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Dr Vinay H.S M.D
HEAD & NECK
INFLAMMATORY LESIONS OF TEETH
GINGIVITIS • Inflammation of soft tissues that surrounds teeth.
• Result of a lack of proper oral hygiene
• Dental plaque- Complex mass of microorganisms from oral flora
- Proteins from saliva
- Desquamated epithelial cells
• Calculus – mineralized bacterial plaque
• C/F: Erythema, edema, bleeding, loss of soft tissue.
PERIODONTITIS
• Inflammation of supporting structures of the teeth (Periodontal ligaments, alveolar bone & cementum)
• May cause Loosening and eventual loss of teeth
• Associated disorders
- HIV
- Leukemia
- Crohns disease
- Diabetes mellitus etc
• Pathogenesis: Anaerobic and microaerophilic gram negative flora
• Actinobacillus
• Actinomycetemcomitans
• Porphyromonas gingivalis
• Prevotella intermedia
• Complications - Infective endocarditis, Pulmonary and Brain abscess.
INFLAMMATORY/REACTIVE TUMOUR LIKE LESIONS
FIBROUS PROLIFERATIVE LESIONS
• Fibroma: Buccal mucosa, Gingivodental margin.
- Fibrous tissue with few inflammatory cells, squamous mucosa.
• Peripheral ossifying fibroma:
-Young, teenage females
- Red ulcerated nodular lesions.
• Peripheral giant cell granuloma (Giant cell epulis): Due to chronic inflammation
- Bluish purple nodules
- Foreign body type of giant cells on microscopy
APHTHOUS ULCERS (CANKER SORES)
• MC superficial ulcers of oral cavity
• >40% affected in US
• Recurrent, small, painful ulcers
• Single or multiple
• Shallow, hyperemic ulcers
• Thin exudate
• Narrow zone of erythema
• Resolve in 7-10 days
GLOSSITIS • Inflammation of tongue: Beefy-
red tongue: Atrophy of papillae & thinning of mucosa
• Causes: • Iron-deficiency anemia +
Glossitis + esophageal dysphagia usually related to webs known as the Plummer-Vinson or Paterson-Kelly syndrome.
• Deficiencies of vitamin B12 (pernicious anemia), riboflavin, niacin, or pyridoxine
INFECTIONS OF ORAL CAVITY
ORAL HERPES
• HSV-1/HSV-2 (genital herpes)
• Primary infection
• Children – 2 to 4yrs
• Asymptomatic
• Acute herpetic gingivostomatitis
• Abrupt onset of vesicles & ulcers
• Fever, lymphadenopathy & anorexia.
• Secondary • Young adults • Reactivation of the virus • Mild disease – Cold sores • Recurrent herpetic stomatitis • Tzanck test • Multinucleated cells • Intranuclear inclusions
ORAL CANDIDIASIS
• MC fungal infection in oral cavity • 3 clinical forms : - Pseudomembranous (can be scraped off) also called as
Oral thrush; most common - Erythematous - Hyperplastic • Commonly seen in immunocompromised state • Superficial curdy gray white inflammatory membrane
• Pseudomembrane • Oval yeast like budding cells
(blastospores)& pseudohyphae
ORAL MANIFESTATIONS OF SYSTEMIC DISEASE
HAIRY LEUKOPLAKIA • Immunocompromised patients • 80% AIDS • Epstein Barr virus • White confluent patches • Lateral border of tongue • Fluffy hyperkeratotic thickening • Microscopy: Ballooning of Squamous cells in upper epithelium
TUMOURS AND PRECANCEROUS LESIONS OF ORAL CAVITY
LEUKOPLAKIA • “A white, plaque-like lesion which can’t be wiped off &
can’t be clinically diagnosed as any other disease entity” • 3% of population affected • 5-25% cases – premalignant • M>F=2:1 • 40 - 70yrs • Sites: Buccal mucosa, Floor of mouth, Ventral aspect of
tongue, Hard palate • Causes: Smoking, Alcohol, Spicy food, Sharp tooth
Homogenous – uniformly white Speckled leukoplakia – white & red
Verrucous leukoplakia – corrugated / nodular Hyperkeratosis, Thickened, acantho>c epithelium
ERYTHROPLAKIA
• Red, velvety slightly depressed plaque
• Underlying epithelium-dysplasia
• Malignant transformation- >50%
• Management: Depends on degree of dysplasia
ORAL CANCER
• 95% - Squamous cell carcinoma • Affects middle aged to elderly; M>F • Predisposing factors – Tobacco – Alcohol – Chronic irritation – Family history
• Sites: Lower lip, Floor of mouth, Ventral surface of tongue, Soft palate, Gingiva
• Presentation: Begins as a plaque, Ulcerates, Forms a proliferative mass
• Spread : Lymph node; Distant metastasis- lungs, liver, bones
Prolifera>ve mass
Ulcerated mass
Kera>n Pearls
NECROTISING LESIONS OF NOSE AND UPPER AIRWAYS • * Kartagener syndrome: Bronchiectasis and situs inversus,
secondary to defective ciliary action.
