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Abstract

Importance

A gap in knowledge exists concerning the functional outcomes and complications when comparing various surgical approaches for retropharyngeal lymph node (RPLN) metastases.

Objective

To explore perioperative outcomes, functional outcomes, and complications associated in the treatment of RPLN metastases

Design

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the PubMed and Scopus databases

Review Methods

We systematically searched 2 databases from inception to January 2023 for articles examining the treatment approaches and postoperative outcomes in the retropharyngeal space. We included English records about surgical approaches, complications, functional outcomes for patients >18 years old with retropharyngeal lymphadenopathy.

Results

One-hundred ninety-nine articles were identified, of which 17 were included in the analysis. Three studies assessed RPLN dissection in the postradiation setting. We identified limited knowledge about functional outcomes and complications following surgery for retropharyngeal lymphadenopathy. Overall, acute postoperative dysphagia was documented in 35/170 patients (20.5%). However, the assessment of dysphagia was limited, and not described in the majority of studies. The overall rate of postoperative neuropathy and hematoma were 4.1% and 4.7%, respectively. No postoperative hematomas were documented in the transcervical approach.

Conclusion

Our findings underscore the need for further research on postoperative outcomes following RPLN dissection. We recommend further studies focusing on objective swallow assessments and long-term outcomes of either surgical approaches.

Graphical abstract

Keywords

retropharyngeal lymphadenopathy retropharyngeal space TORS surgical approaches scoping review

Key Message

• A gap in knowledge exists concerning the functional outcomes and complications when comparing various surgical approaches for retropharyngeal lymphadenopathy.

• Postoperative dysphagia was observed in 20.5% of patients in the collective studies. Nonetheless, there is a paucity of objective swallowing assessment, and standardized surgical outcomes from both transoral or transcervical approaches.

• Further research on postoperative outcomes after retropharyngeal lymph node dissection is required. Emphasis should be placed on conducting studies that concentrate on objective swallow assessments and assess the long-term outcomes associated for the different surgical approaches.

Introduction

Retropharyngeal lymph node (RPLN) metastases are encountered in a variety of head and neck malignancies. This includes nasopharyngeal, oropharyngeal, hypopharyngeal, and occasionally thyroid cancers. In oropharyngeal cancers, RPLN occurs in 13% to 36% of patients, typically from tumors involving the soft palate, tonsil, and lateral pharyngeal wall.^1-8 Increasingly, studies have found an association between RPLN metastases presence and adverse prognosis.^7,9-13 Beyond squamous cell carcinomas, RPLN also presents in papillary thyroid cancers with extensive lymphadenopathy, although the overall incidence remains rare.^14,15

As there remains an important role for surgery in the treatment of oropharynx, nasopharynx, and papillary thyroid cancers, knowledge and understanding of the anatomy, surgical approaches, and anticipated perioperative outcomes is essential for the head and neck surgeon. Anatomically, the boundaries of the retropharyngeal space are the carotid sheath laterally, skull base superiorly, prevertebral fascia posteriorly, and pharynx anteriorly. This space can be divided into 2 nodal basins. The superior group lies laterally, adjacent to the carotid sheath and sympathetic chain, extending from immediately below the skull base, while the medial group lies more inferiorly.¹⁶

While this space remains an anatomic challenging space to access, it is critical for head and neck surgeons to be well versed in the different approaches to access this space. Transcervical approaches to this space, as well as transoral robotic surgery (TORS) has been described; however, a comparison between the 2 approaches, their perioperative outcomes, morbidity, and complications have not been fully described. We conducted a scoping review to identify and map available and emerging evidence in this area.

Methods

The study was performed according to the Arksey and O’Malley framework for scoping reviews, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guidelines.¹⁷ Institutional review board approval and informed consent were not required for this review of previously published studies. No review protocol was registered for this study.

Stage 1: Identify the Question

This scoping review was guided by the question: (1) “What are the perioperative outcomes, functional outcomes, and complications associated with various surgical approaches to the retropharyngeal space?”

Stage 2: Identify Relevant Studies

The initial search was implemented on June 21, 2021, in MEDLINE/PubMed (biomedical sciences, 1946-present) and Google Scholar databases. Relevant keywords, phrases, and MeSH terms were adjusted to fit the specific requirements for each of the individual databases. An example of a search strategy for PubMed/MEDLINE includes: “retropharyngeal” and “lymphadenopathy” and “perioperative” and “outcomes.” The search was last updated in January 2023.

