Educational Pearl
Congenital Tracheoesophageal Fistula
Definition: Tracheoesophageal fistula (TEF) is a common congenital anomaly of the respiratory and gastrointestinal tracts characterized by an abnormal connection (fistula) between the trachea and esophagus. This abnormal communication can allow food, liquids, or air to pass inappropriately between the two structures, presenting in newborns with respiratory distress, feeding difficulties, choking, and aspiration. Esophageal atresia (EA) presents similarly and may occur in conjunction with TEF.
Epidemiology:
Incidence: ~1 in 3,500 live births
Genetics do not appear to play a role
Rates of isolated TEF vs. TEF associated with other congenital anomalies ranges from 38.7% to 57.3%
Etiology:
In utero: Trachea and esophagus originate from shared portion of early foregut
Fourth week of gestation: Epithelial ridges form, dividing the primitive structure into two distinct segments:
Ventral segment: Respiratory tract
Dorsal segment: Esophagus
Types of TEF [Image Source]
Diagnosis:
Prenatal findings: Maternal polyhydramnios and absent fetal stomach bubble on ultrasound
Plan delivery at a facility with a neonatal intensive care unit
Incidental finding: Orogastric or nasogastric catheter cannot be passed further than 10 to 15 cm into stomach
Anterior-posterior chest radiograph will show catheter curled in upper esophageal pouch
Upper GI series with thickened water-soluble contrast: Initial test of choice
Instill contrast distally → withdraw catheter upward (cephalad)
Esophageal endoscopy and bronchoscopy: For direct visualization if there is diagnostic uncertainty or for surgical planning
Methylene blue test: Inject dye into trachea → observe for dye entry into esophagus
CT scan: For diagnostic uncertainty or atypical or recurrent cases
EA with a Distal TEF [Image Source]
Management:
First-line: TEF ligation with primary esophageal anastomosis creation
Potential complications: Anastomosis site leakage, recurrent laryngeal nerve injury, esophageal stricture development, persistent TEF involving upper esophageal pouch, TEF recurrence, mortality
Options to pursue if primary repair is not possible: esophageal lengthening by traction, jejunum or colon interposition, gastric transposition
Postoperative care:
Introduce feedings once healing is complete
High incidence of postoperative gastroesophageal reflux disease
Typically initiate proton pump inhibitor postoperatively
Further Readings:
[1] Congenital and Acquired Pediatric TEF
[2] StatPearls – TEF
Sources:
[1] UpToDate – Intrathoracic Airway Congenital Anomalies and TEF
[2] NIH – TEF Treatment
[3] NIH – Congenital H-Type TEF Diagnosis and Management
Educational Pearl written by Gina Spencer
Queen's University School of Medicine
Question of the Week
A 70-year-old man presents with persistent right-sided otorrhea, dull otalgia, and recent-onset weakness of the right lower lip. He has a history of chronic actinic damage and was recently treated for presumed otitis externa. On exam, there is an ulcerated lesion at the floor of the cartilaginous external auditory canal with granulation tissue. There is no cervical lymphadenopathy. MRI shows an enhancing soft tissue mass involving the cartilaginous external auditory canal with extension into the superficial lobe of the parotid gland and abnormal enhancement along the stylomastoid foramen. Biopsy confirms moderately differentiated squamous cell carcinoma.
Which of the following best explains the mechanism of spread to the parotid gland and facial nerve involvement?
