Low-Cost Otolaryngology Simulation Models for Early-Stage Trainees: A Scoping Review

Importance: There is a notable lack of low-cost OHNS simulation models that are relevant for early medical trainees and students. By conducting this study, we will understand the current landscape of low-cost otolaryngology-head and neck surgery simulation for early medical trainees and students. Objectives: Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature. Evidence Review: This scoping review followed the five stages of Arksey and O’Malley’s Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as “low-cost,” “cost-effective,” or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents. Findings: Of the 1706 studies screened, 17 met the inclusion criteria. Most studies were conducted in HICs. Most models were low fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation. Conclusion and Relevance: Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.


Introduction
Medical simulation is a valuable component of training. 1Historically, simulation usage has been predominantly centered in high-income countries (HICs).Consequently, there exists an opportunity to expand access to simulation education in low-and middle-income countries (LMICs). 2,3While low-cost simulation models have been explored in HICs, the speci c models used in these settings may not be applicable to LMICs due to lacking the same resources.Studies have demonstrated that using locally sourced materials and readily available devices is cost-effective. 4Furthermore, low-delity, or less anatomically realistic, simulation may confer similar bene ts compared to high-delity, or highly anatomically realistic, simulation though with lower costs. 5,6Despite the potential bene ts of simulation in LMICs, there is limited literature, particularly for surgical specialties where workforce shortages, ethical considerations, and nancial constraints limit opportunities for practice. 7 otolaryngology-head and neck surgery (OHNS), simulation training has an opportunity to address the burden of disease centered in LMICs through training of general practitioners (GPs) and primary care providers in regions where subspecialists are limited.The burden of OHNS disease is high, with 1.5 billion people worldwide experiencing hearing loss, primarily in LMICs. 8Paradoxically, low-income countries have 50 times fewer OHNS providers than high income countries. 9Given the burden of OHNS disease far outweighs the current number of providers, it is imperative to train primary healthcare provider to help increase access to essential OHNS care.Simulation is a central component of many HIC OHNS training programs, 10-13 , 14 ; however, many models are largely directed at the skill set of senior residents and physicians.Given that primary care providers such as GPs in LMICs may be the rst or only providers available in rural or rst-level hospitals, the opportunity to develop skills that are critical for managing OHNS emergencies and common conditions is essential to developing con dence and preventing morbidity and mortality.
To address the gap in simulation models for primary care practitioners in common and emergent OHNS conditions, this scoping review aims to describe and evaluate available low-cost OHNS simulation models geared toward early-stage medical trainees or GPs.

Study Design
Given limited and heterogenous literature, a scoping review was selected and conducted in February 2023 in accordance with Arksey and O'Malley's Scoping Review Methodology and following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews Guidelines. 15,16The search strategy aimed to address the research question regarding the outcomes of using low-cost OHNS simulation models for early-stage trainees in education.

Literature Search
A search strategy was developed to capture the maximal results, which included the main search concepts of "simulation," "otolaryngology," "education," and "low cost."These terms were combined using Boolean operators OR (within critical constructed concepts) and AND (between key concepts).The speci c search strategy was adapted to each data base.The search was conducted in the following databases: PubMed, MEDLINE, EBSCO, Scopus, Science Direct, CINAHL, EMBASE, and Web of Science (Supplemental Table 1).
Inclusion criteria included studies of any language that discussed the development or implementation of a physical model of the ear, nose, or throat that were explicitly described as "low-cost," "cost-effective," or de ned as <$150 if explicitly stated related to the care or management of OHNS conditions (operative or non-operative).Models were only considered if they were applicable for training of undergraduate students, medical, dental, or nursing students, and/or early-level residents, and we excluded simulations that would not be applicable to a GP (i.e., advanced OHNS resident level skills).Original research of any study type was included.Letters to the editor, abstracts, systematic reviews, virtual reality simulations, electronic simulations, and studies that utilized mannequin models were not included.
The study team completed a primary title and abstract screening using a Covidence database (Veritas Health Innovation Ltd, Melbourne) based on the search criteria.Two reviewers each independently screened the titles and abstracts of all identi ed articles for relevance to the research question.A third independent reviewer resolved disagreements over article eligibility.In the full-text review, data was extracted and recorded following the Arksey and O'Malley's "descriptive-analytical" approach for data extraction, and the information was summarized from selected articles on an Excel spreadsheet. 15At least two authors reviewed extracted data from the included articles.A third reviewer resoled any remaining con icts.Snowball sampling was used to identify gray literature from study reference lists.

Statistical analysis
Outcomes included study characteristics (authors, year, language, journal of publication, study design), context (study country, target population) simulation details (specialty of simulation model, cost, delity of model, materials used, local sourcing of materials, condition being simulated), and model evaluation (evaluation of surgical skill and e cacy of model).Summary statistics were performed using Microsoft Excel.Categorical variables were presented as counts and percentages n(%).There were no continuous data.

Results
The initial search returned 3355 studies.After 1649 duplicates were removed, 1706 studies underwent title and abstract screening.Of these, 1607 were excluded.Ninety-nine studies were screened for full text review based on inclusion and exclusion criteria.Seventeen studies met inclusion criteria (Fig. 1).Table 1 provides an overview of the included low-cost simulation models for essential OHNS conditions.

