The Global Otolaryngology-Head and Neck Surgery Workforce

Importance

A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed.

Objective

To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories.

Design, Setting, and Participants

A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians.

Main Outcome

The OHNS workforce per capita, stratified by income and region.

Results

Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world's population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally.

Conclusion and Relevance

This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.

Are open access article processing charges affordable for otolaryngologists in low-income and middle-income countries?

PURPOSE OF REVIEW

Open access articles are more frequently read and cited, and hence promote access to knowledge and new advances in healthcare. Unaffordability of open access article processing charges (APCs) may create a barrier to sharing research. We set out to assess the affordability of APCs and impact on publishing for otolaryngology trainees and otolaryngologists in low-income and middle-income countries (LMICs).

RECENT FINDINGS

A cross-sectional online survey was conducted among otolaryngology trainees and otolaryngologists in LMICs globally. Seventy-nine participants from 21 LMICs participated in the study, with the majority from lower middle-income status (66%). Fifty-four percent were otolaryngology lecturers while 30% were trainees. Eighty-seven percent of participants received a gross monthly salary of less than USD 1500. Fifty-two percent of trainees did not receive a salary. Ninety-one percent and 96% of all study participants believed APCs limit publication in open access journals and influence choice of journal for publication, respectively. Eighty percent and 95% believed APCs hinder career progression and impede sharing of research that influences patient care, respectively.

SUMMARY

APCs are unaffordable for LMIC otolaryngology researchers, hinder career progression and inhibit the dissemination of LMIC-specific research that can improve patient care. Novel models should be developed to support open access publishing in LMICs.

Human Papillomavirus-Associated Head and Neck Malignancies in Sub-Saharan Africa: A Systematic Review

PURPOSE

The proportion of head and neck cancers (HNCs) with human papillomavirus (HPV) positivity in sub-Saharan Africa (SSA) is poorly characterized. Characterizing this has implications in staging, prognosis, resource allocation, and vaccination policies. This study aims to determine the proportion of HPV-associated HNC in SSA.

MATERIALS AND METHODS

This systematic review included searches from PubMed, EMBASE, Web of Science, African Index Medicus, Google Scholar, and African Journals Online. All English publications reporting the proportion of HNC specimens from SSA patients who tested positive for HPV and/or p16 were included. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Case Series Studies.

RESULTS

In this systematic review of 31 studies and 3,850 patients, the overall p16 positivity was 13.6% (41 of 1,037 patients tested) with the highest proportion among oropharyngeal cancers (20.3%, 78 of 384 patients) and the overall HPV polymerase chain reaction positivity was 15.3% (542 of 3,548 samples tested) with the highest proportion among nasopharyngeal cancers (16.5%, 23 of 139 patients). Among the 369 HPV strains detected, the most common genotypes were HPV 16 (226 patients, 59.2%) and HPV 18 (78, 20.4%).

CONCLUSION

HPV was found to be associated with a significant proportion of HNC in SSA. The genotypes reported suggest that the nine-valent vaccine and gender-neutral vaccination policies should be considered. Given that these studies may not accurately capture prevalence nor causation of HPV in HNC subsites, additional research is needed to provide a more thorough epidemiologic understanding of HPV-associated HNC in SSA, including risk factors and clinical outcomes.

Management of oral feeding following total laryngectomy around the world: A YO-IFOS international study

BACKGROUND

To analyze worldwide practices regarding the initiation of oral feeding after total laryngectomy (TL).

METHODS

Online survey.

RESULTS

Among the 332 responses received, 278 from 59 countries were analyzed. Our results showed that 45.6% of respondents started water and 45.1% started liquid diet between postoperative days 7 and 10. Semi-solid feeds were initiated between days 10 and 14 for 44.9% of respondents and a free diet was allowed after day 15 for 60.8% of respondents. This timing was significantly delayed in cases of laryngo-pharyngectomy and after prior radiotherapy (p < 0.001). A greater proportion of respondents in Africa and Oceania allowed early oral feeding before day 6 as compared with the rest of the world (p < 0.001).

CONCLUSION

Despite increasing number of publications, there is still a lack of evidence to support early oral feeding. The majority of respondents preferred to delay its initiation until at least 7 days after surgery.