• * Acute fungal infections (including mucormycosis), particularly in diabetic and immunosuppressed patients
• * Wegener granulomatosis
• Danger area of face
NASOPHARYNGEAL CARCINOMA
• Association with EBV infection • Grows silently, recognized often when unresectable;
spread to cervical lymph nodes • 3 patterns - Keratinizing SCC - Non-Keratinizing SCC - Undifferentiated Carcinoma: Non neoplastic lymphoid cells and large cells with vesicular nuclei & Prominent nucleoli in Syncitial pattern
LARYNX
q Reactive nodules(Vocal cord nodules and polyps): In heavy smokers or who strain vocal cords - in singers (singers’ nodules).
• Hoarseness
• Never give rise to cancers
Keratotic, hyperplastic epithelium,
loose myxoid connective tissue core
q Juvenile Laryngeal papillomatosis:
• Polypoidal lesion; multiple in children
• HPV 6 & 11
• Often spontaneously regress at puberty
• Stratified squamous epithelium
• Recurrent but malignant transformation is rare
CARCINOMA LARYNX
• Sequence of hyperplasia-Dysplasia –Carcinoma: Spectrum of epithelial alterations
• Tobacco, alcohol, Asbestos, Irradiation & HPV • 95% Squamous cell carcinoma • Clinically-Persistent hoarseness of voice, cough
EAR
• Cholesteatomas:
- Associated with chronic otitis media
- Cystic lesions 1 to 4 cm with progressive enlargement
- Lined by keratinizing squamous epithelium or metaplastic mucus-secreting epithelium
- Cyst ruptures, inducing the formation of giant cells with necrotic squames debris.
NECK SWELLINGS
• Branchial Cyst (Cervical Lymphoepithelial Cyst) : Upper lateral aspect of the neck along sternocleidomastoid muscle.
- Remnants of the second branchial arch. - 20 to 40years
- Cysts are well circumscribed, 2 to 5 cm - Fibrous walls usually lined by stratified squamous or
pseudostratified columnar epithelium, lymphoid tissue, clear, watery to mucinous fluid.
• Thyroglossal cyst: Remnant of thyroglossal duct (Foramen caecum (Thyroid gland)
• Midline swelling moves with deglutition
• Diagnosis: FNAC: Reactive squamous cells (If above the hyoid bone), rare ciliated epithelium (If below hyoid bone) and thyroid epithelium
• Treatment: Excision
PARAGANGLIOMA (CAROTID BODY TUMOR) • 70% of extra-adrenal paragangliomas occur in the head
and neck region
• Paraganglia related to the great vessels aorticopulmonary chain, including the carotid bodies (most common)
• Gross: Red-pink to brown
• Microscopy: Chiefly composed of nests (Zellballen) that are surrounded by delicate vascular septae. Granular, eosinophilic cytoplasm and uniform.
ZELLBALLEN
SALIVARY GLAND DISORDERS
q Sjogren’s Syndrome: • Females
• Autoimmune disorder; associated with Rheumatoid Arthritis
• Destruction of minor salivary glands & lacrimal glands
• Clinically: dry mouth, dry eyes
q Sialadenitis: • Traumatic, viral, bacterial, autoimmune.
• Viral: Mumps (M/C)
• Complications: Orchitis, pancreatitis
SALIVARY GLAND NEOPLASMS
q Pleomorphic adenoma (Mixed Tumors): • Most common benign tumor
• Parotid gland, F>M, 40-60 yrs.
• Painless, mobile swelling
• Mixed tumor- both epithelial & mesenchymal
• Gross: Round, Well demarcated, <6cm, Encapsulated, Grey white, Myxoid areas and Chondroid areas – blue transparent
• Microscopy:
- Epithelial/myoepithelial cells – ducts, acini, tubules, sheets
- Mesenchyme like stroma – myxoid, chondroid, hyaline
q Warthin’s tumor (Papillary cystadenoma lymphomatosum):
• Benign, M>F, 50-70 yrs, smokers+
• Parotid
• Gross: Round to oval encapsulated, 2-5cm, Solid pale grey surface, Cystic spaces filled with mucinous/ serous secretions
• Microscopy: Papillary projections into cystic spaces; Epithelium – double cell layer; Stroma – mature lymphoid follicles with germinal center
q Mucoepidermoid carcinoma: – M/C primary malignant salivary gland tumor – Gross: Circumscribed, pale grey white, mucin
containing cysts – Microscopy: Mixture of squamous cells, Mucus-
secreting cells & Intermediate cells – Grades: Low, intermediate, High
q Adenoid cystic carcinoma: • MC site minor salivary glands
• M=F, 5th decade
• Asymptomatic enlarging mass, Invade perineural spaces (Pain, paraesthesia, facial weakness)
• Gross: Small, Poorly encapsulated, Infiltrative, Solid, Grey pink lesions
• Microscopy: Small cells – tubular, solid & cribriform pattern, Hyaline matrix
• References:
• Robbins and Cotran Pathologic basis of Disease 8th edition.
• Acknowledgements:
• Dr Ronnie Coutinho (Guidance) • Dr Suneet Kumar
Thank you