CHAPTER 16 Head

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DESEASES OF HEAD, NECK, EAR, NOSE and TRHOAT
Associate Professor Dr. Alexey Podcheko Spring
2015
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1. oral cavity2. upper airways, including the
nose, pharynx, larynx, and nasal sinuses 3.
ears 4. neck5. salivary glands
Topics
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EVERYTHING that touches AIR (columnar) or FOOD
(squamous) in the HEAD/NECK region
ORAL CAVITY UPPER RESPIRATORY
TRACT EARS NOSE SALIVARY GLANDS
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INTENDED LEARNING OUTCOMES Understand the common
disorders of the upper airway and upper digestive
tract (i.e., head and neck) in the usual context
of DEGENERATIVE, INFLAMMATORY, and NEOPLASTIC de
viations of normal anatomy and histology
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ORAL CAVITY

• TEETH/GINGIVA/ALVEOLAR BONE
• INFLAMMATORY/REACTIVE LESIONS
• INFECTIONS HSV, VIRAL, FUNGI
• LEUKOPLAKIA/HAIRY LEUKOPLAKIA
• SQUAMOUS TUMORS BEN/MALIG
• ODONTOGENIC CYSTS/TUMORS

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Time frame of teething

• Incisors 10-15mo
• Bicuspids 15-18mo
• Molars 18-24mo

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Tooth Decay (Cavities, Caries)

• Dental caries one of the most common diseases, is
  the most common cause of tooth loss before age 35
• Result of mineral dissolution of tooth structure
• Processed carbohydrates, i.e., sugars
• Bacterial (Strep. Viridans Strep. Mutans
  Strep. Sanguis Lactobacilli, Actinomycetes)
  acidic erosion of enamel due to ability to
  produce insoluble dextrans
• Role of pH, spacing, brushing, Fl
• Tartar?plaque?calculus bacteria, proteins, cells

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• Gram Positive cocci isolated from the blood of
  patient with bacteremia synthesize dextrans from
  glucose. The bacteria most likely contribute to
  which of the following pathological states?
• A Glomerulonephritis
• B. Sarcoidosis
• C. Erythema nodosum
• D. Migratory polyarthritis
• E. Anterior uvetis
• F. Dental Caries

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• Vindans streptococci, notably S. mutants and S.
  sanguis, are normally present in the human mouth
  and are major contributors of tooth decay and the
  initiation of dental caries. The organisms also
  cause bacterial endocarditis. Viridans
  streptococci are adhere to the surface of tooth
  enamel and heart valves and multiply in those
  locations due to their ability to produce
  insoluble dextrans.

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Find the cavity, i.e., caries, i.e., enamel
erosion
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GINGIVITIS
Gingiva - squamous mucosa in between the teeth
and around them Gingivitis is inflammation of
the mucosa and the associated soft tissues.
Causes Bacteria Actinobacilli, Porphyromona,
Prevotella Viruses HSV1 and 2 Symptoms
erythema, edema, bleeding, changes in contour,
and loss of soft-tissue adaptation and sores
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Periodontitis

• Definition inflammatory process that affects the
  supporting structures of the teeth periodontal
  ligaments, alveolar bone, and cementum
• Causes Bacteria, adult periodontitis is
  associated primarily with
• Actinobacillus actinomycetemcomitans,
• Porphyromonas gingivalis
• Prevotella intermedia
• Affected structures Gingiva, periodontal
  ligaments, bone, cementum

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Periodontitis

• Component of several different systemic diseases
• 1. AIDS
• 2. Leukemia
• 3. Crohn's disease
• 4. Diabetes mellitus
• 5. Down syndrome
• 6. Sarcoidosis,
• 7. Syndromes associated with polymorphonuclear
  defects (Chédiak-Higashi syndrome,
  agranulocytosis, and cyclic neutropenia)
• Etiologic factor in several important systemic
  diseases
• 1. infective endocarditis,
• 2. pulmonary and brain abscesses,
• 3. averse pregnancy outcomes (preeclampsia)

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• A 67-year-old male is hospitalized with low-grade
  fevers fatigue and a diastolic murmur at the left
  sternal border. Blood cultures reveal Gram
  positive cocci that are catalase-negative and
  able to grow in the presence of optocin. This
  patients medical history is most likely to
  reveal which of the following procedures in the
  past month?

