Shawn A. McClure D.M.D., M.D. Miami Oral & Maxillofacial Surgeon Associate Professor, Director of Research Department of Oral & Maxillofacial Surgery

Transcription

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

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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

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24 First level bullet Second level bullet Third level bullet Fourth level bullet Fifth level bullet 24

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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

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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?

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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

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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

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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

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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

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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

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