Unfortunately radiation treatment causes short and long term side effects. RD can damage blood vessels that nourish muscles, nerves, and bones that can result in a progressive condition called "radiation fibrosis syndrome", which causes a variety of complications affecting nerve, muscles, and bones. Some side effects (e.g., nausea, mucositis) are generally more pronounced in those who receive radiation in combination with chemotherapy.
RT can be administered in several ways:
- 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.
- 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.
- 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.
- Reirradiation for recurrent cancer: Radiation is administered for recurrence of head and neck cancer in a previously irradiated area. Repeat irradiation with systemic therapy is a potentially curative option. Long-term disease-free survival has been observed, albeit with the risk of significant, possibly life threatening, late complications.
- Brachytherapy (implanting radioactive source close to the cancer),
- intra-operative radiation therapy,
- Neutron beam radiation therapy ( using higher energy neutron beams),
- Proton beam radiation therapy ( a more precise radiation),
- Radiosurgery ( using Cyberknife®, Gamma Knife® and LINAC),
- TomoTherapy (combines precise 3-D imaging from CT scanning with highly targeted radiation beams delivered precisely to the cancer while minimizing surrounding tissues damage),
- Conformal radiation therapy (radiation beams are shaped to match the tumor’s 3 dimensional picture based on CT and/or MRI scans)
- Radioactive iodine (for thyroid cancer)
A lecture about life challenges after laryngectomy that includes discussion of late side effects of radiation can be viewed on YouTube.
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.
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.
- Avoiding frequent shampooing and using a mild shampoo (such as baby shampoo) without any perfumes.
- Washing the scalp with warm water only and avoiding rubbing and scratching.
- Drying the washed area by patting with a dry soft towel.
- Avoiding excessively combing or brushing the hair.
- Avoiding the use of hair spray, oils or creams.
- Avoiding the use of heat sources (including hair dryers, rollers or curling irons).
- Avoiding perming or coloring the hair until about 4 weeks after RT is complete.
- Protecting the head from the sun, cold and wind by wearing a head covering (i.e., cap, scarf, and cotton hat).
Dry mouth (xerostomia)
Soft and moistened foods; thick soups, mashed potatoes, puddings, and milkshakes are easier to eat and swallow.
For more information see Xerostomia at the Chronic Side Effects section below.
Acceleration of periodontal disease
- Brushing teeth (if soreness of oral mucosa and trismus are present, a small ultra-soft toothbrush can be used).
- Using a fluoridated toothpaste when brushing
toothpaste makes your mouth sore, brush with a solution of 1 teaspoon of salt
mixed with 4 cups of water.
- 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.)
Alterations in taste (dysgeusia)
The sense of taste may also be affected by impaired smelling. These side effects can cause food aversion (dislike) further decrease food intake and contribute to weight loss.
- 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 (i.e., frozen yogurt, ice cream), 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.
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 or thrush) infections are possible. Control of the pain (using opiates or gabapentin) may be needed.
Thrush prevention is described in the Preventive Care section.
• Avoid using toothpicks which can cut your mouth.
• If your gums are sore, only wear your dentures while eating.
(Use 1 teaspoon of salt and 1 teaspoon of baking soda in 1 quart of water.)
• Clean your mouth with a gauze square wrapped around wrapped around your finger or a popsicle stick dipped in baking soda/salt rinse
• Clean your teeth and mouth after meals and before applying topical coating agents or medication for mouth sores.
• Use extra soft toothbrushes and soften them further by putting them in warm water. Change brushes often.
• If flavored toothpastes irritate your mouth, use plain baking soda.
- Regular rinsing with salt and soda solution, and guaifenesin in the early-phase of mucositis.
- Later-phase thickened or larger-volume mucus may respond to combination narcotics and anticholinergic drying agents present in some cough preparations.
- Treatment with mucus drying medications include: an antihistamine, and scopolamine transdermal patch.
- Elevation of the head of the patient’s bed 30° can reduce edema and protect the airway.
- A cool mist vaporizer may help lubrication and expectoration.
- Lorazepam can help prevent repeated gagging and nausea.
- Suction machine can be useful, especially after surgery when effective gargle is difficult.
· Eating small, frequent meals throughout the day instead of three large meals. Nausea is often worse if your stomach is empty.
· Eating and drink 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.
· Avoiding odors, perfumes, incense, and other strong smells.
· 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.
· Having someone cook, as cooking may worsen nausea.
· 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.
· Wearing loose-fitted clothing can prevent irritation of ones throat or stomach and reduce nausea.
· Small amount of urine
· Dark urine
· Rapid heart rate
· Flushed, dry skin
· Coated tongue
· Irritability and confusion
Difficult swallowing (dysphagia), inadequate nutrition and hydration
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.
- 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 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)
- Consuming cold and/or frozen food (including ice cream) may be easier and can also reduce oral pain.
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)
- Drink plenty of fluids and eat as nutritious as possible.
- Avoid caffeine which dries the mouth and can disrupt sleep.
