Latest / Veterinary Ramblings / Ep 12: Intricate Ear Surgery with Nick Saunders

Transcript

Ep 12: Intricate Ear Surgery with Nick Saunders · Veterinary Ramblings

• 0:00
  Mike Brampton: Good evening, Julian!
• 0:02
  Julian Hoad: Good evening, Mike! How are you?
• 0:04
  Mike Brampton: I'm excellent. Thank you. And welcome everybody to Series Two, Episode Four of Veterinary Ramblings. My name is Mike Brampton.
• 0:15
  Julian Hoad: And my name is Julian Hoad.
• 0:18
  Mike Brampton: You know, I didn't quite recognise you there
• 0:21
  Julian Hoad: No I was in disguise.
• 0:22
  Mike Brampton: Oh right, had you got a mask on?
• 0:25
  Julian Hoad: Yeah, you couldn't see it. They're invisible in daily usage.
• 0:29
  Mike Brampton: Oh right, excellent. Yeah, you sort of take it for granted that people are gonna wear masks these days
• 0:33
  Julian Hoad: I don't notice them anymore
• 0:34
  Mike Brampton: No, I don't either. Absolutely.
• 0:38
  Mike Brampton: Hi, I'm Mike Brampton
• 0:40
  Julian Hoad: And my name is Julian Hoad
• 0:42
  Mike Brampton: Welcome to Veterinary Ramblings.
• 0:46
  Mike Brampton: But before we go on, and before we start introducing tonight's guest, I think we should make it perfectly clear to everybody that if you're the sort of person that complains about the table next to
• 0:46
  Mike Brampton: you in a restaurant, talking about wounds, or blood, or Gore, or infections, because it's putting you off your tea, you'd better switch off now.
• 1:14
  Julian Hoad: There's gonna be lots of gore tonight, lots, lots and lots.
• 1:18
  Mike Brampton: Because this is Veterinary Ramblings, and this is where, who knows were the conversation will go, or what we could talk about. We don't want to offend anybody. That's not our intention.
• 1:18
  Mike Brampton: Our intention is to educate, amuse, and generally have some fun. And if you're involved in veterinary or veterinary medical or medical fields, then very often, that's how we unwind.
• 1:43
  Mike Brampton: That's how we get some of the stuff that we deal with on a routine basis out of our system, so that we can pitch up the next day and get through it all again.
• 1:52
  Julian Hoad: So if you don't like jokes about puss making guacamole, then don't listen to that one.
• 1:59
  Mike Brampton: No, don't don't listen to that one, because that would be awful. So should we start the show guy?
• 2:06
  Julian Hoad: Let's start the show. And we've got another very special guest tonight, haven't we?
• 2:10
  Mike Brampton: We have indeed, a very special guest. And he uses lots of long words that I struggle with. So perhaps you be kind enough to tell the audience, Julian, about our guest. And then we'll
• 2:10
  Mike Brampton: announce him and get him in out of the way, because he's, he's actually in the waiting room now.
• 2:27
  Julian Hoad: He's in the waiting room, waiting for us, he's poured himself a gin. So tonight we have Mr. Nick Saunders. Now Mr, of course, means that he's a surgeon, he's a human surgeon at that, not
• 2:27
  Julian Hoad: just a human surgeon, he's one of the leading ENT surgeons in this country. He's an examiner for the Joint College of Surgeries,
• 2:46
  Julian Hoad: the Intercollegiate College. He is also an examiner for the European Board of the ENT Surgery. And he specialises in middle ear and skull base surgery. His name is Nick Saunders, he's in the waiting
• 2:46
  Julian Hoad: room. Let's get him in now.
• 3:05
  Mike Brampton: Nick Saunders, Hi!
• 3:07
  Julian Hoad: Hi Nick!
• 3:09
  Nick Saunders: Good Evening. Good Evening. Good Evening
• 3:11
  Mike Brampton: How the devil are you?
• 3:12
  Nick Saunders: I'm very well thanks, how are you?
• 3:14
  Mike Brampton: I'm excellent, thank you very much indeed. We've told the, we've told the audience that if things get a bit gruesome they should just switch off, they shouldn't be watching us in the
• 3:14
  Mike Brampton: first place.
• 3:23
  Julian Hoad: Yeah, they shouldn't listen to a discussion about puss and discharge and smelly things, blood pouring out everywhere, brains oozing out of the sides and stuff. So we won't mention those
• 3:23
  Julian Hoad: at all.
• 3:36
  Nick Saunders: No, I wouldn't, I wouldn't, not if your squeamish for sure. I wouldn't
• 3:40
  Julian Hoad: Have you got a drink?
• 3:43
  Nick Saunders: I have, I have, I'm on the the Brockmans tonight with with fevertree elderflower, which is, which I have to say is rather the combination,
• 3:53
  Julian Hoad: I've got a bottle of lavender, lavender dry gin with fevertree as well. And it's jolly nice. It's got a sort of pale, pale pink colour
• 4:08
  Mike Brampton: Cheers.
• 4:11
  Julian Hoad: Have you ever had any barbecues recently Nick?
• 4:14
  Nick Saunders: I have. I have with with with my green egg.
• 4:18
  Julian Hoad: Yeah?
• 4:20
  Nick Saunders: Other BBQ's are available
• 4:21
  Julian Hoad: They are Yeah.
• 4:25
  Mike Brampton: I've heard of green tomatoes but green eggs?
• 4:27
  Julian Hoad: It's brilliant, it's a Komodo style oven. Other large monitor lizard based BBQ's are available.
• 4:40
  Nick Saunders: My culinary skills aren't quite up to the level of Julian's but it is. Yeah, it covers a multitude of sins and it can make most things tastes pretty decent
• 4:49
  Mike Brampton: Cool!
• 4:50
  Julian Hoad: And it uses about that much charcoal
• 4:53
  Mike Brampton: Is that because you've got a small green egg and he's got a Mongolian firepit to feed the Mongolian hoades as they ride across the steps to invade China. I've seen, have you seen his
• 4:53
  Mike Brampton: barbecue?
• 5:06
  Nick Saunders: I have seen his barbecue and it is fantastic. It is fantastic, you do expect to see a yak roasting on it.
• 5:13
  Julian Hoad: I've got one on order, it hasn't arrived yet
• 5:16
  Mike Brampton: What a yak? Have you bought it as a whole or as half?
• 5:21
  Julian Hoad: Just a half, half side of yak
• 5:24
  Nick Saunders: Not a tapir?
• 5:27
  Mike Brampton: We can't afford such delicious meats. You have been watching, haven't you, Nick?
• 5:36
  Mike Brampton: I managed to cook Yorkshire pudding on my barbecue last week
• 5:40
  Mike Brampton: Right. What with the Yak?
• 5:45
  Julian Hoad: How dare you talk about my wife like that! No, she sat and watched. I'm gonna get it in the neck for that.
• 5:54
  Mike Brampton: Julian, before before we go too much further, I think we'd be very careful, it appears that, it appears that this guest has actually seen previous episodes.
• 6:05
  Julian Hoad: Bugger
• 6:08
  Julian Hoad: That's never happened before.
• 6:11
  Mike Brampton: I'm going back in incognito. I think.
• 6:14
  Julian Hoad: Let's let's get back on this. I got not enough praise, I think, for my cooking Yorkshire puddings on a barbecue.
• 6:19
  Mike Brampton: Oh, right. You, Oh, you did what Julian? You cooked yorkshire puddings on a barbecue?
• 6:24
  Julian Hoad: Yorkshire puddings, we've got a Dutch oven on top. Put it up to charcoal mark five. And got the temperature nice and hot. Put the oil in, put the yorkshire in. Slightly burned. But yeah,
• 6:24
  Julian Hoad: it was alright.
• 6:35
  Mike Brampton: That's amaz- I can't keep this up
• 6:39
  Julian Hoad: Are you a charcoal man Mike? Or are you?
• 6:43
  Mike Brampton: Me? I'm a woodfired barbecue man.
• 6:45
  Julian Hoad: Yeah. See mine's duel fuel.
• 6:48
  Mike Brampton: Oh Right?
• 6:49
  Julian Hoad: Yeah.
• 6:50
  Mike Brampton: What wood and charcoal?
• 6:52
  Julian Hoad: Wood and charcoal. So wood and older wood.
• 6:58
  Mike Brampton: Yeah. Let's face it. We're all wrecking the planet with our barbecues but yeah
• 7:04
  Julian Hoad: Other ways of wrecking the planet are available.
• 7:06
  Mike Brampton: Yes, yes. Driving to Barnard Castle.
• 7:10
  Julian Hoad: Yes, yes. unnecessarily.
• 7:12
  Mike Brampton: Yep.
• 7:14
  Julian Hoad: And yeah, that's probably about the only one actually, isn't it? Because he's wrecked lockdown and and the environment.
