A randomized controlled trial of nasolaryngoscopy training techniques

UK Oral and Maxillofacial Surgery Trainee Perceptions of Flexible Nasal Endoscopy

INTRODUCTION AND AIM

Flexible nasal endoscopy (FNE) is a useful adjunct in diagnosis and follow-up of oncology patients as well as in airway assessment. Proficiency in this technique is also listed as part of the Oral and Maxillofacial Surgery (OMFS) curriculum. We aimed to explore OMFS trainee perceptions of training and confidence in this technique.

MATERIALS AND METHODS

An electronic survey was undertaken of OMFS higher surgical trainees in the UK. A 10-item questionnaire was formulated using online survey software (SurveyMonkey) and distributed to Specialty Registrars in all deaneries via their regional representatives. Questions on training, exposure to and confidence in FNE were asked.

RESULTS

A total of 43 responses were received which included all grades of higher surgical trainees. A large proportion had undertaken FNE in oncology rotations (78.6%) and as part of airway assessment (85.6%). Nearly half of trainees (47.6%) were confident in diagnosing pathology using FNE although 16.6% had low levels of confidence in the technique. Only 38% had received formal training, and the majority of this training was a teaching session from a senior. A very large proportion of trainees (90.5%) feel formal training should be available in FNE and 76% would undertake a formal OMFS training course in FNE if available.

CONCLUSIONS

Trainees have high levels of exposure to FNE but variable levels of confidence in the technique. Trainees appear to receive limited formal training in the technique, and the introduction of more formalised training could be explored.

Current innovations in otolaryngology medical education in the UK: a systematic literature review

OBJECTIVE

Recent studies have indicated a lack of ENT training at the undergraduate and post-graduate levels. This study aimed to review the impact of recent educational innovations in improving ENT training for medical students and junior doctors in the UK.

METHODS

Three independent investigators conducted a literature search of published articles on ENT education. Included studies were analysed using qualitative synthesis methods.

RESULTS

An initial search yielded 2008 articles; 44 underwent full-text evaluation and 5 were included for final analysis. Most included studies demonstrated benefits for students when compared to existing teaching standards in terms of objective assessment (knowledge and skills gained) or subjective assessment (confidence and preference) following implemented educational innovations.

CONCLUSION

This study identified educational innovations developed in the past 15 years to enhance the teaching of core ENT competencies. More research is needed to establish their impact on the state of ENT medical education in the UK.

Creating a Validated Simulation Training Curriculum in Otolaryngology

Purpose of Review

Simulation-based training is an integral component of surgical training. It allows practice of technical skills within a safe environment without compromising patient safety. This article seeks to review current virtual and non-virtual reality simulation models within the literature and review their validation status.

Recent Findings

Many simulation models exist within otolaryngology and are currently being used for education. New models are also continuously being developed; however, validity should be proven for the models before incorporating their use for educational purposes. Validity should be determined by experts and trainees themselves.

Summary

A validated simulation curriculum should be incorporated within the otolaryngology training programme. A curriculum based on the current training programme at our institution serves as an exemplar for local adoption.

Optimal Timing of Entry-Level Otolaryngology Simulation

Objective

Appropriate timing of subspecialty simulation is critical to maximize learner benefit and guide resource utilization. We aimed to determine optimal timing of a simulation-based curriculum designed to teach entry-level procedural skills for otolaryngology residency.

Study Design

Simulation curriculum intervention tested among 3 comparison groups of varying clinical levels.

Setting

Academic otolaryngology training program and medical school.

Subjects and Methods

We developed a simulation-based technical skills curriculum incorporating the following task trainers: flexible laryngoscopy, peritonsillar abscess drainage, and myringotomy and tube insertion. Preclinical medical students (n = 40), subintern rotators (n = 35), and midyear interns (n = 8) completed the simulation-based curriculum. Pre- and postintervention knowledge/confidence and “level appropriateness” were rated on a 5-point Likert scale, and effect size was calculated.

