Posterior Cordectomy. Our Experience | Acta Otorrinolaringológica Española

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Nuestra experiencia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 690 "Ancho" => 952 "Tamanyo" => 104732 ] ] "descripcion" => array:1 [ "en" => "Posterior cordectomy. Final outcome (at 3 months postoperatively)." ] ] ] "textoCompleto" => "IntroductionLaryngeal paralysis in adduction is an uncommon condition that can cause dyspnoea of varying intensity and that can be treated with different surgical procedures.Posterior cordectomy is a surgical intervention, first described by Dennis and Kashima in 1989,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> which is indicated in dyspnoea by bilateral vocal fold paralysis in adduction.Recurrent bilateral paralysis represents 25% of all cases of recurrent paralysis<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> and its most common cause is iatrogenic (especially after thyroidectomy<a class="elsevierStyleCrossRefs" href="#bib0010">2,4</a>). It is difficult to distinguish from cricoarytenoid joint ankylosis, although it is important to do so because their surgical managements are different.Clinically, it is characterised by dyspnoea of varying intensity, with little or no dysphonia and without dysphagia.In addition to tracheotomy, the surgical treatment of this problem includes several options. Resection techniques (cordectomy and arytenoidectomy) are the most commonly used, but there are also other alternatives such as arytenoidopexy or nerve reinnervation.Breathing voice is sacrificed in all surgical procedures except reinnervation.Posterior cordectomy is a simple operation to perform, almost without complications. Some modifications to improve the outcome have been described. We believe that, at present, it is the technique of choice because it provides the best balance between respiratory and phonatory results, without causing aspiration.MethodsWe conducted a retrospective study of 13 patients who underwent posterior cordectomy due to bilateral vocal fold paralysis in adduction, between June 1998 and January 2008. Of these, 9 were female and 4 were male. Their ages ranged between 25 and 79 years. Classifying by aetiology we found: 4 after thyroidectomy, 1 following traumatic brain injury, 1 due to multinodular goitre, 2 following combined treatment with radiotherapy and chemotherapy due to laryngeal squamous cell carcinoma, 2 from neurological disease (both with multisystem atrophy), and 3 of unknown aetiology (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Clinically, all patients presented dyspnoea on moderate exertion with nocturnal stridor. Two patients had previously undergone surgical procedures for this problem (1 of them on 2 occasions – cordectomy and arytenoidectomy with cordopexy – and the other, arytenoidopexy).We used electrocautery in all cases except for 1, in which CO2 laser was used, due to technical problems. No patient underwent tracheotomy at the time of the intervention.We performed prior tracheotomy in only 1 case. This patient was scheduled for total thyroidectomy surgery (due to large multinodular goitre with intrathoracic extension) and removal of a pituitary adenoma. The tracheotomy was removed after 1 month, without any problems.ResultsAll cases presented significant improvement in dyspnoea 1 year after the intervention. Two patients suffered a worsening of their dyspnoea in the first 2 weeks after surgery, requiring hospital admission. One of them received drug treatment with good response and the other underwent cordectomy.To assess the degree of dysphonia generated, we used the Spanish version of the Voice Handicap Index (VHI) 1 year after the intervention. We excluded the patients who presented dysphonia before surgery, that is, patients with cancer (2), neurological cases (2), patients who had undergone surgery on 2 previous occasions, and patients who underwent cordectomy. Of the 7 remaining cases, 2 suffered a mild dysphonia (VHI under 30), 4 a moderate dysphonia (VHI between 30 and 60) and 1 a severe dysphonia (VHI between 60 and 90). All patients were satisfied with the vocal outcome, except for the one who underwent cordectomy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).The 2 cancer patients and the 2 neurological patients died due to their underlying diseases, without requiring tracheostomy in any case.DiscussionBilateral paralysis of both vocal folds accounts for 25% of cases of recurrent paralysis.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> The most common cause of bilateral recurrent paralysis is the iatrogenic, especially thyroidectomy.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>It may appear as sudden dyspnoea (usually in the immediate postoperative period, perhaps requiring urgent tracheostomy) or, even more frequently, as dyspnoea upon small and moderate efforts. It does not usually cause dysphonia (and when it does appear, it is mild) or deglutitive problems.Whenever possible, it is advisable to wait at least 6 months before performing surgery, because there may be a spontaneous recovery of the paralysis.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>The first surgical intervention for this problem was a cordoventriculectomy performed by Chevalier Jackson<a class="elsevierStyleCrossRef" href="#bib0030">6</a> in 1922. In 1941, King proposed an arytenoidopexy with suture to the omohyoid muscle and Kelly performed an external arytenoidectomy that same year.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Thornell carried out the first endoscopic arytenoidectomy (1948), which Ossoff later repeated with CO2 laser in 1983.