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36 Head and Neck Lymphedema
a
b
Fig. 36.3 (a, b)
Reabsorption maneuver
applied proximally toward
the para-auricular lymph
nodes
299
is performed proximal-to-distal on the lymphedematous area. It is repeated as
many times as necessary, until a decrease in tension of the lymphedematous tissue is perceived (Fig. 36.3).
Efficacy of the maneuvers described has been demonstrated through lympho-•
scintigraphic imaging.
9
Protocol for Manual Treatment of Lymphedema of the Face and Neck
The protocol for the manual treatment of lymphedema requires the use of the
maneuvers as described, with application in the following order:
1. Drainage of the most proximal lymph nodes. These receive the lymph flow
derived from the area involved. In head and neck lymphedema, the proximal
300 A.-M. Vaillant-Newman and S.G. Rockson
lymph nodes are the supra-clavicular lymph nodes, or, if the lymphedema extends
to the shoulder region, the axillary lymph nodes.
2. Drainage of the intermediate lymph nodes of the neck and face:
(a) Sternocleidomastoid lymph nodes
(b) Sub-mental lymph nodes
(c) Sub-mandibular lymph nodes
(d) Pre- and infra-auricular lymph nodes
3. These lymph node maneuvers are followed by the maneuvers on the anastomotic
or substitution pathways. Several anastomotic pathways have been described
(Olivier Leduc, unpublished observations). Two such pathways link the two sets
of auricular lymph nodes, and are distributed above the upper lip and below the
lower lip.
4. Once the maneuvers on the lymph nodes and along the anastomotic pathways
have been completed, the call-up maneuver will be applied (if there is a
lymphedema-free region between the most proximal lymph nodes and the
lymphedematous zone). The call-up maneuver is applied initially to the lymphedema-free area and proximal to the lymphedematous site. This maneuver has
been shown experimentally to enhance the efferent lymph flow from the lymphedematous area. Efficacy of the described maneuvers has been demonstrated
through lymphoscintigraphic imaging.
9
5. Next, the specific treatment of the lymphedematous area begins with applica-
tion of the reabsorption maneuver, proximal-to-distal. The proximal end of
the lymphedematous area is the aspect closest to the draining lymph nodes.
The lymphedematous area will be divided into sections, each of which will be
drained as previously described. The change in the consistency of tissues in
the treated area is the factor that dictates when the maneuver can be considered complete, allowing the therapist to progress to the next, more distal
section.
The lymphedematous area will be drained toward the para-auricular lymph nodes
as well as toward the sub-mandibular lymph nodes.
6. After all of the sections of the lymphedematous facial, neck or scalp area have
been completely addressed with the reabsorption technique, the call-up tech-
nique is applied distal-to-proximal on each section.
7. At the end of the treatment, specific lymph node maneuvers, described above,
will be applied successively to each set of lymph nodes from the most distal set
to the most proximal set, concluding the treatment session.
Multi-Layered Bandaging Leduc Method
The multi-layered bandaging technique requires the application of a set of semirigid bandaging materials that provide a counter-pressure to the pressure generated
by muscular contractions. The multi-layered bandaging technique includes the
application of a stockinette (to protect the skin), foam, and low-stretch bandages
applied to the area involved without exerting any tension.
36 Head and Neck Lymphedema
Fig. 36.4 Multi-layered
bandaging addressing
lymphedema on the right
hemi-face and neck
301
This bandage is effective when the subject is active and performs muscular
contractions in the lymphedematous area.10 In the context of head and neck lymphedema, it is assumed that the patient is not isolated and has some interactions with
others, utilizes facial expressions and head movements, and performs speech. To
address facial lymphedema, the multi-layered bandaging must be anchored in areas
proximal and distal to the involved site. In between these two pieces a bridge applies
pressure to the lymphedematous area (Fig. 36.4). The treatment is best performed in
the home, to minimize stressful situations for the patient. Efficacy of the multi-layered bandaging on colloidal protein reabsorption during muscular activity has been
demonstrated by lymphoscintigraphy.