(A) Lymphatic dissemination to intraparotid nodes and retrograde spread along great auricular nerve
(B) Hematogenous invasion of superficial temporal vein and intracranial extension
(C) Direct extension through fissures of Santorini and perineural spread via facial nerve
(D) Anatomic communication through foramen of Huschke and diffusion into parapharyngeal space
(E) Lymphatic spread via level IIb nodes with associated jugular foramen erosion
Question of the Week written by Luke Reardon
Lincoln Memorial University DeBusk College of Osteopathic Medicine
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Facial Plastic and Reconstructive Surgery
Dr. Jacob Dey, MD
Mayo Clinic - Minnesota
Laryngology / Medical Student Feature
Dr. Karuna Dewan, MD
Louisiana State University Health
Pediatric Otolaryngology
Dr. Sarah Bowe, MD EdM
Brooke Army Medical Center
Rhinology and Skull Base Surgery
Dr. Christina Fang, MD
Montefiore Medical Center
Medical Student Feature Series
The Auricle is proud to introduce a recurring section spotlighting recent medical student-led research published in leading ENT journals — our Medical Student Feature Series
This series celebrates the exceptional scholarship of aspiring otolaryngologists who are actively advancing evidence-based practice in the field during their medical education
Pregnancy & Parity in Idiopathic Subglottic Stenosis Recurrence
Awadallah AS, Fearington FW, Khalil YH, et al. Pregnancy and Parity as Risk Factors for Recurrence in Idiopathic Subglottic Stenosis. Otolaryngol Head Neck Surg. 2025 Aug;173(2):447-452. [Article Link]
From delivery to dyspnea: The toll of pregnancy on iSGS
Idiopathic subglottic stenosis (iSGS) is a rare fibroinflammatory airway disease primarily affecting premenopausal women, and elevated estrogen during pregnancy is thought to promote scar tissue formation and maturation, potentially worsening disease. This retrospective cohort study assessed whether parity was associated with iSGS recurrence in 48 women under age 40 who underwent endoscopic intervention at two tertiary centers between 2002 and 2024. Participants were categorized as parous (n = 36, 75.0%) or nulliparous (n = 12, 25.0%), and recurrence outcomes were analyzed using Poisson, linear, and Cox regression models controlling for age and follow-up time. Parous patients experienced iSGS recurrence at 2.6 times the rate of nulliparous patients (95% confidence interval [CI] 1.5 to 4.8; p = 0.0008), and each additional pregnancy was associated with 0.81 additional recurrences (95% CI 0.05 to 1.57; p = 0.0375). Surgery-free intervals and time to first recurrence were not significantly different between groups (p = 0.2340 and p = 0.31, respectively). Sensitivity analyses confirmed that parity influenced overall recurrence burden but not recurrence timing. These findings establish parity as an independent risk factor for iSGS recurrence and underscore the importance of counseling patients on pregnancy-related disease risks.
Joshua Sorrentino’s Takeaway: This study deepened my appreciation for how reproductive history can influence disease courses in otolaryngology, particularly in chronic airway conditions like iSGS. It reinforced my habit of considering long-term otolaryngology outcomes beyond isolated symptoms.
Summary written by Joshua Sorrentino
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
Andrew Awadallah, MS4
Mayo Clinic Alix School of Medicine
Class of 2026
Are you a medical student with a recently published first author article?
E-mail theauricleotolaryngology@gmail.com to be featured in an upcoming newsletter!
Facial Plastic and Reconstructive Surgery
Midfacial Volume Changes with GLP-1 Agonists
Sharma RK, Vittetoe KL, Barna AJ, et al. Radiographic Midfacial Volume Changes in Patients on GLP-1 Agonists. Otolaryngol Head Neck Surg. 2025;173(2):360-366. [Article Link]
“Ozempic face” - Fact, fiction, or fearmongering?
While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) reduce cardiovascular disease risk factors and help patients lose weight, some users have reported an unwanted side effect dubbed “Ozempic face”, which refers to a loss of facial volume causing a prematurely aged appearance. To quantitatively assess this phenomenon, this retrospective cohort study evaluated the total, superficial, and deep midface volume in patients before and after treatment with a GLP-1 RA using measurements from computed tomography and magnetic resonance imaging scans of the head and neck. The deep midface was defined as fat deep to the zygomaticus muscle and the superficial midface was defined as infraorbital, cheek, and nasolabial fat. Twenty patients (70.0% female, n = 14) with a median age of 54 years were included, while excluding patients with greater than five years out from prescription initiation, comorbidities associated with weight loss, lack of weight loss or medication intolerance, and inadequate imaging. The authors found a 9% (interquartile range [IQR] = 3% to 14%) decrease in total midfacial volume, an 11% (IQR = 5% to 15%) decrease in superficial volume, and a 7% (IQR = -20% to 15%) decrease in deep volume. Spearman correlation showed a positive relationship between weight loss after GLP-1 use and superficial midface volume loss (⍴ = 0.590; p = 0.006), and linear regression showed a loss of 7% facial volume for every 10 kg of weight lost (r = 0.063, standard error = 0.003; p = 0.0293). The findings in this study may be used to guide facial plastic surgeons’ approaches to aesthetic procedures in patients being treated with GLP-1RAs, leading to more favorable results and greater patient satisfaction.
