Save the hearing, an ear surgery training project program to combat deafness in developing countries

Hearing loss is one of the most common health problems affecting people in the developing countries so our aim of the “Save The Hearing Project” was to combat deafness by training local doctors for ear surgery in order to treat their local patients with low cost as possible. The project was done as ear surgery campaigns in peripheral areas in Egypt, Yemen, and other countries, to train young ENT specialists and to treat patients there. Our plan was put according to the frequency of different causes of deafness as shown by previous surveys. We used the previous local and evidence-based researches to make our protocols of management of different diseases. These protocols were further evaluated during our work. The project has five stages. The first stage included management of sudden sensory neural hearing loss (SSNHL), otitis media with effusion (OME), and local anesthesia for the ear surgery—cartilage tympanoplasty and ossiculoplasty. The second stage included mastoidectomy cholesteatoma surgery and otoendoscopy. The third stage included more advanced surgery as stapedectomy and tympanosclerosis. The fourth stage included combating SNHL mainly through audiology and rehabilitation program, beside referral for cochlear implants to specialized centers. The fifth stage was only a plan for doing stem cell research in management of hearing loss. Our teams did about 42 campaigns only and the data of 31 were recorded. There were 259 attendants, 70 had hands on training, and 35 were well trained and became trainers. We did 270 tympanoplasties, 52 mastoidectomies, and cholesteatoma surgery beside 16 operations of stage III. Training an ear surgeon is a tedious and long process, but it is at the end very fruitful and useful for the community. Most causes of HL are preventable. We think that our project plan to combat HL is very suitable to be applied in developing countries in Africa and the Middle East.


Background
Hearing loss (HL) is one of the most common health problems affecting people around the world. It can affect any age and it has many causes. In Egypt, it affects 16% of the population [1]. In children under 14 years old, the incidence of HL was 14%. Conductive (CHL) was found in 86% of them, and sensory neural (SNHL) in 14%. In Egypt, HL was more in males (60%) than females (40%) [2]. A high prevalence of hearing impairment was also reported in Africa [3]. In Uganda, 11.7% of subjects below 15 years of age had HL [3]. There is evidence suggesting that the prevalence of hearing impairment is higher than reported and that much of it is avoidable or treatable [3,4]. HL in children may be a cause of delayed development of language, speech, and cognitive skills so early diagnosis and treatment is mandatory. In adults, it decreases the individual's ability to communicate with others, causing feelings of loneliness and isolation [4].

Aim of "Save The Hearing" project
The aim of this project is to combat deafness by training local doctors in developing countries on evidence-based management of HL and ear surgery in order to treat their local patients with low cost as possible.
History: how the idea became a project Professor S. Soliman in Ain Shams University (ASU) (1979) conducted a survey to know the magnitude of deafness in rural areas in Egypt, and the incidence of otitis media was about 2.5% of the examined population. The needed equipment to do the surgery were available in ministry of health hospitals but trained surgeons were not enough to do surgery. This aroused me to submit the first written project of temporal bone dissection course (TBDC) in 1986. The temporal bone lab was established under supervision of Prof. Magdy Hamed (1995). And I had the honor to be a demonstrator, lecturer, and then the head of the TBD lab till 2012.
Although TBDC is the most important step, yet it is not all ear surgery. Soft tissue dissection and tympanic membrane reconstruction, which are needed in all tympanoplasty operations, were lacking in the training. Also, wrong decision-making was prevailing among many trainees as they thought that tympanoplasty is equal to mastoidectomy although the latter was not needed in most ear surgeries. Besides, there was also a lack of knowledge about the magnitude of different causes of hearing loss and the proper protocol to manage them.
Ear surgery campaigns were done in remote hospitals to treat and to teach local ear surgeons. We designed 5 stages for these campaigns which began as sporadic efforts in the early nineties. The Islamic Medical Association (IMA) of Egypt adopted this project to combat HL from 2012 till 2015. The project was shared also by ministry of health hospitals in Egypt, ASU, and Al-Azhar University members, beside some Arab and African countries (look list of contributors). Another twentyfour training campaigns were done in Egyptian provinces during that time; clever trained surgeons became trainers to continue their work locally.
In Yemen, we began in 1997 till 2008, at al Asaad Hospital in Taiz. Several Yemeni doctors worked with me, the program leader, as assistants, and many attended my operations beside the other scientific activities. Also, 2 competent surgeons were prepared in our ENT department (ASU). In

Survey of hearing loss in Egypt
The first step was to know the causes of hearing loss and the frequency of each cause. The work program was planned according to this knowledge. We depended on previous and relatively recent studies done in ASU supported by WHO [1,2]. The data of these researches were plotted in Fig. 1.
From Fig. 1, we can conclude that the most frequent cause of hearing loss was otitis media with effusion (OME) and Eustachian tube dysfunction (ED) (40%) followed by chronic suppurative otitis media (13%) mostly of the simple tubo-tympanic type (9%) and less frequent the cholesteatoma type (4%). So, the first and the second teaching stages were directed to treat these diseases. The third stage is advanced training directed to treat less frequent causes of hearing loss (8.5%) as otosclerosis and atelectatic ME. The fourth stage is directed to treat SNHL, and most of them (28%) need hearing aids. This was provided by the audiology team. Severe SNHL was found in 8%, and only 1.7% need cochlear implants (CI) which was done by more specialized governmental centers. The fifth stage is planned to do stem cell research to treat profound SNHL as a cheap alternative for cochlear implants, if it is successful.

The ear surgery campaigns
Trainers: 2-4 training personnel were needed. The campaign program lasted for 2-4 days, done in the local district hospitals.
Candidates: attendance of 10-30 ENT specialists interested to do ear surgery, 2-6 of them were trained as hands on and the rest were observers for another chance. Candidates chosen for hands on should have at least master degree and did TBDC.
Equipment: the local hospital should have examination equipment, audiometers for hearing evaluation, lecture room with data show for presentations, operating rooms equipped with 1-2 surgical microscopes with camera and monitors, micro-instrument sets, and drill. Also, the local hospital should have requirements for general and local anesthesia. They also should prepare local patients for surgery according to the campaign stage.
Portable equipment were also brought by the campaign supervisors including 1-2 microscopes with camera and monitor, 3-4 sets of ear micro-instruments, portable drills and burr terminals, with local anesthesia (LA) requirements, beside teaching tools as printed notes, power point presentations, and operative videos which were given to the attending candidates.
Program: each campaign had theoretical lectures introducing the program and practical training including methods of examination, decision-making, and the surgical procedures. Demonstration of the procedures was first done by the supervisors, then candidates did these procedures using well-defined, repeatable steps at least twice in the course under supervision of their trainers. Then they did surgery later on, under supervision of their senior colleagues in their local hospitals. Those who were well trained can help as trainers or supervisors in the next courses. To spread this knowledge, a moral obligatory agreement was done that everyone who becomes well trained should teach and train at least ten of his younger colleagues.
The program was divided into five stages or educational levels. Each campaign concentrates on one stage only as possible. We concentrated on the first 3 stages.
The first stage: basic ear surgery which included the following: 1. Knowledge of basic surgical anatomy 2. Clinical methods of examination and evaluation with decision-making. This includes methods of exam (microscopic and endoscopic), hearing evaluation (PTA, tympanometry, and ABR), imaging (X-ray, CT scan, and MRI).
3. Protocol for management of sudden sensory neural hearing loss (SSNHL) (Appendix 1) as an emergency, early management may save a patient from permanent hearing loss [5,6]. 4. Protocol for local anesthesia in ear surgery as it has many advantages, reduces markedly the surgical costs and complications [7][8][9]. 5. Evidence-based treatment protocol for OME was put and applied in 6 steps (Appendix 2) [10]. Local researches were mainly considered stressing on the role of endoscopy in management [11], peritubal adenoidectomy [12], steroid therapy [13], and the role of milk allergy [14]. The protocol was further evaluated after application. 6. Different methods of middle ear exploration, (permeatal, endaural, postauricular, and endoscopic) and their indications 7. Tympanic membrane reconstruction using tragal cartilage graft as it has high success rate in beginners' hand and less incidence of reperforation [15]. Also, fascia graft is another option for those who prefer it. 8. Regain ossicular continuity mostly with the cartilage graft [15], or using preserved homograft ossicles [16] 9. Butterfly grafts for small residual perforations with healthy middle ear [17] 10. Postoperative care: using special ointment applicator [18], to protect the graft from infection till complete healing

Medical management of acute inflammations of the middle and external ears
The practical training included intratympanic injection, tympanostomy tube application, adenoidectomy (specially peritubal adenoids), local anesthesia, aural polypectomy, cartilage tympanoplasty, and butterfly grafts.

The second stage: mastoidectomy and cholesteatoma surgery
In this stage, our aim was to teach different types of mastoidectomy and cholesteatoma surgery, beside the use of endoscopy in ear surgery. One of the prerequisites to share as hands on is prior training on temporal bone dissection course (TBDC). Mastoidectomy training included decisionmaking specially when to do it with tympanoplasty.
Cholesteatoma management protocol included patient evaluation and decision-making depending on endoscopic examination, audiometry, and CT findings. Cartilage grafts were used to reconstruct the tympanic membrane and the attic wall [19]. The surgical protocol was published before by the authors [20,21]. In most cases (with sclerosed mastoid cavity), canal wall down (CWD) using retrograde attico-antrostomy with variable extent of mastoidectomy following the extension of cholesteatoma was done. This was followed by endoscopic control of hidden areas [20] then partial or complete obliteration of the cavity [21], then followed by tympanoossicular reconstruction with cartilage graft [19] and homograft ossicles [16]. In some cases, with wellpneumatized mastoid, posterior approach was used.

The third stage: advanced training
It was applied for expert surgeons and trainers. It included the following: management of otosclerosis with the classic endaural approach. Endoscopy provided good exposure and assistance [22]. Tympanosclerosis is common in Yemen, and it is managed according to its site and extent [23]. For atelectatic ME, we use TM cartilage graft and regain Eustachian tube function [24]. Congenital aural meatal atresia is treated through posterior approach as it is safer than anterior trans-canal approach [25]. Glomus tympanicum needs hypo-tympanotomy with endoscopic assistance [26]. Facial nerve decompression and grafting are very important if happened due to malpractice from any colleague.
An audiology program was added to stages I, II, and III including the following: training local audiologists on hearing evaluation and screening programs beside training the local ENT surgeons to read and interpret basic hearing evaluation including pure tone audiometry, speech audiometry, and tympanometry and how to make surgical decisions based on the audiological evaluation besides education about how to avoid SNHL.

The fourth stage: management of SNHL and screening of HL
This stage included an audiological, rehabilitation, education, and screening program, which included the following: 1. Neonatal hearing screening using OAE and screening ABR. Those who failed in screening tests were sent to full hearing evaluation and rehabilitation in specialized centers. 2. Screening for OME and Eustachian dysfunction using tympanometry in infants and children 3. Screening for adults with SNHL and elderly having presbycusis and refer to get hearing aids (HA) 4. Audiological evaluation and referral of CI cases The fifth stage was a research plan for using stem cells in management of SNHL as a cheap alternative for CI. We stopped at the stage of meta-analysis and systematic review. The inconvenient situations in developing countries limited the progress of this research.

Results
In Egypt, 24 campaigns were done from May 2012 till August 2015. Many campaigns were done before that. Most of them were only 1 day scientific lectures and operative demonstration without training. Only the available data were presented in Table 1.

Discussion
Hearing loss is one of the most common health problems affecting people around the world with an average international incidence of 5% [4]. In Egypt, it affects 16% of the population [1] with an incidence of 14% in children less than 14 years old. Eighty-six percent of deaf patients had conductive hearing loss (CHL), while SNHL was found in 14%, with a male to female ratio of 3:2 HL [2]. A high prevalence of hearing impairment was also reported in Africa [3]. In Uganda, 11.7% of subjects under 15 years of age had HL [3]. There is evidence suggesting that the prevalence of hearing impairment is higher than reported and that much of it is avoidable or treatable [3].
In children, 60% of hearing loss is attributable to preventable causes. This figure is higher in low-and middleincome countries (75%) as compared to high-income countries (49%) [4]. Neglected HL in children may lead to delayed language and cognitive skill development. So early diagnosis and treatment are mandatory.
Overall, preventable causes of childhood hearing loss include the following: infections such as mumps, measles, rubella, meningitis, and cytomegalovirus infections, which can be avoided by the obligatory vaccinations. Use of ototoxic dugs can be avoided by increasing the patients and pediatricians' awareness about their complications. The largest sector causing HL is chronic otitis media which accounts for about 60% of HL in Egypt (including OME, simple CSOM and cholesteatoma, AME, and tympanosclerosis) (Fig. 1). Our project is directed mainly to this category of patients. This project was also discussed in local conferences in Egypt and Tanzania [27]. The similarity of the causes of hearing loss in Africa and other developing countries made this project successfully applicable in these countries.
In stage I, a lot of controversy is present about management of OME which is the most frequent cause of hearing loss in children (30-40%). We put a protocol depending on meta-analysis [10] (Appendix 2) that proved the validity of antibiotics and steroids as medical treatment [13] and adenoidectomy as surgical procedure [12]. Our local studies showed that removal of peritubal adenoids relieve most of these patients [12]. Also, in recurrent cases we found that milk allergy [14] is an important factor beside recurrent peritubal adenoids. This protocol was tested in the campaign by our groups and proved its validity [10]. These findings may differ from guidelines in European countries due to different racial and ecological factors.
Another protocol was put for managing SSNHL as an emergency that threatens hearing. This protocol is based on international and local studies [5,6] (Appendix 1). Both protocols are simple to teach, easy to apply, and saving a lot of patients from hearing loss. They also show the effect of local studies in management of  local health problems. Beside teaching the protocols, we provided training on peritubal adenoidectomy application of tympanostomy tubes and intratympanic injection to fulfill the aims of this stage. We considered use of local anesthesia in ear surgery as a practical non-expensive suitable method for these campaigns. It has many advantages as better hemostasis, testing hearing, facial nerve action, and Eustachian tube patency during operation [7,8] beside marked reduction of the surgical costs [9]. We had long experience to perform it at ASU.
We put soft tissue work in tympanoplasty as the main aim of training in stage I, as it is needed in all tympanoplasty operations. This step is lacking in the TBDC training. We use tragal cartilage grafts with underlay technique. The success rate of this technique in beginners' hands is above 95%, while it is less than 50% with fascia grafts [15]. Cartilage grafts need minimal blood supply and can survive with poor circulation, proving that it was stable in its bed. Although the cartilage cells may degenerate, yet the matrix remains intact. New chondrocytes may form after several years [28]. Fascia graft is considered as another option for those who prefer it. Butterfly grafts [17]are an easy procedure, but proper selection of cases is important as it has limited indication for clean small residual perforations with healthy middle ear.
Regaining ossicular continuity is mostly done with the cartilage graft itself [15] or using preserved homograft ossicles which is much cheaper easy to collect from previous operations well tolerated by human body [16].
Postoperative care, instructions for doctors and patients, and using special ointment applicator [18] can protect the graft for a long time, if there is lack of long postoperative follow-up. The practical training includes all the previously mentioned techniques, which were chosen according to our researches and experience in ASU.
The aim of the second stage was to teach different types of mastoidectomy and cholesteatoma surgery, beside the use of endoscopy in ear surgery. Attendance of previous TBDC is mandatory to share as hands on in this stage.
Mastoidectomy training includes decision-making. Non-indicated mastoidectomies are usually overdone in simple tympanoplasty after attending TBDC. Beside training how to do the operation, knowledge of different anatomical variations was explained as Korner septum, which may hide underlying pathology [29].
Cholesteatoma management protocol was previously mentioned (retrograde modified radical mastoidectomy with endoscopic control and partial cavity obliteration). We chose this technique because it was easy to apply and to teach. Besides, it is one-stage technique, low cost, and can be done under local or general anesthesia. It has a very low incidence of recidivism (residual and recurrent cholesteatoma) [20]. So, staging of the operation and long follow-up are not needed in most cases, which is suitable with the nature of surgical campaigns. In some patients, with well-pneumatized mastoid, posterior approach was used. Retrograde mastoidectomy is rarely done in TBDC programs.
The third stage included advanced training for expert surgeons and trainers, to have experience to face surgical problems in the program, also for other audience as a forward step of improving their learning curve.
The repeated well-defined steps of the same techniques or protocols make it easy to master by the trainees. Also, providing videos of the lectures and of the operations with well-explained steps showing the tips and tricks of the art helped a lot to revise the scientific material. This was obvious in some countries that were visited once, like Syria when I saw the effect and impression of the colleagues even those who did not attend the campaign. Most of the needed videos were published as free on the internet (YouTube).  Hotline telephone contact was established between trainees and trainers if they face any difficult situation during operation at their hospitals. This was very helpful in emergency situations, e.g., dislocated stapes, the advice was to close oval window with fascia and return stapes in place and postoperative vertigo after inner ear fistula closure, the advice was to give antibiotic and steroid injections and so on.
Analysis of results' tables showed that training an ear surgeon is tedious and long process, but it is at the end very fruitful and useful for the community. The moral contract with the trainees to spread the knowledge and to teach at least 10 younger colleagues was very useful to spread the required knowledge and experience among ear surgeons.
The fourth stage was achieved mainly by the audiology team aimed to spread prophylactic knowledge against SNHL for both doctors and patients as the effect of noise, ototoxic drugs, and vaccination against viral diseases that may cause HL. Also, the team provided suitable hearing aids (HA) to those who needed them with the help of charity associations and national insurance hospitals. Most patients needing HA are old people with presbycusis which accounts for 23% of HL in Egypt [1]. Another issue was to discover neonatal SNHL and direct them to the specialized centers for CI if indicated.
We did not concentrate on CI surgery in our campaigns, as only 1.7% of patients with HL needed it. In Egypt, it is done by several specialized centers including ASU hospitals. CI needs also long postoperative followup and training beside the high cost. The relatively high expenses can be directed to much less costly and more frequent causes of hearing loss.
The fifth stage was ambitious to put a nucleus for use of stem cells for management of severe SNHL, which may be achieved later on as a sheep alternative for CI.

Comparison with other projects
Most previous projects which care for hearing loss problems are directed to survey the magnitude of the problem in the population [1] or in smaller sectors as neonates [30] or children [2], sometimes directed to special causes as noise induced HL. Many projects were directed to prophylactic education to avoid HL as viral vaccination, genetic counseling, instruction to avoid the effects of noise especially in noisy factories and music workers, also training on sign language and lip reading. Some institutes provide hearing aids. Few campaigns in Africa as in Ethiopia, Kenia, and Tanzania were directed to cochlear implants, although important but the service was expensive and given to a limited number of the deaf population (internet news).
Little efforts were directed to the major causes namely, all types of chronic otitis media COM, which represent 55.5% of the deaf population. These are preventable and treatable causes, if we put good educational plan for both patients and doctors beside providing good training to face them, which is the main aim of this project. No previous recorded campaigns were directed to treat those patients or to train doctors to treat them. Probably, this project is the first recorded one to achieve this aim on national level.
Cooperation between different health authorities is important to achieve maximum benefit. This includes university professors providing expert trainers, local studies about the problem, and how to manage it, beside the ministry of health providing local trainees and hospital equipment and charity societies providing financial support.

Advantages of this project
This project has a lot of advantages including: (1) it manages a real national health problem in Egypt which has higher incidence than other countries and may lead to speech and teaching problems in children. Besides, it has a global comprehensive view of the HL problems, giving more attention to the more frequent causes. (2) It is based on trustful survey of the causes of HL in Egypt [1] and it treats the most frequent causes of deafness in Egypt, Africa, and most Arab countries. (3) The protocols and methods of management depend on evidence-based medicine (meta-analysis, systematic reviews) also on local researches done in ASU, which is more suitable to our patients. (4) Our protocols beside being scientific they were simple, depending on repeatable fixed standard steps as possible making them easy to apply and learn. Besides, it provides gradual increase of microsurgical abilities of the candidates and covers the training defects that are not practiced in TBDC (mainly soft tissue work). (5) The program has low cost that is suitable for developing countries. (6) Cooperation with the enthusiastic ENT departments' members of the ministry of health hospitals was the main factors of success. Also, cooperation with ASU was very helpful as it provides the expert trainers, research programs, HL survey, TBDC for the candidates, rehabilitation, and hearing aids for old patients and CI program for those who need it. (7) Follow-up of the candidates, with the results of management, allowed to improve the guidelines of the protocol. A hot telephone line was set between the candidates and their trainers to have a guide during surgical operations if difficult situations arise.

Conclusion
Training an ear surgeon is a tedious and long process, but it is at the end very fruitful and useful for the community. Most causes of HL are preventable. We think that our project plan to combat HL is very suitable to be applied in developing countries in Africa and the Middle East.