Three-dimensional heavily T2-weighted FLAIR in the detection of blood-labyrinthine barrier leakage in patients with sudden sensorineural hearing loss: comparison with T1 sequences and application of deep learning-based reconstruction.

OBJECTIVE: Blood-labyrinthine barrier leakage has been reported in sudden sensorineural hearing loss (SSNHL). We compared immediate post-contrast 3D heavily T2-weighted fluid-attenuated inversion recovery (FLAIR), T1 spin echo (SE), and 3D T1 gradient echo (GRE) sequences, and heavily T2-weighted FLAIR (hvT2F) with and without deep learning-based reconstruction (DLR) in detecting perilymphatic enhancement. METHODS: Fifty-four patients with unilateral SSNHL who underwent ear MRI with three sequences were included. We compared asymmetry scores, confidence scores, and detection rates of perilymphatic enhancement among the three sequences and obtained 3D hvT2F with DLR from 35 patients. The above parameters and subjective image quality between 3D hvT2F with and without DLR were compared. RESULTS: Asymmetry scores and detection rate of 3D hvT2F were significantly higher than 3D GRE T1 and SE T1 (respectively, 1.37, 0.11, 0.19; p < 0.001). Asymmetry scores significantly increased with DLR compared to 3D hvT2F for experienced and inexperienced readers (respectively, 1.77 vs. 1.40, p = 0.036; 1.49 vs. 1.03, p = 0.012). The detection rate significantly increased only for the latter (57.1% vs. 31.4%, p = 0.022). Patients with perilymphatic enhancement had significantly higher air conduction thresholds on initial (77.96 vs. 57.79, p = 0.002) and 5 days after presentation (63.38 vs. 41.85, p = 0.019). CONCLUSION: 3D hvT2F significantly increased the detectability of perilymphatic enhancement compared to 3D GRE T1 and SE T1. DLR further improved the conspicuity of perilymphatic enhancement in 3D hvT2F. 3D hvT2F and DLR are useful for evaluating blood-labyrinthine barrier leakage; furthermore, they might provide prognostic value in the early post-treatment period. CLINICAL RELEVANCE STATEMENT: Ten-minute post-contrast 3D heavily T2-weighed FLAIR imaging is a potentially efficacious sequence in demonstrating perilymphatic enhancement in patients with sudden sensorineural hearing loss and may be further improved by deep learning-based reconstruction. KEY POINTS: • 3D heavily T2-weighted FLAIR (3D hvT2F) is a sequence sensitive in detecting low concentrations of contrast in the perilymphatic space. • 3D hvT2F sequences properly demonstrated perilymphatic enhancement in sudden sensorineural hearing loss compared to T1 sequences and were further improved by deep learning-based reconstruction (DLR). • 3D hvT2F and DLR are efficacious sequences in detecting blood-labyrinthine barrier leakage and with potential prognostic information.

Differences in the metabolomic profile of the human palatine tonsil between pediatrics and adults.

Palatine tonsils (PT) are B cell-predominant lymphoid organs that provide primary immune responses to airborne and dietary pathogens. Numerous histopathological and immunological studies have been conducted on PT, yet no investigations have been conducted on its metabolic profile. We performed high-resolution magic angle spinning nuclear magnetic resonance spectroscopy-based metabolic profiling in 35 pediatric and 28 adult human palatine tonsillar tissue samples. A total of 36 metabolites were identified, and the levels of 10 metabolites were significantly different depending on age. Among them, partial correlation analysis shows that glucose levels increased with age, whereas glycine, phosphocholine, phosphoethanolamine, and ascorbate levels decreased with age. We confirmed the decrease in immunometabolic activity in adults through metabolomic analysis, which had been anticipated from previous histological and immunological studies on the PT. These results improve our understanding of metabolic changes in the PT with aging and serve as a basis for future tonsil-related metabolomic studies.

Spatial and PMF analysis of particle size distributions simultaneously measured at four locations at the roadside of highways.

