Beyond Swelling: Redefining Head and Neck Lymphedema through Surveillance and Prevention

Purpose: Lymphedema is a common late effect of head and neck cancer treatment that causes various symptoms, functional impairment, and poor quality of life. We completed a pilot, prospective, single-arm clinical trial to determine the feasibility and potential efficacy of the use of photobiomodulation (PBM) therapy for head and neck lymphedema. In this study, we report patients' perceived treatment experience of PBM therapy and provide suggestions to better understand head and neck cancer survivors' experience of PBM therapy. Methods: Head and neck cancer patients who underwent PBM therapy completed face-to-face semi-structured interviews. Interviews were audio-recorded and then transcribed verbatim. Qualitative content analysis was used to analyze the transcriptions from the interviews. Results: Among 12 participants who consented for the study, 11 (91.7%) completed the PBM therapy. Participants described positive experiences and unique benefits about the PBM therapy, for example, decreased swelling, reduced tightness, increased range of motion, increased saliva production, and improved ability to swallow. Some participants (n = 5, 45.5%) delineated challenges related to traffic, travel time, and distance from study location. Many participants proposed suggestions for future research on PBM therapy, for example, research on internal edema and its relationship with swallowing, and indicated patients with severe lymphedema and fibrosis may be more likely to benefit. Conclusions: Findings from this study suggested the potential benefits of PBM therapy in treatment of chronic head and neck lymphedema. Rigorously designed clinical trials are needed to evaluate the effect of PBM therapy for head and neck cancer-related lymphedema. Trial Registration Number and Date of Registration: ClinicalTrials.gov Identifier: NCT03738332; date of registration: November 13, 2018.

Purpose: Head and neck lymphedema is a common condition following head and neck cancer (HNC) treatment, with substantial functional morbidity. This systematic review aimed to (1) identify tools used to assess head and neck lymphedema in HNC patients and (2) determine their validity and reliability. Methods: Electronic and hand searches of Prospero, MEDLINE, Cochrane Library, and Embase were searched from their inception until April 2021, and hand searches were independently screened by two reviewers. Studies were included if they were available in English and measured lymphedema in adult HNC patients (aged ≥18 years). Data including psychometric characteristics were extracted and synthesized narratively, with the Quality Assessment of Diagnostic Accuracy Studies-2 and the COnsensus-based Standards for the selection of health Measurement INstruments checklists used to assess risk of bias. Results: Thirty-three studies, reporting 38 assessment tools, were included. Assessments included clinician rating scales, symptom inventories, size measures, measures of internal edema, radiographic and ultrasonographic measures, and quality-of-life measures. Of the 38 measures cited, only 11 had any degree of validation and reliability testing. Risk of bias varied among the different assessment tools. Conclusion: While many tools are used in the assessment of head and neck lymphedema, the majority of these tools lack validation and reliability data. Only one tool, the Head and Neck Lymphedema and Fibrosis Symptom Inventory, met criteria for strong quality assessment. Further efforts to establish a core set of metrics for this complex condition are warranted.

Ten head and neck cancer survivors diagnosed with head and neck lymphedema (HNL) were imaged using near-infrared fluorescence lymphatic imaging (NIRFLI) prior to and immediately after an initial advance pneumatic compression device treatment and again after 2 weeks of daily at-home use. Images assessed the impact of pneumatic compression therapy on lymphatic drainage. Facial composite measurement scores assessed reduction/increase in external swelling, and survey results were obtained. After a single pneumatic compression treatment, NIRFLI showed enhanced lymphatic uptake and drainage in all subjects. After 2 weeks of daily treatment, areas of dermal backflow disappeared or were reduced in 6 of 8 subjects presenting with backflow. In general, reductions in facial composite measurement scores tracked with reductions in backflow and subject-reported improvements; however, studies are needed to determine whether longer treatment durations can be impactful and whether advanced pneumatic compression can be used to ameliorate backflow characteristic of HNL.

