ENT surgery – Eric Levi

What is an Otolaryngologist? What does an ENT surgeon do? Part 2: Rhinology

27 May 2012

Otology involves mastery of sound physics, acoustic coupling, tympano-ossicular impedance and a lot of ‘vestibulology’ that is dizzying and still all fuzzy wuzzy to me. Rhinology requires understanding of the science of nasal aerodynamics, olfaction and immunology. The skills required to be a great sinonasal surgeon is different to that of the ear surgeon. Both demand extreme precision and impeccable tissue handling, for a similar reason, there is no room for error in the nose.

The otologist works in the hardest bone in the body. The rhinologist works next to the thinnest bone in the body. There is a flake of bone called ‘lamina papyraecea’ (paper thin) in the nose separating the nose and the orbit. It’s called that for a reason. What could go wrong in a nose operation? Well, you could go blind, have permanent double vision, or have a leaking brain fluid.

What does the rhinologist do? They are not people of study rhinoceros. They help you breathe better. Block your nose for 30 seconds and see how much that annoys you. Your mouth is dry and your spech affected. With their expensive endoscopes and fine instruments, the rhinologist can roam around your nose like it was Disneyland. They’ll sweep away every mucous and shave away every polyp from every corner of your nose.

One of the most basic and common operation we ENTs do is called a septoplasty and turbinoplasties. This is because one of the most common problem that presents to us is nasal blockage. The operation involves making a small incision on the inside of your nose to straighten a bent, broken or crushed nasal septum. It’s pretty much like rebuilding a straight wall between two rooms through one tiny window using an ice cream stick. It is probably the most underrated and understated procedure in all of ENT. I have done many appendicectomies as a surgical registrar before ENT, but I found septoplasty to be much harder to master. And with turbinoplasties, we trim the bony cushions that protrude into your nose using a pair of scissors, knife, electrocautery or powered shavers. Just a few centimetres away from your eyeballs.

But what is at the heart of rhinology is a group of intranasal and paranasal sinus procedures called FESS (Functional Endoscopic Sinus Surgery). Some suggest it should be correctly spelled f€$$. This collective procedure range from opening a simple cheek sinus to going all the way up and back to clear the base of skull. It’s a lovely procedure. I stand to the right of the patient’s head. Camera in my left hand, and intruments in my right hand, all through the nostrils. Everything I do in the nose is magnified on the theatre television screen. Booger looks like Mount Everest and bleeding looks like Niagara Falls. With my angled cameras and instruments including shavers rotating at 5000 per minute, I work my way through your nostrils into your cheek, sliding under and between your eyeballs and making my way within millimetres beneath your brain. There are pockets of sinus air cells hiding blood vessels hanging off the roof of your nose and going into your eye socket. Trying to redecorate a room through the keyhole on the door using chopsticks is probably easier. Sometimes the scenery is beautiful, sometimes I am swimming nose deep in mucous, snort, pus and booger.

Operating within milimetres of the brain and eyeballs means that we can potentially access those organs through the nose. We can go through the nose to unblock a tear duct, biopsy an eye tumour, or decompress an eye infection. Sometimes people forget that we can access the eyes quite easily through the nose. I have met, sadly, a beautiful young girl who has lost her vision in one eye because of an eye infection, and she was referred to us much too late. We got to the eye infection when the vision nerve has already been too far damaged. The next time you get a really bad eye infection, you might need a nose surgeon to help you.

The nose is also now becoming the standard pathway to removing certain brain tumours. For example the pituitary gland is easily accessible through the nose via an endoscopic trans-sphenoidal pituitary excision. When we are in the sphenoid, we really are at the centre of the universe. We’ve got internal carotid arteries, optic nerves, cavernous sinuses, and lots of cranial nerves hanging on either side within milimetres of our reach. Thou shalt not sneeze while in the sphenoid. Some major anterior fossa intracranial tumours are now accessed through the nose. Recently I was involved with assisting in the removal of a large meningioma. What we did was rearrange the furniture in the nose, drill out the roof of the nose, which is the floor of the brain. Drop the tumour into the nose, remove the tumour piece by piece through the nostrils. Lift the brain back up. Create a new floor for the brain with cartilage, fascia and muscle. And leave a balloon in the nose to scaffold the roof up for a while. Awesome. This is nose digging par excellence. No cuts. Removing brain tumour through the nose saves the patient a big cut on the forehead and the removal of a large piece of skull. In a few weeks time, we will be repairing the skullbase of a patient who has been spontaneously leaking brain fluid into the nose and getting meningitis.

