April 16th, 2025
Issue #88
Educational Pearl
Branchial Cleft Cyst (BCC): A congenital epithelial cyst that arises on the lateral part of the neck due to incomplete obliteration of the branchial cleft structures during embryonic development.
Anatomy and Embryology: During the fourth week of gestation, neural crest cells migrate into the developing head and neck region, forming six pairs of branchial (pharyngeal) arches. These arches are separated by clefts (externally) and pouches (internally). Normally, these structures are obliterated as development progresses. However, incomplete involution can lead to branchial cleft anomalies, resulting in cysts, sinuses, or fistulae.
Etiology and Pathophysiology: BCCs result from the incomplete involution of branchial cleft structures during embryogenesis. Depending on the degree of obliteration failure, they can manifest as cysts, sinuses, or fistulae.
Presenting Symptoms:
Typically, branchial cleft cysts present as painless, fluctuant masses located lateral to the midline, usually anterior to the sternocleidomastoid muscle
BCCs do not move while swallowing
While often asymptomatic, these cysts can become tender or painful if infected, especially following an upper respiratory infection
Diagnosis: Involves a thorough neck examination, often supplemented by imaging studies.
Ultrasound is typically the first imaging modality used, providing information about the cyst's characteristics
Computed tomography or magnetic resonance imaging may be employed to further delineate anatomical relationships, especially when surgical planning is considered
Treatment and Management: Definitive treatment for a branchial cleft cyst is complete surgical excision of both the cyst and any associated tracts.
Excision of cyst and tracts minimizes the risk of recurrence
If the cyst is infected, initial management includes empiric antibiotic therapy targeting common pathogens like Staphylococcus aureus and Streptococcus pyogenes, with surgical intervention deferred until the infection has resolved
Potential complications include infection of the cyst, tract, or sinus, which can lead to abscess formation
Further Reading:
Cleveland Clinic
StatPearls
Written by Jenilkumar Patel
Tulane University School of Medicine
Question of the Week
A 20-year-old college student presents to the emergency room with a chief complaint of sore throat and fever. He reports that his symptoms have persisted for a week without improvement and that he began experiencing chills this morning. On physical exam, there is tenderness and swelling inferior to the right mandibular angle. What is the most important step in improving outcomes for this patient?
(A) Incision and drainage
(B) Obtain blood cultures
(C) Beta-lactamase resistant antibiotics
(D) Anticoagulation
(E) Chest x-ray
Answer at end of issue
Question by Aimee Lee
Indiana University School of Medicine
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Head and Neck Surgery
Dr. Katelyn Stepan, MD
Northwestern University
Laryngology
Dr. Benjamin Laitman, MD
Icahn School of Medicine at Mount Sinai
Otology and Neurotology
Dr. Emily Stucken, MD
University of Michigan
Pediatric Otolaryngology
Dr. Brentley Lindsey, MD
San Antonio Military Medical Center
Rhinology and Skull Base Surgery / Basic Science Spotlight / Medical Student Feature
Dr. Christina Fang, MD
Montefiore Medical Center
Sleep Surgery
Dr. Kevin Motz, MD
Johns Hopkins Medicine
Medical Student Feature Article of The Month
Microbiological Profiles and Patterns of Resistance in Patients With Sinus Infections After Endoscopic Sinus Surgery
Adelman AE, Tangutur A, Archilla AS, Vengerovich G. Microbiological Profiles and Patterns of Resistance in Patients With Sinus Infections After Endoscopic Sinus Surgery. Otolaryngol Head Neck Surg. 2025;172(4):1442-1449. [Article Link]
Endoscopic sinus surgery (ESS) can significantly alter the sinonasal microbiome, shifting it from typical preoperative flora—such as Staphylococcus aureus, Staphylococcus epidermidis, and gamma-hemolytic streptococci—to include organisms like Streptococcus pneumoniae and Haemophilus influenzae. Prior studies have reported considerable variability in the microbiological landscape of chronic rhinosinusitis (CRS) post-ESS, complicating empirical antibiotic selection in the absence of culture data. This retrospective cohort study sought to reconcile some of this variation through the analysis of 351 endoscopic-guided cultures from 125 symptomatic post-ESS patients from a private practice in Southeast Florida from August 2020 to December 2023. The study found Gram-negative bacteria were most prevalent (47.0%, n = 165), followed by Gram-positives (35.6%, n= 125), fungi (4.0%, n = 14), and anaerobes (2.9%, n = 10), which was similarly reflected when the group was stratified by revision surgery status and by presence of nasal polyps. Notable resistance patterns include Methicillin-sensitive S. aureus to penicillins (52.8%), Methicillin-resistant S. aureus to quinolones (53.6%) and clindamycin (35.7%), Enterobacteriaceae to amoxicillin-clavulanate (42%) and penicillins (37.1%), and Pseudomonas aeruginosa to quinolones (17.7%). These findings are particularly relevant for guiding empiric antibiotic therapy in primary care or urgent care settings, where post-ESS patients often present prior to ENT consultation. Future research could expand this investigation on a national scale to assess regional variability in microbiological profiles and resistance patterns.