A. Dental extraction B. Skin biopsy C.
Sinus drainage D. Nasal polypectomy E.
Cystoscopy
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• (Choice A) Dental extraction is associated with
  endocarditis caused by S. viridans, a Gram
  positive coccus. In most cases, S. viridans
  causes subacute bacterial endocarditis in already
  abnormal heart valves (e.g. congenital valvular
  abnormalities valves damaged by rheumatic
  fever.)

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Inflammatory/Reactive Tumor-like Lesions

• MC fibrous proliferative lesions of the oral
  cavity
• fibroma (61)
• reactive nodules of the oral cavity peripheral
  ossifying fibroma
• pyogenic granuloma
• peripheral giant-cell granuloma
• gingival hyperplasia

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Irritation fibroma

• primarily occurs in the buccal mucosa along the
  bite line or at the gingivodental margin.
• Morphology nodular mass of fibrous tissue, with
  few inflammatory cells, covered by squamous
  mucosa.
• Rx Surgical excision

Smooth pink exophytic nodule on the buccal
mucosa.
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Irritation Fibroma
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Peripheral ossifying fibroma

• Growth of the gingiva that is considered to be
  reactive in nature rather than neoplastic.
• Result of the maturation of a long-standing
  pyogenic granuloma
• Rx Surgical excision down to the periosteum
  (recurrence rate of 15 to 20)

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Pyogenic granuloma

• Highly vascular pedunculated lesion on the
  gingiva (children, young adults, pregnant women
  (pregnancy tumor).
• Growth can be rapid, raising the fear of a
  malignant neoplasm.
• Histology vascular proliferation that is similar
  to granulation tissue (capillary hemangioma?)
• Regress with formation of peripheral ossifying
  fibroma.
• Rx surgical excision

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PYOGENIC GRANULOMA
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A 6-year-old boy presents with a painful sore in
his mouth. Physical examination reveals a small,
elevated, and locally ulcerated red-purple
gingival lesion. A soft red mass measuring 1 cm
in diameter is surgically removed. Histologic
examination discloses highly vascular granulation
tissue, with marked acute and chronic
inflammation. What is the most likely
diagnosis? (A) Acute necrotizing gingivitis (B)
Aphthous stomatitis (C) Herpes labialis (D)
Pyogenic granuloma (E) Tuberculosis
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Peripheral giant cell granuloma

• bluish purple tumor-like lesion
• Histology aggregation of multinucleate, foreign
  bodylike giant cells separated by a
  fibroangiomatous stroma, not encapsulated
• can cause resorption of alveolar bone
• Rx Surgical excision
• Dif. diagnosis central giant-cell granulomas of
  bones and brown tumors seen in
  hyperparathyroidism

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Histology of peripheral giant cell granuloma
reveals a dense infiltrate of histiocytes and
multi-nucleated giant cells within the
subepithelial fibrous stroma.
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APHTHOUS ULCERS (CANKER SORES)

• superficial ulcerations of the oral mucosa affect
  up to 40 of the population in the United States
• Etiology stress, fatigue, illness, injury from
  accidental biting, hormonal changes,
  menstruation, sudden weight loss, food allergies,
  and deficiencies in vitamin B12, iron, and folic
  acid , recurrent apthous ulcers may be associated
  with celiac disease and inflammatory bowel
  disease.
• Clinic extremely painful and often recurrent
  sores, tendency to be prevalent within certain
  families.
• Morphology Single or multiple, shallow,
  hyperemic ulcerations covered by a thin exudate
  and rimmed by a narrow zone of erythema
• Histology Mononuclear infiltrate
• Prognosis Spontaneously resolve in 7 to 10 days
  or be stubbornly persistent for weeks
• Rx local anesthetics

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Canker sore Aphthous ulcer
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GLOSSITIS

• Inflammation of the tongue
• atrophy of the papillae of the tongue and
  thinning of the mucosa, exposing the underlying
  vasculature
• Atrophic Glossitis Causes Deficiencies of
  vitamin B12 (pernicious anemia), riboflavin,
  niacin, or pyridoxine, sprue and iron-deficiency
  anemia.
• Ulcerative Glossitis Causes jagged carious
  teeth, ill-fitting dentures, and, rarely, with
  syphilis, inhalation burns, or ingestion of
  corrosive chemicals
• Clinic Plummer-Vinson syndrome - combination of
  iron-deficiency anemia, glossitis, and esophageal
  dysphagia mostly in postmenopausal women

