Volume 7 Issue 3 - 2014

We have an excellent issue with many articles pertaining to training and therefore I am sure it will be of interest to both trainees and trainers. There has been much debate recently amongst the ENT community in the U.K. regarding the selection process and the training of future ENT Surgeons and there is no doubt that the debate has some way to go before we find the correct answer to this challenging issue. However it is generally thought that the selection process continues to select excellent trainees and some of the articles in this issue highlight the fact that trainees, as always, must continue to work hard throughout the training program to obtain a Consultant post. With the reduction in working hours simulation will continue to play an ever increasing role in training and Professor Nirmal Kumar and his team have provided us with some excellent articles on this topic in this issue.

Training in otolaryngology is very exciting because of the opportunity to learn a wide range of complex technical skills. Traditionally these skills were obtained through an apprenticeship model of training and supplemented by the easy availability of cadaveric material such as temporal bones. The current difficulty in obtaining these and the advent of an increasing range of non-organic simulation models gives us the opportunity to accelerate skills acquisition before stepping foot in the operating theatre. The airline industry has also taught us the benefits of using simulation in training and the enormous strides in airline safety over the last 50 years needs to be matched in the healthcare industry.


Bone anchored hearing aid (BAHA) surgery is increasingly being performed to rehabilitate hearing in adult and paediatric patient populations with a wide variety of underlying aetiologies. In carefully selected patients BAHA is generally a well tolerated day case procedure with favourable long-term outcomes. Here we review a variety of the common and relatively rare complications that have been reported.


In the current age of austerity, clinicians are expected to provide a high-quality but cost-effective clinical service. This is a particular challenge in surgical practice, primarily due to the overall cost of operative procedures, particularly when requiring admission. Innovative techniques applied in the outpatient setting may help achieve this. Balloon sinuplasty can be performed under local anaesthetic in an outpatient setting in a selected patient cohort.


Since the introduction of highly active antiretroviral therapy (HAART) to combat HIV disease in 1996 there has been a shift in the focus of its management from that of a rapidly life limiting condition to one of chronic disease management, in the developed world.

As ENT surgeons may be involved with the care of these patients increasingly from a chronic disease perspective, a sound knowledge of its manifestation in the head and neck is needed. We also look into conditions that have now become pathognomic for the disease and explain their aetiology.

The eyes play a critical role in human expression and communication. The dynamics of the brow and periorbital region enable a person to convey emotions. Changes in positioning of the brow, furrowing of the glabella, alterations in the shape of the palpebral fissure, and fullness or sagging of the lids during the process of aging, may significantly alter a person’s expression of emotion.

The structure of surgical training in Otolaryngology in the United Kingdom has changed dramatically due to the introduction of the European Working Time Directive (EWTD), which has caused training curriculums to change from being time-based to competency-based. Due to this reduction in surgical exposure, simulation is a method of training which is starting to be utilised to maximise training opportunities. This article is an overview describing what simulation is, how it is being used within Otolaryngology and what we can expect in the future.



Temporal bone surgery is a difficult and complex skill to learn. In response to the limited availability of cadaveric temporal bones for training and the reduction in surgeons working hours, virtual reality temporal bone simulation has been developed. This review evaluates whether training utilising virtual reality temporal bone simulators improves clinical operative skills.


A comprehensive literature review was conducted via NHS evidence and pertinent articles were reviewed. Seven experimental trials were identified, as well as two relevant comparative questionnaires.


The results indicate that virtual reality simulator training is beneficial. Positive outcomes were identified when cadaveric temporal bone dissection was undertaken after virtual reality training compared to either cadaveric practice or no tuition. There was limited evidence indicating the transferability of these results to real-life operating. In addition no data was available about the long-term benefits of virtual reality training and no information about the cost effectiveness of virtual reality simulators.


The limited data available supports the utilisation of virtual reality temporal bone simulators, especially in the novice phases of training and for the more complex parts of temporal bone dissection. In view of the heterogeneity of evidence available, further research is required into this developing area.


Objectives: To assess post-operative shoulder morbidity in patients undergoing various types of spinal accessory nerve sparing neck dissection.

Design: All data was collected prospectively. A standardised quality of life questionnaire was used to assess morbidity subjectively. Physical examination of the shoulder, including range of motion with a goniometer and muscle strength using the Oxford scale, was performed to assess morbidity objectively.

Setting: Head and Neck cancer department at Royal Glamorgan Hospital.

Participants: All Head and Neck cancer patients who underwent neck dissection between March 2010 and October 2011.

Main outcome measure: The relationship between the level of neck dissection, with or without adjuvant radiotherapy and degree of post-operative morbidity.

Results: In total 50 neck dissections were performed during this timeframe of which 44 were suitable for the study. All levels of neck dissection were associated with a degree of shoulder morbidity. Clearance of level V nodes was associated with the greatest degree of shoulder stiffness and weakness. Adjuvant radiotherapy did not influence patient outcome.

Conclusions: The study confirms that level V dissection is associated with greatest degree of shoulder morbidity.

We are well into the second decade of the 21st century and many aspects of training seem to change at an exceedingly fast pace. Surgical training in this age is very different to what it was when the current supervisors were trainees themselves. This change, sometimes unjustified or unexplained, brings many new challenges to today’s ENT trainees. Some changes are brought to improve training, others to improve services but many are focused on patient and health professionals’ safety. Errors and untoward incidents are extremely costly in terms of time and resources; something all parties would rather avoid.

The requirements for ENT trainees to achieve their CCT are clearly set out in the ENT curriculum on ISCP (www.iscp.ac.uk). The purpose of this article is to clarify these requirements so trainees understand what is required of them to satisfy the standard that the GMC (through the SAC) has set for a competent emergency safe consultant otolaryngologist.

The Spinal Accessory nerve is a very popular topic in the FRCS viva. Questions may crop up in the cadaveric neck specimen section or during the operative surgery viva. You should be fully conversant with its surgical anatomy.


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