1. DISEASES OF THE ORAL CAVITY
Prof. İlhan TOPALOĞLU
Otolaryngology Department
Yeditepe University
School of Medicine

2. 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

3. 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

4. Exam: Lips

5. Exam: Lips-palpation Color, consistency
Area for blocked minor salivary glands
Lesions, ulcers

6. Pyogenic granuloma

7. Fibroma

8. Lip cancer

9. Lower lip carcinoma

10. 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, minör salivary gland tm.

11. Sensory innervation of the tongue
1 – chorda tympani and lingual nerve
2 – glossopharyngeal nerve
3 – vagal nerve

12. Exam: Tongue

13. Exam: Tongue
You may observe lingual varicosities

14. Exam: Tongue
You may observe geographic tongue (erythema migrans)

15. Exam: Tongue
You may observe drug reaction

16. Exam: Tongue
Observe signs of nutritional deficiencies

17. Leukoplakia

18. Hemangioma

19. CANCERS OF TONGUE Lateral border Ocult met. 30%
Stage, nodal metastases, lenfovasculer, perineural invasion and thickness of tumor are important prognostic factors.

20. CANCER OF THE ANTERIOR PORTION OF THE TONGUE

21. Tongue ca.

22. Tongue ca.

23. Examination: Buccal Mucosa
Linea alba
Stenson’s duct

24. Lichen Planus

25. ALVEOLAR RIDGE

26. Ameloblastoma

27. Gingival cyst

28. Mucoepidermoid tumor

29. Exam: Retromolar trigone

30. Exam: Retromolar trigone
Edentulous

31. Exam: Floor of mouth

32. Palpation of the floor of the mouth

33. Exam: Floor of mouth Visualize, palpate - bimanually Wharton’s 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

34. Squamous Cell Carcinoma

35. 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)

36. Exam: Hard palate

37. Median Palatal Cyst

38. 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

39. ORAL PREMALİGNANCY
Leukoplakia
Erythroplakia
Mucosal atrophy

40. MALIGNANT LESIONS SQUAMOUS CELL CARCINOMA VERRUCOUS CARCINOMA
MINOR SALIVARY GLAND TUMOURS
SARCOMATOID CARCINOMAS
MALIGNANT MELANOMA

41. 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 Plummer-Vinson 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

42. Symptoms Otalgia Odynofagia Bleeding Dysfagia Loss of teeth
Restriction of mouth movement
Trismus

43. EPIDEMIOLOGY 95 % SCC 95 % patiet  40 years old
Mean age 60 years old
After the treatment of oral cavity ca if the patient doesn’t give up smoking, second primary or recurrence rate is 40 %

44. TREATMENT
surgery RT
surgery + RT
KT + RT
Surgery + RT + adjuvant KT

45. The last cigarette

47. DISEASES OF OROPHARYNX
Prof. Dr. İlhan TOPALOĞLU
Otolaryngology Department
Yeditepe University
School of Medicine

48. 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
İnferior: the plane of the hyoid bone

49. OROPHARYNX SUBSIDES Soft palate and uvula Base of the tongue
Tonsillar region (tonsillar fossae and pillars)
Oropharyngeal walls (lateral and posterior)

50. 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 Waldeyer-Hartz.

51. 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

52. Anatomy Tonsils Adenoids
Between arcus palatoglossus (ant plica) and arcus palatofaryngeus (post plica)
Adenoids
The tonsil is nestled in a fossa formed by the muscular anterior and posterior tonsillar pillars (palatoglossus and palatopharyngeus) and lying superficial to the superior constrictor muscle; preservation of these muscular condensations and the overlying mucosa is critical to maintaining physiologic function of the palate postoperatively.
The tonsil is contiguous inferiorly with the lingual tonsil. The point of attachment (plica triangularis) must be transected during tonsillectomy. In pts with marked hypertrophy, this extension is freq quite large and can result in troublesome bleeding at the pt of transection at the base of the tongue.
The adenoid is positioned in the midline of the posterior wall of the NP immediately inferior to the rostrum of the sphenoid and extending laterally to but not onto the lateral wall of the NP. It makes up the most rostral portion of the pharyngeal lymphoid tissue termed Waldeyer’s ring. The space created lateral to the adenoid and posteromedial to the ET orifice is termed the FOSSA of Rosenmuller.
Gerlach’s tonsil is lymphoid tissue within lip of the fossa of Rosenmuller; goes into ET.
Inferiorly, the adenoid extends nearly to the superior margin of the superior constrictor…Passavant’s ridge.

