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.

Nasopharyngeal carcinoma in Ibadan, Nigeria: a clinicopathologic study.

INTRODUCTION: nasopharyngeal carcinoma is relatively common in our environment. It is one of the most difficult malignancies to diagnose at an early stage. The aim of the study was to determine the clinical features, clinical disease stage of nasopharyngeal carcinoma at presentation and at diagnosis as well as the histologic types at the University College Hospital, Ibadan, Nigeria. METHODS: this was a ten year retrospective study of all histologically confirmed nasopharyngeal carcinoma between January 2007 to December 2016 using clinical and pathology records and files. RESULTS: there were 73 cases. The male: female ratio was 1.7. The age of patients ranged from 12 to 80 years with a mean age of 39 ± 16 years. The median age at diagnosis was 40 years. The peak age group of occurrence was 40-49 years. The most common symptoms were namely epistaxis in 67.1% of patients at presentation, neck mass/swelling (64.4%) and nasal mass/obstruction (63.0%). Majority (54.8%) of the patients presented late with stage 3 or 4 disease. Most (94.5%) of the tumours were of the non-keratinizing squamous cell carcinoma subtype. The keratinizing and basaloid variants accounted for 4.1% and 1.4% of the tumours respectively. CONCLUSION: vague, non-specific symptoms make patients present at late stages of the disease, making it almost impossible to attempt cure. The dominant histopathological type is non-keratinizing squamous cell carcinoma and resembles that seen in most parts of Nigeria and endemic areas of the world.

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.

Stage of chronic kidney disease and cochlear function: A cross-sectional survey.

BACKGROUND: Studies have shown that hearing loss increases in patients with chronic kidney disease (CKD) with decreasing glomerular filtration rate. The hearing loss in CKD patients may worsen over time which in turn will negatively affect the patient's ability to effectively communicate with people, resulting in low self-esteem, social isolation, anger and depression. We aimed to assess the relationship between stage of CKD and hearing threshold in patients with CKD in Kaduna. PATIENTS AND METHODS: A cross-sectional study of patients with CKD in Kaduna. Individuals were selected consecutively using convenience sampling. Ethical approval and informed consent were obtained. The patients were grouped based on the stage of the disease. The pure tone audiometry was carried out using a Diagnostic Audiometer (Graphic Digi-IS, USA). The hearing threshold of the patients was then compared based on stage of the disease. The data collected was analysed using Statistical Product and Service Solutions, version 20. RESULTS: Sixty CKD patients (120 ears) were assessed. Their mean age was 43.2 ± 13.4 years and 70% were males. Of the 120 ears studied, 51 (42.5%) had normal hearing thresholds and 69 (57.5%) had hearing loss. Of the 69 ears with hearing loss, 11 (15.9%), 22 (31.9%) and 36 (52.2%) were in Stage III, IV and V, respectively, and the difference was statistically significant (P = 0.006). All those with Stage III CKD had mild hearing loss and the hearing loss worsen with advancing stage. Stage III CKD had significantly better hearing than those with stage IV and V (P < 0.001). CONCLUSION: Our study showed a statistically significant relationship between advancing stage of CKD and hearing loss. The hearing loss worsen with advancing stage of CKD.

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.

Gustatory Function of Pregnant and Nonpregnant Women in a Tertiary Health Institution.

Physiological changes in pregnancy may cause taste dysfunction. The aim of this study was to determine and compare gustatory function of pregnant women with nonpregnant women and also to investigate the effect of pregnancy on gustatory function. It was a case-control study of consecutive 70 healthy pregnant women (cases) and 70 healthy nonpregnant women (control). Participants scored their taste perception on a visual analogue scale (1-10) and their gustatory function was assessed using "taste strips" impregnated with graded concentration of sweet, sour, salty, and bitter taste substances applied on tongue surfaces. Subjective mean gustatory score, correct identification of taste in the strips and total taste strip (TTS) score were compared between both groups and analysis was done using appropriate statistics. The mean age of pregnant women (30.5 [3.9]) and controls (28.5 [6.6]) were comparable. Twenty-one (30%) pregnant women changed their diet in first trimester due to change in taste sensation. Almost all cases developed craving for spicy and salty foods and, aversions to fish, beans, and vegetables. There was a significant difference in the subjective rating of taste perception between the 2 groups ( P = .037). About 2.9% of pregnant women have hypogeusia. There was a significant difference between pregnant and nonpregnant women in sour taste ( P = .006; 2.90 [0.71] vs 3.92 [0.82]) and TTS ( P = .02; 27.50 [3.48] vs 29.21 [2.69]) scores, respectively. In conclusion, gustatory function was reduced in pregnancy compared to nonpregnant women and this led to dietary change in some pregnant women.

