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   Table of Contents - Current issue
July-December 2020
Volume 8 | Issue 2
Page Nos. 47-157

Online since Tuesday, December 8, 2020

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Transoral surgery: The developing paradigm of minimally invasive organ and function preserving surgery Highly accessed article p. 47

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Developing the South Asian region's first head-and-neck surgical oncology multi-institutional program: Journey, milestones, challenges, and future Highly accessed article p. 50

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Transoral Robotic Thyroid Surgery: Technical Considerations p. 53

Recently, many surgeons worldwide have adopted the transoral thyroidectomy approach owing to the associated advantages of less surgical morbidity, excellent cosmesis, and superior postoperative vocal outcomes. Specifically, transoral robotic thyroidectomy, in which a surgical robot is used, has been performed to hide or avoid visible neck scars and overcome the limitations associated with the endoscopic procedure. The transoral robotic thyroidectomy technique involves creation of three oral vestibular incisions and use of an additional axillary port, if indicated. Transoral robotic thyroidectomy is feasible and comparable to conventional transcervical thyroidectomy for highly selected patients. However, some unusual complications, such as CO2 embolism, mental nerve injury, surgical site infection, and skin burn and trauma, are noted. Appropriate patient selection is important for the safety and success of this surgery.
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De-escalation Strategies in Human Papilloma Virus-Positive Oropharyngeal Cancer p. 61

Human papilloma virus (HPV) is now attributable to most of the oropharyngeal squamous cell cancers (OPSCCs) occurring in western world. The HPV-associated OPSCC effect younger, otherwise healthy population and is typically associated with better outcome. Traditional treatment strategies, while successful, are associated with significant long-term morbidity and poorer quality of life. This has led to various trials and investigations to de-escalate the treatment in this patient population while maintaining excellent outcome. The objective of this review is to discuss various de-escalation strategies and trials.
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Patenting pathways: A practical primer p. 67

Patenting a product may lead to a whole new aspect of the dimension of a process or a product or a service that has never been known before and that becomes an invention. This is important, and whenever something new is added to a preexisting invention, it becomes innovation. In India, there is a Make in India. Therefore, we must have an Invest in India. Similarly, we must also have a Create in India. This is a key principle since at present we are importing the material and assembling it within India. The need of the hour is a massive step toward creating in India.
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Interleukins in Periodontics p. 70

Key modulators of inflammation are interleukins (ILs). There is a complex network of interactions in acute and chronic inflammation which is modulated by ILs. Mechanistic explanations for positive and negative interactions between individual ILs will also depend on new insights into the signal transduction pathways for each IL. ILs are the cytokines that act specifically as mediators between leukocytes. Approximately more than 35 ILs have been described, each having unique biological activity and role in periodontal health or disease. It seems quite likely that the lymphocyte may behave in a manner similar as a neuron that receives information from several other neurons and integrates the positive and negative signals and then corresponds accordingly by initiating or refraining from initiating action potential. Like a neuron, the response of the lymphocyte will depend both on the positive and negative signals and also on the nature of their individual signal transduction pathways.
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Effect of intraoperative vasopressor use on free flap outcome following major head-and-neck reconstructive surgeries p. 76

Introduction: Major head-and-neck surgeries involving wide excision of the tumor usually necessitate reconstruction with free flaps for tissue cover. Even with meticulous fluid management with crystalloids, colloids, albumin, blood, and blood products, many patients become hemodynamically unstable and require the use of vasopressors perioperatively. Objectives: The purpose of this analysis was to assess the safety, role, and present-day trends of the use of vasopressor agents in free flap surgeries and to find any relation of graft rejection or failure of flap surgeries or postoperative complications with perioperative use of such agents. Methods: Reviewing the literature regarding the usage of vasopressors in head-and-neck free flap surgeries, percentage of flap survival, thrombosis of the artery, venous edema, and need for revision surgery were analyzed. Most of the published data had shown that optimizing hemodynamic stability with vasopressors had a more beneficial effect on overall flap perfusion and minimized the complications of iatrogenic fluid overload. The common conclusion was that perioperative vasopressor administration was not detrimental to free flap survival. Conclusion: Based on available data, it is concluded that perioperative use of vasopressors does not adversely affect free flap outcome in patients undergoing head-and-neck reconstructive surgeries and could even be beneficial considering the avoidance of complications of liberal intravenous fluid administration.
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Flaps based on facial arteriovenous system for the reconstruction of head-and-neck cancer defects p. 80

