Virtual Reality Simulation for the Middle Cranial Fossa Approach: A Validation Study.

BACKGROUND AND OBJECTIVES: Virtual reality (VR) surgical rehearsal is an educational tool that exists in a safe environment. Validation is necessary to establish the educational value of this platform. The middle cranial fossa (MCF) is ideal for simulation because trainees have limited exposure to this approach and it has considerable complication risk. Our objectives were to assess the face, content, and construct validities of an MCF VR simulation, as well as the change in performance across serial simulations. METHODS: Using high-resolution volumetric data sets of human cadavers, the authors generated a high-fidelity visual and haptic rendering of the MCF approach using CardinalSim software. Trainees from Neurosurgery and Otolaryngology-Head and Neck Surgery at two Canadian academic centers performed MCF dissections on this VR platform. Randomization was used to assess the effect of enhanced VR interaction. Likert scales were used to assess the face and content validities. Performance metrics and pre- and postsimulation test scores were evaluated. Construct validity was evaluated by examining the effect of the training level on simulation performance. RESULTS: Twenty trainees were enrolled. Face and content validities were achieved in all domains. Construct validity, however, was not demonstrated. Postsimulation test scores were significantly higher than presimulation test scores ( P < .001 ). Trainees demonstrated statistically significant improvement in the time to complete dissections ( P < .001 ), internal auditory canal skeletonization ( P < .001 ), completeness of the anterior petrosectomy ( P < .001 ), and reduced number of injuries to critical structures ( P = .001 ). CONCLUSION: This MCF VR simulation created using CardinalSim demonstrated face and content validities. Construct validity was not established because no trainee included in the study had previous MCF approach experience, which further emphasizes the importance of simulation. When used as a formative educational adjunct in both Neurosurgery and Otolaryngology-Head and Neck Surgery, this simulation has the potential to enhance understanding of the complex anatomic relationships of critical neurovascular structures.

How standardised are antibiotic regimens in otologic surgery?

BACKGROUND: Within otologic surgery, a paucity of well-controlled studies assessing the use of systemic antibiotic to reduce surgical site infections exists. Moreover, discrepancies in wound classification of procedures challenge consensus in antimicrobial prescribing patterns. We sought to compare surgeons from two different health systems to examine how surgeons' prescribing habits compared to practice guidelines for numerous otologic procedures. METHODS: An online questionnaire was distributed to 33 Canadian and 32 Austrian surgeons who regularly perform otologic surgery. Current systemic antibiotic prescribing habits for cochlear implantation, cholesteatoma surgery, stapes surgery, and tympanoplasty ± ossiculoplasty were collected. RESULTS: Eighteen of 33 (54.5%) Canadian surgeons provided responses, while 18 of 32 (56.3%) of Austrian surgeons answered. Clear consistency with clinical practice guidelines exists for pre-operative antibiotics use in cochlear implant surgery and infected cholesteatoma surgery. However, for stapes surgery and tympanoplasty ± ossiculoplasty, consensus is lacking for both pre- and post-operative antibiotic prescribing habits. Notable differences between the two countries include post-operative antibiotics for cochlear implant surgery (Austria: 36.4%, Canada: 71.4%) and uninfected cholesteatoma surgery (Austria: 33.3%, Canada: 77.8%). Across all procedures, both induction and post-operative antibiotic administration was not significantly associated with surgeon seniority when stratified by five-year increments. CONCLUSION: The lack of consensus among each country's otologic surgeons underscores the uncertainty in wound classification and thus, adherence to clinical practice guidelines.

Using augmented reality to guide bone conduction device implantation.

