Does microscopic experience influence learning curve in endoscopic ear surgery? A multicentric study.

OBJECTIVE: The aim of the present study was to illustrate the learning curve of endoscopic type-1 tympanoplasty comparing experts in microscopic otology versus neophyte surgeons. METHODS: Eight ear surgeons, from tertiary referral centers, who had performed at least 30 endoscopic type 1 tympanoplasties were included in the study. Demographic data and medical records regarding the first 30 endoscopic type-1 tympanoplasties were retrospectively collected by each surgeon. A 14-questions survey focused on subjective aspects of the learning curve was administered. Surgeons were divided in two groups: one with previous experience in microscopic ear surgery (group 1) and one with no previous experience in ear surgery (group 2). The learning curve of endoscopic type 1 tympanoplasty was compared between the groups. RESULTS: Mean surgical time was 89.2 min in group 1 vs. 79.5 min in group 2 (p < 0.01). When divided in 5 surgeries-steps, the only significant difference was appreciated in the first 5 surgeries with a longer mean time in group 1 vs. group 2 (+28.4 min; p < 0.05). CONCLUSIONS: Surgeon's previous experience may influence the EES learning curve. Our results show that the first 5 surgical procedures are more challenging for surgeons experienced in microscopic surgery, subsequently the curve progression improves sharply and appears reversing the initial trend by the end of the 30 surgeries.

A comparison of endoscopic and microscopic inlay butterfly cartilage tympanoplasties and their educational utility.

OBJECTIVES: Inlay butterfly cartilage tympanoplasty (IBCT) is a simple grafting technique. Endoscopy facilitates visualization by eliminating blind spots. We analyzed the outcomes of IBCT using both endoscopic and microscopic approaches, and assessed how trainees perceived the educational opportunities afforded. MATERIALS AND METHODS: Sixty patients who underwent IBCT were allocated to Group I (n = 30; microscopic IBCT) and Group II (n = 30; endoscopic IBCT) by the dates of their visits. Anatomical success was defined as an intact, repaired tympanic membrane; functional success was defined as a significant decrease in the air-bone gap. Postoperative discomfort was analyzed using a visual analog scale (VAS). Thirteen trainees completed structured questionnaires exploring anatomical identification and the surgical steps. RESULTS: The surgical success rates were 96.7% in Group I and 100% in Group II. We found no between-group differences in the mean decrease in the air-bone gap or the extent of postoperative discomfort. Significant postoperative hearing improvements were evident in both groups. The mean operative time was shorter when the microscopic approach was chosen (17.7±4.53 vs. 26.13±9.94 min). The two approaches significantly differed in terms of the identification of external and middle ear anatomical features by the trainees, and their understanding of the surgical steps. CONCLUSION: Both endoscopic and microscopic IBCT were associated with good success rates. The endoscopic approach facilitates visualization, and a better understanding of the middle ear anatomy and the required surgical steps and thus is of greater educational utility.

The learning curve for endoscopic tympanoplasties: a single-institution experience, in Birmingham, UK.

OBJECTIVE: This study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery. METHODS: A retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties. RESULTS: In total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent. CONCLUSION: This study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.

Safety of tympanoplasty and ossiculoplasty performed by otorhinolaryngology trainees.

OBJECTIVE: This study aimed to examine the impact of trainee involvement in performing tympanoplasty or tympano-ossiculoplasty on outcomes. METHODS: A retrospective analysis was performed of a prospective database of all patients undergoing tympanoplasty and tympano-ossiculoplasty in a single centre during a three-year period. Patients were divided into three primary surgeon groups: consultants, fellows and residents. The outcomes of operative time, surgical complications, length of hospital stay, and air-bone gap improvement were compared among the groups. RESULTS: The study included 398 tympanoplasty and tympano-ossiculoplasty surgical procedures, 71 per cent of which were performed by junior trainees (residents). The junior trainee group was associated with a significantly longer surgical time, without adverse impact on outcomes. CONCLUSION: Trainee participation in tympanoplasty and tympano-ossiculoplasty surgery was associated with longer surgical time, but did not negatively affect the peri-operative course or hearing outcome. Therefore, resident involvement in these types of surgery is safe.

Outcomes of Adopting Endoscopic Tympanoplasty in an Academic Teaching Hospital.

