Feasibility and Acceptability of Web-Based Structured Oral Examinations for Postgraduate Certification: Mixed Methods Preliminary Evaluation.

BACKGROUND: The COVID-19 pandemic disrupted postgraduate certification examinations globally. The Colleges of Medicine of South Africa continued hosting certification examinations through the pandemic. This was achieved by effecting a rapid transition from in-person to web-based certification examinations. OBJECTIVE: This formative evaluation explored candidates' acceptability of web-based structured oral examinations (SOEs) hosted via Zoom (Zoom Communications Inc). We also reported the audiovisual quality and technical challenges encountered while using Zoom and candidates' overall experience with these examinations conducted during the early part of the COVID-19 pandemic. Additionally, performance in web-based certification examinations was compared with previous in-person certification examinations. METHODS: This mixed methods, single-arm evaluation anonymously gathered candidates' perceptions of web-based SOE acceptability, audiovisual quality, and overall experience with Zoom using a web-based survey. Pass rates of web-based and previous in-person certification examinations were compared using chi-square tests, with a Yates correction. A thematic analysis approach was adopted for qualitative data. RESULTS: Between June 2020 and June 2021, 3105 candidates registered for certification examinations, 293 (9.4%) withdrew, 2812 (90.6%) wrote, and 2799 (99.9%) passed, and 1525 (54.2%) were invited to a further web-based SOE. Examination participation was 96.2% (n=1467). During the first web-based examination cycle (2020), 542 (87.1%) of 622 web-based SOE candidates completed the web-based survey. They reported web-based SOEs as fair (374/542, 69%) and adequately testing their clinical reasoning and insight (396/542, 73.1%). Few would have preferred real patient encounters (173/542, 31.9%) or in-person oral examinations (152/542, 28%). Most found Zoom acceptable (434/542, 80%) and fair (396/542, 73.1%) for hosting web-based SOEs. SOEs resulted in financial (434/542, 80%) and time (428/542, 79%) savings for candidates. Many (336/542, 62%) supported the ongoing use of web-based certification examinations. Only 169 technical challenges in using Zoom were reported, which included connectivity-related issues, poor audio quality, and poor image quality. The thematic analysis identified 4 themes of positive and negative experiences related to web-based SOE station design and content, examination station environment, examiner-candidate interactions, and personal benefits for candidates. Our qualitative analysis identified 10 improvements for future web-based SOEs. Candidates achieved high pass rates in web-based certification examinations in 2020 (1583/1732, 91.39%) and 2021 (850/1067, 79.66%). These were significantly higher (2020: N=8635; χ21=667; P<.001; 2021: N=7988; χ21=178; P<.001) than the previous in-person certification examination pass rate of 58.23% (4030/6921; 2017-2019). CONCLUSIONS: Web-based SOEs conducted by the Colleges of Medicine of South Africa during the COVID-19 pandemic were well received by candidates, and few technical difficulties were encountered while using Zoom. Better performance was observed in web-based examinations than in previous in-person certification examinations. These early findings support the ongoing use of this assessment method.

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.

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.

Human Papillomavirus-Associated Head and Neck Malignancies in Sub-Saharan Africa: A Systematic Review.

