This is The Era of ENT

Manish M George1; Jay Goswamy1

1University Hospital South Manchester, Southmoor Road, Manchester, M23 9LT

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Due to the limited exposure of ENT in UK medical school, the details of what exactly being an Otolaryngologist involves is lost to many students and doctors irrespective of their grade. There are a huge number of professions to enter within medicine and inevitably job satisfaction and career choice is quite a subjective assessment. Objectively however, due to the plethora of skills developed, the variety of patient demographics, the role as surgeon physician hybrid and the fact that Otolaryngology is a dynamic and developing specialty we argue that it is the premier specialty to enter.

Conflict of Interest: These views are those of trainee Otolaryngologists

From North America to the Antipodes, Otolaryngology is consistently one of, if not the most desirable career choices. It is unfortunate however that those attending medical school in the UK have very little experience of this specialty and this lack of knowledge can continue through to their Consultant appointment.

By the end of this article the reader will not only have a glimpse into the workings of Otolaryngology, but also an understanding about why those within the field hold it in such high regard.

So what’s the truth?

There are many reasons why ENT surgeons consider it the most satisfying career to enter:

1) The variety in Otolaryngology is immense and unparalleled throughout the medical field.

No other specialty requires the development of such a broad range of skills. An Otolaryngologist must be able to perform macroscopic surgery, endoscopic surgery and microsurgery. Most also have advanced skills in micro-vascular surgery, laser surgery and a growing number are becoming skilled in robotic surgery. Procedures can vary from less than 15 minutes in botox for vocal spasms to in excess of 12 hours for major head and neck resections.

Head and neck surgery provides its own unique experience with large, clear open neck operations. Reconstruction after cancer resection can be done through a variety of both local and distal flap reconstruction with some Otolaryngologists developing their skills in the highly technical microvascular anastamosis. This field can be satisfying knowing that in many instances, as the surgeon involved your skills directly contribute to the improved prognosis for an individual. Oncological surgery has evolved from the focus purely on cure to a holistic approach that takes into account function and long-term quality of life. Head and Neck Cancer patients are in general a very rewarding group to work with. Complex trans-oral laser and trans-oral robotics are advancing the post resection function and quality of life for patients. The relationship of the Oncological surgeon and their patient does not end with the operation but evolves through their complex recovery and this is a particular benefit that inspires so many surgeons. Otolaryngologists now undertake the majority of thyroid and salivary gland surgery.

Otology requires precision, high level surgical skills and finesse; usually with the aid of a microscope or micro-endoscope. When dissecting with diamond burr drills, as small as 1mm in caliber, at high velocity, an incredible appreciation of the hugely complex temporal bone anatomy is required. An otologist performs surgery on the external ear for stenosis of cosmesis, the middle ear for hearing of benign tumours and the inner ear for hearing of balance with implantable technology improving year on year. Lateral skull base surgeons may deal with acoustic neuroma excision, CSF leaks and other skull base masses whilst working in conjunction with Neurosurgeons. Ultimately vertigo and hearing loss have huge quality of life implications and as an Otolaryngologist you can positively influence these problems. The cochlear implant has the highest number of quality of life improved years of all operations.

Rhinology, including anterior skull base surgery encompasses everything from nasal blockage to epistaxis, from septoplasty to trans-sphenoidal hypophysectomy. Pathological chronic nasal blockage can be debilitating and dealing with all the aetiologies including rhinitis, rhinosinusitis, polyps, inverted papillomas septal deviation, inferior turbinate hypertrophy amongst many others is standard practice. Structural and cosmetic surgery on the nose is more complex than the inexperienced may realize with a huge number of components (caudal excess, saddle nose, columellar show, dorsal hump, inverted V, hypertrophic scarring, nasal valve, open roof, rotation and pollybeak) to be aware of. With improvements in endoscopic technology and surgeon expertise tumours of the pituitary or anterior skull base can now be excised endo-nasally with marked improvement in patient experience and recovery.

