ABSTRACT
Objectives
Transoral robotic surgery (TORS) and transoral videolaryngoscopic surgery (TOVS) have been increasingly adopted for the treatment of head and neck tumors. However, their effectiveness and the differences in their effects on postoperative quality of life (QOL) have not been established. We aimed to evaluate and compare the postoperative QOL of patients who underwent TORS and TOVS.
Methods
This study included 103 patients with head and neck tumors treated with TOVS (83 patients) and TORS (20 patients) between 2016 and 2024. QOL was assessed preoperatively and 1, 3, 6, 12, and 18 months postoperatively using QOL questionnaires (EORTC QLQ‐C30 and QLQ‐H&N35).
Results
Pain and mouth opening limitation were significantly worse at 1 month postoperatively than preoperatively for the TOVS and TORS groups. However, when comparing both groups, no statistically significant difference was observed in postoperative QOL symptom scores, including pain and mouth opening limitation. Multivariate analysis revealed that pain was associated with neck dissection, and mouth opening limitation was associated with neck dissection and oropharyngeal cancer.
Conclusion
Postoperative QOL after TORS and TOVS was associated with pain and mouth opening limitation. However, no statistically significant difference in postoperative QOL was observed between TOVS and TORS.
Level of Evidence
3.
Keywords: EORTC QLQ‐C30, EORTC QLQ‐H&N35, quality of life, transoral robotic surgery, transoral videolaryngoscopic surgery
1. Introduction
The head and neck region is an area that plays an important role in maintaining quality of life (QOL), including breathing, speech, and swallowing, and head and neck tumors often have a negative impact on QOL due to the disease itself and its treatment. Therefore, treatment strategies that preserve QOL and address long‐term treatment toxicity are needed. Robot‐assisted surgery has recently been developed to provide a minimally invasive option for head and neck cancers, and its oncological and functional outcomes have been reported [1]. It has also been associated with better QOL than conventional Chemo‐Radiotherapy or open surgery [2] and comparable QOL to that of radiation therapy [3].
Transoral videolaryngoscopic surgery (TOVS) for head and neck tumors, which was developed in Japan, is minimally invasive and has demonstrated oncological efficacy [4]. It has also been associated with the preservation of swallowing function and postoperative QOL [5, 6, 7]. We have also been actively implementing TOVS for pharyngeal and laryngeal tumors and have developed methods to improve its safety and effectiveness [8].
Transoral robotic surgery (TORS) has been reported to significantly reduce tumor exposure at the resection margins [9]. Furthermore, it may offer superior therapeutic outcomes relative to TOVS, as positive horizontal resection margins after TOVS are associated with poor prognosis [10]. In contrast, TORS has significant challenges related to implementation: the equipment is expensive, there are situations where TORS cannot be performed when using robots for surgeries in other fields, and in Japan, it requires qualifications established by academic societies. Conversely, TOVS is less expensive than TORS, and the burden of introducing it is lower [11]. Therefore, TOVS and TORS are important, and research is needed to understand the characteristics of each procedure and to perform even better surgeries.
Several studies have reported on postoperative QOL following TORS. Dysphagia and pain are common within the first few months to 1 year after TORS [12, 13], and older patients have a higher risk of dysphagia [14]. Further, the treatment site and neck dissection have been reported as factors contributing to reduced postoperative QOL after TORS [15]. However, TORS has demonstrated favorable functional outcomes relative to other surgical approaches and Chemo‐Radiotherapy [16]. This indicates that TORS is an excellent treatment from oncological and functional perspectives.
We have previously reported that TOVS preserves postoperative QOL and swallowing function [17]. Additionally, swallowing disorders may occur in older patients, those with impaired function near the larynx, those with poor pharyngeal clearance, and those who have undergone extensive resection [17, 18, 19]. Several reports have been published on postoperative swallowing function following TORS and TOVS; however, studies on postoperative QOL after both procedures are scarce [3, 12, 13, 17, 18]. Furthermore, few studies have compared postoperative QOL after TORS and TOVS. Based on our previous research, we hypothesized that postoperative QOL following TOVS is not significantly different from that following TORS.
We aimed to determine and compare the postoperative QOL of patients who underwent TOVS and TORS and the factors affecting them.