PURPOSE: The proportion of head and neck cancers (HNCs) with human papillomavirus (HPV) positivity in sub-Saharan Africa (SSA) is poorly characterized. Characterizing this has implications in staging, prognosis, resource allocation, and vaccination policies. This study aims to determine the proportion of HPV-associated HNC in SSA. MATERIALS AND METHODS: This systematic review included searches from PubMed, EMBASE, Web of Science, African Index Medicus, Google Scholar, and African Journals Online. All English publications reporting the proportion of HNC specimens from SSA patients who tested positive for HPV and/or p16 were included. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Case Series Studies. RESULTS: In this systematic review of 31 studies and 3,850 patients, the overall p16 positivity was 13.6% (41 of 1,037 patients tested) with the highest proportion among oropharyngeal cancers (20.3%, 78 of 384 patients) and the overall HPV polymerase chain reaction positivity was 15.3% (542 of 3,548 samples tested) with the highest proportion among nasopharyngeal cancers (16.5%, 23 of 139 patients). Among the 369 HPV strains detected, the most common genotypes were HPV 16 (226 patients, 59.2%) and HPV 18 (78, 20.4%). CONCLUSION: HPV was found to be associated with a significant proportion of HNC in SSA. The genotypes reported suggest that the nine-valent vaccine and gender-neutral vaccination policies should be considered. Given that these studies may not accurately capture prevalence nor causation of HPV in HNC subsites, additional research is needed to provide a more thorough epidemiologic understanding of HPV-associated HNC in SSA, including risk factors and clinical outcomes.

Management of oral feeding following total laryngectomy around the world: YO-IFOS international study.

BACKGROUND: To analyze worldwide practices regarding the initiation of oral feeding after total laryngectomy (TL). METHODS: Online survey. RESULTS: Among the 332 responses received, 278 from 59 countries were analyzed. Our results showed that 45.6% of respondents started water and 45.1% started liquid diet between postoperative days 7 and 10. Semi-solid feeds were initiated between days 10 and 14 for 44.9% of respondents and a free diet was allowed after day 15 for 60.8% of respondents. This timing was significantly delayed in cases of laryngo-pharyngectomy and after prior radiotherapy (p < 0.001). A greater proportion of respondents in Africa and Oceania allowed early oral feeding before day 6 as compared with the rest of the world (p < 0.001). CONCLUSION: Despite increasing number of publications, there is still a lack of evidence to support early oral feeding. The majority of respondents preferred to delay its initiation until at least 7 days after surgery.

Race and Ethnicity in Otolaryngology Academic Publications.

OBJECTIVE: Within otolaryngology, race is commonly included as a study covariate; however, its value in clinical practice is unclear. This study sought to explore how race and ethnicity have been used and applied over time in otolaryngology publications. DATA SOURCES: PubMed database. REVIEW METHODS: A systematic review was done to identify original otolaryngology studies between January 1, 1946, and June 25, 2020, with the following search terms: "otolaryngology" AND "race" OR "ethnicity." RESULTS: Of the 1984 yielded studies, 932 were included in the final analysis. Only 2 studies (0.2%) defined race, and 172 (18.5%) gave participants the opportunity to self-identify race. Less than half (n = 322, 43.8%) of studies controlled for confounders. One hundred studies (10.7%) linked race to genetic factors. An overall 564 (60.5%) made conclusions about race, and 232 (24.9%) mentioned that race is relevant for clinical decision making. The majority of studies had first and senior authors from high-income countries (93.9% and 93.8%, respectively). Over time, there was a significant increase in publications that controlled for confounders, the number of race categories used, and studies that highlighted disparities. CONCLUSION: Race and ethnicity are often poorly defined in otolaryngology publications. Furthermore, publications do not always control for confounding variables or allow participants to self-identify race. On the basis of our findings, we suggest 7 foundational principles that can be used to promote equitable research in otolaryngology publications. Future efforts should focus on incorporating research guidelines for race and ethnicity into journal publication standards.

Machine Learning Algorithms as a Computer-Assisted Decision Tool for Oral Cancer Prognosis and Management Decisions: A Systematic Review.

INTRODUCTION: Despite multiple prognostic indicators described for oral cavity squamous cell carcinoma (OCSCC), its management still continues to be a matter of debate. Machine learning is a subset of artificial intelligence that enables computers to learn from historical data, gather insights, and make predictions about new data using the model learned. Therefore, it can be a potential tool in the field of head and neck cancer. METHODS: We conducted a systematic review. RESULTS: A total of 81 manuscripts were revised, and 46 studies met the inclusion criteria. Of these, 38 were excluded for the following reasons: use of a classical statistical method (N = 16), nonspecific for OCSCC (N = 15), and not being related to OCSCC survival (N = 7). In total, 8 studies were included in the final analysis. CONCLUSIONS: ML has the potential to significantly advance research in the field of OCSCC. Advantages are related to the use and training of ML models because of their capability to continue training continuously when more data become available. Future ML research will allow us to improve and democratize the application of algorithms to improve the prediction of cancer prognosis and its management worldwide.

