Structural Equation Modelling Applications in Ear, Nose and Throat Diagnosis and Management: A Comprehensive Framework and Future Directions

Abstract Ear, Nose and Throat (ENT) disorders represent a significant global health burden, with complex relationships between disease characteristics, treatments and outcomes. Traditional statistical approaches often fail to capture this complexity. Structural Equation Modelling (SEM) offers a powerful framework for modelling complex relationships between observed and latent variables simultaneously, yet remains underutilised in ENT research. We developed a comprehensive theoretical framework for applying SEM to ENT diagnosis and management. This includes measurement models for key ENT constructs, structural models for understanding relationships between these constructs and extensions for multi-group and longitudinal analyses. We then illustrated its application through the specific examples across ENT subspecialities. The framework was successfully applied to develop the models in otology (hearing loss impact and tinnitus distress), rhinology (chronic rhinosinusitis management and allergic rhinitis impact), laryngology (voice disorder treatment outcomes and professional voice user models), head-and-neck oncology (treatment decision-making and post-treatment quality of life) and sleep medicine (obstructive sleep apnoea treatment pathways and paediatric sleep-disordered breathing). Integration into clinical decision support systems showed potential for enhancing diagnostic accuracy, treatment selection and outcome prediction. SEM offers the significant advantages for addressing the complex research questions in ENT diagnosis and management. The theoretical framework and specific models presented provide a foundation for future research and clinical applications. Implementation of SEM-based clinical decision support tools could enhance evidence-based, personalised approaches to ENT care, ultimately improving the outcomes for patients.