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Non- malignant disease
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oforal mucosa
andoralcavity
Lesions ofthe cutaneous lip
The lip is at the junction of the skin and mucosa,
which makes it prone to disease processes from both.
Lesions here can be usefully divided into infective
and non-
infective lesions.
The oral cavity 195
Impetigo contagiosa
This Staphylococcus aureus or Streptococcus pyogenes
infection causes papules on the skin, which progress
to erythematous vesicles then pustules with golden
crusts. It is highly infectious and spread by contact. It
rarely has systemic symptoms. Usually found in
young children especially those suffering from underlying malnutrition. The diagnosis is confirmed on culture, but should be differentiated from other
vesiculo- bullous lesions such as HSV. Treatment is
with topical antibacterial creams or oral flucloxacillin
if systemic symptoms.
Infective lesions
Herpes labialis (cold sore)
This is a secondary reactivation of a previous herpes
simplex virus (HSV) infection, latent in the trigeminal
ganglia. Initially an itching and burning sensation, a
crop of vesicles will develop into a confluent crusting
ulcer before resolving. Maybe precipitated by trauma,
sunlight, menstruation, underlying physiological
stress and immunosuppression. Treatment usually
symptomatic but infection may be curtailed by early
and regular application of a topical antiviral such as
aciclovir or famciclovir. Should be differentiated from
other infective causes such as varicella zoster or
impetigo and malignancy including basal or squamous cell carcinoma.
Herpes zoster (shingles)
This is a secondary reactivation of previous varicella
zoster infection. It presents as a dull ache or mimics
toothache, followed by the classical presentation of
an itchy or painful rash following the trigeminal dermatomes. It can progress to mouth ulcers.
It is usually triggered by underlying physiological
stress or immunosuppression. A positive Hutchinson’s
5
sign
(rash of the tip of nose) is important as it indicates nasociliary nerve involvement, a prelude to herpes zoster ophthalmicus. This can result in reduced
vision, eye pain and photophobia, with a potential for
severe eye damage and blindness. Treatment is with
an antiviral (usually aciclovir).
5
Sir Jonathan Hutchinson (1828–1913); Surgeon, London.
He described many signs, including Hutchinson’s freckle
(a premalignant melanoma) and the pegged teeth of
congenital syphilis.
Angular stomatitis (angular cheilitis)
Inflammatory condition of the corners of the mouth,
usually due to infection with Candida albicans but
bacterial species such as Staphylococcus aureus and/
or Streptococcus may also be present. Other causes
include underlying iron or vitamin B deficiency,
immunocompromise and overhang of the upper lip
resulting in deep furrows. Seen most commonly in
the elderly edentulous patient. Clinical features
include sore erythematous fissures at the oral commissure with concomitant mucosal leucoplakia.
Treatment is of the underlying cause and topical
antifungals. New dentures may be needed to reduce
any associated denture- induced stomatitis and
increase lower face height.
Non- infective lesions
Erythema multiforme
Immune- mediated hypersensitivity reaction to drugs
such as NSAIDs, carbamazepine, phenytoin and penicillins. It may also be triggered by HSV infection, UV
light, pregnancy, malignancy and chemicals. The
cause cannot always be identified.
Symptoms can range from mild to life- threatening.
It can affect skin, mucosa or both. There is circumoral crusting with serosanguinous exudate. In its
minor form, it will affect only one site. Treatment is
withdrawal of any identified triggering factors and
supportive with analgesia and rehydration. Steroids
and antivirals may also be required, depending on
aetiology.
In its major form, Stevens- Johnson’s Syndrome, it
can cause significant systemic illness and affect
multiple sites including eyes and genitals and
will require admission for parenteral steroids or
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otherimmunosuppressants and supportive therapy
including intravenous rehydration and nutrition.
Other oral lesions
Several other non- infective oral lesions may be identified which are associated with either genetic or
inflammatory conditions:
Peutz- Jeghers
•
mal dominant condition associated with intestinal
hamartomatous polyps which may cause obstruction due to intussusception.
