"My Voice"

Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.

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Obtain and/or view a video presentation, a slide presentation and an instructive manual how to ventilate laryngectomees and neck breathers (all free). A self examination guide for detection of primary and recurrent head and neck cancer is available.

Side effects of radiation treatment for head and neck cancer



Radiation therapy (RT) is often used to treat head and neck cancer. It can be used as the only treatment, in combination with chemotherapy (chemoradiation therapy), or after surgery (adjuvant radiation therapy) The goal of radiation therapy is to kill cancer cells. Because these cells divide and grow at a faster rate than normal cells they are more likely to be destroyed by radiation. In contrast although they may be damaged, healthy cells generally recover. Unfortunately radiation treatment causes short and long term side effects.


RT can be administered in several ways:

1.     “Organ preservation”: Radiation is aimed at the tumor site (with or without chemotherapy) is used in an attempt to cure the disease without surgically removing the larynx. However, this is not always an option because of the size and location of the tumor and the recommendation is to proceed directly to surgery.

2.     "Palliative treatment": Radiation (with or without chemotherapy) is given in an attempt to prolong life when the tumor is too large and/or inoperable and cure is highly unlikely.


3.     Radiation after surgery: Radiation is given after surgery to destroy any local residual cancer cells that may spread to other organs such as the lung, liver, or brain. 


Types of radiation therapy

Most patients with for head and neck cancers are treated with external beam radiation therapy (using X-rays or gamma rays). The current standard of care is to use intensity-modified RT (IMRT). This method adjusts the beams to maximize radiation to cancerous tissue and not to normal tissue. This reduces side effects of RT. An individual face mask is made for each patient to insure accurate delivery of radiation. The number of treatments a person may get depends on the cancer type. Some patients get radiation only a single RT time while others get radiation once a day, 5 days a week, for up to 7 weeks.

Other methods of radiation include: brachytherapy (implanting radioactive source close to the cancer), intra-operative radiation therapy, neutron beam radiationtherapy ( using higher energy neutron beams), proton beam radiation therapy ( a more precise radiation), radiosurgery ( using  Cyberknife®, Gamma Knife® and LINAC), and radioactive iodine (for thyroid cancer)

If RT is recommended the radiation oncologist sets up a treatment plan
that includes the total dose of radiation to be administered, the number of treatments to be given, and their schedule. These are based on the type and location of the tumor, the patient's general health, and other present or past  treatments. For early stage disease, doses of 66-74 Gy are generally administered.


The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation.The side effects of RT for head and neck cancer are divided into early (acute) and long term (chronic) effects. Early side effects occur during the course of therapy and during the immediate post therapy period (approximately 2-3 weeks after the completion of a course of RT). Late effects can manifest any time thereafter, from weeks to years later.


I described my own experiences getting RT in my book My Voice” in chapter 4 ”Getting irradiated”, and chapter 5 "Life after irradiation".

A lecture about life challenges after laryngectomy that includes discussion of late side effects of radiation can be viewed on YouTube.





Patients are usually most bothered by the early effects of RT, although these will generally resolve over time. However, because long term effects may require lifelong care it is important to recognize these in order to prevent them and/or deal with their consequences. Knowledge of the radiation side effects can allow their early detection and proper management. 

Individuals with head and neck cancer should receive counseling about the importance of smoking cessation. In addition to the fact that smoking is a major risk factor for head and neck cancer, the risk of cancer in smokers is further enhanced by alcohol consumption. Smoking can also influence cancer prognosis. When smoking is continued both during and after RT, it can increase the severity and duration of mucosal reactions, worsen the dry mouth (xerostomia), and compromise patient outcome. Patients who continue to smoke while receiving RT have a lower long-term survival rate than those who do not smoke.







Early side effects

Early side effects include inflammation of the oropharyngeal mucosa (mucositis), painful swallowing (odynophagia), difficulty swallowing (dysphagia), hoarseness, lack of saliva (xerostomia), orofacial pain, dermatitis, nausea, vomiting, inadequate nutrition and hydrationand weight loss. These complications can interfere with, and delay treatment. To some degree these side effects occur in most patients and generally dissipate over time.
The severity of these side effects is influenced by the amount and method by which the RT is given, the tumor’s location and spread, and the patient’s general health and habits (i.e. continued smoking, alcohol consumption).

Skin damage (radiation-induced dermatitis)

RT can cause a sunburn-like damage (radiation dermatitis) to the skin which can be further aggravated by chemotherapy. It is one of the most common side effects of RT and can cause pain and discomfort. The dermatitis depend upon the radiation dose and can be mild, moderate and severe. The severity of dermatitis and healing time are significantly increased in patients taking radiosensitizing agents.

