Otoscopy simulation training in a classroom setting: A novel approach to teaching otoscopy to medical students

"Seeing inside out": revealing the effectiveness of otoscopy training in virtual reality enhanced practical exams - a randomized controlled trial

BACKGROUND

The study aimed to assess the impact of different training modalities on otoscopy performance during a practical exam using a high-fidelity simulator and to determine if objective evaluation of otoscopy is feasible using a simulator that records insertion depth and tympanic membrane coverage.

METHODS

Participants were assigned to one of four groups: control and three intervention groups with varying training approaches. Participants received otoscopy training and then were assessed through a practical exam on a high-fidelity simulator that uses virtual reality to visualize the ear canal and middle ear. Performance was evaluated using a modified Objective Structured Assessment of Technical Skills checklist and Integrated Procedural Performance Instrument checklist. Insertion depth, tympanic membrane coverage, and correct diagnosis were recorded. Data were tested for normal distribution using the Shapiro-Wilk test. One-way ANOVA and, for non-normally distributed data, Kruskal-Wallis test combined with Dunn's test for multiple comparisons were used. Interrater reliability was assessed using Cohen's κ and Intraclass correlation coefficient.

RESULTS

All groups rated their training sessions positively. Performance on the OSATS checklist was similar among groups. IPPI scores indicated comparable patient handling skills. The feedback group examined larger tympanic membrane areas and had higher rates of correct diagnosis. The correct insertion depth was rarely achieved by all participants. Interrater reliability for OSATS was strong. IPPI reliability showed good correlation.

CONCLUSION

Regardless of training modality, participants perceived learning improvement and skill acquisition. Feedback improved examination performance, indicating simulator-guided training enhances skills. High-fidelity simulator usage in exams provides an objective assessment of performance.

Pediatric Chest Compression Improvement Via Augmented Reality Cardiopulmonary Resuscitation Feedback in Community General Emergency Departments: A Mixed-Methods Simulation-Based Pilot Study

BACKGROUND

Yearly, more than 20,000 children experience a cardiac arrest. High-quality pediatric cardiopulmonary resuscitation (CPR) is generally challenging for community hospital teams, where pediatric cardiac arrest is infrequent. Current feedback systems are insufficient. Therefore, we developed an augmented reality (AR) CPR feedback system for use in many settings.

OBJECTIVE

We aimed to evaluate whether AR-CPR improves chest compression (CC) performance in non-pediatric-specialized community emergency departments (EDs).

METHODS

We performed an unblinded, randomized, crossover simulation-based study. A convenience sample of community ED nonpediatric nurses and technicians were included. Each participant performed three 2-min cycles of CC during a simulated pediatric cardiac arrest. Participants were randomized to use AR-CPR in one of three CC cycles. Afterward, participants participated in a qualitative interview to inquire about their experience with AR-CPR.

RESULTS

Of 36 participants, 18 were randomized to AR-CPR in cycle 2 (group A) and 18 were randomized to AR-CPR in cycle 3 (group B). When using AR-CPR, 87-90% (SD 12-13%) of all CCs were in goal range, analyzed as 1-min intervals, compared with 18-21% (SD 30-33%) without feedback (p < 0.001). Analysis of qualitative themes revealed that AR-CPR may be usable without a device orientation, be effective at cognitive offloading, and reduce anxiety around and enhance confidence in the CC delivered.

CONCLUSIONS

The novel CPR feedback system, AR-CPR, significantly changed the CC performance in community hospital non-pediatric-specialized general EDs from 18-21% to 87-90% of CC epochs at goal. This study offers preliminary evidence suggesting AR-CPR improves CC quality in community hospital settings.

Utilization of Video Otoscopes for Otoscopy Skills Training of Third Year Medical Students

Purpose

Effective teaching and assessment of otologic examinations are challenging. Current methods of teaching otoscopy using traditional otoscopes have significant limitations. We hypothesized that use of all-in-one video otoscopes provides students with an opportunity for real-time faculty feedback and re-practicing of skills, increasing self-reported confidence.

Methods

An otoscopy microskills competency checklist was provided to third-year medical students during their pediatric clerkship to self-assess otoscopy technique during patient examinations, and to clinical preceptors to assess and provide feedback during exams. Over the course of two years, we collected data from students randomly assigned to train on a video otoscope or a traditional otoscope during the clerkship. Pre- and post-clerkship surveys measured confidence in performing otoscopy microskills, making a diagnosis and documentation of findings. For those students who trained on the video otoscope, we solicited post-clerkship feedback on the experience of using a video otoscope.

Results

Pre-clerkship confidence did not differ between the groups, but the video otoscope trained group had significantly higher scores than the traditional otoscope trained group on all self-reported technical and diagnostic microskills confidence questions items post-clerkship. Students trained on video otoscopes had a significant increase in confidence with all microskills items (p-values<0.001), however confidence in the traditional otoscope trained group did not change over time (p-values>0.10). Qualitative feedback from the video otoscope trained group reflected positive experiences regarding "technique/positioning" and "feedback from preceptors.".

