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.

Sinus Surgery Is Associated with a Decrease in Aspirin-Induced Reaction Severity in Patients with Aspirin Exacerbated Respiratory Disease

BACKGROUND

Nasal polyps influence the burden of aspirin-exacerbated respiratory disease (AERD) by contributing to eicosanoid production. AERD is diagnosed through graded aspirin challenges. It is not known how sinus surgery affects aspirin challenge outcomes.

OBJECTIVE

To investigate the effects of endoscopic sinus surgery (ESS) on aspirin-induced reaction severity and on the levels of eicosanoids associated with these reactions.

METHODS

Twenty-eight patients with AERD were challenged with aspirin before and 3 to 4 weeks after ESS. Respiratory parameters and plasma and urine levels of eicosanoids were compared before and after challenges.

RESULTS

Before ESS, AERD diagnosis was confirmed in all study patients by aspirin challenges that resulted in hypersensitivity reactions. After ESS, reactions to aspirin were less severe in all patients and 12 of 28 patients (43%, P < .001) had no detectable reaction. A lack of clinical reaction to aspirin was associated with lower peripheral blood eosinophilia (0.1 K/μL [interquartile range (IQR) 0.1-0.3] vs 0.4 K/μL [IQR 0.2-0.8]; P = .006), lower urinary leukotriene E₄ levels after aspirin challenge (98 pg/mg creatinine [IQR 61-239] vs 459 pg/mg creatinine [IQR 141-1344]; P = .02), and lower plasma prostaglandin D₂ to prostaglandin E₂ ratio (0 [±0] vs 0.43 [±0.2]; P = .03), compared with those who reacted.

CONCLUSIONS

Sinus surgery results in decreased aspirin sensitivity and a decrease in several plasma and urine eicosanoid levels in patients with AERD. Diagnostic aspirin challenges should be offered to patients with suspected AERD before ESS to increase diagnostic accuracy. Patients with established AERD could undergo aspirin desensitizations after ESS as the severity of their aspirin-induced hypersensitivity reactions lessens.

Intraoperative Image Guidance during Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is one of the most commonly performed procedures in otorhinolaryngology and is associated with a definite risk for both intraoperative and postoperative complications. Intraoperative image guidance is expected to have a major effect on procedures such as ESS by allowing the clinician to more efficiently remove pathology and by improving surgeon confidence and knowledge of anatomy, particularly in revision procedures or in patients with altered anatomy. As a consequence, complications during these pro-’ cedures will decrease and patient safety will increase. Several guidance modalities are available including computed tomography (CT), magnetic resonance imaging (MRI), and fluoroscopy. This article will describe current applications of each of these three techniques with respect to ESS while focusing on innovative techniques that use MRI and CT to provide intraoperative guidance with unmatched convenience, reliability, and utility.

Medical Students’ Attitudes toward the use of an Endoscopic Sinus Surgery Simulator as a Training Tool

Background

Modern adult learning theory characterizes self-directed learning as most effective. While studying the effectiveness of an endoscopic sinus surgery simulator (ES3) as a training tool and acknowledging that its successful integration into a training program is dependent on its acceptance and self-driven use by trainees, we sought to determine our study subjects’ attitudes toward the simulator.

Methods

Twenty-six medical students were enrolled and trained in our ES3 study. Each student was asked to complete a 28-item questionnaire on completion of training. This questionnaire contained 10-point Likert scale instruments, yes/no questions, and one open-ended question.

Results

All but four subjects responded to the questionnaire; 90.9% of the respondents rated the training benefit derived from the simulator's novice mode as 6 or greater on a 10-point scale; the mean was 7.82 (±2.22). The training benefit of the intermediate mode also was scored highly, with a mean score in the 7–9 range for all but one component–-heart rate response to actions performed. Trainees appreciated the simulator's ability to help them adapt to a three-dimensional space on a two-dimensional display. They also noted its strengths in elucidating intranasal anatomy.

Conclusion

Medical students who enrolled in our study, as a group, felt that the ES3 provided them with significant training benefits. Although subjective, these attitudes, coupled with objective data indicating that there is a measurable benefit from use of the ES3, will ensure its full acceptance and use in otolaryngology training programs.

