Facial nerve dehiscence

Facial Nerve Dehiscence and Cholesteatoma: A Comparison between Decades

Facial Nerve Dehiscence and Cholesteatoma: A Comparison between Decades by Giampiero Gulotta et. al. Department of Sense Organs, Sapienza University of Rome, Rome, Italy.  

This paper has a few important take-home messages for surgeons who are not asking for an HRCT temporal bone routinely for cholesteatoma cases due to several constraints. The main patient side constraint is the added cost of HRCT temporal. For surgeons, the inability to interpret the findings on HRCT Temporal bone. Nevertheless, an HRCT temporal bone can help in identifying potential risk factors pre-operatively and prevent complications. HRCT can also in planning surgery and reconstruction as well as prevent surgical complications. The most important take-home message for me is, after the tympanic segment, the next common site of facial canal dehiscence is the geniculate ganglion area. Other conclusions of the paper are:   

  1. The total incidence of FND has progressively decreased over the years.
  2. An increase in the incidence of patients with a longer disease history.  
  3. The tympanic tract of the facial nerve remains the most frequent site of dehiscence, confirming the importance of the anterior epitympanum as a high-risk localization.
  4. The incidence of FCD is higher in patients affected by primary acquired cholesteatoma in both decades, specifically in those with a combined pars tensa-pars flaccida cholesteatoma. 
  5. Fistulas of the semicircular canals are likely to occur where there is an FND, probably due to erosion of the bone covering the canal caused by cholesteatoma.
  6. Patients with a stage III disease have a higher incidence of dehiscence.

The complete paper can be read or downloaded from The Journal of International Advanced Otology at this link: https://advancedotology.org/en/facial-nerve-dehiscence-and-cholesteatoma-a-comparison-between-decades-163386.

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Eagle’s Sign

HRCT Temporal bone - Coronal view: Slide 36.

The Eagle’s sign: How to identify the Hypoglossal canal on Coronal sections of HRCT Temporal bones.  

The hypoglossal canal passes antero-laterally through the occipital condyle from the posterior fossa into the upper neck. On coronal sections of the temporal bone, the jugular tubercle extends over the hypoglossal canal like an Engle’s beak. The jugular tubercle and occipital condyle together give an appearance of the profile of an Eagle’s head. The hypoglossal canal passes under the neck of the Eagle. Identifying the hypoglossal canal is easy on the axial coronal images. 

HRCT Temporal bone - Coronal view: Slide 37.


  1. Osborn AG, Brinton WR, Smith WH. Radiology of the jugular tubercles. (1978) AJR. American journal of roentgenology. 131 (6): 1037-40. doi:10.2214/ajr.131.6.1037 – Pubmed
  2. M. Thu, N. Waters, M. Gandhi, J. Sommerville A Pictorial Review – Hypoglossal Canal (ePoster) doi:10.1594/ranzcr2015/R-0091
  3. https://radiopaedia.org/articles/hypoglossal-canal
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Visualize and manifest in your life and Surgical craft!

Cobb: An idea is like a virus. Resilient. Highly contagious. And even the smallest seed of an idea can grow. It can grow to define or destroy you.

Yusuf: Brain function in the dream will be about twenty times to normal. When you enter a dream within that dream, the effect is compounded: it’s three dreams, that’s ten hours times twenty.

Eames: I’m sorry, uh, maths was never my strong subject. How much time is that? 

Cobb: It’s a week the first level down. Six months the second level down, and… the third level… 

Ariadne: …is ten years! Who would wanna be stuck in a dream for ten years? 

Yusuf: Depends on the dream.

Eames: Listen, if you are going to perform ……….., you need imagination. 

Did these dialogues make any sense? Any guesses? It’s from Christopher Nolans’ movie Inception! If you have guessed it right, hearty congratulations. How many understood the concept of that movie the first time around!? Honestly, I didn’t. I watched it four times to get a sense of it! The gist of the movie is, for successful inception, an architect who can visualize and build the artificial dream world is essential! What a novel concept! It’s like opium on the giant silver screen! Anyway, what’s vital for us here is the Power of visualization. Albert Einstein has famously said, “Imagination is everything. It is the preview of life’s coming attractions.

Around Circa 2000, I produced a few Surgical Instructional Video on Micro-ear surgeries to raise money for our Rotary free ear surgery program. They sold like hotcakes and crossed many shores. When I met some of the people who watched those videos sometime later, they complimented me for them. They told me that they have learned to perform all ear surgeries just by watching those videos! I wondered how could that even be possible? 

Anyway, my story was not different, either. I joined a Hospital in Kerala in 1997 as a foreign returned surgeon! I had returned from the USA as I couldn’t get into the ENT residency program despite having good USMLE scores. I could have got into either internal medicine or pediatrics. I decided against it, as joining any other branch would have been a dishonor to my teachers at PGIMER, Chandigarh, where I did my residency. Initial expectations to perform were very high, internally as well as externally. Internal reasons, my USA misadventure, had left me with huge debts. The external reason, I was from a premier institute and foreign returned! But my initial Otology surgical results were miserable. I couldn’t afford to go and work with somebody or attend workshops, initially.  

“Create a vision of who you want to be, and then live into that picture as if it were already true,” thus spake Arnold Schwartzanager. Around that time, I met Dr. Mahadevaiah, and he told me he had produced some surgical videos. I wrote to him immediately. I promptly received a personal hand-written letter within a week with the list of videos, their prices, and how to procure them. I followed the instruction, and in another week, I had all the videos with me. I must have watched those videos repeatedly until the tapes were worn out! When I was not watching them on a TV, I played those videos on my mind. My success rates with ear surgeries improved within a short time. That was the power of Visualization. That compelled me to buy tapes of many surgeons available at that time.  

