Addressing Unmet Surgical Needs in an Underserved Nigerian Community: Report of a 'Town and Gown' Initiative

BACKGROUND

Access to quality and timely care prevents unnecessary deaths and morbidity from potentially curable surgical diseases. This study describes the magnitude of unmet surgical needs in a Nigerian community and describes the experiences garnered during a surgical outreach organized by a tertiary institution in an underserved community.

METHODS

This is a descriptive study highlighting details of a surgical outreach to a community in south-Western part of Nigeria. The project was based on a collaboration between a University Teaching Hospital (gown) and the community (town). Details of the patients' demographic and disease characteristics as well as barriers to seeking medical care were obtained. The operational workflow, treatment offered, and outcomes are highlighted. Results are presented as descriptive statistics.

RESULTS

Over a two-day period, 83 out of 3,056 patients who were screened had surgically treatable conditions (2.7%), predominantly hernias (37, 46.6%), goitres (13, 15.7%) and soft tissue swellings (9, 10.8%). The majority were adults (56, 67.5%) while 27 (32.5%) were in the paediatric age group. The mean duration of symptoms was 8.64 months ± 9.5 months. About half of the patients (46.9%) had never visited a medical facility on account of their index illnesses. Lack of funds was cited by many patients as the main reason for having not presented at a hospital. Sixty-three surgical operations were performed with no peri-operative adverse events.

CONCLUSION

Lack of financial access was the major barrier to surgical care in the sampled community. Moving from 'gown to town' helped address a significant proportion of the unmet needs over a relatively short period. Tertiary hospitals can provide surgical oversight to communities within their jurisdiction using this approach.

Percutaneous Endoscopic Gastrostomy in Ile-Ife, Nigeria:An Initial Report

BACKGROUND

Protein-energy malnutrition is a common problem in critically ill patient and it is a major cause of accelerated morbidity and mortality in this group of patients. Recent dramatic advances in both enteral and parenteral nutritional support have ensured that most of these critically ill patients are adequately nutritionally supported. Unfortunately, most of these advancements in nutritional supports are far from the reach of most patients in developing countries. In this report, we highlighted the indications, success, challenges of the use of percutaneous endoscopic gastrostomy (PEG) in Nigeria patients.

PATIENTS AND METHODS

All cases of PEG performed at the Endoscopy Unit of Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Osun State from January 2011 and June 2012 were recruited into the study. The data obtained included the sociodemographic parameters, indication and duration of the procedure, complications, and follow up.

RESULTS

During the 18 months study period 645 upper gastrointestinal endoscopic procedures were performed. Majority [601(93.2%)] of the cases were for diagnostic purposes. Six (0.9%) cases of PEG were performed. Most (5 of 6) of the patients had central nervous system impairment while only one had severe chronic facial infection with naso-oral fistula. The median age of patients was 60.5 years. The entire procedure including endoscopy lasted an average of 25 minutes with a range of 12-35 minutes. Only one case had peristoma infection which resolved with antibiotics and repeated dressing with povidone iodine. There was no episode of aspiration pneumonitis or procedure related mortality. The average follow up was 6 months with variable weight gain during the follow up period.

CONCLUSION

PEG is a simple, cost effective and safe method to rehabilitate nutritionally all chronically ill patients in less developed countries such as Nigeria. The need to increase awareness and acceptability of PEG among physicians managing such patients and the society cannot be overemphasized.

Percutaneous endoscopic gastrostomy in ile-ife, Nigeria: an initial report

BACKGROUND

Protein-energy malnutrition is a common problem in critically ill patient and it is a major cause of accelerated morbidity and mortality in this group of patients. Recent dramatic advances in both enteral and parenteral nutritional support have ensured that most of these critically ill patients are adequately nutritionally supported. Unfortunately, most of these advancements in nutritional supports are far from the reach of most patients in developing countries. In this report, we highlighted the indications, success, challenges of the use of percutaneous endoscopic gastrostomy (PEG) in Nigeria patients.

PATIENTS AND METHODS

All cases of PEG performed at the Endoscopy Unit of Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Osun State from January 2011 and June 2012 were recruited into the study. The data obtained included the sociodemographic parameters, indication and duration of the procedure, complications, and follow up.

