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Welcome back, everyone. I know we've got a few minutes to go until the uh 335 timeline. We've got Mister Liam Highland with us gonna talk about a career in ear, nose and throat surgery. He's assured me that it's gonna be a very interesting talk and uh I'm sure many of you will be persuaded to, to join the specialty going forwards. So without any further ado if you're happy to share your screen, um, whenever you're ready, I will share away bear with. Uh OK. I'm assuming you can all see that first slide all. Ok. Yeah, if you just press hide on that little T oo, right. That's fine. Go back onto that. Yeah, that can be seen all perfect. Ok. Uh, afternoon everyone. Um I hope you've had a good day so far listening to all the different specialties, but now it's the time to listen to what is undoubtedly the best surgical specialty, which is, of course ent so I'm gonna be going over everything there is to do with it and also then focusing on, um, you know, training and things like that, which I know you've already had talks about with other surgical specialties. Er, I'm Act Two, working in the East Midlands, er, specifically at the Queens Medical Center in Nottingham. Um, and yeah, I'll get, I'll get started. So why choose ENT, so the first bit I've actually focused on here is a, this is a, a survey result that came from the, the GMC survey sent out in 2018 where they were focusing a little bit or part of it was focusing on what specialties make the happiest doctors. And obviously comparing overall satisfaction, er, with workload and as can be seen, ent kind of come slap bang in the middle there, er, seems to do quite well on the better side of the scale in terms of overall satisfaction and again, slightly over on the best side of the scale in terms of workload. So, er, what can be appreciated here is that while some of these specialties have much better overall satisfaction, the, er, management of workload is not necessarily, er, the same. So I think this is important to remember that ent overall does create more satisfied, er, doctors but also has a workload that is, er, within reason, fairly manageable. And again, there's a few other surgical specialties that are the same. Er, the other big thing about ENT is that there is a strong medical aspect to it. So there's medicine involved, there's surgery involved obviously, er, and, um, in that regard, I think back to a quote, er, that I think Claire Marks, er, said she was a former president of the Royal College of Surgeons where she said that, er, a good surgeon, er, knows how to operate. Er, a better surgeon knows, er, when to operate, but the best surgeon knows when not to operate. And I think having that sort of phrase or quote in your head is a very, very worthwhile thing going forward. I think about it all the time And I think it's certainly apt when it comes to ent surgery. Another good thing about ent we deal with presentations from a variety of ages, literally from when a child is born, maybe with some airway problems all the way up until the end of life with a patient that may be suffering with a very advanced head and neck cancer. So in that regard, there is a lot of variety on a daily basis. And I think that's another thing that I absolutely love about ent um, it's very hands on. It's a very, very hands on specialty, not just in the operating theater, but also when you're on call, when you're on the ward, when you're in the emergency clinic. So for nearly every patient that you see, you will be looking in their ears, you will be having a look, uh you know, be using the headlight and the tongue depressor to have a look in them mouth. You'll be using the thud speculum here to have a look in the nose, you'll be palpating their neck for any lymphadenopathy or any uh lumps or bumps that may have come up. You'll be doing this as well. F ne flexible nose endoscopy, we do this on a daily basis for patients. I'm on call today and I've already done about two, if not three of these. So again, if you like using your hands, if you like being hands on with patients, it's certainly a specialty to think about because it is very, very hands on and to a certain extent, the fact that you can get directly involved with your hands and assessing patients managing them independently when they get better, you can say to yourself. Well, I'm the one who's instigated all of that, I've managed to assess them properly. I've either drained that Quinsy or I've caught to right that leading point and now they can go home. So, and again, getting further advanced into training, you can say, wow, I've done that tonsillectomy or I put that grommet in, er, or I resected that tumor and again, it's all that hands on exposure and having that direct care of patients and feeling as though you've, you've done that full job, uh, you know, from start to finish, er, bringing all of that together is, is in a case of what is essentially a tonsillectomy here and you can see just how much, er, there is equipment and tools being involved. So we have, you know, the surgeon using their headlight here. They've got some bipolar diathermy in the right hand. They've got some Dennis Brown tonsil holding forceps in the left. We have the Boyle Davis mouth gag in situ it's secured in place with some drain rods. We have some tonsillar swabs. You know, we have a tonsil tie. So you can see just even for one procedure in theater tonsillectomy, the most common ent procedure, er, you're having a lot of equipment involved. So again, if you like using lots of different equipment and instruments and you like getting your hands involved, then do really consider ent another big part of the NT, which again is a, what I love about it is the anatomy