I had read an interview with Dr. William Devries, somewhere. He performed the “world’s first artificial heart” surgery. He said that his belief concerning surgery had always been ‘rehearse, rehearse, and then rehearse some more! For if you ‘stick to this principle, when it comes time to perform the actual operation, the procedure will have become almost routine for you.” When our residents are struggling to learn surgeries, I ask them to watch our surgical videos repeatedly and visualize them before coming to the OR. 

Our first endoscopic skull base surgery was Pituitary macroadenoma, a huge one with supra-sellar extension. We did a reasonably good job as a team in that two nostrils and four-hand techniques. Our neuro-chief was supremely pleased and asked me, “Have you done many cases earlier? Where did you get an opportunity to practice in a small place like Chitradurga?” I just smiled. I only had done a cadaver dissection at Niece in France. However, I had rehearsed the surgery thousands of times in my mind. I had visualized and internalized each step, their nuances, pitfalls, and complications. I had also used a few other techniques called ‘deconstruction,’ ‘London cabby technique,’ and ‘Parallel/Perpendicular’, etc., and I will write about them sometime in the future.  

I teach this concept of operating on each patient at least ten times during my presentations for learning surgery. The ten steps are: 

  1. The moment you advise him surgery, run the entire surgical process in your mind. 
  2. When the patient gets admitted to visualize it again. 
  3. The previous night, if required, read about that surgery and discuss with a friend or teacher or run that mental video again. 
  4. During my morning “Octavation” session, I have a step called “Most Important Task of the day,” during which I go through the complete process step by step. 
  5. Just before surgery, while scrubbing, I replay the mental video. 
  6. The actual surgery. 
  7.  When they come back for follow-up, I assess what I did and positive or negative results. 
  8. Show the work to others. 
  9. Present your work in courses and conferences, 
  10. Publish it. 

American Engineer, Philosopher Alfred A. Monepart, has stated, “To accomplish great things we must first dream, then visualize, then plan…believe….act!” I am always in awe of one person, and who is a kind of idol for me is Josh Waitzkin. The famous movie ‘Searching for Bobbie Fisher’ is Josh’s biography. Josh is an American child chess prodigy. He is one of the few people who have managed to draw with Gary Kasparov. He became an international chess grandmaster at the age of 16. Josh successfully used the visualization technique to beat his opponents in chess and play blind-folded chess or playing with multiple participants at the same time.  

Dr. Prem Jagyasi, the author of the beautiful book, ‘Carve your life: Live a great life with Carvism, has beautifully said, “In order to find your true potential, what you need to do is simply determine your core values, visualize the person you want to be, challenge common thought traps, and have a clear sense of your goals.” When Josh lost interest in chess, he used visualization techniques to change his career, based on mental faculty such as chess to physical faculty such as Aikido and Brazilian Jiu-Jitsu. He won the 2004 world championship title in Taiji Push-Hands. Josh is a black belt in Brazilian Jiu-Jitsu. He successfully guided many teammates in the visualization technique and helped them to win world titles. He has authored two excellent books, Attacking Chess: Aggressive Strategies, Inside Moves from the U.S. Junior Chess Champion, and The Art of Learning: An Inner Journey to Optimal Performance.  

One remarkable story about Josh is winning his 2004 World Championship title in Taiji Push-Hands. Few months before the Championship draw, he gets severely injured during a practice session. However, the visualization technique helps him practice the game and develop the same physical and mental ability required to win the World Championship. History is full of such stories where several athletes have used a similar technique to win their titles. An American of Lebanese origin and the author of the book ‘The Second Harvest,’ Nabil N. Jamal has quoted, “You cannot advance if you cannot visualize the end from the start. The colleagues who want to become a master of their crafts must-read Josh Waitzkin’s book, The Art of Learning: An Inner Journey to Optimal Performance.     

Visualization cannot only help in mastering surgeries, but it can also help in designing our lives. A famous Indian author of multiple life-transforming books, Sanchita Pandey writes in her book “Lessons from my Garden,” “If you can visualize it, you can certainly manifest it in your life.” The visualization faculty is something readily available to everyone. Genevieve Behrend, one of the earliest French-born Mental science teacher, observed, “We all possess more power and greater possibilities than we realize, and visualizing is one of the greatest of these powers. Everyone visualizes whether he knows it or not. 

Even though it is disputed, the human brain cannot differentiate between the real and imagined.  I will write more about it sometime in the future.  Till then, visualizing is a great secret of success.”  

With warm regards, 

Dr. Prahlada N.B

We appreciate your valuable comments, advice, constructive criticism, suggestions, or feedback. Please feel free to write.

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If you want to succeed, build your OKRs, and double your failure rate.

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way.”

These are the best opening lines of any novels I have read till today. They are from Charles Dickens’ A tale of two cities. I had read somewhere it took him years to come up with these fantastic lines. One can understand his dilemma and uncertainty, which persists even as of today, the world over.
Many of our colleagues have shared such dilemmas with me. I grew up around the Swami Vivekananda movement, and his words are a guiding light for me. Nobody has emphasized better than Swami Vivekananda about motivating the youth. His quote, “Arise, awake, and stop not until the goal is reached”, keeps ringing me in my ears all the time. Hence, one of my most favorite free time activity is motivating the youth. We regularly organize “Re-write your Destiny” courses or go to different institutions to inspire the youth and help them find their inner potential. During such sessions, the first question I ask each of them is what is your goal in your life. Unfortunately, only 5% of people have a very specific goal or vision about their life. The remaining all are uncertain about their future.

