Why I love my job

Today is Thanksgiving Day in the US. Between this morning’s cases I had some moments to ponder on a consultation I had with a patient a few days ago. One of those conversations that is like a glitch in the matrix, seared into my conscience.


Here I am In Canada, far away on the other side of the hemisphere from where I used to be in Australia. I sat with a patient in clinic. People were speaking French behind the door and there was snow falling outside. The view through the window is magical. This gentleman in his 70s sitting in front of me is 5 years away from his treatment of mucosal melanoma of the oral cavity. For a head and neck surgeon, that is significant. Mucosal melanoma is an invariably fatal disease. It’s rare and it gets less media attention compared to its deadly cousin, skin melanoma. The survival statistics is bad. The five year survival rate is about 20%, that is, four in five patients will not be alive 5 years from diagnosis. After his diagnosis, he underwent a major head and neck resection. This was a major deforming surgery that often last 6-10 hours. Some doctors call operations like these ‘horrendoplasties”. Often the question is asked if the treatment is worse than the disease. With such a poor outlook, why, bring someone through such a massive surgery? He has a bigger chance of being dead than alive in a few months.


Because this week he sat in front of me and said, “I am thankful to be alive.”


Like a ton of bricks, it hit me again. This is why I do what I do. This is why I love my job. This is why I devote so much of my time learning to treat head and neck cancer. This is why I train so long and hard. This is why I do the late nights, the incessant oncalls, the long trips to conferences. This is why I stand for 6-10 hours sometimes to finish the job in the operating room. This is why I rely on a team of head and neck cancer nurses, radiation oncologists, medical oncologists, anaesthetists, speech pathologists, dietitians, etc.


It is an incredibly awesome privilege to hear my patients say, “I am thankful to be alive.”


Happy Thanksgiving Day.


Be thankful.

Christmas Wish For My Patients

Here’s what I’m wishing for my patients:



Waterproof hearing aids that do not rely on batteries.

A tablet taken in the first trimester that would eliminate the development of congenital ear malformation.

A percutaneous, image guided insertion of a cochlear implant under local anaesthesia.

A pill to eradicate otosclerosis and acoustic neuroma.

A trans tympanic suction device that would extract cholesteatoma.

A fibreoptic trans tympanic device to microscopically inspect the middle ear.

An ultrasonic lithotripsy device to eliminate otoliths and BPPV.

A once off nasal spray to cure Meniere’s.

Tissue engineered ear drum.



A once off injection to desensitize the nasal mucosa and ablate polyposis.

A nasal spray that would shrink the inferior turbinate.

A microscopic robotic fibreoptic device for sinus surgery, transsphenoidal pituitary and anterior cranial fossa surgery.

A small cream application to expand and stiffen the nasal aperture and eliminate nasal obstruction.



A once off inhaled medication to prevent tonsillitis, pharyngitis, laryngitis.

A tablet to reduce the size of tonsils and base of tongue to reduce OSA.

An inhaled medication to eradicate vocal cord polyps.

An antiviral tablet to eradicate laryngeal papilloma.

Stem cell and tissue engineered vocal cords.


Head & Neck

An antiviral medication to eradicate Human Papilloma Virus.

A blood test to screen for and diagnose, thyroid and head and neck cancer.

A stem cell application to re-grow a resected tongue, floor of mouth and palate.

A sculptured implantable larynx, maxilla and mandible.

Endoscopic parotidectomy.

A handheld robotic fibreoptic device for transoral tumour removal.

Injections that would kill malignant cells in the lymph nodes.

A tablet that would kill melanoma cells.


Paediatric ENT

A nasal spray to stiffen the larynx and eliminate laryngomalacia.

A perfectly designed and implantable laryngotracheooesophageal complex to treat airway stenosis, laryngeal clefts and tracheooesophageal fistula.

A cream to eliminate arteriovenous malformation.

An inhaled medication to eradicate upper respiratory tract infection and otitis media.


And many other wishes.