involved. Um, arguably head and neck anatomy is the most complex anatomical area. Um, indeed, I remember when I was revising for MRC S, it was always the part that most of us dare I say, hated the most because there was always a large amount of it. But uh it was through that revision that I became, I fell more in love with the specialty. Er, so again, there's such a wide variety of head and neck procedures that can be done and that could be appreciated in pretty much any head and neck operation, whether it be a neck dissection, laryngectomy, thyroidectomy, er, submandibulectomy, parotidectomy. So, yeah, lots of nice anatomy involved. So, if you've always enjoyed anatomy again, do consider ent, now I know that the previous doctor, Doctor Barts, er, mentioned about urology being the friendliest surgical specialty. But I'm sorry, I have to disagree. Ent is the friendliest surgical specialty. Um, and again, I think having that good camaraderie with your colleagues, er, is what helps to make every day, such a pleasure to work in that specialty. Um, so, yeah, I'm sure there's probably been surveys and studies done on this, about the friendliest specialty. Uh, I don't know exactly what is number one, but II wouldn't be surprised if ENT does almost come out near the top. So, um yeah, do bear that in mind if you're looking to work with um other individuals who don't take things too seriously but are, you know, are good, they are hard working surgeons and they like to have a good time as well and they like to have a good balance, good work life balance. Then again, do consider ent so just in terms of what ent surgeons do, I've already covered this a little bit, but essentially we are dealing with any uh diseases that are affecting ear, nose and throat principally and also head and neck in general. And I think the important thing to remember here is to, to what extent that impacts on a patient's life, hearing, balance, breathing, eating, speaking, these are basic functions that patients need to have on a daily basis to go about their daily lives whenever anything affects any one of those, it honestly has such an impact on them because they've, they've probably not been used to it before. So if we can do anything to try and help improve those basic functions, honestly, you are never gonna get enough gratitude from a patient if you're able to do that. And again, that er feeling of reward you get from it is um you know, honestly, so good. The other thing to say is that there's almost about 1500 ent surgeons working within the NHS. And this is going by a workforce report done by the R CSU K earlier this year. So in that regard, it makes them one of makes us one of the biggest surgical specialties actually within the NHS. Er again, it's highlighting here the fact of how there is a strong medical component associated with it. So again, if you're in that camp, whereby you're applying for surgery, but maybe you're not quite sure whether you are, whether your heart's fully into the full surgical side of things or if there's part of me that's thinking, well, actually, I did quite enjoy my medical specialties when I did them again, consider ent because there's always gonna be that medical input involved. This is an important figure here, only about 15% of patients being seen by ent surgeons will go on to have an operation. Again, I bring you back to that quote, the best surgeon will know when not to operate. This is not about, you know, later down the line, getting all your cases, getting all your numbers operating on every patient. No, we wanna see patients. We want to fully assess them and we want to see actually do they need to have an operation? Can we employ conservative treatment measures to try and help get them better before we even need to step foot in the operating theater? And again, the variety of age groups brings with it a variety of presentations. And I think that's what makes G ent so great and so variable. You are not seeing the same thing every single day, every day is a new problem and a new challenge and a new way to have fun just to come on now quickly into the subspecialties within ent. So we have autolog dealing with the ears. This is the endoscopic image of the middle ear in which the tympanic membrane is either completely perforated or been retracted. Er, we can see some very nice complex anatomy here. So we have part of the Incas, er, we have the stapes here that's going into the over window. We have the round window here. We have the promontory, very nice complex anatomy, very fine working area. So again, if you are potentially interested in working in nice type, you know, small spaces which I know is not to everyone's interest, then autolog is something to consider. This is an endoscopic view of the inside of the nose. So this comes under rhinology and we have the septum on this side and we have the inferior turbinate on this other side. And this looks like either to be a very large nasal polyp or some other sort of tumor potentially, which will no doubt get biopsied and we will have a dissection via the use of a microdebrider. Then er, we move on to disorders, disorders, sorry of the voice box. Er, this is a very young pediatric airway in which there can be evidence of what's called laryngomalacia. So this is essentially where you have weakening or softening of the structures around the voice box and the larynx. And you can see here, you've got a very tight omega shaped epiglottis. We have very tight aryepiglottic folds either side and we have flapping inwards of arytenoids, er arytenoid cartilages. You can just make out this patient's airway here with the vocal cords either side. So again, this would no like no doubt require some form of surgical intervention to snip away some parts