1
|
Kwon JJ, Milner TD, Kürten C, Pang EH, Chen W, Tran KL, Wilson D, Dimond D, Salcudean SE, Prisman E. Towards transcervical ultrasound-guided transoral robotic surgery. Oral Oncol 2025; 161:107167. [PMID: 39752794 DOI: 10.1016/j.oraloncology.2024.107167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 12/16/2024] [Accepted: 12/25/2024] [Indexed: 01/29/2025]
Abstract
BACKGROUND In the context of transoral robotic surgery (TORS) for oropharyngeal squamous carcinoma (OPSCC), preoperative imaging and intraoperative visualization plays a pivotal role in optimizing resection margins. Prior work has demonstrated the ability of transoral ultrasound (US) in identifying OPSCC margins and vascular structures. This study evaluates the effectiveness of transcervical ultrasound (TUS), as well as other preoperative imaging modalities, in evaluating OPSCC volumes and compares this to post TORS pathological OPSCC volumes. METHODS Forty-one patients undergoing TORS between 2021 and 2023 were included. TUS was performed in all 41 patients, of which 37 had preoperative CT, 16 had PET-CT and 15 had MRI. Tumor dimensions on TUS, CT, and MRI were measured in craniocaudal, anteroposterior, and mediolateral planes to compute tumor volumes. Preoperative PET-CTs were analyzed to compute the metabolic tumour volume (MTV). Pathological tumor volumes served as the gold standard for comparison. RESULTS No statistically significant differences were found between pathological tumor volumes and those measured by TUS, CT, PET-CT, or MRI (p = 0.57, 0.47, 0.28, 0.29). Both TUS and PET-CT showed strong correlation with pathology (R = 0.92, p < 0.0001), followed by CT (R = 0.83, p < 0.0001) and MRI (R = 0.55, p = 0.031). The percent difference of radiologic volumes from pathology volumes was lowest for MRI (19.37 % ± 28.28), followed by TUS (26.12 % ± 20.97), PET-CT (32.59 % ± 21.95), and CT (39.94 % ± 62.94). CONCLUSIONS TUS demonstrates comparable accuracy to CT, PET-CT, and MRI in assessing primary tumor volumes in patients with oropharyngeal squamous cell carcinoma (OPSCC) undergoing TORS. The strong correlation of TUS with final pathology, combined with its relatively non-invasive transcervical (versus transoral) approach and real-time acquisition, suggests that TUS has the potential to supplement TORS with image guidance.
Collapse
Affiliation(s)
- Jamie Jy Kwon
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of British Columbia, Canada
| | - Thomas D Milner
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of British Columbia, Canada
| | - Cornelius Kürten
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of British Columbia, Canada
| | - Emily Ht Pang
- Department of Radiology, University of British Columbia, Canada
| | - Wanwen Chen
- Department of Electrical and Computer Engineering, University of British Columbia, Canada
| | - Khanh Linh Tran
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of British Columbia, Canada
| | - Don Wilson
- Department of Surgery, University of British Columbia, Canada
| | - Dennis Dimond
- Department of Radiology, University of British Columbia, Canada
| | - Septimiu E Salcudean
- Department of Electrical and Computer Engineering, University of British Columbia, Canada
| | - Eitan Prisman
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of British Columbia, Canada.
| |
Collapse
|
2
|
Mouratidou S, Chaidas K. Transoral Robotic Surgery for Patients with Obstructive Sleep Apnoea: A Systematic Literature Review of Current Practices. Life (Basel) 2024; 14:1700. [PMID: 39768406 PMCID: PMC11676293 DOI: 10.3390/life14121700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Revised: 11/23/2024] [Accepted: 12/20/2024] [Indexed: 01/11/2025] Open
Abstract
Transoral robotic surgery (TORS) for tongue base reduction (TBR) and/or epiglottic surgery is an effective treatment option for selected patients with moderate to severe obstructive sleep apnoea (OSA). This systematic review aims to provide an up-to-date overview of current practices and challenges associated with TORS for OSA. PubMed and Embase databases were searched up to December 2022 following PRISMA guidelines. Primary outcome measures were surgical technique, intraoperative measures, postoperative management and complications. A total of 32 articles, including 2546 patients, met the inclusion criteria. TORS was most commonly performed as part of a multilevel surgical approach. Nasotracheal intubation was the preferred method for general anaesthesia. The surgical technique for TORS tongue base and epiglottis did not differ significantly among institutions, although some variations exist. Postoperative management varied, with most authors aiming for immediate postoperative extubation, routine postoperative ward admission and early oral intake initiation. Common postoperative complications were dysphagia and bleeding, with no reported mortality. TORS is established as a safe and feasible surgical option for selected OSA patients, addressing tongue base and/or epiglottic obstruction. However, further studies are required to determine patients' selection criteria, preferred volume of excised tongue tissue and to assess the necessity for postoperative intensive care unit monitoring.
