Squamous CellsSquamous Cells

Physiology:Physiology:Why is it important to Speech Why is it important to Speech

Pathologists?Pathologists?

Presented by Kelly GeorgePresented by Kelly George

OutlineOutline

PhysiologyPhysiology What can go wrongWhat can go wrong

Signs/SymptomsSigns/Symptoms What these things causeWhat these things cause What do we as Speech PathologistsWhat do we as Speech Pathologists

Squamous CellsSquamous Cells

Squamous refers to shape – flat except for Squamous refers to shape – flat except for nucleus making it bulge a little nucleus making it bulge a little

Do not receive direct blood supplyDo not receive direct blood supply Oxygen and nutrients travel through other Oxygen and nutrients travel through other

cells to reach squamous layerscells to reach squamous layers These cells renew frequentlyThese cells renew frequently

Types of Squamous (flat) CellsTypes of Squamous (flat) Cells

Simple – cells are flat, scale-like, in a Simple – cells are flat, scale-like, in a single layer supported by and underlying single layer supported by and underlying basement membrane.basement membrane. Where – mesothelium that lines all body Where – mesothelium that lines all body

cavities and covers all organs, and the cavities and covers all organs, and the endothelium that makes up the walls of the endothelium that makes up the walls of the capillaries and the inner lining of blood capillaries and the inner lining of blood vessels and lung air sacsvessels and lung air sacs

Function - protectFunction - protect Membrane - permeableMembrane - permeable

Types (cont.)Types (cont.)

Stratified – Flat & 2 or more layersStratified – Flat & 2 or more layers Where –Where –

Non-keratinizing = wet surfaces receiving Non-keratinizing = wet surfaces receiving significant wear and tearsignificant wear and tear

Inside mouth, esophagus, and anal canalInside mouth, esophagus, and anal canal

Keratinizing = same morphology but outer layer Keratinizing = same morphology but outer layer undergoes change to tough non-living layer of undergoes change to tough non-living layer of keratinkeratin

Function- protectFunction- protect Membrane - permeableMembrane - permeable

Vocal Fold EpitheliumVocal Fold Epithelium

Stratified squamous Stratified squamous Yes flat, but has microridges to increase Yes flat, but has microridges to increase

surface areasurface area Desmosomes help adhesion in deeper layers, Desmosomes help adhesion in deeper layers,

lesson closer to the surface to allow for lesson closer to the surface to allow for exfoliationexfoliation

Complete with nucleus, nucleolus, Golgi Complete with nucleus, nucleolus, Golgi Apparatus, rough endoplasmic reticulum, Apparatus, rough endoplasmic reticulum, lysosomes, mitochondria, and tonofiliments lysosomes, mitochondria, and tonofiliments that provide rigidity and resiliencethat provide rigidity and resilience

Vocal Fold: Basement MembraneVocal Fold: Basement Membrane Transitional area between squamous and Transitional area between squamous and

lamina proprialamina propria Secures the two layers togetherSecures the two layers together Disease: epidermolysisDisease: epidermolysis

Genetic basisGenetic basis Leads to incomplete formation of anchoring Leads to incomplete formation of anchoring

fibersfibers Fatal – skin can’t stay on bodyFatal – skin can’t stay on body

Some cancers secrete enzymes that “eat Some cancers secrete enzymes that “eat away” at the basement membrane, taking away” at the basement membrane, taking away its natural barrier for tumor growth.away its natural barrier for tumor growth.

Basil Cell LayerBasil Cell Layer

Vocal Fold: Lamina PropriaVocal Fold: Lamina Propria Ground substanceGround substance

Contains fluid and insterstitial matrixContains fluid and insterstitial matrix Under normal conditions, fluid is limitedUnder normal conditions, fluid is limited Tissue injury causes accumulation of fluid from Tissue injury causes accumulation of fluid from

capillaries - inflammationcapillaries - inflammation

FibroblastsFibroblasts Cells that synthesis most extracellular material Cells that synthesis most extracellular material

Collagen, elastin, and ground substanceCollagen, elastin, and ground substance

Elastic fibersElastic fibers Run parallel to vocal fold edgeRun parallel to vocal fold edge Can stretch to approx. 2 x natural length and return to Can stretch to approx. 2 x natural length and return to

natural shapenatural shape

Vocal Fold: Lamina Propria (cont.)Vocal Fold: Lamina Propria (cont.)

