatre, abruptly separate from the
plain. After passing several lakes like blue eyes in the desert some red
sloping hills appeared to make a link in the perspective, and I reached my
first stopping-place, the famous Madura.
First I drove to that part of the great temple dedicated to Minachi, Siva's
wife, and then to the Sundareswara Temple dedicated to Siva himself under
that name.
The typical Dravidian temple, the Southern form of the Hindoo style of
architecture, consists of a pyramidal building on a square base divided
externally into stories, and containing image, relic or emblem in a central
shrine. This Vimana is surrounded at some distance by a wall with great
entrance gateways or Gopuras, similar in general design to the central
building but rectangular instead of square in plan, and often larger and more
richly decorated outside than the Vimana itself. Then there is also the porch
of the temple or Mantapam, the tank or Tappakulam, the Choultry or hall of
pillars and independent columns or Stambhams, bearing lamps or images.
The Sacred Tank and the Rock, Trichinopoly.
It was a vast double door some distance in front of me, beyond a series
of wide passages and courts, a colossal door larger than those two of wood
and iron at the entrance to the Vatican, where the Swiss guards stand in their
yellow-slashed uniforms with the halberds of earlier days, doors with no
carving save that of worms and weather, but, like the one before me, more
impressive by tremendous size and appearance of strength than the bronze
gates of Ghiberti. It was a portal for gods over whose unseen toes I, a
pygmy, might crane my neck. The vast perspective in front, the sense of
possible inclusion of unknown marvels commensurate with such an
entrance, a mystery of shadow towards the mighty roof,—all made me stand
and wonder, admiring and amazed. Porch succeeded porch, with statues of
the gods, sometimes black with the oil of countless libations, sometimes
bright and staring with fresh paint. Dirt mingled with magnificence and
modern mechanical invention with the beauty of ancient art. Live men
moved everywhere among the old, old gods.
Walking along a corridor, astounded at its large grotesque sculptures, I

noticed at my elbow two squatting tailors with Singer sewing-machines,
buzzing as with the concentrated industry of a hive of bees. I wished that a
prick of the finger would send them all to sleep, tailors, priests, mendicants
and the quivering petitions of importunate maimed limbs.
Neither Darius nor Alexander, had they been able to march so far, could
have seen Madura, for, after all, these temples are not yet so very old, but
Buonaparte— Ah! he of all men should have seen it! I think of him on his
white horse, gazing with saturnine inscrutability at the cold waves of carved
theogonies surging, tier on tier, up the vast pyramids of the immense
gopuras, till the golden roofs of inner gleaming shrines drew him beyond.
Brief—oh how much too brief—was the time permitted me to spend at

Madura, for the same night I was to reach Trichinopoly.
I dressed by lamplight and was on the road just at dawn, driving through
the poorer quarter of the town. By a white gateway of Moorish design,
erected on the occasion of the last royal visit, and still bearing the legend
—"Glorious welcome to our future Emperor"—I entered the wide street of
the main bazaar at the far end of which the "rock" appeared.
Trichinopoly, inside this gate, is entirely a city of "marked" men, the

lower castes, together with the Eurasians and the few European officials
living outside its boundaries.
The great bare mass which rises out of the plain to a height of 273 feet
above the level of the streets below, was first properly fortified in the
sixteenth century, under the great Nayakka dynasty of Madura, by which it
was received from the King of Tanjore in exchange for a place called
Vallam; and after being the centre of much fighting between native powers
and French and English, it passed quietly into the hands of the latter by
treaty in 1801.
From the roadway at the foot a series of stone stairways leads to the
upper street, which encircles the rock and contains a hall from which other
stairways lead up to a landing with a hundred-pillared porch on each side of
it. In one of these lay in a corner with their legs in air a number of bamboo
horses, life-size dummies, covered with coloured cloths and papers for use in
the processions. On a still higher landing I reached the great temple (whither
the image of Siva was removed from its former place in a rock-temple at the
base of the precipice), which Europeans are forbidden to enter.
THE MAIN BAZAAR, TRICHINOPOLY.
By engaging a man in a long argument with Tambusami as interpreter,

about certain images visible as far within as I was able to see from the
landing, I managed to rouse a desire to explain rightly, so that he made the
expected suggestion and took me twenty yards within the forbidden
doorway. Deafening noise of "temple music" filled the air, the most strident
being emitted from short and narrow metal trumpets.
Twenty yards within that stone doorway guarded by the authority of

