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Oral CavityQ

  1. Torus is a submucosal bony outgrowth, involving hard palate or mandible.
  2. Ranula:
    1. a cystic translucent lesion seen in the floor of mouth on one able of frenulum.
    2. Arises from the sublingual salivary gland.
    3. Some extend into the neck (plunging ranula)
Ranula is: (AIPG 2011)
  1. Thyroglossal cyst
  2. Epulis
  3. Bifid uvula
  4. Cyst at the floor of mouth
Ans. D Cyst at the floor of mouth
    1. Leucoplakia
    2. Erythroplàkia
    3. Chronic hypoplastic condidiasis
    4. Submucus fibrosis
    5. Syphilitic glassitis
    6. Sideropenic dysphagia
    1. Shows hyperkeratosis, parakeratosis & dysperatosis (dysplasia).
    2. Smoking is the most common etiology (II is tabacco showing)
  1. Smoking
  2. Tabacco chewing
  3. Alcohol
  4. Dental sepsis, jagged sharp teeth & ill fitting dentures.
    1. Poor prognostic indicators include nerve involvement, fixation to the maxilla or mandible, cancer arising on the upper lip or commissure, positive nodal disease, and age younger than 40 years at diagnosis. 
    2. A depth of tumor invasion of 4 to 5 mm has been shown to be a cutoff above which the incidence of cervical nodal disease is significantly increase
    3. Defects encompassing between half and two thirds of the lip require augmentation. 
    4. The Estlander flap is used when the defect involves the commissure, whereas the Abbé flap is used for more midline defects and requires second-stage division of the pedicle. The Karapandzic flap is one-stage procedure used for defects involving more than two thirds of the lip. 
    5. For defects greater than two thirds, the Webster, Gillies, or Bernard types of repairs may also be used.
    6. M. Common. Carcinoma of oral cavity, common : Basal ceucarcinoma
    7. Type of oral cavity carcinoma, with best prognosis (due to early detection)
    8. M. Common Type is squamous cell carcinoma (of lower lip), lower lip (90-95%) upper lip (2-7%)
    9. M. Common Lymphnode involved is – submental
    10. May cause cancer on the lip at the site of contact (kiss cancer)
    11. Factor: white men, pipe smoking, sunexposure
    1. M. C. site — middle 1/3 of the lateral margins.
    2. M.C.age—50--7OYears
    3. M. C. type— Squamous cell carcinoma.
    4. M. C. Lymph nodes involved — submandibular and upper deep cervical nodes.
    5. If late stages, local pain, dysphagia, otalgia may occur
    6. M. Corn aetiological agents — Tabacco chewing & smoking, 
    1. M. C. site —buccal sulcus (where tobacco quid is kept).
    2. Spread to submandibular and upper deep cervical nodes.
    3. Treatment:
    4. Small lesion — RT or Surgery
    5. Extensive lesion — Extensive excision + Radical neck dissection + plastic reconstruction.
    1. Two types - squamous cell (more common) and adenoid cystic.
    2. Starts as a superficial asymptomatic ulcer with rolled out edges.
    3. Lymphatic spread to submandibular and upper deep cervical nodes.
    4. Painless
    5. Treatment — resection along with underlying bone.
(Ref: L & B 23e/ 658, 24e/730)
  • They represent 5% of Head & neck tumor (Sabiston Textbook of Surgery, 18th Edition)

While 60% of minor salivary glands tumor are MALIGNANTQ.
  1. MC involved gland is PAROTID (70%)Q
  2. MC benign tumor = PLEOMORPHIC ADENOMA Q
(for ease: Schwartz )
70% Tumors of all salivary gland tumor are in parotid. Q
70% of all parotid tumor are benign Q
70% of all benign parotid tumor are PLEOMORPHIC ADENOMA Q
  1. Overall, equal sex incidence (Robbin’s 475). Q
  2. Non neoplastic processes account for 25% of parotid masses. Q
  • Investigations
    1. For parotid & submandibular gland CT & MRI are best for imaging tumors
    2. Open surgical biopsy of intrinsic neo plasm of major glands is absolutely contraindicated.
    3. ENA biopsy is a safe alternative to open biopsy of a major gland. If needle gauge is less than 18G. there is no risk of dissemination.
    4. FNA may be helpful for planning surgical excision. It is helpful of inflammatory / neoplastic process in
    5. parotid lymph node.
    6. MRI gives BEST anatomic information of tumor size and penetration.
    7. CT/MRI may delineate position of tumor with respect to facial nerve.
    8. Preoperative scanning is done if following are suspected:
    • Biopsy  complete local excision with normal tissue (margin)
      Minor salivary gland - Incisional/punch biopsy.
      Confirmatory diagrosis Frozen section examination.
