oral cancers by dr. sintayehu sirino

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CONTENTS✓ Tumorsofso)*ssues✓ Epithelial✓ Connec2ve2ssue✓ Vascular✓ Nerve2ssue✓ Salivaryglands✓ Tumorsofhard*ssues✓ Nonodontogenictumors✓ Diseasesofsalivaryglands

•  Objec*vesAttheendeachstudentsshouldknow•  Whatdowemeanbytumors•  Whatdowemeanbyso?andhard2ssues•  Tumorsofso?2ssues•  Tumorsofhard2ssues•  Somediseasesofsalivaryglands

EPITHELIALTUMORS•  Papilloma…..benigntumor•  carcinoma…...malignanttumor/cancer•  Melanoma…...malignanttumor

EpithelialtumorsA.PapillomaDefini*on➢ Papillomaisabenigntumorknowntogrowinanoutwarddirec*on,itproducesfrond-liketumorsthatcandevelopanywhereonthebody.

➢ Papillomaarealsoknownasneoplasms.➢ Papillomacanoccurinareasthroughoutthebody.➢ Papillomaontheskin(cutaneouspapilloma)arecommonlyreferredtoaswarts.

Etiology"  Viral

HPV"  Nonviral

Tissueinjury…...Nasalpapilloma

CLINICALFEATURES

•  Commonbenignneoplasmorigina*ngfromsurfaceepithelium

•  Exophy*cgrowthmadeoffingerlikeprojec*ons

•  Roughened,Verrucousorcauliflowerlikeappearance

•  Wellcircumscribed,pedunculated,•  Foundontongue,lips,buccalmucosa,

gingiva&palate•  Fewmmsindiametertoseveralcms

•  Mul*plepapillomasareseeninfocaldermalhypoplasiasyndrome

•  Treatment -Excisionthroughthepedicle

carcinomasquamouscellcarcinoma

basalcellcarcinoma

SquamousCellCarcinoma

•  Defined as amalignant epithelial neoplasmexhibi*ng squamous differen*a*on ascharacterized by the forma*on of kera*nand/orthepresenceofintracellularbridges.

Epidemiology

•  SoutheastAsianscenario-•  6,44,600in19992•  Na*onalcancerRegistryProgramme

E*ology

•  UnequivocallyassociatedwithTobaccochewinghabits&usuallyprecededbypremalignantlesions&condi*ons.

•  Alcohol•  Syphilis•  Nutri*onaldeficiencies•  Sunlight•  Miscellaneous-Trauma,irita*on•  Viruses-HPV,

Carcinomaoflip

•  Occurschieflyinelderlymen•  Lowerlipinvolvedmorecommonly•  Greatestincidencebetween55-75years

E*ology

•  Tobacco•  Leukoplakia

Clinicalfeatures

•  Vermillonborderoflip•  Smallareaofindura*on,ulcera*onorirregularity

•  Smallcrater-likedefect•  Slowmetastasistoipsilaterallymphnodes

Treatmentandprognosis

•  Surgicalexcision•  X-rayradia*on

•  Factorsaffec*ngsuccessoftreatment•  Sizeoflesion•  Dura*on•  Metastases•  Histologicgrade

Carcinomaoftongue

•  Comprises25-50%ofintraoralcancer•  Lesscommoninwomen•  Averageagerange32-87years

E*ology

•  Syphilisseenco-existentwithcarcinoma•  Leukoplakia•  Poororalhygiene•  Chronictrauma•  Alcoholtobacco

Clinicalfeatures

•  Painlessmassorulcer•  Painfulifsecondarilyinfected•  Lateralborderorventralsurfaceoftongue•  Ifinposteriorpor*onoftongue-causeearlymetastases&poorprognosis

Treatment&prognosis

•  Judiciouscombina*onofsurgery&X-rayradia*on

Carcinomaoffloorofmouth

•  Clinicalfeatures•  Induratedulcer•  Mayormaynotbepainful•  Anteriorpartmoreo)eninvolved•  Earlyextensionintolingualmucosa•  Limitsmo*onoftongue•  Metastasestosubmaxillarylymphnodes

Treatment&prognosis

•  X-rayradia*on•  Useofradium

CarcinomaofbuccalmucosaE*ology-"  tobaccochewing&carryingbetelnutquid

•  LeukoplakiaClinicalfeatures•  Alongorinferiortoalineoppositeocclusalplane

•  Highrateofmetastases

Treatment&prognosis

•  SurgeryorX-rayradia*on•  Prognosisdependsonprescenceofmetastases

Carcinomaofgingiva

•  Morecommoninmandibulargingiva•  Anareaofulcera*on,erosion,orexophy*cgrowthTreatment&prognosis-Surgicalexcision

Carcinomaofpalate

•  Manifestsasapoorlydefined,ulcerated,painfullesionononesideofmidline

Treatment&prognosisBothsurgery&radia*onhavebeenused.

MELANOMA

•  Akamalignantmelanoma•  Isatypeofcancerthatdevelopsfromthepigmentcontainingcellsknownasmelanocyteswhicharelocatedbetweenepidermisanddermis

•  Typicallyoccurintheskinbutmayrarelyoccurinthemouth,intes*neandeyes

•  Neoplasmofepidermalmelanocytes.•  Cutaneousmelanomasareincreasinginincidence.•  Among dark skinned ethics it 1 per 100,000 and inlight-skinnedupto50andhigherinsomeareasoftheworld.

•  Melanoma may occur or near a previously exis*ngprecursorlesionorinhealthyappearingskin.

