ChatGPT performance in laryngology and head and neck surgery: a clinical case-series

Abstract

Objectives

To study the performance of ChatGPT in the management of laryngology and head and neck (LHN) cases.

Methods

History and clinical examination of patients consulting at the Otolaryngology-Head and Neck Surgery department were presented to ChatGPT, which was interrogated for differential diagnosis, management, and treatment. The ChatGPT performance was assessed by two blinded board-certified otolaryngologists using the following items of a composite score and the Ottawa Clinic Assessment Tool: differential diagnosis; additional examination; and treatment options. The complexity of clinical cases was evaluated with the Amsterdam Clinical Challenge Scale test.

Results

Forty clinical cases were submitted to ChatGPT, accounting for 14 (35%), 12 (30%), and 14 (35%) easy, moderate and difficult cases, respectively. ChatGPT indicated a significant higher number of additional examinations compared to practitioners (p = 0.001). There was a significant agreement between practitioners and ChatGPT for the indication of some common examinations (audiometry, ultrasonography, biopsy, gastrointestinal endoscopy or videofluoroscopy). ChatGPT never indicated some important additional examinations (PET–CT, voice quality assessment, or impedance-pH monitoring). ChatGPT reported highest performance in the proposition of the primary (90%) or the most plausible differential diagnoses (65%), and the therapeutic options (60–68%). The ChatGPT performance in the indication of additional examinations was lowest.

Conclusions

ChatGPT is a promising adjunctive tool in LHN practice, providing extensive documentation about disease-related additional examinations, differential diagnoses, and treatments. The ChatGPT is more efficient in diagnosis and treatment, rather than in the selection of the most adequate additional examination.

