so what I'll talk about is a little bit
about the anatomy and pathology the oral
cavity in the oral pharynx and what
we're gonna do is we're going to step
through the oral pharynx then go to the
oral cavity some of the things we've
covered already we've changed the names
like I said before just to confuse you
but having said that hopefully you'll
have a better perspective as well so the
first area that we'll talk about in the
oral pharynx and we'll specifically talk
about the tongue base and now there are
two parts of the tongue there is this
area right here which is referred to as
a circumvallate papillae and then right
at the apex of the Chevron and the
circumvallate papillae is the frame and
cecum everything anterior to that
circumvallate papillae is referred to as
the mobile or the oral tongue which is
in the oral cat- on the oral cavity but
this part of the lecture is going to be
dealing with the oral pharynx which is
that part of the tongue which is
posterior to the circumvallate papillae
so on the right hand side is a schematic
illustration of a squamous cell
carcinoma of the tongue and the spread
patterns one question that comes up is
how do we distinguish between the oral
cavity or the floor of the mouth and the
tongue base and this illustration
demonstrates the transverse fibers which
indicates the tongue base when you see
the longitudinal fibers that indicates
to you that you're really looking at the
oral cavity as opposed to the oral
pharynx so these are two examples of
squamous cell carcinoma again I'm not
going to go into this but into the
spread patterns but rather just to help
you generate and build a differential
diagnosis so for instance we can see the
genial glassess muscles the Geno
glassess muscles going from the Cheaney
Oh typical back to the tongue base and
you can see that this mass is centered
more on the transverse fibers which
indicates that it's been tongue base
similarly here the anterior posterior
oriented muscle fibers these the genial
glassess muscles and we can see the
transverse fibers that indicate that
you're in the tongue base so the number
one thing that you'll see is squamous
cell carcinoma now secondly what do you
think the second most likely diagnosis
is going to be in the oral pharynx
squamous cell carcinoma is one what do
you think number two would be we think
there are couple choices
lymphoma or minor salivary gland okay
number two is actually going to be
lymphoma because as dr. saundra furred
to its waldeyer ring so waldeyer
ring is this ring of tissue with
adenoidal with lymphoid tissue behind
the tonsil so that's the base of the
ring the lateral portions of the ring
are as the lymphoid tissue within the
tonsils and the top of the ring is
adenoidal tissue when so when you think
of waldeyer ring it's not based on
cross-sectional imaging but it's looking
in someone's mouth that's how waldeyer
initially described the ring so number
two is going to be lymphoma and then
number three is going to be minor
salivary gland tumor so this is an
example of a minor salivary gland tumor
it's really indistinguishable from
squamous cell carcinoma but the three
things that you look at if you're
looking for a differential diagnosis or
if you will tissue guessing is gonna be
squamous cell carcinoma one lymphoma
number two and minor salivary gland the
tumors number three and we all know the
miner salary gland tumors right benign
pleomorphic adenoma Wharton's tumors
malignant Mew clappa dermoid or adenoid
cystic carcinoma so another example of a
play morphic adenoma a minor salivary
gland tumor involved in the tongue bass
I think I showed this case earlier now
the one thing that made it kind of nice
was if you look at this lymph node right
here it's actually low attenuation and
enlarged and this was actually minor
salivary gland tumor that literally
metastasized I don't have metastasized
of the right word but it spread through
the lymph nodes through their lymph rich
lymphatics involving the tongue base so
one of these is squamous cell carcinoma
and one of these is an inflammation of
the lingual tonsils or tissue located
behind the tongue base
sometimes it's referred to as lingual
tonsillitis a well known disease entity are
referring physicians and it's really
really hard to differentiate between the
two this happens to be the lingual
tonsillitis and this is the squamous
cell carcinoma and as previously
mentioned you know the lymph nodes just
don't help because they can be enlarged
in either one in situations like this if
you're not wor- working at a tertiary
or quaternary institution
we can just page the you're referring
physicians and you are out in the
community it is completely appropriate
