jose carlo r. villanueva, md; alejandro p. opulencia, md
TRANSCRIPT
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Myringotomy and Tympanostomy Tube Insertion Training
Device: A Surgical Simulator Jose Carlo R. Villanueva, MD; Alejandro P. Opulencia, MD
University of the East Ramon Magsaysay Memorial Medical Center Inc., Quezon City, Philippines
Jose Carlo R. Villanueva, M.D. University of the East Ramon Magsaysay Memorial Medical Center Inc., Quezon City, Philippines Email: [email protected] Phone: +632-716-1789
Contact 1. Chen N, Chang D. Peritonsillar Abscess Procedural Simulator. Otolaryngology -- Head and Neck Surgery. 2013 Sept; (149)157, doi:10.1177/0194599813496044a47 2. Kau L. Myringotomy training device. South Dakota Journal of Medicine 1969; 22(6):27-8 3. Jesudason WV, Smith I. How we do it: the Bradford grommet trainer: a model for trainer in myringotomy and grommet insertion. Clinical Otolaryngology. 2005; 30: 371-3. 4. Holt R, Parel S, Shuler S. A Model Training Ear for Teaching Paracentesis, Myringotomy, and Insertion of Tympanostomy Tubes. Otolaryngology- Head and Neck Surgery June 1983; 91: 333-335,
doi:10.1177/019459988309100327 5. Tuaño M, Martinez M. Model Myringotomy Practice Set: A Do-It-Yourself and Inexpensive Alternative. Philipp J Otolaryngol Head Neck Surg 2008; 23 (1): 31-34. 6. Wheeler B, Doyle P, Chandarana S, Agrawal S, Murad H, Ladak H. Interactive Computer-Based Simulator for Training in Blade Navigation and Targeting in Myringotomy. Computer Methods and Programs in
Biomedicine. 2010; (98) 130-139. 7. Australian Safety and Efficacy Register of New Interventional Procedures – Surgical. Surgical Simulation for Training: Skills Transfer to the Operating Room. 2007 8. Volsky P, Hughley B, Peirce S, Kesser B. Construct Validity of a Simulator for Myringotomy with Ventilation Tube Insertion. Otolaryngology-Head and Neck Surgery. 2009; 141:603. DOI:
10.1016/j.otohns.2009.07.015 9. Fernando A, Calavera K. Endoscopic Myringotomy and Ventilation Tube Placement: A Valuable Otolaryngologic Procedure under Topical Anesthesia. Philipp J Otolaryngol Head Neck Surg 2012; 27 (1): 41-43 10. Javia L, Deutsch E. A Systematic Review of Simulators in Otolaryngology. Otolaryngology -- Head and Neck Surgery 2012 147: 999. DOI: 10.1177/0194599812462007
References
1. Develop a task simulator for myringotomy and pressure
equalizing tube insertion.
2. Develop a simulator that can be used to hone a participant’s
micro surgical skills.
Objectives
Introduction
The conceptualization, design, and prerequisites of the Myringotomy
and Tube Insertion Simulator was conducted by a team of
Otolaryngologists.
The concept for the simulator was to be able to come up with a life size
human head with anatomically correct pinnae and external auditory canal.
There should be a way to easily place and remove in the model an artificial
tympanic membrane and middle ear fluid. The maneuvers involved during
procedures like manipulating the pinna and having to deal with the isthmus
and curvature of the canal should be available in the simulator.
With the basic concept for the simulator in mind, a design for a model
head with a core made up of wood and polyester body filling was made.
The external facial features were replicated with the use of molded clay.
The pinna and the external auditory canal were then made from carved
wood. Rubber fittings were used to attach the pinna to the lateral aspects
of the head in order to allow some degree of mobility to the pinnae.
In order to simulate the tympanic membrane and middle ear cavity, a
solution bottle’s cap was used. This cap served as the tympanic membrane
cartridge. A thin single sheet of polyethelene film (Glad Cling Wrap) was
used to simulate the tympanic membrane. 8 Sealing off the open end of the
cap with the cling wrap, an enclosed cavity was made within the cap acting
as the middle ear cavity. A stainless steel hose ring was used to secure the
cling wrap to the cartridge. Different consistencies of fluid were placed with
in the supposed middle ear space to check if it can be held with in the
cavity.
