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. 2022 Dec 1;29(12):9416–9427. doi: 10.3390/curroncol29120740

Transoral Approach to Parotid Tumors: A Review of the Literature

Giuseppe Riva 1,*, Andrea Lorenzi 1, Andrea Borello 1, Andrea Albera 1, Andrea Canale 1, Giancarlo Pecorari 1
PMCID: PMC9776422  PMID: 36547154

Abstract

Different surgical techniques have been proposed for parapharyngeal space tumors, including transcervical, transparotid, trans-mandibular, infratemporal, and transoral. The choice of the correct approach depends on the size, localization and nature of the tumor. The transoral approach can be used for benign prestyloid masses, such as tumors of the deep lobe of the parotid gland. It guarantees a short hospitalization without skin scars. The narrowed access represents the main limitation of this technique. This review will summarize and analyze the current knowledge about the transoral approach to parotid lesions. Thirty-seven studies were included in a qualitative and quantitative synthesis. The novelty of this review is the quantitative analyses of the clinical data reported in the included studies.

Keywords: salivary gland, salivary tumor, transoral approach, parapharyngeal space, parapharyngeal space tumor

1. Introduction

Parapharyngeal space (PPS) is located laterally to the pharynx and has the shape of an inverted pyramid extended from the cranial base to the greater cornu of the hyoid bone [1,2]. PPS is divided into prestyloid and retrostyloid compartments by stylohyoid ligament and muscles. Prestyloid space contains the deep lobe of the parotid gland, lymph nodes, ascending pharyngeal artery, ascending palatine artery, and fat, while retrostyloid space contains internal jugular vein, internal carotid artery, cranial nerves (from IX to XII), and lymph nodes (Figure 1) [2].

Figure 1.

Figure 1

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Anatomical representation of the parapharyngeal space. Abbreviations: CN, cranial nerve; ICA, internal carotid artery; IJV, internal jugular vein; m./mm., muscle(s).

PPS tumors are uncommon, representing only 0.5% of head and neck neoplasms. Most of them are benign and originate from the deep lobe of the parotid gland [3,4,5]. Magnetic resonance imaging (MRI) with gadolinium and fine needle aspiration cytology (FNAC) represent the gold standard for determining the diagnosis and thus the correct management of the patient. Other radiological examinations may include computed tomography (CT) with contrast, ultrasound scan and magnetic resonance angiography, which is recommended especially for vascularized tumors [6].

Different approaches to PPS tumors have been proposed, such as transcervical, transparotid, transmandibular, infratemporal, and transoral [7,8]. The choice of the surgical approach is based on the type and localization of the tumor and its relationships with neurovascular structures [7,9]. The transoral approach can be used for benign prestyloid masses, such as tumors of the deep lobe of the parotid gland [8].

The transoral approach is performed through an incision near the anterior tonsillar pillar mucosa, thus exposing prestyloid space under the superior pharyngeal constrictor muscle. Stylopharyngeal and styloglossus muscles are important landmarks for the transoral approach to PPS, since they divide pre- and retrostyloid spaces. Therefore, they represent the structures that should not be crossed to avoid severe vascular and nervous damages [10].

This review aims to summarize and analyze the current knowledge about the transoral approach to parotid lesions, with particular attention to tumor features and potential complications.

2. Materials and Methods

A review of the English literature was performed through several databases (PubMed, Scopus, accessed on 30 October 2022) to identify articles published before 30 October 2022. A primary search was performed using the terms “parotid AND transoral AND (tumor OR cancer OR adenoma OR warthin)”. Search strategies were adapted for each database. The references of selected publications were then examined to identify further reports that were not found by database searching, and the same selection criteria were applied.

The inclusion criteria were clinical trials, cohort studies, case-control studies, case series, and case reports, regarding the transoral approach for parotid gland tumors. Exclusion criteria were as follows: non-human studies, non-English literature, transoral approach for non-salivary tumors, and insufficient clinical data (i.e., tumor origin) reported in the paper.

The abstracts of all relevant articles were examined using the inclusion criteria for applicability. The references of the selected publications were reviewed to identify further reports that were not found by database searching. Two independent reviewers (AL, AB), working separately, extracted the data from all the eligible studies, which were subsequently cross-checked. All retrieved full-texts articles were included in the review by a consensus of all the authors.

