Our sixth episode takes an inside look into the subspecialty of laryngology with our guest Dr. Jun Lin! Dr. Lin attended medical school and otolaryngology residency at the University of British Columbia. She has a fellowship in laryngology and care of the professional voice, and a master’s degree in science specializing in clinical research from the University of Pittsburgh Medical Center. She is an otolaryngologist and associate scientist at St. Michael’s Hospital, and an assistant professor at the University of Toronto.

Show Notes

Emily: Hello and welcome to The Oto Approach, a podcast created by medical students for medical students, to teach you about all things ENT.  I'm your host, Emily, and today we are joined by Dr. Jun Lin! 

Dr. Lin attended medical school and otolaryngology residency at the University of British Columbia. She has a fellowship in Laryngology and Care of the professional Voice, and a Master’s Degree in Science specializing in clinical research from the University of Pittsburgh Medical Center. She is an otolaryngologist and associate scientist at St. Michael’s Hospital, and an assistant professor in the Department of Otolaryngology - Head and Neck Surgery at the University of Toronto. Her research focuses primarily on therapies for vocal fold paralysis, vocal fold atrophy, vocal fold scarring, and dysphagia. 

Thank you so much for joining us today Dr. Lin!

Dr. Lin: Thank you for having me Emily. It is a pleasure to be here. 

Emily: So we’re hoping to hear a bit about your career as an otolaryngologist, specifically in the subspecialty of laryngology. Could you tell us a little bit about what a laryngologist does?

Dr. Lin: Sure Laryngology is actually a relatively new subspeciality in Otolaryngology. And it has really only gained traction maybe within the last 15 years or so, with some new developments in technology in terms of laryngeal diagnosis and in office procedures as well. So, It is a subspeciality that focuses in the care of the larynx, including voice, swallowing and also airway disorders, so for example glottic stenosis, upper airway stenosis like subglottic and tracheal stenosis. 

Emily: Thanks Dr. Lin for sharing with us what laryngology encompasses. In terms of training, what training is required to become an laryngologist?

Dr. Lin: So if one wants to do high-level laryngology so basically sub specializing in the field, usually you would be required to go otolaryngology residency and then basically pursue a fellowship afterwards. Typically a laryngology fellowship would be one year, in addition to a 5 year Otolaryngology residency training and it also depends on your interests as well. I was interested in academic otolaryngology, so that's why I also pursued a research degree in clinical trials as well. So that added an extra research year to my laryngology fellowship but it's definitely not required. 

Emily: So it sounds like there’s a lot of training options to become a laryngologist depending on how you want to structure your practice. 

Dr. Lin: Correct and also within the laryngology fellowship you can specialize in voice care and then there are a few fellowships where the focus is actually primarily dysphagia for people with 5 significant swallowing disorders and some of them will focus a little more on airway reconstruction. Most of the fellowships are sort of general laryngology, with a focus in each one of the areas. But you can definitely even more subspecialize in laryngology if you really want to. 

Emily: Okay, thank you for elaborating. Could you also share with us what initially drew you to otolaryngology and laryngology? 

Dr. Lin: Sure. So for otolaryngology I was always interested in the head neck anatomy. So the neck is a very small anatomical area in the body but it houses some of the most important structures right. So the major vessels, great vessels and then you’ve got the larynx obviously, which in my mind is probably the most humane organ in the entire body. So and then there are different surgery options that are available. So if you're interested in big surgeries, reconstruction etc, then head and neck oncology and otolaryngology maybe something for you. You can also do minimally invasive surgery like sinus, skull based, then there is otologic surgery as well. And also for laryngology it's a combination of endoscopic minimally invasive surgery vs open surgery.

Otolaryngology is the only surgical speciality that  doesn't have some medical counterpart, which is very interesting to me. So, then by being out with a laryngologist I can practice some medicine and I'm also a surgeon at the same time. And by medical counterpart, I mean that, so for example general surgeons their medical counterpart will be gastroenterology and for neurosurgery their medical counterpart would be neurology. But for otolaryngologists, we don’t have a medical counterpart, so for us we kind of do a combination of medicine and surgery which I really enjoy.  

Emily: So it sounds like otolaryngology and laryngology offers both the medical and surgical aspects of medicine. What would you say is the “bread and butter” of laryngology? 

Dr. Lin: In my personal practice, I see probably 60% of voice disorder, then maybe 25%, like 20-25% of airway disorder, and the rest would be swallowing issues. So for voice issues oftentimes you will see vocal cord paralysis which can be unilateral or bilateral. So for unilateral vocal cord paralysis typically patients will have issues with their voice or aspiration pneumonia. And with bilateral vocal cord paralysis typically it’s an airway issue. And then you can also get something called phono-traumatic vocal cord lesions, which are benign growths along the vocal cord due to overusing or misusing your voice. And you can also see a variety of other conditions that affect the voice as well. For the airway, it is typically subglottic stenosis which is an area that I am doing research on. For swallowing, you can get upper esophageal issues like zenker’s diverticulum or cricopharyngeal dysfunction etc. So it’s a pretty wide breath of conditions that I will see.   

Emily: It sounds like Laryngology offers a very wide variety of cases. Are there any procedures or presentations that you think are most interesting?

Dr. Lin: That’s a good question. So procedure wise, I guess the most gratifying ones are probably vocal cord implant surgery. So I would put in a vocal cord silastic implant to push a paralyzed vocal cord back to a median position to facilitate complete closure of the vocal cords. So the goal of that surgery is to restore the voice and also prevent aspiration. So it’s a very gratifying procedure because basically you can tell the patient- the surgery is done under something called a conscious sedation, so as you put in the implant during the surgery you can actually immediately notice the voice change in the patient, which can be quite traumatic. So that’s one of the procedures.  And the second procedure would be airway surgery because having difficulty breathing is not a nice feeling. So again, by doing airway surgery, enlarging people’s airway and they are able to breathe right away. And then they go from, you know, significant exercise intolerance, you know, not being able to walk two minutes without getting short of breath to being able to run a marathon. So that’s pretty gratifying and amazing to me.  

