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Ritter A, Barzilai-Birenboim S, Rapana OG, Fischer S, Levy I, Soudry E, Gilony D. Changing Trends in the Survival of Immunosuppressed Children with Invasive Fungal Rhinosinusitis. Am J Rhinol Allergy 2022; 36:568-573. [PMID: 35360956 DOI: 10.1177/19458924221090915] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute invasive fungal rhinosinusitis has been associated with high mortality rates. OBJECTIVE We aimed to explore the contribution of novel detection and treatment methods on the outcome of immunosuppressed children with acute invasive fungal rhinosinusitis. METHODS The records of all children with a hematologic or oncologic disease who developed acute invasive fungal rhinosinusitis between 2005-2020 were reviewed. RESULTS Thirty-four patients were included. Aspergillosis and mucormycosis were diagnosed in 20 patients (59%) and 12 patients (35%), respectively. Panfungal polymerase chain reaction (PCR) was associated with a change of treatment in 36% of patients. A more aggressive surgical approach as well as treatment with liposomal amphotericin B and novel antifungals were adopted in recent years. Overall, 26% of patients died of disease, however no disease-specific death occurred since 2012. Diagnosis using panfungal PCR (p = .04) and treatment with novel antifungal medications (p = .017) were significantly associated with disease-specific survival. CONCLUSION Enhanced fungal detection using panfungal PCR and treatment with novel antifungal agents, combined with rapid diagnosis and treatment, aggressive surgical approach and better control over the underlying oncological disease, may significantly improve the outcome of immunosuppressed children with acute invasive fungal rhinosinusitis.
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Affiliation(s)
- Amit Ritter
- Department of Otolaryngology Head and Neck Surgery, 36632Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel
| | - Shlomit Barzilai-Birenboim
- Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel.,The Rina Zaizov Division of Pediatric Hematology-Oncology, 36739Schneider Children's Medical Center, Petah Tikva, Israel
| | - Olga Gordon Rapana
- Department of Otolaryngology Head and Neck Surgery, 36632Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel
| | - Salvador Fischer
- Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel.,The Rina Zaizov Division of Pediatric Hematology-Oncology, 36739Schneider Children's Medical Center, Petah Tikva, Israel
| | - Itzhak Levy
- Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel.,Pediatric Infectious Diseases Unit, 36739Schneider Children's Medical Center, Petah Tikva, Israel
| | - Ethan Soudry
- Department of Otolaryngology Head and Neck Surgery, 36632Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel
| | - Dror Gilony
- Sackler Faculty of Medicine, 26745Tel Aviv University, Tel Aviv, Israel.,Department of Otolaryngology, 36739Schneider Children's Medical Center, Petah Tikva, Israel
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Fungal Infections in Liver Transplant Recipients. J Fungi (Basel) 2021; 7:jof7070524. [PMID: 34210106 PMCID: PMC8304186 DOI: 10.3390/jof7070524] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/25/2021] [Accepted: 06/21/2021] [Indexed: 01/03/2023] Open
Abstract
Invasive fungal infections (IFIs) are one of the most feared complications associated with liver transplantation, with high rates of morbidity and mortality. We discuss the most common invasive fungal infections in the setting of liver transplant, including Candida, Aspergillus, and Cryptococcal infections, and some less frequent but devastating mold infections. Further, we evaluate the use of prophylaxis to prevent invasive fungal infection in this population as a promising mechanism to reduce risks to patients after liver transplant.
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Samadi DS, Goldberg AN, Orlandi RR. Granulocyte Transfusion in the Management of Fulminant Invasive Fungal Rhinosinusitis. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240101500408] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Usually, fulminant, invasive fungal rhinosinusitis is observed in the immunocompromised patient and is associated with significant morbidity and mortality. A high index of suspicion and early diagnosis is imperative for optimizing outcome. Mainstays of treatment include antifungal agents and radical resection of necrotic tissue. Reversal of the underlying medical condition, when possible, is a critical part of the management. In the neutropenic population, granulocyte transfusion may represent an adjunct to current therapy. We provide the first report of a case of invasive fungal rhinosinusitis in which this intervention was used.
