What is the best treatment approach for a patient with nasal mucositis, likely due to chemotherapy or radiation therapy?

Treatment of Nasal Mucositis

While the available evidence focuses predominantly on oral mucositis management, nasal mucositis should be approached using similar principles: basic nasal care with frequent saline rinses, appropriate pain management, and avoidance of ineffective interventions.

Initial Management Approach

The cornerstone of treatment involves implementing systematic care protocols adapted from oral mucositis guidelines, as the pathophysiology of chemotherapy and radiation-induced mucosal injury is similar across anatomic sites 1.

Basic Nasal Care Protocol

• Perform frequent non-medicated saline nasal rinses 4-6 times daily to maintain mucosal hydration and remove debris 1
• Use a gentle approach to nasal hygiene, avoiding trauma to already compromised mucosa 1
• Patient education on proper technique is essential for reducing severity of mucositis 1

Pain Management Strategy

For significant nasal mucositis pain, follow this hierarchical approach:

• First-line: Topical morphine preparations (0.2% morphine solution can be adapted for nasal application, extrapolating from oral mucositis evidence) 2, 3
• Second-line: Systemic opioids including patient-controlled analgesia with morphine or transdermal fentanyl for severe cases 1, 3
• Regular pain assessment using validated self-reporting instruments is essential 1

Infection Surveillance

• Actively exclude fungal and bacterial superinfection, particularly in leukopenic patients who have significantly higher infection risk (P = 0.005) 2
• Perform direct visualization to assess for white plaques suggesting candidiasis or purulent discharge indicating bacterial infection 2
• If infection is confirmed, treat appropriately with antifungals or antibiotics as indicated 2

Prevention Strategies for Future Cycles

If the patient requires additional chemotherapy or radiation cycles:

• Consider palifermin (60 μg/kg/day for 3 days before and 3 days after treatment) for patients receiving high-dose chemotherapy with hematopoietic stem cell transplantation 1
• Benzydamine rinses may be beneficial if adapted for nasal use in patients receiving moderate-dose radiation therapy (up to 50 Gy) 1, 3

Critical Interventions to AVOID

The following have Level I or II evidence demonstrating lack of efficacy or harm:

• Do NOT use sucralfate (Level I evidence against) 1, 3
• Do NOT use chlorhexidine (Level II-III evidence against) 1, 3
• Do NOT use antimicrobial lozenges for prevention (Level II evidence against) 1
• Do NOT use GM-CSF preparations (Level II evidence against) 1, 3
• Do NOT use intravenous glutamine (Level II evidence against) 3

Common Pitfalls

• Attempting to use agents proven ineffective in oral mucositis (sucralfate, chlorhexidine) based on theoretical benefits rather than evidence 1
• Underestimating infection risk in neutropenic patients, leading to delayed diagnosis of superinfection 2
• Inadequate pain control due to reluctance to use appropriate opioid analgesia 1, 3
• Failing to implement preventive protocols before subsequent treatment cycles 1

Nutritional Considerations

• Screen immediately for malnutrition risk, as comorbid malnutrition significantly worsens outcomes 2
• Initiate early enteral nutrition if swallowing difficulties develop from posterior nasal drainage or associated oral involvement 2