With the Incidence of Otosclerosis Declining, Should Stapedectomy Remain a Key‐Indicator Case for Otolaryngology Residents?

Abstract

Stapedectomy remains a joint key-indicator case with ossiculoplasty for otolaryngology residents in the United States. Yet, residents consistently report feeling inadequately prepared to perform stapes surgery following graduation. Applying recently described age- and sex-standardized incidence rates of surgically confirmed cases of otosclerosis to the US populace, upper and lower estimates of residents’ case exposure to stapedectomy can be approximated. With this, uppermost projections estimate 6484 new cases of stapes surgery are performed annually nationwide. With approximately 1424 otolaryngology residents nationally, the average case exposure is 7.8 stapedectomies throughout their training, with upper and lower estimates of 17.1 and 4.2 cases, respectively. As such, proficiency in stapedectomy is no longer a realistic expectation for US graduating residents. This reality supports the removal of “stapedectomy” from the list of 14 key-indicator case requirements, leaving ossiculoplasty as its own key-indicator case, thereby reinforcing true competence in this fundamental procedure for the graduating otolaryngologist.

The Case Against Stapedectomy as a Core Competency for General Practice: A Study of Care Patterns in the Department of Defense

“…The dearth of cases may affect their residency training, as well. With the decreased incidence of otosclerosis, the argument has been made that the disease process only supports 4.2 cases per resident training (7), well below both the ACGME's Ossicular Chain Surgery key indicator 10 case minimum 6 and resident-logged case average between 2010 and 2015, which ranged from 15.3 to 19 (12) This case log data suggests ossiculoplasty contributes to a higher proportion of the dual stapedectomy and ossiculoplasty key indicator procedure requirements and raises concern surrounding the improbability of sufficient training in stapes surgery nationally. Stapedectomy has earned a reputation as a technically challenging procedure with well-defined outcomes of closure of the air-bone gap to less than 10 dB considered success.…”

“…Based on the epidemiologic trends over the past 50 years, it has been recently argued (7) that it is extremely difficult for every resident to meet the ACGME-required 10 case minimum via stapes surgery alone. Survey data substantiate this, showing few general otolaryngologists perform stapedectomy routinely in their practice (8).…”

Augmented Reality in Otology/Neurotology: A Scoping Review with Implications for Practice and Education

“…All of these factors can result in limited trainee exposure to complex cases. 8 The classic model of surgical training is a skills apprenticeship, whereby trainees spend time with mentors in and out of the operating room, gradually gaining autonomy until they are ready for independent practice. However, in the face of the modern pressures of surgical training, including a greater emphasis on surgeon/hospital productivity and patient safety, 9,10 a purely apprenticeship-based model is no longer an efficient way to train residents.…”

“…Possible barriers to teaching these procedures include the complex three‐dimensional anatomy, the single‐operator nature of the surgeries, the intrinsic difficulty of microsurgery and the relative rarity of certain disease processes. All of these factors can result in limited trainee exposure to complex cases 8 …”

Estimated Costs Associated With Management of Otosclerosis With Hearing Aids vs Surgery in Europe

“…Its incidence has been estimated between 3.9 per 100 000 individuals and 1 per 100 individuals, with female predominance. Although its incidence seems to be decreasing, otosclerosis remains the main cause of conductive hearing loss with intact tympanic membrane. In mild cases, treatment can involve monitoring, but patients with an air-bone gap greater than 20 dB are typically offered hearing aids or surgical treatment.…”