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Affiliation(s)
- Daniel S. Samadi
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Andrew N. Goldberg
- Department of Otolaryngology–Head and Neck Surgery, University of California–San Francisco, San Francisco, California
| | - Richard R. Orlandi
- Department of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah
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Abstract
BACKGROUND Immunosuppressive therapy places pediatric patients at risk of developing life-threatening sinonasal infections. Diagnosis and treatment are challenging owing to nonspecific signs and symptoms. The aim of this study was to present our department's experience with the surgical management of acute rhinosinusitis in immunosuppressed children. METHODS The records of all children with a hematologic or oncologic disease who underwent endoscopic sinus surgery (ESS) for acute rhinosinusitis from January 2005 to May 2014 were reviewed. Data were retrospectively collected on demographics, clinical and imaging characteristics, microbiology, pathology, treatment and outcome. RESULTS Thirty-four-immunosuppressed children underwent ESS for acute rhinosinusitis. Most patients had a fungal infection. Nineteen patients died at the end of follow-up; 10 deaths were infection-related. Facial swelling was the only symptom that correlated with death of infection. Relapse of the underlying disease, bone marrow transplantation, and long duration of neutropenia correlated with infection-related mortality. Fungal infection, and specifically Aspergillus, correlated with death from infection. CONCLUSIONS ESS is a safe and efficient procedure for diagnosing and treating immunosuppressed pediatric patients with acute rhinosinusitis. Early detection and aggressive medical and surgical treatment, with control of underlying risk factors, are crucial to improve outcome.
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Park AH, Muntz HR, Smith ME, Afify Z, Pysher T, Pavia A. Pediatric Invasive Fungal Rhinosinusitis in Immunocompromised Children With Cancer. Otolaryngol Head Neck Surg 2016; 133:411-6. [PMID: 16143192 DOI: 10.1016/j.otohns.2005.04.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Accepted: 04/22/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES: 1) To determine the factors that predispose towards invasive fungal rhinosinusitis (FS) in immunocompromised children with cancer, and 2) to propose practice guidelines for management of pediatric FS in immunocompromised patients. METHODS: Retrospective chart review of 9 patients who developed invasive FS compared to 8 patients who did not develop invasive FS during the study period. Presenting signs and symptoms, nasal endoscopic findings, radiographs, laboratory studies, histologic and microscopic samples, and outcomes were compared. RESULTS: Seventeen consecutive pediatric immunocompromised patients with hematologic and lymphoid neoplasms underwent nasal endoscopy and biopsy for possible FS. Nine patients were diagnosed with 10 episodes of FS; 1 patient developed FS with different organisms on 2 separate occasions separated by 6 months; 8 patients were not diagnosed with FS. Eight patients had acute myelogenous leukemia (AML); 6 patients had acute lymphoblastic leukemia (ALL); 1 patient had Burkitt's lymphoma, 1 patient had undifferentiated leukemia; and 1 patient had biphenotypic acute leukemia. All patients with FS had an absolute neutrophil count (ANC) 600 or less (range 0-600). All patients with FS had either persistent fevers or sinus symptoms (facial pain, nasal congestion, rhinorrhea). Sinus CT scans were abnormal in all patients with FS and without FS. Two patients with FS had maxillary sinus retention cysts. Operative endoscopic findings were helpful diagnostically when necrosis or ulceration was found. All patients in the non-FS group normalized their ANCs; 2 of the 9 patients in the FS group did not normalize their ANC. These 2 patients died from disseminated FS or from complications due to their immunosuppression. CONCLUSION/SIGNIFICANCE: All patients with FS had either persistent fevers or symptoms localized to the sinuses (facial pain, nasal congestion, or rhinorrhea). Endoscopic examination was helpful when necrosis was detected. We recommend directed biopsies of suspicious lesions, the middle and inferior turbinate, in immunocompromised, neutropenic pediatric patients with cancer who present with either persistent fevers or localizing symptoms to the sinuses. We favor the use of “rush” biopsies over frozen sections because of the better-quality sections and ability to perform appropriate stains.
