This week in Otolaryngology (ENT)

Welcome to This Week in Otolaryngology. This week we're covering 10 notable papers spanning hearing rehabilitation and airway inflammation, head and neck oncology decision-making, and a set of procedural and medical management questions from laryngology, rhinology, sinus and salivary disease. Let's dive in.

We'll start with hearing, where a question most of us thought was settled has finally been tested properly. In JAMA Otolaryngology-Head and Neck Surgery, Smith and colleagues randomised 275 adults aged 50 and older with age-related hearing loss, all new to amplification, to either one hearing aid or two, at audiology clinics at Duke and Vanderbilt, and followed them for three months using the Abbreviated Profile of Hearing Aid Benefit as the primary outcome [1]. Both groups improved meaningfully from their unaided baseline. The bilateral group did better, by about five points on that scale, and that difference was statistically detectable — but the authors are careful to say it is not clear whether five points crosses the threshold for clinical meaningfulness. Their own framing is that these results inform, but do not establish, a standard-of-practice recommendation for bilateral fitting. For practice, that is a useful piece of honesty to carry into the counselling room: two aids probably give a bit more benefit, one aid still gives real benefit, and for a patient balancing cost against expected gain, the evidence does not support telling them that a single aid is inadequate treatment.

Moving to head and neck oncology, two papers this week push in the same direction — away from fixed rules and toward individualised risk. Also in JAMA Otolaryngology, Fleming and colleagues performed a secondary analysis of the NRG RTOG 1016 trial, with two expert head and neck radiologists reviewing computed tomography simulation scans from 586 patients with node-positive, p16-positive oropharyngeal cancer for imaging-detected extranodal extension [3]. Three fifths of the cohort had it, and those patients had worse five-year overall survival — roughly 79 percent versus 87 percent — and a larger gap in progression-free survival, about twelve points. On multivariable analysis, imaging-detected extranodal extension was independently associated with worse survival and worse progression-free survival, with the risk of death raised by more than half. Importantly, though, when the new ninth edition nodal schema was compared head-to-head with the eighth edition, the two performed essentially identically on discrimination statistics. So the biology is real and prognostically meaningful, but this dataset does not show that upstaging on the basis of imaging-detected extranodal extension improves overall staging performance. Use it in your prognostic conversations; be cautious about assuming the new staging system is a measurable upgrade. Alongside that, Head and Neck published an international survey by Gazzini and colleagues challenging the thirty-five-year-old twenty percent rule for elective neck dissection in the clinically node-negative neck [5]. Among just over two thousand respondents, including head and neck surgeons, other clinicians and lay participants, more than half would accept a neck dissection at an occult metastasis risk of ten percent or lower, and among head and neck surgeons around three quarters endorsed a threshold of five percent or lower for adding levels two-B, four and five. Ninety percent of surgeons said individual risk calculation plus a shared discussion with the patient is more appropriate than any fixed cut-off. This is opinion, not outcome data, but it tells you that the twenty percent threshold no longer reflects how the field actually thinks.

Staying in the operative sphere, Otolaryngology-Head and Neck Surgery published a meta-analysis by Xiao and colleagues pooling 47 studies and 30,002 free flaps in head and neck reconstruction [7]. Flap compromise occurred in about one in twelve cases and complete failure in roughly four percent. Prior radiotherapy carried by far the largest signal, quadrupling the odds of compromise, with diabetes roughly doubling it. What makes this practically useful is the modifiable list: perioperative fluid overload, prolonged operative time, low serum albumin, low body mass index and low haemoglobin were each independently associated with compromise, fluid overload and operative duration roughly doubling the odds. Those are levers you can actually pull in preoperative optimisation and intraoperative anaesthetic planning. In a similar de-escalation vein, the same journal published a narrative review by Hack and colleagues on intraoperative parathyroid hormone monitoring in sporadic primary hyperparathyroidism [8]. Their argument is that focused parathyroidectomy, hormone-guided surgery and bilateral exploration all achieve high cure rates when applied appropriately, and that the incremental value of intraoperative hormone monitoring is concentrated in situations of residual uncertainty — discordant or non-localising imaging, atypical biochemistry including normocalcaemic disease, familial or syndromic presentations, reoperative necks and unfavourable anatomy. In a narrow subgroup with sporadic disease, favourable anatomy and concordant high-quality localisation, ideally surgeon-performed ultrasound plus four-dimensional computed tomography, routine monitoring rarely changes management. They stop short of recommending abandonment, and they insist on a low threshold for intraoperative escalation.

