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

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.