Quantifying Intubation Forces on Incisors and Tongue Base Across Exposure Difficulty and Experience in a Simulator.

OBJECTIVE: Laryngoscopy simulators quantifying forces on critical structures in progressively challenging airways and operator expertise are lacking. We aimed to quantify laryngoscopy forces across expertise and exposure difficulty. STUDY DESIGN: Prospective observational study Setting: Tertiary care medical center Methods: Force gauges were affixed to a difficult airway mannequin to quantify teeth and tongue forces across increasingly challenging airway exposure. Medical students (n=10), residents (n=11), and otolaryngology staff (n=10) performed direct laryngoscopy using a Miller size 3 laryngoscope with 1) normal neck/jaw mobility, 2) restricted neck extension, 3) restricted jaw opening, and 4) restricted neck/jaw mobility. Incisor and tongue pounds of force (lbf) were continuously measured. RESULTS: As the difficulty setting increased, forces exerted by the students, residents, and staff on the incisors and tongue base increased (p=0.01). Between normal and maximally restricted settings, force delivered to the incisors increased by 6.95 lbf (standard error (SE) 1.29), 5.93 lbf (SE 0.98), and 5.94 lbf (SE 0.70) for the students, residents, and staff, respectively. At the tongue base, force increased by 0.37 lbf (SE 0.18), 0.46 lbf (SE 0.14), and 0.73 lbf (SE 0.15) for the students, residents, and staff, respectively. Esophageal intubations occurred in 50% of the students, 23% of the residents, and 45% of the otolaryngology staff at maximal difficulty, with none at the easiest setting (p=0.33). Compared to the residents, the staff applied significantly increased pressure on the tongue base during laryngoscopy (p=0.02). CONCLUSION: Forces exerted on the incisors and tongue base varied across exposure difficulty and expertise levels, suggesting that they may be useful markers for training and competence assessment.

The Case Against Stapedectomy as a Core Competency for General Practice: A Study of Care Patterns in the Department of Defense.

OBJECTIVE: Stapedectomy remains a key indicator case reportable to the Accreditation Council of Graduate Medical Education despite the decline in the incidence of otosclerosis over the last half century. This study compared the rates of stapedectomy performed by otolaryngologists at academic and nonacademic centers. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral academic centers, nonacademic centers, and civilian purchased-care across the Department of Defense between 2015 and 2020. PATIENTS: Department of Defense beneficiaries with otosclerosis near a military treatment facility with an otolaryngologist. INTERVENTIONS: Stapedectomy (Current Procedural Terminology codes 69,660, 69,661, and 69,662). MAIN OUTCOME MEASURES: Number of stapedectomies performed by setting. RESULTS: From 2015 to 2020, 426 stapedectomies were performed at or near a military treatment facility with an otolaryngologist (274 directly by military otolaryngologists, 152 by community providers). Military providers performed 94% of stapedectomies at or near military academic centers, versus only 30% at or near nonacademic centers ( p < 0.0001). Among the 60 stapedectomies performed at nonacademic centers, only 30 were performed by general otolaryngologists (7% of all stapedectomies performed; 11% of procedures by military providers) while the rest were performed by fellowship-trained otologist or neurotologist. CONCLUSIONS: Low stapes surgical volume by military general otolaryngologists reinforces recent epidemiologic trends and suggests that few general otolaryngologists graduate residency with sufficient competency to pursue independently performing stapedectomy or have difficulty maintaining competency after graduation.

Asynchronous learning among otolaryngology residents in the United States.

OBJECTIVE: Otolaryngology resident learning has historically relied on didactic lectures, textbook reading, and practical hands-on patient care. However, evidence suggests that an increasing proportion of residents in other specialties are deviating from this paradigm. This work aims to characterize otolaryngology residents' current asynchronous learning practices (i.e., personal learning outside of didactics and patient care). METHODS: A thirteen-question survey of otolaryngology residents in the United States was performed from 10/1/2020-12/1/2020 assessing demographics, educational resource utilization, and educational resource preference. RESULTS: Nearly all (99 %) respondents reported engaging with educational materials outside of didactics and case prep. Textbook reading comprised 27 % of residents' total study time, with additional time split between board-review book reading (20 %), searching the web (18 %), watching online videos (15 %), and listening to podcasts (10 %). Residents' highest ranked resources were videos, board-review books, textbooks, podcasts, and recorded lectures. Among electronic and multimedia resources, more than half of residents used the following resources: Iowa Head and Neck Protocols (91 %), Board Vitals (75 %), UpToDate (60 %), YouTube (57 %), Google (56 %), and Headmirror (54 %). CONCLUSION: Current otolaryngology resident learning involves substantial use of asynchronous learning, including videos, web-based learning, and podcasts, which currently outpace traditional textbook- and didactic-based education. This underscores the need to consider a paradigm shift within academic otolaryngology education away from textbooks and other tradition media to the generation of high-quality multimedia resources for resident learning.

Determining the Prognosis of Bell's Palsy Based on Severity at Presentation and Electroneuronography.

OBJECTIVE: To examine the demographics of Bell's palsy and determine how House-Brackmann (HB) grade at nadir and electroneuronography (ENoG) results correlate with HB grade after recovery and development of synkinesis. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care military medical center. METHODS: Patients with acute Bell's palsy and adequate follow-up, defined as 6 months or return to HB grade I function, were included. Demographic information, HB scores at nadir and recovery, and ENoG results were collected. RESULTS: A total of 112 patient records were analyzed. Ages ranged from 8 to 87 years with peaks at 21 to 25 and 61 to 65 years. Among patients, 16.3% reached a nadir at HB II, 41.9% at HB III, 5.4% at HB IV, 16.3% at HB V, and 20.1% at HB VI. The overall recovery rate was 73.2% to HB I function, 17.0% to HB II, and 9.8% to HB III. The chance of recovery to HB I decreased as the severity of paralysis increased (rs = -1.0, P < .0001). Mean time to recovery to HB I was 6 weeks. Greater degeneration on ENoG suggested worse recovery (rs = 0.62, P = .01). Patients with HB V and VI were most likely to develop synkinesis. CONCLUSION: More severe paralysis increased the chance of recovery to HB II or III function. The granularity of this study provides prognostic insights that may inform the counseling of patients with Bell's palsy with respect to prognosis and recovery timeline.