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Ok. Hi, everyone. Thanks for joining us today. My name is Anastasia and I'm part of the careers team at mind the bleep. Um We have some new members on the careers team, including myself and we are going to be producing a series of webinars and articles um talking more about different specialty trainings in the UK as well as alternative career options. So to start off with, we have uh Mr Nate Steiner with us today. He is a consultant ent surgeon um from Slovenia. He moved here to do a fellowship in skull base surgery. And today he's gonna be talking to us about um different subspecialties of ent um common pathologies and surgeries seen as well as the day and the life of an En TSH O registrar and consultant. There'll be time in the end for questions and um I believe you'll also get a certificate of attendance afterwards which you can add to your portfolio if you would like to. So, over to you, Nate, thank you. Hello, everyone. So, yeah, like Anastasia mentioned today, we're gonna talk about how a day in Ent looks like. Um I'm coming from a small country. Uh in the heart of Europe. And for those who haven't visited, um it's a really beautiful country and I uh if you have a chance every in the future to spend a few days uh there, I'm sure you're gonna like it. I guarantee it. So I finished my medical degree in Slovenia uh in Igan on March of 2015. And then I did a residency in Ent uh University Medical Center in Humana from 2017 and until March 2022 and I continued to work there as an ent consultant and I was uh head of uh NTE NTA mu department and head of ENT hospitals residency program. I also did a phd which I finished this year in February. I studied the effect of platelet rich plasma in the treatment of tympanic membrane perforations and as Anastasia men, men, hematologist and skull base surgeon. And in order to um learn about called the surgery, uh a fellowship is needed and I decided to do one in Manchester. So, so I had to move to UK in September 2023 when I started and now I'm slowly finishing this year, have approximately one month left. And then I've met and joined this group of great surgeons. One of them on my right side in the picture is uh Pro Floyd on the other side, uh Mister Freeman, and I liked it here in Manchester so much that I decided to stay So in September 2024 few months, I'm starting as a consultant in uh Manchester University NHS Foundation Trust. So why have I decided to become an ENT um I was introduced to Ent in my fifth medical year. Um And at that time I decided that I lost interest in uh f facial uh in the plastic surgery and um cardiothoracic surgery that I was interested before. And I was searching and waiting for something to inspire. And when I went to um Ent and Ent Clinic to be more precise, I saw um cochlear implant fitting or in different words, the first turn on of the, of the, when they turned on the uh cochlear implant for a child, which was one years old and to, to see all those emotions of joy and happiness. Uh when he, he heard his mom's voice for the first time, um must said that it really inspired me and um I decided to become an NOTO and this time I'm, I've been involved in approximately 200 cochlear implants and I've done approximately 100 myself. And still, every time I do it, it brings a big smile and a lot of happiness to me. And um it's really, it's really, it's really inspiring that with medicine and a small device that we insert an electrode into a co that we can create hearing. And uh I love it and that's why I decided to become an ent more precisely aist. And for those who haven't seen how it looks like when a cochlear implant is turned on, um I suggest that you scan this QR code and it's gonna take you to youtube channel. There's a video of uh different um different people who experience the, hear the sound um for the first time, you know, it's, it's lovely and um and invite you to see for yourself. So if you continue, um and talk a little bit about which subspecialists are part of an ent as from the name suggests, ear, nose and throat. Uh If we start with nose rhinologist, see patients who have different pathologies. For example, on the top left picture, we see a deviated septum and these patients have problems with breathing through the nose and then with the surgery, we can improve that. Uh we can straighten the septum and improve the breathing through the nose. On the picture. On the top, right, we see a as somatic presentation sagittal view of a patient with uh coral atresia where basically the nose is blocked from the uh from the throat. And on the bottom left picture, we see an endoscopic picture of a nasal polyp that obstructs the brain, the passages of the nose. And on the bottom, right picture, we see a chronic uh maxillary Rhinos stenosis and in these kind of surgeries, a surgeon needs to open the passages to the sinuses in order to improve the clearance pathway. And help the patient. Other pathologies could be uh nasal septal perforations, nasal fractures, tumors, cerebrospinal leak, rhinorrhea, et cetera. Um How do we approach the nose? So we can do the examination with something called an interior nosy. What's what we see on the top picture? It's basically where, where we use a speculum and just divide the nostrils and look into the nose. We cannot see much, but we can see if the patient has a septal deviation or if there is