2. Materials and Methods
2.1. Ethical Considerations
This study adhered to the principles of the Declaration of Helsinki. The protocol for this study, entitled “Swallowing function and QOL in head and neck treatments,” was approved by the Institutional Review Board of Tokai University (approval no. 25R067; date of approval: August 19, 2025). Participants who did not consent could opt out of the study.
2.2. Participants
In this study, the primary endpoint was to confirm that there is no difference in postoperative QOL between TOVS and TORS. Furthermore, exploratory analyses were conducted as secondary endpoints to identify the symptoms contributing to the deterioration of postoperative QOL in both procedures and to clarify the factors associated with symptom worsening.
This retrospective study included data from 103 of the 136 patients who underwent TOVS or TORS for pharyngolaryngeal cancer in our department between July 2016 and December 2024; these patients had consented to participate in the study, met the inclusion criteria, and did not meet any of the exclusion criteria. The inclusion criteria for this study were as follows: (1) cases of malignant tumors with primary lesions in the oropharynx, hypopharynx, or supraglottis in which TOVS or TORS was performed; (2) clinical presentation of Tis/T1/T2/T3 lesions; (3) absence of lymph node metastasis or presence of resectable cervical lymph node metastasis; (4) limitation of lesions to half of the circumferential extension; and (5) absence of distant metastases. The exclusion criteria were as follows: (1) ages < 18 years; (2) Eastern Cooperative Oncology Group performance status ≥ 2; (3) contraindications for transoral resection, such as trismus; (4) surgery involving two or more subregions simultaneously; (5) tracheostomy during the evaluation period; (6) postoperative radiation therapy; and physician‐determined ineligibility (such as obvious aspiration pneumonia or incapacity to provide consent). Patients who had recurrence during the evaluation period, developed new lesions involving the esophagus or head and neck, or underwent treatment or developed conditions that affected swallowing function or QOL postoperatively were excluded from evaluation after the event. The eighth edition of the Union for International Cancer Control guidelines was used for TNM staging.
The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ‐C30 and EORTC QLQ‐H&N35) [20, 21] were administered preoperatively and at 1, 3, 6, 12, and 18 months postoperatively.
2.3. Surgical Procedure
The surgical approach was based on the TOVS method described by Tomifuji et al. [7, 19] The FK‐WO retractor (Olympus Medical Systems, Tokyo, Japan) or the Weerda distending laryngoscope (Karl Storz, Tuttlingen, Germany) was used to establish the surgical field. The surgical field was visualized using a video endoscope with a movable tip, such as the OLYMPUS LTF‐S190‐5 or ENDOEYE FLEX 3D (Olympus Medical Systems). Electrocautery was performed using a Colorado microdissection needle (Stryker Japan KK, Tokyo, Japan) or a malleable electrocautery needle (KD 600, Olympus Medical Systems). The grasping forceps included the STEINER grasping forceps, LARYNGOFORCERII grasping forceps (Karl Storz, Tuttlingen, Germany), and MicroFrance Heart‐Shaped grasper (Integra MicroFrance, Saint Aubin le Monial, France). The lesions were confirmed using narrow‐band imaging systems and iodine‐staining techniques.
TORS has been performed using the Da Vinci Xi (Intuitive Surgical Inc., USA) since June 2022. The tumors were resected en bloc with a safety margin of 5–10 mm. Fibrin glue and polyglycolic acid sheets were applied to cover the mucosal defects [22]. Neck dissection was performed for cases with cervical lymph node metastases. Tracheostomy was not routinely performed.
2.4. Statistical Analysis
Statistical analyses were performed using JMP (ver. 18). The QOL scores at the different time points were compared using the Kruskal–Wallis test and Dunn's multiple comparison test, with the preoperative QOL score as the control. The QOL scores at 1 and 12 months post‐TORS and post‐TOVS were compared using the Mann–Whitney U test. We performed univariate analyses of pain and mouth opening at 1 month postoperatively in a total of 103 patients who underwent TOVS or TORS. We evaluated age (≥ 70 vs. < 70), sex, body mass index (BMI) (≥ 22 vs. < 22), T stage (Tis‐1 vs. T2‐3), history of esophageal cancer, history of head and neck cancer, history of radiation therapy, neck dissection (with vs. without), and surgical procedure (TOVS vs. TORS) using the Mann–Whitney U test. Multivariate analysis was performed using a generalized linear mixed model, focusing on factors that were statistically significant in the univariate analysis. Statistical significance was set at p < 0.05.