Learning Curves, Acquisition, and Retention of Skills Trained with the Endoscopic Sinus Surgery Simulator

Background

As an initial step in evaluating the effectiveness of training otolaryngology residents on an endoscopic sinus surgery simulator (ES3), we have assessed the ability of the ES3 to train persons inexperienced in sinus surgery (medical students) to perform certain simulated procedural tasks needed in endoscopic sinus surgery (ESS).

Methods

A total of 26 medical students were enrolled and trained on the ES3 following a preset protocol in the three levels of difficulty and complexity (novice, intermediate, and advanced modes).

Results

In the novice mode (three-dimensional abstract images are used to teach the use of endoscopic surgical equipment), medical students displayed a steep learning curve within three to five trials on the simulator and after an additional four to five trials, they reached a plateau in their learning curves to within 90% of that of experienced sinus surgeons. In the intermediate mode (ESS is performed on a simulated patient with teaching aids), medical students were able to reach a plateau in their learning curves to within 80% of that of experienced surgeons. This performance was sustained in the advanced mode (simulated sinus surgery without teaching aids). We observed that medical students, who had novice or intermediate mode training interrupted with an interval of 11–60 days, were able to resume their training without deviation from their prior learning curves.

Conclusion

Intensive, proctored training on the ES3 can train inexperienced persons to perform simulated ESS within a reasonable approximation of the performance of experienced sinus surgeons on the ES3 and the training that an inexperienced person receives on the simulator is not short term but is retained over a period of at least 2 months.

Comparison of Endoscopic Sinus Surgery with and without Image Guidance

Background

Image guidance based on preacquired computed tomography scans of the patient is a technique used to assist the physician during endoscopic sinus surgery (ESS). This study seeks to compare ESS with and without image guidance, analyzing a number of parameters that can impact on efficacy.

Methods

Retrospective chart review took place at a tertiary care referral center. The study group consisted of 97 consecutive patients confirmed to have undergone ESS using an electromagnetic intraoperative image guidance system (IGS). The control group consisted of 61 consecutive patients who underwent ESS, before the IGS was available at the study hospital. The main outcomes measured were analysis of patient profile, including coexisting conditions such as asthma and polyposis, assessment of which specific sinuses underwent surgical treatment; major and minor complications; estimated blood loss (EBL); operative time; and the need for repeat surgery.

Results

The IGS group had 74% of patients with polyposis; more sinuses, on average, which underwent surgical revision; one major and three minor complications; an average EBL of 134 cc, an average procedure time of 154 minutes; and one patient who needed repeat surgery in a 3-month follow-up period. The non-IGS group had 40% of patients with polyposis; seven major complications and one minor complication; an average EBL of 94 cc; and three patients who needed repeat surgery within 3 months.

Conclusions

The use of an IGS for endoscopic sinus surgery may reduce the complications associated with the procedure and allow for a more thorough operation. However, operative time and EBL may be increased.

Antibiotic use patterns in endoscopic sinus surgery: a survey of the American Rhinologic Society membership

BACKGROUND

There is a paucity of data supporting antibiotic use in endoscopic sinus surgery (ESS). The objective of this study is to determine perioperative antibiotic use patterns and factors which influence use in ESS.

METHODS

An online-based survey was distributed to members of the American Rhinologic Society (ARS). Outcomes included timing of perioperative antibiotic use, practice environment, years of experience, and patient factors that influenced antibiotic use.

RESULTS

There were 204 responses (response rate 18.3%); 36.8% of respondents were in academic positions, 32.8% were in private practice, and 30.4% were in academic-affiliated private practice; 20.6% routinely gave preoperative antibiotics, most commonly to reduce bacterial burden (59.5%) and mucosal inflammation (59.5%); 54.4% routinely gave intraoperative antibiotics, most commonly to reduce the risk of postoperative infection (63.1%); 62.3% routinely gave postoperative antibiotics, citing the need to reduce the risk of postoperative infection (75.6%). Diagnosis influenced postoperative antibiotic use in 63.0%. Preoperative antibiotics were more likely to be prescribed by respondents with more than 5 years of experience (odds ratio [OR] 2.97; 95% confidence interval [CI], 1.04 to 8.54; p = 0.043). Compared to private practitioners, academicians were more likely to give intraoperative antibiotics (OR 2.68; 95% CI, 1.39 to 5.17; p = 0.003), but not preoperative or postoperative antibiotics. Use of nonabsorbable packing was significantly associated with use of postoperative antibiotics (OR 2.01; 95% CI, 1.07 to 3.77; p = 0.031).