If we dig deeper, we find that a common factor that prevents people from having a vision or goal is a fear of failure. At the end of every year, I take a stock of my goals and achievements. I have failed as much as 50 % of the time the first time around. That was depressing! I used to blame it on the law of mathematical probability! However, retrospectively I realize that I have fared better than some of my friends who never tried at all in the same areas! That was a revelation.

Around this time, I read a quote by IBM founder Tom Watson Jr II, who said, “If you want to succeed double your failure rate.” Popular American Basketball Player Michael Jordan famously quoted, I have failed over and over again in my life and that is why I have succeeded.” How can we win a game which we never played at all in the first place? Former British PM, a great statesman and WWII war hero Churchill has aptly said, “Success consists of going from failure to failure without loss of enthusiasm.” Another great quote of his is, “Success is not final, failure is not fatal: it is the courage to continue that counts.” I was a great fan of Churchill until I came to know he hated India! Anyway, my admiration for him will never fade away as he is one man who has lived up to his words. As a high school student, I had bunked my classes for nearly two months to devour all his twelve volumes of memoirs on WW II at our public district library!It is my experience that failure teaches us in ways success cannot. Failures mold us as a person. Failures make us resilient. People who cultivate a stronger relationship with failures, attract success faster. Failures teach us lessons. I have failed so many times and I have learned so many lessons that I must be a scholar now! LOL! Smiley!

My failures have paralyzed me many times. What helped me was indomitable willpower. One of my favorite author Robin Sharma says, “Failure is not having the courage to try, nothing more and nothing less.” Some people do have ambitions. However, the majority do not have the will power to pursue their dreams. Celebrated authors Roy F. Baumeister and John Tierney describe this as “Ego depletion” in their book “Will Power.” Ego depletion is a person’s diminished capacity to regulate their thoughts, feelings, and actions.” When we do things we fear, we grow fearless. It’s a kind of self-psychological counseling and therapeutic regime.

Google Inc., one of the most innovative companies that have produced more than 100 innovative digital products such as Youtube, Gmail, and Chrome browser, fails as much as 40% of the times in its objectives! When a giant like google fails 40% of the time, another extra 10% failure rate appears to be a consolation prize for me! My favorite motivational speaker Tony Robbins has said, “There is no such thing as failure. One of the commonest quotes quoted by most speakers belongs to Thomas Edison, “I have not failed. I’ve just found 10,000 ways that won’t work.”

Earlier, I used to follow the SMART principles of goalkeeping strictly. The SMART stands for Specific, Measureable, Achievable, Reasonable, and Time-bound. However, this missed the “Why” factor. Later, it was modified to SMARTER goals. I changed the Measurable to Meaningful, and besides, Evaluate and Re-adjust were added to it. I have written earlier how I failed to copy the surgical skills of Dr. Mahadeviah until I made my goals meaningful.

We have a lot to learn from Google Inc. Look at their mission, “Organise the world’s information and make it universally accessible and useful.” Google’s current success is attributed to its collaborative goal-setting protocol called Objectives and Key Results, OKRs in short! The OKRs are not just for companies. Any teams, families, or individuals can use it. OKRs follow the adage, “Ideas are easy. Execution is everything.”

An Objective involves Rudyard Kipling’s five honest servants: what, where, who, why, when to be achieved. Whereas, Key Result benchmarks monitor the sixth servant, HOW we accomplish the Objective. The Objectives are ideally inspirational, concrete, significant, and action-oriented. The effective Key Results are specific and time-bound, aggressive, yet realistic. Most important, they are verifiable and measurable. Hence, key results must have a number or percentage such as revenue, growth, active users, quality, safety, market share, customer engagement. Either we meet a KR goal or not, and there is no buffer zone.

An effective OKR system links goals to a team’s broader mission, lending purpose, alignment, clarity, and job satisfaction to the entire organization.
According to Google’s erstwhile CEO, Eric Schmidt, “OKRs changed the company’s course forever.” OKRs helps a company to focus its efforts on the same essential projects throughout the organization. OKRs are the brainchild of Andy Grove, the founder of Intel, based on Peter Drucker’s “Management by Objectives” (MBD). Andy Grove taught it to John Doerr, a venture capitalist and a billionaire who backed Google during its infancy. Oh! I have used too many management jargon! But, they are interesting and they help. If you want to learn more about OKRs, please read John Doerr’s “Measure What Matters.”

I was discouraged by most of my friends and relatives when I decided to build our hospital in a small place like Chitradurga. They feared that it will not be financially viable. But, the OKRs helped me to prove to them that they were wrong. My objectives were very clear: It has to be a hospital with compassion, a training center for our colleagues, and a research center. I failed in a few objectives and succeeded in many. If I had not tried at all, I would have been helping someone else build their OKRs!The message is loud and clear. If you want to succeed, build your OKRs, and double your failure rate. And how do we start? Start by paying gratitude to his almighty for what you already have! Here is a small video – Part -1 of my Octavation system composed with the help of my friends.

Dr. Prahlada N.B

We appreciate your valuable comments, advice, constructive criticism, suggestions, or feedback. Please feel free to write.

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Success is directly proportional to efficient time management.

Success is directly proportional to efficient time management.