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> In 1989, Dennis and Kashima<a class="elsevierStyleCrossRef" href="#bib0005">1</a> published posterior cordectomy, an even more restricted procedure on the glottis. With the development of endolaryngeal microsurgery and lasers, external approaches have been practically abandoned (except in children, in whom endoscopic approaches can still be performed<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>; some authors have obtained better results with external approaches<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a>).The most commonly used techniques are resections, including cordectomy (endoscopic or external), which often causes severe dysphonia.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> Arytenoidectomy (external or endoscopic) has aspiration as a major complication<a class="elsevierStyleCrossRefs" href="#bib0025">5,12,13</a> (although some technical variants have been described that avoid it) or cricoid necrosis (especially in irradiated patients).<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Lastly, posterior cordectomy achieves sufficient air passage with moderate vocal sacrifice.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Possible non-resection surgical procedures include arytenoidopexy, which can be external or endoscopic (Lichtenberger has designed instrumentation that facilitates it<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>). Its main advantage is that arytenoidopexy is potentially reversible, while its main disadvantage is that its results seem to worsen over time.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>Laryngeal reinnervation was first described by Tucker in 1976,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> with excellent results<a class="elsevierStyleCrossRef" href="#bib0080">16</a> (he used a myoneural pedicle from the hypoglossal loop to the posterior cricoarytenoid muscle).<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The intervention is technically difficult and has shown worse results in other series.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Other procedures such as a laryngeal pacemaker<a class="elsevierStyleCrossRef" href="#bib0085">17</a> or botulinum toxin<a class="elsevierStyleCrossRef" href="#bib0090">18</a> may become important alternatives in the future.Posterior cordectomy consists in a transverse incision of the vocal fold in front of its insertion into the vocal process, which must completely sever the elastic cone reaching the cricoid perichondrium<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Some authors employ variants of posterior cordectomy, such as procedures on both vocal folds<a class="elsevierStyleCrossRefs" href="#bib0060">12,19,20</a> or extending the resection to the ventricular band or the vocal fold or vocal process.<a class="elsevierStyleCrossRefs" href="#bib0105">21–23</a> Although it was originally described with CO2 laser, it can also be performed with KTP laser<a class="elsevierStyleCrossRefs" href="#bib0115">23–25</a> or with electrocautery, as in 1 case within our series.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Some authors employ a prior tracheotomy,<a class="elsevierStyleCrossRefs" href="#bib0035">7,13</a> although we generally do not consider it necessary and have only used it in 1 case.This intervention is simple to perform, but its main drawback is the appearance of dyspnoea in the immediate postoperative period (15% of our cases). This dyspnoea is caused by granulomas, oedema, or crusts attached to the surgical site during scarring.<a class="elsevierStyleCrossRefs" href="#bib0060">12,25</a> Nevertheless, it is transient and can be treated medically (with anti-inflammatory drugs, antibiotics, mucolytics, humidifiers, etc.).It is important to distinguish whether the bilateral immobility of the vocal folds is caused by recurrent paralysis or cricoarytenoid ankylosis, although few series make this distinction.<a class="elsevierStyleCrossRefs" href="#bib0025">5,19,26</a> Cricoarytenoid ankylosis is mainly due to endotracheal intubation,<a class="elsevierStyleCrossRefs" href="#bib0025">5,26</a> followed by autoimmune diseases (Wegener, rheumatoid arthritis<a class="elsevierStyleCrossRef" href="#bib0135">27</a>). Cricoarytenoid ankylosis can be resolved through other surgical procedures such as sectioning scar tissue or adhesions that fix the arytenoids, intra-articular injection of corticosteroids or others.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Laryngeal electromyography can be of great help in differentiating both conditions, as well as in establishing a prognosis in recurrent paralysis.<a class="elsevierStyleCrossRefs" href="#bib0015">3,5,6</a>With respect to respiratory outcomes, almost all studies report satisfactory results, between 95%<a class="elsevierStyleCrossRef" href="#bib0120">24</a> and 100% of cases (as in our series), although with reoperation rates ranging from 50%<a class="elsevierStyleCrossRefs" href="#bib0105">21,24,25</a> to 33% as in the first communication by Dennis and Kashima<a class="elsevierStyleCrossRef" href="#bib0005">1</a> or 7% as in our series. The parameters used to measure these results differ from 1 study to the next. Some, including ours, use the subjective improvement of dyspnoea or the degree of patient satisfaction,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> while others use the percentage of decannulations<a class="elsevierStyleCrossRefs" href="#bib0040">8,21</a> or pulmonary function tests (flow volume curves,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> body plethysmography<a class="elsevierStyleCrossRefs" href="#bib0095">19,22,23</a>).We used the Spanish version of the VHI to evaluate the vocal results.