Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: Transoral robotic surgery (TORS) yields excellent oncologic outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC). Early post-operative swallow function may be associated with pain and dysphagia. Our study aims to evaluate our institutional protocol of optimizing a safe, early initiation of an oral diet by assessing both patient perception and objective measures of swallow function.
Methods: This retrospective cohort study includes OPSCC-patients treated with TORS (2017-2024). Speech-language pathologists (SLP) evaluated swallowing with a video fluoroscopic swallow study (VFSS) utilizing the DIGEST (Dynamic Image Grade of Swallowing Toxicity) scoring system preoperatively. Patients also completed the MD Anderson Dysphagia Inventory (MDADI) questionnaire to evaluate the patient’s perception of their swallow function and were counseled on post-operative swallowing expectations. At our institution, on postoperative day 1, SLPs perform a clinical swallow evaluation and recommend compensatory postural maneuvers when appropriate to manage pain or swallow deficiencies. Based on the results of the swallow evaluation, an oral diet is initiated, using the International Dysphagia Diet Standardization Initiative (IDDSI) for pureed solids and thin or mildly thick liquids for 2 weeks. Data on duration of hospitalization and nasogastric tube placement (NGT) were collected. When available, data from repeat clinical swallow evaluation, VFSS and/or MDADI were analyzed, at 6 weeks post-operatively before initiation of adjuvant therapy.
Results: Two hundred thirty-seven OPSCC patients (16% female, mean age: 62) underwent TORS, with an average hospital stay of 3 days (IQR 2–3). At baseline, 95% had normal MDADI and VSS scores. On postoperative day 1, compensatory swallow maneuvers were recommended to 147 patients (62%). By time of discharge, 95% were eating pureed solids with thin or mildly thick liquids and only 12 (5%) required NGT. At 6 weeks, 66% of patients with MDADI data reported a worsening in their swallow perception compared with baseline. Eighty-six percent of patients with a postoperative VFSS showed no objective decline in swallowing (i.e., DIGEST score of 0 or 1 - normal or mildly impaired function), and 95% of the cohort was consuming a soft to regular diet at 6 weeks.
Conclusion: SLPs are heavily involved in the pre- and perioperative care of OPSCC patients undergoing TORS and provide compensatory swallowing strategies in the majority of patients. NGT were rarely utilized and our patients were discharged home quickly and safely. The majority of patients were able to tolerate a modified oral diet according to our TORS protocol in the immediate postoperative period. Analysis of available data at 6 weeks showed a discrepancy between the patient’s perception of swallowing per MDADI scores and the diet that they reported. Almost all patients were eating a regular diet at 6 weeks. Available VFSS revealed normal DIGEST scores.