March 19th, 2025
Issue #87
Educational Pearl
Light Amplification by the Stimulated Emission of Radiation (LASER) is utilized for a wide variety of purposes in otolaryngology. Regarded for their precision, minimal tissue damage, and ability to target specific areas. Lasers deliver focused, high-energy light to precisely affect tissue
Mechanics
The effect a specific laser will have on a tissue varies based on the wavelength and the type of tissue being treated
The choice of laser depends on the tissue being treated (skin, mucosa, vessels, scar) and the desired impact (ablation of tissue, coagulation, debulking, etc)
As wavelength increases, depth increases up to 1000 nm
After this wavelength, water absorption increases, and therefore penetration becomes more superficial
Categorizing Lasers
CO2
Wavelength: 10,600 nm (infrared/invisible)
A visible helium-neon beam is utilized to aim the CO2 laser
Absorption: tissue with higher water content (0.2-0.3 mm)
Uses:
Precise cutting/vaporization (i.e., recurrent respiratory papillomatosis, supraglottic laryngectomy, stapedectomy, subglottic hemangioma)
Neodymium Yttrium-Aluminum-Garnet (ND-YAG):
Wavelength: 1065 nm (infared/invisible)
Absorption: tissue with higher melanin or hemoglobin (4 mm)
Uses:
Pigmented lesions, tattoo removal, tracheobronchial lesions, esophageal lesions, vascular lesions
Difficult to use on higher-pigmented skin
Useful for blood vessel coagulation and bleeding control
Potassium-Titanyl-Phosphate (KTP):
Wavelength: 532 (visible)
Absorption: tissue with higher hemoglobin (0.9-1 mm)
Uses:
Stapedectomy/ middle ear surgery, laryngeal/tracheal surgery, sinus surgery, solar lentigos, actinic keratosis, port wine stain, recurrent respiratory papillomatosis
Minimizes bleeding, useful for delicate areas
Erbium-doped Yttrium-Aluminum-Garnet (ER-YAG):
Wavelength: 2940 nm (infrared/invisible)
Absorption: tissue with higher water content
Uses:
Stapedectomy and skin resurfacing (photoaging, rhytids, cutaneous lesions)
Minimal heat production reduces risk of deep tissue damage
Alexandrite:
Wavelength: 755 nm (visible)
Absorption: tissue with high melanin content
Uses:
Tattoo removal, varicose vein treatment, hair removal
Ruby Q:
Wavelength: 694 nm (visible)
Absorptions: Tissue with high melanin content
Uses:
Tattoo removal (red pigments)
Further Reading:
Recent advances in the use of lasers in otolaryngology
Clinical applications of lasers in otolaryngology
Laser safety in otolaryngology
Written by Camryn Marshall
Charles E. Schmidt College of Medicine, Florida Atlantic University
Question of the Week
A 24-year-old woman presents to clinic with rhinorrhea and nasal congestion that has been ongoing for the past two months. She states she was initially sick and felt the drainage has never improved. Within the last few weeks, she has noticed difficulties with smelling. She has no medical history except for some seasonal and dust allergies. What symptoms are at risk of developing?
A. Angioedema
B. Bronchitis
C. Chronic otitis media
D. Nasal polyps
E. Brain abscess
Answer at end of issue
Question by Aimee Lee
Indiana University School of Medicine
Our faculty content reviewers have been instrumental in ensuring that we continue to share high-quality content.
We thank them for their contributions to the Auricle!