• 7:21
  Mike Brampton: Yeah. Yeah. But it's-
• 7:23
  Julian Hoad: I said, I wouldn't talk about Dominic Cummings tonight.
• 7:25
  Mike Brampton: Yeah.
• 7:26
  Julian Hoad: So I won't
• 7:30
  Mike Brampton: It gets a little bit political sometimes
• 7:32
  Julian Hoad: So when you're not, when you're not on your barbecue Nick, you are cutting bits of skull out of people's heads?
• 7:40
  Nick Saunders: Cutting drilling. Very occasionally chiselling. Yeah, yeah, all, other methods of removing bone are available.
• 7:48
  Julian Hoad: And yes, I've seen them, I was a Millwall football match once
• 7:51
  Nick Saunders: I do quite a lot of that, just sort of, yeah, removing various bits of bone and putting new bits of bone in different places and moving stuff around. And yeah.
• 8:06
  Julian Hoad: Now one of the things that you- you constantly amaze me actually the things you do because I do, obviously, surgery on dogs and cats. You make my surgery look more like I've got a
• 8:06
  Julian Hoad: chainsaw because you do very very precise surgery. And you actually replace the the ossicles of the ear, don't you?
• 8:29
  Nick Saunders: Yeah, Yeah, I do. The fiddlyist operation, I think probably the fiddlyist operation that anyone does actually, probably in the whole of surgeries is called stapedectomy. And I don't, I
• 8:29
  Nick Saunders: don't know if many animals have stapes? Most of them are single ossicles and collimator aren't they, but the human ears got the three ossicles and sometimes the
• 8:52
  Nick Saunders: stapes gets fixed, it should move in and out like a piston in a cylinder. And if you extend the the car analogy, essentially that the piston rings get coked up and the stapes stops moving. And that
• 8:52
  Nick Saunders: gives you hearing loss and you can use a hearing aid or you can, you can try and bypass it with some surgery and the surgeries- Yes, it's quite fiddly. You
• 9:14
  Nick Saunders: basically take off the top end of the stapes, It looks like a stirrup hence the name, and you take off the legs and laser a little hole in the footplate, the bottom bit and then hang a new piston,
• 9:14
  Nick Saunders: hang a new prosthesis in there. To give you some idea, the diameter of the hole the laser is point eight millimetre. The diameter of the piston is point six
• 9:43
  Nick Saunders: millimetre, it's four and a half millimetres long with a little coat hanger on the top you've got to hang over the incus and then laser in place. So it's not one to do after a big night out.
• 9:57
  Julian Hoad: And you don't have too many coffees that morning, do you?
• 10:00
  Nick Saunders: I actually, I'm quite, coffee doesn't give me a tremor. So I'm quite lucky on that one. But no, you wouldn't you wouldn't want to be doing it if your hand was a bit shaky for sure.
• 10:10
  Mike Brampton: So you're not doing one tomorrow morning then?
• 10:13
  Nick Saunders: No, no, I'm not. You'll be pleased to hear I'm not.
• 10:18
  Julian Hoad: How long would you say it takes you to do that sort of surgery?
• 10:21
  Nick Saunders: That's a couple of hours, which is, which is actually quite quick compared to a lot of the stuff I do. Some of the, some of it'll take three or four hours. If you get a big middle ear
• 10:21
  Nick Saunders: cholesteatoma or something? Yeah, that'll be three or four hours of gurgling around is something about the size of your thumbnail.
• 10:40
  Julian Hoad: Yeah, it's a little guzzling around, isn't it? The big problems, I guess, are going to be avoiding the delicate structures of the facial nerve, the venous Plexuses.
• 10:52
  Nick Saunders: Yeah. I mean, there's, there's a lot of clockwork, you don't want to mess up in quite a small area. And it's all in three dimensions. And it is, yeah, you've got to kind of know where
• 10:52
  Nick Saunders: you're going. And you've got to know it fairly intuitively. Quite, I teach on quite a lot of anatomy courses, and I run a couple
• 11:18
  Mike Brampton: Are you operating down a microscope then Nick?
• 11:20
  Nick Saunders: Oh, yeah. Yeah.
• 11:24
  Julian Hoad: How do you learn to do that? Well, how do you accurately teach to do that?
• 11:35
  Nick Saunders: There are all sorts of clever 3d haptic simulators, which are not great. Some of the some of them are okay. But then they're fine if you for absolutely, we're all beginners, but for
• 11:35
  Nick Saunders: once you get past that stage, there's no real substitute for simulation. And there's plastic temporal bones you can use and those are quite good. But actually, there's no real
• 12:03
  Nick Saunders: substitute for categoric dissection and the courses I run are based on that. Because you've got to know your anatomy intuitively,the spiel I give to the to the candidates is because all the anatomys
• 12:03
  Nick Saunders: usually derranged and you're in there, there may only be one or two landmarks and all the rest may have been destroyed. You've got to know it in the
• 12:25
  Nick Saunders: same way that if you've grown up in a village all your life, and you get dropped off at three in the morning. After too many pints in the fog. You know how to get home from one lamppost.
• 12:41
  Julian Hoad: This sounds very much like a trip back from The Riser on one Christmas
• 12:48
  Mike Brampton: Was at the time you fell in the fish, in the pond, in the village pond?
• 12:52
  Nick Saunders: It was very icy. It was very icy.
• 12:55
  Julian Hoad: Yeah, we almost ended up in the little stream. It was about that time when we used our friend Jonathan as a toboggan, wasn't it? A few of us sat on him and scooted along.
• 13:07
  Nick Saunders: Yeah, I don't think he enjoyed that much to be fair.
• 13:08
  Julian Hoad: Never forgiven us no, so can you, when you have students learning how to do this, do you ever record what they do and talk them through it afterwards?
• 13:22
  Nick Saunders: Yeah, we've started doing that, we've done, we've done quite a lot of stuff.
• 13:26
  Julian Hoad: Only I'd read your paper earlier that you'd written about that.
• 13:29
  Nick Saunders: Oh, well done! You've done your research! Yeah, you can record it, you can send it back. You can go back and critique it, you try and do that individually rather than in front of
• 13:29
  Nick Saunders: everyone else because, you know, teaching by humiliation is apparently passe these days
• 13:49
  Julian Hoad: Do you give a feedback sandwich?
• 13:51
  Nick Saunders: I tend to use a baggette. I was talking about bagettes I think, i was slightly, I was just, I was just Parma ham and nice cheese. I was miles away. Sorry.
• 14:08
  Mike Brampton: Here we go. feedback sandwiches.
• 14:11
  Julian Hoad: Well, the point that I was making was, this other instructor didn't quite get it. Do you see, so we had to give a feedback sandwich, you do something good, you did something bad, you did
• 14:11
  Julian Hoad: something good. So he looked at his fellow climber, he said that was crap! And the instructors said no, no, no, you've got to do a feedback sandwich.
• 14:28
  Julian Hoad: You say something good, then something needs a bit of a tweak and then something good, something positive at the end. He said okay umm urr. You, I like your harness. It's new is It? Anyway, your
• 14:28
  Julian Hoad: climbings shit. Your bum looks good in the harness.
• 14:48
  Mike Brampton: Something tells me that Nicki is far more subtle than that Julian
• 14:52
  Julian Hoad: Oh I don't know are you Nick?
• 14:55
  Nick Saunders: Um, yes. For the purposes of this podcast. I am a model tutor.
• 15:02
  Julian Hoad: I thought so. You wouldn't ever say to an intern, please feel free to cope if you need help.
• 15:16
  Nick Saunders: I would occasionally, occasionally use, obviously purely in jest. Yeah, as a, as a as a, as a supportive trainer. I would, I would only use that to someone who I felt was ready to cope
• 15:16
  Nick Saunders: with that level of banter, shall we say
• 15:35
  Julian Hoad: So, I managed to bring the conversation round to climbing but actually, Mike, you you rather neatly bought around the cycling, didn't you?
• 15:44
  Mike Brampton: Yeah. Yeah.
• 15:46
  Julian Hoad: Nick, do you?
• 15:47
  Mike Brampton: Nick, stay with the programme here.
• 15:54
  Nick Saunders: I was still on cheese and ham baguettes, sorry
• 15:56
  Mike Brampton: Have you eaten tonight, Nick?
• 15:58
  Nick Saunders: Yes, I have sorry.
• 15:59
  Mike Brampton: You have, but you didn't get a cheese and ham baguette did you? That's your ultimate favourite dish? Isn't it? Cheese and ham baguettes.
• 16:07
  Nick Saunders: Yeah.
• 16:08
  Mike Brampton: Well, I'll tell you what, if you pay attention, we'll get your cheese and ham baguette
• 16:11
  Nick Saunders: I've had some really good cheese and ham baguettes cycling!