Profile of paediatric tuberculosis mastoiditis - a case series

BACKGROUND

Tuberculosis (TB) otitis media is an uncommon site of extrapulmonary TB and can primarily present as a complicated TB mastoiditis (TBM). This complication is rare in children, even in TB endemic areas but necessitates early identification as delays can lead to severe morbidities. We describe the clinical characteristics as a case series to raise awareness of the condition, and highlight fundamentals related to diagnosis and management.

METHODS

A retrospective chart review of clinical and radiological information of five children with TBM seen at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, over the last 5 years. Variables collected included symptomatology, duration of disease, investigations and management.

RESULTS

All were under 5 years of age and presented with typical features of acute bacterial mastoiditis. Mean duration of symptoms was 12 days (range 3-30 days). Two children had known TB contacts. Two children had pulmonary involvement, one with miliary TB. CT of the temporal bone demonstrated extensive bony destruction of the petromastoid and demineralised ossicles in all cases. Three children had intracranial extension. Four children demonstrated hearing loss between 30 dB and 83 dB. Necrotising granulomatous inflammation was present in the mastoid specimens in all cases. Confirmatory diagnosis was made via GeneXpert polymerase chain reaction (PCR) (2), Ziehl-Nielson (ZN) stain (1) or a positive TB culture (2). Postoperatively, one patient had normal hearing, two patients had mild conductive hearing loss (CHL), one had mild-moderate CHL and one had profound hearing loss.

CONCLUSION

Delays in identification and management result in marked bony destruction and hearing loss. Radiological and surgical findings typical of TBM, therefore, require tissue sampling from the ear for urgent microscopic, PCR and histologic testing, allowing the avoidance of a mastoidectom. In a TB endemic setting, children with typical findings and necrotising granulomatous inflammation on histology should be considered for prompt commencement of anti-TB therapy while awaiting a definitive diagnosis.

Machine Learning Algorithms as a Computer-Assisted Decision Tool for Oral Cancer Prognosis and Management Decisions: A Systematic Review

INTRODUCTION

Despite multiple prognostic indicators described for oral cavity squamous cell carcinoma (OCSCC), its management still continues to be a matter of debate. Machine learning is a subset of artificial intelligence that enables computers to learn from historical data, gather insights, and make predictions about new data using the model learned. Therefore, it can be a potential tool in the field of head and neck cancer.

METHODS

We conducted a systematic review.

RESULTS

A total of 81 manuscripts were revised, and 46 studies met the inclusion criteria. Of these, 38 were excluded for the following reasons: use of a classical statistical method (N = 16), nonspecific for OCSCC (N = 15), and not being related to OCSCC survival (N = 7). In total, 8 studies were included in the final analysis.

CONCLUSIONS

ML has the potential to significantly advance research in the field of OCSCC. Advantages are related to the use and training of ML models because of their capability to continue training continuously when more data become available. Future ML research will allow us to improve and democratize the application of algorithms to improve the prediction of cancer prognosis and its management worldwide.

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".

AfHNS fellowship: Model to improve access to head and neck cancer care in Africa and developing countries

BACKGROUND

Head and neck cancers occur predominantly in developing countries where access to care is poor. Sub-Saharan Africa has <20 head and neck surgeons for >1 billion people and has only two fellowship training programs.

METHODS AND RESULTS

The AfHNS Head and Neck Fellowship is being introduced to accelerate training of African surgeons to improve access to resource appropriate cancer care. By avoiding fixed time-in-training and single training sites, training can be offered at multiple centers in Africa, even with lower patient volumes. It also creates opportunities for accredited international surgical outreach programs to contribute to training.

CONCLUSIONS

Having prescribed reading and appropriate Entrustable Professional Activities that are assessed through Workplace Based Assessment, and having a summative virtual oral examination ensures that fellows are fit-for-purpose to practice in an African resource-constrained setting. Other developing countries are encouraged to adopt a similar approach to expanding head and neck cancer services.

