Complications
Oral mucositis secondary to cancer therapy is an acute inflammation of the oral mucosa in response to systemic chemotherapy and/or radiotherapy to fields involving the oral cavity. The clinical presentation ranges from a general erythaematous stomatitis to erosive lesions and overt ulceration. Lesions are often very painful, may compromise nutrition and oral hygiene, and increase the risk of local and systemic infection. Furthermore, severe oral mucositis may warrant an undesirable chemotherapy dose-reduction and/or a break in radiotherapy.
Treatment is symptomatic, and includes oral hygiene and pain control.
Risk depends on total dose of radiotherapy to the mandible and volume of mandible radiated. Patients receiving ≥50 Gy radiotherapy dose to the jaw are at risk of developing osteoradionecrosis.[131] For patients undergoing concurrent chemoradiotherapy, risk ranged from 5% to 7%.[91][93][94] For prevention, all patients should be assessed by a dental professional familiar with radiotherapy before radiotherapy.[131] Techniques such as intensity-modulated radiotherapy and intensity-modulated proton therapy should be used to reduce radiotherapy exposure to the jaw.[131] Antibiotics and hyperbaric oxygen are the main treatments. Surgery may be required in refractory cases.
Secondary to fibrosis of the TMJ and pterygoid muscles. Risk increases with radiotherapy dose to these structures. IMRT may decrease radiotherapy dose to the TMJ and reduce risk. Because there is no uniform definition for trismus, its incidence after radiotherapy for oropharyngeal cancer ranges from 2% to 13%.[91][92]
The oropharynx plays a key role in phonation. Surgery, even with reconstruction, is associated with altered speech, as voice quality is not the same. Transoral robotic surgery is widely thought to be associated with significantly better postoperative functional outcomes, related to speech, swallowing, and need for tracheostomy.
Radiotherapy often damages the salivary glands, and induces permanent xerostomia, which affects patient quality of life. The severity of xerostomia depends on the dose to the parotid glands. New radiotherapy techniques, such as intensity-modulated radiotherapy, can reduce the radiotherapy dose to the parotid glands (mean dose <26 Gy), and allow recovery of salivary flow.[125]
Patients undergoing chemotherapy and radiotherapy are at particular risk because cisplatin alone can induce damage to the cochlea. Patients older than 40 years and patients with pre-existing hearing deficit are at increased risk.[126][127][128] Risk depends on radiotherapy dose to the cochlea, and is potentiated by cisplatin. Radiotherapy dose as low as 10 Gy can produce hearing deficit when combined with cisplatin.[129] All patients undergoing chemoradiotherapy should have baseline audiometry before and after radiotherapy. Hearing aids or cochlear implants can improve quality of life if patients develop hearing deficit after radiotherapy.[130] New agents are being investigated to reduce cisplatin-induced toxicity.[109]
Thyroid function should be monitored routinely, and patients instructed about signs and symptoms of hypothyroidism for thyroid hormone replacement.
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