Pilot Temporal Bone Course – Mbarara, Uganda

2016 Temporal Bone Course Report

Course Report compiled by Flordeliz Osler, MD (University of Manitoba); Doreen Nakku, MD (Mbarara University of Science and Technology); Kimberly Luu, MD (UBC); Ronald de Venecia, MD, PhD (Mass Eye and Ear/Harvard); Brian Westerberg, MD (UBC)

MUST Otolaryngology

The Department of Otolaryngology at Mbarara University of Science and Technology is dedicated to the task of overcoming the many challenges of providing high quality otolaryngology care to an underserved population in a low-income country with limited medical resources. Uganda is an east African country with a population of 37.8 million people, the majority of whom live in a rural setting. The annual GDP is only 680USD. This population of nearly 38 million is serviced by less than 30 practicing otolaryngologists, some whom do primarily administrative work.

Mbarara is the largest urban center in the western region of Uganda with a rapidly growing population that has more than doubled in the last 4 years (82K to 195K in the 2010 and 2014 censuses respectively). The city is home to one of three regional referral hospitals, Mbarara Regional Referral Hospital (Mbarara Hospital) which is affiliated with the medical school at Mbarara University of Science and Technology (MUST). It is a public hospital with over 600 beds that is often over capacity. The Otolaryngology department at MUST consists of three staff physicians:

  • Professor Evelyn Llovet, Department Head, cross appointed from Cuba
  • Dr. Doreen Nakku, Neuro-otology
  • Dr. Victoria Nyaiteera, Rhinology

The department is currently training three residents, two in their final year and one in his first year. In addition, a dedicated clinical officer also provides clinical care to patients.

Mission Statement

The MUST Faculty of Medicine has a mission to establish itself as a place of healthcare excellence.  Aligned with this goal, the Otolaryngology department has a mission statement of creating a Center for Excellence in Otolaryngology for all of Uganda. The main tenets of this vision are:

  • To develop capacity to offer the best public otolaryngology care for the people of Uganda
  • To continue faculty excellence through professional and skills development
  • To provide comprehensive training to faculty, the residency group and medical students
The Team

Under the direction of Dr. Doreen Nakku, there is tri-partner collaboration between:

  • Mbarara University of Science and Technology (MUST)
  • Massachusetts Eye and Ear (MEE)
  • University of British Columbia (UBC)/University of Manitoba/Canadian Society of Otolaryngology-Head and Neck Surgery (CSO-HNS)

Through a tradition of three trips to MUST per year (2 MEE and 1 CSO-HNS) the group works at building the educational infrastructure of the MUST Otolaryngology department and expanding their clinical capacity to improve the quality of local care.

Needs Assessment

Cadaveric temporal bone dissection in a temporal bone laboratory is an important component in training and maintaining the skills of a competent otolaryngologist. Until recently, there was no such well-equipped facility in Uganda; the one attempt for such a facility at Mulago hospital is limited by lack of functional equipment. Residents have generally learnt temporal bone anatomy and dissection skills through a textbook and traditional clinical exposure. However, it was identified that residents at both MUST and Makerere University in Kampala had either very limited or no experience in using a drill to perform a mastoidectomy on a cadaver or in a real-life clinical scenario. The identification of this gap in skills prompted the temporal bone lab project.

Pre-Trip Planning

Planning for the temporal bone lab and course began approximately 6 months before the course. The importance of a local leader and advocate who develops the vision for the project and is able to execute the necessary planning should be noted; these leaders were Dr. Nakku and Dr. Nyaiteera at MUST. Drs. Gigi Osler (University of Manitoba), Brian Westerberg (UBC), and Ron de Venecia (MEE) also contributed to course coordination.

Equipment

A temporal bone lab requires a space that can fit the necessary equipment and has electrical and plumbing capability to accommodate each station. A room in the Ophthalmology building at MUST was secured with the capacity to fit 4 temporal bone stations

Temporal bone stations were donated in 2013 by Harvard University, Boston, as a philanthropic donation through the Office of Global Surgery and Health at Massachusetts Eye and Ear. MUST was able to provide funding for transport to Uganda. The stations included:

  • 4 desks
  • 4 microscopes with an observation arm
  • 1 station connected to a monitor for demonstration
  • 4 temporal bone holders
  • 4 suction canisters and 1 main vacuum device

