Purpose of review Acute invasive fungal rhinosinusitis (AIFRS) is a rare and often fatal disease, that remains incompletely understood. Case series and literature reviews constitute most of the literature on AIFRS, and act as the standards by which we treat these extremely complex patients. This review discusses management of AIFRS, with focuses on optimal diagnostic and therapeutic strategies. Recent findings Mortality rates remain high, around 50% overall, though some recent studies have shown higher survival rates with early diagnosis and complete surgical resection. Some recent publications on AIFRS have focused on the utility of frozen section analysis both to diagnose and potentially guide the completeness of endoscopic surgical debridement. It was also recently shown that complete endoscopic resection of disease leads to higher survival than when disease was incompletely resected. Additionally, a new antifungal agent was recently approved by the FDA, which has a more favorable pharmacologic and side effect profile, though more studies are necessary to determine its utility. Summary Early diagnosis requires identification of sinusitis symptoms in immunocompromised patients, followed by intranasal biopsy and frozen section analysis. Early surgical debridement and antifungal therapy then remain the cornerstones of AIFRS management. Video abstract See Video, Supplemental Digital Content 1, http://bit.ly/2BKeblx. Correspondence to John R. Craig, MD, Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA. Tel: +1 313 971 9320; fax: +1 313 916 7263; e-mail: JCraig1@hfhs.org. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://bit.ly/2QPN9Uo). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2BGEFVj
Τετάρτη 26 Δεκεμβρίου 2018
Analysis of neuromonitoring signal loss during retroauricular versus conventional thyroidectomy
Objective
Loss of signal (LOS) during intraoperative neuromonitoring (IONM) of robotic or endoscopic thyroidectomy via a retroauricular approach (RAT) and during conventional open thyroidectomy (COT) was investigated to compare the risk of recurrent laryngeal nerve (RLN) injury between the two groups.
Study Design
Original article.
Methods
This is a retrospective case series study performed between May 2014 and September 2016. IONM using the NIM 3.0 system (Medtronic Xomed, Inc., Jacksonville, FL) was used for this study. Pre‐ and postoperative vocal cord functions were assessed using a flexible laryngoscope. LOS types noted intraoperatively and their associations with postoperative vocal cord palsy (VCP) were evaluated. LOS rate and temporary and permanent VCP rates were compared between the two groups. The surgical events associated with LOS were also documented and analyzed in this study.
Results
In total, 153 patients were recruited, and 111 patients were enrolled in the RAT group; the remaining 42 patients were enrolled in the COT group. No statistically significant differences in intraoperative LOS (P = 0.812) and postoperative VCP rates (early, permanent; P = 0.259 and P = 0.577, respectively) between the two groups were observed. IONM accuracy of predicting postoperative VCP was 99.1% in our case series.
Conclusion
On the basis of IONM findings, the risks of injury to RLN were similar between the two groups. Comparison of LOS was an objective method for verifying the novel RAT approach. We applied our IONM protocol and troubleshooting algorithm during RAT with acceptable accuracy, but the international standardized method of IONM is applicable and recommended for reducing false results using vagal nerve stimulation.
Level of Evidence
3b. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2ENJJtX
Prevention of tracheal stenosis with pirfenidone after tracheotomy: An experimental study
Objectives
In this study, pirfenidone's role about reducing tracheal stenosis by suppressing fibrosis and inflammation was examined.
Methods
Tracheotomy was performed on 14 rats, and their cannulas were fixed to tracheotomy area by stoma suture. Two working groups were established. Rats in the first group were given 15 mg/kg/day (1 mL pirfenidone solution) pirfenidone intraperitoneally for 10 days. In the second group as a control group, 1 mL saline solution was applied intraperitoneally. Ten days later, rats were decanulated and kept alive for 3 more weeks.
Anesthetized rats were sacrificed on day 30. All rat tracheas were resected between the first and seventh rings. Epithelial damage, inflammation, and fibrosis were determined histopathologically; diameters of intratracheal lumen and their mucosal thickness parameters were determined histomorphometrically; and TGFβ‐1 (the growth factor beta), TNFα (tumor necrosis factor alpha), and IL‐1β (Interleukin‐1 beta) values were determined immunohistochemically.
Results
According to the parameters of the control group, fibrosis; diameters of intratracheal lumen; and values of TGFβ‐1, TNFα, and IL‐1β were found to be statistically significant.
