Welcome to Episode 2 of The Oto Approach! Rhinology is a subspecialty within Otolaryngology - Head and Neck Surgery. In this episode, we are joined by Dr. Christopher Chin, an assistant professor at Dalhousie University who completed a Rhinology, Skull Base, and Head & Neck Oncology fellowship at the University of Toronto. Listen along to get an inside look into the subspecialty.

Show Notes

Katie: 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 Katie and today we're going to be joined by Dr. Christopher Chin. 

Dr. Chin attended medical school in London Ontario at Western University and completed his Residency at Western as well. He has a fellowship in Rhinology anterior skull base surgery and Head and Neck Oncology from the University of Toronto. He has been a practicing otolaryngologist in Saint John since 2016 and is currently a professor within the division of otolaryngology-head and neck surgery at Dalhousie University. Dr. Chin has published over thirty peer-reviewed articles and is actively involved in the research in medicine program at Dalhousie University, as well as the emergencies in otolaryngology boot camp. He's the current Vice chair in the Canadian Society of Otolaryngology Rhinology working group. 

So, thank you so much for joining us today Dr. Chin.

Dr. Chin: Thanks for having me!

Katie: So we are hoping to hear a bit about your career in otolaryngology, specifically in the subspeciality of Rhinology. Could you tell us a bit about what rhinologists do?

Dr. Chin: Sure. So a rhinologist is somebody who focuses on the pathology that affects the nose and paranasal sinuses. So that can be anything from nasal obstruction, to pathology called chronic rhinosinusitis, which basically makes people feel like they have a cold all day every day and that that's a pretty common condition, so that makes up the bulk of what we do in rhinology. There's also the second part of that which is the anterior skull base surgery and that basically refers to addressing problems that affect the brain and the pituitary gland, particularly that portion of the brain that is accessible to the nose and sinuses, so that's the anterior skull base. So when I did my fellowship that was a big focus. That's kind of the rhinology side of things.

Katie: Okay thank you, that definitely provides some insight for our listeners. In terms of patient presentations and procedures. What would you say is the bread and butter of your speciality?

Dr. Chin: Well, we are in a unique Center in Saint John. As somebody who has a fellowship my practice is skewed towards that, so I do, as I was mentioning, the rhinology and anterior skull based stuff but I also do kind of general otolaryngology and the other aspects, the other parts of otolaryngology. So the true bread-and-butter parts of otolaryngology would be tubes and tonsils typically in the Pediatric population for hearing issues or recurrent ear infections and sleep apnea. So that's a very common pathology and procedure that we would do. The other ones would be septoplasty, so that straightening the nose so somebody can breathe better through their nose. As well as thyroid surgery, so thyroid surgery is pretty common now for the otolaryngologist to do. So that’s another thing that would be considered pretty standard, pretty I guess bread-and-butter. The other thing would be skin cancers. So a lot of, across Canada, otolaryngology has really taken a role managing a lot of that, skin cancers that affect the head and neck area. So those are things that are pretty common that we see on a regular basis. Specifically, with rhinology, endoscopic sinus surgery for the treatment of chronic rhinosinusitis would be a very common thing to do and that's something that I do basically on a weekly basis in the operating room. 

Katie: Okay so even within the more common procedures in your practice there's still a lot of variety. Are there any procedures or patient presentations that you think are most interesting in the specialty?

Dr. Chin: Yeah so for me, I mean the reason that you do a fellowship is so that you have that expertise in managing the complex patients. Most otolaryngologists across Canada are going to do some sinus surgery but with the fellowship it allows me to do things that are a little bit tougher and maybe the patient who have had three or four prior surgeries and still having symptoms, those are the ones that then get sent to me and that's where I can help them. I guess the other ones would be if somebody had a tumour in the sinuses, those are also challenging cases and those are ones that I can usually be useful for. Then lastly the pituitary pathology, so when people have pathology or tumours in the pituitary gland. Just to recap, the pituitary gland is basically in the middle of your head and it's a very small gland, in a very tight location and if you get any pathology there it can cause significant issues. So it can compress the optic nerve, it can cause vision issues that can affect hormone output, if it gets big enough it can start to squish the brain. It can cause significant issues. The easiest and typically the best way to get there is actually through the sinuses. When patients present with this type of pathology, I’m often asked to be involved in those cases at our center. Those are the cases I enjoy doing with the assistance of neurosurgery. 

