May 14th, 2025
Issue #90
Educational Pearl
Otosclerosis: (from oto, meaning “ear,” and sclerosis, meaning “hardening”) is an abnormal process of bone remodeling within the bony labyrinth, primarily affecting the oval window. It most commonly involves the stapes, which gradually becomes fixated to the oval window. This fixation impairs the ossicle's ability to vibrate, leading to conductive hearing loss while the tympanic membrane remains normal. Depending on the location and extent of involvement within the bony labyrinth, otosclerosis may be asymptomatic or present with hearing loss.
Presenting Symptoms:
The most common presentation is hearing loss that begins unilaterally and progresses to bilateral involvement over time
Other symptoms may include vertigo, tinnitus, dizziness, and speaking in a low volume or monotone voice
Patients often report improved hearing in noisy environments compared to quiet ones, a phenomenon known as “Paracusis Willisii”
Epidemiology:
Typically presents in early adulthood (20s to 30s)
More prevalent in women than men, with a 2:1 female-to-male ratio
Occurs more frequently in White populations, followed by Asian and African American populations (10%, 5, and 1%, respectively)
Etiology and Pathophysiology:
The exact cause is unknown but is likely multifactorial
Involves mesenchymal cell clusters in the endochondral layer of the otic capsule that form spongy bone and ultimately cause abnormal bone deposition
Diagnosis:
Must obtain a detailed clinical history
Tuning Fork Tests Findings:
Rinne test: negative (bone conduction > air conduction)
Weber’s test: lateralizes to the ear with more severe conductive hearing loss
Audiometry and Tympanometry Findings:
Reduced air conduction, particularly at low frequencies
Carhart notch: a characteristic dip in bone conduction at 2,000 Hz
Treatment:
Goal is to prevent or slow disease progression
Bisphosphonates: used to inhibit bone resorption by inducing osteoclast apoptosis
Surgery: partial or total stapedotomy to restore ossicular mobility
Cochlear implantation: considered in cases of bilateral deafness
Further Reading:
NIH - Otosclerosis StatPearls
NIH - Otosclerosis Fact Sheet
Educational Pearl by Jenilkumar Patil
Tulane Medical School
Question of the Week
A 59-year-old man presents to the emergency department with acute-onset vertigo, nausea, and difficulty walking that began three hours ago. He denies hearing loss or tinnitus. On examination, he has left-beating horizontal nystagmus that does not fatigue and persists regardless of gaze direction. He is unable to walk unassisted due to severe imbalance. Neurologic examination reveals mild dysmetria on finger-to-nose testing on the right side but no weakness or sensory deficits. Dix-Hallpike maneuver does not reproduce his symptoms. A head computed tomography scan is unremarkable. Which of the following findings would most support a central rather than peripheral cause of vertigo in this patient?
(A) Nystagmus that fatigues and is triggered by specific head positions
(B) Improvement with Epley maneuver
(C) Presence of tinnitus and hearing loss
(D) Direction-changing nystagmus
(E) Symptoms resolving within one minute of onset
Find the correct answer and its rationale at the bottom of this issue
Question of the Week by Adriana Báez Berríos
Icahn School of Medicine at Mount Sinai
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Head and Neck Surgery / Medical Student Feature
Dr. Akina Tamaki, MD
University Hospitals-Cleveland Medical Center
Otology and Neurotology
Dr. Terence Imbery, MD
The University of Chicago
Pediatric Otolaryngology
Dr. Sarah Bowe, MD, EdM
San Antonio Military Medical Center
Rhinology and Skull Base Surgery
Dr. Peter Papagiannopoulos, MD
Rush University Medical Center
Medical Student Feature Article of the Month
Effect of Histamine-2 Receptor Antagonists on Hypocalcemia after Thyroidectomy: A Retrospective Cohort Study and Sensitivity Analysis
Rossip M, Lorenz FJ, Sciscent B, et al. Effect of Histamine-2 Receptor Antagonists on Hypocalcemia after Thyroidectomy: A Retrospective Cohort Study and Sensitivity Analysis. Otolaryngol Head Neck Surg. 2025;172(4):1199-1207. [Article Link]
Should we limit H2RA use in thyroidectomy patients?
