Key points: 1. Tonsillectomy is associated with risks, including primary and secondary haemorrhage, frequently requiring readmissions and methods that minimise these risks should be advocated. 2. The current analysis includes a data set of 953 children who underwent tonsillectomy using cold-steel dissection technique   3.  Nine patients (1%) were readmitted, one for infection and 8 (0.8%) for haemorrhage. One (0.1%) patient suffered primary haemorrhage and required conservative management only. 4. The commonest indication for surgery was recurrent acute tonsillitis and all the patients with post tonsillectomy haemorrhage were from this group. Obesity and obstructive sleep apnoea did not adversely affect outcome. 5. None of the patients in this study population needed reoperation to control bleeding. Cold steel dissection tonsillectomy, combined with a strict protocol produced very few complications in these series.

Objective Currently, there is no adult specific decision aid (DA) to support decision making around recurrent tonsillitis. This study intends to address this gap by piloting a prototype DA. Design Randomised clinical trial Setting Single centre trial at a tertiary otolaryngology department. Participants 43 patients were randomised to either the DA or Treatment as Usual (TAU) group. Main Outcome Measures Primary objective: To measure how patients rate the quality of their decision-making experience at the time of the decision and at follow up (SURE scale). Secondary objective: The level of decisional satisfaction at the time of the decision and at follow up; and to explore the numbers of people opting for surgery from each study condition. (SHARED tool and patient feedback) Results Quality: This study demonstrates no statistically significant difference in the degree by which patients rate the quality of their treatment decision between DA and TAU, both at baseline (P = 0.553) and follow-up (P = 0.062). Satisfaction: This study showed a statistically significant level of decisional satisfaction at the time the decision was made for Qu2 of the shared tool (U = 113, P = 0.026). No other significant difference was found between participants who received the DA and TAU. Conclusion The DA is an acceptable and useful tool which could be incorporated into the pathway for recurrent tonsillitis, helping to eliminate physician implicit bias. However, preliminary qualitative evidence from this pilot study does not suggest that inclusion of the DA improves the quality of decision making.

Intro: In Australia, older Aboriginal and Torres Strait Islander (hereafter Indigenous) Australians have the highest prevalence of hearing loss, with Indigenous-specific audiological services being provided. However, there is limited research on the experiences older Indigenous Australians have with hearing loss and audiological services. Therefore, this study aimed to consolidate existing literature with a scoping review, specifically on the above to identify gaps and guide future research. Method: Ten databases were searched, identifying 539 records; twenty-one studies met our inclusion criteria. Our inclusion criteria constituted research of any design on the experiences of older Indigenous Australians (aged 45+) with hearing loss and audiological services. Results: Sixteen studies reported on experiences with hearing loss, four studies reported on experiences with audiological services, and one study reported on both experiences. Prevalence of hearing loss was estimated to be 20-34% in older Indigenous Australians; a discrepancy between self-reported and objective hearing difficulties was also identified. Audiological services currently available to older Indigenous Australians were also underutilised. Conclusions: Future experimental/correlational research with Indigenous Australians is required to uncover: (1) the reasons for underreported hearing loss; (2) types of hearing loss experienced; (3) barriers to accessing audiological services; and (4) best hearing-loss management and rehabilitation practices.

No abstract provided as per author guidelines for Clinical Experience submissions.

Objective It is often recommended that, in children with bilateral epistaxis, only one side of the nasal septum should be cauterised at a time in order to reduce the risk of septal perforation. This advice may have been reasonable when hot wire electrocautery was in common use. The risk of septal perforation after silver nitrate cautery is unknown but probably low. Methods Retrospective casenote review of children attending the nurse-led epistaxis clinic between 2019 and 2022. Results Nine hundred and twenty children were seen in the nurse-led clinic between January 2019 and December 2022. Six hundred and one children (79%) underwent nasal cautery. Simultaneous bilateral nasal cautery was carried out in 176 (29%) children. Our follow up period ranged between 303 days and 1,744 days, with a median of 809.5 days. No child presented to emergency or ENT services with septal perforation or any other complication of simultaneous bilateral nasal cautery. Conclusion To the author’s knowledge, this is the largest study assessing the safety of simultaneous bilateral nasal cautery with silver nitrate in children. No adverse results have been found after cauterising both sides of the septum at the same sitting, and doing so potentially saves time and money for patients and the health service.

