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Gkrinia E, Ntziovara AM, Brotis AG, Tzimkas-Dakis K, Saratziotis A, Korais C, Hajiioannou J. Endoscopic Versus Microscopic Tympanoplasty: A Systematic Review and Metanalysis. Laryngoscope 2024; 134:3466-3476. [PMID: 38415937 DOI: 10.1002/lary.31365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 01/20/2024] [Accepted: 02/02/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Endoscopic ear surgery is no longer a promising technique, but a well-established one. This study aims to compare endoscopic and microscopic tympanoplasty based on current literature evidence, in terms of their efficacy and safety characteristics. DATA SOURCES We conducted a systematic literature search of four medical databases (Pubmed, Cochrane Library, Scopus, ClinicalTrials.gov), focusing on randomized controlled or observational studies comparing microscopic to endoscopic tympanoplasty. REVIEW METHODS Data related to the efficacy and safety of each technique were extracted. Outcome data were summarized using pooled mean differences or pooled odds ratio along with their 95% confidence intervals. The risk of bias was estimated, by using the ROBINS-I and RoB-II assessment tools, while the overall quality of evidence was evaluated according to the GRADE working group. RESULTS Thirty-three studies, with 2646 patients in total, were included in the meta-analysis. Success rate was evaluated by estimating tympanic graft failure (pooled mean difference:-0.23; 95% CI: -0.61, 0.14, I2 = 33.42%), and air-bone gap improvement (pooled mean difference:-0.05; 95% CI:-0.23, 0.13, I2 = 52.69%), resulting in comparable outcomes for the two techniques. A statistically significant difference favoring the endoscopic technique was detected regarding postoperative wound infection (OR: -1.72; 95% CI: -3.39, -0.04, I2 = 0%), dysgeusia (OR: -1.47; 95% CI: -2.47, -0.47, I2 = 0%), otitis externa development (OR: -1.96; 95% CI: -3.23, -0.69, I2 = 0%), auricular numbness (OR: -2.56; 95% CI: -3.93, -1.19, I2 = 0%), as well as surgical duration (OR: -1.86; 95% CI: -2.70, -1.02, I2 = 43.95%), when compared to the postauricular microscopic approach. CONCLUSION Endoscopic tympanoplasty is an innovative alternative to the microscopic technique, resulting in commensurate outcomes regarding success rate. Furthermore, it offers superior results concerning postoperative complications, while it presents a significant reduction in the duration of surgery, mainly when it is compared to the postauricular microscopic approach. LEVEL OF EVIDENCE NA Laryngoscope, 134:3466-3476, 2024.
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Affiliation(s)
- Eleni Gkrinia
- ENT Department, University Hospital of Larissa, Larisa, Greece
| | | | | | | | | | - Christos Korais
- ENT Department, University Hospital of Larissa, Larisa, Greece
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Kennedy EJ, Cleere EF, Crotty TJ, Keogh IJ. Training in Endoscopic Ear Surgery: A Scoping Review. Laryngoscope 2023; 133:3269-3278. [PMID: 37098824 DOI: 10.1002/lary.30717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/31/2023] [Accepted: 04/09/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification. DATA SOURCES A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included. REVIEW METHODS A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed. RESULTS Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present. CONCLUSIONS Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.
