12.7-ENT-Head and Neck 1 (1).pdf

OTORHINOLARYNGOLOGY Module 12 Head and Neck 1 Dr. Jemelyn Lapitan TRANS 07 TOPIC OUTLINE I. Salivary Gland Neoplasms A. Major Salivary Glands B. Minor Salivary Glands C. Distribution of Salivary Gland Neoplasms D. Histology of Benign Salivary Gland Tumors E. Non-Tumor Differential Diagnosis for Paro...

OTORHINOLARYNGOLOGY Module 12 Head and Neck 1 Dr. Jemelyn Lapitan TRANS 07 TOPIC OUTLINE I. Salivary Gland Neoplasms A. Major Salivary Glands B. Minor Salivary Glands C. Distribution of Salivary Gland Neoplasms D. Histology of Benign Salivary Gland Tumors E. Non-Tumor Differential Diagnosis for Parotid Swelling F. Pleomorphic Adenoma (Benign Mixed Tumor) G. Warthin Tumor (Papillary Cystadenoma Lymphomatosum) H. Imaging of Salivary Gland Tumors i. Ultrasonography ii. Indications for High Resolution Imaging (CT/MRI) iii. Fine Needle Aspiration Biopsy (FNAB) I. Management i. Parotidectomy ii. Submandibular Gland Excision J. Complications II. Benign Tumors and Tumorlike Lesions of the Oral Cavity A. Congenital Conditions i. Torus ii. Lingual Thyroid B. Developmental Cysts i. Dermoid Cyst ii. Duplication Cyst iii. Nasoalveolar Cyst C. Inflammatory/Traumatic Conditions i. Mucocele ii. Ranula iii. FibromaPyogenic Granuloma D. Benign Neoplasms i. Papilloma ii. Granular Cell Tumor iii. Hemangioma III. Odontogenic Cysts and Tumors A. Odontogenic Cysts i. Radicular Cysts ii. Dentigerous Cyst iii. Odontogenic Keratocyst B. Odontogenic Tumors i. Ameloblastoma ii. Calcifying Epithelial Odontogenic (Pindborg) Tumor iii. Odontoma C. Benign Non-Odontogenic Tumors i. Ossifying Fibroma ii. Fibrous Dysplasia iii. Osteoma IV. Nose and Paranasal Sinuses A. Juvenile Nasopharyngeal Angiofibroma (JNA) B. Sinonasal Inverted Papilloma V. Thyroid and Parathyroid A. Cause of Thyroid Nodules B. Thyroidectomy C. Complications VI. Others Group Number A. Lipoma B. Branchial Cleft Cyst C. Thyroglossal Duct Cyst VII. Approach to Patients A. History and PE i. Age ii. Mass Growth Pattern iii. Symptoms iv. Review of Systems v. Personal and Social History vi. COVID-19 Vaccination vii. Lymphatic Drainage of the Head and Neck viii. Mass Localization ix. Mass Characteristics x. Components of the General Examination B. Diagnostic Tests i. Ultrasound ii. Computer Tomography iii. Magnetic Resonance Imaging iv. Positron Emission Tomography CT Scan (PET-CT) v. Fine Needle Aspiration vi. Core Biopsy vii. Image Guided Biopsy viii. Excision/Incision Biopsy C. Diagnosis i. Infectious Etiology ii. Differential Diagnosis iii. Suspect Malignancy iv. Establish Diagnosis D. Management VIII. Key Points -----------------------------------------------------------------------------LEGEND Lecturer’s additional notes = (e.g Trivia, nice-to-know) Disclaimer = (e.g. not included nor discussed) important terms = Bold and black text This was a live lecture I.SALIVARY GLAND NEOPLASMS Divided into ➜ Major Salivary Glands Sublingual) ➜ Minor Salivary Glands (Parotid, Submandibular, Table 1. Contribution to and Relative Viscosities of Saliva by Salivary Glands (From Mandel ID: Sialochemistry in diseases and clinical situations affecting salivary glands. Crit Rev Clin Lab Sci 1980;12:321.) Gland Acinar Type Viscosity Whole Unstimulated Daily Saliva (%) Parotid Serous Watery 25 SubMixed Semiviscous 71 mandibular Sublingual Mucous Viscous 3-4 Minor Mucous Viscous Trace NOT FOR SALE 1 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 ➜ Ductal papillomas ➜ Other adenomas: basal cell, sebaceous, cystadenoma, sialadenoma, ductal adenomas, canalicular adenomas A. MAJOR SALIVARY GLANDS Table 2. The Major Salivary Glands and their corresponding Ducts Major Salivary Ducts Location Glands Parotid Stensen Opposite the upper 2nd molar Submandibular Wharton Floor of the mouth near the frenulum Sublingual (Ducts of) Rivinus E. NON-TUMOR DIFFERENTIAL DIAGNOSIS FOR PAROTID SWELLING Viral parotitis Bacterial parotitis ➜ Often in elderly, malnourished, immunocompromised patients Inflammatory/reactive lymph node Sjogren syndrome dehydrated, or F. PLEOMORPHIC ADENOMA (BENIGN MIXED TUMOR) 3 Major Salivary Glands ➜ PAROTID ➜ SUBMANDIBULAR ➜ SUBLINGUAL Stensen’s duct drains the parotid gland opposite the upper second molar Wharton’s duct drains the submandibular and some sublingual glands into the floor of the mouth near the frenulum of the tongue B. MINOR SALIVARY GLANDS Location: deeper submucosal planes of ➜ Oral cavity (lip, hard and soft palates) ➜ Paranasal sinuses ➜ Pharynx ➜ External auditory canal ➜ Nose Not typically identified on imaging unless they are pathologically enlarged or involved with tumor, of which they are an important tissue of origin. C. DISTRIBUTION OF SALIVARY GLAND NEOPLASMS Table 3. Distribution of Salivary Gland Neoplasms Glands Incidence Benign Malignant Parotid 70% 75% 25% Sub22% 57% 43% mandibular Minor 8% 18% 85% TOTAL 100% Incidence (most common to least common): ➜ Parotid neoplasms → Submandibular neoplasms → Minor salivary gland neoplasms Minor salivary gland neoplasms - least common but usually malignant D. HISTOLOGY OF BENIGN SALIVARY GLAND TUMORS Figure 1. Pleomorphic Adenoma (Benign Mixed Tumor) Most common benign salivary gland tumor (45-75%) Most common location: PAROTID Female > Males Patients in their 20-50s Well circumscribed by a fibrous capsule Combination of myoepithelial cells and small ducts within a chondromyxoid stroma (Fig. 1, Lower left inset, 400x) Myoepithelial cells can be spindled, epitheloid, plasmacytoid, or have clear cytoplasm Presentation: ➜ Unilateral ➜ Located most often in parotid (tail; at the angle of the mandible) and submandibular glands ➜ Well-defined, non-tender, freely mobile Pleomorphic Adenoma ➜ aka Benign Mixed Tumor ➜ most common Warthin Tumor ➜ aka Papillary Cystadenoma Lymphomatosum ➜ 2nd most common Others: ➜ Myoepithelioma ➜ Oncocytoma Group Number 11B NOT FOR