Optimal Timing of Entry-Level Otolaryngology Simulation

A Reproducible Peritonsillar Abscess Incision and Drainage Model for Junior Trainees

OBJECTIVES

To describe the design and construction of a reproducible, low-cost, peritonsillar abscess (PTA) incision and drainage simulator and assess its impact on trainees' confidence.

METHODS

The 2-part simulator we developed consisted of a manikin head with a fixed, partially open mouth and a modular PTA mold. The mold is created by injecting a lotion and water mixture into plastic bubbles, followed by silicone solidification. Neodymium magnets secure the silicone-abscess packet to the manikin's palate. The simulator was utilized during an academic otolaryngology residency training program Annual Otolaryngology Boot Camp. A self-assessment Likert scale questionnaire was used to evaluate participants' confidence before and after simulator training. Fourth-year medical students and junior (first and second year) residents who participated in the boot camp and agreed to complete the evaluation were included.

RESULTS

Three medical students, 17 PGY-1, and 10 PGY-2 residents agreed to complete the evaluation. All trainees agreed the model was useful for learning skills. The overall post-training confidence Likert scores of participants, and PGY-1 residents in particular, significantly improved compared to their pre-training scores (P < .001).

CONCLUSIONS

Our model offers an affordable and efficient training opportunity for residents to enhance their competence in managing PTAs. This approach, with its simple yet effective design and low production cost, shows potential for scalability on a broader scale.

A Systematic Review of Peritonsillar Abscess Simulators: Enhancing Training and Identifying the Need for Standardization

OBJECTIVES

To systematically review the literature regarding previously described peritonsillar abscess (PTA) drainage simulation.

DATA SOURCES

PubMed, Scopus, Web of Science, Ovid, and Cochrane.

REVIEW METHODS

A search of the abovementioned databases was performed in August 2022 using the terms "peritonsillar abscess/quinsy," "incision/drainage/aspiration," and "simulation." No time restrictions were applied. We included studies that clearly described how their PTA models were built and underwent validation from experts and/or evaluation from trainees. Articles describing a model only without any evaluation and reports in languages other than English were excluded.

RESULTS

Our search initially yielded 80 articles after duplicate removal, 10 of which met our criteria and were included. Two studies trained participants on both needle aspiration and incision and drainage (I&D), four studies on I&D only, and four on needle aspiration only. 87.5% to 100% of junior residents reported minimal exposure to PTA prior to simulation. Five studies provided some form of validation to their models. The value of the simulators to train participants on skills received better appreciation than their anatomical fidelity. The perceived confidence level of trainees in managing PTA, which was assessed in 7 studies, substantially improved after training.

CONCLUSION

PTA simulation improves the confidence of trainees to perform PTA drainage. There is, however, a lack of standardization and evidence regarding transfer validity among PTA simulators. The development of a standardized PTA simulator could allow for more widespread use and increase resident comfort with this procedure in a pre-clinical setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2495-2501, 2024.

Gathering validity evidence for a 3D-printed simulator for training of myringotomy and ventilation tube insertion

Objectives

This study aimed to gather validity evidence according to Messick's framework for a novel 3D-printed simulator for myringotomy with ventilation tube insertion for use in technical skills training of otorhinolaryngology (ORL) residents.

Methods

The study included 15 junior ORL residents (trainees) and 13 experienced teaching otolaryngologists (experts). Experts and trainees first received an identically structured introduction to the procedure, simulator, and simulation setup. Five procedures performed by each participant were video-recorded and ordered randomly for blinded rating by two independent raters. The rating tools used were a global rating scale (GBRS) and a task-specific checklist. Validity evidence was collected according to Messick's framework. Differences in time consumption and performance scores were analyzed. Finally, a pass/fail standard was established using the contrasting groups' method.

Results

Trainees used significantly more time per procedure (109 s, 95% CI: 99-120) than experts (82 s, 95% CI: 71-93; p < .001). Adjusted for repetition and rater leniency, experts achieved an average GBRS score of 18.8 (95% CI: 18.3-19.2) out of 20 points, whereas trainees achieved an average of 17.1 points (95% CI: 16.6-17.5; p < .001). In contrast to the task-specific checklist, the GBRS score discriminated between repetition number and participant experience. The pass/fail standard for the GBRS was established at 18.4 points.

