Otolaryngology Training Programs Research Articles

Practice Patterns, Safety, and Rationale for Tracheostomy Tube Changes: A Survey of Otolaryngology Training Programs

Practice Patterns, Safety, and Rationale for Tracheostomy Tube Changes: A Survey of Otolaryngology Training Programs

Practice Patterns, Safety, and Rationale for Tracheostomy Tube Changes: A Survey of Otolaryngology Training Programs

Tracheotomy for long-term ventilation is a common surgical procedure in the hospital setting. Although the postoperative care is often perceived as routine, complications associated with tracheostomy changes may result in loss of airway and death. In addition, the practice patterns, rationale, and complications related to tube changes have been poorly described. A survey of chief residents in accredited otolaryngology training programs was performed to determine the management strategies, rationale, and complications associated with postoperative tracheostomy tube changes. The first tube change was performed after a mean of 5.3 (range, 3-7) days after the procedure, most frequently by junior residents. The first change was performed in a variety of locations including the intensive care unit (88%), step down unit (80%), and regular floor (78%). Twenty-five percent performed these changes at night or on weekends. The most frequently reported rationale for performing routine tracheotomy changes was examination of the stoma for maturity (46%), prevention of stomal infection (46%), and confirmation of stability for transport to a less monitored setting (41%). Twenty-five (42%) respondents reported awareness of a loss of airway, and nine (15%) respondents reported awareness of a death as a result of the first tube change at their institution during their residency. A statistically significant higher incidence of airway loss was reported by respondents who reported performing the first tube change on the floor (96.1% vs. 63.6%). There is significant variability in the approach to postoperative tracheostomy tube management. The occurrence of major complications including deaths from routine tube changes requires an examination of the rationale and safety of this practice.

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

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. 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. 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. 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 itsfull acceptance and use in otolaryngology training programs.

Implementation of duty hour standards in otolaryngology-head and neck surgery residency training

To determine what impact, if any, of the recently implemented duty hour standards have had on otolaryngology-head and neck surgery residency programs from the perspective of program directors. We hypothesized that the implementation of resident duty hour limitations have caused changes in otolaryngology training programs in the United States. Information was collected via survey in a prospective, blinded fashion from program directors of otolaryngology-head and neck residency training programs in the United States. Overall, limitation of resident duty hours is not an improvement in otolaryngology-head and neck residency training according to 77% of the respondents. The limitations on duty hours have caused changes in the resident work schedules in 71% of the programs responding. Approximately half of the residents have a favorable impression of the work hour changes. Thirty-two percent of the respondents indicate that changes to otolaryngology support staff were required, and of those many hired physician assistants. Eighty-four percent of the respondents did not believe that the limitations on resident duty hours improved patient care, and 81% believed that it has negatively impacted resident training experience. Forty-five percent of the program directors felt that otolaryngology-head and neck faculty were forced to increase their work loads to accommodate the decrease in the time that residents were allowed to be involved in clinical activities. Fifty-four percent of the programs changed from in-hospital to home call to accommodate the duty hour restrictions. According to the majority of otolaryngology-head and neck surgery program directors who responded to the survey, the limitations on resident duty hours imposed by the ACGME are not an improvement in residency training, do not improve patient care, and have decreased the training experience of residents. This study demonstrates that multiple changes have been made to otolaryngology-head and neck surgery training programs because of work hour limitations set forth by the ACGME.

Virtual temporal bone dissection: an interactive surgical simulator.

Our goal was to integrate current and emerging technology in virtual systems to provide a temporal bone dissection simulator that allows the user interactivity and realism similar to the cadaver laboratory. Iterative design and validation of a virtual environment for simulating temporal bone dissection. University otolaryngology training program with interdisciplinary interaction in a high-performance computer facility. The system provides visual, force feedback (haptic), and aural interfaces. Unlike previous "fly through" virtual systems, this environment provides a richer emulation of surgical experience. The system provides a high level of functional utility and, through initial evaluations, demonstrates promise in adding to traditional training methods. The system provides an environment to learn temporal bone surgery in a way similar to the experience with cadaver material where the subject is able to interact with the data without constraints (nondeterministic). Eventually, it may provide the "front end" to a large repository of various temporal bone pathologies that can be accessed through the Internet.

