[Velopalatal coupling in sleep endoscopy: collapse-pattern based analysis of simulated airway opening]. / Velopalatinales Coupling in der medikamentös induzierten Schlafendoskopie: Analyse der Kollapsmuster.

OBJECTIVE: Drug-induced sleep endoscopy (DISE) is an established diagnostic procedure to assess the upper airway in patients with obstructive sleep apnea. During DISE airway opening is regularly simulated by various maneuvers. One of them is mandibular advancement by the modified jaw-thrust maneuver (MJTM). MATERIAL AND METHODS: All DISE examinations evaluated by VOTE classification in the last 15 months were included. The effect of MJTM on anatomical levels was analyzed retrospectively. Frequency and type of collapse at the anatomic levels were recorded. Apnea-hypopnea index (AHI), body mass index (BMI), Epworth Sleepiness Scale (ESS) were determined. RESULTS: 61 patients were included (f=13, m=48, 54.3±12.9 y, ESS 11±5.5, AHI 30.2±19/h, BMI 29.7±4.5 kg/m2). A correlation of r=0.30 was found between AHI and BMI (p=0.02). At velum level, concentric collapse was detected in 16.4%, anterior-posterior (a.p.) collapse in 70.5%, and lateral collapse in 11.5%. A resolution of the collapse using the MJTM was observed in 75.5% of patients. However, in the presence of concentric collapse, opening was evident in 33.3% of cases in contrast to 86.5% in patients with a.p. collapse. Base of tongue collapse was resolved in 98.0% of the cases. CONCLUSION: A correlation between the success of the MJTM on airway opening at the velum level and the pattern of palatal collapse was found. In therapies aimed at mandibular advancement, e.g. hypoglossal nerve stimulation, an effect on velopalatal airway opening has relevance, so optimization of preoperative diagnosis is of particular importance.

Reducing Back Exertion and Improving Confidence of Individuals with Low Back Pain with a Back Exosuit: A Feasibility Study for Use in BACPAC.

OBJECTIVE: Low back pain (LBP) is hallmarked by activity limitations, especially for tasks involving bending. Back exosuit technology reduces low back discomfort and improves self-efficacy of individuals with LBP during bending and lifting tasks. However, the biomechanical efficacy of these devices in individuals with LBP is unknown. This study sought to determine biomechanical and perceptual effects of a soft active back exosuit designed to assist individuals with LBP sagittal plane bending. To understand patient-reported usability and use cases for this device. METHODS: Fifteen individuals with LBP performed two experimental lifting blocks once with and without an exosuit. Trunk biomechanics were measured by muscle activation amplitudes, and whole-body kinematics and kinetics. To evaluate device perception, participants rated task effort, low back discomfort, and their level of concern completing daily activities. RESULTS: The back exosuit reduced peak back extensor: moments by 9%, and muscle amplitudes by 16% when lifting. There were no changes in abdominal co-activation and small reductions maximum trunk flexion compared to lifting without an exosuit. Participants reported lower task effort, back discomfort, and concern about bending and lifting with an exosuit compared to without. CONCLUSIONS: This study demonstrates a back exosuit not only imparts perceptual benefits of reduced task effort, discomfort, and increased confidence in individuals with LBP but that it achieves these benefits through measurable biomechanical reductions in back extensor effort. The combined effect of these benefits implies back exosuits might be a potential therapeutic aid to augment physical therapy, exercises, or daily activities.

Hypoglossal Nerve Stimulation Therapy.

Hypoglossal nerve stimulation (HNS) has been shown to be a safe alternative in the treatment of moderate-to-severe obstructive sleep apnea (OSA). A recent meta-analysis of 12 studies by Costantino et al. indicated the surgical success rates at 55-75%, a reduction of the apnea hypopnea index (AHI) of 18 events/h, and a reduction of the Epworth Sleepiness Scale (ESS) of 2.9-5.3. After animal studies in the 1970s, the first trial on humans to decrease upper airway resistance by transcutaneous electrical stimulation of the genioglossus was reported in 1989. A separate stimulation of protruding and retracting muscles was realized in 1995 by fine-wire electrodes that were placed into the tongue transoral. Over the next years, several companies developed implantable devices for hypoglossal stimulation in OSA. Initially, devices were developed that used unilateral stimulation of the hypoglossal nerve. In 2014, a device for unilateral respiratory frequency-controlled hypoglossal stimulation finally received FDA approval after a successful phase III trial. In recent years, a device for bilateral breath rate-independent stimulation of the hypoglossal nerve has been added to these approaches as a new development. Accordingly, hypoglossal nerve stimulation, on the one hand, is now an established tool for patients with OSA when standard treatments are not satisfactory. Beyond that, hypoglossal stimulation is undergoing a continuous and impressive development like hardly any other field of surgical therapy for OSA.