It is advisable to keep the irradiated area clean and dry, wear loose-fitting clothes to avoid friction injuries, wash the skin with lukewarm water and mild soap (preferably synthetic soaps), and avoid exposure to potential chemical irritants, skin irritants such as perfumes and alcohol-based lotions, direct sun and wind, and local application of lotions or ointments prior to RT that might change the depth of radiation penetration. 

There are a number of skin care products that can be used during radiation treatment to lubricate and protect the skin. These include aloe vera-based gels and water-based lotions. Although such preparations may provide symptom relief, none promotes or accelerates healing of the radiation-induced dermatitis.


Mild  dermatitis starts improving with 10 days after completing of radiation, while severe dermatitis is associated with prolonged inflammation and healing time, resulting in skin fibrosis.

Skin cancer can rarely develop at the irradiated area.

Wearing adhesive heat and moisture exchanger (HME) housing is not recommended during RT and the recovery period as the skin around the stoma usually become inflamed.


Skin damage after radiation

Dry mouth (xerostomia)

The loss of saliva production (or xerostomia) is the most common long-term complication of radiation therapy, and  is  related to the administered irradiation dose and the volume of salivary tissue irradiated.

Prevention of permanent salivary gland damage can be attempted in selected patients by using parotid-sparing intensity-modulated radiation therapy (IMRT)reduce the radiation dose to the submandibular and minor salivary glands (if oncologcally feasible), submandibular salivary gland surgical transfer, and administration of amifostine (a radiation protective organic thiophosphate medication).

Although xerostomia generally improves with time, it is often a permanent problem that can adversely impacts quality of life. Drinking adequate fluids, frequent sipping or spraying of the mouth with water,  and rinsing and gargling with a weak solution of salt and baking soda are helpful to refreshing the mouth, loosen thick oral secretions, and alleviate mild pain.
The use of saliva substitutes, or stimulation of saliva production from intact salivary glandular tissues by taste/mastication, pharmacological sialogogues (a drug  that increases the flow rate of saliva),or acupuncture can also be helpful.

For more information see Xerostomia at the Chronic side effects section below.









Acceleration of periodontal disease


Patients who experience low function of their salivary gland and xerostomia must maintain excellent oral hygiene to minimize the risk of oral lesions. 


Periodontal disease can be accelerated and caries can become rampant unless preventive measures are instituted. Multiple preventive strategies should be considered.
Periodontal disease can be accelerated and caries can become rampant unless preventive measures are instituted. Multiple preventive strategies should be considered.
This evolves performing systematic oral hygiene at least 4 times per day (after meals and at bedtime) which includes:
  • Brushing teeth (if soreness of oral mucosa and trismus are present, a small ultrasoft toothbrush can be used).
  • Using a fluoridated toothpaste when brushing.
  • Flossing once daily.
  • Applying a prescription-strength fluoride gel at bedtime to prevent caries.
  • Rinsing with a solution of salt and baking soda 4 to 6 times a day (½ tsp salt and ½ tsp baking soda in 1 c warm water) to clean and lubricate the oral tissues and to buffer the oral environment.
  • Sipping water frequently to rinse the mouth and alleviate mouth dryness.
  • Avoiding foods and liquids with a high sugar content. (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)


Use of topical fluoride has demonstrable benefit in minimizing caries formation. During radiation treatment, it has been recommended that mouth guards be filled with topical 1% sodium fluoride gel and placed over the upper and lower teeth. The appliances should remain in place for 5 minutes, after which the patient should not eat or drink for 30 minutes.


Mouth guards can be filled with topical fluoride gel 


Alterations in taste (dysgeusia)

Radiation can induce changes in taste as well as tongue pain. Foods can alternately taste too bland or too spicy due to the tongue's limited taste receptors. Some foods may taste different than they did in the past, some foods may taste bland, or every food may taste the same. Specifically, bitter, sweet, and salty foods may taste different, and some people may have a metallic or chemical taste in their mouth, especially after eating meat or other high-protein foods.

The sense of taste may also be affected by impaired smelling. These side effects cancause food aversion (dislike) further decrease food intake and contribute to weight loss.


RT as well as chemotherapy can impair the sense of taste because of their effects on the in the tongue and nasal epithelium receptors. Additional factors that may contribute to an altered sense of taste include a bitter taste from chemotherapy drugs, poor oral hygiene, infection, and mucositis.

Taste changes and tongue pain caused by radiation treatment usually begin to improve three weeks to two months after the end of treatment. Improvement may continue for about a year, but the sense of taste may not entirely return to the way it was before treatment, especially if there is damage to the salivary glands. 

In most instances, there are no specific treatments for taste problems.

