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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The Nerve! And Why It’s Important to Choose a Really Good Head and Neck Surgeon

“Doctor, when I undergo a thyroidectomy, will I not be able to talk for a month? My neighbor said so”

“Doctor, when have my mass from the parotid gland removed, will half of my face not be able to move?

Above are just some questions I get from patients before undergoing a procedure. And I understand where the fear is coming from.

The head and neck is the a very delicate area when it comes to surgery. After all, this is where 4 of the 5 senses are located (sense of sight, hearing, smell and taste). Furthermore. it contains the nerves which control the movement of the face as well as the movement of the vocal cords which is crucial to our communication and swallowing, among other things.

Have you tried looking for a needle in a haystack? Well, unless, as a surgeon, you’ve done hundreds of surgeries, as well as applied the things you read in the surgical books, finding these important nerves is like finding a haystack under a big tumor.

See this picture on the left. This is a thyroidectomy procedure (we were removing a goiter from a patient). occupying the upper half of the picture is the thyroid gland being held by Babcock clamps . See the white thing (in the center of the picture) being pointed to with the forceps and the green arrow? That is the recurrent laryngeal nerve inserting at the cricothyroid area to control the vocal cords. The yellow round thing at the end of the blue arrow is the parathyroid gland, which controls calcium production.

With this picture, you see how small these important structures are in relation to the surrounding structures. The nerve in this area typically has a diameter of 1 to 2 MILLIMETERS. And this is a small thyroid gland. it was around 4 x 3 CENTIMETERS. We’ve done surgeries with tumors much bigger (as much as 4 times this size) than this, and still preserved the nerve and the parathyroid, AND still had minimal blood loss. It’s all about knowledge, skills and attention to details.

Below is another picture of anatomy details. This is a parotid cancer (I’ll be writing another blog about this case). On the right side is the diagram of the anatomy of the right side of the neck and jaw. See how delicate neck surgery is with all the great vessels supplying the head as well as nerves controlling tongue movement, shoulder movement, diaphragm movement. Any trauma to these structures will be of detriment to the patient, and may affect him or her for the rest of her life.

This last case is something I will write about in another blog. This is an ear cancer. This is a picture after we removed the tumor from the external ear, drilled down the mastoid bone and traced the facial nerve from bone up to the 5 branches. See the beautiful detail to anatomy, compared to the diagram on the right?

I hope these pictures show how important it is for you to choose a knowledgeable and competent surgeon especially when it comes to head and neck procedures.

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Have You Seen a Hole in Front of Your Ear?

ENT Manila, Philippines - pre-auricular sinusThis is a common congenital anomaly called a PRE-AURICULAR SINUS.

You see, when you were just a fetus in your mother’s wombs, you looked like a tadpole. And the external ear or the pinna, looked like gills.

These “gills” are called the Hillocks of His which are seen at around the 6th week of gestation. These Hillocks then fuse together to become our external ear.

An incomplete fusion of these Hillocks results in any ear deformity, including a PRE-AURICULAR SINUS.

Pre-auricular sinuses are frequently seen on routine physical examination by an ENT in Philippines as small holes in front of the external ear.

These holes are openings into a narrow tube or duct which connects into the perichondrium (or the thin cover) of the ear cartilage.

Most people with pre-auricular sinuses are asymptomatic. Only one third of persons are aware of their malformations.

However, some patients may have pus or foul-smelling discharge from the small opening. These draining sinuses are prone to become infected.

Infections of these pre-auricular sinuses present with swelling of the area anterior to the ear and ulcerations. Often, these ulcerations are treated with antibiotics and the pre-auricular sinus, which is the source of the infection, is neglected. When the infections are recurrent, the area becomes scarred and deformed.

[This is a picture of a 10 year old I operated on for a chronically infected pre-auricular sinus.]

Once a patient has infection of the sinus, antibiotics must be started. Other laboratory studies such as culture of the abscess may be done to make sure the pathogens are covered for by the given drugs.

Surgical removal of the sinus tract is advised once infection occurs because the risk of repeated infections is high.

