Skull base surgery for ENT's? NS and ENT replies especially

[samsoccer7]

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Does anybody, NS or ENT folk, know if you HAVE to have a fellowship to perform skull base surgery? I'm trying to find a happy medium since I love NS but don't think I want to put in the hours after residency. Skull base would still probably give me that fix and I think I could be more than happy doing that. Opinions? And how often do ENT's really do those surgeries if they're in private or academics? I know some institutions leave a lot of that stuff for ENT's anyway. I figure there aren't any acute pit. tumors, so you at least wouldn't be doing it at 3 in the morning.

 

[ent_doc]

Originally posted by samsoccer7
Does anybody, NS or ENT folk, know if you HAVE to have a fellowship to perform skull base surgery? I'm trying to find a happy medium since I love NS but don't think I want to put in the hours after residency. Skull base would still probably give me that fix and I think I could be more than happy doing that. Opinions? And how often do ENT's really do those surgeries if they're in private or academics? I know some institutions leave a lot of that stuff for ENT's anyway. I figure there aren't any acute pit. tumors, so you at least wouldn't be doing it at 3 in the morning.

The short answer: yes, you would need to obtain neurotology fellowship training to perform LATERAL skull base surgery; very few people doing skull base tumor cases (acoustic neuroma/paraganglioma/etc) without additional training. Those that are trained in the days when fellowships weren't as widespread.

ANTERIOR skull base surgery also generally requires additional training in head and neck oncology or rhinology; depends on the type of case.

Generally the surgeries of which you speak are performed at an academic center or large urban tertiary referral center. You might be associated with a large urban hospital without being in academics but you would likely still have to undergo subspecialty training.

Keep in mind that in private practice, emphasis is on high volume surgeries that pay well...it is more lucrative to perform 3 FESS operations than to perform an anterior skullbase approach, your patients will be outpatients, and you won't have an inpatient to take care of.

Also, large skull base tumors often require more than one specialty for their management: neurosurgeon, neurotologist, head and neck surgeon, often XRT is involved, sometimes oncology; these kinds of teams only exist at larger centers

Hope this answers your question. If you want to do skull base in the future you owe it to yourself and your patients to acquire the additional training that a fellowship provides. You just don't get experience doing these kinds of cases in your general ENT residency--your time is necessarily spent learning laryngectomy, sinus surgery, thyroidectomy, neck dissection, more basic ear surgery.

Let me know if you have more questions

--Future neurotologist/skullbase surgeon

 

[ent_doc]

Originally posted by samsoccer7
Does anybody, NS or ENT folk, know if you HAVE to have a fellowship to perform skull base surgery? I'm trying to find a happy medium since I love NS but don't think I want to put in the hours after residency. Skull base would still probably give me that fix and I think I could be more than happy doing that. Opinions? And how often do ENT's really do those surgeries if they're in private or academics? I know some institutions leave a lot of that stuff for ENT's anyway. I figure there aren't any acute pit. tumors, so you at least wouldn't be doing it at 3 in the morning.

By the way, otolaryngologists don't perform hypophysectomy; that is the realm of the neurosurgeon

They often do perform the transsphenoidal approach, however.

 

[Airborne]

Although I am reluctant to disagree with a PGY3 - I will say that we had (left 1 year ago) a general ENT doc who did EVERYTHING except cochlear implants (including lateral temporal surgery) -

His training was from Cleveland Clinic (and he is not fellowship trained).

Not too sure if he is the exception to the rule, but definitely a mentor never-the-less...

Kind regrards,

Airborne

 

[ent_doc]

Originally posted by Airborne
Although I am reluctant to disagree with a PGY3 - I will say that we had (left 1 year ago) a general ENT doc who did EVERYTHING except cochlear implants (including lateral temporal surgery) -

His training was from Cleveland Clinic (and he is not fellowship trained).

Not too sure if he is the exception to the rule, but definitely a mentor never-the-less...

Not disagreeing..from my post

"very few people doing skull base tumor cases (acoustic neuroma/paraganglioma/etc) without additional training. Those that are trained in the days when fellowships weren't as widespread."

Former chairman at my program(retired just a few years ago) also did EVERYTHING, including CI, AN, parotidectomy, sinus, ND, anterior skullbase, has instruments named after him

That type of individual could exist in the days when fellowships really didn't exist. Today you really couldn't have that kind of practice

 

[ent_doc]

Originally posted by Airborne
Although I am reluctant to disagree with a PGY3 - I will say that we had (left 1 year ago) a general ENT doc who did EVERYTHING except cochlear implants (including lateral temporal surgery) -

One more followup:

I can safely say that if you start training in ENT now you WILL NOT be taking out acoustic neuromas without fellowship training. Period.

 

[durphy]

that's not necessarily true. I know of several residency program graduates who were doing AN's without fellowship training. Just happened to be at a program where there were a good amount of them and they got some hands-on experience while in training. this is definitely an exception but you still should not say never...

