European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 253256

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SFORL Guidelines

Manag antreatm d Guidel HeSociety

D. Blanch elsF. Espital rt j, SFORL wa Service dORL, centre Franc ois-Baclesse, centre de lutte contre le cancer Basse-Normandie, 3, avenue Gnral-Harris, BP 5026, 14076 Caen, Franceb Cabinet de radiothrapie, 7, rue Laromiguire, 75005 Paris, Francec Service de cancrologie, hpital Beaujon, 100, boulevard du gnral-Leclerc, 92110 Clichy, Franced Service danesthsie, institut Gustave-Roussy, 114, rue douard-Vaillant, 94805 Villejuif, Francee Service de mdecine physique et de radaptation, hpital de Bellevue, 42055 Saint-tienne cedex, Francef Service de chirurgie maxillo-faciale, CHU Nord, place Victor-Pauchet, 80054 Amiens cedex, Franceg Service dORLh Dpartementi Hpital Bretonj Service dORL k Service dORL

a r t i c

Keywords:MucositisNeuropathyRadiodermatitOsteoradionec

1. Introdu

Head ancases diagnfounded onapy.

These trThey may inwith the ma(RT) and/or

CorresponE-mail add

http://dx.doi.o1879-7296/ et de chirurgie cervico-faciale, hpital Htel-Dieu, CHU, 1, place Alexis-Ricordeau, 44093 Nantes cedex, France danesthsie-ranimation, CHU, 42100 Saint-tienne, Franceneau, CHU, 2, boulevard Tonnell, 37000 Tours, Franceet de chirurgie de la face et du cou, groupe hospitalier Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France

et de chirurgie de la face et du cou, hpital Bretonneau, CHU, 2, boulevard Tonnell, 37000 Tours, France

l e i n f o

isrosis

a b s t r a c t

Objectives: The authors present the section of the guidelines of the French Otorhinolaryngology Headand Neck Surgery Society (SFORL) for the management of somatic pain induced by head and neck cancertreatment concerning management of pain following radiation therapy and chemotherapy.Methods: A multidisciplinary work group was entrusted with a literature review. Guidelines were drawnup based on the articles retrieved and the group members experience. They were read over by an editorialgroup independent of the work group. A coordination meeting drew up the nal version. Guidelines weregraded A, B or C or as expert opinion in decreasing order of level of evidence.Results: Particular care should be given to detection and early adapted treatment of pain induced byradiation therapy and/or chemotherapy, to improve quality of life in head and neck cancer patients.

2014 Published by Elsevier Masson SAS.

ction

d neck cancer is frequent in France, with 16,000 newosed yearly [1] (level of evidence 1). Management is

treatment by surgery, radiation therapy or chemother-

eatments may be applied in isolation or association.duce painful symptomatology. The present article dealsnagement of somatic pain induced by radiation therapy

chemotherapy.

ding author.ress: d.blanchard@baclesse.fr (D. Blanchard).

2. Method

A multidisciplinary work group was set up and entrustedwith a review of the literature. The group met several timesand drew up a position paper for the guidelines. The resultingtexts were read over by an editorial group independent of thework group. A coordination meeting drew up the nal guide-lines.

Guidelines were graded A, B or C by decreasing level of evi-dence, following the literature analysis and guidelines gradingguide published by the ANAES national health accreditation andassessment agency (January 2000, Table 1). This classication isintended to explain the bases upon which the guidelines are estab-lished.

rg/10.1016/j.anorl.2014.07.0012014 Published by Elsevier Masson SAS.ement of somatic pain induced by headent: Pain following radiation therapy anines of the French Otorhinolaryngology

(SFORL)

arda,, M. Bolletb, C. Dreyerc, M. Binczakd, P. Calmierg, M. Navezh, C. Perrichoni, S. Testelin f, S. Albeork groupd neck cancerchemotherapy.ad and Neck Surgery

e, C. Couturaudf,S. Morinirek,

254 D. Blanchard et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 253256

Table 1Levels of evidence and guideline grades.

Level of evidence from the literature Guideline grade

Level 1High-powstudiesMeta-analstudiesDecision astudies

Level 2Low-poweWell-condcomparatiCohort stu

Level 3Case-contComparat

Level 4ComparatRetrospecCase serieDescriptiv(transvers

Any other puopinion, etNo publica

Table adapted grading of guid

3. Guidelin

3.1. Preven

3.1.1. GeneImmedia

the mucosaLate pain iscostoclavicuropathic pafunction.