3. Results
TOVS and TORS were performed in 83 and 20 patients, respectively. The TOVS group included 76 males and 7 females. Their median age was 71 years (range: 43–87 years) (Table 1). The primary sites were the oropharynx (37 cases: 15 in the tonsils, 4 in the tongue base, 8 in the posterior wall, and 10 in the soft palate), hypopharynx (42 cases: 39 in the piriform sinus, 2 in the postcricoid region, and 1 in the posterior wall), and supraglottis (4 cases).
TABLE 1.
Characteristics of TOVS and TORS.
| TOVS (%) | TORS (%) | |
|---|---|---|
| Total | 83 | 20 |
| Sex (Male:Female) | 76:7 | 17:3 |
| Median age [range] | 71 [43–87] | 73.5 [36–79] |
| T stage | ||
| Tis | 15 (18.1) | 1 (5.0) |
| T1 | 32 (38.6) | 6 (30.0) |
| T2 | 34 (41.0) | 12 (60.0) |
| T3 | 2 (2.4) | 1 (5.0) |
| History of esophageal cancer treatment | 44 (53.0) | 5 (25.0) |
| History of head and neck cancer treatment | 30 (36.1) | 7 (35.0) |
| In same area | 11 (13.3) | 2 (10.0) |
| In other area | 11 (13.3) | 5 (25.0) |
| In same + other area | 8 (9.6) | |
| History of radiotherapy | 16 (19.3) | 1 (5.0) |
| With neck dissection | 13 (15.7) | 10 (50.0) |
| Primary site | ||
| Oropharynx [16+] | 37 [24] (44.6) | 14 [9] (70.0) |
| Tonsil | 15 [5] (18.1) | 10 [8] (50.0) |
| Tongue base | 4 [2] (4.8) | 2 [1] (10.0) |
| Posterior wall | 8 [7] (9.6) | 2 [0] (10.0) |
| Soft palate | 10 [10] (12.0) | |
| Hypopharynx | 42 (50.6) | 5 (25.0) |
| Piriform sinus | 39 (47.0) | 3 (15.0) |
| Postcricoid | 2 (2.4) | 1 (5.0) |
| Posterior wall | 1 (1.2) | 1 (5.0) |
| Supraglottis | 4 (4.8) | 1 (5.0) |
Abbreviations: TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
The TORS group included 17 males and 3 females, and their median age was 73.5 years (range: 36–79 years). The primary sites were the oropharynx (14 cases: 10 in the tonsils, 2 in the anterior wall, and 2 in the posterior wall), hypopharyngeal piriform sinus (3 cases), postcricoid region (1 case), posterior wall (1 case), and supraglottis (1 case).
The analysis of the QLQ‐C30 questionnaire responses revealed improved emotional scores for the TOVS group at 3, 12, and 18 months postoperatively relative to the preoperative scores (Table S1 and Figure 1). The QLQ‐C30 Role scores for the TORS group improved significantly, but the improvement was not significant relative to the preoperative scores (Table S2 and Figure 2). The pain, mouth opening, and painkiller scores for the TOVS group on the QLQ‐H&N35 questionnaire were significantly higher at 1 month postoperatively than preoperatively (Table S3 and Figure 1). The weight loss score on the QLQ‐H&N35 for the TOVS group changed significantly, but the change was not significant relative to the preoperative score. The mouth opening score was higher at 1 month postoperatively, whereas the weight gain score on the QLQ‐H&N35 questionnaire for the TORS group was higher at 6 months postoperatively than preoperatively. The pain and painkiller scores changed, but their differences from the preoperative scores were not significant (Table S4 and Figure 2).
FIGURE 1.
Curves illustrating the evolution of EORTC QLQ‐C30 and QLQ H&N35 symptom scores for the TOVS group. (A) emotional, (B) pain, (C) mouth opening, (D) painkiller use, and (E) weight loss. *p < 0.05. EORTC, European Organization for Research and Treatment of Cancer.
FIGURE 2.
Curves illustrating the evolution of EORTC QLQ‐C30 and QLQ‐H&N35 symptom scores for the TORS group. (A) Role, (B) pain, (C) mouth opening, (D) painkiller use, and (E) weight gain. *p < 0.05. EORTC, European Organization for Research and Treatment of Cancer.
The QOL scores at 1 and 12 months after TORS and TOVS did not differ significantly (Table 2).
TABLE 2.