Conclusion

We established educational validity evidence for a novel 3D-printed model for simulation-based training of ventilation tube insertion and established a reliable pass/fail standard.

Level of Evidence

1b.

Otolaryngology-Head and Neck Surgery Boot Camp in Preclinical Undergraduate Medical Education: A Pilot Study

Objectives: There are limited opportunities in the medical school curriculum to learn about the field of Otolaryngology-Head and Neck Surgery (ORL) and to acquire relevant clinical skills, especially during preclinical years. The purpose of this pilot study was to investigate the impact of implementing an ORL boot camp in preclinical undergraduate medical education to help first- and second-year medical students learn about common ORL problems and become more comfortable performing basic ORL clinical skills so that they are better prepared to provide care for patients during clerkships and beyond. Methods: First- and second-year medical students were recruited to a single 3-hour boot camp session consisting of didactics/demonstrations and clinical experiences. The boot camp provided an introduction into the field of ORL, description of common ORL pathologies, associated management and procedures, and demonstrations of basic ORL procedures typically performed in clinic. Under supervision, subjects practiced complete head and neck physical examinations (H&NPE) on their peers including otoscopy, tuning fork tests, examination with a nasal speculum, and oral, basic cranial nerve, and neck examination. Pre- and post-tests assessing subjective (0-5 point Likert scale) and objective (content exam) measures of ORL knowledge, comfort level performing ORL skills, and interest in ORL were used to evaluate the intervention. Results: A total of 17 students participated in the boot camp as part of an extracurricular session. Seventeen students completed pre-tests and 16 completed post-tests. Ratings of self-reported knowledge of ORL (2.06 vs 3.00; P = .019) and comfort level in performing H&NPE (1.76 vs 3.44; P < .001) increased significantly after the boot camp. Mean performance on an ORL content exam also increased significantly from 42.17% to 71.35% (P < .001). Conclusions: An ORL boot camp may be an effective method of teaching for preclinical medical students. Further studies with a larger cohort are warranted.

Exploring pre-hospital healthcare workers' readiness for chemical, biological, radiological, and nuclear threats in the State of Qatar: A cross-sectional study

Background

Hazardous Material-Chemical, Biological, Radiological, and Nuclear (HazMat-CBRN) incidents, though infrequent, are environmentally precarious and perilous to living beings. They can be deliberate or accidental or follow the re-emergence of highly contagious diseases. Successful management of such incidents in pre-hospital settings requires having well-trained and prepared healthcare workers.

Aims

This study aimed to explore the reliability and validity of a satisfaction survey, answered by Specialized Emergency Management (SEM) personnel from a national Middle Eastern ambulance service, with a "Hazardous Material Incident Management" course offered to them as a continuing professional development activity and seek their opinion regarding Hamad Medical Corporation Ambulance Service personnel needs for other HazMat-CBRN related training topics.

Method

In the cross-sectional study, we conducted an online satisfaction survey for this group of course participants to obtain their feedback as subject matter experts. Aiken's content validity coefficient (CVC) was calculated to assess the content validity. Cronbach's α coefficient was determined to explore the survey's reliability. IBM®-SPSS® version 26 was utilized to explore the data.

Results

The SEM satisfaction survey demonstrated important satisfaction with the implemented training with its robust reliability and content validity (Cronbach's α = 0.922 and CVC = 0.952). The participants also recommended additional related topics.

Conclusion

Sustaining and reinforcing the HazMat-CBRN Incident Management course was strongly recommended, considering the increase of HazMat-CBRN threats worldwide.

The Otolaryngology boot camp: a scoping review evaluating commonalities and appraisal for curriculum design and delivery

OBJECTIVE

Surgical boot camps are becoming increasingly popular in Otolaryngology-Head and Neck Surgery (OHNS) residency programs. Despite pioneering virtual reality and simulation-based surgical education, these boot camps have lacked critical appraisal. The objective of this article was to examine the adoption and utility of surgical boot camps in OHNS residency training programs around the world.

