The otology clinic contains patients whose symptoms may not be explained by standard inflammatory or mechanical pathologies, and the term ‘functional’ brings us into the interface between neurology, psychology, psychiatry and ENT. Assessment can be far from straightforward. This issue's paper of the month,^{Reference Scholfield, Chandrasekharan, Bahra, Williams and Patel1} by a team from Whipps Cross (London) and Anglia Ruskin (Cambridge), considers the matter in some detail, proposing a helpful model to assist the clinician in assessing this tricky group of patients. Reassuring a patient with the message that ‘the tests are normal with no need to worry’ is inadequate on its own, and this paper can help us offer the patient more. The interface between psychiatry and tinnitus patients was considered in an article published in The Journal of Laryngology & Otology some years ago,^{Reference Pinto, Marcelos, Mezzasalma, Osterne, de Melo Tavares de Lima and Nardi2} and the insights in this month's paper has relevance to other functional symptoms in ENT, as may be seen also in the rhinology and laryngology clinic. This was reviewed very well by the Nottingham team back in 2013, which covered the specialty-wide topic of ‘medically unexplained symptoms’.^{Reference Ullas, McClelland and Jones3}

Benign paroxysmal positional vertigo (BPPV) and its clinical subtypes have been a regular feature of The Journal,^{Reference Ichijo4} and comprise a significant proportion of the clinical caseload in balance clinics,^{Reference Kim, Jeong and Shin5} with the condition often initially misdiagnosed. This issue has a paper from several centres in the USA, which assesses clinical practice guidelines for BPPV,^{Reference Pandya, Suresh, Shah, Romeo, Ravin and Barrette6} and emphasises the potential for such guidelines in improving speed of diagnosis and evidence-based treatment outcomes for this common condition. The authors find that some of the current guidelines are disappointing, failing to achieve what could be expected or hoped for from such guidelines, but the American Academy of Otolaryngology – Head and Neck Surgery guidelines perform better in meeting their criteria in the various domains.

The problem of the arytenoid (vocal process) granuloma has taxed laryngologists for generations, with a paper from St Clair Thomson appearing in The Journal over a century ago^{Reference Thomson7} and Pat Bradley from Nottingham reviewing the history of the topic in 1997.^{Reference Bradley8} This issue has two papers, one from Yiwu (China), which prospectively looks at the relevance of granuloma location to its response to proton pump inhibitors (PPIs),^{Reference Ding and Lou9} and one from Pune (India), which retrospectively describes a single institution's experience of a large case series.^{Reference Gandhi, Ganesuni, Shenoy, Bhatta and Ghanpur10} The former paper finds that granulomas that are on the cord or adjacent to the vocal process do well with vocal hygiene and PPIs, but those on the surface of the vocal process and body of the arytenoid do badly, even if PPI use is continued for long periods. The latter paper reports that two-thirds of cases respond to medication, and discusses adjuvant treatments when cases proceed to surgery.

Recent years have seen more education-related papers submitted to The Journal. This is a welcome addition to more disease-focused material in light of the revolution in approaches to training since the Calman reforms and working hours reductions, with topics including: shortening of training hours, simulation training, introduction of information technology, deleterious effects of the coronavirus disease 2019 pandemic^{Reference Kapoor, Ramavat, Mehndiratta, Agrawal, Arora and Goel11} and the need for training models that are different from the traditional apprenticeship model. This issue has a paper from the North of England (ENT North Collaborative), which looks at the competencies and skills that can be expected for specialist registrars who are beginning their registrar training (specialty trainee year three, known as ‘ST3’). Expectations of these young trainees can easily be too low as well as too high, so some consensus is needed. This study found a high degree of consensus on what could be expected from a junior registrar, with consultants and trainees agreeing on the skills needed,^{Reference Rocke, Heward and Stapleton12} so this can hopefully be put into practice. The study used a ‘Delphi’ technique, which has been used previously in ENT training matters^{Reference Powell, El Dean, Carrie, Wilson and Paleri13} and, although it has limitations, deserves wider use.