to look at this and say both of us have
increased attenuation involving the
region the lingual tons or tissue that's
totally appropriate to evaluate to
correlate this with physical exam
because this one on the right the
referring physicians will come back and
say this is soft and and compressible
lingual tonsillitis where this was more
rock hard and this was a squamous cell
carcinoma so realize the radiological
appearance can overlap now we talked
about this earlier this is the normal
descent of the thyroid gland it starts
to the frame and cecum and eventually
ends up in its normal resting place in
the anterior neck just anterior to the
third to the tracheal cartilages if
there is tonsillar tissues excuse me a
thyroid tissue that's solid that remains
at the foramen cecum again solid that is
lingual thyroid tissue and to confirm
this you can perform a CT of the neck
and you can see there is no thyroid
tissue
another example here densely enhancing
thyroid tissue at the level of the frame
and cecum I think we can all suggest
this or sort of be unusual to have an
aneurysm in this location but you can
never say never but I think in general
would all say its lingual thyroid
another example of lingual thyroid
tissue may be what can tip you off is
the central area of increased it's t2
signal certainly a mass on its own you
you have to think of squamous cell
carcinoma but hopefully you'll have the
proper testing to suggest that the
patient's hypothyroid and this is a
sagittal non-contrast t1 weighted
imaging again demonstrating to lingual
thyroid at the level of the frame and
cecum if you have that thyroid tissue
and it starts to secrete and contains
fluid remember the water balloon analogy
then you have the thyroid Glassell ducts
sis so both of these are related cousin
solid versus cystic so that's the first
part of the oral pharynx as a tongue
base will then move on to the tonsil now
they're different components to the
tonsil there's actually three components
to the tonsil the primary component of
tonsil is this lymphoid tissue
which forms the walls of waldeyer ring
so when you look in someone's mouth
remember the ring goes from top to
bottom side to side and this tissue also
is referred to as a Palantine or the
facial tonsil again two names for the
exact same structure that's why we like
to confuse you right that's part of the
challenge of head and neck
the majority of tonsillar carcinomas
arise within this tonsillar tissue there
are two other components of the tonsils
and they're actually well known to our
ENT surgeons one portion the tonsil runs
to the palate to the tongue base and
remember our Greek root remember we
talked about lingual versus Colossus so
this piece of muscle is known as a
palatoglossus muscle and it's also
referred to as the anterior tonsillar
pillar this muscle goes to the palate -
the pharyngeal wall this is a palatopharyngeus muscle and this is
what's referred to as the posterior
tonsure pillar so there's three
components of the tonsil the fossil of
the Palatine cut tonsil the anterior
tonsure pillar and the posterior tonsure
pillar and we went over what muscles
constitute the anterior and the
posterior tonsure pillar so on the left is a
schematic illustration of a spread
pattern of tonsure carcinoma in the mid
portion here here's a tonsor carcinoma
and there's a certain finding here that
tells you that this really cannot be
resected purely through an intraoral
approach and if you look at the space
its lateral to the pharynx this
triangular space that's the pair of
pharyngeal space and on the patient's
left hand side we can see this tumor has
extended deeply to involve the pair of
pharyngeal space so this subtle deep
spread pattern illustrated here on the
left hand image indicates that this
patient if they wish to be treated
surgery would have to have both
approaches really in 2015 most of these
patients are treated with combined
chemotherapy and radiation therapy
however there's some tonsure carcinomas
that the surgeons may feel that can be
easily resected intro-orally but
this essentially both of these are
actually relative contraindications to
that because again another example of
deep spread into the pair of pharyngeal
space so number one is going to be
squamous cell carcinoma now as I
mentioned before
we have to understand the normal
constituent anatomy or the composition
of the anatomy so what do you think
would be the second most likely
diagnosis it's not squamous cell
carcinoma so what would be number two a
lymphoma exactly right and now we know
it's lymphoma why because of the
palentine or the facial tonsil contains
lymphoid tissue so naturally number two
