'Seeing is believing' - gender disparities in otolaryngology-head and neck surgery in Africa: a narrative review.

PURPOSE OF REVIEW: Various factors affect otolaryngology - head and neck surgery (OHNS) services in low- and middle-income countries (LMICs); including inadequate infrastructure, limited academic positions, unfavorable hospital research policies, and traditional misconceptions about gender and surgery, among others. Although gender inequalities exist globally, they are particularly pronounced in LMICs, especially in Africa. RECENT FINDINGS: A comparative narrative literature review for relevant manuscripts from January 1, 2017 to through January 10th, 2024, using PubMed, Embase and Google Scholar for articles from the United States/Canada and Africa was done. 195 relevant articles were from the United States/Canada, while only 5 were from Africa and only 1 manuscript was relevant to OHNS. The reviewed articles reported that gender disparities exist in medical training, authorship, and career advancement. We highlight possible solutions to some of these disparities to promote a more gender-diversified workforce in OHNS in Africa as well as all over the world. SUMMARY: Additional studies on gender disparities in Africa, are needed. These studies will highlight need for inclusive policies, structured and accessible mentorship programs; through which these disparities can be highlighted and addressed. This will in the long run ensure sustainability of OHNS care in LMICs.

ISOM 2023 research Panel 4 - Diagnostics and microbiology of otitis media.

OBJECTIVES: To identify and review key research advances from the literature published between 2019 and 2023 on the diagnosis and microbiology of otitis media (OM) including acute otitis media (AOM), recurrent AOM (rAOM), otitis media with effusion (OME), chronic suppurative otitis media (CSOM) and AOM complications (mastoiditis). DATA SOURCES: PubMed database of the National Library of Medicine. REVIEW METHODS: All relevant original articles published in Medline in English between July 2019 and February 2023 were identified. Studies that were reviews, case studies, relating to OM complications (other than mastoiditis), and studies focusing on guideline adherence, and consensus statements were excluded. Members of the panel drafted the report based on these search results. MAIN FINDINGS: For the diagnosis section, 2294 unique records screened, 55 were eligible for inclusion. For the microbiology section 705 unique records were screened and 137 articles were eligible for inclusion. The main themes that arose in OM diagnosis were the need to incorporate multiple modalities including video-otoscopy, tympanometry, telemedicine and artificial intelligence for accurate diagnoses in all diagnostic settings. Further to this, was the use of new, cheap, readily available tools which may improve access in rural and lowmiddle income (LMIC) settings. For OM aetiology, PCR remains the most sensitive method for detecting middle ear pathogens with microbiome analysis still largely restricted to research use. The global pandemic response reduced rates of OM in children, but post-pandemic shifts should be monitored. IMPLICATION FOR PRACTICE AND FUTURE RESEARCH: Cheap, easy to use multi-technique assessments combined with artificial intelligence and/or telemedicine should be integrated into future practice to improve diagnosis and treatment pathways in OM diagnosis. Longitudinal studies investigating the in-vivo process of OM development, timings and in-depth interactions between the triad of bacteria, viruses and the host immune response are still required. Standardized methods of collection and analysis for microbiome studies to enable inter-study comparisons are required. There is a need to target underlying biofilms if going to effectively prevent rAOM and OME and possibly enhance ventilation tube retention.

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.

Vestibular migraine in low- and lower-middle-income countries: A scoping review.

Background: Vestibular migraine (VM) is a common cause of dizziness that is underrecognized, underdiagnosed, and challenging to effectively treat. The prevalence, appropriate diagnostic workup, and therapies for VM in low- and lower-middle-income countries (LLMICs) remain understudied. The objective of this scoping review is to evaluate the current state of VM research in LLMICs. Methods: PubMed, Embase, and Web of Science databases were searched to execute a scoping review of VM. Keywords "vestibular diseases" and "vertigo" were used in combination with terms referring to LLMICs as defined by the World Bank. Title and abstract screening, full-text review, and data collection were conducted by two authors independently. Results: Twenty-six studies were included in the scoping review. Most studies were cross-sectional (57.7%) or case studies/series (23.1%) and were conducted in urban settings only (92.3%). Geographic distribution of studies was skewed, with 65.4% of articles originating from India. The prevalence of VM among clinic patients ranged from 0.3% to 33.3%. VM most frequently presented as headache, nausea and vomiting, and photophobia. Radiographic imaging, audiometry, and electronystagmography/videonystagmography were the three most commonly utilized diagnostic modalities in the dizziness workup. The most studied pharmacotherapies included calcium channel blockers, followed by beta-blockers and antiepileptics. Case studies and series discussed less common VM pharmacotherapies, such as ayurvedic medicine. Conclusions: There is a need for more VM research in LLMICs, including innovative diagnostic approaches and therapies that can improve VM care globally. Equitable partnerships between LLMIC and high-income country researchers must expand vestibular research capacity and productivity in LLMICs.