Safety and effectiveness in explantation and re-implantation of hypoglossal nerve stimulation devices.

PURPOSE: Since 2001, hypoglossal nerve stimulators have been implanted in patients with obstructive sleep apnea around the world, initially in trial situations but more recently also in regular care settings. Medium term data indicate effectiveness and tolerability of treatment. However, when assessing the safety of the procedure, the safe feasibility of explantation or reimplantation must also be considered. PATIENTS AND METHODS: Nine patients with an implanted respiratory-driven hypoglossal nerve stimulator. We have evaluated the feasibility and safety of explantation or re-implantation with another stimulation system. RESULTS: In 2012, nine patients were implanted with a respiratory-driven hypoglossal nerve stimulator as part of the Apnex Medical Pivotal Study. The study was ended in 2013. For a variety of reasons, the system was explanted from all nine patients by the year 2019. Three of these patients were re-implanted with a different system with respiratory sensing during the same session (mean incision to closure time for explantation 88.2 ± 35.01 min., mean incision to closure time for re-implantation 221.75 ± 52.73 min.). Due to extensive scar tissue formation, all procedures were technically challenging. Complication rate was significantly higher when re-implantation was performed or attempted in the same surgical session (0 of 5 patients with explantation versus 3 of 4 patients with attempted re-implantation; p = 0.018). There was no significant difference between the AHI values before and after implantation in patients with re-implantation. CONCLUSION: Explantation and re-implantation are technically challenging though possible procedures. The single-staged equilateral reimplantation of another hypoglossal nerve stimulation system can, but need not, be successful.

Incidence and survival of HNSCC patients living with HIV compared with HIV-negative HNSCC patients.

PURPOSE: The aim was to analyze the incidence and survival of patients living with HIV (PLWH) with head and neck squamous cell carcinoma (HNSCC) and to compare with a control group of HIV-negative HNSCC patients. METHODS: Clinicopathological data and predictors for overall survival (OS) and disease-free survival (DFS) were investigated (2009-2019). RESULTS: 50 of 5151 HNSCC patients (0.97%) were PLWH, and 76% were smokers. Age ≤ 60 years, HIV-PCR ≤ 50 copies, CD4 cells ≤ 200/mm3, cART treatment, T and UICC classification, oral cavity and nasal/paranasal sinuses, and therapy were significantly associated with OS in univariate analysis. In the multivariate analysis, only age and HIV-PCR independently predicted OS. The OS of the 50 PLWH was not significantly altered compared with the 5101 HIV-negative controls. However, OS and DFS were significantly inferior in advanced tumor stages of PLWH compared with an age-matched control group of 150 HIV-negative patients. CONCLUSIONS: PLWH were diagnosed with HNSCC at a significantly younger age compared to HIV-negative patients. Taking into account patient age at initial diagnosis, both OS and DFS rates in PLWH are significantly worse compared with a matched control group of HIV-negative patients in advanced tumor stages UICC III/IV. The prognosis (OS) is improved when taking cART treatment, the HIV viral load is undetectable and CD4 count is high.

Apnea and hypopnea characterization using esophageal pressure, respiratory inductance plethysmography, and suprasternal pressure: a comparative study.

