10.14639/0392-100X-N2022
Objective. The Neck Dissection Impairment Index (NDII) questionnaire is a useful and validated Quality of Life (QoL) evaluation instrument in patients undergoing major head-neck surgery. Its English version has been used in several studies in the last years. The aim of this work is to validate the NDII in Italian for both patient assessment and future studies. Materials and methods. Cross-cultural adaptation of the NDII was performed using standard techniques. Items of the original NDII were translated into Italian by a professional translator and two bilingual investigators. A final consensus version was obtained and given to two professional translators to produce a literal translation into English. The two translators and an expert committee synthesised the results of the translations in an English back-translated version that was compared with the original to check that they had the same semantic value. Results. Finally, a total of 42 patients completed both copies of the translated questionnaires. Internal consistency proved to be excellent, with Cronbach’s alpha = 0.95. Conclusions. The NDII was successfully translated into Italian and its use was easy for patients. The translation of the NDII can represent a useful tool for individual patient assessment and future research.
text/xml
1827-675X
2022
en
Giancarlo Tirelli
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
validation
Italian validation of the Neck Dissection Impairment Index questionnaire
Text.Serial.Journal
https://www.actaitalica.it/
42
Head and neck
2022-06-30
2022-01-27
2022-07-26
2022-07-26
230-236
1
Giancarlo Tirelli
2022/06/30
10.14639/0392-100X-N2022
230
Otorhinolaryngology and Head and Neck Surgery Clinic, Azienda Sanitaria Universitaria Giuliano Isontina - ASUGI, Trieste, Italy
1827-675X
validation
en
236
Italian validation of the Neck Dissection Impairment Index questionnaire
https://www.actaitalica.it/article/download/2022/820
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:230-236; doi: 10.14639/0392-100X-N2022




Head and neck


Italian validation of the Neck Dissection Impairment
Index questionnaire
Validazione in italiano del questionario Neck Dissection Impairment Index
Alberto Vito Marcuzzo1, Erica Sacchet1, Vincenzo Capriotti1, Nicoletta Gardenal1, Paolo Boscolo-Rizzo1,
Douglas Brian Chepeha2, Giancarlo Tirelli1
1
    Otorhinolaryngology and Head and Neck Surgery Clinic, Azienda Sanitaria Universitaria Giuliano Isontina - ASUGI, Trieste, Italy;
2
    Department of Otolaryngology-Head & Neck Surgery, University of Toronto UHN, Toronto General Hospital Toronto, ON, Canada


SUMMARY
Objective. The Neck Dissection Impairment Index (NDII) questionnaire is a useful and
validated Quality of Life (QoL) evaluation instrument in patients undergoing major head-
neck surgery. Its English version has been used in several studies in the last years. The aim
of this work is to validate the NDII in Italian for both patient assessment and future studies.
Materials and methods. Cross-cultural adaptation of the NDII was performed using standard
techniques. Items of the original NDII were translated into Italian by a professional transla-
tor and two bilingual investigators. A final consensus version was obtained and given to two
professional translators to produce a literal translation into English. The two translators and
an expert committee synthesised the results of the translations in an English back-translated
version that was compared with the original to check that they had the same semantic value.
Results. Finally, a total of 42 patients completed both copies of the translated question-
naires. Internal consistency proved to be excellent, with Cronbach’s alpha = 0.95.
Conclusions. The NDII was successfully translated into Italian and its use was easy for
patients. The translation of the NDII can represent a useful tool for individual patient as-
sessment and future research.
KEY WORDS: quality of life, neck dissection, questionnaire, head and neck surgery,
validation                                                                                        Received: January 27, 2022
                                                                                                  Accepted: April 25, 2022

