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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.
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I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.
Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.
I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:
pathology.org -- my cyberfriends, great for current news and browsing for the general public
EnjoyPath -- a great resource for everyone, from beginning medical students to pathologists with years of experience
Medmark Pathology -- massive listing of pathology sites
Estimating the Time of Death -- computer program right on a webpage
Pathology Field Guide -- recognizing anatomic lesions, no pictures
Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.
Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.
Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.
Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.
If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:
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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.
Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.
I cannot examine every claim that my correspondents
share with me. Sometimes the independent thinkers
prove to be correct, and paradigms shift as a result.
You also know that extraordinary claims require
extraordinary evidence. When a discovery proves to
square with the observable world, scientists make
reputations by confirming it, and corporations
are soon making profits from it. When a
decades-old claim by a "persecuted genius"
finds no acceptance from mainstream science,
it probably failed some basic experimental tests designed
to eliminate self-deception. If you ask me about
something like this, I will simply invite you to
do some tests yourself, perhaps as a high-school
science project. Who knows? Perhaps
it'll be you who makes the next great discovery!
Our world is full of people who have found peace, fulfillment, and friendship
by suspending their own reasoning and
simply accepting a single authority that seems wise and good.
I've learned that they leave the movements when, and only when, they
discover they have been maliciously deceived.
In the meantime, nothing that I can say or do will
convince such people that I am a decent human being. I no longer
answer my crank mail.
This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.
During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and William Carey as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at William Carey for making it still possible, and my teaching assistants over the years.
Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!
* It's not what you eat with your mouth that makes you dirty, it's what you say with your mouth that makes you dirty.
-- Matthew 15:11
* Aristotle mentioned that women have fewer teeth than men. Although he was twice married, it never occurred to him to verify this statement by examining his wives' mouths.
--Bertrand Russell
Head and Neck / Salivary Glands
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Head and Neck
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Head and Neck Slides
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Head & Neck
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Head & Neck
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Mouth Exhibit
Virtual Pathology Museum University of Connecticut
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Oral Pathology
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Head and Neck
Brown Digital Pathology
Some nice cases
KCUMB Students
"Big Robbins" -- Head & Neck
Lectures follow Textbook
QUIZBANK: Disk 6: Oral region (all)
TOOTH DECAY ("dental caries"): Lancet 369: 51, 2007. The familiar "cavity" is the major cause of loss of teeth in persons under 35.
Action of the mixed bacterial flora of the mouth (Streptococcus mutans is implicated) results in acidification, proteolysis, and decalcification of the enamel and dentin.
The bacteria are protected within a cocoon of "dental plaque" on the surfaces of the teeth, along with food particles, etc. "Dental plaque" is a polysaccharide matrix derived from foodstuffs (notoriously sucrose). When plaque calcifies, it is called "calculus".
Risk factors for caries include a high sucrose diet (why?), xerostomia from any cause (drugs, radiation, Sjogren's syndrome), perhaps heredity. Germ-free animals do not get caries.
Protective factors include good oral hygiene and (for children) fluoridation of drinking water (fluoride renders enamel less susceptible to acid decalcification.)
Unless restored, caries will lead to pulpitis....
PULPITIS and PERIAPICAL DISEASE
Infection and suppuration inside the tooth is called "pulpitis", the common cause of throbbing toothache.
When the infection spreads to involve the periodontal ligament, "periapical disease" will result, and the patient will describe pain on chewing.
Suppurative disease here in the apical periodontium is the very painful "apical abscess" (alveolar abscess), which may drain out through bone to erupt as a "gum boil". Bad cases can turn into osteomyelitis, etc., etc.
From here, cellulitis may spread to the floor of the mouth ("Ludwig's angina", which can spread to occlude the upper airway) or even the cavernous sinus (with thrombosis, etc.)
Chronic periapical disease produces the "periapical granuloma" (actually necrotic tissue walled off by fibrosis) which may subside into a "radicular cyst," etc.
PERIODONTAL DISEASE: The major cause of loss of teeth in persons over 35.
