Does sentinel lymph node biopsy have a role in node-positive head and neck squamous carcinoma?

OBJECTIVES/HYPOTHESIS: The objective of the study was to determine whether sentinel lymph node biopsy (SLNB) can be used to reduce clinical overstaging of cervical nodes in head and neck squamous cell carcinoma (SCC) in a developing world setting. STUDY DESIGN: Sentinel and echelon lymph nodes were identified by means of a combination of lymphoscintigraphy, gamma probe and blue dye identification. They were analysed histologically and their pathological status was compared with the rest of the neck dissection specimen to determine diagnostic accuracy in patients with T1-4 N0-3 SCC of the oral cavity or oropharynx undergoing primary surgical resection and neck dissection. RESULTS: Thirty-three patients were included in the study, 13 in the node-negative (N0) and 20 in the node-positive (N+) group. In the clinically N0 group the sensitivity of SLNB was 100% and the negative predictive value (NPV) 100%. In the clinically N+ group the sensitivity was 71% and the NPV 60% for staging the nodal status of the neck. CONCLUSIONS; The accuracy of SLNB in the clinically N+ neck is too low for SLNB to be a means of avoiding comprehensive neck dissection. LEVEL OF EVIDENCE: 2B.

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.

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.

Semon Lecture: 'Laryngectomy Practice Based on Personal Research', Royal Society of Medicine, 5 November 2020, London, UK.

I wish to thank the Semon Committee for inviting me to deliver the 2020 Semon lecture. This is a very special honour, as is evidenced by the list of distinguished lecturers dating back to the inaugural lecture delivered at University College London in 1913. I am not the first South African to deliver the Semon lecture, having been preceded by my previous chairman Sean Sellars in 1993, and by Jack Gluckman in 2001, who was South African raised and educated and who subsequently became the chairman of otolaryngology in Cincinnati, USA.

Reintroduction of elective paediatric otolaryngology procedures in South Africa during the COVID-19 pandemic.

Cancelling elective clinical consultations and surgical procedures was instrumental in assisting hospitals prepare for the COVID-19 crisis. Essential bed space was made available, and it allowed mobilisation of health workers and enforced social distancing. A shift in patient-centred ethics to public health ethics was required to provide a utilitarian approach to the crisis. However, at some point, clinicians need to start becoming patient centred again, and this needs to happen within the utilitarian framework. Children only account for 1 - 5% of confirmed COVID-19 cases, and they present with a much milder disease spectrum than adults. Consequently, paediatric units may be at the forefront of implementing reintroduction of patient-centred elective clinical and surgical procedures. The following recommendations provide a framework to do this in a way that minimises risk to patients and clinicians. They are the first paediatric guidelines in the literature to propose a strategy to reintroduce elective surgical procedures.

Does thyroid-sparing total laryngectomy decrease the risk of hypothyroidism?

BACKGROUND: Thyroid lobectomy is recommended with total laryngectomy for laryngeal cancer in the National Comprehensive Cancer Network ('NCCN') guidelines. However, it is associated with a 32-89 per cent risk of hypothyroidism, with or without adjuvant radiotherapy. OBJECTIVE: The study aimed to determine whether preserving the whole thyroid, compared to a single lobe, does indeed significantly lower the incidence of hypothyroidism in the setting of total laryngectomy. METHOD: A retrospective study was conducted at Groote Schuur Hospital in Cape Town, South Africa. RESULTS: Eighty-four patients met the inclusion criteria. The overall incidence of hypothyroidism was 45.2 per cent. The incidence of hypothyroidism was significantly reduced in patients who underwent thyroid-sparing total laryngectomy compared to hemithyroidectomy (p = 0.037). Adjuvant radiotherapy was associated with a higher incidence of hypothyroidism (p = 0.001). CONCLUSION: Thyroid-preserving laryngectomy should be advocated in carefully selected patients with advanced laryngeal carcinoma, as it reduces the incidence of hypothyroidism.

Tympanostomy tube insertion practice in under-18-year-olds in the South African private healthcare sector insured by Discovery Health.

BACKGROUND: The reported rates of tympanostomy tube insertion (TTI) in children vary significantly internationally. Lack of adherence to evidence-based clinical guidelines may contribute to these differences. OBJECTIVES: To study the rates of TTI in South Africa (SA) in children ≤18 years old in the private healthcare sector, both nationally and regionally, to compare these with international TTI rates, and to determine the use of preoperative audiometry and tympanometry. METHODS: A retrospective analysis was done of data obtained from the Discovery Health database. Rates of TTI were analysed nationally and regionally and in different age groups, as was the use of tympanometry and audiograms. RESULTS: The SA TTI rates were much higher than published international rates except for the 0 - 1-year age group in Canada and Denmark and the 0 - 15-year age group in Denmark. There was a statistically significant regional variation in TTI rates as well as in the use of preoperative audiometry and tympanometry. CONCLUSIONS: SA private sector TTI rates are high by international standards. Significant regional variations may indicate over- or underservicing in certain regions. Further investigation of causes for the high TTI rate and regional variations is recommended. Education of healthcare professionals on recognised indications for TTI may improve patient selection.

