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Nguyen HMH, Le MTQ, Nguyen HT, Tran HV, Tran LV. Investigation of vascularization patterns in juvenile Angiofibroma and the impact of preoperative embolization on surgical excision. Am J Otolaryngol 2025; 46:104632. [PMID: 40286546 DOI: 10.1016/j.amjoto.2025.104632] [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: 11/09/2024] [Revised: 02/06/2025] [Accepted: 04/20/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Juvenile nasopharyngeal angiofibroma (JNA) is a rare, highly vascular tumor posing a significant challenge for endoscopic excision due to excessive intraoperative bleeding. Exploring feeding vessels and preoperative embolization could reduce intraoperative blood loss and improve surgical outcomes for JNA. This study investigates the vascularization patterns of JNA and the impact of preoperative embolization on surgical excision. METHODS This was a descriptive cross-sectional study of 30 histopathologically confirmed JNA patients who underwent preoperative embolization followed by endoscopic surgical excision from January 2019 to May 2023 at Ear Nose Throat Hospital of Ho Chi Minh City. The distribution of vascular supply of tumors, as well as the role of preoperative embolization, were analyzed. RESULTS Most tumors received exclusive blood supply from the internal maxillary artery (IMA) accounting for 50%, with 20% of cases being supplied by bilateral IMAs. A combined supply pattern involving the IMA and other external carotid artery branches was observed in 26.6%. Three complex cases (10%) received blood from the internal carotid artery (ICA). Embolization was performed at branches originating from the external carotid artery (ECA) but not from the ICA to avoid complications. All patients achieved complete endoscopic JNA excision. The average intraoperative blood loss was 608 mL (range: 100 mL - 3000 mL), and the average Boezaart score was 2.63. No major surgical complications occurred in the perioperative period. Significant differences in blood loss were observed among different UPMC tumor stages (p < 0.001) and tumor sizes (p = 0.008). Advanced-stage tumors were more likely to have an ICA blood supply (p = 0.038). CONCLUSION Understanding the vascularization patterns of juvenile angiofibroma and the role of preoperative embolization can facilitate endoscopic excision of these tumors.
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Affiliation(s)
- Hon Minh Hao Nguyen
- Ear Nose Throat Hospital of Ho Chi Minh City, 155 Tran Quoc Thao Street, District 3, Ho Chi Minh city, Viet Nam; Department of Otolaryngology Head and Neck Surgery, Pham Ngoc Thach University of Medicine, 2 Duong Quang Trung street, District 10, Ho Chi Minh city, Viet Nam
| | - Minh Tran Quang Le
- Ear Nose Throat Hospital of Ho Chi Minh City, 155 Tran Quoc Thao Street, District 3, Ho Chi Minh city, Viet Nam
| | - Hai Thanh Nguyen
- Ear Nose Throat Hospital of Ho Chi Minh City, 155 Tran Quoc Thao Street, District 3, Ho Chi Minh city, Viet Nam
| | - Hong Viet Tran
- Department of Otolaryngology Head and Neck Surgery, Pham Ngoc Thach University of Medicine, 2 Duong Quang Trung street, District 10, Ho Chi Minh city, Viet Nam
| | - Luan Viet Tran
- Department of Otolaryngology Head and Neck Surgery, Pham Ngoc Thach University of Medicine, 2 Duong Quang Trung street, District 10, Ho Chi Minh city, Viet Nam.
