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Moshtaghi Fard Z, Aghadoost S, Moradi N, Sarmadi S, Mohammadi F, Bahrami N. Quality of Life in Adolescents and Young Adults with Cleft Lip and Palate with and Without Speech Therapy During COVID-19. Cleft Palate Craniofac J 2023:10556656231219413. [PMID: 38115690 DOI: 10.1177/10556656231219413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE Cleft-related speech concerns can affect the quality of life (QOL) in patients with cleft lip and palate (CLP). During the coronavirus disease 2019 (COVID-19), in-person speech therapy (ST) was restricted due to fear of getting infected. This study aimed to compare QOL in patients with CLP with and without ST during the pandemic. DESIGN Cross-sectional Study. SETTING CLP team at Tehran University of Medical Sciences (TUMS). PATIENTS/PARTICIPANTS Thirty-six CLP subjects with a mean age of 17.33 ± 4 years participated in two groups, including with and without ST. Fifteen subjects had cleft palate only (CPO) and others had CLP. INTERVENTIONS ST group received at least 10 ST sessions, and group without ST didn't receive ST during COVID-19. MAIN OUTCOME MEASURE(S) A virtual link of demographic and QOL adolescent cleft (QoLAdoCleft) questionnaires were sent to fill out. Results were extracted and transferred to SPSS. RESULTS Total and subscales' scores of QoLAdoCleft were lower in ST group than without ST but differences between them weren't statistically significant (P > .05). Furthermore, according to cleft type, there weren't any statistically significant differences in total, physical, and social subscales of QoLAdoCleft (P > .05); however, psychological subscale in CLP had a higher significant score than CPO (P < .05). CONCLUSIONS QOL was weak in all patients with CLP, and receiving/not receiving ST couldn't make noticeable differences between them. It seems; COVID-19 pandemic can have an adverse effect on these results. Also, subjects with CLP had weaker psychological than CPO due to negative psychosocial feedback related to Orofacial deformities received from society.
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Affiliation(s)
| | - Samira Aghadoost
- Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
| | - Negin Moradi
- Department of Communication Sciences and Disorders, University of Wisconsin-River Falls, USA
| | - Sarvin Sarmadi
- Department of Orthodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Farnoosh Mohammadi
- Craniomaxillofacial Research Center, Oral and Maxillofacial Surgery Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Naghmeh Bahrami
- Craniomaxillofacial Research Center, Department of Tissue Engineering and Applied Cellular Sciences, Tehran University of Medical Sciences, Tehran, Iran
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2
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Kitaya S, Suzuki J, Ikeda R, Sato A, Adachi M, Shirakura M, Kobayashi Y, Shirakura S, Suzuki Y, Imai Y, Katori Y. Impact of palatoplasty techniques on tympanic membrane findings and hearing prognosis in children with cleft palate. Int J Pediatr Otorhinolaryngol 2023; 174:111747. [PMID: 37820571 DOI: 10.1016/j.ijporl.2023.111747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing. METHODS We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results. RESULTS Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups. CONCLUSIONS Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty.
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Affiliation(s)
- Shiori Kitaya
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | - Jun Suzuki
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Ryoukichi Ikeda
- Department of Otolaryngology, Head and Neck Surgery, Iwate Medical University, School of Medicine, Shiwa, Iwate, Japan
| | - Akimitsu Sato
- Department of Plastic and Reconstructive Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mika Adachi
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Masayuki Shirakura
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yuta Kobayashi
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shiho Shirakura
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yuka Suzuki
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshimichi Imai
- Department of Plastic and Reconstructive Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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3
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Stanton E, Kondra K, Brahme I, Lasky S, Munabi NCO, Jimenez C, Jacob L, Urata MM, Hammoudeh JA, Magee WP. Tympanostomy Tubes: Are They Necessary? A Systematic Review on Implementation in Cleft Care. Cleft Palate Craniofac J 2023; 60:430-445. [PMID: 35044261 DOI: 10.1177/10556656211067901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To understand the indication for and the effects of early ventilation tube insertion (VTI) on hearing and speech for patients with cleft lip and/or palate (CLP). DESIGN We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-guided systematic review of relevant literature. SETTING Setting varied by geographical location and level of clinical care across studies. PATIENTS, PARTICIPANTS Patients with CLP who underwent VTI were included. INTERVENTIONS No interventions were performed. MAIN OUTCOME MEASURE(S) Primary outcome measures were hearing and speech following VTI. Secondary outcome measures were tube-related and middle ear complications. Early VTI occurred before or at time of palatoplasty while late VTI occurred after palatoplasty. RESULTS Twenty-three articles met inclusion criteria. Articles varied among study design, outcome measures, sample size, follow-up, and quality. Few studies demonstrated support for early VTI. Many studies reported no difference in hearing or speech between early and late VTI. Others reported worse outcomes, greater likelihood of complications, or needing repeat VTI following early tympanostomy placement. Several studies had significant limitations, including confounding variables, small sample size, or not reporting on our primary outcome. CONCLUSIONS No consistency was found regarding which patients would benefit most from early VTI. Given the aforementioned variability and sub-optimal methodologies, additional studies are warranted to provide stronger evidence regarding VTI timing in cleft care.