Etiology

•  A)environmentalfactors:•  Sunexposure•  Ar*ficialUVsources•  Socioeconomicstatus•  Fairskin,frecklesandredhair•  Numberofmelanocy*cnevi•  B)gene*cfactors:•  Familialmelanoma•  Xerodermapigmentosum

ClinicalfeaturesSuperficialspreadingmelanoma:•  CommoncutaneousmelanomainCaucasians.•  Existsinaradial-growthphasecalledpremalignantmelanosisorpagetoidmelanomainsitu.

•  Thever*calgrowthphaseischaracterizedbyanincreaseinsize,changeincolor,nodularity,ulcera*on.

Nodularmelanoma:•  Accountsforapproximately13percentofcutaneousmelanomas.

•  Noclinicallyrecognizableradial-phasegrowth,existssolelyinver*cal-growthphase.

•  Theymaybepink(amelano*cmelanoma)orpink.

•  Predilec*onforbackandheadandneckskinofmen.

Len*gomalignamelanoma:•  Accountsfor10percentofcutaneousmelanomas.

•  Existsinaradial-growthphaseknownaslen*gomalignaormelano*cfreckleofhutchinson.

•  Showsfemalepredilec*on.

Acrallen*ginousmelanomas:•  Melanomadevelopingonthepalmsandsoles,fingersandtoes.

•  Thetumorischaracterizedbymacular,len*ginouspigmentedareaaroundanodule.Mucosallen*ginousmelanomas:•  Developfrommucosalepitheliumthatlinestherespiratory,gastrointes*nalandgenitourinarysystems.Noncutaneousmelanomasarecommoninolderage.

•  Len*gomelanomashaveaggressivecourse.

Amelano*cmelanomas•  Seenaserythematousorpink,erodednodule.

Oralmanifesta*ons:•  Primaryoralmelanomatwiceascommoninmen.•  Israngebetween40-70years.•  Predilec*onforpalateandmaxillaryalveolarridge.

•  Appearsasdeeplypigmentedareas.•  Ulceratedandhemorrhagic.•  Increaseinsizeprogressively.

Treatment

Beforeithasspread• surgery

A)erhasspread• Immunotherapy• Biologictherapy• Radia*ontherapy• Chemotherapy

CONNECTIVETISSUETUMORS•  Fibroma……...benigntumor•  Lipoma……….benigntumor•  fibrosarcoma...malignanttumor

Fibroma

"  Benigntumorsthatarecomposedoffibrous"  Akairritationfibroma

•  Theyusuallyemergeinthecheeks,tongue,palateandgums.

•  Fibroidsusuallygrowveryslowly

Etiology"  Unknowncauses"  Tissuerxntominorinjury"  Geneticcomponents

Clinicalfeatures

•  Epulisfissuratum•  Sessileorpedunculated•  Asymptomaticandmoderatelyfirm•  Whitenessfromthethickenedsurfacekeratin•  Ulcerationfromrecurringtrauma

Differentialdiagnosis

PyogenicgranulomaNeurofibromafrictionalkeratosissquamouscellcarcinoma

Treatment• Conservativesurgicalexcision• Itmayrecura)ersurgeryifthesourceofirrita*oncon*nuessomanagethesourceofirritation

• Oralfibromasdonotdisappearwithouttreatment.

Lipoma

"  Benign tumor of fat "  It represents the most mesenchymal

tumor, however most of them occur in the trunk and extremities – Head and Neck are less common ✧  Asymptomatic and present for several years

Etiology"  Hereditaryconditionlikefamilialmultiplelipomatosis(butnothereditary)

"  Gardenerssyndrome"  Dercum’ssyndrome

Clinicalfeatures"  Buccal mucosa and vestibule are the most

common sites "  >40 years; female = male "  Oral lipomas are soft nodular masses that

is sessile or pedunculated with yellow color "  Softtothetouch,usuallymovable,andaregenerallypainless.

" Small(<1cm)butcanenlarge(6cm<)" Localized,lobular,non-tender"  Semi-fluctuant" Mobile

DDXFibrosarcomasHerniaspapillomaNeurofibromasAbscessSebaceouscystEpidermoidcyts

Treatment

• conservative local excision

Fibrosarcoma

Isamalignantmesenchymaltumourderivedfromfibrousconnec*ve*ssuecharacterizedbythepresenceofimmatureprolifera*ngfibroblastsorundifferen*atedanaplas*cspindlecellsinastoriformpalern.Itisusuallyfoundinmalesaged30to40.Itoriginatesinfibrous*ssuesoftheboneandinvadeslongorflatbonessuchasfemur,*bia,andmandible.Italsoinvolvesperiosteumandoverlyingmuscle

Etiology"  Unknownornodefinecauses"  Mayberelatedtogeneticmutation"  Ascomplicationofotherconditions

Clinicalfeatures➢ Nosexpredilec*on➢ Commontumorsofadults,althoughtheycanoccurinanyagegroup

andevenbepresentascongenitalneoplasms.Microscopic➢ Thecellsarearrangedinfasciclesthatintersecteachotheratacute

angles,resul*nginaherringboneappearance.➢ Theindividualcellsresemblenormalfibroblasts,andare*culinstain

demonstratesabundantfiberswrappedaroundeachcell.

Differentialdiagnosis

"  Monophasicsynovialsarcoma,"  Liposarcoma,"  Malignantfibroushistiocytoma,

Diagnosis• Incisionalorexcisionalbiopsy

Treatment"  Geneticandimmunohistochemicaltesting"  Surgicalresection(standardtx)"  chemotherapy(notbeenencouraged)

VASCULARTUMORS•  Heamangioma…...benigntumor•  Lymphangioma…..benigntumor

Hemangioma"  Benigntumorsofmesenchymalcells

➢ Hemangiomasarethemostcommontumorsoftheheadandneckininfancyandchildhood,

➢ Comprisingapproximately7%ofallbenignso)*ssuetumors.

