Question of the Week

A 19-year-old man presents to the emergency department 3 hours after being struck in the face during a soccer game. He reports worsening nasal pain and bilateral nasal obstruction but denies loss of consciousness, vision changes, or clear rhinorrhea. Examination reveals nasal edema and tenderness with mild deviation of the nasal dorsum, and anterior rhinoscopy demonstrates boggy, compressible swelling along both sides of the anterior nasal septum. Computed tomography (CT) of the facial bones shows a minimally displaced nasal bone fracture without additional facial fractures.

Which of the following is the most appropriate next step in management?

(A) Discharge with analgesics and reevaluate after nasal edema resolves
(B) Immediate incision and drainage of septal swelling
(C) Closed reduction of nasal fracture followed by outpatient observation
(D) Needle aspiration of septal swelling followed by intranasal corticosteroid therapy
(E) Elective septorhinoplasty after nasal fracture has completely healed

Question of the Week written by Sarah Atallah
University of Toledo College of Medicine and Life Sciences

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Med Student Feature Series

Our “Med Student Feature Series” spotlights recently published medical student-led research in top otolaryngology journals.

Join us as we celebrate evidence-based discoveries made by aspiring otolaryngologists during medical school.

Hearing Loss in Adults With Sickle Cell Disease

de Santana Hager M, Brown TD, Sopchak AE, Varavenkataraman G, Carr MM. Prevalence of Hearing Loss in Adult Patients With Sickle Cell Disease: A Retrospective Cohort Study. Laryngoscope. 2026 May;136(5):2291-2298. [Article Link]

What does a lifetime of crises cost the ear?

Sickle cell disease causes recurrent vaso-occlusion and hemolysis, but its otolaryngologic manifestations, particularly hearing loss in adults, remain underrecognized. Using TriNetX, this retrospective cohort study compared ICD-10-coded outcomes in 13,870 adults with sickle cell disease and 13,870 adults without sickle cell disease, propensity score-matched 1:1 on age, sex, race, and ethnicity, whose index outpatient visits occurred between May and December 2022. Hearing loss was documented in 831 patients with sickle cell disease (6.0%) versus 365 matched controls (2.6%; odds ratio [OR] 2.36, 95% confidence interval [CI] 2.08-2.67; p<0.001), driven by sensorineural hearing loss in 437 patients (3.2%) versus 179 (1.3%; OR 2.49, 95% CI 2.09-2.97; p<0.001), while conductive hearing loss did not differ between groups (n=49, 0.4% vs n=38, 0.3%; OR 1.29, 95% CI 0.84-1.97; p=0.238). Obstructive sleep apnea was also more common in the sickle cell disease cohort (n=1,646, 11.9% vs n=945, 6.8%, OR 1.84, 95% CI 1.69-2.00; p<0.001), as were allergic rhinitis (n=817, 5.9% vs n=505, 3.6%, OR 1.66, 95% CI 1.48-1.86; p<0.001) and acute or chronic sinusitis (n=726, 5.2% vs n=624, 4.5%; OR 1.17, 95% CI 1.05-1.31; p=0.004). The authors propose that recurrent vaso-occlusion of labyrinthine vessels may compromise the cochlea’s end-arterial blood supply, causing ischemic and reperfusion injury that progressively damages the organ of Corti, while noting that diagnosis codes may under-represent mild or subclinical hearing loss and that routine hearing assessment may facilitate earlier detection in adults with sickle cell disease.

Andrew Sopchak's Takeaway: An otolaryngology visit for a non-hearing loss-related complaint may still provide an opportunity to identify underrecognized hearing loss in adults with sickle cell disease. I would therefore ask such patients directly about difficulty hearing or following conversation rather than waiting for them to raise these concerns themselves.

