Aina Brunet

Background: The 20% occult metastasis threshold proposed by Weiss in 1990 has long guided elective neck dissection (END) in clinically node‐negative (cN0) head and neck cancer, despite advances in surgical safety and oncologic evidence. Methods: An international web‐based cross‐sectional survey evaluated acceptable risk thresholds and attitudes toward END among head and neck (HN) surgeons, other healthcare professionals, and non‐healthcare participants. The primary outcome was the acceptable occult metastasis risk to justify END; secondary outcomes included acceptable 5‐year mortality increase and complication trade‐offs. Results: Of 2077 responses, 2008 were analyzed. Overall, 55% would undergo END at ≤ 10% occult metastasis risk and 86% at 20%. Responses differed significantly across groups ( p < 0.0001), with lower thresholds among HN surgeons; 57% endorsed END at ≤ 10% and 92% at ≤ 20%. Among HN surgeons, a threshold of 5% or lower was considered sufficient to include the following levels in the dissection: 78% of surgeons for Level IIB, 75% for Level IV, and 69% for Level V. The majority of HN surgeons (90%) considered it more appropriate to calculate the individual risk and discuss the indication with the patient rather than relying on a fixed threshold. Conclusions: Most respondents—particularly HN surgeons—favor lower thresholds than the historical 20%, supporting individualized risk‐based decision‐making rather than reliance on a fixed cut‐off.

Importance: Significant international variations exist for prevention methods, diagnostic, and management criteria for pharyngocutaneous fistula. Objective: To formulate best practice management guidelines for pharyngocutaneous fistula after total laryngectomy. Design: Modified Delphi consensus study conducted between January 2024 and November 2025 using two rounds of a structured survey. Levels of consensus were evaluated through a 9‐point Likert scale and predefined cutoffs: strong consensus (≥ 80% in 7–9 range, median ≥ 9), consensus (≥ 80% in 7–9 range, median 8–9), near‐consensus (≥ 70% in 7–9 range), or no‐consensus (< 70% agreement). Setting: International multicenter study. Participation of experts from 18 countries of America, Europe, Asia, South America, and Oceania, under the guidance of the International Federation of Oto‐rhino‐laryngological Societies (IFOS). Participants: A multidisciplinary international panel of 36 experts in head and neck surgery, otolaryngology, radiation oncology, radiology, and plastic surgery. The panelists were chosen for their clinical expertise in the area of total laryngectomy and pharyngocutaneous fistula management; published work in the form of peer‐reviewed publications, as well as geographical representation. Main Outcomes and Measures: The level of consensus in 59 statements regarding fistula definition and classification, preoperative risk factors, prevention strategies, diagnostic modalities, conservative management protocols, surgical intervention criteria, nutritional support, and patient outcomes. Results: A consensus or strong consensus was reached on 30 of 59 statements (50.8%). Strong consensus levels were reached for preoperative nutrition optimization (median 9.0), postoperative enteral feeding support (median 9.0), standardized surveillance protocols (median 9.0), and revision surgery for persisting fistulae (median 9.0). Consensus was also achieved for the use of vascularized tissue reinforcement in selected high‐risk settings, although the preferred reconstructive strategy varied according to flap type and clinical scenario. Of the 29 statements, 5 (8.5%) were excluded at Round 1 as a result of conceptual repetition as highlighted by panel feedback, and 24 (40.7%) did not reach consensus after both rounds, including fistula classification systems, prophylactic salivary bypass tubes, time to resume oral feeding postoperatively and negative pressure wound therapy. Conclusions and Relevance: This Delphi study from an international panel provides areas of agreement and ongoing equipoise across the prevention, diagnosis, and management of PCF, while demonstrating significant practice variability in terms of their classification, the use of prophylactic interventions, and conservative therapies.

Background: We characterized oncological outcomes of head and neck verrucous carcinomas (HNVC) and explored treatment‐associated outcomes. Methods: Medical records of 106 HNVC patients (1994–2024) were reviewed, analyzing clinical history, tumor characteristics, treatment modality, and outcomes. Results: Among 106 patients, 101 underwent surgery. Five‐year overall survival and recurrence‐free survival were 82.2% and 85.3%, respectively. Cox regression identified age ≥ 65 years as significantly increasing recurrence risk (HR = 5.989; 95% CI 2.02–17.77), while tobacco consumption decreased risk (HR = 0.309; 95% CI 0.12–0.81). Clinical T stage influenced recurrence: cT2 (HR = 0.22), cT3 (HR = 1.366), cT4 (HR = 1.525). Compared with local resection, partial organ resection (HR = 0.841) and total organ resection (HR = 0.501) showed lower recurrence rates. Conclusion: HNVC demonstrates excellent five‐year survival. Surgery remains the primary treatment, with wider resections significantly reducing recurrence risk, emphasizing the importance of achieving clear margins for durable local control.