Results

Overall self-reported knowledge/confidence levels improved in all 3 groups preintervention (1.05, 2.15, 3.17) to postintervention (2.79, 3.45, 4.38, respectively; all P < .01). Preclinical medical students uniformly reported very little to no familiarity with the procedures prior to the curriculum, while interns approached independence following the intervention. Large effect sizes were seen in all tasks for preclinical students (d = 3.13), subinterns (d = 1.46), and interns (d = 2.14). Five-point Likert scale measures of level appropriateness (1 = too challenging, 5 = too easy) for preclinical students, subinterns, and interns were 2.70 (95% CI, 2.56-2.84), 3.11 (95% CI, 2.97-3.25), and 3.75 (95% CI, 3.35-4.15), respectively.

Conclusion

Subinternship may represent the optimal timing for entry-level skills simulation training. The proposed curriculum shows utility for clinical levels ranging from medical students to postgraduate year 1 resident levels, with large effect sizes for all tested groups.

Hereditary angioedema education in otolaryngology residencies: survey of program directors

BACKGROUND

The objective of this work was to assess resident education regarding contemporary management of hereditary angioedema using a web-based survey.

METHODS

An 11-item, multiple-choice, electronic questionnaire was sent to all 106 accredited otolaryngology training programs in November 2016. Questions focused on resident education, management principles, and formalized assessment.

RESULTS

A total of 34 program directors responded, representing 32% of otolaryngology residences. Ninety-seven percent believed otolaryngology residents should be knowledgeable in the management of hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE). Specifically, 38% and 26% of program directors felt their residents were comfortable and very comfortable in C1-INH-HAE management, respectively. Of those surveyed, 18% have educational simulation activities and a protocol in place for C1-INH-HAE management. Forty-seven percent of respondents felt their training program provided adequate education and exposure to C1-INH-HAE. Over the last 5 years, 45% felt residents were exposed to 1 to 5 cases of C1-INH-HAE. Sixty-seven percent of residents were trained in the management of C1-INH-HAE through in-person lectures. Seventy-one percent of programs had no formal assessment of resident competency in C1-INH-HAE management.

CONCLUSION

This study is the first to offer insight into C1-INH-HAE education and management principles in otolaryngology training programs. Surveyed program directors believe residents need a strong knowledge base in the management of C1-INH-HAE but less than half feel their trainees acquire the necessary exposure to this emergent disease process. Future research efforts in this area should aim to determine optimal educational activities as well as how to best incorporate this into otolaryngology residency curricula.

The Benefits and Limitations of Targeted Training in Flexible Transnasal Laryngoscopy Diagnosis

Importance

Targeted laryngoscopy training can be used successfully in de novo learners.

Objective

To determine the value of targeted laryngoscopy education in interns.

Design, Setting, and Participants

This prospective study of fiberoptic laryngoscopy interpretations enrolled 13 participants in an academic hospital setting from August 1 to December 31, 2015. Participants included 10 postgraduate year 1 emergency and otolaryngology interns and 3 board-certified otolaryngology attending physicians.

Interventions

Participants viewed 25 selected and digitally recorded fiberoptic laryngoscopies and were asked to rate 13 items relating to abnormalities in the pharynx, hypopharynx, larynx, and subglottis; the level of concern; and confidence with the diagnosis. A laryngoscopy teaching video was then administered to the interns before rating a second set of 25 videos. Improvement in diagnosis and intraclass correlation coefficients (ICC) were calculated for each question and compared between the first and second administration.

Main Outcomes and Measures

Improvement in correct diagnosis of abnormalities in recorded laryngoscopies.

Results

All 13 participants completed the interventions. The ICCs for all questions were generally low for the intern groups and higher for the attending group. For vocal cord mobility, a preintervention ICC of 0.25 (95% CI, 0.16-0.37) improved to 0.47 (95% CI, 0.36-0.59) among interns after the intervention. The ICCs for vocal cord mobility were higher among attendings for the preintervention (0.89; 95% CI, 0.84-0.93) and postintervention (0.89; 95% CI, 0.83-0.93) assessments. Minimal improvement was observed in intern scores for base of tongue abnormalities, subglottic stenosis, vocal cord abnormalities, level of comfort, level of concern, pharyngeal abnormalities, or laryngeal, pharyngeal, and hypopharyngeal masses.

