ENT - OMFs - Plastics?

[HariSeldon]

Hi Everyone,

I'm not new to SDN, but this is my first time posting. My question is on the differences in surgical capabilities that the various residencies for the following specialities provie : (a) Oral & Maxillofacial, (b) Otolaryngology-Head and Neck, and (c) Plastics. And this is just in the head and neck areas. I was trying to answer this question myself by looking on hospital websites, but the curriculum for residencies is generally very sparce and I only found a couple of hospitals that publish privelleges/credentialling requirements online.

And Im not really bothered about the general convention in specific hospitals or cities, so obviously in Hospital A, ENT may take Patient X, while OMF take Pateint Y, while in Hospital B its reversed. Rather Im looking for what procedures would a surgeon out of residency be qualified to perform in the head and neck. So things like skull base tumors, neck pathologies, facial reconstruction, complec facial trauma etc.

If this question has been asked and answered before Id love if anybody could just copy over any of the good threads, rather than repeating the information that'd be great either way.

Cheers,
Hari

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[hiya20]

Hey,
Current ENT resident here. I may be able to answer some of your questions. If I understand correctly you want to know what a graduate of an OMFS vs plastics vs ENT residency is capable of managing and not so much how it is done at specific institutions. I can probably speak most authoritatively on what an ENT is capable of managing and can add some information about plastic surgery and OMFS.

- ENT: I would say that doing an ENT residency allows you to do the full range of procedures within the head and neck (obviously some of these procedures may require advanced level fellowship to be comfortable with). A graduate straight out of residency would be able to do thyroids, parotids, neck dissections, sinus procedures, basic otology/middle ear surgeries. Most complex head and neck cancers and skull base tumors are managed by fellowship trained ENT physicians. If you are interested in doing head and neck procedures I would say that there are very few doors that are closed to you by doing an ENT residency. The procedures that our typically out of the realm of ENT within the head and neck include TMJ disorders, dental stuff (wisdom teeth extraction), pediatric craniofacial procedures (cleft palate/lip), and obviously anything related to the eye.

- Plastics: Within the head and neck plastics is capable of managing almost all facial trauma cases and are the main players in pediatric craniofacial procedures. Obviously they are most often involved in cosmetic surgeries in the head neck (face lifts, rhinoplasty, etc etc). They will not do resection for head and neck cancers, skull base tumors, neck pathology, or anything ear/sinus related.

- OMFS: I can only make broad claims about OMFS trained graduates because we don't have an OMFS program at my institution so I am not exactly sure what their scope of practice entails. I have often been told that they are most involved with TMJ surgeries and dental/wisdom teeth extraction. They are typically not involved with head and neck cancers, cosmetic procedures, or any neck pathology.

Hope that helps.

 

[InformMe123]

OMS procedures: OMS Procedures | AAOMS

 

[HighPriest]

There are OMFS guys who do cosmetics. It just depends upon what kind and how much they're doing. There are a lot of guys who advertise as "Board Certified Oral-Maxillofacial Surgeon and facial plastic surgeon..." which kind of makes it seem like they're a board certified plastics guy, when they aren't.
I know an OMFS guy who does rhinoplasties, (facial) implants, genioplasties, and of course orthagnathics. But I do think you're pushing the envelope a bit doing that sort of thing, and as stated, you can make good cash money pulling teef, so that's what most do. Technically they can treat trauma and drain abscesses, but they don't have to do it so most do not. Some will excize small oral cancers. I wouldn't let one do that to me. Outside of the US, it's really common for OMFS guys to do head and neck, but it's pretty rare in the US unless they've done a fellowship (and even that is pretty rare). I met an Oral Surgeon once who had done an "oncology" fellowship, and I generally didn't agree with the way he approached things. Maybe it was ok, but it wasn't how I was trained to do it in ENT.

Plastics guys will do free flaps for recon, cosmetics, craniofacial. I know some who will do salivary glands, but not many. But, keep in mind that not all PRS fellowships are the same. Some are hand-oriented, burns, etc. You'll always have exposure to whatever you need for your boards, but if the question is "what will you feel comfortable with out of residency?," then that depends. Same goes for OMFS.

Same also goes for ENT. There are residencies that are very hands on, and you might feel comfortable doing a lot. Some are not. Maybe they're very academically oriented, and you'll feel like you -need- to do a fellowship to do complex cases. I feel like out of residency I could do almost anything except intracranial cases and resections that required free flaps. And for the latter cases, we were doing them and having a plastics guy do the recon. I would not have done an acoustic or something like that, and I also wasn't credentialed to do it. Same with free flaps. But we did labyrinthectomies, stapedotomies, total laryngectomies, split mandibles (again, with a PRS guy if we needed recon), cosmetic rhinos, trauma. I never had the chance to do a skull base tumor, but if I was assisting a neurosurgeon, and the stars were aligned, I might have. I didn't to a facelift, but I could have for sure. Of course, we did parotids, thyroids, sinuses, tonsils, sleep surgery, etc. I wouldn't have tried a tracheal recon or airway recon. I don't do a lot of that now. As time has gone on, I see too few of certain things to stay comfortable doing them, and I specifically choose not to do other things. The other side of the coin is: what do you want to do primarily, and where are you going to practice. If I'd moved to a large city, I probably wouldn't have had a chance to do a lot of that stuff without a fellowship. Or, at least, it would have been hard to argue a case for me to do a big cancer case if there was a HN oncologist down the road. A lot of guys finish ENT residencies feeling comfortable with plastics, but if there's a lot of nearby competition, it might be hard to establish a plastics-heavy practice without some extra credentials behind your name.

