Diseases of the Upper Aerodigestive Tract

Question 1

A child comes in with a superficial, painful ulceration of the oral mucosa. What is the likely diagnosis and when should it resolve?

Answer 1

Aphthous ulcer (canker sore)

Resolves in 1-2 weeks spontaneously

Question 2

What is an irritation fibroma and what causes it?

Answer 2

In response to persistent trauma or local irritation, fibroblasts proliferate and cause formation of a nodule of fibrous connective tissue

Question 3

Where is an irritation fibroma normally found, and how is it cured?

Answer 3

Normally on the buccal mucosa, i.e. gets caught during chewing

Will only get worse if you keep irritating it, so it often must be excised

Question 4

What is a pyogenic granuloma?

Answer 4

A misnomer -> red-purple soft, painless, polyploid mass which may grow rapidly and commonly arrises on buccal gingiva between teeth

-> made of excessive granulation tissue, very vascular

Question 5

What typically causes the development of pyogenic granuloma and how is it treated?

Answer 5

Typically related to irritation or hormonal (often during pregnancy)

Treated with excision (curative), but often regresses in pregnant women, or can even progress to ossify if untreated

Question 6

What strain of herpes most often causes mucous membrane infections and who tends to get it?

Answer 6

HSV-1, tends to occur in young children, but it is very common overall

Question 7

What is the common mouth infection caused by HSV-1 and what are the symptoms?

Answer 7

Acute herpetic gingivostomatitis

Symptoms:
Fever, lymphadenopathy, painful vesicles of oral mucosa

Question 8

What is recurrent herpetic stomatitis? What precedes it?

Answer 8

Cold sores -> viral reactivation which tends to occur on lip / vermillion border (herpes labialis)

-often preceded by initial pain and tingling

Question 9

What does HSV-1 look like under the microscope?

Answer 9

The vesicles in the mucosa will have multinucleated epithelial cells with ground-glass nuclei and often eosinophilic intranuclear inclusions

Question 10

What is thrush also called and what are the risk factors?

Answer 10

Acute oral pseudomembranous candidiasis

Risk factors:
Immunosuppression
Corticosteroids / antibiotics
Xerostomia (reduced saliva)

Question 11

What are the defining characteristics of thrush?

Answer 11

Creamy white plaque, composed of pseudomembrane which is adherent to mucosa. However, it CAN be scraped off to show budding yeast and pseudohyphae

Question 12

Who typically gets hairy leukoplakia and what causes it?

Answer 12

Caused by EBV infection of the mucosa along the tongue. Typically happens in immunosuppressed (especially HIV) patients who are smokers

Question 13

What the features of hairy leukoplakia and why?

Answer 13

White plaque with folds and tiny hair-like protrusions usually on lateral surface of the tongue which CANNOT be scraped off

Thickening of the mucosa due to proliferation in squamous epithelial cells, keratin is very white.

Question 14

How does hair leukoplakia appear under the microscope?

Answer 14

Will cause hyperkeratosis, or parakeratosis if the nuclei are still present

Balloon cells -> present in stratum spinosum, cells appear inflated and pale

Question 15

What infection is associated with a swollen, erythematous tongue with prominent papillae and sometimes a white coating?

Answer 15

Strawberry tongue -> Scarlet fever -> S. pyogenes

Question 16

When, where, and in what infection do Koplik spots appear?

Answer 16

In the prodrome of Measles (rubeola)

-> small, blue-white specks on an erythematous buccal mucosa opposite the upper molars

Question 17

Why can diphtheria cause an emergency state?

Answer 17

Dense, gray, mucosal pseudomembrane can overly the tonsils and pharynx and obstruct breathing

Question 18

What cancer is associated with gingival infiltration and enlargement?

Answer 18

Acute monocytic leukemia

Question 19

What syndrome is associated with development of melanosis inside the mouth and hamartomatous polyps of the GI tract?

Answer 19

Peutz-Jeghers syndrome

Question 20

What is the main risk factor for Leukoplakia and Erythroplakia?

Answer 20

Tobacco use of any kind

Question 21

What is leukoplakia and how does it look under the microscope?

Answer 21

A white patch of the oral mucosa which cannot be scraped off and cannot be attributed to another condition (i.e. hairy leukoplakia)

Has a wide spectrum under the microscope -> hyperkeratotic and benign to carcinoma in situ

MUST be biopsied to tell -> potentially premalignant

Question 22

What does erythroplakia look like and is it more or less worrying than leukoplakia?

Answer 22

Smooth, soft, flat, or slightly eroded red patch which is not otherwise accounted for (looks like a pizza burn)

More worrying -> often highly dysplastic or representing squamous cell carincoma with subjacent inflammation

Question 23

What accounts for most malignancies of the head and neck?

Answer 23

Squamous cell carcinoma

Question 24

What are the risk factors for squamous cell carcinoma in the oral cavity?