Conclusion
In our study, it was found that pirfenidone reduces fibrosis and narrowing of intratracheal lumen diameter significantly.
Level of Evidence
NA. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EOwhXK
Factors associated with epiglottic petiole prolapse repositioning success
Objective
Epiglottic petiole prolapse is an overlooked entity that could lead to supraglottic airway obstruction for patients with complex airway history. Classical symptoms include exercise intolerance, obstructive sleep apnea, and difficulty with decannulation. The goal of this project was to evaluate the factors associated with epiglottic petiole repositioning success.
Methods
Retrospective case series of patients with a complex history of airway reconstruction evaluated by the aerodigestive team at a tertiary pediatric hospital from May 2003 to August 2017. All patients underwent repositioning for petiole prolapse.
Results
We had a total of 59 patients (14 females, 23.7%) with complex airway anomalies with petiole prolapse noted during a microlaryngoscopy and bronchoscopy. Mean age was 12.9 ± 6.1 year old (range 1.3–35.9). Patients had a history of 2.2 (1–5) open airway surgeries, and 51 of 58 (87.9%) of them had a prior complete laryngofissure. Laryngotracheoplasty and petiole repositioning were performed as a double‐stage surgery for 54 of 58 (91.5%) patients. Epiglottic petiole prolapse was persistent in 20 patients (33.9%) and became symptomatic for 14 of them (23.7%). The main preventive factor of petiole prolapse recurrence was pre‐epiglottic fat debulking at the time of the repositioning, with an odds ratio of 0.06 (95% confidence interval 0.007–0.6, P = 0.01). Stent placement, longer duration of stent placement, and double‐stage procedure also increased the likelihood of success (all P < 0.05).
Conclusion
Patients with petiole prolapse have a history of complete laryngofissure and multiple open airway surgeries. Pre‐epiglottic fat debulking and longer stent placement at the time of the repositioning surgery appear to significantly increase the long‐term success rate.
Level of Evidence
4. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EJ6RKl
Laryngeal reconstruction for recurrent desmoid tumor using three‐dimensional modeling: A unique approach for a rare tumor
Desmoid tumors are exceedingly rare within the larynx and cause significant morbidity due to their locally aggressive and infiltrative nature. Surgery is the mainstay of treatment with previous reports describing total and near‐total laryngectomy for cure. We present a case of recurrent glottic desmoid tumor managed with hemilaryngectomy and reconstructed with temporoparietal free tissue, rib, and buccal grafts. Three‐dimensional modeling was utilized to optimize aerodigestive function after laryngeal reconstruction. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2ESO6VA
Diode laser thermal effect on the paranasal sinus osteoma
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EMkF6E
Pharyngobasilar fascia as a landmark in endoscopic skull base surgery: The triangulation technique
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EQazm6
Over‐the‐Counter Tinnitus “Cures”: Marketers’ Promises Do Not Ring True
Objectives
The Clinical Practice Guideline of the American Academy of Otolaryngology–Head & Neck Surgery (2014) stated that clinicians should not recommend dietary supplements for the treatment of tinnitus. The aim of this study is to characterize over‐the‐counter tinnitus remedies (OTCTR) on the U.S. market, describe the ingredients and prices, and characterize the methods of promoting these products.
Methods
OTCTR were identified via Web search and visits to retail establishments. Information was collected regarding OTCTR chemical composition, product labeling, advertisements and marketing, price, and customers reviews.
Results
A wide array of unproven OTCTR exist on today's market. All make unfounded claims of relief from ear ringing. Most of the products considered in this study consist of mixtures of inexpensive and common vitamins, minerals, and/or herbs sold at a premium compared to similar preparations not expressly advertised for tinnitus. Certain brands, most notably Arches Tinnitus Formula (Arches Natural Products Inc., Salt Lake City, UT) and Lipo‐Flavonoid (Clarion Brands Inc., Solon, OH), target otolaryngologists by advertising in specialty journals and prominently featuring supposed endorsement by "Ear‐Nose‐and‐Throat Doctors" in their marketing.