• Hereditary haemorrhagic telangiectasia (Osler-
Weber- Rendu syndrome
nal telangiectasia and associated gastrointestinal
bleeding.
Lichen planus: white striae, atrophic, erosive, can
•
affect multiple intra-
• Lip swelling: may be symptomatic of allergic angioedema, hereditary angioedema, orofacial granulomatosis (Crohn’s disease or sarcoidosis).
2
circumoral pigmentation: autoso-
6
): associated with intesti-
and extraoral sites.
Lesions ofthe oral
mucosa including lip
mucosa
Lesions within the mouth are related to the oral
mucosa and underlying connective tissue and glands.
Many will also have cutaneous/extraoral manifestations as already described.
Infective oral ulceration
Primary herpes simplex
(gingivostomatitis)
Oral lesions usually due to HSV1 and carried by 60% of
the population. Transmitted by direct contact or bodily
fluids with incubation period of 3–7 days. Infection is
usually subclinical. Presents with painful punched out
6
Sir William Osler (1849–1919), Professor of Medicine,
successively at McGill University, Montreal, Canada; Johns
Hopkins University, Baltimore, MD, USA; and the University
of Oxford. Henri Rendu (1844–1902), Physician, Necker
Hospital, Paris, France. Frederick Parkes Weber (1863–1962),
a London Physician with an interest in rare disorders. e
disease was actually rst described by Henry Sutton in 1864.
ulceration at gingival margins and multiple vesiculobullous ulcers of the oral mucosa which can become
confluent. Systemic symptoms of infection include
malaise, fever, lymphadenopathy and anorexia.
Diagnosis is usually clinical. Treatment is supportive;
analgesia, bed rest, fluids, antipyrexials, analgesia, antiviral agents if immunosuppressed or early diagnosis.
Other infective causes may need to be excluded, as
should erythema multiforme and leukaemia. Herpes
simplex may recur as cold sores.
Herpangina
Multiple small vesicular ulcers (2–4mm) secondary
to coxsackie type A infection. Commonest in children
under 4 and spread by the faecoepidemic in nature. Most cases are mild and can present with associated fever and malaise. Treatment is
supportive as the infection is self-
oral route; it can be
limiting.
Primary varicella (chickenpox)
Oral lesions may precede skin presentations and mimic
primary HSV on the mucosa but without gingival lesions.
Long incubation of 14–21 days with prodromal symptoms of malaise, pharyngitis and rhinitis. Treatment is
mainly supportive or antivirals where immunocompromised or ocular involvement. May recur as shingles.
Other infective causes of oral ulceration include
hand foot and mouth disease, Epstein Barr virus,
syphilis, tuberculosis and measles.
Non- infective oral ulceration
Oral ulceration is disruption in the continuity of the
oral epithelium leading to exposure of the underlying
connective tissue.
Ulcers oflocal aetiology
These are usually solitary and solo in nature, and are
related to localized trauma including biting habits, sharp
teeth or dental restorations, burns including irradiation,
ill-
fitting dentures. Other causes of ulceration should be
excluded, in particular malignancy. Treatment is symptomatic and removal of causative agent if chronic.
Recurrent aphthous stomatitis
(aphthae)
This is a common cause of oral ulceration often with
no clear causative agent. Predisposing factors include
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haematinic deficiency, phase of menstrual cycle, food
allergies and stress.
Investigations: check underlying medical history
for systemic disorders. Blood tests for haematinics
and autoantibodies. Consider biopsy if no evidence of
resolution to exclude other causes and malignancy.
Treatment: Treat any underlying conditions. Treat
symptoms with chlorhexidine or benzydamine
mouthwash. May require topical corticosteroids
(mouthwash, pellets) including eclomethasone or
oral prednisolone.
Behçet’s syndrome
Autoimmune vasculitis characterized by recurrent
oral ulcers, genital ulcers, uveitis and arthritis.
Treatment includes topical/ intralesional steroids,
and immunosuppression.