53. Common Diseases of the Tonsils and Adenoids
Acute adenoiditis/tonsillitis
Recurrent/chronic adenoiditis/tonsillitis
Obstructive hyperplasia
Malignancy

54. Acute Adenotonsillitis
Etiology
5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO)
Streptococcus pyogenes (Group A beta-hemolytic streptococcus GABHS most important pathogen because of potential sequelae
1. MC bacteria:
Beta streptoccoci, staphylococci, streptoccocus pneumoniae, hemophilus
2. Prevalence of beta-lactamase producing organisms is rising:
from 2 % in 1980 to 44% in (FIND STUDY)
3. Prevalence of anaerobic org is also rising
Asymptomatic streptococcal pharyngitis responsible for at least 1/3 of ARF in 3rd world. Gold std is throat culture.
Blood agar plate with septra more sensitive than plain agar plate.
Culture both tonsils; if only one, may miss 25%.
Rapid streptococcal antigen test, 12 min.; highly specific but variable sensitivity; must confirm negative result with a throat cx.
Newer solid-phase enzyme immunoassay
Older latex agglutination test
Treat with 10 day course of PCN if high clinical suspicion (augmentin, clinda, pcn + rifampin for recurrence)
Post treatment culture: high risk RF, remain symptomatic, recurring symptoms; if asymptomatic but positive cx, treat if h/o RF or if FH of RF
Suspect infectious mononucleosis if sore throat and malaise persist despite abx treatment; order WBC and Paul-Bunnell. Characterized by white membrane covering one or both tonsils and hypersensitivity to ampicillin. Look for atypical mononuclear cells and positive Paul-Bunnell blood test.

55. Differential diagnosis
Infectious mononucleosis Malignancy: lymphoma, leukemia, carcinoma Diptheria Scarlet fever Agranulocytosis

56. Supratonsillar Cleft
This recess near the superior pole of the tonsil tends if large to collect debris. A mass of yellow fetid tissue can be extruded from the tonsil with pressure, and discomfort, halitosis are symptoms. Tonsillectomy may be necessary.

57. Peritonsillar Abscess
Displacement of tonsil and uvula medially, trismus, dysphagia, pain referred to the ear, malaise, fever, cervical adenopathy.
Initial mgmt is needle aspiration, IM penicillin, oral penicillin.
Quinsy tonsillectomy for uncooperative, toxic patient, bleeding.

58. Papilloma

59. ICA Aneurysm
This patient came to the ER for sore throat

60. Toncil ca.

61. TONCIL CA 75-80% of oropharyngeal cancer
İncidance of lymphatic metastases rate is high 75% (mostly jugulodigastric met.)

62. Candidiasis
A fungal infection of the pharynx and one of the most common upper respiratory tract manifestation of AIDS. Also seen in neonates and may complicate treatment with broad spectrum antibiotics.
Characterized by extensive white areas (either continuous or punctate) covering the entire oropharynx and not limited to the tonsil.
Swab shows candida albicans.

63. Other Tonsillar Pathology
Hyperkeratosis, mycosis leptothrica
Tonsilloliths
Yellow spicules due to hyperkearatineized areas of epithelium are sometimes extensive over the tonsil. It is important to probe the tonsil to be certain these areas are not exudate. No treatment is required unless assoc with tonsillitis.
Tonsilloliths are yellow gritty particles in crypts, more commonly seen in adults with a h/o recurrent tonsillitis.
Elongated styloid process causes pain exacerbated during maximal deglutition and deep breathing…. 2nd branchial arch derivitative, approx 2.5 cm long, located btw internal and ECA just lateral to tonsillar fossa.

64. 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
Contraindications:
Tonsillectomy
Acute infection
Anemia
Disorders of hemostasis

65. TONSIL SIZE 0 in fossa +1 <25% occupation of oropharynx +2 25-50%% %
+4 >75%
Avoid gagging the patient

66. Principles of Surgical Management
Numerous techniques
Guillotine
Snare (Scissor dissection, Fisher’s knife dissection, Finger dissection)
Electrodissection, Plasmadissection
Laser dissection (CO2, KTP)
… Surgeon’s preference

67. 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

68. 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)
Contraindications:
Adenoidectomy
Overt or submucous CP
Neurologic or neuromuscular abnormalities with impaired palatal function
Anemia
Disorders of hemostasis