"  Etiology…..congenital

classificationcongenitalhemangiomacavernoushemangiomacapillaryhemangiomacentralhemangioma

Clinicalfeatures ➢ Most common tumors of infancy

➢ More common in females (3:1)

➢ Most common in Head and Neck (60% of

cases) ➢ Mostly occurs as single lesions

➢ Red/blue lesions that occur in skin, lips,

tongue and buccal mucosa; ➢ The lesion blanches when compressed

➢ Intraosseous lesions also occur – Mandible >

Maxilla and occurs as multilocular radiolucency

DDXMacularstainsVascularmalformationPyogenicgranuloma

Investigation

➢ Imagingtechniques(CTscanandMRI)areusedasdiagnos*caidstodocumenttheextentofthedeephemangioma.

➢ Arteriographyisrarelyindicatedforthediagnosisofahemangioma.

Treatment

"  Most congenital lesions will involute

(“Watchful Neglect”) ➢ Surgical removal and sclerotherapy with 95%

ethanol ➢ Corticosteroid medication

➢ Laser treatment

➢ Medicated gel

Lymphangioma Definition

•  Benign hamartomatous tumors of lymphatic vessels

• Most frequent site in the oral cavity - anterior 2/3 of the tongue where it causes MACROGLOSSIA

• Pebbly surface resembling cluster of translucent vesicles (similar to frog eggs)

Etiology"  Lympha*csystemblockage

-maternalalcohol,viralinfec*on"  Gene*cdisorder

Classification:

• Capillarylymphangioma-Capillarylymphangiomaarecomposedofsmall,capillary-sizedlympha*cvesselsandarecharacteris*callylocatedintheepidermis.

• Cavernouslymphangioma-Composedofdilatedlympha*cchannels-Characteris*callyinvadesurrounding*ssues.

✓ Cys*chygromas✓ Cys*chygromasarelarge,macrocys*clymphangiomasfilledwithstraw-colored,protein-richfluid.

✓ Hemangiolymphangioma✓ Hemangiolymphangiomaarelymphangiomawithavascularcomponent.

.

Cyst’ssizebasedclassificationAccordingtothesizeoftheircysts.

➢ Microcys*clymphangioma➢ Microcys*clymphangiomaarecomposedofcysts,eachofwhichmeasureslessthan2cm3involume.

➢ Macrocys*clymphangioma➢ Macrocys*clymphangiomacontaincystsmeasuringmorethan2cm3involume.

➢ Mixedlymphangioma➢ Lymphangiomaofthemixedtypecontainbothmicrocys*candmacrocys*ccomponents

Clinicalfeatures

"  Predilection to the head and neck with 50 – 75% occurring "  Cavernous lymphangiomas are most

common in oral cavity "  Thesemalformationscanoccuratanyageandmayinvolveanypartofthebody"  But,90%occurinchildrenlessthan2yearsofageandinvolvetheheadandneck.

Vasculartumors✓ Lymphangiomaofso)*ssueshowingdilatedspaceslinedbyflalenedendothelium.

✓ Ascaleringoflymphocytesispresentinstroma

Vasculartumors

Treatment• surgery• sclerotherapy

TUMORSOFNERVETISSUES•  Neurofibroma•  Neurofibromatosis•  Trauma2cneuroma

Tumorsofnerve*ssuesA.NeurofibromaDefinition o BenigntumorarisingfromCTofnervesheath.o Horizontalmobilityonly.o  Mostcommon

Tumorsofnerve*ssues…ctd..o Consistsofneural(ectodermal)&fibrous(mesodermal)elements.

o Benigno Single/mul*pleo Fusiformswellinginthedirec*onofnerve

Tumorsofnerve*ssues…ctd..•  Sites•  Cranial•  Spinal•  peripheral

Tumorsofnerve*ssues…ctd..

Typesofneurofibroma•  Nodular•  Plexiform•  Generalised•  Elephan*a*c•  Pachydermatocoele

Tumorsofnerve*ssues..ctd..

Nodularo Commonlyaffectsperipheralnerveso Adultso Single,smooth,firmo Movesperpendiculartothedirec*onofthenerve.o Presentsaspainfulsubcutaneousnodule.o Skincanbeli)edup.

Tumorsofnerve*ssues…ctd..Plexiform• Cangrowfromnervesintheskinor• Frommoreinternalnervebundles,&canbelarge• Skincanbeli)edup.• Tinglingparesthesia• Obstructsvision• Erodesintobone,orbit&deeperstructures• Myxomatousdegenera*on

Tumorsofnerve*ssues…ctd..

Tumorsofnerve*ssues…ctd..

Generalized✓ AkavonRecklinghausen’sdisease✓ Inheritedautosomaldisease✓ 1in4000births✓ 2types-

– Type1-chr.17muta*on– Type2-chr.22muta*on

Tumorsofnerve*ssues…ctd..•  So),non-tender,mul*ple•  Skeletaldeformi*es•  Neurologicaldisturbance•  Caféaulaitspots•  Lischnodules•  MaybeassociatedwithMENtype2b

Tumorsofnerve*ssues…ctd..

Tumorsofnerve*ssues…ctd..

Tumorsofnerve*ssues…ctd..Elephan2a2c❖ Advancedstageofplexiformvariety❖ Involveslimbs❖ Dry,coarse,thickskin❖ Congenitalorigin

Tumorsofnerve*ssues…ctd..Pachydermatocele•  VariantofplexiformNF•  Neckisinvolved

Tumorsofnerve*ssues…ctd..