<a class="elsevierStyleCrossRefs" href="#bib0140">28,29</a> This is a questionnaire with 3 parts (functional, physical, and emotional), with 10 questions each, which are answered with a value of 0–4, that is, with a maximum score of 120. A VHI below 30 is considered as a mild dysphonia, between 30 and 60 as moderate dysphonia, between 60 and 90 as intense dysphonia, and between 90 and 120 as severe dysphonia. Other studies use patients’ subjective assessments<a class="elsevierStyleCrossRefs" href="#bib0095">19,20,24</a> or resort to other parameters (Yanagihara scale based on spectrogram,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Göttingen scale,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> or Dejonckhere scale<a class="elsevierStyleCrossRef" href="#bib0130">26</a>). We obtained good vocal results in most cases (85% of mild or moderate dysphonia in our series) and all patients reported being satisfied with their voice.Neither our series nor any of those reviewed reported deglutitive disorders after the intervention.Some studies compared the outcome between posterior cordectomy and arytenoidectomy,<a class="elsevierStyleCrossRefs" href="#bib0130">26,30</a> without finding significant differences in either vocal or respiratory results. Nevertheless, they have found that arytenoidectomy often causes subclinical aspiration whereas posterior cordectomy does not.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> No differences in outcome were found when using either CO2 or KTP laser.<a class="elsevierStyleCrossRefs" href="#bib0105">21,24,25</a>ConclusionsDyspnoea caused by bilateral paralysis of vocal folds in adduction is rare, but it represents a delicate problem. Posterior cordectomy is a rapid, simple intervention that has few complications. In most cases, this intervention provides a sufficient increase in glottic space (similar results to other techniques), with a mild or moderate dysphonia without aspiration. We believe that, at present, this is the technique of choice in this pathology.Conflict of InterestsThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres94926" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec82078" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres94927" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec82079" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-03-02" "fechaAceptado" => "2011-06-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82078" "palabras" => array:3 [ 0 => "Bilateral vocal fold paralysis" 1 => "Laser surgery" 2 => "Respiratory distress" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82079" "palabras" => array:3 [ 0 => "Parálisis cuerda vocal bilateral" 1 => "Cirugía laser" 2 => "Insuficiencia respiratoria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveSeveral surgical procedures have been proposed for the treatment of respiratory distress secondary to bilateral cord palsy. We performed a retrospective study of our experience in posterior cordectomy with a laser CO2, analysing the improvement of dyspnoea and voice quality after surgery. MethodsThis was a retrospective study of 13 cases (9 female, 4 male). The age range was 25–79 years. Iatrogenic post-thyroidectomy (4 cases) was the most common aetiology of bilateral laryngeal palsy in our study.We assessed the subjective improvement of respiratory function and voice quality after laser surgery using the Spanish adaptation of the Voice Handicap Index (VHI). ResultsDyspnoea improved in all patients. Two cases had a worsening of dyspnoea in the immediate postoperative period and one case was successfully solved with a new surgical intervention.After surgery, most of patients suffered from mild or middle dysphonia. ConclusionsThe posterior cordectomy is an easy, safe, and effective treatment for dyspnoea secondary to bilateral laryngeal palsy, maintaining acceptable voice quality." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosLa paralisis bilateral en adducción de las cuerdas vocales ocasiona una disnea de intensidad variable, que puede ser tratada con diferentes procedimientos quirúrgicos. Se realiza una revisión retrospectiva de nuestros casos tratados mediante cordectomía posterior con laser CO2, analizando tanto el resultado respiratorio (mejoría de la disnea) como el resultado vocal. MétodosSe realiza un estudio retrospectivo de 13 casos (9 mujeres y 4 varones) con edades comprendidas entre 25 y 79 años. En nuestra serie la causa más frecuente de la parálisis laríngea bilateral es la tiroidectomía (4 casos).Se valora la mejoría de su disnea según la opinión subjetiva de los pacientes y la disfonía generada, utilizando la versión española del Voice Handicap Index (VHI). ResultadosTodos los pacientes mejoraron significativamente de su disnea. Dos pacientes tuvieron que ser ingresados por disnea la primera semana del postoperatorio y uno de ellos fue reintervenido. Tras la intervención la mayoría de los pacientes sufrieron una disfonía leve o moderada. ConclusionesLa cordectomía posterior es un tratamiento fácil y seguro, que proporciona buenos resultados respiratorios con una disfonía leve o moderada en la mayoría de los casos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Landa M, et al. Cordectomía posterior. Nuestra experiencia. Acta Otorrinolaringol Esp. 2012;63:26–30." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 725 "Ancho" => 952 "Tamanyo" => 88908 ] ] "descripcion" => array:1 [ "en" => "Posterior cordectomy. Immediate postoperative period (the day after the intervention)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 690 "Ancho" => 952 "Tamanyo" => 104732 ] ] "descripcion" => array:1 [ "en" => "Posterior cordectomy. Final outcome (at 3 months postoperatively)." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BT: brain trauma; VHI: Voice Handicap Index." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Aetiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Prior Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CO2 Laser \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Prior Tracheotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Postoperative Dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reintervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">VHI \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ + \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroid goitre \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179710.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Scheme of Cases Studied and Vocal Result With VHI." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.P. Dennis" 1 => "H. Kashima" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Otol Rhinol Laryngol" "fecha" => "1989" "volumen" => "98" "paginaInicial" => "930" "paginaFinal" => "934" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2589760" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inmovilidad glótica: estudio retrospectivo de 229 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "X. León" 1 => "M.P. Venegas" 2 => "C. Orus" 3 => "M. Quer" 4 => "E. Maranillo" 5 => "J.R. Sañudo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Otorrinolaringol Esp" "fecha" => "2001" "volumen" => "52" "paginaInicial" => "486" "paginaFinal" => "492" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11692963" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changing etiology of vocal fold immobility" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.S. Benninger" 1 => "S. Michael" 2 => "J.B. Gillen" 3 => "B. John" 4 => "J.S. 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Posterior Cordectomy. Our Experience

Cordectomía posterior. Nuestra experiencia

Mikel Landa

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mamiklan@hotmail.com

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, Iñigo Luqui, Javier Gómez, Zuriñe Martínez

Unidad de Foniatría, Servicio de ORL, Hospital Donostia, San Sebastián, Guipúzcoa, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laryngeal paralysis in adduction is an uncommon condition that can cause dyspnoea of varying intensity and that can be treated with different surgical procedures&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Posterior cordectomy is a surgical intervention&#44; first described by Dennis and Kashima in 1989&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which is indicated in dyspnoea by bilateral vocal fold paralysis in adduction&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Recurrent bilateral paralysis represents 25&#37; of all cases of recurrent paralysis<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> and its most common cause is iatrogenic &#40;especially after thyroidectomy<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a>&#41;&#46; It is difficult to distinguish from cricoarytenoid joint ankylosis&#44; although it is important to do so because their surgical managements are different&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Clinically&#44; it is characterised by dyspnoea of varying intensity&#44; with little or no dysphonia and without dysphagia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition to tracheotomy&#44; the surgical treatment of this problem includes several options&#46; Resection techniques &#40;cordectomy and arytenoidectomy&#41; are the most commonly used&#44; but there are also other alternatives such as arytenoidopexy or nerve reinnervation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Breathing voice is sacrificed in all surgical procedures except reinnervation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Posterior cordectomy is a simple operation to perform&#44; almost without complications&#46; Some modifications to improve the outcome have been described&#46; We believe that&#44; at present&#44; it is the technique of choice because it provides the best balance between respiratory and phonatory results&#44; without causing aspiration&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of 13 patients who underwent posterior cordectomy due to bilateral vocal fold paralysis in adduction&#44; between June 1998 and January 2008&#46; Of these&#44; 9 were female and 4 were male&#46; Their ages ranged between 25 and 79 years&#46; Classifying by aetiology we found&#58; 4 after thyroidectomy&#44; 1 following traumatic brain injury&#44; 1 due to multinodular goitre&#44; 2 following combined treatment with radiotherapy and chemotherapy due to laryngeal squamous cell carcinoma&#44; 2 from neurological disease &#40;both with multisystem atrophy&#41;&#44; and 3 of unknown aetiology &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Clinically&#44; all patients presented dyspnoea on moderate exertion with nocturnal stridor&#46; Two patients had previously undergone surgical procedures for this problem &#40;1 of them on 2 occasions &#8211; cordectomy and arytenoidectomy with cordopexy &#8211; and the other&#44; arytenoidopexy&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We used electrocautery in all cases except for 1&#44; in which CO<span class="elsevierStyleInf">2</span> laser was used&#44; due to technical