would be lymphoma a nice example here of
enlarged if you will blandish lymph
nodes and there is a metastatic or
involved I should say retro pharyngeal
lymph node from lymphoma similar to what
we saw before about lingual tonsillitis
you can have asymmetrical tonsillar
tissue and again one of these is
squamous cell carcinoma and one of this
is just an enlarged tonsils or tissue
now which one is which while there's
squamous cell carcinoma on your right
and tonsillar asymmetry on your left
again if you're in a community based
practice and you don't have the cell
phones of all your ENT surgeons that you
feel comfortable calling it's totally
appropriate at least in my opinion to go
in and just correlate with your physical
exam and this one on your left hand side
would be nice and soft on the right hand
side this would be rock hard so on the
right is your squamous cell carcinoma
and on the left hand side is your
tonsillar asymmetry what about this
diagnosis it looks kind of nasty when
you first look at it it looks kind of
big and and ugly but then we see these
guys right here so real quickly someone
shout out the diagnosis here yeah
exactly tonsil lift and tonsil if this
typically due to chronic inflammation of
the tonsils again the Palantine or the
facial tonsils and if it's been around
long enough it can deposit some
dystrophic calcification so the tonsil
it's can be bilateral in this case or
unilateral as in the case on your right
now this was an interesting case again
this was one of my misdiagnosis because
I looked at this and and I thought that
this was just going to be a tonsillar
sister or a retention cyst
you know one of the case that one of the
papers I'm still working on my own
institution we have a hundred and forty
cases of pathologically proven branchial
cleft cysts or branchial clefts
anomalies and we're sort of familiar
with the Bailey class
vacation and doctor some shows some
typical second branchial Ephesus well
Bailey actually described four types of
second branchial Ephesus and this in
fact is a type four second bronchial
cleft cyst and what's interesting is
that the type fours are located deep to
the carotid space or if you will the
carotid sheath and oftentimes the cysts
that are in these atypical locations
they're oftentimes referred to as
retention cysts or unusual cysts and in
actuality these are probably remnants of
branchial cleft cyst that if you go back
and you know it's fascinating for me to
read the old literature to go back and
read Bailey's article in 1929 I find it
fascinating tells me how smart these
people really were cause we still often
times use these classifications so if
you see these lists cysts in the tonsure
area and you say wow it's wonder what
that is
but in the back your mind think of could
this be a a bronchial cleft assist well
here's a tonsillar abscess and this is a
tonsure abscess and it from an ENT
surgical standpoint this can be referred
to as a peritonsillar abscess now the
difference is in fact that we learned
this last year at the course was that
radiologically we'll call this a tonsil
abscess but our referring physicians may
refer to this as a peritonsillar abscess
when I think of peritonsillar abscess I
always felt it was peritonsillar region
so anything that involved the pair of
pharyngeal space or the tonsil of the
soft palate would be quote unquote parry
tonsure but in actuality what our
referring physicians tell us that if
it's actually within the capsule of the
tonsil then that's what they refer to as
a peritonsillar abscess so
radiologically I'll call this a tonsil
abscess but clinically this is
oftentimes referred to as a
peritonsillar abscess this on the other
hand is an abscess involving the pair of
pharyngeal space the difference is is
that if the if the abscess is limited to
the tonsil itself this can be drained
intra-orally however it involves a pair
of pharyngeal space and this would have
to be drained surgically why am I so
confident this because this was a case
back when I was at UNC it was initially
called the tonsor
multiple attempts were attempted to
drain it intro orally nothing came back
the next day they brought it to us and
we said well it's in the para pharyngeal
space and the child went to the
operating room the next day to have it
drained the next area of the oral
pharynx is a soft palate and again this
is Waldeyer’s ring so here's a lingual
tonsils the adenoidal tissue involving
the tonsil and here is a nasal
pharyngeal adenoidal tissue so this gray
right here forms Waldeyer’s ring the
soft palate as we discussed earlier
looks sort of like a Roman arch to me so
if you will the top of the arch is a
soft palate the walls of the archer I