{12366} periodontal disease ("gingivitis ")
{12430} bad periodontal disease ("pyorrhea")
{12432} periodontal disease
Calculus, especially in the gingival crevice (sulcus), causes inflammation of the gingival tissues ("gingivitis"), which often extends to the periodontal ligament, alveolar bone, and cementum of teeth ("periodontitis"). This does irreversible damage and results in the loss of teeth.
The tissue response to calculus is markedly increased during puberty and pregnancy and in other disease involving the gingiva (scurvy, monocytic leukemia, thrombocytopenia.)
The inflammatory infiltrate is mostly lymphocytes and plasma cells. Really bad periodontitis with pus formation used to be known as "pyorrhea". A few people still use this as a generic term for periodontal disease.
BACTERIAL INFECTIONS
Necrotizing gingivitis (Vincent's angina, trench mouth) is a mixed infection with Borrelia vincentii and Fusobacterium. There is necrosis of the gingival margins and interdental papillae as well as signs and symptoms of systemic illness.
Usually this affects young adults with poor oral hygiene who are under stress (college students, military recruits, soldiers in wartime.)
{12433} "trench mouth" (necrotizing gingivitis)
"Noma," a terrible necrotizing stomatitis seen in some patients with kwashiorkor, is the most severe form.
The disease is not contagious and responds to penicillin.
Gonorrhea, syphilis, tuberculosis, and actinomycosis are other notable causes of oral infections.
It's good to remember here that bacteria will enter the bloodstream whenever the dentist cleans or fixes your teeth ("oral sepsis"). To keep strep viridans from growing on the inner surfaces of the heart, people with valve problems or other heart deformities should receive antibiotic coverage at these times.
NON-PATHOLOGY OF THE TONGUE
There are a variety of poorly-understood changes that involve the tongue papillae, typically for no apparent reason. These include "geographic tongue" (travelling areas of papillary and epithelial atrophy), "transient lingual papillitis" (one papilla gets red, swollen, and sore, nobody's got a clue why: Oral Surg. Or. Med. Or. Pa. 82: 441, 1996), "median rhomboid glossitis" (loss of papillae in the middle from candida), "hairy tongue" (long filiform papillae, not the same as "hairy leukoplakia"), and "scrotal" (brain-like) tongue.
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BENIGN TUMORS AND QUASI-TUMORS
Papilloma: a viral wart.
Fibrous hyperplasia: a quasi-tumor of fibroblasts that develops at sites of longstanding injury (i.e., ill-fitting dentures)
Pyogenic granuloma: a mass of granulation tissue sticking out of the gum between the teeth. This is neither "pyogenic" (has nothing to with pus or germs), nor a "granuloma" (no epithelioid cells). In the mouth, this is most common in pregnant women. It's probably a less-fibrous version of the irritation fibroma described in "Big Robbins".
* Granular cell myoblastoma (the "cell of origin" is really the Schwann cell) is an important lesion to remember because of overlying pseudoepitheliomatous hyperplasia that can look like squamous cell carcinoma to the unwary. These tumors commonly occur on the tongue.
MALIGNANT TUMORS AND RELATED CONDITIONS: Mouth and throat cancer comprises 2-5% (estimates vary widely) of all cancers.
Mouth Cancer
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Leukoplakia is a term applied to any hyperkeratotic lesion from histologically benign to dysplastic to malignant, that doesn't have another cause. (* Lichen planus and the less-common identifiable hyperkeratotic diseases are by definition excluded.)
You can distinguish this from candida and mouth-crud because it can't be scraped off.
HPV-16 (the same nasty strain that so often causes cancer of the cervix and penis) is common in these lesions. Having it on board may double your risk (NEJM 344: 1125, 2001). However, HPV-positive oropharyngeal cancers respond better to treatment and have a better prgnosis (NEJM 363: 24, 2010).
If "leukoplakia" is not particularly keratotic, but vascular-inflamed and hence reddish, it is called "erythroplakia". These lesions are almost always dysplastic.
It is strongly correlated with tobacco, particularly some (not all) "smokeless" varieties (Oral Surg. 73: 750, 1992. "I see right where you put your tobacco.") Snuff is much more obnoxious than chewing tobacco; especially the latter seldom produces cancer, and even snuff is far safer than smoking.