These tips may help to cope with taste changes:

  • Choosing foods that smell and taste good, even if the food is not familiar.
  • Eliminating cooking smells by using an exhaust fan, cooking on an outdoor grill, or buying precooked foods. Cold or room-temperature foods also smell less.
  • Eating cold or frozen food, which may taste better than hot foods.
  • Using plastic utensils and glass cookware to lessen a metallic taste.
  • Trying sugar-free, mint gum or hard candies (with flavors such as mint, lemon, or orange) to mask a bitter or metallic taste in the mouth.
  • Trying other protein sources (such as poultry, eggs, fish, peanut butter, beans, or dairy products) if red meats don't taste good.
  • Marinating meats in fruit juices, sweet wines, salad dressings, or other sauces.
  • Flavoring foods with herbs, spices, sugar, lemon, or sauces.
  • Not eating one to two hours before and up to three hours after chemotherapy to prevent food aversions caused by nausea and vomiting. Additionally, avoiding favorite foods before chemotherapy helps prevent aversions to those foods.
  • Rinsing with a salt and baking soda solution (½ teaspoon of salt and ½ teaspoon of baking soda in 1 cup of warm water) before meals, which may help neutralize bad tastes in the mouth.
  • Keeping a clean and healthy mouth by brushing frequently and flossing daily.
  • Considering zinc sulfate supplements, which may help improve taste in some people. However, one should consult with their physician before taking any dietary supplements, especially during active treatment.




Inflammation of the oropharyngeal mucosa (mucositis and odynophagia )

Radiation, as well as chemotherapy, damage the oropharyngeal mucosa resulting in mucositis, and odynophagia (pain with swallowing) which develops gradually, usually 2-3 weeks after starting RT. Its incidence and severity depend upon the field, total dose and duration of RT. Chemotherapy can aggravate the condition. Mucositis can be painful and interfere with food intake and nutrition. 

Management includes meticulous oral hygiene, dietary modification, and ingestion of topical anesthetics combined with an antacid  and antifungal suspension ("cocktail") before eating. Spicy, acidic, sharp, or hot food should be avoided,as well as alcohol. Reducing the pain on swallowing and increase food and liquid consumption. Secondary bacterial, viral (i.e. Herpes), and fungal (i.e. Candida) infections are possible. Control of the pain (using opiates or gabapentin) may be needed.

Mucositis can lead to nutritional deficiency. Those who experience significant weight loss or recurrent episodes of dehydration may require feeding through a gastrostomy feeding tube.



Mucositis following radiation


Pain in the mouth and/or face

Pain in the mouth and/or face (orofacial) is common in patients with head and neck cancer. It occurs in up to half of the patients before RT,  80% of patients during treatment and about one third of patients six months after treatment. The pain can be caused by mucositis which can be aggravated by concurrent chemotherapy, and by damage from the cancer, infection, inflammation, and scarring due to surgery or other treatments.
Pain management includes the use of analgesics and narcotics.









Nausea and vomiting

RT may cause nausea. When it occurs, it generally happens from two to six hours after a RT session and lasts about two hours. Nausea may or may not be accompanied by vomiting.

Management includes:

·       Eating small, frequent meals throughout the day instead of three large meals. Nausea is often worse if your stomach is empty.
·       Eating slowly, chewing the food completely, and staying relaxed.
·       Eating cold or room temperature foods. The smell of hot or warm foods may induce nausea.
·        Avoiding difficult to digest foods, such as spicy foods or foods high in fat or accompanied by rich sauces.
·        Resting after eating. When lying down, the head should be elevated about 12 inches.
·        Drinking beverages and other fluids between meals instead of drinking beverages with meals.
·        Drinking 6-8 ounce glasses of fluid per day to prevent dehydration. Cold beverages, ice cubes, popsicle, or gelatin are adequate.
·        Eating more food at a time of the day when one is less nauseous.
·        Informing one's health care provider before each treatment session when one develops persistent nausea.
·        Treating persistent vomiting immediately as this can cause dehydration.
·        Administering anti-nausea medication by a health care provider.

Persistent vomiting can result in the body losing large amounts of water and nutrients. If vomiting persists for more than three times a day and one does not drink enough fluids, it could lead to dehydration. This condition can cause serious complications if left untreated.

Signs of dehydration include:

·        Small amount of urine
·        Dark urine
·        Rapid heart rate
·        Headaches
·        Flushed, dry skin
·        Coated tongue
·        Irritability and confusion

Persistent vomiting may reduce the effectiveness of medications. If persistent vomiting continues, radiation treatments may be stopped temporarily. Fluids administered intravenously assist the body in regaining nutrients and electrolytes.



