Postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx.

OBJECTIVE: Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx. METHODS: Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected. RESULTS: Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age (P=.004), antithrombotic treatment (P=.012), and robotic assistance (P=.009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients. CONCLUSION: Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.

Restricted neural plasticity in vestibulospinal pathways after unilateral labyrinthectomy as the origin for scoliotic deformations.

Adolescent idiopathic scoliosis in humans is often associated with vestibulomotor deficits. Compatible with a vestibular origin, scoliotic deformations were provoked in adult Xenopus frogs by unilateral labyrinthectomy (UL) at larval stages. The aquatic ecophysiology and absence of body-weight-supporting limb proprioceptive signals in amphibian tadpoles as a potential sensory substitute after UL might be the cause for a persistent asymmetric descending vestibulospinal activity. Therefore, peripheral vestibular lesions in larval Xenopus were used to reveal the morphophysiological alterations at the cellular and network levels. As a result, spinal motor nerves that were modulated by the previously intact side before UL remained permanently silent during natural vestibular stimulation after the lesion. In addition, retrograde tracing of descending pathways revealed a loss of vestibular neurons on the ipsilesional side with crossed vestibulospinal projections. This loss facilitated a general mass imbalance in descending premotor activity and a permanent asymmetric motor drive to the axial musculature. Therefore, we propose that the persistent asymmetric contraction of trunk muscles exerts a constant, uncompensated differential mechanical pull on bilateral skeletal elements that enforces a distortion of the soft cartilaginous skeletal elements and bone shapes. This ultimately provokes severe scoliotic deformations during ontogenetic development similar to the human syndrome.

Vestibular disorders following BNT162b2 mRNA COVID-19 vaccination: A retrospective case series.

BACKGROUND: There are few publications regarding manifestations of vestibular disorders (VDs) following BNT162b2 mRNA COVID-19 vaccination. PURPOSE: We describe cases of VD potentially related to BNT162b2 vaccination and calculate its reporting rate, in order to enlarge knowledge about this adverse effect. METHODS: A retrospective analysis of cases of VD following BNT162b2 vaccination reported to the pharmacovigilance centre of Georges-Pompidou European Hospital (France), in 2021 was performed. In order to identify these cases from the pharmacovigilance database containing all our registered cases, we used the Standardised MedDRA Query (SMQ) 'vestibular disorders'. Then we analysed cases with vestibular symptoms, based on the association of typical manifestations. The reporting rate was calculated based on the number of VD cases and the number of vaccinated patients. RESULTS: Among 6608 cases reported to our centre related to COVID-19 vaccines during 2021, 34 VDs associated with BNT162b2 administration were included. They were mainly reported in females (79%), 62% occurred after the first dose and 32% were serious. Symptoms had completely resolved in 13 cases (38%). Vertigo was the most common symptom followed by balance disorders. Three patients received second dose without reappearance of VD. The final diagnosis was reported in 10 patients (six cases of vestibular neuritis, two cases of central VD, two cases of benign paroxysmal positional vertigo). The regional reporting rate was 26 [95% CI: 17-34] cases of VD per 1 million persons vaccinated. CONCLUSION: Although the relationship between vaccination and VD cannot be established, clinicians should be aware of this rare adverse effect.

Glottic bamboo nodules from systemic lupus erythematosus.

Bamboo nodules of the glottis are of late being described as a distinct entity seen in patients with autoimmune diseases. We report the symptoms, clinical features, and management of a case of bamboo nodules of the glottis in a patient with systemic lupus erythematosus. We discuss the pathogenesis and management of this condition on the basis of a review of the medical literature.

Trade-off between survival and laryngeal preservation in advanced laryngeal cancer: the otorhinolaryngology patient's perspective.

