Oral cavity Flashcards
What can you tell me about oral cavity
- GI starts from the oral cavity, never ignore oral cavity, sometimes the beginning of a problem may start from the oral cavity special related to teeth. In developing countries dental care is not a high priority. From young age must clean teeth to avoid gingivitis
- Second teeth are under the baby’s teeth so if child has antibiotics this may affect the teeth underneath.
- The periapical cyst granuloma abscess (in the second teeth) inflammatory process and bacteria can stay with us for years and when the immune system is low then this is when you may experience problems caused by the infection causing sepsis
- If the teeth are broken, they can injure the tongue and cause injury and healing and this can cause dysplasia.
- Artificial teeth cause problems as they atrophy the gums and the implants is a fixed junction to the bone and there are no ligaments so causes problems to the gum when chewing and some patients can’t accept the implant or its too expensive
- Therefore, taking into account the oral hygiene, artificial teeth, smocking you need to advice from young age to look after the teeth
- We have squamous cell neoplasia in the oral cavity, which is not good as resection is difficult as you don’t want to destroy the tongue, oral cavity is also an opening of the GI tract and respiratory system so you can’t just remove the mandibula and leave a gap in the face, therefore, operation is very difficult. The throat is close to the brain and so if you have malignant processes in the oral cavity it may metastasis to the surrounding located lymph nodes
What are the different types of salivary gland
Tumors of the Salivary Glands • Most of the salivary gland tumors are benign • Benign tumors of salivary gland are: 1. Pleomorphic adenoma (most common) 2. Warthin tumor
• Malignant tumour of the salivary glands are:
1. Mucoepidermoid Carcinoma
Pleomorphic adenoma (mixed tumor)
- This is a neoplastic tomour of parotid glands, less common of submandibular glands and rae of minor salivary glands
- Pleomorphic adenoma are usually benign but somtiems malignant
- Benign salivary gland tumour consisting of stroma and epithelial tissue (epithelial&mesechymal differentiation)
- Female dominant; commonly involves parotid gland (60%)
• Usually encapsulated but possibly not complelty
o Mix of
Salivary galnd epithelial cells
• May form dense cellular sheets or scattered duct like strucutes possibly keratinzied or make mucin
Myoepithelial cells
• Can be clear cell, spindle or plasmacytoid
Spindled stroma
• Maybe myxoid, cholndroid, hyalinized or raely ossesous
o Ratio of epithelial, myoepithelial, stromal cells varies widely
• Rare mitosis, no necrosis no perineural invasion
• A metastaszided mixed tumour is histologically identical but has metastaszied. May see petal shaped, tyrosine rich or oxalate crystals
• Morphology
o Gross:
slow¬ growing, discrete masses within the salivary gland
well-demarkared, rounded, up to 6 cm
Partly Encapsulated tongue-like protrusions
cut surface is gray-white with myxoid and blue translucent areas of chondroid tissue
o Histo:
Great heterogenity
Epithelial elements arranged into ducts formations, acini, irregular tubules, strands, or sheet of cells
• Epithelial cells (epithelial differentiation)
• Myoepithelial cells present (mesechymal diffferntiation)
stroma loose myxoid tissue containing islands of chondroid tissue, rarely foci of bones.
Epithelial, myoepithelial, stromal ratio varies
In most cases there is no cellular atypia or mitotic activity
- Clinical features: painless, movable mass
- Complication: can transform to adenocarcinomacarcinoma ex pleomorphic adenoma/malignant mixed tumour histologically identical but has metastasized; recurrence
Warthin Tumor (Papillary Cystadenoma Lymphomatosum)
• Benign cystic tumor with abundant lymphocytes and somrtimes germinal centers (lymph node-like stroma);
• 2nd most common tumor of the salivary gland
• Morphology:
• Gross:
o arises almost exclusively in parotid gland
o About 10% are multifocal and 10% bilateral
o Round to oval encapsulated masses 2 to 5 cm in diameter
o Gray surface punctuated by narrow cystic or cleft like spaces filled with mucinous or serous secretions
• Histologically:
o Spaces are lined by a double layer of neoplastic epithelial cells resting on a dense lymphoid stroma sometimes bearing germinal centers
Mucoepidermoid Carcinoma
- The most common malignant tumor of salivary gland
- Composed of squamous cells, mucus ¬secreting cells, and intermediate cells
- Large tumor (up to 8 cm in diameter), lack well defined capsules – ooften infiltrative at the margins.