Katie: So, you tend to enjoy the more elaborate cases, where you can really apply your fellowship training. So, one big question medical students often have is “what is your life like in the run of a week?”

Dr. Chin: Sure, my week is very variable, every week is a little bit different. Generally, I'm going to be in my outpatient clinic or my outpatient office, probably anywhere from 1 to 3 days a week. I'm usually in the hospital clinic where we have a minor procedure room, I'm probably there once a week on average. I'm usually operating anywhere from 1 to 3 days a week. There's a huge amount of variety. So this past week, I was operating one and a half days in the operating room. This week coming up it’s another two and a half days. It really fluctuates depending on what the week is, what OR time is available and If I'm doing any collaborative cases. So for instance this past week, I was doing a pituitary tumour that was relatively urgent. So that came in and we had to do that, so that was half a day there where I was doing that with the neurosurgeon. This week coming up, it's mostly advanced sinus cases and head and neck cancer cases, but again there's another half-day where I'm collaborating with one of my other colleagues with some other cancer cases he is doing. 

There's a huge variety there. I'm on call once a week and then every 4th week I'm on call Friday Saturday Sunday. So it works out. I'm on call every 4th day on average and our call is relatively good most of the time but when we get called in it's usually for something emergent. There's not a lot of things that we get called in for, that we don't have to go in, because we are the kind of Masters of the air way. If someone's calling in, it's usually because there is an airway emergency or there is some sort of serious pathology in the head or neck like a penetrating trauma or severe nosebleed or something like that. Usually when we get called in it's something we have to go in relatively quickly for. So that's the call side of things. But overall, it's a very balanced schedule, we do a fair amount of clinical but we also operate a fair amount. It's a good mix of the two. I think that variety keeps it interesting. 

Katie: Right and I think variety is something that tends to draw people to ENT in general. So, I noticed you said you collaborate with some of the other physicians within the hospital on cases, what’s your role in these scenarios? 

Dr. Chin: That's a great question. The collaborative side of things is probably one of my favourite parts of my job and there's a lot of ways that Otolaryngology is involved with different specialties. So for the pituitary in particular and the skull base. Just to recap, the pituitary is a gland, basically in the middle of the head. Classically that has fallen under the domain neurosurgery from a surgical standpoint. But we've realized that the best way to get to it is through the sinuses because the pituitary is just superior and posterior to the sphenoid sinus. So instead of making big cuts on the head and lifting up the brain and stuff like that, we realize that you can go through the sinuses and reach the pituitary gland much quicker and typically much safer. So generally, the best person to get to the pituitary gland is an otolaryngologist who has a fellowship in skull based training. So that's where my role is. These patients are typically seen in our pituitary Clinic where they are accessed by neurosurgeon and they are accessed by an endocrinologist. They will get worked up from a hormone standpoint and they will also have visual field testing ordered because the pituitary gland sits right underneath the optic chiasm. So pathology there can affect the visual fields. Then if a patient is deemed that they need surgery, then that's when I get involved and help kind of with that side of things. 

The other kind of collaborative things that I do on a regular basis, so as part of my fellowship- the other half of my fellowship was head and neck cancer and we did a lot of ultrasound-guided biopsies. So that's kind of a unique thing, where I have some extra training using the ultrasound for biopsying masses in the neck and in the thyroid. So some of my colleagues if they have a thyroid nodule they want me to assess it. They are capable of doing the biopsy themselves if they can feel it and capable of managing a thyroid nodule. But for the biopsy specific using an ultrasound, that’s where I can be helpful. So that's another example. A third example would be for head and neck cancer cases. If we have big tumours that need a reconstruction we work very closely with plastic surgery. We do these cases on a not-insignificant frequency as well where somebody will have a big tumour typically involving the tongue or the floor of mouth or some other part of the head or sometimes the larynx and needs to be resected but you can't just leave nothing there, you have to rebuild it. In a lot of centres and across Canada, otolaryngology actually does the reconstruction as well. Depending on who you talk to, that is fantastic. 

