Question of the Week

A 62-year-old man presents with progressive right-sided hearing loss over the past three years, with increasing difficulty understanding speech, particularly in noisy environments. He denies vertigo, otalgia, otorrhea, or tinnitus. There is no history of noise exposure or ototoxic medication use. Otoscopic examination reveals intact, normal-appearing tympanic membranes bilaterally, with a subtle reddish hue over the right promontory, as shown in the image below. 

Tuning fork examination demonstrates bone conduction (BC) greater than air conduction (AC) in the right ear and AC greater than BC in the left ear, with Weber lateralizing to the right. Audiometry shows right-sided conductive hearing loss with a dip in bone conduction thresholds at approximately 2000 Hz. Tympanometry reveals reduced compliance of the right tympanic membrane with normal middle ear pressure. Which of the following best explains the pathophysiology of this patient’s condition?

(A) Fixation of the stapes footplate due to abnormal bone remodeling
(B) Disruption of the incudostapedial joint from chronic inflammation
(C) Chronic tympanic membrane perforation
(D) Loss of outer hair cells in the basal turn of the cochlea
(E) Endolymphatic hydrops affecting cochlear mechanics 

Question of the Week written by Adriana Báez Berríos
Icahn School of Medicine at Mount Sinai

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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.

Superior Laryngeal Nerve Block for Chronic Cough

Peachman AT, Root ZT, Alsavaf MB, Kim B, deSilva BW, Matrka L. Prospective Study of Long-Term Outcomes and the Patient Experience With Superior Laryngeal Nerve Block for Chronic Cough. Laryngoscope. Published online October 6, 2025. [Article Link]

When the cough keeps calling, can an injection block it?

Chronic cough lasting longer than eight weeks without an identifiable cause is often attributed to neurogenic cough, which is thought to result from hypersensitivity of the internal branch of the superior laryngeal nerve (SLN). While SLN block has demonstrated short-term benefit, data guiding patient counseling on expected response and duration of effect remain limited. This prospective cohort study evaluated 122 adults with refractory chronic cough who underwent SLN block at a single laryngology clinic, with assessments performed at baseline, 2 weeks, and 6 to 9 months post-injection. Outcomes included patient-reported cough improvement, Cough Severity Index (CSI), quality of life (QoL) scores, and side effects. At two weeks, 63.1% (N = 77) of patients reported cough improvement, with significant reductions in CSI (mean difference 12.32 ± 11.54; p < 0.001) and QoL scores (mean difference 3.63 ± 2.96; p < 0.001). Improvement occurred an average of 4.3 days post-injection, with a mean duration of benefit of 4.1 ± 2.3 months. Side effects were reported by 56.6% (N = 69) of patients and were most commonly mild and transient, including altered throat sensation and soreness. This study supports SLN block as a reasonable, low-risk, office-based intervention and provides concrete data to guide patient counseling in laryngology practice, including likelihood of response, expected onset of improvement, duration of benefit, and side-effect profile.

Med Student Feature Summary written by Thuyduong (Michelle) Nguyen
Edward Via College of Osteopathic Medicine - Virginia

Facial Plastic and Reconstructive Surgery

Anterior Digastric Myectomy in Facelift and Neck Lift

Gray AJ, Starkman SJ. Patient-Reported Outcomes of Anterior Digastric Myectomy in Deep Plane Facelift and Neck Lift Surgery. Facial Plast Surg Aesthet Med. Published online November 24, 2025. [Article Link]

The anterior digastric muscle: To cut or not to cut? 

Neck contour is a major determinant of patient satisfaction in facial rejuvenation, and traditional approaches that overemphasize subcutaneous fat removal can result in cervical hollowing. Modern strategies therefore focus on subplatysmal structures, including the anterior digastric (AD) muscles. Although AD myectomy was historically avoided because of concerns for postoperative dysphagia, anatomical evidence suggests that hyolaryngeal elevation relies primarily on the mylohyoid and posterior digastric muscles, potentially limiting swallowing risk. In this retrospective cohort study of 452 patients undergoing deep plane facelift and neck lift, 310 patients (68.6%) underwent AD myectomy and 142 patients (31.4%) did not. On three-month follow-up, no significant difference (p > 0.05) was observed in overall primary functional complaints, including dysphagia, dysarthria, and throat pain, between the non-AD myectomy group (9.9%, 95% confidence interval [CI] 6.0 to 15.9) and the AD myectomy group (10.0%, 95% CI 7.1 to 13.8; p = 1.0). Although transient lip weakness was more frequent in the AD myectomy cohort (27/310, 8.7% vs. 2/142, 1.4%; p = 0.004), AD myectomy was associated with significantly lower rates of persistent neck tightness (15/310, 4.8% vs. 19/142, 13.4%; p = 0.0015) and fewer revision surgeries (12/310, 3.9% vs. 13/142, 9.2%; p = 0.027). AD myectomy may be considered a safe adjunct that improves aesthetic definition and long-term patient comfort without compromising swallowing outcomes.

