Otorhinolaryngology (Head and Neck Surgery; Ear, Nose and Throat Surgery)
The Otorhinolaryngological Academic/Research unit at Glasgow Royal Infirmary
In the early 1970s, Professor Sir Andrew Watt Kay, who held the Regius Chair of Surgery at the Western Infirmary, Glasgow and Professor Brian Jennet, Professor of Neurosurgery at the Southern General Hospital, were on the Medical Research Council and Neurosciences Boards respectively. To both Boards, it was clear that hearing impairment in adults was common and grossly under researched. An MRC Institute of Hearing Research (IHR) was proposed, with three regional centres and headquarters at Nottingham University.
At that time, Mr JA (Sandy) Doig was the visiting neuro-otologist to the Department of Neurosurgery, based at Glasgow Royal Infirmary. Dr George Forwell was Chief Medical Officer at the Greater Glasgow Health Board (GGHB). Sir Andrew Watt Kay was also at that time the first Chief Scientific Officer at the Scottish Office. The almost inevitable decision was made to have the Scottish Section of the MRC IHR in Glasgow at the SGH Institute of Neurological Sciences, supplemented by funding from Greater Glasgow Health Board, the Chief Scientist Office and the University of Glasgow.
Subsequently, more appropriate accommodation for access to otorhinolaryngological (ORL) patients was found at the Royal Infirmary and the Scottish IHR section was transferred there. It was closer to an Audiology Department, that in due course incorporated the Scottish School of Audiology. The quality of the Scottish IHR research has consistently been rated alpha plus at the quinquennial reviews. Currently the Section is housed in much larger and better equipped facilities, rented from Glasgow University, in the New Lister Building at the Royal Infirmary. At the Scottish IHR Section’s initiation, a Senior Lecturer post in ORL was created at the Royal Infirmary within the University Department of Surgery, then led by Professor Leslie H Blumgart.
Funding for this post was 50% GGHB, 25% MRC and 25% University, administered by the latter. Subsequently, a second Senior Lecturer Post was created on the same basis.
George G Browning was appointed to the first post in 1978, and Iain RC Swan to the second in 1986. Subsequent Professors of Surgery (David C Carter and Tim G Cooke) gave considerable personal support. Neither of these Senior Lecturer ORL posts was continued when Browning and Swan retired.
The setting up of links with Audiology
In the 1970s, Audiology was starting to make technological advances of scientific value. This was predominantly the ability to record neurological electrical responses to sound and stimulation of the vestibular system. Both the first (Mark Lutman) and second (Stuart Gatehouse) Scientists in Charge of the Scottish IHR section had such a background. On the closure of the Glasgow Ear Nose and Throat (ENT) Hospital in 1982, the Scottish School of Audiology had to find a new home. It was natural that it be transferred to the Royal Infirmary, administrated by Doig and subsequently by GGHB. The School continued there until 1999, when GGHB funding was withdrawn as it was considered out with their area of responsibility.
Building the Academic and Research Team
For those following him at the Department of ENT at Glasgow Royal Infirmary, Sandy Doig, consultant in ORL, was considered to be the founding father of the academic and teaching department that developed. He was at the forefront in the UK of the use of the microscope for ear surgery, having visited the leading proponents in the USA. He also was one of the first to use the rigid endoscope in the nose in pituitary surgery.
He was keen to pass on his knowledge, to train others and to demonstrate that Glasgow was not a backwater for ENT. He was extremely supportive of the foundation of the MRC Scottish Section of the Institute of Hearing Research, and persuaded his British colleagues to hold the British Academic Conference in Otolaryngology in Glasgow in 1987. This was a stunning success, including the first UK live ear surgical demonstrations by international stars on cadaveric bones. Sandy died the following year, but his influence lives on.
George Browning trained initially in the Western Infirmary as a general surgeon. His interest in thyroid and head and neck surgery encouraged a shift to ENT surgery. This required additional training at the Glasgow ENT Hospital.