Exact placement of bone conduction implants requires avoidance of critical structures. Existing guidance technologies for intraoperative placement have lacked widespread adoption given accessibility challenges and significant cognitive loading. The purpose of this study is to examine the application of augmented reality (AR) guided surgery on accuracy, duration, and ease on bone conduction implantation. Five surgeons surgically implanted two different types of conduction implants on cadaveric specimens with and without AR projection. Pre- and postoperative computer tomography scans were superimposed to calculate centre-to-centre distances and angular accuracies. Wilcoxon signed-rank testing was used to compare centre-to-centre (C-C) and angular accuracies between the control and experimental arms. Additionally, projection accuracy was derived from the distance between the bony fiducials and the projected fiducials using image guidance coordinates. Both operative time (4.3 ± 1.2 min. vs. 6.6 ± 3.5 min., p = 0.030) and centre-to-centre distances surgery (1.9 ± 1.6 mm vs. 9.0 ± 5.3 mm, p < 0.001) were significantly less in augmented reality guided surgery. The difference in angular accuracy, however, was not significantly different. The overall average distance between the bony fiducial markings and the AR projected fiducials was 1.7 ± 0.6 mm. With direct intraoperative reference, AR-guided surgery enhances bone conduction implant placement while reduces operative time when compared to conventional surgical planning.

The feasibility and safety of eustachian tube dilation with a standard endovascular balloon: a clinical pilot study.

BACKGROUND: Obstructive eustachian tube dysfunction is a common pathology, generally accepted as the underlying cause for chronic ear diseases. Eustachian tube dilation has shown promising results in randomized controlled trials, but is a costly procedure. The aim of the current study was to assess the feasibility of transnasal balloon dilatation of the eustachian tube with an endovascular balloon in the context of ease of use, maneuverability, and safety. METHODS: Clinical pilot study carried out at a university tertiary care facility. In total, twelve patients, were included over a period of 6 months. All patients underwent tympanoplasty or tympanomastoidectomy surgeries. Eustachian tube dilation was carried out transnasal using an endovascular balloon. A computed tomography was carried out after surgery to assess for any potential damages and compared to preoperative imaging studies. Postoperative endoscopy was performed intraoperatively and at follow up to assess for any potential damages. RESULTS: All eustachian tube dilations were carried out successfully. No severe adverse events were noted during the procedure, in the postoperative period, or on imaging studies. Minor adverse events such as mild intraoperative bleeding was managed in a routine fashion. CONCLUSIONS: Balloon dilation of the eustachian tube with the endovascular balloon was feasible and safe in all cases. It is likely a more cost-effective alternative to commercially available balloons with similar designs and specifications. Trial registration The study was registered at clinicaltrials.gov; NCT04809753, initial release February 24th, 2021.

Examining the utility of a photorealistic virtual ear in otologic education.

BACKGROUND: Otolaryngology-head and neck surgical (OHNS) trainees' operating exposure is supplemented by a combination of didactic teaching, textbook reading, and cadaveric dissections. Conventional teaching, however, may not adequately equip trainees with an understanding of complex visuospatial relationships of the middle ear. Both face and content validation were assessed of a novel three-dimensional (3D) photorealistic virtual ear simulation tool underwent face and content validation as an educational tool for OHNS trainees. METHODS: A three-dimensional mesh reconstruction of open access imaging was generated using geometric modeling, which underwent global illumination, subsurface scattering, and texturing to create photorealistic virtual reality (VR) ear models were created from open access imaging and comiled into a educational platform. This was compiled into an educational VR platform which was explored to validate the face and content validity questionnaires in a prospective manner. OHNS post-graduate trainees were recruited from University of Toronto and University of Calgary OHNS programs. Participation was on a voluntary basis. RESULTS: Total of 23 OHNS post-graduate trainees from the two universities were included in this study. The mean comfort level of otologic anatomy was rated 4.8 (± 2.2) out of 10. Senior residents possessed more otologic surgical experience (P < 0.001) and higher average comfort when compared to junior residents [6.7 (± 0.7) vs. 3.6 (± 1.9); P = 0.001]. Face and content validities were achieved in all respective domains with no significant difference between the two groups. Overall, respondents believed OtoVIS was a useful tool to learn otologic anatomy with a median score of 10.0 (8.3-10.0) and strongly agreed that OtoVIS should be added to OHNS training with a score of 10.0 (9.3-10.0). CONCLUSIONS: OtoVIS achieved both face and content validity as a photorealistic VR otologic simulator for teaching otologic anatomy in the postgraduate setting. As an immersive learning tool, it may supplement trainees' understanding and residents endorsed its use.