Summary Written by Michelle Nguyen
Edward Via College of Osteopathic Medicine –Virginia
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Avraham Adelman
Schmidt College of Medicine at Florida Atlantic University
Class of 2026
Facial Plastic and Reconstructive Surgery
Functional Outcomes of Free Flap Reconstruction After TORS
Kaki PC, Sangal NR, Lam D, et al. Functional Outcomes of Free Flap Reconstruction After TORS in Early-Stage HPV-Positive Oropharyngeal Cancer. Otolaryngol Head Neck Surg. 2025 Mar 11. [Article Link]
This study examines the impact of free flap reconstruction (FFR) on swallowing outcomes after transoral robotic surgery (TORS) for small (pT1-2) HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) tumors with presence of a retropharyngeal carotid artery (RPC). A retrospective review was conducted from 2010 to 2022 at a single tertiary care center. 93 patients were divided into two groups, those who underwent FFR (N = 31) and those who did not (nFFR) (N = 62). Patients who underwent FFR were cleared for first oral intake in a median of 16.00 days (IQR: 15.00, 20.50), compared to 14.00 days (IQR: 12.00, 17.75) in nFFR patients (P = .002), with swallowing function initially similar between groups but showing better recovery at 3 and 6 months in the nFFR group (p=.026, p=0.040). However, after one year, swallowing outcomes were comparable between groups. Overall, the study concludes that FFR is a viable option for soft tissue coverage of HPV+ pT1-2 OPSCC tumors with RPC present after TORS.
Summary written by Caitlin Cavarocchi
Philadelphia College of Osteopathic Medicine
Head and Neck Surgery
Intraoperative Frozen Section in Oropharyngeal Carcinoma
Ramadan S, Bellas A, Al-Qurayshi Z, et al. Use of Intraoperative Frozen Section to Assess Surgical Margins in HPV-Related Oropharyngeal Carcinoma. JAMA Otolaryngol Head Neck Surg. 2025;151(3):253-262. [Article Link]
Using intraoperative frozen histology during resection of oropharyngeal SCC - hot take or ice cold?
Surgical margin status is strongly associated with survival in patients with HPV-related oropharyngeal squamous cell carcinoma (OPSCC), with positive margins often indicating a need for additional treatments such as chemotherapy, radiation, and re-resection. In this retrospective single-institution study, the authors investigate the accuracy of intraoperative frozen section histology (IFSH) in predicting final margin status in 299 patients who underwent transoral surgery for HPV-related OPSCC. All pathology reports of patients with at least one margin assessed with IFSH were reviewed along with patient charts to determine survival and identify incidences of recurrence. Results reveal that while IFSH showed an accuracy of 97.1%, sensitivity of 72.2%, and specificity of 99.1% in assessing individual margins, it had a sensitivity of just 21.7% when assessing overall margin status. In addition, IFSH demonstrated a PPV of 86.7% (95% CI [78.7%-92.6%]) and an NPV of 97.8% (95% CI [97.0%-98.5%]). Though IFSH demonstrated high accuracy for determining the status of individual margins, it was far less reliable for assessing overall final surgical margins. However, its high NPV supports its use in guided resection as it is highly accurate at identifying patients with no disease based on negative margins.
Gabriella Adams’ Takeaway: While IFSH is useful in the guided re-resection of HPV-related OPSCC, it is less reliable for determining the status of overall final surgical margins. This, combined with the fact that this study was retrospective and utilized specimens sampled at each surgeon’s discretion, supports the need for larger prospective studies to more accurately assess the potential benefit of IFSH in transoral resection of OPSCC.
Summary written by Gabriella Adams
Eastern Virginia Medical School
Laryngology
Vocal Function Changes in Patients With Benign Thyroid Nodules After Radiofrequency Ablation
Hsieh CH, Lin YF, Huang YC, Chen PC, Tsai HY, Lin WC. Vocal Function Changes in Patients With Benign Thyroid Nodules After Radiofrequency Ablation. J Voice. 2025 Mar 6:S0892-1997(25)00072-4. [Article Link]
Burning questions: Does RFA set your voice off-key?
