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Méndez Gutiérrez JC, García-Covarrubias L, Reding-Bernal A, Velázquez Chong HA, Fernández Ángel DF, García Covarrubias A, Hernández-Rivera JC. Utility of a clinical risk scale to predict the requirement of advanced airway management in patients with a diagnosis of deep neck abscess. Braz J Otorhinolaryngol 2024; 90:101360. [PMID: 38035470 PMCID: PMC10698535 DOI: 10.1016/j.bjorl.2023.101360] [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: 09/28/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES To analyze the clinical utility of a clinical risk scale to predict the need for advanced airway management in patients with deep neck abscess. METHODS Observational, analytical, cross-sectional study. Patients over 18 years old, both genders, with surgical management of a deep neck abscess, between January 1st, 2015 to December 31th, 2021, who were applied the clinical risk scale (https://7-414-5-19.shinyapps.io/ClinicalRiskScore/). The sensitivity, specificity, and predictive values of the scale were calculated based on the identified clinical outcomes. A p<0.05 was considered significant. RESULTS A sample of 213 patients was obtained, 121 (56.8%) men, of whom 50 (23.5%) required advanced airway management. Dyspnea was the variable with the most statistical weight in our study, (p=0.001) as well as the multiple spaces involvement, (p=0.001) the presence of air corpuscles, (p=0.001) compromise of the retropharyngeal space (p=0.001) and age greater than 55 years (p=0.001). Taking these data into account, were found for the clinical risk scale a sensitivity of 97% and a specificity of 65% (p=0.001, 95% CI 0.856-0.984). CONCLUSIONS The clinical risk scale developed to predict advanced airway management in patients with a diagnosis of deep neck abscess may be applicable in our environment with high sensitivity and specificity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Juan Carlos Méndez Gutiérrez
- Hospital de Especialidades Dr. Bernardo Sepúlveda Gutiérrez, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Head and Neck Department, Mexico City, Mexico
| | - Luis García-Covarrubias
- Hospital de Especialidades Dr. Bernardo Sepúlveda Gutiérrez, CMN XXI, Instituto Mexicano del Seguro Social, Gastro-Surgery Department, Mexico City, Mexico; Hospital General de México "Dr. Eduardo Liceaga", Surgery Department, Mexico City, Mexico.
| | - Arturo Reding-Bernal
- Hospital General De México "Dr. Eduardo Licega", Research Department, Mexico City, Mexico
| | - Héctor A Velázquez Chong
- Hospital de Especialidades Dr. Bernardo Sepúlveda Gutiérrez, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Head and Neck Department, Mexico City, Mexico
| | | | | | - Juan Carlos Hernández-Rivera
- Hospital de Especialidades Dr. Bernardo Sepúlveda Gutiérrez, CMN Siglo XXI, Instituto Mexicano del Seguro Social, Medical Research Unit on Nephrological Diseases, Mexico City, Mexico
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Acree L, Day T, Groves MW, Waller JL, Bollag WB, Tran SY, Padala S, Baer SL. Deep neck space infections in end-stage renal disease patients: Prevalence and mortality. J Investig Med 2024; 72:220-232. [PMID: 38102746 DOI: 10.1177/10815589231222198] [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: 12/17/2023]
Abstract
Deep neck space infections (DNSI) are severe infections within the layers of neck fascia that are known to be associated with underlying immunocompromised states. Although uremia associated with kidney disease is known to cause immune system dysfunction, DNSI in patients with kidney disease has been poorly studied. This study investigated the prevalence of DNSI and the associated risk of mortality within the United States end-stage renal disease (ESRD) population, using a retrospective cohort study design and the United States Renal Data System database of patients (ages 18-100) who initiated dialysis therapy between 2005 and 2019. International Classification of Disease-9 and -10 codes were used to identify the diagnosis of DNSI and comorbid conditions. Of the 705,891 included patients, 2.2% had a diagnosis of DNSI. Variables associated with increased risk of DNSI were female sex, black compared to white race, catheter, or graft compared to arteriovenous fistula (AVF) access, autoimmune disease, chronic tonsillitis, diagnoses in the Charlson Comorbidity Index (CCI), tobacco use, and alcohol dependence. DNSI diagnosis was an independent risk factor for mortality, which was also associated with other comorbidity factors such as older age, catheter or graft compared to AVF access, comorbidities in the CCI, tobacco use, and alcohol dependence. Because of the increased mortality risk of DSNI in the ESRD population, health professionals should encourage good oral hygiene practices and smoking cessation, and they should closely monitor these patients to reduce poor outcomes.