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.

Malignant tumors of the larynx: Clinicopathologic profile and implication for late disease presentation.

BACKGROUND: Malignant laryngeal tumors are uncommon. Late presentation of the disease may worsen management outcomes. We described the epidemiologic, clinicopathologic profile, and management outcomes of laryngeal tumors in a tertiary health institution in Nigeria. MATERIALS AND METHODS: An 11-year retrospective review of medical records of patients managed for malignant laryngeal tumor at the University College Hospital, Ibadan, Nigeria, was performed. RESULTS: There were 97 patients comprising 74 (76.3%) males and 23 (23.7%) females with a mean age of 60.48 ± 12.15 years. The mean duration of illness was 7.3 ± 3.8 months. History of cigarette smoking and alcohol consumption was in 2.1% and 14.4% patients, respectively. The most common clinical presentations were hoarseness, cough, and dyspnea. Transglottis (91.8%) was the most common anatomic tumor location and 92.8% patients presented in advanced disease stage. Four histologic types were identified with squamous cell carcinoma accounting for 96.9%. About 92% patients had emergency tracheostomy and 56 (57.7%) patients had total laryngectomy. The postoperative complications were pharyngocutaneous fistula (5.2%) and peristomal recurrence (3.1%). The 5-year survival rate was 52.5%. CONCLUSIONS: Malignant laryngeal tumors are uncommon, but more females are getting the disease. Squamous cell carcinoma is the most common histologic variant. Late stage disease presentation and initial wrong diagnosis contributed to the poor management outcome.

Neonatal hearing screening in a rural/sub-urban community in Nigeria, sub-Saharan Africa-a preliminary report.

INTRODUCTION: The implementation of Neonatal Hearing Screening (NHS) program is still at the preliminary stage particularly in developing countries despite the burden of permanent congenital and early-onset hearing impairment. There has been an earlier report of NHS in a city in Nigeria, however, this is a report of a preliminary NHS carried in a rural/sub-urban area in Nigeria. METHOD: This prospective study, which took place between October 2009 and April 2010, involved all newborns delivered at the University College Hospital, Ibadan and the Bilal Missionary Maternity, Agodi, Ibadan, a small maternity service located in Agodi community serving predominantly low socioeconomic class people. All the neonates delivered during the study period were included in the screening. The screening was performed within 72 h of delivery using automated auditory brainstem response (AABR) and repeated after 6 weeks among those with referral result. Subsequently the neonates were referred to diagnostic audiology. RESULT: Among the 453 newborns (231 males and 222 female), AABR screening showed referral, in 43.7% of neonates. At first screening, 224 (49.4%) were referred while 229 (50.6%) passed, however, during the post-natal period 40/229 (17.5%) reported for second screening, out of these 26 showed pass to the screening. This gave a total pass of 255/453 (56.3%). The presence of maternal pre-ecclampsia (P = 0.05) was found to be a significant morbidity factor associated with referral in the screening, while parental socioepidemiological variables; and the neonates' birthweight, gestational age and APGAR score were not. CONCLUSION: The proportion of referral on hearing screening encountered was far higher than previously reported, however, continuation of infant screening in future should be comprehensive with viral and genetic analysis in order to address the issue of aetiologic diagnosis; in addition, the implementation should factor the high drop out from the first stage screening in order to substantiate the findings in our region.

Hearing impairment in persons with the hemoglobin SC genotype.

