Objectives As part of the UN peacekeeping mission in Mali, the People’s Republic of China have deployed a level 2 medical treatment facility (CHN L2). The aim of this study was to review the cases managed by the otolaryngology service within this facility.
Methods The medical records of all patients treated by the otolaryngology service at the CHN L2 from 1 March 2015 to 1 March 2018 were retrospectively assessed.
Results 614/10189 (6%) of all cases seen in the hospital during this period were referred to the otolaryngology service. 7/614 cases required admission to hospital (1.14%) and 40/614 cases required surgery (6.51%). 3/40 cases requiring surgery (7.5%) were performed under general anaesthesia and 37 cases (92.5%) were under local anaesthesia. The most common surgical treatment was facial soft-tissue injury debridement and closure. Acute rhinosinusitis was the most common diagnosis, followed by acute pharyngitis and allergic rhinitis. Four patients required medical evacuation to a level 3 medical treatment facility.
Conclusions Disease non-battle injury in the form of ear disease was the most common presentation. Maxillofacial soft-tissue injury was the most common cause of traumatic injury. There were limits that the service could provide in terms of medical equipment and consumables, necessitating increased training of otolaryngologists prior to deployment.
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Disease non-battle injury in the form of ear disease was the most common presentation.
Maxillofacial soft-tissue injury was the most common cause of traumatic injury.
There were limits that the service could provide in terms of medical equipment and consumables.
Increased training of otolaryngologists prior to future similar deployments is required.
The Northern Mali Conflict, Mali Civil War or Mali War refers to armed conflicts that started from January 2012 between the northern and southern parts of Mali in Africa. In 2013, a UN Security Council Resolution was passed to establish the United Nations Multidimensional Integrated Stabilisation Mission in Mali (MINUSMA).1 This is aimed at supporting the political progress within the country, carrying out security-related tasks and protecting human rights.2
Since July 2013, China has sent 70 military medical staff to the peacekeeping area in Mali every year, based at the Chinese level 2 medical treatment facility (CHN L2) in Sector East (SE) of MINUSMA (Gao, Mali). According to the Medical Support Manual for United Nations Field Missions, the CHN L2 aims to provide medical care, including routine clinical care and life-saving treatment.3 The CHN L2 is primarily deployed to serve UN military peacekeepers, police and civilian staff members deployed in theatres of operations in Gao. It does on occasion offer assistance to local civilians in need. Peacekeepers are derived primarily from Bangladesh, Senegal, Egypt, Cambodia, Netherlands, Niger and Germany. The treatment facility consists of 16 doctors, 10 nurses and three medical technicians. Doctors who have deployed include an orthopaedic surgeon, a general surgeon, a cardiothoracic surgeon, a neurosurgeon, an otolaryngologist, a burn surgeon and an ophthalmologist. The facility can perform three to four surgical general anaesthetic cases daily. It has the capability to provide 10 to 20 patients with up to 7 days of inpatient care and can receive up to 40 outpatients daily. The MINUSMA does not require a level 2 medical treatment facility to be regularly manned with an otolaryngologist. This aim of this article was to review the distribution of the otolaryngology diseases and otolaryngology surgeries operated in CHN L2 at Gao from 1 March 2015 to 1 March 2018, during three mission periods.
A retrospective study using electronic hospital records was conducted for all presentations to the otorhinolaryngology department at the CHN L2 in the Sector East of MINUSMA, Gao, Mali, during the period from 1 March 2015 to 1 March 2018. This corresponded to three mission periods. Retrospective diagnoses were made by specialists in otolaryngology. The term rhinosinusitis was used to group sinusitis and rhinitis together.
During this 3-year period, 614/10189 (6%) of all cases seen in the hospital during this period were referred to the otolaryngology service (Figure 1). A total of 7/614 cases required admission to hospital (1.14%) and 40/614 cases required surgery (6.51%). Ninety-two per cent were men (n=567) and 8% women (n=47), with a mean age of 34 years (range 23–60 years).
Of the 614 cases referred to otolaryngology, 552/614 (89.9%) were managed in clinic and 62/614 (10.1%) were emergencies. A total of 7/614 cases required admission to hospital (1.14%) and 40/614 cases required surgery (6.51%). Ear diseases were the most common cause of disease non-battle injury (DNBI), followed by the diseases of the nose and nasal sinus, pharyngeal diseases and laryngeal diseases (Figure 2). Thirty-four cases were due to battle injury (Figure 3). The distribution of otolaryngology diseases types are shown in Figures 4 and 5.
