OK, we have a lot to catch up on. My lasts couple of posts have been emotionally-driven, so I’ll try to avoid that with the next couple of posts. Our clinical volume and acuity here has dramatically increased which has contributed to my absence. We also just finished our first campaign of this academic year, so I finally have a little bit of time to reflect.
To get through all the cool clinical things I’ve seen recently, I’ll break them up into 3 categories: Trauma, Head and Neck, and Airway. And, since more and more learners (including my residents here) are starting to follow along with this blog, I’m going to try to do some basic teaching along the way. Sorry for all your Guru otolaryngologists out there that don’t need extra education.
Lets begin with airway!
And stay tuned for a hyena bite injury to the larynx, trachea, and esophagus.
Almost exactly a year ago I came to Mekelle alone to see what I was getting myself into. I was welcomed with open arms and greeted with a teenager with unilateral choanal atresia. This week, I had the opportunity to repeat this case and it was nostalgic and satisfying. I remember struggling with fogging of the zero degree endoscope and the limited reach of the ear drill. It gave me a pitted sense of dread for the frustrations of operating in Ethiopia, but a year later the struggles still exist, but I have become a significantly more patient surgeon. At the completion of this year, it will be interesting to reflect on how I’ve changed. Here is a video of his pretty open choana :). The coolest thing about him is that he was already a pretty elite soccer athlete. I’m curious to see how being able to breathe with two nares will augment his skill.
As an example of how my perspective has changed already, I wonder how I would have approached the next case if I were still in America. A 25-year-old female, currently 8 months pregnant presented with very bothersome nasal obstruction, dysphagia, and difficulty sleeping due to a choking sensation. A quick look into her mouth revealed a translucent nasopharyngeal mass bulging from the nasopharynx. I could understand her discomfort. With every swallow, the mass likely interfered with food bolus mobilization. I could also understand how her airway could become obstructed with deep sleep. Her right naris revealed a clear polyp originating under the middle turbinate. I told her that surgery to remove the polyp correctly would require general anesthesia and because of the risk of anesthesia to her baby, I recommended against it and asked her to wait until after birth. Unexpectedly, she explains that she’d rather lose her baby than spend another night with this polyp. A bit lost for words, I explained I could try to pull it out from her oropharynx. She emphatically encouraged me to proceed. As the video shows, gripping the polyp caused it to burst and release quite a bit of fluid. Expecting her to look up at me furious, she turns and gives me a huge smile of affirmation.
I told her to see me one month after her child was born so we could arrange a proper function endoscopic sinus surgery and removal of this polyp formally. Sometimes the non-traditional management provides acceptable results.
Along the same lines, we had the unfortunate event of a 1.5-year-old baby that presented in the middle of the night with airway distress. The decision from the overnight team was to intubate the child and place a tracheostomy, which was done. But when the team looked into the oral cavity after the trach was completed to explore the child’s etiology, a retropharyngeal abscess was discovered and needle drained. Thus, when I arrived in the morning, we now had a baby that was given an inappropriate tracheostomy and a partially drained retropharyngeal abscess.
If you break down the factors at work that night, it plays out like this. A sick baby presents to our hospital with airway distress. A second-year resident is charged with making the clinical decision. He applies what he has learned in textbooks that the definitive airway is a tracheostomy. Combine this with the resident’s strong desire to perform a pediatric trach (rarely done here) and now the incorrect decision has been deemed as the most appropriate. A quick call to the attending on call confirms the decision process and autopilot kicks in.
Everyone involved has the ONLY pediatric otolaryngologist in the country’s cell phone number on speed dial. It bothers me to no end that I wasn’t consulted. Here, more than in the US, consulting the attending is seen as a sign of weakness of the resident. A perception I am battling to crush. Therefore, a series of bad decisions and lack of oversight placed this baby in a very dangerous situation. Having a tracheostomy as a baby in the united states requires immense support, nursing care and a ton of supplies (including a portable suction). Very little of that is available here and surviving even in the pediatric ICU with a tracheostomy is difficult let alone in the Afar region (where this family is from; 4 hour drive from Ayder…if they can find a car).