Painful swallowing, inadequate nutrition and hydration


RT for head and neck cancer can cause many side effects (see above) that may contribute to inadequate calorie, protein and liquid intake. These side effects include lack of appetite, taste changes or lack of taste, painful chewing and swallowing (odynophagia), dry mouth, early satiety, diarrhea, nausea and general disinterest in food and eating.

It is important to continue to eat during RT. Not using the muscle of masication weakens them. Furthermore, the scaring induced by radiation are reduced by chewing. 

Calorie and protein needs are increased in individuals treated for cancer. These increased needs, combined with the many possible side effects, may lead to weight loss and dehydration. It is very important to try and maintain one’s weight while receiving radiation therapy. It is advisable to obtain guidance from a dietitian how to maintain good nutrition and avoid weight loss and dehydration.

The basic principles to avoid weight loss and dehydration include:
  • Eating small frequent meals -- six to eight times per day.
  • Making every bite and sip count by eating calorie-dense foods and add calories to foods.
  • Limiting foods and beverages low in calories.
  • Eating a variety of foods -- include various colors, textures and flavors. Even though one needs a high calories and high protein diet, a balanced diet with foods from all food groups is essential. It is desirable to continue to include fruits and vegetables in addition to high calorie foods.
  • Carrying food at all times to eat while whenever possible.
  • Consuming liquid diet when swallowing becomes difficult. This can be made by using a blender or by ingesting bottles liquid commercial food (i.e., Ensure, Boost )

As side effects become worse, most patients must focus on liquids and soft foods to obtain adequate calories. Often liquids can provide more calories than solids.
Selecting the best food is individual depending on taste and ability to swallow, and is often a trial and error process.

If ingestion of adequate calories and liquid is inadequate surgical installation of a gastric tube may be necessary.  Placement of such a tube is also done prior to initiation of the radiation treatment to offer an alternative feeding route.


If dehydration and/or severe malnutrition occurs urgent admission to the hospital may be required to correct these.





Tiredness (fatigue)

Fatigue is one of the most common side effects of RT. RT can cause cumulative fatigue (fatigue that increases over time). It usually lasts from three to four  weeks after treatment stops, but can continue for up to two to three months.

Factors that contribute to fatigue are anemia, decrease food and liquid intake, medications, hypothyroidism, pain, stress, depression, and lack of sleep (insomnia) and rest.

Rest, energy conservation, and correcting the above contributing factors may ameliorate the fatigue. The following strategies can reduce fatigue and improved quality of life:
  • Assess and document the level of fatigue daily by using a diary or worksheet to monitor fatigue daily. The fatigue level assessment includes monitoring its severity (none, minor, moderate, advanced) over the times the day.
  • Perform regular daily tasks and activities especially during the time of day when feeling less fatigue. (based upon one’s diary or worksheet)
  • Maintain a daily exercise program.
  • Consult a social worker or psychologist.
  • Seek evaluation and treatment of underlying medical and psychological conditions (i.e., anemia, hypothyroidism). 








Other side effects

These include trismus and hearing (see below) problems.





LATE side EFFECTS 

Late side effects include permanent loss of saliva, osteoradionecrosis, ototoxicity, fibrosis, lymphedema, hypothyroidism, and damage to neck structures.

Permanent dry mouth (xerostomia)

Although the dry mouth (xerostomia) improves in most people with time, it can be long lasting and affects ones quality of life. 

Saliva has important function that can be adversely effected following RT. These include:

• Lubrication and moistening of food for swallowing
• Solubilizing material so it can be tasted
• Initiating digestion
• Preventing dental caries
• Maintaining oral and upper gastrointestinal pH
• Health of oral mucosa
• Preventing opportunistic infections: microfloral balance
• Speech
• Denture / prosthesis comfort and function
• Cleansing of mouth and clearing the esophagus

RT can lead to irreversible salivary glands cell damage. Serous salivary glands (parotid & submandibular) are most sensitive to radiation and RT often leads to marked changes in the quantity and quality of saliva after just a few doses of radiation, and alters the saliva's consistency from watery to more viscous. The exposure to 

Xerostomia can lead to:

• Opportunistic infections (mostly fungal)
• Denture stomatitis
• Alterations in pH 
• Alteration in secretory IgA
• Radiation caries (subgingival)


Aside from being bothersome to patients, including making it difficult to eat, swallowing and speak, there is greater risk of dental cavities and dental disease because saliva helps prevent dental disease. The maintenance of dentures can become problematic.

Patients who experience low function of their salivary gland and xerostomia must maintain excellent oral hygiene to minimize the risk of oral lesions. Periodontal disease can be accelerated and caries can become rampant unless preventive measures are instituted. Multiple preventive strategies should be considered.