Government embodied in official placards fastened on the wall! Shall I
divulge the mysteries within? Indeed it would fill too many of these pages to
spin from threads of temple twilight a wonder great enough to warrant such
exclusion of the uninitiated.
Yet another flight of steps leads up round the outside to a final series
roughly cut in the rock itself, rising to the topmost temple of them all, a
Ganesh shrine, whence there is a grand view over the town and far
surrounding plain.
Among the smaller shrines in the streets the one which seemed to me the
most curious—was that of the "Black God, Karapanasami," a wooden club
or baluster similar in design to those carved in the hands of stone watchmen
at temple gates. Wreathed with flower garlands it leaned against the wall on
a stone plinth and was dripping with libation oil. I was told that
Karapanasami may be present in anything—a brick, or a bit of stone, or any
shapeless piece of wood.
Among the native people, quite apart from the would-be guides who
haunt the temples, those who speak a little English seem proud to display
their knowledge and ready to volunteer information. Before a statue of Kali
in a wayside shrine a boy ventured to say he hoped I would not irritate the
goddess, adding, "This god becomes quickly peevish; it is necessary to give
her sheep to quiet her."
That afternoon I painted the "Tappakulam" or tank at the base of the

great rock with the dainty "Mantapam" or stone porch-temple in the middle
of it, working from the box seat of a gharry to be out of the crowd, but their
curiosity seemed to be whetted the more, and Tambusami was kept busy in
efforts, not always successful, to stop the inquisitive from clambering the
sides of the vehicle, which lurched and quivered as each new bare foot tried
for purchase on the hub of a wheel.
The dazzling brilliancy of the scene was difficult to realize on canvas,

for beyond all other elements of brightness a flock of green parrots flying
about the roof sparkled like sun-caught jewels impossible to paint.
KARAPANASAMI, THE BLACK GOD.
The next morning I dressed by lamplight, and it was not yet dawn when
Tambusami put up the heavy bars across back and front doorways of my
room at the dak bungalow for the safety of our belongings during a day's
absence. Old Ratamullah, the very large fat "butler," watched us from his
own house a little further back in the enclosure, as in the grey light we
started to drive to Srirangam, and before the least ray of colour caught even
the top of the Rock we saw a group of women in purple and red robes
getting water at a fountain. The large, narrow-necked brass jars gleamed like
pale flames, the colour of the words John Milton that shine from the west
side of Bow Church in Cheapside.
Outside the houses of prosperous Hindoos I noticed, down upon the red
earth, patterns and designs that recalled the "doorstep art" practised by the
peasants in many parts of Scotland. The dust of the day's traffic soon
obscures the patterns, but at that early hour they had not yet been trodden
upon. Brass lamps glimmered in the poorer huts, but we were soon away
from Trichinopoly and crossing the long stone bridge over the Cauvery. The
river was very wide but by no means full, and scattered with large spaces of
bare sand. Over the water little mists like the pale ghosts of a crowd of white
snakes curled and twisted in a strange slow dance.
When we had crossed the thirty-two arches of this bridge we were upon
the island of Srirangam, on which there is that vast and, it is said, wealthy
temple to Vishnu, about which one is always told that its design ought to
have been turned inside out, as it becomes less imposing the farther one
penetrates within. To me it was one long succession of delights and wonders,
and in the freshness of the early morning I found an enjoyment in the crude
designs of gods and heroes, freshly painted in strong outline of burnt sienna
colour on whitewashed walls, as well as in the older elaborate and
sometimes beautiful carvings of pillar and panel, niche and architrave.
Adjoining the so-called hall of a thousand columns a great bamboo