Cases necessitating surgery or hospitalisation
Forty patients required surgery and seven patients required admission to hospital during the period studied. Also, 27/40 patients needing surgery were due to battle injuries (n=27, 67.5%), primarily from improvised explosive devices (IEDs), gunshot wounds, shell fragments and buried landmines. Six patients required surgery for non-battle injury (15%), of which the causes were from sports, falls and road traffic accidents. The remaining seven patients (17.5%) required surgery for chronic conditions. Moreover, 3/40 cases requiring surgery (7.5%) were performed under general anaesthesia and 37 cases (92.5%) were under local anaesthesia (Table 1).
There were 4/614 patients who required aeromedical evacuation to the level 3 medical treatment facility located in Bamako, Mali. This hospital has three otolaryngologists and three dentists. One patient suffered tympanic membrane perforation from an IED explosion. One patient required surgical treatment of a zygomatic bone fracture. One patient required further evaluation for hoarseness. Finally, one patient was suffering from a nasopharyngeal space-occupying lesion and needed a comprehensive work-up.
During the period studied, 38 different types of diseases were seen in 614 patients. The foreign military in Mali had almost no otolaryngology specialists.4 The doctors at the level 1 facilities lacked knowledge in otolaryngology diseases, resulting in the large number of otolaryngology outpatient referrals. Ear diseases were the most common, followed by nasal diseases and pharyngeal diseases. This is different to the distribution of diseases in mainland China, where nasal diseases is the most common.5 This likely reflects difficulty in soldiers keeping their external auditory canal clean, as well as noise-induced hearing loss from the use of equipment including rifles. In response to this, we have set up educational lectures to demonstrate the importance of hearing protection measures in their contingents. Acute rhinosinusitis was one of the most common presentations of DNBI, followed by acute pharyngitis and allergic rhinitis. This most likely reflects the weather in the region. The Gao area is located in the southern part of the Sahara desert, with frequent dust storms that is potentially allergenic and a respiratory disease trigger.6 7 There is a requirement for the increased use of nasal drugs to prepare for this, particularly in the form of intranasal glucocorticoids.
Maxillofacial trauma was the most common cause of both battle and non-battle injuries and required careful assessment due to airway risks.8 9 Soft-tissue wounds were debrided and sutured within 2 to 16 hours after injury. One patient with a zygomatic fracture could be managed conservatively, but another required aeromedical evacuation to the level 3 hospital for open reduction and internal zygomaticomaxillary suture fixation. Nine patients (18 ears) required admission to hospital due to explosive events. This resulted in hearing loss from tympanic membrane perforation in four patients (six ears). Patients with tympanic membrane perforation had cleaning of their external auditory canals with 4% boric alcohol and the external auditory meatus was occluded with a sterile cotton ball. All nine patients were treated with ginkgo biloba extract, methylprednisolone and mecobalamin.10–12 Five ears with tympanic membrane perforation healed within 20–38 days, and one ear required surgical repair in the level 3 hospital. Fifteen ears had an overall improvement in hearing after treatment, and in three ears there was no effect.
The overwhelming majority of surgery was performed were local anaesthesia. Seven patients required tracheostomy for emergency life-saving indications.13 Furthermore, 4/7 cases were performed as an emergency to manage acute laryngeal obstruction and 3/7 were performed electively to manage retention of lower respiration secretions. One tracheostomy resulted in postoperative subcutaneous emphysema, potentially related to an overly long tracheal incision, which was required due to the patient’s dyspnoea, which stopped them being supine.
Due to the lack of specialist examination equipment available at the level 3 facilities located in Bamako, Mali, and Dakar, Senegal, or the level 4 facility located in Cairo, Egypt, aeromedical evacuation to these level 3 or 4 facilities needs to be approved by the Force Medical Officer and Chief Medical Officer of MINUSMA, with medical expenses paid by the UN alone. This placed some pressure to accurately diagnose early to prevent incorrect evacuation. There were, however, difficulties in the diagnosis of some diseases, particularly Meniere’s disease, nasal polyps and vocal nodules. It was also difficult to objectively define the degree of hearing loss level due to a lack of a pure tone audiometer, although tuning fork tests were available (Rinne test, Weber test, Schwabach test and Gelle test).14 One patient with vestibular vertigo and one patient with Bell’s palsy were admitted due to horizontal nystagmus and incomplete facial paralysis, respectively; both patients got better after receiving medical treatment.
Six per cent of patients at the Chinese level 2 medical treatment facility in Mali were managed by the otolaryngology service. DNBI in the form of ear disease was the most common presentation. Maxillofacial soft-tissue injury was the most common cause of traumatic injury. There were limits that the service could provide in terms of medical equipment and consumables, necessitating increased training of otolaryngologists prior to deployment.
Contributors YZ is in charge of the design of paper. XM should be considered co-first author, in charge of the data collection and drafting thesis. YL is in charge of data collection. QF makes important changes to the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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