Cervicofacial lymphoedema is a recognised side-effect that may result following treatment for head and neck cancer. This study aimed to investigate the perspectives of affected patients and the beliefs that treating health professionals hold about head and neck lymphoedema. Ten patients with head and neck lymphoedema and 10 health professionals experienced in the treatment of head and neck cancer patients agreed to participate in semi-structured face to face interviews. Interviews were recorded, audio files were transcribed and coded and then analysed for themes. Themes of experiences of patients with head and neck lymphoedema and the beliefs of health professionals largely overlapped. Given its visible deformity, the main effect of lymphoedema in head and neck cancer patients was on appearance. In some cases this lead to negative psychosocial sequelae such as reduced self-esteem, and poor socialisation. Clinicians need to be aware of those patients more likely to experience lymphoedema following treatment for head and neck cancer, and how they are affected. Understanding how patients with facial lymphoedema are affected psychologically and physically, and the importance of prompt referral for lymphoedema treatment, might ultimately improve outcomes and ensure optimal management.

Secondary lymphedema after head and neck cancer treatment is a serious complication and its management can be a challenge. The purpose of this study was to verify which physical therapy modalities were applied in the treatment of head and neck lymphedema through a retrospective analysis. A retrospective study was developed, based on the analysis of medical records of 32 patients treated in the physiotherapy outpatient department of the Brazilian Institute of Cancer Control (IBCC). The physiotherapy included manual lymphatic drainage, massage, exercises, patient education, and compression therapy with an average of 23.9 ± 14.8 sessions. Measurement results showed a significant reduction of face and neck lymphedema (p < .05) and pain (from 7.8 ± 2.2 to 3.6 ± 1.6; p < .001). The physical therapy modalities based on strategic manual lymphatic drainage, shoulder girdle massage, facial, tongue and neck exercises, compressive therapy at home, and patient education showed reduction of the lymphedema and pain, both of them secondary to head and neck cancer treatment.

Fasciocutaneous Vascularized Lymph Node Transfer for Head and Neck Lymphedema: A Case Report.

Head and neck lymphoedema (HNL) is a chronic and often debilitating consequence of head and neck cancer (HNC) treatment. Despite the chronicity, it is often under-recognised and under-treated. There is a finite resource of specialists to provide HNL intervention, necessitating self-management as an important pillar of patient management. This study aims to explore healthcare professionals (HCPs) understanding, perceptions and experiences of HNL management to promote self-management and adherence to HNL interventions in patients following completion of HNC treatment. Eight focus groups were conducted with HCPs (n = 39) from different professional disciplines, acute and community settings and countries. Reflexive thematic analysis was adhered to in the development of key themes using an inductive approach. Two main themes were established: (1) 'Raising awareness of HNL as a chronic and complex condition' and (2) 'What are the solutions for promoting HNL self-management?' Data demonstrated that HCPs lack confidence and understanding in providing HNL support. There was a lack of clarity towards roles and responsibilities of HNL management among HCPs, with many having a desire to be better equipped to promote patient self-management and adherence. HCPs involved in care delivery of patients with HNC require education and training on HNL, to support patient and family engagement with HNL self-management. To advance adherence and compliance of HNL self-management, there is a need to develop a dedicated HNL self-management intervention, integrating theory and evidence.

This study examined symptoms reported by patients after open-ended questioning vs those systematically assessed using a 48-question survey. Consecutive patients referred to the palliative medicine program at the Cleveland Clinic Foundation were screened. Open-ended questions were asked initially followed by a 48-item investigator-developed symptom checklist. Each symptom was rated for severity as mild, moderate, or severe. Symptom distress was also evaluated. Data were collected using standardized pre-printed forms. Two hundred and sixty-five patients were examined and 200 were eligible for assessment. Of those assessed, the median age was 65 years (range 17-90), and median ECOG performance status was 2 (range 1-4). A total of 2,397 symptoms were identified, 322 volunteered and 2,075 by systematic assessment. The median number of volunteered symptoms was one (range zero to six). Eighty-three percent of volunteered symptoms were moderate or severe and 17% mild. Ninety-one percent were distressing. Fatigue was the most common symptom identified by systematic assessment but pain was volunteered most often. The median number of symptoms found using systematic assessment was ten (0-25). Fifty-two percent were rated moderate or severe and 48% mild. Fifty-three percent were distressing. In total, 69% of 522 severe symptoms and 79% of 1,393 distressing symptoms were not volunteered. Certain symptoms were more likely to be volunteered; this was unaffected by age, gender, or race. The median number of symptoms found using systematic assessment was tenfold higher (p<0.001) than those volunteered. Specific detailed symptom inquiry is essential for optimal palliation in advanced disease.

