Neck Surgery. Brendan C. Stack, Jr., Mauricio A. Moreno, MD

12. Rehabilitation After Neck Dissection

Peter S. Vosler and Douglas B. Chepeha Abstract

Rehabilitation after neck dissection is perceived as important, but there has been little research on specific regimens or protocols to help patients recover after neck dissection. This chapter evaluates the types of impairment following neck dissection, treatment factors that influence impairment, the assessment tools used to evaluate function, and optimal rehabilitation following neck dissection. Emphasis is placed on evidence regarding the impact of the extent and type of treatment on shoulder impairment. The literature is reviewed to determine the evidence supporting different rehabilitation modalities for both shoulder impairment and lymphedema. Best practice suggestions are provided based on synthesis of the content of the chapter in the conclusion section.

Keywords: neck dissection, rehabilitation, shoulder impairment, lymphedema, pain, dysphagia, head and neck cancer

12.1 Introduction

Neck dissection is a surgical procedure commonly performed to improve regional control of head and neck malignancy of the upper aerodigestive tract, thyroid, parotid, or skin. The extent of neck dissection is determined by the primary tumor and the presence and location of regional metastasis.

Most patients undergoing selective neck dissection (SND) experience relatively little disability. When neck dissection is more extensive, and when there is injury to the accessory nerve or when multiple treatment modalities are employed, there is an increased likelihood of impairment. The impairments include loss of skin sensation, paresthesia, loss of depressor anguli oris function, decreased range of motion of the neck and shoulder, neck pain, neck stiffness, and loss of strength for lifting of objects. Recent research has evaluated psychosocial and psychological sequelae in addition to functional impairments of neck dissection that warrant consideration in proper rehabilitation. This chapter describes the impairment following neck dissection, the treatment factors that influence impairment, the assessment tools used to evaluate function, and optimal rehabilitation following neck dissection.

12.1.1 Prevalence of Impairment Following Neck Dissection

Shoulder impairment following radical neck dissection (RND) was first described by Ewing and Martin in 1952.¹ The prevalence of impairment following neck dissection, predominately manifested by shoulder and upper limb impairment, ranges between 18 and 77%.² Prevalence is difficult to report on because of the different types of neck dissection, the different primary site treatments associated with neck dissection, and the number of different measures that are used to assess neck dissection-related impairment.

12.1.2 General Factors That Affect Functional Outcome after Neck Dissection

There are a number of patient factors that can contribute to the difficulty of neck dissection and potential complications postoperatively. Factors that limit surgical exposure such as morbid obesity and decreased range of motion of the neck increase likelihood of damage to the neural and vascular structures in the neck. Patient comorbidities such as smoking, alcohol consumption, diabetes, and coagulopathy can increase the likelihood of a wound complication that in turn can increase postoperative scarring and mobility. Patients with a history of atherosclerosis have an increased likelihood of stroke.

12.1.3 Late Effects of Neck Dissection

The late effects of neck dissection include impaired neck and shoulder mobility and strength, cervical paresthesia, pain, lymphedema, dysphagia, psychosocial issues,³ and impaired quality of life.⁴ Evaluation of patients who underwent neck dissection and comparing to patients without neck dissection revealed impairments in intelligibility of speech, health-related quality of life, and decreased employment.³ Similar results were obtained using the University of Washington-QOL and Functional Assessment of Cancer Therapy Head and Neck questionnaires in patients who did and did not undergo neck dissection. Five years after treatment, patients who underwent neck dissection had worse scores with regard to aesthetics, willingness to eat in public, decreased levels of activity, and decreased involvement with recreation or entertainment than patients who did not undergo neck dissection.⁴

12.2 Components of Impairment after Neck Dissection

There are critical structures in each level of the neck that, when dissected, can contribute to impairment following neck dissection (Table 12.1).

12.2.1 Level I

Component of level I include the following: level Ia, the submental nodes, extending from the mandible anteriorly, bordered by the anterior belly of the digastric bilaterally, and the hyoid inferiorly. Removal of fibrofatty tissue from this area can lead to a cosmetic contour deformity. The area can be not only depressed, but also excessively full due to lymphedema. It is generally thought that there is no treatment for these sequelae.