The hidden curve behind COVID-19 outbreak: the impact of delay in treatment initiation in cancer patients and how to mitigate the additional risk of dying-the head and neck cancer model

PURPOSE

The rapid spread of the SARS-CoV-2 pandemic around the world caused most healthcare services to turn substantial attention to treatment of these patients and also to alter the structure of healthcare systems to address an infectious disease. As a result, many cancer patients had their treatment deferred during the pandemic, increasing the time-to-treatment initiation, the number of untreated patients (which will alter the dynamics of healthcare delivery in the post-pandemic era) and increasing their risk of death. Hence, we analyzed the impact on global cancer mortality considering the decline in oncology care during the COVID-19 outbreak using head and neck cancer, a known time-dependent disease, as a model.

METHODS

An online practical tool capable of predicting the risk of cancer patients dying due to the COVID-19 outbreak and also useful for mitigation strategies after the peak of the pandemic has been developed, based on a mathematical model. The scenarios were estimated by information of 15 oncological services worldwide, given a perspective from the five continents and also some simulations were conducted at world demographic data.

RESULTS

The model demonstrates that the more that cancer care was maintained during the outbreak and also the more it is increased during the mitigation period, the shorter will be the recovery, lessening the additional risk of dying due to time-to-treatment initiation.

CONCLUSIONS

This impact of COVID-19 pandemic on cancer patients is inevitable, but it is possible to minimize it with an effort measured by the proposed model.

Inflammatory leiomyosarcoma of the head and neck: Case report

Introduction and importance

Primary sarcomas in the head and neck region are rare. Inflammatory leiomyosarcoma was first described in 1995. The case reported herein is the first reported inflammatory leiomyosarcoma occurring in the head and neck.

Presentation of case

A 37-year-old male presented with a long history of an asymptomatic slowly enlarging neck mass. Examination revealed a firm mass in the lower third of the right sternocleidomastoid muscle. Computerized tomography and magnetic resonance imaging showed a lobulated, well-circumscribed tumour with malignant features. A wide local excision was performed and histopathological examination confirmed an inflammatory leiomyosarcoma.

Discussion

Inflammatory leiomyosarcoma is a recently described peculiar soft tissue tumour with histological features overlapping conventional leiomyosarcoma, and dense lymphocytic inflammation and immunohistochemical reactivity for both smooth and skeletal muscle markers. These are indolent tumours and wide local excision is curative.

Conclusion

This case highlights the importance of considering primary sarcomas in the differential diagnosis of asymptomatic head and neck masses.

•

The differential diagnosis of asymptomatic head and neck masses is broad.

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Non-epithelial neoplasms should be considered.

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Primary sarcomas in the head and neck region are rare.

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Inflammatory leiomyosarcoma is a recently described peculiar soft tissue tumour.

•

This case is the first reported head and neck inflammatory leiomyosarcoma.

Research Equity in Otolaryngology-Head and Neck Surgery

Equitable research collaborations benefit the quality and relevance of global otolaryngology-head and neck surgery research. However, analyses of existing global health literature have shown disproportionate representation by foreign authors. To avert this inequity and improve global otolaryngology-head and neck surgery research, we propose a framework that emphasizes local representation and capacity building in research.

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.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic.

DATA SOURCES

Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols.

REVIEW METHODS

The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management.

CONCLUSIONS

Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results.

IMPLICATIONS FOR PRACTICE

Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

IVORY Guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS): A Consensus on Surgical Videos in Ear, Nose, and Throat

Objectives/Hypothesis

Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology.

Study Design

DELPHI survey.

Methods

Twenty‐seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained.

Results

The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high‐definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ‐specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre‐ and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery.

Conclusions

International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery.

Level of Evidence

5 Laryngoscope, 131:E732–E737, 2021

The role of the University of Cape Town, South Africa in the training and retention of surgeons in Sub-Saharan Africa

BACKGROUND

Sub-Saharan Africa (SSA) has a shortage of surgeon specialists. Many SSA countries lack specialty training programs but South Africa, an upper middle-income country, has several post-graduate surgical training programs. The primary objective of this study was to describe the retention rates of non-South African SSA surgical trainees from the University of Cape Town (UCT) on the African sub-continent. The secondary objective was to describe advantages and disadvantages of foreign surgical trainees on the UCT surgical training programs.

