Management of difficult airways in surgical patients at the Port Moresby General Hospital operating theatre and intensive care unit

We report on the results of a retrospective audit of airway management in patients presenting to the Port Moresby General Hospital from 1998 to 2009. Safe and secure airway management can be challenging in the operating room during head and neck surgery. These challenges continue into the postoperative period and can present significant issues to intensive care staff. This series includes many patients with upper airway and upper gastrointestinal malignancy, head and neck trauma, head and neck infections, thyroid pathology and cleft palate. This series highlights the importance of anticipating the possibility of difficult airway preoperatively and modifying the airway management appropriately. We consider that all members of the operating team including surgeons, anaesthetists, intensive care physicians and nursing staff should cooperate and communicate effectively to optimize outcomes for these potentially difficult cases. A proposed airway management algorithm is presented to guide surgical teams performing head and neck surgery in Papua New Guinea and similar regions.

A technique of a one-stage repair of soft tissues in severe bilateral cleft lip without presurgical orthodontics or lip adhesion

The repair of severe bilateral cleft lip is usually done electively at three months after orthodontic appliances have pushed back the protuberant premaxilla to its expected position in the dental arch shelves. Historically the premise that the repair will break down or that the premaxilla will not recede has been challenged. This paper describes a technique that the author has used as a one-stage 'putting it all together' repair without presurgical orthodontics or lip adhesion. The results have been favourable and may bring about a rethink on the tissues' inherent plasticity, the need for early orthodontics and the effect of a muscular strut as an effective substitute for artificial appliances.

An unusual case of severe cervicofacial actinomycosis masquerading as pseudosarcomatous tumour of soft tissues of the head

An unusual case of severe facial and scalp actinomycosis is described. A Papuan man presented with an ulcerative tumour that was progressively spreading on the left face and scalp. Biopsy reported pseudotumour on two occasions and just granulation tissue once. Non-operative treatment was frustrating until a discharge of sulphur granules led to the diagnosis of actinomycosis. The final diagnosis was made histologically after a careful search. This report highlights the usual and unusual points in the diagnosis and management of a case of actinomycosis.

The use of a forehead flap to reconstruct the soft and hard palate after cancer excision

The successful use of a modified forehead flap technique to reconstruct an extensive defect of the soft palate after cancer resection is described. Postoperative swallowing and speech were good and nasal incontinence was short-lived. This can be an addition to the limited techniques available to surgeons working in this challenging area.

Selective surgical management of penetrating anterior abdominal wounds at the Angau Memorial Hospital: a prospective study

Trauma is a leading cause of admissions to the surgical ward in Papua New Guinea (PNG), accounting for about 35% of cases. Of these, 15% of cases are abdominal injuries, of which 19% are penetrating injuries. Selective surgical management of patients with a low-velocity anterior abdominal wound (AAW) is beneficial in some patients.

AIM

To determine if selective surgical management is a viable therapeutic option in PNG.

METHODS

A non-random prospective study of consecutive cases was done on 60 patients with an AAW based entirely on clinical symptoms and signs. The outcome measures were length of hospital stay, morbidity and mortality. Data were analysed using SPSS 10.0 for Windows and Microsoft Excel.

RESULTS

Immediate laparotomy was done on 24 (40%) of cases and 36 (60%) had nonoperative conservative management, of which 6 (17%) failed and went on to have laparotomy on demand. The average hospital stay was 4 days shorter (p = 0.0001) for the nonoperative group, which had significantly fewer complications (p = 0.01). No deaths were recorded in either of the two groups of patients.

CONCLUSION

Selective nonoperative management of stable patients with an AAW with or without omental signs is a safe therapeutic option in PNG.

Two cases of Peutz-Jeghers syndrome presenting as bowel obstruction from intussusception

Two unusual cases of small intestinal intussusception presenting as bowel obstruction are presented. They both had freckle-like pigmentation of the perioral area, palms and soles of the feet with intestinal polyps which acted as lead points in the intussusception. Peutz-Jeghers syndrome was diagnosed. This report highlights the high risk of cancer of the intestines and extra-intestinal sites associated with this interesting but rare condition.

Case report of a thermal burns patient with diabetes insipidus

We report a rare case of diabetes insipidus following fire burn injury. Meticulous fluid balance and the use of carbamazepine resulted in her survival.