Complications
Oral mucositis secondary to cancer therapy is an acute inflammation of the oral mucosa in response to systemic chemotherapy and/or radiation to fields involving the oral cavity. The clinical presentation ranges from a general erythematous 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 radiation therapy.
Treatment is symptomatic and includes oral hygiene and pain control.
Risk depends on total dose of radiation to the mandible and volume of mandible radiated. Patients receiving ≥50 Gy radiation dose to the jaw are at risk of developing osteoradionecrosis.[118] For patients undergoing concurrent chemoradiation, risk ranged from 5% to 7%.[91][93][94] For prevention, all patients should be evaluated by a dental professional familiar with radiation therapy before radiation.[118] Techniques such as intensity-modulated radiation therapy and intensity-modulated proton therapy should be used to reduce radiation exposure to the jaw.[118] 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 radiation dose to these structures. IMRT may decrease radiation dose to the TMJ and reduce risk. Because there is no uniform definition for trismus, its incidence after radiation 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.
Radiation therapy 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 radiation therapy techniques such as intensity-modulated radiation therapy can reduce the radiation dose to the parotid glands (mean dose <26 Gy) and allow recovery of salivary flow.[130]
Patients undergoing chemotherapy and radiation 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.[131][132][133] Risk depends on radiation dose to the cochlea and is potentiated by cisplatin. Radiation dose as low as 10 Gy can produce hearing deficit when combined with cisplatin.[134] All patients undergoing chemoradiation should have baseline audiometry before and after radiation. Hearing aids or cochlear implants can improve quality of life if patients develop hearing deficit after radiation.[135] New agents are being investigated to reduce cisplatin-induced toxicity.[107]
Thyroid function should be monitored routinely and patients instructed about signs and symptoms of hypothyroidism for thyroid hormone replacement.
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