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Bosschieter PFN, Liu SYC, Chao PY, Chen A, Kushida CA. Using standardized ultrasound imaging to correlate OSA severity with tongue morphology. Sleep Med 2024; 120:15-21. [PMID: 38843751 DOI: 10.1016/j.sleep.2024.05.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Ultrasound imaging has been explored as a potential diagnostic tool for obstructive sleep apnea (OSA); we reported backscatter ultrasound imaging (BUI) of the tongue correlates with OSA severity in adults. We focus on anatomical features of the tongue using standardized ultrasonography and hypothesize that differences in morphology correlate with OSA severity. METHODS This prospective study was IRB approved (53,172) and conducted at Stanford University Sleep Surgery Clinic. Patients ≥18 years with polysomnography (PSG) underwent a standardized submental ultrasound scan using a laser alignment tool to observe the upper airway in supine position during tidal respiration. Images acquired from this scan were divided into 4 equiangular regions (A-D). RESULTS A total of 144 patients (30 women) July 2020-December 2022 were included with mean age 41.6 years (±12.9 SD), BMI 27.2 kg/m2(±4.7 SD), and AHI 19.7 (±20.0 SD). Moderate-to-severe OSA patients had significantly narrower airspace at regions A, B and C with p-values ranging from <0.0001 to 0.0003. These patients had a significantly wider (p = 0.0021-0.0045 for regions A, B and C) tongue and thicker (p = 0.0403 for region B) deep tissue. The predictive model to assess the risk of moderate-to-severe OSA achieved an area under the receiver operating characteristic curve of 0.839 (95 % CI: 0.769 to 0.895). CONCLUSIONS With standardized, computerized ultrasound imaging of the shape and configuration of the tongue, we identified regions that correlated well with OSA severity. Further research is needed to determine the clinical implications of such pathophysiological findings.
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Affiliation(s)
- Pien F N Bosschieter
- Department of Otolaryngology, head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Stanley Y C Liu
- Department of Otolaryngology, head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Argon Chen
- Institute of Industrial Engineering, National Taiwan University, Taipei, Taiwan.
| | - Clete A Kushida
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
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Ontimare Manlises C, Chen JW, Huang CC. A gated recurrent unit model based on ultrasound images of dynamic tongue movement for determining the severity of obstructive sleep apnea. ULTRASONICS 2024; 141:107320. [PMID: 38678641 DOI: 10.1016/j.ultras.2024.107320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
Obstructive sleep apnea (OSA) presents as a respiratory disorder characterized by recurrent upper pharyngeal airway collapse during sleep. Dynamic tongue movement (DTM) analysis emerges as a promising avenue for elucidating the pathophysiological underpinnings of OSA, thereby facilitating its diagnosis. Recent endeavors have utilized artificial intelligence techniques to categorize OSA severity leveraging electrocardiography and blood oxygen saturation data. Nonetheless, the integration of ultrasound (US) imaging of the tongue remains largely untapped in the development of machine learning models aimed at determining the severity of OSA. This study endeavors to bridge this gap by capturing US images of DTM dynamics during wakefulness, encompassing transitions from normal breathing (NB) to the performance of the Müller maneuver (MM) in a cohort of 53 patients. Leveraging the modified optical flow method (MOFM), the trajectories of patients' DTM were tracked, facililtating the extraction of 27 parameters vital for model training. These parameters encompassed nine-point lateral movement, nine-point axial movement, and nine-point total displacement of the tongue, resulting in a dataset of 186,030 samples. The gated recurrent unit (GRU) method, renowned for its efficacy in motion tracking, was employed for model development in this study. Validation of the developed model was conducted via stratified k-fold cross-validation (SCV). The systems' overall performance in classifying OSA severity, as quantified by mean accuracy (MA), yielded a value of 43.49%. This pilot investigation marks an exploratory endeavor into the utilization of artificial intelligence for the classification of OSA severity based on US images and dynamic movement patterns. This novel model holds potential to assist clinicians in categorizing OSA severity and guiding the selection of pertinent treatment modalities tailored to the individual needs of patients afflicted with OSA.