Conclusions and Relevance

Learning of flexible laryngoscopy can be improved with the use of a teaching video; however, additional interventions are needed to attain competence in accurately diagnosing upper airway lesions. Clinicians who seek to perform flexible laryngoscopy require robust training.

Airway management education: simulation based training versus non-simulation based training-A systematic review and meta-analyses

Background

Simulation-based training (SBT) has become a standard for medical education. However, the efficacy of simulation based training in airway management education remains unclear.

Methods

The aim of this study was to evaluate all published evidence comparing the effectiveness of SBT for airway management versus non-simulation based training (NSBT) on learner and patient outcomes.

Systematic review with meta-analyses were used. Data were derived from PubMed, EMBASE, CINAHL, Scopus, the Cochrane Controlled Trials Register and Cochrane Database of Systematic Reviews from inception to May 2016. Published comparative trials that evaluated the effect of SBT on airway management training in compared with NSBT were considered. The effect sizes with 95% confidence intervals (CI) were calculated for outcomes measures.

Results

Seventeen eligible studies were included. SBT was associated with improved behavior performance [standardized mean difference (SMD):0.30, 95% CI: 0.06 to 0.54] in comparison with NSBT. However, the benefits of SBT were not seen in time-skill (SMD:-0.13, 95% CI: −0.82 to 0.52), written examination score (SMD: 0.39, 95% CI: −0.09 to 0.86) and success rate of procedure completion on patients [relative risk (RR): 1.26, 95% CI: 0.96 to 1.66].

Conclusion

SBT may be not superior to NSBT on airway management training.

Simulation-based otolaryngology – head and neck surgery boot camp: ‘how I do it’

Background:

In otolaryngology, surgical emergencies can occur at any time. An annual surgical training camp (or ‘boot camp’) offers junior residents from across North America the opportunity to learn and practice these skills in a safe environment. The goals of this study were to describe the set-up and execution of a simulation-based otolaryngology boot camp and to determine participants' confidence in performing routine and emergency on-call procedures in stressful situations before and after the boot camp.

Methods:

There were three main components of the boot camp: task trainers, simulations and an interactive panel discussion. Surveys were given to participants before and after the boot camp, and their confidence in performing the different tasks was assessed via multiple t-tests.

Results:

Participants comprised 22 residents from 12 different universities; 10 of these completed both boot camp surveys. Of the nine tasks, the residents reported a significant improvement in confidence levels for six, including surgical airway and orbital haematoma management.

Conclusion:

An otolaryngology boot camp gives residents the chance to learn and practice emergency skills before encountering the emergencies in everyday practice. Their confidence in multiple skillsets was significantly improved after the boot camp. Given the shift towards competency-based learning in medical training, this study has implications for all surgical and procedural specialties.

Ex vivo ovine model for pediatric flexible endoscopy training

OBJECTIVES

Medical students and residents in training have limited opportunities to develop pediatric endoscopy skills and would benefit from a realistic simulation model. We sought to develop such a model for flexible endoscopy using fresh head and neck tissue from young sheep.

METHODS

Tissue was collected from pre-pubescent sheep (n=5; mean age: 4 months; mean mass: 28kg) following humane euthanasia at the end of an in vivo protocol. No live animals were used in this study. The head and neck of the sheep were disarticulated 4-6cm above the sternal notch and stored at 5°C for 1-5 days. With the preparation was supported in supine position, flexible nasopharyngolaryngoscopy and transnasal endoscopic intubation were performed with video recording.

RESULTS

Five sheep were studied. Endoscopy was performed by a medical student under direct supervision by a pediatric otolaryngologist. Differences between ovine and human pediatric airway anatomy were defined.

CONCLUSIONS

Despite variations in proportion and structure, the experience of passing a flexible nasopharyngoscope through a sheep's airway is remarkably similar to pediatric endoscopy. The nasal anatomy is elongated, but very much like a child's in terms of anatomy, color and texture. The tactile feedback is nearly identical. Annoying secretions and their associated "whiteout" phenomena nicely simulate these challenges in pediatric endoscopy. When performing transnasal intubation, navigating to the larynx and advancing an endotracheal tube under guidance have the look and feel of the pediatric procedure. Issues of cost, availability, risk of zoonotic infection, and ethics are discussed.

