Oral Cavity and Sinuses

Question 1

Candidiasis (moniliasis, thrush): location, presentation, who

Answer 1

• oral
• white patch clinically, easily removed by scraping
• diabetes or immunocompromised associated

Question 2

Tumor-like conditions

Answer 2

• pyogenic granuloma/lobular capillary hemangioma

- mucoceles

Question 3

Pyogenic granuloma/lobular capillary hemangioma

Answer 3

• benign reactive process
• nodular growth on the mucosal surface
• not a granulomatous process*

Question 4

Mucoceles

Answer 4

• obstruction of oral mucosa mucous glands
• leads to inflammation
• caused by trauma
• cystic dilation of ducts filled with mucin

Question 5

Potentially premalignant lesions

Answer 5

• leukoplakia (white patch)

- erythroplasia (red patch)

Question 6

Leukoplakia (white patch)

Answer 6

• can be benign or dysplastic/carcinoma
• cannot be removed by scraping
• irritation, inflammation can cause leukoplakia reaction
• must always be considered potentially pre cancerous unless proven otherwise (malignancy 1-15%)

Question 7

Erythroplakia (red patch)

Answer 7

• more likely to be associated with malignancy, up to 50%

Question 8

Leukoplakia (white patch): histology of benign disease

Answer 8

• hyperkeratosis
• mucosal epithelial hyperplasia
• orderly maturation
• no distortion of architectural order

Question 9

Leukoplakia or erythroplakia with severe dysplasia

Answer 9

• architectural disorder
• nuclear irregularity
• nuclear pleomorphism

Question 10

Squamous carcinoma of lip/skin: etiology, survival, differentiation

Answer 10

• etiology: sun (UV)
• survival: best
• differentiation: well

Question 11

Squamous carcinoma: floor of mouth, anterior tongue, hard palate: etiology, survival, differentiation

Answer 11

• etiology: ETOH, smoking
• survival: intermediate, poor
• differentiation: variable

Question 12

Squamous carcinoma of oropharynx: etiology, survival, differentiation

Answer 12

• etiology: HPV
• survival: favorable
• differentiation: variable

Question 13

Result of oropharyngeal cancer being associated with HPV

Answer 13

• better survival than non-HPV associated carcinomas

- nearly exclusively seen in men

Question 14

Oral cavity/oropharyngeal squamous carcinoma: treatment

Answer 14

• surgical: surgical margins guided by intra operative frozen sections
• post op radiation/chemoradiation given for metastatic or incompletely resected tumor

Question 15

Salivary gland sialadenitis

Answer 15

• acute and chronic forms

- can be secondary to obstruction of a major excretory duct

Question 16

Chronic sialadenitis

Answer 16

• duct obstruction–inflammation–tissue destruction: acinic atrophy, ductal metaplasia, duct dilation, chronic inflammation (lymphocytes), fibrosis (few cells)

Question 17

Autoimmune sialadenitis

Answer 17

• sjogren’s syndrome

Question 18

Sjogren’s syndrome

Answer 18

• autoimmune multi organ process
• affects lacrimal and salivary glands
• dry eyes, dry mouth
• pathologic finding: lympho-plasmacytic infiltration

Question 19

Sjogren’s syndrome: histologic finding

Answer 19

• inflammatory FOCUS

Question 20

Salivary gland tumors: general info

Answer 20

• uncommon
• large number of types of tumors
• major glands: parotid, submandibular, sublingual
• parotid gland: 85% of salivary gland tumors

Question 21

Salivary gland tumors: facts

Answer 21

• 65-80% of parotid tumors are benign
• smaller the gland, more likely the tumor will be malignant
• most salivary gland tumors are slow growing
• all salivary gland tumors are treated primarily by surgical removal

Question 22

Benign salivary tumors

Answer 22

• pleomorphic adenoma

- warthin’s tumor (papillary cystadenoma lymphomatosum)

Question 23

Pleomorphic adenoma: frequency, sit

Answer 23

• frequency: most common tumor

- site: usually parotid, may occur in any salivary gland

Question 24

Pleomorphic adenoma: cell involvement

Answer 24

• mixed tumor: epithelial cells (ducts, acini); mesenchymal cells (myoepithelial, chondroid, myxoid)

Question 25

Salivary gland tumors: treatment

Answer 25

- total excision of parotid gland hampered by facial nerve (separates superficial and deep lobes) - most pleomorphic adenomas occur in superficial lobe - facial nerve at risk of surgical treatment of histologically benign process

