This story is dedicated to my dear friend and much-missed colleague, Heinz Stammberger, with whom some of these moments were shared (or endured).
Having used a rigid endoscope in my postgrad thesis in the early 1980s to show that the inferior antrostomy was not the answer to a maiden’s prayer for chronic rhinosinusitis, I was very happy to consider its use in facilitating surgery. It will be hard for most readers to comprehend the impact of this fabulous illumination, revolutionising our appreciation of the nasal anatomy, physiology and pathology in an area where surgeons had previously feared to tread with only a headlight to peer into the rhinologic darkness.
Endoscopic sinus surgery was being proselytised by the doyen of functional endoscopic sinus surgery (FESS), Professor Heinz Stammberger from Graz in Austria, who I had first met in Japan in the 1980s. On that occasion – like Satler and Waldorf, the two old men in the Muppets – my colleague, Ian Mackay, and I had muttered sceptically from the balcony that topical steroids would likely work just as well as FESS. However, my own research and clinical experience quickly converted me to FESS with its superior results and generally minimal morbidity, which proceeded to take the world by storm.
Heinz had his own surgical mentor, Professor Messerklinger, who was a very tough cookie. If he said black was white, apparently you agreed and when Messerklinger finally fell over, broke his hip and refused surgery which ultimately led to his demise, no one dared to argue that an operation would have helped. Prof Messerklinger was one of the earliest adopters of nasal endoscopy, with which he would observe the patterns of mucus being carried through the nose. This he did by dropping iron filings onto the nasal and sinus mucosa and watching the mucociliary clearance, which macabrely he did in the mortuary on freshly dead individuals. Heinz, a junior trainee at the time, was told to be the cameraman – one of those offers you are unable to refuse. The image of Messerklinger wearing black rubber gloves and hunched over a fresh corpse scattering iron filings is difficult to forget. He had produced one of the first books on the use of endoscopy in the nose and this had gone on to win a prize in the USA. However, Prof Messerklinger absolutely refused to speak anything except German and so Heinz, who spoke excellent English, was deputed to go on his behalf to accept the prize and discuss the technique – the rest, as they say, is history.
Messerklinger had worked with the KARL STORZ company in Germany, which in turn had joined forces with Harold Hopkins, Professor of Optical Physics at Reading University. Unable to obtain funding to develop his invention of the solid-lens optical rod or endoscope in the UK, Hopkins contacted KARL STORZ. Together, they refined the instrument for medical use, having originally devised the rigid endoscope mainly for engineering purposes to inspect mechanical equipment. Harold Hopkins was the epitome of the English eccentric professor – a polymath and inventor of not just the rigid endoscope, but also light fibres for flexible scopes and the binocular operating microscope. He was also equally proud of inventing gardening equipment for his wife, Cynthia. Wishing to recognise his contribution to FESS, we invited him to speak at the opening ceremony of a European Rhinologic Society conference held in London in 1990. As he was retired at this point, he declined to give a lecture but asked if he might tell a short joke. He thought that Cynthia’s hearing was not what it was and, being a scientist, he determined to scientifically test the hypothesis. To this end, he conducted an experiment to attract the attention of Cynthia who had her back to him whilst she was kneeling to weed the flower beds, doubtless with one of his designed gardening tools. Standing 30 feet away, he asked, “Cynthia, can you hear me?” Getting no response, he moved to 20 feet. “Cynthia, can you hear me?”, but she continued with her weeding. At 10 feet, Harold exclaimed, “Cynthia, you must be able to hear me now!” At that point, Cynthia wearily got to her feet, turned and said, “Harold, for the third time, what is it you want?” Now, that is a template for any opening ceremony speech.
It should also be remembered that radiology of the head and neck area was undergoing a massive change during this period. Gone were the hazy plain x-rays and hypocycloidal tomograms, replaced by the wonders of computerised tomography (CT) and magnetic resonance imaging (MRI). The revelation of sinonasal anatomy by CT also accelerated the uptake of FESS by providing the roadmap but, as always, there was considerable resistance to change. I remember the gasps of dismay from the older members of the ENT audience when I suggested in a talk at the Royal Society of Medicine in the late 1980s that all sinus surgery should be preceded by a CT scan and, furthermore, that most cases of CRS could be better treated by an endoscopic approach. This went down like a lead balloon amongst my ‘elders and betters’.
Despite this reticence in senior circles, endoscopic sinus surgery (ESS) was rapidly adopted — not just because it offered a better solution to a common problem (and, joy of joys, we could actually see what we were doing) — but also because it was new and exciting, which surgeons find irresistible. Not to mention the catchy acronym, £E$$, which began to circulate amid this enthusiasm. Surgery in the nose and sinuses has always carried potential risks due to the proximity of the eyes and brain. Before ESS, such complications had occurred even with ostensibly simpler procedures, such as the removal of nasal polyps with a snare, using only a headlight for illumination. But now we were going deeper into areas ‘where no man had (usually) gone before’ so that the potential for mishap was potentially increased. Of course at this point, rigid endoscopes were being used widely in many areas of medicine. A prime example was endoscopic cholecystectomy, which was rapidly replacing open approaches to the gallbladder in general surgery. However, there had been several high-profile disasters in which, tragically, patients had died. As a consequence, it was recognised that rapid action was required amongst the surgical community to improve the teaching of these techniques, which led to an explosion of courses run through the surgical colleges and other institutions all around the world.
