Chapter 49: Care of Patients with Oral Cavity and Esophageal Problems

During the process of healing, the body may substitute Barrett's epithelium (columnar epithelium) for the normal squamous cell epithelium of the lower esophagus.

Although this new tissue is more resistant to acid and therefore supports esophageal healing, it is considered premalignant and is associated with an increased risk for cancer in patients with prolonged GERD

With acute sialadenitis, be sure to

Assess facial function because the branches of cranial nerve VII (the facial nerve) lie close to the salivary glands.

Esophageal Trauma

Causes •Blunt injuries •Chemical burns •Surgery or endoscopy (rare) •Continuous severe vomiting Treatment •Keep NPO - esophageal rest •Prevention of sepsis •Surgery may be needed

abscess

Collection of pus underneath the skin

If radiation therapy is part of the oral cancer patient's treatment plan, home care considerations include health teaching and management strategies.

Complications from radiation to the head or neck can be acute or delayed. Acute effects include treatment-related mucositis, stomatitis, and alterations in taste. Long-term effects such as xerostomia (excessive mouth dryness) and dental decay require ongoing oral care, the use of saliva substitutes, and follow-up dental visits

Radiation therapy for oral cancers can be given by external beam or interstitial implantation to reduce the size of the tumor before surgery.

External-beam radiation passes through the skin or mucous membrane to the tumor site. Typically, treatments are given as five daily treatments per week, with a 2-day break each week, over a 6- to 9-week period.

Patients who have undergone parotidectomy (surgical removal of the parotid glands) or submandibular gland surgery are at risk for weakness or loss of function of the facial nerve because the nerve courses directly through the gland.

Facial nerve repair with grafting can be done at the time of surgery

GERD drug therapy

H2 receptor blockers, proton pump inhibitors, antacids

GERD: Assessment: Recognize Cues

History •Morning hoarseness •Coughing or wheezing at night Physical Assessment/Signs and Symptoms •Dyspepsia •Auscultate lungs for crackles Psychosocial Assessment Diagnostic assessment •Upper endoscopy (EGD) •Ambulatory esophageal pH monitoring

Stomatitis can result from

INFECTION, allergy, certain foods, vitamin deficiency, systemic disease, & irritants, such as tobacco & alcohol.

Erythroplakia

A clinical term used to describe an oral mucosal lesion that appears as a smooth red patch or granular red and velvety patch. any red patch of tissue in the oral cavity that cannot be associated with inflammation There are more malignant changes in erythroplakia than in leukoplakia; therefore erythroplakia is often considered "precancerous" in presentation. As such, these lesions should be regarded with suspicion and analyzed by biopsy. Erythroplakia is most commonly found on the floor of the mouth, tongue, palate, and mandibular mucosa. I

Mucosal erythroplasia is the earliest sign of oral carcinoma. Oral lesions that appear as red, raised, eroded areas are suspicious for cancer.

A lesion that does not heal within 2 weeks or a lump or thickening in the cheek is a symptom that warrants further assessment

Patients who have a nasogastric tube also have decreased esophageal sphincter function. The tube keeps the cardiac sphincter open and allows acidic contents from the stomach to enter the esophagus.

Other factors that increase intra-abdominal and intragastric pressure (e.g., pregnancy, wearing tight belts or girdles, bending over, ascites) overcome the gastroesophageal pressure gradient maintained by the LES and allow reflux to occur.

The most specific common problem for patients with esophageal cancer is

Potential for compromised nutrition due to impaired swallowing and possible metastasis

The barium swallow study with fluoroscopy is the most specific diagnostic test for identifying hiatal hernia.