Comparison of the EORTC QLQ‐C30 and QLQ‐H&N35 symptom scores at 1 and 12 months after TOVS and TORS.
| QLQ‐C30 | 1 month after TOVS | 1 month after TORS | TOVS vs. TORS | ||
|---|---|---|---|---|---|
| Mean | SD | Mean | SD | p | |
| Physical | 90.8 | 11.11 | 91.6 | 9.247 | 0.8181 |
| Role | 88.7 | 19.19 | 91.1 | 17.67 | 0.9362 |
| Emotional | 86.8 | 15.14 | 92.8 | 8.254 | 0.1651 |
| Cognitive | 87.4 | 15.39 | 91.1 | 12.39 | 0.6212 |
| Social | 92.5 | 12.55 | 93.3 | 10.54 | 0.8069 |
| Global health status | 70.1 | 22.46 | 71.7 | 19.36 | 0.7201 |
| Fatigue | 21 | 18.88 | 19.3 | 14.83 | 0.4254 |
| Nausea and vomiting | 1.13 | 5.238 | 2.22 | 5.864 | 0.2529 |
| Pain | 14.1 | 19.45 | 14.4 | 16.51 | 0.536 |
| Dyspnea | 10.3 | 15.56 | 6.67 | 13.8 | 0.1977 |
| Insomnia | 9.6 | 19.62 | 13.3 | 24.56 | 0.8507 |
| Appetite loss | 7.34 | 15.25 | 11.1 | 16.27 | 0.6211 |
| Constipation | 10.7 | 16.88 | 8.89 | 15.26 | 0.3779 |
| Diarrhea | 6.9 | 13.62 | 0 | 0 | 0.057 |
| Financial difficulties | 5.36 | 13.89 | 0 | 0 | 0.1263 |
| QLQ‐H&N35 | Mean | SD | Mean | SD | p |
|---|---|---|---|---|---|
| Pain | 14 | 17.94 | 22.8 | 22.15 | 0.1166 |
| Swallowing | 16.1 | 16.51 | 18.9 | 17.1 | 0.5364 |
| Teeth | 7.34 | 15.25 | 11.1 | 20.57 | 0.7716 |
| Mouth opening | 11.3 | 18.16 | 28.9 | 35.34 | 0.1151 |
| Dry mouth | 19.2 | 26.41 | 17.8 | 21.33 | 0.4018 |
| Sticky saliva | 20.3 | 29.7 | 22.2 | 27.22 | 0.9759 |
| Sense problems | 3.45 | 9.239 | 5.56 | 12.06 | 0.5609 |
| Coughing | 17.5 | 19.92 | 20 | 24.56 | 0.5027 |
| Speech problems | 13.6 | 16.27 | 14.1 | 17.04 | 0.6372 |
| Felt ill | 13.6 | 19.69 | 11.1 | 27.22 | 0.1968 |
| Trouble with social contact | 4.76 | 9.574 | 4.1 | 5.798 | 0.6387 |
| Trouble with social eating | 17.4 | 15.05 | 19 | 15.48 | 0.6283 |
| Less sexuality | 17.3 | 24.84 | 6.67 | 18.69 | 0.0829 |
| Painkiller use | 35.6 | 48.29 | 40 | 50.71 | 0.7593 |
| Nutritional supplements | 11.9 | 32.61 | 0 | 0 | 0.1678 |
| Feeding tube | 3.39 | 18.25 | 6.67 | 25.82 | 0.58916 |
| Weight loss | 25.4 | 43.92 | 46.7 | 51.64 | 0.1123 |
| Weight gain | 22.4 | 42.07 | 6.67 | 25.82 | 0.1734 |
| QLQ‐C30 | 12 months after TOVS | 12 months after TORS | TOVS vs. TORS | ||
|---|---|---|---|---|---|
| Mean | SD | Mean | SD | p | |
| Physical | 88.7 | 13.38 | 80 | 16.33 | 0.2158 |
| Role | 90.2 | 19.3 | 100 | 0 | 0.2091 |
| Emotional | 92.6 | 11.74 | 96.7 | 4.564 | 0.8252 |
| Cognitive | 86.8 | 13.47 | 86.7 | 13.94 | 1 |
| Social | 96.1 | 10.9 | 100 | 0 | 0.3853 |
| Global health status | 71.8 | 20.41 | 71.7 | 24.01 | 0.9829 |