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Mârțu C, Tîrnovanu ȘD, Mârțu I, Ferariu D, Mârțu D, Jităreanu A, Rădulescu L. Alveolar Rhabdomyosarcoma of Nasopharynx and Paranasal Sinuses in Children Diagnosis and Treatment-Review of the Literature and Case Report. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:80. [PMID: 39859062 PMCID: PMC11766809 DOI: 10.3390/medicina61010080] [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: 11/05/2024] [Revised: 12/29/2024] [Accepted: 12/30/2024] [Indexed: 01/27/2025]
Abstract
Alveolar rhabdomyosarcoma (aRMS) is a rare pediatric malignant tumor with a poor prognosis, particularly when located in the rhinopharynx and sphenoidal floor, which complicates diagnosis and increases the risk of misclassification as benign growths. The specific genotype of aRMS is associated with a worse clinical outcome. In young children, especially those aged 4 to 12 years, rhinopharyngeal masses are often attributed to chronic adenoiditis; however, other benign (e.g., angiofibroma in boys) and malignant tumors may also be present. Initial symptoms frequently include nasal obstruction, muco-purulent nasal discharge, serous otitis media, sinusitis, and epistaxis. Rhabdomyosarcoma is the second most common ENT neoplasm in children, following lymphoma, with an incidence of approximately 6 cases per 1,000,000 annually. This report presents the case of an 8-year-old boy diagnosed with aRMS, accompanied by a literature review. Alveolar rhabdomyosarcoma should be suspected in children presenting with a vegetative tumor in the rhinopharynx or paranasal sinuses. Combined treatment approaches (surgery, radiotherapy, and chemotherapy) should be tailored to tumor characteristics. Neuronavigation-guided functional endoscopic sinus surgery (FESS) is an effective option for achieving complete tumor excision, depending on tumor size and extent. The prognosis remains reserved and is contingent upon accurate evaluation and timely intervention. Rigorous follow-up, including endoscopic and imagistic investigation, is crucial for early detection of recurrences, thereby improving treatment outcomes.
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Affiliation(s)
- Cristian Mârțu
- ENT Clinic Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, Universitatii Street 16, 700115 Iasi, Romania; (C.M.); (D.M.); (L.R.)
| | - Ștefan Dragoș Tîrnovanu
- Department of Orthopedics and Traumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
- Department of Orthopaedics and Traumatology, “Sf. Spiridon” Emergency Universitary Hospital, 700115 Iasi, Romania
| | - Ioana Mârțu
- Department of Oral Implantology, Removable Dentures and Technology, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, Universitatii Street 16, 700115 Iasi, Romania
| | - Dan Ferariu
- Department of Pathology, Regional Institute of Oncology, 700483 Iasi, Romania;
| | - Dan Mârțu
- ENT Clinic Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, Universitatii Street 16, 700115 Iasi, Romania; (C.M.); (D.M.); (L.R.)
| | - Alexandra Jităreanu
- Department of Toxicology, Faculty of Pharmacy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Luminița Rădulescu
- ENT Clinic Department, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, Universitatii Street 16, 700115 Iasi, Romania; (C.M.); (D.M.); (L.R.)
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3
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Liu S, Tang R, Mao S, Zhang W. Clinical outcomes of coblation-assisted pediatric endoscopic endonasal skull base surgery. Int J Pediatr Otorhinolaryngol 2022; 156:111089. [PMID: 35255444 DOI: 10.1016/j.ijporl.2022.111089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/06/2022] [Accepted: 02/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric skull base surgeries are confined by developmental and anatomical issues. Radiofrequency coblation integrates the functions of ablation, suction, and coagulation with the ability to dissolve tissues with limited thermal injury, making it an ideal instrument for pediatric skull base surgery. We sought to evaluated the clinical outcomes of coblation-assisted pediatric endoscopic skull base surgery. METHODS Medical records of patients under 15 years of age undergoing endoscopic skull base surgery were retrospectively reviewed. The estimated blood loss (EBL)/operating time (OT) and Wormald grade were used for intraoperative blood loss grading. RESULTS Generally, 28 patients (17 males, 11 females) with an average age of 8.4 ± 4.2 years, (range, 11 months to 15 years old) were included. Coblation was applied in 20 patients for mucosa coagulation and handling, cartilage removal, tumor separation and excision. The primary diagnoses included juvenile nasopharyngeal angiofibroma (n = 5), traumatic cerebrospinal fluid (CSF) leak (n = 6), congenital meningoencephalocele (n = 6) and miscellaneous sinonasal and skull base neoplasm (n = 11). The application of coblation was related with a significant decrease in EBL/OT (34.1 ± 17.5 vs 56.3 ± 22.6 ml/h, p = 0.048) and Wormald grade (5.7 ± 1.5 vs 6.9 ± 2.0, p = 0.038), compared with the traditional techniques. All surgical procedures were uneventful. No significant difference in postoperative complications, including cranial nerve dysfunction and CSF rhinorrhea were documented during the follow-up period (average, 34.7 ± 4.4 months). CONCLUSION We suggested the coblation be a safe and effective instrument for pediatric skull base surgery.
