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Ajler P, Davila EZG, Plou P, Casto F, Christiansen S, Boccalatte LA, Larrañaga J. Multidisciplinary approach to anaplastic and metastatic meningioma: A case report and review of the literature. Surg Neurol Int 2023; 14:230. [PMID: 37560559 PMCID: PMC10408638 DOI: 10.25259/sni_222_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/14/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Meningiomas are slow-growing neoplasms, accounting for 20% of all primary intracranial neoplasms and 25% of all intraspinal tumors. Atypical and anaplastic meningiomas are infrequent, representing fewer than 5% of all meningiomas. Unusually, they can show aggressive behavior, and extracranial metastases are extremely rare, representing approximately 0.1% of all reported cases. CASE DESCRIPTION Fifty-six-year-old male patient diagnosed with atypical basal frontal meningioma with multiple resections, both endoscopic endonasal and transcranial. After hypofractionated radiosurgery, the patient showed new tumor recurrence associated to right cervical level II ganglionic metastasis. We opted for complete resection of the meningioma and reconstruction with anterior rectus abdominis muscle flap, as well as selective cervical ganglionectomy. Anatomical pathology showed neoplastic proliferation of meningothelial cells in syncytial cytoplasm, oval or spherical nuclei with slight anisocariosis and hyperchromasia, and intranuclear vacuoles, all compatible with anaplastic meningioma. CONCLUSION Due to a lack of consensus on how to treat a metastatic malignant meningioma, this pathology requires a multidisciplinary approach, and treatment needs to be adapted to each particular case. Complete resection of the lesion is the primary goal, and this requires complex procedures involving endocranial as well as extracranial surgeries, which result in composite defects difficult to resolve. Microvascular free flaps are considered the gold standard in reconstructions of large skull base defects, with high success rates and few complications.
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Affiliation(s)
- Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina
| | | | - Pedro Plou
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina
| | - Florencia Casto
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina
| | - Silvia Christiansen
- Department of Pathological Anatomy, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina
| | - Luis Alejandro Boccalatte
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina
| | - Juan Larrañaga
- Reconstructive Surgery, Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina
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Kejner AE, Lee BJ, Pipkorn P. Lateral Skull Base and Auricular Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00073-7. [PMID: 37258407 DOI: 10.1016/j.otc.2023.04.016] [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: 06/02/2023]
Abstract
Reconstruction of the lateral temporal bone with adequate functional and cosmetic outcomes depends on a multidisciplinary approach including the head and neck surgeon, reconstructive surgeon, neurotologist, and anaplastologist. Approaching the defect includes consideration of the location, tissue type, function, and patient/tumor characteristics. Anatomic limitations due to prior therapy also play an important role in reconstructive choices. Here, we review contemporary literature regarding the reconstruction of this complex region.
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Affiliation(s)
- Alexandra E Kejner
- Division of Head & Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue MSC 550, Charleston, SC 29436, USA.
| | - Byung Joo Lee
- Division of Maxillofacial Prosthodontics, MUSC 135 Rutledge Avenue MSC 550, Charleston, SC 29436, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8115, St. Louis, MO 63110, USA
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Plou P, Boccalatte L, Padilla-Lichtenberger F, Figari M, Ajler P, Larrañaga J. Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:22-31. [PMID: 36623890 DOI: 10.1016/j.neucie.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/25/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Resection of malignant tumors located in the anterior and middle fossae of the skull base requires thorough anatomical knowledge, as well as experience regarding the possible reconstructive options to resolve the resulting defects. The anatomical and functional relevance of the region, the complexity of the defects requiring reconstruction and the potential complications that can occur, represent a true challenge for the surgical team. The goal of this study is to describe the microsurgical reconstructive techniques available, their usefulness and postoperative complications, in patients with malignant tumors involving the skull base. MATERIALS AND METHOD This observational, retrospective study, included all patients who underwent surgery for malignant craniofacial tumors from January 1st, 2009 to January 1st, 2019 at a University Hospital in Argentina. Only patients who required reconstruction of the resulting defect with a free flap were included. RESULTS Twenty-four patients required reconstruction with FF; 14 were male (58.3%) and mean age was 54.9 years. Sarcoma was the most frequent tumor histology. Free flaps used were the following: anterolateral thigh, rectus abdominis, radial, latissimus dorsi, iliac crest and fibular. Complications occurred in 6 cases and no deaths were reported in the study group. CONCLUSION Free flaps are considered one of the preferable choices of treatment for large skull base defects. In spite of the complexity of the technique and the learning curve required, free flaps have shown to be safe, with a low rate of serious complications. For these patients, the surgical resolution should be performed by a multidisciplinary team.
