Identifying a Problem
Training in otology has included training on cadaveric temporal bones for over 100 years. Otologists recognized that the anatomy they work with in the ear is full of essential structures that are situated very close to one another. As such it is easy to injure those structures, making ex vivo training that much more important. We agree that having a detailed knowledge of anatomy makes operating on critical structures safer, faster and more effective.
Creating an Opportunity
In 2001-2002, Dr. Steven Zeitels, my laryngology fellowship director at the time, was in the process of introducing new surgical techniques for voice restoration, especially for unilateral vocal fold paralysis (1, 2 – references). These techniques introduced concepts that were difficult to fully grasp without understanding the laryngeal anatomy and physically manipulating the component structures. Since there are limitations to learning this with living subjects, we created an ex vivo opportunity.
Seth Dailey
Chief, Division of Laryngology; Professor; Laryngology Fellowship Program Director; Laryngology Dissection Course Director
First Steps
With the assistance of Dr. James Kobler, PhD, at the Massachusetts Eye and Ear Infirmary, we designed and built a physical station (made out of plywood, steel and brass) designed to allow the use of cadaveric larynges for simulated endoscopic and open laryngeal surgery (3). This station allowed me and, subsequently, many others to practice laryngeal procedures and even to conceive of new ones (4). Central benefits of practicing on cadaveric larynges are that the anatomy is either identical in the case of human larynges or reasonably close in the case of canine larynges or even porcine larynges. Also the tissues’ subtypes, such as cartilage, are identical and help teach anatomical relationships and tissue tolerances in a zero-risk environment. The station can be used for solo work or with one or more people simultaneously. When a microscope is used for endoscopic work, the microscope usually has a “teaching head” so that another person can watch in real time; modern microscopes almost all have video output so that the surgeon’s view is displayed on a video monitor for group learning.
Codifying the Learning
With the encouragement of our first laryngology fellow at the University of Wisconsin-Madison, Dr. Sunil P. Verma, a laryngeal surgery guide was pursued. He and I asked expert authors to contribute chapters on 33 very specific procedures. Each chapter was illustrated with the laryngeal dissection station and cadaveric larynges to illuminate ideas. Each chapter has presented key clinical points, including important takeaways and common mistakes, as well as appropriate references. Dr. Verma and I and our co-authors finished the book and it was published by Thieme in 2011. It was modified and translated into Mandarin in 2013.
Refinements
Dr. Verma introduced a variant of the original station to create an alternative low-lost physical platform for laryngeal surgical learning. He and his team called this VOCALSS: Versatile optimally constructed aid for laryngeal surgery simulation (5).
Regional Contributions and the Laryngeal Dissection Course
The Laryngeal Dissection and Surgery Guide book grew out of efforts to educate our UW otolaryngology-head and neck surgery residents on laryngeal anatomy and surgery. Initially, these hands-on sessions took place in the temporal bone lab, where we performed standard procedures such as vocal fold injection, epithelial vocal fold resection, thyroplasty, and various laryngoplasty techniques. Our teaching aids were simple: chalkboards and stapled-together surgical guides.
Over time, these stapled guides evolved into the comprehensive book we now use as our primary teaching resource. Recognizing the importance of community and diverse perspectives, we invited regional laryngology faculty and their otolaryngology-head and neck surgery residents to join the course. Participants included faculty and residents from Loyola, Rush, University of Chicago, Northwestern, Medical College of Wisconsin, University of Iowa, Mayo Clinic in Rochester, Cleveland Clinic, Case Western, and others.
We deeply appreciate the generosity and dedication of all the faculty who have contributed over the years. Special thanks to Dr. Joel Blumin of the Medical College of Wisconsin, who has generously donated his time and expertise to all 16 Laryngeal Dissection Courses we have held.
We were fortunate to have additional faculty from across the U.S. join us. Initially, the course was CME-approved. However, the COVID-19 pandemic necessitated changes, and we transitioned to a hands-on course for UW residents. As we emerged from the pandemic, we introduced in-person masterclasses where surgical experts demonstrated operations to small groups using cadaveric platforms. This was quickly recognized as a high-yield learning opportunity. Eventually, like many things during COVID, it became a virtual offering.
For the last few years, we have offered a half-day session of six masterclasses in the morning and a hands-on session in the afternoon for local and regional residents and faculty in our beautiful Clinical Simulation Center. For the masterclasses, we try to have a balanced program of operations/procedures focused primarily on adult voice, swallowing and airway, with some pediatric laryngology options. Each masterclass video features a pre-recorded demonstration by the presenter, who provides voiceover narration highlighting essential techniques and common challenges. After the video, the presenter is available for a live question-and-answer session.
Over 400 participants from more than 15 countries and 4 continents have participated in this course, and numbers continue to grow. Forward!
References
- Adduction arytenopexy: a new procedure for paralytic dysphonia with implications for implant medialization.
Zeitels SM, Hochman I, Hillman RE.Ann Otol Rhinol Laryngol Suppl. 1998 Sep;173:2-24
PMID: 9750545 - Cricothyroid subluxation: a new innovation for enhancing the voice with laryngoplastic phonosurgery.
Zeitels SM, Hillman RE, Desloge RB, Bunting GA.Ann Otol Rhinol Laryngol. 1999 Dec;108(12):1126-31. doi: 10.1177/000348949910801206.
PMID: 10605916 - A laryngeal dissection station: educational paradigms in phonosurgery.
Dailey SH, Kobler JB, Zeitels SM.Laryngoscope. 2004 May;114(5):878-82. doi: 10.1097/00005537-200405000-00017.
PMID: 15126748 - Local vascularized flaps for augmentation of Reinke’s space.
Dailey SH, Gunderson M, Chan R, Torrealba J, Kimura M, Welham NV.Laryngoscope. 2011 Feb;121 Suppl 3(Suppl 3):S37-60. doi: 10.1002/lary.21186.
PMID: 21271606 - VOCALSS: Versatile optimally constructed aid for laryngeal surgery simulation.
Foulad A, Bui P, Dailey SH, Verma SP.Laryngoscope. 2015 May;125(5):1169-71. doi: 10.1002/lary.25091. Epub 2014 Dec 24.
PMID: 25545359