GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013 Dec 13;12:Doc08. doi: 10.3205/cto000100.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology.

GMS current topics in otorhinolaryngology, head and neck surgery

Jochen P Windfuhr

PMID: 24403976 PMCID: PMC3884543 DOI: 10.3205/cto000100

Abstract

BACKGROUND: Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS: A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS: The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION: Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Keywords: adenoidectomy; cervical lymph node; complication; death; fatality; litigation; malpractice; negligence; septoplasty; tonsillectomy; tonsillotomy

References

1. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001802 - PubMed
2. Laryngorhinootologie. 1990 Jun;69(6):303-7 - PubMed
3. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30 - PubMed
4. Otolaryngol Head Neck Surg. 1997 Dec;117(6):628-32 - PubMed
5. Laryngoscope. 2011 Feb;121(2):279-88 - PubMed
6. Acta Otolaryngol. 2012 May;132(5):533-9 - PubMed
7. Arch Otolaryngol Head Neck Surg. 2008 Jan;134(1):10-5 - PubMed
8. Z Laryngol Rhinol Otol. 1953 Jul-Aug;32(7-8):413-4 - PubMed
9. J Laryngol Otol. 2006 Jun;120(6):450-4 - PubMed
10. J Laryngol Otol. 2002 Apr;116(4):272-4 - PubMed
11. J Laryngol Otol. 2009 Feb;123(2):199-202 - PubMed
12. Cochrane Database Syst Rev. 2010 Jul 07;(7):CD005607 - PubMed
13. Otolaryngol Head Neck Surg. 2005 Feb;132(2):281-6 - PubMed
14. J Laryngol Otol. 2009 Sep;123(9):1010-4 - PubMed
15. J Cardiovasc Pharmacol Ther. 2012 Sep;17(3):298-302 - PubMed
16. Int J Pediatr Otorhinolaryngol. 1993 Jan;25(1-3):149-54 - PubMed
17. Facial Plast Surg. 1997 Jan;13(1):3-14 - PubMed
18. Clin Otolaryngol Allied Sci. 1997 Jun;22(3):226-32 - PubMed
19. Monatsschr Ohrenheilkd Laryngorhinol. 1960 Jun;94:164-8 - PubMed
20. Laryngorhinootologie. 1993 Feb;72(2):86-90 - PubMed
21. J Laryngol Otol. 1988 Sep;102(9):796-8 - PubMed
22. HNO. 2007 Feb;55(2):100-3 - PubMed
23. Monatsschr Ohrenheilkd Laryngorhinol. 1971;105(5):228-32 - PubMed
24. Otolaryngol Head Neck Surg (1979). 1979 Mar-Apr;87(2):159-66 - PubMed
25. Anesthesiology. 2003 Jun;98(6):1497-502 - PubMed
26. J Laryngol Otol. 1984 Jun;98(6):647-54 - PubMed
27. Laryngol Rhinol Otol (Stuttg). 1981 Feb;60(2):56 - PubMed
28. SD J Med Pharm. 1957 May;10(5):160-1; passim - PubMed
29. Acta Otolaryngol. 1985 Mar-Apr;99(3-4):466-8 - PubMed
30. Radiol Clin Biol. 1970;39(4):357-65 - PubMed
31. Clin Otolaryngol Allied Sci. 2003 Dec;28(6):489-91 - PubMed
32. Laryngoscope. 2012 Jun;122(6):1265-6 - PubMed
33. Otolaryngol Head Neck Surg. 2003 Oct;129(4):360-4 - PubMed
34. Arch Otolaryngol Head Neck Surg. 2003 Oct;129(10):1086-9 - PubMed
35. Laryngorhinootologie. 1992 Jun;71(6):332-3 - PubMed
36. Laryngoscope. 1997 Oct;107(10):1322-31 - PubMed
37. Nervenarzt. 1989 Sep;60(9):572-5 - PubMed
38. Am J Otolaryngol. 2005 Nov-Dec;26(6):406-7 - PubMed
39. Otolaryngol Head Neck Surg. 2000 Feb;122(2):228-32 - PubMed
40. Arch Facial Plast Surg. 2010 Jan-Feb;12(1):4-10 - PubMed
41. Otolaryngol Head Neck Surg. 2001 Dec;125(6):670-2 - PubMed
42. Wien Klin Wochenschr. 2008;120(11-12):336-42 - PubMed
43. Laryngoscope. 1972 Jan;82(1):139-40 - PubMed