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Affiliation(s)
- Shixian Liu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ru Tang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Song Mao
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Weitian Zhang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Manogaran RS, Mathialagan A, Singh V, Mishra P, Jain R, Keshri A. Role of Transarterial Angiography with Embolization in Deciding Surgical Approach to Juvenile Nasopharyngeal Angiofibroma: A Step-Ladder Approach. J Neurol Surg B Skull Base 2021; 82:547-555. [PMID: 34513561 DOI: 10.1055/s-0040-1715594] [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: 02/16/2020] [Accepted: 06/21/2020] [Indexed: 10/23/2022] Open
Abstract
Objective This study was aimed to understand the usefulness of transarterial angiography and embolization in management of juvenile nasopharyngeal angiofibroma (JNA) and to apply the information obtained to stage the disease, select appropriate surgical approach, predict intraoperative bleeding, and prognosticate the disease. Study Design This study represents a retrospective review of the patients of JNA with major focus on transarterial angiography and embolization findings and its clinical and surgical implications. Setting The study conducted at a tertiary-care super-specialty referral center. Participants Forty-two patients who had undergone transarterial angiography and embolization followed by surgery over the period of 5 years from July 2015 till February 2019 were participated in this study. Main Outcome Measures Tumor vascular pattern based on transarterial angiography, staging of the disease based on extent and vascular supply, surgical approach selected, and prognosticating the disease were determined from this study. Conclusion Transarterial angiography with embolization becomes a prudent preoperative investigation for management of JNA. It provides a complete three-dimensional map of the tumor with stage-specific vascular pattern, reduces vascularity of the tumor, and predicts the sites from where bleeding can occur intra operatively. Thus, it helps in choosing the appropriate surgical approach aiding in complete tumor removal with minimal bleeding.
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Affiliation(s)
- Ravi S Manogaran
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arulalan Mathialagan
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajat Jain
- Division of Neuro-otology, Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Keshri
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Jaiswal AS, Kumar R, Thakar A, Kumar R, Verma H, Bhalla AS, Kairo AK, Kakkar A, Chandra Sharma S, Sakthivel P. Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma. Int J Pediatr Otorhinolaryngol 2020; 139:110410. [PMID: 33022553 DOI: 10.1016/j.ijporl.2020.110410] [Citation(s) in RCA: 5] [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: 07/12/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Juvenile nasopharyngeal angiofibroma is the vascular and locally aggressive tumor of the posterior nares and nasopharynx. Endoscopic excision is the preferred surgical modality in early Radkowski stages. The prime challenge is intraoperative bleeding. Literature is in favor of the use of plasma ablation to overcome surgical challenges. OBJECTIVE To evaluate the effectiveness of plasma ablation technique in the surgical management of juvenile nasopharyngeal angiofibroma. MATERIALS AND METHODS The current study recruited 36 patients of clinico-radiologically diagnosed cases of primary JNA of stage I and II (Modified Radkowski). In prospective arm, 18 consecutive patients were recruited, who underwent plasma ablation assisted endoscopic excision. In retrospective arm, 18 consecutive patients who underwent excision by traditional endoscopic instruments in the past two years, were recruited. Both the groups were compared for baseline characteristics, intraoperative blood loss, duration of surgery, length of hospital stay, and recurrence rates. RESULTS The use of plasma ablation decreased overall blood loss by 338 ml (mean difference) which was not statistically significant (p = 0.26). On subgroup analysis, the use of plasma ablation significantly decreased mean blood loss (648 ml, p = 0.046) and duration of surgery (83 min, p < 0.001) in patients who underwent embolization. No statistically significant difference was noted between two groups in length of hospital stay (p = 0.36) and recurrence rates (p = 0.64). CONCLUSION Plasma ablation is an effective technique available to decrease blood loss and duration of surgery during endoscopic excision of post embolized stage I and II patients of JNA.
