3/19/2014

Lesions of the Oral Cavity

Jason C. Fowler, MPAS, PA‐C Meadville ENT – Meadville, PA

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Disclosures

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Learning Objectives

• Identify common oral cavity , lesions and illnesses, as well as form a • Select appropriate testing based on the history and physical findings • Develop a medical management plan including referral and follow up as necessary

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

1 3/19/2014

Lesions of the Oral Cavity

Head and Neck Anatomy Oral Cavity: • Functions: respiration, digestion, , taste • External components (vestibule) – , – vermillion border, / philtrum • Internal components – – (hard / soft) – buccal mucosa, – Gingiva / alveolar ridges – major salivary ducts

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Anterior view of the Oral Cavity

www..gov

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Anatomy of the Tongue

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

2 3/19/2014

Clinical History • Important factors to consider – Age and gender – Constitutional symptoms: e.g. Weight loss, , night sweats – Duration of symptoms – Co-morbid medical conditions: e.g Immunocompromise – Environmental risk factors (ETOH / TOBACCO) – Dysphagia / Odynophagia / hemoptysis / Halitosis – Respiratory distress / Shortness of Breath • Duration of symotoms – : usually < 7 days – suggests inflammatory – Chronic: present for years, often asymptomatic – suggests congenital – Recurrent: multiple x per year, often painful – suggests infectious / autoimmune / nutritional – Weeks: months, +/- painful – suggests possible neoplastic process • – Need to localize and quantify as accurately as possible. Malignancy may often be masked by low degree of pain – REFERRED PAIN – unilateral ear pain with a normal ear exam should raise suspicion for oropharyngeal or laryngeal malignancy, especially in patients with social risk factors such as alcohol and tobacco

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral cavity –Basic Anatomy

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Normal Anatomy

Gingiva

Gingival‐labial fold

Soft palate and uvula

Frenulum RM T

Submandibular duct

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

3 3/19/2014

Physical Exam of the Oral Cavity

• Extra‐oral exam – Carefully exam the skin and symmetry of the head / neck – Examination of lymphatic zones in the neck – Palpation of parotid and submandibular glands • Intra‐oral Exam *MUST REMOVE DENTURES!!!* – Start with vestibule and upper / lower lips – Buccal mucosa (including parotid ducts) and alveolar ridge – Retromolar trigone – Tongue –dorsal / ventral and lateral – Floor or (incl. submandibular ducts) *BIMANUAL PALPATION* – Hard / and uvula – Palpate tonsillar fossae and base of tongue

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Examination of the oral Cavity

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral Cavity Exam cont.

Palpation of Left Base Of Tongue and Left tonsil

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

4 3/19/2014

Floor Of Mouth exam with bimanual palpation

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Ulcerative Lesions of the Oral Cavity

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Stomatitis – defined as of the mouth with or without ulceration

• Oral Causes • Systemic Causes – Poor hygiene – – Poor fitting dentures • Viral – Trauma (hot foods, • Fungal chemicals) • Bacterial – Ingested toxins – Drug reactions – Allergic reactions – / Radiation Gingivostomatitis – when inflammation – Nutritional deficiencies also affects the gingiva

Mucositis – not to be used interchangeably, as this refers to systemic mucosal often as a result of chemo / RT

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

5 3/19/2014

Examples of Severe

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Evaluating Stomatitis and Oral Ulcers

• Questions to Consider: – Acute or chronic process – Single or multiple lesions – Location of lesion(s) Aphthous of hard palate – Duration of symptoms – Associated pain or prodrome of pain? Fowler 2014 – Systemic symptoms or mucocutaneous lesions elsewhere? – – Timing of symptoms – i.e., triggers

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Systemic associated with oral ulcers

Fowler 2014

Preeti et al. J Oral Maxillofac Pathol. 2011 Sep‐Dec; 15(3): 252–256 –with permission

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

6 3/19/2014

Common Forms of Stomatitis

• Aphthous • Viral – Herpetic – – Zoster • Fungal – Angular Chelitis – Diffuse oral (“Thrush”)

