The role of simulation in teaching sinus surgery in otolaryngology residency: A survey of rhinologists

Augmented and Virtual Reality Applications in Rhinology: A Scoping Review

OBJECTIVES

Virtual reality (VR) and augmented reality (AR) are innovative technologies that have a wide range of potential applications in the health care industry. The aim of this study was to investigate the body of research on AR and VR applications in rhinology by performing a scoping review.

DATA SOURCES

PubMed, Scopus, and Embase.

REVIEW METHODS

According to PRISM-ScR guidelines, a scoping review of literature on the application of AR and/or VR in the context of Rhinology was conducted using PubMed, Scopus, and Embase.

RESULTS

Forty-nine articles from 1996 to 2023 met the criteria for review. Five broad types of AR and/or VR applications were found: preoperative, intraoperative, training/education, feasibility, and technical. The subsequent clinical domains were recognized: craniovertebral surgery, nasal endoscopy, transsphenoidal surgery, skull base surgery, endoscopic sinus surgery, and sinonasal malignancies.

CONCLUSION

AR and VR have comprehensive applications in Rhinology. AR for surgical navigation may have the most emerging potential in skull base surgery and endoscopic sinus surgery. VR can be utilized as an engaging training tool for surgeons and residents and as a distraction analgesia for patients undergoing office-based procedures. Additional research is essential to further understand the tangible effects of these technologies on measurable clinical results. Laryngoscope, 2024.

Construct and Validation of a Three-Dimensional Physical Model for Training in Transnasal Office Procedures

Most simulation models in rhinology are costly and are primarily meant to enhance endoscopic surgical skills. The present study aimed to construct a 3-dimensional model of the nose which is easily constructible with commonly available low cost plaster of Paris (POP) and assess its usefulness in training residents in basic transnasal procedures. A nose model was created using plaster of Paris and assessed for face and content validity by experts in rhinology while a construct validation was performed on five specified tasks by residents. All experts agreed with the resemblance of 10 of the 13 anatomical landmarks in the POP model and its utility in teaching basic transnasal procedures. There was a statistically significant difference in the time taken by I and III year residents in performing a diagnostic nasal endoscopy (p = 0.007), anterior nasal packing with polyvinyl alcohol tampon (p = 0.007), posterior nasal packing with Foley's catheter (p = 0) and nasopharyngeal swabbing (p = 0.025). This study demonstrates the construct of a low cost 3-dimensional POP model and validates its utility in training residents in routine transnasal rhinological procedures. Face and content validation showed a high degree of resemblance to human anatomy with good agreement that this model could increase resident competency. The significant difference in time taken by residents at various levels of experience in performing rhinological procedures also confirmed a reliable construct validity. The described model could be an affordable and easily constructible alternative tool to other simulation models in otorhinolaryngology residency programs especially in developing countries.

Thinking Beyond the Temporal Bone Lab: A Systematic Process for Expanding Surgical Simulation in Otolaryngology Training

The COVID-19 pandemic led to a temporary lapse in the development of otolaryngology trainee operative skills due to the cancellation of elective procedures and redeployment of trainees and attendings to COVID-19 units. Although transient, this disruption provided an opportunity for otolaryngology programs to develop contingency plans and formalize nascent simulation training curricula. Integration of formal simulation training alongside current didactic and surgical education may offset lost exposure during surgically lean times while providing the framework and resources for enhanced baseline training. Here, we provide an up-to-date overview of surgical simulation models in otolaryngology and identify easily implementable, low-cost, low fidelity models for junior trainees. By taking advantage of rapid advancements in technology and a paradigm shift to a more hands-on approach in medical education, formal simulation training may prove to be a beneficial tool at all stages of residency training, allowing for expanded peer-mentored skill development and providing a safe haven during unforeseen disruptions in surgical case volume.

Use of simulation-based training of surgical technical skills among ENTs: an international YO-IFOS survey

PURPOSE

The aim of this study was to investigate and compare the use of simulation-based technical skills training (SBTST) in the otolaryngology curriculum in different countries, and to explore the needs and opinions about the use of simulation among young otolaryngologists.

METHODS

An e-survey conducted among Young Otolaryngologists of the International Federation of Oto-rhino-laryngological Societies (Yo-IFOS) members.