“When I run after what I think I want,
my days are a furnace of distress and anxiety;
If I sit in my own place of patience, what I need flows to me,
and without any pain.
From this I understand that what I want also wants me,
is looking for me and attracting me.
There is a great secret in this for anyone who can grasp it.”

  • Rumi. 

Rumi’s poem has a profound meaning. My favorite author of Alchemist fame, Paolo Coelho, has a quote in that same book, “When you want something, all the universe conspires in helping you to achieve it.”  Our goals with a higher purpose have a magnetic power to attract them towards us effortlessly! 

My sincerest gratitude to all friends who have written me words of appreciation for my earlier blogs. Many asked me to teach Time management techniques. As Sadhguru aptly observed, “Guru” is one of the most abused four-letter words. I really don’t want to be a Guru. Let me share how to manage my time with my own life’s experiments. 

Success is directly proportional to efficient time management. When we master our minutes and we enhance our productivity. Time management and success go hand-in-hand. I personally experienced this phenomenon when I wanted to learn about Endoscopic skull base surgery (ESBS).    

Around Circa 2008, I was looking for new avenues. The ESBS was the new thing. Unfortunately, neither we had a neurosurgeon nor an ICU with an intensivist in my city. Nevertheless, learning ESBS became my new goal. As if it is magic, I received an email about an ESBS cadaver dissection course at Niece, France. I immediately registered for it, where I had an opportunity to be guided by Prof. Ricardo Carrau, a great human being and a versatile surgeon. As if like a coincidence, I met my Neuro Chief in a clinical meeting, who invited me to join his team. His corporate hospital offered me a Senior consultancy position, and soon I was in the group of some of the best Neurosurgeons. My CA told me that my new goalpost would be financially suicidal. I still took that bite. The experience I gained from working in a corporate hospital for nearly four years was worth more than I lost. 

Later, I traveled to Bangalore twice a week for another four years to be part of the ESBS team. That was the peak time of Atal Bihari Vajpayee’s dream project Diamond and Golden Quadrangle roads. Sometimes it used to take 5 -6 hours of commute 200 km as construction was going on the entire stretch of the project simultaneously. Many times it was frustrating to wait in the long traffic jams. However, I applied the E + R = O equation and changed my response. I appointed a good driver. I made my car a mobile library. As soon as I got into the car, I would put on my seat belt, stabilize my head with a neck pillow, and immerse myself in my iPad.

I read hundreds of books on diverse subjects. Besides Otorhinolaryngology, I read books on non-fiction, personal management, biographies, and engineering. I reviewed thousands of scientific articles. When it became too straining to eyes, I would listen to Audiobooks or soothing music. But I never complained. And I never gave up. I devoured knowledge of anything and everything which attracted my attention. To avoid delays, I always started 2 hours before. I was on time for surgeries during the entire four years, and there is not even a single instance of my delay. Now when we were under lockdown for nearly six months due to Covid-19, this non-medical knowledge earned a livelihood for myself and my 32 staff members of the hospital and their families. We also contributed a substantial amount of GST to support our Government when the GDP was nose-diving.      

My morning wake-up time for a very long-time is 4 am and the first 2 – 3 hours of the day are dedicated to non-negotiable objectives such as exercise, meditation, and personal growth. I don’t have to emphasize family time. Family time was a huge issue for me with my crazy traveling and operating schedule. One of my senior friends had a dedicated family day, and on that day, he would spend his entire day with his family. I couldn’t do even that! One of the ways I have solved this issue is by making my family members part of my vision, mission, and values. Since then, it appears to me that I am always with them and I am also working on my pet projects. When you have shared dreams, you create more synapses, synchrony, and synergy! Soon you will find your family life to be a symphony! In management lingo, 4-S phenomenon!

For more than 20 years, I slept only 4-5 hours a day on the misconstrued premise that sleep quality is more important than the quantity. And I have paid a heavy price for that. According to Tom Rath, the author of the popular book Eat, Love, Sleep, “Ninety minutes of less sleep than you need equates to a one-third drop in cognition. Hence, for personal mastery, adequate sleep is a must.       

Direct and indirect positive impact exercises and learning have been established by a study done at the University of British Columbia. The researchers have found that regular exercises, irrespective of the type, enhance the hippocampus’s size, handling verbal memory learning. Most Indian doctors known to me have a healthy exercise habit. I use my exercise time to listen to my favorite non-fiction audiobooks. Exercise and education go hand-in-hand. I have failed multiple times with my weight reducing or waist-trimming goals. Hence, I have re-phrased it to “Gain enough strength to operate for a long period of life!” And that has helped me!

I believe in the adage, “Eyes cannot see what mind doesn’t know.” Vast theoretical knowledge is a must to master the nuances of any surgical field. I have a dedicated daily non-negotiable growth time that has helped me regularly update my knowledge and learn new things. The regular reading habit has also helped me acquire a speed reading capability, which helps us gather a large amount of knowledge quickly.    

I believe in rituals. Rituals create a purpose. The purpose automatically enhances our performance. However, earlier I didn’t want to sound like an orthodox person. I used to call it a success ritual. It was my surefire formula to bust my stress, keep me healthy, learn anything new easily, master any surgery quickly, and get whatever I aspired. This success ritual has eight components to address eight different aspects of our lives. As it contains eight elements to activate eight different aspects of our lives, I call it Octa-vation. But, now I have come to terms with the ancient tradition and accepted it as a form of fusion meditation! I firmly say meditation is a vaccine against failures in all aspects of your lives, hence I also call it succination! Now, there are more than 16,000 scientific research studies on the benefits of meditation. Meditation is more being spiritual than religion. Meditation has no binding to any specific religion or sect. People with any religious beliefs, including atheists, can practice meditation. Meditation helps to set our day in order. Day becomes weeks. Weeks become months, and months become years. My daily Octavation schedule is 05.00 am Indian time (+5.30 GMT) and lasts for 30 – 40 minutes. If any friends are interested in Octavating themselves, can join online! Write to me if interested and get connected to this life-line!      