Objectives: This study aims to examine the effects of autologous platelet-rich plasma (PRP), which increases new connective tissue synthesis and revascularization, on healing in parotid surgery wound, prevention of salivary fistula formation, drain removal time, and hospitalization in the postoperative period. Materials and Methods: Fifty-four patients who had an operation on superficial parotidectomy were randomized, and then two groups were created. PRP was gained by centrifuging the blood taken from the patients at the end of the surgery in the study group. This gained PRP was injected into the surgical site, and then the wound flap was closed by suturing. Patients were evaluated for the parameters such as the development of salivary fistula, duration of drain removal, discharge time, all other complications during the postoperative 4 weeks. Results: Drain removal time and discharge time of the PRP group cases were statistically shorter than those in the control group. The rate of development of salivary fistula according to the groups was remarkably high in the control group, but it was not statistically significant. Statistically significant correlation was found between the location of the compared tumor, and volume of material removed, and the incidence of all complications. Conclusions: PRP reduced the duration of drain removal and discharge time for those who had an operation on superficial parotidectomy. Thus, the decreased discharge time provides both reduced health costs and the risk of developing nosocomial infections. Although it was not statistically significant, a significant difference was observed in the rates of salivary fistula development.

Objective: To assess the effectiveness of auditory and visual distraction interventions on patient discomfort, pain and anxiety during office-based Otolaryngologic upper airway procedures. Data Sources: Literature searches were done through Cochrane Central Register of Controlled Trials, Lilacs, MEDLINE, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature. Review Methods: The protocol was registered in PROSPERO on August 17 th 2022, under Registration number CRD42020204354. Results: We identified 138 records; two randomized controlled trials using virtual reality as a distraction technique in adults and one in children were included. All studies had some concerns regarding risk of bias. In adults, anxiety was lower in the virtual reality group than in the standard of care, (mean difference -16.72, 95% CI -27.19 to -6.24, p=0.002, I 2=0%). There was no difference in procedure related pain between groups, (mean difference -0.28, 95% CI -1.24 to 0.68, p=0.57, I 2=10%). There was no difference in satisfaction between groups (Standardized mean difference 0.18, 95% CI -0.22 to 0.58, p = 0.37, I 2=0%). Only one Pediatric study was included hence no meta-analysis was done. Anxiety and pain were lower and satisfaction was higher in the group using virtual reality. Conclusions: The use of virtual reality distraction in addition to standard analgesia during office-based Otolaryngology upper airway procedures reduced anxiety in adults. It did not decrease pain or increase the level of patient satisfaction. In the paediatric population, there is a reported benefit for procedural anxiety, pain and satisfaction.

We take great pleasure in introducing this supplement dedicated to management of head neck squamous cell cancer from an unknown primary (HSCCUP).

