Diseases of The Oral Cavity and Oropharynx

Diseases of The Oral Cavity and Oropharynx

DISEASES OF THE ORAL CAVITY Prof. lhan TOPALOLU Otolaryngology Department Yeditepe University School of Medicine ANATOMY OF THE ORAL CAVITY

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 1- Lips 2- Anterior portion of the tongue 3- Buccal mucosa 4- Upper and lower alveolar ridges 5- Retromolar trigone 6- Floor of the mouth

7- Hard palate Exam: Lips Exam: Lips-palpation Color, consistency

Area for blocked minor salivary glands Lesions, ulcers Pyogenic granuloma Fibroma Lip cancer Lower lip carcinoma

CANCERS OF THE LIP 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, minr salivary gland tm. Sensory innervation of the tongue

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 Exam: Tongue Exam: Tongue You may observe

lingual varicosities Exam: Tongue You may observe geographic tongue (erythema migrans) Exam: Tongue

You may observe drug reaction Exam: Tongue Observe signs of nutritional deficiencies Hairy Leukoplakia

Hemangioma Granular Cell Tumor Exam: Tongue You may observe cancer CANCER OF THE ANTERIOR


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 Linea alba Stensons duct Examination: Buccal

Mucosa Lesions white, red Lichen Planus, Leukedema CANCER OF THE BUCCAL MUCOSA

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 80 % lower gingiva and 1/3 posterior region. Incidance of mandibular invasion rate is high

upper gingiva invasion of maksillary sinus 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 TRGONE CA

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

Visualize, palpate - bimanually Whartons duct Must dry to observe Does lesion wipe off?

Where are the two most likely areas for oral cancer? lateral border of the tongue Floor of mouth Exam: Floor of mouth Palpation of the floor of the

mouth Exam: Floor of mouth Squamous Cell Carcinoma Squamous Cell Carcinoma FLOOR OF THE MOUTH CA.

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 Minor salivary glands Median Palatal Cyst CANCER OF THE HARD PALATE

uncommon SCC and Adenoid cystic ca Misdiagnosed as maxillary sinus tm Incidance of neck metastases is low Elective neck treatment is

unnecessary Prostodontist ORAL PREMALGNANCY Leukoplakia Erythroplakia Mucosal atrophy


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 patients 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: Cigarette Alcohol

Exposure to the human papilloma virus (HPV) or Epstein-Barr virus (EBV) ionizing radiation Prolonged sun exposure, especially linked to cancer in the lip area and skin cancer.

Fair skin, also linked to lip cancer and skin cancer. 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). Poor nutrition.

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

Otalgia Odynofagia Bleeding Dysfagia Loss of teeth

Restriction of mouth movement Trismus EPIDEMIOLOGY 95 % SCC 95 % patiet 40 years old

Mean age 60 years old After the treatment of oral cavity ca if the patient doesnt give up smoking, second primary or recurrence rate is 40 % CARCINOGENESIS

tobacco ionizing radiation dental travma and poor oral hygiene alcohol tertiary syphilis human papilloma virus

candida albicans

some nutritional factors oral submucous fibrosis lichen planus discoid lupus erythematosus dystrophic epidermolysis bullosa dyskeratosis congenita TREATMENT

surgery RT surgery + RT KT + RT Surgery + RT + adjuvant KT

The last cigarette DISEASES OF OROPHARYNX Prof. Dr. lhan TOPALOLU 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 nferior: 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 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 WaldeyerHartz . Waldeyer's ring

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 Between arcus

palatoglossus (ant plica) and arcus palatofaryngeus (post plica) Adenoids Blood Supply Tonsils

Ascending and descending palatine arteries Tonsillar artery 1% aberrant ICA just deep to superior constrictor

Adenoids Ascending pharyngeal, sphenopalatine arteries Histology Tonsils

Specialized squamous Extrafollicular Mantle zone Germinal center Adenoids

Ciliated pseudostratified columnar Stratified squamous Transitional Common Diseases of the Tonsils and Adenoids Acute adenoiditis/tonsillitis Recurrent/chronic

adenoiditis/tonsillitis Obstructive hyperplasia Malignancy 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 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

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

Hyperkeratosis, mycosis leptothrica Tonsilloliths Candidiasis

Syphilis Retention Cysts Supratonsillar Cleft Indications for Tonsillectomy Paradise study

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: 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)

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) Recommend adenoidectomy with M & T as the initial

surgical treatment for children with MEE > 90 days and CHL > 20 dB Indications for Adenoidectomy Obstruction:

Chronic nasal obstruction or obligate mouth breathing OSA with FTT, cor pulmonale Dysphagia Speech problems Severe orofacial/dental abnormalities Infection:

Recurrent/chronic adenoiditis (3 or more episodes/year) Recurrent/chronic OME (+/- previous BMT) PreOp Evaluation of Adenoid Disease

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

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 cooperation. PreOp Evaluation of Tonsillar Disease History

Documentation of episodes by physician Cor pulmonale Poststreptococcal GN Rheumatic fever PreOp Evaluation of Tonsillar Disease TONSIL SIZE

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

Historical screening CBC, PT/PTT, BT, vWF activity Hematology consult von Willebrands disease ITP Sickle cell anemia Principles of Surgical

Management Numerous techniques: Guillotine

Tonsillotome Becks snare Dissection with snare (Scissor dissection, Fishers knife dissection, Finger dissection Electrodissection Laser dissection (CO2, KTP) Surgeons preference Post Operative Managment Criteria for Overnight Observation

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:

Sore throat, otalgia, uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma Rare Complications

Velopharyngeal Insufficiency Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisels syndrome

Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA Toncil ca. TONCIL CA

75-80% of oropharyngeal cancer ncidance of lymphatic metastases rate is high 75% (mostly jugulodigastric met.) T1 T2 RT N2 N3 surgery + RT T3 T4 surgery + RT

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