Med Student Feature Series Summary written by Andrew Sopchak
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo

Head & Neck

FNA and CNB for Parotid Masses

Buhler LEC, Prince A, Bunda N, et al. Comparative Outcomes of Fine Needle Aspiration and Core Needle Biopsy for Parotid Masses. Otolaryngol Head Neck Surg. 2026;175(3):632-640. [Article Link]

Getting to the core of the matter

Accurate preoperative diagnosis of parotid masses remains challenging, as fine needle aspiration (FNA) performance varies with sampling adequacy and cytologic interpretation, while core needle biopsy (CNB) use has been limited by concerns about complications and diagnostic delays. This single-center retrospective cohort study compared ultrasound-guided FNA (n=426, 87.6%) and CNB (n=59, 12.2%) in 485 adults who underwent parotidectomy with facial nerve preservation between 2018 and 2023, using final surgical histopathology as the reference standard. Although the modalities performed similarly for detecting neoplasia, CNB demonstrated higher sensitivity (80.0% vs 54.9%; p=0.032), positive predictive value (87.0% vs 56.4%; p=0.01), and accuracy (86.4% vs 68.5%; p=0.007) for malignancy, as well as greater tissue-specific accuracy (67.8% vs 49.5%; p=0.009). CNB also demonstrated greater tissue-specific accuracy for squamous cell carcinoma (6/6, 100% vs 20/48, 41.7%; p=0.009) and mucoepidermoid carcinoma (4/5, 80.0% vs 3/21, 14.3%; p=0.01), while FNA had a higher nondiagnostic rate (85/426, 20.0% vs 3/59, 5.1%; p=0.004). Complication rates were low and comparable between CNB (2/59, 3.4%) and FNA (9/426, 2.1%; p=0.64), with no facial nerve injuries or tumor seeding, and median time to surgery for malignant cases did not significantly differ (51 vs 42 days; p=0.10). The authors concluded that CNB should be considered for parotid lesions with high clinical or radiographic suspicion for malignancy or when a histology-level diagnosis would alter operative planning, while FNA retains a role for lesions with low pretest probability at centers with on-site cytopathology.

Supriya Kumar's Takeaway: I find it interesting how much influence practice pattern has on patient care, as biopsy modality was largely determined by the performing service, with radiologists performing CNB and otolaryngologists performing FNA. This finding suggests that a patient's preoperative diagnosis may hinge on the service they are referred to, creating a potential source of variability for something as consequential as a cancer diagnosis.

Head & Neck Summary written by Supriya Kumar
University of Toledo College of Medicine and Life Sciences
 

Laryngology

Diet and Lifestyle vs Medication for LPR

Lechien JR. Comparison of Diet and Lifestyle Program with 3 Medication Approaches for Laryngopharyngeal Reflux Disease Management. JAMA Otolaryngol Head Neck Surg. 2026;152(8):816-821. [Article Link]

Could the first prescription just be a grocery list?

Laryngopharyngeal reflux (LPR), characterized by reflux reaching the laryngopharynx, accounts for up to 10% of otolaryngology and gastroenterology consultations and carries substantial treatment costs. Although proton pump inhibitors (PPIs) have long been first-line therapy, meta-analyses have failed to demonstrate superiority over placebo, and no prior controlled study has directly compared the main dietary and medication approaches. This retrospective cohort study included 145 patients with LPR confirmed by 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing who completed 3 months of a strict antireflux diet plus stress-reduction activities (n=48, 33.1%), PPIs (n=32, 22.1%), alginates (n=38, 26.2%), or antacids (n=27, 18.6%), with changes in reflux symptom score (RSS), reflux sign assessment (RSA), and response rates compared. All four groups had significant reductions in RSS and RSA over 3 months (all within-group RSS p<0.001; RSA p≤0.021), with no significant between-group differences in symptom-change trajectories (p=0.81) or sign-change trajectories (p=0.75). The diet group had the highest responder rate, with 39 of 48 patients (81.2%) responding, compared with 18 of 32 (56.3%) receiving PPIs, 22 of 38 (57.9%) receiving alginates, and 20 of 27 (74.1%) receiving antacids (overall p=0.04), and diet also resulted in a lower estimated mean posttreatment RSS than antacids (mean difference 38.73 points, 95% confidence interval [CI] 4.24-73.23; p=0.02). The authors concluded that a strict low-fat, low-quick-release-sugar, high-protein diet combined with stress reduction may offer symptom relief comparable or superior to medication and may be particularly relevant given the high cost burden of pharmacologic LPR management, although randomized trials are needed given the study’s nonrandomized treatment allocation, attrition, and potential selection bias from including only adherent completers.

