1
|
Castellucci A, Malara P, Martellucci S, Alfarghal M, Brandolini C, Piras G, Armato E, Ruberto RR, Brizzi P, Presutti L, Ghidini A. Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation? Audiol Res 2023; 13:802-820. [PMID: 37887852 PMCID: PMC10604197 DOI: 10.3390/audiolres13050071] [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: 09/16/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023] Open
Abstract
Surgical plugging of the superior semicircular canal (SSC) represents an effective procedure to treat disabling symptoms in superior canal dehiscence (SCD), despite resulting in an impaired vestibulo-ocular reflex (VOR) gain for the SSC. On the other hand, SSC hypofunction on video head impulse test (vHIT) represents a common finding in patients with SCD exhibiting sound/pressure-induced vertigo, a low-frequency air-bone gap (ABG), and enhanced vestibular-evoked myogenic potentials (VEMPs). "Spontaneous canal plugging" has been assumed as the underlying process. Nevertheless, missing/mitigated symptoms and/or near-normal instrumental findings would be expected. An endolymphatic flow dissipation has been recently proposed as an alternative pathomechanism for SSC VOR gain reduction in SCD. We aimed to shed light on this debate by comparing instrumental findings from 46 ears of 44 patients with SCD exhibiting SSC hypofunction with post-operative data from 10 ears of 10 patients with SCD who underwent surgical plugging. While no difference in SSC VOR gain values was found between the two groups (p = 0.199), operated ears developed a posterior canal hypofunction (p = 0.002). Moreover, both ABG values (p = 0.012) and cervical/ocular VEMP amplitudes (p < 0.001) were significantly higher and VEMP thresholds were significantly lower (p < 0.001) in ears with SCD compared to operated ears. According to our data, canal VOR gain reduction in SCD should be considered as an additional sign of a third window mechanism, likely due to an endolymphatic flow dissipation.
Collapse
Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Pasquale Malara
- Audiology & Vestibology Service, Centromedico, 6500 Bellinzona, Switzerland;
| | | | - Mohamad Alfarghal
- Otorhinolaryngology—Head and Neck Section, Surgery Department, King Abdulaziz Medical City, Jeddah 21556, Saudi Arabia;
| | - Cristina Brandolini
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (L.P.)
| | - Gianluca Piras
- Department of Otology and Skull Base Surgery, Gruppo Otologico, Casa Di Cura Privata “Piacenza” S.P.A., 29121 Piacenza, Italy;
| | - Enrico Armato
- Faculty of Medicine, University of Lorraine, 54000 Vandoeuvre-lès-Nancy, France;
| | - Rosanna Rita Ruberto
- Audiology and Ear Surgery Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (R.R.R.); (P.B.)
| | - Pasquale Brizzi
- Audiology and Ear Surgery Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (R.R.R.); (P.B.)
| | - Livio Presutti
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (L.P.)
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| |
Collapse
|
2
|
Renteria AE, Elblidi A, Altamami N, Alhabib S, Saliba I. Video Head Impulse Test Demonstrates a Residual Function after Plugging of Dehiscent Superior Semicircular Canal. Otol Neurotol 2023; 44:252-259. [PMID: 36728463 DOI: 10.1097/mao.0000000000003794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Plugging a symptomatic dehiscent superior semicircular canal (SSCC) often leads to a nonfunctional postoperative canal. However, in some instances, a residual function has been described. This study attempts to describe what factors may lead to such residual function. STUDY DESIGN Retrospective study. SETTING Tertiary referral center. PATIENTS Thirty-five patients with confirmed SSCC dehiscence. INTERVENTION Video head impulse test was conducted pre- and postoperatively to assess any difference in the function of the SSCC. MAIN OUTCOME MEASURES Mean gain and pathological saccades were recorded according to well-established thresholds along with dehiscence length and location to evaluate any associations to residual canal function. RESULTS When comparing preoperative to postoperative SSCC abnormal gains, a significant increase was observed after plugging ( p = 0.023). This also held true when abnormal gain and pathologic saccades were taken together ( p < 0.001). Interestingly, 55.3% of patients were observed to remain with a residual SSCC function 4 months postoperatively even with a clinical improvement. Of these, 47.6% had normal gain with pathologic saccades, 38.1% had an abnormal gain without pathologic saccades, and 14.3% had normal gain without pathologic saccades (normal function). Preoperatively, SSCC abnormal gain was associated with a larger dehiscence length mean ( p = 0.002). Anterosuperior located dehiscences were also associated with a larger dehiscence length mean ( p = 0.037). A residual SSCC function after plugging was associated with a shorter dehiscence length regardless of location ( p = 0.058). CONCLUSION Dehiscence length and location may be useful in predicting disease symptomatology preoperatively and canals function recovery after plugging. These factors could be used as indicators for preoperative counseling and long-term management.
