Current Opinion in Otolaryngology & Head and Neck Surgery最新文献

Purpose of review: Currently, no universally accepted definition or management strategy for chronic rhinosinusitis (CRS) and its acute exacerbations (AECRS) exists. This review aims to provide an overview of the current research in this field and to present recent advances in diagnosis and management.

Recent findings: A variant in the CDHR3 gene has been identified as a risk factor for AECRS, associated with increased viral replication, type-2 cytokine upregulation, and downregulation of Toll-like receptor mediated responses. Microbiome studies show that patients with AECRS are more likely to harbor rare microbial taxa, and most strains isolated during exacerbations form biofilms. Biologic therapies targeting type-2 inflammation have reduced exacerbation rates and decreased the need for antibiotics and systemic corticosteroids. Culture-directed antibiotics may improve longer-term endoscopic outcomes, though short-term symptom and quality-of-life benefits remain unclear. Cost-effectiveness modeling suggests observation is usually the most efficient initial strategy, unless the probability of bacterial etiology exceeds ~49%. In addition, a new patient-informed definition of AECRS has been proposed, although further validation is needed.

Summary: Advances in genetics, microbiome analysis, and biologic therapy offer promising avenues, yet definitions and outcome measures remain inconsistent. Robust, long-term studies are still needed to harmonize definitions and standardize management.

Purpose of review: Increasing evidence suggests that epigenetic regulation plays a central role in chronic rhinosinusitis pathogenesis, heterogeneity, and treatment response. This review summarizes current knowledge of epigenetics in CRS pathogenesis, their role in endotype differentiation, and potential as diagnostic and therapeutic targets.

Recent findings: Distinct epigenetic signatures have been identified across CRS subtypes. Hypermethylation of TSLP and differential regulation of FZD5, IL8, and EMT-related genes distinguish eosinophilic CRSwNP from other phenotypes. Specific microRNAs (miR-941, miR-21, miR-125b, miR-155) correlate with disease severity, tissue eosinophilia, and corticosteroid responsiveness, highlighting their utility as noninvasive biomarkers. Experimental data suggest that targeting DNMTs or HDACs may reverse pathogenic remodeling. Emerging therapeutic approaches - such as biologics modulating epigenetically controlled cytokines (e.g. tezepelumab) and engineered extracellular vesicle-based miRNA delivery - illustrate translational promise.

Summary: Epigenetic mechanisms critically influence CRS pathogenesis and clinical variability. Their modulation offers novel opportunities for biomarker discovery, disease stratification, and personalized therapy. Future research should focus on standardizing epigenetic profiling methodologies, validating candidate biomarkers in diverse populations, and integrating multiomics and single-cell approaches to uncover cell-specific regulatory networks. These advances may enable precision medicine in CRS, bridging the gap between molecular mechanisms and targeted clinical management.

Purpose of review: This article synthesises the recent sinus microbiome literature, identifying common themes in research findings as well as surveying the varied methodological approaches used across these studies.

Recent findings: While there remains no clear consensus as to which microbes define dysbiosis in chronic rhinosinusitis (CRS), certain trends are emerging. Increasingly, the evidence points towards a pathogenic role in the overabundance of Moraxella , Haemophilus and Pseudomonas species, whilst the genera Cutibacterium, Anaerococcus and Dolosigranulum tend towards commensalism. However, the roles of the most common genera in the sinus microbiome, Staphylococcus and Corynebacterium, remain uncertain. Given the diversity and abundance of species within these genera, species and function-level analyses are needed to clarify their contributions to the aetiopathogenesis of CRS. Comprehensive study of the sinus microbiome in healthy individuals further shows that community composition shifts with age, suggesting that dysbiosis may manifest differently across the lifespan. Beyond bacteria, growing evidence highlights the importance of fungi and viruses, underscoring the need to incorporate these microbionts into future analyses.

Summary: Progress towards a clinically meaningful consensus will require standardised approaches to sequencing, species-level resolution in these analyses, and consideration of the heterogeneous clinical and immunological subgroups of CRS.

Purpose of review: In this review, we summarize the current state of medical treatment for cystic fibrosis (CF) patients and how cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy has revolutionalized the landscape of CF management, including from a sinonasal perspective. We describe the indications for endoscopic sinus surgery (ESS), perioperative decisions otolaryngologists must consider, and the most effective surgical treatment approaches.

Recent findings: Effective CFTR modulator therapy reduces SNOT-22 scores as well as endoscopic and radiographic scores. In this era, surgical indications for people with CF and chronic rhinosinsusitis (CRS) includes persistent, recalcitrant symptoms despite medical interventions, including CFTR therapy. The decision to pursue surgery should incorporate sinus symptoms, as ESS solely for pulmonary function improvement remains controversial. When ESS is performed, extended approaches to the sinuses may be beneficial, although evidence in this area is limited.

Summary: Despite prominent advances in disease modifying therapies, ESS remains a treatment option to manage refractory sinonasal symptoms and CRS in people with CF who do not respond to medical therapy. The decision to pursue ESS remains individualized and should involve a multidisciplinary discussion between clinicians to optimize patient selection, surgical goals, and perioperative medical management.

Purpose of review: To examine how the clinical management of adults with laryngotracheal stenosis (LTS) by speech and language therapists (SLTs) has evolved over the past decade. The review highlights changes in assessment, counselling, and rehabilitation practices in response to advances in surgical interventions and explores implications for multidisciplinary care.