Turning to laryngology and rhinology, The Laryngoscope published a European practice consensus on office-based laryngology from Lechien and colleagues, in which 25 laryngologists across the British Laryngological Association, the European Laryngological Society and the Union of European Phoniatricians used a modified Delphi process to approve 60 statements over two voting rounds [2]. The agreed primary indications include polyps, Reinke's oedema, varices, leukoplakia, biopsies, granulomas, recurrent respiratory papillomatosis and selected vocal fold augmentation, with statements covering preprocedural assessment, technique, postprocedural care and success criteria, and even environmental and economic outcomes. If you are building or defending an office-based service, this gives you a European reference document to anchor patient selection. The same journal reports something more preliminary but conceptually interesting from Larkin and colleagues on idiopathic subglottic stenosis — a chart review of more than 250 patients that identified just three who started a JAK inhibitor for coexisting rheumatoid arthritis after their airway diagnosis [9]. In those three, the mean surgical-free interval roughly doubled, from about 317 days to 631 days, and the annualised dilation rate fell from about 1.2 to under 0.4 procedures per patient-year. Single-cell sequencing showed JAK-STAT pathway activation concentrated in CD4-positive T cells and neutrophils rather than epithelium. Three patients is a hypothesis, not a therapy, but this is the clearest rationale yet for a prospective trial of adjuvant medical therapy in a disease that currently has none.

On the medical management side, Otolaryngology-Head and Neck Surgery published a state-of-the-art review of laryngopharyngeal reflux from Lechien and colleagues arguing that pharyngeal reflux events are predominantly gaseous and alkaline, with alkaline-activated enzymes detected in upper aerodigestive mucosa and saliva [4]. On that basis, three recent consensuses emphasise objective testing with 24-hour hypopharyngeal-oesophageal impedance-pH monitoring before committing to treatment, and the emerging clinical data favour alginate and magaldrate over proton pump inhibitors, which only address gastric acidity. The honest caveat is that no randomised trial in the last five years has compared alginate, magaldrate, diet and proton pump inhibitors head-to-head. Still, the direction of travel is away from reflexive acid suppression. And in chronic rhinosinusitis, the same journal published a post hoc analysis of the ReOpen trials by Schlosser and colleagues examining whether the exhalation delivery system with fluticasone works differently with and without polyps, pooling 206 patients with polyps and 341 without across 24 weeks [6]. Both groups showed substantially greater benefit than exhalation-delivery placebo on composite symptoms, smell identification testing, sinus opacification on computed tomography, acute exacerbation frequency and quality of life, and the treatment-by-subgroup interaction indicated a similar magnitude of effect regardless of polyp status. Benefit persisted in the subgroup still symptomatic despite recent standard nasal steroid spray. Finally, on salivary disease, Otolaryngology-Head and Neck Surgery reports a retrospective series from Wimmer and colleagues covering 177 patients with multiple sialolithiasis and 556 stones treated with minimally invasive gland-preserving techniques, averaging around two and a half interventions per patient [10]. Nearly half of patients needed a multimodal approach, and stone-free or symptom-free status was achieved in all submandibular cases and just under 98 percent of parotid cases, with gland preservation in over 97 percent overall. Multiple stones should not by itself trigger a conversation about gland removal.

If you only have time for one paper this week, make it the randomised trial of unilateral versus bilateral hearing aids in JAMA Otolaryngology [1]. It is the first proper randomised evidence for a decision you make several times a week, and its measured conclusion — statistically better with two, but of uncertain clinical magnitude — should change how you counsel cost-conscious patients tomorrow.

Here are the key takeaways from this week in Otolaryngology. Bilateral fitting gives modestly greater self-reported benefit than a single aid, but a single aid still delivers meaningful improvement, so a one-aid plan remains a defensible choice. Imaging-detected extranodal extension in human papillomavirus-positive oropharyngeal cancer carries genuine prognostic weight, yet the ninth edition nodal schema did not outperform the eighth on discrimination in trial data. The historical twenty percent threshold for elective neck dissection no longer matches surgeon preference — most now favour individualised risk estimation and shared decision-making at much lower thresholds. In free flap reconstruction, prior radiotherapy dominates the risk profile, but fluid overload, operative duration, albumin, haemoglobin and body mass index are modifiable and worth targeting. And in chronic rhinosinusitis, exhalation-delivery fluticasone worked similarly with and without polyps, including in patients already failing conventional steroid sprays.

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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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.