problems&#46; No patient underwent tracheotomy at the time of the intervention&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We performed prior tracheotomy in only 1 case&#46; This patient was scheduled for total thyroidectomy surgery &#40;due to large multinodular goitre with intrathoracic extension&#41; and removal of a pituitary adenoma&#46; The tracheotomy was removed after 1 month&#44; without any problems&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">All cases presented significant improvement in dyspnoea 1 year after the intervention&#46; Two patients suffered a worsening of their dyspnoea in the first 2 weeks after surgery&#44; requiring hospital admission&#46; One of them received drug treatment with good response and the other underwent cordectomy&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">To assess the degree of dysphonia generated&#44; we used the Spanish version of the Voice Handicap Index &#40;VHI&#41; 1 year after the intervention&#46; We excluded the patients who presented dysphonia before surgery&#44; that is&#44; patients with cancer &#40;2&#41;&#44; neurological cases &#40;2&#41;&#44; patients who had undergone surgery on 2 previous occasions&#44; and patients who underwent cordectomy&#46; Of the 7 remaining cases&#44; 2 suffered a mild dysphonia &#40;VHI under 30&#41;&#44; 4 a moderate dysphonia &#40;VHI between 30 and 60&#41; and 1 a severe dysphonia &#40;VHI between 60 and 90&#41;&#46; All patients were satisfied with the vocal outcome&#44; except for the one who underwent cordectomy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The 2 cancer patients and the 2 neurological patients died due to their underlying diseases&#44; without requiring tracheostomy in any case&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Bilateral paralysis of both vocal folds accounts for 25&#37; of cases of recurrent paralysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> The most common cause of bilateral recurrent paralysis is the iatrogenic&#44; especially thyroidectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">It may appear as sudden dyspnoea &#40;usually in the immediate postoperative period&#44; perhaps requiring urgent tracheostomy&#41; or&#44; even more frequently&#44; as dyspnoea upon small and moderate efforts&#46; It does not usually cause dysphonia &#40;and when it does appear&#44; it is mild&#41; or deglutitive problems&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Whenever possible&#44; it is advisable to wait at least 6 months before performing surgery&#44; because there may be a spontaneous recovery of the paralysis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The first surgical intervention for this problem was a cordoventriculectomy performed by Chevalier Jackson<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in 1922&#46; In 1941&#44; King proposed an arytenoidopexy with suture to the omohyoid muscle and Kelly performed an external arytenoidectomy that same year&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Thornell carried out the first endoscopic arytenoidectomy &#40;1948&#41;&#44; which Ossoff later repeated with CO<span class="elsevierStyleInf">2</span> laser in 1983&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In 1989&#44; Dennis and Kashima<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> published posterior cordectomy&#44; an even more restricted procedure on the glottis&#46; With the development of endolaryngeal microsurgery and lasers&#44; external approaches have been practically abandoned &#40;except in children&#44; in whom endoscopic approaches can still be performed<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#59; some authors have obtained better results with external approaches<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The most commonly used techniques are resections&#44; including cordectomy &#40;endoscopic or external&#41;&#44; which often causes severe dysphonia&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Arytenoidectomy &#40;external or endoscopic&#41; has aspiration as a major complication<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;12&#44;13</span></a> &#40;although some technical variants have been described that avoid it&#41; or cricoid necrosis &#40;especially in irradiated patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Lastly&#44; posterior cordectomy achieves sufficient air passage with moderate vocal sacrifice&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Possible non-resection surgical procedures include arytenoidopexy&#44; which can be external or endoscopic &#40;Lichtenberger has designed instrumentation that facilitates it<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#41;&#46; Its main advantage is that arytenoidopexy is potentially reversible&#44; while its main disadvantage is that its results seem to worsen over time&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Laryngeal reinnervation was first described by Tucker in 1976&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> with excellent results<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;he used a myoneural pedicle from the hypoglossal loop to the posterior cricoarytenoid muscle&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The intervention is technically difficult and has shown worse results in other series&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Other procedures such as a laryngeal pacemaker<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> or botulinum toxin<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> may become important alternatives in the