Методичні розробки 3 модуль

the skin and oral mucosa. The skin lesions may be so numerous and prominent that they become cosmetically significant with cutaneous melanin pigmentation described as café-au-lait spots which precede the neural lesions. Malignant transformation may be seen in 5-15% of cases of neurofibromatosis.

Microscopically neurofibroma shows a mixture of Shwann cells and fibroblast cells, with varying amount of collagen and mucinous material.

The differential diagnosis of neurofibroma includes: traumatic neuroma, traumatic fibroma, granular cell tumor, some other connective tissues lesions.

Treatment: surgical excision for single neurofibroma, for surgical excision is impractical for neurofibromatosis.

Neurilemmoma (schwannona) is uncommon benign neoplasm of axon sheath origin

(Schwann‘s sheath), but it is more common than neurofibroma. Clinically neurilemmoma appears as painless slowly growing, submucosal mass; the tongue is favored site, also may occur in bone, producing radiolucent areas and may associate with pain or parestesia.

Histologically neurilemmoma shows two characteristic patterns:

Antony A, which consists of parallel rows or whorls of collagen fibers and spindle with palisaded

nuclei.

Antony B, which consists of disorderly arranged cells and collagen fibers in a mucinous microcystic stroma.

The different diagnosis of neurilemmoma includes: traumatic neuroma, salivary gland tumors, some other benign mesenchymal tumors.

Treatment:surgical excision with excellent prognosis.

Traumatic neuroma is a non-neoplastic, but considered as a reactive hyperplasia of peripheral nerve fibers as a result of traumatic injury. Traumatic neuroma is common in areas of previous surgery. Traumatic neuroma is uncommon lesion in the oral cavity and appears as small rounded nodules, which can give rise to pain on pressure.

Microscopically traumatic neuroma shows nerve fibers, Shwann cells, and connective tissue

stroma.

The differential diagnosis of traumatic neuroma includes: any small mass painful on pressure (a typical facial pain).

Treatment: surgical excision.

6. Types of individual work of students. A. To study the following questions:

1. Photos of patients with tumors and tumor-like formations of peripheral nerves of face.

2. Charts of examination of оncostomatological patients.

B. Tasks for self-control:

1. Patient, 78 years old, appealed to the clinic with complaints in the presence of the rounded painful formation on a transitional fold of low jaw, that appeared half-year back. A year ago complete removable prosthetic appliance was made to the patient. Objectively: a face is symmetric, inframandibular lymphatic nodes are not palpated. Expressed atrophy of alveolar sprout of low jaw is determined. On the area of the right mental foramen there is painfull, densely-elastic rounded formation to 0,5 cm in a diameter.

What previous diagnosis? (Answer: Traumatic neuroma.)

2.A patient, 48 years old, grumbles about the painful swelling of the left cheek. Objectively: a face is asymmetric due to the swelling of the left cheek area, skin without changes, lymphatic nodes are not palpated. The painful rounded formation to 5 cm in a diameter of densely-elastic consistency is determined in the layer of the left cheek. Formation is not soldered with adherent tissues.

To diagnoses.

(Answer: Neurofibroma.)

3.At patient, 68 years old, there is distortion of face and neck at the left due to swagging of skin, left auricle. Pain, decline of turgor of skin, dense strands in the form noodles are marked at palpation. Diagnose.

(Answer: neurofibromatosis (Recklinghausen‘s disease).)

C.Materials for test control. Test tasks with the single right answer (α =II):

1. That is reason of development of neurofibroma?

A.Innate vice of nerves.

B.Postraumatic disorder.

C.Trauma of face.

D.Infectious diseases.

E.Etiology is not found out.

(Right answer: А)

2.Where is a neurofibroma mostly localized? A. Tongue.

B. Cheek. C. Chin.

D. Zygomatic bone. E. Lips.

(Right answer: В)

3.Neurofibromatosis it is:

A.Engle-Recklinghausen‘s disease.

B.Taratinov‘s disease.

C.Recklinghausen‘s disease.

D.Boyen‘s disease.

E.Lihtenshteyn‘s disease.

(Right answer: С)

D. Educational tasks of 3th level (atypical tasks):

1.Patient, 69 years old, appealed with complaints about unbearable pains in the left half of face, impossibility of the use by prosthetic appliance. A patient is extremely angry. New formation to 1 cm in a diameter is determined on a transitional fold on the area of the left mental foramen.

