著者

古川 雅史 梶川 泰 松代 直樹 北村 貴裕 大畠 和也 北原 糺 鎌倉 武史

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.105, no.10, pp.913-918, 2012 (Released:2012-10-01)

参考文献数

12

被引用文献数

2

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We studied 804 patients with idiopathic sudden sensorineural hearing loss (ISSNHL) regarding the correlation between the duration from the onset to the start of treatment and hearing outcome. An analysis of the 804 yielded the following results: 1) The overall cure rate was 30.0%. 2) The cure rate was better in patients with a shorter duration (within about 10 days) between the onset and the start of treatment. 3) In patients with mild hearing loss (Grade 1, 2), the cure rate was better in patients with a shorter duration. 4) In patients with severe hearing loss (Grade 3, 4), the cure rate of over 8-10 days was clearly worse, and it is very important to start treatment within 8-10 days.

著者

唐澤 勇

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.36, no.7, pp.635-643, 1941

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音響傳導問題即チ空氣傳導及骨傳導ニ關シテハ耳科學發達ノ道程ニ於テ巳ニ久シキ以前ヨリ論議セラレ Joh. Müller, Politzer 等ハ純粹骨傳導ノ存在ヲ肯定シ Bezold ハ其ノ存在ヲ否定シタ. 而シテ本問題ニ關シテ最モ華ヤカナル論爭ノ闘ハサレタルハ1907-1908年以來 Wittmaack 並ニ Siebenmann 學派ノ間ニ行ハレタル病理組織學的檢索ニ基ク音響障碍ニ關スル所謂空氣傳導説及骨傳導説デアル.<br>余ハ本論ニ於テ此等兩説ガ何故相對立シ撞着ヲ來スニ至リシカ其ノ所以ヲ述ベ而シテ古來科學ノ進歩發達ノ途上ニ於テ鬪ハサレ而シテ今尚鬪ヒツツアル機械説並ニ生氣説ノ觀點ヨリシテ之ヲ批判シ論ゼントス.<br>斯クテ第1章ニ於テハ機械説並ニ生氣説ノ歴史的觀察ヲ述ベ, Schleiden ノ植物細胞學説建設ヨリ次デ Schwann ノ動物細胞學説ニ至リ, Virchow ノ所謂細胞病理並ニ細胞生理學ノ發展ニ迄至ル道程ヲ略記シ之ニヨリテ現代醫學界ニ於ケル Mechanist (機械説學派) 及 Vitalist (生氣説學派) ノ立場ヲ明カナラシメントス.<br>次デ第2章ニ於テハ Wittmaack 學派ノ所謂一次性「ノイローン」二次性感覺細胞説並ニ Siebenmann 學派ノ一次性感覺細胞二次性「ノイローン」説ニ對シ, 此等兩説對立ヲ來シタル理由ヲ述ベ斯クテ之ニヨリテハ兩説共ニ純骨導ノ存否ヲ證明シ能ハザルコトヲ論ズ. 而シテ Wittmaack ノ"Tonuslehre"(緊張學説) ニヨリテ初メテ純粹骨傳導ノ存在ヲ肯定シ得ルニ至ルコト, 且又機械説並ニ生氣説觀點ヨリスル時ハ Siebenmann 學派ハ機械説學派ニ屬シ Wittmaack 學派ハ生氣説學派ニ屬スルコトヲ主張スル. 蓋シ現代醫學ニ於ケル Vitalist ハ顯微鏡下ニ組織細胞ノ變化ヲ論ジ Bichat, Morgagni ヲ經テ Virchow 以來所謂細胞病理學説ノ根據ニ立脚スルモノナルコトヲ説ク.<br>第3章ニ於テハ音響傳導ニ關スル自説ヲ記述スル. 即チ第1節ニ於テハ音叉音並ニ單絃琴音ニ關スル奇現象トシテ. 音叉ニヨルジエレー氏法陰性, リンネ氏法絶對的陰性及リンネ氏法絶對的陽性ノ出現ヲ論ジ且又單絃琴音ニヨルリンネ氏法ニ於テハ最高音階ハ氣導ヨリモ骨導ニ於テ勝ルコトヲ述ベ, 第2節ニ於テハ前節ニ於ケル奇現象ハ音叉若クハ單絃琴ヨリ出ズル音響ノ特性ニハ非ズシテ蝸牛殼神經其ノモノノ特異性即チ撰擇性若クハ感受性ニ歸スベキモノトスル. 斯クテ第3節ニ於テハ第2節ニ於ケル理論ヲ容認スルタメニ音響感覺ニ關スル Ewald 説並ニ Helmholtz 説ノ根本觀念ニ就テ之ヲ論ズルコトトシタ.<br>結論ニ於テハ音響傳導ニ關スル問題ハ機械説ノミニヨリテハ今日尚未ダ之ヲ解決スルコト不可能ニシテ科學的根據ニ立脚シ生氣説ヲ導入スルコトニヨリテ初メテ説明シ得ラルルモノナルコトヲ論ジタ.