OBJECTIVES: To compare the outcomes of endoscopic versus microscopic tympanoplasty during the initial period of a surgeon adopting the new endoscopic technique and teaching the surgical approach to residents assisting in surgery. METHODS: Retrospective medical chart review of 60 consecutive operations for repair of isolated tympanic membrane perforations from 2011 to 2016 performed by a single surgeon assisted by residents in an academic teaching hospital. The outcomes of 20 ears repaired microscopically before the senior author adopted endoscopic ear surgery (Group A) were compared with the outcomes of the first 20 ears that were attempted with endoscopic surgery (Group B) and the next 20 ears performed endoscopically (Group C). Sixty ear operations were performed on 52 patients as 8 patients had bilateral ear surgery. RESULTS: The tympanic membrane closure rate was 80% for Group A, 80% for Group B, and 95% for Group C. Mean air-bone gap improvement was 12.8 dB in Group A, 8.3 dB in Group B, and 12.1 dB in Group C. Mean duration of surgery was 99.2 minutes in Group A, 91.3 minutes in Group B, and 90.5 minutes in Group C. In Group B, 20% of the ears (4/20) were converted to a microscopic approach; in Group C, none required conversion. CONCLUSIONS: Maintenance of good outcomes and similar results can be maintained during a surgeon's transition to adopting endoscopic tympanoplasty and teaching it to residents.

Implementation and results of a surgical training programme for chronic suppurative otitis media in Cambodia.

BACKGROUND: Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy. METHODS: A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported. RESULTS: A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes. CONCLUSION: The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

Impact of Resident Participation on Operative Time and Outcomes in Otologic Surgery.

Objectives To describe the impact of resident involvement in tympanoplasty on operative time and surgical complication rates. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods Current Procedural Terminology codes were used to identify patients in the 2011-2014 public use files of the American College of Surgeons National Surgical Quality Improvement Program who underwent a tympanoplasty or tympanomastoidectomy. Cases were included if the database indicated whether the operating room was staffed with an attending alone or an attending with residents. Categorical and continuous variables were compared with chi-square, Fisher's exact, and Mann-Whitney U tests. Generalized linear models with a log-link and gamma distribution were used to examine the factors affecting operative time. Results Overall, 1045 cases met our study criteria (tympanoplasty, n = 797; tympanomastoidectomy, n = 248). Resident involvement increased mean operative time for tympanoplasties by 46% (107 vs 73 minutes, P < .001) and tympanomastoidectomies by 49% (175 vs 117 minutes, P < .001). While controlling for confounding factors, the variable with the largest impact on operative time was resident involvement. There were no significant differences observed in the rate of surgical complications between attending-alone and attending-resident cases. Conclusion Resident involvement in tympanoplasty and tympanomastoidectomy did not affect the surgical complication rate. Resident involvement increased operative time for tympanoplasties and tympanomastoidectomies; however, the specific reasons for the increase are not explained by the available data.

Endoscopic tympanoplasty: learning curve for a surgeon already trained in microscopic tympanoplasty.

The aim of this study was to evaluate the learning curve of endoscopic tympanoplasty for a surgeon already trained in microscopic tympanoplasty. We analyzed the clinical records of 81 patients who underwent transcanal endoscopic type 1 tympanoplasty and 30 control patients who underwent microscopic tympanoplasty between 2013 and 2015 in a tertiary hospital. All operations were performed by a single surgeon already trained in microscopic tympanoplasty. Patients were divided into four groups according to the date of surgery chronologically (group 1 early stage, group 2 intermediate stage, group 3 advanced stage and group 4 control). We evaluated the four groups according to surgery duration, audiometric results, and graft intake success. The operation duration shortened in accordance with the surgeon's experience and there were two subsequent steps during the learning curve: first, after 30 procedures; and second, after 60 procedures. The mean operation duration was 88.60 ± 21.10 min in group 1, and 62.00 ± 12.48 min in group 2. After 60 procedures, the mean operation duration was 43.81 ± 8.34 min in group 3. In the control group, the microscopic tympanoplasty duration was 69.93 ± 12.56 min. When we compared audiologic results (air conduction, bone conduction, and air-bone gap) and graft intake success rates, there were no significant differences between groups. Endoscopic tympanoplasty is a minimally invasive and effective technique. Mastering endoscopic tympanoplasty takes approximately 60 operations for a surgeon already trained in microscopic tympanoplasty. Graft intake success rates and hearing results are stable during the learning curve.

Microsurgical skills training with a new tympanoplasty model: learning curve and motivational impact.