But most of all,

That the whole world would stop smoking.


What are your Christmas wish for your patients?

Why did I choose ENT?

Easy. It is the most beautiful of all the surgical specialties. I know, I’m biased. Let me tell you why (and I am about to have a word diarrhea here)

It’s true that ENT does not get a lot of fanfare in Medical Schools. Most medical schools may spend 1-2 weeks on ENT teaching. ENT is often out of sight and out of mind in many curricula. That is, until a doctor does a term in Emergency, Family Medicine, general medical ward or critical care. Suddenly ENT problems are appearing everywhere: nosebleeds, headaches, dizziness, tinnitus, ear infection, hearing loss, sore throat, sinusitis, airway emergency, thyroid problems, sleep apnoea, hoarse voice, tongue lesions, parotitis, dry mouth, etc.

In ENT, we get to deal with the most urgent of all conditions (airway emergency), to the least (facial plastics and cosmetics). We deal with the most common of all surgical operations (tonsils, adenoids, middle ear tubes) and the least (open craniofacial resection, orbital exenteration, tracheal reconstruction, brain stem auditory implants). We deal with newborns (EXIT procedure, choanal atresia repair, laryngotracheal reconstructions) and the elderly (skin cancer, etc.) We deal with medical conditions (headaches, dizziness, ear infections) and surgical conditions (facial trauma, head and neck cancer). We have short ops (middle ear tubes, botox injections) and long ones (head and neck reconstruction, acoustic neuroma excision, skull base resection). We do things beyond our traditional territories: CSF leak repair, middle cranial fossa approach, pituitary tumour, orbital decompression, scapula and fibula free flap. We do some really fine procedures (vocal cord laser, stapedectomy) and some big knife ones (maxillectomy, mandibulectomy, facial reconstruction). We cure quickly (Epley’s maneuver, tonsillectomy) or we care slowly (chronic rhinosinusitis, vestibular migraine). We do old procedures (tonsillectomy) and new ones (bionic ear, transoral robotic surgery). In essence, we do way more than most people think.

And we like it that way. The variety is interesting for us, and no one else knows what we do. We keep it kinda like a magician’s secrets.

Let me list some of the exciting things we do to give you a sample:

Otology (Ears)

Otoplasty, exostosis drillout, canal atresia repair, microtia reconstruction, myringoplasty, tympanoplasty, ossicular chain reconstruction, mastoidectomy, stapedectomy, endoscopic ear surgery, facial nerve decompression, semicircular canal plugging, superior canal dehiscence repair, meningioma, CSF leak repair, acoustic neuroma (transmastoid, middle cranial fossa, restrosigmoid), etc.

Rhinology (Nose)

Rhinoplasty, Septoplasty, turbinectomy, sinus surgery, endoscopic maxillectomy, transsphenoidal pituitary resection, endoscopic dacrocystorhinostomy, sphenopalatine artery ligation, orbital decompression, endoscopic craniofacial reconstruction, nasopharyngectomy, oesteoma drillout, meningioma, CSF repair, orbital abscess drainage, etc.

Laryngology (voice)

Vocal cord microsurgery, vocal cord injection, botox, laser vocal cord surgery, papilloma shave, vocal cord medialisation and lateralisation etc.

Head and Neck Cancer

Skin excision, lip reconstruction, glossectomy, pharyngectomy, laryngectomy, laryngopharyngectomy, maxillectomy, mandibulectomy, neck dissection, tracheostomy, craniofacial resection, rhinectomy, microsurgical reconstruction, thyroid, parathyroid, sialendoscopy, parotidectomy, etc.


Tonsils, adenoids, ear tubes, airway reconstruction, choanal atresia repair, microtia repair, mandibular distraction, laryngolamacia supraglottoplasty, vascular malformation, bionic ears, bone anchored hearing aid, drooling surgery, etc

Facial plastics

Rhinoplasty, mentoplasty, facelift, blepharoplasty, brow lifts, fillers, TCA peels, botox, liposuction, implants, fat transfer, etc


Head and neck trauma, skull base trauma., etc

And those are the surgical cases. There are plenty more non-surgical fun to be had in ENT.