Conclusion
It is important for otolaryngologists who are caring for tinnitus sufferers to be aware that a robust and diverse market exists for unproven OTC tinnitus remedies. It is troubling that heavily advertised brands profess support by otolaryngologists. Responsible specialty organizations in the field should consider opposing such commercially motivated representations. Otolaryngology journals may wish to adopt a policy along the lines of The Journal of the American Medical Association publications to decline advertisements of dietary supplements that make unproven therapeutic claims.
Level of Evidence
5. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EQ0QeC
The Impact of Nasalance on Cepstral Peak Prominence and Harmonics‐to‐Noise Ratio
Objectives/Hypothesis
Cepstral peak prominence (CPP) has been reported as a reliable measure of dysphonia and a preferred alternative to harmonics‐to‐noise ratio (HNR). However, CPP has been observed to be sensitive to articulatory variation and vocal intensity. The aim of this study was to examine the impact of nasalance on CPP and HNR of voice signals. It was hypothesized that increased nasalance would be associated with decreased CPP.
Study Design
Within‐subject correlation design.
Methods
Thirty vocally healthy female participants were recorded reading and producing a vowel in alternation with a nasal consonant while wearing a nasometer for calculation of nasalance. Recorded vowel, nasalized, and nasal segments of speech were used to calculate CPP using Analysis of Dysphonia in Speech and Voice software, and HNR and vocal intensity using Praat software.
Results
Significant main effects of conditions were observed for CPP. CPP values decreased significantly when phonation changed from vowel to nasalized vowel and to nasal. There was correlation between CPP and nasalance and between CPP and intensity. HNR was slightly higher in the nasal condition than in vowel. There was a weak correlation between HNR and nasalance. No correlation was found between HNR and intensity.
Conclusions
CPP is sensitive to changes in vocal tract configuration caused by nasalization as well as intensity, whereas HNR is not. Therefore, CPP may reflect the periodicity in source signal or the filtering effects of vocal tract. Further research is needed to clarify the application and interpretation of CPP in clinical practice.
Level of Evidence
4 Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EPZXn9
CT Navigation and sialendoscopy‐assisted transfacial removal of a parotid stone: A technical note
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EMkEQ8
Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence‐Based Review
Objectives/Hypothesis
Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non‐opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty.
Study Design
Evidence‐based systematic review.
Methods
PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included.
Results
Thirty‐seven studies met inclusion criteria for this evidence‐based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti‐inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution.
Conclusions
Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α‐agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost‐effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large‐scale, multi‐institutional, controlled studies are needed to provide definitive recommendations.
Level of Evidence
NA Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EOwfiA
The Effect of Octanoic Acid on Essential Voice Tremor: A Double‐Blind, Placebo‐Controlled Study
Objectives/Hypothesis
The purpose of this study was to determine the effects of octanoic acid on acoustic, perceptual, and functional aspects of essential voice tremor (EVT).
Study Design
Prospective, double‐blind, placebo‐controlled, crossover study.
Methods
Sixteen participants with a diagnosis of EVT were randomized to a 3‐week dosing condition of octanoic acid or placebo, followed by a 2‐week washout period and crossover to the other condition for an additional 3 weeks. Baseline and post‐testing sessions were completed before and at the completion of each condition. Primary outcome measures were the magnitude of amplitude and frequency tremor, measured from the acoustic signal. Secondary outcomes were auditory‐perceptual ratings of tremor severity and self‐ratings of voice handicap.
Results
Magnitude of amplitude and frequency tremor were significantly lower after 3 weeks of octanoic acid dosing as compared to the placebo condition. Auditory‐perceptual ratings of tremor severity did not show significant differences between conditions. A trend toward better voice was seen for the sustained vowel ratings, but not the sentence‐level ratings. No significant differences between conditions were seen on self‐reported voice disability as assessed on the Voice Handicap Index‐10.
Conclusions
The results of this controlled investigation support the potential utility of octanoic acid for reducing the magnitude of tremor in people with EVT. Further research is needed to determine whether different dosing or treatment combinations can improve functional communication in EVT.