here to try and help open up the airway, essentially er facial plastics. I know this looks like a very drastic image. This is essentially an open septorhinoplasty. Uh The thing to mention with this is obviously going down to something like facial plastics is obviously gonna give you a bit of a gateway to going down to something like private practice, which is obviously always something that we want to consider. We like to say that we're not going down to surgery for the money, but I'm sure somewhere along the line, it's quite a nice thought to have if you, you know, f further down the line, if you are wanting to potentially go down a, a private route. Uh So yeah, that's another subspecialty pediatrics. Uh The most common operations you're doing in this regard will be tonsillectomies and grommets. Uh tonsillectomy being performed here by the use of coblation techniques. So this is to a certain extent, an up and coming technique. It's actually been going around for the past 10 to 20 years. But in the last 5 to 10 years, it's really come to the forefront of the anti surgery. And it's essentially whereby the tonsillar tissue is being dissected away by the use of radio frequency waves rather than the standard using some um er metal dissected to kind of away at the tonsil. This is kind of um shaving it away on the top and you can see the forceps are being used here to make sure that the uvula is fully pushed out of the way. So it's not getting damaged and grommets. Yeah. So most commonly for pediatric patients is being done for recurrent or persistent glue ear. And again, it's to try and help equalize the pressure between the outside and the middle ear. And then lastly the very big subspecialty of head and neck surgery. This is a proper big boy anatomy, big boy surgery that's done with an ent huge subspecialty, lot of responsibility given over to this in terms of you, if you are a head and neck consultant, this is an intraoperative view of a laryngectomy being done and we can see that the tracheo has been completely cut into and we've got the endotracheal tube literally going into it from the front of the neck and we have other associated very complex anatomy either side by way of the large vessels. And we've got stenoclada mastoides, er, coming into view. And then on the right here, we have an interoperative view of what is actually a thyroidectomy. Now, for orientation purposes, we have the chin here and we have the chest uh just on the bottom part here. This is actually one thyroid lobe, this is the left thyroid lobe and I believe this, this is the right thyroid lobe. Um whether this is a cancer or not, that would be proven upon er sending us off for a biopsy. I wouldn't be surprised if, if, if it was indeed cancerous, but obviously, this patient has no doubt had this procedure done to help relief of compressive symptoms from this. So we've covered all the different subspecialties as you can probably appreciate compared to other surgical specialties, like maybe general surgery, urology, TN O ent has loads of subspecialties. So if there's an area, if you think to yourself, oh, I'm not particularly keen on ears or I'm not particularly keen on the voice box stuff, don't worry about it. There's plenty of others to choose from granted. When you go through training, you're gonna have to become accustomed to all of them. But there's so much to choose from. There's such variety. So do remember that the thing about ent because we're dealing with everything, head and neck related. We liaise with loads of people, audiology, max facts, plastics, oncology, radiology, speech and language team, dieticians, we liaise with them on a daily basis. So it is very much a multidisciplinary team specialty and multidisciplinary team plans that we're putting in place for patients. So again, we're working with such a vast variety of people. So in that regard, again, it's a very social specialty. We're getting to know lots of other people, common ent operations. I've already covered this a little bit but most commonly grommets, er adenoids and tonsils, septoplasty fes, which stands for functional endoscopic sinus surgery. So that's for clearing out sinuses and tracheostomy. Now, for those of you who aren't er exposed or haven't been exposed that much at ent you might think. Oh God, are you doing emergency tracheostomies every day? The answer is no, there are a lot more advancements er made now within er, the techniques and the skills of anesthetics and they can intubate quite a lot of very tricky airways. We are not having to do front of neck access and stab uh slash tracheas on a daily basis. Don't get me wrong. They do happen, but it is not as common as what it probably used to be. The other thing to remember is that tracheostomy is not just an emergency procedure, it can be done as an elective procedure as well. So just to come on quickly to the training pathway, I know this picture has already been used during the course of the day today, so I won't go into it too much. I'm assuming most of you are around this F two slash F three F four trust grade level. Um So you're, you're, you know, I'm sure sure all of you are looking to apply for course surgical training at the moment. I've added a few bits and Bobs in here in the way of exams and the fellowship part at the end. So, from my perspective, er MRC S part A, if you haven't got it done already, then get it done is my simple statement for that, the sooner you get that done the better. Um because when you come onto course surgical training, you will be busy trying to get your numbers in, get your publications in presentations, audits. And the last thing you're gonna want to have lurking in the background all the time is the ning thing of the exam. Um If once you've