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Bruening J. Robotic Surgery in the Head and Neck: Presurgical Considerations and Post-treatment Appearance. Semin Roentgenol 2023; 58:374-383. [PMID: 37507177 DOI: 10.1053/j.ro.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Jennifer Bruening
- Department of Otolaryngology and Communication Sciences, Head and Neck Surgical Oncology and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Mella MH, Chabrillac E, Dupret-Bories A, Mirallie M, Vergez S. Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps. J Clin Med 2023; 12:jcm12062303. [PMID: 36983308 PMCID: PMC10056198 DOI: 10.3390/jcm12062303] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.
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Affiliation(s)
- Mariam H. Mella
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
| | - Emilien Chabrillac
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Agnès Dupret-Bories
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Mathilde Mirallie
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Sébastien Vergez
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-67-77-17-32
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Arora A, Brunet A, Oikonomou G, Tornari C, Faulkner J, Jeyarajah J, Touska P, Sandison A, Rovira A, Simo R, Jeannon JP. Establishing and integrating a transoral robotic surgery programme into routine oncological management of head and neck cancer - a UK perspective. J Laryngol Otol 2022; 136:1231-1236. [PMID: 35189991 DOI: 10.1017/s002221512100476x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The introduction of transoral robotic surgery into routine management of patients is complex. It involves organisational, logistical and clinical challenges. This study presents our experience of implementing such a programme and provides a blueprint for other centres willing to establish similar services. METHODS Implementation of the robotic surgery programme focused on several key domains: training, logistics, governance, multidisciplinary team awareness, pre-operative imaging, anaesthesia, post-operative care, finance, patient selection and consent. Programme outcomes were evaluated by assessing operative outcomes of the first 117 procedures performed. RESULTS The success of the transoral robotic surgery programme has been possible because of the scrupulous planning phase before the first procedure, and the time invested on team awareness and training. CONCLUSION Implementation of a new transoral robotic surgery service has led to: the development of a dedicated transoral robotic surgery patient care protocol, the performance of progressively more complex procedures, the inclusion of transoral robotic surgery training and the establishment of several research projects.
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Affiliation(s)
- A Arora
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - A Brunet
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
- Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute ('IDIBELL'), Hospitalet de Llobregat, Barcelona, Spain
| | - G Oikonomou
- Department of Otorhinolaryngology, Head and Neck Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - C Tornari
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
| | - J Faulkner
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
| | | | | | - A Sandison
- Histopathology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - A Rovira
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
| | - R Simo
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
| | - J-P Jeannon
- Departments of Otorhinolaryngology, Head and Neck Surgery, London, UK
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Evaluation of chronological changes in videofluorographic findings after transoral videolaryngoscopic surgery to reveal mechanism of dysphagia. Auris Nasus Larynx 2022; 50:374-382. [PMID: 36075789 DOI: 10.1016/j.anl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Transoral surgery preserves good swallowing function in most cases, however, postoperative dysphagia sometimes leads to fatal complication such as aspiration pneumonia. We investigated the chronological changes in swallowing function have not been revealed relationship with dysphagia. The primary aim of this study was to reveal the mechanism of dysphagia following transoral surgery by analyzing chronological videofluorography (VF) findings. Moreover, the secondary aim of this study was to evaluate the relationship between mechanism of dysphagia and risk factors of patients to clarify the risk for dysphagia lead to prevention of postoperative complications. METHODS 22 patients who underwent transoral videolaryngoscopic surgery (TOVS) for either supraglottic or hypopharyngeal cancer were evaluated swallowing function. We performed VF during the preoperative, postoperative acute, and stable phases and investigated the chronological changes in the VF findings. The following parameters were evaluated by VF: horizontal distance of laryngeal movement, vertical distance of laryngeal elevation, laryngeal elevation delay time (LEDT), Bolus Residue Scale (BRS) scores, and Penetration Aspiration Scale (PAS) scores. Additionally, we evaluated risk factors for postoperative aspiration by investigating relationships between preoperative VF parameters, age of patients, history of radiation therapy, resection area, tumor (T) stage, postoperative Numeric Rating Scale (NRS), and PAS and BRS scores. RESULTS The median time at which oral feeding was resumed in this study was 9 (2-200) days. The patients who had postoperative acute PAS scores of 4 and above exhibited delays in resuming oral ingestion after surgery. TOVS did not impair laryngeal elevation and LEDT; however, the BRS and PAS scores temporarily worsened in the acute phase compared to the preoperative scores. These scores almost recovered to their preoperative states in the stable phase, and both the BRS and PAS scores worsened and recovered concurrently. Patients who exhibited poor vertical distance in laryngeal elevation as observed via preoperative VF or who had histories of radiation therapy had worse PAS scores in postoperative acute phase VF. Patients with broad resection areas had worse BRS scores in postoperative acute phase VF. CONCLUSION TOVS didn't impair the function of laryngeal elevation and elicitation of the swallowing reflex whereas pharyngeal bolus clearance, laryngeal penetration, and aspiration temporarily deteriorated concurrently but eventually almost recovered to their baseline values. Patients with histories of radiotherapy, poor laryngeal elevation, and broad resection areas are at the risk of postoperative dysphagia after TOVS. Patients with these risk factors need appropriate evaluation before resuming postoperative oral intake.
