Lymphedema, neck swelling, pain and numbness after radiation and surgery

A lecture about life challenges after laryngectomy including lymphedema care can be viewed on YouTube.

Lymphedema

The lymph vessels drain fluid from tissues throughout the body and allow immune cells to travel throughout the body. Lymphedema is a localized lymphatic fluid retention and tissue swelling caused by a compromised lymphatic system. 

Lymphedema, a common complication of radiation and surgery for head and neck cancer, is an abnormal accumulation of protein-rich fluid in the space between cells which causes chronic inflammation and reactive fibrosis of the affected tissues. 

Radiation creates scarring which interferes with the function of the lymphatics. The cervical lymph nodes are generally removed when the cancer is excised. When the surgeons remove these glands they also take away the drainage system for the lymphatics and cut some of the sensory nerves. Unfortunately, most of the severed lymphatics and nerves are permanently cut. Consequently, it takes longer to drain the area, resulting in swelling. Like flooding after a heavy rain when the drainage system is broken, the surgery creates a backup of lymphatic fluid that cannot drain adequately, as well as numbness of the areas supplied by the severed nerves (usually in the neck, chin, and behind the ears). As a result, some of the lymphatic fluid cannot re-enter the systemic circulation and accumulates in the tissues.

The lymphatic system is similar to the gutter in draining

There are two types of lymphedema that can develop in patients with head and neck cancer: an external visible swelling of the skin or soft tissue and an internal swelling of the mucosa of the pharynx  and larynx. Lymphedema generally starts slowly and is progressive, rarely painful, causes discomfort in the form of a sensation of heaviness and achiness, and may lead to skin changes.

Lymphedema has several stages:

Stage 0: Latency stage – No visible/palpable edema

Stage 1:  Accumulation of protein-rich edema, presence of pitting edema that can be reduced with elevation

Stage 2;  Progressive pitting, proliferation of connective tissue (fibrosis)

Stage 3:  No pitting, presence of fibrosis, sclerosis, and skin changes

Lymphedema of the head and neck can cause several functional impairments.  

These include:

• Difficulty in breathing
• Impairment in vision
• Motor limitations (reduced neck motion, jaw tightness or trismus and chest tightness)
• Sensory limitations
• Speech, voice and swallowing problems (inability to use an electrolarynx difficulty in articulation, drooling, and loss of food from mouth)
• Emotional issues (depression, frustration and embarrassment)

Fortunately over time the lymphatics find newer way of drainage and the swelling generally goes down. Specialists in reducing edema (usually physical therapists) can assist the patient to enhance the drainage and shortening the time for the swelling to decrease. This treatment can also prevent the area from becoming permanently swollen and from developing fibrosis.

Lymphedema of the chin and  neck

Treatment of lymphedema includes:

1. Manual lymph drainage ( face and neck, deep lymphatics, trunk, intra oral) 
2. Compressive bandages and garments
3. Remedial exercises
4. Skin care
5. Elastic therapeutic tape (Kinesiotape)
6. Oncology rehabilitation

Diuretics, surgical removal (debulking), liposuction, compression pumps, and elevation of the head alone are ineffective treatments. 

Neck tightness and swelling due to lymphedema generally improve over time. Sleeping with the upper body in an elevated position can use gravity to speed the process of lymph fluid drainage.  A lymphedema treatment specialist can perform and teach manual lymph drainage that can help in reducing edema.  Manual lymph drainage involves a special type of gentle skin massage to help blocked lymphatic fluid drain properly into the bloodstream. Movement and exercise are also important in aiding lymphatic drainage. A head and neck lymphedema therapist can teach the patient specific exercises to improve the range of head and neck motion.

Manual massage to reduce lymphedema

                                           Manual massage to reduce lymphedema

A head and neck lymphedema therapist can select non-elastic bandages or compression garments that are worn at home. These place gentle pressure on the affected areas to help move the lymph fluid and prevent it from refilling and swelling. Application of bandages should be done as directed by a specialist. There are several options, depending on the location of the lymphedema to improve comfort and avoid complications from pressure on the neck.

Bandages used to reduce lymphedema 

There are also exercises that can reduce the neck tightness and increase the range of neck motion. One needs to perform these exercises throughout life to maintain good neck mobility. This is especially true if the stiffness is due to radiation. Receiving treament by experienced physical therapies who can also break down the fibrosis is very helpful. The earlier the intervention the better. 

A new treatment modality that reduces lymphedema, fibrosis and neck muscle stiffness using external laser is also available. This method uses a low energy laser beam administered by an experienced physical therapist. The laser beam penetrates into the tissues where it is absorbed by cells and changes their metabolic processes. The beam is generated by the LTU-904 Portable Laser Therapeutic Unit. This treatment can reduce the lymphedema in the neck and face and increase the head’s range of motion. It is a painless method that is done by placing the laser instrument at several locations over the neck for about 10 seconds’ intervals. 