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Affiliation(s)
- Pedro Plou
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina.
| | - Luis Boccalatte
- Section of Head and Neck Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina
| | | | - Marcelo Figari
- Section of Head and Neck Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| | - Juan Larrañaga
- Section of Head and Neck Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina; Section of Reconstructive Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina
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Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Tanaka K, Suesada N, Homma T, Mori H, Sugawara T, Tsutsumi T, Asakage T, Okazaki M. The different concepts of surgical managements between anterior and lateral skull base reconstructions based on surgical purposes. Auris Nasus Larynx 2021; 49:271-278. [PMID: 34462170 DOI: 10.1016/j.anl.2021.08.005] [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: 12/27/2020] [Revised: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Anterior and middle cranial fossa defects require different strategies, depending on their anatomical location. The aim of this study was to elucidate the surgical managements for the defects based on surgical purposes and to clarify the conceptional differences relating to anterior and lateral skull base reconstructions. METHODS This study included patients who had undergone reconstructive surgery for anterior or middle cranial fossa defects in our institution between July 2008 and June 2019. It consisted of 66 patients who had been subject to anterior skull base reconstructions, and 84 patients who had experienced lateral skull base reconstructions. The medical records were examined retrospectively, and the surgical purposes and procedures performed were reviewed. The surgical purposes were divided into four groups: Separation, Restoration, Augmentation, and Coverage. RESULTS Regarding anterior skull base reconstructions, the Separation group included 65 patients, who represented 98% of this category. There were 26 cases in the Separation-only group, 20 of which were reconstructed with locoregional flaps, and 6 of which with free tissue transfers. A Combination group, which consisted of Separation and Other purposes, consisted of 40 cases. Within this group, 5 cases were reconstructed with locoregional flaps, and 35 with free tissue transfers. Regarding lateral skull base reconstructions, the Separation group included 34 patients, who represented 40% of this category. The rate of the Other purposes represented the majority. In the Separation-only group of 24 patients, 16 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In the Combination group of 10 patients, 2 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In groups other than the Separation group, 27 cases were reconstructed with locoregional flaps and 23 cases with free tissue transfers. CONCLUSION In most anterior cranial fossa defect cases, the surgical purpose is separation. In middle cranial fossa defect cases, there are many cases in which the surgical purpose is not separation. In the Separation groups, relating to both anterior and lateral skull base reconstructions, the use of locoregional flaps was an effective measure. Free tissue transfers were required in many cases of the Combination group. Outside of the Separation group associated with lateral skull base reconstructions, the use of locoregional flaps and free tissue transfers were almost equal in proportion, and the selection of reconstructive procedures tended to change from locoregional flaps to large free flaps with increase in the numbers of surgical purposes.
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Affiliation(s)
- Kentaro Tanaka
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
| | - Nobuko Suesada
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Tsutomu Homma
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Takashi Sugawara
- Department of Neurosurgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Tsutsumi
- Department of Otolaryngology, Graduate School of Medical Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahiro Asakage
- Department of Head and Neck Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mutsumi Okazaki
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Liu HJ, Li DZ, Li XJ, Qian HP, An CM, Wan JH. Free Flap Transfer, a Safe and Efficient Method for Reconstruction of Composite Skull Base Defects After Salvage Resection of Advanced Intracranial and Extracranial Communicating Tumors. World Neurosurg 2021; 152:e62-e70. [PMID: 33940259 DOI: 10.1016/j.wneu.2021.04.084] [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: 03/02/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Surgical treatment of advanced intracranial and extracranial communicating skull base tumors is challenging, especially for the reconstruction of the large composite defect left by tumor resection. The aim of the study is to evaluate the utility of the free flap reconstruction of the defects resulting from radical resection of these tumors in a single institution. METHODS The clinical data of 17 consecutive patients who underwent free flap reconstruction for defect left by salvage resection of advanced intracranial and extracranial communicating tumors from 2013 to 2019 were retrospectively collected and analyzed. RESULTS There were 5 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 basal cell carcinomas, 2 meningiomas, 1 anaplastic hemangiopericytoma, 1 pleomorphic adenoma, 1 osteosarcoma, and 1 chondrosarcoma. All patients had recurrent neoplasms, 2 of whom had pulmonary metastasis. A modified radical cervical dissection was performed in 6 patients. The anterolateral thigh myocutaneous flap and rectus abdominis myocutaneous flap were used in 15 patients (88.2%) and 2 patients (11.8%), respectively. Complications were seen in 3 of 17 patients (17.6%) with 1 total flap loss. The median progression-free survival duration was 31 months. The 3- and 5-year progression-free survival rates were 0.47 and 0.24, respectively. The mean overall survival duration was 66 months. The 3- and 5-year overall survival rates were 0.85 and 0.68, respectively. CONCLUSIONS Free flap transfer is a safe and effective method with acceptable complications, useful for reconstruction of large composite skull base defects after salvage resection of advanced intracranial and extracranial communicating tumors. The functional and cosmetic results are satisfying.