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Affiliation(s)
- Lillian Acree
- Department of Medicine Augusta University, Augusta, GA, USA
| | - Tyler Day
- Department of Dentistry, Dental College of Georgia, Augusta University, Augusta, GA, USA
| | - Michael W Groves
- Department of Otolaryngology - Head and Neck Surgery, Augusta University, Augusta, GA, USA
| | - Jennifer L Waller
- Department of Population Health Sciences, Augusta University, Augusta, GA, USA
| | - Wendy B Bollag
- Department of Medicine Augusta University, Augusta, GA, USA
- Departments of Physiology, Augusta University, Augusta, GA, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Sarah Y Tran
- Department of Medicine Augusta University, Augusta, GA, USA
| | - Sandeep Padala
- Department of Medicine Augusta University, Augusta, GA, USA
| | - Stephanie L Baer
- Department of Medicine Augusta University, Augusta, GA, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
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Nie W, Du L, Chen G, Zheng Y, Yang X, Li B, Zhang W, Zheng J. Ultrasound-guided puncture drainage versus surgical incision drainage for deep neck space abscesses: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2024; 14:e077631. [PMID: 38176871 PMCID: PMC10773404 DOI: 10.1136/bmjopen-2023-077631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION Deep neck space abscesses (DNAs) are serious surgical emergencies, associated with life-threatening complications. Surgical incision and drainage combined with antibiotics is the main treatment for DNAs, but drawbacks still exist. Ultrasound-guided puncture drainage is an alternative treatment for some DNAs with limited clinical evidence. Hence, the optimal drainage technique for the treatment of DNAs remains unclear. Therefore, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of ultrasound-guided puncture drainage for DNAs. METHODS AND ANALYSIS PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang database, VIP database and trial registry databases will be searched from inception to September 2023 to identify randomised controlled trials of patients diagnosed with DNAs accepting ultrasound-guided puncture drainage. The primary outcome will be the length of hospital stay. The secondary outcomes will be the cure rate, incidence of retreatment, complications and overall cost to the healthcare system. Fixed-effects or random-effects model will be used according to the statistical heterogeneity. Mean differences or standardised mean differences with 95% CIs for continuous data and risk ratio (RR) with 95% CIs for dichotomous data. The Cochrane risk-of-bias tool 2, Grading of Recommendations Assessment, Development and Evaluation (GRADE) and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias. ETHICS AND DISSEMINATION Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42023441031.
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Affiliation(s)
- Wei Nie
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Du
- Department of Anesthesiology, Sichuan Cancer Hospital and Research Institute, Chengdu, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yongbo Zheng
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xibiao Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bo Li
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jianqiao Zheng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Loperfido A, Stasolla A, Giorgione C, Mammarella F, Celebrini A, Acquaviva G, Bellocchi G. Management of Deep Neck Space Infections: A Large Tertiary Center Experience. Cureus 2023; 15:e34974. [PMID: 36938157 PMCID: PMC10019553 DOI: 10.7759/cureus.34974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Deep neck space infections (DNIs) represent serious bacterial infections affecting the deep cervical space and fascial planes of the neck. This study aims to describe our clinical and surgical experience in the management of DNIs, emphasizing the importance of appropriate imaging in the diagnostic setting and the role of the multidisciplinary approach according to the severity of the infection. METHODS In this retrospective study, we describe 85 patients affected by DNIs coming to the Otolaryngology department observation from the Emergency Room of San Camillo Forlanini Hospital in Rome from January 2006 to December 2021 and treated both by pharmacological and surgical therapy. RESULTS 54 patients (64%) were male, and 31 (36%) were female, with a mean age of 50.5 years. The most common cause of DNI was odontogenic, accounting for 70% of all collected cases. In 68 patients (80% of all cases), the surgical approach consisted of an extended unilateral cervicotomy, whereas in 17 patients (20% of all cases), a bilateral cervicotomy was performed. Surgical revision was required in 15 cases (18%). A tracheostomy was necessary in seven cases. The overall survival rate was 96.5%. CONCLUSIONS DNI represents a serious and life-threatening condition, remaining a constant challenge for the head and neck surgeon. Contrast-enhanced computed tomography is critical for therapeutic planning, which requires both a surgical approach and antibiotic therapy. Surgical treatment should be performed as soon as possible. In severe cases, the multidisciplinary approach is advisable.
