The 11th nerve syndrome in functional neck dissection

The role of intraoperative neuromonitoring in preventing lesions of the spinal accessory nerve during functional neck dissection

Intraoperative neuromonitoring (IONM) in thyroid surgery offers a valid aid to the operator in identifying the recurrent laryngeal nerve and preserving its function. Recently, IONM has also been used in other surgeries, such as spinal accessory nerve dissection, during lymphectomy of the II, III, IV, and V laterocervical lymph nodes. The goal is the preservation of the spinal accessory nerve, whose macroscopic integrity does not always indicate its functionality. A further difficulty is the anatomical variability of its course at the cervical level. The aim of our study is to assess whether the use of the IONM helps to reduce the incidence of transient and permanent paralysis of the spinal accessory nerve, compared to "de visu" identification by the surgeon alone. In our case series, the use of the IONM reduced the incidence of transient paralysis, and no permanent paralysis was recorded. In addition, if the IONM registers a reduction in nerve potential, compared to the baseline value during surgery, it could indicate the need for early rehabilitation treatment, increasing the patients' chances of regaining function and reducing the costs of prolonged physiotherapy treatment.

A randomized controlled trial of scapular exercises with electromyography biofeedback in oral cancer patients with accessory nerve dysfunction

PURPOSE

This study aims to investigate the effects of electromyography (EMG) biofeedback on scapular positions and muscle activities during scapular-focused exercises in oral cancer patients with accessory nerve dysfunction.

METHODS

Twenty-four participants were randomly allocated to the motor-control with biofeedback group (N = 12) or the motor-control group (N = 12) immediately after neck dissection. Each group performed scapular-focused exercises with conscious control of scapular orientation for 3 months. EMG biofeedback of upper trapezius (UT), middle trapezius (MT), and lower trapezius (LT) was provided in the motor-control with biofeedback group. Scapular symmetry measured by modified lateral scapular slide test; shoulder pain; active range of motion (AROM) of shoulder abduction; upper extremity function; maximal isometric muscle strength of UT, MT, and LT; and muscle activities during arm elevation/lowering in the scapular plane were evaluated at baseline and the end of the intervention.

RESULTS

After the 3-month intervention, only the motor-control with biofeedback group showed improving scapular symmetry. Although both groups did not show significant improvement in shoulder pain, increased AROM of shoulder abduction and muscle strength of the UT and MT were observed in both groups. In addition, only the motor-control with biofeedback group had improved LT muscle strength, upper extremity function, and reduced UT and MT muscle activations during arm elevation/lowering.

CONCLUSIONS

Early interventions for scapular control training significantly improved shoulder mobility and trapezius muscle strength. Furthermore, by adding EMG biofeedback to motor-control training, oral cancer patients demonstrated greater effectiveness in stabilizing scapular position, muscle efficiency, and upper extremity function than motor-control training alone.

TRIAL REGISTRATION

Institutional Review Board: This study was approved by the Chang Gung Medical Foundation Institutional Review Board (Approval No: 201901788A3. Approval Date: 2 January, 2020).

CLINICAL TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (ClinicalTrials.gov ID: NCT04476004. Initial released Date: 16 July, 2020).

Trapezius muscle branch of the spinal accessory nerve without penetrating the sternocleidomastoid muscle as a pitfall in neck dissection: prevalence in a Japanese institution and a protocol for the prevention of iatrogenic injury

BACKGROUND

The spinal accessory nerve (SAN) has several anatomical variations, which may be a pitfall in neck dissection (ND). These include the trapezius muscle branch (TB), which stems from the common trunk before entering the sternocleidomastoid muscle (SCM).

AIMS/OBJECTIVES

To investigate the prevalence of this variation and suggest a protocol for preventing unexpected injury of the TB in ND.

MATERIALS AND METHODS

We conducted a retrospective cohort study for 93 patients who had undergone neck dissection (117 sides) without resection of the SCM nor SAN. We recorded the division of the TB after and before penetration of the SCM by the common trunk (penetrating type TB [PTB]) and non-penetrating type TB [NPTB], respectively).

RESULTS

Among NDs, PTB and NPTB were observed in 61 (52%) and 56 (48%) sides, respectively. In the subgroup of 24 cases with bilateral ND, PTB/PTB, NPTB/NPTB, and NPTB/PTB were observed in eight (33%), nine (38%), and seven (29%) cases, respectively. The prevalence of PTB/NPTB did not differ according to age, sex, or laterality.

CONCLUSIONS AND SIGNIFICANCE

NPTB is a common anatomical variation. The presence or absence of a branch from the common trunk must be initially checked to avoid unexpected damage to the TB.

Getting Recovery Right After Neck Dissection (GRRAND-F): mixed-methods feasibility study to design a pragmatic randomised controlled trial protocol

INTRODUCTION

We will evaluate the feasibility of a randomised controlled trial to estimate the effectiveness and cost-effectiveness of a rehabilitation intervention on pain, function and health-related quality of life following neck dissection (ND) after head and neck cancer (HNC).

METHODS AND ANALYSIS

This is a pragmatic, multicentred, feasibility study. Participants are randomised to usual care (control) or usual care plus an individualised, rehabilitation programme (Getting Recovery Right After Neck Dissection, GRRAND intervention). Adults aged over 18 with HNC for whom ND is part of their care will be recruited from specialist clinics. Participants are randomised in 1:1 ratio using a web-based service. The target sample size is 60 participants. Usual care will be received by all participants during their postoperative inpatient stay consisting standard National Health Service care supplemented with a booklet advising on postoperative self-management strategies. The GRRAND intervention programme consists of usual care plus up to six individual physiotherapy sessions including neck and shoulder range of motion (ROM) and progressive resistance exercises, advice and education. Between sessions participants will be advised to complete a home exercise programme. The primary outcome is to determine recruitment and retention rates from study participants across sites. Outcomes will be measured at 6 and 12 months. Participants and physiotherapists will be invited to an optional qualitative interview at the completion of their involvement in the study. The target qualitative sample size is 15 participants and 12 physiotherapists. Interviews aim to further investigate the feasibility and acceptability of the intervention and to determine wider experiences of the study design and intervention from patient and physiotherapist perspectives.

ETHICS AND DISSEMINATION

Ethical approval was given on 29 October 2019 (National Research Ethics Committee Number: 19/SC/0457). Results will be reported at conferences and in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN11979997.

STATUS

Trial recruitment is ongoing and is expected to be completed by 30 August 2021.