scaffolding was being put up for the erection of an annexe roof, to be
supported by sixty temporary pillars to make the full complement for the
December festival. It was from here that I painted a sketch looking through
the great passage, festooned with dry and withered mano leaves, under the
White Tower, with a Gopura beyond, mauve in the early morning light. The
Ana on one of the temple elephants was very pertinacious in his demands for
backsheesh, and his very obedient servant caused me some inconvenience by
the way in which the end of his trunk kept appearing between my brushes
and palette.
Before driving back to Trichinopoly I stopped to have a good look at the

great outer gateway of the temple, a magnificent granite structure of a
different style to the rest of the buildings. It gives the appearance of breaking
off suddenly at a lower height than its completion would have attained, but
its splendid symmetry, its severe contours and its fine proportions stamp it
forever as a grand piece of architecture and confute those who speak of the
Dravidian style as careless or haphazard in planning.
All that it was possible for me to do in this part of Southern India was to
visit a few of the most important temples, and as they are well known and oft
described I will not devote much space to them here.
The chief in the Dravidian style after Madura and Trichinopoly is, of
course, Tanjore—much earlier in date, being of the fourteenth century, if not
much earlier still,—with a pyramidal sikra of thirteen storeys high (it is
surmounted by a spiked ornament, which gives its name to the construction),
and a stone Mantapam covering the famous Nandi, the colossal stone bull of
Siva, which is over 12 feet high and blackened with centuries of oil
anointings.
The temple is partly surrounded by the great walls and bastions of the
old fort of Tanjore and a wide moat, over which a bridge leads to the
gateway. All along the west and north sides of the great open space within
the walls runs a colonnade in which are placed, as in a long series of side-
chapels, 108 lingams. The walls of these cloister-like recesses are covered
with pictures of gods and miracles in sienna red, and on another side of the
enclosure is the superbly graceful later shrine, called Subramanya, to the
warrior son of Siva. The whole temple is attached to Tanjore Palace and
under the control of the Senior Ranee, Her Highness Matosree Jijayeeamba
Boyee Sahib.
The huge apartments of the five-storeyed palace are still inhabited by

this lady and her sister, also a widow, and a host of dependants. In the
courtyard stands a tower which served for many years as an armoury, and
still contains the wooden stands and racks used for storing guns. It is a
characterless stucco building, and its upper part has been for some time in a
dangerous condition; but I was well repaid for the long clamber up its dark
narrow stairway by the wide view from the top. In the palace there were
durbar halls to see and indifferent oil-paintings of the rajahs and their
ministers; but far more interesting than these is the old library, a famous
collection including many valuable manuscripts, of which a great number
are written on palm leaves. It was here I found, to my delight, the Elephant
Book. The words are older than the illustrations, and are the writings of a
certain rishi about all elephants. When the Hindoo librarian brought out this
treasure the daylight was rapidly going, and as I did not wish to see the
pictures by lamp-light, he had it carried outside for me and I turned the
pages to the sound of music, which was being played under a tree in a corner
of the courtyard. In the time of the rishi, elephants had wings, but the sound
of their flapping disturbed him when he wanted to rest, and that is why
elephants have no wings at all nowadays. In the pages of this book there
were painted elephants of every colour imaginable, and a large simple
treatment characterised the designs throughout. Some of the pictures made
me think of Blake, though they rarely contained human figures, and one of a
tree covered with little winged elephants reminded me of Blake's first vision
as a child when he saw a fruit tree full of winged cherubs.
Madras I would call the dusty town of interminable distances.