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Affiliation(s)
| | - Eoin F Cleere
- Department of Otolaryngology, Galway University Hospital, Galway, Ireland
| | - Thomas J Crotty
- Department of Otolaryngology, Galway University Hospital, Galway, Ireland
| | - Ivan J Keogh
- School of Medicine, University of Galway, Galway, Ireland
- Department of Otolaryngology, Galway University Hospital, Galway, Ireland
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Wong K, Gorthey S, Arrighi-Allisan AE, Fan CJ, Barber SR, Schwam ZG, Wanna GB, Cosetti MK. Defining the Learning Curve for Endoscopic Ear Skills Using a Modular Trainer: A Multi-Institutional Study. Otol Neurotol 2023; 44:346-352. [PMID: 36805421 DOI: 10.1097/mao.0000000000003826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Quantify the learning curve for endoscopic ear skills acquisition in otolaryngology residents using a simulator. The secondary objective was to determine if demographic factors or previous endoscopic experience influenced skill development. STUDY DESIGN Prospective, multicenter study. Resident participants each completed 10 amassed trials using a validated endoscopic ear skill trainer. SETTING Two academic teaching hospitals. SUBJECTS Otolaryngology residents. MAIN OUTCOME MEASURES Trial completion times; rate of improvement over time. RESULTS Thirty-eight residents completed the study, 26 from program A and 12 from program B. Fifteen participants were women and 23 were men. Mean age was 30 years old (range 26 to 34 years). Previous experience with otoendoscopy (B = -16.7, p = 0.005) and sinus endoscopy (B = -23.4, p = 0.001) independently correlated with lower overall trial times. Age, gender, postgraduate year, handedness, interest in otology, and video gaming were not associated with trial times. On multivariate logistic regression, resident completion times improved with trial number, and residents without previous endoscopy experience improved at a faster rate than those with experience ( p < 0.001). CONCLUSIONS Novice surgeons may acquire basic endoscopic ear experience with self-directed simulation training. The learning curve for transcanal endoscopic ear surgery is comparable to those demonstrated for other otologic surgeries, and specific task competencies can be achieved within 10 trials, suggesting that previous experiences, or lack thereof, may not dictate the ability to acquire new skills. There may be a translational value to previous endoscopic sinus experience on learning transcanal endoscopic ear surgery.
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Affiliation(s)
| | - Scott Gorthey
- Department of Otolaryngology, Albert Einstein College of Medicine, New York, NY
| | | | | | - Samuel R Barber
- Department of Otolaryngology, University of Arizona College of Medicine, Tucson, AZ
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Pollastri F, Locatello LG, Bruno C, Maggiore G, Gallo O, Pecci R, Giannoni B. Otoendoscopy in the era of narrow-band imaging: a pictorial review. Eur Arch Otorhinolaryngol 2023; 280:1683-1693. [PMID: 36129549 PMCID: PMC9988719 DOI: 10.1007/s00405-022-07656-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/12/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Otoendoscopy represents the initial non-invasive diagnostic cornerstone for external and middle ear disorders. Recently, new techniques of enhanced imaging such as narrow-band imaging (NBI) have been introduced but their role as a potential aid in otological practice remains unproven. In this pictorial review, we want to present the potential application of this endoscopic method, highlight its limitations, and give some hints regarding its future implementation. METHODS Representative cases of external and/or middle ear pathologies were selected to illustrate the role of NBI in this regard. RESULTS NBI may represent a useful aid in the otological work-up, in the differential diagnosis of ear tumor-like masses, and, possibly, in the prognosis of tympanic perforations. For other ear disorders, instead, this technique does not seem to add anything to the standard clinical practice. CONCLUSIONS NBI might prove useful in the assessment of selected external and middle ear disorders but its role must be prospectively validated.
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Affiliation(s)
- Federica Pollastri
- Unit of Audiology, Oncological and Robotic Head and Neck Surgery, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy. .,Department of Neuroscience, Psychology, Drug's Area and Child's Health, University of Florence, Florence, Italy.