always look at it as being involved by
the tonsils and the top of the Roman
arch is tethered by the two if you will
Italian muscles and those are the lea-
levator and the velipalatini muscles so
those muscles tether the top of the
palatal arch to the skull base
radiologically here's a squamous cell
carcinoma involving the soft palate they
tend to have a circumferential
appearance to this and this is an ulceral
infiltrative carcinoma involving the
soft palate this is another example of a
squamous cell carcinoma involving the
soft palate t1-weighted image with
contrast demonstrating the aggressive
mass extending to the junction of the
hard palate and the soft palate another
a coronal image here we see a squamous
cell carcinoma and the coronal image
involving the soft palate and here we
see it on MR a contrast-enhanced
t1-weighted image it with fat
suppression so again the number one
tumor as with anywhere in the visceral
space is squamous cell carcinoma now one
other thing we have to consider from a
value-added standpoint it's here the
squamous cell carcinoma involved in the
soft palate now there's a finding here
that tells you it's probably going to be
unresectable and what is that finding
well if you look at the normal surface
anatomy here's the tours tube aureus
here's the opening the station tube and
here's the fossa Rosa Muller we can see
that surface anatomy is obliterated and
when we look at the skull base this
tumor is growing superiorly into the
nasal pharynx and here we can see
replacement of the normal
that should be in the petrous apex
by this tumor so this indeed was
superior spread of a squamous cell
carcinoma all of this was sub mucosal it
could not be seen clinically as a result
when the when they looked at the imaging
studies this patient was deemed
unresectable so squamous cell carcinoma
is number one what do you think number
two is going to be now is there
adenoidal is there lymphoid tissue in
the soft palate is the main question
there's not right so number two is going
to be what do you think minor salivary gland
tumor so embryologically when the soft
and hard palate form there's a higher
proportion of remnants of minor salivary
gland tissue in the hard palate and the
soft palate so from a differential
diagnosis standpoint number one is going
to be squamous cell carcinoma and number
two in the soft palate is going to be
minor salivary gland tissue and this is
just a little interesting case here's a
lesion that's involving the soft palate
it contains fat and so what's the
differential for a fat containing lesion
and soft palate
I think lipomas one and what's the other
germ cell tumor that contains fat yeah
dermoid yeah and if it's fat plus
calcium its teratoma but if it's just
fat alone then we we tend to consider
dermoid would so let's move on to the oral
cavity so the first area of the oral
cavity is the buccal region and this is
located between your cheek and your gums
so as I mentioned I was just in India a
little while ago one of the higher
incidence of buccal carcinomas felt to
be doing to the chewing and the sucking
of the betelnut now whether it's due to
some direct toxicity from the aflatoxins or the storage of the betelnut I
I still haven't gotten a firm answer on
that but you have to remember that it's
sometimes this is referred to in that
cultural context so there's our space
for the buccal carcinoma here's a
contrast-enhanced t1 weighted imaging
demonstrating the enhancing buccal
carcinoma and here's another example of
a gingiva buccal sulcus carcinoma again
we don't need to get a CT scan to make
the diagnosis but what we always want to
do is to look at the under
bone to see if there's any bone erosion
so again back in the old days when I was
a resident took a while to do the bone
windows at that time now we have
high-resolution bone algorithm I hope
all of you in the audience are
reconstructing all of your neck CT in
bone algorithms this is also referred to
as a snuff tippers carcinoma so I don't
know if any of the audience dip snuff
anybody here so I'm from Kentucky
anybody from Kentucky nobody see I'm a
redneck Hindu so I grew up in in
Ken- never heard that one before
right so you know so when I grew up you
know it would put a little snuff between
your cheek and your gum I'd hang out at
the 7-eleven you never would have
guessed that about me right so so
anyways snuff is actually back if you do
go hang out at your local 7-eleven which
I'm tend to do on a Friday night snuff
is not free and not in its free powder
anymore it's actually in little packets
and some of these packets are flavored
with lime and cherry and peppermint and
you know they're not targeting
middle-aged men like me but I think