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Affiliation(s)
- Albert H Park
- Division of Otolaryngology--Head and Neck Surgery, University of Utah, Salt Lake City, 84132, USA.
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Drozd-Sokolowska JE, Sokolowski J, Wiktor-Jedrzejczak W, Niemczyk K. Sinusitis in patients undergoing allogeneic bone marrow transplantation - a review. Braz J Otorhinolaryngol 2016; 83:105-111. [PMID: 27184506 PMCID: PMC9444742 DOI: 10.1016/j.bjorl.2016.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 02/13/2016] [Accepted: 02/19/2016] [Indexed: 11/08/2022] Open
Abstract
Introduction Sinusitis is a common morbidity in general population, however little is known about its occurrence in severely immunocompromised patients undergoing allogeneic hematopoietic stem cell transplantation. Objective The aim of the study was to analyze the literature concerning sinusitis in patients undergoing allogeneic bone marrow transplantation. Methods An electronic database search was performed with the objective of identifying all original trials examining sinusitis in allogeneic hematopoietic stem cell transplant recipients. The search was limited to English-language publications. Results Twenty five studies, published between 1985 and 2015 were identified, none of them being a randomized clinical trial. They reported on 31–955 patients, discussing different issues i.e. value of pretransplant sinonasal evaluation and its impact on post-transplant morbidity and mortality, treatment, risk factors analysis. Conclusion Results from analyzed studies yielded inconsistent results. Nevertheless, some recommendations for good practice could be made. First, it seems advisable to screen all patients undergoing allogeneic hematopoietic stem cell transplantation with Computed Tomography (CT) prior to procedure. Second, patients with symptoms of sinusitis should be treated before hematopoietic stem cell transplantation (HSCT), preferably with conservative medical approach. Third, patients who have undergone hematopoietic stem cell transplantation should be monitored closely for sinusitis, especially in the early period after transplantation.
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Affiliation(s)
| | - Jacek Sokolowski
- The Medical University of Warsaw, Department of Otorhinolaryngology, Warsaw, Poland.
| | - Wieslaw Wiktor-Jedrzejczak
- The Medical University of Warsaw, Oncology and Internal Diseases, Department of Hematology, Warsaw, Poland
| | - Kazimierz Niemczyk
- The Medical University of Warsaw, Department of Otorhinolaryngology, Warsaw, Poland
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Ortiz E, Altemani A, Vigorito AC, Sakano E, Nicola EMD. Rhinosinusitis in hematopoietic stem cell-transplanted patients: influence of nasosinus mucosal abnormalities? Stem Cell Res Ther 2014; 5:133. [PMID: 25476934 PMCID: PMC4445805 DOI: 10.1186/scrt523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 10/13/2014] [Indexed: 03/17/2023] Open
Abstract
Introduction Rhinosinusitis is characterized by inflammation extending from the mucosa of the nasal cavity into the paranasal sinuses. There are some aggravating features, such as immunosuppression, that can cause the nasal mucosal inflammation to linger for a long period, resulting in chronic or recurrent episodes. Such immunosuppression is the major feature of patients undergoing a hematopoietic stem cell transplant (HSCT); rhinosinusitis prevalence is higher in this group compared to immunocompetent patients. Nasal epithelial abnormalities have been described in, and may have some influence over, recurrent sinus infections among those patients. However, it is not clear whether rhinosinusitis can trigger mucosal abnormalities or whether a preexisting vulnerability for sinusitis recurrence is more likely. The objective of the study was to verify the influence of rhinosinusitis on nasal epithelial damage in patients undergoing hematopoietic stem cell transplantation. Method A total of 30 allogeneic HSCT patients were divided into two groups: 24 patients with chronic or recurrent rhinosinusitis and 6 patients without rhinosinusitis. These patients underwent a biopsy of the uncinate process that was analyzed by transmission electron microscopy and optical microscopy. Results The nasal mucosa analysis by optical microscopy showed no significant abnormalities. The ciliary orientation was obviously normal in the transplanted patients without rhinosinusitis. There was a trend toward a difference in the amount of cilia (decreased) and the primary modification of the ultrastructure of transplanted patients with rhinosinusitis. Conclusion HSCT patients, with and without rhinosinusitis, showed no significant histological abnormalities, except for ciliary disorientation and a possible decrease in ciliary and ultrastructural abnormalities in HSCT patients with rhinosinusitis.
