Chapter 16: Head and Neck Flashcards
1
Q
Inflammatory process affecting the supporting structures of the teeth (peridontal lig.), alveolar bone, and cementum?
A
Periodontitis
2
Q
What are the normal class of bacteria that colonize healthy gingival sites?
A
Facultative gram positives
3
Q
Which systemic diseases are associated w/ Periodontitis?
A
- AIDS
- Leukemia
- Chron disease
- DM
- Down syndrome (high risk for leukemia)
- Sarcoidosis
- Dz asso. w/ defect in neutrophils (Chediak-Higashi, agranulocytosis, and cyclic neutropenia)
4
Q
Which diseases can periodontal infections be the origin for?
A
- Infective endocarditis
- Pulmonary and Brain abscesses
5
Q
Which inflammatory lesion is typically found on the gingiva of children, young adults, and pregnant woman (pregnancy tumor)?
A
Pyogenic granuloma
6
Q
Which test is diagnostic for Acute Herpetic Gingivostomatitis?
What are you looking for?
A
- Tzanck test, microscopic examination of the vesicle fluid
- Presence of multinucleate polykaryons (giant cells) or eosinophilic intranuclear viral inclusions
7
Q
Which infection produces a characteristic dirty white, fibrinosuppurative, tough, inflammatory membrane over the tonsils and retropharynx?
A
Diptheria
8
Q
Which infection produces spotty enanthema in the oral cavity often preceding a skin rash; ulcerations on the buccal mucosa about Stensen duct producing Koplik spots (small red lesions w/ blue-white centers)?
A
Measles
9
Q
Which 3 hematologic disorders may present w/ oral changes?
A
1) Pancytopenia (agranulocytosis, aplastic anemia)
2) Leukemia
3) Monocytic leukemia
10
Q
Hairy leukoplakia is caused by what virus?
Found where in oral cavity?
A
- EBV
- Lateral border of the tongue
11
Q
Which oral lesion is characterized by a distinct microscopic appearance consisting of hyperkeratosis and acanthsosis with “balloon cells” in the upper spinous layer?
A
Hairy leukoplakia
12
Q
Until proven otherwise, all leukoplakias must be considered __________.
A
Precancerous
13
Q
What are the histological changes of the epithelium seen with erythroplakia?
A
Severe dysplasia, carcinoma in situ, or minimally invasive carcinoma
14
Q
Around 95% of the cancers of the head and neck are of which type?
Remainder largely consists of which type?
A
- Squamous Cell Carcinoma (SCC) = majority (95%)
- Adenocarcinomas of salivary gland origin = remainder
15
Q
In the oropharynx, as many as 70% of SCCs, particularly those involving the tonsils, base of the tongue, and the pharynx, harbor what?
A
- Oncogenic variants of HPV
- Particularly HPV-16
16
Q
What is the prognosis (5-year survival rate) of the “classic” (smoking and alcohol related) early-stage SCC?
Late stage?
A
- Good (80%)
- Drops to 20% for late-stage disease
17
Q
Which observation associated with tumors of the upper aerodigestive tract has led to the concept of “field cancerization?”
A
Development of multiple primary tumors is more common here than any other malignancy
18
Q
What is the basis of “Field Cancerization?”
A
Multiple individual primary tumors develop independently in the upper aerodigestive tract as a result of years of chronic exposure of the mucosa to carcinogens
19
Q
Which genetic mutations are commonly associated with the “classic - tobacco/alcohol” SCC subset?
A
- Frequently involve p53
- p63 and NOTCH1
20
Q
What is typically overexpressed in HPV-associated SCC’s?
Other common genetic alterations?
A
- p16 (cyclin dependent kinase inhibitor) = overexpressed
- p53 inactivation –> E6
- RB inactivation –> E7
21
Q
Change in oral flora —> ________ + ________ = periodontitis
A
Change in oral flora —> anaerobic + microaerophilic G (-) = periodontitis
22
Q
Apthous ulcers (canker sores) tend to be more prevalent in and associated with what disorders?
A
- IBD
- Celiac disease
- Behcet disease
23
Q
What is the morpholgy of peripheral ossifying fibroma?
