Challenges and outcomes of airway surgery in a post‐war low‐resource setting: A case series from Mekelle, Ethiopia

Abstract

Objective

This study aims to document and analyze the challenges and outcomes of performing complex airway surgery in a low‐resource, post‐war setting in Mekelle, Ethiopia.

Methods

This prospective case series examines clinical data from five patients who underwent airway reconstruction surgeries and one patient who underwent total laryngectomy at Ayder Comprehensive Specialized Hospital in Mekelle. Data included patient demographics, airway stenosis etiology and severity, operative details, postoperative outcomes, complications, and hospital length of stay. Ethical approval was obtained from institutional review boards at Mayo Clinic and Mekelle University.

Results

The study included six patients aged 9–62 years, with surgeries comprising three cricotracheal resections, two tracheal resections, and one laryngectomy. Three reconstructions were for war‐related injuries. Challenges included power outages during surgeries, limitations in medical supplies and equipment, and inadequate perioperative care. Despite these, three patients requiring tracheostomies were successfully decannulated within a year. However, complications such as restenosis, infections, and the need for reintubation were common.

Conclusion

Airway surgeries in a low‐resource, post‐war setting face significant hurdles, including perioperative care quality, resource limitations, and infrastructure issues. Successful outcomes require multidisciplinary training tailored to local contexts, investments in hospital infrastructure and reliable electricity, and proper perioperative nutrition. This study highlights the need for comprehensive interventions to improve surgical care in such settings.

Level of evidence: IV.

This case series explores the challenges and outcomes of airway reconstruction and laryngectomy in Mekelle, Ethiopia in the aftermath of the Tigray War. It highlights hurdles like inadequate perioperative care, limited medical supplies, and power outages. Despite these challenges, three out of four patients were successfully decannulated, but complications were common, indicating the need for improved resources and training.

1. INTRODUCTION

In the aftermath of a conflict, the landscape of healthcare often experiences increased challenges. The Tigray War, an armed conflict which took place between November 2020 and November 2022 provides an important example of these challenges. The conflict in and around the city of Mekelle resulted in large disruptions in healthcare, food and water access, and other humanitarian needs. ¹ Injuries and casualties that were reported around Mekelle included otolaryngologic‐head and neck injuries. ² , ³

The role of otolaryngology‐head and neck surgery in both the battlefield and post‐war contexts has been increasingly appreciated. Despite progressive advancements in combat body armor that results in reduced incidence of injuries to the torso, injuries to the head and neck remain prevalent, ⁴ with roughly one‐third of battlefield injuries located in the head and neck in recent conflicts. ⁵ , ⁶ In post‐conflict settings, there is often a significant burden of head and neck injuries secondary to mechanisms such as penetrating trauma (explosive blasts, shrapnel, ballistics), chemical/heat, infection, and airway foreign bodies. Of particular concern is the spectrum of facial fracture and laryngotracheal injuries that result from these mechanisms. ⁷

Airway reconstruction is a specific surgical treatment that can be required in an intra‐ and post‐war environment. While airway procedures consisted primarily of tracheostomy for airway obstruction or tracheal laceration repair prior to the 20th century, ⁸ modern and complex airway procedures have been developed, including laryngotracheal reconstruction and tracheal stenting. However, performing these complex airway surgeries in a low‐resource setting presents many challenges. Limited medical equipment and human resources, and inconsistent access to essential services such as electricity greatly impacts the quality and outcomes of these surgeries.

Here, we explore the complexities of performing airway reconstruction and other airway surgery in the aftermath of the Tigray War and within the specific geographic context of Mekelle, Ethiopia. Our goal is to characterize the challenges that surround these procedures. Using a case series approach, we aim to analyze the challenges, interventions, and outcomes of these procedures in this setting and explore lessons learned for future interventions.

