June 11th, 2025
Issue #92
Educational Pearl
Thyroid Storm (Thyrotoxic Crisis): A rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis. Thyroid storm can be triggered by the sudden stopping of antithyroid medications or by acute stressors such as thyroid or non-thyroid surgery, trauma, infection, exposure to a large iodine load, or childbirth. With a mortality rate ranging from 10% to 30%, thyroid storm requires not only antithyroid medications but also intensive supportive care in an intensive care unit (ICU) setting, along with prompt identification and management of any underlying precipitating factors.
Epidemiology:
An incidence of 0.36 per 100,000 persons per year, and 0.9 per 1000 hospitalized patients per year in the United States
Can develop in patients with longstanding untreated hyperthyroidism (Graves' disease, toxic multi-nodular goiter, solitary toxic adenoma)
Etiology and Pathophysiology:
Proposed mechanism: a rapid surge in serum thyroid hormone levels, heightened sensitivity to catecholamines, and amplified cellular responses to thyroid hormone that occur during physiologic stress
Presenting Symptoms:
Neurologic: Agitation, delirium, psychosis, stupor, or coma (the key to diagnosis and linked to higher mortality)
Cardiovascular: Severe tachycardia (>140 bpm), atrial fibrillation, congestive heart failure, hypotension, and potential cardiovascular collapse
Thermoregulatory: Hyperpyrexia (104-106℉) is common
Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain, possible hepatic failure with jaundice
Endocrine: Goiter, Graves' ophthalmopathy, lid lag, tremor, warm moist skin
Diagnosis:
Based on the presence of severe symptoms in a patient with biochemical evidence of hyperthyroidism
Although various diagnostic guidelines exist, no guideline is universally accepted so diagnosis is ultimately based on clinical judgement
Thyroid function tests:
Elevation of free T4 and/or T3 and suppression of TSH
Degree of hyperthyroidism is not a criterion for diagnosing thyroid storm
Determining the etiology:
Most patients with thyroid storm have Graves' disease, and some have toxic adenoma or toxic multi-nodular goiter
Treatment:
All patients should be admitted to the ICU for aggressive medical management
Pharmacologic options:
Beta blockers: Control adrenergic symptoms
Thionamide: Inhibit new hormone synthesis
Iodine solution: Block hormone release
Anti-thyroid agents (Propylthiouracil [PTU], iodinated radiocontrast agent): Reduce peripheral T4 to T3 conversion
Glucocorticoids: Reduce T4 to T3 conversion, support adrenal function, and stabilize vasomotor tone
Bile acid sequestrates: Reduce enterohepatic recycling of thyroid hormones in severe cases
Definitive treatment: Total thyroidectomy or radioactive iodine ablation of the thyroid gland
Further Reading:
Thyroid Storm Clinical Review and Management Update
StatPearls - Thyroid Storm
Educational Pearl written by Gina Spencer
Queen's University School of Medicine (Canada)
Question of the Week
A 45-year-old man presents to the otolaryngology clinic with progressive hearing loss in his right ear and episodes of dizziness that worsen with loud sounds and when he strains, such as during lifting or coughing. He also reports that when he talks, his voice sounds unusually loud in his right ear. In addition, he hears his heartbeat and even the movement of his eyes on that side. He denies any ear pain, ringing in the ears, or history of frequent ear infections. On exam, the outer and middle parts of the ear appear normal. The Tullio phenomenon is elicited, and Weber tuning fork testing lateralizes to the right ear. Audiometry demonstrates a low-frequency air-bone gap with normal tympanometry, and vestibular-evoked myogenic potentials testing reveals abnormally low threshold responses.
What is the most likely diagnosis?
(A) Otosclerosis
(B) Superior semicircular canal dehiscence
(C) Presbycusis
(D) Ménière’s disease
(E) Cholesteatoma
See the bottom of this issue for image source and correct answer with explanations!