Summary written by Gabriella Adams
Eastern Virginia Medical School
Head and Neck Surgery
Pembrolizumab for Locally Advanced Head and Neck SCC
Uppaluri R, Haddad RI, Tao Y, et al. Neoadjuvant and Adjuvant Pembrolizumab in Locally Advanced Head and Neck Cancer. N Engl J Med. 2025;393(1):37-50. [Article Link]
The benefit of adding perioperative pembrolizumab to standard treatment for resectable, locally advanced head and neck squamous cell carcinoma (HNSCC) was previously unclear. This phase three randomized trial enrolled 714 patients with stage III and IVA HNSCC, including oropharyngeal (human papilloma virus [HPV]-positive and negative), laryngeal, hypopharyngeal, and oral cavity cancers, where participants received either neoadjuvant and adjuvant pembrolizumab plus standard care (surgery and adjuvant radiotherapy ± cisplatin) or standard care alone. At three years, event-free survival was significantly improved with pembrolizumab (57.6% vs. 46.4%, hazard ratio [HR] = 0.73; p = 0.008), with consistent benefit across programmed cell death ligand-1 (PD-L1) expression subgroups. Major (≤10% viable tumor) and complete (no viable tumor) pathological responses occurred in 9.4% and 3.0% of pembrolizumab patients, respectively, versus 0.0% in the control group. Surgery completion rates were similar between groups (88.4% vs. 87.7%). While grade three or greater treatment-related adverse events were comparable, immune-mediated toxicities (e.g., hypothyroidism, pneumonitis) were more frequent with pembrolizumab (43.2% vs. 10.2%). These findings suggest that neoadjuvant and adjuvant pembrolizumab could become a new standard of care, offering a substantial improvement in outcomes for patients with resectable locally advanced HNSCC.
Summary written by Anuhya Kanchibhatla
Case Western Reserve University School of Medicine
Laryngology
AI-Assisted Ultrasound Assessment of Injection Laryngoplasty
Tseng WH, Lee MS, Hong SC, Hsiao TY, Yang TL. Application of an AI-Based Model for Non-Invasive Sonographic Assessment for Injection Laryngoplasty. Otolaryngol Head Neck Surg. 2025;173(1):144–153. [Article Link]
What if AI could “see” your voice filler fading away?
Injection laryngoplasty (IL) with hyaluronic acid (HA) is a common treatment to improve voice in patients with unilateral vocal fold paralysis, yet the persistence of vocal benefit despite HA degradation remains unclear. Quantifying residual injectate is important for counseling patients on treatment longevity, planning future interventions, and understanding whether voice improvements stem from the filler’s presence or secondary tissue changes. This prospective cohort study followed 27 adults after IL with HA using serial ultrasonography and voice assessments at two weeks, two months, and six months. A novel artificial intelligence (AI)-based image segmentation model, Temporal Convolutional Segmentation Network, was used to estimate HA volume from ultrasound frames, mimicking how clinicians interpret motion. Residual HA volume significantly declined over time (1.21 ± 0.53 mL at two weeks, 0.63 ± 0.35 mL at two months, and 0.32 ± 0.25 mL at six months; all p < 0.001), while voice outcomes, such as Voice Handicap Index-10 (baseline 27.00 ± 9.57 to 14.82 ± 5.90 at two weeks; p < 0.001) and normalized glottal gap area (9.93 ± 7.03 to 0.66 ± 0.84; p < 0.001), significantly improved and remained stable. No association was found between residual HA volume and patient age, symptom duration, or voice outcome scores. This study supports AI-enhanced ultrasound as a non-invasive tool to monitor HA degradation and highlights a disconnect between material presence and clinical benefit, potentially reflecting tissue remodeling or neuromuscular adaptation.
Summary written by Aida Hasson
Medical School for International Health
Otology and Neurotology
Outcomes of Vestibular Rehab with Dynamic Posturography
David EA, Shahnaz N, Wiseman I, David Y, Cochrane CL. Vestibular Rehabilitation Using Dynamic Posturography: Functional Stability and Fall Risk Outcomes From a Randomized Trial. Otolaryngol Head Neck Surg. Published online July 7, 2025. [Article Link]
From unsteady to ready
Vestibular rehabilitation is recommended for patients with vestibular dysfunction to prevent falls and related risks, though the most effective intervention for balance improvement remains unclear. This study compared a novel balance regimen, computerized vestibular retraining therapy (CVRT), with a traditional home exercise program (HEP) in patients experiencing unilateral vestibular deficits, aiming to identify optimal treatments for postural instability. The unblinded, randomized trial included 37 participants who reported imbalance symptoms impairing activities of daily living and lasting over six months due to stable unilateral peripheral vestibular deficits confirmed by videonystagmography and vestibular evoked myogenic potential testing, were assigned to either 12 CVRT sessions, a six-week HEP, or a crossover group transitioning from HEP to CVRT. Outcomes measured via a limits-of-stability test included reaction time, directional control, movement velocity, endpoint and maximum excursion, and endpoint and maximum functional stability region (FSR). Participants in the CVRT group (n = 18, 48.6%) demonstrated significant improvements over the HEP group (n = 12, 32.4%) in directional control (mean difference = 24, 95% confidence interval [CI] 4.4 to 43.6; p = 0.01), movement velocity (1.5 degrees per sec, 95% CI 0.6 to 2.3; p < .001), endpoint excursion (21.1, 95% CI 4.8 to 37.4; p < 0.01), and endpoint FSR (6,744, 95% CI 1,060 to 12,428; p = 0.02), though no differences were found in the rate of loss of balance (LOB), reaction time, maximum excursion, or maximum FSR. The crossover group from HEP to CVRT exhibited additional improvement in directional control (mean difference = 23.1, 95% CI 1.1 to 45.0; p = 0.046) and movement velocity (1.3 degrees per sec, 95% CI 0.4 to 2.2; p = 0.04) but showed no further gains in the rate of LOB, reaction time, endpoint excursion, or maximum excursion. These findings support CVRT as an effective treatment for significantly improving postural stability and reducing fall risk among patients with unilateral vestibular dysfunction, paving the path for a role for CVRT in the multimodal treatment regimen for vestibular dysfunction.