You can imagine how exciting ENT is, when we start fiddling with brains and eyeballs. The nose is a beautiful organ inside and out. On one day I can be dancing on the facial nerve in the ear, flipping ear ossicles, putting a cochlear implant in, and the next day I can be pulling out brain tumours through the nose, tickling a pituitary gland, or fixing a skull base brain fluid leak.

Awesome ENT. You’ve tasted ears and noses, next stop: throat. Laryngology.

What is an Otolaryngologist? What does an ENT surgeon do? Part 1: Otology

20 May 2012

It is no secret that I have found gold in ENT. It is by far the best medical specialty in all of Medicine and Surgery. A few people who do not know us well enough are curious at what we do. It’s like a black box specialty, filled with magic and wonder. Public opinion suggests that other than ear wax, grommets, tonsils and adenoids, we drink lots of tea. Well that may be true in some places, but here in Australia, we get to have a lot of fun.

An Otolaryngologist, Otorhinolaryngologist or ENT Surgeon is a Specialist Surgeon who investigates and treats conditions of the Ear, Nose, Throat, and Head and Neck.

I’m going to take you on a journey to explore ENT fun across our ENT family of subspecialties. Disclaimer: You might really, really fall in love with ENT.

Part 1: Otology

We’re all ears when it comes to hearing and balance.

Yes, wax, gets in the way. It is suprising how a simple problem like wax can affect the quality of life of many. With some simple equipments, we can make a huge difference particularly in the elderly.

Ear infections can lead to a whole host of problems. One of our biggest bang-for-buck surgeries is insertion of middle ear ventilation tubes (aka ‘grommets’ in Australia). Grommets in children with recurrent middle ear infections result in better hearing, better language development, better learning and behaviour, reduced morbidity of ear infections. Amazing. A tiny tube perfectly placed on the paper thin tiny ear drum under microscope could make a huge difference. I love putting them in.

The main course of the Otologists’ world are the bigger ear operations: canalplasty, meatoplasty, myringoplasty, tympanoplasty, cortical mastoidectomy, modified radical mastoidectomy, ossicular chain reconstruction, facial nerve decompression, stapedectomy, acoustic neuroma excision (translabirynthine, retrosigmoid, middle fossa approaches), and lateral skull base or middle fossa surgeries for semicircular canal dehisences.

I love the precision and finesse involved in ear surgery. When I enter the ear through the mastoid, I must work through fine layers of skin and tissues behind the ear, harvest a piece of muscle fascia behind the temple for later use in ear drum reconstruction, then use a cutting or diamond drill at 5000 rotations per minute to drill through the thickest bone in the body (apparently it takes 1500kg of force to break the mastoid bone). Within this thick bone lies a brain venous lake full of blood called the sigmoid sinus and the fine spaghetti thin facial nerve which controls half of your face. I use my drill to work gingerly around the sigmoid sinus and the facial nerve. I travel deeper with my drill between the two and under the layer of dura covering the middle fossa brain matter. When I’m deep enough, I will then have to work around some of the most amazingly designed and engineered acoustic coupling system, the three tiny hearing bones malleus, incus and stapes, each the size of a grain of rice. To make it more challenging, the hearing and balance centre, the facial nerve, and the taste nerve to your tongue are all milimetres away. In the ear, milimetres make a huge difference. This is also why I cannot have too much coffee before surgery and most otologists do not drink coffee. A minor finger tremor when you’re holding a high speed drill near the brain, vessels, nerves and ossicles could spell disaster for the patient. There is not much room, literally, for error in the ear. It’s almost like defusing a bomb under the microscope with a jackhammer. I sometimes forget to breathe when I’m in someone’s ear. Thrilling.

Hearing and balance are quality of life issues. Try blocking one ear with blue tack for a day and see how much that affects you. You can’t localise sound, you can’t hear properly in noisy environments, you might even feel dizzy. Remember the last time you were feeling dizzy or drunk or sea sick? Can you imagine being like that 24/7 all the time every day with some vestibular problems? Though it’s not life and death, living with hearing loss and balance problems renders one ineffective and unable to enjoy the pleasures of life. Inability to hear the sound of music, my wife’s or son’s voice would make me a very depressed man. I marvelled even at studying the basic science of sounds. The process of sound travel from your computer speakers to your brain and what it does to your brain is enough to make me smile.

ENTs get referred lots of dizzy patients. Hall-Pike, Epley’s, Sermont, Brandt-Daroff exercises and manouvres are part of our armamentarium. Also various medications orally and injectables through the ear drum are some of the things we can use to help with hearing loss and balance disorders. I can recall examining a dizzy patient and later on finding that he has a brain tumour. We do get the interesting and uncommon presentations once in a while. Hearing loss and balance problems can also be an initial presentation in many other systemic conditions such as autoimmune, connective tissue, or neurological disorders, and we love a bit of detective work.