TreatmentExcision-❑ Symptoma*c❑ Cosme*c❑ Recentincreaseinsize❑ Malignanttransforma*on

Tumorsofnerve*ssues…ctd..B.NEUROFIBROMATOSISDefinition ANeurofibromatosisisanautosomaldominantgene9cally-inheriteddisorderinwhichthenerve9ssuegrowsabnormallytoformtumors(neurofibromas)thatmaybebenignormaycauseseriousdamagebycompressingnervesandother9ssues

Tumorsofnerve*ssues…ctd..•  Affectsallneuralcrestcells(Schwanncells,melanocytesandendoneurialfibroblasts).

•  Melanocytesalsofunc*onabnormallyinthisdisease,resul*ngindisorderedskinpigmenta*onandcaféaulaitspots.

•  Approximatelyhalfofcasesareduetodenovomuta*onsandnootheraffectedfamilymembersareseen.

•  Itaffectsmalesandfemalesequally.

Tumorsofnerve*ssues…ctd..NEUROFIBROMATOSISTYPE1(vonRecklinghausendisease)

•  Mul*systemneurocutaneousdisorder•  Mostcommonphakomatosis•  MostcommoninheritedCNSdisorder,autosomaldominateddisorder

•  1:3000,M:F•  50%inherited,50%spontaneous

Tumorsofnerve*ssues…ctd..•  ThediagnosisofNF1ismadeifanytwoofthefollowing7criteriaaremet:

•  1.Twoormoreneurofibromasonorundertheskin,oroneplexiformneurofibroma(alargeclusteroftumorsinvolvingmul*plenerves)

Tumorsofnerve*ssues…ctd..•  2.Freckling(crowesign)ofthegroinortheaxilla2-3mmindiam.3.Caféaulaitspots:(HallmarkofNF1)-Sixormoremeasuring5mmingreatestdiameterinprepubertalindividualsandover15mmingreatestdiameterinpostpubertalindividuals.

Tumorsofnerve*ssues…ctd..

•  4.Lischnodules(hamartomasofiris),frecklingintheiris-2ormore5.Tumorsontheop*cnerve,alsoknownasanop*cglioma

Tumorsofnerve*ssues…ctd..•  6.Adis*nc*veosseouslesionsuchassphenoiddysplasiaorcor*calthinningoflongboneswithorwithoutpseudoarthrosis.

•  7.Afirstdegreerela*vewithNF1whosediagnosiswasbaseduponthesecriteria.

Tumorsofnerve*ssues…ctd..Signandsyndrome•  Macrocephalyin30-50%ofthepediatricpopula*onwithoutanyhydrocephalus

•  Epilepsy(seizures)•  Juvenileposteriorlen*cularopacity•  Scoliosiswithorwithoutkyphosis•  Hydrocoele•  Earlypuberty

Tumorsofnerve*ssues…ctd..Neurofibromatosistype2(NF2)•  Alsocalled"centralneurofibromatosis“•  Isresultsfrommuta*onofthemerlin(alsoknownas"schwannomin")inchromosome22q12.i.eNF2gene

•  Itaccountsforonly10%ofallcasesofNF

Tumorsofnerve*ssues…ctd..Thedisordermanifestsinthefollowingfashion:1. Bilateralacous9cneuromas:❖ Tumorsoftheves*bulocochlearnerveorcranialnerve8(CNVIII)alsoknownasschwannoma)

❖ ThehallmarkofNF2ishearinglossduetoacous*cschwanoma.

Tumorsofnerve*ssues…ctd..2.

– headache– balanceproblems,andperipheralver*goduetoschwannomaandinvolvementoftheinnerear

–  facialweakness/paralysisduetoinvolvementorcompressionofthefacialnerve.

–  braintumors,aswellasspinaltumors.– deafnessand*nnitus

Tumorsofnerve*ssues…ctd..Diagnosis•  FetusChorionicvillussamplingoramniocentesiscanbeused•  MRI•  Slitlamp

Tumorsofnerve*ssues…ctd..Treatment•  Thereisnocureforthecondi9onsotheonlytherapyforpa9entswithneurofibromatosisistomanagesymptomsorcomplica9ons.

•  Surgerymaybeneededwhenthetumorscompressorgansorotherstructures.

•  Lessthan10%ofpeoplewithneurofibromatosisdevelopcancerousgrowths;inthesecases,chemotherapymaybesuccessful.

•  Gene9cscreeningandcounsellingforfamilieswithneurofibromatosis.

Tumorsofnerve*ssues…ctd..

C.Trauma2cneuroma➢ Akaamputa*ontraumaorpseudotrauma➢ Isatypeofneuromawhichresultsfromdamagetothenerve,usuallyduringsurgicalprocedures

➢ Morethan50%oftheselesionsarerelatedtotoothextrac*on

Themostcommonoralloca*on:➢ Tongue&➢ Closetomentalforamenofthemouth

"   Reactive proliferation of neural tissue after damage to

nerve bundle "   Smooth nodules most common in mental foramen,

tongue and lower lip with a history of trauma; intraosseous lesions appear as radiolucencies

"  Any age but mostly middle-age, with F>M

"  Hallmark is PAIN which could be intermittent or constant

and mild or severe; "  Mental nerve neuromas are painful especially with denture

flange impingement

Tumorsofnerve*ssues…ctd.Classifica*onTwomajorcategories:(i)Spindleneuromasareinternal,focal,fusiformswellingssecondarytochronicfric*onorirrita*ontoanondisrupted,injuredbutintactnervetrunk.•  ii)Lateralorterminalneuromas

aretheresultofseveretraumawithdisrup*onortotaltransec*onofanerve

Tumorsofnerve*ssues…ctd.