Stimulated by Doig in microscopic ear surgery, he was awarded an MRC Werner-Piggot Travelling Fellowship at Harvard University/Massachusetts Eye and Ear Hospital in 1976-77. In 1978, he was appointed as senior lecturer to the first Glasgow University academic post in ENT surgery with sessions at the Scottish Section Institute of Hearing Research.
His personal University of Glasgow Professorial Chair was awarded in 1990.
- His main clinical interest was in adult chronic middle ear disease, aided by its high prevalence in the West of Scotland. A clinical classification of the differing types of chronic otitis media was evolved and is now widely accepted, based on the type of histology involved. Another dominant surgical interest was in the evaluation of the benefit of implantable bone conduction hearing aids, initially the House Audient and then the Tjelstrom Bone Anchored Hearing Aid. Scientific publications resulted, and these, together with other otological interests, gained him UK and international recognition. Research at the IHR initially was with the National Study of Hearing, particularly its middle ear disease components and subsequently in medico-legal implications for noise induced deafness.
- A further three month period in Boston in 1988 at the Harvard School of Public Health founded his interest in systematic reviews and Quality of Life Questionnaires. This led subsequently to the development of the now internationally used Glasgow Benefit Inventory, mainly validated on the otological surgery at the GRI. The Glasgow Benefit Plot was developed to categorise the different degrees of benefit from middle ear surgery, dependent of the level of hearing in the contra-lateral, non-operated ear. Finally he was lead clinician and the primary author of the majority of papers from TARGET, a UK randomised clinical trial of ventilation tubes for childhood otitis media with effusion.
- National and international post-graduate training and continuing medical education was a strong thread throughout Browning’s career. He was President of the Royal Society Section of Otology, 1999-2000; Chairman of the Academic Board of the Presidents of the 54 Sections, 2001-3; and Vice-President of the Royal Society of Medicine, 2005-7. From 2004 to 2014 he was the editor of Clinical Otolaryngology, and at the end of his tenure, the impact factor of the journal had risen from near the bottom to being 6th of 34 ORL journals. He was the Otology editor for the 2008 7th Edition of Scott Brown’s Otolaryngology, Head and Neck Surgery, for which the Glasgow Royal Infirmary ORL team wrote a total of nine chapters.
Stuart Gatehouse was appointed in 1978 as a senior physicist at the Scottish IHR section. He was promoted to Scientist in Charge at the Scottish Section in 1982, a post he held until his early death in 2007. He was Honorary Professor from 1993. From 2004, he was concurrently assistant Director of the MRC IHR in Nottingham. During his tenure he became an internationally renowned auditory scientist for his work on basic research (spatial hearing), quality of life of the adult hearing impaired, and government policy for the delivery of audiological services. He clinically developed the use of generic quality of life and health status measures for the evaluation of audiological and otological services, which led to the Glasgow Benefit Inventory and other questionnaires. Throughout his period at the Scottish Section, he worked closely with all the consultants with non-otological, sub-specialty interests in their scientific projects, resulting in many collaborative publications.
Iain Swan’s Glasgow training in ORL was supplemented with a one year clinical fellowship in Germany with Professor D Plester. He gained his MD with work based at the MRC IHR Scottish Section in 1985. He was appointed to the second University of Glasgow Senior Lecturer ORL post, based at the Royal Infirmary and MRC IHR department (1986-2016). His clinical interests strongly supported the NHS department’s involvement in chronic middle ear disease and the resultant research, along with the IHR development of outcomes. His more specific research interests were in running a Scottish trial of steroids for idiopathic facial palsy, and the Scottish ENT Outcomes Study (SENTOS).
UK national posts that he held as President were:
- Young Consultant Otolaryngologists / Head and Neck Surgeons
- the British Association of Academics in Otolaryngology
- the Section of Otology at the Royal Society of Medicine
- the Otorhinolaryngological Research Society
- Scottish Otolaryngological Society, and the British Society of Otology.
