The Laryngoscope

C 2015 The American Laryngological,

V

Rhinological and Otological Society, Inc.

Low-Cost Modular Phonosurgery Training Station:

Development and Validation
Michael A. Holliday, MD; Victoria M. Bones, MD; Sonya Malekzadeh, MD; Nazaneen N. Grant, MD
Objective: Phonosurgery requires technical precision and careful tissue handling. Typically, phonosurgical procedures
require single-operator techniques, making it difficult for novice residents to develop necessary skills. We developed a lowcost phonosurgery simulator to allow practice and acquisition of microlaryngeal skills.
Study Design: Validation study assessing the simulators face and content validity in surgical education.
Methods: For construction, the simulator is composed of a simulation station and laryngeal modules, each constructed
with inexpensive, easily accessible materials including plywood and polyvinyl chloride pipe. Laryngeal modules were constructed using rubber bands, bacitracin, and plastic wrap to simulate layers of the true vocal fold. Three separate modules
were developed to address specific skills: 1) basic instrumentation; 2) papilloma debulking; 3) subepithelial and epithelial
lesion excision. Papillomas, subepithelial, and epithelial lesions were simulated with grapefruit, caulk, and suture, respectively.
The Kantor-Berci video laryngoscope was used for visualization.
For validation, face and content validity were assessed by attending otolaryngologists (n 5 16), who performed the three specific skills using the simulation station and completed a 5-point Likert-type postsimulation questionnaire.
Results: Most participants (89%) strongly agreed that the simulator incorporates essential phonosurgery skills and that
portions of the model simulated an actual case (content validity). All participants (100%) agreed that the simulator is an
adequate training device to increase resident competency and would be interested in using it to train residents (face
validity).
Conclusion: This simulator has the potential to be an important component of phonosurgical education and preoperative preparation. Advantages include a realistic experience, modular design, and inexpensive construction.
Key Words: Phonosurgery, simulation, Kantor-Berci, residency.
Level of Evidence: N/A.
Laryngoscope, 125:14091413, 2015

INTRODUCTION
Phonosurgery requires fine motor techniques that
are difficult to master. The single-operator, microscopic
surgery has a narrow margin of error, and imprecise
technique may cause untoward effects including scarring, sulcus vocalis, and worsened dysphonia.1 Despite
this difficulty, there is a lack of standardized phonosurgery training in U.S. residency programs.2 Whereas temporal bone and sinus surgery courses are well-integrated
in U.S. and Canadian otolaryngology training programs,
Shah et al. (2013) found that 82% of otolaryngology
Additional Supporting Information may be found in the online
version of this article.
From the Department of OtolaryngologyHead and Neck Surgery,
MedStar Georgetown University Hospital (M.A.H., V.M.B., S.M.); and the
Georgetown University School of Medicine (N.N.G.), Washington, DC,
U.S.A.
Editors Note: This Manuscript was accepted for publication
December 15, 2014.
Presented at the Fall Voice Conference: Atlanta, Georgia, USA,
October 17, 2013.
Funding source: MedStar Washington Hospital Center Department
of OtolaryngologyHead and Neck Surgery. The authors have no other
funding, financial relationships, or conflicts of interest to disclose.
Send correspondence to Michael A. Holliday, MD, MedStar Georgetown University Hospital, Department of OtolaryngologyHead and
Neck Surgery, 1 Gorman, 3800 Reservoir Rd, NW, Washington, DC
20007. E-mail: michael.a.holliday@gunet.georgetown.edu
DOI: 10.1002/lary.25143

