NON-RECURRENT RECURRENT LARYNGEAL NERVE

We do so many thyroid operations that we occasionally see unusual anatomy such as the non-recurrent recurrent laryngeal nerve. In the case illustrated here, there is a right non-recurrent recurrent laryngeal nerve that we astutely (or luckily) identified. The recurrent nerve branches directly off the vagus nerve rather than taking the recurrent route.The biggest problem with this anomaly is that the nerve can be injured during thyroid surgery.

Right non-recurrent recurrent laryngeal nerve. (Note that the retraction is
pulling the vagus nerve to the patient's right and pulling the trachea to the
patient's left)

Normal course of the recurrent laryngeal nerves

Right non-recurrent recurrent laryngeal nerve

PICTURE

I came across this picture, painted by a medical missionary, Kuhn Hong. It depicts a scene at the Mbingo Hospital in Cameroon. When I saw it it reminded me of the Nigerian Christian Hospital and Dr. Farrar, its founder.

DESPAIR

Not all cases end happily. These two children came in very late-one with an encephalocoele and one with hydrocephalus. We referred them to a neurosurgeon.

LITHOPEDION-SMALL BOWEL OBSTRUCTION

This specimen came from a woman with a SBO. We operated and found a hard calcified mass in the omentum with a loop of attached small bowel. If you look carefully you can see an eye (one eye is covered by omental fat), mouth and the femurs. This woman had an intraabdominal pregnancy that died and calcified!

CHECKUP

This lady came for a checkup. Last trip she had a hemimandibulectomy for fibrous dysplasia. She is eating and speaking normally.

FUNGATING BREAST CANCER

This lady is sweet and tough. She always had a smile. She underwent 3 courses of chemo for her breast cancer and then we did a mastectomy. She never complained and was raising her hands up to praise the Lord on day one. We all hope she does well.

THYROGLOSSAL DUCT CYST

This your girl came with a neck cyst that was slowly growing for years. It was a thyroglossal duct cyst. This is not uncommon in Nigeria. I was proud of this case since we were able to remove it without rupturing the cyst. We performed a Sistrunk procedure.

BRENDAN MADU, MD

Brendan Madu is an upper level resident at the Federal Medical Center in Umuahia, Nigeria. I have known Brendan for several years and he is a humble, extremely pleasant chap who is eager to learn surgery. These qualities make him a very easy to teach. In just a few weeks during this past trip, Brendan became quite adept at thyroid surgery. He will be a great surgeon one day and I am glad to have the opportunity to teach him.

Brendan Madu, MD

PAROTID MASS

As I arrived at NCH this trip, I met this young man, Kingsley, on the road. I examined him right then and told him we would help. His case turned out to be a big challenge. He had a massive tumor that extended into the oral cavity. After a radical resection, the left side of the oral cavity was gone. We let him rest for a few days, then returned to surgery. First, we performed a temporalis flap to close the oral cavity. Then we performed a pectorals major myocutaneous flap to provide coverage for the face. Amazingly, it all worked! By the time I left, he was eating a regular diet. He will need radiation therapy.

Large parotid mass

Note involvement of skin

After resection-mandible exposed and left buccal mucosa resected

Temporalis flap raised

Temporalis flap used to reconstruct oral cavity

Pectoralis flap raised

One week post surgery

One week post surgery

BIRTHDAY OUTFIT

This is my Nigerian birthday outfit-made by Eric and Florence Oje.

Author in Nigerian outfit

"Long live the number one doctor"

Eric Oje-the best nurse anesthetist

FIBROUS DYSPLASIA OF THE MAXILLA

Last trip, this young lady came to NCH with a terribly disfiguring right maxillary mass. We removed the tumor. The orbital floor was destroyed so we made a sling of Vicryl mesh to support the eye and transferred a temporalis muscle flap into the maxillary cavity. The pathology was fibrous dysplasia-a non-malignant, but not so benign disease where normal bone is replaced by fibrous tissue. Today she  came to visit us. She is very happy with the results of her surgery. I explained that we could make her look even better with some smaller surgeries but she refused. As long as she is happy, that is the most important thing.

Massive fibrous dysplasia of the right maxilla

Surgical Specimen

Three months post surgery

EXHAUSTION

We have completed 126 surgeries in 17 days at NCH and an additional  43 cases in Ogoni Land! We are all tired!

Ebere Erundu-Surgical Technician

DENTIGEROUS CYST AND TELEMEDICINE

A 16 year old girl came in with a recurrent swelling of the right maxilla. She had surgery several years ago. She arrived with a CT which is unusual. We took a picture of the CT and emailed it to my friend and radiologist John Melvin in the USA. His report: "expansile lesion of the maxilla which may be originating in the area of a tooth root.  The bone appears expanded and remodeled (rather than destroyed) suggesting a relatively slowly growing mass. The first thing that comes to my mind is a dentigerous cyst or periapical cyst with ameloblastoma being my next choice.  Dr. Melvin was correct. We explored her maxilla and found an ectopic tooth with a dentigerous cyst. There was a molar tooth in the lateral aspect of the maxillary wall. We removed the tooth and she recovered without problems. 

CT of maxilla (note image is reversed

Molar tooth in superior, lateral aspect of sinus

Ectopic molar

OGONI LAND

On October 1, Team Camazine joined Dan Kama, President of Professionals for Humanity, in Ogoni Land, for a mini-surgical clinic at the Gokana General Hospital-Terabor. Also participating were Drs. Gbaanador, Dimpka, Jombo, Okpa, Akpanudo, Madu, Nkeonye, and Oje; nurse anesthetists, Wilson, Oje and Uruakpa, surgical technician Micah and photographer Azuka. In two days we did 43 cases-34 hernias, 3 neck cases, 1 splenectomy, 1 ganglion, 3 lipomas and an I&D!!!

This was a free surgical clinic. When we arrived the patients had been pre-screened and more than 500 patients showed up for 2 days of surgery. It was chaos and many fights broke out. 

The surgical team

Chaos-lining up for a surgical slot

More chaos

Dr. Jombo, NCH Administrator, addressing the crowd

Giant abdominal mass-patient referred to NCH for operation

Basic operating room with three tables!

MAXILLARY TUMOR

This young lady came September, 2012 with a right maxillary tumor. We did a maxillectomy and the pathology showed pleomorphic sarcoma. I sent her for radiation but she never went! She came back with a massive growth in the mouth. She could barely breath and it was bleeding so we operated and performed a total maxillectomy. She did great!!! Naturally, she has some problems eating but solved them herself with a bulb syringe.

Pleomorphic sarcoma

After total maxillectomy

Two days after surgery

Feeding with a bulb syringe

BLADDER STONE

We removed a large bladder stone today!

STERNAL TUMOR

The internet has been a problem but I now have a mini-airport station. The connection is slow but adequate. 

The first interesting case to report is a 46 year-old female with a three-year history of a slow growing sternal mass. We were able to get a CT of the chest which showed the mass growing both into and out of the chest with destruction of the sternum. The great vessels appeared to be free from the tumor. We took her to surgery.

As soon as possible, we explored the chest and determined the mass was resectable. The mass extended in to the neck and involved the thyroid so a total thyroidectomy was necessary. In order to close the wound, we performed a right pectoralis muscle flap and reconstructed the lower sternum with mesh. Finally, we mobilized both breasts in order to close the wound. The patient was out of bed the next morning!

Sternal mass

Exposure of the great vessels after resection

Right pectoralis major muscle flap

Flap covering the great vessels

Mesh reconstruction of the lower sternum

Closure

Specimen

Specimen bivalved

One week post surgery