got your part A done, then it's moving on to the to the part B. Now again, I'll briefly mention cos some of you may already be aware the MRC S Ent which has for a while been its own separate part B exam that is uh going out of fashion and that is going to be done come February 2026. That is the last sitting for that after which time it's gonna be the MRC S part B. So, so that I will say that if any of you right now are thinking yes, full steam ahead ent, get your part a done and then get your MRC S ent done before January 2026 comes around. All right. Er Fr CS is obviously the exam that you're going to be doing. When you go on to become a consultant, you don't need to worry about it now, but I'll put it in here just for a reference that it will be being done from when you are at least ST six and above fellowship. So again, this is where once you've completed your training and you've done all the way up to ST eight, you will have some at least one if not two years, er, working within a particular subspecialty. So, er, one in which I've heard a lot about recently is head and neck, for example. And the head and neck consultants that are working here at the Q MCI, think all of them have gone out to do one if not two years out in Australia or New Zealand. It's a very, very good head and neck fellowship is what I've been told, but there's obviously multiple different subspecialties and multiple different areas in which to do that fellowship. Now just coming on to application side of things and I literally just copied and pasted. What is the E NTS T three National Recruitment Self Assessment guidelines for this coming year? So this is what I've had to have drilled into my brain because I'm applying for ST three this year. Er The main thing to say about this at the moment, I appreciate you guys are going into core surgical training and not into ST three. So this may be a little bit more advanced at the moment. But the main changes are that they have focused on quality rather than quantity. And at the moment, going by this year, they have scrapped allied specialties as giving points. So remember that as to whether that's gonna come back into the fold in a year or 2 may be the case, but we won't know that until they then re release it in a, in a year or so's time. So looking here at time in ent as long as you're making sure, as long as you make sure you're getting that minimum of six months and not going over two years, then that will get you the maximum points audits again, instead of them looking for four or five audits where you've already done one cycle, they want audits in which you have been involved in leadership, you've done a couple of cycles, you've invoked change and you have presentative at the meeting. Doesn't matter how complex or how simple the audit is. If you've done two cycles and you can see that there's been an improvement and you've presented it then that is good enough for them, er, publications. Again, I appreciate they are difficult to get. I've had a struggle with this, to be honest with you, er, and what you can probably see here, things like editorials, reviews, case reports, they do still get you points, albeit just the one point now. So if you are gonna go down something in the way of research and publication, which I will obviously advocate to do, you need to try and get something that's gonna be a little bit more worthwhile and be deemed a little bit higher class and more quality. Er, that's what they're really looking for here. Er, presentations again, posters and oral presentations, posters. Again, they get points but your, you know, to get the, to get the top points here, you really need to be trying to get oral presentations, don't get me wrong. They are, you know, it's easier said than done and they can be very difficult to get. But, uh, and again, what the good thing about this application is, they've outlined all the different meetings which will count for, um, where you've presented particular presentations at Surgical Logbook. So this has been the other big, main thing about this year. They are now looking for a minimum of 15 procedures within each category in order to get the maximum number of points. And this time they've separated it out into five separate categories of which you have, er, ear procedures here, which is mostly grommets. We have nose procedures, tonsillectomy, er, throat and neck procedures and then emergencies. Now, as you can see things like uh reduction of fractured nose, you can, they get loads of those done in the emergency clinic. Um things here like removal of a foreign body I and D of a neck, abscess, drainage of an ear abscess. You do all of this when you're on call, you do all of it when you're in e clinic. So if you have an ENT job and you're thinking you might go down ent in the future, log all of these cases on your E log book because believe it or not from now or from before, whenever you've done ent they will count towards ST three and believe me, you'll need the numbers. Ok. So very quickly now just coming on to the competition ratios, I've literally again, screenshot of these er that have been uh you know, over how however many years, no doubt most of you will be aware there's been a rapid increase in competition ratios for co surgical training. With the latest ratio being 5.25 to 1 er ent it did go steep up until 2020. The reason for that wasn't because of the increased number of applications, but actually the sudden plummet in posts and that was again, just because of COVID times, they've now come up to a more normal level with around 60 posts. Er, so almost coming up to 3 to 1 and I do not doubt that this year, the competition ratio will probably go above that 3 to 1 ratio. So by the time you guys apply, if you do go