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Affiliation(s)
- Avinash Shekhar Jaiswal
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Rakesh Kumar
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Alok Thakar
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Rajeev Kumar
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Hitesh Verma
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Ashu Seith Bhalla
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Arvind Kumar Kairo
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Aanchal Kakkar
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.
| | - Suresh Chandra Sharma
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Pirabu Sakthivel
- Department of Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
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Gargula S, Saint-Maurice JP, Labeyrie MA, Eliezer M, Jourdaine C, Kania R, Wassef M, Adle-Biassette H, Houdart E, Herman P, Verillaud B. Embolization of Internal Carotid Artery Branches in Juvenile Nasopharyngeal Angiofibroma. Laryngoscope 2020; 131:E775-E780. [PMID: 33001464 DOI: 10.1002/lary.29119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 07/15/2020] [Accepted: 08/29/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Preoperative embolization of juvenile nasopharyngeal angiofibroma (JNA) is usually performed by the occlusion of branches of the external carotid artery (ECA). However, a significant proportion of JNAs also receive blood from the internal carotid artery (ICA). The objective of this study was to report on the feasibility and clinical impact of superselective embolization of ICA branches in complex cases of JNA. METHODS This was a single-center retrospective study of all patients operated on for JNA between 2000 and 2018. The patients treated with embolization of branches of the ICA were identified. The results in terms of complications, intraoperative blood loss, and rate of residual disease were analyzed and compared to those of a control group of patients treated only with embolization of ECA branches and matched by age, stage, angiographic pattern, surgical approach, and previous surgery. RESULTS Ninety-two patients were included. Embolization of branches of the ICA was attempted in 14 cases of advanced or recurrent tumors and was ultimately possible in nine cases. There were no complications after embolization. The mean intraoperative blood loss was 1428 mL. Residual disease was found in three cases (33%). There was no significant difference compared with the control group (mean intraoperative blood loss = 1355 mL, residual disease = 4 (44%); all P > .05). CONCLUSION In this retrospective study, we report the feasibility of superselective embolization of ICA branches in selected cases of JNA. There was no observed benefit of this technique in terms of intraoperative bleeding or decreased risk of residual disease. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E775-E780, 2021.
