Patient Profile: Mr. A’s Laryngectomy

Left to right: One of Mr. A’s 50 children, Mr. A, Dr. Mitchell, Dr. Aboiyar (ENT apprentice)

Mr. A is a 65 (best guess since birth dates are often not recorded) year old male from the Tiv tribe. He was evaluated by a local ENT surgeon and found to have cancer of the larynx. The surgeon recommended laryngectomy, which is the surgery that removes the voice box and leaves a hole in the neck to breathe through. Another option is radiation therapy which is the usual initial therapy in the states, and has very good results. Radiation is not as controlled or as effective in Nigeria. Mr. A decided to have radiation in March 2008. It did not work and his cancer returned and was blocking his airway by July 2008. He was to have surgery at the University Hospital, but there were logistical problems and the surgery was going to be postponed until September or even November. The ENT surgeon asked if we could do the surgery here at Evangel Hospital. I agreed and I assisted him in the laryngectomy in late August.
Unfortunately things have not gone well and the patient has had multiple complications. His wound completely broke down and opened up. His feeding passage (pharynx) opened up as well. Much of this was a result of the radiation which causes poor healing in the tissues that have received radiation. Mr. A has gone back to the “main theatre” (operating room) four times to try and close the wound. We have taken tissue from his chest and put it up into his neck to try and cover the wound. He has remained in the hospital for 5 weeks. I have been seeing him daily. The University ENT surgeon has left the care to me. He did not foresee the long hospital stay, and the ENT surgeon has actually gone to India for a six week training course. Fortunately one of Mr. A’s sons has been staying with him for the entire time and doing excellent nursing care. The son has been doing the tube feeding, dressing changes, tracheotomy tube cleaning, and even monitoring his oxygen saturation with a pulse oximeter.
We are discharging Mr. A to his home, though he is not healed. He lives in a village about a 6 hour drive from here. He was supposed to go home yesterday, but his hospital bill is 200,000 Naira ($1,800), and he did not have the money on him. A patient or family member must pay in cash in full before the patient is allowed to leave the hospital. If the patient dies, the hospital will hold the body until the bill is paid by the family. Fortunately Mr. A is a relatively wealthy farmer. He has made a lot of money from his crops over the years. He has had seven wives, four are now living. He has 50 children that his accompanying son is aware of. One of his sons is coming later today to pay the bill. Mr. A will return to our clinic in 2 weeks. We pray that some healing will have taken place.

Michael Mitchell, MD