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Bang J, Lee OH, Kim GJ, Sun DI, Kim SY. The Role of Open Conservation Surgery in the Era of Minimally Invasive Surgery for Hypopharyngeal Cancer. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1873. [PMID: 37893591 PMCID: PMC10608416 DOI: 10.3390/medicina59101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Total laryngectomy with partial pharyngectomy is traditionally the principal curative treatment for hypopharyngeal cancer; however, conservative surgical approaches that minimize functional disability are attracting increasing interest. Thus, we evaluated the appropriateness and oncological outcomes of open conservation surgery for such patients. Materials and Methods: We reviewed the medical records of 49 patients who underwent vertical hemipharyngolaryngectomy from 1998 to 2018 at a single institution. Results: Locoregional recurrences developed in 19 patients (38.8%) and distant metastases in 6 (12.2%). Histopathologically, paraglottic space invasion was apparent in 13 patients (26.5%), pre-epiglottic space invasion in 4 (8.2%), thyroid cartilage invasion in 9 (18.4%), thyroid gland invasion in 2, perineural invasion in 11 (22.4%), and lymphovascular invasion in 35 (71.4%). The 5-year overall survival of patients who underwent open conservation surgery was comparable to that of patients who underwent total laryngectomy with partial pharyngectomy (68.7% vs. 48.4%, p = 0.14). Pre-epiglottic space invasion significantly decreased the 5-year disease-free survival rate after open conservation surgery (69.7% vs. 17.9%, p = 0.01). Conclusions: We found that pre-epiglottic space invasion negatively impacted disease control after open conservation surgery, emphasizing the crucial role played by a preoperative evaluation during patient selection.
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Affiliation(s)
- Jooin Bang
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Oh-Hyeong Lee
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Geun-Jeon Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Dong-Il Sun
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sang-Yeon Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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Casanueva R, López F, García-Cabo P, Álvarez-Marcos C, Llorente JL, Rodrigo JP. Oncological and functional outcomes of transoral laser surgery for hypopharyngeal carcinoma. Eur Arch Otorhinolaryngol 2023; 280:829-837. [PMID: 36056169 PMCID: PMC9849286 DOI: 10.1007/s00405-022-07622-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/16/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Surgical resection or radiotherapy (RT) are standard approaches for early-staged hypopharyngeal squamous cell carcinoma (HPSCC). Transoral laser microsurgery (TOLMS) seems to provide good oncological and functional results with few local complications. The aim of our study was to analyze the outcomes of TOLMS, with or without neck dissection or RT, in the treatment of HPSCC in a tertiary referral center. METHODS A retrospective study was conducted in patients with early T-category (T1-T2) HPSCC treated by TOLMS. RESULTS A total of 34 patients were included in the study. The series includes 17 (50%) T1 and 17 (50%) T2 classified tumors. The 5-year overall survival and disease-specific survival rates were 51% and 66%, respectively, with a 5-year local control rate of 92%. All patients reassumed oral diet and none of them had a tracheostomy at the end of the follow-up. CONCLUSIONS TOLMS offers an effective treatment option in terms of oncologic control and function preservation in locally circumscribed HPSCC.
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Affiliation(s)
- Rodrigo Casanueva
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, Avenida de Roma, s/n, 33011, Oviedo, Spain
| | - Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, Avenida de Roma, s/n, 33011, Oviedo, Spain.
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), ISCIII, Madrid, Spain.
- Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain.
| | - Patricia García-Cabo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, Avenida de Roma, s/n, 33011, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), ISCIII, Madrid, Spain
- Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain
| | - César Álvarez-Marcos
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, Avenida de Roma, s/n, 33011, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), ISCIII, Madrid, Spain
- Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain
| | - José Luis Llorente
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, Avenida de Roma, s/n, 33011, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), ISCIII, Madrid, Spain
- Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain
| | - Juan Pablo Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, Avenida de Roma, s/n, 33011, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), ISCIII, Madrid, Spain
- Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain
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Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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The Emerging Role of Robotic Surgery among Minimally Invasive Surgical Approaches in the Treatment of Hypopharyngeal Carcinoma: Systematic Review and Meta-Analysis. J Clin Med 2019; 8:jcm8020256. [PMID: 30781660 PMCID: PMC6406881 DOI: 10.3390/jcm8020256] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 12/12/2022] Open
Abstract
The aim of this systematic review with meta-analysis was to investigate the available literature on transoral approaches in the treatment of hypopharyngeal squamous cell carcinoma, with a special focus on transoral robotic surgery (TORS). A systematic review was conducted according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) check-list, and 15 studies were included. Five of the included studies evaluated TORS, while ten studies focused on transoral laser microsurgery (TLM) for the treatment of early or advanced stage hypopharyngeal cancer. Overall, survival rates of TLM and TORS studies, analyzed together in the cumulative meta-analysis, were 66.4% (95% confidence interval (CI) 54.3%–76.7%) at 36+ months of follow up. The TORS subgroup showed a higher cumulative survival rate (85.5%, 95% CI 55.8%–96.5%) compared to TLM (58.5%, 95% CI 46.6%–69.6%). Cumulative data showed that 29.3% (95% CI 24.0%–35.3%) of deaths were attributable to cancer. The results were similar between TLM and TORS studies. The larynx function preservation cumulative rate was 94.3% (95% CI 91.8%–96.1%). The results were similar among the two subgroups. The present review supports the use of transoral approaches in the treatment of hypopharyngeal cancer. TORS is oncologically sound and provides excellent functional results with low complication rates.