{12361} oral leukoplakia
{21206} leukoplakia where the guy keeps his snuff
Squamous cell carcinoma is by far the commonest mouth cancer (95+%, includes "verrucous carcinoma").
Most common sites are lower lip, tongue, and floor of mouth (probably in that order).
It's likely that the key risk factor is HPV infection, usually by HPV-16. HPV is present in 95% or so of these cancers if you know how to look (Am. J. Clin. Path. 134: 36, 2010). These cancers are becoming more common even as smoking and other tobacco use decreases.
Other risk factors include tobacco (both smoked and smokeless), alcohol, herpes simplex virus I, and syphilis (the last is mostly of historic interest.) The first three appear to act synergistically. Sunlight is bad for the lower lip.
The farther posterior the lesion is located in the mouth, the less well differentiated (and more aggressive) it is likely to be.
Unless the lesion is excised while very small, the prognosis is generally poor.
There are three subtypes:
2. Non-keratinizing. These often have Epstein-Barr (herpes 4) on board too.
3. "Lymphoepithelioma", a poorly-differentiated squamous carcinoma rich in lymphocytes, with Epstein-Barr virus invariably found in the squamous cancer cells. This is very common in the Far East and is presently blamed on a combination of Epstein-Barr infection and pickled fish and pickled vegetables. (* I told the trendoids that kimchee was probably bad for...)
{12169} squamous cell carcinoma of the lip
{38614} carcinoma of tongue, patient
Cancer of the tongue
Exophytic
Wikimedia Commons
Doctors: Don't forget to look at the oral mucosa, including under the tongue, when you do a physical exam. Apparently most physicians don't, which is why this gets diagnosed so late (Cancer 72(S3): 1061, 1993.)
* Victims of throat cancer include Babe Ruth and Beatle George Harrison.
ORAL LICHEN PLANUS
This is a common chronic disease of the skin and oral mucosa. In the mouth, it appears as lacy, white patches. The problem seems to be type IV immune injury to the basal cells.
{12360} oral lichen planus
{12604} oral lichen planus, good filigree
APHTHOUS STOMATITIS ("canker sores")
An extremely common disease in which painful ulcers occur repeatedly on the oral mucosa, often during times of stress or following trivial injury.
The ulcers are large infarcts caused by a local immune-complex vasculitis The pathogenesis apparently involves streptococcal (* sanguis, others) antigens others).
*I treat aphthous ulcers by melting a hydrocortisone tablet against each one; this isn't FDA approved. Topical tetracycline is supposed to work for the secondarily-infected ones. And consider a therapeutic trial of thiamine: Oral Surg Oral Med 82: 634, 1996).
Herpes virus does not cause aphthous stomatitis (recurrent intra-oral herpes lesions are uncommon.)
Patients with Crohn's disease (regional enteritis, ileitis, etc.) tend to get aphthae in the mouth, rectum, elsewhere.
Whenever you see several aphthae, you must think of neutropenia and check the white count!
Beçet's syndrome: aphthous ulcers, genital ulcers, and iridocyclitis, caused by autoimmunity against heat-shock proteins (Lancet 350: 28, 1997). One treatment is thalidomide (Pediatrics 103: 1295, 1999; NEJM 336: 1487, 1997), an anti-TNF drug. Another is sucralfate (Arch. Derm. 135: 529, 1999; Ann. Int. Med. 128: 494, 1998).
Aphthae are a major nuisance for many AIDS patients. Thalidomide has been a great help to these people (NEJM 336: 1487, 1997).
More mouth ulcers: agranulocytosis, lupus, pemphigus vulgaris, mucous membrane pemphigoid, erythema multiforme and variants
VIRAL INFECTIONS
Herpetic stomatitis is a primary infection with Herpes simplex type I. Nasty little blister-ulcers cover the lips and oral mucosa. This is a disease of children and young adults, with peak age 1-3 years. (Most people meet herpes simplex but most people never get this.)