| Fatigue | 21.9 | 19.63 | 22.2 | 15.71 | 0.8637 |
| Nausea and vomiting | 2.45 | 7.262 | 0 | 0 | 0.5245 |
| Pain | 4.9 | 11.26 | 3.33 | 7.454 | 0.8413 |
| Dyspnea | 13.7 | 20.3 | 26.7 | 14.91 | 0.1039 |
| Insomnia | 12.7 | 20.13 | 16.7 | 16.67 | 0.5411 |
| Appetite loss | 15.7 | 26.25 | 20 | 29.81 | 0.6109 |
| Constipation | 10.8 | 24.23 | 13.3 | 18.26 | 0.3551 |
| Diarrhea | 9.8 | 17.46 | 6.67 | 14.91 | 0.8634 |
| Financial difficulties | 3.92 | 13.64 | 6.67 | 14.91 | 0.4974 |
| QLQ‐H&N35 | Mean | SD | Mean | SD | p |
|---|---|---|---|---|---|
| Pain | 2.96 | 5.912 | 0 | 0 | 0.2817 |
| Swallowing | 8.89 | 11.36 | 8.33 | 10.21 | 0.8814 |
| Teeth | 8.33 | 14.66 | 6.67 | 14.91 | 0.8343 |
| Mouth opening | 3.13 | 9.871 | 0 | 0 | 0.5108 |
| Dry mouth | 13.5 | 20.49 | 13.3 | 18.26 | 0.8073 |
| Sticky saliva | 12.5 | 18.45 | 13.3 | 18.26 | 0.8728 |
| Sense problems | 3.33 | 9.181 | 0 | 0 | 0.4257 |
| Coughing | 11.5 | 18.18 | 6.67 | 14.91 | 0.6155 |
| Speech problems | 7.78 | 12.77 | 0 | 0 | 0.1478 |
| Felt ill | 10.4 | 17.84 | 6.67 | 14.91 | 0.8118 |
| Trouble with social contact | 2.58 | 9.84 | 3.33 | 6.667 | 0.6355 |
| Trouble with social eating | 12.9 | 12.7 | 8.33 | 6.804 | 0.6474 |
| Less sexuality | 24.7 | 33.22 | 29.2 | 47.87 | 0.809 |
| Painkiller use | 12.1 | 33.14 | 0 | 0 | 0.4328 |
| Nutritional supplements | 12.1 | 33.14 | 50 | 57.74 | 0.0606 |
| Feeding tube | 0 | 0 | 0 | 0 | NS |
| Weight loss | 6.06 | 24.23 | 25 | 50 | 0.0805 |
| Weight gain | 30.3 | 46.67 | 25 | 50 | 0.853 |
Note: The Mann–Whitney U test was used to determine statistical significance (p < 0.05).
Abbreviations: EORTC, European Organization for Research and Treatment of Cancer; NS, not significant; SD, standard deviation; TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
Univariate analysis of pain and mouth opening at 1 month after surgery revealed statistically significant differences in both outcomes for T stage, history of esophageal cancer, history of head and neck cancer, neck dissection, and oropharyngeal cancer (Table 3). Using the factors that were statistically significant in the univariate analysis, we performed multivariate analysis using a generalized linear mixed model to assess pain and mouth opening score at 1 month after surgery. The results showed that neck dissection was an independent risk factor for pain, whereas neck dissection and oropharyngeal cancer were independent risk factors for mouth opening limitation (Table 4).
TABLE 3.
Univariate analysis of pain and mouth opening at 1 month postoperatively in 103 patients who underwent TOVS or TORS.