RIASSUNTO                                                                                         Correspondence
Obiettivi. Lo scopo del lavoro è convalidare il questionario Neck Dissection Impairment           Alberto Vito Marcuzzo
Index (NDII) in italiano, unico questionario specifico per valutare in maniera specifica la       Otorhinolaryngology and Head and Neck Surgery
qualità di vita dei pazienti sottoposti a svuotamento laterocervicale.                            Clinic, Azienda Sanitaria Universitaria Giuliano
Materiali e metodi. L’adattamento interculturale dell’NDII è stato eseguito utilizzando           Isontina - ASUGI, strada di Fiume 447, 39149
                                                                                                  Trieste, Italy
tecniche standard. Gli elementi dell’NDII originale sono stati tradotti in italiano da un
                                                                                                  Tel. +39 040 3994099
traduttore professionista e due investigatori bilingue. Una versione finale di consenso è         E-mail: avmarcuzzo@gmail.com
stata ottenuta e data a due traduttori professionisti per produrre una traduzione lettera-
le in inglese. I due traduttori e un comitato di esperti hanno sintetizzato i risultati delle
traduzioni in una versione retrotradotta in inglese che è stata confrontata con l’originale         How to cite this article: Marcuzzo AV, Sacchet
per verificare che avessero lo stesso valore semantico. Infine, un totale di 42 pazienti ha         E, Capriotti V, et al. Italian validation of the Neck
                                                                                                    Dissection Impairment Index questionnaire. Ac-
completato entrambe le copie dei questionari tradotti.
                                                                                                    ta Otorhinolaryngol Ital 2022;42:230-236. https://
Risultati. La consistenza interna si è rivelata ottima, con alfa di Cronbach = 0,95. L’NDII         doi.org/10.14639/0392-100X-N2022
è stato tradotto con successo in italiano e il suo utilizzo è stato facile per i pazienti.
Conclusioni. La traduzione dell’NDII potrebbe rappresentare uno strumento molto utile             © Società Italiana di Otorinolaringoiatria
per la valutazione del singolo paziente e la ricerca futura.                                      e Chirurgia Cervico-Facciale

PAROLE CHIAVE: qualità di vita, svuotamento laterocervicale, questionario, chirurgia
                                                                                                                 OPEN ACCESS
testa e collo, validazione
                                                                                                  This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
Introduction                                                                                      Commercial-NoDerivatives 4.0 International) license. The
                                                                                                  article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
Carcinomas of the head and neck are estimated to be the 6th most common                           only in the original version. For further information: https://
cancer worldwide, and metastatic spread to the lymph nodes is extremely fre-                      creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                 Italian version of the Neck Dissection Index questionnaire




quent 1. Therapeutic options for this disease are surgery          lected because no substantial change was expected to take
and radio-chemotherapy, in several combinations. With              place in the subjects’ condition within this period. When
regard to surgery, uni- or bilateral neck dissection (ND)          completing the second NDII, the subjects did not have the
is widely accepted as the gold standard treatment for neck         chance to check their responses on the previous question-
nodes 2. ND is not, however, free from medium- and long-           naires.
term complications, such as XI, VII and XII cranial nerve
deficit and aesthetic burden of the surgical scar 3. With          Translation and cross-cultural adaptation
the progress of surgical techniques and increased aware-           Cross-cultural adaptation of the NDII questionnaire
ness of the importance of the psychological impact on pa-          was performed using standard techniques 8. Items of
tients, more attention is being given to the quality of life       the original NDII were translated into Italian by a pro-
(QoL). In 2002, Taylor et al. developed the Neck Dissec-           fessional translator and two bilingual investigators. Two
tion Impairment Index (NDII) questionnaire 4, a 10-item            independent otolaryngologists familiar with the process
instrument that assesses several aspects of everyday life          of instrument validation examined semantic, idiomatic
following ND. To date, this is the only tool assessing QoL         and conceptual issues to further refine these versions. A
in head and neck cancer patients that specifically analyses        final consensus version was obtained and given to two
the physical and psychological impact of ND. The aim               professional translators to produce a literal translation
of our study was to develop and validate an easily usable          into English. The two translators and an expert committee
version of the NDII questionnaire for Italian-speaking pa-         synthesised the results of the translations in an English
tients.                                                            back-translated version that was compared with the origi-
                                                                   nal to check that they had the same semantic value. Points
Materials and methods                                              of disagreement were resolved, as shown in the section
                                                                   “translation” of the results chapter. The final Italian ver-
                                                                   sion is shown in Table I.
Patients
The study group was selected among all patients con-               Questionnaire and calculation of the final score
secutively treated with ND for any head and neck cancer            The NDII is a 10-item validated questionnaire. The
between 1st January 2019 and 31st December 2019 at the             translated and adapted final copy of the questionnaire
Department of Otolaryngology - Head and Neck Surgery               was administered to the patients twice approximately 2
of Cattinara Hospital (Trieste, Italy). Eligibility criteria in-   weeks apart. The patients were asked how much they
cluded previously untreated and diagnosed head and neck            had been bothered by the listed symptoms in the past 4
cancer and concurrently requiring ND as part of the man-           weeks, on a 5-point scale: “not at all,” “a little bit,” “a
agement of the cancer, no neurological associated disease,         moderate amount,” “quite a bit,” or “a lot”. Scoring was
and cognitive ability within normal limits (Mini-Mental            achieved by rating the item responses from 1 to 5, with 5
State Examination > 25, corrected for age and educational          representing better quality of life related to neck dissec-
level) 5. Patients were excluded if they had undergone sur-        tion. The single scores were summed up to obtain a raw
gery less than 11 months previously, reported any history          score, which was then transformed to a 0 to 100-point
of unrelated neck or shoulder pathological conditions, had         scale by applying the following equation: [(raw score -
known recurrent disease at the time of evaluation, or had a        10)/40] x 100.
lack of basic written and oral command of the Italian lan-
guage.                                                             Statistics
Demographic data were collected retrospectively, together          Continuous variables were expressed as means and stand-
with clinical and pathological tumour stage using the 8th          ard deviation or medians and interquartile ranges, accord-
edition of American Joint Committee on Cancer. (AJCC)/             ing to data distribution determined with the Shapiro-Wilk
Union Internationale Contre le Cancer (UICC)/TNM clas-             test. Categorical variables were summarised as counts and
sification 6. Neck dissections were defined according to the       percentages. Means were compared using the Student t-
classification provided by the American Academy of Oto-            test. The X2 test was used to compare percentages. Internal
laryngology – Head and Neck Surgery in 1991 and subse-             consistency was tested using Cronbach’s coefficient alpha.
quent updates 7.                                                   Values ≥ 0.7 were regarded as satisfactory 9. Reproducibil-
To evaluate the test-retest reliability of the NDII, the ques-     ity, or test-retest reliability, was assessed using Pearson’s
tionnaire was administered twice approximately 2 weeks             correlation coefficient between the first and the second ad-
apart to all patients enrolled. This interval period was se-       ministrations of the questionnaire.