OBJECTIVES: To determine if recording of suprasternal pressure (SSP) can classify apneas and hypopneas as reliably as respiratory inductance plethysmography (RIP) belts and to compare the two methods to classification with esophageal pressure (Pes), the reference method for assessing respiratory effort. METHODS: In addition to polysomnographic recordings that included Pes, SSP was recorded. Recordings from 32 patients (25 males, mean age 66.7 ± 15.3 years, and mean BMI 30.1 ± 4.5 kg/m2) were used to compare the classification of detected apneas and hypopneas by three methods of respiratory effort evaluation (Pes, RIP belts, and SSP). Signals were analyzed randomly and independently from each other. All recordings were analyzed according to AASM guidelines. RESULTS: Using Pes as a reference for apnea characterization, the Cohen kappa (κ) was 0.93 for SSP and 0.87 for the RIP. The sensitivity/specificity of SSP was 97.0%/96.9% for obstructive, 93.9%/98.3% for central, and 94.9%/97.9% for mixed apneas. The sensitivity/specificity of the RIP was 97.4%/91.9% for obstructive, 87.5%/97.9% for central, and 85.6%/96.6% for mixed apneas. For hypopnea characterization using the Pes as a reference, κ was 0.92 for SSP and 0.86 for the RIP. The sensitivity/specificity of SSP was 99.7%/97.6% for obstructive and 97.6%/99.7% for central. The sensitivity/specificity of the RIP was 99.8%/81.1% for obstructive and 81.1%/99.8% for central. CONCLUSIONS: These results confirm the excellent agreement in the detection of respiratory effort between SSP, RIP belts, and Pes signals. Thus, we conclude that apnea and hypopnea characterization in adults with SSP is a reliable method.

The Diagnostic Yield of Excisional Biopsy in Cervical Lymphadenopathy: A Retrospective Analysis of 158 Biopsies in Adults.

OBJECTIVES: Cervical lymph nodes are the most common site of peripheral lymphadenopathy. The underlying etiologies are usually benign and self-limiting but may include malignancies or other severe life-threatening diseases. The aim of the current study was to investigate the various underlying pathologies of cervical lymphadenopathy as assessed by the diagnostic yield of excisional lymph node biopsies of the neck in a tertiary adult practice. The evaluation was performed in light of previous literature and regional epidemiological patterns. METHODS: Retrospective analysis of hospital charts of 158 adult patients who underwent an excisional biopsy for suspected cervical lymphadenopathy at a tertiary referral head and neck service between January 2017 and December 2019. RESULTS: The most common underlying pathology was unspecific and/or reactive lymphadenitis in 44.5% of specimens, followed by malignant disease in 38.6% of cases. An age above 40 years was significantly correlated with an increased likelihood of malignant disease. Lower jugular and posterior triangle lymph nodes showed higher malignancy rates than other groups (100% and 66.7%, respectively). The overall surgical complication rate was 2.5%. CONCLUSIONS: The results of the current study serve as an indicator of the variety of etiologies causing cervical lymphadenopathy. In particular, given the increasing incidence of malignant diseases in recent decades, the findings should alert physicians to the importance of lymph node biopsy for excluding malignancy in persistent cervical lymphadenopathy especially in older adults. The findings emphasize the value of excisional lymph node biopsy of the neck as a useful diagnostic tool in adult patients with peripheral lymphadenopathy.

Clinical Applicability of Ultrasound Shear Wave Elastography in Patients under Hypoglossal Nerve Stimulation Therapy.

Relationship between stiffness of genioglossi (GG) and geniohyoidei (GH) muscles under electric hypoglossal nerve stimulation therapy (HNS) in relation to success of therapy was investigated with additional special focus on tongue movement. PATIENTS AND METHODS: Clinical and sleep laboratory parameters of a cohort of 18 patients with known shear wave velocity (SWV) data of the ipsilateral and contralateral musculi GG and GH (sGG, sGH and nGG, nGH) before and under HNS therapy were analyzed. The SWV was already determined using the ultrasonic shear wave elastography (US-SWE) technique. RESULTS: Median Epworth Sleepiness Scale (ESS) was 8 (IQR 12), median baseline Apnoe-Hypopnoe Index (AHI) 31.65 (IQR 25.1), median AHI under HNS therapy 16.3 (IQR 20.03). Therapy success: 9/18 patients (AHI during therapy < 15/h). There was no significant difference in SWV (sGG, sGH, nGG and nGH) between therapy responders and non-responders during therapy. Also, no difference could be seen with respect to the difference and increase in SWV values without and with stimulation. Examination of SWV values (sGG, sGH, nGG, nGH during stimulation, difference of SWV values stimulation - no stimulation, increase factor of SWV) revealed a significant negative correlation between the AHI under therapy and the measured SWV of the musculus GH of the contralateral side during stimulation (-0.622, p = 0.006). Patients with bilateral protrusion of the tongue differed regarding to therapy success in increase in SWV in sGG (p = 0.032). Tongue protrusion to contralateral: A significant difference between patients with AHI during therapy < 15/h in SWV values at sGG without stimulation (p = 0.021) was seen, with also a correlation to the current AHI under therapy (p = 0.047) and the change factor of the AHI (p = 0.015). CONCLUSION: Stiffness of the target muscle does not appear to be an isolated measure of the success of HNS therapy. This observation may have implications for future decision-making processes in the process of titrating electrical therapy parameters. But the technique of US-SWE may be useful for future research of the neurophysiology of the tongue and OSA phenotyping.

