Question of the Week

A 58-year-old man presents with a left-sided neck mass that has progressively enlarged over the past 3 months. He denies odynophagia, dysphonia, and unintentional weight loss. He has a 30-pack-year smoking history and drinks alcohol socially. Physical examination reveals a firm 3.5-cm left level III cervical lymph node fixed to the underlying structures. Flexible laryngoscopy reveals subtle pooling of secretions in the left pyriform sinus but no obvious mucosal lesion. CT scan of the neck with contrast demonstrates a necrotic cervical lymph node with extranodal extension as well as asymmetric thickening of the hypopharyngeal mucosa. Panendoscopy with directed biopsies is negative for malignancy.

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

(A) Observation with repeat imaging in 3 months
(B) Repeat panendoscopy with random biopsies
(C) PET-CT scan of the head and neck to identify an occult primary tumor 
(D) Open excisional biopsy of the necrotic cervical lymph node identified on CT
(E) Empiric chemoradiation to the neck without further workup

Question of the Week written by Luke Reardon
Lincoln Memorial University DeBusk College of Osteopathic Medicine

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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.

Deep Learning Model for Pediatric Middle Ear Disease

Surapaneni S, Rangarajan N, Davis K, et al. Toward an Unbiased Deep Learning Classifier of Pediatric Middle Ear Disease. Otolaryngol Head Neck Surg. 2025;173(6):1485-1493. [Article Link]

Can your smartphone diagnose an ear infection?

Otitis media is one of the most common pediatric diagnoses, yet distinguishing acute otitis media (AOM) from otitis media with effusion (OME) remains challenging and contributes to inappropriate antibiotic use. In this multicenter prospective cohort study, 737 tympanic membrane (TM) images from 219 children aged 6 months to 10 years undergoing myringotomy and tympanostomy tube placement were obtained using consumer-grade smartphone otoscopes to train a deep learning classifier. Images were labeled intraoperatively as AOM (N = 73, 9.9%), OME (N = 190, 25.8%), no effusion (N = 274, 37.2%), or no TM in image (N = 200, 27.1%). The model achieved a mean weighted accuracy of 92.5%, with category-specific weighted accuracies of 94.7% for AOM, 88.4% for OME, 87.9% for no effusion, and 98.8% for no TM in image. Precision ranged from 56.0% to 98.0%, and recall ranged from 77.0% to 98.0% across categories. Although the model was developed using anesthetized children in the operative setting, its strong performance suggests meaningful potential for translation into outpatient and telemedicine settings. This study represents an important step toward scalable, artificial intelligence (AI)-assisted otoscopic evaluation that may improve diagnostic accuracy, reduce inappropriate antibiotic prescribing, and expand access to pediatric ear care.

Emily Chestnut’s Takeaway: This study highlights how AI can be designed to prioritize both accuracy and equity. As telemedicine continues to expand, tools like this model may help bridge diagnostic gaps while supporting more responsible antibiotic use in pediatric populations.

Med Student Feature Series Summary written by Emily Chestnut
Indiana University School of Medicine
 

Facial Plastics & Reconstruction

Reconstruction After Nasal Skin Cancer Resection

Longino ES, Sharma RK, Desisto NG, et al. Reconstruction After Nasal Skin Cancer Resection: Nasal Obstruction and Associated Factors. Facial Plast Surg Aesthet Med. 2025;27(6):523-530. [Article Link]

Does function meet form after nasal reconstruction?