10
Stimulation of Muscular Activity
The patient should be educated in exercises of the facial musculature. These should
be performed specifically while wearing the multi-layered bandaging. Asking the
patient to repeat vowels in front of the mirror, 3–4 times a day, is an easily comprehended form of such exercise.
Compression Garment
To maintain the results gained by the manual lymph drainage and multi-layered
bandaging a compression garment will be required. For mild cases of facial
302 A.-M. Vaillant-Newman and S.G. Rockson
lymphedema, a ski mask can fulfill this function, but a medical garment for facial
edema may be necessary. The garment is typically worn in the home.
Education in Precautions to Apply to Avoid Exacerbation of Symptoms
The patient must be educated to avoid sun exposure, as well as activities that expose
the involved regions of the skin to abrasion, laceration or burn. The patient will be
asked to practice strict hand hygiene to avoid self-contamination. Avoidance of skin
scratching and eye rubbing is recommended.
Education in skin care is paramount, when one considers that infection is the
major complication of lymphedema. Strict skin and hair hygiene is recommended,
with, minimally, a daily evening shower. Regular use of a skin moisturizer is also
strongly recommended.
Education in Self-Treatment
If the patient demonstrates a good understanding of the condition and is willing to
participate in the lymphedema management, education in the approach to selftreatment is feasible. At times, a family member will volunteer to apply the manuaI technique. In the case of a child suffering from lymphedema, the parents will
be educated. In these situations, the patient or parents will be educated in a simplified version of manual lymph drainage. Maneuvers are taught, to be applied by a
family caregiver. The patient or family caregiver will be taught to initially apply
the maneuver to the supraclavicular, sub-mental, sub-mandibular, and pre-auricular lymph nodes. The call-up and reabsorption maneuvers are not incorporated.
Similarly, multi-layered bandaging is not incorporated into the self-treatment
approach, which simply features skin mobilization combined with the application
of very gentle pressure. The maneuver is undertaken by the patient or caregiver,
progressing proximal-to-distal at the lymphedematous site. After the entire
involved area has been treated, the maneuvers on the lymph nodes are repeated.
The self-treatment should be closely monitored. The patient, or the parents of the
patient, should be provided with a pictorial guide, including practical comments.
If self-treatment education is feasible, it will be implemented early in the treatment intervention, to permit thorough training. Self-management techniques are
not as effective as those applied by a physical or occupational therapist, but they
do permit the patient, or family caregiver, to perceive changes in the consistency
of tissues or in the skin temperature. The patient, or parents, should be made
aware of the necessity to seek medical care if a change in tissue volume, tissue
consistency, or skin temperature is detected. Erythema or pain in the area involved
36 Head and Neck Lymphedema
a
b
303
should also prompt medical consultation, as these symptoms may indicate the
development of dermatolymphangioadenitis.
Multi-layered bandaging is purposefully not incorporated into the self-treatment
approach, inasmuch as there is a risk that uneven pressure application and undesired
pressure gradients will be created when the bandaging materials are applied by the
patient or a family member.
In the Leduc method the notion of self-treatment is not considered to be appropriate. Initial and maintenance stages of the treatment are performed by the physical
therapists.
An Example of Self-Treatment of Head and Neck Lymphedema
We will consider the case of a child affected by left-sided facial lymphedema. After
initial instruction, the parents are photographed performing the technique.
These photographs are provided to the parents to guide their attempts at selftreatment.
In this case, the treatment begins with the lymph node maneuver on the supraclavicular lymph node (Fig. 36.5), progressing to the nodes at the side of the neck,
then to the sub-mental and sub-mandibular lymph nodes (Fig. 36.6), and, finally, the
pre- and infra-auricular lymph nodes (Fig. 36.7).
