oral cavity and esophageal disorders

• Stomatitis


  Broad term refers to inflammation within oral cavity, erosion of tissue integrity of the mouth. very painful. At risk for bleeding and infection
• Candidiasis (thrush)


  Fungal infection, secondary to stomatitis. Caused by candida albicans can be from long term antibiotics, chemo, radiation and steroids
• Leukoplakia


  Oral cavity disorder. Causes thickened white patches that are slightly raised and cannot be scraped off, often benign, small % become cancerous. Caused by smoking, poorly fitted dentures, broken/chipped teeth, immunocompromised eg, HIV
• Erythroplakia


  Erythro (red), appears red velvety of surface of oral mucosa, considered precancerous, found on mouth, tongue, palate, and mandibular mucosa
• Squamous cell carcinoma


  Most oral cancers are this type. 90% arise from the surface of epithelium. Red, raised, eroded, suspicious for cancer. Lesion that does not heal in 2 weeks or lump or thickening required further eval. Major risks- advanced age, tobacco, alcohol, some occupations (textile workers, palmers, coal and metal workers), sun exposure, poor nutrition intake, poor oral hygiene, HPV infection, periodontal or gum disease
• Basal cell carcinoma


  Primarily on lip, lesions asymptomatic, raised scab, not metastasized but can aggressively involve skin on face. Major risk factor - sunlight exposure
• Kaposi's sarcoma


  Malignant lesion of blood vessels, vascular tumor that is painful. Raised, red nodule or plaque. Hard palate is the most common site. Can be on gums, tongue, or tonsils. And most often associated with AIDS
• Oral Cancer Assessment


  • Bleeding
  • Poor appetite
  • Difficulty chewing
  • Dysphagia
  • Weight loss
  • Painless oral lesion
  • Lump in cheek
• Oral Cancer Management - Nonsurgical


  1. Suction

  2. Patient in semi or high fowler to prevent aspiration

  3. Increases air exchange

  4. Steroids may be given for inflammation or edema

  5. Antibiotics maybe

  6. Cool mist applied to face via face test to help with O2 transport and edema control

  7. Oral hygiene every 2 hrs with a soft bristle toothbrush and avoid commercial mouthwash (alcohol) or lemon glycerin swabs

  8. Rinse with sodium bicarbonate or warm saline in water based lubricant to moisten lips and mucosa
• Oral Cancer Management - Radiation, chemo or target therapy


  Depending on tumor type, location and stage
• Oral Cancer Management - Surgical


  1. Cryotherapy - extreme cold application

  2. Carbon dioxide laser therapy

  3. Glossectomy - removal of tongue

  4. Mandibulectomy - partial or total mandible resection

  5. Commando procedure - combined neck dissection, cervical neck metastasize, removal of cervical lymph node dissection on affected side if metastasized, CN 11 (accessory nerve), internal jugular vein and sternocleidomastoid removal
• Post op care for oral cancer


  Bleeding/infection, protect airway, trach, manage pain and bleeding, drain, nutrition because cant really eat especially if with trach, avoid oral care, and elevate head of bed
• Esophageal Disorders


  From reflux or gastric acid into esophagus from excessive relaxation of lower esophageal sphincter (LES), seen in GERD, pH acid of stomach 1.5-2, pH acid of distal esophagus is 6-7
• Gastroesophageal Reflux Disease (GERD)


  Most common upper GI disorder, persistent esophageal reflux, most common cause relaxation of lower esophageal sphincter
• GERD Risks


  • Overweight and obese
  • Caffeine
  • Alcohol
  • Tomatoes and tomato production
• GERD Manifestations


  • Heartburn
  • Belching (burping)
  • Dyspepsia (indigestion)
  • Regurgitation
  • Flatulence
  • Nausea/Vomiting
  • Water brash (salivary hypersecretion)
  • Painful swallowing
  • Difficult swallowing
  • Chronic cough mostly at night while lying down
  • Atypical chest pain
  • Asthma
  • Voice hoarseness
• Barrett's epithelium


  Occurs during the process of healing, body may substitute the normal squamous cell epithelium of lower esophagus, premalignant and associated with risk for cancer with pts with prolonged GERD
• Esophageal stricture


  Narrowing of esophagus, occurs with fibrous scaring in healing process, strictures lead to Progressive dysphagia
• GERD Complications


  • Asthma
  • Laryngitis
  • Dental decay
  • Cardiac disease
  • Hemorrhage
  • Aspiration pneumonia
• 24 hour esophageal pH monitoring


  Most accurate method to diagnosing GERD, small catheter placed through nose, diary of symptoms for 24 hrs, pH continuously monitored and recorded
• EGD


  Esophagogastroduodenoscopy, diagnostic procedure for GERD
• GERD Nonsurgical Management


  • Nutrition - decrease LES, chocolate, no alcohol, fatty foods especially fried, caffeine, carbonated beverages, spicy and acidic foods, peppermint, avoid large meals, 4-6 meals, don't eat food at least 3 hours before bed
  • Lifestyle changes - elevate HOB 6-12 inches for sleep, wedge or pillow, sleep on R side, avoid smoking, alcohol, reduce weight, avoid wearing constricting clothing and lifting heavy objects or straining
  • Weight reduction
  • Drugs that lower LES reflex and pressure, avoid oral contraceptives, nonsteroidals, sedatives, anticholinergic meds, nitrates, calcium channel blockers
• GERD Surgical Management


  1. Endoscopic procedures - STRETTA, physician applies radio frequency energy through endoscope using needles placed by gastroesophageal junction, radiofrequency emergency reduces vagus nerve frequency reducing discomfort, clear liquids for 24 hours after

  2. Laparoscopic Nissen Fundoplication (LNF) - minimally invasive procedure for severe GERD, reinforces LES by taking fundus of stomach around distal esophagus and anchors it and reinforces LES
• GERD Medications


  • Antacids - Mylanta, Gaviscon, relieve occasional heartburn, deactivate pepsin, and increases gastric pH
  • Histamine receptor antagonists - Ranitidine (Zantac), Famotidine (Pepcid), Nizatidine (Axid), decrease acid secretion by blocking histamine receptors
  • Proton pump inhibitors (PPIs) - Omeprazole (Prilosec), Rabeprazole (Aciphex), Pantoprazole (Protonix), Esomeprazole (Nexium), decreased acid production by affecting Proton pump and gastrin, main treatment for GERD, side effects include hip fractures, interfere with Ca and protein digestion
  • Omeprazole/sodium bicarbonate (Zegerid) - newer med, immediate relief, designed for short term use
  • Dexlansoprazole (Kapidex)