44. Monatsschr Ohrenheilkd Laryngorhinol. 1970;104(3):130-5 - PubMed
45. Clin Otolaryngol Allied Sci. 1991 Feb;16(1):21-4 - PubMed
46. Acta Otolaryngol Suppl. 2002;(546):164-72 - PubMed
47. HNO. 2012 Feb;60(2):135-40 - PubMed
48. Zh Ushn Nos Gorl Bolezn. 1979 Jul-Aug;(4):82-3 - PubMed
49. Arch Otorhinolaryngol. 1988;245(2):74-6 - PubMed
50. Rhinology. 1978 Sep;16(3):123-38 - PubMed
51. SD J Med Pharm. 1958 Jan;11(1):1-2 - PubMed
52. B-ENT. 2005;1(4):197-200 - PubMed
53. Laryngorhinootologie. 1999 Jul;78(7):405-7 - PubMed
54. Arch Otolaryngol. 1981 Aug;107(8):491-3 - PubMed
55. J Laryngol Otol. 1997 Nov;111(11):1077-8 - PubMed
56. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jun;109(6):820-4 - PubMed
57. Masui. 1998 Aug;47(8):955-62 - PubMed
58. Otolaryngol Head Neck Surg. 2000 Apr;122(4):572-3 - PubMed
59. J Laryngol Otol. 2002 Apr;116(4):299-300 - PubMed
60. Pol J Radiol. 2010 Jan;75(1):88-91 - PubMed
61. Laryngoscope. 1982 Aug;92(8 Pt 1):873-7 - PubMed
62. Anesthesiology. 1949 Nov;10(6):729-32 - PubMed
63. Int J Pediatr Otorhinolaryngol. 2005 Dec;69(12):1615-20 - PubMed
64. Arch Otolaryngol Head Neck Surg. 1986 Jun;112(6):651-3 - PubMed
65. Clin Otolaryngol Allied Sci. 1988 Apr;13(2):139-43 - PubMed
66. AMA Arch Otolaryngol. 1958 Sep;68(3):301-13 - PubMed
67. Clin Otolaryngol. 2005 Aug;30(4):338-46 - PubMed
68. Ann Otol Rhinol Laryngol. 2005 Mar;114(3):233-6 - PubMed
69. Int J Pediatr Otorhinolaryngol. 2009 Nov;73(11):1576-9 - PubMed
70. Laryngoscope. 2010 Oct;120(10):2119-24 - PubMed
71. Int J Pediatr Otorhinolaryngol. 1999 Apr 25;48(1):1-7 - PubMed
72. Laryngoscope. 1986 Nov;96(11):1243-7 - PubMed
73. Dan Med J. 2012 May;59(5):A4422 - PubMed
74. Laryngorhinootologie. 2010 Feb;89(2):100-2 - PubMed
75. Neurology. 1965 Jan;15:7-18 - PubMed
76. Int J Pediatr Otorhinolaryngol. 1997 Feb 14;39(1):67-76 - PubMed
77. Clin Otolaryngol. 2007 Oct;32(5):366-71 - PubMed
78. Int J Pediatr Otorhinolaryngol. 2005 Apr;69(4):497-500 - PubMed
79. Eur Arch Otorhinolaryngol. 2009 Jan;266(1):111-6 - PubMed
80. Pediatrics. 2002 Jul;110(1 Pt 1):7-15 - PubMed
81. Acta Otolaryngol Suppl. 2002;(546):99-109 - PubMed
82. HNO. 1990 Mar;38(3):105-9 - PubMed
83. Eur Arch Otorhinolaryngol. 2010 Feb;267(2):289-93 - PubMed
84. Braz J Otorhinolaryngol. 2010 Nov-Dec;76(6):796 - PubMed
85. Minerva Chir. 2006 Feb;61(1):57-62 - PubMed
86. HNO. 2002 Sep;50(9):836-43 - PubMed
87. Laryngol Rhinol Otol (Stuttg). 1987 Nov;66(11):583-5 - PubMed
88. Ann Otol Rhinol Laryngol. 1996 Nov;105(11):868-70 - PubMed
89. Eur Arch Otorhinolaryngol. 2006 Dec;263(12):1105-8 - PubMed
90. Lancet. 2004 Aug 21-27;364(9435):697-702 - PubMed
91. Acta Otorrinolaringol Esp. 2006 May;57(5):247-50 - PubMed
92. Ear Nose Throat J. 2004 Jan;83(1):28, 30, 32 passim - PubMed
93. Acta Chir Scand. 1974;140(6):453-5 - PubMed
94. HNO. 2005 Jan;53(1):46-57 - PubMed
95. Head Neck Surg. 1985 Jan-Feb;7(3):225-30 - PubMed
96. Otolaryngol Clin North Am. 2009 Apr;42(2):253-60, viii - PubMed
97. Can Anaesth Soc J. 1982 Jul;29(4):391-4 - PubMed
98. HNO. 2000 Feb;48(2):135-41 - PubMed
99. Laryngorhinootologie. 1999 May;78(5):293-4 - PubMed
100. Laryngoscope. 1975 May;85(5):835-40 - PubMed
101. Dtsch Arztebl Int. 2008 Dec;105(49):852-60; quiz 860-1 - PubMed
102. Int J Pediatr Otorhinolaryngol. 1999 Dec 15;51(3):171-6 - PubMed