Facial Plastic and Reconstructive Surgery
Dr. Leslie Kim, MD MPH
The Ohio State University Wexner Medical Center
Head and Neck Surgery
Dr. Michael Topf, MD
Vanderbilt University Medical Center
Laryngology
Dr. Inna Husain, MD
Community Healthcare System, Indiana
Otology and Neurotology
Dr. Terence Imbery, MD
The University of Chicago
Pediatric Otolaryngology
Dr. Michele Carr, MD, DDS, MEd, PhD
University at Buffalo, Jacobs School of Medicine and Biomedical Sciences
Rhinology and Skull Base Surgery / Basic Science Spotlight
Dr. Peter Papagiannopoulos, MD
Rush University Medical Center
Sleep Surgery/Medical Student Feature
Dr. Reena Dhanda Patil, MD
University of Cincinnati
Medical Student Feature Article of The Month
Efficacy and Complications of Interarytenoid Injection for Dysphagia in Infants 1-Year-Old and Under
House T, Scheffler P, Gerber ME, et al. Efficacy and complications of interarytenoid injection for dysphagia in infants 1-year-old and under. Otolaryngol Head Neck Surg. 2025;172(3):1036-1043. [Article Link]
Interarytenoid injection augmentation (IAIA) is a second-line treatment for pediatric dysphagia in patients who have failed first-line medical management. In this retrospective chart review conducted at Phoenix Children’s Hospital between 2020 and 2024, the efficacy and safety of IAIA, its associated complication rates, and the effect of concurrent perioperative feeding therapy (FT) were evaluated in 65 infants aged 13 months or younger, of whom 54 (83.1%) received FT. Outcomes were assessed using pre- and postoperative videofluoroscopic swallow study (VFSS) scores, Dysphagia Outcome and Severity Scale (DOSS) scores, and the "Aspiration Score," a detailed VFSS-based measure of penetration and aspiration risk adapted from the International Dysphagia Diet Standardization Initiative viscosity scale. After IAIA, 44 patients (67.7%) showed improvement in aspiration scores (p<.0001), and 33 (55.9%) demonstrated DOSS score improvement (p<.0001), with no intra- or postoperative complications reported. Given the study’s small sample size, no significant effect of concurrent FT on aspiration or DOSS scores was observed. These findings provide preliminary evidence supporting IAIA as a safe and effective treatment for persistent dysphagia in infants, with outcomes comparable to those in older children. While multimodal treatment with concurrent FT may be beneficial, further research is needed to determine its impact on IAIA outcomes.
Summary written by Sue Li
Texas Tech University School of Medicine
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Elliot Sina
Sidney Kimmel Medical College at Thomas Jefferson University
Class of 2026
Facial Plastic and Reconstructive Surgery
Association Between Blood Transfusion and Outcomes of Free Flap Head and Neck Cancer Surgery
Ma CC, Si C, Adegboye F, et al. Early division of the paramedian foreheadCotton KM, Mangan AR, Gardner JR, et al. Association between blood transfusion and outcomes of free flap head and neck cancer surgery. Am J Otolaryngol. 2024;45(6):104497. [Article Link].
What factors increase the risk of blood transfusion in free flap procedures?
Recent literature suggests that red-blood-cell-transfusions (RBCTs) arecould be associated with worse patient outcomes in the setting of head and neck cancer, but risk factors for perioperative transfusion have yet to be elucidatedare still unclear. This study was retrospective and assessed 400 patients undergoing free flap reconstruction for head and neck cancerretrospective study analyzed 400 patients undergoing free flap reconstruction for curative treatment of biopsy-proven head and neck cancer, , stratifying them by demographic and post-operative treatment data. The primary outcomes assessed were the need for RBCT and the volume transfusedFor patients receiving RBCT, total volume transfused was also recorded. . The type of free flap utilized significantly impacted intraoperative (p≤0.001) and postoperative (p≤0.001) RBCTs were significantly associated with the type of free flap used intraoperatively (p≤0.001) and postoperatively (p≤0.001), with anterolateral thigh flaps being the most common flap type to require RBCT (N=34/58, 58.6%) and the radial forearm free flap being the least common (N=7/58, 12.1%, p≤0.001). Average volume of transfused blood was significantly greater for African American patients compared to White patients (855.0 mL vs. 437.1 mL, p=0.005), however, race was not associated with the need for RBCT. There was no significant correlation between intraoperative or postoperative RBCT and , flap tissue composition (soft tissue, bone, or both), postoperative cancer recurrence, or pathology. This study highlights significant risk factors for perioperative RBCT in free flap head and neck cancer surgery, emphasizing the need for further investigation to inform standard clinical decision-making.