Management and prevention include:

  • Palliative use of salivary substitues (gels; rinses)
  • Non pharmacological saliva stimulation
  • salivary stimulants
  • Prophylactic chlorhexidine
  • Antifungal therapy
Management of xerostomia includes salivary substitutes or artificial saliva (containing hyetellose, hyprolose, or carmellose) and frequent sips of water. This may lead to increase frequent of urination especially during the night, in men with prostatic hypertrophy and in those with small bladders. Other 

Non pharmacological substances that can stimulate salivary flow include acidic or bitter substances,  and to a lesser degree sweet substances such as sugar-free hard candy. Chewing sugarless gum can provide both gustatory and tactile also stimuli to salivary flow.

Available pharmacological medications include salivary stimulants (sialagogues), such as pilocarpine, amifostine, and cevimeline.  Pilocarpine is the only drug approved by the U.S. Food and Drug Administration for use as a sialogogue (5-mg tablets of pilocarpine hydrochloride) for radiation xerostomia. Preliminary data suggest that acupuncture and hyperbaric oxygen can provides benefit for patients with xerostomia who have some residual salivary gland function. 

Dietary change from dry, tough food to moist, softer one can greatly improve nutritional status and quality of life. Use of a humidification especially in the bedroom can also provide some relief.



Dry mouth after radiation





Pharyngoesophageal stenosis

Pharyngoesophageal stenosis is delayed complication of radiation. Pharyngoesophageal (PE) stenosis is an area of narrowing in the pharynx or esophagus. This stenosis can make it difficult to eat, particularly solid food. If the PE segment becomes completely closed off, the patient will be  unable to eat or drink anything by mouth and will need a feeding tube placed directly into the stomach (gastric tube). Treatment of this complication might include frequent placement of dilating catheters down the throat to stretch open the narrowed segment or surgical removal of the blocked segment with flap reconstruction. 

This is discussed in the swallowing difficulties section in the Eating, swallowing, smelling and basic skills in laryngectomees page. 





Swallow test radiographs of a high pharyngoesophageal stricture after laryngopharyngectomy



Dental caries


The risk of dental caries increases after RT of head and neck cancer due to a number of factors, including increase in the number of caries producing bacteria (Streptococcus mutans and Lactobacillus species) in the mouth, reduced concentrations of salivary antimicrobial proteins, and loss of mineralizing components.

Treatment strategies must be directed to each component of the caries process. Optimal oral hygiene must be maintained, and xerostomia should be managed whenever possible by using salivary substitutes or replacements. Caries resistance can be enhanced with the use of topical fluorides and/or remineralizing agents (high in calcium phosphate and fluoride). Efficacy of topical products may be enhanced by increased contact time on the teeth by application using dental trays. Those unable to effectively comply with use of fluoride trays should be instructed to use brush-on gels and rinses.


Topical fluorides or chlorhexidine rinses may lead to reduced levels of S. mutans but not Lactobacilli. Because of adverse drug interactions, fluoride and chlorhexidine dosing should be separated by several hours.






Osteoradionecrosis of the jaw

This is one potentially severe complication that can necessitate surgical intervention and reconstruction. Depending on the location and extent of the lesion, symptoms may include pain, bad breath, taste distortion (dysgeusia), “bad sensation”, numbness (anesthesia) , trismus, difficulty with mastication and speech, fistula formation, pathologic fractures, and local, spreading, or systemic infection. Patients who have received high-dose radiation to the head and neck are at lifelong risk for osteoradionecrosis , with an overall risk of approximately 15%.

The jaw bone (mandible) is the most frequently affected bone, especially in those treated for nasopharyngeal cancer. Maxillary involvement is rare because of the collateral blood circulation it receives.

Tooth extraction and dental disease in irradiated areas are major factors in the development of osteoradionecrosis.  In some cases it is necessary to remove teeth before RT if they will be in the area receiving radiation and are too decayed to preserve by filling or root canal. An unhealthy tooth can serve as a source of infection to the jawbone, that can be particularly difficult to treat after radiation. 


Repair of nonrestorable and diseased teeth prior to RT may reduce the risk of this complication. Oral disease should be eliminated pretreatment whenever possible. Dentition that exhibits poor prognosis and is within high-dose radiation fields should be extracted before RT begins. Ideally, at least 7 to 14 days should be allowed for healing before initiation of RT; some have suggested allowing up to 21 days.

Mild osteoradionecrosis can be conservatively treated with debridement, antibiotics, and occasionally ultrasound. Topical antibiotics (e.g., tetracycline) or antiseptics (e.g., chlorhexidine) may contribute to wound resolution. Wherever possible, exposed bone should be covered with mucosa and necrotic bone removed. Analgesics for pain control are often effective. When necrosis is extensive, radical resection, followed by microvascular reconstruction is often used.