Medtronic Africa supported the educational program by providing

  • Drill consoles
  • Drill handles
  • Drill bits

Additional equipment needs

–      Transformers and power bars were needed for all the North American equipment to use with African outlets

–      Additional back up bulbs were needed for the microscopes during the course

  • Care was taken to ensure that electrical capacity was sufficient such that all stations could run simultaneously
  • Sufficient Otolaryngology surgical instruments to equip all stations for the course were loaned from UBC/CSO-HNS

All equipment (except for the Medtronic components) were sent and set up at an earlier trip (October 2015) to ensure the space was ready. The space needed to be modified for additional plumbing and electrical needs, which occurred between October and December 2015. Final set-up of equipment, suction, and irrigation lines was performed several days prior to the inaugural course when drills for each station became available.

Temporal Bone Course

Course Preparation

Medtronic equipment was sent to Kampala, transported to Mbarara and set up by the team

Temporal bones were purchased, with enough bones for each participant to drill 2 temporal bones during the course

  • 6 bones came from Makerere University anatomy department
  • 6 heads came from MUST anatomy department, and were provided free of charge as the medical students had completed their anatomy dissection; these heads had the additional benefit of allowing students to practice soft tissue work
Course Schedule and Activity

As this was the first temporal bone course run at MUST, the vision was to offer the course free of charge to otolaryngology residents. Participants included 4 senior residents from Makerere University, and 4 MUST residents and Otolaryngology staff who attended January 19-21, 2016.

The course schedule (see Appendix 1) was developed with anticipated flexibility to align with learner needs. Dr. Westerberg and Dr. de Venecia provided lectures, and in conjunction with Dr. Nakku, temporal bone lab teaching. The number of workstations available allowed for only 4 participants to drill at one time. Despite the space and equipment limitations, all trainees successfully completed the goals of canal wall up mastoidectomy, canal wall down mastoidectomy, transmastoid labyrinthectomy, endolymphatic sac decompression, facial nerve decompression, and translabyrinthine exposure of the internal auditory canal. Thus each temporal bone specimen was used to maximal educational benefit. Each participant drilled out two specimens, and was assessed on their work with the second specimen.

A low fidelity simulator, the ear trainer, was also introduced throughout the 2.5-day course. This simple device mimics the ear canal and tympanic membrane to allow simulation of performing tasks in the ear under a microscope. All temporal bone course participants used the ear trainer to perform four tasks: removal of a foreign body, insertion of a tympanostomy tube, transcanal myringoplasty, and suture manipulation. Students then practiced these skills on the ear trainer. Their performance of the four tasks was evaluated before and after the practice. The ear trainer now remains in the temporal bone lab and can be used by medical students and residents at MUST to practice their microscopic and otologic surgery skills.

Day 1 course observations:

It was important and beneficial to have an official opening ceremony as it helped to promote the Otolaryngology department and garner further support from University administration. The opening ceremony was officiated by Dr. Nakku.

Day 2 course observations:

Students were eager for more time in the temporal bone lab so the second day was reorganized to have all the lectures done in the morning and residents were paired up at each station for the rest of the day. One resident would observe while the other drilled to take advantage of peer learning. Participation of the observing resident was variable, especially in the afternoon and may not have been the optimal learning environment.

Day 3 Participant Evaluation

Residents were evaluated through the completion of an OSAT evaluating their skill performing a mastoidectomy. These were recorded and can be compared to future OSATs to evaluate the retention of skill.

Course Feedback

Verbal and written feedback was collected from all participants at the end of the course. Overall, the feedback was very positive. Participants were asked to evaluate course contents and effectiveness, speakers, course venue, and the overall course. Evaluation forms were collected from 7 of the 8 course participants.

Course content and effectiveness

Participants were asked to rate their knowledge/skills at the beginning and at the conclusion of the course using a scale of Minimal = 1, Good = 2, Excellent = 3:

Average at Beginning Average at Conclusion
Knowledge of temporal bone anatomy 1.14 2.43
Knowledge of temporal bone surgery 1.43 2.57
Skill level in temporal bone surgery 1.14 2.14
Speakers

Participants were asked to rate their level of satisfaction with the speakers using a scale of Poor = 1, Fair = 2, Satisfactory = 3, Good = 4, Excellent = 5. Drs. Nakku, Westerberg, and de Venecia all received positive feedback on their subject matter expertise, teaching effectiveness, level of interactivity, and level of satisfaction with teaching material. Participant level of satisfaction ranged from good (4) to excellent (5).