Once the maneuver on the lymph nodes has been completed, the maneuver on
the anastomotic or substitution pathways is performed. This maneuver consists of
mobilization of the skin in the direction of the left, non-involved, pre-auricular, and
infra-auricular lymph nodes. This mobilization is initially applied close to the left
lymph nodes and progressively further from the non-involved auricular lymph nodes
Fig. 36.5 (a, b) Maneuver of the supra-clavicular lymph nodes
304 A.-M. Vaillant-Newman and S.G. Rockson
Fig. 36.6 Maneuvers on the lymph nodes
located along the jaw (sub-mandibular
lymph nodes). Position your hand as
illustrated on the picture. Apply gentle
pressure and mobilize the skin (5-7
repetitions). Precautions: do not slide skin,
do not rub skin, mobilize the skin gently,
apply very gentle pressure, rhythm must be
slow (example of documentation remitted to
the parents to illustrate a specific maneuver)
Fig. 36.7 Mobilization of the
skin, combined with gentle
pressure, toward the
para-auricular lymph nodes,
as indicated by the arrow
along a line running horizontally above the upper lip and simultaneously along a
horizontal line running below the lower lip. When the fingers meet the involved area
the maneuvers are interrupted.
The single maneuver described above is applied proximal-to-distal on the lymphedematous area, and repeated as many times as necessary to trigger a decrease in
the tension of the lymphedematous tissues
36 Head and Neck Lymphedema
305
The treatment will end with the lymph node maneuver, applied to the pre- and
infra-auricular lymph nodes, the sub-mandibular and sub-mental lymph nodes,
along the neck, and, finally, to the supra-clavicular lymph nodes. As mentioned
above, the parents will be provided with a pictorial guide with practical comments
(Fig. 36.6).
Rehabilitation to Address Functional Impairments
As mentioned initially, injury to the spinal accessory nerve may trigger denervation
of the upper trapezius muscle and, sometimes, minor impairment of the sternocleidomastoid muscle. These nerve lesions generate shoulder drop and protracted,
limited active range of motion, especially in shoulder flexion and, sometimes, in
shoulder abduction, muscle strength impairment, and pain.11 The medical literature
amply documents the profound impact of shoulder dysfunction on quality-of-life in
patients treated for head and neck cancer. Shah et al., in a study of short- and longterm quality of life after neck dissection, documented that shoulder dysfunction and
neck tightness had the greatest negative impact.12 Thus, post-surgical evaluation,
with frequent, regular assessment of shoulder function should be implemented in
these patients, in order to initiate immediate physical or occupational therapy when
needed. During sessions of physical or occupational therapy, assessment of balance
and strength should be implemented for early remediation or life style adaptations.
Quality of Life
As stated initially, treatment of head and neck cancers may trigger a variety of
dysfunctional consequences beyond lymphedema. Patients receiving radiationbased therapy for locally advanced squamous carcinoma of the head and neck
develop acute dysphagia consequent to pain, copious mucous production, xerostomia and tissue swelling. Early evaluation and treatment by speech and language
pathologists permits the identification of patients with clinically significant aspiration; in these cases, a treatment plan that includes patient education and swallowing therapy can significantly enhance quality-of-life. Well-monitored dietary
adaptations must be implemented to address swallowing and the risk of maladaptive feeding changes.
Lymphedema of the face and neck generates emotional and social dysfunction
which must be assessed and addressed in a timely fashion to maximally enhance the
quality-of-life for patients and family.
13
306 A.-M. Vaillant-Newman and S.G. Rockson
References
1. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol.
2008;52(10):799-806.
2. Rockson S. Current concepts and future directions in the diagnosis and management of lym-
phatic vascular disease. Vasc Med. 2010;15(3):223-231.
3. Rockson SG. Secondary lymphedema: Is it a primary disease? Lymphat Res Biol. 2008;6(2):
63-64.
4. Rockson S. Lymphedema: evaluation and decision making. In: Cronenwett JL, Johnston KW,
eds. Rutherford’s Vascular Surgery. Philadelphia: Elsevier; 2010:1004-1016.
5. Mortimer PS. Managing lymphedema. Clin Dermatol. 1995;13(5):499-505.
6. Withey S, Pracy P, Vaz F, Rhys-Evans P. Sensory deprivation as a consequence of severe head
and neck lymphoedema. J Laryngol Otol. 2001;115(1):62-64.
7. Fialka-Moser V, Crevenna R, Korpan M, Quittan M. Cancer rehabilitation: particularly with
aspects on physical impairments. J Rehabil Med. 2003;35(4):153-162.
