LYMPHEDEMA OF THE NECK

LYMPHEDEMA OF THE NECK

Related Term: Neck edema, Neck swelling, Swollen neck, Lymphedema

Lymphedema of the neck (with possible facial inclusion) is generally caused by removal of lymph nodes for cancer biopsy. Other causes may include surgical removal of tumors, infections (cellulitis, lymphangitis, lymphadenitis), radiation damage to existing lymph nodes and medications indicated for hypertension. In rare cases neck edema and/or lymphedema may be caused by tumors, cystic hygromas or other growths.

While most swelling is resolved by treatment of the underlying or causative medical condition, there are times when the swelling becomes permanent.

****If the swelling becomes permanent, whether the cause is known or unknown, the diagnoses of lymphedema must be considered****

What is Lymphedema?

Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.

A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.

How is Lymphedema Treated?

The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual lymphatic drainage (MLD), there are variances, but most involve these two type of treatment.

It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally.

With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.

Manual lymphatic drainage plus compression bandaging, lymph node stimulation (clearance), exercises are indicated for lymphedema. See our revised page Treatment for a full description of treatment methods.

What are some of the complications of lymphedema?

1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immunodeficient.

2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.

4. Loss of Function due to the swelling and limb changes.

5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.

7. Sepsis, Gangrene are possibilities as a result of the infections.

8. Possible amputation of the limb.

9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations

Can lymphedema be cured - what is the long term prognosis?

No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.

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Neck Lymphedema and Compression

Dr. Tony Reid - Dr. Reid's Corner

I have received several questions recently about the use of compression for treatment of edema of the neck and jaw. Both questions were from patients who suffered from cancer of the throat/tongue. Since I treat many of these patients, I am very familiar with the problems they encounter and I am very concerned about the use of compression for these patients. Edema is common after surgery and radiation for cancer anywhere in the throat or neck. The lymphatic system is disrupted by both radiation and surgery resulting in the accumulation of excess edema. These patients suffer unsightly swelling and frequently have pain from the surgery and from the edema. While compression is very helpful for patients with edema of the extremities, it can be dangerous for patients with edema around the neck, throat or upper chest. Compression in and around the neck can result in compression of the carotid artery and can potentially lead to syncope (black outs), bradycardia (very slow heart rate) and strokes. Every medical student is taught to never apply even light pressure to both sides of the neck at the same time.

    Most patients with edema of the neck area improve over a period of several months after the surgery and radiation is over. In fact, the skin usually becomes firm and leathery after the acute inflammation following radiation and surgery heals. In my practice, I do not use compression for edema of the neck area because I believe that the risks for the patient are too high. While edema is certainly a problem, living with a stoke is far worse.

    Some patients have persistent edema or swelling that makes breathing or swallowing difficult. These patients need some form of medical intervention; however, in my experience this is very uncommon. When the edema becomes so bad that breathing or swallowing is compromised, I recommend a very careful evaluation by a surgeon, oncologist or other physician familiar with these problems. Since patients with cancer or elderly patients frequently have significant blockage of the carotid arteries due to cholesterol, it is probably advisable to assess the extent of carotid artery blockage prior to the use of compression. An exam or CT scan is advisable to make certain that the problem is not due blockage of veins in the chest (superior vena cava syndrome). The vena cava syndrome is a very serious problem and should not be treated with compression

    Surgery can alter the anatomy of the neck, making it very difficult to know the exact effect of compression on blood flow in the arteries. Because of the altered anatomy, arterial blood flow could be diminished even when the compression is applied several centimeters away from the carotid artery. In my opinion, compression is rarely indicated for these patients but if compression is used it should only be applied to one side at a time. Bandages can be used to apply compression; however, it is very difficult to know the amount of pressure applied when bandages are used. In addition, any movement or turning of the head can change not only the position of the bandages but the amount of pressure applied and bandages slip and change position. I am unaware on any reputable devices specifically designed to apply compression safely to the neck area. If such a device exists, it would certainly have to be designed to apply compression to only one side at a time and be designed to avoid any possibility of compression to the carotid artery. In summary, I feel that compression for edema around the neck is generally not warranted and could be potentially very dangerous. Any treatment of edema of the neck should be under the strict guidance of a physician after an evaluation to exclude vena cava syndrome and other causes of edema where compression would be contraindicated.

