What is an Otolaryngologist? What does an ENT surgeon do? Part 4: Paediatric ENT

I still remember vividly the day I sliced open the trachea of a neonate who weighed less than my Apple Mac computer. Such tiny creatures with no necks. Such soft and delicate beings. Such a narrow airway. All my instruments were small. The retractors I used in the neck were actually eyelid retractors. And the tracheostomy tube I inserted was a little bigger than the diameter of my pen.

One of the reasons ENT captures my heart is because we operate on all ages. One day I could be in the mouth taking out a tongue cancer on a 70 year old who weighs 100 kg. Another day I could be doing a tonsillectomy on a 2 year old with no space in the mouth for my fingers. In fact, a typical ENT practice would involve seeing lots of kids. That keeps me happy. And truly humbled. I have a 3 year old son. I can only imagine the anxiety I would have if I had to surrender my son to a total stranger to cut into him. As an ENT surgeon I hold dearly the privilege and trust I am given to operate on another person’s child.

What keeps the pediatric ENT surgeon busy? Tonsils, adenoids, ear infections and foreign bodies that children put in their ears, noses and throat.

Tonsillectomy is the most common operation any ENT surgeon does. It is also the operation that keeps the ENT surgeon humble. We do it both in children and adults, for obstructive sleep apnoea, recurrent tonsillitis, or for cancer. I love and I fear the tonsillectomy. There is no such thing as an easy tonsil, and no 2 tonsils are ever the same, even in the same person. A senior ENT surgeon I highly respect asked me at the beginning of my training: What are the 3 most dangerous ENT operations? Answer: tonsillectomy, FESS and rigid oesophagoscopy (I’ll tell you why some other time).

Some of my most difficult tonsillectomies were done on adults with recurrent infections because they bled, and bled and bled. Even more difficult than those are the tonsillectomies I do on children under 3 with congenital syndromes. Down syndrome, Pierre Robin, cleft palate, neuromuscular disorders or any craniofacial disorders make tonsillectomy and adenoidectomy fraught with so much more danger. These tiny creatures are placed on an oversized operating bed. I insert a metallic gag to hold their tongue down. Parents would say no if I showed them the gag and medieval support I put around their child’s mouth. I suspend their mouth open with their necks extended. Every step of positioning them is hard enough because they are so tiny, flimsy, floppy, cute and so, so breakable. And with my headlight and instruments I get into these tiny mouths and I peel away the tonsils from the muscles that hug the tonsils. The closest analogy I could think of is this: try rolling a sunnyside egg and place it down the bottom of a drinking glass. Now use chopsticks and toothpicks to dissect off the yellow from the white, while someone pours a little shiraz into the glass once in a while. To make matters more challenging, just behind the flat layer of muscle that hugs the tonsil lie several major structures: the nerves that move your tongue and provide sensation to it, the internal jugular veins, and the internal carotid arteries that feed the brain. Kaboom, if you hit them.

If it is fraught with so much danger, why do we still do them? It is because the benefits that outweigh the risks. Parents tell me excitedly 6 weeks after their child’s adenotonsillectomy that I’ve given them a new child. Tonsillectomy gives a child with obstructive sleep apnoea the precious gift of well-oxygenated sleep. For the first time in their lives, they sleep through the night. That gives them a much needed rest, and gives their brains the opportunity to develop. There’s more and more evidence to show that a child cured of sleep apnoea do better in memory development, language, behaviour, attention span, etc. Next to grommet insertions, adenotonsillectomy is our bang for buck surgery. An intervention with so much biopsychosocial benefits.

The paediatric ENT surgeon also deals with many other conditions mostly of congenital nature. We do laryngeal surgeries for kids with floppy larynx (laryngomalacia). I remembered doing this supraglottoplasty with laser on a gorgeous kid who looked so much like my own son. We repair laryngeal clefts, tracheo-oesophageal fistulas, recurrent laryngeal nerve palsies, complete tracheal rings, branchial arch anomalies, ear diseases, mastoiditis, sinus diseases, head and neck tumours, and many others. Laryngotracheoplasty is one of the most exquisite procedures we do. It is amazing. Sometimes, sadly, we also do some horrible surgeries such as maxillectomy or mandibulectomy for paediatric tumours. There are so many others things I could talk about. Everything is just a little harder with kids. Even putting grommets in a 6 month old baby with Down syndrome takes all the strength and wisdom one could muster. It feels so good when it’s perfectly placed though.

And we work closely with paediatricians, paediatric audiologists and paediatric speech pathologists. We have a lot of fun looking after these kids. Can you imagine the multidisciplinary care involved in managing a child with permanent tracheostomy? It takes more than just knowledge and skills to work with kids. It takes a bit of childlikeness and sillyness. Building a rapport with kids and their parents require a little magic. It is said, truly, that you do not choose to work with kids. The kids choose you.

I loved it so much I thought I was going to grow up to become a paediatric ENT surgeon. Well, perhaps, maybe. We’ll see. The beauty of ENT is that no matter what I end up doing, I will still see lots of kids in my practice. That’s a beautiful privilege given to the ENT surgeon.

But my love affair with ENT doesn’t stop here. We’ve done ears, noses, throats and kids. What else is there in ENT? Well, a lot more, believe it or not. Wait and see.

What is an Otolaryngologist? What does an ENT surgeon do? Part 3: Laryngology

The finesse of the ear surgeon and the precision of the nose surgeon is matched by the throat surgeon’s light-handedness. Tremor can be hidden in most other surgeries, but not in laryngology. This one needs a real steady hand. A good laryngologist has a set of steady hands, a calm demeanor, an approach matching that of a psychologist, and an artistic, cultured manner. Why? Because they deal with voice, and professional voice users, including performers, singers, teachers and politicians. Prominent VIPs with expensive voices see the laryngologists, hence the need to be impeccably presentable.