Postoperative Pain Treatment With Continuous Local Anesthetic Wound Infusion in Patients With Head and Neck Cancer: A Nonrandomized Clinical Trial

Importance

Up to 80% of patients with head and neck cancer undergoing ablative surgery and neck dissection develop postoperative pain with detrimental effects on quality of life that also contributes to neuropathic and chronic postoperative pain.

Objective

To investigate the association of continuous local anesthetic wound infusion with pain management after head and neck surgery.

Design, Setting, and Participants

This prospective, longitudinal, nonrandomized clinical study carried out in a single tertiary referral center (December 1, 2015, to July 1, 2017) included 2 groups of 30 patients. Patients were consecutively enrolled and presented for ablative head and neck surgery including selective neck dissection and studied from the preoperative through the fourth postoperative day.

Interventions

The control group was treated according to a standardized escalating oral treatment protocol (ibuprofen, metamizole, opioids). The intervention group was treated with an intraoperatively applied pain catheter (InfiltraLong plus FuserPump, Pajunk, ropivacaine, 0.2%, 3 mL/h) that was removed 72 hours after operating.

Main Outcomes and Measures

Average and maximum pain intensities on a numeric rating scale; quality of life using the acute version of the validated 36-Item Short Form Survey; and neuropathic pain using the validated 12-Item painDETECT questionnaire. Consumption of opioid and nonopioid analgesics and evaluation of catheter-associated complications.

Results

During postoperative days 1 through 4, patients of the intervention group (mean [SD] age, 63.2 [13.3 years; 9 [30%] women) experienced lower mean (SD) (1.6 [1.4] vs 2.7 [1.8]; η2p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η2p = 0.11 [0.01-0.24]) pain intensities compared with the control group (mean [SD] age, 62.5 [13.6] years; 5 [17%] women). The intervention group also reported less neuropathic pain (mean [SD], 5.4 [3.4] vs 7.6 [5.1]; η2p = 0.09 [0.004 - 0.22]) and higher quality of life regarding vitality (56.2 [21.5] vs 43.8 [20.9], r = 0.29; 95% CI, 0.01-0.52) and pain (66.8 [27.3] vs 49.5  [27.7], r = 0.31; 95% CI, 0.04-0.54). Patients from the intervention group requested nonopioid analgesics considerably less often (n = 17 [57% ]vs n = 29 [97%]; ϕ = 0.47; 95% CI, 0.30-0.67) associated with a noticeably lower need to escalate pain treatment (n = 3 [10%] vs n = 9 [30%]; mean [SD] ibuprofen dose: 500 [173] mg vs 1133 [650] mg; r = 0.64; 95% CI, 0.02-0.91). No catheter-associated complications were observed.

Conclusions and Relevance

Continuous anesthetic wound infusion is associated with reduced postoperative pain and decreased demand for analgesics. It therefore expands the treatment options for postoperative pain in head and neck cancer.

Trial Registration

German Clinical Trials Register: DRKS00009378.

Surgical treatment of trapezius palsy: A systematic review

BACKGROUND

Trapezius palsy results from injury to the spinal accessory nerve. The condition presents with loss of shoulder abduction, pain, and winging of the scapula. Surgical treatment may improve functional outcomes and quality of life.

PURPOSE

The purpose of this study was to report and evaluate the clinical outcomes following surgical management of trapezius palsy.

STUDY DESIGN

Systematic review.

METHODS

The electronic databases EMBASE, MEDLINE, and PubMed were searched for studies and relevant data were abstracted. Only studies reporting on outcomes after the surgical treatments of trapezius palsy were included.

RESULTS

A total of 10 studies including 192 patients were included in this review. All surgical interventions resulted in improved function and pain reduction. Patients reported high satisfaction (90-92%) following nerve reconstruction or the Eden-Lange procedure, in comparison to neurolysis. The most common procedure reported was the Eden-Lange muscle transfer (32% reported cases) demonstrating the highest patient satisfaction rates with low complication rate of 7.7%.

CONCLUSION

Patients failing conservative treatment report good outcomes following surgical treatment of trapezius palsy. All reported surgical procedures demonstrate reduction in pain the best results from the Eden-Lange muscle transfer. Further high-quality comparative studies are required to make definitive conclusions regarding the comparative efficacy of each surgical procedure.

Neck Dissection in the Surgical Treatment of Thyroid Cancer

The incidence of thyroid cancer is increasing, largely attributable to overdetection related to prevalent diagnostic and radiologic imaging modalities. Papillary thyroid cancer remains the most common thyroid malignancy. It has a high tendency for regional metastasis to the cervical lymph nodes. The optimal management of the neck in patients with thyroid carcinoma has long been an important topic of debate. This article addresses central and lateral neck dissection, providing a simplified guide to the most up-to-date and evidence-based practices.

Positive association between the cross-sectional area of the rhomboid muscle, and the range of shoulder abduction after neck dissection surgery

OBJECTIVE

To evaluate the association between the cross-sectional area of selected shoulder and scapular muscles and the range of shoulder abduction, early after neck dissection surgery.

PATIENTS AND METHODS

Twenty-seven patients (contributing 34 upper limbs), who had undergone neck dissection surgery for head and neck malignancy, were enrolled into the study. Loss of strength of the trapezius muscle at 1-month post-surgery was quantified by the change in active range of shoulder abduction (%A-ROM), measured by hand-held goniometry in a standing position, from baseline, before surgery. The cross-sectional area of the following muscles were measured on unenhanced computed tomography images after surgery: trapezius, rhomboid, serratus anterior, pectoralis major, deltoid, and biceps brachii.

RESULTS

There was a significant positive correlation between the %A-ROM and the cross-sectional area of the rhomboid muscle.

CONCLUSION

Greater active shoulder abduction early after surgery is associated with a greater cross-sectional area of the rhomboid muscle. This muscle should be included in intensive programs for rehabilitation of upper limb movement after neck dissection surgery.

Comparison of hospital based and home based exercise on quality of life, and neck and shoulder function in patients with spinal accessary nerve injury after head and neck cancer surgery

OBJECTIVES

The purpose of this study was to compare the effects of hospital-based and home-based exercise programs on quality of life (QOL) and neck and shoulder function of patients who underwent head and neck cancer (HNC) surgery.

METHODS

This clinical trial included 40 patients with neck and shoulder dysfunction after HNC. The exercise program included range of motion (ROM) exercises, massage, stretching, and strengthening exercises. Twenty patients who were assigned to the hospital-based exercise group performed physical therapy for 40 min three times a week for four weeks, and the remaining 20 patients were assigned to the home-based group. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck Questionnaire (EORTC QLQ-H&N), the Neck and Shoulder Disability Index (NDI), ROM, and numeric rating scale (NRS) were assessed before and after the exercise program. The program consisted of a 10-minute ROM to the neck and shoulder, a 10-minute massage, and 15 min of progressive resistance exercises, followed by a five-minute stretching exercise.

