Babak Sadoughi

The role of virtual reality in surgical training in otorhinolaryngology

Purpose of reviewThis article reviews the rationale, current status and future directions for the development and implementation of virtual reality surgical simulators as training tools. Recent findingsThe complexity of modern surgical techniques, which utilize advanced technology, presents a dilemma for surgical training. Hands-on patient experience – the traditional apprenticeship method for teaching operations – may not apply because of the learning curve for skill acquisition and patient safety expectation. The paranasal sinuses and temporal bone have intricate anatomy with a significant amount of vital structures either within the surgical field or in close proximity. The current standard of surgical care in these areas involves the use of endoscopes, cameras and microscopes, requiring additional hand–eye coordination, an accurate command of fine motor skills, and a thorough knowledge of the anatomy under magnified vision. A surgeons disorientation or loss of perspective can lead to complications, often catastrophic and occasionally lethal. These considerations define the ideal environment for surgical simulation; not surprisingly, significant research and validation of simulators in these areas have occurred. SummaryVirtual reality simulators are demonstrating validity as training and skills assessment tools. Future prototypes will find application for routine use in teaching, surgical planning and the development of new instruments and computer-assisted devices.

Image‐Guidance for Endoscopic Sinus Surgery

Objectives/Hypothesis: Image‐guided surgery (IGS) is a critical tool. However, its clinical validity remains controversial. A review of indications and a consensus based on literature are presented.

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 childrens 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.

Deep cervical lymph node hypertrophy: A new paradigm in the understanding of pediatric obstructive sleep apnea

To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy.

Criterion-Based (Proficiency) Training to Improve Surgical Performance

OBJECTIVE To investigate whether training otorhinolaryngology residents to criterion performance levels (proficiency) on the Endoscopic Sinus Surgery Simulator produces individuals whose performance in the operating room is at least equal to those who are trained by performing a fixed number of surgical procedures. DESIGN Prospective cohort. SETTING Two academic medical centers in New York City. PARTICIPANTS Otorhinolaryngology junior residents composed of 8 experimental subjects and 6 control subjects and 6 attending surgeons. INTERVENTION Experimental subjects achieved benchmark proficiency criteria on the Endoscopic Sinus Surgery Simulator; control subjects repeated the surgical procedure twice. MAIN OUTCOME MEASURES Residents completed validated objective tests to assess baseline abilities. All subjects were videotaped performing an initial standardized surgical procedure. Residents were videotaped performing a final surgery. Videotapes were assessed for metrics by an expert panel. RESULTS Attendings outperformed the residents in most parameters on the initial procedure. Experimental and attending groups outperformed controls in some parameters on the final procedure. There was no difference between resident groups in initial performance, but the experimental subjects outperformed the control subjects in navigation in the final procedure. Most important, there was no difference in final performance between subgroups of the experimental group on the basis of the number of trials needed to attain proficiency. CONCLUSIONS Simulator training can improve resident technical skills so that each individual attains a proficiency level, despite the existence of an intrinsic range of abilities. This proficiency level translates to at least equal, if not superior, operative performance compared with that of current conventional training with finite repetition of live surgical procedures.

Endoscopic endonasal surgery simulator as a training tool for ophthalmology residents.

Purpose: Surgical training on the endoscopic endonasal surgery simulator had proven efficacy for otorhinolaryngology residents in preparation for endoscopic endonasal and sinus surgery. Its use for ophthalmology residents in preparation for endoscopic endonasal dacryocystorhinostomy has not been previously studied. Methods: Eight of 15 ophthalmology residents recruited for this experimental study underwent training on the endoscopic endonasal surgery simulator, completing the novice and intermediate modules. All 15 residents then participated in cadaver surgical training, performing defined surgical tasks including endoscopic navigation, identification of nasal anatomy, endonasal injection, and middle turbinate medialization. Performance on these tasks was videotaped and graded by 2 masked observers. Total mean scores and variance by task category were compared between subjects and controls and interobserver variance was compared between observers. Results: Correlation between the 2 masked observers’ scores was strong (R = 0.677), with total mean scores of 2.34 and 2.38, respectively. Total mean scores were 2.79 for subjects, and 1.86 for controls (F value 0.735, p = 0.01). Residents who trained on the simulator performed significantly better during endonasal navigation (mean scores 2.58 for subjects versus 1.74 for controls, p = 0.04) and endonasal injection (mean scores 2.73 for subjects versus 1.72 for controls, p = 0.03) and minimally better at identification of nasal anatomy (mean scores 2.93 for subjects versus 1.88 for controls, p = 0.18) and middle turbinate medialization (mean scores 3.13 for subjects versus 2.78 for controls, p = 0.36). Conclusions: Ophthalmology residents who trained on the surgical simulator had significantly enhanced endoscopic endonasal surgical skills for endonasal navigation and injection.

