Patients with head and neck neoplasms often run the risk of suffering malnutrition because of the location of the tumor, its stage, surgery and radio-chemotherapy treatments to which he/she is subjected, and the metabolic alterations induced by the cancer.

The percentage of patients suffering malnutrition at the moment of the diagnosis of the disease ranges from 3 to 52%. As a result of radio-chemotherapy treatments, the percentage of malnourished patients increases to a range from 44 to 88% (1).

Cancer of the head and neck affect areas such as oral cavity, oropharynx, hypopharynx, larynx, rhinopharynx, nasal cavities and paranasal sinuses. These areas are involved in important vital functions necessary for nutritional functions such as chewing, swallowing and breathing, which are compromised due to the localization of the tumor. Moreover, other issues may occur due to the treatments which the patient undergoes.

In almost all cases, radiotherapy causes side effects such as mucositis, stomatitis by Candida albicans, xerostomia, osteoradionecrosis, trismus, dysgeusia, dysphagia and pain (2).

Following chemotherapy, the most common side effects are nausea, vomiting, diarrhea, constipation, asthenia, anemia and leukopenia.

Due to the aforementioned issues, the patient’s ability to feed him/herself is often impaired and a state of malnutrition occurs.

Malnutrition is defined as a condition of functional and structural change and impaired development of the organism caused by an imbalance in nutrient requirements, intake and utilization, resulting in excess morbidity and mortality or impaired quality of life (3).

When associated with pathologies, malnutrition also causes the deterioration of muscle tone and of other bodily functions. Furthermore, malnutrition has a negative impact on clinical outcomes. It can result in the need to reduce doses of or discontinue radio-chemotherapy. This can lead to more complications and an increased mortality rate (4).

Providing the patient who suffers from head-neck neoplasms with a nutritional pathway, is necessary to reduce the risk of malnutrition. The nutritional status of the patient suffering from head and neck cancer should be assessed at the beginning of the diagnostic-therapeutic process and constantly monitored during all therapeutic phases.

The nutritional process is adapted according to the needs and new clinical conditions of the patient in order to identify, at an early stage, those who needs specific nutritional support so as to promote survival and a response to cancer therapy.

The main purposes of a nutritional intervention are:

• Preventing and treating malnutrition
• Enhancing the effects of cancer therapy
• Reducing the side effects of cancer therapy
• Improving quality of life

The management of the nutritional pathway includes three stages:

1. SCREENING: makes it possible to identify those at risk of malnutrition
2. NUTRITIONAL EVALUATION: it is performed through a thorough physiological and pathological anamnesis and an accurate physical examination (anamnestic data, food intake, anthropometry, biohumoral parameters, functional parameters). It defines nutritional status; specific tests define even the degree of a possible state of malnutrition
3. NUTRITIONAL SUPPORT AND MONITORING: on the basis of the results of the nutritional evaluation performed, a specific nutrition plan is developed for each patient. If the patient with normal nutrition is not able to fully meet metabolic demands, then nutritional supplements are prescribed to compensate this. If the patient is unable to feed himself/herself naturally, artificial nutrition is used.

We then point out some dietary and behavioural tips aimed to improve some of the most common side effects caused by therapeutic treatments, in order to facilitate nutrition in patients who are able to feed themselves. Please note that these recommendations do not intend in any way to replace the pharmacological therapies prescribed by your doctor.

XEROSTOMIA (dry mouth)

Xerostomia is defined as a pathological condition characterized by a particular and lasting dryness of the mucosa of the mouth resulting from a prolonged absence of saliva production.

The following tips can help alleviate the discomfort caused by xerostomia:

• Sip drinks frequently, especially during meals; drink at least 1-1.5 litres of liquids and rinse your mouth often. Drinking water or drinks without sugar during meals will facilitate chewing and swallowing. Alternatively, you can keep an ice cube in your mouth to maintain the mucosa moist.
• Give preference to soft foods, in purée form, chopped, cream form, smoothies, enriched with sauces and toppings (such as smoothies, milkshakes, yogurt, fruit and vegetable purée, soft cheeses). These can help alleviate the discomfort and moisten your mouth.
• Eat fresh fruit with a high content of water (such as melon, watermelon, peach).
• To stimulate saliva production, add lemon juice to food and drinks if there are no ulcers in mouth.
• Chewing a sugar-free chewing gum or candy can help stimulate saliva production.
• Avoid spicy or salty foods which cause mouth irritation.
• Reduce caffeine intake. Therefore, avoid drinks that contain it such as coffee, tea and some fizzy drinks.
• Reduce alcohol intake: it causes irritation and dehydration.

• Recipes indicated for Tumors of the head and neck area in case of Xerostomia (dry mouth)

MUCOSITIS (stomatitis)

Oral cavity inflammation is a very common side effect in patients suffering from head and neck area neoplasms. This can occur in several forms: aphthae, ulcers, bacterial and fungal infections. To resolve these inflammations the doctor will prescribe appropriate medications. Yet, it is important to maintain proper oral hygiene and to take some precautions in the choice of foods.