RESULTS

There were statistically significant differences in the changes of neck and shoulder disability index (p < .05). Additionally, there were significant differences in neck extension and rotation ROM and NRS in the hospital-based group compared with the home-based group (p < .05). QOL was not significantly different between the two groups.

CONCLUSIONS

Home-based exercise was effective for improving QOL, shoulder function, and pain relief. Hospital-based exercise had better effects on physical function of the neck and shoulder and reduced pain.

Shoulder Morbidity in Patients after Head and Neck Reconstruction with the Pedicled Supraclavicular Island Flap

Supplemental Digital Content is available in the text.

Background:

The pedicled supraclavicular artery island flap (SCAIF) for reconstruction of the head and neck has been shown to be a pliable alternative to established pedicled flaps, such as the pectoralis major myocutaneous flap. Because there are limited published data regarding shoulder morbidity after SCAIF procedure, we aimed to investigate it with 2 established questionnaires for the upper extremity [Constant-Murley score and Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) score].

Methods:

The authors designed and implemented a retrospective cohort study of patients who received a defect reconstruction by SCAIF. Analyzed parameters were demographics, comorbidities, donor-site morbidity and shoulder morbidity in terms of range of motion, pain, strength, and daily activities evaluated and compared between the donor site and contralateral arm.

Results:

Of the 61 consecutively performed head and neck reconstructions with SCAIF, 20 met inclusion criteria (curative intended treatment, head and neck squamous cell cancer, follow-up time more than 4 months). Mean follow-up was 17.3 months (±10.4 months) ranging from 4–35 months. Donor-site complication rate was low with 5% major (surgical revision) and 30% minor complications (conservative management). Overall Constant-Murley-Score (P = 0.334), pain (P = 0.150), overall range of motion (P = 0.861), and strength of the extremity (P = 0.638) of the shoulder receiving a SCAIF showed no significant differences to the contralateral extremity. Mean of Disabilities of the Arm, Shoulder and Hand Outcome Measure score was 32.5 (±28.6).

Conclusion:

The results of the present study suggest very low shoulder morbidity in patients after SCAIF procedure with no significant functional impairment of the donor shoulder compared with the contralateral side.

Shoulder Function in Various Types of Neck Dissection. Role of Spinal Accessory Nerve and Cervical Plexus Preservation

Aims and background

The aim of this study is to determine the effects of two different types of nerve-sparing neck dissection on shoulder function. Even if the spinal accessory nerve is spared in functional neck dissection, some degree of shoulder syndrome may occur. The role of the cervical plexus in shoulder function and the effects of dissection of level 5 are emphasized.

Methods

Twenty-six patients with laryngeal carcinoma were studied prospectively. Seventeen anterolateral and 15 functional neck dissections were performed. Electromyographic evaluation was carried out in all patients to assess spinal accessory nerve function preoperatively and at the sixth week and sixth month postoperatively. Shoulder disability was evaluated by a questionnaire (shoulder pain disability index) and goniometric measurements were done preoperatively and at the sixth postoperative month.

Results

In patients who underwent anterolateral neck dissection, the goniometric results were better than in the functional neck dissection group. The questionnaire results also showed better quality of life of patients who underwent anterolateral neck dissection. Electrophysiological evaluation of the trapezius muscles of both groups at the sixth week showed significant differences. The distal motor latency values of the anterolateral neck dissection group were shorter than those of the other group. Electrophysiological evaluation at the sixth postoperative month showed shorter distal latency values in the anterolateral dissection group, without statistical significance.

Conclusions

Preservation of the cervical plexus and less disturbance of the spinal accessory nerve are important to diminish postoperative shoulder disability. The type of neck dissection has an important influence on shoulder function.

Uncertain effect of preventative shoulder rehabilitation for patients who underwent total laryngectomy with neck dissection

INTRODUCTION

Total laryngectomy (TL) with neck dissection (ND) is considered as crucial management for advanced-stage of laryngeal cancer. Shoulder dysfunction has long been recognized as a potential complication resulting from neck dissection. The aim of this study was to evaluate the effect of early prophylactic rehabilitation program in patients who underwent TL with ND.

METHODS

A prospective, nonrandomized design was used. Seventy-six participants who underwent TL with ND were assigned into either an intervention or a control group. The control group received current standard care with no formal shoulder exercise provided, while the intervention group attended early preventive rehabilitation lasting 12 weeks. Participants were assessed at baseline, and at 3 and 6 months after surgery. Measured outcomes included shoulder function and patient-reported quality of life. General linear models with repeated measures were used to examine outcome changes in both groups over the designated assessment intervals.

RESULTS

Improvement in shoulder function and patient-reported quality of life were both statistically significant over time, with no significant difference between control or intervention groups, indicating little or no benefit of preventative intervention on shoulder function outcomes. Analysis involving five subscales and the summary score of the quality of life questionnaire had only statistically significant improvement over time for both the control or intervention groups, except for physical well-being domain which had statistical significance both over time and between the control and intervention groups.

CONCLUSION

In this study, preventative exercise program initiated immediately after surgery had a limited impact on both shoulder function and perceived quality of life.

Survivorship: Morbidity, Mortality, Malignancy

Survivorship encompasses the entire therapeutic, psychosocial, functional, and financial experience of living with and through a cancer diagnosis. The period of survivorship starts on the day of the cancer diagnosis and lasts until the end of the survivor's life, regardless of the cause of death. The National Cancer Institute's Office of Cancer Survivorship expands the term "survivor" to include, importantly, caregivers, family, and friends close to the survivor who also live through this period.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer

OBJECTIVE

To determine the association of neck dissection and radiation treatment for head and neck cancer (HNC) with subsequent shoulder range of motion (ROM) and quality of life (QOL) in 5-year survivors.

DESIGN

A cross-sectional convenience sample.

SETTING

Otolaryngology clinics at tertiary care hospital and Veterans Affairs medical center.

PATIENTS

Five-year, disease-free survivors of HNC.

METHODS

Demographic and cancer treatment information was collected, including type of neck dissection (none, spinal accessory "nerve sparing," and "nerve sacrificing") and radiation. QOL questionnaires were administered, and shoulder ROM was measured.