Answer 24

Tobacco smoking and alcohol

Chewing betel nut (Asian cultures it’s like chewing tobacco)

Question 25

What are the risk factors for squamous cell carcinoma in the lower lip and the oropharynx?

Answer 25

Lower lip - UV radiation, pipe smoking

Oropharynx - HPV, especially HPV16

Question 26

Does tobacco-induced squamous cell carcinoma or HPV-induced have a better prognosis? What proteins does the latter affect?

Answer 26

HPV-induced does

p53 - inactivated by E6
Rb - inactivated by E7

p16 is a CDKI which is also overexpressed and becomes oncogenic

Question 27

How does squamous cell carcinoma appear grossly, and where does it tend to spread?

Answer 27

Appears as a firm mass with central ulceration and raised, irregular borders

Tends to spread first to cervical lymph nodes (it is a carcinoma, not a sarcoma)

Question 28

Who are infectious and allergic rhinitis told apart?

Answer 28

Infectious is due to a Type I hypersensitivity -> eosinophils will be present

Question 29

What leads to formation of nasal polyps and what are they?

Answer 29

Repeated episodes of rhinitis leading to excessive mucosal enlargement
-> edema and lymphocytic infiltrate which can obstruct nasal passages or become infected themselves

Question 30

What leads to acute sinusitis and what are some complications?

Answer 30

Rhinitis impairs drainage of sinus secretions

• > paranasal sinuses become inflamed
• > bacterial superinfection with normal nasal flora, i.e. S. pneumonia, H. influenzae, M. catarrhalis, S. aureus

Complications:
Empyema of sinus (suppurative exudate)
Mucocele (mucinous secretions)

Question 31

What is chronic sinusitis and what are some complications?

Answer 31

Persistent sinusitis (>3 months)

Invasion into adjacent bone (osteomyelitis) and cranium (meningitis, abscess)

Question 32

What are the most common causes of viral pharyngitis / tonsillitis, and how is bacterial pharyngitis / tonsillitis generally grossly identified?

Answer 32

Viral - rhinovirus / adenovirus

bacterial - will have suppurative exudate in addition to the mucosal edema, erythema, and reactive enlargement of tonsils

Question 33

A patient comes in with a locally aggressive and destructive benign neoplasm of the nasopharynx causing epistaxis. Name and describe his condition, and what demographics he most likely is?

Answer 33

Nasopharyngeal angiofibroma (it is aggressive despite being benign)

Highly vascular neoplasm which causes profuse bleeding and has a high recurrence rate

Almost exclusively in adolescent males, especially with fair skin and red hair

Question 34

What typically causes nasopharyngeal carcinoma and who is it seen in?

Answer 34

Seen in African children and Chinese adults

Associated with EBV infection classically, also nitrosamines and tobacco / fumes

Question 35

What does nasopharyngeal carcinoma look like microscopically?

Answer 35

Appears like poorly differentiated squamous cell carcinoma (pleomorphic, keratin-positive), surrounded by lymphocytes (mostly T cells to fight EBV infection)

Question 36

What additional metastatic finding is usually found with nasopharyngeal carcinoma, and what usually correlates with prognosis?

Answer 36

Cervical lymph node involvement

Nonkeratinizing carcinomas fare much better than keratinizing, as tumor must be susceptible to radiation therapy

Question 37

What microbe is associated with laryngoepiglottitis in infants?

Answer 37

respiratory syncytial virus, also Beta-hemolytic strept

Question 38

What infection does a steeple sign on X-ray indicate probably? What are its symptoms?

Answer 38

Subglottic tracheal narrowing seen in laryngotracheobronchitis (croup)

• > caused by parainfluenza virus
• > seal-like, barking cough and inspiratory stridor

Question 39

What are reactive nodules on the vocal cords called? What are they composed of? What symptoms do they cause?

Answer 39

Usually bilateral -> called Singer’s nodules, from overuse

Composed of loose fibrovascular connective tissue covered by normal squamous epithelium

Will cause progressive hoarseness / voice changes

Question 40

What is a benign neoplasm of the vocal cords called, and what causes it?

Answer 40

Squamous papilloma -> caused by HPV 6 and 11

Question 41

How do squamous papillomas present different in adults vs children, and what do they look like?

Answer 41

Present as single in adults, but multiple in children

Look alot like genital warts but on vocal cords -> covered with stratified squamous epithelium. High recurrence rate.

Question 42

What are the risk factors for squamous cell carcinoma of the larynx?

Answer 42

Smoking with concurrent alcohol use are most common causes, but can result from HPV infection

Question 43

How does squamous cell carcinoma of the larynx differ from oral cavity in terms of course, and how does it present?

Answer 43

Larynx has a more linear progression from dysplasia -> carcinoma in situ

Oral cavity is more random

Presents with hoarseness, in middle-aged male smokers

Question 44

Where in the larynx does squamous cell carcinoma occur?

Answer 44

Can be supraglottic (above vocal folds), subglottic, or glottic (on vocal folds)

If glottic -> picked up earliest (causes most hoarseness)