Oral cancer in Papua New Guinea: looking back and looking forward.

Oral diseases, including cancers, affect 3.5 billion people globally and remain largely untreated in low- to middle-income countries because of lack of resources. In Papua New Guinea (PNG), oral cancer has, for many decades, been identified as the most common cancer in men, but as the GLOBOCAN 2018 data are estimates extrapolated from surrounding countries, the real prevalence of this disease is not known. The PNG National Health Plan (2011-2020) highlights the need to improve health care, but oral health is not identified as a priority. Alcohol, tobacco, and areca nut/betel quid, which are the social and commercial determinants of oral cancer, are common risk factors, and there are robust data linking these risk factors to oral cancer in PNG. Our recent Global Challenges Research Fund Workshop on Oral Cancer, held in Port Moresby, PNG, brought together a number of researchers in oral cancer epidemiology and translational science with clinicians from PNG to assess the current situation and plan ways to move forward. In this article, we will review the literature on oral cancer in PNG, and make suggestions as to how, collaboratively, we can address the issues identified, ultimately, for the benefit of the people of PNG.

Airway scleromas and their extensions.

BACKGROUND: Scleroma is a rare, chronic, granulomatous infectious disease of the respiratory tract mucosa which begins in the nose and spreads to the respiratory tract and adjoining structures. We report on the extensions and the management of 134 cases of scleroma in the Highlands region of Papua New Guinea. METHODS: The charts and treatment records of 134 scleroma cases were retrospectively reviewed from 1995 to 2013. The staging, extensions, treatment and results of treatment were reviewed and analysed. RESULTS: Of the 134 cases, 72 (53.7%) were females and the age ranged from 6 to 65 years. The disease was confined to the nose and nasopharynx in 71 (53.0%) cases. Extension of the disease from the nose to the Eustachian tube occurred in nine (6.7%) cases and into the middle ear in four (3.0%) cases. Further extensions to the larynx and trachea were seen in 17 (12.7%) cases each and the bronchus in three (2.2%) cases. Primary laryngoscleroma without involvement of the nose and nasopharyngeal stenosis without laryngeal involvement were managed in 11 (8.2%) and nine (6.7%) cases respectively. Others cases treated were ethmoid scleroma with proptosis and scleroma involving the upper lip in one (0.75%) case each. Ninety-nine (74.9%) patients were treated medically while 35 (26.1%) patients required surgery. Cure were achieved in 83 (61.9%) cases treated medically and 26 (19.4%) had successful surgical outcome. CONCLUSION: Scleroma begins in the nose and when not arrested, extends causing obstruction to the airway and cosmetic deformity which requires surgical intervention.

Transpalatal approach with pedicled palatal osteo-muco-periosteal flap.

BACKGROUND: In the conventional technique of transpalatal approach, the palatal mucoperiosteum is incised and widely elevated and hard palate bone is removed in piece meal and discarded. These technique lead to complications, namely, temporary or permanent palatal fistula, palatal scarring leading to palatal disfiguration and velopharyngeal incompetence. In this article we describe a new technique of doing palatotomy to avoid these complications. METHODS: A retrospective review of post-operative complications of 20 patients that underwent transpalatal approach by the conventional technique was performed. To avoid the complications encountered in these cases, a new approach was designed when the palatal mucoperiosteum on the pathological side was elevated partially, greater palatine artery was coagulated and palatal osteotomy was performed from the oral side. On the non-pathological side, hard palate was sectioned from the nasal side, thus preserving the ipsilateral palatal mucoperiosteum. The entire mucoperiosteum with attached hard palate was reflected orally as a single block which was pedicled on the greater palatine artery and palatal mucoperiosteum of the non-pathological side, thereby creating palatal osteo-mucoperiosteal flap. The flap was placed back at the end of the procedure. Eight patients were operated by this new technique. RESULTS: All 20 patients operated by the conventional transpalatal approach developed post-operative complications. In the eight patients operated by the new technique, no post-operative complications were encountered after 2 years' follow-up. CONCLUSIONS: We found palatal osteo-mucoperiosteal flap an easy and safe way of preserving the hard palate mucoperiosteum and bone with its vasculature resulting in quicker healing and minimal functional impairment.

Intracranial spread of chronic middle ear suppuration.

OBJECTIVE: The aim of the study was to review the pathogenesis and the result of management of the intracranial complications of chronic middle ear suppuration. METHODS: This was a retrospective review of charts of 32 cases with intracranial complications due to chronic middle ear infection managed between 1993 and 2007. The symptoms, clinical findings, and medical and surgical management were reviewed and analyzed. RESULTS: There were 10 (31.2%) patients in the age group of 0 to 10 years, 9 (28.1%) patients in the age group of 11 to 18 years, and 13 (40.6%) patients older than 18 years. Males were involved twice as much as females. Among the 32 patients, 18 (56.3%) had a single intracranial complication, whereas 14 (43.7%) had multiple intracranial complications. Among all the intracranial complications in the 32 patients, otitic meningitis was the commonest intracranial complication and was seen in 14 (43.7%) patients; it was followed by lateral sinus thrombosis in 10 (31.2%), cerebellar abscess in 6 (18.7%), epidural abscess in 7 (21.8%), and perisinus abscess in 5 (15.6%). Other less common but serious intracranial complications encountered were cerebral abscess and interhemispheric abscess in 2 (6.2%) each, and subdural abscess, otitic hydrocephalus, and otogenic cavernous sinus thrombosis in 1 (3.1%) each. Upon admission, all patients received a combination of parenteral antibiotics. Canal wall down mastoidectomy was performed in all but 1 patient. In addition, lateral sinus was explored in 13 (40.6%) and cerebellar abscesses were drained in 5 (15.6%) patients. The overall mortality rate of 31.2% was found in our series. CONCLUSION: The prognosis was worse with delayed presentation because of overwhelming intracranial infection due to multiple pathways of extension from chronic otitis media. Infected thrombus in the dural venous sinus should be removed to prevent dissemination of septic emboli.

Critical look at the surgical approaches of nasopharyngeal angiofibroma excision and "total maxillary swing" as a possible alternative.

OBJECTIVES: We critically analyzed different surgical approaches used for the excision of nasopharyngeal angiofibroma (NPA) at our hospital in a 10-year period and proposed "total maxillary swing" as a possible alternative approach. METHODS: Retrospective review of the clinical and operative records was done regarding 39 cases of NPA that were surgically managed from 1995 to 2005. The duration of the surgical procedures, amount of blood loss and transfusion, time to recurrence, frequency of recurrence, functional and cosmetic deformity, and complications of all surgical procedures were thoroughly analyzed. These parameters were compared with total maxillary swing, a new approach recently being used by us, for the one-time excision of NPA. RESULTS: A total of 61 operations including revision surgeries for recurrences were done in the 39 cases of NPA. Conventional surgical approaches were performed in 37 cases, and the total maxillary swing approach was used in 2 cases. This new approach provided a wider surgical exposure for complete tumor resection and better hemostasis without any recurrence or major functional deformity, which were seen with some of the conventional approaches. CONCLUSIONS: We found total maxillary swing to be a relatively safe alternate approach for the resection of NPA. We removed the entire tumors in a wider surgical field under the microscope with reduced blood loss and minimal complications or chance of recurrences.