Strange Postoperative Behaviors in ORL

It is not uncommon for post operative patients to manifest strange behaviors. This is often noted as complications of medications, anesthesia or the pre morbid condition the patient had prior to surgery. Post operative confusion and agitated behaviors commonly seen in the elderly, for example, have been attributed to several factors. 

In the past 10 years, I have experienced 2 cases of young adult females demonstrating what I considered weird post operative behaviors outside the realm of psychosis. 

Case 1: Dateline 2007. A young adult female presented with features of inactive CSOM and persistent annoying ipsilateral tinnitus. Clinical and audiometric analysis showed moderate conductive hearing loss and a 75% pas tensa perforation. The handle of malleus was eroded. So a type 3 tympanoplasty was planned and carried out. Now as was explained to her pre operative, her follow up would entail review on day 3, day 7(for removal of sutures) and day 10(for first graft inspection).  However following discharge home on day 3, she absconded (with aural packs in situ!) only to re-appear on day 20 post op complaining of persistent tinnitus and requesting for referral to 'go abroad' for further care. Examination revealed the aural packs were already removed (by who?). Apparently she had travelled 800 km (Abuja to Lagos) to go and consult another facility where she claimed the sutures and packs were removed!!! Apparently she also had attempted securing entry visa to the particular country to meet with her 'fiancé' and failed prior to coming for surgery, and was planning to use the surgery and the report as a means of authenticating her visa claim. Lesson learned: do not carry out tympanoplasty on anyone whose main worry for coming to surgery is tinnitus

Case 2: Dateline 2014. A young female with left parotid tumor of 8 months duration was referred by her sister to a private facility for review and surgery. Clinical examination showed a firm, smooth, non-tender left tail-of-parotid tumor measuring 4x5 cm, with limited mobility, no skin involvement and intact facial nerve. She had no palpable neck nodes associated. Prior to referral she had FNAC with inconclusive cytology report. U.S. Scan confirmed tail of parotid lesion. She was clinically diagnosed as Pleomorphic adenoma. She has superficial Parotidectomy and as was the practice at that setting, she was handed the specimen for onward transfer to Histopathology at nearby facility. Her follow up after was tied to her collecting and presenting the histology report. However she absconded and represented 4 months later with a pea-size mobile nodular swelling inferior to site of previous surgery, and hyperpigmented overlying skin. Apparently she had gone to collect her histology report, read it and referred herself for oncology treatment. She already had chemo-radiation and only noticed the nodular swelling after completion of therapy, all without the knowledge of the primary surgeon!!! A repeat biopsy with neck dissection was suggested. She again absconded, went to a third facility where the excision of nodular swelling was done. She presented again to the primary surgeon 12 months after with cutaneous involvement. At this stage, all that the primary surgeon could do was referral for palliative oncology care. 

It is, up to the present, perplexing why such bizzare postoperative behaviors could  manifested in otherwise sane, young and educated women. 

Observe the nodular swelling just inferior to hyperpigmented (post XRT) skin area. This was at second presentation after initial default to postop visit. 

Further Reading

1.  Post operative confusion - Guide to management. https://mpatkin.org/surgery_clinical/post_op_confusion.htm

2. Confused about postoperative confusion. 

http://www.jhartfound.org/blog/confused-about-post-operative-confusion/ 

Acceptance and Rejection of Academic Papers in ORL

This past weekend has been one of emotional roller-coaster for me. Of the 3 papers from the studies I was involved in, I got notification of 1 acceptance and 1 rejection. That in itself is no big issue: acceptance and rejection is commonplace in the life of an academic. There are several reasons a paper get rejected (see http://www.deakin.edu.au/__data/assets/pdf_file/0011/269831/reasons_papers_rejected-_24.08.pdf )

It hurts because the reason for rejection is preventable human errors. In an attempt to rush a paper to publication because of the excitement of 'discovery' by the author(s), certain details get overlooked. And the reviewer is often not forgiving of such 'silly inconsistencies' in a scientific paper ( I know because aside from being an author, I've been a reviewer to several journals). So the author is left to lonely whisper of 'I can't believe I could be so stupid' while accepting the decision of the editor. Plagiarism is a serious offence in academics and there is no way the poor editor can discern honest but stupid mistake of a paper's authors from the former. The only times I've cried as an adult were times when my papers get rejected!!  But then, the author picks the gauntlet from his raw data and starts all over again. 

Surgery in The Global Agenda

I got this interesting complimentary access to the Lancet Commission on Global Surgery recently published. 

The Commission was written by a group of 25 leading experts from across fields of Surgery and Anesthesia, with contribution from more than 110 countries. 

The focus of this commission was to examine the case for Surgery as an integral component of health care, with particular focus on resource poor countries where the need is greatest. The entire commission is accessible at www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X.pdf 

The Health Records Challenge of 2015

The Health Record for 2015 Challenge requested that a cost-effective, platform-agnostic electronic health record system be conceived to enable patient fill in registration information themselves on a tablet. The caveat was that such liberty given to patient must not compromise database security or integrity. 

A simple solution to this challenge, as conceived by me is as follow:

1. The back end of the database is Apache server and MySQL. PostgreSQL is an alternative option. For this experiment, I used XAMPP combo. 

2. The front end of the database is html pages interacting with the server through PHP. 

3. Now the tricky part is bringing in the tablet interface to input the data. A simple solution is to use VNC apps communicating via WiFi to 'share' desktop interface. This is like extending a longer hand to the patient to work on the desktop using the computer. The privileges set for the desktop is what is assessed. 