RESULTS

139 Yo-IFOS members from 51 countries completed the survey. During residency training, 82.7% of respondents have used SBTST on cadavers, 51.8% on physical simulators, and 43.8% on virtual reality simulators. High costs (65.5%), lack of availability (49.2%) and lack of time (25.5%) were the main barriers limiting the practice of SBTST. These barriers also limited teaching using simulation. Sinonasal surgery (72.7%), temporal bone surgery (67.6%), and head/neck surgery (44.6%) were significantly more frequently taught using SBTST than suspension microlaryngoscopy (25.9%) and pediatric surgery (22.3%) (p < 0.001). The procedures rated as the most important to learn through SBTST were tracheotomy (50.4%), emergency cricothyroidotomy (48.9%), and rigid bronchoscopy (47.5%). On an analogic visual scale (0-100) for the question "how important will simulation be for future ENTs in surgical training?", the mean score was 79.5/100 (± 23.3), highlighting the positive attitude toward the use of SBTST in otorhinolaryngology training.

CONCLUSION

SBTST is an attractive learning and teaching method in otorhinolaryngology, but associated costs, lack of access, and lack of time are the main barriers limiting its use. Emergency procedures are key technical skills to be learned using simulation but in some cases, lack relevant simulators for training.

Medical Liability in Sinus Surgery: A Westlaw Database Analysis From 2000 to 2017

BACKGROUND

Medical malpractice occurs when a hospital or health-care provider through negligent act or omission results in an injury to a patient. More than 50% of otolaryngologists have faced at least 1 claim, with rhinology being the most litigated subspecialty. This study aims to analyze medical litigation trends in Rhinology from 2000 to 2017 in the United States.

METHODS

The Westlaw database was reviewed from 2000 to 2017. Data were compiled on the demographics of the plaintiffs, procedures, nature of damages, legal allegations, and the use of expert witnesses, physician demographics/practice characteristics, verdicts, indemnities, and county/state of case.

RESULTS

There were 75 cases that met inclusion criteria after review of 125 cases. Majority of cases went to trial over settlement (80%) and were found in the Northeast region of the United States (36%). Most common cited legal allegations were improper performance and failure to follow standard of care. The most common nature of injuries were eye injury (29%) and intracranial complications (27%). The highest payouts were for progression of disease followed by intracranial injury. Of the 75 total cases analyzed, 37 (49.3%) used expert witnesses. When an expert witness was used at trial, the verdict statistically favored the defendant (62.5%).

CONCLUSIONS

Our analysis reveals the importance of meticulous surgical techniques and thorough preoperative evaluations.

Exploring Balloon Sinuplasty Adverse Events With the Innovative OpenFDA Database

Background

Balloon sinuplasty (BSP) has become a common, minimally invasive treatment for chronic sinusitis. Like any surgical procedure, there are definite risks when using it as a stand-alone procedure or in conjunction with other revision procedures.

Objective

To explore the adverse events of BSP using the openFDA cloud with regard to malfunction and injury following surgery.

Methods

Between January 2015 and December 2018, the Food and Drug Administration’s (FDA) openFDA database was queried for adverse event use. Reports were further categorized by procedure location, injury type, device malfunction, procedure (stand-alone BSP vs hybrid), and source of complication (anatomical or surgeon related).

Results

Seventy-eight events were reported to the FDA in the study period. Majority of cases consisted of device malfunctions (64.1%), while patient injuries consisted of 43.5%. Frontal sinus procedures had the greatest presence of adverse events (47.4%) with the majority reporting significant cerebrospinal fluid (CSF) leaks ( P < .001) and device retention ( P = .021). Orbital complications ( P = .004) were found to be significantly associated with dilation of the maxillary sinus. Skull-based injuries were the only factor incident in which surgeon-reported anatomical complications were significant ( P = .018).

Conclusions

As balloon dilation procedure continues to rise in the United States, significant adverse events continue to occur. Frontal sinus BSP leads to the highest number of complications and a 4.75 reported CSF leaks yearly. Based on real data, surgeons performing the procedure should be acquainted with common BSP-related injuries so they can prepare for those circumstances and share informed consent with their patients.

Use of 3D-Printed and 2D-Illustrated International Frontal Sinus Anatomy Classification Anatomic Models for Resident Education

OBJECTIVE

To examine the impact of 2-dimensional (2D) illustrations and 3-dimensonal (3D)-printed anatomic models of the frontal sinuses according to the International Frontal Sinus Anatomy Classification in the education of otolaryngology and radiology residents.

STUDY DESIGN

A crossover study design with half of the study participants randomized to the 2D illustration intervention first and the other half randomized to the 3D-printed model first.

SETTING

Regularly scheduled resident didactic lectures at a tertiary care center.

