Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
418
CHAP TER13 The mouth, lips, andteeth
cUlceration and blistering
While lip and mouth ulcers are usually benign, it is important not to overlook oral cancer. The duration of ulceration can be of help in arr iving at
a dierential diagnosis. For example traumatic, aphthous, and herpetic
ulcer s typically resolve spontaneously within a few weeks. In contrast,
malignanc y tends to present a s a progressive, non- healing ulcer, which is
relatively painless in many cases. For lesions extending beyond the oral
cavity into other mucocutaneous sites, conditions such as pemphigoid,
pemphigus, and SJS should be considered.
cTraumatic ulcers andburns
Patients with traumatic ulcers or burns from hot food or dr inks will usually have a clear history of this. Ulcers commonly occur in areas of the
mouth which can be bitten, namely the lips, cheek s (buccal mucosa), and
tongue, while bur ns are more common on the palate and tongue. Both
are often painful. Ulcers and burns can also present as blisters, with a
sloughy white sur face membr ane, which sheds to reveal an erythematous or bleeding base. These lesions tend to look inamed around the
periphery.
Ulcers caused by repeated trauma (such as a shar p broken tooth,
or denture ange) can be dicult to distinguish from an oral cancer.
Malignancies however, tend to have a rmer, indurated consistency, with
round rolled margins. An important dierentiating factor is chronicity—
traumatic ulcer s and burns tend to heal spontaneously within 2 weeks,
so long as the cause of the trauma has been removed. In contrast, malignancy tends to be more progressive and persistent. If in doubt , clinical photographs and biopsy by a specialist will assist in giving a clearer
diagnostic picture.
Management
Treatment of traumatic ulcers and burns is symptomatic. Patient s can
use simple oral analgesia. If necessary, topical local anaesthetic gels
and mouth rinses can be prescribed. Patients should have a bland diet,
avoiding irritant avours (such as salt, vinegar, citrus, and chilli). Very hot
food and drinks should be avoided. Antibacterial chlor hexidine mouth
rinse may help in preventing bacterial superinfection. Patient s should be
reviewed by a dentist or maxillofacial surgeon to ensure the lesion has
resolved. All non- healing ulcers need urgent referral.
cHerpetic infection (primary herpetic stomatitis,
coldsores)
Widespread oral ulceration and blister ing is commonly due to herpetic
viral infection. This may be primary herpetiform stomatitis, or secondary cold sores. Primar y HSV typically presents in children and teenager s
as painful widespread oral mucosal blisters. Patients may also experience malaise, fever, and lymphadenopathy. Eating and drinking may be
restricted by pain. In contrast, secondary HSV (cold sores) present as
more localized vesicular swellings, typically periorally, with a characteristic prodrome of tingling and pain. These swellings are highly contagious,
ULCERATION AND BLISTERING
and can be triggered by stress or immunocompromise. Herpetic infection is often diagnosed clinically, but can be conrmed with viralswab.
Shingles (herpes zoster virus) can involve the oral cavit y. Usually it is
conned to one side (dermatomal distribution), whereas HSV is more
widespread.
HSV and herpes zoster virus infection may respond to aciclovir if treat-
ment is initiated promptly at the onset of symptoms. O therwise treatment is symptomatic, involving analgesia, hydration, and rest. Rarely,
hospital admission is required for severe eruptions where pain prohibits
any oral intake. In these instances, patients may benet from systemic
analgesia and IV hydr ation.
eStevens– Johnson syndrome
Where lesions are extensive and acute, SJS should be considered
(Figure 13.1). Also known as toxic epidermal necrolysis, SJS presents
as widespread mucosal and skin ulcers, resulting from a delayed hyper sensitivity reaction with separation of the epidermis from the dermis
and subsequent epidermal necrolysis. SJS occurs typically in response
to medications (in particular antibiotics) and following some infections
(including HSV, inuenza, and mumps). SJS is a medical emergency with
a high mortalit y, often due to secondary wound infection. Patients
are often managed conservatively, with all non- essential medication
stopped. Patient s with severe oral ulceration require IV hydration and
nutritional suppor t. Analgesic mouth rinse and wound dressings may
aid in supportive therapy. Treatment with corticosteroids is controversial. If there is ocular involvement, refer also to ophthalmology. SJS frequently causes scar tissue inside the eyelids and a host of other ocular
problems.
419
Figure13.1 Stevens– Johnson syndrome.
