Oral Mucositis Head and Neck

Prior to the initiation of chemoradiation, the pediatric patient should have an oral exam to determine what, if any, treatments are required to help prevent the development of mucositis and to ensure there is no interference with the radiation fi eld Otmani 2007 ; Barbería et al. 2008 ; Qutob et al. 2013a . If possible, cavities should be fi lled and fi xed appliances in the radiation fi eld removed 7–10 days before the initiation of ther- apy Barbería et al. 2008 . Families and patients should be advised in regard to the importance of maintaining oral hygiene including regular tooth and tongue brushing with a soft brush and fl uori- dated toothpaste in children ≥18 months and regular mouth washing Qutob et al. 2013 b . A standardized multidisciplinary hospital oral care protocol has been shown benefi cial, as well as bland rinses such as saline or sodium bicar- bonate; chlorhexidine has not been proven help- ful Keefe et al. 2007 ; Peterson et al. 2011 ; McGuire et al. 2013 . Nutritional status should be monitored and those at risk for malnutrition 5 weight loss from baseline should be started on total parenteral nutrition TPN if with orogastrointestinal mucositis or have percutane- ous endoscopic gastrostomy PEG placement if with a head and neck tumor Ladas et al. 2005 . Additionally, hydration status in patients with severe mucositis must be monitored with intrave- nous fl uids given if required. Multiple well-studied agents in adult patients receiving RT have not been shown benefi cial including cryotherapy i.e., ice chips, oral cool- ing, antimicrobial lozenges, misoprostol mouth- wash, amifostine, glutamine, and pilocarpine for the prevention of oral mucositis and oral sucral- fate for treatment of mucositis Keefe et al. 2007 ; Hensley et al. 2009 ; Gibson et al. 2013 ; Jensen et al. 2013 ; Nicolatou-Galitis et al. 2013 ; Peterson et al. 2013 ; Saunders et al. 2013 ; Yarom et al. 2013 . Therapies that have shown potential ben- efi t include prophylactic zinc, morphine mouth rinse, doxepin rinse, morphine patient-controlled analgesia PCA, use of midline radiation blocks with EBRT, not utilized with IMRT, benzyda- mine locally acting nonsteroidal anti- infl ammatory, low-level laser therapy LLLT, and palifermin keratinocyte growth factor-1 [KGF-1] Keefe et al. 2007 ; Hensley et al. 2009 ; Clarkson et al. 2010 ; Peterson et al. 2011 ; Gibson et al. 2013 ; Migliorati et al. 2013 ; Nicolatou- Galitis et al. 2013a ; Raber-Durlacher et al. 2013 ; Saunders et al. 2013 ; Yarom et al. 2013 . The strongest evidence in the adult literature exists for benzydamine, LLLT and palifermin. Of note, benzydamine has not been approved by the United States Food and Drug Administration. LLLT is recommended in adult patients receiv- ing HSCT with or without TBI and head and neck patients undergoing RT Peterson et al. 2011 ; Migliorati et al. 2013 . A pilot study of LLLT in children showed potential benefi t in the preven- tion of chemotherapy-induced mucositis Abramoff et al. 2008 . Palifermin, 60 mcgkg day, for 3 days prior to conditioning and 3 days posttransplantation for autologous and possibly allogeneic HSCT with TBI has shown benefi t in adult patients Keefe et al. 2007 ; Hensley et al. 2009 ; Raber- Durlacher et al. 2013 . Recent stud- ies in adult head and neck cancer patients are promising in reducing the severity and duration of mucositis symptoms although without improve- ment in event-free and overall survival Le et al. 2011 ; Henke et al. 2011 . Data on palifermin usage in the pediatric population are signifi cantly limited. Srinivasan et al. 2012 recently reported on a phase I dose-fi nding study in 12 children receiving myeloablative HSCT and found that 90 mcgkgday was tolerated with skin rash being the most common side effect; mucositis was seen in only 25 of the cohort but without a compara- tive control group. See Chap. 11 for a full discus- sion regarding oral mucositis and mouth care.

13.5.2 Dysgeusia

Patients undergoing radiation for head and neck tumors are at risk for altered taste due to direct radiation effect on the fungiform papillae and taste buds Otmani 2007 . Taste loss can precede mucositis with histologic signs of degeneration and atrophy occurring after 10 Gy, with taste loss increasing exponentially with higher cumulative RT doses, and with bitter and acid fl avors being most affected Kielbassa et al. 2006 . Pediatric patients may develop anorexia due to dysgeusia and therefore nutritional status must be moni- tored closely. Zinc and amifostine for prophy- laxis or treatment of dysgeusia in adult patients have not consistently shown benefi t and are not recommended Hovan et al. 2010 . Dysgeusia