Functional nasal outcomes after Mohs nasal reconstruction remain understudied, and few studies have used validated aesthetic and functional measures to assess recovery over time. To address this gap, this study evaluated patient-, defect-, and reconstructive-specific factors associated with postoperative nasal obstruction using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS-O) in a retrospective cohort analysis of 193 adults undergoing nasal reconstruction after Mohs surgery. Subjective nasal obstruction, examination findings, and SCHNOS-O scores were assessed preoperatively, at three months postoperatively, between three and six months postoperatively, and beyond six months postoperatively. Overall, 47 patients (24.4%) reported postoperative nasal obstruction at a mean of 116 days after surgery, and 20 of those 47 patients (42.5%) ultimately reported symptom improvement or resolution at a mean of 235 days postoperatively. SCHNOS-O scores did not differ significantly from baseline at any postoperative time point across the total cohort. Factors independently associated with increased risk of postoperative nasal obstruction within one year of surgery included female sex, medial or lateral ala primary defect subunit, and auricular cartilage use (female sex: odds ratio [OR] = 2.76, 95% confidence interval [CI] 1.32 to 6.04, p = 0.008; medial ala: OR = 4.75, 95% CI 1.23 to 21.4, p = 0.030; lateral ala: OR = 5.79, 95% CI 1.90 to 22.1, p = 0.004; auricular cartilage: OR = 5.28, 95% CI 1.90 to 15.5, p = 0.002), whereas reconstruction with a skin or composite graft was associated with decreased risk (OR = 0.20, 95% CI 0.03 to 0.79, p = 0.045). These findings suggest that although nasal reconstruction rarely results in persistent postoperative functional compromise at the cohort level, patients with alar primary defects or cartilage grafts may be at higher risk and may benefit from patient-specific counseling, surgical planning, and postoperative monitoring.

Facial Plastics & Reconstruction Summary written by Ritu Bhalerao
University of Arizona College of Medicine - Phoenix


 

Head & Neck

Osteoradionecrosis After IMRT vs Proton Therapy

Yang F, Dee EC, Singh A, et al. Osteoradionecrosis After Intensity-Modulated Radiation Therapy or Proton Therapy in Oropharyngeal Carcinoma. JAMA Otolaryngol Head Neck Surg. 2026;152(2):135-143. [Article Link]

Osteoradionecrosis (ORN) is a debilitating complication of radiotherapy after treatment of head and neck cancer, yet the relationship between ORN and proton-based treatment remains underexplored. This retrospective cohort study evaluated rates and predictors of ORN in 1564 patients with oropharyngeal squamous cell carcinoma (mean age 61.5 ± 9.6 years) treated with radiotherapy between January 2013 and December 2023, specifically comparing ORN outcomes between intensity-modulated radiation therapy (IMRT; N = 1389, 88.8%) and proton-based treatment (N = 175, 11.2%). A total of 68 patients (4.3%) developed ORN, which corresponded to an overall three-year ORN incidence of 3.0% (95% confidence interval [CI] 2.2% to 4.1%). More specifically, the three-year ORN incidence was 6.9% (12/175) in the proton-based treatment group compared with 4.0% (56/1389) in the IMRT group, with a significantly higher three-year ORN rate after proton therapy than IMRT (proton therapy: 6.4%, 95% CI 3.1% to 12.9% vs IMRT: 2.7%, 95% CI 1.4% to 4.9%; hazard ratio [HR] = 2.6, 95% CI 1.4 to 4.9). Factors independently associated with ORN included proton-based treatment, concurrent chemotherapy, and smoking history (proton-based treatment: multivariable Cox HR = 2.9, 95% CI 1.6 to 5.5; concurrent chemotherapy: HR = 3.3, 95% CI 1.0 to 10.5; smoking history: HR = 2.3, 95% CI 1.4 to 3.9). These findings suggest increased ORN risk among patients receiving proton-based treatment and warrant further prospective study to clarify proton dose parameters and optimize treatment planning while preserving therapeutic benefits.

