2011-07-PATHO-Head and Neck Disorders 1

8/6/2019 2011-07-PATHO-Head and Neck Disorders 1

1/11

1

Oral Soft Tissue

y Inflammatory/reactivelesions: Non neoplastic. Usuallyaresponsetochronic

irritation,ieill fitting dentures, bracesor

dentalcaries

o Fibrousproliferativelesionso Aphthousulcers (cankersores)o Glossitis

y Infectionsy Tumorsand pre cancerouslesions

Inflammatory/reactive lesions

y Fibrousproliferativelesionso Irritation fibroma: see diagram below

61% ofproliferativelesions Primarilyoccursinthe buccal

mucosaalongthe bitelineatthe

gingivodentalmargin

Consistsofanodularmassoffibroustissuewithfew

inflammatorycellscovered by

squamousmucosa Grossly,lesionissmooth. Takeson

coloroflocaltissue. Erosionsmay

bepresent.

o Pyogenicgranuloma: see diagrambelow

12% ofproliferativelesions Similartocapillaryhemangioma Regressesspontaneously,

particularlyafterpregnancyor

undergofibrosis

May developintoaperipheralossifyingfibroma

Vascularlesion,soreddishhue Commoninlowerlip Pedunculated,highlyvascular,

brightred lesionoccurringinthe

gingivalofchildren,youngadults,

and commonly,pregnantwomen

(pregnancytumor)

Histologically: overlyingepitheliumiseroded and proliferationof

capillarysized blood vessels

surrounded byinflammatorycells

o Peripheral ossifying fibroma 22% ofproliferativelesions Reactivegrowthofgingival (red,

ulcerated,nodularlesions)with

unknownetiology

Someariseasresultofmaturationoflongstandingpyogenicgranuloma,others donot;

may bemistakenclinicallyfor

pyogenicgranulomas

Peakincidence: youngfemaleso Peripheral giant cell granuloma (Giant

Cell Epulis)

5% ofproliferativelesions Similartopyogenicgranuloma butis

more bluishpurpleincolor

Lesionprotrudesfromgingivalatsitesofchronicinflammation

Covered bygingivalmucosa butmay beulcerated

Histologically: aggregatesofmultinucleated,foreign body type

giantcellsseparated bya

fibrovascularstroma.

Note: Dr.Pascualsaid thatthefrequencyofthe

abovelesionsis,in descendingorder:

y Irritation fibromay Pyogenicgranulomay Peripheral giant cell granulomay Peripheral ossifying fibroma

However,thepercentagesaboveweretakenfrom

the book. So,useyour judgmentshould this

questionappearontheexam.

y Canker Sores, aka Aphthous Ulcers: seediagram below

o Etiologyunknown, butsomesaymay bestressrelated

Subject: PathologyTopic: Head and Neck 1Lecturer: Dr. PascualDate of Lecture:July 26, 2011Transcriptionist: MopsterEditor: TelsioPaoPages: 9

SY

2011-2012


2/11

2

o Commonsuperficial,painful,oftenrecurrentulcerationsoftheoral

mucosa

o Lesionsappearassingleormultipleo Shallow,hyperemiculcerwiththinrim

ofexudatesand rimmed byanarrow

zoneoferythema

y Glossitis:see diagram belowo Inflammationoftongueo Beefyred tongueencountered in

certain deficiencystates (VitaminB12,

niacin,pyridoxine,riboflavin deficiency,

iron deficiencyanemia)

o Plummer Vinson Syndrome/PatersonKellySyndrome

Triad: glossitis,esophagealwebs,iron deficiencyanemia.

o Atrophyofpapillaethinningofmucosaexposureofunderlying

vasculaturebeefyred tongue

o Glossitiswithulcerativelesions(sometimesalongthelateral

bordersofthetongue),mayalso be

seenwith jagged cariousteeth,ill

fitting dentures,and rarely,with

syphilis,inhalation burns,or

ingestionofcorrosivechemicals

Infections

y Herpes Simplex virus infectionso CommonlyHSV1 butmayalso be

caused byHSV2o Morphology: vesiclefilled withserous

fluidrupturepainfululcer

o FindingsonTzancksmear: multinucleated giantcells intranuclearinclusions intercellularedema (acantholysis)

o Cold sores

Blistersand vesiclesaroundmucosalorifices (lips,nose)

Formed byintercellularedemaandballooning degenerationof

epidermalcells

o Gingivostomatitis Usuallyencountered inchildren;

