Head & Neck Path

Question 1

HSV1

Answer 1

“cold sores”
Clusters of vesicles (acute gingivostomatitis)
Tzanck test
-Observe multinucleated giant cells in floor of lesion

Question 2

Herpetic Stomatitis

Answer 2

caused by HSV-1 (genital herpes is HSV-2).
most cases are mild “cold sores”
-but in children & in immunocompromised persons:
severe diffuse gingivostomatitis with clusters of vesicles & shallow ulcers
healing occurs in few weeks, but the virus remains dormant in the trigeminal ganglion
the virus becomes reactivated on exposure to cold,
sunlight & infections  “cold sores”
recurrent lesions are usually milder & heal faster than the primary ones

Question 3

Aphthous Stomatitis

Answer 3

Also call aphthous ulcers or canker sores
Occur in up to 40% of the population
Superficial ulcerations of oral mucosa
Appear as single shallow hyperemic ulcerations
-Covered by a thin exudate
-Variable course
-Cause is unknown

Question 4

Canker sore etiology

Answer 4

40% of us have had them, painful, and you can bet there are inflammatory cells at the base.
Things related to them include: stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies, and deficiencies in vitamin B12, iron, and folic acid (wikipedia). Whenever a condition is associated with LOTS of things, like this, we call this an “obscure” etiology

Question 5

Oral Candidiasis (Thrush)

Answer 5

Appears as a superficial curdy, white inflammatory membrane
-Can be scraped off
Caused by a fungus Candida albicans
Disease observed in infants, diabetics, neutropenia, immunocompromised patients, patients with xerostomia, and antibiotic Tx
Otherwise not observed in normal healthy people

Question 6

Glossitis

Answer 6

Implies inflammation of the tongue
Often applied to the beefy red tongue of various nutrient deficiency states
Ulcerations may be associated with jagged carious teeth, ill-fitting dentures
Part of the Plummer-Vinson or Patterson-Kelly syndrome (combined with iron deficiency anemia and esophageal dysphagia).

Question 7

Xerostomia

Answer 7

Dry mouth
Major feature of Sjögren syndrome
-Associated with inflammatory enlargement of salivary glands
May also be radiation or drug induced

Question 8

Reactive lesions

Answer 8

Present as tumor masses, but are reactive
Suspicious lesions should be biopsied
1) Irritation fibroma
2) Pyogenic granuloma
-A capillary hemangioma of the gingiva
Seen in kids, young adults and pregnant women (i.e., pregnancy tumor)

Question 9

Oral Manifestations of Systemic Disease

Answer 9

Many systemic diseases associated with oral lesions
-E.g., scarlet fever, measles (Koplik spots)
Chronic ingestion of drugs for example phenytoin
hairy leukoplakia

Question 10

Hairy leukoplakia

Answer 10

Observed in immunocompromised individuals
Virtually restricted to HIV infected patients
-May be first inkling of the disease
Appears as white confluent patches of fluffy hyperkeratotic thickening situated on the lateral border of the tongue that cannot be scrapped off
-May be superimposed with thrush
Sometimes associated with HPV
EBV (Epstein-Barr virus) is accepted as the cause

Question 11

Tumors and Precancerous Lesions

Answer 11

Leukoplakia and erythroplakia

Squamous Cell Carcinoma

Question 12

Leukoplakia and erythroplakia

Answer 12

Leukoplakia means “white plaque”
Erythroplakia means “red plaque”
85-90% caused by epidermal proliferations
-Cannot be removed by scraping and cannot be classified clinically or microscopically as another disease entity
Range from benign lesions to carcinoma in situ
Considered precancerous until proven otherwise

Question 13

Erythroplakia (dysplastic leukoplakia)

Answer 13

Epithelial changes markedly atypical with much higher risk of malignant transformation
Males (ages 40-70) predominate
Occurs anywhere in oral cavity
Most common antecedent is tobacco use
-Other associated irritants: Alcohol, HPV
Need for biopsy with persistent post avoidance of irritants

Question 14

Squamous Cell Carcinoma

Answer 14

95% of the cancers of oral cavity
Early detection is paramount
Linked to alcohol and tobacco use
-Especially oral tobacco use
HPV also associated
-A substantial increase in the past 30 years of these cancers that are not associated with alcohol or tobacco, but possibly related to a change in sexual practices in the population (oral sex)
Actinic radiation and pipe smoking factors in lower lip Ca
Genetics also a factor
Favored locations: floor of mouth, ventral surface of tongue, gingiva, and soft palate
keratin pearl

