This Week in Otolaryngology — Jul 16, 2026

Welcome to This Week in Otolaryngology. This week we are covering 10 notable papers spanning diagnostic refinements in otology and cranial base pathology, evolving therapeutic strategies in head and neck oncology, and critical updates in airway management across pediatric and adult populations. Let us dive in.

We begin in the field of otology and neurotology, where distinguishing between Meniere's disease and vestibular migraine remains a common diagnostic challenge. A prospective clinical study published in Otology and Neurotology evaluated 231 patients over at least two years using high-resolution magnetic resonance imaging to assess endolymphatic hydrops [2]. The investigators found that in patients with Meniere's disease, grade one cochlear hydrops was most common, occurring in roughly sixty percent of cases, while grade two vestibular hydrops was seen in about half of the patients. Conversely, more than half of the patients with vestibular migraine had no evidence of cochlear or vestibular hydrops at all. When hydrops was present in vestibular migraine patients, it was almost always mild. These findings indicate that while mild hydrops can occasionally overlap, the presence of moderate-to-severe hydrops strongly points toward a diagnosis of Meniere's disease, helping clinicians make more objective diagnostic decisions.

Evolving our understanding of cranial base pathology, another study in Otology and Neurotology investigated the prevalence of superior semicircular canal dehiscence in patients with lateral spontaneous cerebrospinal fluid leaks [5]. In a retrospective cohort of 161 patients undergoing middle fossa craniotomy skull base repair, the researchers compared preoperative high-resolution computed tomography scans with direct intraoperative findings. Interestingly, the actual intraoperative prevalence of superior canal dehiscence was about seven percent, and near-dehiscence was about ten percent. Both rates were significantly lower than what preoperative computed tomography scans predicted, which estimated dehiscence at thirteen percent and near-dehiscence at nearly thirteen percent. While clinical markers like obesity, sleep apnea, and intracranial opening pressure did not predict true intraoperative dehiscence, patients with confirmed dehiscence were nearly five times more likely to experience preoperative dizziness. The study highlights that while computed tomography has an excellent negative predictive value of nearly ninety-six percent, its positive predictive value is only fifty-three percent, meaning we should rely on intraoperative confirmation rather than imaging alone before concluding a patient has true dehiscence.

For patients undergoing middle ear surgery, managing postoperative pain, nausea, and vomiting is a primary clinical goal. A systematic review and meta-analysis of seven randomized controlled trials involving 459 patients, published in Otology and Neurotology, evaluated the efficacy of regional nerve blocks, specifically the superficial cervical plexus block and the great auricular nerve block [3]. The analysis revealed that regional nerve blocks significantly reduced postoperative pain at one, twelve, and twenty-four hours. Additionally, these blocks led to a substantial reduction in intraoperative remifentanil consumption and cut the risk of postoperative nausea and vomiting by more than half. Because these techniques provide superior pain relief and accelerate recovery without increasing adverse events like vertigo or tinnitus, they represent a highly valuable adjunct to standard perioperative care.

Closing our cranial base discussion, a scoping review in The Laryngoscope investigated the diagnostic challenges of unilateral facial paralysis caused by occult malignancies [10]. Evaluating 66 patients across 27 studies, the authors reported a staggering mean diagnostic delay of twenty-one months. The most common underlying malignancy was squamous cell carcinoma, which was frequently associated with a history of regional skin cancer. Crucially, over half of the patients experienced concurrent trigeminal symptoms, and nearly a quarter had additional cranial neuropathies. This review serves as a vital clinical reminder: if a patient presents with progressive facial paralysis, fails to recover, exhibits trigeminal symptoms or other cranial neuropathies, or has a history of skin cancer, we must perform repeat imaging and consider a surgical biopsy, even if the initial imaging was reported as completely normal.

Moving into head and neck oncology, we examine a critical safety signal regarding antibiotic use during immunotherapy. A retrospective study published in Head and Neck evaluated 316 patients with recurrent or metastatic head and neck squamous cell carcinoma treated with immune checkpoint inhibitors [4]. Nearly forty-seven percent of these patients received antibiotics surrounding their immunotherapy. The researchers found that antibiotic exposure was independently associated with a roughly fifty percent increase in the risk of death. While the route of administration and the spectrum of the antibiotic did not impact survival, the total number of antibiotic classes used was a strong independent predictor of worse overall survival, alongside poor performance status, low PD-L1 expression, and oral cavity primary sites. These findings suggest that antibiotic exposure may impair the efficacy of immune checkpoint inhibitors, highlighting the need for rigorous antibiotic stewardship in this patient population.

Also in the journal Head and Neck, researchers addressed whether curative-intent primary surgery is beneficial for geriatric patients with oral cavity squamous cell carcinoma [6]. In a single-center retrospective study of 1,744 patients, researchers compared clinical outcomes between patients aged forty to sixty-nine and those aged seventy and older. Surprisingly, the elderly cohort demonstrated significantly better five-year disease-free survival, while overall survival was comparable between the two groups. Multivariable analysis confirmed that age seventy or older was independently associated with improved disease-free survival, whereas advanced tumor stage, nodal metastasis with extranodal extension, and lymphatic invasion were the strongest predictors of worse overall survival. This study strongly supports offering primary curative surgery to eligible elderly patients, demonstrating that prognosis is driven by functional reserve and tumor biology rather than chronological age alone.