420
CHAP TER13 The mouth, lips, andteeth
eMucous membrane pemphigoid, pemphigus vulgaris
If widespread blister ing and ulceration occur s without an obvious cause
consider uncommon causes such as pemphigus vulgaris and mucous
membrane pemphigus.
Pemphigus vulgaris is an autoimmune mediated mucocutaneous disease which results in intra- epidermal blistering. It is known to aect
the oral mucosa prior to other cut aneous sites. It can produce painful
blisters which inhibit oral intake. Diagnosis is via biopsy— fresh specimens are preferred as they bet ter permit immunouorescence. Once
conrmed, refer ral for ophthalmic assessment is prudent, as vesicular
lesions are k nown to aect the corneal surfaces of the eyes, potentially
threatening vision.
Mucous membrane pemphigoid is another for m of autoimmune
blistering disease restricted to mucosal surfaces, particularly gingivae,
sinuses and genitourinary tract. It is heralded clinically by a positive
Nikolsky’s sign— that is rubbing a non- aected site will create a bulla,
due to reduced intraepithelial adhesion. Formal diagnosis is made via
biopsy with immunouorescence.
Management
Prompt treatment of pemphigus is essential to prevent sepsis from infection of the blister s once they have burst. Treatment typically involves
high- dose oral prednisolone as a rst- line drug. Antibiotics should be
prescribed for any wound infection, and analgesia titrated according to
need. Admission may be warranted for severe vesiculobullous disease
preventing oral intake, or with established infection.
In contrast, management of mucous membrane pemphigoid tends
to be more localized than for pemphigus, and involves soft diet, or al
hygiene, and topical steroids.
bAphthous ulceration
Patients presenting with episodic oral ulcers may be suering from aphthous ulceration. Aphthous ulcers are non- contagious, painful ulcers
which predominately aect the labial and buccal mucosa, lateral tongue
and oor of mouth. They most commonly aec t teenager s and young
adult s, and tend to spontaneously resolve within 2 weeks of onset.
Although the exact cause of aphthous ulceration is unknown, several
factors are postulated to contribute, including haematinic deciency
(vitamin B12, folate, and iron), immunocompromise, and stress. Ulcer s
are typically er ythematous macules, with intensely red halos of inammation surrounding them. The surface may be covered by a yellow- grey
brinous slough.
While the diagnosis of aphthous ulceration is often clinical, ulcers
should be followed up to ensure they resolve. In resistant cases blood
test s are employed to exclude a haematinic deciency.
The treatment of aphthous ulceration is typically symptomatic, as for
traumatic ulcer s and burns. In addition, vitamin B12, folate, and iron supplementation as required may help to prevent ulcer recur rence. Patients
should have a bland diet during episodes of ulcer ation to reduce pain and
irritation. Topical steroids may help. Severe episodes of painful ulceration precluding oral intake may require admission for IV hydration and
systemic steroids, although this israre.
ULCERATION AND BLISTERING
cOral/ lipcancer
Oral/ lip cancer typically present s as a non- healing ulcer, with raised
rolled edges. The patient may have a histor y of risk factors, including
smoking, alcohol, and sun exposure. Any ulcer which is progressively
enlarging, and persists for >2 weeks, should be referred for urgent
biopsy to exclude dysplasia or malignancy. Patients with suspected cancer should also be checked for signs of cervical lymphadenopathy, weight
loss, and chest involvement.
Clinical features of a malignant ulcer include:
• Firm
• Fixed
• Indurated
• Non- healingulcers
• Often painless
• Friable
• Round/ rolled/ heaped margins.
While oral squamous cell carcinomas can occur anywhere in the mouth,
the most common locations are the oor of mouth and posterolateral
tongue. Other less common types of cancer include salivary gland malignancy (consider this in any palatal swelling or non- healing ulcer) and lymphoma. See Figures 13.2 and13.3.
Malignant melanoma is rare. Management involves fur ther imaging to
determine whether there is regional lymph node involvement or distant
spread. Following discussion at a head and neck multidisciplinar y team
meeting, treatment may be active or palliative, comprising surgery, chemotherapy, and radiation.
421
Figure13.2 Exam ple of oral cancer(1).