Tumor volume (V) was calculated assuming ellipsoid shape (l = length, w = width, h = height) [11]:

V=43×π×l2×w2×h2

If the third dimension (h) was not reported, its approximation was [11]:

h=23×l

3. Review of the Literature

A total of 400 published papers were identified through database searches. After abstract screening for eligibility, 63 articles were considered eligible. Among these, we included 37 articles in qualitative and quantitative synthesis after full-text assessment. The other 26 papers were excluded for the following reasons: non-parotid tumors (n = 6), not transoral approach (n = 8), and incomplete clinical data (n = 12) (Figure 2).

Figure 2.

Figure 2

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Review of the English literature through PubMed and Scopus, accessed on 30 October 2022. Primary search was performed using the terms “parotid AND transoral AND (tumor OR cancer OR adenoma OR Warthin)”.

Among the papers that matched the inclusion criteria, 14 publications were case reports and 23 were retrospective studies. One hundred and thirty-nine cases were included in the review (Table 1).

Table 1.

Transoral approach to parotid tumors: review of the literature.

Reference Year of Publication Age (y) Sex Length (mm) Width (mm) Height (mm) Volume (cm3) Histology Approach Complications/Recurrences Follow-Up (Months)
Goodwin et al. [12] 1988 66 F NR NR NR NA PA TO None 120
Goodwin et al. [12] 1988 73 F NR NR NR NA PA TO None 180
Goodwin et al. [12] 1988 68 M NR NR NR NA PA TO Recurred after 39 months 39
Goodwin et al. [12] 1988 64 M NR NR NR NA PA TO None 74
Goodwin et al. [12] 1988 69 F NR NR NR NA BCA TO None 21
Goodwin et al. [12] 1988 58 F NR NR NR NA PA TO None 22
Luna–Ortiz et al. [13] 2005 37 M 90 NR NR NA PA TC + TO None 19
Rahbar et al. [14] 2006 14 M NR NR NR NA MEC TO Positive margins, addressed by superficial parotidectomy 13
Bozza et al. [15] 2009 23 M 30 NR NR NA PA TO None 192
Bozza et al. [15] 2009 53 F 30 NR NR NA PA TO None 168
O’Malley et al. [16] 2010 52 F 25 NR NR NA PA TORS None 37
O’Malley et al. [16] 2010 75 F 60 NR NR NA PA TORS Pharyngeal dehiscence 35
O’Malley et al. [16] 2010 58 F 43 NR NR NA PA TORS None 33
O’Malley et al. [16] 2010 69 F 58 NR NR NA PA TORS None 32
O’Malley et al. [16] 2010 35 F 31 NR NR NA PA TORS Pharyngeal dehiscence 32
O’Malley et al. [16] 2010 64 F 32 NR NR NA PA TORS None 31
O’Malley et al. [16] 2010 40 M 70 NR NR NA PA TO None 16
Betka et al. [17] 2010 68 F 50 30 20 15.7 rPA TO None NR
Betka et al. [17] 2010 37 M 70 50 40 73.3 rPA TO None NR
Betka et al. [17] 2010 54 F 50 45 30 35.3 PA TO None NR
Betka et al. [17] 2010 72 F 60 50 40 62.8 rPA TO None NR
Betka et al. [17] 2010 36 F 50 40 40 41.9 PA TO None NR
Betka et al. [17] 2010 52 F 55 50 35 50.4 CXPA TO None NR
Betka et al. [17] 2010 53 F 55 30 30 25.9 PA TO None NR
Kovačić et al. [18] 2012 45 F 50 50 NR 43.6 PA TO None 24
De Virgilio et al. [19] 2012 49 F 40 32 NR 17.9 PA TORS None NR
De Virgilio et al. [19] 2012 43 M 55 40 NR 42.2 PA TORS None NR
De Virgilio et al. [19] 2012 25 M 85 55 NR 138.7 PA TP + TORS None NR
De Virgilio et al. [19] 2012 31 M 86 55 NR 142.0 PA TP + TORS None NR
De Virgilio et al. [19] 2012 36 M 60 30 NR 37.7 PA TP + TORS None NR
De Virgilio et al. [19] 2012 39 M 30 30 NR 9.4 PA TORS None NR
De Virgilio et al. [19] 2012 57 F 40 30 NR 16.8 PA TORS None NR
De Virgilio et al. [19] 2012 24 M 50 40 NR 34.9 PA TP + TORS None NR
