head and neck pathology

1. Head and Neck Pathology

3. This lecture is just a taster of pathology affecting the head and neck regions!

4. Teeth and Supporting Structures Dental caries is a bacterial infection which results in the dissolution of enamel and infection of dentin and pulp A periodontal or periapical abscess may present as a gum boil or parulis

5. Parulis or gum boil

6. Gingiva and Periodontium Inflammation of the gingiva (gingivitis) is usually the result of poor oral hygiene Periodontitis may affect the bone supporting teeth and result in loose teeth, bad breath, infection and ultimately tooth loss

7. Reactive proliferations A fibroma (focal fibrous hyperplasia) may develop following trauma to any intraoral site A pyogenic granuloma is a mass granulation tissue which forms in response to irritation

8. Aphthous Ulcers (Canker Sores) Extremely common recurrent painful round ulcers affecting the mobile tissues such as the buccal mucosa, labial mucosa and tongue Rarely associated with systemic diseases such as Crohn�s, Bechet�s syndrome or Celiac sprue

9. Acute Primary Herpetic Gingivostomatitis (HSV) Sudden onset, fever, malaise, lymphadenopathy Vesicles and ulcers affecting any oral site (gingiva, buccal mucosa, tongue) Mobile and non-mobile mucosa affected Subclinical cases Usually occur in young children but may also occur in adults

12. Hairy Leukoplakia Oral manifestation of a systemic infection HIV/ AIDS Rough corrugated white plaques posterolateral borders of the tongue Plaques do not rub or scrape off

13. Hairy Leukoplakia

14. Hairy Leukoplakia

15. Hairy Leukoplakia Epithelial hyperplasia Epstein-Barr virus infection Insitu hybridization can be used to identify EBV Not to be confused with hairy tongue

16. Hairy Leukoplakia

17. Insitu hybridization EBV

18. Reactive conditions should not be confused with hairy leukoplakia Hairy Tongue Geographic Tongue

19. Hairy Tongue

20. Hairy Tongue due to elongation of filiform papilla

21. Black Hairy Tongue

22. Black Hairy Tongue

24. Geographic Tongue Common condition 1-3% population Female:Male ratio 2:1 Multiple zones of erythema due to loss of filiform papillae Zones are surrounded by a slightly elevated yellow-white border Strong association with fissured tongue

25. Geographic Tongue Lesions move about the tongue Usually asymptomatic Infrequently may affect other oral sites If a biopsy was obtained = Psoriasiform mucositis (Munro abscesses)

28. Kaposi�s Sarcoma Classic Endemic (African) Iatrogenic immunosuppression associated AIDS-related Intraoral lesions are common in the AIDS related form

29. Kaposi�s Sarcoma Malignant vascular neoplasm Palate and gingiva commonly affected Purple patch, plaque or nodule Second most common oral malignancy in most large centers

30. KS

31. KS

32. Kaposi�s Sarcoma Viral induced or viral associated tumor KSHV (Human Herpes Virus type 8) Cellular neoplasm composed of CD-34 positive spindle shaped cells forming slit like spaces

33. Kaposi�s Sarcoma

34. Oral Squamous Cell Carcinoma Incidence is about 3% Five year mortality rate = 50% Risk factors - smoking, alcohol and increased age, other habits, ?HPV U-V radiation for lip cancer

35. Oral Squamous Cell CarcinomaFavored Sites Posterolateral border of the tongue Floor of the mouth Soft palate Diagnosis by incisional biopsy TNM staging system

36. Oral Squamous Cell CarcinomaClinical Appearance Leukoplakia Erythroplakia Non-healing ulcer Nodule Wart like growth The initial presentation may be cervical lymphadenopathy

37. Leukoplakia (Clinical Term) White patch or plaque which can not be wiped off nor can it be identified as a specific disease Biopsy is mandatory

38. Leukoplakia

39. Leukoplakia 10% are moderate epithelial dysplasia or worse Tabacco, alcohol and increased age are risk factors

40. Leukoplakia(Spectrum of lesions) Hyperkeratosis/Hyperplasia/Acanthosis Mild Epithelial Dysplasia Moderate Epithelial Dysplasia Severe Epithelial Dysplasia Carcinoma in Situ Invasive Squamous cell carcinoma

41. Leukoplakia

42. Leukoplakia

43. Leukoplakia - Epithelial Dysplasia

44. Leukoplakia - Epithelial Dysplasia

45. 6 years later

47. Leukoplakia = CIS

49. Erythroplakia Red or velvety patch of the mucous membranes that can not be diagnosed as a specific clinical entity 90% are severe epithelial dysplasia, carcinoma in situ or invasive carcinoma

50. Erythroplakia

51. Erythroplakia

52. Squamous cell carcinoma

53. Squamous cell carcinoma

54. 38 year old male � squamous cell carcinoma of the tongue

56. 27 year old male No risk factors

58. Squamous cell carcinomaNodule

59. Nodule = SCCa

60. How fast does a cancer grow?

61. 4 months later�

62. Verrucous Carcinoma Rare low grade variant of squamous cell carcinoma Was thought to be related to snuff or chewing tobacco but is related to HPV infection Wart like growth Males 60+ Bland histology

63. Verrucous Carcinoma

64. Verrucous Carcinoma

65. Upper Airways Nose Nasopharynx Larynx

66. Nose The common cold could be called infectious rhinitis Allergic rhinitis affects 20% of the population Nasal polyps are focal protrusions of the mucosa Sinonasal papillomas are benign epithelial growths

