Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Otitis media with effusion in Africa‐prevalence and associated factors: A systematic review and meta‐analysis

Objectives
To estimate the overall and subgroup prevalence of otitis media with effusion (OME) in Africa, and identify setting‐specific predictors in children and adults.

Methods
PubMed, African Journals Online, African Index Medicus, Afrolib, SciELO, Embase, Scopus, Web of Science, The Cochrane Library, GreyLit and OpenGray were searched to identify relevant articles on OME in Africa, from inception to December 31st 2019. A random‐effects model was used to pool outcome estimates.

Results
Overall, 38 studies were included, with 27 in meta‐analysis (40 331 participants). The overall prevalence of OME in Africa was 6% (95% CI: 5%‐7%; I2 = 97.5%, P < .001). The prevalence was 8% (95% CI: 7%‐9%) in children and 2% (95% CI: 0.1%‐3%) in adolescents/adults. North Africa had the highest prevalence (10%; 95% CI: 9%‐13%), followed by West and Southern Africa (9%; 95% CI: 7%‐10% and 9%; 95% CI: 6%‐12% respectively), Central Africa (7%; 95% CI: 5%‐10%) and East Africa (2%; 95% CI: 1%‐3%). There was no major variability in prevalence over the last four decades. Cleft palate was the strongest predictor (OR: 5.2; 95% CI: 1.4‐18.6, P = .02). Other significant associated factors were age, adenoid hypertrophy, allergic rhinitis in children, and type 2 diabetes mellitus, low CD4 count in adults.

Conclusion
OME prevalence was similar to that reported in other settings, notably high‐income temperate countries. Health care providers should consider age, presence of cleft palate, adenoid hypertrophy and allergic rhinitis when assessing OME in children and deciding on a management plan. More research is required to confirm risk factors and evaluate treatment options.

A Novel and Simple Technique of Reconstructing the Central Arch Mandibular Defects-a Solution During the Resource-Constrained Setting of COVID Crisis

The current COVID 19 pandemic has a major impact on healthcare delivery globally. Oral cancer involving anterior arch of mandible is difficult to reconstruct and ideally, requires free fibular osteomyocutaneous flap. During this time of resource constraint situation, these free flaps are not a great choice, as it increases exposure of both patient and surgical team to the deadly virus. We are describing a novel method of reconstruction after resection of oral cancer involving anterior arch of mandible. In this new technique, we have reconstructed central arch defect by hanging bipaddle pectoralis major myocutaneous flap with orbicularis oris muscle using ethylene terephthalate suture. Operative time, early postoperative complications and early cosmetic and functional outcome were assessed. We have used this novel technique in eight patients of T4a oral cancer involving anterior arch of mandible and skin over chin. Mean operative time was 180 min. One patient had minor flap loss with surgical site infection (Clavien-Dindo grade I). In all patients, we were able to discharge all patients on eighth postoperative day. Cosmetic outcome and functional outcomes were mostly satisfactory. All patients were able to oppose their lips without any oral incompetence and drooling. Tongue mobility was good. There was no incidence of ‘Andy Gump deformity’. This is a feasible option for reconstructing anterior arch defect in resource- and time-limited setting of COVID 19 pandemic. This technique can also be used in comorbid conditions where it is not advisable to do very long surgery.

Changing the face of global health: short-term surgical trips

With the growth of global health awareness, global surgery has emerged as a key focus area. This article examines short-term surgical trips (STSTs) as one of the ways used to address some of the gaps in global surgery. It demonstrates the Kenyan experience in organising and participating in a short-term surgical trip with a 10-year history. Their experience has been that STSTs should be co-organised between the regional hosting surgeons and the visiting surgical team, with an emphasis on education rather that the ‘number of surgeries’ performed during each camp.

Evaluation of Portable Tablet-Based Audiometry in a South Indian Population

While a comprehensive booth audiogram is the gold standard for diagnosis of hearing loss, access to this may not be available in remote and low resource settings. The aims of this study were to validate a tablet-based audiometer in a tertiary medical center in India and explore its capacity in improving access to hearing healthcare. Subjects presenting to Ear–Nose–Throat clinics for conventional booth audiometry testing were recruited for subsequent tablet-based audiometric testing. Testing with the tablet was conducted in a non-sound-treated hospital clinic room. Bilateral air and bone conduction hearing threshold data from 250 through 4000 Hz were validated against conventional booth audiometry. In addition, a small feasibility study was conducted in rural clinics. 70 participants (37 adults and 33 children between the ages 5–18) were assessed. 69% were male, with a mean age of 29.7 years. Sensitivity and specificity for the tablet were 89% (95% CI 80–94%) and 70% (95% CI 56–82%), respectively. While median differences in air conduction thresholds between conventional and tablet audiograms showed statistical significance at 250, 500, and 1000 Hz (p < 0.001), the threshold results of the tablet audiometer were within 5 dB of the conventional audiogram and not clinically significant. Ten patients were successfully screened in rural clinics with tablet audiometry. Tablet portable audiometry is a valid tool for air and bone conduction threshold assessment outside of conventional sound booths. It can accurately identify hearing impairment and offers a screening tool for hearing loss in low resource settings.

Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.

Oral cancer: Clinicopathological features and associated risk factors in a high risk population presenting to a major tertiary care center in Pakistan

Oral squamous cell carcinoma (OSCC) has the highest prevalence in head and neck cancers and is the first and second most common cancer in males and females of Pakistan respectively. Major risk factors include peculiar chewing habits like areca nut, betel quid, and tobacco. The majority of OSCC presents at an advanced stage with poor prognosis. On the face of such a high burden of this preventable cancer, there is a relative lack of recent robust data and its association with known risk factors from Pakistan. The aim of this study was to identify the socioeconomic factors and clinicopathological features that may contribute to the development of OSCC. A total of 186 patients diagnosed and treated at a tertiary care hospital, Karachi Pakistan were recruited. Clinicopathological and socioeconomic information was obtained on a structured questionnaire. Descriptive analysis was done for demographics and socioeconomic status (SES) while regression analysis was performed to evaluate the association between SES and chewing habits, tumor site, and tumor stage. The majority of patients were males and the mean age of OSCC patients was 47.62±12.18 years. Most of the patients belonged to low SES (68.3%) and 77.4% were habitual of chewing. Gender (male) and SES were significantly associated with chewing habits (p<0.05). Odds of developing buccal mucosa tumors in chewers (of any type of substance) and gutka users were 2 and 4 times higher than non-chewers respectively. Middle age, chewing habits, and occupation were significantly associated with late stage presentation of OSCC (p<0.05). In conclusion, male patients belonging to low SES in their forties who had chewing habits for years constituted the bulk of OSCC. Buccal mucosa was the most common site in chewers and the majority presented with late stage tumors.

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.

Assessment of Eustachian Tube Functioning Following Surgical Intervention of Oral Submucus Fibrosis by Using Tympanometry & Audiometry

Oral Submucus fibrosis has been reported to cause variation in hearing sensitivity & changes in middle ear function. This study was conducted to validate the influence of OSMF and its surgical correction on middle ear function and hearing sensitivity. In this study, 20 patients (40 ears) suffering from biopsy proven OSMF (Group 2 & 3) were tested for Middle ear dysfunction and hearing sensitivity using Tympanometry & Audiometry. On Tympanometry, Type A curve was obtained in 29 ears, Type B curve in 11 ears preoperatively. Immediate postoperatively TYPE A curve was obtained in 27 ears, TYPE B curve in 13 ears. After 1 month and 3 month Type B curve was not obtained in any ear. On Audiometry,28 ears showed normal hearing and 12 ears showed minimal conductive hearing loss preoperatively and Immediate postoperatively. Tests after 1 month and 3 months showed all 40 ears having normal hearing. Results were found statistically significant with p value 0.000 and F value of 11.331 in Tympanometry and 11.143 in Audiometry. Pearson correlation test revealed that results from both the test are highly co related (0.902). OSMF causes fibrotic changes in paratubal muscles which in addition with restricted mouth opening hampers proper Eustachian tube functioning in turn causing changes in Middle ear function. This feature is seldom/infrequently found in Group 2 and 3 and if encountered can be dealt effectively with surgical intervention.

The Impact of Cleft Lip/Palate and Surgical Intervention on Adolescent Life Outcomes: Evidence from Operation Smile in India

Cleft Lip/Palate (CLP) is a congenital orofacial anomaly appearing in approximately one in 700 births worldwide. While in high-income countries CLP is normally addressed surgically during infancy, in developing countries CLP is often left unoperated, potentially impacting multiple dimensions of life quality. Previous research has frequently compared CLP outcomes to those of the general population. But because local environmental and genetic factors both contribute to the risk of CLP and also may influence life outcomes, such studies may present a downward bias in estimates of both CLP status and restorative surgery. Working with the non- profit organization Operation Smile, this research uses quasi-experimental causal methods on a novel data set of 1,118 Indian children to study the impact of CLP status and CLP correction on the physical, psychological, and social well-being of Indian teenagers. Our results indicate that adolescents with median-level CLP severity show statistically significant losses in indices of speech quality (-1.55), academic and cognitive ability (-0.43), physical well-being (-0.35), psychological well-being (-0.23), and social inclusion (-0.35). We find that CLP surgery improves speech if carried out at an early age, and that it significantly restores social inclusion.