Hyperbaric oxygen therapy (HBO) has been often used in patients at risk or those who develop osteoradionecrosis of the jaw. However, the available data are conflicting about the clinical benefit of HBO for prevention and therapy of osteoradionecrosis.


HBO has been reported to increase oxygenation of irradiated tissue, promote angiogenesis, and enhance osteoblast repopulation and fibroblast function. HBO is usually prescribed as 20 to 30 dives at 100% oxygen and 2 to 2.5 atmospheres of pressure. If surgery is needed, ten dives of postsurgical HBO are recommended. Unfortunately, HBO technology is not always accessible to patients who might otherwise benefit because of lack of available units and the high price of care.

Patients should remind their dentists about their RT prior to extraction or dental surgery. Osteonecrosis may be prevented by administration of a series of  HBO therapy before and after these procedures. This is recommended if the involved tooth is in an area that has been exposed to a high dose of radiation. Consulting the radiation oncologist who delivered the radiation treatment can be helpful in determining the extent of prior exposure.  

Dental prophylaxis can reduce the risk of osteoradionecrosis. Special fluoride treatments may help with dental problems along with brushing, flossing, and regular cleaning by a dental hygienist.



A home care dental lifelong routine is recommended:

1. Flossing each tooth and brushing with toothpaste after each meal.

2. Brushing the tongue with a tongue brush or a soft bristled toothbrush once a day.

3. Rinsing with a baking soda rinse daily. Baking soda helps neutralize the mouth.
One teaspoon added to 12 oz. of water. The baking soda rinse can be used throughout the day.

4. Using fluoride in fluoride carriers once a day. Fluoride carriers are custom made by a professional dentist. A 1.1% sodium fluoride or 0.4 % stannous fluoride is placed in the fluoride carriers and applied over the teeth for 10 minutes. One should not rinse, drink, or eat for 30 minutes after fluoride application. 








Necrosis in the oral cavity


Tissue necrosis (death of cells) and secondary infection of previously irradiated tissue is a serious complication for patients who have undergone RT for head and neck cancers. Acute effects damage typically involve the mucosa of the mouth. Chronic changes involving bone and mucosa are a result of the process of vascular inflammation and scarring that in turn result in tissue damage because of reduced blood and oxygen. Infection secondary to tissue injury and osteonecrosis confounds the process.

Soft tissue necrosis can occur in any mucosal surface in the mouth. Trauma and injury are often associated with nonhealing soft tissue necrotic lesions, though spontaneous lesions can also happen. Soft tissue necrosis begins as an ulcerative break in the mucosal surface and can spread in diameter and depth. Pain will generally become more prominent as soft tissue necrosis becomes worse. Secondary infection can also take place.





Upper palate necrosis



Fibrosis and trismus

High doses of radiation to the head and neck can result in fibrosis. This condition may be aggravated after head and neck surgery where the neck may develop a woody texture and have limited movement. Radiation-induced fibrosis can develop as a late effect of RT in skin and subcutaneous tissue,  muscles, or other organs, depending upon the treatment site. Radiation-induced fibrosis may cause both cosmetic and functional impairment, which can lead to  deterioration in the quality of life.

Late onset of fibrosis can also occur in the pharynx and esophagus, leading to stricture, and temporomandibular joint problems including mandibular dysfunctionPatients can be instructed in physical therapy interventions such as mandibular stretching exercises and the use of prosthetic aids designed to reduce the severity of fibrosis. It is important that these approaches be instituted before trismus develops. If clinically significant changes develop, several approaches can be considered, including stabilization of occlusion, and use of trigger-point injection and other pain management strategies, muscle relaxants, and tricyclic medications.


Fibrosis of the muscles of mastication can lead to the inability to open the mouth (trismus or lockjaw) which can progress over timeThe prevalence of trismus increases with increasing doses of radiation, and levels in excess of 60 Gy are more likely to cause trismus. Generally eating becomes more difficult but articulation is not affected. Radiation of the highly vascularized temporomandibular joint (TMJ) and muscles of mastication can often lead to trismus. Chronic trismus gradually leads to fibrosis. 

Trismus impedes proper oral care and treatment and may cause speech/swallowing deficits.  Forced opening of the mouth, jaw exercises and the use of a dynamic opening device (TherabiteTM) can be helpful. This device is increasingly used during radiation therapy as a prophylactic measure to prevent trismus. One of the benefits of the Therabite System is that it not only stretches the connective tissue that causes trismus, but also allows for proper mobilization of the temporomandibular joint, thus addressing a secondary cause of pain and tightness.





The Terabite system

Early treatment of trismus has the potential to prevent or minimize many of the consequences of this condition. As restriction becomes more severe and likely irreversible, the need for treatment becomes more urgent. 