| | | | - Chiara Bruno
- Department of Otorhinolaryngology, Careggi University Hospital, Florence, Italy
| | | | - Oreste Gallo
- Department of Otorhinolaryngology, Careggi University Hospital, Florence, Italy
| | - Rudi Pecci
- Unit of Audiology, Oncological and Robotic Head and Neck Surgery, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Beatrice Giannoni
- Unit of Audiology, Oncological and Robotic Head and Neck Surgery, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.,Department of Neuroscience, Psychology, Drug's Area and Child's Health, University of Florence, Florence, Italy
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Tu LJ, Fina M, Golub JS, Kazahaya K, Quesnel AM, Tawfik KO, Cohen MS. Current Trends in Endoscopic Ear Surgery. OTOLOGY & NEUROTOLOGY OPEN 2022; 2:e023. [PMID: 38516579 PMCID: PMC10950159 DOI: 10.1097/ono.0000000000000023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/21/2022] [Indexed: 03/23/2024]
Affiliation(s)
- Leona J. Tu
- Drexel University College of Medicine, Philadelphia, PA
| | - Manuela Fina
- Department of Otolaryngology—Head and Neck Surgery, University of Minnesota, Minneapolis, MN
| | - Justin S. Golub
- Department of Otolaryngology—Head and Neck Surgery, Valegos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Otorhinolaryngology/Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Alicia M. Quesnel
- Department of Otolaryngology—Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
| | - Kareem O. Tawfik
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael S. Cohen
- Department of Otolaryngology—Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
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Patient-Reported Postoperative Pain and Numbness: Applications for Endoscopic vs. Microscopic Ear Surgery. J Pers Med 2022; 12:jpm12101718. [PMID: 36294857 PMCID: PMC9604827 DOI: 10.3390/jpm12101718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Transcanal endoscopic ear surgery (TEES) avoids a postauricular incision, which has been shown to minimize pain and numbness. Our objective is to assess how much patients value minimizing pain and numbness relative to other postoperative otologic outcomes. Methods: Cross-sectional anonymous surveys were distributed to otolaryngology clinic patients in a tertiary care center. Patients were instructed to rate how much they value various outcomes when undergoing hypothetical ear surgery on a scale of 0 (not important) to 10 (very important). Results: 102 patients responded. Ten percent of survey respondents were Spanish-speaking. Outcomes of the highest importance included hearing (mean 9.3; SD 1.9), staff friendliness (8.9; 1.8), numbness (8.3; 2.4), and pain (8.1; 2.5). Outcomes of moderate importance included time spent under anesthesia (7.0; 3.2), scar visibility (6.3; 3.5), incision size (5.5; 3.4), incision hidden in the ear canal (5.4, 3.9), and surgery cost to the hospital (5.1; 3.9). In linear regression analysis, increasing age was associated with decreased value placed on incision size (p < 0.001) and scar visibility (p < 0.001). Conclusion: Patients placed a high value on minimizing pain and numbness after ear surgery, nearly as much as a good hearing outcome. These patient-centric outcomes are important in justifying the minimally invasive approach of TEES.
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Microscopic Versus Endoscopic Stapes Surgery: A Systematic Review and Metanalysis. The Journal of Laryngology & Otology 2022; 136:1014-1022. [PMID: 35012693 DOI: 10.1017/s0022215121004436] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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谭 志, 刘 映, 刘 斌, 肖 旭, 肖 欢, 彭 韬, 周 恩. [Clinical study on repairing subtotal perforation of tympanic membrane with cartilage island technique combined with palisade technique under otoscope]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2021; 35:1009-1013. [PMID: 34886605 PMCID: PMC10128369 DOI: 10.13201/j.issn.2096-7993.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Indexed: 06/13/2023]
Abstract
Objective:To investigate the healing rate of subtotal perforation of tympanic membrane repaired by cartilage island technique combined with palisade cartilage technique under otoscope. Methods:A retrospective analysis was performed on 189 patients with chronic suppurative otitis media who were admitted to the Department of Otolaryngology and Head and Neck Surgery of Hunan Provincial People's Hospital from January 2018 to January 2020. The patients were divided into twogroups, in group onethere were 100 patients treated by senior surgeon, which were divided into two subgroups, Group A (68 cases) were treated with cartilage island technique alone, and Group B (32 cases) were treated with cartilage island technique combined with palisade cartilage technique. In group two there were 89 patients treated by junior surgeons, which were divided into two subgroups. In group C, 50 cases were treated with cartilage island technique alone, and in group D, 39 cases were treated with cartilage island technique combined with palisade cartilage technique. Results:The healing rate of tympanic membrane in group 1 was 96.0% (96/100), and in group 2 was 87.6%(78/89).There was statistically significant in group 1 and group 2(χ²=4.504, P=0.034).The healing rate of tympanic membrane was 94.1% (64/68) in group A, 100%(32/32)in group B, 80.0%(40/50) in group C, and 97.4% (38/39) in group D. There was no statistically significant difference between group A and group B (χ²=1.961, P=0.161), there was statistically significant difference between group C and group D (χ²=6.149, P=0.013), and there was statistically significant difference between group A and group C(χ²=5.492, P=0.019)There was no statistical difference between group B and group D(χ²=0.832, P=0.362). Conclusion:For beginners of tympanoplasty, the use of cartilage island technique combined with palisade cartilage technique in otoscope can significantly improve the success rate of tympanoplasty with subtotal tympanic perforation.