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Affiliation(s)
- Stéphane Gargula
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean-Pierre Saint-Maurice
- Department of Neuroradiology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Marc-Antoine Labeyrie
- Department of Neuroradiology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Michael Eliezer
- Department of Neuroradiology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Clément Jourdaine
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Romain Kania
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, INSERM U1141, Université de Paris, Paris, France
| | - Michel Wassef
- Department of Pathology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Homa Adle-Biassette
- Department of Pathology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Emmanuel Houdart
- Department of Neuroradiology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Philippe Herman
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, INSERM U1141, Université de Paris, Paris, France
| | - Benjamin Verillaud
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique - Hôpitaux de Paris, INSERM U1141, Université de Paris, Paris, France
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Maroda AJ, Beckmann NA, Sheyn AM, Elijovich L, Michael LM, DiNitto JM, Rangarajan SV. Trimodal embolization of juvenile nasopharyngeal angiofibroma with intracranial extension. Int J Pediatr Otorhinolaryngol 2020; 130:109805. [PMID: 31864085 DOI: 10.1016/j.ijporl.2019.109805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/25/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVES/PURPOSE 1. Understand three different techniques for embolization of juvenile nasal angiofibroma (JNA) and assess their combined efficacy. 2. Perform successful endoscopic intralesional embolization of highly vascular sinonasal neoplasms. METHODS In this study, we present the case of a 10-year-old male patient diagnosed with juvenile nasal angiofibroma (JNA) who successfully underwent trimodal embolization and resection at a tertiary academic medical center after failed coil embolization in his home country. We examine the clinical details of the case and a review of pertinent literature. RESULTS Preoperative embolization is common in the treatment of JNA, but there is little consensus as to the proper timeframe and techniques utilized. In our case, preoperative imaging revealed a vascular tumor with intracranial extension consistent with UPMC Stage V JNA. Diagnostic angiogram revealed significant arborization from the internal and external carotid systems. A trimodal embolization technique, utilizing transarterial, percutaneous, and direct endoscopic intralesional injection of n-Butyl Cyanoacrylate (n-BCA) was performed. A two-staged endoscopic and open resection was subsequently performed one week later with minimal blood loss. In our case, combining intralesional embolization with traditional transarterial techniques resulted in an improved operative field and a successful clinical result. CONCLUSION Embolization of highly vascular sinonasal tumors with n-BCA is not limited to endovascular techniques, but can be safely combined with percutaneous and endoscopic intralesional embolization up to one week prior to surgical resection.
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Affiliation(s)
- Andrew J Maroda
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nicholas A Beckmann
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Anthony M Sheyn
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - L Madison Michael
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Julie M DiNitto
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA; Siemens Healthcare AG, Memphis, TN, USA.
| | - Sanjeet V Rangarajan
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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Burton BN, Gilani S, Desai M, Saddawi-Konefka R, Willies-Jacobo L, Gabriel RA. Perioperative Risk Factors Associated With Morbidity and Mortality Following Pediatric Inpatient Sinus Surgery. Ann Otol Rhinol Laryngol 2019; 128:13-21. [PMID: 30328698 DOI: 10.1177/0003489418805504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES: Pediatric sinus surgery is indicated for a wide range of sinonasal and skull base pathologies, but it is most commonly performed for recalcitrant chronic rhinosinusitis or complicated acute sinusitis. The authors aim to report medical risk factors of morbidity and mortality following inpatient sinus surgery in the pediatric population. METHODS: Using data from the Kids' Inpatient Database from 2003 to 2012, patients with International Classification of Diseases, Ninth Revision, procedure codes for primary sinus surgery were identified. Mixed-effect multivariable logistic regression was used to identify risk factors of inpatient postoperative morbidity and mortality. RESULTS: The final sample included a weighted estimate of 4965 pediatric patients. The rates of inpatient morbidity and mortality were 6% and 1%, respectively. Respiratory complications (2.5%) were the most prevalent postoperative adverse events. The most prevalent comorbidities were chronic sinusitis (59.8%), acute sinusitis (27.8%), and cystic fibrosis (26.4%). Compared with patients who did not experience any morbidity, patients with inpatient morbidity had higher rates of pneumonia, mycoses, and nasal or paranasal benign neoplasm ( P < .05). The odds of inpatient morbidity and mortality were highest for patients with leukemia (odds ratio, 2.74; 95% confidence interval, 1.59-4.72; P < .001) and mycoses (odds ratio, 15.84; 95% confidence interval, 6.45-38.89; P < .001), respectively. CONCLUSIONS: This study is the first to report the national comorbidity burden and risk factors for postoperative adverse events following inpatient sinus surgery. Knowledge of the comorbidities and independent factors associated with morbidity and mortality will help in directing preoperative optimization and counseling. LEVEL OF EVIDENCE: 2c.