I love ENT because of the variety that I see everyday. A good mix of acute and chronic, medicine and surgery, kids and adults., rare and common conditions, routine and creative procedures, quick and complex cases, and lots more.

We’ve found gold, and that’s a secret that we hide from the rest of the world. Best of all, we get to help some people! Every specialty within medicine and surgery is fascinating. I happened to have found something I dearly love and enjoy.

Field Notes on Tracheostomy Part 2: The Problems

So you’ve got a patient with a tracheostomy tube. And Houston, we’ve got a problem. What do we do? Here are some common problems and basic troubleshooting actions:

Tube dislodgment

This is often a problem in the first few days of tracheostomy when the wound is still fresh and the tracheostomy tract is still not mature or patent. Risk factors: thick neck, big neck, no neck, short tube, insecure tube (not in a sense of low self esteem, but tubes which are not well stitched to skin or well tied), emergency insertion (higher chance of poor technique), patient movement (frequent rolling or bed transfers for procedures, delirium, etc), high ventilation pressures (higher chance of tube migration), frequent coughing. It is always better to watch out for these red flags and do all you can to prevent tube dislodgement. Stitching in and tying down the tube may look uncomfortable but your patient will thank you for preventing an accidental decannulation. What happens if the tube gets dislodged though? Either a complete decannulation or creation of a false passage with the tip of the tracheostomy sitting in the soft tissues of the neck. If the patient is still machine-ventilated, you’ll get the immediate and obvious subcutaneous emphysema from the creation of the false passage. Pull the tube out altogether. Do not attempt to blindly reinsert as further false passage may be created. We’ve lost the airway.

So relax. Take a deep breath. You have some time.

Call for help.

Gently open up the wound or tracheostoma with your thumb and index finger. This is often enough to create a patent passage all the way into the trachea where you can pass a sucker or feed an oxygen cannula. You will need a light to be able to see down the hole, though.

With a tracheal dilator (or a pair of haemostat, artery, mosquito, scissors, nasal speculum, anything available in the trach tray which should be next to the patient), insert the tip into the trachea between the tracheal rings which had been previously cut and open the instrument up to open the airway.

Take another breath.

Suction the area around it and the track into the trachea.

Re-insert a new tracheostomy tube, or insert a flexible sucker or flexible scope into the airway and use it as a guidewire to insert the new tracheostomy tube.

Confirm the position visually with a scope, or with capnography.

If all the above maneuvers fail, and in a true airway emergency, simply put your index finger down the stoma hole until you can feel tracheal rings. Put the tip of your finger into the lumen of the trachea. Then either feed a tracheal dilator by feel into the airway, or feed the new tracheostomy into the airway alongside your finger. That’s the quickest way of re-establishing the airway.

If the tracheostomy tract is old (more than 2 weeks) and mature, usually the stoma is patent and you can reinsert a new tracheostomy tube under direct vision without much trouble.

Tube occlusion

This is probably the most common problem. Tracheostomy tubes can be occluded by blood, or frequently dried mucous and sputum. The use of humidification will reduce the chances. Regular cleaning of inner cannula helps. Regular suctioning with a flexible suction catheter down the lumen of the tube into the trachea also helps to prevent and relieve the tube of obstruction. A small amount of normal saline can be put down the tube to dislodge these crusts. In some cases, granulation tissue may be the obstructing lesion. This can be identified with the use of a flexible scope. Repositioning of the tube and some systemic steroids may help reduce the granulation tissue. Sometimes surgical removal of the offending tissue may be required.