Stage 3: Study Selection

Inclusion criteria included reports of adult patients >18 years of age who underwent a transoral or transcervical surgical approach to the retropharyngeal space, with a diagnosis of a head and neck cancer. Exclusion criteria were as follows: non-English language; insufficient reported data; article type was conference abstract, letter to the editor, or book chapter. We further excluded studies that did not present operative outcomes to the retropharyngeal approach and studies that evaluated outcomes for patients who underwent a combined tonsillectomy retropharyngeal lymph node dissection (RPLND) in oropharyngeal squamous cell carcinoma (OPSCC).

Stage 4: Data Charting Process

Literature searches were conducted independently by 2 investigators (C.M.K.L.Y. and S.T.). All articles were initially screened by title and abstract. Studies that met the inclusion criteria were downloaded and the full texts manually assessed for their eligibility based on our aforementioned criteria. Discrepancies between screening authors were resolved with a third reviewer.

Data were independently extracted by 2 reviewers (C.M.K.L.Y. and S.T.) for the following variables: first author, year of publication, study design, number of patients, histology, type of surgical approach, concurrent procedures, history of prior radiation, functional, and surgical outcomes.

Stage 5: Collating, Summarizing, and Reporting the Results

We grouped the studies by the surgical technique that was described, and summarized the study designs, sample size, histology, and surgical outcomes following the PRISMA-ScR reporting guidelines (Supplemental Appendix A). Surgical outcomes were then summarized and presented for each surgical technique.

Results

An Overview of All Studies and Patient Characteristics

The search strategy identified 204 articles. After deduplication, 199 records remained. We discarded all but 31 records that were further assessed for eligibility (Figure 1). Nine studies were further excluded after full-text assessment due to lack of perioperative outcome data, 3 were excluded due to combined oropharyngectomy and RPLND. A total of 17 studies were included for final analysis (Table 1).

Figure 1.

PRISMA-ScR flow chart. PRISMA-ScR, Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

Table 1.

Characteristics of Studies.

Author	Study design	Sample size	Histology	Approach (number of cases)
Togashi et al¹⁸	Cross-sectional study	12	Papillary thyroid carcinoma	Trans-cervical (11), transcervical-transparotid (1)
Chen et al¹⁹	Cross-sectional study	6	Papillary thyroid carcinoma	Transcervical
Otsuki et al²⁰	Cross-sectional study	16	Papillary thyroid carcinoma	Transcervical
Giordano et al²¹	Case report	2	Papillary thyroid carcinoma	Transcervical (minimally-invasive video-assisted technique)
Ning et al²²	Case report	1	Papillary thyroid carcinoma	Transcervical
Harries et al²³	Cross-sectional study	27	Differentiated thyroid carcinoma	Transcervical (19), transoral (8)
Le and Cohen²⁴	Cross-sectional study	6	Differentiated thyroid carcinoma	Transoral
Shellenberger et al²⁵	Case- series study	3	Papillary thyroid carcinoma and medullary thyroid carcinoma	Transoral
Fujiwara et al²⁶	Case report	1	Papillary thyroid carcinoma	Transoral (ultrasound-guided videolaryngoscopy)
Tanaka et al²⁷	Case report	1	Oral cavity SCC	Transoral videolaryngoscopy
Kholmatov et al²⁸	Case report	1	Papillary thyroid carcinoma	Transoral
Givi et al¹⁸	Case-control study	12	Oropharynx (9) Thyroid (3)	TORS Outcome comparison to pharyngectomy alone (2:1)
Troob et al²⁹	Case-control study	30	Oropharynx (30)	TORS Outcome comparison to pharyngectomy alone (37 pt.)
Goepfert et al³⁰	Case report	1	Papillary thyroid carcinoma	TORS
Liu et al³²	Cross-sectional study	31	Nasopharyngeal carcinoma	Salvage transcervical
Ding et al³³	Case- series study	10	Nasopharyngeal carcinoma	Salvage TORS
Dabas et al³¹	Case- series study	10	6 Oropharynx 1 Unknown primary	Salvage TORS

Abbreviations: SCC, squamous cell carcinoma; TORS, transoral robotic surgery.