103. J Maxillofac Surg. 1986 Oct;14(5):281-4 - PubMed
104. Am J Respir Crit Care Med. 2007 Feb 15;175(4):367-416 - PubMed
105. Rev Laryngol Otol Rhinol (Bord). 1954 May-Jun;75(5-6):448-66 - PubMed
106. Acta Otolaryngol. 2007 Jan;127(1):62-4 - PubMed
107. Lasers Surg Med. 2010 Oct;42(8):693-8 - PubMed
108. Ear Nose Throat J. 1998 May;77(5):418-21 - PubMed
109. Otolaryngol Head Neck Surg. 2007 Sep;137(3):378-84 - PubMed
110. Laryngoscope. 2011 Nov;121(11):2322-6 - PubMed
111. Laryngorhinootologie. 2005 May;84 Suppl 1:S101-17 - PubMed
112. Nervenarzt. 2005 Apr;76(4):462-6 - PubMed
113. Acta Otorhinolaryngol Belg. 2001;55(3):207-13 - PubMed
114. Turk Neurosurg. 2011;21(4):680-4 - PubMed
115. Eur Arch Otorhinolaryngol. 1991;248(3):132-4 - PubMed
116. Eur Arch Otorhinolaryngol. 2013 Mar;270(3):1099-104 - PubMed
117. Cochrane Database Syst Rev. 2001;(4):CD002211 - PubMed
118. J Ultrasound Med. 2002 Oct;21(10):1159-63 - PubMed
119. Int J Oral Maxillofac Surg. 1996 Oct;25(5):363-5 - PubMed
120. BMJ. 2004 Sep 18;329(7467):651 - PubMed
121. Rev Bras Anestesiol. 2005 Aug;55(4):441-4 - PubMed
122. J Laryngol Otol. 2004 Mar;118(3):248-9; author reply 249 - PubMed
123. Laryngorhinootologie. 1996 Aug;75(8):447-54 - PubMed
124. J Contemp Dent Pract. 2004 Nov 15;5(4):148-54 - PubMed
125. Ear Nose Throat J. 1979 Jan;58(1):73-6, 81-2 - PubMed
126. Facial Plast Surg. 2006 Nov;22(4):289-97 - PubMed
127. J Am Med Assoc. 1955 Mar 12;157(11):877-81 - PubMed
128. Laryngoscope. 2008 Aug;118(8):1389-94 - PubMed
129. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007810 - PubMed
130. Surgeon. 2005 Aug;3(4):296-8 - PubMed
131. Head Neck. 1996 Jul-Aug;18(4):347-51 - PubMed
132. Laryngol Rhinol Otol (Stuttg). 1981 Jun;60(6):342 - PubMed
133. J Infect. 2009 Feb;58(2):113-8 - PubMed
134. J Laryngol Otol. 1981 Aug;95(8):801-5 - PubMed
135. JAMA. 1985 Jun 28;253(24):3576-81 - PubMed
136. J Coll Physicians Surg Pak. 2010 Dec;20(12):781-4 - PubMed
137. Laryngorhinootologie. 2010 Jul;89(7):424-8 - PubMed
138. HNO. 2008 Mar;56(3):312-20 - PubMed
139. BMJ. 2011 Sep 06;343:d5154 - PubMed
140. J Laryngol Otol. 1986 Feb;100(2):175-7 - PubMed
141. Laryngoscope. 1994 Aug;104(8 Pt 1):981-8 - PubMed
142. Vestn Otorinolaringol. 1978 Nov-Dec;(6):74-5 - PubMed
143. Arch Facial Plast Surg. 2003 Jul-Aug;5(4):316-9 - PubMed
144. Otolaryngol Head Neck Surg. 2004 Dec;131(6):833-6 - PubMed
145. Int J Pediatr Otorhinolaryngol. 1987 Oct;13(3):237-44 - PubMed
146. J Clin Anesth. 1997 May;9(3):236-8 - PubMed
147. Otolaryngol Head Neck Surg. 2000 Mar;122(3):445-9 - PubMed
148. Aust Fam Physician. 2006 Jul;35(7):535-6 - PubMed
149. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004402 - PubMed
150. Auris Nasus Larynx. 2002 Apr;29(2):159-64 - PubMed
151. Rhinology. 1999 Jun;37(2):74-9 - PubMed
152. Otolaryngol Head Neck Surg. 1998 Jan;118(1):61-8 - PubMed
153. J Laryngol Otol. 2006 Feb;120(2):e7 - PubMed
154. Acta Anaesthesiol Scand. 2001 Sep;45(8):1042-4 - PubMed
155. Braz J Otorhinolaryngol. 2005 Jan-Feb;71(1):18-22 - PubMed
156. J Laryngol Otol. 2006 Sep;120(9):800-1 - PubMed
157. Surg Radiol Anat. 2005 Dec;27(5):404-8 - PubMed
158. Arch Otolaryngol Head Neck Surg. 1989 Apr;115(4):519-22 - PubMed