Clinicalfeatures•  Trauma*cneuromasappeargrosslyasfirm,oval,whi*shnodulesthatarerarelylargerthan2cm.

•  Atsec*oning,theyhaveadensefibrousappearancewithlillevascularity.

•  Anervemayterminateattheupperpoleofthemass.

•  Althoughnotencapsulated,theouterlayeroffibrous*ssueiso)eninseparablefromthesurroundingscar,andmicroscopically,anouterlayerofconnec*ve*ssueiscon*nuouswiththeperineuriumoftheintactnervetrunk

Tumorsofnerve*ssues…ctd.

Differen*aldiagnosisPalisadedencapsulatedneuroma

Tumorsofnerve*ssues…ctd.

TreatmentLymphadenectomy•  Neckdissec*on,orcervicallymphadenectomy,isaprocedureforeradica*ngmetastasestotheregionallymphnodes

• SALIVARYGLANDDISEASES&TUMORS

✧  Salivaryglanddiseases-Developmental-Func*onal-Inflammatory-Cystsandtumors-Miscellaneous

SALIVARYGLANDTUMORS✧ Pleomorphicadenoma✧ Adenocarcinoma✧ Warthin’stumor✧ Adenoidcys2ccarcinoma✧ Mucoepidermoidcarcinoma

Salivaryglanddiseases

A)Developmentaldisorders•  Aberrancy•  Aplasia&Hypoplasia•  Hyperplasia•  Atresia•  Accessoryducts•  Diver*culi•  Congenitalfistula

B)Functionaldisorders

•  Sialorrhoea

•  Xerostomia

C)Obstructivedisorders

•  Sialolithiasis

•  Mucusplug•  Stricture&stenosis•  Foreignbodies•  Extraductalcauses

D)Cyst•  Mucocele•  Ranula

E)Asymptoma*cenlargement•  Sialosis•  Allergic•  Associatedwithmalnutri*onandalcoholism

Inflammatory

F)Infec*on•  Viral•  Bacterial•  Myco*cG)Autoimmunedisorders•  Sjogren’ssyndrome•  Mikulicz’sdisease•  Uveoparo*dfever•  Recurrentnonspecificparo**s

Developmentalanomalies

Aberrantsalivaryglands•  Anaberrantorectopicissalivarygland*ssuethatdevelopsatasitewhereitisnotnormallyfound.

Clinicalfeatures

"   Site–cervicalregionneartheparotidglandorbodyofmandible.

Posteriortofirstmolar"   Clinicalsignifance-Sitefordevelopmentofretentioncystorneoplasm

Aplasia&hypoplasia

Itiscongenitallyabsenceofsalivarygland.•  Aplasiaoccursincombina*onwithcongenital

anomalies.•  Hypoplasiainpa*entwithMelkersenRosenthal

syndrome.

Clinicalfeatures

"   Oneorgroupofglandsmissingunilaterallyorbilaterally.

" Xerostomia"   Dentalcaries"   Earlylossofteeth"   Dry&smoothoralmucosa"   Cracking&Fissuringatcornerofmouth.

Management"   Goodoralhygiene.

Functionaldisorders

SialorrhoeaorptyalismItisincreasesalivarysecre*on.S*mula*onofparasympathe*ccausesprofusesecre*onofwaterysaliva.

EtiologyDrugslikesialogogues

"   LocalfactorsANUG,erythemamultiforme"   Systemiclikeparalysis"   Misc.likemetalpoisoning

Clinicalfeatures

Droolingfrommouth•  Lipchapping•  Infec*onfromconstantexposuretosaliva•  Cheekscarring.

Management"   Oralmotordraining"   Biofeed"   Removaloflocalfactors"   Anticholinergicdrugs(atropinesulphate0.4mginadults.01mg/kginchildrenupto0.4"   Surgery

Sialadenitis(sialoadenitis)

ü  isinflamma*onofasalivarygland.

•  Itmaybesubdividedtemporallyintoacute,chronicandrecurrentforms

AcutePredisposingfactors

•  sialolithiasis•  decreasedflow(dehydra*on,post-opera*ve,drugs)

•  poororalhygiene•  exacerba*onoflowgradechronicsialoadeni*s

Clinicalfeatures

•  Painfulswelling•  Reddenedskin•  Edemaofthecheek,Periorbitalregionandneck•  lowgradefever•  malaise•  raisedESR,CRP,leucocytosis•  purulentexudatefromductpunctum

chronic

Chronicsclerosingsialadenitis

ClinicalFeatures•  unilateral•  mildpain/swelling•  commona)ermeals•  ductorificeisreddenedandflowdecreases•  mayormaynothavevisible/palpablestone.•  Paro*dglandRecurrentpainfulswellings•  Submandibulargland•  Usuallysecondarytosialolithiasisorstricture

Treatment

•  Inchronicrecurrentsialadeni*sorchronicsclerosingsialadeni*s,acutealacksaremanagedwithconserva*vetherapiessuchashydra*on,analgesics(mainlyNSAIDs),sialogoguestos*mulatesalivarysecre*on,andregular,gentleglandmassage.

•  Ifinfec*onispresent,appropriateculturesshouldbeobtained,followedbyempiricalan*bio*ctherapyini*ally,forexampleamoxicillin/clavulanateorclindamycinwhichcoveroralflora.