Hypocalcemia is a common complication following thyroidectomy, and previous research has linked proton pump inhibitors (PPIs) to an increased risk of reduced calcium levels. This retrospective cohort study investigated whether H2 receptor antagonists (H2RAs) are associated with a similar risk. Data were collected and analyzed using the TriNetX database, with cohort matching performed between patients taking H2RAs and those not taking them. Patients who underwent thyroidectomy while on H2RAs had a significantly increased risk of postoperative hypocalcemia, with relative risks of 1.17 (95% CI 1.1 – 1.2, p < .001) at one month, 1.40 (95% CI 1.3 – 1.5, p < .001) at six months, and 1.42 (95% CI 1.3 – 1.6, p < .001) at twelve months. These patients were also more likely to visit the emergency department and receive intravenous calcium infusions, with a relative risk of 1.83 (95% CI 1.7 – 2.0, p < .001). The authors suggest that calcium malabsorption due to gastric acid suppression by H2RAs may lead to compensatory parathyroid hormone elevation, similar to the mechanism proposed for PPIs. Perioperative management of H2RA use should be considered on an individual basis.
Summary written by Sue Li
Texas Tech University School of Medicine
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Maxwell Rossip
Penn State College of Medicine
Class of 2026
Facial Plastic and Reconstructive Surgery
Selective Neurectomy with Regenerative Peripheral Nerve Interface Surgery for Facial Synkinesis
Gu JT, Ganesh Kumar N, Kung TA, Rudy SF, Moyer JS, Kim JC. Selective Neurectomy with Regenerative Peripheral Nerve Interface Surgery for Facial Synkinesis. Facial Plast Surg Aesthet Med. 2025 Mar-Apr;27(2):136-142. [Article Link]
From spasm to smile: RPNI reduces synkinesis severity and Botox requirements
Facial synkinesis, a sequela of facial paralysis, is the involuntary contraction of muscles due to aberrant nerve regeneration and reinnervation. Selective neurectomy (SN) involves the resection of facial nerve branches implicated in synkinesis to provide symptomatic relief, but patients often require renewed botulinum toxin injections in the long term. This posits regenerative peripheral nerve interface (RPNI), the process of implanting the distal end of a transected nerve into a free muscle graft, as a method to prevent anomalous facial muscle innervation. In this retrospective cohort study, 24 patients who were treated with SN for facial synkinesis were included, half of whom additionally underwent RPNI surgery wherein the ipsilateral sternocleidomastoid muscle was secured to the intervening nerve endings. By measuring botulinum toxin dosage and frequency of administration, this study assessed improvement in facial synkinesis at 12 months or later in patients who received SN only versus those who received SN and RPNI. There was a 16.0% decrease in botulinum toxin dosage in the RPNI cohort compared to the non-RPNI cohort (72.2 vs. 90.3, p = .045, Z = 2.019), as well as a greater percent change in the interval between botulinum toxin treatments pre- and postoperatively, with an 83.5% increase in the RPNI cohort versus a 17.9% increase in the non-RPNI cohort (p = .007, Z = -2.629). The results of this study suggest that although no surgical technique may eliminate facial synkinesis, SN with RPNI can reduce the symptom burden, as measured by postoperative botulinum toxin dosage and treatment frequency.
Sree Chinta’s Takeaway: This study suggests that SN with RPNI is a more effective method for decreasing the symptom burden of facial synkinesis compared to SN alone. The authors note that they use postoperative botulinum toxin frequency as a proxy for synkinesis severity, but operating with SN with RPNI may introduce a placebo effect that reduces the patient’s perceived need for more frequent botulinum toxin injections. Objective measures of synkinesis, such as electromyography or computerized video analysis, may help address this potential placebo effect.