Appendices

Appendix 1: Clinical case features and ChatGPT results

N	G	Age	Symptoms	History/medication	Clinical examination	Otolaryngologist consultation findings
						Additional examinations	Diagnosis	Treatment
37	F	30	Recurrent throat pain fever and lymphadenopathy chronic dysphagia (5 years)	Tonsil abcess (2 times) treated with antibiotics	Grade III tonsils	–	Recurrent tonsil infections	Tonsillectomy
7	F	24	Globus, throat clearing, abdominal pain, postnasal drip/sticky mucus (2 years)	None	Tongue tonsil hypertrophy, laryngo-pharyngeal inflammation	HEMII-pH testing Negative allergy test	LPR	Diet, stress reduction, PPI/alginate
8	F	40	Dysphonia, globus, throat pain (6 months)	Suspected LPR	Vocal fold erythema laryngeal inflammation	Voice quality assessment	Suspected LPR	Diet, stress reduction, PPI/alginate
9	F	53	Dysphonia, dysphagia, throat clearing, throat mucus (> 1 year)	Ehlers Danlos	Coated/tongue, tonsil hypertrophy, laryngo-pharyngeal inflammation	Voice quality assessment	Suspected LPR	Diet, stress reduction, PPI/alginate
21	M	56	Right neck mass, weight loss (10 kg) dysphagia (6 months)	Alcohol/tobacco overuses (30 years)	Right piriform sinus exophytic mass	Neck CT, PetCT, biopsy, biology and nutrition check-up	Hypopharyngeal primary carcinoma	Oncological board discussion
23	F	32	Dysphonia post-thyroidectomy (1 month)	Thyroidectomy for goiter	Right vocal cord paralysis	Voice quality assessment	Vocal cord paralysis	Medialization, speech therapy
3	M	22	Left hearing loss, tinnitus, throat clearing, globus, cough (6 months)	Recurrent LPR recurrent otitis media	Bilateral ear retraction pocket, laryngo-pharyngeal inflammation	Audiometry, Tympanometry, naso-pharyngeal pH testing	Chronic otitis media, recurrent suspected LPR	Nasal saline irrigation, corticoids, diet, stress reduction, PPI/alginate
17	F	53	Chronic hoarseness, throat clearing, globus, sticky mucus (> 4 years)	Tobacco overuse (30 PY)	Bilateral Reinke edema (grade III), laryngo-pharyngeal inflammation	Voice quality assessment	Reinke edema	Stop tobacco, in-office laser surgery, speech therapy
5	M	39	Recurrent throat clearing, postnasal drip, sticky mucus (> 3 years)	Nasopharyngeal reflux (Restech)	Mulberry turbinate, and hypertrophy laryngeal inflammation	Normal sinus CT Nasopharyngeal Reflux	Recurrent/chronic LPR	Drug change: magaldrate to alginate, continue diet and stress reduction
1	F	33	Left cervical painful mass (3 months)	Asthma	Submandibular mass	Neck US, MRI and biology	Salivary lithiasis	NSAID, pilocarpin, sialadenoscopy
10	F	24	Dysphonia, dysphagia, throat sticky mucus (> 12 months)	Tonsillectomy vocal cord nodules	Vocal cord nodules, laryngopharyngeal inflammation	Voice quality assessment	Vocal cord nodules suspected chronic LPR	Diet, stress reduction, PPI/alginate, Speech therapy
20	F	32	Sudden dysphonia after crying (1 weeks)	Voice professional	Right vocal cord hemorrhage	Voice quality assessment	Vocal cord hemorrhage	In-office laser cauterization
14	M	53	Dysphonia, cough, sticky mucus, throat clearing (24 months)	Septoplasty, Nonacid naso-pharyngeal reflux	Postnasal drip Laryngopharyngeal inflammation	Nasopharyngeal pH testing: nonacid nasopharyngeal reflux	LPR	Diet, stress reduction, alginate only
2	M	65	Hearing loss throat clearing, globus (6 months)	External ear stenosis, GERD	Bilateral total EED stenosis, laryngeal inflammation	Audiometry (bone) ear CT	Bilateral EED stenosisn acute suspected LPR	Canaloplasty diet, stress reduction, PPI/alginate
12	F	54	Dysphagia, globus, heartburn tinnitus (> 15 months)	Breast cancer, COPD, hypo-thyroidism	Inferior turbinate hypertrophy, laryngo-pharyngeal inflammation	Voice quality assessment, audiometry, tympanometry	Eustachian tube dysfunction, suspected LPR	Diet, stress reduction, PPI/alginate
13	M	67	Cough, throat pain, postnasal drip, globus (7 months)	Nonacid LPR (HEMII-pH)	Coated tongue, tonsil erythema, laryngeal inflammation	HEMII-pH: nonacid LPR	LPR	Diet, stress reduction, alginate only
15	F	62	Dry mouth, sticky mucus, cough, globus follow-up (> 6 months)	Recurrent suspected LPR aspecific laryngitis	Sticky mucus, tongue tonsil edema laryngeal inflammation	Biology: positive for chlamydia pneumonia	Resistant LPR to PPI, infectious laryngitis	Diet, stress reduction, alginate, antibiotics (clarithromycin)
16	M	27	Globus, dysphonia, sticky mucus, left nasal obstruction, halitosis (> 19 months)	Hearth insufficiency ineffective PPI-therapy	Left septal deviation laryngopharyngeal inflammation	Normal sinus CT nonacid naso-pharyngeal reflux	Recurrent/chronic nonacid LPR	Diet, stress reduction, alginate only
18	M	51	Dysphonia, suspicion of vocal fold paralysis, globus, throat clearing (6 months)	Crohn, COVID-19 suspected LPR	Left vocal fold polyp laryngopharyngeal inflammation	Voice quality assessment	Left vocal fold polyp suspected LPR	In-office laser polyp surgery, speech therapy, diet/stress, alginate