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Recurrent

• A.k.a. Canker Sores • Affect 30‐35% of the population Equal age / gender distribution • Last 10‐30 days on average • Vary in size and shape – Minor: 80% <1cm heal without scarring – Major: >1cm often associated with delayed healing and scarring • Clinical features – White‐gray ulceration with erythematous halo, occasionally with fibrinopurulent – Buccal, labial, soft palate, FOM, lateral / ventral tongue • Treatment aimed at pain reduction and promoting healing – Topical/ systemic (Kenalog in Orabase, prednisolone liquid) – Topical pain relief (2% viscous ) – Identifying systemic triggers (e.g., nutritional deficiency or systemic disease)

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Treatment of Aphthous Stomatitis

Preeti et al. J Oral Maxillofac Pathol. 2011 Sep‐Dec; 15(3): 252–256 –with permission

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

7 3/19/2014

Many types of “Magic Mouthwash”

• 80ml each: • Other preparations may – Nystatin 100,000U suspension include: Sucralfate (coating – Prednisolone 15mg / 5ml agent), erythromycin or solution tetracycline – Benadryl 12.5mg / 5ml elixir • Need to be aware of potential – Maalox drug interactions / side effects – 2% viscous lidocaine – Distilled H2O

• Sig: 10ml swish, gargle, spit q 6hr as needed. • BMX –variant with only lidocaine, Maalox and benadryl

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Aphthous Stomatitis • Work‐up for recurrent ulcerative stomatitis may include – CBC – ESR / CRP – Iron studies – B12 titiers – SS‐A / SS‐B, autoimmune studies – Glucose levels – Thyroid function – HSV titers – HIV

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oro‐labial (HSV‐1)

• DNA transmitted via saliva • Up to 90% of adults are have to HSV‐1 • Increase prevalence with age • Associated with lower socioeconomic status • Clinical: may have , lymphadenopathy, fatigue with multiple painful mucosal ulcers • May have prodrome of pain / burning

• Treatment with topical / Fowler 2014 systemic antivirals

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

8 3/19/2014

Oro‐labial HSV1

• Ulcerated vesicles often in groups • Typically found on keratinized mucosa – Lips – Gingiva – Hard palate

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Treatment of Primary HSV‐1 Acyclovir 400 mg Sig: 400mg PO TID x 7‐10 days

Famvir 250 mg Sig: 250mg PO TID x 7‐10 days (recurrence = 1000mg PO x 1d)

Treat early; meds are no help after day 5 or 6.

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Treatment of recurrent oro‐labial HSV‐1

Topical Therapy: Systemic Therapy:

• Acyclovir 5%ointment • RX: Valacyclovir 1 gm (Zovirax) (Valtrex) Disp: 15 gm • RX: 500 mg Sig: Apply hourly at sx (Famvir) onset • RX: Acyclovir 400mg • Pencyclovir 1% cream (Zovirax) (Denavir) Disp: 2 gm Sig: Apply every 2 hrs for 4 days • Give multiple refills

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

9 3/19/2014

Herpangina

• Not as common as Herpetic lesions of the oral cavity • • Typically multiple small ulcers on palate • May have single larger ulcerations or bullae • ‐‐Mouth Disease if similar eruptions on hand and feet • Usually self‐limited within 10 days

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Herpes Zoster /

• May present as clusters of vesicular ulcers in a dermatomal‐ like distribution • Varizella‐Zoster virus (Human Herpes Virus HHV‐3) • May have prodrome of burning or itching mimicking pain • Post‐herpetic may linger for a month or more after resolution of oral ulcerations • Antiviral tx within 48‐72 hours of treatment • Vaccination booster over 60 yrs if not contraindicated

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral Candidiasis

• Most common fungal infection of oral cavity. Detected in 55% of healthy individuals – Very young / elderly common • Dependent on host immune status – DM, HIV, pregnancy, chemo / RT – Pulmonary inhalers (eg Advair) • Usually mild‐self limiting with recurrent infections necessitating underlying disease • Treat with topical / systemic antifungal therapy