The attached video is a demo of this simple concept:

http://m.youtube.com/watch?v=JmRUOj-nyw0 

Will 3D Printing Significantly Affect our Life & Health?

I spent the last few days (of Xmas holiday) exploring the roles the mobile technology is playing in our health / wellness. Specifically, using my 1-month old iPhone 6 plus (128Gig), I downloaded and tried out a couple of mobile Apps that claimed to be designed to measure Pulse rate, Blood Pressure, and hearing loss. I was amazed at the ingenuity app developers put into making otherwise complicated gadgets for vital signs and hearing loss measurement much simpler using deeper familiarity with how mobile phone hardwares work. And then it was Xmas and people are jokingly asking friends and acquaintances to email / FB / Tweet their Xmas cakes. And then reflecting on the recent news of 3-D Printing of anatomical parts (calvarium, false teeth, hip and knee replacement prosthesis, and ceramic jaws, among others) and juxtaposing that on another more recent news of astronauts on the ISS making a 3-D printed wrench from the email specifications sent from ground station, simply put everything together like missing parts of a jigsaw puzzle: 2015 is likely going to be a year in which the expression 'emailing / Facebooking / Tweeting Xmas or BDay cakes' may move away from the realm of cursory jokes to reality. 

    

References:

1. The Guardian Sunday 24 August 2014. (theguardian.com)

2. NASA Makes 3D Printed Wrench Model Available. (science.slashdot.org )

3. 3D Printing - Wikipedia. en.wikipedia.org 

Can your neck pain make everywhere "spinny"

While the influence of neck position on equilibrium  has been known and documented since 1800s, it is often difficult to assume any relationship in situations of neck pain or stiffness associated with dizziness. 

That was until 1955 when Ryan & Cope described a syndrome of disequilibrium and disorientation in patients with many different diagnoses of neck pathology including cervical spondylosis, cervical trauma, and cervical arthritis. They labelled this syndrome cervical vertigo. 

A flurry of publications on cervical vertigo was to follow. The argument for the existence of this diagnosis was premised on the fact that Proprioceptive input from the neck participates in the coordination of eye, head, and body posture as well as spatial orientation. 

However, the interesting fact is that true spinning vertigo is rarely associated with this disease,making some worker to suggest alternative diagnosis of cervicogenic dizziness for this condition. 

Also interesting is the fact that  while some entities previously defined as cervical vertigo have survived the test of time and may be found in the literature today for example  rotational vertebral artery syndrome, post-traumatic cervical vertigo, and cervicogenic proprioceptive vertigo, others such as cervical sympathetic syndrome (Barré-Lieou syndrome), have been discredited. 

It was also subsequently elaborated that since neck contains mechanisms directly involved in balance control (neck afferents), cardiovascular control (carotid bodies), and purely vascular structures (carotid and vertebral arteries), and since neck movements are also invariably associated with head movements, then perhaps experiencing unsteadiness or vertigo associated with neck movements could be due to a disorder in vestibular, visual, vascular, neurovascular, or cervicoproprioceptive mechanisms.

The interesting aspect of this exposition is that currently there is no consensus concerning how one diagnoses cervical vertigo, and the literature is replete with poorly carried out studies as well as studies containing strange suggestions regarding mechanism or treatment.

As such the publications on "cervical vertigo" has plummeted in the last half decade. 

         

References:

1. J Neurol Neurosurg Psychiatry 2001;71:8-12 doi:10.1136/jnnp.71.1.8

2. Neurologia. 2012 Sep 13. pii: S0213-4853(12)00211-3. doi: 10.1016/j.nrl.2012.06.013

3. Cervicogenic Dizziness. http://vestibular.org/cervicogenic-dizziness

4. Cervical Vertigo. http://www.dizziness-and-balance.com/disorders/central/cervical/cervical.html 

Will HNS replace CPAP in OSAS?

Obstructive sleep apnoea syndrome (OSAS) is characterized by repeated episodes of pharyngeal obstruction during sleep, including airway collapse or narrowing resulting in recurrent airflow cessation. 

Identified risk factors include obesity, male sex, Craniofacial and upper airway anomalies, increasing age, and alcohol consumption. 

Traditional  approach to treating OSAS focused on weight reduction (occasionally easy to prescribe, but hard to comply with), removal of obstructive airway lesions (adenotonsillectomy), palatal implants, mandibular advancement surgery (for retrognathia), our own UPPP (uvulopalatopharyngoplasty)  and of course the popular (GPs) option - the CPAP. The interesting fact is compliance rate with CPAP is just about 40-60% (can you stand mask and tubes coming between you and your spouse while on bed?). 

Recent interest in OSAS focuses on genioglossus muscle as therapeutic target, for simple reason: if you get the tongue out of the way, the oropharyngeal airway blockage is removed. 

Devices that stimulate this muscle directly were demonstrated to improve disease severity in OSAS sufferers. However, the interesting aspect is that such direct stimulation would often arouse the patient!!!

This led to the choice of targeted electrical stimulation of the hypoglossal nerve which is directly motor to the genioglossus fibers, with little or no sensory innervation. 

The Hypoglossal Nerve Stimulation (HNS) system is currently undergoing trials in several countries and may be the next interesting toy for treatment of OSAS, though its current cost puts it far beyond the reach of all but very endowed OSAS cases with mild to moderate ( not severe) OSAS. Maybe for severe OSAS, we are stuck with CPAP for some time to come!!!

References:

1. Health Policy Advisory Committee on Technology - Technology Brief: hypoglossal nerve stimulation for sleep apnoea. http://health.qld.gov.au/healthpact/docs/briefs/WP097.pdf

2. Cure Opin Pulm Med. 2011;17(6):419-424