2. METHODS

Patients were prospectively identified from a database maintained by the Otolaryngology‐Head and Neck Surgery Department at Ayder Comprehensive Specialized Hospital, a major teaching hospital in the Mekelle, Ethiopia. Consultants from the department identified patients who were to receive care as part of a short‐term surgical trip in June 2023. While the main focus of the case series is airway reconstruction surgeries in the context of violent conflict, a laryngectomy was included in the series to document delays in care resulting from the conflict and the experience of performing these surgeries at this institution. Five patients requiring airway reconstruction surgery and one patient requiring laryngectomy were identified. Initial data were collected prospectively by creating a register with deidentified clinical information. Follow‐up and outcomes data were also collected prospectively during subsequent clinical visits by the otolaryngology team.

Variables of interest included baseline patient demographic characteristics, etiology of the patients' airway stenosis and grading of stenosis severity, operative characteristics, postoperative symptoms and complications, postoperative airway evaluation findings and additional procedures performed, need for tracheostomy tubes following the laryngotracheal resection intervention, and total length of stay in the hospital. The characteristics of the airway stenosis were classified using the Myer‐Cotton and McCaffrey grading system. ⁹ , ¹⁰ The study was approved by the institutional review boards of Mayo Clinic (IRB# 22‐006024) and Mekelle University.

3. RESULTS

This case series includes six patients aged 9–62 years. The surgeries consisted of three cricotracheal resections, two tracheal resections, and one laryngectomy. Three of the airway reconstructions were for airway stenosis directly or indirectly caused by traumatic injuries sustained as war casualties. Demographics and characteristics of patients included in this case series are seen in Table 1.

TABLE 1.

Patient demographics and characteristics.

Patient	Age (years)	Sex	Airway surgery	Indication for surgery	Preoperative stenosis grades
1	20	Male	Staged cricotracheal resection	Tracheal stenosis	Myer‐Cotton: 4, McCaffrey: 3
2	9	Male	Single‐stage tracheal resection	Tracheal stenosis	Myer‐Cotton: 3, McCaffrey: 3
3	25	Male	Staged cricotracheal resection	Glottic, subglottic, tracheal stenosis	Myer‐Cotton: 4, McCaffrey: 2
4	9	Female	Single‐stage tracheal resection	Papillary thyroid carcinoma with tracheal invasion	N/A
5	62	Male	Total laryngectomy	Laryngeal cancer	N/A
6	40	Male	Staged cricotracheal resection	Subglottic and tracheal stenosis	Myer‐Cotton: 3, McCaffrey: 3

Three out of the four patients requiring tracheostomies were successfully decannulated. The postoperative outcomes for each patient are summarized in Table 2.

TABLE 2.

Postoperative outcomes.

Patient	ICU/Ward stay length (days)	Postoperative complications	Decannulation
1	42	Granulation tissue, restenosis	No
2	6	Re‐intubation, granulation tissue	N/A
3	6	1 cm restenosis, granulation tissue	Yes
4	32	None	Yes
5	11	Stoma site infection	N/A
6	15	Tracheostomy site infection	Yes

3.1. Case 1

A 20‐year‐old male developed tracheal stenosis due to prolonged intubation following a severe penetrating brain injury, having been intubated for 18 days. He had sought medical attention three times for airway complaints. Initially, endoscopic balloon dilation was attempted but the balloon ruptured. A tracheostomy was then placed. On preoperative evaluation, the stenosis was classified as Myer‐Cotton grade 4 (of the cricoid and suprastomal area) and McCaffrey grade 3.

The patient underwent a staged cricotracheal resection along with the stoma site, creation of a new distal stoma and placement of a 7.0 endotracheal tube stent. Given limitations in medical supply chain, a standard 7.0 endotracheal tube was used to create a modified T‐tube to sit above the tracheostomy, similar to the Zeitels spring stent. ¹¹ The surgery, as was the case for all the cases in this series, was interrupted by a power outage (Figure 1). Postoperatively, he remained in the medicine ward for 6 weeks at which point the stent was removed. Due to resource limitations and patient follow‐up issues, maintenance therapies such as serial dilations or topical medications could not be utilized to optimize the healing site. At the 6‐month follow‐up bronchoscopy, the patient had a recurrence of symptoms and was found to have re‐stenosis at the site of anastomosis. He has not been able to be decannulated. There was no observed surgical anastomosis failure, infection, re‐intubation, bleeding, or fistula.

FIGURE 1.

Operating with cell phone light after an electricity outage.

3.2. Case 2

A 9‐year‐old male presented with tracheal stenosis due to prolonged intubation from an infectious encephalopathy that caused Guillain‐Barré syndrome and secondary paralysis. He never received a tracheostomy due to resource limitations during the war. Following discharge, he had visited the hospital twice for shortness of breath during exertion. On preoperative evaluation the stenosis was classified as Myer‐Cotton grade 3 and McCaffrey grade 3. He underwent a single‐stage tracheal resection without stent placement (Figure 2).

FIGURE 2.

Tracheal resection before anastomosis.

Postoperatively, he was admitted to the Intensive Care Unit (ICU) and subsequently the medicine ward, with a total length of stay of 6 days. The patient had required re‐intubation immediately postoperatively due to poor management of sedation and lack of minimally invasive positive pressure. At his 6‐month follow‐up, there was minimal granulation at his anastomotic site. At his 1 year follow‐up, he had no breathing complaints and performed multiple sprints outside the clinic without significant work of breathing. He did not experience failure of the surgical anastomosis, surgical site infection, bleeding into the airway, or fistula formation.

3.3. Case 3

A 25‐year‐old male with previous tracheal injury that resulted from war‐related penetrating neck trauma presented with glottic, subglottic, and tracheal stenosis. He had a tracheostomy tube which was placed on the day of his tracheal injury. On preoperative evaluation, he had stenosis classified as Myer‐Cotton grade 4 and McCaffrey grade 2. The patient underwent a staged cricotracheal resection and placement of an 8.0 endotracheal tube stent (Figure 3).

FIGURE 3.

Double‐stage airway reconstruction after a traumatic bullet injury, complicated by a recurrent keloid.

Postoperatively, the patient was hospitalized in the medicine ward for 6 days. On his surveillance 6 months postoperatively, his stenosis had improved to Myer‐Cotton grade 1, with 1 cm of restenosis and granulation tissue. He was decannulated at his 1‐year postoperative visit after his reconstruction. He did not have surgical anastomosis failure, surgical site infection, bleeding into the airway, or formation of a fistula.

3.4. Case 4

A 9‐year‐old female presented with papillary thyroid carcinoma with local invasion to the trachea. She underwent a subtotal thyroidectomy as well as a single‐stage tracheal resection. The thyroidectomy was complicated by suspected bilateral recurrent laryngeal nerve (RLN) injury. Because of this, the anesthesia team was instructed to keep the patient intubated after surgery to allow time for potential nerve recovery. Despite several attempts to communicate the risks of extubation, the anesthesia team proceeded with extubation which led to acute desaturation. As a result, the patient was reintubated and the surgical team performed a tracheostomy.

Postoperatively, she was admitted to the ICU and subsequently the ward for a total of 32 days. Her postoperative care was complicated by the effects of the war. Due to interruptions in the transportation of medical supplies during the conflict, ¹² calcium and levothyroxine were not available after her thyroidectomy. Additionally, the lack of access to suction equipment for her tracheostomy made her airway management challenging. By her 6‐month postoperative follow‐up, she had been successfully decannulated. At her 1‐year follow‐up, examination of her vocal cords by direct rigid laryngoscopy revealed return of function. She did not experience surgical site infections, bleeding, or fistula formations.

3.5. Case 5

A 62‐year‐old male presented with a history of T4 laryngeal cancer. He had no history of previous oncological treatment despite having had pathological and clinical diagnosis for 2 years. The patient's care was delayed by the combined impact of the COVID‐19 pandemic and the Tigray war, which led to cancellation of elective surgeries at the hopsital ¹³ and severe shortages of chemotherapy drugs. ¹² Radiation therapy is not available in Mekelle. He underwent a total laryngectomy. Postoperatively, he stayed in the medicine ward for 11 days. At the 6‐month follow‐up, no granulation tissue was observed, but the patient had experienced a mild stoma site infection. There were no other surgical complications such as anastomosis failure, re‐intubation, bleeding, or fistula formation.

3.6. Case 6

A 40‐year‐old male presented with subglottic and tracheal stenosis secondary to prolonged intubation following penetrating traumatic brain injury. Preoperatively, he presented with stridor and increased work of breathing. The stenosis was classified as Myer‐Cotton grade 3 and McCaffrey grade 3. The patient underwent a staged laryngotracheal resection and placement of an 8.0 endotracheal tube stent. Postoperatively, the patient was treated in the ICU and ward for 15 days. At his 6‐month postoperative visit, his airway was patent with no stenosis or granulation tissue. His tracheostomy was decannulated at this visit. Surgical complications for this patient included a tracheostomy site infection, but he did not require re‐intubation or have anastomosis failure, bleeding, or a fistula.

4. DISCUSSION

This case series documents six airway surgeries performed by the local team aided by a visiting otolaryngologist, as part of a short‐term surgical trip shortly after the Tigray War in Mekelle, Ethiopia. Three of the airway reconstructions were for airway stenosis resulting directly or indirectly from traumatic neck or brain injuries sustained as casualties of the war. Two of these three patients had been decannulated 1‐year post‐operation. Additionally, two cases involved delayed airway management due to the conflict. Overall, with three out of the four patients requiring tracheostomies successfully decannulated, performing complex airway surgeries in this low‐resource, post‐war setting proved to be feasible despite numerous challenges.

One of the main difficulties was the quality of perioperative care, which greatly impacts the outcomes of complex airway surgery. Perioperative care was limited by unavailability of essential equipment and medications, deficiencies in equipment for intensive care management, inadequate specialized training for nurses, and insufficient nurse‐to‐patient ratios, consistent with findings of previous assessments of ICUs and Post Anesthesia Care Units (PACU) in Ethiopia. ¹⁴ , ¹⁵ While many of these were existing issues, many were exacerbated during and after the war. The conflict led to interruptions in transportation of essential medications, medical equipment and consumables into the region. ¹² In addition, the conflict led to a mass displacement of healthcare workers. ¹⁶ Many healthcare professionals fled the region due to safety concerns, leading to a reduction in the workforce available to provide care at Ayder Hospital. Despite the availability of ICU beds, the local team often reported that patients received better care in the general medicine ward than in the ICU secondary to understaffing and limitations in ICU supplies and equipment. Consequently, many patients were transferred to the medical ward postoperatively, despite the lack of continuous vital sign monitoring. Patients were only sent to the ICU postoperatively if they required ventilator support. Therefore, future intervention to build airway surgical capacity should not only include surgical education and training, but also capacity building in the perioperative care settings.

Longitudinal teaching missions in LMICs, such as Operation Airway, have shown improvement in airway surgery outcomes through a multidisciplinary approach that targets both surgeons and perioperative team members. ¹⁷ Operation Airway has achieved a decannulation rate of 82% in pediatric airway surgeries over a 10‐year period of training missions. ¹⁷ Achieving similar sustainable results in Ethiopia will require visiting teams to provide multidisciplinary training that is specific to the local context, existing infrastructure, and the needs of the local teams. Considering financial and logistic constraints, low‐fidelity simulation for laryngotracheal reconstruction can be used to train surgeons in a practical and cost‐effective way. ¹⁸ Additionally, creating online or offline educational resources that the local team can continue to access will allow for ongoing learning and reinforcement of the skills and knowledge acquired during training missions. ¹⁷

