Introduction to ENT Operations
This section aims to provide some information about the most commonly performed ENT procedures, including indications, the length and basic steps of the procedure, potential complications and postoperative care and prescriptions.
NB The detail of the operative steps given is for reference only, in order to support professionals in delivering good peri-operative care. It is not intended to be sufficient to attempt the procedure yourself or to consent patients without further training.
Why is this important?
Some ENT SHOs intending to apply for specialist training are likely to start performing core procedures under senior supervision. An integral part of this process is knowledge of the proper indications for common operations, their complications, and what patients should expect post-operatively.
Even if you are not intending to stay in the specialty, it is essential to know the basics of each procedure and its complications, so that you can answer patient queries and provide good peri-operative care.
A word on consent *UPDATED*
Many SHOs are asked to consent patients for theatre as part of their duties. In the UK, the Royal College of Surgeons of England publishes up-to-date guidelines on surgical consent. All doctors should familiarise themselves with Consent: Supported Decision Making.
In 2015, the ruling of the UK Supreme Court in the case of Montgomery v Lanarkshire Health Board fundamentally changed the practice of consent, shifting the focus of the consent process to the specific needs of each individual patient.
Under previous law, a patient must be informed of a particular risk of an operation, if a body of surgeons would consider this risk to be significantly common or serious. The emphasis has now changed from this clinician-centred approach, whereby surgeons must make every effort to ensure that the patient is aware of all risks that are material to the patient themselves.
The College has developed guidance on consent that sets out the principles for working with patients through a process of supported decision-making. Consent is a multi-stage process whereby the patient is informed of the benefits of the proposed operation, the risks of the operation (see above), and the alternatives to the operation. Through discussion with the surgeon, an agreement is reached about how best to proceed in their particular case. The process should begin in the outpatient department, and should not be left until the morning of the operation – patients need time to consider the options with all the available information. For emergency patients, the outpatient consultation is not possible but it is just as important to allow adequate time to discuss the planned operation.
Consent should ideally be taken by the surgeon who will perform the operation. This ensures the patient has access to the most accurate information about the procedure, and if possible, surgeon-specific statistics (e.g. sensorineural hearing loss rate in stapedectomy). The consent form is important documentation of the consent process, but is neither necessary nor sufficient for proper consent.
If it is impractical for all patients to be consented by the operating surgeon, the task may be delegated to another doctor on the team who:
- Can perform the operation, or
- Fully understands the procedure and its complications.
Ideally this doctor will be assisting in theatre. We strongly believe that best practice is for the operating surgeon to take consent and/or to confirm consent.
If you are asked to obtain consent for an operation you are not familiar with, do not proceed. Explain to your senior that you do not understand the procedure well enough to consent for it. Remember to use this as a learning opportunity – observe them obtaining consent in order to improve your understanding.
CORE & PAEDIATRIC ENT PROCEDURES
These are the most frequently-performed general ENT operations. They are performed most often on children, but quite frequently on adults as well.
Parents especially will want to know what to expect post-operatively, and how to care for their child. It is important to strike a balance between reassurance and clear information about the risks of the procedures.
Parents and patients often ask how long a procedure will take. This is partly for logistical reasons, but also because lay people often (erroneously) equate a short operation with a less risky one, and vice versa. Give a general idea of the expected length of the operation, but remind them that there is often some time either side of the operation (e.g. recovery), that will mean the patient is away for longer than this.
It is not unknown for parents or patients to have doubts, or decide against the operation on the morning of surgery. This is sometimes a failure of the consent process, as they should already be aware of the potential risks following their clinic consultation.
However, it is essential to recognise that this is elective surgery: never attempt to persuade a patient to undergo surgery when they are unsure. It is safer to cancel the procedure and book the patient an outpatient appointment to discuss further.
Remember that practice can vary from unit to unit and from consultant to consultant: if you are unsure about anything, ask.
Otology operations may be aimed at treatment of chronic ear disease, or reconstruction of hearing.
It is essential to recognise that this is elective surgery: never attempt to persuade a patient to undergo surgery when they are unsure. It is safer to cancel the procedure and book the patient an outpatient appointment to discuss further. Careful consent is particularly crucial in complex ear procedures, particularly with regard to surgeon-specific and procedure-specific complication rates. It is therefore unusual for an SHO to consent for these procedures.
Page last reviewed: 17 September 2017