422
CHAP TER13 The mouth, lips, andteeth
Figure13.3 Example of o ral cancer( 2).
cKaposi’s sarcoma
Kaposi’s sarcoma is rare, of ten presenting in HIV- positive patients, as
a clinical manifestation of AIDS. It is an angiosarcoma caused by human
herpesvirus 8 (HHV8). It t ypically presents as a violaceous (dark red,
blue, or black) macule on the palate which then ulcerates and becomes
painful. Diagnosis is via biopsy of the lesion, which tends to be highly vascular. Kaposi’s sarcoma cannot be cured, but it may regress and be controlled by use of HAART (highly active anti- retroviral therapy). Other
treatment options include cryotherapy, radiation, and chemotherapy.
bNecrotizing sialometaplasia
This is a benign ulcerative lesion found mostly on the posterior hard palate. It is due to necrosis of the minor salivary glands sometimes following
an injury (such as palatal inltrations of local anaesthetic or trauma during intubation). It can also arise spontaneously. Necrotizing sialometaplasia is more common in smokers. It may be confused with malignancy as
it shares common features. Biopsy is necessary in most cases to besure.
cSyphilitic lesions
Syphilis, although uncommon, can present with a characteristic triad of
oral lesions
• Primary syphilis— chancre
• Secondary syphilis— condylomalata
• Tertiary syphilis— gumma.
Primary syphilitic chancres are typically painless, rm ulcers, which present approximately 1 month after or al sexual contact with an infec ted
ULCERATION AND BLISTERING
individual. Chancres are infectious, caused by Treponema pallidum. They
typically heal spontaneously af ter several weeks. If syphilis is untreated,
it will progress to the secondar ystage.
Secondary syphilis presents approximately 3months after initial infec-
tion as a non- itchy r ash which can involve the whole body, even the palms
and soles. On mucosal surfaces including the oral cavit y, the lesions present as infectious wart- like projections, called condyloma lata. Patients
may also complain of malaise, fever, and sore throat at this time. These
symptoms tend to self- resolve within 1month of occurring.
Tertiary syphilis presents years after initial infection, and can present as
a gumma— an exophytic round soft tissue swelling which can involve the
skin, bone, or internal organs. Intraorally, the palate is the most common
site of involvement. Tertiary syphilis can also aect the brain (neurosyphilis), with seizures, paresis, or dementia. Tertiary syphilis is not infectious.
Syphilis is diagnosed with serology, or dark eld microscopy of a biopsy
to identify the charac teristic causative spirochete, Treponema pallidum.
Treatment is with a single injection of penicillin. Once syphilis advances
to the tertiar y stage, the damage is generally irrever sible.
bAngina bullosa haemorrhagica
This is characterized by the sudden appearance of one or more blood
blisters within the oral cavity. The cause is unknown. Blisters may occur
following mild trauma but usually rupture quickly and heal without scarring. Generally the condition is not serious. Blisters usually aect the palate or oropharynx. Diagnosis is based on exclusion of other conditions
and the history of blood as the blister (hence thename).
bAngular cheilitis
Cracked painful ssures at the corner s of the mouth (commissures) are
termed angular cheilitis. This may signify a nutritional deciency, such as
iron, vitamin B12, or folate. It is also seen in denture- wearers with prominent perioral wrinkles that collect salvia, allowing opportunistic candidal
infection in the moist tissue folds. Angular cheilitis can be diagnosed clinically. Exclude deciencies of iron, vitamin B12 and folate. Construction
of new dentures with increased vertical dimension should open the facial
height, thereby reducing perioral wrinkling to prevent pooling of moist
saliva in these regions.
cDrug induced
Chemother apy (and radiotherapy) can produce widespread painful
ulcer ation. Nicorandil (used to manage angina) can result in large solitary
oral ulceration which may resemble major aphthous ulcers or squamous
cell carcinoma. The ulcers may cause severe symptoms, including weight
loss from pain and dysphagia. They usually resolve completely on cessation of thedrug.
bErosive lichenplanus
This is a chronic painful condition aecting mucosal surfaces, mainly the
mouth (oral lichen planus) and the genitals (vulval or penile lichen planus). Ulceration commonly occurs in the mouth and gums. It is sometimes associated with classical cutaneous lichen planus or other forms of
mucosal lichen planus.
423
424
CHAP TER13 The mouth, lips, andteeth
Management
The management of erosive lichen planus can be very challenging.
Topical and systemic treatment may be required. Topical steroids generally applied daily are the mainstay of treatment in most patient s. Systemic
steroids such as prednisone may be prescribed for severecases.
bBehçet’s disease
This is a rare immune- mediated vasculitis that often presents with recurrent oral aphthous ulcers, genital ulcers, and uveitis. It can also involve
the GI tract, pulmonary, musculoskeletal, cardiova scular, and ner vous
systems. Treatment includes steroids, but patients should be referred
to a specialist.
