BLA CONNECTIONS | Series 5,   Episode 5 

Navigating Laryngology Care in South Africa with Dr Andile Sibiya

In this episode, host Natalie Watson speaks with ENT surgeon Dr Andile Sibiya about laryngology care in South Africa, and the unique challenges facing the population in terms of the size of the area and population, and the huge reliance on limited public health services.

When Dr Sibiya first started in the province, she was tasked with re-strategising the entire ENT service. She spent a lot of time visiting different facilities to determine areas that were being underserved, laryngology being one of them.

In the latter half of the episode, there is a discussion about innovations like the Trachealator that have been transformational to the community as a whole, emphasising the significant role of collaboration and training in improving patient outcomes. As well as discussions around access to training and other development opportunities.

We hope you enjoy this insightful episode.

Transcript

We have at the moment probably around seven or eight EMT specialists serving in the public sector within that population, 70% of that 11 million is reliant on our services. When the finance manager is concerned about the budget for the hospital, that does not mean he’s not concerned about patient outcomes. He’s just using a different language to speak to his own priorities. And so I had to find a way to learn what that was and how to use that language. To address my concerns and my priorities for our patients.

Natalie Watson
Welcome to BLA connections at Clear Voice – here is the final episode of Series five. I’m your host Natalie Watson, and I’m delighted to bring you discussions and insights from experts from across the globe, on all things laryngology. In today’s episode, we speak to Dr Andile Sibiya, EMT surgeon with a specialist interest, expertise and training in advanced laryngology and otology. Passionate about developing and implementing strategies for improving clinical care service delivery, and access to specialised care, experience in medical education, strategic planning and business unit development with her MBA. She is also very much interested in clinical research. Welcome Andile. So firstly, let’s open up by just telling us about laryngology care in South Africa.

Dr Andile Sibiya
So I think the key difference in South Africa is that most of us are actually general ENT specialists, and so the purview of subspecialty care really becomes more around special interest and your local, regional sort of demand and needs, and so whilst there are individuals in South Africa who are very much laryngologists and do a lot of incredibly important and special work, it is one of those areas of ENT where you develop into it based on your own interest and your access to the additional training.

Natalie Watson
I know Lance Marron, a laryngologist in Jo Berg, is he now? Yes, but are there any laryngologists apart from you in your region, anyone else with a specialist interest in it?


Dr Andile Sibiya

Within the public sector, I largely lead the laryngology service, although I have learned a lot from Dr Muhammad Tanda, who works in the private sector and assists us with sessions here in the public sector as well, and he’s been really great in starting up some of what I was enabled to carry on with. We’re now at a point where many of our registrars and other consultants have started to take on some of the more finer areas of what we define as laryngology, simply because of the demand and structure of our health care service here, most of our ENT surgeons remain general ENT practitioners and so they would do areas of laryngology, papilloma care you know vocal cord nodules and polyps but that would be very much within the scope of general ENT rather than within super specialised or subspecialist care.

Natalie Watson
We chatted before about how large your region is. You’ve shown a fabulous slide once when you were lecturing, and your region is humongous it’s nearly the size of Great Britain.

Dr Andile Sibiya
It is. We serve a population of about 11 million from tip to toe. The United Kingdom as a whole is the length of South Africa, but the size of England alone is the size of our province and within that province we have this population of about 11 million. I believe London is sitting somewhere around 9 million. So we have 20% of the country’s population within our province. Very broad distribution.

People travel sometimes two days just to get to our centre of care, but we’re also really privileged. It’s a beautiful province. You know beautiful beaches, amazing mountaining, but in terms of health care delivery and systems, that becomes a real factor when you’re factoring in how long do people take to get to me? How long does it take for them to get back home? Should they stay overnight? Can I do a case in the rooms? Now these become part of the considerations learning to pick up the red flags when somebody who is in a hospital, somebody will get to you only 12 hours from now. When that person calls you, you need to be able to very quickly figure out what can they do at base. What do they need to rush over to me? What needs a helicopter? It’s making those decisions.

Natalie Watson
So how do you manage such stretched services, because presumably your services are stretched. I mean, how do you cater for such a large population?