obviously they're targeting the younger
generation so you put the little packets
between your cheek and your gum and put
you at higher risk you can perform CTs
with these and we tend not to do things
like the puff cheeks you know I think you
potentially can see the lesions better
but really the physicians the clinicians
that I've worked with before they can
see the lesion well what they're again
looking for the deep extent in the bone
algorithm so we tend not to we tend not
to do the puff cheeks or other maneuvers
such as this so number one is squamous
cell carcinoma what do you think number
two is gonna be it's a tough one it
could be one of the other it's actually
lymphoma
number two the lymphoma is the second
most common tumor that arises within the
buccal region so number one squamous
cell number two lymphoma now what about
some other lesions that could involve
the buccal space and again you've
probably figured out I've got a pretty
boring life like I'll spend like a
beautiful sunny day reading literature
that's a hundred years old it's one of
the oddities of my of my genetics I
guess but there was a fascinating paper
written in 1960s by Alaskan who was a
dentist
and I think I met him actually a while
ago I was kind of fascinating but he
wrote the typical spread patterns not of
tumors but of infections so if you if
you have an odontogenic infection and it
erodes the buccal cortex the mandible
then this infection is going to extend
out into the soft tissues in the buccal
space so you can actually have buccal
space abscesses and if you see something
like this it's important to go back and
look at the bone to see if there is any
erosion of the cortical bone so if you
see something like this certainly you
have to skit think skin infections but
in the back of your mind you have to ask
yourself could this be spread from Odontogenic infection extending
anteriorly and this was another buccal
space mass this in fact was just a
little lymphatic malformation again a
fluid collection no appreciable
enhancement this was just a pre simple
lymphatic malformation for me in this
case it's not necessarily important
where the lesion at what the lesion is
but just make sure you can map it into
the buccal space so the second area in
the oral cavity is the oral tongue and
as I mentioned before there's a
circumvallate papillae
here's excuse me here's a certain about
the pillow here's a frame and cecum so
anything anterior is referred to as the
oral tongue it can also be referred to
as a mobile tongue as well - so either
one of those terminologies is acceptable
so on the left is a schematic
illustration of squamous cell carcinoma
both of these are examples of squamous
cell carcinoma the one in the middle
here extends to midline and the one on
your right here a little off midline
again very bland appearance nothing
fancy about it number one two and three
the most common tumor to involve the
oral tongue is going to be squamous cell
carcinoma but what about this case
here's an example of a newborn child we
see a fat containing structure we do a
CT scan we see
diffuse calcification so fat and
calcification equals teratoma exactly
right and there is the teratoma that was
removed at resection the teratomas tend
to be midline lesions in when you have
midline lesions in the cranial facial
area these are off
time to associate with other midline
abnormalities in this case we see a bite
the tongue and this kid actually had
duplication of the pituitary stocks as
well too so when you do see these
midline tumors remember there can be
associated midnight abnormalities other
things to look for would be not only the
duplicate a pituitary stock but remember
to look at the corpus callosum because
you can't have a genesis of the corpus
callosum as well
this was another kid that had a teratoma
one thing I've learned over time is that
radiologically at least for me when you
start seeing these punctate
calcifications it's difficult to
differentiate between a benign and a
malignant teratoma these calcifications
don't look too bad I think yeah they're
not really the aggressive type but this
was actually an immature / malignant
teratoma so from my standpoint if I can
make the diagnosis of teratoma that's
great
I'll let the pathologist determine
whether it's benign or malignant i.e
mature or immature I think
radiologically it's very difficult to do
and this was just diffuse enhancement of
the tongue this was a large hemangioma
excuse me a vascular malformation of the
tongue so we talked about the floor of
the mouth earlier so again we'll go over
the anatomy the anatomy anatomy anatomy
so remember the analogy that I gave you