Research Equity in Otolaryngology-Head and Neck Surgery.

Equitable research collaborations benefit the quality and relevance of global otolaryngology-head and neck surgery research. However, analyses of existing global health literature have shown disproportionate representation by foreign authors. To avert this inequity and improve global otolaryngology-head and neck surgery research, we propose a framework that emphasizes local representation and capacity building in research.

Africa: A window on challenges and opportunities for head and neck cancer.

BACKGROUND: Head and neck cancer occurs predominantly in the Developing World, with significant challenges relating to a high burden of disease, late presentation, and poor access to curative and palliative care. AIMS: This article describes challenges relating to head and neck cancer care in Sub-Saharan Africa. MATERIAL & METHODS: Educational and training innovations that have been undertaken to improve access to cancer care are presented under the following headings: Open Access Educational Resources African Head and Neck Society (AfHNS); African head and neck surgery fellowship training; AfHNS Virtual Tumor Board; The AfHNS Clinical Practice Guidelines for Head & Neck Cancers in Developing Countries and Limited Resource Settings. Concerns are also raised about universally applicable cancer staging systems. RESULTS: The challenges facing African patients apply to equally to many other parts of the developing world. DISCUSSION: The challenges facing African patients apply to equally to many other parts of the developing world. CONCLUSIONS: For outcomes of head and neck cancers to be improved globally, a far greater investment needs to be made in education and training to improve access to care in developing countries. To make a meaningful global impact on morbidity and mortality related to HNC, clinicians, academic institutions and professional societies in developed countries need to be sensitive to these developing world challenges and should directly engage in improving access to care through promoting open access educational resources, offering specialist and fellowship training, collaborating with appropriate research, and establishing and strengthening centers of excellence in developing countries. LEVEL OF EVIDENCE: 2c "Outcomes research".

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.

Inflammatory leiomyosarcoma of the head and neck: Case report.

INTRODUCTION AND IMPORTANCE: Primary sarcomas in the head and neck region are rare. Inflammatory leiomyosarcoma was first described in 1995. The case reported herein is the first reported inflammatory leiomyosarcoma occurring in the head and neck. PRESENTATION OF CASE: A 37-year-old male presented with a long history of an asymptomatic slowly enlarging neck mass. Examination revealed a firm mass in the lower third of the right sternocleidomastoid muscle. Computerized tomography and magnetic resonance imaging showed a lobulated, well-circumscribed tumour with malignant features. A wide local excision was performed and histopathological examination confirmed an inflammatory leiomyosarcoma. DISCUSSION: Inflammatory leiomyosarcoma is a recently described peculiar soft tissue tumour with histological features overlapping conventional leiomyosarcoma, and dense lymphocytic inflammation and immunohistochemical reactivity for both smooth and skeletal muscle markers. These are indolent tumours and wide local excision is curative. CONCLUSION: This case highlights the importance of considering primary sarcomas in the differential diagnosis of asymptomatic head and neck masses.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer.

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

The hidden curve behind COVID-19 outbreak: the impact of delay in treatment initiation in cancer patients and how to mitigate the additional risk of dying-the head and neck cancer model.

