Annals of Otology,Rhinology & Laryngology

This study aimed to evaluate pain management strategies implemented by otolaryngologists for acute infectious otologic conditions including Acute Otitis Externa (AOE), Acute Otitis Media (AOM) and Bullous Myringitis (BM). The primary objective was to evaluate pain assessment and treatment across these groups. Secondary objectives analyzed repeat visit rates and their association with incident pain, demographic and clinical characteristics.

A retrospective case-control study of 478 patients presenting to the ED between 01/2022 and 01/2023. Otologic cases were evaluated in the otolaryngology ED and included AOE (n = 316) and AOM / BM (n = 95). Controls consisted of patients with conservatively treated ureterolithiasis (n = 67). Data included demographic and clinical variables, along with a structured evaluation of pain documentation, treatment, and discharge plans. For high-scoring discharge plans, the specifics of prescribed medications were analyzed.

Otologic patients had a mean visual analog scale (VAS) score of 5.0, compared to ureterolithiasis 6.7. Otologic pain management was less comprehensive, with ED treatment administered to 12% to 13%, compared to 72.6% of ureterolithiasis patients (P < .001). Similarly, only 6% to 14.8% of otologic patients received comprehensive analgesic discharge plans, compared to 71.2% in the ureterolithiasis cohort (P < .001). Opioid-based monotherapy was the primary treatment modality in the otologic groups (86%-90%) compare to more diverse and synergistic, NSAID based regimens in the ureterolithiasis cohort. No differences in ED revisits were observed. Age, sex, ethnicity, and comorbidities did not significantly correlate with pain levels or outcomes.

This study reveals shortcomings in pain management in acute otologic conditions. Given the reported inadequacies in pain management training among Otolaryngology trainees, and continued neglect of pain recommendations proposed by specialty- specific clinical practice guidelines, there is an urgent need for analgesic awareness and standardized protocols to ensure consistent and effective care in these everyday conditions.

The role of conductive factors on olfactory acuity has received little attention. The relationships between nasal anatomy, inspiratory airflow and olfaction remain unclear, including if nasal anatomic and functional factors account for some variabilities in odor identification in the absence of sensorineural defects. This preliminary study aimed to analyze olfactory cleft airflow dynamics using computational modeling techniques and to develop linear regression models linking smell identification scores to nasal anatomy and computational-derived functional metrics.

Computational fluid dynamics modeling was used to generate nasal airflow-related parameters based on radiographic images of 10 subjects with varying olfactory acuity, but without prior nasal surgery or nasal deformity. Olfaction was assessed using the University of Pennsylvania Smell Identification Test (SIT).

Average olfactory airflow volume comprised only 2.43% of total nasal airflow volume. Higher olfactory resistance demonstrated strong associations with higher SIT scores. No one particular anatomic or functional parameter correlated strongly with SIT score. However, the 3-parameter linear regression model comprising bilateral nasal surface area-to-volume ratio, bilateral nasal resistance and olfactory resistance accounted for 82% of the variations in SIT scores (P = .01). Among 2-parameter linear regression models, the model comprising bilateral nasal surface area-to-volume ratio and bilateral nasal resistance accounted for 52% of SIT score variability (P = .08).

These findings demonstrate that a significant portion of variability in SIT scores can be explained by the combination of nasal resistance, olfactory resistance, and nasal surface area-to-volume ratio, suggesting that nasal anatomy and airflow-related quantities contribute toward variability in olfaction.

III.

Obstructive sleep apnea (OSA) affects many children, particularly those with Down syndrome (DS), with prevalence estimates ranging from 50% to 100%. Although adenotonsillectomy is the traditional first-line treatment, individuals with DS frequently have residual OSA (rOSA) because to their complex airway architecture. Lingual tonsil hypertrophy has been found as a significant risk factor for rOSA; however, the role of lingual tonsillectomy (LT) in this population is uncertain.