If this were an adult, there wouldn’t be much of a problem. Once the infection improved, he would be decannulated and his tracheal injury would heal over. Its not the same for a baby. Tracheal rigidity is created by a series of cartilaginous arches with only one concentric ring at the top. Not only is the back wall of the trachea soft, but the young tracheal cartilage is weak and pliable. The knife that was used to create the tracheostomy bifurcated at least 3 of these arches, robbing them of their innate rigidity. Additionally, every day the tracheostomy remains between that bifurcated cartilage, the anterior wall of the trachea becomes weaker and weaker. Simply removing the tracheostomy after the resolution of the abscess would likely result in respiratory failure from tracheal collapse (tracheomalacia). Not to mention, if the baby survived and it healed, there would probably be significant tracheal stenosis.
Thus, the decision was made to perform a revision transoral drainage, bronchoscopy, nasotracheal intubation/decannulation, and primary anterior tracheal wall repair. Given the lack of literature on the idea or technique, it was important to keep it as simple as possible. The goal was to use submucosal permanent suture to re-approximate the tracheal arches via a transcervical route and to leave the airway stented with a nasotracheal tube to allow for scar formation. The thought is that only with initial scar formation would the anterior wall be strong enough to avoid collapse against the demands of the negative pressure created by the muscles of respiration. After an air-tight closure was confirmed and 5 days of anxiety-provoking intubation, she was extubated in the OR following a clean bronchoscopy. Two days following, she was discharged home to Afar with only a small anterior neck scar to show for her troubles. I’m not sure how this trachea will heal over time, but I hope that she returns so I can follow her closely.
Here are some action shots from that procedure:
Part of the issue in post op care was determining her actual saturation. After extubation she was moving air just fine, but the pulse ox was reading in the 60s and 70s. So we got a new one and put both and two fingers on the same hand:
So, what would have been the correct management? A 1.5 year old presenting with respiratory distress is a medical emergency and the priority is to protect the airway. If saturation doesn’t improve with nasal or face mask oxygen, then it would escalate to non-invasive positive pressure. This device pushes a high volume of air through the nasopharynx into the trachea. It would have been helpful here, but we don’t have that, nor CPAP mask (for a baby). So, the next step would be intubation. If the baby was truly in distress, this would have most likely happened in the ER, but since she wasn’t in immediate life or death danger, she was taken to the OR. Now, if there was time to do this, there was probably time to perform a flexible fiberoptic laryngeal exam that would have discovered the retropharyngeal mass and determined how difficult the intubation would have been. Then, ideally, otolaryngology would perform the intubation with a simultaneous bronchoscopy to diagnose the etiology of respiratory distress. If we had all of this information, only then would the decision for tracheostomy come up. If the consensus was the etiology was untreatable or she would need to be intubated for more than 2 weeks, then perhaps we could perform a trach at this time. But, generally speaking, if a baby can be intubated a trach should not be placed until all information is gathered.
In this case, the abscess would have been identified, drained and maybe the baby would have stayed intubated for one more night. That’s it.
Now this is my job. How can we educate the first line responders to triage these patients appropriately? It requires good lectures, practical learning, practice with bronchoscopy in the OR, and great oversight. Its fine for learners to make mistakes; as a rule, they do. But as teachers, we can’t protect out residents or patients from incorrect decisions if we are not there to oversee the process. Thus, part of my teaching goes towards the staff. They had little to no oversight during their training, so it’s not natural to provide it. Its this self-fulfilling prophecy of passing on a bad practice that prevents institutions from growing as a whole. Breaking this cyclical problem requires outside perspective and change.
As a side note, this baby represented the first intubated pediatric critical airway and gave an opportunity to teach and standardize care in the ICU. We adopted airway sheets we used in Lurie Children’s Hospital to convey essential education and airway management. We had the ICU residents read these points to the nursing staff and parents as well. We also took this opportunity to create similar airway sheets for all the tracheostomies in the hospital. Although it was a difficult situation, a lot of good has come from it.
Lets step away from non-evidenced based medicine and return to the true standard of care. A 27-year-old female who has been battling myasthenia gravis and has been intubated many times presented to us with loud biphasic stridor and increased work of breathing. We could glimpse evidence of tracheal stenosis of flexible laryngoscopy and the larynx was otherwise normal. Thanks to an amazing donation from Partners of Global Hearing, that was completing an excellent week-long mission here at the same time, we were able to perform the first endoscopic airway balloon dilation in Mekelle. The video is better than words, but she had a spiral-like thin band of stenosis centered around the cricoid. Following the dilation with a 14 and 16mm balloon, the airway was certainly improved, but still tight. I’ll watch her closely, but she may require a segment resection in the future.
In the next post I will talk about our encounters with anaplastic thyroid carcinoma and the lessons we learned for its management.