Perhaps the icing on the mostly edible cake and the jewel in the almighty beautiful crown in otology is the innovation of the bionic ear, or cochlear implant. I have been privileged to train and operate in the very theatres where the cochlear implant was born. The standards of excellence, research and development in this ENT unit is truly world class. I’ve worked with the world standard bearers, and I’m humbled. At this stage in my training I’ve already been involved in the surgeries of about 30 cochlear implants. The marriage between surgical innovation and biotechnology is exemplified in the bionic ear. Who would have thought that you could make the deaf hear? We’ve gone from multiple designs of non implantable hearing aids, to a magical implantable hearing device. Is it for everyone? Of course not. Like any treatments, medical or surgical, they have to be tailored to the right patient for the right indications.

When it comes to cochlear implant, I have had the privilege of standing on the surgeon’s side. But I also have had the honour of standing on the patient side. My precious little sister was born with profound sensorineural hearing loss. Due to many reasons, she had the bionic ear implanted late as a prelingual deaf teenager. I remembered when I was in her hospital room and seeing the ENT Professor and his team doing rounds. Her results were different, but wonderful nonetheless.

Who would have thought that many years later I would be granted the privilege of assisting in these surgeries as a trainee surgeon?

ENT is simply amazing. And we’re only in ears.

Next: Rhinology.

On the getting of wisdom

4 April 2012

Every medical and surgical specialty is exploding with knowledge. There are so many wonderful things going on in the amazing world of ENT. The future for our patients is bright, that is, if we can translate and materialise what we have learned into our day to day practice as surgeons.

The best of the best in Otorhinolaryngology Head and Neck Surgery came to Adelaide for a 3-day conference. In fact, the axis of the earth moved a little. There were so many ENT surgeons in one place it became the centre of the universe. As a trainee, I saw some great surgical leaders and innovators pushing the boundaries to provide better care for our patients.

Beside gaining much surgical skills and knowledge, it was also a time for me to mingle and rub shoulders with the surgical elders and heroes of my ENT community.

Here are 3 things I learned at the Conference:

1. The patient is the focus, not the disease.

As a trainee surgeon I need to always remember that everything I do should be focused on the patient. Every new research, new developments, new procedures, and new equipments are designed with the patient in mind. This focus and single-mindedness is what separates the great surgeons from the good. I can see that the great leaders of my specialty always place the patients’ interest as an ultimate priority.

2. Surgical advancement is based on hard work and sacrifice.

These great surgeons toil and struggle. They work harder and longer than their peers. They push hard. They persist. They think outside the box. They do certain things that are not normally done, often making many big sacrifices along the way. So how much am I willing to sacrifice? What am I willing to sacrifice on the altar of surgical advancement? My family? My health? My faith?

3. Surgical humility is the key to surgical satisfaction and longevity.

This surgical trail is a long, tough and lonely road. It takes on the average, 15 years to become a surgeon, 6 days a week doing 14-16 hour shifts and research pursuits in addition. Its tough and rough. The surgeons I look up to are those with what I call surgical humility. They are content doing what they do. They find joy in the simple things they do. They are honest when reflecting on their outcomes. They are happy to accept responsibilities for their complications, and they are content with not having to be the top dog in town. These are the happy surgeons.

Would these 3 be also applicable to what you do?

Robots

31 March 2012

Boys and their toys. We just can’t help it. We love to play. And we love to score. Put a group of surgeons together around a million-dollar robotic surgery console, and we start competing and comparing skills and trying to get the highest score. I don’t see that as a bad thing. As long as the score is the patient outcome.

As a surgeon, the highest score we can get for the patient’s benefit is a good quality of life, disease free. It is no longer enough for a Head and Neck Cancer Surgeon to say “We took out your cancer”, and leave the patient PEG or tracheostomy dependent with a poor quality of life. To that end, we need to employ every means possible.

We used to take out cancers with massive, deforming, debilitating head and neck surgeries. Then radiation and chemotherapy came on board, leaving them with organs, but with poor long term functions. Then endoscopic surgery came along. Then laser surgery, then laser-assisted microscopic surgeries. And now, robots are on the horizon. The urologists have been using this for some time, but ENT surgeons are a little slow in adopting. In 2007, 60% of all radical prostatectomies in the US were done with robots.