8. Murphy BA, Gilbert J, Cmelak A, Ridner SH. Symptom control issues and supportive care of
patients with head and neck cancers. Clin Adv Hematol Oncol. 2007;5(10):807-822.
9. Leduc O, Bourgeois P, Leduc A. Manual lymphatic drainage scintigraphic demonstration of its
efficacy on colloidal protein reabsorption. In: Partsch H, ed. Progress in Lymphology. Oxford:
Elsevier; 1988:551-554.
10. Leduc O, Peters A, Bourgeiois P. Bandages: scintigraphic demonstration of its efficacy on col-
loidal protein reabsorption during muscle activity. Lymphology. 1990;12:421-423.
11. Cappiello J, Piazza C, Giudice M, De Maria G, Nicolai P. Shoulder disability after different
selective neck dissections (levels II-IV versus levels II-V): a comparative study. Laryngoscope.
2005;115(2):259-263.
12. Shah S, Har-El G, Rosenfeld RM. Short-term and long-term quality of life after neck dissec-
tion. Head Neck. 2001;23(11):954-961.
13. Murphy BA, Gilbert J. Dysphagia in head and neck cancer patients treated with radiation:
assessment, sequelae, and rehabilitation. Semin Radiat Oncol. 2009;19(1):35-42.
Chapter 37
Genital Lymphedema
Waldemar L. Olszewski
Introduction
The involvement of the external genitalia, leading to a marked increase in volume
is an uncomfortable clinical situation, with impairment of movement, hygiene procedures, voiding in the standing position, and sexual intercourse.
Genital lymphedema develops as a consequence of:
(a) Stagnation of lymph flow in the skin and subcutaneous tissue of the scrotum,
penis, labia, and hypogastrium after infection of external genitalia, inguinal lymphadenectomy in cancer of the penis, labia or perineal region, and radiotherapy of
the inguinal and iliac areas as adjunctive cancer therapy (Fig. 37.1a, b).
(b) Chyloperitoneum with backflow of intestinal lymph to the peritoneal cavity,
genitals, and lower limbs.
(c) Chyluria with oozing of lymph into the retroperitoneal space and backflow to
the pelvis and genitalia.
Anatomy
Genital lymphedema usually affects the skin and subcutaneous tissue of the scrotum,
penis, labia, and hypogastrium, but not the testes, uterus, or ovaries. The lymphatic
drainage of genital skin is directed toward the inguinal nodes (Fig. 37.2).
W.L. Olszewski
Department of Surgical Research and Transplantology,
Medical Research Centre, Warsaw, Poland
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_37, © Springer-Verlag London Limited 2011
307
308 W.L. Olszewski
a
b
a
b
1
2
3
4
11
10
9
Glans penis
Lateral plexus of the frenulum (Oanezza’s plexus)
Coronary trunk of the glans
Collectors of the skin of the penis
Scrotum
Superomedial superficial inguinal l.n.’s
Inferomedial superficial inguinal l.n.’s
Medial collectors of the thigh
Perineal collectors
Inferolateral inguinal l.n.’s
Raphe of the penis, scrotum, and perineum
1
2
3
4
5
6
7
8
9
10
11
Superomedial superficial inguinal l.n.’s
Inferomedial superficial inguinal l.n.’s
Skin of the penis
Scrotum
inferolateral inguinal l.n.’s
Superficial dorsal vein of the penis
1
2
3
4
5
6
8
7
6
5
6
1
2
3
4
5
Fig. 37.1 (a) Lymphedematous scrotum hiding the penis. Papilloma-like hypertrophy of the epi-
dermis and blisters containing stagnant lymph. Edema developed within 1 year and was followed
by frequent septic attacks of dermato-lymphangio-adenitis. (b) Lymphedema of the penis and scrotum pulling down the hypogastrium skin. Swelling appeared after inflammation of the preputium
Fig. 37.2 The anatomy of the lymphatic drainage of the perineum, scrotum, and penis. Note that
the lymphatics drain the skin and subcutaneous tissue, but not the testes. The draining targets are
the inguinal superficial nodes