What tactics of doctor?

(Answer: to conduct conversation with a patient and explain the necessity of urgent operation due traumatic neuroma.).

2.Patient, 56 years old, the neurofibroma of the left cheek and zygomatic area is diagnosed. A patient is convinced, that she has malignant tumor.

That must be done to the doctor.

(Answer: to convince a patient to appeal to the psychotherapist.).

4. At patient, 67 years old, neurofibromatosis of head (Recklinghausen‘s disease) is preliminary diagnosed.

What additional examination must be conducted for raising of final diagnosis?

(Answer: X-ray photos, histological investigation of new formation, clinical and biochemical analysises of blood and urine.).

7.LITERATURE: 7.1. Basic literature:

1.Wray D. General and oral surgery / D. Wray, D. Stenhouse, D. Lee, A. Clark. – Edinburg, London, New York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 2003. – 336 p.

2.Miloro M. Peterson‘s Principles of Oral and Maxillofacial Surgery / M. Miloro, G.E. Ghali,

P.E. Larsen, P.D. Waite. – Hamilton, London, Ontario: BC Decker Inc, 2004. – 1461p.

3.Moore U.J. Principles of Oral and Maxillofacial Surgery / U.J. Moore. – Blacwell Science, 2005. – 273p.

4.Coulthard P. Master Dentistry / P. Coulthard, K. Horner, Ph. Sloan, D.E. Theader. – Edinburg, London, New York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 2003. – 251 p.

5.Pedlar J. Oral and Maxillofacial Surgery / J. Pedlar, J. Frame. – Edinburg, London, New York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 2003. – 325 p.

6.Fradiskos D. Fradiiskos. Oral Surgery / Fradiskos D. Fradiiskos. – Springer, 2005. – 365 p.

7.Skikevich M.G. Benign tumors and tumor-like formations of maxilla-facial region / M.G. Skikevich, V.N. Gavrilyev. – Poltava: ASMI, 2008. – 132 p.

7.2. Additional literature:

1.Mitchell D. An Introduction to Oral and Maxillofacial Surgery / D. Mitchell. – Oxford University Press, Jan, 2006. – 356 p.

2.Skikevich M.G. The basics of stomatology / M.G. Skikevich, D.S. Aveticov. – Poltava. – ASMI, 2012. – 176 p.

3.Tkachenko P.I. Propaedeutics of surgical stomatology and inflammatory diseases of maxillofacial region / P.I. Tkachenko, A.I. Pan‘kevich, K.Yu. Rezvina. – Poltava. – ASMI, 201. – 283 p.

Ministry of health Ukraine

Higher state educational establishment of Ukraine

«Ukrainian medical stomatological academy»

It is «ratified» at meeting of chair of surgical stomatology and maxillofacial surgery with plastic and reconstructive surgery of the head and neck

The Head of the chair doctor of medicine Aveticov D. S.

METHODICAL INSTRUCTION

FOR INDEPENDENT WORK OF STUDENTS DURING PREPARATION FOR PRACTICAL

(SEMINAR) LESSON

Poltava – 2012

1. SUBJECT URGENCY.

Benign tumors and cysts of salivary glands are rather difficult pathology of a maxillofacial site which equally often meets at men and women of different age. This group of diseases has a various, often similar, clinical picture which needs detailed knowledge at future doctors concerning an etiology, clinic, diagnostics and treatment.

2.SPECIFIC GOALS:

2.1.To analyze clinical manifestations of epithelial and non-epithelial tumors of salivary glands.

2.2.Ethiological and pathogenetical factors of development of tumor-like formations of soft

tissues.

2.3.The main and additional investigations of patients with epithelial and non-epithelial tumors of salivary glands.

2.4.To treat emergence and development of epithelial tumors of salivary glands.

2.5.To draw schemes, graphics of classification of epithelial tumors of salivary glands.

2.6.To analyze classification of epithelial tumors of salivary glands.

2.7.To make the plan of treatment of patients with epithelial tumors of salivary glands.

3.BASIC LEVEL OF PREPARATION.

4. TASKS FOR INDEPENDENT WORK DURING PREPARATION FOR LESSON.

4.1. The list of the main terms, parameters, characteristics which the student should know during preparation for lesson:

4.2. Theoretical questions for lesson:

1.Anatomical structure dental-maxillary system.

2.Embriogenesis and histological structure of maxillary bones and tissues of maxillo-facial area.