OBJECTIVES: We performed a prospective study to evaluate, from the patient's perspective, the trade-off between speech and survival that individuals face when given a diagnosis of advanced-stage laryngeal cancer amenable to either total laryngectomy or a laryngeal preservation protocol using chemotherapy and radiotherapy. METHODS: Volunteers (309) consecutively seen at the otorhinolaryngology clinic of a university teaching hospital in France completed an anonymous questionnaire designed to determine their position if they faced the diagnosis of an advanced-stage laryngeal cancer. Univariate analysis was performed for potential statistical relationships with various variables. RESULTS: We found that 12.9% of patients were unable to determine their position regarding the two treatment options offered, and this group had a significant statistical relationship with four variables (age, education, professional status, and history of cancer among relatives). We found that 24.6% of patients made survival their main consideration and would not consider any trade-off. Among the 62.5% who considered the trade-off, the percentage of cure that patients were ready to lose in order to preserve their larynx varied from 5% to 100% (mean, 33%; SD, 23%). Aside from the undecided group, none of the variables analyzed was related either to the decision as to whether to consider a trade-off or to the percentage of c re that patients agreed to trade to preserve their larynx. CONCLUSIONS: In patients with advanced-stage laryngeal cancer, treatment should be initiated only after careful evaluation of the patient's attitude toward both laryngeal preservation and survival.

Functional organization of vestibular commissural connections in frog.

Central vestibular neurons receive substantial inputs from the contralateral labyrinth through inhibitory and excitatory brainstem commissural pathways. The functional organization of these pathways was studied by a multi-methodological approach in isolated frog whole brains. Retrogradely labeled vestibular commissural neurons were primarily located in the superior vestibular nucleus in rhombomeres 2/3 and the medial and descending vestibular nucleus in rhombomeres 5-7. Restricted projections to contralateral vestibular areas, without collaterals to other classical vestibular targets, indicate that vestibular commissural neurons form a feedforward push-pull circuitry. Electrical stimulation of the contralateral coplanar semicircular canal nerve evoked in canal-related second-order vestibular neurons (2 degrees VN) commissural IPSPs (approximately 70%) and EPSPs (approximately 30%) with mainly (approximately 70%) disynaptic onset latencies. The dynamics of commissural responses to electrical pulse trains suggests mediation predominantly by tonic vestibular neurons that activate in all tonic 2 degrees VN large-amplitude IPSPs with a reversal potential of -74 mV. In contrast, phasic 2 degrees VN exhibited either nonreversible, small-amplitude IPSPs (approximately 40%) of likely dendritic origin or large-amplitude commissural EPSPs (approximately 60%). IPSPs with disynaptic onset latencies were exclusively GABAergic (mainly GABA(A) receptor-mediated) but not glycinergic, compatible with the presence of GABA-immunopositive (approximately 20%) and the absence of glycine-immunopositive vestibular commissural neurons. In contrast, IPSPs with longer, oligosynaptic onset latencies were GABAergic and glycinergic, indicating that both pharmacological types of local inhibitory neurons were activated by excitatory commissural fibers. Conservation of major morpho-physiological and pharmacological features of the vestibular commissural pathway suggests that this phylogenetically old circuitry plays an essential role for the processing of bilateral angular head acceleration signals in vertebrates.

[Unilateral laryngeal paralysis in the adult patient]. / Paralysies laryngées unilatérales de l'adulte.

Based on a review of the recent medical literature, the authors document the epidemiological evolution, pathophysisology diagnosis and recent advances in treatment for adult patients with unilateral laryngeal paralysis. Speech therapy, which used to be the only therapeutic option, is nowadays complemented by efficient surgical techniques, which have modified the management of many patients.

Vestibular asymmetry as the cause of idiopathic scoliosis: a possible answer from Xenopus.

Human idiopathic scoliosis is characterized by severe deformations of the spine and skeleton. The occurrence of vestibular-related deficits in these patients is well established but it is unclear whether a vestibular pathology is the common cause for the scoliotic syndrome and the gaze/posture deficits or if the latter behavioral deficits are a consequence of the scoliotic deformations. A possible vestibular origin was tested in the frog Xenopus laevis by unilateral removal of the labyrinthine endorgans at larval stages. After metamorphosis into young adult frogs, X-ray images and three-dimensional reconstructed micro-computer tomographic scans of the skeleton showed deformations similar to those of scoliotic patients. The skeletal distortions consisted of a curvature of the spine in the frontal and sagittal plane, a transverse rotation along the body axis and substantial deformations of all vertebrae. In terrestrial vertebrates, the initial postural syndrome after unilateral labyrinthectomy recovers over time and requires body weight-supporting limb proprioceptive information. In an aquatic environment, however, this information is absent. Hence, the lesion-induced asymmetric activity in descending spinal pathways and the resulting asymmetric muscular tonus persists. As a consequence the mostly cartilaginous skeleton of the frog tadpoles progressively deforms. Lack of limb proprioceptive signals in an aquatic environment is thus the element, which links the Xenopus model with human scoliosis because a comparable situation occurs during gestation in utero. A permanently imbalanced activity in descending locomotor/posture control pathways might be the common origin for the observed structural and behavioral deficits in humans as in the different animal models of scoliosis.