159. J Otolaryngol. 1991 Feb;20(1):33-4 - PubMed
160. Int J Pediatr Otorhinolaryngol. 2005 Oct;69(10):1321-5 - PubMed
161. Otolaryngol Head Neck Surg. 2009 Feb;140(2):191-6 - PubMed
162. Otolaryngol Head Neck Surg. 1996 Jul;115(1):94-7 - PubMed
163. Z Laryngol Rhinol Otol. 1964 May;43:296-300 - PubMed
164. Clin Otolaryngol Allied Sci. 1984 Dec;9(6):347-50 - PubMed
165. Facial Plast Surg. 2006 Nov;22(4):230-9 - PubMed
166. J Forensic Leg Med. 2008 Nov;15(8):516-8 - PubMed
167. Laryngorhinootologie. 2006 Sep;85(9):665-6 - PubMed
168. J Laryngol Otol. 1995 Oct;109(10):1005-9 - PubMed
169. Can J Otolaryngol. 1975;4(1):177-9 - PubMed
170. Z Laryngol Rhinol Otol. 1950 Nov;29(11):546-51 - PubMed
171. Am J Hematol. 1989 Dec;32(4):258-61 - PubMed
172. Ann Otol Rhinol Laryngol. 2012 May;121(5):337-40 - PubMed
173. Laryngorhinootologie. 2008 Dec;87(12):870-3 - PubMed
174. Otolaryngol Head Neck Surg. 1998 May;118(5):732-3 - PubMed
175. Laryngoscope. 2002 Aug;112(8 Pt 2 Suppl 100):35-6 - PubMed
176. Otolaryngol Head Neck Surg. 1996 Jul;115(1):145-9 - PubMed
177. Vasa. 2011 Nov;40(6):491-4 - PubMed
178. J Laryngol Otol. 2003 Apr;117(4):314-7 - PubMed
179. Int J Pediatr Otorhinolaryngol. 2006 May;70(5):941-6 - PubMed
180. Int J Pediatr Otorhinolaryngol. 1994 Nov;30(3):227-32 - PubMed
181. Chirurg. 1999 Jun;70(6):690-3 - PubMed
182. Ear Nose Throat J. 2009 Feb;88(2):790-2 - PubMed
183. Laryngorhinootologie. 2004 Sep;83(9):579-84 - PubMed
184. J Craniofac Surg. 2010 Sep;21(5):1638-9 - PubMed
185. Otolaryngol Head Neck Surg. 2007 Apr;136(4 Suppl):S50-3 - PubMed
186. Ir Med J. 2005 Nov-Dec;98(10):243-4 - PubMed
187. Int J Pediatr Otorhinolaryngol. 2008 Jul;72(7):1029-40 - PubMed
188. HNO. 2006 Jan;54(1):59-69; quiz 70 - PubMed
189. Otolaryngol Head Neck Surg. 1999 May;120(5):678-82 - PubMed
190. Auris Nasus Larynx. 2003 Dec;30(4):391-6 - PubMed
191. Ann Otol Rhinol Laryngol. 1996 Apr;105(4):295-9 - PubMed
192. J Laryngol Otol. 2004 Dec;118(12):937-40 - PubMed
193. J Laryngol Otol. 2008 Jan;122(1):88-92 - PubMed
194. Laryngoscope. 1990 May;100(5):491-3 - PubMed
195. Pain. 1991 Dec;47(3):305-308 - PubMed
196. Otolaryngol Head Neck Surg. 1998 Oct;119(4):361-3 - PubMed
197. Ear Nose Throat J. 2001 Nov;80(11):790, 795-8, 800 passim - PubMed
198. Auris Nasus Larynx. 2005 Dec;32(4):381-6 - PubMed
199. Arch Otolaryngol. 1973 Jul;98(1):38-41 - PubMed
200. N Engl J Med. 1984 Mar 15;310(11):674-83 - PubMed
201. Vestn Otorinolaringol. 1980 Mar-Apr;(2):70-1 - PubMed
202. Otolaryngol Head Neck Surg. 1997 Jun;116(6 Pt 1):680-3 - PubMed
203. Laryngoscope. 2003 Jun;113(6):1047-9 - PubMed
204. Laryngoscope. 2007 Jul;117(7):1272-9 - PubMed
205. Int J Pediatr Otorhinolaryngol. 2001 Apr 6;58(1):69-73 - PubMed
206. JPEN J Parenter Enteral Nutr. 1982 Nov-Dec;6(6):526-7 - PubMed
207. Eur Arch Otorhinolaryngol. 2006 May;263(5):473-6 - PubMed
208. Int J Pediatr Otorhinolaryngol. 2008 May;72(5):565-70 - PubMed
209. J Laryngol Otol. 1991 Oct;105(10):836-8 - PubMed
210. Laryngoscope. 2005 Apr;115(4):591-4 - PubMed
211. Laryngoscope. 2007 Apr;117(4):717-24 - PubMed
212. Otolaryngol Head Neck Surg. 2006 May;134(5):852-5 - PubMed
213. Arch Otolaryngol Head Neck Surg. 2008 Jan;134(1):102-7 - PubMed
214. HNO. 1964 Jul;12:201-5 - PubMed
215. ANZ J Surg. 2010 Sep;80(9):668-9 - PubMed