Question 15

Infectious rhinitis (the common cold)

Answer 15

Viral in origin
-Adenoviruses, echoviruses, rhinoviruses
Clinical course
 -Catarrhal discharge
-Edematous nasal mucosa
-May extend to pharyngotonsillitis
-Secondary bacterial infection possible
-Clears up in 7 days, if treated; 1 week, if ignored

Question 16

Allergic rhinitis (hay fever)

Answer 16

Initiated by sensitivity to an allergen
-Plant pollen, fungi, animal allergens
Affects 20% of population
IgE-mediated with early and late phases
Marked mucosal edema, erythema, mucus secretion, and eosinophilic infiltrate

Question 17

Nasal polyps

Answer 17

Caused by recurrent rhinitis leading to mucosal protrusions
May become ulcerated or infected with chronicity
If large, may encroach on airway and impair sinus drainage
Most patients not atopic

Question 18

Chronic rhinitis

Answer 18

Due to repeated attacks of rhinitis
Superimposed bacterial infection develops
May be ulceration or desquamation of mucosa and an inflammatory infiltrate
May extend into the air sinuses

Question 19

Acute Sinusitis

Answer 19

Usually preceded by acute or chronic rhinitis
Nonspecific inflammatory reaction
Impairment of sinus drainage important factor
-May lead to empyema of sinuses
May give rise to chronic sinusitis

Question 20

Chronic sinusitis

Answer 20

Usually a mixed microbial flora consisting of normal oral inhabitants
Can be caused by fungi also (mucormycosis in diabetics)
May spread to the orbit or other cranial structures

Question 21

NECROTIZING LESIONS OF THE NOSE AND UPPER AIRWAYS

Answer 21

Spreading fungal infections
Wegener granulomatosis
Extranodal NK/T Cell LYMPHOMA

Question 22

Pharyngitis and tonsillitis

Answer 22

Result from usual viral upper respiratory infections
-E.g., rhinoviruses, echoviruses, adenovirues
-Also respiratory syncytial and influenza viruses
Bacterial infections may be primary or secondary
-Most commonly, group A, ß-hemolytic streptococci
-Occasionally, Staphylococcus aureus
Particularly severe forms seen in those who are immunocompromised, neutropenic, diabetic, small children
Usually see erythema and edema in the pharyngeal mucosa
-May be covered by an exudative membrane (pseudomembrane)
-Tonsils may be enlarged and covered also
The major importance of streptococcal “sore throats” is possible development of poststreptococcal complications
-E.g., rheumatic fever, glomerulonephritis

Question 23

Tumors of the nose, sinuses, and naso- pharynx

Answer 23

Tumors are infrequent, but cover the whole range of neoplasms

1. Nasopharyngeal angiofibroma
2. Inverted papilloma
3. Isolated plasmacytomas
4. Olfactory neuroblastoma
5. Nasopharyngeal carcinomas

Question 24

Nasopharyngeal angiofibroma

Answer 24

Highly vascular tumor in adolescent males

Benign, but bleeds profusely during surgery

Question 25

Inverted papilloma

Answer 25

Benign, but locally aggressive Occur in nose and paranasal sinuses Inverted papillomatous growth into the mucosa -Consists of squamous epithelium Potential invasion into the orbit or cranial vault

Question 26

Isolated plasmacytomas

Answer 26

A solitary myeloma | If not adequately excised can recur and invade orbit and cranial vault

Question 27

Olfactory neuroblastoma

Answer 27

Uncommon, highly malignant tumor arising from neuroendocrine cells dispersed in the olfactory mucosa

Question 28

Nasopharyngeal carcinomas

Answer 28

Characterized by distinctive geographic location, a close anatomic relationship to lymphoid tissue, and an association with the Epstein-Barr virus (EBV) Influenced by heredity, age, and EBV Three histologic patterns: -Keratinizing squamous cell carcinomas -Nonkeratinizing squamous cell carcinomas -Undifferentiated carcinomas Tend to grow silently until unresectable -By then, have spread to cervical nodes or beyond