    • Treatment of salivary gland tumors (H -562):
      1. Most benign tumors - Surgical excision Q
      2. Invasive tumors - surgery & RT (esp. Neutron radiation)
      3. Facial nerve is tried to be preserved.
      4. For metastatic disease - therapy is mainly palliative, usually chemotherapy with doxorubicin +1- cisplatin
      5. Lympimode involvement - appropriate neck dissection (Prophylactic only for sub-mandibular gland tumor)
    • Prognosis
      1. Best (amongst cancers) - Acinic cell carcinoma.
      2. Worst - adenoid cystic carcinoma
    1. MC benign tumor of salivary glands
    2. K/a MIXED TUMOR (has both epithelial and mesenchymal elements) Q
    3. Site: Parotid (MC), submandibular or other minor salivary glands. Q
      1. In parotid : MC from SUPERFICIAL LOBE (also from deep lobe & may present as parapharyngeal tumor in oropharynx). Q
    4. Sex, Age incidence (epidemiology): Q
      1. Usually in 3rd/4th decade (Dhingra) Q
      2. More in females (But in L & Bailey 659: Equal sex incidence) Q
    5. Slow growing, well demarcated, ‘apparently’ encasulated
    6. Clinical features.
      1. M.C.: Painless swelling at angle of jaw (Robbins)
      2. Facial nerve is rarely involved.
    7. Pathology:
      1. Characteristic feature - HETEROGENICITY
      2. Amorphous myxoid stroma resembling cartilage with interspersed islands and strands of myoepithelial cell.
      3. Multiple projections of tumor cells penetrating capsule (responsible for recurrence after surgery in 30-50%).
      4. Malignant transformation
        1. May be seen after 10-20 yrs. (Malignant mixed salivary gland tumor) in 2-10% cases, usually adenocarcinoma.
        2. More common in submandibular glands.
        3. Associated with
  1. CA-Skin, Breast, Thyroid, Colour.
  2. Radiation exposure, tobacco use, occupational and genetic factors.
    1. In 10% cases, tumors arise deep to plane of facial nerve oral examination may show bulging of tonsillar fossa or soft palate showing parapharyngeal space invasion.
  1. Prognosis
    1. Recurrence rate may be 30-40% after surgery, ideally should be 1%-5% (Sabiston)
    • 2nd MC benign parotid tumorQ
    • Also K/a Papillary cystadenoma lymphomatosum
    • Marked Male predominance (Schwartz), in 5-7th decadeQ
    • Site - Tail of parotid.Q
  1. Pathology:
    1. Lymphocytic infiltrate with cystic epithelial proliferation.
    2. Well developed lymphoid tissue
      1. Small, well encapsulatid, soft & cystic, & often fluctuant.
      2. Malignant transformation is RARE (<0.03%).
      3. Produces Hot Spot in 99Tcpertechnate scan.
      4. Probably arise from parotid tissue included in lymph nodes which are usually present within parotid gland. 
  • Treatment
    1. Superficial partoidectomy is the TOC. Q
    2. Recurrence rate =10% (incomplete excision/multicentricity or a second primary tumor).
    1. MC malignant tumor.
    2. MC Site - Minor salivary glands
    3. Age and Sex: Peak in 6th decade, equal sex incidence.
    4. Infiltrates widely into tissue planes and muscles. Invades perineural spaces & lymphotics resulting in pain and 7th nerve palsy.
    5. Can metastasize to lymph nodes (15%).
    6. Slow growing; metastasis may reach brain, lung, bone.
    7. High chances of recurrence.
    8. Pathology : Cribriform or lace like appearance of myoepithelial cells.
    9. MC presenting feature = PAIN
Radical parotidectomy
    1. MC malignant tumor (logan Turner 131) = Adenoid cystic CA. Q
    2. MC malignancy of parotid = Mucoepidermoid (Sabiston) Q.
    3. Almost always present as DISCRETE MASS
    4. Pain seen in 20%.
    5. Other symptoms - Forrnication
    6. Facial nerve dysfunction / paresis.
    7. Remember : Facial nerve palsy must be considered a possible sign of malignancy. Q
    8. MC symptom is PAIN
    9. Most specific sign = Nerve palsy. Q
    10. MC site of distant metastasis = Lung.
    1. Frey’s syndrome. (Auriculotemporal syndrome) (Gustatory sweating) Q
    2. A complication of parotid surgery characterised by sweating and flushing of preauricular skin during mastication. D/t damage to auriculotemporal nerve.
    3. D/t aberrant irmervation of sweat glands by parasympathetic secretiomotor fibres meant for parotid.
    4. Treatment : Tympanic neurectomy.
      Tumors of minor salivary glands:
      • MC in hard and soft palate. Q
      • May present as submucosal or ulcerative masses.
      • MC benign is - PLEOMORPHIC ADENOMA. Q
      • MC malignancies - Mucoepidermoid and adenoid carcinoma. Q
      • Treatment: Wide local excision including subjacent bone, with adjuvant Reserved for malignant cases.
