Oral/Esophageal Path - Nelson Flashcards
Give me a name for heterotopic collections of sebaceous glands in the oral cavity:
Fordyce’s Granules
There should NOT be sebaceous glands there…
Patient presents to you with her third bout of small ulcers on the inside of her lower lip. They are painful, she says the last time they lasted just 2 weeks. She found out 3 weeks ago that she has inflammatory bowel disease.
Diagnosis?
Aphthous Ulcers (Canker sores)
May be associated with Inflammatory bowel disease or celiac disease
One of your pregnant patients presents to you with frequent nosebleeds. Upon nasal exam you see a very red polypoid (polyp-like) lesion composed of prolific capillaries on her anterior nasal septum. After examining her mouth you see another similar lesion on her gingiva.
What do you think doc?
Sounds like a pyogenic granuloma.
Usually occurs in children, young adults, and pregnant women. MOST often on gingiva.
(can occur in nasal septum and other areas too, but probably just concentrate on gingiva)
Remember: polyp-like, very red, and capillaries
A 10 year old patient presents with a beefy red tongue, weakness and pallor. Upon exam his reflexes are diminished in all four extremities, and he has tingling and some loss of sensation in his distal extremities.
His blood labs show megaloblastic anemia
6 months ago the patient had surgery for a bullet wound and his entire ilium was resected.
What is beefy red tongue in doctor talk? What could be causing this condition?
Beefy Red Tongue = glossitis
This is a case of B12 deficiency. The distal ilium is where you absorb most of your B12 (cobalamine).
Megaloblastic anemia is due to the inhibition of DNA synthesis (specifically purines and thymidine)
Neuro symptoms result because your body uses B12 to maintain the myelin sheath, etc.
Describe mucosal fibromas:
Any associations?
Reactive proliferation of squamous mucosa and subepithelial fibrous tissue
Typically secondary to chronic irritation
Patient presents in clinic with intermittent dysphagia with solids felt in the throat. He says he chokes occasionally while eating. His wife says she thinks he looks pale, he feels fatigued, and has had some dyspnea as well. Upon examining his mouth you notice striking glossitis. What are you thinking?
Plummer Vinson Syndrome
(Iron-deficinecy anemia + glossitis + esophageal webs)
Esophageal webs can cause dysphagia
Pallor, fatigue, and dyspnea are secondary to iron deficiency anemia. (bleed)
You look at a patient’s tongue and all you can think about is planning your next vacation because it looks like Europe. What condition is this? What causes it?
Geographic tongue
Focal loss of papillae causes the map-like appearance
Describe a squamous papilloma:
What does it look like?
Associations?
papillary proliferation of squamous mucosa.
Associated with HPV
or trauma and irritation
Describe the appearance of hairy leukoplakia, and its clinical significance:
- white confluent patches of fluffy hyperkeratosis
- lateral side of tongue
- can’t be scraped
- immune-compromised
- secondary to EBV infection
Tobacco user presents in clinic with:
- white patch in oral cavity
- can’t characterize as infection or something benigh
What is it?
Leukoplakia!
Pt presents with leukoplakic lesion of the outside lower lip. You notice that the normal vermillion border that demarcates the edge of the lip is no longer clear. Patient is a professional surfer. What is it?
Actinic cheilitis
Sun exposure is a risk factor
very similar to actinic keratosis, but on the lip
Which is more likely to have pre-cancerous dysplasia, leukoplakia or erythroplakia?
Erythroplakia
What would be the presentation of erythroplakia?
A red, velvety patch in the oral cavity.