Summary written by Sree Chinta
Rutgers New Jersey Medical School
Head and Neck Surgery
Fluoconazole for Preventing Radiation-Induced Oral Mucositis: A Randomized Controlled Trial
Ueangphairot W, Muangwong P, Suwannaphong P, et al. Fluconazole for Preventing Radiation-Induced Oral Mucositis: A Randomized Controlled Trial. Head Neck. 2025;47(4):1168-1175. [Article Link]
Kicking Candida to the curb
Radiation-induced oral mucositis (RIOM) is a common complication of concurrent chemoradiotherapy (CCRT) in patients with head and neck cancer (HNC), often exacerbated by Candida infections. This double-blind, randomized controlled trial investigated whether daily prophylactic fluconazole (100 mg) could reduce the incidence of grade ≥ 2 RIOM and Candida carriage during CCRT. Seventy-eight patients with HNC were randomized 1:1 to receive either fluconazole or placebo during treatment. Fluconazole significantly reduced the incidence of grade ≥ 2 RIOM at week seven, with an adjusted odds ratio (OR) of 0.29 (95% CI 0.1 – 0.9, p = .039), and decreased overall RIOM severity (OR = 0.47, 95% CI 0.2 – 0.9, p = .023). Candida colonization was also significantly lower in the fluconazole group, with fewer positive cultures at weeks four and seven (p = .024 and p = .029, respectively). No serious adverse events attributable to fluconazole were reported. These findings support the use of fluconazole prophylaxis as an effective strategy to reduce RIOM severity and Candida colonization in HNC patients undergoing CCRT.
Summary written by Whitney Jin
Baylor College of Medicine
Laryngology
Recurrence Rates Across Surgical Techniques in Idiopathic Subglottic Stenosis
Bowen AJ, Awadallah AS, Ali H, et al. Surgical Recurrence Across Endoscopic Surgical Techniques in Idiopathic Subglottic Stenosis. Laryngoscope. 2025 Apr 15. [Article Link]
Idiopathic subglottic stenosis (iSGS) is a rare condition that commonly affects otherwise healthy women and often recurs after treatment. This study looked at how long it took for iSGS to recur following different types of surgical intervention: standard dilation (ED), dilation with steroid injections (ED + SILSI), and laser surgery (LWE). This was a two-center retrospective study that analyzed recurrence times in iSGS patients treated with ED, ED + SILSI, or LWE, using Kaplan–Meier survival analysis to estimate time to reoperation and Cox proportional hazards modeling to compare recurrence risk across surgical groups. In this study, 126 patients received LWE, while 32 underwent ED and 23 had ED + SILSI, showing one-year recurrence rates of 9% for LWE, 53% for ED, and 0% for ED + SILSI, and five-year rates of 45%, 90%, and 19%, respectively. Statistical analysis showed that ED had a significantly higher risk of recurrence compared to LWE (2.25, 95% CI 1.3 – 3.9), while ED + SILSI had a similar risk of recurrence compared to LWE (0.84, 95% CI 0.3 – 2.3). In conclusion, LWE led to a longer time before recurrence compared to ED in patients with iSGS. However, when SILSI was added after ED, recurrence rates were reduced to levels similar to those seen with LWE, suggesting further research into using LWE, SILSI, or both together is needed.
