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Conflicts of interest
None to declare.
References
1 Browning G.G. (2009) The first chapter of an ORL detective
novel. Clin. Otolaryngol. 34, 365
2 Goldman A., Govindaraj S. & Rosenfeld R. (2000) A meta-analy-
sis of dexamethasone use with tonsillectomy. Otolaryngol. Head
Neck Surg. 123, 682–686
3 Ewah B.N., Robb P.J. & Raw M. (2006) Postoperative pain, nau-
sea and vomiting following paediatric day-case tonsillectomy.
Anaesthesia 61, 116–122
4 Robinson P.M. & Ahmed I. (1994) Diclofenac and post-tonsillec-
tomy haemorrhage. Clin. Otolaryngol. 19, 344–355
5 Srinvasan K., Hughes L.F. & Lin S.Y. (2003) Postoperative hem-
orrhage with nonsteroidal anti-inflammatory drug use after
tonsillectomy. Arch. Otol. Head Neck Surg. 129, 1086–1089
6 Gunter J.B., Willging J.P. & Myer C.M. III (2009) Postoperative
hemorrhage with nonsteroidal anti-inflammatory drug use after
tonsillectomy. (Correspondence). JAMA 301, 1764
Undergraduate ENT education: what students want
9 August 2009
Sir,
The ENT (Ear, Nose and Throat) syllabus at medical
school must contend for space with many other sub-
jects. In the UK, the ENT block is an average of just
1.5 weeks, often taught as a ‘combined’ subject with
other disciplines, while some schools provide no formal
teaching whatsoever.1 Published evidence already
indicates that junior doctors and GPs found their
undergraduate experience too short.2,3 Considering this,
we sought medical students’ perspectives on the
situation and their suggestions for improvement
through a questionnaire survey of all 389 final year stu-
dents at a British medical school after finishing their
week-long ENT placement. We achieved an 80%
response rate. Teaching of basic examination skills was
not universal: 66% of students were taught ear
examination, 63% were taught neck examination. Fewer
students were taught nose (32%), oral cavity (24%)
and throat (25%) examination. Fifty-two per cent felt
‘underconfident’ or ‘not at all confident’ in distinguish-
ing a normal from an abnormal ear drum. Students’
confidence in recognising common ENT conditions on
otoscopy is shown in Fig. 1. Only 24% felt the ENT
placement was long enough for their educational needs.
Crucially, the proportion of students who felt
adequately prepared to handle common elective ENT
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ear DrumPerforation
Cholesteatoma Acute OtitisExterna
CSOM Glue Ear
615
6 10 10
31
55
33
55 57
56
28
53
32 30
7 3 8 3 3
Very ConfidentQuite confidentUnderconfidentNot at all confident
Fig. 1. Students’ confidence in recognis-
ing common conditions using an
otoscope.
CO
RR
ES
PO
ND
EN
CE
:L
ET
TE
RS
584 Correspondence
� 2009 Blackwell Publishing Ltd • Clinical Otolaryngology 34, 577–588
complaints and common ENT emergencies was 28%
and 23% respectively. Students ranked learning activi-
ties: they spent most time in clinics, followed by self
study and theatre time. When asked which activities they
considered best for learning ENT, students ranked clinics
first, followed by tutorials and thirdly, self study. Students
ranked theatre time fifth out of six possible activities.
When asked for their ideas on improving courses, recur-
ring suggestions included more formal tutorials, clinical
skills sessions, online learning methods (lectures, photos
and interactive web-based tools), models and simulators.
ENT is necessarily afforded limited time in already bur-
geoning medical curricula. Teaching and learning must
therefore be as efficient as possible and focus on essentials,
namely basic ENT examination and management of com-
mon elective complaints and emergencies. Our study has
highlighted specific ways to improve training, as indicated
by students themselves. Our findings are likely to apply to
other UK medical schools which have similar course
lengths and teaching methods, as well as to all ENT
undergraduate instructors who wish to update their meth-
ods of course delivery. Ultimately, we must aim to protect
and expand the ENT undergraduate experience, while
ensuring that students get as much out of their placement
as possible.
Conflict of interest
None to declare.
Chawdhary, G.,* Ho, E.C.� & Minhas, S.S.�
*General Surgical Unit, St Mary’s Hospital, Paddington, London,
UK, and �Department of Otolaryngology, Walsall Manor Hospital,
Walsall, UK.
E-mail: [email protected]
References
1 Mace A.D. & Narula A.A. (2004) Survey of current undergraduate
otolaryngology training in the United Kingdom. J. Laryngol. Otol.
118, 217–220
2 Clamp P.J., Gunasekaran S., Pothier D.D. et al. (2007) ENT in
general practice: training, experience and referral rates. J. Laryn-
gol. Otol. 121, 580–583. Epub 2006 Oct 19
3 Sharma A., Machen K., Clarke B. et al. (2006) Is undergraduate
otorhinolaryngology teaching relevant to junior doctors working
in accident and emergency departments? J. Laryngol. Otol. 120,
949–951. Epub 2006 Jul 31
Flap retraction during septoplasty
13 August 2009
Sir,
During the early stage of mucoperichondrial flap
development for septal surgery via hemitransfixation
incision, a retractor, usually of the Killian type, is
generally inserted. As an alternative at this early
phase of dissection, we propose the use of straight
artery forceps on the flap without the use of a
retractor.
The weight of the forceps automatically retracts the
flap away from the cartilage thus exposing the cartilage
for dissection with the elevator in the usual way (see
Fig. 1). This technique has the following advantages over
the use of Killian’s bivalve speculum during the initial
steps:
• The retraction is relatively gentle
• There is good light without shadowing by a speculum
• There is no slippage as can sometimes occur with a
speculum
• Suction to the dissection site can be accurately applied
as necessary
The forceps can then be replaced by a speculum as the
dissection advances in the usual way.
Fig. 1. Artery forceps to retract mucoperichondrial flap.
Correspondence 585
� 2009 Blackwell Publishing Ltd • Clinical Otolaryngology 34, 577–588