著者

松田 和徳 堀 洋二 雫 治彦 武田 憲昭

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.98, no.10, pp.809-814, 2005

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In the present study, we evaluated daytime sleepiness in 32 patients with obstructive sleep apnea syndrome (OSAS) using epworth sleepiness scale (ESS). ESS scores of patients with OSAS were significantly higher than those of patients with simple snoring and healthy subjects. ESS scores of patients with OSAS were significantly correlated with apnea-hypopnea index, the longest apnea time, but not with the lowest oxygenation. It is suggested that ESS score is a predictive index of the severity of OSAS. We then examined whether ESS in combination with body mass index (BMI) can identify patients with OSAS among patients complaining of snoring. When the cut off points were 11 in ESS and 25 in BMI, the combination of ESS and BMI correctly classified 18 of 25 patients with OSAS (sensitivity=72.0%) and 7 of 10 patients without OSAS (specificity=70.0%). We concluded that the combination of ESS and BMI was useful for screening of sleep apnea syndrome.

著者

山崎 可夫

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.63, no.8, pp.813-815, 1970

著者

松尾 美央子 力丸 文秀 檜垣 雄一郎

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.105, no.4, pp.369-373, 2012 (Released:2012-04-01)

参考文献数

8

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TS-1® is an oral anticancer drug composed of tegafur which is a derivative of 5FU and 5-chloro-2,4-dihydroxypyridine (CDHP) and oxonic acid. We report on a patient with acute toxicosis who orally ingested a large dose of TS-1® 1400 mg in an effort to commit suicide. First of all, we treated him with gastric lavage, laxative and hydration. After that, he underwent hemodialysis. Before hemodialysis the blood concentration of tegafur was 25200 ng/mL, 5-FU was 3000 ng/mL and CDHP was 1870 ng/mL. These blood concentrations were high, compared with cases where 50 mg of TS-1® has been ingested. After the 2nd hemodialysis, all blood concentrations decreased to the normal level, so the patient was saved without severe side effects. To our knowledge, there has been no report of a case involving ingestion of a large dose of TS-1®, and we therefore report our experience of this rare case.

著者

梶川 泰造

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.30, no.3, pp.343-380, 1935

著者

須藤 正治 高橋 晴雄 田邊 牧人 長谷部 誠司

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.91, no.1, pp.23-27, 1998-01-01

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Although impairment of middle ear ventilation and subsequent middle ear negative pressure have been regarded as important pathogenetic factors in middle ear diseases, impairment of middle ear ventilation has not been proven to necessarily cause progressive negative middle ear pressure. Toynbee phenomenon is another possible cause of active production of negative middle ear pressure. Accordingly, we investigated the incidence and pathophysiology of Toynbee phenomenon in various middle ear diseases.<br>The incidence of positive Toynbee phenomenon was 75% (18124) in controls. Whereas, the incidence was 14% (8/59) in cases of otitis media with effusion (OME), 50% (13126) in cases of chronic otitis media (COM), 38% (5/13) in cases of adhesive otitis media (Adh), and 30% (3/10) in patients with cholesteatoma. However, the negative pressure induced by the Toynbee maneuver was significantly more profound in cases of Adh (- 116.0±58.6 mmH₂O) than in normal ears (-8.05±53.9 mmH₂O, p<0.005). Also the average induced negative pressures in the other diseased ears tended to be more profound than in normal ears; -23.6±37.1 mmH₂O in OME, -23.1±55.1 mmH₂O in COM, -45.0±18.0 mmH₂O in cholesteatoma. Considering that middle ear diseases often accompany nasal diseases and are also often induced or aggravated by upper respiratory infections or nasal allergies (when the nose is congested), and that the eustachian tubes in diseased ears often cannot equalize negative middle ear pressure, Toynbee phenomenon may be related to the pathogenesis of these ear diseases.