The most fearsome complication is a fistula between the trachea and the innominate artery or any of the great vessels in the superior mediastinum. Note that a tracheostomy tube is only centimetres away from the arch of aorta, brachiocephalic and carotid arteries. Pathologies, surgical interventions, and radiation therapy may distort the anatomy and increase the chance of a fistula. If this was to occur, it could be fatal, and an emergency surgical intervention by ENT, vascular and/or thoracic surgeons is necessary. Tamponading the bleed by inflating the tracheostomy cuff and putting pressure around the stoma is the only temporizing method. The definitive treatment is by surgical exploration, ligation or endoluminal stenting of the artery.

Thankfully however, such a massive bleeding complication is rare. The more common is a small to moderate amount of bleeding that is non life-threatening. Most common cause of bleeding is at the subcutaneous level. Small vessels around the wound site may bleed. With a light source, suction and a little skin retraction, most clinicians will be able to identify a bleeding spot under the flange around the stoma. Several options: inject with local (eg xylocaine) and adrenaline which vasoconstricts the vessels, cauterize with bipolar or silver nitrate sticks, pack with surgicell or kaltostat. Another possible source of bleeding is the thyroid gland a little deeper. Injections don’t work too well here, but cauterization and packing still works.

Cuff leak

Not too uncommonly, the cuff pressure may be difficult to maintain. This can be due to a perforation in the cuff or the inflation line. If this is the problem, then unfortunately the cuff will always leak and a tracheostomy tube change is warranted in a safe elective setting. However, I have found many occasions when the one-way valve of the pilot balloon is faulty. Placing an IV bung on the end of that valve seem to sort that problem quite easily.

Tracheostomy tube change

Often done about day 7 and every few weeks after that as necessary. You will need 3 essential things: a light source (head light or procedural light), aflexible & rigid sucker, and a trache dilator. The older the tracheostomy tract is, the easier the tube change will be, as the tract is often mature, patent and epithelialized. In new tracheostomies, the tissue layers are still soft and may slide and herniate into the tract easily. The bigger the neck, the longer is the distance between skin and trachea, and therefore the more challenging it would be. Always have on standby an oxymetry, an airway exchange catheter (or a flexible suction catheter to guidewire slide tube in and out if necessary), a new stitch and stitch cutter, a trache tape, a new trache tube of the same size and one size smaller (in case there’s significant resistance putting in the same size, put a smaller one in).

Suction the airway, pull out the tube, retract the skin, suck around the stoma, inspect the track, put another one in with an introducer.

Bedside tray

Tracheostomy tube care is reliant on specific instruments. On the trache patient’s bedside there should be a box of tools that would help in routine management and the emergency care should an urgent problem arise. This should include: trache dilators, flexible and rigid suckers, torchlight, new trache tubes of same size or smaller, inner cannulas, gauze, normal saline, pickup forceps, tapes, stitch cutter, scissors.

Tracheostomy patients

Our beloved patients need to be empowered through education. The tracheostomy tube is a marker of severe life threatening illness. The tracheostomy tube is a safe airway but the only airway that the patient has. This is often in the context of patients who need multi-systemic and multi-disciplinary care. Meticulous care is required. Educating the patient in aspects of tracheostomy tube care will go a long way in alleviating their anxieties.

Thank you for looking after the patient with tracheostomy tube.

Field Notes on Tracheostomy Part 1: The Basics

Hello! This is not a comprehensive textbook on how to manage patients with tracheostomies. This is a humble collection of practical brief notes, as requested by a twitter friend. This is a primer. For more extensive information, feel free to consult the big texts.


Someone once said that a tracheostomy tube is a piece of plastic that sits between 12 specialties. I can only count 9 (ENT, ICU, Anaesthesiology, Respirology, Thoracic, Nursing, Speech Pathology, Physiotherapy, Emergency), but I get the drift. Many of us will manage patients with tracheostomy tubes and find it a little uncomfortable. I hope to give you some practical basics to hang on to. There would certainly be tracheostomy protocols in most of the hospital you work with. Do read them.

Tracheostomy is a tracheo-cutaneous airway fistula surgically created to provide direct cannulation of the trachea and therefore direct ventilation of the lower airway. The opening on the skin is called a tracheostoma. (I know, some purists would say that tracheostoma refers only to the permanent stomal opening of the trachea after a laryngectomy- removal of the larynx and separation of the digestive and upper airway tracts – another topic altogether.)