In urban areas, particulate matter emitted from vehicles directly affects the health of citizens near roads. Thus, in this study, particle size distribution was measured by the horizontal and vertical distances along a highway road with heavy traffic to characterize the dispersion phenomena of particulate matter emitted from vehicles. In addition, the contribution of pollution sources was analyzed using a source-receptor model. A concentration gradient was observed in which the concentration decreased with the increase in the distance from the road when the wind blew from the road to the monitoring locations. The concentration was slightly higher within 50 m of the road when the wind blows parallel to the road, and similar concentrations were found at the other monitoring locations further away from the roads. In particular, the higher the turbulence intensity of the wind, the lower is the concentration gradient coefficient because of the more enhanced mixing and dispersion. A positive matrix factorization (PMF) model with the measured particle size distribution data in the range of 9-300 nm resulted in a contribution of about 70 % (number) and 20 % (mass) to particle concentrations because of six types of vehicles including LPG, two gasoline vehicles (GDI, MPI), and three diesel vehicles with 3rd, 4th, and 5th emission classes. It showed a decrease in the vehicular contribution as the distance from the road increased. Particle number concentrations decreased with increasing altitude up to 30 m above the ground. The results of this study can be useful in deriving generalized gradient equations of particle concentrations exposed by distance and wind direction at the roadside using traffic and meteorological conditions and for establishing environmental policies, such as roadside exposure assessment, in the future. A CAPSULE ABSTRACT: Dispersion of particles emitted from vehicles on a busy highway was characterized by roadside measurements of horizontal and vertical profiles of particle size distributions measured at four locations. The source profiles and contributions were estimated by major sources using a source-receptor model such as PMF.

Comparative Analysis of Long-Term Care in OECD Countries: Focusing on Long-Term Care Financing Type.

This study aims to examine the characteristics of long-term care (LTC) financing in Organization for Economic Cooperation Development (OECD) countries. To this end, the 26 OECD countries that have introduced LTC systems were classified into three types of models: tax-based, health insurance, and LTC insurance (LTCI) systems. Thereafter, these systems were analyzed using Gilbert and Terrell's policy analysis framework. The results indicated differences in the characteristics of each type of financing in terms of allocation, benefit provision, service delivery, and finance. It is likely that while the LTC insurance model was mainly based on universalism and showed the highest level of coverage, the tax-based and health insurance models adopted selectivism with lower level of benefits per capita. In terms of service delivery, local authorities tended to have the responsibility to decide LTC service users and provide services in many countries, regardless of the type of model. In terms of finance, LTC insurance-based countries had the highest LTC expenditure as a percentage of GDP, followed by countries with tax-based and health insurance systems.

Phenotypic toxicity, oxidative response, and transcriptomic deregulation of the rotifer Brachionus plicatilis exposed to a toxic cocktail of tire-wear particle leachate.

Tire-wear particles (TWPs) are potential source of microplastic (MP) pollution in marine environments. Although the hazardous effects of MPs on marine biota have received considerable attention, the toxicity of TWPs and associated leachates remain poorly understood. Here, to assess the toxicity of TWP leachate and the underlying mechanisms of toxicity, the phenotypic and transcriptomic responses of the rotifer Brachionus plicatilis were assessed with chemistry analysis of a TWP leachate. Although acute toxicity was induced, and a variety of metals and polyaromatic hydrocarbons were detected in the leachate, levels were below the threshold for acute toxicity. The results of particle analysis suggest that the acute toxicity observed in our study is the result of a toxic cocktail of micro- and/or nano-sized TWPs and other additives in TWP leachate. The adverse effects of TWP leachate were associated with differential expression of genes related to cellular processes, stress response, and impaired metabolism, with further oxidative stress responses. Our results imply that TWPs pose a greater threat to marine biota than other plastic particles as they constitute a major source of nano- and microplastics that have synergistic effects with the additives contained in TWP leachate.

Effect of treadwear grade on the generation of tire PM emissions in laboratory and real-world driving conditions.

Tires generally wear out due to the friction between the tire and the road surface. Minimizing tire wear could reduce the non-exhaust particulate matter (PM) emissions from tires. Typically, tire treadwear grade can be used as an indicator of PM emissions from tires. Tires that wear out quickly will produce higher PM emissions than more durable tires. In this study, the effect of treadwear grade on the generation of tire PM emissions was investigated through laboratory and on-road driving measurements. In the laboratory measurements, a tire wear simulator installed in an enclosed chamber was used to eliminate artifacts caused by interfering particles during the generation and measurement of tire wear particles. For realistic on-road driving measurements, a mobile sampling vehicle was employed to sample road dust. The road dust was chemically analyzed using pyrolysis gas chromatography-mass spectrometry (GC-MS) to characterize the tire-road wear particles. Both measurements showed that the higher treadwear grade generated lower tire PM emissions due to the high strength of the rubber, except for the UTQG 700 tire. The UTQG 700 tire, which had the highest treadwear grade, produced higher PM emissions than the UTQG 350 and 500 tires because it readily formed the fine particles due to lamellar peeling rather than tearing or curling of tire treads. Notably, tire nanoparticles were observed in laboratory measurements due to the volatilization and nucleation of the sulphur (S) and zinc (Zn) compounds in the tire tread due to the frictional heat between the tire and paved road surface.