[Isolated unilateral laryngeal nerve paralysis in adults. An inception cohort of 591 patients managed in a French--university--teaching hospital]. / Paralysies laryngées unilatérales isolées de l'adulte: etude d'une cohorte de 591 patients pris en charge en centre hospitalo-universitaire.

UNLABELLED: We analyzed an inception cohort of 591 adults with isolated unilateral laryngeal paralysis managed at a French teaching hospital during the period 1990-2008. Symptoms, causes, treatment and outcome were compared between two periods (1990-2000 vs 2001-2008), using the Chi squared test and Mann Whitney U test. Dysphonia, swallowing impairment and respiratory impairment were present in respectively 98.3%, 34.8% and 4.1% of cases, The causes of paralysis were surgical and non surgical in respectively 65.1% and 21.1% of cases. Cancer (mainly lung cancer) was present in 59.6% of cases, and 22% of these patients were receiving palliative treatment. Thoraco-mediastinal surgery and thyroid-parathyroid surgery accounted for 79.4% of surgical causes. Malignancies accounted for 76.8% of non surgical causes. Within the idiopathic group (13.8% of the cohort), a tumor lying along the path of the paralyzed nerve was detected in 3.7% of cases. Larynx motion was recovered in 19.6% of cases; nerve transection, the etiology, and the time since symptom onset were predictive factors for motion recovery. Treatment consisted of laryngeal medialisation and isolated speech therapy in 40.1% and 59.9% of cases, respectively. The current success rate of laryngeal medialisation is 90.3%. CONCLUSIONS: The three main causes of unilateral laryngeal nerve paralysis were tumors, surgery and cardiovascular disorders (surgical and non surgical). Laryngeal medialisation is now a major component of rehabilitation in our center.

Influence of allergy in patients with nasal polyposis after endoscopic sinus surgery.

CONCLUSION: Allergy does not modify the symptoms and steroid consumption (oral and local) of nasal polyposis (NP) patients after functional endoscopic sinus surgery (FESS). OBJECTIVES: To assess the role of allergy in the evolution after FESS of patients presenting with the diagnosis of NP. PATIENTS AND METHODS: This was a prospective study of 63 consecutive patients with NP (57% males, mean age 45.8 years), who were analyzed to detect whether the results of a surgical treatment of NP were influenced by the presence of positive allergic tests (Phadiatop). Three nasal criteria were scored: nasal obstruction, posterior rhinorrhea, and the loss of smell. The frequency of asthma was evaluated. Medical treatment of NP after FESS consisted of washing of the nasal cavities, steroid spray, and oral steroid administration. The amount of consumption of steroids (prednisolone and beclomethasone) was studied. RESULTS: Decrease of all nasal symptoms was not statistically different in the two groups of patients with and without allergy. Cumulative consumption of prednisolone and beclomethasone after surgery was similar in the two groups.

Evaluation of combined medical and surgical treatment in nasal polyposis - III. Correlation between symptoms and CT scores before and after surgery for nasal polyposis.