RESULTS

During the 18 months study period 645 upper gastrointestinal endoscopic procedures were performed. Majority [601(93.2%)] of the cases were for diagnostic purposes. Six (0.9%) cases of PEG were performed. Most (5 of 6) of the patients had central nervous system impairment while only one had severe chronic facial infection with naso-oral fistula. The median age of patients was 60.5 years. The entire procedure including endoscopy lasted an average of 25 minutes with a range of 12-35 minutes. Only one case had peristoma infection which resolved with antibiotics and repeated dressing with povidone iodine. There was no episode of aspiration pneumonitis or procedure related mortality. The average follow up was 6 months with variable weight gain during the follow up period.

CONCLUSION

PEG is a simple, cost effective and safe method to rehabilitate nutritionally all chronically ill patients in less developed countries such as Nigeria. The need to increase awareness and acceptability of PEG among physicians managing such patients and the society cannot be overemphasized.

Laryngeal carcinoma: our experience at Obafemi Awolowo University Teaching Hospital complex, Ile-Ife, Nigeria

OBJECTIVES

To determine the prevalent age, frequency, pattern ofpresentation, investigations and outcome of management of laryngeal carcinoma in our environment.

DESIGN

10 year retrospective study (January 1994 to December 2003).

SETTING

Teaching hospital.

SUBJECTS

13 patients with tissue diagnosis managed for laryngeal carcinoma.

MAIN OUTCOME MEASURES

The age, sex, occupation, presentation, use of cigarettes and alcohol, investigations, tissue diagnosis, outcome of management and duration of follow up were extracted from hospital records and analysed.

RESULTS

The age of patients ranged 38 to 88 years (median 69, male: female ratio=12:1). The histopathology was squamous cell carcinoma in all. Common symptoms included hoarseness of voice and breathlessness in all the patients, cough and weight loss in seven patients and otalgia in six. Only one patient indulged in alcohol while two were regular cigarette smokers. All the patients presented in stage IV with respiratory distress necessitating emergency tracheostomy in all. Seven patients had total laryngectomy plus post-operative radiotherapy while two patients had pharyngo-laryngectomy, thyroidectomy and radical neck dissection plus post-operative radiotherapy and thyroxine supplement. Post operative complications included pharyngocutaneous fistula in two patients, pharyngeal stenosis, stoma stenosis, and hypocalcaemia with hypothyroidism in one patient each. The fistulae were management conservatively. Prognosis was good despite late presentation.

CONCLUSION

Laryngeal carcinoma occurs predominantly in males. Presentation is late with hoarseness of voice and breathlessness in our community. Soft tissue neck X-ray is a useful diagnostic tool. Scarcity of radiotherapy centres, ignorance, local taboos, poverty and poor recognition by general medical practitioners negatively affected management of the patients. Laryngeal carcinoma should be excluded when managing elderly patients for bronchial asthma.

Laryngeal carcinoma: experience in Ile-Ife, Nigeria

OBJECTIVES

This study aimed to determine the prevalent age, pattern of presentation, histopathology type, and outcome of management of laryngeal carcinoma in our environment.

DESIGN AND SETTING

This was a 10-year retrospective study carried out at a teaching hospital.

MATERIALS AND METHODS

Records of patients managed for laryngeal carcinoma from January 1994 to December 2004 were reviewed. Only 13 cases with tissue diagnosis were included in this review. The age, sex, occupation, presentation, use of cigarette and alcohol, investigations, histology, outcome of management, and duration of follow-up were extracted and analyzed.

RESULTS

The patients had a mean age of 69.9 years (range 38-88 years) and a male-to-female ratio of 12:1. Histopathology was squamous cell carcinoma in all. Symptoms included hoarseness in voice and breathlessness in all, cough in 7 (53.8%), weight loss in 7 (53.8%), and otalgia in 6 (46.2%). Two patients indulged in alcohol and two were also regular cigarette smokers. All the patients presented with stage IV disease and in respiratory distress necessitating emergency tracheostomy. Seven (53.8%) patients had total laryngectomy plus postoperative radiotherapy while 2 (15.4%) had pharyngolaryngectomy, thyroidectomy, radical neck dissection plus postoperative radiotherapy and thyroxine supplement. Surgical complications included pharyngocutaneous fistula in 2 (15.4%) patients, pharyngeal stenosis, stomal stenosis, and hypocalcemia with hypothyroidism in 1 patient each. The fistulae were managed conservatively and prognosis was good despite late presentation.