One area which can consume a lot of our Time is Surgical Time. I did a time-audit of commonly performed surgeries and reduced surgical time as much as possible. In my OT, with my staff, and when I am not teaching, I can perform a Tympanoplasty with canaloplasty and cortical mastoidectomy, skin-to-skin in less than 30 minutes!   

Hereby I am bringing my success principles through my webinar on “Time management in Middle Ear and Mastoid surgeries” on October 18, 2020, at 08.00 pm, Indian time (+5.30 GMT).  

ZOOM ID: 994 031 2004
PASSCODE: 686868. 

Please join me and save your precious time!

With regards, 

Dr. Prahlada N.B

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When your WHY is big enough, you will find your HOW!

Image Courtesy: https://www.interiorsandsources.com/article-details/articleid/22727/title/maslow-hierarchy-design-architecture-impacts

“I am already very busy, and how can I find more time to learn more?”  

This is one of the commonest excuses given by some of our colleagues.

In 2005, I was at the peak of my clinical practice. I was teaching at Medical School. I was traveling in India and abroad for academic and not-for-profit assignments. I was also president of the local Rotary Club and organized 365 charitable activities for the club, other than weekly meetings, zonal, and annual conferences. One day the Superintendent of Police was a chief guest for our club program. Before leaving, he asked me to meet at his office when I am free. I met him within two days. That day, he asked me to become the Commandant of Homeguards, an Honorary Gazetted Post, leading one thousand home guards of the district. I refused as I was already very busy. He said, “I know you are a very busy doctor. However, only busy people can squeeze more time to work on subjects close to their hearts. Please accept it. You can manage it.” I had a revelation that day. Later, I successfully lead the force for ten years.             

Indian doctors have one of the craziest timings. However, many are busy being busy. Suresh Pandey and Vidushi Sharma recently published an article in the Indian Journal of Ophthalmology, “Doctor, heal thyself: Addressing the shorter life expectancy of doctors in India.” According to them, doctors’ life expectancy is 59 years compared to 67.9 years of India’s average person. The leading cause of such low life expectancy is depression and stress. The Covid-19 has exposed the vulnerability of Indian doctors further. Poor time management is one of the main culprits leading to anxiety and depression.  

Unfortunately, time and personal management are not part of our curriculum in our medical schools. During the early part of my career, I realized their importance and made a few amendments to my lifestyle. Two things that helped me learn whatever I wanted to learn or get in my life are a personal vision statement or optimal time management.

In the first year of my clinical practice, the results of Otological surgeries were dismal. During this time, I had an opportunity to participate in a live surgery program of late Dr. A.B Mahadevaiah. His work was like magic, and I was mesmerized by his surgeries. That day I made a goal for myself to be a famous surgeon like him within three years. But, nothing changed and, my results didn’t move even an iota! That is when I was approached by the Rotary International to do a “Free Ear Surgery Project” for poor patients. That day I had another revelation and changed my goalpost. My new goal was to “help many patients through my surgical skills and teach junior colleagues.” Bingo! Within one year, I was demonstrating surgery as invited faculty in a workshop side-by-side with Dr. Mahadeviah. I realized that when we have a broader personal vision statement, the success automatically moves towards you! When your WHY is big enough, you will find your HOW! One of the most popular TED speaker, and the author of the popular book, “Know your why,” Simon Sinek has aptly said, “People don’t buy what you do. People buy why you do it.”

Since then, I started moving in the opposite direction of Abraham Maslow’s expanded hierarchy of needs (Refer to the pic). Starting with “Self-transcendence” helped me achieve whatever I wanted to achieve. Instead of climbing up the hierarchy of needs as most in the world would do, I started climbing down. And climbing down a pyramid or mountain is always a lot easier!  

Maslow theorized that self-transcendence is the highest level of living. Living from this plane is achieved when a person focuses beyond the self. A self-transcendent individual sees the world as their responsibility. They work from a place of altruism, spiritual awakening, liberation from egocentricity, and the unity of being. Neale Donald Walsch, the author of the world-renowned Conversations with God series of books, has famously said, “Your life is not about you. Rather, it’s about the lives of every single person you touch. Make an effort to remind yourself of this. When you really get this, when you truly shift and make your life about others, you will never wake up depressed, stressed, or fearful ever again. When you walk into a room with the intention to heal the room, when you wake up with the desire to serve the world, your problems, the negative you feel, disappears.”

These beautiful words have transformed my life and career. I have found this is the way to see abundance in personal and professional life. The day I read these words, I changed my vision and mission statements as follows: 

My Vision: I don’t want to be a genius. I want to be a person with a bundle of experience. 

My mission: Help others achieve their life’s objectives in my presence or absence!

My Values: Creating value for others. 

To put in words of popular motivational speaker Vishen Lakhiani, “Living in this way pulls an individual forward in a way that’s motivating and thrilling and joyful.” At this juncture, I fondly remember the poem “Shining Bright” by one of the few black women who have made it big in America, Lisa Nichols.    