                                                                                                                                     231
A.V. Marcuzzo et al.




Table Ia. English translation of the Italian version of the Neck Dissection Impairment Index Questionnaire.
 With regard to the treatment received on your neck for your cancer, how much discomfort have the following caused you over the past 4 weeks?
 Q1. Have you suffered from pain or discomfort in your neck or shoulder?
      Not at all             A little bit             A moderate amount                                  Quite a bit                  A lot

 Q2. Have you experienced stiffness in your neck or shoulder?
      Not at all             A little bit             A moderate amount                                  Quite a bit                  A lot

 Q3. Have you experienced limitations in looking after yourself because of your neck and shoulder (e.g., combing your hair, dressing, washing yourself, etc.)?
      Not at all               A little bit               A moderate amount                   Quite a bit                  A lot

 Q4. Have you been limited in lifting light objects because of your neck or shoulder?
      Not at all              A little bit              A moderate amount                                Quite a bit                  A lot

 Q5. Have you been limited in lifting heavy objects because of your neck or shoulder?
      Not at all              A little bit             A moderate amount                                 Quite a bit                  A lot

 Q6. Have you been limited in reaching up for objects placed high up (e.g., on shelves, tables counters) because of your neck or shoulder?
      Not at all              A little bit            A moderate amount                    Quite a bit             A lot

 Q7. Have you suffered limitations in your overall activities because of your neck or shoulder?
      Not at all              A little bit               A moderate amount                 Quite a bit                                A lot

 Q8. Has the treatment you received affected your participation in social activities?
      Not at all             A little bit             A moderate amount                                  Quite a bit                  A lot

 Q9. Has your neck or shoulder limited your ability to carry out leisure or recreational activities?
      Not at all             A little bit               A moderate amount                    Quite a bit                              A lot

 Q10. Has your neck or shoulder limited your ability to work (including work at home)?
     Not at all              A little bit              A moderate amount                                 Quite a bit                  A lot



Table Ib. Italian version of the Neck Dissection Impairment Index Questionnaire.
 Riguardo il trattamento ricevuto al collo per la sua neoplasia, quanto disagio le hanno causato i seguenti disturbi nelle ultime 4 settimane?
 Q1. Ha avuto disagi causati dal dolore o dal fastidio al collo o alla spalla?
      Per nulla               Poco                  Moderatamente                               Abbastanza                    Molto