SALE 2 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 4. Pleomorphic adenoma of the deep lobe of a parotid gland causes medial displacement of the palate and tonsil. Figure 2. Blue arrow points to clinical presentation of a Pleomorphic Adenoma Figure 5. Large pleomorphic adenoma of the parotid gland. Axial computed tomography with gadolinium. The tumor involves the superficial and deep lobes of the parotid gland and lies anterior to the styloid process (prestyloid; white arrowhead). The fat of the parapharyngeal space is displaced medially, and the carotid artery is displaced posteriorly. The isthmus of tumor between the superficial and deep components passes through the stylomandibular space and is therefore relatively narrow, giving the appearance of a dumbbell (black arrowheads). Figure 3. Pleomorphic adenoma of the submandibular gland Group Number 11B NOT FOR SALE 3 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 6. Pleomorphic adenoma of the palate, intraoperative view. G. WARTHIN TUMOR (PAPILLARY CYSTADENOMA LYMPHOMATOSUM) aka Papillary Cystadenoma Lymphomatosum 2nd most common benign salivary gland neoplasm after pleomorphic adenoma First described by Aldred Warthin in 1929 Accounts for approximately 10% of all parotid tumors and is found almost exclusively in the parotid gland May also be found in submandibular glands Bilateral tumors occur in 10% of cases and may be simultaneous Males > females Smokers Presentation: ➔ Slow growing mass often in the superficial lobe of the parotid gland at the angle of the mandible ➔ A few patients will present with swelling, pain, and other inflammatory changes that may be secondary to an immunologic response to the lymphoid element Group Number 11B Figure 7. Papillary projection protruding into a cystic space. Papillary projections are lined by a double layer of cuboidal to columnar oncocytic epithelial cell, with ample pink, granular cytoplasm and nuclei with central, prominent nucleolus and an underlying lymphoid stroma (lower right box, 400x magnification) Doc said this is nice to know only and might show up in the board exams H.IMAGING OF SALIVARY GLAND TUMORS Routine use of imaging in patients with small, well-defined masses of the superficial love of the parotid gland is probably not warranted, because the results of imaging are not likely to change the treatment plan Ultrasonography ➜ Inexpensive, non-invasive, simple to perform, and virtually free of complications ➜ Can be used to differentiate solid from cystic masses in the salivary glands ➜ Most salivary gland diseases can be diagnosed ultrasonographically ➜ Ultrasound guidance may also enhance the accuracy of FNAB in nonpalpable tumors and in masses with a highly heterogeneous architecture CT Scan/MRI ➜ Indications: ◆ Tumors that present with clinical findings suggestive of malignancy ○ fixed hard mass ○ facial paresis ○ skin induration ○ trismus ◆ Those that arise from the deep lobe of the parotid gland or the parapharyngeal space ◆ Tumors of the submandibular and minor salivary glands ◆ In such case, imaging provides accurate delineation of the location and extent of the tumor, its relation to: ○ major neurovascular structures ○ perineural spread ○ skull base invasion ○ intracranial extension Fine Needle Aspiration Biopsy (FNAB) ➜ overall sensitivity: 85.5% to 99% NOT FOR SALE 4 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 ➜ overall specificity: 96.3% to 100% ➜ in general, diagnostic accuracy is higher for benign than for malignant salivary gland tumors ➜ however, the accuracy of FNAB depends greatly on the experience of the cytopathologist and the overall volume of patients with salivary neoplasms evaluated in any given institution ➜ the most common source of diagnostic error of FNAB is inadequate sampling I.MANAGEMENT PAROTIDECTOMY Figure 10. Unless displaced by a tumor, the nerve is usually located approximately 1 to 1.5cm deep and inferior to the tragal pointer. All branches are sequentially and meticulously dissected. Figure 8. SCM = sternocleidomastoid muscle P F= parotid fascia PT = parotid tail PM = platysma muscle SUBMANDIBULAR GLAND EXCISION Submandibular incision made in a natural skin crease 3 to 4 cm inferior to mandible Marginal mandibular nerve generally lies just superficial to the anterior facial vein Great care should be taken to avoid injury of the marginal mandibular nerve The nerve lies immediately beneath the deep cervical fascia, and it can be identified crossing the anterior facial vein Figure 9. The facial nerve. Identification of the main trunk of the facial nerve, which is usually identified by dissecting the main trunk (white arrow) in the region between the tragal pointer (white arrow head) and the attachment of the posterior belly of the digastric muscle (DGM) to the mastoid bone Group Number 11B NOT FOR SALE 5 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 13. Frey’s syndrome Figure 11. Submandibular Gland Excision Mylohyoid is retracted anteriorly, and the gland is retracted posteriorly This exposes the lingual nerve, submandibular ganglion and Wharton duct. Pathophysiology: ➔ aberrant cross-reinnervation between the postganglionic secretomotor parasympathetic fibers to the parotid gland and the postganglionic sympathetic fibers that supply the sweat glands of the skin Diagnosis: ➔ Starch-iodine test Figure 14. Starch iodine Test. In this test, iodine is applied to the symptomatic side of the face. After it dries, cornstarch is applied. When the patient sweats (with food stimulus), the affected area gets dark. Treatment: ➔ Antiperspirant ➔ Glycopyrrolate (1%) roll-on lotion ➔ Botox ➔ Tympanic neurectomy Figure 12. The facial nerves J. COMPLICATIONS Order of sequence if one treatment failed: antiperspirant → Glycopyrrolate → Botox → Tympanic neurectomy GUSTATORY SWEATING: FREY’S SYNDROME Flushing and sweating of the