EARS, NOSE & THROAT (ENT)

Topic: Diseases of the Oral Cavity and Pharynx

Lecturer: Dr. Uy, Sidney

THE ORAL VESTIBULE AND ORAL CAVITY DISEASES OF THE ORAL CAVITY
 Oral vestibule bounded: Benign Lesions
o Externally: by lips and cheeks 1.) Torus
o Internally: by alveolar processes and teeth  Mucosally covered bony outgrowths
 When teeth are in occlusion, it communicates with oral cavity via a  Pedunculated or multilobulated, broad based, smooth bony mass
space behind last molar  Appears on the second decade of life
 Key role in food ingestion and speech production
 Oral cavity opens into: 2 TYPES OF TORUS
o Pharynx at the faucial isthmus TORUS PALATINUS

ORAL CAVITY
 Bounded:
o Anteriorly and Laterally by: alveolar ridge and teeth
 Torus is found at the hard
o Superiorly: by hard and soft palate
palate
o Posteriorly: by faucial isthmus
 Faucial isthmus is narrow opening between oral cavity and pharynx,
bordered by soft palate with uvula and by dorsum of tongue at its
junction with tongue base

CHEEK TORUS MANDIBULARIS

 Lateral boundary of vestibule
 Buccinator forms muscular framework
 Buccal fat pad smoothens cheek contour; between buccinator and  Torus is found at the mandible
masseter
 Excretory duct of parotid gland runs through buccinator and opens into
mucosa of cheek opposite upper second molar

TEETH
 Dentition consists of two sets of teeth:
o Deciduous teeth replaced by permanent teeth, eight occupy
each half of the maxilla and mandible
 Alveolar processes of maxilla also form floor of maxillary sinuses
2.) Micrognathia
PALATE
 Hard palate formed by:
o Anteriorly: Palatine processes of maxilla
o Posteriorly: Incisive bone, and horizontal plates of palatine
bones
 Oral cavity is sealed posteriorly by soft palate with its pendulant process
(uvula)
 Palatal muscles form framework of soft palate, innervated by
pharyngeal plexus (CN IX and CN X)
3.) Prognathism
TONGUE
 A muscular structure with apex, body, and base/root.
 Body separated from base by the terminal sulcus
 Papillae: filiform, fungiform, vallate, and foliate
NOTE: Torus CANNOT be treated MEDICALLY. The only treatment is
SURGICAL via surgical removal. So you remove the mucosal covering and drill
out the excess bone
 Dimunition in size of jaw
 Congenital or acquired
 Failure at the growth center in the condyle
 TREATMENT: You treat the underlying cause
o If cause is hormonal  treat it medically
o If NOT hormonal  treat it via maxillary mandibular
advancement surgery to increase the size of the jaw into the
normal parameters
 Enlargement or anterior placement of the lower jaw
It is the opposite of micrognathia
 May be absolute or relative
 Multifactorial hereditary trait
 TREATMENT:
o If the underlying cause is hormonal  treat it medically
o If NOT hormonal  treat it with surgery by reducing the size
of the jaw

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Oral Cavity and Pharynx
Lecturer: Dr. Uy, Sidney

4.) Macroglossia  1 parent w/ cleft: 3.2% CL & CP, 6.8% CP

 Enlargement of the tongue If one of the parent has cleft  there is a 3.2% chance of their child
 Most congenital cases are due to lymphangioma or developing cleft lip and cleft palate and 6.8% chance of developing
hemangiolymphangioma cleft palate only

HEMANGIOMA TREATMENT:  1 parent and 1 child w/ cleft: 15% CL & CP

 Medical treatment if there is If one of the parents and one of their children has cleft  there is a
infection (oral antibiotics) 15% chance of their child having cleft lip and cleft palate
 If NO infection  undergo
surgery via excision biopsy to
remove the hemangioma

CAVERNOUS LYMPHANGIOMA TREATMENT:

 No medical treatment for this
 SURGERY (Hemiglossectomy) 
remove part of the tongue
 To reduce complications of
Unilateral Cleft Lip and Cleft Palate
bleeding, refer the patient first to
interventional radiology, 24-48
hours prior to surgery  what 8.) Odontogenic Cyst
they do is embolization of the  Cyst of dental origin
major vessels of the tongue to 2 Types:
reduce complications of bleeding  Radicular cyst
o Periapical
5.) Ankyloglossia
o Lateral
 It is secondary to a congenitally o Residual
short lingual frenulum.
 Dentigerous cyst
 If it is not corrected before the
patients can speak, the patient Radicular Cyst:
will have problems with speech
 Must always be associated with a
(tongue tied)
nonvital tooth
 TREATMENT:
 The tooth may be rendered nonvital by:
o Frenulum could be clipped in infancy
o Trauma
o Z plasty could be performed to lengthen frenulum and produce
o Caries
more tongue mobility
o Periodontal space extension

6.) Lingual Thyroid

 How do you classify the different radicular
 Failure of the thyroid gland to descend
cysts?
from the foramen cecum to the anterior
o Periapical cyst  found on the
neck
periapical region
 90% of all ectopic thyroid tissue is o Lateral radicular cyst  a
associated with the dorsum of the variant of the periapical cyst found laterally from the periapical
tongue region
 This is one of the more uncommon conditions you will see in the OPD or o Residual cyst  it is usually a periapical or lateral radicular cyst
during the ENT rotation that is left behind following tooth extraction
 Patients usually are of pediatric age  complaining of sore throat  All of these cysts are inflammatory cysts
o Parents might think patient is just having tonsillopharyngitis
but upon P.E. you will see that there is thyroid tissue inside the Dentigerous Cyst:
oral cavity  It must be associated with a crown of an
 TREATMENT: unerupted tooth or a developing tooth or
o If with infection  oral antibiotics odontoma
o After treating the infection  you advise the parents to have  The dentigerous cyst form when fluid
the patient undergo thyroidectomy accumulates between the reduced enamel
epithelium and the tooth crown
7.) Cleft Lip and Cleft Palate
 Most common congenital anomalies of the head and neck TREATMENT of Odontogenic Cyst:
 CL = 1:1000; CP = 1:2000  You can treat dentigerous cyst and
radicular cyst  via SURGERY (do excision
Chances of child having cleft: of the dentigerous or radicular cyst)
 1 child w/ cleft: 4.4% CL & CP, 2.5% CP  When you do excision of the
If the parents have 1 child having cleft  there is a 4.4% chance of DENTIGEROUS CYST, you also need to
their 2nd child having cleft lip & cleft palate and 2.5% chance of remove the unerupted tooth/developing tooth/odontoma that caused
having cleft palate only
the dentigerous cyst

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Oral Cavity and Pharynx
Lecturer: Dr. Uy, Sidney

Odontogenic Cysts: Information from Handout of the Department 11.) Lip Mucocele
Radicular Cysts:  Mucous cysts are pseudocysts, because no
 The periapical cyst  must be associated with a nonvital tooth. The true lining is present; they are also called
tooth may be rendered nonvital by trauma, caries, or periodontal space mucous retention cysts
extension.  These lesions are usually located on the
 Lateral radicular cyst  a variant of the periapical cyst. It is associated mucous surface of the lower lip and are
with a nonvital tooth, but instead of being at the apex of the tooth the asymptomatic.
cyst is located lateral to the tooth root(s).  They appear to be the result of traumatic
 Residual cysts  majority of these cysts will be the result of leaving a rupture of the ducts of minor salivary glands.
periapical cyst “behind” following tooth extraction. All of these cysts are  With leakage of the contents into the tissue,
inflammatory cysts. an inflammatory process ensues, with the resultant formation of
granulation tissues surrounding the cystic space.
Dentigerous Cyst:
 TREATMENT:
 The dentigerous cyst by definition must be associated with the crown
of an unerupted tooth, developing tooth, or odontoma. o Surgical  Excision biopsy
 Dentigerous cysts form when fluid accumulates between reduced
enamel epithelium and tooth crown. 12.) Ranula
 As alluded to earlier, the accumulation of fluid may be partially or largely  It is a mucocele but it is found over the
surrounded by connective tissue and epithelium. submandibular gland.
 Because the third molars and maxillary canines are the teeth most  It is a mucous retention of the sublingual
frequently impacted, they are also the most likely to be associated with gland found under the tongue
dentigerous cysts  TREATMENT:
 However, any impacted tooth has an increased risk o Excision biopsy + Marsupialization