CONCLUSION: Computed tomography (CT) in nasal polyposis (NP) patients has three functions before any treatment. CT provides objective evidence of the disease and precise topography of the disease, and is an indicator of the disease severity. After functional endoscopic sinus surgery (FESS), CT is an indicator of the residual disease severity and permits detection of asymptomatic mucoceles. OBJECTIVE: NP affects nearly 4% of the population. CT has become the examination of choice for the exploration of NP. FESS is accepted for NP treatment in the setting of failure of medical management. The aim of this study was to find out whether any correlation exists between symptom severity and CT scan score before and after FESS. PATIENTS AND METHODS: A total of 114 CT scans were performed in NP patients without contrast medium before and after FESS (mean follow-up 5 years), and were scored according to the Lund-MacKay system. RESULTS: Lund-MacKay scores before treatment ranged from 8 to 24. There was a correlation between symptom and CT scores before any treatment. Postoperative Lund-MacKay scores ranged from 0 to 24. There was a correlation between symptom and CT scores after surgery. There was no correlation between postoperative symptom and baseline CT scores. Eleven asymptomatic mucoceles were found.

Survival and laryngeal preservation tradeoff in advanced laryngeal cancer: From the otorhinolaryngology patient to the managing physician.

BACKGROUND: The purpose of this study was to document the tradeoff between survival and laryngeal preservation in advanced-stage laryngeal cancer amenable to chemoradiation or total laryngectomy. METHODS: We conducted a prospective analysis based on a questionnaire completed by 209 laryngeal cancer specialists and 269 volunteers from an otorhinolaryngology clinic. RESULTS: Of the responders, 34.5% would not consider any decrease in survival to preserve their larynx. This percentage varied from 52% in otorhinolaryngologists to 27.3% in radiotherapists and 28.6% in volunteers (P < .001). Among the responders prepared to trade, the percentage of survival they were willing to trade to preserve their larynx varied from 5% to 100% (median 30%). On univariate analysis, 3 variables significantly affected this percentage: (1) the living status (single or not); (2) the existence of children; and (3) the study group (volunteers, radiation therapists, or otorhinolaryngologists) to whom the responders belong. CONCLUSION: The significant variations noted should develop modes of practice that cater to this and stimulate further research in this field.

Influence of allergy on the symptoms and treatment of nasal polyposis.

CONCLUSION: Allergy does not modify the symptoms of nasal polyposis, either initially or after a 1-year medical treatment. OBJECTIVES: To assess the role of allergy in the symptoms and treatment of patients presenting with the diagnosis of nasal polyposis. PATIENTS AND METHODS: Two simultaneous studies were carried out. In the first study, 180 consecutive patients with nasal polyposis (60% males, mean age = 48.4 years) were analyzed to detect whether the severity of their symptoms correlated with the presence of positive allergic tests. In the second study, 74 consecutive patients (57.5% males, mean age = 48.3 years) were analyzed to detect whether the results of a 1-year medical treatment of nasal polyposis were influenced by the presence of positive allergic tests (Phadiatop). Five nasal criteria were scored: nasal obstruction, anterior and posterior rhinorrhea, facial pain, and the loss of sense of smell. The frequency of asthma was evaluated. Treatment of nasal polyposis consisted of washing of the nasal cavities, steroid spray, and oral steroid administration. The amount of steroid consumption (prednisolone and beclomethasone) was studied. RESULTS: In the first study, mean scores of nasal symptoms did not differ between the two groups of patients with and without allergy. The prevalence of asthma (p = 0.03) was higher in the group with than without allergy. In the second study, decrease of all nasal symptoms was not statistically different in the two groups. Cumulative consumption of prednisolone and beclomethasone between baseline and year 1 were similar in the two groups.

Adrenal suppression and osteoporosis after treatment of nasal polyposis.

CONCLUSION: Patients with severe nasal polyposis (NP) and a high steroid consumption have a high prevalence of glucocorticoid-induced osteoporosis and secondary adrenal insufficiency. OBJECTIVES: To evaluate the risk of complications of the medical treatment in patients presenting with the diagnosis of NP. PATIENTS AND METHODS: This was a prospective study. A total of 46 consecutive patients with NP were included when the oral steroid consumption during the past year was greater than three short courses of systemic steroid treatment (i.e. more than 21 days per year of treatment, prednisolone 1 mg/kg body weight per day, for 6-10 days). The nasal function was checked on the basis of five criteria: nasal obstruction, anterior rhinorrhea, posterior rhinorrhea, facial pain, and loss of sense of smell. Two tests were carried out for each patient: (i) a bone mineral density evaluation by dual energy X-ray absorptiometry (DXA) at three different sites in the lumbar spine and femur, and (ii) an evaluation of the hypothalamic-pituitary-adrenal (HPA) axis by the synacthen test. RESULTS: Most of the patients had a severe NP associated with asthma (78.3% of the population), and aspirin idiosyncrasy (28.3%). In all, 10.9% and 43.5% of patients had osteoporosis and osteopenia at the lumbar spine site. Twenty patients (48.8% of the tested patients) had an asymptomatic adrenal insufficiency.