Conclusion

Teaching otoscopy skills to pediatric clerkship medical students using a video otoscope significantly enhanced confidence compared to those training on a traditional otoscope by 1. enabling preceptors and students to simultaneously visualize otoscopy findings 2. allowing preceptors to provide real-time feedback and 3. providing opportunity for deliberate practice of microskills. We encourage the use of video otoscopes to augment student confidence and self-efficacy when training in otoscopy.

Automated multi-class classification for prediction of tympanic membrane changes with deep learning models

BACKGROUNDS AND OBJECTIVE

Evaluating the tympanic membrane (TM) using an otoendoscope is the first and most important step in various clinical fields. Unfortunately, most lesions of TM have more than one diagnostic name. Therefore, we built a database of otoendoscopic images with multiple diseases and investigated the impact of concurrent diseases on the classification performance of deep learning networks.

STUDY DESIGN

This retrospective study investigated the impact of concurrent diseases in the tympanic membrane on diagnostic performance using multi-class classification. A customized architecture of EfficientNet-B4 was introduced to predict the primary class (otitis media with effusion (OME), chronic otitis media (COM), and 'None' without OME and COM) and secondary classes (attic cholesteatoma, myringitis, otomycosis, and ventilating tube).

RESULTS

Deep-learning classifications accurately predicted the primary class with dice similarity coefficient (DSC) of 95.19%, while misidentification between COM and OME rarely occurred. Among the secondary classes, the diagnosis of attic cholesteatoma and myringitis achieved a DSC of 88.37% and 88.28%, respectively. Although concurrent diseases hampered the prediction performance, there was only a 0.44% probability of inaccurately predicting two or more secondary classes (29/6,630). The inference time per image was 2.594 ms on average.

CONCLUSION

Deep-learning classification can be used to support clinical decision-making by accurately and reproducibly predicting tympanic membrane changes in real time, even in the presence of multiple concurrent diseases.

Classification of Ear Imagery Database using Bayesian Optimization based on CNN-LSTM Architecture

The external and middle ear conditions are diagnosed using a digital otoscope. The clinical diagnosis of ear conditions is suffered from restricted accuracy due to the increased dependency on otolaryngologist expertise, patient complaint, blurring of the otoscopic images, and complexity of lesions definition. There is a high requirement for improved diagnosis algorithms based on otoscopic image processing. This paper presented an ear diagnosis approach based on a convolutional neural network (CNN) as feature extraction and long short-term memory (LSTM) as a classifier algorithm. However, the suggested LSTM model accuracy may be decreased by the omission of a hyperparameter tuning process. Therefore, Bayesian optimization is used for selecting the hyperparameters to improve the results of the LSTM network to obtain a good classification. This study is based on an ear imagery database that consists of four categories: normal, myringosclerosis, earwax plug, and chronic otitis media (COM). This study used 880 otoscopic images divided into 792 training images and 88 testing images to evaluate the approach performance. In this paper, the evaluation metrics of ear condition classification are based on a percentage of accuracy, sensitivity, specificity, and positive predictive value (PPV). The findings yielded a classification accuracy of 100%, a sensitivity of 100%, a specificity of 100%, and a PPV of 100% for the testing database. Finally, the proposed approach shows how to find the best hyperparameters concerning the Bayesian optimization for reliable diagnosis of ear conditions under the consideration of LSTM architecture. This approach demonstrates that CNN-LSTM has higher performance and lower training time than CNN, which has not been used in previous studies for classifying ear diseases. Consequently, the usefulness and reliability of the proposed approach will create an automatic tool for improving the classification and prediction of various ear pathologies.

A Web-Based Deep Learning Model for Automated Diagnosis of Otoscopic Images

OBJECTIVES

To develop a multiclass-classifier deep learning model and website for distinguishing tympanic membrane (TM) pathologies based on otoscopic images.

METHODS

An otoscopic image database developed by utilizing publicly available online images and open databases was assessed by convolutional neural network (CNN) models including ResNet-50, Inception-V3, Inception-Resnet-V2, and MobileNetV2. Training and testing were conducted with a 75:25 breakdown. Area under the curve of receiver operating characteristics (AUC-ROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to compare different CNN models' performances in classifying TM images.