Our final theme covers airway management, sleep medicine, and pediatric interventions, beginning with the systemic cardiovascular impact of hypoglossal nerve stimulation. A retrospective cohort study in JAMA Otolaryngology-Head and Neck Surgery matched 3,786 patients undergoing hypoglossal nerve stimulation with 3,395 sleep apnea controls who were non-adherent to positive airway pressure therapy [1]. Because the cardiovascular effects of surgery are not immediate, the authors utilized a time-varying model. Within the first two years, the stimulation group actually showed a higher risk of new hypertension and higher rates of cardiovascular events. However, after the two-year mark, the hazard of developing diabetes dropped by eighty percent, and the hazard of developing hypertension was halved. Additionally, the risk of minor or major cardiovascular events began decreasing significantly after two years. This suggests that while there is an initial diagnostic or therapeutic lag, hypoglossal nerve stimulation provides substantial, long-term cardiovascular and metabolic protection.

Next, a histopathological study in The Laryngoscope examined the direct physical impact of endotracheal intubation on the trachea [7]. Analyzing tracheal specimens from 46 patients undergoing tracheotomy and comparing them to 20 controls, the researchers found that intubation was associated with extensive tissue damage, including ulceration, inflammatory infiltration, and granulation tissue. Crucially, the rates of tracheal dilatation and perichondritis increased significantly with longer intubation times. To minimize these permanent structural injuries and associated complications, the authors recommend considering a surgical tracheotomy within the first fourteen days of intubation.

In pediatric airway management, predicting a difficult airway is notoriously difficult due to unique anatomical variations. A prospective, double-blind observational study in the International Journal of Pediatric Otorhinolaryngology evaluated 240 children to assess whether preoperative airway ultrasound could improve risk stratification [8]. The researchers measured skin-to-epiglottis distance and skin-to-hyoid distance. The skin-to-epiglottis distance demonstrated the highest individual predictive accuracy, and when combined with the skin-to-hyoid distance, the diagnostic accuracy reached a remarkable ninety-six percent area under the curve. Multivariable regression identified both ultrasound measurements, a Mallampati class of three or four, and facial anomalies as independent predictors of difficult intubation. Because airway ultrasound is objective, reproducible, and does not require patient cooperation, it represents a major clinical advancement for preoperative pediatric airway planning.

Finally, a ten-year retrospective study in The Laryngoscope evaluated the outcomes of endoscopic endonasal repair of congenital choanal atresia using mucoperiosteal flaps without postoperative stenting in 36 children [9]. Although long-term neochoanal patency was achieved in ninety-seven percent of patients, postoperative complications were common. Granulation tissue occurred in twenty-two percent, synechiae in thirty-three percent, and restenosis in thirty-nine percent of cases, resulting in an overall relook surgery rate of forty-seven percent, most commonly within the first postoperative month. These results demonstrate that while a stentless, flap-based approach yields excellent long-term patency with low morbidity, clinicians must prepare families for a high likelihood of early, minor revision procedures to maintain airway patency.

If you only have time for one paper this week, make it the scoping review on the diagnostic delay of unilateral facial paralysis caused by occult malignancy, published in The Laryngoscope [10]. This paper highlights a critical clinical blind spot, revealing a staggering average diagnostic delay of nearly two years, and provides clear red flags-such as progressive paralysis, trigeminal symptoms, and a history of skin cancer-that should prompt us to look beyond a negative initial magnetic resonance imaging scan.

Here are the key takeaways from this week in Otolaryngology. First, do not rule out an occult facial nerve malignancy based on a single negative magnetic resonance imaging scan; progressive paralysis, lack of recovery, or concurrent trigeminal symptoms require repeat imaging and a high index of suspicion for surgical biopsy. Second, when treating patients with head and neck squamous cell carcinoma undergoing immune checkpoint inhibition, exercise strict antibiotic stewardship, as antibiotic exposure is independently associated with decreased overall survival. Third, chronological age should not be a barrier to curative-intent primary surgery in oral cavity cancer; elderly patients can achieve excellent disease-free and overall survival, with prognosis driven primarily by tumor biology and pathological features. Fourth, incorporate ultrasound measurements, specifically the skin-to-epiglottis and skin-to-hyoid distances, into your pediatric airway assessments, as they provide highly accurate, objective, and non-cooperative-dependent predictions of a difficult airway. And fifth, while hypoglossal nerve stimulation may show a transient increase in cardiovascular events in the first two years, it is associated with a dramatic reduction in the long-term incidence of diabetes, hypertension, and major cardiovascular events after two years.

That's your roundup for This Week in Otolaryngology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary - for clinical decisions, always consult primary sources and current guidelines. See you next week.

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