Rolling hernias are usually clearly visible, and sliding hernias can often be observed when the patient moves through a series of positions that increase intra-abdominal pressure. To visualize sliding hernias, an esophagogastroduodenoscopy (EGD) may be performed to view both the esophagus and gastric lining

Sliding Hiatal Hernias vs Rolling

Sliding Hiatal Hernias • Heartburn • Regurgitation • Chest pain • Dysphagia • Belching Paraoesophageal (rolling) Hernias • Feeling of fullness after eating • Breathlessness after eating • Feeling of suffocation • Chest pain that mimics angina • Worsening of manifestations in a recumbent position

Esophageal Tumors

Some can be benign; most are malignant More than half metastasize Primary risk factors include alcohol intake, diet, obesity, smoking, untreated GERD •Silent tumor" in early stages •Dysphagia is the most common symptom

Laparoscopic Nissen fundoplication (LNF)

Surgical procedure to correct a hiatal hernia and considered the preferred operative procedure

Dyspepsia, also known as indigestion, and regurgitation are the main symptoms of GERD, although symptoms may vary in severity (Chart 54-1).

Symptoms associated with "indigestion" may include abdominal discomfort, feeling uncomfortably full, nausea, and burping. Because indigestion might not be viewed as a serious concern, patients may delay seeking treatment. The symptoms typically worsen when the patient bends over, strains, or lies down. If the indigestion is severe, the pain may radiate to the neck or jaw or may be referred to the back, mimicking cardiac pain.

Leukoplakia not associated with HIV infection is more often seen in people older than 40 years.

The incidence of leukoplakia is two times higher in men than in women; however, this ratio is changing because increasing numbers of women are smoking.

Salivary gland inflammation can have a bacterial or viral cause, such as infection with cytomegalovirus (CMV).

The most common bacterial organisms are Staphylococcus aureus, Staphylococcus pyogenes, Streptococcus pneumoniae, and Escherichia coli.

Post irradiation Sialadenitis

The salivary glands are sensitive to ionizing radiation, such as from radiation therapy or radioactive iodine treatment of thyroid cancers. Exposure of the glands to radiation produces a type of sialadenitis known as xerostomia (very dry mouth caused by a severe reduction in the flow of saliva) within 24 hour Xerostomia may be temporary or permanent, depending on the dose of radiation and the percentage of total salivary gland tissue irradiated. Little can be done to relieve the patient's dry mouth during the course of radiation therapy. Frequent sips of water and frequent mouth care, especially before meals, are the most effective interventions

The fibrosis and scarring that accompany the healing process from GERD can produce esophageal stricture (narrowing of the esophageal opening).

The stricture leads to progressive difficulty swallowing. Uncontrolled esophageal reflux also increases the risk for other complications such as asthma, laryngitis, dental decay, cardiac disease, as well as serious concerns for hemorrhage and aspiration pneumonia

The health care provider can often remove small, noninvasive lesions of the oral cavity in an ambulatory surgical center with local anesthesia.

The surgical opening is usually small enough to be closed by sutures. These smaller lesions may also be responsive to carbon dioxide laser therapy or cryotherapy (extreme cold application), as well as photodynamic therapy. These procedures can be performed as an ambulatory care procedure in a surgical center but may require general anesthesia.

Another option is the implantation of radioactive substances (interstitial radiation therapy or brachytherapy) to either boost the dosage or deliver a radiation dose close to the tumor bed.

This form of implant therapy can be curative in early-stage lesions in the floor of the mouth or anterior tongue. It may also add a boost of radiation to a tumor that received external-beam radiation.

Hiatal hernias

a portion of the stomach protrudes through the diaphragm into the thoracic cavity •Also called diaphragmatic hernias •Protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest •Types I through IV

Diverticula

abnormal side pockets in the intestinal wall Surgical management is aimed at removing the diverticula. After surgery, the patient is NPO status for several days to promote healing. During that period, he or she receives IV fluids for hydration and tube feedings; after that, he or she is given oral fluid and food. Provide pain relief measures and monitor for complications such as bleeding or perforation.

Patients who receive radiation for the treatment of cancers of the head and neck or thyroid may develop decreased salivary flow, predisposing them to

acute or persistent sialadenitis.

A decrease in the production of saliva (as in dehydrated or debilitated patients or in those who are on NPO status after surgery for an extended time) can lead to

acute sialadenitis.

