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Part 2Management of Patients

With Oral andEsophageal Disorders

2ed Years Student, 2ed Semester

Miss Iman shaweesh

January 2008

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Disorders of the TeethDENTAL PLAQUE AND CARIES

Tooth decay is an erosive process that begins with the action of bacteria on fermentable carbohydrates in the mouth, which produces acids that dissolve tooth enamel. The extent of damage to the teeth depends on the following:

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The presence of dental plaque The strength of the acids and the ability of

the saliva to neutralize them The length of time the acids are in contact

with the teeth •The susceptibility of the teeth to decay

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Prevention

Measures used to prevent and control dental caries include practicing effective mouth care, reducing the intake of starches and

sugars (refined carbohydrates), applying fluoride to the teeth or

drinking fluoridated water, refraining from smoking, controlling diabetes, and using pit and fissure sealants

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Disorders of the Lips, Mouth, and Gums

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Abnormalities of the Mouth

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Abnormalities of the Gums

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Gerontologic Considerations

Many medications taken by the elderly cause dry mouth, which is uncomfortable, impairs communication, and increases the risk of oral infection. These medications include the following:

• Diuretics

• Antihypertensive medications

• Anti-inflammatory agents

• Antidepressant medications

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Gerontologic Considerations

Poor dentition can exacerbate problems of aging, such as

• Decreased food intake • Loss of appetite • Social isolation • Increased susceptibility to systemic infection (from periodontal disease) • Trauma to the oral cavity secondary to thinner, less vascular oral mucous membranes

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DENTOALVEOLAR ABSCESSOR PERIAPICAL ABSCESS

more commonly referred to as an abscessed, involves the collection of pus in the apical dental periosteum (fibrous membrane supporting the tooth structure) and the tissue surrounding the apex of the tooth (where it is suspended in the jaw bone). The abscess has two forms: acute and chronic. Acute periapical abscess is usually secondary to a suppurative pulpitis (a pus-producing inflammation of the dental pulp)

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Clinical Manifestations

The abscess produces a dull, gnawing, continuous pain, often with a surrounding cellulitis and edema of the adjacent facial structures, and mobility of the involved tooth. The gum opposite the apex of the tooth is usually swollen on the cheek side. Swelling and cellulitis of the facial structures may make it difficult for the patient to open the mouth.

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Management

In the early stages of an infection, a dentist or dental surgeon

may perform a needle aspiration or drill an opening into the pulp chamber to relieve tension and pain and to provide drainage.

After the inflammatory reaction has subsided, the tooth may be extracted or root canal therapy performed. Antibiotics may be prescribed.

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Nursing Management

The nurse assesses the patient for bleeding after treatment and instructs the patient to use a warm saline or warm water mouth rinse to keep the area clean.

The patient is also instructed to take antibiotics and analgesics as prescribed, to advance from a liquid diet to a soft diet as tolerated, and to keep follow-up

appointments.

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Disorders of the Jaw

Temporomandibular disorders are categorized as follows (National Oral Health Information)

• Myofascial pain—a discomfort in the muscles controlling jaw function and in neck and shoulder muscles

• Internal derangement of the joint—a dislocated jaw, a displaced disc, or an injured condyle

• Degenerative joint disease—rheumatoid arthritis or osteoarthritis in the jaw joint

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Disorders of the Salivary Glands

Parotitis (inflammation of the parotid gland) is the most common inflammatory condition of the salivary glands, although inflammation can occur in the other salivary glands as well. Mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly affecting children, is an inflammation of a salivary gland, usually the parotid.

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SIALADENITIS

(inflammation of the salivary glands) may be caused by dehydration, radiation therapy, stress, malnutrition, salivary gland calculi (stones), or improper oral hygiene. The inflammation is associated with infection by S. aureus, Streptococcus viridans, or pneumococcus.

