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DESEASES OF HEAD, NECK, EAR, NOSE and TRHOAT Associate Professor Dr. Alexey Podcheko Spring 2015.

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Presentation on theme: "DESEASES OF HEAD, NECK, EAR, NOSE and TRHOAT Associate Professor Dr. Alexey Podcheko Spring 2015."— Presentation transcript:

1 DESEASES OF HEAD, NECK, EAR, NOSE and TRHOAT Associate Professor Dr. Alexey Podcheko Spring 2015

2 1. oral cavity 2. upper airways, including the nose, pharynx, larynx, and nasal sinuses; 3. ears 4. neck 5. salivary glands Topics:

3 EVERYTHING that touches AIR (columnar) or FOOD (squamous) in the HEAD/NECK region ORAL CAVITY “UPPER” RESPIRATORY TRACT EARSNOSE SALIVARY GLANDS

4 INTENDED LEARNING OUTCOMES Understand the common disorders of the upper airway and upper digestive tract (i.e., head and neck) in the usual context of: DEGENERATIVE, INFLAMMATORY, and NEOPLASTIC …deviations of normal anatomy and histology

5 ORAL CAVITY TEETH/GINGIVA/ALVEOLAR BONE INFLAMMATORY/”REACTIVE” LESIONS INFECTIONS: HSV, VIRAL, FUNGI LEUKOPLAKIA/”HAIRY” LEUKOPLAKIA SQUAMOUS TUMORS: BEN/MALIG ODONTOGENIC CYSTS/TUMORS

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7 Time frame of teething Incisors 10-15mo Bicuspids 15-18mo Molars 18-24mo

8 Tooth Decay (Cavities, “Caries”) Dental caries one of the most common diseases, is the most common cause of tooth loss before age 35 Result of mineral dissolution of tooth structure “Processed” carbohydrates, i.e., sugars Bacterial (Strep. Viridans: Strep. Mutans + Strep. Sanguis; Lactobacilli, Actinomycetes) acidic erosion of enamel due to ability to produce insoluble dextrans Role of pH, spacing, brushing, Fl Tartar  plaque  calculus = bacteria, proteins, cells

9 Gram Positive cocci isolated from the blood of patient with bacteremia synthesize dextrans from glucose. The bacteria most likely contribute to which of the following pathological states? A Glomerulonephritis B. Sarcoidosis C. Erythema nodosum D. Migratory polyarthritis E. Anterior uvetis F. Dental Caries

10 Vindans streptococci, notably S. mutants and S. sanguis, are normally present in the human mouth and are major contributors of tooth decay and the initiation of dental caries. The organisms also cause bacterial endocarditis. Viridans streptococci are adhere to the surface of tooth enamel and heart valves and multiply in those locations due to their ability to produce insoluble dextrans.

11 Find the “cavity”, i.e., caries, i.e., enamel erosion

12 Gingiva - squamous mucosa in between the teeth and around them Gingivitis is inflammation of the mucosa and the associated soft tissues. Causes: Bacteria: Actinobacilli, Porphyromona, Prevotella Viruses: HSV1 and 2 Symptoms: erythema, edema, bleeding, changes in contour, and loss of soft- tissue adaptation and sores GINGIVITIS

13 Periodontitis Definition: inflammatory process that affects the supporting structures of the teeth: periodontal ligaments, alveolar bone, and cementum Causes: Bacteria, adult periodontitis is associated primarily with: –Actinobacillus actinomycetemcomitans, –Porphyromonas gingivalis –Prevotella intermedia Affected structures: Gingiva, periodontal ligaments, bone, cementum

14 Component of several different systemic diseases: 1. AIDS 2. Leukemia 3. Crohn's disease 4. Diabetes mellitus 5. Down syndrome 6. Sarcoidosis, 7. Syndromes associated with polymorphonuclear defects (Chédiak-Higashi syndrome, agranulocytosis, and cyclic neutropenia) Etiologic factor in several important systemic diseases: 1. infective endocarditis, 2. pulmonary and brain abscesses, 3. averse pregnancy outcomes (preeclampsia) Periodontitis

