A week of surgical exchange in Ghana reveals the power of collaboration, resilience and mutual learning in advancing global ENT care.
Isabelle JM Williams.
Isabelle’s perspective
It was a Saturday lunchtime at Heathrow airport, terminal 3. Professor David Howard, Miss Lulu Ritchie and I shared a celebratory glass of fizz as we discussed our eagerly awaited week with the ENT department at Korle-Bu Teaching Hospital in Accra, Ghana, hosted by Prof Emmanuel Kitcher and Drs Kenneth Baidoo, Kafui Searyoh and Adam Jangu. Prof Howard has been mentoring the ENT team at Korle Bu for over 20 years.
This marked my third surgical trip to Africa, having previously visited Tanzania to deliver a paediatric ENT and anaesthesia course as an AGA-ENT Karl Storz fellow. The week ahead promised to be both challenging and rewarding. The department had selected complex airway and head and neck oncology cases for us to assess and possibly operate on. Our aim was not just to assist surgically but to exchange knowledge with the ENT residents at Korle-Bu, build relationships and explore opportunities for future collaborations. There is much to learn from working in resource-limited settings, where simplicity often drives disruptive innovations.
"There is much to learn from working in resource-limited settings, where simplicity often drives disruptive innovations"
After a six-hour direct flight, we land in Accra, greeted by a wave of humid air and warm welcomes from Prof Kitcher and Dr Baidoo. We navigate the bustling streets of this busy, urbanised city, past street sellers and the occasional cow, before arriving at the Dean’s Guesthouse on the Korle-Bu campus. Featuring newly paved roads, the campus is sizable, boasting a new urology and renal centre and the renowned Moorfields Eye Hospital (named after its London counterpart). Exhausted, we fall into slumber, ready for the week ahead.
The work begins
The next day, awakened by the sound of crockery and cockerels, we gathered for a breakfast of omelettes and bread before Prof Kitcher took us on a morning ward round. Among the patients we saw was a woman with recurrent squamous cell carcinoma obstructing her oro-/hypopharynx. Cachexic and reliant on a tracheostomy, with no established enteral feeding route, her case highlighted the critical role of preoperative nutrition.
David Howard talking to Kenneth Baidoo in theatre.
Other patients presented with similarly advanced pathologies, including laryngotracheal trauma often secondary to road traffic accidents. Late presentations of disease are strongly linked to societal and cultural beliefs; herbal healers, pastors and spiritual remedies are often favoured over medical interventions, even amongst the very well-educated.
(L–R): Lulu Ritchie, Isabelle Williams and Estella Bilson-Amoah.
David Howard teaching the residents.
(L–R): David Howard, Estella Bilson-Amoa and Lulu Ritchie outside the Korle-Bu Teaching Hospital, Accra, Ghana.
Monday’s clinic brought a flurry of activity. In a packed room filled with medical students, residents and family members, we reviewed cases and examined radiographs illuminated by a lightbox. The cases were both fascinating and educational. One patient with severe multi-level laryngopharyngeal stenosis due to caustic ingestion illustrated the complexity of managing complete upper aerodigestive stenosis affecting swallowing, ventilation and voice. Another pressing issue that came to light was the obvious incidence of obesity, even in Ghana, particularly amongst women, complicating airway management and surgical outcomes. Advising and coaching our patients about lifestyle and weight loss will become essential for ENT / airway surgeons on an international scale.
In theatre
The remainder of the week was spent in theatre, with Dr Baidoo leading operations and Prof Howard teaching and reiterating lessons and philosophies of surgery previously instilled amongst the residents. Resource limitations presented daily challenges: power outages, malfunctioning equipment and logistical delays. A craniofacial resection of an ameloblastoma was cancelled due to the patient’s inability to pay upfront costs.
Communication issues also surfaced. During a diagnostic MLB on an infant with suspected vocal cord paralysis and / or subglottic stenosis, a miscommunication led to the administration of a paralytic agent, delaying cord assessment and highlighting the importance of streamlined decision-making and effective teamwork.
Communication is crucial in managing complex cases and, in high-income countries (HICs), such decision-making occurs within multidisciplinary teams (MDTs). In low- and middle-income countries (LMICs), however, MDTs often do not exist, leaving complex decisions to one or two individuals. For example, Dr Baidoo and Prof Howard faced the challenging decision of whether to operate on a young man with aggressive midface / oropharyngeal SCC. While the patient was fit, the surgery would be extensive, requiring craniofacial surgery, orbital exenteration, a forehead flap, an obturator prosthesis and postoperative chemo-radiotherapy.