Facial plastic surgery probably requires little introduction. There is huge crossover with both dermatology and plastics. Both BCC and SCC of the face and neck and subsequent reconstruction is a common presentation. There are countless flaps and grafts to employ and each procedure is individual, requiring a continuous evaluation of which flap to use and which alterations to make to ensure the best cosmetic outcome. Less frequent, but highly satisfying is the ear and nose reconstruction for congenital deformity, post trauma or Mohs surgical resection. The Otolaryngologist will perform more rhinoplasties than any other specialty and can perform all facial plastic procedures (excluding oculoplastics). Whilst a challenging cohort of patients, the aesthetic and functional components of these procedures can be very rewarding when executed well.

Paediatric Otolaryngology deals with hearing, sleep apnoea, airway issues and neck masses amongst many other routine operations. Congenital facial malformations can be very challenging to manage and the Otolaryngologist is essential to the optimization of their management. Usually the children undergoing ENT operations are well and generally there is high patient and family satisfaction. Dealing with and making significant difference in children’s lives is incredibly rewarding.

Laryngology is about voice, and due to the growing evidence base and technological advances it has been described as one of the fastest growing specialties within Otolaryngology. The voice is hugely important, being a fundamental component of communication for most of us. It forms part of our projected personality that we present and facilitates important social interaction. Teachers, singers, politicians may all form part of your patient cohort.

These descriptions barely scratch the surface of the Otolaryngologists repertoire. Spend some time in a busy Otolaryngology department and allow this to stoke your interest.

2) Otolaryngology offers a genuine balance between medical management and surgery.

The Otolaryngologist is a surgeon and a physician. Outpatients can be a busy place. Many patients visiting their Otolaryngologists will not require an operation. This in itself is enjoyable. Surgically unique, Otorhinolarygnology although proposing surgery when medical management fails, is not an island. Clinically we work closely with Oral and Maxillofacial surgeons, Plastic surgeons, Neurosurgeons, Respiratory physicians and Paediatricians. Outside of medical specialties we also work closely with audiologists, physiotherapists, speech therapists and a variety of specialist nurses.

3) The demographics that Otolaryngology regularly caters to are vast.

A third of Otolaryngology patients are children and all specialists will have experience in managing patients of all ages, from neonates with airway compromise to the very elderly with malignancies. Excluding paediatric surgery, Otolaryngologists see and treat the largest proportion of children across the surgical specialties. As mentioned before, this can be satisfying surgery. The vast majority is elective, the children are usually relatively well and child and parental satisfaction is generally very good. There is also a large working age population with a wide variety of presentations from cholesteotomas to nasal polyposis to oropharyngeal cancer – increasing in incidence in a younger non-smoking population due to rising HPV prevalence. The post retirement cohort is also well represented with numerous head and neck skin malignancies from many years of sun exposure in a sensitive fair skinned population and deteriorating hearing acuity being common complaints.

4) ENT on calls are varied but generally manageable.

Although the Otolaryngologist does not dominate the emergency operating list like other specialties, when there is an emergency it is usually very exciting. Neck stabbings, imminent airway loss, intra-temporal and peri-orbital abscesses all require urgent ENT management. Teams usually cross cover several sites but the life of an on-call Consultant is not as frantic as many other specialties, which lends itself to greater career longevity and permits pursuing interests outside of medicine.

5) Otolaryngology is an exciting, dynamic and fast moving field.

The largest and most obvious recent development is the use of cochlear implants and more recently auditory brainstem implants in aiding the profoundly deaf to hear. Other advances have occurred in endoscopy, specifically in neuro-navigation that is used in anterior and lateral skull base surgery. There are also huge strides being made in the use of robotics in cancer resections and many areas of the UK are catching up with other departments of excellence around the world.

6) Competition ratios are changing.

There have always been concerns regarding pursuing competitive fields. Due to workforce planning more jobs are becoming available in Otolaryngology and as a result competition ratios are becoming more favourable. Your best chances of gaining a training number remain firmly earlier in you career due to the graded loss of allocated portfolio points when you (currently) cross 18 months and then 30 months of experience in clinical Otolaryngology posts.

In summary, due to the variety of skills developed, variety of patient demographics, role as surgeon physician hybrid, manageable on calls, dynamic changing specialty and improving competition ratios, Otolaryngology remains one of the premier specialties to enter. This is the era of ENT.

The authors would like to re-declare they are heavily biased in favour of Otolaryngology.

But we hope you see now, it’s for good reason.