Laryngoscope 125: June 2015

residents in the United States and Canada had no laboratory training in phonomicrosurgery.2 Only 22% of
respondents reported that they were very comfortable
with phonomicrosurgery.2
Numerous training modelsfrom synthetic models
to cadaveric animal or human laryngeshave been
developed over the last 2 decades to simulate phonosurgery and endolaryngeal surgery.38 Although these models have provided exposure to microsurgical skills outside
of the operating room, none have become widely adopted.
We sought to develop and validate a low-cost phonosurgery simulation station for laboratory training. Using
readily available materials, we designed a modular system that accurately represents true vocal-fold layers and
various lesions to hone essential phonomicrosurgical
skills. The customizable model fosters development of
advanced phonosurgical techniques and allows for
rehearsal prior to performing the procedure in the operating room.
After developing the simulation station, we examined its validity in surgical education. When developing
a surgical simulator, a rigorous series of individual validations is required prior to its use on the target population. This process begins with face and content validity,
which are derived from expert opinion.9 Through face
validity, the simulators overall appropriateness as a
learning instrument is determined. Content validity is
Holliday et al.: Phonosurgery Training Station

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Fig. 1. (a) Basic dissection station

with laryngoscope. (b) Insertion of
laryngeal cartridge. [Color figure can
be viewed in the online issue, which
is available at www.laryngoscope.
com.]

established by conducting a detailed examination of each

step by experts to determine if those steps are used in
the actual procedure.9

MATERIALS AND METHODS

This project was exempt from full review by the MedStar
Health Institutional Review Board. Construction and assembly of
the model are described in detail below. Several tasks were designed
to simulate phonosurgery and specific descriptions are outlined.

Simulator Assembly
Dissection station (Fig. 1): The model was constructed
with 11=4-inch diameter polyvinyl chloride pipe cut in 12-inch
lengths and fixed to a plywood base with copper pipes and conduit hangers. The station is designed to accommodate a KantorBerci video laryngoscope (Karl Storz Endoscopy America, Inc.,
El Segundo, CA) in a stable suspension-like position at one end
and an interchangeable laryngeal cartridge with simulated
pathology at the opposite end.
Laryngeal cartridge (Supp. Fig. S1): A fundamental
component of the simulator is the modular laryngeal cartridge.
This unit was fashioned using 9-cm segments of plastic pipe
(11=4-inch diameter), with three notches cut into each end.
Rubber bands representing true vocal folds were wrapped

lengthwise and secured into notches of the pipe. Self-adherent

hook-and-loop tape (Velcro, Manchester, NH) was applied to the
nonworking side for ease of assembly. Vocal fold anatomy was
simulated with a #64 rubber band as the vocal ligament/vocalis
body, and self-sealing plastic wrap (Glad Pressn Seal, Oakland, CA) was used as the epithelial cover. Reinkes space was
simulated with bacitracin ointment.

Simulated Tasks and Pathology

Basic module (Supp. Fig. S2): Three sutures were
passed through the anterior two-thirds of the rubber band. Of
those, two were held in place by friction and the third was knotted
with an air knot. The task consisted of grasping and removing the
first two sutures and then grasping and cutting the third suture.
Epithelial lesion (Fig. 2): Small 2-mm diameter beads of
silicone-based caulk were applied via 18g angiocatheter to 4-cm
by 4-cm sections of plastic wrap. The sticky side of the sealing
wrap was pressed onto and folded over the rubber band,
with the caulk along the striking surface of the vocal fold.
Bacitracin ointment was infiltrated into Reinkes space (between
the plastic wrap and rubber band) with an 18g angiocatheter.
The task consisted of subepithelial injection of air posterolateral
to the lesion with a 24g laryngeal needle (Merz Aesthetics, Inc.,
San Mateo, CA). This formed an air bubble in the ointment, verifying the correct plane of dissection. The lesion was next grasped

Fig. 2. Epithelial (left cord) and subepithelial (right cord) lesions: (a) with
markings; (b) endoscopic view.
[Color figure can be viewed in the
online issue, which is available at
www.laryngoscope.com.]

