Severe prolonged dysphagia following transoral resection of bilateral synchronous tonsillar carcinoma

Alert the reader to the complication of severe dysphagia following transoral laser microsurgery (TLM) or transoral robotic surgery (TORS) for bilateral simultaneous or synchronous tonsillar squamous cell carcinoma. A case series of four patients treated at an academic tertiary center between 2008 and 2012 is presented; two treated with transoral laser microsurgery and two with transoral robotic surgery for biopsy-proven untreated bilateral primary squamous cell carcinoma. Main outcome measures included functional swallowing determined by the Functional Outcome Swallowing Scale. The incidence of significant postoperative complications was recorded. Two patients had surgery for discontiguous involvement of bilateral palatine tonsils with squamous cell carcinoma, while two patients had surgery for bilateral tonsillar squamous cell carcinoma with unilateral extension into the base of tongue. Complete swallowing failure as characterized by the Functional Outcome Swallowing Scale was seen postoperatively in 3/4 patients who underwent TLM or TORS for bilateral simultaneous tonsillar carcinoma, while one patient was lost to follow-up. Severe dysphagia in the setting of bilateral oropharyngectomy for simultaneous or synchronous tonsillar squamous cell carcinoma is rarely described but a significant concern. In an era with increased use of transoral surgery as de-escalation therapy, this unusual complication warrants consideration. We report that transoral bilateral pharyngectomy is quite harmful to near-term and intermediate-term swallowing outcomes. This paper serves to provide warning against primary surgical intervention in this setting, while demonstrating that non-surgical treatment may be the best viable option.