RESULTS

Our database included 400 images, organized into normal (n = 196) and abnormal classes (n = 204), including acute otitis media (n = 116), otitis externa (n = 44), chronic suppurative otitis media (n = 23), and cerumen impaction (n = 21). For binary classification between normal versus abnormal TM, the best performing model had average AUC-ROC of 0.902 (MobileNetV2), followed by 0.745 (Inception-Resnet-V2), 0.731 (ResNet-50), and 0.636 (Inception-V3). Accuracy ranged between 0.73-0.77, sensitivity 0.72-0.88, specificity 0.58-0.84, PPV 0.68-0.81, and NPV 0.73-0.83. Macro-AUC-ROC for MobileNetV2 based multiclass-classifier was 0.91, with accuracy of 66%. Binary and multiclass-classifier models based on MobileNetV2 were loaded onto a publicly accessible and user-friendly website (https://headneckml.com/tympanic). This allows the readership to upload TM images for real-time predictions using the developed algorithms.

CONCLUSIONS

Novel CNN algorithms were developed with high AUC-ROCs for differentiating between various TM pathologies. This was further deployed as a proof-of-concept publicly accessible website for real-time predictions.

Undergraduate audiology students' perceived competence and confidence in conducting otoscopic examination following video otoscopic training

BACKGROUND

Emerging research indicates that video otoscopy can be used as a teaching tool to enhance students' ability to identify outer and middle ear pathologies. However, there is little research on the perceptions of audiology students regarding their competence and confidence following video otoscopic training, and how they view the use of video otoscopy as a teaching tool. Therefore, this study aimed to determine undergraduate (UG) audiology students' perceived competence and confidence in conducting otoscopy following training by video otoscopic examination.

METHODS

A survey methodology with a cross sectional design was employed. An electronic questionnaire was distributed to all third and fourth year (senior) (N = 79) UG audiology students using Survey Monkey. Ethical approval and permission from relevant stakeholders were obtained. Data were analysed using both descriptive and inferential statistics.

RESULTS

60 % of the students felt competent in performing otoscopy, while 63.3 % felt less competent in interpreting otoscopic examination findings. 43.3 % felt they can confidently and competently identify outer ear pathologies. There was no association between the number of video otoscopic examinations performed and perceived competence or/and confidence. There was also no statistically significant relationship between year of study (e.g., third year versus fourth year) and perceived competence or/and confident (p = 0.7131). Almost all (97 %) students felt that video otoscopic training should continue to be part of the clinical training as it helped them enhance their skills in performing otoscopy.

CONCLUSIONS

Current findings highlight the need to improve students' practical training, incorporating pathologic ears into the curriculum. These findings also highlight the importance of supplementing practical training methodologies with changing technological advancements, particularly where tele-audiology opportunities may exist.

Face, Content, and Construct Validity of a Virtual Reality Otoscopy Simulator and Applicability to Medical Training

Objective

Otologic diseases are common in all age groups and can significantly impair the function of this important sensory organ. To make a correct diagnosis, the correct handling of the otoscope and a correctly performed examination are essential. A virtual reality simulator could make it easier to teach this difficult-to-teach skill. The aim of this study was to assess the face, content, and construct validity of the novel virtual reality otoscopy simulator and the applicability to otologic training.

Study Design

Face and content validity was assessed with a questionnaire. Construct validity was assessed in a prospectively designed controlled trial.

Setting

Training for medical students at a tertiary referral center.

Method

The questionnaire used a 6-point Likert scale. The otoscopy was rated with a modified Objective Structured Assessment of Technical Skills. Time to complete the task and the percentage of the assessed eardrum surface were recorded.

Results

The realism of the simulator and the applicability to medical training were assessed across several items. The ratings suggested good face and content validity as well as usefulness and functionality of the simulator. The otolaryngologists significantly outperformed the student group in all categories measured (P < .0001), suggesting construct validity of the simulator.

Conclusion

In this study, we could demonstrate face, content, and construct validity for a novel high-fidelity virtual reality otoscopy simulator. The results encourage the use of the otoscopy simulator as a complementary tool to traditional teaching methods in a curriculum for medical students.

Evaluation of digital otoscopy in pediatric patients: A prospective randomized controlled clinical trial

BACKGROUND

Acute otitis media is often misdiagnosed. Pediatric trainees learn otoscopy from supervisors who cannot concurrently view the eardrum. Digital, smartphone otoscopes show promise to improve the visibility and learning due to a concurrent view by trainees and supervisors. We aimed to determine whether use of digital otoscopes improved accuracy of the ear exams between medical trainees and their supervisors, compared to using traditional otoscopes. Secondarily, we evaluated whether the use of digital otoscopes reduced the number of repeat ear examinations by supervisors, changed the trainee's confidence in their exam findings, and led to differences in the rate of antibiotics prescribed.

METHODS

This study was a randomized controlled trial comparing use of a digital otoscope to a traditional otoscope, in a pediatric emergency department and primary care clinic in an academic tertiary care children's center. We used a modified validated image-based grading scale to compare accuracy of the ear exam between trainees and supervisors. Surveys documented modified OMgrade scores, frequency of supervisor exams, trainee confidence on a 5-point Likert scale, and antibiotic prescriptions. Inter-rater agreement of trainees and supervisors, the number of supervisor confirmatory examinations performed, trainee confidence, and antibiotic prescription rates were evaluated.

