Virtual Reality Temporal Bone Research Articles

Trainee-perceived benefits of a virtual temporal bone competition.

To assess the perceived benefits of a novel educational approach for otolaryngology trainees: a virtual reality temporal bone simulator drilling competition. Regional otolaryngology trainees participated in the competition. Drilling activities using the Voxel-Man TempoSurg simulator were scored by experts. Questionnaires that contained questions covering motivators for attending, perceived learning and enjoyment were sent to participants. Agreement with statements was measured on a 10-point Likert scale (1 = strongly disagree, 10 = strongly agree). Eighteen trainees participated. The most cited reason for attending was for learning and/or education (61 per cent), with most attendees (72 per cent) believing that competition encourages more reading and/or practice. Seventeen attendees (94 per cent) believed Voxel-Man TempoSurg-based simulation would help to improve intra-operative performance in mastoidectomy (mean 7.83 ± 1.47, p < 0.001) and understanding of anatomy (mean 8.72 ± 1.13, p < 0.001). All participants rated the competition as 'fun' and 83 per cent believed the competitive element added to this. The virtual reality temporal bone competition is a novel educational approach within otolaryngology that was positively received by otolaryngology trainees.

A6Virtual reality simulation as a tool for ENT training: an autoethnographic study

Autoethnography is an emerging category of qualitative research that seeks to connect the rigorous analysis of traditional science with the undeniable influence of human experience [1]. Despite remaining under-utilized within surgical and simulation-based education research [2], autoethnography has great potential for sharing systematic, personal reflections with the wider readership, particularly with surgical trainees who rely on experiential learning as a cornerstone of their training. This study examines the use of autoethnography to investigate virtual reality (VR) temporal bone (TB) drilling simulation as a learning tool for Ear, Nose and Throat (ENT) training from the perspective of a surgical novice. The primary researcher undertook 16 three-hour sessions learning to perform a virtual cortical mastoidectomy on the Voxel-Man TempoSurg (VMT) TB simulator from October 2021 to July 2022. Qualitative data including field notes and reflective journal logs were collected using a template. These data were coded using NVivo12 and analysed using inductive thematic analysis. Additional quantitative data on surgical simulation performance derived from the Modified Welling Scale and Modified Stanford Assessment were plotted using Microsoft Excel and statistically analysed using simple linear regression. Six themes were ultimately yielded relating to the learning experience: (1) VMT as a surgical learning tool, (2) internal and external causes of rushing leading to inaccuracy, (3) overcoming VMT technological issues, (4) reflecting on reflection and the importance of feedback, (5) the physical impact of surgery on the operator and (6) overcoming demotivation. The author’s reflections on each theme were subsequently discussed in detail and analysed in the context of the current literature to meet the study objectives. Statistical analysis of the quantitative data demonstrated statistically significant improvements in procedural skills and ability over the 16-session period ( This study demonstrates a novel application of autoethnography showing VR TB simulation to be an effective ENT training tool for learning anatomy and technical skills when used in combination with the regimented reflection and feedback of autoethnography. We found that rushing caused by assessment-driven behaviour and hunger led to errors. These errors led to demotivation and stress, emotions frequently experienced by operating surgeons [3]. Therefore, we have also demonstrated that VR TB simulation can successfully model several human factors commonly found in operating theatres which must be self-identified and prompt seeking senior support to prevent patient harm. This evidence should provide a springboard for future autoethnographic research in the field of surgical and simulation-based literature. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Impact of virtual reality training on mastoidectomy performance: a prospective randomised study

PurposeThe opportunities for surgical training and practice in the operating room are in decline due to limited resources, increased efficiency demands, growing complexity of the cases, and concerns for patient safety. Virtual reality (VR) offers a novel opportunity to enhance surgical training and provide complementary three-dimensional experience that has been usually available in the operating room. Since VR allows viewing and manipulation of realistic 3D models, the VR environment could enhance anatomical and topographical knowledge, in particular. In this study, we explored whether incorporating VR anatomy training improves novices’ performance during mastoidectomy over traditional methods.MethodsThirty medical students were randomized into two groups and taught mastoidectomy in a structured manner. One group utilized a VR temporal bone model during the training while the other group used more traditional materials such as anatomy books. After the training, all participants completed a mastoidectomy on a 3D-printed temporal bone model under expert supervision. Performance during the mastoidectomy was evaluated with multiple metrics and feedback regarding the two training methods was gathered from the participants.ResultsThe VR training method was rated better by the participants, and they also needed less guidance during the mastoidectomy. There were no significant differences in operational time, the occurrence of injuries, self-assessment scores, and the surgical outcome between the two groups.ConclusionOur results support the utilization of VR training in complete novices as it has higher trainee satisfaction and leads to at least as good results as the more traditional methods.

