Shawn A. McClure D.M.D., M.D. Miami Oral & Maxillofacial Surgeon Associate Professor, Director of Research Department of Oral & Maxillofacial Surgery
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1 Shawn A. McClure D.M.D., M.D. Miami Oral & Maxillofacial Surgeon Associate Professor, Director of Research Department of Oral & Maxillofacial Surgery NOVA/NSU COLLEGE OF DENTAL MEDICINE 1
2 Diseases of Head and Neck: What Should a Primary Care Physician Be Looking For? June 22 nd, 2012
3 If the patient complains of a painless mass or lump in the neck, what initial examination should the physician proceed to do immediately? Look in the oral cavity 3
4 EXTRAORAL EXAMINATION Proper positioning of the fingers Have the patient open and close slowly. 4
5 EXTRAORAL EXAM 5
6 EXTRAORAL EXAMINATION Preauricular nodes. Palpation of the anterior cervical nodes. 6
7 EXTRAORAL EXAMINATION Bilateral palpation of the occipital nodes. Be sure to also observe the skin in this area. Postauricular nodes. 7
8 EXTRAORAL EXAMINATION Palpation of the posterior cervical nodes. Bilateral palpation of the supraclavicular lymph nodes. 8
9 EXTRAORAL EXAMINATION Palpate the submandibular lymph nodes using a cupped hand as shown. Digital palpation of the submental lymph nodes. 9
10 EXTRAORAL EXAMINATION Palpation of the parotid gland. Palpation of the submandibular glands. 10
11 EXTRAORAL EXAMINATION Bimanual palpation of the thyroid gland. Hold the fingers lightly over the gland while the patient swallows. 11
12 Differential of Neck Masses CONGENITAL NECK MASS Branchial cleft cyst Thyroglossal duct cyst Vascular anomalies Laryngocele Ranula Teratoma Dermoid cyst Thymic cyst INFLAMMATORY NECK MASS Infectious inflammatory disorders - Reactive viral lymphadenopathy - Bacterial lymphadenopathy Noninfectious inflammatory disorders NEOPLASTIC DISORDERS Metastatic head and neck carcinoma Thyroid masses Salivary gland neoplasm Paragangliomas Schwannoma Lymphoma Lipoma and benign skin cysts 12
13 Dermoid Cyst 13
14 Dermoid Cyst 14
15 INTRAORAL EXAMINATION 15
16 Proper Head & Neck Examination 16
17 17
18 INTRAORAL EXAMINATION Palpating the hard palate. Use firm pressure. Normal structures of the anterior palate hard palate. 18
19 INTRAORAL EXAMINATION Normal structures of the posterior hard palate. Observe the dimensions (height and width) of the vault. 19
20 INTRAORAL EXAMINATION Visual examination of the upper labial mucosa. Visual examination of the lower labial mucosa. 20
21 INTRAORAL EXAMINATION Use digital palpation pressing the tissues against the body of the mandible for both the lingual and the facial aspects. The mirror is used to visualize the anterior lingual portion of the mandible. 21
22 INTRAORAL EXAMINATION Examination of the lateral borders of the tongue. Visual examination of the floor of the mouth. Note the normal structures of the area. 22
23 23
24 First level bullet Second level bullet Third level bullet Fourth level bullet Fifth level bullet 24
25 25
26 Selected diseases of the oral mucosa Inflammatory Disorders
27 Selected diseases of the oral mucosa Inflammatory Disorders Infections
28 Selected diseases of the oral mucosa Inflammatory Disorders Infections Herpes Simplex
29 Selected diseases of the oral mucosa Inflammatory disorders Infections: Herpes Simplex Majority of infections with HSV are subclinical Either HSV type 1 or 2 may be involved
30 Selected diseases of the oral mucosa Inflammatory disorders Infections: Herpes Simplex Primary herpetic gingivostomatitis Infants, young children, immunosuppressed individuals
31 Selected diseases of the oral mucosa Inflammatory disorders Infections: Herpes Simplex Primary herpetic gingivostomatitis Multiple, painful, discrete vesicles that rupture to form ulcers Cervical lymphadenopathy, malaise, and fever
32 Primary Herpetic Gingivostomatitis
33 Selected diseases of the oral mucosa Inflammatory Disorders Infections: Herpes Simplex Recurrent herpetic infections Viral latency after clinical or subclinical infection Reactivated by febrile illness, trauma, or other forms of stress
34 Recurrent Herpes
35 Recurrent Herpes