Collagenous fibersCollagenous fibers Also run parallel to vocal fold edgeAlso run parallel to vocal fold edge Gives resilienceGives resilience

FibronectinFibronectin Adhesive functions – made of proteinAdhesive functions – made of protein Important in wound healing Important in wound healing

Following injury, fibronectin is deposited on damaged collagen Following injury, fibronectin is deposited on damaged collagen serving as a scaffold for the tissue – lots of fibronectin in the lamina serving as a scaffold for the tissue – lots of fibronectin in the lamina propria indicates severe injury and reparationpropria indicates severe injury and reparation

Not removed after healing – Found in Nodules, not in PolypsNot removed after healing – Found in Nodules, not in Polyps CapillariesCapillaries GlandsGlands

SerousSerous MuousMuous

EdemaEdema Water retention – abnormal insterstitial fluid Water retention – abnormal insterstitial fluid

accumulation - can be seen in other parts of the body accumulation - can be seen in other parts of the body many timesmany times

What causes itWhat causes it InjuryInjury HormonesHormones

Renin – chemical reaction allowing angiotensin to constrict the Renin – chemical reaction allowing angiotensin to constrict the arterioles in the kidneys (and elsewhere) resulting in sodium arterioles in the kidneys (and elsewhere) resulting in sodium retention, causing H2O retention, and increasing arteriole pressureretention, causing H2O retention, and increasing arteriole pressure

Norepinepherine also resulting in renal constrictionNorepinepherine also resulting in renal constriction Aldosterone – transports sodium and potassium through renal Aldosterone – transports sodium and potassium through renal

tubular walls, and instead of getting rid of too much potassium, just tubular walls, and instead of getting rid of too much potassium, just increases fluid to balanceincreases fluid to balance

Birth control - progestinBirth control - progestin Liver/kidney disturbancesLiver/kidney disturbances Heart Failure – pulmonary edema Heart Failure – pulmonary edema

Edema – related to VoiceEdema – related to Voice Increased interstitial fluid in the lamina propria and the squamous Increased interstitial fluid in the lamina propria and the squamous

cells increases mass of the vocal folds – lowering voicecells increases mass of the vocal folds – lowering voice Reinke’s Edema – swelling of the superficial layer of the Lamina Reinke’s Edema – swelling of the superficial layer of the Lamina

propriapropria Often caused from smoking, Laryngo-pharyngeal reflux disease, and Often caused from smoking, Laryngo-pharyngeal reflux disease, and

straining to produce voice.straining to produce voice. High Sopranos can lose entire top octaveHigh Sopranos can lose entire top octave Females may not appreciate lowering of voice if they depend on Females may not appreciate lowering of voice if they depend on

using their voice for their job.using their voice for their job. Morning vs. EveningMorning vs. Evening

Wake up – arms and faceWake up – arms and face Evening – legs and feetEvening – legs and feet Gravity pulls it down, thus voice would probably be most effected in the Gravity pulls it down, thus voice would probably be most effected in the

morning.morning. After Cancer treatment, edema lasting 3 months or more suggests After Cancer treatment, edema lasting 3 months or more suggests

residual cancer cells or a recurrent tumor developing.residual cancer cells or a recurrent tumor developing.

Edema: What can people do?Edema: What can people do? Lie down in day time – distributes more evenly – won’t help with the Lie down in day time – distributes more evenly – won’t help with the

voice.voice. Avoid tight fitting clothesAvoid tight fitting clothes ExerciseExercise Include diuretic foodsInclude diuretic foods

Anise, Celery, Onion, Parsley, Coffee or tea (unless caffeine is a Anise, Celery, Onion, Parsley, Coffee or tea (unless caffeine is a concern), Eggplant, Garlic, and Peppermint.concern), Eggplant, Garlic, and Peppermint.

