This Week in Otolaryngology — Sep 17, 2026

Welcome to This Week in Otolaryngology. This week we're covering 10 notable papers spanning perioperative safety in tonsil surgery, sleep-disordered breathing from the polysomnogram to Medicare policy, skull base reconstruction and cerebrospinal fluid leak detection, and two papers on doing more with less — less opioid, and less surgery. Let's dive in.

We'll start with tonsil and adenotonsil surgery, where three papers this week all ask versions of the same question: which routine practices are actually earning their keep. In the International Journal of Pediatric Otorhinolaryngology, Adler and colleagues report a prospective observational study of continuous overnight oximetry in children admitted after adenotonsillectomy at a tertiary children's hospital [1]. Among 147 non-syndromic children — a genuinely high-risk group, with about seven in ten obese, plus children under three and children with polysomnogram-confirmed severe obstructive sleep apnea — just under nine percent had at least one severe desaturation event overnight, defined as oxygen saturation below 85 percent for more than 30 seconds, and about seven and a half percent needed supplemental oxygen. So the great majority of these admitted, high-risk children had an uneventful night. The most useful clinical signal was earlier than the ward: needing supplemental oxygen in the recovery unit was associated with roughly a twelvefold increase in the odds of needing oxygen overnight. Children who desaturated severely also accumulated many more moderate desaturation events, a median of twelve versus about two or three. The practical reading is that the recovery room is doing a lot of the triage work for you, and that supplemental oxygen in the postanesthesia care unit, or preoperative upper respiratory symptoms, should push you toward observation — while the flat overnight course in most admitted children strengthens the case for refining, rather than simply expanding, admission criteria.

Two papers in The Laryngoscope round out the tonsillectomy theme. Saad and colleagues reviewed 945 tonsillectomies over a decade at a Lebanese tertiary centre and found post-tonsillectomy hemorrhage in 25 patients, an overall rate of about two and a half percent [2]. Ninety-two percent of the bleeds were secondary, clustering around postoperative day seven, and the only independent predictor was adult age, which roughly tripled the odds — with adults bleeding at about seven percent versus under two percent in children. Sex, operative time, the individual surgeon, concurrent procedures and routine preoperative laboratory values all fell out of the model, which is a quiet argument against reflexive preoperative coagulation screening and a loud argument for counselling adults specifically about the day-seven window. One in five of the bleeding patients required transfusion, so this is not a trivial complication. Alongside that, Goldberg and colleagues looked at whether routine histopathology of tonsillectomy specimens is worth it in a United States safety-net hospital, a population with an elevated cancer risk profile where this had not been studied [3]. Across 769 specimens, there were no pediatric malignancies at all. Twenty adult malignancies were found, but 19 of the 20 were either biopsy-proven or clinically suspected before surgery; a single unexpected mantle cell lymphoma amounted to about two in a thousand adult specimens. Preoperative clinical assessment, in other words, performed well as a triage instrument even here, supporting risk-stratified rather than universal pathology protocols — with the honest caveat the authors themselves make, that at this sample size the incidence estimate is imprecise.

Moving to sleep-disordered breathing, where one paper looks down the microscope at sleep itself and another looks at who pays for treating it. In The Laryngoscope, Gedamu and colleagues characterised sleep architecture in 461 children with obstructive sleep apnea, of whom 42 percent were obese [4]. The interesting finding is a dissociation: body mass index category, not apnea severity, was independently associated with total sleep time, sleep efficiency, deep slow-wave sleep and the proportion of rapid eye movement sleep. Children with class two and class three obesity slept roughly half an hour less, were less efficient sleepers, and spent more time awake after sleep onset, with reduced rapid eye movement sleep. Apnea severity, by contrast, tracked only with the proportion of light stage one sleep. The implication for counselling is that in an obese child, fixing the airway may not fix the sleep — weight-related sleep disruption looks like a partly separate problem, and families should hear that before surgery rather than after.

On the policy side, Otolaryngology-Head and Neck Surgery carries a commentary from Yu and colleagues on the Centers for Medicare and Medicaid Services' Wasteful and Inappropriate Service Reduction model, known as WISeR, which introduced prior authorization review for hypoglossal nerve stimulation effective the first of January 2026 in six states [5]. Hypoglossal nerve stimulation was the only otolaryngology procedure included in the model — a direct consequence of how fast utilisation has grown and of payor anxiety about where it's heading. The authors' argument is that this is better treated as an opportunity than an insult: if the specialty defines and documents evidence-based patient selection and outcome reporting itself, it keeps control of the indication. If you implant, this is the week to audit how defensibly your selection criteria are recorded.