Everywhere seems to be miles away from everywhere else, and more liberal
space about public buildings was surely never seen. The great desideratum is
some kind of gliding shoe which will carry you back and forth at will,
without any demands upon the muscles of the leg.
About the middle of the great front is Fort St George, with its three and
four-storeyed barracks and officers' bungalows. It is of no strategic
importance, but there are very rightly stringent regulations against sketching
within its precincts. Thanks to the courtesy of the officers in charge I
obtained permission with regard to St Mary's Church where Clive was
married, and which claims to be not only the oldest English church in India,
but the oldest English building in India of any kind, dating from 25th March
1678, when the first sod was turned for its erection.
I had received a verbal permission from the commanding officer, but had
no sooner taken up my position than I was stopped by a sergeant. He insisted
on the need for a written permit. Now this involved a second walk of some
distance to the commanding officer's house, but I was sufficiently far from
any feeling of annoyance to smile at that sergeant, saying I would comply
with pleasure, and complimenting him on his zeal. His severe rejoinder was
a delicious contrast to the fluent suavity of Eastern politeness. Looking at me
sternly with flashing eyes, my compatriot exclaimed:—"Now look 'ere, don't
you give me none of your sarcasm neither!"
Most of the public buildings in Madras, such as the Railway Station, the
Government Offices and the Law Courts, are of red brick, and their
architecture an ingenious mixture of East and West.
Maimed and deformed beggars seem to abound. They come up to you

shaking their quivering limbs, showing you sores or touching your arm
softly with uncanny hands to draw your eyes to see some monstrous horror
of a leg.
I wanted, before leaving the South, to see the Nilgiris, and with this end
took train inland to Mettapalaiyam, where I changed on to the narrow gauge
railway which climbs one in twelve, a central rack-rail making such an angle
possible. As the engine was at the lower end I was able to sit on the extreme
front of the train and watch the scenery to advantage. A look-out man by my
side stopped the train in one deep cutting as we caught sight of a piece of
rock which had fallen from above and lay across the metals in front of us.
There were some coolies near at hand, and the obstacle was quickly
removed, but it dramatically suggested one of the dangers of mountain
railways.
The vegetation was very like that on the journey to Newara Eliya in
Ceylon; bamboos, areca-nut palms, plantains and the same little orange-
flowered shrub everywhere. Here and there the red earth showed but only
rarely for where there were no trees the ground was generally bare grey rock.
Hanging in gum trees or eucalyptus I noticed many paper nests of wasps. At
Runnymede Station, 4500 feet above sea-level, we were turned into a siding
for a down-coming train to pass. This was full of children shouting and
cheering loudly, coming away for Christmas holidays from the Lawrence
Asylum School at Ootacamund.
As we crossed small bridges over clefts and gorges I could see torrents
under my feet between the sleepers; and then, rugged and precipitous, the
hillside dropped below on one side and reared up on the other far above our
heads, as we crept along some narrow ledge.
At Coonoor, which was, at the time of my visit, still the end of the
railway, I shared a two-horse "tonga" with an engineer. He had been for
many years making railways in Assam, had been down with dysentery and
about to go home on leave when he was asked at Calcutta to get the "Ooty"
railway finished, and change of air and a "soft" job had decided him to take
the work.
HINDOO MOTHER AND CHILD.

