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Tzelnick S, Alkan U, Leshno M, Hwang P, Soudry E. Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery. Cochrane Database Syst Rev 2018; 11:CD011988. [PMID: 30407624 PMCID: PMC6517168 DOI: 10.1002/14651858.cd011988.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Endoscopic sinus surgery (ESS) is often recommended for symptomatic patients with recurrent acute or chronic rhinosinusitis who have failed conservative treatment. Postoperative care has been felt to be critical for both maintaining the surgical patency of the operated sinuses and improving patient symptoms. Debridement of the sinonasal cavities is one such postoperative care measure that has frequently been studied in the literature, often with conflicting conclusions. OBJECTIVES To assess the effects of postoperative sinonasal debridement versus no debridement following endoscopic sinus surgery. SEARCH METHODS The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); PubMed; EMBASE; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 May 2018. SELECTION CRITERIA Randomised controlled trials comparing postoperative nasal debridement versus no debridement in adult patients with recurrent acute or chronic rhinosinusitis undergoing endoscopic sinus surgery. We included studies in which the patients acted as self-controls (i.e. one side of the nose underwent debridement and the other side did not) only for the secondary endoscopy outcomes. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were: health-related quality of life, disease severity (patient-reported symptom scores) and significant adverse effects (bleeding requiring intervention, severe pain, iatrogenic injury). Secondary outcomes were: postoperative endoscopic appearance of the sinonasal surgical cavities (endoscopic scores), recorded use of postoperative medical treatment and rate of revision surgery. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included four studies (152 participants), with a follow-up duration ranging from three months to 12 months. In two studies patients acted as self-controls, i.e. one side of the nose underwent debridement and the other side did not ('split-nose' studies). The risk of bias in all studies was high, mostly due to the inability to blind the patients to the debridement procedure.Primary outcomesDisease-specific health-related quality of life scoresOnly one study (58 participants) provided data for disease-specific health-related quality of life. At six months follow-up, lower disease-specific health-related quality of life scores, measured using the Sino-Nasal Outcome Test-22 (SNOT-22, range 0 to 110), were noted in the debridement group but the difference was not statistically significant (9.7 in the debridement group versus 10.3 in the control group, P = 0.47) (low-quality evidence).Disease severity (patient-reported symptom score)Only one study (60 participants) provided data for disease severity measured by visual analogue scale (VAS) score. No significant differences in total symptom score were observed between groups postoperatively (low-quality evidence).Significant adverse effectsSignificant adverse effects related to the debridement procedure were not reported in any of the included studies, however it is not clear whether data regarding adverse effects were not collected or if none were indeed observed in any of the included studies.Secondary outcomesAll four studies assessed thepostoperative endoscopic appearance of the sinonasal cavities using the Lund-Kennedy score (range 0 to 10). A pooled analysis of endoscopic scores in the two non 'split-nose' studies revealed better endoscopic scores in the debridement group, however this was not a statistically significant difference (mean difference -0.31, 95% confidence interval (CI) -1.35 to 0.72; I² = 0%; two studies; 118 participants) (low-quality evidence). A sub-analysis of the adhesion formation component of the endoscopic score was available for all four studies and revealed a significantly lower adhesion rate in the debridement group (risk ratio 0.43, 95% CI 0.28 to 0.68; I² = 29%; four studies; 152 participants). Analysis of the number needed to treat to benefit revealed that for every three patients undergoing debridement, the endoscopic score would be decreased by one point in one patient. For every five patients undergoing debridement adhesion formation would be prevented in one patient.Use of postoperative medical treatment was reported in all studies, all of which recommended nasal douching. Steroids (systemic or nasal) were administered in two studies. However, the data were very limited and heterogeneous, therefore we could not analyse the impact of concomitant postoperative medical treatment.The rate of revision surgery was not reported in any of the included studies, however it is not clear whether these data were not recorded or if there were no revision surgeries in any of the included studies. AUTHORS' CONCLUSIONS We are uncertain about the effects of postoperative sinonasal debridement due to high risk of bias in the included studies and the low quality of the evidence. Sinonasal debridement may make little or no difference to disease-specific health-related quality of life or disease severity. Low-quality evidence suggests that postoperative debridement is associated with a significantly lower risk of adhesions at three months follow-up. Whether this has any impact on longer-term outcomes is unknown.