DATA SOURCES

Ovid Medline and PubMed databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews. Additionally, a grey literature search was performed.

REVIEW METHODS

Inclusion criteria were peer-reviewed publications and grey literature sources that reported on OHNS boot camps for the novice learner. The search was restricted to human studies published in English. Studies were excluded if they were not examining junior trainees.

RESULTS

A total of 551 articles were identified. Following removal of duplicates, screening, and full text review, 16 articles were included for analysis. Seven major boot camps were identified across various academic sites in the world. Most boot camps were one-day intensive camps incorporating a mixture of didactic, skill specific, and simulation sessions using an array of task trainers and high-fidelity simulators focusing on OHNS emergencies. Studies measuring trainee outcomes demonstrated improvement in trainee confidence, immediate knowledge, and skill acquisition.

CONCLUSION

Surgical boot camps appear to be an effective tool for short term knowledge and skill acquisition. Further studies should examine retention of skill and maintenance of confidence over longer intervals, as little is known about these lasting effects.

A novel approach to myringotomy simulation

Objective

In the wake of the 2019 coronavirus disease pandemic, elective cases and opportunities for clinical application have decreased, and the need for useful simulation models has become more apparent for developing surgical skills. A novel myringotomy with ventilatory tube insertion simulation model was created.

Methods

Residents across all levels at our institution participated in the simulation. Participants were evaluated in terms of: time of procedure, microscope positioning, cerumen removal, identification of middle ear effusion type, canal wall trauma, tympanic membrane damage and tube placement.

Results

Eleven residents participated. Scores ranged from 14 to 34, out of a maximum of 40. The average score among junior and senior residents was 24 and 31, respectively. The simulation was felt to be representative of the operating theatre experience.

Conclusion

This study demonstrates a low-cost simulation model that captures several important, nuanced aspects of myringotomy with tube insertion, often overlooked in previously reported simulations.

Current Evidence for Simulation-Based Training and Assessment of Myringotomy and Ventilation Tube Insertion: A Systematic Review

OBJECTIVE

Myringotomy and ventilation tube insertion (MT) is a key procedure in otorhinolaryngology and can be trained using simulation models. We aimed to systematically review the literature on models for simulation-based training and assessment of MT and supporting educational evidence.

DATABASES REVIEWED

PubMed, Embase, Cochrane Library, Web of Science, Directory of Open Access Journals.

METHODS

Inclusion criteria were MT training and/or skills assessment using all types of training modalities and learners. Studies were divided into 1) descriptive and 2) educational interventional/observational in the analysis. For descriptive studies, we provide an overview of available models including materials and cost. Educational studies were appraised using Kirkpatrick's level of educational outcomes, Messick's framework of validity, and a structured quality assessment tool.

RESULTS

Forty-six studies were included consisting of 21 descriptive studies and 25 educational studies. Thirty-one unique physical and three virtual reality simulation models were identified. The studies report moderate to high realism of the different simulators and trainees and educators perceive them beneficial in training MT skills. Overall, simulation-based training is found to reduce procedure time and errors, and increase performance as measured using different assessment tools. None of the studies used a contemporary validity framework and the current educational evidence is limited.

CONCLUSION

Numerous simulation models and assessment tools have been described in the literature but educational evidence and systematic implementation into training curricula is scarce. There is especially a need to establish the effect of simulation-based training of MT in transfer to the operating room and on patient outcomes.

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Otolaryngology Curriculum During Residency Preparation Course Improves Preparedness for Internship

OBJECTIVES/HYPOTHESIS

Residency preparation courses (RPCs) have become a widely adopted practice to ease the transition of medical students into residency, but these courses often lack training in skills expected of subspecialty interns. To fill this gap, a simulation-based curriculum in otolaryngology (ORL) was implemented at the University of Michigan Medical School. The curriculum aimed to improve confidence and perceived ability to perform common ORL skills for graduating students prior to internship.

