Phase 3 trial of domiciliary humidification to mitigate acute mucosal toxicity during radiation therapy for head-and-neck cancer: first report of Trans Tasman Radiation Oncology Group (TROG) 07.03 RadioHUM study.

PURPOSE: To assess the impact of domicile-based humidification on symptom burden during radiation therapy (RT) for head-and-neck (H&N) cancer. METHODS AND MATERIALS: From June 2007 through June 2011, 210 patients with H&N cancer receiving RT were randomized to either a control arm or to receive humidification using the Fisher & Paykel Healthcare MR880 humidifier. Humidification commenced on day 1 of RT and continued until Common Terminology Criteria for Adverse Events (CTCAE), version 3.0, clinical mucositis (CMuc) grade ≤1 occurred. Forty-three patients (42%) met a defined benchmark for humidification compliance and contributed to per protocol (PP) analysis. Acute toxicities, hospitalizations, and feeding tube events were recorded prospectively. The McMaster University Head and Neck Radiotherapy Questionnaire (HNRQ) was used for patient-reported outcomes. The primary endpoint was area under the curve (AUC) for CMuc grade ≥2. RESULTS: There were no significant differences in AUC for CMuc ≥2 between the 2 arms. Humidification patients had significantly fewer days in hospital (P=.017). In compliant PP patients, the AUC for CTCAE functional mucositis score (FMuc) ≥2 was significantly reduced (P=.009), and the proportion who never required a feeding tube was significantly greater (P=.04). HNRQ PP analysis estimates also in the direction favoring humidification with less symptom severity, although differences at most time points did not reach significance. CONCLUSIONS: TROG 07.03 has provided efficacy signals consistent with a role for humidification in reducing symptom burden from mucositis, but the influence of humidification compliance on the results moderates recommendations regarding its practical utility.

Retrospective audit of the use of the Marx Protocol for prophylactic hyperbaric oxygen therapy in managing patients requiring dental extractions following radiotherapy to the head and neck.

OBJECTIVE: The study's primary objective was to review (for the years 2003 to 2006) the outcomes of using prophylactic hyperbaric oxygen therapy (HBOT) to prevent osteoradionecrosis (ORN) in a group of patients previously exposed to radiotherapy of the head and neck. A secondary objective was to evaluate any HBOT-associated vision changes. DESIGN: The study was a retrospective audit of the clinical outcomes of HBOT for the prevention of ORN following dental extractions in previously irradiated jaws. METHODS: Information was obtained from dental records held at Green Lane Clinical Centre (Auckland) and Oxygen Therapies Ltd (Quay Park Health, Auckland). Data included patient age, gender, site of tumour, radiation dose, time lapse between radiotherapy and tooth/teeth extracted, extraction procedures and the HBOTprotocol used. Follow-up data were obtained through a telephone interview using a standardised questionnaire. RESULTS: Of the 29 treated patients, 26 (90%) were available for follow-up. Of these, one failed to heal after dental extractions following the use of prophylactic HBOT, and only nine (34%) developed temporary vision changes. CONCLUSION: The outcome of this audit suggests that it is appropriate to use prophylactic HBOT in association with dental extractions in patients who have previously had radiotherapy to the head and neck. Acute vision changes following the 30th HBOT were transient.

Migrating foreign body in the tongue.

We present an unusual case where a foreign body entered and migrated through the tongue. In its path, it created a multitude of different symptoms including ecchymoses, small lumps, submental swelling and neuralgic-type pain. The foreign body had migrated from the left postero-lateral surface of the tongue, anteriorly along the lateral then dorsal surfaces of the tongue, until it self-exfoliated on the right anterior floor of the mouth. A brief literature review is also presented.

Home-based humidification for mucositis in patients undergoing radical radiotherapy: preliminary report.