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Affiliation(s)
- Eloise Stanton
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA
| | - Katelyn Kondra
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA
| | | | - Sasha Lasky
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Christian Jimenez
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA
| | - Laya Jacob
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA
| | - Mark M Urata
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA.,University of Southern California, Los Angeles, CA, USA
| | - Jeffrey A Hammoudeh
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA.,University of Southern California, Los Angeles, CA, USA
| | - William P Magee
- 5150Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, Los Angeles, CA, USA
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Hidaka H, Ito M, Ikeda R, Kamide Y, Kuroki H, Nakano A, Yoshida H, Takahashi H, Iino Y, Harabuchi Y, Kobayashi H. Clinical practice guidelines for the diagnosis and management of otitis media with effusion (OME) in children in Japan - 2022 update. Auris Nasus Larynx 2022:S0385-8146(22)00232-2. [PMID: 36577619 DOI: 10.1016/j.anl.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/02/2022] [Accepted: 12/09/2022] [Indexed: 12/28/2022]
Abstract
This is an update of the 2015 Guidelines developed by the Japan Otological Society and Oto-Rhino-Laryngeal Society of Japan defining otitis media with effusion (OME) in children (younger than 12 years old) and describing the disease rate, diagnosis, and method of examination. Recommended therapies that received consensus from the guideline committee were updated in consideration of current therapies used in Japan and based on available evidence. METHOD Regarding the treatment of OME in children, we developed Clinical Questions (CQs) and retrieved documents on each theme, including the definition, disease state, method of diagnosis, and medical treatment. In the previous guidelines, no retrieval expression was used to designate a period of time for literature retrieval. Conversely, a literature search of publications from March 2014 to May 2019 has been added to the JOS 2015 Guidelines. For publication of the CQs, we developed and assigned strengths to recommendations based on the collected evidence. RESULTS OME in children was classified into one group lacking the risk of developing chronic or intractable disease and another group at higher risk (e.g., children with Down syndrome, cleft palate), and recommendations for clinical management, including follow-up, is provided. Information regarding management of children with unilateral OME and intractable cases complicated by adhesive otitis media is also provided. CONCLUSION In clinical management of OME in children, the Japanese Clinical Practice Guidelines recommends management not only of complications of OME itself, such as effusion in the middle ear and pathologic changes in the tympanic membrane, but also pathologic changes in surrounding organs associated with infectious or inflammatory diseases.
