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SECTION II — Diseases of Nose and Paranasal Sinuses
FRONTAL SINUS MALIGNANCY
Frontal sinus malignancies are uncommon and are seen
in the age group of 40–50 years with male predominance
(5:1).
Clinical Features
Pain and swelling of the frontal region are the presenting features. Growths may erode through the floor of
frontal sinus and present as a swelling above the medial
canthus. Growths of frontal sinus may extend through
the ethmoids into the orbit. Dura of anterior cranial fossa
may be involved if growth penetrates the posterior wall
of the sinus.
Treatment
Frontal sinus malignancy is treated by preoperative
radiation followed by surgery. Surgery includes frontal
sinusotomy with ethmoid and orbital exenteration.
Neurosurgical approach may be required to resect the
dura of anterior cranial fossa, if involved.
SPHENOID SINUS MALIGNANCY
Primary malignancy of the sinus is rare. It has to be differentiated from the inflammatory lesions in this area. Plain
X-rays, CT scan and biopsy through sphenoidotomy are
essential to know the nature and extent of disease. Radiotherapy is the mainstay of treatment.
Chapter 41
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Proptosis
Orbit has rigid walls; any space occupying lesion of
the orbit causes eyeball to protrude forward or also displace in some other direction, i.e. medial, lateral, up or
down depending on location of the pathology in the
orbit. Proptosis should be differentiated from pseudoproptosis, i.e. apparently proptosed eyeball though it
is normal in position (Figure 41.1). This happens with
enophthalmos of the contralateral eye due to previous forgotten trauma such as orbital blowout fractures.
Lid retraction and high myopia can also make the
eyeball look proptosed. Proptosis can be measured by
exophthalmometer.
AETIOLOGY
Table 41.1 shows the various conditions causing proptosis
and can be remembered by the acronym of VEIN.
Figure 41.1. A mucocele of the left ethmoid causing displacement
and proptosis of the eyeball.
Various conditions of concern to the ENT surgeon
include orbital cellulitis or orbital abscess, subperiosteal
abscess, fungal infections of sinuses, Graves ophthalmopathy, benign and malignant neoplasms of nose and
paranasal sinuses, such as angiofibroma, inverted papilloma, nasal polyposis, mucoceles, esthesioneuroblastoma,
paranasal sinus malignancies and trauma following endoscopic surgery.
Some important diseases are described below.
1. Idiopathic orbital inflammation. As the name indi-
cates, cause is uncertain. It may be diffuse or localized
to specific structures in the orbit, e.g. muscles (myositis),
lacrimal gland, sclera (scleritis) or optic nerve (perineuri-
tis). Patient complains of dull orbital pain especially on
eye movements. Proptosis is seen in 70-80% of patients.
CT scan with enhancement shows enlargement of the
affected structures. An important feature is involvement
of muscle and its tendon attached to the globe and differ-
entiates it from thyroid-related disease where only muscle
belly is involved but not its tendon. Biopsy shows non-
specific inflammation without evidence of vasculitis.
Treatment is oral steroids. In some cases, immunosup-
pression with cyclophosphamide, cyclosporine or radio-
therapy may be required.
2. Graves ophthalmopathy. This is the most common
cause of bilateral and sometimes unilateral proptosis.
Patient is hyperthyroid but sometimes he is euthyroid
or even hypothyroid. Lid retraction and lid lag may
be present with chemosis and lid oedema. CT scan is
useful to differentiate it from idiopathic orbital inflam-
mation (vide supra). Visual loss can occur. Extreme
proptosis causes corneal ulceration and may require
orbital decompression which nowadays can be done
endoscopically through the nose.
3. Haemangioma of orbit. It can be cavernous or cap-
illary. Cavernous haemangioma is the most common
TABLE 41.1 CAUSES OF PROPTOSIS (REMEMBER THE MNEMONIC VEIN)
Vascular. Venous varix, cavernous haemangioma, carotid-cavernous fistula
Endocrinal. Graves’ disease which may cause bilateral or sometimes even unilateral proptosis
Inflammations and infections. Idiopathic orbital inflammation (pseudotumour of orbit), orbital cellulitis or abscess, mucormycosis or
aspergillosis of sinuses, Wegener’s granulomatosis, inflammations of lacrimal gland.
Neoplastic. Tumours (both benign and malignant) or tumour-like conditions arising from the orbital contents or its adjoining structures.
Orbit contains eyeball, optic nerve, muscles, nerves, blood vessels and lacrimal gland and tumour and tumour-like conditions can arise
from them. They can also arise from paranasal sinuses and cranial cavity and invade the orbit.