• 16:14
  Mike Brampton: Have you really? So you utilise the carbohydrate means of fueling
• 16:21
  Nick Saunders: You want to mix carb and protein. Obviously, a little bit protein from the ham and cheese. So yes, yes. And it doesn't get sweaty in your back pocket.
• 16:33
  Mike Brampton: I think I'd just miss the baguette out, have the butter and the cheese and a little bit of ham wrapped around it.
• 16:40
  Julian Hoad: Sorry can i just say to viewers, never carry around a chicken and ham baguette in your back pocket. It probably goes against several hygiene rules. And it is wrong. Don't put it in your
• 16:40
  Julian Hoad: front pocket that looks even worse
• 16:57
  Mike Brampton: As more and more people are out in the roads, and more drivers are actually giving cyclists some space on the roads nowadays. The best thing I found for this happened quite by accident,
• 16:57
  Mike Brampton: was that early one morning I came across a pheasant that had been freshly killed on the road.
• 17:12
  Mike Brampton: And I thought that's not going to waste. So I tucked said pheasant down the back of my jersey and I had a predominantly white jersey on at the time. So that was interesting. And the tail feathers were
• 17:12
  Mike Brampton: sticking out the back.
• 17:28
  Mike Brampton: And so it sort of looks as if I've been shot in the back with the blood seeping through the white jersey and obviously dripping down or, some of my end trails were hanging out the side. I had no
• 17:28
  Mike Brampton: problem with cars giving me a wide berth that morning, whilst I've got the dead pheasant in my back. But I wouldn't recommend that either.
• 17:50
  Nick Saunders: Is that in the highway code that you should use a dead pheasant to avoid cars passing you too close? Because it should be, it should be if it isn't.
• 17:59
  Julian Hoad: I think it is, Mike's essentially carb free aren't you, your still carb free Mike?
• 18:03
  Mike Brampton: No not really. Not really, as you, as you can see I drink fever tree tonic, this evening as we've discussed I'm drinking this but
• 18:17
  Julian Hoad: Lonewolf Mccade, you were essentially carb free while they weren't you?
• 18:21
  Mike Brampton: Yeah. Particularly when I was racing bicycles. So that was no bread, no pasta, no rice, no potatoes. Essentially, yeah, carb free.
• 18:33
  Nick Saunders: That's controversial for racing cyclists.
• 18:39
  Mike Brampton: You've come across the big controversy at the moment of cyclists taking ketones?
• 18:44
  Julian Hoad: I'm just going to drink gin for a while by the way you carry on guys, you carry on.
• 18:50
  Mike Brampton: Yeah, you carry on drink gin. I don't know. The pros will spend a couple of months in the winter doing low level fat burning training and they are essentially carb free during that
• 18:50
  Mike Brampton: point. Julian's getting a double shot of carbs there. Okay. Julian
• 19:13
  Julian Hoad: It's exciting stuff. So this is the keto diet in it?
• 19:17
  Mike Brampton: Yeah, this ketone diet but what's the big controversy recently, was it is it Oxford University have produced a readily assimilable form of ketones that people can drink to fuel their
• 19:17
  Mike Brampton: activities?
• 19:34
  Julian Hoad: umm no someone drunk some nail polish remover by mistake.
• 19:40
  Mike Brampton: No, it's quite a bit controversy because it's not banned as a performance enhancing substance, and why would it be
• 19:49
  Nick Saunders: Then neither is Tramadol.
• 19:54
  Mike Brampton: Have you been doing your research?
• 19:56
  Nick Saunders: Did you know that Julian? Your allowed Tramadol in the last bottle, say in your last bottle before you, before the sprint. A lot of racing cyclists will have Tramadol. That was blamed
• 19:56
  Nick Saunders: for a lot of crashes at the end of big races because they reckon that they were just a little bit slowed down on Tramadol.
• 20:17
  Julian Hoad: Really? My, it wouldn't work for me because I projectile vomit after eating Tramadol. Mind you if there's someone ahead of me on the bike, they'd stop they'd have to clean their jersey
• 20:17
  Julian Hoad: wouldn't they so
• 20:32
  Nick Saunders: If you can turn your head while projectile vomiting then that will give you some form of propulsion.
• 20:39
  Julian Hoad: I don't know if I've got the time or control.
• 20:44
  Nick Saunders: and may also upset the people trying to overtake you.
• 20:47
  Mike Brampton: Yeah, but well, that's a big advantage.
• 20:51
  Julian Hoad: Okay, I'll try it.
• 20:53
  Mike Brampton: Yeah, no, don't
• 20:54
  Julian Hoad: Fancy a bike ride, Nick?
• 21:01
  Mike Brampton: I want to get into these, a bit more into the surgery you're doing their Nick, because well some of the stuff I saw was, you're talking about surface ear?
• 21:14
  Nick Saunders: Oh, yeah. That's an interesting one. Um, the ear canal is the only place in the body where skin sits directly on bone. And there seems to be an odd reaction when you get immersed in
• 21:14
  Nick Saunders: cold water, that makes you make more bone. And if you surf, windsurf open water swim in cold water.
• 21:46
  Nick Saunders: You get these boney growths in the ear canal that can almost completely close off your ear canal. Some people have done some quite fun research to look at why and how it happens. It's very much down
• 21:46
  Nick Saunders: to repeated immersion. So if you're in the water for a long time, you don't get them.
• 22:04
  Nick Saunders: Divers don't tend to get them. And it seems to be down to cooling. So if you look at the surfers on the west coast of the states, as we know surfers spend most of the time sitting on their board
• 22:04
  Nick Saunders: looking out to sea waiting for the next wave.
• 22:18
  Mike Brampton: Yeah
• 22:18
  Nick Saunders: In the States, there's a prevailing northerly wind in the winter. And if you look at the surfers out there, they have twice as many Exostosis in their right ear as they do in their left
• 22:18
  Nick Saunders: ear, it's the cold wind blowing in their right ear that gives them bad exostosis.
• 22:33
  Mike Brampton: So if these guys really got into it and actually put earphones in, to listen to The Beegees, or the latest West Coast surfer sound then they probably wouldn't suffer from problems.
• 22:49
  Nick Saunders: Probably not, they might ruin the earphones, but they, they do actually wear earplugs now. And the recommendation is to wear earplugs. And in fact, there's some quite quite funky little
• 22:49
  Nick Saunders: ones, they've got a little cortex membrane down the middle, so you can still hear the wave coming. You can still hear people shouting get off my wave.
• 23:08
  Julian Hoad: I've seen those, they help?
• 23:10
  Nick Saunders: They work really well.
• 23:11
  Mike Brampton: Alright. So I figured in that case, then I'm going to share my screen with you, you wouldn't recommend this then.
• 23:20
  Nick Saunders: Oh, no
• 23:22
  Mike Brampton: For those at home that can't actually see this. I'm showing a picture of a surfer captured a couple of years ago in the Arctic Circle. And he is catching a wave and surfing aggressively
• 23:22
  Mike Brampton: under the moonlight. But also lit by the aurora borealis and northern lights shining down on a snow capped peak.
• 23:49
  Mike Brampton: So you wouldn't recommend that?
• 23:52
  Nick Saunders: He'd probably be alright because it's probably so cold, they'll only be in there for about five minutes. So he'd probably get away with it because it's actually down to repeated
• 23:52
  Nick Saunders: immersion and duration. So he'd probably be all right.
• 24:02
  Mike Brampton: Oh Okay
• 24:03
  Nick Saunders: And actually, interestingly one of the things they say is that, the reason people get them now is because of wetsuits, because in the old days you couldn't stay in the water very long,
• 24:03
  Nick Saunders: so you didn't get Exostosis, but now you can stay in the water longer.
• 24:14
  Mike Brampton: Right
• 24:14
  Nick Saunders: You get Exostosis because we've got these wetsuits. But they've used them for all sorts of things, they've used them for anthropology, because there's not just surfer that get them. And
• 24:14
  Nick Saunders: if you look at skulls from from burials, you can work out what people did and how they got their food because, you know, in 3000 years BC if you wanted to get fish you had to go in the water and get
• 24:37
  Nick Saunders: you didn't have a boat or a net or a carbon fishing rod. So you can tell what was happening in communities and whether they were fishing and you can even look at, you can look at sociology with it. If
• 24:37
  Nick Saunders: you look at the Roman burials from different parts of Italy, you can work out the social structure because if you see whats obviously a rich burial.
• 25:01
  Nick Saunders: In some, in some towns in the rich burials, the scholars don't have Exostosis, in the poorer burials they do, implying its a fairly hierarchical structure and the richer people did what you expect
• 25:01
  Nick Saunders: rich Romans to do and sit around feeding each other grapes.
• 25:18
  Mike Brampton: And orgies...