Vesicles and ulcers, primarily on the gingiva. Systemic illness is unusual, and the lesions heal in a few weeks.
{12114} herpes simplex I, primary infection
Herpes labialis (cold sores, fever blisters) is recurrent lesions caused by Herpes simplex type I. These blisters usually last a few days, then dry up and vanish after a few more. They can be uncomfortable.
The virus is mysteriously reactivated by injury, fever, stress, hormonal chaos, UV light, and so forth.
Keep your ungloved fingers away from herpes lesions or you may catch it.
You remember how to spot herpes perikaryons (multinucleate cells) on Tzanck prep.
{21239} herpes simplex, recurrent, severe
Herpangina is not a herpes infection at all, but a vesicular eruption centered on the anterior tonsillar pillars. The etiologic agent is usually Coxsackie A virus (sometimes others.)
{21249} herpangina
{21640} herpangina
FUNGAL INFECTIONS OF THE MOUTH
Candida infections of the oral mucosa appear as white patches of mycelia that invade the superficial underlying tissues ("thrush"). You can scrape it off and confirm your diagnosis under the microscope. It is common in babies, diabetics, and immunosuppressed patients.
{05273} oral candidiasis ("thrush")
{09386} oral candidiasis ("thrush")
{12364} oral candidiasis
Any pathogenic fungus can involve the mouth (South American "blasto" often results from a man picking his teeth with a piece of wood in the jungle).
Salivary Gland Exhibit
Virtual Pathology Museum
University of Connecticut
DISEASES OF THE SALIVARY GLANDS (Med. Cli. N.A. 83: 197, 1999)
Causes of salivary gland enlargement include bacterial infection, mumps, Sjogren's, cirrhosis, and many other systemic diseases. Most salivary gland enlargement is non-neoplastic.
Mucocele develops from distended minor salivary glands. By the time the lesion gets excised, the epithelial elements are usually gone, and the lesion is a mass of mucus rather than a "mucous cyst."
Big ones under the tongue that retain an epithelial lining are called "ranulas", because of a fanciful comparison to a frog's throat.
{21264} "mucous retention phenomenon" (mucocele / ranula), gross
{21265} "mucous retention phenomenon" (mucocele / ranula), histology
Calculi (calcium phosphate stones, "sialolithiasis") in the ducts are a minor problem, most common in the submandibular gland.
* Sialoadenitis is inflammation of the salivary glands. You'll learn about mumps another time. Bacterial parotitis is rare, due to staph or strep, and for some obscure reason usually follows major surgery elsewhere in the body.
Suppurative parotitis |
Sjogren's syndrome is familiar to you. The usual histologic picture in the salivary gland in this group of conditions is dense lymphocytic infiltration and only a few islands of epithelial cells (* "the lymphoepithelial lesion").
* Necrotizing sialometaplasia is a benign, self-limited process often mistaken for carcinoma (squamous cell, mucoepidermoid) (JADA 127: 1087, 1996).
Most commonly occurring on the hard palate and in smokers, biopsy shows necrosis, mucous pools, squamous metaplasia of regenerating ducts.
President Grover Cleveland's "mouth cancer" (cured surgically) was probably necrotizing sialometaplasia (J. Oral Surg. 39: 747, 1981).
* Future pathologists: Other necrotizing lesions in the salivary gland can also give you squamous metaplasia that can simulate tumors: Path. Res. Pract. 193: 689, 1997.
* Ectopic salivary gland tissue (salivary gland choristomas) can pop up most anywhere.
SALIVARY GLAND NEOPLASMS
All the common varieties are lesions of older adults.
The parotid is the site of origin for the majority of each of these tumors, and Warthin's tumor almost never occurs anywhere else. The others can and do arise wherever there are salivary glands (submandibular, sublingual, mouth, throat, larynx, larger airways, lymph nodes of the neck).
No matter what the histology, the "cell of origin" seems to be the undifferentiated salivary gland stem cell.
Each presents as a mass. Even benign parotid tumors can result in damage to the facial nerve and other structures. The tumors, their percentage frequencies in the parotid, and their behaviors....