216. J Laryngol Otol. 1993 Nov;107(11):1011-3 - PubMed
217. J Laryngol Otol. 1997 Oct;111(10):950-2 - PubMed
218. Ear Nose Throat J. 2004 Aug;83(8):553-5 - PubMed
219. Ear Nose Throat J. 1998 Oct;77(10):827, 830-1 - PubMed
220. Laryngoscope. 1976 Jul;86(7):992-5 - PubMed
221. Monatsschr Ohrenheilkd Laryngorhinol. 1950 Jul-Sep;84(7-9):208-10 - PubMed
222. Otolaryngol Head Neck Surg. 2006 Jul;135(1):1-7 - PubMed
223. J Laryngol Otol. 2010 Jan;124(1):59-66 - PubMed
224. Otolaryngol Head Neck Surg. 2008 Jan;138(1 Suppl):S1-8 - PubMed
225. HNO. 2001 Sep;49(9):706-12 - PubMed
226. Laryngorhinootologie. 2011 Aug;90(8):489-90 - PubMed
227. Arch Otolaryngol Head Neck Surg. 2001 Oct;127(10):1271-5 - PubMed
228. Z Laryngol Rhinol Otol. 1969 Feb;48(2):85-98 - PubMed
229. J Laryngol Otol. 2003 Mar;117(3):186-9 - PubMed
230. Otolaryngol Head Neck Surg. 2008 Mar;138(3):315-20 - PubMed
231. Arch Otolaryngol Head Neck Surg. 1987 Sep;113(9):992-4 - PubMed
232. Clin Otolaryngol Allied Sci. 1992 Jun;17(3):208-10 - PubMed
233. J Laryngol Otol. 2003 Aug;117(8):619-23 - PubMed
234. Laryngorhinootologie. 2012 Jan;91(1):16-21 - PubMed
235. Laryngorhinootologie. 2003 Nov;82(11):754-5 - PubMed
236. Laryngoscope. 2002 Aug;112(8 Pt 1):1445-9 - PubMed
237. Orv Hetil. 1990 Jul 8;131(27):1465-7 - PubMed
238. Arq Bras Oftalmol. 2006 Mar-Apr;69(2):249-50 - PubMed
239. Eur J Cardiothorac Surg. 1999 Aug;16(2):200-5 - PubMed
240. Laryngoscope. 1998 Sep;108(9):1325-8 - PubMed
241. Anesth Analg. 2003 Jan;96(1):68-77, table of contents - PubMed
242. Br J Oral Maxillofac Surg. 1993 Aug;31(4):236-8 - PubMed
243. HNO. 2012 Jun;60(6):511-7 - PubMed
244. Eur Arch Otorhinolaryngol. 2006 Jun;263(6):556-9 - PubMed
245. Laryngorhinootologie. 2007 Oct;86(10):706-13 - PubMed
246. J Laryngol Otol. 1991 Dec;105(12):1052-6 - PubMed
247. Int J Pediatr Otorhinolaryngol. 2005 Apr;69(4):463-9 - PubMed
248. HNO. 1984 Dec;32(12):521-2 - PubMed
249. Lamp. 1977 Aug;34(8):23 - PubMed
250. Am J Epidemiol. 1978 Jan;107(1):65-70 - PubMed
251. Laryngorhinootologie. 2003 Nov;82(11):799-804 - PubMed
252. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jan;109(1):e11-4 - PubMed
253. J Laryngol Otol. 1995 Dec;109(12):1166-7 - PubMed
254. Ann Otol Rhinol Laryngol. 2008 Jul;117(7):528-30 - PubMed
255. Eur Arch Otorhinolaryngol. 2006 Nov;263(11):1041-3 - PubMed
256. Otolaryngol Head Neck Surg. 1981 Sep-Oct;89(5):758-62 - PubMed
257. Eur Arch Otorhinolaryngol. 2008 Jan;265(1):115-7 - PubMed
258. Otolaryngol Head Neck Surg. 1997 Dec;117(6):641-7 - PubMed
259. Int J Pediatr Otorhinolaryngol. 1987 Jun;13(1):69-75 - PubMed
260. Ann Plast Surg. 2004 Nov;53(5):492-5 - PubMed
261. Int J Pediatr Otorhinolaryngol. 2005 Nov;69(11):1579-82 - PubMed
262. Laryngoscope. 1977 Jul;87(7):1134-6 - PubMed
263. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591 - PubMed
264. Ann Laringol Otol Rinol Faringol. 1966 Sep-Oct;65(5):650-3 - PubMed
265. Eur Arch Otorhinolaryngol. 2009 Jul;266(7):1011-5 - PubMed
266. Int J Pediatr Otorhinolaryngol. 2006 May;70(5):853-61 - PubMed
267. HNO. 2007 Sep;55(9):684-9 - PubMed
268. Monatsschr Ohrenheilkd Laryngorhinol. 1956 Dec;90(6):348-53 - PubMed
269. Int J Pediatr Otorhinolaryngol. 2005 Aug;69(8):1135-9 - PubMed