He was also Chairman of the clinical audit and practice advisory group of the British Association of Otolaryngologists and Head and Neck Surgeons.
In 2007, he became more involved in the Glasgow University MB ChB undergraduate course, progressing through being Deputy Director of years 4 and 5 to being Director of the 4th year, then Deputy Head of the Undergraduate Medical School 2013-2017.
Kenneth Mackenzie trained in Otorhinolaryngology in Newcastle upon Tyne, Glasgow ENT Hospital, Glasgow Royal Infirmary and other Glasgow Hospitals, with a period of Fellowship in Paediatric Surgery and Head and Neck Surgery at Dunedin Hospitals, New Zealand. He was appointed Consultant Otorhinolaryngologist in Head and Neck Surgery at Glasgow Royal Infirmary in 1989.
His subspecialty interests were initially in Paediatric ENT, and Laryngology and Head and Neck surgery. His paediatric interests led, in conjunction with Professor Janet Wilson, to the creation of the annual British Course in Paediatric Otorhinolaryngology in 1994. This was the principal UK Specialist course on the subject for ten years, until they transferred it to the current UK Faculty. Over a similar period, they also initiated and ran the annual UK course in ENT Radiology. In the late 1990’s he focused his clinical interests exclusively in Laryngology and Head and Neck surgery. In combining these, he was one of the main instigators of endoscopic resection of laryngeal malignancy in the UK. He was instrumental in developing guidelines on assessment, both pathologically and functionally, with these combined approaches now being the standard of care for early laryngeal cancer in the UK. In conjunction with others, principally Professors Wilson, Deary and Carding, he developed outcomes in relation to patient reported quality of voice. This resulted in many peer reviewed journal publications, the collation and application of which resulted in him being awarded The King James IV Professorship by The Royal College of Surgeons of Edinburgh in 2009.
As a result of his comprehensive approach to Laryngology and Head and Neck cancer he was appointed Lead Clinician for the first Managed Clinical Network in the West of Scotland for Head and Neck Cancer, establishing standards for the consistent management of head and neck malignancy.
His national appointments included
- President of Laryngology & Rhinology Section of the Royal Society of Medicine (2010-2011)
- ENT Specialty Advisor to the Chief Medical Officer for Scotland (2007-2013)
- ENT Specialty Advisor to the Chief Scientist’s Office for Scotland (2009-2014)
- Chairman of ENT UK Head and Neck (2008-2011)
- President of the Scottish ENT Society (2010-2011)
- Chairman of the Royal College of Surgeons of Edinburgh Specialty Advisory Board (2006- 2011)
- Chairman of the Scottish ENT Society (2007-2010)
- Visiting Professor to The School of Psychological Studies & Health, University of Strathclyde, with PhD students developing techniques used in the management of laryngeal disorders and Head and Neck cancer (2013)
Janet A Wilson was Consultant Otorhinolaryngologist (1992-1995) at the Royal Infirmary, where she made a considerable contribution to the development of the department as an academic unit, but more particularly in starting national CME courses including paediatric and radiological ORL. In 1995 she was appointed Professor of Otorhinolaryingology at Newcastle University, where she has developed a significant research profile in tonsillectomy, and use of proton pump inhibitor drugs for acid reflux symptoms in the throat and larynx.
Gerald W McGarry trained in General Surgery and Otolaryngology in the West of Scotland and did a Head and Neck Fellowship in Brisbane, Australia before appointment to the Royal Infirmary as a Consultant in 1995. At the time of his appointment, Gerry was already heavily involved in the development of endoscopic sinus surgery techniques, and in the dissemination of safe practice through his establishment of surgical training courses. The Department was the first in the UK to have a dedicated rhinology clinic and before long this service became a national tertiary referral base. Gerry published extensively on aspects of advanced endoscopic sinus surgery, including some of the earliest series to look at outcomes, safety and the first series of endoscopic tumour resections. Involvement in surgical training saw courses established in Glasgow and with colleagues in Dundee, and participation in worldwide international courses.
