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Novel Peritonsillar Abscess Drainage Task Simulator
Steven R Taylor, MD, Faith Phillips, BSN, RN, C.W. David Chang, MD
University of Missouri - School of Medicine
University Of Missouri Healthcare System
Contact 1. Satava R. Emerging trends that herald the future of surgical simulation. Surg Clin North Am. 2010;90:623-633.
2. Malekzadeh, S. A Novel Low-Cost Sinus Surgery Task Trainer. Otolaryngology–Head and Neck Surgery 145(4) 530–533.
3. Volsky PG, Hughley BB, Pierce SM, et al. Construct validity of a simulator for myringotomy with ventilation tube insertion.
Otolaryngology–Head and Neck Surgery (2009) 141, 603-608.
4. Gantwerker E, Toth P, Provenzano M, et al. Development and Pilot Testing of a Task Trainer for Tonsillectomy Simulation: A Feasible, Cost-
Effective, and Re-Usable Model. http://www.researchposters.com/Posters/AAOHNSF/AAO2012/SP118.pdf. Accessed 9/12/2013.
5. Javia L, Deutsch ES. A Systematic Review of Simulators in Otolaryngology. Otolaryngology–Head and Neck Surgery 147(6) 999–1011.
6. Steyer T. Peritonsillar Abscess: Diagnosis and Treatment. Am Fam Physician 2002;65:93-6.
7. Van Nortwick SS, et al. Methodologies for establishing validity in surgical simulation studies. Surgery 147; 5:622-630.
References
Objective: To develop a low-cost task simulator for peritonsillar abscess drainage, in order to help new residents gain familiarity with the instrumentation and essential steps involved in the procedure.
Methods: A latex moulage fashioned from a plaster mold was constructed to replicate an oropharynx with a unilateral tonsillar abscess. The moulage with a pseudo-abscess was secured behind a 2.5” PVC pipe and horizontally mounted. Participants were given a series of tasks to expose, anesthetize, aspirate, and drain the abscess.
Results: Initial impressions were favorable that the models sufficiently replicated the tasks requisite for draining a peritonsillar abscess. Completion of the simulated task required bimanual dexterity and comfort with use of headlight and instrumentation within an enclosed space similar to that required in the real situation. The anatomy of the oropharyngeal moulage was thought to be adequate. Cost of the construct and initial model is less than 10 dollars, with subsequent models much less than 25 cents to produce.
Conclusion: Production of a low-cost task stimulator for drainage of a peritonsillar abscess is feasible and may provide a reasonably realistic environment to allow residents to practice and develop this skill. Further study is needed to formally assess face, construct, and content validity of this simulator for teaching and assessment of procedural competency.
Abstract
An initial study of 12 medical professionals (2 medical students, 8 residents, and 2 faculty), was performed at our simulation center. Table 1 represents their responses to the questionnaire. 5 participants had drained >15 abscesses, 2 participants drained 6-10, and 5 drained 0-2.