METHODS

This was a two-part cross-sectional survey administered via email between June 1, 2018 and March 1, 2019 to UCT 1) surgical residents and fellows who graduated between 2007 and 2017 and whose country of origin was in SSA but outside South Africa, and 2) UCT surgical division heads.

RESULTS

Thirty out of 78 (38%) trainees responded; 83% (n = 25) were male. There was a 96% retention rate of surgical trainees in SSA, 80% (n = 24) returned to their country of origin after training, 83% (n = 25) worked in the public sector, and 90% (n = 27) in teaching hospitals. Seven out of ten surgical division heads responded. Reported advantages of SSA trainees included more junior staff (n = 5, 71%) and the establishment of SSA networks (n = 4, 57%). Disadvantages included increased training responsibilities for educators (n = 2, 29%) and fewer cases for South African trainees (n = 2, 29%).

DISCUSSION

Retention on the African sub-continent of surgeons who trained at UCT was high. SSA doctors can utilize South African post-graduate surgical training programs until their own countries increase their training capacity. The majority of trainees returned to their countries of origin, utilizing their skills in the public and academic sectors, and contributing to the teaching of more trainees. These training partnerships also contribute to knowledge-sharing and facilitate a regional network of African surgeons. Active recruitment of more female trainees is needed to ensure gender equity.

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.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

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.

Open Access Publishing of Textbooks and Guidelines for Otolaryngologists in Developing Countries

Accessing educational and scientific material is key to improving otolaryngology care in developing countries. Yet current financial models of publishers restrict access to academic information. This article describes the author's experience with self-publishing 2 open access textbooks, Open Access Atlas of Otolaryngology, Head and Neck Operative Surgery and Open Access Guide to Audiology and Hearing Aids for Otolaryngologists, as well as the African Head and Neck Society (AfHNS) Clinical Practice Guidelines for Head and Neck Cancer in Developing Countries and Limited Resource Settings. The author outlines the simplicity, advantages, and popularity of this form of publication and why societies and individuals should embrace open access publishing to benefit especially those studying and practicing in developing countries. He discusses some of the challenges related to open access publishing and calls for medical societies to become involved in evaluating the quality of open access texts and videos for their members.

Intralingual Mucous Extravasation Cyst: An Uncommon Lingual Cyst

OBJECTIVE

We report a rare case of an intralingual ranula. The differential diagnosis, etiology, diagnostic features, and management are discussed.

CASE REPORT

An 18-year-old man presented with a mass that extended along the ventral surface of the tongue and up to the tip. The computed tomography scan clearly defined the extent of a cystic lesion. The pathologic diagnosis of an intralingual ranula was made.

CONCLUSION

Lingual cysts have a varied etiology. Diagnosis hinges on histological examination of the cyst wall. Conservative resection and histological examination is the standard of care.

What is the availability of services for paediatric ENT surgery and paediatric surgery in Africa?

BACKGROUND

Children constitute 50% of Africa's population. Sub-Saharan Africa has the highest under-five mortality rates in the world. This study is the first to document the availability of paediatric ENT and paediatric surgery services in Africa.

OBJECTIVE

To determine the availability of paediatric ENT services in Africa, as well as that of paediatric surgery that would complement paediatric ENT.

METHOD

A descriptive observational study in the form of an online questionnaire was distributed by email to known ENT and paediatric surgeons based in Africa.

RESULTS

Surgeons from twelve of 23 African countries responded to the survey. Seven countries had both ENT and paediatric surgery responses. In 8 of the 11 countries, the number of ENT surgeons per country was<6% of that of the UK, with 1 ENT surgeon per 414,000 people and 1 paediatric surgeon per 1,181,151 people. Ten of 11 countries reported hearing assessments in schools were poor/unavailable. Seventy-three percent responded positively for access to rigid laryngoscopes, bronchoscopes, cameras and fibre optic cables, tracheostomy, anaesthesia and nurse practitioners. Access was reported as poor/unavailable for balloon dilators 73% (8/11 countries); CPAP machines 73% (8/11) and sleep studies 82% (9/11 countries). Flexible endoscopes were available in 50% (4/8 countries), 75% (6/8 countries) had access to a camera, monitor and stack. Thirty-eight percent (3/9 countries) reported no ENT specialists with paediatric training.