Head & Neck Summary written by Brooke Swain
Vanderbilt University School of Medicine


 

Laryngology

Platelet Rich Plasma Injections for Vocal Pathology

Mackay G, Prigent C, Allen J. Single Platelet Rich Plasma Glottic Injections in Vocal Pathology Demonstrate Long Term Benefits. Laryngoscope. 2026;136(2):847-853. [Article Link]

Platelet rich plasma glottic injections: Less is (usually) enough

Novel platelet rich plasma (PRP) glottic injections aim to restore lamina propria viscoelasticity by promoting tissue regeneration and may offer a less invasive alternative to traditional medialization techniques for vocal fold pathology. In this prospective study, 83 patients underwent 123 awake bilateral PRP injections under local anesthesia, including 54 patients (65.1%) who received a single bilateral injection and 29 (34.9%) who received multiple bilateral injections ranging from 2 to 7. Patients were assessed at 1, 3, 6, and 12 months using videostroboscopy, nasal endoscopy, the Voice Handicap Index-10 (VHI-10), and the Vocal Fatigue Index-1 and -2 (VFI-1/2). In the single-injection group, VHI-10, VFI-1, and VFI-2 improved significantly from baseline to 12 months post-injection (VHI-10: 20.1 vs 11.7, p < 0.001; VFI-1: 28.6 vs 16.7, p < 0.001; VFI-2: 7.8 vs 5.3, p = 0.003). Despite this, mean VHI-10 improvement did not differ significantly between the single- and multiple-injection groups at 3, 6, or 12 months post-injection (p > 0.05 for all comparisons). Patients with prior vocal fold procedures or vocal fold scarring were more likely to require multiple injections (p = 0.04 and p = 0.008, respectively). Overall, these results support starting with a single PRP injection based on subjective and objective voice outcomes, while reserving multiple injections for patients with vocal fold scarring or prior vocal fold procedures.

Laryngology Summary written by Yash Dixit
Sidney Kimmel Medical College at Thomas Jefferson University


 

Otology & Neurotology

Implications of Elevated Serum Prestin in Tinnitus

Adamczyk P, Wilson D, Prakash P, et al. Elevation of Serum Prestin in Patients With Tinnitus: Pathophysiological Implications and Biomarker Potential. Otol Neurotol. 2026;47(3):e500-e507. [Article Link]

Tinnitus lacks objective diagnostic biomarkers despite its high prevalence and established association with cochlear outer hair cell dysfunction. In this prospective case-control study, the authors evaluated whether serum levels of prestin, an outer hair cell motor protein involved in cochlear amplification, are elevated in patients with chronic tinnitus. A total of 89 adult patients were stratified into two study groups, including 49 patients (55.1%) with chronic tinnitus (at least 3 months of tinnitus symptoms) and 40 patients (44.9%) with no tinnitus (controls), and all underwent audiometry, noise dosimetry, and serum prestin quantification via automated Western blot with multivariable analyses controlling for age, hearing thresholds, and daily noise exposure. The tinnitus group demonstrated significantly greater 97 kilodalton (kDa) prestin isoform area and width than controls (analysis of covariance F(1,87) = 4.52, p = 0.016 and F(1,87) = 15.99, p < 0.001, respectively), and these differences persisted after matching for age and hearing thresholds, including in younger participants without hearing loss. In the control group, the 97 kDa prestin isoform correlated with noise exposure (Rho = 0.31, p = 0.03), whereas the 140 kDa prestin isoform correlated with noise exposure in the tinnitus group (Rho up to 0.518, p < 0.001). Overall, prestin metrics did not correlate with Tinnitus Handicap Inventory scores. These findings support a potential association between altered prestin expression and tinnitus, highlighting circulating 97 kDa prestin as a candidate biomarker with the potential to help distinguish peripheral from central tinnitus diagnoses.