Facial artery is a branch of the external carotid system extending from the upper neck to the nasion. Various flaps are described in the literature based on the facial artery and vein in the neck and face to reconstruct the head-and-neck cancer defects, either superiorly based or inferiorly based. This article summarizes the flaps and their variations based on the facial arteriovenous system. The flap harvest techniques, the indications, advantages and the limitations of the nasolabial flap, facial artery myomucosal flap, and submental flap are described, with appropriate case demonstrations. Variations of the flaps are also discussed.
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Pattern and Etiology of Maxillofacial Trauma among Sudanese Population p. 87

Background: Maxillofacial trauma has the potential to cause disfigurement and loss of function. It can be fatal by causing severe bleeding or interference with the airway. Objectives: The objectives of this study were to assess the etiology, site, timing, age, and gender predilection of maxillofacial trauma in a sample of Sudanese patients. Materials and Methods: This was a prospective descriptive-analytical hospital-based study. The records of 96 trauma patients who attended Khartoum Dental Teaching Hospital from February to April 2017 were investigated for the following information: the etiology of the trauma, site of the fracture, time of the injury as well as the patients’ age and gender. Data were analyzed using the Statistical Package for the Social Sciences software (IBM Corp., Armonk, NY USA). Results: During the study period, 96 patients with 204 fractures were treated. 82.3% of the patients were males. The age group between 13 and 23 years showed the highest rate of incidence of maxillofacial trauma. The most common cause of the trauma was assault (36.5%) in males and falls in females (47.1%). Dentoalveolar fractures were the most common site of fractures (25.6%) followed by condylar fractures (14%). The majority of the injuries (34.4%) took place during the day between 1 pm and 6 pm. Conclusions: Causes and patterns of maxillofacial trauma vary greatly from one region to another. This can remarkably aid in raising public awareness and establishing specific prevention and treatment programs.
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Pattern of Head-and-Neck Malignancies in the Pediatric Population p. 91

