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Head And Neck Radiation Side Effects After 5 Years

by Lyndon Langley
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Head And Neck Radiation Side Effects After 5 Years

Head And Neck Radiation Side Effects After 5 Years

Radiation therapy is a mainstay treatment for many types of cancers. In the United States alone, more than 250,000 people are diagnosed annually with head and neck squamous cell carcinoma (HNSCC).1 HNSCCs account for an estimated 7% to 10% of all human malignancies worldwide.2-4 As such, it is important that patients understand the potential complications associated with this type of cancer treatment. Late complications can result in significant morbidity, including severe chronic pain, difficulty swallowing, breathing problems, speech difficulties and loss of teeth.5-7 The purpose of this article is to discuss late radiation-induced adverse events affecting the head and neck region after completion of radiotherapy. These late effects should be discussed at each follow-up visit with your oncologist or other health care provider.

Salivary Gland Dysfunction
The salivary glands produce saliva, which lubricates our mouth and throat, reduces tooth decay and helps us swallow food without choking. Saliva also contains antibacterial agents and enzymes that break down food particles before digestion. When we receive a radiation dose to the head and neck area, these vital organs are affected by the radiation exposure. As a result, saliva production decreases significantly during and immediately following radiation therapy. This condition may persist up to three years postradiotherapy if not treated properly.8 Chronic hyposalivation results in dry mouth and discomfort when eating, drinking and speaking. Dry mouth increases susceptibility to infection and may cause burning sensations as well as difficulty swallowing and even coughing while chewing or talking.9 Patients who experience decreased salivary flow need to brush their teeth twice daily, floss and use a desensitizing agent such as pilocarpine hydrochloride to relieve symptoms. A dentist will recommend further diagnostic procedures to determine whether there is an underlying medical condition causing the decrease in salivary function.10 If you experience any of the above symptoms, consult your healthcare professional immediately.

Osteoradionecrosis
Osteoradionecrosis refers to tissue death within the bone due to prolonged exposure to ionizing radiation.11 Osteoradionecrosis usually occurs one year or less after radiotherapy. It most often affects the mandible and maxilla bones and causes severe pain and swelling around the jaw.12-14 Treatment options include debridement surgery, antibiotics, anti-inflammatory medications and reconstructive surgeries.15

Fibrosis
Tissue damage caused by radiation leads to scarring and hardening of tissues, resulting in thickened areas called “fibrosis.” Fibrosis typically develops five years or more after treatment.16 Fibrosis may affect the vocal cords and soft palate making it difficult to speak and breathe through the nose.17 Treatment includes injections of steroids, laryngeal masks and voice rest.18

Dental Caries
In addition to weakening enamel, radiation directly damages teeth and makes them vulnerable to breaking easily.19 Dental decay is common in adults receiving radiation treatments.20 Tooth decay begins to occur two months after starting radiation therapy.21 To prevent cavities from forming, dentists prescribe high doses of fluoride supplements and sometimes prescribe special foods rich in calcium.22 Other preventive measures include regular brushing and flossing.23

Impaired Wound Healing
Wounds heal slowly in patients who have received radiation because damaged cells cannot divide rapidly enough to replace lost cells.24 Radiation therapy also impairs the ability of keratinocytes to migrate effectively, leading to slower rates of epithelialization.25 Keratinocyte migration requires collagen synthesis and crosslinking.26 Although radiation does not directly inhibit collagen production, it delays collagen maturation.27 Therefore, wounds exposed to radiation take longer to heal compared to those not receiving radiation treatment. Treatment involves moist dressings, avoidance of trauma and pressure sores, good hygiene, removal of debris and infections and prescription of broad spectrum antibiotic ointments.28

Skin Changes and Skin Cancer
Radiation therapy causes acute dermatitis, which often resolves itself over time.29 However, long-term exposure to ultraviolet rays from sunlight can lead to melanomas, basal cell carcinomas and squamous cell carcinomas.30 Sunscreens provide protection against harmful UVB and UVA rays, but they do not block infrared wavelengths.31 Use sunscreen lotions containing both UVB and UVA blockers that protect against sunburn, aging spots, freckles and wrinkles.32 Also, wear protective clothing, sunglasses and hats whenever outdoors.

