In April 2016, for the sixth academic module in the training collaboration between the ENT Department at Mbarara University of Science and Technology (MUST) and Massachusetts Eye and Ear, Mark Varvares, MD returned to expand upon the previous module dedicated to salivary gland tumors. Dr. Varvares, a member of the Head and Neck faculty at Mass Eye and Ear/Harvard, focused the week on evaluation and management of neck masses in adults.
Head and neck cancer represents a significant disease burden in sub-Saharan African countries, with head and neck squamous cell carcinoma prevalence two to four times higher than in developed countries. There is limited access to treatment due in part to low numbers of trained and equipped surgical providers, limited chemoradiotherapy availability, and insufficient screening and community outreach, especially outside of the capital city of Kampala. This results in a mean five-year survival rate that is among the lowest of common cancers[i].
As part of the educational activities during the week, Dr. Varvares administered oral examinations and OSATS, gave didactic lectures, and demonstrated the steps of a neck dissection on a cadaver. Oral exams, administered on the first and last day of the module, required residents, upon being given a brief history of a patient presenting with a neck mass, to:
- Take a complete history
- Describe a detailed examination highlighting key areas of concern
- Develop a differential diagnosis
- Request and interpret appropriate radiographic and pathology data
- Arrive at a final diagnosis
- Formulate a treatment plan
- Discuss strengths and weaknesses of the various treatment options
- Discuss the treatment pathway and possible outcomes
- Manage possible treatment-related complications
Residents received immediate feedback, allowing the examination to become an educational opportunity.
For this module, OSATS evaluated the resident’s understanding of the performance of a modified radical neck dissection. In the anatomy lab, Dr. Varvares demonstrated the procedure, detailing a step-by-step approach, including concepts such as patient positioning, appropriate incision design, the key planes of dissection and surgical landmarks, the management of the major neurovascular structures in the neck, inspection of the surgical bed prior to closure for bleeding and chyle leak, wound closure, and the appropriate orientation and procession of the surgical specimen. Residents were given the opportunity to replicate the procedure on cadavers the beginning and end of the week.
Between sets of examinations, Dr. Varvares gave didactic lectures on the history of neck dissections, the classification system of neck dissections, surgical anatomy of the neck, a description of the lymph node regions and patterns of metastases of various head and neck primary sites, indications for neck dissection, and steps of the procedure and management of complications. Reinforcement of a methodical approach helped to structure and bring together the different aspects of head and neck management, from the clinical to the surgical.
In addition to didactic and surgical skills lab teaching, Dr. Varvares walked the residents through the operative management of three patients with head and neck pathology. On the department’s scheduled operating theatre day, the team resected a 6 cm pleomorphic adenoma in a child, excised a submandibular gland for a hilar stone in an adult, and performed a total parotidectomy in an elderly man who had a multicystic parotid pathology that included a prestyloid parapharyngeal space mass that was resected through a subtotal parotidectomy approach.
Outside of the training provided by Dr. Varvares, the faculty and residents at MUST have obtained the majority of their exposure to managing head and neck surgical cases through specialized surgical camps such as the one offered annually in Kenya by James Netterville, MD (Vanderbilt University, More Than Medicine) in conjunction with the Department of Otolaryngology at the University of Nairobi. Over the last two years, the ENT Department at Case Western Reserve University School of Medicine, led by Chad Zender, MD, has partnered with Jeffrey Otiti, MD, head of the Uganda Cancer Institute’s Head and Neck program, to provide twice yearly surgical camps attended by residents and faculty at Makerere University in Kampala as well as MUST. The two initiatives have recently begun to work together.
At the end of the week in Mbarara, Dr. Mark Varvares and Doreen Nakku, MD (MUST faculty), accompanied by Mack Cheney, MD (Mass Eye and Ear, Director of Global Surgery), Victoria Nyaiteera, MD (MUST faculty), and Jamilah Nabukenya (MUST Resident), traveled to the Uganda Cancer Institute in Kampala to meet with Dr. Otiti (UCI), Dr. Zender (Case Western Reserve), Dr. Netterville (Vanderbilt), and George Galiwango, MD (CORSU Rehabilitation and Reconstruction Hospital) to discuss the possibility of developing an advanced head and neck surgery training consortium in Uganda. Consolidating these training opportunities to target the development of in-country surgical talent is a way to counter the traditional narrative that specialized training mandates out-of-country travel. By training in-country, it also challenges public training hospitals to improve capacity at the same rate as the surgeons in training, including anesthesia, ICU nursing care, operating theatre and hospital management. If head and neck surgeons are going to be retained by the country that trained them, they must be able to practice in an environment that allows them to provide care in the manner in which they were trained.
[i] Kakande K, Byaruhaga, Kamulegeya A. Head and neck squamous cell carcinoma in a Ugandan population: a descriptive epidemiological study. J Afr. Cancer (2010) 2:219-225.