Cardiac metastasis after squamous cell carcinoma of the base of tongue

OBJECTIVES Metastases to the heart are rare. We report a case of squamous cell carcinoma of the base of tongue secondarily complicated with cardiac metastasis 6 months after surgical treatment resulted in successful local control. METHODS The lesion was found using computerized axial tomography in a patient with minimal cardiologic symptoms. RESULTS The patient died shortly due to complications of his metastatic disease. No curative treatment was possible. CONCLUSIONS Cardiac metastasis should be suspected when new cardiovascular symptoms are observed in patients with a history of head and neck neoplasm. The prognosis of the condition typically is inevitably fatal.

Preservation of the marginal mandibular branch of the facial nerve using a plexus block nerve stimulator

Preserving the marginal mandibular branch of the facial nerve is essential in submandibular neck dissection to avert disfiguring complications. Despite the high incidence of postoperative palsy, old‐fashioned techniques of nerve identification remain widespread. The use of disposable plexus block nerve stimulators as a safe and accurate method to localize the nerve intraoperatively is suggested herein. Such devices are significantly more affordable and user‐friendly than larger facial nerve monitoring devices, which are rather favored for those procedures more extensively jeopardizing the branches of the facial nerve. In this report, disposable stimulators led to successful identification of the nerve in 100% of 25 patients between 2003 and 2005, with no postoperative paralysis. In addition, stimulation devices are constantly gaining in reliability and safety, and the number of surgical fields supporting their use is expanding. Therefore, their routine use for surgery on the submandibular area is recommended by the authors.

Time course of recovery of idiopathic vocal fold paralysis

To clarify the time course of recovery in patients with idiopathic vocal fold paralysis.

Computer‐assisted rating of surgical skills: introduction to urate

resource-constrained settings, implementation of such programmes can be challenging. Our investigation documents the implementation of an objective structured clinical or practical examination (OSCE ⁄ OSPE) for undergraduate pharmacy students in Uganda. The project focused on the effective training of standardised patients (SPs) and faculty evaluators in a short amount of time. Why the idea was necessary One of the objectives of our problem-based learning curriculum is to enhance the teaching and assessment of the clinical skills of our students, including information gathering, medication counselling and minor physical patient examination. Up to now, most assessment tools have focused on knowledge recall, using multiple-choice questions, short and long essays and oral assessment, none of which are resource-intensive. Clinical skills and reasoning are tested at the bedside using oral examination procedures, but these assessments are limited in their reliability and scope. In addition, practical skills including medication formulation and preparation are not adequately assessed. Moreover, faculty members have limited exposure to the concepts of assessment reliability and newer methods of assessment. What was done We developed a 10-station OSCE ⁄ OSPE to assess students clinical and practical skills. All 25 Year 3 pharmacy students participated in the summative assessment. Feedback was obtained from examinees and faculty about their perceptions of the examination process. Six of the stations focused on clinical skills and 4 on practical drug formulation skills. Two examples of the cases used are: a patient with malaria fever, and insulin use in a newly diagnosed type 1 diabetes patient. A typical practical station asked students to identify critical components of machines for drug analysis, and to make accurate measurements for drug formulation using available, inexpensive materials. Orientation materials were also prepared for examinees who had never previously experienced this type of examination. For the OSCE, we trained Year 5 (resident) pharmacy students for 4 hours to portray patients typically seen by practising pharmacists. During a 3-day faculty workshop, basic concepts in assessment were presented. Faculty reviewed curriculum objectives and were trained to create cases that reflected these. In addition, faculty were trained to score the encounter using checklists of critical actions. Faculty from the Assessment Task Force were briefed on the project and its results. Evaluation of results and impact Overall, 65% of the examinees indicated that they strongly preferred the OSCE format to ward-based bedside assessment, and 80% preferred the OSCE format to the oral examination. Over 50% perceived that the OSPE was more focused than the traditional form of practical assessment. Over 70% indicated that the mode of assessment was consistent with their expectations of future work as pharmacists. Faculty appreciated the authenticity of the encounters. The Assessment Task Force appears to be more aware of the need for alignment between education objectives and assessment. This form of assessment is time-efficient compared with traditional bedside assessment. Effective faculty and SP training occurred in a short time. Other departments, such as the Department of Internal Medicine, are preparing to modify their assessment methods. Future steps in the Department of Pharmacy include modification of the educational programme based on the results of the OSCE examination.