Question of the Week written by Adriana Báez Berríos
Icahn School of Medicine at Mount Sinai
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Facial Plastics and Reconstruction
Dr. Leslie Kim, MD, MPH
The Ohio State University Wexner Medical Center
Head and Neck
Dr. Michael Topf, MD
Vanderbilt University Medical Center
Pediatric Otolaryngology
Dr. Michele Carr, MD, DDS, PhD
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
Rhinology and Skull Base Surgery
Dr. Christina Fang, MD
Montefiore Medical Center
Medical Student Feature Article of the Month
Tracheostomy Techniques in Severe COVID-19: Open vs. Percutaneous Approaches
Kennedy D, Chong NYK, Wiegn MT, Carnino JM, Levi JR. Evaluating Tracheostomy Techniques in Severe COVID-19: Open vs. Percutaneous Approaches. J Laryngol Otol. 2025 Apr 4:1-10. [Article Link]
Breathing new life into the efforts against severe COVID-19
Patients with severe COVID-19 infection who require long-term mechanical ventilation typically undergo tracheostomy to ensure airway protection and adequate oxygenation. This study assessed the mortality and complication rates of open surgical versus percutaneous tracheostomy to evaluate the safety and efficacy of both techniques in this population. A total of 4810 patients with prior COVID-19 infection who underwent either open surgical or percutaneous tracheostomy were identified through the 2020 National Readmissions Database. Mortality and complication rates were determined for 2061 patients who underwent open surgical tracheostomy and 2749 patients who underwent percutaneous tracheostomy. The results revealed a significantly lower mortality rate in the open surgical group compared to the percutaneous group (543/2061, 26.4% vs. 804/2749, 29.3%; p = 0.027), suggesting that open surgical tracheostomy may offer a survival benefit in patients requiring airway and oxygenation support following severe COVID-19 infection. These findings support the need for further research to guide optimal procedural selection in this patient population.
Summary written by Gabriella Adams
Eastern Virginia Medical School
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Dean Kennedy
Boston University Chobanian and Avedisian School of Medicine
Class of 2026
Head and Neck
Medial Sural Artery Perforator Free Flap Donor Site Morbidity in Head and Neck Reconstruction
Dattilo LW, de Groot ECM, Nyirjesy S, et al. Donor Site Morbidity of the Medial Sural Artery Perforator (MSAP) Free Flap for Head & Neck Reconstruction. Head Neck. 2025 May 9. Online ahead of print. [Article Link]
Is an MSAP flap the best donor site?
The medial sural artery perforator (MSAP) free flap is increasingly used in head and neck reconstruction due to minimal donor site morbidity; however, functional donor site outcomes remain poorly understood. This retrospective cohort study analyzed 22 patients who underwent MSAP flaps for head and neck reconstruction from 2022 to 2024, using a modified Lower Extremity Functional Scale (LEFS) to assess lower extremity function, with a maximal score of 80. LEFS scores steadily improved from an average of 56.0 (95% CI 43.8 to 68.2) within one month postoperatively to 79.8 (95% CI 79.8 to 80.0) at 12 months, indicating minimal to no long-term functional impairment. Minor donor-site complications occurred in 18.2% of patients, predominantly minimal wound dehiscence, with no long-term functional or cosmetic deficits. The authors also found that the MSAP flap has excellent pedicle length and arteriovenous caliber, commonly matching the facial artery well with a single draining vein. The versatility of the MSAP flap makes it a highly favorable choice compared to the radial forearm, as there are minimal donor site complications, lack of long-term functional deficits, and favorable cosmetic outcomes. These findings support its discussion in pre-operative counseling for patients hoping to avoid long-term functional morbidity at the donor site.
Priyanka Shah’s Takeaway: This study highlights the versatility of the MSAP flap compared to the radial forearm. However, while the results are promising, the small sample size and single institution setting underscore the need for larger, multicenter studies to confirm generalizability and guide clinical decision-making.
Summary written by Priyanka Shah
Edward Via College of Osteopathic Medicine
Laryngology
Prevalence and Treatment of Dysphonia in Parkinson's Disease
Liu V, Smith D, Yip H. Prevalence and Treatment of Dysphonia in Parkinson's Disease: A Cross-Sectional National Database Study. Laryngoscope Investig Otolaryngol. 2025 May 14;10(3):e70149. [Article Link]
Why aren’t we listening to Parkinson’s voices?
