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Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 126-130

Postoperative physiotherapy management for complications related to cancer of buccal mucosa (head and neck cancer)

Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission24-Jun-2019
Date of Decision13-Aug-2019
Date of Acceptance13-Aug-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Oshin Diana Mathias
Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Nehru Nagar, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_52_19

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Buccal mucosa squamous cell carcinoma is rare and is considered as an aggressive form of oral cavity cancer. It is also associated with a high rate of local regional recurrence and is seen commonly in people who are habitual tobacco chewers and/or smokers with or without alcohol intake. This case report represents a 40-year-old, moderately built female of buccal mucosa carcinoma who visited the surgical oncology department with involvement of the underlying skin and underwent commando surgery with complaints of pain, restriction of movements at the operated site, chest pain and breathlessness, swelling of left side of cheek, and limited mouth opening as postoperative complications, highlighting on the postsurgical physiotherapy management in commando surgery for buccal mucosa carcinoma and alleviating symptoms that were apparent with improvement in the quality of life of the patient.

Keywords: Buccal mucosa, Commando surgery, Pain, Quality of life, Range of motion

How to cite this article:
Pattanshetty R, Mathias OD. Postoperative physiotherapy management for complications related to cancer of buccal mucosa (head and neck cancer). Indian J Phys Ther Res 2019;1:126-30

How to cite this URL:
Pattanshetty R, Mathias OD. Postoperative physiotherapy management for complications related to cancer of buccal mucosa (head and neck cancer). Indian J Phys Ther Res [serial online] 2019 [cited 2022 Oct 1];1:126-30. Available from: https://www.ijptr.org/text.asp?2019/1/2/126/273725

  Introduction Top

Oral cancer is regarded as the sixth most common cancer all across the world with all cases comprising oral squamous cell carcinoma (OSCC). Squamous cell carcinoma (SCC) of the buccal mucosa is a common malignant tumor in Southeast Asia including India, Taiwan, and China.[1] The associated risk factors of SCC include betel quid and tobacco chewing with heavy alcohol consumption. It is important to note that around 4%–10% of these cases are not associated with the risk factors. Other factors like infective agents such as human papillomavirus, immune defects or immunosuppression, defects of carcinogen metabolism, or defects in DNA-repair enzymes may also be implicated in some cases of OSCC.[1]

Buccal mucosa SCC is considered as an aggressive malignant form of tumor in the oral cavity. It is associated with a high rate of regional recurrence which affects mostly the inner lining of the cheeks, lateral border of the tongue, oropharynx, floor of the mouth, and lips.[1] The most common postoperative oral problems occurring after radiation and chemotherapy are mucositis, infection, pain, bleeding, difficulties in swallowing, injury to the glands that produce saliva (xerostomia) or damage the muscles and joints of the jaw and neck (trismus), loosening of teeth, difficulty wearing dentures, painful swallowing (odynophagia), speech impairment (dysarthria), and development of a neck mass as a sign of lymph node metastasis.[1],[2]

Composite resection of the head and neck is also referred to as the “commando” procedure, which involves the resection of primary tumor, a part of the mandible and surrounding cervical lymph nodes. This surgery is mainly done in cancers affecting the tongue, floor of the mouth, larynx, pharynx, maxilla, mandible, and palate.[3] Pain, spinal accessory nerve dysfunction, muscle weakness, shoulder movement restraint, deformity, and inability to perform abduction of upper extremity above 90° occur as results of denervation of the trapezius muscle. Shoulder dysfunction with physical changes such as muscular atrophy, capsular adhesions, fibrosis and restricted functional and overhead movements as well as cervical disability, chronic neck pain with muscle spasm, numbness and restriction further causing forward head posture, and cosmetic disfigurement occur following the surgeries.[3] Neurologic complications include injury to the phrenic nerve causing paralysis to the ipsilateral diaphragm, which manifests as pulmonary complications such as breathlessness, chest pain, bronchopneumonia, pneumothorax, pulmonary embolism, and cardiopulmonary distress.[4]

Physiotherapy plays a major role in the rehabilitation of patients with oral cancers who undergo various treatments including head and neck exercises, mouth opening exercises using Therabite devices, and shoulder mobility.[5] It prevents and/or treats multiple complications arising because of cancer treatments. Physiotherapy rehabilitation program helps mainly postoperatively such cancer survivors in restoring themselves physically, emotionally, and socially to gain proper functional range of the motion (ROM) and thus improve the quality of life.[6]