Is Gene Therapy the Game-Changer for Autosomal Recessive Deafness 9?Dear editor! One of the most challenging forms of hearing impairment is autosomal recessive profound prelingual deafness (DFNB9), which makes up over 80% of all congenitally occurring hearing loss cases (1). Otoferlin protein, encoded by the OTOF gene, is located at the inner hair cells, which mediates signal transduction for proper sound propagation. The OTOF gene mutations impair the physiological otoferlin function and account for almost 1–8% of all the DFNB9 cases (2). Currently, there are no medical therapies available to combat this disorder, and in this critical context, adeno-associated virus (AAV) serotype 1 carrying a human OTOF transgene (AAV1-hOTOF) may offer promising results.AAV1-hOTOF is an experimental gene therapy intended to treat DFNB9. It transports the functional copy of the OTOF gene to the hair cells via an adenovirus vector. This enables the hair cells to produce newly functioning otoferlin protein, thereby regaining proper signal transduction and sound propagation.A groundbreaking clinical trial, recently published in The Lancet, evaluates the efficacy and safety of this AAV1-hOTOF gene therapy for restoring hearing in patients with DFNB9. This first-of-its-kind trial demonstrated that AAV1-hOTOF showed excellent results and helped in reclaiming significant functional hearing in all the patients enrolled in the trial (3). Furthermore, along with enhanced hearing, gene therapy also assisted in improving speech perception in the patients. In addition to its increased efficacy, gene therapy had a favorable safety profile, with no reports of serious adverse events or drug-limiting ototoxicity (3). These findings of a successful response to gene therapy are in line with the case report by Qi et al., which also showed that AAV1-hOTOF helped restore substantial hearing in two children (4).In South Asia, 1.62 out of every 1000 newborns suffer from congenital hearing loss, making it one of the most prevalent chronic pediatric illnesses (5). Due to the unavailability of any medical intervention, DFNB9 goes untreated, substantially affecting the quality of life of patients. However, with the introduction of gene therapies like AAV1-hOTOF, there is newfound hope for these patients. This pioneering therapy may completely eradicate DFNB9 and significantly enhance auditory function, providing a viable substitute for cochlear implants and conventional hearing aids. More clinical trials assessing larger patient populations are warranted to provide greater evidence for the effectiveness and tolerability of this therapy.Keywords: autosomal recessive deafness 9; AAV1-hOTOF; congenital hearing loss; AsiaDisclaimer: None to declareConflict of Interest: None to declareFunding Disclosure: None to declareREFERENCESDuman D, Tekin M. Autosomal recessive nonsyndromic deafness genes: a review. Front Biosci (Landmark Ed). 2012 Jun 1;17(6):2213-36. doi: 10.2741/4046. PMID: 22652773; PMCID: PMC3683827.Azaiez H, Thorpe RK, Smith RJH. OTOF -Related Deafness. 2008 Feb 29 [updated 2021 Jan 21]. In: Adam MP, Feldman J, Mirzaa GM, Pagon RA, Wallace SE, Bean LJH, Gripp KW, Amemiya A, editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993–2024. PMID: 20301429.Lv J, Wang H, Cheng X, Chen Y, Wang D, Zhang L, Cao Q, Tang H, Hu S, Gao K, Xun M, Wang J, Wang Z, Zhu B, Cui C, Gao Z, Guo L, Yu S, Jiang L, Yin Y, Zhang J, Chen B, Wang W, Chai R, Chen ZY, Li H, Shu Y. AAV1-hOTOF gene therapy for autosomal recessive deafness 9: a single-arm trial. Lancet. 2024 May 25;403(10441):2317-2325. doi: 10.1016/S0140-6736(23)02874-X. Epub 2024 Jan 24. Erratum in: Lancet. 2024 May 25;403(10441):2292. PMID: 38280389.Qi J, Tan F, Zhang L, Lu L, Zhang S, Zhai Y, Lu Y, Qian X, Dong W, Zhou Y, Zhang Z, Yang X, Jiang L, Yu C, Liu J, Chen T, Wu L, Tan C, Sun S, Song H, Shu Y, Xu L, Gao X, Li H, Chai R. AAV-Mediated Gene Therapy Restores Hearing in Patients with DFNB9 Deafness. Adv Sci (Weinh). 2024 Mar;11(11):e2306788. doi: 10.1002/advs.202306788. Epub 2024 Jan 8. PMID: 38189623; PMCID: PMC10953563.Korver AM, Smith RJ, Van Camp G, Schleiss MR, Bitner-Glindzicz MA, Lustig LR, Usami SI, Boudewyns AN. Congenital hearing loss. Nat Rev Dis Primers. 2017 Jan 12;3:16094. doi: 10.1038/nrdp.2016.94. PMID: 28079113; PMCID: PMC5675031.

Level of Evidence: 3 Objective(s) To identify the risk factors for Cholesteatoma in a large UK cohort. Although some risk factors are well established (male sex, history of chronic otitis media), others require further evidence (deprivation, smoking). Design and Setting 1,140 cholesteatoma cases from UK BioBank were compared to 4,551 non-cholesteatoma middle ear disease and 493,832 ear disease-free controls. Adjusted odds ratios were calculated for demographic factors including age, sex, ethnicity, deprivation and smoking status with logistic regressions. Odds ratios for overlapping ICD-10 codes are also calculated. Results Cholesteatoma was significantly associated with sex (Adjusted odds ratio (AOR) for males=1.33), age (AOR=1.02) and deprivation (AOR=1.08) compared to ear disease-free controls ( p<0.001). Age and deprivation distributions for cholesteatoma and non-cholesteatoma ear disease were similar. Although there was no significant association with smoking status, cholesteatoma was significantly associated with the ICD-10 code mental and behavioural disorders due to tobacco use (OR=2.34, p<0.001). Cholesteatoma was also strongly associated with a wide range of inflammatory middle ear conditions and chronic sinus inflammation, suggesting an increased susceptibility to inflammation of the upper airways. Conclusion This study shows a large overlap between cholesteatoma and non-cholesteatoma ear disease in terms of numbers and demographics, with sex being a key factor distinguishing between the two, suggesting that there are both common and distinct risk factors exist.