• 25:19
  Nick Saunders: And orgies, obviously and orgies, whereas in some of the burials, even the rich burials, had Exostosis, so even the rich people went fishing, and it was thought to be a more a flatter,
• 25:19
  Nick Saunders: less hierarchical structure. So you can even use it for sort of anthropological sociology, which is about the only thing in ENT that you can to be fair.
• 25:38
  Julian Hoad: And there was a theory wasn't there, that actually, it may be due as well to people, using the frigidariums, that these three rooms of the baths, the caldarium, the tepidarium, the
• 25:38
  Julian Hoad: frigidarium. And so, a lot of the Romans that were found to have these exostoses growths probably spent a lot of time in the tepidarium and frigidarium rather than necessarily, the caldarium.
• 26:10
  Julian Hoad: And there was a feeling, is it more expensive to use all three? But they, are they the ones who just use those ones because they preferred it or say they could only afford the the colder ones?
• 26:20
  Nick Saunders: I have to say, every every day's a school day, because I didn't know that so you got me on that one.
• 26:25
  Julian Hoad: Google Scholar today.
• 26:27
  Julian Hoad: I want to lead us back on to cholesteatomas, because the same thing has happened there, that they've been able to, to look at quite a few skulls because of course, because cholesteatomas tend to cause
• 26:27
  Julian Hoad: bone loss and so rather than having these bony growths with cholesteatomas you've got bone loss, the soft tissue has gone away, the deposits that cause the cholesteatoma has eroded and dissipated.
• 26:54
  Julian Hoad: But these eroded lesions within the skull are still there. So they've looked to see that the health of people's hearing up to 6-7 thousand years ago
• 27:08
  Nick Saunders: You get a very characteristic bone loss, a very characteristic pattern of bone erosion. And that's an interesting one because I'm not convinced there is a strong socio economic bias to
• 27:08
  Nick Saunders: cholesteatoma. It's said that it's it's got some socio economic proponents even,
• 27:29
  Nick Saunders: I'm not convinced I think it's fairly flat from that point of view but you certainly can look at health and you can say people die from because it does kill you.
• 27:42
  Julian Hoad: Yeah, it predisposes to neural infections, isn't it brain infections?
• 27:47
  Nick Saunders: That means if you've got a cholesteatoma, you've got about a 2% annual chance of intracranial infection. So brain abscess, meningitis, stuff like that, which is why we tend to operate
• 27:47
  Nick Saunders: on it.
• 28:00
  Julian Hoad: So if we rewind for a minute, for those viewers who are about to switch off, thinking their talking long words, we're gonna know where they are. A cholesteatoma is, well oma means growth,
• 28:00
  Julian Hoad: but there's not a tumour. So do you want to tell us what these growths are?
• 28:17
  Nick Saunders: It sounds like a growth of cholesterol and it's exactly not that. It's got nothing to do the cholesterol and its not a growth. Basically the ear canal skin is naturally migratory. The,
• 28:17
  Nick Saunders: the skin and the drum and the ear canal are covered in squamous epithelium, which has got to shed the top layer like any other squamous epithelium,
• 28:41
  Nick Saunders: and because the ear canals are tube, it would very quickly just fill up with dead skin. So there's a clever migratory pattern from the middle of the eardrum out onto the ear canal and out to the
• 28:41
  Nick Saunders: outside. Whereby the ear cleans itself, dead skin come out and that's how we make earwax and you can actually see that.
• 29:00
  Nick Saunders: If you put a little dot of ink on someone's ear drum and watch over a few weeks you see that dot of ink move outwards and move out on the eardrum and along the ear canal.
• 29:09
  Julian Hoad: We should say don't do that at home guys.
• 29:12
  Mike Brampton: Yeah.
• 29:18
  Nick Saunders: Yeah, I wouldn't do it with a big biro, a very soft felt tip might be alright.
• 29:23
  Julian Hoad: Not one of those point three mil pencils because
• 29:26
  Nick Saunders: No, and definitely not propelling pencil.
• 29:28
  Julian Hoad: Right. Right. Sorry. Yes do carry on.
• 29:33
  Nick Saunders: Which is a really really clever mechanism if it's going outwards, but if you get retracted eardrum or sometimes if you get a certain perforations it can start to go inwards. And then it
• 29:33
  Nick Saunders: takes on some really, really really nasty characteristics and it can start to eat wet bone and set up infection and you get all sorts of granulations.
• 29:56
  Nick Saunders: It activates osteoclasts, all the bone disappears. And it's generally bad because as we mentioned earlier, there's quite a lot of important clockwork in that area, there's a facial nerve, there's the
• 29:56
  Nick Saunders: inner ear, there's your brain, and you don't really want it eating away at that. So umm
• 30:11
  Mike Brampton: What do patients present with that Nick?
• 30:14
  Nick Saunders: Normally painless discharge. So recurrent infections say they've had it, they've had a runny ear on and off for a year or two, or sometimes sometimes 15 years. So it's sometimes just
• 30:14
  Nick Saunders: hearing loss. But normally it's just recurrent painless discharge in the ear. And animals do get cholesteatomas actually.
• 30:33
  Julian Hoad: Yeah, I've treated a few the, you say they are painless. And they are painless until you try and remove the plug.
• 30:42
  Nick Saunders: Yes.
• 30:43
  Julian Hoad: And then they become very, very painful
• 30:48
  Nick Saunders: Not when I do them
• 30:51
  Julian Hoad: So so everyone should go and see you. But but some of them are picked up, I think routine appointments aren't they for umm
• 30:59
  Nick Saunders: yeah, I mean they are incidental findings quite quite commonly. And I think one that sticks in their mind is I remember a five year old girl who came in with a bead stuck in her ear and
• 30:59
  Nick Saunders: I took the bead out and there was a cholesteatoma behind it. You know, they they are sometimes incidental,
• 31:21
  Nick Saunders: you could argue that she'd stuck the bead in the ear because the ear was irritating and because she had a cholesteatoma which is possible. But yeah, you do pick them up incidentally. And then when you
• 31:21
  Nick Saunders: pick them up incidentally in someone who's older or not so fit for anesthetic
• 31:36
  Nick Saunders: you've then got that difficult decision of, Do you operate on something that's a potential health threat but isn't causing him any symptoms in someone whom an anaesthetic can be an issue? So yeah,
• 31:36
  Nick Saunders: that's that's often a difficult a discussion.
• 31:54
  Julian Hoad: And when you remove them, do you remove them via the ear canal or do you have to,
• 31:59
  Nick Saunders: Ah, no, I do them all in an incision behind the ear. You can do all sorts of clever things. And increasingly now, for small ones, we're using endoscopic techniques. So with a
• 31:59
  Nick Saunders: combination of the endoscope and the laser, you can get all sorts of things that you didn't used to be able to get to.
• 32:18
  Nick Saunders: And the lasers, lasers really good for you can you can just take a little bit of cholesteatoma off the ossicles without taking the ossicles out which is which is a big, big step forward, we used to
• 32:18
  Nick Saunders: have to do big operations, remove all the bone, remove the ossicles, and we're getting a bit more subtle with it now.
• 32:35
  Julian Hoad: We were still at the not subtle stage, I've got a picture here of one. People who are of squeamish nature may want to turn away,
• 32:44
  Mike Brampton: Brenda, you shouldn't be on this far anyway.
• 32:47
  Julian Hoad: But here's here's the ear canal from a dog with a cholesteatoma. And this huge, it was actually emanating from the middle ear nd had actually taken over the whole of the horizontal canal.
• 32:47
  Julian Hoad: So dogs have this L shaped horizontal canal and vertical canal.
• 33:11
  Mike Brampton: For listeners to the show rather than viewers, Julian was holding up a photographic, a cutaway of an actual operation that he'd done on a dog's ear. And the way to get ahold of that, of
• 33:11
  Mike Brampton: course, is to tune in online and watch the video version of this and you'll be able to see quite graphic detail, the retractors and the blood and the drapes and all of the good surgery he's done.
• 33:40
  Julian Hoad: It ended up like this. So there we go. There's and there's a line of sutures and they actually do very well. It's a big op, its very painful for them, they've got to be kept in for a few
• 33:40
  Julian Hoad: days. And it's total ear canal ablation, usually with a lateral bulla osteotomy combined.
• 33:57
  Julian Hoad: So we're taking out the ossicle. We're taking out the, usually a lot of debris from the tympanic bulla, but we lack the finesse at the moment to be able to remove the cholesteatomas endoscopically.
• 33:57
  Julian Hoad: It's coming. We'll get there.
• 34:18
  Mike Brampton: You've got, you've got an endoscope?
• 34:22
  Julian Hoad: I have, I have yeah. 11 millimetres a bit big.
• 34:28
  Mike Brampton: Get a small one.