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Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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Bunch PM, Patwa HS, Hughes RT, Porosnicu M, Waltonen JD. Patient Selection for Transoral Robotic Surgery (TORS) in Oropharyngeal Squamous Cell Carcinoma: What the Surgeon Wants to Know. Top Magn Reson Imaging 2021; 30:117-130. [PMID: 33828063 DOI: 10.1097/rmr.0000000000000269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT Transoral robotic surgery (TORS) is an excellent treatment strategy for well-selected patients with oropharyngeal squamous cell carcinoma. Potential benefits of TORS are greatest among patients for whom surgical resection will reduce or eliminate the need for adjuvant therapy. Proper patient selection largely depends on imaging, which is used to determine tumor resectability, to inform expected morbidity and functional outcome, to assess the potential need for adjuvant therapy, to evaluate for vascular or other anatomic contraindications, and to gauge adequacy of transoral access to the tumor. This article provides the radiologist with a practical and accessible approach to interpreting preoperative imaging among patients with oropharyngeal cancer, emphasizing what the surgeon wants to know to inform the determination of whether the patient is a TORS candidate and why this information is important. By accurately reporting this information, the radiologist facilitates the multidisciplinary care team's selection of a treatment regimen optimized for the circumstances of the individual patient.
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Affiliation(s)
- Paul M Bunch
- Department of Radiology Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Hafiz S Patwa
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC
| | - Mercedes Porosnicu
- Department of Hematology and Oncology, Wake Forest School of Medicine, Winston Salem, NC
| | - Joshua D Waltonen
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston Salem, NC
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McKenzie RM, Parhar HS, Ng TL, Prisman E. Muscle invasion in oropharyngeal carcinoma undergoing transoral robotic surgery. Head Neck 2020; 43:1194-1201. [PMID: 33355962 DOI: 10.1002/hed.26582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/15/2020] [Accepted: 12/08/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUNDS Pathologic features of oropharyngeal squamous cell carcinoma (OPSCC) treated with trans-oral robotic surgery predict prognosis and adjuvant therapy. We hypothesized that pathologic muscle invasion (pMI) is associated with poor pathological markers. METHODS Retrospective review of surgically treated OPSCC to identify pMI and its association with poor pathologic markers. RESULTS pMI was present in 12/37 patients, and compared to non-pMI, was associated with higher rates of lymphovascular invasion (75% vs. 36%, p = 0.03), perineural invasion (16.7% vs. 0%, p = 0.04), extranodal extension (66.7% vs. 20%, p < 0.01), and tumor stage (8.3% vs. 48% pT1, 75% vs. 52% pT2 and 16.7% vs. 0% pT3). pMI was associated with having a positive margin on main specimen (41.7% vs. 12%, p = 0.04) but not after considering additional margins. CONCLUSIONS Muscle invasion was associated with higher pathologic tumor staging, poor pathologic factors, and higher rates of positive margin on main specimen.