Emily: So it sounds like Laryngology plays a huge part in improving the quality of life of patients. 

Dr. Lin: Yes absolutely.

Emily: We were also wondering if you could tell us what the most challenging and rewarding part of your job?

Dr. Lin: So I guess the challenging part of my job is, I work in an academic institution. So in addition to taking care of my patients in my clinical practice, I also have to juggle research and admin responsibilities, as well as the education of medical students and residents. And there’s not really any dedicated time for me to do so, which means that oftentimes I have to utilize my personal time in the evenings and weekends to do those things that I’m supposed to be doing. So definitely time management and also allocating time for work and for my family would be a huge challenge. But we all kind of learn to adapt to that. So I have some rules that I try to adhere to, so that I can ensure that I have some family time. So for example, I try not to check emails from work, you know, after I come home, I try to finish all my dictations at work, all the phone calls at work, so when I come home I’m just home and I don’t deal with anything from work unless I’m on call. So I find that’s been working out really well.  

Emily: Thank you for sharing with us your experience! It’s always great to hear from a specialist about the challenging things in a specialty, especially for medical students who are deciding on their career. You mentioned you were taking part in some research, would you be able to share what your research entails? 

Dr. Lin: Sure, so for myself, I have an interest in a condition called idiopathic subglottic stenosis. So idiopathic, meaning that there’s really no cause for it. Subglottic stenosis is basically airway scarring, in an area that’s immediately below the vocal cords and above the trachea. So for this condition, it actually occurs exclusively in Caucasian women and we don’t really know why. And it’s a rare condition occurring maybe in about 1/4000 people. Some etiologies have been proposed in the literature, because you only see it in women, people say many there’s a hormonal component to it and they did find elevated estrogen receptors in this area. And then other people suggested, maybe it’s reflux, maybe it’s chronic bacterial colonization but no one really knows for sure. So right now, my research is actually doing something called an RNA sequencing on the tissue that I collected from this patient population that I collect during surgery. So by doing RNA sequencing, basically we are looking at the whole genomic changes in this patient population. So hopefully we will be able to find an answer to the cause of this condition. And that’s something new in our field and I don’t think that other people are really doing that and we are definitely running the biggest study, as far as I know, in North America.

Other areas in Laryngology that are cutting edge, is that, you know, all the medical fields are trying to get into AI and machine learning and things like that. So, in laryngology that’s definitely lagging behind a little bit. So I think a lot of researchers are trying to get to that space.

Emily: Great, it sounds like there’s a lot of interesting and innovative projects going on in the laryngology field right now. You touched on this previously, but I was wondering if you could tell us more on how laryngology differs in larger centres vs community sites?

Dr. Lin: Sure, so I think equipment would be the main issue. So to do high level otolaryngology, so not only- not only does the surgeon have to require some sort of subspecialty training and you also need really good laryngoscopes and video towers to do a thorough laryngeal exam. So we use something called a stroboscopy to look at vocal cord vibration and that sort of subspecialized equipment is very expensive. So if you are a solo surgeon practicing in a small community in rural Ontario, for example, I’m not sure if it’s really worthwhile to make that kind of investment into that kind of equipment to do that sort of laryngeal exam. And I also do in-office procedures, so basically we have lasers in my clinic where I can do small operations within the clinic when the patient is completely sitting up and completely awake. So again, the laser machines and the laser fibers are expensive. So I don’t think that a lot of community otolaryngologists would really dabble in that kind of procedure.  

Emily: Okay, so it seems like laryngology requires newer technology that community hospitals might not have access to at this point. To end off our interview, we were wondering if you have any advice for students who are interested in pursuing otolaryngology? 

Dr. Lin: Yeah, so I suggest that maybe keep your interest broad. So I wouldn’t necessarily narrow yourself to a subspeciality right away, unless you have a very keen interest in that specific area. For myself, personally I didn’t really decide to pursue otolaryngology seriously until I was in my third year. So I think in my first and second year of medical school I kept a pretty open mind, so I shadowed a lot of different doctors. So I shadowed internists, pathologists, I actually went to the morgue and watched autopsies and things like that cause I had no idea what they do before I had gone to medical school. And then I shadowed general surgeons, anesthetists. So basically I tried to keep an open mind, but ultimately for the reasons that I mentioned before I decided to pursue otolaryngology. And for a lot of people how I decided in third year might have been a little bit too late, but i think if you show a keen interest and when you show up for your clerkship rotation, you know, you show up on time, you’re keen, you’re always around, you read up on cases before you come to the clinic or come to the OR, people will realize that you do have a sincere interest in the speciality and that would be looked upon favorably.       

Emily: Great, thanks so much for joining us Dr. Lin. We really appreciate all your advice and insight. 

Dr. Lin: Thank you again for having me, Emily. I really appreciate the opportunity.  

Emily: And thank you to everyone that tuned in to this episode. You can head over to our website at www.theotoapproach.com to learn more about the podcast and you can also find us on Instagram, Twitter, Spotify and Apple podcast. See you next time.

We would like to extend our sincerest thanks to the Saint John Regional Hospital Department of Surgery within the Horizon Health Network for their generous support. Please head to our website at www.theotoapproach.com for our show notes, and to sign up for our newsletter to stay up to date with our latest episodes.