Quality of life after total laryngectomy: evaluating the effect of socioeconomic status.

OBJECTIVE: Total laryngectomy is considered the primary treatment modality for advanced laryngeal carcinoma. This study assessed the quality of life in patients after total laryngectomy, and ascertained whether quality of life is affected by socioeconomic status. METHOD: Forty-seven patients (20 state- and 27 private-sector) who underwent total laryngectomy between 1998 and 2014 responded to the University of Washington Quality of Life Questionnaire, the Voice-Related Quality of Life Questionnaire and the Brief Illness Perception Questionnaire. RESULTS: Significant differences were found in socioeconomic status between state- and private-sector patients (p < 0.001). There was no significant difference in overall quality of life between groups (p = 0.210). State-sector patients scored significantly higher Voice-Related Quality of Life Questionnaire scores (p = 0.043). Perception of illness did not differ significantly between groups. CONCLUSION: Overall quality of life after total laryngectomy appears to be similar in patients from different socioeconomic backgrounds. However, patients from lower socioeconomic circumstances have better voice-related quality of life. The results illustrate the importance of including socioeconomic status when reporting voice outcomes in total laryngectomy patients.

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.

Transoral laser resection of glottic carcinoma: what is the significance of anterior commissure involvement?

BACKGROUND: The optimal management of glottic carcinoma involving the anterior commissure is controversial. METHOD: A retrospective analysis was conducted of 76 patients with glottic squamous cell carcinoma treated by transoral carbon dioxide laser resection by a single surgeon. RESULTS: Sixty-three patients (with tumour stage Tis-T3) were eligible for inclusion. Thirty patients had involvement of the anterior commissure; these patients were significantly more likely to have either uncertain or positive margins (63.3 vs 30.3 per cent, p = 0.012), and were also more likely to receive adjuvant radiotherapy (40 vs 3.2 per cent, p = 0.0005). The overall laryngeal preservation rate was 96.8 per cent; there was no statistically significant difference between those with and without anterior commissure involvement (96.7 and 96.9 per cent respectively). CONCLUSION: Transoral laser resection with the use of adjuvant radiotherapy in a minority of patients with adverse pathological findings can be recommended for the primary treatment of anterior commissure glottic cancer from an oncological perspective; excellent local control and laryngeal preservation rates can be achieved.

Survey of otolaryngology services in Ukraine and neighbouring Central and Eastern European countries.

OBJECTIVE: The present humanitarian crisis in Ukraine is putting strains on its healthcare system. This study aimed to assess services and training in otolaryngology, audiology and speech therapy in Ukraine and its geographical neighbours. METHOD: Survey study of 327 otolaryngologists from 19 countries. RESULTS: Fifty-six otolaryngologists (17 per cent) from 15 countries responded. Numbers of otolaryngologists varied from 3.6 to 12.3 per 100 000 population (Ukraine = 7.8). Numbers of audiologists varied from 0, in Ukraine, to 2.8 per 100 000, in Slovakia, and numbers of speech therapists varied from 0, in Bulgaria, to 4.0 per 100 000, in Slovenia (Ukraine = 0.1). Ukraine lacks newborn and school hearing screening, good availability of otological drills and microscopes, and a cochlear implant programme. CONCLUSION: There is wide variation in otolaryngology services in Central and Eastern Europe. All countries surveyed had more otolaryngologists per capita than the UK, but availability of audiology and speech and language therapy is poor. Further research on otolaryngology health outcomes in the region will guide service improvement.

Suprahyoid approach to base-of-tongue squamous cell carcinoma.

OBJECTIVE: To evaluate the suprahyoid approach to treatment of squamous cell carcinoma of the base of the tongue at Groote Schuur Hospital between 1999 and 2004. DESIGN AND METHOD: Retrospective analysis was done of patients with base-of-tongue squamous cell carcinoma treated using the suprahyoid approach. RESULTS: Seventeen patients underwent treatment for base-of-tongue squamous cell carcinoma utilising the suprahyoid approach. Complete medical records were available for 15 of these patients. The most common presenting symptoms were neck mass (40%) and referred otalgia (33%). Alcohol was a risk factor in more patients (64%) than smoking (47%). Adverse pathological findings were present in less than 50% of patients (involved margins 20%, perineural invasion 40%, vascular invasion 33%). Functional outcome in terms of speech intelligibility was excellent and there were minimal swallowing problems, with most patients using compensatory strategies and dietary modification. There were 2 subsequent deaths (13%) as a result of distant metastasis and a second primary. CONCLUSION: The suprahyoid approach to treatment of base-of-tongue squamous cell carcinoma provides good exposure, local tumour control and excellent functional outcome.

Tonsillectomy rates in the South African private healthcare sector.