INTRODUCTION: Oropharyngeal mucositis is a frequent, severe complication of local irradiation for tumours in the head and neck. We postulated that heated humidification of inspired air via a nasal interface may palliate symptoms of mucositis by reducing the discomfort associated with dry, sticky secretions. We sought to review the effect of home-based humidification on hospital admissions and the patient reported experience of that humidification. METHODS: This study was a retrospective review. A historical (control) group of patients did not receive home humidification at any stage (n = 55) and a study group (n = 53) received home humidification at or after the onset of grade 3 mucositis. A questionnaire was sent to study group patients to obtain information about their experience of using the humidifier at home. RESULTS: There were no demographic differences between the study and control groups, but the study group had significantly more advanced cancer (stage IV; p = .0307) and significantly higher total fractions and days treated (p < .01). Group comparison showed no difference in subsequent overall hospital admissions (p = .9269), but 7 of the 55 control group patients (12.7%) were admitted for supportive care within 2 months of completing radiotherapy, whereas none of the 53 patients who used home humidification were admitted after starting that use (p < .01). Almost all (95%) of the study group patients reported that humidification was of benefit, and 81% stated that it relieved mouth or throat pain. CONCLUSION: Humidification of inspired gas offers a simple, drug-free option for managing a number of the adverse mucosal effects of radiation and chemoradiation in head and neck cancer patients.

Studies on the relationship between electrogustometry and sour taste perception.

OBJECTIVE: Electrogustometry is used as a measurement of taste perception. The prevailing theory is that the anodal current delivered to the tongue mucosa stimulates the sour taste receptors, but this is not universally accepted. Our aim was to evaluate to what extent electrogustometry relates to an ability to detect sour taste--rather than sweet, salt, or bitter. METHODS: We compared automated electrogustometric thresholds with visual analogue scale (VAS) ratings of various tastant solutions in 114 subjects. The whole mouth, and each side of the tongue were tested separately. VAS scores from the strongest set of solutions, and the lowest electrogustometry thresholds for each location were used for statistics. RESULTS: There was a significant correlation between electrogustometry threshold and the whole mouth perception of the salt taste solution. Electrogustometry correlated significantly but weakly for all taste qualities when testing was confined to left and right oral tongue. The positive predictive values of electrogustometry were no better in relation to sour taste perception than to the other taste qualities. CONCLUSIONS: Our results do not support the theory that electrogustometry is mediated by sour taste receptors or even that it reflects the sour taste quality. We postulate that electrogustometry measures a function of taste perception, which is different from that induced by chemical stimuli.

Optimal nocturnal humidification for xerostomia.

BACKGROUND: Xerostomia is associated with a difficulty of maintaining oral hygeine and with symptoms of daytime oral discomfort and nocturnal sleep disturbance. METHODS: A pilot study was conducted to test the efficacy of a new method of delivering heated humidified air (37 degrees C, 100% water vapor saturated, at 20-25 L/min flow rate via specially designed nasal prongs) overnight for 2 weeks to 10 volunteers with Sjögrens Syndrome. Effectiveness was assessed by means of questionnaire, including the validated Xerostomia Inventory together with specific questions related to quality of sleep and oral comfort. RESULTS: Nine subjects completed the study. Daytime xerostomia symptoms were significantly reduced in participants (p = .004). Night-time oral comfort was significantly improved (p = .005) as was early morning mouth comfort (p = .008). Frequency of dry cough was also significantly reduced over the study period (p < .001). CONCLUSIONS: The body temperature, pressure saturated, delivery system was well tolerated and succeeded in alleviating the major oral and pharyngeal symptoms produced by xerostomia. These results have encouraged us to pursue further research in the application of this method of providing heated humidification.

Association of osteonecrosis of the jaws and bisphosphonate pharmacotherapy: dental implications.

Bisphosphonates are drugs of choice in the management of a variety of bone disorders including osteoporosis, Paget's disease and bone cancer. Recently there have been increasing reports of a possible relationship between bisphosphonate therapy and osteonecrosis of the jaws. Osteonecrosis may occur following extractions or dental surgery and, in some cases, may appear spontaneously. Because of the potentially serious nature of these complications and the failure of exposed bone to heal, dentists must be aware of recommended precautions for the management of patients taking bisphosphonate medication.

Patterns of sensory recovery in the lingual nerve after surgical trauma.