Collapse
Affiliation(s)
| | - Konstantinos Chaidas
- ENT Department, University Hospital of Alexandroupolis, Democritus University of Thrace—Medical School, 68100 Alexandroupolis, Greece
- ENT Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| |
Collapse
|
3
|
Pavone M, Seeliger B, Teodorico E, Goglia M, Taliento C, Bizzarri N, Lecointre L, Akladios C, Forgione A, Scambia G, Marescaux J, Testa AC, Querleu D. Ultrasound-guided robotic surgical procedures: a systematic review. Surg Endosc 2024; 38:2359-2370. [PMID: 38512350 PMCID: PMC11078854 DOI: 10.1007/s00464-024-10772-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/24/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Ultrasound has been nicknamed "the surgeon's stethoscope". The advantages of laparoscopic ultrasound beyond a substitute for the sense of touch are considerable, especially for robotic surgery. Being able to see through parenchyma and into vascular structures enables to avoid unnecessary dissection by providing a thorough assessment at every stage without the need for contrast media or ionising radiation. The limitations of restricted angulation and access within the abdominal cavity during laparoscopy can be overcome by robotic handling of miniaturised ultrasound probes and the use of various and specific frequencies will meet tissue- and organ-specific characteristics. The aim of this systematic review was to assess the reported applications of intraoperative ultrasound-guided robotic surgery and to outline future perspectives. METHODS The study adhered to the PRISMA guidelines. PubMed, Google Scholar, ScienceDirect and ClinicalTrials.gov were searched up to October 2023. Manuscripts reporting data on ultrasound-guided robotic procedures were included in the qualitative analysis. RESULTS 20 studies met the inclusion criteria. The majority (53%) were related to the field of general surgery during liver, pancreas, spleen, gallbladder/bile duct, vascular and rectal surgery. This was followed by other fields of oncological surgery (42%) including urology, lung surgery, and retroperitoneal lymphadenectomy for metastases. Among the studies, ten (53%) focused on locating tumoral lesions and defining resection margins, four (15%) were designed to test the feasibility of robotic ultrasound-guided surgery, while two (10.5%) aimed to compare robotic and laparoscopic ultrasound probes. Additionally two studies (10.5%) evaluated the robotic drop-in probe one (5%) assessed the hepatic tissue consistency and another one (5%) aimed to visualize the blood flow in the splenic artery. CONCLUSION The advantages of robotic instrumentation, including ergonomics, dexterity, and precision of movements, are of relevance for robotic intraoperative ultrasound (RIOUS). The present systematic review demonstrates the virtue of RIOUS to support surgeons and potentially reduce minimally invasive procedure times.
Collapse
Affiliation(s)
- Matteo Pavone
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France.
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France.
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Barbara Seeliger
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
- Department of Digestive and Endocrine Surgery, University Hospitals of Strasbourg, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Elena Teodorico
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Marta Goglia
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Cristina Taliento
- Department of Obstetrics and Gynecology, University Hospital Ferrara, Ferrara, Italy
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Lise Lecointre
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
- Department of Gynecologic Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Cherif Akladios
- Department of Gynecologic Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | | | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Jacques Marescaux
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
| | - Antonia C Testa
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Denis Querleu
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| |
Collapse
|
4
|
Vergara J, Miles A, Lopes de Moraes J, Chone CT. Contribution of Wireless Wi-Fi Intraoral Cameras to the Assessment of Swallowing Safety and Efficiency. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:821-836. [PMID: 38437030 DOI: 10.1044/2023_jslhr-23-00375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Clinical evaluation of swallowing provides important clinical information but is limited in detecting penetration, aspiration, and pharyngeal residue in patients with suspected dysphagia. Although this is an old problem, there remains limited access to low-cost methods to evaluate swallowing safety and efficiency. PURPOSE The purpose of this technical report is to describe the experience of a single center that recently began using a wireless Wi-Fi intraoral camera for transoral endoscopic procedures as an adjunct to clinical swallowing evaluation. We describe the theoretical structure of this new clinical evaluation proposal. We present descriptive findings on its diagnostic performance in relation to videofluoroscopic swallowing study as the gold standard in a cohort of seven patients with dysphagia following head and neck cancer. We provide quantitative data on intra- and interrater reliability. Furthermore, this report discusses how this technology can be applied in the clinical practice of professionals who treat patients with dysphagia and provides directions for future research. CONCLUSIONS This preliminary retrospective study suggests that intraoral cameras can reveal the accumulated oropharyngeal secretions and postswallow pharyngolaryngeal residue in patients with suspected dysphagia. Future large-scale studies focusing on validating and exploring this contemporary low-cost technology as part of a clinical swallowing evaluation are warranted.