(a) Primary tumours of orbit, its walls or adnexa (lid, lacrimal gland and conjunctiva). Dermoid cyst, cavernous or capillary haemangioma,
schwannoma, glioma, retinoblastoma, fibrous dysplasia, osteoma, histiocytosis X, orbital meningioma, pleomorphic adenoma of
lacrimal gland. Malignant tumours include rhabdomyosarcoma, lymphoma, leukaemic deposits, malignant tumours of lacrimal gland
and melanoma of choroid.
(b) Tumours of paranasal sinuses. Mucocele of frontal or ethmoidal sinuses, inverted papilloma, angiofibroma, malignant tumours of sinuses.
Tumours from cranial cavity. Meningioma of the sphenoid ridge.
(c) Metastatic tumours. Carcinoma breast (most common), lung, prostate, kidney, thyroid, gastrointestinal tract.
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SECTION II — Diseases of Nose and Paranasal Sinuses
benign tumour in adult. It is more common in females
in the age group of 18-67 years. It manifests as painless, progressive, unilateral proptosis. CT/MRI reveals
a round or oval mass without associated inflammation
or infiltration around it. It is an encapsulated mass.
Intraconal in location and enhances on i.v. contrast.
Treatment is complete excision with its capsule by lateral orbitotomy.
4. Capillary haemangioma. Most common tumour of
orbit in infants and children. May be isolated or associated with a lesion on the upper lid or elsewhere on
the skin. Most of them involute by age 7. CT/MRI with
contrast is diagnostic. Tumour is nonencapsulated and
infiltrates the surrounding structures. Local or systemic steroids help to involute the mass. Total excision is
not possible.
5. Venous varix of the orbit. It presents with positional
proptosis and congestion. Proptosis can also be induced by Valsalva manoeuvre. A carotid-cavernous
fistula is either spontaneous or traumatic; it presents
with pulsatile proptosis, bruit, visual loss, dilated and
arterialized blood vessels in the conjunctiva or limbus.
6. Lymphoma. It is the most common malignant tumour
of adults. It may be isolated or associated with systemic disease. Most of the patients are between 50 and
70 years with female preponderance. It presents as
painless progressive exophthalmos. Usually lesions are
located anteriorly and can be palpated or seen under
the conjunctiva. Most of them are extraconal. CT shows
a homogenous tumour without bone involvement. Biopsy is necessary to differentiate it from the benign
lymphoid or other tumours. Isolated lymphoma can
be treated by radiation alone while systemic ones require chemotherapy in addition to orbital radiation.
7. Rhabdomyosarcoma. It is the most common primary
malignant tumour of orbit in children and is usually
seen at 6-7 years of age. It can occur even in the newborn. It presents as painless but progressive proptosis
and can spread to the adjoining paranasal sinuses. It
may be intraconal or extraconal. CT is helpful in diagnosis. Biopsy should be taken. Treatment is radiation
and chemotherapy. Five-year survival of 90% can be
achieved in localized disease.
8. Dermoid cyst. It is the most common benign tumour
of orbit in children. It is due to the trapped ectoderm
that occurs at suture lines during development. Deep
dermoids of orbit arise from the sphenoethmoid or
sphenozygomatic sutures. They may remain asymptomatic till adult age. They present with painless, progressive proptosis with globe displacement. CT orbit
may show a cyst with pressure effects (Figure 41.2).
Large cysts may communicate with temporal fossa,
paranasal sinuses or the cranial cavity. Treatment is
surgical excision.
9. Tumours of optic nerve. Glioma of optic nerve is
usually seen in children and may be associated with
neurofibromatosis. It causes progressive proptosis and
visual loss.
EVALUATION OF PROPTOSIS
A case of proptosis requires a detailed history including onset, duration and progression of the disease. Associated
illnesses (thyroid disease, tumours of nose or paranasal sinuses, systemic disorders such as leukaemia, lymphoma,
Wegener’s granulomatosis) should be looked for. Pain is a
feature of inflammation or infection. Visual loss may be
present and should be documented.
Physical examination should include a type of propto-
sis (straight forward or of globe displacement in upward,
downward, lateral or medial direction), condition of the
conjunctiva (swelling and chemosis), scleral appearance,
Figure 41.2. A dermoid cyst of the right orbit. (A) Axial and (B) coronal views (arrows). The patient presented with a mild proptosis.
Chapter 41 — Proptosis
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ocular movements and vision. Note should also be made
if the proptosis is pulsatile or associated with change in
position of the head or appears on performing Valsalva
(venous varix).