A wide array of appliances are available for the treatment of trismusDevices range widely in cost. Many devices must be custom made for each patient, thus increasing the cost of treatment. Others, such as continuous passive motion devices are rented on a daily or weekly basis. These devices include the following:
  • Cages that fit over the head.
  • Heavy springs that fit between the teeth.
  • Screws that are placed between the central incisors.
  • Hydraulic bulbs placed between the teeth.
The most commonly used treatment is the use of tongue depressors. These are stacked, forced and held between the teeth in an attempt to push the mouth open over time.


Muscle tightness can often serve as trigger of headaches which may eventually lead to migraine. Treatment of muscle fibrosis can often alleviate and reduce the frequency of such headaches.

Exercise can reduce neck tightness and increases the range of neck motion. One needs to perform these exercises throughout life to maintain good neck mobility. This is especially the case if the stiffness is due to radiation. Receiving treatment by experienced physical therapies who can also break down the fibrosis is very helpful. The earlier the intervention, the better it is for the patient. A new treatment modality using external laser is also available. There are physical therapy experts in most communities who specialize in reducing swelling.




Neck exercises 

Fibrosis in the head and neck can become even more extensive in those who have had surgery or further radiation. Post radiation fibrosis can also involve the skin and subcutanous tissues, causing discomfort and lymphedema

Swallowing dysfunction, due to fibrosis often requires a change in diet, pharyngeal strengthening, or swallow retraining especially in those who have had surgery and/or chemotherapy. Swallowing exercises are increasingly used as a preventing measure.
Partial or total oropharyngeal stricture can occur in severe cases.



Swallowing exercises



Impaired wound healing 

Some laryngectomees may manifest wound healing impairment following surgery, especially in areas that have received RT. Some may develop a fistula ( an abnormal connection between the inside of the throat and the skin). Wounds that heal at a slower pace can be treated with antibiotics and dressing changes by specialists.





Skin changes


Patients with an initial severe dermatitis, may experience inflammatory waves that can occur weeks to years after radiation exposure. Late-stage or chronic radiation dermatitis typically presents months to years after radiation exposure. It is characterized by skin fibrosis, and slight color changes to the skin or mild swelling, atrophy, and widened blood vessels on the skin (telangiectasias).

Individuals generally lose hair in the region that received radiation.  







Permanent skin damage after radiation


Lymphedema

Obstruction of the cutaneous lymphatics results in lymphedema. Significant pharyngeal or laryngeal edema may interfere with breathing and may require temporary or long term tracheostomy. Lymphedema, strictures, and other dysfunctions predispose patients to aspiration and the need for a feeding tube. 

Read more about lymphedema at the "Lymphedema, neck swelling, pain and numbness after radiation and surgery"  page.



Hypothyroidism

RT is almost always associated with hypothyroidism. The incidence varies; it is dose-dependent and increases as time elapsed since the RT. Read more about it in the Low thyroid hormone (hypothyroidism) and its treatment section.





Neurological damage

RT to the neck can also affect the spinal cord, resulting in a self-limited transverse myelitis, known as "Lhermitte sign". The patient notes an electric shock-like sensation mostly felt with neck bending (flexion). This condition rarely progresses to a true transverse myelitis which is associated with Brown-Séquard syndrome (A loss of sensation and motor function caused by the lateral cutting of the spinal cord) and typically resolves within one year. 







RT may cause neuropathy due to nerve injury, although it may take several years for symptoms to appear. RT can also cause peripheral nervous system dysfunction resulting from external compressive fibrosis of soft tissues and reduced blood supply caused by fibrosis. Peripheral neuropathy (see Side effects of chemotherapy for head and neck cancer section) is a disorder that occurs when the nerves outside the brain and spinal cord, called the peripheral nervous system, are damaged. Depending on which nerves are affected, symptoms that include a change in sensation, especially in the hands and feet, (e.g., numbness, tingling, or pain); muscle weakness, (i.e., myopathy); and changes in organ function, resulting in constipation or dizziness can occur.


RT of head and neck cancer seemed to have adverse but insignificant effects on the cognitive functions of the patients.



Damage to the middle ear (ototoxicity) 

Radiation to the ear may result in serous otitis (otitis with effusion). This is a condition associated with accumulation of fluid in the middle ear and a temporary reduced hearing.  High doses of irradiation can cause and sensorineural hearing loss (damage to the inner ear, the auditory nerve, or the vestibular apparatus). Damage to the vestibular apparatus can damage it causing dizziness and vertigo.