•  Iftherearealacksmorethanapproximately3*mesperyearorseverealacks,surgicalexcisionoftheaffectedglandshouldbeconsidered

ViralInfections

MumpsContagiousviralinfec*oncausedbyparamyxovirus

Clinicalfeatures

Unilateral&bilateralswellingofsalivarygland"   Fever,malaise,anorexia."   Tender&painoneatingsorefood"   Involvedglandcontinuestoenlargefor2-3days&

comesbacktonormal.Complicationoophritis,orchitis,meningitis,encephalitis.

Management

"   Selflimiting"   MMRvaccine"   Systemiccorticosteroids

Sarcoidosisheerdfordtsyndrome

•  Akauveoparo*dfever

•  Araremanifesta*onofsarcoidosis

symptoms:

Includeinflammationoftheeye(uveitis),swellingoftheparotidgland,chronicfever,andinsomecases,palsyofthefacialnerves.

Causes

•  TheexactcauseofHeerfordt'ssyndromehasnotyetbeendefini*velydetermined.

•  Ofthosepa*entswhohavebeendiagnosedwithHeerfordt'ssyndrome,15%haveacloserela*vewhoalsohasthesyndrome.

•  Onepossibleexplana*onisthatthesyndromeresultsfromacombina*onofanenvironmentalagentandahereditarypredisposi*on.

•  MycobacteriumandPropionibacteriaspecieshavebothbeensuggestedastheenvironmentalagent,thoughtheevidenceforthisisinconclusive.

Diagnosis

•  Inpa*entsthathavealreadybeendiagnosedwithsarcoidosis,Heerfordt'ssyndromecanbeinferredfromthemajorsymptomsofthesyndrome,whichincludeparo**s,fever,andfacialnervepalsy.

•  Incasesofparo**s,ultrasound-guidedbiopsyisusedtoexcludethepossibilityoflymphoma.

•  Therearemanypossiblecausesoffacialnervepalsy,includingLymedisease,HIV,Melkersson–Rosenthalsyndrome,schwannoma,andBell'spalsy.

•  Heerfordt'ssyndromeexhibitsspontaneousremission.

Treatments

•  Cor*costeroidsandimmunosuppressivedrugs.

NecrotizingSialometaplasia

• Uncommonlocallydestruc*veinflammatorycondi2onofthesalivaryglands.

Cause:•  unknownbuttheybelieveitistheresultofischemiaofthesalivary*ssuethatleadstolocalinfac2on.

ISCHEM

IA

OXYGEN

Predisposingfactors:

– Trauma*cinjuries– Dentalinjec*ons– Illfirngdentures– Upperrespiratoryinfec*ons– Adjacenttumors– Previoustumors***Howevermanycasesoccurwithoutany

knownpredisposingfactors.

CLINICALFEATURES

✓ Mostfrequentlydevelopsinthepalatalsalivaryglands✓ Hardpalate>so)palate✓ 2/3ofpalatalcasesareunilateral,withtherestbeingbilateralormidlineinloca2on

CLINICALFEATURES

• Hasalsobeenreportedinotherminorsalivaryglandsitesandoccasionallyintheparo*dgland.

• Submandibularandsublingualglandsarerarelyaffected.

CLINICALFEATURES

• Mostcommoninadultsandinmen

•  Thecondi*onappearsini*allyasanon-ulceratedswellingo)enassociatedwithpainorparesthesiawithcrater-likeulcerthatcanrangefromlessthan1cmtomorethan5cmindiameterappearingwithin2to3weeks.

CLINICALFEATURES

Bilateral

Midlineinloca*on

Unilateral

Treatment

• Thelesionisself-limi*nginmostinstancesandhealsunevenuully.

autoimmunediseases

Sjorgen’ssyndrome•  Chronicinflammatorydiseasethatpredominantlyaffects

salivary,lacrimal&otherexocrineglands•  ItwasfirstdescribedbyHENNIKSJOGRENin1933.

Types

primary–dryeyes,drymouth.secondary–dryeyes,drymouth,collagendisordersusuallyrheumatoidarthritis&SLE.

Salivaryglanddiseases

ClinicalFeatures

•  Middleagedandfemalearecommonly

infected•  Xerostomia•  Sorenessanddifficultyincontrollingdentures•  Pusfromduct•  Difficultyinea2ngandunpleasanttaste•  Unilateralandbilateralenlargementofparo2dgland

•  Frothysaliva•  Severedentalcaries•  Depapilla2onoftongue•  Dryeyes•  Vaginaldryness•  Connec2ve2ssuedisorder•  Enlargementoflymphnodes

RadiographicFindings"   Snowstormappearance

"   Insomecasescherryblossomappearance

MANAGEMENT

SYMTOMATICTREATMENT" Occularlubricant-artificialtearscoatingmethyl

cellulose

"   Salivasubstitute"   Oralhygiene

"   Surgeryforenlargementofglands

MIKULICZ’SDISEASE•  Symmetricorbilateralchronicpainless

enlargementoflacrimalorsalivaryglandhasinflammatorycharacteris*cs.