OBJECTIVES: To evaluate the microsurgical skills training on a tympanoplasty model with regard to the learning curve and the participants' motivation for a surgical specialty. STUDY DESIGN: Randomized controlled prospective study. SETTING: Department of Otolaryngology, Head and Neck Surgery, Medical Campus Carl Gustav Carus at the Technische Universität Dresden, Germany. SUBJECTS: Thirty randomly chosen fifth-year medical students divided into 2 groups. INTERVENTIONS: Group 2 (n = 16) had to perform an ossicular and tympanic membrane reconstruction on a tympanoplasty model on Days 1, 7, 14, and 21 and Group 1 (n = 14) on Days 1 and 21, while observing the procedure at Days 7 and 14. Six otosurgeons served as gold standard. Attempts and time of prosthesis placement and time for tympanic membrane reconstruction were recorded. Tremor frequency and amplitude were obtained at the same time points. An adjusted study interest questionnaire was used to assess students' motivation. RESULTS: Students in Group 2 showed a significant improvement in all reconstruction parameters over the study period compared with both, baseline measurement on first day and Group 1. However, the obtained learning curve did not reach the experts level. Tremor indices and students' motivation showed no correlation with the reconstruction parameters, whereas the training itself had a positive impact on students' interest in the surgical specialty. CONCLUSION: Training with the tympanoplasty model is suitable to acquire first microsurgical motor skills in otolaryngology and to arouse students' interest in the surgical field and otorhinolaryngology.

Tympanoplasty: is exposure adequate for otorhinolaryngology residents in Nigeria?

AIMS AND OBJECTIVES: This study is aimed at identifying the extent of exposure of residents to tympanoplasty procedure during their training in Otorhinolaryngology (ORL) and proffer ways of improving such exposure. PATIENTS AND METHODS: Questionnaire assessing the exposure to tympanoplasty procedures was administered to ORL residents who were randomly selected from six teaching hospitals in Nigeria. RESULTS: Twenty five residents from six teaching hospitals answered the questionnaire. The residents had varied duration of training from 11 months to 6years. Forty eight per cent (12 out of 25) of the residents had exposure to tympanoplasty, while only twenty per cent (5) had assisted at tympanoplasty procedure, and none had ever performed the procedure. The causes of poor practical exposure to tympanoplasty were identified as absence of necessary equipment and lack of expertise in the training centres. Ninety-two (23) per cent rated the low exposure to tympanoplasty procedure as moderate to gross omission in the ORL fellowship training. Eighty seven per cent of the respondents advocated provision of equipment and posting to centres with facilities as a way of solving this problem. All the residents indicated willingness to train in tympanoplasty procedures in Nigeria or overseas. CONCLUSION: ORL residents are poorly exposed to tympanoplasty procedures in Nigeria. The need to train residents in this procedure in centres with facilities for better ORL services is hereby stressed.

[Evaluation of the Dresden Tympanoplasty Model (DTM)]. / Evaluation des Dresdner Tympanoplastik Modells (DTM).

The training of microsurgical motor skills is essentiell for surgical education if the interests of the patient are to be safeguarded. In otosurgery the complex anatomy of the temporal bone and variations necessitate a special training before performing surgery on a patient. We therefore developed and evaluated a simplified middle ear model for acquiring first microsurgical skills in tympanoplasty.The simplified tympanoplasty model consists of the outer ear canal and a tympanic cavity. A stapes model is placed in projection of the upper posterior tympanic membrane quadrant at the medial wall of the simulated tympanic cavity. To imitate the annular ligament flexibility the stapes is fixed on a soft plastic pad. 41 subjects evaluated the model´s anatomical analogy, the comparability to the real surgical situation and the general model properties the using a special questionnaire.The tympanoplasty model was very well evaluated by all participants. It is a reasonably priced model and a useful tool in microsurgical skills training. Thereby, it closes the gap between theoretical training and real operation conditions.

The costs and quality of operative training for residents in tympanoplasty type I.

CONCLUSION: A teaching hospital would incur more operation room costs on training surgical residents. OBJECTIVE: To evaluate the increased operation time and the increased operation room costs of operations performed by surgical residents. As a model we used a very common surgical otology procedure -- tympanoplasty type I. SUBJECTS AND METHODS: From January 1, 2004 to December 31, 2004, we included in this study 100 patients who received tympanoplasty type I in Taipei Veterans General Hospital. Fifty-six procedures were performed by a single board-certified surgeon and 44 procedures were performed by residents. We analyzed the operation time and surgical outcomes in these two groups of patients. The operation room cost per minute was obtained by dividing the total operation room expenses by total operation time in the year 2004. RESULTS: The average operation time of residents was 116.47 min, which was significantly longer (p<0.0001) than that of the board-certified surgeon (average 81.07 min). It cost USD $40.36 more for each operation performed by residents in terms of operation room costs. The surgical success rate of residents was 81.82%, which was significantly lower (p=0.016) than that of the board-certified surgeon (96.43%).