Pleomorphic adenoma...75%... Benign, often recurs if inadequately excised
Warthin's tumor... 15%...Benign, often multifocal (10%)
Mucoepidermoid tumor...3%... Malignant, most are low-grade
Acinic cell tumor... 2%... Malignant, many are low-grade
Adenoid-cystic carcinoma... 2%... Malignant, slow-growing but lethal.
Adenocarcinoma... 2%... Malignant, prognosis depends on grade
Undifferentiated... thankfully rare; Eskimo-and-East-Asian Epstein-Barr-related cancer mentioned above (Cancer 80: 357, 1997; Cancer 78: 695, 1996; Arch. Path. Lab. Med. 118: 994, 1994; Cancer 80: 357, 1997).
Around 1% of all malignant tumors in humans arise in the salivary glands. Death is due to local disease, often after many years.
In the parotid, 20-30% of tumors are cancer. Half of submandibular tumors (and 90% of tumors of minor salivary glands) are malignant.
The only clear risk for any of the cancers listed above is radiation exposure (Cancer 79: 1465, 1997). Heredity, alcohol, tobacco, stones, and trauma apparently are not risk factors.
*An anaplastic, lymphocyte-rich salivary gland carcinoma is very common in Eskimos and seems to arise from a Sjogren-like lesion, the habit of chewing ashes, and particularly to the Epstein-Barr virus.
Pleomorphic adenoma ("mixed tumor")
Malignant mixed tumor of the parotid
Pittsburgh Pathology Cases
This curious, common tumor supposedly arises from myoepithelium, and hence shows both epithelial-looking and mesenchymal-looking areas.
Grossly, a round, firm, sharply-circumscribed lesion embedded in the parotid gland. The surgeon must overcome the temptation to merely shell the tumor out, as it extends into the surrounding parenchyma and these extensions will grow back as several tumors unless a rim of surrounding gland is taken.
The tumor is usually located superficially and the facial nerve may be spared by the surgeon.
Microscopically, the tumor appears to contain both epithelial and mesenchymal structures.
"Cartilage" and glands are usual, and there may be myxoid tissue, bone, squamous pearls, sebaceous glands, etc.
*Plus tyrosine crystals (Arch. Path. Lab. Med. 122: 644, 1998), sulfur crystals (Virchows Archiv 399: 41, 1983), and collagen crystals (Am. J. Path. 118: 194, 1985).
These tumors occasionally become malignant (* adenocarcinoma, * squamous cell carcinoma, etc.; J. Lar. Ot. 109: 240, 1995)
{10154} mixed tumor ("pleomorphic adenoma") of salivary gland
{10437} mixed tumor ("pleomorphic adenoma") of salivary gland
{26870} mixed tumor ("pleomorphic adenoma") of salivary gland
{40149} mixed tumor ("pleomorphic adenoma") of salivary gland
Cancer arising in
a pleomorphic adenoma
Pittsburgh Pathology Cases
Warthin's tumor (*"adenolymphoma", * papillary cystadenoma lymphomatosum")
This is a papillary adenoma composed of pink-staining, mitochondrion-packed cells ("oncocytes", "Hürthle cells") with a dense stromal infiltrate of lymphocytes. Grossly, the tumor is a well-circumscribed mass which is brown because of all the cytochrome in the mitochondria.
It was once a man's disease, but is now common in women too; the usual cause seems to be cigaret smoking (South. Med. J. 90: 416, 1997). It is very rare outside the parotid gland. It is often bilateral.
Occasionally one sees salivary gland adenomas made up of similar epithelial cells but without the lymphocytes ("oncocytomas", "Hürthle cell adenomas").
{11434} Warthin's tumor, gross
{15530} Warthin's tumor, histology
{15531} Warthin's tumor, histology
{15532} Warthin's tumor, histology
{15413} oncocytoma of salivary gland
Warthin tumor
several images
Wikimedia Commons
Acinic cell tumor
A spectrum of tumors "showing differentiation toward the salivary gland acinus". In the best-differentiated examples, the tumor appears to be normal parotid gland except for the absence of ducts.
