So you want to be an otolaryngologist, or ENT. You like the idea of working on the ears, nose, and throat. Overall the head just really gets you going. Let’s debunk the public perception myths, and give it to you straight. This is the reality of otolaryngology.
What is ENT?
ENT is a surgical subspecialty focused on diseases of the head and neck region, including laryngology, referring to the vocal cords and larynx, rhinology, referring to the nose and sinuses, ears, including not only the external ear but also inner ear, and endocrinology, including the thyroid and parathyroid. ENT also deals with head and neck cancers and facial plastics.
Delineating what exactly ENT does requires identifying the areas of overlap with other specialties. ENT will handle cancers of the head and neck region as far down as the esophageal inlet. Anything distal to that, meaning further down the GI tract, is handled by gastroenterologists or general surgeons.
Plastic surgeons work all around the body and pioneered many aesthetic and reconstructive techniques from head to toe. Otolaryngologists that specialize in facial plastics do cosmetic procedures of the head and neck only. In terms of reconstruction, until recently plastic surgeons would harvest local or free flaps to help otolaryngologists with reconstructive cases. However, ENT is moving in the direction of now doing their own local and free flaps without plastic surgery assistance. These are most commonly used with oral cancers, specifically laryngeal. This includes the almost science fiction work of harvesting tissues from one part of the body, like the radial forearm flap or fibular flap, and moving it to a new part of the body for coverage after trauma or cancer resection.
There are a few ways to categorize the specialty.
Ears vs Nose vs Throat
ENT can be thought of as Ear, Nose, and Throat, plus facial plastics, sleep, allergy, and head & neck surgery.
For the ear, you have two primary functions: hearing and balance. Otologists, dealing with the ears exclusively, work on cochlear implants, masses within the ear, such as cholesteatomas, dizziness, infections, and trauma to the ear.
Experts of the nose, or rhinologists, deal with polyps in the nose, deviated septums, and other sinus surgeries, such as for resecting a tumor or mass. They may also work in conjunction with neurosurgery in gaining access to various tumors localized in the skull base or in the pituitary. Emergencies in this field include invasive fungal infections and difficult to control epistaxis, such as if someone is on blood thinners.
Experts of the throat, or laryngologists, deal with singers and celebrities who have issues with their voice. They’ll use a scope to visualize the vocal cords. Sometimes there are nodes or injuries to the recurrent laryngeal nerve requiring attention. They deal with swallowing issues, for which they may perform an esophageal dilation. If a patient has tracheal stenosis, which means scarring and narrowing of the airway, they may use lasers to remedy the problem. Emergencies that happen in the airway are securing a surgical airway when anesthesiologists are unable to intubate in the traditional manner. This is actually one of the most common emergent interventions otolaryngologists take care of, and it’s high acuity, meaning you have to drop everything and handle it immediately. Other emergencies in this area include foreign bodies in the airway or upper esophagus, often due to children swallowing random objects.
Otolaryngologists specializing in facial plastics deal with botox, fillers, rhinoplasty, and facial trauma including jaw and mid-face fractures. They also help with facial transgender procedures, such as facial feminization whereby they make changes to one’s hairline, lips, cheekbones, jaw, and chin to appear more feminine. They’ll also handle facial traumas, which usually are not emergent, unless there is uncontrolled bleeding or issues with vision.
Head and neck specialists are the ones who remove cancers of the head and neck and reconstruct the defects with free flaps. This can be as minor as a local excision to as massive as taking bone and muscle from the leg, or another part of the body, to reconstruct the face, jaw, and throat.
Other general complications include necrotizing fasciitis, also known as flesh-eating bacteria, of the head or neck area, tonsil bed bleeding after tonsillectomy, some types of infections and abscesses in the head and neck spaces, or angioedema, which is diffuse swelling of the mouth and throat.
Academic vs Community vs Private Practice
Academic otolaryngologists work at teaching hospitals, where in addition to clinical responsibilities, they handle teaching and research as well. At these academic centers, which are tertiary care centers, meaning they have specialists and more robust resources, you’ll be seeing more complicated cases. That’s because community ENT’s don’t have the resources to handle complicated cases requiring additional resources and interdisciplinary consults. Your hours will be dependent on your subspecialization within ENT, but you can expect regular 9 to 5 hours on clinic days, but more variable hours when in the operating room. For example, if you’re doing flaps, some cases can take over 8 hours, but if you’re doing facial plastics, each case is much shorter in duration.
Community and private practice ENTs deal with more of the bread and butter of the field – the simpler, more common, and straightforward cases. There’s less research and less teaching, although some of these otolaryngologists get connected with local academic programs for some light duty mentorship and teaching opportunities. Overall, you’ll see more emergent cases at academic and tertiary care centers over smaller community practices.
Misconceptions About ENT
ENT is an often misunderstood field. Many people don’t realize that ENT is actually a surgical subspecialty, and isn’t just clinical in nature. And no, they’re not glorified nose pickers, but rather handle everything from the simple straightforward issues of the head and neck to complex cancer resections and reconstructions.
Also, otolaryngologists do not do hearing or vestibular tests – that’s done by audiologists. However, ENT’s do interpret the results and prescribe treatment when necessary.
How to Become an ENT
After medical school, ENT is a 5-year categorical residency, meaning you match straight into an ENT residency program. Some programs are up to 7 years with research years, but 5 years is the norm.