Peak incidence in whom?
Treatment of choice?
A
- Red, ulcerated and nodular lesions of gingiva
- Increased incidence in young/teenage females
- Complete surgical exicison down to periosteum
24
Q
Which form of Oral Candidiasis (Thrush) is the most common?
How does it appear in the oral cavity?
A
- Pseudomembranous form
- Superficial, gray to white inflammatory membrane, that can be readily scarped off
25
What is the typical **age of onset** and **sex** most affected by leukoplakia and erythroplakia?
- Age **40-70**
- M:F (**2****:1**)
26
Actinic radiation (sunlight) and pipe smoking are known predisposing factors for what type of oral cancer?
**SCC** of the **lower lip**
27
How does an HPV (+) vs. HPV (-) SCC affect the prognosis?
- HPV (+) = **BETTER** **prognosis** if **p16+**
- HPV (-) = **worse prognosis**
28
How does the progression of oral SCC differ from that of cervical cancer?
- **Oral SCC** may invade underlying CT stroma **before** progression to full-thickness dysplaisa (carcinoma in situ)
- In **cervical cancer**, carcinoma in situ, develops **before** invasion
29
What are the 5 favored locations in the oral cavity for the development of SCC?
- Ventral surface tongue
- **Floor of mouth**
- Lower lip (associated w/ sun exposure and pipe smoking)
- Soft palate
- Gingiva
30
What is the morphology of oral SCC in the early stage?
**Raised**, **firm**, **pearly plaques** or **irregular**, **roughened** or **verrucous** areas of mucosal thickening --\> may look like **leukoplacia**
31
What are the favored sites for **local metastasis** of SCC?
Favored sites for **distal metastasis**?
- **Local** ---\> cervical LN's
- **Distal** ---\> mediastinal LN's, lungs, liver, and bones
32
Which type of cyst is defined as originating around the crown of an unerupted tooth and is thought to be the result of fluid accumulation between the developing tooth and dental follicle?
Detingerous cyst
33
Radiographically, **dentigerous cysts** are seen as what type of lesions and most often associated with which teeth?
Treatment?
- **Unilocular** lesion
- Impacted **third molar (wisdom) teeth**
- Complete removal = **curative**
34
What is the significance of Keratocystic Odontogenic Tumors (OKC's)?
Must be differentiated from other cysts due to its **aggressive behavior**
35
Keratocystic Odontogenic Tumors (OKC's) are most often diagnosed between what ages and which sex is more commonly affected?
Where do they most often arise within the oral cavity?
- Ages **10-40 yo**; most often in **males**
- **Posterior mandible**
36
Multiple Keratocystic Odontogenic Tumors (OKC's) occuring in a patient should prompt evaluation for what?
Nevoid basal cell carcinoma (**Gorlin syndrome**)
37
Nevoid basal cell carcinoma (Gorlin syndrome) is associated with mutations in what gene and on what chromosome?
- ***PTCH*** (tumor suppressor gene)
- Cr. **9**
38
Periapical, Residual, and Paradental cysts of the oral cavity are classified how (inflammatory or developmental cysts)?
**Inflammatory** cysts
39
Periapical cysts are common lesions found where in the oral cavity?
Apex of teeth
40
What are the common causes of Periapical cysts (Periapical Granulomas)?
- **Long-standing inflammation** of a **tooth** (**pulpitis**)
- May be due to **advanced carious lesions** or **trauma** to the **tooth**
41
Ameloblastoma arises from ___________ and shows **no** \_\_\_\_\_\_\_\_\_\_\_\_\_
Ameloblastoma arises from **odontogenic epithelium** and shows **no ectomesenchymal differentiation**
42
What is the most common Odontogenic tumor?
Odontoma
43
Where do Odontomas arise from?
Show extensive deposition of?
- Arise from **epithelium**
- Extensive deposition of **enamel** and **dentin**
44
Odontomas are more likely __________ rather than true neoplasms
Hamartomas
45
What is the inheritance pattern of Rendu-Osler-Weber syndrome?
Autosomal **Dominant**
46
Which disorder is associated w/ multiple congenital aneurysmal telangiectasias beneath mucosal surfaces of the oral cavity and lips?