ClinicalFeatures

Womeninmiddleandlaterlife"   Site-unilateralorbilateralenlargementofparotidor

submandibulargland"   Fever"   Upperrespiratorytractinfection"   Occasionalpain" Xerostomia"   Diffusepoorlyoutlineandenlargementofgland

Management

Surgicalexcision

Investigations

Non-invasiveinves*ga*ons

•  Radiographs•  ComputerizedTomography•  Ultrasoundscanning•  Magne*cresonanceimaging•  SinglePhotonemissionComputedTomographyInvasiveInves*ga*ons•  Biopsy•  FineneedleAspira*oncytologySialography

SALIVARYGLANDTUMORS

SALIVARYGLANDTUMORS

Classifica*onoftumorsBenign✧ Pleomorphicadenoma✧ Warthin’stumor✧ Ductalpapillomas✧ Basalcelladenoma✧ Canalicularadenoma✧ oncocytoma

Benign tumors

✓ Painless ✓ Slow growing ✓ No facial palsy

Epidemiology

•  Rule of 80’s •  Mucoepidermoid – MC

malignancy1.2%ofallneoplasms

Malignant

MucoepidermoidcarcinomaAdenocarcinomaAdenoidcys*ccarcinomaAciniccellcarcinomaSquamouscellcarcinoma

Indications of malignancy

•  Facial nerve involvement

•  Indurations / ulceration of skin , mucous membrane

•  Lymph node metastasis

•  Rapid tumor growth

Investigations

o FNAC

o Open biopsy

o CT

o MRI

Pleomorphicadenoma

•  Commonest benign tr

•  Pseudocapsule

•  Pseudopodal extensions •  Not multicentric

Clinicalfeatures

Age—anyagebutmorecommonb/n30-50yrs

Sex--women

Site–post.hardpalate&ant.softpalatemucosafollowedbyupperlip&buccalmucosa

•  Mixed tumor

•  Consists of cartilage besides epithelial cells

•  Cartilage not of mesodermal

origin •  Derived from mucin secreted by

epithelial cells

Diagnosis

•  Lobulated,painlessswelling

•  Longdura*on

•  Neitheradherenttoskin/massetermuscle

•  Generallyfirm/variableconsistency

DDx

Otherbenignandmalignantsalivaryglandtumors

Ø  Necrotisingsialadenometaplasia

Ø  Lipoma

Malignanttransformation•  3 – 5 % of cases

•  Pain

•  Rapid growth •  Hard •  Fixed to masseter

•  Fixity to skin

•  Lymph nodes •  Restricted jaw movements

Tx

•  Superficial parotidectmy

•  Total parotidectomy

Warthin’stumor

(Papillary cystadenoma lymphamatosum)

•  Abenigncys2ctumor•  containsabundantlymphocytes&germinalcenters(LN-

likestroma)•  5 – 15 % of parotid trs

•  Always at the lower pole of the parotid •  Overlies the angle of mandible Etiology unknown ,smoking

Clinicalfeatures

•  More in white races

•  Not seen in negroes

•  Encapsulated lesions •  No malignant transformation

Clinicalfeatures

•  Only salivary neoplasm more in males

•  Elderly males

•  Slow growing •  painless

•  Surface is smooth •  Well defined •  Distinct margins •  Soft in consistency with

fluctuation •  Not tansilluminant

Investigation

•  FNAC Tc99 scan – hot spot DDX •  Sebaceous lymphadenoma •  oncocytoma

SALIVARYGLANDTUMORS

Tx•  Superficial parotidectmy

•  Enucleation

Malignanttumors

•  Commonest site –minor glands

•  Palate

•  MC in females

•  7th decade •  Previous irradiation

Mucoepidermoidcarcinoma

•  MC •  The tumor made up of 3 types of cell

(mucous,epidermoid,inter.)

•  Parotid &minor gland •  Slow growing tr •  Lung, bone, brain -15%

epidemiology"   Occursinadult

"   Peakincidence—20-40yrs

"   CausallinkwithCMVhasbeenstronglyimplicated

Clinicalfeatures"   Presentas:

Ø  painless,

Ø  slow-growingmass,

Ø  w/cfirm/hard

Ø  mostappearclinicallyasmixedtumors

Tx

✓ Determinedbythetumor:gradeLoca*onClinicalpresenta*on

Adenoidcysticcarcinoma

•  Malignant cylindroma •  The third MC •  Rare in parotid •  60% in sublingual gland •  Generally,slow growing and

well defferentiated

•  Perineural invasion

•  Nerve palsy even before mass

•  Also spread along haversian system and

•  neural canals of bone

•  Mets LN –direct spread

Tx"   Surgical removal "   Fast neuron therapy "   chemotherapy

Adenocarcinoma

isatypeofcancerthatformsinmucussecretingglandsthroughoutthebody.

Clinicalfeatures"   Rare "   Mainly parotid "   80% as adherent masses "   5thto8thdecades"   F>M"   Parotidandminorsalivaryglands"   Presentation:

–Enlargingmass–25%withpainorfacialweakness

Dx

BoipsyCTscanMRI

TxSurgery

RadiationtherapyChemotherapy

HARDTISSUETUMORS

NONODONTOGENICTUMORS

•  Nonodontogenictumorsofthejaworigina*ngfromboneanditsmesenchymal*ssuerepresentalargegroupofdiversediseases.

Thefollowingprimarytumorsbelongtothisgroup;

1.  Bonetumorsa)  Benign;osteoma,osteoblastomaand

osteoidosteomab)  Malignant;osteosarcoma2.car*lagetumorsa)  Benign;chondroma,chondroblastoma,cho

ndromyxoidfibroma,osteochondromab)  Malignant;chondrosarcoma

3.Fibroplas*ctumors•  Desmoplas*cfibroma•  Fibrosarcoma4.Ewingsarcoma5.Plasmocytomaandmalignantlymphoma6.Vasculartumors•  Haemangioma•  Malignantvasculartumors

• OsteogenicTumorOsteoma•  (Alsorefferedtoasexostosis)almostuniquelyoccursinthecranialbones.