Table 12.1 Contributors to neck and shoulder disability based on level of neck dissection

Anatomical level	Structure affected	Impairment/disability
Level Ia	Fibrofatty tissue	Mild cosmetic deformity
Level Ib	Hypoglossal N Lingual N Marginal mandibular N	Ipsilateral tongue hemiplegia, dysphagia, dysarthria Ipsilateral tongue paresthesia, dysphagia, dysgeusia, dysarthria Paralysis of lower lip depressor, cosmetic deformity, lower lip trauma
Level IIa	Spinal accessory N Hypoglossal N Great auricular N	Shoulder and neck ROM and strength Ipsilateral tongue hemiplegia, dysphagia, dysarthria Ipsilateral pinna paresthesia
Level IIb	Spinal accessory N	Shoulder and neck ROM and strength
Level III	Phrenic N Ansa cervicalis N	Hemi diaphragm paralysis/DOE, pneumonia Hyolaryngeal elevation
Level IV	Phrenic N Thoracic duct	Hemidiaphragm paralysis/DOE, pneumonia Chyle leak
Levels II—IV	Jugular vein Vagus N Cervical rootlets Sympathetic trunk Carotid artery	Lymphedema Ipsilateral vocal cord paralysis, dysphonia, aspiration Cervical paresthesia Horner’s syndromea TIA, stroke
Level V	Spinal accessory Nb Brachial plexus Cervical rootlets	Shoulder and neck ROM and strength Hand and arm paresthesias and weakness, hand or arm paralysis, severe pain Cervical paresthesia

Abbreviations: DOE, dyspnea on exertion; N, nerve; ROM, range of motion; TIA, transient ischemic attack. ^aHorner’s syndrome: triad of ptosis, meiosis, and anhydrosis resulting from injury to the cervical sympathetic trunk. increased shoulder impairment with dissection of this level.

Level Ib, which is bordered by the mandible superiorly, and the digastric muscle inferiorly, contains multiple neurovascular structures. The most notable structures include the hypoglossal and lingual nerves. Injury to the hypoglossal nerve, which supplies ipsilateral motor innervation to the tongue, can lead to dysphagia and dysarthria. The ansa hypoglossi is a branch of C1 and travels with the hypoglossal nerve to innervate the thyrohyoid and the geniohyoid. The nerve branch to the thyrohyoid (which passes to level III) is frequently cut during neck dissection, but the impact of this transection is not well understood. The lingual nerve supplies sensory innervation to the ipsilateral tongue. Dysgeusia is very uncommon after neck dissection.

The marginal mandibular nerve is a branch of the facial nerve and it innervates the depressor anguli oris muscle, which depresses the ipsilateral corner of the mouth. The nerve courses inferior to the mandible within the fascia overlying the submandibular gland and can be injured during dissection of this level. Rates of injury are reported to be up to 23% in one observational study of 66 patients.⁵ The main complaint of patients following injury to the nerve is cosmetic deformity manifested by smile asymmetry. Patients may also complain of biting their lower lip when eating and some difficulties with oral competence.

12.2.2 Level II

Level II extends from the skull base superiorly to the hyoid inferiorly. The medial border is the deep cervical fascia overlying the paravertebral muscles and the levator scapulae. Level II is divided into level IIa that is superior to the spinal accessory nerve (SAN; cranial nerve [CN] XI) and with level IIb that is below CN XI.

CN XI supplies motor innervation to the sternocleidomastoid muscle (SCM). The motor innervation of the upper trapezius is supplied by variable contributions of CN XI and the cervical plexus. The sacrifice of CN XI results in shoulder impairment in 60 to 80% of patients.⁶ Even when intact, the extent of CN XI dissection is correlated with the degree of shoulder impair- ment.7,8 Deficits in shoulder function from dissection or sacrifice include reduced abduction and decreased range of motion, scapular winging, scapular droop, neck stiffness, and neck pain.

12.2.3 Level III

The boundaries of level III include the hyoid superiorly to the inferior border of the cricoid inferiorly, and the sternohyoid and deep cervical fascia over the paravertebral muscles medially. The largest segment of the ansa cervicalis provides motor innervation to the infrahyoid strap muscles to induce hyolaryng- eal stabilization and depression. The contribution of these muscles is not well understood. The infrahyoid strap muscles are a counterbalance to the suprahyoid muscles. Contraction of the suprahyoid musculature produces hyoid and laryngeal elevation and causes the base of tongue to cover the laryngeal inlet and fold over the epiglottis (epiglottic inversion). The infrahyoid strap muscles provide a counterbalance to this swallowing action. Transection or resection of the ansa branches or the infrahyoid strap muscles do not seem to result in swallowing or airway impairment. If the patient undergoes multimodality (radiation) treatment that includes extensive resection including the SCM and the infrahyoid musculature, decreased hyoid elevation is observed during swallowing that can lead to increased incidence of aspiration.

The phrenic nerve arises in level III from contributions of C3- C5, traverses superficial to the anterior scalene muscle, and runs in a lateral-to-medial direction. Damage to the phrenic nerve during a neck dissection usually results in elevation of the hemidiaphragm, and this can impair respiration.