MAIN OUTCOME MEASUREMENTS

University of Washington Quality of Life (UWQOL), Functional Assessment of Cancer Therapy (FACT) Head and Neck, and Performance Status Scale for Head and Neck. Shoulder ROM measurements included abduction, adduction, flexion, extension, internal and external rotation.

RESULTS

One hundred and five survivors completed QOL surveys; 85 survivors underwent additional shoulder ROM evaluations. The nerve sacrifice group exhibited significantly poorer scores for UWQOL measures of disfigurement, level of activity, recreation and/or entertainment, speech and shoulder disability, and willingness to eat in public, FACT functional well-being, and FACT Head and Neck (P < .05). Shoulder ROM for flexion and abduction was poorest in the nerve sacrifice group (P < .05). Radiation was associated with significantly worse UWQOL swallowing (P < .05), but no other differences were found for QOL or ROM measurements. Decreased QOL scores were associated with decreased shoulder flexion and abduction (P < .05). Survivors with decreased shoulder abduction had significantly (P < .05) worse scores in disfigurement, recreation and/or entertainment, employment, shoulder disability, and FACT emotional well-being.

CONCLUSIONS

Sparing the spinal accessory nerve during neck dissection is associated with significantly less long-term shoulder disability in 5-year survivors of HNC. QOL measures demonstrated the highest level of function in the no dissection group, an intermediate level of functioning with nerve sparing, and poorest function when the nerve is sacrificed. Decreased shoulder flexion and abduction is associated with reduced QOL in long-term survivors of HNC.

Shoulder pain, functional status, and health-related quality of life after head and neck cancer surgery

Head and neck cancer (HNC) patients experience treatment-related complications that may interfere with health-related quality of life (HRQOL). The purpose of this study was to describe the symptom experience (shoulder pain) and functional status factors that are related to global and domain-specific HRQOL at one month after HNC surgery. In this exploratory study, we examined 29 patients. The outcome variables included global HRQOL as well as physical, functional, emotional, and social well-being. Symptom experience and functional status factors were the independent variables. In the symptom experience variables, shoulder pain distress was negatively associated with physical well-being (R (2) = 0.24). Among the functional status variables, eating impairment was negatively related to global HRQOL (R (2) = 0.18) and physical well-being (R (2) = 0.21). Speaking impairment and impaired body image explained a large amount of the variance in functional well-being (R (2) = 0.45). This study provided initial results regarding symptom experience and functional status factors related to poor HRQOL in the early postoperative period for HNC patients.

Transoral resection of pharyngeal cancer: summary of a National Cancer Institute Head and Neck Cancer Steering Committee Clinical Trials Planning Meeting, November 6-7, 2011, Arlington, Virginia

Recent advances now permit resection of many pharyngeal tumors through the open mouth, an approach that can greatly reduce the morbidity of surgical exposure. These transoral techniques are being rapidly adopted by the surgical community and hold considerable promise. On November 6-7, 2011, the National Cancer Institute sponsored a Clinical Trials Planning Meeting to address how to further investigate the use of transoral surgery, both in the good prognosis human papillomavirus (HPV)-initiated oropharyngeal cancers, and in those with HPV-unrelated disease. The proceedings of this meeting are summarized.

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

Rehabilitation in relation to cancer can be preventative, restorative, supportive, and palliative. It is recognized that patients may have rehabilitation needs throughout their care pathway. The role of physiotherapy in the cancer rehabilitation is less understood and particularly in the head and neck cancer (HNC) patients. This results in various residual deformities and dysfunctions for the patients with HNC. The objective of this review is to provide detailed information regarding the problems faced after the cancer treatments and rehabilitation of patients who suffered with HNC. The fact that cancer patients are facing several months of chemotherapy and/or radiotherapy and usually major surgery, as well as the direct effect of immobility due to pain, means that muscle wasting, joint stiffness, as well as de-conditioning and fatigue are inevitable. The absence of physiotherapy intervention would be detrimental to patient care and the ability of the patient/family to cope with the effects of the disease or its treatment on their functional capacity and quality of life. Following any treatment for HNC, physical therapy may play an essential role in preventing various complications and helping patients to mitigate impairments, and restoring function of the shoulder joint, neck, and face.

Exercise interventions for shoulder dysfunction in patients treated for head and neck cancer

BACKGROUND

Shoulder dysfunction is a common problem in patients treated for head and neck cancer. Both neck dissections and radiotherapy can cause morbidity to the shoulder joint. Exercise interventions have been suggested as a treatment option for this population.

OBJECTIVES

To evaluate the effectiveness and safety of exercise interventions for the treatment of shoulder dysfunction caused by the treatment of head and neck cancer.

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 7 July 2011.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any type of exercise therapy compared with any other intervention in patients with shoulder dysfunction due to treatment of head and neck cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias and extracted data from studies. We contacted study authors for information not provided in the published articles.

MAIN RESULTS

Three trials involving 104 people were included. We classified one study as having low risk of bias; the others had some limitations and we classified them as having high risk of bias.Two studies (one with low risk of bias and the other with high risk of bias) applied progressive resistance training (PRT) combined with range of motion exercises and stretching; the comparison group received standard care. Pooled data demonstrated that PRT can improve shoulder pain (mean difference (MD) -6.26; 95% confidence interval (CI) -12.20 to -0.31) and shoulder disability (MD -8.48; 95% CI -15.07 to -1.88), both measured using the Shoulder Pain and Disability Index (SPADI) (range 0 to 100). Similarly, secondary outcomes were also improved: active range of motion for external rotation (MD 14.51 degrees; 95% CI 7.87 to 21.14), passive range of motion for abduction (MD 7.65 degrees; 95% CI 0.64 to 14.66), forward flexion (MD 6.20 degrees; 95% CI 0.69 to 11.71), external rotation (MD 7.17 degrees; 95% CI 2.20 to 12.14) and horizontal abduction (MD 7.34 degrees; 95% CI 2.86 to 11.83). Strength and resistance of scapular muscles was assessed in one study and the results showed a statistically significant benefit of PRT. The studies did not demonstrate a statistically significant difference in quality of life. Only two non-serious adverse events were described in the PRT group compared with none in the standard care group.One study with high risk of bias used a broad spectrum of techniques including free active exercises, stretching and postural care for a period of three months following surgery. This study did not demonstrate a difference between the exercise group and routine postoperative physiotherapy care in shoulder function and quality of life, but serious methodological limitations could explain this. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

Limited evidence from two RCTs demonstrated that PRT is more effective than standard physiotherapy treatment for shoulder dysfunction in patients treated for head and neck cancer, improving pain, disability and range of motion of the shoulder joint, but it does not improve quality of life. However, although statistically significant the measured benefits of the intervention may be small. Other exercise regimes were not shown to be effective compared to routine postoperative physiotherapy. Further studies which apply other exercise interventions in head and neck cancer patients in the early postoperative and radiotherapy period are needed, with long-term follow-up.