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Affiliation(s)
- Cyrel Ontimare Manlises
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; School of Electrical, Electronics, and Computer Engineering, Mapua University, Manila 1002 Philippines
| | - Jeng-Wen Chen
- Department of Otolaryngology-Head and Neck Surgery, Cardinal Tien Hospital and Schhool of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Otolaryngology-Head and Neck Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Chung Huang
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
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Rodriguez Alcala C, Rodriguez Alcala L, Ignacio Garcia JM, Plaza G, Baptista P, Lujan G, Mazzei P, Ibañez-Rodriguez JA, O’Connor-Reina C. Use of Ultrasound to Verify the Impact of Telemedicine Myofunctional Therapy on Sleep Apnea Syndrome: Study Protocol Proposal. Life (Basel) 2024; 14:197. [PMID: 38398705 PMCID: PMC10890081 DOI: 10.3390/life14020197] [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: 12/13/2023] [Revised: 01/03/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
The anatomy of the upper airways influences the risk of obstructive sleep apnea (OSA). The size of soft tissue structures, such as the tongue, soft palate, and lateral walls of the pharynx, contributes to the pathogenesis of OSA. New lines of treatment for sleep apnea, such as myofunctional therapy (MT), aim to strengthen the oropharyngeal musculature to improve the defining parameters of apnea. The present protocol uses ultrasound imaging to measure the size of the lingual musculature non-invasively and cost-effectively and evaluates the changes in its morphology. Eligible patients include those with OSA who have undergone submental cervical ultrasound and drug-induced sleep endoscopy before starting MT with the AirwayGym app. Follow-up evaluations are conducted at 3 months after beginning treatment. Patients diagnosed with OSA via questionnaires and polysomnography or respiratory polygraphy are evaluated anatomically and functionally using the Iowa Oral Performance Instrument, a tongue digital spoon, somnoscopy, and submental cervical ultrasound to assess their responses to the AirwayGym app. The lingual thickness (mm) and volume (cm3) and the distance between both lingual arteries (mm) are measured. The AirwayGym app helps users and therapists monitor the patient performance of MT. Incorporating submental ultrasound can be a useful non-invasive tool to evaluate OSA and MT.
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Affiliation(s)
| | - Laura Rodriguez Alcala
- Otorhinolaryngology Department, Hospital Quironsalud Marbella, 29680 Marbella, Spain; (L.R.A.); (P.M.); (J.A.I.-R.)
- Otorhinolaryngology Department, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
| | | | - Guillermo Plaza
- Otorhinolaryngology Department, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28943 Madrid, Spain;
- Otorhinolaryngology Department, Hospital Sanitas la Zarzuela, 28023 Madrid, Spain
| | - Peter Baptista
- Otorhinolaryngology Department, Clínica Universitaria de Navarra, 31008 Pamplona, Spain
| | - Guillermina Lujan
- Otorhinolaryngology Department, Hospital Quironsalud Marbella, 29680 Marbella, Spain; (L.R.A.); (P.M.); (J.A.I.-R.)
- Otorhinolaryngology Department, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
| | - Paula Mazzei
- Otorhinolaryngology Department, Hospital Quironsalud Marbella, 29680 Marbella, Spain; (L.R.A.); (P.M.); (J.A.I.-R.)
- Otorhinolaryngology Department, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
| | - Juan Antonio Ibañez-Rodriguez
- Otorhinolaryngology Department, Hospital Quironsalud Marbella, 29680 Marbella, Spain; (L.R.A.); (P.M.); (J.A.I.-R.)
- Otorhinolaryngology Department, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
| | - Carlos O’Connor-Reina
- Otorhinolaryngology Department, Hospital Quironsalud Marbella, 29680 Marbella, Spain; (L.R.A.); (P.M.); (J.A.I.-R.)
- Otorhinolaryngology Department, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
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Kalkanis A, Testelmans D, Papadopoulos D, Van den Driessche A, Buyse B. Insights into the Use of Point-of-Care Ultrasound for Diagnosing Obstructive Sleep Apnea. Diagnostics (Basel) 2023; 13:2262. [PMID: 37443656 DOI: 10.3390/diagnostics13132262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/06/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a sleeping disorder caused by complete or partial disturbance of breathing during the night. Existing screening methods include questionnaire-based evaluations which are time-consuming, vary in specificity, and are not globally adopted. Point-of-care ultrasound (PoCUS), on the other hand, is a painless, inexpensive, portable, and useful tool that has already been introduced for the evaluation of upper airways by anesthetists. PoCUS could also serve as a potential screening tool for the diagnosis of OSA by measuring different airway parameters, including retropalatal pharynx transverse diameter, tongue base thickness, distance between lingual arteries, lateral parapharyngeal wall thickness, palatine tonsil volume, and some non-airway parameters like carotid intima-media thickness, mesenteric fat thickness, and diaphragm characteristics. This study reviewed previously reported studies to highlight the importance of PoCUS as a potential screening tool for OSA.
