b'CONSERVATIVE MANAGEMENT:In the second phase (Maintenance Phase), the aim is to LYMPHEDEMA RISK REDUCTION ANDmaintain the benefits achieved in the first phase of SURVEILLANCE FOR HIGH-RISK PATIENTS treatment. Patients continue proper skin care, exercise, using compression garments, and, when necessary, Author: Robin Kauffman, PT, CLT-LANA MLD while monitoring for changes in symptomatology. Recognizing those susceptible to developingFor patients undergoing CDT, a certified lymphedema lymphedema is an important component of reducingtherapist (CLT), Lymphology Association of North the risk of lymphedema. Early intervention can takeAmerica (LANA)-certified therapist, or an equivalent many forms, such as appropriate patient educationpractitioner can provide education and support in and professional surveillance for high-risk individuals.applying all four components necessary to complete Written materials, such as those available on LE&RNstreatment. website, should be offered to the patient to promote continued learning throughout the treatment process.Proper measurement and fitting for bandages At-risk patients should also be informed about and compression garments is essential, as is their local lymphedema services. For the physicianpatient compliance with wear guidelines.tasked with monitoring for the early detection of lymphedema, the following assessments should takeMaintenance treatment can also be supplementedplace during office appointments: with short stretch bandages, pneumatic compression, 1. A history detailing the patients symptoms,and other medical goods. emphasizing any changes in appearance, size, or sensation of the affected area. MANAGEMENT AND SURVEILLANCE OF 2. A thorough physical examination of the affectedHEAD AND NECK LYMPHEDEMA (LE) limb. Author: Roman Skoracki, MD, FRCSC, FACS3.Volume measurements of both limbs using any ofSwelling in the head and neck due to lymphedema can the previously mentioned methods. Recommendmanifest as external swelling (present in up to 46% of that these measurements, if possible, be taken patients suffering from head and neck lymphedema), prior to treatments (e.g., surgery, radiation,internal swelling (present in 68%), or a combination of chemotherapy) to document a baseline and the above (present in up to 38% of patients) 61 . External then track changes from baseline. swelling will manifest as pitting edema, usually in the upper neck and/or the submental region, which in COMPLETE DECONGESTIVE more advanced cases will also affect the lower third of THERAPY (CDT) the face, resulting in fullness of the lower cheek(s). In Author: Robin Kauffman, PT, CLT-LANA more severe cases the periorbita may be involved and Current evidence suggests that completemay even include loss of vision due to excessive upper decongestive therapy (CDT) is associated with aand lower lid swelling. Patients will struggle with significant reduction in lymphedema volume60. tightness and discomfort, as well as the aesthetic CDT occurs in two phases (Intensive and Maintenancestigma of visible volume excess. However, it is the Phases) and consists of four components: internal swelling that has a more profound impact on the patients function, as minimal volume changes will 1. Meticulous skincare significantly affect speech and swallow function.2. Compression therapy (e.g., short stretch, multi- As such, patients with internal head and neck layer compression bandaging) lymphedema (HNL) may experience symptoms such3. Manual lymphatic drainage (MLD) as dysphonia, dysphagia, difficulty breathing, and 4. Remedial exercise (e.g., range of motion exercises,restricted range of motion. These may be exacerbatedand deep breathing). and difficult to diagnostically separate from theother head and neck cancer treatment changes that During the first phase of treatment (Intensive Phase),result from surgery, chemotherapy, and radiation. skin and nail hygiene, MLD, exercise, and limbSupraglottic, laryngeal and hypopharyngeal strictures, compression (utilizing compression bandaging), aredenervation and fibrosis will all worsen speech, repetitively utilized. This regimen is carried out four toswallow, and respiratory function, which will be further five times per week in 60 to 90minute sessions for aexacerbated by soft tissue swelling in a physically duration of two to four weeks depending on numerousrestricted space. Like other forms of lymphedema, factors, which include the number of limbs involved,early detection and treatment of HNL often leadspresence and severity of wounds, tissue conditionto improved outcomes regarding the prevention of (texture of the tissue), etc.swelling and chronic soft tissue changes. Head and neck lymphedema is unique in that early intervention | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|19'