Otology & Neurotology Summary written by Gabriella Adams
Eastern Virginia Medical School


 

Pediatric Otolaryngology

Posterior vs Anterior Tympanostomy Tube Placement

Zayan K, Shaffer A, Rushchak M, et al. Randomized Clinical Trial of Post-Operative Outcomes Following Posterior Versus Anterior Tympanostomy Tube Placement: Preliminary Results at 2-12 Week Follow-Up. Int J Pediatr Otorhinolaryngol. 2026;201:112704. [Article Link]

Tympanostomy tube (TT) placement is among the most common pediatric otolaryngology procedures, but evidence comparing early outcomes between anterior‑inferior (AI) and posterior‑inferior (PI) placement remains limited. This study aimed to determine whether PI placement is non‑inferior to the traditional AI quadrant in short‑term hearing outcomes and postoperative complications. In this randomized controlled trial, 386 children aged 6 months to 14 years undergoing first‑time bilateral TT placement received an AI tube in one ear and a PI tube in the contralateral ear. Follow‑up evaluations from 2 to 12 weeks postoperatively included audiometry, tympanometry, clinician assessment, and caregiver questionnaires. Rates of clinician‑reported tube occlusion (5.8% PI vs 4.7% AI), caregiver‑reported blockage (5.6% PI vs 5.9% AI), postoperative otorrhea (25.7% PI vs 24.4% AI), and flat tympanograms (9.8% PI vs 7.3% AI) did not differ significantly between TT placement quadrants. Although PI tubes were more difficult to visualize for patency (41.9% vs 3.5%), this did not translate into worse clinical outcomes. Overall, PI placement was non-inferior to AI placement for early hearing outcomes, TT function, and postoperative complications, suggesting that PI is a reasonable alternative when AI placement is technically challenging.

Pediatric Otolaryngology Summary written by Chinelo Eruchalu
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo


 

Rhinology & Skull Base Surgery

Steroid Nasal Irrigation in Surgically-Naive CRSwNP

Sant'Ana J, Pontes I, Floriano C, Rios R, Cortez M, Miyake M. Effect of Budesonide Nasal Irrigation in Patients With Chronic Rhinosinusitis With Nasal Polyps Without Prior Sinus Surgery: A Randomized, Double-Blind, Placebo-Controlled Study. Int Forum Allergy Rhinol. Published online February 13, 2026. [Article Link]

Corticosteroid nasal irrigation is a common treatment for chronic rhinosinusitis with nasal polyps (CRSwNP) following endoscopic sinus surgery (ESS), but its benefit in CRSwNP patients who have not yet undergone ESS remains unclear. In this randomized, double-blind, placebo-controlled trial, 52 adults with diffuse type 2 CRSwNP who had never undergone ESS were randomized equally to placebo (N = 26, 50.0%, mean age 46.5 ± 12.1 years) or budesonide (N = 26, 50.0%, mean age 53.8 ± 13.7 years), with both groups treated intranasally twice daily for 4 weeks using either 5% glycerin placebo or 1 mg budesonide solution. The primary outcome was change in Sinonasal Outcome Test-22 (SNOT-22) score from baseline to 4 weeks, with higher scores indicating greater symptom severity and a 14-point reduction representing the minimal clinically important difference. Secondary outcomes included patient-reported sinonasal symptom severity using a 0 to 10 Visual Analogue Scale (VAS), Nasal Polyp Score (NPS), and the Connecticut Chemosensory Clinical Research Center (CCCRC) test for olfactory function. The budesonide group demonstrated significantly greater SNOT-22 improvement than placebo (between-group difference = 18.1 points, 95% confidence interval [CI] 3.4 to 32.8, p = 0.017), with clinically meaningful improvement achieved by 19 of 26 (73.1%) budesonide patients versus 8 of 26 (30.8%) placebo patients (p = 0.049). Secondary outcomes also favored budesonide for VAS symptom severity and NPS scores after 4 weeks (VAS mean between-group difference = 2.2 points, 95% CI 0.4 to 4.1, p = 0.018; NPS mean between-group difference = 0.7 points, 95% CI 0.3 to 1.2, p = 0.003), while CCCRC olfactory scores did not differ significantly between groups (CCCRC mean between-group difference = 0.2 points, 95% CI -0.7 to 1.2, p = 0.630). Overall, these findings suggest that 1 mg budesonide nasal irrigation may be an effective, low-cost, and well-tolerated treatment for CRSwNP, with the potential to reduce polyp burden and improve quality of life in patients who have not yet undergone ESS.

