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November 2007 EVALUATION OF THE PERCEIVED BENEFITS OF TRADITIONAL UVULECTOMY AMONG A COHORT POPULATION IN ILORIN, NIGERIA. BY DR OLAYINKA ABDULMAJEED SULEIMAN DEPARTMENT OF OTORHINOLARYNGOLOGY UNIVERSITY OF ILORIN TEACHING HOSPITAL, ILORIN, KWARA STATE, NIGERIA A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE FELLOWSHIP OF THE MEDICAL COLLEGE IN OTORHINOLARYNGOLOGY NOVEMBER 2007 DECLARATION I, Dr Olayinka Abdulmajeed Suleiman, hereby declare that I am the sole author of this project, and that all references has been consulted by me and this dissertation have not been previously submitted for the award of a higher degree either in part or in full and neither has it been submitted to any Journal for publication. …………………………………………… Dr A O Suleiman Department of O R L, University of Ilorin Teaching Hospital, Ilorin June 2007 CERTIFICATION This is to certify that this work “Evaluation of the perceived benefits of traditional uvulectomy among a cohort population in Ilorin, Nigeria” was done under our supervision ……………………………………………………….. Professor C C Nwawolo Associate Professor/Consultant ENT Surgeon, ENT Unit; Department of Surgery, Lagos University Teaching Hospital, Idi-araba, Lagos, Nigeria ………………………………………………………… Dr F E Ologe Senior Lecturer/Consultant ENT Surgeon, Department of ENT, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria ACKNOWLEDGEMENT I give thanks to Almighty God for His mercy and grace in the completion of this dissertation. I am grateful to Prof CC Nwawolo, and Dr F E Ologe, for their tireless supervision, guidance and support in writing this project. My gratitude goes to Prof P A Okeowo, Professor of Otorhinolaryngology and Dr A D Dunmade, Mr. S. Segun-Busari, Dr B S Alabi and Dr A Aluko Consultant ENT Surgeons for their support and guidance. I acknowledge with thanks the efforts of Prof GTA Ijaduola, Professor of Otorhinolaryngology University College Hospital, Ibadan, for some references, which were helpful. My gratitude to Mallam Abdullahi, a tailor in Sango, for his time and assistance during the period of my data collection. Finally I thank my wife; Medinat and my daughters; Aaliyah and Thariyah for their love and support. SUMMARY Background: Traditional healers are an important part of African society. They are known to cover the health needs of a substantial proportion of the population. It is unfortunate, however, that the knowledge of the extent and nature of this form of traditional healing, and the people involved in the practice is still limited. Objective: To evaluate the perceived benefits of traditional uvulectomy among a cohort population in Ilorin. Materials and Methods: This study was conducted in Sango area due to the high concentration of traditional Surgeons in this community. The control population used is from the Oja gboroo area in Ilorin. The study was conducted between February and June 2006; everyday of the week except Sunday from 4pm to 6pm. Sample size of three hundred and seventy-six subjects was used for the study and three hundred and forty-four for the control. Results: The proportion of male that had uvulectomy done was 235(62.5%) and female 141(37.5%) with sex ratio of 1.6:1. Prevention of sore throat, treatment of sore throat, prevention of childhood illnesses such as diarhoea, delayed growth and refusal of feeds and elongated uvula which is causing choking feeling in the throat were major reasons for the procedure. Complications are rare, commonest is sore throat 34(9%), bleeding which is usually insignificant in most cases 26(6.9%). There was no difference in the frequency of sore throat among the two study groups. Eighty-seven percent (87%) of subjects who had uvulectomy are satisfied with the outcome. Conclusions: There is no significant difference in the frequency of sore throat among the subject population compared to the control group. There is no significant difference in the occurrence of childhood illnesses among subjects who had uvulectomy and the control group. This community has strong confidence in the practice of traditional uvulectomy and gives it more than 85% approval rating. CHAPTER 1 INTRODUCTION Traditional healers are important part of African society. They are known to cover the health needs of a substantial proportion of the population. It is unfortunate, however, that the knowledge of the extent and nature of traditional healing, and the people involved in the practice is still limited 1. Traditional medical care tends to be patronized by older people, males and those who are far from conventional medical centres 2. Traditional medical service is cheap, accessible and socially acceptable 3. Therefore they have a large patronage. In East Africa ninety percent of the population rely on traditional healers 4. The cooperation between traditional and western medicine is still in its infancy. Efforts to synthesize both have been erratic, varying from country to country 4, 5. Health educators, Doctors and health policy makers believe that the positive aspects of what traditional healers can contribute to health