36 Selected diseases of the oral mucosa Inflammatory Disorders Infections: Candida (Monilia) Albicans Stomatitis in young children and in adults with debilitating diseases prolonged broad spectrum antibiotics, or immunosuppressive therapy
37 Thrush
38 Selected diseases of the oral mucosa Inflammatory Disorders Infections: Acute necrotizing ulcerative gingivitis Severe necrotizing gingivitis occurring in patients with poor oral hygiene and decreased resistance to bacterial infection
39 Acute Necrotizing Ulcerative Gingivitis
40 Relation of Periodontal Disease and Systemic Diseases Periodontal disease, a chronic inflammatory disease, is linked to other health risks. Heart Disease and Stroke Pregnancy Problems Diabetes Respiratory Diseases 40
41 Selected diseases of the oral mucosa Inflammatory Disorders Infections: Viral Papillary Lesions Associated with Human Papilloma Virus Exophytic and appear as cauliflower-like lesions High rate of recurrence 41
42 Condyloma 42
43
44 Selected diseases of the oral mucosa Inflammatory Disorders Recurrent Aphthous Ulcers Idiopathic disorder characterized by recurrent episodes of painful, round or oval yellow-white ulcers surrounded by an erythematous halo
45 Selected diseases of the oral mucosa Inflammatory Disorders Recurrent aphthous stomatitis Three forms Minor type Major type Herpetiform type
46 Recurrent Aphthous Stomatitis
47 Selected diseases of the oral mucosa Inflammatory disorders Pyogenic Granuloma Asymptomatic tumescence composed of granulation tissue
48 Pyogenic granuloma
49 Selected diseases of the oral mucosa Inflammatory disorders Lichen planus
50 Selected diseases of the oral mucosa Inflammatory disorders Lichen Planus (autoimmune) Common chronic inflammatory mucocutaneous disease Oral lesions may be the only manifestation* Disease of middle age that affects the sexes nearly equally
51 Selected diseases of the oral mucosa Inflammatory disorders Lichen planus Several forms
52 Selected diseases of the oral mucosa Inflammatory disorders Lichen planus Several forms Reticular form
53 Lichen planus
54 Selected diseases of the oral mucosa Inflammatory Disorders Lichen planus Several forms Reticular form Erosive form
55 Erosive Lichen Planus
56 PRECANCEROUS LESIONS?
57 Clinical appearance Minimal pain during early growth phase. Exophytic Endophytic Leukoplakia Erythroplakic Erythroleukoplakic
58 Leukoplakia: Premalignant Lesions A white patch or plaque that cannot be characterized clinically A descriptive term, not a histological diagnosis. Generally asymptomatic Presents as a white lesion that may be flat, slightly elevated with rugated or smooth texture The buccal mucosa, lower lip vermilion and gingiva account for most oral cavity leukoplakia More than 70% of patients with leukoplakia are smokers The malignant transformation of these lesions has been studied extensively with no definitive conclusions
59 Leukoplakia
60 Premalignant Lesions Erythroplakia A red patch that cannot be characterized clinically More likely to present with dysplasia or carcinoma in situ Common sites are floor of the mouth and retromolar fossa. Appearance can be bright red, homogenous, and may or may not have a sharply demarcated border Often associated with areas of leukoplakia (Erythroleukoplakia)
61 Erythroplakia
62 HOW DOES ORAL CANCER PRESENT IN THE MOUTH?
63 63
64 Oral Cancer Oral cancer accounts for around 3% of all newly diagnosed cancers Eighth most common cancer affecting males in the United States Squamous cell carcinoma (SCC): 85-95% of all oral cancer Other malignant lesions can be found in the oral cavity such as: Salivary Gland Tumors Melanoma Sarcoma Lymphoma Metastatic disease Even with recent advances in locoregional control and adjunctive therapy, 5 year survival rates have not improved significantly
65 Risk Factors No single causative agent can be attributed to the development of all oral cancers Tobacco and alcohol appear to have a great impact on malignancy development Smokers are 2 to 12 times more likely to develop malignancies in the oral cavity than non smokers 90% of individuals with oral cancer report a smoking history.
