Air invaded Robert Buchanan’s head and neck in all the wrong places. Two years of persistent medical investigation at Stanford finally gave it a name.
July 11, 2014 - By Sara Wykes
Edward Damrose, MD, chief of the Division of Laryngology, has nearly 20 years of practice under his belt, but what he observed in U.S. Navy Cmdr. Robert Buchanan stumped him. “I had never encountered anything quite like it before,” Damrose said.
When he had done what he could, he sent Buchanan to Jayakar Nayak, MD, PhD, one of Stanford’s top specialists in the workings of the nasal cavity and sinuses. After Buchanan shared his symptoms with Nayak, he, too, was puzzled by the condition.
Nayak, assistant professor of otolaryngology, thought some of Buchanan’s issues might be related to a problem with his left tear duct, so he called Andrea Kossler, MD, assistant professor of ophthalmology and co-director of the Ophthalmic Plastic, Reconstructive Surgery and Orbital Oncology Service at the Byers Eye Institute at Stanford. She looked at Buchanan and agreed with Damrose and Nayak. Whatever it was that was plaguing Buchanan “was something we had never seen,” Kossler said.
What these three expert doctors were chasing was an explanation for air — harmless when it goes where it is needed. Buchanan, however, came to Stanford exhibiting a strange phenomenon: If he pushed his hand along his neck, he could produce a sound like a frog. Air had entered the tissues of his neck and was trapped, causing a painful constellation of symptoms. Before coming to Stanford, Buchanan had gone from doctor to doctor — to dozens, in fact — hoping for treatment, but finding none. Sometimes, he was told, “Learn to live with it.” Sometimes, he was doubted. “I knew myself well enough to know I wasn’t crazy,” Buchanan said. “There was something physiological happening to me.”
What no one could explain was how to find that misplaced air and the tormenting symptoms it caused: an irregular heartbeat and a cluster of issues on his left side — a drooping eyelid, constricted pupil, hypersensitive sinuses, jaw pain and neck swelling.
Buchanan had lived most of his adult life as a U.S. Navy aviator, flying combat jets at hundreds of miles per hour at thousands of feet in the air. By the time he arrived at Stanford in 2012, he had been grounded from flight since March 20, 2006, a day that changed everything for him.
Flying back to the aircraft carrier after a mission in the Middle East, he began to notice some powerful pressure fluctuations in the cockpit of the jet. He was wearing an oxygen mask and, as all aviators do, knew how to react to the symptoms of oxygen deprivation. But what he was feeling was different from lack of oxygen. “I remember the feeling of incapacitation,” Buchanan said, “and then there was some sort of lapse.”
When his awareness faded out, he was flying at about 27,000 feet above the sea and 450 miles from the nearest U.S. Air Force base. At 9,000 feet, Buchanan regained consciousness to the voice of a fellow pilot, flying nearby, repeatedly yelling his call sign over the radio. With help, Buchanan managed to fly back to the aircraft carrier. He remembers getting out of the plane and having a hard time keeping his balance. (Buchanan said he could not share further details about the incident.)
The aircraft carrier’s doctors believed Buchanan had experienced oxygen deprivation, but he didn’t respond to the designated treatment. He was flown to Germany, to the largest military hospital outside the United States. There, doctors determined that Buchanan had suffered from decompression sickness — what divers call the bends. Caused by a rapid decrease in environmental pressure, this phenomenon prevents the body from clearing gases from the lungs. Without quick treatment, those gas bubbles can travel throughout the body. Decompression injuries can be permanent without treatment.
At Stanford, Damrose, associate professor of otolaryngology, evaluated Buchanan and found an air-filled sac in Buchanan’s neck that can appear after gunshot wounds to the neck or fractures of the facial bones. “We felt this was a strange presentation of a common phenomenon,” Damrose said. He believed that air was traveling toward Buchanan’s eye and brain, into his vestibular system — a nest of canals and capsules in the inner ear — and back down into his chest. “Air escaping throughout the body can kill a person,” Damrose said.
‘We could not find a source’
He surgically removed the sac, but Buchanan’s symptoms continued, and the mystery remained. Damrose looked again, this time at Buchanan’s esophagus, lungs and voice box. “Once we knew where the air was not coming from, we were concerned about where it was really coming from,” Damrose said. “We looked everywhere that would be expected, and we could not find a source.”
An extensive search of medical literature and consultations with colleagues at other medical institutions didn’t get them closer to a diagnosis, either. Damrose turned to Nayak. “I needed somebody who could take a fresh look at the evidence and say, ‘This might be something new that we’ve not encountered before,’” Damrose said. Nayak looked at Buchanan’s CT scans and found only changes in his sinuses typical of those caused by years of high-altitude flying.
Bit by bit, Nayak explored the interior cavities of Buchanan’s face and skull endoscopically and with medical imaging.