We conducted a systematic review and meta-analysis according to PRISMA and Cochrane guidelines, registered with PROSPERO (CRD42024552955). We included studies of pediatric patients (≤18 years) with DS and rOSA who underwent LT. Primary outcomes were changes in apnea-hypopnea index (AHI), obstructive AHI (OAHI), and oxygen nadir (O₂). Secondary outcomes included postoperative complications.

Three retrospective case series comprising 68 patients met the inclusion criteria. Pooled analysis demonstrated a mean improvement in oxygen nadir of 4.58% (95% CI: 2.73-6.43, I² = 0%). AHI and OAHI scores were decreased by −2.97 (95% CI: −8.88 to 2.94, I² = 24%) and −8.20 (95% CI: −13.46 to −2.94, I² = 0%) respectively. Complication rates were low but inconsistently reported.

Lingual tonsillectomy appears effective in improving OSA severity in children with DS. While promising, outcome improvements may be less pronounced than in the general population, likely due to complex anatomical and physiological factors unique to this group. Standardized outcome measures and prospective studies are needed to better guide management in this high-risk group.

To assess the risk of persistent opioid use after forehead flaps with preserved vascular pedicles.

This multi-center cohort study used the TriNetX, LLC US Collaborative Network to identify patients undergoing forehead flaps with preservation of the vascular pedicle. Patients were grouped based on whether they received an opioid prescription within 1 week of surgery. Propensity matching controlled for age, race, sex, pain diagnoses, and previous opioid use. Baseline characteristics were analyzed with t-tests and chi-squares. Risk ratios assessed associations between variables and development of new persistent opioid use (new opioid prescription 3-9 months after forehead flap reconstruction).

Overall, 7214 patients (3280 female [45.5%]) underwent forehead flap reconstruction with preservation of the vascular pedicle and 2660 (36.9%) receive a postoperative opioid prescription. Unadjusted analysis demonstrated a statistically significant association between gender and receipt of a postoperative opioid prescription, with male patients more likely than female patients to receive an opioid prescription (χ² = 14.94, P < .001). After propensity score matching, 1352 patients (588 women [43.3%]) with a mean (SD) age of 67.3 (14.7) years, were included for analysis. Patients who receive a postoperative opioid prescription were at 3.21 times greater risk of developing new persistent opioid use compared to patients not prescribed postoperative opioids (RR = 3.21; 95% CI (2.27, 4.52)).

Patients who receive postoperative opioid prescriptions after forehead flap reconstruction may be at greater risk of developing new persistent opioid use.

This study aims to compare the accuracy of the TUNE, American Speech-Language-Hearing Association (ASHA), and Common Terminology Criteria for Adverse Events (CTCAE) grading systems in reflecting the severity of treatment-related hearing loss, as measured by pure-tone audiometry and patient-reported hearing loss using the Speech, Spatial, and Qualities of Hearing scale compare questionnaire (SSQ).

This study is a prospective, multicenter, cross-sectional, and observational study from 2018 to 2024 conducted at the Netherlands Cancer Institute - Antoni van Leeuwenhoek Amsterdam, Leiden University Medical Center, and University Medical Center Utrecht. In this trial, 109 patients with an indication for curative platinum-based chemotherapy (dose ≥ 200 mg/m²) were included, of whom 74 were eligible for analysis. Standard frequency and extended high-frequency pure tone audiometry were measured at baseline and follow-up. The SSQ was administered at follow-up to assess patient-reported outcome measures for hearing loss. The TUNE, ASHA, and CTCAE criteria were derived from audiometry. Concordance and Spearman’s correlations were evaluated between all 3 grading systems and the SSQ.

 The concordance of TUNE with the SSQ was 81%. The concordance of CTCAE and ASHA with the SSQ was 73% and 68%, respectively. A statistically significant Spearman’s correlation coefficient of −.35 (P = .01) was found between TUNE and the SSQ. The Spearman’s correlation coefficient with CTCAE or ASHA and SSQ was −.10 (P = .10) and .04 (P = .75), respectively.