future&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Posterior cordectomy consists in a transverse incision of the vocal fold in front of its insertion into the vocal process&#44; which must completely sever the elastic cone reaching the cricoid perichondrium<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Some authors employ variants of posterior cordectomy&#44; such as procedures on both vocal folds<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;19&#44;20</span></a> or extending the resection to the ventricular band or the vocal fold or vocal process&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a> Although it was originally described with CO<span class="elsevierStyleInf">2</span> laser&#44; it can also be performed with KTP laser<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a> or with electrocautery&#44; as in 1 case within our series&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Some authors employ a prior tracheotomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13</span></a> although we generally do not consider it necessary and have only used it in 1 case&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">This intervention is simple to perform&#44; but its main drawback is the appearance of dyspnoea in the immediate postoperative period &#40;15&#37; of our cases&#41;&#46; This dyspnoea is caused by granulomas&#44; oedema&#44; or crusts attached to the surgical site during scarring&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;25</span></a> Nevertheless&#44; it is transient and can be treated medically &#40;with anti-inflammatory drugs&#44; antibiotics&#44; mucolytics&#44; humidifiers&#44; etc&#46;&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is important to distinguish whether the bilateral immobility of the vocal folds is caused by recurrent paralysis or cricoarytenoid ankylosis&#44; although few series make this distinction&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;19&#44;26</span></a> Cricoarytenoid ankylosis is mainly due to endotracheal intubation&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26</span></a> followed by autoimmune diseases &#40;Wegener&#44; rheumatoid arthritis<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#41;&#46; Cricoarytenoid ankylosis can be resolved through other surgical procedures such as sectioning scar tissue or adhesions that fix the arytenoids&#44; intra-articular injection of corticosteroids or others&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Laryngeal electromyography can be of great help in differentiating both conditions&#44; as well as in establishing a prognosis in recurrent paralysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">With respect to respiratory outcomes&#44; almost all studies report satisfactory results&#44; between 95&#37;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and 100&#37; of cases &#40;as in our series&#41;&#44; although with reoperation rates ranging from 50&#37;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;24&#44;25</span></a> to 33&#37; as in the first communication by Dennis and Kashima<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> or 7&#37; as in our series&#46; The parameters used to measure these results differ from 1 study to the next&#46; Some&#44; including ours&#44; use the subjective improvement of dyspnoea or the degree of patient satisfaction&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> while others use the percentage of decannulations<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;21</span></a> or pulmonary function tests &#40;flow volume curves&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> body plethysmography<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;22&#44;23</span></a>&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We used the Spanish version of the VHI to evaluate the vocal results&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> This is a questionnaire with 3 parts &#40;functional&#44; physical&#44; and emotional&#41;&#44; with 10 questions each&#44; which are answered with a value of 0&#8211;4&#44; that is&#44; with a maximum score of 120&#46; A VHI below 30 is considered as a mild dysphonia&#44; between 30 and 60 as moderate dysphonia&#44; between 60 and 90 as intense dysphonia&#44; and between 90 and 120 as severe dysphonia&#46; Other studies use patients&#8217; subjective assessments<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20&#44;24</span></a> or resort to other parameters &#40;Yanagihara scale based on spectrogram&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> G&#246;ttingen scale&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> or Dejonckhere scale<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#41;&#46; We obtained good vocal results in most cases &#40;85&#37; of mild or moderate dysphonia in our series&#41; and all patients reported being satisfied with their voice&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Neither our series nor any of those reviewed reported deglutitive disorders after the intervention&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Some studies compared the outcome between posterior cordectomy and arytenoidectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;30</span></a> without finding significant differences in either vocal or respiratory results&#46; Nevertheless&#44; they have found that arytenoidectomy often causes subclinical aspiration whereas posterior cordectomy does not&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> No differences in outcome were found when using either CO<span class="elsevierStyleInf">2</span> or KTP laser&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;24&#44;25</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">Dyspnoea caused by bilateral paralysis of vocal folds in adduction is rare&#44; but it represents a delicate problem&#46; Posterior cordectomy is a rapid&#44; simple intervention that has few complications&#46; In most cases&#44; this intervention provides a sufficient increase in glottic space &#40;similar results to other techniques&#41;&#44; with a mild or moderate dysphonia without aspiration&#46; We believe that&#44; at present&#44; this is the technique of choice in this pathology&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "Objective"