Drug therapy for stomatitis

antimicrobials, immune modulators, and symptomatic topical agents A regimen of IV acyclovir (Zovirax, Xerese ) is prescribed for immunocompromised patients who contract herpes simplex stomatitis. For fungal infections such as yeast, nystatin (Mycostatin, Nadostine , PMS-Nystatin ) oral suspension swish/swallow is most commonly prescribed. Ice-pop troches (lozenges) of the antifungal preparation allow the drug to slowly dissolve, and the cold provides an analgesic effect.

gastroesophageal reflux disease (GERD)

backflow of contents of the stomach into the esophagus, often resulting from abnormal function of the lower esophageal sphincter, causing burning pain in the esophagus •Most common upper GI disorder in the U.S. •Occurs as a result of backward flow of stomach contents into esophagus •Hiatal hernias increase risk for GERD •During healing, Barrett's epithelium and esophageal stricture are concerns

Secondary stomatitis

caused by - cancer - HIV - viruses - bacteria - chemo - long term antibiotic use - yeast

Oral Tumors: Premalignant Lesions

leukoplakia and erythroplakia

Basal cell carcinoma of the mouth occurs primarily on the

lips

Prevention strategies for oral cancer include

minimizing sun and tanning-bed exposure, tobacco cessation, and decreasing alcohol intake

Primary stomatitis

occurs most often, and the most common types are aphthous stomatitis (or canker sores) that present as painful, small oral ulcers that are focal or diffuse Herpes simplex stomatitis and traumatic ulcers are also considered primary.

Salivary gland tumors

rare, generally benign, and occur in parotid gland

The most common type of stomatitis, ____, affects more than 20% of the population of North America; incidence is higher in females than males

recurrent aphthous ulcers (RAUs)

More than 90% of oral cancers are

squamous cell carcinomas that begin on the surface of the epithelium Squamous cell cancer can be found on the lips, tongue, buccal mucosa, and oropharynx

An increased rate of squamous cell cancer is found in people with occupations such as

textile workers, plumbers, and coal and metal workers, mainly as a result of prolonged exposure to polycyclic aromatic hydrocarbons (PAHs).

Three factors influence the extent of surgery performed for oral cancers:

the size and location of the tumor, tumor invasion into the bone, and whether there has been metastasis (cancer spread) to neck lymph node

Leukoplakia

thickened, white, leathery-looking spots on the inside of the mouth that can develop into oral cancer Leukoplakia is the most common oral lesion among adults Most of these lesions are benign. However, a small percentage of them become cancerous. Although leukoplakia can be found anywhere on the oral mucosa, lesions on the lips or tongue are more likely to progress to cancer. Leukoplakia results from mechanical factors that cause long-term oral mucous membrane irritation, such as poorly fitting dentures, chronic cheek nibbling, or broken or poorly repaired teeth.

People should visit a dentist at least ____ a year for professional dental hygiene and oral cancer screening, which includes inspecting and palpating the mouth for lesions.

twice

Upper endoscopy

visual examination of the GI tract, from esophagus to duodenum

GERD health promotion and maintenance

•Patients may be initially asymptomatic •Healthy eating habits •Limitation of fried, fatty, spicy foods and caffeine •Sit upright for one hour after eating

GERD: Potential Problems

•Potential for compromised nutrition status due to dietary selection •Acute pain due to reflux of gastric contents •Adhere to appropriate diet, medication therapy, and lifestyle modifications •Minimized or absence of pain

Stomatitis: Planning and Implementation: Generate Solutions & Take Action

•Preserving tissue integrity •Minimizing pain •Have healthy oral mucosa without inflammation or infection •Experience minimized or absence of pain

Stomatitis: Assessment History

•Recent infections •Nutrition changes •Oral hygiene habits •Trauma •Stress •Physical Assessment/Signs & Symptoms •Psychosocial Assessment •Impaired tissue integrity •Pain

Care of the Patient With Problems of the Oral Cavity

•Remove dentures if the patient has severe stomatitis or oral pain. •Encourage the patient to perform oral hygiene or provide it after each meal and as often as needed. • Increase mouth care to every 2 hours or more frequently if stomatitis is not controlled. • Use a soft toothbrush or gauze for oral care. • Encourage frequent rinsing of the mouth with warm saline, sodium bicarbonate (baking soda) solution, or a combination of these solutions. •Teach the patient to avoid commercial mouthwashes, particularly those with high alcohol content, and lemon-glycerin swabs. •Help the patient select soft, bland, and nonacidic foods. •Apply topical analgesics or anesthetics as prescribed by the health care provider and monitor their effectiveness.