Summary written by Russell Whitehead
Rush Medical College
Otology and Neurotology
Ototoxicity Monitoring for Head and Neck Cancer Patients
Patel J, Beiriger J, Liu K, et al. Ototoxicity Monitoring: The Evolution Of A Protocol For Head And Neck Cancer Patients. OTO Open. 2025 Apr 7;9(2):e70070. [Article Link]
Ototoxicity from platinum-based chemotherapy drugs, specifically cisplatin, is common among head and neck cancer (HNC) patients. This retrospective cohort study evaluated the impact of an ototoxicity monitoring program (OMP) for HNC patients undergoing chemotherapy. Conducted at a tertiary academic center, the study compared 240 patients, with 131 (54.6%) treated before and 109 (45.4%) treated after the OMP’s initiation. The implementation of the OMP significantly increased the pretreatment audiogram rate (pre-OMP: 34.4% vs. post-OMP: 66.1%; p < .001), with enrolled patients 3.8 times more likely to receive one (95% CI 2.2 – 6.6, p < .001). Although there was an increase in pretreatment testing, there was no significant improvement in posttreatment audiogram completion or hearing aid utilization. Despite a significant increase in reported otologic symptoms after OMP implementation (pre-OMP: 18.0% vs. post-OMP: 36.0%; p = .002), hearing aid utilization declined from 11.0% pre-OMP to 6.4% post-OMP (p = .02), and only 28.0% of eligible patients pursued hearing aids even though 31.2% of the total cohort met candidacy criteria. These findings demonstrate that while an OMP improves early monitoring of hearing function prior to chemotherapy initiation, long-term audiologic follow-up and hearing aid implementation remain challenges in HNC patients receiving platinum-based chemotherapy.
Summary written by Caitlin Cavarocchi
Philadelphia College of Osteopathic Medicine
Pediatric Otolaryngology
Surgical Intervention Disparities in Pediatric Submucous Cleft Palate and Velopharyngeal Dysfunction
Eljamri S, Reddy PD, Shaffer A, Harley RJ, Jabbour N. Disparities in Surgical Intervention in Pediatric Patients With Submucous Cleft Palate and Velopharyngeal Dysfunction. Otolaryngol Head Neck Surg. 2025;172(4):1403-1408. [Article Link]
Which social factors impact timing and access to surgical care in SMCP and VPD patients?
Approximately half of patients with submucous cleft palate (SMCP) develop velopharyngeal dysfunction (VPD), and earlier SMCP repair has been linked with a reduced risk of VPD. This retrospective cohort study evaluated whether socioeconomic and structural factors influence the likelihood and timing of surgical intervention in 168 pediatric patients with SMCP and VPD. The study analyzed the relationship between surgical timing and SMCP severity, baseline Pittsburgh Weighted Speech Scores (PWSS), Area Deprivation Index (ADI), Child Opportunity Index, distance to care, and insurance status. Surgical patients were more likely to have overt SMCP (p = .03), an earlier SMCP diagnosis (p = .02), and higher baseline PWSS (p < .001). Younger age at surgery was significantly associated with higher PWSS (β = –0.12, 95% CI -0.2 – -0.1, p < .001) and lower state ADI deciles (β = 0.16, 95% CI 0.01 – 0.3, p = .03). Patients with private insurance had lower PWSS compared to those with public insurance (p = .04), although insurance status was not associated with age at diagnosis or age at surgery. The findings suggest that symptom severity and socioeconomic disadvantage impact surgical timing, and integrating social determinants of health into patient evaluations may improve timely care access.
Summary written by Emaan Dawood
Virginia Commonwealth University School of Medicine
Rhinology and Skull Base Surgery
3-Year Outcomes of Temperature-Controlled Radiofrequency Ablation of the Posterior Nasal Nerve in Patients with Chronic Rhinitis
Stolovitzky JP, Ow RA, Silvers SL, et al. 3-Year Outcomes of Temperature-Controlled Radiofrequency Ablation of the Posterior Nasal Nerve in Patients With Chronic Rhinitis. Int Forum Allergy Rhinol. 2025 Apr 4:e23577. [Article Link]
Chronic rhinitis: Is radiofrequency effective in the long term?