7
Drug reactions
Oral mucosal ulceration can occur secondary to medications, such as the immunosuppressants everolimus and sirolimus. Pathogenesis can be due to focal
irritation, allergic hypersensitivity or cytotoxicity.
Common drugs implicated include NSAIDs and
nicorandil.
Pemphigus vulgaris
This vesiculobullous autoimmune disease produces
circulating autoantibodies to epithelial desmosomes
(sticky areas on the surface of keratinocytes near the
bottom of the epidermis) resulting in intraepithelial
clefting. Clinical presentation includes fragile bullae/
erosions of mucosa preceding skin lesions. Lateral
sheer pressure on skin may cause epithelial separation (positive Nikolsky sign
Investigations: Biopsy will show intraepithelial vesicles, and immune deposits on direct immunofluorescence. Plasma antiand Dsg3) will be raised and correlate to disease
activity.
Differential diagnosis includes mucous membrane
pemphigoid. Treatment is with immunosuppression
7
Hulusi Behçet (1889–1948), Professor of Dermatology,
Istanbul, Turkey.
8
Pyotr Vasilyewich Nikolsky (1858–1940), Professor of
Dermatology, University of Warsaw. e sign dierentiates
intra- epidermal blisters from subdermal blisters.
8
).
desmosomal antibodies (Dsg1
including steroids, immune sparing drugs and other
medications such as dapsone or monoclonal
antibodies such as rituximab.
Mucous membrane pemphigoid
Most common of all the vesiculobullous lesions, presenting in the older populations. Subepithelial clefting
is caused by antiies, resulting in thick walled bullae that are less likely
to rupture, but will scar. In addition to oral manifestations, it may affect genital, nasal, oesophageal, laryngeal tissues and skin. Biopsy will show subepithelial
clefting and linear IgG and C3 deposits at the basement membrane. Treatment is similar to that for pemphigus and includes immunosuppression with
steroids and other systemic therapies.
Other autoimmune disease resulting in oral ulceration includes Epidermolysis Bullosa, Systemic Lupus
Erythematosus.
basement membrane autoantibod-
Potential malignant
disorders ofthe mouth
Lichen planus
A relatively common immune- mediated condition of
the stratified squamous epithelium affecting mouth,
skin and genitalia. 2% of the population are affected
by oral lichen planus. When in response to a drug it is
described as a lichenoid reaction.
Clinical features
Often bilateral white striae or erosions of oral mucosa.
May be asymptomatic or painful and sore if atrophic
or ulcerated. Extra oral manifestations include violet
papules on flexor surfaces, vertical ridges of nails, alopecia, lesions on genitalia.
Special investigations
Biopsy of non- ulcerated lesion, blood tests (full blood
count and haematinics). Erosive and atrophic areas
are at small risk of malignant change.
Treatment
Treatment is only necessary if symptomatic. Topical
steroids such as hydrocortisone or betamethasone
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lozenges, spray or inhaler with escalation to intralesional or oral steroids. Occasionally further immunosuppression is necessary.
Candidiasis
Candida albicans is a commensal organism in the
oral cavity but can become a source of infection if
there is a change in the local environment (denture
wear, xerostomia) or underlying immune status of the
patient (steroids, diabetes). Malnutrition, smoking,
and broad spectrum antibiotics can also predispose
to infection.
Clinical features
There are three common types of candida infection:
Pseudomembranous: Acute (thrush) or chronic.
•
Creamy white plaques or deposits that can be
wiped away leaving erythematous areas.
Erythematous: smooth red mucosa of tongue,
•
hard palate and buccal mucosa.
Hyperplastic: Leukoplastic lesions are considered
•
at high risk of malignant transformation to squamous cell carcinoma.
Special investigations
Mucosal swabs should confirm the infection. Diabetes
should always be excluded as a cause. Concerning
lesions should be biopsied.
Treatment
Topical (e.g. nystatin) or systemic (e.g. fluconazole) antifungal medication. Oral and denture hygiene should be
improved and underlying risk factors eliminated.