Objective: Vocal fold immobility (VFI) is a cause of significant morbidity and mortality in the paediatric population. Laryngoscopy is the current first-line investigation for patients with suspected VFI. Laryngeal ultrasound (LUS) has recently emerged as an alternative method of identifying VFI. Compared to laryngoscopy, LUS is less invasive, does not require anaesthesia, and can be performed by non-otolaryngologists. The primary objective of this study is to evaluate LUS as a diagnostic method for the identification of unilateral VFI in a cohort of paediatric patients in Aotearoa New Zealand (NZ). The secondary objective is to estimate the frequency of use of LUS in the paediatric population around the world. Methods: A retrospective, single-centre cohort study was performed on all paediatric patients who had undergone laryngoscopy and LUS at Starship Children’s Health between 2020 to 2023 in Auckland, NZ. An eight-question survey was also developed and distributed to better understand clinicians’ use of LUS to diagnose paediatric VFI globally. Results: Twenty-three paediatric patients met the inclusion criteria. LUS demonstrated high sensitivity (100%), specificity (63%), positive predictive value (83%), and negative predictive value (100%) for detecting unilateral VFI within our patient population. Out of the eighty-seven respondents to the survey, nearly half utilise LUS in their clinical practice in the paediatric population. The main barrier for those who do not is lack of expertise, equipment, and training. Conclusions: These findings support the use of LUS as a safe and accurate diagnostic tool for the detection of unilateral VFI. Further studies in non-surgical populations and standardised guidelines for LUS technique and reporting are required.

USE OF 3D EXOSCOPE FOR FREE FLAPS MICROANASTOMOSIS

Introduction: Measurements in endoscopic sinus surgery (ESS) are usually obtained with variable accuracy. We aimed to validate endoscopic multipoint integrated laser systems (EIMLS) for use in ESS, which can acquire measurements within one-hundredth of a millimetre. Methods: 4.4mm flexible endoscopic EIMLS projecting 49 laser points into the view was used to assess simulated anterior skullbase defects. Antero-posterior and lateral measurements were obtained and repeated twenty times by two surgeons. These were compared to measurements with surgical calipers. Intra and inter-observer reliability was assessed. Results: 80 measurements were obtained of simulated skullbase defects by each otolaryngology surgeon and compared to manual measurements. The mean difference shown was 0.56cm. Bland-Altman plot shows low bias (0.044) but wide 95% limits of agreement (-1.8 – 1.9). Conclusion: EIMLS allows reliable and easy to obtain measurements within a simulated ESS environment. Translation of this technology offers promise in a future clinical setting but will require further refinement to improve accuracy.

Minimum surgeon volumes have been introduced in multiple specialties in the UK with the aim of improving patient outcomes. This includes endocrine surgery, pertinent to ENT surgeons performing thyroid and parathyroid surgery, where a minimum annual workload of 20 cases is recommended. Further implementation of minimum surgeon volumes could lead to substantial changes to service provision, including centralisation of procedures, turf wars between specialties, an accelerated shift of elective surgery to the private sector and a disproportionate impact on female surgeons.

1. The overwhelming majority of patients referred into secondary care with suspected head and neck cancer (HNC) do not have cancer (~95%). 2. During the COVID-19 pandemic telephone triage of patients with suspected HNC was necessary. During this time, a validated HNC risk-calculator, HaNC-RC-v2 (a set of symptomatology-based questions) was recommended by ENT UK to stratify patients into high or low risk of having HNC via telephone triage [(1)](#ref-0001) 3. Ufonia, a digital health company which uses an Artificial Intelligence (AI) voice assistant to automate clinical conversations via telephone, and *INSTITUTION*, were awarded an SBRI Healthcare grant to help develop an AI-delivered HNC triage telephone call. This was based on the HaNC-RC-v2 and co-created with HNC patients from the Heads2Gether charity via round-table discussions and one-to-one sessions. 4. Twenty-nine patients underwent a clinician-supervised AI-delivered HNC triage conversation as part of their standard telephone consultation. 100% of calls were completed with an average agreement of 89% between the clinician and the AI system for all symptoms asked. The technology was highly acceptable to patients with a median net promoter score (NPS) score of 8 out of 10. 5. Novel technologies involving AI automated telephone calls can be generated to remotely triage suspected HNC patients. This technology may offer an exciting opportunity to help departments triage suspected HNC referrals in an ever increasingly resource pressurised NHS.

