Download diseases of the oral cavity and oropharynx

DISEASES OF THE ORAL
CAVITY
Prof. İlhan TOPALOĞLU
Otolaryngology Department
Yeditepe University
School of Medicine
ANATOMY OF THE ORAL
CAVITY
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anterior : vermillion
border of the lips
posterior: oropharynx
oropharyngeal isthmus :
(superior) junction of the
hard and soft plates .
(lateral) anterior tonsillar
pillars
(inferior) the line of the
circumvallate papillae
ANATOMY OF THE ORAL CAVITY
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Lips
Anterior portion of the tongue
Buccal mucosa
Upper and lower alveolar ridges
Retromolar trigone
Floor of the mouth
Hard palate
Exam: Lips
Exam: Lips-palpation
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Color, consistency
Area for blocked minor salivary
glands
Lesions, ulcers
Pyogenic granuloma
Fibroma
Lip cancer
Lower lip carcinoma
CANCERS OF THE LIP
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88-98% lower lip
2-7% upper lip
0,09-6,1% oral commisure
Male and older than 60 years old 
SCC 
Basal cell ca, melanoma, minör salivary
gland tm.
Sensory innervation of the
tongue
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1 – chorda tympani
and lingual nerve
2 – glossopharyngeal
nerve
3 – vagal nerve
Motor innervation of the tongue
Extrinsic muscles of the tongue are innervated by cranial
nerve XII
-Genioglossus
-Hyoglossus
-Styloglossus
-Palatoglossus
 Intrinsic muscles of the tongue are also innervated by
cranial nerve XII
-Superior longutudinal
-Inferior longutudinal
-Vertical
-Transverse
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Exam: Tongue
Exam: Tongue
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You may observe
lingual varicosities
Exam: Tongue
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You may observe geographic
tongue (erythema migrans)
Exam: Tongue
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You may observe drug reaction
Exam: Tongue
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Observe signs of nutritional
deficiencies
Hairy Leukoplakia
Hemangioma
Granular Cell Tumor
Exam: Tongue
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You may observe
cancer
CANCER OF THE ANTERIOR
PORTION OF THE TONGUE
Tongue ca.
Tongue ca.
CANCERS OF TONGUE
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Lateral border
Ocult met. 30%
No  supraomohyoid dissection
T1- T2 surgery or RT
T3- T4 surgery+RT
Stage, nodal metastases, lenfovasculer,
perineural invasion and thickness of tumor
are important prognostic factors.
Examination: Buccal Mucosa
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Linea alba
Stenson’s duct
Examination: Buccal Mucosa
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Lesions – white, red
Lichen Planus, Leukedema
CANCER OF THE BUCCAL MUCOSA
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Advanced stage
Tm pterigoid muscles, maxilla, mandible, skin
clinic N(+)RND or MRND + cheek resection
There is no natural barrier
T1 surgery or RT
T2 surgery or RT
T3 and T4 surgery+ RT
Ameloblastoma
Gingival cyst
Malignant Melanoma
Mucoepidermoid tumor
CANCERS OF THE GINGIVA AND
ALVEOLAR RIDGE
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80 % lower gingiva and 1/3 posterior region.
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Incidance of mandibular invasion rate is high
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upper gingiva invasion of maksillary sinus
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Pull out the tooth invasion of bone marrow
uncommon
Lower jaw ( posterior 1/3 dental arch)
Marginal mandibular resection
Stage 1-2 , surgery
Stage 3-4 ,surgery+ (+) neck MRND
(-) Neck Rtx
Exam: Retromolar trigone
Exam: Retromolar trigone
Edentulous
RETROMOLAR TRİGONE CA
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Uncommon
Invasion of mandible
Late diagnose , advanced stage, cervical
metastases are bad prognostic factors
T1 T2 surgery or RT
T3 T4 surgery + RT
Exam: Floor of mouth
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Visualize, palpate - bimanually
Wharton’s duct
Must dry to observe
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Does “lesion” wipe off?
Where are the two most
likely areas for oral cancer?
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lateral border of the tongue
Floor of mouth
Exam: Floor of mouth
Palpation of the floor of the mouth
Exam: Floor of mouth
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Squamous Cell Carcinoma
Squamous Cell Carcinoma
FLOOR OF THE MOUTH CA.