like hypertrophy of or if there is a foreign body sound as we can see it like this. If you wanna inspect the nose a little bit more in detail, then we use a nasal endoscope. We have two types uh of endoscopes. One are flexible and one are uh rigid. And for the nose, we mostly use rigid ones because a lot of times you have to go in and just push or move something in order to get a better view. So we covered um nose and if you talk about the throat, uh laryngologist or, or ent specialist who subspecialized in um laryngology, I see patients with different pathology, for example, like um dysphagia, dysphonia in patients that have other pathologies in throat also includes queeny abscesses or quinsy uh tonsillitis. Mm Other tumors or other pathology. Here in the bottom picture, we see a cleft pellet, mostly maxillofacial surgeons operate that. But we see a lot of patients like that on the top right picture, we see a quesy um I mean on the top left picture on the top, right, uh we see a pathology on the vocal cords and also on the top, on the bottom, right picture how do we approach the larynx? Um in the clinic, we can use a mirror to look behind the, the tongue and see the vocal cords. If you wanna inspect it in more detail, then we can use the endoscope. In this case, it's a flexible one so that we can navigate it through the nose and look on the larynx from above. And on the right side, we have uh two photos of how we do the surgery. We insert the region laryngoscope um in through the mouth into the larynx and then we can uh insert the instruments and operate on vocal cords. Yeah, because it's quite far away. And such a small uh pathology, we need microscope or in some cases, we can also use exoscope. It's really rare. It's pretty rare, but uh it's basically a device that magnifies and presents a picture uh on a screen. And usually it's a 3d picture. If we can, if we continue to the ears ontologist, see patients who has different pathologies again can mention microtia, external canal atresia, ear infections, depending me perforations, hearing loss, vertigo foma tumors. On the top left picture, we see a child with microtia and next to it is a Tympanic member, perforation and endoscopic photo on the bottom, middle picture, we see a tumor of the uh of the ear and on the bottom, right, another tympanic me perforation and that white part that you see, it's a cholesteatoma in grown skin in ee everything is really small in ear and that's why we need a microscope. Or more recently, uh surgeon started also to use um endoscope. Mm I mostly don't just in a few cases we can to look behind some structure that we cannot see with the microscope. And otherwise I use microscope. And on the bottom left picture, you see endoscopic picture of the middle ear and on the finger. And there you see three little ossicles and it can just show you how small they are. The smallest one is called sties and in a disease called autos sclerosis, it's fixed, it cannot move. And that's why we have to insert a small prosthesis through it. And in this surgery, uh we have to make a 0.8 millimeter in diameter perforation in order to put in the prosthesis. So yeah, like I said, everything is really, really, really small. So just to look through everything that I just mentioned. So we have ear, nose and throat, a lot of different pathologies, a lot of different surgeries, different approaches to the pathology, but that's not it. I'm sure you've heard about head and neck surgery. It's also part of the ent and basically it includes different pathology and different surgeries in the region from the neck to the head and mostly head and neck surgeons deal with benign and malignant tumors of head and neck, um deep neck infections. And sometimes when they remove big tumors, there's a big defect and it has to be covered with flaps and they can be local regional and flip flaps, flip flaps and depends on the center. But some, some centers in some centers, ent surgeons do the flaps in some centers, the plastic surgeons do that depends. And I've mentioned that in nose, we usually use endoscopes in larynx. We can use direct laryngoscopy or flexible ones in ears, microscopes in head and neck surgery. Just basically don't use any instruments. Some surgeons use for to improve the silat visualization, the magnifying loops or in some cases really rarely. Um the da Vinci robot can be used in order to operate on the larynx. But like I mentioned, it's really rare on the bottom, right picture. You can see how we operate tonsils. We have a headlamp and on the bottom left picture, you can see a nice example of how surgeon of different sub specialist operate. At the same time in the top left corner behind the surgeons operating on the ear, on the bottom, right? You can see that we have a thing the um the fat uh from abdomen and the closest to us is uh the head and neck surgeons taking the flap from the forearm, radialis So ear, nose and throat had the neck surgery and we also cover pediatric ent, um, a lot of pathologist in cases are similar to the adult one, but they're present in different uh percentages and some of them are also specific just to Children. And then we have also from centers to centers. In some centers, we have only pediatric ent or in other centers, we have um surgeons for that, operate adults and Children. So for example, autolog would operate ears on adults and Children. So it depends again from