Tony Reid MD Ph.D

Acknowledgement:

Dr. Reid's Corner

http://www.lymphedema.com/neckedema.htm

Peninsula Medical

http://www.lymphedema.com

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Types of compression garments used with patients experiencing lymphedema following medical intervention for head and neck cancer

Rehabilitation Oncology, 2001 by Augustine, Elizabeth

Lymphedema is an accumulation of lymphatic fluid resulting from impairment of the lymphatic transport system. Lymphedema is commonly associated with lymphadenectomy and/or radiation therapy for cancer. The development of lymphedema following medical intervention for head and neck cancer is not an unusual occurrence even though the exact incidence is unknown. Lymphedema can cause pain, chronic inflammation, fibrosis, reduced mobility, impaired function, psychological morbidity, and impaired physical appearance. Lymphedema management of this patient population has not been adequately addressed in the literature.

Traditionally in this country lymphedema of the extremities has been managed with compression pumps and garments even through in the 1950s Keith Stillwell, MD from the Mayo Clinic recommended the use of multiple modalities consisting of the compression pump, elevation, massage, isometric exercises, and compression garments. In Europe a combination of techniques for lymphedema management such as skin care, manual lymph drainage massage, exercise, low stretch compression bandaging, and compression garments is called complex decongestive physiotherapy (CDP). Within the last decade CDP has gained acceptance in this country for lymphedema management. Manual lymph drainage massage helps to mobilize the stagnant lymphatic fluid from a congested area to a healthy area for reabsorption into the lymphatic system and compression garments maintain the reduction and prevent the reaccumulation of lymphatic fluid after the conclusion of treatment.

Selecting the compression garment with the appropriate compression is critical to a successful treatment plan (see chart for details). Elastic fibers of compression garments wear out, and the garment should be replaced every 4 to 6 months. If not replaced, the compression garment will not adequately control the lymphedema and the body part will begin to swell again. It has been my personal experience as a clinician working with patients diagnosed with head and neck cancer that manual lymph drainage and some form of a compression garment are effective treatment techniques for managing head and neck lymphedema. Also equally important is the early diagnosis of lymphedema. Lymphedema is a progressive disease and there is no cure for it. If ignored, lymphedema will progress from a mild stage to severe. Early referral to physical therapy or to a therapist who has received advanced training in lymphedema management after the onset of lymphedema will results in the best results. The longer one waits to treat lymphedema, the more difficult and expensive it is to manage.

REFERENCES

Boris M, Weindorf S, Saskinski B. Lymphedema reduction by non-invasive complex lymphedema therapy. Oncology. 1994;8(9):95-106.

Foldi M, Kubik S. Lehrbuch der Lymphologie. Gustav Fischer Verlag. Stuttgart, Germany: 1989.

3. Hohlbaum G, Milde L, Schmitz R, Weber G. The Medical Compression Stocking. Stuttgart, Germay: Schattauer; 1989.

4. Stillwell GK, Redford J, Krusen E Further studies on the treatment of lymphedema. Arch Phys Med Rehabil. 1957;38:435-- 441.

Tubbs-Gingerich R Caring for a patient with lymphedema of the head, neck, chest and upper back post-laryngectomy complicated by osteoradionecrosis. National Lymphedema Network. 2000;12(4):5&12.

Weissleder H, Schuchhardt C. Lymphedema: Diagnosis and Therapy. Bonn, Germany; Kagerer Kommunikation; 1997.