Facial Plastic and Reconstructive Surgery Summary written by Anuhya Kanchibhatla
Case Western Reserve University School of Medicine
 

Head and Neck Surgery

Contralateral Neck Disease in HPV+ BOT Cancer

Halle TR, Cao AC, Naik AG, et al. Risk of Occult Contralateral Neck Metastasis in Early-Stage HPV-Related Lateralized Cancer of the Base of the Tongue. Head Neck. Published online December 10, 2025. [Article Link]

Management of the clinically negative contralateral (CL) neck in early-stage, lateralized, human papillomavirus (HPV)-associated base of tongue (BOT) squamous cell carcinoma (SCC) remains controversial, as estimates of occult nodal risk are often derived from heterogeneous cohorts including HPV-negative disease, advanced tumors, and midline involvement. The authors of this study performed a retrospective review of 106 patients with HPV-positive BOT SCC (pT1-2, pN0-1) treated with transoral robotic surgery and ipsilateral neck dissection between the years 2007 and 2022, including only well-lateralized tumors ≥ 1 cm from midline and no clinical or radiographic evidence of CL nodal disease. Of these patients, 43.3% (46/106) did not receive CL neck treatment, 29.2% (31/106) underwent elective CL neck dissection, and 27.4% (29/106) received CL neck radiation, with no occult CL metastases identified among those undergoing elective dissection (0/31, 0.0%). After a median follow-up of 49.1 months, there was no significant difference in overall survival (hazard ratio [HR] = 0.95, 95% confidence interval [CI] 0.23 to 4.00) or disease-free survival (HR = 1.43, 95% CI 0.55 to 3.71) between patients who did and did not receive CL treatment. Two CL neck recurrences occurred among patients who did not receive CL treatment, but both were successfully salvaged without further disease. These findings suggest that CL neck treatment may be safely omitted in carefully selected patients with early-stage, well-lateralized HPV-positive BOT cancer undergoing primary surgical management.

Head and Neck Surgery Summary written by Ashton Huppert Steed
University of Arizona College of Medicine Phoenix
 

Laryngology

Botulinum Toxin for Adductor Laryngeal Dystonia

Chang J, Ovbiebo N, Lo CH, et al. Botulinum Toxin Treatment for Adductor Laryngeal Dystonia Reduces Speech-Related Cognitive Load. Laryngoscope. Published online December 12, 2025. [Article Link]

The cognitive cost of speech

Adductor laryngeal dystonia (ADLD) is a focal laryngeal movement disorder characterized by strained and effortful speech. While botulinum toxin (BTX) treatment is known to improve voice quality and voice-related quality of life, its effects on speech-related cognitive load have not been examined. This prospective longitudinal study evaluated adults with ADLD undergoing routine laryngeal BTX injection, with assessments on the day of injection and at 1 week and 4 to 6 weeks post-injection. Speech-related cognitive load was measured using the mental and physical demand subscales of the NASA Task Load Index, voice-related quality of life using the Voice-Related Quality of Life (VRQOL) scale, and perceptual voice quality via blinded clinician ratings. By 4 to 6 weeks post-injection, mental and physical demand scores significantly decreased (p = 0.001 and p = 0.019, respectively) and median VRQOL improved from 40.0 to 67.5 (p < 0.001). Overall voice severity and strain significantly improved (p = 0.001 and p < 0.001, respectively), while breathiness transiently increased at 1 week before improving (p < 0.001). Multilevel regression showed that reductions in mental demand (β = -0.38; p = 0.003) and improvements in perceptual voice quality (β = -0.42; p = 0.001) were independently associated with improved VRQOL, whereas physical demand was not (p = 0.16). These findings suggest that BTX reduces the cognitive burden of speaking in ADLD and that speech-related cognitive load may be a previously underrecognized determinant of voice-related quality of life.

Matthaeus Hendricks’ Takeaway: The lack of correlation between speaking-related physical effort and VRQOL scores suggests that addressing mental demand may provide the greatest improvement in overall quality of life for patients with ADLD. Future studies comparing the impact of speech and cognitive behavioral therapy with BTX could further inform management strategies.