So maybe the world didn’t give you permission to be here, but you didn’t ask for it either. Sometimes you have to stop asking for permission, and instead, just give the world notice.
I invite you to give the world notice that you’re coming. Give the world notice that you’ve been here.
Give the world notice that you played polite long enough—now it’s time to play full out.
Give the world notice that unapologetic just showed up.
Give the world notice that non-negotiable just showed up.
Give the world notice that if they can’t handle your light— you’re no longer going to dim your light.
THEY can put on some shades.”
“Because when you become that bold, when you become that audacious, when you become that unapologetic, all of a sudden, you become INFECTIOUS.
All of a sudden, just the mere glimmer of you, the mere glimpse of you, just being in your hemisphere, and your atmosphere, and your zip code causes something to happen to me because I’m in proximity to YOU.
And then you become absolutely aware of the true assignment on your life, that you are here to save us.
You are here to inspire us by the way you walk, by the way you rise above your own uncertainty, by the way you push past your religious conversation, your cultural conversation, your economic conversation, your gender conversation, by the way you show up and say, “How can I serve humanity?”
By the way you recognize that your human spirit is unbreakable, your human spirit is unshakable, your human spirit is unstoppable.
Your human spirit is simply asking for you to give it a command.
Who will we serve next?
What will we do, and what mountain will we require to bow down?
And when you get that, and you operate with that knowing, all of a sudden, you become contagious, and people just want to be in your space, and share your oxygen.
Because you make them believe again.
So what is YOUR vision?”

Concerning time management, I have divided my schedule into negotiable and non-negotiable events. My sleep, exercise, meditation, family, and growth time are non-negotiable events. Nothing else can disturb them or steal their time! Now you may ask me where my work schedule is? When we subtract non-negotiable time from the total time, we get work time! Matter of factly a schedule where you can perform all your professional chores. And there are multiple innovative ways of generating extra-time in our 24 hours a day schedule! More at “High Voltage Learning!”

With regards, 

Dr. Prahlada N.B

We appreciate your valuable comments, advice, constructive criticism, suggestions, or feedback. Please feel free to write.

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ROAR! – Recreating our artificial reality.

“Neo, you take the blue pill…the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill…you stay in Wonderland, and I show you how deep the rabbit hole goes.” 
– Morpheus, Matrix. 

Neo pops the red pill and joins the rebellion. 

I don’t know how many of you remember this scene from the 90’s superhit movie of Wachowski sisters (erstwhile brothers). However, this was a defining moment for Neo (Keanu Reaves).    

I am showered with appreciation from many colleagues for my earlier introductory article about our upcoming course, “High VOLTage learning!” Thank you very much, friends. You are all a constant source of inspiration. I am also swarmed with many questions and comments. Few examples are here:

“If everyone is blessed with tools, time, and training, why only a few become outstanding surgeons?” 

“I want to learn more. But, I am already busy with what I am doing, where do I find the time?”

“Out of 800, maybe we can just perform one or two emergency surgeries due to the risk posed by the Covid-19 pandemic. How can we learn anything at all?” 

“Is it essential to learn all 800 surgeries? Can’t I focus on any one single field?”

Answer to the last question, follow your heart, and the interest. The basic idea behind our course, “High VOLTage Learning,” is making you great surgeons in the field of your choice. Otherwise, a collective answer to all questions is, “Take that red pill.” The blue pill represents an artificial reality of negativity or mediocrity. The red pill allows us to escape us to a world of positivity or excellence. All that needed is a decision to down the red pill and stop being prisoners of false beliefs. 

What is real are the God-created beautiful universe and our physical existence in it. The rest are all artificially created around us. When we are borne, our parents provide us a name and a religion. As we grow, our society gives us an identity. The country offers a nationality. Our schools impart our knowledge. Either we create a job for ourselves or work for others. 

Similarly, many do not become good surgeons because of an artificial negative aura created by themselves or others. It is common to hear, “it is a difficult surgery.” “The complications are high!” “That is not the way!” “The incision is too long!” “It should have been 30′ upwards!” “Not all should do it!” “Not a surgical hand!” Blah, blah, blah. Often it is being done subtly as if like educating someone. Negativity is all the more evident with the advent of social media. (Honestly, and unfortunately, I have also contributed to this negativity many times. And, I regret that). Many people get paralyzed by these disempowering comments and slip southwards. These damaging statements can leave permanent scars on residents or postgraduates.

A great visionary and most outstanding entrepreneur of our times, Steve Jobs, has said, “Life can be much broader once you discover one simple fact. That is—everything around us that you call Life was made up by people no smarter than you. And you can change it. You can influence it. Once you learn that, you’ll never be the same again.” We can change it by stoping to go with the flow and start questioning the false beliefs. A top motivational speaker Vishen Lakhiani states, “Ideas, memes, and culture are meant to evolve and change, and we are best served when we question them.” Lakhiani calls these self-defeating rules as Brules – a hybrid word for bullshit rules. He goes on saying, “We know intellectually that this sort of change happens, yet billions of us cling to self-defeating rules from the past that should not exist in today’s world because technology, society, and human consciousness have simply evolved beyond them.”  

Eleanor Roosevelt has famously said, “No one can make you feel inferior without your consent.” One best advice anyone gets from is from Steve Jobs’s address to the Stanford University graduates. “Your time is limited, so don’t waste it living someone else’s Life. Don’t be trapped by dogma—which is living with the results of other people’s thinking. Don’t let the noise of others’ opinions drown out your own inner voice. And “most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.” We cannot stop what others say or comment on us. However, we can control how we react to them. Dr. Robert Resnick, a Psychotherapist from Los Angeles, has designed the right equation to illustrate this point. 