Associated with carcinoma and microinvasive carcinoma
List the similar, key risk factors for the development of oral cavity, oropharyngeal, hypopharyngeal, and laryngeal squamous cell carcinoma:
Smoking and drinking are KEY
HPV - oropharyngeal
sunlight/pipe smoke - lower lip
**In oropharynx HPV+ patients do BETTER than HPV- Test with for over expressed p16
Nasopharyngeal squamous cell carcinoma is different than oral cavity, oropharyngeal, hypopharyngeal, and laryngeal squamous cell carcinomas because its main risk factor is:
EBV
Strongly associated
Why are inverted sinonasal papillomas more likely to recur than other sinonasal papillomas?
the inverted type arises from lateral nasal wall and is especially recurrent due to its inverted growth pattern
(word for word what he said).
You are an oncologist, you see a patient for the first time. Their family doc send them to you suspecting pharyngeal squamous cell carcinoma. What physical exam will help evaluate local metastasis? What should you monitor in terms of distal metastases?
Would this change for oral cavity SCC?
Local metastasis →
Check cervical neck LN’s.
Distant metastasis →
mediastinal Lymph nodes, lung, liver, bone
Check the same areas for metastases in oral cavity SCC
What is xerostomia?
What causes it?
Dry mouth and decreased saliva production.
Caused by Sjogrens, radiation treatment, or medications
What is the technical term for a salivary duct stone?
Sialolithiasis
What is the term for inflammation fot he salivary glands caused by trauma, infections, autoimmune disease of sialolithiasis?
Sialadenitis
Lymphoepithelial Sialadenitis (LESA) is an autoimmune disease involving the salivary glands.
What is the underlying pathology?
What similar conditions must be eliminated from the differential diagnosis.
- 50% of cases are salivary gland manifestations of Sjogrens Syndrome (affects salivary and lacrimal glands)
- Polyclonal lymphoid inflammation of gland leads to legion
Similar conditions:
>HIV-associated sialadenitis
>B-cell MALT lymphoma (primary lymphoma of salivary gland)
17 year old male comes into clinic very worried about painful cyst-like cavity on lower inner lip. He kissed a girl yesterday and is worried he caught something (cooties?). Upon further questioning, he does also remember accidently running his face into a sliding glass door this morning. What is your first thought? SHOULD HE BE WORRIED?
Mucocele
Don’t worry.
You are an oncologist again. A patient of yours has come in very concerned about progressive loss of eyesight. 10 years ago she had a couple minor salivary gland tumors removed. Without looking at the medical chart, what kind of salivary tumor do you think it was?
adenoid cystic carcinoma
These tumors are slow-growing and can occur in major or minor salivary glands.
The key to this presentation is that they have a predilection for neural invasion! This patient probably has a metastasis to her optic nerves.
Low long-term survival.
Patient is forced into clinic by his wife because she is concerned about a mass that has been slowly growing on the side of his face below the jaw angle. On biopsy the pathologist reports a MIX of proliferating cells associated with myxoid, hyaline, and chrondoid tissue.
Name that tumor!
Pleomorphic adenoma
An 8 year old child presents with a growing mass under the angle of the jaw. There is a mix of squamous, mucous, and intermediate cells on the biopsy. What do you think?
Mucoepidermoid Carcinoma
most common is kids
50 yr old female smoker presents with enlarged parotid salivary gland. Morphologically the tumor consists of well-encapsulated papillary, cytic lesion. Has dual layer of bland eosinophilic epithelium.
Name that tumor!
Warthin tumor
State the most common benign and the most common malignant salivary gland tumors
Salivary gland neoplasms are uncommon and represent less than 2% of all tumors.
Pleomorphic Adenoma (mixed): Most common benign salivary gland tumor; usually found in the parotid gland
Mucoepidermoid carcinoma: Most common malignant salivary gland tumor in adults and children. Approximately 60-70% occur in the parotid gland.
Which salivary gland is most often involved by salivary gland neoplasms?
65-85% arise in the parotid gland (15-30% malignant),
10% in the submandibular gland (40% are malignant)
Rest in the minor salivary glands or sublingual gland
Most of the tumors arise in adults.
What is esophageal stenosis?
How do people acquire it?
Narrowing or tightening of esophagus, causes swallowing difficulties.