Humza Sheikh's Takeaway: This study reframed my understanding of LPR management by showing that a structured diet and wellness program may be as effective as commonly prescribed medications, including PPIs. However, because only adherent completers were analyzed and treatment was not randomized, I would consider lifestyle modification a strong option for shared decision-making while recognizing that these findings do not establish its superiority over pharmacotherapy.

Laryngology Summary written by Humza Sheikh
Rush University Medical College
 

Otology & Neurotology

Low-Dose Aspirin and Central Presbycusis

Rance G, Zanin J, Britt CJ, Tran C, McNeil JJ. Low-Dose Aspirin and Central Presbycusis: A Substudy of the ASPREE Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2026;152(6):560-568. [Article Link]

An aspirin a day won't keep presbycusis away

Presbycusis affects more than half of adults 70 years or older, and microvascular and inflammatory pathology may contribute to degeneration of both peripheral and central auditory pathways. In this substudy of the double-blind, placebo-controlled ASPREE trial, the authors investigated whether aspirin could slow central auditory decline by randomizing 124 healthy adults ≥70 years old (mean [standard deviation] age 72.8 [3.5] years; female: n=60, 48.4%) to 100 mg of daily enteric-coated aspirin (n=61, 49.2%) or placebo (n=63, 50.8%), with auditory assessments at baseline and 18, 36, 48, and 60 months using cortical auditory evoked potentials and speech-in-noise testing. Cortical N1 latencies increased by 1.3 milliseconds per year (ηp²=0.08; 95% confidence interval [CI] 0.02-0.13; p<.001), with no aspirin effect (ηp²<0.001; p>.99) or aspirin × time point interaction (p=.33). N1/P2 amplitudes decreased by 0.2 μV per year (p=.01) and showed a main aspirin effect (estimated marginal mean difference 0.64 μV, 95% CI 0.37-0.91; p=.02), but no aspirin × time point interaction (p=.77), indicating a baseline group difference rather than a treatment effect. Speech reception thresholds worsened by 0.1 dB per year only when target speech and noise were spatially separated (both p=.01), with no aspirin effect in any listening condition. Overall, low-dose aspirin had no clinically important effect on central presbycusis, although participants demonstrated substantial central auditory deterioration over 5 years, including a mean 0.5-dB increase in speech reception thresholds in everyday-like listening conditions, equivalent to a ~10% reduction in speech intelligibility. These findings suggest that functionally significant central auditory decline is common after age 70 and warrants continued investigation of potential therapies.

Sonaal Verma's Takeaway: Before reading this paper, I thought of presbycusis as primarily a cochlear problem, but the decline in speech perception specifically when speech and noise originate from different directions presented by these authors highlights the aging brain’s reduced ability to use binaural cues. For older patients who struggle with conversation in noisy settings despite a reasonable audiogram, this supports adding speech-in-noise testing rather than stopping at pure tones.