Dr Andile Sibiya
For our population. We have, at the moment, probably around seven or eight ENT specialists serving in the public sector. Within that population, 70% of that 11 million is reliant on our services in the public sector. They don’t have the option of private health care, and so what then happens is that one has to be quite strategic about it, right? There are a lot of problems. Our province has that quadruple burden of disease, where we’ve got the HIV, the TB, we’ve got poverty, we’ve got a lot of socioeconomic issues as well going on, and so when one is planning for a service in a province like ours where resources are limited, one has to rationalise where your service goes, and that is a really painful thing to do as a health care practitioner, you have a wide scope of expertise, you may have a wide scope of interest, a wide range of patients coming to see you, but within that, you have to really be mindful of what would yield the most for the time, the effort, and the outcome, ultimately for the patients that I do see. When you have limited theatre time, thinking about that as well becomes part of your considerations, right? So how do I best spend these four, five, six hours in theatre for the patients that I select.

From our side as a discipline, when I started in the province, I was tasked with sort of re-strategizing the entire ENT service for this region and I had a couple of meetings with my colleagues working at some of the other institutions. We sat around and had a couple of really in-depth discussions around the constraints in each unit and each centre, in each facility. I spent a lot of time just listening, visiting, driving out to the different facilities to see what the situation on the ground was, and then we spent time gathering to sort of share that, and together we had to identify what our hit list was going to be, picking our battles, what as a team throughout the province did we feel we were best equipped to do and do well, and what did we need to bring in. And so definitely Airway and Laryngology was one of the things that we felt we were really undeserving our patients. We have a big population, a lot of comorbidities, lots of post-intubation injury, tracheostomies, from adults to paediatrics. Our tertiary centre alone has a pool of 200 kiddies with tracheostomies.

We have a papillomis slate that accounts for 25 per cent of our theatre time centrally, and so thinking about which conditions to serve to best improve our yield, for the limited resources we had, and that yield includes, obviously, patient outcomes. That was part of that decision making, and so Airways was certainly one of the things in the lead here in care, became one of our key priorities and then head and neck cancer and early intervention, and by being able to kind of centre ourselves around those three key themes, we were then able to really be strategic around what kind of resources we asked our province, our provincial government, to invest in for us. How we structured our training, how we reorganised our clinics, our services, how we interacted with the hospitals that refer into us In terms of outreach and education, allowing them to also be upskilled, and early identification of key conditions so that they could send the correct patients to us at the correct time. And all of this is a work in progress. You know you play the long game when you work in the public sector.

Natalie Watson
Yeah, absolutely. It sounds like you’ve done amazing work. I mean, you’ve been a consultant since 2019.

Dr Andile Sibiya

So I’ve been in this province since 2019 as the head of the service here. I’ve been a consultant since 2014, I believe. However, I was in Pretoria then, a really wonderful place to teach and learn, but two academic centres in that province. It’s the only province with a population larger than ours but served by almost four times the number of specialists in ENT. And so the entire service that I was working within, their training within, whilst also constrained, was quite different. I was working at a really high end academic facility, really fortunate to be in an environment where I could start to tap into some of the things which are really, I suppose, a privilege in many areas. I was able to reimagine and develop a voice clinic with the speech therapist there. You know that was a real luxury in some regions, where just the idea of doing phono surgery or voice surgery was really at the bottom of everybody’s list, but I was able to do that there.

When I moved into the province I’m in now, I actually moved into a rural tertiary hospital where, at the time that I started, we didn’t even have a flexible laryngoscope for the ENT clinic, and so that really did become around the business unit development, and that was actually what inspired the MBA. It was sort of thinking around, you know, the province would come in and everybody in that hospital was struggling. All of the units were struggling with sort of resources and making decisions around how to spend it. And as much as I do love my work, I recognise that it’s not the only job out there and that the orthopaedic surgeons have their needs and the ophthalmologists also have their priorities and somehow through that process learnt that there was this need for people to be able to sit around a table and sort of check in with each other.

Natalie Watson
Yeah, I mean it’s really important that you’re strategising on a large scale and I think it’s people like you who have made such a difference, because I mean these are not easy solutions or problems to create solutions. You know, with a huge population, very limited resources and huge comorbidities and pathology out there that you have to then triage, I mean it’s quite phenomenal and I think we feel it’s kind of difficult in the NHS. But I think, if you take your perspective, I can’t imagine the whole of London being served by seven ENT surgeons. I mean, there are more than seven in our paediatric hospital alone. So yeah, it’s a phenomenal thing that you do.