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Ortiz E, Sakano E, Meirelles LR, Vigorito AC, Cintra ML, Paschoal IA, Chone CT. Histological features of the nasal mucosa in hematopoietic stem cell transplantation. Am J Rhinol Allergy 2012; 25:191-195. [PMID: 22186237 DOI: 10.2500/ajra.2011.25.3644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Immunosuppression is the leading cause of recurrent sinus infections after hematopoietic stem cell transplant (HSCT), with increased incidence of sinusitis in patients with chronic graft versus host disease (GVHD). Histological descriptions of the oral mucosa, lung ciliary epithelium, and intestinal mucosa related to HSCT have been described. However, few have described the nasal mucosa. We, therefore, sought to elucidate the histological and ultrastructural features of the nasal mucosa in patients after HSCT to better understand the pathophysiology of the immune response. METHODS Uncinate processes from 24 HSCT patients and 12 immunocompetent patients were subjected to histological analyses via light and transmission electron microscopy (TEM). RESULTS TEM revealed aberrant cilia structure, altered mitochondria quantity, microvilli, and cytoplasm vacuolization. All HSCT patients with rhinosinusitis had significant loss or absence of cilia (p = 0.018). Apoptotic bodies were increased and Goblet cells decreased in nasal epithelium from patients with chronic GVHD (p = 0.04). CONCLUSION This tissue destruction likely enhances pathogen penetration resulting in recurrent infection.
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Affiliation(s)
- Erica Ortiz
- Department of Otolaryngology, UNICAMP Campinas, Sao Paulo, Brazil.
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Moeller CW, Martin J, Welch KC. Sinonasal Evaluation Preceding Hematopoietic Transplantation. Otolaryngol Head Neck Surg 2011; 144:796-801. [DOI: 10.1177/0194599810395089] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. To determine the efficacy of sinonasal evaluation preceding hematopoietic cell transplant (HCT) and to correlate pretransplant findings with subsequent risk of post-HCT complications based on radiographic, endoscopic, and microbiologic findings. Study Design. Case series with chart review. Setting. Academic tertiary care center. Subjects and Methods. Seventy-one patients underwent pre-HCT sinonasal evaluation. Pre-HCT imaging and endoscopic exams were evaluated via standardized scales. Middle meatus culture results were also recorded. Pre-HCT intervention was noted, as was any post-HCT evaluation and intervention. Results. Seventy-one patients underwent pre-HCT evaluation. Sixty-five percent of patients were asymptomatic at the time of evaluation. On computed tomography (CT) imaging, the average Lund-Mackay score was 2.2 ± 3.7. Mean endoscopic grading score was 0.6 ± 1.6. The majority of cultures grew commensal organisms only. Four of 71 patients (6%) had evidence of chronic rhinosinusitis pre-HCT; 3 patients underwent endoscopic sinus surgery, and 1 patient was treated medically. None developed rhinosinusitis following HCT. Four different patients were evaluated for sinonasal symptoms post-HCT. Two were diagnosed with acute rhinosinusitis: 1 was treated medically, and 1 was treated surgically. No patient developed invasive fungal sinusitis. Conclusions. All patients who required pre-HCT medical or surgical intervention had symptoms of rhinosinusitis and positive endoscopy and/or CT imaging. Two patients who developed acute rhinosinusitis post-HCT had no evidence of rhinosinusitis during pre-HCT evaluation. Evaluation and studies are costly, time-consuming, and not found to be predictive in this study.