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Oncological and Functional Evaluation of Open Conservation Surgery for Hypopharyngeal Cancer with/without Reconstruction. Int J Otolaryngol 2018; 2018:2132781. [PMID: 29780420 PMCID: PMC5892243 DOI: 10.1155/2018/2132781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 01/28/2018] [Accepted: 02/12/2018] [Indexed: 11/24/2022] Open
Abstract
Objectives Oncological and functional results of open conservation surgery for hypopharyngeal cancer have been desired. Methods We performed a chart review of 33 patients with hypopharyngeal cancer who underwent open conservation surgery. Oncological and functional results were evaluated in surgery with primary closure (Group A) and surgery with reconstruction (Group B). Postoperative functions were evaluated by interval to resumption of oral intake, Functional Outcome Swallowing Scale (FOSS) and Communication Scale (CS). Results Five-year disease-specific and overall cumulative survival rates by Kaplan-Meier method for all cases were 95.7% and 82.3%, respectively. Duration from surgery to full oral intake was 12 days in Group A and 14 days in Group B. FOSS rates were 83.3 in Group A and 95.5 in Group B. CS was 0 in both groups. Conclusion Oncological and functional results of open conservation surgery were comparable to those with transoral surgery and chemo/radiotherapy. Our technique represents a reliable treatment for hypopharyngeal cancer.
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Hung LT, Huang HI, Wang LW, Yang MH, Chu PY. Oncologic results and quality of life in patients with squamous cell carcinoma of hypopharynx after transoral laser microsurgery. Lasers Surg Med 2017; 50:117-124. [DOI: 10.1002/lsm.22742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Li-Ting Hung
- Department of Otolaryngology; Taipei Veterans General Hospital and National Yang-Ming University; Taipei Taiwan
| | - Hsin-I Huang
- Department of Otolaryngology; Taipei Veterans General Hospital and National Yang-Ming University; Taipei Taiwan
| | - Ling-Wei Wang
- Department of Oncology Medicine; Taipei Veterans General Hospital and National Yang-Ming University; Taipei Taiwan
| | - Muh-Hwa Yang
- Department of Oncology Medicine; Taipei Veterans General Hospital and National Yang-Ming University; Taipei Taiwan
| | - Pen-Yuan Chu
- Department of Otolaryngology; Taipei Veterans General Hospital and National Yang-Ming University; Taipei Taiwan
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Weiss BG, Ihler F, Wolff HA, Schneider S, Canis M, Steiner W, Welz C. Transoral laser microsurgery for treatment for hypopharyngeal cancer in 211 patients. Head Neck 2017; 39:1631-1638. [DOI: 10.1002/hed.24814] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 02/18/2017] [Accepted: 03/14/2017] [Indexed: 02/06/2023] Open
Affiliation(s)
- Bernhard G. Weiss
- Department of Otorhinolaryngology, Head and Neck Surgery; University Medical Center Göttingen; Göttingen Germany
| | - Friedrich Ihler
- Department of Otorhinolaryngology, Head and Neck Surgery; University Medical Center Göttingen; Göttingen Germany
| | | | - Simon Schneider
- Department of Medical Statistics; University Medical Center Göttingen; Göttingen Germany
| | - Martin Canis
- Department of Otorhinolaryngology, Head and Neck Surgery; University Medical Center Göttingen; Göttingen Germany
| | - Wolfgang Steiner
- Department of Otorhinolaryngology, Head and Neck Surgery; University Medical Center Göttingen; Göttingen Germany
| | - Christian Welz
- Department of Otorhinolaryngology, Head and Neck Surgery; University Medical Center Göttingen; Göttingen Germany
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Kim N, Lee J, Kim KH, Park JW, Lee CG, Keum KC. Early hypopharyngeal cancer treated with different therapeutic approaches: a single-institution cohort analysis. Radiat Oncol J 2016; 34:280-289. [PMID: 28030898 PMCID: PMC5207370 DOI: 10.3857/roj.2016.01711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/06/2016] [Accepted: 09/01/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose Early hypopharyngeal squamous cell carcinoma (HPSCC) is a rarely diagnosed disease, for which the optimal treatment has not been defined yet. We assessed patterns of failure and outcomes in early HPSCC treated with various therapeutic approaches to identify its optimal treatment. Materials and Methods Thirty-six patients with stage I (n = 10) and II (n = 26) treated between January 1992 and March 2014 were reviewed. Patients received definitive radiotherapy (RT) (R group, n = 10), surgery only (S group, n = 19), or postoperative RT (PORT group, n = 7). All patients in both the R and PORT groups received elective bilateral neck irradiation. In the S group, 7 patients had ipsilateral and 8 had bilateral dissection, while 4 patients had no elective dissection. Results At a median follow-up of 48 months, the 5-year locoregional control (LRC) rate was 65%. Six patients had local failure, 1 regional failure (RF), 3 combined locoregional failures, and 2 distant failures. There was no difference in 5-year LRC among the R, S, and PORT groups (p = 0.17). The presence with a pyriform sinus apex extension was a prognosticator related to LRC (p = 0.01) in the multivariate analysis. Patients with a bilaterally treated neck showed a trend toward a lower RF rate (p = 0.08). Conclusion This study shows that patients with early stage HPSCC involving the pyriform sinus apex might need a tailored approach to improve LRC. Additionally, our study confirms elective neck treatment might have an efficacious role in regional control.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Won Park
