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Vol. 28 No. 2 - A Multi-modal Approach to Treatment of Head and Neck Lymphedema Following Thyroid Cancer: A Case Study

By Adrien Grey MacKenzie, PTA, CLT-LANA, LMT
Vanderbilt Lymphedema Therapy Clinic, Vanderbilt University Medical Center, Nashville, TN

Vol. 28 No. 2 - Lymphlink Reprint, Archived April 2015

Reason for Presenting Case Study

A variety of cancers affect the head and neck, and treatments for these vary widely. All patients receiving cancer treatments that disrupt the lymphatic system are at risk for lymphedema. Complete decongestive therapy (CDT), the treatment approach to address lymphedema, may require unique adaptations and different applications when addressing the face, head, and neck as opposed to a limb.1-3 This report covers the successful treatment of a case of head and neck lymphedema following treatment for thyroid carcinoma utilizing components of CDT4 along with other manual techniques.5

Medical History

The patient, JM, received her cancer diagnosis in September 2013 and was treated with a total thyroidectomy, parathyroidectomy, and left neck dissection to level V, as well as radioactive iodine and oral chemotherapy following surgery. Prior to her cancer treatment, she had no evidence of facial swelling and reported no functional limitations in her job as a surgical nurse or in her home life. 

Lymphedema Diagnosis

JM reported that she was given some exercises to perform independently at home by the acute care physical therapist after her surgery. She stated, however, that no one educated her about the risks of lymphedema at any point during her initial cancer treatment; she was surprised when she experienced swelling and a sense of strangulation, causing difficulty swallowing, along with post-surgical limitations in her strength and cervical (neck) and shoulder range of motion. At approximately ten weeks post-surgery, she was taught some lymphedema self-care exercises by her surgical oncologist and presented to the lymphedema clinic approximately 12 weeks post-surgery. 

Examination

The evaluating certified lymphedema therapist (CLT) diagnosed stage 1 lymphedema, palpating thick fluid along the chin and left neck, and a major loss of myofascial mobility at the site of the scar. Swelling was visible, along with an inability to lift the left side of the mouth into a smile. The patient was unable to independently lift the left shoulder to 100 degrees in standing. Strength of this joint was measured at 3-/5; cervical lateral flexion was limited to 11 degrees left and 20 degrees right. A moderate loss of cervical extension was noted; and rotation was found to be severely limited bilaterally. Additional symptoms included hypersensitivity of the left ear and neck, anxiety, sleep difficulties, and left shoulder pain. This left shoulder pain resulted in significant job challenges and the inability to dress independently. The patient reported that her greatest source of anxiety and concern was a constant sense of strangulation felt circumferentially.

Functional Limitations

JM works as a surgical nurse and continued working as able during her cancer and lymphedema treatment. She reported, however, that she was no longer able to dress herself or tie on her scrub cap independently, requiring the assistance of others or resting her elbow against the wall to allow her to lift her shoulder to perform this activity. She stated that although she was able to swallow, the act was significantly painful, causing increased anxiety. Hypersensitivity of her left ear and neck along with left shoulder pain affected her ability to sleep, as she had been in the habit of sleeping on her left side. 

Psychosocial History

JM lives with her adult son and husband, along with three dogs and one cat. She reported a history of anxiety, aggravated by the strangulation sensation. Her post-surgical anxiety led to use of Alprazolam. 

Pre-treatment Goals

  • Swelling of affected area will decrease by 2%.
  • Pain will decrease to 0.
  • Patient will be independent in self-care management of lymphedema (skin care, self-manual lymph drainage (MLD), compression).
  • Patient will demonstrate proper posture awareness and be proficient in home exercise program. 
  • Shoulder flexion will return to full range of motion in standing, cervical extension to moderate loss. 
  • Therapist will assess for appropriate compression garment and instruct in proper donning/doffing techniques.
  • Improve upper extremity functional scale to 80 (beginning score of 72/80 with difficulty lifting a bag of groceries overhead, grooming hair, dressing, and sleeping).
  • The patient’s stated goal was to achieve neck movement with decreased strangulation sensation. 

