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
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
PORTION OF THE TONGUE Tongue ca. Tongue ca. CANCERS OF TONGUE
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
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
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
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
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):
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:
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