Browsing by Author "Fagan, Johan"

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    Aminoglycoside-induced hearing loss: South Africans at risk
    (2009) Bardien, Soraya; de Jong, Greetje; Schaaf, H Simon; Harris, Tashneem; Fagan, Johan; Petersen, Lucretia
    South Africa is currently experiencing a TB epidemic with an estimated incidence of 940/100 000 population/year, and the country has been ranked 4th among the 22 high-burden TB countries worldwide by the World Health Organization (WHO). A potentially devastating threat to TB control is the emergence of multidrug-resistant TB (MDR-TB) and, more recently, extensively drug-resistant TB (XDR-TB), mainly as a result of poor drug adherence by TB patients and incorrect management or treatment regimens by health providers; however, direct transmission of drug-resistant strains also plays an important role. The MDR/XDR-TB strains necessitate prolonged chemotherapy for up to 2 years or more, and the use of more toxic second-line drugs including the aminoglycoside (streptomycin, kanamycin and amikacin) and polypeptide (capreomycin) antibiotics. In South Africa, in accordance with WHO guidelines, streptomycin is used for retreatment of TB while kanamycin, amikacin and capreomycin are used to treat MDR/XDR-TB.
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    Anterior Skull Base Resection: External Approaches
    (University of Cape Town, 2025-03-04) VanKoevering, Kyle; Prevedello, Daniel; Carrau, Ricardo; Fagan, Johan
    The sinonasal cavity and anterior cranial fossa can be involved by a wide variety of diverse, rare neoplasms. Surgical extirpation of these lesions is often the mainstay of multimodal treatment for both benign and malignant diseases. However, these tumours pose a variety of challenges for surgical management, including complex anatomic considerations. The nasal cavity can be imagined as a quadrangular corridor that is narrower at the top and divided into right and left compartments by a midline septum. It communicates with the exterior through anterior openings, the nares (nostrils). Posteriorly, it opens into the nasopharynx through the posterior choanae. Its external shape reflects its skeletal support, which is composed of the paired nasal bones and the upper and lower lateral nasal cartilages as they surround the pyriform aperture. The walls of each nasal fossa include the nasal septum medially, the horizontal portion of the maxillary bone and palatine bone inferiorly, and the inferior turbinates and ethmoid bones laterally.
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    Biopsy of Head and Neck Tumours & Cervical Lymph Nodes
    (University of Cape Town, 2025-05-21) Fagan, Johan; Taylor, Kathy; Bolding, Ellen; Fagan, Johan
    Almost any mass or tumour requires cytological or histological diagnosis before a management plan can be formulated. Performing tissue biopsy of masses and lymph nodes of the head and neck fills many junior doctors with fear due to the complex anatomy and the vascular structures and nerves that traverse the head and neck. Yet diagnostic material can be safely obtained from most masses in the head and neck in an ambulatory care setting.
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    Closure of Paediatric Tracheocutaneous Fistula: Surgical Technique
    (University of Cape Town, 2025-03-03) Hlomani, Buhlebenkosi; Peer, Shazia; Fagan, Johan
    A tracheocutaneous fistula (TCF) is an epithelial-lined communication between skin and trachea that persists after decannulation (removal) of a tracheostomy tube. TCF rates are higher in paediatric patients. It is a recognised complication of long-standing tracheostomies and has been linked to long-er duration of tracheostomy dependence. Complications associated with a persistent TCF include skin irritation; inadequate glottic closure causing a weak cough and air-way compromise; poor phonation; poor cosmesis; increased risk of aspiration during swimming, bathing etc. Addressing a persistent TCF avoids delays with integration into society and mainstream schooling. TCF is due to squamous epithelialisation of the tracheostomy tract. Closure is achieved by excising the fistula followed either by primary closure or allowing for healing to occur by secondary intention. Although primary closure provides immediate resolution of the fistula and better cosmesis, it may be associated with life-threatening complications. Allowing healing by secondary intention minimises such potential complications. It may however be perceived as “inconvenient” for the patients.
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    Cricopharyngeal Myotomy: Surgical Technique
    (University of Cape Town, 2025-03-03) Fagan, Johan; Fagan, Johan
    Cricopharyngeal dysfunction/achalasia may be primary or secondary. Primary achalasia refers to persistent spasm or failure of the cricopharyngeus to relax, where the pathology is confined to the muscle and there is no underlying neurologic or systemic cause. It may be idiopathic or be associated with intrinsic disorders of the muscle e.g. polymyositis, muscular dystrophy, and hypothyroidism. Cricopharyngeal spasm may be secondary to neurologic disorders e.g. poliomyelitis, oculopharyngeal dysphagia, stroke, and amyotrophic lateral sclerosis (ALS), or diabetic neuropathy, myasthenia gravis, and peripheral neuropathies.