RT, of wing with totevidence 1)total RT dur

Preventiirradiated vpotentiatio

As well a1), pain maing the chanshown to devidence 3)

In recenof conformadaptation organs (con(level of evi

These hiof evidence

GuidelinTo lim

formal ahomogenas far as

3.2. Prevention and treatment of acute post-RT complications

Management of acute pain (with onset during RT or generallywithin 9 weeks) consists in the usual WHO stepwise treatment of

ound

Preveet of

heay [7,itionf evie RToundy fee

ted, m healof sef ev

okinged loventir edtionf theCa).

delino redtritio

ructiode B

l andence

s anrradi

soft

y uer randomized comparative

ysis of randomized comparative

nalysis based on well-conducted

Grade AEstablished proof

r randomized comparative studiesucted non-randomizedve studiesdies

Grade BScientic presumption

rol studiesive studies with historical series

Grade CLow level of evidence

ive studies with serious biastive studiesse epidemiological studiese, longitudinal)blication (case report, expertc.)tion

Professional agreement

from Sackett Score, following the ANAES guide to literature analysis andelines of January 2000.

es

tion and treatment of pain following radiation therapy

ral preventionte post-RT pain is closely related to inammation of

(mucositis) and skin (dermatitis) in the radiation eld. related to radiation-induced brosis of support tissue:lar or temporomandibular joint disorder, trismus, neu-in, or more rarely brachial plexitis with loss of motor

hatever type, can induce pain, with intensity correlat-al dose and potentiation by chemotherapy [2] (level of

or anti-EGFR antibodies and inversely correlating withation.on thus depends on treatment optimization in terms of

backgr

3.2.1. Ons

RT andtherapdenutr(level oprecedbackgrgered bcorrecimpairis risk (level o

Smincreas

Pretion (oinstruclines oHAS/IN

GuiT

a nuinst(Gra

Oraof evid

assesmit i

use a3);

appl

olume, total dose and dose per session and associatedn.s the obvious quality of life impact [3] (level of evidencey necessitate interruption or termination of RT, impair-ces of cure. The probability of tumour control has been

ecrease by 1.4% per day of RT interruption [4] (level of.t years, RT techniques have progressed with the advental and intensity-modulated radiation, enabling betterof dose to tumour and reduced exposure of healthyserved salivary function and reduced xerostomia [5]dence 2)).gh-tech RT techniques improve quality of life [3,6] (level

3).

e 1it early and late toxicity, RT should at least be con-nd, if indicated, intensity-modulated, to deliver aeous dose to target volumes and spare healthy tissuepossible (Grade B).

with marters throu

perform r[9] (level

Bacteriafor, as it prrelieve pain

GuidelinTo pre

ommend

assesstransm

use a s apply perform

tion; ensure

or viral and episodic (including paroxysmal) pain.

ntion and treatment of radiation-induced mucositis mucositis is classically at the end of the rst week ofling is usually achieved within 2 to 3 weeks of end of8] (level of evidence 4). Certain comorbidities, such as, should be screened as risk factors for mucositis [9]dence 4). Nutritional assessment should systematically. Once established, radiation-induced mucositis induces

pain exacerbated by paroxysmal episodes, mainly trig-ding or mere swallowing. Odynophagia, if not properlyay lead to nutritional deciencies which in turn may

ing. Enteral feeding should be initiated early when therevere dysphagia, especially in case of potentiation [9,10]idence 3).

increases the intensity and duration of pain, due tocal inammation.on of pain is thus based on precise patient informa-ucation) regarding hygiene and diet and also posturals, and preventing smoking and alcohol abuse (guide-

French Health Authority and National Cancer Institute:

e 2uce RT-induced pain, patients should be prescribednal assessment with hygiene and diet and posturalns and cessation of smoking and alcohol abuse).

dental care and hygiene should be systematic [8] (level 2). It is recommended to:

d eradicate dental infection sites ahead of RT and trans-ated volumes to the dentist;

toothbrush, replacing it regularly [9] (level of evidence

oride (Fluocaril Bi Fluore 2000: the only uoride gelket authorization in France) to the thermoformed gut-ghout RT and then lifelong;egular mouth-rinse with non-alcoholic saline solutionof evidence 2).

l, fungal or viral superinfection should be screenedolongs and exacerbates lesions, while treatment helps.

e 3vent and treat radiation-induced mucositis, it is rec-ed to (Grade B):

and eradicate dental infection sites ahead of RT andit irradiated volumes to the dentist;oft toothbrush, replacing it regularly;uoride to the dental splints;

regular mouth-rinse with non-alcoholic saline solu-

early diagnosis and treatment of any bacterial, fungal superinfection.