The hemoglobin (Hb) SC genotype is seen in persons who have inherited the gene for hemoglobin S from one parent and the gene for hemoglobin C from the other. Some people with this genotype develop Hb SC disease, a variant of sickle cell disease. Hb SC disease, a compound heterozygous condition, is the most common of the hemoglobinopathies and the least severe, although it is still serious. One of the documented complications of the presence of the Hb SC genotype is sensorineural hearing loss (SNHL). We conducted a prospective case-control study of 43 subjects, aged 15 to 65 years, who had the Hb SC genotype to determine the incidence of SNHL and to determine if the hearing loss in these subjects was correlated with sex or age. Our control group was made up of 100 generally healthy, sex- and age-matched subjects with the normal Hb AA genotype. SNHL was defined as a loss of more than 25 dB HL at two or more frequencies in the same ear or at one or more frequencies in both ears. We found that SNHL was present in 12 of the 43 subjects (27.9%) in the Hb SC group (17 of 86 ears [19.8%]) and in 17 of the 100 subjects (17.0%) in the Hb AA group (21 of 200 ears [10.5%]; the difference between the two groups was not statistically significant (chi(2) = 1.589; p = 0.105). We found that in the Hb SC group, SNHL was more common among females than males (38.5 vs. 11.8%), although the difference was not quite significant statistically (chi(2) = 2.435; p = 0.056); in the Hb AA group, the incidence was fairly equal-15.4 and 18.8%, respectively (chi(2) = 0.033; p = 0.427). Therefore, we conclude that the hearing loss in the subjects of this study was not correlated with the presence of the Hb SC genotype in either sex. In terms of age, SNHL was significantly more common in subjects aged 41 to 65 years than in those aged 15 to 40 years in both genotype groups. In the Hb SC group, SNHL was present in 4 of the 33 younger subjects (12.1%) and in 8 of the 10 older subjects (80.0%) (chi(2) = 14.354; p < 0.001). In the Hb AA group, the corresponding figures were 7 of 85 (8.2%) and 10 of 15 (66.7%) (chi(2) = 26.840; p < 0.001). Therefore, we conclude that the hearing loss in the subjects of this study was a function of age and was not associated with the presence of the Hb SC genotype.

Assessments of the size of tympanic membrane perforations: a comparison of clinical estimations with video-otoscopic calculations.

We conducted a study to determine how accurate various ENT specialists were in estimating the size of 100 tympanic membrane (TM) perforations with standard otoscopy. The specialists included, in descending order of rank, 2 Consultant Surgeons, 2 Senior Registrars, and 2 Registrars, all of whom had confirmed good vision. We compared their estimates, which were made independently and expressed as a percentage of the total area of the TM, with exact measurements calculated with computer-based video-otoscopy. We found that the video-otoscopic calculations were far superior to the estimates of the specialists, even the most experienced Consultants (p < 0.01). We recommend that video-otoscopy be used whenever possible.

Sinonasal paraganglioma: a case report.

OBJECTIVE: To highlight the importance of a high index of suspicion and meticulous evaluation of a patient with bleeding sinonasal mass in the diagnosis of sinonasal paraganglioma. METHOD: Case report of a 39-year-old female who presented with a bleeding lobulated left nasal mass necessitating multiple blood transfusions is presented. RESULT: Diagnostic investigations revealed that the patient was HIV-positive (ELISA and Western blot) and a tumour histology of paraganglioma. She had a CD4+ count of 487 cells/mm3. The urinary vanillylmandelic acid assay and echocardiography were normal. Subsequently, she had complete tumour excision through a medial maxillectomy and has remained without a recurrence 12 months after. CONCLUSION: To our knowledge, this is the first report in the world literature of sinonasal paraganglioma in a HIV-positive patient and the first reported case of sinonasal paraganglioma in Africa. It is, however, not clear from this report if the patient's HIV status preceded her development of the paraganglioma or not.

Migraine and Meniere's disease: two different phenomena with frequently observed concomitant occurrences.