Summary written by Emily Chestnut
Indiana University School of Medicine
Head and Neck Surgery
Effect of duration of antibiotic prophylaxis on infection rates following head and neck reconstruction with osteocutaneous free flaps
Chacko K, Galochkina Z, Lee JH, Conrad D, Dirain C, Dziegielewski P. The effect of antibiotic prophylaxis duration on infection rates and outcomes after head and neck reconstruction with bony free flaps and hardware. Am J Otolaryngol. 2025;46(1):104584. [Article Link]
Current guidelines recommend a shorter duration of antibiotic prophylaxis in free flap surgery to reduce risk of surgical site infections (SSI). However, there is a paucity of evidence clarifying if this recommendation differs when the flap contains bone. In this retrospective cohort study, surgical site infection data was extracted from 198 patient charts at a single institution who received a short course (24-72 hours) or long course (>72 hours) of antibiotic prophylaxis after head and neck surgery with osteocutaneous free flaps and hardware. Multivariable regression analysis was conducted to determine risk factors associated with SSI, including duration of antibiotic course. In this cohort, 39% of patients who received a short course of antibiotics developed SSI within 30 days after surgery compared to 33% of patients in the long course (p=0.460) in total patients as well as SSI in the head and neck region (p=0.527), with no increased risk of hardware exposure (p>0.999). Based on these findings, antibiotic prophylaxis longer than 72 hours does not reduce risk of SSI rates after osteocutaneous free flaps. While this can inform clinical practice, further work to investigate confounding variables and application of these findings across multiple institutions is indicated.
Summary written by Alisha Pershad
The George Washington University School of Medicine and Health Sciences
Laryngology
Acoustic Analysis for Predicting Voice Recovery Following Injection Laryngoplasty in Patients with Unilateral Vocal Fold Paralysis
Kim GH, Lim DW, Cheon YI, Shin SC, Lee BJ, Lee YW. Acoustic Analysis for Predicting Voice Recovery Following Injection Laryngoplasty in Patients With Unilateral Vocal Fold Paralysis. J Voice. Published online February 7, 2025. [Article Link]
How can we better predict vocal recovery following injection laryngoplasty?
Injection laryngoplasty (IL) is a widely used treatment for unilateral vocal fold paralysis (UVFP) to improve glottic closure and voice quality. This study investigated whether additional acoustic measures beyond maximum phonation time (MPT) could predict voice recovery following IL. In this prospective pre-post study, 177 patients with UVFP underwent IL with hyaluronic acid, with voice assessments including MPT, Acoustic Voice Quality Index (AVQI), and Acoustic Breathiness Index (ABI). Paired t tests showed significant post-IL improvements across all acoustic and perceptual measures (p < 0.01), with MPT increasing from 3.3 ± 1.7 to 5.1 ± 1.8 seconds, and AVQI and ABI showing corresponding declines. Receiver-operating characteristic (ROC) analysis determined an MPT cutoff value of 3.0 seconds (Area Under Curve (AUC) = 0.781) for predicting voice recovery. AVQI and ABI also demonstrated high diagnostic accuracy (AUC ≥ 0.73), supporting their clinical relevance. This study suggests that integrating these acoustic parameters with MPT may provide a more precise assessment of IL outcomes, enhancing voice recovery monitoring.