12.2.4 Level IV

Level IV is bounded by the cricoid superiorly and the clavicle inferiorly. The medial border is the deep cervical fascia over the paravertebral muscles. The posterior border is aligned with the posterior border of the SCM. The structure most commonly injured in level IV is the thoracic duct, which is on the left, although there are large lymphatics found on the right. Injury to the lymphatics in level IV can lead to a chylocele that, in some cases, does not spontaneously resolve and may need treatment to resolve electrolyte loss that can lead to electrolyte abnormalities.

12.2.5 Common Structures in Levels II to IV

Structures common to levels II to IV include the internal jugular vein (IJV), carotid artery, vagus nerve, sympathetic trunk, and the SCM. Sacrifice of a single IJV contributes to lymphedema of the neck that can result in increased neck stiffness and an impaired cosmetic appearance. If both IJVs are transected, life-threatening cerebral edema can result. If both are transected acutely, a bypass should be performed. Stroke can result from manipulation of the carotid vessels; however, there appears to be no long-term sequelae from ligation of the external carotid artery. The vagus nerve provides innervation important for swallowing and it innervates the ipsilateral vocal cord; therefore, injury to the vagus can result in dysphagia, dysphonia, and aspiration. Finally, the sympathetic trunk courses within the carotid sheath, and injury can result in Horner’s syndrome of ptosis, meiosis, and anhydrosis.

12.2.6 Level V

The posterior triangle of the neck is bounded by the trapezius posteriorly, the clavicle inferiorly, and, for surgeons, the cervical rootlets anteriorly. It is divided into sublevels Va (superior) and Vb (inferior) by the plane of the inferior border of the cricoid. Level V contains CN XI. CN XI picks up branches of C2 as CN XI exits the SCM. The branches of C2 can variably provide motor innervation to the trapezius. Dissection of CN XI results in worse shoulder function in most patients.⁷⁸⁹ Dissection or sacrifice, of cervical rootlets, can lead to neck, earlobe, or upper chest paresthesia.

12.2.7 Level Vl

Level VI is bordered superiorly by the hyoid, inferiorly by the innominate artery, and laterally by the carotid arteries. The deep boundary is the visceral fascia around the thyroid and larynx. Critical structures include the recurrent laryngeal nerves and the parathyroid glands. Dissection of the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve can lead to weakness and changes in voice production. Dissection of the inferior thyroid artery of the parathyroid glands can lead to hypocalcemia.

12.3 Treatment Factors

If a neck dissection includes more levels, there will be more im- pairment—particularly if level V is dissected. It is important to note the both radiation and radiation with chemotherapy also contribute to impairment after neck dissection.

12.3.1 Types of Neck Dissection

The underlying disease determines the extent of neck dissection, and it should be the foremost determinate as to the type of neck dissection performed. The classification of neck dissection includes RND, modified RND (MRND), and SND.

RND involves removal of the ipsilateral cervical lymph nodes from levels I to V with sacrifice of the SCM, CN XI, and the IJV. The other neck dissections are variations of the RND with regard to levels of dissection and preservation of nonlymphatic structures. MRND also involves removal of ipsilateral cervical lymph nodes in levels I to V, but with preservation of one or more of the aforementioned nonlymphatic structures (SCM, CN XI, IJV). Functional neck dissection is a term that is no longer used that describes preservation of the SCM, CN XI, IJV, part of the cervical plexus, or one or more levels of the neck. SND involves removal of one or more nodal levels with preservation of nonlymphatic structures.

12.3.2 Extent of Neck Dissection

RND is associated with the worst functional outcome by virtue of sacrifice of vital structures for shoulder and neck function as well as cosmetic deformity with removal of the SCM. A retrospective review that assessed 224 patients who underwent 308 neck dissections evaluated pain, impaired shoulder function by measuring shoulder drop, reach above and arm abduction, increased neck and shoulder stiffness, and increased neck constriction for patients undergoing radical, MRND or SND. Sacrifice of CN XI was associated with worse outcome across all measures. If level V was not dissected, then patients had better outcomes across all measures. Cosmetic outcome was associated with the preservation of the SCM.¹⁰

Multiple studies validate the association of dissection of CN XI and increased impairment with different outcome measures. A retrospective comparison of SND levels II to IV (n = 20) with SND levels II to V (n = 20) showed that level V dissection was associated with impaired shoulder muscle strength, shoulder range of motion limitation, shoulder droop, protraction, and flaring, and decreased electromyographic potentials.⁷ Impairment in strength and function was predominately reported as mild. Similarly, retrospective review compared 15 patients who underwent MRND with preservation of the SCM, CN XI, and IJV with 17 patients who underwent SND levels II to IV. This study demonstrated a trend toward increased pain, increased disability as assessed by the Shoulder Pain Disability Index (SPDI), and decreased range of motion as measured by goniometry 6 months postoperatively in the MRND group despite sparing SCM, CN XI, and IJV.¹¹ This finding is further corroborated in a retrospective review of 121 SND and 46 SCM and CN XI-sparing MRND where impaired shoulder function was found using the Neck Dissection Impairment Index (NDII) in the patients who received MRND.⁸