Diuretic drugs may not be safe during pregnancyDiuretic drugs may not be safe during pregnancy Birth ControlBirth Control

Squamous cells on vocal folds same type as on cervix, thus very Squamous cells on vocal folds same type as on cervix, thus very sensitive to birth control hormone progestinsensitive to birth control hormone progestin

New BC on market targeting women who experience weight gain while New BC on market targeting women who experience weight gain while on the pill – Yasmin – uses different form of progestin - drospirononeon the pill – Yasmin – uses different form of progestin - drospironone Has diuretic propertiesHas diuretic properties However loss of too much water and sodium may raise potassium levelsHowever loss of too much water and sodium may raise potassium levels This can create severe heart concernsThis can create severe heart concerns Those with kidney or liver disease should not take thisThose with kidney or liver disease should not take this

Nodules & PolypsNodules & Polyps

Nodes – fibronectin depositsNodes – fibronectin deposits

Polyps Polyps Primary injury in Lamina PropriaPrimary injury in Lamina Propria Basement membrane not usually injuredBasement membrane not usually injured Reinke’s EdemaReinke’s Edema

Keratinocyte Cancer:Keratinocyte Cancer: Squamous Cell Carcinoma Squamous Cell Carcinoma

Happens all over the body: Along with Basal Cell Happens all over the body: Along with Basal Cell Carcinoma = the most common type of skin cancer (but Carcinoma = the most common type of skin cancer (but not most lethal = melanoma). not most lethal = melanoma).

Underrepresented in registries, and combined with BCC Underrepresented in registries, and combined with BCC in studies – little known about SCC incidence and in studies – little known about SCC incidence and patterns specifically. patterns specifically. Numbers rising about 3 – 10% each yearNumbers rising about 3 – 10% each year One source: SCC most commonly found in head and neck in One source: SCC most commonly found in head and neck in

Caucasians Caucasians While another source said the reverse.While another source said the reverse. In darker pigmented individuals (Africans, East Asians, South In darker pigmented individuals (Africans, East Asians, South

Asians) often in areas of chronic injury or cutaneous irritationAsians) often in areas of chronic injury or cutaneous irritation Leg ulcers, burn scars, skin infections, irritation from tight clothingLeg ulcers, burn scars, skin infections, irritation from tight clothing Most often in lower extremitiesMost often in lower extremities

SCC in LarynxSCC in Larynx

Most tumors can be readily seen, palpated, Most tumors can be readily seen, palpated, evaluated and biopsies easily taken. evaluated and biopsies easily taken.

Early may appear as an nodule that won’t go Early may appear as an nodule that won’t go away or shallow ulcer with poorly defined edgesaway or shallow ulcer with poorly defined edges

Tumors may be exophytic or infiltrative and may Tumors may be exophytic or infiltrative and may extend rapidly into underlying muscle tissue extend rapidly into underlying muscle tissue causing fixation causing fixation May result in fixation – difficulty with swallowing and May result in fixation – difficulty with swallowing and

speechspeech Tumors usually respond well to radiation therapy Tumors usually respond well to radiation therapy

if caught in time, especially if they are still limited if caught in time, especially if they are still limited to the mucosa.to the mucosa.