3.Origin theories of pleomorphic and monomorphic adenomas of salivary gland.

4.Clinical picture of pleomorphic and monomorphic adenomas of salivary gland.

6. Diagnostics and differential diagnostics pleomorphic adenomas of salivary gland..

7. Treatment methods of pleomorphic and monomorphic adenomas of salivary gland.

4.3. Practical works (tasks) which are carried out on lesson:

1.To seize a technique of inspection of the patient with pleomorphic adenomas of salivary gland.

2.To carry out a kuration of the patient with pleomorphic adenomas of salivary gland.

3.To fill an out-patient medical card of the patient from pleomorphic adenomas of salivary gland.

5. ORGANIZATION OF THE MAINTENANCE OF THE TRAINING MATERIAL.

The non-neoplastic salivary gland diseases represent a disparate group of disorders affecting both the major and minor salivary glands. These conditions range from inflammatory disorders of infectious, granulomatous, or autoimmune etiology to obstructive, developmental, and idiopathic disorders. The major salivary glands are most often involved, and many of these salivary gland disorders are associated with the presence of other systemic illnesses. A thorough history and physical examination is typically adequate to recognize and differentiate this group of conditions, and an elaborate diagnostic evaluation is usually not required to manage these illnesses.

This presentation will attempt to achieve the following objectives. The first is to provide a useful scheme for classifying these hetergeneous disorders so that they may be approached in a systematic manner. The second is to enumerate the distinguishing features of these entities to aid in their appropriate recognition. Finally, general management principles for the various conditions will be discussed.

Benign epithelial tumors

Pleomorphic adenomas (benign mixed tumors) are the most common tumors of the salivary gland and are most often located in the tail of the parotid gland. When found in the minor salivary glands, the hard palate is the site most frequently involved, followed by the upper lip.

These tumors were termed pleomorphic because of the epithelial and connective tissue components that compose them in varying degrees. Their gross appearance is a round, smooth mass with a thin, delicate, incomplete capsule. Of note, pleomorphic adenomas that arise in the minor salivary glands usually lack a capsule. These tumors grow slowly, although they may become larger than other SGTs. The thin, delicate capsule may have projections into the surrounding parotid tissue. This is of particular clinical significance because obtaining clean margins and avoiding spillage are mandatory to minimize recurrence.

Microscopically, benign mixed tumors are characterized by variable, diverse, structural histologic patterns. Frequently, they have growth patterns of sheets, strands, or islands of spindle and stellate cells, with a myxoid configuration occasionally predominating. Treatment of benign neoplasms involves the complete surgical excision of the affected gland. If the parotid gland is involved, superficial parotidectomy with standard facial nerve dissection and preservation is the procedure of choice. Enucleation is contraindicated because of the tendency towards tumor spillage that can lead to tumor recurrence.

Warthin tumor (papillary cystadenoma lymphomatosum, cystic papillary adenoma,

adenolymphoma)

Albrecht first recognized this tumor in 1910, and Warthin later described it in 1929. In gross appearance, it is a smooth, soft, parotid mass. It is well encapsulated when located in the parotid gland and contains multiple cysts. Histologically, the Warthin tumor has a heavy lymphoid stroma and aciniform epithelial cells that line the cystic areas with papillary projections. Malignant transformation has not been observed. All patients with this tumor survive, and the recurrence rate is 5%. The Warthin tumor tends to be bilateral (10% of cases) and is usually found in the major glands, as are most other types.

Intraductal papilloma

IDP is a small, tan, fairly smooth lesion that is usually found in the submucosal layer. Microscopically, IDP consists of a cystically dilated duct partially lined with a cuboidal epithelium with complex anastomosing papillary fronds of variable size filling the cystic area. IDP of the minor salivary gland is a rare lesion that has been described only in various case reports.

Histologically, the differential diagnosis of IDP includes papillary cystadenoma, which is commonly but erroneously diagnosed as IDP. In papillary cystadenoma, intraductal hyperplasia occurs

and the dilated duct contains some papillary folds and projections. However, this occurs much less frequently than in IDP.

Oxyphil adenoma (oncocytoma)

Duplay first described the oncocytic tumor in 1875. Oncocytomas of the salivary glands are very uncommon. Such neoplasms occur more often in women than in men, with a female-to-male ratio of 2:1. Patients are older than 50 years, and the superficial lobe of the parotid gland is the most commonly reported location. Oncocytomas rarely, if ever, occur in the minor salivary glands. Oncocytomas manifest as small (< 5 cm in diameter), firm, slow-growing, spherical masses. Bilateral oncocytomas of the parotid glands have been described. Histologically, they are large and spherical and have a distinct capsule. Uniform cells are arranged in solid sheets. These tumors recur if excision is incomplete.