 Hand held laser for lymphedema treatment 

There are physical therapy experts in most communities who specialize in reducing swelling and edema. Consult one's surgeon to find out if physical therapy is a good therapeutic option for lymphedema. 

The National Lympedema Network has a web site that can assist in locating a lymphedema specialists in North America, Europe and Australia. 

A facial and neck self massage guide is also available.

The lymphatic system in the neck

A slide presentation about the diagnosis and treatment of lymphedema in head and neck cancer patients is available. It was presented at the Milton J. Dance, Jr. Head and Neck  Center 15^th Annual Conference on Head &Neck Rehabilitation on October 26,  2012.

Skin numbness after surgery

The cervical lymph nodes, or glands, are generally surgically removed when the cancer is excised. When the surgeons remove these glands, they also cut some of the sensory nerves that supply the lower facial and neck skin. This creates numbness in the areas supplied by the severed nerves. Some of the numb areas may regain sensation in the months following the surgery, but other areas may remain permanently numb.

Skin nerves of the face and neck

Most individuals become accustomed to the numbness and are able to prevent damage to the skin from sharp objects, heat or frost. Men learn not to injure the affected area when shaving by using an electric shaver.

The numb skin should be protected from sun burn by applying sunscreen and/or by shielding it with a garment. Frostbite can be prevented by covering the area with a scarf. 

Neck and shoulder pain after surgery and radiation

Persistent difficulty with movements of the shoulder, neck, face, and jaw often result from head and neck surgery. These difficulties are the result of the removal or manipulation of the region’s muscles, nerves, and lymphatic and blood vessels during surgery and their exposure to radiation therapy. Often, varying degrees of muscle weakness, scar tissue, and lymphedema are lifelong complications that can affect a person’s neck and shoulder health.

Because of the proximity of the lymphatic vessels to nerves that innervate the face, neck, and shoulder, they are frequently removed or damaged during surgery of the head and neck. Excision of the cancer may require manipulation or removal of the facial or spinal accessory nerves. The removal of the nerves affects of the movement of face, neck, and shoulder complex muscles. The effect is generally temporary after nerve manipulation during surgery, but may be permanent if the nerve has been severed. Nevertheless, regeneration of the nerves may occur within six weeks to several years.

Following complete severance of the nerves that innervate neck and shoulder muscles, they become limp and fail to stabilize the scapular joints (between the scapula and thorax and the humeral bone)(see Figure below). The affected joints are, therefore, at risk for further injury. 

                                                      The shoulder complex

When the scapular stabilizer muscles (middle trapezius and rhomboids) are compromised, (see Figure below) it is difficult to maintain an erect posture that allows for proper shoulder retraction. Without adequate retraction of the shoulder girdle, the glenohumeral joint (between the scapula and the humeral bone) cannot elevate the arm through a full range of 180 degrees. Lifting the arm when the scapula is in a protracted (forward) position creates a bony block from the humeral bone hitting the shoulder blade (acromion process) and does not allow full motion.

 Scapular muscles

Partial dislocation of the shoulder joint (glenohumeralsubluxation) can take place because of the lack of muscle stabilization in the shoulder. This creates shoulder instability and an inability to lift the arm through the full range of motion at the shoulder. Further damage to the shoulder joint and rotator cuff can occur with repetitive attempts to use the arm when it is weak.

Reduced stability of the joints also creates a structural strain on the neurovascular bundle of the shoulder and surrounding muscles, producing myofascialpain syndrome (chronic dull radiating pain from neck to hand) through the neck, shoulder, and arm.

The “leaning forward” posture that gradually develops lengthens the upper back muscles and fascia and shortens the muscles in the chest and neck region. This out of balance posture generates increased strain on the upper back, neck, and shoulder joints.

Radiation therapy further aggravates the situation because of the formation of scar tissue on top of existing scars from the surgical process and complicates one’s ability to stretch tight areas. Tissues contractures can also develop in the chest and neck.

Scar formation through fibrin formation constitutes the body’s healing mechanism following injury and trauma, such as surgery or radiation. The post surgery process of laying down scar tissue is carried out for about a year. However, since radiation permanently damages DNA and normal cellular processes, scarring typically continues for the rest of the person’s life.

The fibrin is laid down inside and outside the blood vessels, bones, tendons, ligaments and nerves in the affected areas. The resultant condition is called radiation fibrosis syndrome (RFS) and can occur within several weeks or months following radiation. The intensity of the fibrosis depends on the area, the amount and the duration of the radiation. Other factors, such as age and medical comorbidities, also contribute to the amount of RFS created. Rehabilitation medicine physicians with extensive training in neuromuscular and musculoskeletal medicine, as well as in the principles of functional restoration, are uniquely positioned to improve the quality of life for cancer survivors with radiation fibrosis syndrome.

Many factors contribute to neck and shoulder pain after surgery in the neck region. Education and active participation in the management process after surgery of the head and neck are important to minimizing the resulting discomfort. One should contact a physical and/or occupational therapist to help gather all the tools needed to manage chronic changes.