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Incidance of mandibular invasion rate is
high
Ocult met  10-30%
Primary resection of the floor of the mouth
is peformed with ipsilateral or bilateral
neck dissection (if the tumor is located at
the midline)
Exam: Hard palate
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Minor salivary glands
Median Palatal Cyst
CANCER OF THE HARD PALATE
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uncommon
SCC and Adenoid cystic ca
Misdiagnosed as maxillary sinus tm
Incidance of neck metastases is low
Elective neck treatment is unnecessary
Prostodontist
ORAL PREMALİGNANCY
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Leukoplakia
Erythroplakia
Mucosal atrophy
MALIGNANT LESIONS
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SQUAMOUS CELL CARCINOMA
VERRUCOUS CARCINOMA
MINOR SALIVARY GLAND TUMOURS
SARCOMATOID CARCINOMAS
MALIGNANT MELANOMA
PATIENT EVALUATION
Diagnosis
Neoplasms of the oral cavity
Complete head and neck examination
Chest x-ray and liver function tests plus additional
laboratory tests dictated by patient’s medical history
CT/MRI scan for extent of primary and possible cervical
nodal evaluation
Dental evaluation
Radiotherapy evaluation
Staging endoscopy and biopsy
ETIOLOGY
Risk factors for oral cavity and
oropharyngeal cancer include:
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Cigarette
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Alcohol
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Exposure to the human papilloma
virus (HPV) or Epstein-Barr virus
(EBV)
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ionizing radiation
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Prolonged sun exposure,
especially linked to cancer in the
lip area and skin cancer.
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Fair skin, also linked to lip cancer
and skin cancer.
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Age. People over the age of 45
years old are at increased risk for
oral cancers (though it can
develop in people of any age).
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Poor nutrition.
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Irritation from poorly fitting
dentures in people who use
alcohol and tobacco products.
Chewing betel nuts, a nut
containing a mild stimulant
popular in Asia.
Weakened immune system.
Vitamin A deficiency.
A rare condition called PlummerVinson Syndrome, which involves
iron deficiency and causes
difficulty swallowing.
Gender. Men are more likely to
get lip cancer than women.
lichen planus
discoid lupus erythematosus
dystrophic epidermolysis bullosa
Symptoms
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Otalgia
Odynofagia
Bleeding
Dysfagia
Loss of teeth
Restriction of mouth movement
Trismus
EPIDEMIOLOGY
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95 % SCC
95 % patiet  40 years old
Mean age 60 years old
After the treatment of oral cavity ca if the
patient doesn’t give up smoking, second
primary or recurrence rate is 40 %
CARCINOGENESIS
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tobacco
ionizing radiation
dental travma and poor
oral hygiene
alcohol
tertiary syphilis
human papilloma virus
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candida albicans
some nutritional factors
oral submucous fibrosis
lichen planus
discoid lupus
erythematosus
dystrophic epidermolysis
bullosa
dyskeratosis congenita
TREATMENT
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surgery
RT
surgery + RT
KT + RT
Surgery + RT + adjuvant KT
The last cigarette
DISEASES OF OROPHARYNX
Prof. Dr. İlhan TOPALOĞLU
Otolaryngology Department
Yeditepe University
School of Medicine
ANATOMY OF THE OROPHARYNX
Anterior : oropharyngeal
isthmus;
(superior) junction of the
hard and soft plates .
(lateral) anterior tonsillar
pillars
(inferior) the line of the
circumvallate papillae
İnferior: the plane of the
hyoid bone
OROPHARYNX
SUBSIDES
 Soft palate and uvula
 Base of the tongue
 Tonsillar region
(tonsillar fossae and
pillars)
 Oropharyngeal walls
(lateral and posterior)
Diseases of the Tonsils & Adenoid
Waldeyer's ring
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Waldeyer's tonsillar ring (or
pharyngeal lymphoid ring) is an
anatomical term describing the lymphoid
tissue ring located in the pharynx and to
the back of the oral cavity.
It was named after the nineteenth century
German anatomist Heinrich Wilhelm
Gottfried von Waldeyer-Hartz.
Waldeyer's ring
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Pharyngeal tonsil (also known
as 'adenoids' when infected)
Tubal tonsil (where Eustachian
tube opens in the
nasopharynx)
Palatine tonsils (commonly
called "the tonsils" in the
vernacular, less commonly
termed "faucial tonsils")
Lingual tonsils
Anatomy
Tonsils
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Between arcus
palatoglossus (ant
plica) and arcus
palatofaryngeus (post
plica)
Adenoids
Blood Supply
Tonsils
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Ascending and
descending palatine
arteries
Tonsillar artery
1% aberrant ICA just
deep to superior
constrictor
Adenoids
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Ascending pharyngeal,
sphenopalatine arteries
Histology
Tonsils
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Specialized squamous
Extrafollicular
Mantle zone
Germinal center
Adenoids
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Ciliated pseudostratified
columnar
Stratified squamous
Transitional
Common Diseases of the Tonsils
and Adenoids
Acute adenoiditis/tonsillitis
 Recurrent/chronic
adenoiditis/tonsillitis
 Obstructive hyperplasia
 Malignancy
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Acute Adenotonsillitis
Etiology
 5-30% bacterial; of these
39% are beta-lactamaseproducing (BLPO)
Streptococcus pyogenes
(Group A beta-hemolytic
streptococcus GABHS
most important pathogen
because of potential
sequelae
Microbiology of Adenotonsillitis
Most common organisms cultured from
patients with chronic tonsillar disease
(recurrent/chronic infection, hyperplasia):
 Streptococcus pyogenes (Group A betahemolytic streptococcus)
 H.influenza
 S. aureus
 Streptococcus pneumoniae
Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis
Malignancy: lymphoma, leukemia, carcinoma
Diptheria
Scarlet fever
Agranulocytosis
Medical Management
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PCN is first line, even if throat culture is negative for
GABHS
Antibiotics aimed against BLPO and anaerobes
For acute UAO: IV abx, NP airway, steroids, and
immediate tonsillectomy for poor response
Obstructive Hyperplasia
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Adenotonsillar hypertrophy most common cause
of SDB in children
Diagnosis
Indications for polysomnography
Interpretation of polysomnography
Perioperative considerations
Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
 Acute infective
 Chronic infective
 Hypertrophy
 Congenital
Neoplastic
Peritonsillar Abscess
ICA Aneurysm
Pleomorphic Adenoma
Toncil ca.