| Pain | Mouth opening | |||||||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | p | Mean | SD | p | |||
| Age | ≥ 70 | 15.8 | 20.2 | 0.7603 | 15.2 | 25.05 | 0.8271 | |
| < 70 | 16 | 17.59 | 14.8 | 21.35 | ||||
| Sex | Male | 16.4 | 14.58 | 0.9177 | 20.1 | 23.66 | 0.5342 | |
| Female | 12 | 10.3 | 18.5 | 24.22 | ||||
| BMI | ≥ 22 | 18.7 | 22.63 | 0.419 | 18.2 | 27.75 | 0.538 | |
| < 22 | 13.5 | 15.64 | 12.5 | 19.52 | ||||
| T stage | Tis, T1 | 12.6 | 15.54 | 0.0031 | 8.11 | 16.49 | 0.0142 | |
| T2, T3 | 19.2 | 21.99 | 22.2 | 27.6 | ||||
| History of esophageal cancer treatment | Yes | 10.1 | 16.57 | 0.0026 | 6.14 | 13.1 | 0.0013 | |
| No | 22.1 | 20 | 24.8 | 28.4 | ||||
| History of head and neck cancer treatment | Yes | 16.4 | 20.59 | 0.7428 | 11.1 | 15.98 | 0.551 | |
| No | 15.5 | 18.33 | 17.8 | 27.55 | ||||
| History of radiotherapy | Yes | 24.4 | 27.44 | 0.1482 | 19 | 17.12 | 0.1384 | |
| No | 13.8 | 16.27 | 14.1 | 24.92 | ||||
| Neck dissection | Yes | 39.4 | 27.18 | < 0.001 | 44.4 | 27.22 | < 0.001 | |
| No | 9.77 | 9.889 | 7.47 | 15.35 | ||||
| Primary site | OPC | 23.6 | 23.86 | 0.0031 | 27.8 | 27.02 | < 0.001 | |
| HPC, SG | 8.33 | 7.857 | 2.7 | 9.224 | ||||
| Surgical procedure | TOVS | 14.1 | 18.08 | 0.1507 | 11.5 | 18.26 | 0.0823 | |
| TORS | 22.8 | 22.15 | 28.9 | 35.34 | ||||
Note: The Mann–Whitney U test was used to determine statistical significance. Statistical significance (p < 0.05) is indicated in bold.
Abbreviations: BMI, body mass index; HPC, hypopharyngeal cancer; OPC, oropharyngeal cancer; SD, standard deviation; SG, supraglottic cancer; TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
TABLE 4.
Multivariate analysis of pain and mouth opening at 1 month postoperatively in 103 patients who underwent TOVS or TORS.
| Pain | F‐value | p |
|---|---|---|
| Age ≥ 70 | 0.5724 | 0.452 |
| Sex (male) | 0.0289 | 0.8666 |
| BMI ≥ 22 | 0.0642 | 0.8008 |
| T stage (Tis‐T1) | 1.0137 | 0.3177 |
| History of esophageal cancer treatment | 0.8729 | 0.3536 |
| Neck dissection | 24.945 | < 0.001 |
| Oropharyngeal cancer | 1.3963 | 0.2417 |
| Mouth opening | F‐value | p |
|---|---|---|
| Age ≥ 70 | 1.6337 | 0.2057 |
| Sex (male) | 2.01 | 0.161 |
| BMI ≥ 22 | 0.0009 | 0.9765 |
| T stage (Tis‐T1) | 0.073 | 0.7878 |
| History of esophageal cancer treatment | 2.0069 | 0.1614 |
| Neck dissection | 21.984 | < 0.001 |
| Oropharyngeal cancer | 5.4506 | 0.0227 |
Note: A generalized linear mixed model was used to determine statistical significance. Statistical significance (p < 0.05) is indicated in bold.
4. Discussion
Transoral surgery for head and neck tumors is minimally invasive and has been associated with favorable oncological outcomes [1, 2, 3, 4]. This has led to its rapid global adoption. Several studies have reported the oncological and functional efficacies of TOVS and TORS. However, postoperative QOL has been reported for both approaches, and few studies have compared QOL following these two techniques. The data presented here, which highlight the association between QOL decline following TORS and TOVS based on changes in patient condition, are clinically useful.
TOVS and TORS were associated with postoperative pain, mouth opening limitation, and weight changes. Furthermore, this study demonstrated that neck dissection was independently associated with pain at 1 month postoperatively, whereas oropharyngeal cancer and neck dissection were independently associated with difficulty opening the mouth. It is easy to imagine that pain would be more severe when neck dissection is performed in conjunction with transoral surgery. In contrast, in cases where the primary lesion is located in the oropharynx, the pain may have been caused by surrounding inflammation resulting from resection of the pharyngeal constrictor muscles [23, 24], increased muscle tension in the medial pterygoid muscle [25, 26], and reflexive inhibition of mouth opening because of pain during swallowing or mouth opening. If a decline in QOL occurs when resection extends to the deep muscular layers, such as the pharyngeal constrictor muscles, in the oropharynx, a decline in QOL may also occur in cases where resection extends to the deep muscular layers in the hypopharynx and supraglottis.
