An underestimated pitfall of oral candidiasis in head and neck cancer patients undergoing radiotherapy: an observation study

Background Oral candidiasis is a common problem associated with head and neck radiation therapy (RT) consequences being pain, burning sensation, taste change, and systemic infection. There are difficulties in differentiating between oral candidiasis and radiation induced oral mucositis. We conducted a prospective study to explore the incidence of clinical oral candidiasis and evaluate the accuracy of diagnosis among head and neck cancer (HNC) patients receiving RT or concurrent chemoradiotherapy (CCRT). Methods This study included 86 HNC patients who had no clinical signs or symptoms of oral candidiasis. Oral mucosa and tongue swabs were carried out and analyzed three times by fungal cultures at the following time points: (1) before RT, (2) at the time of clinically diagnosed candidiasis or during RT at between the 15th–17th fraction (whichever occurred first), and (3) at the end of RT. The accuracy of clinical oral candidiasis was explored and confirmed by fungal colonization techniques. The incidence and risk factors associated with fungal colonization before and throughout the treatment were analyzed. Results The overall incidence of clinical oral candidiasis was 53.5% throughout the course of RT. Confirmation of fungal colonization was found in 39.5%, 65.9%, and 57.7% of cases before RT, during RT, and end of RT, respectively. The accuracy of the diagnosis using only clinical presentation was demonstrated in 60%, 50%, and 52% before RT, during RT, and end of RT, respectively. Logistic regression analysis showed that age, CCRT, and using 2% viscous lidocaine solution were independent risk factors for fungal colonization. Conclusions The results of this study demonstrated an underestimation of clinical oral candidiasis before and throughout the course of radiotherapy from using only clinical sign and symptoms. Crucial attention to detail and testing in the oral examination could improve decision making for detection of oral candidiasis in HNC patients receiving RT or CCRT.

Intubation-Related Laryngeal Pathology Precluding Tracheostomy Decannulation: Incidence and Associated Risk Factors

Objectives: To identify the incidence and risk factors for intubation-related laryngeal lesions that preclude tracheostomy decannulation in a large population. Methods: A 3-year retrospective case-control study was performed of tracheotomized adults in acute rehabilitation facilities who underwent routine endoscopic evaluation of the airway as part of the facilities’ decannulation protocol. Patients with known upper airway pathology, external laryngeal trauma, cricothyrotomy or emergent tracheostomy, prior head and neck radiation, isolated tracheal lesions, and patients with incomplete reports were excluded. The laryngeal pathologies were classified, and demographics and clinical features were compared between those whose lesions precluded decannulation and all other patients. Results: Three hundred seventy-one patients met inclusion criteria. One hundred six (28.6%) had laryngotracheal lesions. Forty-nine patients (13.2%) had intubation-related lesions of the larynx that precluded decannulation. These lesions included posterior glottic stenosis (30.6%), granulation tissue (24.5%), vocal fold immobility (16.3%), subglottic stenosis (16.3%), a combination of granulation tissue and stenosis (10.2%), and glottic edema (2.0%). A BMI ≥ 25 kg/m2 was associated with laryngeal lesions precluding decannulation. There was no difference in age, sex, race, diabetes mellitus, endotracheal tube size, number of days intubated, and number of intubations between groups. Seventy-eight percent of patients with lesions precluding decannulation were decannulated after medical or surgical therapy. The decannulation rate of patients without lesions precluding decannulation was 79.9%. Conclusions: BMI ≥ 25 kg/m2 may increase the risk of development of laryngeal lesions preventing decannulation. Given that 13.2% of tracheotomized patients have laryngeal lesions precluding decannulation, an endoscopic evaluation of the airway is important to prevent decannulation failure and future airway symptoms.

Magnetic Resonance and CT Imaging Biomarkers for Prediction of Acute and Chronic Radiation-Induced Xerostomia

Xerostomia is a common adverse effect of radiation therapy at the head and neck area. Radiation-induced xerostomia can be severe and detrimental for the quality of life. Clinicians and radiologists have focused on the prevention of xerostomia as feasible, which has been significantly improved in the recent decades with the use of the contemporary radiation technology. However, radiation-induced xerostomia still remains one of the most devastating side effects of radiation therapy. Clinical risk factors have been identified, but the variation of its incidence and presentation has turned the focus on the investigation of parameters that would be able to predict the onset of acute or chronic xerostomia for each individual patient. Recently, potential imaging parameters and biomarkers are investigated in order for early prediction of the incidence and severity of xerostomia. Here, we compile the resulting imaging biomarkers as have been identified in the recent literature based on MRI and CT performed in correlation with radiation therapy. The identification of such biomarkers is very promising for the prevention and control of xerostomia in the head and neck radiation setting.

Predictors of Tracheostomy Decannulation in Adult Laryngotracheal Stenosis

Objective Predictors of tracheostomy decannulation in patients with laryngotracheal stenosis are not fully known, making prognosis difficult. The aim was to identify predictors of tracheostomy decannulation in adult patients with acquired stenosis of the larynx and/or trachea who were tracheostomy dependent. Study Design Case series. Setting Academic teaching hospital. Methods A total of 103 consecutive adult patients with laryngotracheal stenosis who were tracheostomy dependent and seen by the otolaryngology clinic from January 1, 2013, to August 2, 2018, were included. Exclusion criteria included age <18 years, history of laryngeal cancer or head and neck radiation, or history of laryngeal fracture. The primary outcome was the presence of tracheostomy at last follow-up. The patients’ etiology of stenosis, comorbid conditions, and characteristics of the stenosis were analyzed to determine if there was a statistically significant relationship with decannulation. Results A total of 103 patients were included: 67% of patients were women and the average age was 53.5 years. Sixty-four patients (62%) were successfully decannulated. In multivariate analysis, patients who were successfully decannulated presented to the otolaryngology clinic earlier after tracheostomy was performed, were more likely to have been intubated due to trauma, and were less likely to have gastroesophageal reflux disease. In patients with subglottic or tracheal stenosis, those with granulation tissue without firm scar were more likely to be decannulated, and those who underwent rigid dilation were less likely to be decannulated. Conclusion Early evaluation by an otolaryngologist may increase the likelihood of tracheostomy decannulation in patients with laryngotracheal stenosis. Patient comorbidities may assist in predicting which patients will be successfully decannulated.