A three-dimensional printed myringotomy, tympanostomy and ventilation tube placement simulator.

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.

Investigating the learning curve in endoscopic compared to microscopic myringotomy and ventilation tube insertion.

OBJECTIVE: Rate of learning is often cited as a deterrent in the use of endoscopic ear surgery. This study investigated the learning curves of novice surgeons performing simulated ear surgery using either an endoscope or a microscope. METHODS: A prospective multi-site clinical research study was conducted. Seventy-two medical students were randomly allocated to the endoscope or microscope group, and performed 10 myringotomy and ventilation tube insertions. Trial times were used to produce learning curves. From these, slope (learning rate) and asymptote (optimal proficiency) were ascertained. RESULTS: There was no significant difference between the learning curves (p = 0.41). The learning rate value was 68.62 for the microscope group and 78.71 for the endoscope group. The optimal proficiency (seconds) was 32.83 for the microscope group and 27.87 for the endoscope group. CONCLUSION: The absence of a significant difference shows that the learning rates of each technique are statistically indistinguishable. This suggests that surgeons are not justified when citing 'steep learning curve' in arguments against the use of endoscopes in middle-ear surgery.

Tympanostomy Tubes-A Visual Guide for the Young Otolaryngologist.

OBJECTIVES: To illustrate some of the common dilemmas in tympanostomy tube care and describe time-tested ways to address them. METHODS: Computerized literature review. RESULTS: Issues including the correct diagnosis of recurrent acute otitis media, tympanostomy tube types and techniques for tube placement, management of tube clogging and otorrhea, and methods for tube removal and patching are illustrated. CONCLUSIONS: Tympanostomy tube placement is the most common surgery performed in children requiring general anesthesia. While some elements of tympanostomy tube care have been addressed in clinical studies, much of clinical practice is guided by shared experience.

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.

A Surgical Simulator for Tympanostomy Tube Insertion Incorporating Capacitive Sensing Technology to Track Instrument Placement.

We describe a device engineered for realistic simulation of myringotomy and tympanostomy tube insertion that tracks instrument placement and objectively measures operator proficiency. A 3-dimensional computer model of the external ear and cartilaginous external auditory canal was created from a normal maxillofacial computed tomography scan, and models for the bony external auditory canal and tympanic cavity were created with computer-aided design software. Physical models were 3-dimensionally printed from the computer reconstructions. The external auditory canal and tympanic cavity surfaces were coated with conductive material and wired to a capacitive sensor interface. A programmable microcontroller with custom embedded software completed the system. Construct validation was completed by comparing the run times and total sensor contact times of otolaryngology faculty and residents.

Low cost, easy-to-replicate myringotomy tube insertion simulation model.

INTRODUCTION: Simulation is an established part of modern surgical education. Several training centers have proposed different simulation models for myringotomy tube (MT) placement and validated their effectiveness in medical student and resident training. None is widely used. Early models were simple tubes that lacked important microsurgical elements. Newer simulators are more comprehensive, but are difficult and expensive to build. We present a MT placement simulator that is low cost, easy to construct with basic power tools and allows for acquisition of the most necessary MT placement skills. METHODS: The model incudes a rotating spherical "head", a 4 mm oval speculum, a drilled-out working shaft similar in size to the external auditory canal, and a realistic paper tympanic membrane target, set at an anatomically correct angle. To evaluate the model's efficacy, we assessed the performance of 10 surgically naïve medical student volunteers before training and after 30 min of instruction with the model. Their speed was recorded and operative performance was assessed using a validated Global Rating Scale. RESULTS: After 30 min of practice on the model, there was significant improvement in MT placement skill scores and significant decrease in time for tube placement (p < 0.05). CONCLUSION: This MT placement simulation model is inexpensive and easy to build. Unlike existing planar models, it simulates patient head orientation, and requires realistic hand positioning on a 4 mm speculum. Practice with the model for 30 min resulted in statistically significant improvement in MT placement skill scores for inexperienced student surgeons.