Transcervical Approaches to the Retropharynx

A total of 5 studies reported solely on the transcervical approach to the RPLN.^18-22 Another study by Harries et al²³ presented all 3 approaches to the RPLN with the majority of patients undergoing a transcervical approach.

Dysphagia following transcervical approaches

There were 6 case studies that described the postoperative course for 56 patients who underwent a transcervical approach to a RPLND. Overall, 43% (24) of patients were documented as having some degree of dysphagia postoperatively, though only one study documented how dysphagia was measured. In the study by Otsuki et al,²⁰ 16 consecutive patients who underwent RPLND underwent postoperative video-laryngoscopic swallow assessment under speech therapist guidance. Dysphagia was documented in 11/16 patients, with 8 patients recovering after 3 weeks, and the other 3 patients within 2 months. Within the same study, oral intake was initiated between postoperative day (POD) 1 and 40, with a median of 7.5 days, with 11 patients requiring a nasogastric tube. All patients were found to recover within this study.

Cranial neuropathy following transcervical approaches

Cranial neurorapthies were rare (3/56). There was a single patient who was reported to have a vagal nerve injury that recovered within 1 year after surgery. Two patients were described as having a hypoglossal nerve injury that recovered after 3 months after surgery.

Complications, hematoma, infection, length of stay

There were no reports of hematomas, or postoperative infections. The use of perioperative antibiotics was not described. In the study by Giordano et al,²¹ 2 patients were described with 1 patient who underwent an isolated RPLND requiring a drain and a hospital stay of 5 days, whereas in a second patient who underwent concomitant neck dissection, 2 drains were placed, and they home on POD 4.

Pathology yield

The number of retropharyngeal nodes removed were documented. Four studies^18,20-23 reported the laterality of RPLND. Bilateral dissection was not performed in any patient, including in the setting of bilateral disease.²³ Retropharyngeal nodal sizes were presented in 4 studies; Togashi et al¹⁸ reported a median size of 23 mm (range 12-37), Chen et al¹⁹ reported a nodal range of 13 to 28 mm, Otsuki et al²⁰ reported a nodal range of 7 to 40 mm, and Harries et al²³ reported a median size of 2.0 (0.8-4.2) cm. Retropharyngeal nodal sizes in most studies were based on preoperative imaging, with only the study by Togashi et al¹⁸ reporting pathological nodal size.

Transoral Approaches to the Retropharynx

A total of 8^16,24-30 studies evaluated patients who underwent a transoral approach to the retropharynx. Of these, 3^16,29,30 studies described the utility of a robotic system. The study by Givi et al¹⁶ and Troob et al²⁹ were both from the same center with overlapping years, comparing patients who underwent combined TORS RPLND to patients who underwent TORS pharyngectomy alone. Outcomes were combined for both studies.

Dysphagia following transoral approaches

Swallowing assessments were not routinely reported following transoral approaches to the retropharyngeal space. Resumption of oral diet ranged from POD 1 to 37. In a case report by Tanaka et al,²⁷ videofluorography at POD 1 was normal and the patient started oral diet 24 hours after surgery. Similarly, in a single case by Fujiwara et al,²⁶ there was a normal videofluoroscopic swallowing study, and a functional outcome swallowing scale of grade 0. However, the exact timing of those assessments was not documented. Shellenberger et al²⁵ mentioned that 3/3 patients resumed oral diet within 24 hours following surgery. Both studies of Givi et al¹⁶ and Troob et al²⁹ utilized duration of nasogastric feeding tube as a surrogate for swallowing. In the study by Givi et al,¹⁶ a nasogastric feeding tube was required for a median of 3 days (range 1-46 days) in patients undergoing combined TORS RPLND compared with 14 days (range 2-37 days) for patients who underwent TORS pharyngectomy alone, although the difference was not statistically different. Similarly, the study by Troob et al²⁹ had no differences in median length of feeding tube placement between the RPLND group and TORS pharyngectomy alone (12 vs 9 days, respectively, P = .89) or body mass index change after surgery (P = .27). A case report by Goepfert et al³⁰ mention a mild postoperative dysphagia with related 10 lb weight loss that resolved after 2 months.

