Surgical Component of ENT

[Medbound786]

I am actually a second year medical student and currently trying to decide between ENT and Neurosurgery. I love medical content of both fields but my concern is about the surgical volume in ENT. I know that Oto's handle both medical and surgical cases in ENT but can someone tell me how much of the ENT is surgical (in terms of percentage)? On average, how many days per week do ENT surgeons spend in the OR vs. like say Neurosurgeons?

I ask this because I absolutely adore surgery and I want to maximize my time in the OR as much as possible. Can someone please help in this matter?

thanks so much

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[fongool]

ENT residency -

R2 - OR one or two days a week doing trachs, tonsils, unless on a pedi rotation then in the OR nearly every day doing tonsils, tubes. Rest of the time in clinic

R3 - about the same amount of time in OR but head and neck cases, ears, sinuses

R4 - More in the OR with more responsiblity

R5 - Nearly always in OR, still have clinic days once or twice a week for preop, etc.

Most ENT residencies have a hierarchy that follows this more or less.


Out of residency -

Once out it depends on you.

There are fellowships for head and neck, facial plastics, otology where when you're done you'll probably operate at least 2-3 days a week.

A general ENT typically has between 1 and 2 OR days, split up in various ways.

 

[TheThroat]

Don't know how much time a typical NSG spends in the OR, but for oto, its about 20-30% (about 10 hours a week, average, I've heard). That can be higher after H&N subspeciality, I suppose.

If you really love to operate, there are other fields where you will spend more time in the OR than in oto.

 

[H_Caulfield]

If you're in love with surgery as you seem to be, there may be better fields for you than neurosurgery. In my (very) limited experience: lots of medical management and working through small holes, using lasers, magnifying glasses and microscopes strapped to your head and ears, etc.

Don't you wanna dive into a deep abdomen? I'm just saying...if you love surgery and want to see more than a series of pedicles and duras through a small hole in the back...

Neuro is fascinating but it just seems too neat and precise for a surgery nut. When you say you love surgery, do you want to be covered in blood? or working very delicately with something close to the surface (e.g. oto)?

 

[TheThroat]

or working very delicately with something close to the surface (e.g. oto)?

Don't necessarily agree with this last statement. Today, I did a total glossectomy, total laryngopharyngectomy, radial forearm free flap, pec flap, parapharyngeal space exploration, bilateral neck dissection, partial cervical esophagectomy, skin graft, laryngoscopy, esophagoscopy, and bronchoscopy. Case took about 7 hours with a team approach.

Good case. Not so close to the surface. Of course, that is also not an everyday case for me, but could be for a head and neck surgeon.

 

[mh82ai3]

A follow-up question to the OP is this: If the time of an ENT is split between surgery and medicine and ENT's get less surgical experience, does it make them worse surgeons?

It's a given that no matter what you do, doing more of one thing makes you better at that. So if an ENT does 2-3 days/wk clinic and 2-3 days/wk in the OR, it seems like it takes a lot away from their operative experience. I can't see how operating 2-3 days a week can compete against a gen surg resident operating 4-5 days a week. I don't know, maybe the type of procedures that you do as a general or peds ENT are pretty easy that it doesn't affect your performance and maybe if you do more complex cases, like H&N then you end up getting that operative experience in your fellowship anyway.

I see some similarities between OB and ENT as far as how medicine/surgery is split and I for one think OB's are lousy surgeons. I'd never let an OB come close to me with a scalpel after all the perfed bowels following tubals that I've seen/heard. (being male helps in that aspect) But then again, Gyn/onc surgeons are pretty skilled and I have a lot of respect for them.

It just seems to me that being more medically oriented will take more away from being surgically skilled as an ENT.

 

[Pir8DeacDoc]

Have you ever seen an ENT surgeon operate?

To make a comparison between a head and neck surgeon and an OB is ridiculious. If you want to see the skill of an ENT watch them do a deep lobe parotidectomy with facial nerve monitoring throughout. Or a modified radical neck dissection. Slow, delicate, and precise surgery for sure.

An ENT is no different than any other surgical specialist i.e. urologist, orthopod, etc. Even your friendly general surgeon spends a lot more time in clinic than you might imagine once in practice. It takes a certain amount of clinic to diagnosis and decide to take these patients to the OR. General surgery residents may operate more as residents but that would seem to make sense as they are "general" surgeons, not specialists.

 

[TheThroat]

Oto and Uro are more closely related than Oto and OB. Both have specialized equipment, spend about 2/3 to 3/4 of their time in clinic, and do a combination of "small procedures" and larger, sometimes very long surgeries. No one should argue that a well trained Uro shouldn't be taking out a kidney or that a well trained oto shouldn't be doing that thyroid these days.