The tip-off is very large secretory-type granules, best seen on electron microscopy. They often light up with alpha-1 antitrypsin, alpha-1 antichymotrypsin, and amylase.
Some pathologists consider these all to be malignant, though many are very low-grade; there are many long survivals with eventual death due to the tumor.
Mucoepidermoid tumor
Squamous features plus mucin production distinguish these tumors, which "are all malignant."
Like acinic cell tumors, most are low-grade but many kill late. (* Tumors with a pushing border or low cellularity seldom kill.)
{15415} mucoepidermoid carcinoma of salivary gland
Mucoepidermoid carcinoma
H&E
Wikimedia Commons
Adenoid cystic carcinoma ("cylindroma")
This cancer is composed of bland-looking cells in a particular pattern ("Swiss cheese", "lace-like", "cribriform"). It typically invades along the perineural spaces.
* The "cell of origin" is myoepithelium, and these cancers stain for smooth muscle actin and other myoepithelial markers. More solid growth areas give a higher grade (Grade I has less than 30% solid growth, Grade II has 30-60%, grade III has more than 60%).
It is infamous for causing late deaths (5 year survival 75%, 20 year survival 15%).
{19414} adenoid cystic carcinoma, histology
{19416} adenoid cystic carcinoma, histology
{19417} adenoid cystic carcinoma, histology
{19419} adenoid cystic carcinoma, histology
Adenoid cystic carcinoma
Several good photos
Wikimedia Commons
* Polymorphous low-grade adenocarcinoma: Tame-looking variant Cancer 86: 207, 1999. Usually on the soft / hard palate. Let the pathologist make the call.
* Mixtures: Arch. Path. Lab. Med. 123: 698, 1999.
* SALIVARY DUCT CARCINOMA, another rarity, looks and acts like aggressive ductal breast cancer. It is a man's disease and features a curious mix of markers, including strong androgen-receptor and prostate-specific antigen positivity in place of estrogen or progesterone receptors.
* Metastatic renal cell carcinoma not uncommonly presents as a mass somewhere in the head or neck.
* CYSTS OF THE JAWS
Radicular cysts are of inflammatory origin. Dentigerous cysts have a tooth in their wall and swell by osmosis. Odontogenic keratocyst is lined by stratified squamous epithelium and full of keratin (i.e., it's a wen), and can be nasty. I've seen or read about at least twenty-five others.
TUMORS AND QUASI-TUMORS OF THE JAWS
Again, many different types are described, most having their origin in the tooth structure ("odontogenic tumors").
{46456} myxoma of the jaw
* Odontoma is a totally scrambled tooth, one of the classic examples of a hamartoma.
Ameloblastoma is the most important. The "cell of origin" is uncertain but the tumor is agreed to resemble the developing tooth.
Nests of loose fibroblasts (* "stellate reticulum") are surrounded by a peripheral row of palisaded columnar cells with subnuclear vacuoles.
Ameloblastomas are very destructive locally but seldom metastasize (many pathologists consider them "benign" and analogous to * craniopharyngiomas.)
{49122} ameloblastoma, gross
{19437} ameloblastoma, histology
Fibrous dysplasia: overgrowth of fibrous tissue within the bone, with lots of osteoblasts making new (woven) bone. ("Dysplasia" is a bad choice of words -- there's no cellular atypia, and this isn't pre-cancerous.)
* Ossifying fibroma: a benign bony tumor
MORE ODD MOUTH-AND-THROAT BUMPS
Branchial cleft cysts
Slow-growers in the parotid, back of throat, or side of neck. They can get to be a few centimeters across.
You'll see a mix of lymphoid tissue plus epithelium (stratified squamous or pseudostratified respiratory).
Giant cell central granuloma of the jaw (* "epulis")
An uncommon quasi-tumor of the jaw, full of fibrous tissue and osteoclasts. * The more aggressive ones have more osteoclasts.
Angiofibroma of the throat
It presents as a white mass in the throat. Do not biopsy these. They are extremely vascular and will bleed horribly.
They may be excised as required.
A solid mass of at-least-somewhat-anaplastic plasma cells.