Leukoplakia
Leukoplakia is the diagnosis of exclusion for a white
patch or plaque on the oral mucosa that cannot be
characterized clinically or pathologically as any other
lesion. It is found in 3% of adults, usually middle aged
or elderly and presents as a thickened white area of
mucosa that cannot be removed on wiping. It can be
found at any site within the oral cavity. Leukoplakia
affecting the lateral border of tongue and floor of
mouth are considered high risk for malignant transformation. Chronic irritation including the 5 S’s
(smoking, spices, sharp tooth, syphilis and alcohol
(spirits)) are aetiological factors.
Heterogenous lesions, they can variably be white,
erythematous or speckled, with a flat or exophytic
section. This is reflected in the variable histol-
crossogy; atrophic epithelium, hyperplasia without hyperkeratosis, dysplasia of varying degrees (none, mild,
moderate, severe), or even carcinoma.
Biopsy is recommended if an irregular appearance
or evidence of erythroplakia and will guide treatment.
Risk factors should be modified and consideration
given to longSeverely dysplastic lesions should be removed in their
entirety and mandate close follow-
term follow- up including photography.
up.
Other white patches
Include trauma such as cheek biting, keratosis (frictional, smokers, other tobacco related, sublingual),
hairy leukoplakia. Malignancy should be excluded.
Intraoral pigmented
lesions
Haemangioma
These lesions represent a congenital vascular malformation or tumour that presents and grows rapidly
after birth, which later stabilizes and then gradually
regresses. Treatment is conservative unless these is
impact on functional development such as vision or
there is significant bleeding. Active management
includes intralesional steroid, interferon, laser or
surgery.
Other benign causes of intraoral pigmentation
include drug induced, amalgam tattoo, racial pigmentation, purpura and naevi.
Intraoral lumps
The majority of intraoral lumps are benign in nature
and related to trauma.
Mucocele
Described as mucous retention cysts, these are
extremely common. They are considered secondary
to trauma to a minor salivary gland within the submucosa, such as the lower labial mucosa, and may
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go through a cycle of recurrent swelling and discharge. They appear as a blue domed, wellswelling just underlying the mucosa and may transilluminate if large enough. Some will resolve spontaneously but treatment is surgical excision under
local anaesthetic.
defined
Ranula
A ranula, from the Latin for frog, is a mucous
extravasation cyst in the floor of the mouth commonly related to the sublingual gland. It is usually a
large, blue, translucent swelling. Although many
are managed conservatively, definitive treatment
requires removal of the ipsilateral sublingual gland,
rather than direct excision or marsupialization of
the cyst.
Trauma- induced hyperplasia
Chronic irritation from a denture flange or dental
restoration, rather than causing ulceration, can
induce hyperplasia of the affected mucosa. This
may be seen as a painless lump or leaf underlying
the flange of a denture (denture granuloma) par-
ticularly in the lower labial sulcus. Definitive diagnosis is by excision biopsy, and recurrence
prevented by reducing the denture flange or source
of irritation.
Fibroepithelial polyp
These are trauma/ irritation induced pedunculated
or sessile overgrowths of epithelial or submucosal tissue and are found throughout the oral cavity. It is
described as an epulis when found presenting on the
gingiva. They may bleed or become ulcerated if
acutely traumatized so mimicking a soft tissue
tumour. Definitive diagnosis and treatment is by excision biopsy under local anaesthetic.
cutaneous lip
Surgical excision oflesions
ofthe lip
Cutaneous lesions of the lip should be excised with
sufficient margin to ensure full clearance. This can
range from a superficial excision to full thickness
resection of skin, muscle and mucosa or distinct anatomical areas such as the philtrum or commissure. Up
to one- third of the lip can be removed using a wedge
excision and reconstructed with primary closure. For
larger resections, local or free flaps may be needed.