CONCLUSION

This study demonstrates the significant variation in perioperative antibiotic use among otolaryngologists. These results provide support for the establishment of evidence-based practice guidelines for perioperative antibiotic use in ESS.

Endoscopic modified Lothrop procedure after failure of primary endoscopic sinus surgery: a meta-analysis

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) has been used as a salvage technique for frontal sinusitis following failed endoscopic sinus surgery (ESS). We aim to examine the safety and efficacy of the EMLP following failure of primary ESS.

METHODS

All English-language publications from 2000 to 2016 reporting the use of EMLP after primary ESS were identified using the PubMed database and evaluated per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects summaries of patient demographics, comorbidities, and surgical outcomes were obtained through meta-analysis.

RESULTS

Eleven studies constituting 778 patients were included and 86.5% had chronic rhinosinusitis (CRS). Mean follow-up duration was 28.4 months. The mean number of surgeries prior to EMLP was 3.5. Symptom improvement was reported in 82.3%. Subgroup analysis of 7 studies in which all 357 patients had CRS revealed a mean follow-up of 31.5 months. Symptom improvement occurred in 75.9% of cases and 23.1% experienced polyp recurrence. The cerebrospinal fluid leak rate was 2.5%. Restenosis of the neo-ostium occurred in 17.1% with complete closure occurring in 3.9% of cases. The reoperation rate after EMLP was 9.0%. Aspirin sensitivity was associated with an increased risk of cerebrospinal fluid (CSF) leak (p = 0.0339) and a reduced incidence of neo-ostium closure (p = 0.0001). Aspirin sensitivity and asthma were associated with a reduced incidence of reoperation (p ≤ 0.001) and increased symptom improvement (p < 0.005). Restenosis or closure of the frontal neo-ostium was associated with less symptom improvement (p < 0.04) but not with reoperation.

CONCLUSION

The EMLP is an effective salvage procedure for refractory frontal sinusitis based on data from higher-volume centers.

Improving Rhinology Skills with Simulation

The convergence of technology and medicine has led to many advances in surgical training. Novel surgical simulators have led to significantly improved skills of graduating surgeons, leading to decreased time to proficiency, improved efficiency, decreased errors, and improvement in patient safety. Endoscopic sinus surgery poses a steep learning curve given the complex 3-dimensional anatomy of the nasal and paranasal cavities, and the necessary visual-spatial motor skills and bimanual dexterity. This article focuses on surgical simulation in rhinological training and how innovative high-fidelity and low-fidelity simulators can maximize resident training and improve procedural skills before operating in the live environment.

Leadership Training in Otolaryngology Residency

Although residency training offers numerous leadership opportunities, most residents are not exposed to scripted leadership instruction. To explore one program's attitudes about leadership training, a group of otolaryngology faculty (n = 14) and residents (n = 17) was polled about their attitudes. In terms of self-perception, more faculty (10 of 14, 71.4%) than residents (9 of 17, 52.9%; P = .461) considered themselves good leaders. The majority of faculty and residents (27 of 31) thought that adults could be taught leadership ability. Given attitudes about leadership ability and the potential for improvement through instruction, consideration should be given to including such training in otolaryngology residency.

Feasibility of near real-time image-guided sinus surgery using intraoperative fluoroscopic computed axial tomography

Objective

One of the main limitations of image-guided surgery is that navigation relies on the use of a CT scan obtained before surgery and is unable to be updated during the procedure. A software addition has been developed to allow reconstruction of CT-like images from a series of fluoroscopic scans and integrate these into an image-guided system (GE Healthcare Surgical Navigation, Lawrence, MA). We report our initial experience with a series of patients undergoing intraoperative fluoroscopic navigation in sinus surgery.

Study Design and Settings

After institutional review board clearance, we prospectively studied 14 consecutive patients undergoing image-guided sinus surgery with the use of intraoperative fluoroscopy.

Results

All patients had preoperative and postoperative fluoroscopic images reconstructed into CT-like images. By the conclusion of the study, images were adequate in quality and accurate navigation was achieved.

Conclusion

Real-time image-guided sinus surgery using fluoroscopy is feasible. Future studies will need to focus on defining the procedures that could benefit, such as tumor resection, to enhance patient safety during these operations.

Case-control study evaluating competing risk factors for angioedema in a high-risk population

OBJECTIVES/HYPOTHESIS

Black race is a risk factor for angioedema. The primary aim was to examine the relationship between race-ethnicity and risk factors for angioedema.