9.) Nasoalveolar Cyst 13.) Stomatitis

 It is treated through lip gargles
o Example: Bactidol
 The patient is advised to practice proper
dental hygiene
 Can be oral or gingival stomatitis

14.) Leukoplakia

 Nasoalveolar cysts are 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.
 Patients typically present with swelling in the nasolabial area, which
causes unilateral elevation of the nasal ala.
 Intraorally, a smooth, mucosal, covered mass in the gingival labial
sulcus is seen
 TREATMENT:
o Surgical excision
 Oral leukoplakia can be defined as a white patch or plaque that cannot
be otherwise characterized clinically as representing any other disease
10.) Dermoid Cyst
entity.
 Dermoid cysts are cystic masses
 Main differential diagnosis: Oral Candidiasis
found along embryonic fusion lines
Both present as white patch or plaque inside the oral cavity.
and form from epithelial crests.
Difference is that:
 Histologically, dermoid cysts are  Oral candidiasis  you can scrape off the white patch or
lined by squamous epithelium of plaque
the keratinizing variety.  Leukoplakia  white patch or plaque cannot be scraped off
 They contain elements of
epidermal appendages including:  Oral leukoplakia are usually premalignant lesions
o Hair follicles  Punch biopsy is usually done  sent for histopathologic exam to be
o Sweat glands sure that it is not an oral carcinoma
o Connective tissue.  Although the cause of oral leukoplakia is unknown, several associated
 TREATMENT: habits or behaviors are associated with the presence of this clinical
o No medical treatment lesion.
o Surgical  Excision biopsy  Most closely associated with leukoplakia is the use of tobacco in its
many forms including smoking and several forms of smokeless tobacco
use

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Oral Cavity and Pharynx
Lecturer: Dr. Uy, Sidney

Leukoplakia continued….. Ameloblastoma continued…..