 

[ent_doc]

Originally posted by durphy
that's not necessarily true. I know of several residency program graduates who were doing AN's without fellowship training. Just happened to be at a program where there were a good amount of them and they got some hands-on experience while in training. this is definitely an exception but you still should not say never...

I'm not talking about people who have already trained. I stated that if you start training in ENT NOW you will not do AN resection without fellowship. I stand by this statement, and challenge you to show me anyone graduating now who will be doing AN resection without fellowship.

I am also not talking about just doing the approach...I am talking about removing schwannoma. R5 residents in my program (very strong in otology-neurotology) do not do AN resection. They participate in the exposure (ie perform the labyrinthectomy in a translab acoustic) but they do not take out tumor nor do they take down the posterior fossa plate, drill out the IAC, etc. On a middle fossa, the residents do the craniectomy but they don't touch the petrous temporal...that is the fellow's realm.

 

[samsoccer7]

ent_doc.... do private practice guys do head/neck surgeries often? From what it sounds like, those guys do the bread/butter stuff WAY more than anything else, although I've heard private docs do head and neck tumor surgeries and other "cooler" things. What do you think? The only way I could do ENT is if I can do some wicked surgeries, skull base or AT LEAST dissect the head/neck and reconstruct.

 

[neutropeniaboy]

Originally posted by samsoccer7
ent_doc.... do private practice guys do head/neck surgeries often? From what it sounds like, those guys do the bread/butter stuff WAY more than anything else, although I've heard private docs do head and neck tumor surgeries and other "cooler" things. What do you think? The only way I could do ENT is if I can do some wicked surgeries, skull base or AT LEAST dissect the head/neck and reconstruct.

It depends on the comfort level of the private practice ENT physician or his/her tolerance of long-term follow-up and tolerance of potentially protracted inpatient stays. It might also be dependent upon the ability of the hospital at which he practices and their ability to manage a potentially big whack.

A lot of private practice ENTs will do parotid tumors, thyroid tumors, small oral cavity lesions, and skin lesions. Many will do neck dissections without apparent primary lesions as well.

I don't know what you mean by "wicked surgeries," but most ENT physicians do not do reconstructions or skull-base surgeries. If you want to do H&N surgery and reconstructions, do an ENT residency, a H&N fellowship and get microvascular training (7 years). If you want to do skull base resections, do an ENT residency and a neurotology fellowship (6 years) or a neurosurgery residency and oncology fellowship (7-8 years).

But, you really ought to learn more about ENT and neurosurgery, because it doesn't sound like you know too much about what either physician does.

 

[ent_doc]

Originally posted by samsoccer7
ent_doc.... do private practice guys do head/neck surgeries often? From what it sounds like, those guys do the bread/butter stuff WAY more than anything else, although I've heard private docs do head and neck tumor surgeries and other "cooler" things. What do you think? The only way I could do ENT is if I can do some wicked surgeries, skull base or AT LEAST dissect the head/neck and reconstruct.

I posted this on another thread...in whatever field you pursue, you have to be able to do the bread and butter. If you can't then you might want to look elsewhere.

To answer your question...right now I am doing one of my private practice ENT rotations for my residency and the group does everything but cochlear implants, acoustic neuroma, and microvascular/free flap reconstruction. They don't refer much to the academic center. Depends on the training and comfort of the private practitioner.

 

[ent_doc]

Originally posted by neutropeniaboy
It depends on the comfort level of the private practice ENT physician or his/her tolerance of long-term follow-up and tolerance of potentially protracted inpatient stays. It might also be dependent upon the ability of the hospital at which he practices and their ability to manage a potentially big whack.

A lot of private practice ENTs will do parotid tumors, thyroid tumors, small oral cavity lesions, and skin lesions. Many will do neck dissections without apparent primary lesions as well.

I don't know what you mean by "wicked surgeries," but most ENT physicians do not do reconstructions or skull-base surgeries. If you want to do H&N surgery and reconstructions, do an ENT residency, a H&N fellowship and get microvascular training (7 years). If you want to do skull base resections, do an ENT residency and a neurotology fellowship (6 years) or a neurosurgery residency and oncology fellowship (7-8 years).

But, you really ought to learn more about ENT and neurosurgery, because it doesn't sound like you know too much about what either physician does.

Most neurotology fellowships are now 2 years. One major exception is Silverstein's fellowship in Florida.

 

[Minimalist M]

Samsoccer7

I see you've given ENT more thought. How is your neurosurgery research projects? Have you managed to give them a head and neck spin? How about your surgery rotation? Are you doing ent? Good luck!