Laryngology Summary written by Matthaeus Hendricks
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
 

Pediatric Otolaryngology

Impact of GJB2 Mutations in Pediatric Hearing Loss

Akhbari E, Salehi R, Tafrihi M, Jafarzadeh Esfehani R. Characterizing the Spectrum and Clinical Impact of GJB2 Mutations in Patients With Hearing Loss: Insights Into Genetic Variability and Phenotypic Outcomes. Int J Pediatr Otorhinolaryngol. 2025;199:112634. [Article Link]

Lost in transmission: GJB2 gene mutations in hearing loss

Mutations in GJB2 (connexin 26), a protein forming cochlear gap junctions, are a major genetic contributor to nonsyndromic hearing loss (NSHL), but the phenotypic variability and relationship to hearing loss severity remain poorly defined. This cross-sectional study investigated the mutation spectrum and its correlation to hearing loss severity among patients from northeastern Iran, a region with high consanguinity and ethnic diversity. A total of 282 patients (mean age of 27 ± 6 years, range 1 to 33 years; male:female ratio 1.2:1) with NSHL or family history of NSHL were screened for GJB2 mutations using Sanger sequencing. Hearing thresholds were classified by pure-tone audiometry into mild (21 to 40 decibels [dB]), moderate (41 to 70 dB), severe (71 to 95 dB), and profound (greater than 95 dB). Among 22 patients (7.8%) with confirmed hearing loss, the most common variant, c.35delG (12/22, 54.5%), was significantly associated with severe-to-profound loss (11/12, 91.7% vs. 1/12, 8.3% in the moderate group; p < 0.010), while c.487A>G, which was the second most frequent variant (4/22, 18.1%) correlated with severe loss (3/4, 75.0% vs. 1/4, 25.0% in the moderate group; p < 0.050). Less frequent variants, such as c.71G>A (3/22, 13.6%) and c.88A>G (1/22, 4.5%), showed variable presentations from mild to profound hearing loss. These findings emphasize the need for regional genetic screening to identify high-risk variants like c.35delG and support broader implementation of GJB2 sequencing in high-consanguinity populations.

Sonaal Verma’s Takeaway: This study highlights the need to tailor genetic screening to specific patient populations, reinforcing the broader importance of population-specific testing and personalized care not only in pediatric otolaryngology but across medicine.

Pediatric Otolaryngology Summary written by Sonaal Verma
SUNY Downstate College of Medicine
 

Rhinology and Skull Base Surgery

Steroid Irrigation vs. Spray for CRSwNP Polyps

Promsopa C, Quannuy T, Chinpairoj S, Kirtsreesakul V, Prapaisit U, Suwanparin N. A Randomized, Double-Blind Study Comparing Corticosteroid Irrigations and Nasal Sprays for Polyp Size Reduction in CRSwNP. Laryngoscope. 2025;135(10):3550-3555. [Article Link]

Irrigation over inhalation?

Chronic rhinosinusitis with nasal polyps (CRSwNP) is often treated with intranasal corticosteroid sprays (INCS), but up to half of patients have inadequate response due to limited drug penetration in edematous mucosa or large polyps. This prospective, randomized, double-blind, placebo-controlled study compared high-volume corticosteroid saline irrigation (CSI) with standard INCS in adults, evaluating polyp size reduction, symptom control, and hypothalamic-pituitary-adrenal-axis safety. Among 24 randomized non-surgical CRSwNP patients (CSI + placebo spray group: N = 13, 54.2%; INCS + placebo irrigation group: N = 11, 45.8%), endoscopic inflammation assessed by the modified Lund-Kennedy score improved in both groups, with a significantly greater reduction in the CSI group (p = 0.003), while polyp size reduction did not reach statistical significance (p = 0.187). Nasal symptoms improved in patients across both groups, with no difference in improvement between groups. Serum cortisol levels remained within the normal range with no significant changes at 4 or 12 weeks (p = 0.601), and adverse events were mild and comparable between groups. These results support CSI as a safe, high-volume therapy that may provide superior endoscopic inflammatory control compared with standard sprays. Thus, CSI may represent a practical, non-surgical escalation option for improving inflammatory control in non-surgical CRSwNP patients.

Rhinology and Skull Base Surgery Summary written by Michael Evans
Kansas City University College of Osteopathic Medicine
 

Sleep Surgery

Body Metrics in DISE With Positive Airway Pressure

Sina EM, Robinson J, Platukus A, et al. Anthropometric Predictors in Drug-Induced Sleep Endoscopy With Positive Airway Pressure. Otolaryngol Head Neck Surg. Published online October 1, 2025. [Article Link]

Why do some airways fold under pressure?