E + R = Outcome

We have all the power within us to make a choice. Either we can blame the event (E) for the lack of our Outcomes (O). Instead, we can change our responses (R) to the events until we get the results we want. If we are not getting the results we desire, we have to change our answer. The founder and chairman of the X Prize Foundation, Peter Diamandis, quoted, “If you can’t win, change the rules. If you can’t change the rules, ignore them.”  

An even more damaging factor is under-estimating ourselves and our capabilities. Many even do not attempt to explore their worth. These self-defeating beliefs can snowball to become the biggest hurdles for all our achievements. We can recite the self-depreciating beliefs as:  

“First a man takes a belief
Then the belief takes more beliefs
Then the beliefs takes a man
(Sincere apologies to Scott Fitzgerald).  

Ultimately and unknowingly, we become Pavlov’s dogs with conditioned self-defeating behaviors. Marisa Peer, a British hypnotherapist, calls this as “Biggest Disease Affecting Humanity.” Consumer psychologist Paul Marsden, Ph.D. aptly describes it as, “we inherit and transmit behaviors, emotions, beliefs, and religions, not through rational choice but contagion.” Mediocrity and underperformance are a kind of social contagion.    

Nevertheless, these malicious mental hacks are also artificial. A silver lining in the dark clouds of self-defeating beliefs is that we can change them. And we can change them instantaneously. Studies by Darwin, Harari, and many others have found that the homo-sapiens are highly adaptable species on the planet. The human being can adapt to extremes of weather. We adapt to new food habits (McDonalds & KFCs). We adapt to changing family and job circumstances. We adapt to a life-partner, unknown to us until then. We adapt to the laws of the nation-changing from time to time. Similarly, we can change our negative beliefs instantaneously and adapt to empowering new beliefs.

Some people call this Bending Reality. Some christen it as rewriting your destiny. Some say Nirvana. Others call it reality warping. I simply say, ROAR! That is an acronym for “Recreating Our Artificial reality.”

The way we have created an artificial reality of negative beliefs around us, we can create positive beliefs. We will teach the technique of ROAR in our upcoming online course, “High VOLTage Learning.”  

To be an achiever, Take that “Red pill” and “ROAR.” 

With regards, 

Dr. Prahlada N.B

We appreciate your valuable comments, advice, constructive criticism, suggestions, or feedback. Please feel free to write.

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Mastering 800 ENT Surgeries and 10,000 Hour Rule!

Mastering 800 ENT Surgeries and 10,000 Hour Rule!

I became a laughing stock on social media when I said there are more than 800 surgeries in the Otorhinolaryngology Specialty. Even I was surprised when I stumbled upon this number. A few years back, I joined a corporate Hospital as a senior consultant on a fee for service basis. Earlier, there was no Otorhinolaryngology department there, and I had to establish everything from scratch. One of the first tasks assigned to me by the finance and billing department was fixing the fee for various Otorhinolaryngology surgeries. I couldn’t source this information from any other hospital in the city. So I had to go back to the surgical logbook I had maintained meticulously. Indeed, I had performed more than 800 types of surgeries until then. I had performed all the surgeries mentioned in our different textbooks, at least once, with good results and minimum complications.

Medical science has taken a giant leap in the last few decades. Specialties have given way to subspecialties and super specialties. The general trend is practicing more and more about less and less! Necessity is the mother of evolution, and surgeons like me practicing in peripheries cannot restrict to a narrow area of our specialties. Moreover, there is no cap in our country for the types of surgeries we can perform within our field under appropriate conditions. Rather, there is a lot of overlap with many other branches of medicine.

The question here is not the number of surgeries in Otorhinolaryngology. Many junior colleagues who take part in our training courses ask me, is it possible to learn so many surgeries? When mastering anything requires a narrow field focus, how can we be proficient in such diverse surgeries of a vast field, such as Otorhinolaryngology? The answer is, as Rome was not built in a day, we cannot attain skills in a short period. At least during my time.

Let me illustrate this point by a legend about Pablo Picasso. When Picasso was in the market, a woman charmed by his work approaches him to draw something for her. Picasso obliges her request, draws a beautiful sketch within a few seconds, and hands it to her. While the woman adores that drawing, he says, “That will be thirty thousand dollars.”
The woman is taken aback and protests, “But, Mr. Picasso, how can you charge so much when the drawing has taken only a few seconds.” Mr. Picasso shot back, saying, “Madame, it took me thirty years to learn that art.” Italian sculptor Michelangelo has said, “If people knew how hard I worked to get my mastery, it wouldn’t seem so wonderful at all.”

It was not a comfortable journey for me, either. It took me more than 20 years of an arduous expedition to learn the nuances of these surgeries, one at a time. It was long and protracted hard work and perseverance to hone these skills like the prolonged work by PWD of Rome! Even now, I am learning. The surgical training is comparable to martial arts Karate. Karate has nine levels of a hierarchy of proficiency, represented by different colors. A gakusei or a student starts with a white belt. He becomes a Deshi or top student or Sensei, a teacher or master when he attains the black-belt after training and raising through all levels. The point to note is that the white belt gakusei gets the same karate training as the black belt gakusei. The only difference is he has not practiced enough. The black belt gakusei has the same fundamental skills of white belt gakusei, with ample practice.