  Case Report Top

A Forty (40)-year-old Indian female reported to a tertiary care hospital at the department of surgical oncology with the complaints of pain and burning sensation in the left cheek region. The symptom ignorance lead to a black wound growing at the same site at a later stage. She was taken to the local hospital and treated with medications for symptomatic relief. Pain and swelling occurred after few days and then was advised to undergo investigations such as biopsy, which revealed the presence of 3 cm × 3 cm ulceroproliferative lesion growth on her left buccal mucosa in the oral cavity. The patient's history revealed a habit of chewing tobacco and betel nut for 30–35 years. She was recommended computed tomography face and neck and chest X-ray, which showed the presence of a mass involving the left buccal mucosa and a metastatic lymph node, suggestive of a preoperative clinical staging T4aN2cMo. An excisional biopsy from the papillary growth of the cheek revealed a well-differentiated infiltrating SCC and malignant neoplasm comprising round and polygonal cells infiltrating into deeper areas, showing cell keratinization forming keratin pearls in the subepithelium and stoma cells along with nuclear hyperchromatism.

She underwent three cycles of chemotherapy of injection paclitaxel 220 mg and injection cisplatin 100 mg for a course of 2 months' presurgery. A commando surgical approach with composite resection and reconstruction was carried out subsequently with hemimandibulectomy, radical resection of tumor site, and cervical unilateral neck dissection. Physiotherapy evaluation was done on the postoperative day (POD) 1 and the patient presented with complaints of pain, restricted movements of upper limb, swelling in the cervical and shoulder region, difficulty in swallowing, restricted mouth opening, fatigue, and muscle weakness [Table 1]. Respiratory assessments done on POD 1 revealed that the patient had breathlessness, cough, and use of accessory respiratory muscles [Table 2]. On percussion of upper, middle, and lower lung fields, dull sound was noted on the left lung and resonant on the right while crepitus and rhonchi were heard on auscultations over the left lung fields. She also had poor balance in standing and alterations in the gait parameters, such as reduced step duration, cadence, step length, and arm swing.
Table 1: Musculoskeletal evaluation of the patient

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Table 2: Other recorded observations

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Acute hospitalization phase lasted for 7 days, and the tailor-made treatment protocol varied and progressed daily [Table 3]. The patient demonstrated improvements in cervical, shoulder, and mouth opening ranges. Numerical pain scoring on visual analog scale (VAS) was reduced compared to POD 1. Overall improvements in variables such as strength in terms of manual muscle testing, pain using VAS, range of motion (ROM) using goniometry, balance and quality of life measures using disability of arm, shoulder, and hand assessment (DASH), Vanderbilt Head and Neck Symptom Survey Questionnaire, and Functional Assessment of Cancer Therapy-Head and Neck (FACT-HNN) were clinically significant [Table 4].
Table 3: Treatment protocol for commando surgery approach to head and neck cancer

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Table 4: Comparison of total scores of outcome measures

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  Discussion Top

This case report presents the overall physical therapy needs of the patient who has undergone treatment for head and neck cancer with a commando resection. Buccal mucosa cancer survivors suffer from high morbidity associated with various treatments such as chemotherapy, radiation, and surgery. Postoperative rehabilitation exercises have positive outcomes that potentially may increase quality of life in such subjects.[7] The results of the present case report showed that improvements in terms of reduction in pain using VAS, restricted range of movements with goniometer, and strength and quality of life using FACT-HNN and DASH questionnaires were appreciably significant, which further indicates that transcutaneous electrical nerve stimulation (TENS, Technomed Electronics Chennai India SI No TG1448) of a low frequency (50–100 Hz) of a continuous mode when given along with exercises proves to yield a better improvement [Table 3].