Radiofrequency ablation (RFA) is a minimally invasive and safe treatment for benign thyroid nodules; however, it carries a small risk of transient voice changes due to thermal injury to the recurrent laryngeal nerve. In this study, 75 patients underwent RFA and were evaluated with thyroid sonography and vocal function assessments before, immediately after, and three months post-procedure. Maximum phonation time (MPT) significantly decreased immediately post-RFA (MPT = 11.25; P < 0.001) and at three months (MPT = 12.40; P = 0.007) compared to pre-RFA (MPT = 13.88), suggesting potential dysphonia. Acoustic characteristics, including jitter and shimmer, increased transiently post-RFA (P = 0.013 and P = 0.039, respectively) but returned to baseline at three months, indicating vibratory recovery. No significant correlations were found between pre-RFA nodule volume or volume reduction ratio and MPT changes. Overall, RFA led to temporary vocal function changes regardless of nodule volume or reduction. Otolaryngologists should conduct objective vocal analyses and consider comprehensive speech therapy, including laryngeal muscle training, to monitor and improve vocal function pre- and post-RFA.
Summary written by Russell Whitehead
Rush Medical College
Otology and Neurotology
Hearing Preservation in Microsurgery for Small Vestibular Schwannomas
Jiramongkolchai P, Vacaru A, Wahlin T, Schwartz MS, Friedman RA. Hearing Preservation Outcomes in 230 Consecutive Patients with Small Vestibular Schwannomas Treated with Microsurgery. Otol Neurotol. 2025;46(3):303-307. [Article Link]
Can we save hearing by operating early?
Advancements in MRI have increased the detection of small sporadic vestibular schwannomas (VS), prompting interest in hearing preservation through microsurgical resection. This retrospective study evaluated hearing preservation (word recognition score ≥ 50%) and facial nerve function in 230 patients with small VS (≤ 15 mm) who underwent microsurgery from 2018 to 2023 at a single academic center. Hearing was preserved in 61% of patients, with the highest rate (72%) in those with tumors ≤ 10 mm. On multivariate analysis, preoperative vertigo was associated with lower odds of hearing preservation (OR = 0.33, 95% CI 0.2 – 0.5). In contrast, smaller tumors were associated with significantly higher odds of hearing preservation: tumors ≤ 5 mm and 5.1 – 10 mm had odds ratios of 3.62 (95% CI 1.4 – 9.4) and 2.52 (95% CI 1.3 – 4.9), respectively, compared to tumors > 10 mm. Facial nerve function was preserved in 95% of patients (House–Brackmann grade I or II). These findings support early surgical intervention in tumors ≤ 10 mm to improve hearing outcomes and inform surgical decision-making.
Summary written by Rushi Vekariya
University of Central Florida College of Medicine
Pediatric Otolaryngology
Predictors of Thyroglossal Duct Cyst Recurrence and Complications Following Surgery
Campbell BA, Kelly Z, Kim HY, Cunningham MJ, Choi SS. Predictors of Thyroglossal Duct Cyst Recurrence and Complications Following Sistrunk Procedure. Laryngoscope. 2025 Feb 20. [Article Link]
Thyroglossal duct cysts (TGDC) are one of the most common congenital neck masses, and the gold standard of care has been well established as surgical excision, referred to as the Sistrunk procedure. Despite correct operative technique and modifications, recurrence occurs in about 6 percent of patients, as well as postoperative complications such as seroma formation, wound infection, and fistulas. In this large retrospective study, chart review was conducted over a 23-year period at a single institution for patients with TGDC who underwent Sistrunk procedures to elucidate factors associated with recurrence. Out of a total of 357 patients, only two factors were significantly associated with TGDC postoperative recurrence: postoperative infection (adjusted OR = 11.98 [95% CI: 3.38, 42.49], p = <0.001) and postoperative seroma (adjusted OR = 5.03 [95% CI: 1.17, 21.62], p = −0.030). Patient factors and operative considerations such as tongue base findings, pre-operative infection/number of pre-operative infections, placement of a post-operative drain, and type of drain were not found to be associated with recurrence. Male sex, however, was associated with a higher rate of postoperative complications (adjusted OR = 3.26 [95% CI: 1.55, 6.89], p = 0.002). Postoperative infection and seroma do not directly cause or predict TGDC recurrence, but are more likely associated with residual disease and warrant further patient surveillance.