12.3.3 Dissection of Sublevel llb

There is controversy in the field regarding the utility of sublevel IIb dissection. Multiple papers have evaluated patients who have a clinical and radiological N0 classification neck and showed the incidence of positive level IIb nodes within a range of 0 to 10.4%.¹² Of note, there were only three episodes of isolated level IIb nodes out of 332 patients. None of the studies to date evaluate shoulder function when controlling for sublevel IIb dissection. In theory, dissection level IIb after level IIa dissection could lead to increased shoulder impairment postoperatively without improved oncologic control.

In summary, the literature supports the findings that sacrifice or dissection of key structures, particularly CN XI in level V, causes increased impairment.

12.3.4 Radiation and Chemotherapy

Adjuvant therapy for head and neck cancer also plays a role in head and neck cancer treatment-related morbidity. A multivariable analysis was performed using the NDII as the assessment tool to compare MRND sparing CN XI with SND, and adjuvant radiation or chemoradiation were independent predictors associated with shoulder impairment.⁸

Similarly, in a study of 25 who underwent SND levels I to III, and 86 who underwent extended SND (levels I-V) with sacrifice of SCM, the extended SND was associated with greater cervical range-of-motion deficit compared to SND levels I to III. In this study, 98 patients received radiation and the combination of extended SND and radiation produced additional impairments in cervical range of motion compared to extended SND alone. Radiation therapy as a single modality did not result in increased morbidity of cervical range of motion, mouth opening, swallowing, or lymphedema at 12 months posttreatment.¹³ Postoperative radiation therapy after neck dissection was associated with impairment of upper limb function and increase shoulder pain as measured by the NDII and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) survey in a retrospective study examining 89 patients treated with SCM and CN XI-sparing neck dissections.¹⁴

Primary radiation or chemoradiation for treatment of oropharyngeal and nasopharyngeal carcinomas allows for examination of posttreatment effects. Examination of patients presenting with dysphagia greater than 5 years postradiation or chemoradiation for head and neck cancer revealed dysarthria or dysphonia, cranial neuropathies, and pneumonia in 76, 46, and 86% of patients, respectively.¹⁵ When looking at post-chemora- diation therapy (post-CRT) neck dissection for patients without complete response, nearly all patients had returned to a soft or regular diet by 2 years posttreatment with 10% of patients remaining gastrostomy tube dependent.¹⁶ The rate of gastrostomy tube dependence did not appear to be associated with posttreatment neck dissection

Overall, chemoradiation does not seem to cause shoulder morbidity as a primary therapy within 2 years of treatment. Use of chemoradiation in the adjuvant setting exacerbates the morbidity caused by neck dissection.

12.3.5 Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy (SNB) is the standard staging tool for the management of melanoma, and it has been studied for use in early classification (T1-T2) of oral cavity squamous cell carcinoma demonstrating a negative predictive value of 95%.¹⁷ Few studies have been carried out examining the impairment of sentinel node biopsy versus elective neck dissection.

A retrospective comparison of 62 patients with early classification oral tongue lesions (T1-T2) who underwent either SNB (n = 33) or SNB followed by elective neck dissection (n = 29) demonstrated SNB was associated with less shoulder impairment than SNB followed by SND using the NDII and constant score as outcome measures.¹⁸

12.4 Assessment Tools for Neck Disability

There are many different tools available for the assessment of shoulder disability. Table 12.2 outlines the most commonly used questionnaires in the head and neck literature to assess shoulder function. Most of the assessment tools were designed to assess rotator cuff and/or glenohumeral joint disease.

The two patient-reported outcome (PRO) measures for assessment of shoulder function after neck dissection are the NDII and the DASH questionnaire. The NDII was specifically designed and validated in the head and neck cancer popula- tion.¹⁹ The DASH has undergone the most rigorous psychometric analysis and validation of any of the questionnaires listed in Table 12.2, and it is the best tool for comprehensive assessment of upper extremity function. A comprehensive review of the outcome measures has been conducted and the NDII was found to be the most appropriate assessment tool at this time.²⁰

The DASH questionnaire was validated in the head and neck cancer patient population in a cross-sectional study comparing RND, MRND, and SND. Evaluation of the DASH by both physicians and patients met sensibility criteria, which means the DASH questionnaire asked questions appropriate for patients who underwent neck dissection. The DASH was also able to discriminate between the different types of neck dissection, and it was also validated in this patient population with high correlation of the DASH with the head and neck cancer patient-validated NDII.²¹ The Shoulder Disability Questionnaire (SDQ), NDII, and Shoulder Pain and Disability Index (SPADI) were also validated in a cohort of patients who underwent neck dissection; however, only the NDII was able to discriminate between types of neck dissection.²²

In summary, there are two convenient questionnaires that are reliable constructs for evaluation of shoulder impairment following neck dissection—the NDII and DASH. Although the SPADI and SDQ are also validated in patients undergoing neck dissection, these measures do not appear to be as sensitive as the NDII and DASH.