Collapse
Affiliation(s)
| | - Ahlem Elblidi
- †Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Nasser Altamami
- †Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Salman Alhabib
- †Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | | |
Collapse
|
3
|
Kim H, Ha J, Gu GY, Choung YH. Improved Bone Conduction Hearing After Middle Ear Surgery: Investigation of the Improvement Mechanism. Clin Exp Otorhinolaryngol 2023; 16:20-27. [PMID: 36330708 PMCID: PMC9985987 DOI: 10.21053/ceo.2022.01039] [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: 07/25/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES When performing middle ear operations, such as ossiculoplasty or stapes surgery, patients and surgeons expect an improvement in air conduction (AC) hearing, but generally not in bone conduction (BC). However, BC improvement has often been observed after surgery, and the present study investigated this phenomenon. METHODS We reviewed the preoperative and postoperative surgical outcomes of 583 patients who underwent middle ear surgery. BC improvement was defined as a BC threshold decrease of >15 dB at two or more frequencies. Subjects in group A underwent staged ossiculoplasty after canal wall up mastoidectomy (CWUM), group B underwent staged ossiculoplasty after canal wall down mastoidectomy (CWDM), group C underwent ossiculoplasty only (thus, they had no prior history of CWUM or CWDM), and group D received stapes surgery. We created a hypothetical circuit model to explain this phenomenon. RESULTS BC improvement was detected in 12.8% of group A, 9.1% of group B, and 8.5% of group C. The improvement was more pronounced in group D (27.0%). A larger gain in AC hearing was weakly correlated with greater BC improvement (Pearson's r=0.395 in group A, P<0.001; r=0.375 in group B, P<0.001; r=0.296 in group C, P<0.001; r=0.422 in group D, P=0.009). Notably, patients with otosclerosis even experienced postoperative BC improvements as large as 10.0 dB, from a mean value of 30.3 dB (standard error [SE], 3.2) preoperatively to 20.3 dB (SE, 3.2) postoperatively, at 1,000 Hz, as well as an improvement of 9.2 dB at 2,000 Hz, from 37.8 dB (SE, 2.6) to 28.6 dB (SE, 3.1). CONCLUSION BC improvement may be explained by a hypothetical circuit model applying the third window theory. Surgeons should keep in mind the possibility of BC improvement when making a management plan.
Collapse
Affiliation(s)
- Hantai Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Konyang University College of Medicine, Daejeon, Korea.,Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea
| | - Jungho Ha
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.,Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
| | - Ga Young Gu
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.,Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
| | - Yun-Hoon Choung
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.,Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
4
|
Reynard P, Idriss S, Ltaief-Boudrigua A, Bertholon P, Pirvan A, Truy E, Thai-Van H, Ionescu EC. Proposal for a Unitary Anatomo-Clinical and Radiological Classification of Third Mobile Window Abnormalities. Front Neurol 2022; 12:792545. [PMID: 35087471 PMCID: PMC8786803 DOI: 10.3389/fneur.2021.792545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: An increased number of otic capsule dehiscence (OCD) variants relying on the third window pathomechanism have been reported lately. Therefore, a characterization of the anatomical structures involved and an accurate radiological description of the third window (TW) interface location have become essential for improving the diagnosis and appropriate therapeutic modalities. The purpose of this article is to propose a classification based on clinical, anatomical, and radiological data of third mobile window abnormalities (TMWA) and to discuss the alleged pathomechanism in lesser-known clinical variants. Materials and Methods: The imaging records of 259 patients who underwent, over the last 6 years, a high-resolution CT (HRCT) of the petrosal bone for conductive hearing loss were analyzed retrospectively. Patients with degenerative, traumatic, or chronic infectious petrosal bone pathology were excluded. As cases with a clinical presentation similar to those of a TW syndrome have recently been described in the literature but without these being confirmed radiologically, we thought it necessary to be integrated in a separated branch of this classification as “CT - TMWA.” The same goes for certain intralabyrinthine pathologies also recently reported in the literature, which mimic to some extent the symptoms of a TW pathology. Therefore, we suggest to call them intralabyrinthine TW-like abnormalities. Results: Temporal bone HRCT and, in some cases, 3T MRI of 97 patients presenting symptomatic or pauci-symptomatic, single or multiple, unilateral or bilateral OCD were used to develop this classification. According to the topography and anatomical structures involved at the site of the interface of the TW, a third-type classification of OCD is proposed. Conclusions: A classification reuniting all types of TMWA as the one proposed in this article would allow for a better systematization and understanding of this complex pathology and possibly paves the way for innovative therapeutic approaches. To encompass all clinical and radiological variants of TMWA reported in the literature so far, TMWAs have been conventionally divided into two major subgroups: Extralabyrinthine (or “true” OCD with three subtypes) and Intralabyrinthine (in which an additional mobile window-like mechanism is highly suspected) or TMWA-like subtype. Along these subgroups, clinical forms of OCD with multiple localization (multiple OCD) and those that, despite the fact that they have obvious characteristics of OCD have a negative CT scan (or CT – TMWA), were also included.
