Comparative treatment outcomes for patients with idiopathic subglottic stenosis

Alexander Gelbard, Catherine Anderson, Lynne D. Berry, Milan R. Amin, Michael S. Benninger, Joel H. Blumin, Jonathan M. Bock, Paul C. Bryson, Paul F. Castellanos, Sheau Chiann Chen, Matthew S. Clary, Seth M. Cohen, Brianna K. Crawley, Seth H. Dailey, James J. Daniero, Alessandro De Alarcon, Donald T. Donovan, Eric S. Edell, Dale C. Ekbom, Sara Fernandes-TaylorDaniel S. Fink, Ramon A. Franco, C. Gaelyn Garrett, Elizabeth A. Guardiani, Alexander T. Hillel, Henry T. Hoffman, Norman D. Hogikyan, Rebecca J. Howell, Li Ching Huang, Lena K. Hussain, Michael M. Johns, Jan L. Kasperbauer, Sid M. Khosla, Cheryl Kinnard, Robbi A. Kupfer, Alexander J. Langerman, Robert J. Lentz, Robert R. Lorenz, David G. Lott, Anne S. Lowery, Samir S. Makani, Fabien Maldonado, Kyle Mannion, Laura Matrka, Andrew J. McWhorter, Albert L. Merati, Matthew C. Mori, James L. Netterville, Karla ODell, Julina Ongkasuwan, Gregory N. Postma, Lindsay S. Reder, Sarah L. Rohde, Brent E. Richardson, Otis B. Rickman, Clark A. Rosen, Michael J. Rutter, Guri S. Sandhu, Joshua S. Schindler, G. Todd Schneider, Rupali N. Shah, Andrew G. Sikora, Robert J. Sinard, Marshall E. Smith, Libby J. Smith, Ahmed M.S. Soliman, Sigríur Sveinsdóttir, Douglas J. Van Daele, David Veivers, Sunil P. Verma, Paul M. Weinberger, Philip A. Weissbrod, Christopher T. Wootten, Yu Shyr, David O. Francis

Research output: Contribution to journalArticle

Abstract

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-Term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Original languageEnglish
Pages (from-to)20-29
Number of pages10
JournalJAMA Otolaryngology - Head and Neck Surgery
Volume146
Issue number1
DOIs
Publication statusPublished - 2020 Jan

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Pathologic Constriction
Dilatation
Rare Diseases
Recurrence
Therapeutics
Endoscopy
Cohort Studies
Propensity Score
Proportional Hazards Models
Chronic Obstructive Pulmonary Disease
Multicenter Studies
Decision Making
Eating
Quality of Life
Outcome Assessment (Health Care)
Technology
Research