Are open access article processing charges affordable for otolaryngologists in low-income and middle-income countries?

PURPOSE OF REVIEW: Open access articles are more frequently read and cited, and hence promote access to knowledge and new advances in healthcare. Unaffordability of open access article processing charges (APCs) may create a barrier to sharing research. We set out to assess the affordability of APCs and impact on publishing for otolaryngology trainees and otolaryngologists in low-income and middle-income countries (LMICs). RECENT FINDINGS: A cross-sectional online survey was conducted among otolaryngology trainees and otolaryngologists in LMICs globally. Seventy-nine participants from 21 LMICs participated in the study, with the majority from lower middle-income status (66%). Fifty-four percent were otolaryngology lecturers while 30% were trainees. Eighty-seven percent of participants received a gross monthly salary of less than USD 1500. Fifty-two percent of trainees did not receive a salary. Ninety-one percent and 96% of all study participants believed APCs limit publication in open access journals and influence choice of journal for publication, respectively. Eighty percent and 95% believed APCs hinder career progression and impede sharing of research that influences patient care, respectively. SUMMARY: APCs are unaffordable for LMIC otolaryngology researchers, hinder career progression and inhibit the dissemination of LMIC-specific research that can improve patient care. Novel models should be developed to support open access publishing in LMICs.

19 Months Toddler with a Giant Oral Capillary Hemangioma, a Case Report.

Head and neck vascular tumors are common in children. Capillary hemangiomas are often easily confused with pyogenic granulomas due to histopathological resemblance. Furthermore, predisposing factors to pyogenic granulomas include an existing hemangioma, which may be co-existing entities. Surgical excision of large unsightly tumors causing functional deficits is a feasible management option. We report a case of a rapidly growing oral lesion in a toddler with feeding difficulties and anemia. It triggered a diagnostic dilemma as it was clinically consistent with a pyogenic granuloma but histologically diagnosed as a capillary hemangioma. It was successfully excised with no recurrence after 6 months.

Female and low- and middle-income authorship trends in high-impact ENT journals (2011-2020).

Introduction: Despite a recent drive to increase diversity, the global academic workforce is skewed in favor of authors from high-income countries, and women are under-represented in the published medical literature. Objectives: To explore the trends in authorship of three high-impact otolaryngology journals over a ten-year period (2011-2020). Methods: Journals selected: JAMA Otolaryngology-Head and Neck Surgery, The Laryngoscope and Rhinology. Articles were reviewed from four issues per journal per year, and data was collected on: time of publication; subspeciality; number of authors; sex of first and last authors; country of practice of first author and country where each study was conducted. Trends were examined though univariate and multivariate logistic regression models. Results: 2998 articles were included. 93.9% of first authors and 94.2% of studies were from high-income countries.Women were first authors in 31.5% (n = 912) and senior authors in 18.4% (n = 524) of articles. Female first authorship significantly increased between 2011 and 2020 however female senior authorship remained the same. There have been no significant changes in the proportion of published articles from low-and middle-income countries (LMIC) over time (p = .65). Amongst the LMIC articles, 72% came from Brazil, Turkey or China and there were no published papers from countries with a low-income economy (gross national income per capita of $1085 or less). Conclusions: Although female first authorship has increased in the last decade, there has been minimal other demographic change in authorship over this time. High-impact otolaryngology journals poorly represent academia in low-and-middle income countries. There is a need for increased advocacy promoting gender and geographical research equity in academic medicine. Level of Evidence: III.

Barriers to head and neck cancer care in high-income and low- and middle-income countries: a scoping review.