Comparing oto to g-surgery, on the whole, as far as surgical expertise is concerned, is like comparing g-surg to ortho. Are g-surgeons, on the whole, better than orthos? Who cares? No g-surgeon can do what an ortho can and no ortho guy better be messing with my gallbladder!

I'd rather have an oto who knows his stuff in clinic and steps lightly and slowly around the facial nerve than surgical Lebron who takes an only hearing ear in for a stapes.

 

[aggernodi]

AND... I'm sure all ENTs have been asked to help the General Surgeon out and even have had patients referred by them to us... ie, the "surprise" pleomorphic adenoma excisional biopsy, thyroidectomy with the cut RLN, tracheostomy in the "difficult" anatomy patient, etc.

We sometimes end up FIXING their surgical mistakes.

 

[resxn]

AND... I'm sure all ENTs have been asked to help the General Surgeon out and even have had patients referred by them to us... ie, the "surprise" pleomorphic adenoma excisional biopsy, thyroidectomy with the cut RLN, tracheostomy in the "difficult" anatomy patient, etc.

We sometimes end up FIXING their surgical mistakes.

Agreed. I don't think I ever heard a general surgeon rip on my surgical skill. In fact, when I was in the Air Force, whenever the general surgeons got a thyroid, they'd ask me to assist. I did about 90% of them anyway and was about twice as fast through an incision about 70% of the size of theirs.

We both shared lots of cases and learned plenty from each other. I had them assist me with neck dissections as well.

 

[drivesmecraazee]

Don't know how much time a typical NSG spends in the OR, but for oto, its about 20-30% (about 10 hours a week, average, I've heard). That can be higher after H&N subspeciality, I suppose.

If you really love to operate, there are other fields where you will spend more time in the OR than in oto.

Could you name a few of those fields? I got sort of interested in this topic cause I would love to operate, but on the other hand, I wouldn't like to totally lose contact with pts as seen in some quirurgical-based residencies, I would like to do a residence with some versatility, but spending LOTS of hours in the OR...I was thinking about cardiovascular surgery, or g-surgery focused on the thorax.

 

[drivesmecraazee]

Whats exactly you rspeciality Throat? How bout you res?

Thanks for you help.

 

[resxn]

Whats exactly you rspeciality Throat? How bout you res?

Thanks for you help.

I'm general ENT. I don't do big oncology cases because I don't want to do major H&N anymore and I don't have the tumor board that I feel I need to do it. I miss it a little, but not much.

I tend toward pediatrics because I had exceptional peds training. But I love sinus, thyroid, and sleep apnea surgery as well.

 

[drivesmecraazee]

I have plenty of time to think about my residency, but Im sure that I don't want anything related to pediatrics, it's just a personal thing, I can't see kids suffering...so if you have the guts to threat them instead of feeling sorry for them, I respect you.

 

[resxn]

I have plenty of time to think about my residency, but Im sure that I don't want anything related to pediatrics, it's just a personal thing, I can't see kids suffering...so if you have the guts to threat them instead of feeling sorry for them, I respect you.

I felt the same way on my peds inpt rotation. I hated seeing those sick kids so much. And fellowship-trained Peds ent is very similar. However, I love general peds ENT because most of the problems are fixable relatively quickly. The kids do great and the parents love you for fixing everything so efficiently when they have often been battling the issue for a few months before they see you. General ENT peds is good stuff for that reason.

 

[drivesmecraazee]

I felt the same way on my peds inpt rotation. I hated seeing those sick kids so much. And fellowship-trained Peds ent is very similar. However, I love general peds ENT because most of the problems are fixable relatively quickly. The kids do great and the parents love you for fixing everything so efficiently when they have often been battling the issue for a few months before they see you. General ENT peds is good stuff for that reason.

Where are you working right now?

 

[TheThroat]

Whats exactly you rspeciality Throat? How bout you res?

Thanks for you help.

General oto.

I like pretty much everything. Don't do much cosmetic FP except the occasional rhinoplasty and don't do neuro-oto, but do pretty much everything else (H&N, peds, sinus, OSA surgery, laryngeal, ears, etcetcetc).

 

[dpms]

On a similar note, what is neuro-oto like? % big whacks, clinic versus or, pt health, and lifestyle & compensation. Seems like an interesting field, but I cannot find much info on it. Thanks

DPMS

 

[resxn]

Where are you working right now?