- Microscopically - cords, sheets, or cystic configurations of squamous, mucous, or intermediate cells
- Prognosis is poor; 5 year survival = 50%
- Malignant tomours of the salivary gland, specially the tiny ones scattered in the oral cavity have poorly defined margins, recurrent, widely infiltrating difficult for surgery and well differentiated and so does not respond well to chemotherapy radiation
Oesophagus
- Oesophagus is a transmission pipe which is linked by the mucosa, none keratinised squamous cells, muscularis, propria and the fatty tissue and important organs surrounding it
- If we have pathology in the oesophagus which is transmural (existing or occurring across the entire wall of an organ or blood vessel.) in the oesophagus or during gastroscopy the oesophagus is perforated = problematic as can cause mediastinitis symptoms or death to the patient.
- Anatomy the oesophagus has three openings, but if there is burns due to inhalation of chemicals, gases etc these can cause narrowing of the oesophagus and operation is difficult as it is in the thorax and difficult to access
GERD (reflux esophagitis)
• Most common pathology of oesophagus = GERD (gastroesophageal reflux disease
• Gastroesophageal Reflux Disease (GERD) is a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the oesophagus. GERD affects people of all ages—from infants to older adults.
• Reflux disease = the acid in the stomach coming up effecting 1/3 of the lower oesophagus, patient has symptoms of burning pain behind sternum.
• Proton pump inhibitors can reduce the acidity – the higher the acidity of the stomach the higher the contraction of the sphincter is to not allows the acid to move to the oesophagus so by administrating proton pump inhibitors to reduce the acid – therefore, this effects the function of the sphincter and so its best to ask patient to alter eating habits rather than just treat with proton pump.
• Reflux disease is mostly present when the patient is lying down, so ask what time do you sleep and before you sleep you should not eat for 5 hours and avoid acidic food during the night
• However, you also need to see what is causing the acid reflux and it may require medication and won’t be fixed with altering patients diet e.g., helicobacter pylori can cause acid reflux and so needs to be treated
o So check the patients stool for helicobacter pylori
• Do not be so quick to decrease the acid in the stomach, the acid is healthy for digestion and kills the unwanted pathogens in the stomach
• GERD can also cause or bring about Barrett oesophagus
- Reflux of gastric contents (acid) into lower oesophagus, resulting in oesophageal irritation and inflammation
- Pathogenesis: transient LES relaxation; incompetent LES
- Gross: simple hyperaemia
- Histology: inflammatory cells in squamous epithelial layer; basal zone hyperplasia; elongation of lamina propria papillae; capillary congestion
- Clinical features: heartburn; atypical chest pain; dysphagia
- Complications: oesophageal ulceration; hematemesis; Barrett oesophagus
Barrett oesophagus
• We have metaplasia because the glandular epithelium of the stomach gastric type appears in the lower 1/3 of the oesophagus replaces the squamous non-keratinized cells. The non-keratinized squamous epithelium is more resilient than the fragile glandular epithelium and so may become damaged more easily by food during swallowing causing prolonged inflammatory process and eventually may lead to dysplasia and the Barret oesophagus may even develop into adenocarcinoma of the oesophagus
• However, If she asks about malignancy of oesophagus
o The number one malignancy of oesophagus is squamous cell carcinoma, the adenocarcinoma of the oesophagus is NOT the standard malignancy of the oesophagus.