Cellular ChangesCellular Changes Intracellular edema – due to protein imbalance within the Intracellular edema – due to protein imbalance within the

cell and interstitiallycell and interstitially Inflammatory cell infiltrationInflammatory cell infiltration Increase of mucosal collagenIncrease of mucosal collagen Wrinkling of basement membraneWrinkling of basement membrane ““Disorganized” layering of the cellsDisorganized” layering of the cells Appearance of keratohyalin in the cells adjacent to the Appearance of keratohyalin in the cells adjacent to the

basement membranebasement membrane Dispersing of nuclear chromaticDispersing of nuclear chromatic Multiple nucleoli with abnormal shapesMultiple nucleoli with abnormal shapes Lack of cellular maturationLack of cellular maturation Presence of mitotic figures near superficial layerPresence of mitotic figures near superficial layer www.emedicine.comwww.emedicine.com – – excellent source of informationexcellent source of information

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If the squamous cells on the vocal folds are non-If the squamous cells on the vocal folds are non-keratinizing, then why is the laryngeal squamous keratinizing, then why is the laryngeal squamous cell carcinoma a keratinocyte cancer?cell carcinoma a keratinocyte cancer? Keratosis = the production of keratin superficially in Keratosis = the production of keratin superficially in

the epithelium and is a normal process on the skin, the epithelium and is a normal process on the skin, but not on a mucosal surface. Keratin appears dull but not on a mucosal surface. Keratin appears dull white, think or thick, and sometimes rough and white, think or thick, and sometimes rough and papillary. It does not rub off. (Leukoplakia)papillary. It does not rub off. (Leukoplakia) Note the word Leukoplakia has clinically become known for Note the word Leukoplakia has clinically become known for

non-white atypical specimens.non-white atypical specimens.

KeratosisKeratosis

Keratosis without atypia is usually benign Keratosis without atypia is usually benign (as described in class) – can be callus like.(as described in class) – can be callus like.

Hyperkeratosis – redundant term used for Hyperkeratosis – redundant term used for white horny projections from the vocal white horny projections from the vocal folds. Often are recurring and are folds. Often are recurring and are considered well differentiated carcinomas.considered well differentiated carcinomas.

Keratosis with atypia – dry reddend, Keratosis with atypia – dry reddend, thickend, roughend, or granular patches. thickend, roughend, or granular patches. Needs to be removed to be tested.Needs to be removed to be tested.

Other terms:Other terms: Carcinoma in situCarcinoma in situ

Malignant cells present – confined to the epithelial layersMalignant cells present – confined to the epithelial layers ErythroplasiaErythroplasia

A superficial flat lesion that is red velvet in appearance and bleeds A superficial flat lesion that is red velvet in appearance and bleeds easily.easily.

Represents atypia on the mucosal surfaceRepresents atypia on the mucosal surface Is at least carcinoma in situ, and may be associated with invasive carcinomaIs at least carcinoma in situ, and may be associated with invasive carcinoma

InvasionInvasion Any pattern of malignant epithelial cells down to the basement Any pattern of malignant epithelial cells down to the basement

membranemembrane May occur without surface abnormalityMay occur without surface abnormality

MetaplasiaMetaplasia The transformation of an adult cell type into another cell type – typically The transformation of an adult cell type into another cell type – typically

glandular epithelium changes to squamous epithelium. Metaplasia glandular epithelium changes to squamous epithelium. Metaplasia sometimes precedes squamous cell carcinoma.sometimes precedes squamous cell carcinoma.

Effects of Radiation TherapyEffects of Radiation Therapy If cancer returns, radiation may not be an option If cancer returns, radiation may not be an option

because the tumor may be the result of cells that were because the tumor may be the result of cells that were left over from the first course of radiation, and apparently left over from the first course of radiation, and apparently resistant to it.resistant to it.

Pain may be worse than that which results from surgery, Pain may be worse than that which results from surgery, and the elderly seem not to tolerate the radiation well.and the elderly seem not to tolerate the radiation well.

If done after laryngectomy, may prevent recurrence in If done after laryngectomy, may prevent recurrence in the stoma ( which is very bad!!!) if there is any thought of the stoma ( which is very bad!!!) if there is any thought of undetected metastisis.undetected metastisis.

