PANCE Blueprint EENT (7%)

Oral leukoplakia

Patient will present as → a 42-year-old male with symptoms of the flu. On social history, the patient describes drinking 2-3 beers per day as well as smoking 1 pack of cigarettes per day. He is noted on physical exam to have a white plaque-like lesion on the side of the tongue which could not be scraped off with a tongue depressor.

Oral leukoplakia is an oral potentially malignant disorder that presents as white patches of the oral mucosa that cannot be wiped off with a gauze (compare this to oral candidiasis)

  • Tobacco use (smoked and especially smokeless), alcohol abuse, HPV infections
  • Leukoplakia is in itself a benign and asymptomatic condition. However, about 5% will eventually develop squamous cell carcinoma (SCC)
  • If there is an associated erythematous appearance (erythroplakia), there is a higher risk of dysplasia or cancer (90%)

*A separate disorder that is not premalignant is oral hairy leukoplakia, an Epstein-Barr virus-induced lesion that occurs almost entirely in HIV-infected patients

The diagnosis of leukoplakia is suspected in patients presenting with a white lesion of the oral mucosa that cannot be wiped off with a gauze and that persists after eliminating potential etiologic factors, such as mechanical friction, for a six-week period

  • Excisional biopsy is indicated for any undiagnosed leukoplakia

leukoplakia - all should be treated

  • For 2–3 circumscribed lesions, surgical excision
  • For multiple or large lesions where surgery would cause unacceptable deformity, consider cryosurgery, or laser surgery
  • Removal of predisposing habits (alcohol and tobacco)
  • Complete excision is the standard treatment for dysplasia or malignancy
  • After treatment, up to 30% of leukoplakia recurs, and some leukoplakia still transforms to squamous cell carcinoma

Oral Hairy Leukoplakia is unlikely to progress to squamous cell carcinoma

  • Treatment with zidovudine, acyclovir, ganciclovir, foscarnet, and topical podophyllin or isotretinoin. Therapy is usually not indicated

The diagnosis of leukoplakia is suspected in patients presenting with a white lesion of the oral mucosa that cannot be wiped off with a gauze and that persists after eliminating potential etiologic factors, such as mechanical friction, for a six-week period

  • Excisional biopsy is indicated for any undiagnosed leukoplakia
Question 1
Hairy leukoplakia has the greatest prevalence of distribution on the
A
palate
Hint:
See C for explanation.
B
floor of the mouth
Hint:
See C for explanation.
C
lateral tongue
D
gingiva
Hint:
See C for explanation.
Question 1 Explanation: 
The lateral border of the tongue is where hairy leukoplakia is commonly seen.
Question 2
A 45 year-old smoker presents with a sore mouth and increasing difficulty eating for two weeks. Physical examination reveals a 1 cm white lesion on the buccal mucosa that cannot be rubbed off. Which of the following is the most likely diagnosis?
A
Oral cancer
B
Oral candidiasis
Hint:
Oral candidiasis presents with white patches. Unlike leukoplakia, the patches easily rub off.
C
Aphthous ulcer
Hint:
While aphthous ulcers are commonly found on the buccal mucosa, they are usually 1 to 2 mm round ulcerative lesions.
D
Necrotizing ulcerative gingivitis
Hint:
Necrotizing ulcerative gingivitis is common in young adults under stress. Clinically, it presents with painful acute gingival inflammation and necrosis.
Question 2 Explanation: 
The presence of leukoplakia in a smoker over the age of 40 should be biopsied to rule out the presence of oral cancer.
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Other oropharyngeal disorders (Pearls) (Prev Lesson)
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