Temperature-controlled radiofrequency ablation of the posterior nasal nerve has been shown to improve symptoms and quality of life in patients with chronic rhinitis at short-term follow up. This prospective, multicenter study aims to determine if these effects are sustained after three years of treatment. 59 patients in the active treatment and control crossover arms were assessed at baseline and three years post-treatment using total nasal symptom score (rTNSS), postnasal drip (PND) and cough scores, and quality of life measured by the Mini Rhinoconjunctivitis Quality-of-Life Questionnaire. rTNSS was reduced by 57.3% with a mean change of –4.7 (95% CI -5.3 – -4.1, p < .0001). The average cough score decreased from a baseline of 1.5 (95% CI 1.3 – 1.7) to 0.7 (95% CI 0.5 – 0.9) with an average change of -0.8 (p < .0001), and PND symptoms decreased from 2.5 (95% CI 2.4 – 2.7) to 1.4 (95% CI 1.2 – 1.7) with an average decrease of -1.1 (p < .0001). The majority of patients (79.7%) had a sustained response to treatment at three years follow up with no severe adverse events reported. This study demonstrates that chronic rhinitis symptom control and safety were maintained three years after treatment with temperature-controlled radiofrequency ablation.
Summary written by Nick Melott
Des Moines University College of Osteopathic Medicine
Basic Science Spotlight
Age-Related Decline in Neural Phase-Locking to Envelope and Fine Structure
Ponsot E, Devolder P, Dhooge I, Verhulst S. Age-Related Decline In Neural Phase-Locking To Envelope And Temporal Fine Structure Revealed By Frequency-Following Responses: A Potential Signature Of Cochlear Synaptopathy Impairing Speech Intelligibility. J Assoc Res Otolaryngol. 2025 Apr 21. [Article Link]
Can your brainwaves reveal how old your ears really are?
This basic science study examined how aging affects phase-locking, or the brain’s ability to fire in sync with sound wave patterns. Researchers used frequency-following responses (FFRs), a type of noninvasive brainwave recording, to measure how accurately participants’ brainstems followed the rhythm and fine details of sound, including both slower changes in loudness (envelope) and faster sound patterns (temporal fine structure, or TFS). Forty-five adults were studied across three groups: young normal-hearing (n = 15), older normal-hearing (n = 16), and older hearing-impaired (n = 14). Older participants showed significantly reduced neural phase-locking to both envelope and TFS cues (p < .001), and computational modeling indicated that these reductions were consistent with approximately 50% loss of auditory nerve fibers, a pattern suggestive of cochlear synaptopathy. Notably, this neural degradation did not correlate with TFS perception performance. These findings highlight FFRs as a potential objective marker of age-related auditory nerve decline not detected on routine hearing tests.
Zohair Ahmed’s Takeaway: This study showed me how electrophysiologic tools like FFRs can detect hidden hearing loss that may not appear on standard audiograms, providing insight into why older adults may struggle to understand speech in noisy environments despite having clinically normal hearing.
Summary written by Zohair Ahmed
The University of the Incarnate Word School of Osteopathic Medicine
Question of the Week Answer
Correct Answer: (D) Direction-changing nystagmus
Answer Explanation:
This patient’s presentation is most consistent with central vertigo, likely due to a posterior circulation stroke affecting the cerebellum. The most distinguishing feature is direction-changing nystagmus, which strongly supports a central rather than peripheral cause of vertigo.
Answer choice (A), nystagmus that fatigues and is triggered by specific head positions, is characteristic of benign paroxysmal positional vertigo (BPPV), a peripheral etiology. Similarly, answer choice (B), improvement with Epley maneuver, also suggests BPPV, as repositioning maneuvers like Dix-Hallpike and Epley are typically effective in treating symptoms caused by dislodged otoliths. Answer choice (C), the presence of tinnitus and hearing loss, points to other peripheral causes of vertigo such as Meniere’s disease or labyrinths, and is not typically seen in central vertigo. Lastly, answer choice (E), symptoms resolving within one minute of onset, is also consistent with BPPV, where vertigo episodes are brief and positional.
In contrast, central vertigo tends to cause persistent, non-fatiguing symptoms, often accompanied by neurologic deficits such as dysmetria and gait instability. The presence of direction-changing nystagmus, which is rarely, if ever, seen in peripheral causes of vertigo, makes answer choice (D) the correct answer.
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