about the tea cup so here is the
mandible here's the mylohyoid muscle and
this muscle goes to the hyoid bone to
the bottom of the tongue so this is our
high OH Colossus muscle medial to the
high o glossa muscle is a sub lingual
artery and the sublingual vein between
the little notch right here between the
mylohyoid muscle and the high o Colossus
muscle we have another vein and we have
this little green structure right here
which is what anybody remember what
duct it was starts to the W Wharton's duct
exactly also known as the the
submandibular duct so anatomically there
we're getting to our tea cup and there's
our tea cup again so think of the rim of
the tea cup again as amendable below all of
the tea cup is the mylohyoid muscle and
the base of the tea cup here by the
hyoid bone so everything within the tea
cup is in the floor of the mouth now
earlier as I mentioned before we had
neck guys we like to fool you
I refer to as this same space earlier as
a sublingual space but now we're going
through the classification of the oral
cavity and the oral pharynx when we talk
about the oral cavity this is now
referred to as the floor of the mouth so
here is an example of a floor mouth
carcinoma this is what they refer and
physician sees and this is what we see
radiologically these four mouth
carcinomas they can enhance they may not
enhance I showed a very subtle one
earlier that just had a little bit of
obliteration of fat in the sublingual
space so for me the enhancement doesn't
help that much the key thing is a
symmetry symmetry symmetry and remember
to to compare one side to the opposite
side so squamous cell carcinoma is
number one what do you think number two
is gonna be lymphoma or minor salivary
gland minor salivary gland exactly right
and this in fact was Mucoepidermoid
carcinoma involving the floor of the
mouth because there's not a lot of
lymphoid tissue within the floor of the
mouth again if you if you're nutty like
me and you actually go back and read
ruby a ruby a 1936 one of the most
boring books I've ever read
I just got limited myself to the head
and neck but from what I do it's probably
one of the most helpful things I ever
read because Ruby a did describe small
little lymph nodes in the sublingual
space itself we we tend to think of the
level 1 lymph nodes in the submandibular
space but there there are some tiny
lymph nodes in the sublingual space they
oftentimes don't get involved or we can
see radiologically but having said that
that larger component of remnant tissue
is going to be minor salivary gland
tissue so here's an example here I think
I know if I showed this before a little
guy right here presents with the
obstructive scialinis - so that's a little
sigh Alif involved in the floor mouth I
think I showed that one when earlier
their little little sigh Alif here and
remember again from alaskans work
anytime that you have an odontogenic
infection remember if it eroded the
buccal cortex and what space would the
abscess be in would be yeah in the
buccal space but if erodes a lingual
cortex and this is how you develop a
floor mouth abscess so it's always
important to go back and look at the
bone and to see
if this is of odontogenic origin now
just for grins if this infection was
involving the molar tooth the second or
third molar and the abscess and the
erosion extended posteriorly then you
would develop our at risk for a
masticators space abscess so again a lot
of these are based on the spread
patterns and exactly what part of the
bone is eroded Ludwig's angina but it's
actually described by wilhelm frederick
ludwig in 1836 right and the interesting
thing about Ludwig's angina is that
certainly it was it was made before CT
and MR and i with all due respect to the
cardiologists they stole the term angina
from us because angina was actually mean
strangulation and so when ludwig
described this what he actually
described was based on clinical
examination so this was actually a
clinical Ludwig's angina demonstrating
all this inflammation now radiologically
what we see in Ludwig's angina is
essentially a compartment syndrome with
multiple abscesses so why does the
patient get strangulation well because
these abscesses and inflammation caused
the tongue to extend posterior superiorly
which compresses the airway and if you
look here the the epiglottis is actually
swollen as well too so that's why the
patients get this strangulation feeling
and somehow the cardiologists told the
term angina from us but the original
term was actually strangulation how was
this treated well the surgeons can go in
do a midline incision and in this case I
use a figure or take a ronjue if you
will and try to eliminate all the saptations