Dr Andile Sibiya
I must say I’m really fortunate to have some amazing people to work with, not just within ENT but also in other disciplines the hospital management all the way up to top leadership within the province. I think when you find people who have the heart for the work, the rest is really just about telling the right story for them to hear how your story matches their own strategy for service delivery, and finding that alignment, I think, was really the key for me. I spent a lot of time knocking on doors and frustrated that things weren’t moving, you know, and then realised that I needed to sort of find a way to speak to other people’s objectives as well, and those objectives weren’t necessarily they weren’t mutually exclusive to me. When the finance manager is concerned about the budget for the hospital, that does not mean he’s not concerned about patient outcomes. He’s just using a different language to speak to his own priorities, and so I had to find a way to learn what that was and how to use that language to address my concerns and my priorities for our patients.

Natalie Watson
One of the major things is talking in management speak, isn’t it, so that you can get the best outcomes you need for your patients? Definitely. So moving forward, we have lots of innovations in laryngology and you have also been central in innovation in in-office procedures and providing in-office care or outpatient procedural care for patients who may not want a general anaesthetic. Actually, from a socioeconomic point of view, you need them back into their homes and their work much more quickly. So there are many challenges that you’re facing as a laryngologist in South Africa. We’ve talked about rationalisation. You’re using in-office procedures, you were saying, to help with that rationalisation. What procedures are you able to do in office and what is the best approach that you found with your population?

Dr Andile Sibiya
The in-office care for us is something really limited at this stage, and part of that is the need to have a safety net for our patient group. So if something were to go wrong, what would happen? And I think as a system, even in the United Kingdom, I think it’s only recently started to grow. The United States were a lot faster in taking on in-office care, and I think we’re lagging there. We definitely need to do more, particularly in the airway. We’ve really made strides in the ear care side and otology side, but certainly not so much with the airway. We run our voice clinic. We do our Botox and our injections in office, but a lot of the other procedures we still reserve for the operating theatre, and that is something we are working towards.

In-office care requires a number of things. The first is the infrastructure to be able to do it safely. The second is the human resources, and so you need a trained set of hands next to yours to be able to do that, and while we have some amazing practitioners I think I mentioned Dr Tanda earlier who does a lot of that in our office, we don’t really have the nursing support within our clinic setup to be able to do that safely at this stage. It is something we’re working on and part of that would need us to be creative about how we use the resources. So perhaps tapping into a service that already has that infrastructure, like our gastroscopy suite, those are options that we’ve been exploring to be able to bring that on board, rather than asking the hospital to invest within our ENT little corner upstairs.

Moving us downstairs to a setup that already exists is what we’re currently exploring. We’re looking at that. Probably in about six months we’re hoping to start doing that a lot more. We’ve started some very tentative sort of dipping our foot into the water, getting people used to the idea. I’m sure you’re aware anytime you’re introducing something new into a system, it’s not just your technical expertise that needs to be there, it’s the nursing staff, it’s the receptionist, the whole team has to be willing to come on board with you and that’s a process.

Natalie Watson
Absolutely, and it’s the same in the UK. I mean, making these changes in the NHS is incredibly difficult. In private it’s also extremely difficult, but I think in the NHS it’s actually more possible and it’s still not adopted everywhere in the UK either. I think people are worried about it and they have their ideas and expectations of what in-office work is. And when you’re dealing with the larynx, there will be some patients who go into laryngospasm, but not very many. Or they have some people who faint, but again not very many, not as many as you would have anticipated with someone who actually has absolutely no sedation at all.

Dr Andile Sibiya
I think, watching some of the stuff that you do, from when I was watching your videos. I really was inspired by some of that, just thinking around again going back to this resource rationalisation, right is how much of what we do in theatre actually could be decanted from that system. Reduce some of that burden on the system, then take it elsewhere. I’ve already mentioned the high volume of patients we have who already have tracheostomies in place, and that already means that there’s a lot of people who are already in the hospital. That means that there’s a group of patients who sort of have a little bit of a safety net for airway where you can start introducing that, I think.

