A medical student-run newsletter showcasing the latest cutting edge research in otolaryngology
Issue #98
22 October 2025
Educational Pearl
Granulomatosis with Polyangiitis (GPA)
Overview: GPA is a necrotizing small-vessel vasculitis with variable organ involvement and disease severity. Common manifestations include glomerulonephritis, pulmonary nodules, constitutional symptoms, skin lesions, and peripheral neuropathy. Otolaryngologic findings may include chronic sinusitis with bloody nasal discharge, sinonasal masses, strawberry gingivitis, tooth loosening, septal perforation and saddle nose deformity, subglottic granulomas or stenosis, otitis media, hearing loss, or vestibular dysfunction.
ENT Involvement and Skin or Mucosal Lesions in GPA [Image Source]
Epidemiology:
Typical age of onset: 60 to 79 years
Most common in patients of European ancestry
Incidence increases with distance from the equator
Prevalence ranges from 2.3 to 146 cases per 1,000,000 people
Etiology:
Caused by anti-neutrophil cytoplasmic antibodies (ANCA) directed against proteinase 3 (PR3) on neutrophils
ANCA–PR3 binding leads to neutrophil activation, increased endothelial adherence, degranulation, and vessel wall damage
Diagnosis: based on clinical findings, laboratory testing, imaging, histopathology
Laboratory Tests:
ANCA (positive in 82 to 94% of patients)
Other: CBC, BMP, ESR, CRP, LFTs, ANA, anti-GBM antibodies, complement, blood cultures, viral serologies, TB, urinalysis
Imaging:
Chest X-ray and CT to detect pulmonary lesions
Selective head or neck CT for sinonasal or subglottic symptoms
Biopsy: Tissue sampling at sites of suspected active disease for histopathologic confirmation
Management:
Goal: Achieve rapid, sustained remission
For Organ-Threatening Disease: Glucocorticoid plus rituximab or cyclophosphamide for induction; add plasma exchange if severe
For Non-Organ-Threatening Disease: Glucocorticoid plus methotrexate for induction
Maintenance: Rituximab (or alternatives) for 12 to 24 months
Further Readings:
[1] StatPearls - GPA
[2] ENT Involvement in GPA - Presentation, Severity, Outcomes
Educational Pearl written by Gina Spencer
Queen's University School of Medicine
Question of the Week
A 45-year-old woman presents for reconstruction following Mohs micrographic surgery for a nodular basal cell carcinoma of the right nasal ala. The 1.2 cm preoperative lesion involved the alar rim. After tumor clearance, she is left with a 1.5 x 1.5 cm full-thickness defect involving the external skin, lower lateral cartilage, and vestibular lining, extending to the nasal sill. On examination, there is loss of alar contour and collapse on inspiration. She has no history of nasal surgery or radiation and does not smoke. She works in a client-facing public relations role and is concerned about both nasal symmetry and breathing. She is seeking a reconstructive option that will optimize cosmetic and functional outcomes.
Which of the following reconstructive options is most appropriate for this patient?
(A) Full-thickness skin graft from the postauricular area
(B) Bilobed transposition flap
(C) Paramedian forehead flap with cartilage graft and intranasal lining flap
(D) Primary closure with layered suturing
(E) Nasolabial flap without cartilage reconstruction
Question of the Week written by Luke Reardon
Lincoln Memorial University DeBusk College of Osteopathic Medicine
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Our national otolaryngology faculty reviewers have been instrumental in ensuring that we continue to share high-quality content. We thank them for their monthly contributions to The Auricle.
Head and Neck Surgery
Dr. Michael Topf, MD
Vanderbilt University Medical Center
Otology and Neurotology / Medical Student Feature
Dr. Terence Imbery, MD
University of Chicago Medical Center
Pediatric Otolaryngology
Dr. Michele Carr, MD, DDS, PhD
Jacobs School of Medicine, University at Buffalo
Pediatric Otolaryngology
Dr. Peter Papagiannopoulos, MD
Rush University Medical Center
Med Student Feature Series
The Auricle proudly spotlights med student-led research published in top otolaryngology journals through our Med Student Feature Series. Here we celebrate future otolaryngologists and the evidence-based discoveries they made during medical school.