 

[Pir8DeacDoc]

I'll give you some ways to figure out who does what..
1. Is the patient privately insured? If yes, consider oral surgery
2. Is it Mon-Thursday between 9-4? If yes, consider oral surgery
3. Does the problem involve a third molar? If yes, consider oral surgery

Otherwise care should be delegated to ENT or Plastic Surgery- especially if it's after hours or weekends, no matter whether it's a dental problem or not.
Oral Surgeons have phenomenal training and are well equipped to do a lot of things. But getting them to actually do those things in a useful part of the healthcare system is an entirely separate issue.

 

[HighPriest]

That is definitely accurate. And the ADA looks out for their people...unlike some other acronymous organizations...I would also include: Is the patient willing to pay out-of-pocket?

 

[The Anhedonia]

I'll give you some ways to figure out who does what..
1. Is the patient privately insured? If yes, consider oral surgery
2. Is it Mon-Thursday between 9-4? If yes, consider oral surgery
3. Does the problem involve a third molar? If yes, consider oral surgery

Otherwise care should be delegated to ENT or Plastic Surgery- especially if it's after hours or weekends, no matter whether it's a dental problem or not.
Oral Surgeons have phenomenal training and are well equipped to do a lot of things. But getting them to actually do those things in a useful part of the healthcare system is an entirely separate issue.

At my institution it's almost entirely the opposite. From an OMFS's perspective:
- Trauma is split 50/50 between OMF and plastics, and even then it gets punted to OMFS as plastics covers hand. All hours, all comers.
- more of our patients are public insurance than private when looking at all procedures we do (yes most dentoalveolar stuff is private)
- getting the folks over at the eye & ear infirmary in the building next door to come over to evaluate a TM rupture? good luck. too busy dropping tympanostomy tubes on insured kids 🙂

Sorry to hear the OMFS's dont take pride in their reputation at your institution :/

 

[Wordead]

At my institution it's almost entirely the opposite. From an OMFS's perspective:
- Trauma is split 50/50 between OMF and plastics, and even then it gets punted to OMFS as plastics covers hand. All hours, all comers.
- more of our patients are public insurance than private when looking at all procedures we do (yes most dentoalveolar stuff is private)
- getting the folks over at the eye & ear infirmary in the building next door to come over to evaluate a TM rupture? good luck. too busy dropping tympanostomy tubes on insured kids 🙂

Sorry to hear the OMFS's dont take pride in their reputation at your institution :/

Does an impacted wisdom tooth need to be evaluated in the emergency room? Have that TM follow up outpatient that's probably why they're ignoring you

 

[Phantomrih]

Hey,
Current ENT resident here. I may be able to answer some of your questions. If I understand correctly you want to know what a graduate of an OMFS vs plastics vs ENT residency is capable of managing and not so much how it is done at specific institutions. I can probably speak most authoritatively on what an ENT is capable of managing and can add some information about plastic surgery and OMFS.

- ENT: I would say that doing an ENT residency allows you to do the full range of procedures within the head and neck (obviously some of these procedures may require advanced level fellowship to be comfortable with). A graduate straight out of residency would be able to do thyroids, parotids, neck dissections, sinus procedures, basic otology/middle ear surgeries. Most complex head and neck cancers and skull base tumors are managed by fellowship trained ENT physicians. If you are interested in doing head and neck procedures I would say that there are very few doors that are closed to you by doing an ENT residency. The procedures that our typically out of the realm of ENT within the head and neck include TMJ disorders, dental stuff (wisdom teeth extraction), pediatric craniofacial procedures (cleft palate/lip), and obviously anything related to the eye.

- Plastics: Within the head and neck plastics is capable of managing almost all facial trauma cases and are the main players in pediatric craniofacial procedures. Obviously they are most often involved in cosmetic surgeries in the head neck (face lifts, rhinoplasty, etc etc). They will not do resection for head and neck cancers, skull base tumors, neck pathology, or anything ear/sinus related.

- OMFS: I can only make broad claims about OMFS trained graduates because we don't have an OMFS program at my institution so I am not exactly sure what their scope of practice entails. I have often been told that they are most involved with TMJ surgeries and dental/wisdom teeth extraction. They are typically not involved with head and neck cancers, cosmetic procedures, or any neck pathology.

Hope that helps.

If you do pediatric ENT fellowship, can you do cleft palate then?

Also as someone interested in global health, I want to know if being an ENT gives the flexibility to work in resource-poor areas. I know it's very technological. But, are the clinic skills at least transferrable, in a way that emergency or ICU skills are? Thanks!

 

[Wordead]

If you do pediatric ENT fellowship, can you do cleft palate then?

Also as someone interested in global health, I want to know if being an ENT gives the flexibility to work in resource-poor areas. I know it's very technological. But, are the clinic skills at least transferrable, in a way that emergency or ICU skills are? Thanks!

Not in and of itself - some places do clefts so dont. Most are not heavy cleft centers so unless you go to a couple select programs you are not going to do peds craniofacial.

ENTs can work in resource poor areas though not as easily as many other specialties. We are pretty technology reliant. There are outreach programs to third world countries for head and neck cancer and otology at the very least. But these require resources and fundraising and such.

 

[HighPriest]

If you're asking if you can do ENT and then go on a medical mission and do clefts - yes. Absolutely. I would argue that you wouldn't even necessarily have to do a fellowship, so long as you understand the procedure and feel that you can perform it well. I know ENT docs who do this, even though it's not a routine part of their practice at home.

But if you want to do a ton of clefts here, you'll probably need either a plastics or pediatric fellowship, and you'd need to match somewhere where they do them routinely, and you'd then need to find a job somewhere where the ENT department does the clefts (which can be a hard thing to find), OR you can start building a cleft practice somewhere, but that'll be a bit of an uphill battle. Possible, but not easy.