A cost-effectiveness analysis of a preventive exercise program for patients with advanced head and neck cancer treated with concomitant chemo-radiotherapy

Background

Concomitant chemo-radiotherapy (CCRT) has become an indispensable organ, but not always function preserving treatment modality for advanced head and neck cancer. To prevent/limit the functional side effects of CCRT, special exercise programs are increasingly explored. This study presents cost-effectiveness analyses of a preventive (swallowing) exercise program (PREP) compared to usual care (UC) from a health care perspective.

Methods

A Markov decision model of PREP versus UC was developed for CCRT in advanced head and neck cancer. Main outcome variables were tube dependency at one-year and number of post-CCRT hospital admission days. Primary outcome was costs per quality adjusted life years (cost/QALY), with an incremental cost-effectiveness ratio (ICER) as outcome parameter. The Expected Value of Perfect Information (EVPI) was calculated to obtain the value of further research.

Results

PREP resulted in less tube dependency (3% and 25%, respectively), and in fewer hospital admission days than UC (3.2 and 4.5 days respectively). Total costs for UC amounted to €41,986 and for PREP to €42,271. Quality adjusted life years for UC amounted to 0.68 and for PREP to 0.77. Based on costs per QALY, PREP has a higher probability of being cost-effective as long as the willingness to pay threshold for 1 additional QALY is at least €3,200/QALY. At the prevailing threshold of €20,000/QALY the probability for PREP being cost-effective compared to UC was 83%. The EVPI demonstrated potential value in undertaking additional research to reduce the existing decision uncertainty.

Conclusions

Based on current evidence, PREP for CCRT in advanced head and neck cancer has the higher probability of being cost-effective when compared to UC. Moreover, the majority of sensitivity analyses produced ICERs that are well below the prevailing willingness to pay threshold for an additional QALY (range from dominance till €45,906/QALY).

A double blind randomised trial of IIb or not IIb neck dissections on electromyography, clinical examination, and questionnaire-based outcomes: a feasibility study

The aim of this double-blind randomised controlled trial was to evaluate the feasibility of a study to compare differences using electromyographic (EMG) or nerve conduction studies (NCS), questionnaires completed by patients, and range of movement, after selective supraomohyoid neck dissection in patients with and without level IIb for node-negative oral cancer. Between January 2006 and July 2008 we recruited 57 previously untreated consecutive patients with node-negative T1 or T2 squamous cell carcinomas (SCC) of the anterior two-thirds of the tongue and floor of the mouth. Thirty-eight patients were randomised (32 unilateral and 6 bilateral dissections) into two groups. Preoperatively and at 6 weeks postoperatively we collected EMG or NCS data on trapezius muscle activity (primary outcome), the University of Washington quality of life scale (UWQoLv4), the neck dissection impairment index (NDII), and range of movement. At 6 months data on range of movement and data from the questionnaires were obtained. There was a greater mean fall in trapezius M-response amplitude for those who had IIb dissected, which suggested that inclusion of this level caused additional morbidity. However, it was not significant for patients who had unilateral dissections or for all necks combined. Changes in M-amplitude from baseline to 6 weeks, and from baseline to 6 months were strongly associated with changes in the shoulder domain of the UWQoL and the NDII, but were less strong for change in range of movement. This feasibility study has shown that a randomised controlled trial (RCT) is achievable. The combination of EMG or NCS with questionnaire data preoperatively and to 6 weeks would suffice and would simplify a new study design.

Physiotherapy for accessory nerve shoulder dysfunction following neck dissection surgery: a literature review

BACKGROUND

Neck dissection is an operation that can result in accessory nerve injury. Accessory nerve shoulder dysfunction (ANSD) describes the pain and impaired range of motion that may occur following neck dissection. The aim of this review was to establish the level of evidence for the effectiveness of physiotherapy in the postoperative management of ANSD.

METHODS

A literature search of physiotherapy and ANSD using Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), and Cochrane Library databases was undertaken.

RESULTS

Physiotherapy has been shown to be well tolerated in this patient group following surgery. However, few studies exist as to the effect of physiotherapy on ANSD.

CONCLUSIONS

There is a need for research to investigate the effects of early, appropriate physiotherapy on the development of ANSD following neck dissection surgery. Such a study has the potential to improve the functional outcome and quality of life in this patient group, and ultimately to promote best practice guidelines for management.

Morbidity of supraomohyoidal and modified radical neck dissection combined with radiotherapy for head and neck cancer: a prospective longitudinal study

BACKGROUND

The purpose of this study was to show the investigated impact of supraomohyoidal neck dissection and modified radical neck dissection, both combined with radiotherapy, on cervical range of motion (CROM), mouth opening, swallowing, lymphedema, and shoulder function.

METHODS

One hundred eight patients who had neck dissections and 98 patients who had non-neck dissections were evaluated in a prospective, nonselective, longitudinal cohort study by a physiotherapist and a speech-language pathologist (SLP) before the start of radiotherapy and up to 12 months after treatment.

RESULTS

The incidence of shoulder disability after neck dissection was 18%. Supraomohyoidal neck dissection had no significant effect on the evaluated parameters at any time point. Modified radical neck dissection significantly reduced CROM and mouth opening 2 months after treatment, but after 12 months only cervical rotation was still significantly reduced.

CONCLUSION

In patients treated with external beam radiation (EBRT), modified radical neck dissection induced additional morbidity regarding CROM but not regarding mouth opening, swallowing, and lymphedema 1 year after treatment. Both modified radical neck dissection and supraomohyoidal neck dissection induced shoulder disability.

Anatomic relationship between the spinal accessory nerve and internal jugular vein in the upper neck

OBJECTIVE

The goal of this study was to precisely detail the relationship between the spinal accessory nerve (SAN) and the internal jugular vein (IJV) in the upper neck, specifically at the level of the posterior belly of the digastric muscle.

STUDY DESIGN

Case series with planned data collection.

SETTING

University hospital.

SUBJECTS AND METHODS

This information was prospectively gathered intraoperatively in patients undergoing a neck dissection. The neck dissections were performed for the treatment or diagnosis of cancer, independent of the research goals. Eighty-six subjects underwent neck dissections, 56 unilateral and 30 bilateral. The position of the SAN was determined to be oriented lateral to the IJV, medial to the IJV, posterior to the IJV, or directly through the IJV at the level of the posterior belly of the digastric muscle.