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SALIVARY CALCULUS (SIALOLITHIASIS)

Sialolithiasis, or salivary calculi (stones), usually occurs in the submandibular gland. Salivary gland ultrasonography or sialography (x-ray studies filmed after the injection of a radiopaque substance into the duct) may be required to demonstrate obstruction of the duct by stenosis. Salivary calculi are formed mainly from calcium

phosphate.

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Cancer of the Oral Cavity

Cancers of the oral cavity, which can occur in any part of the mouth or throat, are curable if discovered early. These cancers are associated with the use of alcohol and tobacco.

Cancer of the oral cavity accounts for less than 2% of all cancer deaths in the United States. Men are afflicted more often than women.

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Pathophysiology

Malignancies of the oral cavity are usually squamous cell cancers. Any area of the oropharynx can be a site for malignant growths, but the lips, the lateral aspects of the tongue, and the floor of the mouth are most commonly affected.

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Clinical Manifestations

Many oral cancers produce few or no symptoms in the early stages. Later, the most frequent symptom is a painless sore or mass that will not heal. A typical lesion in oral cancer is a painless

indurated (hardened) ulcer with raised edges. Tissue from any ulcer of the oral cavity that does not heal in 2 weeks should be examined

through biopsy.

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Medical Management

Surgical resection, radiation therapy, chemotherapy, or a combination of these therapies may be effective. In cancer of the lip, small lesions are usually excised liberally; larger lesions involving more than one third of the lip may be more appropriately treated by radiation therapy because of superior cosmetic results.

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If the cancer has spread to the lymph nodes, the surgeon may perform a neck dissection. Surgical treatments leave a less functional tongue; surgical procedures include hemiglossectomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue).

Often cancer of the oral cavity has metastasized through the extensive lymphatic channel in the neck region

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Neck Dissection

Malignancies of the head and neck include those of the oral cavity, oropharynx, hypopharynx, nasopharynx, nasal cavity,paranasal sinus, and larynx (Fig)

These cancers account for fewer than 5% of all cancers. Depending on the location and stage, treatment may consist of radiation therapy, chemotherapy, surg or a combination of these modalities.

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A radical neck dissection involves removal of all cervical lymph nodes from the mandible to the clavicle and removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory muscle on one side of the neck.

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Group Discussion Nursing Management NURSING PROCESS: THE PATIENT WITH

CONDITIONS OF THE ORAL CAVITY Neck Dissection NURSING PROCESS: THE PATIENT

UNDERGOING A NECK DISSECTION

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Disorders of the Esophagus

The esophagus is a mucus-lined, muscular tube that carries food from the mouth to the stomach. It begins at the base of the pharynx and ends about 4 cm below the diaphragm. Its ability to transport food and fluid is facilitated by two sphincters. The upper esophageal sphincter, also called the hypopharyngeal sphincter, is located at thejunction of the pharynx and the esophagus. The lower esophageal sphincter, also called the gastroesophageal sphincter, is located at the junction of the esophagus and the stomach.

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Dysphagia (difficulty swallowing) is the most common

symptom of esophageal disease. This symptom may vary from an uncomfortable

feeling that a bolus of food is caught in the upper esophagus (before it eventually passes into the stomach) to acute pain

on swallowing (odynophagia).

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Achalasia is absent or ineffective peristalsis of the distal

esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. Achalasia may progress slowly and occurs most often in people 40 years of age or older.

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Clinical Manifestations

The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus. As the condition progresses, food is commonly regurgitated, either spontaneously or intentionally by the patient to relieve the discomfort produced by prolonged distention of the esophagus by food that will not pass into the stomach. The patient may also complain of chest pain and heartburn

(pyrosis).

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Assessment and Diagnostic Findings

X-ray studies show esophageal dilation above the narrowing at the gastroesophageal junction. Barium swallow, computed tomography

(CT) of the esophagus, and endoscopy may be used for diagnosis; however, the diagnosis is confirmed by manometry, a process in which the esophageal pressure is measured by a radiologist or gastroenterologist.

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Management

The patient should be instructed to eat slowly and to drink fluids with meals. As a temporary measure, calcium channel blockers and nitrates have been used to decrease esophageal pressure and improve swallowing.

