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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: carlovillanueva.md@gmail.com 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.