• 34:29
  Julian Hoad: What size is yours, Nick?
• 34:32
  Mike Brampton: Well he goes down to point eight millimeters
• 34:34
  Nick Saunders: This is not something I say very often Julian but I'm pleased to say it's smaller than yours.
• 34:43
  Nick Saunders: What do you think?
• 34:45
  Julian Hoad: It's a surgeon disguised as a rubber duck. That's brilliant.
• 34:48
  Nick Saunders: I suspect it probably is
• 34:49
  Julian Hoad: Fantastic. So he's wearing surgical scrubs and a mask.
• 34:54
  Julian Hoad: Excellent. I like that.
• 34:57
  Mike Brampton: I think our viewers will like that as well. I hope your rubber duck isn't special to you Nick.
• 35:09
  Julian Hoad: Harm could come to a rubber duck that people want like that
• 35:13
  Nick Saunders: It was given to me by a friend. When I started doing paediatric ENT, I used to keep a rubber duck in my, in my briefcase for distraction. And, and it was amazingly good actually. And I
• 35:13
  Nick Saunders: always used to say never underestimate the power of the duck. And that was a present from a friend of mine. Yes.
• 35:38
  Julian Hoad: Pop Star
• 35:40
  Mike Brampton: What?
• 35:41
  Julian Hoad: How do you turn a duck into a pop star? You stick him in the microwave till he's Bill Withers.
• 35:52
  Nick Saunders: I've not had enough gin for that one
• 35:54
  Julian Hoad: Sorry to do have another sip.
• 35:55
  Mike Brampton: get another one quick
• 35:58
  Julian Hoad: So we've done Exostosis in surfers ear, we've done Stapedectomy, we've done cholesteatomas. I know, one of your, one of your favourite operations is mastoidectomys .
• 36:16
  Julian Hoad: See, we don't have mastoids in dogs and cats. So I've never done one. But you've, you've found a great deal of success performing radical mastoidectomy haven't you?
• 36:28
  Nick Saunders: Yeah, yeah, that's, that's the operation, one of the operations I did for cholesteatoma, so in animals, obviously, it's just really something down the ear canal. But in humans, because
• 36:28
  Nick Saunders: we've got this, this mastoid, this big honeycomb with bone behind the ear. That's where the cholesteatoma tends to go and where it tends to hide.
• 36:46
  Nick Saunders: And so you spend a long time trying to get it out of the mastoid with, doing as little damage as you can. And I I try and move more away from one of our radical mastoids into into all sorts of other
• 36:46
  Nick Saunders: things now and, because one of the downsides of radical mastoidectomy is that is,
• 37:08
  Nick Saunders: you basically, you've not got a normal ear, it accumulates wax, you've got to keep water out of it. And you're kind of giving someone a chronic health issue, they need to come and have their ears
• 37:08
  Nick Saunders: cleaned out every few months, it's something they've got to worry about, which is okay, it's not the end of the world.
• 37:26
  Nick Saunders: But certainly in kids I don't like doing it and in anyone who is a young, active, wants to swim or whatever. I've moved away from radical mastoids and I do other stuff now. And there's all sorts of
• 37:26
  Nick Saunders: ways of doing what's called a combined approach procedure, where you tunnel through the mastoid and through the ear canal, often use endoscopes for that, often use the laser with that.
• 37:50
  Nick Saunders: And you actually try and give someone as normal an ear canal as you can. Sometimes it takes more than one operation, often you do as a planned two stage procedure. because firstly, a nasty habit of
• 37:50
  Nick Saunders: coming back and you can't always see if it's come back. And scans aren't quite there yet, in terms of picking that out, some of the MRI sequences, now we're getting better at it.
• 38:13
  Nick Saunders: But they're still not quite there. So yeah, I've done about six, six or 700 now, I could probably say that no two have been actually the same. You just kind of deal with what you've got. And I
• 38:13
  Nick Saunders: wouldn't say make it up as you go along but you certainly adapt as you operate.
• 38:36
  Mike Brampton: Your making you my ears very itchy.
• 38:41
  Julian Hoad: I've been dying to scratch.
• 38:43
  Mike Brampton: Ah!
• 38:47
  Mike Brampton: absolutely.
• 38:49
  Julian Hoad: One of the biggest problems we have with dogs and cats ears is that recurrent infection. And obviously with antibiotic over usage, we're constantly being advised to reduce our antibiotic
• 38:49
  Julian Hoad: usage.
• 39:04
  Julian Hoad: And we do that by performing cultural sensitivity tests before we give the antibiotics, but also we try and use other things we use flushes, we use washes, these things like Bureau's solution and
• 39:04
  Julian Hoad: acetic acid and even honey these days. Do you have problem with recurrent ear infections in people that aren't caused by cholesteatoma?
• 39:28
  Nick Saunders: Oh yeah, for sure. You get a lot of recurretn otitis externa which is basically just a skin infection of the ear canal. Similarly, we try and avoid using antibiotics if we can. Acetic
• 39:28
  Nick Saunders: acid we use, and there's some stuff called EarCalm you can buy over the counter
• 39:45
  Nick Saunders: which is basically an acetic acid spray because obviously, you change the pH the bugs don't like that. Not tried honey, have to say its not one I've tried, I'd imagine it'd be quite sticky in an ear.
• 39:57
  Nick Saunders: But yeah, we do see quite a lot of recurrent ear infections. In humans, the easy way of doing it is you just tell people to get their ears dry. And and if you're, if you're a swimmer you wear
• 39:57
  Nick Saunders: earplugs, and nine times out of 10, that stops it. Obviously, with dogs is slightly harder to get earplugs in them
• 40:17
  Julian Hoad: A little bit, in some ways the ear plugs would exacerbate the problem. Because of this right angle turn they have and the fact that dogs with inside out the ears, floppy ears, have a
• 40:17
  Julian Hoad: natural barrier which creates a sort of incubator in their ears. And it's usually multifactorial.
• 40:39
  Julian Hoad: So we see dogs with allergic skin disease having the worst ear problems. And more often than not just changing the food to a hypoallergenic food will sort them out and making sure you say that if
• 40:39
  Julian Hoad: their swimmers, reduce their swimming.
• 40:57
  Nick Saunders: Would you suggest hypoallergenic kibble for my patients?
• 40:59
  Julian Hoad: I would do, yeah. Yeah. Try try them on them Hills Z/D, other ones are available. Or salmon and potato. That's quite a good one.
• 41:08
  Mike Brampton: If you actually to hide it in the two sides of a baguette, then there you go, feedback sandwich. Well, or feedback baguette as this is now going to become known. Yeah.
• 41:25
  Julian Hoad: One of the treatments for chronic otitis in dogs used to be to do something called a lateral wall resection, have you come across that?
• 41:36
  Nick Saunders: Sorry I was on baguettes again, sorry you were saying?
• 41:41
  Julian Hoad: So we used to treat dogs surgically to help with chronic ear infections, by doing this thing called a lateral wall resection where we make an incision either side of the ear canal and
• 41:41
  Julian Hoad: fold the canal down and create a sort of draining platform. And they invariably not work.
• 42:00
  Julian Hoad: It was crap procedures called zepps procedure and he should have been burned at the stake for even suggesting it. I think there are still a few vets that qualified before 1976 are still doing it. But
• 42:00
  Julian Hoad: by and large, it's not a good procedure. And there must be a lot of procedures I guess in the human field as well that used to be derocher 20 years ago or so.
• 42:26
  Mike Brampton: Yes, Mr. Zap What can I do for you? You're watching the internet live. Right? No, no, no. If you if you hadn't phoned us then you'd have heard that Julian was extolling the virtues of
• 42:26
  Mike Brampton: Mr. zepps procedure, your procedure? Yep. No, no, no. Watch it again on replay.
• 42:51
  Mike Brampton: It's going to be on in a few hours time. Yeah, yeah. No problem. Thank you for your call. Mr Zepp. Yep. Mind how you go, bye! Julian that was Mr Zepp on the phone. Yeah, he's gone.
• 43:02
  Julian Hoad: He's gone, sorry Zeppo. Anything you used to do when you first qualified that had gone out of favour?
• 43:13
  Nick Saunders: Oh, lots of stuff. Lots of stuff. Some because better stuffs come along. Some because it just didn't work. Yeah, I mean, we used to do all sorts of horrible things to people, we used to
• 43:13
  Nick Saunders: cauterise their noses with hotwire and if you're having recurrent nosebleeds you you would literally get a what looked quite a lot like a soldering iron. And essentially, it is with a local
• 43:48
  Mike Brampton: yeah, I had that done for not handing my Latin homework in once.
• 43:53
  Nick Saunders: I bet they didn't use the anesthetic for you did they? No, it worked quite well. Patients don't like having the smell of their own burning flesh in their nose. That was one of the
• 43:53
  Nick Saunders: drawbacks. And also, you'd singe the hair it was just bad. So we stopped doing that.