Hwang et al. [20] 2013 34 M 84 65 39 111.5 PA TC + TO Deep neck space seroma that was surgically drained and treated with intravenous antibiotics 3
Park et al. [21] 2013 42 M NR NR NR NA PA TORS None NR
Park et al. [21] 2013 31 M NR NR NR NA PA TORS None NR
Park et al. [21] 2013 39 M NR NR NR NA PA TORS None NR
Park et al. [21] 2013 47 F NR NR NR NA PA TORS None NR
Park et al. [21] 2013 57 F NR NR NR NA PA TORS None NR
Park et al. [21] 2013 29 M NR NR NR NA PA TORS None NR
Park et al. [21] 2013 21 F NR NR NR NA PA TORS None NR
Park et al. [21] 2013 54 F NR NR NR NA PA TORS None NR
Park et al. [21] 2013 30 M NR NR NR NA PA TORS None NR
Hussain et al. [22] 2014 49 F 60 50 35 55.0 PA TO None 72
Hussain et al. [22] 2014 60 F 50 40 28 29.3 PA TO None 42
Chen et al. [23] 2014 22 F 70 70 NR 119.7 PA EATO None 21
Chen et al. [23] 2014 33 F 70 60 NR 102.6 PA EATO None 16
Chen et al. [23] 2014 42 M 60 60 NR 75.4 PA EATO None 16
Chen et al. [23] 2014 53 M 40 40 NR 22.3 WT EATO None 9
Chen et al. [23] 2014 61 M 60 50 NR 62.8 PA EATO None 8
Samoy et al. [24] 2015 66 M 50 NR NR NR PA TORS None 9
Li et al. [25] 2015 59 F 65 52 49 86.7 PA EATO None NR
Li et al. [25] 2015 48 F 40 35 31 22.7 PA EATO None NR
Li et al. [25] 2015 42 F 52 49 43 57.4 PA EATO None NR
Iseri et al. [26] 2015 57 F 42 32 26 18.3 PA EATO None 6
Iseri et al. [26] 2015 53 F 27 31 37 16.2 NR EATO None 6
Iseri et al. [26] 2015 50 M 59 44 37 50.3 PA EATO Hyperemia of the skin of angulus mandibulae 6
Chan et al. [27] 2015 34 F 47 NR NR NA PA TORS None 1
Chan et al. [27] 2015 51 F 60 NR NR NA BCA TORS None 13
Chan et al. [27] 2015 43 F 54 NR NR NA PA TORS None 15
Woo et al. [28] 2016 55 M 40 40 NR 22.3 PA EATO None 6
Dallan et al. [29] 2016 34 F 44 NR NR NA PA EATO None 14
Dallan et al. [29] 2016 57 F 45 NR NR NA PA EATO None 14
Dallan et al. [29] 2016 39 M 43 NR NR NA PA EATO None 14
Casale et al. [30] 2016 67 M 56 43 22 27.7 WT TO Small collection of saliva, treated with drainage and intravenous antibiotics, solved after 5 days NR
Boyce et al. [31] 2016 74 M 35 25 17 7.8 rPA TORS Yes 18
Boyce et al. [31] 2016 32 F 25 19 8 2.0 PA TORS None 13
Boyce et al. [31] 2016 70 M 39 23 15 7.0 MEC TORS None 50
Boyce et al. [31] 2016 54 M 40 12 10 2.5 PA TORS None 5
Boyce et al. [31] 2016 58 M 30 20 10 3.1 PA TORS None 20
Boyce et al. [31] 2016 73 F 40 35 7 5.1 BCA TORS None 2
Boyce et al. [31] 2016 48 M 70 70 30 77.0 PA TC + TORS None 11
Boyce et al. [31] 2016 60 F 42 37 33 26.9 PA TORS None 3
Boyce et al. [31] 2016 70 M 50 40 40 41.9 PA TORS None 1
Boyce et al. [31] 2016 78 F 22 15 6 1.0 O TORS None 3
Boyce et al. [31] 2016 65 M 28 12 10 1.8 PA TORS None 10
Boyce et al. [31] 2016 21 M 34 17 10 3.0 PA TC + TORS Yes 1
Boyce et al. [31] 2016 54 F 23 19 7 1.6 PA TORS None 10
Boyce et al. [31] 2016 72 F 50 42 30 33.0 PA TORS None 1
Wu et al. [32] 2018 52 F 33 NR NR NR BCA EATO None 11
Wu et al. [32] 2018 48 F 60 40 30 37.7 BCA EATO None 20
Wu et al. [32] 2018 41 F 40 30 NR 16.8 BCA EATO None 37
Meng et al. [33] 2018 65 F 50 42 30 33.0 PA TO None 20
Meng et al. [33] 2018 67 M 50 40 30 31.4 CXPA TO None 14
Meng et al. [33] 2018 51 M 60 50 50 78.5 PA TO None 14
Meng et al. [33] 2018 45 F 43 40 35 31.5 PA TO None 14
Meng et al. [33] 2018 66 M 25 20 17 4.5 PA TO None 10
Meng et al. [33] 2018 51 F 50 45 30 35.3 PA TO None 8
Meng et al. [33] 2018 44 M 42 32 30 21.1 PA TO None 4
Meng et al. [33] 2018 28 M 58 42 32 40.8 PA TO None 3