Pleomorphic adenoma of the nasal septum and its relationship with Epstein-Barr virus.

OBJECTIVES: Pleomorphic adenoma is the most common benign tumor of the major salivary glands, especially of the parotid gland. It is much less common in the minor salivary glands of the oral cavity, and it rarely occurs in others sites in the head and neck. Even if virus involvement in salivary glands tumor has been many times discuted, the etiology of this tumor keeps being unknown. As compared to other nasal tumors, we tried to prove if Epstein-Barr virus (EBV) could be involved in the development of pleomorphic adenoma in this particular nasal localization. METHODS: Three cases of pleomorphic adenomas of the nasal septum (two women and a man in age of 23-59 years) were retrospectively studied. All had positive rate of EBV-related blood antibodies. All the patients had undergone endoscopic surgery to remove the complete tumor. We used hybridation technique in the search for EBV-DNA in the three tumors. RESULTS AND CONCLUSION: We had positive EBV-DNA detection in the tumor in one case, which seemed to prove relationship between pleomorphic adenoma and this virus. The literature concerning the subject is reviewed in order to explain EBV involvement in the development of such tumors in this particular localization.

[Tinnitus and cognitive-behavioral therapy: results after 1 year]. / Acouphènes et thérapie comportementale et cognitive. Résultats à un an.

INTRODUCTION: Tinnitus is a common auditory symptom that interferes with activities of daily living and is often associated with anxiety and depression. METHOD: This study included consecutive patients with chronic intense tinnitus for more than six months who were treated with Tinnitus Retraining Therapy (TRT), a cognitive-behavioral therapy, after previous treatment failed and after a clinical evaluation based on standardized questionnaires, including the Tinnitus Handicap Questionnaire (THQ). One year after the end of the TRT, the treatment was evaluated by the same standardized questionnaires. RESULTS: This prospective study included 96 consecutive patients (49 women, 47 men, mean age: 48 years). Tinnitus improved significantly in 75%, where significant improvement was defined as a final THQ score of less than 500 after CBT. This improvement varied according to initial THQ scores and was seen in: all patients with moderate (THQ<500), 70.3% of the patients with intermediate (5001001), and 34.8% of patients with severe (THQ>1000) tinnitus. CONCLUSION: CBT shows promise as a treatment of tinnitus-related distress.

[Magnetic stimulation of the auditory cortex for disabling tinnitus: preliminary results]. / Stimulation magnétique du cortex auditif dans les acouphènes invalidants: résultats préliminaries.

OBJECTIVE: Tinnitus - the perception of sound in one or both ears or in the head when no external sound is present - can be disabling and is especially difficult to treat. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive technique for activating or inactivating specific areas of the cortex. The aim of this study was to assess the feasibility of magnetic neurostimulation of the primary and secondary auditory cortex in the treatment of disabling chronic tinnitus. PATIENTS AND METHODS: Thirteen patients with tinnitus refractory to several conventional treatments underwent transcranial magnetic stimulation guided by functional magnetic resonance imaging (fMRI). We compared two types of stimulation of targets in the auditory cortex, identified by fMRI: 3-second pulses at high frequency (10 Hz) and 20-minute stimulations at a lower frequency (1 Hz). RESULTS: Brief high-frequency pulses of cortical magnetic stimulation (10 Hz) were not effective. On the other hand, prolonged low frequency (1 Hz) stimulation was effective in 62.5% of patients; the effect appeared 48 h after treatment and lasted for approximately 5 days. DISCUSSION: RTMS may be a new noninvasive technique for studying the cortical plasticity associated with the pathophysiologic mechanisms of chronic tinnitus and may lead to new treatment strategies for patients with disabling tinnitus resistant to all treatment.