RESULTS

Amongst 188 children, 375 ears were examined by 85 trainees and 22 supervisors. The digital otoscope was utilized in 92 (48.9%) exams and 96 (51.1%) used the traditional otoscope. Accuracy of ear exam findings between trainees and supervisors improved by 11.2% (95% CI: 1.5, 21.8%, p = 0.033) using the Cellscope Oto (74.8%, 95% CI: 67.3, 82.1%) compared to the traditional otoscope (63.5%, 95% CI: 56.7, 70.4%). Fewer repeat supervisor exams were performed in the digital otoscope group (27.2%) vs. the traditional otoscope group (97.9%) (p < 0.001). There was no difference in mean trainee confidence in their examination (p = 0.955) or antibiotic prescription rates when using digital versus traditional otoscopes (p = 0.071).

CONCLUSIONS

Utilization of a digital otoscope resulted in increased accuracy of the ear exam between trainees and supervisors, and fewer total number of examinations performed on a given child. Compared to a traditional otoscope, a digital otoscope may be a more efficient and effective diagnostic tool.

Current Status of Handheld Otoscopy Training: A Systematic Review

OBJECTIVE

Otoscopy is a frequently performed procedure and competency in this skill is important across many specialties. We aim to systematically review current medical educational evidence for training of handheld otoscopy skills.

METHODS

Following the PRISMA guideline, studies reporting on training and/or assessment of handheld otoscopy were identified searching the following databases: PubMed, Embase, OVID, the Cochrane Library, PloS Medicine, Directory of Open Access Journal (DOAJ), and Web of Science. Two reviewers extracted data on study design, training intervention, educational outcomes, and results. Quality of educational evidence was assessed along with classification according to Kirkpatrick's model of educational outcomes.

RESULTS

The searches yielded a total of 6064 studies with a final inclusion of 33 studies for the qualitative synthesis. Handheld otoscopy training could be divided into workshops, physical simulators, web-based training/e-learning, and smartphone-enabled otoscopy. Workshops were the most commonly described educational intervention and typically consisted of lectures, hands-on demonstrations, and training on peers. Almost all studies reported a favorable effect on either learner attitude, knowledge, or skills. The educational quality of the studies was reasonable but the educational outcomes were mostly evaluated on the lower Kirkpatrick levels with only a single study determining the effects of training on actual change in the learner behavior.

CONCLUSION

Overall, it seems that any systematic approach to training of handheld otoscopy is beneficial in training regardless of learner level, but the heterogeneity of the studies makes comparisons between studies difficult and the relative effect sizes of the interventions could not be determined.

Using Computer-Assisted Instruction to Increase Otolaryngology Education During Medical School

INTRODUCTION

A quarter of all complaints seen in adult primary care and half of all complaints seen in pediatric primary care are otolaryngology related. Even though half of all medical students enter primary care fields, there is no standardized curriculum for otolaryngology during medical school. Due to increasing limitations on specialty teaching during general medical education, computer-assisted instruction has been suggested as a format for increasing exposure to otolaryngology.

METHODS

We designed a computer-based learning module for teaching high-yield otolaryngology topics for third- and fourth-year medical students during their primary care clerkship at our institution from 2016-2018. We evaluated students' prior otolaryngology knowledge with 11 case-based, multiple-choice questions and then evaluated the efficacy of the module by a similar posttest.

RESULTS

Three-hundred and sixty-five students completed the module. The average pre- and posttest scores were 44% (SD = 21%) and 70% (SD = 17%), respectively, showing that the module resulted in significantly increased scores (p < .01).

DISCUSSION

The improvement of test scores indicates that this module was an effective educational intervention at our institution for increasing exposure and improving otolaryngology knowledge in third- and fourth-year medical students. As medical schools shift toward adult learning principles such as independent and self-directed learning, computer-assisted instruction is an alternative to classroom-based didactics. Creating resources for independent study will allow more time for otolaryngology faculty and residents to teach clinical exam skills and interactive case-based discussions, which are less suitable to teach via computer-assisted instruction.

Teaching pediatric otoscopy skills to the medical student in the clinical setting: preceptor perspectives and practice

BACKGROUND

Acute otitis media (AOM) is the most frequent indication for antibiotic treatment of children in the United States. Its diagnosis relies on visualization of the tympanic membrane, a clinical skill acquired through a deliberate approach. Instruction in pediatric otoscopy begins in medical school. Medical students receive their primary experience with pediatric otoscopy during the required pediatric clerkship, traditionally relying on an immersion, apprentice-type learning model. A better understanding of their preceptors' clinical and teaching practices could lead to improved skill acquisition. This study investigates how pediatric preceptors (PP) and members of the Council on Medical Student Education in Pediatrics (COMSEP) perceive teaching otoscopy.