down for ent uh I would expect you to probably still be around the 3 to 1, maybe a little bit higher than that. Uh very quickly going over your responsibilities and what you do as an sho I've literally taken this from my current rotor. Er, these were the two long days I did earlier this week. This was a long day yesterday and this is my long day today. Um So you will have long days where you are on call and you're gonna be seeing things like tonsillitis, quinsy epistaxis, maybe foreign bodies, epiglottitis, er, maybe really bad ear infections, a whole variety of things. OK? And that's probably best for another talk at another time, er, nights again, you know, obviously there's an on call element. You'll be seeing the same sorts of things maybe more. So, seeing trauma, trauma patients dependent upon where you're working and you may have to suture up an ear or suture up a nose or something like that theater. Hopefully wherever you work you will get allocated theater sessions and if not push to get into theater at the end of the day, if you're a core surgical trainee, it is your right to be in theater and it is your right to get the number of cases that you need. So, you know, don't be letting you know as much as they may want to experience stuff. Don't be letting the F twos or the F threes get in you have the priority there. Ok. Er E CIC again, um dependent upon where you work. Sometimes the registrars run the E clinic but sometimes you know, the SH OS run the E clinic if you are working in a trust in which the registrar is running the E clinic go along and say, can I see patients by myself or can I present the cases to you, the more you get hands on, the more you get independently reviewing and assessing these patients, the more comfortable you'll feel with it and dare I say, trust me, when I say the more you actually start wanting to start doing ENT because it is very hands on and it's very independent and then of course, now and again, you'll get your ward er, sessions as well. Er, typical week for an ENT consultant will consist of maybe 2 to 3 days of theater depending on the particular subspecialty. A couple of days of clinic, er, one day of admin slash er, kind of MDT as well as then having supervisor meetings and, er, teaching. Er, how am I for time? Jono? Am I have? I got a couple of a few more minutes still. You've gone over by about a minute? Ok. Fine. Just give me literally one or two more minutes. I'll be very, very quick. Um, these are the different operations that take place in the ent, I've already alluded to the, some of them already. I'm gonna have to skip through these. But grommets we have pan endoscopies and scopes and biopsies. We've got tonsillectomy there. We have septoplasty, we have fes so the endoscopic sinus surgery, things like tympanoplasty and myringoplasty. There. We have thyroidectomies. Er, we have cochlear implants, er, parotidectomy, er, mastoidectomy and revision mastoidectomies, neck dissection and laryngectomy. This is the perfect picture for you to be able to see what is the scope and the breadth of ent surgery. From the very, very short putting grommets in to the very, very long where it made 12 hours plus with the laryngectomy. OK. This is ent in a nutshell. All right. Uh Future VNT very quickly robotics, ablation A I. So, robotics is coming into place for a resection of head and neck cancers ablation is being used more and more. Now for tonsillectomies A I is coming in vastly with so many different surgical specialties and I've chosen a picture here where they're using it for developing the latest cochlear implants. What can you do now to become an ent surgeon. Again, I've alluded to some of these already do audits, make sure there are a couple of cycles and you're presenting them and you're invoking change. Get to theater pro suturing. Even if it's just doing an incision or closing a wound, it's practice. Do your presentations attend courses like this temporal bone course here, publishing journals where you can attend courses in conferences like this one here and I put in the Bao International one, which is our biggest ENT conference where people from all over the world come to it. I don't know where it's taking place actually in 2026 but that is the next time it's taking place. So again, if you're interested in the ent, make sure you come to it. Uh just some quick associations and resources. Er I am the CT rep for a OT. It is our biggest junior level ent trainee er gathering group. It's a great um society, society to be part of very friendly people. Everyone is more than willing and happy to try and help you to develop with an ENT and to become the best surgeon that you possibly can. En TSH O you'll have probably already heard of this and there is an app that you can download for it as that you already know Royal College of Surgeons here, ENT UK and FO UK, which is a student and Foundation Doctors Society for ent all of those are gonna be helpful for you. This is a quick plug for the next a ot conference taking place next next year and it will be down Brighton. So make sure you come along because plenty of people to meet plenty of like minded individuals, great for networking and that is all I have to say sorry if I've overrun slightly. Uh I will leave my email address very quickly on there just for about 1020 seconds. Cos I appreciate we're probably not gonna have time for questions. Uh But yeah, if any of you do have any questions, feel free to email me. I'm more than happy to answer any questions that you have about Ent in general because I love it so much. Um And yeah, thank you very much for listening to me. I hope you have a great rest of your afternoon and remember, just choose Ent cos it's the best specialty. All right. Thank you guys.