Acute Sialadenitis

•Salivary gland inflammation that is usually bacterial in origin and presents with pain, swelling, erythema, fever, and trismus; parotid gland most common site •Untreated infections of the salivary glands can evolve into abscesses, which can rupture and spread infection into the tissues of the neck and the mediastinum •Often occurs with ionizing radiation to head or neck •Treatment includes hydration, moist heat, massage, NSAIDs, antibiotics

Oral Cancer

•Visit dentist twice a year for professional dental hygiene; oral cancer screening •Occupational exposure can increase risk •Most are squamous cell carcinomas (lips, tongue, buccal mucosa, oropharynx) •Basal cell carcinoma (lips) •Kaposi's sarcoma (hard palate, gums, tongue, tonsils)

A pH monitoring examination is the most accurate method of diagnosing GERD. This involves either

(1) placing a small catheter through the nose into the distal esophagus or (2) temporarily attaching a small capsule to the wall of the esophagus during an upper endoscopy (the 48-hour Bravo esophageal pH test). The patient is asked to keep a diary of activities and symptoms over 24 to 48 hours

Both the presence of tumors of the oral cavity and the effects of their treatment threaten the integrity of the oral mucosa and the patient's airway

If the patient has extensive tumor involvement and copious, tenacious (thick and "stringy") secretions, maintaining an open airway is your priority for care to promote Implement interventions to manage the patient's airway by increasing air exchange, removing secretions, and preventing aspiration as needed. Assess for dyspnea resulting from the tumor obstruction or from excessive secretions. Assess the quality, rate, and depth of respirations. Auscultate the lungs for adventitious sounds, such as wheezes caused by aspiration. Listen for stridor caused by partial airway obstruction. Promote deep breathing to help produce an effective cough to mobilize the patient's secretions.

The most extensive oral operations are composite resections, which combine partial or total glossectomy (tongue removal) and partial mandibulectomy (jaw removal).

In the commando (co-mandible) procedure (COMbined neck dissection, MANDibulectomy, and Oropharyngeal resection), the surgeon removes a segment of the mandible with the oral lesion and performs a radical neck dissection (see Chapter 29).

Kaposi's sarcoma is a malignant lesion in blood vessels, appearing as a raised, purple nodule or plaque, which is usually painless.

In the mouth, the hard palate is the most common site of Kaposi's sarcoma, but it can be found also on the gums, tongue, or tonsils. It is most often associated with AIDS.

Hairy Leukoplakia

Lateral border, white, corrugated lesions, associated with HIV, Epstein Barr virus.

A common type of secondary stomatitis is caused by Candida albicans. Candida is sometimes present in small amounts in the mouth, especially in older adults.

Long-term antibiotic therapy destroys other normal flora and allows the Candida to overgrow. The result can be candidiasis, also called moniliasis, a fungal infection that is very painful. Candidiasis is also common in those undergoing immunosuppressive therapy, such as chemotherapy, radiation, and steroids.

It is important to work with the patient to establish an oral hygiene routine. Perform oral hygiene every 2 hours for ulcerated lesions or infection or in the immediate postoperative period.

Modifications might be needed because of oral discomfort, bleeding, or edema. Oral care with a soft-bristled toothbrush is preferred. If the platelet count falls below 40,000/mm3 , switch the patient to an ultrasoft "chemobrush." The use of "Toothettes" or a disposable foam brush is discouraged because these products may not adequately control bacteremia-promoting plaque and may further dry the oral mucosa. Lubricant can be applied to moisten the lips and oral mucosa as needed.

