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.

Objective: To investigate Colony-Forming Unit (CFU) reduction on contaminated flexible endoscopes without a working channel after UV-C light disinfection compared to the current disinfection method with the Endoscope Washer Disinfector. Design, setting: After pharyngolaryngoscopy, a manual pre-cleaning with tap water was performed. A culture was then collected by rolling the distal 8-10 cm of the flexible endoscope over an Agar plate. The flexible endoscope was disinfected using the D60 (60-second disinfection process with UV-C light) or the Endoscope Washer Disinfector (golden standard reprocessing process with water and chemicals). Another culture was then taken. After incubation, a CFU count was performed. Results: Two hundred flexible endoscopes without a working channel were divided equally between the two disinfection groups. After clinical use and manual pre-cleaning, 84 of the 100 (84.0%) (UV-C light group) and 79 of the 100 (79.0%) (EWD) flexible endoscopes were contaminated with at least 1 CFU. Flexible endoscopes that showed no contamination after use were excluded from further analysis. After disinfection with UV-C light, 72 (85.7%) flexible endoscopes showed no contamination (i.e. 0 CFUs) versus 66 (83.5%) flexible endoscopes after reprocessing with the Endoscope Washer Disinfector. Conclusion: There is no difference in CFUs reduction on contaminated flexible endoscopes without a working channel between UV-C light disinfection and the current gold standard, the Endoscope Washer Disinfector.

Objectives: This rapid review aims to evaluate the impact of the COVID-19 pandemic on incidence of head and neck cancer (HNC) and stage distribution at diagnosis. Design: Rapid Review and Meta-analysis Participants: comparative data for new HNC patients between a pre-pandemic cohort (before March 2020) and a pandemic cohort (after March 2020 during the lockdown period). Main Outcomes Measured: data on tumour stage, incidence, referral pathway (number of new patient referrals) or workload levels (number of HNC treatments). Data on stage were summarised as odds ratios (OR) with 95% confidence intervals (CI), data related to changes in numbers of diagnoses, referrals and workload levels were summarised as a narrative synthesis. Results: 31 reports were included in this review. Individually 16 out of 23 studies did not show a significant impact on stage relative to the pre-pandemic period. However, the meta-analysis revealed that patients diagnosed with HNC during the pandemic were 16% more likely to have nodal involvement (OR=1.16; 95% CI 1.00–1.35), 17% more likely to have a late overall stage (OR=1.17; 95% CI 1.01–1.36), and 32% more likely to present with advanced tumour extent (T3 and T4 stage) (OR=1.32; 95% CI 1.08–1.62). Data on incidence was extremely limited and not currently sufficient to assess trends in burden of disease. Conclusions: This review indicates that during the COVID-19 pandemic there was upstaging of HNC at diagnosis, suggesting the provision of care to HNC patients was significantly affected.

Introduction: The purpose of this study was to investigate whether patient, tumor and radiation therapy factors are associated with development of middle ear effusion (MEE) in nasopharyngeal carcinoma (NPC) patients. Methods: A retrospective review of NPC patients treated between January 2000 and June 2018 at Rabin Medical Center. Patient factors, tumor factors, radiation doses and radiation fields were collected and outlined if needed (middle ear, eustachian tube (ET), tensor veli palatini (TVP) and levator palatini (LVP) muscles), then analyzed and compared between patients with MEE and those without and between sides in patients with unilateral MEE. Results: 73 patients were enrolled. Most were males (71.2%) with advanced stage diseases (78%). At the time of diagnosis 14 patients (19.2%) presented with MEE and in 18 (24.6%) patients post radiation MEE was observed (15 ipsilateral to the tumor and 3 bilateral). Tumor stage, histology and laterality were not associated with development of MEE. Comparison of mean radiation field dosages including - gross target volume (GTV), clinical target volume (CTV) and patient target volume (PTV) showed no association with post radiation MEE. In addition, no difference was found in the radiation doses to the middle ear, ET or the LVP nor the TVP between ears with and without MEE. Conclusions: Postirradiation MEE remains a common adverse effect in NPC patients. Surprisingly, tumor stage, tumor laterality and histology were not associated with MEE. Similar findings were observed for total radiation doses and specific doses to the middle ear, ET and ET muscles.