 In general the appearance can range from a thin grayish surface Ameloblastoma, Mandible
alteration demonstrating a white translucent quality with ill-defined
margins and generally smooth surface qualities to discrete, sharply
marginated, thick and opaque plaques.
 In general terms such lesions may be homogeneous and smooth, focal
or diffuse, or heterogeneous and multifocal with variable textures.
 Surface textural alterations can range from a fine granularity to a
slightly papillary outline
 The main difference of an ameloblastoma with dentigerous cyst is that:
15.) Oral Candidiasis o Age:
 Candidiasis is a common opportunistic  Ameloblastoma  usually seen in adult patients
infection of the oral cavity, oropharynx,  Dentigerous cysts  usually seen in pediatric patients
and corners of the mouth. o Radiologic evaluation:
 Candida albicans represents the most  Dentigerous cysts  cystic in appearance and always
common candidal species. associated with an unerupted tooth
 The finding of atrophic red patches or white curdlike surface colonies  Ameloblastoma  there is solid cortical bone
with or without angular cheilitis in relation to discomfort in the more expansion
acute forms of the disease is usually compelling.  TREATMENT:
 TREATMENT: o Surgical
o Antifungals  Nystatin swish and swallow o No more need to do chemotherapy or radiation because
ameloblastomas are not malignant (but they are very
RISK FACTORS aggressive)
 Heavy smoking
 Foreign bodies (dentures, nasogastric tubes) 17.) Pyogenic Granuloma
Local Factors 
 Radiation-induced mucositis Pyogenic granulomas of the oral cavity
(mucosal barrier
 Inhalational and topical corticosteroid use and oropharynx can occur on any
function)
 Xerostomia mucosal surface subject to acute or
 Mucosal tumors chronic trauma or infection
 Immunosuppression  TREATMENT:
 Age o No medical treatment
 Viral (retroviral infections) o Excision biopsy  send for histopathologic examination to be
 Chemotherapy sure that it is not a premalignant or malignant lesion
 Corticosteroid use
Systemic Factors
 Diabetes mellitus Malignant Lesions
 Intrinsic immunodeficiency 18.) Squamous Cell Carcinoma
 Myelodysplasia  It is the most common
 Leukemia cancer of the oral cavity.
 Antibiotic administration
 It can occur on the buccal
mucosa or on the tongue.
CLINICAL FORMS
 It can present as leukoplakias
OF CANDIDIASIS
with ulceration
Acute  Pseudomembranous (thrush)
 TREATMENT:
Candidiasis  Erythematous/atrophic
o Tongue: Total glossectomy
 Hyperplastic (candidal leukoplakia)
Chronic o Palate: Total excision of tumor +
 Denture related (chronic erythematous / atrophic)
Candidiasis Reconstruction + Chemo and
 Median rhomboid glossitis
Radiation therapy
16.) Ameloblastoma o Almost all of the head and neck
cancers  gold standard is
 Ameloblastoma is the most common neoplasm
SURGERY + RECONSTRUCTION
of odontogenic origin.
+ CHEMO & RADIATION
 Ameloblastomas are thought to arise from
THERAPY
crests of primitive dental lamina related to the
 Information from handout:
enamel organ in alveolar bone.
o The gold standard for
 Patients are typically seen in the third decade of
treatment of head and neck
life with a painless mass involving the maxilla or
cancers is surgical removal
mandible.
 Cortical bone expansion can be seen.
 Histologically, ameloblastomas are solid infiltrating tumors with a
follicular or plexiform pattern, which exhibit an element of cystic
change

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Oral Cavity and Pharynx
Lecturer: Dr. Uy, Sidney

PHARYNX DISEASES OF THE PHARYNX

 A tubular, fibromuscular space from skull base to upper esophageal 1.) Chronic Adenotonsillar Hypertrophy
sphincter  The tonsils are always enlarged but it is
 Bounded externally by muscle to coordinate the act of swallowing, not due to infection or inflammation.
immune response to infection, and as a resonator of speech sounds\  It is graded according to size.
 Divided into 3 regions:  There can be enlarged palatine tonsils
o Nasopharynx and adenoids
o Oropharynx  The patient is prone to having
o Laryngopharynx (Hypopharynx) obstructive sleep apnea (OSA).
 TREATMENT:
Nasopharynx o Surgery  remove the tonsils and adenoids (tonsillectomy
 Extends from skull base (sphenoid sinus) to velum and adenoidectomy)
 Communicates with nasal cavity (choanae) and middle ear (ET) 
 Bounded posteriorly by first cervical vertebra, with its overlying
prevertebral cervical fascia and prevertebral musculature 2.) Juvenile Nasopharyngeal Angiofibroma
 Angiofibroma usually occurs in adolescent males and is thus commonly
Oropharynx called JNA
 Extends from lower boundary of velum to upper margin of epiglottis Significance:
 Communicates with oral cavity via faucial isthmus If you have a patient who has epistaxis and is an adolescent male
 Boundaries: tongue base (anterior); lingual tonsil and by C2 to C3 and you think that the patient has a nasopharyngeal mass, YOU
vertebrae with prevertebral fascia (posterior); faucial pillars (lateral) DON’T DO a nasopharyngeal biopsy but what you do is CT scan with
which flank the palatine tonsils contrast and look out for a positive Holman Miller Sign
Holman Miller Sign  anterior bowing of the posterior maxillary
Hypopharynx wall
 Extends from superior border of epiglottis to inferior border of cricoid
cartilage.  It is nonmalignant but they are very aggressive
 Posterior wall is C3-C6 vertebrae.  It accounts for less than 1% of all head and neck tumors.
 Anterior wall is larynx, protrudes to form two lateral mucosal pouches  The tumor mass is locally infiltrative and usually has a wide-based
(piriform sinuses), which rejoin at level of esophageal inlet attachment to the NP and to its surrounding related anatomy.
 The gross pathology usually shows a sessile, lobulated, rubbery dark red
TONSILLAR RING (WALDEYER’S RING) to tan gray mass that can be large in size.
 Lymphoepithelial “organs”  Mucosal ulceration is uncommonly seen and the tumor is
 Similar to lymph nodes but lacks afferent lymphatic vessels unencapsulated and composed of an admixture of vascular tissue and
 Pharyngeal tonsil (Adenoid tonsils) - ciliated epithelium fibrous stroma.
 Eustachian tube tonsils (Gerlach’s tonsils)  The vessel walls lack elastic fibers and have incomplete or absent
o Pharyngeal and ET tonsils are found at nasopharyngeal area smooth muscle that will account for their tendency to bleed
 Palatine and lingual tonsils - stratified, nonkeratinized squamous  TREATMENT:
epithelium o Surgery  either an endoscopic surgery or open surgery
o Palatine tonsils  found at oropharyngeal area (midface degloving, palatal splint)
o Lingual tonsils  found at laryngopharyngeal /
hypopharyngeal area 3.) Acute Tonsillopharyngitis
 One of the most common conditions
you will see in the OPD
 Patient usually complains of sore
throat, hoarseness, dysphagia,
odynophagia, and fever, cough or
colds
 Virus is the most common cause of acute tonsillopharyngitis.
 Usually, antibiotics are not given because if the cause is viral, it is self
limiting.
 If there is presence of exudates, it is caused by bacteria.
 Antibiotics are given for bacterial cases
o Penicillins or Beta-lactams
o Macrolides  given if allergic to penicillin or beta-lactams
 Example: Clarithromycin, Erythromycin, Clindamycin