  1. Benign, arises from oncocytes
  2. MC on minor salivary gland.
  3. Rarely undergo malignant transformation
  4. MC site of acinic cell CA is PAROTID.
  5. Highest incidence of lymph node metastases is seen in the malignancy developing from pleomorphic adenoma.
  6. Graft for facial nerve repair is usually SURAL NERVE.
  1. Salivary gland tumor in PEDIATRICS Q
    (Ref. : Nelson 16th/1564)
    1. MC neoplasms = Benign hemangiomas and lymphangiomas (usually present in infancy).
    2. For these Contrast, CT is Investigation of choice. Q
    3. Hemangiomas involute eventually Surgery may be required for lymphangiomas.
    4. MC epithelial origin tumor = Benign mixed tumor. Q
    5. Mucoepidermoid CA, Acinar cell CA, Adeno carcinomas
      1. Majority of malignant epithelial tumors in children and adolescents.
      2. Treatment is surgical +1- RT
      3. Prognosis is usually good.
    6. Most common benign tumor of chest wall — LipomaQ
    7. Most common 1° malignant tumor of chest wall — ChondrosarcomaQ
    8. Most common site of chondrosarcoma of chest wall — Costochondral junctionQ
    Most common tumors —
    1. Anterior mediastinum:
      1. Thymoma
      2. Lymphoma
      3. Germ cell tumors
    2. Middle and mediaiastinum:
      1. Cysts
      2. Lymphoma
      3. Mesenchymal tumors
    3. Posterior mediastinum:
      1. Neurogenic tumors
      2. Cysts
      3. Mesenchymal tumors
    4. Superior mediastinum:
      1. Lymphoma
      2. Thyroid tumors
      3. Parahyroid tumors
    1. Most common in Adults : Thymoma
    2. Most common in Children : Neurogenic tumors
    3. Most common in mediastinal : Lymphoma malignancy
    4. Most common tumor of middle mediastinum:
      1. Cysts (Pericardial cyst, to be specific)
      2. But most common mass of middle mediastinum is:
    5. Aortic aneurysm (but it’s not considered to be a tumor)
      1. Pericardial cysts are also known as spring water cysts and mesothelial cysts
    1. Most common tumor of anterior mediastinum. Q
    2. Most common mediastinal tumor in adults.
    3. Mostly benign
    4. Highly associated with Myasthenia gravis
    5. The type of thymoma, usually associated with Myasthenia gravis is Lymphocytic.
    6. Thymoma has been shown to be associated with:
      1. Myasthenia gravis
      2. Hypogammaglobulinemia
      3. Aplastic anemia
      4. Pure red cell aplasia
      5. White blood cell aplasia
      6. Hyperthyroidism’
      7. Cushing’s syndrome
    1. Also called Bronchogenic cysts.
    2. Develop from primitive lung bud, near bronchi.
    3. Mostly solitary and unilocular.
    4. Most common location — Subcarinal & Right Paratracheal.
    5. Two third are intrapulmonary (though contradictory, its better for us to consider this one and the above fact to be correct)
    6. Not premalignant
    7. May become infected
    8. T/t :- surgical removal.
    1. Most common primary tumor of pleura
    2. Most common predisposing factor — Asbestos exposure (Amphibole variety)
    3. Usually presents as bloody pleural effusion.
    4. Treatment:
      1. Symptomatic + Pleural effusion management
      2. Pleurodesis (adhesion formation between parietal and visceral pleura) may be done by injecting some fibrosing agent in pleural space
    5. Agent used for pleurodesis are:
      Tetracycline - Minocyclin
      Quinacrin - Talc
      Mustine (Nitrogen mustard) - Bleomycin
      Doxorubicin - 5-FU
      Thiotepa - Interferon —
      Interleukiris - Corynebacteriumparvum
  7. HEART
    1. Most common cardiac tumor — SecondariesQ
    2. Most common primary cardiac tumor — MyxomaQ
    3. Most common site of myxoma — Left atrium. Q
    4. Most common primary tumor to give Heart secondaries:
      1. In males—CA LungQ
      2. In females — CA BreastQ
    5. Tumor with highest relative incidence of metastasis to heart — Malignant melanoma
    6. Most common primary cardiac malignancy — Sarcoma
    1. Most commonly in third to sixth decades.
    2. Female predilection
  1. Pathologically, myxoma cells imbedded in a stroma rich in glycosaminoglycans.
  2. Clinical presentation: Q
    1. Obstructive, embolic or constitutional signs and symptoms.
    2. Mimics mitral valve disease: MS or MR
    3. a “tumor plop” maybe audible during early or middiastole.
    4. Ventricular myxomas may mimic sub aortic or sub pulmonic stenosis.
    5. May also present with emboli or constitutional symptoms, Raynaud’s phenomenon, anemia, polycythemia, elevated ESR, embolic phenomena.
  3. Investigation - Two dimensional transthoracic or transesophageal echocardiography
  4. Treatment - Surgical excision
Post of recurrence may occur, but is rare.

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