Background Up to 25% of patients with HPV-positive head and neck squamous cell carcinoma (HNSCC), which is mainly comprised of oropharyngeal SCC (OPSCC), will experience disease recurrence, which is often considered incurable when manifested at a metastatic and/or recurrent stage. Objectives To provide an overview of the molecular landscape of recurrent/metastatic HPV-positive HNSCC, novel molecular biomarkers and current trends in treatment options. Type of review A critical qualitative systematic review. Design A literature review was conducted to identify studies reporting on the molecular characteristics of recurrent/metastatic HPV-positive HNSCC, novel molecular biomarkers and treatment options. The reviews of abstracts, full articles, and revision of the included studies, followed by data extraction and quality assessment were performed by three independent assessors. Results The literature search resulted in the identification of 1995 articles. Sixty-six articles were selected for inclusion in the systematic review. Several studies reported that recurrent/metastatic HPV-positive HNSCC had higher rates of TP53 mutation and were genomically similar to HPV-negative HNSCC. The detection of circulating tumour tissue-modified HPV DNA (ctHPVDNA) as a specific biomarker has shown promising results for monitoring treatment response and recurrence in the subset of HPV-positive HNSCC. Conclusions Our review outlines the latest evidence on the distinct molecular profiles of recurrent/metastatic HPV-positive HNSCC as well as the clinical potential of ctHPVDNA testing in routine practice. More controlled and longitudinal studies are needed to identify additional molecular targets and to assess the performance and benefits of novel molecular biomarkers in clinical practice.

Background: Ototoxicity is a common disabling side effect of platinum-based chemotherapy. This study aimed to systematically assess the evidence on the management of platinum-induced ototoxicity in adult cancer patients. Methods: Three databases were searched up to November 1, 2022. Original studies were included if they reported on a pharmacologic or non-pharmacologic intervention to prevent or treat platinum ototoxicity in adults. The articles’ quality was assessed with two grading scales. Results: Eighteen randomized controlled trials and five quasi-experimental studies with 1673 patients were analyzed. Eleven interventions were identified, nine pharmacological and two non-pharmacological. Six of the interventions (sodium thiosulfate, corticoids, sertraline, statins, multivitamins, and D-methionine) showed mild benefit preventing cisplatin-induced ototoxicity. The data must be carefully analyzed due to the low quality and underreporting of side effects. Conclusions: Current interventions have mild benefits preventing cisplatin-induced ototoxicity in adult cancer patients. High-quality research is required to clarify the significance of these findings.

KEY POINTS 1. This is the first study to use a qualitative methodology to assess the potential advantages and disadvantages of the application of 3D endoscopes in pediatric otolaryngology surgery. 2. Open-ended, structured interviews were conducted with six pediatric Otolaryngologist operating at a tertiary pediatric centre, with a minimum one year of experience using a 3D endoscopy system. 3. Thematic analysis of the surgeon's responses identified 3D endoscopy to provide improved surgical field visualization which thus served as a valuable teaching tool. 4. The surgeons interviewed found 3D endoscopy to improve surgical outcomes in pediatric airway surgery, particularly in surgeries involving the larynx. 5. Further quantitative evaluation of patient outcomes could delineate the precise clinical role 3D endoscopy may hold in future pediatric Otolaryngology practice.

Objectives: In this study, we retrospectively reviewed and intended to further compare the treatment outcomes and complications of office transnasal vocal fold polypectomy (TVFP) with those of microplarygoscopic surgery (MLS) for different clinical and histopathological features of broad-based sessile vocal fold polyps. Methods: We retrospectively reviewed the records of 159 consecutive patients with broad-based sessile vocal fold polyps treated by TVFP or MLS. The differences in efficacy and complication between these two surgical techniques were compared according to the different types of vocal fold polyps. Results: Satisfactory outcomes of both TVFP and MLS treatments were reported in patients with edematous, gelatinous and vascular types of vocal fold polyps (p > 0.05). The efficacy of TVFP was slightly worse than MLS in fibrous polys group (p < 0.05). The TVFP-treated patients did not exhibit obvious complications, whereas several MLS-treated patients had suffered different complications. Conclusion: The therapeutic effects of both TVFP and MLS on the treatment of broad-based sessile vocal cord polyps are related to their clinical characteristics and histological types. Satisfactory outcomes are achieved in edematous, gelatinous, and vascular types of polyps after either surgical procedure. TVFP has fewer surgical complications than MLS which can be a preferred option for the treatment of broad-based sessile vocal cord polys at outpatient setting. TVFP also can be an alternative surgery option for patients who could not tolerate general anesthesia or laryngeal suspension. In contrast, MLS has proven to be particularly advantageous in patients who have fibrous type of polyps.