Achalasia may be treated conservatively by pneumatic dilation to stretch the narrowed area of the esophagus (Fig. 35-6). Pneumatic dilation has a high success rate.

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Achalasia may be treated surgically by esophagomyotomy

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DIFFUSE SPASM

spasm is a motor disorder of the esophagus. The cause is unknown, but stressful situations can produce contractions of the esophagus. It is more common in women and usually manifests in middle age.

characterized by difficulty or pain on swallowing (dysphagia, odynophagia) and by chest pain similar to that of coronary artery spasm.

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Assessment and Diagnostic Findings

Esophageal manometry, which measures the motility of the esophagus and the pressure within the esophagus, indicate that simultaneous contractions of the esophagus occur irregularly. Diagnostic x-ray studies after ingestion of barium show separate areas of spasm.

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Management

Conservative therapy includes administration of sedatives and long-acting nitrates to relieve pain. Calcium channel blockers have also been used to manage diffuse spasm. Small, frequent

feedings and a soft diet are usually recommended to decrease the esophageal pressure and irritation that lead to spasm.

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HIATAL HERNIA

The esophagus enters the abdomen through an opening in the diaphragm and empties at its lower end into the upper part of the stomach. Normally, the opening in the diaphragm encircles the esophagus tightly, and the stomach lies completely within the abdomen. In a condition known as hiatus (or hiatal) hernia, the opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach tends to move up into the lower portion of the thorax.

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There are two types of hiatal hernias: sliding and paraesophageal

Sliding, or type I, hiatal hernia occurs when the upper stomach and the gastroesophageal junction (GEJ) are displaced upward and slide in and out of the thorax (Fig. 35-8A). About 90% of patients with esophageal hiatal hernia have a sliding hernia.

A paraesophageal hernia occurs when all or part of the stomach pushes through the diaphragm beside the esophagus

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Clinical Manifestations

may have heartburn, regurgitation, and dysphagia, but at least 50% of patients are asymptomatic. Sliding hiatal hernia is often implicated in reflux. The patient with a paraesophageal hernia usually feels a sense of fullness after eating or may be asymptomatic.

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Assessment and Diagnostic Findings

Diagnosis is confirmed by

x-ray studies,

barium swallow,

and fluoroscopy.

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Management

Management for an axial hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advisednot to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. Surgery is indicated in about 15% of patients.

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Management

Medical and surgical management of a paraesophageal hernia is similar to that for gastroesophageal reflux; however, paraesophageal hernias may require emergency surgery to correct torsion (twisting) of the stomach or other body organ that leads to restriction of blood flow to that area.

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DIVERTICULUM

A diverticulum is an outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature. Diverticula may occur in one of the three areas of the esophagus—the pharyngoesophageal or upper area of the esophagus, the midesophageal area, or the epiphrenic or lower area of the esophagus— or they may occur along the border of the esophagus intramurally.

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The most common type of diverticulum, which is found three times more frequently in men than in women, is Zenker’s diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch). It occurs posteriorly through the cricopharyngeal muscle in the midline of the neck. It is usually seen in people older than 60 years of age.

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Clinical Manifestations

include difficulty swallowing, fullness in the neck, belching, regurgitation of undigested food, and

gurglingnoises after eating. The diverticulum, or pouch, becomes filled with food or

liquid. When the patient assumes a recumbent position, undigested food is regurgitated, and coughing may be caused by irritation of the trachea.

Halitosis and a sour taste in the mouth are also common because of the decomposition of food retained in the diverticulum.

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Assessment and Diagnostic Findings

A barium swallow may be performed to determine the exact nature and location of a diverticulum.

Manometric studies are often performed for patients with epiphrenic diverticula to rule out a motor disorder.

Esophagoscopy usually is contraindicated because of the danger of perforation of the diverticulum,

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Management

Because pharyngoesophageal pulsion diverticulum is progressive,the only means of cure is surgical removal of the diverticulum. During surgery, care is taken to avoid trauma to the common carotid artery and internal jugular veins.