ipsilateral facial skin during mastication (gustatory sweating) ➜ Sequela of parotidectomy ➜ May follow other surgical, traumatic and inflammatory injuries of the parotid and submandibular glands and the cervical and upper thoracic portions of the sympathetic trunk Figure 15. Application of botox treatment for Frey’s syndrome Group Number 11B NOT FOR SALE 6 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 GREATER AURICULAR NERVE (GANE Usually divided during parotidectomy Sensory deficits in the dermatomal distribution of the great auricular nerve ➜ lower third of the pinna (includes the earlobe) ➜ adjacent preauricular and postauricular skin ➜ motor innervation to depressor anguli oris, depressor labii inferioris, mentalis and the orbicularis oris Lingual Nerve ➜ sensory innervation to floor of the mouth and anterior ⅔ of the tongue Hypoglossal Nerve ➜ provides motor control of the extrinsic muscles of the tongue: ◆ genioglossus ◆ hypoglossus ◆ styloglossus ◆ intrinsic muscle of the tongue II.BENIGN TUMORS AND TUMORLIKE LESIONS OF THE ORAL CAVITY A. CONGENITAL CONDITIONS TORUS Figure 16. The greater auricular nerve FACIAL PARESIS Iatrogenic injury to the facial nerve branches during parotidectomy House-Brackmann scoring Developmental anomaly usually present in 2nd decade of life continue to grow throughout life 3-56% of adults F>M typically pedunculated or multilobulated, broadly based, smooth, cony masses consist of dense lamellar bone with relatively small marrow spaces that do not involve the deeper cancellous bones of the mandible or palate patients usually asymptomatic, unless the torus interferes with denture placement or is repeatedly traumatized when the patient eats Management: ➜ In symptomatic patients, the tori can be treated by removing them from the underlying cortex with osteotomes or cutting burs Recurrence is occasionally seen Malignant transformation has not been reported Table 4. House-Brackmann Facial Nerve Grading System Grade I Normal Grade II Slight facial weakness or other mild dysfunction. Normal tone and symmetry at rest. Complete closure of the eye without effort. Slight asymmetry of the mouth when facial movements occur Grade III Assigned to patients dealing with moderate dysfunction; these patients generally do not display any noticeable facial weakness with synkinesis, they maintain complete eye closure and good forehead movement with effort Grade IV Assigned to patients dealing with severe dysfunction. Obvious facial weakness. Incomplete eye closure, no forehead movement, asymmetrical mouth movement, and synkinesis Grade V Assigned to patients who have little to no ability to smile, frown, or make other facial expressions. The closure of the eye is incomplete, and there is not forehead movement Grade VI No facial motion SUBMANDIBULAR GLAND EXCISION Figure 17. Torus palatinus Marginal Mandibular Nerve Group Number 11B NOT FOR SALE 7 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Signs & Symptoms: dysphagia or the sensation of a lump in the throat, dysphonia or (rarely) bleeding Symptoms may occur at times of increased metabolic demands (growth spurts in adolescence or during pregnancy) Malignant transformation is rare Treatment: ➜ Hormone replacement therapy: for hypothyroid patients (Levothyroxine) may also reduce size, in turn, reduce obstructive symptoms ➜ Surgery: for symptomatic euthyroid patients with need for postoperative exogenous thyroid hormone replacement therapy, because approx. 70% of thyroid patients will have the lingual thyroid as the only functioning thyroid Figure 18. Torus mandibularis. Found in the lingual surface of the anterior mandible, primarit in the premolar region. LINGUAL THYROID ~ 90% of all ectopic thyroid tissue is associated with the dorsum of the tongue reflects the lack of descent of thyroid tissue during development found in the midline in the area of the foramen cecum usually asymptomatic can be associated with hypothyroidism ➜ up to 70% of patients with a lingual thyroid also have hypothyroidism Figure 20. Lingual Thyroid B. DEVELOPMENTAL CYSTS DERMOID CYST cystic masses found along embryonic fusion lines that form from epithelial rests lined by squamous epithelium of the keratinizing variety contain elements of epidermal appendages that include hair follicles, sweat glands, and connective tissue Figure 19. Lingual thyroid presentation might cause airway obstruction and/or difficulty swallowing Group Number 11B NOT FOR SALE 8 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 21. Histology of Dermoid cyst Presentation: cystic, well-defined mass with fatty, fluid, or mixed components On CT: Low density, a variety of internal appearances depending on composition, wall may enhance contrast Figure 23. Dermoid cyst on MRI with “bag of marbles” appearance Figure 22. Dermoid cyst on CT-Scan On MRI: ➜ On T1: fatty elements appear bright, fluid dark ➜ On T2: fast is dark and fluid is bright ➜ On T1 post-contrast thin wall enhancement possible Group Number 11B slow-growing median age at presentation is 30 male to female ratio is 3:1 Treatment: Complete excision to include all epithelial components DUPLICATION CYST lined with stratified squamous and columnar epithelium are found anywhere along the digestive tract, including the tongue and floor of the mouth NOT FOR SALE 9 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Presentation: ➜ Swelling in the nasolabial are, which cases unilateral elevation of the nasal ala ➜ Intraorally, a smooth, mucosal, covered mass in the gingival labial sulcus is seen ➜ Remodelling of the anterior maxilla is also seen Figure 24. Duplication cyst involving the tongue Motor innervation to depressor anguli oris, depressor labii inferioris, mentalis and the orbicularis oris Presentation: In the oral cavity, appears at birth as an asymptomatic swelling that involves the tongue and floor of the