and place drains to drain these
abscesses anterior midline lesions
involving the floor mouth we have
epidermoid why is that cause because the
fusion of the the mid-face tends to be
symmetrical if we get a little bit of
ectoderm that's pinched between the the
developing cranial facial bones we can
develop this epidermoid this we talked
about earlier this is a ranula if the
ranula is located above the mylohyoid
muscle it's referred to as a
simple ranula, ranula can be unilateral or
bilateral and one of the things I've
learned over time is I see something on
one side I sure start to look at the
other side and sometimes these things
can be be pretty small if the ranula
extends and extends inferiorly  then it
becomes a complex diving or plunging
ranula and these ranulas can be tricky
too because they can extend posterior in
the pair of pharyngeal space and in this
case the ranula did extend inferioirly and
i think i mentioned the importance of
this before because if it's just
intra-orally ii these can be marsupirlized but if it extends through the
mylohyoid muscle it requires a cervical
excision we talked a little bit about
the thyroglossal duct remnants this was
just a small little thyroid docile duct
remnant involving the sublingual space
again anywhere the course a thyroid
gland accends it can leave little
droplets if the droplets are solid then
that's what we referred to as ectopic
thyroid tissue or thyroglossal duct
remnants and in this particular case
this was just a large arteriovenous
malformation involving the floor the
mouth here we can see these big flow
voids so the next area that we'll talk
about is the retromolar trigone now the
retromolar Trigon we're actually all
familiar with if we can remember to name
the teeth right so we have the central
incisor lateral incisor canine first
premolar second premolar first molar
second molar third molar so the
retromolar Trigon is this triangular
space that's behind the third molar now
how many in the audience have had your
wisdom teeth out but and you what you
probably don't know is that you have the
largest retromolar trigons in the room
did you ever know that right because
essentially what you do is when you take
your third molar out you remove your
wisdom teeth and you increase the space
of the retromolar Trigon so that's I bet
you never knew that but that's for free
anyway so of all the tumors that that
I've seen the retromolar Trigon is
probably the most under staged tumor
clinically because the retromolar
Trigon is behind that tooth and based on
the normal spread patterns these tumors
can grow a lot
the superior constrictor muscle go to
the right to the terrible mandibular Ave
and continue along the buccinator muscle
and it's really hard to see all of that
spread pattern on clinical exam alone
similarly the bulk of the tumor this
tumor was located within the oral
tongue and you had a certain amount of
volume there's not gonna be any bone
erosion but if you stick that tumor and
you place it in the retromolar trigon as
that tumor grows it's more likely to
erode the bone why because the anterior
aspect of the mandible is just behind
that little triangular space behind that
last more tooth so in general at least
in my experience retromolar trigons tend
to have a little bit higher likelihood
of earlier bone erosion compared if you
took that same tumor and put it in a
different location in the head and neck
so the last here that we'll end up with
is the hard palate so we already talked
about the teeth but now we'll talk a
little bit of applied anatomy so this
anterior area is the incisive canal this
plate right here is actually the
junction between the the sphenoid bone
and the posterior aspect of the hard
palate and here are the pterygoid plates
so if you can have cysts involving the
incisive canal this was a incisive canal
cyst it can look somewhat ominous you
look at this and say wow that looks
pretty bad
but if you're not sure look at that
transition zone between the system's
surrounding bone notice how we don't
have that scalloped eroded moth-eaten
appearance and that crisp transition in
this area really tells you that you're
just dealing in this case with a very
very large incisive canal is this
squamous cell carcinoma is the number
one tumor to involve the hard palate and
here's our spread pattern here's a tumor
involving the hard palate extending
posterior into the masticator space so
here's squamous cell carcinoma again
schematically this is what we see
radiologically typically the mucosa over
the saw as the hard palate is just like
two or three millimeters thick it's not
very thick at all so if you see
something like this this corresponds
