Current view on the most common postoperative complications and quality of life of patients after vestibular schwannoma surgery

Czech version

Authors: J. Lazák ¹; J. Betka ¹; E. Zvěřina ¹; A. Vlasák ²; Z. Balatková ¹; M. Bonaventurová ¹; M. Kaňa ¹; Z. Fík ¹
Authors‘ workplace: Klinika otorinolaryngologie a chirurgie hlavy a krku 1. LF UK a FN v Motole, Praha ¹; Neurochirurgická klinika dětí a dospělých 2. LF UK a FN v Motole, Praha ²
Published in: Otorinolaryngol Foniatr, 73, 2024, No. 4, pp. 239-245.
Category: Review Article
doi: https://doi.org/10.48095/ccorl2024239

Overview

Microsurgical extirpation is one of the basic modalities of treatment for patients with vestibular schwannoma. Considering the significant decrease in mortality and morbidity of patients with vestibular schwannoma in the past decades, the quality of life has become the most important criterion of current treatment management. Despite the great scientific and technological progress in the surgical treatment of vestibular schwannoma, we can encounter a number of serious complications that can have a major impact on the quality of life. A number of questionnaire studies confirm that these are mainly postoperative facial nerve lesion, dizziness and long-term headache. In contrast, tinnitus or unilateral hearing loss may be a less serious handicap in terms of overall quality of life.

Keywords:

Quality of life – vestibular schwannoma – postoperative complications

Sources

1. Betka J, Zverina E, Balogova Z et al. Complications of microsurgery of vestibular schwannoma. Biomed Res Int 2014; 2014: 315952. Doi: 10.1155/2014/315952.

2. Samii M, Gerganov VM, Samii A. Functional outcome after complete surgical removal of giant vestibular schwannomas. J Neurosurg 2010; 112 (4): 860–867. Doi: 10.3171/2009.7.JNS0989.

3. Enee V, Guerin J, Bebear JP et al. Acoustic neuroma surgery. Results and complications in 348 cases. Rev Laryngol Otol Rhinol (Bord) 2003; 124 (1): 45–52.

4. Carlson ML, Tveiten OV, Driscoll CL et al. Long--term quality of life in patients with vestibular schwannoma: an international multicenter cross-sectional study comparing microsurgery, stereotactic radiosurgery, observation, and nontumor controls. J Neurosurg 2015; 122 (4): 833–842. Doi: 10.3171/2014.11.JNS14594.

5. Fik Z, Vlasak A, Zverina E et al. Which Epidemiological Characteristics Drive Decision Making in the Management of Patients with Vestibular Schwannoma? Biomedicines 2023; 11 (2). Doi: 10.3390/biomedicines11020340.

6. Zverina E. Acoustic neuroma – vestibular schwannoma – personal experience of up-to--date management. Cas Lek Cesk 2010; 149 (6): 269–276.

7. Fik Z, Lazak J, Hruba S et al. Hearing improvement after vestibular schwannoma surgery in the era of the hearing preservation rule – case report and literature review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2022; 166 (3): 347–352. Doi: 10.5507/bp.2021.067.

8. Halliday J, Rutherford SA, McCabe MG et al. An update on the diagnosis and treatment of vestibular schwannoma. Expert Rev Neurother 2018; 18 (1): 29–39. Doi: 10.1080/14737 175.2018.1399795.

9. Keillor JM, Barrett AM, Crucian GP et al. Emotional experience and perception in the absence of facial feedback. J Int Neuropsychol Soc 2002; 8 (1): 130–135.

10. Bradbury ET, Simons W, Sanders R. Psychological and social factors in reconstructive surgery for hemi-facial palsy. J Plast Reconstr Aesthet Surg 2006; 59 (3): 272–278. Doi: 10.1016/j.bjps.2005.09.003.

11. Andersson G. Anxiety, optimism and symptom reporting following surgery for acoustic neuroma. J Psychosom Res 1999; 46 (3): 257–260. Doi: 10.1016/s0022-3999 (98) 00093-2.

12. Boucek J, Vokral J, Cerny L et al. Baha implant as a hearing solution for single-sided deafness after retrosigmoid approach for the vestibular schwannoma: surgical results. Eur Arch Otorhinolaryngol 2017; 274 (6): 2429–2436. Doi: 10.1007/s00405-017-4505-z.

