March2018

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One of My Interesting Head and Neck Surgeries

I love my job. Being an otorhinolaryngologist-head and neck surgeon means you’ll never know what surgical challenge may come your way. One day, it may be doing a revision of a cleft lip surgery. On another day, it may be removing a fishbone stuck in a patient’s throat. Or some days, it may be a challenging head and neck cancer surgery such as this case.

She was referred to me by another head and neck surgeon for co-management. Her story began 1 year before the consult when there was a rapidly enlarging mass under her left ear. 2 months before her consult, she noted weakness in her smile and her ability to close her eyes. A needle biopsy was done which revealed a high-grade mucoepidermoid carcinoma of the parotid gland (a cancer of the salivary gland) and she was advised surgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

his is the picture of her CT scan showing invasion of the structures deep to the jaw. There was also spread to the lymph nodes near the great vessels of the left neck. She was then scheduled for surgery: wide excision of parotid gland tumor, facial nerve sacrifice, and modified radical neck dissection on the left. In layman’s terms, that means removing the tumor, with margins of 1.5 cm of normal tissue, identifying the trunk of the nerve which moves the face (remember that she already had facial nerve paralysis before the surgery so that means the nerve was already invaded by the tumor) and removal of all the lymph nodes surrounding the great vessels of the neck.

The next picture was taken after the tumor was removed. The reason why this is one of my memorable surgeries is, despite the size of the tumor, because of the details of the anatomy.

In the picture below, I placed the picture taken intra operatively after removing the tumor, side by side with the diagram from the anatomy book. This is the dissection of the area near the jaw. In this picture, you will appreciate how, despite the big tumor, we were able to preserve, and dissect with care the great vessels supplying the head and the brain (the carotid and the jugular), the hypoglossal nerve (Cranial nerve 12-the nerve which controls tongue movement), the spinal accessory nerve (Cranial nerve 11, which controls shoulder movement), the facial artery, as well as other structures like the digastric muscle, and even the ansa cervicalis. I’m sure this sounds like Greek to most non medical readers. But my greater point here is that choosing a competent surgeon is important especially for head and neck surgeries because of all the vital structures that control our voice, swallowing, shoulder and tongue movements and supply blood to our brain.

 

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I was just sending a patient home yet it felt like Valentine’s Day

Vacations are supposed to be enjoyable times for most people. However, things change when you get sick and you have to seek medical care, especially if you’re in a foreign country. The stress most probably gets doubled if your condition requires surgery.

I met my patient in the Emergency room bringing an xray showing fractures in his jaw. After explaining his condition, I advised him for surgery of the fracture.

I saw hesitation in his face, as well as his 6 other friends. And of course, they asked a lot of questions. At one point, they even were contemplating of going back to their country of origin (Israel) to have the surgery done there. I provided him with the necessary paperwork which he then forwarded to his doctors there via email.

The next day, he said to me they’ve decided to have the surgery done by me because his doctors back in Israel agreed with my management. So we proceeded with doing the surgery: open reduction and internal fixation of the mandibular fractures with titanium plates under general anesthesia. The post operative course was unremarkable and I was able to send him home after a few days.

Imagine my big surprise when I saw what they actually had a bouqet of roses and a wine bottle for me when I made my rounds to give my instructions before sending them home. There was even a little note that said ” Doctor, Thanks for the devoted care and all ”

I was so touched! It was the cutest, sweetest thing ever! They said they were just so happy that everything went well. And that ,despite this minor hiccup in their travel, they would still be able to go on with their 4-month backpacking tour around Asia. 🙂

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