Otology Fellowship, Royal Victorian Eye & Ear Hospital, Melbourne

Introduction

I am indebted to the HCA foundation for their generous contribution towards funding the last 12 months that I have spent as the otology fellow at the Royal Victorian Eye & Ear Hospital (RVEEH), Melbourne. The whole experience was exceptionally valuable and without doubt has transformed my confidence, skill and approach to being a consultant in otology and neurotology as well as equipping me with new techniques unavailable during my training.

Clinical

Professor Rob Briggs has run the fellowship for many years and has crafted a timetable that he fiercely protects enabling the otology fellow to maximise all opportunities. He is rightly held in the highest regard by otologists in Victoria and is an exceptionally gifted surgeon and mentor. That combined with a healthcare system in Australia that enables him to operate 3.5 days per week provides ample opportunity to gain surgical experience under his wing!

As a House Institute trained fellow, he predominantly uses variations on the House technique with the emphasis always being on defining landmarks, good access and safe surgery. His approach to finding the facial nerve, such a central part of otological surgery, and often avoided or performed with great difficulty has helped my confidence a great deal. His logical, stepwise and principled approach to all operations provides a great framework for every case and the confidence to deal with the huge variety of advanced pathology a tertiary centre treats. Theatre time also includes regular sessions with Professor Jean-Marc Gerard who worked in Brussels for many years and has vast experience in cochlear and middle-ear implantation as well as middle ear and skull-base surgery, Claire Iseli who trained in North Carolina and is a highly-skilled neurotologist and excellent mentor and occasional lists with Simon Ellul and Markus Dahm, who also provide a wealth of experience and sage advice.

Over the course of the year my logbook included: 25 translabyrinthine approach to cerebellopontine angle tumours,20 retrosigmoid approaches and one middle cranial fossa approach. These are performed at the Royal Melbourne Hospital predominantly. The team is very well established and incredibly efficient. Knife-to-skin is usually 8.45am and cases are usually finished by 5pm. Many of the tumours are extremely large and I learned many advanced techniques for dealing with more unusual cases I had not previously been exposed to. In addition, my logbook included 35 cochlear implants performed at RVEEH (and once a month at the Royal Children’s Hospital), including patients with cochlea anomalies, and staged procedures after mastoid obliteration. I was involved with 44 mastoid operations (both canal wall up and down), 65 tympanoplasties including ossiculoplasties, 6 blind sac closures, 5 mastoid obliterations, 1 glomus, 30 canalplasties including for exostoses, 30 stapedectomies, 10 meatoplasties, 3 superior semi-circular canal dehiscence repairs and 3 BAHA surgeries. I really appreciated the department’s approach to decision-making around mastoid surgery and will certainly employ this on my return. In addition to surgery, there is a temporal bone laboratory next to the hospital with free access to temporal bones which provided me with a wonderful opportunity to fine-tune surgical skills. It is worth noting that the department’s favoured approach for subtotal and revision myringoplasties is the overlay technique which as far as I know is not used in the UK where a more European approach is used. The results show the technique is very successful (raising success rate from below 80% to 95%) and I was fortunate enough to carry out over 20 in my time with a 100% success rate on early follow up. This will undoubtedly translate into direct patient benefit due to reducing the need for revision surgery and allow me to pass on the technique to other trainees under my supervision.

The fellow sees patients on Monday and Tuesday afternoons in the general otology clinic which sees tertiary level referrals for otology from the state of Victoria. There are usually 8 clinic rooms running simultaneously with 4-5 senior otologists providing a collegiate environment that encourages regular discussion around patient care and certainly challenged my UK training in a positive and expansive way. Every month the fellow sees patients under the supervision of Rob Briggs in a cochlear implant clinic at RVEEH and a skull-base clinic at Royal Melbourne Hospital, both of which are highly focused clinics and excellent for decision making around these two specialised areas. Every Monday there is a very well-established cochlear implant meeting held jointly with audiologists, ENT surgeons, and speech pathologists. Every referral from Victoria and Tasmania, operation and post-operative patient is discussed as well as special cases. Cochlear implant patients are seen regularly by audiologists and ENT, which differs from the UK system I was exposed to, enabling surgeons to monitor outcomes more closely.

The fellow is involved with decision making around the care of inpatients on the ward at RVEEH as well as carrying out general ward rounds on weekend when on call. RVEEH also have a busy emergency department and the fellow attends fortnightly weekday and 1 in 5 Saturday shifts seeing ENT patients as they present. This is predominantly service provision but due to the large volume of patients attending and highly specialised nature of the hospital gives a different and very well evidence-based perspective on the management of common ENT emergencies.

The healthcare system in Australia differs from the UK in that 45% or so of patients have private healthcare insurance incentivised by a tax levy on those who don’t take out insurance earning over $90,000. Fellows at RVEEH benefit from working there not only due to the tertiary nature of the hospital but also because many of the more straightforward procedures are carried out privately and the caseload is subsequently skewed.

Research

Thursdays and occasional Fridays are allocated to research under the supervision of Professor Stephen O’Leary. Stephen is a fantastically enthusiastic and positive supervisor with a wealth of knowledge and experience. He runs a large and prolific research team and I was fortunate to enough to be involved with many research projects over the course of the year. He sits the fellow down at the beginning of the year to discuss your background and interests as well as current active projects within the department before making an agreement as to what work to focus on. As the year progressed many opportunities presented for involving myself in other areas. In particular, my involvement included setting up a new research project correlating intra-operative cochlear implant function with electrode array position. I also worked closely with an extremely capable engineer and Professor Gerard on a new tool for assessing middle ear transfer function on cadaveric ears and ultimately clinical use. I also was involved in a project looking at training surgeons using virtual reality temporal bones. There is the opportunity to engage in a weekly research meeting where all the team’s projects are discussed. I learned a great deal in this process both regards to knowledge of inner ear physiology and also how to successfully manage a research team.

Rob Briggs is also very involved with clinical research projects and I was fortunate enough to be involved with three projects during my time under his supervision, one involving a new type of cochlear implant device, one involving collaboration with the ophthalmologists at the hospital and one involving careful temporal bone dissection of 5 temporal bones and cochlear implant array insertion and subsequent analysis.

Education

I was fortunate to be invited to talk on the State of Victoria’s ENT registrar training sessions which are conveniently held at RVEEH and enjoyed giving talks on cochlear implants and middle ear implants. I also attended the state temporal bone course and was able to demonstrate temporal bone dissection as well as supervise registrars from Australia. As always there is plenty of opportunity for informal local teaching which I thoroughly enjoyed.

Future

The fellowship provided advanced training in techniques that I was both familiar and unfamiliar with in otological surgery. These will all directly translate into improved patient care in the NHS. I will be working in a hospital where I will be regularly training ENT registrars and therefore able to expand my circle of influence by further training them. The experience I gained in decision-making around complex otological problems in outpatients will similarly directly benefit NHS patients and my ability to train trainees. Research has the potential to make the biggest impact on healthcare with development of new technology, techniques and treatment options and the skills I have gained will allow me to also make a significant contribution in future research.

Conclusion

My fellowship in Melbourne was a truly fantastic year and one that I will never forget. It would not have been possible without the help of the HCA foundation and I am extremely grateful that the grant made it possible. I would thoroughly recommend to any future trainee from the UK interested in neurotology, strongly considering this fellowship as it offers so much in addition to training gained in the UK and will make an enormous difference to my contribution to the NHS over the next 30 years.