METHODS

A 30-item online survey was administered to a purposeful sample of PP at six institutions in 2017. A comparable 23-item survey was administered to members through the 2018 COMSEP Annual Survey. Only COMSEP members who identified themselves as teaching otoscopy to medical students were asked to complete the otoscopy-related questions on the survey.

RESULTS

Survey respondents included 58% of PP (180/310) and 44% (152/348) of COMSEP members. Forty-one percent (62/152) of COMSEP member respondents identified themselves as teaching otoscopy and completed the otoscopy-related questions. The majority agreed that standardized curricula are needed (PP 78%, COMSEP members 97%) and that all graduating medical students should be able to perform pediatric otoscopy (PP 95%, COMSEP members 79%). Most respondents reported usefulness of the American Academy of Pediatrics (AAP) AOM guidelines (PP 95%, COMSEP members 100%). More COMSEP members than PP adhered to the AAP's diagnostic criteria (pediatric preceptors 42%, COMSEP members 93%). The most common barriers to teaching otoscopy were a lack of assistive technology (PP 77%, COMSEP members 56%), presence of cerumen (PP 58%, COMSEP members 60%), time to teach in direct patient care (PP 46%, COMSEP members 48%), and parent anxiety (PP 62%, COMSEP members 54%).

CONCLUSIONS

Our study identified systemic and individual practice patterns and barriers to teaching pediatric otoscopy. These results can inform education leaders in supporting and enabling preceptors in their clinical teaching. This approach can be adapted to ensure graduating medical students obtain intended core clinical skills.

Low-fidelity otoscopy simulation and anatomy training: A randomized controlled trial

OBJECTIVES

To evaluate whether the use of low-fidelity otoscopy simulation improved medical students' theoretical knowledge of middle ear anatomy and pathologies compared to traditional teaching methods.

METHODS

This was a randomized controlled trial. Simulation workshops were conducted in April 2019 in the Lyon Sud University medical faculty, France. Students were randomly assigned to the simulation group (n=105) or to the control group (n=95). The students in the control group answered a questionnaire evaluating theoretical knowledge (25 true-false questions) before the simulation tutorial, while the students in the simulation group answered the same questions after the tutorial. Both groups also filled out a satisfaction questionnaire for feedback.

RESULTS

196 of the 200 students who participated in the study completed the knowledge assessment questionnaire. Scores were 32.0% higher in the simulation group than in the control group (mean scores, 12.0/20 vs. 9.1/20; P<0.0001). 184 of the 191 students who completed the satisfaction questionnaire (96.3%) were satisfied or very satisfied with the workshop, and all but one (99.5%) recommended keeping it in the curriculum. In the free comments fields, students highlighted the educational value of learning without the stress of patient discomfort.

CONCLUSION

Otoscopy simulation is an effective training method, improving theoretical knowledge compared with conventional theoretical training.

Development of video otoscopy quiz using a smartphone adaptable otoscope

Background

Otoscopy examination can be challenging. Traditional teaching uses still image illustrations. Newer attempts use video samples to simulate the otoscopy exam which is a dynamic process.

Aims/Objective: To assess whether recorded otoscopy videos from a smartphone adaptable otoscope can be used to develop a video-based otoscopy quiz which may be used for instructing and familiarizing participants to normal anatomy and pathologic ear conditions. To use this quiz to assess current pediatric residents’ competency of common otoscopy diagnosis.

Method and materials

This study was conducted in 2018. Video samples of ear pathology were collected at the Albany Medical Center using a smartphone adaptable otoscope- Cellscope. The videos were used to create a video otoscopy quiz (VOQ) without clinical vignettes. 45 pediatric residents from 3 academic institutions were evaluated with the quiz.

Results

The weighted mean for the VOQ was 66.90% (95%CI 58.89%–68.42%). The breakdown by questions are: myringosclerosis 72.88%, retraction pocket 80.65%, cholesteatoma 42.22%, hemotympanum 75.04%, tympanic membrane perforation 79.62%, cerumen impaction 95.46%, otitis externa 52.54%, otitis media with effusion 63.30%, acute otitis media 75.55%, normal ear 36.39%.

Conclusion

We found that videos of otoscopy exams can be obtained with a smartphone adaptable otoscope and validated to develop a video-based quiz, which may be used to supplement otoscopic instruction. Following our testing process, we found pediatric residents are relatively well equipped to identify ear pathology on VOQ.

Development and Evaluation of an Objective Tympanic Membrane Visualization Assessment Technique

OBJECTIVES

To introduce an inexpensive method for objectively evaluating otoscopic visualization of the tympanic membrane wherein learners match what they visualize in standardized patients to tympanic membrane photographs.