All Science Journal Classification (ASJC) codes

  • Surgery
  • Otorhinolaryngology

Cite this

Gelbard, A., Anderson, C., Berry, L. D., Amin, M. R., Benninger, M. S., Blumin, J. H., ... Francis, D. O. (2020). Comparative treatment outcomes for patients with idiopathic subglottic stenosis. JAMA Otolaryngology - Head and Neck Surgery, 146(1), 20-29. https://doi.org/10.1001/jamaoto.2019.3022
Gelbard, Alexander ; Anderson, Catherine ; Berry, Lynne D. ; Amin, Milan R. ; Benninger, Michael S. ; Blumin, Joel H. ; Bock, Jonathan M. ; Bryson, Paul C. ; Castellanos, Paul F. ; Chen, Sheau Chiann ; Clary, Matthew S. ; Cohen, Seth M. ; Crawley, Brianna K. ; Dailey, Seth H. ; Daniero, James J. ; De Alarcon, Alessandro ; Donovan, Donald T. ; Edell, Eric S. ; Ekbom, Dale C. ; Fernandes-Taylor, Sara ; Fink, Daniel S. ; Franco, Ramon A. ; Garrett, C. Gaelyn ; Guardiani, Elizabeth A. ; Hillel, Alexander T. ; Hoffman, Henry T. ; Hogikyan, Norman D. ; Howell, Rebecca J. ; Huang, Li Ching ; Hussain, Lena K. ; Johns, Michael M. ; Kasperbauer, Jan L. ; Khosla, Sid M. ; Kinnard, Cheryl ; Kupfer, Robbi A. ; Langerman, Alexander J. ; Lentz, Robert J. ; Lorenz, Robert R. ; Lott, David G. ; Lowery, Anne S. ; Makani, Samir S. ; Maldonado, Fabien ; Mannion, Kyle ; Matrka, Laura ; McWhorter, Andrew J. ; Merati, Albert L. ; Mori, Matthew C. ; Netterville, James L. ; ODell, Karla ; Ongkasuwan, Julina ; Postma, Gregory N. ; Reder, Lindsay S. ; Rohde, Sarah L. ; Richardson, Brent E. ; Rickman, Otis B. ; Rosen, Clark A. ; Rutter, Michael J. ; Sandhu, Guri S. ; Schindler, Joshua S. ; Schneider, G. Todd ; Shah, Rupali N. ; Sikora, Andrew G. ; Sinard, Robert J. ; Smith, Marshall E. ; Smith, Libby J. ; Soliman, Ahmed M.S. ; Sveinsdóttir, Sigríur ; Van Daele, Douglas J. ; Veivers, David ; Verma, Sunil P. ; Weinberger, Paul M. ; Weissbrod, Philip A. ; Wootten, Christopher T. ; Shyr, Yu ; Francis, David O. / Comparative treatment outcomes for patients with idiopathic subglottic stenosis. In: JAMA Otolaryngology - Head and Neck Surgery. 2020 ; Vol. 146, No. 1. pp. 20-29.
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title = "Comparative treatment outcomes for patients with idiopathic subglottic stenosis",
abstract = "Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5{\%}) were female and 787 (97.2{\%}) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4{\%}), ERMT (n = 121; 14.9{\%}), and CTR (n = 86; 10.6{\%}). Overall, 185 patients (22.8{\%}) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2{\%}]; ERMT, 15 [12.4{\%}]; and ED, 169 [28.0{\%}]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95{\%} CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-Term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.",
author = "Alexander Gelbard and Catherine Anderson and Berry, {Lynne D.} and Amin, {Milan R.} and Benninger, {Michael S.} and Blumin, {Joel H.} and Bock, {Jonathan M.} and Bryson, {Paul C.} and Castellanos, {Paul F.} and Chen, {Sheau Chiann} and Clary, {Matthew S.} and Cohen, {Seth M.} and Crawley, {Brianna K.} and Dailey, {Seth H.} and Daniero, {James J.} and {De Alarcon}, Alessandro and Donovan, {Donald T.} and Edell, {Eric S.} and Ekbom, {Dale C.} and Sara Fernandes-Taylor and Fink, {Daniel S.} and Franco, {Ramon A.} and Garrett, {C. Gaelyn} and Guardiani, {Elizabeth A.} and Hillel, {Alexander T.} and Hoffman, {Henry T.} and Hogikyan, {Norman D.} and Howell, {Rebecca J.} and Huang, {Li Ching} and Hussain, {Lena K.} and Johns, {Michael M.} and Kasperbauer, {Jan L.} and Khosla, {Sid M.} and Cheryl Kinnard and Kupfer, {Robbi A.} and Langerman, {Alexander J.} and Lentz, {Robert J.} and Lorenz, {Robert R.} and Lott, {David G.} and Lowery, {Anne S.} and Makani, {Samir S.} and Fabien Maldonado and Kyle Mannion and Laura Matrka and McWhorter, {Andrew J.} and Merati, {Albert L.} and Mori, {Matthew C.} and Netterville, {James L.} and Karla ODell and Julina Ongkasuwan and Postma, {Gregory N.} and Reder, {Lindsay S.} and Rohde, {Sarah L.} and Richardson, {Brent E.} and Rickman, {Otis B.} and Rosen, {Clark A.} and Rutter, {Michael J.} and Sandhu, {Guri S.} and Schindler, {Joshua S.} and Schneider, {G. Todd} and Shah, {Rupali N.} and Sikora, {Andrew G.} and Sinard, {Robert J.} and Smith, {Marshall E.} and Smith, {Libby J.} and Soliman, {Ahmed M.S.} and Sigr{\'i}ur Sveinsd{\'o}ttir and {Van Daele}, {Douglas J.} and David Veivers and Verma, {Sunil P.} and Weinberger, {Paul M.} and Weissbrod, {Philip A.} and Wootten, {Christopher T.} and Yu Shyr and Francis, {David O.}",
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Gelbard, A, Anderson, C, Berry, LD, Amin, MR, Benninger, MS, Blumin, JH, Bock, JM, Bryson, PC, Castellanos, PF, Chen, SC, Clary, MS, Cohen, SM, Crawley, BK, Dailey, SH, Daniero, JJ, De Alarcon, A, Donovan, DT, Edell, ES, Ekbom, DC, Fernandes-Taylor, S, Fink, DS, Franco, RA, Garrett, CG, Guardiani, EA, Hillel, AT, Hoffman, HT, Hogikyan, ND, Howell, RJ, Huang, LC, Hussain, LK, Johns, MM, Kasperbauer, JL, Khosla, SM, Kinnard, C, Kupfer, RA, Langerman, AJ, Lentz, RJ, Lorenz, RR, Lott, DG, Lowery, AS, Makani, SS, Maldonado, F, Mannion, K, Matrka, L, McWhorter, AJ, Merati, AL, Mori, MC, Netterville, JL, ODell, K, Ongkasuwan, J, Postma, GN, Reder, LS, Rohde, SL, Richardson, BE, Rickman, OB, Rosen, CA, Rutter, MJ, Sandhu, GS, Schindler, JS, Schneider, GT, Shah, RN, Sikora, AG, Sinard, RJ, Smith, ME, Smith, LJ, Soliman, AMS, Sveinsdóttir, S, Van Daele, DJ, Veivers, D, Verma, SP, Weinberger, PM, Weissbrod, PA, Wootten, CT, Shyr, Y & Francis, DO 2020, 'Comparative treatment outcomes for patients with idiopathic subglottic stenosis', JAMA Otolaryngology - Head and Neck Surgery, vol. 146, no. 1, pp. 20-29. https://doi.org/10.1001/jamaoto.2019.3022