Table 12.2 Patient-related outcome questionnaires for shoulder function

Instrument	# Questions	Recall period	Time to complete	Type of question	Scoring	Total score	Advantages	Disadvantages
Neck Dissection Impairment Index (NDII)	10	4 wk	<5min	QOL, ADL, work- and activity-related questions	0-5: 0 worst, 5 best	100 (higher = less disability)	Designed and validated specifically to assess disability after neck dissection; simple, quick to complete; easy to score	No MDC or SEM
Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)	30	1 wk	13 min	21 functional, 6 symptom items, and 3 social/role function items; 2 optional 4-question modules: assess shoulder function on work or sport/arts	0-5: 1 = no difficulty; 5 = extremely difficult	100 (higher = greater disability)a	Extensive development and psychometric property assessment Best tool for comprehensive assessment of upper extremity Can detect patients with nerve injury	Region specific, i.e., not specific to shoulder Longer time to complete
Constant’s Shoulder Score (CSS)	10	1 wk	5-7 min	Combination of ROM and strength testing with pain and activity limitations	Pain 0-15 VAS; 0 = maximal; 15 = no pain Activity 0-5 Likert scale: 0 = worst; 5 = best Mobility 0-10: 0 = worst; 10 = best Strength 1 point/0.5 kg, max 25 points	100 (higher = less disability)	Clinically relevant content with high responsiveness, formal strength, and range of motion testing, very fast assessment for physical testing, used across many disease types	No psychometric assessment in H&N cancer patients
Shoulder Pain and Disability Index (SPADI)	13	1 wk	7 min	5 pain-related items; 8 disabil- ity/function-re- lated items	0-10 VAS: 0 = none; 10 = worst	100 (higher = greater disability)	Content validity determined with expert review Most responsive shoulder instrument to detect impairment Validated in H&N cancer patients	Item reduction No direct patient input for development Main focus is on pain; less emphasis on other potential symptoms
Shoulder Disability Questionnaire (SDQ)	16	24 h	<5min	13 pain-related questions; 3 questions-sleep- ing, need to rub, and irritability	Yes = 1, No = 0; no. of yes re- sponses/ no. of completed itemsa 100 Higher score = more disability	Higher = greater disability	Able to differentiate clinically stable versus improvement (MDC 95%); Simple, quick to complete; Easy to score; Validated in H&N cancer patients	Poor content validity
American Shoulder and Elbow Surgeons standardized score (ASES)	11	1 wk	4min	10 pain-related items; 1 function question	Score for both R & L shoulders Pain 0-10 VAS: 0 = none; 10 = worst Function 0-3: 0 = unable; 3 = no difficulty	Higher = less disability	Good construct validity, responsiveness, and reliability Quick to complete	No reliability or validity testing in H&N cancer patients Scoring complicated by VAS conversion Limited sensitivity

Continued

Table 12.2 continued

Instrument	# Questions	Recall period	Time to complete	Type of question	Scoring	Total score	Advantages	Disadvantages
Simple Shoulder Test(SST)	12	Time to completion	3 min	Questions regarding subjective component and activity-specific performance. Physical activity	1 =yes, 0 = no; max. score of 12 converted to percentage score out of 100	100% (higher =less disability)	Quick and easy to use Can differentiate patients with various shoulder conditions	Limited functional items Lack of construct validity in H&N cancer patients
Abbreviations: ADL, activities of daily living; H&N, head and neck; MDC, minimal detectable change; QOL, quality of life; R & L, right and left; ROM, range of motion; SEM, standard error of the mean; VAS, visual analogue scale. aWork and sports/performing arts modules scored separately.

12.5 Shoulder Rehabilitation

Based on electromyographic studies, the type of injury that occurs during CN XI-persevering neck dissection is axonotmesis, and the expected recovery for nerve recovery is between 12 and 18 months.²³ During this time, the injury to the SAN results in trapezius muscle weakness causing malposition of scapula inferiorly, medially, and in abduction, resulting in decreased shoulder and arm range of motion and strength. If there is no physical therapy intervention, then patients acquire adhesive capsulitis, characterized by pain, decreased internal and external shoulder rotation, and limited shoulder abduction and flexion.² Treatment for adhesive capsulitis is unfortunately limited; therefore, prevention from physical therapy is the best practice following neck dissection. Overall, the goal of physical therapy is to maintain strength, length of muscles, range of motion, and prevent adhesive capsulitis.