3D printed myringotomy and tube simulation as an introduction to otolaryngology for medical students.

OBJECTIVES: Surgical simulation models have been shown to improve surgical skill and confidence for surgical residents before real life procedures. Surgical simulators can be similarly applied in undergraduate medical education as a tool to introduce students to the field of otolaryngology. METHODS: Ear models were created using 3D printing and high-performance silicone. Twenty medical students participated in a slide presentation and a myringotomy tube simulation station, each completing a pre- and post-survey using a 5-point Likert scale. RESULTS: A previously validated 3D myringotomy simulator was used. Twenty medical student volunteers participated in the simulation including 14 first-year and 6 s-year medical students. None of the participating students reported observing myringotomy and placement of tympanostomy tubes before the session. Medical student participants rated their knowledge of the steps of the procedure and where to insert the tympanostomy tube at 2 (2 = disagree) or below with a mean of 1.35 SD = 0.47 and 1.2 SD = 0.41 respectively. At the completion of the educational session, the medical students rated their knowledge of the steps of the procedure as significantly improved at 4.45 SD = 0.6 (p = 0.00001). DISCUSSION: We found that medical students with no prior exposure to ear anatomy or surgical training were able to use the simulator as an introduction to the specialty. There was a perceived improvement in their medical knowledge and basics of a procedural skill. CONCLUSION: Medical schools can provide an inexpensive, safe, procedural practice tool using 3D printing as an introduction for students interested in surgical procedures.

Physical Models and Virtual Reality Simulators in Otolaryngology.

The increasing role of simulation in the medical education of future otolaryngologists has followed suit with other surgical disciplines. Simulators make it possible for the resident to explore and learn in a safe and less stressful environment. The various subspecialties in otolaryngology use physical simulators and virtual-reality simulators. Although physical simulators allow the operator to make direct contact with its components, virtual-reality simulators allow the operator to interact with an environment that is computer generated. This article gives an overview of the various types of physical simulators and virtual-reality simulators used in otolaryngology that have been reported in the literature.

Objective assessment of Myringotomy and tympanostomy tube insertion: A prospective single-blinded validation study.

OBJECTIVES/HYPOTHESIS: Despite the transition to competency-based education in surgery, few standardized assessment tools exist in otolaryngology training. In particular, myringotomy and tympanostomy tube insertion (M+T) is a common surgical procedure with few validated assessment tools available. Our objectives were to develop an objective structured assessment of operative skills in M+T and to provide validity evidence for the developed assessment tool within otolaryngology training. STUDY DESIGN: Prospective study involving the evaluation of an assessment tool. METHODS: Through consultation with a panel of experts in otolaryngology and medical education we developed a Task-Specific Checklist and Global Rating Scale for M+T. Postgraduate year 2 junior residents, postgraduate year 3 senior residents, and attending otolaryngologists were video recorded performing M+T at a tertiary care pediatric hospital. The videos were subsequently reviewed and independently evaluated by three blinded raters from an unaffiliated academic institution. RESULTS: The average score of junior residents, senior residents, and attending otolaryngologists using the Task-Specific Checklist was 21.7/30 (±7.1), 26.3/30 (±3.5), and 27.3/30 (±6.2), respectively (P = .04). For the Global Rating Scale, the scores for junior residents, senior residents, and attending surgeons were 27.7/50 (±11.2), 34.5/50 (±9.5), and 45.1/50 (±4.6), respectively (P < .001). The inter-rater and intrarater reliability were both above 0.88. CONCLUSIONS: The Task-Specific Checklist and Global Rating Scale for M+T appear reliable, with validity evidence supporting their use in otolaryngology training. LEVEL OF EVIDENCE: NA Laryngoscope, 126:2140-2146, 2016.

Face and content validity of a virtual-reality simulator for myringotomy with tube placement.

