Introduction 1 Case report 1 Fig. 1 left right  The patient was then treated with radiation therapy to a total dose of 52 Gy in 26 fractions. At the end of the radiation course, a grade 1 mucositis and grade 1 erythema were observed. A complete regression of the disease occurred. After 4 years, the defect in the palate was closed surgically using a temporalis muscle flap. Four years later she developed a sore throat and swallowing complaints. On examination, a tumor-like lesion with a central ulcer was seen on the posterior pharyngeal wall. A CT-scan of the head and neck region showed a soft tissue mass on the posterior pharyngeal wall with extension from the level of the soft palate and nasopharynx to the level of the epiglottis. Biopsy showed the same histologic appearance as previously. The site of the original lesion was without any signs of abnormalities. It was decided to treat this new localization with re-irradiation. During treatment, the patient experienced grade 1 erythema and grade 2 mucositis. She experienced swallowing complaints for 4 months. Complete regression occurred again. Four years after re-irradiation the patient presented again with progressive swallowing complaints and nasal speech. On physical examination, an ulcer was seen on the posterior pharyngeal wall with a diameter of 1-cm, which had a different clinical appearance than the former two lesions. Therefore, the differential diagnosis included a radiation-induced ulcer or recurrence midline destructive disease. Biopsy was not taken because it was most likely that pathological examination of this lesion could not distinguish between these two entities and because of an increased probability of wound-healing problems after biopsy in a highly irradiated area. We decided to treat this lesion as a radiation ulcer and the patient was proposed to undergo hyperbaric oxygen therapy, which she refused. Therefore, as an alternative, we decided to treat her with pentoxyfilline and high dose vitamin E, which she has used for one year. In the subsequent 12 months, the ulcer as well as her complaints gradually decreased. During the last follow-up visit (more than 5 years after re-irradiation), there were no signs of recurrent tumor or other severe radiation sequels, while a small ulcer still persists. Besides a mild xerostomia, she had no other complaints. Discussion 2 2 1 3 4 5 1 3 1 4 1 3 In our case, a total dose of 52 Gy in 26 fractions was used which is generally considered to be sufficient. The margins taken during the first treatment were adequate according to the clinical tumor extension. Also because of the long time-interval, the second lesion can be considered to be a new localization of the disease. 6 8 1 3 3 1 In conclusion, radiation therapy is the treatment of choice for idiopathic midline destructive disease. In case of a second localization in the irradiated area re-irradiation should be considered.