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

10 3/19/2014

Oral Candidiasis

Severe ulcerative candidiasis due to Diffuse candidiasis after extended inhaled use antibiotic therapy for pneumonia

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Angular / Candidiasis

• Oral candidal infection of the corner of the mouth often seen in denture wearers • Can also be seen with s. aureus infection, nutritional deficiency, , Sjogrens, and Crohns disease • Treatment usually directed topically at fungal source: – Nystatin – Clotrimazole – Ketaconazole – Amphoteracin B • Culture if failure to resolve • Search for systemic source

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Median Rhomboid • Candidal infection that generally manifests as a denuded area of erythematous mucosa on the dorsal tongue usually anterior to the circumvallate papillae • Often an incidental finding • Treatment if symptomatic is with topical anti‐fungals – Nystatin – Clotrimazole • Patients with pain, dysphagia or otalgia would warrant a Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

11 3/19/2014

Geographic Tongue • Benign inflammatory condition of unknown etiology. • Characterized by areas of atrophic erythematous mucosa • Up to 15% of adults F>M 2:1 • Often asymptomatic and self‐limited • Treatment directed at symptomatic relief and judicious use of topical corticosteroids

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Geographic Tongue

a.k.a. Benign Migratory Glossitis

Images courtesy of Jose Mercado, PA‐C 2011

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Hairy Tongue • Results from failure of the filiform papillae to desquamate • Precipitating factors: – poor – Medications – xerostomia (head / neck RT, Sjogrens) • Roughly 0.5% of adult population • Treatment is scraping or brushing of the tongue in order to denude the papillae Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

12 3/19/2014

Torus Mandibularis

• Dense bony outgrowth usually along the inner table of the • Most often near premolars • 90% bilateral • More common in Asians • Etiology not clearly understand • Can be susceptible for overlying ulcers • Can be problematic with denture fitting

• Excision not often helpful, although Fowler 2014 laser excision a possibility

Rocca et al. YAG Laser: A New Technical Approach to Remove and . Case Rep Dent. June 2012; online.

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Torus Palatinus

• Bony protrusion of the palate • Usually less than 2cm, but can fluctuate in size • Almost always midline • More common in Asians

/ Inuits Fowler 2014 – 20‐35% in US • 2x more common in females • Denture fitting can be problematic and necessitate excision

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Ankyloglossia “tongue tie” • Tethering of the anterior tongue tip due to thickened frenulum • Incidence ranges from <1% to 10%, depending on criteria for diagnosis* • Associated with: – breast feeding difficulties (up to 25%)** – speech / language difficulty – Tongue mobility issues • Treatment: Frenotomy, Fowler 2014 speech

*Mueller DT, Callanan VP. Congenital malformations of the oral cavity. Otolaryngol Clin North Am. 2007;40(1):141.

**Messner, (2000). ": Incidence and associated feeding difficulties". Archives of otolaryngology—head & neck 126 (1): 36–9

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

13 3/19/2014

Oral Cavity • Most common “tumor” or • Localized growth of fibrous tissue in response to chronic trauma / irritation – Buccal mucosa, lateral tongue • F>M 2:1 30‐50 years • Often painless / asymptomatic • Local excision

• May recur if persistent Fowler 2014 trauma – i.e., poorly fitting dentures

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Pyogenic granuloma (lobular capillary )

• Benign hemangioma of the oral cavity characterized by histologic Fowler 2014 arrangement of vessels (lobular) • All ages with = gender distribution – Increase incidence in pregnancy • Lips, gingiva, cheek and tongue • Non‐painful but may bleed easily • Conservative local excision curative – Pregnancy‐induced tend to regress following delivery Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Squamous Papilloma