center to center and last but not least part of the ent is also sway surgery and we divide skull base on the anterior skull base on and on the lateral skull base. The main main difference is that to the anterior skull base, we usually come from the point of view, we come through the uh nose and from the lateral skull base, we come through the ear and these are, this can be quite difficult surgeries. They take a lot of time, for example, for sure. Um most of you have heard about vestibular splenoma. It's a benign tumor of the eighth cranial nerve. And if it needs to be operated, we mostly do it through a approach which is called trans liberin approach, which is basically through the whole ear and inner ear, we expose the tumor and the internal auditory may. And from the anterior point for anterior skull base, we go as mentioned, through the nose and in both cases, lateral and anterior, the ent part is to create a pathway uh for our colleagues neurosurgeons then to operate on the tumor. And for example, the longest surgery that I've been involved in was started at 10 a.m. and we finished approximately at 1 a.m. It was a long one started with us. And we did the approach, for example, for four hours for approximately four hours and was the removal of a big tumor which lasted for another eight. And in the end, also, there was some, the parts that we had to um also do, for example, in some cases, uh the tumor is pressing so much on the facial nerve that the facial nerve or basically, the tumor is growing from the facial nerve and the facial nerve is lost. And that's when we need to do. Also the reconstruction harvested the nerve from the neck and then uh put it in between two ends of the the on the damaged facial nerve. OK. So now I talked about ent and different pathologists and as you've seen, it's a lot of different pathologist. It's a very diverse specialty. And now I'm gonna talk a little bit about how a day in the life of an ent looks like. Mhm. I'm gonna talk how a little bit how the day of an sit registrar and a consultant looks like. So in the hospital, they usually start at 8 a.m. with the morning round. It depends from hospital, from hospital to hospital. But sh register and consultant usually go to the morning rounds there. They can see patients that were admitted from the emergency department overnight. Um They can see patients who are uh uh i in inpatient after the surgery, they can see patients who are admitted for some diagnostic procedures, et cetera. And when they go on the morning round, um they make a plan and treatment plan and uh get some tasks that, that he needs to chase. For example, they need to chase, for example, radiology or something else. And they also carry a bleep usually and then they get referrals which they discuss with the ent registrar who is responsible. It can be called like an on call to the day. Ent registrar or some in some centers. They call them hot registrar, which is basically means that it uh responsibilities for the day are wards and everything, every referrals and uh he's there to, for CS to so that to consult him or her. And then the SHS also cover a rapid access clinic where patients who don't need to be seen immediately but needs to be seen in a couple of days time. Then they come in and they review there and depends from hospital to hospital and the amount of uh sits that are employed. Um Then they also sometimes go to theaters as a retra. Uh as I mentioned, the one who's on call, goes to the morning round. And when that finishes, they also usually carry a bleep or they just reached on, on their phone if needed. And they either go to a clinic where they work with their consultant, um different cases as I mentioned before and they can also go to theater and usually they go there with the, with the consultant and they operate on cases together with the consultant. Um uh or sometimes when they're more experienced, they can also do um few cases on their own more, for example, um like tonsils um or adenectomy and grommets that kind of way. And in the beginning, um on a specialty training, we always start with the um the more general ent surgeries which are tonsillectomies adenectomy and as I mentioned, gromes, and then slowly we progress to more complicated, for example, like uh nasal septum deviations, um hypertrophy of. So we basically do radiofrequency ablation and then we progress and a day in the life of an ent consultant. So every ent consultant has a different job plan um depending on the subspecialty. If the patients are inpatient or the day cases, the day starts with the morning rounds. For example, hematology, most of the patients that we operate are day case. So um we don't, I don't do uh morning rounds. We don't, we don't have patients um hospitalized and then every consultant has a individual individual job plan that consists of 10 professional activities per week. One pa is four hours and it can be a clinic, theater research if it's on the job plan, clinical supervision and teaching. So if we continue and talk about out of hour, uncles uh also depends from hospital to hospital. But mostly if the hospital covers ENT is on site, it depends from hospital to hospital. Again, it can be an ENT sh or it can be an s who covers different specialties at the same time. Uh Inter regrant consultants are on call from home. They have brought us and for example, now I'm on one and six. So I have uh every six