mouth Treatment: Complete excision to include all epithelial components NASOALVEOLAR CYST Thought to originate from trapped nasal epithelium between the developing lateral and medial maxillary nasal processes. The manifestations of nasoalveolar cysts usually occur in adulthood as the cyst increases in size Figure 26. Anterior maxilla remodelling seen on CT-Scan Treatment: Complete excision, usually by a sublabial approach Figure 25. Duplication cyst presentation with straw-colored fluid Group Number 11B NOT FOR SALE 10 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 29. Gross findings of ranula Figure 27. Sublabial excision of the Duplication cyst Pseudocysts (no true cystic wall) Appear as blue, fluctuant swellings Lateral to the midline in the lower mouth If sialoliths are a suspected contributing factor, radiologic evaluation may be done CT scan may be done as well C. INFLAMMATORY/TRAUMATIC CONDITIONS MUCOCELE Result of trauma and spillage of mucin into the surrounding soft tissues or obstruction of the salivary gland duct May spontaneously resolve especially in children and infants Figure 30. Radiographic and CT scan findings of ranula Management: ➜ Intraoral/extra oral excision ➜ Aspiration ➜ Marsupialization ➜ Observe FIBROMA Common tumor-like condition of the oral cavity and oropharynx Inflammatory and fibrous hyperplastic response to chronic irritation or trauma Found in 1.2% of adults, 66% female predilection Can occur at any age, usually becomes apparent during or after the fourth decade of life Figure 28. Gross findings of mucocele RANULA Mucoceles that occur in the floor of the mouth and usually involve the major salivary glands Due to improper drainage of sublingual glands ➜ Congenital ➜ Acquired due to trauma Group Number 11B NOT FOR SALE 11 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 33. Histology findings of fibroma Treatment: conservative excision ➜ Recurrence is unlikely, unless the precipitating trauma is continued or repeated Figure 31. Gross findings of fibroma Usually solitary and are seldom larger than 1.5cm Asymptomatic, sessile or pedunculated firm mass that typically involves the buccal mucosa and, less commonly, the labial or tongue mucosa Figure 34. Removal of fibroma lesion PYOGENIC GRANULOMA Figure 32. Fibroma involving the buccal mucosa ➜ Histology: dense and minimally cellular fascicles of collagen fibers and have relatively avascular appearance Group Number 11B Can occur on any mucosal surface subject to acute or chronic trauma or infection Mostly involve the gingiva and can also be found in labial and buccal mucosa as well as the tongue Raised or pedunculated lesions that remain less than 2.5 cm in size May bleed with minor trauma NOT FOR SALE 12 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 37. Gross findings of papilloma Typically presents as a single, asymptomatic, soft, pedunculated mass with numerous fingerlike projections at the surface Histology: Projections have fibrovascular cores and demonstrate a relatively narrow base Figure 35. Gross findings of pyogenic granuloma. Also found in patients with poor dental hygiene Variants: ➜ Epulis Gravidarum - pregnancy ➜ Epulis Granulomatosa - recent tooth extraction Treatment: Excision and removal of potential traumatic or infective factors D. BENIGN NEOPLASMS PAPILLOMAS Squamous papillomas ➜ most commonly associated with HPV-6 & 11 virus subtypes. Figure 38. Histologic findings of papilloma Treatment: Surgical excision or ablation using CO2 laser Usually presents in adults Low recurrence rate Singular lesions Less proliferative than squamous papillomas of other sites of the head and neck (ex. larynx) Figure 39. Surgical excision of papilloma on the uvula Recurrence in the oral cavity of oropharynx is unlikely GRANULOMA CELL Usually diagnosed during or after the third decade of life More than half of all cases occur in the oral cavity >⅓ of granular cell tumors involve the dorsum of the tongue Other sites of occurrence: ➜ Soft palate ➜ Uvula ➜ Labial mucosa Up to 15% of patients will have synchronous lesions Present as firm, painless, relatively immobile, sessile, nodular-appearing lesions less than 1.5cm in greatest dimension Figure 36. Gross findings of papilloma Development of precancerous proliferative verrucous leukoplakia within squamous papillomas is rare Sites of occurrence: ➜ lingual, buccal, and labial mucosa ➜ tongue Group Number 11B NOT FOR SALE 13 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 42. Hemangioma GRANULOMA CELL Figure 40. Granular cell tumor of the lingual dorsum CONGENITAL EPULIS Neonatal form of granular cell tumors Evident at birth and characteristically involves the maxillary gingiva Unifocal growth measuring not more than 2cm May interfere with feedings Lip is the most frequent site Mucosal Hemangioma ➜ Soft, painless mass ➜ Red or blue Typically less than 2cm Can become quite extensive and may involve significant portions of the oral cavity and oropharynx, including the tongue Tend to spontaneously regress over the years Involution may be incomplete, or associated fibrosis may develop Hemangiomas that limit the form and function of the oral cavity and oropharynx are usually treated with conservative surgical excision Recurrence or persistence is not unusual Other treatment options: ➜ Intralesional sclerosing agents ➜ Interferons ➜ Laser treatment ➜ Local and systemic steroids ➜ Radiation III.ODONTOGENIC CYSTS AND TUMORS A.ODONTOGENIC CYSTS Figure 41. Congenital epulis involving the maxillary gingiva HEMANGIOMA Usually present at birth in a rapid proliferative phase, but may become clinically evident later in life May be associated with a number of conditions that include Struge-Weber-Dimitri syndrome and von Hippel-Lindau syndrome Types of Odontogenic Cysts ➜ Radicular (Periapical) Periapical Cyst ➜ Dentigerous Cyst ➜ Odontogenic Keratocyst / Keratocystic Odontogenic Tumor ➜ Lateral Periodontal Cyst ➜ Gingival Cyst of the Newborn ➜ Eruption Cyst ➜ Glandular Odontogenic Cyst ➜ Calcifying Odontogenic Cyst (Calcifying Cystic Odontogenic Tumor) RADICULAR CYST Etiology and Pathogenesis ➜ preceded by periapical granuloma associated with non-vital tooth ➜ Rests of Malassez stimulated by chronic inflammation ➜ Products of cyst epithelium and inflammation cause bone resorption ➜ Cyst expands because of increasing osmotic pressure in lumen Clinical Features ➜ Most common type of odontogenic cyst ➜ Cannot distinguish cyst from preexisting granuloma radiographically Group Number 11B NOT FOR SALE 14 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 ➜ Incompletely removed cyst lining results in residual cyst Histopathology ➜ Lined by nonkeratinized stratified squamous epithelium of variable thickness ➜ With large numbers of neutrophils ➜ With fewer numbers of lymphocytes involved Differential Diagnosis ➜ Periapical granuloma ➜ Periapical cemento-osseous dysplasia ➜ Odontogenic tumors Treatment ➜ Removal of non-vital tooth ➜ Root canal therapy ➜ Apicoectomy ➜ Excision and curettage ➜ Third molars and canine teeth are the most commonly affected ➜ Stimulus is unknown Clinical Features ➜ Lucency associated with crown of impacted tooth Histopathology ➜ Lined by nonkeratinized stratified squamous epithelium ➜ Proliferation of reduced enamel epithelium Differential Diagnosis ➜ Odontogenic keratocyst ➜ Ameloblastoma ➜ Ameloblastic fibroma Treatment ➜ Removal of the associated tooth ➜ Enucleation of the pericoronal soft tissue component Figure 43. Panoramic X-ray of a Radicular Cyst. Radicular cysts are usually found underneath nonviable(dead) teeth or teeth that had a root canal and is unilateral Figure 45. Panoramic X-rays of a Dentigerous Cyst. Figure 44. Gross Image of a Radicular Cyst DENTIGEROUS CYST Etiology and Pathogenesis ➜ Second most common odontogenic cyst Group Number 11B ODONTOGENIC KERATOCYST (OKC) Etiology and Pathogenesis ➜ Develop from dental lamina remnants in the mandible and maxilla ➜ Overexpression of the antiapoptotic protein Bcl-2 and several growth factors ➜ Expression of MMPs 2 and 9 Clinical Features ➜ Aggressive ➜ Risk of recurrence ➜ Association with nevoid basal cell carcinoma syndrome ➜ Solitary cysts are common ◆ Recurrence rate 10%-30% ➜ Multiple cysts: 5% of OKC patients NOT FOR SALE 15 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 ◆ Recurrence rate is greater than solitary cysts ➜ Syndrome-associated multiple cysts: 5% of OKC patients ◆ Recurrence rate is greater than multiple cysts Histopathology ➜ Thin epithelium (6-10 cell layers) ➜ Refractile, parakeratotic lining ➜ Epithelial budding and “daughter” cysts ➜ Characteristic microscopic features are lost when inflamed ➜ Orthokeratinized odontogenic cyst Differential Diagnosis ➜ Dentigerous cyst ➜ Ameloblastoma ➜ Odontogenic myxoma ➜ Adenomatoid odontogenic tumor ➜ Ameloblastic fibroma Treatment ➜ Surgical excision with curettage/peripheral osteotomy Figure 47. Panoramic (a) and cross-sectional (b) CBCT images that show an OKC with well-defined and lobulated margins located in the interforaminal region of the mandible (indicated by the asterisk). Root resorption (Arrowheads) and perforated cortices (curved arrows). Scalloping of the endosteal surface of the cortical plates (small black arrows) and small internal septum (wavy arrow) are also seen. Left mental foramen (large black arrow); Left canine (33); Left first premolar (34); Left second premolar (35); Left first molar (36). Figure 46. Panoramic CBCT images of a maxillary OKC (indicated by the asterisk) originating from the molar region distally to the second molar tooth. The OKC causes significant sinus floor elevation (indicated by the arrowheads). Curved arrows indicate the posterior wall of the maxillary sinus, while the straight arrow indicates the lateral pterygoid lamina. Figure 48. Panoramic CBCT with 20-mm slice thickness. A shows a multilocular OKC. Septa seems to divide the lesion into multiple loculations. B is a cross-sectional CBCT in 0.5 mm thick sections demonstrating some septa are complete (arrowheads), some are incomplete (wavy arrows). Some small loculations (black asterisk, white and black stars) correspond to a single large loculation with scalloped borders. Compression and lingual displacement of the mandibular canal, deep to the root of the third molar (48) is shown (opposing arrows). Mandibular foramen (curved arrow). Mandibular canal (arrows) B.ODONTOGENIC TUMORS Types of Odontogenic Tumors ➜ Ameloblastoma ➜ Calcifying Epithelial Odontogenic (Pindborg) Tumor ➜ Odontoma Group Number 11B NOT FOR SALE 16 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Figure 50. Gross image of an Ameloblastoma Figure 49. List of Odontogenic Tumors and their Etiology AMELOBLASTOMA Etiology and Pathogenesis ➜ Adults are most commonly affected ➜ Broad age range; mean age: 40 years ➜ No gender preponderance (Male = Female) Clinical Features ➜ Benign, aggressive tumor ➜ Invasive and persistent ➜ Solid or multicystic ➜ Mandibular molar-ramus - most commonly affected site ➜ Always radiolucent ➜ Unilocular or multilocular ➜ Slow-growing and typically well defined radiographically Histopathology ➜ Palisading columnar cells around epithelial nests in a pattern similar to that of ameloblasts of the enamel organ ➜ Central to these cells are loosely arranged cells that mimic the stellate reticulum of the enamel organ ➜ Budding of tumor cells from neoplastic foci in a pattern reminiscent of tooth development Differential Diagnosis ➜ Dentigerous cyst ➜ Odontogenic keratocyst Treatment ➜ Wide excision with 1 cm bone margins Group Number 11B Figure 51. Reconstruction Surgery of an Ameloblastoma with Fibular Free Flap PINDBORG TUMOR Etiology and Pathogenesis ➜ Unknown; may be dental lamina or stratum