Objective: The aim of this investigation was to explore the potential correlation between signal intensity ratio (SIR) at internal auditory canal (IAC) bottom and hearing impairment in MD, thereby providing a foundation for further comprehension of the underlying mechanisms contributing to hearing loss. Design: Fifty patients diagnosed with unilateral definited MD were enrolled in the study. 3D-FLAIR MRI was conducted four hours after intravenous administration of gadobutrol to determine the SIR of bilateral IAC bottom. The difference of SIR of IAC bottom was assessed between affected and unaffected sides, followed by an analysis of its correlation with low-, middle-, and high-tone hearing thresholds. Additionally, correlation analysis was conducted between the degree of EH in vestibular and cochlea and the SIR on the affected side. Results: The degree of EH in MD can be clearly visualized through 3D-FLAIR MRI. The SIR on the affected side was significantly higher than that on the unaffected side (P=0.000). Furthermore, a positive correlation was observed between the SIR at the affected and low (r=0.692, P=0.000), middle (r=0.615, P=0.000) and high-tone (r=0.440, P=0.001); the SIR showed no significant correlation with cochlear (r=0.315, P=0.088) or vestibular hydrops (r=0.215, P=0.244). Conclusion: 3D-FLAIR MRI can observe the degree of EH in MD; impairment of the internal auditory barrier may be one of the factors of hearing loss in MD.

Objective Machine learning has been effective in other areas of medicine, this study aims to investigate this with regards to HNC and identify which algorithm works best to classify malignant patients. Design An observational cohort study. Setting Queen Elizabeth University Hospital. Participants Patients who were referred via the USOC pathway between January 2019 and May 2021. Main outcome measures Predicting the diagnosis of patients from three categories, benign, potential malignant and malignant, using demographics and symptoms data. Results The logistic regression-based models with a penalty term worked best on the data, ridge achieving an AUC of 0.7081. The demographic features describing living alone and recreational drug use history were the most important variables alongside the red flag symptom of a neck lump. Conclusion Further studies should aim to collect larger samples of malignant and pre-malignant patients to improve the class imbalance and increase the performance of the machine learning models.

Objectives: A recent paper [Moore, B.C.J., Lowe, D.A., Cox, G. (2022). Guidelines for diagnosing and quantifying noise-induced hearing loss. Trends in Hearing, 26, 1-21] has proposed guidelines for diagnosing noise-induced hearing loss (NIHL). It is referred to here as the MLC guidelines. Our aim was to evaluate the specificity of those guidelines (i.e., freedom from false positive outcomes). Design: We applied the MLC guidelines to three data sets composed of adults who do not have a history of material noise exposure and therefore cannot have NIHL. Setting: National Health Service (NHS) ENT clinic. Participants: 536 patients with hearing difficulty and/or tinnitus who denied material noise exposure. Two large archival population studies of hearing were also assessed, which included 3250 participants without material noise exposure. Main outcome measure: False positive outcome from guidelines. Results: The MLC guidelines demonstrated high false positive rates overall, the magnitude depending on the noise exposure scenario and whether clinical or population samples were considered. For the procedure applicable to steady broadband noise exposure, the false positive rate averaged 56% in the population samples, compared to 31% for previous guidelines. For exposure to intense impulse sounds, the MLC guidelines take a different approach and the false positive rate was 70% in the population samples and even higher in the clinic sample. For exposure to intense tones, the MLC guidelines take yet another approach and the false positive rate reached 80%. Conclusions: The MLC guidelines demonstrate poorer specificity than previous guidelines. Medical experts should be aware of their poor specificity and consequential likelihood of false positive diagnoses of NIHL.