Treatment 

Treatment consisted of 12 sessions over eight weeks and covered skin care, risk reduction, education, MLD, exercise, and management of scar tissue. The patient declined compression due to a sense of strangulation and ear-area hypersensitivity.

Manual interventions focused approximately equally on MLD and on myofascial release (MFR). MLD was utilized to redirect fluid along alternate pathways toward the occipital and spinal accessory nodes. A simplified form of this technique was taught to the patient for self-treatment. MFR was employed to mobilize scar tissue adhesions and anterior cervical fascial restrictions in the hope of maximizing available lymphatic pathways and improving range of motion and pain levels in general. Cervical and upper extremity stretching and strengthening exercises were added to increase range of motion and strength for a return to normal work function. Elastic taping (ET) techniques were utilized to assist lymph flow by lifting and stretching the skin to redirect fluid toward the occiput and break fascial adhesions. Flow was addressed with fan shaped pieces anchored at the posterior neck applied at 0-20% stretch; asterisks applied at 50% stretch were used to address adhesions. 

Outcomes

Over the course of treatment, the patient and therapist observed both visually and with measurements that the minimal swelling reduction goal (2%) was met despite some residual swelling. Ten months after treatment, the patient reported that swelling continued to diminish and that pain was reduced to 0 for the most part, although she experienced “occasional spikes,” particularly while sleeping. Upon discharge, she was proficient in home exercise, self-MLD, and partially so for self-release of scar tissue. She achieved improved posture, shoulder range of motion within functional limits, and cervical range of motion in extension limited to a moderate loss; specific measurements for these were not taken as the patient, experiencing this functional improvement, chose not to attend her final visit for discharge measurements. She was fully able to dress and do her hair independently. She stated that she was pleased with her outcome and only wishes that she had started with lymphedema interventions sooner, as that may have lessened the severity and duration of her strangulation sensation. 

One year after cancer treatment, she had transitioned from full-time to part-time employment and reported improved quality of life as a result. She reported that accommodating to synthetic thyroid medication had been challenging, requiring frequent dosage adjustments until a few months after completing CDT in early 2014. 

Discussion 

Notable improvements in the patient’s post-treatment condition include a continued downward trend in edema with improved lateral symmetry, along with better swallowing and decreased pain. She did not receive a referral for treatment until 12 weeks post-op despite continued functional challenges. Without intervention, would this patient have had the level of improvement she achieved, or, lacking the strength to return to work, been at risk of permanent disability? Was ET critical to her success? Would she have fared better with standard compression treatment? Does exercise help to increase strength and range of motion more than myofascial release or are both required? Was MFR, MLD, or ET the key component to decreasing the sensation of strangulation? These are areas worthy of future research in head and neck lymphedema to best serve this population in a timely and cost-efficient manner.

XI. Summary.

Lymphedema and associated symptoms following treatment for thyroid cancer are complex, often requiring aggressive multi-modal therapeutic techniques. Compression may not be an acceptable component of treatment if these patients are experiencing hypersensitivity of areas proximal to the surgical site or anxiety producing symptoms such as strangulation sensations. MFR may be used to reduce aspects of the condition exacerbated by scar tissue and fascial adhesions. Modalities such as MLD and elastic taping may provide results that significantly improve appearance and quality of life.

References:

  1. Smith BG, Hutcheson KA, Little LG, et al. Lymphedema Outcomes in Patients with Head and Neck Cancer. Otolaryngol Head Neck Surg. 2014.
  2. Coopee, R. Use of “elastic taping” in the treatment of head and neck lymphedema. Lymphlink. 2008;20(4): 10-12.
  3. Zuther JE, Norton S, Armer JM. Lymphedema management, the comprehensive guide for practitioners. Thieme Medical Pub; 2013.
  4. Tomlinson CA, Archer KR. Manual therapy and exercise to improve outcomes in patients with muscle tension dysphonia: a case series. Phys Ther. 2015;95(1):117-28.

Acknowledgements:
Charlene Zimmerman, PT, DPT, CLT
Sheila H. Ridner, PhD, RN, FAAN