METHODS

Two standardized patients had photographs taken of their tympanic membranes using a commercially-available digital otoscope. First- and third-year medical students were asked to perform an otoscopic examination on each patient using a conventional handheld otoscope and to match what they saw with the correct tympanic membrane image among distractor photographs belonging to other patients. The ability of students to match the standardized patients' tympanic membrane to the correct photographs was assessed before and after a didactic training session. These measurements were compared between the two cohort groups for construct validity.

RESULTS

Fifty-one first-year medical students (with no previous otoscopy experience) and 44 third-year medical students (with otoscopy experience from completing pediatric and family medicine clinical clerkships) were recruited to voluntarily participate in this study. At baseline, a larger percentage of third-year students correctly matched both tympanic membranes compared to first-year students (27% vs 8%, P < .01). After otoscopy training, correct matching of both tympanic membranes significantly improved among both first-year students (8-31%, P < .01) and third-year students (27-54%, P < .01).

CONCLUSION

The use of tympanic membrane photographs from standardized patients provides a novel technique for objectively assessing proficiency in otoscopic visualization of the middle ear. The concept is low cost, uses live patients, and can be easily implemented in pre-clinical instruction and beyond.

Automated Classification of the Tympanic Membrane Using a Convolutional Neural Network

Precise evaluation of the tympanic membrane (TM) is required for accurate diagnosis of middle ear diseases. However, making an accurate assessment is sometimes difficult. Artificial intelligence is often employed for image processing, especially for performing high level analysis such as image classification, segmentation and matching. In particular, convolutional neural networks (CNNs) are increasingly used in medical image recognition. This study demonstrates the usefulness and reliability of CNNs in recognizing the side and perforation of TMs in medical images. CNN was constructed with typically six layers. After random assignment of the available images to the training, validation and test sets, training was performed. The accuracy of the CNN model was consequently evaluated using a new dataset. A class activation map (CAM) was used to evaluate feature extraction. The CNN model accuracy of detecting the TM side in the test dataset was 97.9%, whereas that of detecting the presence of perforation was 91.0%. The side of the TM and the presence of a perforation affect the activation sites. The results show that CNNs can be a useful tool for classifying TM lesions and identifying TM sides. Further research is required to consider real-time analysis and to improve classification accuracy.

A Practical Recommendation for Teaching Neck Anatomy During Neck Dissection in the Operating Room

Anatomy knowledge is not only essential for surgeons but also has importance for anyone who performs an invasive procedure on a patient, and provides examination and diagnosis of patients and sharing of these findings to the patient and other medical professionals. It is accepted that most surgical procedures could facilitate anatomic perception in surgical internships. There is an educational tendency to explore innovative instructional tools and methods that can help support current education styles. This study investigates the effect of a green laser pointer on students' perceptions and educational effectiveness when neck dissection is performed in the operating room.

Ear Disease Knowledge and Otoscopy Skills Transfer to Real Patients: A Randomized Controlled Trial

OBJECTIVE

To determine which teaching method-otoscopy simulation (OS), web-based module (WM), or standard classroom instruction (SI)-produced greater translation of knowledge and otoscopy examination skills to real patients.

DESIGN

In a prospective randomized controlled nonclinical trial, medical students were randomized to 1 of 3 interventional arms: (1) OS, (2) WM, or (3) SI. Students were assessed at baseline for diagnostic accuracy and otoscopy skills on 5 volunteer patients (total of 10 ears), followed by the intervention. Testing was repeated immediately after intervention on the same patients. Student reported confidence in diagnostic accuracy and otoscopy examination were also captured. Assessors were blinded to the intervention group, and whether students were pre- or post-intervention.

SETTING

Clinical Teaching Centre, Queen's University.

PARTICIPANTS

Twenty-nine participants were initially randomized. Two students were unable to attend their specific intervention sessions and withdrew. Final group sizes were: OS-10, WM-9, SI-8. Five patients with external/middle ear pathologies were voluntarily recruited to participate as testing subjects.

RESULTS

Baseline diagnostic accuracy and otoscopy clinical skills did not differ across the groups. Post-intervention, there were improvements in diagnostic accuracy from all groups: OS (127.78%, 2.30 ± 1.42, p = 0.0006), WM (76.40%, 1.44 ± 1.88, p = 0.0499), and SI (100.00%, 1.50 ± 1.20, p = 0.0093). For otoscopy skills, post-intervention improvements were noted from OS (77.00%, 3.85 ± 2.55, p < 0.0001) and SI (22.20%, 1.25 ± 1.20, p = 0.0011), with no significant improvement from WM (13.46%, 0.78 ± 1.92, p = 0.1050). Students across all groups reported significantly improved confidence in diagnostic accuracy (p < 0.0001) and otoscopy skill (p < 0.0001) after the intervention.

CONCLUSION

All 3 teaching modalities showed an improvement in diagnostic accuracy immediately post-intervention. Otoscopy clinical skills were found to have increased only in OS and SI, with the OS group demonstrating the largest improvement. Simulation-based medical education in Otolaryngology may provide the greatest transfer of medical knowledge and technical skills when evaluated with real patients.