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Affiliation(s)
- Brittany N Burton
- 1 School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Sapideh Gilani
- 2 Division of Otolaryngology - Head and Neck Surgery, University of California, San Diego, La Jolla, CA, USA
| | - Milli Desai
- 1 School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Robert Saddawi-Konefka
- 2 Division of Otolaryngology - Head and Neck Surgery, University of California, San Diego, La Jolla, CA, USA
| | | | - Rodney A Gabriel
- 4 Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
- 5 Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
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10
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Recurrence Rate after Endoscopic vs. Open Approaches for Juvenile Nasopharyngeal Angiofibroma: A Meta-analysis. J Neurol Surg B Skull Base 2018; 80:577-585. [PMID: 31750043 DOI: 10.1055/s-0038-1676562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022] Open
Abstract
Context The effect on recurrence rate between patients with juvenile nasopharyngeal angiofibroma (JNA), treated by an endoscopic versus open approach, has not been well established. Objective A meta-analysis of the available literature concerning recurrence rate in patients who underwent surgery for JNA. Methods A retrospective meta-analysis of studies analyzing recurrence rate after endoscopic or open surgery for patients with JNA was performed using the DerSimonian-Laird random-effects method. English and non-English articles were reviewed using Embase, Medline, and Cochrane databases. Results Among nine studies, including 362 patients from 1981 to 2015, with a mean follow-up of 49.4 months, a total of 89 patients (24.5%) had recurrence. Our analysis revealed a total effect size of -0.16 in favor of endoscopic approach (-0.25 to -0.06, CI [confidence interval] 95%). When analyzing tumor by stage (Radkowski's IA-IIIB n = 299), the endoscopic approach proved to be superior independent of tumor stage (2 vs. 17% for tumors stage IA-IIA, and 26 vs. 32% for tumor stage IIB-IIIB for endoscopic and open approaches respectively; p < 0.05). The endoscopic approach has a statistical significant lower recurrence rate in patients without intracranial compromise when compared with the open approach (13 vs. 28%; p < 0.02). No statistical difference was seen in patients with intracranial compromise ( p = 0.5) Conclusion The use of an endoscopic approach to treat JNA has a significantly lower recurrence rate when compared with open approaches. Independent of disease stage, an endoscopic approach should be the standard of care to surgically treat JNA. For cases with intracranial compromise, either approach can be used for surgical resection.
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Jones JW, Usman S, New J, Holcomb A, Gunewardena S, Tawfik O, Hoover L, Bruegger D, Thomas SM. Differential Gene Expression and Pathway Analysis in Juvenile Nasopharyngeal Angiofibroma Using RNA Sequencing. Otolaryngol Head Neck Surg 2018; 159:572-575. [PMID: 29634432 PMCID: PMC7147957 DOI: 10.1177/0194599818769879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascularized and locally aggressive tumor that typically presents in adolescent males. The molecular biology of this tumor remains understudied. We sought to identify differentially expressed genes in the JNA transcriptome through messenger RNA sequencing of primary fibroblasts from 2 tumor explants and tonsil tissue from tumor-free subjects. In total, 1088 significant, differentially expressed genes were identified with 749 upregulated and 339 downregulated. Pathway analysis identified a number of activated signaling pathways, most notably, the vascular endothelial growth factor (VEGF) pathway (adjusted overlap P = .03). VEGF-A showed a 4.4-fold upregulation in JNA samples. In addition, the angiogenic receptor, fibroblast growth factor receptor 2 (FGFR2), was not present in tumor-free samples but increased in JNA. We validate these findings with immunohistochemistry, demonstrating upregulation of VEGF and FGFR2 in patient sections. Inhibition of the VEGF or FGFR signaling axes may have therapeutic potential in the treatment of JNA.