HSV1

Vesiculareruptionextendingfromthetonguetotheretropharynxassociated withcervical

lymphadenopathy

o Recurrent herpetic stomatitis Occurseitheratthesiteofthe

primaryinoculationorinadjacent

mucosalareasthatareassociated

withthesameganglion

Taketheformofgroupsofsmall (1to 3 mm)vesiclesinthelips,hard

palate,nasalorifices

y Oral candidiasis (Thrush)o Mostcommonfungalinfectioninthe

oralcavity

o Candida albicanso Factorsthatincreaselikelihood of

infection:

Immunestatus StrainofC. albicanspresent Compositionofindividualsflora

o 3 clinicalforms: Pseudomembrane: can bescraped

offtorevealahyperemic base Erythematosus Hyperplastic

o Commonin: Diabetesmellitus Bonemarrowororgantransplant Neutropenia Chemotherapyinduced

immunosuppression

AIDS Useofbroad spectrumantibiotics

Tumors and pre cancerous lesions

y Smokingisthemostcommonantecedenty Leukoplakia: see 4 diagrams below

o Awhitepatchorplaquethatcannot bescraped off(which differentiatesitfrom

oralthrush)and cannot be

characterized clinicallyorpathologically

asanyother disease

o Allleukoplakiasmust beconsideredprecancerous

o Mayoccuranywhereintheoralcavity(favored locations: buccalmucosa,

floorofthemouth,ventralsurfaceof

tongue,gingival,palate)

o Morphology: Solitary,ormultiple,withindistinct

orsharply demarcated borders

May beslightlythickened andsmoothorwrinkled and fissured or


3/11

3

mayappearasraised,sometimes

corrugated,verrucousplaques

o Histologically: hyperkeratosisacanthotic,orderlyormarkedly

dysplasticmucosalepithelium

y Erythroplakia: see both diagrams belowo Lesscommon butmoreominousthan

leukoplakia,incurringahigherriskof

malignanttransformation

o Red: intensesubepithelialinflammationwithvascular dilatation

o Markedly dysplasticepithelium,velvety,sometimeseroded area

o May beslightly depressed or blend inwithsurroundingarea.

o Histologically: Superficialerosionswith dysplasia,

carcinomainsitu,oralready

developed carcinoma

Intensesubepithelialinflammatoryreactionwithvascular

dilatationred appearance

y Speckled leukoerythroplakiao Intermediateformswiththe

characteristicsofbothleukoplakiaand

erythroplakia

y Squamous Cell Carcinomao 95% ofhead and neckcancersareSCC,

mostcommonlyintheoralcavity

o HNSCC: aggressive Multipleprimarytumors: field

cancerization

Riskfactors Smoked tobacco Alcohol HPVoncogenicvariants Familyhistoryofhead and neck

cancer

Actinicradiation: exposuretoUVradiation

Pipesmoking Betelchewing Chronicirritation

o Molecular biology Geneticalterationhave been

identified and related to

morphologicchangesinepithelium:

InactivationofP16genehyperplasia/hyperkeratos

is

Mutationofp53dysplasia Alterationsand deletionsat 4q,

6p, 8p, 11q, 13q, 14qfrank

malignancy

o SCC of the Oral Cavity Sites: floorofmouth,ventral

surfaceoftongue,lowerlip,soft

palate,gingival

Mayinvadetheunderlyingstromawithoutgoingthroughfull

thicknessCISstage


4/11

4

Differentiation dependson degreeofkeratinization, but doesnot

correlatewith behavior

Tendstoinfiltratelocally beforedistantmetastasis

Spread and metastasis: Tendstoinfiltratelocally before

distantmetastasis

Metastasisisprimarily bylymphaticroute: Cervicallymphnodes Favored distantsites:

Mediastinallymphnodes

Lungs Liver Bones

o Prognostic determinants: Location: bestprognosislowerlip

(5yearSR = 90%) b/cofearlier

detection duetoitsobvious

visibility (asopposed to,say,the

backofthetongue).

Stage: depthofinvasion,lymphnodeinvolvement,metastasis

Grade Desmoplasticreaction: inthelip,

florid desmoplasiaisamarkerof

aggressive behavior

Tissueeosinophilia (favorablefactor)

LossofHantigen (precursorantigeninRBCswhichhelps determine

blood type)invasivenessand

distantspread

Overexpressionofp21genefavorableprognosisintongue

cancer

Amplificationof3q26-3 locuspoorprognosis

---------------------------------------------------------------------

Upper Airways: nose, sinuses, pharynx, larynx

Inflammation:

o Infectious Rhinitis:o Infectious rhinitis (common cold)