Patient-specific virtual and mixed reality for immersive, experiential anatomy education and for surgical planning in temporal bone surgery

ObjectiveThe recent development of extended reality technology has attracted interest in medicine. We explored the use of patient-specific virtual reality (VR) and mixed reality (MR) temporal bone models in anatomical teaching, pre-operative surgical planning and intra-operative surgical referencing. MethodsVR and MR temporal bone models were created and visualized on head-mounted display (HMD) and MR headset respectively, by a novel webservice that allows users to convert computed tomography images to VR and MR images without specific knowledge of programming. Eleven otorhinolaryngology trainees and specialists were asked to manipulate the healthy VR temporal bone model and to assess its validity by filling out a questionnaire. Additionally, VR and MR pathological models of petrous apex cholesteatoma were utilized for surgical planning pre-operatively and for referring to the anatomy during the surgery. ResultsMost participants were favorable about the VR model and considered HMD as superior to a flat computer screen. 91% of the participants agreed or somewhat agreed that VR through HMD is cost effective. In addition, the VR pathological model was used for planning and sharing the surgical approach during a pre-operative surgical conference. The MR headset was worn intra-operatively to clarify the relationship between the pathological lesion and vital anatomical structures. ConclusionRegardless of the participants’ training level in otorhinolaryngology or VR experience, all participants agreed that the VR temporal bone model is useful for anatomical education. Furthermore, the creation of patient-specific VR and MR models using the webservice and their pre- and intra-operative usages indicated the potential of innovative adjunctive surgical instrument.

The assessment of virtual reality training in antromastoidectomy simulation

Virtual reality (VR) may be a good alternative for cadaveric temporal bone surgical dissection courses, which are an important part of otolaryngology resident’s training. The aim of the study was to assess the VR temporal bone surgery simulator in an antromastoidectomy simulation. The VR system was based on the Geomagic Touch Haptic Device from 3D System. The research was designed as a prospective study, with three sessions of VR simulation training. The group of four ENT specialists unexperienced in otosurgery and 11 otorhinolaryngology residents performed a series of virtual dissections of a VR temporal bone model. Two experts with a broad experience in ear surgery participated in the study as supervisors for all the participants. At the end of each session, the experts controlled the accuracy of the simulated surgery performance assigning positive points for each correctly performed step and negative points for each mistake. After each session, participants of the study were asked to fill in the questionnaire concerning their impression of a VR system simulation. The evaluation of every simulation (total score) was based on the duration of a VR session, the quality of performance (positive points) and the number of mistakes (negative points). During consecutive VR sessions, evident shortening of the length of performance, as well as an improvement in the quality of performance and reduction in mistakes, was observed. Sixty percent of study participants answered that signaling damage to the critical elements was good (40%—sufficient), and 67% assessed that they had made a progress in consecutive sessions. After three sessions, 100% of participants indicated higher self-confidence in relation to their own surgical skills. Also, all the participants indicated that VR training should be included in a routine educational program for medical students. VR training provides a structured, safe and supportive environment to familiarize oneself with complex anatomy and practical skills.

Automated assessment of cortical mastoidectomy performance in virtual reality.