• 44:13
  Julian Hoad: Good. I got Nick a bottle of this. Now this was so, it was a special birthday.
• 44:20
  Mike Brampton: This is a gift was it? A special gift?
• 44:23
  Julian Hoad: Knowing how Nick and I share a love of whiskies, and knowing how he likes whiskey. I went into the whiskey shop and he said 'You need to try this.' So it was an English whiskey. And I
• 44:23
  Julian Hoad: said, 'Well, not convinced' and they said 'No, no, no it's very rare.' So bought a bottle. It was stupidly overpriced, and I thought I'll give it to Nick and we'll try it together. Jesus, it was
• 44:50
  Nick Saunders: I'm not one to be ungrateful about a present.
• 44:53
  Julian Hoad: It was undrinkable. It was foul, I would prefer to drink creosote and have done
• 45:02
  Nick Saunders: I've actually since used it to treat the fence
• 45:08
  Julian Hoad: Don't put the egg anywhere near it, will you? Which is odd though isn't it because the Welsh single malt is
• 45:19
  Nick Saunders: That's quite decent, that's decent
• 45:20
  Julian Hoad: It was nice.
• 45:23
  Mike Brampton: What do the scots thing of this?
• 45:26
  Julian Hoad: They don't mind, they're making enough money on there's. I'm actually always in awe, Nick, about the the surgery that you do. It's absolutely fascinating. We tend to do sort of butchery
• 45:26
  Julian Hoad: I think, sadly rather than surgery. That total ear canal ablation I showed you, yeah, there's a bit of finesse, you know, you've got to mind the artery and the facial nerve.
• 45:57
  Julian Hoad: And so there's some fine dissection but it's basically whacking out the whole ear. And I can't help feeling every time I do it, there's got to be a better way. Fortunately, I do fewer and fewer,
• 45:57
  Julian Hoad: because actually, these days we can medically manage most of them. But it's a horrific op.
• 46:16
  Julian Hoad: Most times it works. And if you dose them up with enough analgesia that they're fine, two to three days later, they're perfect and never look back. About one in 20, I suppose, get a recurrence of the
• 46:16
  Julian Hoad: infection, and they then develop these deep seated abscesses that are a real nightmare to get rid of.
• 46:40
  Julian Hoad: Because you then got to go in there and dissect everything out and try and find the facial nerve again and the drain and we susually use active suction drains. I'm lucky all the ones I've gone in on
• 46:40
  Julian Hoad: again have got better, but there are some horrific stories of dogs that have been put to sleep because you can't control the infections, there recurrent and they get the facial nerve paralysis.
• 47:07
  Nick Saunders: How often would you prang a facial nerve on something like that?
• 47:10
  Julian Hoad: You prang with cats, about 1 in 2, but temporarily. All cats will develop horners for 3 or 4 days afterwards. And some cats will have mild facial nerve paralysis for three or four weeks
• 47:10
  Julian Hoad: afterwards.
• 47:29
  Julian Hoad: About one in five dogs will have mild facial nerve paralysis and about one in 10 dogs will have complete version of paralysis because they're the ones that develop calcifications around the facial
• 47:29
  Julian Hoad: nerve and you try your very best to dissect them away. But there's some that you-
• 47:47
  Nick Saunders: -Can you get EMG monitoring then for dogs? Because we use passive EMG monitoring that whole time on the facial nerve
• 47:57
  Julian Hoad: The answer is yes. I'm sure you could. But it's not done purely through cost reasons, well I say purely for cost reasons, we, no one has the setup to do it.
• 48:12
  Nick Saunders: And you've also got to have them not paralysed, do you paralyse them when you ventilate them or do you have them not paralysed?
• 48:19
  Mike Brampton: Not paralysed. That's one of the things that I find... How do I describe this? Slightly frustrating from a physiological point of view, in human medicine, if somebody is going to be
• 48:19
  Mike Brampton: hooked onto a ventilator, they are paralysed. In veterinary medicine, we hook them onto a ventilator because they're anaesthetised.
• 48:44
  Mike Brampton: And it's, from a finesse point of view. Again, we're talking about finesse, in surgery and in anaesthesia is that there's a massive difference. Although interestingly, I was in an orthopaedic list
• 48:44
  Mike Brampton: fairly recently just before lockdown and the patient was being actively supported.
• 49:08
  Mike Brampton: So the level of anaesthesia was such that the patient was having a total hip replacement under local anaesthetic. So we, the patient sedated, not heavily enough that we couldn't communicate with them.
• 49:43
  Mike Brampton: They weren't intubated. But there was a pressure sensor on their, on their mask, such that if the ventilator felt they required extra assistance to breathe or to take a deep breath, then it delivered
• 49:43
  Mike Brampton: supplementary support. This is way beyond anything that's going on a routine veterinary medicine.
• 49:50
  Julian Hoad: Absolutely
• 49:51
  Nick Saunders: That's quite clever
• 49:53
  Mike Brampton: It was incredible. I mean, we were literally talking to the -It was quite a surreal situation because we were watching the monitors and the ventilator delivering or helping to deliver a
• 49:53
  Mike Brampton: full breath to the patient that we were talking to. Whilst the head of the femur was hanging off the side of the table, as the surgeon was, was chopping off the end of the the head, neck of the femur.
• 50:22
  Nick Saunders: I think that the trickiest anaesthetic I've seen given is, is when you're doing stapes or middle ear surgery under local, and we used to do quite a lot in Australia and then you've got
• 50:22
  Nick Saunders: a base because injecting a local into the ear was spectacularly painful. Yeah. So you give them basically not quite a GA.
• 50:42
  Nick Saunders: But without intubation to stick that local in. And so obviously, got to try and keep their airway but keep them breathing spontaneously, and then wake them up during the operation without them going
• 50:42
  Nick Saunders: 'What the hell is going on?'
• 51:00
  Nick Saunders: So that by the time you then put the prosthesis in, you know, make sure it's in the right place, and ask them if they can hear. And that's quite a clever bit of anaesthesia.
• 51:10
  Mike Brampton: I think that's superb. I've seen similar stuff in eye surgery as well. Again, where you're communicating with the patient, and and you need to be able to, but they're all locked out and
• 51:10
  Mike Brampton: you've got half the eye out. Yeah. Now that's incredible stuff. I'd love that idea that the idea that sort of stuff.
• 51:30
  Mike Brampton: I said, 'so you got the FACO going now have you?' He said, 'That's right. Yeah.' 'What did you set the pressure at?' He said 'minus 25.' Pretty good. And so he said, 'Are you not at all squeamish
• 51:30
  Mike Brampton: about this?' And I said, 'I'd be squeamish, If I suddenly heard you say, ah oh ****'. Until that point, no.
• 52:00
  Mike Brampton: Nick you've been suffering, haven't you? Because you're wearing a mask and a visor for your stuff.
• 52:21
  Nick Saunders: Oh, we've had all sorts of stuff. I haven't done a mastoid since COVID. But we've got to wear NP3 masks for that. So those are the proper sealed ones because of all the aerosol and
• 52:21
  Nick Saunders: stuff. And those are, they're not unlike that being sort of scuba diving rig for the whole time, there's a level of resistance.
• 52:44
  Nick Saunders: And when we were doing the trackers and stuff, we were in the full, full hood, full spacesuits. And that was quite interesting, okay, because you're trying to coordinate a theatre team where you're in
• 52:44
  Nick Saunders: a space hood, your assistances in a space hood, the anesthetists in a space hood and trying to actually coordinate that is, we had to learn all sorts of new ways of working quite quickly. It is Yeah,
• 53:16
  Julian Hoad: It's interesting, not not pleasant. I worked for a brief time at Pirbright doing rinderpest and foot and mouth, anthrax, etc. And we were, there's a cap four lab. And so, we're in those
• 53:16
  Julian Hoad: sealed masks and mrbc suits. And the lab was set at a constant, I think 15 degrees centigrade.
• 53:51
  Julian Hoad: Because any lower than that. And the air would humidify too quickly. And the mask would bung up, any hotter than that and you would just work for 20 minutes and collapse, so it's 15. Yeah, and it was
• 53:51
  Julian Hoad: pretty strange. If it went up to 18, then alarms would ring and you'd have to pop out for a while till the air con cut in again.
• 54:20
  Julian Hoad: But that was unpleasant and all your movements actually were controlled. So the first few days I found it awful, really oppressive and thought, geez, I'm never gonna enjoy working here. After that,
• 54:20
  Julian Hoad: actually, you get used to it and you're there and the effort you take to breathe in, breathe out becomes unnoticeable.
• 54:40
  Julian Hoad: But when you go out again afterwards, so you go out and you have a shower on the way through and then you change and you suddenly think oh gosh, I'm taking huge breaths.