STUDY DESIGN

Cross-sectional study.

METHODS

Six basic simulations (tracheostomy, flexible laryngoscopy, otomicroscopy, myringotomy and tube insertion, epistaxis and peritonsillar abscess management) were included in the first course in 2019. The course was expanded in 2020 with the addition of three advanced simulations (ear foreign body extraction, tracheostomy complications, and "cannot intubate, cannot ventilate" situations). Pre- and postsession surveys were collected to assess individual simulations and the course overall.

RESULTS

A total of 32 students participated in the ORL simulation curriculum in Spring 2019 and 2020. Paired t-tests showed significant improvement in self-perception of ability on every simulation. Qualitative feedback revealed that students particularly valued the opportunity for hands-on learning. Non-ORL students rated their baseline abilities significantly lower than ORL students on five stations, but they achieved statistically equivalent postsession ratings on all but the otomicroscopy station.

CONCLUSIONS

An ORL-specific curriculum is a valuable addition to procedural RPCs. The curriculum resulted in increased confidence and perceived ability in skill performance for both students pursuing ORL residencies, as well as those pursuing other procedural specialties.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2143-E2148, 2021.

SimTube: A National Simulation Training and Research Project

OBJECTIVE

To test the feasibility and impact of a simulation training program for myringotomy and tube (M&T) placement.

STUDY DESIGN

Prospective randomized controlled.

SETTING

Multi-institutional.

SUBJECTS AND METHODS

An M&T simulator was used to assess the impact of simulation training vs no simulation training on the rate of achieving competency. Novice trainees were assessed using posttest simulator Objective Structured Assessment of Technical Skills (OSATS) scores, OSATS score for initial intraoperative tube insertion, and number of procedures to obtain competency. The effect of simulation training was analyzed using χ² tests, Wilcoxon-Mann-Whitney tests, and Cox proportional hazards regression.

RESULTS

A total of 101 residents and 105 raters from 65 institutions were enrolled; however, just 63 residents had sufficient data to be analyzed due to substantial breaches in protocol. There was no difference in simulator pretest scores between intervention and control groups; however, the intervention group had better OSATS global scores on the simulator (17.4 vs 13.7, P = .0003) and OSATS task scores on the simulator (4.5 vs 3.6, P = .02). No difference in OSATS scores was observed during initial live surgery rating (P = .73 and P = .41). OSATS scores were predictive of the rate at which residents achieved competence in performing myringotomy; however, the intervention was not associated with subsequent OSATS scores during live surgeries (P = .44 and P = .91) or the rate of achieving competence (P = .16).

CONCLUSIONS

A multi-institutional simulation study is feasible. Novices trained using the M&T simulator achieved higher scores on simulator but not initial intraoperative OSATS, and they did not reach competency sooner than those not trained on the simulator.

Non-technical skills and otolaryngology: systematic review

OBJECTIVES

This study aimed to assess the published literature on non-technical skills in otolaryngology surgery and examine the applicability of any research to others' practice, and to explore how the published literature can identify areas for further development and guide future research.

METHODS

A systematic review was conducted using the following key words: 'otolaryngology', 'otorhinolaryngology', 'ENT', 'ENT surgery', 'ear, nose and throat surgery', 'head and neck surgery', 'thyroid surgery', 'parathyroid surgery', 'otology', 'rhinology', 'laryngology' 'skull base surgery', 'airway surgery', 'non-technical skills', 'non technical skills for surgeons', 'NOTSS', 'behavioural markers' and 'behavioural assessment tool'.

RESULTS

Three publications were included in the review - 1 randomised, controlled trial and 2 cohort studies - involving 78 participants. All were simulation-based studies involving training otolaryngology surgeons.

CONCLUSION

Little research has been undertaken on non-technical skills in otolaryngology. Training surgeons' non-technical skill levels are similar across every tested aspect. The research already performed can guide further studies, particularly amongst non-training otolaryngology surgeons and in both emergency and elective non-simulated environments.