Oral Cavity and Salivary Gland Disease
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[edit] Oral Cavity and Salivary Gland Disease
Dennis D. Diaz
The oral cavity consists of the lips, cheeks, and oral cavity proper, including the tongue and teeth. The lips and cheeks are essentially similar in structure, consisting primarily of an external layer of skin, a middle muscular layer (orbicularis oris for the lips and buccinator for the cheeks), and an internal layer of mucous membrane.
The parotid gland is the largest salivary gland opening into the oral cavity via Stensen's (parotid) duct, which penetrates the buccinator muscle. The duct opens bilaterally out the parotid papilla, which is situated at the level of the second upper molar. The submandibular gland is located in the submandibular triangle. Wharton's duct, which is the opening for this salivary gland, extends forward and empties through the floor of the mouth just lateral and on each side of the lingual frenulum at the sublingual caruncle. The sublingual gland is the smallest of the major salivary glands and lies above the mylohyoid muscle immediately below the mucosa of the floor of mouth. This gland opens via a series of small, minor ducts along the sublingual fold. Sometimes a major sublingual duct may open into Wharton's duct. Scattered throughout the oral cavity are numerous minor salivary glands. Small superficial yellow sebaceous glands are often seen close to the free borders of the lips.
The hard palate is primarily a bony plate covered with mucous membrane that separates the oral cavity from the nasal cavity. The soft palate, part of the oropharynx, is muscular tissue covered by mucous membrane. It plays an active role in swallowing and vocal resonance. The oropharynx, with the soft palate, also includes the anterior and posterior tonsillar pillars, tonsils, base of the tongue, and posterior pharyngeal walls. The tongue helps to form the floor of mouth. Muscles, nerves, and vessels enter through the base of the tongue. It is divided into anterior two thirds and posterior one third at the V-shaped sulcus terminalis. The tongue's bumpy appearance is caused by numerous lingual papillae, the largest of which are the circumvallate papillae. They are arranged in a V-shaped row just anterior to the sulcus terminalis. The fungiform papillae are irregularly scattered over the tongue.
Examination of the oral cavity and its structures is relatively easy and requires only a strong light source (a head light allows free use of both hands) and two tongue blades. Most conditions are diagnosed from history and physical examination alone. With these tongue blades, tissue can be spread and manipulated, allowing complete inspection and visualization of all areas of the oral cavity and oropharynx. Attention should be directed to the lips, buccal mucosa, teeth, gingiva, floor of mouth, tongue, hard and soft palate, and oropharynx. The base of tongue and posterior oropharynx may be seen, but this area often requires a mirror for improved visualization. Systemic examination of the oral cavity ensures that no abnormalities are overlooked. Dentures, if present, should be removed. Palpation of the oral cavity, especially if an abnormality is noted, provides important information. Palpation is extremely helpful in assessing the salivary glands because normal glands are not palpable.
Table 180-1, Table 180-2, Table 180-3, Table 180-4, and Table 180-5 summarize common disease processes seen in otolaryngology–head and neck surgery as they present in the oral cavity, oropharynx, and salivary glands. Box 180-1 lists diseases rarely or infrequently associated with these structures.