As part of my training in London, we did a lot of free flap reconstruction and a lot of head and neck cancer reconstruction. But in a Center like Saint John, it makes the most sense for us to work closely with our plastic surgery colleagues who have experience doing this. So we rely on them and that's a great experience as well, getting them involved and they do the reconstruction for us. I guess the last thing I would just mention is, we are recently starting another collaborative Clinic. Myself and one of the respirologists, looking specifically at very severe sinus pathology because chronic sinusitis is essentially the same disease as asthma, except it's just in a different part of the airway. So we're working very closely- or I’m going to be working very closely with him in respirology and we're going to be managing these severe sinus patients.

Katie: Okay so it definitely seems like there are a lot of opportunities to collaborate with other professionals. So of course, within Canada there are lots of different practice styles, depending on the type of center you're located at. How would you say rhinology differs in larger centers versus community centers. 

Dr. Chin: That’s a very good question. So I guess the first thing I would say is my location, my Center, is very unique across Canada. So I'm in Saint John New Brunswick and we are kind of what I refer to as a pseudo Community but also pseudo-academic meaning that we have clerks, we have elective students, and we have residence but we don't have them all the time. So while we do have that academic aspect of things we're not doing it full-time, like some of the other academic centres across Canada. The other aspect that is in terms of what we actually do and operate. So. I kind of break down the centers into smaller community centres and larger Academic Centers, and I would put Saint John, New Brunswick in the middle there. The smaller community centres otolaryngologists generally are going to do a wide variety of cases across pretty much all the different facets of otolaryngology, but they're generally not going to do the more advanced or complex cases. So they're going to do from Pediatrics they would do tubes and tonsils. From the head and Neck oncology side of things they might do hemithyroidectomy, maybe parathyroidectomy, or maybe parotidectomy, the occasional neck dissection. From rhinology, they are going to do septoplasty and basic sinus surgery typically. From facial plastics, they might do some skin cancer excisions and that sort of stuff. 

Then if you go to the flip side of that, to an academic centre, most of the people working in those centers, like London, Toronto, Halifax, Edmonton, those physicians are going to work almost exclusively in their own domain. So if you're a head and neck cancer surgeon, you're just doing head and neck cancer usually or at least 90 to 95% of your practices is just head and neck cancer. Similarly, if you're a rhinologist or skull-base surgeon, that's really all you see. Again, on call you might see the occasional neck abscess or something like that but the vast majority of your practice is going to be just rhinology. Not only are you going to just see rhinology, but you're going to see the full spectrum of that. So you are going to see the basic sinus stuff sometimes, although a lot of the time at the academic centres, their pathology gets skewed more significantly to the complex disease. So for instance, in my fellowship- in my rhinology fellowship, the vast majority of the surgeries I was doing was revision sinus surgery. It was very rare for me to do just a basic version or primary sinus case because most of the time those are done in the community and if they have issues or ongoing problems then they get sent to the tertiary center. My practice kind of falls in between, so like I kind of alluded to I do these complex sinus cases, the pituitary cases, and I do these big head and neck cancer resection and reconstruction, but then I'm also doing the basic and kind of more general side of otolaryngology as well. I do the occasional tonsillectomy. I do the occasional set of tubes. I do very little ear surgery, that's just kind of a cork in my practice, because everything has been shifted more towards the rhinology and head and neck cancer sign of things, but I still do some general otolaryngology. 

Katie: Right okay, so definitely some differences depending on whether you're working in a larger city or community center. So another question that, again, a lot of medical students have when talking to physicians is, in your opinion what are the pros and cons of a career in Rhinology?

Dr. Chin: Sure. So I think, you know obviously I'm biased because I am an otolaryngologist, but there's a lot of pros about this type of career. It's a very diverse speciality, I think that's the thing that a lot of people will say about otolaryngology. You're not doing the same thing over and over again. If you look at an OR list that I have, I made do, like I was saying, a set of tubes and then I made you a tonsillectomy and then I may go do a thyroidectomy for cancer or airway obstruction or something, and then I may go do like a pituitary tumour. So it's a very diverse specialty and it allows you a lot of flexibility. I think the ability to see a patient, diagnosed pathology and then treated it right away, or in the very near future with surgery, is something that is very rewarding. It's not something where you- for most of the conditions we see- you're not going to say “okay well try this medication and you know hopefully it will help you out,” usually if we're seeing there's often a structural thing that we can address with surgery and that's obviously something is very attractive as a surgeon. 