Background: Head-and-neck malignancies are uncommon in childhood unlike in adults, also it contributes to low proportion of overall cancer incidence among children. The number in India has been increasing in the recent past. Hence, we conducted a study to know the pattern of head-and-neck cancers in hospitalized patients of 0–18 years’ age group. Aim: The aim was to study the pattern of different types of head-and-neck malignancies in the pediatric age group (<18 years) in a referral hospital. Subject and Methods: We have conducted an observational study of pediatric head-and-neck malignancies in our tertiary care center. All children in the age group of 0–18 years were included in the study. A total of 72 cases were taken retrospectively and prospectively from various departments of hospital which deal with pediatric patients. Results: Our study comprises total 72 cases, maximum cases were of acute lymphocytic leukemia with secondaries in neck n = 21, followed by 9 cases were of acute myeloid leukemia with secondaries in the neck. Carcinomas of the nasopharynx and parotid both were 8 in number; 15 cases were of Hodgkin/non-Hodgkin lymphoma with involvement of neck nodes. The least number of cases was of carcinoma mandible, Burkitt lymphoma, and chronic myeloid leukemia with secondary neck nodes. Most cases presented with right-sided neck mass or lymphadenopathy. Male-to-female ratio was 1.78:1 in all cases. Most of the cases were diagnosed either by bone marrow aspiration biopsy, fine-needle aspiration cytology, or excisional biopsy. Conclusion: Malignancy is one of the differentials of pediatric neck masses. Hematological malignancies and lymphomas are still two major contributors of head-and-neck cancers in the pediatric age group.
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A Clinical Study of Second Branchial Cleft Anomalies: Our Experience in a Teaching Hospital in Northern India p. 96
M Anoop, Ram Avtar, Waseem Akhtar, Yogendra Yadav
Background: Branchial cleft anomalies are of five types. Among these, second branchial cleft anomalies are the most common developmental disorders. The aim of the study was to evaluate the clinical data in various subsets among the patients who had been diagnosed and treated for second branchial anomalies in the past 2 years. Materials and Methods: The present study was a retrospective study conducted from January 2018 to January 2020 in our institute. We collected the clinical data from patient’s medical records, radiological reports, surgical files, and histopathological reports. Results: A total of 22 patients presented with second branchial cleft anomalies. Among these, 18 (81.8%) were branchial cysts and 4 (18.2%) were branchial sinuses. There was no branchial fistula. The highest number of cases belonged to the second decade (72.7%). The mean age was found to be 16.8 years. The male-to-female ratio was 1.75:1. The rural-to-urban ratio was 3.4:1. There was no proclivity to any one side of the neck. All 22 patients underwent surgical excision as the treatment. There was no recurrence. Conclusion: We concluded that branchial cysts are the main type among second branchial cleft anomalies. Most patients belonged to the second decade of life. Early detection and reaching correct diagnosis are the major factors influencing treatment outcome. Preferably, surgical excision has to be performed in noninfected neck. Meticulous dissection helps in avoiding recurrence. Genetic disorders such as branchio-oto-renal syndrome have to be kept in mind in the evaluation of any branchial cleft anomalies.
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Tracheostomy Experience among Indian Otolaryngology-Head and Neck Surgery Residents – A Survey p. 102

Background: Tracheostomy is a common surgical procedure which otolaryngology-head and neck surgery (ORL-HNS) trainees are expected to perform in both emergency and elective settings. Few papers deal specifically with resident training in this procedure. we surveyed the standard of training in the Indian context. Materials and Methods: A questionnaire-based survey was conducted among residents attending the annual national conference of the Association of Otolaryngologists of India. The results of the survey were tabulated using Microsoft Excel. Results: Ninety questionnaires were circulated among postgraduate trainees in their 1st, 2nd, or 3rd year of training (P-1, P-2, and P-3) as well as senior residents (SR). The response rate was 47%. The majority of the respondents (51%) were P-2. The distribution between elective and emergency tracheostomy was variable. The most common indication for tracheostomy in our survey was prolonged Intensive Therapy Unit (ITU) ventilation (42%). In elective tracheostomy, the primary surgeon was either an SR or P-3 (60%) and used a horizontal incision (52%). In emergencies, the primary surgeon was either an SR or P-3 and preferred a vertical incision (65%). Most trainees exposed the trachea by layer dissection; only 6% used monopolar diathermy. Entry through vertical incision and dilator was the preferred method (51%). The first tube change was performed at 72 h by 49% of the respondents. Eighty-four percent of the trainees were confident of performing emergency tracheostomies independently. Conclusions: ORL-HNS trainees should be competent in tracheostomy. The lack of supervision by faculty, variation in steps, and postoperative management all impact the outcome. A standardized technique and faculty supervision are vital for optimum training.
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Role of sonoelastography beyond sonography for differentiation between reactive and metastatic lymphadenopathy p. 109