In your first year of residency, also called your intern year, you’ll be required to rotate on various services, just as you would with any other residency. You’ll get exposure to ICU, anesthesiology, ophthalmology, plastic surgery, and general surgery among others. You’ll also get a few months exposure to ENT. You’ll be carrying the pager and learning how to deal with consults as an intern, with a few OR days mixed in. From your second year onward, you’ll be exclusively on ENT rotations. During your 2nd and 3rd year, you gradually get more OR time as you will rotate through the various subspecialties of ENT. In your 4th and 5th years, you’ll oversee your juniors, teach, and have greater autonomy in the OR as you prepare to graduate and be on your own as an attending. This is the fun part, as you’ll do many surgeries on your own with little supervision, or assist the attendings with more complicated cases.
ENT is a highly competitive specialty, consistently ranking at number 5 right after dermatology, plastic surgery, neurosurgery, and orthopedic surgery. Most recently, ENT residents averaged 248 on USMLE Step 1 and 256 on USMLE Step 2CK, with an average publication number of 13.7.
Medical students that pursue ENT are generally detail-oriented, overachieving, and often somewhat quirky. ENT’s are often considered the “nice surgeons” in the hospital.
Subspecialties within ENT
Despite ENT already being a fairly narrow surgical subspecialty, there’s a great deal of further subspecialization and fellowships to choose from.
Laryngology is a 1-year fellowship focusing on the voice, swallowing, and airway-related concerns. This includes taking care of trachs, esophageal dilations for swallowing, and vocal cord procedures such as injections, medialization, implants, reinnervations, or resections. These are the ENTs that are interested in music, as many of them seem to play instruments.
Rhinology is a 1 year fellowship with a primary focus on sinus surgery. They deal with simple stuff like deviated septums to more complicated issues, like removing diseased segments with micro-debridement, addressing invasive and noninvasive fungal sinus infections, and helping neurosurgeons with skull base tumors and pituitary approaches.
Facial plastics is a 1-year fellowship for the Instagram influencers of ENT surgeons with dollar signs in their eyes. They focus on aesthetic facial procedures, like botox, fillers, facial feminization, rhinoplasties, blepharoplasties, but also facial trauma.
Neurotology is a 2-year fellowship for the nerdy and highly meticulous ENT surgeons, as they are working in incredibly small structures. They work primarily on the middle and inner ear, dealing with cholesteatomas, tympanic membrane perforations, and they work alongside neurosurgeons for schwannomas and approaching brain tumors.
Head & Neck
Head and neck is a 1-year fellowship for the jocks of ENT that enjoy long and complicated surgeries. They’re often resecting cancers and reconstructing the empty space, but also deal with thyroidectomies and less complicated procedures too. Most commonly, they deal with squamous cell carcinoma of the throat, often related to smoking and drinking, and then use thigh or forearms flaps in reconstruction. If bony structures require reconstruction too, they’ll use a fibular flap from the leg.
Sleep is a newer, 1-year fellowship, and academic centers see this as the hot new thing. If a patient has obstructive sleep apnea and non-surgical management isn’t working, the ENTs specializing in sleep may operate on the tonsils or septum. They also use hypoglossal nerve stimulators that cause the patient to protrude their tongue while breathing to prevent snoring or breathing issues.
Pediatrics is a 1-year fellowship for the ENTs that love kids. You’ll be dealing with lots of tonsillectomies, adenoidectomies, tubes in ears, mastoidectomies, and congenital abnormalities. For example, some babies are born without ears or their jaws may be underdeveloped, and these require surgical intervention.
What You’ll Love About ENT
There’s a lot to love about ENT.
The lifestyle is great, and you can make good money with a good work/life balance such that it’s family-friendly. Compared to some other surgical subspecialties, there can be more clinic time, and you can split your time 50/50 between each. Clinical days will have regular 9 to 5 hours, and OR days can either be half days or full 12 hour days if you’re dealing with more complicated cases. In terms of compensation, it’s up there with other surgical subspecialties, right under orthopedic surgery or plastic surgery, averaging $455,000 per year.
In terms of your patient population, you’ll be dealing with a wide range of ages, from newborns to those at the end of their life, and it’s quite rewarding to provide massive quality of life improvements to all your patients. Helping a deaf person hear is tremendously satisfying.
There’s also a good amount of variation in the surgery. Even as a general ENT surgeon, you can have a wide breadth from the E’s, N’s, and T’s. And if you want the adrenaline rush, there’s acuity to get that fix.
And if you want to go the private practice option and have a cash-based practice, facial plastics provides that route.
What You Won’t Love About ENT
While ENT is great, it’s not for everyone.
Compared to some other specialties, the anatomy is relatively limited – not only are you limited to one region of the body, but that region is also incredibly complex, and even as a resident, you may find it difficult to understand and navigate. Plus, getting access to various structures is also often tricky, as one structure is often hidden behind multiple other delicate structures.
There’s also often many noises, fluids, and nastiness in the various crevices and compartments of the head and neck. If you don’t have a strong stomach and are easily grossed out, steer clear.
Depending on the type of ENT you subspecialize in, you may also find yourself in the operating room for the whole day. Complex reconstructions dealing with free flaps, such as in cancer resections and reconstructions, can take 12 or even 14 hours.
And while helping patients can be rewarding, it can also be incredibly frustrating when dealing with a non-adherent patient. You’ll find yourself feeling helpless as you watch their head or neck cancer grow.
Should You Become an ENT?
How can you decide if ENT is the right fit for you? If you are detail-oriented, don’t mind working on just one region of the body, and aren’t put off by complex anatomy or strange sounds and smells, ENT might be a good fit.
You should also enjoy the balance between both clinic and surgery. ENT is similar to urology in this regard, as there’s more clinic time compared to certain other surgical subspecialties like plastics, orthopedics, neurosurgery, and general surgery. If you’re the kind of person that hates clinic and just wants to operate all day, ENT may not be a good fit. You should also be ok doing small office procedures like cleaning earwax, removing small skin cancers, and the like. It isn’t all big cases all the time.