24	M	56	Recurrent laryngeal cancer after primary chemoradiation (cT3 carcinoma)	Alcohol/tobacco overuses	Persistent carcinoma 5 months after the treatment	PetCT and biopsy: resistant carcinoma	Laryngeal carcinoma resistant to chemoradiation	Salvage laryngectomy
11	F	65	Hypoacusis, dysphonia, dysphagia, sticky mucus (> 9 months)	Recurrent chronic otitis media	Adenoid hypertrophy, chronic otitis media, laryngeal inflammation	Audiometry, Tympanometry, voice quality assessment	Chronic otitis media, LPR, Eustachian tube dysfunction	Diet, stress reduction, PPI/alginate, nasal saline irrigation and corticoids
30	M	70	Bilateral odynophagia, otalgia (6 months)	None	Bilateral stylo-hyoid calcified ligaments	Neck CT scan	Eagle syndrome	Transoral robotic styloidectomy
27	F	50	Chronic cough, negative pH testing, normal pulmonary examinations	None	Laryngopharyngeal hypersensitivity	HEMII-pH testing: negative	Laryngeal hypersensitivity	Amitryptilin, GABA pentin, or superior laryngeal nerve infiltration
6	M	75	Nasal congestion, heartburn, dysphonia (> 12 months)	Nasopharyngeal reflux, (Restech)	Laryngopharyngeal hypersensitivity and inflammation	Normal sinus CT Nasopharyngeal reflux	Nasopharyngeal reflux	Diet, stress reduction, PPI/alginate, nasal saline irrigation and corticoids
39	F	38	Dysphonia, dysphagia, cough, globus, sticky mucus (4 years)	Thyroidectomy diabetes, arthrosis	Normal vocal cord mobility, laryngeal inflammation	HEMII-pH testing voice quality assessment	Suspected LPR	Diet, stress reduction, PPI/alginate
4	F	71	Sudden smell loss, globus, dry eyes, sticky mucus, throat clearing (7 months)	COVID-19	Dry eyes, coated tongue, Laryngopharyngeal inflammation	Psychophysical evaluations	Postviral OD suspected LPR	Olfactory cleft PRP injection, diet, stress reduction, PPI/alginate
25	F	66	cT3 supraglottic cancer, weight loss (6 kg), dysphagia	Radiotherapy for supraglottic cancer	Epiglottis carcinoma	Neck CT, PetCT Biopsy: carcinoma	Second supraglottis carcinoma	Salvage surgery
				(10 years), hypertension
26	F	49	Aspirations, cough, globus, throat, sticky mucus (9 months)	None	Coated tongue, normal FEES, laryngeal inflammation	Videofluoroscopy	Suspected LPR	Diet, stress reduction, PPI/alginate
40	F	45	Singer with difficulty to reach high-pitch sounds (6 months)	Thyroidectomy (12 months), hip prosthesis (2 years)	Normal vocal cord mobility, hyposensitivity right tongue base	Voice quality assessment	Superior laryngeal nerve injury during surgery	Speech therapy
19	F	61	Right parotid tumor, progressive growth (6 months)	Gastritis HIV, pacemaker	Right parotid mass	Neck MRI and CT cytology (US)	Parotid lympho-epithelial cyst	Imaging and cytology
22	F	36	20 kg loss after a diet, dysphonia, voice fatigue (3 months)	None	Glottal insufficiency	Voice quality assessment	Glottis insufficiency	Speech therapy, vocal cord augmentation
28	F	36	Dysphonia, voice fatigue (6 months)	Asthma, inhaled corticosteroids (9 months)	Vocal fold dryness, sticky mucus	Voice quality assessment	Laryngitis post-inhaled corticosteroids	Stop inhaled corticoids/change drugs
29	M	66	Bilateral vocal cord paralysis post-thyroidectomy, tracheotomy, Wish for decannulation	Thyroid cancer Thyroidectomy Tracheotomy	Bilateral vocal cord paralysis in adduction	Neck CT scan	Bilateral vocal cord paralysis	Bilateral CO2 anterior crico-arytenoidectomy
33	M	40	Progressive dyspnea when playing trumpet, neck mass, dysphagia (9 months)	None	Left laryngeal ventricle hypertrophy, left neck mass	Neck CT	Laryngocele	Surgery
34	M	70	Dysphagia, globus, throat pain (1 year)	Cervical arthro-desis (1 year), diabetes, hypertension	FEES: normal	Videofluoroscopy neck CT	Arthrodesis-related dysphagia (iatrogenic)	Speech therapy (swallowing)
38	M	20	Left tonsil ulceration (3 months)	Oral sexual practice	Left tonsil ulceration	Biology (sexual diseases), biopsy and culture	Syphilis	Antibiotics
35	F	36	Dysphonia, throat pain voice professional (12 months)	Vocal cord nodule surgery (12 mo)	Lack of vibration of vocal cord	Voice quality assessment	Vocal fold scars	Speech therapy, resection of scars, PRP injection
36	F	41	Sudden dysphonia (12 months)	Diabetes, burnout	Normal cough, aphonia, NFN	Voice quality assessment	Psychogenic dysphonia	Speech therapy, psychotherapy
31	F	66	Recurrent dysphagia, globus, weight loss, telangiectasia (3 years)	Resistant LPR to PPI, alginate, magaldrate	Telangiectasia (fingers), laryngeal inflammation	Manometry, GI, biology (immun), biopsy	CREST syndrome esophageal scleroderma	Vasodilators, immunosuppressant
32	F	34	Dysphonia, arthralgia, voice professional (> 12 months)	None	Orange nodules on vocal cord	Voice quality assessment, biology (autoimmun), biopsy	Bamboo nodes rheumatoid polyarthritis	Corticoids, speech therapy