Cranial neuropathy following transoral approaches

Cranial neuropathies were reported in 4 of 73 patients (total number of transoral patients). Two patients developed Horner syndrome in the Givi et al’s¹⁶ study, with one requiring 3 months to recover. Troob et al²⁹ presented one patient with tongue dysesthesia and one patient with hypoglossal weakness.

Complications, hematoma, infection, length of stay

A total of 7 of 73 patients developed immediate postoperative retropharyngeal hematoma; 6 cases in the study by Troob et al and a single case by Le and Cohen.²⁴ Of them, 5 patients needed surgical intervention. Givi et al¹⁶ and Troob et al²⁹ also reported 5 cases of postoperative aspiration pneumonitis/pneumonia. Length of stay ranged from 1 to 11. Shellenberger et al²⁵ discharged 2 patients on POD 1 and 1 patient on POD 4, Le and Cohen²⁴ administered preoperative antibiotics to all patients and they were discharged at the same day or POD 1. Goepfert et al³⁰ discharged their patient at POD 1. Troob et al²⁹ found no differences in median length of stay between the RPLND group and TORS pharyngectomy alone [4 (range 2-11) vs 4 days (range 3-17), respectively, P = .58]. There were no reports of return to the emergency department or hospital within 30 days.

Pathology yield

The studies by Givi et al¹⁶ and Troob et al²⁹ described a median of 1 resected RPLN (range 1-9). They did not report nodal sizes. The study by Goepfert et al reported a single node measuring 2.6 cm on magnetic resonance imaging. None of the other studies described the number of RP nodes dissected or median lymph node size.

Postradiation Salvage RPLND

Three studies reported on 51 patients undergoing RPLND in the postradiation setting.^31-33 A study by Liu et al³² presented their experience with salvage endoscopic-assisted transcervical approach to RPLND in patients with recurrent nasopharyngeal carcinoma. Ding et al³³ and Dabas et al³¹ described TORS approach in a total of 20 patients; of which, 3 cases were converted to transcervical approach. Ding et al³³ additionally advocated for the use of intraoperative ultrasound to assist with localizing of retropharyngeal lymphadenopathy.

Dysphagia following postradiation salvage RPLND

A total of 51 patients underwent salvage surgery for RPLN recurrences. Swallowing assessment varied between studies and could not be compiled. Following salvage endoscopic-assisted transcervical retropharyngeal neck dissection, dysphagia was captured and reported in 6/31(19.4%) cases, with 3 (9.7%) requiring permanent feeding tube usage. Ding et al³³ used the Common Terminology Criteria for Adverse Events version 5.0 to document postoperative dysphagia following TORS salvage retropharyngeal lymphadenopathy. They found that 4/10 (40%) of patients had dysphagia; 3 of them had grade 1 and a single patient had grade 3 (severe dysphagia, requiring enteral feeding). Of note, Dabas et al³¹ used the FOIS scoring system to assess the pre- and postoperative swallowing, and noted that at 1 month from surgery, all patients reached total oral intake.

Cranial neuropathy following salvage approaches

No direct nerve damage was reported in the salvage approach studies. However, postoperative tongue atrophy and shoulder problems were noted in 3/31 (9.7%) of salvage transcervical endoscopic-assisted approaches. In the TORS salvage approach to the retropharynx, one case was reported to have postoperative tongue atrophy, of which recovery was not reported.³³

Complications, hematoma, infection, length of stay

A total of 6/51 salvage patients (11.7%) were reported to have pharyngeal fistula. Two of them occurred following an endoscopic assisted transcervical approach, while the other 4 occurred following a TORS approach (with 2 requiring a conversion to an open approach). Velopharyngeal incompetence was reported by Dabas et al, and occurred in 4/10 patients. Postoperative hematoma was documented in 1/31 patients that was operated in the transcervical approach. No postoperative infections were documented. Liu et al³² reported a median postoperative hospitalization duration of 8.7 days (range 3-21 days) and Dabas et al³¹reported an average hospital stay of 1.8 days. Operative time was reported by Liu et al for their TORS approaches, ranging from 140 to 520 minutes.

Pathology yield

Only Dabas et al³¹ presented the number of lymph node yield; 9 patients had a single positive node, and 1 patient had 2 positive nodes. Liu et al³² and Ding et al³³ presented the mean preoperative imaging nodal size of 12.2 mm × 10.4 mm and 10.8 mm, respectively.