Collapse
Affiliation(s)
- José Vergara
- Department of Surgery, Head and Neck Surgery, University of Campinas, São Paulo, Brazil
| | - Anna Miles
- Department of Speech Science, School of Psychology, University of Auckland, New Zealand
| | - Juliana Lopes de Moraes
- Department of Otorhinolaryngology and Head and Neck Surgery, University of Campinas, São Paolo, Brazil
| | - Carlos Takahiro Chone
- Department of Otorhinolaryngology and Head and Neck Surgery, University of Campinas, São Paolo, Brazil
| |
Collapse
|
5
|
Wyszomirski K, Walędziak M, Różańska-Walędziak A. Obesity, Bariatric Surgery and Obstructive Sleep Apnea-A Narrative Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1266. [PMID: 37512076 PMCID: PMC10385107 DOI: 10.3390/medicina59071266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
The purpose of this review was to analyze the available literature on the subject of obesity and obstructive sleep apnea. We searched for available articles for the time period from 2013 to 2023. Obesity is listed as one of the most important health issues. Complications of obesity, with obstructive sleep apnea (OSA) listed among them, are common problems in clinical practice. Obesity is a well-recognized risk factor for OSA, but OSA itself may contribute to worsening obesity. Bariatric surgery is a treatment of choice for severely obese patients, especially with present complications, and remains the only causative treatment for patients with OSA. Though improvement in OSA control in patients after bariatric surgery is well-established knowledge, the complete resolution of OSA is achieved in less than half of them. The determination of subpopulations of patients in whom bariatric surgery would be especially advantageous is an important issue of OSA management. Increasing the potential of non-invasive strategies in obesity treatment requires studies that assess the efficacy and safety of combined methods.
Collapse
Affiliation(s)
- Krzysztof Wyszomirski
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine-National Research Institute, Szaserów 128 St., 04-141 Warsaw, Poland
| | - Anna Różańska-Walędziak
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland
| |
Collapse
|
6
|
Chen W, Kalia M, Zeng Q, Pang EHT, Bagherinasab R, Milner TD, Sabiq F, Prisman E, Salcudean SE. Towards transcervical ultrasound image guidance for transoral robotic surgery. Int J Comput Assist Radiol Surg 2023:10.1007/s11548-023-02898-y. [PMID: 37103728 DOI: 10.1007/s11548-023-02898-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE Trans-oral robotic surgery (TORS) using the da Vinci surgical robot is a new minimally-invasive surgery method to treat oropharyngeal tumors, but it is a challenging operation. Augmented reality (AR) based on intra-operative ultrasound (US) has the potential to enhance the visualization of the anatomy and cancerous tumors to provide additional tools for decision-making in surgery. METHODS We propose a US-guided AR system for TORS, with the transducer placed on the neck for a transcervical view. Firstly, we perform a novel MRI-to-transcervical 3D US registration study, comprising (i) preoperative MRI to preoperative US registration, and (ii) preoperative to intraoperative US registration to account for tissue deformation due to retraction. Secondly, we develop a US-robot calibration method with an optical tracker and demonstrate its use in an AR system that displays anatomy models in the surgeon's console in real-time. RESULTS Our AR system achieves a projection error from the US to the stereo cameras of 27.14 and 26.03 pixels (image is 540[Formula: see text]960) in a water bath experiment. The average target registration error (TRE) for MRI to 3D US is 8.90 mm for the 3D US transducer and 5.85 mm for freehand 3D US, and the TRE for pre-intra operative US registration is 7.90 mm. CONCLUSION We demonstrate the feasibility of each component of the first complete pipeline for MRI-US-robot-patient registration for a proof-of-concept transcervical US-guided AR system for TORS. Our results show that trans-cervical 3D US is a promising technique for TORS image guidance.