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HERPES SIMPLEX VIRUS INFECTIONS

• Mostly herpes simplex virus type 1 (HSV-1)
• Enveloped double-stranded DNA virus
• Primary HSV infection typically occurs in
  children age 2 to 4 years,
• Forms
• acute herpetic gingivostomatitis MOST Common
  form of primary infection
• cold sores (Herpes labialis)
• recurrent herpetic stomatitis

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HERPES SIMPLEX VIRUS INFECTIONS
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HERPES SIMPLEX VIRUS INFECTIONS

• Morphology
• Intracellular and intercellular edema
  (acantholysis) yielding clefts that may become
  transformed into macroscopic vesicles.
• Cells have eosinophilic intranuclear viral
  inclusions,
• multinucleate polykaryons
• Tzanck test microscopic examination of the
  vesicle fluid to find multinucleated polykarions

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TZANCK SMEAR
The neat thing about a Tzanck smear is that you
can do it easily in your office, just gently
scrape a vesicle, smear it, stain it with just
about anything, and look for much larger than
usual squamous nuclei with inclusions. Most
vesicles caused by herpes family viruses can have
a POSITIVE Tzanck (pronounced zank) smear, or
test.
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• A 2-year-old male is brought to clinic with fever
  irritability, and decreased oral intake. Physical
  examination reveals swollen gums with ulcerative
  lesions and enlarged, tender cervical lymph
  nodes. Oral lesion scrapings demonstrate cells
  with intranuclear inclusions. Which of the
  following is most likely responsible for this
  patients disease?

A. Enveloped double-stranded DNA virus B.
Non-enveloped double-stranded DNA viru C.
Non-enveloped single-stranded DNA virus D.
Non-enveloped positive-sense RNA virus E.
Enveloped positive-sense RNA virus F. Enveloped
negative-sense RNA virus
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• A 5-year-old male is brought to the clinic with a
  several day history of fever, irritability and
  refusal to eat. Physical examination demonstrates
  painful gingival ulcers, swollen gums, and
  cervical lymphadenopathy. Microscopic examination
  of the oral ulcer base scrapings is shown on the
  slide below. This patient current situation is
  most likely represent

A Primary infection B. Virus reactivation C.
Latent infection D. Abortive infect E. Slow
virus infection
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ORAL CANDIDIASIS (THRUSH)

• Candidiasis is by far the most common fungal
  infection in the oral cavity.
• Factors
• (1) immune status of the individual
• (2) the strain of C. albicans present
• (3) the composition of an individual's oral flora
• (4) Abt therapy
• (5) Underlying diseases (AIDS, Diabetes)
• Major clinical forms of oral candidiasis
• Pseudo-membranous (thrush)
• Erythematous
• Hyperplastic,

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Finding the NON-septate hyphae (i.e.,
pseudo-hyphae) along with yeasts and budding
yeasts in your simple office lab, is diagnostic.
Almost any simple stain will show this. The PAS
stain is best, because it imparts a bright red
color to yeasts and pseuduhyphae
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Oral Manifestations of Systemic Disease
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Oral Manifestations of Systemic Disease
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HAIRY LEUKOPLAKIA

• Hairy leukoplakia - white patch or plaque that
  cannot be scraped off and cannot be characterized
  clinically or pathologically as any other
  disease, caused mostly by EBV infection
• 80 of patients with hairy leukoplakia are
  infected with the human immunodeficiency virus
  (HIV)!!!
• Dif. diagnosis with Candidiasis - lesion cannot
  be scraped off.
• Histology Hyperparakeratosis and acanthosis
  with balloon cells in the upper spinous layer,
  koilocytosis of the superficial, nucleated
  epidermal cells,
• Prognosis In HIV-positive individuals, with
  hairy leukoplarkia, symptoms of AIDS follow in 2
  to 3 years!