Discussion

Retropharyngeal metastasis poses not only a surgical challenge, but a treatment selection challenge to the head and neck oncology team. When considering surgical treatments, the ideal surgical approach for a specific patient, this is often influenced by the surgical approach of the primary tumor, nodal characteristics, patient anatomy, and prior treatment. The aim of our scoping review was to identify and compare the outcomes for patients who require RPLND. We identified 17 studies related to the surgical approaches and summarizes the perioperative outcomes, complication rates, and functional outcomes of these patients.

In general, the transcervical approach may be favored when wide exposure, and identification of the critical neural structures, is paramount. This is particularly important in the presence of extranodal extension, where separating planes between the lymph node and internal carotid is critical. Exposure can be further improved for superiorly based retropharyngeal nodes with the assistance of an endoscope, whereby as evidenced by Liu et al,³² even small lymph nodes measuring around 1 cm can be dissected. Transoral approaches provide more minimally invasive and direct access, where particularly with the advent of TORS, superiorly based small lymph nodes can be accessed. However, transoral approaches may not be an option for those with trismus, aberrant carotid anatomy, or extranodal extension. In certain scenarios, an intraoral ultrasound may also assist with identification of the carotid vasculature and location of the lymph node.

From our review there are several further important pitfalls to consider during RPLN dissection:

Care should be taken not to mistake the superior sympathetic ganglion for a lymph node. This can be avoided by dissecting the superior and inferior extent of the node clearly before ligation. The superior sympathetic ganglion is a fusiform swelling of the sympathetic chain and would taper into a nerve superiorly and inferiorly.

The glossopharyngeal nerve should be identified and preserved if possible. The glossopharyngeal nerve exits the skull base medial to internal jugular vein and just lateral the internal carotid artery, descending between the styloid process and stylopharyngeus. At the level of the soft palate, it has a close relationship with the internal carotid artery, running just behind the styloid musculature.

Attempting RPLNDs in the salvage setting can be considered after careful discussion with the patient. The surgeons should be prepared to pivot to a transcervical approach to gain greater control of the carotid vessels. Assessment of the circle of Willis patency with preoperative balloon occlusion tests should be considered for lymph nodes abutting the internal carotid. Experience with intraoral ultrasonography or endoscopes (in transcervical approaches) may aid in the identification of critical anatomy and dissection. Being prepared to rotate muscle or perform free tissue transfers may minimize pharyngeal fistulas and complications associating with an exposed carotid vessel.

Our review found that there is a paucity of objective swallowing assessment, and standardized surgical outcomes from transoral or transcervical approaches. Cases that are managed surgically are highly selected, and preclude a direct comparison between transoral and transcervical approaches. Most important, our study found that when objective dysphagia analysis was performed, there remains a nontrivial number of patients who do develop postoperative dysphagia in transcervical approaches that tend to recover by 3 months. Nerve injuries were documented in both transcervical and transoral approach and included the sympathetic chain, vagus, and hypoglossal. The presence of glossopharyngeal injury may be underreported, but may contribute to postoperative dysphagia. Another underreported outcome following transoral approaches is velopharyngeal insufficiency. This is an important consideration given the impact on both speech and swallowing. Hematomas were documented only in the transoral approach. Following a comprehensive assessment of various outcomes, the literature lacks consistently recorded swallowing outcomes. Furthermore, there is a lack of information on the preoperative radiographic features that may have influenced treatment decision, and the final pathologic features including margin assessments of these lymph nodes.

Complication and outcome rates between transoral and cervical approaches in patients with thyroid disease and RPLN metastasis were suggested to be similar, although cases were highly selective, and sample size small.²³ A recent systematic review on surgical approaches in RPLND suggested that complication rate was higher in patient who underwent TORS compared to the transcervical and transoral approach [48.6% (n = 34/70) vs 11.2% (n = 26/233) and 14.3% (n = 2/14), respectively].³⁴ However, in their study, they did not differentiate between combined oropharyngectomy with RPLND [in OPSCC vs papillary thyroid carcinoma] and salvage post-radiation cases. In addition, the limited number of studies with small number of subjects limits a real comparison between techniques.