Summary ofsystemic causes oforal ulceration
• Bacterial infections— TB, secondary syphilis
• Behçet’s disease
• Candidia
• Chemotherapeuticagents
• Chronic renal failure
• Crohn’s disease
• Dermatitis herpetiformis lichenplanus
• Epidermolysis bullosa
• Haematological disease — vit amin B12, folate, and iron deciencies
• Kawasaki disease
• Linear immunoglobulin Adisease
• Nicorandil
• Reiter’s syndrome
• SJS,SLE
• Strachan’s syndrome
• Sweet’s disease
• Viral infections— HSV, herpes zoster virus, coxsackievirus, Epstein–
Barr virus, hand, foot, and mouth disease, HIV infection
• Wegener’s granulomatosis.
Swellings
Diuse oral swelling can have many causes. Some of them can progress rapidly. Life- threatening causes of swelling, such as anaphylaxis and
Ludwig’s angina, must not be overlooked.
Swelling is fairly self- evident and can be diuse or relatively localized. It
can also be acute or chronic. Diuse swelling is more likely to be related
to a systemic cause such as anaphylaxis, whereas localized swelling is
more likely with an abscess, or following trauma. It is impor tant to identify the chronicity of the swelling, and to determine whether it pr imarily
involves the soft tissues or the underlyingbones.
Patients presenting with swelling of the lips should always be checked
for swelling intraorally, notably the tongue and airway. If advanced, oral
swelling (particularly in the oor of mouth), can cause problems with
swallowing, speech, or even breathing. In severe infection, such as
Ludwig’s angina, potentially life- threatening swelling can occur rapidly
over a fewhours.
If the onset of the swelling has been more gradual, soft tissue condi-
tions such as haemangioma, lymphangioma, orofacial granulomatosis,
and amyloidosis could be considered. If the swelling appears to be due to
underlying bony distension, it may signif y a bony disease, such as ossifying broma, brous dysplasia, or Paget’s disease. The recent onset of pain
and increased growth in any swelling suggests the possibility of infection or
malignancy.
cTraumatic swelling
Localized lip and oral swelling is very common following an acute trauma,
in which case there is usually a clear history of injury. If there is a wound,
consider the possibility of a foreignbody.
cSublingual haematoma
Sublingual haematoma is usually secondary to trauma or dental treatment, and may resemble a large, rm bruise in the oor of the mouth,
with distension of the sublingual tissues and tongue displacement.
Patients may experience problems with moving the tongue, speaking,
and swallowing. Massive sublingual haematoma is often a sign of signicant trauma, and patients should be assessed for a mandibular fracture.
Beware of patients taking anticoagulants as the swelling may continue to
grow. Occasionally CT is required.
cInfections/ abscesses
See also E Chapter 11 and E Chapter 12.
Clinical features
Patients most commonly present with a focal infection (abscess).
Occasionally, a cellulitis may develop, resulting in more diuse swelling,
redness and pain. Abscesses and cellulitis are associated with acute onset
of swelling, typically occurring 24– 48 hours prior to presentation. They
tend to be painful, warm, and uc tuant to touch. Most intraoral infections arise from an infected tooth. Other causes include an infected fracture (or it s xation plate) and osteomyelitis. An OPT should be taken to
check the status of the teeth and bones. Bloods including FBC and CRP
will aide in determining whether the patient is systemically unwell. Some
patients with a lip or facial abscess may have a history of skin infection,
dental pain, or recent facial/ tongue piercing, which helps with diagnosis.
If an oral, facial, dental, or lip abscess is suspected, maxillofacial referral
may be required.
Management
Abscesses should be treated by incision and drainage, either in an inpatient or outpatient setting, depending on the site/ size of the abscess,
patient cooperation, and whether they are systemically unwell.
Antibiotics are commonly given, but it is important to remember that
antibiotics alone are never a substitute for surgical incision and drainage
ofpus.
SWELLINGS
425
426
CHAP TER13 The mouth, lips, andteeth
eLudwig’sangina
Patients with deep- seated facial or dental infections may present with
rapidly progressive swelling within the mouth and neck. Examination of
the oor of mouth is essential to check for impending airway compromise. If the oor of the mouth is elevated, tense, with restricted tongue move-
ments, and inability to swallow saliva, the patient requires urgent intubation
and surgical decompression. Even if there is no demonstrable collection of
pus, cellulitic swelling still benets from incision and drainage, to reduce
bacterial load and inammatory tissue oedema. Ludwig’s angina is life-
threatening , and occurs when fascial space infections track down into the
neck and mediastinum. Patients will be systemically unwell, febrile, with an
accompanying leucocytosis and elevated CR P. CT scanning of the neck
and chest may demonstrate fascial space collections along with mediastinitis, but this is a very late and imminently life- threateningsign.
