Functional Impairments of Head and Neck Lymphedema

Scottsdale, AZ—Head and neck lymphedema (HNL) is a common but underrecognized and poorly managed complication of treatment for head and neck cancer, but its accompanying functional impairments can be improved with targeted therapy, according to Jan S. Lewin, PhD.

"Everybody recognizes that there's a huge cosmetic component, but I think far fewer recognize the significance of the functional consequences," said Dr Lewin at the 2016 Multidisciplinary Head and Neck Cancer Symposium.

Up to 75% of treated head and neck cancer patients will develop HNL. There is currently no standard method of assessment for the condition, and the data surrounding it remain sparse.

"External presentation of HNL is what we're most familiar with," said Dr Lewin, a professor in the Department of Head and Neck Surgery and Section Chief of Speech Pathology and Audiology at The University of Texas MD Anderson Cancer Center in Houston. It involves overtly visible edema of the neck, face, oral cavity, and supraclavicular region and is typically characterized by a "double chin." It ranges from soft and reversible edema to hard, pitting, irreversible edema.

The other type of HNL is internal, and it is a chronic edema of the larynx and pharynx. "This is a challenging type of lymphedema, because it's invisible to peripheral examination," she said. "The problem is we can't physically assess or treat it because we can't palpate it."

Significant Functional, Emotional, and Psychosocial Impact

HNL affects respiration and communication, particularly when present in the laryngeal region. In the oral phase, patients with HNL experience difficulty with mastication and transit, food spillage, and drooling, and in the pharyngeal phase, a narrowing of the pharynx can cause difficulty with the transit of food. "And when lymphedema is present in the submental region, patients can experience difficulty performing the strategies and exercises that have been shown to be so beneficial in assisting with swallowing problems," Dr Lewin added.

Patients with HNL can also experience significant difficulty with reading, writing, and walking, as well as general discomfort, depression, frustration, and embarrassment.

What Works and What Doesn't

According to Dr Lewin, diuretics provide only temporary relief; debulking and/or liposuction of the head and neck flaps offer no long-term benefit; elevation of the head is not effective; and most people do not tolerate compression pumps.

"And in our experience to date, we see very little benefit to relief of internal HNL from external compression," she noted.

"What does work is complete decongestive therapy (CDT)," she said. CDT combines 4 different areas of treatment: gentle massage that helps with manual lymph drainage, compression bandaging and the use of garments to help mitigate swelling, skin care (when needed), and remedial exercises, particularly swallowing exercises, that are practiced when patients are wearing these garments or Kinesio Tape.

The CDT program involves an intensive phase employed for 2 to 4 weeks at a frequency of 3 to 5 days per week, a maintenance phase consisting of daily home therapy for 1 to 3 months, and a home program performed by the patient or their significant other.

MD Anderson Retrospective Cohort

Dr Lewin and her colleagues at MD Anderson recently published a retrospective cohort study characterizing their experience with more than 1200 patients with lymphedema, and they have just begun analyzing the patients who have returned for follow-up.

Tumor sites and surgery type in the study cohort varied, and all patients received a CDT home management protocol, with or without formal outpatient treatment. Of 1202 total patients, 83% complained of cosmetic problems, but more than one-third (37%) also complained of functional problems, and, of those, more than two-thirds (68%) complained of swallowing problems.

"I want to emphasize that the majority of these patients are doing this therapy at home," Dr Lewin said. "But even if patients do this therapy at home, initial results show 60% are improving and sustaining improvement."

"What predicted our outcomes was really exercise adherence," she added. "The good news is, if patients even partially did what we asked them to do, they had a significant improvement over those who did not adhere to the therapy protocol." Physical outcomes at last follow-up (median, 6 months) show 70% overall improvement, she reported.

According to Dr Lewin, future investigations must distinguish important variables associated with durable response in order to help minimize lymphatic damage and establish new methods of treatment for refractory HNL.

"The measurement and management of internal HNL must be a priority if we are going to improve related swallowing dysfunction," she stated. 

Reference

Lewin JS. Role of lymphedema therapy. Presented at: Multidisciplinary Head and Neck Cancer Symposium; February 18-20, 2016; Scottsdale, AZ.