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Vol. 26 No. 1 - Head and Neck Cancer-Related Lymphedema: A Case Study

Head and Neck Cancer-Related Lymphedema: Case Study

By: David Adcock1, Jie Deng2, Carmin Bartow3, Barbara A. Murphy3, Sheila H. Ridner2, Andrew Moore4
1 St. Thomas Health, Nashville, TN USA, 2 School of Nursing, Vanderbilt University, Nashville, TN, USA,
3 Vanderbilt-Ingram Cancer Center, Nashville, TN, USA, 4 Southeast Health, Cape Girardeau, MO, USA

Vol. 26 No. 1 - Lymphlink Reprint, Archived January 2014

Secondary lymphedema is a significant problem in head and neck cancer patients.1,2 Depending on the site, head and neck lymphedema can be classified as external lymphedema (involving external structures of the head and neck, eg, facial lymphedema) and internal lymphedema (involving mucosa of the upper aerodigestive track, eg, laryngeal lymphedema).1 Head and neck lymphedema can substantially impact daily functions (eg, swallowing, speaking) and cause distressful symptoms (eg, body image disturbance).1-4 

The current standard care for any type of lymphedema is complete decongestive therapy (CDT);5-8 however, no supporting data for head and neck lymphedema is available.4 No standard therapy protocol is available for head and neck internal lymphedema.4 Clinical observations indicate that the treatment of external lymphedema with CDT improves symptoms of both external and internal lymphedema in head and neck cancer patients. Thus, the purpose of this case study is to evaluate the effects of CDT on external and internal lymphedema, symptoms (specifically in swallowing difficulty), and cervical range of motion (CROM). 

Case Description

1. Background

WG is a 55-year-old male who was diagnosed with squamous cell carcinoma of the anterior floor of mouth in 2010. He underwent resection of the anterior floor of mouth, ventral tongue, and mandible. A left neck dissection, including lymphatic nodal levels 1 through 4, and a right neck dissection, including level 1, was done. He had three positive nodes. He also underwent free flap reconstruction. Subsequently, he completed concurrent chemoradiation in September 2010. Radiation was delivered to the oral cavity, plus the left and right nodal beds, with a total dosage of 5600Gy. His medical history included pancreatitis, liver disease, and depression. He developed stage I external lymphedema occurring at midline of chin, diagnosed by the medical oncologist in August 2010 during his chemoradiation therapy. An exacerbation of lymphedema from an undetermined cause occurred in 2012; this was treated with CDT commencing in July 2012.

2. Assessment

WG underwent the following evaluations prior to CDT: 1) external lymphedema/fibrosis by physical examination; 2) internal lymphedema and swallowing function by fiberoptic endoscopic evaluation of swallowing (FEES); 3) cervical range of motion measure (CROM); 4) symptoms via Vanderbilt Head and Neck Symptom Survey (VHNSS) and Lymphedema Symptom Intensity and Distress Survey-Head & Neck (LSIDS-H&N).9,10 

WG presented with external lymphedema extending from the forehead ending at the lower neck. The left cheek and neck areas had increased involvement. Minimal fluid was seen distal to surgical scarring. The lymphedema was diagnosed stage 2 on the Foldi’s scale by the first author. 

A scar was visible along midline of the chin ending at the lip. The right dissection scar started at the apex of chin and scalloped down and lateral ending below and before the temporomandibular joint (TMJ). This lateral scar was mid distance from clavicle to TMJ. Scarring on the left side followed the same pattern but was more involved ending under the ear.

Skin assessment showed redness in the forehead, nose and adjacent area, left cheek, and left neck. WG had moderate edema in the pharynx and larynx. FEES showed that the patient was a functional communication measure (FCM) of 3 with moderate dysphagia. The patient’s posture was a forward head with protracted scapulae and a functionally increased thoracic kyphosis. The CROM assessment was neck extension of 29 degrees, right rotation of 54, left rotation of 62, right lateral flexion of 35, and left lateral flexion of 20. Strength deficits were found in right and left lateral flexion, with the balance of cervical strength testing within functional limits. Based on the VHNSS and LSIDS-H&N, problems identified included dysphagia, choking, food becoming stuck in the throat, poor sleeping, fatigue, and decreased ability to turn his head. WG described pain occurring in the floor of mouth and the throat. Swallowing generated the pain (odynophagia); it was rated a 4 of 10.

3. Intervention (CDT phase I-Lymphedema therapy and home self-care)

WG’s clinical intervention occurred over 4 weeks at 2 visits per week. Lymphedema therapy was described below. Functional training was incorporated in all areas. 