Elizabeth Augustine, MS, PT

National Institutes of Health, Clinical Center

Rehabilitation Medicine Department

Bethesda, Maryland

http://www.findarticles.com/p/articles/mi_qa3946/is_200101/ai_n8953153

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Manual lymph drainage as therapy of edema in the head and neck area

Schweiz Rundsch Med Prax. 2003 Feb

Reiss M, Reiss G.

Klinik für Hals-Nasen-Ohrenheilkunde, Städtisches Klinikum Görlitz. reiss@klinikum-goerlitz.de

Depending on its genesis, edema must be treated by medication or diet. Simultaneous application of lymph drainage may be beneficial in some cases, especially in combined edema. The manual lymphdrainage is a special method of massage. In some kinds of edema, in particular lymphedema, only therapeutic lymph drainage introduced into medicine by Vodder, Asdonk and Kuhnke can attain an improvement, since there is no drug which acts on the lymphatic system. We report about primary and secondary lymphedemas of the face and head. Secondary lymphedemas are a result of surgical therapy, cancer therapy, irradiation or are caused of tumors or their metastases respectively. Depending on the state of the edema a lymphatic drainage treatment is indicated palliatively.

http://www.ncbi.nlm.nih.gov/pubmed/12621908?ordinalpos=34&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

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Selenium in the treatment of head and neck lymphedema.

Bruns F, Buntzel J, Mucke R, Schonekaes K, Kisters K, Micke O.

Department of Radiotherapy, Medical School Hannover, Hannover, Germany.

OBJECTIVE: To investigate the impact of selenium in the treatment of lymphedema of the head and neck region after radiotherapy alone or in combination with surgery.

SUBJECTS AND MATERIALS: Between June 1996 and June 2001 a total of 36 cancer patients (29 male, 7 female; median age 61 years) were treated with selenium for persistent, extensive or progressive lymphedema of the head and neck region. Twenty had interstitial endolaryngeal edema associated with stridor and dyspnea. All patients received 350 microg/m(2) body surface sodium selenite medication p.o. daily (total dose 50 microg per day) for a period of 4-6 weeks after radiotherapy. The optimal effect of the selenium treatment was assessed after 4 weeks of therapy using the Miller score system. A visual analogue scale on a scale of 0-10 was used to assess the patient's quality of life prior to and after selenium.

RESULTS: 75% of the patients had an improvement of the Miller score of one stage or more. The self-assessment of quality of life using the visual analogue scale improved significantly after selenium treatment with a reduction of 4.4 points (p < 0.05). Of the 20 patients with endolaryngeal edema tracheostomy was not necessary in 13 patients (65%), but 5 and 2 received a temporary or permanent tracheostomy, respectively. No episode of erysipelas was observed in all study patients.

CONCLUSION: Our results suggest a short positive effect of sodium selenite on secondary head and neck lymphedema caused by radiotherapy alone or in combination with surgery. Copyright 2004 S. Karger AG, Basel

Publication Types:

Clinical Trial

PMID: 15181321 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15181321&itool=iconabstr&query_hl=9&itool=pubmed_docsum

http://www.headandneckrehab.com/HTML/surgical.html

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Indications and risks of manual lymph drainage in head-neck tumors

Laryngorhinootologie. 1998 Apr

Preisler VK, Hagen R, Hoppe F.

Klinik und Poliklinik für Hals-, Nasen- und Ohrenkranke, Universität Würzburg.

BACKGROUND: Secondary lymphedema of the head and neck can develop as a result of obstruction of lymphatic channels following the surgical removal of lymph nodes and fibrosis due to irradiation. This can be treated with manual lymphatic drainage. An increase of tumor recurrence due to this therapy is at controversial discussion.

PATIENTS: In a retrospective study 191 patients treated for head and neck cancer were questioned on occurrence of lymphedema and therapy with manual lymphatic drainage.