Characteristics of studies
Of the studies examined, 82% (n = 14) of studies were conducted in HICs, and the majority were conducted in the United States or in the United Kingdom (Fig. 2).94% (n = 16) of the studies utilized a cross sectional study design.Most articles targeted general OHNS care (n = 8, 47%).82% (n = 14) of the models were low-delity models (less anatomically realistic), which was de ned by the primary study authors.The characteristics of the studies are summarized in Table 2.

Audience
One (6%) study was geared towards medical students, eight (47%) towards residents, two (12%) towards both medical students and residents, one (6%) towards nurses, one towards anesthesia students, and one (6%) towards paramedics.Out of the eight resident-focused models, three were geared towards emergency medicine residents.Two (12%) models were geared towards attendings or consultants, and both models were included given the models' transferability to simulate other more basic skills.

Cost
Eleven (65%) models reported a dollar value associated with their model.The average price per model was $36.45 USD (range: $10 -$105).The remaining models were described as "low-cost" by authors without speci c information about the cost of the materials.Fifteen (88%) studies reported using locally sourced materials.

Simulation Evaluation
Sixteen (94%) studies assessed model e cacy.Models were evaluated using both questionnaires (n = 8, 47%), direct observation of skills (n = 4, 24%), or both (n = 4, 24%).Three of the eight studies that included direct observation (38%) used video monitoring to evaluate clinical skill.Participant questionnaires included a variety of themes such as participants' comfort with the skill, model realism, ease of use, and participant con dence performing the skill.

Discussion
Given the substantial burden of OHNS disease worldwide and current limited OHNS workforce, simulation training tools tailored for primary care providers are critical in developing OHNS knowledge and skills to increase access to OHNS care globally. 8,9Existing low-cost OHNS simulations primarily target residents and consultants and can often overlook the essential skill set required by GPs. 17,18These skills encompass emergent and common OHNS conditions such as epistaxis, emergent surgical airway, and ear and nose foreign body removal.Equipping medical students and early-trainees with basic OHNS care skills is vital.This type of task shifting can alleviate delays in care, transportation challenges, and alleviate the burden on tertiary centers.This is the rst study to evaluate low-cost OHNS simulations tailored to GPs and early-trainee education, emphasizing locally sourced models.The low number of studies highlights that simulations addressing the skill set of early trainees and primary care providers is an area for future educational research depending on regional needs and resource availability.Our ndings describe the available low-cost simulations in OHNS and highlights insu cient availability of such models.Future work should focus on developing additional low-cost, contextually appropriate models to bridge gaps in healthcare training and delivery in resource-constrained settings.
Simulated medical models have proven highly effective in imparting essential OHNS procedure skills and can provide an important avenue to improve surgical training in resource constrained environments.
However, our data show that most low-cost simulation models (n = 14, 82%) are developed and utilized in HIC, which aligns with prior studies that report a lack of locally developed low-cost simulations in LMIC contexts. 7Furthermore, many "low-cost" simulation models rely on high-cost materials such as 3D printers or specialized mannequins, which may not be available in LMICs.When considering model sustainability and applicability of these models in LMICs, it is important to recognize the limitations of certain high-delity models in such resource-constrained environments.Prior studies demonstrate that low delity simulation models do not necessarily lead to worse skill outcomes, which emphasizes the potential of low-cost, less intricate models as valuable tools for skill acquisition. 5,19 previous systematic review of low-cost simulations in OHNS identi ed 18 studies on low-cost ENT simulations. 14However, only ve of these simulations were relevant to GPs as shown in Table 3.In contrast, our study included 17 simulations directly applicable to GPs.There is potential for expanding the range, reach, and applications of existing models.Most of the models in our study focused on peritonsillar abscess simulations, which may not always fall within a GP's scope of practice.These results highlight the need to develop additional models for skills like epistaxis management and nasal/ear foreign body removal.Additionally, several of the existing models could be adapted for a broader set of GP-level skills, such as using ear models for foreign body removal and cerumen management, in addition to myringotomy.There is also a clear need for alternatives to animal models, which can be harder to procure or reuse, leading to higher operation and maintenance costs.Additionally, most models in this study did not explore the use of locally sourced materials.Collaborating with LMICs to adapt models to utilize locally available materials is an essential next step to enhance accessibility and effectiveness.Finally, our study identi ed heterogeneity in evaluations of the e cacy of these simulations in augmenting the knowledge, skills, and con dence of GPs.This suggests that future research should incorporate standardized metrics to assess the utility of low-cost OHNS simulations.Our study has some limitations.Not all the studies we included provided exact cost information for the simulations, which, if available, could have contributed to our understanding of the cost-effectiveness of these models.We also did not independently evaluate delity and instead relied on delity assessments as reported by the authors for the scope of this study.. Furthermore, excluding studies involving 3D printing or mannequins might have resulted in overlooking potentially useful insights regarding the development and components of these models.As 3D printing technology becomes more affordable, cost and access may not be a barrier in the future, opening exciting possibilities for its integration into future research studies and innovations across various elds.Additionally, a notable portion of the

Table 3
Low-cost OHNS simulations identi ed in prior studies versus our results JN & SN contributed to study design, data extraction and management, data analysis, data interpretation, and manuscript writing/revisions EC, EAO, KVS, EKK contributed to data extraction, data analysis, data interpretation, and manuscript writing/revision JW, OM, NS, and MJX contributed to study design, data interpretation, and manuscript revision and nal approval.