CONCLUSIONS

There is a great shortage of paediatric ENT and paediatric surgery services in Africa. More regional training opportunities and health infrastructure for these surgical specialties are needed. Collaborative development of paediatric ENT, surgery and anaesthesia should be considered to improve ENT-related child health in Africa.

Radiological differences between HIV-positive and HIV-negative children with cholesteatoma

INTRODUCTION

HIV-positive children are possibly more prone to developing cholesteatoma. Chronic inflammation of the middle ear cleft may be more common in patients with HIV and this may predispose HIV-positive children to developing cholesteatoma. There are no studies that describe the radiological morphology of the middle ear cleft in HIV-positive compared to HIV-negative children with cholesteatoma.

OBJECTIVES

Compare the radiological differences of the middle ear cleft in HIV-positive and HIV-negative children with cholesteatoma.

METHODS

A retrospective, cross-sectional, observational analytical review of patients with cholesteatoma at our institute over a 6 year period.

RESULTS

Forty patients were included in the study, 11 of whom had bilateral cholesteatoma and therefore 51 ears were eligible for our evaluation. HIV-positive patients had smaller (p=0.02) mastoid air cell systems (MACS). Forty percent of HIV-positive patients had sclerotic mastoids, whereas the rate was 3% in HIV-negative ears (p<0.02). Eighty-two percent of the HIV-positive patients had bilateral cholesteatoma compared to 7% of the control group (p<0.02). There was no difference between the 2 groups with regards to opacification of the middle ear cleft, bony erosion of middle ear structures, Eustachian tube obstruction or soft tissue occlusion of the post-nasal space.

CONCLUSION

HIV-positive paediatric patients with cholesteatoma are more likely to have smaller, sclerotic mastoids compared to HIV-negative patients. They are significantly more likely to have bilateral cholesteatoma. This may have implications in terms of surveillance of HIV-positive children, as well as, an approach to management, recurrence and follow-up. HIV infection should be flagged as a risk factor for developing cholesteatoma.

ENT Outreach in Africa: Rules of Engagement

To address inequality of access to ear, nose, and throat (ENT) care, there must be significant and sustained investment in education and training of surgeons, audiologists, speech therapists, clinical officers, anesthetists, and specialized nurses engaged in ENT in sub-Saharan Africa and other developing nations. Outreach by ENT surgeons from developed countries is essential if we are to address the critical lack of access to ENT care in SSA. However, it should be based on mutual respect, shared values, aspirations, a desire to create a durable and sustainable impact, and internationally accepted best practice. In this article, we propose rules of engagement for outreach projects in SSA and other developing countries to optimize their contributions by making them useful, sustainable, productive, and developmental. These proposed rules of engagement are based on our personal experiences and observations—good and bad—of outreach activities in our countries.

Management of pediatric cholesteatoma based on presentations, complications, and outcomes

OBJECTIVES

To highlight important aspects and paradigms in the management of paediatric cholesteatoma in a developing world setting.

METHODS

A retrospective audit was conducted of paediatric cholesteatomas that underwent tympanomastoid surgery between 2008 and 2012 at the Red Cross War Memorial Children's Hospital in Cape Town. The following was audited: initial presentation; cholesteatoma complications; types of surgery, intraoperative findings and outcomes of surgery in terms of hearing, otorrhoea and recidivism; and the reliability of follow-up and how this might influence the type of surgery.

RESULTS

Fifty-seven children aged 2-13 years with 61 cholesteatomas (4 bilateral) were reviewed. Fifty-five mastoidectomies were done; 11% presented with complicated cholesteatoma. Referrals from primary care were significantly delayed (>6 months) in 76%. Canal wall down surgery was done in 71%. Forty-five percent had improved hearing (within 15dB of better hearing ear) and a further 15% had no or only mild hearing loss. Ossicular chain involvement and ossicles encased in inflammatory tissue were associated with poorer hearing outcomes. Sixty-four percent of ears remained dry. Forty-five percent of the canal wall up, and 23% of canal wall down mastoidectomies had recidivism. Twenty-six percent of patients were lost to follow-up.