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Hajare PS, Bellad SA, Anand A, Narahari S, Jadhav AV. Disparate Presentations of Retropharyngeal Abscess: An Experience From a Tertiary Care Centre. Indian J Otolaryngol Head Neck Surg 2022; 74:5984-5989. [PMID: 36742485 PMCID: PMC9895137 DOI: 10.1007/s12070-021-02655-0] [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: 04/13/2021] [Accepted: 05/17/2021] [Indexed: 02/07/2023] Open
Abstract
To discuss the varied presentations, diagnosis, and prompt management of retropharyngeal abscess for academic importance. A retrospective study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery in Belagavi district of Karnataka. Six cases of varied age group with diagnosis of retropharyngeal abscess were studied during two-year period from January 2019 to January 2021. Thorough assessment of all cases was done which included symptoms at the time of presentation, clinical examination findings, imaging studies and laboratory results, medical and surgical interventions. Six patients (4 males, 2 females) were diagnosed as having Retropharyngeal abscess. Youngest age of presentation was 2 month infant. The most common symptoms at presentation included fever and odynophagia seen in all six patients. The clinical examination revealed bulge in posterior pharyngeal wall in all cases, cervical lymphadenopathy in one case, drooling of saliva in three and stridor in one patient, diffuse neck swelling in two ptatients, and trismus in two patients. Contrast Enhanced Computerized Tomographic (CECT) scanning was performed in five patients and one patient underwent Magnetic Resonance Imaging (MRI). The abscess was surgically drained in all patients and received intravenous antibiotics after which there was significant improvement. Retropharyngeal space infection if left untreated, they carry the potential to cause life-threatening complications and death. Although with availability of broad-spectrum antibiotics, the mortality rate is low, appropriate and successful management requires a thorough understanding of the anatomy of the neck, knowledge of usual causative organisms and appropriate medical and surgical management.
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Affiliation(s)
- Priti S. Hajare
- Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka India
| | - Shama A. Bellad
- Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka India
| | - Anshika Anand
- Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka India
| | - Sindhu Narahari
- Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka India
| | - Ajinkya V. Jadhav
- Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka India
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Doya L, Doya L, Ghanem A. Salmonella typhi: a rare cause of neck abscess. Oxf Med Case Reports 2022; 2022:omac120. [DOI: 10.1093/omcr/omac120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/25/2022] [Accepted: 09/20/2022] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT
Salmonella typhi neck abscess represents a rare cause of focal salmonellosis. Most of the cases in the literature reviews were reported in immunosuppression adults; just two of them were in children. Herein we report a case of 7-year old healthy girl with a neck abscess caused by S. typhi. The patient was diagnosed according to serological and radiological findings. Incision and drainage of the abscess accompanied by broad-spectrum antibiotics were performed for treatments. S. typhi should be kept in mind as a cause of neck abscesses.