RESULTS

Of 116 neck dissections, 112 (96%) were oriented lateral to the IJV at the level of the superior border of the posterior belly of the digastric muscle. In three necks (3%), the SAN was positioned medial to the IJV, and one (1%) traveled directly through the IJV.

CONCLUSION

The SAN has an intimate anatomic relationship with the IJV as it travels through the neck. The SAN is nearly always oriented lateral to the IJV, and the IJV and SAN are likely at some increased risk of injury during neck dissection in cases where the nerve travels medial to or through the IJV.

Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissection for FNA-confirmed metastases in other levels

BACKGROUND

The purpose of the present study was to determine the utility of routine dissection of level II-B and level V-A in patients with papillary thyroid cancer (PTC) undergoing lateral neck dissection for ultrasound-guided fine-needle aspiration (FNA)-confirmed lateral nodal metastasis in at least one neck nodal level.

METHODS

In a retrospective review, we studied the charts of 53 consecutive patients (February 2002-December 2007) with PTC who had undergone therapeutic lateral neck dissection that included at least level II-(A and B) and/or level V-(A and B). The levels were designated as such in situ prior to surgical pathology specimen processing. Reports of the preoperative FNA cytopathologic findings, the extent of lateral neck dissection by levels, and the postoperative final histopathologic examination were reviewed.

RESULTS

A total of 53 patients underwent therapeutic lateral neck dissection for FNA-confirmed nodal metastasis of PTC at a minimum of one lateral neck level. All 53 patients had preoperative ultrasonography and FNA confirmation of lateral neck disease: 46 patients had PTC, 5 had the tall cell variant of PTC, and 2 had the follicular variant of PTC on final surgical pathology. Ten patients underwent neck dissection at the time of thyroidectomy, and 43 patients underwent neck dissection for lateral neck recurrence/persistence of PTC following a previous thyroidectomy and radioactive iodine +/- previous neck dissection. A total of 46 patients underwent unilateral neck dissection and 7 patients underwent bilateral neck dissection; thus 60 neck dissection specimens were evaluated. Level II (A and B) was excised in 59/60 neck dissections, with 33 of 59 specimens (33/59 = 60%) positive for metastasis. Level II-B was positive 5 times (5/59; 8.5-95% CI: 2.4, 20.4), and each time level II-B was positive, level II-A was also grossly (and histopathologically--seen at the time of surgery) positive for metastasis. Level III was excised 58 times and was positive in 38 specimens (38/58 = 66%). Level IV was excised 58 times and was positive in 29 specimens (29/58 = 50%). Level V (A and B) was excised 40 times and was positive in 16 specimens (16-40 = 40%). Level V-A did not account for any of the positive level V results (0%).

CONCLUSIONS

Cervical lateral neck metastases in PTC occur in a predictable pattern, with levels III, II-A, and IV most commonly involved. Patients with PTC who undergo lateral neck dissection for FNA-confirmed nodal metastases might harbor disease in level II-B, especially if level II-A is involved. We recommend elective dissection of level II-B only when level II-A is involved, based on FNA confirmation, or when it is grossly involved on intraoperative evaluation. Routine dissection of level V-B is recommended in this patient population, while elective dissection of level V-A is not necessary.

Impact of shoulder complaints after neck dissection on shoulder disability and quality of life

OBJECTIVE

To explore relationships between shoulder complaints after neck dissection, shoulder disability, and quality of life. To find clinical predictors for mid- to long-term shoulder disability.

STUDY DESIGN

Prospective.

PATIENTS AND METHODS

Shoulder pain, shoulder mobility, and shoulder droop, as well as scores on shoulder disability questionnaire and RAND-36 (quality of life), were measured at baseline, discharge (T1), and 4 months postoperatively (T2) on 139 patients admitted for neck dissection to major head and neck centers in the Netherlands.

RESULTS

Shoulder mobility was significantly decreased at T1 and did not improve. Significant relationships between shoulder function, shoulder disability score, and RAND-36 domains were found. Two clusters of clinical symptoms could be identified as independent predictors for shoulder disability.

CONCLUSIONS

Objective deterioration in shoulder function after neck dissection is associated with perceived shoulder disability and related to physical functioning and bodily pain. Predictors for shoulder disability can be found.

The relationship between shoulder pain and damage to the cervical plexus following neck dissection

The aim of our study was to evaluate the relationship between shoulder pain and damage to the cervical plexus after neck dissection. The study was performed prospectively on 34 neck sides of 17 patients with laryngeal cancer who underwent laryngectomy plus bilateral selective neck dissection (II, III, IV, +/- VI) at the Department of Otorhinolaryngology of Uludag University between December 2003 and October 2004. The cervical plexus was protected on one side of the neck and sacrificed on the other, while the accessory nerve was spared on both sides. The degree of sensorial innervation of the cervical plexus and shoulder pain were evaluated in the preoperative period and postoperatively at 2 weeks, 1 month, 3 months, and 6 months. Data obtained from both sides of the neck were compared. Sensory reception scores were statistically higher in the neck sides in which the cervical plexus was spared than in those where the plexus was sacrificed (P < 0.05). However, the degree of shoulder pain was similar on both sides of the neck (P > 0.05). Damage to the cervical plexus during neck dissection causes loss of sensorial innervation of the neck, but sacrificing the cervical plexus during selective neck dissection has no negative effect on shoulder pain.

The spinal accessory nerve in head and neck surgery

PURPOSE OF REVIEW

To describe landmarks and tips used for minimizing surgical traumas to the spinal accessory nerve, and different options in case of its injury.

RECENT FINDINGS

Modified radical and selective neck dissections reduce the prevalence of shoulder syndrome, a sequela of radical neck dissection. Impaired shoulder mobility and pain may be present even after nerve-sparing procedures, as shown using electromyography, particularly when dissection is extended to level V. In these cases physical therapy is mandatory to prevent shoulder pain and functional limitations. The issue of spinal accessory nerve repair when macroscopically damaged or transected remains critical.

SUMMARY

Subclinical spinal accessory nerve impairment can be observed even after selective neck dissections (levels II-IV) due to routine clearance of sublevel IIB. Further studies should be performed to select patients in whom this sublevel could be left undissected without impairing oncologic radicality and to demonstrate if such a policy leads to better functional results. Early diagnosis of shoulder syndrome by questionnaires and clinical tests is recommended to appropriately plan physical therapy. Spinal accessory nerve repair is advocated to reduce the prevalence of shoulder syndrome after radical neck dissection. More data are needed to assess the superiority of newer techniques such as nerve transposition or bioresorbable nerve guides.