Collapse
Affiliation(s)
- Pierre Reynard
- Department of Audiology and Neurotology, Lyon University Hospital, Lyon, France.,Department of Physiology, Claude Bernard Lyon 1 University, Lyon, France.,Paris Hearing Institute, Institut Pasteur, Inserm U1120, Paris, France
| | - Samar Idriss
- Department of Audiology and Neurotology, Lyon University Hospital, Lyon, France.,Department of Otolaryngology - Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
| | | | - Pierre Bertholon
- Department of Otorhinolaryngology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Andreea Pirvan
- Department of Audiology and Neurotology, Lyon University Hospital, Lyon, France
| | - Eric Truy
- Department of Physiology, Claude Bernard Lyon 1 University, Lyon, France.,Department of Otorhinolaryngology, Lyon University Hospital, Lyon, France
| | - Hung Thai-Van
- Department of Audiology and Neurotology, Lyon University Hospital, Lyon, France.,Department of Physiology, Claude Bernard Lyon 1 University, Lyon, France.,Paris Hearing Institute, Institut Pasteur, Inserm U1120, Paris, France
| | - Eugen C Ionescu
- Department of Audiology and Neurotology, Lyon University Hospital, Lyon, France.,Department of Physiology, Claude Bernard Lyon 1 University, Lyon, France.,Paris Hearing Institute, Institut Pasteur, Inserm U1120, Paris, France
| |
Collapse
|
5
|
Zhang Y, Cheng Y, Chen Z, Chen F, Zhang Q. Case Report: Preservation of Otolithic Function After Triple Semicircular Canal Occlusion in a Patient With Intractable Ménière Disease. Front Neurol 2022; 12:713275. [PMID: 35002908 PMCID: PMC8732767 DOI: 10.3389/fneur.2021.713275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
Operative measures are considered when medical treatment fails to control vertigo in patients with intractable Ménière disease. The present report discusses a case in which triple semicircular canal occlusion was performed in a 30-year-old female patient who responded poorly to previously performed endolymphatic sac surgery. Her vestibular and auditory functions were evaluated both before and after surgery. Class A control of vertigo was achieved during the 76-month postoperative follow-up period. Ocular and cervical vestibular evoked myogenic potentials could be elicited before and after surgery. This case suggests that relatively long-term preservation of otolithic function can be achieved following triple semicircular canal occlusion, highlighting its potential as an alternative treatment for patients with Ménière disease.
Collapse
Affiliation(s)
- Yuzhong Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ying Cheng
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zichen Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Feiyun Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qing Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
6
|
Nieto P, Gallois Y, Molinier C, Deguine O, Marx M. Surgical treatments of superior semicircular canal dehiscence: A single-centre experience in 63 cases. Laryngoscope Investig Otolaryngol 2021; 6:1414-1420. [PMID: 34938882 PMCID: PMC8665461 DOI: 10.1002/lio2.684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/16/2021] [Accepted: 10/14/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Different procedures have been described to treat superior canal dehiscence. The present study aims to describe the results obtained with middle fossa approach, transmastoid approach, and round window reinforcement in a large series of patients. METHODS AND DESIGN In this single-center retrospective study, we report the results of the procedures performed between 2006 and 2019 using the three main surgical approaches, middle fossa approach (MFA), transmastoid approach (TMA), and round window reinforcement (RWR). The outcome on cardinal cochlear and vestibular symptoms, audiometric results, and changes in cervical vestibular evoked myogenic potentials (cVEMPs) were analyzed. The patients were also interviewed 12 months to 13 years post-treatment to establish their overall satisfaction following surgery. RESULTS Sixty-three patients were divided into three groups: 42 MFA; 12 RWR; 9 TMA. Postsurgical control rates exceeded 80% for the majority of symptoms in the MFA and TMA groups, and ranged from 11.1% to 83.3% for the RWR group. Over 90% of MFA or TMA patients and 60% of the RWR cohort were satisfied overall with their treatment. Hearing thresholds were intact following surgery in the MFA and TMA groups. There was one case of profound postoperative deafness in the RWR group. CONCLUSION MFA and TMA are both safe and effective techniques in the treatment of disabling SSCD. Since MFA is the more invasive technique, we suggest that TMA should be proposed as first-line treatment, temporal bone anatomy permitting. RWR outcomes are more variable in term of symptomatic control, and this option could be offered to patients at risk under general anesthesia. LEVEL OF EVIDENCE Level 4 evidence.