RESULTS: 100 patients had received lymphatic drainage, whereas 91 patients belonged to the group without lymphatic drainage therapy. In 37 cases a tumor recurrence or local metastases were reported, 18 of whom had received lymphatic drainage and 19 belonged to the control group. Among these 37 patients neither the group with lymphatic drainage nor the control group differed significantly concerning stage of cancer, histopathological grading, the in sano/non in sano resection of the primary tumor and a lymphangiosis carcinomatosa. An increased recurrence rate among patients who underwent a lymphatic drainage therapy could not be found.

CONCLUSION: A lymphatic drainage therapy for patients presenting with lymphedema after the oncological therapy does not increase the rate of local recurrencies. Moreover it improves the quality of life after the cancer therapy. As only few data are available for cases with non in sano surgery and tumors with lymphangiosis carcinomatosa these cases should be excluded from a lymphatic drainage therapy. A spreading of occult tumor cells in these patients might be possible.

PMID: 9592754 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/9592754?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA

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Early rehabilitation of head-neck edema after curative surgery for orofacial tumors

Piso DU, Eckardt A, Liebermann A, Gutenbrunner C, Schafer P, Gehrke A.

Department of Physical Medicine, Medical School Hannover, Germany.

OBJECTIVE: To evaluate a rehabilitative program for postoperative head-neck edema. DESIGN: Eleven patients completed the study. A series of ten manual lymphatic drainage were initiated and completed early after surgery. On discharge from the hospital, the patients wore "made-to-measure" or customized compression garments for the next several weeks. Tape measurements and sonographic evaluation of the soft-tissue width were used to quantify the extent of the swelling. RESULTS: After 6 wk of therapy, the patients exhibited a statistically significant (P < 0.05; Wilcoxon's test) remission; the remission continued in eight patients who were measured at 12+/-3 wk.

CONCLUSIONS: This initial trial demonstrates that sequential therapy of manual lymphatic drainage and compression garments can significantly reduce early postoperative edema after curative surgery for orofacial tumors. The outcome can be quantified by comparing the course of distances between the defined anatomic marks and by sonographic evaluation of soft-tissue width. This pilot study encourages that more controlled, randomized studies, with larger numbers of patients, be conducted to verify these results.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11277132&dopt=Abstract

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Radiotherapy of ENT tumors and risk of lymphedema

Z Lymphol. 1996 Jun

Ewald H.

Klinik für Strahlentherapie, Christian-Albrechts-Universität zu Kiel.

Radiotherapy is a useful tool in the treatment of head and neck cancer either in an adjuvant or in a palliative setting. The tolerance doses of many tissues are near or even lower than the necessary therapeutic doses. Therefore some side effects of radiotherapy are unavoidable, others can be reduced if special technics are applied. Lymphedema of the head and neck is more often caused by radical surgery than by radiotherapy. If a combined modality treatment is used with surgery and radiotherapy, it results in an increased risk of lymphedema. If lymphedema results from radiotherapy it is caused by the late reaction of blood vessels and connective tissue within the irradiation field. Direct irradiation effects on lymphatic vessels are less important. Finally we stated four rules for the practical management of patients with visible lymphedema or the risk of developing an edema.

PMID: 8768045 [PubMed - indexed for MEDLINE]

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External Links and Related Information

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Head and Neck Rehab

What is a neck dissection?

Excerpt - Click on link for entire article

Neck dissection is an operation done to remove groups of lymph nodes from the neck. It can be done on one or both sides of the neck. Lymph node groups in the neck are numbered I-V. Selective neck dissection is removal of only a few of the groups of lymph nodes on one side of the neck. Comprehensive neck dissection involves removal of all lymph node groups on one side of the neck (levels I, II, III, IV, and V).

http://www.headandneckrehab.com/HTML/surgical.html

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Neck Swelling

familydoctor.org

http://familydoctor.org/x2556.xml

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Neck Swelling

wrongdiagnosis.com

http://www.wrongdiagnosis.com/sym/neck_swelling.htm

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Swollen Neck Lymph Nodes

wrongdiagnosis.com

http://www.wrongdiagnosis.com/sym/swollen_neck_lymph_nodes.htm

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Irbesartan-associated persistent edema of the eyelids, face, and neck - Case Reports