Learning curve of tympanoplasty type I.

OBJECTIVE: To determine the time required to train a surgeon to skillfully perform tympanoplasty type I. MATERIALS AND METHODS: From July 1, 2001 to December 31, 2006, 75 patients who underwent tympanoplasty type I were enrolled in this study. All of the procedures were performed by two surgeons trained in the same tertiary referral center. We stratified the patients into groups according to the surgeon level at the time of their surgery. We analyzed the operation time and surgical outcomes of these patients. RESULTS: The average operation time of resident physicians was 116.36 min, which was significantly longer (p<0.0001) than that of the attending physicians (average 83.11 min). There was no statistical difference in surgical success rate and post-operative complication between the resident year and attending year groups. We stratified the patients according to surgeon years, from year 3 to year 7. The operation time of the 4th and the 5th year surgeons was not statistically different from that of 3rd year surgeons. However, the operation time of the 6th and 7th year surgeons was statistically shorter than that of 3rd year surgeons. There was no difference on surgical success rate and complications among all year groups. CONCLUSION: A surgeon's years of experience could make the difference in terms of speed of operation. It takes 5 years for surgeons to reach a plateau in learning curve on the speed of performing tympanoplasty type I. We therefore conclude that it takes 5 years to train a surgeon for tympanoplasty type I.

[Middle ear surgery in Mongolia--first results with middle ear prostheses]. / Erste Erfahrungen mit Prothesen in der Mittelohrchirurgie in der Mongolei.

BACKGROUND: Medical care of the Mongolian population is still far behind the standard of industrialised countries. Also in the field of otorhinolaryngology there are clear deficits in regard to an adequate diagnosis and treatment of difficult cases. Microsurgery of the ear is still in the very beginning due to missing essential equipment and surgical skills of the few ORL-units that exists in the country. The integration of tympanoplastic procedures into surgical routine is the main goal of a support programme that exists between the medical faculties of the universities of Wuerzburg (Germany) and Ulan Bator (Mongolia). The aim of this work is to present the outcome of these operations in Mongolia. METHODS AND PATIENTS: As a result of the continuous education and support programme it was possible to perform 90 tympanoplastic procedures between 2005 and 2006 in the local ORL center of Ulan Bator (EMJJ-clinic). The focus of this report is on the postoperative audiological outcome following reconstruction of the ossicular chain either using autologous ossicles or middle ear prostheses. Besides, prostheses made of polyethylene or Teflon (Russian production) as well as titanium prostheses (Kurz Company, Germany) were implanted. RESULTS: The final evaluation of the audiological results was performed 6 month postoperatively. The titanium prostheses provided the most favourable hearing improvement (mean 26 dB) when compared to the other materials (polyethylene 7 dB, Teflon 18 dB), but also compared to the autologous ossicles (8,6 dB). CONCLUSIONS: The standard tympanoplastic procedures, which were developed over decades, proved to be highly reliable also in a country with reduced medical care. The hearing results obtained especially with titanium prostheses demonstrated, that this highly biocompatible alloplastic material is the most suitable and reliable for middle ear reconstruction also in a difficult surrounding.

[A new model for training in tympanoplasty]. / Entwicklung eines Tympanoplastik-Trainingsmodells.

BACKGROUND: Functional simulation of middle ear reconstruction is a valuable tools for training in otosurgery. We introduce a new experimental model which provides a direct acoustic feedback of the functional quality of ossicular chain reconstruction. METHOD: In this model the tympanic membrane and the ossicular chain have to be reconstructed for proper sound transmission to an artificial inner ear receptor. The received signal is converted into acoustic information and consecutively provided via headphone. RESULTS: Any changes in the reconstruction (e. g. tilting the prosthesis) can be experienced online and immediately optimized by the surgeon or a trainee. CONCLUSION: The experimental model can be used for demonstration and training in otosurgery. This model is also suitable for comparing measurements of transfer functions in a calibrated version and can be applied to development and critical evaluation of middle ear prostheses.

Surgical skills training in middle-ear surgery.

Until recently the practice of otological procedures on cadaver temporal bones was a common occurrence in otolaryngology departments. The difficulty in acquiring specimens has led to alternative techniques which involve artificial and computer-aided models. This article looks at the present situation in these rapidly developing areas and describes an artificial model developed by the senior author for training in middle-ear procedures.