This young guy had just been visiting the USA for the sheer fun of it, and had picked up a cold along the way. Travel exposes any of us to new viruses and we all succumb to them no matter how healthy we like to think we are. He shook off the cold, but it left his throat rather raw, and so an abscess formed in one of his tonsils or other pharyngeal lymph glands. The throat is the front door of the body, and is equipped with a lot of immune system tissues which act like bouncers to see off any incoming threats. Sometimes these worthy defenders become massively inflamed under fire and directly threaten the airway. I give you “the quinsy”:
On this occasion the abscess pointed both outwards and inwards. It bridged the outer airway and also the inner fascial planes of the neck, a place it had no business being in. With every cough and sneeze, pus was driven deep into the tissues of his neck and beyond.
Within a few hours the whole of his neck and central chest were suffused with very nasty bacteria producing gas which only insufflated his tissues more than his coughs and sneezes were already doing. This handsome young fellow began to resemble this personage:
I was summoned in to the hospital by my colleague who was clearly out of her depth. I felt no more certain than her of solving the problem. The patient was rapidly choking to death. I asked the attending surgeon if he could perform an emergency tracheostomy under local anaesthesia, but he blanched at the suggestion as the front-of-neck anatomy was so distorted. This left only one option: an awake fibre-optic intubation; this was a procedure I had only read about but never performed.
An intubating bronchoscope was rapidly fetched from theatres and a narrow-bore endotracheal tube was slid over it. I inserted the ‘scope into the patient’s nostril injecting and spraying local anaesthetic all the way. The anatomy was all grossly distorted by the swelling. I found my way to his larynx and trachea by just following the bubbles of exhaled air. Once the tip of my endoscope was in the windpipe I ordered the general anaesthetic drugs be given, and I was then able to railroad the breathing tube over the ‘scope and secure his airway definitively.
At this point the crisis was over. We shipped the patient off to the care of ENT and chest surgeons who were at some distance from our simple district hospital. The patient did well and resumed his studies after a couple of weeks. This is a true story, and I earned a fair few grey hairs during the living out of it.