A low-cost alternative for nasolaryngoscopy simulation training equipment: a randomised controlled trial

OBJECTIVES

Flexible nasolaryngoscopy is a key diagnostic procedure used in many specialities. Simulation-based teaching is beneficial for endoscopy training, but it is expensive. This study assessed whether an inexpensive simulation model is an effective training method for flexible nasolaryngoscopy.

METHODS

A three-armed, randomised, controlled trial was performed. One group received no simulation training, while two others were trained with either a high-cost or a low-cost model. All candidates then performed flexible nasolaryngoscopy on a volunteer. Their ability to perform this task was assessed by the patient discomfort score and time taken by a blinded expert.

RESULTS

Simulation-based teaching reduced patient discomfort and improved candidate skill level. Low-cost model training did not have a negative effect when compared with high-cost model training.

CONCLUSION

Simulated flexible nasolaryngoscopy training may be more accessible with the use of an effective low-cost model.

Qualitative synthesis and systematic review of otolaryngology in undergraduate medical education

OBJECTIVE

Although 25% of primary care complaints are otolaryngology related, otolaryngology instruction is not required in most medical schools. Our aim was to systematically review existing literature on the inclusion of otolaryngology in undergraduate medical education.

DATA SOURCES

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center.

STUDY DESIGN/REVIEW METHODS

Our search encompassed all indexed years through December 29, 2014. Inclusion criteria were English language, original human data, and a focus on medical student education. Data regarding study design, teacher, educational topic, educational methods, and setting were extracted from each article. Two investigators independently reviewed all articles.

RESULTS

Our initial search yielded 436 articles; 87 underwent full-text evaluation and 47 remained in the final review. The majority of studies were conducted in the United States (40%), United Kingdom (23%), and Canada (17%) and represented a single institutional experience. Studies were classified as needs assessments (36%), curriculum descriptions (15%), educational methods (36%), and skills assessments (32%); 81% were levels of evidence 3 or 4. Most reports indicated that otolaryngology rotations are not compulsory.

CONCLUSIONS

Studies indicated the need for increased exposure to otolaryngology. Educational methods such as team-based learning, simulation, online learning, and clinical skills assessments may offer ways to increase exposure without overburdening clinical faculty and require further study. Data suggest that a universal otolaryngology medical student curriculum would be valuable and aid in resource sharing across institutions. We recommend that an assessment be performed to determine topics and skills that should comprise this curriculum.

LEVEL OF EVIDENCE

NA.

A randomized controlled trial of simulation-based training for ear, nose, and throat emergencies

OBJECTIVES/HYPOTHESIS

Life-threatening ear, nose, and throat (ENT) emergencies are uncommon but require immediate skilled management. We investigated if traditional lecture-based teaching can be improved by a simulation and lecture hybrid approach.

STUDY DESIGN

A single-blinded, prospective, randomized controlled trial.

METHODS

Two groups of interns with no previous ENT experience were randomized to one of two training groups: a simulation/lecture hybrid group or a lecture-only control group. Both groups received 90 minutes of training covering the assessment of critically ill patients and four ENT emergency topics. Both groups received the same initial lecture slides. The control group received additional slides, and the simulation group received simulated emergency scenario training using basic mannequins. Following the training, candidates were asked to provide feedback on their perception of training, and they were formally assessed with a standardized one-to-one viva.

RESULTS

Thirty-eight interns were recruited: 18 in the control group and 20 in the simulation group. The candidates in the simulation group performed significantly better in all viva situations (P < .05) and had better perception of learning (P < .05). Additionally, the simulation group was more likely to recommend the training to a colleague (P < .05).

CONCLUSIONS

We have demonstrated that replacing traditional lecture-based training with a mixture of lectures and emergency scenario simulation is more effective at preparing junior doctors for ENT emergencies, and better met their learning needs. Implementing this kind of teaching is feasible with a minimum of additional resources or time.

LEVEL OF EVIDENCE

1b