Survivorship: Late Effects After Radiation for Head and Neck Cancer

Side Effects of Cancer Treatment

There are different types of side effects that you may have during or after cancer treatment.

• Short-term: side effects that happen while you are on treatment and end shortly after treatment. Example: mouth sores that heal within a few weeks after treatment is finished.
• Long-term: side effects that happen while you are on treatment and last for months to years. Some of these side effects will not go away. Example: neuropathy.
• Late effects: side effects that happen months to years after you have finished treatment. Example: scar tissue forming in your throat.

This article focuses on the late effects of radiation treatment for head and neck cancer.

Late effects can be health issues or psychological, emotional, and practical challenges.

Late Effects After Radiation for Head and Neck Cancer

Side effects from radiation treatment affect the area of the body in the treatment field. The treatment field includes the cancer and in some cases nearby healthy tissue. The way radiation is given has changed over the years, leading to a lower risk of late effects. Talk with your radiation oncologist to find out which areas were in your treatment field.

Late effects of radiation treatment for head and neck cancers include:

Damage to the Mouth, Throat, and Salivary Glands

Mouth: Radiation to the head and neck can cause dental problems including tooth decay, enamel erosion, and tooth sensitivity. To reduce the risk of these problems:

• Be sure to brush twice a day and floss once a day.
• Have dental exams and cleaning every 6 months and be sure your dentist knows about your radiation treatment history.
• You should avoid smoking, secondhand smoke, vaping, hookah, and using oral tobacco products, which can make oral problems from radiation worse.
• Contact your provider if you have new or worsening jaw pain.

Throat: Radiation to the head and neck can cause damage to the throat resulting in:

• Swallowing problems: Radiation can cause scar tissue in your throat or esophagus months to years after treatment. This can lead to swallowing problems. Tell your provider about any changes in your swallowing. It may help to see a speech and swallowing specialist.

Salivary Glands: Radiation to the head and neck can harm the salivary (parotid) glands. This can lead to changes in saliva production resulting in dry mouth or thickened saliva.

• Dry mouth can lead to cavities. Using a saliva substitute, sipping on fluids, and sucking on sugar-free candy can help dry mouth.
• Thickened saliva can be managed by drinking fluids to thin your spit, using a cool or warm air humidifier, and warm showers. Some medications can be used to treat thickened saliva.

Ask your care team about seeing a Registered Dietitian if you are having trouble eating because of dry mouth, decreased taste/smell, or difficulty chewing or swallowing.

Damage to the Muscles, Bones, and Nerves

• Radiation can cause small cracks (fractures) in the bones that are in the treatment field. Try to avoid trauma including falls or accidents. If you do get hurt, ask your provider if you need an x-ray to check for bone damage.
• Radiation to the jaw can cause osteoradionecrosis (ORN) of the jawbone, but this is rare. It causes the jaw bone to not be able to heal after minor trauma. It can happen after a dental procedure such as pulling a tooth. It may start as jaw pain or being unable to open the jaw. You should tell you provider about any pain or trouble with opening your mouth. Let your dentist know that you have had radiation to the jaw, so they can watch for ORN.
• Radiation fibrosis: This is the scarring that can make the muscles feel stiff or tough. The scarring can cause spasms, stiffness, pain and weakness. Scarring of muscles in the neck can cause your head to be turned and tilted to the side or make it hard to hold up your head. Physical therapy, cancer rehabilitation, supportive devices, and certain medications can help manage these problems.
• Nerve Issues: Nerves in the radiation area can be damaged or pinched by scar tissue, causing weakness or pain in the area.
• Trismus: This is an ongoing tightening of the muscle that opens and closes your mouth (TMJ). Trismus makes you unable to open your mouth normally. This can make it hard to eat, speak, or do your normal dental care. Your oncology team can give you jaw exercises to prevent or help improve trismus. For some patients, jaw manipulation (movement) by a dentist or treatment by a cancer rehabilitation provider can be helpful.

Lymphedema 

Lymphedema is swelling caused by injury to the lymphatic system. Swelling of the face, chin, and neck area can happen. Tell your provider if you notice any swelling. Physical therapy can be used to treat and manage lymphedema.

Sinus Problems

When the sinuses are in the field of radiation treatment, you may develop chronic sinusitis, a swelling of the sinus tissues. Signs of sinusitis include:

• Post-nasal drip.
• Nasal discharge.
• Facial pain.
• Headaches.

You may need to see an otolaryngologist (ENT) to help manage these issues.

Vision and Eye Changes

If your eyes were in the area that received radiation, you are at risk of getting cataracts at an early age. Signs of cataracts are blurry vision, light sensitivity, poor night vision, double vision in one eye, seeing "halos" around objects, needing brighter light to read, or fading or yellowing of the colors you see. If you have any of these signs you should tell your provider.

Your lacrimal glands (tear ducts) can be harmed. This can cause a loss of or less tears being made and chronic dry eyes. You may be given artificial tears or medications to help make tears. Patients with dry eyes from radiation treatment may be at a higher risk for infections in the cornea (the front part of the eye).

Other late effects can include:

• The eye getting smaller or loss of the eye.
• Corneal abrasions (scratches) and ulcers.
• Glaucoma.
• Damage to the optic nerve, leading to vision loss or blindness.

You will need to be seen by an eye doctor (ophthalmologist) on a regular basis. If you notice any changes in your vision, you should tell your provider right away.

Possible Hearing and Ear Changes

Radiation to the head can damage the cochlea (a part of the inner ear), and/or the ear canal. This can cause hearing loss, dryness of the ear canal, and fluid collection in the inner ear. These problems can cause:

• A full or clogged ear feeling.
• Dizziness.
• Ringing in the ears (tinnitus).
• Vertigo (sensation of spinning or loss of balance).

If you are having any of these issues, you should call your provider. An audiogram (hearing test) or seeing an audiologist can help decide how to treat these side effects.

Skin Changes

Radiation can lead to permanent changes in the skin.

• You may find new scars or changes in the color or texture of your skin. Radiation can also change the color and texture of your hair or can cause permanent hair loss in the treated area.
• The soft tissue and muscles under the skin can lead to scarring and/or shrinkage, which can lead to a loss of flexibility and movement or chronic swelling in the area treated.
• You may get chronic or recurring ulcers of the skin in the area treated. Blood vessels of the skin may become dilated (larger) and more visible, but this is not harmful.
• If the skin feels tight or sore, you can put vitamin E to the skin.
• Use fragrance and dye-free soaps and moisturizers in the area if your skin is sensitive after radiation.

After radiation, the skin in the treated area is more sensitive to sunlight. This sensitivity will last for your lifetime. Practice sun safety, use plenty of sunscreen, wear a wide-brimmed hat, and keep skin in the treated area covered with clothing. Try not to be out in the sun between the hours of 10 am-4 pm when it is the strongest.

If you notice any new or worsening skin issues, you should call your provider. inics

Managing Late Effects

Tell your care team about any new or worsening symptoms. Some side effects need care from healthcare providers who specialize in working with cancer survivors. There are interdisciplinary survivorships clinics at many cancer centers. If there is not a survivorship clinic near you, talk with your oncology care team about support for managing your late effects.

After treatment, talk with your oncology team about getting a survivorship care plan, which can help you in your transition to survivorship and learn about life after cancer. You can build your own survivorship care plan using the OncoLife Survivorship Care Plan.