66 Exophytic lesion Typically irregular or papillary surface forming the mass Superficial color can be from NORMAL, to red, to white depending on keratinization or ulcerated Tumor feels indurated
67 Endophytic lesion Typically have depressed irregularly shaped ulcerated central area with surrounding rolled border of normal or white mucosa Rolled border from invasion of tumor downward and laterally
68 Risk Factors The United States has an aggressive anti-smoking campaign, resulting in the decrease of smokers and oropharyngeal malignancies but increase in the incidence of HNC in young men, non-smokers, and non-drinkers
69 HUMAN PAPILLOMA VIRUS
70 Human Papillomavirus 85% of humans will have and HPV infection during their lifetime, enter via a break in the stratified squamous epithelium of the oral mucosa 90-95% are associated with HPV 16 Mork et al demonstrated 14 times greater risk in people testing positive for HPV 16
71 Human Papillomavirus Enter the cell via endocytosis Enter the nucleus and the viral genome is incorporated into the cell line Main culprit,, has a higher affinity to bind to tumor suppression genes
72 Prognosis HPV-positive patients have better overall survival outcomes than HPV-negative HPV-positive tumors are much more radiosensitive Tachezy et al, showed HPV-positive tumors have an absence of p53 mutations
73 Tongue 22 to 49% of all oral cancer Anterior 2/3: 75% of cases Posterior one-third: 25% of cases Metastasis to level II, followed by levels III and I. Possibility of skip metastasis to level IV About 40% will have cervical node metastasis at time of presentation
74 Floor of Mouth Second most common location for oral cavity SSC Resection is treatment of choice for most surgeons Anterior lesions may require sialodochoplasty
75 Retromolar Trigone Can resemble oropharyngeal primary cancer in behavior Larger lesions may invade the pterygomandibular space and extend towards the skull base Surgical Management: -Wide local excision -Marginal mandibulectomy -Segmental Resection Elective neck radiation or selective neck dissection should be considered in T2 or greater lesions
76 Lip Cancer Approximately 2 to 42% of oral cavity cancers. Often seen in white males with increased sun exposure Metastasis from the lower lip: submental, submandibular, and perifacial nodes Metastasis from upper lip and commisure: Preauricular, periparotid, and submandibular nodes
77 Lip Cancer Surgical Treatment: -CO2 laser ablation -Vermilionectomy - Wedge resection Infrequent nodal metastasis- Neck dissection usually not indicated Five-year survival of 90% for stage I and Stage II
78 Buccal Mucosa Represents 2 to 10% of all SCC of the oral cavity Cervical lymph node metastases seen in 10 to 25% of patients First-echelon lymphatic drainage is level I followed by level II
79 Buccal Mucosa Excision often results in complex defects of the cheek that can be difficult to reconstruct 2-Year Survival Rate Early Stage: % Stage III: 41% Stage IV: 15%
80 Alveolar Ridge 2 to 18% of oral cancers Mandible more common than maxilla About 30% of these tumors will exhibit some bony involvement at time of presentation Metastasis more common in mandibular ridge tumors than in maxillary tumors. Nodal drainage most frequently to levels I and II (25 to 30% at diagnosis)
81 Alveolar Ridge Surgical Management May Include: -Partial or total maxillectomy -Marginal Mandibulectomy -Segmental Mandibulectomy Overall 5-year survival rate is 50 to 65% Poor outcome is associated with: -advanced stage -perineural spread -positive margins
82 Hard Palate About 3 to 6% of all oral cavity SCC Metastasis in 10-25% of patients at time of presentation Metastasis usually to levels I and II Metastaor nodes that are not palpable on a clinical examination sis can be to retropharyngeal nodes Elective treatment of the neck mostly for T3 or T4 lesions
83 Staging
84 Pigmented Lesions BLUE/PURPLE VASCULAR LESIONS: Hemangioma Varix Angiosarcoma Kaposi s Sarcoma Hereditary Hemorrhagic Telangiectasia 84
85 Hemangioma Kaposi s Sarcoma 85