 Q2. Ha avuto disagi causati dalla rigidità del collo o della spalla?
      Per nulla               Poco                   Moderatamente                              Abbastanza                    Molto

 Q3. Ha avuto disagi legati a limitazioni nel prendersi cura di se stesso a causa del collo o della spalla (ad esempio, pettinarsi, vestirsi, lavarsi, etc.)?
      Per nulla                  Poco                   Moderatamente                     Abbastanza                    Molto

 Q4. Si è sentito/a limitato/a, a causa del collo o della spalla, nel sollevare oggetti leggeri?
      Per nulla                 Poco                 Moderatamente                      Abbastanza                            Molto

 Q5. Si è sentito/a limitato/a, a causa del collo o della spalla, nel sollevare oggetti pesanti?
      Per nulla                 Poco                 Moderatamente                     Abbastanza                             Molto

 Q6. Si è sentito/a limitato/a, a causa del collo o della spalla, nel prendere oggetti posti in alto (ad esempio, su mensole, su tavoli o banconi)?
      Per nulla                 Poco                 Moderatamente                    Abbastanza                  Molto

 Q7. Ha avuto disagi legati alle sue attività in genere a causa del collo o della spalla?
      Per nulla                Poco                  Moderatamente                              Abbastanza                    Molto

 Q8. La terapia che ha ricevuto al collo ha condizionato la sua partecipazione ad attività sociali?
      Per nulla               Poco                 Moderatamente                   Abbastanza                                 Molto

 Q9. Il collo o la spalla hanno limitato le sue capacità nell’eseguire attività di piacere o ricreative?
      Per nulla                 Poco                 Moderatamente                     Abbastanza                             Molto

 Q10. Il collo o la spalla hanno limitato la sua capacità di lavorare (inclusi i lavori a casa)?
     Per nulla                  Poco                 Moderatamente                      Abbastanza                            Molto




232
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P values < 0.05 (two-sided) were considered statistically        Table II. Patient and disease characteristics. Continuous variables are re-
significant. Statistical analyses were performed using SPSS      ported as mean (standard deviation). Categorical variables are reported as
                                                                 number (percentage).
Version 26 (IBM Corp., Armonk, NY, USA).
                                                                  Patient and disease characteristics                          n = 42
                                                                  Age                                                         67.5 (2.0)
Results                                                           Gender
                                                                     Male                                                     23 (54.8)
Patient and disease characteristics                                  Female                                                   19 (45.2)
Sixty-three patients underwent neck dissection at our centre      BMI                                                         26.0 (3.8)
during the selected period. Six had received previous neck        Primary tumour
surgery, four had received previous radiotherapy, five were          Oral cavity                                               24 (57)
lost to follow-up, one refused to participate in the study for       Oropharynx                                                7 (16.7)
personal reasons, four did not complete the second copy              Larynx                                                    3 (7.1)
of the questionnaire and one showed cognitive decline ac-            Hypopharynx                                               1 (2.4)
cording to the Mini-Mental State Examination. Finally, a             Thyroid                                                   2 (4.8)
total of 42 patients completed both copies of the translated         Salivary glands                                           2 (4.8)
questionnaires, 19 (45.2%) females and 23 (54.8%) males,
                                                                     Facial skin                                               1 (2.4)
with a mean age 67.5 years (2.0).
                                                                     Unknown primary                                           2 (4.8)
The primary tumours mainly involved the oral cavity
                                                                  Histology
(24/42, 57.1%). The most common histology was squa-
                                                                     Squamous cell carcinoma                                   37 (88)
mous cell cancer (37/42, 88.1%). Most patients presented
                                                                     Adenoid cystic carcinoma                                  1 (2.4)
with a cN0-cN1 neck (17/42 [40.5%], 14/42 [33.3%], re-
                                                                     Melanoma (skin)                                           1 (2.4)
spectively). Patient and disease characteristics are summa-
rised in Table II.                                                   Papillary thyroid carcinoma                               2 (4.8)
                                                                     Malignant peripheral nerve sheath tumour                  1 (2.4)
Treatment characteristics                                         cT
Eleven patients received bilateral ND; of these, two patients        X                                                         2 (4.8)
also completed the original English version of the ques-             1                                                        7 (16.7)
tionnaire. Twelve patients received adjuvant radiotherapy            2                                                        14 (33.3)
(12/42, 28.6) and seven adjuvant chemotherapy (16.7%).               3                                                        6 (14.3)
Details on the type of neck dissection and adjuvant treat-           4                                                        13 (31.0)
ment are listed in Table III.                                     cN
                                                                     0                                                        17 (40.5)
Translation                                                          1                                                        14 (33.3)
In the review of the forward translations into Italian the           2b                                                       6 (14.3)
translators had 3 points of disagreement. Of these, all rep-         2c                                                        2 (4.8)
resented different wordings, but the meaning was the same.           3b                                                        3 (7.1)
More in detail, the inconsistencies regarded the following        Tumour stage
expressions:                                                         I                                                        11 (26.2)
• “treatment” (Pre-question box, question 8); the words              II                                                       12 (28.6)
   “trattamento” and “terapia” have been proposed; a con-
                                                                     III                                                      10 (23.8)
   sensus was obtained on “terapia” since it is more specific
                                                                     IVa                                                       4 (9.5)
   for a medical context, while “trattamento” includes non-
                                                                     IVb                                                      5 (11.9)
   medical practices;
• “...bothered...” (Pre-question box, questions 1-2-3-7);
   the words “disturbo” and “disagio” have been pro-
   posed; a consensus was obtained on “disagio” since               housework (question 10); among various translations
   this word better includes the psychological aspects re-
                                                                    (“lavori a casa”, “lavori domestici”, “faccende do-
   lated to the disease;
• ‘...work at home...’ according to original paper, the             mestiche”) we opted for “lavori a casa”, that appeared
   wording referred to both working from home and                   more inclusive and reflected the original meaning.



