'Seeing is believing' - gender disparities in otolaryngology-head and neck surgery in Africa: a narrative review

PURPOSE OF REVIEW

Various factors affect otolaryngology - head and neck surgery (OHNS) services in low- and middle-income countries (LMICs); including inadequate infrastructure, limited academic positions, unfavorable hospital research policies, and traditional misconceptions about gender and surgery, among others. Although gender inequalities exist globally, they are particularly pronounced in LMICs, especially in Africa.

RECENT FINDINGS

A comparative narrative literature review for relevant manuscripts from January 1, 2017 to through January 10th, 2024, using PubMed, Embase and Google Scholar for articles from the United States/Canada and Africa was done. 195 relevant articles were from the United States/Canada, while only 5 were from Africa and only 1 manuscript was relevant to OHNS. The reviewed articles reported that gender disparities exist in medical training, authorship, and career advancement. We highlight possible solutions to some of these disparities to promote a more gender-diversified workforce in OHNS in Africa as well as all over the world.

SUMMARY

Additional studies on gender disparities in Africa, are needed. These studies will highlight need for inclusive policies, structured and accessible mentorship programs; through which these disparities can be highlighted and addressed. This will in the long run ensure sustainability of OHNS care in LMICs.

Building a sustainable free flap program in a resource-limited setting: A 12-year humanitarian effort

BACKGROUND

We present a sustainable complex reconstructive program built through 12 years of surgical outreach work at Kijabe Hospital in Kenya.

METHODS

Retrospective chart review and anecdotal experiences.

RESULTS

In 2011, surgeons from a US-medical center performed Kijabe Hospital's first 3 successful free flap surgeries. Since then, they have returned 7 times, performing a total of 31 tumor excisions with microvascular reconstruction. One flap failure occurred that was reconstructed on a subsequent trip. In 2013, a US-trained missionary surgeon and a Kenyan-trained general surgeon began working with the visiting team with the goal of performing these surgeries independently. In 2016 they performed their first independent free flap reconstruction and have since performed 32 independent cases with only three flap losses. Establishing infrastructure, staff education, selective patient criteria, and continuous communication are the factors that enabled the success of this program.

CONCLUSIONS

Establishing a successful microvascular reconstruction program in a resource-limited setting is feasible.

Participant Evaluation of a Multi-disciplinary Oncology Preceptorship Training Program for Oncology Health Professionals from Kumasi, Ghana

A critical shortage of skilled healthcare workers is a primary cause of disparate global cancer outcomes. We report participant evaluation of a multidisciplinary preceptorship program. In collaboration with the city of Kumasi, Ghana, Mayo Clinic and the City Cancer Challenge hosted a preceptorship program for comprehensive multidisciplinary breast and cervix cancer training. A total of 14 healthcare workers from Kumasi received two weeks of training at Mayo Clinic in November and December 2021. Each participant and preceptor were requested to complete an anonymous post-participation survey. Of the 14 trainee participants, 10 (71%) completed the survey. All respondents found the program "valuable and applicable to their clinical practice." Ninety percent reported they were able to "review effective and critical elements in the development and expansion of the multidisciplinary team" and able to "solve practical clinical cases as a team". General themes of satisfaction included: (1) organization and administration, (2) clinical observations and demonstrations, (3) guidelines development, and (4) recognizing the central importance of cultivating a team-based approach. Of the 40 preceptors, 16 (40%) completed the survey. All respondents reported they felt the training would meaningfully "influence patient care in Ghana", that participation "added value or joy to their clinical practice," and all wished to "participate in future preceptorship programs". After a focused two-week program, trainees reported high satisfaction, usefulness from observing specialized cancer care, and value in closely observing a multidisciplinary oncology team. Preceptors reported the experience added joy and perspective to their clinical practice and wished to participate in future programs.

Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa

PURPOSE OF REVIEW

With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option.

RECENT FINDINGS

Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints.

SUMMARY

With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.

Delphi Method Consensus on Priority Global Otolaryngology-Head and Neck Surgery Conditions and Procedures

OBJECTIVE

The objective of this study was to develop an international expert consensus on priority otolaryngology-head and neck surgery conditions and procedures globally for which national health systems should be capable of caring.