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Affiliation(s)
- 志强 谭
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - 映辰 刘
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - 斌 刘
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - 旭平 肖
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - 欢 肖
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - 韬 彭
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - 恩 周
- 湖南省人民医院 湖南师范大学附属第一医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People′s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
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Abstract
Endoscopic ear surgery (EES) has become an integral part of otologic surgery. Training in EES involves learning fundamental techniques for endoscopic visualization, becoming proficient at one-handed dissection, mastering use of instruments designed for endoscopic ear surgery, and learning to optimize the operating room setup specifically for EES. Despite the steep learning curve, EES offers several advantages over the microscope for otologic procedures. With the rise in the demand for minimally invasive approaches, EES has a clear role in the future of otologic surgery. Identifying strategies to improve the training process of EES for the novice and experienced otolaryngologist is paramount.
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Affiliation(s)
- Samuel R Barber
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Tucson, AZ 85724, USA
| | - Divya A Chari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
| | - Alicia M Quesnel
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA.
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Beckmann S, Yacoub A, Fernandez IJ, Niederhauser L, Fermi M, Caversaccio M, Bonali M, Anschuetz L. Exclusive Endoscopic Laser-Stapedotomy: Feasibility of an Ovine Training Model. Otol Neurotol 2021; 42:994-1000. [PMID: 33935254 DOI: 10.1097/mao.0000000000003168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Stapedotomy is an effective treatment for conductive hearing loss associated with otosclerosis. However, the procedure, especially using the endoscopic technique requires extensive training and experience for optimal results. Due to limited training options in endoscopic stapes surgery, we aim to develop an ovine stapedotomy model and assess its feasibility for surgeons at different training levels. METHODS A fully endoscopic ovine laser-stapedotomy model was developed and described. During repetitive dissections, surgical time required for the different steps to assess the training curve and associated intraoperative complications were recorded in three surgeons of different training level. Additionally, subjective feedback was assessed. RESULTS Successful endoscopic laser-stapedotomy was performed in 25 cases in the ovine model. Assessment of surgical time revealed a stable curve for the experienced surgeon (mean 15:01 min) for the whole training with no intraoperative complications. The fellow showed a gradual reduction of surgical time from 27:21 (first five cases) to 24:10 minutes (last five cases) and the resident a reduction from 42:38 to 21:08 minutes respectively. The assessed learning curve for the trainees revealed a significant association between the operative time and observed intraoperative complications. DISCUSSION In this study, an ex-vivo model for exclusively endoscopic laser-stapedotomy was developed and tested for feasibility. We suggest the ovine model as a cost-effective, easily available, and realistic training model for future otologic surgeons. The surgeons were able to improve their performance with satisfactory results despite the small number of cases.
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Affiliation(s)
- Sven Beckmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Abraam Yacoub
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ignacio Javier Fernandez
- Department of Otorhinolaryngology, Head and Neck Surgery, Modena University Hospital, Modena, Italy
| | - Laura Niederhauser
- Department of Psychology, Swiss University of Distance Education, Brig, Switzerland
| | - Matteo Fermi
- Department of Otorhinolaryngology, Head and Neck Surgery, Modena University Hospital, Modena, Italy
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Bonali
- Department of Otorhinolaryngology, Head and Neck Surgery, Modena University Hospital, Modena, Italy
| | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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A three-dimensional printed myringotomy, tympanostomy and ventilation tube placement simulator. The Journal of Laryngology & Otology 2021; 135:420-425. [PMID: 33952362 DOI: 10.1017/s0022215121001146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tympanostomy is one of the most commonly performed surgical procedures in otolaryngology, and its complexity is challenging for trainee surgeons. Investing in medical education is a cornerstone of good patient safety practices. For trainees, use of simulators before operating on actual patients helps mitigate risks. This study aimed to develop a three-dimensional printed model simulator for myringotomy, tympanostomy and ventilation tube placement. METHODS An articulated model with a detachable portion, base and plastic bag to simulate the external auditory canal, middle ear and tympanic membrane, respectively, was modelled and printed. RESULTS The final simulator was made from acrylonitrile butadiene styrene polymer and measured 4 × 4 × 12 cm. It was designed to mimic the angulation of patient anatomy in the myringotomy position and simulate the texture and colour of the tissues of interest. The cost was low, and testing with an operating microscope and endoscope yielded satisfactory results. The advent of three-dimensional printing technology has made surgical simulation more accessible and less expensive, providing several advantages for medical education. CONCLUSION The proposed model fulfilled expectations as a safe, inexpensive, reproducible, user-friendly and accessible surgical education tool that can be improved and reassessed for further research.