Benign nonepithelial tumors

Hemangiomas are the most common SGTs in children and usually involve the parotid gland. Less often, they may involve the submandibular gland. These vascular tumors may be distinguished from vascular malformations by their presence early in life, rapid growth phase in children aged approximately 1-6 months, and gradual involution over 1-12 years. The typical presentation is an asymptomatic, unilateral, compressible mass. Gross examination reveals a dark red, lobulated, unencapsulated mass. Microscopically, hemangiomas are composed of solid masses of cells and multiple anastomosing capillaries that replace the acinar structure of the gland. Because they lack a capsule, they tend to infiltrate neighboring structures.

Treatment should initially consist of steroids administered 2-4 mg/kg/d. Although the response may be immediate, only 40-60% of hemangiomas exhibit a response to steroids. Despite the tendency toward spontaneous involution, specific conditions may warrant surgical excision.

Lymphangioma (cystic hygroma) are most commonly located in the head and neck region of infants and children. They are believed to be due to lymphatic sequestration of primitive embryonic

lymph ducts that undergo irregular growth and canalization. They are spongy, multiloculated masses with a yellowish or bluish surface and are formed by endothelial-lined spaces. More than 50% manifest at

birth, and 80% manifest by age 2 years. Usually, they manifest as painless masses that may involve parotid glands, submandibular glands, or both. Diagnosis is made based on clinical findings. Surgical

excision with preservation of the vital structures is the treatment of choice. Lymphangiomas rarely cause

symptoms of airway obstruction, and excision is usually for cosmetic reasons.

Lipoma tumors are relatively uncommon in a major salivary gland. They derive from fat cells and appear grossly as smooth, well-demarcated, bright-yellow masses. Histologically, the tumor consists of mature adipose cells with uniform nuclei.

These tumors manifest as soft, mobile, painful masses and peak in the fifth and sixth decades of life, with a male-to-female ratio of 10:1. They are slow-growing tumors with an average diameter of 3 cm. Treatment is surgical excision.

6. MATERIALS FOR SELF-CHECKING:

A.To study the following questions:

1.Anatomy and physiology of salivary glands of human.

2.Embriogenesis and histologic structure of big and small salivary glands.

3.Theories of an origin of benign tumors of salivary glands.

4.Histologic and clinical classifications of benign tumors of salivary glands.

5.Clinical picture of benign tumors of salivary glands.

6.Diagnostics and differential diagnostics of benign tumors of salivary glands.

7.Methods of treatment of benign tumors of salivary glands.

8.A prognosis and complication in time and after treatment of benign tumors of salivary glands.

B. Test tasks for self checking:

1. The patient of 65 years came to the stomatologist-surgeon with complaints to a swelling in the left half of the face addressed. At the review of the patient it was established that: in the left parotid site the new growth in the size 3х 4 cm. At a palpation the new growth has dense character, painless, to surrounding tissues isn't soldered. After carrying out contrast radiological research on sialogramme is revealed that normal drawing of branchings excretory canal the passage sharply breaks on a limit with pathological process.

For what disease characteristic such sialografichesky picture?

What else additional methods of inspection need to be carried out? (Answer: tumor of salivary gland)

2. The patient of 57 years came to the surgeon-stomatologist with the complaint to asymmetry of the face. Objectively: in a site of the right parotid salivary gland the tumor of densely elastic consistence is found painless, mobile, a roundish form with a hilly surface. The tumor tends to slow increase.

It is possible to establish what previous diagnosis in this case? (Answer: the mixed tumor)

C Materials for test control. Test tasks with the individual right answer (α=2):

1.Benign tumors doesn't treat: A. adenoma;

B. Adenolimfoma; C. The mixed tumor;

D. mucoepidermal tumor; E. cyllindroma;

(Right answer: D)

2.Clinical picture of adenoma of salivary glands

A.Tumor painless dense, with the smooth surface, not soldered to surrounding tissues.

B.Tumor painless, mobile, the round or extended form, a chardelastic consistence.

C.The tumor grows is quickly soldered to surrounding tissues.