Comparison of total PM emissions emitted from electric and internal combustion engine vehicles: An experimental analysis.

Electric vehicles (EVs) are regarded as zero emission vehicles due to the absence of exhaust emissions. However, they still contribute non-exhaust particulate matter (PM) emissions, generated by brake wear, tire wear, road wear, and resuspended road dust. In fact, because EVs are heavier than internal combustion engine vehicles (ICEVs), their non-exhaust emissions are like to be even higher. While total PM emissions, including exhaust and non-exhaust PM emissions, from ICEVs and EVs have been compared based on the emission factors (EFs) listed in national emission inventories, there have been no comparisons based on experimental determinations. In this study, exhaust and non-exhaust emissions generated from a gasoline ICEV, diesel ICEV, and EV were experimentally investigated. The results showed that the EFs for the total PM emissions of ICEVs and EV were dependent on the inclusion of secondary exhaust PM, the brake pad type, and the regenerative braking intensity of the EV. When only primary exhaust PM emissions were considered in vehicles equipped with non-asbestos organic (NAO) brake pads, the total PM10 EF of the EV (47.7-49.3 mg/V·km) was 10-17 % higher than those of the gasoline ICEV (42.3 mg/V·km) and diesel ICEV (43.2 mg/V·km). However, in vehicles equipped with low-metallic (LM) brake pads, the total PM10 EF of the EV (49.2-57.7 mg/V·km) was comparable or lower than those of the gasoline ICEV (56.3 mg/V·km) and diesel ICEV (57.2 mg/V·km). When secondary PM emissions were included, the EF was always significantly lower for the EV than ICEVs. The total PM10 EF of the EV (47.7-57.7 mg/V·km) was lower than those of the gasoline ICEV (56.5-70.5 mg/V·km) and diesel ICEV (58.0-72.0 mg/V·km). Since secondary PM particles are mostly of submicron size, the EFs of the PM2.5 fraction of the ICEVs (28.7-33.0 mg/V·km) were two times higher than those of the EV (13.9-17.4 mg/V·km).

Chemical Leaching from Tire Wear Particles with Various Treadwear Ratings.

Physical friction between a tire and the road surface generates tire wear particles (TWPs), which are a source of microplastics and particulate matter. This study investigated the trends of chemical leaching from TWPs depending on the treadwear rating of the tire. A road simulator was used to produce TWPs from tires with various treadwear ratings. Liquid chromatography-tandem mass spectrometry was used to analyze the chemical leaching from TWPs, with a particular focus on benzothiazole and its derivative 2-hydroxy benzothiazole. However, chemical mapping via high-resolution tandem mass spectrometry detected another derivative: 2-mercaptobenzothiazole. The benzothiazole groups were observed to have different leaching tendencies, implying that using benzothiazole as a marker compound may lead to incorrect TWP quantitation. The results of this research also suggest that the ecotoxicological influence of TWPs can vary with the treadwear rating of a tire.

Real-time detection of vehicle-originated condensable particulate matter through thermodenuder integrated aerosol measurement method at tailpipes.