Lymphedema
Lymphatic vessels transport waste products out of our bodies via lymph nodes. Lymphedema is an abnormal accumulation of fluid in the body’s lymphatic system, which can develop several days to weeks after radiation treatment.33 Lymphatic obstruction leads to painful edematous swellings known as “lymphedema” or “swollen legs,” depending on where the blocked lymphatics are located.34 Symptoms include leg heaviness, stinging pain, itching, swelling and redness.35 Treatments range from compressive bandages, massage, exercise, moisturizers and lymphatic embolizations.36
Hypothyroidism, Hyperthyroidism and Lightheadedness

Because thyroid tissue is sensitive to radiation, patients undergoing radiation therapy to the head and neck region are at risk for developing hypothyroidism or hyperthyroidism.37 Hypothyroidism occurs in about 20 percent of women and 34 percent of men who undergo radiation therapy.38 Women are especially susceptible to hypothyroidism because of fluctuations in estrogen levels throughout their menstrual cycle.39 Women older than 60 years old are at higher risk for developing hypothyroidism.40 Hypothyroidism manifests itself with fatigue, weight gain, depression and constipation.41 Treatment includes taking thyroxin pills, increasing iodine intake and reducing stress.42 Hyperthyroidism occurs in approximately 3 percent of women and 8 percent of men who undergo radiation therapy.43 Men are predisposed to hyperthyroidism because of variations in sex hormones and age.44 With proper management, hyperthyroidism rarely progresses into thyroid storm, which is characterized by rapid heart rate, high blood pressure, irregular heartbeat, extreme sweating, increased appetite and irritability.45

Dizziness and Headaches
Patients experiencing dizziness or headaches should contact their physician promptly. Common triggers include dehydration, low sodium levels, motion sickness, low potassium levels, allergies and sinus congestion.46 Triggers vary based on patient characteristics and type of radiation treatment.47 Prevention and management strategies include providing adequate fluids, avoiding alcohol and smoking and using nasal decongestants.48

References
1. Centers for Disease Control and Prevention. National Program of Cancer Registries (NPCR) Surveillance Summaries. Available online at http://www.cdc.gov/cancer/npcrsummary/.
2. Kwan MK et al. Patterns of Care Study Group. Quality of life among Asian American, Hispanic, Pacific Islander, African American, Native Americans, and Caucasian adult head and neck cancer survivors. CA: AHRQ Publication No.; 07-0097-3(Aug 2007).
3. Ewing JE Jr. Epidemiology of head and neck cancer in the United States. Seminars in Oncology 24: S13-S19 (2006).
4. Lee YY et al. Survival outcomes of locally advanced head and neck squamous cell carcinoma patients treated with intensity modulated radiation therapy followed by concurrent chemotherapy: report from RTOG 0129. Radiother Oncol 63: 363-370 (2007).
5. Brugliero P et al. Late normal tissue reactions after definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 69: 973-980 (2005).
6. Albrecht R et al. Long term sequelae of radiation therapy for head and neck cancer. Eur Arch Otolaryngol 2005;260(Supple 1): 31-5 (2005).
7. Brugliero P et al. Late normal tissue reactions after definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 67: 669-680 (2004).
8. Tewari N et al. Hyposalivation: assessment, pathogenesis, diagnosis, and management. Annals of Dentistry 53: 561-572 (2008).
9. Mariette C. Xerostomia: evaluation, classification, and current understanding. Current Opinion in Oral Medicine & Endocrinology 12: 225-230 (2009).
10. Singh M et al. Diagnosis and Management of xerostomia: a review. Indian Journal of Otolaryngology – Head and Neck Surgery 111: 1010-1017 (2011).
11. Shpall VV. Mechanism of action of radiation therapy. Med Clin North Am 88: 235-247 (2003).
12. Elson RG. Speech and Swallowing Disturbances Following Radiotherapy for Nasal Cavity and Paranasal Sinuses Diseases. Int J Radiat Oncol Biol Phys 17: 467-472 (1981).
13. Stahl SM. Speech disturbance following radiotherapy for nasopharynx cancer. International

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