with this patient squamous cell
carcinoma now when the surgeon looks in
she or he and I didn't want to say she
or he can look in there and does not
know the whether or not the bones eroded
if indeed there's no bone erosion then
these tumors can be easily respected
through a wide local excision but on the
other hand if we the radiologists say
that bones eroded then the patient will
apt have to undergo some type of Mac
Selecta me in order to resect it again
oral pharynx tumors are typically better
treated with chemotherapy and radiation
therapy whereas tumors such as a hard
palate I think I put obviously it's
going to depend on the institution but
most institutions I've worked at are
still preferentially treated with
surgery but again that differentiation
it's very difficult for the surgeons to
determine whether or not that underlying
bone is eroded again that's the value
that we add as radiologists another
example here but it's not squamous cell
carcinoma so what do you think number
two is gonna be minor salivary gland or
lymphoma minor salivary gland exactly
right and there's no way that I can
distinguish between squamous cell
carcinoma and minor salivary gland it's
got to be just by statistics squamous
cell is number one minor salivary gland
is number two they can have more of a
benign appearance like this or a much
more aggressive moth-eaten appearance as
you see in the in the middle and the
images on your right now one thing about
minor salivary gland tumors that that
could tip us off that could tip us off
is that minor salivary gland tumors have
a propensity for perineural spread as
does squamous cell carcinomas there's no
doubt either one could but if you do see
smaller volume lesions that have
perineural spread then you may want to
think of minor salivary gland tumors so
anytime a tumor of the hard palate
expense back involving this and let me
just draw this out real quick here as I
love to draw all right I didn't have a
lot of money growing up I couldn't
afford an etch-a-sketch so now I finally
can etch a sketch here right so what's
the name of the foramen right here
between the sphenoid bone and the little
bone right here the Palatine
that's our that's our spino Palantine
foramen then we have a fossa that ghosts
in the pterygoid plates and the Palatine
bone so that's the tear go Palatine
fossa and then we have the terrible
maxillary fissure it almost looks like a
vuvuzela or a trumpet if you will so we
have the foramen fossa and fissure spino
Palantine frame and tear go Palantine
fossa pterygomaxillary fissure right
there so the V 2 runs in the roof of the
Terrigal Palantine fossa so anytime that
we have tumors that are extending back
here in the Terrigal Palantine fossa
they can jump along v2 and grow post
early now typically the referring
physicians knows that you're already
dealing with a malignancy why because
the patients typically present with
numbness they can look in and see a mass
and if the patient's numb they know
something's bad but what they don't know
is what is the proximal extent of the
tumor so if indeed the tumors located to
the hard palate remember the one I
showed before they could do a maxillectomy but on the other hand if we
as radiologists say the tumor is in the
tear go Palatine fossa and now there's
retrograde perineural spread along v2
and this is framin rotunda into the
cavernous sinus at most institutions now
this is not being treated with surgery
but in most institutions is chemotherapy
and radiation therapy years ago when we
would show this at least there were some
skepticism amongst our skull base
surgeon they would say well you know I'm
not sure if I believe that but now I
think over the last 20 years or so there
is great acceptance that radiologically
we can detect these in fact the
radiological findings oftentimes precede
the clinical findings so if we show this
now oftentimes these patients will now
be treated with chemotherapy and
radiation therapy in fact just think of
the third type of surgery this patient
would have to undergo it's almost like a
hemi-head ectomy right they'd have to
take out part of the clivus and have to
take out the cavernous sinus right in
the cavernous sinus of the main venous
drainage for the that deep portion of
the brain and also take out what cranial
nerves 3 4 5 & 6 pretty morbid procedure
so and now in general that tends to be
avoided I would say in most institutions
so in summary what I've tried to do was
go over the anatomy the oral pharynx and
the oral cavity we went over the
sub-sites we focus on differential
diagnosis and why don't we stop there
we'll go for lunch and we'll see you at
1:15 I think thank you very much for
your attention