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Affiliation(s)
- Alexandros Kalkanis
- Department of Respiratory Diseases, University Hospitals Leuven, KU Leuven, Campus Gasthuisberg, 3000 Leuven, Belgium
| | - Dries Testelmans
- Department of Respiratory Diseases, University Hospitals Leuven, KU Leuven, Campus Gasthuisberg, 3000 Leuven, Belgium
| | - Dimitrios Papadopoulos
- Department of Respiratory Diseases, University Hospitals Leuven, KU Leuven, Campus Gasthuisberg, 3000 Leuven, Belgium
| | | | - Bertien Buyse
- Department of Respiratory Diseases, University Hospitals Leuven, KU Leuven, Campus Gasthuisberg, 3000 Leuven, Belgium
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Lun HM, Liu RC, Hu Q, Liu YL, Wei LS, Wu D, Wang F, Zhu SY. Potential ultrasonic anatomical markers of obstructive sleep apnoea-hypopnoea syndrome. Clin Radiol 2023; 78:e137-e142. [PMID: 36344281 DOI: 10.1016/j.crad.2022.09.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
AIM To investigate the potential value of ultrasonography in evaluating the pathophysiology of obstructive sleep apnoea-hypopnoea syndrome (OSAHS) by assessing the correlation of critical ultrasonic anatomical characteristics of the oropharynx with the severity of OSAHS. MATERIALS AND METHODS One hundred and seventy-one patients with suspected OSAHS underwent oropharyngeal sonographic examination and overnight polysomnography. Ultrasonic measurement was compared with the apnoea-hypopnoea index (AHI) and other parameters. An ordinal logistic regression model was used to identify potential ultrasonic anatomical markers for OSAHS. RESULTS The AHI was significantly correlated with lingual height (r=0.40, p<0.01), maximal width of the tongue (r=0.35, p<0.01), and distance from the symphysis of the mandible to the hyoid bone (M-HB) (r=0.24, p<0.01). A positive relationship between Friedman tongue position (FTP) grades and lingual height (r=0.24, p<0.01), between FTP grades and maximal width of the tongue (r=0.23, p<0.01), and between FTP grades and width of tongue base (TB; r=0.17, p<0.05) was found. Multivariate models adjusted for sex, age, and body mass index (BMI) revealed that lingual height (95% confidence interval [CI]: 1.04-1.24; p=0.004) is independently associated with a higher risk for the severity of OSAHS. CONCLUSIONS Ultrasonography may be a potential imaging method for providing additional useful information about the correlation between ultrasound findings and the severity of OSAHS. Lingual height could be considered an ultrasonic anatomical marker for determining the severity of OSAHS patients independent of age, sex, and BMI.
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Affiliation(s)
- H-M Lun
- Department of Medical Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, China; Department of Ultrasound, People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, Nanning, Guangxi, 530021, China
| | - R-C Liu
- Department of Medical Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Q Hu
- Department of Ultrasound, People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, Nanning, Guangxi, 530021, China
| | - Y-L Liu
- Department of Medical Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - L-S Wei
- Department of Ultrasound, People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, Nanning, Guangxi, 530021, China
| | - D Wu
- Department of Pediatrics, People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, Nanning, Guangxi, 530021, China
| | - F Wang
- Department of Gastroenterology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - S-Y Zhu
- Department of Medical Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, China.
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Bordoni B, Escher AR, Toccafondi A, Mapelli L, Banfi P. Obstructive Sleep Apnea and Role of the Diaphragm. Cureus 2022; 14:e29004. [PMID: 36159353 PMCID: PMC9495286 DOI: 10.7759/cureus.29004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 11/07/2022] Open
Abstract
Obstructive sleep apnea (OSA) causes multiple local and systemic pathophysiological consequences, which lead to an increase in morbidity and mortality in patients suffering from this disorder. OSA presents with various nocturnal events of apnoeas or hypopneas and with sub-clinical airflow limitations during wakefulness. OSA involves a large percentage of the population, particularly men, but the estimate of OSA patients could be much broader than data from the literature. Most of the research carried out in the muscle field is to understand the causes of the presence of chronic nocturnal desaturation and focus on the genioglossus muscle and other muscles related to dilating the upper airways. Sparse research has been published regarding the diaphragm muscle, which is the main muscle structure to insufflate air into the airways. The article reviews the functional anatomy of the muscles used to open the upper respiratory tract and the non-physiological adaptation that follows in the presence of OSA, as well as the functional anatomy and pathological adaptive aspects of the diaphragm muscle. The intent of the text is to highlight the disparity of clinical interest between the dilator muscles and the diaphragm, trying to stimulate a broader approach to patient evaluation.