Condensable particulate matter (CPM) corresponds to primary particulate matter ≤2.5 µm (PM2.5) obtained through the condensation of gaseous air pollutants caused by temperature drops in the atmosphere. The internal combustion of vehicle engines can produce CPM because of the condensable compounds in the exhaust gas. Conventional CPM measurement methods have been developed for coal-fired power plants with stable emissions through sampling and off-site analyses. They are therefore unsuitable for detecting the rapidly changing vehicle-originated CPM. In addition, the current system for evaluating PM2.5 from vehicles, based on the particle measurement program (PMP) protocol, provides only the emission factors of total PM2.5 (and not CPM separately) at a fixed temperature (∼25 °C) and dilution ratio (∼ × 35). This study reports, for the first time, the development of a real-time detection method for vehicle-originated CPM through a thermodenuder (TD) integrated with real-time aerosol instruments. This method was designed to reduce the loss of CPM due to condensation and diffusion while sampling the exhaust gas. It permits the investigation of the effects of dilution gas temperature (5-45 °C) and dilution ratio (up to × 30) on the formation of CPM. During the feasibility test of this method using a diesel vehicle (Euro-4), the real-time total particle number concentrations (PNs) matched well with those obtained by a PMP protocol-based evaluation system. Moreover, this method detected PNs concentrations ten times higher than the detection limit (4 × 106 particles/cm3) of the PMP-based system. The emission factors of the total PM2.5 with a bulk density (1 g/cm3) measured by this method also showed consistency with the results of the PMP protocol. The mass emission factor of CPM determined by deploying the TD was ∼14.57 mg/km (∼63% contribution to the total PM2.5).

The Clinical Value of Periventricular White Matter Hyperintensity on MRI in Sudden Sensorineural Hearing Loss.

OBJECTIVES: To assess the clinical value of periventricular white matter hyperintensity (PWMH) found on brain magnetic resonance imaging (MRI) in patients with sudden sensorineural hearing loss (SSNHL). METHODS: In this prospective study, 115 patients who were diagnosed with SSNHL aged between 55 and 75 years were analyzed. All subjects underwent brain MRI and were divided into a PWMH and control groups, depending on the presence of PWMH on MRI. PWMH was subdivided into 3 groups according to severity. Pure-tone average results and hearing gain were compared between the 2 groups before treatment and 2 months after treatment. Hearing improvement was assessed using Sigel's criteria. RESULTS: A total of 106 patients (43 in the PWMH group and 63 in the control group) finally completed the 2-month follow-up. Average hearing gain in the PWMH group was significantly higher than in the control group (34.8 ± 20.3 and 25.9 ± 20.3, respectively, P = .029). PWMH score 1 showed significantly better hearing levels and hearing gain compared to PWMH score 3 and the control group. Multivariate analysis revealed that younger age, better initial hearing level, and the presence of PVWM score 1 were associated with good recovery. CONCLUSIONS: The presence of PWMH score 1 on brain MRI in patients with SSNHL was associated with better treatment response and was a good prognostic factor in a multivariate analysis while the hearing recovery in more severe PWMH (scores 2, 3) was not different from the control group.

A longitudinal study of changes of congenital auricular deformity regarding self-correction.

This study aimed to investigate the factors associated with congenital auricular deformities and evaluate the long-term frequency of their self-correction. Ninety newborns were enrolled in the study, and data were collected within 2 weeks after birth and at 1 year. The shape of the auricle was classified into seven categories using a digital image. At 2 weeks after birth, several birth-related factors were evaluated in the auricular deformity and normal groups. At 1 year after birth, the images of auricles were compared with the images at birth, and the changes in the auricle shape were investigated. Congenital auricular deformities were observed in 139 out of 180 ears, and the major type noted was helix rim deformity (47 ears), followed by normal ears (41 ears), and cup ears (33 ears). Male sex was found to have a statistically significant association with the occurrence of auricular deformity. In the longitudinal study, among 43 neonates (86 ears) followed-up 12 months later, the self-correction rate was approximately 50%. The normal auricle and prominent ear increased, helix rim deformity and cup ear decreased significantly. The prognosis of deformity varied depending on the type of deformity. Considering the low self-correction rate in the prominent and cup ears, newborns with these deformities might be recommended to undergo management such as auricle molding technique, as required.

Comparison of Medial Underlay and Lateral Underlay Endoscopic Type I Tympanoplasty for Anterior Perforations of the Tympanic Membrane.