• 54:48
  Mike Brampton: Tell us about your experiences with COVID Nick.
• 54:51
  Nick Saunders: Yeah, it was about as much fun as I've not had ever really. Yeah, I came home one night, I felt a bit fluey, just a bit achy. So I said, I think I'm gonna go sleep in the spare room. I
• 54:51
  Nick Saunders: was supposed to be going in the next day for a meeting. And I phoned up and said, I really don't think I should be coming in.
• 55:16
  Nick Saunders: And they went 'What's your temperature?' 'Only 37 but I don't feel great' and they went 'You should probably come in.' So I came in, sat in the corner, didn't go anywhere near anyone, got home
• 55:16
  Nick Saunders: temperature was 38 and then spent the next 10 days in the spare room.
• 55:34
  Nick Saunders: And it was basically what happened was about the first three days I just felt rubbish, fluey, really knackered, and then felt better my temperature came down. I thought this is great. This is really
• 55:34
  Nick Saunders: good. And then the night of day three started to feel rubbish again. And then just got worse and worse and worse.
• 55:53
  Nick Saunders: And then got the dry cough. And I think day seven was the worst when the temperature didn't come down at all all day, about 38 even though I was going through a lot of paracetamol and stuff. And just
• 55:53
  Nick Saunders: felt awful. And that was the time when you were, this was early in COVID.
• 56:11
  Nick Saunders: And the received wisdom of that stage was day seven you either got better or went to hospital and went to ICU. But I was getting getting at my worst. So that was quite yeah, that was quite troubling.
• 56:11
  Nick Saunders: And then about day eight temperature came down a bit, still spiking up to about 39.
• 56:30
  Nick Saunders: And then eventually, day nine day 10 it came down. I was quite lucky that I didn't get too much in the way of respiratory stuff, I did lose my sense of smell, which was a real worry when it came to
• 56:30
  Nick Saunders: the wine cellar.
• 56:43
  Julian Hoad: How long did it take to come back?
• 56:44
  Nick Saunders: I did a little randomised control trial on myself and stuck some nasal stone on one side of my nose and not the other. And it made absolutely no difference at all. And they both came ba
• 56:44
  Nick Saunders: k after about three week
• 57:00
  Julian Hoad: So they now think it's the cells for the olfactory neurons, don't they?
• 57:08
  Nick Saunders: I mean a lot of viruses are toxic to the olfactory neurons, influenza viruses known to be toxic to the olfactory neuron. So that's probably the commonest cause of
• 57:17
  Julian Hoad: Particularly the NWS version.
• 57:23
  Nick Saunders: But it seems
• 57:24
  Mike Brampton: -The not safe for work version, Julian?
• 57:27
  Julian Hoad: Sorry?
• 57:28
  Mike Brampton: The not safe for work version.
• 57:30
  Julian Hoad: No, the NWS not NSFW. There's neurotrophic form of influenza.
• 57:39
  Nick Saunders: The thing that was striking when I got better was just how knackered I was, I mean our garden is not long, it's not a big garden. And I thought when I felt better I'd go for a little
• 57:39
  Nick Saunders: walk. And I got about a third of the way up the garden and had to stop and sit down for 10 minutes and then get back to the house.
• 58:03
  Nick Saunders: Then after about a week had enough energy to go out for a bit of a dog walk and got up the end of the road and turned left and gone up a little slope and started to get some chest pain. So that was,
• 58:03
  Nick Saunders: which was interesting. I did all the research went Oh, there's nothing and you can get this you can get that but there's nothing about any sort of coronary symptoms.
• 58:26
  Nick Saunders: So I thought I'm just putting this on so I went out the next day and went a bit further and got a bit more chest pain and went maybe there's something in this so I then went on the turbo and just got
• 58:26
  Nick Saunders: the heart rate monitor on and just did a ramp test, went up sort of by five, five BPM each each five minutes.
• 58:43
  Nick Saunders: Got up to about 130 and didn't die so I thought I'm probably alright and I think I probably had a bit pericarditis cuz I got rid of chest pain on and off afterwards. But yeah, got better than I just,
• 58:43
  Nick Saunders: took me about another three weeks to get back to work. And then it just got a better, sort of rehabed myself, so actually now I'm the fittest I've been for years.
• 59:06
  Nick Saunders: And that's just because I sort of rehab myself and didn't stop. So it was not fun.
• 59:11
  Mike Brampton: So how long, how long would you say that It's impacted you then?
• 59:16
  Nick Saunders: I was well, I was ill 10 days, off work for another two and a half weeks and not right for about a month after that. So probably a couple of months.
• 59:25
  Mike Brampton: So a couple of months. So you're into your your bike riding, your long distance cycle rides, your taps. So 60-70 hundred mile ride. You just go and do it, wouldn't you?
• 59:39
  Nick Saunders: Yeah.
• 59:40
  Mike Brampton: Okay. So a fit, healthy, individual and it's taken you out of the game for a couple of months.
• 59:47
  Julian Hoad: Yeah. Incredibly fit. It's in. It's in the upper fifth centile. This is, I think what it's saying is actually don't piss around, wear a mask, is it?
• 1:00:01
  Mike Brampton: Yeah, absolutely. I think we probably should Julian, and looking at the time, I'm wondering whether we should actually close out our CPD session of ENT surgery, both human and
• 1:00:01
  Mike Brampton: veterinary this evening. Have you got a certificate for us?
• 1:00:16
  Julian Hoad: I have. I have, I've got a certificate. Yeah. So here we go. Here's a certificate. It says certificate and theres a lot of little small writing. 'Certificate of seriously intensive
• 1:00:16
  Julian Hoad: knowledge acquisition.
• 1:00:31
  Julian Hoad: This certifies that our faithful viewer watched at least some of this week's broadcast.' It says 'You rock dud!' because it didn't recognise dude on autocorrect.
• 1:00:47
  Nick Saunders: I thought that was a hommage to Dudley Moore?
• 1:00:50
  Julian Hoad: Well, actually, Dudley Moore, he rocked, Didn't he? But anyway, there we go. So there's, there's another problem you tend to see in general practice, which is squamous cell carcinoma of
• 1:00:50
  Julian Hoad: the ear, treated by penectomy, squamous cell carcinoma of a nose treated by nosectomy.
• 1:01:17
  Julian Hoad: And unfortunately, we also see that and I know that you see a lot of aggressive trauma cases. We spoken about those other times, and maybe if we have you on again, you could tell us some of these fun
• 1:01:17
  Julian Hoad: stories like keys in ear canals and things like that.
• 1:01:35
  Nick Saunders: Yes, that was an interesting one. Yeah.
• 1:01:37
  Mike Brampton: Well, fair enough. For some viewers I think we should explain the ectomy means removal. So if you didn't actually get the nose ectomy
• 1:01:48
  Julian Hoad: or or a northern cry of pass it to me, peck to me.
• 1:01:55
  Mike Brampton: On me head, on me head. No, I don't do football. So let's, let's close out our CPD. I think because, you have to do CPD as well don't you Nick? Do you not have to show that you have?
• 1:02:10
  Nick Saunders: We have to do, we have to do quite a lot. Yeah, yeah. Some of it we have to go to pretty horrible places in the world to do as well.
• 1:02:18
  Mike Brampton: Yeah.
• 1:02:19
  Nick Saunders: They kind of, they've kind of stop that. So you have to pay for yourself. But yeah, they do often put the conference on in some some dreadful locations.
• 1:02:32
  Mike Brampton: Yeah. So this is up at seven, get the first lift up, ski till 11. Three hours of lectures and then back out on the slopes again, to get the last lift down where you might have a meeting
• 1:02:32
  Mike Brampton: in the bar afterwards?
• 1:02:49
  Nick Saunders: I couldn't possibly comment.
• 1:02:51
  Mike Brampton: Okay
• 1:02:52
  Julian Hoad: We go to Birmingham for most of our CPD. Although from next year, we're going to Manchester
• 1:02:59
  Mike Brampton: How much CPD do you have to do then Nick?
• 1:03:02
  Nick Saunders: 50 hours a year
• 1:03:03
  Mike Brampton: Right. Okay.
• 1:03:06
  Nick Saunders: So yeah, which actually, when most meetings are sort of, can be three or four hours its quite a lot.
• 1:03:13
  Mike Brampton: The vets have got it easy then.
• 1:03:15
  Nick Saunders: Obviously. We work ridiculously hard as surgeons so yeah, anyone else is just, you know,
• 1:03:22
  Mike Brampton: yeah
• 1:03:23
  Nick Saunders: They don't know they're born really.
• 1:03:24
  Mike Brampton: Well, there you go. But, uh, but you don't have to reflect on your CPD do you?
