The child with ear disease/cholesteatoma

An encounter that inspired rural ENT practice

It was a lazy Monday morning, my usual theatre day but didnt have scheduled surgeries that day. One of our medical officers called me for a ward review of a child admitted in our pediatric ward. He reported that there was this child who had a ‘small’ abscess behind the ear and he was planning to go for an incision and drainage. He was thinking of doing it under local/sedation since it was a ‘quick’ procedure and since I was around he needed my opinion. I obliged since I was available and had nothing planned for the day.

The Journey…

Quickly I found my way to the pediatric ward and asked one of our nurses to lead me to the child with an abscess whom they were planning to take for I & D. She was a 5 year old girl who had been referred from one of our remote facilities called Chemolingot and had a discharging ear for the past one year or so. They had tried several medication including some oils from chicken/ brake fluids without success. The father noted that about four weeks ago he noticed a swelling behind the ear which slowly expanded and started discharging pus, he notes that he had tried all the treatments he had been provided with religiously without success. After a few history, i decided to look into the ear. It had frank pus coming out, a huge abscess behind the ear/mastiod region that was discharging pus. She had conductive hearing loss using the tuning folk test. As desired we requested for a high  resolution CT Scan for the temporal bone, PTA and blood work ups as we prepare for theatre. I was new to the rural set-up, fresh from my masters done in a level 6 facility where all the above were available, oblivious of what awaited me. Shock on me- not even one of my request was going to be fulfilled! We decided to refer the patient to an advanced facility about 100KM away, hoping they will be sorted there. I left the facility having done a quick teaching round for the medical and clinical officers. My main aim was to introduce them to chronic ear infections and why it was not as easy as doing a ‘quick I & D’.

One day down the line, i went to the ward to get feedback on our patient, shock on me- they were still around. They had decided that they were not going to be referred anywhere other than going back home if I cant sort their problem. I felt stuck, desperate, and helpless. Everyone seem to be looking for solutions from me, yet i seemed not to have. I quickly decide to consult one of my senior colleagues and our hospital anaesthetist with the view of knowing the options i had at hand given the circumstances we found ourselves in. I knew I needed at a bare minimum a procedure called cortical mastoidectemy. On the other hand there was no imaging available, no drills, no operating miscroscope. I just had to work with what was available! 

Such a scenario in most rural setups. All you got is your skill and knowledge to provide the service to the disadvantaged. In short, we managed to sort the child, luckily it was what we call a cholesteatoma and it had eaten the whole mastoid  bone. All we had to do was to remove the sac wholly and curratage the remnant mastoid cells. It was a success! Two weeks down the line the child was discharged home, healed, dry ear and most of all a happy and smiling father who incessantly kept thanking me for not referring them to the ‘city’. At that moment I reflected on my calling and it was clear that the rural setup was my place of most impact to fellow human beings. Such was a noble encounter that changed my perspective of specialized healthcare practice.