As for oral hygiene, it is recommended to use soft bristle brushes and to rinse your mouth with water and baking soda (avoid the use of alcoholic mouthwashes).

Another option is to rinse your mouth with sunflower oil.  This practice consists in taking a tablespoon of sunflower oil and rinsing out your mouth.  The oil must be passed between one tooth and another and between the tongue and teeth. If the cleansing is performed correctly, the sunflower oil will eventually turn whiteish. At that point you can expel the oil, and if necessary, rinse your mouth one last time with water to expel toxins and microbes.

As regards food, here are some useful tips:

• Choose soft, very moist and low-salted foodsas they are easier to chew and swallow and cause less irritation. Consume foods like smoothies, purées, homogenized foods, puddings, yogurt, ice creams. For example, you could make (peeled) fruit smoothies and mix them with yogurt or vegetable drinks; or you can cook vegetables and blend them to make a cream. If severe mucositis arises, it is recommended to consume whole grains in the form of a cream (see brown rice cream).
• For more difficult situations, drink a lot of water throughout the day with the aid of a drinking-straw if necessary.
• Be careful about the temperature of foods: avoid hot foods as they can irritate the mouth or throat; it is better to eat cold, room-temperature or warm food.
• Use a spoon when eating, so as to ingest smaller bites of food.
• Avoid very sour, acidic or salty foods and drinks because they cause irritation (citrus fruits, fruits with small seeds, pickled foods).
• Avoid spices and irritating seasonings (pepper, chili, horseradish, curry, mustard, etc.).
• Avoid dry foods (crackers, chips, bread) as they can scratch your mouth.
• Avoid drinking alcohol.

• Recipes indicated for Head and Neck Area Tumors in case of Mucositis and Stomatitis

NAUSEA and VOMITING

Nausea and vomiting can be caused both by the location of the tumor, as well as by the pharmacological treatments to which patients are subjected but also by possible infections, psychological factors and emotional state. If these are not properly managed, they can cause weight loss, dehydration, metabolic problems and electrolyte imbalance.

Nausea is a sensation of discomfort, accompanied at times by dizziness, cold sweat and abundant salivation, which can be followed by vomiting.

Vomiting is the rapid and forced emission from the mouth, through the oesophagus and pharynx, of the contents of the stomach and in exceptional cases from the intestine of foods or other ingested substances, gastric juices, mucus and blood.

Oncologists prescribe special medication to fight nausea and vomiting. In addition, it may also be helpful to follow some dietary advice to relieve symptoms. Nutrition can be a good strategy to limit the perception of these unpleasant effects.

• Have small and frequent meals: split meals into 5-6 snacks so that the stomach never stays empty, and chew food slowly
• It is preferable to have someone prepare your meals, or you can prepare meals, freeze them and then heat them on days when you do not feel well
• Avoid foods with strong smellssuch as garlic, onions, peppers, horseradish, broccoli, cabbage, etc.
• Avoid sweets, fried food. fatty food and very tasty/spicy food.
• Avoid alcoholic and theine-containing beverages and caffeine
• Choose cold or room-temperature food(they have less smell less than hot food)
• Choose salty and dry food, with a high content of easy-to-digest carbohydrates(pasta, bread, breadsticks, crackers or better still rice cakes)
• Have a salted brown rice cake. Alternatively, you can add a pinch of miso (fermented seasoning rich in protein and vital enzymes, consisting of yellow soya, salt, rice or barley)
• You can ease symptoms with gingerbut do not exceed quantities: Sip a ginger herbal tea, eat candied ginger, or add the freshly chopped root or dried ginger to dishes. However, if you have problems with inflammation of the oral cord, the use of ginger is not recommended
• When you have nausea, it is initially useful to eat only light foods such as soups or cream puddingsand gradually add small portions of your favourite dishes
• Drink plenty of water throughout the dayand not only during meals. Water should be sipped. Also drink tea (mint for example), fruit juices and herbal teas

• Recipes for Head-Neck Trait Tumors in Case of Nausea and Vomiting

1. Malnutrition and cachexia in patients with head and neck cancer treated with (chemo) radiotherapy. Gorenc M. et al. Rep Pract Oncol Radiother. (2015).
2. Complicanze orali della radioterapia della testa e del collo: prevalenza e gestione. Germano F. et al. Minerva Stomatologica (2015).
3. American Society for Parenteral and Enteral nutrition Board of Directors: Definition of terms used in A.S.P.E.N. guidelines and standards. JPEN (1995).
4. Malnutrition and clinical outcomes: The case for medical nutrition therapy. Gallagher-Allred CR et al. Journal of the American Dietetic Association (1997).