How is it inserted?

Two main ways. Open surgical tracheostomy via skin incision and dissection of anterior neck tissues down to tracheal cartilages. Secondly, percutaneously through needle insertion and guidewire directed dilatation. This is usually assisted by a flexible scope to confirm position intraluminally. There are many percutaneous tracheostomy kits available. As you can imagine, there are advantages and disadvantages to both methods and complications associated with them.

Why tracheostomies?

In the emergency situation: to secure the airway in the context of upper airway pathology (eg. Laryngeal tumours, epiglottitis, Ludwig’s angina, base of tongue cancer, facial fractures, etc.)

In the elective situation: for prolonged intubation and ventilation (ICU patients, long term ventilation and toileting in neuromuscular disorders, etc), as adjunct to other procedures (eg. Major head and neck maxillofacial resection and reconstruction), and congenital airway pathologies (vocal fold palsies, craniofacial syndromes, etc.)

Tube choices

This can be quite confusing, but it’s actually quite logical. There are many options available, and we choose them on the basis of the indications.

First, choose the size in the same way you would choose an endotracheal tube size. Therefore most adult would be a size 7 or 8.

Secondly, do you need a cuff (balloon)? Usually the answer is yes. Having a cuff would provide a seal around the tube for ventilation, and prevent secretions or blood from going down into the lower airway. When would you choose an uncuffed tube? When the patient is able to breathe on their own and maintain their own secretions by swallowing. This is usually when the patient is expected to be tracheostomy tube dependent for a prolonged period.

Thirdly, do you need longer tubes? Depending on the anatomy of the neck, sometimes you need to choose a longer tube. The extension can be on the proximal or distal segment. In an obese neck, we need a proximal extension. In a long thin neck and high tracheostomy, we need distal extension. Some tubes have a flange that can be moved so the proximal extension length can be modified to the patient’s neck thickness.

Easy enough?

Other special features:

Inner cannula: an inner tube or cannula allows the lumen to be easily cleaned regularly. This is important as blood, mucous, and sputum can occlude the lumen easily. Pull it out, wash it out, put it back in. Easy. Note also though that an inner cannula narrows the internal diameter of the tube. The smaller you go, the harder the airflow.

Suction: Some tubes have suction-aid: a small suction hole just above the cuff so that secretions above the cuff can be suctioned. Very useful.

Fenestration: some uncuffed tube provide fenestration opening on the superior surface of the tube. This is useful for vocalization in patients who are tracheostomy dependent. Patients can breathe around and through the tube fenestration to project air into the larynx and oral cavity, and therefore speak.

Materials: most tubes are made of hard plastic. Some are made of flexible silicone to reduce pressure around the neck and trachea. There are even those made of metal for long term tracheostomy dependent patients. Note that different materials will result in different sizes of internal and external diameter of the tube. So a size 8 tube may have different outer diameters based on the materials, which means it may be a little wider and harder to insert.

Tracheostomy care in the first few days

I tell my residents that there are 3 significant potential complications within the first few days of tracheostomy: tube dislodgement, tube occlusion and bleeding. Tracheostomy tube care is critical in the first few days. Positioning of the neck and the tube is important, particularly as patients are being rolled or moved in bed. If the tube is not stitched to skin, a firm tape around the neck is essential. Sometimes firm padding around the flange is helpful. Humidification is important as the humidifying properties of the nose is bypassed in patients with tracheostomy. Humidification prevents dried mucous to become an obstructing plug in and around the tube. The use of inner cannula is recommended and the inner cannula should be washed and cleaned several times a day to prevent crusting and occlusion. Regular suctioning transorally above the cuff and through the tube under the cuff is necessary to prevent excessive secretions from seeping down into the lower airway and interfering with ventilation. Most newly tracheostomised patients are not able to swallow well or clear secretions with the tube in situ. Remember that patients are not able to produce an effective cough with tracheostomy tube in situ. Suctioning takes over the toileting properties of a cough. It is normal for small amounts of blood and mucous to be expressed around the stoma and during suctioning. Simple packing with gauze and suctioning usually resolve most problems.