Recent findings: Recent literature and clinical experience demonstrate that SLTs play a critical role in managing voice and swallowing outcomes for patients with LTS. While established care pathways exist for reconstructive surgery, the increasing use of minimally invasive endoscopic procedures and complex cases require more nuanced, individualized approaches. Prospective studies have defined the impact of LTS and its treatments on voice and swallowing, and a core outcome set (COS-LTS) has been developed to standardize outcome reporting in future research. Psychosocial support and patient-centred decision-making have become integral components of care.

Summary: Adults with LTS experience multifaceted challenges affecting breathing, voice, and swallowing. SLTs are essential members of the multidisciplinary team, providing pre and postoperative assessment, counselling, and rehabilitation. Advances in treatment options and recognition of psychosocial impacts necessitate flexible, holistic care strategies. Future research should focus on validating outcome measures, implementing the COS-LTS, and incorporating patient priorities to optimize functional and quality-of-life outcomes.

Purpose of review: This review summarizes recent advances in the use of botulinum toxin (BoNT) for laryngeal disorders. It highlights the growing therapeutic relevance of BoNT across both motor and sensory conditions, focusing on novel indications, evolving mechanisms of action, and innovations in injection techniques.

Recent findings: BoNT remains the primary treatment for laryngeal dystonia, with increasing personalization in dosing, target selection, and outcome assessment. New evidence supports its application in functional dysphonia, vocal process granuloma, chronic cough, inducible laryngeal obstruction, and abnormal throat sensation. Studies suggest both peripheral and central neuromodulatory effects, including modulation of afferent input and neuroplastic changes. Guidance techniques such as electromyography, ultrasound, and flexible endoscopy are improving injection accuracy. Adjunctive therapies, including pharmacological agents and sensory retraining approaches, show promise for partial or nonresponders.

Summary: BoNT is an increasingly versatile and well tolerated treatment across a broadening spectrum of laryngeal disorders. As knowledge of laryngeal neurobiology expands, BoNT is being redefined as both a focal therapeutic and a neuromodulator with broad implications for voice and airway management.

Purpose of review: Management of fetal airway obstruction requires a multidisciplinary approach to optimize the safety of the pregnant patient and fetus. For severe cases of fetal airway obstruction, ex-utero intrapartum treatment (EXIT) is recommended. This review highlights indications and rationale for EXIT and presents an approach to fetal airway management from an otolaryngologic perspective.

Recent findings: Approach to the fetus with airway obstruction differs in the literature. Recent studies have sought to identify prenatal risk factors that portend the need for surgical intervention at delivery, with identification of three fetal anomalies that justify delivery modification: micrognathia, congenital high airway obstruction, and head and neck masses. There remains heterogeneity within this cohort, contributing to the varied approach to fetal airway obstruction. What remains consistent is the need for early identification of at-risk fetuses and multidisciplinary input throughout pregnancy to ensure that the appropriate teams are present at delivery.

Summary: EXIT is a mainstay in the management of fetal airway obstruction, as it enables airway intervention while preserving uteroplacental circulation. Further research is needed to define indications for EXIT and develop management algorithms starting from identification of airway obstruction on prenatal imaging. Multidisciplinary collaboration is tantamount to a successful procedure.

Purpose of review: This review aims to provide a comprehensive analysis of the pathophysiology and treatment of middle ear myoclonus (MEM), a rare and under-recognized cause of objective and subjective tinnitus.

Recent findings: MEM is increasingly recognized as a distinct subset in tinnitus patients, with symptoms arising from involuntary contractions of the stapedius and/or tensor tympani muscles. Pharmacological management currently centres around agents such as clonazepam, carbamazepine, and piracetam. Surgical resection of middle ear tendons has yielded highly encouraging results, albeit with risks such as hyperacusis and symptom recurrence due to tendon reattachment. Endoscopic surgical techniques offer improved visualization and reduced invasiveness. Emerging data support the potential role of botulinum toxin as a less invasive and reversible therapeutic option, particularly with intratympanic delivery methods demonstrating early safety and efficacy in recent studies.

Summary: MEM is a complex otologic condition with limited high-quality data guiding its diagnosis and management. Due to its variable presentations and response to treatment, a multidisciplinary and individualized approach remains essential. While pharmacological treatments and surgical outcomes are generally favourable, interest in botulinum toxin continues to grow. Further large-scale, controlled studies are needed to clarify pathophysiological mechanisms, optimize diagnostic accuracy, and standardize treatment protocols.

Purpose of review: Drug delivery to the cochlea has been hampered by the very mechanisms that exist to protect its delicate neurosensory epithelium from pathogens. The blood-brain barrier restricts the distribution of systemic therapies, while local administration is constrained by basal to apical gradients. As we progress towards restorative and regenerative therapies, precise delivery of therapeutics to their target site is required. This review discusses the surgical approaches to cochlear therapeutic delivery that can overcome these barriers.

Recent findings: Recent advancements in microneedle technology have facilitated nondestructive round window membrane penetration that overcomes restrictive diffusion. Direct intracochlear catheterisation provides a solution to traditional basal to apical gradients along the cochlear duct, particularly when combined with fenestration for allowance of efflux. Drug-eluting implants present a unique opportunity for direct intrascalar administration, which may be extended in a sustained-release format. Finally, surgical approaches for direct injection to the modiolus have been detailed, allowing maximum survival of stem cell grafts.

Summary: The evolution of precise pharmacotherapy to specific subsites of the cochlea demands precise methods of administration. These novel strategies often require a surgical approach and can overcome the protective barriers of the cochlea that traditionally restrict pharmacodynamics and pharmacokinetics.