270. Pediatrics. 1992 Apr;89(4 Pt 2):691-5 - PubMed
271. BMJ. 2007 May 5;334(7600):939 - PubMed
272. Laryngoscope. 2011 Dec;121(12):2553-60 - PubMed
273. Eur Arch Otorhinolaryngol. 2011 Dec;268(12):1803-7 - PubMed
274. Otolaryngol Head Neck Surg. 1999 Sep;121(3):303-4 - PubMed
275. Ann Otolaryngol. 1951;68(8-9):722-6 - PubMed
276. Braz J Otorhinolaryngol. 2005 Jan-Feb;71(1):94-6 - PubMed
277. Head Neck. 1995 Jan-Feb;17(1):69-72 - PubMed
278. J Laryngol Otol Suppl. 1996;20:1-25 - PubMed
279. Eur Arch Otorhinolaryngol. 2012 Feb;269(2):667-71 - PubMed
280. Hum Pathol. 2003 Oct;34(10):1053-7 - PubMed
281. J Laryngol Otol. 1973 Dec;87(12):1171-82 - PubMed
282. Plast Reconstr Surg. 1999 Dec;104(7):2202-9; discussion 2210-2 - PubMed
283. Otolaryngol Head Neck Surg. 2000 Jan;122(1):31-8 - PubMed
284. Plast Reconstr Surg. 1970 Apr;45(4):352-5 - PubMed
285. HNO. 1953 Aug 31;4(1):15-8 - PubMed
286. J Coll Physicians Surg Pak. 2003 Oct;13(10):565-8 - PubMed
287. Laryngorhinootologie. 1997 Nov;76(11):663-6 - PubMed
288. Acta Otolaryngol. 1975 May-Jun;79(5-6):451-9 - PubMed
289. Acta Otorhinolaryngol Ital. 2005 Aug;25(4):245-9 - PubMed
290. Laryngorhinootologie. 2005 Sep;84(9):680-2 - PubMed
291. Anesthesiology. 1992 May;76(5):869 - PubMed
292. HNO. 2002 May;50(5):470-8 - PubMed
293. Laryngol Rhinol Otol (Stuttg). 1979 May;58(5):463-5 - PubMed
294. Laryngoscope. 2004 Dec;114(12):2196-9 - PubMed
295. Laryngoscope. 1976 Jun;86(6):804-13 - PubMed
296. Can Med Assoc J. 1924 Aug;14(8):745 - PubMed
297. Otolaryngol Clin North Am. 1987 May;20(2):383-90 - PubMed
298. Clin Otolaryngol Allied Sci. 2002 Feb;27(1):57-60 - PubMed
299. Am J Otolaryngol. 2007 May-Jun;28(3):191-3 - PubMed
300. Anaesthesist. 1993 May;42(5):320-3 - PubMed
301. Laryngorhinootologie. 2005 Sep;84(9):651-2 - PubMed
302. J Laryngol Otol. 1995 May;109(5):440-1 - PubMed
303. Schweiz Med Wochenschr. 1991 Nov 2;121(44):1612-7 - PubMed
304. Rhinology. 2003 Mar;41(1):2-6 - PubMed
305. Laryngoscope. 2007 Apr;117(4):654-61 - PubMed
306. Laryngol Rhinol Otol (Stuttg). 1980 Jul;59(7):433-7 - PubMed
307. Mund Kiefer Gesichtschir. 2001 May;5(3):193-7 - PubMed
308. Arch Otolaryngol. 1968 Sep;88(3):307-10 - PubMed
309. Am J Otolaryngol. 2004 Sep-Oct;25(5):354-6 - PubMed
310. Laryngorhinootologie. 2004 Aug;83(8):501-6 - PubMed
311. Trans Pac Coast Otoophthalmol Soc Annu Meet. 1976;57:201-5 - PubMed
312. Swiss Med Wkly. 2007 Aug 11;137(31-32):454-61 - PubMed
313. Otolaryngol Head Neck Surg. 1994 Dec;111(6):733-8 - PubMed
314. B-ENT. 2010;6(2):91-5 - PubMed
315. Laryngorhinootologie. 1995 May;74(5):282-5 - PubMed
316. Curr Opin Otolaryngol Head Neck Surg. 2006 Dec;14(6):375-80 - PubMed
317. East Mediterr Health J. 2008 Jan-Feb;14(1):228-30 - PubMed
318. ORL J Otorhinolaryngol Relat Spec. 2013;75(3):166-73 - PubMed
319. Trans Am Acad Ophthalmol Otolaryngol. 1970 Nov-Dec;74(6):1146-54 - PubMed
320. HNO. 2003 Dec;51(12):986-92 - PubMed
321. Dan Med J. 2012 Feb;59(2):A4382 - PubMed
322. Acta Anaesthesiol Taiwan. 2009 Sep;47(3):134-7 - PubMed
323. ORL J Otorhinolaryngol Relat Spec. 2009;71(5):273-8 - PubMed
324. Anaesthesia. 1994 Feb;49(2):151-4 - PubMed
325. HNO. 2001 Jun;49(6):465-70 - PubMed
326. Ann Laringol Otol Rinol Faringol. 1961 Sep-Oct;60:652-63 - PubMed
327. Laryngoscope. 2002 Jan;112(1):94-8 - PubMed