Food and fluids are withheld until x-ray studies

show no leakage at the surgical site. The diet begins with liquids and progresses as tolerated.

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PERFORATION

The esophagus is not an uncommon site of injury. Perforation may result from stab or bullet wounds of the neck or chest, trauma from motor vehicle crash, caustic injury from a chemical burn (described later), or inadvertent puncture by a surgical instrument during examination or dilation.

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Clinical Manifestations

The patient has persistent pain followed by dysphagia. Infection,

fever, leukocytosis, and severe hypotension may be noted. In

some instances, signs of pneumothorax are observed.

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Assessment and Diagnostic Findings

Diagnostic x-ray studies and fluoroscopy are used to identify the site of the injury.

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Management

Because of the high risk of infection, broad-spectrum antibiotic therapy is initiated. A nasogastric tube is inserted to provide suction and to reduce the amount of gastric juice that can reflux into the esophagus and mediastinum. Nothing is given by mouth; nutritional needs are met by parenteral nutrition. Parenteral nutrition is preferred to gastrostomy because the latter might cause reflux into the esophagus. Surgery may be necessary to close the wound, and postoperative nutritional support then becomes a primary concern.

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CHEMICAL BURNS

Chemical burns of the esophagus may be caused by undissolved medications in the esophagus. This occurs more frequently in the elderly than it does among the general adult population. A chemical burn may also occur after swallowing of a battery, which may release caustic alkaline. Chemical burns of the esophagus occur most often when a patient, either intentionally or unintentionally, swallows a strong acid or base

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RX Esophagoscopy and barium swallow- to

determine the extent and severity of damage.

The patient is NPO, and IV fluids adm

A NGT may be inserted by the physician.

Vomiting and gastric lavage are avoided to prevent further exposure of the esophagus to the caustic agent.

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RX The use of corticosteroids to reduce

inflammation and minimize subsequent scarring and stricture formation is of questionable value.

The value of the prophylactic use of antibiotics for these patients has also been questioned

For strictures that do not respond to dilation, surgical management is necessary.

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GASTROESOPHAGEAL REFLUX DISEASE

Some degree of gastroesophageal reflux (back-flow of gastric or duodenal contents into the esophagus) is normal in both adults and children. Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, or a motility disorder. The incidence of reflux seems to increase with aging.

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Clinical Manifestations(GERD)

pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (difficulty swallowing, pain on swallowing), hypersalivation, and

esophagitis. The symptoms may mimic those of a heart attack.

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Assessment and Diagnostic Findings(GERD)

Diagnostic testing may include an endoscopy or barium swallow to evaluate damage to the esophageal mucosa.

Ambulatory 12- to 36-hour esophageal pH monitoring is used to evaluate the degree

of acid reflux. Bilirubin monitoring (Bilitec) is used to measure

bile reflux patterns.

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Management (GERD)

Management begins with teaching the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation.

The patient is instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods

containing peppermint or spearmint, and carbonated beverages; to avoid eating or drinking

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Management (GERD)

2 hours before bedtime; to maintain normal body weight; to avoid tight-fitting clothes; to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks; and to elevate the upper body on pillows.

If reflux persists, the patient may be given medications such as antacids or histamine receptor blockers. Proton pump inhibitors (medications that decrease the release of gastric acid,

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Management (GERD)

Surgical management involves a fundoplication (wrapping of a portion of the gastric fundus around the sphincter area of the esophagus). Fundoplication may be performed by laparoscopy.

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CANCER OF THE ESOPHAGUS

USA carcinoma of the esophagus occurs more than three times as often in men as in women. It is seen more frequently in African Americans than in Caucasians and usually occurs in the fifth decade of life. Cancer of the esophagus has a much higher incidence in other parts of the world, including China and northern Iran

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cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. There seems to be an association between GERD and adenocarcinoma of the esophagus. People with Barrett’s esophagus (which is caused by chronic irritation of mucous membranes due to reflux of gastric and duodenal contents) have a higher incidence

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Pathophysiology

Esophageal cancer is usually of the squamous cell epidermoid type; however, the incidence of adenocarcinoma of the esophagus is increasing in the United States.