Introduction
Peritonsillar abscess(PTA) model construction was performed by a team of otolaryngologists and simulation center staff (Figure 1). A 3” (7.7cm) length of 2.5” (6.4 cm) diameter PVC pipe was used to represent the oral cavity. A hole was drilled into the lateral aspect of the PVC to allow for introduction of a camera. A clay mold was sculpted to create the “negative space” of the oral cavity. Indentations were made in the mold representing the uvula, normal tonsil, and a right-sided infected tonsil. A “positive” latex moulage was created by applying layers of liquid latex over the mold. Each layer was allowed to dry before the application of the next layer. Three thin layers of flesh colored latex was used to create adequate support. Once dry, a large rubber band secured the latex moulage to posterior end of the PVC pipe. Abscess liquid was made from sugar-free vanilla pudding and non-refrigerated coffee creamer mixed to the proper consistency. A small latex balloon filled with 3 cc of the liquid was then wrapped in a 3mm piece of foam. The foam created a submucosal space to separate the latex moulage from the balloon abscess. The abscess and foam were secured with packing tape to the posterior aspect of the moulage. Lips were constructed using layers of latex molded over a plaster model. This was secured to the anterior end of the PVC pipe with a round clamp. A tongue borrowed from a simulator model was secured inside the PVC pipe with Velcro. To hold the simulator, a 3” rubber cap lined with foam tape was mounted on to a vertically oriented piece of plywood (Figure 2). The completed PTA construct was placed into the rubber cap. A flexible GI endoscope was passed through the side-wall hole of the PVC pipe. An endoscopic tower was attached to the scope to enable video recording. Participants of the study consisted of faculty members, residents, and rotating medical students in the Department of Otolaryngology. Each member was given the same instruments and an instruction sheet regarding the steps to follow to drain the abscess. Their ability to use a headlight to expose the oropharynx, use a tongue blade, anesthetize the posterior oropharynx, aspirate, and incise the abscess was recorded. Following the procedure, a 13-question survey was supplied to evaluate the simulator, and volunteers were asked to grade their experience on a five-point Likert scale (Questions below). Questions focused specifically on the ability of the trainer to replicate tasks requisite for PTA drainage, as well as general questions about the value of a PTA task simulator. Level of training and number of abscesses were also included in the questionnaire.
Methods and Materials
Participants felt the tasks were appropriate and accurate in simulating draining a PTA. It teaches the basic principles necessary to approach a patient, visualize, anesthetize, and attempt to drain an abscess. All agreed that this trainer helps develop bimanual dexterity and use of a headlight. All but one participant agreed or strongly agreed that this simulation helps with learning to anesthetize the oropharynx and aspirate and incise the abscess. However, our questionnaire indicated that many felt the moulage does not represent the posterior oropharynx accurately (50%). This led some (33.3%) to be unsure how well this simulator would help with competency in draining PTAs. Participants wanted more accurate anatomy, such as posterior pillars, a more accurate uvula and “feel” when incising the oropharyngeal tissues. In spite of this, participants still felt (83.3%) the skills are represented well with this simulator. We feel these results come from using a lower fidelity model with a latex model, whereas some desired complete fidelity. This model provides a low-cost construct for training younger residents techniques for draining a PTA. Cost of the construct and initial model is approximately 10 dollars, with subsequent models less than 25 cents to create, given only the abscess, foam, and latex moulage need to be replaced. Simulators and task trainers are becoming an important aspect of training new residents1,2,7. It allows physicians to be exposed to new situations and procedures in a safe manner. Simulators also allow for practice of techniques to develop skills necessary to more effectively operate. Transoral PTA drainage is a very common procedure performed by otolaryngologists and other medical professionals. There is a steep learning curve given the unfamiliar anatomy, need for adequate exposure, and experience when residents first perform this procedure. Younger residents may not see their first PTA until on call, when they need to safely drain the abscess. Proper technique, adequate visualization, anesthetizing, and drainage of the abscess are all important techniques that need to be learned to consistently and safely drain an intraoral abscess. The techniques mastered in draining a PTA can also extend into other transoral cases where use of headlight, exposure, and bimanual dexterity is required.
Discussion
The role for simulators in resident training continues to expand and the demand for low-cost, but valid, models is increasing. The creation of a low-cost PTA simulator can provide increased training, especially to younger residents, regarding safe technique for draining the abscess. This model provides a low-cost, reusable, and safe method for training otolaryngology residents competencies needed for draining PTAs. Further research needs to be performed regarding the face, content, and construct validity of this simulator, which is currently underway.
