Open Access Publishing of Textbooks and Guidelines for Otolaryngologists in Developing Countries

Accessing educational and scientific material is key to improving otolaryngology care in developing countries. Yet current financial models of publishers restrict access to academic information. This article describes the author’s experience with self-publishing 2 open access textbooks, Open Access Atlas of Otolaryngology, Head and Neck Operative Surgery and Open Access Guide to Audiology and Hearing Aids for Otolaryngologists, as well as the African Head and Neck Society (AfHNS) Clinical Practice Guidelines for Head and Neck Cancer in Developing Countries and Limited Resource Settings. The author outlines the simplicity, advantages, and popularity of this form of publication and why societies and individuals should embrace open access publishing to benefit especially those studying and practicing in developing countries. He discusses some of the challenges related to open access publishing and calls for medical societies to become involved in evaluating the quality of open access texts and videos for their members.

A ccessing educational and scientific material is key to improving otolaryngology (ENT) care in developing countries. Yet many trainees, practitioners, and researchers cannot afford textbooks and pay-to-view journals. The author self-publishes 2 open access textbooks, Open Access Atlas of Otolaryngology, Head and Neck Operative Surgery (OAA) and Open Access Guide to Audiology

The OAA
The OAA (http://www.entdev.uct.ac.za/guides/open-accessatlas-of-otolaryngology-head-neck-operative-surgery) provides detailed descriptions of surgical procedures. The authors are mostly international leaders who volunteered to contribute. It includes surgical procedures no longer performed in developed countries such as hammer and gouge mastoidectomy, which would not be included in modern textbooks. Being in electronic format, chapters are very detailed with numerous photographs and videoclips. Chapters are still being added, and existing chapters are edited from time to time. This illustrates an important advantage of electronic textbooks: they do not have to be completed before being published, as chapters can be added over time. Figure 1 illustrates the growing popularity of the OAA: as additional chapters are added, it becomes better known and translations are added. The OAA received the Open Education Consortium 2017 Award for Open Education Excellence, a tribute to its contributors (http://www.oeconsortium.org/projects/openeducation-awards-for-excellence/2017-oe-award-winners-oercategories/).

Audiology and Hearing Aid Fitting for Otolaryngologists
Only 4 countries in sub-Saharan Africa train audiologists. Hence, audiology and hearing aid fittings are generally done by ENTs, as occurs in some central European countries. 1,2 This textbook, Open Access Guide to Audiology and Hearing Aids for Otolaryngologists (http://www.entdev.uct .ac.za/guides/open-access-guide-to-audiology-and-hearing-aidsfor-otolaryngologists), aims to improve audiologic care by ENTs. Figure 2 illustrates its growing popularity.

Publishing Process
Chapters are submitted in Microsoft Word format, and the author (J.J.F.) edits, formats, and uploads a PDF version to the University of Cape Town webserver. The textbooks are registered with the Creative Commons, a nonprofit corporation that issues public copyright licenses (https://creativecommons.org). Readers may use material provided it is referenced. Hyperlinks to individual chapters are maintained on the IFOS Developing World ENT website (www.entdev.uct.ac.za.guides/).

Popularity
Compared with big ENT textbooks that sell about 4000 copies, chapters have been downloaded .2.3 million times, currently 2100 downloads per day (ie, every 41 seconds). Although intended for developing countries, 8 of the 10 top users are developed countries ( Table 1).

Popular Chapters
Editors have little idea what readers wish to read when planning a textbook. However, online textbooks, of which chapters are individually downloaded, provide such data ( Table 2). Surprisingly, pectoralis major flap is the most popular chapter.

Open Access Textbooks as Revenue Generator
Even though it is tempting to monetize open access textbooks to raise funds for worthy causes, this was not done, as the authors contributed with the understanding that it is a philanthropic project.

AfHNS Clinical Practice Guidelines for Head and Neck Cancer in Developing Countries and Limited Resource Settings
International guidelines have limited value in limited resource settings because of lack of cytology, imaging, (chemo)radiation, complex surgery, and even thyroid and calcium replacement after thyroidectomy. Clinicians in the ''Global South'' should therefore develop resourceappropriate guidelines for developing countries, rather than be guided by institutions in the ''Global North,'' as they know best what the challenges, limitations, and possibilities are to deliver care. The AfHNS (www.afhns.org) launched this novel open access resource in 2019. African surgeons and oncologists formulated the guidelines (https://developingworldheadandneckcancerguidelines.com/) in consultation with American and European colleagues to ensure resource-appropriate best care for patients in developing countries. Thyroid, parotid, and submandibular gland guidelines have been released and are precisely tailored to availability of diagnostic investigations and therapeutic interventions. Guidelines for other head and neck sites will be released in the future. This ability to self-publish webbased guidelines permits countries in the ''Global South'' to assume leadership and take responsibility for their own regions without having to work through established institutions or publishers. That there were 1630 visitors and 7860 page views of the guidelines in the first 3 months demonstrates the power of web-based publishing.
Why Adopt an Open Access Policy? However, open access publishing presents challenges such as the pay-to-publish model, a barrier for authors from developing countries, and concerns about the quality of predatory journals. Just as governments are regulating social media, medical societies should identify reputable YouTube videos, textbooks, and journals for their membership.

Author Contributions
Johannes J. Fagan, conceived, designed, and authored the article. Ranula and sublingual salivary gland excision 5

Disclosures
Modified and radical neck dissection technique 6 Total laryngectomy 7 Thyroidectomy 8 Surgical drainage of deep neck abscesses 9 Mastoidectomy and epitympanectomy 10 Myringoplasty and tympanoplasty