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.

Advancing African otolaryngology and head & neck surgery education and training through virtual academic platforms and multidisciplinary teams.

PURPOSE OF REVIEW: To overview the rise of virtual tools to propagate academia and clinical service within Africa, in the field of otolaryngology, propelled by the coronavirus disease 2019 (COVID-19) pandemic. RECENT FINDINGS: The rise of the COVID-19 virus saw a dramatic reduction in elective surgery and outpatient services with a subsequent reduction in experiential learning for trainees. This has spurred the rising trend to maintain the mission of education and clinical service, virtually. There have been unprecedented levels of international collaboration in the 'pandemic year of 2020' that has seen various platforms conceived to harmonize varying practices from global experts towards the ultimate goal of education propagation and improved patient care. The continent of Africa, amidst its own unique challenges, has boldly stepped into the virtual realm in form of a resident-centred platform coined University Of Cape Town-Africa Virtual ENT, and two multidisciplinary team (MDT) meetings: the African Head and Neck Society Virtual Tumour Board and the African Virtual Cochlear Implant Meeting. SUMMARY: The COVID-19 pandemic will have long-lasting effects on clinical practice and training programs globally. This has demanded academicians to re-imagine novel ways to buoy academia and maintain international collaboration in an inexpensive and convenient way to nourish the sacred mission of education and clinical service within our spirited continent.

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.

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.

African head and neck fellowships: A model for a sustainable impact on head and neck cancer care in developing countries.

BACKGROUND: There is an extreme shortage of head and neck surgeons in Africa. Fourteen head and neck surgeons have completed fellowships in Cape Town and Cameroon. This study determines whether such Africa-based fellowships are a good model for developing countries by making a sustainable impact on head and neck cancer care. METHODS: An observational study was conducted by emailing questionnaires to past fellows. RESULTS: All fellows had returned to teaching hospitals in their counties. Seven established new multidisciplinary cancer teams. Head and neck operations had increased by >335%, as had complexity of the surgery. There was effective transfer of surgical skills to trainees. All considered head and neck fellowships to be the best model to grow head and neck care. CONCLUSION: Head and neck fellowships in developing countries are effective models for establishing training programs and for increasing provision of specialized surgical services in a sustainable fashion.

Oral cavity cancer management guidelines for low-resource regions.

BACKGROUND: The diagnosis and management of oral cavity cancer has been well described in developed countries, however, in regions with fewer medical resources, alternative methods may need to be used. We outline an approach to evaluation and treatment of oral cavity cancer in low-resource areas. METHODS: Reviews of the Cochrane and Pubmed databases were performed and literature compiled. Expert opinions from the American and African Head and Neck Societies were also provided. RESULTS: Treatment guidelines for managing oral cavity cancer in low-resource regions are outlined and the level of supporting evidence is defined. DISCUSSION: Successful treatment typically involves the use of upfront surgical resection of the primary lesion and any involved or at-risk cervical lymph node basins, with adjuvant therapy based on the final pathology findings. In situations where services such as adjuvant therapy and/or appropriate reconstruction are not available, alternative approaches to treatment may be needed.

Glomus tumor presenting as complex regional pain syndrome of the left upper limb: a case report.

BACKGROUND: Glomus tumors of the hand are rare, benign but debilitating neoplasms arising from the neuromyoarterial glomus body. They may present a diagnostic dilemma, and take years with multiple consultations and investigations before an appropriate diagnosis is made, but once a diagnosis is made, surgical excision is curative. CASE PRESENTATION: This is a case presentation of a 35-year-old African man who presented with complex regional pain syndrome of his left upper extremity, whose genesis was found to be a glomus tumor of the pulp of his left middle finger. Surgical excision resulted in resolution of the chronic regional pain syndrome and a return to a normal lifestyle. Chronic regional pain syndrome is a rare presentation of a glomus tumor, which has only been previously reported in patients with neurofibromatosis type 1, and one patient who did not have neurofibromatosis. CONCLUSIONS: Patients with glomus tumors may spend many years in pain and distress because of misdiagnosis. Sensitization and education of both the public and health care workers will help in early diagnosis and treatment of this otherwise potentially disabling pathology for which surgical excision is curative.