• 1:03:30
  Nick Saunders: Oh God. I have to not only reflect on the CPD, I have to then demonstrate how it has improved my practice, and reflect on how it's improve my practice.
• 1:03:39
  Julian Hoad: Really, we just have to reflect
• 1:03:41
  Mike Brampton: We just reflect
• 1:03:42
  Julian Hoad: Shall we show you? We'll do some now,
• 1:03:44
  Mike Brampton: Let's reflect on the CPD that we've had tonight. And, and thank you very much indeed, gentlemen, for such intense CPD, but a moment of reflection please.
• 1:04:01
  Mike Brampton: Freakin awesome. I think if we go by Nick's rules, we're gonna have to reflect on how it's actually improved our practice. So I suppose if I put the cap on the lid to clean it out.
• 1:04:18
  Nick Saunders: I didn't see that, I so didn't see that.
• 1:04:20
  Mike Brampton: No, no, no, no, no, no, no, Nick, Nick. Nick. I have been paying attention, I have capped the end. So it's not just the pointy, pointy bit.
• 1:04:34
  Julian Hoad: I was once told that you shouldn't put anything smaller than your elbow down your ear.
• 1:04:38
  Nick Saunders: That is actually very, very good advice.
• 1:04:42
  Mike Brampton: How am I going to get my elbow down my ear?
• 1:04:46
  Julian Hoad: How many injuries do you see due to cotton buds in ears?
• 1:04:51
  Nick Saunders: Oh Loads, loads. My general advice for cotton buds is actually to get all your cotton bones and build a small pile of them in the garden and burn them.
• 1:05:08
  Julian Hoad: They're good for ferrets though.
• 1:05:12
  Mike Brampton: Are they?
• 1:05:14
  Nick Saunders: In what sense?
• 1:05:16
  Julian Hoad: Well, now, I'm glad you asked if
• 1:05:19
  Mike Brampton: -Did we have an option>
• 1:05:20
  Julian Hoad: No. If you keep a female ferret on her own, then unless she's vaginally stimulated on occasions, she will develop osteoporosis and die. Now, the best thing to do is to keep a male ferret
• 1:05:20
  Julian Hoad: or ideally a vasectomised male ferret and they can do the job. We had an American lecturer of college telling us about this.
• 1:05:44
  Julian Hoad: And he said, what you can do if you've not got a male is, you can stimulate her with a Q tip.
• 1:05:51
  Julian Hoad: And I was thinking...
• 1:05:57
  Julian Hoad: you've got to be good.
• 1:06:01
  Julian Hoad: I didn't know that Q tips were cotton buds in America.
• 1:06:04
  Mike Brampton: Julian is simulating the motion of a snooker player about to pot a ball on the green beige of snooker table. Q tips are ear buds. In fact, it's quite interesting because-
• 1:06:20
  Julian Hoad: No, no, no they're not ear buds, they're their cotton buds. Never ever put a cotton bud down your ear.
• 1:06:27
  Mike Brampton: Okay
• 1:06:28
  Julian Hoad: Because it actually compresses the wax, solidifies the wax and can damage the eardrum
• 1:06:34
  Nick Saunders: It's very much like if you're loading a cannon, and you know those big things used to stick the gunpowder down.
• 1:06:42
  Mike Brampton: Yeah, ram rods?
• 1:06:44
  Nick Saunders: Yeah, that's pretty much exactly what a cotton bud does in your ear.
• 1:06:48
  Mike Brampton: So it would probably be better to pour honey into our ear and get our dogs to lick it?
• 1:06:58
  Julian Hoad: Sorry about that. Yeah.
• 1:07:00
  Mike Brampton: We could reciprocate, no, we couldn't reciprocate.
• 1:07:04
  Julian Hoad: You can't, no, the RSPCA against that with good reasons. So never, take home message. Never stick anything down your ear. Hmm. Good.
• 1:07:15
  Nick Saunders: Unless it's someone else's elbow.
• 1:07:17
  Julian Hoad: Unless it's someone else's elbow.
• 1:07:19
  Nick Saunders: Which is fine.
• 1:07:23
  Mike Brampton: I used to play rugby too.
• 1:07:29
  Julian Hoad: So tongiht been fantastic.
• 1:07:31
  Mike Brampton: It's absolutely super Nick having you on, Have you got a joke Julian?
• 1:07:38
  Julian Hoad: Yes, I have actually yeah, I have got a joke. I've got a joke about, I made it up earlier so It might be absolutely awful, but it's about cycling. And it's about Nick as he was cycling
• 1:07:38
  Julian Hoad: along during one of his taps. Making a pretty good speed, what would be good speed on the flat for you?
• 1:07:56
  Julian Hoad: Kilometres an hour? Because I know in the rules, you've got to talk kilometres an hour haven't you? You can't do this miles per hour stuff.
• 1:08:02
  Nick Saunders: 30-35
• 1:08:04
  Julian Hoad: Okay, so you do about 35 and, and you look behind you. And there's this little kid on a bike. Rapidly catching up. And you think, what the bloody hells going on here? So you've drop the
• 1:08:04
  Julian Hoad: gears down a bit. So you're off, you're up to 40 kilometers an hour and you turn back.
• 1:08:24
  Julian Hoad: This little kid catching up rapidly, start to go up hill. You drop another couple of cogs. Give it a handful, off you go. Zoom, straight up. And you turn around and he's almost at the back of your
• 1:08:24
  Julian Hoad: bike shouting 'Mister. Mister. Mister.' So you slow down a bit. He says 'Mr. You look like you can, you're pretty good at cycling.' 'Yeah, I've done a bit.' 'How do you change gears on this?'
• 1:09:01
  Nick Saunders: Do we have sound effects for tumbleweed?
• 1:09:04
  Julian Hoad: Yeah, we do every week. Theres another bit of tumbleweed that goes past. Yeah.
• 1:09:09
  Mike Brampton: Yeah, no, I think, I think it's called saying good night. And if anybody's enjoyed this evening, including-
• 1:09:18
  Julian Hoad: -until then
• 1:09:19
  Mike Brampton: Julian's joke, joke. Then don't forget to click like, follow. And you'll be updated on all the new stuff that's happening on the show. And join us next week when we'll have another
• 1:09:19
  Mike Brampton: incredible guest. Nick Saunders, thank you very much indeed for joining us.
• 1:09:42
  Nick Saunders: It's been a delight.
• 1:09:43
  Mike Brampton: Such an insight into your world of surgery so, If I can bid you good evening and may your dog go with you.
• 1:09:52
  Julian Hoad: May a dog go with you.
• 1:09:54
  Mike Brampton: Cheers.
• 1:09:56
  Nick Saunders: Cheers.
• 1:09:57
  Julian Hoad: Cheers, Nick.
• 1:09:59
  Mike Brampton: And cut!
• 1:10:01
  Julian Hoad: That's it. That was fairly painless, wasn't it?
• 1:10:05
  Nick Saunders: Was that all right?
• 1:10:06
  Mike Brampton: Was that all right?
• 1:10:07
  Julian Hoad: Brilliant. Brilliant. Thank you so much. Excellent.
• 1:10:09
  Mike Brampton: Did you enjoy yourself?
• 1:10:10
  Nick Saunders: That was great fun! It's just like being down the pub, talking crap.
• 1:10:18
  Julian Hoad: And hopefully some people will watch this, with that in mind, their going to think that were having a bit of banter and
• 1:10:26
  Julian Hoad: Brenda this is not aimed at you.
• 1:10:29
  Nick Saunders: I did actually forget to mention that I have tonight, I've slightly reversed the dress code, because the current COVID dress code is smart up, casual underneath.
• 1:10:44
  Mike Brampton: No, don't stand up Nick! Don't stand up!
• 1:10:50
  Julian Hoad: You can stand up.
• 1:10:51
  Mike Brampton: Go on. We trust you.
• 1:10:56
  Nick Saunders: Dinner Jacket, trousers and nice shoes, I just thought why not?
• 1:11:03
  Julian Hoad: Brilliant.
• 1:11:03
  Mike Brampton: Nick, can I say thank you very much indeed.
• 1:11:06
  Nick Saunders: It's been a it's been a pleasure Mike
• 1:11:08
  Mike Brampton: So as long as you've enjoyed yourself!
• 1:11:10
  Nick Saunders: It's been splendid, it's been great
• 1:11:13
  Mike Brampton: good.
• 1:11:14
  Julian Hoad: Nick, thank you so much. Thanks for coming on such short notice as well.
• 1:11:17
  Mike Brampton: Yeah, really appreciate that, too.
• 1:11:19
  Nick Saunders: No problems.
• 1:11:20
  Mike Brampton: Thanks,
• 1:11:53
  Nick Saunders: Goodnight Guys, cheers!
• 1:12:40
  Mike Brampton: He's gone.
• 1:12:50
  Julian Hoad: What a decent guy.