67. Nasopharynx Nasopharyngeal Angiofibroma Teenage boys Unilateral nasal obstruction and epistaxis Avoid incisional biopsy CT/MRI used to image the extent of disease

68. Nasopharynx Nasopharyngeal carcinoma Malignancy arising from the epithelium of the nasopharynx May present initially with cervical lymph node metastasis Associated with EBV Three Histologic types Keratinizing Non-keratinizing Undifferentiated

69. Larynx Reactive Nodules ( Vocal cord polyps) are common in smokers and singers Benign squamous papillomas or papillomatosis may develop and is due to HPV types 6&11 Squamous cell carcinoma may develop from a dysplasia which may present clinically as hoarseness Carcinomas may develop from a preexisting dysplasia which may be seen as leukoplakia

70. Squamous cell carcinoma of the true vocal cord

71. Neck Dermoid Cyst Branchial Cyst (Lymphoepithelial cyst) Thyroglossal Tract Cyst

72. Dermoid Cyst Midline floor of mouth Doughy mass Benign cystic teratoma but three germ layers usually not present Maybe above or below geniohyoid muscle

73. Dermoid Cyst

74. Dermoid Cyst

75. Dermoid Cyst

76. Dermoid Cyst

77. Cervical Lymphoepithelial Cysts Lateral aspect of the neck, usually anterior to the Sternocleidomastoid muscle Thought to arise from epithelium (salivary gland) in lymphoid nodes Late childhood/ early adulthood

78. Cervical Lymphoepithelial Cysts Painless swelling +/- draining fistula SCCa does not arise in the cysts - suspect metastatic carcinoma Surgical excision

79. Lymphoepithelial cyst

80. Oral Lymphoepithelial Cysts Develops where oral tonsils are found Anterior floor of mouth, posterior lateral border of tongue, soft palate, oropharynx Asymptomatic 5 mm yellowish or tan submcosal mass Conservative surgical excision

82. Thyroglossal Duct Cyst Midline cyst arising from remnants of the thyroglossal duct May be associated with the hyoid bone Sistrunk procedure

83. Thyroglossal Duct Cyst

84. Thyroglossal Duct Cyst

85. Salivary Glands Reactive Lesions Infections Immune Mediated Disorders Benign Neoplasms Malignant Neoplasms

86. Mucocele Submucosal swelling lower lip Usually midway between midline and commissure Children and young adults Traumatic origin � the connection between the duct and the surface is lost Treated by excision (+/- aspiration) with removal of several feeder glands

87. Mucocele

88. Mucocele

89. Sialolithiasis Salivary stone Most submandibular duct Pain and swelling at mealtime Unilateral swelling just below inferior border of the mandible Occlusal radiograph helpful to identify most stones Fluids, heat, massage, lacrimal dilators Surgical Excision

90. Sialolith

91. Sialolith

92. Sialolith

93. Acute Bacterial Sialadentitis

94. Acute Sialadentitis

95. Acute Sialadentitis

96. Xerostomia �Dry Mouth� Quantitative and/or qualitative change in Saliva Multifactorial Dehydration, Anxiety, (OTC) medications, Diabetes, Sj�gren�s syndrome, Idiopathic

97. Xerostomia

98. Sj�gren�s Syndrome Middle aged females +/- Connective tissue disease (RA, SLE) Dry eyes & mouth Firm enlargement of salivary glands Systemic disease ESR, IgG high RF, ANA (anti-SS-A, anti-SS-B)

102. Labial Salivary Gland Biopsy

103. Sj�gren�s Syndrome

104. Sj�gren�s Syndrome

105. Benign Salivary Gland Neoplasms Pleomorphic Adenoma Warthin�s Tumor

106. Pleomorphic Adenoma Most common benign neoplasm Parotid gland, palate, lip Mixed tumor Painless, slow growing mass 30 - 50 years of age Surgical excision

107. Pleomorphic Adenoma

108. Pleomorphic Adenoma

109. Mixed Tumor - Histology

110. Mixed Tumor

111. Warthin�s Tumor Walnut sized lesion Parotids only Second most common benign neoplasm Painless, slow growing mass Smokers in 6th - 7th decades Bilateral

112. Warthin�s Tumor

113. Warthin�s Tumor

114. Warthin�s Tumor

115. Warthin�s Tumor - Histology

116. Warthin�s Tumor - Histology

117. Malignant Salivary Neoplasms Mucoepidermoid Carcinoma Adenoid Cystic Carcinoma

118. Mucoepidermoid Carcinoma Most common malignant neoplasm Epidermoid cells and mucous cells Parotid or minor salivary glands Wide age range Treatment complete surgical excision with a margin of normal tissue

119. Adenoid Cystic Carcinoma 5 th - 7 th decade Mass, +/- pain Slow growth Perineural invasion, bone invasion Metastatic to lungs Surgery +/- radiotherapy

120. Adenoid Cystic Carcinoma Prone to local recurrence Uncommon lymph node metastasis Five year survival - 70% Twenty year survival - 20%

121. Adenoid Cystic Carcinoma

122. Adenoid Cystic Carcinoma Swiss Cheese Tumor

123. Adenoid Cystic Carcinoma - Histology

124. Adenoid Cystic Carcinoma - Perineural invasion