We had been running rhinology courses at the Royal National Throat, Nose and Ear Hospital (RNTNEH) since the early 1980s, so it was an easy transition to an annual Endoscopic Approach to Rhinosinusitis course, which I ran with Ian Mackay and other excellent colleagues such as Claire Hopkins up until 2017 and at which we were usually joined by Heinz. In addition to our own courses in Graz and London, Heinz and I attended numerous courses worldwide – usually delivering lectures, conducting live endoscopic anatomy demonstrations on cadaver specimens and assisting with the participants’ dissection courses. Heinz was the perfect travelling companion in far-flung parts of the world, displaying a wonderfully subtle sense of humour when things did not always go according to plan. The innumerable audiovisual problems, the maggots waving back from the dissection specimens and other mishaps are best not recounted.
Many years ago when we attended the first endoscopic sinus surgery course to be held in Istanbul, we were met by armed guards with submachine guns as we entered the university.
“Student unrest?”, I queried.
“No, the course has been oversubscribed and there may be gate crashers”, came the deadpan response.
In the event, 3000 endoscopic enthusiasts managed to squeeze into the auditorium where Heinz and I performed continuously, alternating our lectures with personally signing the 3000 certificates of attendance. The specimens provided for dissection disturbingly suggested that the donors had not died from natural causes, leading us to momentarily wonder if they might have been ill-advised gate crashers.
Things were often quite bizzare closer to home. At an early FESS course held in Birmingham, we were treated to the spectacle of an elderly anatomist trying to show tiny pieces of a disarticulated skull at the front of a large classroom to a bemused audience of 40 or so surgeons who could just about make out that he was holding a piece of bone. I’m afraid the giggles got the better of me.
Whilst in Edinburgh, Heinz had been invited by a senior ENT professor to perform a demonstration endoscopic anatomy dissection, visible on monitors via the endoscopic camera to the assembled course participants. An ancient anatomy department technician with a cigarette hanging out the corner of his mouth shuffled in with a trolley, on which was a draped anatomy specimen. Heinz looked into the nose with the endoscope.
“Nein nein, this has already had an endoscopic dissection.”
The technician reluctantly wheeled his trolley away and returned with the second specimen, which turned out to be the same, since no one had bothered to check. Finally, to everyone’s relief, a third previously unoperated specimen was produced. Surprisingly, none of the organisers seemed the least bit embarrassed.
Another guest lecturer on our London course was a delightful French colleague who has now very sadly died but would, I hope, have forgiven me for saying looked and sounded a little bit like Inspector Clouseau, as immortalised by Peter Sellers. The French at that time were generally performing endoscopic surgery under local anaesthetic, whilst a general anaesthetic has always been the preferred modus operandi in the UK. For the live surgery, we had found a willing patient. While our French surgeon operated, I acted as the link between the operating theatre and the lecture theatre, where Ian was with the course participants. As the operation progressed, in his delightful French accent, our invited surgeon observed that in France they would now remove the middle turbinate, but he knew this was not commonly done in the UK.
“What would we like me to do?” he asked.
So we asked our audience, in a fake French accent, whether it should remain or be removed. The audience, suddenly confronted with this decision, shouted volubly, “Take it out, take it out!”
Of course, we had completely forgotten that the patient was awake and could hear all these exchanges. At this point, he sat up on the operating table and understandably asked, “This middle turbinate, what is it? Do I need it?” Quick as a flash, our French friend replied, “I am sorry, but I do not know what it does. I am a surgeon, not a scientist!” Rarely have I been more embarrassed, and the middle turbinate remained.
Finally, later that day, our dear French colleague was lecturing on the course about some studies on nasal polyps and kept referring to “the other group” doing this and “the other group” doing that. Ian asked me what I thought the other group was. Equally perplexed, I asked our speaker,
“What is this other group?”
“The other group,” he insisted.
“Yes, but what is the other group?”
“The ASA group… the group with aspirin-sensitive asthma, naturellement!”
You had to be there – it brought the house down for a second time that day.
This series of stories is dedicated to those of you with whom some of these moments were shared (or endured) and, above all, to my amazing and long-suffering husband, David Howard. Most of you know him as an exceptional head and neck surgeon but, since Covid, he has been involved in a large multi-speciality international charitable project reintroducing negative pressure non-invasive breathing support which could transform the management of respiratory disease all round the world. If you are interested, please visit www.exovent.org for further information and, if you enjoy the stories, please consider donating to the charity through the Exovent website (Click DONATE on the home page drop down menu).