Clinical results of rehabilitation for accessory nerve palsy after radical neck dissection

CONCLUSIONS

Occupational therapy significantly improves shoulder range of motion in patients with accessory nerve palsy after radical neck dissection, but it has limited effects on the associated pain.

OBJECTIVE

To evaluate the outcome of occupational therapy rehabilitation for patients with accessory nerve palsy.

PATIENTS AND METHODS

The occupational therapy group involved 35 shoulders of 29 patients with accessory nerve palsy after radical neck dissection; the control group included 10 shoulders of 9 patients who did not receive occupational therapy. All patients had a malignant tumor in the head or neck that necessitated radical neck dissection. We collected data pertaining to resting pain, motion pain, and the active and passive range of motion during shoulder flexion and abduction.

RESULTS

Occupational therapy did not adequately relieve resting or motion pain, but all patients achieved independence in activities of daily living and housekeeping activities. Although occupational therapy significantly improved shoulder elevation for all movements, shoulder elevation was significantly better for flexion than for active and passive abduction.

Selective neck dissection in patients with upper aerodigestive tract cancer with clinically positive nodal disease

OBJECTIVES

We evaluated the efficacy of the application of selective neck dissection to cases of clinically node-positive disease.

METHODS

We performed a retrospective review at the University of Pittsburgh Head and Neck Cancer Database. A database of 65 patients was followed for an average of 36 months (range, 2 to 128 months) after they underwent selective neck dissection for clinically node-positive regional disease.

RESULTS

Regional failure occurred in 8 patients (12.3%). In-field failure was experienced in 4 patients (6.1%), and failures outside the field of dissection occurred in 4 patients (6.1%). The overall incidence of extracapsular spread was 33.8% (22 of 65). Only 2 of 8 regional recurrences were associated with extracapsular spread at the initial neck dissection; however, both recurrences were in the contralateral, undissected side of the neck. Four regional failures were salvaged with surgery, with eventual overall regional control in the neck of 93.9%. Only 1 of 4 ipsilateral recurrences (25%) was successfully salvaged. In contrast, 3 of 4 contralateral failures (75%) were successfully salvaged. In our study population, 21 of 65 cases (32%) that were initially staged as clinically node-positive had no evidence of nodal metastases on pathologic examination.

CONCLUSIONS

The application of selective neck dissection and postoperative irradiation in patients with clinically Nl and limited N2 clinical disease appears to be oncologically efficacious. Clinical overstaging occurred frequently in this sample, and may put patients at risk for more morbid surgical procedures.

Accessory Nerve Function in Lateral Selective Neck Dissection with Undissected Level IIB

BACKGROUND

To investigate the accessory nerve function in lateral selective neck dissections (LSND) performed in laryngeal squamous cell carcinoma patients without dissection of level IIB.

METHODS

Fifteen LSND were performed in 11 N0 laryngeal carcinoma patients with preservation of level IIB. Distal latencies, compound muscle action potentials (CMAP), and electromyography findings were investigated before surgery, during the 3rd postoperative week, and 3 months thereafter to compare the effects of the procedure on the accessory nerve.

RESULTS

Distal latencies and CMAP values were significantly lower in the early and late postoperative periods when compared with preoperative values. In 8 patients, there was no motor unit potential (MUP) in the early postoperative period. However, in the late postoperative period, there was no MUP loss.

CONCLUSIONS

Only temporary functional deterioration of the accessory nerve was seen in patients in whom LSND was performed with undissected level IIB.

Neurological complications following functional neck dissection

A retrospective study was done to assess the incidence and factors associated with neurological complications in patients who have undergone a functional neck dissection (FND). Four hundred forty-two epidermoid cancer patients operated on from January 1984 to December 2002 were included in the study. Clinical parameters, neurological sequelae, and other complications were evaluated in all cases. The incidence of neural damage was calculated on the nerves at risk (n =714). Paralysis of the 11th nerve occurred in 12 cases (1.68%). A lesion of the marginal branch of the 7th cranial nerve was observed in nine cases (1.26%). Bernard-Horner's syndrome and hypoglossal nerve paralysis were noted in four and three cases (0.56 and 0.42%), respectively. Thus, the incidence of neurological sequelae after FND is low. Neurological complications were not associated with either clinical parameters or non-neurological complications (P >0.05). None of the factors studied can predict the appearance of neural problems in the postoperative period.

A new shoulder orthosis for paralysis of the trapezius muscle after radical neck dissection: a preliminary report

Despite recent advances using more conservative approaches, standard classical radical neck dissection is still one of the most frequently performed procedures in head and neck cancer patients who have advanced metastatic neck disease. The trapezius muscle paralysis following division of the spinal accessory nerve results in severe pain and cosmetic disturbance related to malalignment of the shoulder joint. The objective of this study is to report our results with a newly developed orthosis to prevent and correct shoulder dysfunction following standard radical neck dissection. Thirty-four patients who underwent standard radical neck dissection as a part of their surgical treatment from 1997-2002 were rehabilitated by the shoulder orthosis. Beginning 2 weeks after surgery, the patients were allowed to use their orthosis. By using a standard questionnaire, the pain and activity scores were recorded at the 1st, 3rd, 6th and 12th months postoperatively. Six patients were excluded from the study, of whom two succumbed to their disease and four discontinued the use of the orthosis. Of 28 patients included in the study, 20 (72%) were completely pain free within 3 months following the surgery. Four patients (14%) noted their pain level as tolerable, and four patients (14%) reported no considerable gain in the pain threshold and/or physical activity levels. Despite the fact that the active abduction range increased only 5 to 20 degrees , the relief of pain and improved malalignment of the scapula and consequently clavicle and humerus led to functional gains, which increased the patients' endurance. At the end of the study, 23 patients (82%) were able to return to their previous jobs or activity levels. Current preliminary reports suggest that this orthosis can be recommended to prevent significant disability in patients with trapezius palsy due to ablative cancer surgery or other reasons.

Shoulder and neck morbidity in quality of life after surgery for head and neck cancer

BACKGROUND

Quality of life has become a major issue in determining the outcome of treatment in head and neck surgery with curative intent. The aim of our study was to determine which factors in the postoperative care, especially shoulder and neck morbidity, are related to quality of life and how these outcomes compared between patients who had undergone surgery and a control group.