Purpose: To evaluate the diagnostic accuracy of sonography including Doppler and sonoelastography in differentiation between reactive and metastatic cervical lymphadenopathy. Materials and Methods: A cross-sectional study was undertaken with 50 study participants after defined inclusion and exclusion criteria as per the study needs and imaging limitations. Sonographic and sonoelastographic examination was done by two examiners and diagnosis was reached in consensus. Sonographic features assessed were size, short/long axis ratio, presence or absence of echogenic hilum, intra-nodal necrosis including pattern of vascularity. With ultrasonoelastography, color-coded elastograms and strain ratio (SR) were evaluated. Then, the accuracy of individual sonographic and sonoelastographic parameters as well as combined sonographic and sonoelastographic evaluation were evaluated against histopathological examination diagnosis. Cutoff for all the combined evaluation was determined from the receiver operating characteristic curve. Results: Sensitivity of individual sonographic parameters ranged from 81% to 96.3%, whereas specificity was from 50% to 96.3%. Maximum accuracy of 94.3% was obtained with intra-nodal necrosis and echogenic hilum individually. Color-coded elastograms with pattern >3 suggesting metastatic showed sensitivity of 100% but specificity of 75%. Maximum accuracy was achieved by SR >1.99 with 96.3% sensitivity and 93.02% specificity. Combined ultrasonography evaluation had sensitivity of 70.4% and specificity of 87.5%, whereas combined sonographic plus elastographic evaluation increased sensitivity and specificity to 92.6% and 100%, respectively. Conclusion: Combined sonographic and sonoelastographic assessment is better than individual assessment; hence, elastographic findings complement sonographic assessment and further increases the diagnostic confidence.
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Basaloid squamous cell carcinoma of the head and neck: Our experience p. 114

Basaloid squamous cell carcinoma (BSCC) of the head and neck is a distinctive variant of squamous cell carcinoma known for its basaloid appearance and aggressive behavior. Being a rare variant, clear evidence is lacking for the management and outcome of the lesion. In this observational study, we have tried to evaluate the clinical, radiological, and histopathological characteristics along with the management and treatment outcome of ten patients diagnosed with having BSCC of the head and neck who were diagnosed and treated at our hospital.
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The incidence and grade of tubercle of zuckerkandl and its relationship to the course of recurrent laryngeal nerve in thyroid surgery p. 119

Aim of the Study: The aim is to study the incidence and grade of Zuckerkandl’s tubercle (ZT) and the course of recurrent laryngeal nerve (RLN) with respect to the grade of ZT. Settings and Design: A prospective observational anatomical study. Materials and Methods: The relationship of ZT to RLN was studied, and the size of the ZT was measured and graded according to Pelizzo’s grading system in all cases of routine thyroidectomy in 36 patients (45 sides) from December 2018 to November 2019. Results: ZT was present in 32 (71.11%) of the sides, more commonly on the right side in 24 (88.89%) with a P value of 0.001. Among the total thyroidectomy, bilateral ZT was present in 7 cases (77.78%). In the 45 sides Grade 0 was noted in 13/45 (28.89%), Grade I 14/45 (31.11%), Grade II 9/45 (20%), and Grade III 9/45 (20%) with a P value of 0.001. ZT more than 0 but less than 1 cm was the most common occurrence (Grade I and II). In the 32 sides which had ZT, 23/32 (71.88%) were Type A (posterior) and 9/32 (28.12%) were type D (lateral) with a P value of 0.01. Conclusions: The identification and meticulous dissection of ZT ensures completeness of thyroidectomy. As the size of the ZT increases, the nerve often runs posterior and medial to surface of ZT. The site of ZT can be considered an eloquent area in thyroid surgery as it lies in proximity to the RLN and superior parathyroid gland.
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Characteristics and patterns of surgical interventions in differentiated thyroid cancer with distant metastasis p. 124