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Chern A, Sharma RK, Maurrasse SE, Drusin MA, Ciarleglio AJ, Golub JS. Educational Value of Endoscopic Versus Microscopic Ear Surgery. Ann Otol Rhinol Laryngol 2021:34894211012600. [PMID: 33957787 DOI: 10.1177/00034894211012600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the educational value of endoscopic ear surgery versus microscopic ear surgery among medical students. METHODS Medical students anonymously completed a cross-sectional survey immediately after observing endoscopic or microscopic ear surgery. A Likert scale (1 = worst, 5 = best) was used to analyze variables across 3 domains including: (1) area of interest visibility, (2) optical quality, (3) education and understanding. The Mann-Whitney U-test and multivariable linear regression were used to compare mean scores of individual items and domain means between endoscopic and microscopic groups. RESULTS Forty-four surveys were analyzed (20 endoscopic and 24 microscopic ear surgeries). Across domains, the endoscope was superior to the microscope (adjusted P < .05) for visibility of the area of interest (mean ± SD: 4.74 ± 0.26 vs 4.28 ± 0.50), optical quality (4.78 ± 0.38 vs 4.28 ± 0.64), and education and understanding (4.70 ± 0.47 vs 4.13 ± 0.61). In multivariable linear regression, the mean domain score for visibility of the area of interest was 1.23 (95% CI = 0.56, 1.90; adjusted P < .01) points higher for the endoscopic group, compared to the microscopic group, adjusting for surgeon, procedure, and student type. The mean domain score for education and understanding was 1.19 (95% CI = 0.49. 1.90; adjusted P < 0.01) points higher for the endoscopic group, compared to the microscopic group, adjusting for the same confounders. CONCLUSIONS Among medical students, endoscopic ear surgery was superior to microscopic ear surgery for several visual quality indicators and perceived educational benefit. These findings have implications for medical student education and surgical training.
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Affiliation(s)
- Alexander Chern
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons and Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA.,Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Rahul K Sharma
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons and Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Sarah E Maurrasse
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons and Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA.,Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Madeleine A Drusin
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons and Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA.,Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Adam J Ciarleglio
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Justin S Golub
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons and Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA
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Berges AJ, Razavi C, Shahbazi M, Taylor R, Carey JP, Creighton FX. Characterization of patient head motion in otologic surgery: Implications for TEES. Am J Otolaryngol 2021; 42:102875. [PMID: 33418180 DOI: 10.1016/j.amjoto.2020.102875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Middle ear disease is increasingly being managed via transcanal endoscopic ear surgery (TEES). A limitation of TEES is that it restricts the surgeon to single-handed dissection. One solution to this would be an endoscope holder to facilitate two-handed dissection. Current endoscope holders are stationary, and can cause potential damage from endoscope contact with the ossicles or ear canal if unintended head motion occurs from inadequate anesthetic. A dynamic device that could detect and react to patient motion would mitigate these concerns, but currently there is little formal characterization of the frequency, velocity and acceleration of unintended patient head motion during otologic procedures performed under general anesthesia. The present study aims to characterize intraoperative patient head motion kinematics during cases utilizing TEES. MATERIALS AND METHODS This is a prospective study of adults undergoing otologic procedures performed with general anesthesia and without paralysis. Head motion was characterized using a nine-axis inertial measurement unit (IMU), (LPMS-B2, Life Performance Research) mounted to each patient's forehead for the procedure duration. RESULTS Data was collected across 10 cases; 50% of patients were female and mean age was 50 ± 14 years. There was observed patient head motion in 40% of cases with maximum linear acceleration of 0.75 m/s2 and angular velocity of 12.50 degrees/s. CONCLUSIONS Patient movement during otologic procedures was commonly observed, demonstrating the need for a dynamic holder to allow two-handed TEES. Results from this study are the first objective characterization of patient head motion kinematics during otologic procedures performed under general anesthesia.