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Affiliation(s)
- Carl W. Moeller
- Department of Otolaryngology–Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - James Martin
- Loyola University Chicago Stritch School of Medicine, Chicago, Illinois, USA
| | - Kevin C. Welch
- Department of Otolaryngology–Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
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Knipping S, Holzhausen HJ, Koesling S, Bloching M. Invasive aspergillosis of the paranasal sinuses and the skull base. Eur Arch Otorhinolaryngol 2007; 264:1163-9. [PMID: 17534639 DOI: 10.1007/s00405-007-0336-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 05/01/2007] [Indexed: 11/24/2022]
Abstract
Invasive aspergillosis (IA) originating from the paranasal sinuses can cause an intracranial growth mainly along the skull base and larger vessels. This study reports our experience in the diagnosis and treatment of a series of patients with IA. A retrospective chart review of four patients with chronic invasive intracranial aspergillosis was performed. Clinical signs, physical examinations, radiographs, histological samples, and outcome were demonstrated. The patients demonstrated different symptoms like exophthalmus, ophthalmoplegia, loss of vision, and hypaesthesia of the ophthalmic and maxillary nerve. Computed tomography and MRI revealed extensive sino-orbital and skull base lesions. The patients were treated with aggressive endonasal debridement, intravenous antifungal agents and daily irrigations with antimycotic suspensions. Furthermore, we applied hyperbaric oxygenation. Two patients died from complications due to subarachnoidal hemorrhage and accompanied complications respectively. Despite the high mortality rate patients with an invasive aspergillosis can be effectively treated in some cases by an early and rigorous treatment schedule using all surgical and conservative therapeutic options.
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Affiliation(s)
- Stephan Knipping
- Department of Otorhinolaryngology Head and Neck Surgery, Martin Luther University Halle-Wittenberg, Magdeburger Str 12, Halle/Saale, Germany.
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Mirza N, Lanza DC. Diagnosis and management of rhinosinusitis before scheduled immunosuppression: a schematic approach to the prevention of acute fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33:313-21. [PMID: 10736406 DOI: 10.1016/s0030-6665(00)80007-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute (invasive) fungal rhinosinusitis is an aggressive and potentially lethal complication of insulin dependent diabetes, as well as immunosuppression from chemotherapy and bone marrow transplant. The goal of this article is to describe methods to help with the diagnosis and treatment of sinusitis prior to developing this state of immune-compromise. This will help eliminate a significant risk factor for these patients that can lead to serious morbidity and ultimately mortality.
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Affiliation(s)
- N Mirza
- Department of Microbiology, Duke University Medical Center, Durham, North Carolina, USA
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Mirza N, Montone KT, Stadtmauer EA, Lanza DC. A schematic approach to preexisting sinus disease for the immunocompromised individual. AMERICAN JOURNAL OF RHINOLOGY 1998; 12:93-8. [PMID: 9578926 DOI: 10.2500/105065898781390226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fungal rhinosinusitis is an aggressive and potentially lethal complication of chemotherapy and bone marrow transplant-induced neutropenia. Preexisting noninvasive sinusitis may be a significant risk factor in this population. An illustrative case is presented where preexisting noninvasive fungal sinusitis developed into the tissue-invasive and angio-invasive form of aspergillosis during chemotherapy. We propose an algorithmic approach to all patients before chemotherapy or bone marrow transplantation. If there is a suspicion of sinusitis based on a screening questionnaire, we recommend an otolaryngology consultation and a CT of the paranasal sinuses. Evidence of sinus disease should then be treated aggressively before chemotherapy or a bone marrow transplantation. Close posttreatment surveillance during the neutropenic phase is necessary with "urgent" biopsies if recurrence of disease is suspected.
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Affiliation(s)
- N Mirza
- Department of Otolaryngology, Head and Neck Surgery, University of Pennsylvania Medical Center, Philadelphia 19104, USA
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