Dysgeusia Head and Neck
13.5.3 Xerostomia
A reduction in salivary function is most com- monly seen with head and neck RT and has also been noted post-HSCT with and without TBI Jensen et al. 2010a . In a systematic review by Jensen et al. 2010a , xerostomia prevalence remained 70 from the time of development to 2 years post conventional RT. Pediatric data are limited; it appears the risk of chronic xerostomia is low although has been described after both head and neck RT and TBI conditioning with HSCT Jensen et al. 2010a . Xerostomia risk is dose related, with minimal risk at mean doses of 10–15 Gy to the parotid gland and a decrease in glandular function 75 with mean doses 40 Gy Deasy et al. 2010 . Xerostomia risk has been reported to be signifi cantly reduced with sparing of one parotid or even, potentially, one submandibular gland, with IMRT although in the review by Jensen et al. 2010a prevalence of xero- stomia after IMRT was similar to that noted with conventional RT at all time points due to variation in technique and ability to spare the parotid and submandibular glands Saarilahti et al. 2006 . Multiple potential management strategies exist in the adult literature and have most recently been systematically reviewed by Jensen et al. 2010b as part of MASCCISOO. Recommendations include the use of IMRT with salivary gland spar- ing when oncologically feasible, muscarinic ago- nist stimulation pilocarpine over newer and less well-studied agents cevimeline and bethanechol after RT completion but not during RT, oral mucosal lubricantssalivary substitutes, salivary gland transfer in strictly selected cases, and acu- puncture to stimulate salivary gland secretion Jensen et al. 2010b . Agents that are not recom- mended include amifostine as opposed to the 2008 ASCO guidelines by Hensley et al. [ 2009 ], gustatory and masticatory stimulation sugar-free lozenges, acidic candy, chewing gum, and hyper- baric oxygen HBO therapy Jensen et al. 2010b . Pediatric data on such interventions are extremely limited.13.5.4 Ear Complications
Depending on the extent of the radiation fi eld and cumulative dose, patients have been reported to acutely develop serous otitis media and externa in addition to radiation dermatitis of the external ear and ear canal. Otitis media occurs in conjunc- tion with mucosal edema leading to tinnitus and high-frequency hearing loss in rare cases requir- ing myringotomy tubes Chopra and Bogart 2009 . Excessive earwax buildup has also been noted after the completion of RT Chopra and Bogart 2009 . Patients may require deconges- tants and oral antibiotics for serous otitis media, otic antibiotic drops for otitis externa, and carb- amide peroxide ear drops for wax buildup. Corticosteroid drops can be utilized for radiation dermatitis in the external ear canal. Audiometric testing should be done on clinically symptomatic patients. Sensorineural deafness, a late effect of RT, is dose dependent and permanent, occurring at 50 Gy and synergistic with platinum chemo- therapy Huang et al. 2002 . Tissue protection with IMRT has signifi cantly reduced the risk of this complication Huang et al. 2002 .13.5.5 Laryngeal Complications
Radiation to the oropharynx can lead to laryn- geal edema as well as reduced laryngeal closure resulting in aspiration, especially at doses 50 Gy although risk has been decreased with the use of IMRT Chopra and Bogart 2009 ; Rancati et al. 2010 . Patients should be moni- tored closely and treated symptomatically with antitussives, pain medication, and steroids to reduce edema. RT treatment interruption may be necessary depending on the underlying cause of the edema and the severity. ENT evaluation and hospitalization may be required for more com- plicated cases. Adolescent patients should be advised against smoking during and after RT as it has been reported to lead to persistent hoarse- ness in adults with glottic tumors Chopra and Bogart 2009 .13.6 Gastrointestinal
Complications The stomach and small bowel are often inciden- tally irradiated when treating upper GI tract, infe- rior lung, retroperitoneal, and pelvic tumors. Acute gastrointestinal RT-induced side effects include nausea, vomiting, and anorexia immedi- ately after treatment as well as dysphagia, esopha- gitis, dyspepsia, ulceration, bleeding, enteritis GI mucositis manifesting as cramping, diarrhea, and malabsorption, and proctitis within the fi rst few weeks of therapy Kavanagh et al. 2010 ; Michalski et al. 2010 . Late small bowel obstruction due to RT-induced fi brosis and secondary adhesions as well as chronic dyspepsia, ulceration, diarrhea, fi stula, perforation, bleeding, strictures, and chronic radiation proctitis must be considered but are beyond the scope of this chapter. RT dose- volume constraints for the stomach and small bowel are diffi cult to determine as partial volume irradiation is usually undertaken; ≥45 Gy for the whole stomach and for partial small bowel 195 mL are thresholds that have been published for adult patients Kavanagh et al. 2010 .13.6.1 Dysphagia and Esophagitis
Radiation to the oropharynx can lead to pharyn- geal edema as well as dysphagia while RT to the thorax can lead to esophagitis. Adult patients receiving chemoradiation or hyperfractionated RT have been noted to have a 15–25 risk of severe acute esophagitis with symptoms peaking 4–8 weeks after the commencement of RT Werner-Wasik et al. 2010 . Of note, esophageal infections such as oroesophageal OE candidiasis or herpes simplex esophagitis can lead to similar symptoms and must be ruled out; additionally, preexisting gastroesophageal refl ux GER can worsen esophagitis and should be treated Werner- Wasik et al. 2010 . If infection is a concern, patients should undergo diagnostic endoscopy unless the level of symptoms contradicts such a procedure; in such cases empiric therapy e.g., fl u- conazole for OE candidiasis may be required. Radiation doses 40–50 Gy in adults have been shown to correlate with increased risk of acute esophagitis Werner-Wasik et al. 2010 . Data in the pediatric population are lacking. Amifostine has shown some potential benefi t in non-small cell lung cancer patients, but the reports are inconsistent, and recommendation for its use is also not uniform Keefe et al. 2007 ; Hensley et al. 2009 ; Peterson et al. 2011 . No other agent has been well studied; oral sucralfate has been utilized, but data are confl icting, and it is not recommended in consensus guidelines for RT-induced esophagitis Bradley and Movsas 2004 . General treatment strategies include treat- ment of underlying GER with an H 2 blocker or proton pump inhibitor, ruling out and treating infectious etiologies for esophagitis, and prescrib- ing viscous lidocaine and analgesics for pain. Promotility agents such as metoclopramide can also be tried. Patients should be advised to avoid acidic and spicy foods as well as alcohol and cof- fee. Nutritional status should be closely moni- tored, and patients at risk for malnutrition should receive oral supplementation, nasogastric feeds, PEG placement if with a head and neck tumor, or TPN, depending on the underlying clinical sit- uation; see Chap. 12 for more details. Pediatric patients with a history of chemoradiation- induced esophagitis are at risk for esophageal stricture and should be monitored for this potential late compli- cation Mahboubi and Silber 1997 .13.6.2 Nausea, Vomiting and Anorexia
Radiation-induced nausea and vomiting RINV has been reported to occur in 50–80 of adult patients dependent on the radiation fi eld, RT dose,Parts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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