13. Pruijn IMJ, Kievit W, Hentschel MA et al. What determines quality of life in patients with vestibular schwannoma? Clin Otolaryngol 2021; 46 (2): 412–420. Doi: 10.1111/coa.13691.

14. Carlson ML, Tombers NM, Kerezoudis P et al. Quality of Life Within the First 6 Months of Vestibular Schwannoma Diagnosis With Implications for Patient Counseling. Otol Neurotol 2018; 39 (10): e1129–e1136. Doi: 10.1097/MAO.0000000000001999.

15. Gomaa MA, Elmagd MH, Elbadry MM et al. Depression, Anxiety and Stress Scale in patients with tinnitus and hearing loss. Eur Arch Otorhinolaryngol 2014; 271 (8): 2177–2184. Doi: 10.1007/s00405-013-2715-6.

16. Cross T, Sheard CE, Garrud P et al. Impact of facial paralysis on patients with acoustic neuroma. Laryngoscope 2000; 110 (9): 1539–1542. Doi: 10.1097/00005537-200009000-00024.

17. Santa Maria C, Santa Maria PL, Bulsara V et al. Long-term quality of life in patients with vestibular schwannoma managed with microsurgery. J Laryngol Otol 2019; 133 (11): 953–959. Doi: 10.1017/S0022215119002172.

18. Vachata P, Sameš M. Lícní nerv: anatomie, patologie, léčba. Praha: Mladá fronta 2016.

19. Condie D, Tolkachjov SN. Facial Nerve Injury and Repair: A Practical Review for Cutaneous Surgery. Dermatol Surg 2019; 45 (3): 340–357. Doi: 10.1097/DSS.0000000000001773.

20. Fik Z, Kraus J, Cada Z et al. Hemihypoglossal-facial nerve anastomosis: results and electromyographic characterization. Eur Arch Otorhinolaryngol 2022; 279 (1): 467–479. Doi: 10.1007/s00405-021-06893-4.

21. Kalfeřt D, Čelakovský P, Školoudík L et al. Periferní paréza lícního nervu při středoušní manifestaci Wegenerovy granulomatózy. Otorinolaryngol Foniatr 2009; 58 (2): 117–120.

22. Walker NR, Mistry RK, Mazzoni T. Facial Nerve Palsy. In: Treasure Island (FL): StatPearls 2022.

23. Hohman MH, Hadlock TA. Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope 2014; 124 (7): E283–E293. Doi: 10.1002/lary.24542.

24. Lipschitz N, Kohlberg GD, Tawfik KO et al. Cerebrospinal Fluid Leak Rate after Vestibular Schwannoma Surgery via Middle Cranial Fossa Approach. J Neurol Surg B Skull Base 2019; 80 (4): 437–440. Doi: 10.1055/s-0038-1675752.

25. Pollock BE, Lunsford LD, Kondziolka D et al. Vestibular schwannoma management. Part II. Failed radiosurgery and the role of delayed microsurgery. J Neurosurg 1998; 89 (6): 949–955. Doi: 10.3171/jns.1998.89.6.0949.

26. Husseman J, Mehta RP. Management of synkinesis. Facial Plast Surg 2008; 24 (2): 242–249. Doi: 10.1055/s-2008-1075840.

27. Sanchez-Ocando M, Gavilan J, Penarrocha J et al. Facial nerve repair: the impact of technical variations on the final outcome. Eur Arch Otorhinolaryngol 2019; 276 (12): 3301–3308. Doi: 10.1007/s00405-019-05638-8.

28. Darrouzet V, Dutkiewicz J, Chambrin A et al. [Hypoglosso-facial anastomosis: results and technical development towards end-to--side anastomosis with rerouting of the intra-temporal facial nerve (modified May technique) ]. Rev Laryngol Otol Rhinol (Bord) 1997; 118 (3): 203–210.

29. di Summa PG, Kingham PJ, Campisi CC et al. Collagen (NeuraGen (R)) nerve conduits and stem cells for peripheral nerve gap repair. Neurosci Lett 2014; 572: 26–31. Doi: 10.1016/j.neulet.2014.04.029.

30. Yawn RJ, Dedmon MM, Xie D et al. Delayed Facial Nerve Paralysis after Vestibular Schwannoma Resection. J Neurol Surg B Skull Base 2019; 80 (3): 283–286. Doi: 10.1055/s-0038-1669941.