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
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Wang CC, Liu SA, Wu SH, Wang CP, Liang KL, Jiang RS, Lin JC. Transoral robotic surgery for early T classification hypopharyngeal cancer. Head Neck 2015; 38:857-62. [PMID: 26559383 DOI: 10.1002/hed.24160] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND For hypopharyngeal cancer, transoral robotic surgery (TORS) has been reported as a new organ preserving treatment but outcomes are rarely reported. METHODS From 2010 to 2013, 10 patients with early T classification pyriform sinus cancer were selected to receive TORS and conventional neck dissection. The clinical parameters, including rates of adjuvant radiotherapy, survivals, as well as organ and function preservation, were retrospectively analyzed. RESULTS TORS was successful in all 10 patients, and 5 patients received adjuvant radiotherapy. After mean follow-up of 26 months, 1 patient died of distant metastasis and 1 patient died of other malignancy. There was no local recurrence and larynxes were all preserved. Eight surviving patients who were followed up continuously could receive oral intake and had a serviceable voice without tracheostomy or feeding tubes. CONCLUSION TORS is a feasible transoral approach for selected patients with early T classification hypopharyngeal cancer. The reported oncologic/functional outcomes are satisfactory. © 2015 Wiley Periodicals, Inc. Head Neck 38: 857-862, 2016.
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Affiliation(s)
- Chen-Chi Wang
- Department of Otolaryngology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Speech Language Pathology and Audiology, Chung Shan Medical University, Taichung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-An Liu
- Department of Otolaryngology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shang-Heng Wu
- Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ching-Ping Wang
- School of Speech Language Pathology and Audiology, Chung Shan Medical University, Taichung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kai-Li Liang
- Department of Otolaryngology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Rong-San Jiang
- Department of Otolaryngology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jin-Ching Lin
- Department of Otolaryngology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
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Kuo CL, Chen YT, Shiao AS, Lien CF, Wang SJ. Acid reflux and head and neck cancer risk: A nationwide registry over 13 years. Auris Nasus Larynx 2015; 42:401-5. [PMID: 25998850 DOI: 10.1016/j.anl.2015.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 03/12/2015] [Accepted: 03/20/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Gastro-esophageal reflux disease (GERD) is a highly prevalent disorder; however, important questions remain regarding the link between GERD and extra-esophageal cancers. This nationwide cohort study investigated the risk of developing head and neck cancers (HNCs) among patients with GERD. METHODS Newly diagnosed GERD patients aged ≥20 years without antecedent cancer were included. Case data were obtained from the National Health Insurance Research Database covering period from 1998 to 2010. We compared the standardized incidence ratios (SIRs) of cancer among GERD patients with those of the general population. RESULTS A total of 98 cancers were identified among the 39,845 GERD patients in the study, representing 128,361 person-years. The SIR for all cases of cancer was 1.59 (95% CI 1.29-1.93). GERD patients exhibited significantly higher SIRs for oropharyngeal (SIR 3.58, 95% CI 1.85-6.25) and hypopharyngeal (SIR 3.96, 95% CI 2.35-6.26) cancers. Male patients had a significantly higher risk of HNCs (SIR 1.70, 95% CI 1.36-2.10), particularly oropharyngeal (SIR 4.01, 95% CI 2.00-7.17) and hypopharyngeal (SIR 3.91, 95% CI 2.28-6.26) cancers. Following adjustment for age and co-morbidities, the hazard ratio was 9.06 (95% CI 4.70-17.44) for males compared to females. CONCLUSION There may be a potential association between GERD and risk of HNCs, which however merits further studies to confirm the causal relationship. Our observations indicate a need for careful extra-esophageal examination of patients with acid reflux. Our findings also underline the importance of raising awareness among clinicians regarding the possibility of concurrent HNCs in GERD patients with refractory laryngo-pharyngeal symptoms.
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Affiliation(s)
- Chin-Lung Kuo
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Otolaryngology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Otolaryngology, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan, ROC; Department of Otolaryngology-Head and Neck Surgery, National Defense Medical Center, Taipei, Taiwan, ROC.
| | - Yung-Tai Chen
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan, ROC
| | - An-Suey Shiao
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Otolaryngology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Otolaryngology-Head and Neck Surgery, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chiang-Feng Lien
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Otolaryngology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan, ROC.
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