12.5.1 Evidence Basis for Physiotherapy

Physiotherapy improves shoulder function following neck dissection; however, there is controversy regarding an optimal physiotherapy regimen. The pathophysiology underlying shoulder impairment following neck dissection is focused on CN XI injury that results in trapezius and scapular muscles that work synerg- istically with the trapezius. Exercises that target the glenohumeral joint or rotator cuff muscles are unlikely to improve the impairment caused by CN XI neuropraxia or axonotmesis.²³ Therefore, the type of physiotherapy should be modified based on type of nerve injury. If the nerve is transected, as in RND, then there is likely limited benefit to targeted strength training of the trapezius muscle. If the nerve is spared as in SND or MRND, then progressive resistance training has a higher theoretical benefit.

There is limited evidence regarding the benefit of physiotherapy following RND where the SCM and CN XI are sacrificed. In a Japanese study, rehabilitation with an undisclosed physiotherapy regimen improved arm abduction in patients who underwent SCM and CN XI sacrifice compared to patients with the same operation who did not receive rehabilitation.¹⁰

A Cochrane review of the only three randomized control trials conducted up to 2012 examining physical therapy exercises to treat shoulder impairment following neck dissection concluded that progressive resistance training reduced shoulder disability and pain, but it did not result in statistically significant reduction of neck dissection impairment and fatigue, or improved QOL.²⁴ Review of literature to evaluate the effectiveness of physiotherapy following neck dissection found poor scientific rigor in evaluation of efficacy and therefore little evidence-based literature for the type of physiotherapy modality employed. It was concluded that exercise-based physiotherapy has the greatest promise for improved function.²³

A more recent prospective randomized control trial analyzed the efficacy of progressive scapular-strengthening exercises versus standard physiotherapy, consisting of generalized shoulder and neck exercises, in a cohort of 53 patients that underwent CN XI- preserving neck dissection. The prevalence of shoulder impairment across groups was 36.86%, and adherence to the therapy was

76.6 and 82.2% in the intervention and control groups, respectively. Overall, both the group receiving progressive scapular strengthening and the control group showed improvement in the SPADI and NDII. Shoulder abduction was increased with progressive scapular strengthening at 3 months, but there was no difference between the two groups at 6 and 12 months post-neck dissection.²⁵

In summary, there is little evidence to support specific physiotherapy regimens following neck dissection, but sufficient evidence to support the recommendation that all patients who undergo either SAN-sacrificing or SAN-preserving neck dissection should undergo some shoulder physiotherapy regimen.

12.6 Rehabilitation of Pain

There are limited controlled trials evaluating pain management following neck dissection in the context of shoulder impairment. This is likely multifactorial as there is clinically significant cervical paresthesia from transection of cutaneous nerves and, in the case of level V dissection, cervical rootlet transection. Postoperative pain is most often due to shoulder impairment, and as many neck dissections occur in the context of a primary tumor site resection, it is difficult to distinguish if the cause of pain is from the neck dissection or primary tumor resection.

Inflammation is a significant component of postoperative pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit inflammation and are safe to use postoperatively. Further, administration of NSAIDs decreases opioid requirements, thereby reducing opioid-related complications and improving patient satisfaction.²⁶ Patients with preoperative opioid requirements requiring long-acting opioids may benefit from consultation of acute pain or palliative care physicians.

12.7 Lymphedema

The surgical removal of lymphatics results in decreased lymphatic drainage of the head and neck; the addition of radiation causes lymphatic apoptosis, decreased dermal lymphatics, and reduction in lymph transport.

Both can result in lymphatic back flow, chronic inflammation, edema, and fibrosis, all of which can lead to functional deficits and aesthetic disfigurement.

Lymphedema affects from 50 to 75% of head and neck cancer survivors who undergo neck treatment.^{27 28} Head and neck lymphedema (HNL) can occur internally within the mucosa of the upper aerodigestive tract or externally with visible swelling of the skin and soft tissues. The MD Anderson Cancer Center (MDACC) HNL scale is modified from Foldi’s scale to allow for categorization of nuanced findings specific to HNL.²⁷ An evaluation protocol developed at the MDACC has been developed that combines seven facial measurements to calculate a composite facial score with three neck circumference measurements for a composite neck score to accurately assess lymphedema.²⁷ This protocol allows for pre- and posttreatment evaluation of HNL to assess for efficacy of therapy.