15 A 67-year-old male is hospitalized with low-grade fevers fatigue and a diastolic murmur at the left sternal border. Blood cultures reveal Gram positive cocci that are catalase-negative and able to grow in the presence of optocin. This patient’s medical history is most likely to reveal which of the following procedures in the past month? A. Dental extraction B. Skin biopsy C. Sinus drainage D. Nasal polypectomy E. Cystoscopy

16 (Choice A) Dental extraction is associated with endocarditis caused by S. viridans, a Gram positive coccus. In most cases, S. viridans causes subacute bacterial endocarditis in already abnormal heart valves (e.g. congenital valvular abnormalities valves damaged by rheumatic fever.)

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18 Inflammatory/Reactive Tumor- like Lesions MC fibrous proliferative lesions of the oral cavity: fibroma (61%) reactive nodules of the oral cavity peripheral ossifying fibroma pyogenic granuloma peripheral giant-cell granuloma gingival hyperplasia

19 Irritation fibroma primarily occurs in the buccal mucosa along the bite line or at the gingivodental margin. Morphology: nodular mass of fibrous tissue, with few inflammatory cells, covered by squamous mucosa. Rx: Surgical excision Smooth pink exophytic nodule on the buccal mucosa.

20 “Irritation” Fibroma

21 Peripheral ossifying fibroma Growth of the gingiva that is considered to be reactive in nature rather than neoplastic. Result of the maturation of a long-standing pyogenic granuloma Rx: Surgical excision down to the periosteum (recurrence rate of 15% to 20%)

22 Pyogenic granuloma Highly vascular pedunculated lesion on the gingiva (children, young adults, pregnant women (pregnancy tumor). Growth can be rapid, raising the fear of a malignant neoplasm. Histology: vascular proliferation that is similar to granulation tissue (capillary hemangioma?) Regress with formation of peripheral ossifying fibroma. Rx: surgical excision

23 PYOGENIC GRANULOMA

24 A 6-year-old boy presents with a painful sore in his mouth. Physical examination reveals a small, elevated, and locally ulcerated red-purple gingival lesion. A soft red mass measuring 1 cm in diameter is surgically removed. Histologic examination discloses highly vascular granulation tissue, with marked acute and chronic inflammation. What is the most likely diagnosis? (A) Acute necrotizing gingivitis (B) Aphthous stomatitis (C) Herpes labialis (D) Pyogenic granuloma (E) Tuberculosis

25 Peripheral giant cell granuloma bluish purple tumor-like lesion Histology: aggregation of multinucleate, foreign body– like giant cells separated by a fibroangiomatous stroma, not encapsulated can cause resorption of alveolar bone Rx: Surgical excision Dif. diagnosis: central giant- cell granulomas of bones and “brown tumors” seen in hyperparathyroidism

26 Histology of peripheral giant cell granuloma reveals a dense infiltrate of histiocytes and multi-nucleated giant cells within the subepithelial fibrous stroma.

27 APHTHOUS ULCERS (CANKER SORES) superficial ulcerations of the oral mucosa affect up to 40% of the population in the United States Etiology: stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies, and deficiencies in vitamin B12, iron, and folic acid, recurrent apthous ulcers may be associated with celiac disease and inflammatory bowel disease. Clinic: extremely painful and often recurrent sores, tendency to be prevalent within certain families. Morphology: Single or multiple, shallow, hyperemic ulcerations covered by a thin exudate and rimmed by a narrow zone of erythema Histology: Mononuclear infiltrate Prognosis: Spontaneously resolve in 7 to 10 days or be stubbornly persistent for weeks Rx: local anesthetics

28 “Canker” sore = Aphthous ulcer

29 GLOSSITIS Inflammation of the tongue atrophy of the papillae of the tongue and thinning of the mucosa, exposing the underlying vasculature Atrophic Glossitis Causes: Deficiencies of vitamin B12 (pernicious anemia), riboflavin, niacin, or pyridoxine, sprue and iron-deficiency anemia. Ulcerative Glossitis Causes: : jagged carious teeth, ill-fitting dentures, and, rarely, with syphilis, inhalation burns, or ingestion of corrosive chemicals Clinic: Plummer-Vinson syndrome - combination of iron-deficiency anemia, glossitis, and esophageal dysphagia mostly in postmenopausal women