The Diagnostic Performance of Multiparametric Ultrasound in the Qualitative Assessment of Inconclusive Cervical Lymph Nodes.

BACKGROUND: Enlarged cervical lymph nodes (CLNs) can result from infection or malignancies, and a definitive diagnosis requires histological examination. Ultrasound (US) remains the first-line imaging modality for detection, and new US techniques may improve characterization. The aim of our study was to investigate whether the qualitative assessment of multiparametric US (mpUS) can improve diagnostic performance in the differentiation of benign and malignant CLNs. METHODS: 107 CLNs in 105 patients were examined by preoperative mpUS consisting of B-mode US, color-coded duplex sonography (CCDS), shear wave elastography (SWE) and contrast-enhanced US (CEUS). US images were evaluated in consensus by two experienced US operators. Histopathological examination was used as reference standard. RESULTS: SWE and CEUS combined showed the highest overall diagnostic performance (91% sensitivity, 77% specificity, 87% positive predictive value (PPV), 83% negative predictive value (NPV), 90% accuracy, χ2 (1) = 51.485, p < 0.001) compared to B-mode US and CCDS (87% sensitivity, 44% specificity, 73% PPV, 65% NPV, 73% accuracy χ2 (1) = 12.415, p < 0.001). In terms of individual techniques, SWE had higher specificity than B-mode and CCDS (71% sensitivity, 90% specificity, 92% PPV, 64% NPV, 78% accuracy, χ2 (1) = 36.115, p < 0.001), while qualitative CEUS showed the best diagnostic performance of all investigated US techniques (93% sensitivity, 85% specificity, 91% PPV, 87% NPV, 90% accuracy, χ2 (1) = 13.219, p < 0.001). Perfusion patterns, homogeneity, presence of necrosis, and malignancy differed significantly between malignant and benign CLNs (p < 0.001). CONCLUSIONS: SWE and CEUS can facilitate the differentiation of inconclusive CLNs when performed to supplement B-mode US and CCDS. MpUS may thus aid the decision between surgery and a watch-and-scan strategy in enlarged CLNs.

Telepresence for surgical assistance and training using eXtended reality during and after pandemic periods.

Existing challenges in surgical education (See one, do one, teach one) as well as the COVID-19 pandemic make it necessary to develop new ways for surgical training. Therefore, this work describes the implementation of a scalable remote solution called "TeleSTAR" using immersive, interactive and augmented reality elements which enhances surgical training in the operating room. The system uses a full digital surgical microscope in the context of Ear-Nose-Throat surgery. The microscope is equipped with a modular software augmented reality interface consisting an interactive annotation mode to mark anatomical landmarks using a touch device, an experimental intraoperative image-based stereo-spectral algorithm unit to measure anatomical details and highlight tissue characteristics. The new educational tool was evaluated and tested during the broadcast of three live XR-based three-dimensional cochlear implant surgeries. The system was able to scale to five different remote locations in parallel with low latency and offering a separate two-dimensional YouTube stream with a higher latency. In total more than 150 persons were trained including healthcare professionals, biomedical engineers and medical students.

Persistent Treatment-Emergent Central Sleep Apnea (TECSA) Following Hypoglossal Nerve Stimulation.