"Every wasted minute not only escalates anaesthesia costs but also increases morbidity and mortality risks, ultimately reducing the number of patients who can be treated"
In Ghana, death is less of a taboo topic, and religion profoundly influences health and healing, providing patients with hope even in the face of a bleak prognosis. Despite a candid discussion about the severity of his condition and the implications of surgery, our patient wanted to proceed. “He has no choice”, says his daughter. While Prof Howard acknowledged the feasibility of the surgery, Dr Baidoo ultimately decided against it. I was struck by the mutual respect, shared knowledge and camaraderie between them. Whilst, as ‘visiting’ surgeons, we are able to operate on complex pathologies, there must always be a recognition of the context in which these operations are occurring, with consideration of resources, time, and long-term outcomes. This would be an all-day case, meaning fewer patients operated on overall, for an already uncertain prognosis.
Reflections and connections
Prof Howard reminded us all frequently during the week that “time is our greatest commodity.” Every wasted minute not only escalates anaesthesia costs but also increases morbidity and mortality risks, ultimately reducing the number of patients who can be treated.
Certain aspects of organisation and practice, such as the absence of morning briefs, seemed less structured compared to the UK, yet I observed Dr Baidoo and his residents dedicating time to truly listen to and examine each patient. Despite crowded, bustling waiting rooms, they approached their work with calmness and focus, free from an overwhelming sense of urgency. Patients, in turn, waited patiently, showing gratitude and respect rather than frustration, a stark contrast to the increasingly strained dynamics in the UK healthcare system. Here, a toxic culture has emerged, whereby rushed consultations compromise patient care. We often prioritise clearing the board, or list, over genuinely engaging with individuals, driven by the need to impress our teams or seniors rather than addressing the patient’s needs, or using a case as a learning opportunity. This misplaced view of competence undermines the essence of quality healthcare: time, attention and empathy.
I returned from Ghana with a renewed sense of purpose, with my perspective broadened and my enthusiasm reignited. This trip served as a powerful reminder that a career in medicine is, at its heart, rooted in connection, resilience and our unwavering commitment to achieving better outcomes for each individual patient. Global surgery does this on an international scale, optimising outcomes for those that need them most.
Estella Bilson-Amoah.
Estella’s perspective
As a young ENT consultant specialising in otology and paediatric ENT in Accra, Ghana, I had the privilege of hosting a team of distinguished UK ENT surgeons alongside my senior colleagues.
ENT practice in Ghana
Practising ENT in Ghana presents challenges, including limited diagnostic tools, inadequate health insurance and shortages of essential equipment such as flexible fibreoptic endoscopes, blood products and imaging services. Despite these constraints, the ENT team at Korle-Bu remains committed to the delivery of quality health and surgical care. The visiting team’s expertise in complex head and neck surgeries, particularly transoral laser microsurgery for laryngeal and pharyngeal procedures, provided us all with unique learning opportunities.
David Howard operating with the CO2 Laser.
Lulu Ritchie and Estella Bilson-Amoa outside the Rebecca Akufo-Addo Paediatric Intensive Care Unit at the Korle-Bu Teaching Hospital.
Learning from experts
Observing and assisting in paediatric microlaryngoscopy procedures was a highlight for me. Drs Ritchie and Williams emphasised meticulous technique, appropriate instrument selection and the critical role of topical anaesthesia during these cases. Their structured approach, thorough preoperative planning, clear communication with anaesthetists and surgical precision reinforced the importance of good preparation in optimising outcomes. Prof Howard’s insights into managing laryngotracheal trauma were particularly impactful. He highlighted the devastating effects of motorcycle-related accidents and stressed the need for collaboration between ENT surgeons and public health officials to promote preventive measures.
Challenges and observations
The visiting team’s expertise was invaluable, yet they occasionally struggled to fully grasp the local resource limitations shaping our clinical decisions. The absence of essential equipment for bedside exams often necessitates improvisation from our side.
We were grateful for the equipment donations, including laryngotracheal stents, tracheostomy tubes, pulmonary balloon dilatation catheters and laryngeal mirrors. These tools will significantly enhance patient care and demonstrates the power of international collaboration in addressing resource gaps.
Conclusion
Beyond clinical and academic activities, we engaged with the visiting doctors on a personal level, sharing stories about our lives and cultures over dinner.
The skills and knowledge I have gained will influence my practice, particularly in paediatric ENT and trauma management. The donated equipment will have a lasting impact on our department’s capacity to provide quality ENT care. But most importantly, this collaboration highlighted the value of international partnerships in bridging gaps in knowledge, resources, and expertise. Inspired by this experience, I am committed to fostering further collaborations to advance ENT care in Ghana.