Otology & Neurotology Summary written by Sonaal Verma
SUNY Downstate Health Sciences University

 

Pediatric Otolaryngology

Tonsil Surgery for Pediatric OSA With Comorbidities

Virkkunen J, Kirjavainen T, Nokso-Koivisto J, Sakki AJ. Tonsil surgery is an effective treatment for pediatric obstructive sleep apnea irrespective of underlying comorbidities. Int J Pediatr Otorhinolaryngol. 2026;206:112883. [Article Link]

Small tonsils, big airway wins in kids with complex diagnoses

Children with craniofacial abnormalities or neurologic disorders are at increased risk of obstructive sleep apnea (OSA), but evidence regarding outcomes after tonsil surgery in these populations remains limited. This retrospective cohort study evaluated 33 children younger than 16 years with OSA-predisposing comorbidities who underwent adenotonsillar surgery: tonsillotomy (N=26, 78.8%) or tonsillectomy (N=7, 21.1%), with pre- and postoperative polysomnography. Median obstructive apnea-hypopnea index (oAHI) decreased from 17.7 to 1.9 events per hour (p<0.0001), and 70% of children (N=23) achieved a postoperative oAHI <5 events per hour. Tonsil size correlated only weakly with improvement in oAHI (R2 = 0.11; p=0.035). No postoperative hemorrhage occurred after tonsillotomy, compared with 1 case (14%) after tonsillectomy. Although limited by its small sample, this study supports tonsil surgery, including tonsillotomy, as an effective treatment for OSA in medically complex children.

Malek Ajam's Takeaway: This study challenged an assumption I had absorbed without questioning: that small tonsils on physical examination are a reason to hold off on surgical intervention. The weak correlation between tonsil size and postoperative oAHI improvement presented by these authors will make me weigh symptoms and polysomnogram findings more heavily than examination alone when considering whether surgery may benefit a patient in clinical practice.

Pediatric Otolaryngology Summary written by Malek Ajam
University of California Davis School of Medicine
 

Rhinology & Skull Base Surgery

Efficacy of Full and Limited ESS in CRSwNP

Virkkula P, Hammarén-Malmi S, Laulajainen-Hongisto A, et al. Efficacy of Full and Limited Endoscopic Sinus Surgery in Chronic Rhinosinusitis With Nasal Polyps: A Randomised Controlled Trial. Allergy. Published online July 30, 2026. [Article Link]

How much surgery is enough? Ask the patient or the polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) frequently requires endoscopic sinus surgery when nasal lavage and intranasal corticosteroids fail, yet the optimal extent of surgery remains uncertain. In this open-label randomized controlled trial, 97 adults aged 18 to 65 years with severe, uncontrolled CRSwNP despite adequate medical therapy were randomized 1:1 to full functional endoscopic sinus surgery (FESS) or limited FESS, with change in the patient-reported 22-item Sino-Nasal Outcome Test (SNOT-22) at 12 and 24 months as the primary outcome. Among the 94 patients in the per protocol analysis (n=47, 50% per group), mean SNOT-22 scores fell by 30.3 points after full FESS and 25.3 points after limited FESS at 12 months (-27.4 and -28.9 points, respectively, at 24 months), exceeding the minimal clinically important difference (MCID) of 8.9, while the between-group difference was not significant and did not reach the MCID. Full FESS demonstrated superior secondary outcomes at 12 months, including olfaction by Sniffin’ Sticks-12 (p<0.001), endoscopic polyp burden on the nasal polyp score (p=0.003), modified Lund-Kennedy score (p=0.010), radiographic disease on the Lund-Mackay computed tomography (CT) score (p<0.001), and disease control by European Position Paper on Rhinosinusitis and Nasal Polyps 2012 (EPOS 2012) criteria (p=0.010). Oral corticosteroid use decreased comparably in both groups, while 10 patients (11.1%) required a change in treatment plan within 24 months, including 9 of 90 patients (10.0%) who underwent limited FESS. Both approaches provided durable, clinically meaningful quality-of-life improvement, suggesting that limited FESS may be a reasonable option for patients who prefer or require a smaller procedure, while the greater inflammatory and olfactory improvement after full FESS may offer advantages in disease control.

