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
Diseases of Head and Neck: What Should a Primary Care Physician Be Looking For? June 22 nd, 2012
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
EXTRAORAL EXAMINATION Proper positioning of the fingers Have the patient open and close slowly. 4
EXTRAORAL EXAM 5
EXTRAORAL EXAMINATION Preauricular nodes. Palpation of the anterior cervical nodes. 6
EXTRAORAL EXAMINATION Bilateral palpation of the occipital nodes. Be sure to also observe the skin in this area. Postauricular nodes. 7
EXTRAORAL EXAMINATION Palpation of the posterior cervical nodes. Bilateral palpation of the supraclavicular lymph nodes. 8
EXTRAORAL EXAMINATION Palpate the submandibular lymph nodes using a cupped hand as shown. Digital palpation of the submental lymph nodes. 9
EXTRAORAL EXAMINATION Palpation of the parotid gland. Palpation of the submandibular glands. 10
EXTRAORAL EXAMINATION Bimanual palpation of the thyroid gland. Hold the fingers lightly over the gland while the patient swallows. 11
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
Dermoid Cyst 13
Dermoid Cyst 14
INTRAORAL EXAMINATION 15
Proper Head & Neck Examination 16
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INTRAORAL EXAMINATION Palpating the hard palate. Use firm pressure. Normal structures of the anterior palate hard palate. 18
INTRAORAL EXAMINATION Normal structures of the posterior hard palate. Observe the dimensions (height and width) of the vault. 19
INTRAORAL EXAMINATION Visual examination of the upper labial mucosa. Visual examination of the lower labial mucosa. 20
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
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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Selected diseases of the oral mucosa Inflammatory Disorders
Selected diseases of the oral mucosa Inflammatory Disorders Infections
Selected diseases of the oral mucosa Inflammatory Disorders Infections Herpes Simplex
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
Selected diseases of the oral mucosa Inflammatory disorders Infections: Herpes Simplex Primary herpetic gingivostomatitis Infants, young children, immunosuppressed individuals
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
Primary Herpetic Gingivostomatitis
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
Recurrent Herpes
Recurrent Herpes
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
Thrush
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
Acute Necrotizing Ulcerative Gingivitis
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
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
Condyloma 42
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
Selected diseases of the oral mucosa Inflammatory Disorders Recurrent aphthous stomatitis Three forms Minor type Major type Herpetiform type
Recurrent Aphthous Stomatitis
Selected diseases of the oral mucosa Inflammatory disorders Pyogenic Granuloma Asymptomatic tumescence composed of granulation tissue
Pyogenic granuloma
Selected diseases of the oral mucosa Inflammatory disorders Lichen planus
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
Selected diseases of the oral mucosa Inflammatory disorders Lichen planus Several forms
Selected diseases of the oral mucosa Inflammatory disorders Lichen planus Several forms Reticular form
Lichen planus
Selected diseases of the oral mucosa Inflammatory Disorders Lichen planus Several forms Reticular form Erosive form
Erosive Lichen Planus
PRECANCEROUS LESIONS?
Clinical appearance Minimal pain during early growth phase. Exophytic Endophytic Leukoplakia Erythroplakic Erythroleukoplakic
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
Leukoplakia
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)
Erythroplakia
HOW DOES ORAL CANCER PRESENT IN THE MOUTH?
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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
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.
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
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
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
HUMAN PAPILLOMA VIRUS
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
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
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
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
Floor of Mouth Second most common location for oral cavity SSC Resection is treatment of choice for most surgeons Anterior lesions may require sialodochoplasty
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
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
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
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
Buccal Mucosa Excision often results in complex defects of the cheek that can be difficult to reconstruct 2-Year Survival Rate Early Stage: 83-100% Stage III: 41% Stage IV: 15%
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)
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
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
Staging
Pigmented Lesions BLUE/PURPLE VASCULAR LESIONS: Hemangioma Varix Angiosarcoma Kaposi s Sarcoma Hereditary Hemorrhagic Telangiectasia 84
Hemangioma Kaposi s Sarcoma 85
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
Peutz-Jeghers Syndrome Physiologic Pigmentation Café au Lait 87
Pigmented Lesions BROWN HEME-ASSOCIATED LESIONS Ecchymosis Petechia Hemochromatosis 88
Ecchymosis 89
Pigmented Lesion GRAY/BLACK PIGMENTATIONS Amalgam Tattoo Graphite Tattoo Hairy Tongue Pigmentation Related to Heavy-Metal Ingestion 90
Amalgam Tattoo Hairy Tongue 91
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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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Selected diseases of the oral mucosa Tumor like conditions Fibroma
Selected diseases of the oral mucosa Tumor like conditions Fibroma Hyperplastic fibrous lesion resulting from trauma or chronic irritation
Fibroma
Selected diseases of the tongue Geographic tongue
Geographic tongue
Selected Diseases of the Tongue Geographic Tongue Median Rhomboid Glossitis
Median Rhomboid Glossitis
Selected diseases of the tongue Geographic tongue Median rhomboid glossitis Hairy tongue
Black Hairy Tongue
Selected diseases of the tongue Geographic tongue Median rhomboid glossitis Hairy tongue Fissured ( scrotal ) tongue
Fissured Tongue
Paget s disease
Paget s Disease
Pathology of the Jaws
Pathology of the Jaws Miscellaneous Jaw Lesions Overgrowth of Mature Bone Tori ( torus ) Midline of palate
Maxillary Tori
Pathology of the Jaws Miscellaneous Jaw Lesions Overgrowth of mature bone Tori ( torus ) Midline of palate Lingual surface of mandible
Mandibular Tori
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
Exostosis
Salivary Glands
3 paired glands Salivary Glands Parotid Submandibular Sublingual 121
MINOR SALIVARY GLANDS 700-800 Minor salivary glands are located beneath the mucosa Tongue Buccal mucosa Floor of the mouth Oropharynx Upper and lower lip
MINOR SALIVARY GLANDS Extraoral sites Paranasal sinuses Hypopharynx Nasopharynx Larynx Neck
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
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
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
Mucocele
Pathology of the Salivary Glands Obstructive disorders Sialolithiasis Mucocele Ranula: Involves, most frequently, the sublingual gland and, less frequently, the submandibular gland
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
Ranula
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
Epidemiological Data 65% Parotid glands 22% minor salivary glands 8% submandibular glands
Pathology of the Salivary Glands Salivary Gland Tumors: Benign Vs. Malignant Parotid: 80/20 Submandibular 50/50 Sublingual 20/80 Minor depends on location
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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
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
Pleomorphic Adenoma
Pathology of the salivary glands Salivary gland tumors Benign Papillary cystadenoma lymphomatosum ( Warthin s tumor )
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
Warthin s Tumor
Pathology of the Salivary Glands Salivary gland tumors Malignant (20%)
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% )
Pathology of the salivary glands Salivary gland tumors Malignant Mucoepidermoid carcinoma Most common salivary malignancy in children*
Mucoepidermoid carcinoma
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
Mucoepidermoid carcinoma
Pathology of the Salivary Glands Salivary gland tumors Malignant Malignant mixed tumors
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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
Pathology of the Salivary Glands Salivary gland tumors Malignant Adenoid cystic carcinomas
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
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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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
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
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
Clinical Presentation Facial Swelling 10 38.4% Gingival Swelling 9 34.6% Pain 7 26.9% Paresthesia 5 19.2% Pathologic Fracture 3 11.5% TMD 3 11.5% Non-Healing Extraction 2 7.6% Facial Nerve Palsy 1 3.8% Loose Teeth 1 3.8%
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
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 0-103 months