Operations on the face and neck are extremely delicate and, if done incorrectly, the results can be disastrous. Cambodia has just two surgeons qualified to carry them out. Julie Masis investigates what is being done to rectify the shortage.
Him Chom, 36, lies flat on her back with her eyes open, covered by a blanket in her hospital bed. She cannot speak, although she can still swallow her food. A plastic tube is inserted directly into the bottom of her neck, which is what allows her to keep breathing. A tumour in the back of her mouth has blocked her trachea.
Doctors at the Khmer Soviet Friendship hospital have done a biopsy and found out that Chom’s tumour grows slowly. The good news is that it isn’t cancer. The bad news is that removing a tumour from the throat is a complex operation and there isn’t anyone in Cambodia who can do it.
Chom needs the help of a maxillofacial surgeon – a specially trained dentist who can operate on the face and the neck. According to World Health Organization’s guidelines, a country needs one maxillofacial surgeon per 100,000 people. But Cambodia has only two surgeons who can do these operations. Both were trained decades ago in the Soviet Union and both will retire in the next two years. To replace them – and to fill a huge unmet need – Cambodia’s first master’s program in maxillofacial surgery was set up last year at the International University.
Since there aren’t any professors of maxillofacial surgery in Cambodia, the program operates with the assistance of visiting volunteer maxillofacial surgeons from Australia, Japan, Singapore, and the United States. The first three students will graduate from the course in three years, and two more will receive their diplomas the following year.
“There is a big demand here, that’s why we need more training,” said Dr. Hong Someth, one of the student trainees.
“We do some simple cases, but complex cases we’ve been referring [patients] to Vietnam and Thailand.”
The program, which accepts students strictly based on results of an admission test, will start with a review of basic science and then move to the treatment of patients at the Khmer-Soviet Friendship hospital under the supervision of visiting professors. Students will learn about saliva glands, bone reconstruction with plates, the locations of nerves on the face, post-operative care in an intensive care unit, and everything else they need to know to become specialist surgeons of the head and neck.
According to Barbara Woodhouse, an Australian maxillofacial surgeon who is one of the volunteer professors in the new program, things can and do go terribly wrong when an operation on the face is performed by someone without proper training.
“If they use the wrong types of incision, the patient can lose the ability to move their face because the nerves have been cut,” she said. “If the teeth are put together wrong, they won’t be able to close the mouth and drool saliva, or they might be unable to chew and be on a liquid diet for the rest of their lives.”
Woodhouse says she’s seen all these cases at the Khmer Soviet Friendship hospital. One patient was even left unable to close his eyes after surgery – a condition that will lead to blindness, she said.
Due to the shortage of maxillofacial surgeons, even benign tumours on the face and neck can result in death for Cambodian patients.
Without proper training, Cambodian surgeons could easily reshape the face to normal size but fail to remove the entire tumour, Woodhouse says. As a result, patients end up coming back for more surgery, until eventually their tumour eats away so much of their face that nothing more can be done and they’re sent home to die. These patients could have been cured with just one operation if a trained maxillofacial surgeon had performed it, according to Woodhouse.
One type of tumour, called ameloblastoma, is particularly common in Cambodia. It arises from the cells that form teeth. Patients with ameloblastoma have a huge swelling on their jaw. This swelling can displace the lips and tongue, move into the eye socket and eventually erode into the brain, Woodhouse said.
“We don’t know why it’s more common in Cambodia. It’s something you see in Australia once a year, but in Cambodia once a week,” she said.
Doctors at the Khmer Soviet Hospital see many oral tumours – in part because of betel nut chewing and smoking, they say.
According to Callum Durward, a New Zealand dentist who works in Cambodia, oral cancer is among the top five cancers in Cambodia, yet many local dentists don’t know how to screen for it, and patients aren’t aware that they should seek medical help for an ulcer that won’t go away or a lump in the mouth.
The problem isn’t confined to tumours. In the room beside Chom in the Khmer Soviet Friendship Hospital is Song Vutha, a 22-year-old man who got into a motorcycle accident after having a few beers. He looks OK at first glance, but he can barely open his mouth. The doctors look at his x-ray: they explain that several bones in Vutha’s face are broken and need to be fixed with six metal plates and more than a dozen screws. Without the operation, he will end up with an asymmetrical face which will look flat on one side.
The need for the services of maxillofacial surgeons has been growing in the past few years due to an increase in traffic accidents and falls from construction sites, according to Dr Keat Lysan at the hospital.
“Most traffic accidents involve alcohol. Some passengers don’t wear helmets, especially in the provinces, and some helmets are not good,” he said.
Lysan added that the dental department suffers from lack of funds, since titanium plates and screws are very expensive. Another problem is that the ICU at the hospital is not well equipped, and that many patients can’t afford to pay for x-rays and CT scans. Due to lack of radiation therapy and chemotherapy equipment, the hospital currently cannot treat cancer except the cases that can be cured with surgery.
The other problem is assessing the incidence. Doctors in Cambodia don’t have accurate data on the incidence of oral cancers, facial trauma, cleft palate, or the prognosis for benign tumour patients.The Khmer-Soviet Friendship Hospital’s dentistry department keeps files on patients who stay in the hospital overnight, but they do not add up the numbers to analyse this data.
Graduate students in the new programme will help them do just that.
Three of the students in the maxillofacial surgery programme have already submitted abstracts for their master’s theses, which include the study of cleft palate in Cambodia, the outcomes of benign facial tumour treatment at the Khmer Soviet Friendship Hospital, and the management of facial trauma.
Maxillofacial surgery is not the only area of dentistry where Cambodia lacks specialists.
In fact, this is the case in almost every area of dentistry since there are almost no professors with advanced degrees teaching in Cambodia’s dental schools, according to Durward.
There are no specialists in root canal treatment or periodontics in the country. Cambodia has only two specialists who deal with crowns, bridges and dentures – and Durward himself is the one and only pediatric dentist.
However, improvements are on the horizon.
A few Cambodian dentists are about to graduate from Thai universities with dentistry degrees. The first group of students graduated from an orthodontics master’s program this year, and the first program in root canal treatment started two months ago.
“Cambodia has reached the stage of development where a lot of dentists are interested in improving their skills,” Durward said.
Back at the Khmer-Soviet hospital, Chom is seen by Dr. Masa Iwata, a volunteer surgeon from Japan who specializes in neck tumours. But he is only in Phnom Penh for a few days and will not have the time to operate on her now, he says. She will have to wait until December, with the breathing tube, until he comes back to Cambodia.
Then it’s time for a small surgical lesson: Iwata helps a group of dental students remove a small cyst from another dental student’s face.
“This is where the nerves are,” he says as he draws with his finger on the patient’s face. “This is the safe area. You can cut here.”
Hopefully in three years, when the first group of students graduates from the maxillofacial surgery program, a patient like Chom won’t have to wait for months for an operation.