Question:  A 53 year old woman presents to your clinic with a long history of nasal obstruction, recurrent pneumonias, and hearing loss.  She recalls being told in the past that she was "ANCA positive" but otherwise has sought no treatment for this.  An audiogram shows a mixed hearing loss, with a significant conductive component and type C tympanograms bilaterally.  Nasal endoscopy reveals thick crusts and irritated appearing mucosa throughout the nasal cavity.  Otoscopy reveals retracted drums and serous otitis media.  After cleaning the nasal cavity, you note areas of ulceration and elect to biopsy this tissue.  What pathologic findings would be most suggestive of the underlying diagnosis?

[Answer will be posted with next week's new question]

Answer to last week's question, Lumps and Bumps (Mar 2, 2015): 

First branchial cleft anomaly, Work type II.  First branchial cleft cysts represent the second most common branchial cleft anomaly (the most common is a 2nd cleft anomaly).  Without a tract to the skin, this would be termed a "second branchial cleft cyst".  With the tract, it would be a "sinus".  If a fistulous tract were identified originating in the neck and terminating in the tonsillar fossa, it would be a "fistula".