Tiered Protocol Advancing to Total Oral Diet After TORS

Introduction: Transoral robotic surgery (TORS) is a minimally invasive surgical alternative to chemoradiotherapy in the treatment of oropharyngeal malignancies. Oropharyngeal dysphagia in the early postoperative period is associated with TORS, however few studies have explored objective swallowing outcomes in these patients. In this study we examined a combination of subjective and objective swallowing outcomes and suggest a tiered approach to a safe, total oral diet in the immediate postoperative period.

Methods: A retrospective study of patients who underwent TORS for oropharyngeal malignancy from 2018-2022. A feeding tube was placed transnasally before leaving the operating room. All patients underwent a clinical swallow exam (CSE) by speech and language pathology (SLP) team on postoperative day (POD)-1. A formal swallow study was pursued if CSE was inconclusive. After a safe swallow was confirmed, total oral diets were initiated and the feeding tube was removed. Patients were typically discharged on POD-2.

Results: A total of 75 patients met inclusion criteria. The palatine tonsil (N=49) was the most common subsite. The mean age on the day of operation was 58.5 ± 10.4 years. An intraoperative dobhoff feeding tube was placed in 95% of patients (N=70). CSE was performed on POD-1 in 70 patients, and 27 (38.6%) were cleared for total oral diet with a NOMS ≥ 4. An additional 17 of 28 patients (60.7%) who underwent VFSS were cleared for total oral diet. The mean pain scale value with immediate swallowing was 2.74 ± 2.94 out of 10. A total of 45 (60.8%) patients were cleared for a total oral diet and the feeding tube was removed prior to discharge on POD-2. The mean cumulative time the feeding tube was in place was 4.42 ± 5.29 days with a median of 2 days, (N=67). At one week follow-up, an additional 15 patients were cleared for a full oral diet after outpatient VFSS. In total, 60 patients (81.1%) achieved total oral diet within one week after TORS.

Conclusions: VFSS is a useful tool for evaluating the safety of post-operative swallowing. With this, a majority of patients are discharged on, or return to total oral nutrition shortly after TORS.