Malignant disease oforal
mucosa andoral cavity
Malignant disease of the head and neck is the 7th most
commonly occurring cancer in the UK. It is more
common in men and with a median age at diagnosis
of 60. Cancer in patients under 45 is often associated
with an oncogenic virus. Head and neck cancer is a
diverse group. Arising from the structures within the
oral cavity and oropharynx, over 90% are squamous
cell carcinoma. The cancer can arise de novo, in a previous premalignant lesion, such as leucoplakia, erythroplakia, chronic hyperplastic candidiasis, lichen
planus, and oral submucous fibrosis. Other tumours
can include those of the minor salivary glands such as
adenocarcinoma and mucoepidermoid carcinoma.
Squamous cell carcinoma ofthe
oral cavity
Predisposing factors
Tobacco usage and increased alcohol consumption
are considered the primary causative factors. Betel
nut chewing increases the risk, and in India 40% of all
cancers are oropharyngeal.
Oncogenic viruses such as human papilloma virus
(HPV), especially types 16 and 18, and the Epstein
9
Barr
virus are independent risk factors for oro-
pharyngeal cancer.
Malignant disease of the cutaneous lip is treated as
per the protocols for other cutaneous cancers of the
face. Basal cell carcinoma and squamous cell carcinoma are seen most commonly. These are discussed
in Chapter11.
9
Michael Anthony Epstein (b. 1921), Professor of Pathology,
University of Bristol, Bristol, UK. Yvonne Barr (1932–2016),
Virologist and research assistant of Epstein when both were
at the Middlesex Hospital, London, UK.
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Clinical features
Many oral cancers are diagnosed incidentally after
examination by a dentist or primary care physician.
Symptoms can include a painless ulcer, sore throat,
difficulty swallowing or sensation of a foreign body,
pain (either local to the tumour or distant including
toothache and earache), a lump in the neck or local
mass, and weight loss.
On clinical examination it may appear as an indurated ulcer, an exophytic mass or an area of erythroplakia. There may also be evidence of a cranial nerve lesion
such as loss of sensation (trigeminal nerve), a facial
palsy (facial nerve), deviation of the tongue (hypoglossal nerve) or voice changes (glossopharyngeal nerve).
Common sites for SCC in the oral cavity include the
lateral border of tongue, floor of mouth and buccal
mucosa. If a lesion is suspected examination should
include full assessment of the oral cavity, endoscopic
examination of the nasopharynx, oropharynx and larynx, and examination of the neck for palpable masses
and lymph nodes.
Diagnosis
This requires histological examination of tissue by direct
biopsy of a visible lesion or fine needle aspiration of a
suspected mass or node. Open biopsy of a neck lump is
avoided. If previous biopsies are inconclusive and in
absence of an identifiable primary lesion, a planned
resection of the lymph nodes of the neck will be completed to aid diagnosis and avoid metastatic spread.
Special investigations
• Plain radiography (OPG) is helpful in assessment
for dental health.
Cross- sectional imaging of the site of tumour to
•
assess local invasion, and neck and chest to exclude
metastases. Magnetic resonance imaging (MRI) is
preferred to CT for its increased accuracy in assessing depth and volume of tumours and neck disease,
and is superior in demonstrating the presence of
perineural invasion in salivary gland tumours.
Treatment
Treatment aims to eradicate disease, minimizing
morbidity and effecting the highest possible cure
rates. The three modalities of treatment are surgery,
radiotherapy and chemotherapy, and these may be
used in isolation or combination depending on the
primary site, histological appearance and stage.
Surgery
A surgical approach is used to remove the tumour,
control disease in the neck and reconstruct the site to
reduce post-
•
Primary site– access to many tumours of the oral
cavity are via a transoral approach, but as tumours
increase in size or are more posterior, access may
be necessary via a lip split and mandibulotomy,
the neck or transfacial. The size and location of the
tumour will determine the need for reconstruction beyond primary closure or healing by secondary intention.
• The neck: Block dissection of the lymph nodes of
the neck may be done as a staging or therapeutic
procedure. Alternatively, sentinel node sampling
of the neck may be done if no abnormal neck
nodes are identified on imaging.
A patient may require tracheostomy to support the
airway through the surgical period, and potentially
long term.
treatment morbidity.