STUDY DESIGN

Using a retrospective case-control study design, data was extracted with the Clinical Looking Glass utility, a data collection and management tool that captures data from electronic medical record systems within the Montefiore Healthcare System. Cases were emergency department (ED) visits with primary or secondary International Classification of Diseases, Ninth Revision, code diagnoses of angioedema in adults aged ≥ 18 years from January 2008 to December 2013 at three Montefiore centers in Bronx, New York. Controls were a random sampling of adult ED visits during the same period.

METHODS

In primary analyses, angiotensin-converting enzyme inhibitor (ACE-I) and black race were evaluated for synergy. The influence of different risk factors in the development of angioedema was evaluated using logistic regression models. Finally, race-ethnicity was further explored by evaluating for effect modification by stratification of models by race-ethnicity categories.

RESULTS

There were 1,247 cases and 6,500 controls randomly selected from a larger control pool. ACE-I use (odds ratio [OR] 3.70, 95% confidence interval [CI] 2.98, 4.60), hypertension (OR 1.88, 95% CI 1.55, 2.29), and black race (OR 2.25, 95% CI 1.86, 2.72) were the strongest risk factors. ACE-I use and black race were not synergistic (OR 1.10, 95% CI 0.80, 1.51). Race-ethnicity was an effect modifier for certain risk factors.

CONCLUSION

Race-ethnicity acts as an effect modifier for particular angioedema risk factors. The two strongest risk factors, ACE-I use and black race, were not synergistic.

LEVEL OF EVIDENCE

3b. Laryngoscope, 126:1823-1830, 2016.

Simulation Activity in Otolaryngology Residencies

OBJECTIVES

Simulation has become a valuable tool in medical education, and several specialties accept or require simulation as a resource for resident training or assessment as well as for board certification or maintenance of certification. This study investigates current simulation resources and activities in US otolaryngology residency programs and examines interest in advancing simulation training and assessment within the specialty.

STUDY DESIGN

Web-based survey.

SETTING

US otolaryngology residency training programs.

SUBJECTS AND METHODS

An electronic web-based survey was disseminated to all US otolaryngology program directors to determine their respective institutional and departmental simulation resources, existing simulation activities, and interest in further simulation initiatives. Descriptive results are reported.

RESULTS

Responses were received from 43 of 104 (43%) residency programs. Simulation capabilities and resources are available in most respondents' institutions (78.6% report onsite resources; 73.8% report availability of models, manikins, and devices). Most respondents (61%) report limited simulation activity within otolaryngology. Areas of simulation are broad, addressing technical and nontechnical skills related to clinical training (94%). Simulation is infrequently used for research, credentialing, or systems improvement. The majority of respondents (83.8%) expressed interest in participating in multicenter trials of simulation initiatives.

CONCLUSION

Most respondents from otolaryngology residency programs have incorporated some simulation into their curriculum. Interest among program directors to participate in future multicenter trials appears high. Future research efforts in this area should aim to determine optimal simulators and simulation activities for training and assessment as well as how to best incorporate simulation into otolaryngology residency training programs.

Simulation Activity in Otolaryngology Residencies

Objectives:

(1) Determine simulation resources available within United States otolaryngology training institutions. (2) Determine current involvement in simulation within otolaryngology training programs. (3) Gauge interest in advancing simulation for training and assessment.

Methods:

A voluntary survey was sent to 104 program directors. The introduction provided a broad definition of simulation. Responses were collected between March 21 and April 5, 2013. Descriptive results are presented.

Results:

Responses were received for 43 (41%) of the surveys. A total of 39 of 43 respondents (91%) have a simulation center or program at their institution. A total of 34 of 43 respondents (79%) have onsite simulation, 32 (74%) have models, manikins, or other devices, and 25 (58%) have staff resources within their institution. A total of 8 of 43 respondents (19%) have extensive, 26 (60%) have limited, and 8 (19%) have no otolaryngology simulation activity at their institution. The most common applications of simulation within otolaryngology are emergency management (23 of 43 respondents; 53%) and otology (21 of 43; 49%). All 31 respondents use simulation for clinical training (100%), 11 (33%) for proficiency, and 7 for mastery (21%). Three of 36 (22%) use extensive, 12 (33%) limited, and 21 (58%) no simulation in research. None of 34 use simulation for otolaryngology credentialing, although 2 (6%) use simulation for advanced cardiac life support credentialing. A total of 31 of 37 respondents (84%) are interested in participating in multicenter trials of simulation initiatives.