CT and MRI are important and give clue to the type
of tumour (intraconal/extraconal), smooth or infiltrative,
location in the orbit and its extent, any changes in the
adjoining bone or extension to sinuses or cranial cavity.
They can help to differentiate thyroid orbitopathy from
the idiopathic orbital inflammation.
Ultrasonography may be required to find abscess or cystic lesions.
FNAC or biopsy of the lesion may be required for histologic diagnosis.
Systemic diseases causing orbital lesions such as lymphoma, Grave’s disease and leukaemia should be investigated as mandated by history and clinical examination
and relevant investigation.
MANAGEMENT
Imaging techniques help to make the diagnosis. Biopsy
of the lesion can be taken depending on its location in
the orbit. Anteriorly located lesions can be approached
by lid or conjunctival incision. Excisional biopsy is useful in encapsulated and well-circumscribed lesions such
as dermoid, cavernous haemangioma and pleomorphic
adenoma of the lacrimal gland. All cases causing proptosis do not require surgery. Medical treatment includes
antibiotics in orbital cellulitis, steroids in pseudotumour,
chemotherapy for lymphoma, radiation for malignancies
and sometimes pseudotumour. Surgery of orbit includes
debulking of lymphangioma or plexiform neurofibroma
to relieve pressure on the optic nerve orbital exenteration for mucormycosis and malignancies. Endoscopic
orbital decompression may be required in Graves ophthalmopathy. Lateral orbitotomy is required for lesions of
lacrimal gland or those situated intraconally. Transcranial
approach is used for lesions at the orbital apex or those
invading intracranially from the orbit or vice versa.
remember. In children, dermoid cyst of the orbit is the
most common benign tumour and rhabdomyosarcoma
the malignant one.
In adults, cavernous haemangioma is the most common benign tumour of orbit and lymphoma the malignant one.
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SECTION III
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Diseases of Oral Cavity
and Salivary Glands
S e c t i o n o u t l i n e
42 Anatomy of Oral Cavity, 243
43 Common Disorders of Oral Cavity, 245
44 Tumours of Oral Cavity, 251
45 Non-neoplastic Disorders of Salivary Glands, 259
46 Neoplasms of Salivary Glands, 263
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Chapter 42
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Anatomy of Oral Cavity
APPLIED ANATOMY
The oral cavity extends from the lips to the oropharyngeal isthmus, i.e. up to the level of anterior pillar of tonsils.
It is divided into the following sites (Figure 42.1):
1. Lips. They form anterior boundary of the oral vestibule.
2. Buccal or cheek mucosa. It lines the inner surface of
cheeks and lips, and extends up to pterygomandibular
raphe. Anteriorly, it extends to the meeting line of lips.
3. Gums (gingivae). They surround the teeth and cover
the upper and lower alveolar ridges.
4. Retromolar trigone. It is a triangular area of mucosa
covering anterior surface of the ascending ramus of
mandible. Its base is posterior to the last molar while
its apex is adjacent to the tuberosity of maxilla.
5. Hard palate. It forms roof of the oral cavity.
6. Oral tongue. Only anterior two-thirds of tongue are
included in the oral cavity. Posterior one-third or base
of tongue is situated behind the circumvallate papillae and forms part of the oropharynx. Oral tongue is
divided into tip, lateral borders, dorsum and the undersurface.
7. Floor of mouth. It is a crescent-shaped area between
the gingivae and undersurface of tongue. Anterior portion of the floor is best seen when patient raises the tip
of tongue to touch the hard palate. Frenulum and sublingual papillae with openings of submandibular ducts
can be easily seen. Lateral portion of floor of mouth is
best seen by displacing the lateral surface of tongue in
medial direction with the help of a tongue depressor.
LYMPHATIC DRAINAGE OF ORAL CAVITY
1. Lips. Lower: Medial portion of lower lip drains into
submental and lateral portion to submandibular
nodes. Upper: Drain into preauricular, infraparotid and
submandibular nodes.
2. Buccal mucosa. Submental and submandibular nodes.
3. Upper and lower alveolar ridges. Buccal aspect of
mucosa drains into submental and submandibular
nodes.
4. Hard palate. Upper deep cervical and lateral retropharyngeal nodes. Anterior part of palate drains into
submandibular nodes.
5. Floor of mouth. Anterior portion of floor of mouth
drains into submandibular nodes. Lymphatics from
this area also cross the midline.
Posterior portion drains into upper deep cervical
nodes.
6. Tongue. Tip of tongue drains into submental and
jugulo-omohyoid nodes, lateral portion drains into
ipsilateral, submandibular and deep cervical nodes.
Central portion and base drain into deep cervical
nodes of both sides.
Figure 42.1. Various sites in oral cavity.