CONCLUSION

Laryngeal carcinoma mainly occurs in males. Presentation is late with hoarseness in voice and breathlessness in our community. Soft-tissue neck x-ray is a useful diagnostic tool. Scarce radiotherapy centers, ignorance, local taboo, poverty, and poor recognition by primary healthcare providers have a negative impact on its management. Laryngeal carcinoma should be excluded when managing elderly patients for bronchial asthma.

A retrospective analysis of aetiology and management of epistaxis in a south-western Nigerian teaching hospital

BACKGROUND

Epistaxis is a common otolaryngological emergency and is often due to lesions within or around the nose and systemic conditions. Controlling epistaxis presents a challenge in the underdeveloped, resource-poor centres where there are limited facilities.

OBJECTIVE

To describe the aetiopatogenesis of epistaxis in our hospitals.

METHODS

This was a retrospective review of the cases of epistaxis managed at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile Ife, over a three-year period: January 2003 - through December, 2005. Information on sociodemographic characteristics, clinical presentation and management of epistaxis was obtained from the hospital records both in the accident and emergency units and the ENT outpatient clinic.

RESULTS

A total of 106 cases were managed during the period. The peak age incidence was in the 21-40-year group. There was a significant male preponderance, ratio 3.4:1. Trauma contributed to 75 (70.9%) of the cases managed. Maxillofacial injuries were the most common injury encountered (50.7%). This was mainly secondary to the road traffic accident (RTA). Malignant neoplasms were the second most common aetiological factor seen in this study while idiopathic causes were the third most common. There were two cases with systemic problems associated with renal failure. Nasal packing was adequate to control the epistaxis in most cases. Nasal packing was done with gloved finger cots and vasellinated gauze. Two patients (1.9%) had external carotid artery ligation. Eleven patients (10.4%) received blood transfusion.

CONCLUSION

Epistaxis is a common presentation of head and neck trauma. Non-surgical control of epistaxis (nasal packing) is adequate in many cases. Reducing the incidence of trauma from RTA will reduce the incidence of emergency epistaxis in our centers.

Review of skull base surgery in a Nigerian teaching hospital

BACKGROUND AND OBJECTIVES

There is dearth of information on skull base surgery in Nigerians. This study was conducted to determine types of skull base lesions describe surgical approaches to the lesions and determine outcome of surgical management of the lesions over the study period.

METHODS

We retrospectively reviewed the case notes of the patients who underwent skull base neurosurgical procedures between January 2001 and June 2007 in our centre. We obtained information on demography, clinical presentation, diagnosis, cranial computerised tomography findings, type of surgery, intraoperative findings and outcome of surgical management at the time of discharge from the hospital.

RESULTS

Brain tumours were diagnosed in 28 patients, head injuries in 9 patients and one patient each had anterior encephalocele and frontal sinus mucocele. Eighteen patients had frontal craniotomy, three patients had temporal craniotomy and two patients had lateral rhinotomy in addition to bifrontal craniotomy. Two patients had frontoorbitotomy while retrosigmoid craniectomy was performed in one patient. Thirty three patients showed significant postoperative improvement at discharge.

CONCLUSION

Brain tumour was the most common indication for skull base surgery in our centre. These tumours were mainly located in the anterior cranial fossa. Frontal craniotomy was the most common surgical approach. Non-availability of modern neurosurgical facilities confined us to the use of mainly traditional approaches. The availability of these facilities will assist in improving our management outcome in the future.

Challenges in management of chronic suppurative otitis media in a developing country

Background:

In developing countries, the rate of complications from chronic suppurative otitis media is still high, due to factors associated with poverty. This study aimed to determine the prevalence of chronic suppurative otitis media and associated complications.

Patients and methods:

We prospectively studied all patients presenting with chronic suppurative otitis media to the ear, nose and throat unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, over a two-year period.