• ‐like growth consisting of squamous mucosa in an exophytic pattern • Most common benign “” in the oral cavity • Strong assoc with HPV 6‐11 • Benign with little potential to progress to malignancy • M>F (slight), W>AA (slight) 30‐50 yrs • Local excision or laser Fowler 2014 usually curative

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

14 3/19/2014

Squamous Papilloma –Soft Palate

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Pharyngitis • Defined as infection and or irritation of and tonsils • Majority of cases are viral and self –limited, however most bacterial cases are due to Group A streptococci . Candida also a possibility • Delayed use of antibiotics is encouraged. – Judicious use of antibiotic treatment reduces risk of complications and need for re‐evaluation / retreatment * – Most cases will resolve spontaneously

* Little P et al. Antibiotic prescription strategies for acute : a prospective observational cohort study. Lancet Infect Dis. Jan 16 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Pharyngitis Pearls

• Group A strep (GAS) most common in 4‐7 yo age range – 14‐30% of pharyngitis in school‐ aged children* – Only 10% of adult pharyngitis is GAS* • Sudden onset more likely GAS • Cough generally NOT assoc with GAS • and vomiting are more consistent with GAS than a viral etiology • Recent orogenital contact may suggest gonococcal source

*Alcaide AL, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2006

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

15 3/19/2014

CENTOR Criteria for GAS Pharyngitis

• 4 catergories worth 1 point each – Fever – Absence of cough – Tonsillar exudate – Tender cervical adenopathy

• 0‐1 makes diagnosis likely, with 4 being likely • Positive predictive values of 40% and 50% for scores of 3 and 4, respectively • Validity is often conflicting

Roggen et al. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open. 2013 Apr 22;3(4).

Fine et al. Large Scale Validation of the Centor and McIssac scores to predict group A streptococcus. Arch Intern Med. 2012 June 11, 172 (11): 847‐52.

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Treatment of GAS Pharyngitis • Most cases resolve within 3‐ • Antibiotic therapy: 4 days without antibiotics, – Penicillin G although prompt treatment – Penicillin VK may shorten the duration – Amoxicillin by 1 day. – Cephalexin • Antibiotics are mainly given – Azithromycin to prevent acute rheumatic – Erythromycin (resist fever, despite an already rates up to 30%) low incidence in the US – Clindamycin • Good for patients with • Supportive therapy and multiple recurrent increase patient episodes / carriers comfort levels – Ceftriaxone – NSAIDS, acetaminophen, steroids

Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Review). The Cochrane Collaboration. 2007;(1):1‐41.

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Complications of Strep Pharyngitis

• Cervical Adenitis • Otitis Media / Acute sinusitis • Peritonsillar • Retropharyngeal abscess • Rheumatic fever / rheumatic heart disease – <1 case per 1 million* • Post‐streptococcal R peritonsillar abscess w/ CT demonstrating R glomerulonephritis displaced tonsil PTA fluid collection (arrow)

*Centers for Disease Control and Prevention. Summary of notifiable , United States, 1997. MMWR Morb Mortal Wkly Rep. Nov 20 1998;46(54):ii‐vii, 3‐87

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

16 3/19/2014

Mononucleosis Pharyngitis

• Epstein‐Barr infection • Prodrome of fatigue, low‐ • Pharyngitis is most common grade fever, and finding in an otherwise myalgias over 1‐2 weeks are syndromic entity common • 45 cases per 100,000 • Pharyngeal and tonsil • No sex or ethnic symptoms often severe and predilection exudative • • Highest incidence in 15‐25 Lymphadenopathy in almost yo all cases, anterior and posterior • Splenomegaly with rupture • more often cause of fatal May have or jaundice events, albeit rare.