Maglione et al. [34] 2018 23 M 72 62 38 88.8 PA TORS None 36
Maglione et al. [34] 2018 23 F 60 50 18 28.3 PA TORS None 39
Maglione et al. [34] 2018 44 M 60 30 25 23.6 PA TO None 42
Duek et al. [35] 2018 66 F NR NR NR 111.0 PA TORS None 4
Duek et al. [35] 2018 78 F NR NR NR 28.0 PA TC + TORS None 4
Duek et al. [35] 2018 42 M NR NR NR 36.0 CXPA TC + TORS None 4
Duek et al. [35] 2018 69 F NR NR NR 32.0 CXPA TC + TORS None 4
Duek et al. [35] 2018 30 M NR NR NR 80.2 AC TC + TORS Marginal mandibular branch weakness, completely solved within 3 months 4
Duek et al. [35] 2018 33 M NR NR NR 60.0 PA TC + TORS None 4
Duek et al. [35] 2018 64 F NR NR NR 67.5 PA TORS None 4
Mani et al. [36] 2019 43 F 10 10 NR 0.3 PA TO None 8
Chen et al. [37] 2019 32 M 50 30 NR 26.2 PA EATO None 50
Chen et al. [37] 2019 34 M 50 40 NR 34.9 PA EATO None 69
Chen et al. [37] 2019 26 M 55 45 25 32.4 PA EATO None 44
Chen et al. [37] 2019 28 M 70 50 35 64.1 PA EATO None 50
Chen et al. [37] 2019 61 M 60 45 30 42.4 PA EATO None 31
Chen et al. [37] 2019 56 M 50 40 20 20.9 PA EATO None 50
Chen et al. [37] 2019 38 F 80 60 NR 134.0 PA EATO None 25
Chen et al. [37] 2019 45 M 62 38 NR 51.0 PA EATO None 12
Chen et al. [37] 2019 43 M 60 45 NR 56.5 PA EATO None 9
Chen et al. [37] 2019 38 F 58 37 30 33.7 PA EATO None 8
Shen et al. [38] 2020 72 M 35 30 20 11.0 WT TO None 23
Shen et al. [38] 2020 61 M 60 45 30 42.4 CXPA TO None 51
Moffa et al. [39] 2020 23 F 30 NR NR NA PA TORS None 12
Li et al. [40] 2020 61 F 32 29 23 11.2 BCA EATO None 52
Li et al. [40] 2020 66 M 28 25 20 7.3 BCA EATO None 32
Yavuz et al. [41] 2021 70 F 53 48 34 45.3 PA TO None NR
Voora et al. [42] 2021 37 M 40 30 NR 16.8 PA TO None NR
Tsunoda et al. [43] 2021 62 M 70 NR NR NA PA EATO None >120
Tsunoda et al. [43] 2021 37 M 70 NR NR NA PA EATO None >120
Tsunoda et al. [43] 2021 65 M 60 NR NR NA BCA EATO None >120
Jbali et al. [44] 2021 50 M 52 38 NR 35.9 PA TP + TO House–Brackmann grade III facial palsy that solves using corticosteroid NR
Shin et al. [45] 2022 60 F 36 NR NR NA PA TO None 62
Salzano et al. [46] 2022 71 M 35 32 30 17.6 PA TORS None 6
Salzano et al. [46] 2022 63 F 40 20 20 8.4 PA TORS None 6
Salzano et al. [46] 2022 64 F 45 40 25 23.6 PA TORS None 6
Salzano et al. [46] 2022 23 M 40 30 20 12.6 PA TORS None 6
Salzano et al. [46] 2022 43 M 30 28 25 11.0 PA TORS None 6
Salzano et al. [46] 2022 33 F 35 30 20 11.0 PA TORS None 6
Salzano et al. [46] 2022 59 F 45 40 30 28.3 PA TORS None 6
Salzano et al. [46] 2022 25 F 35 28 20 10.3 PA TORS None 6
Salzano et al. [46] 2022 55 F 35 20 20 7.3 PA TORS None 6
Salzano et al. [46] 2022 27 M 35 30 30 16.5 PA TORS None 6
Salzano et al. [46] 2022 74 F 43 40 20 18.0 PA TORS None 6
Salzano et al. [46] 2022 58 F 40 35 20 14.7 PA TORS None 6
Salzano et al. [46] 2022 35 F 40 40 20 16.8 PA TORS None 6
Salzano et al. [46] 2022 42 M 38 25 25 12.4 PA TORS None 6
Lenzi et al. [47] 2022 76 F 30 23 21 7.6 PA EATO None 6
Cadena–Piñeros et al. [48] 2022 59 M 28 17 4 1.0 CXPA TORS None 6
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Abbreviations: AC, adenocarcinoma; BCA, basal cell adenoma; CXPA, carcinoma ex pleomorphic adenoma; EATO, endoscopic assisted transoral; F, female; M, male; MEC, mucoepidermoid carcinoma; NA, not applicable; NR, not reported; O, oncocytoma; PA, pleomorphic adenoma; rPA, recurrent pleomorphic adenoma; TC, transcervical; TO, transoral; TORS, transoral robotic surgery; TP, transparotid; WT, Warthin tumor.

