Shawn A. McClure D.M.D., M.D. - Baptist Health lesions.pdfShawn A. McClure D.M.D., M.D. Miami Oral &...

Shawn A. McClure D.M.D., M.D.Miami Oral & Maxillofacial Surgeon

Associate Professor, Director of ResearchDepartment of Oral & Maxillofacial SurgeryNOVA/NSU COLLEGE OF DENTAL MEDICINE

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Diseases of Head and Neck: What Should a Primary Care Physician Be Looking For?

June 22nd, 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

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EXTRAORAL EXAMINATION

Proper positioning of the fingers

Have the patient open and close slowly.

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EXTRAORAL EXAM

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Preauricular nodes.

Palpation of the anterior cervical nodes.

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Bilateral palpation of the occipital nodes. Be sure to also observe the skin in this area.

Postauricular nodes.

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Palpation of the posterior cervical nodes.

Bilateral palpation of the supraclavicular lymph nodes.

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Palpate the submandibular lymph nodes using a cupped hand as shown.

Digital palpation of the submental lymphnodes.

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Palpation of the parotid gland.

Palpation of the submandibular glands.

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Bimanual palpation of the thyroid gland.

Hold the fingers lightly over the gland while the patient swallows.

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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 virallymphadenopathy

- Bacteriallymphadenopathy

Noninfectious inflammatory disorders

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NEOPLASTIC DISORDERS• Metastatic head and neck carcinoma• Thyroid masses• Salivary gland neoplasm• Paragangliomas• Schwannoma• Lymphoma• Lipoma and benign skin cysts

Dermoid Cyst

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Dermoid Cyst

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INTRAORAL EXAMINATION

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Proper Head & Neck Examination

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Palpating the hard palate. Use firm pressure.

Normal structures of the anterior palate

hard palate.

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INTRAORAL EXAMINATION Normal structures of the posterior hard

palate. Observe the dimensions (height and width) of the vault.

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Visual examination of the upper labial mucosa.

Visual examination of the lower labial mucosa.

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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.

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Examination of the lateral borders of the tongue.

Visual examination of the floor of the mouth. Note the normal structures of the area.

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First level bullet

Second level bullet

Third level bullet

Fourth level bullet

Fifth level bullet

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Selected diseases of the oral mucosa

Inflammatory Disorders



Infections



Infections

Herpes Simplex


Inflammatory disorders

Infections:

Herpes Simplex Majority of infections with HSV

are subclinical

Either HSV type 1 or 2 may be involved



Infections:

Herpes SimplexPrimary herpetic gingivostomatitis

Infants, young children, immunosuppressed individuals



Infections:

Herpes Simplex

Primary herpetic gingivostomatitis

Multiple, painful, discrete vesicles that rupture to form ulcers

Cervical lymphadenopathy, malaise, and fever

Primary Herpetic Gingivostomatitis



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



Infections:

Candida (Monilia) AlbicansStomatitis in young children and in

adults with debilitating diseases

prolonged broad spectrum antibiotics, or immunosuppressive therapy

Thrush



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

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Infections:

Viral Papillary Lesions

Associated with Human Papilloma Virus

Exophytic and appear as cauliflower-like lesions

High rate of recurrence

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Condyloma

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Recurrent Aphthous UlcersIdiopathic disorder characterized by

recurrent episodes of painful, round or oval yellow-white ulcers

surrounded by an erythematous halo



Recurrent aphthous stomatitis

Three forms

Minor type

Major type

Herpetiform type

Recurrent Aphthous Stomatitis



Pyogenic Granuloma

Asymptomatic tumescence composed of granulation tissue

Pyogenic granuloma



Lichen planus


Inflammatory disordersLichen Planus (autoimmune)

Common chronic inflammatory mucocutaneous disease

Oral lesions may be the only manifestation*

Disease of middle age that affects the sexes nearly equally



Lichen planus

Several forms



Lichen planus

Several forms

Reticular form

Lichen planus



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

Premalignant Lesions

Leukoplakia:

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 rugatedor 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 LesionsErythroplakia

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 retromolarfossa.

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?