Background: Intra and post-operative blood loss is a major risk in head and neck (H&N) surgery. Recently the use of tranexamic acid (TXA) has been investigated by multiple studies for reducing intra and post-operative bleeding, however reported results are variable. Objectives: To determine the safety and efficacy of tranexamic acid use in Head and Neck surgery. Methods: Systematic review of MEDLINE, EMBASE, CINAHL, Cochrane Library, PubMed, ClinicalKey and Clinicaltrials.gov according to the PRISMA guidelines. Studies were included if they reported on intraoperative bleeding, volume or duration of post-operative drain or return to theatre rate for post-operative haemorrhage in adult populations following use of TXA. Risk of bias assessment with Cochrane Risk of Bias (RoB2) tool for RCTs and NOS tool for non-randomised studies. Results: 16 studies were identified (114, 407 patients). 8 studies evaluated TXA in major H&N surgery and 8 studies in tonsillectomy. Primary outcomes were reduction in intraoperative or post-operative bleeding. Secondary outcomes included the duration of post-operative drain placement and return to theatre rate. No adverse events were reported in any patients. TXA is effective in reducing intra-operative blood loss in tonsillectomy. However, the effect on post-tonsillectomy haemorrhage was unclear. Insufficient evidence exists of benefit of TXA on intra-operative bleeding in major H&N procedures. Post-operative bleeding rates were substantially reduced in most major H&N studies. The duration of drain placement and risk of blood transfusion was unchanged in most cases. Conclusion: TXA use is safe in H&N patients. Whilst sufficient evidence exists to support the use of TXA in tonsillectomy, insufficient evidence exists to recommend use in major H&N surgery. Key words: Tranexamic acid, Head and Neck surgery, thyroidectomy, tonsillectomy

Objective: To investigate post-intubation laryngeal complications in severe COVID-19 patients. Methods: From September 2020 to April 2021, consecutive patients presenting with laryngological symptoms following severe COVID-19 infection and related intubation were included. Demographic, age, gender, comorbidities, symptoms, intubation duration, tracheostomy features, and laryngeal findings were collected. Videolaryngostroboscopy findings were analyzed by two senior laryngologists in a blind manner. Results: Forty-three patients completed the evaluations. The intubation duration was <14 days in 22 patients (group 1) and >14 days in 21 patients (group 2). The following abnormalities were found on an average post-intubation time of 51.6 days: posterior glottic stenosis (N=14), posterior commissure hypertrophy (N=19) or laryngeal diffuse edema (N=10), granuloma (N=8), laryngeal necrosis (N=2), vocal fold atrophy (N=2), subglottic stenosis (N=1) and glottic flange (N=1). Sixteen patients required surgical treatment (N=17 procedures). The number of intubation days was significantly higher in patients with posterior glottic stenosis (26.1 ± 9.4) compared with those presenting posterior commissure hypertrophy (11.5 ± 2.9) or granuloma (15.1 ± 5.8; p<0.001). Fourteen patients required surgical management. Conclusion: Prolonged intubation used in severe COVID-19 patients is associated with significant laryngeal disorders. Patients with a history of >2-week intubation have a higher risk of posterior glottic stenosis.

Key Points: ● The Facial Clinimetric Evaluation (FaCE) scale, consisting of six subscales, measures facial palsy-specific quality of life. ● Each subscale’s weight in the total FaCE score is based on the number of questions but may not reflect the subscale’s true contributions to ‘overall’ facial-palsy specific quality of life. ● In 80 patients, we analyzed the subscales’ correlations with a validated Visual Analogue Scale (VAS) score that quantifies overall facial palsy-related burden. ● Social function and facial comfort had stronger correlations with overall facial palsy-related quality of life than their weights in the FaCE total score suggests. ● Greater importance should be placed on social function and facial comfort when estimating the quality of life of patients with facial palsy.