The results of this univariate analysis showed that, at the 1‐month postoperative time point, pain and limited mouth opening were not statistically associated with a history of head and neck cancer or radiation therapy. Furthermore, the results of the multivariate analysis showed no statistically significant association with a history of esophageal cancer or T stage. Although a history of radiation therapy or surgery may be a factor in scarring or sensory dysfunction [27], it may not have a significant impact on early postoperative pain or mouth opening. Additionally, since early‐stage pharyngeal cancer is typically characterized by superficial mucosal spread with a tendency for lateral extension rather than deep invasion [28], it is possible that there was no impact from damage to the deep muscles. Prolonged use of a mouth opener is another potential cause of mouth opening difficulties. Reports have documented a significant increase in the prevalence of mouth opening difficulties and pain after tonsillectomy and prolonged mouth opener use [29]. Postoperative pain and mouth opening difficulties may contribute to reduced QOL after TOVS and TORS. Focusing on postoperative pain management and shortening the surgical duration may further enhance QOL.
Statistical analysis of the QLQ‐C30 questionnaire data revealed significant improvements in the “emotions” and “role” categories in the TOVS and TORS groups, respectively. In the TOVS group, emotional scores improved at 3, 12, and 18 months post‐treatment compared to pre‐treatment, suggesting that emotional scores were low prior to treatment. In the TOVS group, the high proportion of patients with a history of esophageal cancer or prior radiation therapy may have influenced pre‐treatment emotional scores. Conversely, in the TORS group, the lower proportion of patients with a history of esophageal cancer or prior radiation therapy may have contributed to the postoperative improvement in role scores.
This study found no statistically significant difference in postoperative QOL between the TOVS and TORS groups at 1 and 12 months postoperatively. We have previously reported on good tumor control following TOVS using three‐dimensional endoscopy and an endoscopic holder to improve resection accuracy [8]. These efforts to enhance resection accuracy may have reduced excessive resection of deep muscle layers, including the pharyngeal constrictor muscles, and horizontal margins during TOVS, which is thought to have contributed to outcomes comparable to those of TORS in terms of postoperative QOL. Although TOVS relies on long forceps for resection, TORS, particularly in single‐port cases, features multiple joints in the arm, providing a wide range of motion and allowing for intuitive resection maneuvers close to the camera [30]. Consequently, differences in operability between the two techniques may directly influence postoperative functional outcomes. In contrast, the results of this study suggest that, through innovations in resection devices and forceps, it may be possible to achieve postoperative QOL equivalent to that of TORS.
Further efforts are needed to improve the oncological and functional outcomes and postoperative QOL of TOVS and TORS. TOVS for hypopharyngeal cancer is associated with high rates of positive resection margins and local recurrence [31]. Koyama et al. reported that PLET for expanding the hypopharyngeal field further improves visibility [32]. Refining the surgical field is expected to further enhance tumor control. Additionally, administering postoperative pharyngeal spray [33] and providing appropriate pain management may further improve the QOL of patients undergoing TORS and TOVS.
This study is limited by its single‐center design and small sample size. It was predominantly used for oropharyngeal cases, whereas TOVS was more common for hypopharyngeal lesions. These factors significantly undermine the statistical reliability of direct comparisons between the two techniques. Further, the study may not be generalizable due to insufficient stratification and statistical analysis based on factors affecting swallowing function and pain, such as age, resection extent, and resection site. The influence of prior treatments for other conditions could also not be fully excluded. Notwithstanding, previous reports on QOL after TORS and TOVS are insufficient. Therefore, this study stands out for comparing both approaches, and the findings have new regulatory implications. The mention of factors contributing to QOL decline is also clinically significant and enhances the value of this report. Further studies should include more cases, conduct multicenter analyses, and examine the effectiveness of additional interventions for pain and mouth opening limitation in improving QOL.
5. Conclusion
Postoperative QOL after TORS and TOVS was associated with pain, limited mouth opening, and weight change. However, no statistically significant difference in postoperative QOL was observed between TOVS and TORS.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐C30 scores in the TOVS group.
Table S2: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐C30 scores in the TORS group.
Table S3: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐H&N35 scores in the TOVS group.
Table S4: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐H&N35 scores in the TORS group.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐C30 scores in the TOVS group.
Table S2: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐C30 scores in the TORS group.
Table S3: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐H&N35 scores in the TOVS group.
Table S4: Kruskal–Wallis and Dunn's tests for the EORTC QLQ‐H&N35 scores in the TORS group.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.