Oral Cancer

Oral cancer accounts for around 3% of all newly diagnosedcancers

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 MelanomaSarcomaLymphomaMetastatic 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 oropharyngealprimary 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

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Hemangioma

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Kaposi’s Sarcoma

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

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Peutz-Jeghers Syndrome

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Physiologic Pigmentation Café au Lait

Pigmented Lesions

BROWN HEME-ASSOCIATED LESIONS

Ecchymosis

Petechia

Hemochromatosis

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Ecchymosis

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Pigmented Lesion

GRAY/BLACK PIGMENTATIONS

Amalgam Tattoo

Graphite Tattoo

Hairy Tongue

Pigmentation Related to Heavy-Metal Ingestion

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Amalgam Tattoo

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Hairy Tongue

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%.

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Tumor like conditions

Fibroma


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


Geographic tongue

Median rhomboid glossitis

Hairy tongue

Black Hairy Tongue


Geographic tongue

Median rhomboid glossitis

Hairy tongue

Fissured ( scrotal ) tongue

Fissured Tongue

Paget’s disease

Paget’s Disease

Pathology of the Jaws


Miscellaneous Jaw LesionsOvergrowth of Mature Bone

Tori ( torus )Midline of palate

Maxillary Tori


Miscellaneous Jaw LesionsOvergrowth of mature bone

Tori ( torus )

Midline of palateLingual surface of mandible

Mandibular Tori


Miscellaneous Jaw LesionsOvergrowth of mature bone

Tori (Torus)

Midline of palateLingual surface of mandible

Exostosis ( exostoses )Buccal surfaces of maxilla and mandible

Exostosis

Salivary Glands

Salivary Glands

3 paired glands

Parotid

Submandibular

Sublingual

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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 diseasesAcute bacterial infection

Signs and symptoms: Pain, tenderness, and swelling

Red, swollen duct orifice

Pus may be expressed by massageof the gland or duct


Obstructive disordersSialolithiasis:

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


Obstructive Disorders:

SialolithiasisMucocele:

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


Obstructive disordersSialolithiasisMucoceleRanula:

Involves, most frequently, the sublingual gland and, less frequently, the submandibular gland


Obstructive disordersSialolithiasisMucoceleRanula:

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


Salivary Gland Tumors:Benign Vs. Malignant

Parotid: 80/20

Submandibular 50/50

Sublingual 20/80

Minor depends on location

First level bullet

Second level bullet

Third level bullet

Fourth level bullet

Fifth level bullet

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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 tumorsBenign:

Pleomorphic adenoma

Most common salivary gland tumor*Variable mix of epithelial and mesenchymal elements

Slow growing, but can reach considerable size

Pleomorphic Adenoma


Salivary gland tumorsBenign

Papillary cystadenomalymphomatosum ( Warthin’s tumor )


Salivary gland tumorsBenign

Papillary cystadenomalymphomatosum ( Warthin’s tumor )

Occurs most frequently in the “tail”

of the parotid gland of white, middle aged men

Warthin’s Tumor


Salivary gland tumorsMalignant (20%)


Salivary gland tumorsMalignant

Mucoepidermoid carcinomaMost common malignant salivarygland tumor*Parotid glands ( 60% to 70% )Minor glands ( 15% to 20% )Submandibular glands ( 10% )



Mucoepidermoid carcinomaMost common salivary malignancy in children*

Mucoepidermoid carcinoma



Mucoepidermoid carcinomaConsists of mucus secreting cells and epidermoid cellsRange from low grade, well differentiated tumors to high grade aggressive cancers

Mucoepidermoid carcinoma



Malignant mixed tumors



Malignant mixed tumorsRepresents the malignant form of pleomorphic adenomaInvolves the parotid glands, less often the submandibular glands, and rarely the minor salivary glands



Adenoid cystic carcinomas




Most frequent neoplasms of minor salivary glands*

16% to 25% of all tumors50% of all malignant tumors




Slow growing, but have a relentless course

Affinity for perineural invasionRecurrence is common and ultimate prognosis is poor

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. Breast2. Lung3. Kidney4. Bone5. 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. Breast2. Lung3. Kidney4. Bone5. 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

Shawn A. McClure D.M.D., M.D. - Baptist Health lesions.pdfShawn A. McClure D.M.D., M.D. Miami Oral &...

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