STUDY DESIGN

The Delphi method was employed via a multiround online survey administered to attending otolaryngologists in an international research collaborative of >180 otolaryngologists in >40 countries.

SETTING

International online survey.

METHODS

In round 1, participants listed the top 15 otolaryngologic conditions and top 15 otolaryngology procedures for their World Bank regions. In round 2, participants ranked round 1 responses in order of global importance on a 5-point Likert scale. In round 3, participants reranked conditions and procedures that did not achieve consensus, defined as 50% of the round 2 Likert responses being ranked as "important" or "very important." Descriptive statistics were calculated for each round.

RESULTS

The survey was distributed to 53 experts globally, with a response rate of 38% (n = 20). Fifty percent (n = 10) of participants were from low- and middle-income countries, with at least 1 participant from each World Bank region. Ten consensus surgical procedures and 10 consensus conditions were identified.

CONCLUSION

This study identified a list of priority otolaryngology-head and neck surgery conditions and surgical procedures for which all national health systems around the world should be capable of managing. Acute and infectious conditions with preventative and emergent procedures were highlighted. These findings can direct future research and guide international collaborations.

Africa: A window on challenges and opportunities for head and neck cancer

BACKGROUND

Head and neck cancer occurs predominantly in the Developing World, with significant challenges relating to a high burden of disease, late presentation, and poor access to curative and palliative care.

AIMS

This article describes challenges relating to head and neck cancer care in Sub-Saharan Africa.

MATERIAL & METHODS

Educational and training innovations that have been undertaken to improve access to cancer care are presented under the following headings: Open Access Educational Resources African Head and Neck Society (AfHNS); African head and neck surgery fellowship training; AfHNS Virtual Tumor Board; The AfHNS Clinical Practice Guidelines for Head & Neck Cancers in Developing Countries and Limited Resource Settings. Concerns are also raised about universally applicable cancer staging systems.

RESULTS

The challenges facing African patients apply to equally to many other parts of the developing world.

DISCUSSION

The challenges facing African patients apply to equally to many other parts of the developing world.

CONCLUSIONS

For outcomes of head and neck cancers to be improved globally, a far greater investment needs to be made in education and training to improve access to care in developing countries. To make a meaningful global impact on morbidity and mortality related to HNC, clinicians, academic institutions and professional societies in developed countries need to be sensitive to these developing world challenges and should directly engage in improving access to care through promoting open access educational resources, offering specialist and fellowship training, collaborating with appropriate research, and establishing and strengthening centers of excellence in developing countries.

LEVEL OF EVIDENCE

2c "Outcomes research".

Otolaryngology burden of disease and surgical case triage in resource-limited settings: An example from Cameroon

OBJECTIVES

Otolaryngology services worldwide faced an unprecedented demand for case triage during the SARS-CoV-2 pandemic. We propose and apply a novel case-leveling schema in a resource-limited setting. Describing the surgical burden of otolaryngologic disease in this setting may critically inform resource planning to address global surgical disparities.

METHODS

This is a retrospective study of otolaryngology cases performed over a 28-month period (1/2016-4/2018) at a hospital in rural Cameroon. Case details were collated and categorized as a surrogate measure of otolaryngologic disease in resource-limited settings. A case-levelling schema based on temporal urgency and anticipated impact on health was proposed and applied.

RESULTS

1277 cases took place during the study. The largest proportion of cases were head and neck (517, 40%), followed by pediatrics (316, 25%). A four-tiered leveling system was generated: level 1 cases were immediately life-saving; level 2 cases were expected to result in a significant return to functions of daily living, or would prevent future death from cancer; level 3 cases aimed to significantly improve quality of life; level 4 cases were purely elective. Upon application of the schema, most cases were deemed to be level 2 (661, 52%).

CONCLUSION

We use our experience in a resource-limited setting to generate and apply a novel schema to be used for otolaryngology case triage in services facing unprecedented states of emergency such as the SARS-CoV-2 pandemic. This is the first study describing the surgical otolaryngologic disease burden in a resource-limited setting, data which may be used for future resource allocation.