                                                                                                                                          233
A.V. Marcuzzo et al.




Table III. Characteristics of neck dissection and adjuvant therapy. Data are               Table IV. Validation tests of the Italian version of the Neck Dissection.
reported as number (percentage).                                                                                                                 r          p-value
 Treatment characteristic                                        All                        Internal consistency test
                                                               n = 42
                                                                                            Cronbach alpha = 0.95
    Neck dissection*                                                  53 (100.0)
                                                                                            Test-retest correlation
    Unilateral                                                         31 (73.8)
                                                                                               Q1                                            0.87          < 0.001
    Bilateral                                                          11 (26.2)
                                                                                               Q2                                            0.82          < 0.001
    Side*
                                                                                               Q3                                            0.88          < 0.001
       Right                                                           30 (56.6)
                                                                                               Q4                                            0.80          < 0.001
       Left                                                            23 (43.4)
                                                                                               Q5                                            0.77          < 0.001
    Type*
                                                                                               Q6                                            0.90          < 0.001
       Selective 1-3                                                   15 (28.3)
                                                                                               Q7                                            0.82          < 0.001
       Selective 1-4                                                   12 (22.6)
                                                                                               Q8                                            0.76          < 0.001
       Selective 2-4                                                    5 (9.4)
                                                                                               Q9                                            0.76          < 0.001
       Radical                                                          3 (5.7)
                                                                                               Q10                                           0.84          < 0.001
    Modified radical                                                   18 (34.0)
                                                                                               Total                                         0.95          < 0.001
       Preserved IJV**                                                 17 (94.4)
                                                                                            Italian-English test-retest correlation
       Preserved SCM**                                                18 (100.0)
                                                                                               Q1                                            0.94          < 0.001
       Preserved SAN**                                                 15 (83.3)
                                                                                               Q2                                            0.90          < 0.001
    Adjuvant radiotherapy
                                                                                               Q3                                            0.94          < 0.001
       Yes                                                             12 (28.6)
                                                                                               Q4                                            0.73           0.02
       No                                                              30 (71.4)
                                                                                               Q5                                            0.76           0.01
    Adjuvant chemotherapy
                                                                                               Q6                                            0.99          < 0.001
       Yes                                                              7 (16.7)
                                                                                               Q7                                            0.94          < 0.001
       No                                                              35 (83.3)
                                                                                               Q8                                            0.73           0.02
*
  Percentage refers to the total of the neck dissections per group. ** Percentage refers
to the total of modified radical ND per group. IJV: internal jugular vein; SCM: sterno-        Q9                                            0.95          < 0.001
cleidomastoid.                                                                                 Q10                                           0.94          < 0.001
                                                                                               Total                                         0.98          < 0.001

