Week 12 Flashcards

RADTH 301 - Principles of Radiation Therapy

what are the 8 components of a neurologic assessment

• balance

• coordination

• cranial nerves

• gait

• mental status

• motor function

• sensory function

• speech

What are the common signs of increased ICP

headches (often worse in morning or with straining), N+V (suddent or projectile), changes in consciousness, visual changes (blurred vision/double vision), papilledema (optic disc swelling seen on eye exam), seizures (in some cases)

what is cushing’s triad of late stage ICP (and potential brain herniation)

• increased systolic blood pressure

• bradycardia

• irregular respirations

What are key positioning strategies to help reduce ICP?

Elevate head of bed ~30° and keep head/neck midline to promote venous drainage.

What actions should be avoided in patients with increased ICP?

Avoid anything that increases intracranial pressure such as straining, coughing, Valsalva, or neck flexion/rotation.

What are common medical treatments used to reduce ICP?

Steroids (e.g., dexamethasone), osmotic therapy (mannitol/hypertonic saline), anticonvulsants, and oxygen/supportive care.

What is the overall management focus for increased ICP?

Reduce intracranial pressure, monitor neurological status closely, and treat the underlying cause (e.g., tumor, bleed, obstruction).

Is it easier to do oral assessments for H&N patients or question them about concerns

easier to perform an oral assessment

are MRTs allowed to do swallowing assessments and palpate near the oral cavity?

no, we do visual observation only

Voice auditory assessment

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

converse with patient

• 1 = normal

• 2 = deeper or raspy

• 3 = difficulty talking or painful

swallow observation assessment

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

ask patient to swallow

• 1 = normal

• 2 = pain on swallowing

• 3 = unable to swallow

lip visual observation

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

observe and feel tissue

• 1 = normal, pink and moist

• 2 = dry or cracked

• 3 = ulcerated or bleeding

tongue visual observation

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

feel and observe appearance of tissue

• 1 = pink, moist and papilae present

• 2 = coated or loss of papilae with a shiny appearance with or without redness

• 3 = blistered or cracked

saliva tongue blade observation

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

insert blade into mouth, touching center of the tongue and floor of the mouth

• 1 = watery

• 2 = thick and ropy

• 3 = absent

mucous membrane visual observation

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

observe appearance of tissue

• 1 = pink and moist

• 2 = reddended or coated (increased whiteness) without ulcerations

• 3 = ulcerations with or without bleeding

gingiva tongue blade or visual observation

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

gently press ttisue with tip of blade

• 1 = pink, stippled, and firm

• 2 = edematous with or without redness

• 3 = spontaneous bleeding or bleeding with pressure

teeth or denture area visual observation

• method of measurement

• Rating 1 description

• Rating 2 description

• Rating 3 description

observe appearance of teeth or denture bearing area

• 1 = clean and no debris

• 2 = plaque or debris in localized areas

• 3 = plaque or debris generalized along gum line

what is amifostine used for? why is it contraversial

amifostine is a cytoprotectant agent used to reduce xerostomia caused by RT

• it is contraversial because it is not fully understood if it reduces treatment efficacy or not

alopecia dose onset

20 Gy - severity and grade of alopecia is based on the nature of hair loss

temporary alopecia

May occur with doses as low as 5 Gy. Hair growth typically begins 3-6 months after treatment completion

patchy alopecia

Common in scalp areas receiving ~45 Gy during partial brain RT

permanent alopecia

doses of 30 Gy can result in permanent vertex alopecia for whole brain and 45Gy for partial brain may produce permanent hair loss

alopecia pathophysiology

Alopecia is caused by radiation damaging hair follicles during their rapid growth and proliferation phase.