Conclusions:

Simulation resources are widely available in otolaryngology training institutions. Survey respondents report limited but widespread participation in simulation activity, and widespread interest in participating in simulation trials.

Structural and functional vocal fold epithelial integrity following injury

OBJECTIVES/HYPOTHESIS

An intact epithelium is an important part of vocal fold defense. Damage to the epithelium can compromise vocal fold homeostasis and protection of the host tissue from viral and bacterial invasion. Elucidating the effects of damage on epithelial architectural and barrier integrity provides insight into the role of epithelium in protecting vocal folds. Using an animal model, we evaluated the time course of structural and functional epithelial restoration following injury.

STUDY DESIGN

Prospective, controlled animal study.

METHODS

Forty rats underwent surgery to remove vocal fold mucosa unilaterally. Larynges were harvested at five time intervals between 3 to 90 days postinjury and were prepared for histological and permeability analyses.

RESULTS

Rapid restoration of structural integrity was demonstrated by return of a multilayerd epithelium, intercellular junctions, and basement membrane at 5 days postinjury. Atypical epithelial permeability was observed up to 5 weeks postinjury.

CONCLUSION

Restoration of epithelial barrier integrity lags epithelial structural restoration. Consequently, epithelial regeneration cannot be equated with return of functional barrier integrity. Rather, ongoing leakiness of regenerated epithelium indicates that vocal folds remain at risk for damage, pathogen invasion, and remodeling postinjury.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 124:2764-2769, 2014.

Risk factors associated with severe and recurrent angioedema: an epidemic linked to ACE-inhibitors

OBJECTIVES/HYPOTHESIS

To evaluate the etiology and risk factors for severe manifestation and recurrent episodes of angioedema; to evaluate efficacy of short-term and long-term management strategies for angioedema among a high-risk population.

STUDY DESIGN

Institutional review board-approved retrospective review of a large, urban population.

METHODS

Data from 875 adult patients treated from January 2008 to December 2013 with the diagnosis of angioedema were obtained using the Clinical Looking Glass utility and review of medical records. Demographic and clinicopathologic risk factors were recorded. The major outcomes evaluated were hospital admission, need for airway intervention, and recurrent episodes of angioedema following the first presentation. Initial treatment strategy and follow-up recommendations were also recorded.

RESULTS

The most common cause of angioedema was angiotensin converting enzyme inhibitor (ACEi)-induced (496 [56.6%]). Significant risk factors for severe cases of angioedema included older age, Hispanic race, ACEi-induced angioedema type, American Society of Anesthesiologists class III or above, coexistent cardiopulmonary disease, and a positive smoking history. A total of 17.2% of patients experienced recurrent attacks of angioedema; of those patients, 25.9% were still taking an ACEi at subsequent presentation. Risk factors for recurrent episodes included older age, idiopathic angioedema type, and coexistent cardiopulmonary disease. Only 54.1% of patients who experienced ACEi-induced angioedema had electronic medical record documentation of these allergies.

CONCLUSIONS

Knowledge of risk factors for severe and recurrent episodes of angioedema and improved education for both healthcare providers and patients, specifically related to ACEi use and allergy documentation, may significantly decrease the burden and morbidity of angioedema among high risk populations.

LEVEL OF EVIDENCE

2b.

Laryngeal Inflammation: Diagnosis and Treatment Challenges

Program Description:

Using an interactive format, panelists will discuss epidemiology, symptomatology, and co-morbid conditions contributing to laryngopharyngeal inflammation; diagnosis/differential diagnosis; challenges in diagnosing causative factors; addressing diagnostic challenges to define a treatment plan; current evidence; treatment challenges and impact of co-morbid conditions; and future research and management implications. The panel will consider “real world” patient management algorithms. The audience will help answer the following questions: What are the typical ‘challenges’ in diagnosing laryngopharyngeal inflammation? What diagnostic testing options should be employed? Which after first treatment failure? What are the common treatment pathways? What differential data should be considered? What healthcare costs impact options? When is referral recommended?

Educational Objectives:

1) Describe current practice trends on the diagnosis and management of laryngopharyngeal inflammation. 2) Recognize the common challenges in diagnosing laryngeal inflammation to define appropriate treatment strategies. 3) Evaluate current evidence-based literature supporting current diagnosis and treatment paradigms.