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Holliday et al.: Phonosurgery Training Station

Fig. 3. Endoscopic view of papilloma module: (a) cruciate marking;

(b) microdebriding grapefruit. [Color
figure can be viewed in the online
issue, which is available at www.
laryngoscope.com.]

with curved microalligator forceps in the contralateral hand and

excised with microscissors in the ipsilateral hand.
Subepithelial lesion (Fig. 2): A 5-0 silk suture was
placed through the rubber band three times and tied with an
air knot to simulate a subepithelial lesion (Supp. Fig. S3). Plastic wrap was applied to the rubber band and pressed against
itself to form a seal. Bacitracin ointment was then infiltrated
into Reinkes space, as above. The prescribed task consisted of
subepithelial injection of air posterior to the lesion with a 24g
laryngeal needle, followed by the development of a medially
based microflap over the lesion. The lesion was grasped, and
each suture was cut individually with microscissors. Dissecting
the lesion free from the rubber band after creating the microflap simulates a subepithelial lesion with multiple deep
attachments. Last, the microflap was redraped.
Papilloma module (Fig. 3): Plastic wrap was stretched
over the rubber bands of the laryngeal cartridge (Supp. Fig. S4).
Slices of grapefruit flesh were placed on the plastic wrap to represent papilloma, followed by a second sheet of plastic wrap to
seal this in place (Supp. Figs. S4b,c). The task consisted of incising the plastic wrap in cruciate fashion, followed by gentle
retraction of each leaflet and debulking of the papilloma with
the Skimmer blade (Medtronic Xomed Inc., Minneapolis, MN) on
the microdebrider until the deep plastic wrap was uncovered.

Validity

Hospital, and eight performed the simulations at a junior resident boot camp simulation course but did not
complete the papilloma module due to time and facility
constraints. Nine physicians had been practicing longer
than 10 years, and seven had been practicing 10 or
fewer years. Eleven surgeons have completed 20 or more
microlaryngeal cases, whereas five surgeons have completed fewer.

Face Validity
When evaluating the simulator for overall appropriateness and value as a simulator for otolaryngology residents, the model performed well (Fig. 4). For the
questions pertaining to each exercises overall value,
100% of the respondents agreed (scored at least 4 out of
5) that the basic skills and excision of epithelial lesion
exercises were valuable. For the subepithelial lesion
excision, the mean Likert score was 4.9. For this exercise, 88% of respondents agreed that the exercise was
valuable; one participant (6%) was neutral on this item;
and one participant (6%) did not respond to this item.
Finally, the mean Likert score for the microdebrider
module was 4.6, with an agreement rate of 86% due to
one no response (14%).

Face and content validity of the simulator were determined through expert evaluation and feedback. Subjects consisted of attending otolaryngologists who completed the
presimulation demographic questionnaire and the postsimulation evaluation questionnaire (Supp. Table SI) rated on a 5point Likert scale. Items on the questionnaire were adapted
from similar validation studies of other surgical simulators.9,10

Statistical Analysis
Statistical analyses were performed using GraphPad
Prism Version 6.01 (GraphPad Software, Inc., La Jolla, CA).
Descriptive statistics were used to determine validity.

RESULTS
Demographics
Participants included 16 attending physicians. Of
those, eight otolaryngologists performed the simulations
in a surgical skills lab at Georgetown University
Laryngoscope 125: June 2015

Fig. 4. Face validity: average score on 5-point Likert-type scale

for each exercise. Percentage of responses of 4 or 5 denoted at
right.

Holliday et al.: Phonosurgery Training Station

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Fig. 5. Content validity: average score on 5-point Likert scale for

each task. Percentage of responses of 4 or 5 denoted at right.

Content Validity
After thorough evaluation of each step, the simulator performed well in content validity (Fig. 5). All surgeons agreed that the simulator helped develop hand
eye coordination, dexterity of phonosurgical instruments
(scissors, graspers, injection needle), and skills related to
the excision of epithelial and subepithelial lesions. The
least well-regarded task was the papilloma module, with
only 71% of surgeons (n 5 7) finding that it helped
develop skimmer skills. As expected, the simulator was
less helpful in developing exposure skills.