TENS is a physiotherapeutic modality which is widely used to relieve painful conditions, resulting from cancer and its associated treatments. It generates a nonpainful sensation which is strong and rapid. TENS can be administered to reduce the postoperative pain symptoms at the site of the surgery using a low frequency of a continuous mode type and adjusting the intensity that is tolerated by the patient for duration of time depending upon the level of pain as mentioned above. Efficacy of TENS on pain relief in patients afflicted with cancer has shown to be an effective tool in reducing pain and assist in improving joint ROM in cancer survivors.[8]

Other physiotherapeutic interventions were utilized to address patient's specific impairments, target pain, and improve the quality of life. The most useful rehabilitation techniques have been reported as muscle stretching, strengthening exercises, chest physiotherapy, mobility exercises, and various maneuvers. Physical therapy has shown to help relax the muscles, increase joint flexibility, reduce fatigue, increase awareness of the altered posture, walking, and breathing patterns, manage difficulty in swallowing as well as mouth opening, and subsequently improve physical and functional well-being.[8],[9] The clinical implications of physiotherapy management protocols to relieve cancer pain in palliative care have been well documented. Physiotherapy treatment has shown to be beneficial for symptomatic relief and improving quality of life in cancer patients.[9] Physiotherapy in postoperative complications of head and neck cancers have suggested that multidisciplinary rehabilitation should be made an integral part of the total management of the head and neck cancer survivors.[10]

  Conclusion Top

The present case report highlights the importance and successful outcome of the cancer patient with a commando surgery in terms of decrease of pain, improvement in cervical and upper limb ROM, mouth opening ranges, and balance and gait with a well-designed therapist protocol during the hospitalization phase. Balance and gait impairments due to decreased ankle reflexes and peripheral neuropathies are usually the most common signs related to chemotherapy toxicities within a month of administration. The history of the present case also mentions three cycles of chemotherapy, the residual effects of which may persist for more than 2 years after the last cycle. This reason explains why the authors framed the therapy protocol that included balance and gait training. The other postoperative complications related to cancer and its treatments such as chemotherapy and surgery have to be managed due to the possibility of reoccurrence during the remission of the long-term health issues. However, the results of the present study may be reinforced in the form of clinical trials in a similar clinical setup using the similar therapist designed protocol.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Reddy RK, Dasara MR. Oral squamous cell carcinoma of buccal mucosa in a young patient-a case report. J Adv Med Dent Sci Res 2015;3:165.  Back to cited text no. 1
Huang CH, Chu ST, Ger LP, Hou YY, Sun CP. Clinicopathologic evaluation of prognostic factors for squamous cell carcinoma of the buccal mucosa. J Chin Med Assoc 2007;70:164-70.  Back to cited text no. 2
Kolokythas A. Long-term surgical complications in the oral cancer patient: A Comprehensive review. Part II. J Oral Maxillofac Res 2010;1:e2.  Back to cited text no. 3
Guru K, Manoor UK, Supe SS. A comprehensive review of head and neck cancer rehabilitation: Physical therapy perspectives. Indian J Palliat Care 2012;18:87-97.  Back to cited text no. 4
[PUBMED]  [Full text]  
Mittal BB, Pauloski BR, Haraf DJ, Pelzer HJ, Argiris A, Vokes EE, et al. Swallowing dysfunction – Preventative and rehabilitation strategies in patients with head-and-neck cancers treated with surgery, radiotherapy, and chemotherapy: A critical review. Int J Radiat Oncol Biol Phys 2003;57:1219-30.  Back to cited text no. 5
Balamurugan J, Hariharasudhan R. Physical therapy interventions are beyond adjunct care in improving quality of life and alleviating pain related to cancer and its treatment: Perspectives and confronts. J Cell Sci Ther 2015;6:1.  Back to cited text no. 6
Stubblefield MD, editor. Cancer Rehabilitation 2E: Principles and Practice. Department of medical education and rehabilitation Rutgers New Jersy Medical school: Springer Publishing Company; 2018.  Back to cited text no. 7
Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG. Transcutaneous Electric Nerve Stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev 2012;14:CD006276.  Back to cited text no. 8
Roscoe E. Effects of Oncology Rehabilitation for Head and Neck Cancers-A Systematic Review (Doctoral Dissertation) 2013:1-29.  Back to cited text no. 9
Kumar SP. Cancer pain: A Critical review of mechanism-based classification and physical therapy management in palliative care. Indian J Palliat Care 2011;17:116-26.  Back to cited text no. 10


  [Table 1], [Table 2], [Table 3], [Table 4]

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