September 2019 HSC Section 1 Congenital and Pediatric Problems

Benign and Malignant Pediatric Oral Lesions

not resolve these lesions (ie, treating for underlying systemic illness, as detailed pre- viously). Warning signs for malignant lesions include those with irregular borders, friable and bleeding tissue, particularly painful lesions, rapidly enlarging lesions, le- sions destructive to adjacent structures, paresthesias, and cranial neuropathies. Furthermore, masses accompanied by systemic symptoms, such as night sweats, fe- vers, child, and weight loss, should include lymphoma and hematologic malignancies in the differential diagnosis. Lymphoma Although lymphoma can be noted in oral cavity subsites, oropharyngeal subsites, including the base of tongue (lingual tonsils) and tonsils (palatine tonsils), are more frequent sites due to the presence of lymphoid tissue. Both Hodgkin and non- Hodgkin lymphomas have been reported, with the greatest incidence in children younger than 5 years and teenagers. 76 In any patients with an easily accessible lesion, such as the oral tongue or elsewhere in the anterior oral cavity, a biopsy can be per- formed in the clinic if they are cooperative, making sure to send tissue fresh for lym- phoma protocol and not in preservative solution. Importantly, patients with oropharyngeal lesions should be referred to an otolaryngologist or oral surgeon because they can undergo flexible laryngoscopy in the clinic to characterize base of tongue involvement and may require biopsy in the operating room. Any patient in whom lymphoma is a consideration should at a minimum have a complete blood cell count and requires consultation with a pediatric oncologic to ensure adequate work-up. On examination, it is important to ensure mirror or flexible laryngoscopy is performed and that the base of tongue and neck are palpated. Specific treatment pro- tocols for lymphoma and hematologic malignancies are beyond the scope of this anal- ysis but are nonsurgical, involving chemotherapy and potentially radiotherapy. Sarcoma Rhabdomyosarcoma is the most common soft tissue malignancy of the head and neck in the pediatric population, often involving the oral cavity and pharynx following the orbit. These lesions are fast growing, are locally destructive, and can have distant metastases. Due to the close proximity of critical structures to the oral cavity, missing an early-stage lesion harbors devastating potential consequences. Surgery plays a definitive role in localized lesions, although the decision to pursue surgical resection depends on the expected morbidity of surgical resection, accessibility of the lesion, and whether negative margins can be obtained. Beyond surgery, radiotherapy plays an important potential role in local control, but all patients require adjuvant chemo- therapy. Of the histologic subtypes, embryonal rhabdomyosarcoma is seen in younger children and has better survival than alveolar and pleomorphic histologic patterns. 77 Survival is strongly associated with extent of disease rather than primary site. 78 Osteosarcoma is the most common bone malignancy in the pediatric population, 79 with only 10% localized to the head and neck. 80 Among children, presentation occurs at an average of 15 years of age. These patients present with severe jaw pain and numbness, and CTs are helpful for delineating bony anatomy and involvement. Although there is a 17% rate of distant metastasis for head and neck lesions, survival rates are still superior to cases occurring outside of the head and neck at approxi- mately 80% over 5 years. 81,82 In cases of localized disease, aggressive surgical resec- tion with the ability to obtain negative surgical margins and adjuvant chemotherapy is key for successful therapy, particularly among patients who have positive surgical margins. 80,83,84

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