Table 180-1 Common Disease Processes Affecting the Oral Cavity
| Disease | Cause | Symptoms | Patients | Appearance | Course | Treatment |
|---|---|---|---|---|---|---|
| Herpangina | Coxsackievirus A (fall and summer months) | Severe sore throat, odynophagia, sudden high fever, malaise | Primarily children, adolescents | Initially, numerous small vesicles with red halos; flat ulcers later | Usually less than 1 week | Self-limiting; supportive and symptomatic |
| Aphthous stomatitis | Herpes simplex virus | Multiple, yellowish erosions/vesicles, high fever, oral pain | Primarily infants, small children | Lesions localized to anterior oral cavity and gums | 1-2 weeks | Tetracycline syrup as mouthwash |
| Recurrent aphthous ulcer | Unknown | No stomatitis; ulcers tender when touched; eruptions at mucosal folds | Older children, adults | Reddened, raised, millet seed to pea-sized bumps; ulcerated at center, covered by yellowish fibrinous exudate | 7-10 days; history of recurrence | Supportive and symptomatic; tetracycline 250 mg mouthwash four times daily for 5-7 days |
| Herpes zoster | Varicella-zoster virus | Extremely painful; burning pain; may have fever, malaise | Elderly adults with impaired host defenses | Unilateral vesicles on buccal mucosa, tongue, uvula, pharynx, larynx; erosions noted when vesicles rupture | 7-14 days | Antiviral drugs, otherwise symptomatic |
| Herpes simplex labialis | Herpes simplex virus type I | Itching, tension, or neuralgiform complaints as prodromes; painful when ulcers form | Children, adults | Recurrent, episodic eruptions of yellowish fluid–filled vesicles on upper/lower lip, nose | 7-14 days; history of recurrence | Supportive and symptomatic |
| Cheilitis sicca | Exogenous damage by weather, drying, solar radiation | Itching, burning, or “cracked” lips | Children, adults | Dry, fissured, reddened or scaling lip mucosa | Symptomatic | |
| Angular cheilitis | Infection, genetic, neoplasm, others | Dryness and burning sensation at corners of mouth | Children, adults | Macerated, deep fissures or cracks at corners of mouth | Resolve; exacerbation common | Empiric based on etiology |
| Burning tongue | Variety of local and systemic disorders | Pain, burning, itching, or stinging of mucous membrane | Adults, rare in children | Tissues usually normal | Remission rare | Supportive and symptomatic |
| Kaposi's sarcoma | AIDS (HIV infection) | Purplish tender or painful nodules on mucous membrane | Can occur at any age | Purplish macules; can also be raised, nodular, or ulcerated | Diagnosis established by biopsy or HIV serology | |
| Hand-foot-and-mouth disease | Viral | Sore mouth, low-grade fever, coryza | Young children, 6 months to 5 years | Maculopapular exanthemous and vesicular lesions of skin; small, multiple, vesicular and ulcerative oral lesions | Self-limiting; usually regresses within 1-2 weeks | No specific treatment; local measures |
| Candidiasis | Candida albicans (found on 15%-20% of normal mucous membrane surfaces) | White to yellow lesions in cheek, at folds, and on tongue; seen at any age, especially in debilitated or chronically ill patients | Newborns; persons with impaired host defenses or poor oral hygiene | Soft, white to yellow, slightly elevated plaques; “milk curds;” wiping reveals erythematous mucosal surface | Can be persistent | Specific antifungal agents |
| AIDS, Acquired immunodeficiency syndrome;HIV, human immunodeficiency virus. | ||||||
Table 180-2 Common Disease Processes Affecting the Oropharynx
| Disease | Cause | Symptoms | Patients | Appearance | Course | Treatment |
|---|---|---|---|---|---|---|
| Acute tonsillitis | Group A β-hemolytic streptococci most important treatable pathogen | Sudden-onset intense throat pain, odynophagia, fever, chills, malaise; painful “glands” in neck; cough, coryza, and rhinorrhea suggestive of viral etiology | Children, adults | Sickly; pharyngeal erythema with intensely red palatine tonsils and faucial arch; yellow exudate; painful cervical adenopathy; rapid strep test or throat culture helpful | 7-14 days of medical therapy; risk of serious sequelae in inadequately treated cases | Penicillin, clindamycin; alternatives: cephalexin, cefadroxil, erythromycin; local and symptomatic measures |
| Peritonsillar abscess | Inflammatory infiltration and abscess formation | Despite initial antibiotic therapy, worsening severe unilateral throat pain, fever, malaise, difficulty eating, drooling, fetid breath, “hot potato” voice | Any age, peak occurrence in second to fourth decades | Marked erythema and bulging of peritonsillar area; deviation of uvula to unaffected side; fluctuance of soft palate, exudate; painful cervical adenopathy; trismus | Initial sore throat, followed by symptom-free interval, then worsening | Needle aspiration, incision and drainage of abscess, tonsillectomy; appropriate antibiotic therapy |