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Hairy leukoplakia
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Hairy leukoplakia
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Premalignant lesions in the oral cavity

• Leukoplakia - a white patch or plaque that cannot
  be scraped off and cannot be characterized
  clinically or pathologically as any other disease
  
• until it is proved otherwise via histologic
  evaluation, all leukoplakias must be considered
  precancerous!
• Erythroplakia -red, velvety, possibly eroded area
  within the oral cavity that usually remains level
  with or may be slightly depressed in relation to
  the surrounding mucosa
• Speckled leukoerythroplakia ErythroLeukoplakia

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Histologic progression of Leukoplakia into
squamous cell carcinoma
NORMAL? DYSPLASIA? CARCINOMA-IN-SITU?INFILTRATING
MALIGNANCY
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Head and Neck are Squamous Cell Carcinomas
(HNSCCs)

• 95 of cancers of the head and neck
• overall long-term survival has remained at less
  than 50
• individual who is fortunate to live 5 years after
  the initial primary tumor has up to a 35 chance
  of developing at least one new primary tumor
  within that period of time
• Etiology Tabacco, Alcohol, actinic radiation
  (sunlight), pipe smoking, chewing of betel quid,
  mouthwash (25 alcohol)

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Morphology of squamous cell carcinoma of the oral
cavity

• Favored locations
• 1. ventral surface of the tongue
• 2. Floor of the mouth
• 3. Lower lip, soft palate, and gingiva

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Morphology of squamous cell carcinoma of the oral
cavity Raised, firm, pearly plaques or as
irregular, roughened, or verrucous areas of
mucosal thickening
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Morphology of squamous cell carcinoma of the oral
cavity

• There are the 3 types of differentiation of
  squamous cell cancer Well, moderate, poor.
• In well you can see pearls. (pearl above).
• In moderate, you can usually see intercellular
  bridges, but not pearls.
• In poor you usually have no real idea that it
  even looks squamous at all, and you have to rely
  on squamous or immunochemical markers, such as
  cytokeratin markers, or a whole host of others.

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WELL MODERATE POOR
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ODONTOGENICCYSTS

• Definition cyst like structures derived from
  epithelial linings or epithelial remnants in the
  jaw bone
• Classification
• INFLAMMATORY CYSTS (e.g., Periapical Radicular
  - most common)
• DEVELOPMENTAL CYSTS (DENTIGEROUS - most common)

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Periapical cyst
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Periapical cyst

• extremely common lesions found at the apex of
  teeth.
• Result of long-standing pulpitis or periapical
  abscess.
• Periapical inflammatory lesions persist as a
  result of the continued presence of bacteria or
  other offensive agents in the area

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Dentigerous cyst

• Def Cyst that originates around the crown of an
  unerupted tooth and is thought to be the result
  of a degeneration of the dental follicle.
• Xray unilocular lesions and are most often
  associated with impacted third molar (wisdom)
  teeth.
• Histology they are lined by a thin layer of
  stratified squamous epithelium with chronic
  inflammatory cell infiltrate in the connective
  tissue stroma.
• Rx Excision
• Complications recurrence or, very rarely,
  neoplastic transformation into an ameloblastoma
  or a squamous cell carcinoma.

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DENTIGEROUS CYST
lined by a thin layer of stratified squamous
epithelium with chronic inflammatory cell
infiltrate in the connective tissue stroma
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Odontogenic keratocyst (OKC)

• locally aggressive and has a high rate of
  recurrence
• Most often diagnosed in patients between ages 10
  and 40.
• Males within the posterior mandible.
• Xray well-defined unilocular or multilocular
  radiolucencies
• Histo layer of parakeratinized or
  orthokeratinized stratified squamous epithelium
  with a prominent basal cell layer and a
  corrugated appearance of the epithelial surface.
• Rx Complete removal of the lesion

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Odontogenic tumors

1. Odontoma- the most common type of odontogenic
   tumors (app. 70), arises from epithelium but
   shows extensive depositions of enamel and dentin.
   Odontomas are probably hamartomas rather than
   true neoplasms and are cured by local excision.
2. Ameloblastoma (app. 30) - from odontogenic
   epithelium. It is commonly cystic, slow growing,
   and locally invasive but has an indolent course
   in most cases

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Odontoma on x-ray?
Ameloblastoma on x-ray?
Circular sunburst opacity surrounded by a thin
radiolucent border
Large expansile multilocular or soap-bubble
radiolucency favored location is posterior
mandible
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Histologic view of odontoma and ameloblastoma
Ameloblastoma notice the stellate reticlulum and
the row of ameloblasts with vacuoles (40x).
Odontoma consists of a mixture of hard
substances, epithelial structures, and empty
spaces formerly occupied by enamel matrix, 20x
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Odontomas
Ameloblastomas