1. The additional examinations in italics consisted of results of examination at the consultation time
2. COPD chronic obstructive pulmonary disease, COVID-19 coronavirus disease 2019, CRS(w)NP chronic rhinosinusitis (without) nasal polyposis, CT computed tomography, EMG electromyography, FEES fiberoptic endoscopic evaluation of swallowing, FESS functional endoscopic sinus surgery, EED external ear duct, ETD Eustachian tube dysfunction, GERD gastroesophageal reflux disease, GI gastrointestinal endoscopy, LPRD laryngopharyngeal reflux disease, MRI magnetic resonance imaging, NFN normal nasofibroscopy, NSAID non-steroidal anti-inflammatory drug, OD olfactory dysfunction, OSAS obstructive sleep apnea syndrome, PPI proton pump inhibitors, PRP platelet-rich plasma, PY pack/year, US ultrasonography

Appendix 2: ChatGPT findings regarding clinical cases

N	Otolaeryngologist	ChatGPT
	Diagnosis	Additional examination	Differential diagnosis	Treatment regarding the clinical presentation
37	Recurrent tonsil infections	Throat culture, Neck CT or MRI, PSG	Chronic tonsillitis, tonsillar hypertrophy, tonsilloliths	Antibiotics, tonsillectomy
7	LPR	Sinus CT, sinus X-ray, biology (CRP)	Acute sinusitis, GERD, upper aerodigestive tract infection, COPD, viral bronchitis	PPI and H2 blockers diet and stress management
8	Suspected LPR	Sinus CT, X-ray, biology (CRP)	Acute sinusitis, GERD, laryngopharyngeal infection, COPD, viral bronchitis	PPI and H2 blockers diet and stress management
9	Suspected LPR	Neck CT, prick test, genetics for Ehlers Danlos swallowing study, GI	LPR, chronic pharyngitis, vocal cord dysfunction, eosinophilic esophagitis, oral candidosis, tongue tonsillitis	Speech therapy, PPI and H2 blockers diet and stress management
21	Hypopharyngeal primary carcinoma	Biopsy, neck CT or MRI	Laryngeal or pharyngeal carcinoma, metastasis, benign mass, granulomatosis, pseudotumor	Biopsy, neck CT or MRI
23	Vocal cord paralysis	EMG, Neck CT and MRI	Recurrent laryngeal nerve injury	Speech therapy, medialization, thyroplasty, reinnervation
3	Chronic otitis media, recurrent suspected LPR	Audiometry, Tympanometry pH metry, GI, throat bacteriology	Chronic otitis media (effusion/suppurative), cholesteatoma, tympanosclerosis	Nasal corticoids or transtympanic tube, allergy checkup
17	Reinke edema	Vocal cord biopsy, stroboscopy, lung testing (spirometry)	Reinke edema, vocal cord dysfunction, vocal cord polyps, bilateral vocal cord nodules	Vocal hygiene, speech therapy, smoking cessation, surgery
5	Recurrent/chronic LPR	pH metry, GI, neck CT, sinus/throat cultures	GERD, unspecified CRS, allergic rhinitis, LPR, Chronic tonsilitis	PPI and H2 blockers diet and stress management
1	Salivary lithiasis	Neck US, MRI, BIOLOGY, Prick skin tests	Adenitis, abcess, adenopathy, parotidis, thyroiditis	Hot compress, pilocarpin, Surgery
10	Vocal cord nodules Suspected chronic LPR	Neck CT, voice quality assessment, allergy testing	Vocal cord nodules, vocal cord polyps, GERD, LPR, chronic laryngitis	Corticoids, voice rest, PPI and H2 blockers diet and stress management
20	Vocal cord hemorrhage	None	Vocal cord hemorrhage	Voice rest, anti-inflammatory drugs, vocal cord abuse reduction
14	LPR	Neck CT, throat cultures, allergy tests	Acute laryngitis, chronic laryngitis, GERD, COPD, vocal cord nodules	PPI and H2 blockers diet and stress management
2	Bilateral EED stenosis, acute suspected LPR	Ear CT pH metry, GI, throat bacteriology	EED stenosis, Chronic otitis media, Presbycusis, ETD, GERD, CRS, allergic rhinitis, LPR, chronic tonsilitis	Canaloplasty, balloon dilatation, saline irrigation, skin flap, PPIs, H2 blockers, diet/stress management
12	Eustachian tube dysfunction, suspected LPR	Neck CT, thyroid function tests	LPR, unspecified CRS, hypothyroidism, bronchitis, cancer-related symptoms (unspecified?)	PPI and H2 blockers, diet and stress management, nasal decongestants, antibiotics and corticoids
13	LPR	Neck CT, throat swab, allergy testing	Chronic tonsilitis, chronic pharyngitis, GERD, LPR	PPI and H2 blockers diet and stress management
15	Resistant LPR to PPI, infectious laryngitis	Neck CT, salivary gland function test, Allergy, polysomnography	CRSwNP, chronic tonsilitis, GERD, OSAS, Sjögren syndrome	PPI and H2 blockers, stress reduction, diet, antibiotics
