HEAD & NECK

Dr Vinay H.S M.D

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: Beefyred tongue: Atrophy of papillae & thinning of mucosa ! Causes: ! Iron-deficiency anemia + Glossitis + esophageal dysphagia usually related to webs known as the PlummerVinson 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 cant be wiped off & cant 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

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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

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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
!! 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

!! 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) :
-! 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. Upper lateral aspect of the neck along sternocleidomastoid muscle.

! 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.
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SALIVARY GLAND DISORDERS

!!Sjogrens Syndrome:
! Females ! Autoimmune disorder; associated with Rheumatoid Arthritis ! Destruction of minor salivary glands & lacrimal glands ! Clinically: dry mouth, dry eyes

!!Sialadenitis:
! Traumatic, viral, bacterial, autoimmune. ! Viral: Mumps (M/C) ! Complications: Orchitis, pancreatitis

SALIVARY GLAND NEOPLASMS

!!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

!!Warthins 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

!!Mucoepidermoid carcinoma:
! M/C primary malignant salivary gland tumor ! Gross: Circumscribed, pale grey white, mucin containing cysts ! Microscopy: Mixture of squamous cells, Mucussecreting cells & Intermediate cells ! Grades: Low, intermediate, High

!!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