| Infectious mononucleosis | Epstein-Barr virus | Severe sore throat most common symptom; odynophagia, high fever, malaise, headache | Primarily adolescents and young adults | Bilateral tender cervical adenopathy; huge tonsils; gray-white fibrinous deposit on tonsils; leukocytosis with increased monocytes | Usually runs course in 10-21 days | Monospot test; specific treatment not available; antibiotics for sore throat complicated by group A streptococci |
| Chronic tonsillitis | Group A β-hemolytic streptococci chronic inflammation, microabscesses | Frequent sore throats, “scratchy” throat, oral fetor, “swollen glands” | Children, adults | Redness around tonsils; fissured tonsils; yellowish concretions expressed with pressure | Waxing and waning, painful flare-ups | Antibiotics, local measures; surgery if four or more infections of tonsils per year despite medical therapy |
| Tonsillar hypertrophy | Excessive reactive proliferation of tonsil tissue | Mouth breathing, eating difficulties, snoring, sleep disorder, change in speech resonance | Children most often; adults | Increase in volume of palatine tonsils; cervical adenopathy; unilateral hypertrophy referred for head and neck evaluation by otolaryngologist | Progressive with worsening upper airway symptoms | Surgery if dental malocclusion, impaired orofacial growth, upper airway obstruction, severe dysphagia, sleep disorders |
| Acute pharyngitis | Primary viral infection followed by bacterial superinfection | Raw, dry burning throat with odynophagia; in children, associated with fever and cervical adenopathy; adults, milder course; rhinorrhea, cough | Children, adults | Dry, red, thickened pharyngeal mucosa; exudate | 7-14 days | Analgesics, local measures, antibiotics for group A β-hemolytic streptococci |
| Chronic pharyngitis | Chronic mucosal inflammation by numerous etiologies | Habitual throat clearing, globus sensation, cough; thick colorless phlegm; no fever, no malaise | Usually adults | Varying degrees of pharyngeal irritation with mucosal thickening; thick, colorless to yellow secretions | Waxing and waning for years | Underlying cause (e.g., infection, GERD, tobacco); local measures |
| GERD, Gastroesophageal reflux disease. | ||||||
Table 180-3 Lesions and Morphologic Changes of the Oropharynx and Oral Cavity
| Cause | Symptoms | Appearance | Course | Treatment | |
|---|---|---|---|---|---|
| Papilloma | Human papillomavirus | Nonpainful mass | Single or multiple raspberry-like masses | Predilection for mucocutaneous junctions | Excisional biopsy with histologic examination |
| Torus palatinus or mandibularis | Exostosis or outgrowth of bone | Usually none; incidental finding | Hard bony growth with intact mucosa unless traumatized | Incidence:
Palatinus, 20%-25% Mandibularis 6%-8% | No treatment needed |
| Basal cell carcinoma of lips | Prolonged exposure to sunlight | Lesion ulcerates, heals over, then breaks down again; history of ultraviolet light exposure | Crusting ulcer with heaped or rolled borders; induration | Untreated lesions: enlarge, infiltrate adjacent and deeper tissues | Biopsy for diagnosis; each lesion considered separately when choosing therapy |
| Squamous cell carcinoma | |||||
| Oral cavity, floor of mouth, anterior tongue | Lack of specific etiology Tobacco, alcohol, poor oral hygiene, syphilis implicated | Usually painless ulcer unless nerves or periosteum involved; fetid breath | Ulcerated lesion with raided borders; bimanual palpation of mouth and tongue mandatory; deep invasion if trismus noted | Comprise about 90% of oral cancer; no barriers to extension in oral cavity; regional metastasis in neck | Biopsy for diagnosis; therapy depends on staging: surgery, radiation, photodynamic, chemotherapy, combined modalities |
| Oropharynx (tonsil) | Lack of specific etiology; tobacco, alcohol implicated | Usually painful ulceration; dysphagia, odynophagia, weight loss present; referred otalgia possible | Angry looking; ulcerated enlarged mass involving one or both tonsils; tongue base and palate, bimanual palpation | Early involvement of regional lymph nodes | Biopsy for diagnosis; depends on staging but usually combined therapy |