Hearing Phenotypes in Children With Congenital CMV
Liang S, Huang E, Stout J, et al. Comparison of Hearing Phenotypes Among Children with Congenital Cytomegalovirus and Other Non-Cytomegalovirus Conditions. OTO Open. 2025;9(2):e70087. [Article Link]
Listening for clues
Congenital cytomegalovirus (cCMV) accounts for approximately 25% of non-genetic sensorineural hearing loss (SNHL) in children over four years old. This study aimed to determine whether audiograms reveal a distinct hearing phenotype diagnostic of cCMV. A retrospective cohort study was conducted from 2006 to 2022 of 72 pediatric SNHL patients treated at a tertiary children's hospital with confirmed diagnoses of cCMV with isolated SNHL, enlarged vestibular aqueduct (EVA), connexin 26 mutation, or idiopathic SNHL. Outcomes were assessed using audiometric thresholds across frequencies (250 to 4,000 Hz) and pure tone averages (PTA), which were analyzed with ANOVA and receiver-operating characteristic (ROC) curve modeling. The cCMV with isolated SNHL group demonstrated significantly greater hearing threshold asymmetry than the connexin 26 (p < 0.001), EVA (p < 0.001), and idiopathic SNHL groups (p < 0.006), with a PTA difference of 58.6 dB identifying cCMV with 94% specificity and the highest ROC area for prediction (AUC 0.81, 95% CI 0.66 to 0.95). Longitudinally, hearing progression did not differ between the cCMV and idiopathic groups. These findings suggest that children with cCMV often have distinct asymmetrical hearing thresholds, which may serve as a useful diagnostic marker when traditional testing is unavailable.
Med Student Feature Summary written by Priyanka Shah
Edward Via College of Osteopathic Medicine
Shi Liang
University of Utah Spencer Fox Eccles School of Medicine, Class of 2026
Are you a medical student with a recent first-author publication?
Email theauricleotolaryngology@gmail.com to be featured!
Facial Plastic and Reconstructive Surgery
Osteotome Versus Piezoelectric Rhinoplasty
Vural O, Koycu A. Comparison of Upper and Lower Eyelid Edema and Ecchymosis Following Rhinoplasty: A Study of Osteotome Versus Piezoelectric Techniques. Facial Plast Surg Aesthet Med. Published online June 25, 2025. [Article Link]
Postoperative periorbital edema and ecchymosis are common after rhinoplasty, but differences between the upper and lower eyelids have not been well studied. Although both conventional osteotomes and piezoelectric devices can be used during rhinoplasty, the authors of this study hypothesized that the latter technique results in decreased eyelid edema and ecchymosis. This prospective randomized clinical study compared conventional osteotomes with piezoelectric devices in 124 patients undergoing rhinoplasty by the same surgeon. Patients were randomly assigned to either technique, and edema and ecchymosis were assessed by a blinded evaluator on postoperative days (POD) one, three, and seven using a standardized 0 to 4 scale. Edema was consistently greater in the upper eyelids in both groups across all time points (p < 0.001). Ecchymosis was initially greater in the lower eyelids on POD one but became more prominent in the upper eyelids on POD three and seven. The piezoelectric group showed significantly less ecchymosis in the lower eyelids on all PODs (p < 0.001) and in the upper eyelids on POD seven (p = 0.026). Because all surgeries were performed by the same surgeon without postoperative steroid use, these results highlight the potential advantages of piezoelectric devices over traditional osteotomes in reducing periorbital ecchymosis after rhinoplasty.