intermedium ➜ Adults 30-50 years old Clinical Features ➜ Favors posterior mandible ➜ Benign behavior ➜ Recurrence potential: 1 cm size with FDG activity Often with preserved morphology but reactive inflammation may lead to loss of the fatty hilum Biopsy reveals follicular hyperplasia LYMPHATIC DRAINAGE OF THE HEAD AND NECK Table 10. Lymphatic Drainage of the Head and Neck LYMPH NODE ANATOMIC AREAS DRAINED GROUP Occipital Posterior scalp Postauricular Temporal and parietal scalp Preauricular Anterior and temporal scalp, midface, nose, anterior ear canal and pinna, lateral conjunctivae Parotid Forehead and temporal scalp, midface nose, external ear canal, middle ear, gums, parotid gland Submandibular Cheek, nose, lips, anterior tongue, (submaxillary) submandibular gland, buccal mucosa Submental Central lower lip, floor of mouth, tongue Superficial cervical Skin, lower larynx, lower ear canal, parotid Superior deep Tonsil, adenoid, posterior scalp and cervical neck, tongue, larynx, hypopharynx, thyroid, palate, nose, esophagus, paranasal sinuses, nasopharynx, other cervicofacial nodes Inferior deep Dorsal scalp and neck, nasopharynx, cervical superficial pectoral region of the arm, superior deep cervical MASS LOCALIZATION Table 11. Mass Localization REGION CONSIDER Preauricular/Angle Saliva or lymphoid tissue in the parotid of the jaw system ++consider facial nerve function in evaluation and tissue sampling Central neck Thyroid enlargement/tumor Dermoid cyst Anterior SCM (High Lymph node metastasis jugulodigastric) 2nd Brancial cleft syct Posterior triangle Lymph node metastasis - possible Group Number 11B nasopharyngeal carcinoma Lymph node metastasis - lung, gynecological, GI sources Table 12. Mass Characteristics ETIOLOGY CHARACTERISTICS Reactive Discrete, mobile, firm, rubbery, and lymphadenopathy slightly tender Malignant Rock hard, fixed/ tumor/Lymph node Matted to underlying structures, metastasis nontender Infected lymph Isolated, asymmetric, tender, warm, nodes erythematous, +/- fluctuant *Congenital cyst Soft, ballotable, mobile *HPV-related Nodal metastases may present as a oropharyngeal cystic neck mass (increased index of squamous cell CA suspicion for patients >40 years old) Lymphoma Rapidly expanding mass (over days to weeks) Carotid body Firm lateral neck mass that moves from tumor/Vagal side to side but not up and down schwannoma Vascular lesion Pulsatile, bruits Thyroid tumor Midline neck mass, elevates with Thyroglossal duct swallowing (thyroid tumor) or tongue cyst protrusion (TDC) COMPONENTS OF GENERAL EXAMINATION Table 13. Components of General Examination Oral Thorough inspection of mucosa, Cavity/Oropharynx bimanual palpation of floor of mouth, palpation of tongue and neck Ears Note any unilateral serous effusion (may relate to nasopharyngeal CA) Nasopharyngeal Perform if no obvious etiology on oral exam and oropharyngeal exam (Mirror or Rigid/Flexible Endoscope) Skin of head and Potential primary skin malignancy neck (Melanoma/Squamous cell CA) Cranial nerve Can suggest neural tumor or neural function involvement by adjacent nodes Thyroid gland Palpate carefully, note movement when swallowing Trachea Note for any deviation Abdominal exam Take note of any liver or spleen enlargement B. DIAGNOSTIC TESTS ULTRASOUND Indications: ➜ Low risk malignant disease ➜ Thyroid nodules without clinical evidence of extra thyroidal extension invasion/rapid growth ➜ Pediatric patients ➜ Frequent surveillance imaging Table 14. Advantages vs Disadvantages of Ultrasound ADVANTAGES DISADVANTAGES Non-invasive Operator dependent Real-time assessment of NOT FOR SALE Limited permanent images for 24 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 mass and relation to adjoining use in consultant evaluation or structures operative setting Helpful in later evaluation of malignancies (not so for initial evaluation) Guides fine needle aspiration Varied interobserver reliability Inexpensive Different ultrasound systems may produce significant differences in image quality and interpretation COMPUTER TOMOGRAPHY Indications: ➜ Initial study of choice for most adult patients with head and neck masses, malignant masses, masses that involve deep neck spaces (eg. parapharyngeal & masseteric space) Table 15. Advantages vs Disadvantages of CT ADVANTAGES DISADVANTAGES Well tolerated by patients More expensive than ultrasound Allow evaluations in all relevant planes Exposure to ionizing radiation (caution in pediatric patients Yields excellent bone detail and those who need very frequent surveillance imaging) Fast acquisition time Possible contrast allergy Angiographic imaging variants (to assess masses with possible vascular origin) MAGNETIC RESONANCE IMAGING Indications: ➜ Masses that require further definition of soft tissue (eg. infiltrative soft tissue masses, suspicion of malignant perineural spread, or potential central nervous system origin) FINE NEEDLE ASPIRATION Preferred diagnostic approach for most neck masses ➜ Gauge 25 or 27 needle on 20mL syringe Table 18. Nature of aspirate may suggest particular etiologies NATURE OF ASPIRATE POSSIBLE ETIOLOGY Blood Vascular lesion Serous dark brown fluid Thick viscous yellow fluid Turbid yellow fluid Purulent Papillary thyroid cancer Mucocele Branchial cleft cyst Abscess FNA can also be submitted for PCR testing for viruses such as EBV (suggest nasopharyngeal Ca) or HPV (reported in oropharyngeal squamous cell Ca) Safe, highly accurate diagnostic procedure Dependent upon the skills of the clinician performing the procedure to avoid sampling errors and the accuracy of cytopathological interpretation A meta-analysis found an overall accuracy of 93% (ranged 73% to 98%) for FNA in diagnosing all neck masses regardless of location or histology In patients > 40 years, lateral neck cysts may represent cervical metastasis from HPV-associated OPSCC In these