BACKGROUND: Adeno-/tonsillectomy is a commonly performed procedure with internationally standardised and recognised indications. Despite this, there exists considerable international (190 - 850/100 000 people ≤19 years of age) and regional variation in rates. This cannot be accounted for by differences in clinical need or regional morbidity. OBJECTIVES: To describe the adeno-/tonsillectomy rate in the South African (SA) private healthcare sector and regional variations thereof. To compare local rates with international rates and assess trends in adeno-/tonsillectomy practice. METHODS: Analysis of 2012 and 2013 adeno-/tonsillectomy data provided by the largest SA private healthcare funder, accounting for 30% of the medical scheme market. Rates are expressed per 100 000 people ≤19 years of age. RESULTS: The tonsillectomy rate in the SA private healthcare sector was 1 888/100 000 people ≤19 years of age in 2012. In 2013, the rate dropped significantly (p<0.001) to 1 755/100 000. This is more than double the highest national tonsillectomy rate reported in the literature. There was also considerable regional variation in this rate within SA. DISCUSSION: The SA tonsillectomy rate is very high when compared with international trends and varies regionally within the country. The literature does not support an increased burden of disease as the reason behind this. Rather, it is differences in training and clinical practice of clinicians, as well as social and family factors, that have been implicated. CONCLUSION: The adeno-/tonsillectomy rate in the SA private healthcare sector is substantially higher than international norms. The reasons for this discrepancy require further consideration.

Supernumerary registrar experience at the University of Cape Town, South Africa.

BACKGROUND: Despite supernumerary registrars (SNRs) being hosted in South African (SA) training programmes, there are no reports of their experience. OBJECTIVES: To evaluate the experience of SNRs at the University of Cape Town, SA, and the experience of SNRs from the perspective of SA registrars (SARs). METHODS: SNRs and SARs completed an online survey in 2012. RESULTS: Seventy-three registrars responded; 42 were SARs and 31 were SNRs. Of the SNRs 47.8% were self-funded, 17.4% were funded through private organisations, and 34.8% were funded by governments. Average annual income was ZAR102 349 (range ZAR680 - 460 000). Funding was considered insufficient by 61.0%. Eighty-seven percent intended to return to their home countries. Personal sacrifices were deemed worthwhile from academic (81.8%) and social (54.5%) perspectives, but not financially (33.3%). Only a small majority were satisfied with the orientation provided and with assimilation into their departments. Almost half experienced challenges relating to cultural and social integration. Almost all SARs supported having SNRs. SNRs reported xenophobia from patients (23.8%) and colleagues (47.8%), and felt disadvantaged in terms of learning opportunities, academic support and on-call allocations. CONCLUSIONS: SNRs are fee-paying students and should enjoy academic and teaching support equal to that received by SARs. Both the university and the teaching hospitals must take steps to improve the integration of SNRs and ensure that they receive equal access to academic support and clinical teaching, and also need to take an interest in their financial wellbeing. Of particular concern are perceptions of xenophobia from SA medical colleagues.

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.

Educational workshops with graduates of the University of Cape Town Karl Storz Head and Neck Surgery Fellowship Program: a model for collaboration in outreach to developing countries.

The University of Cape Town Karl Storz Head and Neck Surgery Fellowship is the only head and neck surgery fellowship in Sub-Saharan Africa. This article briefly describes this fellowship and outlines the experience and ongoing collaborative efforts of members of the American Academy of otolaryngology-head and neck surgery with graduates of this program who are now building head and neck surgery programs in East Africa. This educational collaboration avoids many common pitfalls associated with short-term humanitarian outreach and represents a successful model for international collaborative educational efforts with head and neck surgeons in developing countries in Africa.

Hearing loss in the developing world: evaluating the iPhone mobile device as a screening tool.

BACKGROUND: Developing countries have the world's highest prevalence of hearing loss, and hearing screening programmes are scarce. Mobile devices such as smartphones have potential for audiometric testing. OBJECTIVES: To evaluate the uHear app using an Apple iPhone as a possible hearing screening tool in the developing world, and to determine accuracy of certain hearing thresholds that could prove useful in early detection of hearing loss for high-risk populations in resource-poor communities. METHODS: This was a quasi-experimental study design. Participants recruited from the Otolaryngology Clinic, Groote Schuur Hospital, Cape Town, South Africa, completed a uHear test in three settings--waiting room (WR), quiet roon (QR) and soundproof room (SR). Thresholds were compared with formal audiograms. RESULTS: Twenty-five patients were tested (50 ears). The uHear test detected moderate or worse hearing loss (pure-tone average (PTA) > 40 dB accurately with a sensitivity of 100% in all three environments. Specificity was 88% (SR), 73% (QR) and 68% (WR). Its was highly accurate in detecting high-frequency hearing loss (2 000, 4 000, 6 000 Hz) in the QR and SR with 'good' and 'very good' kappa values, showing statistical significance (p < 0.05). It was moderately accurate in low-frequency hearing loss (250, 500, 1 000 Hz) in the SR, and poor in the QR and WR. CONCLUSION: Using the iPhone, uHear is a feasible screening test to rule out significant hearing loss (PTA > 40 dB). It is highly sensitive for detecting threshold changes at high frequencies, making it reasonably well suited to detect presbycusis and ototoxic hearing loss from HIV, tuberculosis therapy and chemotherapy. Portability and ease of use make it appropriate to use in developing world communities that lack screening programmes.