Hiatal Hernias: Interventions: Take Action

Nonsurgical management •Nutrition modification •Stool softeners or bulk laxatives •Daily incisional inspection •Signs to report to the health care provider •Avoidance of those who are ill Surgical management •Performed transabdominally or transthoracically

Esophageal Tumors: Interventions: Take Action

Nonsurgical management •Nutrition therapy •Swallowing therapy •Chemotherapy •Radiation therapy •Chemoradiation •Photodynamic therapy Surgical management

Because you are accountable for the delegated task, remind the UAP to

Use a soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity. Use toothpaste that is free of sodium lauryl sulfate (SLS), if possible, because this ingredient has been associated with stomatitis. Follow up by inspecting the patient's oral cavity after the UAP completes the task. Teach the patient to rinse the mouth every 2 to 3 hours with a sodium bicarbonate solution or warm saline solution (may be mixed with hydrogen peroxide). He or she should avoid most commercial mouthwashes because they have high alcohol content, causing a burning sensation in irritated or ulcerated areas

While examining the mouth....

Wear gloves, use a penlight to ensure adequate lighting, and use a tongue blade to aid examining the oral cavity. Assess the mouth for lesions, coating, and cracking. Document characteristics of the lesions, including their location, size, shape, odor, color, and drainage. If lesions are seen along the pharynx and the patient reports dysphagia (difficulty on swallowing) or throat pain, the lesions might extend down the esophagus

Place patients on radiation transmission precautions while the materials are active or in place. Patients need to be placed in a private room with lead-lined walls or movable panels.

When permitted, visitors may stay only 30 minutes or less each day and must sit or stand away from the patient in designated areas. Pregnant women and children younger than 18 years should not be permitted to visit

OralCDx BrushTest

a diagnostic procedure usually performed by a dentist during a routine dental examination. The procedure involves brushing of a lesion and is helpful in determining whether the lesion is precancerous (OralCDx, 2017). However, biopsy is the definitive method for diagnosis of oral cancer.

NCLEX Tipz

• Be aware that airway management is the priority of care for patients having surgery for oral cancer. • Place patients having oral cancer surgery in a high-Fowler's position to facilitate breathing and prevent aspiration. • Assess for swallowing ability to prevent aspiration by checking the gag reflex before offering liquids or food to the patient who has had oral cancer surgery. Instruct patients to avoid harsh commercial mouthwashes if they have oral lesions. • Provide gentle oral care for patients with oral lesions by using chemobrushes and warm saline or sodium bicarbonate solution. • Be aware that patients with stomatitis receive antimicrobials, anti-inflammatory agents, immune modulators, and topical agents for relief of symptoms. • Differentiate leukoplakia and erythroplakia: leukoplakia presents as thin, white patches; and erythroplakia presents as red, velvety lesions.

Factors Contributing to Decreased Lower Esophageal Sphincter Pressure

• Caffeinated beverages, such as coffee, tea, and cola • Chocolate • Citrus fruits • Nitrates • Peppermint, spearmint • Alcohol • Tomatoes and tomato products • Smoking and use of other tobacco products • Calcium channel blockers • Anticholinergic drugs • High levels of estrogen and progesterone • Nasogastric tube placement

Gastroesophageal Reflux Disease Symptoms

• Dyspepsia (indigestion) • Regurgitation (may lead to aspiration or bronchitis) • Coughing, hoarseness, or wheezing at night • Water brash (hypersalivation) • Dysphagia • Odynophagia (painful swallowing) • Epigastric pain • Generalized abdominal pain • Belching • Flatulence • Nausea • Pyrosis (heartburn) • Globus (feeling of something in back of throat) • Pharyngitis • Dental caries (severe cases)

Health Promotion and Lifestyle Changes to Control Reflux

• Eat four to six small meals a day. • Limit or eliminate fatty foods, coffee, tea, cola, and chocolate. • Reduce or eliminate from your diet any food or spice that increases gastric acid and causes pain. • Limit or eliminate alcohol and tobacco and reduce exposure to secondhand smoke. • Do not snack in the evening and do not eat for 2 to 3 hours before you go to bed. • Eat slowly and chew your food thoroughly to reduce belching. • Remain upright for 1 to 2 hours after meals, if possible. • Elevate the head of your bed 6 to 12 inches using wooden blocks or elevate your head using a foam wedge. Never sleep flat in bed.• If you are overweight, lose weight. • Do not wear constrictive clothing. • Avoid heavy lifting, straining, and working in a bent-over position. • Chew "chewable" antacids thoroughly and follow with a glass of water.

