Highlights
- Primary TORS for OPSCC yields excellent short-term swallowing outcomes with most patients tolerating oral intake by hospital discharge.
- Early postoperative evaluation and swallow rehabilitation by speech-language pathologists (SLP) are integral in optimizing recovery.
- Despite patient-reported worsening of swallowing perception at 6 weeks post-TORS, objective videofluoroscopic swallow studies demonstrate minimal functional decline.
- Complication rates including enteral feeding tube requirements remain low, underscoring TORS safety in experienced tertiary centers.
Background
Oropharyngeal squamous cell carcinoma (OPSCC) incidence has increased globally, driven largely by human papillomavirus (HPV) associated cases. Treatment options include radiotherapy, chemoradiotherapy, and increasingly, minimally invasive surgical approaches such as transoral robotic surgery (TORS). TORS allows precise tumor resection with organ preservation, aiming to maintain functional outcomes, particularly swallowing, which significantly impact quality of life. However, swallowing dysfunction remains a concern post-treatment, potentially leading to aspiration, malnutrition, and prolonged feeding tube dependence. Early and structured assessment of swallowing physiology using Dynamic Image Grade of Swallowing Toxicity (DIGEST) scores via videofluoroscopic swallow study (VFSS), complemented by patient-reported outcomes like the MD Anderson Dysphagia Inventory (MDADI), provides critical insights into perioperative swallowing function. Despite increasing adoption of TORS, comprehensive data on perioperative swallowing outcomes and complications, especially with early rehabilitation, remain insufficiently characterized.
Key Content
1. Swallowing Outcomes After Primary TORS for OPSCC
The largest recent cohort study by de Groot et al. (2026) encompassing 212 patients treated between 2017 and 2024 at a tertiary center utilized serial VFSS with DIGEST scoring alongside MDADI assessments. Baseline VFSS was normal in 97.6% patients. Nearly all patients underwent bedside swallow evaluations by SLP on postoperative day (POD) 1, with compensatory strategies recommended as needed. Most patients (97.6%) tolerated oral diets at discharge within a median 2-day hospital stay. Enteral feeding tube placement occurred in only 6.6% during the immediate postoperative period. At 6 weeks, despite 63.6% reporting subjective worsening in swallowing via MDADI, only 9.1% demonstrated objective VFSS deterioration. Importantly, over 95% maintained a soft to regular diet at 6 weeks, highlighting recovery of function.
2. Swallowing Outcomes in Salvage TORS with Reconstruction
In patients with recurrent OPSCC undergoing salvage TORS combined with submental island flap reconstruction (SMIF), outcomes differ due to prior therapy and tissue changes. A smaller cohort (n=8) reported by a 2025 study demonstrated no significant change in swallowing function at 6 weeks and 6 months postoperatively, despite longer enteral feeding durations (median 43 days) and higher complication rates compared to primary TORS. SMIF provides robust vascularized tissue outside prior radiation fields, favoring functional preservation.
3. Impact of Specific TORS Procedures on Swallowing
Elective lingual tonsillectomy for carcinoma of unknown primary (CUP) with p16+ nodes was associated with less acute swallowing morbidity compared to therapeutic base of tongue (BOT) resections. Analysis from a 2021 cohort revealed improved DIGEST scores and lower odds of moderate/severe dysphagia in CUP diagnostic lingual tonsillectomy versus primary BOT tumor resections. This indicates patient selection and extent of surgical resection influence swallowing outcomes significantly.
4. Comparative Functional Outcomes: TORS vs. Radiotherapy
The multicenter, randomized ORATOR trial (published 2019) compared radiotherapy with TORS plus neck dissection in early-stage OPSCC. At 1 year post-treatment, radiotherapy patients exhibited superior swallowing-related quality of life (MDADI scores) compared to TORS, although the difference was not clinically meaningful. Toxicity profiles differed with more hematologic and otologic side effects in radiotherapy, while TORS patients had higher trismus rates. Crucially, swallowing dysfunction was present in both modalities, underscoring the need for individualizing treatment based on patient factors and multidisciplinary consultation.