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Chapter 43
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Common Disorders of Oral Cavity
ULCERS OF ORAL CAVITY
Some of the common ulcers are described in this chapter. The causes of the ulcers of oral cavity are listed in
Table 43.1.
A. INFECTION
Viral
1. herpangina. It is a coxsackie viral infection mostly
affecting children. To begin with, multiple small vesicles
appear on the faucial pillars, tonsils, soft palate and uvula. They rupture to form ulcers which are usually 2-4 mm
in size, have a yellow base and red areola around them.
They seldom persist beyond 1 week.
2. herpetic gingiVostomatitis. Also known as orola-
bial herpes. It is caused by herpes simplex virus and is of
two types: primary and secondary.
(a) The primary infection affects children and is character-
ized by clusters of multiple vesicles which soon rupture to form ulcers. Any part of the oral cavity may be
affected. Constitutional symptoms like fever, malaise
and headache may accompany sore throat and lymphadenopathy.
(b) Secondary or recurrent herpes chiefly affects adults. It
is milder in form as adults have some immunity to
this virus. Most commonly, it involves the vermilion
TABLE 43.1 CAUSES OF ULCERS OF THE ORAL
CAVITY
1. Infections
(a) Viral. Herpangina, herpes simplex (primary and secondary),
hand, foot and mouth disease
(b) Bacterial. Vincent infection, TB, syphilis
(c) Fungal. Candidiasis
2. Immune disorders. Aphthous ulcer, Behçet syndrome
3. Trauma
(a) Physical. Cheek bite, jagged tooth, ill-fitting denture
(b) Chemical. Silver nitrate, phenol, aspirin burns
(c) Thermal. Hot food or fluid, reverse smoking
4. Neoplasms
5. Skin disorders. Erythema multiforme, lichen planus, benign
mucous membrane pemphigoid, bullous pemphigoid, lupus
erythematosus
6. Blood disorders. Leukaemia, agranulocytosis, pancytopenia,
cyclic neutropenia, sickle cell anaemia
7. Drug allergy. Mouth washes, toothpaste, etc. Reactions to
systemic drugs
8. Vitamin deficiencies
9. Miscellaneous. Radiation mucositis, cancer chemotherapy,
diabetes mellitus, uraemia
border of the lip (herpes labialis) but less often lesions
appear intraorally on the hard palate and gingiva. In
recurrent herpes, it is presumed that virus lies dormant in the trigeminal ganglion and, when reactivated, travels along peripheral sensory nerves to involve
oropharyngeal mucosa. Precipitating factors include
emotional stress, fatigue, fever, pregnancy or immune
deficiency states. Treatment is mostly symptomatic.
Acyclovir, 200 mg, five times a day for 5 days helps to
cut down the course of recurrent herpes labialis.
3. hand, Foot and mouth disease. It is also a viral
infection affecting children. Oral lesions are seen on the
palate, tongue and buccal mucosa. Vesicles also develop
on the skin of hands, feet and sometimes buttocks.
Bacterial
1. Vincent inFection (Acute NecrotiziNg ulcerAtive
giNgivitis). It is similar to Vincent’s angina. Causative or-
ganisms are the same (a fusiform bacillus and a spirochaeteBorrelia vincentii). More often the disease affects young
adults and middle-aged persons. It starts at the interdental
papillae and then spreads to free margins of the gingivae
which get covered with necrotic slough. Gingivae also
become red and oedematous. Similar ulcer and necrotic
membrane may also form over the tonsil (Vincent’s angina).
Diagnosis is made by smear from the affected area. Treatment is systemic antibiotics (penicillin or erythromycin
and metronidazole), frequent mouth washes (with sodium
bicarbonate solution) and attention to dental hygiene.
2. speciFic bacterial inFections. Tuberculosis, syphi-
lis and actinomycosis may present as chronic ulcers.
Fungal
MoniLiaSiS (canDiDiaSiS). It is caused by Candida
albicans and occurs in two forms:
1. Thrush. It appears as white grey patches on the oral
mucosa and tongue. When wiped off, they leave an
erythematous mucosa. The condition is seen in infants and children. Adults are also affected when they
are suffering from systemic malignancy and diabetes
or taking broad-spectrum antibiotics, cytotoxic drugs,
steroids or radiation.
2. Chronic hypertrophic candidiasis. Also called candidal
leukoplakia. The lesion appears as white patch which
cannot be wiped off. Mostly affects anterior buccal
mucosa just behind the angle of mouth.
Thrush can be treated by topical application of nystatin or clotrimazole. Hypertrophic form usually requires
excisional surgery.
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