Comparative treatment outcomes for patients with idiopathic subglottic stenosis. / Gelbard, Alexander; Anderson, Catherine; Berry, Lynne D.; Amin, Milan R.; Benninger, Michael S.; Blumin, Joel H.; Bock, Jonathan M.; Bryson, Paul C.; Castellanos, Paul F.; Chen, Sheau Chiann; Clary, Matthew S.; Cohen, Seth M.; Crawley, Brianna K.; Dailey, Seth H.; Daniero, James J.; De Alarcon, Alessandro; Donovan, Donald T.; Edell, Eric S.; Ekbom, Dale C.; Fernandes-Taylor, Sara; Fink, Daniel S.; Franco, Ramon A.; Garrett, C. Gaelyn; Guardiani, Elizabeth A.; Hillel, Alexander T.; Hoffman, Henry T.; Hogikyan, Norman D.; Howell, Rebecca J.; Huang, Li Ching; Hussain, Lena K.; Johns, Michael M.; Kasperbauer, Jan L.; Khosla, Sid M.; Kinnard, Cheryl; Kupfer, Robbi A.; Langerman, Alexander J.; Lentz, Robert J.; Lorenz, Robert R.; Lott, David G.; Lowery, Anne S.; Makani, Samir S.; Maldonado, Fabien; Mannion, Kyle; Matrka, Laura; McWhorter, Andrew J.; Merati, Albert L.; Mori, Matthew C.; Netterville, James L.; ODell, Karla; Ongkasuwan, Julina; Postma, Gregory N.; Reder, Lindsay S.; Rohde, Sarah L.; Richardson, Brent E.; Rickman, Otis B.; Rosen, Clark A.; Rutter, Michael J.; Sandhu, Guri S.; Schindler, Joshua S.; Schneider, G. Todd; Shah, Rupali N.; Sikora, Andrew G.; Sinard, Robert J.; Smith, Marshall E.; Smith, Libby J.; Soliman, Ahmed M.S.; Sveinsdóttir, Sigríur; Van Daele, Douglas J.; Veivers, David; Verma, Sunil P.; Weinberger, Paul M.; Weissbrod, Philip A.; Wootten, Christopher T.; Shyr, Yu; Francis, David O.