31. Jia XH, Gao Z, Lin NE et al. Delayed Facial Nerve Paralysis After Vestibular Schwannoma Resection. World Neurosurg 2023; 170: e431–e435. Doi: 10.1016/j.wneu.2022.11.036.

32. Scheller C, Richter HP, Engelhardt M et al. The influence of prophylactic vasoactive treatment on cochlear and facial nerve functions after vestibular schwannoma surgery: a prospective and open-label randomized pilot study. Neurosurgery 2007; 61 (1): 92–98. Doi: 10.1227/01.neu.0000279728.98273.51.

33. Strauss C, Romstock J, Fahlbusch R et al. Preservation of facial nerve function after postoperative vasoactive treatment in vestibular schwannoma surgery. Neurosurgery 2006; 59 (3): 577–584. Doi: 10.1227/01.NEU.0000230260.95477.0A.

34. Scheller C, Rampp S, Leisz S et al. Prophylactic nimodipine treatment improves hearing outcome after vestibular schwannoma surgery in men: a subgroup analysis of a randomized multicenter phase III trial. Neurosurg Rev 2021; 44 (3): 1729–1735. Doi: 10.1007/s10143-020-01368-2.

35. Chorath K, Go BC, Kaufman A et al. Perioperative Nimodipine to Improve Cranial Nerve Function: A Systematic Review and Meta-Analysis. Otol Neurotol 2021; 42 (6): 783–791. Doi: 10.1097/MAO.0000000000003101.

36. Trakolis L, Ebner FH, Machetanz K et al. Postoperative Tinnitus After Vestibular Schwannoma Surgery Depends on Preoperative Tinnitus and Both Pre- and Postoperative Hearing Function. Front Neurol 2018; 9: 136. Doi: 10.3389/fneur.2018.00136.

37. Myrseth E, Pedersen PH, Moller P et al. Treatment of vestibular schwannomas. Why, when and how? Acta Neurochir (Wien) 2007; 149 (7): 647–660. Doi: 10.1007/s00701-007-1179-0.

38. Lysaght AC, Kao SY, Paulo JA et al. Proteome of human perilymph. J Proteome Res 2011; 10 (9): 3845–3851. Doi: 10.1021/pr200346q.

39. Edvardsson Rasmussen J, Laurell G, Rask-Andersen H et al. The proteome of perilymph in patients with vestibular schwannoma. A possibility to identify biomarkers for tumor associated hearing loss? PLoS One 2018; 13 (6): e0198442. Doi: 10.1371/journal.pone.0198442.

40. Stankovic KM, Mrugala MM, Martuza RL et al. Genetic determinants of hearing loss associated with vestibular schwannomas. Otol Neurotol 2009; 30 (5): 661–667. Doi: 10.1097/MAO.0b013e3181a66ece.

41. Baguley DM, van Dijk P, Knipper M. Tinnitus Research: Improvement and Innovation. Trends Hear 2019; 23: 2331216519837135. Doi: 10.1177/2331216519837135.

42. Norena AJ, Eggermont JJ. Changes in spontaneous neural activity immediately after an acoustic trauma: implications for neural correlates of tinnitus. Hear Res 2003; 183 (1–2): 137–153. Doi: 10.1016/s0378-5955 (03) 00225-9.

43. Catalano PJ, Post KD. Elimination of tinnitus following hearing preservation surgery for acoustic neuromas. Am J Otol 1996; 17 (3): 443–445.

44. Ren Y, MacDonald BV, Tawfik KO et al. Clinical Predictors of Facial Nerve Outcomes After Surgical Resection of Vestibular Schwannoma. Otolaryngol Head Neck Surg 2021; 164 (5): 1085–1093. Doi: 10.1177/0194599820961389.

45. Kohno M, Shinogami M, Yoneyama H et al. Prognosis of tinnitus after acoustic neuroma surgery--surgical management of postoperative tinnitus. World Neurosurg 2014; 81 (2): 357–367. Doi: 10.1016/j.wneu.2012.09.008.

46. Chovanec M, Zvěřina E, Profant O, et al. Does attempt at hearing preservation microsurgery of vestibular schwannoma affect postoperative tinnitus? Biomed Res Int 2015; 2015: 783169. Doi: 10.1155/2015/783169.