Non-keratinized Squamous cell lines the oesophagus
o The adenocarcinoma of oesophagus is only secondary to Barrett oesophagus!!
o So never say that adenocarcinoma is the number one malignancy of oesophagus only say the squamous cell carcinoma is the number one malignancy of the oesophagus
• Intestinal metaplasia within the oesophageal stratified squamous mucosa
• complication of long-standing GERD
• Gross: patches of red velvety mucosa
• Histology: Replacement of normal stratified squamous epithelium by more resistant intestinal columnar epithelium (non-ciliated); mucin secreting goblet cells
o Dysplasia possible (low/high grade)
• Complication: oesophageal adenocarcinoma
• Diagnosis: endoscopy and biopsy
Squamous cell carcinoma
- Oesophageal epithelial malignant tumour
- Most common type of oesophageal carcinoma
- Male-dominant, >45 years
- Risk factors: smoking; alcohol; achalasia; caustic injury; hot beverages
- Location: 50% - middle 1/3 of oesophagus
- Morphology: Initially – in situ squamous dysplasia, small, Gray-white plaque; Eventually- polyploidy/exophytic tumour masses, luminal narrowing; moderately to well differentiated
- Clinical features: dysphagia; odynophagia; weight loss; haemorrhage and sepsis if tumour ulceration
- 5 year survival = 9% (v poor prognosis!)
Adenocarcinoma of oesophagus
- Malignant epithelial tumour with glandular differentiation
- More frequently in Caucasians; x7 >common in men
- Risk factors: Barrett oesophagus and long-standing GERD; Obesity; Tobacco; radiation; ↓fruit/veg
- Location: distal 1/3 of oesophagus; may invade gastric cardia
- Gross: flat/ raised patches, intact mucosa, ≥5cm
- Histologic types: 1) mucin producing, form glands - common 2) signet ring cell type 3) small poorly differentiated cells (rare)
- Signs and symptoms: pain; difficulty swallowing; weight loss; hematemesis; chest pain; vomiting
Mallory-Weiss Syndrome
- Longitudinal tears at gastro-oesophageal junction due to severe retching or vomiting
- Most common cause: alcoholism
- Morphology: Linear lacerations, few mm to several cms
- Up to 10% of upper GI bleeding cases
- presents as hematemesis
- Complication: boerhaave syndrome (distal oesophageal rupture)
Oesophageal tumours are?
mesenchymal origin; o types: 1. leiomyomas – most common 2. fibromas 3. Lipomas 4. haemangiomas
Malignant tumours:
• 2 types:
o Squamous cell carcinoma – most common type
o Adenocarcinoma
Oesophageal infections – fungal, viral, bacterial
• Normally the infections of the oesophagus are seen in patients that are immunocompromised e.g. undergoing chemotherapy, AIDs, prolong steroid therapy, starvation process
• Fungal infection is not seen as commonly specially in healthy people
• Polyps in the oesophagus like papilloma’s are not common in the oesophagus
• Oesophageal varices are popular = mainly seen in liver cirrhosis patients and as a result of liver cirrhosis these patients have portal hypertension and so blood finds new routes of transmission
o E.g. rectal varices, capdial mudusca on the abdominal cavity, and oesophagus varices
o Liver cirrhosis dominates in alcoholics but can also be found in HBV and HVC patients and sometimes due to dietary intake or addiction to drugs
Oesophageal varices
- Found in the lower 1/3 of the oesophagus
* Mainly seen in liver cirrhosis patients
Complications with oesophagus
- Surgery of the oesophagus due to malignancy of the oesophagus is very difficult as it is hard to know how many cm to cut out and sometimes you use a loop of the small intestine to restore parts of the oesophagus, this is done by pulling the part of the intestine up into the oesophagus so not to disturb the blood supply that already innervates the intestine, the two ends are joined together and allows food to pass through
- Malignancies developing in the oesophagus quickly cause losing weight because you have narrowing of the oesophagus making it difficult to eat and patient may avoid large solid meals and may change to soup, liquid and lowers the body weight
- At the end stage of malignancies, you have cachexia – which is wasting of the body caused by the malignant tumour switching on some process to increase metabolism e.g., secrets TNF tumour necrosis factor or I1 (interleukin 1). So, the TNF or I1 switches the metabolism from anabolism (building muscles or overeating causing build-up of adipose tissue) to catabolism (burning) – hence why malignant tumour patients lose a lot of weight
- In GI – even before reaching end stage of the malignancy the patient starts to loss weight due to difficulty in eating and switching to a liquid diet – effects the oesophagus and the stomach
- Therefore, need to ask the patient if they are losing weight and find out what the cause is for the weight loss to rule out malignant tumours