This study found that the TUNE is better in reflecting platinum-related patient-reported hearing loss compared to the CTCAE and ASHA.

Unilateral vocal fold paralysis (UVFP) causes denervation of intrinsic laryngeal muscles in varying degrees and results in different types of glottal configurations. While the primary goal of surgery is to improve vocal function, outcomes are strongly influenced by how effectively the underlying laryngeal physiology and alignment are restored. Denervation of the posterior cricoarytenoid (PCA) muscle causes the arytenoid to fall anteriorly and medially. Static procedures such as medialization thyroplasty does not address this. This study evaluates the impact of non-selective laryngeal reinnervation (LR) on arytenoid position and vocal function.

A retrospective study was conducted on 41 patients with UVFP who underwent Non selective reinnervation between 2021 and 2024 at a tertiary care hospital. Arytenoid prolapse was graded using a 3-point scale from laryngoscopy videos pre- and 6 months post-operatively. Voice outcomes were assessed using Maximum Phonation Duration (MPD) and Voice Handicap Index-10 (VHI-10).

Improvement in arytenoid position was defined as an upgrade by at least one grade in the prolapse grading system.70.7% of the patients showed improvement in arytenoid position 6 months post non selective reinnervation surgery. Significant postoperative improvements were observed in both MPD and VHI-10 scores (P < 0.01), correlating with arytenoid stabilization and improved phonatory function.

Non-selective reinnervation not only improves vocal quality but also restores arytenoid position, addressing a key component of glottic insufficiency in UVFP. These findings support reinnervation as a physiologic, durable solution with functional and anatomic advantages over static medialization.

To assess the effect of rhinophototherapy (RPT) on nasal mucosa and inflammatory cells in allergic rhinitis compared to intranasal corticosteroids (INCS).

Adult patients (≥18 years) with newly diagnosed perennial allergic rhinitis (AR) were randomly divided into 2 groups, RPT and INCS. Treatment was administered for 2 weeks. Primary outcome was evaluation of the inflammatory cells and mucosal damage via inferior turbinate biopsy, performed post-treatment. Secondary outcomes measured were visual analogue score (VAS) of clinical symptoms (overall, runny nose, sneezing, nasal block, nasal itchiness and ocular itchiness) and nasal patency using rhinomanometry and peak nasal inspiratory flow (PNIF).

Thirty-five patients were included, with 18 patients randomized into RPT and 17 patients into INCS. The mean age of patients was 31.3 ± 9.6 (range: 19-57). There was no statistically significant difference observed in terms of inflammatory cells in both groups. Similarly, both groups had no differences in mucosal damage parameters. Patients in RPT group showed statistically significant improvement for overall and specific symptoms VAS score (P < 0.05). Comparing both groups, patients using INCS reported bigger effect size for overall VAS score and specific VAS score for runny nose, sneezing, nasal and eye itchiness. Both groups showed improvement in PNIF reading post-treatment although only RPT group showed statistical significance (P = .015). In terms of rhinomanometry, both groups showed significant improvement in post-treatment nasal flow rate (P < .05). There was decrease in total nasal resistance observed in both groups, albeit with RPT being statistically significant (P = .004). There were no adverse events reported in both groups.

There is no significant difference in inflammatory cells of inferior turbinate mucosa and mucosal damage between RPT and INCS. RPT is a safe and suitable short-term alternative (2 weeks) for AR patients who are contraindicated for or unable to tolerate INCS.

The study was registered with ClinicalTrials.gov with the ID: NCT05919316.

This study aims to assess the effectiveness of high-fidelity simulation training in enhancing skills for frontal sinus surgery (FSS) within the framework of continuing medical education.