Efficacy of Surgical Simulators for Otolaryngology Training

Program Description:

Recently, there has been growing interest in developing and using simulation technologies for basic surgical skills training for residents. In addition, as our specialty continually evolves and we make efforts for quality and lifelong learning, simulation technologies may also be useful for keeping experienced surgeons up-to-date with their skills. We will present currently available surgical simulators for temporal bone dissection, endoscopic sinus surgery, airway endoscopy, and tonsillectomy. The presenters will provide descriptions and show videos demonstrating the function of these devices. In addition, each panelist will present data evaluating the efficacy of these simulators as being effective teaching instruments.

Educational Objectives:

1) Differentiate the variety of simulation technology devices available for surgical skills training in otolaryngology–head neck surgery. 2) Recognize the advantages and limitations of using simulation technologies for acquiring and maintaining surgical skills. 3) Assess the validity of the studies presented to evaluate the efficacy of simulation devices as valuable learning tools.

From Simulation to Surgery: Making It Real

Program Description:

Does learning on a simulator really help surgeons operate better? Can learning or directed practice on a simulator contribute to faster or better skill acquisition? What are the advantages and disadvantages of virtual, high tech, or home-made simulators? How do I get started? A panel of experts will provide examples from otology, sinus, and airway surgery; and describe their experiences, recommendations, and visions for the future. Dr. Fried: virtual sinus surgery; Dr. Wiet: virtual temporal bone surgery; Dr. Amin: simulation for office-based procedures; Dr. Malekzadeh: make it yourself; Dr. Ishman: how do we assess competency? Dr. Wang: return on investment.

Educational Objectives:

1) Describe how simulators can be used to develop or improve surgical skills. 2) Compare the advantages of different types of simulators. 3) Use a competency-based assessment tool.

The use of image-guided surgery in endoscopic sinus surgery: an evidence-based review with recommendations

BACKGROUND

The frequency of endoscopic sinus surgery (ESS) appears to be increasing, and the use of image-guided surgery (IGS) in these procedures is becoming more widespread. The use of IGS in ESS and anterior skull base surgery is predicated on the notion that its ability to aid in anatomic identification during surgery will lead to fewer complications and improved surgical outcomes. The purpose of this article is to provide an evidence-based examination of the benefits of IGS in ESS.

METHODS

A systematic review of the literature was performed and recommendations were created based on the Clinical Practice Guideline Manual, Conference of Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instruments.

RESULTS

This review identified and evaluated literature regarding the effect of IGS on surgical complications and on postoperative outcomes in ESS. Currently, there is grade C evidence to support the use of IGS in ESS.

CONCLUSION

Based on the best available evidence in the literature, the use of IGS has not clearly been shown to decrease surgical complications or improve surgical outcomes. These evidence-based recommendations are based on limited literature with suboptimal research methodology. However, the importance, utility, and acceptance of IGS through expert opinion and consensus are supported by the available literature. Therefore, the use of IGS in ESS is an option and should be based on clinical judgment and applied on a case-by-case basis.

Mentor and Mentee Skills: Tools from Residency to Practice and Beyond

Program Description: The ability to mentor and be mentored is important to the individual and collective success of our specialty. Successful organizations have long benefited from the voluntary contributions of individuals stimulated by a mentoring relationship. On a professional level, mentoring is critical to recruit, retain, and promote a diverse and dynamic otolaryngology work force in a time of changing needs. While the apprentice model of mentoring is familiar, understanding the various options available to aid career transitions and professional development is increasingly important. The panel will explore several aspects attributable to the changing environment of the mentor relationship and provide tools for addressing these needs. Generational differences will be discussed as they relate to changing priorities of the younger mentee and transformation of the traditional mentor role. A successful residency-mentoring program will be presented and this model adapted to various practice applications. The concept of mentorship will be explored from the perspective of the mentor and mentee and topics of physician practice, academy involvement, and work-life balance will be covered. The panel, providing tools for those seeking mentoring, will discuss the needs, expectations, and responsibilities of the mentee. Resources available within medicine, the AAO-HNS, and the business world will be provided for use.

Educational Objectives: 1) Understand the changing mentor/mentee relationship and have the tools to apply to those situations. 2) Improve the mentoring process by incorporating systematic methods reviewed and learn about resources available. 3) Identify individual mentor and mentee needs by encouraging an active role.