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Affiliation(s)
- Joel W. Jones
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Shireen Usman
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Jacob New
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA,Department of Anatomy and Cell Biology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Andrew Holcomb
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Sumedha Gunewardena
- Department of Molecular and Integrative Physiology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Ossama Tawfik
- Department of Pathology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Larry Hoover
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Daniel Bruegger
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Sufi Mary Thomas
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA,Department of Anatomy and Cell Biology, University of Kansas School of Medicine, Kansas City, Kansas, USA,Department of Cancer Biology, University of Kansas School of Medicine, Kansas City, Kansas, USA
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Imaging features of sinonasal tumors on positron emission tomography and magnetic resonance imaging including diffusion weighted imaging: A pictorial review. Clin Imaging 2018; 51:217-228. [DOI: 10.1016/j.clinimag.2018.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/17/2018] [Accepted: 05/24/2018] [Indexed: 11/19/2022]
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13
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Overdevest JB, Amans MR, Zaki P, Pletcher SD, El-Sayed IH. Patterns of vascularization and surgical morbidity in juvenile nasopharyngeal angiofibroma: A case series, systematic review, and meta-analysis. Head Neck 2017; 40:428-443. [DOI: 10.1002/hed.24987] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/15/2017] [Accepted: 09/15/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- Jonathan B. Overdevest
- Department of Otolaryngology - Head and Neck Surgery; Division of Rhinology; San Francisco California
| | - Matthew R. Amans
- Department of Radiology; University of California San Francisco School of Medicine; San Francisco California
| | - Peter Zaki
- School of Medicine; University of California San Francisco School of Medicine; San Francisco California
| | - Steven D. Pletcher
- Department of Otolaryngology - Head and Neck Surgery; Division of Rhinology; San Francisco California
| | - Ivan H. El-Sayed
- Department of Otolaryngology - Head and Neck Surgery; Division of Rhinology; San Francisco California
- Department of Otolaryngology - Division Head and Neck Surgical Oncology, and Center for Minimally Invasive Skull Base Surgery; University of California; San Francisco California
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Association between vascular supply, stage and tumour size of juvenile nasopharyngeal angiofibroma. Eur Arch Otorhinolaryngol 2016; 273:4295-4303. [DOI: 10.1007/s00405-016-4136-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/06/2016] [Indexed: 11/29/2022]
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15
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McLaughlin EJ, Cunningham MJ, Kazahaya K, Hsing J, Kawai K, Adil EA. Endoscopic Radiofrequency Ablation–Assisted Resection of Juvenile Nasopharyngeal Angiofibroma. Otolaryngol Head Neck Surg 2016; 154:1145-8. [DOI: 10.1177/0194599816630942] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 01/15/2016] [Indexed: 11/16/2022]
Abstract
Objectives To evaluate the feasibility of radiofrequency surgical instrumentation for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and to test the hypothesis that endoscopic radiofrequency ablation–assisted (RFA) resection will have superior intraoperative and/or postoperative outcomes as compared with traditional endoscopic (TE) resection techniques. Study Design Case series with chart review. Setting Two tertiary care pediatric hospitals. Subjects and Methods Twenty-nine pediatric patients who underwent endoscopic transnasal resection of JNA from January 2000 to December 2014. Results Twenty-nine patients underwent RFA (n = 13) or TE (n = 16) JNA resection over the 15-year study period. Mean patient age was not statistically different between the 2 groups ( P = .41); neither was their University of Pittsburgh Medical Center classification stage ( P = .79). All patients underwent preoperative embolization. Mean operative times were not statistically different ( P = .29). Mean intraoperative blood loss and the need for a transfusion were also not statistically different ( P = .27 and .47, respectively). Length of hospital stay was not statistically different ( P = .46). Recurrence rates did not differ between groups ( P = .99) over a mean follow-up period of 2.3 years. Conclusion There were no significant differences between RFA and TE resection in intraoperative or postoperative outcome parameters.
