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.