The otolaryngology research paradox.

To determine the attitude toward and the state of research within the field of otolaryngology-head and neck surgery. A questionnaire was sent to the chairpersons of departments of otolaryngology where residency training is provided. Program directors of academic otolaryngology training programs. Responses to questionnaire. Questionnaires were sent to 95 programs from which 86 responses were received. Respondents believed strongly that research was important to the specialty. Only two thirds of the full-time clinical faculty, however, do research, and on average they devote only 17% of their time to this activity. About a third of those doing research have funding, and the National Institutes of Health support only 12% of clinician-investigators. Although program directors believe that clinicians should do research, three fourths stated that clinicians were too busy to accomplish this goal. Surprisingly, half of the respondents were unaware of residency programs that offered 2 years of research training, aimed to develop clinician-investigators, who can become competitive for attainment of research funding. Although leaders within our specialty believe that research is important, clinicians are not provided with enough time to conduct research. Furthermore, pathways that would enhance their competitiveness to obtain research funding are not recommended to our future clinicians.

Complications of Rhytidectomy in an Otolaryngology Training Program

Complications of rhytidectomy have been widely reported in the literature. This study examines the incidence of complications after rhytidectomy in the hands of chief residents under appropriate attending supervision in an otolaryngology-head and neck surgery training program. The charts of 96 consecutive SMAS rhytidectomy patients were retrospectively reviewed. Patients were selected for surgery from a clinic designed exclusively for cosmetic facial surgery patients. This clinic was run by the otolaryngology chief resident and was supervised by an attending staff surgeon. Most patients elected local anesthesia and sedation administered by the surgical team. Submental liposuction was performed followed by SMAS plication rhytidectomy. Follow-up ranged from 1 to 60 months. Complications included expanding hematoma (1%), temporary facial nerve weakness (3%), pretragal/mastoid skin slough (4.2%), permanent ear numbness (1%), hypertrophic scar (3.1%), wound infection (1%), and dissatisfaction with result (4%). There were no cases of permanent facial nerve injury. These complication rates compare favorably with reported rates of larger studies over the past 30 years. These data support the conclusion that rhytidectomy can be performed safely by otolaryngology residents with little morbidity and good patient satisfaction.

Perspective: committed to excellence.

Perspective: committed to excellence.

Facial plastic surgery in the otolaryngology training program: An update

In 1985, we demonstrated that, following the institution of a specific curriculum in facial plastic surgery, the number of cosmetic procedures generated and performed by residents rose dramatically. We have now demonstrated that this increase has been sustained in the 5 years since establishing the curriculum. We continue to maintain that the key to a successful curriculum in facial plastic surgery is the presence of at least one full-time staff member whose primary function is the practice and teaching of facial plastic surgery.

Aesthetic facial surgery in the otolaryngology training program.

A major evolutionary change in the past decade has been to broaden the exposure and enhance the experience of the otolaryngology resident in the field of facial plastic surgery. A strong background in head and neck surgical oncology has been established in most residency programs and subsequent introduction to facial plastic surgery through reconstructive procedures has opened a new horizon to the regional specialist. The increased importance of an aesthetically acceptable surgical result in the face with its strong social and psychologic connotations imposes more pressure on the head and neck surgeon to develop appropriate surgical skills. As the specialty continued to strive toward this goal in reconstructive surgery and in maxillofacial trauma, it predictably developed a greater interest in elective cosmetic surgery. The American Board of Otolaryngology appropriately responded in past years to this evolution by including topics on facial plastic surgery as a significant part of the certification

Research training for residents.