OBJECTIVE: To examine the pattern of sensory recovery in the lingual nerve following injury, with an emphasis on qualitative changes. METHODS: Using data from one patient with prolonged dysaesthesia after surgical trauma to the lingual nerve, we correlated changes in perceived sensory function during recovery with results from qualitative and quantitative taste tests, and patient-reported quality-of-life measures. RESULTS: Recovery of quantitative taste testing as measured by automated electrogustometry, and qualitative whole of mouth taste testing, preceded perceptual recovery of taste. On the other hand, taste acuity as measured by regional qualitative taste testing tended to lag behind perceptual recovery. The pattern of recovery in the different qualitative taste sensations suggests variation in sensitivity of the nerve fibres responsible for carrying taste sensation, with the fibres relating to bitter and sour taste being the last to recover. CONCLUSION: To our knowledge, taking into account the limitations of this study, this picture of differential recovery of taste function in the lingual nerve has not been previously reported.

On completion of curative treatment of head and neck cancer: why follow up?

PURPOSE OF REVIEW: To review the rationale and evidence for maintaining clinical contact with patients who have received curative treatment for head and neck cancer. RECENT FINDINGS: Very little work has been published in the scientific literature on this subject. Most information regarding follow-up care has focused on survival outcomes rather than the rationale for, or cost-effectiveness of, routine surveillance of head and neck cancer patients. Perhaps this is because there seems to be very little controversy. A large survey of surgeons has revealed a diminishing frequency of follow-up with time after treatment, although with variance in respect of specific investigations such as bone scans. Notwithstanding the current paper identifies areas that need to be considered when decisions are made regarding the scheduling of follow-up appointments SUMMARY: Regular post-treatment surveillance is important for patients' general well-being and for the management of late complications of treatment in long-term survivors. It is unclear whether surveillance provides any survival advantage; this information requires the sort of clinical trial that has been conducted for tumors at other sites, such as colorectal cancer and breast cancer, but not head and neck cancers.

Treatment of parotid ductal stenosis and concomitant resolution of autonomic symptomatology.

Salivary retention and recurrent sialadenitis as a result of ductal stenosis is an uncommon condition that presents difficult management problems. Ductal dilation with small angioplasty balloons is recognized to be of low morbidity and can eliminate the possible need for surgical intervention. This case report is interesting in that the successful treatment of parotid duct stenosis was accompanied by the resolution of a spectrum of autonomic symptoms that had seriously compromised the patient's quality of life.

Xerostomia and you.

The aims of management of patients with xerostomia include the provision of a definitive aetiology and diagnosis, and a prognosis for the salivary dysfunction. Salivary flow assessment and function testing, other relevant laboratory tests, and even referrals should be performed as necessary. Management of the condition depends on diagnosis and severity, and includes enhancement of salivary flow, oral lubrication, control of soft-tissue infections and discomfort, and prevention of dental caries.

A clinical trial of the anticaries efficacy of casein derivatives complexed with calcium phosphate in patients with salivary gland dysfunction.

OBJECTIVE: The purpose of this study was to compare the caries preventive efficacy of a mouthrinse solution containing casein derivatives coupled with calcium phosphate (CD-CP) with that of a 0.05% sodium fluoride mouthrinse among individuals with dry mouth. STUDY DESIGN: A randomized control trial design was used. Participants included individuals who had had radiotherapy for head and neck cancer (n = 82) and others with Sjögren's syndrome (n = 56). Baseline data collection was followed by reexamination 12 months later. Posterior bite-wing radiographs were taken on both occasions. RESULTS: A total of 124 participants, 61 (49.2%) in the sodium fluoride group and 63 (50.8%) in the CD-CP group, completed the 12-month examination. The baseline characteristics of the 2 groups did not differ. Coronal caries incidence was higher in the sodium fluoride group than in the CD-CP group (34.4% and 27%, respectively), but the difference was not statistically significant. Similarly, the small difference in coronal caries increment between the 2 groups was not statistically significant (0.4 and 0.3 surfaces, respectively). There was insufficient root surface caries experience between the 2 groups observed for differences to be examined. Proportionately more of the CD-CP group lost 1 or more teeth, and the mean number of tooth loss was higher. The participants with the highest incidence and increment were those with Sjögren's syndrome in the CD-CP group. Some of that difference was accounted for by differences in baseline caries status. CONCLUSION: It appears that CD-CP preparations hold promise as caries preventive agents for individuals with dry mouth, although confirmation of this study's findings in other settings is warranted before a definitive conclusion can be reached.