Question 29

Laryngitis

Answer 29

May be sole manifestation of allergic, viral, bacterial, or chemical insult (e.g., tobacco smoke) May be the result of infection -More commonly, part of a generalized upper respiratory infection

Question 30

Infectious laryngitis

Answer 30

Most nonspecific involvements are self-limited Occurs in systemic diseases (TB, diphtheria) May be serious in infants and young children when obstruction occurs -Laryngoepiglottitis -Croup

Question 31

Laryngoepiglottitis

Answer 31

Caused by Hemophilus influenzae or group B ß-streptococci | Sudden swelling of epiglottis or vocal cords is a potential medical emergency

Question 32

Croup (laryngotracheobronchitis)

Answer 32

Inflammatory narrowing of the airway producing inspiratory stridor

Question 33

Reactive nodules (vocal cord polyps)

Answer 33

Develop most often in people who are heavy smokers or impose great strain on their vocal cords Usually located on the “true” vocal cords Ulcerations may occur if cords impinge on each other Characteristically change the character of the voice -Often cause progressive hoarseness Virtually never give rise to cancers

Question 34

Larygeal carcinoma

Answer 34

There is a spectrum of epithelial alterations -Range from hyperplasia to invasive carcinoma -Initially the thickened lesions have little potential for malignant transformation *Risk rises 1-2% over 5-10 years with mild dysplasia *Risk rises 5-10% over 5-10 years with severe dysplasia Therefore, level of atypia when patient presents determines likelihood of malignant development -ONLY HISTOLOGICAL EXAMINATION CAN EVALUATE THE GRAVITY OF THE CHANGES Changes most often related to tobacco smoke Alcohol and HPV (HPV 16 cause > 90%) are also risk factors

Question 35

Carcinoma morphology

Answer 35

~ 95% are typical squamous cell carcinomas Usually develops directly on the vocal cords -May arise above or below the cords, on the epiglottis or on the aryepiglottic folds. Or in the pyriform sinuses May be intrinsic or extrinsic in relation to the larynx

Question 36

Carcinoma clinical course

Answer 36

Manifests as persistent hoarseness At presentation, 60% confined to larynx Later may produce pain, dysphagia, and hemoptysis -Patients vulnerable to infection of the ulcerating lesion With treatment, ⅓ of patients still die -Usually of infection or metastases

Question 37

laryngeal Squamous papilloma & papillomatosis

Answer 37

Benign neoplasms usually on “true” vocal cords -Form raspberry-like excrescences Usually single in adults, multiple in kids (juvenile laryngeal papillomatosis) Lesions caused by HPV types 6 and 11 usually do not become malignant -Frequently recur

Question 38

Acute Otitis media

Answer 38

Occurs mostly in infants and young children When viral, produces a serous exudate Bacterial infections are suppurative -Common offenders: nontypeable Hemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarhalis

Question 39

Chronic Otitis Media

Answer 39

Occurs with repeated bouts of otitis media without resolution Caused by Pseudomonas aeruginosa (in diabetics may cause necrotizing otitis media), Staphylococcus aureus, and fungi May cause eardrum perforation and spread to the mastoid spaces or into the cranial vault

Question 40

Cholesteatomas

Answer 40

Not neoplasms and don’t necessarily contain cholesterol Are cystic lesions filled with amorphous squamous debris By progressive enlargement can erode into the structures of the inner ear and may produce visible neck masses

Question 41

Otosclerosis

Answer 41

Abnormal bone deposition in the middle ear about the rim of the oval window into which the footplate of the stapes fits Both ears usually affected Ankylosis of the structures results in hearing loss Usually familial

Question 42

Ear Tumors

Answer 42

The tumors of the ear are many and varied but RARE except for squamous cell carcinomas of the pinna - Usually seen in elderly men and associated with actinic radiation - Squamous cell carcinomas arising in the external canal may invade the cavity or metastasize to regional nodes