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Affiliation(s)
- Sharon Tzelnick
- Rabin Medical CenterDepartment of Otolaryngology ‐ Head and Neck SurgeryPetah TikvaIsrael
| | - Uri Alkan
- Rabin Medical CenterDepartment of Otolaryngology ‐ Head and Neck SurgeryPetah TikvaIsrael
| | - Moshe Leshno
- Tel Aviv UniversityTel Aviv University's Faculty of Management and Sackler Faculty of MedicineTel AvivIsrael
| | - Peter Hwang
- Stanford University School of MedicineDivision of Rhinology, Department of OtolaryngologyStanfordCaliforniaUSA
| | - Ethan Soudry
- Rabin Medical CenterDepartment of Otolaryngology ‐ Head and Neck SurgeryPetah TikvaIsrael
- Tel Aviv UniversitySackler Faculty of MedicineTel AvivIsrael
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Abstract
PURPOSE OF REVIEW Chronic rhinosinusitis with and without nasal polyps is a common disease affecting people all over the world. Functional endoscopic sinus surgery (FESS) has become the gold standard treatment for medically refractive disease. Postoperative care is recommended by international leaders as an important part of the patient's management. This article is a critical review and discussion focusing on postoperative care, which is based on expert opinion, clinical studies, randomized controlled trials and meta-analysis studies. RECENT FINDINGS Postoperative care including nasal rinsing, topical corticosteroids, antibiotics and avoidance of nasal packing are unanimously considered to be the cornerstone of best practice following FESS. However, the effectiveness of in-office nasal debridement is still under debate. SUMMARY There is a lack of consensus regarding the necessity of performing in-office nasal debridement and the majority of clinicians carry out their postoperative care according to experience and their own preference. This is often determined by the extent of surgery performed, the severity of the postoperative inflammation, as well as being dependent on the patient's discomfort, the time constraints associated with postoperative care and the costs associated with additional appointments. Ideally, nasal debridement should be performed by the operating surgeon under endoscopic control both gently and atraumatically.
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Stern-Shavit S, Nachalon Y, Leshno M, Soudry E. Middle meatal packing in endoscopic sinus surgery-to pack or not to pack?-a decision-analysis model. Laryngoscope 2017; 127:1506-1512. [PMID: 28449210 DOI: 10.1002/lary.26506] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 11/26/2016] [Accepted: 12/16/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Packing of the middle meatus and ethmoid cavities is a common practice in endoscopic sinus surgery (ESS), but its necessity recently has been challenged. The aim of this study was to formulate a decision-analysis model to determine the need for packing in ESS and identify variables affecting the decision. METHODS A systematic review of the literature was conducted for all randomized control trials comparing packing to no packing in ESS, and a decision-analysis model was generated. Probabilities and utilities were derived from the literature. Sensitivity analysis was used to determine which variables most affected the model. RESULTS No packing was associated with better expected utilities than packing. On sensitivity analysis, packing was preferred when the disutility of no packing outweighed the disutility of packing, and when the probability for synechiae was greater than 35% without packing or lower than 2% with packing. When the component of packing removal was subtracted from the overall disutility simulating absorbable packing, the results favored packing. CONCLUSION Our decision-analysis model indicates that middle meatal packing is not advantageous for patients undergoing ESS. Absorbable packing materials have a less adverse effect on quality of life than nonabsorbable materials. LEVEL OF EVIDENCE 1a. Laryngoscope, 127:1506-1512, 2017.
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Affiliation(s)
- Sagit Stern-Shavit
- Department of Otorhinolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Yuval Nachalon
- Department of Otorhinolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Moshe Leshno
- Sackler Faculty of Medicine, Tel Aviv, Israel.,Faculty of Management, Tel Aviv University, Tel Aviv, Israel
| | - Ethan Soudry
- Department of Otorhinolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv, Israel
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Endoscopic Endonasal Repair of Spontaneous and Traumatic Cerebrospinal Fluid Rhinorrhea: A Review and Local Experience. Neurosurg Clin N Am 2016; 26:333-48. [PMID: 26141354 DOI: 10.1016/j.nec.2015.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article presents an overview of endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea. In recent years, endoscopic repair has become the standard of care for managing this condition, because it gradually replaces the traditional open transcranial approach. Discussion includes the etiologic classification of CSF rhinorrhea, management paradigm for each category, diagnosis algorithm, comprehensive description of the surgical technique, and an updated review of the literature regarding the safety and efficacy of this procedure. In addition, the authors present their experience, including 2 surgical videos demonstrating endoscopic repair of CSF rhinorrhea in 2 distinct clinical scenarios.