• Radiation causes the premature conversion of hair follicles from the active phase to the resting phase, which results in hair being shed at an increased rate

alopecia - gentle scalp hygiene

• intervention

• MoA

wash hair gently with mild shampoo 1-2x per week

• minimize mechanical and chemical irritation to the sensitive scalp and follicles

alopecia - minimize physical trauma

• intervention

• MoA

use a soft head bristle brush

• diminish follicular injury that could occur with harsher grooming

alopecia - scalp lubrication

• intervention

• MoA

apply water soluble lubricants to scalp

• help manage dryness and maintain skin integrity during treatment course

alopecia - UV protection and chemical avoidance

• intervention

• MoA

avoid sun exposure, hair dyes, and permanent hair treatments

• by applying SPF 30+ sunscreen, wearing hats, and avoiding hair dyes, further damage to follicles is reduced

alopecia - wigs, hair pieces, surgical reconstruction

• MoA

addresses the psychological and aesthetic impact of hair loss

In a patient with alopecia, why are focal assessments to the scalp / head done, and what are some symptoms that should be watched out for

ocal assessment of the scalp to monitor for complications that could worsen the patient's condition, such as dry scalp, radiation dermatitis, hyperpigmentation, and delayed wound healing (particularly at craniotomy or burr hole sites).

• Also check skin folds, such as the area behind the auricles, for moist desquamation

Dose onset of xerostomia

20-30 Gy

Grade 1 xerostomia

Symptomatic (dry or thick saliva) without significant dietary alterations; unstimulated saliva flow > 0.2 ml/min

grade 2 xerostomia

requires oral intake alterations (e.g., copious water, other lubricants, or a diet limited to purees and soft foods); unstimulated saliva 0.1 to 0.2 ml/min

grade 3 xerostomia

Inability to adequately aliment orally; tube feeding or total parenteral nutrition (TPN) indicated; unstimulated saliva < 0.1 ml/min

Grade 4 & 5 xerostomia

N/A

Pathophysiology of xerostomia

Radiation therapy causes salivary gland dysfunction by directly damaging secretory cells and damaging membrane components that are essential for signalling.

• For every 1 Gy of radiation to a gland causes 5% reduction in functional output

Xerostomia - Amifostine

• intervention

• MoA

preventive cytoprotectant agent administered before RT

• reduces incidence and severity of xerostomia

Xerostomia - lubrication

• interventions

• MoA

adequate hydration (2-3 L), cool humidifer, vaporizers, natural lubricants (milk, butter, vegetable oil), saliva substitudes and gels

• Provide artificial and accessible lubricants to reduce oral dryness

xerostomia - sugar free candy/gum (containing xylitol)

• MoA

the act of mastication and the presence of flavor stimulate any remaining residual salivary flow

xerostomia - food choice

• intervention

• MoA

Eating foods that require vigorous chewing or consuming papaya

• Chewing stimulates saliva production, while papaya specifically helps reduce the thickness of ropey saliva

xerostomia - pilocarpine (salagen) or cevimeline

• MoA

Chemically stimulate gland production

oral mucositis dose onset

20-30 Gy

Grade 1 Mucositis

Asymptomatic or mild symptoms; no intervention indicated

Grade 2 Mucositis

Moderate pain or an ulcer that does not interfere with oral intake; a modified diet is required. Inhibits instrumental ADLs

Grade 3 mucositis

Severe pain that interferes with oral intake. Inhibits self-cleaning ADLs

Grade 4 mucositis

Life-threatening consequences; urgent intervention indicated

Grade 5 mucositis

death

Inflammatory phase of mucositis

Lethal and non-lethal DNA damage occurs. Injured tissues release ROS causing the release of cytokines which increase inflammation

epithelial phase of mucositis

Cytotoxic and apoptotic effects on basal cells.

Ulcerative/Bacteriologic Phase of mucositis

Breakdown exposes nerve endings causing pain. Secondary infections may occur

Healing Phase of mucositis

Remaining basal epithelial cells migrate and differentiate to restore mucosal lining

mucositis - cryotherapy

• intervention

• MoA

holding ice chips in mouth 5 mins prior, during, and 30 mins after 5-FU infusions

• decreases the incidence and severity of mucositis

mucositis - Benzydamine Hydrochloride

• intervention

• MoA

This anti-inflammatory mouth rinse is recommended for patients receiving moderate doses of radiation

• prevents or relieves pain and inflammation

mucositis - bland oral rinses

• intervention

• MoA

Frequent rinsing (minimum of four times daily) with salt and sodium bicarbonate mixtures.

