This week in Otolaryngology (ENT)

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Welcome to This Week in Otolaryngology. This week we're covering 10 notable papers spanning the pediatric airway, tranexamic acid for bleeding, head and neck oncology, and immune-targeted therapies for airway disease. Let's dive in.

We start with the pediatric airway, where a large randomised trial and a new consensus statement both address how we manage young children's airways. In the BMJ, Han and colleagues randomised 400 children aged two to six years undergoing adenotonsillectomy at four tertiary hospitals in China to ventilation with either a laryngeal mask airway or an endotracheal tube [1]. Perioperative respiratory adverse events, a composite of laryngospasm, bronchospasm, desaturation, airway obstruction, severe cough and stridor, occurred in about one in five children with the laryngeal mask, compared with more than half of the children intubated, an absolute reduction of 35 percentage points. Most of that gap appeared after surgery, and severe cough in particular fell from roughly four in ten children to about one in ten. Laryngospasm occurred only in the tube group, the laryngeal mask needed conversion in just three children, and neither arm had serious adverse events. The authors stress that experienced anaesthesiologists placed the devices, so the findings apply most directly to high-volume centres with that expertise, but as a multicentre randomised trial this is firm evidence that the laryngeal mask is a safer default airway for this operation. Also on the pediatric airway, Crotty and colleagues in The Laryngoscope report the first international multidisciplinary Delphi consensus on recurrent croup [2]. Their review of 28 studies found definitions and workup all over the map, with most of the studies at moderate to high risk of bias. The panel reached strong consensus on prioritising direct laryngoscopy and bronchoscopy in atypical presentations, including subglottic sizing and ruling out a laryngeal cleft, and on limiting allergy testing to children with suspected atopy. It also agreed on shared otolaryngology and respiratory care, avoiding routine imaging, and reserving advanced reflux investigation for refractory cases. Notably, there was no consensus on empirical inhaled corticosteroids or antireflux therapy, which marks medical management as the open research question. This is expert opinion rather than trial data, but it offers a common framework where none existed.

Tranexamic acid is the thread connecting our next two papers, both from the emergency department, and both with more nuanced results than the headlines might suggest. In The Laryngoscope, Majidi and colleagues ran a double-blind, placebo-controlled trial in 162 adults with spontaneous epistaxis that had not stopped with first aid [3]. Topical tranexamic acid applied directly to the bleeding site achieved initial hemostasis more often than placebo, though the difference only just reached statistical significance. Rebleeding within 24 hours, including significant rebleeding, did not differ between the groups. So the evidence supports tranexamic acid as an adjunct for stopping the acute bleed, but not, on this trial, for preventing recurrence. In Otolaryngology–Head and Neck Surgery, Lear and colleagues evaluated a standardised algorithm using nebulized tranexamic acid for children presenting with post-tonsillectomy hemorrhage, comparing 121 patients before and after the protocol was introduced at a tertiary children's hospital [4]. Overall, the drop in return to theatre, from about 80 percent to about two thirds, was not statistically significant. The signal came from children with small clots covering less than half the tonsillar fossa, where surgery fell from nearly nine in ten children before the protocol to about one in five afterwards. The authors estimate 32 operations avoided and roughly 138 thousand dollars saved, with no adverse events. This is a retrospective study against historical controls, so the small-clot finding is hypothesis-generating, but it points to a defined subgroup in whom nebulized tranexamic acid may safely replace a trip to the operating room.

Head and neck oncology dominates the rest of the week, with several papers testing how much treatment is enough. In Head and Neck, Katzenberg and colleagues report 102 patients with oropharyngeal, laryngeal or hypopharyngeal squamous cell carcinoma treated in a community cancer program, in whom elective nodal volumes received only 30 or 40 gray before a boost to gross or high-risk disease [5]. With a median follow-up of just over two years, there were no elective nodal failures in either dose group, and two-year locoregional control was about 94 percent. Dose assignment reflected physician preference, the series is non-randomised, and almost every patient received concurrent systemic therapy, so the authors explicitly warn against extrapolating to radiotherapy alone. Still, it adds community-setting support to academic reports of nodal de-escalation. A similar question of how far to treat the clinically negative neck arises in salivary cancer. Using the National Cancer Database, Patel and colleagues in The Laryngoscope studied about thirteen hundred patients with node-negative submandibular gland cancer [6]. Roughly a fifth of patients underwent elective neck dissection, and about a quarter of those dissections revealed occult nodal disease, rising to half of cT4 tumours and about 40 percent of poorly differentiated cancers. Elective neck dissection itself was not associated with better survival, yet occult metastasis carried more than a threefold higher risk of death, with five-year survival falling from 83 percent to 50 percent. The authors conclude that routine dissection purely for staging is hard to justify, especially without adverse features; as registry data, it cannot settle the question for high-grade or advanced tumours. For recurrent or metastatic salivary duct carcinoma, Rosenthal and colleagues, also in The Laryngoscope, pooled studies of androgen receptor-targeted therapy [7]. Across 417 patients in the main analysis, about a quarter of patients responded, and close to half of patients derived clinical benefit, with median overall survival around 27 months. Combined androgen blockade produced roughly four times the response rate of monotherapy, about 36 versus 9 percent. The evidence is largely non-randomised and heterogeneous, and the authors note that HER2 status, receptor expression level and treatment line all belong in the decision. Finally on the oncology side, Vittayakoonsakulchai and colleagues in The Laryngoscope tested intratympanic sodium thiosulfate gel against cisplatin ototoxicity in 28 patients, using one ear as treatment and the other as control [8]. The primary measure, the incidence of ototoxicity by audiology association criteria, did not differ between ears. Treated ears did show smaller threshold shifts of roughly 7 to 10 decibels at high and extended-high frequencies, at the cost of transient vertigo or dizziness in a minority of injections and perforation in about 4 percent. This is a negative primary result in a small trial, with a high-frequency signal that would need a larger study to confirm.

Our final theme is immune-targeted therapy for chronic airway disease. In The Laryngoscope, Amin and colleagues report extended follow-up of the phase one and two trial of INO-3107, a DNA immunotherapy for HPV 6 and 11 recurrent respiratory papillomatosis [9]. Among 32 adults treated, the mean number of surgeries fell from about four in the year before treatment to under two in year one and about one in year two. Most evaluable patients showed expanded HPV-directed T-cell populations in blood and, importantly, in laryngotracheal tissue, and there were no treatment-related serious adverse events. Without a control arm, this remains early evidence, but the durability and the tissue-level immune data strengthen the case for a non-surgical option in this disease. In Rhinology, Boscolo-Rizzo and colleagues followed 69 adults with severe chronic rhinosinusitis with nasal polyps starting dupilumab or mepolizumab, measuring both orthonasal and retronasal smell [10]. Retronasal identification improved within four weeks, while orthonasal scores climbed more gradually, from severe impairment to near the normal range by 24 weeks. Dupilumab was associated with greater gains in retronasal function, symptoms and polyp scores than mepolizumab. Treatment was not randomised, so the comparison between agents is observational, but the authors propose retronasal testing as an early functional marker of response.

If you only have time for one paper this week, make it the BMJ trial from Han and colleagues comparing the laryngeal mask with the endotracheal tube in pediatric adenotonsillectomy [1]. It brings randomised, multicentre evidence to one of the most common operations in our specialty and reopens a long-standing debate about the default airway for these children.

That's your roundup for This Week in Otolaryngology. The full transcript and references are available on the episode page. See you next week.

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