What about tube dislodgement or excessive bleeding? What about change of tracheostomies? We’ll talk about that in Part 2: Problems.

5 Reasons Why Surgeons are better at Tweeting

I wrote this on 20th November 2011 on my previous anonymous blog. This was meant to poke fun at surgeons and Twitter. what do you think today?

A/Prof Katherine Chretien and team has recently published a landmark study on Twitter Physicians. It was aptly titled “Physicians on Twitter”, published in The Journal of The American Medical Association, February 9, 2011—Vol 305, No. 6, pg 566-568. There are some very interesting statistics there. Definitely an article worth a read particularly if you’re interested in the use of Social Media in Health Care.

There have been many correspondences and blog posts written in response to the article. Most of them have indicated the good progress that doctors and medical professionals are making in utilising tools such as Twitter, Facebook and the like.

When the article detailed the profile of doctors on Twitter, there were a few surprises.

Guess which group of medical specialists Twitter the most?


That’s right! There are more Tweeting Surgeons than other specialties. (Read the article for the rest of the specialties and see how your specialty ranks.) I found this a little interesting because we surgeons often work longer hours and are usually stuck in theatre doing stuff. When do we find the time to Twitter?

So I started to analyse my own tweeting habits, and asked myself why Surgeons tweet more than other specialties.

I think I’ve found 5 reasons why Surgeons are Superior at Tweeting. Here are the reasons:

5. We are always waiting for theatre.

I don’t know how it works in your corner of the world, but here in Australia, taking someone to theatre is like getting a bride to the church altar. We have to book the church, get the certificates signed, get all the equipments, romance the anaesthetists (who are usually the atheists who do not believe the surgery need to happen and withhold their blessings), bla.. bla.. bla… After all the hard work of organising theatre,  we wait till the cows come home or pigs fly. So we surgeons end up having lots of times twiddling our thumbs waiting. We wait, therefore we tweet.

4. We are brief, succinct, and to the point.

We are simple people. We’re not multifactorial. We can’t compute the cosmological reasons why someone should be on omeprazole instead of esomeprazole in some situations. Hence, our simplicity limits our thought processes to 140 characters only. Perfect for twitter.

3. We’re more comfortable speaking out when no one talks back.

The beauty of twitter is that there are so many conversations going on at any one time. It’s like a college party. So many tangential conversations, and in the morning you can’t remember who you’ve talked to last night. Surgeons, being surgeons, love to impress people, and perhaps we like to impress but not really want to be spoken back to. Perfect communication style for twitter. Follow me, and I might follow back, maybe.

2. We are not comfortable socializing with real people.

We like our consults brief,  our operations long, our patients asleep, and our anaesthetists asleep as well. Just like twitter.

And the top reason why Surgeons are More Superior at Tweeting:

1. We have the most outstanding, intelligent and witty one liners.

Perfect for twitter. Some call it sarcasm, others call it irony. We say, witty.

Now if you are a surgeon, any other reasons you are better at Twitter compared to your non-surgical colleagues? If you’re not a surgeon, aren’t we right?

What will greet me this Christmas: ENT Emergencies.

I’ve been told many times, “You’re doing ENT, that’s great. Early Nights and Tennis. Easy life with no emergencies, right?”. I’ve also been asked many times, “Is there such thing as an ENT emergency?”

Well, let me list some of the emergencies I’ve personally been involved with over the last few years. When I’m oncall for 10 days straight over the Christmas & New Year period, these are the emergencies that I will meet at odd hours of the night.

·      Post operative tonsillectomy bleed: a bleed from a branch of the high-pressure external carotid artery into the oral cavity and airway. Picture those horror movies where blood pours out of the nose and mouth. I have had to put my hand in a girl’s mouth and knelt over her body as we got wheeled into the operating room with full on resuscitation.