LEVEL OF EVIDENCE

4.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

Head and neck surgery global outreach: Ethics, planning, and impact

Background

Head and neck surgical oncology and reconstruction are uniquely suited to address burdens of disease in underserved areas. Since these efforts are not well known in our specialty, we sought to understand global outreach throughout our society of surgeons.

Methods

Survey distributed to members of the American Head and Neck Surgery involved in international humanitarian head and neck surgical outreach trips.

Results

Thirty surgeons reported an average of seven trips to over 70 destinations. Identification of candidates, finances, on‐site patient care, complications, long‐term post‐surgical care, ethics, and educational goals are reported. We report a success rate of 90% on 125 free flaps performed in these settings.

Conclusions

The effort to answer the call for alleviating the global burden of surgical disease is strong within our specialty. There is a shared focus on humanitarian effort and teaching. Ethics of high resource surgeries such as free flap reconstruction remains controversial.

European white paper: oropharyngeal dysphagia in head and neck cancer

Purpose

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

Methods

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

Results

Twenty-four sections on HNC-specific OD topics.

Conclusion

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

The humanitarian and outreach ethics charter in ENT. Ethics at the heart of missions

Humanitarian action, in the broad sense, including global outreach missions by ENT physicians, has been effective for many years. These volunteer missions have not had any specific regulatory framework, be it medical, social or above all ethical. The testimony of ENT physicians in certain "recipient" countries, in particular during the 2017 Paris Congress of the International Federation of Otorhinolaryngological Societies (IFOS), revealed the importance of adequate coordination between "provider" and "recipient" teams. Several ethical reports have been made, but few specifically focused on ENT outreach. The present review is based on feedback from several missions given to the French Society of OtoRhinoLaryngology and Head and Neck Surgery (SFORL) and IFOS, and on a review of the literature. A specific charter of global outreach and humanitarian missions in ENT has been drawn up. This review is essential for optimizing the sharing of knowledge and training in otorhinolaryngology across the world while respecting mandatory sociocultural and ethical rules.

Is AJCC/UICC Staging Still Appropriate for Head and Neck Cancers in Developing Countries?

By 2030, 70% of cancers will occur in developing countries. Head and neck cancers are primarily a developing world disease. While anatomical location and the extent of cancers are central to defining prognosis and staging, the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) have incorporated nonanatomic factors that correlate with prognosis into staging (eg, p16 status of oropharyngeal cancers). However, 16 of 17 head and neck surgeons from 13 African countries cannot routinely test for p16 status and hence can no longer apply AJCC/UICC staging to oropharyngeal cancer. While the AJCC/UICC should continue to refine staging that best reflects treatment outcomes and prognosis by incorporating new nonanatomical factors, they should also retain and refine anatomically based staging to serve the needs of clinicians and their patients in resource-constrained settings. Not to do so would diminish their global relevance and in so doing also disadvantage most of the world’s cancer patients.

Ultrasound Training for Head and Neck Surgeons in Rural Kenya: A Feasibility Study

OBJECTIVE

To determine the feasibility of training otolaryngologists to perform head and neck ultrasound in low- and middle-income countries over a short timeframe.

DESIGN

Prospective cohort evaluating an ultrasound training course for otolaryngologists in low- and middle-income countries.

SETTING

Surgical training camp for otolaryngologists in semirural Kenya.

METHODS

Participants were prospectively recruited to participate in an ultrasound training course during a 2-week surgical training camp. They performed baseline ultrasound exams (9-item test, 5-point scale) with no assistance, followed by didactic sessions teaching ultrasound techniques. Participating surgeons then performed head and neck ultrasound exams on patients in clinic or in the operating room with direct supervision. Postcourse ultrasounds were performed, and the results of these tests were compared to baseline exams.