Level of Evidence
1 Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EKi4u6
Updates in management of acute invasive fungal rhinosinusitis
Purpose of review Acute invasive fungal rhinosinusitis (AIFRS) is a rare and often fatal disease, that remains incompletely understood. Case series and literature reviews constitute most of the literature on AIFRS, and act as the standards by which we treat these extremely complex patients. This review discusses management of AIFRS, with focuses on optimal diagnostic and therapeutic strategies. Recent findings Mortality rates remain high, around 50% overall, though some recent studies have shown higher survival rates with early diagnosis and complete surgical resection. Some recent publications on AIFRS have focused on the utility of frozen section analysis both to diagnose and potentially guide the completeness of endoscopic surgical debridement. It was also recently shown that complete endoscopic resection of disease leads to higher survival than when disease was incompletely resected. Additionally, a new antifungal agent was recently approved by the FDA, which has a more favorable pharmacologic and side effect profile, though more studies are necessary to determine its utility. Summary Early diagnosis requires identification of sinusitis symptoms in immunocompromised patients, followed by intranasal biopsy and frozen section analysis. Early surgical debridement and antifungal therapy then remain the cornerstones of AIFRS management. Video abstract See Video, Supplemental Digital Content 1, http://bit.ly/2BKeblx. Correspondence to John R. Craig, MD, Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA. Tel: +1 313 971 9320; fax: +1 313 916 7263; e-mail: JCraig1@hfhs.org. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://bit.ly/2QPN9Uo). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2BGEFVj
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2BGEFVj
Analysis of neuromonitoring signal loss during retroauricular versus conventional thyroidectomy
Objective
Loss of signal (LOS) during intraoperative neuromonitoring (IONM) of robotic or endoscopic thyroidectomy via a retroauricular approach (RAT) and during conventional open thyroidectomy (COT) was investigated to compare the risk of recurrent laryngeal nerve (RLN) injury between the two groups.
Study Design
Original article.
Methods
This is a retrospective case series study performed between May 2014 and September 2016. IONM using the NIM 3.0 system (Medtronic Xomed, Inc., Jacksonville, FL) was used for this study. Pre‐ and postoperative vocal cord functions were assessed using a flexible laryngoscope. LOS types noted intraoperatively and their associations with postoperative vocal cord palsy (VCP) were evaluated. LOS rate and temporary and permanent VCP rates were compared between the two groups. The surgical events associated with LOS were also documented and analyzed in this study.
Results
In total, 153 patients were recruited, and 111 patients were enrolled in the RAT group; the remaining 42 patients were enrolled in the COT group. No statistically significant differences in intraoperative LOS (P = 0.812) and postoperative VCP rates (early, permanent; P = 0.259 and P = 0.577, respectively) between the two groups were observed. IONM accuracy of predicting postoperative VCP was 99.1% in our case series.
Conclusion
On the basis of IONM findings, the risks of injury to RLN were similar between the two groups. Comparison of LOS was an objective method for verifying the novel RAT approach. We applied our IONM protocol and troubleshooting algorithm during RAT with acceptable accuracy, but the international standardized method of IONM is applicable and recommended for reducing false results using vagal nerve stimulation.
Level of Evidence
3b. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2ENJJtX
Prevention of tracheal stenosis with pirfenidone after tracheotomy: An experimental study
Objectives
In this study, pirfenidone's role about reducing tracheal stenosis by suppressing fibrosis and inflammation was examined.
Methods
Tracheotomy was performed on 14 rats, and their cannulas were fixed to tracheotomy area by stoma suture. Two working groups were established. Rats in the first group were given 15 mg/kg/day (1 mL pirfenidone solution) pirfenidone intraperitoneally for 10 days. In the second group as a control group, 1 mL saline solution was applied intraperitoneally. Ten days later, rats were decanulated and kept alive for 3 more weeks.
Anesthetized rats were sacrificed on day 30. All rat tracheas were resected between the first and seventh rings. Epithelial damage, inflammation, and fibrosis were determined histopathologically; diameters of intratracheal lumen and their mucosal thickness parameters were determined histomorphometrically; and TGFβ‐1 (the growth factor beta), TNFα (tumor necrosis factor alpha), and IL‐1β (Interleukin‐1 beta) values were determined immunohistochemically.
Results
According to the parameters of the control group, fibrosis; diameters of intratracheal lumen; and values of TGFβ‐1, TNFα, and IL‐1β were found to be statistically significant.
Conclusion
In our study, it was found that pirfenidone reduces fibrosis and narrowing of intratracheal lumen diameter significantly.