Results:

One hundred and sixty new cases of chronic suppurative otitis media were seen. These constituted 11.1 per cent of all new cases and 21.5 per cent of all otological cases seen. About half (51.7 per cent) of these patients were younger than 15 years. Most patients were from rural areas and had been previously managed by unlicensed, untrained practitioners. Complications were mostly seen in children. Intracranial complications were seen in 10 (6.3 per cent) cases; this was associated with a high mortality rate.

Conclusion:

This study found that, in Nigeria, a developing country, ‘safe’ chronic suppurative otitis media was not without serious problems. Provision of adequate health facilities may reduce such problems.

Oesophageal denture impaction producing Horner's syndrome: a case report

BACKGROUND

Dentures in the oesophagus have been associated with various complications; however, Horner's syndrome following denture impaction has not been reported in our locality.

CASE REPORT

Horner's syndrome developed in a 26-year-old woman following accidental swallowing of an upper denture which then became impacted in the oesophagus. The denture was retrieved via cervical oesophagotomy. The syndrome abated completely by the seventh day post-surgery. The clinical features of Horner's syndrome are discussed.

CONCLUSION

Compression of the stellate ganglion, with resultant Horner's syndrome, can be associated with denture impaction in the cervical oesophagus.

Epidemiology of otitis media in a local tropical African population

BACKGROUND

Otitis media is one of the most common childhood infections. There are however very few community based studies on the prevalence of this disease in Nigeria children.

OBJECTIVES

To establish the community prevalence of otitis media: and to identify associated environmental and the host risk factors in Nigerian children.

SETTING

A semi urban community of Ife Central Local Government area of Osun State, Southwestern part of Nigeria.

MATERIAL AND METHODS

Thirty enumeration areas within the study location were randomly picked and their boundaries were defined with the assistance of the National Population Commission (NPC) Officials. Households were used as sampling units within the area. Children aged 1 day old-12 years in each selected household were identified. A questionnaire was administered to the mother/guardian of each child. Otoscopic examination, in addition to the general physical examination was carried out on each child. The data were analyzed using simple descriptive statistics, correlation and multivariate regression technique.

RESULT

600 children aged 0-12 years were investigated. There were 299 males and 301 females. The prevalence of otitis media was found to be 14.7%. This comprises of acute otitis media (AOM) in 11.8%, chronic suppurative otitis media (CSOM) in 2.5%, while Otitis media with effusion (OME) was diagnosed in less than 1%. The peak age of incidence was found to be in the age group 1-4 years 55 (9.2%), while the least age of occurrence was found to be in the age group less than 1 year 10 (1.7%). There was no statistical association between the duration of breastfeeding practice and occurrence of otitis media among the subject (P>0.05). There was no statistical association between the occurrence of otitis media and immunization (p>0.05). However there were 3 children who had otitis media associated with measles infection. A highly significant association was shown between exposure to household cooking fuel (wood smoke) and the occurrence of otitis media (P<0.05). Mother's educational status, number of children sleeping in the same room greater than four was found to demonstrate a strong association with the occurrence of Otitis media (p<0.05).

CONCLUSION

Otitis media is prevalent among Nigeria children and it is found to occur more in children of mothers with lower educational status and in number of children greater than 4 sleeping in the same room. A strong association was found between exposure to wood smoke in the living environment and the occurrence of otitis media.

Acute Otitis media, malaria and pyrexia in the under five age group

BACKGROUND

Acute Otitis media is one of the most common childhood infections. It is responsible for every third visit to a pediatrician in a developed world. However, in Nigeria there is scanty knowledge about the incidence of Acute Otitis Media (AOM).

OBJECTIVE

This study aimed at determining the incidence of AOM among under five year old children presenting with pyrexia, and to compare the incidence of AOM as a cause of pyrexia with the incidence of malaria in pyrexic children.

DESIGN

It is a cohort study of 200 children of between the ages of 2 weeks and five years with a rectal temperature of 38 degrees C and above, seen over a period of 3 months.

SETTING

The study was conducted at the Obafemi Awolowo University Teaching Hospital (OAUTHC) Comprehensive Health Centre, Eleiyele, and the children emergency room of the OAUTHC, Ile-Ife.

