How do you stage lymphedema of the head & neck?

head neck rehab wildflower therapy Nov 22, 2022

As a certified lymphedema therapist there are many debates on how to assess, evaluate and monitor our patient's progress. One thing is not debatable. Utilizing staging each visit is essential for assessing change. 

What are the three scales used to stage lymphedema? 

1. The Foldii Scale

2. The MDACC Head & Neck 

3. The ISL (International Society of Lymphology)

What scale do we utilize in our clinic? 

We utilize in our clinic the MDACC Head & Neck. This is a scale that specifies and allows our clinicians to monitor the lymphostatic changes of the tissue by palpating. 

How does a clinician assess the stages? 

The clinician assesses the stage by touching the neck and working the tissue in a directional methodical manual lymph drainage method. Based on what that clinician is trained to feel he or she will determine the appropriate stage. 

What are the stages of the MDACC Head & Neck?

Stage 0: No clinical symptoms. In this stage the patient does not have signs or symptoms of lymphedema. They are not presenting with any complaints typically. 

Stage 1a: The patient presents with clinical swelling with no pitting. The edema is moveable and there are no functional effects. 

Stage 1b: The patient presents with clinical swelling with reversible pitting edema and potentially functional effects. 

Stage 2: Hard swelling that does not recede with elevation and probable functional effects. 

Stage 3: Elephantiasis with tissue changes, rare.  (I have never seen in the head & neck). 

Why do I chose as a certified lymphedema therapist to utilize the MDACC?

This allows me to differentiate between 1a and 1b staging. Over time tissues change with the head & neck. The tissue may become harder, the patient may complain of increased difficulty with swallowing and pitting may occur. Pitting edema is used to describe when I as the clinician can press into the skin and the skin does not rebound as it should.  This lack of rebound leaves something called a pit or indention. The elasticity and properties of the tissue have changed. In cases following head & neck cancer treatment with radiation it is challenging to reverse this symptom. 

How often do I stage my patient's head and neck lymphedema and what are the challenges? 

Staging is utilized every single visit the patient receives a manual lymph drainage treatment. The challenges include subjectivity. Variability across the clinician when staging. I may decide a patient is a 1a while my colleague may decide the patient is 1b. Like all things in science this is not perfect and does have room for human variability based on trainings. If you are a patient ask your CLT what stage am I?  


Lewin, JS, Hutcheson KA, Barringer DA & Smith BG. SIG 13 Perspectives on Swallowing Disorders (Dysphagia). June 2010; 19; 45-52. 

International Society of Lymphology Executive Committee. Lymphology 2013. 

Smith, B. G., & Lewin, J. S. (2010). Lymphedema management in head and neck cancer. Current opinion in otolaryngology & head and neck surgery, 18(3), 153–158.