Based on available data, the mean age was 49.44 ± 15.73 years (range 14–78 years), with a male/female ratio of 67/72 (48.2% male, 51.8% female). The maximum tumor size ranged from 10 to 90 mm (mean 48.01 ± 15.29 mm, calculated on 116 patients). The maximum size was greater than 50 mm in 59 cases (42.4%). The mean tumor volume, calculated on 100 patients, was 36.52 ± 32.20 cm3 (range 0.35–141.99 cm3). Therefore, the transoral approach may be a feasible technique also for large tumors of the deep parotid lobe that involve PPS.

Pleomorphic adenoma was reported in most cases (116 patients, 84.1%). Other histotypes were basal cell adenoma (9 patients, 6.5%), carcinoma ex pleomorphic adenoma (6 patients, 4.3%), Warthin tumor (3 patients, 2.2%), mucoepidermoid carcinoma (2 patients, 1.4%), oncocytoma (1 patient, 0.7%), and adenocarcinoma (1 patient, 0.7%). Histology was not reported in one case (0.7%). The transoral approach was used for benign masses in most cases (129 patients, 92.8%, Figure 3). Indeed, benign capsulated masses may be removed through a blunt dissection with a lower risk of injury of vascular PPS structures than malignant lesions that infiltrate surrounding tissues. Preoperative imaging (MRI) is mandatory to evaluate the presence of a tumor capsule or pseudocapsule and correctly select patients for the transoral approach (well-circumscribed masses with a clear cleavage plane from great vessels). Extensive tumors without smooth borders and/or surrounding the facial nerve or major vascular structures may not be suitable for this approach. Moreover, the transoral approach has not been used for retrostyloid masses in the selected studies.

Figure 3.