Under Gerry’s leadership, the GRI team secured funding for the only Advanced Medical Training Fellowship in endoscopic anterior skull base surgery. Undergraduate training and teaching in Surgical Anatomy in Glasgow University saw a number of students undertaking clinical attachments in GRI before eventually entering the specialty.
Gerry served as a Lead assessor for the GMC Performance Section, Secretary and Vice President of RSM Laryngology Section, Chair of RCSEd Surgical Specialty Board in ORL, Lead Cancer Clinician for WoSCAN Head and Neck Managed Clinical Network, and Clinical Director of ENT for Greater Glasgow and Clyde NHS. He continues to publish clinical research, lecture and author book chapters in major international textbooks. He is section Editor for Rhinology in Scott Brown’s Otolaryngology 9th Edition.
Teaching and research
Undergraduate Teaching of ORL at Glasgow University
In 1979, the teaching of ORL was co-ordinated between the five teaching hospitals, with centralised lectures and standardised examination of competence at examining the ear, nose, throat and neck. A textbook ‘Updated ENT’ by George Browning, which ran to three editions, was written to enhance this. Multiple departmental videos were recorded using the GU audio-visual facilities and used in the lecture course, illustrating techniques of examination of the ear, nose, throat and neck.
Postgraduate ORL Surgical training at Glasgow Royal Infirmary
In the 1970s, appointments to training posts at all levels were made by the consultant staff at the GRI. However, with the progressive centralisation under the control of the Postgraduate Education Board, there was progressive loss of this ability. This allowed the department to evolve as a UK and international centre of excellence in training overseas fellows, predominantly from Commonwealth countries, including Malaysia, Singapore, Egypt, New Zealand and South Africa. Over 12 GRI trainees have subsequently been appointed to Professorial posts. In the late 1980s a programme of training for an MSc at Glasgow University was set up, supported by the appointment of a clinical lecturer which was advertised to be filled by an overseas fellow. This programme ceased in 1995.
National post-graduate training and continuing medical education in ORL
In the 1980s, the UK provision of continuing medical education for those in Otolaryngology was minimal. The first Temporal Bone surgical skills course in the UK was set up in 1979 by Pettigrew and Baxter along with Browning, who all had spent time at the Massachusetts Eye and Ear Infirmary. To date, Browning has been involved in over 120 such courses world-wide, relevant both for trainees and specialists.
An Otology and Audiology course was started in 1979 and continued yearly until 2008 for which Browning’s textbook, Otology and Audiology, was written. It ran for 3 editions and was awarded the BMA Walter Jobson Horne Prize in 1998. An Evaluation of the literature course was initiated in I983 and ran till 2007.
By the 1990s the ORL team at the Royal Infirmary had staff with the range of sub-speciality interests that was hard to match in the UK. This allowed the introduction of a broader range of national CME courses, including paediatric and radiological ORL, including a range of national and international experts. Further practical surgical Rhinology and Head and Neck skills courses were created.
Research
The GRI ORL departmental research dominated the Otorhinolaryngological Research Society presentations for many years, leading to Browning, Swan and Wilson being appointed its President. All three also became Chairman of the British Society of Academics in Otolaryngology. The latter in due course led to Browning and Swan being appointed to the Speciality Advisory Committee in Otolaryngology. GGB subsequently became vice-president, and also sat on the SAC in Audiological Medicine.
Numerous publications resulted from the group’s research and the team’s international status has been recognised in many ways, but particularly evidenced in the 8th Edition of Scott Brown’s Otorhinolaryngology and Head and Neck Surgery, an international evidence based text of which Browning was Otology volume editor, and along with Swan, Mackenzie, Wilson and McGarry contributed nine Chapters. For the 9th edition, McGarry is the rhinology section editor.
Research continues in the Hearing Unit in the University of Glasgow's New Lister Building at the Royal Infirmary.
Professor George Browning
Image of McGarry et al provided by Professor Browning