SUBJECTS AND METHODS

Forty-one otolaryngology and radiology residents were assessed with pre- and postintervention questionnaires that included subjective and objective methods of assessment.

RESULTS

Overall, there was a statistically significant improvement in total number of answers correct and in confidence score between the pre- and postintervention assessments (P < .0001). The primary outcome of order of intervention (ie, 2D → 3D vs 3D → 2D) did not result in statistically significant differences in postevaluation scores. In regard to the secondary outcome of learner preference for educational modality, radiology residents favored the 2D illustrations to understand anatomic relationships, while otolaryngology residents preferred the 3D model to be more helpful in surgical planning (P = .0075).

CONCLUSION

There is no difference between 2D-illustrated and 3D-printed International Frontal Sinus Anatomy Classification anatomic models in overall educational outcome, despite the preference of learners. Together, these models can be used as helpful tools in frontal sinus education for otolaryngology and radiology trainees.

Construct validity of a low-cost medium-fidelity endoscopic sinus surgery simulation model

OBJECTIVE

Assess construct validity of a low-cost medium-fidelity silicone injection molded model task trainer for endoscopic sinus surgery (ESS) training.

METHODS

Fellowship-trained rhinologists, otolaryngology attendings, and otolaryngology residents at various levels of training performed sinus endoscopy and seven procedures on the model. Construct validity was evaluated by comparing novice to various levels of experienced performance using a validated checklist.

RESULTS

Thirty-two subjects participated in this study. Otolaryngology attendings and postgraduate year (PGY) 3 to 5 otolaryngology residents significantly outperformed PGY 1 to 2 otolaryngology residents on most tasks in the task-specific checklist.

CONCLUSIONS

This study demonstrated the construct validity of the low-cost medium-fidelity ESS model.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1505-1509, 2019.

[The rhinological simulator: the upgrade and validation study with the evaluation of the effectiveness of its application]

The objective of the present study was to upgrade the rhinological simulator employed as a tool for the teaching of the basic technical skills in endoscopic sinus surgery (ESS). The new ESS simulator providing a model of the nasal cavity consists of the replaceable cylinders and the adaptable table stand. It includes a set of 3D printed nasal models. Each of them is the elliptical tube of a specific size. The participants of the study performed different tasks depending on the structural properties of the tubes. A wide variety of surgical instruments and esndoscopes could be fitted to the simulator. 16 otorhinolaryngologists having no previous experience with ESS were recruited into the study to evaluate the effectiveness of the training procedures. After a brief tutorial, the participants practiced an one hour-long exercise per day during 5 days. The pre-training and post-training performances were videotaped. The task-performance time and the number of technical errors made by the operators were estimated immediately before and after the training session. To assess the subjective attitudes of the operators toward the new technology, the participants of the study were asked to complete the model questionnaire soon after the termination of the training course. The questionnaire contained 34 items. The correctness of the answers was assessed based on the 5-point Likert scale, with score 1 meaning 'totally disagree' and score 5 - 'totally agree'. The statistically significant reduction of the performance time and the number of technical mistakes was documented within the first 5 hours after the onset of teaching (p<0.05) which suggests the effectiveness of the training procedures. The questionnaire study has demonstrated the positive attitude of the trainees toward the proposed technology. The average score based on the Likert scale was higher than 3 for all kinds of questions. It is concluded that the results of this study give evidence of the positive assessment of the upgraded rhinological simulator as an effective tool for the teaching of the basic skills necessary to operate various surgical instruments and endoscopes by the novice surgeons in the field of endoscopic sinus surgery .

Teaching Residents Frontal Sinus Anatomy Using a Novel 3-Dimensional Conceptualization Planning Software-Based Module

BACKGROUND

The Frontal Sinus Masterclass (FSMC) is an effective method for teaching frontal sinus anatomy. A third party developed new software using the same 3-dimensional building block concept. The authors sought to determine whether the use of the software for the educational module yielded similar results to the original FSMC, which used wooden blocks.

METHODS

The study was performed at a sinus course for residents. A precourse test assessed the ability to decipher frontal sinus anatomy prior to the course. Computed tomography (CT) scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy using the new software. Subsequently, the course instructor explained the anatomy and showed a short corresponding surgical video of the frontal sinusotomy. Cases progressed in anatomical difficulty and inflammatory load. A postcourse test determined knowledge after the course.

RESULTS

In sum, 50 residents completed the pre- and postcourse tests. Overall scores increased from 60.5% to 65.2% ( P = .004). Subanalysis also demonstrated improved ability to locate the frontal drainage pathway from 32.5% to 46% ( P = .011) and label the frontal recess cell structures from 64% to 67.6% ( P = .045).