The gold standard for treatment of lymphedema of the head and neck or in the extremities is complete decompressive therapy (CDT). This includes manual decompressive therapy, application of compressive garments or bandages, exercises, and skin care.²⁹ A retrospective study out of MDACC examined 1,202 patients with posttreatment HNL and evaluated CDT response in 733 of those patients. CDT resulted in 60% of patients with improved HNL, and treatment response was significantly related to treatment adherence.²⁹

A protocol for CDT developed at MDACC includes use of compression garments both before and after manual lymphatic drainage. Manual lymphatic drainage consists of massage of the supraclavicular region, followed by massage of the trunk, neck, and face. This is coupled with cervical range of motion exercises to facilitate drainage. These techniques are taught to patients in an outpatient setting and patients are given a decompressive regimen to perform at home daily.²⁷

12.8 Rehabilitation of Swallowing

The incidence of dysphagia ranges from 37 to 82% of patients undergoing organ-preserving CRT for head and neck cancer.¹⁶ However, there is a paucity of literature regarding dysphagia following primary neck dissection, which is likely related to limited swallowing impairment caused by neck dissection alone. Accordingly, examination of swallowing impairment in a QOL study comparing no neck dissection, nerve sparing neck dissection, and nerve-sacrificing neck dissections revealed no differences in dysphagia as measured by the University of Washington QOL questionnaire.⁴

Evaluation of patients that received post-CRT neck dissections for incomplete clinical response demonstrated dysphagia with trimodal therapy, with 10% of patients remaining gastrostomy tube dependent 24 months after completion of treatment. The incidence of post-CRT neck dissection is similar to published dysphagia and gastrostomy tube dependence in patients who underwent CRT alone, suggesting that addition of neck dissection did not exacerbate dysphagia.¹⁶

Therapy for dysphagia, regardless of treatment modality employed, necessitates involvement of speech-language pathologists for discussion of food consistency, swallowing exercises, and strategies.

12.9 Conclusion

In summary, neck dissection is essential for oncological staging and locoregional control in the management of head and neck cancer. While oncologic rationale is the primary objective, judicious selection of the levels of neck dissection should be based on known patterns of metastasis, and neck levels that are unlikely to harbor metastasis should be left untouched in order to mitigate complications. The evidence demonstrates that neuropraxia or axonotmesis occurs with all neck dissections involving the SAN as measured by strength, range of motion, pain, and electromyography. Accordingly, more extensive dissection of the SAN produces greater impairment, with the best evidence demonstrated for dissection of level V. There is limited evidence for greater impairment with dissection of level IIb, but there is are a small percentage of metastases to this sublevel; therefore, it is recommended that level IIb dissection be reserved for patients with known level IIa-positive nodes. Adjuvant chemotherapy and radiation contribute to shoulder impairment, but radiation and chemotherapy without surgical intervention show no immediate impairment. The potential late effects of chemotherapy, and especially, radiation therapy, particularly with regard to dysphagia, require further study, as the long-term complications from these treatments can be substantial.

Rehabilitation following neck dissection should focus on the two main complications—shoulder impairment and lymphedema. Progressive scapular resistance makes sense from a pathophysiology perspective for shoulder rehabilitation albeit the current evidence suggests that any shoulder physiotherapy is beneficial as long as it precedes formation of adhesive capsulitis. The current standard of care for HNL is CDT, and it should be utilized for all patients who have HNL. Finally, there are two complimentary and validated questionnaires in the head and neck cancer population that are recommended for evaluation of shoulder impairment—NDII and DASH. Standard use of these questionnaires in future research will improve interpretability of shoulder rehabilitation research involving neck dissection.

References

[1] Ewing MR, Martin H. Disability following radical neck dissection; an assessment based on the postoperative evaluation of 100 patients. Cancer. 1952; 5 (5):873-883

[2] Bradley PJ, Ferlito A, Silver CE, et al. Neck treatment and shoulder morbidity: still a challenge. Head Neck. 2011; 33(7):1060-1067

[3] Spalthoff S, Zimmerer R, Jehn P, Gellrich N-C, Handschel J, Krüskemper G. Neck dissection’s burden on the patient: functional and psychosocial aspects in 1,652 patients with oral squamous cell carcinomas. J Oral Maxillofac Surg. 2017; 75(4):839-849

[4] Eickmeyer SM, Walczak CK, Myers KB, Lindstrom DR, Layde P, Campbell BH. Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer. PM R. 2014; 6(12):1073-1080

[5] Batstone MD, Scott B, Lowe D, Rogers SN. Marginal mandibular nerve injury during neck dissection and its impact on patient perception of appearance. Head Neck. 2009; 31(5):673-678

[6] Leipzig B, Suen JY, English JL, Barnes J, Hooper M. Functional evaluation of the spinal accessory nerve after neck dissection. Am J Surg. 1983; 146(4):526-530