PATIENTS AND METHODS

A questionnaire to collect information on the demographic data was administered to each mother/guardian of the patient. Otoscopic examination using a battery-operated hand held otoscope and magnifying lenses were done in addition to general systemic physical examination. Thin and thick blood smears were made for malaria parasite. The dried slides were examined under the microscope using the X 100 objective. Sixteen of the patients' slides were lost after processing.

RESULTS

Out of the 200 patients that were studied, 58 (29%) had AOM. The highest incidence was recorded in the age group 12-24 months while the least age of occurrence was found to be the age group 4-5 years. Malaria parasitemia was found in 81 (43.5%) while 21 (25.9%) of those with parasitemia also had AOM. But 76 (36%) of the study population had neither AOM nor malaria parasitemia.

CONCLUSION

Acute Otitis media was found in 29% of under five years old presenting with pyrexia. It was found to be highest in the first and second year of life, and was found to be least in the 5th year of life. Malaria was found in 81 (43.5%) of the children, and 21 (10.5%) of the children had malaria with a co-existing AOM.

Burkitt's lymphoma of the head and neck region in a Nigerian tertiary hospital

BACKGROUND

Burkitt's lymphoma is endemic in Nigeria; it forms about 39% of all childhood cancers. In recent times more of these cases are being seen presenting first to the Ear Nose and Throat clinic.

OBJECTIVE

This study is designed to look at the pattern of presentation of head and Neck Burkitt's lymphoma at a Nigerian Tertiary hospital and to evaluate current treatment modality.

DESIGN

It is a retrospective study of all confirmed Burkitt's lymphoma of the head and neck region seen at the Obafemi Awolowo University Teaching Hospital Ile Ife (OAUTHC) between 1986 and 2002.

PATIENTS AND METHODS

The medical records of all the patients with the histopathologically confirmed Burkitt's lymphoma over a 17-year period (1986-2002) were evaluated. The proportion of the tumor affecting the Head and neck region were noted. The data extracted were entered into a questionnaire and analysis of data was done using the SPSS 10.0 software.

RESULTS

A total of 196 cases of Burkitt's lymphoma were seen over the period out of which 140 (71.4%) were in the head and neck region. There was a male preponderance with the incidence of 72% and 28% in females. The peak age incidence was found to be within the first decade of life. The most common sites that were affected are; the jaw (65.9%), nasal and paranasal sinuses (12.2). Majority of the patients presented with advanced disease. Combination Chemotherapy comprising Cyclophosphamide, Oncovin, Methotrexate and Prednisolone (COMP) was the mainstay of management. The treatment outcome was only favorable in 36.6%. Default rate was (11.7%) while the mortality rate was (12.6%). Relapse\recurrence was found in (5.1%) of cases. Frank drug resistance was found in (2.6%). Blindness was found to be a major morbidity associated with this disease. Septicemia and severe anemia were found to be the major causes of mortality. Some complications of treatment were noted.

DISCUSSION

The importance of the findings in this work was discussed in line with the existing literature.

CONCLUSION

Head and neck remain the mostly affected parts in Burkitt's lymphoma in this environment. Presentation with advanced disease is the bane. This partly explains high morbidity and mortality in affected children.

Pattern of head and neck malignant tumours in a Nigerian teaching hospital--a ten year review

BACKGROUND

In Nigeria record of incidence and pattern of Head and Neck malignancies is scanty. In our Hospital, there had been no prior published report on this subject.

OBJECTIVE

To study the pattern of occurrence of Head and Neck malignancies treated in Obafemi Awolowo university Hospitals Complex, Ile Ife, Nigeria.

METHODS

medical records of patients with histopathologically confirmed head and neck malignancies over a 10 year period (1989--1998) were analyzed.

MAIN RESULTS

Three hundred and thirteen (313) cases, made up of 184 (59%) males and 129 (41%) females were found. The most common sites for head and neck malignancies were found to be in the oral cavity (36.8%), the neck (26.8 %), the thyroid (13.7 %), and the esophagus (5.1%). The paranasal sinuses and the ear were the least affected anatomical sites with one (0.3 %) of cases each. The histopathological tumour types found in this work were lymphoma (40.26%), squamous cell carcinoma (25.23%), sarcoma (2.6%), while many other minor histopathological variants accounted for 31.9%. Lymphoma was the most common in children, while carcinoma was found in, and forms the most common histopathological variant of head and neck malignancies in the older age group.