Objective: Unlike most head and neck cancers, the presence of distant metastasis (DM) does not preclude curative intent treatment and surgical interventions are common in metastatic disease. This research attempts to study the demographics, patterns of metastasis, and surgical interventions in patients of differentiated thyroid cancer (DTC) with DM. Materials and Methods: The retrospective cohort study of thirty-two patients of DTC with radiologically or histopathologically/cytopathologically confirmed DM who underwent surgery at a tertiary care center from August 2011 to December 2018. Results: The study population comprised of 59% of women and had a median age of 55 (19–79) years. Thorax was the most common site of metastasis, documented in 56% patients, while 53% of patients had bone metastases. Multiple DM were noted in 8 patients. Surgery for metastatic sites was possible in 14 patients (44%), with debulking and spine fixation being the most common surgical intervention for metastasis. The median dose of radioactive iodine (RAI) received by patients was 400 (25–749) mCi in one to four sessions (median-2 sessions). Three patients received conventional chemotherapy, while four received Sorafenib. Conclusion: Metastasectomy in DTC with DM is feasible in selected patients, and surgical interventions are most commonly performed on the spine to prevent neurological complications. RAI ablation is universally administered in this subset of patients and in very high doses, often distributed in multiple sessions. The role of chemotherapy and tyrosine kinase inhibitor is still restricted to palliative settings and cost constraints remain a detriment to more widespread use.
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Prognosticators for quality of life in surgically treated head-and-neck cancer patients p. 129

Introduction: Physiological, functional, and psychological implications of head-and-neck cancer treatment are significant. Improving outcomes in cancer care must include due diligence to quality of life (QOL) along with disease control. This study assesses QOL of head-and-neck cancer patients before and after treatment and explores predictive factors. Materials and Methods: Prospective observational study of consecutive head-and-neck cancer patients. QOL assessments were made at baseline, and different stages of their treatment and prognostic factors such as age, gender, socioeconomic strata, comorbidities, tumor stage, requirement of reconstruction, adjuvant treatment, were examined. EORTC QOL questionnaire-H and N0 35 were employed, and prognostic factor correlation was studied by logistic regression analysis. Results: Ninety-eight patients at least 12 months post-treatment scored worst for dryness of the mouth (33.4), followed by sticky saliva (23.4). Although results steadily improved over time, this did not reach statistical significance (P = 0.235). Stage of the primary tumor, requirement of reconstruction, and adjuvant treatment were statistically significant prognostic factors (P < 0.05). Conclusion: Understanding of QOL parameters would improve treatment planning, counseling of head-and-neck cancer patients and care-givers and enable physical, functional, and social rehabilitation.
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Conducting interdepartmental tele-joint clinic during the coronavirus disease 2019 pandemic in a tertiary cancer care center p. 134

Introduction: The coronavirus disease 2019 pandemic has posed numerous challenges to health care across the globe. Time is of the essence in cancer care to prevent disease progression. Materials and Methods: TrueConf ®, a local area network-based software, has been used for holding joint clinic meetings which are an essential part of cancer management at our hospital. Results: A total of 12 meetings were held over a period of 12 weeks where 42 patients were examined and their clinicoradiological evaluation was done. Further treatment decisions were made based on these joint clinics. Conclusion: TrueConf ® is an economical platform and easily implementable system, easing decision-making for critical cases, avoiding crowding in outpatient departments.
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Multidisciplinary Approach for Vision Recovery after a Diving Accident with a Needlefish in Cancun p. 137

Needlefish (Strongylura Notata) are known to cause painful injuries in humans. There are several reports of serious puncture wounds to the chest, abdomen, neck, and extremities. In this report, we describe an impressive puncture lesion to the face that resulted in unilateral partial loss of vision with perforation of the cranial vault secondary to an encounter with a fish while diving. A 39-year-old female presented to the emergency department 1 week after a diving trip to Cancun with pain and swelling in the right orbital region. She had associated right-sided partial vision loss and a puncture wound on the right malar region. Computed tomography scan of the head showed two foreign bodies; one which crossed the orbit from the inferior lateral side displacing medially the optic nerve and into the cranial cavity. The second foreign body was located in the inferolateral side of the malar bone. Multidisciplinary surgical removal of the objects resulted in complete resolution of visual acuity deficits as well as total recovery of her diplopia. Fortunately, minimal limitation in the abduction of the right eye persisted.
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Non-small Cell Lung Cancer Presenting as Parotid and Scalp Swellings: A Rare Clinical Presentation p. 141

