Expert Opinions: Professor Christos Georgalas MD, PhD, DLO(Eng), MRCS(Ed), FRCS (ORL-HNS), FEBORL-HNS(Hon)

Expert Opinions: Professor Christos Georgalas MD, PhD, DLO(Eng), MRCS(Ed),

FRCS (ORL-HNS), FEBORL-HNS(Hon)

Professor in Surgery – Head and Neck, University of Nicosia Medical School,
Director, Endoscopic  Skull Base Center, Hygeia Hospital (Athens)

Academic Associate, Leiden University Medical Center

(Netherlands)

Christos Georgalas  PhD, DLO, FRCS(ORL-HNS) graduated from the University of Athens and was trained in Otolaryngology in London. He completed a rhinology/facial plastic fellowship in Hopital Lariboisiere, Paris and Academic Medical Centre, Amsterdam, where he was appointed Associate Professor and Director of the Endoscopic Skull Base Department (2007 to 2015). In 2015 he moved to  Athens, Hygeia Hospital, where he has created the Endoscopic Skull Base – Athens, while he is also collaborating with the Leiden University Medical Center. He has more than 100 peer-reviewed publications with >9.000 citations. He is International Editor of Clinical Otolaryngology Journal and American Journal Of Rhinology, was  National representative for Netherlands at the European Rhinology Society from 2010-2015 and he is currently secretary of the Greek Rhinology Society, and founding member and General Secretary of the Hellenic Society of Head and Neck Oncology. He is member of the Board of the European Board Exams in Otolaryngology and Lead in Rhinology and editor of the Rhinology and Skull Base Surgery Textbook by Thieme.

Read below, his very interesting answers  to 

  THE HEAD AND NECK BLOG!

Dr. Georgalas, why did you choose to specialize in Otolaryngology? What attracted you in the field then and what attracts you now?

I must admit, when I was a medical student Otolaryngology was not in my sights! Like most medical students, I was drawn to and impressed by the “big “ surgical specialties and internal medicine. Neurosurgery, Neurology and (funny enough) plastic surgery were specialities I flirted with! Otolaryngology does not get a lot of time in the curriculum of most medical schools – reflecting its status as a “second class” surgical specialty . However, later I realized that it combines elements from all my favourite specialties – it has arguably the most technically diverse surgery (open surgery – head and neck and thyroid / microsurgery – ear and cochlear surgery  / endoscopic surgery – sinus and skull base and aesthetic surgery – rhinoplasty and facial plastic. This diversity fascinates me and makes every day in theatre exciting; equally, the diversity of patients (from children with glue ear, to adults with sinonasal and skull base tumors, to cosmetic patients requiring rhinoplasty. I enjoy the interaction with them– and more than anything being able to provide “niche”, highly specialized service for patients with endoscopically accessed skull base tumors, which would have been untreatable otherwise is a privilege. Especially as the patients with sinonasal and skull base tumors – the oncological patients – are, in my experience, among the nicest and most thankful patients one could encounter.

You are subspecialized in Rhinology and Skull Base Surgery. What makes it special for you? Could you briefly describe a typical working week of yours?

I enjoy dealing with one of the most complex anatomically regions of the body – and one, that is a virtual interface – both anatomically (brain, sinuses, eyes) and functionally / in a multidisciplinary way (interacting with neurosurgeons, orbital surgeons, endocrinologists, radiation oncologists, neuro-radiologists, oncologists and pediatric oncologists. A lot of my time includes interacting with such specialties (MDT meetings with pediatric oncologists, discussion with neuro-radiologists over specific patients with skull base tumors, MDT meetings with radiotherapists and a very close collaboration with neurosurgeons.  Usually I have 3 days per week of operating time and 2 days of outpatients clinics. I try to maintain the same timetable as I had in Amsterdam and London – i.e. working from 7:30 to 6pm doing clinical work and then divide the evening between my family and academic work. Most of the weeks we have visiting fellows, either from Greece or from abroad (we had visiting surgeons / fellows from the UK, Netherlands, Bulgaria, Turkey, Italy,  Cyprus, Spain, Portugal  and Argentina.) I believe firmly in the importance of education, and I owe my knowledge and clinical skills to my trainers in the UK and Netherlands - so, I try to make up by transmitting as much as I can to the next generation. I strongly believe that the age from 35-45 is probably physically the best time in the career of a surgeon – I really hate to see people being undervalued or not appreciated in this period of their life.

You hold outstanding publications record in the field of Otolaryngology -9262 citations as of February 2019. How are you combining research activity and clinical practice and how has it helped your career so far? How do you see the role of Surgeon-Scientists in modern healthcare?