BACKGROUND: Myringotomy with tube insertion can be challenging for junior Otolaryngology residents as it is one of the first microscopic procedures they encounter. The Western myringotomy simulator was developed to allow trainees to practice microscope positioning, myringotomy, and tube placement. This virtual-reality simulator is viewed in stereoscopic 3D, and a haptic device is used to manipulate the digital ear model and surgical tools. OBJECTIVE: To assess the face and content validity of the Western myringotomy simulator. METHODS: The myringotomy simulator was integrated with new modules to allow speculum placement, manipulation of an operative microscope, and insertion of the ventilation tube through a deformable tympanic membrane. A questionnaire was developed in consultation with instructing surgeons. Fourteen face validity questions focused on the anatomy of the ear, simulation of the operative microscope, appearance and movement of the surgical instruments, deformation and cutting of the eardrum, and myringotomy tube insertion. Six content validity questions focused on training potential on surgical tasks such as speculum placement, microscope positioning, tool navigation, ear anatomy, myringotomy creation and tube insertion. A total of 12 participants from the Department of Otolaryngology-Head and Neck Surgery were recruited for the study. Prior to completing the questionnaire, participants were oriented to the simulator and given unlimited time to practice until they were comfortable with all of its aspects. RESULTS: Responses to 12 of the 14 questions on face validity were predominantly positive. One issue of concern was with contact modeling related to tube insertion into the eardrum, and the second was with the movement of the blade and forceps. The former could be resolved by using a higher resolution digital model for the eardrum to improve contact localization. The latter could be resolved by using a higher fidelity haptic device. With regard to content validity, 64% of the responses were positive, 21% were neutral, and 15% were negative. CONCLUSIONS: The Western myringotomy simulator appears to have sufficient face and content validity. Further development with automated metrics and skills transference testing is planned.

Detecting tympanostomy tubes from otoscopic images via offline and online training.

Tympanostomy tube placement has been commonly used nowadays as a surgical treatment for otitis media. Following the placement, regular scheduled follow-ups for checking the status of the tympanostomy tubes are important during the treatment. The complexity of performing the follow up care mainly lies on identifying the presence and patency of the tympanostomy tube. An automated tube detection program will largely reduce the care costs and enhance the clinical efficiency of the ear nose and throat specialists and general practitioners. In this paper, we develop a computer vision system that is able to automatically detect a tympanostomy tube in an otoscopic image of the ear drum. The system comprises an offline classifier training process followed by a real-time refinement stage performed at the point of care. The offline training process constructs a three-layer cascaded classifier with each layer reflecting specific characteristics of the tube. The real-time refinement process enables the end users to interact and adjust the system over time based on their otoscopic images and patient care. The support vector machine (SVM) algorithm has been applied to train all of the classifiers. Empirical evaluation of the proposed system on both high quality hospital images and low quality internet images demonstrates the effectiveness of the system. The offline classifier trained using 215 images could achieve a 90% accuracy in terms of classifying otoscopic images with and without a tympanostomy tube, and then the real-time refinement process could improve the classification accuracy by 3-5% based on additional 20 images.

[Outpatient Surgery in German ENT in Teaching Hospitals--Economic Nonsense?]. / Ambulante Operationen in HNO-Ausbildungskliniken - ökonomischer (Un)sinn?

