Download Rehabilitation in Head and Neck Cancer

Sarah Gregory
Physiotherapy Principal Clinical Specialist
Critical Care, RSCH
January 2015
Background
 Malignant tumours of the upper aerodigestive
tract are the 6th most common cancers.
 Histologically more than 90% of these
tumours are squamous cell carcinomas (SCC).
 Squamous cell carcinomas of the upper
aerodigestive tract tend to metastasise.
Lymphatic Drainage
The lymph flow in the head and
neck area is drained by 300
lymph nodes.
.
This lymph flow follows certain
predictable directions towards
groups of lymph nodes.
Lymph Node Levels
 I
Submental and
submandibular
 II
Upper jugulodigastric group
draining naso pharynx
 III Middle jugular nodes
draining naso- and
oropharynx, oral
cavity, hypopharynx,
larynx.
 IV Inferior jugular nodes
draining hypopharynx,
subglottic larynx, thyroid,
oesophagus.
 V
Posterior triangle group
 VI Anterior compartment group
Neck Dissection
 Undertaken by Maxillo-facial and ENT surgeons
 As part of bigger surgical procedure
 As stand alone surgery
Types
 Radical Neck
Dissection:
 Levels I to V
dissected, including
resection of the
internal jugular
vein,sternocleidomastoid muscle and
accessory nerve
 Modified (Radical)
Neck Dissection:
 Levels I to V
dissected but
preserving one or
more of the
accessory nerve,
internal jugular vein
or
sternocleidomastoid
muscle
 Selective Neck
Dissection:
 Denotes preservation
of one or more lymph
node groups (levels I
to V) and preservation
of the accessory
nerve, internal jugular
vein and the
sternocleidomastoid
muscle
 Extended Neck
Dissection
 Denotes the removal
of 1 or more
additional lymph node
groups or nonlymphatic structure
not encompassed by
the RND.
 E.g. Carotid A, Vagus
N, paratracheal LN
Spinal Accessory Nerve
Spinal Accessory Nerve
 CN XI
 Supplies Trapezius
 Scapular elevation
 Scapular retraction
 Scapular rotation
 Neck side flexion /
extension
 Supplies Sterno-cleido-
mastoid
 Head rotation
 Head side flexion
 Neck forwards flexion
Accessory Nerve Shoulder
Dysfunction (ANSD)
 “not uncommon for patients who have undergone ND
to be referred to outpatient physiotherapy
department for frozen shoulder”
 1952
 1980
 1989
 1991
 2004
 2007
60% pts  shoulder mvt following RND
60% pts  shoulder mvt despite trying to spare
AN
% pts with  shoulder mvt under reported
77% pts subjectively had difficulties
46% failed to return to work because of
shoulder difficulties
67% pts suffer AN injury despite SND/MRND
39% pts report shoulder problems even with
SND
ANSD – causes?
 RND
 Sacrifice of Spinal Accessory Nerve
 SND
 Neuropraxia – microtrauma through intra-operative
manipulation and traction
 R/T
 Fibrosis of muscle fibres and neural sheath
 Nerve demyelination
 General  in physical activity
ANSD 1
 muscle strength of upper and middle trapezius
Depression, abduction and medial rotation of scapula
 Lateral rotation and elevation of scapula
 Active shoulder abduction and flexion
Abnormal mechanics  shoulder pain and dysfunction
ANSD 2
 muscle strength of upper trapezius muscles bilat.
Tension in upper trapezius muscles
Poor cervical posture
Cervical spine dysfunction
Physiotherapy
 Postural awareness / scapular setting
 Active exercises
 Neck ROM exs
 Targeted exercises for scapular muscle deficit



Bilateral upper trapezii
Unilateral middle trapezius
Unilateral serratus anterior
 GHJ ROM exs


Shoulder flexion (including auto assisted as required)
External rotation
 Advise / exercise leaflet, Home exercise
programme +/- OPD sessions
References






The impact of selective neck dissection on shoulder and cervical spine movements
B. Scott, D. Loweb, S.N. Rogers
Physiotherapy (2007) 93 102–109
An exploratory trial of preventative rehabilitation on shoulder disability and quality of life in patients
following neck dissection surgery
Lauchlan D.T., Mccaul J.A., Mccarron T., Patil S., Mcmanners J. & Mcgarva J.
European Journal of Cancer Care (2011) 20, 113–122
Impact of Neck Dissection on Scapular Muscle Function: A Case-Controlled Electromyographic Study
Aoife C. McGarvey, Peter G Osmotherly, Gary R. Hoffman, Pauline E. Chiarelli,
Archives of Physical Medicine and Rehabilitation (2013); 94:113-9
Maximising shoulder function afer accessory nerve injury and neck dissection surgery: a multicentre
randomised controlled trial
Mcgarvey AC, Hoffman GR, Osmotherly PG, Chiarelli PE
Head and Neck - DOI 10.1002 / HED MONTH 2014
Neck Dissection Classification Update Revisions Proposed by the American Head and Neck Society and
the American Academy of Otolaryngology–Head and Neck Surgery
K. Thomas Robbins, MD; Garry Clayman, MD; Paul A. Levine, MD; Jesus Medina, MD; Roy Sessions, MD;
Ashok Shaha, MD; Peter Som, MD; Gregory T. Wolf, MD; and the Committee for Head and Neck Surgery and
Oncology, American Academy of Otolaryngology–Head and Neck Surgery
Arch Otolaryngol Head Neck Surg. 2002;128(7):751-758
http://archotol.jamanetwork.com/article.aspx?articleid=482968#CLASSIFICATIONOFNECKDISSECTION
http://emedicine.medscape.com/article/849516-overview#aw2aab6b4