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Characterization of patient head motion in otologic surgery: Implications for TEES. Am J Otolaryngol 2021; 42:102827. [PMID: 33181483 DOI: 10.1016/j.amjoto.2020.102827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 10/30/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE Middle ear disease is increasingly being managed via transcanal endoscopic ear surgery (TEES). A limitation of TEES is that it restricts the surgeon to single-handed dissection. One solution to this would be an endoscope holder to facilitate two-handed dissection. Current endoscope holders are stationary, and can cause potential damage from endoscope contact with the ossicles or ear canal if unintended head motion occurs from inadequate anesthetic. A dynamic device that could detect and react to patient motion would mitigate these concerns, but currently there is little formal characterization of the frequency, velocity and acceleration of unintended patient head motion during otologic procedures performed under general anesthesia. The present study aims to characterize intraoperative patient head motion kinematics during cases utilizing TEES. MATERIALS AND METHODS This is a prospective study of adults undergoing otologic procedures performed with general anesthesia and without paralysis. Head motion was characterized using a nine-axis inertial measurement unit (IMU), (LPMS-B2, Life Performance Research) mounted to each patient's forehead for the procedure duration. RESULTS Data was collected across 10 cases; 50% of patients were female and mean age was 50 ± 14 years. There was observed patient head motion in 40% of cases with maximum linear acceleration of 0.75 m/s2 and angular velocity of 12.50 degrees/s. CONCLUSIONS Patient movement during otologic procedures was commonly observed, demonstrating the need for a dynamic holder to allow two-handed TEES. Results from this study are the first objective characterization of patient head motion kinematics during otologic procedures performed under general anesthesia.
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Anschuetz L, Siggemann T, Dür C, Dreifuss C, Caversaccio M, Huwendiek S. Teaching Middle Ear Anatomy and Basic Ear Surgery Skills: A Qualitative Study Comparing Endoscopic and Microscopic Techniques. Otolaryngol Head Neck Surg 2020; 165:174-181. [PMID: 33287674 DOI: 10.1177/0194599820977191] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Endoscopic ear surgery is gaining popularity as a minimally invasive surgical technique for middle ear diseases. Its ongoing implementation into clinical routine has consequences regarding teaching of middle ear anatomy and surgery. To improve undergraduate and postgraduate training, we investigated the perception of and preference for endoscopy as compared with microscopy at different educational levels. STUDY DESIGN Qualitative study based on a thematic analysis approach. SETTING Tertiary academic medical center. METHODS After a standardized curriculum was run on endoscopic and microscopic anatomy and surgical skills education, 5 focus groups were held. The interviews were conducted, video recorded, transcribed, and analyzed. Analysis of the data gave rise to 11 themes showing the participants' perceptions and preferences. RESULTS Five medical students, 11 otorhinolaryngology residents, and 3 staff members participated in this qualitative study. For anatomy teaching, there was a clear preference for the endoscopic technique. The main advantages were the enhanced overview and perception of the anatomic details provided through endoscopy. For skills acquisition, the perceived advantages of the techniques were the same view of the surgical field for endoscopy and the 2-handed surgical technique for microscopy. However, there was no clear preference between the techniques for skills acquisition. CONCLUSION The endoscopic technique was generally judged more beneficial for teaching anatomy, especially due to the greater visualization of the complex middle ear anatomy. Given that both techniques will remain important to future surgeons, the relative unique benefits of each must be considered when designing and optimizing curricula for otologic education.