Similarly, the surgical field has different surgeries and many levels of learning. An experienced surgeon is a master or black belt of what he has already learned and a white belt of things he is yet to know. Like success, mastery is a journey. As the author of the book the one thing, Gary Keller aptly says, “The path is one of an apprentice learning and learning the basics on a never-ending journey of greater experience and expertise.”

American author Marianne Williamson once said, “The top of one mountain is always the bottom of another.” A mountaineer doesn’t stop after scaling a mountain. He goes to the next and the next, the taller ones. When he goes, he carries all the experience of climbing earlier mountains. My surgical goals and the journey were akin to a mountaineer. During the initial period of my career, I focused on one sub-specialty at a time, with deliberate practice, until I reached reasonable mastery. Here is a slide from one of my presentations, which depicts my Otological journey, which is comparable to a mountaineer.

Psychologist K. Anderson Ericsson published an article in 1993, “The Role of Deliberate Practice in the Acquisition of Expert Performance” in the journal Psychological Review. This landmark publication deflated the earlier opinion that expert performers were gifted, naturals, or even prodigies. Ericsson proposed the “10,000-hour rule” and gave us the first real insights into mastery. His research concluded that elite performers were the result of a typical regular and deliberate practice pattern over the years.

Ericsson’s premise was based on his observation of elite violinists who had more than 10,000 hours of practice by age 20. Malcolm Gladwell’s best selling book, “Outliers” is primarily based on Ericsson’s findings. “Time on task, over Time, eventually beats talent every time,’ says Garry Keller. According to him, most elite performers accomplish this feat in about ten years, provided they practice deliberately, three hours a day, every day of the year. If we want to award ourselves some resting or family time and work only 5 or 6 days a week, we need more time.

With deliberate practice, the American pilots trained at TOP GUN school of TOP GUN movie fame, improved 1,150%! Earlier, Americans were losing their fighter planes at 1:1 proportions during the Vietnam war. With deliberate practice, they could reduce it to 12.5:1.

There is an apocryphal story about the Little Master, Sunil Gavaskar, one of the best cricketer the world has seen. His score in test cricket equals the height of Mount Everest in feet. Even as a child, he was a cricketing prodigy. As getting him “out” from batting was difficult for his teammates, there was a different set of rules for him. He was called out even if he hits a four or six! Sunil Gavaskar’s achievements were a result of deliberate practice. His record of playing of all 60 overs during the first match of the first edition of the one-day world cup series with 36 runs, not-out, will remain unbeaten forever.

Many junior colleagues underestimate themselves thinking, “only a few people are blessed to become good surgeons.” That’s a wrong assumption. American Psychiatrist Jose Silva has said, “I believe that each one of us has been given all of the tools, talent, and training that we need to accomplish the mission we were sent here to do.” The only thing is that we have to take that first step towards that objective.

Now, the times have changed, and the Ericsson’s 10,000 Hour rule has also been debunked. Now we have new tools, talent, training, and techniques to master any surgery in lesser time. We have a curated an online course, “High VOLTage learning,” to help our junior colleagues to become great and versatile surgeons. The course details will be announced soon.

With Regards,

Dr. Prahlada N.B

We appreciate your valuable comments, advice, constructive criticism, suggestions, or feedback. Please feel free to write.

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International Webinar on Pediatric Airway Problems – Second Session.

Theme: Pediatric Tracheostomy

Program details:

Moderator: Dr. E.V Raman, Manipal Hospital, Bangalore, India

Pediatric Tracheostomy – Technique: Dr . Ajoy Mathew Varghese
Prof & Head, Department of ENT-HNS, CMC Vellore.

Post -Tracheostomy Care: Dr. Deepa Shivnani
Fellow, Pediatric Otorhinolaryngology, Manipal Hospital, Bangalore.

Tracheostomy complications: Dr. K.K Ezzy
Consultant ENT Surgeon, Mumbai.

Interesting case discussion / Journal scan / Ask the Expert
Dr. Shashidhar Tatavarty, Senior Consultant, Artemis Hospital, New Delhi.
Dr. Rakesh Srivastava, Laryngologist & Senior Consultant, Susrut Hospital, Lucknow.

Dr. Mary Kurien,  Pondichery, India
Dr. Suja Sreedharan, Mangalore, India
Dr. Kishore Sandu, Lausanne, Switzerland
Dr. Deepak Mehta, Texas, USA
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An International Webinar on Pediatric Airway Problems – 1

Date: On Sundays, starting from July 5th, 2020, 

Time: 05.30 – 07.30 pm, Indian Time (+05.30 GMT). 

This week program: 

Program details:

Moderator: Dr. E.V Raman

Children’s Airway and Swallowing center, Manipal Hospital, Bangalore, India

Evaluation of Pediatric airway: Dr. Prahlada N.B. Senior consultant & M.D.,

Karnataka ENT Hospital, Chitradurga, India

Nuances of Flexible laryngoscopy: Dr. Mahesh Babu Ramamurthy

Senior Consultant & Head, Pediatric Pulmonology and Sleep

National University Hospital, Singapore

An Interesting Case Presentation: Dr. Shashidhar Tatavarty Head, ENT – H.N. Surgery,

Artemis Hospitals, Gurgaon, India


Dr. Rakesh Srivastav,  Consultant Laryngologist,

Susrut Institute of Plastic Surgery & Super specialty hospital, Lucknow, India

Dr. Mary Kurien,  Professor & Head, ENT-Head & Neck Surgery,

Pondichery Institute of Medical Sciences, Pondichery, India.

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