May cause significant edema (rare), usually edema May cause significant edema (rare), usually edema shows recurrenceshows recurrence

May cause laryngeal chondritis and necrosis (rare)May cause laryngeal chondritis and necrosis (rare) Late sequelae may involve telangiectasis, subcuntaeous Late sequelae may involve telangiectasis, subcuntaeous

fibrosis, or an immobile laryinxfibrosis, or an immobile laryinx

Genetics on the Squamous cells (in Nucleus)Genetics on the Squamous cells (in Nucleus) Genetic studies show that sporadic SCC’s have allelic loss on several Genetic studies show that sporadic SCC’s have allelic loss on several

chromosomes, most of the sites for mutations are unknown. chromosomes, most of the sites for mutations are unknown. Environmental factors can initiate the mutationsEnvironmental factors can initiate the mutations Tumor suppressor gene, TP53, mutated from UV rays with substitutions Tumor suppressor gene, TP53, mutated from UV rays with substitutions

of nucleic acids of nucleic acids Thymine-thymine for Cytosine-Cytosine in the DNA – If this doesn’t kill Thymine-thymine for Cytosine-Cytosine in the DNA – If this doesn’t kill

the cell itselfthe cell itself In Sporadic cases, the mutation must be present at more than siteIn Sporadic cases, the mutation must be present at more than site

Proteins in the membrane of the squamous cells have been found to Proteins in the membrane of the squamous cells have been found to have tumor suppressing properties – if cell doesn’t produce these have tumor suppressing properties – if cell doesn’t produce these proteins more susceptible to tumorproteins more susceptible to tumor

Environmental irritantsEnvironmental irritants Smoking/tobacco & alcoholSmoking/tobacco & alcohol AsbestosAsbestos Heavy metalsHeavy metals Chronic Irritation – GERD & LPRDChronic Irritation – GERD & LPRD

Cessation of Smoking found to decrease chances for Lung Cancer, Cessation of Smoking found to decrease chances for Lung Cancer, but not Laryngeal Squamous Cell Carcinomabut not Laryngeal Squamous Cell Carcinoma

HPVHPV

Human Papilloma virus may be found in 15%-50% of Human Papilloma virus may be found in 15%-50% of Squamous cell carcinomas depending on where in the Squamous cell carcinomas depending on where in the body. body.

HPV is present in 90% of cervical cancers.HPV is present in 90% of cervical cancers. Beginning in the 1980’s, HPV was starting to be found in Beginning in the 1980’s, HPV was starting to be found in

oral squamous cell carcinomas.oral squamous cell carcinomas. HPV stops normal cell growth regulatory processes to HPV stops normal cell growth regulatory processes to

support the growth/survival of the virus.support the growth/survival of the virus. Also targets TP53, which would self destruct mutated Also targets TP53, which would self destruct mutated

cell.cell. Leads to immortal cellsLeads to immortal cells

Epstein-Barr VirusEpstein-Barr Virus

Main virus to cause Mono-NucleosisMain virus to cause Mono-Nucleosis A few studies have shown EB viral DNA in A few studies have shown EB viral DNA in

squamous cell carcinoma cells.squamous cell carcinoma cells. Further investigation is being conductedFurther investigation is being conducted

As SLPs.As SLPs.

We see patient much more often than the We see patient much more often than the doctors – may be the first to hear a complaint. doctors – may be the first to hear a complaint. We need to be able to know if it is a concern.We need to be able to know if it is a concern.

When dealing with the medical community, we When dealing with the medical community, we should be able to know language or at least be should be able to know language or at least be able to know where to find the info.able to know where to find the info.

Patients may ask us what the doctor meant.Patients may ask us what the doctor meant. The voice is delicate, and the cells are very The voice is delicate, and the cells are very

similar to many throughout the body. Voice may similar to many throughout the body. Voice may be effected before symptoms elsewhere.be effected before symptoms elsewhere.

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Works Cited (cont.)Works Cited (cont.)Gilbert, S. (n.d.). iVillage nutritionist. Gilbert, S. (n.d.). iVillage nutritionist. Bloating: Foods to Fight Water Retention. Bloating: Foods to Fight Water Retention.

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