Laryngology is about voice, and it is probably the fastest growing subspecialty within ENT. This is because of the progress of technology and the accumulation of evidence and experience in treating voice disorders. We’ve talked about hearing, smell and taste. Now think about voice. Voice is who you are. You may loose hearing, smell and taste, but still be an active person. Once you lose your voice, you are crippled in communication. Vocal frequencies, intonations and projections add colour to who you are. Voice expresses your character and emotions as much as the face. If you had a different voice, would you still be you?

We ENT’s are privileged to be dancing on this immaculately delicate organ called the vocal cords. I attended a conference once by a laryngologist who is the chief surgeon to some famous broadway productions in New York. He would sit and listen during rehearsals and be able to pick out which one of these professional singing and dancing troupe members not using their voice carefully. He is charged with a mission to get a vocal cord better as soon as possible. Those professional singing vocal cords are insured and are worth millions. Imagine if an ENT says strict voice rest to a lead Broadway Musical performer. How much does that decision cost the production company?

In the past 2 months I had danced about 7 times over vocal cords. Each time it was for a different procedure. One I was really anxious about was when I did vocal cord surgery on a fellow hospital colleague and dear friend who is a professional voice user. This gorgeous young girl spends her day educating, liasing, organising and communicating with so many people around the hospital. Everyone knows her voice. She was a little hoarse, and it was due to a small cyst on her vocal cord. This small cyst has changed the mucosal waves and vibrations of the cords, changing the airflow physiology of her voice production. Operating on her meant everyone in the hospital will hear and know of my results. A few milimetres too shy would result in a potential recurrence of her cyst and keeping her still hoarse. A few milimetres too aggressive could potentially cause her permanent voice damage.

She laid on the operating bed. I wrapped her head with a towel like she has just washed her blonde hair. I stood on the head of the bed. Using a few medieval contraptions I inserted a device that would keep her mouth and throat open in a straight line to her voice box. This device suspended her throat as I mounted it on a chest support over her body. Placed wrongly, I could twist her neck, break a few teeth, bruise her gums, tear her tongue, or damage her larynx. I had to get the perfect position so I could bring a multi-thousand-dollar operating microscope over her throat and work through a small opening onto her larynx.

Once her larynx is well suspended and her vocal cords are in full view I inserted various microscopic instruments through the scope. I used a combination of microscopic knives, forceps, scissors, needles and laser equipment. They are about an arm’s length and the tip is only visible through the microscope. This is why you absolutely need steady hands. The tip of your knife is held about 25cm away through a tiny hole under a microscope over thin vocal cords. Every little movement and tremor is like an earthquake on the microscope view. Removing the cyst and putting the vocal cord back together again so my dear friend could return to work was nothing less than stressful. I was mindful that I was using laser and microscopic instruments on her instrument of living, her voice.

In phonomicrosurgery (vocal cord procedures) I needed to be like a trapeze artist dancing on a tightrope. I did not drink any coffee or tea and made sure I was not in any way rushed or flustered. I had to be in a zen moment.

That’s why I love it! Just like when I tiptoe over the facial nerve and taste nerve in the ear under a microscope, or hanging off the skulbase a little off the eyeballs in the nose, vocal cord surgery gives me that adrenaline rush mixed with zen-like peace. Micromilimetres spell success or disasters. A man I highly respect once said “Faith is walking amongst miracles always at the edge of disaster”. I think ENT is like that too. We can approach the larynx from inside, and outside, whether the patient is asleep or awake. There is one particular procedure we do where we make a cut on the neck next to the Adam’s apple and we fiddle with the voice until we get it just right, all while the patient is awake and we have a knife in their throat. We can put a camera through the nose into the throat, and while we hover over the larynx, we can stab the larynx from the outside with a needle containing steroids to bulk up the cords. In fact, some performers do that regularly before their seasons. Cords on steroids as a performance enhancing drug.

Laryngologists fix vocal cords in all shapes and forms. Those with growths on it, both benign and malignant, those that are fixed, crippled or paralysed in any way, those that are just not working, and those that are the main source of extravagant income in professional users.

But we ENTs do not do it alone. We do it with the help of our friends the Speech and Language Pathologists or Therapists. ENTs work closely with allied health: audiologists, vestibular physiotherapists, and ‘speechies’. We love them, and in particular, the ‘speechies’. Why? (And here’s another reason why ENT is such a blessed specialty.) Because the speechies by far are the best looking of the allied health lot. Seriously. I don’t know why, but it is universal knowledge that speechies tend to attract really good looking people. Most of the speechies I know are pleasant to the eyes. One of the recent Miss America winner was (or going to be) a speechie. And I too have had the blessed privilege of examining a patient with a speechie who is a professional fashion model. You can imagine how hard it was for me to concentrate on her examining the physiology of swallowing on a patient while my mind was on the picture of that revealing dress or swimwear she wore in one of the magazines.

Speechies look good. And speechies make ENTs look good. They train the vocal cords, rehabilitate voice and speech, assess and re-train swallowing, helps children to speak and articulate, looks after tracheostomy and PEG-tube dependent patients, etc. Their clientele include paediatric, trauma, stroke, neurological patients, and many others. They are really good in what they do. And they look good. Have I said that already?

I do take my hat off to the Speechies, Audiologists, Physiotherapists, Dieticians, Psychologists, and many other allied health teams we ENTs work with.

Have you had enough of ENT fun? I’m only halfway through. There’s more to talk about. We’ve now done Ear, Noses, Throats, and next stop: Paediatric ENT! Where fun is really what the patient needs.