Cortical mastoidectomy is a core skill that Otolaryngology trainees must gain competency in. Automated competency assessments have the potential to reduce assessment subjectivity and bias, as well as reducing the workload for surgical trainers. This study aimed to develop and validate an automated competency assessment system for cortical mastoidectomy. Data from 60 participants (Group 1) were used to develop and validate an automated competency assessment system for cortical mastoidectomy. Data from 14 other participants (Group 2) were used to test the generalisability of the automated assessment. Participants drilled cortical mastoidectomies on a virtual reality temporal bone simulator. Procedures were graded by a blinded expert using the previously validated Melbourne Mastoidectomy Scale: a different expert assessed procedures by Groups 1 and 2. Using data from Group 1, simulator metrics were developed to map directly to the individual items of this scale. Metric value thresholds were calculated by comparing automated simulator metric values to expert scores. Binary scores per item were allocated using these thresholds. Validation was performed using random sub-sampling. The generalisability of the method was investigated by performing the automated assessment on mastoidectomies performed by Group 2, and correlating these with scores of a second blinded expert. The automated binary score compared with the expert score per item had an accuracy, sensitivity and specificity of 0.9450, 0.9547 and 0.9343, respectively, for Group 1; and 0.8614, 0.8579 and 0.8654, respectively, for Group 2. There was a strong correlation between the total scores per participant assigned by the expert and calculated by the automatic assessment method for both Group 1 (r=.9144, P<.0001) and Group 2 (r=.7224, P<.0001). This study outlines a virtual reality-based method of automated assessment of competency in cortical mastoidectomy, which proved comparable to the assessment provided by human experts.

Surgical approach to the facial recess influences the acceptable trajectory of cochlear implantation electrodes.

To provide practical guidance to the operative surgeon by mapping the location, where acceptable straight-line virtual cochlear implant electrode trajectories intersect the facial recess. In addition, to investigate the influence of facial recess preparation, virtual electrode width and surgical approach to the cochlea on these available trajectories. The study was performed on imaging data from eight cadaveric temporal bones within the University of Melbourne Virtual Reality (VR) Temporal Bone Surgery Simulator. The facial recess was opened to varying degrees, and acceptable trajectory vectors with varying diameters were calculated for electrode insertions via cochleostomy or round window membrane (RWM). The percentage of acceptable insertion vectors through each location of the facial recess was visually represented using heatmaps. Seven of the eight bones allowed for acceptable vector trajectories via both cochleostomy and RWM approaches. These acceptable trajectories were more likely to lie superiorly within the facial recess for insertion via the round window, and inferiorly for insertion via cochleostomy. Cochleostomy insertions required a greater degree of preparation and skeletonisation of the junction of the facial nerve and chorda tympani within the facial recess. The width of the virtual electrode had only marginal impact on the availability of acceptable trajectories. Heatmaps emphasised the intimate relationship the acceptable trajectories have with the facial nerve and chorda tympani. These findings highlight the differences in the acceptable straight-line trajectories for electrodes when implanted via the round window or cochleostomy. There were notable exceptions to both surgical approaches, likely explained by the variation of hook region anatomy. The methodology used in this study holds promise for translation to patient specific surgical planning.

Development of a virtual reality clinically oriented temporal bone anatomy module with randomised control study of three-dimensional display technology

ObjectiveTo investigate the effectiveness of a virtual reality (VR), three-dimensional (3D) clinically orientated temporal bone anatomy module, including an assessment of different display technologies.MethodsA clinically orientated, procedural and interactive anatomy...

The impact of virtual reality temporal bone simulator on the development of the surgical skill of identifying the surgical landmarks of mastoidectomy among the third-year Otolaryngology residents

The impact of virtual reality temporal bone simulator on the development of the surgical skill of identifying the surgical landmarks of mastoidectomy among the third-year Otolaryngology residents

The Melbourne Mastoidectomy Scale: Validation of an end-product dissection scale for cortical mastoidectomy.

Cortical mastoidectomy is a common otolaryngology procedure and represents a compulsory part of otolaryngology training. As such, a specific validated assessment score is needed for the progression of competency-based training in this procedure. Although multiple temporal bone dissection scales have been developed, they have all been validated for advanced temporal bone dissection including posterior tympanotomy, rather than the task of cortical mastoidectomy. The Melbourne Mastoidectomy Scale, a 20-item end-product dissection scale to assess cortical mastoidectomy, was developed. The scale was validated using dissections by 30 participants (10 novice, 10 intermediate and 10 expert) on a virtual reality temporal bone simulator. All dissections were assessed independently by three blinded graders. Additionally, all procedures were graded with an abbreviated Welling Scale by one grader. There was high inter-rater reliability between the three graders (r=.9210, P<.0001). There was a significant difference in scores between the three groups (P<.0001). Additionally, there was a large effect size between all three groups: the differences between the novice group and both the intermediate group (P=.0119, η2 =0.2482) and expert group (P<.001, η2 =0.6356) were significant. The difference between the intermediate group and expert group again had a large effect size (η2 =0.3217), but was not significant. The Melbourne Mastoidectomy Scale correlated well with an abbreviated Welling Scale (r=.8485, P<.0001). The Melbourne Mastoidectomy Scale offers a validated score for use in the assessment of cortical mastoidectomy.

