Severe Prolonged Dysphagia Following Transoral Resection of Bilateral Synchronous Tonsillar Carcinoma

Alpen B. Patel, MD1; Taylor R. Pollei, MD1; Michael L. Hinni, MD1; Richard E. Hayden, MD1; Eric J. Moore, MD2 1Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Phoenix, AZ

2Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, MN

© 2013 Mayo Foundation for Medical Education and Research

Discussion

• Bilateral simultaneous or synchronous tonsillar carcinoma is a rare entity. Due to the increasing frequency of cases reported and treated with surgery, we would like to alert the reader to this increased risk of dysphagia in the setting of TOS.

• We report a 75% incidence of persistent dysphagia (FOSS Stage V) in patients who underwent TOS for bilateral tonsillar carcinoma, with one patient lost to inadequate follow-up. Only one patient was able to have their feeding tube removed within ten months following surgery. As shown in this small series, surgery for bilateral disease comes with a risk of prolonged dysphagia and should be considered when advising patients about treatment options.

• Patients treated with TLM have been shown to retain long term swallowing function. Patients who require placement of permanent gastrostomy tubes typically do so following combined modality treatment, which may lead to swallowing dysfunction secondary to acute complications or delayed and progressive complications. The cumulative effects of treatment are important to consider and these treatments cannot be viewed exclusively. In our series, only one patient had previous history of radiation or CXRT exposure with this patient demonstrating no swallowing dysfunction until after surgery. Rarely does this dysphagia persist beyond ten days, and if it does, it is thought to be related to excessive trauma to the pharyngeal musculature or resection bed scar tissue formation.

• In our case series, the etiology is likely multifactorial. With bilateral dissection, we believe that the risk of complication increases secondary to the amount of pharyngeal constrictor resected. Even with the most meticulous dissection technique, pharyngeal musculature and CN IX injury in addition to mucosal scarring are possible. However, with the contralateral musculature compensating to preserve swallowing function prolonged issues are rarely seen. It is likely this lack of compensation that is the underlying etiology for prolonged, severe dysphagia.

Conclusions

• The incidence of bilateral tonsillar SCCA is a rare entity. Bilateral TOS tonsillectomy or oropharyngectomy for simultaneous or synchronous SCCA can carry an increased risk of severe dysphagia when compared to unilateral resection likely secondary to pharyngeal constrictor disruption. Dysphagia in this setting, has a much greater occurrence, however, it has the potential to resolve. With the increasing movement towards use of TOS approaches in the oropharynx, this unusual complication warrants discussion. The clinician must proactively seek to avoid this complication when surgically treating bilateral oropharyngeal disease.

References

1. Moualed D, Qayyum A, Price T et al. Bilateral synchronous tonsillar carcinoma: a case series and review of the literature. Eur Arch Otorhinolaryngol. 2012;269:255-9.

2. Smith RO, Pokala K, Medina JE, et al. Tonsillar carcinoma in the contralateral tonsil. Laryngoscope. 2010;120 Suppl 4:S176.

3. Hsairi M, Luce D, Point D, Rodrigueez J, Brugere J, Leclerc A. Risk factors for simultaneous carcinoma of the head and neck. Head Neck. 1989;11:426–430.

4. Cianchetti M, Mancuso AA, Amdur RJ, et al. Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Laryngoscope. 2009 Dec;119(12):2348-54.

5. Grant DG, Salassa JR, Hinni ML, et al. Carcinoma of the tongue base treated by transoral laser microsurgery, part one: Untreated tumors, a prospective analysis of oncologic and functional outcomes. Laryngoscope. 2006;116:2150-5

Abstract

Objective: 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 (SCCA).

Study Design: Retrospective review; case series.

Setting: Academic, tertiary referral center.

Subjects and Methods: A retrospective review of four patients who presented to an academic, tertiary referral center between 2008-2012 were reviewed; two treated with TLM and two with TORS for biopsy proven previously untreated bilateral primary oropharyngeal SCCA. Main outcome measures included functional swallowing determined by the Functional Outcome Swallowing Scale (FOSS). The incidence of significant postoperative complications was recorded.

Results: Two patients had surgery for discontiguous involvement of bilateral palatine tonsils with SCCA, while two patients had surgery for bilateral tonsillar SCCA with unilateral extension into the base of tongue. Complete swallowing failure as characterized by the FOSS 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.

Conclusions: Severe dysphagia in the setting of bilateral oropharyngectomy for simultaneous or synchronous tonsillar SCCA is rarely described but a significant concern. In an era with an increasing use of transoral surgery, this unusual complication warrants consideration.