Rendu-Osler-Weber syndrome
47
Irritation fibroma (aka traumatic fibroma) typically arise where in the oral cavity?
**Buccal mucosa along the bite line** or **the gingiva**
48
Xerostomia is a major feature of?
Sjorgren Syndrome
49
Complications of Xerstomia include increased rates of?
- Dental caries
- **Candidiasis**
- Difficulty swallowing **and** speaking
50
What is the most common type of salivary gland lesion?
Mucoceles
51
What is the most common form of **viral sialadenitis**?
Which major salivary is most commonly affected?
- Mumps
- Parotids b/l = **most common**
52
Which glands may be affected w/ a mumps infection?
- Parotids b/l
- Testes - **orchitis**
- Pancreas
53
Mucoceles are caused by what?
Most commonly found where in oral cavity and due to what?
- **Blockage/rupture** of the **salivary gland duct** w/ leakage of saliva into CT stroma
- Most often **LOWER LIP** due to **TRAUMA**
54
How do Mucoceles present clinically (i.e., how do they look on examination)?
Patients often report what in regards to the size of the lesion?
**- Fluctuant swellings** of **lower lip** that have a **blue translucent hue**
- Often report **hx of changes in size** in **assoc. w/ meals**
55
What is the histological characteristics of Mucoceles?
Most common inflammatory cell present?
- **Pseudocysts** w/ cyst-like spaces **lined by granulation tissue** or **fibrous CT**
- Cystic spaces filled w/ **mucin** and most often **MACROPHAGES**
56
What is the Tx for Mucoceles?
Complete excision of the cyst **and** its accompanying minor salivary gland
57
What is a Ranula?
**Epithelial-lined cysts** that arise when **duct of sublingual gland** has been **damaged**
58
Bacterial sialadenitis, most often involves the __________ glands and is a common condition secondary to \_\_\_\_\_\_\_\_\_\_\_
Bacterial sialadenitis, most often involves the **submandibular** glands and is a common condition secondary to **sialolithiasis**
59
What are the 2 most common organisms responsible for sialolithiasis leading to sialadentitis?
Unilateral or bilateral process?
1) *S. aureus*
2) *S. viridans*
- **UNILATERAL**
60
A patient presenting with unilateral, sialadentitis with overt suppurative necrosis and abscess formation should raise suspicion of?
**Sialolithiasis** causing **sialadentitis**, likely due to ***S. aureus*** or *S**. viridans***
61
The likelihood of a salivary gland tumor being malignant is more or less ___________ proportional to the size of the gland
Inversely
\*Smaller the gland = higher risk of malignancy
62
Majority of salivary gland tumors arise where?
Parotid gland
63
What is the most common tumor of the salivary gland and is it benign or malignant?
Pleomorphic adenoma (60%) -- **benign**
64
Pleomorphic adenomas contain a mixture of _________ and _________ cells
Pleomorphic adenomas contain a mixture of **ductal (epithelial)** and **myoepithelial** cells
\***MIXED tumor**
65
Exposure to what increases risk for Pleomorphic Adenomas?
Associated with what genetic mutation?
- **Radiation**
- ***PLAG1***overexpression --\> Increased cell growth
66
How do pleomorphic adenomas present clinically (i.e., mass where, any pain, and rate of growth)?
**Painless**, slow-growing, **mobile**, discrete masses within the **parotid** or **submandibular** areas or in the **buccal cavity**
67
A carcinoma arising in a pleomorphic adenoma is referred to as a?
Carcinoma ex pleomorphic adenoma **or** malignant mixed tumor
68
What type of tumor is shown here and how can you tell?
- **Pleomorphic adenoma**
- **Well-demarcated tumor** w/ **epithelial** cells and **myoepithelial** cells within a **chondroid matrix = DOMINANT histological features**
69
What is the prognosis of a malignant pleomorphic adenoma (i.e., *carcinoma ex pleomorphic adenoma*)?
- Most **aggressive** of **all** salivary gland tumors
- Mortality rates of **30-50% at 5 years**
70
Which benign tumor is virtually restricted to the parotid gland?