Key PointsPrevious studies have linked recurrent or persistent BPPV to age, anxiety or/and depression and medical comorbidityFactors such as the socioeconomical status have not been assessed.In our retrospective powered cohort we showed that there is a positive correlation between recurrent or persistent BPPV and ageWe found no correlation with the presence of underlying anxiety/depression and recurrent or persistent BPPV and age.While one would have expected that the socioeconomical and educational status would have had an impact on recurrent/persistent BPPV, using the Scottish Index of Multiple Deprivation, we did not identify such link.

Objectives The aim of this study was to assess the efficacy of a new emergency department intervention for the management of epistaxis, aiming to reduce epistaxis admissions. Design Tranexamic acid (TXA) (500mg/ml) soaked NasoPore® packing was in the pathway for epistaxis which did not terminate following 10 minutes of simple first aid. The pathway was utilised for adult patients presenting with non-traumatic, anterior epistaxis. Pre- and post-implementation admission rates and re-attendance rates were recorded by retrospective audit at a large central London hospital. Results Epistaxis admissions were reduced by 51.7% (p<0.05) following the implementation of the TXA-soaked NasoPore® pathway. Conclusions The significant reduction in epistaxis admissions demonstrates that this intervention is beneficial for patient outcomes. This has the potential to be introduced in other A&E departments and also pre-hospital settings.

Objectives: To investigate the prevalence and risks factors associated with electrode migration in cochlear implant (CI) recipients. Design: Retrospective cohort study of all CIs performed between 1 January 2018-1 August 2021 in a single tertiary adult and paediatric cochlear implant centre in the UK. Main outcome measures: The primary aim is to determine the prevalence of electrode migration, based on comparing intraoperative surgeon report and results of a routine plain X-ray performed 2 weeks after surgery. Electrode migration is defined as the detection of movement of 2 or more electrodes out of the cochlea from time of surgery. Multivariate analysis was performed to investigate risk factors including preoperative factors and intraoperative factors that might predispose to migration. Results: 465 patients, having 516 distinct surgery sessions, with 628 implants were analyzed. Electrode migration occurred in 11.5% of all implants. Pre-existing cochlear abnormality was an independent associated risk factor for electrode migration (OR:3.40<1.20-9.62> p=0.021). Demographics, surgical technique, usage of a precurved electrode, CSF leak, surgeon seniority and intraoperative telemetry did not influence risk of migration. There were 5 implants which migrated later than 2 weeks, median: 263days, for which head injury was a common precipitating factor. There was some difference between different lateral wall electrodes Conclusion: Electrode migration in the early postoperative period is a common occurrence and is more likely in implant recipients with obstructed or malformed cochleae. Keywords : Cochlear implants, Electrode migration, Risk factors, Cochlear abnormalities, Postoperative X-ray

Objective: To investigate the association between laryngopharyngeal reflux (LPR), gastroesophageal reflux disease (GERD) and recalcitrant chronic rhinosinusitis (CRS). Data sources: PubMed, Cochrane Library, and Scopus. Review methods: Three investigators search database for studies investigating the relationship between LPR, GERD and recalcitrant CRS with or without polyposis. The following outcomes were investigated with PRISMA criteria: age; gender; reflux and CRS diagnosis; association outcomes and potential treatment outcomes. Authors performed a bias analysis of papers and provided recommendations for future studies. Results: A total of 17 studies investigated the association between reflux and recalcitrant CRS. According to pharyngeal pH monitoring, 54% of patients with recalcitrant CRS reported hypo or nasopharyngeal acid reflux events. The numbers of hypo- and nasopharyngeal acid reflux events were significantly higher in patients compared to healthy individuals in 4 and 2 studies, respectively. Only one report did not find group differences. The proportion of GERD was significantly higher in CRS patients compared to controls, with a prevalence ranging from 32% to 91% of cases. No author considered nonacid reflux events. There was an important heterogeneity in the inclusion criteria; definition of reflux and association outcomes, limiting the draw of clear conclusion. Pepsin was found in sinonasal secretions more frequently in CRS patients than controls. Conclusion: Laryngopharyngeal reflux and GERD may be a contributing factors of CRS therapeutic resistance, but future studies are still needed to confirm the association considering nonacid reflux event.