For some reason, these usually do NOT disseminate as plasma cell myeloma, though they can be locally destructive.
A FEW OTHER PROBLEMS that seldom come to the attention of anatomic pathologists....
Temporomandibular joint problems ("TMJ disorders"): NEJM 299: 123 and 958, 1987
Slipping condyles are a nuisance and no mystery. However, the "myofascial syndrome" is often missed clinically. It occurs in nervous people that grind their teeth ("bruxors"), or after "whiplash" (ask a lawyer -- J. Oral Surg. 45: 653, 1987). They can end up hurting all over their heads and necks.
Atypical facial pain and burning mouth syndrome: mysterious, disabling pain syndromes that tend to respond to tricyclic antidepressants (Oral Surg. 64: 171, 1987).
Having your amalgams removed to cure your alleged mercury toxicity remains a lucrative fad. There's no question that a bit of the mercury does get into your system. The pop claims are that mercury in the amalgams causes (1) male infertility; (2) emotional, intellectual, and behavioral disorders, including chronic fatigue syndrome and attention-deficit disorder; (3) renal toxicity; and that (4) MRI scans rip mercury from your fillings causing horrid overexposure. These have all been tested in controlled studies in the past four years, with uniformly negative results. This has not stopped the hoopla and mud-slinging, and there probably is some real danger to dentists working with mercury all day. Mercury probably does cause some cases of "oral lichenoid reaction" due to allergy.
Nice review: Postgrad. Med. 102 117, 1997.
STAINED TEETH: tetracycline exposure, bilirubin (hemolytic anemia), excess fluoride (mottling) (all must occur while teeth are developing)
DEFORMED TEETH: congenital syphilis (Hutchinson's incisors, mulberry molars), osteogenesis imperfecta, leukemia therapy during childhood (Cancer 59: 1640, 1987), many other diseases
ATROPHIC GLOSSITIS (tongue red, smooth, sore): iron deficiency, B12 deficiency, other B-vitamin deficiencies
(The "Plummer-Vinson syndrome": atrophic glossitis, esophageal webs, iron deficiency anemia. Pathogenesis is mysterious.)
GINGIVAL HYPERPLASIA: familial, monocytic leukemia, phenytoin ("Dilantin"), cyclosporin A (Oral Surg. 64: 293, 1987), nifedipine. KNOW these three drugs.
GINGIVAL HEMORRHAGE: bleeding diathesis (scurvy, decreased platelets), gingival disease
BLUE GUMS: heavy metal poisoning ("lead line")
ANGULAR STOMATITIS ("cheilosis"): iron deficiency, B-vitamin deficiency, edentulousness (the last is commonest)
PIGMENTATION OF ORAL MUCOSA: adrenal cortical insufficiency, Peutz-Jegher's syndrome
BUMPS: tuberous sclerosis (Oral Surg. 64: 207, 1987), Cowden's, a few others
PETECHIAE ON PALATE: infectious mononucleosis, other causes (Oral Surg. 52: 417, 1981.)
TELANGIECTASES ON THE LIPS: Osler Weber Rendu syndrome (autosomal dominant, these people have GI bleeding)
JAW PAIN: remember coronary artery disease....
BREATH ODOR: ethanol, metalloid poisoning (arsenic, phosphorus, selenium -- supposed to smell like garlic), diabetic ketoacidosis, fetor hepaticus (stink of liver failure), trench mouth, bronchiectasis, lung abscess, pyloric stenosis
NOTE: The usual cause of bad breath is rotting crud between the teeth and/or stuck to the tongue. The remedy is dental floss, first between the teeth, then run over the back of the tongue. (Br. Med. J. 308: 217, 1994, I discovered it first). Mouthwash and chlorophyll tablets are health frauds. The odor is mostly CH3SH, and there's other stuff too.
The smelly, caseous (cheese-like, not caseous necrosis) junk that accumulates in the tonsillar crypts in most people from time to time (you hacked it up) is composed of primarily of keratin. It means nothing and apparently has no proper name today (it was once called "tonsil cheese"; you may hear it called "exudate", which is silly). Calcified debris is the less common "tonsillolith".