“There were areas that looked entirely normal, but if you touched them, they were exquisitely tender,” Nayak said. First, he repaired the damage typically caused by high-altitude flying. “Dr. Nayak told me it looked as if a bomb had gone off in my sinuses,” Buchanan said.
A few days later, when Buchanan came to Nayak with a nosebleed, Nayak found its source to be an area that had never before bled in any of his patients. He looked closer and noticed a movement in the tissues and prominent blood vessels at the back of one sinus wall that synchronized with Buchanan’s breathing. Could this be the long-sought entrance of the unwanted air? “I put a Q-tip over the entry spot and miraculously, for the first time in seven years, the air stopped going into Buchanan’s neck,” Nayak said.
All that time, air passage through this small pore — invisible to the naked eye, forced open by the decompression event at high altitude — had created the exquisite sensitivity Nayak had discovered almost by accident.
What happened next was a medical game of Whac-A-Mole: Nayak would block one suspected avenue of air, and another would emerge. He proceeded cautiously, patching, one by one, portions of Buchanan’s sinuses he believed might be responsible for the unwanted passage of air. Nayak cut out one particularly sensitive piece of Buchanan’s sinus and, in a surgical first for him, took other sinus tissue from Buchanan to cover all those tiny and unusual spots where air was making its way through his head and neck. For a month, the somewhat unorthodox fix worked. But as had happened before, a new symptom developed — this time in the tear duct of Buchanan’s left eye. Kossler suspected that the tear duct, abnormally large and convoluted, was allowing air to pass into Buchanan’s nose, into the deep tissues of his face and then to his neck. She also found in the tear duct a pocket of mucosa— soft, moist tissue — that had folded up on itself, trapping air. Kossler removed that to clear the duct.
By this time, the team working on Buchanan had expanded to include several other Stanford doctors in relevant specialties, including anesthesiology and thoracic surgery, all looking for possible corridors through which air could pass into the head, neck and respiratory tract. Finally, up against a timeline the military had set for Buchanan to return to active duty, the team decided to try a set of experiments. Kossler and Nayak surgically created a new, higher tear duct drainage port to bypass his malfunctioning and sensitive tear duct. Damrose then used a laser for a quick corrective surgery to treat an area of pain at the base of Buchanan’s tongue. Then, in a series of separate procedures, Nayak placed human tissue-based graft sheeting between Buchanan’s sinuses and the deep tissues of his face — the fifth and sixth patching procedure in that area of high sensitivity.
“We all agree that we don’t 100 percent know why it all worked, but together it worked,” Kossler said. Nor could they completely pin down definitively just what combination of factors had caused this kind of decompression injury.
Their combined fixes, however, worked well enough for Buchanan to attempt the U.S. Navy simulator tests that would determine if he could fly again.
This winter, eight years after his near-fatal flight and two years after he came to Stanford for help, after a slew of diagnostic tests and more than a dozen incremental surgeries to fix his injuries, Buchanan passed those tests and qualified to fly again. With that step, he can move toward commanding a squadron of fighter pilots. “That’s the pinnacle of an aviator’s career,” he said.
“This case taught me to never, never take it for granted that you know it all,” Damrose said. “The answers aren’t always in textbooks.” The literature search also revealed other patients suffering from similar symptoms, almost all related to decompression injury, he said. “And Cmdr. Buchanan spurred us to keep going.”
“Many of the procedures that we ultimately performed did not have formal names and had not been previously performed,” Nayak said, “so we had to be creative about extending principles of surgery and tissue reconstruction to meet this patient’s most unusual predicament.”
Kossler also acquired some important takeaways. “When you finish your training, you think you know everything,” she said, “but the more you learn, the more you learn that you don’t know everything. In this case, we put our minds together and didn’t give up.”
That will likely make a difference for others. “Through this process, we learned of two other Navy pilots with similar decompression injuries that hadn’t been previously reported,” Kossler said.
This case taught me to never, never take it for granted that you know it all.
Buchanan helped uncover new knowledge about this type of decompression injury. “It had never been in the emergency procedures book before, but now it’s an action item that pilots have to memorize and are tested on routinely,” he said. “The Navy’s done a fantastic job of realizing that this is something we can do better, to help aviators as we put them in harm’s way.”
The Stanford doctors did have to come up with a name for this now-identified decompression injury. It doesn’t exactly roll off the tongue, but it’s finally part of medicine’s lexicon: a sino-cervical fistula.
Nayak is waiting for one small token of thanks he wants from Buchanan. “I want him to call me from somewhere higher than 20,000 feet, from the cockpit of his F-18, doing what he does best and what he loves to do.”
The opinions contained in this presentation are solely those of Cmdr. Buchanan and are not intended to represent the opinions of the Department of Defense, Department of the Navy or any part of the United States Government. Furthermore, the opinions and information contained in this presentation should not be construed as implying an endorsement of any organization by the Department of Defense, Department of the Navy, or any part of the United States Government.
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