A port on the occipital portion of the model head was made that would
accommodate the tympanic membrane cartridge. The port was made in
such a way that the cap when inserted would fall exactly at the medial end
of the external auditory canal. Thus, completing the representation of
external and middle ear structures.
Several trial runs of myringotomy, suctioning of middle ear fluid, and
tube insertion was done on the simulator by the authors.
Methods and Materials
Simulators and task trainers are becoming an important
aspect of training residents. It allows physicians to be exposed
to relatively unfamiliar situations and procedures in a safe
manner.
This simulator has the potential to help train residents and
students in the proper instrumentation when it comes to doing
myringotomy and tube insertion. It also provides a safe
environment to develop dexterity, familiarity, and confidence in
doing the aforementioned procedures.
There are several things that can be done in order to
validate the efficiency and reliability of the simulator.
Several participants can be asked to rate the simulator with
the use of grading scale. The scores can then be averaged and
analyzed to have a statistical measure of how the simulator is
rated in the hands of novice and expert surgeons.
A construct validity of this simulator can also be undertaken
in the future.
Doing a CT-scan of the model may be beneficial in seeing
how closely the model approximate actual human dimensions.
Discussion
Surgery is performance of a set of tasks that would
eventually, lead to improvement if not cure of a patient. There
is no question that whatever operation is to be performed on a
human being, it places some degree of pressure on the
surgeon as there are a myriad of complications that can
happen. Performance of such tasks often requires quick and
deliberate actions. Employing finesse and coordinated
movements and constant presence of mind.
We have started to shy away from the traditional way of
surgical training where in a resident learns by performance of
procedures on actual patients under the supervision of more
experienced surgeons.
The benefits of surgical simulation have been proven. With
the presence of simulators, constant practice and objective
evaluation of skill can be done without placing added risks to
the patient under the hands of a surgeon still on the learning
curve.
The creation of this simulator is a step towards the
improvement of surgical training, evaluation of residents, better
health economics, and patient safety.
Conclusions
The use of simulators have started to become available and
the need for such devices in surgical training has been
recognized including in Otolaryngology. The use of such
simulators allows trainees to have a relatively unpressured and
relaxed environment to perform surgical tasks. Decreased
errors, decreased operative time and in general a safer
procedure for patients are cited results. Simulators are such
vital tools that allow for safe repetition of techniques to train the
minds and hands of surgeons how to operate.1
Myringotomy and insertion of pressure equalizing tube is
one of the most basic and common procedures done by an
Otolaryngologist. These perhaps are the reasons why
simulators for this procedure was among the first to emerge in
the field of Otolaryngology.
The earliest attempt at making a simulator for myringotomy
was in 1969 which was composed of an acrylic external ear
with a bronze base and used tracing paper as the simulated
tympanic membrane.2
In the past also, there have been other simulators emerging
from the relatively cheap construct of tubing sealed on the
distal end with either a rubber or plastic. Differences for these
simulators have been seen in the type of tubing used to
represent the external auditory canal and the material used to
simulate the tympanic membrane.3,4,5 More recently, virtual
imaged and computer based simulators have been seen.6
It has been proven that simulation has a significant effect on
operative time and task performance, and yet wide spread use
of surgical simulation is still to be seen.7 With this device, we
try to offer a relatively cheap and high fidelity simulator for
myringotomy and tympanostomy tube insertion.
Picture 1. Different views of the simulator.
Results We were able to construct a simulator for doing myringotomy,
evacuation of middle ear fluid, and tympanostomy tube
insertion. The simulator when tested proved to be sturdy, easy
to use, and economical. Fidelity with actual performance of
these procedures also seems to be a quality of this simulator.
Picture 2. Middle ear cavity cartridge.
Picture 3. Myringotomy done through simulated tympanic membrane.
Picture 4. Pressure equalizing tube in place with middle ear fluid being suctioned.