DRY MOUTH: dehydration, drugs, Sjogren's, previous radiation, pregnancy and menstruation, various other endocrine alterations
ARC-AIDS: Kaposi's sarcoma, candida, hairy leukoplakia (Oral Surg. 64: 50, 1987), CMV (Oral Surg. 64: 183, 1987).
* PINK TEETH: In the living, congenital erythropoietic porphyria. In the dead, decomposition and staining of the dentin from heme pigment.
{05268} oral hairy leukoplakia in AIDS
{05278} oral hairy leukoplakia in AIDS
Rathke's cleft cyst
Pittsburgh Pathology Cases
ORAL BIOPSY: for the diagnosis of amyloidosis or Sjogren's syndrome (Can. J. Surg.: 25: 186, 1982.)
{20034} cytomegalic inclusion disease, salivary
gland
{39654} Kawasaki disease, patient
{12131} hand, foot, and mouth disease
{12132} hand, foot, and mouth disease
{12133} hand, foot, and mouth disease
{38620} amyloidosis of tongue
{09868} graft vs. host disease, tongue, histology (note attacking lymphocytes)
{21536} "Sturge-Weber" patient, looks like phenytoin hyperplasia of gums
{14802} tongue, dorsum
{14803} tongue, dorsum
{14804} fungiform filiform papillae
{14805} fungiform filiform papillae
{14806} circumvallate papillae
{14807} circumvallate papillae
{14808} taste bud
{14809} taste bud
{14810} oral pap smear, squamous cells
{14811} parotid gland, normal
{14812} parotid gland, normal
{14813} parotid gland, normal
{14814} excretory duct (salivary gland), normal
{14815} excretory duct (salivary gland), normal
{14816} submandibular gland, normal
{14817} sublingual salivary gland, normal
{14818} sublingual salivary gland, normal
{14819} mucous acinus, serous demilune
{14820} mucous acinus, serous demilune
{14821} pharyngeal tonsil, normal
{14822} pharyngeal tonsil, normal
{14823} pharyngeal tonsil, normal
{14824} pharyngeal tonsil, normal
{14825} palatine tonsil, normal
{14826} palatine tonsil, normal
{14900} epiglottis, normal
{15155} papilla, fusiform and fungiform
{15160} papilla, fusiform
{15162} tongue, epithelium
{15163} parotid gland
{15164} parotid gland
{15166} parotid gland
{15167} parotid gland
{15168} parotid gland
{15169} submandibular gland
{15170} submandibular gland
{15171} sublingual gland
{15172} sublingual gland
{15173} sublingual gland
{15174} sublingual gland
{15221} tonsil, palatine
{15222} tonsil, palatine
{15223} tonsil, palatine
{15224} tonsil, pharyngeal
{15225} tonsil, pharyngeal
{15227} tongue, lamina propria
{15228} von Ebner's glands, tongue
{15229} von Ebner's glands, tongue
{15230} von Ebner's glands, tongue
{15232} parotid gland, normal
{15233} submandibular gland, normal
{15234} submandibular gland, normal
{15235} sublingual gland, normal
{20829} circumvallate papilla
{20830} circumvallate papilla and assoc. gland
{20831} taste bud, circumvallate papilla
{20832} parotid gland
{20833} parotid gland, intercalated duct
{20834} parotid gland, striated duct
{20835} parotid gland, fat
{20836} submandibular gland
{20837} sublingual gland
{20840} tonsil, pharyngeal
{21672} mouth, normal
{21673} mouth, normal
BIBLIOGRAPHY / FURTHER READING
I urge anyone interested in learning more about oral pathology to consult these standard textbooks.
In my notes, the most helpful current journal references are embedded in the text. Students using these during lecture strongly prefer this. And because the site is constantly being updated, numbered endnotes would be unmanageable. What's available online, and for whom, is always changing. Most public libraries will be happy to help you get an article that you need. Good luck on your own searches, and again, if there is any way in which I can help you, please contact me at scalpel_blade@yahoo.com. No texting or chat messages, please. Ordinary e-mails are welcome. Health and friendship!
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