| Leukoplakia | Multifactorial (e.g., tobacco use, trauma, lupus, lichen planus, irritative reactions) | Painless white patch or plaque on surface of mucosa | White patch, with predilection for lips, tongue, palate, floor of mouth, and buccal mucosa | Not all are precancerous but complete evaluation for diagnosis suggested | Often incidental finding; biopsy, especially if risk factors in history (e.g., tobacco use, alcohol) |
Table 180-4 Common Disease Processes Affecting the Salivary Glands✢
| Cause | Symptoms | Appearance | Course | Treatment | |
|---|---|---|---|---|---|
| Bacterial sialadenitis | Streptococci or staphylococci most common | Severe pain, fever, overlying skin warm; trismus; parotid most often affected | Swollen, tender, firm gland; purulent discharge from punctum of involved gland; absent or decreased salivary flow | Acute, progressive if not treated; often seen in debilitated, hospitalized patients | Local and symptomatic measures; hydration; sialogogues; antistaphylococcal penicillin; alternatives: clindamycin, cephalosporin, vancomycin |
| Mumps | Paramyxovirus | Mild temperature elevation, malaise; sudden onset of acute distention, pain | Painful, diffuse, doughy swelling over parotid gland; gland feels tense and tender; usually bilateral; puncta congested; expressed saliva clear | Self-limited | Local and symptomatic measures; hydration; analgesia |
| Sialolithiasis | Formation of calculus in excretory duct; foreign body | Sudden painful swelling of affected gland initiated by eating; usually reduces in size once meal complete; submandibular gland most common | Tender, swollen gland may be detected; bimanual palpation may detect calculus; Panorex or bite wing radiographs may identify stone in affected submandibular gland | Recurrent; if obstruction not relieved, complications include infection, fistula, abscess, strictures | Stones may pass spontaneously; if not, intraoral removal attempted if stone within 1 cm of puncta; hydration, analgesics, antibiotics; surgical treatment for chronic recurrence |
| Radiation sialadenitis | Injury to salivary gland parenchyma by ionizing radiation | Burning, dry mouth with decreased taste; xerostomia with atrophy of mucosa | Dry, violaceous mucosa with thick secretions | May improve after radiation therapy | Local and symptomatic; sialogogues; hydration; dietary consult recommended; oral pilocarpine (Salagen) |
| Sjögren's syndrome | Autoimmune; classic triad; xerostomia, keratoconjunctivitis sicca, connective tissue disorder (rheumatoid arthritis most common) | Gradual swelling and enlargement of parotid/submandibular gland; usually bilateral; increasing xerostomia; dry eye when lacrimal gland involved; arthritis; laryngitis | More common in women; dry lips or mouth; diminished salivary flow; parotid/submandibular glands enlarged bilaterally; viscous mucus when expressed from salivary ducts | Progressive; rheumatology evaluation | Local and symptomatic; humidification and hydration; biopsy for diagnosis; no medications that decrease salivary flow |
| Pleomorphic adenoma | Most common benign salivary gland tumor | Painless, slow-growing, salivary gland mass (parotid most common) | Firm, nontender mass without fixation to overlying skin; more common in women | Slow growing; enlarges greatly if ignored | Surgical excision with preservation of facial nerve |
| Warthin's tumor (adenolymphoma) | Almost exclusively in parotid gland | Painless, slow-growing, palpable mass | Soft, nontender, mobile mass; frequently bilateral | Primarily males, fifth to sixth decades | Surgical excision with preservation of facial nerve |
| Mucoepidermoid carcinoma | Most common malignancy of parotid gland; 3:1 female predominance | Low grade: slow-growing, painless mass; high grade: fast-growing, painful mass; facial nerve paralysis, regional spread | Low grade: circumscribed nodule with variable consistency; high grade: fixed, painful mass; facial nerve paralysis, cervical adenopathy | Usually fourth to fifth decades; most common malignant salivary gland tumor in children | Surgical excision with or without facial nerve preservation depending on degree of invasion |
| Adenoid cystic carcinoma | Most common malignancy of submandibular gland | Slow growth initially; pain or paresthesia later | Hard fixed mass; facial paralysis fairly common; regional and distant spread common | Spread of tumor along perineural and perivascular spaces | Surgery |
✢Salivary gland neoplasms are uncommon in children. For children, most common benign tumor of salivary gland is hemangioma; most common malignant tumor is mucoepidermoid carcinoma; most common benign epithelial tumor is pleomorphic adenoma.
