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.

Determining the Minimum Dataset for Surgical Patients in Africa: A Delphi Study.

BACKGROUND: It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry. METHODS: A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds). RESULTS: Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described. CONCLUSIONS: The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

The impact of COSECSA in developing the surgical workforce in East Central and Southern Africa.

BACKGROUND: The Association of Surgeons of East Africa (ASEA) was formed in 1952. In 1996 a Steering Committee was formed to transform ASEA into a surgical college. The College of Surgeons of East Central and Southern Africa was officially launched in December 1999 in Nairobi, Kenya. Today the College consists of 14 constituent member countries but trains in 20 countries in Sub-Saharan Africa. PROGRAMMES: COSECSA runs a 5 year training programme in all the surgical specialties. In the first 2 years trainees do the Membership (MCS) programme. This is followed by 3 years of the Fellowship (FCS) programme. More recently the College has started a 2 year sub-specialty Fellowship in paediatric orthopaedics. GRADUATES: The main aim of the College was to expand and improve surgical training in the COSECSA region. This goal was partially realised in December 2020 when the total number of surgeons produced by the College from inception reached 557. RETENTION: Another key success story of COSECSA is that the majority of graduates have remained in the region leading to a high retention rate of 88.3%. WOMEN IN SURGERY AFRICA (WISA): Since the formation of WISA in 2015 the College has witnessed an increase in the number of female trainees. Currently only 9% of surgeons in the region are women. CONCLUSION: In its current Strategic Plan (2021-2025) COSECSA aims not only to increase the surgical workforce in the region but also to modernise its training programmes and strengthen its governance structures.

Childhood musculoskeletal impairment in Malawi from traumatic and non-traumatic causes: a population- based assessment using the key informant method.

BACKGROUND: Musculoskeletal impairment (MSI) in children is an under-recognised public health challenge. Although preventable, road injuries and other traumas continue to cause significant impairments to children worldwide. The study aimed to use the Key Informant Method (KIM) to assess prevalence and causes of MSI in children in two districts in Malawi, estimating the associated need for services provision, with a focus on traumatic aetiology. METHODS: The KIM was conducted in the districts of Thyolo (Southern Malawi) and Ntcheu (Central Malawi) in 2013. Five hundred key informants were trained to identify children who may have one of a range of MSI. The identified children were referred to a screening camp where they were examined by medical experts with standardised assessment protocols for diagnosing each form of impairment. RESULTS: 15,000 children were referred to screening camps. 7220 children were assessed (response rate 48%) for an impairment of whom 15.2% (1094) had an MSI. 13% of children developed MSI from trauma, while 54% had a neurological aetiology. For MSI of traumatic origin the most common body part affected was the elbow. Less than half of children with MSI (44.4%) were enrolled in school and none of these children attended schools with resources for disability. More than half of children with MSI (60%) had not received required services and 64% required further physical therapy. CONCLUSIONS: The KIM method was used to identify a high prevalence of MSI among children in two districts of Malawi and estimates an unmet need for dedicated MSI services.

The Creation of a Sustainable Otolaryngology Department in Malawi.

There is a significant lack of surgeons in the developing world. Malawi Africa is one of the poorest and medically underserved countries in the World, with surgical care particularly lacking. Providing surgical services has numerous barriers, such as availability of well-trained surgeons, infrastructure, continuity of care, and access to care. There is currently one otolaryngologist in Malawi who provides complete access to this subspecialty. The development of the otolaryngology department was successful through institutional, local, national, and international collaboration, with a long-term goal of sustainability. An established department can train the next generation of surgeons for the preservation and growth of the surgical workforce. Once the department approaches independence, the role of outside collaboration transforms primarily from financial to a bi-directional partnership encompassing education, training, and leadership.

The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study.

Background: Operative note writing is one of the fundamental parts in surgical practice. Accurate documentation is critical, to be of value when used for postoperative care, research, academic purposes and medical legal clarity. Although guidelines guiding surgeons on how to write operative notes exist, deficiencies are noted worldwide. Purpose: To assess quality of hand-written operative notes in surgical unit at Queen Elizabeth Central Hospital (QECH) using the RCSEng guidelines as a standard. Methods: To identify key areas of weaknesses, a sole observer in this study assessed prospectively the quality of operative notes in our setting. The audit loop was completed after adoption of new interventions. Results: Sixty-seven percent of the notes were written by trainees in both audits. Key areas of missing data were on time of performing the operation, urgency, estimated blood loss, complications and extra procedure in the first audit, with a frequency of 0%, 2%, 14%, 38% and 11% respectively. The results improved significantly to 62%, 84%, 62%, 70%and 32% respectively [p<0.05] in the second audit. Half of the postoperative care instructions were inadequate with 29% of the notes partially illegible or completely illegible. Conclusion: The study identifies significant deficiencies in our operative note writing. Surgeon's education, use of detailed pro formas with heading prompts and aide memoirs for vital information play a major role in better note completion. The role of electronic health records is highlighted.

Trauma care in Malawi: A call to action.

Injuries are a global public health concern because most are preventable yet they continue to be a major cause of death and disability, especially among children, adolescents, and young adults. This enormous loss of human potential has numerous negative social and economic consequences. Malawi has no formal system of prehospital trauma care, and there is limited access to hospital-based trauma care, orthopaedic surgery, and rehabilitation. While some hospitals and research teams have established local trauma registries and quantified the burden of injuries in parts of Malawi, there is no national injury surveillance database compiling the data needed in order to develop and implement evidence-based prevention initiatives and guidelines to improve the quality of clinical care. Studies in other low- and middle-income countries (LMICs) have demonstrated cost-effective methods for enhancing prehospital, in-hospital, and post-discharge care of trauma patients. We encourage health sectors leaders from across Malawi to take action to improve trauma care and reduce the burden from injury in this country.