Adenovirus,echovirus,rhinovirus Thickened,edematousand red

mucosa

o Allergic rhinitis (hayfever) TypeIhypersensitivityreaction Edema,redness,mucusreaction Eosinophilsareprominentinthe

inflammatoryreaction

o Chronic rhinitis Resultsfromrepeated attacksof

acuterhinitiswith developmentof

bacterialinvasion

Superficial desquamationorulceration

Mixed inflammatoryinfiltrates:Neutrophils,lymphocytes,and

plasmacell

y Nasal polyps: see 2 diagrams belowo Focalprotrusionsofthenasalmucosa

secondarytorecurrentattacksof

rhinitis

o 3 -4 cm;edematousmucosa;hyperplasticorcysticmucousglands

o Histologically: Polypoid structureslined by

respiratoryepithelium

Inflammatoryinfiltrates:Neutrophils,eosinophils,plasma

cells,occasionallylymphocytes

y Sinusitiso Mostcommonlypreceded byacuteor

chronicrhinitis

o Occasionally,isanextensionofperiapicalinfection (maxillarysinusitis)

o Inflammatoryedemaofthemucosaimpairs drainageofthesinus

ifsuppurativeexudatesempyemaofthesinus

Accumulationofmucussecretionand cysticformationmucocele

Mayspread totheorbitand otherbonystructuresduralveinsinus

thrombosis

y Pharyngitis/tonsillitiso Usuallyafterorpartofaviral URTIo Etiology: rhinovirus,echovirus,

adenovirus, -hemolyticstreptococcus

o Reddeningtoslightedemaofthenasopharynx

o Enlarged,reddened (follicular)tonsils(duetoreactivelymphoid hyperplasia)

y Laryngitiso Mostcommon diseaseinthelarynxo Causes:

Partofageneralized URTI Heavyexposuretotobaccosmoke


5/11

5

Partofasystemic disease (TB,diphtheria)

o Inchildren (whoselarynxaresmall),severeedemaand inflammationcause

obstruction

laryngeoepiglottitis (H. influenza, - hemolytic Strep)

laryngotracheobronchitis (croup)inspiratorystridor

Tumors

y Nasopharyngeal angiofibromao Veryvascularo Almostexclusivelyinadolescentmaleso Despiteits benignnature,maycause

seriousclinicalproblems becauseofits

tendencyto bleed profusely during

surgery

y Sinonasalpapilloma: see diagram belowo Lined bysquamousorcolumnar

epithelium

o HPVtype6and 11o 3 forms:

Septal(mostcommon) Inverted: benign butlocally

aggressive (no desmoplasia)can

invadetheorbitorrarely, develop

intocarcinoma. Called inverted

becauseitseemsto begrowing

inward instead ofoutward.

Cylindrical Figure below: inverted type

y Reactive nodules (vocal cord nodules andpolyps)

o Etiologicfactors Heavysmoking Greatstrainonvoice (singers)can

lead tochangeincharacterofvoice

orlead toprogressivehoarseness

o Smooth,rounded,sessileorpedunculated excrescences

o Covered bysquamousepithelium(keratotic,hyperplastic,orslightlydysplastic)

o Loosemyxoid CTcoreo Vocalcord polypstend to beunilateralo Vocalcord nodulestend to be bilateral

y Squamouspapilloma: see diagram belowo Ariseontruevocalcordso Singleinadults

o Multipleinchildrenjuvenilelaryngealpapillomatosis

o Etiology: HPVtype6and 11o Morphology:

Soft,raspberry likeexcresences,


6/11

6

y Laryngeal carcinoma: see diagrams belowo Spectrumofhyperplasia dysplasia-

carcinomaisseen

o Riskfactors: tobacco,alcoholo Clinicalmanifestations: persistent

hoarsenessleadingtopain, dysphagia,

hemoptysis

o 95% ofthesecasesareofthesquamouscellcarcinomatype

o Smooth,white,orreddened focalthickeningso Verrucousorulcerated,whitetopinkor

graylesions

o 60% areconfined tothelarynx(intrinsic);ifoutsidethelarynxextrinsic

---------------------------------------------------------------------

Neck

y Branchial cysto Fromremnantsofbranchialarchesor

from developmentalsalivarygland

inclusionswithincervicallymphnodes

o 2 5cm;lined bystratified squamousorpseudostratified columnarepitheliumunderlain byintense

lymphoid aggregates

y Thyroglossal duct cysto 1 4 cm;lined bystratified squamous

epithelium (ifnearthetongue)or by

pseudostratified columnarepithelium

(ifitislower)

o Withinthecystwallarelymphoidaggregatesand remnantsofthyroid

tissue

y Carotid bodytumor (paraganglioma)o Referstoextra adrenaltumorsarising

fromparaganglia

o Developin 2 generallocations: Paravertebralparaganglia: with

sympatheticconnections;50%

elaborate

catecholamineschromaffinpositive

Aorticopulmonarychain (includingcarotid bodies,etc)

