Although there are many problems, benefit for some patients occurs

As usual, it was a busy, interesting week. Tamale Teaching Hospital has a catchment area of one and a half million people, resulting in more work than our limited staff can handle. Our otolaryngology care also extends to maxillofacial and plastic surgery since we do not have these specialties.

 The infant mentioned in my previous blog, who required a tracheostomy, presented this  week with shortness of breath. He was referred to Kofo Anokye Teaching Hospital, Kumasi, where there are more specialists and facilities. No word yet.

Three weeks ago, we operated on a fifteen year old boy who had been incorrectly treated for psychological problems, then migraines. He had a large calcified, fungal cyst of the sinuses which extended to the base of his skull.  He presented this week with a headache, vomiting and fever. I thought our surgery for treatment of his cyst may have caused meningitis. However, in actuality he had malaria, the most common disease here.

The child pictured below had an upper respiratory infection which spread to the left orbit forming an abscess.  Seventy five cm of exudate were drained, resulting in improvement and eventual discharge with good vision.

On Presentation

A Few Days Before Discharge

The Difference Between Manhattan and Northern Ghana

Buying donated clothes at the market.

Contrast in shopping between Northern Ghana and Manhattan.

Photo of tetanus child.

This five year old presented with tetanus, spasms of his jaw and neck from toxin produced by the bacteria clostridia tetanus. With excellent care, tetanus has a ten percent mortality rate, but due to the lack of resources has a sixty percent mortality rate here. This child was vaccinated, but breaks in the cold chain may have rendered the vaccine impotent. Tetanus spores commonly enter the body from a deep contaminated wound. This child has an ear infection in which he may have introduced the tetanus bacteria by rubbing with his dirty soil contaminated fingers.

Rope injury to neck of six year-old boy.

This boy was a passenger riding on a motorcycle when a rope across the road caught him in the neck. It caused a partial laceration of his trachea. This super guy allowed me to pass an endoscope without anesthesia through his nose down to examine his injured voice box. With conservative management he did well. Upon discharge, his mother thanked us for saving her son’s life. Better pay one cannot receive.

Follow up on the thirteen month old child who swallowed the clothesline clip necessitating a tracheostomy.Now fine.

Road Traffic Accidents and Ingested Foreign Bodies in Children in Africa

This past week, a modified Benz bus slid on its side injuring five women who were on that side of the bus. Four of the women had their right arms amputated, two also had their ear totally avulsed, and one partially avulsed her eyelid. One was a fifteen year- old girl. Luckily no one was killed. Road traffic accidents in the developing world will soon kill more than malaria, which kills two a minute.

Clothesline clip at 12 0'clock, bottle cap removed at 1 o'clock and other items removed from children.

Children put coins and other objects in their mouth. One thirteen month-old child aspirated a steel clip which was from a clothesline fastener. The plastic ends of the clothesline fastener had broken off, freeing up the metal clip. The two sharp ends of the clip were pointed upward and as it was removed, the sharp ends caught behind the larynx. The child needed a tracheostomy to prevent upper airway obstruction and was transferred to Kofo Anokye Teaching Hospital, Kumasi, where they were able to remove it several days later. This is the third child I have seen who swallowed a clothesline metal clip. I asked the manager of the local Melcom Department store to order clothesline clips which are steel and would not break. He readily agreed. Another practice here is opening soda bottles using one's teeth on the cap. A fourteen year-old boy swallowed the soda bottle cap and it was removed with difficulty.

Woman with loss of right arm and repaired eyelid

Ebola and fish bone ingestion in Ghana

The Ebola epidemic was the topic of this week’s clinical conference. This virus is named after the Ebola river in what is now the Democratic Republic of Congo where the disease was first identified in 1976. It is transmitted by close contact with an infected person’s skin or body secretions. The Public Health Authorities here advise against bringing a suspected patient directly to the hospital where he could contaminate others, but prefer instead that a trained team go out to the suspected patient’s house to properly isolate and transport him to a unit which has the proper equipment and trained health care providers. There have been no proven cases in Ghana.