Warthin Tumor (aka papillary cystadenoma lymphomatosum)
71
When do Warthin tumors usually arise?
Which sex is most affected?
What is a major risk factor?
- **5th to 7th decade** of life
- More common in **males**
- Smokers have **8x** the risk
72
What are some of the distinct morphological characteristics of a Warthin tumor?
- **Round** to **oval** **encapsulated** mass, **2-5 cm in diameter**, in superfical parotid gland
- **Double layer** of lining cells resting on **dense lymphoid stroma** sometimes w/ **GERMINAL** **centers**
- Upper layer = **palisading columnar cells** w/ abundant, finely **granular**, eosinophilic cytoplasm
- Lower layer = **cuboidal to polygonal cells**
73
What is the reason for the granular appearance of the cytoplasm in the upper layer of cells seen in Warthin Tumors?
NUMEROUS **mitochondria**, feature referred to as "**oncocytic**"
74
Which genetic mutation (i.e., translocation and gene products) is thought to play a key role in Mucoepidermoid carcinoma?
- Balanced (**11;19**) translocation
- Creates fusion gene = ***MECT1*** *and **MAML2 genes***
75
What is the most common primary malignant tumor of the salivary glands?
Mucoepidermoid carcinoma
76
What are the histological characteristics of a mucoepidermoid carcinoma?
How large do they grow?
- Grow to **8 cm in diameter** and are circumscribed, but lack well-defined capsules and are **infiltrative at margins**
- Cords, sheets, or cystic configurations of **squamous, mucous,** or **intermediate cells**
77
Which stain helps to visualize a mucoepidermoid carcinoma?
Mucin stains
78
What is the prognosis of both low-grade and high-grade Mucoepidermoid Carcinomas?
- **Low grade** ---\> 5-year survival of **90%**
- **High grade** ---\> 5-year survival of **50%**
79
Adenoid cystic carcinoma is most often seen where?
- **Minor salivary glands** (particularly the **palatine** glands)
- May also be seen in **major** salivary glands (**parotid** and **submandibular**)
80
What is the morphology of Adenoid cystic carcinomas?
- Small, **poorly encapsulated**, infiltrative, gray-pink lesions
- Small cells w/ **dark, compact nuclei** and scant cytoplasm
- Often create a **cribiform pattern**
81
Adenoid cystic carcinoma of the salivary gland often shows which type of pattern?
Cribiform
\*Gaps between the cancer cells within the duct, with an **appearance similar to the ‘holes in swiss cheese‘** or perhaps ‘ripples‘.
82
Adenoid cystic carcinomas have a tendency to invade which spaces?
Often metastasize to which distant locations?
- Invade **perineural spaces**
- **Bone, liver,** and **brain**
83
What is the most common and second most common site for Acinic cell carcinoma of the salivary glands?
- **Most common** = parotids
- **2nd** = submandibular glands
84
What is the morphological hallmark of Acinic cell carcinoma of the salivary glands?
**Clear** cytoplasm
85
What is the prognosis of Acinic cell carcinoma after resection?
- Overall recurrence = **uncommon**
- 90% at 5 years and 60% at 20 years = **good prognosis**
86
Pt presenting w/ a fiery red tongue w/ prominent papillae (raspberry tongue); white-coated tongue through which hyperemic papillae project should raise suspicion of which infection and organism?
- Scarlet Fever
- *Strep pyogenes* --\> **Gram (+)**
87
A pt presenting with acute pharyngitis and tonsilitis w/ a gray-white exudative membrane; enlargement of LN's in the neck and **palatal petechiae** should raise suspicion of which type of infection and by what?
- Infectious mononucleosis
- **EBV** of the ***Herpeviridae* family** = dsDNA virus
88
How does the clinical presentation in terms of lesions differ between the classic type and HPV-type of oral SCC?
- **Classic-type -** lesions can be on ventral tongue, floor of mouth, lower lip, soft palate, gingiva
- **HPV-type** - has **NO preceding/precancerous lesion.** Originate in **tonsillar crypts, base of tongue,** or **pharynx**
89
The prognosis and clinical course of Mucoepidermoid Carcinomas are dependent on what?
Grade of the neoplasm