masses, the cyst lining is often the only diagnostic component, which decreases the specificity of FNA, especially that performed without image guidance Table 16. Advantages vs Disadvantages of MRI ADVANTAGES DISADVANTAGES Outstanding soft tissue Longer acquisition time vs. CT differentiation scan Lack of ionizing radiation May be challenging for claustrophobic patients Infrequent contrast allergy Angiographic imaging variants available More expensive than ultrasound/CT scan POSITRON EMISSION TOMOGRAPHY CT SCAN (PET-CT) Indications: ➜ Malignant tumors ➜ Identification of primary disease ➜ Detection of distant metastasis ➜ Surveillance Table 17. Advantages vs Disadvantages of PET-CT ADVANTAGES DISADVANTAGES Does not impart a significantly Expensive high radiation dose Group Number 11B Figure 70. A large mass in the neck is a symptom of oropharyngeal cancer, with human papilloma virus being a leading cause of increased rate of throat cancer CORE BIOPSY If the information provided by an FNA does not establish the diagnosis Performed under local anesthesia with a 14 to 20 gauge cutting needle ➜ 1 to 5 passes with an automatic needle gun for precise tissue acquisition NOT FOR SALE 25 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 and vagal n.) Metastatic squamous cell carcinoma (node) deficits Completion lymph node dissection may be more difficult Risk of tumor spillage and requires resection of prior inclusions and surrounding scar May require higher radiotherapy dosing to the prior surgical bed when definitive nonsurgical treatment is delivered Open biopsy can be more acceptable in the setting of an FNA or core biopsy being positive of lymphoma, but additional tissue is necessary for subtyping Figure 71. Core Biopsy Table 19. Advantages vs Disadvantages of Core Biopsy ADVANTAGES DISADVANTAGES Greater tissue yield/lower Potential trauma from largerrates of nondiagnostic bore needles samples Decreased variability in pathological interpretation Improved diagnostic accuracy in specific disease processes that require analysis of tissue architecture or flow cytometry (ex. lymphoma) **rates of tumor seeding after FNA or core biopsy were 40 years Streptococcal pharyngitis; skin infections; tularemia; plague; cat scratch disease; diphtheria; chancroid; rat bite fever; early Lyme disease; early (primary) syphilis GENERALIZED Brucellosis; leptospirosis; lymphogranuloma venereum; typhoid fever; secondary syphilis VIRAL Human immunodeficiency virus; Epstein-Barr virus; herpes simplex virus; cytomegalovirus; mumps; measles; rubella; hepatitis B; dengue fever MYCOBACTERIAL Mycobacterium tuberculosis; atypical mycobacteria FUNGAL Histoplasmosis; coccidioidomycosis; cryptococcosis PROTOZOAL Toxoplasmosis; leishmaniasis Skin lesions on scalp, face, neck Nerve involvement (facial paresis, paresthesia) LOCALIZED DIFFERENTIAL DIAGNOSIS In ruling out other factors: ➜ Congenital ➜ Infectious ➜ Neoplastic ◆ Benign ◆ Malignant - the next one to rule out! A neck mass in the adult patient should be considered malignant until proven otherwise SUSPECT MALIGNANCY Table 23. Presentation of malignant neck masses HISTORY FINDINGS Infectious etiology ruled out Size >1.5 cm Duration of ≥2 weeks or unknown Firm to hard on palpation Fixed/reduced mobility Induration/ulceration of overlying skin/mucosa Table 24. Additional findings that increase suspicion for malignancy Group Number 11B Odynophagia or dysphagia Hemoptysis or blood in saliva Dyspnea Unexplained weight loss An asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer ESTABLISH DIAGNOSIS Consider the neck mass benign: ➜ Congenital ➜ Infectious ➜ Neoplastic ◆ Benign ◆ Malignant Table 25. Examples of Benign and Congenital Head and Neck Masses BENIGN HEAD AND NECK CONGENITAL HEAD AND MASSES NECK MASSES Thyroid nodules/cysts Branchial cleft cyst Salivary gland neoplasm Thyroglossal duct cyst (pleomorphic adenoma, Vascular anomalies Warthin tumor) (hemangioma, Ranula hemangioepithelioma) Paraganglioma Laryngocele Schwannoma Ranula Lipoma Teratoma Benign skin cysts (sebaceous Dermoid cyst cyst, epidermal inclusion cyst) Thymic cyst D. MANAGEMENT Medical or surgical management Referral to other subspecialties for further management (includes but not limited to the following): ➜ ENT - Head and Neck Surgeons ➜ Neurosurgeons ➜ Radiation Oncologists ➜ Medical Oncologists ➜ Endocrinologists NOT FOR SALE 27 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 ➜ Medical Nutritionists ➜ Psychiatrists ➜ Dentists VIII. KEY POINTS Evaluation of a neck mass begins with a thorough history and physical examination Physical Examination should be able to localize and characterize the mass, as well as include examination of the oral cavity, cranial nerves, as well as a comprehensive general examination Laboratory and imaging studies should be ordered based on findings from the history and physical examination Most neck masses in adults are neoplastic or malignant A neck mass in an adult patient is considered MALIGNANT until proven otherwise An asymptomatic neck mass may be the only manifestation of head and neck cancer The immunogenicity of the COVID-19 vaccine can lead to reactive cervical, axillary or subpectoral adenopathy ipsilateral to the injection site Elective screening studies for head and neck cancer patients should be scheduled either before or at least six week after the COVID-19 vaccine If imaging must be obtained sooner, the vaccine should be administered contralateral to the patient’s cancer when possible REFERENCES Doc Lapitan’s Lecture on Head and Neck Tumors TRANSCRIBERS Group 11B PROOFREADERS NB AA Group Number 11B NOT FOR SALE 28 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 c. Biopsy d. Control of epistaxis REVIEW QUESTIONS A. PAST EXAM (2023) 1. Which of the following is part of the posterior triangle of the neck? a. Occipital b. Carotid c. Muscular