The Otolaryngology boot camp: a scoping review evaluating commonalities and appraisal for curriculum design and delivery.

OBJECTIVE: Surgical boot camps are becoming increasingly popular in Otolaryngology-Head and Neck Surgery (OHNS) residency programs. Despite pioneering virtual reality and simulation-based surgical education, these boot camps have lacked critical appraisal. The objective of this article was to examine the adoption and utility of surgical boot camps in OHNS residency training programs around the world. DATA SOURCES: Ovid Medline and PubMed databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews. Additionally, a grey literature search was performed. REVIEW METHODS: Inclusion criteria were peer-reviewed publications and grey literature sources that reported on OHNS boot camps for the novice learner. The search was restricted to human studies published in English. Studies were excluded if they were not examining junior trainees. RESULTS: A total of 551 articles were identified. Following removal of duplicates, screening, and full text review, 16 articles were included for analysis. Seven major boot camps were identified across various academic sites in the world. Most boot camps were one-day intensive camps incorporating a mixture of didactic, skill specific, and simulation sessions using an array of task trainers and high-fidelity simulators focusing on OHNS emergencies. Studies measuring trainee outcomes demonstrated improvement in trainee confidence, immediate knowledge, and skill acquisition. CONCLUSION: Surgical boot camps appear to be an effective tool for short term knowledge and skill acquisition. Further studies should examine retention of skill and maintenance of confidence over longer intervals, as little is known about these lasting effects.

Pain Management Following Otological Surgery: A Prospective Study of Different Strategies.

OBJECTIVES: The aim of this study was to prospectively assess pain and associated analgesic consumption after otological surgery comparing two prescription patterns. STUDY DESIGN: A prospective nonrandomized consecutive cohort study. METHODS: 125 adult patients undergoing ambulatory otologic surgery-cochlear implantation and endaural middle ear surgery, were assigned (according to surgeon's preference) and prospectively studied in two arms: 1) acetaminophen 500 mg + ibuprofen 400 mg; 2) acetaminophen 500 mg + codeine 30 mg. Pain levels, medication dose, disposal patterns of opioids, and suspected side effects were evaluated. RESULTS: All patients reported mild to moderate pain. There was a statistically significant reduction of pain from day to day, which was on average 0.26 lower than the day before. Sufficient pain control could be achieved with both drug regimens with no significant difference in pain levels. Only 50% of patients who were prescribed opioids used them. Additionally, the median tablet intake was 3 tablets while 10 to 20 tablets were prescribed. The majority of patients (97%) did not dispose of these drugs safely. CONCLUSION: Adequate analgesia was achieved in both arms of this study. Pain control following otologic surgery with a combination of acetaminophen and nonsteroidal anti-inflammatory drugs is recommended unless contraindications or chronic opioid use are present. If opioids such as codeine (30 mg) are prescribed, the amount should be reduced as low as possible, such as five tablets, based on our studied population. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:204-211, 2022.

Is otologic surgery contributing to the opioid epidemic?

BACKGROUND: The opioid epidemic is a significant public health crisis challenging the lives of North Americans. Interestingly, this problem does not exist to the same extent in Europe. Surgeons play a significant role in prescribing opioids, especially in the context of post-operative pain management. The aim of this study was to compare the post-surgical prescribing patterns of otologists comparing Canada and Austria. METHODS: An online questionnaire was sent to 33 Canadian and 32 Austrian surgeons, who perform otologic surgery on a regular basis. Surgeons were asked to answer some questions about their background as well as typical prescribing patterns for postoperative pain medication for different ear surgeries (cochlear implant, stapedotomy, tympanoplasty). In addition, surgeons were asked about the typical use of local anesthetics for pain control at the end of a procedure. Otologists gave an estimate how confident they were that their therapy and prescriptions provide sufficient pain control to their patients. RESULTS: Analysis of the returned questionnaires showed that opioids are more commonly prescribed in Canada than in Austria. Nonsteroidal anti-inflammatory drugs are used for postoperative pain more regularly after ear surgery in Austria, as opposed to Canada. Some of the prescribed drugs by European otologists are not available in North America. The use of local anesthetics at the end of surgery is not common in Austria. Surgeons´ confidence that the prescribed pain medication was sufficient to control postoperative symptoms was higher in the group not prescribing opioids than in the group that did routinely prescribe opioids. CONCLUSION: Prescribing patterns differ substantially between the two evaluated countries. This data suggests an opportunity to reduce opioid prescriptions after otologic surgeries. Studies to evaluate pain after these operations as well as efficacy of analgesics following ear surgery are an important next step.