Head and neck lymphedema can occur in the internal or external structures of the head and neck region. Little is known about the development of this condition over the course of treatment for head and neck cancer. This study aimed to observe the development of internal and external lymphedema from diagnosis to 12weeks postacute treatment. A single center, prospective observational cohort study assessed participants for external lymphedema, internal lymphedema, quality of life, and symptom burden. Assessments were conducted prior to starting radiotherapy (RT), at the end of RT, 6 and 12weeks after RT. Forty-six participants were recruited. External lymphedema as measured by percentage water content, increased from 41.9 at baseline (95% CI: 39.3-44.4) to 50.4 (95% CI: 46.0-54.8) at 12weeks following RT (p-value<.001). After adjusting for changes in weight and participant age at baseline, a general increase in tape measurements was observed over time with significant increases from baseline to 12weeks post-RT for all measurement points. By 12weeks post-RT, all participants had lymphedema present in eight of 13 internal sites assessed. Internal and external head and neck lymphedema was observed to increase from baseline to 12weeks after completion of RT without abatement. People with head and neck cancer should be educated about the potentially extended duration of this treatment side effect. Further research is required to determine the point at which swelling symptoms recede.

The purpose of this review is to summarize current evidence regarding management of head and neck lymphoedema (HNL) to improve dysphagia outcomes following head and neck cancer (HNC) treatment. This review aims to support complete decongestive therapy (CDT) comprising compression, manual lymphatic drainage (MLD), exercises and skincare as an adjunct of dysphagia rehabilitation. Research in the limbs supports the use of CDT to improve lymphoedema outcomes. Emerging evidence supports the use of CDT for the head and neck, though, there is no consensus on optimal treatment required to improve dysphagia outcomes. Current evidence is limited due to a paucity of randomized controlled trials, case series or cohort studies with small participant numbers, and a lack of functional and instrumental dysphagia outcome measures. This provides a foundation to design and test an individually tailored programme of HNL intervention to evaluate swallowing outcomes post CDT. As the incidence of HNC is increasing with HPV, with patients living for longer with late effects of HNC treatment, it is vital to understand how the presence of HNL impacts on the swallow, and if functional dysphagia outcomes improve following treatment of HNL. Prospective, longitudinal research with objective and functional outcome measures are required to help determine optimal management of HNL and its impact on the swallow.

Purpose:Lymphedema is a common debilitating late effect among patients post-head and neck cancer (HNC) treatment. Head and neck lymphedema was associated with symptom burden, functional impairment, and decreased quality of life. The objective of this study was to determine the feasibility and potential efficacy of the use of photobiomodulation (PBM) therapy for head and neck lymphedema, symptom burden, and neck range of motion among HNC survivors.Methods:This was a single-arm, pre- and post-design clinical trial. Eligible patients included those with lymphedema after completion of complete decongestive therapy (CDT) and 3 to 18 months after completion of cancer therapy. The intervention included PBM therapy 2 times a week for 6 weeks for a total of 12 treatments. Lymphedema, symptom burden, and neck range of motion were measured at baseline, end-of-intervention, and 4-week post-intervention.Results:Of the 12 patients enrolled in the study, 91.7% (n = 11) completed the study intervention and assessment visits, and no adverse events were reported. When comparing the baseline to 4-week post-intervention, we found statistically significant improvements in the severity of external lymphedema, symptom burden, and neck range of motion (all P < .05).Conclusion:PBM therapy was feasible and potentially effective for the treatment of head and neck lymphedema. Future randomized controlled trials are warranted to examine the efficacy of PBM therapy for HNC-related lymphedema.Trial Registration Number and Date of Registration:ClinicalTrials.gov Identifier: NCT03738332; date of registration: November 13, 2018.