Purpose: Since 2001, hypoglossal nerve stimulators (HNS) have been used worldwide to treat patients with obstructive sleep apnea (OSA). Recently, a few studies reported treatment-emergent central sleep apnea (TECSA) with spontaneous resolution following HNS. However, the evidence of persistent development of TECSA during long-term care visits was lacking. As a result, this study first report two patients with persistent TECSA and describe their development phenotype during more than two years of follow-up visits to help explore the influencing factors and underlying mechanisms. Patients and Methods: This retrospective study included twenty-seven patients who underwent HNS implantation from 2016 to 2021. Their demographic data, pre- and postoperative sleep study characteristics, and device use settings were collected. The possible factors associated with post-operative elevated CSA (central apnea index ≥5) were evaluated. Moreover, the development phenotype of the TECSA was observed and followed up with a titration trial study. Results: Among overall 27 patients with OSA, 3 patients with an increased preoperative Epworth Sleepiness Score (ESS) got an elevated CSA (CAI ≥ 5). Two of these 3 patients developed a persistent TECSA with a significant negative correlation between obstructive apnea index (OAI) and central and mixed sleep apnea index (CMAI) (R = -0.745, P = 0.021). These development phenotypes might be associated with different stimulation amplitudes of the HNS device. Furthermore, the following titration trial study also suggested that different amplitudes would influence the development of TECSA following HNS. Conclusion: OSA patients with severe daytime sleepiness are more likely to have elevated CSA following HNS. An inappropriate stimulation amplitude might influence the development course of TECSA in such patients.

Modified dindo-clavien system for registration of perioperative complications in children undergoing adenotonsillectomy.

Introduction: Surgical procedures in children are among the most commonly performed procedures in otolaryngology. Perioperative safety and documentation of complications are becoming increasingly important. This study investigates perioperative complications in a clinical cohort of children with adenotonsillar hyperplasia undergoing adenotonsillectomy using the standardized Dindo-Clavien reporting system. Patients and Methods: Retrospective evaluation of 402 children who underwent adenotonsillectomy between 2009 and 2015. Patient parameters including all perioperative complications were investigated. Results: In the study, 124 complications were found (106 mild, 16 severe). According to the Dindo-Clavien classification, 93 grade I, 15 grade II, 5 grade III, 11 grade IV and 0 grade V complications were documented. Complications were associated with additional diagnoses (p = 0.001), long-term medication intake (p = 0.003), duration of hospitalization (p < 0.001) and duration of surgery (p < 0.001), undergoing tonsillotomy (p = 0.022) or tonsillectomy (p < 0.001), differences in ASA score (p = 0.005) and differences in OSA-18 score (p = 0.011). Severe complications, classified as grade III and IV, were associated with premature birth (p = 0.026), additional diagnoses (p = 0.017), long-term medication intake (p < 0.001) and differences in ASA score (p =< 0.001). Conclusion: The Dindo-Clavien classification is a standardized reporting system which can also be used for surgical procedures in children with adenotonsillar hyperplasia. The system shows associations with clinical parameters and thus can help to identify subgroups at risk of severe complications.

Endoscopic ear examination improves self-reported confidence in ear examination skills among undergraduate medical students compared with handheld otoscopy.

Objectives: Handheld otoscopy is the standard tool used to teach ear examination in undergraduate and postgraduate medical education. Previous studies have shown that the undergraduate teaching of ear examination with handheld otoscopes is inadequate, resulting in low self-reported levels of student confidence in their diagnostic skills. With the increase in popularity of endoscopic ear surgery, an increasing number of otolaryngologists are using endoscopes for office examinations of the ear due to the method's superior visualization and excellent image qualities. However, medical students usually do not receive exposure to endoscopic ear examination during their undergraduate curriculum. The aim of this study is to assess our preliminary experience with teaching endoscopic ear examination to undergraduate medical students. Methods: A two-hour-long pilot practical course on basic ear examination was administered to undergraduate medical students with little to no previous experience with ear examination. The course was designed to minimize the duration of campus attendance and patient contact during the COVID-19 pandemic. The course included theoretical didactics, exemplary digital endoscopic images and peer physical practice of ear examination with both a handheld otoscope and a 0-degree endoscope. At the end of the course, the students completed a survey questionnaire consisting of eight questions mainly relating to their subjective confidence level with ear examination using either handheld otoscopes or endoscopes and their overall preference for either examination tool. Results: Most students expressed a preference for ear examination with endoscopes over that with handheld otoscopes and reported an improved confidence level in their diagnostic ability with the former technique. The vast majority of students supported the teaching of endoscopic ear examination to future medical students. Conclusion: The findings of this pilot project report and survey study support the early exposure of novice medical learners to endoscopic ear examination, which may help improve the confidence and diagnostic skill of medical students with regard to ear examination. The findings may have implications for the undergraduate teaching of ear examination in the post-COVID-19 era.

Quantitative Multiparametric Ultrasound (mpUS) in the Assessment of Inconclusive Cervical Lymph Nodes.