    1. Manual Lymphatic Drainage (MLD). The MLD session was performed with the patient positioned in two ways: on a table reclined with a wedge and in the sitting position. The head and neck sequence was performed. Secondary to the left dissection scar extending to under the ear and the degree of lymphatic system removed, the MLD of left face and neck proximal to scar was modified. These areas were drained posteriorly. Self-MLD training was done with a simplified pattern. Initially the patient expressed concern regarding difficulty performing self-MLD. After hands on training and providing detailed written instructions, he demonstrated it correctly. WG was instructed to do MLD daily in the morning; he was also trained to sleep in a reclined position. 
    2. Compression: Concurrent with the MLD sessions, WG was educated on the necessity of night compression. Secondary to financial constraints and no insurance coverage, a compression device was developed by the study therapist (the first author) and patient. The therapist created a pad from grey foam; the patient developed a chin strap that incorporated the cheeks. Consistent use of compression was reviewed throughout treatment; near the end of clinical treatments, he stated his compression use was inconsistent and only used 2-3 times per week. 
    3. Exercise: An important part of lymphatic treatment was postural and cervical strengthening along with range of motion exercise. WG was educated on the importance of good posture and the risk of progressive weakness of postural strength following head and neck cancer treatment. The home exercise program addressed strengthening of scapular retraction and stabilization. Range of motion was addressed focusing on cervical rotation and retraction. WG was independent and compliant with the daily home exercise program. 
    4. Risk Reduction Education: Methods to prevent and/or improve the lymphedema were covered. Skin care, sleeping positions, and importance of avoiding cuts/burns were discussed. As mentioned earlier, self-MLD was stressed as the key manner of reducing future exacerbations. 
    5. Recap of Self-Management Training: WG was trained and performed self-MLD. Postural and range of motion home exercise program was taught to the patient. He was trained in using the overnight compression item fashioned by therapist and patient; he was educated regarding the optimal sleeping position. Skin care training was completed. The outcome of training was reported by the patient as follows: a) self-MLD was done daily; b) home exercises were completed daily; c) compression was used inconsistently, but reported 2-3 times per week; d) appropriate sleeping position was adopted; and e) skin care training was followed.

4. Outcomes

Following completion of clinical treatments, WG was re-evaluated. Facial lymphedema improved and reduction was observed by the CLT in the forehead, eyes, cheeks, and left chin. The base of anterior neck had a mild increase in fluid. Based on the Foldi’s scale, the patient’s external lymphedema was reduced from stage 2 to stage 1. Skin color decreased in degree of redness. Internal lymphedema and CROM were unchanged. Post treatment FEES testing showed that the patient’s swallowing function had no changes. However, the patient’s self-reported symptoms and function were substantially improved. That is, his soft food swallowing was improved from a pre-treatment severity of 10 to a post-treatment rating of 0. His fatigue level was reduced from 7 to 0. Sleeping problems were decreased from 5 to 0. Self-reported pain was reduced from 4 to 0. 

Discussion 

This case was selected because the patient developed lymphedema, as well as self-reported swallowing problems. WG underwent Phase I CDT. WG was educated and reported following through in self-MLD, exercise, adopted sleeping position, and skin care while compression occurred sporadically. Compared to WG’s pre-treatment, he had significant improvement in all areas of external lymphedema. Although internal lymphedema, dysphasia, and CROM had no changes, the patient’s self-reported symptoms (swallowing, sleeping, energy level, and pain) were substantially improved. The findings from this case study provide important information regarding the potential effectiveness of CDT on external lymphedema and symptom burden. In this study, we emphasized daily home self-care. Thus, these findings also point out that self-care of lymphedema is essential to successful lymphedema management. The findings indicate that studies with rigorous design are needed to evaluate effectiveness of CDT on head and neck lymphedema and to provide evidence for best management of head and neck lymphedema.

References 

    1. Deng J, Ridner SH, Dietrich MS, et al. Prevalence of secondary lymphedema in patients with head and neck cancer. J Pain Symptom Manage. 2012;43(2):244-52. 
    2. Smith BG, Lewin JS. Lymphedema management in head and neck cancer. Curr Opin Otolaryngol Head Neck Surg. 2010;18(3):153-8.
    3. Deng J, Murphy BA, Dietrich MS, et al. Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life. Head Neck. 2013;35(7):1026-35.
    4. Deng J, Ridner SH, Murphy BA. Lymphedema in patients with head and neck cancer. Oncol Nurs Forum. 2011;38(1):E1-E10.
    5. Oncology Nursing Society. http://www.ons.org/Research/PEP/Lymphedema. Accessed October 15, 2013.
    6. National Lymphedema Network. http://www.lymphnet.org/lymphedemaFAQs/positionPapers.htm. Accessed October 15, 2013.
    7. Zuther J E, Norton S. Lymphedema Management: The Comprehensive Guide for Practitioners. 2nd ed. New York,NY: Thieme; 2009.
    8. M.D. MF. Földi’s Textbook of Lymphology, For Physicians and Lymphedema Therapists. Mosby Incorporated; 2012. 
    9. Murphy BA, Dietrich MS, Wells N, et al. Reliability and validity of the Vanderbilt Head and Neck Symptom Survey: a tool to assess symptom burden in patients treated with chemoradiation. Head Neck. 2010;32(1):26-37. 
    10. Deng J, Ridner SH, Murphy BA, Dietrich MS. Preliminary development of a lymphedema symptom assessment scale for patients with head and neck cancer. Support Care Cancer. 2012;20(8):1911-8.