Summary written by Catherine Nguyen
Eastern Virginia Medical School
Rhinology and Skull Base Surgery
Beyond the Lung. Impact of Elexacaftor / Tezacaftor / Ivacaftor on Sinonasal Disease in Children With Cystic Fibrosis
Petitjean M, Letierce A, Bonnel AS, et al. Beyond the Lung. Impact of Elexacaftor/Tezacaftor/Ivacaftor on Sinonasal Disease in Children With Cystic Fibrosis. Int Forum Allergy Rhinol. 2025 Mar 6:e23557. [Article Link]
While CFTR modulator Elexacaftor/Tezacaftor/Ivacaftor (ETI) has been shown to significantly improve sinonasal symptoms in adults with cystic fibrosis (CF), its effects in school-aged children and adolescents remain underexplored. This prospective multicenter study examines the impact of ETI on sinonasal symptoms, patient reported quality of life, and sinus imaging over 12 months. Sinonasal symptoms were assessed through patient-reported outcomes, the Sinus and Nasal Quality of Life Survey (SN-5) questionnaire, and Lund-Mackay computed tomography score (LMKS) at baseline and follow-up visits over one year. At baseline, 64 (16.3%) patients self-reported nasal obstruction with 34 of those patients (53.1%) reporting significant improvement at 12 months of ETI (p < 0.001). Mean SN-5 global score was similar at baseline compared to controls, with significant improvement at 1 month that sustained over 12 months (SN-5 change: -0.4 (1.05), p < 0.001). In 43 patients who underwent CT at month 0 and month 12, LMKS improved significantly from 11.3 ± 5.1 at month 0 to 4.2 ± 2.9 at month 12 (p < 0.0001). These results suggest that ETI significantly improved nasal obstruction, SN-5 global scores, and sinus opacification on CT in children and adolescents with CF and self-reported nasal obstruction over a 12 month period.
Summary written by Nick Melott
Des Moines University College of Osteopathic Medicine
Basic Science Spotlight
GZMK-Expressing CD8+ T Cells and Recurrent Airway Inflammatory Diseases
Lan F, Li J, Miao W, et al. GZMK-Expressing CD8+ T Cells Promote Recurrent Airway Inflammatory Diseases. Nature. 2025;638(13):490-498. [Article Link]
The immune system never forgets - sometimes to our detriment
Chronic rhinosinusitis with nasal polyps is an inflammatory condition in which the immune mechanisms driving disease persistence remain unclear. This translational study analyzed nasal polyp tissues from patients undergoing repeated surgeries (N = 6) and healthy controls (N = 7) using T cell receptor and single-cell RNA sequencing, along with a mouse asthma model to investigate the role of CD8+ T cells expressing Granzyme K (GZMK). The authors found that persistent CD8+ T cell clones accumulate in nasal polyps and express GZMK, which activates the complement cascade and exacerbates inflammation. Elevated GZMK levels correlated strongly with disease severity and comorbid asthma (p < 0.001), outperforming traditional biomarkers such as eosinophilia or IL-5. In mice, GZMK-expressing CD8+ T cells worsened airway inflammation following repeated allergen exposure, leading to lung dysfunction. However, genetic deletion or pharmacological inhibition of GZMK after disease onset significantly reduced tissue damage and improved lung function (p < 0.01). These findings suggest that targeting GZMK could help prevent disease recurrence and improve treatment outcomes for chronic airway inflammation in patients with chronic rhinosinusitis with nasal polyps.
Aida Hasson’s Takeaway: This study identifies GZMK-expressing CD8+ T cells as key drivers of recurrent airway inflammation, emphasizing that targeting immune memory, rather than just inflammation, could enhance long-term treatment strategies for conditions like chronic rhinosinusitis with nasal polyps.
Summary written by Aida Hasson
Medical School for International Health at Ben Gurion University
Question of the Week Answer
Correct Answer: (C) Beta-lactamase resistant antibiotics
Answer Explanation: The clinical presentation is consistent with Lemierre syndrome, a rare but serious condition that typically begins as an oropharyngeal infection, most often caused by Fusobacterium necrophorum. The infection can extend into the internal jugular vein, leading to septic thrombophlebitis and potentially to septic emboli, most commonly affecting the lungs.
The most important initial step in improving outcomes is prompt initiation of empiric antibiotic therapy (C), particularly with agents that cover anaerobes and are resistant to beta-lactamase. These antibiotics help penetrate fibrin clots that may form in the venous system. Treatment should later be guided by susceptibility testing due to potential resistance.
While incision and drainage (A) may be necessary in cases with abscess formation, antibiotics remain the cornerstone of management.
Blood cultures (B) can help identify the causative organism, though F. necrophorum can be challenging to isolate due to its anaerobic nature.
Anticoagulation (D) remains controversial and is typically reserved for patients with extensive clot burden, bilateral involvement, or progression despite antibiotic therapy.
Chest X-ray (E) may assist in detecting septic emboli, but it is not a first-line intervention and does not directly improve outcomes.
Source: Allen BW, Anjum F, Bentley TP. Lemierre Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 31, 2023. [Article link]
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