D.Tumor painless, not mobile, the correct form, a plotnoelastichny consistence grown together with skin.

(Right answer: А)

3. What method of treatment belongs to surgical tumors of salivary glands.

A.across Lviv.

B.on Kovtunovich-Mukhin.

C.according to Hitrov.

D.according to Gorbushenina.

E.according to Limberg.

(Right answer: В)

4. Ranula is more often located:

A.in submaxillary salivary gland

B.in parotid salivary gland

C.to hypoglossal salivary gland

(Right answer: С)

D.Educational problems of the 3rd level (atypical tasks):

1.The patient of 65 years addressed to the stomatologist-surgeon with a swelling in a parotid site. After

carrying out contrast radiological research on sialogramme seen that normal drawing of branchings of a channel sharply breaks on a border with pathological process. At a puncture received transparent viscous liquid.

What diagnosis?

(Right answer: Cyst of parotid salivary gland.)

2.The patient of 57 years addressed to the surgeon-stomatologist with the complaint to asymmetry of a face. Objectively: in a site of parotid salivary gland is formation painless, mobile, a roundish form softelastic consistences. The tumor tends to slow increase. Funtion of gland isn't broken.

It is possible to establish what preliminary diagnosis in this case? (Right answer: Cyst of parotid salivary gland).

3.The patient of 35 years addressed to the doctor stomatologist with complaints to a swelling under language.There is the new growth in hypoglossal area in the size of 3х4 cm transparent to appearance, at a palpation painless.

It is possible to establish what preliminary diagnosis: (Answer: Ranula | hypoglossal salivary gland).

4.The patient address to the surgeon-stomatologist with complaints to a new growth on the bottom jaw at the left. Objectively skin over a new growth isn't changed, at a palpation the tumor isn't soldered to surrounding fabrics is painless.

To what expert is need to direct the patient for diagnosis specification? (Right answer: oncostomatologist)

7. Literature:

7.1. Basic literature:

1.Пачес А.И. Опухоли головы и шеи. - М.: Медицина, 1983.

2.Дунаевский В.А., Шеломенцев Ю.А. Предопухолевые заболевания и злокачественные опухоли слизистых оболочек полости рта. - М.: Медицина, 1986.

3.Колесов А.А., Воробьев Ю.И., Каспарова Н.Н. Новообразования мягких тканей и костищ лица в детей и подростков. - М.: Медицина, 1989.

4.Blot, W.J., J.K. McLaughlin, D.M. Winn, D.F. Austin, R.S. Greenberg, S. Preston-Martin, L. Bernstein, J.B. Schoenberg, A. Stemhagen, and J.F. Fraumeni. 1988. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 48:3282-3287.

5.Bricker, S.L., R.P. Langlais and C.S. Miller. 1994. Oral Diagnosis, Oral Medicine, and Treatment Planning, Second Edition. Philadelphia, Lea and Febiger Publishing.

6.Greenblatt, M.S., W.P. Bennett, M. Hollstein, C.C. Harris. 1994. Mutations in the p53 tumor suppressor gene: clues to cancer etiology and molecular pathogenesis. Cancer Research 54(18):48554878.

7.Lidral, A.C., J.C. Murray, K.H. Buetow, A.M. Basart, H. Schearer, R. Schiang, A. Naval, E. Layda, K. Magee, W. Magee. 1997. Studies of the candidate genes TGFB2, MSX1, TGFA, and TGFB3 in the etiology of cleft lip and palate in the Philippines. Cleft Palate - Craniofacial Journal 34(1):1-6.

7.2.Additional literature:

1.Rice DH. Non-neoplastic Diseases of the Salivary Glands. In: Paparella, et al, eds. Otolaryngology. Philadelphia: WB Saunders, 1991: 19.

2.Wenig BM. Non-neoplastic Diseases of Salivary Glands. In: Atlas of Head and Neck Pa2AM ogy. Philadelphia: WB Saunders, 1993: 18.

Ministry of health Ukraine

Higher state educational establishment of Ukraine

«Ukrainian medical stomatological academy»

It is «ratified» at meeting of chair of surgical stomatology and maxillofacial surgery with plastic and reconstructive surgery of the head and neck

The Head of the Department doctor of medicine Aveticov D. S.

METHODICAL INSTRUCTION

FOR INDEPENDENT WORK OF STUDENTS DURING PREPARATION FOR PRACTICAL

(SEMINAR) LESSON

Poltava – 2012