著者

田辺 正博 上原 範子

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.73, no.4, pp.673-677, 1980

被引用文献数

2 1

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Evidence of a foreign body in the esophagus is not rare. When characteristics of the foreign body are unknown and are non-contrasted with x-ray, the diagnosis is often difficult.<br>We report a case of a foreign body which was overlooked for more than two months.<br>A 47-year-old woman experienced severe pain in her throat when she swallowed a piece of sponge cake. A foreign body lodged in the throat was ruled out by two otolaryngologists.<br>Five weeks later, she developed retrosternal pain and epigastralgia and an esophagogram was done.<br>She was sent to our clinic as there was an abnormal shadow detected on the esophagogram.<br>Flexible fibro-optic esophagoscopy revealed a foreign body lodged in the esophagus.<br>Under general anesthesia, a piece of quadrilateral plastic film with sharp corners was removed using a rigid esophagoscope.<br>The patient had a good postoperative course and esophagogram done five months after removal of the foreign body showed no stenosis of the esophagus due to scar formation.

著者

竹田 泰三 柿木 章伸 竹内 俊二 齋藤 齋藤

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.85, no.12, pp.1893-1901, 1992

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Recent advances in imaging technique, including high resolution thin section computed tomography scanning and magnetic resonance imaging (MRI), permit the easy diagnosis of congenital malformations of the osseous labyrinth, which have so far been lumped together as "Mondini dysplasia". In the present study the anatomic patterns from the radiographic appearance and the clinical manifestation were examined in 18 patients (23 ears) with radiographic abnormalities of the inner ear. The most common abnormal configuration was a large vestibule (20 of 23 ears). This anomaly of the vestibule often involved the lateral semicircular canal, revealed as a round high signal zone on T2-weighted MRI. However, a large vestibule was not always associated with an abnormal cochlea. Abnormal cochleas were found in 8 of the 20 ears with a large vestibule, and most of these 8 ears had total or profound deafness. But 4 of the 10 ears with residual hearing had low tone deafness and 6 had fluctuating hearing loss, which was frequently associated with attacks of dizziness. These clinical manifestations of Mondini dysplasia are similar to those of patients with endolymphatic hydrops.

著者

奥園 達也

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.76, no.10, pp.2565-2580, 1983

被引用文献数

7 2

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著者は, 身体重心動揺の方向性を重視し, 新たに動揺の各規定方向毎の動揺量を表示できるベクトル動揺図 (命名, Vector Statokinesigram; V-Skg. と略) を考案した. V-Skg. は, 重心動揺計の左右及び前後への身体動揺記録 (Statokinesigram; Skg. と略) を用い, 特製プログラムを有するマイクロコンピューターにより作成する, 即ちV-Skg. 上の動揺方向は, Skg. 上単位時間毎移動点, 2点間のΔy/Δxの逆正接より求め, 併せて動揺量は同2点間の距離より求めた. 動揺方向の一計測単位を5度とし, 360度を72分割すれば, 動揺方向毎動揺量の計測値は72個得られる. これを, 極座標上72本の放射状線分として, CRT上に描出した.<br>1) 本法により健康成人29名のV-Skg. を記録した. 動揺の型別は, 求心型, びまん型, 前後型, 多中心型, 左右型の他, 閉眼安定型を加えた. 各型別の総軌跡長, 20度毎18方向別の平均値と標準偏差を求めた. これを健常者の型別, 対照値とした.<br>2) 健康高令者65名のSkg. とV-Skg. を記録した. この型別分類, 総軌跡長及び18方向別の動揺量を求め, 健康成人群と比較した. 身体動揺は加令により増加した. 型別分類では左右型と閉眼安定型の増加が注目された.<br>3) 一側性末梢前庭障害例では左右型の動揺を示す. 動揺量は健康成人群の左右型より有意に大きい.<br>4) 小脳脳幹障害例では前後型の動揺を示すが, 健常群の前後型に比し動揺量は大きい.<br>5) 体平衡障害の代表例2例を呈示した. 本V-Skg. は, 変動する動揺の方向性を明示し, その動揺量を計量し得る方法である.

著者

田端 敏秀 斎藤 載 西村 新 園田 裕 池田 昌生 島田 忠雄 岡本 進 大台 道夫 葛原 敏捷 桜井 〓士 岩間 紀行 釘貫 依子 小向 美奈子

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.61, no.7, pp.849-850, 1968

著者

田端 敏秀 西村 新 大台 道夫 斎藤 載 島田 忠雄 園田 裕 葛原 敏捷 池田 昌生 岡本 進 桜井 禎士 岩間 紀行 小向 美奈子

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.60, no.9, pp.699-704, 1967

著者

玉城 進 齋藤 春雄 村田 清高

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.74, no.4, pp.746-752, 1981

被引用文献数

2 3

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A huge cholesteatoma in a 50-year-old female involving the petrous apex was reported. The prominent features of the case were recurrent attacks of very slowly progressing facial paralysis with a 11-year interval and insidious destruction of labyrinthine function.<br>The cholesteatoma extended into all the air cell tracts up to the petrous apex, and to the retro- and infralabyrinthine-areas.<br>The cholestoma destroyed the otic capsule at the crus commune and resolved the dura mater to such an extent that the cerebellum could be seen through it. As she had experienced acute otitis media on only one occasion at the age of 4 and only had a small dry attic perforation, the possibility of a congenital cholesteatoma of the petrous apex was considered in addition to her clinical course.