Journal of Drugs in Dermatology

Philip R. Cohen

December 2002

http://www.findarticles.com/cf_dls/m0PDG/3_1/110220341/p1/article.jhtml

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Deep Neck Spaces and Infections

Elizabeth J. Rosen, MD and Byron J. Bailey, MD

04/17/02

Slides and Commentary

http://www.utmb.edu/otoref/Grnds/Deep-Neck-Spaces-2002-04/Deep-NeckSpaces-2002-04-slides.pdf

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HEAD AND NECK MANIFESTATIONS OF AMYLOIDOSIS

J. Cary Moorhead, MD

April 9, 1992

The Bobby R. Alforrd Department of Otorhinolaryngology and Communicative Sciences

http://www.bcm.tmc.edu/oto/grand/4992.html

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Head and Neck Compression Garments

These types of garments always need to be custom made, the following vendors offer products:.

JoViPak

http://www.jovipak.com/index.shtml

http://www.jovipak.com/pdf/Head_Custom_Packet.pdf

Solaris - Tribute Garments

http://www.solaris-tribute.com/lymphedema/consumers/garments/collection.html

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Medical Encyclopedia

Lymph tissue in the head and neck.

Lymph nodes play an important part in the body's defense against infection. Swelling might occur even if the infection is trivial or not apparent.

Update Date: 5/20/1999

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http://www.instantanatomy.net/headneck/vessels/lneckchains.html

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See also:

Comparison of Edema versus Lymphedema

http://www.lymphedemapeople.com/thesite/edema_or_lymphedema.htm

Edema and Chronic Venous Insufficiency

http://www.lymphedemapeople.com/thesite/edema_chronic_venous_insufficiency.htm

Edema and Deep Venous Thrombosis

http://www.lymphedemapeople.com/thesite/lymphedema_deep_venous_thrombosis.htm

Edema and Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

http://www.lymphedemapeople.com/thesite/edema_and_reflex_sympathetic_dystrophy.htm

Edema and Venous Pooling

http://www.lymphedemapeople.com/thesite/edema_and_venous_pooling.htm

Edema and Angioedema

http://www.lymphedemapeople.com/wiki/doku.php?id=angioedema

Edema of the Neck

http://www.lymphedemapeople.com/thesite/lymphedema_of_the_neck.htm

Edema and Nephrotic Syndrome

http://www.lymphedemapeople.com/thesite/edema_nephrotic_syndrome.htm

Edema and Thrombophlebitis

http://www.lymphedemapeople.com/thesite/edema_thrombophlebitis.htm

Edema and Diabetes

http://www.lymphedemapeople.com/thesite/lymphedema_and_diabetes.htm

Edema and Congestive Heart Failure

http://www.lymphedemapeople.com/thesite/lymphedema_and_congestive_heart_failure.htm

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Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

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Subscribe:

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Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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For information about Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema\

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/wiki/doku.php?id=complications_of_lymphedema

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=3

For information about How to Treat a Lymphedema Wound

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound

For information about Lymphedema Treatment

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment

For information about Exercises for Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema

For information on Infections Associated with Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema

For information on Lymphedema in Children

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

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Lymphedema People - Support Groups

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Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

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Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

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MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

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All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

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Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

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All About Lymphedema

For our Google fans, we have just created this online support group in Google Groups:

Homepage: http://groups-beta.google.com/group/All-About-Lymphedema

Group email: All-About-Lymphedema@googlegroups.com

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Lymphedema Friends

http://groups.aol.com/lymphedemafriend

If you an AOL fan and looking for a support group in AOL Groups, come and join us there.

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Lymphedema People New Wiki Pages

Have you seen our new “Wiki” pages yet? Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more. Come and take a stroll!

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema

Arm Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema

Leg Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema

Acute Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema

The Lymphedema Diet

http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet