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