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Affiliation(s)
- Leen Doya
- Tishreen University Department of pediatrics, faculty of medicine, , Lattakia, Syria
| | - Lama Doya
- Tishreen University Hospital Department of Laboratory, , Faculty of Medicine, Lattakia, Syria
| | - Abdulmoniem Ghanem
- Tishreen University Department of pediatrics, faculty of medicine, , Lattakia, Syria
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Cavernous Sinus Involvement and Near Miss Mediastinitis following Mandibular Tooth Infection Treated during the COVID-19 Pandemic: Clinical Diagnosis and Treatment. Case Rep Dent 2022; 2022:8650099. [PMID: 35865553 PMCID: PMC9296300 DOI: 10.1155/2022/8650099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/03/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Odontogenic infections represent a frequent condition that in some cases, if not treated promptly, can spread quickly to the rest of the body and turn into life-threatening infections. In this work, the case is reported of a 59-year-old woman, diabetic and overweight, who presented to the Odontostomatology and Otolaryngology Section of the Policlinic of Bari with mandibular tooth infection that had developed into a deep neck space infection leading to the involvement of cavernous sinuses and near mediastinum. The diagnosis, the surgical drainage of the phlegmon and removal of infection foci, appropriate control of the airways, and a correct antibiotic therapy made it possible to avoid a potentially fatal condition. Prompt management and early diagnosis of deep space neck infections, such as phlegmon and/or necrotizing fasciitis, with the auxilium of CT scans and tools such as LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), NLR (Neutrophil-to-Lymphocyte Ratio), and LRINECxNLR scores (Laboratory Risk Indicator for Necrotizing Fasciitis and Neutrophil to Lymphocyte Ratio), are advised to evade delays and complications that could potentially worsen the patient’s outcome.
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Shi L, Wang L, Cui Q. The clinical effects of high-quality nursing interventions after a diagnosis of upper gastrointestinal bulging lesions with mEUS. Am J Transl Res 2021; 13:9655-9662. [PMID: 34540092 PMCID: PMC8430168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/25/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE To study and analyze the clinical effectiveness of miniprobe endoscopic ultrasonography (mEUS) in upper gastrointestinal eminence lesions caused by tumors. METHODS We recruited 210 patients admitted to our hospital from March 2018 to June 2020 as the study cohort, all of whom were diagnosed with upper gastrointestinal eminence lesions caused by tumors using routine endoscopies. To further clarify the type of disease, mEUS was used in all the patients along with high-quality nursing interventions. The results and the patients' anxiety and depression levels before and after the examinations were analyzed. RESULTS After their admission, the patients' SAS and SDS scores were high. Their scores decreased significantly after the nursing (P < 0.05). There were 75 patients with esophageal disease diagnosed among the 223 patients with upper gastrointestinal eminence lesions, accounting for 33.63% of the total. 114 patients with gastric disease were found, accounting for 51.12%; and there were 5 cases of cardia disease, accounting for 2.24% of the total. Another 29 cases of duodenal disease were detected, accounting for 13%. According to the determinations of the pathological types, the main disease types were stromal tumors and leiomyomas, with 79 cases (35.43%) and 53 cases (23.77%). The mEUS examinations in the 210 patients detected a total of 223 eminence lesions. In total, the 213 lesions were consistent with the pathological examinations, and the total diagnosis coincidence rate was 95.52% (213/223). CONCLUSION mEUS examinations combined with nursing care applied to tumor-induced upper gastrointestinal swelling lesions can eliminate patient tension and anxiety and other unhealthy emotions and can improve patient compliance with the examinations. mEUS examinations can show the hierarchical structure of the upper gastrointestinal wall and accurately locate any upper gastrointestinal swelling lesions, effectively clarify the nature of the disease, and have a guiding significance for the differential diagnosis and treatment of the disease.