PURPOSE OF REVIEW: Identify patient-perceived barriers to head and neck cancer care and compare differences in barriers by country income status. RECENT FINDINGS: Of the 37 articles, 51% ( n  = 19) were from low- and middle-income countries (LMICs), while 49% ( n =  18) were from high-income countries. Of the papers from high-income countries, unspecified head and neck cancer (HNC) subtype (67%, n =  12) were the most common cancer type, while upper aerodigestive tract mucosal malignancies (58%, n =  11) were more common in LMICs ( P  = 0.02). Based on World Health Organization barriers, level of education ( P  =  < 0.01) and alternative medicine use ( P  = 0.04) were greater barriers in LMICs compared to high-income countries. At least 50% of articles listed barriers at all three 'Three Delays' timepoints. There were no significant differences by country income status for the 'Three Delays' timepoints of deciding to seek care ( P  = 0.23), reaching the healthcare facility ( P  = 0.75), or receiving care ( P  = 1.00). SUMMARY: Patients face barriers to care for head and neck cancer regardless of country income status. There is overlap in several barriers and a need for systemic improvement in access. The differences in education and alternative medicine may guide region-specific interventions to improve the provision of head and neck services.

Essential equipment and services for otolaryngology care: a proposal by the Global Otolaryngology-Head and Neck Surgery Initiative.

PURPOSE OF REVIEW: To highlight the need for comprehensive resource lists to provide baseline care of otolaryngologic conditions; to present a proposed list of essential equipment and services that may be applied toward surgical systems research, policymaking, and charitable efforts in global otolaryngology-head and neck surgery. RECENT FINDINGS: To provide effective and high-quality surgical care across care settings, there must be a global standard for equipment and ancillary services necessary to provide baseline care. Though there have been efforts to devise resource standards via equipment lists and appraisal tools, these have been limited in scope to general surgery, emergency care, and a few other subspecialty surgical contexts. Recent efforts have brought attention to the significant burden imposed by otolaryngologic conditions such as hearing loss, otitis media, head and neck cancer, head and neck trauma, and upper airway foreign bodies. Yet, there has not been a comprehensive list of resources necessary to provide baseline care for common otolaryngologic conditions. SUMMARY: Through an internal survey of its members, the Global Otolaryngology-Head and Neck Surgery Initiative has compiled a list of essential equipment and services to provide baseline care of otolaryngologic conditions. Our efforts aimed to address common otolaryngologic conditions that have been previously identified as high-priority with respect to prevalence and burden of disease. This expert-driven list of essential resources functions as an initial framework to be adapted for internal quality assessment, implementation research, health policy development, and economic priority-setting.

Implementing hearing screening among children aged 0-59 months at established immunization clinics in Uganda: A multi-center study.

OBJECTIVE: The prevalence of childhood hearing loss (HL) is high in low and middle income countries (LMICs), with many of the affected children facing communication delays and poor opportunities for education. Despite the increased advocacy for childhood hearing screening globally, Uganda has no established childhood hearing screening programs. This study set out to introduce hearing screening services by non-specialist health workers at routine immunization clinics among children aged 0-59 months and describe the prevalence and factors associated with failed hearing screening (HS) in these children. METHODS: A cross-sectional multi-center study was conducted at immunization clinics at three regional referral hospitals (RRHs). A semi structured questionnaire was used to capture data on socio-demographic, clinical factors and the two stage Transient Evoked Oto-acoustic emissions (TEOAEs) screening performed on children aged 0-59 months. A child that failed two stage screening was considered to have failed HS. Logistic regression was used to calculate odds ratios (OR) for factors associated with failed HS. RESULTS: 1217 children were recruited at three RRHs, with a median age of 2 months (range: 0 to 59), half were male 52% (n = 633). Overall 45 children failed two staged TEOAE screening giving a prevalence of failed HS of 3.7%, of these 27 (2.2%) and 18 (1.5%) failed unilaterally and bilaterally respectively. Children of rural residence (aOR = 2.18, p = 0.027), of low birth weight (aOR = 0.42, p = 0.045), with relatives having hearing loss (aOR = 4.64, p= <0.001), who were admitted in hospital after birth (aOR = 3.72, p = 0.012) and a history of a childhood suppurative otitis media (aOR = 9.53, p = 0.015) all had increased odds of failed HS. CONCLUSIONS: The prevalence of failed screening is high. Implementation of childhood hearing screening by non-specialist health workers at immunization clinics using TEOAEs is possible and may be a necessary initial step in starting countrywide hearing screening in Uganda.

Gender Disparities in Otolaryngology: A Case Report Reflecting Global Perspectives.

OBJECTIVES: To explore the impact of female sex on the experiences of trainees and surgeons in otolaryngology from LMIC and HIC. METHODS: This study includes perspectives of five consultants and two resident physicians from the United States, United Kingdom, Uganda, Kenya and South Africa. RESULTS: Six themes emerged from these interviews. Overall, LMIC and HIC women shared similar experiences of microaggressions during patients, working along ancillary staff, related to pregnancy, imposter syndrome, difficulties during job search, and unique barriers as consultant. CONCLUSIONS: The findings of this study highlight that gender disparities are present at all levels in Otolaryngology but can present differently depending on context. Laryngoscope, 133:547-551, 2023.

Feasibility of establishing an infant hearing screening program and measuring hearing loss among infants at a regional referral hospital in south western Uganda.

INTRODUCTION: Despite the high burden of hearing loss (HL) globaly, most countries in resource limited settings lack infant hearing screening programs(IHS) for early HL detection. We examined the feasibility of establishing an IHS program in this setting, and in this pilot program measured the prevalence of infant hearing loss (IHL) and described the characteristics of the infants with HL. METHODS: We assessed feasibility of establishing an IHS program at a regional referral hospital in south-western Uganda. We recruited infants aged 1 day to 3 months and performed a three-staged screening. At stage 1, we used Transient Evoked Oto-acoustic Emissions (TEOAEs), at stage 2 we repeated TEOAEs for infants who failed TEOAEs at stage 1 and at stage 3, we conducted Automated brainstem responses(ABRs) for those who failed stage 2. IHL was present if they failed an ABR at 35dBHL. RESULTS: We screened 401 infants, mean age was 7.2 days (SD = 7.1). 74.6% (299 of 401) passed stage 1, the rest (25.4% or 102 of 401) were referred for stage 2. Of those referred (n = 102), only 34.3% (35 of 102) returned for stage 2 screening. About 14.3% (5/35) failed the repeat TEOAEs in at least one ear. At stage 3, 80% (4 of 5) failed the ABR screening in at least one ear, while 25% (n = 1) failed the test bilaterally. Among the 334 infants that completed the staged screening, the prevalence of IHL was 4/334 or 12 per 1000. Risk factors to IHL were Newborn Special Care Unit (NSCU) admission, gentamycin or oxygen therapy and prematurity. CONCLUSIONS: IHS program establishment in a resource limited setting is feasible. Preliminary data indicate a high prevalence of IHL. Targeted screening of infants at high risk may be a more realistic and sustainable initial step towards establishing IHS program s in a developing country like Uganda.

Maternal knowledge on infant hearing loss and acceptability of hearing aids as an intervention at a Referral Hospital in southwestern Uganda.

OBJECTIVE: Infant hearing screening enables early detection and management of hearing loss (HL) so that speech and language development delays are minimized. Parents play a critical role in successful screening and management of Infant Hearing loss (IHL) but there is limited data from resource limited settings on parental knowledge about HL and acceptability of IHL interventions. This study was aimed at exploring the maternal knowledge on the various causes of IHL and their acceptability of hearing aids as an intervention for IHL. METHODS: A cross-sectional study was conducted at a referral hospital in southwestern Uganda. A semi-structured questionnaire was used to interview postpartum mothers to assess their knowledge on causes of IHL and acceptability of a hearing aid if prescribed. Logistic regression was used to calculate odds ratio (OR) for the factors associated with hearing aid refusal. RESULTS: 401 mothers with a mean age of 25 years (Standard Deviation = 5.6 years) were recruited. Half of the mothers correctly identified at least five causes of IHL. The most well-known causes were measles (63.3%) and a positive family history of HL (61.6%). 60% of mothers held at least one superstitious belief as a cause of IHL. Majority of mothers (86%) would accept a hearing aid as an IHL intervention. Mothers with a positive family history of HL (OR = 0.42, p = 0.04), in middle or higher socioeconomic class (OR = 0.45, p = 0.01) and those with more than 3 antenatal visits in their recent pregnancy (OR = 0.44, p = 0.01) were less likely to refuse a hearing aid while mothers that were either widowed or separated from their spouses (OR = 15.64, p = 0.01) were more likely to refuse a hearing aid. CONCLUSION: Although mothers had limited knowledge on some causes of IHL, there was a high acceptability of hearing aids as an intervention for IHL. Marital status, family history of hearing loss, socioeconomic status and antenatal care attendance are factors that could be used to identify mothers that might accept or refuse a hearing aid for their infant. There is need to increase awareness about causes of hearing loss to improve knowledge as well as dispel any non-biological beliefs held by communities.