328. Laryngoscope. 1980 Mar;90(3):522-5 - PubMed
329. Am J Otolaryngol. 1985 Jul-Aug;6(4):264-7 - PubMed
330. Laryngorhinootologie. 1989 May;68(5):301-3 - PubMed
331. Laryngoscope. 1995 Aug;105(8 Pt 3 Suppl 74):1-17 - PubMed
332. Laryngorhinootologie. 2005 Sep;84(9):665-70 - PubMed
333. HNO. 1987 May;35(5):195-8 - PubMed
334. HNO. 1953 Dec 31;4(3):90 - PubMed
335. Zh Ushn Nos Gorl Bolezn. 1973 Jul-Aug;33(4):103 - PubMed
336. Eur Arch Otorhinolaryngol. 2011 Jun;268(6):807-16 - PubMed
337. Arch Otolaryngol Head Neck Surg. 1993 Mar;119(3):292-3 - PubMed
338. Ear Nose Throat J. 2005 Oct;84(10):660-1 - PubMed
339. Eur Arch Otorhinolaryngol. 2012 Dec;269(12):2581-4 - PubMed
340. J Otolaryngol. 2002 Feb;31(1):18-22 - PubMed
341. Laryngoscope. 1953 Dec;63(12):1197-8 - PubMed
342. Int J Gen Med. 2012;5:643-5 - PubMed
343. Clin Otolaryngol. 2011 Dec;36(6):531-42 - PubMed
344. Laryngorhinootologie. 2010 Jun;89(6):373-84 - PubMed
345. AMA Arch Otolaryngol. 1950 Oct;52(4):642-5 - PubMed
346. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004619 - PubMed
347. Laryngoscope. 2004 Apr;114(4):627-38 - PubMed
348. Rhinology. 2007 Sep;45(3):220-3 - PubMed
349. Arch Otolaryngol Head Neck Surg. 2009 Dec;135(12):1256-60 - PubMed
350. Clin Otolaryngol Allied Sci. 2004 Aug;29(4):362-8 - PubMed
351. Laryngoscope. 2004 Jul;114(7):1206-13 - PubMed
352. Int J Pediatr Otorhinolaryngol. 2001 Dec 1;61(3):217-22 - PubMed
353. Acta Otolaryngol Suppl. 1988;454:265-72 - PubMed
354. Facial Plast Surg. 2006 Nov;22(4):249-54 - PubMed
355. West J Med. 1988 Oct;149(4):457-60 - PubMed
356. Eur Arch Otorhinolaryngol. 2010 Sep;267(9):1403-7 - PubMed
357. Laryngorhinootologie. 2008 Jul;87(7):490-7 - PubMed
358. Int J Pediatr Otorhinolaryngol. 2001 Jun 7;59(2):125-8 - PubMed
359. Versicherungsmedizin. 2004 Sep 1;56(3):148-50 - PubMed
360. Arch Otolaryngol. 1968 Apr;87(4):436-8 - PubMed
361. Acta Otorhinolaryngol Belg. 2001;55(4):285-9 - PubMed
362. Br J Gen Pract. 1998 Jun;48(431):1331-5 - PubMed
363. Arch Otolaryngol Head Neck Surg. 1998 Feb;124(2):163-7 - PubMed
364. Can J Anaesth. 2008 Jun;55(6):376-9 - PubMed
365. Can Med Assoc J. 1933 Nov;29(5):475-9 - PubMed
366. Rhinology. 1977 Dec;15(4):193-204 - PubMed
367. Laryngorhinootologie. 2004 Jul;83(7):466-9 - PubMed
368. Auris Nasus Larynx. 2003 Feb;30 Suppl:S135-6 - PubMed
369. Br J Oral Maxillofac Surg. 2002 Apr;40(2):138-9 - PubMed
370. Int J Pediatr Otorhinolaryngol. 1998 Oct 15;45(3):243-7 - PubMed
371. Clin Otolaryngol Allied Sci. 1994 Aug;19(4):352-4 - PubMed
372. Arch Otolaryngol Head Neck Surg. 2002 Jul;128(7):751-8 - PubMed
373. Anesth Analg. 1997 Jun;84(6):1232-8 - PubMed
374. Pract Otorhinolaryngol (Basel). 1955;17(4):260-2 - PubMed
375. Laryngorhinootologie. 2007 Apr;86 Suppl 1:S1-14 - PubMed
376. Arch Otolaryngol Head Neck Surg. 1997 Mar;123(3):345-7 - PubMed
377. Ann Otol Rhinol Laryngol. 2006 May;115(5):365-9 - PubMed
378. B-ENT. 2006;2(3):109-16 - PubMed
379. Laryngoscope. 1990 Jun;100(6):593-6 - PubMed
380. Am J Ophthalmol. 1994 Jun 15;117(6):812-3 - PubMed
381. Clin Otolaryngol. 2006 Apr;31(2):95-102 - PubMed
382. ANZ J Surg. 2007 Nov;77(11):988-90 - PubMed
383. Arch Facial Plast Surg. 2005 Jul-Aug;7(4):218-26 - PubMed