There are many cases of aspiration and ingestion of foreign bodies in northern Ghana. With modern telescopic equipment and magnified images, the foreign bodies can be successfully removed. However, the local hospitals and clinics lack both x-ray equipment and doctors and the patients present a year later with abscesses, perforations and bleeding. Two cases are typical. A nine year-old boy with a nail in his bronchus presented eighteen months after aspirating it. We were unable to get it out with our first try and while waiting a necessary interim before making another attempt, the patient’s family took him from the hospital and did not return.  We will now try to locate him in order to remove the object and hopefully  prevent his death or having some of his lung removed. In another case, a sixteen  year-old girl presented a week after a fish bone was caught in her throat;  there was  400 ml of exudate in her neck and her larynx and esopha gus were  edematous. The bone could not be located with all the edema.  In two days, after a ten-day course of antibiotics to reduce her infection and edema, a second attempt at removal will be made.

Medical care in Ghana

Even though we saved the lives of several patients in the past few weeks, there were two difficult cases that did not turn out well.

A ten year-old boy from an area north of Tamale was asked by his friends to close his eyes and open his mouth for a surprise. When he complied, a nail was thrown into his mouth that he reflexively swallowed causing him to aspirate it into his lung. He began coughing daily and developed pneumonia resulting in a week of hospitalization. However, not until a year and a half later, was his first chest x-ray taken which showed the object in his lung. He was then referred to our hospital where I unsuccessfully tried to remove the nail that was now embedded in scar tissue. Another attempt will be made in about four days after the swelling subsides.

Another young boy, aged nine, who had developed an abscess in his neck, was initially taken for local treatment to the village herbalist who cut into the infected area. The child began bleeding profusely and after four days was brought to our hospital. He continued to hemorrhage and was transfused with seven units of blood. Unfortunately, our hospital is not equipped to perform arteriography to accurately locate the bleeding site or to embolize the vessel to stop the hemorrhaging. Because he was bleeding to death, we explored his neck and found the origin in the vertebral artery at the base of his skull. Tragically, we could not put an end to the bleeding and the child died.

Tracheostomy in infant with collapsing larynx in Ghana

Three weeks ago I shook the whole bed when sick with malaria, my first attack in nine years working in Ghana. I had been taking malarone faithfully, but I did get mosquito bites while sitting outside one evening the week before. After treatment I was tired for one week and am now back to normal.

Operation Smile and the West African College of Surgeons, ten excellent surgeons in all, each spent one week at Tamale Teaching Hospital doing fifty elective head and neck surgical cases which I had not done because of the volume of emergency cases. It is now necessary to check on these patients’ pathology and refer those who need radiation and chemotherapy.

                                   Four days after tracheostomy tube removal

Four days after tracheostomy tube removal with 75% improvement in breathing and eating

Nine month old failure to thrive infant with tracheostomy for collapsing larynx

Follow up on child with peanut aspiration

The peanut/groundnut mentioned in the previous blog was successfully removed from the infant boy improving his breathing and stopping his cough. However, a repeat chest x-ray still shows a collapsed left lung and bronchoscopy may again be necessary to remove a blocking blood clot or thickened exudate. The peanut was friable, separating as it was being removed and copious exudate and bleeding obscured visibility.

Visiting plastic surgeons released a woman’s contracted, flexed neck by excising her scar tissue and inserting a full thickness skin graft and reconstructed a boy’s mouth damaged from an accidental gunshot wound. Both procedures were beyond my skill and I greatly appreciate their help with my patients. I was also taught better suturing techniques and learned new operations. Medical knowledge and skill is freely and gladly exchanged and I am proud of our health care professionals.

Delayed Treatment

We currently have an eighteen month old male patient who aspirated a groundnut (peanut) four months ago. The mother was roasting the groundnuts when the child picked one up, swallowed it and began coughing. Subsequently, he was brought to their local hospital where he was treated with antibiotics for three weeks, but he did not improve. When he presented to Tamale Teaching Hospital, there were diminished breath sounds in his left lung, and on x-ray the left lung was collapsed. Bronchoscopy will be done to remove the peanut, but after four months, the cartilaginous walls of the bronchus may be destroyed and the left lung may eventually have to be partially or totally removed.

There is also a visiting volunteer team of plastic surgeons, anesthesiologists and nurses who are here to do plastic surgery. Seventy-five patients came to be evaluated, but some require too extensive a surgery to be done at this facility with the equipment and expertise available. Many of our patients present with advanced disease due to their tribal customs and the lack of available care in the areas in which they live.