Laryngopharyngeal Reflux (LPR)

Program Description: Objective: Develop a working algorithm that effectively eliminates dangerous conditions while efficiently provides reasonable alternatives to address LPR symptoms. Methods: use an audience response system in combination with a structured set of questions directed to the audience. End result: a real world proposed treatment algorithm. White paper. Possible basis for outcomes assessment study. The overall goal of this session is to define current practice trends on the management of laryngopharyngeal reflux (LPR) based on actual audience participation/input, and the consideration of appropriate management for a typical patient. Using an interactive panel format, the moderator will prompt panelists to present a quick review of epidemiology, symptomatology, and co-morbid conditions impacting laryngopharyngeal reflux (LPR); diagnosis/differential diagnosis; current evidence on diagnostic and therapeutic management; and future research and management implications. After laying out background, the moderator/panel will consider real world patient management algorithms.

Educational Objectives: 1) Who is the typical patient presenting with laryngopharyngeal reflux (LPR) in an otolaryngology practice? 2) What diagnostic testing options are or should be employed? What are the common treatment pathways? 3) What differential data should be considered? What health care costs impact diagnosis/treatment? When is referral recommended?

Practice Considerations and Contracts for New Employment

Program Description: The AAO-HNS Section for Residents and Fellows and Women in Otolaryngology are sponsoring a miniseminar to assist physicians in embarking on or changing a career in otolaryngology. Important decisions regarding the right type of practice, finding practice opportunities, and interviewing insights will be explored. Discussion will include appropriate questions that physicians should ask themselves and their potential employers. Tips for successful interviewing and placement will be provided by an experienced and highly successful private practice employer. Considerations for those seeking an academic position will also be explored. An attorney will provide insight into negotiation of a fair contract and benefits package from both the employer and employee standpoint. Avoidance of common pitfalls will also be discussed. Issues specific to women in otolaryngology contract negotiation will be addressed, as well. This miniseminar will conclude with an interactive question and answer session.

Educational Objectives: 1) Appreciate factors crucial in evaluating a practice opportunity specific to women and young physicians. 2) Be prepared for a successful interview. 3) Understand the basics of and avoid common pitfalls in negotiating medical employment contracts.

Otolaryngology resident selection: do rank lists matter?

OBJECTIVES

To examine the relationship between National Residency Matching Program (NRMP) rank list position and future otolaryngology residency performance.

STUDY DESIGN

Cohort study.

METHODS

Eight consecutive residency classes (starting 2001-2008; 4 residents/y) were reviewed. Three hundred and thirty-three applicants (40.6 applicants/y) were interviewed, and 316 (94.9%) were ranked. Residents matching with our program were divided 3 different ways: into quarters, thirds, and halves, based on their rank order. Correlation coefficients were obtained to compare resident rank number and rank group (quarter, third, half) to faculty evaluation, coresident evaluation, and in-service score. Chi-square tests were conducted comparing rank group to chief resident selection and annual teaching award.

RESULTS

Resident NRMP rank number was not significantly correlated with faculty evaluation, coresident evaluation, or in-service exam score (-0.21 < r < 0.05; P > .28). There was also no significant correlation between resident quarter, third, or half rank group and faculty evaluation; coresident evaluation; or in-service exam score (-0.29 < r < 0.10; P > .13). Chi-square analysis found no relationship between resident rank group and chief resident (P > .35) or teaching award (P > .13) selection.

CONCLUSIONS

Applicant rank number and rank group did not correlate with performance of this otolaryngology residency cohort as assessed by faculty evaluation, coresident evaluation, in-service exam score, or selection for chief resident or the annual teaching award. Resident selection committees should consider reallocating manpower hours from creating rank order to recruiting applicants and selecting interview candidates.

The Joseph H. Ogura lecture: Teaching and learning--then and now

Education, the process of teaching and learning, has remained a passion of those in academic medicine. The context has changed over time, but the skills required are universal. The goal of these efforts is training the finest otolaryngologists who deliver the best care to their patients and build the future or our specialty. Laryngoscope, 2011.

Mentoring in otolaryngology training programs

Objective: The Accreditation Council for Graduate Medical Education's focus on outcome-based training has made the mentoring process critical for resident education. It is unknown how otolaryngology training programs mentor residents. Our objective was to determine the current state of mentoring in otolaryngology training programs and describe resident perceptions of mentoring.