Background: Dupilumab and mepolizumab are effective add-on therapies for severe chronic rhinosinusitis with nasal polyps (CRSwNP). However, predictors of response and guidance on biologic selection remain limited. The aims were to identify baseline parameters associated with favorable response to dupilumab or mepolizumab at 6 and 12 months in severe CRSwNP and compare outcomes among treatments. Methods: We conducted a multicenter, prospective, non-randomized, real-world cohort study across three tertiary hospitals in Spain. Patients with severe CRSwNP initiating dupilumab or mepolizumab were enrolled and followed at 6 and 12 months. Response was defined using EPOS/EUFOREA 2023 criteria, incorporating nasal polyp score (NPS), sinonasal outcome test (SNOT-22), total symptom score (TSS), olfaction (Sniffin’ Sticks Smell Test), systemic corticosteroid need, and asthma control test. Patients were classified as excellent, good, poor, or non-responders based on criteria fulfilled. Results: Sixty-nine patients were included: 35 received dupilumab and 34 mepolizumab. Asthma was present in 86.8%, and 42.6% had aspirin-exacerbated respiratory disease. Both biologics improved SNOT-22, TSS and NPS at 6 and 12 months ( P < .05), with comparable efficacy for most outcomes. Dupilumab showed superior improvement in olfaction (coefficient B [95% CI] mepolizumab vs dupilumab: −6.30 [−9.42; −3.19]). Overall, 84.2% of patients achieved a good/excellent response at 6 months and 89.6% at 12 months. Factors associated with better response included comorbid asthma and shorter time since last surgery. Conclusions: Dupilumab and mepolizumab improved clinical outcomes in severe CRSwNP, with dupilumab offering greater benefit in olfaction. Asthma and surgical history may help predict response.

Background/Objectives: Diffuse sinonasal exophytic papillomas (DSNEPs) are rare entities, with similarities to recurrent respiratory papillomatosis (RRPs). DSNEP treatment is usually based on surgical excision, but the recurrence rate is high. Bevacizumab injections have been increasingly used as an adjuvant option for RRP, but their role in DSNEP treatment remains unknown. The current study describes the preliminary experience, safety profile, and exploratory outcomes of sublesional bevacizumab injections following surgical excision. Methods: We undertook a retrospective, single-centre study of a cohort of patients diagnosed with DSNEP between 2011 and 2018. All patients were treated with surgical excision and sublesional bevacizumab injections. The effect of bevacizumab was evaluated using a severity score developed to quantify lesion size and the extent of affected areas in each patient. Results: Seven patients diagnosed with DSNEP were treated. All patients were male, with a median age at diagnosis of 42 years [38–44.5]. Human papillomavirus (HPV) DNA was detected in all patients: HPV-11 in six cases (85.7%) and HPV-6 in one case (14.3%). Bevacizumab was injected into the submucosa of their surgical sites. The median follow-up was 55.5 months [40.85–82.73]. Most patients (85.72%) presented recurrence, with a median of 3 years [1.5–4]. A statistically significant reduction in the severity score was observed (p = 0.017), although this finding cannot be attributed solely to bevacizumab due to study design limitations. No relevant complications were reported. Conclusions: Nasal sublesional bevacizumab injections were well tolerated and feasible as an adjuvant approach to DSNEP. Larger prospective studies are needed to confirm its safety and assess its potential benefit.

Background: Ménière’s Disease (MD) is a disease that may be difficult to diagnose and manage. Our UK survey showed variability in the practice of UK Otolaryngology consultants. We hence surveyed Otolaryngology consultants internationally, to assess their confidence levels in diagnosing MD, their use of the AAO-HNS guidelines and current diagnostic and treatment modalities. Methods: An online questionnaire was distributed internationally over four weeks. The questionnaire asked respondents to anonymously rank their confidence in diagnosing MD, identify the minimum investigations required to make a diagnosis, describe their use of the AAO-HNS criteria, share their preferred treatment modalities for acute attacks, and state their 1st and 2nd-line preventative treatment options. Results: A total of 173 responses were collected with 77% of respondents reporting high levels of confidence in diagnosing MD. Most respondents stated the minimum tests required were “History, Otoscopy, Clinical Vestibular testing, and Pure Tone Audiometry” although some chose as few as 1 test. Regarding the use of the AAO-HNS criteria, responses ranged from “always” (20.2%) to “never” (22.5%). Cinnarizine was the first-line treatment for acute attacks followed by betahistine. Betahistine (30.1%) and dietary restrictions (28.3%) were recommended almost equally as first-line preventative measures. The most popular second-line measure was intratympanic steroids injection (30.1%). Conclusion: Our survey revealed disparities in the diagnosis of MD and its management, like the results of our previously conducted UK survey. This suggests the need for an international consensus regarding the diagnosis and subsequent management strategies for this disease. Cite this article as: Koumpa F-S, Parihar S, Neumann C, et al. An international survey of the diagnosis and management of Ménière’s disease amongst otolaryngology consultants. J Int Adv Otol. 2024;20(5):411-416.

Introperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is a well-established technique to aid in thyroid/parathyroid surgery. However, there is little evidence to support its use in non-thyroid or non-parathyroid surgery. The aim of this paper was to review the current evidence regarding the use of IONM in non-thyroid/non-parathyroid surgery in the head and neck and thorax. A literature search was performed from their inception up to January 2024, including the term “recurrent laryngeal nerve monitoring”. IONM in non-thyroid/non-parathyroid surgery has mainly been previously described in oesophageal surgery and in tracheal resections. However, there is little published evidence on the role of IONM with other resections in the vicinity of the RLN. Current evidence is low-level for the use of RLN IONM in non-thyroid/non-parathyroid surgery. However, clinicians should consider its use in surgery for pathologies where the RLN is exposed and could be injured.