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31 HERPES SIMPLEX VIRUS INFECTIONS Mostly herpes simplex virus type 1 (HSV-1) Enveloped double-stranded DNA virus Primary HSV infection typically occurs in children age 2 to 4 years, Forms: acute herpetic gingivostomatitis – MOST Common form of primary infection cold sores (Herpes labialis) recurrent herpetic stomatitis

32 HERPES SIMPLEX VIRUS INFECTIONS

33 Morphology: Intracellular and intercellular edema (acantholysis) yielding clefts that may become transformed into macroscopic vesicles. Cells have eosinophilic intranuclear viral inclusions, multinucleate polykaryons Tzanck test: microscopic examination of the vesicle fluid to find multinucleated polykarions

34 TZANCK SMEAR The neat thing about a Tzanck smear is that you can do it easily in your office, just gently scrape a vesicle, smear it, stain it with just about anything, and look for much larger than usual squamous nuclei with inclusions. Most vesicles caused by herpes family viruses can have a POSITIVE Tzanck (pronounced “zank”) smear, or test.

35 A 2-year-old male is brought to clinic with fever irritability, and decreased oral intake. Physical examination reveals swollen gums with ulcerative lesions and enlarged, tender cervical lymph nodes. Oral lesion scrapings demonstrate cells with intranuclear inclusions. Which of the following is most likely responsible for this patient’s disease? A. Enveloped double- stranded DNA virus B. Non-enveloped double- stranded DNA viru C. Non-enveloped single- stranded DNA virus D. Non-enveloped positive- sense RNA virus E. Enveloped positive-sense RNA virus F. Enveloped negative- sense RNA virus

36 A 5-year-old male is brought to the clinic with a several day history of fever, irritability and refusal to eat. Physical examination demonstrates painful gingival ulcers, swollen gums, and cervical lymphadenopathy. Microscopic examination of the oral ulcer base scrapings is shown on the slide below. This patient current situation is most likely represent: A Primary infection B. Virus reactivation C. Latent infection D. Abortive infect E. Slow virus infection

37 Candidiasis is by far the most common fungal infection in the oral cavity. Factors: (1) immune status of the individual; (2) the strain of C. albicans present (3) the composition of an individual's oral flora (4) Abt therapy (5) Underlying diseases (AIDS, Diabetes) Major clinical forms of oral candidiasis: 1.Pseudo-membranous (thrush) 2.Erythematous 3.Hyperplastic, ORAL CANDIDIASIS (THRUSH)

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39 Finding the NON-septate hyphae (i.e., “pseudo”-hyphae) along with yeasts and budding yeasts in your simple office lab, is diagnostic. Almost any simple stain will show this. The “PAS” stain is best, because it imparts a bright red color to yeasts and pseuduhyphae

40 Oral Manifestations of Systemic Disease

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42 HAIRY LEUKOPLAKIA Hairy leukoplakia - white patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease, caused mostly by EBV infection 80% of patients with hairy leukoplakia are infected with the human immunodeficiency virus (HIV)!!! Dif. diagnosis with Candidiasis - lesion cannot be scraped off. Histology: Hyperparakeratosis and acanthosis with “balloon cells” in the upper spinous layer, koilocytosis of the superficial, nucleated epidermal cells, Prognosis: In HIV-positive individuals, with hairy leukoplarkia, symptoms of AIDS follow in 2 to 3 years!

