Instrumental Assessment of Dysphagia with FEES and VFSS in Long-Term Post-Surgical Head and Neck Cancer Patients: A Single-center Retrospective Observational Study

Background: Major head and neck cancer (HNC) surgery can significantly alter upper aerodigestive tract (UADT) anatomy and function, frequently leading to dysphagia with potential complications, including silent aspiration and aspiration pneumonia. While bedside assessment is the initial approach, Flexible Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallowing Study (VFSS) remain the instrumental gold standards. However, comparative data specifically addressing post-surgical HNC patients remain limited. Materials and Methods: We conducted a retrospective observational study including patients who underwent major UADT resections (hemiglossectomies, partial laryngectomies, oropharyngectomies), with a minimum oncologic follow-up of 2 years and no evidence of disease. Each patient underwent FEES and VFSS within 24 hours during follow-up. Two experienced raters reviewed both examinations, evaluating mucosal sensitivity, swallowing biomechanics, residue, penetration, and aspiration, applying the Penetration–Aspiration Scale (PAS), Yale Pharyngeal Residue Severity Rating Scale (YPRSRS), and Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scales. In addition, a non-validated institutional tool, the PADOVA score, was employed to harmonize data collection and enable structured comparison between the two modalities. Results: Twenty-two patients met the inclusion criteria and were stratified by surgical procedure (LAR: patients who underwent open partial horizontal laryngectomies vs. ORPHAR: patients who underwent glossectomies with or without associated oropharyngectomy, groups). FEES provided more detailed quantification of pharyngeal residue and allowed assessment of supraglottic sensitivity. VFSS demonstrated a higher detection rate of intra-swallow aspiration and enabled evaluation of upper esophageal sphincter hypertonicity, which was more pronounced in the LAR group. The two modalities showed good agreement in assessing bolus clearance, moderate agreement in residue evaluation, but poor concordance regarding penetration–aspiration events. Worse VFSS outcomes were associated with pharyngeal baseline secretions, prolonged meal duration, and poorer clinical/dietetic scores. The PADOVA score facilitated structured comparison across examinations. Conclusions: FEES and VFSS provide complementary diagnostic information in post-surgical HNC dysphagia and should be selected and interpreted according to resected anatomy and clinical presentation. Larger studies with stratification by surgical phenotype are needed to validate these findings and support standardized diagnostic pathways.