Table 180-5 Disorders of the Tongue
| Cause | Symptom | Appearance | Course | Treatment | |
|---|---|---|---|---|---|
| Ankyloglossia | Developmental variation of lingual frenulum | Incidental finding; restriction of elevation and protrusion | Thick, fibrous lingual frenulum; usually does not affect speech; little interference with infant's feeding | If speech delay present, other cause | Frenotomy, often to relieve mother's anxiety, not child's |
| Fissured tongue | Differential: syphilis, tuberculosis, myxedema, acromegaly | Usually painless, except if food debris in grooves leads to irritation | Numerous small furrows of dorsal and lateral surfaces of tongue | Of no concern unless evaluation reveals other underlying disease | Hygiene; stretch/flatten fissures, clean surface with toothbrush/gauze sponge |
| Geographic tongue | No specific cause; may be stress related | 25% report tenderness and burning | Discrete, irregular areas of desquamation, white to yellow in color, resembling a map; “migrates” | Regression and recurrence | No specific treatment necessary |
| Median rhomboid glossitis | Congenital | Food and debris accumulation with inflammation, pain | Ovoid or rhomboid fissured or smooth, red mass in midline of tongue; anterior to V location | More common in men | No specific treatment; hygiene; biopsy if diagnosis uncertain or malignancy suspected |
| Macroglossia | Multiple etiologies | Nothing specific except for large tongue; dysphagia or feeding difficulties in newborn | Large tongue; malocclusion; scalloping of lateral tongue edge | Treat primary cause, surgical debulking | |
| Tongue carcinoma | Associated with tobacco, alcohol use, syphilis | Initial painless mass or ulcer ultimately becomes painful; difficulty with speech, eating; referred ear pain; weight loss | Ulcer or mass with induration and raised borders; fetid breath; firm tongue; neck mass | Metastasis common | Staging biopsy for diagnosis; depending on stage, combined surgery and radiotherapy most beneficial |
| Box 180-1 - Uncommon Processes of the Oral Cavity |
Vascular
|
[edit] ADDITIONAL READINGS
- DD DeWeese, WH Saunders: Textbook of otolaryngology ed 6. St Louis: Mosby; 1982:
- English GM Otolaryngology, vol 3, Diseases of the larynx, pharynx, and upper respiratory tract. Philadelphia: Lippincott; 1992:
- DNF Fairbanks: Pocket guide to antimicrobial therapy in otolaryngology– head and neck surgery Washington, DC: American Academy of Otolaryngology–Head and Neck Surgery Foundation; 1987:
- KJ Lee: Essential otolaryngology–head and neck surgery ed 3. New York: Medical Examination; 1983:
- HH Naumann: Differential diagnosis in otorhinolaryngology New York: Thieme; 1993:
- WS Shafer, MK Hine, BM Levy: Textbook of oral pathology ed 4. Philadelphia: Saunders; 1983:
- Strome M Kelly JH Fried MP Manual of otolaryngology diagnosis and therapy. Boston: Little, Brown; 1985:
