Prof Nwaorgu: The Modern Father Of Otorhinolaryngology In Nigeria Recommends Establishment Of Functional World-Class Centres For Treating Head, Neck Cancers In Nigeria

On July 14, 2016 at the University of Ibadan, Oyo State, it was a gathering of the cream of seasoned academicians, administrators, high-ranking politicians and, most importantly, who’s who in the field of otorhinolaryngology in Nigeria. They gathered at the premier university to witness and listen to the inaugural lecture by a man described in some quarters as the modern father of otorhinolaryngology in Nigeria and whose inputs towards the advancement of the study and practice of otorhinolaryngology in Nigeria and West African sub-region cannot be over-emphasised.

The event had in attendance the Vice-Chancellor of the University of Ibadan, Prof Idowu Olayinka, who was represented by the Deputy Vice Chancellor (Administration), Prof Ambrose Aiyelari. Also present were other personalities that shaped the career of Prof Nwaorgu plus professors and heads of health institutions in Nigeria that he trained, including his 90 year old father, Papa P.N. Nwaorgu, amiable wife, Matron Adenike Oluwakemi Nwaorgu (nee Ajaiyeoba) and others.

For avoidance of doubt, medical dictionary for the health professions and nursing ©Farlex 2012, Encyclopedia and Wikipedia all define otorhinolaryngology also known as otolaryngology as, “the combined specialties of diseases of the ear, nose, pharynx, and larynx; including diseases of the head and neck, tracheobronchial tree, and esophagus.” The American Heritage® Medical Dictionary Copyright 2007 defines it as the study and management of diseases of the ear, nose and throat (ENT).

Prof Nwaorgu’s Inaugural Lecture was the second from the Department of Otorhinolaeyngology after 26 years since Prof GTA IIjaduola described, as a doyen of Otorhinolaeyngology, delivered his lecture in 1990. That inaugural lecture was also the first to be delivered in the West African sub-region by a Professor of Otorhinolaeyngology. The title of his lecture then was “That All May Hear”.

According to Prof Nwaorgu, Otorhinolaeyngology, Head & Neck Surgery or as it is more often called, Ear, Nose and Throat Surgery is a branch of Medicine involved in the study, diagnosis and treatment of diseases of the ear, nose as well as related aspects of the head and neck region. It is worth noting that the Department of Otorhinolaeyngology of the University of Ibadan is the oldest in Nigeria.

The Lecture Theme
The Professor posited: “My research interests/focus has been mainly in the areas of laryngology, head and neck surgery. Over the years, I have addressed the issue of tumours/masses of the head and neck and have described the diagnostic features and rewarding treatment modalities which are novel/modification of treatment modalities. I have also raised the awareness as to the peculiarities of three important malignancies in the specialty in our environment, namely: (a) nasopharyngeal cancer, (b) sinonasal tumour, and (c) laryngeal cancer.

“I have shown in my studies with others how some of the aesthetic and functional restoration challenges facing the otorhinolaryngologist can be resolved by modification of existing techniques. My works have also increased knowledge, awareness and management of upper airway obstruction and corrosive ingestion, which were often misdiagnosed and poorly or inappropriately treated. This is in addition to some of our published works that have highlighted the co-existence of some congenital external ear lesions with brainchiogenic cysts/fistula, and have shown how meticulous search for these apparently hidden lesions can be beneficial.

“Also over the past few years of my employment in the College of Medicine, University of Ibadan and University College Hospital as an otorhinolaryngologist, I have addressed issues on hearing loss amongst, other aspects of neurotology. It is worth nothing that my brother’s case, and other patients I have encountered during my residency, led to my special interest in laryngology, head and neck surgery and thus, choice of the title of this inaugural lecture, Steady Neck, Stable Head, and Unobstructed Throat: The Otorhinolaryngolologist at Work.”

Abridged version of Issues treated at the Lecture

1. Nasopharyngeal Cancer
Nasopharyngeal cancer is a cancer that starts in the nasopharynx, the upper part of the pharynx (throat) behind the nose and close to the base of skull

Nasopharyngeal cancer may occur at any age, occurring in endemic proportions in the Chinese population. The disease is thought to be prevalent amongst the Easterners in Nigeria. The adduced reasons for this include the high prevalence of their use of snuff, the geographical destruction which appears to coincide with that of Burkitu’s lymphoma that has its prevalence in the southern parts of the country where rainfall is maximum, forest widespread, and malaria infection hyper-endemic (Ketiku, Igbinoba & Okeowo 1998).

Due to its cryptic nature, nasopharyngeal cancer may be difficult to diagnose. The reasons for this include relative inaccessibility of the nasopharynx in the past, vague and non-specific symptoms in the early stages, and the tendency for submucosal spread. Some of the symptoms which may serve as early pointers to the lesion in the adult include tinnitus, hearing impairment, sensation of fullness in the ear, progressive nasal obstruction and recurrent epistaxis. Our patients presented with very late disease and diagnosis was hardly in doubt.

Occasionally, the patients may present first to the ophtalmologist (diplopia, ophtalmoplegia, Horner’s syndrome); neurosurgeon (subtemporal lesions); or a neurologist (multiple cranial neuropathies, including vello-pharyngeal incompetence, dysphagia). The commonest symptom at presentation was neck swelling as over 65 per cent of the patients presented with cervical lymph node enlargement.

The other symptoms which induce patient presentation include recurrent epistaxis, chronic or complete nasal obstruction and dysphagia that are non-responsive to alternative medical remedies (faith-healing and traditional remedies) In our 12-year retrospective study of 79 nasopharyngeal cancer patients, we documented for the first time in the country and the sub-Saharan region two essential manifestations - Ptosis (15 per cent) and Horner’s syndrome (3 per cent) (Ogunleye, Nwaorgu & Adaramola 1999), thus drawing more attention to ophtalmo-neurologic form of presentation as an aid to early diagnosis of nasopharyngeal carcinoma.

The treatment of choice for nasopharyngeal cancer is radiotherapy and/or chemotherapy. The place of surgery in the management of nasopharyngeal cancer includes:

* Biopsy of nasopharyngeal lesions;
*Airway management (e.g. tracheostomy in cases with obstructive features);

*Neck dissection with confirmed extirpation of disease at the primary site in the nasopharynx;

*nasopharyngectomy, in cases of recurrence;
It is worrisome that the increase in the number of cases of NPC has not been matched with a commensurate increase in diagnostic and radiochemo-therapeutic centres/facilities for management of the disease. Presently in our country (Nigeria), the prognosis for this cancer is still very gloomy. The five-year survival for stage I, II, 111 diseases are 90 per cent, 70 per cent, and 60 per cent respectively, while stage IV disease with distant metastasis is 40 per cent. However, stage IV disease with distant metastasis has a zero per cent five-year survival. We reported the only case of NPC in this environment for now; a male who survived for eight years following chemoradiation (Elumelu, Adenipekun & Nwaorgu 2006).From the foregoing, it is clear that the key to improved survival is early presentation and diagnosis and treatment.

2. Primary Extranodal Non-Hodgkin’s Lymphoma of the Upper Aerodigestive Tract

Sinonasal cancer is the cancer involving the para-nasal sinuses and the nose. There is lack of specificity in clinical symptoms of sinonasal tumours and this makes them indistinguishable from benign sinonasal diseases. This can lead to a delay in diagnosis of a malignancy. Sinonasal cancer is especially challenging in a patient who has been diagnosed with chronic rhinosinuistis, with temporary improvement and recurrent symptoms. Arising from clinical observations of increasing frequency of sinonasal and nasopharyngeal lymphoma and the paucity of information on primary upper aerodigestive tract lymphomas in our environment, we carried out a 10-year retrospective study highlighting the clinical features, natural history and response to available therapy of the disease (Onuakoya, Adeyi, et al, 2003).

We also recommend further studies on the relationship between sinonasal lymphomas and HIV seropositivty in our environment as an increasing frequency has been associated with HIV infection. The HIV status of our patients in the early part of this review was unknown while those carried out from 1994 to 1998 were negative.

3. Inverted Papilloma of the Nose and Paranasal Sinuses

This is a relatively rare epithelial neoplasm of the nose and paranasal sinuses accounting for 0.5-4 per cent of the primary tumours of the nose (lampertico, Russel & MacComb, 1963). Following the observation of synchronous and metachronous squamous cell carcinoma respectively in two of our patients with recurrent inverted papilloma of the nose, we studied respectively 15 patients that had histologically confirmed inverted papilloma from 1986 – 2000 (Nwaorgu & Odukoya 2002)

Prof Nwaorgu advised that all tissues obtained from patients must be subjected to histology, regardless of the number of times the biopsies were obtained. Based on our findings, we made case for radical surgery (medial maxillectomy) for its management in our environment while stressing the need to intimate any patient with IP to adhere to regular follow-up post surgery. This no doubt will allow for early detection of recurrence or malignant transformation in those with dysplastic changes histologically

4. Carcinoma of the Larynx (CaL)
This important malignant epithelial neoplasm is the third most common carcinoma of the head and neck region observed in the ORL Clinic of the UCH Ibadan. Though the real incidence in our centre has not been established, between 1986 and 1995, laryngeal carcinoma constituted 28.6 per cent of the total ORL carcinomas recorded in Ibadan Cancer Registry. Majority of our patients (65 per cent) presented within one year of the onset of their symptoms reaching a peak of 86.7 per cent at two years. Majority of the patients (90 per cent) had advanced disease (stages III and IV). Hoarseness and difficulty with breathing were the most common symptoms and 88.9 per cent patients presented in a cute upper airways obstruction, necessitating emergency tracheostomy.

t is worth noting that in our environment, presenting late to specialists in the hospital could be attributed to all or any of the following nonspecific symptoms of laryngeal lesions at the early stage: religious and socio-cultural beliefs and practices (spiritual attack, etc) of the people, poverty, illiteracy, and initial self-medication. Non-availability of health facilities with ORL clinics, inadequate and inappropriate number of specialists in the field may also be contributory. Thus, these patients presented with advanced disease and upper airway obstruction, which necessitated emergency tracheostomy.

We reiterated the need for improved awareness of the general populace through social campaign and general health programmes similar to those conducted for lung cancer. This will enable early referral of patients presenting with signs and symptoms of airway obstruction to the ORL specialists for appropriate evaluation and treatment.

Total laryngectomy is our preferred treatment option for advanced CaL (stages III & IV) and cases of failed radiotherapy. However, many of these patients opt for radiotherapy/chemotherapy in spite of adequate counselling against fear of losing voice box (larynx) and thus unable to speak after surgery. Advanced disease and previous irradiation of the neck causes tissue fibrosis, reduce blood supply and hinders wound healing and thus contributes to the development of pharyngocutanous fistula in some of our patients. Faced with this challenge, we used the pectoralis major musculocutanous pedicled flap to carry out a one-stage pharyngo-oesophageal repair of pharyngocutaneous fistula with good result. Our initial experience with the first case was highlighted in the publication titled, ‘One Stage Pharyngo-oesophageal Repair of a Pharyngocutanenous Fistula and Esophageal Stenosis, Using a Pectoralis Major Musculocutaneous Pedicled Flap’ (Nwaorgu & Oluwatosin).

This to our knowledge was the first of such a successful restoration of pharyngo-oesophageal lumen following total laryngectomy complicated by a pharyngocutaneous fistula in Nigeria and the sub-region. Musculocutaneous flaps have the advantage of transferring richly vascularised skin for repairs. Distant axial flaps such as there delto-pectoral flap may provide good repair flaps, but may require; several stages before reaching the recipient site, a wide base to get enough length, and skin-grafting to close the donor site, and may not provide bulk to fill in large defects (Bakamjian 1956).We could not use free flap mainly because there were no easy vessels that could be dissected out for anastomosis. Success stories of other cases of pharyngocutaneous fistula managed with this procedure have followed this initial case in Nigeria.

6. Stomal Recurrence
Tumour recurrence at the tracheostome is a major complication experienced post-surgery for advanced CaL; many a time it has grave prognosis.

Based on the foregoing, we concluded that advanced stage of disease (stages III & IV), involvement of all subsites of the larynx (transglottic) and the presence of preoperative tracheostomy are the likely risk factors that could be associated with stomal recurrence in our environment. The view that incidence of stomal recurrence may be prevented by emergency total laryngectomy within 24-hours of presentation (Rubbin, Johnson & Myers 1990), or combined pre- and post-operative chemoradiation (Leon, Quer, et al, 1996) has been found not to be significantly right. The use of radiotherapy or chemotherapy preoperatively as short course to reduce the stormy recurrence may not ensure the reduction rate of this complication as it may prevent the administration of full therapy post-operatively thereby leading to high recurrence rate. There is the need to plan for elective course of moderate to high dose radiation pre- or post-laryngectomy to involve the stoma and surrounding areas of the neck and chest in high risk patients in order to sterilise these regions (Breneman, et al, 1998; Tong, Moss & Stevens, 1977).

Emergency laryngectomy has not been possible in our environment as the people reject losing their voice at the initial stage of informing them of the type of lesion and possible outcomes. Flowing from our findings, we advise adequate counselling of the prospective laryngectomee and surgery should be carried out in the presence of one or two previous laryngectomees. This has helped in allaying some of the fears hitherto exhibited by our patients as attested to by our recent work (Fasunla, Ogundoyin, et al, 2016). In this year, 11-year review covering 2005-2015 period, 97 cases of CaL were seen and managed in our department. Fifty three (54.6 per cent) out of this had total laryngectomy while 3 (3.1per cent had stomal recurrence. At surgery, dissection of paratracheal, pretracheal and retrosternal nodes and complete excision of previous tracheostomy tract are carried out. This practice has thus reduced the incidence of this complication in our centre.

Challenges and the Way Forward
Not minding all these feats and improvement in the level of awareness on CaL with a consistent rise in the number of patients presented, Prof Nwaorgu stated that a challenge still remains incompletely solved is voice restoration post-laryngectomy. Post-laryngectomy speech rehabilitation in our patients has been by oesophageal speech, except in two patients who are using electrolarynx and more recently, trachea-esophageal voice prosthesis in a patient.

Recommendations for Accurate Diagnosis for Treating Head and Neck Diseases

The treatment modalities for head and neck cancers include surgery, chemotherapy, and radiotherapy. Their successful management depends on accurate diagnosis, tumour stage, and selection of appropriate treatment modality with close post-operative follow-up.

I have highlighted above some of the major challenges of management of our patients which include late disease presentation and acceptance of surgical treatment by patients and their families, initial self-medication, poverty and illiteracy. Thus, a targeted and well-coordinated health education and awareness programme for ORL, diseases and their prevention at the community level through the various media and even religious organisations should be pursued, with the support of appropriate and relevant agencies.

Inclusion of therapy for head and neck cancers in the existing National Health Insurance Scheme in Nigeria will likely encourage early presentation to the ORL specialist, while also reducing default of treatment.

It is desirable that functional world-class centres for the management of head and neck cancers are established in the six geopolitical zones of the country. Programmes aimed at creating awareness and encouraging immunisation against Human Papilloma Virus and other infective agents will go a long way in prevention of the infection and other agents that may result in neck infections and abscess.

Expansion of Otorhinolaryngology in Nigeria
Prof Nwaorgu assumed duty as an academic staff of the University of Ibadan, his alma mater, in June 1995. Barely 10-months afterwards, he found himself as the only academic staff in the department. This was by no means an enviable status! He had medical students on rotation through the department and trainee resident doctors to look after. Two of his trainees (Drs A.A. Adeosun and A.O.A Ogunleye) were later employed in 1996 to assist him train more fellows: Prof Lasisi & Dr Onakoya, who them in December, 2000 and January 2001 respectively. Dr A.OA. Ogunleye later died in an air crash in 2006.

With these seven staff, Nwaorgu was able to train many otolaryngolodists for Nigeria and the sub-region: Prof B.M. Ahma (UMTH Maiduguri), Prof. K.R. Iseh (immediate past Head, ORL Department, UDUTH, Sokoto), Prof A.D. Dunmade, ORL Dept. UITH, Ilorin), Prof T.S. Ibekwe (Head ORL Dept. UATH, Abuja), Dr Aminu Bakare (Ass. Prof. & MD NECC, Kaduna), Dr A.S. Adoga and Dr A.A. Adoga both brothers who are now Readers at JUTH, Jos, Dr L Onotari (Reader, UPTH Port Harcourt), etc).

Prof OGBN have contributed significantly to the development of his specialty in the sub-region, having served four years each as secretary and chairman respectively of the faculty of otorhinolaryngology, West African College of Surgeons. He has also served as member of Faculty Board in both the West African College of Surgeons and National Postgraduate Medical College of Nigeria.

Profile of Prof OGB Nwaorgu
Prof Onyekwere George Benjamin Nwaorgu, a native of Umuodagu Ntu, Ngor-Okpala, Imo State, was born on April 23, 1959 to the family of Mr Paulinus Nkemjika and late Mrs Maria-Celine Adanma Nwaorgu. A former student of St John’s Primary school, Imerienwe; Owerri Grammar School, Imerienwe, and Federal School of Arts and Science, Victoria Island, Lagos. He obtained the MBBS degree from the University of Ibadan in June 1985.

His working career commenced with employment as an house officer at the then General Hospital, Aba (Now Abia State University Teaching Hospital, Aba); NYSC medical officer at the Tombia Health Centre, Delga LGA., Rivers State between 1986 and 1987; employment as a Medical Officer, Alvan Ikoku College of Education Medical Centre, Owerri in 1988.

He had his specialist training as an otorhinolaryngologist at the University of Nigeria Teaching Hospital, Enugu from December 1988 and passed his fellowship examination in April 1995. He became a fellow, West African College of Surgeons in 1995, and a year later Fellow, National Medical College of Nigeria. He was appointed Honorary Consultant Otorhinolaryngologist by the Board of the University College Hospital, Ibadan in August 1995 and has been serving in this capacity till date.

His teaching career began with his appointment as a Lecturer 1 in the Department of Otorhinolaryngology, College of Medicine, University of Ibadan June 1995; promoted Senior Lecturer in October 1998; Reader in October 2003 and professor in October, 2006.

He is a professional through and true. He belongs to several professional organisations. He is a member of the Nigerian Medical Association, International Fellow, American Academy of Otorhinolaryngology, Head & Neck Surgery 2007 to date; Fellow, American-Austrian Foundation since April, 2008; member, European Academy of Allergy & Clinical Immunology (EAACI) from 2008 to date; Vice-President, Otolaryngological Society of Nigeria, from November 2015.

He also served as Secretary, Faculty of Otorhinolaryngology, West African College of Surgeons between January 2007 and July 2011; and more recently as Chairman, Faculty of Otorhinolaryngology, West African College of Surgeons from July 2011 to March 2015. He coordinated yearly update and revision courses for Parts I & II fellowship candidates in otorhinolaryngology for the Faculty of Otorhinolaryngology, West African College of Surgeons from 2001 to 2006.

His administrative responsibilities in University of Ibadan include the following:

Coordinator, Department of Otorhinolaryngology, College of Medicine, April 1996 to December 1999; Acting Head, Department of Otorhinolaryngology, College of Medicine, January 2000 to April 2002 and then June 2007 till August 2009; Professor and Head of Otorhinolaryongology between August 2011 and July 2015.

In addition, he is or has served on the following committees and in the following capacities in the College of Medicine and University, University of Ibadan; Postgraduate Coordinator and Member of Faculty of Clinical Sciences, Department of Otorhinolaryngology representative at the Faculty of Clinical Sciences Committee on Continued Medical Education; Faculty of Clinical Sciences representative on the College of Medicine Board of Survey; Member, College of Medicine Ad-Hoc Committee on Fund-raising; Member, Faculty of Clinical Sciences; Appointments and promotions committee member; Business Committee of Senate, University of Ibadan; Chairman, Board of Health, University Health Services University of Ibadan since September 2013.

Prof Nwaorgu is a regular reviewer of several articles in general and specialty journals. In his own right, he is a well-published researcher, teacher and clinical specialist who have successfully supervised 34 postgraduate residents’ research works. Some of his supervised students are now professors scattered all over Nigeria, including one who is presently the Chief Medical Director in a teaching hospital. Through his well-known researches in the field of otorhinolaryngology, and head and neck surgery, he has 120 publications to his credit, including published abstracts and 112 full length original articles in peer review journals.

A former UICC World Cancer Congress Scholar; former Visiting International Scholar Simmon Cooper Cancer Institute, Springfield Illinois, and International Fellow American Academy of Otorhinolaryngology, Head and Neck Surgery. He has attended over 25 international conferences and several workshops in and outside of Nigeria where he presented high quality papers. He obtained a postgraduate certificate in epidemiology from the World Health Organisation in February, 2000.

This former Professorial Consultant ORL Surgeon to the Aminu Kano Teaching Hospital, Kano, between January 2011 and December 2014; as well as a Visiting Professorial Consultant ORL Surgeon to University of Abuja Teaching Hospital, Gwagwalada since January 2013 serves as an examiner of the Faculty of Otorhinolaryngology fellowship examinations of the National Postgraduate Medical College and West African College of Surgeons. He was the Chief Examiner for the Faculty of ORL, West African College of Surgeons Fellowship Examinations from October 2011 to April 2015.

Prof Nwaorgu is a man of many parts, a man of true faith, a devout Catholic who was ordained a Knight of the ancient and noble order of St. John International (KSJ) in 2003. A truly detribalised gentleman, who is happily married to Adenike Nwaorgu in a union that is blessed with three lovely children, namely: Ayomide Uchenna, Olufemi Victoria and Chimdinma Emmanuella Nwaorgu.

Given the foregoing feats, if this international and world acclaimed otorhinolaryngologist isn’t rated as the modern father of otorhinolaryngology in Nigeria, then I wonder who else. After all, his trainees are now heading most of the otorhinolaryngology units in Nigeria.

Let me formally conclude this treatise by quoting the text that Evangelist (Mrs) Ada Chioma Henrietta Eze (Snr) sent to Prof OGB Nwaorgu in the morning of the Inaugural Lecture presentation, "My dearly beloved brother, PROF. OGB NWAORGU, I greet you this morning in the name of our LORD JESUS CHRIST.

The long awaited day is here. I call on God, His son and the Holy Spirit to please go before you and do what THEY know best to do in the life of a man that has laboured. My most senior brother (Opeem), do remember those old days that you trekked to St. JOHN AMAFOR IMERIENWE, the TRINITY played THEIR role.

When you went to Owerri Grammar school the TRINITY did not abandon you. Your amazing performance especially in ALGEBRA, STATISTICS gave you the name ZAZA and SIR OKOROJO. You went to Federal School of Arts/Science where you nearly ran mad in the pursuit of academic excellence and God helped you. While in d university the TRINITY were there with you. You went to SAGBAMA and TOMBIA, ABA, ENUGU for greener pasture and now UCH Ibadan and the TRINITY are still with you.

I salute you and congratulate ahead of the lecture my brother because you have won. I am proud of you and all your feats and return all the glory to our Great God".

Truly and truly the TRINITY as prayed by this great woman of God was with Prof Nwaorgu during his Inaugural Lecture as he held all his audience spell bound in a lecture termed as the needed tonic for the revolution in the field of Otorhinolaryngology in Nigeria!

EZE CHUKWUEMEKA EZE is a Media Consultant based in Port Harcourt. He can be reached via [email protected] , 08038199163.

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Articles by Eze Chukwuemeka Eze