Rhinology & Skull Base Surgery Summary written by Maaz Haji
Chicago Medical School, Rosalind Franklin University


 

Sleep Surgery

Severity Staging and Response to HGNS for OSA

Ji J, Wang HZ, Jackson RS, et al. Clinical Severity Staging System and Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. Published online February 5, 2026. [Article Link]

Hypoglossal nerve stimulation (HGNS) is an implantable treatment for obstructive sleep apnea (OSA) that stimulates the hypoglossal nerve to maintain airway patency during sleep and can improve outcomes in selected patients who are intolerant of continuous positive airway pressure. This study aimed to identify baseline factors associated with HGNS response and develop a practical prognostic stratification tool for OSA patients. In this retrospective cohort analysis, 119 adult patients (median age 63 years, range 33 to 79 years) who underwent HGNS implantation at a single tertiary care center between 2019 and 2023 were evaluated using demographic, clinical, and sleep-related factors as predictors of treatment response, defined by modified Sher criteria as greater than 50% reduction in apnea-hypopnea index (AHI) and post-implant AHI of less than 15 events/hour. Overall, 69.7% of patients (83/119) met HGNS response criteria, with median AHI improving from 30.7 events/hour to 6.9 events/hour (median difference = -20.7 events/hour, 95% confidence interval [CI] -24.5 to -17.5). Greater likelihood of response was associated with baseline AHI less than 30 events/hour (17.7%, 95% CI 1.6% to 33.8%), absent comorbidities (17.4%, 95% CI 1.5% to 33.4%), body mass index less than 30 kg/m2 (16.8%, 95% CI 0.0% to 33.7%), and smaller neck circumference (12.1%, 95% CI -4.7% to 29.0%). The proposed Clinical Severity Staging System demonstrated moderate discrimination (C statistic = 0.68, 95% CI 0.57 to 0.78), with response rates ranging from 90.9% in the lowest-severity group to 37.5% in the highest-severity group. These findings suggest that readily obtainable clinical factors can help stratify the likelihood of HGNS response and improve preoperative counseling, supporting more individualized patient selection rather than a uniform approach to candidacy.

Sleep Surgery Summary written by Michael Evans
Kansas City University College of Osteopathic Medicine

Question of the Week

Answer and Explanations

Correct Answer: (C) PET-CT scan of the head and neck to identify an occult primary tumor 

Correct Answer Explanation: This patient most likely has cervical nodal metastasis from an occult head and neck squamous cell carcinoma. Concerning features include a necrotic cervical lymph node, fixation to underlying structures, extranodal extension, and asymmetric hypopharyngeal mucosal thickening in the setting of major risk factors such as tobacco and alcohol use. Although panendoscopy with directed biopsies did not identify a primary lesion, the next best step is answer choice (C), PET-CT scan of the head and neck, which can detect an occult primary tumor in the oropharynx or hypopharynx, while also assisting with staging and treatment planning. In patients with cervical nodal metastatic squamous cell carcinoma and no identified primary tumor after initial endoscopic evaluation, PET-CT is the recommended diagnostic next step.

Incorrect Answer Explanations: Answer choice (A), observation with repeat imaging in 3 months, is inappropriate because this patient already has findings highly suspicious for metastatic malignancy, including a fixed necrotic lymph node with extranodal extension, and therefore requires prompt further diagnostic evaluation. Answer choice (B), repeat panendoscopy with random biopsies, is not the best next step after a nondiagnostic directed endoscopic evaluation. At this stage, PET-CT is more useful for localizing an occult primary site and guiding any additional targeted biopsy. Answer choice (D), open excisional biopsy of the necrotic cervical lymph node identified on CT, is generally avoided in suspected metastatic head and neck squamous cell carcinoma because it can disrupt tissue planes and complicate subsequent surgical management. Answer choice (E), empiric chemoradiation to the neck without further workup, is inappropriate because treatment planning should follow completion of staging and additional evaluation for the primary tumor.

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