Distorted odorant perception: analysis of a series of 56 patients with parosmia.

OBJECTIVE: To characterize the self-reported olfactory and gustatory symptoms, olfactory function, and causes in parosmia. DESIGN: Assessment of olfactory symptoms and function in patients with a chief complaint of parosmia. SETTING: A university hospital clinic and research facility. PATIENTS: Fifty-six consecutive patients presented to the ORL Clinic, European Hospital Georges Pompidou, with a chief complaint of parosmia between October 2001 and November 2003. MAIN OUTCOME MEASURES: Subjective olfactory symptom analysis and olfactory function test results. RESULTS: The mean duration of parosmia was 63.0 months. Forty patients (71.4%) reported associated hyposmia and 16 (28.6%) reported anosmia. Olfactory testing revealed moderate to severe olfactory loss in all patients. Quantitative and qualitative alterations occurred simultaneously in 32 patients (57.1%); parosmia onset occurred within 3 months after quantitative dysosmia in 19 patients (33.9%) and after 3 months in 5 patients (8.9%). The sensation of parosmia was always unpleasant. The main odorant triggers eliciting parosmia are described. The mean severity of flavor dysfunction of the population, evaluated using a 10-cm visual analog scale, was 6.4. Thirty-one patients (55.4%) viewed their olfactory alteration as severely affecting their quality of life. The main clinical association of parosmia was upper respiratory tract infection, found in 42.8% of the patients. Others clinical associations are described. CONCLUSION: The series of patients with parosmia presented herein, the largest in the literature, permits a clinical description of this rare olfactory abnormality.

[Bone mineral density after treatment for nasal polyposis]. / Traitement médical de la polypose naso-sinusienne. Effet sur la densité minérale osseuse.

PURPOSE: Medical treatment of nasal polyposis is based on corticotherapy, and the most frequent complication of long-term corticotherapy is corticosteroid-induced osteoporosis. OBJECTIVE: To assess bone mineral density after long-term, high-dose corticosteroid treatment for nasal polyposis. PATIENTS AND METHODS: Bone mineral density at the spine and hip was measured by absorptiometry in 32 patients who had received high doses of corticosteroids for nasal polyposis. None of them had a disease that interfered with bone mineral density RESULTS: Bone mineral density was measured in 32 patients (59% men) aged 49.7 +/- 3.7 years [range: 29 - 74] after corticosteroid therapy for a mean of 5.3 years [range: 2-22 years]. More than 70% of the patients had abnormal bone density (osteopenia or osteoporosis ) at the spine and 44% at the hip. Only eight (25%) patients had normal bone density at both the spine and hip. CONCLUSION: High doses of corticosteroids in the treatment of nasal polyposis affect bone mineral density. Assessment of the benefits and risks of endoscopic sinus surgery must take this iatrogenic risk into account.

An uncommon cause of allergic fungal sinusitis: Rhizopus oryzae.

We report what we believe is the first case of allergic fungal rhinosinusitis (AFRS) caused by the fungus Rhizopus oryzae. Our patient was a 32-year-old woman who presented with unilateral nasal polyps and chronic nasal dysfunction. Computed tomography of the sinuses detected left-sided pansinusitis and bone erosion. T2-weighted magnetic resonance imaging demonstrated a signal void that suggested the presence of a fungal infection. The patient underwent unilateral ethmoidectomy. Histologic examination of the diseased tissue identified allergic mucin with 70% eosinophils and no fungal hyphae. Mycologic culture detected R oryzae. After a short period of improvement, the patient experienced a recurrence, which was confirmed by radiology. A second surgery was performed, and the same fungal hyphae were found in the mucus and on culture, which led us to suspect AFRS. Since no IgE test for R oryzae was available, we developed a specific immunologic assay that confirmed the presence of specific IgG, which identified a high degree of immunologic reaction against our homemade R oryzae antigens. With a long course of systemic antifungal treatment, the patient's symptoms resolved and no recurrence was noted at 5 years of follow-up.