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DISEASES OF THE ORAL CAVITY
Prof. İlhan TOPALOĞLU Otolaryngology Department Yeditepe University School of Medicine
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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
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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
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Exam: Lips
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Exam: Lips-palpation Color, consistency
Area for blocked minor salivary glands Lesions, ulcers
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Pyogenic granuloma
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Fibroma
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Lip cancer
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Lower lip carcinoma
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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.
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Sensory innervation of the tongue
1 – chorda tympani and lingual nerve 2 – glossopharyngeal nerve 3 – vagal nerve
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Exam: Tongue
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Exam: Tongue You may observe lingual varicosities
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Exam: Tongue You may observe geographic tongue (erythema migrans)
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Exam: Tongue You may observe drug reaction
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Exam: Tongue Observe signs of nutritional deficiencies
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Leukoplakia
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Hemangioma
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CANCERS OF TONGUE Lateral border Ocult met. 30%
Stage, nodal metastases, lenfovasculer, perineural invasion and thickness of tumor are important prognostic factors.
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CANCER OF THE ANTERIOR PORTION OF THE TONGUE
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Tongue ca.
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Tongue ca.
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Examination: Buccal Mucosa
Linea alba Stenson’s duct
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Lichen Planus
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ALVEOLAR RIDGE
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Ameloblastoma
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Gingival cyst
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Mucoepidermoid tumor
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Exam: Retromolar trigone
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Exam: Retromolar trigone
Edentulous
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Exam: Floor of mouth
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Palpation of the floor of the mouth
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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
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Squamous Cell Carcinoma
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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)
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Exam: Hard palate
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Median Palatal Cyst
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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
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ORAL PREMALİGNANCY Leukoplakia Erythroplakia Mucosal atrophy
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MALIGNANT LESIONS SQUAMOUS CELL CARCINOMA VERRUCOUS CARCINOMA
MINOR SALIVARY GLAND TUMOURS SARCOMATOID CARCINOMAS MALIGNANT MELANOMA
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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
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Symptoms Otalgia Odynofagia Bleeding Dysfagia Loss of teeth
Restriction of mouth movement Trismus
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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 %
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TREATMENT surgery RT surgery + RT KT + RT Surgery + RT + adjuvant KT
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The last cigarette
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DISEASES OF OROPHARYNX
Prof. Dr. İlhan TOPALOĞLU Otolaryngology Department Yeditepe University School of Medicine
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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
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OROPHARYNX SUBSIDES Soft palate and uvula Base of the tongue
Tonsillar region (tonsillar fossae and pillars) Oropharyngeal walls (lateral and posterior)
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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.
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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
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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.
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Common Diseases of the Tonsils and Adenoids
Acute adenoiditis/tonsillitis Recurrent/chronic adenoiditis/tonsillitis Obstructive hyperplasia Malignancy
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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.
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Differential diagnosis
Infectious mononucleosis Malignancy: lymphoma, leukemia, carcinoma Diptheria Scarlet fever Agranulocytosis
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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.
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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.
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Papilloma
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ICA Aneurysm This patient came to the ER for sore throat
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Toncil ca.
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TONCIL CA 75-80% of oropharyngeal cancer
İncidance of lymphatic metastases rate is high 75% (mostly jugulodigastric met.)
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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.
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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.
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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
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TONSIL SIZE 0 in fossa +1 <25% occupation of oropharynx +2 25-50%
% % +4 >75% Avoid gagging the patient
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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
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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
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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
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