Maintaining tracheostomy care at Ayder Hospital was challenging due to insufficient nurse training and limited resources, a common issue in LMICs. ¹⁹ , ²⁰ Consequently, tracheostomy care knowledge among patients and caregivers was also inadequate. Additionally, Ayder Hospital utilizes single‐lumen metal tracheostomy cannulas. Although cost‐effective and durable, metal cannulas are often rigid, cuffless, and cannot be connected to a ventilator circuit, making them difficult to use in an acute care setting. ²¹ The lack of proper suction equipment further complicated tracheostomy management. The single cannula design is more likely than dual cannulas to become obstructed and require quick removal, necessitating critical care staff to have excellent knowledge and capability to respond rapidly to prevent and manage complications. ²²

Low‐fidelity simulation‐based tracheostomy care training for clinicians and students has been utilized in other resource‐limited settings to improve tracheostomy care knowledge. ²³ , ²⁴ Additionally, implementing protocols for standardized tracheostomy care and nurse documentation of care practices through a multidisciplinary approach can support quality improvement efforts. ²⁵ , ²⁶ Beyond clinicians, tracheostomy care education and training should involve patients and caregivers. Furthermore, providing tracheostomy care kits, including hand‐pump suction devices for caregivers that are compatible with a low‐resource setting could be low‐cost and sustainable. A study in Rwanda demonstrated that tracheostomy care kits could be produced for as little as US$16 in 2018. ²⁴ Without these vital interventions, many patients will remain with tracheostomies with significant reductions in their quality of life, increased disability and overall struggle for these patients to find their place in society. ²⁷

Communication challenges within the operating room also complicated outcomes. The incident of premature extubation in one of the patients exemplifies the absence of effective systemic communication protocols to prevent such errors. Effective communication among surgical team members is associated with lower surgical morbidity and mortality. ²⁸ The implementation of surgery‐specific perioperative checklists has been proposed as a way to improve communication in the operating room. ²⁹ Standardized preoperative team briefings have also been described as effective for improving team functioning in the operating room. ³⁰ Introducing and strengthening team communication protocols through future multidisciplinary efforts can be highly beneficial in reducing such preventable incidents.

Non‐clinical care factors also impacted the outcome of these surgeries. Ensuring adequate nutrition for patients was a challenging as the war sharply increased the prevalence of acute malnutrition and household food insecurity in the Tigray region. ³¹ This complicates outcomes as perioperative nutrition affects postoperative recovery and length of hospitalization. ³² , ³³ Power outages in the operating room posed a significant problem during surgeries as seen in all six cases. Due to the war, Tigray had experienced over a year of power outages, and despite the announcement of power restoration December 2022, electricity remained unreliable with intermittent outages during our surgeries. ³⁴ Without backup systems, the surgical team relied on cell phone lighting to proceed with the surgeries. These power interruptions not only prolonged the surgeries but also increased the risk of intraoperative complications. Securing reliable electricity and backup power systems is essential for safer surgery. This will likely require investing in operating room infrastructure in a collaboration between the government, private industry, and non‐governmental organizations.

This case series is limited by the small sample size of six patients. Additionally, the limited follow‐up duration of 6 months and 1 year may not capture long‐term outcomes and potential late complications. There may have also been variability in perioperative and postoperative care influenced by staffing levels, training, and resource availability, which may affect the consistency of the outcomes.

5. CONCLUSION

This case series describes the challenges of performing airway surgeries in a low‐resource post‐war setting. Surgical outcomes were impacted by the quality of perioperative care, communication challenges in the operating room, and non‐clinical care factors like power outages and nutritional deficiencies. Future interventions should include training and education encompassing both surgical and perioperative care using a multidisciplinary approach tailored to local capacity and needs. Additionally, investments in hospital infrastructure to improve the availability and reliability of resources will be essential.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Eyassu DG, Candelo E, Asgedom BH, et al. Challenges and outcomes of airway surgery in a post‐war low‐resource setting: A case series from Mekelle, Ethiopia. Laryngoscope Investigative Otolaryngology. 2024;9(6):e70034. doi: 10.1002/lio2.70034

DATA AVAILABILITY STATEMENT

The data that support the results of this study are available upon reasonable request from the corresponding author.