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Yu JL, Wiemken A, Schultz SM, Keenan BT, Sehgal CM, Schwab RJ. A comparison of ultrasound echo intensity to magnetic resonance imaging as a metric for tongue fat evaluation. Sleep 2021; 45:6486313. [PMID: 34963001 PMCID: PMC8842321 DOI: 10.1093/sleep/zsab295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/15/2021] [Indexed: 12/30/2022] Open
Abstract
STUDY OBJECTIVES Tongue fat is associated with obstructive sleep apnea (OSA). Magnetic resonance imaging (MRI) is the standard for quantifying tongue fat. Ultrasound echo intensity has been shown to correlate to the fat content in skeletal muscles but has yet to be studied in the tongue. The objective of this study is to evaluate the relationship between ultrasound echo intensity and tongue fat. METHODS Ultrasound coronal cross-sections of ex-vivo cow tongues were recorded at baseline and following three 1 mL serial injections of fat into the tongue. In humans, adults with and without OSA had submental ultrasound coronal cross-sections of their posterior tongue. The average echo intensity of the tongues (cow/human) was calculated in ImageJ software. Head and neck MRIs were obtained on human subjects to quantify tongue fat volume. Echo intensity was compared to injected fat volume or MRI-derived tongue fat percentage. RESULTS Echo intensity in cow tongues showed a positive correlation to injected fat volume (rho = 0.93, p < .001). In human subjects, echo intensity of the tongue base strongly correlated with MRI-calculated fat percentage for both the posterior tongue (rho = 0.95, p < .001) and entire tongue (rho = 0.62, p < .001). Larger tongue fat percentages (rho = 0.38, p = .001) and higher echo intensity (rho = 0.27, p = .024) were associated with more severe apnea-hypopnea index, adjusted for age, body mass index, sex, and race. CONCLUSIONS Ultrasound echo intensity is a viable surrogate measure for tongue fat volume and may provide a convenient modality to characterize tongue fat in OSA.
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Affiliation(s)
- Jason L Yu
- Department of Otorhinolaryngology—Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Wiemken
- Department of Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan M Schultz
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan T Keenan
- Department of Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chandra M Sehgal
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard J Schwab
- Department of Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Corresponding author. Richard J. Schwab, Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, 3624 Market St., Suite 201, Philadelphia, PA 19104, USA.
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Arens P, Fischer T, Dommerich S, Olze H, Lerchbaumer MH. Ultrasound Shear Wave Elastography of the Tongue during Selective Hypoglossal Nerve Stimulation in Patients with Obstructive Sleep Apnea Syndrome. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2869-2879. [PMID: 34303559 DOI: 10.1016/j.ultrasmedbio.2021.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/01/2021] [Accepted: 06/16/2021] [Indexed: 06/13/2023]
Abstract
Currently, there is no established technique to directly measure extrinsic tongue muscle activation during selective hypoglossal stimulation therapy (sHNS) in patients with obstructive sleep apnea syndrome (OSAS) in a simple, non-invasive clinical setting. Ultrasound shear-wave elastography (US-SWE) enables quantitative measurement of tissue stiffness. We investigated whether US-SWE is able to detect changes in muscle stiffness of the tongue during sHNS. Patients with OSAS treated with sHNS were prospectively enrolled. A standardized US-SWE protocol was used to selectively measure tissue stiffness of the geniohyoid muscle (GH) and genioglossus (GG) muscles on the side of stimulator implantation (sGH, sGG) and on the contralateral side (nGH, nGG) without and with sHNS. Eighteen patients were included (median age = 62 years, interquartile range: 56-65, 83.3% male). Median shear-wave velocity (SWV) increased during contraction with each patient's clinically prescribed therapeutic regimen in the sGH (+19%, p = 0.020) and sGG (+81%, p < 0.001) and decreased during contraction in the nGH (-8%, p = 0.107) and nGG (-8%, p = 0.396). Differences in SWV during contraction were significant only on the side of stimulation (sGG +81%, sGH +19%). SWE measurements had excellent reliability as reflected by a Cronbach α value ≥0.9 for all target muscles pre- and post-contraction and an item-total correlation ≥0.5. US-SWE allows reliable measurement of SWV as an indicator of muscle stiffness of extrinsic tongue muscles. This non-invasive method provides new possibilities to distinguish and characterize responders from non-responders in hypoglossal stimulation therapy. Compared with the regular visual assessment of tongue movement, US-SWE of individual muscle groups provides a new non-invasive imaging tool in patients with OSAS.
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Affiliation(s)
- Philipp Arens
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Otorhinolaryngology, Berlin Institute of Health, Berlin, Germany.
| | - Thomas Fischer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Radiology, Berlin Institute of Health, Berlin, Germany
| | - Steffen Dommerich
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Otorhinolaryngology, Berlin Institute of Health, Berlin, Germany
| | - Heidi Olze
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Otorhinolaryngology, Berlin Institute of Health, Berlin, Germany
| | - Markus Herbert Lerchbaumer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Radiology, Berlin Institute of Health, Berlin, Germany
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