Assessment of a virtual reality temporal bone surgical simulator: a national face and content validity study

BackgroundTrainees in Otolaryngology–Head and Neck Surgery must gain proficiency in a variety of challenging temporal bone surgical techniques. Traditional teaching has relied on the use of cadavers; however, this method is resource-intensive and does not allow for repeated practice. Virtual reality surgical training is a growing field that is increasingly being adopted in Otolaryngology. CardinalSim is a virtual reality temporal bone surgical simulator that offers a high-quality, inexpensive adjunct to traditional teaching methods. The objective of this study was to establish the face and content validity of CardinalSim through a national study.MethodsOtolaryngologists and resident trainees from across Canada were recruited to evaluate CardinalSim. Ethics approval and informed consent was obtained. A face and content validity questionnaire with questions categorized into 13 domains was distributed to participants following simulator use. Descriptive statistics were used to describe questionnaire results, and either Chi-square or Fishers exact tests were used to compare responses between junior residents, senior residents, and practising surgeons.ResultsSixty-two participants from thirteen different Otolaryngology–Head and Neck Surgery programs were included in the study (32 practicing surgeons; 30 resident trainees). Face validity was achieved for 5 out of 7 domains, while content validity was achieved for 5 out of 6 domains. Significant differences between groups (p-value of < 0.05) were found for one face validity domain (realistic ergonomics, p = 0.002) and two content validity domains (teaching drilling technique, p = 0.011 and overall teaching utility, p = 0.006). The assessment scores, global rating scores, and overall attitudes towards CardinalSim, were universally positive. Open-ended questions identified limitations of the simulator.ConclusionCardinalSim met acceptable criteria for face and content validity. This temporal bone virtual reality surgical simulation platform may enhance surgical training and be suitable for patient-specific surgical rehearsal for practicing Otolaryngologists.

Combining Stereoscopic Video and Virtual Reality Simulation to Maximize Education in Lateral Skull Base Surgery.

Mastery of lateral skull base (LSB) surgery requires thorough knowledge of complex, 3-dimensional (3D) microanatomy and techniques. While supervised operation under binocular microscopy remains the training gold standard, concerns over operative time and patient safety often limit novice surgeons' stereoscopic exposure. Furthermore, most alternative educational resources cannot meet this need. Here we present proof of concept for a tool that combines 3D-operative video with an interactive, stereotactic teaching environment. Stereoscopic video was recorded with a microscope during translabyrinthine approaches for vestibular schwannoma. Digital imaging and communications in medicine (DICOM) temporal bone computed tomography images were segmented using 3D-Slicer. Files were rendered using a game engine software built for desktop virtual reality. The resulting simulation was an interactive immersion combining a 3D operative perspective from the lead surgeon's chair with virtual reality temporal bone models capable of hands-on manipulation, label toggling, and transparency modification. This novel tool may alter LSB training paradigms.

Ultra-high-fidelity virtual reality mastoidectomy simulation training: a randomized, controlled trial.

