In a 78-year-old patient receiving radiotherapy for vocal-cord squamous cell carcinoma in week 3 who complains of throat pain, what is the recommended management?

Management of Radiation-Induced Throat Pain in Week 3 of Treatment

Initiate immediate pain management with topical morphine 0.2% mouthwash as first-line treatment, combined with basic oral care protocols including saline rinses 4-6 times daily, while avoiding chlorhexidine and sucralfate which are contraindicated. 1, 2

Immediate Pain Management Algorithm

Start with topical morphine 0.2% mouthwash for moderate-to-severe throat pain (Grade 2-3 mucositis), which is specifically recommended for patients receiving chemoradiation therapy for head and neck cancer. 1, 2 This provides targeted pain relief at the site of mucosal injury without systemic opioid side effects initially.

• If topical morphine provides insufficient relief, consider adding 0.5% doxepin mouthwash as an adjunct for additional pain control 1, 2
• Escalate immediately to patient-controlled analgesia with systemic morphine if pain remains uncontrolled by topical measures or if the patient has Grade 3-4 mucositis with severe functional impairment 1, 2
• Transdermal fentanyl may be used as an alternative systemic opioid for severe pain 1, 2

Essential Basic Oral Care Protocol

Implement frequent non-medicated saline mouth rinses 4-6 times daily as the cornerstone of mucositis management. 1, 2 This maintains mucosal hydration, removes debris, and reduces inflammation without causing additional irritation.

• Use a soft toothbrush replaced regularly to maintain oral hygiene without traumatizing damaged mucosa 1, 2
• Strictly avoid alcohol-based mouth rinses as they irritate damaged mucosa and worsen symptoms 1, 2
• Topical anesthetics (lidocaine viscous) can provide short-term pain relief on an empiric basis for breakthrough pain 1

Dietary Modifications and Nutritional Support

Eliminate all painful food stimuli immediately: smoking, alcohol, tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods. 1, 2

• Screen for nutritional risk now given the high risk of malnutrition in week 3 of radiotherapy for head and neck cancer 1, 2
• Initiate early enteral nutrition (feeding tube placement) if swallowing difficulties develop, as this patient is at high risk given age (78 years) and treatment location (vocal cords) 1, 2

Critical Interventions to AVOID

The evidence strongly recommends against several commonly used interventions:

• Do NOT use chlorhexidine mouthwash for prevention or treatment of radiation-induced oral mucositis in head and neck cancer patients (Level II-III evidence against) 1, 2
• Do NOT use sucralfate mouthwash for prevention or treatment of radiation-induced oral mucositis (Level I-II evidence against) 1, 2
• Do NOT use antimicrobial lozenges (PTA, BCoG) for prevention or treatment (Level II evidence against) 1, 2
• Do NOT use GM-CSF mouthwash (Level II evidence against) 1, 2

Prevention Strategies for Remaining Treatment

While the patient is already in week 3, consider these evidence-based preventive measures for the remaining treatment course:

• Benzydamine mouthwash is recommended for prevention in patients receiving moderate-dose radiation therapy (up to 50 Gy) without concurrent chemotherapy (Level I evidence) 1, 2 Note: This is most effective when started before mucositis develops, but may still provide benefit
• Low-level laser therapy (wavelength ~632.8 nm) may be beneficial for prevention in patients undergoing radiotherapy without concurrent chemotherapy (Level III evidence) 1, 2
• Use of midline radiation blocks and three-dimensional radiation treatment planning reduces mucosal injury 1

Common Pitfalls to Avoid

The most common error is using chlorhexidine or sucralfate based on outdated protocols or extrapolation from chemotherapy-induced mucositis guidelines. 1, 2 These agents have strong evidence against their use in radiation-induced mucositis specifically.

Another critical pitfall is inadequate pain assessment and delayed escalation to systemic opioids. 1, 2 Regular pain assessment using validated 0-10 scales is essential, with scores ≥6 indicating severe pain requiring immediate escalation to systemic opioids. 2

Failure to screen for nutritional risk and delayed feeding tube placement leads to significant malnutrition, treatment interruptions, and worse outcomes in this elderly population. 1, 2