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Radiation can be an effective tool in the fight against cancer. It can also cause excruciatingly painful tissue damage in the mouth, nose, ears, and throat.

The reason oral, throat, and ear pain after radiation is so painful after radiation treatment is that both the injury and recovery involve the immune system. Most experts identify five steps.

  1. In the initiation phase, radiation releases free radicals of oxygen in the tissues lining the ears, nose, and throat. Most forms of chemotherapy also cause release of free radicals of oxygen in these tissues.
  2. In the message generation phase, the damage to cells causes them to produce a substance known as nuclear factor kappaB. This substance sends a message to the immune system to send proinflammatory cytokines such as interleukin (IL)–1beta and tumor necrosis factor-alpha (TNF-alpha)
  3. In the signalling phase, tumor necrosis factor alpha (TNF-alpha), which also kills tumors, arrives at the irradiated tissue. It attacks and removes damaged cells. This makes it easier for blood to pass through the injured tissue. As blood flow returns, however, so does more TNF-alpha, amplifying pain and inflammation.
  4. The first three events take about five days. During that time, usually white blood cells begin to break down due to their exposure to radiation. In particular, there may be a shortage of white blood cells known as neutrophils, or neutropenia, which slows down the immune system's ability to respond to infection. During this ulcerative/bacteriologic phase, bacteria, fungi, and yeasts may multiply unchecked. They release inflammatory toxins, which add to the pain already being caused by TNF-alpha.
  5. The healing phase is marked by cell proliferation with reepithelialization of ulcers. The linings of the throat, mouth, nose and ears begin to regenerate, if the immune system can generate enough white blood cells to fight infection. If the immune system is compromised, new growth in the membranes will be destroyed by the infection, and relief is delayed.
The good news about this process is that it is self-limiting. About the fifth day, it can be awful, but it won't get "awfuller." That's because there is only so much tissue that can be destroyed by the combination of radiation and infection. Due to the phenomenon of referred pain, oral care can sometimes reduce ear pain, and vice versa.While the process is going on, there are things you can do to limit the pain. 
  1. Don't brush your teeth too vigorously. The gums are already tender, and they can crack and let bacteria in. Due to weakening of your immune system, it's possible to get a systemic infection from your gums.
  2. Keep your mouth moist. Take small sips of water frequently. Warm (not hot) water is usually best. Dry mouth also invites infection. Your doctor may also be able to recommend mouthwashes that help keep your mouth and tongue moist and less inflamed.
  3. Don't rely on troches (hard medicated candies you put in your cheeks). If your mouth is already dry, they won't dissolve. Troches are not meant to be chewed and swallowed. They need to melt in your mouth.
  4. Ask you doctor about analgesic mouthwashes. A mouth rinse made with a chemical called doxepin is often used to relieve pain caused by radiation therapy. Just rinsing your mouth with salt water will help reduce pain, because the salt causes salivation, which in turn increases the moisture in your mouth.
  5. Unless your doctor tells you otherwise, add salt to your food, but be sure to mix it in your food. Large salt crystals can be painful on the surface of your mouth and throat, but saltier food makes you salivate, which both relieves pain and helps you taste the food.
  6. Sucking on ice chips or popsicles before you have pain can prevent pain.
  7. If you have herpes, ask about getting treatment with an antiviral drug before you get radiation therapy. The stress of cancer treatment, either radiation or chemotherapy, can activate the virus.
  8. Avoid dry foods, like crackers and chips. Sharp edges on the food can injure your mouth and throat and support oral mucositis
  9. Avoid spicy foods and vinegar. Be careful with acidic fruit juices and soft drinks, since they can irritate the damaged lining of your mouth and throat.
  10. Don't try to eat your favorite foods while you are recovering from either radiation or chemotherapy. The memory of how you feel due to your treatment will be recorded with the food, and eating the same food when you get well will be less pleasurable.

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