Rhinology & Skull Base Surgery Summary written by Eric Giannaris
CUNY School of Medicine
 

Basic Science Spotlight

Stromal Remodeling in HNSCC After Chemotherapy

Wei D, Sun Y, Han J, Cao W, Liu J. Single-Cell Profiling Reveals Stromal-Immune Remodeling in HNSCC After TPF-Based Neoadjuvant Chemotherapy. Head & Neck. 2026:1-13. [Article Link]

Honey, I shrunk the tumor

Neoadjuvant therapy can substantially reduce tumor burden in head and neck squamous cell carcinoma (HNSCC), but the cellular composition of treatment-induced regression areas and how they differ from residual tumor remain poorly understood. The authors of this study performed multiregion single-cell ribonucleic acid (RNA) sequencing of 76,416 cells from six patients with tongue squamous cell carcinoma, including three who underwent upfront surgery and three who received docetaxel, cisplatin, and 5-fluorouracil (TPF)-based neoadjuvant chemotherapy, with pathologic regression patterns additionally characterized in an independent cohort of 30 TPF-treated patients. Pathologic regression was heterogeneous, with 17 of 30 tumors (56.7%) demonstrating a predominantly honeycomb-like pattern, 7 of 30 (23.3%) demonstrating a concentric-like pattern, and 6 of 30 (20.0%) achieving complete response, while radiographic regression generally appeared centripetal. Treatment-induced regression areas were relatively enriched for complement factor D-positive (CFD+) inflammatory fibroblasts, whereas residual tumor cores retained periostin-positive (POSTN+) matrix cancer-associated fibroblasts (CAFs) enriched in extracellular matrix remodeling programs. Residual tumor cores also demonstrated greater inferred cell-cell communication, including fibroblast-centered extracellular matrix, epithelial, and immune signaling, while patient-averaged T-cell cytotoxicity, exhaustion, and regulatory T-cell scores did not differ significantly across regions. These findings suggest that neoadjuvant chemotherapy creates spatially distinct stromal niches that may not be captured by radiographic response alone, highlighting CAF remodeling as a potential contributor to treatment resistance and a candidate target for future investigation.

Clara Si's Takeaway: These findings made me consider whether distinguishing treatment-remodeled stroma from truly uninvolved tissue could eventually add another dimension to intraoperative margin assessment after neoadjuvant therapy for HNSCC. However, given that the single-cell analysis included only six patients, larger, spatially resolved studies would be necessary before these stromal patterns could meaningfully inform surgical decision-making.

Basic Science Spotlight Summary written by Clara Si
Vanderbilt University School of Medicine

Question of the Week

Answer and Explanations

Correct Answer: (B) Immediate incision and drainage of septal swelling

Correct Answer Explanation: This patient has a septal hematoma, suggested by the boggy, compressible bilateral septal swelling following nasal trauma. A septal hematoma occurs when blood accumulates between the septal cartilage and perichondrium, disrupting the cartilage’s nutrient supply and placing it at risk for ischemia, necrosis, septal abscess, and subsequent saddle-nose deformity. Answer choice (B), immediate incision and drainage, is therefore the appropriate next step to evacuate the hematoma and prevent these complications.

Incorrect Answer Explanations: Answer choice (A), discharge with analgesics and reevaluation after the edema resolves, is inappropriate because a septal hematoma requires prompt treatment rather than observation. Answer choice (C), closed reduction of the nasal fracture, may be appropriate for selected displaced nasal fractures after swelling subsides but does not address the urgent septal hematoma. Answer choice (D), needle aspiration followed by intranasal corticosteroid therapy, does not provide definitive evacuation of the hematoma, and intranasal corticosteroids do not treat this condition. Answer choice (E), elective septorhinoplasty, may address chronic post-traumatic deformity but is not appropriate when an acute septal hematoma requires immediate treatment.

Source:
[1] Nasal Septal Hematoma Management

Question of the Week Answer written by Sarah Atallah
University of Toledo College of Medicine and Life Sciences