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.

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.

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.

ChatGPT Generated Literature Review: Quod Erat Demonstrandum or Ends Justifying the Means?Dear Editor,We would like to draw your attention to the increasing popularity of the generative artificial intelligence (AI) chatbot, ChatGPT (OpenAI, 2023), and its relationship with scientific literature. We have attempted to replicate two literature reviews recently published in Clinical Otolaryngology using ChatGPT, comparing results, conclusions and references.Lee et al. (2022): Posterior nasal neurectomy for intractable rhinitis: A systematic review, was assessed. ChatGPT’s conclusions generated with the same research questions were comparable. However, ChatGPT’s references were confabulated raising questions of provenance and quality.Cereceda-Monteoliva et al. (2021), reviewed sarcoidosis of the ear, nose, and throat. Again, identical research questions generated near-identical results, including numerical values for incidence, features, and management. One generated reference appeared to be ‘similar’ in terms of the author’s name, but the title and journal were entirely incorrect. Of the remaining four references provided by ChatGPT, only one was a recognisable article. Further investigation shows ChatGPT lacks access to research databases, raising doubts about the reliability of the conclusions it presents.It is interesting that ChatGPT should generate correct conclusions but with incorrect working. We are reminded of school mathematics,quad erat demonstrandum (Q.E.D.), and where incorrect working affords you no marks regardless of a correct answer.ChatGPT is a Large Language Model (LLM) AI. Fundamentally, it mimics human intelligence but does not replicate it. ChatGPT does this by analysing vast quantities of data to predict the next most likely word in an answer – erroneously exemplified by the generated references. A scientific literature review follows a superficially similar process, analysing data and outputting a most likely conclusion. Crucially, the latter involves higher-order evaluation and critical thought based on myriad factors that seem currently out of reach for ChatGPT in this specific use case. Readers familiar with Bloom’s Taxonomy of Cognition will identify its relevance here[1].Often literature review produces an already anticipated conclusion but provides some of the highest quality evidence to base medical practice. Therefore, with ChatGPT, the ends do not justify the means for practiced medicine, even if the most likely worded conclusion is accurate.However, the exponential growth of LLM AIs is extraordinary. Near-future iterations of ChatGPT climbing to the top of Bloom’s Taxonomy are easily imagined. Improved critical reasoning with access to accurate databases of peer-reviewed material would substantiate an output, even if the conclusions are unchanged. An accurate ‘show of working’ could provide a meaningful AI-generated literature review to responsibly guide medical practice.Q.E.D. - Quod Erat DemonstrandumReferencesBloom, B.S.,Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company.Cereceda-Monteoliva, N., Rouhani, M. J., Maughan, E. F., Rotman, A., Orban, N. T., Yaghchi, C. A., & Sandhu, G. S. (2021b). Sarcoidosis of the ear, nose and throat: A review of the literature. Clinical Otolaryngology , 46 (5), 935–940.https://doi.org/10.1111/coa.13814Lee, M. L., Chakravarty, P., & Ellul, D. (2022). Posterior nasal neurectomy for intractable rhinitis: A systematic review of the literature. Clinical Otolaryngology , 48 (2), 95–107.https://doi.org/10.1111/coa.13991OpenAI. (2023). OpenAI. Retrieved from https://openai.com/

Objectives Paediatric feeding difficulties are common, affecting up to 25% of otherwise healthy children, symptoms include food refusal, gagging, choking, and excessive mealtime duration. These symptoms are commonly described in pre-operative discussions about tonsillectomy. This prospective study explores the impact of tonsillectomy on paediatric feeding difficulties. Methods This prospective cohort study invited caregivers of all children undergoing tonsillectomy at our institution to complete a PediEAT questionnaire about their children’s feeding behaviours, pre and post-operatively. The study was completed in two phases with 9 questions administered in phase 1 and three additional questions added for phase 2. A free text comments box was also provided. Responses were graded from 0-5, where 0 is ‘never a problem’ and 5 is ‘always a problem’ with eating behaviours. Results 102 participants were recruited between January 2020 – January 2022. The mean age of participants was 4.1 years, 87% had a concurrent adenoidectomy. The mean time to completion of post-operative questionnaire was 23 weeks after surgery. 9 of the 12 questions showed a statistically significant improvement in post-operative scores using a paired student t-test (p=<0.05). The most significant improvements related to “gets tired from eating and is unable to finish” (1.49 pre-op, 0.91 post op, p<0.01) and “eats food that needs to be chewed” (1.4 pre-op, 0.72 post-op, p<0.01). 13% of participants only underwent tonsillectomy and this group also showed a statistically significant improvement in fatigue during eating (p<0.05). Conclusion Symptoms of fatigue during eating and avoidance of food requiring mastication are most likely to improve following tonsillectomy in children.

Objectives: Existing knowledge on Health Related Quality of Life (HRQoL) after surgical removal of sinonasal inverted papilloma (IP) is limited. Moreover, predictors for a better or worse postoperative HRQoL outcome are not known. Our aim was to assess HRQoL in all three health domains (physical, psychological and social), track its postoperative trajectory, investigate if preoperative observations could predict distinct postoperative HRQoL outcomes, and evaluate whether physicians’ interventions could contribute to improved postoperative HRQoL. Design: Prospective cohort study. Setting: Tertiary referral hospital. Participants: Seventy-four patients who underwent surgery for an IP were included. They were asked to fill in the Endonasal Endoscopic Sinus and Skull Base Surgery Questionnaire (EES-Q) preoperatively, and then two weeks, three months, and one year postoperatively. Main outcome measures: Linear mixed models (LMM) analyses were performed to evaluate the overall postoperative HRQoL and the separate health domains, as well as the impact of specific variables (sex, age, ASA classification, smoker, Krouse staging, preoperative EES-Q score, type of surgery and postoperative antibiotics) on HRQoL improvement. Results: The total EES-Q score (P<.001) as well as the physical (P<.001), psychological (P=.049), and the social (P=.002) domains significantly improved postoperatively. ASA classification (P=.049), preoperative EES-Q score (P<.001) and postoperative antibiotics (P=.036) were significant variables. Conclusions: Overall HRQoL, as well as each of the three health domains, improved significantly. A higher ASA score, a higher preoperative EES-Q score, and the administration of postoperative antibiotics were significant predictors for better HRQoL recovery postoperatively. Further research is necessary to confirm these results.

Objective To assess whether narrow band imaging (NBI) detects fields of cancerisation around suspicious lesions in the upper aerodigestive tract, which were undetected by white light imaging (WLI). Method In 96 patients with laryngeal and pharyngeal lesions suspicious for malignancy, 206 biopsies were taken during laryngoscopy: 96 biopsies of suspicious lesions detected by both WLI and NBI (WLI+/NBI+), 60 biopsies adjacent mucosa only suspicious with NBI (WLI-/NBI+), and 46 biopsies of NBI and WLI unsuspicious mucosa (WLI-/NBI-) as negative controls. Optical diagnosis according to the Ni-classification was compared with histopathology. Results Signs of (pre)-malignancy were found in 88% of WLI+/NBI+ biopsies, 32% of WLI-/NBI+ biopsies, and 0% in WLI-/NBI- (p <.001). In 58% of the WLI-/NBI+ mucosa any form of dysplasia or carcinoma was detected. Conclusion The use of additional NBI led to the detection of (pre)-malignancy in 32% of the cases, that would have otherwise remained undetected with WLI alone. This highlights the potential of NBI as a valuable adjunct to WLI in the identification of suspicious lesions in the upper aerodigestive tract.