Background: Enlarged cervical lymph nodes (CLN) are preferably examined by ultrasound (US) by using criteria such as size and echogenicity to assess benign and suspicious CLN, which should be histologically evaluated. This study aims to assess the differentiation of malign and benign CLN by using multiparametric US applications (mpUS). Methods: 101 patients received a standardized US protocol prior to surgical intervention using B-mode−US, shear-wave elastography (SWE) and contrast-enhanced ultrasound (CEUS). SWE was assessed by 2D real-time SWE conducting a minimum of five measurements, CEUS parameters were assessed with post-processing perfusion software. Histopathological confirmation served as the gold standard. Results: B-mode−US and SWE analysis of 104 CLN (36 benign, 68 malignant) showed a significant difference between benign and malignant lesions, presenting a larger long axis and higher tissue stiffness (both p < 0.001). Moreover, tissue stiffness assessed by SWE was significantly higher in CLN with regular B-mode−US criteria (Solbiati Index > 2 and short-axis < 1 cm, p < 0.001). No perfusion parameter on CEUS showed a significant differentiation between benign and malignant CLN. Discussion: As the only multiparametric parameter, SWE showed higher tissue stiffness in malignant CLN, also in subgroups with regular B-mode criteria. This fast and easy application may be a promising noninvasive tool to US examination to ameliorate the sonographic differentiation of inconclusive CLN.

The Relationship between the M1/M2 Macrophage Polarization and the Degree of Ossicular Erosion in Human Acquired Cholesteatoma: An Immunohistochemical Study.

The differential involvement of the macrophage activation phenotypes (M1 vs. M2) has been linked to disease severity in various chronic inflammatory disorders. Pharmacologic manipulation of the M1/M2 macrophage polarization has shown therapeutic potential. Cholesteatoma is a destructive chronic middle ear disease with potentially life-threatening complications. The distribution of macrophage polarization phenotypes in middle ear cholesteatoma has not been described. In the present study, human cholesteatoma specimens acquired during tympanomastoidectomy were retrospectively retrieved and immunohistochemically characterized using a combination of antibodies labeling M1 macrophages (CD80), M2 macrophages (CD163), and total macrophages (CD68). The correlations between the immunohistochemical findings and clinical presentation were assessed. The findings revealed that cholesteatomas with more extensive ossicular erosion demonstrated a significantly higher number of M1 (CD80+) cells and a higher M1/M2 ratio than less invasive cholesteatomas (Wilcoxon test, p < 0.05). The extent of ossicular erosion correlated significantly with the M1/M2 ratio (Spearman correlation coefficient ρ = 0.4, p < 0.05). Thus, the degree of ossicular erosion in human acquired cholesteatoma appears to be related to the M1/M2 macrophage polarization. The investigation of macrophage polarization and functions in various clinical presentations of middle ear cholesteatoma is of great interest since it may contribute to the development of pharmaceutical treatment approaches.

Assessment of Parotid Gland Tumors by Means of Quantitative Multiparametric Ultrasound (mpUS).

OBJECTIVE: The preoperative diagnostical differentiation of parotid gland tumor (PGT) is not always simple due to several different entities. B-mode-ultrasound (US) remains the imaging modality of choice, while histopathology serves as the gold standard for finalizing the diagnosis. We aimed to evaluate the use of multiparametric US (mpUS) in the assessment of PGT. METHODS: We included 97 PGTs from 96 patients. A standardized mpUS protocol using B-mode-US, shear-wave elastography (SWE), and standardized contrast-enhanced ultrasound (CEUS) was performed prior to surgical intervention. SWE was assessed by real-time measurement conducting a minimum of five measurements, while quantitative CEUS parameters were assessed with a post-processing perfusion software. RESULTS: SWE allowed differentiation between benign PGT (Warthin's Tumor (WT) paired with lymph nodes (LN) and pleomorphic adenoma (PA)), and WT and LN were softer compared to PA. WT showed lower velocities than squamous cell carcinoma (SCC): the most common malignant PGT. CEUS parameters showed significant group differences between WT and PA, WT and malignant lesions, WT and SCC, WT paired with LN versus PA, and WT paired with LN versus SCC. CONCLUSION: MpUS seems to be beneficial in the assessment of PGT characterization, with benign PGT appearing to be softer in SWE than tumors with malignant tendencies. The quantitative CEUS parameter shows higher perfusion in WT than in PA, and malignant PGTs are less vascularized than WTs.