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/

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.

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.

Surgical Management of Broad-basedSessileVocal Cord Polyps: Transnasal Vocal Fold Polypectomy Versus Microlaryngoscopic Surgery- Our Experience in 159 CasesRunning title: Surgical Management of Broad-based Sessile Vocal Cord 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.

Objective: The causative virus of COVID-19 is SARS-CoV-2. The aim of the present study was to invastigate the in vivo virucidal activity of nasal irrigation with saline, nasal irrigation with Povidone-iodine (PVP-I) 1%, nasal irrigation with hypertonic alkaline and nasal irrigation with PVP-I 1% against SARS CoV- 2. Design: The present study was a prospective randomized clinical trial. Setting: A multicenter study involving tertiary care centers. Participants: The study included adult outpatients whose qualitative SARS-CoV-2 RT-PCR tests in nasopharyngeal swabs were positive. One hundred twenty patients divided into four equal groups. Standard COVID-19 treatment was given to group 1 (n=30), nasal irrigation containing isotonic solution was added to patients’ treatment in group 2 (n=30), nasal irrigation containing 1% PVP solution was added to patients’ treatment in group 3(n=30), and nasal irrigation containing 1% PVP solution and nasal irrigation containing hypertonic alkaline solution was added to patients’ treatment in group 4 (n=30). Main outcome measures: On the first day of diagnosis (day 0), nasopharyngeal swab samples were taken, on the 3rd and 5th days the nasopharyngeal viral load reduction in quantitative RT-PCR tests were calculated. Results: Between the 0-3rd Day and 0-5th days, the nasopharyngeal viral load reduction was significant in all groups (p< .05). In paired comparisons of groups, the nasopharyngeal viral load decrease in group 4 in first 3 days was significantly lower than all groups (p < .05). The nasopharyngeal viral load degrease in groups 3 and 4 in the first 5 days were significantly lower than group 1 (p < .05). Conclussion: This study was reveal that the use of hypertonic alkaline nasal irrigation together with 1% povidone-iodine was more effective in reducing viral load in the early period. The decreased nasopharyngeal viral load may reduce the carriage of infectious SARS-CoV-2 in patients. Our results suggest that 1% povidone-iodine and hypertonic alkaline nasal irrigation may be promising modality to prevent the COVID-19 epidemic.

• Non-functional larynx (NFL) was found to affect 30.9 % of patients with locally advanced laryngeal cancer who underwent curative non-surgical laryngeal preservation treatment for stage III/IV disease • The key measures of NFL were long-term gastrostomy and tracheostomy dependence, functional laryngectomy and chronic aspiration. • Multivariate analyses identified current smoking to be associated with 6.8-fold increase in NFL • Patients with pre-treatment hemi-laryngeal fixation were 3.4 times more likely to experience locoregional recurrence.

Background: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for many ENT operations including endoscopic sinus surgery (ESS). We aimed to investigate the safety of ESS in England. Methods: This was an observational, secondary analysis of administrative data. Participants were all patients in England undergoing elective ESS procedure aged ≥ 17 years during for the five years from 1st April 2014 to 31st March 2019. The exposure variable was day-case or overnight stay. The primary outcome was emergency readmission within 30 days post-discharge. Results: Data were available for 49,223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 100% to 20.6%. Rates of day-case surgery increased from 64.0% in 2014/15 to 78.7% in 2018/19. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). For secondary outcomes measures, there was no evidence of poorer outcomes for day-case patients. Outcomes for patients operated on in trusts with ≥80% day-case rates compared to patients operated on in trusts with <50% rates of day-case surgery were similar. Conclusions: ESS can safely be performed as day-case surgery at current rates. There is a potential to increase rates of day-case ESS in England, especially in departments that currently have low rates of day-case ESS.

Abstract Objective: To determine whether Betahistine dihydrochloride is effective in treating primary tinnitus in adults. Design: Intention-to-treat, randomized, triple-blinding, monocentric clinical trial Setting: Botucatu Medical School – State University of São Paulo (Unesp) in Brazil. Participants: 62 adults with primary tinnitus for at least six months (both sexes), and a Tinnitus Handicap Inventory score above 18 were randomized in two equal study groups: betahistine (24 mg of oral betahistine 12/12hs for 90 days), control group (a matched placebo). Main outcomes measures: Primary outcome measure - change in Tinnitus Handicap Inventory score; secondary outcome - Clinical Global Impression Improvement and participants’ perceived improvement after the intervention. Results: Participants had a median age (interquartile range) of 54 (48 to 60) years, with a balanced number of men and women. There was no significant difference in Tinnitus Handicap Inventory change before and after treatment between the study group and control (median difference of -2 points; 95% CI, -8 to 6 points); the Tinnitus Handicap Inventory after intervention was a median (interquartile range) of 4 (-4 to 14) lower in the betahistine group, and a median (interquartile range) of 2 (-6 to 10) lower in the placebo group. The secondary endpoint, covariate adjustment, and per-protocol analysis provided similar results, and side effects were without difference between both groups. Conclusion: Betahistine was ineffective when compared to the placebo in the treatment of the primary tinnitus .

Objectives To summarise current practices in the diagnosis and management of Deep Neck Space Infections (DNSIs) To inform future studies in developing a framework in the management of DNSIs Design This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with 2 independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach. Setting Secondary or Tertiary Care centres that undertook management of Deep Neck Space Infections. Participants All adult patients with a deep neck space infection. Main outcome measures The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs. Results 60 studies were reviewed. 31 studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single RCT all other studies were observational (n=25) or case series (n=36). CT was used to diagnose DNSI in 78% of patients, Mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration. Qualitative analysis identified 7 major themes were identified on DNSI. Conclusion There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

Title: A prospective study comparing Itraconazole and systemic steroids as an adjunct to topical steroids in the post-operative management of Allergic fungal rhinosinusitis ABSTRACT Objectives The objective of this study was to compare the efficacy of Itraconazole and systemic steroids as an adjuvant to topical steroids in post-operative patients with Allergic Fungal Rhinosinusitis (AFRS) using both subjective and objective outcome measurements. Methods A prospective comparative study was conducted in a tertiary care center on 60 patients diagnosed with AFRS. Patients with chronic systemic illness and those undergoing revision surgery were excluded. Post-operative patients were divided into two groups of 30 each which received Itraconazole 400 mg OD or Methylprednisolone in tapering doses over six weeks. The outcomes were measured at the end of 6 weeks -Kupferberg endoscopic staging, Absolute Eosinophilic Count (AEC), Serum Immunoglobulin (IgE), and Sino Nasal Outcome Test - 20 scores. Results Our study showed no statistical significance in outcomes between the two groups treated with Itraconazole and Methylprednisolone regarding recurrence, AEC, IgE, and Quality of Life Assessment (p<0.01). Conclusion Itraconazole was comparable to Methylprednisolone in preventing disease recurrence in the post-operative management of AFRS. It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. Itraconazole given at a dose of 400 mg once daily for six weeks was a safe dose. Keywords: Allergic Fungal Rhinosinusitis, Itraconazole, endoscopy, Quality of Life, Methylprednisolone Key points: • Itraconazole was comparable to systemic steroid (Methylprednisolone) in preventing disease recurrence in the post-operative management of AFRS. • It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. • Itraconazole given at a dose of 400 mg once daily for six weeks was a safe dose. • Recurrence may be treated safely with Itraconazole than with steroids. • The course may be repeated in case of recurrence with close monitoring.