CONCLUSIONS

Children are likely to present with advanced cholesteatoma with ossicular chain involvement. The children present with high rates of complications, poor pre-operative hearing and have high recurrence rates post-surgery. Referral from primary health care is delayed. Canal wall down procedures may be appropriate in a setting where patient follow-up is unreliable and access to operating theatre is limited.

Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review

OBJECTIVES/HYPOTHESIS

Pharyngocutaneous fistulae (PCF) are known to occur in nearly one-third of patients after salvage total laryngectomy (STL). PCF has severe impact on duration of admission and costs and quality of life and can even cause severe complications such as bleeding, infection and death. Many patients need further surgical procedures. The implications for functional outcome and survival are less clear. Several studies have shown that using vascularized tissue from outside the radiation field reduces the risk of PCFs following STL. This review and meta-analysis aims to identify the evidence base to support this hypothesis.

DATA SOURCES

English language literature from 2004 to 2013 REVIEW METHODS: We searched the English language literature for articles published on the subject from 2004 to 2013.

RESULTS

Adequate data was available to identify pooled incidence rates from seven articles. The pooled relative risk derived from 591 patients was 0.63 (95% CI: 0.47 to 0.85), indicating that patients who have flap reconstruction/reinforcement reduced their risk of PCF by one-third.

CONCLUSION

This pooled analysis suggests that there is a clear advantage in using vascularized tissue from outside the radiation field in the laryngectomy defect. While some studies show a clear reduction in PCF rates, others suggest that the fistulae that occur are smaller and rarely need repair.

Initiating and developing clinical services, training and research in a low resource setting: the Malawi ENT experience

Background

Sub-Saharan Africa countries like Malawi have a paucity of ear, nose and throat (ENT) data, services and training opportunities.

Objective

To reflect on new Malawian ENT experience and to propose guidelines to poorly resourced countries.

Design

Analysis of data predating and following establishment of ENT services in Malawi.

Results

In 2008 the first and only Malawian ENT specialist established ENT services with external funding. Fifteen clinical officers have been trained and a nurse placed at each outreach hospital. In 2012, 15,284 consultations were recorded: 543 (3.6%) from outreach clinics. Forty-nine percent needed medical treatment, while 45% needed medical advice. Surgery was performed on 2.7% of patients; 21% for foreign bodies in the nose and throat and 18% for foreign bodies and biopsies of ears.

Conclusions

To establish accessible and sustainable specialist ENT services in a poor country requires building on an established local health delivery system, careful planning and investment in personnel, infrastructure, training and data collection.

Buccal fat pad - a simple, underutilised flap

The pedicled buccal fat pad is a reliable flap for the repair of small oral defects. It is durable, easy to harvest and should be considered in settings where access to free flaps is limited and in cases where previous flaps have failed. We discuss a case where this flap was used successfully for closure of an oro-antral fistula. The indications, anatomy and techniques of successful harvest are discussed.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.

Timing of removal of neck drains following head and neck surgery

Studies of the volume of drainage over a 24-hour period that is sufficient to allow for the removal of a neck drain after head and neck surgery have not been reported, and thus the timing of drain removal varies among surgeons and institutions. We conducted a prospective study of 47 patients who had undergone major head and neck surgery to determine the safety and cost-effectiveness of removing a neck drain when the amount of drainage over a 24-hour period fell to 50 ml or less. When the volume reached that point in any given patient, the drain was clamped, and if no fluid collection was observed the following day, the drain was removed. We found that drain removal according to this protocol was successful in 91% of cases, as only 4 patients (9%) developed a seroma following removal. No other complications were observed. In a separate analysis, we retrospectively reviewed the cases of 22 other patients who had undergone surgery at a different institution. Their drains were not removed until the drainage volume fell to 25 ml over 24 hours. It took a median of 1.3 days (range: 1 to 3) for drainage to fall from 50 ml to less than 25 ml over 24 hours. We conclude that drains can be removed safely when the volume falls to 50 ml or less over a 24-hour period. This would result in less morbidity, shorter hospital stays, and significant cost savings.