• helps keep the mouth moist, clean, and free of debris

mucositis - lidocaine and morphine

• MoA

provide temporary relief for mild (Grade 1) mucositis by numbing painful mucosal surfaces

mucositis - coating agents

• intervention

• MoA

milk of magnesia, magnesium

• coat mucosal surfaces providing a physical barrier for exposed nerve endings

mucositis - fluid intake

• intervention

• MoA

maintain daily intake of 8-12 cups of water

• adequate fluid intake is necessary to keep oral mucosa moist and prevent dehydration

mucositis - texture modification

• intervention

• MoA

As symptoms develop, patients should switch to soft, moist, and bland foods while adding sauces or gravies

• sauces and gravies help moisten and thin food for easier swallowing

mucositis - avoidance of irritants

• intervention

avoid spicy, high-acid, dry, coarse, or extremely hot foods, as well as alcohol and tobacco to reduce pain and injury

mucositis - nutritional support for grade 3-4 mucositis

• intervention

If oral intake is severely limited, enteral nutrition (tube feeding) or IV hydration may be necessary to maintain nutritional status until symptoms resolve

What is candidiasis and what is it’s onset promoted by

Candidiasis (thrush) is a fungal yeast infection that is promoted by dry mouth caused by radiation damage to salivary glands

early grade thrush

Inflamed mucous membranes, white cottage cheeselike patches on tongue or oral mucosa

urgent grade thrush

Requires medical attention within 24 hours. Patient has white patches on oral mucosa or cannot tolerate daily fluid intake

emergent thrush

Requires urgent medical attention. A fever ≥ 38°C, uncontrolled pain, or if the patient is unable to eat or drink for more than 24 hours

what is the pathophysiology of candidiasis

occurs when the normal oral environment is disrupted, allowing for the growth of the Candida fungi. A weakened immune system and the use of corticosteroids diminish the ability to fight off local infections and mask early signs of infection

Candidiasis - topical antifungal agents

• MoA

• instructions

used for localized or initial infections

• avoid drink, eating, and rinsing for 30 mins after use to ensure medication remains in contact with affected tissue

Candidiasis - systemic antifungal agents

• MoA

• drug example

Systemic antifungal agents if the lesions are persistent or infection is more severe

• fluconazole

Candidiasis - IV antifungal medications

• when are they used

If patient is at risk of sepsis, IV antifungal medications are administered as part of hospital care

Candidiasis - extra soft tooth brushes and bland oral rinses

• MoA

rinses with salt and sodium bicarbonate frequently help keep mouth clean and moist.

the soft tooth brush will ensure patient is still able to keep up with oral hygiene

what is the main sign the patient has candidiasis

cottage cheese white patterns on the surface of tongue or mouth

what are some warning signs that the thrush may have caused a more severe infection

Fever, chills, fatigue, muscle aches may indicate infection

Dysgeusia definition

general taste alterations

hypogeusia definition

partial loss of taste

ageusia definition

complete loss of taste

pathophysiology of dysgeusia

Taste dysfunction is caused by radiation directly damaging differentiated taste cells or the progenitor cells that renew them.

• Concurrent chemotherapy, xerostomia, smoking, poor oral health, and hypothyroidism increase the risk

dysgeusia - sweetness and artificial flavours

• MoA

Adding sweetness can increase food palatability for those experiencing a loss of a specific taste quality

dysgeusia - fats, sauces, condiments, and alternate proteins

• MoA

Help moisten food and provide stronger sensory inputs

• Many patients develop aversion to beef, switch to alternative protein (eggs, protein shakes, peanut butter) to ensure adequate nutrition

dysgeusia - masking agents

• intervention

• MoA

mint, lemon-flavoured hard candies, chewing mint gum

• Provide pleasant stimulus to mask distorted/unpleasant tastes

dysgeusia - plastic utensils

• MoA

recommended to minimize metallic tastes

dysgeusia - room temp / cold meals

• MoA

Serving foods at room temp or cold can reduce strong odors and tastes that may be off-putting

dysgeusia - baking soda and salt rinses

• intervention

• MoA

rinse before and after each meal: 1 tsp baking soda, 1 tsp salt, 4 cups water (I think)

• Rinses may help improve oral health and may clear the palate to improve taste

• Oral care essential to prevent secondary infections like candidiasis