Collapse
Affiliation(s)
- Pauline Nieto
- Service d'ORL, Otoneurologie et ORL PédiatriqueCHU Toulouse PurpanToulouseFrance
| | - Yohan Gallois
- Service d'ORL, Otoneurologie et ORL PédiatriqueCHU Toulouse PurpanToulouseFrance
- Service d'ORL, Otoneurologie et ORL PédiatriqueUniversité Toulouse III—Paul SabatierToulouseFrance
| | | | - Olivier Deguine
- Service d'ORL, Otoneurologie et ORL PédiatriqueCHU Toulouse PurpanToulouseFrance
- Brain & Cognition Research Centre, UMR 5549Université Toulouse IIIToulouseFrance
- Service d'ORL, Otoneurologie et ORL PédiatriqueUniversité Toulouse III—Paul SabatierToulouseFrance
| | - Mathieu Marx
- Service d'ORL, Otoneurologie et ORL PédiatriqueCHU Toulouse PurpanToulouseFrance
- Brain & Cognition Research Centre, UMR 5549Université Toulouse IIIToulouseFrance
- Service d'ORL, Otoneurologie et ORL PédiatriqueUniversité Toulouse III—Paul SabatierToulouseFrance
| |
Collapse
|
7
|
Quantitative three-dimensional image analysis of the superior canal after surgical plugging to treat superior semicircular canal dehiscence. Sci Rep 2021; 11:16112. [PMID: 34373484 PMCID: PMC8352905 DOI: 10.1038/s41598-021-95063-x] [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: 11/06/2020] [Accepted: 06/11/2021] [Indexed: 11/08/2022] Open
Abstract
Surgical plugging to treat superior semicircular canal dehiscence (SCD) has been proven to impede the effect of the third mobile window, abating cochleovestibular symptoms. Knowledge of superior semicircular canal (SC)-plugging status has been proposed to serve as a guide for adjuvant treatment. Here, we investigated disturbances in the inner ear fluid space following SC plugging using a novel three-dimensional (3D) reconstruction-based method. This approach used a semi-automatic segmentation algorithm and a direct volume rendering method derived from conventional magnetic resonance images. The variable extents of filling defects at the sites of SC plugging and the positional relation of the defect to the ampulla and common crus were identified. The success group exhibited markedly reduced volumes following surgery, whereas the failure group displayed no changes in volume. These results indicate that the success or failure of SC plugging was related to 3D volume changes in the labyrinth fluid signal. Collectively, this study presents individualized SC-plugging statuses using a novel 3D reconstruction-based method and it facilitates future work regarding easy-to-measure 3D volume changes. This current technology also aids in the exploration of pathologic changes in various targets of interest.
Collapse
|
8
|
Eberhard KE, Chari DA, Nakajima HH, Klokker M, Cayé-Thomasen P, Lee DJ. Current Trends, Controversies, and Future Directions in the Evaluation and Management of Superior Canal Dehiscence Syndrome. Front Neurol 2021; 12:638574. [PMID: 33889125 PMCID: PMC8055857 DOI: 10.3389/fneur.2021.638574] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/08/2021] [Indexed: 01/14/2023] Open
Abstract
Patients with superior canal dehiscence syndrome (SCDS) can present with a range of auditory and/or vestibular signs and symptoms that are associated with a bony defect of the superior semicircular canal (SSC). Over the past two decades, advances in diagnostic techniques have raised the awareness of SCDS and treatment approaches have been refined to improve patient outcomes. However, a number of challenges remain. First, there is currently no standardized clinical testing algorithm for quantifying the effects of superior canal dehiscence (SCD). SCDS mimics a number of common otologic disorders and established metrics such as supranormal bone conduction thresholds and vestibular evoked myogenic potential (VEMP) measurements; although useful in certain cases, have diagnostic limitations. Second, while high-resolution computed tomography (CT) is the gold standard for the detection of SCD, a bony defect does not always result in signs and symptoms. Third, even when SCD repair is indicated, there is a lack of consensus about nomenclature to describe the SCD, ideal surgical approach, specific repair techniques, and type of materials used. Finally, there is no established algorithm in evaluation of SCDS patients who fail primary repair and may be candidates for revision surgery. Herein, we will discuss both contemporary and emerging diagnostic approaches for patients with SCDS and highlight challenges and controversies in the management of this unique patient cohort.
Collapse
Affiliation(s)
- Kristine Elisabeth Eberhard
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Divya A. Chari
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Hideko Heidi Nakajima
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Mads Klokker
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Cayé-Thomasen
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel J. Lee
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| |
Collapse
|