Collapse
Affiliation(s)
- Wanwen Chen
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, BC, Canada.
| | - Megha Kalia
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - Qi Zeng
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - Emily H T Pang
- Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Razeyeh Bagherinasab
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - Thomas D Milner
- Division of Otolaryngology, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Farahna Sabiq
- Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Eitan Prisman
- Division of Otolaryngology, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Septimiu E Salcudean
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
7
|
Helliwell K, Hughes VJ, Bennion CM, Manning-Stanley A. The use of videofluoroscopy (VFS) and fibreoptic endoscopic evaluation of swallowing (FEES) in the investigation of oropharyngeal dysphagia in stroke patients: A narrative review. Radiography (Lond) 2023; 29:284-290. [PMID: 36640583 DOI: 10.1016/j.radi.2022.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Patients with suspected acute stroke require rapid assessment of swallowing on admission. If aspiration is suspected, this takes the form of specialist assessment, using either videofluoroscopy (VFS) or fibreoptic endoscopic evaluation of swallowing (FEES). The review aim was to evaluate and compare the effectiveness of each method in stroke patients. Literature was collected from the databases Scopus, Web of Science and Medline, and articles included in the review were published within the last 10 years, in the English language. KEY FINDINGS Sensitivity and specificity ranged from 0.29-0.33 and 0.96-1.0 for VFS, respectively, and 0.37-1.0 and 0.65-0.87 for FEES, respectively, depending on the type of bolus utilised. VFS is the current gold-standard for the investigation of oropharyngeal dysphagia (OD), however, radiation dose and patient transport implications mean FEES may be preferred. FEES has limitations including 'whiteout' and the invasive nature of the endoscope. The NICE guidelines do not recommend a definitive protocol specifically in stroke patients. This suggests further research may be required to determine the most effective method. CONCLUSION FEES is a beneficial first line examination, providing limited invasiveness, and administering a high level of patient suitability, without using ionising radiation. VFS could potentially be useful following FEES to secure full visualisation, ensuring an aspiration event is not missed during FEES. IMPLICATIONS FOR PRACTICE Use of FEES as the first line test rather than VFS, ensures radiation dose is as low as reasonably practicable (ALARP). Ongoing research to ensure protocols follow current best practice can help ensure accurate management of oropharyngeal dysphagia in stroke patients.
Collapse
Affiliation(s)
- K Helliwell
- Calderdale and Huddersfield NHS Foundation Trust, Calderdale Royal Hospital, Salterhebble, Halifax, HX3 0PW, UK.
| | - V J Hughes
- Department of Diagnostic Radiography, School of Health Sciences, University of Liverpool, Johnston Building, Brownlow Hill, L69 3GB, UK.
| | - C M Bennion
- Department of Diagnostic Radiography, School of Health Sciences, University of Liverpool, Johnston Building, Brownlow Hill, L69 3GB, UK.
| | - A Manning-Stanley
- Department of Diagnostic Radiography, School of Health Sciences, University of Liverpool, Johnston Building, Brownlow Hill, L69 3GB, UK.
| |
Collapse
|
8
|
Lai YJ, Su PL, Li CY, Lin CY, Hung CH, Lin CY. Oropharyngeal Rehabilitation for Patients With Moderate to Severe Obstructive Sleep Apnea After Transoral Robotic Surgery. Otolaryngol Head Neck Surg 2022; 167:971-978. [PMID: 35349361 DOI: 10.1177/01945998221088752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine whether combined transoral robotic surgery and postoperative oropharyngeal rehabilitation are effective for reducing the severity of obstructive sleep apnea. STUDY DESIGN A quasi-experimental study enrolled participants without blinding between May 2019 and April 2021. SETTING Single-center study at National Cheng Kung University Hospital. METHODS Patients with moderate to severe obstructive sleep apnea who were otherwise healthy were recruited from the ear, nose, and throat department at National Cheng Kung University Hospital. The group undergoing transoral robotic surgery with oropharyngeal rehabilitation (n = 18) received a 12-week intervention consisting of home-based rehabilitation exercises following surgery; the transoral robotic surgery group (n = 17) received surgery only; and the control group (n = 15) received conservative treatment, such as continuous positive airway pressure therapy or other oral appliance therapy. Polysomnography data and tongue muscle performance were measured before and after the interventions. RESULTS The group that underwent transoral robotic surgery with oropharyngeal rehabilitation exhibited significantly improved tongue protrusion strength as compared with the transoral robotic surgery-only group, as well as significantly improved apnea-hypopnea index in the supine position vs the control group. CONCLUSION In this study, we demonstrated the synergistic effects of transoral robotic surgery and postoperative oropharyngeal rehabilitation for adult patients with obstructive sleep apnea. Objective records should be used to monitor home-based rehabilitation exercises and examine the lasting synergistic effects.
Collapse
Affiliation(s)
- Yi-Ju Lai
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Po-Lan Su
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Sleep Medicine Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan.,Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Chung-Ying Lin
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Hsia Hung
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Yu Lin
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Environmental and Occupational Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|