47. Del Rio L, Lassaletta L, Diaz-Anadon A et al. Tinnitus and quality of life following vestibular schwannoma surgery. B-ENT 2012; 8 (3): 167–171.

48. Grauvogel J, Kaminsky J, Rosahl SK. The impact of tinnitus and vertigo on patient--perceived quality of life after cerebellopontine angle surgery. Neurosurgery 2010; 67 (3): 601–609; discussion 609-610. Doi: 10.1227/01.NEU.0000374725.19259.EA.

49. Martinez Del Pero M, Lloyd SK, Moffat DA. Hearing improvement in a growing vestibular schwannoma. Skull Base 2009; 19 (2): 159–162. Doi: 10.1055/s-0028-1096203.

50. Badie B, Pyle GM, Nguyen PH et al. Elevation of internal auditory canal pressure by vestibular schwannomas. Otol Neurotol 2001; 22 (5): 696–700. Doi: 10.1097/00129492-20010 9000-00024.

51. Stangerup SE, Thomsen J, Tos M et al. Long-term hearing preservation in vestibular schwannoma. Otol Neurotol 2010; 31 (2): 271–275. Doi: 10.1097/MAO.0b013e3181c34bda.

52. Carlson ML, Vivas EX, McCracken DJ et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Hearing Preservation Outcomes in Patients With Sporadic Vestibular Schwannomas. Neurosurgery 2018; 82 (2): E35–E39. Doi: 10.1093/neuros/nyx511.

53. Preet K, Ong V, Sheppard JP et al. Postoperative Hearing Preservation in Patients Undergoing Retrosigmoid Craniotomy for Resection of Vestibular Schwannomas: A Systematic Review of 2034 Patients. Neurosurgery 2020; 86 (3): 332–342. Doi: 10.1093/neuros/nyz147.

54. Meyer TA, Canty PA, Wilkinson EP et al. Small acoustic neuromas: surgical outcomes versus observation or radiation. Otol Neurotol 2006; 27 (3): 380–392. Doi: 10.1097/001 29492-200604000-00015.

55. Jacob A, Robinson LL Jr, Bortman JS, Yu L, Dodson EE, Welling DB. Nerve of origin, tumor size, hearing preservation, and facial nerve outcomes in 359 vestibular schwannoma resections at a tertiary care academic center. Laryngoscope 2007; 117 (12): 2087–2092. Doi: 10.1097/MLG.0b013e3181453a07.

56. Yates PD, Jackler RK, Satar B, Pitts LH, Oghalai JS. Is it worthwhile to attempt hearing preservation in larger acoustic neuromas? Otol Neurotol 2003; 24 (3): 460–464. Doi: 10.1097/00129492-200305000-00017.

57. Giolas TG, Wark DJ. Communication problems associated with unilateral hearing loss. J Speech Hear Disord 1967; 32 (4): 336–343. Doi: 10.1044/jshd.3204.336.

58. Macielak RJ, Marinelli JP, Spear SA et al. Hearing Status and Aural Rehabilitative Profile of 878 Patients With Sporadic Vestibular Schwannoma. Laryngoscope 2021; 131 (6): 1378–1381. Doi: 10.1002/lary.29315.

59. Drusin MA, Lubor B, Losenegger T et al. Trends in hearing rehabilitation use among vestibular schwannoma patients. Laryngoscope 2020; 130 (6): 1558–1564. Doi: 10.1002/lary.28316.

60. Carlson ML, Tveiten OV, Driscoll CL et al. What drives quality of life in patients with sporadic vestibular schwannoma? Laryngoscope 2015; 125 (7): 1697–1702. Doi: 10.1002/lary.25110.

61. Parietti-Winkler C, Gauchard GC, Simon C et al. Sensorimotor postural rearrangement after unilateral vestibular deafferentation in patients with acoustic neuroma. Neurosci Res 2006; 55 (2): 171–181. Doi: 10.1016/j.neures.2006.02.016.

62. Van de Graaf RC, FF IJ, Nicolai JP. Sir Charles Alfred Ballance (1856-1936) and the introduction of facial nerve crossover anastomosis in 1895. J Plast Reconstr Aesthet Surg 2009; 62 (1): 43–49. Doi: 10.1016/j.bjps.2008.06.052.