Care of the Patient With Oral Cancer at Home

• Follow the treatment plan for cancer therapies. • Remember that taste sensation may be decreased; add nonspicy seasonings to food to better enjoy it. • Use a thickening agent for liquids if dysphagia is present. • Eat soft foods if stomatitis occurs. • Inspect the mouth every day for changes, such as redness or lesions. • Continue meticulous oral hygiene at home using a chemobrush and frequent rinsing; clean brush after every use. • Use saliva substitute as prescribed. • Avoid sun or tanning-bed exposure if radiation is part of therapy. • Clean with a gentle, nondeodorant soap, such as Ivory.

Oral cavity disorders can severely affect TISSUE INTEGRITY, NUTRITION, and GAS EXCHANGE; cause intense discomfort; and affect speech, body image, and self-esteem. These disorders commonly affect people who .....

• Have developmental delays or mental health disorders • Are homeless or have less (decreased) access to care • Reside in institutions • Use tobacco and/or alcohol • Consume an unhealthy diet • Have an oral cancer • Consume dietary excess

Collaborative care for acute salivaitis includes the administration of IV fluids and measures such as these to treat the underlying cause and increase the flow of saliva:

• Hydration • Application of warm compresses • Massage of the gland • Use of a saliva substitute • Use of sialagogues (substances that stimulate the flow of saliva such as lemon slices or citrus and other flavored fruit candy)

Esophageal Tumors Symptoms

• Persistent and progressive dysphagia (most common feature) • Feeling of food sticking in the throat • Odynophagia (painful swallowing) • Severe, persistent chest or abdominal pain or discomfort • Regurgitation • Chronic cough with increasing secretions • Hoarseness • Anorexia • Nausea and vomiting • Weight loss (often more than 20 pounds) • Changes in bowel habits (diarrhea, constipation, bleeding)

Instructions for the patient undergoing large surgical resections may include but are not limited to these expectations after surgery:

• Placement of a temporary tracheostomy, oxygen therapy, and suctioning • Temporary loss of speech because of the tracheostomy • Frequent monitoring of postoperative vital signs • NPO status until intraoral suture lines are healed • Need to have IV lines in place for drug delivery and hydration • Postoperative drug therapy and activity (out of bed on the day or surgery or first postoperative day) • Possibility of surgical drains

With salivary gland tumors, pay particular attention to assessment of the facial nerve because of its proximity to the salivary glands. Assess the patient's ability to:

• Wrinkle the brow • Raise the eyebrows • Squeeze and hold the eyes shut while you gently pull upward on the eyebrows and cheeks beneath the orbit to check for symmetry • Wrinkle the nose • Pucker the lips • Puff out the cheeks • Grimace or smile

Stomatitis

•Any inflammation in the oral cavity •Painful, inflamed ulcerations •Classified according to cause of inflammation Proper oral hygiene helps prevent

How to maintain a Healthy Oral Cavity

•Eat well-balanced diet and stay hydrated •Manage stress •Perform weekly self-examination of mouth •Report changing conditions •Dentures should be in good repair and fit •Brush and floss twice daily •Avoid alcohol-based mouthwash •Avoid drugs that increase inflammation •See dentist regularly

Hiatal Hernias: Assessment: Recognize Cues

•Many people are asymptomatic; others have GERD-like symptoms •Symptoms often increase after a meal or when lying supine •Barium swallow study with fluoroscopy •High resolution manometry with esophageal pressure topography

GERD: Etiology and Genetic Risk

•No single causative agent •31% heritability •Greatest rise in proportion of people with GERD is in 30-39 year old demographic