Severe Cheek and Lower Eyelid Lymphedema After Resection of Oropharyngeal Tumor and Radiation

Abstract

Facial lymphedema, a rare condition with poorly understood pathogenesis, is commonly associated with previous infection, radiation therapy, local tumor growth, or previous surgery in the head and neck region. Few cases of isolated facial lymphedema have been reported in the literature. Surgical excision has emerged as the mainstay of therapy in such cases, although the long-term efficacy and recurrence rate after excision remain unknown. We present a unique case of a patient with severe unilateral facial lymphedema, which manifested many years after extirpation of a floor-of-the-mouth squamous cell carcinoma, bilateral supraomohyoid neck dissections, and radiation therapy. The massive cheek and eyelid lymphedema, which extended from the patient's left lower eyelid to patient's oral commissure measured 11 x 15 cm with a thickened, brawny, lobulated, and bosselated skin surface. This mass interfered with activities of daily life, caused poor oral intake, and contributed to the patient's severe kyphosis. Because the mass did not clinically or radiologically appear to be malignant, we decided to perform a salvage procedure consisting of wide excision of the massive lymphedematous mass and immediate coverage with a split-thickness skin grafting. Temporary tarsorraphy sutures were also used to provide support to the lower eyelid. The patient tolerated the procedure well, with no complications and with full take of the skin graft. Postoperatively, he was very grateful to be relieved of his debilitating symptoms.

A comprehensive review of head and neck cancer rehabilitation: Physical therapy perspectives

“…[83] Lymphedema therapy consists of sequential manual lymphatic drainage of the edematous region according to Vodder's technique. [8485] This can be combined with compression garments.…”

Cutaneous lymphatics and chronic lymphedema of the head and neck

“…Patients clinically present with painless, symmetrical non‐pitting edema localized to the forehead, infraorbital region, midface, nasal saddle, and nasolabial folds. The underlying pathogenesis of the disorder is continually debated in the literature but purportedly involves inflammatory injury to the cutaneous lymphatics (Wilkin,1994; Jansen et al,1998; Wohlrab etal.,2005; Nagasaka et al,2008). Ultimately, this manifests as persistent solid edema of the face, especially if the underlying disease entity is not recognized and treated in its early stages.…”

“…Secondary head and neck lymphedemas harbor a broad array of etiologies. Xanthomas and other infiltrative processes involving the dermis and subcutaneous tissues have been reported to be associated with development of secondary head and neck lymphedema (Tatnall and Sarkany,1988). B‐cell lymphomas (Dragan et al,2000), adenocarcinoma (Jang et al,1998) and lymphedema as part of paraneoplastic syndromes (Gudi et al,2009) have all been rarely reported.…”

“…Mechanisms mediating the miscellaneous group of head and neck lymphedemas have been proposed, similar to those for chronic reactive inflammatory disorders that eventually result in fibrosis (Carney,1966; Aköz et al,1998). Some unique aspects have been elaborated, including chronic lymphedema causing accumulation of dermal lipid secondary to lymphatic destruction and decreased lymphatic clearance, resulting in an atypical pattern of xanthomas in polygenic hypercholesterolemia (Tatnall and Sarkany,1988). Infection and chronic hyperplasia of the gingiva led to a reactive lymphangitis and obstruction of the deep intraoral lymphatics that are intricately connected to the superficial lymphatics of the skin.…”

A Pre-clinical Animal Model of Secondary Head and Neck Lymphedema

“…However, these modalities are difficult to execute for many patients and are associated with poor long-term adherence given their time-consuming and costly nature 17 . For many patients, more extensive surgical therapy becomes the only management option 18–20 . The current management of HNL is not standardized across institutions and has not been studied with long-term patient-reported outcomes.…”