- Maintain a daily exercise program.
- Allow plenty of time for sleep each night.
- Consult a social worker or psychologist, and seek support from family and friends.
- Seek evaluation and treatment of underlying medical and psychological conditions (i.e., anemia, hypothyroidism).
- Try to maintain a positive outlook.
- Trouble concentrating, focusing, or paying attention
- Mental fog or disorientation
- Difficulty with spatial orientation
- Memory loss or difficulty remembering things, especially names, dates, or phone numbers
- Problems with understanding
- Difficulties with judgment and reasoning
- Impaired math, organizational, and language skills. This includes tasks such as not being able to organize thoughts, find the right word, or balance a checkbook.
- Problems multitasking
- Processing information slower
- Behavioral and emotional changes, such as irrational behavior, mood swings, inappropriate anger or crying, and socially inappropriate behavior
- Severe confusion
- Medications, including stimulants, cognition-enhancing drugs, antidepressants, and drugs that block the actions of narcotics
- Occupational therapy and vocational rehabilitation, to help people with the activities of daily living and job-related skills
- Cognitive rehabilitation and cognitive training, to help patients improve their cognitive skills and find ways to cope with these issues.
- Keeping a checklist of daily reminders
- Doing one task at a time without distractions
- Carry around a small pad and a pen or pencil to easily write down notes and reminders. Or, download a note-making app on your smartphone and tablet.
- Using a calendar and a notebook with questions and a to-do list.
- Letting friends, family, work place, and health-care team about one’s memory loss
- Getting counseling and other resources to improve memory.
- Placing sticky notes around the house and workplace to remind about important tasks.
- Use word play, such as rhyming, to help you remember things.
- Get plenty of rest.
- Keeping physically activity to increase mental alertness.
- Conduct brain-strengthening mental activities (i.e., hobbies, solving puzzles, and painting)
- Prepare for the next day by setting out the things you will need the night before.
- Color code or label certain cabinets or drawers where you store things around your home.
- Eliminating clutter, and placing things back in the same place
Other side effects
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
• 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 such as thrush)
• 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 substitutes (gels; rinses)
- Non pharmacological saliva stimulation
- Salivary stimulants
- Prophylactic chlorhexidine
- Anti-fungal therapy
- Thrush prevention (see Preventive care section)
- Drinking plenty of liquids
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 hyperbaric oxygen can provides benefit for patients with xerostomia who have some residual salivary gland function. Acupuncture is widely used in Europe for a dry mouth in people having radiotherapy for head and neck cancers. It is also used for pain and dry mouth after neck surgery and a dry mouth in people with advanced cancer. Several trials seem to suggest that acupuncture can help.
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.
Osteoradionecrosis of the jaw
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.
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.
One teaspoon added to 12 oz. of water. The baking soda rinse can be used throughout the day.
Necrosis in the oral cavity
Fibrosis and trismus
Late onset of fibrosis can also occur in the pharynx and esophagus, leading to stricture, and temporomandibular joint problems including mandibular dysfunction. Patients 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 time. The 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 (Therabite TM) 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.
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.
- 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.
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.
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.
A new treatment modality that reduces lymphedema, fibrosis and neck muscle stiffness using external laser is also available. This method uses a low energy laser beam administered by an experienced physical therapist. The laser beam penetrates into the tissues where it is absorbed by cells and changes their metabolic processes. The beam is generated by the LTU-904 Portable Laser Therapeutic Unit.
Partial or total oropharyngeal stricture can occur in severe cases.
Some patients 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.
Read more about lymphedema at the "Lymphedema, neck swelling, pain and numbness after radiation and surgery" page.
Acupuncture treatment may improve peripheral neuropathy.
Damage to the peripheral and autonomic nervous system can lead to dizziness when standing up from sitting up from sitting or lying down due to postural hypotension.
Cataract: Radiation can cause cataract usually in the posterior sub-capsular and sometimes in the cortical areas of the lens. It is important to note that many other confounding risk factors contribute to lens opacities, for example, age, diabetes mellitus, corticosteroids use, smoking or ultraviolet radiation exposure. Although much work has been carried out in this area, the exact mechanisms of radiation cataractogenesis are still not fully understood.
Radiation retinopathy: This complication following exposure to any source of radiation. It is especially common after radiation treatment for nasopharyngeal, paranasal sinus or orbital tumors. Higher total radiation dose has been shown to increase the risk of radiation retinopathy. The incidence of retinopathy increases at doses above 45 Gy.
Damage to the ear (ototoxicity) and hearing loss
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. This condition and conductive deafness are reversible over time. High doses of radiation can cause and sensorineural hearing loss (damage to the inner ear, the auditory nerve, or the vestibular apparatus).This condition is not reversible. Damage to the vestibular apparatus can damage it causing dizziness and vertigo.
Lightheadedness, dizziness and headaches
Damage to neck structures
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 widen it) or a prosthetic carotid bypass grafting.
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.
More information about complications of RT can be found at the National Cancer Institute Web site.