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Affiliation(s)
- Lukas Anschuetz
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Till Siggemann
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Cilgia Dür
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Corinne Dreifuss
- Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology-Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Sören Huwendiek
- Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland
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谭 志, 彭 韬, 刘 斌, 苗 刚, 卜 梅, 周 恩, 肖 旭, 凌 科. [Clinical application of transcanal endoscopic ear surgery in the diagnosis and treatment of conductive hearing loss with intact tympanic membrane]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2020; 34:1070-1074. [PMID: 33254337 PMCID: PMC10127782 DOI: 10.13201/j.issn.2096-7993.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 11/12/2022]
Abstract
Objective:To explore the clinical efficacy of transcanal endoscopic ear surgery in the diagnosis and treatment of conductive hearing loss with intact tympanic membrane. Method:The clinical data of 16 patients with conductive hearing loss with intact tympanic membrane were retrospectively analyzed. They were diagnosed and treated by transcanal endoscopic ear surgery. Result:All patients were diagnosed by exploratory tympanotomy, including 6 cases of congenital middle ear anomalies, 5 cases of congenital cholesteatoma, 2 cases of congenital middle ear anomalies with congenital cholesteatoma, 2 cases of otosclerosis, and 1 case of traumatic ossicular chain disruption. During the tympanic exploration by transcanal endoscopic ear surgery, different methods of hearing reconstruction were applied according to the intraoperative lesions. Among 14 cases(14 ears), 7 patients underwent reconstruction with partial ossicular replacement prosthesis (PORP), 5 patients had total ossicular replacement prosthesis (TORP), and 2 patients had piston. The remaining 2 patients did not undergot ossicular reconstruction. After the operation, the mean air-conductive threshold of 14 patients decreased from (61.7±6.5) dB HL to (29.8±10.7) dB HL (P<0.01) and the mean ABG decreased from(36.8±3.2) dB HL to (10.7±6.9) dB HL (P<0.01). 1 case of congenital middle ear anomalies with congenital cholesteatoma underwent the lesion resection without ossicular reconstruction. Due to lack of suitable Piston, 1 case of congenital middle ear anomalies with fixed stapes did not perform hearing reconstruction. No serious complications occured after operations. Conclusion:Transcanal endoscopic ear surgery was suitable for the diagnosis and treatment of conductive hearing loss with intact tympanic membrane. It was minimally invasive with low complications, and the patients had a good hearing recovery after ossicular reconstruction.
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Affiliation(s)
- 志强 谭
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 韬 彭
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 斌 刘
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 刚勇 苗
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 梅香 卜
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 恩 周
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 旭平 肖
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - 科技 凌
- 湖南省人民医院耳鼻咽喉头颈外科(长沙,410005)Department of Otolaryngology Head and Neck Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
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Stern Shavit S, Sharma RK, Chern A, Golub JS. Pearls and Pitfalls in Endoscopic Ear Surgery. Otolaryngol Clin North Am 2020; 54:201-209. [PMID: 33153731 DOI: 10.1016/j.otc.2020.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
"Endoscopic ear surgery (EES) has become increasingly popular due to numerous visualization benefits, including angled optics that enable the surgeon to see and dissect around corners. These advantages help the surgeon overcome the visualization limitations of microscopic ear surgery, reducing the need for a post-auricular incision and bone removal. This chapter discusses useful pearls and pitfalls of EES, technical tips and ergonomic strategies, so the learner can understand and solve common obstacles faced when learning EES and incorporate it into his or her practice."
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Affiliation(s)
- Sagit Stern Shavit
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, 180 Fort Washington Avenue, HP8, New York, NY 10032, USA
| | - Rahul K Sharma
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, 180 Fort Washington Avenue, HP8, New York, NY 10032, USA
| | - Alexander Chern
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, 180 Fort Washington Avenue, HP8, New York, NY 10032, USA
| | - Justin S Golub
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, 180 Fort Washington Avenue, HP8, New York, NY 10032, USA.
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Abstract
Since its introduction into the field of otology in 1967 endoscopes are gaining acceptance in evaluation and treatment of middle ear disease. Endoscopes offer a wide field view enabling looking "around the corner" with reduced need for soft tissue and bone removal. Outcomes of middle ear surgery for cholesteatoma and need for second-look procedures are improving because of the addition of endoscopic evaluation. Trainee education using the endoscope improves knowledge of middle ear anatomy. The portability of the endoscopic unit allows performing ear surgery in remote locations.
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Affiliation(s)
- Michal Preis
- Department of Otolaryngology, Maimonides Medical Center, State University of NY Downstate, 919 49th Street, Brooklyn, NY 11219, USA.