Summary written by Whitney Jin
Baylor College of Medicine
Otology and Neurotology
Speech Perception in Noise After Cochlear Implantation for Single-Sided Deafness. A Randomized Clinical Trial
van Heteren JAA, Wendrich AW, Peters JPM, Grolman W, Stokroos RJ, Smit AL. Speech Perception in Noise After Cochlear Implantation for Single-Sided Deafness: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2025 Jan 16. [Article Link]
This randomized clinical trial investigated the impact of cochlear implants (CI), bone conduction devices (BCD), contralateral routing of signals hearing aids (CROS), and no treatment on speech perception in noise among patients with single-sided deafness (SSD). The study included 120 adult patients with SSD who were followed for 24 months after treatment allocation. The primary outcome was differences in speech reception threshold in noise (SRTn) with speech and noise from the front (SONO); speech directed to the poor ear and noise to the better ear (SpeNbe); and vice versa (SbeNpe), with the secondary outcome was disease-specific quality of life (QOL). Results showed that the CI group had significantly better speech perception in noise compared to the BCD (SRTn: SbeNpe, −4.7 dB; 95% confidence interval, −6.6 to −3.0; SpeNbe, −2.2 dB; 95% confidence interval, −4.6 to −1.1), CROS (SRTn: S0N0, −1.3 dB; 95% confidence interval, −1.7 to −0.2; SbeNpe, −5.3 dB; 95% confidence interval, −6.0 to −3.1), and no treatment groups (difference in SRTn: SpeNbe, −6.3 dB; 95% confidence interval, −7.5 to −4.9) (p < 0.001). Patients with CI also reported higher self-perceived speech perception and improved QOL scores compared to BCD, CROS, and the no-treatment group (all groups p<0.001). The study concluded that CI offers the best outcomes for restoring binaural hearing advantages in SSD patients. These findings provide strong evidence supporting CI as a preferred treatment for SSD over other alternatives.
Summary written by Deepthi Akella
University of the Incarnate Word School of Osteopathic Medicine
Pediatric Otolaryngology
Comparing the Effect of Ropivacaine Peritonsillar Injection Before and After Pediatric Adenotonsillectomy on Postoperative Pain
Faramarzi M, Panah A, Hassanpourhaghighi P, et al. Comparing the effect of ropivacaine peritonsillar injection before and after adenotonsillectomy on postoperative pain among pediatric patients: A double-blind randomized clinical trial. Int J Pediatr Otorhinolaryngol. 2025;190:112249. [Article Link]
Pediatric adenotonsillectomy is a common procedure that can cause significant postoperative pain that, if inadequately controlled, may lead to nausea and vomiting, reducing oral intake and causing dehydration. Ropivacaine, a local anesthetic with a prolonged duration of action, has shown promise in controlling post-adenotonsillectomy pain, however, prior studies assessing its efficacy report mixed evidence. In this randomized, double-blind control trial, 99 pediatric patients ages 3-12 years undergoing elective adenotonsillectomy were randomized into three groups based on the time of intervention relative to surgery (preoperative vs. postoperative) and type of intervention (Ropivacaine vs. saline control injection), with two groups receiving Ropivacaine at different time points and the third group receiving the saline control both pre- and postoperatively. Postoperative pain was assessed via Wong-Baker Pain Scale at several time points, as well as postoperative analgesic consumption. The preoperative Ropivacaine group reported significantly lower pain scores at 4, 8, and 24 hours post-adenotonsillectomy (p=0.001) and also required significantly fewer analgesics during hospitalization (p<0.001) and post-discharge (p=0.001). These findings suggest that Ropivacaine has time-dependent effects on post-adenotonsillectomy pain management in pediatric patients, with preoperative administration being more effective than postoperative administration in reducing pain and analgesic use after adenotonsillectomy.
Summary written by Catherine Nguyen
Eastern Virginia Medical School
Rhinology and Skull Base Surgery
Impact of Sinus Surgery for Chronic Rhinosinusitis on Concomitant Depression and Anxiety Symptoms
Cheah XY, Tan CJW, Yeo BSY, et al. The Impact of Sinus Surgery for Chronic Rhinosinusitis on Concomitant Depression and Anxiety Symptoms: A Systematic Review and Meta-analysis. Int Forum Allergy Rhinol. Published online January 15, 2025. [Article Link]
From stuffy noses to smiling minds: The correlation between sinus surgery and mental health
Chronic rhinosinusitis (CRS) is a condition in which the normally air-filled spaces in the head, the sinuses, are persistently inflamed. There is increasing evidence suggesting that CRS may impact both depression and anxiety. However, the correlation between CRS treatment, specifically sinus surgery, and its effect on patients’ concomitant depression and anxiety remains unclear. This meta-analysis gathered data from 11 studies (3067 patients with CRS) and investigated levels of anxiety and depression before and after surgical intervention (endoscopic sinus surgery). To measure anxiety and depression, the researchers used Patient Health Questionnaires (PHQ) 2 and 9, Hospital Anxiety and Depression Scale (HADS), and the Zung Self-Rating Depression Scale (ZAS) as primary outcome measures. Endoscopic sinus surgery was associated with improved depression scores (ratio of means (ROM) = 1.47, 95% CI = 1.03-2.10), anxiety scores (ROM = 1.10, 95% CI = 0.81-1.49), and quality of life markers that are closely linked to positive mental health outcomes. These findings suggest that endoscopic sinus surgery for CRS may improve depression and anxiety levels, and physicians should consider this additional therapeutic benefit when discussing treatment options with their patients.