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    Cricothyroidotomy & Needle Cricothyrotomy
    (University of Cape Town, 2025-03-03) Fagan, Johan; Fagan, Johan
    Cricothyroidotomy, also known as cricothyrotomy refers to the creation of a com-munication between airway and skin via the cricothyroid membrane. It may be achieved by needle cricothyrotomy or by open or percutaneous cricothyroidotomy technique. Advantages of cricothyroidotomy compared to tracheostomy include simplicity, speed, relatively bloodless field, minimal training required, and avoiding hyperextending the neck in patients with possible cervical spinal injury. Indications: 1. Airway obstruction proximal to the subglottis 2. Respiratory failure 3. Pulmonary toilette in patients unable to clear copious secretions 4.Bronchosopy For indications (1) and (2), cricothyroidotomy is generally done as an emergency temporising procedure when a patient cannot be intubated, or when tracheostomy would be too time consuming or difficult. Following cricothyroidotomy the patient should be intubated or a formal tracheostomy done within 24hrs to avoid complications such as glottic and subglottic stenosis.
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    Dental Extraction Technique for ENT and Head & Neck Surgeons
    (University of Cape Town, 2025-03-03) Rabie, Evan; Fagan, Johan; Fagan, Johan
    While dental extraction should ideally be done by trained dental surgeons, head and neck surgeons often extract teeth in the operating room in patients when under-going ablative cancer surgery. This is particularly true in resource constrained settings. This chapter is a practical guide on how to perform dental extractions and to deal with common complications. As head and neck surgeons generally extract teeth in anaesthetised patients undergoing head and neck cancer surgery, local anaesthesia techniques are not discussed.
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    Do proton pump inhibitors reduce the incidence of pharyngocutaneous fistulae following total laryngectomy?
    (2013) Stephenson, Katherine Anna; Fagan, Johan
    Pharyngocutaneous fistula is a common complication of total laryngectomy. We hypothesised that perioperative proton pump inhibitor (PPI) treatment could reduce the incidence of pharyngocutaneous fistulae. This prospective placebo-controlled double-blind randomised controlled trial compared PPI treatment (14 days enteral omeprazole) with a placebo in patients undergoing primary total laryngectomy. The incidence of pharyngocutaneous fistula was recorded.
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    The effect of cloth stoma covers on the tracheal climate of laryngectomised patients
    (2014) Quail, Gavin; Raynham, J J; Fagan, Johan
    Includes summary. Includes bibliographical references.
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    Endoscopic Cholesteatoma, Tympanoplasty, and Middle Ear Surgery
    (University of Cape Town, 2025-03-08) Tarabichi, Muaaz; Fagan, Johan
    The introduction of the binocular operating microscope was a landmark in modern otology as it changed the scope and character of ear surgery. The endoscope offers a new perspective of cholesteatoma and related surgical procedures; it increases the surgeon’s understanding of the disorder and its extension through the temporal bone and provides a wide field of view of the middle ear compared to the microscope. Even though it has been two decades since endoscopy was first used to explore mastoid cavities, the endoscope is used infrequently for surgical management of ear disease; most otologists have not felt compelled to master the newer endoscopic techniques. In addition, there has been a focus on using smaller diameter endoscopes for ear surgery which is counterproductive, as it eliminates the main (and possibly only) advantage of endoscopy i.e. wide field of view compared to that of the microscope. The rationale, advantages, limitations, technique are discussed in this chapter.
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    Endoscopic Management of Idiopathic Spontaneous Epistaxis in Adults
    (University of Cape Town, 2026) Potent, Keith; Smith, Edward; Sivasubramania, Rahuram; Fagan, Johan
    This chapter provides a practical guide to the endoscopic management of idiopathic spontaneous epistaxis in adults. It reviews the relevant nasal vascular anatomy, patient assessment, emergency management, endoscopic identification of bleeding sources, and surgical treatment options. The chapter also discusses postoperative care and strategies for managing recurrent or severe epistaxis.
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    Excision of Preauricular Pits and Sinuses
    (University of Cape Town, 2025-03-03) Fagan, Johan; Fagan, Johan
    Preauricular pits and sinuses are congenital anomalies located in or just in front of the ascending limb of the helix (Figure 1). They may discharge desquamated keratin debris. Although more common on the right, they may be bilateral. The incidence varies, being as high as 10% in parts of Africa. Preauricular sinuses may be sporadic or inherited (autosomal dominant trait with incomplete penetrance and variable expression) and may be associated with branchiootorenal syndrome. Even though excising a sinus is a relatively minor surgical procedure, recurrence is not uncommon if an adequate resection is not done. Surgery is only indicated when it is complicated by recurrent infection or abscesses (Figures 2, 3). An abscess should first be aspirated with a needle and fully treated with antibiotics before surgery is contemplated.
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    Hammer & Gouge Cortical Mastoidectomy for Acute Mastoidsitis
    (University of Cape Town, 2025-03-08) Fagan, Johan; Jackler, Robert; Fagan, Johan
    This surgical guide is intended for the many surgeons in the lower and middle-income countries who do not have access to modern mastoid surgery equipment such functioning mastoid drills, or are regularly faced with power cuts and therefore may be compelled to proceed with a mastoidectomy using a hammer and gouge, and possibly only a headlight and operating loupes. The text and illustrations are based on the description of mastoid surgery: A Treatise on the Surgical Technique of Otorhinolaryngology (1939) by Georges Portmann. The text has been modified to incorporate modern principles of otology. This operative guide should be read in conjunction with the chapter Hammer and Gouge Radical Mastoidectomy for Cholesteatoma. Mastoid surgery can only be safely performed when the surgeon has an intimate knowledge of temporal bone anatomy. It is imperative that surgeons practice temporal bone dissections on cadaver bones.
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    How has the OSD affected our state hospitals?
    (2009) Parkes, Jeannette; Abratt, Raymond; Taylor, Allan; Le Feuvre, David; Murray, Elizabeth; Robertson, Barbara; Kotze, Tessa; Marais, David; Khan, Del; Kilborn, Tracy; Wieselthaler, Nicky; Gajjar, Himal; Handler, Lenny; Fagan, Johan; Spitaels, Ariane; Morrison, Adrian; Davidson, Alan; Salie, Shamiel; Urban, Mike; Rajkumar, Ash; Pretorius, Vincent; van Niekerk, Magriet; Ferreira, Germaine; Wolmerans, Marli; Cyster, Lyall; King, Darren; Okwuosa, Sebastian; van Staden, Sanet; van Niekerk, Margarethe; Winckler, Jana; Meissenheimer, Heinrich; Botes, Annie; Tait, Deon; Visagie, Jodine; Swarts, Steve; Klocke, Marina; Lomas, Vanessa; Marais, Ilke; Vijoen, Werner; Perry, Jennie; Nkosi, Nokwazi; Stuve, Katrin
    The long-awaited occupation-specific dispensation (OSD) process for state-employed doctors has now been concluded. The final offer, signed and accepted in the bargaining chamber despite being rejected by 92% of doctors in a SAMA survey, has not received much attention or fanfare. At the conclusion of this process, which has been drawn out over several years, many points have emerged that are extremely worrying for the future of health care in this country.
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    Implantes Cocleares en Países en Vías de Desarrollo
    (University of Cape Town, 2019) le Roux, Talita; Laurent, Claude; Fagan, Johan
    Este capítulo ofrece una visión general de los implantes cocleares como tratamiento para la pérdida auditiva neurosensorial severa a profunda en niños y adultos que obtienen un beneficio limitado de los audífonos convencionales. Se describen los componentes y el funcionamiento de los implantes cocleares, los criterios de selección de candidatos, los procedimientos quirúrgicos, la programación del dispositivo y las ventajas de la implantación bilateral. Además, se analizan los desafíos relacionados con el acceso a esta tecnología en países en vías de desarrollo, incluyendo las limitaciones económicas, la escasez de servicios especializados y los requisitos para establecer programas sostenibles de implantes cocleares en entornos con recursos limitados.
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    Incus & Malleostapedotomy
    (University of Cape Town, 2025-03-08) Harris, Tashneem; Linder, Thomas; Fagan, Johan
    Stapedotomy refers to the calibrated fenestration of a fixed footplate and insertion of a prosthesis. Prof Ugo Fisch first introduced the terms incusstapedotomy where the prosthesis is attached to the long process of the incus, vs. malleostapedotomy where the prosthesis is attached to the malleis handle. The surgical steps of both procedures will be described as per Prof Ugo Fisch. Otosclerosis is the most common indication for stapedotomy. Histology of temporal bone specimens show that there may be a fairly high incidence (up to 30%) of additional malleal fixation in otosclerosis. Hyalinisation and ossification of the anterior malleal ligament are related to the duration of otosclerosis. Fixation of the malleus head and incus body is usually found in narrow external ear canals. The reported incidence of malleal fixation in clinical studies varies significantly for both primary (0.6 - 6%) 3,4 and revision surgery (3-37%).5,6 In a study (unpublished data) conducted by the senior author (T.L), the incidence was found to be 5% with primary surgery.