A good linguist, he was fond of the natives generally and especially of
the Hindoos. Living for long periods sixty or seventy miles from any white
face, he had grown to dislike "society" and hated calling at the private
houses of officials. "They don't understand me," he said, "and they never
know the native as I know him. At the 'Holi' festival I make holiday with my
people. Early in the morning I go into their quarters, right into their houses
and throw the red water at their women, and then I have them all up to my
camp in parties and they dance to me and all have a royal time. Sometimes it
costs me three or four hundred rupees but I enjoy it, and they have few
pleasures in their lives. Put a lighted cracker in a Hindoo girl's hand and tell
her just when to throw it away, and the delight of it will last her for months.
Of course they buy a few fireworks themselves, but they can't afford the big
pieces and their joy well repays me. As to the talk of unrest, it's all bunkum,
—except among the baboos and a few mischievous priests in their pay. What
does the average native know about the partition of Bengal? He knows
nothing, as a rule, about political divisions at all, and as for wanting to be
ruled by his own people, the last thing in the world he wants is a native
judge. He knows well enough what that means—judgment for the side that
pays most. No—they get some Western learning, but they don't get made
straight. That's one of the reasons why it's impossible to give a native
engineer a top post anywhere. He can't resist bribery, and his sense of 'izzat'
makes him diddle his employers twice over. After all it is a point of honour
with your native not to take a bribe from an Englishman; he regards it as
entirely different from taking bribes from his own people. That is his sense
of 'izzat,' and to compensate for his loss of personal honour he must make
double out of the deal. The other reason is that a native always loses his head
in a crisis."
I do not think there was one thing this engineer said, except the last,
about which I had not heard the direct opposite from other Englishmen; but
he spoke from his own experience as they did, and the various views must be
weighed against each other.
"Ooty" was deserted. There were no happy holiday bachelors under

canvas tents on the club links, no one at all in the hotels. The place is not
unlike Newara Eliya from the scenic point of view as well as the social.
There were the same arum lilies growing near the lake.
Living in small huts on the hillside I saw a few Todas, some of the few
remaining of those early inhabitants of India allied to the Dravidians, but of
Scythian or Mongolian origin. Driven out by the Aryans, in their assumed
invasion from Central Asia, the Dravidians and their Mongolian cousins
were forced down to Southern India and Ceylon, remaining here and there
among the hills. The Todas number only a little over a thousand and are said
to be steadily decreasing in numbers. As they are polyandrous, it is indeed
surprising that any are left at all. Other tribes surviving from these early
peoples are the Bhils, Kols, Ghonds, Santals and Nagas.
"Ooty" is 2000 feet higher than Coonoor, but the finest mountain views
are from the latter neighbourhood. I drove back by night and all along the
road bullock-carts, with lanterns swinging underneath them, were slowly
plodding down with loads of coffee and tea. On the rack-railway there is
only passenger traffic, so they have to go all the way to Mettapalaiyam. The
drivers were all sound asleep and my "sayce" was on the road pretty often,
turning the cattle aside to let us pass. On one side the rocks rose
precipitously, and on the other stretched out a vast panorama of hills, clothed
in a dress more mystic than white samite, the soft pale clarity of moon-lit
mountain air.
It was very late when I reached the railway station, and finding all locked
up I slept on the pavement rolled in rug and ulster.
When I awoke at sunrise the Eastern sky was all rose and amber, and in
the sharp crisp morning air the bells of the horses jingled gaily as I drove up
through the woods above Coonoor, past snug villas now nearly all "to let"
for the season does not begin till February. A zigzag road it was, with roses
and wild heliotrope along its stone-built sides. The eucalyptus were 50 feet
high, rhododendrons with profusion of crimson blossoms grew to large trees,
and the graceful star-topped tree-ferns were very tall.
Suddenly rounding a corner of the road a majestic landscape broke upon

my sight, rising sheer out of plains which seemed to stretch away to a misty
infinity. There was a waterfall above the road, and the horses splashed
through a torrent under creepers hanging from bending tree-tops. Then the
road crept along a narrow ledge with four or five hundred feet of sheer drop
below. I left the carriage to climb to the view-point I wanted, near what is
called Lady Canning's Seat, and thence painted the Droog, the hill from the
steep summit of which Tippoo Sultan is said to have thrown his prisoners of
war. I have seen since other "blue mountains," and it was interesting to
compare the rich intensity of the colouring in the Nilgiris with the more
violet "bloom" of the gum-clad mountains of Australia, and especially this
view of the Droog with Govett's Leap, a scene in New South Wales of
similar configuration.
CHAPTER VII
CALCUTTA
In a heavy storm of rain, thunder and lightning early one Sunday

