This week in Otolaryngology (ENT)

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This week: montelukast does not ease pain after pediatric adenotonsillectomy, a new grading index sorts sinus surgery candidates by their chance of benefit, and personalized sound therapy shows a slow-building effect in chronic tinnitus.

Welcome to This Week in Otolaryngology. We're covering 10 papers this week: 3 in depth, 4 in brief, 3 quick signals.

In The Laryngoscope, Redmann and colleagues report a double-blind, randomized, placebo-controlled trial of perioperative montelukast as an analgesic after adenotonsillectomy [1]. The trial enrolled 116 children aged three to eight with sleep disordered breathing who were having adenotonsillectomy with a planned 23-hour observation stay. Children received montelukast or placebo around the time of surgery, and 92 children went on to receive a second dose. The groups were similar at baseline. The proportion of children who needed opioids in the recovery unit was essentially identical, at about 46 percent with placebo and 45 percent with montelukast. The trial found no difference in the number of postoperative contacts with the medical system, and the authors report no difference in post-tonsillectomy hemorrhage between groups. They conclude that montelukast does not lower postoperative pain in this population. The main limitation is scale: a trial of this size can miss a small effect, and it covers only young children with sleep disordered breathing under overnight observation, so it does not address older children or same-day discharge pathways. As evidence, it is a blinded negative trial that removes one candidate from the list of opioid-sparing adjuncts for pediatric tonsil surgery.

In JAMA Otolaryngology Head and Neck Surgery, Williams and colleagues developed a preoperative grading system for endoscopic sinus surgery [2]. This was a prospective cohort of consecutive patients with chronic rhinosinusitis at academic tertiary rhinology clinics in whom medical management had failed, followed for up to a year after surgery. The analytic cohort was 450 patients, and 64 percent of them achieved clinically meaningful improvement, defined as a gain of at least 8.9 points on the SNOT-22. The final index combines four elements: baseline SNOT-22 severity, a headache or smell-and-taste dominant symptom pattern, and the Lund-Mackay and Lund-Kennedy scores. Across its four grades, the chance of meaningful improvement fell steadily, from about 81 percent in grade one to about 29 percent in grade four, a gap of roughly 52 percentage points. Discrimination was moderate and better than imaging grading alone, calibration held on internal bootstrap testing, and performance was consistent across phenotypes and time points. The key limitation is the absence of external validation, and all the data come from academic centres. As evidence, it offers a structured prognostic tool that the authors propose for preoperative counselling and trial stratification once it has been validated elsewhere.

In Ear and Hearing, Lu and colleagues report a double-blind randomized trial in 66 adults with chronic tinnitus [3]. It compared a sound therapy customized to each person's tinnitus pitch, called digital frequency-customized relieving sound, with unmodified music over twelve months. The primary outcome was change in the Tinnitus Handicap Inventory. Both groups improved, along different paths. Unmodified music gave rapid early gains that levelled off after six months, while the personalized sound produced a slower but progressive decline in symptoms through the full year. After weighting to adjust for baseline imbalances, the personalized arm had a statistically significant greater reduction, of about seven points on the inventory, with additional benefits in anxiety and tinnitus-related distress. An attrition analysis suggested that more severely affected responders often improved substantially within three to six months, which the authors propose as a window for judging response. The limitations are the small sample, baseline imbalances that required statistical adjustment, and a time-window claim drawn from attrition analysis that is hypothesis-generating. As evidence, it adds a year-long blinded comparison favouring pitch-matched sound therapy over music, from a single small trial.

Now, four in brief.

Staying with pediatric tonsil surgery, and alongside the montelukast trial, Campbell and colleagues in Otolaryngology Head and Neck Surgery used the TriNetX multi-institutional database to compare children having adenotonsillectomy before and after the 2019 guideline that shifted care toward opioid-sparing analgesia [4]. After propensity matching, each cohort held about 67 thousand children. The earlier cohort had about a quarter higher risk of dehydration, intravenous fluids, and nausea and vomiting, and about a fifth higher risk of emergency department visits. Hemorrhage rates did not change, and codeine prescribing fell twenty-five-fold. Roughly one emergency visit was avoided per hundred children. This is a retrospective before-and-after comparison, so the improvements are associated with opioid-sparing care rather than proven to result from it.

In The Laryngoscope, Craig and colleagues report a multicentre retrospective cohort of 124 patients whose nasal septal perforations were repaired with an anterior ethmoidal artery flap, followed for one to seven and a half years [5]. Closure was 90 percent at six months but fell to about 70 percent by final follow-up, and about two thirds of reperforations occurred after the first year. Most patients still reported resolution of bothersome symptoms, and 90 percent of patients said they were glad to have had surgery. The design is retrospective and symptoms were recorded only as present or absent, but the long follow-up shows that six-month closure rates overstate durable success for this flap.

Moving to the ear, Hughes and colleagues in Otolaryngology Head and Neck Surgery pooled ten randomized and observational studies covering 2,352 patients with otosclerosis treated with sodium fluoride [6]. Across doses, fluoride was associated with better hearing stabilization and with about an eighty percent lower risk of deterioration compared with controls. Hearing improved or stabilized in about 96 percent of patients on high-dose fluoride, about 84 percent on low dose, and about 57 percent of untreated controls. The authors describe evidence quality as modest, with variable audiologic definitions and wide uncertainty around several estimates, and they support only selective use where medical management is preferred.

Also in otology, Homolac and colleagues in The Laryngoscope reviewed 128 primary cholesteatoma surgeries with a median follow-up of nearly six years [7]. The five-year cumulative risk of recidivism was about 54 percent in patients under twenty and about 19 percent in adults, driven mainly by early residual disease rather than true recurrence. The sinus tympani was a recidivism site far more often in children. Pediatric age, supratubal recess involvement, mastoid extension, and omission of mastoidectomy compared with canal wall down surgery each independently predicted recidivism. With residual disease detected at a median of about fourteen months, the authors support surveillance at twelve to eighteen months. It is a single retrospective series with wide uncertainty around its estimates.

Three quick signals.

In The Laryngoscope, Mora and colleagues compared office-based blue laser treatment for Reinke's edema in 63 patients with microlaryngoscopy under general anesthesia in 40 patients [8]. Voice handicap scores and edema regression improved in both groups, office procedures were far shorter, and about a fifth of office patients needed retreatment. This is a non-randomized single-centre comparison.

In Head and Neck, Le Guevelou and colleagues systematically reviewed 14 mostly retrospective studies of osteoradionecrosis after head and neck radiotherapy [9]. Dental extraction before radiotherapy, especially within a week of starting, and higher mandibular dose consistently predicted it, and periosteal bone surgery was a strong risk factor. Data on immunotherapy combinations remain absent.

In Otology and Neurotology, Zhu and colleagues combined two cases with a systematic review, totalling 72 patients with middle ear myoclonus treated by tensor tympani or stapedial tendon lysis [10]. Complete symptom resolution was reported in about 93 percent of patients. The evidence is descriptive and case-level, with likely publication bias.

Stepping back across this week's papers, the randomized evidence came from small trials, while most of the remaining work rested on retrospective cohorts, case series and pooled observational data. Several observational papers reported large effects or high success rates without a concurrent randomized comparison, and the one prognostic index has yet to be tested outside the centres that built it. Where a blinded trial and a large database touched the same clinical setting, they addressed different questions, so neither tests the other.

If you only have time for one paper this week, make it the chronic rhinosinusitis severity index from Williams and colleagues [2]. It reopens the question of how outcome expectations are set before sinus surgery by folding symptoms and imaging into a single grade, with external validation still to come.

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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