For us, one of the things, for instance, in our clinic, we don’t yet have a flexible fibre optic scope with a working channel. That would be appropriate, right. So that’s a little thing that we’ve put onto our procurement plan. We have a laser in our theatre, but that’s one of those big duo systems with the CO2 and the fibre, but for the clinic we would have to order a blue light, for example, just to start with. Those are all things that are sort of a work in progress. Getting our equipment in terms of the right chair to be able to perform the procedures, upgrading the video camera quality, so that we’ve done in terms of the camera stack, and so you know, it’s all these little moving parts that you’re stacking onto each other to finally get into that place.

Natalie Watson
Exactly, it’s an enormous investment as an outlay for this equipment, and so that’s why I thought it would be interesting to chat with you, because resources are limited in the NHS and in South Africa, but even more so in South Africa, and it’s like how do you deal with this when there’s all these innovations happening, and then you feel frustrated. Do you feel frustrated?

Dr Andile Sibiya
I do feel frustrated, but I always say working in the public sector, you almost have to be a pragmatic optimist, or, incredibly naive, but I like to think I’m a pragmatic optimist. I think I have a fair sense of the fact that most people wake up and come into work wanting to do the best that they can. With whatever they bring in from their home situations and their stressors and their turmoil and whoever their line report may be and what that might be expected of them. But most people, when you walk into your workplace, you’re trying to do good, you’re not trying to frustrate the people around you or restrict access, and I think that goes all the way up.

You know we talk about corruption in political structures, but I don’t think that anyone wakes up wanting to compromise access to care, and so I do think walking into my work with that in mind allows me to have a certain level of optimism. In the time that I’ve been there, I’ve been really privileged to see some amazing investments. You know our province spends more on hospitals and healthcare than it does on education, which I know is controversial, but we do spend a lot of money and every year you look at our budget. They’re spending more, they’re really strategic about investing not just in systems but also in the people in the system.

But those changes take time. 18 months ago, 20 months ago, we didn’t have an auto implant program in our province, which is tragic. In the second largest province in the country, we had no public sector auditory implant program. We now do. We had no mapping audiologists and we now have four, and so these are the things that we need to be able to recognize as ways of moving the ball forward. And we are in the airway care. Up until probably three years ago, the number of patients being decannulated was ridiculously low. We were just salvaging people.

The norm in our institution and in our province, just because of the burden of disease and the late referrals, was that children who came in with aggressive respiratory papillomatosis were getting tracheostomies. And so if you walk into our papilloma clinic at one of our hospitals, you will find a huge number of children who’re sitting around with tracheostomies, which we know is tragic in terms of the added morbidity it adds to the disease itself.

But there was a time that there were only two ENTs working in our public sector province, and so you are sort of putting out fires, putting out fires, and now you see patients coming in early, a mom coming in and saying oh, you know, I noticed that the voice has started to change. Could we schedule this for the school holidays next week? And that shift in understanding of the disease burden and understanding of the natural history in enabling people to come in earlier, all of that is part of this progress that we’re starting to make, because there’s a people who want to do the right thing and just sort of need to be, just need a little bit of guidance, just need to be put in touch with the right people.

Natalie Watson

Yeah, what I wanted to do as well is talk about the innovations that you’ve been involved in, like the trachealator for airway stenosis. Can you tell us a bit about that?

Dr Andile Sibiya
Yeah, so the trachealator is a device that was absolutely amazing. I wasn’t involved in its development, sadly. That was developed by Prof. Darlene Laba, and Ross Hoffmayer down in Cape Town. But this is a non-occlusive balloon, and anybody who’s done any sort of operative field and lumen, knows that the obstruction of flow through that lumen is usually one of the critical limiting factors to what procedures you can do intraluminally, and so the introduction of non-occlusive balloons is not new to ENT but again in the spirit of South Africans adapting and learning from other fields, from other disciplines, in other spaces, that’s what happened here. So this is a multi-channel balloon. It’s a little rosette of balloons that allows you to open up an obstructed airway but still get airflow. For us it’s been really transformational.