Dysphonia is a common yet underrecognized sequela of Parkinson’s disease (PD), with low treatment rates. This cross-sectional study assessed the prevalence of dysphonia and the use of voice-related care among 1968 patients with PD identified from the National Institute of Health (NIH) All of Us database. Despite its high prevalence, only 257 patients with PD (13.1%) had a documented diagnosis of dysphonia. When diagnostic criteria were expanded to include dysarthria, a related speech disorder that can affect voice quality, just 391 patients (19.9%) had a documented voice disorder diagnosis. Overall, 14.5% of PD patients (285/1968) received some form of voice care, compared to 42.8% of non-neurogenic dysphonia patients (2860/6677; p < 0.001). Furthermore, only 6.3% of PD patients (124/1968) received voice disorder treatment, compared to 14.3% of non-neurogenic dysphonia patients (954/6677; p < 0.001). Female sex (adjusted odds ratio [aOR] = 0.62; p = 0.004) and Hispanic ethnicity (aOR = 0.44; p = 0.02) were associated with lower odds of receiving voice care. The authors argue that the slow progression of PD makes it particularly amenable to early voice interventions, which remain substantially underused.
Joshua Sorrentino’s Takeaway: Though limited by coding accuracy, this study highlights an often-overlooked aspect of PD care: the impact of voice dysfunction on communication, quality of life, and social engagement. Addressing this gap will require stronger collaboration between neurology and otolaryngology professionals, along with greater awareness among clinicians and patients of the benefit of early voice intervention.
Summary written by Joshua Sorrentino
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
Otology and Neurotology
Socioeconomic Factors Influencing Delay and Underuse of Cochlear Implants
Zhao M, Huang V, Zhang MH, et al. Comparison of Socioeconomic Factors Influencing Delay and Underuse of Cochlear Implants. Otolaryngol Head Neck Surg. 2025 Apr 10. Online ahead of print. [Article Link]
This retrospective multi-center cohort study evaluated socioeconomic factors associated with delayed or reduced cochlear implant (CI) utilization among 382 adult candidates. Multivariate analysis of patient variables including race, preferred language, insurance status, household income, and distance to CI surgery center was conducted to assess their impact on the likelihood of CI surgery and time to surgery. Among the cohort, 306 patients (80.1%) underwent CI surgery, 29 (7.6%) declined surgery, and 47 (12.3%) either canceled surgery or were lost to follow‐up. Non-English-speaking patients (odds ratio [OR] = 0.31, 95% CI 0.13 to 0.71), older age (OR = 0.97, 95% CI 0.94 to 0.99), male sex (OR = 0.40, 95% CI 0.23 to 0.72), and higher speech recognition scores (21% to 40%: OR = 0.33, 95% CI 0.15 to 0.70; >41%: OR = 0.24, 95% CI 0.08 to 0.74) were associated with lower odds of undergoing CI surgery. Among patients who did proceed with CI surgery, non-English-speaking patients experienced significantly longer delays in time to surgery (hazard ratio [HR] = 0.64; 95% CI 0.43 to 0.97). These findings highlight the need to address barriers to care, particularly language-related obstacles. Increasing CI utilization among appropriate candidates may require focused interventions to reduce language barriers and promote health literacy.
Summary written by Ashton Huppert Steed
University of Arizona College of Medicine Phoenix
Pediatric Otolaryngology
Parent–Child Agreement on Fatigue in Pediatric Otolaryngology Patients
Ensing AE, Zhang AL, Lin RZ, Landes EK, Getahun H, Lieu JEC. Parent-Child Agreement on Fatigue in Pediatric Otolaryngology Patients. Laryngoscope Investig Otolaryngol. 2025 Apr 2;10(2):e70128. [Article Link]
Fatigue: A feeling lost in translation?