Tumor cells may spread beneath the esophageal mucosa or directly into, through, and beyond the muscle layers into the lymphatics.

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Clinical Manifestations

Symptoms include dysphagia, initially with solid foods and eventually with liquids; a sensation of a mass in the throat; painful swallowing; substernal pain or fullness; and, later, regurgitation of undigested food with foul breath and hiccups.

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As the tumor progresses and the obstruction becomes more complete, even liquids cannot pass into the stomach. Regurgitation of food and saliva occurs, hemorrhage may take place, and progressive loss of weight

Later symptoms include substernal pain, persistent hiccup, respiratory difficulty, and foul breath. The delay between the onset of early symptoms and the time when the patient seeks medical advice is often 12 to 18 months.

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Assessment and Diagnostic Findings

new endoscopic techniques are being studied for screening and diagnosis of esophageal cancer, currently diagnosis is confirmed most often by EGD with biopsy and brushings.

Endoscopic ultrasound or mediastinoscopy is used to determine whether the cancer has

spread to the nodes and other mediastinal structures.

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Medical Management

If esophageal cancer is found at an early stage, treatment goals may be directed toward cure; however, it is often found in late stages, making relief of symptoms the only reasonable goal of therapy.

Treatment may include surgery, radiation, chemotherapy, or a combination of these modalities,

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Standard surgical management includes a total resection of the esophagus (esophagectomy) with removal of the tumor plus a wide tumor-free margin of the esophagus and the lymph nodes in the area.

When tumors occur in the cervical or upper thoracic area, esophageal continuity may be maintained by free jejunal graft transfer, in which the tumor is removed and the area is replaced with a portion of the jejunum (Fig).

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A segment of the colon may be used, or the

stomach can be elevated into the chest and the proximal section of the esophagus anastomosed to the stomach.

Tumors of the lower thoracic esophagus are more amenable to surgery than are tumors located higher in the esophagus, and gastrointestinal tract integrity is maintained by anastomosing the lower esophagus to the stomach.

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Surgical resection of the esophagus has a relatively high mortality rate because of infection, pulmonary complications, or leakage through the anastomosis.

Postoperatively, the patient will have a nasogastric tube in place that should not be manipulated. The patient is given nothing by mouth until x-ray studies confirm that

the anastomosis is secure and not leaking.

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Nursing Management

Intervention is directed toward improving the patient’s nutritional and physical condition in preparation for surgery, radiation therapy, or chemotherapy.

A program to promote weigh gain based on a high-calorie and high-protein diet, in liquid or soft form, is provided if adequate food can be taken by mouth.

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Nursing Management

informed about the nature of the postoperative equipment that will be used, including that required for closed chest drainage, nasogastric suction, parenteral fluid therapy, and gastric intubation.

After recovering from the effects of anesthesia, the patient is placed in a low Fowler’s position, and later in a Fowler’s position, to assist in preventing re- flux of gastric secretions.

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Nursing Management

The patient is observed carefully for-regurgitation and dyspnea. A common postoperative complication is aspiration pneumonia.

If jejunal grafting has been performed, the nurse checks for graft viability hourly for at least the first 12 hours. To make the graft visible,

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Nursing Management Moist gauze covers the external portion of the

graft. The gauze is removed briefly to assess the graft for color and to assess for the presence of a pulse by means of Doppler ultrasonography.

The nasogastric tube is removed 5 to 7 days after surgery, and a barium swallow is performed to assess for any anastomotic leak before the patient is allowed to eat.

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Nursing Management Once feeding begins, the nurse encourages the

patient to swallow small sips of water and, later, small amounts of pureed food.

After each meal, the patient remains upright for at least 2 hours to allow the food to move through the gastrointestinal tract.

If radiation is part of the therapy, the patient’s appetite is further depressed and esophagitis may occur.

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