oral cancers by dr. sintayehu sirino
TRANSCRIPT
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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
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