eAnaphylaxis
This acute life- threatening condition results from immunoglobulin Emediated ma ssive degranulation of mast cells in response to an allergen,
commonly food, latex, or medication. Anaphylaxis may present with
diuse swelling of the lips, tongue, and face (angio- oedema), and can
threaten the air way. It may or may not present with a rash. Established
anaphylactic shock is characterized by hypotension, t achycardia, and
warm peripheries. The allergen must be removed, and the patient
treated with oxygen, adrenaline (epinephrine), and antihist amines as
appropriate (refer to local guidelines) Facial swelling tends to resolve
spontaneously as the anaphylaxis settles.
eHereditary angio- oedema
Hereditary angio- oedema result s from a deciency of C1 esterase inhibitor in the complement cascade. This can result in increased vascular permeability and subsequent tissue oedema. It causes episodic swelling of
the face, hands, feet, airway, and GI tract. Episodes may be trig gered by
stress, surger y, and dental treatment. Diagnosis is made by blood test
via liaison with haematology. Prior to surgical or dental treatment, C1inhibitor concentrate, or fresh frozen plasma can be given prophylactically. Treatment of emerging oedema is the same as for anaphylaxis.
bHaemangioma/ lymphangioma
Haemangioma and lymphangioma represent benign lymphovascular
malformations with proliferation of lymphatic or vascular capillaries in
a localized area. This results in a localized swelling, which may be blue
or purplish in colour. The most common or al sites include the lips, buccal mucosa, and tongue. Haemangioma may be congenit al and typically
enlarge with age. If bitten or traumatized, they maybleed.
Treatment of haemangioma depends on the size of the lesion. If small
(<1cm), many can be successfully excised. If larger, options such as cryother apy or sclerotherapy or embolization may be considered. In children, until recently the mainstay of treatment was oral corticosteroid
ther apy. Propranolol has been shown to reduced severe haemangioma
in infants. Other treatments include interferon or vincristine.
bOrofacial granulomatosis
Orofacial granulomatosis (OFG) comprises gradual, painless, persistent
enlargement of the lips and perioral tissues, which typically presents in
adolescence. The lips often feel rm and rubber y. Diagnosis is made by
biopsy. OFG may be linked to other granulomatous conditions, including
Crohn’s disease. Patients should be questioned regarding GI symptoms,
and referred for ga stroenterology assessment if necessary. Treatment
of OFG tends to be conservative, involving dietar y restriction (avoiding
cinnamon and benzoate preservatives). Occasionally, intra- lesion steroids or tissue debulking can be performed for massive and per sistent
lip swelling.
bAmyloidosis
Amyloidosis produces gradual oral swelling, which can be either localized
or generalized. The localized form predominates and most commonly
involves the tongue. Systemic amyloidosis involves the kidneys and heart,
and can initially present with fatigue and weight loss, progressing to proteinuria and signs of congestive cardiac failure. Oral amyloidosis tends
to resemble benign soft nodules with overlying mucosal discolouration,
which may be yellow, purple, and blue. The diagnosis can only be made
by biopsy. Once diagnosed, treatment is targeted to the organs involved
(e.g. diuretics and dialysis), while sur ger y and laser excision may help to
minimize localized symptoms, including dysphagia.
bDermal llers (side eects)
Dermal llers come in many forms, from resor bable to per manent, and
are now commonly undertaken by the cosmetic industry. The face (especially the perior al region) is a commonly injected site. Each kind of dermal ller has its own side eects and these may occur at dierent times.
The most common side eects include:
• Bruising and bleeding
• Itching
• Skin discolouration
• Viral/ bacterial infection
• Redness and swelling at the region of injection
• Allergic reactions
• Lumps under theskin
• Skin ulceration in the injectedsite.
Most of these are uncommon. Allergic reactions are rare. Refer back to
the practitioner that placed the ller.
bFibrous dysplasia
This t ypically presents in teenagers a s a progressive bony expansion. In
most ca ses a single bone is involved (monostotic), and the skull and jaws
are commonly implicated. The patient may present with physical bony
deformity or, in some cases, painful bony expansion. The exact cause of
brous dysplasia is unknown, but it is not a neoplasm. Diagnosis is usually
made formally by CT and bone biopsy. Bone pain can be treated symptomatically, and in extreme cases, surgical debulking may be required.
SWELLINGS
427