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Chandrasekhar SS, Ho S, House JW. The Role for Microsurgery of the Ear. Otolaryngol Clin North Am 2020; 54:211-219. [PMID: 33153737 DOI: 10.1016/j.otc.2020.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Microscopic ear surgery (MES) has been used since the 1950s whereas endoscopic ear surgery (EES) was introduced in the mid-1990s. The advantages of MES should not be forgotten as surgeons turn their attention to new technology. These include depth perception, wide angle view, and the ability to operate with 2 hands. EES affords the ability to look around corners but needs a pristine field and is limited to single-handed surgery in a narrow field. Trainees should be taught both, and technique used should reflect the experience and abilities of the surgeon and the nature of the disease in the particular patient.
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Affiliation(s)
- Sujana S Chandrasekhar
- ENT & Allergy Associates, LLP, 18 East 48th Street, 2nd Floor, New York, NY 10017, USA; Zucker School of Medicine; Icahn School of Medicine.
| | - Sandra Ho
- TJH Medical Services, P.C., 89-06 135th Street, Suite 7D, Jamaica, NY 11418, USA
| | - John W House
- House Ear Institute, Geffen-UCLA Medical Center, 2100 West Third Street, Los Angeles, CA 90210, USA
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Monteiro EMR, Beckmann S, Pedrosa MM, Siggemann T, Morato SMA, Anschuetz L. Learning curve for endoscopic tympanoplasty type I: comparison of endoscopic-native and microscopically-trained surgeons. Eur Arch Otorhinolaryngol 2020; 278:2247-2252. [PMID: 32852570 PMCID: PMC8165066 DOI: 10.1007/s00405-020-06293-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023]
Abstract
Purpose Type I tympanoplasty is one of the first operations to be performed by ear surgeons in training and is increasingly performed using the endoscopic technique. The aim of the present study is to assess and compare the learning curve for type I tympanoplasties between a microscopically trained and endoscopic native ear surgeon. We hypothesize comparable learning curves between the two surgeons regardless of previous microscopic experience. Methods Retrospective analysis and comparison of the 25 first consecutive cases of type I tympanoplasty performed by a microscopically trained ear surgeon (MTES) and a native endoscopic ear surgeon (NEES). Results Mean duration of surgery in MTES and NEES groups was 54 ± 12.3 min and 55.6 ± 17.5 min, respectively. Both surgeons achieved a reduction of the surgery duration over time with statistically significant reduction from the first five cases to the last five cases in both groups. Graft intake rate was 92% after 3 months. Preoperative and postoperative PTA revealed a mean improvement of air bone gap (ABG) of 11.5 ± 7.1 dB HL in MTES group versus 9.3 ± 8.5 dB HL in NEES group, whereby the difference between the two groups was not statistically significant. Conclusion Endoscopic type I tympanoplasty shows comparable results and learning curves in two beginning endoscopic ear surgeons independent of the previous microscopic experience. We recommend if available the parallel learning of both techniques.
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Affiliation(s)
| | - Sven Beckmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland.
| | - Maísa Mendes Pedrosa
- Department of Otorhinolaryngology, Hospital Felicio Rocho, Belo Horizonte, Brasil
| | - Till Siggemann
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
| | | | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland
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Wiet GJ, Deutsch ES, Malekzadeh S, Onwuka AJ, Callender NW, Seidman MD, Fried MP. SimTube: A National Simulation Training and Research Project. Otolaryngol Head Neck Surg 2020; 163:522-530. [PMID: 32450737 DOI: 10.1177/0194599820920833] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Gregory J Wiet
- Department of Otolaryngology, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Ellen S Deutsch
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sonya Malekzadeh
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amanda J Onwuka
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Michael D Seidman
- AdventHealth Medical Group, Otolaryngology-Head & Neck Surgery, Celebration, Florida, USA.,Department of Otolaryngology Head and Neck Surgery, University of Central Florida, Orlando, Florida, USA.,Department of Otolaryngology Head and Neck Surgery, University of South Florida, Tampa, Florida, USA
| | - Marvin P Fried
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine Bronx, New York, USA
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