Why not? This is yet another weapon in our armamentarium to provide better care for our patients. Experience are mounting that with TransOral Robotic Surgery (TORS) the morbidity is lower, time to oral intake shorter, airway is safe, length of stay shorter, but more importantly oncological clearance is same or better than traditional methods.

There is a lot of skepticism. Of course. But a good surgeon should research, investigate, study, assess, experiment and come to a conclusion. There is more than one way to skin a cancer. The robot will be great for some things, but not others. And there’s evidence for that. Probably not so good for thyroid, but excellent for parapharyngeal, supraglottic and tongue base pathologies. We wait for the evidence to declare itself.

I am not concerned about the shape, size and challenges of today’s robot. I’m more interested in tomorrow’s robot. It will be sharper, smoother, smaller, and much more surgically accurate. But how can we make those robots better? By using today’s robot, and improving them. Today I practiced on a 10 year old robot, and I was impressed. In 10 years time, I may well be using robot to do tonsillectomies because it may be deemed a more superior method.

Robots will not replace surgeons. Rather, robots will enhance the surgeon’s performance. And what’s the point of enhancing performance? So patient outcomes are improved.

Surgeons, for the sake of our patients, should be on the cutting edge of technology. We should use all manners of technologies to provide better outcomes for our patients. Even using Apps and Social Media!

What technologies are you using to better your patient outcomes?

Epistaxis: Stop it like a kid.

31 October 2011

What a lovely word! It comes form the Greek word epistazo which means to bleed from the nose (duh!).

Most of us will have nosebleeds at one point in our lifetime (if you haven’t had that experience, try vigorously digging your nose, or call someone ugly). It is said that up to 60% of us will have nosebleeds in our lifetimes, but only 6% will require medical attention, and only a further 6% in that group will require admission to a hospital (and you shall see me!). So rule number 1: not all epistaxis need to be seen by an ENT surgeon (HINT, HINT: ED). However, from an ENT Surgeon’s point of view, it is the most common ENT emergency that gets referred to us.

Let me just mention that big group of nosebleeds to whom medical attention is not required. Guess where is the driest part of the human body? No, not the wallet. It’s the inside of the tip of your nose. The nose is divided left and right by a soft cartilage called the septum. That septum is a narrow passage for air (and dust, and pollen, and grass, and perfumes, and body odours etc). It gets dry very, very easily. (If you don’t believe me, try pinching your nose and breathe through your mouth. See how quickly your mouth dries up.) So to keep the septum from becoming too dry, we set up a massive camp for blood vessels there to warm and humidify the air that gets through the nose past the septum.

That’s a tricky combination isn’t it? To warm the inhaled air, we need lotsa blood vessels under the surface. Yet when it gets too dry and crusty, these vessels bleed easily.

So what should one do when one is epistaxising (nose-bleeding)? Here are some simple tips:

1. Relax. It happens some time. Quickly say sorry to the one you called ugly.

2. Don’t tip your head back. Guess where the blood will go? Swallowed into your belly, which will make you sick. Or inhaled into your lungs, which is not nice, coz you’ll splutter and cough. Tip your head down.

3. Pinch the lower half of the nose, the soft, fleshy cartilage part. You see the top half of your nose is bone, and the bottom half fleshy. No point pressing on the bony part. Well, unless you’ve been punched so badly that the bone is now mush. I suppose you can try pressing on that too.

4. Open your mouth slightly. Take slow deep breath.

5. Point number 4 above is also applicable when giving birth.

6. Suck on ice, or have some cold drinks, preferably non-alcoholic and without a mini umbrella in the cup as it may poke you in the eye. Suck like a kid. Ice cream, icy poles, milkshakes, etc. The cold may help constrict blood vessels and give you a bit of brain freeze too. Have some ice compresses to your forehead or back of neck as well if you like. Call room service if you can’t do this alone.

7. Wait a few minutes. Update your facebook status, tweet, or flush the toilet. Whatever.

8. Most bleeds will settle.

9. Once the bleed settles, remember that inside your nose is a raw area that needs time to heal over a few days. So bungee jumping the next day may result in a repeat bleed. Try not to call anyone bad names in the next few days as well.

10. Moisturise the nose over the next week or so. My recommendation: go to the baby section at your local chemist and grab a baby bottom cream. If it’s good for a baby’s bottom, it must be good for your nose. Just apply a small amount (using your finger, not your baby’s bottom) into your nostrils 2-3 times a day. It should help moisturise the nose while that raw bleeding area crusts over and heal up.

These simple steps will help in managing most bleeds. These are also good advice any doctor can give when managing a patient with epistaxis. But of course, many these often don’t get as far as the doctors or the ENT surgeons (thankfully).

What about the bigger bleeds?