Course venue

Participants were asked to rate their level of satisfaction with the course venue using a scale of Poor = 1, Fair = 2, Satisfactory = 3, Good = 4, Excellent = 5:

Average level of satisfaction
Lecture room 4.57
Temporal bone lab 4.43
Temporal bones 3.86
Food 4.28
Course overall

Participants were asked to rate their overall level of satisfaction with the course using a scale of Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5:

Please rate your level of agreement with these statements: Level of agreement with statements
I was satisfied with this course 4.43
I would recommend this course to a colleague 4.71
I had ample time to ask questions and interact with attendees 3.86
This course is free of commercial bias 4.57
Participant comments
  • I have learned a lot. I learned these three days things I wouldn’t have learned in the last year.
  • Very appreciative for such an arrangement. I have not remained the same in terms of skill and knowledge. I am going to read more and practice as much as I can to consolidate what I have learned.
  • This was a very good course and a very informative experience. Great tutors and great support. More of these courses will be most welcome. Thank you.
  • Very productive surgical camp – knowledge and skill regarding equipment, use and care, disease processes and management, drilling skills and clinical ear procedures.
  • Consistency and sustainability and attract more ENT residents from other countries.
  • I truly appreciate the work that has been done, especially from the teachers (Dr. Brian, Dr. Ron) – the teachings were interesting. And Doreen thanks a lot for your input.
  • A good course. Recommend for other colleagues. To include instruments of Tympanoplasty.

Future Direction/Vision

With the success of the first temporal bone course, the vision is to continue the use of the lab to meet the goals of the MUST Otolaryngology department. Future directions will include

  • Continual learning and use by MUST residents and faculty
  • Annual course for senior residents and faculty open to the entire east Africa region
  • Collaborate to share the resource with: Anesthesia (simulation lab), Ophthalmology, Orthopaedic Surgery and Neurosurgery (microscope)
  • Eventual expansion of the space to include a wet lab for head and neck anatomical dissection or an endoscopic sinus surgery course
  • Efficiencies and continuity of training by having same equipment in the operating theatres as well as in the lab setting

Course Report compiled by Flordeliz Osler, MD (University of Manitoba); Ronald de Venecia, MD, PhD (Mass Eye and Ear/Harvard); Brian Westerberg, MD (UBC); Doreen Nakku, MD (Mbarara University of Science and Technology); Kimberly Luu, MD (UBC)

 

Appendix 1: Mbarara University of Science and Technology (MUST) Temporal Bone Drilling Course

Day 1 – Tuesday, January 19, 2016 (Full day)

  • Welcome and Introductions (Nakku)
  • Ribbon-cutting ceremony for MUST Temporal Bone Lab
  • General overview of course Dr. Nakku

All in lab:

  • Conduct and safety in lab and OR
  • Use and care of the microscope and drill
  • Use and care of microsurgical instruments
  • Demonstration of “Power-up” and “Power-down” to avoid technical issues with equipment
Group 1 Group 2
Lab dissection Principles of canal wall up mastoidectomy
Temporal bone anatomy
Principles of temporal bone surgery including operating room set-up
Principles of canal wall up mastoidectomy Lab dissection
Temporal bone anatomy
Principles of temporal bone surgery including operating room set-up

LAB:  Getting use to instruments and drills. Completed canal wall up mastoidectomy

END OF DAY DEBRIEF (ALL)

Day 2 – Wednesday, January 20, 2016 (Full day)

Group Session: 0800-09:30

Lectures: Principles of CWD mastoidectomy

BREAK

Group 1 Group 2
Lab dissection Peer learning by watching dissection of paired trainee in other group

LUNCH

Group 1 Group 2
Peer learning by watching dissection of paired trainee in other group Lab dissection

LAB:  Complete canal wall down mastoidectomy, labyrinthectomy, exposure internal auditory canal

END OF DAY DEBRIEF (ALL)

Day 3 – Thursday, January 21, 2016 (Half day)

Group 1 Group 2
Lab dissection Tympanoplasty
Directed question and answers
Tympanoplasty Lab dissection
Directed question and answers

LAB:  Fresh specimen: Complete canal-wall-down mastoidectomy, labyrinthectomy

HAND OUT COURSE DIPLOMAS

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