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  Brad Smith: Hi Lee. Haven't been on here in a long time. My apologies for not replying. Answers are as follows.
  
  1. Free flaps in the neopharynx are required when a patient has undergone a laryngopharyngectomy, where part or all of the pharynx has been...  moreHi Lee. Haven't been on here in a long time. My apologies for not replying. Answers are as follows.
  
  1. Free flaps in the neopharynx are required when a patient has undergone a laryngopharyngectomy, where part or all of the pharynx has been removed. It is common in our institution but may not be in locations where patients with H&N cancer are not seen in large volume. This is not perfomred with a more straightforward laryngectomy and necessitates a lengthier recovery and has a higher fistula rate. reallly need to confirm with the plastic surgeon before intervening here. Depending on your surgeon's skill and preference, could be the anterolateral thigh, or the radial forearm but can be some others. Used to use the jejunum, but that has stopped in most places since the mucus production and contractions continue and results in worse swallowing and tracheoesophageal voice.
  
   
  
  2. Base your MLD directionality on scarring and tissue condition. Simply because there is bilateral XRT, that does not require a posterior approach. I reserve that for surgical patients with very thick tethered scars that extend up behind the ear or in cases where the anterior and lateral neck and supraclvicular fossa are severely fibrotic and the skin will not stretch with MLD. Direct to the axillary nodes bilaterally when possible and use the most direct pathway you can. Always moving away form the midline wathershed. If anterior, direct tot he jugular lymphn node chanis. If posterior, move along the lateral scalp, down the neck and either to the the supraclvicular fossa and then the axilla or stratight to the axilla if the SCF is unavailable.
  
   
  
  3. With inpatients you should stay away from scars until released to do so. In reconstructed cases with flaps and reconstructions with vascular anastomoses, you may not be allowed to manipulate anything in the neck for a week or two. Most of the time, the severe swelling will be facial and since the scar is across the neck, posterior is most logical. You can usually address breathing and trunk work without much issue, if the patient is up for it, but honestly unless the swelling is really severe, I wait until they are better healed and let it resolve some for the first few weeks. If you have to address it though, definitely posterior, but check with the doctor re: concerns with manipulation of the area adjacent to the scar.
  
   
  
  4. Current research does not support that MLD or compression will spread cancer. The best article I have found relevant to H&N cancer, MLD, and recurrence is by Preisler in 1998. It is in German but the abstract is in English. in general, it looked at 191 pts who had H&N cancer treatment. 100 received MLD and 91 had not. 37 pts had recurrence or local mets. 18/17 receivd MLD and 19/37 did not. No increased rate of recrrence/mets was identified among the MLD population. That said, I work with pts with active cancer every day. I see no greater recurrence mets rate with my lymphedema pts than I do with the others. However, once there is dermal meatastasis present, I have seen that spread with MLD, which makes sense, since the MLD is stimulating the dermal lymphatics.  So, I explain the risk and give the pt the choice, since usualy dermal metastasis is an indicator of poor prognosis and the treatment is palliative at that time.
  
   
  
  5. Re: Inpt management and H&N Cancer pts with lymphedema, I would refer you to Heid Miranda Walsh at Mercy Hospital in Baltimore since I bleieve she has done lots of inpt work on H&N and likely has more input.  My practice is 99% outpt and we address inpt post-op swelling only when extremely edematous.
  
  I hope that helps.
  
  Brad  less

  • April 8, 2014
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  Lee John → Brad Smith: Head & Neck Lymphedema Questions:
  1) Is it common for larygnectomy patients to have free flap in the neopharynx?  If so, what would the common donor site be? 
  2) I've seen some patients with bilateral neck radiation.  How can I judge if I should try...  moreHead & Neck Lymphedema Questions:
  1) Is it common for larygnectomy patients to have free flap in the neopharynx?  If so, what would the common donor site be? 
  2) I've seen some patients with bilateral neck radiation.  How can I judge if I should try to have lymph drain anterior versus posteriorly?
  3)  Since I'm primarily inpatient, laryngectomy pt's scars will be fresh.  Should I try draining them posteriorly until the scars heal?  If so, how?
  3) Can compression or MLD spread the cancer?  What is the best practice guideline?
  4) Last thing, does anybody have a great source that better details how inpatient CLTs should handle H&N post op pts? 
  Thanks so much!  less

  • October 10, 2013
• 
  Lee John has just joined the community. Say hello!

  • October 10, 2013