When we started here in the province with it, we were using balloon dilatation, but our anaesthetic procedure was then a lot more complicated. As you know, you get occlusion, you’re now kind of timing yourself. How long will the anaesthetist allow me to hold out here with this balloon? Did the anaesthetists take their anxiolytic this morning? Instead of playing that little game of time with each patient trying to get through each balloon. With the balloon, we found that our balloon dilatation time, our desaturations, the number of implementations you need to do into a patient’s airway, have completely transformed.

So, just as a simple example for our subglottic stenosis, if you’re thinking of the number of times you’d have to put in a balloon and inflate and stop three minutes, cycles of inflow, 30 seconds, three minutes, stop, take the balloon out, allow the anaesthetist to bring the saturations back up, because of what we’re doing in other spaces (So we do a lot of our direct laryngoscopies completely tubeless) that’s allowed us to now add this as an intervention within that. So the level of sedation is lower, the recovery time postoperatively is better, the need for postoperative ICU is also lower, and so all of these things are part of the improved system.

Our anaesthetists are phenomenal, and they really came on board with us on this and we sort of had a lot of time sort of learning and working together, figuring out the mechanics of how to do this, innovating in terms of what do you do if you do have the balloon in, although it’s non-occlusive, like how do you jet around it, through it, and sort of working together communication that I’m sure you’re aware of. Any airway surgeon knows the ability to read your anaesthetists’ anxiety, and for them to read, your need to keep pushing for another minute or two and still kind of laugh about it afterwards. All of that is part of how we were able to get here, so we probably do now, I would say five or six balloons a week in our unit.

Natalie Watson
Oh, wow. And on a general stenosis, how long do you keep it for? Because I mean, I’ve seen videos of people keeping them up for 10 minutes of spontaneous lip ventilation.

Dr Andile Sibiya
For me it’s always about the underlying condition, right. So it becomes a matter of how stuck is the stenosis, and what is the additional benefit I’m getting from dilating any longer. In a well-formed, organised stenosis where you’ve got your fibroblasts, you’ve got your collagen layer, I always start by doing a release anyway, either with coplation or laser or cold steel if I need to, and then I balloon through that. Once I’ve done that, really the purpose of the balloon is achieved, and so we seldom keep the balloon in any longer than about three minutes. We do still do serial ballooning, so we would balloon sort of three sequences of three minutes. That would be the norm for us, stopping in between to have a look and see what your airway looks like. But in a fresh stenosis, balloon once for three minutes and you can see if there’s an improvement. Is there really a need to repeat it? Just understanding disease wound healing cycles, going back to your first principles of biology, physiology.

Natalie Watson
Well, that’s amazing. It’s a great advantage, I feel, particularly in certain populations where they’ve got lung fibrosis or lung problems, where you know that they’re going to do that if you use a conventional balloon. So it’s certainly really quite useful. Our traditional time we’d keep a balloon up with a normal cook, or a Boston balloon would be kind of like two minutes for an airway or until, as you say, the anaesthetist just says hang on a minute, you need to breathe. Yeah, so it has changed life a lot having the trachealator.

Dr Andile Sibiya
So from our perspective the translator actually works out a little bit cheaper than the other balloons.

Natalie Watson

Ah, it’s far more expensive for us.

Dr Andile Sibiya

If price were not a factor for you, what would you default to?

Natalie Watson
Well, I have been using the trachealator because I do most of my airway work, as you know, in office. Well, pretty much the only option which is really good in-office is a trachealator, because obviously they can keep on breathing. Otherwise it’s quite occlusive and you can’t keep it up for more than a few seconds for the patient who’s awake. So yes, in office I mean, there’s really no comparison than the trachealator.

But in theatres, under general anaesthetic, we do use the trachealator, but because it’s probably three times more expensive than the Cook or Boston balloon currently, where we can get it, we would err on the side of using those if we feel that we’ve got someone who would cope with two minutes of apnea. But if there’s any suggestion that they won’t, then we’d use the trachealator.

Now there is a different consideration of actually, isusing this multiple balloon rosette shape? Is it better to distribute pressure endoscopically or so that you’re not creating too much necrosis? So I don’t think the studies are out there as a direct comparison to really understand what’s happening to the cells, to know which one is actually better and get better outcomes, and I think that if anyone’s interested in doing that, there’s definitely a project out there.