d. Submandibular 2. Lesions that expand with crying, straining, or compression of the jugular veins are known as? a. Transillumination b. Furstenberg’s test c. Fontaine’s sign d. None of the above 3. A patient present with a bulge in the area of nasal dorsum which expand on crying and transilluminate. What is the primary treatment of choice? a. Incision biopsy b. Medical treatment c. Excision with neurosurgical consult d. Excision alone 4. Which of the following conditions require dermabrasion or secondary healing intention? a. Rhinophyma b. Inverted papilloma c. Nasal polyp d. Glioma 5. A 35-year old female presented with right-sided nasal obstruction. On PE, you noted a pale, polypoid mass at the area of middle meatus. What is your impression? a. Rhinophyma b. Inverted papilloma c. Nasal polyp d. Glioma 6. Which of the following HPV strains is reported to be involved in the etiogenesis of inverted papilloma? a. 16 b. 19 c. 22 d. 1 7. Which of the following Paranasal CT scan finding raises suspicion of malignancy? a. Lytic destruction b. Encapsulated lesion c. Defined hypodensity d. Sparing of skull base 8.A 16-year-old male came to the ER due to recurrent left epistaxis for 3 years. There were no other associated symptoms. On consult, you noted active epistaxis, but patient is stable. What is your initial management? a. CT or. MRI b. Embolization Group Number 11B 9. Which of the following excludes approach in a patient with Juvenile Nasoangiofibroma a. Local Biopsy b. CT or MRI c. Transpalatal surgery d. Embolization 10. A 20-year-old male came in for your opinion due to a mass seen on his skull X-ray showing small protruding hyperlucency on the right frontal sinus. Patient denies any symptoms. What is your impression? a. Juvenile nasoangiofibroma b. Inverted Papilloma c. Nasal polyp d. Osteoma 11. Which of the following oral cavity masses belong to a possible congenital cause? a. Pyogenic granuloma b. Ameloblastoma c. Lingual thyroid d. Ranula 12. A 40-year-old male came in due to bulge in his hard palate causing difficulty in wearing his denture. He claims that this was noted since childhood which slowly grew in size. On PE, it was hard seemingly continuous with the hard palate. What is your suggested approach a. Observe b. Biopsy c. CT Scan d. Surgery 13. What is the management for an oral cavity mucosal mass due to chronic trauma or infection? a. Antibiotics b. Excise c. Incise d. Wait and see 14. Ranula is a type of mucocele that forms in the floor of the mouth. Which of the following is true regarding ranula? a. Injury to the Stensen’s duct b. Extension in the neck is called plunging ranula c. Sialolith is not related to its development d. None of the above 14. Ranula is a type of mucocele that forms in the floor of mouth. Which of the following is true regarding ranula? a. Injury to the Stensen’s duct b. Extension in the neck is called plunging ranula c. Sialolith is not related to its development d. None of the above 15. Which salivary gland is the most common site of salivary NOT FOR SALE 29 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 gland tumors? a. Minor salivary glands b. Sublingual c. Parotid d. Submandibular 22. A 4-year old healthy female consulted the OPD due to anterior neck mass on the midline anterior neck which moves on tongue protrusion. What is the most likely diagnosis? a. Thyroglossal duct cyst b. Branchial cleft cyst c. Dermoid cyst d. Lipoma 16. The presence of which finding likely points to a benign salivary gland tumor? a. Skin discoloration b. Slow growth c. Palpable neck node d. Facial asymmetry 23. What is your treatment of choice? a. Sistrunk procedure b. Incision biopsy c. Excision d. Antibiotics 17. What salivary gland tumor is most commonly associated with cigarette smoking? a. Pleomorphic adenoma b. Benign lymphoepithelial cyst c. Mucoepidermoid carcinoma d. Warthin’s tumor 18.Which condition is associated with the crown of an unerupted tooth usually involving the 3rd molar and maxillary canine? a. Ameloblastoma b. Dentigerous cyst c. Radicular cyst d. Lymphangioma 19. What condition is a benign, slow growing mandibular tumor with low malignancy potential? a. Dentigerous cyst b. Ameloblastoma c. Radicular cyst d. Lymphangioma 20. Which of the following are included in the management of patients with ameloblastoma? a. Mandibulectomy b. Incision and curettage c. Reconstruction d. All of the above 24. An 18-year old male presented with a right lateral neck bulge after a recent upper respiratory tract infection. Patient had no other accompanying symptoms. PE showed a firm, non-tender right lateral neck mass measuring 4x4 cm anterior to the sternocleidomastoid muscle. What is the most probable cause? a. Inflammation of the cervical lymph node b. Locoregional metastatic involvement c. Failure of closure of the tract on descent of thyroid d. Anomalous development of branchial apparatus 25.This is the most common type of branchial cleft anomaly located deep to the anterior border of the sternocleidomastoid muscle with possible connection draining to the tonsillar fossa. a. Fourth b. Third c. Second d. First answers: 1a, 2b, 3c, 4a, 5b | 6a, 7a, 8d, 9a, 10d | 11c, 12d, 13b, 14b, 15c | 16b, 17d, 18b, 19b, 20d | 21a, 22a, 23a, 24d, 25c 21. Which of the following mass is in the lateral neck region? a. Branchial cleft cyst b. Thyroglossal duct cyst c. Dermoid cyst d. Thyroid goiter De La Salle Medical and Health Sciences Institute College of Medicine BATCH 2024 Appendix A Group Number 11B NOT FOR SALE 30 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Odontogenic Tumors Appendix B Group Number 11B NOT FOR SALE 31 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Odontogenic Cyst Appendix C Group Number 11B NOT FOR SALE 32 of 33 OPHTHALMOLOGY : HEAD AND NECK 1 Module 12 - Trans 07 Benign Non-Odontogenic Tumors Group Number 11B NOT FOR SALE 33 of 33