METHODS

We analyzed physical symptoms, psychological symptoms, and social and functional well-being at least 1 year after surgery and evaluated the differences in quality of life between patients who had undergone head and neck surgery and a control group.

RESULTS

Depression scores contributed significantly to all domains of quality of life. Reduced shoulder abduction, shoulder pain, and neck pain are related to several domains of quality of life. The patient group scored significantly worse for social functioning and limitations from physical problems but scored significantly better for bodily pain and health changes.

CONCLUSION

Depression and shoulder and neck morbidity are important factors in quality of life for patients who have undergone surgery for head and neck cancer.

Shoulder function after accessory nerve-sparing neck dissections

BACKGROUND

This study was designed to observe the effect of preserving the spinal accessory nerve (SAN) during neck dissection (ND) and adjuvant radiotherapy (ART) after ND on shoulder function.

METHODS

Fifty-seven patients with head and neck cancer who had undergone primary tumor resection and various types of NDs were enrolled in this prospective study. Postoperative shoulder joint range of motion was evaluated by goniometry, and muscle strength was measured manually. SAN function was evaluated with electromyography (EMG) with respect to percentage of denervation and presence of neurogenic involvement. Patients were grouped by treatment as follows: radical ND (RND) versus modified radical ND (MRND)/selective ND (SND) and ART versus no ART.

RESULTS

Shoulder joint range of motion and shoulder muscle strength were significantly better in the MRND/SND group than in the RND group. However, EMG findings were similar in the RND and MRND/SND groups. When all patients who underwent ND, RND, or MRND/SND were compared with the control group, statistically significant changes in shoulder joint range of motion and shoulder muscle strength were found. Also, denervation and neurogenic involvement of the SAN were significantly higher after all NDs than in the control group. ART did not affect range of motion of the shoulder joint, shoulder muscle strength, or the degree of denervation and neurogenic involvement in any of the ND groups.

CONCLUSIONS

ART does not have a negative effect on shoulder function after ND. SAN is always functionally impaired even if we preserve it macroscopically during ND.

[Neurophysiologic intraoperative monitoring to preserve cranial nerve function in base of skull surgery]

BACKGROUND

Neurophysiologic intraoperative monitoring (NIM) has gone through a renaissance since the advent of computer technology. Currently, both motor and sensory cranial nerves, including the IInd and VIIIth cranial nerves, can be intraoperatively controlled by means of small and mobile systems.

PATIENTS AND METHODS

In order to estimate the value of NIM using the new generation of computer systems, we analyzed the records of 379 patients who underwent skull base surgery since 1996. These comprised NIM of the IInd, VIIth, VIIIth cranial nerves in most cases and of the IXth, Xth, XIth, and XIIth cranial nerves in selected cases.

RESULTS

Whereas 72% of these cases demonstrated changes in the recorded intraoperative NIM signals, only 29% of them gave evidence of either clinical or electrophysiological neural function alterations during the postoperative follow-up.

CONCLUSIONS

NIM is the only available system capable of providing the surgeon with instant intraoperative neural status-related feedback.

Botulinum toxin type A for the treatment of chronic neck pain after neck dissection

BACKGROUND

Neck dissection surgery is often followed by chronic head and neck pain. To date optimal treatment of this type of pain is lacking. Botulinum toxin type A (BTX-A) has been shown to be effective in the treatment of myofascial pain syndrome and headache. In a pilot study, we wanted to test the effectiveness of BTX-A for the treatment of chronic neck pain after neck dissection.

METHODS

Sixteen patients with chronic neck pain after neck dissection were included in this prospective, open study. Eighty to 320 units of BTX-A (Dysport) were injected into muscular trigger points. Outcome measures included chronic pain and shooting pain on the basis of visual analog scales and quality of life improvement (EORTC QLQ-C-30; EORTC QLQ-H and N35) before and 4 weeks after treatment.

RESULTS

Patients showed a significant reduction in chronic pain (4.5 before to 3.3 after treatment, p =,005) and in shooting pain (6.1 before to 4.7 after treatment, p =.005). There was a trend toward improvement in global quality of life (QLQ-C30, p =.097) and an increase on the functional scale "pain" (QLQ-H and N35, p =.071).

CONCLUSIONS

BTX-A treatment of subjects with chronic neck pain after neck dissection resulted in a fast and significant reduction of pain. A significant improvement in quality of life may be expected in a longer time course after treatment.

A pilot study of a randomized controlled trial to evaluate the effects of progressive resistance exercise training on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in head and neck cancer survivors

BACKGROUND

Shoulder dysfunction remains a frequent complication after neck dissection procedures for head and neck cancer.

METHODS

We conducted a pilot study to evaluate the effects of progressive resistance exercise training (PRET) on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in patients with head and neck cancer. Twenty patients (mean age, 61 +/- 7.7 years) were randomly assigned to PRET or standard care intervention. Subjects assigned to the PRET group exercised three times per week for 12 weeks. The goal of the exercise program was to enhance scapular stability and strength of the upper extremity. The resistance-training program was progressive in terms of number of sets and repetitions performed, as well as the amount of weight lifted, depending on performance status.

RESULTS

The completion rate for the trial was 85% (17 of 20). The exercise group completed 93% of scheduled exercise sessions. Significant improvements were found in favor of the PRET group in active shoulder external rotation (p =.001), shoulder pain (p =.038), and overall score for shoulder pain and disability (p =.045).

CONCLUSIONS

The study results demonstrate a high rate of completion and adherence with our PRET program among patients with head and neck cancer. The preliminary findings, although limited, also suggest a potential therapeutic role for resistance exercise as an adjunct to standard physical therapy treatment.

Shoulder pain and disability in daily life, following supraomohyoid neck dissection: a pilot study

INTRODUCTION

The purpose of this pilot study was to assess shoulder morbidity; i.e. pain and disability in daily activities, at least 1 year after unilateral or bilateral supraomohyoid neck dissection.

PATIENTS AND METHODS

52 patients having been subjected to a supraomohyoid neck dissection completed a questionnaire assessing pain and daily activities.

RESULTS

14 (28%) patients complained of ipsilateral shoulder pain following supraomohyoid neck dissection. The disability from shoulder complaints as perceived during daily life was minor. The pain and disability experienced during daily activities led to dependency upon other people in two patients. This dependency only existed during heavy household activities.

CONCLUSION

Despite the fact that this type of neck dissection was developed to reduce shoulder morbidity, 28% of the patients experienced shoulder pain following supraomohyoid neck dissection. The degree of disability due to shoulder complaints, however, was minor.