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Case History

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Image not available. A patient with a T3 N2a M0 hypopharyngeal cancer is admitted to the emergency department on a Saturday. The patient is three weeks into his six-week chemoradiation treatment. He has found it difficult to swallow due to pain for a number of days, and he is unable to swallow solids or liquids. On examination of his oral cavity his mucous membranes are inflamed and there are several ulcers present.

Why does radiation-induced mucositis occur?

How should patients with oral mucositis be assessed?

How should patients with radiation-induced oral mucositis be managed?

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Background

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Image not available. Mucositis refers to the inflammation and/or ulcerative lesions of the oral and or gastrointestinal (GI) tract.1 It can occur as a side effect of both radiotherapy and chemotherapy treatment. Mucositis occurs when radiotherapy is directed at or near to the oral cavity or GI tract.

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Radiotherapy is an important component of the management of head and neck cancers, hence oral mucositis is a common and expected side effect of radiotherapy to this region. Over 80% of patients receiving radical doses of radiotherapy to the head and neck region suffer with severe oral mucositis.1 Patients can experience oral ulcers and varying degrees of odynophagia.

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Typically, patients do not experience any symptoms in the first week of a 4–7-week treatment schedule, and mucositis is often delayed, becoming more severe towards the latter part of treatment. It is important to warn patients that their symptoms will not clear on completion of treatment and that it may take several weeks for the symptoms of mucositis to resolve.

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Why does radiation-induced mucositis occur?

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Although a high proportion of patients treated radically for head and neck cancers develop mucositis, severity varies from patient to patient. This suggests a genetic component, although further research is needed to establish the key factors.

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The pathogenesis of mucositis is also an ongoing area of research. The basic stages thought to be involved in the pathogenesis of both oral and GI mucositis are similar and are outlined in Figure 27.1.

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Figure 27.1

Pathogenesis of oral and gastrointestinal mucositis. Adapted from ref. 2.

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How should patients with mucositis be assessed?

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Mucositis is an expected side effect of radical head and neck radiotherapy; consequently, patients should be assessed prior to, during and after treatment.

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Patients should be assessed by a dentist prior to starting treatment to optimize education concerning oral hygiene, and to complete any necessary dental work before starting treatment. Oral hygiene is particularly important for those patients undergoing chemoradiation to help prevent infection.

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Patients who are unable to manage oral nutrition may require dietary supplements and/or a percutaneous endoscopic gastrostomy (PEG) or a nasogastric (NG) ...

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