D. Blanchard et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 253256 255

The 2011 European Society for Medical Oncology (ESMO)guidelines recommended benzydamine rinse (a local non-steroidanti-inammatory) [9] (level of evidence 2), whereas the Cochrane2011 meta-analysis reported minimal and unreliable benet (4studies, 332unreliable bfor the prev([11] (level ESMO [9]). Cevidence 2)

Local anevidence) [9

A presereports thain radiation

In case authorizatioprovides mor severe m

Treatmesuggested, bprevention and neck RT

3.2.2. PreveRecomm

2) comprisethe skin witing (avoidincosmetics (

For radianeous invashydrate thechecking foapply local (Flamazine

In case orecommend

3.3. Preven

Late posmination of

3.3.1. Preveosteoradion

Most detive changesalivary bufodontal dis

In oral mandible w

Patient amordial.

Oral andafter RT (HA

Fluoridefor life.

In dentainclude vasbone-penet

In incipitoclo protosome years hygiene edu

is associated to mild resection of bone sequesters, to limit radiation-induced brosis and reactivate osteoblastic healing.

In case of failure of medical treatment or of ORN fracture, radicalsurgery is required, preferably associated to reconstruction.

Preveatie

ontraia [2s in ofasenceavoidte lytheraNCa abilictionulinu

by is [22

delint is rful la

vent

motitis.

st-ch

t-cheary ds (v

heal ablatin

reatmbbersensals i

hereh comnd ey, se

200doserapyithdring iatmet prore ha

prevegatoxeted dots recxali

ence patients [11]; level of evidence 2), and minimal andenet with Aloe vera (minimal and unreliable benetention of moderate or severe mucositis) or Sucralfateof evidence 2: intermediate), and not recommended byhlorhexidine rinse is not recommended [9,11] (level of.esthetics may provide transient pain relief (anecdotal] (level of evidence 4).ntly unpublished randomized double-blind studyt doxepin rinse (Quitaxon) signicantly reduced pain-induced mucositis [12] (level of evidence 2).of standard fractionated RT, amifostine has marketn for the prevention of acute and late xerostomia. Itinimal and unreliable benet in preventing moderateucositis [11] (level of evidence 2).nt by low-frequency laser (wavelength 632.8 nm) wasut not recommended, in 3 randomized studies, for the

of radiation-induced mucositis in non-potentiated head [13] (level of evidence 2).

ntion and treatment of radiation-induced dermatitisended preventive measures [14,15] (level of evidence: avoidance of irritating factors (sun exposure), washingh water with or without mild soap, loose cotton cloth-g mechanical irritation) and avoiding alcohol-based

chemical products such as perfumes).tion-induced grade I and II epidermatitis without cuta-ion [14,16] (level of evidence 2), it may be useful to

skin after the RT session to improve comfort, whiler absence of allergy [17] (level of evidence 3), and tocorticosteroids in case of pruritus or silver sulfadiazine), which can reduce radiation-induced epidermatitis.

f broken skin (grade II or III), hydrocolloid dressings areed [17] (level of evidence 2).

tion and treatment of late post-RT complications

t-RT pain involves onset more than 6 months after ter- RT.

ntion and treatment of dental complications andecrosis (ORN)ntal complications implicate qualitative and quantita-s in saliva. Demineralization is associated with impairedfer action, and progresses to insidious decay with peri-ease and ORN [18] (level of evidence 3).or oropharyngeal RT, it is essential to protect theith a lead mask.wareness (education) of oral and dental hygiene is pri-

dental monitoring is indispensable, before, during andS/INCa guidelines, patient guide, September 2010).

gel dental protection gutters should be applied daily

l or periodontal surgery, local anesthesia should notoconstrictors. Each procedure should be associated torating antibiotherapy. Gum suture is mandatory.ent ORN, medical treatment following Delanians Pen-col [19] (level of evidence 3) has been implemented fornow, associated to the above-mentioned oral and dentalcation. This specic treatment of ORN physiopathology

3.3.2. RT p

vical cdystonchangeing myof evid

To facilitaphysio(HAS/I

Rehcal fun

Botspasmtrismu

GuiI

pain

4. Pre

Chemucos

4.1. Po

Possecondalkaloiground(alcoho

Cispfrom tlarge of the chemicbarrier

Sucanes, asensordoses