Metastases to the parotid gland as first presentation of lung cancer are extremely rare and occur in <1% cases most of which are small cell carcinomas. We present such a case of squamous cell carcinoma of the lung who presented with swellings of the parotid gland and over the scalp. He was diagnosed on the basis of fine needle aspiration cytology followed by investigative imaging to search for the primary. He was treated with palliative radiotherapy and chemotherapy but succumbed to his disease at 9 months from the diagnosis. Parotid and skin metastases in lung cancer can occur by both lymphatic and hematogenous spread. Metastases to such visible and accessible parts of the body can help in the early detection of disease, though in most cases, it occurs as a sign of progression in preexisting cancer. Management options are limited in such patients, and overall, the prognosis is poor.
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Eosinophilic Granulomatosis with Polyangiitis Presenting as Acute Nasal Obstruction p. 146

A 55-year-old man presented with high-grade fever, nasal obstruction, and erythematous skin rash for 1 week. He had hypertension for 5 years, uncontrolled diabetes mellitus for 6 years, and bronchial asthma for the past 8 years. He was diagnosed to have eosinophilic granulomatosis with polyangiitis (EGPA) based on the clinical, laboratory, and histopathological findings. He was treated with prednisolone 1 mg/kg which was tapered over months. He had immediate relief for his nasal obstruction following steroids. Fever and skin rash subsided later. We present a patient with acute nasal obstruction during the vasculitic phase of EGPA. Nasal manifestations are usually seen during the early phase along with asthma long before the onset of vasculitic phase. Invasive fungal infections of the paranasal sinuses which can have similar presentations also should be ruled out by histopathology in such patients, especially when they are at risk. Awareness regarding such rare acute presentations of an uncommon vasculitis can avoid diagnostic dilemmas.
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Squamous Cell Carcinoma of the Tongue Remaining Indolent for 8-Years p. 150

Squamous Cell Cancer (SCC) of the tongue is generally known for its overall aggressive behavior. However, there are subsets within this group of cancers that behave differently in its clinical presentation, course, and outcome, and the insights into this are being elucidated with more and more accuracy. It is intriguing to note that some of these cancers present with aggressive primary with the late appearance of lymph nodes, whereas others in the opposite end of the spectrum would show up with very small primary and massive nodes. Knowledge of these variations in presentation and its clinicopathological correlation is essential to plan treatment strategies. Presented here is a case of a 49 year male with no habits, who had a diagnosis of tongue cancer but defaulted treatment and reported after eight years. Surprisingly he had no significant progression of lesion giving room for curative treatment. Besides giving an insight into the unique tumor biology, a possible link to health planning, and economics from a public health perspective is discussed.
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A myomucosal reconstruction solution to stricture postradiation cervical esophagus p. 153
Mihir T Mohan, BS Naveen, Shawn T Joseph, Jose Tharayil
A late side effect of radiation for head and neck cancer that has a significant effect on quality of life is esophageal stricture. Many newer techniques of radiation have evolved, but esophageal stricture still remains a complication, especially in a concurrent chemoradiation setting. The treatment options in such conditions can be either invasive or noninvasive. We present a reconstructive option in the form of islanded facial artery myomucosal (iFAMM) flap which carries less donor site morbidity and also provides a mucosal lining. A patient with carcinoma hypopharynx reported with dysphagia following concurrent chemoradiation. The patient was evaluated clinically (video-laryngoscopy, esophago-gastro-duodenoscopy, and video-fluoroscopy) and radiologically and diagnosed as stricture cervical esophagus. The patient had undergone repeated noninvasive techniques of dilatation and failed. Stricture release and patch pharyngoplasty were done with iFAMM flap. Till the last follow-up of 1 year, the patient showed satisfactory deglutition with normal voice. iFAMM is a viable and esthetically appealing option for reconstruction of partial postradiation hypopharynx and cervical esophagus stricture of up to 6 cm in length that are not amenable to dilatation procedures.
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Response to "Ocular Melanoma: A Rare Entity" p. 157
Mahmood Dhahir Al-Mendalawi
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