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            4 => "Conclusions"
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          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres94927"
          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Introducci&#243;n y objetivos"
            2 => "M&#233;todos"
            3 => "Resultados"
            4 => "Conclusiones"
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          "identificador" => "xpalclavsec82079"
          "titulo" => "Palabras clave"
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        4 => array:2 [
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conclusions"
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        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of Interests"
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        10 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-03-02"
    "fechaAceptado" => "2011-06-30"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec82078"
          "palabras" => array:3 [
            0 => "Bilateral vocal fold paralysis"
            1 => "Laser surgery"
            2 => "Respiratory distress"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82079"
          "palabras" => array:3 [
            0 => "Par&#225;lisis cuerda vocal bilateral"
            1 => "Cirug&#237;a laser"
            2 => "Insuficiencia respiratoria"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Several surgical procedures have been proposed for the treatment of respiratory distress secondary to bilateral cord palsy&#46; We performed a retrospective study of our experience in posterior cordectomy with a laser CO<span class="elsevierStyleInf">2</span>&#44; analysing the improvement of dyspnoea and voice quality after surgery&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective study of 13 cases &#40;9 female&#44; 4 male&#41;&#46; The age range was 25&#8211;79 years&#46; Iatrogenic post-thyroidectomy &#40;4 cases&#41; was the most common aetiology of bilateral laryngeal palsy in our study&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We assessed the subjective improvement of respiratory function and voice quality after laser surgery using the Spanish adaptation of the Voice Handicap Index &#40;VHI&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dyspnoea improved in all patients&#46; Two cases had a worsening of dyspnoea in the immediate postoperative period and one case was successfully solved with a new surgical intervention&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">After surgery&#44; most of patients suffered from mild or middle dysphonia&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The posterior cordectomy is an easy&#44; safe&#44; and effective treatment for dyspnoea secondary to bilateral laryngeal palsy&#44; maintaining acceptable voice quality&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n y objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La paralisis bilateral en adducci&#243;n de las cuerdas vocales ocasiona una disnea de intensidad variable&#44; que puede ser tratada con diferentes procedimientos quir&#250;rgicos&#46; Se realiza una revisi&#243;n retrospectiva de nuestros casos tratados mediante cordectom&#237;a posterior con laser CO<span class="elsevierStyleInf">2</span>&#44; analizando tanto el resultado respiratorio &#40;mejor&#237;a de la disnea&#41; como el resultado vocal&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiza un estudio retrospectivo de 13 casos &#40;9 mujeres y 4 varones&#41; con edades comprendidas entre 25 y 79 a&#241;os&#46; En nuestra serie la causa m&#225;s frecuente de la par&#225;lisis lar&#237;ngea bilateral es la tiroidectom&#237;a &#40;4 casos&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se valora la mejor&#237;a de su disnea seg&#250;n la opini&#243;n subjetiva de los pacientes y la disfon&#237;a generada&#44; utilizando la versi&#243;n espa&#241;ola del <span class="elsevierStyleItalic">Voice Handicap Index</span> &#40;VHI&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes mejoraron significativamente de su disnea&#46; Dos pacientes tuvieron que ser ingresados por disnea la primera semana del postoperatorio y uno de ellos fue reintervenido&#46; Tras la intervenci&#243;n la mayor&#237;a de los pacientes sufrieron una disfon&#237;a leve o moderada&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La cordectom&#237;a posterior es un tratamiento f&#225;cil y seguro&#44; que proporciona buenos resultados respiratorios con una disfon&#237;a leve o moderada en la mayor&#237;a de los casos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Landa M&#44; et al&#46; Cordectom&#237;a posterior&#46; Nuestra experiencia&#46; Acta Otorrinolaringol Esp&#46; 2012&#59;63&#58;26&#8211;30&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Posterior cordectomy&#46; Immediate postoperative period &#40;the day after the