I have been given the almost impossible task of assessing the status of research in otolaryngology residency programs across the country. How best to do this is elusive to me. However, three methods seem appropriate for the task. The first is to sample the philosophical opinions of program directors representing widely varied sized and geographically situated programs. The second is to review the pertinent results of the Society of University Ophthalmologists (SUO) survey, performed in 1981, regarding research and residency programs. The third is the presentation of an example of a program with a mandatory research rotation, specifically, that of the University of Washington, Seattle. Prior to composing this article, I thought it best to sample the opinions of directors of representative otolaryngology training programs. What follows are excerpts from letters composed by seven program directors in response to the question, What roles do researchers play in their training programs

Lacrimal Disorders: Diagnosis and Treatment,

This 170-page monograph will naturally find more utility among ophthalmologists than among otolaryngologists. The surgical techniques that are described for canalicular repairs and dacryocystorhinostomy can be found in other otolaryngology or reconstructive surgery texts. The first chapter, entitled Anatomy and Embryology of the Lacrimal System, is well illustrated and serves as an excellent anatomical reference for the important medial canthal region. A concise review of total reconstruction of the lacrimal drainage system is found in chapter 10. Trauma and reconstructive problems of the eyelids are not discussed. The chapters on dacryocystography, etiology of dacryocystitis, and physiology and secretory disorders of the lacrimal system are of little perti nence to the otolaryngologist. Chapter 7, Clinical Manifestations of Lacrimal Sac Disorders, covers the differential diagnosis of swellings of the medial canthal area. Included are helpful hints in differentiating inflammatory from neoplastic lesions. Overall, however, only those persons involved in otolaryngology training programs

Modern Problems in Ophthalmology, Vol 14: Orbital Disorders

This book is a collection of papers presented at the Second International Symposium on Orbital Disorders, which was held in Amsterdam in 1973. Articles from ophthalmology, otolaryngology, general plastic surgery, neurosurgery, radiology, endocrinology, embryology, and anatomy disciplines are included. Critical review and discussion are unfortunately absent. This wide-based view of orbital diseases, coupled with the grouping of articles in specific problem areas (eg, trauma, tumor surgery, reconstructive surgery), does make the book helpful to the surgeon dealing with orbital and periorbital lesions. Many of the papers will be of minimal interest to the practicing otolaryngologist, but the previously mentioned sections, as well as the portion dealing with radiology of the orbit, make it a worthwhile reference for otolaryngology training programs.

Pathology of the Ear

This is an unprecedented, incomparable, and uniquely outstanding book by Harold F. Schuknecht, the Walter Augustus Lecompte Professor of Otology and Professor of Laryngology, Harvard Medical School, and Chief of Otolaryngology at Massachusetts Eye and Ear Infirmary, Boston. This book is an absolute must for every practicing otologist, and it is an essential reference source for every otolaryngology training program. It is superbly written and is comprehensively illustrated. Dr. Schuknecht, in writing this encyclopedia of the pathology of the ear, has assimilated his vast knowledge of otology into this very basic and complete compendium of otopathology. The careful preparation of the book is apparent in its content and thorough presentation. Dr. Schuknecht begins with the histological method and carries the reader through anatomical concepts. Then he describes the pathophysiology of otologic disorders. Developmental defects, infections, disorders of intoxication, trauma, circulation, innervation, growth, metabolism, and aging follow in sequence. Next, he

Temporal bone removal at autopsy. Preparation and uses.

HUMAN TEMPORAL bones removed at autopsy can be used for either pathological study or for anatomical dissection, both of which are needed for otolaryngology training programs. They are also useful for improving our knowledge of the pathologic basis for otological disease. Freshly removed temporal bones can be placed in Teflon bags, with all the air expelled, and frozen. Such temporal bones provide a ready source of cadaver specimens for teaching otologic surgery. These specimens contain the external auditory canal, middle ear, mastoid, and petrous pyramid which are the important structures for surgical dissection. The training of an otolaryngologist includes the dissection of 10 to 20 temporal bones while utilizing modern surgical equipment and sufficient magnification before the otolaryngologist can engage in surgery on live human beings. It is not practical to perform surgical exercises on the temporal bone of the intact body in the morgue. Appropriate surgical instruments and operating