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    Juvenile onset Recurrent Respiratory Papillomatosis (JoRRP) at Red Cross War Memorial Children’s Hospital, Cape Town: A 2-year review
    (2019) Pretorius, Vincent; Peer, Shazia; Fagan, Johan
    Introduction: Juvenile onset recurrent respiratory papillomatosis (JoRRP) is the commonest benign paediatric neoplasm. There is no curative treatment, but the condition is self-limiting. Current primary treatment is aimed at symptomatic relief, comprising of serial surgical debulking of obstructive papillomas along the respiratory tract, with voice preservation. Adjuvant therapy is indicated in severe cases. Objective: A review of children with JoRRP presenting to the ENT Department at Red Cross War Memorial Children’s Hospital (RCWMCH) over 2 years. Evaluation of the pattern of disease and factors that may contribute to disease severity were reviewed. Method: Retrospective folder review of children with histologically confirmed laryngeal papillomatosis over above the time period. Results: Twenty children were included. Nine were male, 11 were female. The median age at diagnosis was 2.4 years (11 - 109 months). Presentation at < 3 years was noted in 5/7 of the most severe cases. Nine of 20 were HPV serotyped; 5 were type 11, and 4 were type 6. Eighty percent (16/20) were HIV negative; 10% (2/20) HIV positive; and 10% (2/20) were unknown. A total of 90 surgical procedures were performed; the highest number of surgeries per child was 13. Inter-surgical time was 1 to 164 weeks (median 9 weeks). Four received Gardasil vaccination as adjuvant therapy, 3 of who showed a reduction in disease severity. Conclusion: JoRRP commonly presents around the first 3 years of life. Severe cases can be life-threatening, often with multiple hospital admissions for clearance of surgical papillomata. Severe cases presented before 3 years. Gardasil vaccination as adjuvant therapy has promise. No identifiable risk factors in our review were noted. HIV co-infection and HPV type were not risk factors for severity.
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    Laryngeal Phonomicrosurgery for Treatment of Benign Vocal Fold Lesions
    (University of Cape Town, 2025-03-03) Kashat, Lawrence; Wang, Hailun; Rosen, Clark; Fagan, Johan
    Benign vocal fold lesions (BVFL) include a range of pathologies e.g. nodules, polyp(s), cyst(s), and Reinke’s oedema/chronic polypoid corditis. BVFLs represent a common cause of voice disorders, accounting for approximately 11-22% of patients presenting with dysphonia complaints. This chapter summarises the clinical management of BVFLs, including relevant anatomy, pathophysiology, and an overview of appropriate phonomicrosurgical techniques and postsurgical care.
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    Lateral Temporal Bone Resection Surgical Technique
    (University of Cape Town, 2025-03-08) Mathew, Rajeev; Harris, Tashneem; Patel, Parag; Fagan, Johan
    Lateral temporal bone resection refers to en bloc resection of the external auditory canal (EAC) with the tympanic membrane (TM). It is generally performed for malignancies involving the EAC, the most common being primary squamous cell carcinoma. Tumours may arise from the skin of the external ear, parotid, glandular adnexa of the ear or may be metastases to parotid nodes. History and examination are directed at making a diagnosis and determining the extent of the tumour. Refractory pain is a hallmark of advanced malignancy of the ear canal. Other presenting symptoms include chronic ear discharge and hearing loss. A lesion of the ear canal may be visible and there may be a discharge. The parotid and neck should be examined for evidence of metastases. Facial nerve function should be documented. Assessing sensation of the face on the affected side as well as the lower cranial nerves is crucial to detect intracranial and inferomedial extension to foramen ovale and the jugular foramen. Differential diagnoses include skull base osteomyelitis and inflammatory conditions e.g. TB.
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    Local and Regional Anaesthesia Techniques for Otologic (Ear) Surgery
    (University of Cape Town, 2025-03-08) Bein, Alexander; Wagner, Richard; Wilkinson, Eric; Fagan, Johan
    Implementing the use of local anaesthesia to perform middle ear and mastoid surgery in lower- and middle-income countries and in humanitarian outreach settings is challenging, though it has many advantages. This article outlines the rationale for local anaesthesia in otologic surgery as well as educates the reader about local anaesthetic agents and the anatomy of the ear that allow local anaesthesia to be an effective means under which to perform otologic procedures. Performing otologic procedures under local anaesthesia as opposed to general anaesthesia has many advantages in a humanitarian settings. Depending on the specific setting, the main impetus for performing a procedure under local anaesthesia may be a lack of trained anaesthesia support. In the absence of trained anaesthetists or nurse anaesthetists, local anaesthesia is the safest option. Thus, safety of surgery under local anaesthesia is its primary advantage.