[7] 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

[8] Gallagher KK, Sacco AG, Lee JS-J, et al. Association between multimodality neck treatment and work and leisure impairment: a disease-specific measure to assess both impairment and rehabilitation after neck dissection. JAMA Otolaryngol Head Neck Surg. 2015; 141(10):888-893

[9] Terrell JE, Welsh DE, Bradford CR, et al. Pain, quality of life, and spinal accessory nerve status after neck dissection. Laryngoscope. 2000; 110(4):620-626

[10] Nibu K, Ebihara Y, Ebihara M, et al. Quality of life after neck dissection: a multicenter longitudinal study by the Japanese Clinical Study Group on Standardization of Treatment for Lymph Node Metastasis of Head and Neck Cancer. Int J Clin Oncol. 2010; 15(1):33-38

[11] Selcuk A, Selcuk B, Bahar S, Dere H. Shoulder function in various types of neck dissection. Role of spinal accessory nerve and cervical plexus preservation. Tumori. 2008; 94(1):36-39

[12] Lea J, Bachar G, Sawka AM, et al. Metastases to level IIb in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis. Head Neck. 2010; 32(2):184-190

[13] Ahlberg A, Nikolaidis P, Engstrom T, et al. Morbidity of supraomohyoidal and modified radical neck dissection combined with radiotherapy for head and neck cancer: a prospective longitudinal study. Head Neck. 2012; 34(1):66-72

[14] Gane EM, O’Leary SP, Hatton AL, Panizza BJ, McPhail SM. Neck and upper limb dysfunction in patients following neck dissection: looking beyond the shoulder. Otolaryngol Head Neck Surg. 2017; 157(4):631-640

[15] Hutcheson KA, Lewin JS, Barringer DA, et al. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer. 2012; 118 (23):5793-5799

[16] Chapuy CI, Annino DJ, Snavely A, et al. Swallowing function following post- chemoradiotherapy neck dissection: review of findings and analysis of contributing factors. Otolaryngol Head Neck Surg. 2011; 145(3):428-434

[17] Schilling C, Stoeckli SJ, Haerle SK, et al. Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer. Eur J Cancer. 2015; 51 (18):2777-2784

[18] Murer K, Huber GF, Haile SR, Stoeckli SJ. Comparison of morbidity between sentinel node biopsy and elective neck dissection for treatment of the n0 neck in patients with oral squamous cell carcinoma. Head Neck. 2011; 33 (9):1260-1264

[19] Taylor RJ, Chepeha JC, Teknos TN, et al. Development and validation of the neck dissection impairment index: a quality of life measure. Arch Otolaryngol Head Neck Surg. 2002; 128(1):44-49

[20] Goldstein DP, Ringash J, Bissada E, et al. Evaluation of shoulder disability questionnaires used for the assessment of shoulder disability after neck dissection for head and neck cancer. Head Neck. 2014; 36(10):1453-1458

[21] Goldstein DP, Ringash J, Irish JC, et al. Assessment of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire for use in patients after neck dissection for head and neck cancer. Head Neck. 2015; 37(2):234-242

[22] Stuiver MM, ten Tusscher MR, van Opzeeland A, et al. Psychometric properties of 3 patient-reported outcome measures for the assessment of shoulder disability after neck dissection. Head Neck. 2016; 38(1):102-110

[23] McGarvey AC, Chiarelli PE, Osmotherly PG, Hoffman GR. Physiotherapy for accessory nerve shoulder dysfunction following neck dissection surgery: a literature review. Head Neck. 2011; 33(2):274-280

[24] Carvalho AP, Vital FM, Soares BG. Exercise interventions for shoulder dysfunction in patients treated for head and neck cancer. Cochrane Database Syst Rev. 2012; 18(4):CD008693

[25] McGarvey AC, Hoffman GR, Osmotherly PG, Chiarelli PE. Maximizing shoulder function after accessory nerve injury and neck dissection surgery: a multicenter randomized controlled trial. Head Neck. 2015; 37(7):1022-1031

[26] Gupta A, Bah M. NSAIDs in the treatment of postoperative pain. Curr Pain Headache Rep. 2016; 20(11):62

[27] Smith BG, Lewin JS. Lymphedema management in head and neck cancer. Curr Opin Otolaryngol Head Neck Surg. 2010; 18(3):153-158

[28] Shaitelman SF, Cromwell KD, Rasmussen JC, et al. Recent progress in the treatment and prevention of cancer-related lymphedema. CA Cancer J Clin. 2015; 65(1):55-81

[29] Smith BG, Hutcheson KA, Little LG, et al. Lymphedema outcomes in patients with head and neck cancer. Otolaryngol Head Neck Surg. 2015; 152 (2):284-291