Introduction

• Squamous cell carcinoma (SCCA) of the palatine tonsil is the third most common malignancy in the head and neck. Tonsillar SCCA rarely presents as simultaneous discontiguous disease involving both palatine tonsils with less than 15 cases reported in the literature over the last 15 years.1

• The incidence of multiple primary head and neck carcinomas varies from 7.5 to 20% with the incidence of metachronous or synchronous tonsillar carcinomas associated with oropharyngeal carcinoma measuring approximately 9 to 14%. The incidence of metachronous or synchronous carcinomas in the contralateral tonsils in patients with tonsillar primaries is unknown, however, studies estimate an incidence of 4%.1-4

• Over the last two decades, there has been a signifi cant movement towards minimally invasive surgical techniques and approaches including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). Both these forms of transoral surgery (TOS) demonstrate excellent functional and oncologic outcomes. They combine exceptional local control, regional control, and survival benefi t while simultaneously minimizing complications and optimizing functions such as swallowing.5

• Although TOS has shown benefi t in management of unilateral oropharyngeal or tonsillar SCCA, the complication of prolonged, severe dysphagia noted after TOS in patients with bilateral tonsillar carcinoma has not been widely described.

Methods

• A prospective electronic database of all head and neck cancer patients treated from 1994-2012 with TOS at Mayo Clinic Arizona and Mayo Clinic Rochester was reviewed.

• A total of 769 patients who underwent any transoral resection of oropharyngeal SCCA were reviewed and four patients, all treated between 2008 and 2012 met inclusion criteria.

• This included simultaneous or synchronous SCCA involvement of bilateral tonsillar fossa with or without further involvement of the base of tongue, with the development of severe prolonged dysphagia following surgery.

• The Functional Outcome Swallowing Scale (FOSS) was used to quantify swallowing function. Swallowing data and feeding tube usage throughout the treatment and follow-up period were recorded.

Results

• Two patients (2/769) underwent surgery for discontiguous involvement of bilateral tonsillar fossa with SCCA, and two patients (2/769) underwent surgery for bilateral tonsillar SCCA with unilateral extension into the base of tongue. Of the four included patients, one was treated with TLM, two were treated with TORS, and one was treated initially with TORS unilaterally and TLM contralaterally. Three patients developed prolonged and persistent swallowing dysfunction. One had postoperative swallowing dysfunction but was lost to follow-up.

• Follow-up after surgery was performed with dysphagia speech pathology evaluations including MBSS. Prior to surgery, severe dysphagia was not present in any patient and occurred only after the TOS with bilateral resection. Nasogastric tubes were placed in all patients intraoperatively with the need for PEG tube assessed thereafter. One patient did have previous external beam radiotherapy 23 years prior without residual swallowing dysfunction.

• Two patients received adjuvant IMRT following TOS, but had severe to profound swallowing dysfunction prior to therapy initiation. One patient underwent CXRT with PEG tube placement prior to surgery. This patient did not have swallowing dysfunction after CXRT, but developed severe dysfunction following surgery. The fourth patient had swallowing dysfunction after surgery and required PEG tube placement, but was lost to follow-up.

• Of all the patients that were seen longitudinally, one showed improvement and the PEG tube removed ten months following surgery with the other two patients remaining PEG tube dependant with inability for any oral intake.

Clinical Characteristics and Demographics

Case Age Gender Date PresentingSymptom

Primary Tumor Synchronous Tumor

Classifi cation

Site Stage Treatment

1 51 Male 2008 Left neck mass

Left TonsilRight TonsilAdjuvant IMRT

T1/N2/M0T2/N2/M0

Bilateral TORS resectionBilateral neck dissection

Simultaneous

2 52 Male 2011 Bilateralneckmasses

Left TonsilRight TonsilAdjuvant CXRT

T1/N0/M0T2/N2/M0

Bilateral TORS resectionBilateral neck dissection

Simultaneous

3 47 Male 2011 Mucosal lesion, Four months post CXRT

Right Tonsil/ Tongue BaseLeft Tonsil

T3/N2/M0

T1/N0/M0

Right TORS resectionBilateral neck dissectionLeft TLM resection

Simultaneous/synchronous

4 71 Female 2008 Ear pain Left TonsilRight Tonsil/ Tongue Base

T1/N0/M0T3/N0/M0

Bilateral TLM resectionBilateral neck dissection

Simultaneous

Swallowing Function

Case Pre-Operative Post-Operative Nutrition

1 FOSS Stage 1: Normal FOSS Stage 5: Non-oral Feeding PEG: Current (40 mos.)

2 FOSS Stage 1: Normal FOSS Stage 5: Non-oral Feeding PEG: Removed (10 mos.)

3 FOSS Stage 1: Normal FOSS Stage 5: Non-oral Feeding PEG: Current (19 mos.)

4 FOSS Stage 1: Normal FOSS Stage 5: Non-oral Feeding PEG: Placed; Lost to Follow-up