Other cancers ofthe oral cavity
Tumours ofminor salivary glands
See chapter21.
Tumours ofthe jaw
Tumours of the jaw are of extremely wide pathological
variety because they may arise from the bone of the
jaw itself, from the tissues over the surface of the jaw
or, in the case of the maxilla, from the mucosa lining
the maxillary antrum.
Prognostic features
As with most squamous cell cancers, features
suggesting aggressive disease include poor differentiation, perineural invasion, lymphatic invasion,
lymph node metastases and extracapsular spread.
The presence of HPV should also be assessed.
Tumours adjacent tothe oral
cavity
Nasopharyngeal tumours
These lie in the nasopharynx, posterior and superior
to the soft palate. They may present with epistaxis
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and congestion or neck lump, and should be
differentiated from nasal polyps and rhinitis. They are
linked with Epsteinrich in cured fish or meat, so are common in southeast Asia and China. Treatment is with a combination
of
surgery and radiotherapy.
Barr virus infection and diets
Oropharyngeal tumours
These are tumours that lie posterior and inferior to
the oral cavity and in general are managed in the
same way, as they are usually mucosal squamous
carcinomas. They are also associated with HPV.
Tongue base and tonsillar tumours may be treated
with primary chemoradiotherapy.
Tonsil tumours
Usually a squamous carcinoma, more common in
males over the age of 50 and strongly associated with
HPV infection. Differential diagnosis includes lymphoma, small cell carcinoma and secondary deposits
of Merkel cell carcinoma, renal cell carcinoma and
small cell lung cancer. Patients may complain of sore
throat, unilateral otalgia, sensation of foreign body or
difficulty opening their mouth. They may also present
with enlarged cervical lymph nodes. Treatment
depends on size and location.
from invasion of the maxillary branch of the
trigeminal nerve.
Inferior extension: Bulging and ulceration into the
•
palate. Dental pain and tooth mobility.
Metastases to the upper jugular lymph nodes occur at
a relatively late stage.
Special investigations
• Orthopantomogram may show local bony destruction, involvement of teeth and opacity of maxillary
sinus.
Nasal endoscopy may visualize the tumour if it is
•
invading the medial wall of the maxilla, and may
permit biopsy under direct vision.
•
CT and MR imaging are invaluable in defining the
extent of tumour spread, including orbital soft tissue involvement.
Treatment
Treatment is usually surgical resection followed by
radiotherapy. The patient may require orbital exenteration depending on extent of ocular involvement and
the need for followincludes free tissue transfer, obturation or implantretained prosthesis.
up radiotherapy. Reconstruction
Antral tumours
Most commonly squamous carcinomas arising from
the mucous membrane of the maxillary antrum,
and treated with surgery. Other tumours include
adenocarcinoma, adenoid cystic carcinoma and
lymphoma.
Clinical features
Symptoms and signs are late in manifesting themselves as the tumour can expand into the antrum
before becoming clinically obvious. Its clinical presentation depends on the pattern of spread.
•
Medial extension: Blockage of the ostium of the
maxillary antrum with consequent infection of the
sinus, or with nasal obstruction and epistaxis.
•
Lateral extension: Swelling of the face, which often
has an inflammatory appearance and may well be
mistaken for an acute infection.
Superior extension: Orbital invasion with propto-
•
sis, diplopia and lacrimation due to blockage of
the tear duct. Anaesthesia of the cheek may result
Reconstructive surgery
inhead andneck cancer
The head, face and neck is a complex structure that is
a conduit for communication, eating and breathing. It
is also the social interface for most people so adequate cosmesis is vital.
The defect size and site will determine the reconstruction, as will the required tissue and health of the
patient. Reconstruction should be immediate, as simple as possible, with low morbidity and not impact on
the ability to resect the tumour.
Reconstructive ladder
A hierarchy of surgical options is as follows:
Healing by secondary intention: used following
•
laser resection of superficial lesions. Not suitable
in conventional resection due to scarring.
• Primary closure: for small defects, where there is
minimal distortion of adjacent tissues. No donor
site morbidity.