Three papers converge on the skull base, and specifically on cerebrospinal fluid leaks. In The Laryngoscope, Liu and colleagues studied 401 patients undergoing endoscopic endonasal surgery for sellar tumours, measuring beta-trace protein in extracts from the nasal sponges placed for hemostasis and collected on postoperative day two [6]. Sixteen patients, about four percent, had confirmed leaks, and their beta-trace protein concentrations were roughly tenfold higher. At a cutoff of just over two milligrams per litre, the test had sensitivity of about 94 percent and specificity of over 99 percent, with a negative predictive value effectively ruling the diagnosis out. That's an appealingly cheap, non-invasive way to catch an occult leak before it announces itself as meningitis. Complementing that, in the American Journal of Otolaryngology, Günebakan and colleagues prospectively tested whether you can avoid the nasoseptal flap altogether in anatomically favourable transsphenoidal cases [7]. In 42 consecutive patients with low-grade adenomas, a standardised multilayer free-graft reconstruction — fat, inlay and onlay fascia lata with a platelet-rich plasma layer — produced a 30-day leak rate of about seven percent, with all three leaks resolving on conservative management and no septal perforations or major epistaxis. Notably, every leak occurred in patients with suprasellar extension of twelve millimetres or more, and none below that threshold. This is a feasibility study with no comparison group, so read it as a hypothesis about patient selection rather than a licence to abandon the vascularised flap.

The third skull base paper, in Otology and Neurotology, is a sobering long-term look. Wong and colleagues followed 176 adults treated for spontaneous lateral skull base encephaloceles and found that 18 percent developed a new encephalocele after initial repair, at a median of about a year and a half [8]. Most were ipsilateral, but around a fifth were anterior and a few were contralateral — that is, at sites well away from the original defect. In a cohort with a mean body mass index of 35, that pattern points to a diffuse physiological process rather than a single structural hole. The authors recommend wide exposure and repair of the entire skull base at the index operation, and the surveillance message is that these patients need years of follow-up, not months.

Finally, two papers about de-escalation. In JAMA Otolaryngology-Head and Neck Surgery, Bestourous and colleagues report a retrospective cohort of 146 adults undergoing head and neck free flap reconstruction or transoral robotic surgery, comparing protocolised multimodal analgesia with and without adjunctive suzetrigine, the selective NaV1.8 sodium channel inhibitor recently approved in the United States for acute postoperative pain [9]. Inpatient opioid consumption was lower with suzetrigine in both groups — after adjustment, about 76 fewer morphine milligram equivalents over the admission — while pain scores were comparable and no medication-related adverse events were identified. In the transoral robotic surgery patients the difference was striking, with median use falling from around 109 to 29 morphine milligram equivalents. This is non-randomised single-centre data and the authors are appropriately cautious, but it's the first head and neck signal for a genuinely new analgesic class. And in The Laryngoscope, Bashumeel and colleagues report 47 patients who had previously undergone thyroid lobectomy and then had radiofrequency ablation for a nodule in the remaining lobe [10]. Median volume reduction was 81 percent, complications were limited to three cases of temporary vocal cord paresis and two of procedural discomfort, and crucially no patient's thyroid function changed and no one became hypothyroid. For the patient facing completion thyroidectomy and lifelong levothyroxine, that's a meaningful alternative to put on the table — in experienced hands, and acknowledging the small retrospective sample.

If you only have time for one paper this week, make it the suzetrigine cohort in JAMA Otolaryngology-Head and Neck Surgery [9]. A non-opioid adjunct that substantially cuts inpatient opioid requirements after two of our most painful operations, without worse pain scores, is the kind of finding that will reshape head and neck order sets — and it deserves the prospective trial it's asking for.

Here are the key takeaways from this week in Otolaryngology. First, after adenotonsillectomy in high-risk children, most admitted patients have an uneventful night, and needing oxygen in the recovery unit is your strongest early flag for needing it overnight. Second, adult tonsillectomy patients bleed at roughly three times the pediatric rate, mostly around day seven, while routine preoperative laboratory screening and routine specimen histopathology add little. Third, in obese children with sleep apnea, weight rather than apnea severity drives the disruption of sleep architecture, so temper expectations about what surgery will fix. Fourth, on the skull base, beta-trace protein in nasal sponge extract is a highly accurate early test for postoperative cerebrospinal fluid leak, flap-sparing multilayer reconstruction looks feasible only in genuinely low-risk anatomy, and nearly one in five spontaneous lateral encephalocele repairs is followed by a new defect within a few years. And fifth, two de-escalation options worth knowing: adjunctive suzetrigine for postoperative opioid sparing, and radiofrequency ablation as an alternative to completion thyroidectomy that preserves thyroid function.

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.