Parasympatheticconnections Infrequentlyrelease

catecholaminesnon-chromaffinparaganglioma

Senseoxygenand CO2tensionswithinadjacent

vesselschemodectoma

Red pinkto brown;


7/11

7

---------------------------------------------------------------------

Salivary glands

Inflammation

y Sialadenitiso Etiology: traumatic,viral, bacterialor

autoimmune (Sjogrens)

o Types: Acute suppurativesialdenitis:

bacterial

Viral sialadenitis: CMV,paramyxoviruses, EBV,

parainfluenzavirus,influenza

virus (mumps)

Granulomatoussialadenitis Often duetoresponsetofreed

ductalcontentsinobstructive

sialadenopathy

Infectiousinsome Chronic sclerosingsialadenitis

(submandibular gland)

Plasmacyticand lymphocyticperiductalinfiltrates Eventuallyathickfibrous

capsuleenclosesthesalivary

ducts

y Sialolithiasis: see diagram belowo 2 formsoflithiasisinthehead and neck

Angiolithiasis: lesscommon;moreofteninoralorperioralsofttissue

Sialolithiasis: exclusivelyinthesalivarygland

Mayoccurinanygland butmoreoftenthesubmandibular

gland becauseofthemore

torturouscourseofits ductand

itsmoremucinous

natureductal

obstructionglandularswelling

aftermeals

Histologically: Dilated ductsoftenwith

squamousmetaplasia

Variableacinar destructionchronicinflammationandfibrosis

y Cysts: mucocele: see both diagrams belowo ExtravasationMucocele most

common (85%)

Obstructionorruptureofsalivarygland causethesalivatoleakinto

thesurroundingstromamucous

filled pseudocystswithconnective

tissuecapsuleand nolining

epithelium

Mostcommonsites: lips (8

0

%) Ranula: referstomucocelearisingfrom damaged ductofthe

sublingualgland (plungingranula)

o Retention mucocele Salivaryglands Lined byepithelium (flat,cuboidal,

orstratified)

Tumors

y 65 8

0% occurintheparotid (1

0% insubmandibular)

y Likelihood ofmalignancyisinverselyproportionaltothesizeofthegland. Ie,the

smallerthegland thelargerthelikelihood

ofmalignancy.

y Malignant: 15 30% oftumorsintheparotid; 40%...

y F>M


8/11

8

y Pleomorphic adenoma (mixed tumor): seediagrams below

o Mostcommonneoplasmofthesalivarygland

o 60% areintheparotido Painless,slowlygrowingmasso Derived from ductal (orepithelial)cells

and myoepithelailcells

o Recall: mixed tumorismorethanonetissue derived from 1 germlayero Carcinomaexpleomorphicadenomais

malignantcounterpart

o Gross: Rounded and well demarcated Encapsulated exceptinareaswhere

thecapsuleisnotfully developed

withtonguelikeprotrusionsinto

thesurroundingglandular

parenchyma,sotumorislikelyto

recurifitisnotremoved entirely.

o Histologically: Epithelialelements Mesenchymelikemyxoid tissue Chondroid orrarely, bonyislands

y Warthins tumor (papillarycystadenomalymphomatosum): see

diagrams belowo 2ndmostcommonsalivarygland tumoro Almostalwaysseenintheparotid glando Benigno M>F;5th 7th decadesoflifeo 10% aremultifocal; 10% are bilateralo Gross:

Round tooval 2 5cm

Encapsulated Palegreysurfacewithnarrowcystic

orcleft likespacesfilled with

mucinousorserousfluid

o Histologically: Papillaryexcrescencespapillary Cysticspacesarelined by double

liningofcells/polypoid

projectionscystadenoma Surfacelayerofcolumnarcells

(toward lumen)restingonalayerof

cuboidaltopolygonalcells

Beneaththisis densereactivelymphoid stromalymphomatosum

y Mucoepidermoid carcinomao Mostcommonprimarymalignant

tumorofthesalivarygland

o Occursmainlyintheparotid gland (60 70%) butaccountsforalargefractionof

salivarygland tumorsinotherglands,

especiallyminorglands

o Lowgradetumors: Locallyinvasive Rarelymetastasize

o Highgradetumors: Invasive; difficulttoexcise Highrecurrencerate Spreadsto distantsites

o Gross: Upto 8 cm No distinctcapsule Infiltrativeatmargins Palegray whiteparenchymawith

small,mucincontainingcysts

o Histologically: Squamous,mucousand

intermediatecellsincords,sheets

orcysticstructures (see below)


9/11


10/11

10

TheLord islovingand merciful,slowto become

angryand fullofconstantlove.Psalm 145:


11/11

11

2011-07-PATHO-Head and Neck Disorders 1

Documents

Transcript of 2011-07-PATHO-Head and Neck Disorders 1