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• Graft: mucosa, split or full thickness skin, bone,
cartilage, vascular or nerve as determined by the
defect. Sometimes used in conjunction with other
reconstructive techniques such as flaps.
Flaps:
•
– Local– donor tissue is transferred into an adja-
cent small defect and benefits from being of
similar tissue and retaining its vascular supply.
Examples include the nasolabial flap.
– Regional and distant flaps – the donor site is
distant from the defect but the flap is transferred while maintaining its blood supply. The
temporalis flap is considered local to the head
and neck whereas flaps such as pectoralis
major myocutaneous flap or the deltopectoral
flap are distant. These flaps are useful when
other techniques have failed or free tissue
transfer is considered inappropriate due to
associated patient morbidity.
– Free tissue transfer – the donor site is separate
from the defect. The flap is raised with its associated vascular pedicle and detached before
being anastomosed to vessels in the neck.
Although technically challenging and complex
this surgery allows transfer of tissue without
restriction and in larger volumes. These flaps
can be soft tissue, bony or a combination.
Three commonly used flaps are:
∘ Radial forearm flap – usually skin only but
can be composite.
∘ Fibula flap – comprised bone +/- muscle
and skin. Used following mandibular or
maxillary resection.
∘ Anterolateral thigh flap – large skin and
muscle flap.
Complications ofsurgery
Head and neck cancer surgery with resection includes
specific risks of:
•
Airway compromise due to swelling and problems
with the tracheostomy.
• Collection of fluids:
– Seroma.
– Saliva collections.
– Chylous leak.
•
Wound dehiscence and breakdown resulting in
oro-
cutaneous fistula.
Nerve injuries– facial nerve (marginal mandibu-
•
lar branch), phrenic nerve, vagus (recurrent laryngeal), accessory nerve, sympathetic chain.
•
Failure of reconstruction, especially loss of blood
supply to free tissue flaps.
Adjunctive therapy fororal SCC
Radiotherapy: Many patients with oral cavity SCC will
require adjunctive radiotherapy to the site of the
tumour and the neck depending on disease size and
spread, and the success of the resection. Usually, it is
delivered by external beam over a number of sessions,
and although it is useful for disease control it is associated with high levels of morbidity.
Morbidity includes mucositis, skin erythema and
ulceration, loss of taste, impaired nutrition and
weight loss, dry mouth with associated dental disease, lymphoedema, fibrosis and osteoradionecrosis.
Chemotherapy: This is used less frequently as the
role remains controversial. It is used as a primary
therapy in tumours of the tonsil, tongue base and
nasopharynx.
Additional resources
Case 42: A lump on the lip
Case 43: A white plaque on the tongue
Case 44: A baby with two congenital deformities
The salivary glands
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Brian Fish
Learning objective
✓ To know the common benign and malignant conditions of the salivary
glands and their treatment.
21
The salivary glands comprise three paired major glands–
the parotid, submandibular and sublingual – together
with numerous minor salivary glands scattered throughout the oral mucosa and in the posterior third of the
tongue, cheeks and palate. The parotid gland secretes
serous saliva, in contrast to the mucus product of the sublingual glands. The submandibular saliva is seromucus,
and represents 70% of the total saliva produced by the
major glands. The minor glands can either be serous or
mucous and produce 10% of total saliva volume.
The parotid and submandibular glands drain into
the mouth via long ducts, the parotid (Stensen’s
duct opening adjacent to the second upper molar
tooth, while the submandibular (Wharton’s
opens on the floor of the mouth through a papilla at
the base of the frenulum of the tongue. Their orifices
are easily visible in your own mouth and saliva will
be seen to flow if you press on the glands themselves.
The sublingual gland’s mucus secretion drains by a
series of very short ducts into the floor of the mouth.
The two principal surgical conditions of the salivary glands are inflammation, with or without calcu-
1
Niels Stensen (1638–1686), Professor of Anatomy,
University of Copenhagen, Denmark. Gave up his Chair in
1669 to become a bishop.