Recommendations for including surgery on the public health agenda.

BACKGROUND: Surgical care has made limited inroads on the public health and global health agendas despite increasing data showing the enormous need. The objective of this study was to survey interested members of a global surgery community to identify patterns of thought regarding barriers to political priority. MATERIALS AND METHODS: All active members of the nongovernmental organization Surgeons OverSeas were surveyed and asked why surgical care is not receiving recognition and support on the public health and global health agenda. Responses were categorized using the Shiffman framework on determinants of political priority for global initiatives by two independent investigators, and the number of responses for each of the 11 factors was calculated. RESULTS: Seventy-five Surgeons OverSeas members replied (75 of 176; 42.6% response rate). A total of 248 individual reasons were collected. The most common responses were related to external frame, defined as public portrayals of the issue (60 of 248; 24.2%), and lack of effective interventions (48 of 248; 19.4%). Least cited reasons related to global governance structure (4 of 248; 2.4%) and policy window (4 of 248; 1.6%). CONCLUSIONS: This survey of a global surgery community identified a number of barriers to the recognition of surgical care on the global health agenda. Recommendations include improving the public portrayal of the problem; developing effective interventions and seeking strong and charismatic leadership.

Moving from data collection to application: a systematic literature review of surgical capacity assessments and their applications.

BACKGROUND: Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature. METHODS: A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature. RESULTS: Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared. CONCLUSIONS: While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

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.

Addressing Malawi's surgical workforce crisis: a sustainable paradigm for training and collaboration in Africa.

BACKGROUND: The exodus of health professionals including surgeons from sub-Saharan Africa has been well documented, but few effective, long-term solutions have been described. There is an increasing burden of surgical diseases in Africa attributable to trauma (road traffic injuries), burns, and other noncommunicable diseases such as cancer, increasing the need for surgeons. METHODS: We conducted a Descriptive analysis of surgical academic partnership between Kamuzu Central Hospital (KCH) Malawi, the University of Malawi-College of Medicine, the University of North Carolina in the United States, and Haukeland University Hospital, Norway, to locally train Malawian surgical residents in a College of Surgeons of East, Central and Southern Africa (COSECSA) approved program. RESULTS: The KCH Surgery Residency program began in 2009 with 3 residents, adding 3 general surgery and 2 orthopedic residents in 2010. The intention is to enroll ≥ 3 residents per year to fill the 5-year program and the training has been fully accredited by COSECSA. International partners have provided near-continuous presence of attending surgeons for direct training and support of the local staff surgeons, while providing monetary support in addition to the Malawi Ministry of Health salary. CONCLUSION: This collaborative, academic model of local surgery training is designed to limit brain drain by keeping future surgeons in their country of origin as they establish themselves professionally and personally, with ongoing collaboration with international colleagues.

Ectopic thymic tissue presenting as a neck mass in children: a report of 3 cases.

The presentation of ectopic cervical thymic tissue as an anterior neck mass is rare. We report 3 similar cases in 3 boys-2 who had a thymic cyst and 1 who had an ectopic cervical thymus. We discuss the radiographic presentation on ultrasound and magnetic resonance imaging in these cases. We also review the typical histologic picture; histology is the only way of diagnosing this condition.

Hydatid disease of the skull base: report of three cases and a literature review.

We report three cases of hydatid disease of the skull base and the treatment thereof. The first involved the anterior cranial fossa and paranasal sinuses. The second was located in the infratemporal fossa. The last involved the temporal bone and posterior cranial fossa. Hydatid disease is endemic in many parts of the world where livestock farming is practiced and is highly endemic in sub-Saharan Africa. Although hydatid disease of the head and neck is rare, it should be considered in the differential diagnosis of cystic disease in the head and neck region. Of the three forms of hydatid disease, Echinococcus granulosis is most common and gives rise to cystic hydatid disease. Most hydatid cysts are "silent," but become clinically apparent because of their mass effects, when they rupture, or if they become superinfected. Computed tomography scanning and magnetic resonance imaging are the best diagnostic tools. Hydatid disease can be successfully treated by a combination of surgery and chemotherapy.

Adult tonsillectomy--are long waiting lists putting patients at risk?

There is a paucity of data on morbidity associated with long waiting lists for adult tonsillectomy. The aim of this study was to assess the morbidity associated with long waiting lists for adult tonsillectomy in a developing world setting. Of 350 patients on the waiting list at Groote Schuur Hospital for 18 months or more, only 55 were contactable. This low yield (15.7%) from the telephonic survey highlighted the difficulty of managing long waiting lists efficiently in a developing world setting. As only 1/55 patients on the waiting list had a complication (quinsy), it appears to be safe to delay tonsillectomy in adult patients. Only half of patients ultimately required tonsillectomy because of a natural reduction in the number of episodes of tonsillitis with time. In order to avoid unnecessary tonsillectomy we need to find better prognosticators to identify the subgroup of adult patients likely to have continued recurrent tonsillitis.

Squamous cell carcinoma in black patients with discoid lupus erythematosus.

Squamous cell carcinoma has rarely been reported in black African people, with only 11 cases reported in the world literature to date. We report on 2 further cases, the first to be reported in southern Africa, of squamous cell carcinoma in lesions of discoid lupus erythematosus