care needs to be carefully studied, appreciated, and encouraged. Their high risk assessments, treatments, and practices should be outlined in each population group; and both traditional healers and those who patronise them should be taught the dangers in a friendly atmosphere devoid of derogatory comments and remarks 6. Traditional uvulectomy is a surgical form of traditional medical practice whereby the palatine uvula is partially or totally removed by the traditional surgeons who are known to provide affordable care to under served areas 7. Uvulectomy has been described by Byzantine Physicians as far as the Greek age [324-1453AD], and many African countries still perform it as part of traditional medicine 8. In north-west Ethiopia it is performed at a very high rate.9 Uvulectomy is an uncommon procedure in Western Europe and North America. St Clair Thomson and Negus, as far back as in 1948, described it as one of the rarest operations in otorhinolaryngology10, though at present the uvula is routinely removed as part of palatal surgery for snoring 8. It is noted that uvulectomy is really part of uvulopalatoplasty for snoring and some types of obstructive sleep apnoea (OSA) 11-15 but itself is relatively infrequent operation even in Europe and North America. Laser assisted uvulotomy (uvulectomy) is an effective surgical procedure for treatment of snoring and some types of OSA11. Studies done in United Kingdom in August 2005 among Otolaryngologist showed that uvulectomy is an established surgical technique with indications for treatment of snoring and postnasal drip 16.It was reported to have been used to treat persistent chronic cough and cellulitis of the uvula 17,18,19 . It should clear that traditional uvulectomy is in a different category. Traditional uvulectomy is noted to be one of the common negative cultural practices in Nigeria, particularly in the North 20. Other African countries where it is being commonly practiced include Chad, Sudan, Ethiopia, Morocco, Mali, Tanzania, Niger, Eritrea, Sierra Leone and Cameroon.8 Traditional uvulectomy is also widely practiced in the middle East (especially Israel, South Sinai, Lebanon and Yemen)8. Traditional uvulectomy is usually indicated for prevention of throat infections, treatment of recurrent sore throat, and prevention of childhood illnesses among which include diarhoea, delayed growth, refusal of feeds etc, elongated uvula and prevention of suffocation in a child during pharyngitis .8, 10, 21-24 Traditional uvulectomy has been widely practiced in some cultures that it has acquired ethical approval among the people even with the continuous discouragement by orthodox medical practitioners 10. We tend to perceive uvulectomy and other traditional practices as useless, cruel and even medically dangerous. Yet such practices may have their benefits, even if they have deleterious complications; which may have kept these practices persistent. The benefits or otherwise of traditional uvulectomy remains controversial. This study thus looks in to the perceived benefits of this procedure. ANATOMY AND PHYSIOLOGY OF THE UVULA The uvula is a fleshy part of soft palate that hangs down above the base of the tongue. Although small sized and seemingly unimportant, it has remained an object of speculation as to its function throughout the ages8. It derived its name from the Latin word for ‘grape’. It develops from the extension of the membranous ossification of the palatine bones as a last step of fusion of the two halves of the soft palate as it zips up front to back 25. It consists of connective and glandular tissues with diffuse interdigitated muscle fibres, called muscularis uvulae. The uvula plays a role in the production of uvula sound used by Arabic teachers, singers and criers 26. The soft palate together with the uvula has anatomic function of coordinating the movement of air and food in the pharynx 1, 10. Any congenital defect in structure or acquired tissue loss of the uvula affects respiration, deglutition, and speech. Nasal regurgitation of fluid and nasal speech may occur. These functional defects are encountered in bifid uvula and congenital defect of palate. Partial uvulectomy does not prevent the production of uvula sounds or affect velopharyngeal status; it does affect its quality, while radical uvulectomy totally prevents uvula sounds production26, 27. Blood supply to the uvula is from the ascending pharyngeal artery while its nerve supply is from pharyngeal plexus. Lymphatic drainage is to the cervical groups of lymph nodes. DISEASES OF THE UVULA These include congenital defects in structure such as bifid uvula, multiple uvula, elongated uvula or complete absence. These can affect uvula speech. Acquired diseases include inflammation of remnant uvula following partial amputation of uvula from traditional uvulectomy. Allergy with associated quincke’s oedema could be life threatening. Inflammation of uvula from staph aureus, streptococcus infections or primary mycobacterial infection could cause massive enlargement and elongated uvula 8, 28-30.
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