Surgery involves COMPLETELY removing the opening and tracing the duct to the infected pouch, removing even part of the ear cartilage is advocated. Incomplete excision results in recurrence as high as 43 % in some studies.

It is important therefore, that you should consult a skilled head and neck surgeon for removal of your pre-auricular sinus.


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Q-tipSee the image on the left? Yup, the ever famous q tip! This little thing is used by thousands, even millions worldwide to clean their ears everyday.

But, did you know that using Q-tips in your ears can actually do you more harm than good?

Take a look at our skin. Everyday it gets dry, cells are being replaced by new skin cells everyday , we take a bath everyday just to keep our skin clean.

We also have similar skin lining our ear canal.

So, the question is do you have to clean your ears everyday , as you do to the rest of your skin? The answer is NO. you do not “NEED” to clean your ears. And the reason is EARWAX. ear diagram

A lot of people view earwax as just dirt in the ear canal. The fact is earwax helps protect your sensitive ear canal by trapping dirt, sand, insects and other foreign substances.

Earwax is the ear’s moisturizer, it helps prevent excessive dryness in the ear canal and on the outer ear. 

It also repels water.

And, it acts as an antibacterial agent- it helps prevent infection.

Think about it, we already have this built-in self-cleaning, moisturizing, anti-bacterial mechanism in our ears, and yet everyday, we strip our ears of it.

ear canal diagramWhat is worse, is that by using q-tips, if you are not removing the earwax, you are actually pushing it in, into an area, where it is not able to clean itself. Unlike skin in the rest of the body which is replaced in an upward direction., meaning old cells slowly go up where they eventually end in the top layer and easily removed by friction, the skin in the ear canal goes out by MIGRATION: meaning skin goes from the center of the ear drum, to the edge of the eardrum and then goes out slowly to the ear canal. This skin as well as other debris is mixed with the oil and secretions from glands in the outer 1/3 of the ear canal is what forms the earwax.

When you push the earwax in and it builds up inside the canal, it may be more prone to accumulate fungus, bacteria which may cause ear infections

This can also block your hearing and cause deafness, or it may eve n rupture your eardrum

Another reason why you should not clean your ears is because unlike the skin in the rest of the body which is 5 layers thick, the skin in the inner 2/3 of the ear canal is very very thin and is surrounded by bone. By cleaning your ears with q-tips you may be creating micro-abrasions, as well as releasing histamine which causes itchiness. As a reflex of course, when something is itchy, you scratch it again. By doing that, you are actually creating a viscious “scratch-and-itch” cycle. And that pattern has to stop.

It is best to see your ENT doctor so you can have your ears cleaned by a medical professional.eustachian tube ear diagram

In summary, the earwax is the ear’s self cleaning mechanism. It is a water repellant, a moisturizer, and an anti bacterial agent. And this is what happens when you use q-tips to clean your ears:

1. You make our ear canals dry

2. You push the earwax in

3. You may block your hearing,

4. You may rupture your eardrum,

5. You may cause ear infections, and,

6. You create viscious “scratch-and-itch” cycle in your ear.


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A patient came into the emergency room complaining that he could not swallow. This is his back story:

He was 21 years old and had 2 missing front teeth. Of course, he wanted to look good and wanted to get dentures. The problem was he lacked funds. Upon the advice of a friend, he went to a “technician” who allegedly sold cheap dentures. Everything was all right until one day, he fell asleep and ACCIDENTALLY SWALLOWED his dentures.

At the emergency room, laboratory work up and imaging studies were done. He was then rushed to the operating room for emergency esophagoscopy (an operation where a tube is passed via your mouth to visualize the esophagus or the swallowing tube). During the operation however, there was difficulty in removing the dentures because the sharp and jagged edges were buried so deep into the mucosa (inner lining) of the esophagus. A skin incision was subsequently made anterior to the sternocleidomastoid muscle in the neck to make a lateral pharyngotomy approach (making an incision on the muscles to the side of the esophagus) to removing the dentures stuck into his neck.

MORAL LESSON:Philippines ent

  1. Always remove your dentures before sleeping.

  2. Never sacrifice the quality of your dentures for the price. It may end up costing you more.


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