A cross-sectional, within-subject study was conducted during a CME-accredited national frontal sinus surgery simulation course. Participants completed pre- and post-course surveys rating potential deterrents to FSS. Paired statistical analyses assessed changes in deterrent ratings, and correlational analyses evaluated relationships with surgical experience and case volume.

Twenty-eight participants completed both pre- and post-course surveys. Mean time in practice was 14 years, with an average FSS volume of 2 cases per month. Baseline deterrence was moderate (mean 5.10/10), driven primarily by concern for skull base violation and technical difficulty. Following simulation, overall deterrence decreased significantly by 1.27 points (to 3.83; P < .05), with 7 of 9 deterrents showing significant reduction. The largest improvements were seen in apprehension regarding skull base injury, technical challenge, and adequacy of dissection. Factors related to operative time and prior experience showed minimal change. Case volume correlated with lower baseline and post-simulation hesitancy for select deterrents, while years in practice and interval since last FSS did not. All participants reported improved confidence, and the majority anticipated increased incorporation of FSS into their practice.

Simulation-based CME significantly reduced modifiable deterrents and improved confidence among practicing otolaryngologists performing FSS, regardless of years in practice. These findings support simulation as a valuable adjunct for ongoing professional development, enabling experienced surgeons to recalibrate risk perception, refine technical judgment, and support lifelong surgical learning.

Thyroid cartilage hemangiomas are exceedingly rare. We present a rare case of an expansile tumor within the right thyroid ala that was suspected to represent a chondrosarcoma but was found on pathology to represent a hemangioma. Imaging and pathologic features are reviewed as well as approach to resection and reconstruction.

A 46-year-old male presented with progressive neck fullness and decreased vocal range. He was found to have an expansile mass within the right thyroid ala with associated supraglottic fullness on flexible laryngoscopy. Initial primary differential consideration was chondrosarcoma versus chondroma. He underwent open resection with reconstruction of the right thyroid ala using a rib graft and titanium plate which was used to secure the graft to the contralateral thyroid ala and the ipsilateral inner thyroid perichondrium. Intraoperative frozen sections indicated atypical cartilage cells, but final histopathology revealed a hemangioma with suspected reactive changes in the thyroid cartilage.

This case highlights the diagnostic challenges associated with rare presentations of hemangiomas in atypical locations, such as the thyroid cartilage. It is one of the first reports of hemangioma occurring within the thyroid cartilage. Excision with reconstruction using a rib graft can be employed for large thyroid cartilage tumors.

Neonatal suppurative sialadenitis (NSS) is an uncommon but serious complication of salivary gland infection, with few cases reported in literature, most often affecting preterm infants. Typical cases involve the parotid gland and are caused by Staphylococcus aureus infection. Contributing factors include prematurity, dehydration, prolonged hospitalisation, and immature immunity. Sequential bilateral gland involvement through haematogenous spread is rare, and presents significant management challenges in prematurity.

We report the case of a preterm infant, born at 30 weeks gestation, who spontaneously developed acute left-sided parotid swelling at 3 weeks old in NICU. Inflammatory markers were significantly elevated and blood cultures grew Staphylococcus epidermidis. Initial treatment was with broad-spectrum intravenous antibiotics, and after no significant improvement, confirmatory ultrasound, and subsequent bedside percutaneous drainage was performed by ear, nose, and throat (ENT) surgeons. Subsequently, they developed a second abscess in the contralateral submandibular gland, needing further bedside aspiration. Pus cultures isolated Staphylococcus aureus, and they improved with culture-driven antibiotics.

We highlight the importance of combining early antimicrobial therapy with minimally invasive procedural intervention in managing NSS, as well as the rarity of multiple, sequential gland involvement. Early drainage limits progression when empirical treatment fails and helps guide antimicrobial choice. It minimises the need for more invasive surgical intervention, which is complex in preterm infants.

A high index of suspicion, early minimally invasive drainage and prompt initiation of targeted antibiotics, are key to optimal outcomes in NSS, particularly in preterm infants at higher risk of severe disease.