intervention&#41;&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Posterior cordectomy&#46; Final outcome &#40;at 3 months postoperatively&#41;&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">BT&#58; brain trauma&#59; VHI&#58; Voice Handicap Index&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Aetiology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Prior Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CO<span class="elsevierStyleInf">2</span> Laser&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Prior Tracheotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Postoperative Dyspnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Reintervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">VHI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroidectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43; &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroid goitre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oncological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oncological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab179710.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Scheme of Cases Studied and Vocal Result With VHI&#46;</p>"
        ]
      ]
    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
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                    0 => array:2 [
                      "titulo" => "Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;P&#46; Dennis"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Otol Rhinol Laryngol"
                        "fecha" => "1989"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2589760"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Inmovilidad gl&#243;tica&#58; estudio retrospectivo de 229 casos"
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                            0 => "X&#46; Le&#243;n"
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                            2 => "C&#46; Orus"
                            3 => "M&#46; Quer"
                            4 => "E&#46; Maranillo"
                            5 => "J&#46;R&#46; Sa&#241;udo"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11692963"
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                            0 => "M&#46;S&#46; Benninger"
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                            3 => "B&#46; John"
                            4 => "J&#46;S&#46; Altman"
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                        "paginaFinal" => "1350"
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                          0 => array:2 [
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                        "titulo" => "Cl&#237;nicas otorrinolaringol&#243;gicas norteamericanas&#46; Trastornos de la voz y fonocirug&#237;a&#44; parte I"
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                        "editorial" => "McGraw-Hill Interamericana"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endoscopic laser arytenoidectomy"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46;H&#46; Ossoff"
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                            2 => "G&#46;A&#46; Sisson"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lasers Surg Med"
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                        "volumen" => "2"
                        "paginaInicial" => "293"
                        "paginaFinal" => "299"
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                    0 => array:1 [
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                        0 => array:2 [
                          "etal" => false
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                            0 => "C&#46;M&#46; Bower"
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                    0 => array:1 [
                      "Revista" => array:6 [
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                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 21735735
Original language: English

DOI:10.1016/j.otoeng.2012.01.007

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2019 June	143	26	169
2019 May	222	56	278
2019 April	166	20	186
2019 March	42	8	50
2019 February	45	6	51
2019 January	38	16	54
2018 December	43	19	62
2018 November	33	4	37
2018 October	29	7	36
2018 May	0	1	1
2018 April	34	14	48
2018 March	26	14	40
2018 February	52	4	56
2018 January	60	13	73
2017 December	60	2	62
2017 November	50	4	54
2017 October	14	13	27
2017 September	20	33	53
2017 August	23	17	40
2017 July	23	13	36
2017 June	31	27	58
2017 May	34	19	53
2017 April	29	17	46
2017 March	24	29	53
2017 February	40	7	47
2017 January	18	4	22
2016 December	34	14	48
2016 November	30	15	45
2016 October	47	29	76
2016 September	50	11	61
2016 August	43	9	52
2016 July	26	1	27
2016 June	35	24	59
2016 May	36	17	53
2016 April	30	20	50
2016 March	34	25	59
2016 February	45	24	69
2016 January	31	24	55
2015 December	33	19	52
2015 November	24	18	42
2015 October	29	20	49
2015 September	23	6	29
2015 August	45	3	48
2015 July	50	8	58
2015 June	39	7	46
2015 May	42	11	53
2015 April	42	16	58
2015 March	33	18	51
2015 February	28	0	28
2015 January	39	8	47
2014 December	49	5	54
2014 November	31	2	33
2014 October	32	4	36
2014 September	48	4	52
2014 August	37	6	43
2014 July	35	5	40
2014 June	27	4	31
2014 May	16	4	20
2014 April	28	7	35
2014 March	26	3	29
2014 February	18	3	21
2014 January	19	4	23
2013 December	10	6	16
2013 November	17	4	21
2013 October	36	6	42
2013 September	21	6	27
2013 August	16	2	18
2013 July	1	0	1

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