Proud flesh

 

One rarely sees proud flesh outside of the diabetic foot these days, what more in the neck. This patient had a badly infected tracheostomy and was taken of it for a couple of weeks for Pseudomonas infestation. This is the result of a wound desperately trying to fill the gaps with granulation tissue while never being able to epithelialise.

What I had to do was to excise the entire granulating mass with a cuff of skin, all the way down to the strap muscles before redoing the tracheostomy. Wound care is going to be very important for this not to happen again.

Microflap excision

These vocal cords belong to a middle-aged chronic smoker who has suffered from a hoarse voice for close to a year. His wife has been my patient for many years and she decided to bring him to see me. As you can see there is intense leukoplakia on both vocal cords. A CT scan revealed no framework infiltration or extension into the pre-epiglottic space. I had tried several biopsies using a flexible scope but tissue was inadequate.


I put him under for a proper microflap excision today. Seen here is the epithelium and subepithelial layers raised, revealing the vocal ligament and gelatinous lamina propria covering it. One advantage of doing this is that I can directly inspect for deep infiltration and also examine the ventricle and subglottic space (which were free growth).


As the free edge of the vocal cord was not spared by this exophytic lesion, it didn't seem logical to confine my excision to the dorsal surface only. After all, voice-sparing was no longer my concern. More important was to get a good representative specimen. The dilemma/temptation was to get some tissue from the opposite vocal cord but thankfully caution prevailed. Last thing I need is an adhesion anteriorly and ruin his voice forever.

Should the lesion be non-invasive, I can still go in again to do the other side. If it's malignant then some radical modality will be offered. That's the plan.