Ultra-high-fidelity (UHF) graphics in virtual reality (VR) simulation might improve surgical skill acquisitionin temporal bone training.This study aims to compare UHF VR simulation training with conventional, screen-based VR simulation training (cVR) with respect to performance and cognitive load (CL). In a randomized trial with a cross-over design, 24 students completed a total of four mastoidectomiesin a VR temporal bone surgical simulator: two performances under UHF conditions using a digital microscope and two performances under conventional conditions using screen-based VR simulation. Performances were assessed by two blinded raters using an established assessment tool. In addition, CL was estimated as the relative change in secondary-taskreaction time during simulation when compared with individual baseline measurements.Data were analyzed using linear mixedmodelanalysis for repeated measurements. The mean final-product performance score was significantly lower in UHF VR simulation compared tocVRsimulation [mean difference 1.0 points out of 17 points, 95% CI (0.2-1.7), p = 0.02]. The most important factor for performance during UHF simulation was the ability to achieve stereovision (mean difference = 3.4 points, p < 0.001).Under the UHF VR condition, CL was significantly higher than during cVR (28% vs. 18%, respectively, p < 0.001). UHF graphics in VR simulation training reduced performance and induced a higher CL in novices than conventional, screen-based VR simulation training. Consequently, UHF VR simulation training should be preceded by cVR training and might be better suited for the training of intermediates or experienced surgeons.

Understanding the effects of structured self-assessment in directed, self-regulated simulation-based training of mastoidectomy: A mixed methods study

ObjectiveSelf-directed training represents a challenge in simulation-based training as low cognitive effort can occur when learners overrate their own level of performance. This study aims to explore the mechanisms underlying the positive effects of a structured self-assessment intervention during simulation-based training of mastoidectomy. MethodsA prospective, educational cohort study of a novice training program consisting of directed, self-regulated learning with distributed practice (5x3 procedures) in a virtual reality temporal bone simulator. The intervention consisted of structured self-assessment after each procedure using a rating form supported by small videos. Semi-structured telephone interviews upon completion of training were conducted with 13 out of 15 participants. Interviews were analysed using directed content analysis and triangulated with quantitative data on secondary task reaction time for cognitive load estimation and participants’ self-assessment scores. ResultsSix major themes were identified in the interviews: goal-directed behaviour, use of learning supports for scaffolding of the training, cognitive engagement, motivation from self-assessment, self-assessment bias, and feedback on self-assessment (validation). Participants seemed to self-regulate their learning by forming individual sub-goals and strategies within the overall goal of the procedure. They scaffolded their learning through the available learning supports. Finally, structured self-assessment was reported to increase the participants’ cognitive engagement, which was further supported by a quantitative increase in cognitive load. ConclusionsStructured self-assessment in simulation-based surgical training of mastoidectomy seems to promote cognitive engagement and motivation in the learning task and to facilitate self-regulated learning.

Effect of Surgical Training Using a Virtual Reality Temporal Bone Simulator in Medical Education

Effect of Surgical Training Using a Virtual Reality Temporal Bone Simulator in Medical Education

Evaluating the Effect of Virtual Reality Temporal Bone Simulation on Mastoidectomy Performance: A Meta-analysis.

Background The increasing prevalence of virtual reality simulation in temporal bone surgery warrants an investigation to assess training effectiveness. Objectives To determine if temporal bone simulator use improves mastoidectomy performance. Data Sources Ovid Medline, Embase, and PubMed databases were systematically searched per the PRISMA guidelines. Review Methods Inclusion criteria were peer-reviewed publications that utilized quantitative data of mastoidectomy performance following the use of a temporal bone simulator. The search was restricted to human studies published in English. Studies were excluded if they were in non-peer-reviewed format, were descriptive in nature, or failed to provide surgical performance outcomes. Meta-analysis calculations were then performed. Results A meta-analysis based on the random-effects model revealed an improvement in overall mastoidectomy performance following training on the temporal bone simulator. A standardized mean difference of 0.87 (95% CI, 0.38-1.35) was generated in the setting of a heterogeneous study population ( I2 = 64.3%, P < .006). Conclusion In the context of a diverse population of virtual reality simulation temporal bone surgery studies, meta-analysis calculations demonstrate an improvement in trainee mastoidectomy performance with virtual simulation training.