86 Pigmented Lesions BROWN MELANOTIC LESIONS Ephelis and Oral Melanotic Macule Nevocellular Nevus and Blue Nevus Malignant Melanoma Drug-Induced Melanosis Physiologic Pigmentation Café au Lait Pigmentation Smoker s Melanosis Pigmented Lichen Planus Endocrinopathic Pigmentation HIV Oral Melanosis Peutz-Jeghers Syndrome 86
87 Peutz-Jeghers Syndrome Physiologic Pigmentation Café au Lait 87
88 Pigmented Lesions BROWN HEME-ASSOCIATED LESIONS Ecchymosis Petechia Hemochromatosis 88
89 Ecchymosis 89
90 Pigmented Lesion GRAY/BLACK PIGMENTATIONS Amalgam Tattoo Graphite Tattoo Hairy Tongue Pigmentation Related to Heavy-Metal Ingestion 90
91 Amalgam Tattoo Hairy Tongue 91
92 92
93 Oral Mucosal Melanoma Mucosal melanoma of the head and neck is a relatively rare condition, representing 8-15% of all malignant melanomas of the head and neck region and accounting for less than 1% of all melanomas. The prognosis is grim, with most published reports documenting a dismal 5-year survival rate of 10-15%. 93
94 94
95 95
96 96
97 97
98 98
99 99
100 Selected diseases of the oral mucosa Tumor like conditions Fibroma
101 Selected diseases of the oral mucosa Tumor like conditions Fibroma Hyperplastic fibrous lesion resulting from trauma or chronic irritation
102 Fibroma
103 Selected diseases of the tongue Geographic tongue
104 Geographic tongue
105 Selected Diseases of the Tongue Geographic Tongue Median Rhomboid Glossitis
106 Median Rhomboid Glossitis
107 Selected diseases of the tongue Geographic tongue Median rhomboid glossitis Hairy tongue
108 Black Hairy Tongue
109 Selected diseases of the tongue Geographic tongue Median rhomboid glossitis Hairy tongue Fissured ( scrotal ) tongue
110 Fissured Tongue
111 Paget s disease
112 Paget s Disease
113 Pathology of the Jaws
114 Pathology of the Jaws Miscellaneous Jaw Lesions Overgrowth of Mature Bone Tori ( torus ) Midline of palate
115 Maxillary Tori
116 Pathology of the Jaws Miscellaneous Jaw Lesions Overgrowth of mature bone Tori ( torus ) Midline of palate Lingual surface of mandible
117 Mandibular Tori
118 Pathology of the Jaws Miscellaneous Jaw Lesions Overgrowth of mature bone Tori (Torus) Midline of palate Lingual surface of mandible Exostosis ( exostoses ) Buccal surfaces of maxilla and mandible
119 Exostosis
120 Salivary Glands
121 3 paired glands Salivary Glands Parotid Submandibular Sublingual 121
122 MINOR SALIVARY GLANDS Minor salivary glands are located beneath the mucosa Tongue Buccal mucosa Floor of the mouth Oropharynx Upper and lower lip
123 MINOR SALIVARY GLANDS Extraoral sites Paranasal sinuses Hypopharynx Nasopharynx Larynx Neck
124 Pathology of the Salivary Glands Inflammatory diseases Acute bacterial infection Signs and symptoms: Pain, tenderness, and swelling Red, swollen duct orifice Pus may be expressed by massage of the gland or duct
125 Pathology of the Salivary Glands Obstructive disorders Sialolithiasis: Ductal inflammation or stasis can lead to the formation of salivary stones (sialoliths) that obstruct the flow of saliva Most common in the submandibular gland
126 Pathology of the Salivary Glands Obstructive Disorders: Sialolithiasis Mucocele: Involves minor salivary glands Results from obstruction or damage to the duct releasing mucus to form a cyst like pool of mucus Most common location is lower lip
127 Mucocele
128 Pathology of the Salivary Glands Obstructive disorders Sialolithiasis Mucocele Ranula: Involves, most frequently, the sublingual gland and, less frequently, the submandibular gland
129 Pathology of the Salivary Glands Obstructive disorders Sialolithiasis Mucocele Ranula: Relatively large blue to transparent mass in the floor of the mouth that displaces the tongue Obstruction due to a sialolith or mucus plug that results in mucus extravasation that pools superior to the mylohyoid muscle
130 Ranula
131 Epidemiological Data Salivary gland tumors comprise: 3-6% of all tumors of the head and neck (Shah) Less than 1% of all malignancies of the head and neck
132 Epidemiological Data 65% Parotid glands 22% minor salivary glands 8% submandibular glands