16	Recurrent/chronic nonacid LPR	Esophageal manometry, pH Metry, allergy	LPR, GERD, CRSwNP, chronic tonsilitis, postnasal drip	PPI and H2 blockers, stress reduction, diet, nasal saline irrigation and corticosteroids
18	Left vocal fold polyp suspected LPR	Neck CT laryngeal biopsy	LPR, CRSwNP, allergic rhinitis, vocal fold polyp, vocal fold nodules	Polypectomy/resection of mass, corticoids, speech therapy
24	Laryngeal carcinoma resistant to chemoradiation	Neck CT or MRI, oncological board assessment	Persistent carcinoma	Salvage surgery, immunotherapy, clinical trials, palliative
11	Chronic otitis media, LPR, Eustachian tube dysfunction	Throat swab culture, audiometry, swallowing study, GI	Laryngitis, chronic pharyngitis, otitis media, GERD,	Speech therapy, PPI and H2 blockers, diet and stress management, GERD-surgery
30	Eagle syndrome	Neck CT or MRI	Tonsilloliths, tonsillar hypertrophy, chronic pharyngitis, GERD	PPIs, H2 blockers, diet/stress management, saltwater gargles, good oral hygiene/hydration, tonsillectomy
27	Laryngeal hypersensitivity	pH testing, manometry, allergy, inhaled broncho-dilators, methacholine test	Cough variant asthma, GERD, LPR	PPIs, inhaled corticoids, speech therapy
6	Nasopharyngeal reflux	RAST (IgE), nasal cytology (eosinophiles), sinus CT	LPR, allergic rhinitis, CRSNP	Speech therapy PPI and H2 blockers
39	Suspected LPR	pH study, GI, allergy evaluation	LPR, chronic laryngitis, allergic rhinitis	PPIs, H2 blockers, diet/Stress management, speech therapy
4	Postviral OD suspected LPR	Psychophysical evaluations, sinus X-ray, neck CT, biology (B12 level, CRP)	Postviral OD, CRSNP, CRSwNP, neurodegenerative disease, autoimmun disease	PPIs, H2 blockers, diet/stress management
25	Second supraglottic carcinoma	Neck CT or MRI, biopsy	Supraglottic carcinoma	Radiation, chemotherapy or chemoradiotherapy, surgery, immunotherapy
26	Suspected LPR	pH testing, EMG	LPR, chronic laryngitis, laryngeal hypersensitivity, postnasal drip, chronic tonsilitis	Diet, stress reduction, mucolytics, nasal corticoids, antihistamine, PPIs, H2 blockers, laryngeal desensitization (breath)
40	Superior laryngeal nerve injury during surgery	EMG, Neck CT and MRI, neurological consultation	Superior laryngeal nerve dysfunction, hypoglossal dysfunction, vocal cord muscle atrophy	Speech therapy, nerve reconstruction
19	Parotid lympho-epithelial cyst	Neck US, CT, cytology, biology (CRP)	Peiomorphic or Whartin tumor, malignancy, lymph node, metastasis	Surgery
22	Glottis insufficiency	None	Muscle atrophy, vocal cord paresis, psychogenic dysphonia, vocal fold lesions	Biology (autoimmun diseases), speech therapy, psychological support
28	Laryngitis post-inhaled corticosteroids	Lung assessment	Vocal cord dysfunction, Reinke edema, vocal cord nodules, vocal cord polyps, muscle tension dysphonia	Continue asthma treatment
29	Bilateral vocal cord paralysis	–	Bilateral vocal cord paralysis (adduction) and permanent tracheotomy	Vocal cord lateralization, speech therapy, electrolarynx,
33	Laryngocele	Neck CT or MRI, biopsy	Laryngeal papillomatosis, laryngeal cancer, laryngocele, lymphadenopathy	Surgery, radiation, voice therapy
34	Arthrodesis-related dysphagia (iatrogenic)	Esophageal manometry, videofluoroscopy, endoscopic US, biopsy	Achalasia, esophageal stricture, esophageal spasm, esophageal cancer	Calcium channel blockers, nitrates, or botulinum toxin injections, esophageal dilatation, surgery or chemoradiation
38	Syphilis	Throat culture, Neck CT or MRI, biopsy	Bacterial or viral tonsillitis, tonsil abscess, HPV infection, cancer	Antibiotics, analgesics
35	Vocal fold scars	Neck CT or MRI, EMG	Vocal fold scar, granuloma, Reinke edema, vocal cord paresis,	Speech therapy, corticoids, surgery of the lesion
36	Psychogenic dysphonia	EMG and psychological evaluation	Functional dysphonia, muscle tension dysphonia, conversion disorder, vocal fold paresis or spasmodic dystonia	Speech therapy, psychotherapy, muscle relaxants
31	CREST syndrome scleroderma	GI, biology	Scleroderma, GERD	HE blockers, prokinetic, esophageal dilatation
32	Bamboo nodes rheumatoid arthritis	–	Reinke edema, vocal cord polyps	Speech therapy, vocal cord surgery (removal of lesion)