PurposeHead and neck cancer (HNC) treatments often lead to significant morbidity, including lymphedema. This systematic review aims to comprehensively explore the prevalence and impact of head and neck lymphedema (HNL) following treatment.MethodsA systematic literature search was conducted up to September 2023. Studies evaluating HNL prevalence, associated factors, impact, patient-reported outcomes (PROMs), and physical assessments were included. Methodological quality assessment was performed, and data were synthesised narratively.ResultsTwelve studies met the inclusion criteria, with methodological quality ranging from moderate to high. Internal lymphedema prevalence was consistently higher than external lymphedema, with varying rates attributed to treatment modalities and assessment methods. PROMs such as the Lymphedema Symptom Intensity and Distress-Head and Neck and physical assessments including Patterson’s Rating Scale were commonly utilised. HNL significantly impacted quality of life and physical function, with reported symptoms including discomfort, tightness, swallowing difficulties, and psychological distress.ConclusionHNL is a common sequela of HNC treatment with significant implications for individuals’ QoL. Standardised assessment protocols and tailored interventions are needed to address the needs of individuals with HNL and improve overall outcomes.Implications for Cancer SurvivorsThis systematic review highlights a significant prevalence of lymphedema, particularly internal lymphedema in the larynx and pharynx, following treatment. Swallowing difficulties, nutritional issues, anxiety, depression, and body image concerns were associated with both internal and external lymphedema. The impact on quality of life is substantial, with survivors experiencing physical symptoms and psychosocial challenges, emphasising the importance of integrated care approaches tailored to both aspects of well-being.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11764-024-01683-3.

Xerostomia is the most common acute and late side effect of radiation treatment for head and neck cancer. Affecting taste perception, chewing, swallowing and speech, xerostomia is also the major cause of decreased quality of life. The aims of this study were to validate the Italian translation of the self-reported eight-item xerostomia questionnaire (XQ) and determine its psychometric properties in patients treated with radiotherapy for head and neck cancer. An observational cross-sectional study was conducted in the Radiotherapy Unit of the Veneto Institute of Oncology - IOV in Padua. The XQ was translated according to international guidelines and filled out by 102 patients. Construct validity was assessed using principal component analysis, internal consistency using Cronbach's α coefficient and test-retest reliability at 1-month interval using the intraclass correlation coefficient (ICC). Criterion-related validity was evaluated to compare the Italian version of XQ with the European Organization for Research and Treatment of Cancer (EORTC) Core Quality-of-Life Questionnaire (QLQ-C30) and its Head and Neck Cancer Module (QLQ-H&N35). Cronbach's α for the Italian version of XQ was strong at α = 0.93, test-retest reliability was also strong (0.79) and factor analysis confirmed that the questionnaire was one-dimensional. Criterion-related validity was excellent with high association with the EORTC QLQ-H&N35 xerostomia and sticky saliva scales. The Italian version of XQ has excellent psychometric properties and can be used to evaluate the impact of emerging radiation delivery techniques aiming at preventing xerostomia.

Debridement is an essential component of wound care. However, autolysis remains a frequently used method of debridement, despite recent recommendations from the European Wound Management Association and the National Institute for Health and Care Excellence. Community nurses are recognised as front-line clinicians participating in debridement interventions. It is essential that community nurses are able to deliver the most appropriate debridement method regardless of their current skill set. This will require community nurses to revisit the evidence base for debridement, reflect on their current methods of debridement and expand their skill set when required. Guidance exists to ensure community nurses are able to offer appropriate and safe debridement to clients with non-viable tissue which is delaying the wound healing process.

The Importance of Self-Care Rehabilitation in Irradiated Head and Neck Cancer Patients