Fatigue is a common concern in children with hearing loss and sleep disorders, yet little is known about how parent and child fatigue reports align in this population. This cross-sectional study assessed agreement between self- and parent-reported fatigue in 135 pediatric patients aged 5 to 18 years with hearing loss (HL), obstructive sleep apnea (OSA), or other sleep disorders, using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale. Participants were grouped into HL (n = 42), OSA (n = 49), sleep-disordered breathing (n = 10), and control (n = 34) groups. Parent-child fatigue scores showed strong overall correlations (Spearman’s ρ ≥ 0.7), with most differences falling below thresholds for clinical significance. However, discrepancies were more pronounced in subgroups with developmental, speech, or language delays, particularly in general and cognitive fatigue domains. The study findings suggest that parent-proxy reports are generally reliable in patients with HL and OSA but may be less accurate in children with communication or developmental delays. Clinicians should interpret parent-proxy reports cautiously, as parents of children with perceived delays reported lower quality of life for their children than the children reported themselves in this study.
Summary written by Aida Hasson
Medical School for International Health
Rhinology and Skull Base Surgery
RADA-16 Reduces Postoperative Epistaxis After Inferior Turbinate Submucosal Reduction
Xu A, Kwon E, Filipkowski A, et al. RADA-16 Reduces Postoperative Epistaxis After Inferior Turbinate Submucosal Resection. Laryngoscope. 2025 May 19. Online ahead of print. [Article Link]
Pack it in: A new way to tame the turbinates
Postoperative bleeding from inferior turbinate reduction (ITR) is traditionally managed with nasal packing, which can cause patient discomfort, synechiae formation, and foreign body reactions. RADA-16, a self-assembling peptide hydrogel that mimics the human extracellular matrix, offers a potential alternative for postoperative hemostasis and wound healing by minimizing tissue disruption and enabling improved postoperative airflow through precise, thin-layer application. To evaluate the impact of RADA-16 on postoperative epistaxis rates and its cost-effectiveness, this retrospective cohort study analyzed 985 patients who underwent ITR between January 2020 and March 2024. Postoperative bleeding, defined as bleeding requiring intervention within three weeks of ITR, was assessed using Pearson’s χ² test, Fisher’s exact test, and multivariate logistic regression. Among 571 patients in the RADA-16 cohort and 414 patients in the non-RADA-16 cohort, use of RADA-16 was associated with a significantly lower risk of postoperative epistaxis (odds ratio [OR] = 0.17; 95% CI 0.04 to 0.81; p = 0.026) after adjusting for age and anticoagulant use. There was no significant difference in bleeding-related cost per patient between the two cohorts. These findings suggest that the hemostatic and wound-healing properties of RADA-16 may offer a valuable adjunct in ITR surgery.
Summary written by Michael Evans
Kansas City University College of Osteopathic Medicine
Sleep Surgery
Impact of Nasal Pathology on Hypoglossal Nerve Stimulation Efficacy for Obstructive Sleep Apnea
Adibi I, Nayak A, Saeedi A, Yu K, Bentan M, Nord RS. Impact of Nasal Pathology on Efficacy of Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea. Laryngoscope. 2025 Apr 5. Online ahead of print. [Article Link]
Breathe easy? The role of nasal pathology in hypoglossal nerve stimulation response for OSA
Hypoglossal nerve stimulation (HNS) is a treatment option for obstructive sleep apnea (OSA) in patients intolerant of continuous positive airway pressure (CPAP). Although nasal pathologies such as septal deviation or turbinate hypertrophy are common in OSA and impair CPAP adherence, their influence on HNS outcomes remains unclear. This retrospective cohort study examined 90 patients who received HNS at a single institution, stratified by nasal exam findings into four overlapping groups: normal nasal exam, positive anterior rhinoscopy findings, positive nasopharyngoscopy findings, and any positive nasal findings. Changes in Epworth Sleepiness Scale (ESS), apnea–hypopnea index (AHI), and Functional Outcomes of Sleep Questionnaire (FOSQ-10) scores were analyzed to assess whether nasal pathology affects HNS efficacy. All four groups showed significant improvements in AHI and ESS (p < 0.001), regardless of nasal findings. However, patients with anterior rhinoscopy findings experienced smaller FOSQ-10 improvements than those with normal exams (p = 0.025), particularly in general productivity and evening activity. The study authors suggest that while nasal pathology does not impair the physiological effectiveness of HNS, managing anterior nasal obstruction may improve perceived quality of life outcomes.