•  Itrepresentsahamartomatousnewgrowthconsis*ngofmedullaryorcompactbone,andpresen*ngonthesurfaceofthebonefromwhichitarises.

•  Womenaffectedmostfrequently

Clinical&RadiographicFeatures

•  slowgrowing,usuallyasymptoma2ctumor

•  periostealorendostealosteomas•  radiographically:presen2ngasaCircumscribedsclero2cmassconsistentwithbonedensitydependingonthetumorscomponent

•  canbeassociatedwithGardnerssyndrome(mul2pleosteoma,intes2nalpolyposisleadingtocolonCA)

Mul*pleosteomaassociatedwithgardner’ssyndrome

HistopathologicFeatures•  Compactosteoma:densebonewithMinimalmarrow2ssue

•  Cancellousosteoma:trabeculaewithfibro-facymarrow

Differen*aldiagnosis

•  Cementoblastomaandcemen*fyingfibroma

Treatment&Prognosis

Donotneedtobetreated,ifnosymptom

Osteosarcoma

•  Malignant,osteoidproducingmesenchymaltumor;itisthemostfrequentprimarymalignantbonetumor

•  Thedistalfemurandproximal*bia;themostfrequentsites;7%occuringinthejaws

•  Menareaffectedmostfrequently

Clinical&RadiographicFeatures

•  mosto)enoccurringinthethirdandfourthdecadesoflifemales>females,swellingandpainlooseningofteeth,paresthesia,andnasalobstruc*onyoungchildrentotheelderlyvaryingfromdensesclerosistoadmixedsclero*candradiolucentlesion,toanen*relyradiolucentprocess,illdefinedandindis*nctmargin

HistopathologicFeatures•  Directproofoftumorosteoidforma2onby

atypicalmesenchymalcellsisimportantfordiagnosis

•  thetumorotherwiseappearswithbothchondroiddifferen*ated(‘chondroblas*csarcoma),orfibroblas*cformsinthesametumor.

differen*aldiagnosis

•  Osteoma•  Osteoblastoma•  Ossifyingfibroma

Treatment&Prognosis

•  radicalsurgicalexcision•  supplemented:chemotherapy,•  radia2ontherapyorboth

Car*lagetumors

A.  Chondroma(benign)B.  Chondrosarcoma(malignant)

1.Chondroma

•  Benigntumorsofhyalinecar*lagewithatendencyformalignantgrowth.

•  mosto)enlocatedintheshorttubularbonesofthehandandthefeet.

•  rarelybeenreportedinthejaws.HistopathologicalFeaturesmaturecar*lage,verydifficulttodis*nguishfromlowgradechondrosarcoma

TreatmentandPrognosis

•  TotalsurgicalremovalofthetumorDifferen*aldiagnosischondrosarcoma

Chondrosarcoma

•  Malignantneoplasmofhyalinecar*lage.•  mostcommonlylocatedinthemetaphysealregionofthelongbones.

•  rarelyinvolvinginthejaws

ClinicalandRadiographicFeature

•  wideagerange•  averageage:33years•  themostcommonpresen2ngaspainlessorswellingmass

•  themaxillaandmandibleinvolvedwithaboutequalfrequency

•  aradiolucentprocesswithpoorlydefinedborders

•  containingscaceredandvariableamountsofradiopaquefoci

HistopathologicalFeatures

•  Consistsofcar2lagewithvaryingdegreeofmatura2onandcellurarity,andshowinglobulatedgrowthpacern

•  ossifica2on,calcifica2onandchondroidmatrix

Differen2aldiagnosis

•  Radiologically;Itishardlypossibletoclearlydis*ngushthesetumorsronmanyotherbenignormalignantgrowth.

•  Themostimportanthistologicaldifferen*a*onisfromosteosarcomasincethismayshowextensivechondroiddifferen*atedparts

TreatmentandPrognosis

•  Radicalsurgicalexcision•  Poorerprognosisthanosteosarcomaofthejaws

Vasculrtumors

•  Bothbenignandmalignantvasculartumorsrarelyoccurinthejaw

centralhaemangioma•  isabenignvasculartumorrarelyoccuringinthejaw.

•  itoccursmorefrequentlyinwomenandinthemaxilla.

Clinicalfeatures

•  Asymptoma*cswelling,occasionallooseningoftheteethandhaemorrhagefromaroundtheneckofthetooth.

diagnosis/histologicalfindings•  Poorlydemarcatedosteolysis•  Usuallycapillaryhaemangiomas,somewithcavernousspread

Differen*aldiagnosis

•  Otherosteoly*clesiontreatmentandprognosis•  Toothextrac*onmaycauseseverehaemorrhage;angiographyincaseofsuspicion

•  resec*on

Centralgiantcelltumor

•  Itisrela*velyuncommontumorofbone.•  Itischaracterizedbytheprescenceofmul*-nucleatedgiantcells(osteoclastlikecells).

•  Inmostpa*ents,thetumorsareslowtodevelop,butmayrecurlocallyinasmanyas50%ofthecases.

Clinicalfeatures

•  Painandlimitedrangeofmo*oncausedbytumor’sproximitytothejointspace

•  Swelling•  Muscularachesandpaininarms,legsandabdominalpain

Diagnosis

•  Presenceofmul*nucleatedgiantcells•  Surroundingmononuclearandsmallmul*nucleatedcellshavenucleisimilartothoseinthegiantcells

•  SoapbubbleappearanceTreatment•  Surgery•  curelage

Differen*aldiagnosis

•  Aneurysmalbonecyst•  Chondroblastoma•  Simplebonecyst•  Osteoidosteoma•  Osteoblastoma•  osteosarcoma

THANKYOU