Conclusions
Simulators are becoming a vital tool in surgical residency training to teach physicians proper skills and techniques prior to entering the operating room1. The need for simulators is greater now with residency hour restrictions. Simulators allow for safe repetition of techniques to train the minds and hands of surgeons how to operate. Many simulators have already been produced for otolaryngology procedures, ranging from simple low-cost models to use of cadavers or human models2-5. Peritonsillar abscess (PTA) is the most common deep head and neck infection in adults, formed from an untreated, or undertreated, tonsillar infection6. Failure to properly manage a PTA can lead to spread of the infection to neighboring deep neck spaces, oftentimes hospital admission, IV antibiotics, and more extensive, intraoperative, drainage of the abscess. Oftentimes, transoral drainage of a PTA can be safely performed in an emergency room setting, obviating the need of an operating room and further treatment. Proper drainage includes adequate visualization and lighting, anesthetizing the patient appropriately, aspirating the abscess and/or incising the peritonsillar region to allow for adequate drainage. Complications include inability to find the abscess, inadequate drainage, recurrence, or, extremely rare, injury to the carotid artery. Most of the training regarding PTA drainage is “on the job,” learning from watching a more senior physician drain the abscess. To our knowledge, there are no task simulators for draining a peritonsillar abscess that has been published. Our goal was to provide a low-cost, easy to make task simulator to provide younger residents the proper techniques and steps requisite to safely approach and drain a PTA.
Results
Figure 2. Peritonsillar construct. A: Completed construct, mounted, with endoscope in place. B: Use of tongue depressor to evaluate posterior oropharynx. The peritonsillar abscess in located behind the right tonsil. C: Aspirating the peritonsillar abscess after achieving adequate visualization with the use of a headlight and tongue blade.
C W David Chang, MD
Jerry W Templer Faculty Scholar
Program Director and Associate Professor
Tel: (573) 882-6737
Department of Otolaryngology - Head and Neck
Surgery
University of Missouri - School of Medicine
One Hospital Dr MA314, Columbia, MO 65212
Steven R Taylor, MD
Resident Physician
Tel: (573) 882-6737
Department of Otolaryngology - Head and
Neck Surgery
University of Missouri - School of Medicine
One Hospital Dr MA314, Columbia, MO 65212
PERITONSILLAR ABSCESS DRAINAGE MODEL EVALUATION
Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
1. This model adequately represents the anatomy
of the oropharynx and oral cavity in the setting of
a peritonsillar abscess.
0(0) 8.3(1) 41.7(5) 41.7(5) 8.3(1)
2. This model helps develop familiarization with
use of headlight.
0(0) 0(0) 0(0) 25(3) 75(9)
3. This model helps develop skills for
anesthetizing the peritonsillar region
0(0) 0(0) 8.3(1) 58.3(7) 33.3(4)
4. This model helps to develop skills to
aspirate/incise the abscess for adequate
drainage.
0(0) 0(0) 8.3(1) 66.7(8) 25(3)
5. This model helps to develop depth perception
and hand-eye coordination when operating
within the oral cavity.
0(0) 0(0) 0(0) 33.3(4) 66.7(8)
6. This model helps to develop bimanual
dexterity and precision.
0(0) 0(0) 0(0) 41.7(5) 58.3(7)
7. This model helps to develop skills needed for
intraoral procedures.
0(0) 0(0) 8.3(1) 50(6) 41.7(5)
8. Use of this model will increase resident
competency when used to train residents prior to
their first drainage of a peritonsillar abscess.
0(0) 0(0) 33.3(4) 25(3) 41.7(5)
9. This model correlates well with the essential
skills needed for drainage of peritonsillar abscess
0(0) 0(0) 16.7(2) 50(6) 33.3(4)
10. I would be interested in using this model to
train residents.
0(0) 0(0) 25(3) 50(6) 25(3)
11 This model is an adequate training model for
future surgeons.
0(0) 0(0) 33.3(4) 50(6) 16.7(2)
Circle your level of training: Medical
Student
PG
Y1
PGY 2 PGY 3 PGY 4 PGY 5 Faculty
How many peritonsillar abscesses have you
drained?
0-2 3-5 6-10 11-15 >15
Table 1: Participant questionnaire. Responses presented as percentages. Total number in parentheses.
Figure 1: Simulator construction. A: Clay model for latex moulage. B: Latex moulage. C: Mounting of moulage to posterior aspect of PVC pipe. D: Placement of abscess (filled latex balloon wrapped in foam) within the moulage.
A
C
D
B
C
A B
Peritonsillar Abscess