Dr Andile Sibiya
I’m quite curious about that. So I’ve had it a bit of an evolution in my own thinking about what research is and what we need. But you speak about those rosettes and for me it’s almost if we think about the principles of airway, or any sort of cylindrical tube and scarring in a cylindrical tube. What those rosettes do, is obviously they create those little ridges where you’ve got mucosa that hasn’t had the life sucked out of it essentially or squeezed out of it, and just in terms of basic principles of wounds and that for me it just seems like it makes sense.

Now it would be really hard, I think, to really look at outcomes because you’d have to be comparing apples with apples for that. I know Cape Town has put out a few papers about their successes with the balloon and although most of them are on the anaesthetic components and surgical time and yield and general improvement, rather than true comparisons side by side with an occlusive balloon like the Boston or the Cook. But I feel like it makes sense to me.

Natalie Watson
It certainly makes sense academically, that you would protect the mucosa and therefore there’d be less mucosal injury.

Dr Andile Sibiya
Even going back to before the balloon, just this idea of the Mercedes-Benz incision on a stenosis, it’s the same principle, it is indeed.

Natalie Watson
So it’s just an extension of that principle and continuing with that with the balloon, because it does seem a bit stupid to make the Mercedes-Benz sign and then completely occlude everything.

Dr Andile Sibiya
Yes, sometimes doing the very thing that caused the stenosis in the first place, which is these very high pressures.

Natalie Watson
Yeah, I think it is different also when you’re looking at idiopathic and other causes of stenosis. But yeah, I’m sure there’ll be plenty of research opportunities out there to look into this a bit more. So with that food for thought, I want to ask if there’s any final words from you.

Dr Andile Sibiya
Like I think one of the questions you posed earlier was around laryngology in South Africa and, in a way forward. I think, from my side, one of the limitations with any sort of advancement in care is training and access to training. And at the moment, a large bulk of that for us involves travelling abroad, and some countries have concessions for people from LMICs when you’re attending a workshop or training course, where they recognise that the relative burden of attending that workshop is different. And I think for me that’s something that that faculty, as they’re setting up these workshops, needs to be quite mindful of.

We have a huge need for services in the global South. Particularly those of us who serve in these incredibly constrained public service units, don’t have access to private funding to be able to attend all of these workshops and training, and really that does become the limiter right is your access to the advanced training. And so I think really one of the things I would ask for is just a call for mindfulness around how people think around structuring fees to enable access globally to training, because access to training is the first part of access to care for our patients, and so for me, that’s something I’m quite passionate about. Keeping that in mind, of course, those of us who have had the opportunity to attend training and learn these skills now have a duty to share that knowledge locally, and so for me, that’s something I’m quite excited about.

We’ve started, like I think I mentioned earlier, how we’ve had to be quite strategic around our healthcare priorities, and what kind of training we do is also linked to that. So when we decided on our clinical kind of themes for priorities, that we also linked that to our training themes, and so we introduced sort of cadaver based workshops and that sort of thing locally as well, really intentional about being able to match the service need with what we were doing in terms of training as well.

And so this is the next thing for us is being able to introduce some proper advanced day away training courses locally, and some of our partners have done it. I attended one in Pretoria many years ago, but they are few and far between and they can be quite expensive, and so allowing people to be able to access that training locally is the big thing for me now, bringing people like you and other colleagues over to come and share your, your expertise and your knowledge, so that we can facilitate that. And the training is not just for the surgeons, you know, because we’re just a small part of the puzzle that is patient care, patient airway care, patient voice care, it’s the speech therapists, it’s the nursing team, the anaesthetists, it’s our paediatric colleagues, it’s our pulmonologists, and I think being able to bring those people in on the conversation and for all of us to grow together, I think that’s that’s the next barrier, that’s the next frontier.

Natalie Watson
Amazing. Well, you are a true inspiration Andile. Thank you so much for joining us today, sharing your experience of laryngology care in South Africa, particularly in your province, giving us a perspective, the constraints and restrictions you have, and how you develop solutions and give amazing care to the people that you serve. Your dedication is just a real, true inspiration for us. So thank you so much for sharing your time today. I know you’ve just done an airway list and now trying to squeeze this in your lunch break, so thank you so, so much.

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