·      Gunshot wound to the neck. Messy.

·      Gunshot wound to the face. Bloody.

·      Airway obstruction from an invasive thyroid cancer. Emergency awake tracheostomy performed through friable cancer mass. Death stands beside me while the patient in distress stares back at me as I cut her throat awake.

·      Tooth abscess becoming a Ludwig’s angina, compartment syndrome of the floor of mouth. Mouth swollen, can’t be opened.

·      Tongue cancer bleeding into the airway. Cannot intubate through cancer and bleeding tongue the size of cheeseburger in the mouth.

·      Quinsy peritonsillar abscess becoming parapharyngeal abscess and disseminating rapidly inferiorly into the mediastinum. Death.

·      Epiglottitis, cardiac arrest. Emergency specialist and anaesthetist cannot intubate cannot ventilate. Slash tracheostomy in 10 seconds.

·      Massive epistaxis in a haemophilliac, or those on warfarin/Coumadin/aspirin/assasantin/dabegatran, or those with platelet disorders, or arteriovenous malformation.

·      Facial trauma, midface degloving, massive bleeding from ears, noses, eyes, mouth.

·      GCS 5, cerebral abscess and cerebral vein thrombosis from acute otitis media and suppurative mastoiditis.

·      Arteriovenous malformation bleed from an erupted tooth requiring maxillectomy.

·      Airway burns from house fire.

·      10month old child swallowing an opened safety pin, lodged in the larynx next to the carotid arteries.

·      11month old swallowing Christmas ornament, lodged in mid oesophagus.

·      12month old child swallowing a button battery, resulting in perforation of the trachea and oesophagus.

·      Fishbone lodged in the larynx.

·      Lamb bone perforating the oesophagus.

·      Epistaxis from a nasopharyngeal carcinoma, out through the nose, and down into the airway.

·      Lego piece inhaled into the lung.

·      Denture with metal hooks swallowed and lodged between the larynx and oesophagus.

·      GCS7, meningitis due to frontal sinus abscess penetrating into the brain.

·      Eye abscess secondary to bacterial sinusitis. A young lady was blind in 12 hours from a misdiagnosed sinusitis.

·      Acid and alkali ingestion causing airway chemical meltdown.

·      Nasal septal abscess causing bilateral cavernous sinus thrombosis, blindness and death.

·      Carotid artery blowout due to erosion from neck cancer.

·      Relapsing polychondritis and Wagener’s granulomatosis causing cricoid airway obstruction.

·      Kids developing abscesses behind the eye from a bacterial complication of the common cold.

·      Acute mastoiditis from ear infections in young kids, causing facial paralysis and brain abscess.

·      Meningitis and CSF leak from a nasal cancer invading into the brain through the cribiform plate.

·      Retropharyngeal abscess in young kids, causing stiff neck and airway compromise with pus into the airway.

·      Invasive fungal sinusitis/mucormycosis in chemotherapy, transplant and immunosuppressed patients, causing fungal invasion into brain and eyes.

·      Airway obstruction and suffocation in patients with laryngeal cancer.

·      Clothesline injury/hanging injury causing laryngeal fracture and laryngo-tracheal separation.

·      Neonate with airway obstruction from vascular ring, vocal cord paralysis, choanal atresia.

·      Tracheostomy tube eroding into the arch of aorta.

·      Jellybeans, lego, foam in noses that can possibly end up in the lungs.

·      Infected branchial cysts and deep neck space abscess causing airway obstruction.

·      Skullbase fractures, CSF leaks from ears and noses.

·      Sudden deafness and dizziness from brainstem tumour.

·      Airway obstruction from glandular fever.

·      Paradoxical vocal cord movements from whooping cough causing airway obstruction.

·      Neck and airway trauma.

·      And many more.

Season’s greetings!

Wishing you a safe Christmas and praying that none of you would ever need to greet a surgeon this season.