I'm in a suburb of Dallas.

 

[resxn]

On a similar note, what is neuro-oto like? % big whacks, clinic versus or, pt health, and lifestyle & compensation. Seems like an interesting field, but I cannot find much info on it. Thanks

DPMS

Neurotology is a very interesting field in my opinion as far as the surgery is concerned. However, one reason I didn't want to pursue a fellowship in it is because there's basically only 4 patient complaints in the field -- 1) hearing loss 2) dizzy 3) otalgia 4) infection. There is a ton of different pathology but usually relates to 1 of these complaints.

The surgeries are awesome. Technically demanding, rewarding, and financially well-compensated in the relative sense.

I had 2 main neurotologists with whom I trained and 5 others that were associated with our program. From their practices, I'd say 25% of their surgeries were for big whacks, depending on how you define that. I think of it as acoustics, temporal bone resections, and cochlear implants. Some people might not consider cochlear implants a big whack though. Middle range surgery, like revision tympanomastoidectomies, some surgeries for Meniere's, cholesteatoma surgery, petrous apex surgery, and the like account for 30-50% depending on the surgeon. And the bread and butter that many general ENT's also feel comfortable doing like tympanoplasties, simple mastoidectomies, ossicular chain reconstructions (including stapes), BAHA, etc account for the other 40-60%.

Clinic vs OR seemed to be the same for them as the general ENT's. They took less call because they only took otology call, though.

Lifestyle also seemed similar, but I would guess on average the income is mildly higher for most neurotologists vs their general counterparts, although I don't have figures to back that up.

 

[drivesmecraazee]

coclear implants??? wow...that must take some skills!!!

 

[TheThroat]

coclear implants??? wow...that must take some skills!!!

Cochlear implants are not that technically challenging. Acoustic neuroma excisions, far lateral approaches to the clivus, infracochlear approaches to the petrous apex, and glomus jugulare tumor excisions are much more difficult. Also, you have a fair chance of knocking out VII.

 

[resxn]

The Throat's comments reminded me I should also add CN VII decompressions for middle to large surgeries depending on the injury. CN VII grafting in the same category depending on the degree of injury and how much mobilization is needed--can be small to very large.

I'd also agree with The Throat that cochlear implants aren't really exquisitely difficult, but I would say they're tedious and for me every time I had the drill shaft in the facial recess and was drilling into the scala tympani, I had some seriously high sphincter tone. That's especially when you're doing it on kids under 2, but even in adults it made me squeeze a little bit.

 

[drivesmecraazee]

Well...I guess the risk of harming the facial nerve in coclear implants it's not so high...but still...the coclea is very small...and how do you conect the new implanted coclea to the coclear branch of CN VIII? Im getting interested in this field.

 

[resxn]

Well...I guess the risk of harming the facial nerve in coclear implants it's not so high...but still...the coclea is very small...and how do you conect the new implanted coclea to the coclear branch of CN VIII? Im getting interested in this field.

It's probably too long to really explain here, but a cochlear implant is not a cochlear transplant. A cochlear implant is a prosthesis that is inserted into the scala tympani and directly stimulates the cochlear nerve.

It's far more complicated than that, but that's the gist. Wikipedia actually has a reasonable beginner's article on it at http://en.wikipedia.org/wiki/Cochlear_implants I have to add though that the picture is horribly bad showing the electrode array going intracranially to the cochlea. Terrible, awful picture.

 

[TheThroat]

I'd also agree with The Throat that cochlear implants aren't really exquisitely difficult, but I would say they're tedious and for me every time I had the drill shaft in the facial recess and was drilling into the scala tympani, I had some seriously high sphincter tone. That's especially when you're doing it on kids under 2, but even in adults it made me squeeze a little bit.

Its all what you are comfortable with. I would much rather do a CI on a 2 year old than do a rhinoplasty on a 17 year old girl.

 

[TheThroat]

Terrible, awful picture.

That pic is AWESOME. Straight through the ol' temporal lobe!

 

[drivesmecraazee]

It's probably too long to really explain here, but a cochlear implant is not a cochlear transplant. A cochlear implant is a prosthesis that is inserted into the scala tympani and directly stimulates the cochlear nerve.

It's far more complicated than that, but that's the gist. Wikipedia actually has a reasonable beginner's article on it at http://en.wikipedia.org/wiki/Cochlear_implants I have to add though that the picture is horribly bad showing the electrode array going intracranially to the cochlea. Terrible, awful picture.

Ooohh..ok...the coclear implant is that aparatus often seen, sorry, got mixed up.