Figure 3

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Tumor histology in transoral approach (n, %). Abbreviations: AC, adenocarcinoma; BCA, basal cell adenoma; CXPA, carcinoma ex pleomorphic adenoma; MEC, mucoepidermoid carcinoma; NR, not reported; O, oncocytoma; PA, pleomorphic adenoma; WT, Warthin tumor.

A pure transoral approach was performed in 125 cases (89.9%), while a combined transcervical/transparotid and transoral approach was used in 14 patients (10.1%). Robotic surgery was reported in 55 cases (39.5%) of pure transoral approach and 11 cases (7.9%) of combined approaches. An endoscopic-assisted transoral approach was described in 41 cases (29.5%). Robotic systems and endoscopes were used to improve the visualization of the mass and PPS structures. Indeed, the main limitations of the transoral approach include a poor visualization of PPS major neurovascular structures with possible uncontrollable bleeding, capsule disruption and tumor spillage, and incomplete tumor removal. According to the size and localization of the mass, 0-, 30-, and 45-degree endoscopes were used for the dissection of tumors’ lateral, superior, and deep margins. The development of endoscopy and surgical robotics reduced such disadvantages and increased the feasibility of the transoral approach. However, surgeons must be able to convert the procedure to a transcervical/transparotid approach if needed (impossibility of complete transoral removal, uncontrollable bleeding). Furthermore, trismus is a contraindication for the transoral approach.

Complications were reported in nine cases (6.5%). They were represented by pharyngeal dehiscence (two cases), deep neck space seroma/sialocele (two cases), facial nerve palsy (two cases), and hyperemia of the skin near angulus mandibulae (one case). Two cases described by Boyce et al. had a complication. However, since other patients with non-parotid tumor histology were reported without matching complications, we could not identify those related to parotid tumors (Figure 4) [31]. All the reported complications were solved. No severe bleeding was reported. However, surgeons must be aware of possible severe bleeding from great vascular structures and ready for a prompt transcervical ligation of external carotid artery. A medial displacement of the internal carotid artery should be considered a contraindication for the transoral approach. Severe postoperative pain was not reported in any cases. Wound closure was usually performed in more than one layer to reduce the risk of postoperative wound dehiscence.

Figure 4.

Figure 4

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Complications in transoral approach.

The mean follow-up was 26.57 ± 36.58 months (range 1–192 months). However, follow-up was not reported in 31 cases (22.3%). One case of pleomorphic adenoma recurred after 39 months. The low recurrence rate suggests that the transoral approach for selected benign masses has a low risk of capsule disruption and/or incomplete tumor removal. One case of mucoepidermoid carcinoma with positive margins after transoral removal underwent a superficial parotidectomy with traditional open approach. An indication to a pure transoral approach for malignant tumors of the deep parotid lobe involving PPS must be accurately evaluated and reserved to highly selected cases.

The success of the transoral approach for tumors of the deep parotid lobe depends on the correct identification and exposure of the mass to allow the complete removal, prevent recurrence and ensure good functional outcomes, taking into account the risks of PPS surgery.

The main limitations of the published studies include the small number of patients, the short follow-up and the lack of a randomized control group that underwent an external approach.

4. Conclusions and Future Perspectives

Selecting the best approach for PPS tumors originating from the parotid deep lobe is based on the volume and extension of the mass to be removed and its putative nature. With these two parameters being established, the less invasive approach that provided sufficient exposure with a low and acceptable complication rate was then chosen. The transoral approach can be selected for benign lesions of the deep parotid lobe that involve prestyloid space. The literature reported a low complication rate with a good recovery in such cases. The novelty of this review was the quantitative analyses of the clinical data reported in the included studies. Further studies with larger samples are mandatory to better understand the role of the transoral approach for PPS tumors with a particular focus on robotic and endoscopic-assisted surgery.

Acknowledgments

We thank Riccardo Accattatis for the anatomical representation of the parapharyngeal space (Figure 1).

Author Contributions

Conceptualization, G.R. and G.P.; methodology, G.R.; formal analysis, G.R.; investigation, A.L. and A.B.; resources, G.R.; data curation, G.R.; writing—original draft preparation, A.L. and A.B.; writing—review and editing, G.R., A.A., A.C. and G.P.; visualization, G.R.; supervision, G.P.; project administration, G.P. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

Funding Statement

This research received no external funding.

Footnotes

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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