BACKGROUND: Some variants of migraine could be indistinguishable from Meniere's disease, and this has prompted suggestions of possible association between the two disease entities. AIM AND OBJECTIVES: This study aims at determining the prevalence of migraine among Meniere's patients and a possible linkage between the two diseases in our environment. METHODOLOGY: A 10-year retrospective study of patients diagnosed with Meniere's disease using American Academy of Otorhinolaryngology criteria, including those that had associated migranous symptoms in accordance with the International Headache Society (IHS) diagnostic criteria for migraine, between 1996 and 2005. The prevalence of migraine in the Meniere's patients was also compared with lifetime prevalence recorded from a previous population-based study within the same setting. The statistical difference was tested with a Z nonparametric test (significance at P < 0.05). Epicalc2000 and SPSS 11 were used for the statistical analysis. RESULT: A total of 25 patients representing 0.22% of the 11,463 ear, nose and throat outpatients seen within the study period met the diagnostic criteria for Meniere's disease. There were nine (36%) males and 16 (94%) females. Their ages ranged 27-65 years, mean 45.25 years +/- 11.05. Eight (32%) met IHS criteria for migraine. There is a statistically significant difference between the prevalence of migraine in Meniere's patients and migraine in the overall population (32% vs. 5.3%, P = 0.000). CONCLUSION: The significant preponderance in the prevalence of migraine in Meniere's disease suggests a link between the two diseases. However, more molecular or genetic studies are needed to unveil this phenomenon.

Otomycosis in western Nigeria.

Otomycosis is a recognized clinical entity in the tropical regions of the world. However, there is scanty information on this disease in some parts of Sub-Saharan Africa. The aim of this study was to determine the prevalence and pattern of etiological agents of otomycosis in western Nigeria. Medical records of patients with otomycosis seen in the Otorhinolaryngology Department of the University College Hospital, Ibadan from 1996-2005 were reviewed for all essential clinical data. Of the 5784 patients with ear diseases, 378 (6.54%) had otomycosis which consisted of 145 (38.36%) males and 233 (61.64%) females. Seventeen patients (4.50%) had recurrence within six months of treatment, 4 (1.06%) had poorly controlled plasma glucose. A significant number of our patients, 52 (13.76%), had prior topical aural antibiotic treatment following misdiagnosis. The predominant etiological agents in our series were Aspergillus niger (48.35%) and Aspergillus fumigatus (33.96%).

Quality of life in patients with head and neck cancers.

OBJECTIVE: The aim was to assess the psychosocial effects on the quality of life (QOL) of adults with head and neck cancer (HNC) and any gender variations with predictive factors that may influence QOL. PATIENTS AND METHODS: This was a three-month descriptive and prospective evaluation of QOL in 50 adult patients with HNC who were still on treatment but had spent a period of at least four weeks from commencement in a tertiary hospital. MAIN OUTCOME RESULTS: There were 32 males and 18 females with a mean age of 47.74 years. Females had higher mean scores than males in all domains except pain domain, global and general questions. There was no significant difference in the mean score between the genders in all the domains: overall bother, overall satisfaction, response to treatment, site with QOL and health-related QOL (HRQOL). Pain domain correlated significantly with eating and emotion but weakly with stage of the disease. The predictive factor for overall bother was mainly emotion domain, while site of lesion with QOL was for overall satisfaction, response to treatment and HRQOL. CONCLUSIONS: Pain, which is a major problem experienced by these patients with HNC, requires more attention by the caregiver in order to improve their QOL.

Esophageal impacted dentures.

OBJECTIVES: This study aims to highlight the problems associated with impacted acrylic dentures and proffers advice to check them. PATIENTS AND METHODS: Retrospective review of all cases of impacted acrylic dentures over a 16-year period. RESULTS: Twenty-two adults had impacted esophageal acrylic dentures of which 16 (72.7%) and six (27.3%) were males and females, respectively (M:F ratio = 2.7:1) with age range 23-77 years. Fourteen patients (63.6%) had worn their dentures for more than 10 years without check-up, and 54.5% presented within 48 hours of impaction. The common symptoms in all the patients were difficulty with swallowing, throat pain and discomfort, followed by tenderness in the neck in 15 (68.2%). Dentures were extracted through esophagoscopy (17 cases) and cervical (three cases) esophagotomy, respectively. Observed complications included pulmonary edema in one and esophageal perforation in five patients. CONCLUSION: Endoscopic extraction of dentures carries a high risk of perforation. Extraction of an impacted denture via esophagoscopy can be undertaken under direct vision and in an ideal situation with judicious use of the Shears forceps. In the absence of these, the safest option is an esophagotomy. Proper treatment planning in the fabrication of dentures with incorporation of radiopaque materials in the dental resins and adequate postdenture delivery instructions are necessary as preventive measures.