Diseases of the oral cavity & oropharynx

Acute Tonsillitis
Etiology
• Group A beta-hemolytic streptococcus and Group G
streptococcus
• S. pneumoniae, S. aureus, H. influenzae, M. catarrhalis
• Epstein-Barr virus (EBV)
Clinical Features
• symptoms
– sore throat
– dysphagia, odynophagia, trismus
– malaise, fever
– otalgia (referred)
• signs
– tender cervical lymphadenopathy especially
submandibular, jugulodigastric
– tonsils enlarged, inflammation ± exudates/white follicles
– strawberry tongue, scarletiniform rash (scarlet fever)
– palatal petechiae (infectious mononucleosis)
Investigations
• CBC
• swab for C&S
• latex agglutination tests
• Monospot .
Treatment
• bed rest, soft diet, ample fluid intake
• gargle with warm saline solution
• analgesics and antipyretics
• antibiotics
– only after appropriate swab for C&S
– 1st line penicillin or amoxicillin (erythromycin if penicillin
allergic) x 10 days
– rheumatic fever risk emerges approximately 9 days after the
onset of symptoms: antibiotics are utilized mainly to avoid this
serious sequela and to provide earlier symptomatic relief
– no evidence for the role of antibiotics in the avoidance of
post-streptococcal glomerulonephritis
Complications
• deep neck space infection
• abscess: peritonsillar, intratonsillar
• sepsis
• glomerulonephritis
Adenoid hypertrophy
• Increase in size with allergy
and repeated URTI
• Clinical features
– Nasal obstruction
• Adenoid facies
• Hyponasal voice
• OSA
– Rhinitis/sinusitis
– PND and cough
– Recurrent OM
Adenoid Hypertrophy

adenoidal hypertrophy
ANTIGEN EXPOSURE and cellular response

continued exposure
of antigen in trapped nasopharyngeal obstruction
secretions and inspissation of secretions

resolution of acute infection

immunologic memory
established
Adenoid Hypertrophy

• Indications for surgery

ANTIGEN EXPOSURE tonsillar hypertrophy

continued exposure progressive airway obstruction

resolution of acute infection

immunologic memory
established
Indications for Tonsillectomy
• Absolute
• OSA, cor pulmonale
• Suspect malignancy
• Hemorrhagic tonsillitis
• Severe dysphagia
• Relative
• Tonsillar hypertrophy
• Recurrent tonsillitis
• Complications of tonsillitis
Obstructive sleep apnoea syndrome (OSAS)
• Definitions
– Apnoea
• Cessation of airflow at nostrils for 10 seconds or longer
– Apnoea index
• Number of apnoeas per hour of sleep
– Hypopnoea
• Reduction in airflow associated with desaturation
– Sleep apnoea syndrome
• 30 or more apnoeic episodes during a 7-hour sleep
Causes of OSAS
• Nose
– Polyps
– Deviated nasal septum
• Pharynx
– Adenoidal hypertrophy
– Nasopharyngeal tumor
– Large palatine/lingual tonsils
– Retropharyngeal mass
– Large tongue
– Obesity
Clinical features
• Frequent wakening and disturbed sleep pattern
• Snoring
– Sign of partial airway obstruction
• Apnoeic episodes
• Daytime somnolence
• Signs
• Poor nasal airway
• Mouth breathing
• Noisy respiration
• Grossly hypertrophic tonsils
• Short, thick neck
• Obesity
• Complications of OSAS:
– Pulmonary hypertension, RHF, COR pulmonale
 Special investigations
• Sleep studies/polysomnography
• Lateral neck X-ray, CXR, ECG
• Nasendoscopy
Treatment
• Conservative
– Dietary modification
– Nasopharyngeal airway
– CPAP (continuous positive airway pressure)
• Surgical
– Adenotonsillectomy
– UPPP
– Tracheostomy
 Malignant tumors of the oral cavity
• Synonymous with SCC b/c it constitute 95% of cases
• Adenoid cystic carcinoma, sarcomas esp RMS & liposarcoma,
Lymphomas & malignant melanoma
• Kaposi sarcoma, NHL in HIV infected patients
• SCC
– 4% & 2% of all cancers in males & females respectively
– Men affected 2-3 than women
– Average age at diagnosis is 60 years
– Incidence increases with age
– 75% occur in 10% of mucosal surface
- Areas of salivary flow & pooling
- Lateral tongue, retromolar trigone, gingivobuccal sulcus
Fig.
Incidence of SCC in the oral cavity by site
Etiology
• Well established causes
- Tobacco(80-90% of cases)
- Alcohol
- Synergistic effect
- Poor oral hygiene
- Pipe smoking & sun exposure
- Recent studies suggest HSV 1,HPV 2, 11, 16
 Pathogenesis
• Often heralded by Leukoplakia/erythroplakia
– White & red lesions respectively
– Abnormal but not necessarily neoplastic
– Seriousness evaluated by biopsy only
– Can be benign, pre cancerous or frank invasive cancer
– Leukoplakia progress to cancer in 5-10%
– Erythroplakia more likely to progress, 51% at initial biopsy
• Clinically early lesions appear
- Indurated nodules or shallow ulcer with poorly defined margins
- Exophytic, infiltrative resulting in functional abnormalities
• Incidence of nodal metastasis related to site & size
• High incidence for oral tongue & floor of mouth cancers
 Clinical features
• Majority present as ulcer
• Lump in the lip/oral cavity
• White/red patches in the oral cavity
• Palpation yield more information than inspection alone
• Others suggesting malignant growth
- Unusual pain or bleeding
- Difficulty/pain with chewing/swallowing
- Change in fit of dentures
- Referred otalgia, change in voice
 Lab & imaging
• CBC
• Blood chemistry including LFTs
• CT/MRI
• CXR to r/o metastasis
• Additional tests
- Exam under GA - Direct laryngoscopy
- Tumor mapping with toluidine blue & acetic acid
- PET scan - Panorex film of the mandible
- Pre radiation dental evaluation & audiologic assessment
 Treatment
• Biopsy mandatory before any surgical intervention
• Surgery & radiotherapy primary mode of treatment
• Perioperative antibiotics can decrease infectious complications
• Prophylactic antibiotics immediately before surgery and for 24
hours postoperatively.
• Adequate gram-positive coverage in addition to anaerobic
coverage.
• Radiation for high risk of regional recurrences