RESULTS

Eight surgeons were enrolled out of a total of 13 (62%). Three were attending surgeons (37.5%), 1 enrollee was a head and neck surgery fellow, and 4 were senior residents (50%). Six of 8 surgeons were from Kenya. The mean precourse test score was 25 (range 21-30) compared to a mean postcourse test score of 40 (range 37-45, p < 0.005). All participants significantly improved their scores, with a mean improvement of 16 points (range 10-23).

DISCUSSION

Otolaryngologists are uniquely equipped to learn head and neck ultrasound given their familiarity with the anatomy and pathology in this region. Training physicians without prior experience can be done even over short timeframes. Early training should focus on ultrasound, with later stages of training focusing on pathology.

Community health worker-based hearing screening on a mobile platform: A scalable protocol piloted in Haiti

OBJECTIVE

To establish the feasibility of a systematic, community health worker (CHW)-based hearing screening program that gathers Health Insurance Portability and Accountability Act-compliant electronic data (otoscopic images of tympanic membrane and audiometric evaluation) on a smartphone in an effort to streamline treatment options in resource-limited communities.

METHODS

This is a cross-sectional study in which four schools were screened in Port-au-Prince, Haiti, during in April 2018. A total of 122 subjects (61% female) aged 5-17 years underwent an initial brief audiometric screen followed by a more comprehensive air conduction audiometric evaluation if they failed their initial screen. Participants with more than 35-dB loss in any frequency on their comprehensive audiometric evaluation received endoscopic otoscopy.

RESULTS

Seventy-five percent of subjects (91/122) passed their initial screen. Of those who failed, 9% (4/44 ears) had a severe or profound hearing loss on comprehensive evaluation. Abnormal otoscopic findings (11/36 ears, 31%) included are cerumen impaction (n = 6), myringosclerosis (n = 3), tympanic membrane perforation (n = 1), and tympanic membrane retraction (n = 1). The average duration of the initial testing was 100 seconds (SD = 74 seconds), whereas the duration of comprehensive testing was 394 seconds (SD = 175 seconds). Extrapolating from these data, we estimate that a group of seven trained CHWs could gather formal audiologic and otologic data points for 100 children per hour using this protocol.

CONCLUSIONS

A systematic approach that utilizes local resources (CHWs) and existing infrastructure (cell phones and the Internet) can significantly reduce the burden of hearing healthcare specialists while simultaneously facilitating early diagnosis and management of disabling hearing loss in low-resourced settings.

LEVEL OF EVIDENCE

Level 4.

African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings

BACKGROUND

International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources.

METHODS

Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined.

RESULTS

Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines.

CONCLUSIONS

Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

Global Burden of Head and Neck Cancer: Economic Consequences, Health, and the Role of Surgery

OBJECTIVE

We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes.

STUDY DESIGN

Statistical and economic analysis.

SETTING

Research group.

SUBJECTS AND METHODS

We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer.

RESULTS

Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio (P < .0001; adjusted R² = 0.84). There will be a projected global cumulative loss of $535 billion US dollars (USD) in economic output due to head and neck cancer between 2018 and 2030. Southeast Asia, East Asia, and Oceania will suffer the greatest gross domestic product (GDP) losses at $180 billion USD, and South Asia will lose $133 billion USD.

CONCLUSION

The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.

Reconstructive considerations in low and middle-income countries

PURPOSE OF REVIEW

Surgical mission trips in head and neck surgery are common. There are an increasing number of surgical groups performing complex reconstructions in low and middle-income countries (LMIC). Consideration of reconstructive options that are location and patient specific are critical for optimum patient care and local physician education.

RECENT FINDINGS

The pectoralis muscle regional flap is a versatile and reliable option and has been shown to reconstruct defects in nearly every head and neck subsite. Additional regional flap options described are the supraclavicular island flap and submental island flap. There are 15 published case series describing experience with performing microvascular reconstructions in LMIC. The average success rate was 87.1%. Both loupe and microscope magnification are used.

SUMMARY

Complex reconstructions are successfully being performed in LMIC. Although microvascular reconstruction is being utilized by some groups, local and patient-specific factors should be carefully considered, as many regional and local flap options available provide the same reconstruction benefit while minimizing operating room time, resources, and postoperative care needs.