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Affiliation(s)
- Robert M McKenzie
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Harman S Parhar
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tony L Ng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eitan Prisman
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Early T1-T2 stage p16+ oropharyngeal tumours. Role of upfront transoral robotic surgery in de-escalation treatment strategies. A review of the current literature. Oral Oncol 2020; 113:105111. [PMID: 33341006 DOI: 10.1016/j.oraloncology.2020.105111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
Human papillomavirus is responsible of approximately 70% oropharyngeal tumours and is related with more favourable outcomes. It has led to an increasing interest for de-escalation treatment strategies such as Trans Oral Robotic Surgery (TORS). A literature review was performed searching for the role of TORS as de-escalation modality of treatment in patients with p16 positive oropharyngeal squamous cell carcinoma (OPSCC). Special attention was paid to the potential advantage offered by TORS in reducing adjuvant radiation therapy. Six questions were formulated. 67 studies were selected. Several trials analysing the role of upfront TORS to treat early stage p16+ OPSCC and the possibility of reducing the adjuvant radiotherapy were founded. A lot of studies based on the experience of single centres show promising results. Nevertheless to date no definitive data can be extrapolated. The continued investigation of this line of de-escalation therapy with randomized prospective clinical trials is needed.
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Green ED, Paleri V, Hardman JC, Kerawala C, Riva FMG, Jaly AA, Ap Dafydd D. Integrated surgery and radiology: trans-oral robotic surgery guided by real-time radiologist-operated intraoral ultrasound. Oral Maxillofac Surg 2020; 24:477-483. [PMID: 32643077 DOI: 10.1007/s10006-020-00880-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/02/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE We aimed to evaluate the feasibility and utility of intraoral ultrasound as a real-time guidance technique in trans-oral robotic surgery (TORS). METHODS We report our early experiences of radiologist-operated intraoral ultrasound during TORS, providing information on tumour margin and important adjacent structures. Resection specimens were sonographically imaged for margin assessment. RESULTS Four patients underwent ultrasound-guided TORS, with a close correlation between intraoperative and preoperative imaging in each case. The tumour was fully excised in three cases (one did not proceed due to difficult access). No ultrasound-related adverse events occurred, surgical margins were negative, and the treated patients are currently in a state of remission, with functional swallows. CONCLUSION Intraoperative ultrasound can allow previously inaccessible disease to be robotically resected with confidence. Sonographic interrogation of the resected specimen correlated closely with histological margin analysis, and a novel technique of using saline to improve ultrasound conductance and therefore image quality is described.
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Affiliation(s)
- Edward D Green
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK.
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust, London, UK
| | - John C Hardman
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust, London, UK
| | - Cyrus Kerawala
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust, London, UK
| | - Francesco M G Riva
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust, London, UK
| | - Alaa A Jaly
- Department of Radiology, North Middlesex University Hospital, London, UK
| | - Derfel Ap Dafydd
- Department of Radiology, The Royal Marsden Hospitals NHS Foundation Trust, London, UK
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Abstract
Transoral robotic surgery is a useful minimally invasive technique in the treatment of oropharyngeal squamous cell carcinoma, both human papilloma virus (HPV)-positive and HPV-negative patients in certain instances. This treatment modality often has proven useful for certain tumor persistences or recurrences. Good outcomes are possible given appropriate patient selection, both oncologically and functionally.
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Parhar HS, Brody RM, Shimunov D, Rajasekaran K, Rassekh CH, Basu D, O'Malley BW, Chalian AA, Newman JG, Loevner L, Lazor JW, Weinstein GS, Cannady SB. Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction. Laryngoscope 2020; 131:E821-E827. [PMID: 32621638 DOI: 10.1002/lary.28876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/16/2020] [Accepted: 05/27/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS-assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control. STUDY DESIGN Retrospective cohort analysis. METHODS Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019. RESULTS Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin. CONCLUSION In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E821-E827, 2021.
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Affiliation(s)
- Harman S Parhar
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - David Shimunov
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Devraj Basu
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Laurie Loevner
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jillian W Lazor
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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