Summary written by Sue Li
Texas Tech University School of Medicine
Basic Science Spotlight
Cellular Degeneration Patterns in the Peripheral Vestibular Organ due to Head Trauma
Shimura T, Takeuchi M, Keskin Yilmaz N, et al. Otopathologic Patterns of Cellular Degeneration in the Peripheral Vestibular Organ Secondary to Head Trauma. Laryngoscope. 2025 May 13. Online ahead of print. [Article Link]
The relationship between vestibular and balance dysfunction following head trauma is well established in the literature; however, the cellular changes associated with skull fractures (direct injury) versus those without fractures (indirect injury) have not yet been fully analyzed. In this study, archived human temporal bone samples from cases of direct injury (n = 9) and indirect injury (n = 11) were examined for the number of Scarpa’s ganglion cells (ScGCs) and hair cells (type I and type II HCs), compared to matched healthy controls. A significant reduction in ScGCs within the superior and inferior vestibular nerves was observed in the indirect injury group compared to controls (p = 0.040 and p = 0.014, respectively), whereas no significant difference was found in the direct injury group. In addition, the indirect injury group showed significant losses of both type I and type II HCs in the utricle compared to controls (p = 0.008 and p = 0.035, respectively). These findings provide histopathologic and quantitative evidence that head trauma without fractures can lead to more severe vestibular cell damage. Further research is needed to clarify the clinical implications of these results.
Summary written by Aimee Lee
Indiana University School of Medicine
Question of the Week Answer
Correct Answer: (B) Superior semicircular canal dehiscence
Answer Explanation:
This patient’s symptoms of unilateral conductive hearing loss, vertigo triggered by loud sounds and straining, and heightened awareness of internal body sounds such as his voice, heartbeat, and eye movements are characteristic of superior semicircular canal dehiscence, answer choice (B). This condition results from a bony defect over the superior semicircular canal, creating a “third window” that allows sound and pressure to inappropriately stimulate the vestibular system. The Tullio phenomenon (vertigo triggered by loud sounds) and Hennebert phenomenon (vertigo triggered by pressure or straining) further support this diagnosis, as both indicate abnormal vestibular sensitivity caused by a third window lesion. Vestibular-evoked myogenic potential (VEMP) testing provides additional diagnostic confirmation. VEMP evaluates the vestibular system’s response to sound by measuring reflexive muscle activity. In superior semicircular canal dehiscence, answer choice (B), the third window leads to abnormally low VEMP thresholds and high-amplitude responses, reflecting increased sound sensitivity.
Otosclerosis, answer choice (A), causes conductive hearing loss due to fixation of the stapes footplate, but it does not produce vertigo or abnormal VEMP responses.
Presbycusis, answer choice (C), is an age-related, bilateral sensorineural hearing loss that progresses gradually and is not associated with dizziness, sound sensitivity, or changes in vestibular testing.
Ménière’s disease, answer choice (D), involves episodes of vertigo, fluctuating sensorineural hearing loss, and a sensation of fullness in the ear, often with tinnitus. It may show abnormalities on other vestibular tests but typically does not produce enhanced VEMP responses.
Cholesteatoma, answer choice (E), can lead to conductive hearing loss and is often associated with chronic ear infections, drainage, or visible abnormalities of the middle ear, none of which are present in this patient.
Reference:
Steenerson KK, Crane BT, Minor LB. Superior Semicircular Canal Dehiscence Syndrome. Semin Neurol. 2020;40(1):151-159. [Article Link]
Question of the Week Answer written by Adriana Báez Berríos
Icahn School of Medicine at Mount Sinai
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