INTRODUCTION: There is an ever-increasing demand to increase efficiency and decrease costs in health care. This leads to an growing number of outpatient surgeries which are less cost effective. Especially in the setting of university teaching hospitals, this may lead to both an undersupply of qualified physicians, as well as to a worsening of clinical training of residents. In order to quantify a possible undersupply and estimate the expense of teaching residents, the time for medical procedures needs to be quantified and compared between board-certified physicians and residents. This was the aim of the current study. MATERIAL AND METHODS: All outpatient adenotomies of children with or without paracentesis or tympanic drainage insertion performed in 2012 in 2 ENT teaching hospitals were analyzed. The length of the surgical procedure as well as the level of training of the surgeon was analyzed. Operating times of residents in training were analyzed stratified by training level and then compared to operation times of board-certified ENT surgeons. RESULTS: 255 procedures were analyzed. Significant differences of the mean operation time could be identified depending on the level of training of residents compared to board-certified ENT surgeons for all investigated training levels. E. g. 1(st) year residents' surgeries required 2.4 times more time than those of board-certified ENT surgeons. CONCLUSION: Based on an analysis of outpatient ENT-surgical procedures it becomes apparent that due to the extended operating times of residents in training outpatient surgery is by far less cost-effective than by board-certified physicians. To cope with the demand of teaching residents for their clinical training, more resources are necessary in the setting of teaching hospitals.

The Vigo grommet trainer.

INTRODUCTION: Transtympanic grommet placement is perhaps the most common otologic outpatient procedure and is the junior resident's first step in otologic surgery. Drain placement requires a high level of skill and only after painstaking practice, will the young physician be prepared to perform the procedure. TECHNICAL NOTE: We describe a home-made training model for grommet placement, consisting of a wooden base holding a syringe, with a sheet of latex simulating the tympanic membrane. RESULTS: The model is cheap and easy to build. It allows ear tube (grommet) placement to be simulated in a practical and risk-free manner. The technique is reproducible, allowing the young physician to develop his or her skills without patient involvement. CONCLUSION: Although a simulator cannot perfectly replicate surgery, the Vigo grommet trainer is an excellent tool to provide valuable practice in acquiring and developing the skills needed to perform drain placement in the operating theater.

An anatomically sound surgical simulation model for myringotomy and tympanostomy tube insertion.

OBJECTIVE: Myringotomy and tympanostomy tube insertion (MT) is a common surgical procedure. Although surgical simulation has proven to be an effective training tool, an anatomically sound simulation model for MT is lacking. We developed such a model and assessed its impact on the operating room performance of senior medical students. STUDY DESIGN: Prospective randomized trial. METHODS: A randomized single-blind controlled study of simulation training with the MT model versus no simulation training. Each participant was randomized to either the simulation model group or control group, after performing an initial MT procedure. Within two weeks of the first procedure, the students performed a second MT. All procedures were performed on real patients and rated with a Global Rating Scale by two attending otolaryngologists. Time to complete the MT was also recorded. RESULTS: Twenty-four senior medical students were enrolled. Control and intervention groups did not differ at baseline on their Global Rating Scale score or time to complete the MT procedure. Following simulation training, the study group received significantly higher scores (P=.005) and performed the MT procedure in significantly less time (P=.034). The control group did not improve their performance scores (P>.05) or the time to complete the procedure (P>.05). CONCLUSION: Our surgical simulation model shows promise for being a valuable teaching tool for MT for senior medical students. Such anatomically appropriate physical simulators may benefit teaching of junior trainees.

YouTube as an information source for pediatric adenotonsillectomy and ear tube surgery.

OBJECTIVES: Assess the overall quality of information on adenotonsillectomy and ear tube surgery presented on YouTube (www.youtube.com) from the perspective of a parent or patient searching for information on surgery. METHODS: The YouTube website was systematically searched on select dates with a formal search strategy to identify videos pertaining to pediatric adenotonsillectomy and ear tube surgery. Only videos with at least 5 (ear tube surgery) or 10 (adenotonsillectomy) views per day were included. Each video was viewed and scored by two independent scorers. Videos were categorized by goal and scored for video/audio quality, accuracy, comprehensiveness, and procedure-specific content. STUDY DESIGN: Cross-sectional study. SETTING: Public domain website. RESULTS: Fifty-five videos were scored for adenotonsillectomy and forty-seven for ear tube surgery. The most common category was educational (65.3%) followed by testimonial (28.4%), and news program (9.8%). Testimonials were more common for adenotonsillectomy than ear tube surgery (41.8% vs. 12.8%, p=0.001). Testimonials had a significantly lower mean accuracy (2.23 vs. 2.62, p=0.02), comprehensiveness (1.71 vs. 2.22, p=0.007), and TA specific content (0.64 vs. 1.69, p=0.001) score than educational type videos. Only six videos (5.9%) received high scores in both video/audio quality and accuracy/comprehensiveness of content. There was no significant association between the accuracy and comprehensive score and views, posted "likes", posted "dislikes", and likes/dislikes ratio. There was an association between "likes" and mean video quality (Spearman's rho=0.262, p=0.008). CONCLUSION: Parents/patients searching YouTube for information on pediatric adenotonsillectomy and ear tube surgery will generally encounter low quality information with testimonials being common but of significantly lower quality. Viewer perceived quality ("likes") did not correlate to formally scored content quality.

