b'with manual lymphatic drainage and compression willas well as to stage the disease. Injection sites lead to complete resolution, without the need forcommonly include the bilateral temples, the central ongoing therapy, in the majority of patients afterglabella, the right and left forehead at the level of the treatment for head and neck malignancies, which is nothairline, in line with the lateral canthi, as well as the seen in the extremities. For this reason, early diagnosiscentral lower lip in the mental crease. 0.1 cc of ICG and intervention are imperative for head and neckinjected intradermally in each of these sites will lymphedema, where life-threatening swelling can beprovide a clear image of many of the lymphatic treated effectively. The standard of care for head andpathways throughout the head and neck as well as neck lymphedema 62,63 , shares many of the techniquesareas of dermal reflux.used for the treatment of lymphedema throughout theSurgical treatments of head and neck lymphedema body and includes patient education, early detection,include lymphovenous bypass (LVB), vascularized CDT, and can include pneumatic compression therapy.lymph node transplants (this may be in combination Studies suggest that overall edema improvement with tissue transfers that address esophageal stenosis can be achieved with either home-based or hybrid- and fibrosis at the same time), and suction-assisted based (a combination of home and in-clinic sessions)lipectomy (generally used for debulking of the lymphedema therapy. However, overall adherence hassubmental region only). Details of these techniquesbeen shown to be a better predictor of outcome thanwill be outlined in the sections below. treatment strategy. As with all other stages of treatment, it is important for patients to have theGENITAL LYMPHEDEMAopportunity to clarify treatment techniques with their clinician, and for therapists to monitor and maintainAuthor: Shelley DiCecco, PT, PhD, CLT-LANA adherence throughout the treatment process 64 . Genital Lymphedema (GLE) can occur with primaryThere currently exists no reproducible tool for theand secondary lymphedema for both biological sexes measurement of head and neck lymphedema as theand at any age. Unfortunately, GLE is underrepre-tape measure method as described by Smith et al 62 sented in research and often neglected in evaluating has been shown to be invalid. 3D imaging shows greatand treating lower extremity and trunk lymphedema.promise with great intra- and inter-rater reliability forThe diagnosis of GLE is usually missed due to the lackexternal volume measurements. Laryngoscopy andof comfort in discussing or looking at ones genitaliaswallow studies must be an integral part of theby patients and healthcare practitioners (HCPs).assessment of head and neck lymphedema patients.The estimated prevalence is between 1~25% typically While no specific head and neck lymphedema patientand up to 80% in some studies for biological males self-reported outcome tool exists, the FACT-H&N and(BM) and biological females (BF) post-cancer EAT-10 as completed by patients and the clinician- treatments in the pelvis 206213 . Filariasis is the most administered tools PSS-HN and FOIS will provide acommon cause of GLE worldwide, and according to good overview of the patients functional disability aspharmaceutical company Eisai Global, almost halfwell as overall quality of life, specifically related toof the BMs with filariasis have some form of genital head and neck symptoms. We also feel that a week ofdysfunction, and nearly 30% have some form of intensive CDT with accurate record keeping of speechlymphedema 214 . Currently, there are no prevalence and dietary histories by the patient throughout thatnumbers for GLE with primary lymphedema. Youngperiod will give an insight as to the contribution of BMs with primary lymphedema are reported to be the reversible swelling due to lymphedema vis a vismore likely to have GLE, up to 7x more than BFs inother non-reversible treatment effects such as fibrosis,one study 215 . Are BMs more likely to be diagnosed duestenosis, and denervation. The rapidity of return ofto the ease of seeing the enlarged external genitalia speech and swallow dysfunction after a dilation willversus BFs, where the edema may start internally also help to differentiate. A return of dysfunctionbefore progressing to the vulvas? One study reports within a few days of dilation points toward internal the average age of onset of primary GL is 10.17 soft tissue swelling as the primary cause of theyears 216 , and frequently, GLE is associated with patients symptoms, whereas a slow return on theinflammatory bowel diseases (IBD), such as Crohns order of weeks to months points more towarddisease 217222 . The prevalence of IBD has increased recurrent stenosis and fibrosis. For the longer-termover the last several years worldwide, with a change return of dysfunction, lymphedema cannot be ruledfrom 0.01% to 0.81% in the United States 223 . out as a contributing factor, and the above outlinedFrequently, the first symptom of IBD in children isweek of intensive CDT with record keeping may helpGLE, and symptoms associated with GLE, such as to differentiate. edema, pain or discomfort, itching, skin changes or breakdown, and leakage of lymphorrhea or chyleICG lymphography of the head and neck is very usefulin the genital region 217222 .to assess a patients candidacy for surgical intervention | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|20'