Facial Plastic and Reconstructive Surgery Summary written by Maaz Haji
Chicago Medical School, Rosalind Franklin University
Head and Neck Surgery
Survival in Young Low-Risk Oral Cavity SCC
Judd RT, Sethuraman S, Rind F, et al. Survival Outcomes in Young Nonsmoking-Nondrinking Individuals with Oral Cavity Squamous Cell Carcinoma. Head Neck. Published online July 28, 2025. [Article Link]
Not your typical risk factors
The incidence of oral cavity squamous cell carcinoma in young patients without smoking or drinking histories is rising. This retrospective review analyzed 630 surgically treated patients at a single tertiary center (2012 to 2019), stratifying by age (≤ 40 vs. > 40 years) and smoking/drinking status to compare survival outcomes. Patients with tumors outside the oral cavity or involving the cutaneous lip were excluded, and data on demographics, comorbidities, tumor characteristics, staging, surgical details, complications, survival, and recurrence were collected. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Despite higher rates of adjuvant chemoradiation among younger patients (38% vs. 18%; p = 0.007), DFS (log-rank p = 0.687) and OS (log-rank p = 0.097) did not differ significantly between young nonsmoking-nondrinking (NSND) patients and other groups. On multivariable analysis, worse survival was associated with nodal stage (N2 vs. N0 hazard ratio [HR] 3.87, 95% confidence interval [CI] 2.50 to 5.98; N3 vs. N0 HR 3.43, 95% CI 2.11 to 5.58; both p < 0.001), hypothyroidism (HR 2.17, 95% CI 1.52 to 3.10; p < 0.001), perineural invasion (HR 1.99, 95% CI 1.42 to 2.80; p < 0.001), COPD (HR 1.55, 95% CI 1.21 to 1.99; p = 0.021), and low BMI (HR 1.67, 95% CI 1.27 to 2.21; p < 0.001), but not age or smoking/drinking history (all p > 0.05). These findings suggest that young NSND patients may have distinct tumor biology and that intensified therapy alone may not improve survival.
Head and Neck Surgery Summary written by Ashton Huppert Steed
University of Arizona College of Medicine Phoenix
Laryngology
Socioeconomic Status and Pediatric Voice Disorders
Fujiki RB, Thibeault SL. Socioeconomic Status, Voice Disorder Risk, and Voice-Related Handicap Across Childhood. JAMA Otolaryngol Head Neck Surg. 2025;151(10):967-975. [Article Link]
Breaking the silence: Socioeconomic barriers to healthy voices
Voice disorders are common in children and can limit communication, yet their risk factors remain poorly defined. Socioeconomic status may influence both the prevalence and impact of pediatric voice disorders. This prospective cross-sectional survey assessed 1,054 United States participants aged 4 to 17 years for vocal health and socioeconomic indicators. Caregivers of younger children (4 to 12 years) completed the Pediatric Voice Handicap Index (P-VHI), while adolescents (13 to 17 years) completed the Voice Handicap Index (VHI). Sixteen percent of participants reported a voice disorder, with prevalence higher in lower-income households (OR 1.82, 95% CI 1.24 to 2.67 for < $30,000 vs. > $100,000). Lower income and parental education were associated with greater voice-related handicap, and both indices effectively distinguished affected participants from those without voice disorders. These findings highlight socioeconomic disparities in pediatric vocal health and the need for equitable access to voice care.
Laryngology Summary written by Michael Evans
Kansas City University College of Osteopathic Medicine
Otology and Neurotology
Clinically Meaningful Change in Tinnitus Scores
Engelke M, Basso L, Langguth B, et al. Estimation of Minimal Clinically Important Difference for Tinnitus Handicap Inventory and Tinnitus Functional Index. Otolaryngol Head Neck Surg. 2025;173(1):69-79. [Article Link]
The minimal clinically important difference (MCID) represents the smallest change in a patient‐reported outcome that is perceived as clinically meaningful by patients. This multicenter randomized clinical trial evaluated 364 patients and 359 patients for the Tinnitus Handicap Inventory (THI) and Tinnitus Functional Index (TFI), respectively, to determine MCID values. Participants were randomized to 12 weeks of cognitive behavioral therapy, hearing aids, structured counseling, or sound therapy. At 12 weeks, patients reporting “minimally better” tinnitus (N = 112, 30.8% THI; N = 112, 31.2% TFI) showed mean improvements of 16.4 ± 18.0 points in THI and 13.2 ± 17.4 points in TFI, compared with smaller gains of 8.7 ± 14.5 points in THI and 5.9 ± 15.8 points in TFI in the “no change” group (N = 132, 36.3% THI; N = 129, 35.9% TFI). MCID thresholds were higher in patients with more severe baseline tinnitus and at longer follow-up intervals (13 to 16 for THI and 10.1 to 12 for TFI at 36 weeks). These findings confirm that both THI and TFI detect meaningful clinical change but also demonstrate that MCID varies by severity and timing. A standardized, anchor-based consensus is needed to improve comparability and reliability across tinnitus clinical trials.
