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.