OBJECTIVES: To compare the outcomes of medial and lateral underlay endoscopic type I tympanoplasty for anterior tympanic membrane (TM) perforations. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic referral center. PATIENTS: Patients who were diagnosed with either chronic otitis media with dry and stable anterior TM perforations or traumatic anterior TM perforations and underwent endoscopic type I tympanoplasty between 2017 and 2019. INTERVENTIONS: Medial or lateral underlay type I endoscopic tympanoplasty. MAIN OUTCOME MEASURES: Patient demographics, size, and location of TM perforation, graft success rate, and hearing outcome. RESULTS: Of the 170 patients, 68 and 102 patients underwent the medial and lateral underlay techniques, respectively. Patient demographics were not significantly different between groups, except the middle ear mucosa status. Graft success rates were significantly different between groups regardless of the perforation size (85.3 and 95.1%, p < 0.001). The lateral underlay group had a significantly better outcome (p < 0.001) when anterior superior quadrant TM perforation was included than the medial underlay group (p = 0.552). Hearing outcomes did not significantly differ between groups, but a significant audiological improvement was observed in both groups (p < 0.05). CONCLUSION: Lateral underlay type I endoscopic tympanoplasty can be challenging as it requires dissection of the malleus. However, the lateral underlay group had a high graft success rate without sensorineural hearing loss in the repair of anterior TM perforations. Thus, lateral underlay type I endoscopic tympanoplasty should be considered for repairing anterior TM perforations, especially when the anterior superior quadrant is involved.

Mammalian Cochlear Hair Cell Imaging Using Optical Coherence Tomography (OCT): A Preliminary Study.

OBJECTIVES: This study aimed to investigate the feasibility of using optical coherence tomography (OCT) to provide information about cochlear microanatomy at a cellular level, specifically of cochlear hair cells in mammals. MATERIALS AND METHODS: A total of 10 Sprague-Dawley rats were divided into 2 experimental groups for comparing the arrangement of normal and damaged hair cells. Postnatal day 3 Sprague-Dawley rats were used to test the swept-source OCT system, and the images recorded were compared with fluorescence microscope images. RESULTS: Intracochlear structures (the inner hair cells, outer hair cells, and auditory nerve fibers) were clearly visualized at the individual cellular level. CONCLUSION: These images reflect the ability of OCT to provide images of the inner hair cells, outer hair cells, and auditory nerve fibers (ex vivo). OCT is a promising technology, and these findings could be used to encourage research in the area of cochlear microstructure imaging in the future.

Navigation-Assisted Balloon Eustachian Tuboplasty for Eustachian Tube Dilatory Dysfunction.

OBJECTIVES: Balloon Eustachian tuboplasty (BET) is a novel treatment method for Eustachian tube dilatory dysfunction (ETD). However, surgeons cannot identify the insertion depth of the catheter during BET, resulting in potential risks such as internal carotid artery (ICA) injury. Therefore, we developed an image-guided navigation balloon catheter to identify the insertion depth of the catheter and to establish awareness of the proximity of the ICA. This study aimed to evaluate the technical feasibility of this image-guided navigation balloon catheter system in patients with ETD. METHODS: Twenty-nine patients (38 ears; nine bilateral; 21 right ears, and 17 left ears) diagnosed with ETD were assessed. All patients who showed no improvement despite medical therapy with topical steroids, anti-reflux medication, and the Valsalva maneuver for a minimum of 6 weeks received image-guided navigation-assisted BET. The 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score and Valsalva maneuver were used to evaluate patients' symptoms preoperatively and at the postoperative follow-up. RESULTS: Image-guided navigation-assisted BET was safely performed in all patients. The mean total ETDQ-7 score was 25.4±7.1 preoperatively, 17.5±6.2 at 1 month, and 15.2±7.0 at 6 months (P<0.001). In total, a Valsalva maneuver was possible for 28 of 38 ears (73.7%) at the time of the patient's final visit at 6 months post-procedure. CONCLUSION: Image-guided navigation balloon catheters are a potentially valuable tool in patients with ETD. Their use is also technically feasible and safe when performing BET to treat ETD.

The usefulness of Valsalva computed tomography as an assessment tool for the Eustachian tube.