Otology and Neurotology Summary written by Chinelo Eruchalu
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
Pediatric Otolaryngology
OSA Treatment in Children with Down Syndrome
Kim M, Xu LJ, Shih E, et al. Hypoglossal Nerve Stimulator for Obstructive Sleep Apnea in Children with Down Syndrome Younger Than 13. Int J Pediatr Otorhinolaryngol. 2025;196:112497. [Article Link]
Obstructive sleep apnea (OSA) is highly prevalent in children with Down syndrome, and many do not achieve resolution after adenotonsillectomy. In the United States, hypoglossal nerve stimulation (HGNS) is FDA-approved only for patients aged 13 years and older, leaving younger children without reliable treatment options if surgery fails. This retrospective multicenter cohort study evaluated the safety and efficacy of HGNS in 29 children under 13 years of age (median 10 years, range 4 to 12) with Down syndrome and severe OSA (obstructive apnea–hypopnea index [oAHI] > 10). All patients underwent HGNS without intraoperative complications, and one patient (3.4%) experienced minor postoperative wound dehiscence. Median oAHI improved from 18.4 events/hour (interquartile range [IQR] 13.2 to 22.3) at baseline to 3.9 immediately postoperatively (IQR 2.3 to 5.5; p < 0.001), 4.9 at six months (IQR 3.2 to 6.0; p < 0.001), and 3.4 at one year (IQR 2.2 to 4.6; p = 0.003). On initial postoperative polysomnography, 76.9% (20/26) achieved a reduction in oAHI of 50% or more and 80.8% (21/26) had an oAHI below 10, with rates increasing to 95.2% (20/21) and 90.5% (19/21) at six months and 91.7% (11/12) at one year. These findings suggest HGNS is safe and effective for children as young as four, with outcomes comparable to adolescents and potential benefits from earlier intervention.
Pediatric Otolaryngology Summary written by Anders Erickson
Des Moines University College of Osteopathic Medicine
Rhinology and Skull Base Surgery
Trigeminal Nerve Stimulator for Olfactory Dysfunction
Garefis K, Weise S, Hanslik P, et al. Electrical Stimulation of Trigeminal Nerve at the Anterior Nasal Septum in Healthy Individuals and Patients with Olfactory Dysfunction. Int Forum Allergy Rhinol. Published online August 1, 2025. [Article Link]
A shocking new angle on smell loss
Olfactory dysfunction (OD) affects up to 20% of the population and is associated with aging, sinonasal disease (SND), post-viral causes (PVOD) and trauma (PTOD). While the trigeminal nerve has been studied extensively for its chemosensory role, this study examined whether its somatosensory function remains intact in OD. In this multicenter cross-sectional study of 82 adults (28 healthy controls; 54 with OD: 29 PVOD, 15 PTOD, 10 SND), trigeminal sensitivity was measured using electrical thresholds (ETs) after stimulation of the anterior nasal septum. ETs were compared by etiology, olfactory status (normosmia, hyposmia, anosmia), and age. PTOD patients had the highest mean ETs (2.96 ± 3.09 mA vs. 0.73 ± 0.57 mA in controls; p = 0.033), and anosmic patients showed significantly higher ETs than both hyposmic (p = 0.001) and normosmic individuals (p < 0.001). Age correlated with increased ETs in healthy participants (r = 0.245; p = 0.02) but not in those with OD. Trigeminal somatosensory function appeared largely preserved in hyposmia and PVOD, differing from prior chemosensory findings. The results suggest that intranasal trigeminal nerve stimulation may have therapeutic potential for younger, hyposmic, non-PTOD patients who do not respond to standard treatments.