著者

江暗 裕介 中井 義明 大橋 淑宏 金 朋郁

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.85, no.2, pp.227-231, 1992

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A 35-year-old male patient visited our outpatient clinic with sudden onset of right ear fullness. Right tubal stenosis was considered to be responsible for his complaint. A roughsurfaced flat tumor was found close to the right Rosenmuller's fossa, and biopsy was performed immediately under fiberscopy. Whether his hearing loss was due to a conductive or sensorineural disturbance was not conclusively determined because the audiogram was complicated. The tumor was diagnosed histopathologically as not malignant but inflammatory, "epithelioid granulosis in the pharyngeal tonsil". Physical examinations did not support either sacoidosis or active tuberculosis. The final diagnosis, based on a retrospective study of his lesion, was old epipharyngeal tuberculosis and sudden deafness.

著者

瀧口 哲也 岡部 陽三 古川 仭 中川 士郎 大尾 嘉宏巳 道岸 隆敏 水上 勇治

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.85, no.4, pp.607-613, 1992

被引用文献数

1

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A 57-year old man had a left anterior neck tumor, and another small tumor was found in the laryngeal ventricle by indirect laryngoscopy. A CT scan showed a well-circumscribed tumor growing from the thyroid lamina into the paraglottic space. Under general anesthesia the tumor was dissected with fenestration of the thyroid ala without any complications, such as hoarseness or deformity. In Japan 35 cases of cartilagenous tumors arising in the laryngeal cartilage have been reported, including our case. In six of these 35 cases the tumor was in the thyroid cartilage. Both chondrosarcoma and chondroma are often seen in the thyroid cartilage, whereas chondroma is seen more frequently than chondrosarcoma in the cricoid carilage.

著者

安藤 四一 服部 浩

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.67, no.2, pp.129-136, 1974

被引用文献数

7

著者

奥田 稔 深谷 卓 小林 恵子 伊藤 依子 調所 廣之 設楽 哲也 八尾 和雄 小川 浩司 橋口 一弘 佐伯 哲郎 山越 隆行 濱田 はつみ 川崎 和子 石井 豊太 鳥山 稔 増田 哲也 杉山 博 川端 五十鈴 川島 佳代子 八木 昌人 田部 浩生 岡村 浩一郎 木場 玲子 斉藤 晶 安藤 一郎 野村 恭也 吉見 健二郎 窪田 哲明 大谷 尚志 波多野 吟哉 竹山 勇 上杉 恵介 林崎 勝武 鈴木 淳一 澤木 誠司 石塚 洋一 古屋 信彦 安達 忠治 坂井 真 新川 敦 小林 良弘 佐藤 むつみ 山崎 充代 斎藤 洋三 舩坂 宗太郎 斉藤 啓光 石井 正則 浅井 和康 森山 寛 遠藤 朝彦 小林 毅 関 博之 林 成彦 石井 哲夫 窪田 市世 水谷 陽江 荒 牧元 大竹 守 北嶋 整 上田 範子 山口 宏也 牛嶋 達次郎 坊野 馨二 菊地 茂 佐橋 紀男 臼井 信郎 原 俊彰 宮川 晃一 田中 康夫 喜友名 朝盛 井上 庸夫 八木 聰明 大久保 公裕 服部 康夫 町野 満 大塚 博邦 稲葉 真 島田 早苗 添野 眞一 星 慎一 頼 徳成 大橋 和史 村山 貢司 飯塚 啓介 市川 朝也 冨田 寛 小山 明 山内 由紀 渡辺 健一 佐藤 かおる 山田 久美子 木田 亮紀 牧山 清 亀谷 隆一 藤田 洋祐 井上 鐵三 田村 悦代 野原 理 阿部 和也 水野 信一 岩崎 真一 小川 裕 加賀 達美

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.88, no.6, pp.797-816, 1995-06-01