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

Following publication of the original article [1], the authors identified incorrect ordering and incorrect files being used for Figs. 1, 2 and 3.

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

BACKGROUND: Trainees 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. METHODS: Otolaryngologists 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. RESULTS: Sixty-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. CONCLUSION: CardinalSim 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.

Assessing the role of virtual reality training in Canadian Otolaryngology-Head & Neck Residency Programs: a national survey of program directors and residents.

BACKGROUND: Given mounting pressure of work hour restrictions, resource constraints, and variability of clinical exposure, Otolaryngology-Head & Neck Surgery (OHNS) residency training has shifted away from the apprenticeship model to embrace the Royal College of Physicians and Surgeons of Canada's "Competence by Design" initiative. As a result, appraising both current and potential educational adjuncts has become increasingly important. In this investigation, a national needs assessment survey was performed to identify strengths, weaknesses, and future opportunities of the current training landscape. METHODS: An online survey was distributed to all thirteen Canadian OHNS post-graduate administrators for completion by program directors and residents from February to October in 2016. Prior to distribution, the survey was vetted for face validity by a group of staff Otolaryngologists and questions were modified accordingly. Quantitative analysis was performed on SPSS (IBM Corp., Chicago) with non-parametric, two-tailed Mann-Whitney U testing performed on scaled questions. RESULTS: Of the 68 responses, 11 of 13 (84.6%) of program directors and 57 of 168 (33.9%) residents responded to the survey. All 13 programs currently utilize cadaveric laboratory dissections. Associated challenges were ranked as specimen availability, faculty participation, insufficient space, and resident time constraints. 30.8% of programs currently utilize some form of virtual reality simulator, which 90.9% of program directors felt would be a fair and effective platform for evaluation. CONCLUSION: A discrepancy exists between the favourable attitudes of both residents and program directors towards virtual reality simulation and its actual adoption. For successful adoption to occur, the existing barriers to unconventional training must be addressed and the tangible benefits for competency based training will need to be explored.

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.

Anatomy-Specific Virtual Reality Simulation in Temporal Bone Dissection: Perceived Utility and Impact on Surgeon Confidence.

Objective To evaluate the effect of anatomy-specific virtual reality (VR) surgical rehearsal on surgeon confidence and temporal bone dissection performance. Study Design Prospective pre- and poststudy of a novel virtual surgical rehearsal platform. Setting Academic otolaryngology-head and neck surgery residency training programs. Subjects and Methods Sixteen otolaryngology-head and neck surgery residents from 2 North American training institutions were recruited. Surveys were administered to assess subjects' baseline confidence in performing 12 subtasks of cortical mastoidectomy with facial recess. A cadaver temporal bone was randomly assigned to each subject. Cadaver specimens were scanned with a clinical computed tomography protocol, allowing the creation of anatomy-specific models for use in a VR surgical rehearsal platform. Subjects then rehearsed a virtual mastoidectomy on data sets derived from their specimens. Surgical confidence surveys were administered again. Subjects then dissected assigned cadaver specimens, which were blindly graded with a modified Welling scale. A final survey assessed the perceived utility of rehearsal on dissection performance. Results Of 16 subjects, 14 (87.5%) reported a significant increase in overall confidence after conducting an anatomy-specific VR rehearsal. A significant correlation existed between perceived utility of rehearsal and confidence improvement. The effect of rehearsal on confidence was dependent on trainee experience and the inherent difficulty of the surgical subtask. Postrehearsal confidence correlated strongly with graded dissection performance. Subjects rated anatomy-specific rehearsal as having a moderate to high contribution to their dissection performance. Conclusion Anatomy-specific virtual rehearsal improves surgeon confidence in performing mastoid dissection, dependent on surgeon experience and task difficulty. The subjective confidence gained through rehearsal correlates positively with subsequent objective dissection performance.