CONCLUSION

There is minimal literature on proven methods for teaching frontal sinus anatomy. Objectively, participants of the modified FSMC simulation training using new software improved their ability to recognize cells of the frontal recess on CT scans. They especially exhibited better localization of the frontal sinus drainage pathway. Subjectively, participants reported benefit from the course and felt they would be better surgeons.

Intraoperative Functional Endoscopic Sinus Surgery Training: Efficient Teaching Techniques-A New Method

Introduction:

Functional endoscopic sinus surgery is a complex procedure used by otorhinolaryngologists to treat a host of nasal sinus pathologies. Due to the involved nasal anatomy and the nature of the procedure, teaching residents to use an endoscope is challenging. Simulation labs have been helpful but intraoperative instruction can still present difficulty in communication between resident and attending physicians during the teaching process. The purpose of this is to hypothesize a method of teaching intraoperatively that can be used supplemental to or independently of virtual reality teaching.

Method:

Literature review to determine current intraoperative verbal teaching methods used by surgeons was performed. Review was also performed on the effects of simulation techniques in preparing residents for the operating room. Although this was not a systematic review including statistical analysis, a gap was found in the literature on how residents can be efficiently taught intraoperatively to navigate an endoscope while maintaining patient safety. A novel and inexpensive method has been devised as a possible teaching method.

Conclusions:

Extensive literature is not available in intraoperative teaching techniques. It is therefore uncertain whether such a method has been used before. Further study, possibly in the form of surveys and intraoperative trials, must be done to determine the effectiveness of this mechanism.

A systematic review of validated sinus surgery simulators

BACKGROUND

Simulation provides a safe and effective opportunity to develop surgical skills. A variety of endoscopic sinus surgery (ESS) simulators has been described in the literature. Validation of these simulators allows for effective utilisation in training.

OBJECTIVE OF REVIEW

To conduct a systematic review of the published literature to analyse the evidence for validated ESS simulation.

SEARCH STRATEGY

Pubmed, Embase, Cochrane and Cinahl were searched from inception of the databases to 11 January 2017.

EVALUATION METHOD

Twelve thousand five hundred and sixteen articles were retrieved of which 10 112 were screened following the removal of duplicates. Thirty-eight full-text articles were reviewed after meeting search criteria. Evidence of face, content, construct, discriminant and predictive validity was extracted.

RESULTS

Twenty articles were included in the analysis describing 12 ESS simulators. Eleven of these simulators had undergone validation: 3 virtual reality, 7 physical bench models and 1 cadaveric simulator. Seven of the simulators were shown to have face validity, 7 had construct validity and 1 had predictive validity. None of the simulators demonstrated discriminate validity.

CONCLUSION

This systematic review demonstrates that a number of ESS simulators have been comprehensively validated. Many of the validation processes, however, lack standardisation in outcome reporting, thus limiting a meta-analysis comparison between simulators.

Teaching frontal sinus anatomy using the frontal sinus masterclass 3- D conceptualization model

OBJECTIVE

Frontal sinus anatomy is complex and often is a difficult subject to both teach and learn. The traditional surgical dogma of "see one, do one, teach one" is impractical and dangerous in the frontal sinus. Based on the building block three-dimensional conceptualization module, the Frontal Sinus Masterclass (FSMC) was created to teach this anatomy.

METHODS

Study was performed at two academic centers among second- to fifth-year otolaryngology residents. A pretest assessed knowledge prior to the course. Computed tomography scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy. Subsequently, the course instructor explained the anatomy using the building block method and showed a short video of the surgical dissection, pointing out relevant anatomy. Cases progressed in anatomical difficulty and inflammatory load. A posttest determined knowledge after the course.

RESULTS

Thirty of 50 participating residents completed the pre- and posttests (14 junior, 16 senior residents). Correct identification of the frontal sinus drainage pathway increased from 42% to 63% correct (P = 0.054). Anatomical assessment increased from 61% to 68% correct (P = 0.047), and overall assessment increased from 52% to 66% correct (P = 0.016).

CONCLUSION

Objectively, participants of the FSMC expanded on their ability to recognize cells of the frontal recess on CT scans. Before the class, residents could answer less than half of the answers correctly, and by the end of the class they were answering over two-thirds of these complex questions correctly. Subjectively, participants reported benefit from the course and felt they would be better surgeons.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:1294-1298, 2018.