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
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- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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Tzelnick S, Alkan U, Leshno M, Hwang P, Soudry E. Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery. Hippokratia 2016. [DOI: 10.1002/14651858.cd011988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sharon Tzelnick
- Rabin Medical Center; Department of Otolaryngology - Head and Neck Surgery; Petah Tikva Israel
| | - Uri Alkan
- Rabin Medical Center; Department of Otolaryngology - Head and Neck Surgery; Petah Tikva Israel
| | - Moshe Leshno
- Tel Aviv University; Tel Aviv University's Faculty of Management and Sackler Faculty of Medicine; Tel Aviv Israel
| | - Peter Hwang
- Stanford University School of Medicine; Division of Rhinology, Department of Otolaryngology; Stanford California USA
| | - Ethan Soudry
- Rabin Medical Center; Department of Otolaryngology - Head and Neck Surgery; Petah Tikva Israel
- Tel Aviv University; Sackler Faculty of Medicine; Tel Aviv Israel
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Dautremont JF, Rudmik L. When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery. Int Forum Allergy Rhinol 2015; 5:1095-103. [PMID: 26201538 DOI: 10.1002/alr.21601] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/05/2015] [Accepted: 06/18/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic sinus surgery (ESS) is considered a therapeutic option after failure of maximal medical therapy (MMT) for chronic rhinosinusitis (CRS). There is currently no consensus on the definition of MMT. The objective of this systematic review is to describe the various MMT criteria employed prior to considering ESS. METHODS A systematic review was performed using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were adults with CRS based on guideline diagnostic criteria, enrolled to undergo ESS, and study publication within the last 5 years (January 1, 2009, to December 30, 2014). Studies were excluded if the study population included non-CRS indications for ESS. Primary outcome was the MMT criteria employed prior to considering a patient a candidate for ESS. A subgroup analysis was performed based on polyp status. RESULTS Of 387 reviewed studies, 21% reported MMT criteria. When reported, criteria included topical nasal corticosteroids (91% of studies) for a mean of 8 ± 8 weeks, oral antibiotics (89%) for 23 ± 8 days, systemic corticosteroids (61%) for 18 ± 12 days, saline irrigations (39%), oral antihistamines (11%), oral mucolytics (10%), and topical/oral decongestants (10%). CONCLUSION A minority of studies report MMT criteria used as the indication for ESS. When reported, the majority included an 8-week course of topical intranasal corticosteroids and 3-week course of oral antibiotics. Use of systemic corticosteroids did not differ based on polyp status. Because of variation in current MMT criteria, there is a need to develop standardized indications for ESS that will work to improve the appropriateness of care for patients with.
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Affiliation(s)
- Jon F Dautremont
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Green R, Banigo A, Hathorn I. Postoperative nasal debridement following functional endoscopic sinus surgery, a systematic review of the literature. Clin Otolaryngol 2015; 40:2-8. [PMID: 25314101 DOI: 10.1111/coa.12330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic rhinosinusitis is a significant health problem, and the optimal postoperative treatment regime for patients post functional endoscopic sinus surgery has been a topic debated for years. OBJECTIVE OF REVIEW To systematically review and critically evaluate the evidence relating to postoperative debridement of the nasal cavity following functional endoscopic sinus surgery to guide best practice. SEARCH STRATEGY A search of the following databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, and Cochrane Central Register of Control Trials. Ovid Medline, EMBASE, Pubmed. The following key words were used: Postoperative, functional endoscopic sinus surgery, sinus surgery, debridement, follow-up, from 1970 to 2013. EVALUATION METHOD Two independent reviewers assessed the relevant articles using the consort guidance on systematic reviews Moher et al. BMJ 2010; 340: c869. RESULTS The best evidence available was 1B, with six Randomsied control trial (RCTs) identified. Four studies compared debridement against no debridement, and two looked at the frequency of the debridement. Cumulatively, results for 337 patients were included. Visual analogue scores were used in all studies. None of the results at the long-term follow-up showed any difference in sino-nasal outcome test scores or objective endoscopic scores. Four of the six studies demonstrated some benefit in symptom scores but only one in the long term. Two papers demonstrated the debridement group suffered more pain in the postoperative period. CONCLUSIONS Currently, there is no clear evidence for frequent postoperative debridement. Further well-designed RCTs are required to establish clear benefit, optimal frequency, extent and timing of debridement.
