Perfect surgery=good result =happy patient?

Human beings react differently! Repeatedly this has been brought home to me as an ENT surgeon. A successful result regarding hearing or an improvement in voice or even abolition of a long standing complaint does not mean that the patient and the family will be happy.

I operated upon a 76 year old man for thyroplasty. This sprightly old gentleman had lost his voice 13 years ago due to viral vocal cord paralysis. His voice was down to a whisper. He couldn’t laugh heartily and had become a recluse since he couldn’t communicate well. Using a carved Teflon implant-yes, the same substance on your non-stick pan-
I did thyroplasty surgery on him under local anesthesia. The result was instantaneous- good strong voice was restored and I sent the patient home in the evening. He lived with his son and his wife and their three adolescent children. A week after surgery at the first follow-up, the old man was chirpy, but the son and his wife were unusually morose. They requested that we talk in private. They said the old man was constantly jabbering loudly with everybody in the family and on the phone with relatives and friends. He was almost making up for lost time! The peace at home was disturbed because he had almost become demanding ! Short of asking me to reverse the operation and remove the implant, the son sheepishly asked me whether I could temper down his voice! And I thought I had given a marvellous result!

Recently a 45 year old lady came to the clinic for longstanding hearing loss. She too had become reclusive as her communication gradually suffered. She had begun to have paranoid feelings. She assumed the world was talking against her as she couldn’t decipher what people were saying. She was withdrawn and had also become obsessive. Her husband confessed that she was an ‘extremely difficult person’ to live with. She had conductive hearing loss due to otosclerosis. Stapedotomy surgery (the small stapes bone in the ear is replaced with an implant much like a lens implant for cataract) gave a very good hearing result. Though the husband and children were extremely pleased as there was a perceptible change in her attitude, the patient herself was unhappy. She claimed that she now heard things too loudly- rustling of leaves, a dripping tap and a whirring ceiling fan were disturbing! The family claimed that she had banned everybody from watching television at home as even at the lowest volume it was annoying! I did explain to her that these were sounds that we all heard and gradually her brain and higher functions would get used to this. She did get used to ‘normal’ hearing and eventually after five years came in to get the other ear operated.

My classmate, a brilliant and successful gynaecologist, suffered from nasal and sinus polyps. He complained of headaches, constant smelly nasal discharge and his wife complained that he snored like a locomotive due to his blocked nose. Now, polypsis is to the nose and sinuses, like asthma is to the chest. It can be controlled with medication and in some instances by surgery- but there will be periods of worsening interspersed with periods of remission. Recurrences are common. My friend had been operated five times earlier by my erstwhile boss. When he got his sixth recurrence he chose to consult me and I suggested a radical operation. Fortunately, the major surgery did well for him and he has had a 20 year remission without nasal obstruction, snoring, bad breath etc etc. But whenever he meets me socially, he always reminds me that his nose crusts- he has to remove and expel out crusts- and that he can’t smell. When I ask him whether his nose is open, whether he snores and whether he has ever had his old complaints of headache and bad smell from his nose, he says ‘no no-that is all gone, but….’ . I asked him whether he is better than before and he unhesitatingly says certainly, but….

Gradually, I realised that a great surgical result is not always equated with a happy satisfied patient and family. At times, the patient forgets the original troublesome symptoms that he chose to have surgery for. Often patients try to extract a “promise or even a guarantee” from me regarding successful surgery. When I was younger I used to get upset and tersely give the standard reply that the body is not a washing machine or fridge and guarantees couldn’t be given. Now, a mellow (hopefully ?) mature Dr Karnik says that he will do his best every time; a satisfactory result is a matter of nature’s will.

Prabodh Karnik