I feel (with a dose of tongue in cheek) that a monkey can learn how to operate – I have always had deep respect for those that combine surgical skills with academic ability and teaching. Even as a first year resident in the UK, in 1999, I remember how I wrote my first paper – I was observing my Consultant doing an outpatient clinic when a patient with Dermatomyositis and Zenker’s diverticulum came along. I was not allowed to examine the patient myself (first month in the UK) but I asked Simon Bear, my Consultant, if there was a link between the two conditions: He answered, very candidly “ I honestly don’t know – why don’t you check it out?”. Indeed, I did, and realized that it was a very counter-intuitive association (the accepted pathophysiology of Zenker meant that it should never co-exist with a disease associated with reduced muscular strength – so, it meant that another mechanism – in this case, reduced compliance of the sphincter - should be the one causing Zenker – and writing this down produced my first publication.  I always thought that, even though not everyone will be in the position of doing full-time research and produce life-changing papers, even case reports can make you dwell deeply into a subject – help you understand it better, improve your way of expression and collaboration. As you progress, you learn that practice and theory are in a dialectic relationship – and one should complement and work with the other. They say that you really know something if you can teach someone how to do it – I would argue that being able to write about something in a coherent , eloquent way is the proof you understand it. In practice that means staying with a healthy appetite for academic research, for writing and trying to understand and improve, audit you results. And yes, it does take a lot of time – time that is not reimbursed and directly impacts on your income – however, being academic is something that you cannot renounce.

You are in Academic Otolaryngologist for many years. What in your opinion makes a competitive applicant? What are you looking for in an applicant?

Usually, the best candidate will have a strong track record of academic excellence (from high school, to medical school to residency) – using every opportunity to improve, via exams, via publications/presentations and doing research and/or visiting centres of excellence. Unfortunately, in Greece , although the quality of applicants and those who succeed in medical school is very high, reflecting the open and transparent system of exams, the same does not necessarily always hold true for their teachers- equally reflecting the very different system of their selection. Unfortunately, this can have a devastating effect on the attitude of those who wish to follow an academic career – making them feel that there is no point, that everything is futile. These are the best students, and the ones that tend to go abroad – not so much to look for academic excellence, but also in their quest for honesty and transparency.

What would you advice a medical student, aspiring to pursue a career in Otolaryngology? How important is it to have proper mentoring during Medical School and residency training?

He should not be dissuaded by the prophets of doom: He should do his best to get trained in a well structured, transparent system (and personally I would suggest the UK system – it is by far the most transparent and horizontal in Europe, and, beyond medicine, it teaches you to respect the patients as well as your colleagues. Despite the shortcomings of NHS, there is a certain ethos about it, and it remains a very much loved and respected institution in the country.  During your time in medical school and residency, respect your colleagues and fellow residents – it may be a competitive period of your life, but only those who learn to collaborate, work with rather than against their colleagues will progress. The race should be against yourself, not against the others – try to improve but avoid comparing yourself. And always keep your mind to the prize – where you would like to be 20 years from now and how you could achieve that.

Skull Base surgery is heavily dependent on medical technology and has evolved remarkably during the last decades (e.g. the endoscopic trans-nasal sphenoid approach). Could you name 1-2 important turning points in your field in the 21^st century? How do you see the field in the next years?

A big turning point has been the successful use of chemo-radiotherapy and targeted molecular therapies to the field of head and neck cancer – it has significantly reduced the scope and applicability of “heroic” but mutilating procedures in head and neck cancers, and has helped us to focus more on what is important to the patients – organ preservation and quality of life.

Equally, the introduction of endoscopic skull base surgery has opened a new paradigm in surgery – based on collaboration with other specialties and showing that areas that were previously very difficult to reach can be treated with minimal morbidity and maximal accuracy. I always like to compare this to the era of the great discoveries – there has to be a goal to reach (here, the need to reach difficult parts of the skull base), technological advances that make it possible (such as the advent of neuronavigation, high-quality endoscopes and cameras and drills, development of reconstruction options) but most of all, a new mentality (a true multidisciplinary way of working) that made this possible. I expect the use of technology in the form of robotic surgery to take bigger part in endoscopic skull base surgery with development of flexible, smaller robotic arms, and the biggest introduction of precision medicine, with more tailored treatment to individual patients and also the biggest integration of big data in the everyday management of our patients.

Could you please share one of your most rewarding and one of your most challenging moments in your career?

The treatment of young children is always an area fraught with challenges – especially those with cancer. I will never forget a child with Ewing Sarcoma that I treated, after relapse following chemoradiotherapy in Amsterdam. His strength and resilience was an inspiration to all of us – and when he didn’t make it, his parents instead of wallowing in their grief, created a society to support similar children with cancer. I respected immensely their courage, their dignity and their big sense of helping others,- going through their grief but transforming it into a force for good. They have been a humbling experience and taught me to always look no further than my own patients for inspiration and lessons of life.
Similarly, my mentors and friends in the field of endoscopic skull base surgery, professor  Paolo Castelnuovo and professor Ricardo Carrau have been an inspiration – with their genius hidden behind their humility and their simplicity, while in Greece professor Sismanis has been a shining light for anyone interested in otolaryngology – a truly exceptional academic surgeon.