Reliability
Internal consistency proved to be excellent, with Cron-
                                                                                           Chepeha et al. in 2002 and since then it has been used in
bach’s alpha = 0.95.
                                                                                           several studies in English-speaking populations 4,12,13. The
Test-retest reliability for the Italian version was confirmed
                                                                                           questionnaire has also been used as a comparison for the
by the Pearson correlation coefficient (r = 0.95, N = 53,
                                                                                           validation of less specific instruments, such as the Disabili-
p < 0.001). A significant test-retest reliability was also
                                                                                           ties of the Arm, Shoulder, and Hand (DASH) questionnaire
found between the Italian and the English version (r = 0.98,
N = 12, p < 0.001). All items showed a Pearson’s r > 0.70,                                 for use in patients after ND for head and neck cancer 14.
in the test-retest reliability analysis. Detailed results of the                           As for other languages, the NDII has been used in a study
reliability tests are reported in Table IV.                                                on Dutch patients even though, to our knowledge, no of-
                                                                                           ficial validation in Dutch exists 15. Recently, the question-
                                                                                           naire has been translated into Danish and validated on a
Discussion                                                                                 sample of 10 patients 11. Ours is therefore the second study
QoL following cancer treatment is important because of the                                 that would lead to validation of the NDII questionnaire in
long-term effects on activities of daily living and employ-                                another language, and on a larger patient population. Other
ment 10. The growing rates of HPV-induced oropharyngeal                                    questionnaires investigating QoL outcomes following head
cancers have, in fact, lowered the mean age at onset of                                    and neck cancer treatments have also been validated 16-18.
these tumours throughout the world 11. While various tests                                 Marchese et al. demonstrated the reliability of the “Univer-
for the assessment of QoL have been published in the lit-                                  sity of California - Los Angeles (UCLA) Shoulder Scale”,
erature, only one provides a focused analysis of the effects                               of the “Shoulder Pain and Disability Index” (SPADI) and
of ND on QoL. The NDII questionnaire was developed by                                      the Simple Shoulder Test (SST) 18. However, although valu-



234
                                                                                       Italian version of the Neck Dissection Index questionnaire




able and widely adopted, these questionnaires focus on mo-          Ethical consideration
tor functionality following ND without taking into account          This study was performed in accordance with the ethical
the psychological aspects covered by the NDII question-             standards of the National Research Committee and with
naire. The problems of translation from Italian (or any Ro-         the 1964 Helsinki Declaration and its later amendments.
mance language) to English can be cultural and not purely           Informed consent to the use of their data was obtained from
linguistic. Besides linguistic issues (e.g. resolving the inde-     all the participating individuals. Patient data was collected
terminate gender/number) literal translation of some Eng-           retrospectively. Approval from the ethics committee is not
lish expressions can lead to conceptual misunderstanding.           required for this type of study in our institution.
In this work, we have an example of this translating the
word “treatment” whose literal translation is “trattamento”.        References
Both the words “trattamento” and “terapia” could be used            1
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                                                                         Tirelli G, Marcuzzo AV. Lymph nodes of the perimandibular
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gio” were proposed; a consensus was obtained on “disagio”           3
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at home (e.g. use of the PC on smartworking).                       6
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Conclusions                                                         7
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Our data suggest that the Italian version of the NDII ques-              yngol Head Neck Surg 2008;134:536-538. https://doi.org/10.1001/
tionnaire represents a reliable and useful tool for head and             archotol.134.5.536.
neck surgeons, and we hope that further studies will be pos-        8
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Acknowledgements                                                    9
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Dip TEFLA, teacher of Medical English at the University             10
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of Trieste, for her support in editing the manuscript.                   modality neck treatment and work and leisure impairment: a disease-
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Conflict of interest statement                                           893. https://doi.org/10.1001/jamaoto.2015.2049
The authors declare no conflict of interest.                        11
                                                                         Scott SI, Wessman M, Lunderskov E, et al. Danish translation of the
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Funding                                                                  648. https://doi.org/10.1080/00016489.2021.1901986
This research did not receive any specific grant from fund-
                                                                    12
                                                                         Farlow JL, McLean SA, Peddireddy N, et al. Impact of completion
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                                                                    13
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Authors’ contributions                                                   shoulder function among survivors of oropharyngeal squamous cell
                                                                         carcinoma treated with chemoradiation as assessed with the neck dis-
AVM, ES and GT: ideation, draft and review. VC and PB-                   section impairment index. Head Neck 2021;43:1621-1628. https://
R: draft and review. NG: review. DC: ideation and review.                doi.org/10.1002/hed.26636




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