5. Perioperative Complications and Recovery Trajectories
Across studies, overall perioperative morbidity after TORS remains low, with short median hospital stays (2 days in primary TORS, 6.5 days in salvage cases). Major complications such as postoperative hemorrhage are rare but potentially fatal. Early SLP involvement facilitates safe oral diet initiation and rehabilitation. Feeding tube dependence is minimal and typically transient, particularly in primary TORS.
Expert Commentary
The evidence consolidates TORS as a safe and function-preserving approach for select OPSCC patients, especially in the context of experienced surgical and allied health teams. The discrepancy between subjective swallowing perception worsening and objective swallow function stability at 6 weeks suggests multifactorial contributors to patient symptoms, including pain, mucosal sensitivity, and psychological factors post-surgery. Early bedside swallow evaluations and dietary modifications per the International Dysphagia Diet Standardization Initiative (IDDSI) are critical to minimizing aspiration risk and promoting recovery.
Salvage TORS remains more challenging due to prior treatments, with longer nutritional support requirements and elevated complication rates, emphasizing the role of flap reconstruction techniques like SMIF to enhance functional outcomes. Differential swallowing morbidity across TORS procedures — from conservative lingual tonsillectomies to extensive BOT resections — illustrates the importance of tailoring interventions.
The ORATOR trial’s findings demonstrate the nuanced trade-offs between surgical and radiotherapeutic management of OPSCC, advocating for shared decision-making and incorporation of patient preferences, especially regarding swallowing-related quality of life. Methodological limitations include retrospective designs, single-center data, and relatively short follow-up in many studies. Further randomized trials and prospective registries are warranted to refine perioperative rehabilitation protocols, long-term functional trajectories, and integration with adjuvant therapies.
Mechanistic insights into swallowing dysfunction after TORS point to transient denervation, edema, and mucosal injury affecting complex swallowing biomechanics. Rehabilitation strategies leveraging compensatory maneuvers and neuroplasticity are vital. Advances in robotic instrumentation and intraoperative imaging may further reduce collateral tissue damage in the future.
Conclusion
Transoral robotic surgery represents a paradigm shift in managing oropharyngeal squamous cell carcinoma, combining excellent oncologic control with favorable short-term swallowing outcomes. Routine early SLP assessment and individualized diet advancement protocols allow most patients to resume oral intake rapidly with minimal need for prolonged enteral feeding. While subjective symptoms of dysphagia may transiently worsen postoperatively, objective swallow assessments largely confirm functional preservation. Salvage TORS and more extensive resections require heightened multidisciplinary coordination. Comparative data with radiotherapy inform nuanced counseling about expected functional trade-offs. Future research must address longer-term swallowing function, rehabilitation optimization, and mechanistic underpinnings to maximize quality of life after TORS.
References
- de Groot ECM, Kim M, Sim ES, et al. Swallowing Function and Perioperative Complications After Transoral Robotic Surgery. JAMA Otolaryngol Head Neck Surg. 2026;152(6):618-625. PMID:41989773.
- Richmon JD, Holman AS, Calhoun HJ, et al. Salvage Transoral Robotic Surgery With Submental Flap Reconstruction: Functional and Oncologic Outcomes. Ann Otol Rhinol Laryngol. 2025;134(11):797-805. PMID:40539857.
- Tam S, Kerr P, Syed A, et al. TORS Elective Lingual Tonsillectomy Has Less Acute Morbidity Than Therapeutic Base of Tongue TORS. Oral Oncol. 2021;117:105294. PMID:33878679.
- O’Sullivan B, Huang SH, Su J, et al. Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial. Lancet Oncol. 2019 Oct;20(10):1349-1359. PMID:31416685.