63. Magnusson M, Kahlon B, Karlberg M et al. Preoperative vestibular ablation with gentamicin and vestibular ‚prehab‘ enhance postoperative recovery after surgery for pontine angle tumours – first report. Acta Otolaryngol 2007; 127 (12): 1236–1240. Doi: 10.1080/ 00016480701663433.

64. Cada Z, Balatkova Z, Cakrt O et al. Predictors of central vestibular compensation after surgery for vestibular schwannomas. Acta Otorhinolaryngol Ital 2019; 39 (1): 46–52. Doi: 10.14639/0392-100X-1963.

65. Niziol R, Henry FP, Leckenby JI et al. Is there an ideal outcome scoring system for facial reanimation surgery? A review of current methods and suggestions for future publications. J Plast Reconstr Aesthet Surg 2015; 68 (4): 447–456. Doi: 10.1016/j.bjps.2014.12.015.

66. Vidal PP, de Waele C, Vibert N et al. Vestibular compensation revisited. Otolaryngol Head Neck Surg 1998; 119 (1): 34–42. Doi: 10.1016/S0194-5998 (98) 70171-8.

67. Cakrt O, Chovanec M, Funda T et al. Exercise with visual feedback improves postural stability after vestibular schwannoma surgery. Eur Arch Otorhinolaryngol 2010; 267 (9): 1355–1360. Doi: 10.1007/s00405-010-1227-x.

68. Magnusson M, Kahlon B, Karlberg M et al. Vestibular „PREHAB“. Ann N Y Acad Sci 2009; 1164: 257–262. Doi: 10.1111/j.1749-6632. 2009.03778.x.

69. Hruba S, Chovanec M, Cada Z et al. The evaluation of vestibular compensation by vestibular rehabilitation and prehabilitation in short-term postsurgical period in patients following surgical treatment of vestibular schwannoma. Eur Arch Otorhinolaryngol 2019; 276 (10): 2681–2689. Doi: 10.1007/s00405-019-05503-8.

70. Rimaaja T, Haanpaa M, Blomstedt G et al. Headaches after acoustic neuroma surgery. Cephalalgia 2007; 27 (10): 1128–1135. Doi: 10.1111/j.1468-2982.2007.01410.x

71. Levo H, Blomstedt G, Hirvonen T et al. Causes of persistent postoperative headache after surgery for vestibular schwannoma. Clin Otolaryngol Allied Sci 2001; 26 (5): 401–406. Doi: 10.1046/j.1365-2273.2001.00492.x.

72. Pan W, Peng J, Elmofty D. Occipital Neuralgia. Curr Pain Headache Rep 2021; 25 (9): 61. Doi: 10.1007/s11916-021-00972-1.

73. Aihara N, Yamada H, Takahashi M et al. Postoperative Headache after Undergoing Acoustic Neuroma Surgery via the Retrosigmoid Approach. Neurol Med Chir (Tokyo) 2017; 57 (12): 634–640. Doi: 10.2176/nmc.oa.2017-0108.

74. Ducic I, Felder JM 3rd, Endara M. Postoperative headache following acoustic neuroma resection: occipital nerve injuries are associated with a treatable occipital neuralgia. Headache 2012; 52 (7): 1136–1145. Doi: 10.1111/j.1526-4610.2011.02068.x.

75. Sabab A, Sandhu J, Bacchi S et al. Postoperative headache following treatment of vestibular schwannoma: A literature review. J Clin Neurosci 2018; 52: 26–31. Doi: 10.1016/j.jocn.2018.04.003.

76. Pedrosa CA, Ahern DK, McKenna MJ et al. Determinants and impact of headache after acoustic neuroma surgery. Am J Otol 1994; 15 (6): 793–797.

77. Boghani Z, Choudhry OJ, Schmidt RF et al. Reconstruction of cranial base defects using the Medpor Titan implant: cranioplasty applications in acoustic neuroma surgery. Laryngoscope 2013; 123 (6): 1361–1368. Doi: 10.1002/lary.23840.

78. Wazen JJ, Sisti M, Lam SM. Cranioplasty in acoustic neuroma surgery. Laryngoscope 2000; 110 (8): 1294–1297. Doi: 10.1097/00005 537-200008000-00013.