133 Pathology of the Salivary Glands Salivary Gland Tumors: Benign Vs. Malignant Parotid: 80/20 Submandibular 50/50 Sublingual 20/80 Minor depends on location
134 First level bullet Second level bullet Third level bullet Fourth level bullet Fifth level bullet 134
135 Aetiological and Risk Factors of Salivary Gland Tumors 1. In contrast to majority of head and neck tumors: not related to tobacco and alcohol 2. Chronic inflammation is not clearly defined as a risk factor Licitra, Oncology 2003
136 Pathology of the salivary glands Salivary gland tumors Benign: Pleomorphic adenoma Most common salivary gland tumor* Variable mix of epithelial and mesenchymal elements Slow growing, but can reach considerable size
137 Pleomorphic Adenoma
138 Pathology of the salivary glands Salivary gland tumors Benign Papillary cystadenoma lymphomatosum ( Warthin s tumor )
139 Pathology of the Salivary Glands Salivary gland tumors Benign Papillary cystadenoma lymphomatosum ( Warthin s tumor ) Occurs most frequently in the tail of the parotid gland of white, middle aged men
140 Warthin s Tumor
141 Pathology of the Salivary Glands Salivary gland tumors Malignant (20%)
142 Pathology of the Salivary Glands Salivary gland tumors Malignant Mucoepidermoid carcinoma Most common malignant salivary gland tumor* Parotid glands ( 60% to 70% ) Minor glands ( 15% to 20% ) Submandibular glands ( 10% )
143 Pathology of the salivary glands Salivary gland tumors Malignant Mucoepidermoid carcinoma Most common salivary malignancy in children*
144 Mucoepidermoid carcinoma
145 Pathology of the Salivary Glands Salivary gland tumors Malignant Mucoepidermoid carcinoma Consists of mucus secreting cells and epidermoid cells Range from low grade, well differentiated tumors to high grade aggressive cancers
146 Mucoepidermoid carcinoma
147 Pathology of the Salivary Glands Salivary gland tumors Malignant Malignant mixed tumors
148 148
149 Pathology of the salivary glands Salivary gland tumors Malignant Malignant mixed tumors Represents the malignant form of pleomorphic adenoma Involves the parotid glands, less often the submandibular glands, and rarely the minor salivary glands
150 Pathology of the Salivary Glands Salivary gland tumors Malignant Adenoid cystic carcinomas
151 Pathology of the Salivary Glands Salivary gland tumors Malignant Adenoid cystic carcinomas Most frequent neoplasms of minor salivary glands* 16% to 25% of all tumors 50% of all malignant tumors
152 Pathology of the salivary glands Salivary gland tumors Malignant Adenoid cystic carcinomas Slow growing, but have a relentless course Affinity for perineural invasion Recurrence is common and ultimate prognosis is poor
153 153
154 154
155 Maxillofacial Metastasis Metastasis to the maxillofacial region is a rare occurrence, with most of the literature considering 1% of all new head and neck cancers to be metastasis from distant sites. Hirshberg,A. Oral Oncology, Eur J Cancer 1995
156 Primary Tumor According to the literature in larger series the most common sources of primary tumors are: 1. Breast 2. Lung 3. Kidney 4. Bone 5. Colon Hirshberg, A. Oral Oncol, Eur J Cancer 1995
157 Maxillofacial Metastasis Overall there were twenty six patients. 16 Males 10 Females Average age of 63.8 yrs (45-87) Average age of Males 64 yrs Average age of Females 64 yrs MF mets (n=26) Males (16) Females (10) Ave age 64 Ave age 64
158 Clinical Presentation Facial Swelling % Gingival Swelling % Pain % Paresthesia % Pathologic Fracture % TMD % Non-Healing Extraction 2 7.6% Facial Nerve Palsy 1 3.8% Loose Teeth 1 3.8%
159 Primary Tumor According to the literature in larger series the most common sources of primary tumors are: 1. Breast 2. Lung 3. Kidney 4. Bone 5. Colon Hirshberg, A. Oral Oncol, Eur J Cancer 1995
160 At the time of presentation: 16 (62%) had unknown primaries and the metastasis led to the diagnosis of the primary tumor 10 patients had known primaries - average time of diagnosis of a metastatic lesion 31.5 months - range of months
161
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