While obesity-related metrics are well-known risk factors for obstructive sleep apnea (OSA), body mass index (BMI) alone does not capture fat distribution or its impact on airway collapsibility. This study thus aimed to determine whether specific body measurements and/or the body roundness index (BRI) better predict airway collapse patterns and airway resistance during drug-induced sleep endoscopy (DISE) with positive airway pressure (PAP). This single-center retrospective cohort of 73 adult patients with CPAP-intolerant OSA who underwent DISE with PAP between December 2023 and April 2024, correlations were assessed between BMI, BRI, neck, waist, and hip circumferences and DISE collapse patterns and pharyngeal opening pressure (PhOP). Complete concentric collapse of the velum (26/59, 44.1%) was significantly associated with higher BMI, BRI, and all measured body circumferences (p < 0.05), while lateral oropharyngeal wall collapse (37/73, 50.7%) was strongly associated with neck circumference (p < 0.001), BMI (p = 0.017), and waist circumference (p = 0.019). In males, a neck circumference ≥ 42 cm increased the odds of lateral wall collapse more than five-fold (odds ratio [OR] = 5.37, 95% confidence interval [CI] 2.03 to 15.2; p = 0.001), and neck circumference independently predicted complete oropharyngeal collapse on multivariable analysis (OR = 1.48 per cm; p = 0.007), remaining predictive even in patients with a BMI less than 30 (rs = 0.451; p = 0.046). PhOP correlated most strongly with hip circumference (rs = 0.543; p = 0.001). These findings demonstrate that targeted body measurements, particularly neck circumference, provide complementary physiologic information about airway resistance that BMI alone cannot capture, and incorporating them into preoperative assessment may refine patient selection and improve safety and efficiency in CPAP-intolerant OSA care.

Josh Sorrentino’s Takeaway: This study changed how I think about the evaluation of CPAP-resistant OSA patients by emphasizing body metrics as early indicators of unfavorable airway mechanics rather than descriptive details. In practice, this perspective can prompt earlier discussions about the likelihood of lateral wall collapse, help set expectations for the utility of DISE or hypoglossal nerve stimulation, and support more deliberate counseling before operative evaluation.

Sleep Surgery Summary written by Josh Sorrentino
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo

Question of the Week

Answer and Explanation  

Correct Answer: (A) Fixation of the stapes footplate due to abnormal bone remodeling

Correct Answer Explanation: Several findings in this patient’s workup support the diagnosis of otosclerosis:

• Tuning fork examination demonstrates conductive hearing loss, with bone conduction greater than air conduction (BC > AC) in the affected ear and Weber lateralization to the affected side, consistent with impaired sound transmission through the middle ear.
• Audiometry confirms a conductive process by demonstrating an air-bone gap, with air conduction thresholds worse than bone conduction thresholds.
• A characteristic audiometric feature of otosclerosis, the Carhart notch, is present as a dip in bone conduction thresholds at ~2000 Hz, the resonant frequency of the ossicular chain. In otosclerosis, fixation of the stapes footplate eliminates normal ossicular inertia, resulting in an artifactual worsening of bone conduction at this frequency.
• Tympanometry demonstrates decreased compliance (Type As tympanogram), reflecting a stiffened ossicular chain in the setting of an intact tympanic membrane and normal middle ear pressure.

Taken together, these findings are classic for otosclerosis. Therefore, the best explanation for this patient’s pathophysiology and the correct answer to this question is answer choice (A), fixation of the stapes footplate due to abnormal bone remodeling.

Incorrect Answer Explanations:

• Answer choice (B), disruption of the incudostapedial joint, can cause conductive hearing loss but is typically associated with ossicular discontinuity following trauma or chronic otitis media. This results in increased compliance (Type Ad tympanogram) due to a hypermobile tympanic membrane, rather than the decreased compliance seen in this patient.
• Answer choice (C), chronic tympanic membrane perforation, would be evident on otoscopic examination and is commonly associated with a flat (Type B) tympanogram, often accompanied by a history of otorrhea or chronic middle ear disease, none of which are present here.
• Answer choice (D), loss of outer hair cells in the basal turn of the cochlea, describes sensorineural hearing loss, which is characterized by air conduction greater than bone conduction (AC > BC), Weber lateralization to the unaffected ear, and no air–bone gap on audiometry.
• Answer choice (E), endolymphatic hydrops (Ménière disease), presents with episodic vertigo, fluctuating low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Audiometry demonstrates sensorineural, not conductive, hearing loss, and tympanometry is typically normal because middle ear mechanics are unaffected.

Question of the Week Answer written by Adriana Báez Berríos
Icahn School of Medicine at Mount Sinai