Overall Impressions
The participants responded to the overall impression questions positively, with the average responses to
these questions at least 4.5 (Supp. Fig. S5). There was
at least a 93% agreement rate for these four questions,
with only one participant (7%) who was neutral to questions 22 and 23. The respondents overwhelmingly agreed
that the simulator correlates with phonosurgery skills,
and they are interested in using the model for resident
training.

DISCUSSION
The need for laryngeal dissection models for teaching purposes is widely recognized.2,3 The dissection station described herein provides an inexpensive and
feasible way to rehearse phonosurgery, with reasonably
realistic anatomical landmarks and the ability to create
tailored surgical pathology without the need for human
or animal tissue.
Whereas animal larynges were considered for use
based on anatomical similarities with porcine and canine
larynges, there are significant drawbacks to using animal tissue.3,4 First, cadaveric and animal larynges are
limited in supply and are logistically difficult to store
and handle. This adds time and labor to the simulation
process in the form of thoroughly disinfecting delicate
phonosurgery instruments. Even well-preserved biologic
larynges have natural degradation and drying of tissues,
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such that Reinkes space and the epithelial layers are

not accurate representations of the in vivo situation.
Most important, biologic larynges rarely have pathology
to excise, so many surgical situations cannot be simulated. Ultimately, the anatomical accuracy of the human
or animal larynx did not justify these drawbacks or the
expense.
Few synthetic trainers have been described in the
literature. Contag et al. described a fully synthetic
trainer consisting of artificial, interchangeable true vocal
folds mounted on a commercially available model larynx.5 This simulator was successful in differentiating
expert from novice performance and showed objectively
improved performance with repeated use.5 A hybrid simulation station replacing the larynx of an airway manikin with a porcine larynx has also been used to simulate
laser excision of malignant lesions.6
Our laryngeal simulation station is inexpensive
and easily constructed using materials purchased from
local hardware and grocery stores. Each laryngeal
cartridge costs approximately $3.50 to build, and each
trial adds an additional $0.39 to the cost. The dissection station was built for less than $20. The true
advantage of this simulator, however, is the modular
design and the ability to recreate and treat realistic
laryngeal pathology with repetition during training
simulations. One can practice a single difficult maneuver (e.g., a lesion requiring removal with the nondominant hand) or can vary simulations slightly (e.g.,
moving the lesion anteriorly/posteriorly or to the other
vocal fold).
The Kantor-Berci video laryngoscope was appropriate
for this assembly because it obviated the need for a cumbersome microscope, allowed for video recording of the trials, and permitted ergonomic coaching. This is a viable
solution for surgical skills suites that lack an appropriate
microscope but have endoscopy equipment, such as a general surgery skills lab. The simulation station can also be
modified for use with an operative microscope using the
Lindholm laryngoscope (Karl Storz Endoscopy America,
Inc.,El Segundo, CA) or other laryngoscopes.
We believe that these qualities render the simulation station a feasible training tool with a potentially
high likelihood of being adopted by otolaryngology residency programs. Junior residents can gain an introduction to phonosurgical instrumentation and dexterity, and
senior residents can perform more difficult tasks such as
microflap surgery.
Limitations of this study include the small sample
size and its subjective nature. Additionally, there may be
institutional bias in that half of the faculty was from the
authors academic institution. Finally, only one participant was a fellowship-trained laryngologist. Nonetheless,
all participants were experienced in either laryngeal
microsurgery or resident surgical training or both.
Future steps will involve establishing construct
validity of this simulator, which seeks to distinguish
expert from novice performance. Additionally, construct
validity should demonstrate that performance improves
with practice. Ultimately, this simulator may have the
potential to effectively and reliably measure surgical
Holliday et al.: Phonosurgery Training Station

competency as an objective structured assessment of

technical skills.

CONCLUSION
We developed a modular, fully customizable phonosurgery simulation station that is both inexpensive and
easy to assemble. All participants in this study recognized the trainers educational potential and expressed
interest in using it for resident surgical education, confirming face and content validity. This simple construct
is a viable option for laboratory-based phonosurgery
practice.

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