day, I'm on call and every sixth weekend, uh some hospitals especially for uh for consultants, they do like week long uh on calls uh or some do like daily. It depends and mostly also depends from trust to trust, but sometimes uh we cover multiple hospitals. So what are ent emergencies or basically what kind of pathology and what patients we see uh on the on call. True emergencies are epistaxis, post tonsillectomy, bleeds area, obstruction, peritonsillar apsis, or Rey deep neck infections, uh foreign bodies, mastoiditis. And we can also say sudden since hearing loss, as you see here, there are different pathologies and some needs to be addressed immediately. Some patient needs to be operated. Uh some patients can be treated with antibiotics or some of them needs to be seen. Like for example, for sudden instance, or neuro healing loss needs to be seen on the first available working day so that we can assess the hearing and then offer treatment uh with corticosteroids. But as a registrar consultant, especially as a registrar, you see in the emergency setting, more different patients, for example, with different infections in the ent area or facial pulses in that kind of way. Um and a really good um how to say an app or to, to use in this uh for S is the ENT app, you can have, you have a QR code here on the bottom, right? I suggest that it's uh really nice. It's, it's, it has the most important emergencies, how to treat patients with this kind of case uh in this kind, this kind of pathology and when to escalate to your senior. So I think we covered a lot and if we start to finish with the best and worst parts of the speciality as in everything, it depends from person to person. Um What I like about ent is the continuation of care, which means that we see patient from day one, we diagnose them, uh we operate them or treat them and then we also see them on the follow up. And that's, I think it's something really nice to see. Um you develop a relationship with your patients and it's II think it's really important that we see the patient from the beginning to the end. I like it. Um and then what else? And a la lot of uh what, what, what a lot of doctors also ent surgeons say is that it's a very diverse speciality. So it means that if you like theater like me, um there's opportunity to operate a lot to do very specialized uh surgeries. And if you prefer more clinical setting and more treatments in the clinic, this is, that's also possible you can um create your practice uh in that kind of way. So, and, and because this is available, it also means that for example, when you were younger, you can um do something more. Um And then when you get older, you can change your practice in maybe to include more clinical setting in that kind of way. So that's a really good thing um from the bad things. Um like I said, from it's different from person to person and we just, we can only hope that the, that the bad things from the specialty are temporary and um that don't happen that often. And as I always say, um being a doctor is not an easy, easy thing. It's um a lot of stress, a lot of hard working hours and it helps if we choose something that we like. So I will suggest to everyone that you all think about the things that um inspire you, speciality, didn't inspire you and then pursue that, pursue it and that kind of way, it's gonna be easier and you're gonna like it more if we just touch a little bit on the training program. So there was some part in the last years when there was a run through program, but they stopped that. So if you want to become an ent, you have to go through the core s core specialty training and then into higher specialty training. But I'm sure mo more things will be posted from mind to bleep. Uh So just uh stay tuned and uh I think that everything is gonna be covered and now we're back to you Anastasia and if there's any question from the audience. OK, great. Thank you so much. N it was really informative. Um So if there are any questions from anybody, feel free to put them in the chat, um I did have something I wanted to ask um when is it possible to be a generalized ent just where you sort of do all parts of the ent or does everybody subspecialise? Yeah. So that is a possibility. Yeah, especially in, like I said, from different hospitals from it's different in different hospitals. So it's a smaller hospital usually um more do doctors would do a general ent like tonsils, septums and that kind of way. And if it's a tertiary center, then uh doctors are more specialized into one subspecialty or sometimes they cover two, depends on the needs. OK. And when you're on call, do you think cover all of ENT? Yeah. So that's one thing, yeah, even if you um autolog and skull base surgeon uh on call, I cover, we cover everything. So from those and also depends from the center again, if it covers Children. So also sometimes we have to also cover Children, pediatric ent. Ok. All right. And then um also as are all the procedures done generally in theater or do you do some procedures in clinic or in local? So, so yeah, the the nice part of ent is that a lot of things can be also done in the clinic. For example, from ontology. Uh we do trans panic injections uh in clinic. In the treatment room, we spray silicone, spray into the ear, it numbs it up and then it is a really thin needle just to insert it, we can insert gromes. Um uh we can do a myringotomy, we