Question 26

Pleomorphic adenoma: behavior

Answer 26

- conservative surgical therapy, recurrence if not completely removed - rarely, epithelial or both epithelial/mesenchymal cells become malignant

Question 27

Pleomorphic adenoma: malignant transformation

Answer 27

- carcinoma ex pleomorphic adenoma: epithelial malignancy | - carcinosarcoma: epithelial & mesenchymal malignancy

Question 28

Warthin's tumor (papillary cytadenoma lymphomatosum): frequency, site, microscopic, behavior

Answer 28

- frequency: second most common salivary gland tumor, older population usually men SMOKERS - site: parotid, maybe bilateral; arise from epithelial cells in parotid LNs - microscopic: epithelial (oncocytes) overlie lymphoid follicles - behavior: no recurrence but may have multiple or new tumors

Question 29

Herpetic stomatitis (cold sore)

Answer 29

- HSV type I - oral cavity, lips - virus survives in dormant state in nerves - can become more extensive with involvement of brain in immunosuppressed patients

Question 30

Malignant salivary gland tumors

Answer 30

- mucoepidermoid carcinoma - adenoid cystic carcinoma - acinic cell carcinoma

Question 31

Mucoepidermoid carcinoma: site, microscopic

Answer 31

- site: parotid & minor salivary glands | - microscopic: mucus cells & squamous epithelial cells

Question 32

Mucoepidermoid carcinoma: how to tell it involves squamous cells

Answer 32

- intercellular bridges

Question 33

Mucoepidermoid carcinoma: special stain

Answer 33

- mucicarmine stain: stains for mucus

Question 34

Mucoepidermoid carcinoma: differentiation epithelial cell atypia

Answer 34

- high epithelial cell atypia = high grade tumor

Question 35

Mucoepidermoid carcinoma: behavior

Answer 35

- depends on degree of differentiation | - low grade >90%, 5 years; high grade 20-40%, 5 years

Question 36

Adenoid cystic carcinoma: site, microscopic, behavior

Answer 36

- site: major and minor gland, myoepithelial cells participate - microscopic: cribiform pattern, "swiss cheese", **perineural invasion** - behavior: indolent course often marked by recurrence

Question 37

Adenoid cystic carcinoma: treatment

Answer 37

- surgical removal, with attention to free margins and negative margins of nerves - indolent course marked by recurrence, tumor is often fatal, but fatalities may occur 15-20 years after initial presentation * **recurrences related to PERINEURAL invasion***

Question 38

Acinic cell carcinoma: site, microscopic

Answer 38

- site: parotid | - microscopic: recreates salivary gland acinus

Question 39

Acinic cell carcinoma: histological features

Answer 39

- no duct structures | - Zymogen granules

Question 40

Acinic cell carcinoma: treatment, behavior

Answer 40

- treatment: surgical removal, attention to free margins | - behavior: slow growing, 80-90% 5 years

Question 41

Paranasal sinus: inflammatory reaction

Answer 41

- allergic rhinitis

Question 42

Allergic rhinitis (hay fever)

Answer 42

- many allergens responsible, pollens - IgE mediated - repeated exposure--thick mucosa, nasal/sinus polyps

Question 43

Nasal sinus - fungal diseases

Answer 43

- invasive fungal sinusitis - allergic fungal sinusitis - fungus ball

Question 44

Invasive fungal sinusitis

Answer 44

- aspergillus or mucorales (BAD) species - seen in immunocompromised, hematologic malgnancies, diabetic ketoacidosis - vascular invasion by fungi common resulting in necrosis and hemorrhage

Question 45

Invasive fungal sinusitis: course, treatment

Answer 45

- course: fatal infection many times b/c of extension into brain - treatment: immediate surgical removal of infected tissue

Question 46

Allergic fungal sinusitis: definition, presentation, histology

Answer 46

- altered immune response to fungal agents (atopic) - rhinorrhea, pressure in sinus, headaches - histology: mucin, EOSINOPHILS, degenerated epithelial cells

Question 47

Allergic fungal sinusitis: organisms

Answer 47

- Aspergillus | - Dematiaceous: alternaria, bipolaris, curvularia (ABC-D)

Question 48

Fungus ball

Answer 48

- unilateral sinus obstruction and pain - masses of fungal organisms in sinus (aspergillus species) - treatment: removal of fungal mass