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Affiliation(s)
- Lianfang Shi
- Disinfection and Supply Center of Jinan Third People’s HospitalJinan, China
| | - Lijuan Wang
- Department of Rehabilitation, Pingyi People’s HospitalPingyi, Shandong Province, China
| | - Qinhao Cui
- Ultrasound Department, Linyi People HospitalLinyi, China
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Gu X, Chen W, Yuan K, Tan J, Sun S. The efficacy of artificial dermis combined with continuous vacuum sealing drainage in deep neck multiple spaces infection treatment. Medicine (Baltimore) 2021; 100:e24367. [PMID: 33592884 PMCID: PMC7870261 DOI: 10.1097/md.0000000000024367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 12/18/2020] [Indexed: 01/05/2023] Open
Abstract
Deep neck abscesses are dangerous. Artificial dermis combined with seal negative pressure drainage is a new technique for treating refractory wounds.To compare the efficacy of vacuum sealing drainage (VSD) with that of traditional incision drainage approaches for treating deep neck multiple spaces infections.This retrospective analysis includes patient data from our hospital collected from January 2010 to March 2020. A total of 20 cases were identified. Based on the treatment methods, the patients were divided into the VSD group and the traditional group. Inflammation indicators (white blood count, WBC), duration of antibiotic use, hospitalization time, doctors' workload (frequency of dressing changes) and treatment cost were analyzed and compared between the two groups.Of the 20 patients, 11 patients underwent treatment with VSD, while the other 9 underwent traditional treatment. All patients were cured after treatment. Compared with the traditional group, the VSD group had a slower decline in the inflammation index, shorter duration of antibiotic use, shorter hospital stay, and lower doctor workloads (P < .001). There was no significant difference in treatment cost between the two groups (P > .05).VSD technology can markedly improve the therapeutic effect of deep neck multiple spaces infection. This treatment method can be used to rapidly control infections and is valuable in the clinic (P > .05).
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Suehara AB, Rodrigues AAN, Kavabata NK, Menezes MB, Ramos EDEA, Kawamukai JN, GonÇalves AJ. Predictive factors of lethality and complications of deep fascial space infections of the neck. Rev Col Bras Cir 2020; 47:e20202524. [PMID: 32901705 DOI: 10.1590/0100-6991e-20202524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to identify predictive factors for lethality and complications of deep fascial space infections of the neck (DFSIN), establishing an early and aggressive treatment in the neck before the progression to descending mediastinitis. METHODS we retrospectively analyzed 133 cases of DFSIN treated at Discipline of Head and Neck Surgery of the Medicine School of Santa Casa de Misericórdia de São Paulo. We accessed demographic characteristics, associated diseases, clinical presentation, laboratorial tests, length of hospital stay, number of involved anatomic neck spaces, intra-operative and microbiology findings. We analyzed these data using logistic regression to predict DFSIN lethality and life threatening complications (mediastinitis, septic shock, pneumonia, pleural empyema, skin necrosis). RESULTS lethality and complication ratios were 9% and 50.3%, respectively. The logistic regression model showed that patients with septic shock were more likely to have progression to death (p < 0.001) and, the presence of more than two involved neck spaces (p < 0.001) and older individuals (p = 0.017) were more likely to have complicated deep neck infections. Descending necrotizing mediatinitis increased the lethality ratio by 50%, and was associated to necrotizing fasciitis (p=0.012) and pleural empyema (p<0.001). CONCLUSION septic shock is a lethal predictive factor and age as well as more than two involved neck spaces are the predictive factors for complications. Necrotizing fasciitis is an important factor for complications and death. Therefore, its surgical treatment must be more aggressive. Descending mediastinitis has a high lethal rate and the successful treatment is based on early diagnosis and aggressive surgical approach.
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Affiliation(s)
- Alexandre BabÁ Suehara
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia de Cabeça e Pescoço - São Paulo - SP - Brasil
| | | | - Norberto Kodi Kavabata
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia de Cabeça e Pescoço - São Paulo - SP - Brasil
| | - Marcelo Benedito Menezes
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia de Cabeça e Pescoço - São Paulo - SP - Brasil
| | - Evelyn DE Almeida Ramos
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, acadêmica - São Paulo - SP - Brasil
| | | | - Antonio JosÉ GonÇalves
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Disciplina de Cirurgia de Cabeça e Pescoço - São Paulo - SP - Brasil
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