I'm immensely grateful to The Journal of Laryngology & Otology for supporting my visit to the Department of Otology and Neurotology, Toronto General Hospital (Figure 1), Ontario, Canada, during March and April 2010.

Fig. 1 Toronto General Hospital.

Toronto is the largest city in Canada, and is renowned for its low crime rate and clean environment. The Toronto General Hospital Otolaryngology Department boasts the largest residency and fellowship programmes in Canada, and has an impressive reputation for both clinical and academic training.

I arrived on a weekend, with time to settle in and find my way around the city. Toronto is beautiful in spring, crisp and cold with blazing sunshine. I spent a pleasant few days stumbling across some wonderful cafes, museums and bookshops, and exploring the varied and unique parts of the city.

Clinical activities

My supervisor Dr John Rutka and his fellow David Pothier met me at 7.30 a.m. on my first Monday (Figure 2). They'd spent the previous fortnight in Thailand and Laos, working on an ear camp and visiting a refugee camp on the Burmese border. I enjoyed hearing about their fascinating trip over the coffee and cake to which I was regularly treated. It was fun to catch up with David and to hear about his current research ventures. He seems to be enjoying life in Canada, and is brimming with original ideas, all bearing the distinct Pothier hallmark.

Fig. 2 Prodip Das, David Pothier, Emma Stapleton, Michael Halmagyi, Julian Nedzelsky and John Rutka.

It was a privilege to join Dr Rutka at work. His clinics encompass everything otological, from routine ear dewaxing to vanishingly rare and exciting cases. I learned a great deal from observing his assessment of dizzy patients. All patients with balance symptoms receive a structured otoneurological examination, and most undergo a full battery of vestibular tests including electronystagmography, sacculo-collic reflex testing, rotational chair testing, scleral coil studies and electrocochleography. This experience will definitely be beneficial to my future work, both clinical and academic.

Dr Rutka also works in a multidisciplinary head injury clinic, where he addresses the otological symptoms of patients following head injuries. Some of these patients have had major head injuries requiring neurosurgical intervention, whilst other cases involve mainly legal issues and compensation claims. It was fascinating to assess patients from both ends of this spectrum. Dr Rutka's knowledge, experience and understanding of vestibular physiology are remarkable. He didn't seem to mind my continual barrage of questions, and was happy to explain the minutiae of otological disorders and investigations. Within the space of several weeks, many topics which had previously sent my brain spinning became much clearer.

Days in the operating room started promptly at 8 a.m. It was exciting to observe a major cancer case including temporal bone resection carried out in conjunction with the head and neck surgeons, as well as several other otological procedures, including excision of a glomus jugulare tumour and endoscopic tympanoplasty. As an observational fellow I was not permitted to scrub in, and was even prevented from assisting with patient transfer because of potential legal issues! However, I was made very welcome, and had the full benefit of the operating room's excellent visual equipment and commentary from the surgeons.

I was also able to accompany Dr Rutka on his monthly trip to Niagara Falls for a peripheral clinic. We met at 7 a.m. and drove through the suburbs to our destination. The clinic was small and very friendly, and we saw a mixture of patients with vestibular symptoms, chronic ear disease and general ENT conditions.

It was interesting to observe the differences between the UK National Health Service and the Canadian health system. There are certain similarities – Canadian patients carry a health insurance card and healthcare is largely government-provided – but also several differences. Doctors in Canada have good nursing and administrative support, but there is an evident lack of hospital bureaucracy. I didn't encounter a single manager during my visit, and timetables, waiting lists and individual cases appeared to be managed amicably and effectively by doctors and their secretaries.

Social events

Dr Rutka was an extremely sociable and generous host. During my first week in Toronto, we had supper at the CN Tower (Figure 3), which had been the tallest freestanding building in the world until 2007, when it was overtaken by the Burj Khalifa skyscraper in Dubai. The food was amazing, and the restaurant rotated once every 72 minutes. I had trouble understanding the mechanics of this, but it was patiently explained to me over dessert.

Fig. 3 The CN Tower.

I was invited to join Dr Rutka and his family at home on Easter Sunday, where we were treated to a wonderful spread of food, great company, and an exciting Easter egg hunt for the children. It was a privilege to meet Dr Rutka's warm and welcoming family and their dog Rory. At the Rutkas’ Easter gathering I also met Prodip Das, a Specialist Registrar from the South Thames rotation, who is spending a year's otology fellowship in Toronto accompanied by his delightful wife and children.

I'd been looking forward to visiting Niagara Falls. Unfortunately, the day of our visit brought torrential rain, so viewing conditions were not optimal. We spent some time at the Falls, took shelter in the IMAX movie theatre to watch a movie on the history of the Falls, and managed to take a few photographs later in the afternoon when the fog and rain had partly cleared. The day was rounded off in a much more civilised fashion, with superb steaks and wine courtesy of Dr Len Makerewich, an otolaryngologist based in Niagara Falls.

Professor Halmagyi's visit to Toronto

My visit was rounded off by a fortuitous overlap with Professor Michael Halmagyi's visit to the Toronto General Hospital otolaryngology department (Figure 4). Michael Halmagyi is a neurologist and clinical professor at the University of Sydney, and best known for his ground-breaking work on the head impulse test for detecting vestibular loss, as well as several other important areas of vestibular neurophysiology. We took him for lunch at the Art Gallery of Ontario, and then returned to the hospital where he was shown around the department before delivering a superb lecture on his work. I was honoured to have the Halmagyi head thrust test performed on me, by Professor Halmagyi himself (Figure 5)!

Fig. 4 Julian Nedzelsky, Emma Stapleton, John Rutka and Michael Halmagyi.

Fig. 5 Michael Halmagyi performing his head-thrust test.