2
omas Wharton (1614–1673), Physician, St omas’s
Hospital, London, UK.
2
) duct
1
lus, and neoplasm. The nature of the glandular cells
determines the saliva’s composition, explaining the
different incidence of these conditions in each of the
salivary glands.
Inflammation
Aetiology
• Infection (viral or bacterial) usually affects the
)
parotid, rarely the submandibular gland.
•
Chronic recurrent sialadenitis, usually occurs in
the parotid.
Sjogren’s syndrome, involving all the salivary and
•
the lacrimal glands.
• Calculus, usually affecting the submandibular
gland.
Viral infections
The commonest viral infection to affect the salivary
glands is mumps but human immunodeficiency
virus (HIV) and hepatitis C should also be
considered.
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
Mumps
A viral infection (incubation period 17–21days), which
is common in children and affects the parotid glands; it
204 The salivary glands
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Box 21.1 Parotid swelling: differential
diagnosis
A swelling in the parotid region may be one of the
following.
Swelling of the parotid gland itself
•
Parotitis.
•
Pleomorphic adenoma.
•
Adenolymphoma.
•
Carcinoma.
Pseudoparotomegaly
•
Sebaceous cyst.
•
Lipoma.
•
Hypertrophic masseter.
•
Winged mandible.
•
Enlarged pre- auricular or parotid lymph nodes.
•
Neuroma of facial nerve.
•
Ameloblastoma (adamantinoma) and other
tumours of the mandible.
Box 21.2 Parotid swelling: examination
The following should always be performed, in
addition to examination of the gland itself.
•
Inspection of the parotid duct: redness, oedema
of the duct or exudation of pus indicate parotitis.
•
Testing the integrity of the facial nerve: it is
invariably intact in benign swelling, but may be
paralysed in malignant disease.
•
Inspection and palpation of the fauces: a parotid
tumour may plunge into the pharynx.
•
Palpation of the regional lymph nodes: they may
be involved with secondary deposits from a
parotid carcinoma.
is usually bilateral. Rarely, the submandibular or sublingual glands may also be involved. Most children are
now immunized against mumps before starting school.
Mumps may present to the surgeon in the following
ways.
• Acute parotitis: usual in childhood but may occasionally occur as a painful parotid swelling in an
adult (Boxes21.1 and21.2).
• Mumps orchitis: usually presents in adolescents or
young adults, and rare before puberty. Pain and
swelling in the testicle occur 7–10 days after the
onset of the parotitis and may lead to testicular
atrophy. If bilateral orchitis occurs, there may be
sterility or eunuchoidism. Very rarely, the orchitis
occurs without prodromal parotitis.
Pancreatitis, mastitis, thyroiditis or oophoritis are
•
also rarely caused by mumps.
Acute bacterial parotitis
Reduction of salivary flow is an important prerequisite for ascending infection of the parotid gland via its
duct. Aetiological factors include dental sepsis, dehydration, prolonged presence of a nasogastric tube and
poor oral hygiene. This complication may occur in
any severe debilitating illness and in uraemia. The
infection is usually streptococcal (Streptococcus viri-
dans) or staphylococcal (Staphylococcus aureus). It
used to be common after major abdominal surgery
but is less so now due to the use of antibiotics.
Clinical features
Clinically, there is swelling and intense pain in one or
both parotid glands, which are hard, enlarged and
tender, often with associated trismus. There may be a
purulent discharge from the duct. Abscess formation
occasionally occurs.
Treatment
Prophylaxis is important with adequate hydration
and elimination of the above aetiological factors. In
the established case, the patient must be kept fully
hydrated and the flow of saliva encouraged by sucking
citrus sweets or chewing gum. Parenteral antibiotic
therapy is commenced. Occasionally, surgical drainage is required.
Chronic recurrent parotid
sialadenitis
Repeated episodes of pain and swelling in one or both
parotids are not uncommon and are caused by a
combination of obstruction and infection of the
gland. There may be an associated dilation of the duct
system and alveoli of the gland, termed ‘sialectasia’
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