Prevalence of palatal diseases in adults; an observational study in a tertiary care hospital

Aim: The aim of this study is to spot the light on palatal diseases and their prevalence in adults from otolaryngologists' point of view. Materials and Methods: This is an observational study that was conducted on adult patients presented to otolaryngology department of Cairo university hospital in the period from January 2016 to January 2018. Patients were routinely examined by the author however the chief complaint either related to palate or not. Results: Out of 4800 patients have been examined over 2 years, 289 cases have been affected by palatal disease or lesion either primary or secondary. It was clearly noted that the most common pathology affecting the palate is the gastric reflux, 248 patients; the remaining 41 cases have been affected by different diseases of variable etiologies. Conclusion: The palate is a part of routine examination by otolaryngologists. It may carry signs of different diseases and lesions which are not uncommon. The author observed palatal diseases in 6% of the study's sample. Prevalence of those diseases has been entailed in this study.


Introduction
The palate is anatomically located between the nasal cavities and the oral cavity, developmentally formed of anterior bony part and posteriorly soft part ending posteriorly with the uvula. The oral surface of the palate is histologically covered by stratified squamous epithelium. The palate is derived from the 1 st pharyngeal arch & reaches its definitive development at 10 th -12 th week intra uterine life [1][2]. The palate is routinely examined by otolaryngologists every day and other. Many diseases and lesions may affect palate either 1ry like congenital cleft palate, traumatic injury, malignant neoplasms or 2ry like gastric reflux [3][4]. The literature lacks of many studies that show incidence and prevalence of affection of the palate by diseases and lesions. The aim of this study is to spot the light on palatal diseases and their prevalence from otolaryngologists' point of view.

Materials and Methods
This is an observational cross sectional study to determine prevalence and incidence of palatal diseases in adults, that was conducted on a population sample of 4800 adult patients with age range 22-78 years old (Table 1) presented to otolaryngology department of Cairo university hospital, which is one of the main tertiary medical care provider hospitals in Egypt in the period from January 2016 to January 2018. Patients were routinely examined by the author however the chief complaint either related to palate or not. Data of patients of palatal diseases or lesions have been collected for this study and each one was treated according to his/her disease.

Journal of Clinical Otorhinolaryngology
Sameh M Zamzam*

Results
Out of the sample of the study over the 2 years duration, 289 cases (6%) have been affected by palatal disease either 1ry or 2ry (Table 2) ( Figure. 1). It was clearly noted that the most common pathology affecting the palate is the gastric reflux, 248 patients, especially the soft part in the form of congestion and edema associated with the remaining clinical picture of the reflux. Another male, 26 years old patient of cleft hard and soft palate has been reported, it's considered an odd presentation at that age ( Figure  2).
The study has also reported 6 cases of traumatic injury of the soft palate, all of these cases were iatrogenic in cause due to endotracheal intubation either associated with tonsillar injury or not (Fig. 3). 13 patients with nasal mucormycosis involving the hard palate have been participated in this study in the form perforation due to gangrenous necrosis ( Figure 4).
One case of minor vascular malformation has been reported, the patient showed bluish discoloration of the palate with little distortion of the uvula ( Figure 5), this case has been discovered accidentally as the patient hasn't presented with a complaint related to his palate or mouth.
The study has reported 3 patients diagnosed clinically and pathologically as rhinoscleroma, associated with shrunken and fibrosed uvula. Another 5 cases have represented by defective palatal movement & choking & drooling of saliva and hoarseness of voice were diagnosed clinically as pseudobulbar palsy.
Neoplastic lesions have played a role in this study, the study have reported 4 cases of palatal squamous cell carcinoma ( Figure 6) and 8 cases of benign pleomorphic adenoma of minor salivary glands.  Table 2. Types of palatal diseases in this study and their incidence

Discussion
The majority of this study's cases affected with palatal diseases were due to gastroesophageal reflux disease "GERD", 248 cases, either symptomatic or not "silent refluxers" [5][6], soft palatal and oropharyngeal mucosal congestion and edema were clearly seen. Reflux in severe or chronic cases may lead to dental caries [5][6][7]. There are 2 theories explains the oral tissue damage in GERD: reflux theory which is due to direct contact between the acid and the mucosa. The other one is the reflex theory in which there is vagal reflex from distal esophageal exposure to gastric acid [8].
Cleft palate and/or lip are the most common congenital anomalies occur during craniofacial development due to both genetics and environmental causes with incidence in Africa is about 1/2500 live births [9], cases are usually surgically repaired at early childhood to allow proper correct feeding and speech [10]. This study has faced a 26 years old male patient with cleft hard and soft palate with marked rhinolalia aperta and he has trained himself over years on proper feeding to avoid regurge (Figure 1).
This study has reported one case of palatal vascular malformation in the form of bluish or purple discoloration of the palate with minor distortion of the soft part and uvula & was accidentally discovered (Figure 2), this color was blanched when application of pressure on hard palate. Literature has prescribed hemangiomas in 3 debating terms true neoplasm & malformation and hamartomas [11], so choosing the term to describe that case was really confusing. Capillary hemangiomas can be sessile or polyp in shape, they grade in color from deep red to purple, those on the palate are of the capillary in origin [12].
Mucormycosis is an opportunistic invasive fungal infection affecting immune-compromised patients like uncontrolled diabetes or leukemia [13], usually involves the nasal and paranasal sinuses bone leading to vasculitis and gangrenous necrosis and that infection may extends to the bony palate [14][15]. This study has reported 13 cases of nasal and paranasal mucormycosis with palatal involvement, 11 cases of them have showed uncontrolled diabetes and the other 2 cases have given history of leukemia on treatment by chemotherapy.
Penetrating injuries to the palate may be iatrogenic or accidental by using sharp objects, injury may not be limited to the palate only also oropharyngeal mucosa, tonsils and tongue may be involved [16][17]. All the 6 patients who have been included in this study were iatrogenically injured in the soft palate due to vigorous or low experienced endotracheal intubation, only 2 cases have associated with unilateral tonsillar injury.
Palatal carcinomas account for 2% of head and neck malignancies, 50% of all hard palate carcinoma are of squamous cell in nature, other types including minor salivary gland carcinomas & melanomas and sarcomas account for the other 50% [18]. Pleomorphic adenomas the most common salivary gland tumor, it is a benign tumor composed of mixed cellular patterns surrounded by fibrous capsule [19]. This study has reported 12 patients with neoplastic lesion in the palate, all patients have been subjected to biopsy and pathological examination which revealed 4 cases of palatal squamous cell carcinoma and 8 cases of pleomorphic adenoma, carcinoma patients have been proceeding for CT/MRI for staging and mapping. Patients of pleomorphic adenoma were treated by palatectomy/ inferior maxillectomy, on the other hand cases of carcinoma were treated by inferior/total maxillectomy with adjuvant chemo-radiotherapy.
Palatal motor innervation may be affected by any pathology that damages bilateral corticobulbar tracts, the condition usually associated with dysarthria, dysphagia and choking that is what termed pseudobulbar palsy [20][21]. This study has recorded 5 cases of pseudobulbar palsy that referred from neurology department for consultation for tracheostomy.
Literature describes scleroma as an uncommon granulomatous lesion that most commonly affects nose & nasopharynx and larynx, the palate is not a site of primary affection but it may be a site of extension of the granulomatous lesion of the second stage of the disease [22], a study by Badrawy in 1965 had described what was called the "uvula sign" which means retraction or elevation of the uvula in case of diffuse nasopharyngeal infiltration by granulomatous scleroma [23], and that is what was noticed in the present study.