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Affiliation(s)
- Hou-Jie Liu
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - De-Zhi Li
- Department of Head and Neck Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xue-Ji Li
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hai-Peng Qian
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chang-Ming An
- Department of Head and Neck Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jing-Hai Wan
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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[Reconstruction by thoracodorsal perforator flap after petrosectomy]. ANN CHIR PLAST ESTH 2020; 66:100-105. [PMID: 32527620 DOI: 10.1016/j.anplas.2020.04.003] [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: 03/29/2020] [Revised: 04/18/2020] [Accepted: 04/22/2020] [Indexed: 11/24/2022]
Abstract
Petrosectomy is a debilitating intervention, consisting of a resection of the bone forming the external auditory canal, the middle ear and sometimes the internal ear as well. The cavity formed after this surgery can lead to infectious complications. Reconstruction is an essential element for patients' rehabilitation. Most cases require local rotation flaps such as temporal muscle flap. However, when the remaining defect is too large or when the structures have been altered by radiotherapy, free flaps are the most adequate solution for repair. Upon review of the literature, there are very few articles providing options regarding reconstruction possibilities post-petrosectomy. Plastic surgeons are often unfamiliar with this indication, therefore, it is essential to call their attention in order to provide the best options of care in these difficult and complicated cases where possibilities are limited. That is why, it is important for us to share our experience in this domain through the example of our patient presenting with a large osteoradionecroses of the petrous bone, requiring resection and immediate reconstruction using a free flap.
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Hanasono MM. Reconstruction after open surgery for skull-base malignancies. J Neurooncol 2020; 150:469-475. [DOI: 10.1007/s11060-019-03370-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 12/11/2019] [Indexed: 01/20/2023]
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Trojanowski P, Szymański M, Trojanowska A, Andrzejczak A, Szczepanek D, Klatka J. Anterolateral thigh free flap in reconstruction of lateral skull base defects after oncological resection. Eur Arch Otorhinolaryngol 2019; 276:3487-3494. [PMID: 31515663 PMCID: PMC6858904 DOI: 10.1007/s00405-019-05627-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/30/2019] [Indexed: 01/13/2023]
Abstract
Purpose Evaluation of the utility of the free anterolateral thigh flap reconstruction of the defects resulting from radical temporal bone resection in the management of lateral skull base malignancies in a single institution. Methods An analysis of 17 en bloc subtotal petrosectomies for removal of malignant tumours was performed. There were 12 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenoid cystic carcinoma. The tumours were staged with the University of Pittsburgh TNM system. In all patients, the lateral temporal bone with the preservation of the petrous apex and carotid artery was performed. All patients had parotid gland resection. The post-resection defect was reconstructed with an ALT free flap. Results Tumour radical resection and defect reconstruction with an ALT flap was achieved in all patients without intraoperative complications. The transplants were harvested as fasciocutaneous flaps, 11 perfused by musculocutaneous and 6 by septocutaneous perforators. The ALT flaps had a mean pedicle length of 8 cm (6–12 cm), and the flap size ranged between 6 × 15 cm and 15 × 30 cm. The flaps were supplied by nine facial, five occipital and three maxillary arteries. Recipient-site veins included eight internal jugular, seven facial, one retromandibular and one external jugular vein. All arterial pedicles were anastomosed in an end-to-end manner. The veins were anastomosed with interrupted sutures and in 11 cases with Synovis-Coupler® devices. All the flap transfers were performed successfully. Three patients experienced postoperative complications. Conclusions The ALT flap proved to be effective for covering large temporal skull base defects resulting from the radical removal of temporal bone malignancies. The functional and cosmetic results were acceptable with a low complication rate.
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Affiliation(s)
- Piotr Trojanowski
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland.
| | - Marcin Szymański
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland
| | | | - Adrian Andrzejczak
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland
| | - Dariusz Szczepanek
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Janusz Klatka
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland
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Yafit D, Duek I, Abu-Ghanem S, Ungar OJ, Wengier A, Moshe-Levyn H, Yanko-Arzi R, Zaretski A, Margalit N, Abergel A, Muhanna N, Fliss DM. Surgical approaches for infratemporal fossa tumor resection: Fifteen years' experience of a single center. Head Neck 2019; 41:3755-3763. [PMID: 31407445 DOI: 10.1002/hed.25906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 06/01/2019] [Accepted: 07/19/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The aims of this study were to report our center's experience with infratemporal fossa (ITF) tumors, to review the treatment modalities and outcomes. METHODS Data of patients that underwent resection of ITF tumors in a single tertiary referral medical center were collected and analyzed. RESULTS Sixty-three patients were included. Sarcoma was the most common pathology (18; 29%). The most common surgical approach was the preauricular-orbitozygomatic approach (24; 38%), followed by endoscopic, craniofacial resection, and combined approaches. Forty-seven patients (75%) required reconstruction, 23 (49%) involving free tissue transfer. Thirty-five patients (76%) with malignant lesions required adjuvant therapy consisting of radiotherapy, chemotherapy, or both. Thirty-three patients suffered from complications related to surgery or adjuvant therapy. The three- and five-years survival rates for malignancy were 82% and 66%, respectively. CONCLUSION Complete surgical resection of ITF involving tumors is feasible, providing good long-term survival. Multidisciplinary approach is the key for success.
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Affiliation(s)
- Daniel Yafit
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Duek
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Abu-Ghanem
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Wengier
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Helena Moshe-Levyn
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ravit Yanko-Arzi
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arik Zaretski
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nevo Margalit
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nidal Muhanna
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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