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Affiliation(s)
- R Green
- Department of ENT, Lauriston Building, Edinburgh, UK
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Varsak YK, Yuca K, Eryılmaz MA, Arbag H. Single seventh day debridement compared to frequent debridement after endoscopic sinus surgery: a randomized controlled trial. Eur Arch Otorhinolaryngol 2015; 273:689-95. [PMID: 25903686 DOI: 10.1007/s00405-015-3630-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/13/2015] [Indexed: 11/28/2022]
Abstract
UNLABELLED The aim of this study was to evaluate the postoperative debridement frequency following endoscopic sinus surgery. Individual randomized controlled trial. Sixty-two adult patients with a diagnosis of chronic rhino sinusitis (CRS) with nasal polyps (NP) and CRS without NP meeting the inclusion criteria were enrolled in this prospective study. The patients were randomized equally to frequent debridement (FD; at postoperative weeks 1, 2 and 4) or to a single debridement (SD; at postoperative week 1) after surgery. The outcomes were assessed with visual analog scale (VAS) for nine main symptoms concerning patient discomfort within the first 4 weeks, with the modified Lund-Kennedy endoscopic score (MLKES) at weeks 4 and 24 and with the sino-nasal outcome test-20 (SNOT-20) at week 24. Thirty-seven of the patients were male, and twenty-five were female. The mean age was 36.1 ± 13.5 in FD group and 39.2 ± 14.7 in SD group. In the SD group, the VAS scores at postoperative week four showed significantly less discomfort at visits (p = 0.004) and less negative effects on their work (p = 0.013). There was no statistically significant difference between the two groups in the week 4 and 24 MLKES and in the week 24 SNOT-20 scores (p > 0.05). The endoscopic findings did not show significant differences between the groups. Our data indicate that FD causes more discomfort at the required visits, more facial pain and more negative effects on patients' work; this method is not superior to postoperative single seventh day debridement in terms of the 24-week quality of life and endoscopic scores. LEVEL OF EVIDENCE 1b.
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Affiliation(s)
- Yasin Kursad Varsak
- Department of Otorhinolaryngology, Head and Neck Surgery, Meram Medical Faculty, Necmettin Erbakan University, 42080, Konya, Turkey.
| | - Koksal Yuca
- Department of Otorhinolaryngology, Head and Neck Surgery, Selcuk University, Konya, Turkey
| | - Mehmet Akif Eryılmaz
- Department of Otorhinolaryngology, Head and Neck Surgery, Meram Medical Faculty, Necmettin Erbakan University, 42080, Konya, Turkey
| | - Hamdi Arbag
- Department of Otorhinolaryngology, Head and Neck Surgery, Meram Medical Faculty, Necmettin Erbakan University, 42080, Konya, Turkey
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Albu S, Trombitas V, Vlad D, Emanuelli E. The influence of spray cryotherapy on wound healing following endoscopic sinus surgery in chronic rhinosinusitis. Laryngoscope 2015; 126:25-32. [PMID: 25780997 DOI: 10.1002/lary.25257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 01/21/2015] [Accepted: 02/17/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to assess the influence of spray cryotherapy on wound healing following endoscopic sinus surgery (ESS). STUDY DESIGN A prospective, randomized, double-blinded, controlled trial. METHODS The study included 22 consecutive adult patients with chronic rhinosinusitis with and without polyps scheduled for bilateral ESS. At the end of the surgical procedure, patients were randomized to the distribution of spray cryotherapy in one middle meatus and saline contralaterally. Outcomes were only measured for endoscopy scores. Thus, postoperative healing and the amount of edema, crusting, secretions, and scarring were assessed using the validated Lund-Kennedy and Perioperative Sinus Endoscopy (POSE) scores. RESULTS There were no baseline differences concerning POSE and Lund-Kennedy scores between the two groups. Nevertheless, a significant difference was recorded at one, 2, 4, 8, and 12 weeks in both POSE (P = .001, P = .012, P = .02, P = .006, P = .001) and Lund-Kennedy (P = .002, P = .005, P = .02, P = .02, P = .03) scores. CONCLUSIONS These preliminary results reveal an improvement in postoperative scores, demonstrating enhanced healing following spray cryotherapy. However, without patient subjective outcomes, the study is limited. Additional studies with longer follow-up and larger samples are needed to describe the effects of cryotherapy on wound healing.
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Affiliation(s)
- Silviu Albu
- IInd Department of Otolaryngology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Veronica Trombitas
- IInd Department of Otolaryngology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Diana Vlad
- IInd Department of Otolaryngology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Enzo Emanuelli
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera, Policlinico of Padua, University of Padua, Padua, Italy
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