Level of Evidence
NA. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EOwhXK
Factors associated with epiglottic petiole prolapse repositioning success
Objective
Epiglottic petiole prolapse is an overlooked entity that could lead to supraglottic airway obstruction for patients with complex airway history. Classical symptoms include exercise intolerance, obstructive sleep apnea, and difficulty with decannulation. The goal of this project was to evaluate the factors associated with epiglottic petiole repositioning success.
Methods
Retrospective case series of patients with a complex history of airway reconstruction evaluated by the aerodigestive team at a tertiary pediatric hospital from May 2003 to August 2017. All patients underwent repositioning for petiole prolapse.
Results
We had a total of 59 patients (14 females, 23.7%) with complex airway anomalies with petiole prolapse noted during a microlaryngoscopy and bronchoscopy. Mean age was 12.9 ± 6.1 year old (range 1.3–35.9). Patients had a history of 2.2 (1–5) open airway surgeries, and 51 of 58 (87.9%) of them had a prior complete laryngofissure. Laryngotracheoplasty and petiole repositioning were performed as a double‐stage surgery for 54 of 58 (91.5%) patients. Epiglottic petiole prolapse was persistent in 20 patients (33.9%) and became symptomatic for 14 of them (23.7%). The main preventive factor of petiole prolapse recurrence was pre‐epiglottic fat debulking at the time of the repositioning, with an odds ratio of 0.06 (95% confidence interval 0.007–0.6, P = 0.01). Stent placement, longer duration of stent placement, and double‐stage procedure also increased the likelihood of success (all P < 0.05).
Conclusion
Patients with petiole prolapse have a history of complete laryngofissure and multiple open airway surgeries. Pre‐epiglottic fat debulking and longer stent placement at the time of the repositioning surgery appear to significantly increase the long‐term success rate.
Level of Evidence
4. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EJ6RKl
Laryngeal reconstruction for recurrent desmoid tumor using three‐dimensional modeling: A unique approach for a rare tumor
Desmoid tumors are exceedingly rare within the larynx and cause significant morbidity due to their locally aggressive and infiltrative nature. Surgery is the mainstay of treatment with previous reports describing total and near‐total laryngectomy for cure. We present a case of recurrent glottic desmoid tumor managed with hemilaryngectomy and reconstructed with temporoparietal free tissue, rib, and buccal grafts. Three‐dimensional modeling was utilized to optimize aerodigestive function after laryngeal reconstruction. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2ESO6VA
Diode laser thermal effect on the paranasal sinus osteoma
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EMkF6E
Pharyngobasilar fascia as a landmark in endoscopic skull base surgery: The triangulation technique
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EQazm6
Over‐the‐Counter Tinnitus “Cures”: Marketers’ Promises Do Not Ring True
Objectives
The Clinical Practice Guideline of the American Academy of Otolaryngology–Head & Neck Surgery (2014) stated that clinicians should not recommend dietary supplements for the treatment of tinnitus. The aim of this study is to characterize over‐the‐counter tinnitus remedies (OTCTR) on the U.S. market, describe the ingredients and prices, and characterize the methods of promoting these products.
Methods
OTCTR were identified via Web search and visits to retail establishments. Information was collected regarding OTCTR chemical composition, product labeling, advertisements and marketing, price, and customers reviews.
Results
A wide array of unproven OTCTR exist on today's market. All make unfounded claims of relief from ear ringing. Most of the products considered in this study consist of mixtures of inexpensive and common vitamins, minerals, and/or herbs sold at a premium compared to similar preparations not expressly advertised for tinnitus. Certain brands, most notably Arches Tinnitus Formula (Arches Natural Products Inc., Salt Lake City, UT) and Lipo‐Flavonoid (Clarion Brands Inc., Solon, OH), target otolaryngologists by advertising in specialty journals and prominently featuring supposed endorsement by "Ear‐Nose‐and‐Throat Doctors" in their marketing.
Conclusion
It is important for otolaryngologists who are caring for tinnitus sufferers to be aware that a robust and diverse market exists for unproven OTC tinnitus remedies. It is troubling that heavily advertised brands profess support by otolaryngologists. Responsible specialty organizations in the field should consider opposing such commercially motivated representations. Otolaryngology journals may wish to adopt a policy along the lines of The Journal of the American Medical Association publications to decline advertisements of dietary supplements that make unproven therapeutic claims.
Level of Evidence
5. Laryngoscope, 2018
from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2EQ0QeC
Εγγραφή σε:
Αναρτήσεις (Atom)