PRINCIPAL CONCLUSIONS

There is a high incidence of childhood head and neck malignancies found in this study in contrast to the Western literature where the highest incidence is found in the older age group and the elderly. Jaw malignancies constituted the most common malignancies of the oral cavity. Lymphoma and thyroid malignancies are relatively common in our center.

Tracheostomy in surgical practice: experience in a Nigerian tertiary hospital

BACKGROUND

Tracheostomy continues to be a standard surgical procedure for airway management.

OBJECTIVE

This study was conducted to evaluate the indications, and complications associated with the utilization of open surgical tracheostomy in our center.

DESIGN AND SETTING

It is a retrospective study of all patients that had open surgical tracheostomy at the Obafemi Awolowo University Teaching Hospital, Ile-Ife. Nigeria during a 15-year period between January 1986 and December 2000.

PATIENTS AND METHODS

The medical records of the forty-four patients that had open surgical tracheostomy in the operating theatre within the study period were evaluated.

RESULTS

There were 12 females and 32 males. The mean age was 33.6 +/- 24.8 years. The indications for tracheostomy were trauma (n =15), infections (n = 13), laryngeal (benign and malignant) tumors (n = 9), other head and neck malignancies (n = 4), neurological cases with respiratory failure (n = 2), and tracheomalacia (n = 1). All the tracheostomies were performed as an emergency as all the patients presented in respiratory obstruction. Transverse incision was employed in n = 35 cases, while the longitudinal incision was employed in n = 3 and the type of incision was not specified in the remaining six cases. Laryngeal stenosis was found in 6.9% of cases and the mortality was 25%.

CONCLUSION

Upper airway obstruction was the major indication for tracheostomy in our center; and the high mortality may be due to the primary medical problems rather than the complications of tracheostomy alone.

Management of oesophageal foreign bodies in children

OBJECTIVE

To evaluate the pattern and outcome of management of retained oesophageal foreign bodies in children.

DESIGN

Retrospective study.

SETTING

Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, January 1991 to December 2000.

SUBJECTS

One hundred and eight paediatric patients, aged 0-14 years managed for retained oesophageal foreign bodies.

INTERVENTION

The foreign bodies were removed endoscopically, using either a larynoscope or a rigid oesophagoscope, under general anaesthesia.

RESULTS

There were 108 patients, with a mean age of 3.0 +/- 0.8 years and age range of 23 days to 14 years. The male to female ratio was 1.5: 1. Sixty four (59.3%) patients were within 1-5 year age group. Coins constituted 79.6% of the retained foreign bodies. Over 90% of patients presented within the first four days of the incidence. The dominant complaints were drooling of saliva in 37 (40.2%) and difficulty in swallowing in 35 (38.1%) patients. The commonest sites of the foreign body retention were the upper third of oesophagus 52(48.2%) and the hypopharynx 36(33.3%). The main complications following the foreign body removal were oesophageal perforations 4(3.7%) and lacerations 16(15%).

CONCLUSION

Retained oesophageal foreign body is a common childhood health hazard. Early diagnosis and prompt skillful removal are necessary for a satisfactory outcome.

The characterization of bacterial isolates from acute otitis media in Ile-Ife, southwestern Nigeria

The incidence of acute otitis media (AOM) in a comprehensive healthcare setting was investigated in Ile-Ife, Nigeria. Out of the 617 children examined, 53 (11.64 per cent) suffered from the condition based on the criteria used. Staphylococci constituted the predominant organisms associated with the condition with Staphylococcus aureus (25.0 per cent) being the most frequent single microbe recovered from the subjects. This was followed by Proteus mirabilis (16.2 per cent), Staphylococcus sp. (8.8 per cent), Streptococcus pneumoniae (8.8 per cent), Pseudomonas aeruginosa and Haemophilus influenzae (7.4 per cent each). Most isolates tested were multiply resistant to the antibiotics commonly employed in treating infections caused by these organisms. The study highlights the prevalence of multi-resistant organisms amongst the subjects and recommends prompt therapeutic intervention to avert ineffectiveness of antibiotics when used in treating infections caused by these organisms in the community.