被引用文献数

6 3

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To evaluate the effectiveness, safety and utility of Emedastine difumarate (ED) in the treatment of Japanese cedar pollinosis, a multicentered, double-blind comparative study was performed in 290 patients in 1994.<br>Patients with Japanese cedar pollinosis were divided into two groups; the first group was treated with ED at a dose of 4mg/day starting two weeks before the season and continuing for the whole season. The second group was given an inactive placebo instead of ED during the pre-season and the early portion of the season and then replaced with ED during the later portion of the season.<br>As a result, the final improvement rate was significantly higher in the first group than that in the second group.<br>All subjective symptoms such as sneezing, nasal discharge, nasal obstruction and eye itching were suppressed due to ED treatment.<br>In conclusion, it was better to continuously administer ED to patients with pollinosis from the preseasonal period till the end of the season.<br>However, when the ED treatment was started in the midseason, the outcome was good, although less satisfactory than the outcome of continuous treatment given throughout the entire pollen season.

著者

市村 恵一 田中 利善 北原 伸郎

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.82, no.9, pp.1209-1219, 1989

被引用文献数

7 3

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The masseter muscle, which contributes to mastication, originates on the zygomatic arch and inserts into the lateral surface of the mandible. Although relatively rare, benign masseteric hypertrophy and intramasseteric hemangioma are two important conditions affecting this muscle. Patients with these lesions complain of the cosmetic deformity rather than the functional disorder. Unless desired for cosmetic reasons there is little justification for any operative treatment. However, as no report could be found of the esthetic problem being solved by conservative treatment, surgical correction is advised when the chief complaint is esthetic.<br>Surgical treatment involves resection of the hypertrophied musculature or excision of the tumor with a surrounding margin of normal muscle. We list here the important aspects of surgery of the masseter.<br>1) Careful preoperative planning, including CT and MRI, is indispensable.<br>2) An extraoral approach is preferred in most cases. The masseter muscle is exposed through a curvilinear incision around the angle of the mandible for cosmetic reasons. A postauricular incision extending to the submandibular area is used instead of a routine preauricular parotid skin incision.<br>3) Care should be exercised to identify and preserve the lower branches of the facial nerve. They should either be dissected free and retracted (in case of tumor) or remain on the surface of the muscle (in cases of muscle hypertrophy) to protect them from damage.<br>4) Ligation of the feeding vessels helps to minimize blood loss.<br>5) Oozing from the muscle can be controlled by an infrared contact coagulator.<br>6) Postoperatively continuous suction with a fenestrated polyethylene drain for 2 days and a pressure dressing for 5- to 7-days is recommended to prevent hematoma and resultant scar formation, which causes swelling or trismus.<br>7) Patients should begin chewing early to prevent trismus.

著者

由井 誠一郎 福喜多 啓三 福家 博史

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.74, no.5, pp.1312-1320, 1981

被引用文献数

12

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Rhinogenic Intracranial infection is a rare complication. Intracranial complication arising from nasal infections, principally afflictions of the accessory sinuses, is a very grave complication. Since the advent of chemotherapy and various antibiotics, its incidence and morbidity has diminished appreciably.<br>A case of rhinogenic spontaneous Intracranial complication is reported herein. The patient was a 16-year-old man with a swelling around the left eye-lid that had existed for two days. There had been headache and high fever. On examination, the spinal fluid was under pressure with a high cell count, consisting mostly of poly-morphonuclear cells. Four days after admission, he went into coma. Rhinogenic intracranial complication was suspected. A radical ethmoid, antrum and frontal sinus surgery was immediately carried out. Ten grams of SB-PC and 200mg of DKB were administered daily, but 12 days after admission, the careful CT scanning revealed that he had a subdural abscess. Drainage of the subdural abscess was carried out. The patient made a complete recovery 7 weeks after admission.

著者

平野 滋 篠原 尚吾 庄司 和彦 児嶋 久剛

出版者

The Society of Practical Otolaryngology

雑誌

耳鼻咽喉科臨床 (ISSN:00326313)

巻号頁・発行日

vol.89, no.1, pp.75-80, 1996-01-01

被引用文献数

14 2

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Intracapsular enucleation is thought to be a suitable method for preserving post-operative function of the original nerve following treatment for cervical neurilemmomas. In previous studies, however, post-operative palsy occurred in most cases and there have been seen several cases in which nerve funtions did not recover. In the present study, we performed a modified method of Intracapsular enucleation for two cervical neurilemmomas, the first case involved the facial nerve, the second the hypoglossal nerve. In these cases, post-operative palsy has not been observed since immediately after surgery. Important points in this procedure include (1) making the incision line at a point on the capsule where few nerve fibers exist, (2)ablating the capsule from the tumor as gently as possible, (3) monitoring nerve function using a nerve stimulator throughout the procedure.