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Affiliation(s)
- Hiroshi Hidaka
- Department of Otorhinolaryngology-Head and Neck Surgery, Kansai Medical University, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
| | - Makoto Ito
- Department of Pediatric Otolaryngology, Jichi Children's Medical Center Tochigi, Jichi Medical University, Japan
| | - Ryoukichi Ikeda
- Department of Otolaryngology-Head & Neck Surgery, Iwate Medical University, Japan
| | | | | | - Atsuko Nakano
- Division of Otorhinolaryngology, Chiba Children's Hospital, Japan
| | - Haruo Yoshida
- Department of Otolaryngology Head and Neck Surgery, Nagasaki University School of Medicine, Japan
| | - Haruo Takahashi
- Department of Otolaryngology Head and Neck Surgery, Nagasaki University School of Medicine, Japan
| | - Yukiko Iino
- Department of Otolaryngology, Tokyo-Kita Medical Center, Japan
| | - Yasuaki Harabuchi
- Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical University, Japan
| | - Hitome Kobayashi
- Department of Otorhinolaryngology, Showa University School of Medicine, Japan
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Rosenfeld RM, Tunkel DE, Schwartz SR, Anne S, Bishop CE, Chelius DC, Hackell J, Hunter LL, Keppel KL, Kim AH, Kim TW, Levine JM, Maksimoski MT, Moore DJ, Preciado DA, Raol NP, Vaughan WK, Walker EA, Monjur TM. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg 2022; 166:S1-S55. [PMID: 35138954 DOI: 10.1177/01945998211065662] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the term otitis media (middle ear inflammation). This guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The guideline is intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals. PURPOSE The purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research. METHODS In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy. ACTION STATEMENTS The GUG made strong recommendations for the following KASs: (14) clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea; (16) the surgeon or designee should examine the ears of a child within 3 months of tympanostomy tube insertion AND should educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude.The GUG made recommendations for the following KASs: (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown); (2) clinicians should obtain a hearing evaluation if OME persists for 3 months or longer OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties; (5) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (6) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (7) clinicians should offer bilateral tympanostomy tube insertion in children with recurrent acute otitis media who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (8) clinicians should determine if a child with recurrent acute otitis media or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (10) the clinician should not place long-term tubes as initial surgery for children who meet criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube; (12) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (13) clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement; (15) clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes.The GUG offered the following KASs as options: (4) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable, all or in part, to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life; (9) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer; (11) clinicians may perform adenoidectomy as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) OR in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.
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Affiliation(s)
| | - David E Tunkel
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Charles E Bishop
- University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Daniel C Chelius
- Baylor College of Medicine-Texas Children's Hospital, Houston, Texas, USA
| | - Jesse Hackell
- Pomona Pediatrics, Boston Children's Health Physicians, Pomona, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Lisa L Hunter
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Ana H Kim
- Columbia University Medical Center, New York, New York, USA
| | - Tae W Kim
- University of Minnesota School of Medicine/Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Jack M Levine
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | | | - Denee J Moore
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | - William K Vaughan
- Consumers United for Evidence-Based Healthcare, Falls Church, Virginia, USA
| | | | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Schwarz SJ, Brandenburg LS, Weingart JV, Schupp W, Füssinger MA, Pantke CF, Beck RL, Metzger MC. Prevalence of Tympanostomy Tube Placement in Relation to Cleft Width and Type. Laryngoscope 2021; 131:E2764-E2769. [PMID: 34142721 DOI: 10.1002/lary.29602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 04/20/2021] [Accepted: 04/25/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS The prevalence of tympanostomy tube surgery (TTS) in patients with a cleft deformity was investigated, in relation to cleft width and cleft type. STUDY DESIGN Retrospective review of medical health records. METHODS Retrospective review of medical health records. Seventy-eight patients with non-syndromic cleft deformity of the palate and/or alveolus and lip between 2003 and 2017 were investigated. All available medical documents were analyzed. The study group was divided into subgroups: 1) patients with isolated cleft palate (CP) and patients with a cleft palate with cleft lip and alveolus (CLP). 2) According to Veau's classification (I-IV), further subgroups were defined. Cleft width was measured using plaster cast models. RESULTS TTS was performed in 55% of the patients (n = 43). Considering Veau's classification, TTS was conducted as follows: Veau I 65.2% (n = 15/23), Veau II 55.0% (n = 11/20), Veau III 47.6% (n = 10/21), and Veau IV 50.0% (n = 7/14). Cleft classifications, maxillary arch width, and absolute/relative cleft width had no statistical impact on TTS occurrence. Although no significant correlation could be found, patients in our study group with CP (Veau I and II) underwent TTS more often (60.5%, n = 26/43) than patients with CPL (Veau III and IV; 48.6%, n = 17/35) during a three-year follow-up. CONCLUSION None of the cleft characteristics examined had a significant impact on the proportion of patients who received TTS. Nevertheless, patients with lower Veau classification and CP received tympanostomy tubes more often. Therefore, otolaryngologists and pediatricians treating children with cleft palate should maintain a high level of suspicion for chronic middle ear effusion, even in patients with small clefts. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Steffen Jochen Schwarz
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Leonard Simon Brandenburg
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Julia Vera Weingart
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Wiebke Schupp
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Marc Anton Füssinger
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Chiara-Fabienne Pantke
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Rainer Linus Beck
- Department of Otorhinolaryngology, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Marc Christian Metzger
- Department of Oral and Maxillofacial Surgery, Freiburg University Medical Centre of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
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