Summary written by Priyanka Shah
Edward Via College of Osteopathic Medicine
Pediatric Otolaryngology
Pediatric Salivary Gland Diseases: Life Exposures & Risk Factors
Resende de Paiva C, Sørensen KK, Schrøder SA, Foghsgaard J, Torp-Pedersen C, Howitz MF. Early life exposures and risk of salivary gland diseases in childhood: A 28-year nationwide cohort study. Int J Pediatr Otorhinolaryngol. 2025 June;193:112354. [Article Link]
Pediatric salivary gland diseases, including juvenile recurrent parotitis (JRP), salivary stones, and retention cysts, are rare but can significantly impact quality of life. Their etiology remains poorly understood, especially in relation to early-life exposures. This nationwide nested case-control study used Danish registry data from 1994 to 2022 to examine these associations. A total of 4,778 children with salivary diagnoses (JRP: n = 2,637, 55.2%; salivary stones: n = 765, 16.0%; retention cysts: n = 1,376, 28.8%) were matched to 23,890 controls, and seven exposures were analyzed: gestational age, birth weight, maternal age, household income, passive smoking, breastfeeding duration, and maternal body mass index (BMI). JRP risk was significantly increased with preterm birth (hazard ratio [HR] = 1.24, 95% confidence interval [CI] 1.05 to 1.47; p = 0.01), low birth weight for gestational age (HR = 1.38, 95% CI 1.13 to 1.69; p = 0.002), maternal age younger than 20 years (HR = 1.53, 95% CI 1.20 to 1.94; p = 0.001), and low household income (HR = 1.27, 95% CI 1.11 to 1.45; p < 0.001). In contrast, overweight maternal BMI was associated with a significantly decreased risk of JRP (HR = 0.85, 95% CI 0.74 to 0.97; p = 0.018). These findings suggest that socioeconomic and perinatal factors may contribute to JRP development, emphasizing the need for pediatric otolaryngologists to recognize at-risk children and consider targeted prevention strategies.
Summary written by Anders Erickson
Des Moines University College of Osteopathic Medicine
Rhinology and Skull Base Surgery
Olfactory Effects of Middle Turbinate Resection vs. Preservation
Chen YA, Chen CH, Wang WH, Lan MY. Partial Middle Turbinate Resection Versus Preservation on Olfactory Function: A Systematic Review and Meta-Analysis. J Otolaryngol Head Neck Surg. 2025;54:19160216251351566. [Article Link]
Partial middle turbinate resection (MTR) during endoscopic sinus surgery offers numerous benefits including improved nasal breathing, sinus drainage, and intraoperative visualization of anatomic landmarks. Despite these benefits, partial MTR can lead to olfactory dysfunction, though the clinical impact of this dysfunction remains heavily debated. The present systematic review and meta-analysis aimed to elucidate the effect of partial MTR on olfactory function, specifically to determine if partial MTR led to olfactory decline. Of seven included studies (n = 788 patients), the authors compared olfactory outcomes in partial MTR versus middle turbinate preservation. Pooled studies showed no significant difference in scores for olfactory function (standardized mean difference (SMD) = 0.14; 95% confidence interval [CI] -0.16 to 0.44; p = 0.359), though subgroup analysis including studies performing objective tests found that partial MTR improved olfaction significantly (SMD = 0.37; 95% CI 0.17 to 0.56; p < 0.001). While there may be some improved olfaction outcomes for patients undergoing partial MTR, the pooled results suggest if clinically indicated, partial MTR can be conducted during endoscopic sinus surgery without significant loss of olfactory function, especially when better visualization or access is needed.