79. Vass Z, Shore SE, Nuttall AL et al. Trigeminal ganglion innervation of the cochlea – a retrograde transport study. Neuroscience 1997; 79 (2): 605–615. Doi: 10.1016/s0306-4522 (96) 00641-0.

80. Abd-Elsayed A, Falls C, Luo S. Radiofrequency Ablation for Treating Headache: a Follow-up Study. Curr Pain Headache Rep 2020; 24 (4): 15. Doi: 10.1007/s11916-020-0843-4.

81. Becker SS, Jackler RK, Pitts LH. Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches. Otol Neurotol 2003; 24 (1): 107–112. Doi: 10.1097/00129492-200301000-00021.

82. Selesnick SH, Liu JC, Jen A et al. The incidence of cerebrospinal fluid leak after vestibular schwannoma surgery. Otol Neurotol 2004; 25 (3): 387–393. Doi: 10.1097/ 00129492-200405000-00030.

83. Brennan JW, Rowed DW, Nedzelski JM et al. Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg 2001; 94 (2): 217–223. Doi: 10.3171/jns.2001.94.2.0217.

84. Hoffman RA. Cerebrospinal fluid leak following acoustic neuroma removal. Laryngoscope 1994; 104 (1 Pt 1): 40-58. Doi: 10.1288/0000 5537-199401000-00009.

85. Duong DH, O‘Malley S, Sekhar LN et al. Postoperative hydrocephalus in cranial base surgery. Skull Base Surg 2000; 10 (4): 197–200. Doi: 10.1055/s-2000-9331.

86. Campero A, Socolovsky M. Facial reanimation by means of the hypoglossal nerve: anatomic comparison of different techniques. Neurosurgery 2007; 61 (3 Suppl): 41–50. Doi: 10.1227/01.neu.0000289710.95426.19.

87. Scheich M, Ginzkey C, Ehrmann-Muller D et al. Management of CSF leakage after microsurgery for vestibular schwannoma via the middle cranial fossa approach. Eur Arch Otorhinolaryngol 2016; 273 (10): 2975–2981. Doi: 10.1007/s00405-015-3891-3.

88. Fleischman D, Berdahl JP, Zaydlarova J et al. Cerebrospinal fluid pressure decreases with older age. PLoS One 2012; 7 (12): e52664. Doi: 10.1371/journal.pone.0052664.

89. Kehler U, Hirdes C, Weber et al. CSF leaks after cranial surgery – a prospective multicenter analysis. Innovative Neurosurgery 2013; 1 (1): 49–53. Doi: 10.1515/ins-2012-0002.

90. Rodgers GK, Luxford WM. Factors affecting the development of cerebrospinal fluid leak and meningitis after translabyrinthine acoustic tumor surgery. Laryngoscope 1993; 103 (9): 959–962. Doi: 10.1288/00005537-199309000- 00003.

91. Higgins JN, Macfarlane R, Axon PR et al. Headache, Cerebrospinal Fluid Leaks, and Pseudomeningoceles after Resection of Vestibular Schwannomas: Efficacy of Venous Sinus Stenting Suggests Cranial Venous Outflow Compromise as a Unifying Pathophysiological Mechanism. J Neurol Surg B Skull Base 2019; 80 (6): 640–647. Doi: 10.1055/s-0039-16 77706.

ORCID autorů

J. Lazák 0000-0001-5100-4317,

J. Betka 0000-0001-8772-317X,

E. Zvěřina 0000-0002-1018-972X,

A. Vlasák 0000-0002-5724-006X,

M. Bonaventurová 0000-0003-3283-0503,

Z. Balatková 0000-0003-1121-9836,

M. Kaňa 0000-0002-5530-6803,

Z. Fík 0000-0003-4243-9727.

Prohlášení o střetu zájmu

Autor prohlašuje, že v souvislosti s tématem, vznikem a publikací tohoto článku není ve střetu zájmů a vznik ani publikace článku nebyly podpořeny žádnou farmaceutickou firmou. Toto prohlášení se týká i všech spoluautorů

Přijato k recenzi: 5. 9. 2023

Přijato k tisku: 3. 11. 2023

MUDr. Jan Lazák

Klinika otorinolaryngologie a chirurgie hlavy a krku

1. LF UK a FN v Motole

V Úvalu 84

150 06, Praha 5

jan.lazak@fnmotol.cz