Infectious Mononucleosis

Large posterior triangle node in a Large swollen tonsils with significant Monospot positive 12 yo with 2 weeks of edema and exudate fatigue and adenopathy

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Diagnosis and Treatment of Mono

• Work‐up may include • Treatment Monospot test for diagnosis – Supportive – 85% sensitive • Analgesics – May have false + in other viral • Antipyretics illness (kids especially) • Limit physical contact if evidence of splenomegaly • Elevated WBC may be – Corticosteroids useful • Use with caution – Moderate increase in total • Some limited data to suggest WBC, with significant increase improved recovery time in in lymphocytes on differential mono pharyngitis (>50%) – Usually > 10% atypical lymphs • LFTs are often elevated

Omori and Dyne. Mononucleosis in Emergency Medicine. Aberdein and Singer. Clinical Review: A systematic review of Emedicine May 2012. corticosteroid use in infections. Crit Care. 2006; 10(1):203 pub online Nov 2005.

17 3/19/2014

Sebaceous and Tonsilloliths

• Frequently encountered • High association of halitosis* • Frequent source of discomfort and occasionally chronic tonsillitis • Treatment: – Irrigation – Oral lavage – Laser – Tonsillectomy **

*Rio AC et al. Relationship betweenthe presence of tonsilloliths and halitosis in chronic caseous tonsillitis. Br J Dent. 2008 Jan 26; 204(2) Fowler 2014

**Darrow DH, Siemens C (August 2002). "Indications for tonsillectomy and adenoidectomy". Laryngoscope 112 (8 Pt 2 Suppl 100): 6–10

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Sebaceous tonsillitis / Tonsilloliths

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Pre‐malignant Conditions of the Oral Cavity 2 main categories: ‐Generalized state with an associated with signs of increased risk of oral cavity Ca * • • Discoid erythematosus • Submucosal fibrosis ‐Morphologically altered tissue in which oral cavity cancer is more likely to occur • Fowler 2014 •

* Warnakulasuriya S et al.. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med. Nov 2007;36(10):575‐80

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

18 3/19/2014

Oral Lichen Planus

• Chronic inflammatory state • “frond‐like” white plaques – Most often bilateral – Buccal mucosa, lateral tongue, gingiva • +/‐ / ulceration • T‐cell mediated autoimmune disease * • 1‐2% of population** • F =M Usually > age 40 • No racial predilection

*Sugerman P, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med. 2002;13(4):350‐65

**Axéll T, Rundquist L. Oral lichen planus‐‐a demographic Fowler 2014 study. Community Dent Oral Epidemiol. Feb 1987;15(1):52‐6

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral Lichen Planus

• Roughly 2/3 will have symptoms • Associated with use – NSAIDs, Beta‐B, ACE, anti‐malarials • Association w/ sensitivity to dental amalgam (mercury)* – Patch testing • Up to a 5% incidence of malignant transformation** • High incidence of systemic mucosal involvement – female genital > male

* Koch P, Bahmer FA. Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study. J Am Acad Dermatol. Sep 1999;41(3 Pt 1):422‐30

**Silverman S Jr. Oral lichen planus: a potentially premalignant lesion. J Oral Maxillofac Surg. Nov 2000;58(11):1286‐8

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral Lichen Planus

• Dif Dx: – Autoimmune / bullous diseases affecting oral mucosa – Pre‐malignant leukoplakia / erythroplakia – SCCa • Work‐up: – Biopsy most useful • Treatment – Topical steroids (kenalog in Orabase) – Topical tacrolimus – Systemic corticosteroids (selective) – Hydrochloroquine, azathioprine, dapsone, retenoids may have potential

*N Lavnya, et al. Oral lichen planus: An update on pathogenesis and treatments. J Oral Maxillofac Pathol. 2011 May‐Aug; 15(2): 127–132

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

19 3/19/2014

Oral Leukoplakia

• General descriptive term used to describe a white patch on the oral mucosa of uncertain etiology, that cannot be characterized as any other definable lesion.* Fowler 2014 • Increased risk of transformation to Squamous cell (SCCa), albeit low. – Annual malignant transformation rate rarely exceeds 1%* • Etiology: – Tobacco, ETOH, trauma, inflammation – HIV / AIDS ()

Left RMT leukoplakia with central ulcerative changes secondary to trauma * Lodi G, et al. Interventions for treating oral leukoplakia. (dental filling) Cochrane Database Syst Rev. 2004;(3)