Papilloma
Other Tonsillar Pathology
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Hyperkeratosis,
mycosis
leptothrica
Tonsilloliths
Candidiasis
Syphilis
Retention Cysts
Supratonsillar Cleft
Indications for Tonsillectomy
Paradise study
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Frequency criteria: 7 episodes in 1 year or 5
episodes/year for 2 years or 3 episodes/year for
3 years
Clinical features (one or more): T 38.3, cervical
LAD (>2cm) or tender LAD; tonsillar/pharyngeal
exudate; positive culture for GABHS; antibiotic
treatment
Indications for Tonsillectomy
AAO-HNS:
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3 or more episodes/year
Hypertrophy causing malocclusion, UAO
Halitosis, not responsive to medical
therapy
UTE, suspicious for malignancy
Individual considerations
Indications for Adenoidectomy
Paradise study (1984)
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28-35% fewer acute episodes of OM with
adenoidectomy in kids with previous tube placement
Adenoidectomy or T & A not indicated in children with
recurrent OM who had not undergone previous tube
placement
Gates et al (1994)
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Recommend adenoidectomy with M & T as the initial
surgical treatment for children with MEE > 90 days and
CHL > 20 dB
Indications for Adenoidectomy
Obstruction:
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Chronic nasal obstruction or obligate mouth breathing
OSA with FTT, cor pulmonale
Dysphagia
Speech problems
Severe orofacial/dental abnormalities
Infection:
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Recurrent/chronic adenoiditis (3 or more episodes/year)
Recurrent/chronic OME (+/- previous BMT)
PreOp Evaluation of Adenoid
Disease
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Triad of hyponasality,
snoring, and mouth
breathing
Rhinorrhea, nocturnal
cough, post nasal drip
“Adenoid facies”
“Milkman” & “Micky
Mouse”
Overbite, long face,
crowded incisors
PreOp Evaluation of Adenoid
Disease
Evaluate palate
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Symptoms/FH of CP
or VPI
Midline diastasis of
muscles, bifid uvula
CNS or
neuromuscular
disease
Preexisting speech
disorder?
PreOp Evaluation of Adenoid
Disease
Lateral neck films are
useful only when
history and physical
exam are not in
agreement.
Accuracy of lateral
neck films is
dependent on
proper positioning
and patient
PreOp Evaluation of Tonsillar
Disease
History
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Documentation of episodes by physician
Cor pulmonale
Poststreptococcal GN
Rheumatic fever
PreOp Evaluation of Tonsillar
Disease
TONSIL SIZE
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0 in fossa
+1 <25%
occupation of
oropharynx
+2 25-50%
+3 50-75%
+4 >75%
Avoid gagging the patient
PreOp Evaluation for
Adenotonsillar Disease
Coagulation disorders
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Historical screening
CBC, PT/PTT, BT, vWF activity
Hematology consult
von Willebrand’s disease
ITP
Sickle cell anemia
Principles of Surgical
Management
Numerous techniques:
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Guillotine
Tonsillotome
Beck’s snare
Dissection with snare (Scissor dissection, Fisher’s knife
dissection, Finger dissection
Electrodissection
Laser dissection (CO2, KTP)
… Surgeon’s preference
Post Operative Managment
Criteria for Overnight Observation
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Poor oral intake, vomiting, hemorrhage
Age < 3
Home > 45 minutes away
Poor socioeconomic condition
Comorbid medical problems
Surgery for OSA or PTA
Abnormal coagulation values (+/- identified
disorder) in patient or family member
Complications
#1 Postoperative bleeding
Other:
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Sore throat, otalgia, uvular swelling
Respiratory compromise
Dehydration
Burns and iatrogenic trauma
Rare Complications
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Velopharyngeal Insufficiency
Nasopharyngeal stenosis
Atlantoaxial subluxation/ Grisel’s syndrome
Regrowth
Eustachian tube injury
Depression
Laceration of ICA/ pseudoaneursym of ICA
Toncil ca.
TONCIL CA
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75-80% of oropharyngeal cancer
İncidance of lymphatic metastases rate is
high 75% (mostly jugulodigastric met.)
T1 – T2  RT
N2 – N3  surgery + RT
T3 – T4  surgery + RT