Introduction

The practice of otorhinolaryngologic surgery has advanced from the simple excisional surgery to minimally invasive functional endoscopic techniques, reconstruction and the use of lasers ₁,₂ . Accompanying these are various forms of plastic repair of the ear, nose and throat region making the regain of physiologic function a realizable surgical goal. This has thus made the specialty technology – intensive and dependent on equipment such as operating microscopes, sinus endoscopes, surgical navigators and various implants among others ₁,₂ . Unfortunately, this does not seem to be so in the sub-Saharan Africa where otolaryngologic practice is still at the infantile stage. This has resulted in the sparcity of data on otorhginolaryngologic practice from the subregion. This article reports the analysis of 701 patients seen in our practice in 4 years highlighting the spectrum and peculiarities of E.N.T diseases, surgical management and its limitations and identifying research issues which could help in management.

Methodology

This is a retrospective analysis of 701patients seen in Outpatient Consultation Clinic within the last 4 years (2000 – 2004) in one of the biggest tertiary centre in Nigeria. The record of cases seen from the year 2000 were computerized, this allowed for easy retrieval and analysis. The basic biodata, clinical features, diagnostic and therapeutic modalities were retrieved and analysed using simple statistics. The results of distribution of clinical diagnosis among the 701 cases and 111 surgical procedures were presented in pictoral and graphical models.

Results

Seven hundred and one charts were suitable for analysis out of 708 cases seen between December 2000 to December 2004 at the Otorhinolaryngology Clinic of the University College Hospital, Ibadan, Nigeria. These were the cases seen personally by the first author.

The age ranged between 3 months and 77 years (mean = 24.3, SD =18). There were 358 males and 350 females (1:1). Chronic suppurative otitis media was predominant 153 (22%), then sensorineural hearing losses 84 (12%). Inflammatory disorders of the sinuses and larynx accounted for 112 (14%) while head and neck cancers was lowest 9 (1.3%). Figure 1.

Figure 1

In summary, ear pathology was responsible for 414 (59%) of outpatient attendance followed by rhinology 154 (22%), laryngologic cases 105 (15%) and lastly head and neck cases 21 (4%).Figure 2.

Figure 2

Operative procedures accounted for 111(16%). modified radical mastoidectomy and tympanoplasty was the most frequent surgical procedure accounting for 19 (17%). This is followed by intranasal antrostomy 16 (15%), rigid oesophagoscopy for removal of foreign bodies 9 (8%), caldwel-luc antrostomy 8 (7%) adenoidectomy 7 (6%) and tonsillectomy 7 (6%). Endoscopic sinus surgery and fibreoptic laryngo-oesophagoscopy were done in 4 (5%) patients (Figure 3).

Figure 3

Analysing the surgical procedures according to the divisions, laryngologic/head and neck surgery accounted for 47 (42%), rhinologic 31 (28%), otologic 29 (26%) and minimal invasive / endoscopic surgeries 4 (4%).

The diagnostic facilities were inadequate. Only pure tone audiometry was available for investigating hearing losses, cochleography, otoacoustic emission and auditory brainstem response were not available. Hearing aid was affordable by only 3 (4%) out of the 84 patients with hearing loss, the rest were referred to special schools for training.

Out of 79 patients requiring computerized axial tomography scanning for investigation of intracranial and skull base involvement of the lesions, only 12 (15%) could afford it. Hence management was based on plain radiography of the paranasal sinuses and temporal bone. Only nasal smear eosinophil was used to investigate nasal allergy, there were no facilities such skin sensitivity test.

Discussion

Chronic suppurative otitis media and sensorineural hearing loss constituted more than one – third of patient seen in the outpatient consultation. This high prevalence of chronic ear infection is contrary to the reports of advanced countries ₃ . This is probably due to a combination of inaccessibility to health care facilities, local customs and beliefs, harmful traditional practices and poor treatment of acute cases by the first contact health personel ₄,₅ . The predominant proportion of open mastoidectomy in the treatment suggests a high rate of complicated cases of cases seen.

The aetiologic/risk factors identified included recurrent upper respiratory tract and sinus infections, overcrowding and immunodepression. Otitis media with effusion from eustachian tube dysfunction due to adenoid enlargement as reported in the West has not been typically seen in our patients. It is possible that the cases were not presented to us at this early stage. Furthermore, this was attributed to the dry sub-Saharan climate which is not conducive to the growth of spores, allergy and otitis media with effusion and suggested research into racial and genetic factors ₆ . The indication for adenoidectomy has been severe upper airway obstruction leading to snurring and excessive daytime hypersomnolence.

The hearing losses were mostly congenital, the acquired cases were sequelae of viral infections and complications of meningitis. Many of these cases need genetic screening, viral culture and facilities to differentiate sensory from neural hearing losses, this will help in identifying the suitability for cochlear implantation and counseling. Unfortunately these are not available in our centre.

Most of the procedures consist of open (excisional) surgeries: caldwel-luc antrostomy, lateral rhinotomy, frontoethmoidectomy, tonsillectomy and neck dissection

The indications for these procedures were nasal polyposis, invasive fungal swellings, inverted papilloma and pyomucocoeles. These indications are similar to the other authors ₇,₈ . The only three endoscopic sinus surgeries were done following the introduction of sinus endoscopes into our hospital recently, further training of the staff may be needed for this to become established.

It is remarkable that the number of surgeries does not reflect the outpatient consultation. While otology constituted 59% of outpatient consultation, laryngologic surgery was highest 39% followed by nasal and ear surgeries 28% and 26% respectively. The procedure mostly needed by the CSOM patients after achieving a dry ear with aural dressing is simple tympanoplasty. An estimated 1000 patients was reported earlier waiting for tympanoplasty however this could not be done due to absence of microsurgical facility, hence the reduction in otologic surgery ₅ .

Conclusion, the spectrum shows considerable patientload however diagnostic and therapeutic facilities are grossly inadequate when compared with contemporary practice worldwide. This is similar to the experience of Murphy in Ghana ₆ . It is our impression that addressing a change in this trend will require facilitated access to healthcare facilities, provision of diagnostic and operating equipment in most centres and specialized training of surgical personel.

Correspondence to

DR.O.A. LASISI P.O. Box 22040, University of Ibadan, Ibadan, Nigeria. akeemlasisi@gmail.com