The other kind of pros would be we have a relatively good work-life balance. So I would say that in terms of surgical specialties, our call is relatively good for the most part. It's not like when we are on call we are in there every night, which is good. The other things that are good about it would be that in terms of the pathology we see, while we do see a lot of serious pathology, we also do a lot of quality of life stuff too. That can be kind of nice, to work on somebody and just improve their breathing or their sleep or their hearing. That can be very rewarding and those patients actually are sometimes the happiest patients. They went into surgery not being able to hear, or not being able to breathe, or smell and they wake up and that ability is back again. So that is very rewarding to be able to do that. I guess the last thing that I would say is the ability to collaborate with different specialties is, I would say, a very big draw to the speciality. I would say that a big pro, it's a very diverse speciality and that affords these different opportunities. 

There are drawbacks. So being a surgical specialist you are limited by your operating room availability. So that does impact where you can work, there’s just not unlimited OR resources across Canada. So I hate to bring up the job side of things but I think it is important to know and consider when you're considering this career, that you have to be flexible. For instance, I'm not actually from New Brunswick, I’m actually from Ontario and this job opportunity, when we were looking for a job, this really gave me the best opportunity to be able to use my fellowship and to work in this environment that I wanted, but I had to move across the country for it. I think it's really important to keep that in mind. The other thing that I would say is that we do call. So while it's not overly onerous the majority of the time, if fact I am on call right now and haven't had any issues since we started talking, you still have to do that side of things. That does obviously impact your quality of life, when you know it's always better to not be on call then be on call. You just have to keep that in mind, typically as a surgical specialist typically you are going to be doing some call.

Katie: Okay. Yeah, Thank you. It’s always great to hear from a specialist about what the good things are and what the bad things are, because you know every specialty is going to have the good and bad, it's just good to be aware of those things, especially as a medical student. So we're kind of coming to an end here but we've got one last question for you, the team was kind of wondering if you could go back in time and have a chat with yourself as a medical student, what advice would you give yourself?

Dr. Chin: Yeah, that's a great question. So I would say that the advice I give all- that I would give myself, and then I give all my medical students that work with me and shadow me is to try to figure out what you want to do, as early as possible. So unfortunately, the way that our medical system works, you’re kind of forced to decide relatively early in the grand scheme of things, what you want to do, what you want to be when you grow up, and you have to start kind of positioning yourself towards that career earlier, I guess the sooner the better typically. That can be challenging because if you go into medical school and you really have no idea, you know one approach would be to just wait until you do clerkship and kind of see everything the problem with that is, if you go into clerkship and you decide oh wow, I really love otolaryngology, or urology, or plastics whatever or something else anesthesia, or emergency medicine. You are a little behind the 8-ball when it comes to your peers because some of those competitive specialties, a lot of the competitive specialties including otolaryngology, require you to have jumped through certain hoops. What I mean by that is, when people are applying for it medical students have often done a little bit of research, they've often shadowed people from different centres, they have kind of some reference letter starting they are starting to get ready. The sooner you can kind of get on that, I think the better positioned you are. The way that I usually recommend doing this is just spending time with people in the field. So I know in Saint John, the first and second-year students usually have the opportunity to shadow physicians for a semester or two semesters and I think that's a great opportunity just to see what it's like, what a day in the life is like, or not a day I guess, I guess you know a semester in the life. You get to see the different facets of the speciality and decide if that is something you want to do. And further to that, that gives you very good exposure to a physician who, hopefully will become like a mentor can give you some guidance and advice about the specialty, in whether it's something that you want to pursue. That also usually will open up research opportunities. So I've worked with a handful of medical students here now since I've been in Saint John and a lot of them that have spent time with me have ended up doing some research with me. I've also been fortunate enough to be able to send them to different parts across Canada to spend time and do electives and shadow different physicians and colleagues and friends that I know and that I've worked with in the past. I think that's been beneficial for them or I hope it has been anyways. Obviously that changes a little bit with COVID, but hopefully in the near future that's something that will return again. 

Katie: Alright, thanks so much Dr. Chin and thank you to everyone that tuned-in. Make sure to check out our next interview and please fill out the survey on our website. See you next time!