384. Int J Pediatr Otorhinolaryngol. 2010 Sep;74(9):977-9 - PubMed
385. JAMA. 1986 Aug 8;256(6):750-3 - PubMed
386. Surg Radiol Anat. 2012 May;34(4):373-5 - PubMed
387. Dis Chest. 1953 Apr;23(4):397-402 - PubMed
388. HNO. 2005 May;53(5):423-7 - PubMed
389. HNO. 1972 May;20(5):152-3 - PubMed
390. J Otolaryngol. 2004 Dec;33(6):403-4 - PubMed
391. J Anat. 1924 Oct;59(Pt 1):87-96 - PubMed
392. HNO. 2002 Mar;50(3):230-2 - PubMed
393. Plast Reconstr Surg. 1999 Sep;104(4):1131-9; discussion 1140-2 - PubMed
394. Am J Surg. 2000 Sep;180(3):241-3 - PubMed
395. Arch Otolaryngol. 1968 Nov;88(5):551-5 - PubMed
396. J Pediatr Surg. 2007 Nov;42(11):1961-8 - PubMed
397. Arch Otolaryngol Head Neck Surg. 2011 Jun;137(6):558-70 - PubMed
398. Acta Otolaryngol. 2001 Oct;121(7):854-8 - PubMed
399. Laryngorhinootologie. 1999 Jul;78(7):408-9 - PubMed
400. Paediatr Anaesth. 2001 Jul;11(4):491-3 - PubMed
401. Cochrane Database Syst Rev. 2000;(2):CD001874 - PubMed
402. Ear Nose Throat J. 1997 Aug;76(8):575-6 - PubMed
403. Ann Otol Rhinol Laryngol. 1962 Mar;71:158-69 - PubMed
404. Dtsch Arztebl Int. 2010 Sep;107(36):622-8 - PubMed
405. Otolaryngol Head Neck Surg. 2010 Aug;143(2):239-41 - PubMed
406. HNO. 2005 Apr;53(4):383-92; quiz 393 - PubMed
407. HNO. 2003 Aug;51(8):634-9 - PubMed
408. Rev Stomatol Chir Maxillofac. 1976 Sep;77(6):861-4 - PubMed
409. Laryngorhinootologie. 1996 Jan;75(1):59-62 - PubMed
410. Ann Otol Rhinol Laryngol. 1990 Mar;99(3 Pt 1):187-91 - PubMed
411. Otolaryngol Pol. 2011 Mar-Apr;65(2):128-31 - PubMed
412. Eur Arch Otorhinolaryngol. 2008 Dec;265(12):1527-34 - PubMed
413. Eur J Cancer Care (Engl). 2010 Jul;19(4):510-5 - PubMed
414. Int J Pediatr Otorhinolaryngol. 2001 Feb;57(2):161-4 - PubMed
415. Arch Otolaryngol Head Neck Surg. 2008 Jun;134(6):673 - PubMed
416. Ann Otol Rhinol Laryngol. 2002 Nov;111(11):983-8 - PubMed
417. J Laryngol Otol. 2012 May;126(5):529-31 - PubMed
418. J Nippon Med Sch. 2004 Apr;71(2):111-3 - PubMed
419. Laryngoscope. 2012 Jan;122(1):71-4 - PubMed
420. Rhinology. 2003 Jun;41(2):76-9 - PubMed
421. J Laryngol Otol. 2001 Mar;115(3):238-9 - PubMed
422. Acta Otolaryngol. 2011 Jan;131(1):67-71 - PubMed
423. J Laryngol Otol. 1992 Nov;106(11):989-91 - PubMed
424. Otolaryngol Head Neck Surg. 2003 Feb;128(2):298-300 - PubMed
425. Lancet. 1959 Mar 28;1(7074):671-2 - PubMed
426. J Laryngol Otol. 1996 Mar;110(3):281-3 - PubMed
427. Arch Otolaryngol Head Neck Surg. 2004 Nov;130(11):1324-7 - PubMed
428. ORL J Otorhinolaryngol Relat Spec. 1998 Jul-Aug;60(4):230-2 - PubMed
429. Laryngorhinootologie. 1992 Sep;71(9):487-8 - PubMed
430. Zentralbl Chir. 1986;111(21):1312-20 - PubMed
431. Otolaryngol Head Neck Surg. 2012 Jun;146(6):871-9 - PubMed
432. J Laryngol Otol. 1981 Aug;95(8):805-7 - PubMed
433. Otolaryngol Head Neck Surg. 2004 Mar;130(3):283-90 - PubMed
434. HNO. 2004 Mar;52(3):251-4 - PubMed
435. J Laryngol Otol. 2005 Nov;119(11):906-8 - PubMed
436. Laryngorhinootologie. 1998 Sep;77(9):517-20 - PubMed
437. Arch Otolaryngol Head Neck Surg. 1992 Nov;118(11):1229-31 - PubMed
438. Kulak Burun Bogaz Ihtis Derg. 2011 Mar-Apr;21(2):98-101 - PubMed
439. Laryngorhinootologie. 2012 Feb;91(2):98-102 - PubMed
440. Otolaryngol Head Neck Surg. 2000 Mar;122(3):434-9 - PubMed

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