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Case history

image A 66-year-old woman was admitted to the oncology ward from the radiotherapy department with complaints of severe pain in the throat and difficulty eating and drinking. She had been undergoing radiotherapy for right-sided tonsillar cancer.

On examination she had lost 3 kg weight in the past week. Oral examination revealed ulceration with fibrinous membrane in the right oropharynx, including the soft palate, posterior tongue and pharyngeal wall. Mouth opening was painful.

What is the cause of the patient’s symptoms?

What further information should be gathered about this patient?

What is the most appropriate management for this patient?

What complications of radiation mucositis should be considered?

Which other disciplines should be involved in this patient’s care?

What is the cause of the patient’s symptoms?

Figure 20.1 shows a typical grade 3 radiation mucositis in the right oropharynx including soft palate and tonsillar region (Table 20.1). The most distressing side effect of radiotherapy for head and neck cancers is radiation mucositis. Virtually all patients undergoing curative radiotherapy for head and neck malignancies suffer from mucositis. Mucositis typically develops in the third week of treatment and progresses according to the dose and target volume of radiation. The appearance of mucositis starts as erythema and then progresses to ulceration covered with patches of fibrinous exudate which later become confluent. In some cases bleeding may occur. Severe (grade 3) mucositis is seen in up to 80% of patients, especially in those receiving concurrent chemotherapy.

Figure 20.1

Oral cavity showing grade 3 radiation mucositis involving the right soft palate and tonsillar fossa.

Table 20.1Grading of radiation mucositis.

What further information should be gathered about this patient?

Enquire how many fractions of radiotherapy the patient has completed. Severe mucositis is not commonly seen in the first 2 weeks of treatment. Early onset of severe mucositis could indicate a superimposed Candida or bacterial infection. Patients who smoke during radiotherapy also suffer from more severe mucositis. Some patients have intrinsically radiosensitive normal tissues and may have abnormally severe reactions to radiotherapy.

Enquire whether the patient is receiving any concurrent chemotherapy and its schedule. The radiosensitizing effect ...

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