cut, make a little cut in the eardrum and then aspirate the fluid behind the ear and immediately for the hearing of patients, for example, after an ear infection. Um and also some things can be done from the nose from in rhinology and also especially laryngology. A lot of things can be done in the clinic. For example, they have flexible endoscopes with a working channel. So they can insert uh like instruments through it and they can remove some polyps or something from the larynx and or they can use also a laser uh in the clinic and remove polyps and then the patient goes home immediately after the procedure. Interesting. All right, we have a question on the chart. Um Would you recommend any resources or journals that that would help us understand more about the demands of the different subspecialties within Ent? So, um I would recommend two things. One is uh Ent UK web page. There is uh they have offers a lot of different um it like subspecialties courses that are available conferences that you can attend. And it's uh it's, it's really detailed. So I would recommend that it's called ENT UK. And the other one is from the RN. Um They also have a autolog division or Rhinology laryngology and it offers a lot of um like different um introductions to Ent and also offer conferences and they're mostly held in London and it's, it's, it's a really good, nice thing. Yeah. OK. Another question um is there much overlap between ent and anesthetics and airway emergencies? Yeah, of ent anesthetics in, in every emergencies. Yeah. So um it is uh for example, it, we all know if it's an there's an airway emergency, a true airway airway emergency needs to be addressed immediately. And um ent registry and consultant are on call from home, which means that we need sometimes up to maximum 30 minutes to get into the hospital and that it means that anesthetist or has uh needs to address the patient with uh air obstruction, which means that usually when you arrive the area is, is secure. Ok. So if it's like a tracheostomy or something, yeah, exactly. We work, we always work together. So they, um, they create, they, they secure the airway, for example, intubate the patient. And then we address um, the reason for airway obstruction. Sometimes if it's a, if it's a, if it's a tumor that's obstructing it, we need to proceed with the tracheostomy. Sometimes it can be, sometimes we can just wait or sometimes we can give some corticosteroids. And that helps, depends from case to case. But yeah, usually it's the anesthetist who um secures their airway, helps the patient immediately and then we address the the problem later. OK. Another question in a week. How much time do you spend in theater? And how many clinics do you do? And then if you are a skull base surgeon, do you do other generalized clinics or only your subspecialty? Yeah, it's a really good question. So, um how many theater in clinic? So now that I'm on a skull base fellowship, which basically is meant to, to be that uh I operate, the fellow operates as much as possible. Um I'm mostly in theater. Um but registrar depends um depends also on the trust and depends also on the hospital. Um But mostly there is, there's like a day in hosp in theater and day in clinic and then they in doing something else in that kind of way. So it's um it's difficult to answer. Um But for example, in II, in the hospital that I work now, I think they would, there are um 13 or 43 to 4 registrars uh in the list every day. So there, there's always a registrar on the theater list. We try to maximize that as much as possible as a, as a consultant starting for September. And then it's like, for example, a plan would look like on Monday, we'll do a clinic Tuesday, also clinic Wednesday theater and half a Thursday clinic. And then it's a little bit changes in the week one and week two. So I would say mostly 50 50% of that kind of. OK. Um So yeah, another question was if I was called by surgeon, do any generalized clinics along your subspeciality. So we um as an ontologist and lateral skull base surgeon, then I all cover only um ontology patients and skull base, lateral skel bases patients. But this is again me uh different from hospital to hospital in our hospital, which is a tertiary center. We're very specialized and we do only our subspeciality except when we're on call. OK. But perhaps at a smaller hospital like a district general Hospital, the might have clinics with all areas of ent Yeah. So uh the case, this case is for me, but there are, there are doctors who would do, for example, um they will have voice clinic and then they will have normal generalized ent clinic and like that. And then you have rhinologist who do just rhinology and interior clinic. So it it depends and it's um the nice thing is that you can choose how you create your breakfast, breakfast. Mhm. Ok. Um Just wait to see if there are any more questions anyone wants to ask. No. Ok. Well, thank you so much for talking with us today, Nate and thanks everyone for joining. Um I hope you found it useful um and beneficial. Oh, you have one. Just thank you. Thank you. Good. Ok. Yeah, so thank you. Thank you everyone. Thank you s and mind the bleep. Continue doing the great work. All right, thanks very much. Um And you can fill in the feedback form, um It's posted in the chat and then you also get a, a certificate of attendance as well, like I mentioned at the beginning. Thank you. Thanks.