Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa.

PURPOSE OF REVIEW: With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option. RECENT FINDINGS: Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints. SUMMARY: With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.

ENT from afar: Opportunities for remote patient assessment, clinical management, teaching and learning.

Remote communication in ENT has been expanding, spurred by the COVID-19 pandemic. Conferences and teaching have moved online, enabling easier participation and reducing financial and environmental costs. Online multi-disciplinary meetings have recently been instigated in Africa to discuss management of cases in head and neck cancer, or cochlear implantation, expanding access and enhancing patient care. Remote patient consultation has also seen an explosion, but existing literature suggests some caution, particularly because many patients in ENT need an examination to enable definitive diagnosis. Ongoing experience will help us to better understand how remote communication will fit into our future working lives, and also where face-to-face interaction may still be preferable.

Reconstructive considerations in low and middle-income countries.

PURPOSE OF REVIEW: Surgical mission trips in head and neck surgery are common. There are an increasing number of surgical groups performing complex reconstructions in low and middle-income countries (LMIC). Consideration of reconstructive options that are location and patient specific are critical for optimum patient care and local physician education. RECENT FINDINGS: The pectoralis muscle regional flap is a versatile and reliable option and has been shown to reconstruct defects in nearly every head and neck subsite. Additional regional flap options described are the supraclavicular island flap and submental island flap. There are 15 published case series describing experience with performing microvascular reconstructions in LMIC. The average success rate was 87.1%. Both loupe and microscope magnification are used. SUMMARY: Complex reconstructions are successfully being performed in LMIC. Although microvascular reconstruction is being utilized by some groups, local and patient-specific factors should be carefully considered, as many regional and local flap options available provide the same reconstruction benefit while minimizing operating room time, resources, and postoperative care needs.

Survey of otolaryngology services in Central America: need for a comprehensive intervention.

In the developing world, there exists a scarcity of services and training in otolaryngology, audiology, and speech therapy, which is reflected by the gap between health care delivery in high-income countries and low-income countries. We surveyed, by questionnaire, the countries of Central America, except for Belize, because of the lack of otolaryngology services, on the following issues: availability of otolaryngology, audiology, and speech therapy services and equipment; otolaryngologist, audiologist, and speech therapist training; and availability of services in rural areas. Surveys were distributed via email and by hand at the 2011 Central American Congress of Otolaryngology, in San Salvador, El Salvador, to otolaryngologists, audiologists, and speech therapists. Not to our surprise, there is a shortfall in services and training in all three professions. The data collected and presented in this commentary will provide a basis by which change might take place.

International practice of laryngectomy rehabilitation interventions: a perspective from South Africa.

PURPOSE OF REVIEW: This review reflects on the experience of speech rehabilitation of laryngectomees at the Groote Schuur Hospital in Cape Town and expands on ways of dealing with the challenges that practising in a developing world setting presents. RECENT FINDINGS: Postlaryngectomy speech rehabilitation is unavailable in most African countries because of a profound shortage of speech and language therapists, otolaryngologists, and trained head and neck surgeons, as well as fiscal limitations. This article presents our recent tracheoesophageal speech results; discusses the employment of early postlaryngectomy feeding, selection criteria for patients for tracheoesophageal speech, the choice of voice prosthesis, follow-up care of patients coming from afar; and presents the results of a comparative study of the efficacy of different methods of airway humidification. SUMMARY: Our data and experience illustrate that excellent postlaryngectomy speech results can be achieved in a developing world setting by a dedicated team comprising speech and language therapists and otolaryngologists, that early postlaryngectomy feeding is well tolerated, and that a simple cotton cloth stoma cover is as effective as more expensive heat moisture exchange devices.

Do South African universities provide the required training platforms for otolaryngology specialist training?

BACKGROUND: Concern exists about the quality of specialist training platforms at South African universities and teaching hospitals. METHOD: We conducted an audit of the quality of training at South African otolaryngology (ENT) training institutions from the perspective of the registrars. RESULTS: Some institutions were deficient in terms of supervision, theatre time, access to teaching aids and research tools, and range of surgery, and do not provide the required training platforms for ENT specialist training. Five out of 8 institutions have produced <2 publications in peer-reviewed journals over the past 5 years. CONCLUSIONS: The HPCSA fails to adequately police the quality of training in South Africa. Training programme shortcomings must urgently be addressed to ensure proper education and training of otolaryngologists.