PURPOSE: The rapid spread of the SARS-CoV-2 pandemic around the world caused most healthcare services to turn substantial attention to treatment of these patients and also to alter the structure of healthcare systems to address an infectious disease. As a result, many cancer patients had their treatment deferred during the pandemic, increasing the time-to-treatment initiation, the number of untreated patients (which will alter the dynamics of healthcare delivery in the post-pandemic era) and increasing their risk of death. Hence, we analyzed the impact on global cancer mortality considering the decline in oncology care during the COVID-19 outbreak using head and neck cancer, a known time-dependent disease, as a model. METHODS: An online practical tool capable of predicting the risk of cancer patients dying due to the COVID-19 outbreak and also useful for mitigation strategies after the peak of the pandemic has been developed, based on a mathematical model. The scenarios were estimated by information of 15 oncological services worldwide, given a perspective from the five continents and also some simulations were conducted at world demographic data. RESULTS: The model demonstrates that the more that cancer care was maintained during the outbreak and also the more it is increased during the mitigation period, the shorter will be the recovery, lessening the additional risk of dying due to time-to-treatment initiation. CONCLUSIONS: This impact of COVID-19 pandemic on cancer patients is inevitable, but it is possible to minimize it with an effort measured by the proposed model.

YO-IFOS Guidelines for Pediatric ENT Surgery during COVID-19: An Overview of Recommendations.

OBJECTIVE/HYPOTHESIS: To review the literature on pediatric ENT COVID-19 guidelines worldwide, in particular, surgical practice during the pandemic, and to establish a comprehensive set of recommendations. STUDY DESIGN: Review. METHODS: A comprehensive literature review through an independent electronic search of the COVID-19 pandemic in PubMed, Medline, Google, and Google Scholar was performed on April 26-30, 2020. Resources identified comprised of published papers, national and international pediatric ENT society guidelines. RESULTS: Fourteen guidelines fit the inclusion criteria. Key statements were formulated and graded: 1) Strong recommendation (reported by 9 or more/14); 2) Fair recommendation (7-8/14); 3) Weak recommendation (5-6/14); and 4) Expert opinion (2-4/14). Any single source suggestion was included as a comment. Highly scored recommendations included definition of urgent/emergent cases that required surgery; surgery for acute airway obstruction; prompt diagnosis of suspected cancer; and surgical intervention for sepsis following initial first-line medical management. Other well scored recommendations included senior faculty to perform the surgery; the use of open approaches rather than endoscopic ones; and avoidance of powered instruments that would aerosolize virus-loaded tissue. A tracheostomy should be performed on a case by case basis where key technical modifications become necessary. CONCLUSIONS: The COVID-19 pandemic will have a profound short and long-term impact on pediatric ENT practice. During this rapidly evolving climate, guidelines have been based on local practice and expert opinion. Until evidence-based practice in the COVID era is established, a comprehensive set of recommendations for pediatric ENT surgical practice based on a review of currently available literature and guidelines, is therefore, appropriate. Laryngoscope, 131:1876-1883, 2021.

IVORY Guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS): A Consensus on Surgical Videos in Ear, Nose, and Throat.

OBJECTIVES/HYPOTHESIS: Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology. STUDY DESIGN: DELPHI survey. METHODS: Twenty-seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained. RESULTS: The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high-definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ-specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre- and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery. CONCLUSIONS: International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E732-E737, 2021.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Comparison of different guidelines for oral cancer.

BACKGROUND: Guidelines should provide accessible and reliable information for decision-making. Also, they should be translatable to multiple settings, allowing their use in diverse situations. METHODS: We searched in GOOGLE, PUBMED, SCIELO, and SCOPUS for guidelines on oral squamous cell carcinoma. They were evaluated using the AGREE II protocol. RESULTS: We identified 16 guidelines that fulfilled inclusion criteria. The mean score and range for each AGREE II domain were: "scope and purpose" 74.1% (6-100.0%); "stakeholder" 78.6% (0-100.0%); "rigor of development" 71.4% (0-100.0%); "clarity of presentation" 71.4% (6-100.0%); "applicability" 50.0% (0-85.7%); "editorial independence" 57.1% (14.3-85.7%) and "overall assessment" 57.1% (14.3-100.0%). CONCLUSION: Guidelines for oral cancer present variable quality. Among those available, only four surpassed the 70% AGREE II score threshold.