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Affiliation(s)
- Eamon J. McLaughlin
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric Otolaryngology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael J. Cunningham
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ken Kazahaya
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric Otolaryngology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julianna Hsing
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Eelam A. Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Epistaxis or nosebleed is relatively common in the general population. Depending on the location of the bleeding in the nasal cavity, epistaxis can be divided in two types: anterior or posterior type. The anterior type is far more frequent, often self-limiting and, if needed, is relatively easy treatable. Posterior type epistaxis is rare and more likely to require medical attention. The cornerstone of the conservative therapy of posterior epistaxis is nasal packing. Only in patients with persistent or recurrent epistaxis, endovascular intervention or surgery is indicated. Both treatment options have a similar success and complication rate, but endovascular treatment, if feasible, has several advantages above surgical treatment. The choice of procedure should be made on a patient-to-patient basis, taking several parameters into account. In this pictorial essay we present an overview of the relevant radiological anatomy and a review of various causes of epistaxis, with the emphasis on the endovascular treatment.
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17
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Ye D, Shen Z, Wang G, Deng H, Qiu S, Zhang Y. Analysis of factors in successful nasal endoscopic resection of nasopharyngeal angiofibroma. Acta Otolaryngol 2015; 136:205-13. [PMID: 26492972 DOI: 10.3109/00016489.2015.1099734] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS Endoscopic resection of nasopharyngeal angiofibroma is less traumatic, causes less bleeding, and provides a good curative effect. Using pre-operative embolization and controlled hypotension, reasonable surgical strategies and techniques lead to successful resection tumors of a maximum Andrews-Fisch classification stage of III. OBJECTIVE To investigate surgical indications, methods, surgical technique, and curative effects of transnasal endoscopic resection of nasopharyngeal angiofibroma, this study evaluated factors that improve diagnosis and treatment, prevent large intra-operative blood loss and residual tumor, and increase the cure rate. METHODS A retrospective analysis was performed of the clinical data and treatment programs of 23 patients with nasopharyngeal angiofibroma who underwent endoscopic resection with pre-operative embolization and controlled hypotension. The surgical method applied was based on the size of tumor and extent of invasion. Curative effects were observed. RESULTS No intra-operative or perioperative complications were observed in 22 patients. Upon removal of nasal packing material 3-7 days post-operatively, one patient experienced heavy bleeding of the nasopharyngeal wound, which was treated compression hemostasis using post-nasal packing. Twenty-three patients were followed up for 6-60 months. Twenty-two patients experienced cure; one patient experienced recurrence 10 months post-operatively, and repeat nasal endoscopic surgery was performed and resulted in cure.
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Affiliation(s)
- Dong Ye
- a Department of Otorhinolaryngology - Head and Neck Surgery , Lihuili Hospital of Ningbo University , Ningbo , PR China
| | - Zhisen Shen
- a Department of Otorhinolaryngology - Head and Neck Surgery , Lihuili Hospital of Ningbo University , Ningbo , PR China
| | - Guoli Wang
- a Department of Otorhinolaryngology - Head and Neck Surgery , Lihuili Hospital of Ningbo University , Ningbo , PR China
| | - Hongxia Deng
- a Department of Otorhinolaryngology - Head and Neck Surgery , Lihuili Hospital of Ningbo University , Ningbo , PR China
| | - Shijie Qiu
- a Department of Otorhinolaryngology - Head and Neck Surgery , Lihuili Hospital of Ningbo University , Ningbo , PR China
| | - Yuna Zhang
- a Department of Otorhinolaryngology - Head and Neck Surgery , Lihuili Hospital of Ningbo University , Ningbo , PR China
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Dahl JP, Zopf DA, Parikh SR. Do open and endoscopic resection approaches to juvenile nasopharyngeal angiofibroma result in similar blood loss and recurrence rates? Laryngoscope 2015; 125:2436-7. [PMID: 26154365 DOI: 10.1002/lary.25471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/21/2015] [Accepted: 06/08/2015] [Indexed: 11/05/2022]
Affiliation(s)
- John P Dahl
- Department of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
| | - David A Zopf
- Department of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, U.S.A
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