Lightheadedness, dizziness and headaches

Lightheadedness, dizziness, and headaches can be one of a late side effects of radiation of the head and neck.
The perception of the body’s position is determined by the brain by integrating information from the middle ear, eyes, and body’s muscles and joints. Unfortunately, radiation almost always causes head neck muscles fibrosis and can also infrequently damage the middle ear. The perception of lightheadedness and dizziness after radiation treatment may be generated in some individuals by misinformation sent to the cerebellum (the part of the brain that controls the body’s balance) which is inaccurate and contradictory.
Dizziness and lightheadedness can be treated by physical therapy. This includes vestibular rehabilitation and exercises that stretches the fibrotic muscles, reduce neck stiffness, and increase the head and neck range of motion. One needs to perform these exercises throughout life to maintain good neck mobility.

Vestibular rehabilitation therapy is an exercise-based program designed to promote central nervous system compensation for inner ear deficits as well as misinformation sent to the brain from other parts of the body (eyes, skin, muscle, joints etc). 

Dizziness and lightheadedness can be caused by a variety of causes and condition and should be evaluated by one’s physician and medical experts in this condition (neurologist, otolaryngologists).

Muscle tightness and fibrosis can often serve as trigger of headaches which may eventually lead to migraine. Treatment of muscle fibrosis can often alleviate and reduce the frequency of such headaches.






Damage to neck structures

Neck edema and fibrosis are common after RT. Over time the edema may harden, leading to neck stiffness. Damage can also include carotid artery narrowing (stenosis) and stroke, carotid rupture, oropharyngo-cutaneous fistula (the last two are associated also with surgery), and carotid artery baroreceptors damage leading to permanent and proxysmal (sudden and recurrent) hypertension.  



Carotid artery stenosis and carotid artery rupture: The carotid arteries(CA) in the neck supply blood to the brain. Radiation to the neck has been linked to CA stenosis or narrowing, and rarely to CA rupture; representing a significant risk for head and neck cancer patients, including many laryngectomees. Screening ultrasound within the first year since completion of radiotherapy, followed by repeat ultrasounds every two to three years and whenever CA stenosis is suspected can lead to early diagnosis. Smoking increases the risk of CA stenosis. The cumulative risk of stroke after radiation treatment is 12%. CA disease can cause strokes and transient ischemic attack (TIA), though it does not always cause symptoms.  It is important to diagnose carotid stenosis or impending rupture early, before a stroke or severe bleeding has occurred.

Stenosis can be diagnosed by ultrasound as well as angiography. Treatment includes removal of the blockage (endarterectomy), placing a stent (a small device placed inside the artery to widens it) or a prosthetic carotid bypass grafting.

Evidence suggesting impending rupture can be obtained on physical and radiologic examinations. Endovascular stenting is also performed in patients with impending carotid artery rupture. 


Hypertension due to baroreceptors damage: Radiation to the head and neck can damage the baroreceptors located in the carotid artery. These baroreceptors help in regulating blood pressure by detecting the pressure of blood flowing through them, and sending messages to the central nervous system to increase or decrease the peripheral vascular resistance and cardiac output. Some individual treated with radiation develop labile or paroxysmal hypertension.

Labile hypertension. In this condition the blood pressure fluctuates far more than usual within the day. It can rapidly soar from low (e.g.120/80 mm Hg) to high (e.g. 170/105 mm Hg). In many instances these fluctuations are asymptomatic but may be associated with headaches. A relationship between blood pressure elevation and stress or emotional distress is usually present.

Paroxysmal hypertension. Patients exhibit sudden elevation of blood pressure (which can be greater than 200/110 mm Hg) associated with an abrupt onset of distressful physical symptoms, such as headache, chest pain, dizziness, nausea, palpitations, flushing, and sweating. Episodes can last from 10 minutes to several hours and may occur once every few months to once or twice daily. Between episodes, the blood pressure is normal or may be mildly elevated. Patients generally cannot identify obvious psychological factors that cause the paroxysms. Medical conditions that can also cause such blood pressure swings need to be excluded (e.g. pheochromocytoma).

Both of these conditions are serious and should be treated. Management can be difficult and should be done by experienced specialists.  Dr Samuel Mann from Weill-Cornell Medical Center in New York City is one of the leading experts in treating paroxysmal hypertension



Secondary cancers 

Even though radiation is used to treat cancer, paradoxically, years later it can rarely result in new local and systemic cancers appearing. The risk increases with high dosage and greater time since treatment. The secondary cancer can be quite different from the original and could include local cancers such as skin, mediastinal, oral and thyroid  cancer, and systemic cancers sich as  lymphomas, sarcomas and leukemias. It is important to be closely followed by one's physician as well as medical specialist (i.e. dermatologist) to detect secondary malignancies.


Skin cancer



More information about complications of RT can be found at the National Cancer Institute Web site.