Improving learning and confidence through small group, structured otoscopy teaching: a prospective interventional study

Background

Otologic diseases are common and associated with significant health care costs. While accurate diagnosis relies on physical exam, existing studies have highlighted a lack of comfort among trainees with regards to otoscopy. As such, dedicated otoscopy teaching time was incorporated into the undergraduate medical curriculum in the form of a small group teaching session. In this study, we aimed to examine the effect of a small-group, structured teaching session on medical students’ confidence with and learning of otoscopic examination.

Methods

Using a prospective study design, an otolaryngologist delivered an one-hour, small group workshop to medical learners. The workshop included introduction and demonstration of otoscopy and pneumatic otoscopy followed by practice with peer feedback. A survey exploring students’ confidence with otoscopy and recall of anatomical landmarks was distributed before(T1), immediately after(T2), and 1 month following the session(T3).

Results

One hundred and twenty five learners participated from February 2016 to February 2017. Forty nine participants with complete data over T1-T3 demonstrated significant improvement over time in confidence (Wilk’s lambda = .09, F(2,48) = 253.31 p < .001, η² = .91) and learning (Wilk’s lambda = 0.34, F(2,47) = 24.87 p < .001, η² = .66).

Conclusions

A small-group, structured teaching session had positive effects on students’ confidence with otoscopy and identification of otologic landmarks. Dedicated otoscopy teaching sessions may be a beneficial addition to the undergraduate medical curriculum.

Otologic Skills Training

This article presents a summary of the current simulation training for otologic skills. There is a wide variety of educational approaches, assessment tools, and simulators in use, including simple low-cost task trainers to complex computer-based virtual reality systems. A systematic approach to otologic skills training using adult learning theory concepts, such as repeated and distributed practice, self-directed learning, and mastery learning, is necessary for these educational interventions to be effective. Future directions include development of measures of performance to assess efficacy of simulation training interventions and, for complex procedures, improvement in fidelity based on educational goals.

Digital otoscopy versus microscopy: How correct and confident are ear experts in their diagnoses?

Introduction With the growing popularity of telemedicine and tele-diagnostics, clinical validation of new devices is essential. This study sought to investigate whether high-definition digital still images of the eardrum provide sufficient information to make a correct diagnosis, as compared with the gold standard view provided by clinical microscopy. Methods Twelve fellowship-trained ear physicians (neurotologists) reviewed the same set of 210 digital otoscope eardrum images. Participants diagnosed each image as normal or, if abnormal, they selected from seven types of ear pathology. Diagnostic percentage correct for each pathology was compared with a gold standard of diagnosis using clinical microscopy with adjunct audiometry and/or tympanometry. Participants also rated their degree of confidence for each diagnosis. Results Overall correctness of diagnosis for ear pathologies ranged from 48.6-100%, depending on the type of pathology. Neurotologists were 72% correct in identifying eardrums as normal. Reviewers' confidence in diagnosis varied substantially among types of pathology, as well as among participants. Discussion High-definition digital still images of eardrums provided sufficient information for neurotologists to make correct diagnoses for some pathologies. However, some diagnoses, such as middle ear effusion, were more difficult to diagnose when based only on a still image. Levels of confidence of reviewers did not generally correlate with diagnostic ability.

Smartphone-Enabled Otoscopy in Neurotology/Otology

Objective

A smartphone-enabled otoscope (SEO) can capture tympanic membrane (TM) images. We sought to compare a SEO to microscopic otoscopy in the detection and evaluation of TM pathology in an otology/neurotology practice.

Study Design

Prospective single-site study in adults presenting over a 3-month period.

Setting

Neurotology clinic within a tertiary care academic medical center.

Subjects and Methods

Following consent, 57 patients underwent a medical and microscopic ear examination. Afterward, clinicians photographed bilateral TMs using a SEO. A second “blinded” neurotologist received a SEO-acquired image of each TM and a brief patient history. Our primary end point was identification of TM pathology (or lack thereof) and the blinded neurotologists’ corresponding diagnosis. Secondary end points included patient-reported SEO comfort levels.

Results

A single SEO-acquired TM image and brief patient history resulted in correct diagnosis of 96% (23/24) of normal TMs and identification of 100% (33/33) of microscope-confirmed abnormal TMs. When pathology was identified by the “blinded” physician, the diagnosis was identical to that made by the primary treating physician 82% (27/33) of the time. On patient surveys, 93% (53/57) of patients felt “very comfortable” with SEO utilization, and 88% (50/57) reported viewing acquired images was “very useful” in understanding their condition.

Conclusion

A SEO is 96% specific in identifying normal TMs and 100% sensitive in identifying pathology. Its 97% positive predictive value and small false-positive rate makes it a useful screening tool. Furthermore, patients are receptive to this technology and felt comfortable with its utilization in a health care or possible telemedicine setting.

Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents

INTRODUCTION

The objective of this study is to evaluate and compare the perceived need for otolaryngology training and otoscopy diagnostic skills in primary care (Family and Community Medicine, Pediatric Medicine), and Otolaryngology Head and Neck Surgery (OTO-HNS) postgraduate trainees. Participant otoscopy skills were evaluated using the OtoSim simulator.

METHODS

Family and Community Medicine, Pediatric, and OTO-HNS residents were recruited. Each resident participated in 3 separate otoscopy training and assessment sessions. The ability to correctly identify middle ear pathology was objectively evaluated using OtoSim™. Pretest, posttest, and 3-month retention test results were compared among residents in a paired comparison paradigm. Survey data assessing exposure to OTO-HNS during undergraduate and postgraduate training were also collected.

RESULTS

A total of 57 residents participated in the study. All residents reported limited exposure to OTO-HNS during undergraduate medical training. Primary care trainees performed poorly on pretest assessments (30% ± 7.8%; 95% CI). Significant improvement in diagnostic accuracy was demonstrated following a single 1-hour teaching session (30%-62%; p < 0.001). Primary care residents demonstrated a significant decrease in diagnostic accuracy at a 3-month follow-up assessment (62%-52%, p < 0.001). Self-perceived comfort with otology was poorly correlated to pretest performance among primary care trainees (r = 0.26) and showed a stronger positive correlation among OTO-HNS trainees (r = 0.56).

CONCLUSIONS

A single teaching session with an otoscopy simulator significantly improved diagnostic accuracy in primary care and OTO-HNS trainees. Improved performance is susceptible to deterioration at 3 months if acquired skills are not frequently used. Self-perceived comfort with otology may not be an accurate predictor of otoscopic diagnostic skill.

Qualitative synthesis and systematic review of otolaryngology in undergraduate medical education

OBJECTIVE

Although 25% of primary care complaints are otolaryngology related, otolaryngology instruction is not required in most medical schools. Our aim was to systematically review existing literature on the inclusion of otolaryngology in undergraduate medical education.

DATA SOURCES

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center.

STUDY DESIGN/REVIEW METHODS

Our search encompassed all indexed years through December 29, 2014. Inclusion criteria were English language, original human data, and a focus on medical student education. Data regarding study design, teacher, educational topic, educational methods, and setting were extracted from each article. Two investigators independently reviewed all articles.

RESULTS

Our initial search yielded 436 articles; 87 underwent full-text evaluation and 47 remained in the final review. The majority of studies were conducted in the United States (40%), United Kingdom (23%), and Canada (17%) and represented a single institutional experience. Studies were classified as needs assessments (36%), curriculum descriptions (15%), educational methods (36%), and skills assessments (32%); 81% were levels of evidence 3 or 4. Most reports indicated that otolaryngology rotations are not compulsory.

CONCLUSIONS

Studies indicated the need for increased exposure to otolaryngology. Educational methods such as team-based learning, simulation, online learning, and clinical skills assessments may offer ways to increase exposure without overburdening clinical faculty and require further study. Data suggest that a universal otolaryngology medical student curriculum would be valuable and aid in resource sharing across institutions. We recommend that an assessment be performed to determine topics and skills that should comprise this curriculum.

LEVEL OF EVIDENCE

NA.

Face and content validity of a novel, web-based otoscopy simulator for medical education

Background

Despite the fact that otoscopy is a widely used and taught diagnostic tool during medical training, errors in diagnosis are common. Physical otoscopy simulators have high fidelity, but they can be expensive and only a limited number of students can use them at a given time.

Objectives

1) To develop a purely web-based otoscopy simulator that can easily be distributed to students over the internet. 2) To assess face and content validity of the simulator by surveying experts in otoscopy.

Methods

An otoscopy simulator, OtoTrain™, was developed at Western University using web-based programming and Unity 3D. Eleven experts from academic institutions in North America were recruited to test the simulator and respond to an online questionnaire. A 7-point Likert scale was used to answer questions related to face validity (realism of the simulator), content validity (expert evaluation of subject matter and test items), and applicability to medical training.

Results

The mean responses for the face validity, content validity, and applicability to medical training portions of the questionnaire were all ≤3, falling between the “Agree”, “Mostly Agree”, and “Strongly Agree” categories. The responses suggest good face and content validity of the simulator. Open-ended questions revealed that the primary drawbacks of the simulator were the lack of a haptic arm for force feedback, a need for increased focus on pneumatic otoscopy, and few rare disorders shown on otoscopy.

Conclusion

OtoTrain™ is a novel, web-based otoscopy simulator that can be easily distributed and used by students on a variety of platforms. Initial face and content validity was encouraging, and a skills transference study is planned following further modifications and improvements to the simulator.