Oral & Esophageal Pathology

Question 1

What are aphthous ulcers? What do they look like? How common are they?

Answer 1

• AKA canker sores
• recurrent, painful ulcerations of the superficial mucosa of the oral cavity
• look for a grayish base surrounded by erythema
• quite common: 40% of population

Question 2

Which infectious agent is responsible for most orofacial infections? How do patients usually present? Where is the agent found?

Answer 2

• HSV-1 (herpes simplex virus 1)
• primary infections are usually asymptomatic, but 10-20% manifest as acute herpetic gingivostomatitis
• reactivation of the latent virus results in recurrent herpetic stomatitis (cold sores)
• the virus remains dormant in the ganglia of the trigeminal nerve

Question 3

What agent is responsible for oral candidiasis/thrush? When does it occur?

Answer 3

• Candida albicans (fungi)

- C. albicans is a normal component of oral flora; thrush occurs with immunosuppression

Question 4

What is Behcet syndrome? What is it a result of?

Answer 4

• recurrent aphthous ulcers, genital ulcers, and uveitis

- it’s due to immune complex vasculitis of small vessels

Question 5

What is leukoplakia? Erythroplakia? Which is associated with increased risk of malignancy? What is the most common risk factor for each?

Answer 5

• leukoplakia: white plaque that can NOT be scraped off (where as thrush can)
• erythroplakia: a red flat/depressed lesion (it’s essentially vascularized leukoplakia)
• both increase risk for cancer, but erythroplakia has a much greater risk
• tobacco is major risk factor for both

Question 6

What is the most common type of oral cancers? What prognosis is associated with it? What are the two pathogenic pathways?

Answer 6

• squamous cell carcinoma (95%)
• poor prognosis (less than 50% survival rate)
• 2 pathways: chronic alcohol and tobacco intake (lesions develop in oral cavity, usually the floor of the mouth) OR oncogenic HPV-16 (lesions develop in tonsillar crypts or base of the tongue)

Question 7

What is xerostomia? What is a common cause? What pathology is it highly associated with? What does it increase the risk for?

Answer 7

• “dry mouth”; decreased production of saliva
• a common side effect of radiation therapy and many medications
• xerostomia is a major feature of the autoimmune disease Sjorgen syndrome
• increaes risk of candidiasis, cavities, dysphagia, difficult speaking

Question 8

What is sialadenitis? What are three major causes? What’s the major risk factor?

Answer 8

• inflammation of the salivary glands
• autoimmune (Sjorgen syndrome), mumps (viral, mainly affects parotids), and S. aureus and/or S. viridans (bacteria, mainly affects submandibulars)
• major risk factor is obstruction via sialolithiasis

Question 9

What are some major characteristics of mumps? What are some major complications?

Answer 9

• classic bilateral involvement of the parotids, elevated serum amylase (can be BOTH salivary and pancreatic)
• complications: orchitis (infection of testicles) + sterility, pancreatitis, aseptic meningitis

Question 10

Which salivary glands are most commonly involved in neoplastic growth? What is the most common benign lesion? Malignant lesion? What’s a major potential complication?

Answer 10

• parotids are most commonly involved (however, the sublingual glands are involved in most malignant cases)
• benign: pleomorphic adenoma
• malignant: mucoepidermoid carcinoma
• complication: facial nerve involvement

Question 11

Pleomorphic Adenoma vs. Mucoepidermoid Carcinoma

Answer 11

• pleomorphic adenoma: benign, contains stromal and epithelial tissue (biphasic)
• mucoepidermoid carcinoma: malignant, contains mucinous and squamos cells
• both usually develop in parotid

Question 12

Achalasia; What three things characterize it? What’s a primary cause? A secondary cause?

Answer 12

• triad of incomplete lower esophageal sphincter (LES) relaxation, increased LES tone, and lack of esophageal peristalsis
• primary cause: idiopathic degeneration of neural innervation
• secondary: Chagas disease (Trypanosoma cruzi destroys the myenteric plexus of the esophagus)
• increases risk for SCC

Question 13

How do patients with achalasia commonly present? What differs from a patient with only obstruction?

Answer 13

• dysphagia with both solids and liquids, halitosis (putrid breath from rotting caught food), “bird’s beak” sign on barium swallow (dilated esophagus due food/pressure build up with an area of distal stenosis)
• obstruction: dysphagia of only solids

Question 14

What is the most common esophageal laceration? What is it caused by?

Answer 14

• Mallory-Weiss tears: longitudinal lacerations along the gastro-esophageal junction
• associated with severe retching (alcoholics and bulimics) and resulting painful hematemesis
• the tears tend to be superficial and heal rapidly (and are quite benign)

Question 15

Catastrophic esophageal lacerations are known as:

Answer 15

• Boerhaave syndome: transmural tears; a surgical emergency

Question 16

What is the most common cause of esohphagitis? What are some other causes?

Answer 16

• gastro-esophageal reflux disease (GERD)
• results from a decrease in LES tone and/or an increase in gastric/abdominal pressure
• other causes: Candida (white pseudomembrane), HSV-1 (punched-out ulcers), CMV (linear ulcers), chemical ingestion

Question 17

Barrett Esophagus

Answer 17

• a complication of chronic GERD (occurs in the distal esophagus)
• intestinal metaplasia within the esophageal squamous mucosa (stratified nonkeratinized squamous epithelium replaced with nonciliated columnar epithelium with goblet cells)
• increases risk for esophageal adenocarcinoma

Question 18

What is a tracheo-esophageal fistula? What are the major clinical findings?

Answer 18

• abnormal connection between the trachea and esophagus due to a congenital defect
• several variations; most common: proximal esophageal atresia with the distal esophagus coming off of the trachea
• clinical findings: poly-hydramnios (due to inability to digest amniotic fluid), vomiting, abdominal distension with gas (air is easily swallowed), aspiration

Question 19

What is an esophageal web? What part of the esophagus is usually involved? What are some complications? Which syndrome is it associated with?

Answer 19

• protrusion of the mucosa into the lumen, resulting in obstruction
• commonly affects the upper 1/3 of the esophagus
• leads to dysphagia, increased risk for SCC
• associated with Plummer-Vinson syndrome: triad of dysphagia due to esophageal web, iron deficiency anemia, and glossitis (beefy-red tongue)

Question 20

Which diverticulum is found in the esophagus? Is it a true or false diverticulum? Where does it usually develop? How do patients commonly present?

Answer 20

• Zenker diverticulum
• a false diverticulum (only the mucosa enters the muscular wall)
• develops above the upper esophageal sphincter (at the junction of the pharynx and esophagus; the Killian triangle)
• patients present with dysphagia, obstruction, halitosis (rotting, trapped food)
• increased risk of SCC

Question 21

What are the two types of esophageal carcinoma? Where does each type commonly develop? Which is most common in the Western world? World-wide?

Answer 21

• adenocarcinoma (requries metaplasia, Barrett esophagus) and squamous cell carcinoma
• AC: occurs in the lower 1/3, most common in the western world
• SCC: occurs in the upper 2/3, most common world-wide

Question 22

Risk Factors for Esophageal Carcinoma

Answer 22

• AABCDEFFGH
• achalsia, alcohol (SCC), Barrett esophagus (AC), cigarettes, diverticula (SCC), esophageal web (SCC), familial, fat (obesity, AC), GERD (AC), hot liquids (SCC)
• (achalsia, diverticula, and esophageal web involve rotting foods, which are irritants)