Surgical approaches to the RPLN need to be carefully weighed against the treatment efficacy of nonsurgical treatments. To our knowledge, there has not been a direct comparison between surgical and nonsurgical approaches of the RPLN. In Harries et al’s study of metastatic retropharyngeal thyroid metastases, radiation was utilized in 3 patients, though there was no evaluation of its functional impact.²⁴ However, radiation may significantly compromise patients’ quality of life, and sparing contralateral RPLN basins has been suggested to correlate with significantly improved patient-reported quality of life.³⁵ Ultimately, if feasible, surgical management should be considered.

Similar techniques were employed in the salvage setting. However, more advanced considerations, such as use of an intraoral ultrasound, or endoscopic-assisted transcervical approach, and conversion of transoral to transcervical approaches, may be required for safe dissection in this challenging patient population. One important complication that was not described following primary surgical cases was pharyngeal fistulas. This can potentially be a devastating complication with exposure of the carotid artery to saliva. Reconstructive considerations should be taken when embarking on these cases. In our review, around 9% of patients undergoing salvage RPLND from either approach required prolonged enteral feeding. This corroborates with known swallowing challenges in salvage head and neck cancer cases, where a minority recover meaningful oral diet.⁷

Limitations

This review does not include literature published in databases and gray literature after January 2023, so there may be additional records published that were not captured. We addressed this limitation by integrating literature published after the search date within our introduction and discussion sections. Most records that were included in our final analysis reflect cases that have been heavily selected for, and caution must be taken when generalizing findings from this study. Technological advances, and more widespread adoption of robotic systems, may bias recent cases toward transoral approaches.

Following review of the published literature, there remains a knowledge gap on the impact of radiographic features on surgical approach selection, and swallowing outcomes following surgical approaches. Furthermore, there is a lack of evidence comparing short- and long-term sequelae following nonsurgical treatment approaches for retropharyngeal metastases.

Conclusion

There are numerous considerations when selecting the optimal treatment of RPLN metastases. With surgical approaches, careful consideration of the patient’s anatomy, treatment of primary site, and the radiographic features cannot be overstated. Dissection of the retropharynx is not without its complications. Future studies evaluating the surgical approaches to the retropharynx should prioritize objective swallowing studies, assessment of postoperative cranial nerves, and further radiographic studies to further guide decision-making.

Supplemental Material

sj-docx-1-ohn-10.1177_19160216241265092 – Supplemental material for A Comparison of Transoral Versus Transcervical Surgical Approaches to Retropharyngeal Lymphadenectomy: A Scoping Review

Supplemental material, sj-docx-1-ohn-10.1177_19160216241265092 for A Comparison of Transoral Versus Transcervical Surgical Approaches to Retropharyngeal Lymphadenectomy: A Scoping Review by Sharon Tzelnick, Jillian Tsai, Ali Hosni, David P. Goldstein, John R. de Almeida and Christopher M. K. L. Yao in Journal of Otolaryngology - Head & Neck Surgery

Supplemental Material

sj-docx-2-ohn-10.1177_19160216241265092 – Supplemental material for A Comparison of Transoral Versus Transcervical Surgical Approaches to Retropharyngeal Lymphadenectomy: A Scoping Review

Supplemental material, sj-docx-2-ohn-10.1177_19160216241265092 for A Comparison of Transoral Versus Transcervical Surgical Approaches to Retropharyngeal Lymphadenectomy: A Scoping Review by Sharon Tzelnick, Jillian Tsai, Ali Hosni, David P. Goldstein, John R. de Almeida and Christopher M. K. L. Yao in Journal of Otolaryngology - Head & Neck Surgery

Footnotes

Acknowledgements

None.

Author Contributions

S.T. made substantial contributions to the study conception and design, performed the systematically search, and was a major contributor in writing the manuscript; J.T. substantively revised the manuscript; A.H. substantively revised the manuscript; D.P.G. substantively revised the manuscript; J.R.D.A. substantively revised the manuscript; C.M.K.L.Y. made substantial contributions to the study conception and design, performed the systematically search, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.

Availability of Data and Material

Not applicable.

Consent for Publication

Not applicable.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate

Not applicable.

ORCID iD

Sharon Tzelnick

Supplemental Material

Supplemental material for this article is available online.

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