Evaluation of haptic interfaces for simulation of drill vibration in virtual temporal bone surgery.

Surgical training is evolving from an observership model towards a new paradigm that includes virtual-reality (VR) simulation. In otolaryngology, temporal bone dissection has become intimately linked with VR simulation as the complexity of anatomy demands a high level of surgeon aptitude and confidence. While an adequate 3D visualization of the surgical site is available in current simulators, the force feedback rendered during haptic interaction does not convey vibrations. This lack of vibration rendering limits the simulation fidelity of a surgical drill such as that used in temporal bone dissection. In order to develop an immersive simulation platform capable of haptic force and vibration feedback, the efficacy of hand controllers for rendering vibration in different drilling circumstances needs to be investigated. In this study, the vibration rendering ability of four different haptic hand controllers were analyzed and compared to find the best commercial haptic hand controller. A test-rig was developed to record vibrations encountered during temporal bone dissection and a software was written to render the recorded signals without adding hardware to the system. An accelerometer mounted on the end-effector of each device recorded the rendered vibration signals. The newly recorded vibration signal was compared with the input signal in both time and frequency domains by coherence and cross correlation analyses to quantitatively measure the fidelity of these devices in terms of rendering vibrotactile drilling feedback in different drilling conditions. This method can be used to assess the vibration rendering ability in VR simulation systems and selection of ideal haptic devices.

Reducing the preoperative ecological footprint in otolaryngology.

OBJECTIVES: To (1) evaluate the potential for recycling uncontaminated preoperative waste and (2) identify recycling differences within otolaryngology-head and neck surgery subspecialties. STUDY DESIGN: Prospective study. SETTING: Three university-affiliated tertiary level hospitals. SUBJECTS: Otolaryngology-head and neck surgery operative procedures. METHODS: A total of 97 operative procedures were evaluated. Preoperative waste products were sorted into recyclable and nonrecyclable materials; intraoperative waste was weighed for volume but not sorted. The preoperative period was defined as the opening of the surgical supply cart for operating room preparation until procedure initiation. Mass and volume of each type of waste were recorded upon the conclusion of the case. RESULTS: Approximately 23.1% of total operative waste mass (36.7% by volume) was derived from the preoperative set-up, of which 89.7% was recyclable. Pediatric procedures produced the least recyclable material per operation as a proportion of total waste, which was statistically different than the 2 highest recyclable subspecialties, general and rhinology (P = .006); the remaining subspecialties did not statistically differ in proportion of recyclable material produced. CONCLUSION: This study identified a source of clean recyclable materials that could eliminate 21% of operating room waste mass.

Primary squamous cell of the thyroid-an abbreviated clinical presentation.

BACKGROUND: Lacking any squamous epithelium, thyroid gland with primary squamous cell carcinoma (PSCC) proves to be an etiopathophysiological quandary. Two major theories do exist, though few cases have been documented to support either. We present a case that supports the "metaplasia" theory, which serves to enhance our understanding of a disease that carries with it a very poor prognosis. CASE PRESENTATION: We present a case of an extremely advanced, primary squamous cell carcinoma of the thyroid with distant metastases in a thirty-six year-old male. Dying of airway compromise seventeen days following his admission, this is the shortest median survival of all documented cases. CONCLUSION: In addition to being the most abbreviated time period between presentation and death of all documented thyroid primary squamous cell carcinomas, we share the fifth case of thyroid PSCC in the setting of lymphocytic thyroiditis. This case should build awareness of the aggressivity of the disease and the lack of established diagnostic criteria.