PURPOSE: To determine the usefulness of 'computed tomography (CT) with Valsalva maneuver (VM)' (Valsalva CT) for localizing lesions of the eustachian tube (ET) and identifying characteristics of ET dysfunction (ETD). MATERIALS AND METHODS: In this case-control study, 12, 17, and 25 patients with obstructive ETD (OETD), patulous eustachian tube (PET), and conductive hearing loss (control), respectively, underwent Valsalva CT in the supine position. The visualized length to total length ratio of the cartilaginous ET (VTRET) with and without VM were compared in the three groups. In the OETD group, obstructed areas of the ET were identified on multiplanar reconstructed images. RESULTS: VTRET without VM in the PET group was significantly higher than that in the control and OETD groups (p-values, 0.003 and 0.007, respectively). However, there was no significant difference between the control and OETD groups (p = 0.053). VTRET with VM in the PET group was significantly higher than that in the other two groups (p < 0.001), whereas that in the control group was significantly higher than that in the OETD group (p < 0.001). In the OETD group, the obstructed area was clearly identified, and there were one, one, six, and eight patients in the isthmus; bony portion and isthmus; bony portion, isthmus, and cartilaginous portion; and isthmus and cartilaginous portion subgroups, respectively. CONCLUSION: Valsalva CT is particularly valuable as a visualization assessment tool for identifying obstructed areas in the OETD. It may help future research of disease-specific mechanical characteristics of the ET on controlling pressure variables.

Application of Attachable Magnetic Nerve Stimulator in Intraoperative Facial Nerve Monitoring during Ear Surgery.

We developed an attachable magnetic nerve stimulator (AMNS) that connects the metallic instruments to a neurophysiological monitoring unit for monitoring the facial nerve (FN) during ear surgery and present our experiences with intraoperative neuromonitoring (IONM) of the FN using AMNS. The FN in 20 patients who underwent tympanomastoidectomy for chronic ear disease was examined. The electromyography (EMG) amplitudes of the FN using AMNS were assessed. The EMG amplitudes of the FN at 1.00-mA stimulation during drilling were 265 ± 64 µV in the orbicularis oris and 288 ± 57 µV in the orbicularis oculi. The EMG amplitudes using AMNS attached to the surgical instruments under 0.35-mA stimulus at the tympanic segment of the FN were 196 ± 43 µV in the orbicularis oris and 197 ± 41 µV in the orbicularis oculi. The application of continuous stimulation with burr and surgical instruments using the AMNS is feasible and effective for FN stimulation and identification.

Audiologic, surgical and subjective outcomes of active transcutaneous bone conduction implant system (Bonebridge).

Objective: Our objective was to evaluate the surgical restrictions, audiologic benefits and satisfaction from using an active transcutaneous bone conduction device (BCD), Bonebridge® (BB) in patients with mixed/conductive hearing loss (MCHL) or single-sided deafness (SSD).Design: A retrospective review from all patients who underwent BB surgery at the Pusan National University Hospital from 2015 to 2017 for SSD or MCHL was performed.Study sample: Twenty-two patients with SSD and five with MCHL had a BB implanted and analysed.Results: Complete transmastoid implantation of the device was possible for all patients with an intact canal wall (ICW), using lifts if necessary. The overall functional hearing gain (FHG) in SSD and MCHL was 31.4 and 37.6 dB, respectively. The mean percentage of speech recognition in a quiet was 81% (vs. 11% unaided) for MCHL group and 82% (vs. 29% unaided) for SSD group. Mean speech recognition scores in noise improved significantly under various signal-to-noise ratio (SNR) for both groups. Questionnaires showed overall improvement, and there was no significant difference between the two groups.Conclusions: The BB provides improved functional gain, and there were no limitations during surgery despite the large device. Both MCHL and SSD group had benefit and improved quality of life with BB.

Acellular Dermal Matrix Mistaken as Recurrence of Malignancy Following Surgery on Positron Emission Tomography/Computed Tomography: A Case Report.

OBJECTIVES: To report a rare clinical presentation of an acellular dermal matrix (ADM) used during lateral temporal bone resection mimicking recurrence of cancer of external auditory canal (EAC) on positron emission tomography/computed tomography (PET/CT) 9 months after surgery. METHODS: Case report and literature review. RESULTS: A 71-year-old woman underwent lateral temporal bone resection 9 months earlier for management of squamous cell carcinoma of the EAC. She exhibited recurrence of the tumor on 18F-FDG PET/CT with an intense uptake value (SUVmax 12.8) at the operated site. Exploration was conducted as the location of the lesion was unfavorable to perform biopsy. However, histopathologic evaluation revealed that the lesion was the ADM implanted during surgery. CONCLUSIONS: Care should be taken when using an ADM during malignant tumor surgery if the site of surgery is not conducive for fine needle aspiration or biopsy.