 

[samsoccer7]

Hey Minimalist, I've given it more thought definitely, but I'm still not sure. It looks like I'll be getting to do an ENT month here soon, and I can still do NS later if ENT doesn't float my boat. Unfortunately the case report I was writing for NS can't really be given much of an ENT spin, although it includes an arachnoid cyst which I think ENT's can probably help expose for the NS to get in an drain, but still it's mostly an NS topic. How's everything going with you? I worked 40 hrs in 3 days and another 5 this morning, I'll have to see if this is really for me 🙂

 

[Minimalist M]

It looks like I'll be getting to do an ENT month here soon, and I can still do NS later if ENT doesn't float my boat.

That's definitely the important thing for you right now, you need to figure out if you will like ENT enough to pursue it. Like you said, you can always do your neurosurgery later.

Sounds like you're getting a taste of some good floor/OR time in your medical school, probably putting in 100 hours per week. That's basically life as usual for residents (You didn't hear this from me!) and some attendings too! Now's the time to really ask yourself if you can do it for 5-8 years or even the entire length of your career. Good luck!

 

[Airborne]

I have to ask -

Is the reason that ENTs that are training now - and who chose not to do the more complex surgeries (ANs, Skull base, Microvascular, etc) are because the indemnity is a BIG issue, or is it that they have less training than their preceptors who trained a few years before?

If the later is the case, can those who are in the field recommend programs that would allow a more broad and inclusive training?

I, like most of my colleagues, would really enjoy a wide-spread and inclusive training program that allows one to really curtail their training and practice options once the opportunity arrises -

From the sound of this thread - it appears that I may be limited to T&As, limited ear reconstructions and a few thyroids and parotids (should I have the exposure for such surgeries!) - regardless, I can tell you that having chosen to enter a specialty with which I perceived as a brilliant exposure to a multitude of surgical approaches is a bit disenlightening - after reading the discourse in this thread - I really wonder if such opportunities do exist today -

Indeed what can the ENT do that the GS cannot do - asside from selected ear sugeries?

Please tell me I am wrong,

Kind regards,

Airborne

 

[ent_doc]

Originally posted by Airborne
I have to ask -

Is the reason that ENTs that are training now - and who chose not to do the more complex surgeries (ANs, Skull base, Microvascular, etc) are because the indemnity is a BIG issue, or is it that they have less training than their preceptors who trained a few years before?

ENT, as every specialty, has become more complex. Subspecialization has become the norm.

In a peds oto fellowship, you are essentially doing fellowship to learn complex airway reconstruction (laryngotracheoplasty, cricotracheal resection, etc). Everything else in peds oto (except cleft, but that's not really peds oto...that's really plastics) can essentially be managed by a well-trained general otolaryngologist.

In H&N fellowship (nowadays), you really do it to learn microvascular recon (free flaps). If you've come from a good program that has trained you well in H&N, you can do EVERYTHING in H&N but free flaps, and there are many who do.

In facial plastics fellowship, you are really there to learn rhinoplasty, rhytidectomy (facelift), blephs, etc

In otology-neurotology, you are there to learn skull base and AN resection. General oto can and do tympanomastoidectomy, some general oto do cochlear implants. CI is essentially a facial recess tympanomastoidectomy with a cochleostomy, you don't need to do a 2 year fellowship to learn that

Rhinology/sinus fellowships are essentially for academics, but there are some who choose to do a year of sinus to set themselves up as the local sinus expert.

As far as AN resection goes, oto folks have really only been doing them since the 1960's....before that the neurotology field didn't exist. Bill and Howard House in LA (of Rush Limbaugh CI fame) are the folks who really created this field. Now that fellowship training in this field exists, AN resection is really limited to those in that field.

If the later is the case, can those who are in the field recommend programs that would allow a more broad and inclusive training?

Look at progs and choose a program (there are many) that have good representation in all subspecialties.

The private practice group I am in now does everything but CI, AN, peds airway recon, and free flaps.

From the sound of this thread - it appears that I may be limited to T&As, limited ear reconstructions and a few thyroids and parotids (should I have the exposure for such surgeries!) - regardless, I can tell you that having chosen to enter a specialty with which I perceived as a brilliant exposure to a multitude of surgical approaches is a bit disenlightening - after reading the discourse in this thread - I really wonder if such opportunities do exist today -

Indeed what can the ENT do that the GS cannot do - asside from selected ear sugeries?

Huh?

Have you rotated on GS?

How many GS do you see doing tonsillectomy, adenoidectomy, sinus surgery, facial plastic surgery, parotid surgery, neck dissection (there are some out there, but they are older), ANY ear surgery, laryngectomy, vocal cord surgery, septoplasty, oral cavity surgery, sleep apnea surgery, skull base surgery?

GS (there are some exceptions, but they are rare) do not touch the above areas

Many GS do thyroidectomy, but they are trained to do this in residency, as it is part of endocrine surg. Beware in the future though, many endocrinologists are starting to refer to the oto folks on this...it is a turf battle between GS and Oto. 20 years ago there weren't many Oto folks doing thyroid/parathyroid, it is now commonplace