Saturday, April 26, 2008

nervous

the professors used to say there are two nerves that give you trouble with a superficial parotidectomy, the facial nerve and the surgeon's nerves. this is true.

for whatever reason you need to do a superficial parotidectomy (removing the superficial lob of the parotid gland, the main salivary gland) the disection is fine and finicky. the facial nerve, the nerve that supplies the muscles of the face, runs right through the gland, breaking up into its tiny branches right in the middle. the operation requires the surgeon to find the root of the nerve where it comes out of the skull and to painstakingly follow it through the gland, identifying each of its branches as he goes. nerve injury is a real consideration. at best this may cause paralysis of a certain area of the face, depending on what branch is injured. but at worst this can cause total paralysis of one side of the whole face. the patient would have a drooping mouth on the one side and an eye that just won't close. this is a disaster as any attempt to smile would result in a weird distorted facial expression. but even worse, the eye would dry out and finally be damaged too.

so when the state hospital asked me to remove a tennis ball sized mass in the parotid gland, i was apprehensive, but eager. it is a fairly rare operation so it is an opportunity to get the chance to do one. after suitable preparation the operation commenced. usually one would find the nerve behind the gland just below the ear where it comes out of the skull, but with the massive size of the tumour, there was just no space to get into this area. i decided to go for plan b. to find one of the branches of the nerve where it comes out of the gland on the other side and work back. this went quite well until...

most surgery text books discuss in detail how to do a superficial parotidectomy. thereafter most text books mention that sometimes the mass is in the deep lob of the gland. they mention how the branches of the nerve get stretched over the mass and maybe even give a hint or two as to how one should go about getting the mass out without damaging the nerve. but you usually get the feeling that the writer is actually saying with a chuckle; 'good luck with that! you're on your own there!'

and this is what i found. the branches of the nerve had been stretched so tightly over the massive tumour that they had formed groves in the mass. i was not amused. i imagined the patient with a distorted one side of the face after the operation. i also imagined the writers of the chapters about parotid surgery all having a good laugh at my expense. i could not remember in that moment why i had decided to study surgery. i regretted it.

and then, because there was no other choice, i slowly went ahead and removed the tumour between two branches of the facial nerve. by the end my nerves were frayed. but i put a good face on it (symmetrical) and told the state doctor to close the skin and let me know later how much function she had left in the nerve. i feared the worst.

the next day, because they hadn't let me know, i phoned the relevant doctor. he informed me the face was fine. the patient had a normal, symmetrical smile and could close her eye normally. then i remembered again why i had studied surgery.

16 comments:

Devorrah said...

Great post. Reminds me of my "why did I want to be a teacher?" moments. Seeing your patient/student smile reminds you why.

rlbates said...

Nice job, Bongi, with both the surgery and the post!

Buckeye Surgeon said...

nice work.

Alice said...

Impressive.

make mine trauma said...

My sole job as assistant during parotid resections (besides retraction)is to be hyper-vigilant for any twitch of the face indicating that the surgeon is too close to the nerve.
It is indeed nerve wracking!

Sid Schwab said...

I did a couple of superficial parotidectomies in training. Never felt confident enough to do any in practice. I guess the old school surgeons would look down on me; and up to you!

HM said...

Very exciting story, Bongi. Believe it or not, the description of the anatomy in the first few paragraphs made good revision for my neuroanatomy exam this Friday, in fact we were a little confused the other day by the branches of the facial nerve when revising in my friends room.

Anonymous said...

bloed, zweet en tranen... maar gelukkig een brede glimlach als apotheose ! sterk !

Anonymous said...

Years ago I had this surgery for a tumor that grew very large. Thankfully it was a benign tumor but the doctor did have to remove the entire gland. I was only in my early 20s and facial nerve damage was a big concern of his. When he came in the room the next day he was very happy I could do most of the things he asked me to do (whistle, etc) the only thing I cannot do is wink my one eye. I can close it when i close both eyes, but I cannot close it by itself. What I have never understood though is that the surgery was on my left side and it is my right eye I can't wink.

Ming said...

Ermmm
What was the histology of the tumour?
Benign?

Bongi said...

benign pleomorphic adenoma

rlbates said...

You've been tagged. http://rlbatesmd.blogspot.com/2008/05/six-word-memior.html

Devorrah said...

Thank you to all the surgeons with steady hands. My teenage son has to have surgery soon at UCSF to repair a venous leak, and I'm grateful for your skill.

Oxford Medic said...

FANTASTIC: well done. I am a medical student, and we recently covered the course of CNVII and its vulnerability during parotid surgery. I admire you so much - for persevering, for knowing what you were doing, and for having the humility to be scared about what might go wrong. Congratulations :)

Anonymous said...

Ok, so I know this blog post is way old. It got cross posted on a patient parotid forum just recently. I am status post 6 months superficial parotidectomy and your viewpoint and humility of the whole process is great. So thanks for that! Love the art too
Keep up your great work.

Roxanne said...

In 2004 I was on the other side of the knife. I had a total parotidectomy for a malignant tumor. Lower left quadrant of my face is numb, but mobile. I have just the slightest bit of crookedness in my smile.

Your blog was resurrected by a member of the Patientsforum www.patientsforum.com. The forum on that site is a great place to get the patients perspective on parotid tumors.

Best wishes and thanks for sharing.