Can be congenital, but usually it is caused by GERD, irradiation, or caustic injury
What is the difference between esophageal mucosal webs and esophageal (Schatzki) rings?
Webs:
- protrusions of mucosa
- usually upper esophagus
- can be associated with Plummer Vinson Syndrome
Rings:
- thicker than webs and circumferential
- can contain muscularis propria
- usually lower esophagus
Female patient arrives in ER at 5am very anxious and very obviously intoxicated. She said it’s her 21st birthday and she just spent the last hour vomiting. She is scared because she vomited out some blood.
Dx?
Mallory-Weiss Syndrome
You may not even need to scope with such a perfect hx.
Longitudinal lacerations of distal esophagus and proximal stomach associated with severe retching or vomiting.
A patient comes into your Gi clinic with painful swallowing, halitosis, and regurgitation. You send her for a swallow study and see with imaging that ingested material is getting caught in an abnormal pouch just above the upper esophageal sphincter.
What’s going on Doc?
Sounds like Zenker’s Diverticulum.
Not a TRUE diverticulum.
This outpouching of mucosa and submucosa through a weakened posterior cricopharyngeus muscle located above the upper esophageal sphincter can become large enough to accumulate food, producing a mass and these symptoms
Define hiatal hernia, and describe the most common type.
Hiatal hernia: results from separation of the diaphragmatic crura and protrusion of the stomach into the thorax through the defect
Can be congenital, but most are acquired later in life (50% of adults over 50 have hiatal hernia); 10% of patients, get symptoms similar to GERD with inflammation, ulceration, stricture, and hematemesis
95% of hiatal hernias are of the sliding type (Type 1). The herniated part of stomach follows the esophagus rather than another part of the stomach just pouching out on its own adjacently.
List the three most common types of infectious esophagitis that can occur in
immunocompromised patients.
(1) Candida
(2) Herpessimplex
(3) Cytomegalovirus(CMV)
Describe the suspected pathogenic mechanism, microscopic appearance, and clinical presentation of eosinophilic esophagitis.
Clinical presentation:
- Adults and teenagers may present with food impaction, persistent dysphagia, or GERD symptoms that fail to respond to medical therapy
- Children can present with feeding disorders, vomiting, abdominal pain, dysphagia, and food impaction.
Pathogenic mechanism:
-Disorder thought to be food allergy (many patients have allergic rhinitis, atopic dermatitis, or asthma).
Microscopic appearance:
-Esophageal biopsies show greatly increased eosinophilic inflammation with basal epithelial hyperplasia, in the absence of acute inflammation.
Define Barrett’s esophagus and state the major complication of this disorder.
-Conversion of normal squamous mucosa of esophagus to metaplastic columnar epithelium
(AKA intestinal metaplasia)
-Why are all these goblet cells here??? (abnormal for esophagus)
-As a result of GERD
-Major complication is increased risk of esophageal glandular dysplasia and adenocarcinoma
Where are adenocarcinomas located int he esophagus?
distal 1/3
State the most common cause of esophageal squamous papillomas, and the most common benign mesenchymal tumor of the esophagus.
Squamous papilloma:
benign squamous neoplasm, usually exophytic, strong association with HPV.
Leiomyoma: most common benign mesenchymal tumor of the esophagus
What are the risk factors for esophageal adenocarcinoma?
95% arise from background of barret’s esophagus.
Progression occurs with stepwise acquisition of genetic and epigenetic changes
How might a patient with adenocarcinoma present?
- odynophagia
- hematemesis
- angina pectoris
- progressive weight loss
What are the risk factors for esophageal squamous cell carcinoma?
- Alcohol and tobacco use
- Caustic injury to esophagus
- Achalasia
- Tylosis (genetic disorder characterized by thickening of the palms and soles)
- Plummer Vinson
- Very Hot beverage consumption
What is achalasia?
Muscles of lower esophagus fail to relax and allow material into the stomach.