Study Design: Cross-sectional survey.

Setting: Accredited U.S. otolaryngology training programs.

Subjects and Methods: All U.S. otolaryngology residents and program directors were contacted via e-mail with a link to an online survey.

Results: Of the 1411 residents contacted, 27.7 percent responded, representing 71 of the 103 accredited otolaryngology programs. Of the 103 program directors contacted, 37.9 percent responded. Of these programs, 26 had formal mentoring programs, 45 did not have formal mentoring programs, and 12 programs were listed in both categories. Fifty-one percent of male residents and 49 percent of female residents had mentors. The most important mentor characteristics were personality match, good clinical role model, and similar subspecialty interests. Least important characteristics were race, gender, and age. Twenty-six percent of residents felt that mentoring was critical to their training, while 63 percent of residents listed mentoring as important but not critical. Programs with fewer faculty and residents were less likely to offer formal mentoring ( P = 0.007 and 0.054, respectively). Of residents who did not have mentors, 80 percent lacked a mentor because their residency had no formal mentoring program.

Conclusion: Residents perceive mentoring as important, and formal mentoring programs should be incorporated into otolaryngology training programs.

From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment

OBJECTIVE

Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device.

STUDY DESIGN

Prospective, multi-institutional controlled trial.

SETTING

Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs.

SUBJECTS

Twelve ES3-trained novice residents were compared with 13 control novice residents.

METHODS

Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation.

RESULTS

Completion time was significantly shorter in the experimental group (injection P = 0.003, dissection P < 0.001), which, according to the rater panel, also demonstrated higher confidence (P = 0.009), demonstrated skill during instrument manipulation (P = 0.011), and made fewer technical mistakes during the injection task (P = 0.048) compared with the control group. The raters' post hoc internal consistency was deemed adequate (r > 0.5 between serial measurements).

CONCLUSION

The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is one of the few virtual reality simulators with a comprehensive validation record. Advanced simulation technologies need more rapid implementation in otolaryngology training, as they present noteworthy potential for high-quality surgical education while meeting the necessity of patient safety.

Indications for image-guidance in pediatric sinonasal surgery

OBJECTIVES

To determine the indications and safety of image-guidance for pediatric sinonasal surgery.

METHODS

A retrospective review was carried out of all patients undergoing image-guided sinus surgery using a single electromagnetic navigation system. All patients less than 18 years who underwent image-guided endoscopic sinus surgery over a 5-year period at a tertiary children's hospital were included. The means and ranges of age, preoperative setup time, gender distribution, and indications for surgery were determined. Operative time, anatomic regions explored, and intraoperative complications were also analyzed.

RESULTS

Thirty-three patients underwent image-guided surgery over a 5-year period. The mean age was 12 years, with 23 males and 10 females. Mean operative time and preoperative setup time was 128 and 43 min, respectively. Indications for surgery included chronic (30.3%) and acute (12.1%) rhinosinusitis, nasopharyngeal angiofibroma (9.1%), allergic rhinosinusitis (9.1%) and allergic fungal sinusitis (9.1%).

CONCLUSIONS

This series represents the largest collection of pediatric image-guided sinus surgery. In our population, image-guidance was only used for advanced sinonasal procedures where there was an anatomic abnormality or disease that extended to the sphenoid sinus, frontal sinus, orbit, or skull base. No complications were noted.

Endoscopic Sinus Surgery Simulator as a teaching tool for anatomy education

BACKGROUND

Virtual reality simulators provide an effective learning environment and are widely used. This study evaluated the Endoscopic Sinus Surgery Simulator (ES3; Lockheed Martin) as a tool for anatomic education.

METHODS

Two medical student groups (experimental, n = 8; control, n = 7) studied paranasal sinus anatomy using either the simulator or textbooks. Their knowledge was then tested on the identification of anatomic structures on a view of the nasal cavities.

RESULTS

The mean scores were 9.4 +/- 0.5 and 5.1 +/- 3.0 out of 10 for the simulator and textbook groups, respectively (P = .009). Moreover, the simulator group completed the test in a significantly shorter time, 5.9 +/- 1.1 versus 8.3 +/- 2.0 minutes (P = .021). A survey asking the students to rate their respective study modality did not materialize significant differences.

CONCLUSION

The ES3 can be an effective tool in teaching sinonasal anatomy. This study may help shape the future of anatomic education and the development of modern educational tools.