Supporting skill acquisition in cochlear implant surgery through virtual reality simulation

Objectives: To evaluate the effectiveness of a virtual reality (VR) temporal bone simulator in training cochlear implant surgery.Methods: We compared the performance of 12 otolaryngology registrars conducting simulated cochlear implant surgery before (pre-test) and after (post-tests) receiving training on a VR temporal bone surgery simulator with automated performance feedback. The post-test tasks were two temporal bones, one that was a mirror image of the temporal bone used as a pre-test and the other, a novel temporal bone. Participant performances were assessed by an otologist with a validated cochlear implant competency assessment tool. Structural damage was derived from an automatically generated simulator metric and compared between time points.Results: Wilcoxon signed-rank test showed that there was a significant improvement with a large effect size in the total performance scores between the pre-test (PT) and both the first and second post-tests (PT1, PT2) (PT-PT1: P = 0.007, r = 0.78, PT-PT2: P = 0.005, r = 0.82).Conclusion: The results of the study indicate that VR simulation with automated guidance can effectively be used to train surgeons in training complex temporal bone surgeries such as cochlear implantation.

Effects of anatomical variation on trainee performance in a virtual reality temporal bone surgery simulator.

To investigate the importance of anatomical variation in acquiring skills in virtual reality cochlear implant surgery. Eleven otolaryngology residents participated in this study. They were randomly allocated to practice cochlear implant surgery on the same specimen or on different specimens for four weeks. They were then tested on two new specimens, one standard and one challenging. Videos of their performance were de-identified and reviewed independently, by two blinded consultant otolaryngologists, using a validated assessment scale. The scores were compared between groups. On the standard specimen, the round window preparation score was 2.7 ± 0.4 for the experimental group and 1.7 ± 0.6 for the control group (p = 0.01). On the challenging specimen, instrument handling and facial nerve preservation scores of the experimental group were 3.0 ± 0.4 and 3.5 ± 0.7 respectively, while the control group received scores of 2.1 ± 0.8 and 2.4 ± 0.9 respectively (p < 0.05). Training on temporal bones with differing anatomies is beneficial in the development of expertise.

Notes From the Field: Secondary Task Precision for Cognitive Load Estimation During Virtual Reality Surgical Simulation Training.

Cognitive load (CL) theory suggests that working memory can be overloaded in complex learning tasks such as surgical technical skills training, which can impair learning. Valid and feasible methods for estimating the CL in specific learning contexts are necessary before the efficacy of CL-lowering instructional interventions can be established. This study aims to explore secondary task precision for the estimation of CL in virtual reality (VR) surgical simulation and also investigate the effects of CL-modifying factors such as simulator-integrated tutoring and repeated practice. Twenty-four participants were randomized for visual assistance by a simulator-integrated tutor function during the first 5 of 12 repeated mastoidectomy procedures on a VR temporal bone simulator. Secondary task precision was found to be significantly lower during simulation compared with nonsimulation baseline, p < .001. Contrary to expectations, simulator-integrated tutoring and repeated practice did not have an impact on secondary task precision. This finding suggests that even though considerable changes in CL are reflected in secondary task precision, it lacks sensitivity. In contrast, secondary task reaction time could be more sensitive, but requires substantial postprocessing of data. Therefore, future studies on the effect of CL modifying interventions should weigh the pros and cons of the various secondary task measurements.

The effect of fidelity: How expert behavior changes in a virtual reality environment

We compare the behavior of expert surgeons operating on the "gold standard" of simulation-the cadaveric temporal bone-against a high-fidelity virtual reality (VR) simulation. We aim to determine whether expert behavior changes within the virtual environment and to understand how the fidelity of simulation affects users' behavior. Five expert otologists performed cortical mastoidectomy and cochleostomy on a human cadaveric temporal bone and a VR temporal bone simulator. Hand movement and video recordings were used to derive a range of measures, to facilitate an analysis of surgical technique, and to compare expert behavior between the cadaveric and simulator environments. Drilling time was similar across the two environments. Some measures such as total time and burr change count differed predictably due to the ease of switching burrs within the simulator. Surgical strokes were generally longer in distance and duration in VR, but these measures changed proportionally to cadaveric measures across the stages of the procedure. Stroke shape metrics differed, which was attributed to the modeling of burr behavior within the simulator. This will be corrected in future versions. Slight differences in drill interaction between a virtual environment and the real world can have measurable effects on surgical technique, particularly in terms of stroke length, duration, and curvature. It is important to understand these effects when designing and implementing surgical training programs based on VR simulation--and when improving the fidelity of VR simulators to facilitate use of a similar technique in both real and simulated situations.