morning the British India Company's steamship Bengala, on which I had
travelled from Rangoon, began making her way up the Hooghly. Grey mud-
banks appeared vaguely in the stinging drift. There were toddy-palms here
and there and villages of thatched huts with plantains about them, the broad
green leaves standing out against the darker background. Leaves, blown on
the wind, whirled aimlessly across the dirty sea.
The few passengers on the Bengala were all eager to see "James and
Mary"; and beyond another village on a spit of sand with a crowd of small
fishing-boats at anchor, we passed the now celebrated spot where a couple of
masts still protruded above the water. All hands had been called to be ready
before we reached this fatal place, but no siren voices sounded from the
tragic sands.
At Budge Bridge, about 14 miles from Calcutta, where there are large oil
storage tanks, we began to pass jute-mills on the opposite bank and many
brick-making places. At Garden Reach we dropped the pilot and picked up
the Harbour Master just as a Natal coolie emigrant ship, the Umfuli, passed
us on her way out.

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HEAD AND NECK PATHOLOGY, THIRD EDITION ISBN: 978-0-323-47916-5

Previous editions copyrighted in 2013, 2006.

Library of Congress Cataloging-in-Publication Data

Names: Thompson, Lester D. R., editor. | Bishop, Justin A., editor.

Executive Content Strategist: Michael Houston

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Justin A. Bishop, MD Lester D.R. Thompson, MD

Diana Bell, MD James S. Lewis, Jr., MD

Lester D.R. Thompson, MD

■ RHINOSINUSITIS PATHOLOGIC FEATURES

Rhinosinusitis is defined simply as inflammation of the GROSS FINDINGS

Rhinosinusitis is a common condition that can be caused

Rhinosinusitis can also be idiopathic, with no known result of allergies or infection

Chronic rhinosinusitis (i.e., symptoms lasting longer

MICROSCOPIC FINDINGS RHINOSINUSITIS—PATHOLOGIC FEATURES

Rhinosinusitis exhibits sinonasal mucosa with a Gross Findings

cells are generally composed of lymphocytes, plasma cells,

including inflammation, squamous metaplasia (Fig. 1.3A),

SINONASAL INFLAMMATORY POLYPS—DISEASE FACT SHEET SINONASAL POLYPS—PATHOLOGIC FEATURES

Definition Gross Findings

■ An allergic etiology is most common

deposition can be seen.

stuffiness, headaches in allergic polyps)

Treatment and Prognosis The most prominent feature of a sinonasal inflammatory

However, the atypical stromal cells of benign polyps

be sure to exclude the presence of another sinonasal

Sex and Age Distribution

■ Radiographs show expanded sinus with bone erosion and

■ PARANASAL SINUS MUCOCELE ■ Treatment of underlying cause (usually chronic sinusitis)

Mucoceles of the paranasal sinus result from obstruction

squamous metaplasia, scarring, reactive bone, or cholesterol

neoplasm leading to obstruction

The main diagnostic consideration is normal sinonasal

neutrophils, Charcot-Leyden crystals, fibrin, and desqua-

CLINICAL FEATURES ALLERGIC FUNGAL SINUSITIS—DISEASE FACT SHEET

Sex and Age Distribution

■ Sinus contents with firm, rubbery, foul-smelling mucus

Grossly, the secretions of AFS are firm, thick, and

■ Long-term therapy may be needed to control relapses

sinonasal mucosa exhibits edema and chronic inflamma-

The histologic appearance of AFS may resemble non-

(Fig. 1.11A). Finally, AFS must be distinguished from

Treatment includes removal of the mucus as a means to

MICROSCOPIC FINDINGS ANCILLARY STUDIES

favors an encephalocele, but these features are often lost,

HEAD AND NECK PATHOLOGY, THIRD EDITION ISBN: 978-0-323-47916-5