Survey of ENT services in Africa: need for a comprehensive intervention.

BACKGROUND: Burden of disease (BOD) is greatest in resource-starved regions such as Africa. Even though hearing disability ranks third on the list of non-fatal disabling conditions in low- and middle-income countries, ear, nose, and throat (ENT) disorders are not specifically coded for within the framework governing global BOD estimates, and in discussions about health challenges, non-communicable diseases receive scant attention. Implementing cost-effective interventions to address conditions largely neglected by global estimates of BOD such as hearing loss are important contributors to health and economic development. OBJECTIVES: Establish a database of ENT, audiology, and speech therapy services in Sub-Saharan Africa; create awareness about the status of these services; propose effective intervention; gather data to lobby African governments, donor countries, and aid organizations; determine need for Developing World Forum for ENT, Audiology, and Speech Therapy services. DESIGN: Survey of ENT, audiology, and speech therapy services and training in 18 Sub-Saharan Africa countries. RESULTS: There is an alarming paucity of services and training opportunities, and there is a large gap between higher technology, expensive health care in high-income countries and lower technology, low-cost practice in low-income countries. CONCLUSIONS: Lower technology and lower cost Developing World medical practice should be recognized and fostered as a field of medical practice, teaching, and research. Developing World centers of excellence must be fostered to take a lead in teaching, training, and research. A Developing World Forum for ENT Surgery, Audiology, and Speech Therapy, directed and driven by Africa and the Developing World, supported by the First World, should be established, to develop a comprehensive intervention to turn around the severe shortage of services and expertise in the Developing World. Global health policies and practices should include new norms and standards which serve the interests of the global community, and are based on current realities of global health.

A rapid method for detection of five known mutations associated with aminoglycoside-induced deafness.

BACKGROUND: South Africa has one of the highest incidences of multidrug-resistant tuberculosis (MDR-TB) in the world. Concomitantly, aminoglycosides are commonly used in this country as a treatment against MDR-TB. To date, at least five mutations are known to confer susceptibility to aminoglycoside-induced hearing loss. The aim of the present study was to develop a rapid screening method to determine whether these mutations are present in the South African population. METHODS: A multiplex method using the SNaPshot technique was used to screen for five mutations in the MT-RNR1 gene: A1555G, C1494T, T1095C, 961delT+C(n) and A827G. A total of 204 South African control samples, comprising 98 Mixed ancestry and 106 Black individuals were screened for the presence of the five mutations. RESULTS: A robust, cost-effective method was developed that detected the presence of all five sequence variants simultaneously. In this pilot study, the A1555G mutation was identified at a frequency of 0.9% in the Black control samples. The 961delT+C(n) variant was present in 6.6% of the Black controls and 2% of the Mixed ancestry controls. The T1095C, C1494T and A827G variants were not identified in any of the study participants. CONCLUSION: The frequency of 0.9% for the A1555G mutation in the Black population in South Africa is of concern given the high incidence of MDR-TB in this particular ethnic group. Future larger studies are warranted to determine the true frequencies of the aminoglycoside deafness mutations in the general South African population. The high frequencies of the 961delT+C(n) variant observed in the controls suggest that this change is a common non-pathogenic polymorphism. This genetic method facilitates the identification of individuals at high risk of developing hearing loss prior to the start of aminoglycoside therapy. This is important in a low-resource country like South Africa where, despite their adverse side-effects, aminoglycosides will continue to be used routinely and are accompanied with very limited or no audiological monitoring.

Advances in endoscopic sinonasal and anterior skull base surgery.

Endoscopic transnasal surgery is rapidly replacing more radical external 'open' procedures. At Groote Schuur Hospital, Cape Town, we performed 94 advanced endoscopic sinonasal and anterior skull base procedures over a 2-year period. Most of these would previously have been performed using large external incisions requiring more invasive surgery with significantly higher morbidity. Endoscopic surgery is more cost-effective than open procedures because it reduces duration of hospitalisation, operating time and theatre consumables and obviates the need for postoperative intensive care unit admission. We have had no complications other than 2 cerebrospinal fluid leaks, but the potential risks of endoscopic sinonasal and skull base surgery are significant and proper training is required.