Virtual reality myringotomy simulation with real-time deformation: development and validity testing.

OBJECTIVES/HYPOTHESIS: Surgical simulation is becoming an increasingly common training tool in residency programs. The first objective was to implement real-time soft-tissue deformation and cutting into a virtual reality myringotomy simulator. The second objective was to test the various implemented incision algorithms to determine which most accurately represents the tympanic membrane during myringotomy. STUDY DESIGN: Descriptive and face-validity testing. METHODS: A deformable tympanic membrane was developed, and three soft-tissue cutting algorithms were successfully implemented into the virtual reality myringotomy simulator. The algorithms included element removal, direction prediction, and Delaunay cutting. The simulator was stable and capable of running in real time on inexpensive hardware. A face-validity study was then carried out using a validated questionnaire given to eight otolaryngologists and four senior otolaryngology residents. Each participant was given an adaptation period on the simulator, was blinded to the algorithm being used, and was presented the three algorithms in a randomized order. RESULTS: A virtual reality myringotomy simulator with real-time soft-tissue deformation and cutting was successfully developed. The simulator was stable, ran in real time on inexpensive hardware, and incorporated haptic feedback and stereoscopic vision. The Delaunay cutting algorithm was found to be the most realistic algorithm representing the incision during myringotomy (P < .05). The Likert and visual analog scales had strong correlations, suggesting good internal reliability. CONCLUSIONS: The first virtual reality myringotomy simulator is being developed and now integrates a real-time deformable tympanic membrane that appears to have face validity. Further development and validation studies are necessary before the simulator can be studied with respect to training efficacy and clinical impact.

A model for training and evaluation of myringotomy and tube placement skills.

OBJECTIVES/HYPOTHESIS: Simulation is emerging as a mandatory component of surgical training and a means of demonstrating surgical competency. We designed a cost-effective, low-fidelity model to further acquisition of technical skills related to myringotomy and ventilation tube insertion (M&T). The purpose of the study was to examine the skills trainer as a method of assessment to evaluate competency, timeliness, and procedure confidence in junior residents. STUDY DESIGN: Prospective, randomized. METHODS: A simplistic M&T skills box was developed. General surgery interns (n = 20) with no prior procedure training were randomized to receive either didactic instruction or skills training using the model. One hour of lecture or technical skills training was provided to each group. A blinded examiner evaluated the subjects in both groups before and after training. Performance was measured using a global rating scale, task-specific checklist, and time-to-completion. Pre- and postsession questionnaires assessed procedure confidence. RESULTS: Analysis revealed a trend toward improvement in global rating scores between groups. There was a statistically significant difference in time improvement between groups (P = .0211). The skills lab group felt they could perform the procedure faster and with improved abilities, as compared to the didactic group (P = .0069 and 0.0007, respectively). CONCLUSIONS: Junior surgical residents performed an M&T procedure using a novel, low-cost model. This study demonstrated the skills lab's positive effect on training as measured by global rating scale, time-to-completion, and overall resident confidence. We anticipate its application to be valuable not only in training residents but also in assessing competency.