Maaz Haji (Chicago Medical School)’s Takeaway: While I have limited anecdotal evidence pertaining specifically to CRS, I have seen firsthand how other chronic inflammatory conditions, such as Crohn's disease, impact patients in terms of depression and anxiety. This paper suggests a potential connection between chronic inflammatory diseases and the mental wellbeing of patients, a phenomenon that may be observed across multiple disciplines beyond otolaryngology as well.
Sleep Surgery
Machine Learning Predicts Postoperative AHI in Velopharyngeal Surgery
You J, Li J, Zhou Y, Cao X, Zhao C, Zhang Y, Ye J. Postoperative Apnea-Hypopnea Index Prediction of Velopharyngeal Surgery Based on Machine Learning. OTO Open. 2025;9(1):e70061. [Article Link]
Predicting Post-Op Sleep: Can AI Outperform Traditional Methods?
This retrospective cohort study evaluated the ability of machine learning models to predict postoperative apnea-hypopnea index (AHI) in adults undergoing velopharyngeal surgery for obstructive sleep apnea (OSA). Researcher’s analyzed a total of 152 OSA patients using demographic, polysomnographic, and anatomical variables. Compared to traditional linear regression, artificial neural networks (ANNs) achieved the highest accuracy (81.3%) and predictive performance (R² = 0.23, Root Mean Square Error (RMSE) = 10.71 events/h). ANN outperformed conventional Friedman staging in predicting surgical success. The study highlights the potential of machine learning in optimizing patient selection for velopharyngeal surgery, potentially reducing unnecessary procedures and improving surgical outcomes. Future studies should focus on refining models with larger datasets and external validation to enhance clinical applicability.
Summary written by Ahsan Ahmed
Albert Einstein College of Medicine
Question of the Week Answer
Correct Answer: D. Nasal Polyps
Explanation:
The above clinical vignette describes the general progression of Samter’s triad which consists of bronchial asthma, nasal polyps (D), and aspirin intolerance. Pathogenesis is described as an initial upper respiratory tract infection that leads to chronic rhinosinusitis and anosmia. Eventually, the disease progresses to asthma and aspirin intolerance 2-5 years after the development of rhinitis. While hypersensitivity reactions to aspirin or NSAIDs may occur at any point during the disease, the inflammation of airways is progressive and usually starts from the upper airways into the lower respiratory tract. Treatment involves corticosteroids and a trial of an aspirin tolerance challenge.
Angioedema (A) is an adverse reaction that may occur with higher doses of aspirin; it may be seen rather in the aspirin desensitization challenge that may be trialed in patients with Samter’s triad.
Bronchitis (B) and chronic otitis media (C) would not be a part of Samter’s triad.
Brain abscess (E) may be a rare complication of sinusitis in a condition known as Pott’s puffy tumor. However, the clinical pathogenesis described is more indicative of Samter’s triad.
Sources:
Kim SD, Cho KS. Samter's Triad: State of the Art. Clin Exp Otorhinolaryngol. 2018;11(2):71-80. [Article link].
Yamashita T, Tsuji H, Maeda N, Tomoda K, Kumazawa T. Etiology of nasal polyps associated with aspirin-sensitive asthma. Rhinol Suppl. 1989;8:15-24. PMID: 2505369. [Article link].
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