Question 43

``` Branchial cyst (lymphoepithelial cyst) (neck) ```

Answer 43

Benign cysts usually occurring in the anterolateral aspect of the neck Rise either from branchial arch elements or from developmental salivary gland inclusions within cervical lymph nodes Rarely are cancerous and readily excised Similar lesions may appear in the parotid gland or beneath the tongue

Question 44

Thyroglossal tract cyst (neck)

Answer 44

Originates embryologically in the thyroid anlage in the region of the foramen cecum The developing gland descends to its normal position in the anterior neck Remnants of this tract may persist producing cysts -May harbor lymphoid aggregates or thyroid tissue Incomplete excision may allow recurrence

Question 45

Paraganglioma (carotid body tumor) (neck)

Answer 45

Are clusters of neuroendocrine cells (cells dispersed throughout the body) - Some are connected with the sympathetic nervous system * Largest collection is in the adrenal medulla where they give rise to pheochromocytomas - Tumors arising in extra-adrenal paraganglia are called paragangliomas

Question 46

Pargangliomas locations

Answer 46

1) Paravertebral ganglia -Have sympathetic connections and are chromaffin positive -Half elaborate catecholamines 2) Those related to the great vessels of the head and neck E.g., Carotid body tumor

Question 47

Mucocele

Answer 47

MOST COMMON LESION OF SALIVARY GLAND | Results from blockage of duct with saliva leaking into the stroma

Question 48

Salivary gland Inflammation (sialadenitis)

Answer 48

May be viral, bacterial, or autoimmune Mumps is the most common viral form -Other glands may be affected (pancreas; testes) Usually affects the major glands (particularly, the parotid [epidemic parotitis]) Autoimmune disease seen in Sjögren syndrome

Question 49

Sialolithiasis and nonspecific sialadenitis pathogenesis (salivary gland)

Answer 49

Nonspecific bacterial form usually involves major glands (particularly, submandibular) Uncommon and usually secondary to ductal obstruction from calculi (sialolithiasis) Common agents: Staphylococcus aureus and viridans streptococci

Question 50

Sialolithiasis

Answer 50

Stone formation related to obstruction by impacted food debris or edema secondary to trauma Dehydration affecting secretory function may predispose to bacterial infection Long-term phenothiazine therapy may predispose When associated with pyogenic organisms may be associated with suppurative necrosis and abscess Unilateral involvement is the rule The inflammatory involvement causes painful enlargement and sometimes a purulent ductal discharge

Question 51

Salivary gland neoplasms

Answer 51

Give rise to a variety of benign and malignant tumors Only a relatively few tumors make up >90% Gland of origin -65-80% occur in the parotid -10% in the submandibular -Rest in the minor glands and sublingual

Question 52

Salivary gland neoplasms gland of origin

Answer 52

``` Malignant tumors found in: 15-30% of tumors of the parotid 40% of tumors of the submandibular 50% of tumors in the minor glands 90% of tumors in the sublingual Therefore malignancy is more or less inversely proportional to size of gland ```

Question 53

Salivary gland neoplasm occurrence

Answer 53

``` Usually occur in adults Slight female predominance -Warthin tumors more common in males 5% occur in children under 16 Benign tumors occur most often in the 5th to 7th decades ```

Question 54

Salivary gland neoplasms clinical presentation

Answer 54

Regardless of histology, parotid tumors produce distinctive swellings in front of and below the ear When first diagnosed, most tumors are 4-6 cm and mobile except for neglected malignancies Biopsy is necessary for diagnosis of benign vs malignant

Question 55

Pleomorphic adenoma (salivary gland)

Answer 55

Benign tumors Also called mixed tumors because of histologic diversity -Show both epithelial and and mesenchymal differentiation -See epithelial elements dispersed in cartilage or osseous tissue Represent 60% of parotid tumors

Question 56

Pleomorphic adenoma clinical features

Answer 56

Present as painless, slow-growing discrete masses within the parotid or submandibular area or buccal cavity May recur in ~ 4% of parotidectomies Infrequently, a carcinoma arises within the tumor (called a carcinoma ex pleomorphic adenoma) -Usually is an adenocarcinoma or undifferentiated carcinoma

Question 57

Warthin tumor (papillary cystadenoma lymphomatosum)

Answer 57

Second most common salivary gland neoplasm Almost always arises in the parotid gland -Virtually restricted to this gland -Occurs more commonly in males -Usually appears in the 5th to 7th decades -10% are mutifocal; 10% are bilateral Smokers have 8 times the risk pale gray surface cystic spaces filled with mucinous/serous fluid

Question 58

Mucoepidermoid carcinoma

Answer 58

Represents 15% of all salivary tumors Occurs preponderantly in the parotid Accounts for a large fraction of tumors in other salivary glands Overall most common primary malignant tumor in the salivary glands Most common radiation-induced neoplasm