Summary written by Maaz Haji
Chicago Medical School, Rosalind Franklin University
Sleep Surgery
Palatopharyngeal Surgery Modification Effectiveness in OSA
Tschopp S, Meinert F, Mantokoudis G, Caversaccio M, Borner U. Effectiveness of Palatopharyngeal Surgery Modifications in Obstructive Sleep Apnea: A Meta-Analysis. OTO Open. 2025;9(2):e70144. Published 2025 Jun 19. [Article Link]
Patients with obstructive sleep apnea often seek surgical alternatives to continuous positive airway pressure, with palatopharyngeal surgery being the most common approach. Newer surgical techniques emphasize tissue repositioning over resection to reduce complications and improve outcomes. This meta-analysis analyzed 45 studies involving 1,501 adults undergoing palatopharyngeal surgery without tonsillectomy, comparing seven technique categories using a random-effects model to assess reduction of apnea-hypopnea index (AHI), responder rates, and trends in outcomes over time. Overall, surgery significantly reduced AHI by 5.2 events per hour (95% confidence interval [CI] 2.7 to 7.7; p < 0.0001), with powered instruments showing the most significant effect at 26.3 per hour (95% CI 18.9 to 33.7), followed by muscle relocation (20.2 per hour) and suture techniques (15.3 per hour), while palatal implants and laser techniques showed minor effects. The overall responder rate was 51% (95% CI 41% to 60%; p < 0.0001), with the highest rates among powered, relocation, and suture methods, with no significant changes over time. These results highlight the effectiveness of tissue-preserving techniques, such as muscle relocation and suture pharyngoplasty, in reducing AHI, offering otolaryngologists valuable guidance for individualized surgical planning. However, given that randomized trials have shown that tonsillectomy alone significantly reduces AHI, the exclusion of this treatment in this analysis suggests that the findings may underestimate the full potential of combined surgical approaches.
Summary written by Michael Evans
Kansas City University College of Osteopathic Medicine
Question of the Week
Correct Answer Reveal + Explanations
Correct Answer: (C) Direct extension through fissures of Santorini and perineural spread via facial nerve
All Answer Explanations:
The fissures of Santorini are small congenital defects in the anterior and inferior cartilaginous external auditory canal (EAC). These openings permit direct communication between the EAC and the superficial lobe of the parotid gland. Squamous cell carcinoma (SCC) in this location can invade the parotid by crossing through these fissures, even when the tumor appears confined to the canal externally. Perineural invasion is a well-established pattern of spread in SCC. The facial nerve exits the skull base at the stylomastoid foramen, located just posterior to the EAC. Involvement of this foramen on imaging, in conjunction with clinical facial weakness, is highly suggestive of perineural spread via the facial nerve.
This combination of tumor extending through the fissures of Santorini into the parotid and perineural invasion of the facial nerve is the most accurate explanation based on anatomy and imaging findings.
Answer choice (A), lymphatic dissemination to intraparotid nodes and retrograde spread along great auricular nerve, is incorrect because the great auricular nerve is a superficial sensory branch of the cervical plexus and does not communicate with the facial nerve or allow for perineural tumor spread. While intraparotid nodes may be involved in EAC squamous cell carcinoma, this would not explain facial nerve dysfunction or stylomastoid foramen enhancement. Answer choice (B), hematogenous invasion of superficial temporal vein and intracranial extension, is also incorrect because hematogenous spread is uncommon in SCC and this venous pathway does not directly communicate with the parotid or cranial nerves. Answer choice (D), anatomic communication through foramen of Huschke and diffusion into parapharyngeal space, is incorrect because the foramen of Huschke, if present, connects the EAC to the temporomandibular joint and not to the parotid or stylomastoid region. Additionally, diffusion is not a recognized mechanism of tumor spread. Answer choice (E), lymphatic spread via level IIb nodes with associated jugular foramen erosion, is incorrect because the jugular foramen houses cranial nerves IX, X, and XI, not cranial nerve VII, and does not explain the facial paresis or stylomastoid enhancement.
Source:
[1] Pasha R, Golub JS. Otolaryngology Head and Neck Surgery: Clinical Reference Guide. 4th ed. Plural Publishing; 2014.
Question of the Week Answer written by Luke Reardon
Lincoln Memorial University DeBusk College of Osteopathic Medicine
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