Joshua Sorrentino’s Takeaway: This study demonstrates that while somatosensory trigeminal function is preserved in many patients with OD, its ability to restore smell is limited because mechanical and nociceptive inputs cannot replace true odorant detection. However, the close interaction between olfactory and trigeminal systems makes this pathway an intriguing target for future research.
Rhinology and Skull Base Surgery Summary written by Joshua Sorrentino
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
Basic Science Spotlight
S100A8/A9 Promotes Fibrosis in Laryngotracheal Stenosis
Mafla LM, Abd-Elazem I, So RJ, et al. S100A8/A9 Promotes Fibrosis in Iatrogenic Laryngotracheal Stenosis. Laryngoscope. Published online August 8, 2025. [Article Link]
Fibrosis under the microscope
Fibrosis, an abnormal wound-healing response, is a major cause of airway narrowing after prolonged intubation or tracheostomy in critically ill patients. This study identified how the damage-associated molecular pattern S100A8/A9 drives scar formation in iatrogenic laryngotracheal stenosis (iLTS). Single-cell RNA sequencing and immunohistochemistry was performed for human tracheal tissue and showed upregulation of S100A8/A9 in iLTS fibroblasts compared with healthy controls. To assess causality, the authors used a murine iLTS model in which recombinant S100A8/A9 increased lamina propria thickness (117.7 ± 23.7 vs. 67.7 ± 33.1 μL; p = 0.03) and upregulated collagen genes Col1a1 (p < 0.05) and Col5a1 (p < 0.01). Blocking S100A8/A9 signaling reduced fibroblast activation and subsequent fibrosis. Together, these results demonstrate that S100A8/A9 is elevated in human disease and functionally drives fibrosis in vivo. The authors concluded that targeting S100A8/A9 may represent a novel therapeutic strategy to prevent or reduce fibrosis in iLTS.
Basic Science Spotlight Summary written by Nicole Reynoso
University of California, San Francisco School of Medicine
Question of the Week
Correct Answer Reveal + Explanations
Correct Answer: (C) Paramedian forehead flap with cartilage graft and intranasal lining flap
All Answer Explanations:
A full-thickness nasal ala defect requires reconstruction of all three layers: skin coverage, structural framework, and internal lining. The paramedian forehead flap provides well-vascularized skin with excellent color and texture match for the nasal ala. Auricular conchal or septal cartilage is harvested to restore alar contour and prevent external valve collapse. An intranasal lining flap, such as a septal mucosal flap or composite graft, re-establishes the vestibular lining. This layered reconstruction restores both form and function, addressing the patient’s concerns regarding airway patency and aesthetic appearance.
Answer choice (A), a full-thickness skin graft from the postauricular area, is suitable for superficial skin-only defects, but it does not provide structural support or internal lining. Answer choice (B), bilobed transposition flap, works well for small to moderate superficial defects of the lower third of the nose, but it cannot reconstruct missing cartilage or mucosa. Answer choice (D), primary closure with layered suturing, is generally not feasible for nasal ala defects due to limited tissue mobility and the risk of nasal aperture distortion. Answer choice (E), nasolabial flap without cartilage reconstruction, provides skin coverage but not structural reinforcement, increasing the risk of airway compromise from valve collapse.
Sources:
[1] Pasha R, Golub JS. Otolaryngology–Head and Neck Surgery: Clinical Reference Guide. 4th ed. San Diego, CA: Plural Publishing; 2014.
[2] American Academy of Otolaryngology–Head and Neck Surgery Foundation. Primary Care Otolaryngology Handbook. 4th ed. Alexandria, VA: American Academy of Otolaryngology–Head and Neck Surgery Foundation; 2019:70-76.
Question of the Week Answer written by Luke Reardon
Lincoln Memorial University DeBusk College of Osteopathic Medicine
Special Podcast Feature: Sundays with Saima & Co.
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