Hearing loss, sinusitis, asthma and allergies are just some of the common reasons why patients of varied ages visit their doctors – and otorhinolaryngologists, to be exact. Otorhinolaryngologists, more commonly referred to as called ear, nose and throat (ENT) specialists, essentially deal with those areas in the body with the addition of the head and neck entirety.

This interesting specialty can be further subdivided into allergy, facial plastic and reconstructive surgery, head and neck, laryngology, otology or neurotology, pediatric otolaryngology and rhinology. Some otorhinolaryngologists will undergo additional studying to specialise in one of those areas – and subsequently limit their services to the management of their chosen specialty. To further understand this area of expertise, the MIMS team sits down with ENT consultant and Head and Neck surgeon, Dr Shailendra Sivalingam from Sunway Medical Centre.

Dr Shailendra sees mostly nasal-related cases such as allergic rhinitis, rhinosinusitis and nasal polyps. Other common cases include ear infections, vertigo, sore throat, tonsillitis, tumours of the head and neck and loss of hearing. He’s also come across emergency cases like epistaxis, foreign bodies in children, breathing difficulties and lacerations.

Immense use of tools, excellent fine movement skill and awareness

Dr Shailendra stresses on the importance of awareness as an ENT doctor, besides being able to handle equipment and operate in confined areas. “One of the most important things to have is awareness. You need to be aware of the best method for treating the patient. Sometimes, you may be able to treat the patient surgically, which means you have the skill and ability to perform a complex surgery to treat the patient – but, it may not be the best way of treating him/her. He/she might have a better outcome from a completely non-surgical form of treatment,” he explains.

An ENT specialist working in a private practice in the United States, Dr Christina Gillespie, remarks that it is important to be flexible in this field. “ENT physicians deal with a wide variety of problems and patients. We care for everyone from newborns to the elderly. You also need to be able to function well in stressful situations. While most of what we do is low stress, we are called to deal with emergencies, such as airway obstruction and epistaxis,” she said.

For those sitting on the fence between medicine and surgery, this chosen specialty is perfect as it gives a good balance between medical and surgical opportunities in the average weekly routine. As Dr Shailendra points out, most of the diseases in this field require medical treatment first prior to reverting to surgery. (Also, he is in the clinic everyday and does not have a fixed operating day in private practice; he operates as and when there is a procedure scheduled.)

Another fascinating part about this field is of course the exposure to many cutting edge technologies. A great deal of innovative techniques is warranted to work in such small areas and holes like the ear, nose and throat. Examples of tools would include lasers to remove lesions in the airway, prostheses to reconstruct ossicles in the middle ear, drills for mastoid surgery, hearing aids, cochlear implants, aerodigestive tract and sinus endoscopes, plates and screws for facial reconstruction, microdebriders for polyp ablation; and the latest, robotics for numerous surgeries. The application of these gadgets to the job provides much excitement and entails creativity, as they are sophisticated and often small.

“Each place (where you have to do surgery in) requires different equipment. Some people like doing surgery, but only with their hands. If you don’t like using equipment, then ENT is not for you. A lot of surgeries are fine surgeries. Therefore, you have to get used, and be familiarised to handling instruments like endoscopes and microscopes,” according to Dr Shailendra. “And this clearly comes with constant training and practice,” he adds.

ENT expert, Dr Shailendra says one of the most important skills of a surgeon is awareness. Photo credit: Dr Shailendra Sivalingam
ENT expert, Dr Shailendra says one of the most important skills of a surgeon is awareness. Photo credit: Dr Shailendra Sivalingam

Driven by a successful patient outcome

Undeniably, patient satisfaction comes with any specialty. Once you treat the patient successfully – and if the patient is satisfied – all the more reason for you to be happy, too. Dr Shailendra is driven by a successful outcome in his patient. “What gives me the most satisfaction is when I am able to do something that is technically challenging. That means when you are able to achieve a successful outcome in a case that is difficult to treat for anyone. A successful outcome doesn’t just mean being able to do the surgery – that is half of it,” elaborates Dr Shailendra.

“The outcome is sometimes dependent on more than just the procedure itself. Rather, it is dependent on your after care. When you are able to achieve a successful surgical outcome three or four months down the line – from the time you did the surgery, patient is now free of disease, the area you operated on is still free of disease and has maintained the structure you have created – then yes, that gives you the most satisfaction,” he continues.

As a tradition at Sunway Medical Centre, the team throws celebratory parties for the first switch-on of cochlear implants – a significant moment for the parents, considering how much they have gone through – from accepting the diagnosis until the child’s major surgery. “When you first implant it, it isn’t functioning yet because only the internal component is implanted. The first switch-on is when the audiologist attaches the external component, and then switches it on. The patient only hears sound at the outset. We celebrate by having a banner, inviting guests to join us; like the patient’s family. There’ll be cake and food, and everyone’s singing to the ‘Happy Switch-On Song’,” shares Dr Shailendra.

Keeping up with the times

Dr Ho Eu Chin, a consultant at Tan Tock Seng Hospital’s Department of Otorhinolaryngology (ENT) notes that hearing implants such as cochlear or auditory brainstem implants have revolutionised the management of hearing impairment. As roughly 50 to 60 cochlear implantations are performed in countries such as Singapore annually – constant refinement in technology is vital. In Malaysia, Dr Shailendra relays that University Malaya alone (where he worked for a period of time) performs eight cochlear implants a month.

New technology is being researched and developed regularly to increase efficiency in this domain. “We have a lot of new equipment you can use. For example, in ear surgery, a new treatment method is endoscopic ear surgery. Sometimes combining microscopes and endoscopes during surgery provides better visualisation. For the nose, method like ballooning, which is a less invasive form of sinus surgery, is new. For head and neck, there are techniques like endoscopic retroauricular thyroidectomy,” asserts Dr Shailendra.

It is important to stay updated when working in this field – as Dr Shailendra emphasises – through channels such as online publications, courses and conferences, which provide the opportunity for knowledge sharing and increased exposure to new treatment modalities.

To aspiring otorhinolaryngologists out there, Dr Shailendra says, “You really need to have the motivation for it because it is a long road.” Photo credit: Sunway Echo Media
To aspiring otorhinolaryngologists out there, Dr Shailendra says, “You really need to have the motivation for it because it is a long road.” Photo credit: Sunway Echo Media

ENT in Malaysia

While relating this field of expertise back to our local scene, Dr Shailendra shares some insights into the demand for otorhinolaryngolosists. “Most specialists in this field are concentrated in the heavily populated parts of the country and the distribution is not equal. We probably need a better distribution of sub-specialisation. A lot of ENT graduates want to sub-specialise in rhinology. Not many want to do head and neck, larynx or ear. There is no system currently in place to regulate this. It is solely the graduates’ choice,” remarks Dr Shailendra.

Malaysia has an ENT programme that is well established with good techniques. “The only thing we are lacking is skills updating. It is not mandatory here. Sometimes, new techniques learnt in places like CMEs help to show that your skills are current. However, in terms of surgery, there is no mandatory up-skilling for surgeons. If you are used to doing something from the 1980s – there is no one to compel you to improve your skills. Most surgical specialities are the same,” highlights Dr Shailendra.

To those aspired to immerse in this field, Dr Shailendra advises that one really needs “to have the motivation for it because it is a long road. I meet a lot of house officers and medical students wanting to be neurologists or paediatric cardiologists or orthopaedic surgeons. It’s a long road for you to be so specific. You may find that you like something else along the way. Don’t be narrow-minded and do not have tunnel vision. The bottom line is you have to do what you are passionate for – else, you won’t be successful.” MIMS

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