43 “Hairy” leukoplakia

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45 Premalignant lesions in the oral cavity Leukoplakia - a white patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease until it is proved otherwise via histologic evaluation, all leukoplakias must be considered precancerous! Erythroplakia -red, velvety, possibly eroded area within the oral cavity that usually remains level with or may be slightly depressed in relation to the surrounding mucosa Speckled leukoerythroplakia :Erythro+Leukoplakia

46 NORMAL  DYSPLASIA  CARCINOMA-IN-SITU  INFILTRATING MALIGNANCY Histologic progression of Leukoplakia into squamous cell carcinoma

47 Head and Neck are Squamous Cell Carcinomas (HNSCCs) 95% of cancers of the head and neck overall long-term survival has remained at less than 50% individual who is fortunate to live 5 years after the initial primary tumor has up to a 35% chance of developing at least one new primary tumor within that period of time Etiology: Tabacco, Alcohol, actinic radiation (sunlight), pipe smoking, chewing of betel quid, mouthwash (25% alcohol)

48 Morphology of squamous cell carcinoma of the oral cavity Favored locations: 1. ventral surface of the tongue 2. Floor of the mouth 3. Lower lip, soft palate, and gingiva

49 Morphology of squamous cell carcinoma of the oral cavity Raised, firm, pearly plaques or as irregular, roughened, or verrucous areas of mucosal thickening

50 There are the 3 types of differentiation of squamous cell cancer: Well, moderate, poor. In “well” you can see “pearls”. (pearl above). In “moderate”, you can usually see “intercellular bridges”, but not pearls. In “poor” you usually have no real idea that it even looks squamous at all, and you have to rely on squamous or immunochemical markers, such as cytokeratin markers, or a whole host of others. Morphology of squamous cell carcinoma of the oral cavity

51 WELL MODERATE POOR

52 ODONTOGENIC CYSTS Definition: cyst like structures derived from epithelial linings or epithelial remnants in the jaw bone Classification: INFLAMMATORY CYSTS (e.g., Periapical “Radicular” - most common) DEVELOPMENTAL CYSTS (DENTIGEROUS - most common)

53 Periapical cyst

54 extremely common lesions found at the apex of teeth. Result of long-standing pulpitis or periapical abscess. Periapical inflammatory lesions persist as a result of the continued presence of bacteria or other offensive agents in the area

55 Dentigerous cyst Def: Cyst that originates around the crown of an unerupted tooth and is thought to be the result of a degeneration of the dental follicle. Xray: unilocular lesions and are most often associated with impacted third molar (wisdom) teeth. Histology: they are lined by a thin layer of stratified squamous epithelium with chronic inflammatory cell infiltrate in the connective tissue stroma. Rx: Excision Complications: recurrence or, very rarely, neoplastic transformation into an ameloblastoma or a squamous cell carcinoma.

56 DENTIGEROUS CYST lined by a thin layer of stratified squamous epithelium with chronic inflammatory cell infiltrate in the connective tissue stroma

57 Odontogenic keratocyst (OKC) locally aggressive and has a high rate of recurrence Most often diagnosed in patients between ages 10 and 40. Males within the posterior mandible. Xray: well-defined unilocular or multilocular radiolucencies Histo: layer of parakeratinized or orthokeratinized stratified squamous epithelium with a prominent basal cell layer and a corrugated appearance of the epithelial surface. Rx: Complete removal of the lesion

58 Odontogenic tumors 1.Odontoma- the most common type of odontogenic tumors (app. 70%), arises from epithelium but shows extensive depositions of enamel and dentin. Odontomas are probably hamartomas rather than true neoplasms and are cured by local excision. 2.Ameloblastoma (app. 30%) - from odontogenic epithelium. It is commonly cystic, slow growing, and locally invasive but has an indolent course in most cases

59 Odontoma on x-ray? Circular sunburst opacity surrounded by a thin radiolucent border Ameloblastoma on x-ray? Large expansile multilocular or soap- bubble radiolucency; favored location is posterior mandible

60 Ameloblastoma: notice the stellate reticlulum and the row of ameloblasts with vacuoles (40x). Odontoma consists of a mixture of hard substances, epithelial structures, and empty spaces formerly occupied by enamel matrix, 20x Histologic view of odontoma and ameloblastoma

61 Ameloblastomas Odontomas


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