1. COPD chronic obstructive pulmonary disease, COVID-19 coronavirus disease 2019, CRS(w)NP chronic rhinosinusitis (without) nasal polyposis, CT computed tomography, EMG electromyography, FEES fiberoptic endoscopic evaluation of swallowing, FESS functional endoscopic sinus surgery, EED external ear duct, ETD Eustachian tube dysfunction, GERD gastroesophageal reflux disease, GI gastrointestinal endoscopy, LPRD laryngopharyngeal reflux disease, MRI magnetic resonance imaging, NFN normal nasofibroscopy, NSAID non-steroidal anti-inflammatory drug, OD olfactory dysfunction, OSAS obstructive sleep apnea syndrome, PPI proton pump inhibitors, PRP platelet-rich plasma, PY pack/year, US ultrasonography

Appendix 3: Main diagnoses

Primary diagnoses	Easy	Moderate	Difficult	Total
	ACCS 6–14	ACCS 15–23	ACCS 24–30
Laryngeal disorders
Chronic suspected or confirmed laryngopharyngeal reflux	6	7	1	14
Vocal fold polyp, hemorrhage, nodules or scarring	2	1	1	4
Acute suspected or confirmed laryngopharyngeal reflux	2	1	0	3
Recurrent suspected or confirmed laryngopharyngeal reflux	1	2	0	3
Unilateral or bilateral vocal cord paralysis	1	0	1	2
Bacterial laryngitis	0	1	0	1
Reinke edema	1	0	0	1
Bamboo nodes (vocal folds)	0	0	1	1
Glottis insufficiency	0	0	1	1
Laryngeal primary hypersensitivity	0	1	0	1
Iatrogenic laryngitis	0	0	1	1
Laryngocele	0	0	1	1
Iatrogenic laryngeal superior nerve injury	0	0	1	1
Psychogenic dysphonia	0	0	1	1
Swallowing disorders
Cervical arthrodesis inducing iatrogenic dysphagia	0	0	1	1
Eagle syndrome	0	1	0	1
Esophageal scleroderma (CREST syndrome)	0	0	1	1
Recurrent tonsil infection	1	0	0	1
Head and neck disorders
Salivary lymphoepithelial cyst	0	0	1	1
Salivary lithiasis	1	0	0	1
Hypopharyngeal primary carcinoma	1	0	0	1
Supraglottic laryngeal carcinoma (resistant to radiation)	0	1	0	1
Second laryngeal carcinoma	0	0	1	1
Pharyngeal syphilitic ulceration	0	0	1	1
Associated otological or rhinological conditions
Chronic otitis media	1	1	0	2
Eustachian tube dysfunction	0	2	0	2
Postviral olfactory dysfunction	0	1	0	1
Rheumatoid polyarthritis	0	0	1	1
Bilateral ear external duct stenosis	1	0	0	1

1. ACCS Amsterdam Clinical Challenge Scale test