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Oral Cavity and Pharynx
Lecturer: Dr. Uy, Sidney

4.) Peritonsillar Abscess

 There is abscess in the peritonsillar
area (around the tonsils).
 Pushes the palatine tonsils which
blocks the oropharyngeal cavity
(faucial isthmus)
 Patient complains of severe throat
pain, difficulty of breathing, but the
most pathognomonic feature is hot potato voice
 The tonsils are not enlarged but may seem large because it is being
pushed by the peritonsillar area which contains the abscess.
 Usually it is unilateral.
 TREATMENT:
o Before doing any medications you need to do Incision and
Drainage of the peritonsillar abscess
You get a large bore needle and stick it on the most
dependent part in the peritonsillar area and try to aspirate
the pus from inside the peritonsillar are  send specimen
to the laboratory for gram staining and culture and
sensitivity (to guide for antibiotic therapy)
If you aspirate BLOOD and not pus  it might be a case
PERITONSILLAR CELLULITIS. You still treat it as a
peritonsillar abscess, so you still give empirical antibiotic
therapy
Change antibiotic based on the result of the culture and
sensitivity for a more targeted approach for the bacteria

INDICATIONS FOR TONSILLECTOMY

Absolute
 Hypertrophy resulting in cor pulmonale
 Hypertrophy resulting in sleep apnea
 Hypertrophy resulting in dysphagia with associated weight loss
 Consideration of malignancy
 Recurrent peritonsillar abscess or abscess extending into adjacent
tissue spaces

Relative
 Documented recurrent bouts of tonsillitis
Paradise Criteria:
 If patient has 7 or more bouts of tonsillitis that happens
within 1 year
 If patient has 5 or more documented bouts of tonsillitis that
happens every year for 2 consecutive years
 If patient has 3 or more bouts of tonsillitis happening every
year for the past 5 consecutive years
 If patient has been hospitalized, missed work, missed school
from an acute bout of tonsillitis for at least 2 weeks or more
 If patient has an episode or peritonsillar abscess/cellulitis

If they have one of these criteria  then they may go tonsillectomy

 Tonsil and adenoid hypertrophy associated with orofacial or dental

abnormalities that narrow the upper airway
 Rheumatic fever history with heart damage associated with chronic
recurrent tonsillitis

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