In: JAMA Otolaryngology - Head and Neck Surgery, Vol. 146, No. 1, 01.2020, p. 20-29.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Comparative treatment outcomes for patients with idiopathic subglottic stenosis

AU - Gelbard, Alexander

AU - Anderson, Catherine

AU - Berry, Lynne D.

AU - Amin, Milan R.

AU - Benninger, Michael S.

AU - Blumin, Joel H.

AU - Bock, Jonathan M.

AU - Bryson, Paul C.

AU - Castellanos, Paul F.

AU - Chen, Sheau Chiann

AU - Clary, Matthew S.

AU - Cohen, Seth M.

AU - Crawley, Brianna K.

AU - Dailey, Seth H.

AU - Daniero, James J.

AU - De Alarcon, Alessandro

AU - Donovan, Donald T.

AU - Edell, Eric S.

AU - Ekbom, Dale C.

AU - Fernandes-Taylor, Sara

AU - Fink, Daniel S.

AU - Franco, Ramon A.

AU - Garrett, C. Gaelyn

AU - Guardiani, Elizabeth A.

AU - Hillel, Alexander T.

AU - Hoffman, Henry T.

AU - Hogikyan, Norman D.

AU - Howell, Rebecca J.

AU - Huang, Li Ching

AU - Hussain, Lena K.

AU - Johns, Michael M.

AU - Kasperbauer, Jan L.

AU - Khosla, Sid M.

AU - Kinnard, Cheryl

AU - Kupfer, Robbi A.

AU - Langerman, Alexander J.

AU - Lentz, Robert J.

AU - Lorenz, Robert R.

AU - Lott, David G.

AU - Lowery, Anne S.

AU - Makani, Samir S.

AU - Maldonado, Fabien

AU - Mannion, Kyle

AU - Matrka, Laura

AU - McWhorter, Andrew J.

AU - Merati, Albert L.

AU - Mori, Matthew C.

AU - Netterville, James L.

AU - ODell, Karla

AU - Ongkasuwan, Julina

AU - Postma, Gregory N.

AU - Reder, Lindsay S.

AU - Rohde, Sarah L.

AU - Richardson, Brent E.

AU - Rickman, Otis B.

AU - Rosen, Clark A.

AU - Rutter, Michael J.

AU - Sandhu, Guri S.

AU - Schindler, Joshua S.

AU - Schneider, G. Todd

AU - Shah, Rupali N.

AU - Sikora, Andrew G.

AU - Sinard, Robert J.

AU - Smith, Marshall E.

AU - Smith, Libby J.

AU - Soliman, Ahmed M.S.

AU - Sveinsdóttir, Sigríur

AU - Van Daele, Douglas J.

AU - Veivers, David

AU - Verma, Sunil P.

AU - Weinberger, Paul M.

AU - Weissbrod, Philip A.

AU - Wootten, Christopher T.

AU - Shyr, Yu

AU - Francis, David O.

PY - 2020/1

Y1 - 2020/1

N2 - Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-Term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

AB - Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-Term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

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UR - http://www.scopus.com/inward/citedby.url?scp=85074663517&partnerID=8YFLogxK

U2 - 10.1001/jamaoto.2019.3022

DO - 10.1001/jamaoto.2019.3022

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C2 - 31670805

AN - SCOPUS:85074663517

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JO - JAMA Otolaryngology - Head and Neck Surgery

JF - JAMA Otolaryngology - Head and Neck Surgery

SN - 2168-6181

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