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Leukoplakia

Homogeneous R buccal plaque Irregular R buccal plaque c/w w/ h.o chewing tobacco use

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral Erythroplakia • Red patch on the oral mucosa that cannot be attributed to any other definable pathology • Floor of mouth, tongue and soft palate most common • Usually > 50 yrs M>F 3:1 • EtOH and tobacco =

synergistic Fowler 2014 • 40%‐85% incidence of sever , Carcinoma Left buccal erythro‐leukoplakia in a in‐situ and SCCa in biopsy 65 yo wm w/ 50+ pack years specimens*

* Hashibe M et al. Chewing tobacco, alcohol and the risk of erythroplakia. Cancer Epidemiol Biomarkers Prev. 2000 Jul;9(7):639‐45

* Shafer WG, Waldron CA. Erythroplakia of the oral cavity. Cancer. 1975 Sep;36(3):1021‐8.

20 3/19/2014

Squamous Cell Carcinoma

• Accounts for ~90% of all • Tobacco = 20x increase oral cavity malignancy • Alcohol = 5x increase • Older men AA > W • Alcohol + tobacco = 50x • and lateral tongue most increase! common • Tobacco, EtOH, betel nut, radiation, diet • HPV –16 (oropharyngeal)* • Presentation can range from a painless ulcer or lump to cervical metastases

*Campisi G, et al. Human papillomavirus: its identity and controversial role in oral oncogenesis, premalignant and malignant lesions (review). Int J Oncol. Apr 2007;30(4):813‐23

Squamous Cell Carcinoma of the Lip

Fowler 2014 Fowler 2014

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

SCCA of the Tongue

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

21 3/19/2014

SCCA of the Palate

Fowler 2014

81 yo WF with 35# weight loss and mouth pain.Fowler Tx 2014 for 26 yo WM with no social risk factors and 6 thrush x 3 in 4 month period. weeks of severe right mouth pain. ***Must remove dentures for exam!! Pancytopenic on work‐up. Work up for Fanconi anemia

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

PET‐CT of 81 yo WF with left palate SCCa (previous slide)

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Alveolar Ridge SCCa

At presentation Post‐radiation therapy

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

22 3/19/2014

Floor of Mouth SCCa

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Left Buccal Mucosa SCCa

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Oral Cavity SCCa

• Work‐up • Treatment Options: – Biopsy or exfoliative • Surgery cytology – Primary or salvage • FNA for neck masses – Conservative vs radical – CT, MRI, PET‐CT – Pan‐endoscopy to r/o • Radiation therapy second primary • Chemotherapy – CXR • Brachytherapy –rare w/ – Bone scan in select cases improvements in IMRT – Labs –LFTs, CBC, Ca++ • Gene Therapy / targeted therapy –new and on the horizon

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

23 3/19/2014

Surgical Specimens ‐ SCCa

Fowler 2014 Fowler 2014

SCCa of anterior maxillar gingival‐labial sulcus and subsequent anterior maxillectomy

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Surgical Specimens ‐ SCCa

Left primary palate SCCa Left orbital exenteration and hemimaxillectomy

Fowler 2014 Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Surgical Specimens ‐ SCCa

Fowler 2014

Fowler 2014 R lateral hemiglossectomy R hemimandibulectomy for RMT SCCa (arrow)

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

24 3/19/2014

Questions?

Red arrow = Uvula

Green arrow = frenulum

Fowler 2014

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

References

• www.cancer.gov • Head and Neck Pathology: A vol of Foundations in Diagnostic Pathology. Lester D.R Thomson MD, ed. Elsevier. 2006 • www.entusa.com Kevin Kavanagh MD • www.emedicine.Medscape.com/article/1079920‐ overview#aw2aab6b3 Viral Infections of the Mouth. Gordon et al. • Tyldesley W. Color Atlas of ‐ 2nd ed. Moseby‐Wolfe. 1994

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

25