The good lecture.

Postgraduate medical education often relies on the traditional lecture model with low knowledge retention rates of 5-20%. Cognitive overload from excessive information during lectures diminishes learning efficacy. To optimise learning, evidence suggests prioritising active engagement, streamlining visual aids, introducing clinical scenarios, and incorporating audience response systems may further enhance retention and comprehension. In conclusion, the traditional lecture must evolve into more interactive and engaging modalities to facilitate increased participant long-term learning as summarised in this review.

Variability in Manual Segmentation of Temporal Bone Structures in Cone Beam CT Images.

PURPOSE: Manual segmentation of anatomical structures is the accepted "gold standard" for labeling structures in clinical images. However, the variability in manual segmentation of temporal bone structures in CBCT images of the temporal bone has not been systematically evaluated using multiple reviewers. Therefore, we evaluated the intravariability and intervariability of manual segmentation of inner ear structures in CBCT images of the temporal bone. METHODS: Preoperative CBCTs scans of the inner ear were obtained from 10 patients who had undergone cochlear implant surgery. The cochlea, facial nerve, chorda tympani, mid-modiolar (MM) axis, and round window (RW) were manually segmented by five reviewers in two separate sessions that were at least 1 month apart. Interreviewer and intrareviewer variabilities were assessed using the Dice coefficient (DICE), volume similarity, mean Hausdorff Distance metrics, and visual review. RESULTS: Manual segmentation of the cochlea was the most consistent within and across reviewers with a mean DICE of 0.91 (SD = 0.02) and 0.89 (SD = 0.01) respectively, followed by the facial nerve with a mean DICE of 0.83 (SD = 0.02) and 0.80 (SD = 0.03), respectively. The chorda tympani had the greatest amount of reviewer variability due to its thin size, and the location of the centroid of the RW and the MM axis were also quite variable between and within reviewers. CONCLUSIONS: We observed significant variability in manual segmentation of some of the temporal bone structures across reviewers. This variability needs to be considered when interpreting the results in studies using one manual reviewer.

Further Validity Evidence for Patient-Specific Virtual Reality Temporal Bone Surgical Simulation.

OBJECTIVE: Patient-specific virtual reality (VR) simulation of cochlear implant (CI) surgery potentially enables preoperative rehearsal and planning. We aim to gather supporting validity evidence for patient-specific simulation through the analysis of virtual performance and comparison with postoperative imaging. METHODS: Prospective, multi-institutional study. Pre- and postoperative cone-beam CT scans of CI surgical patients were obtained and processed for patient-specific VR simulation. The virtual performances of five trainees and four attendings were recorded and (1) compared with volumes removed during actual surgery as determined in postoperative imaging, and (2) assessed using the Copenhagen Cochlear Implant Surgery Assessment Tool (CISAT) by two blinded raters. The volumes compared were cortical mastoidectomy, facial recess, and round window (RW) cochleostomy as well as violation of the facial nerve and chorda. RESULTS: Trainees drilled more volume in the cortical mastoidectomy and facial recess, whereas attendings drilled more volume for the RW cochleostomy and made more violations. Except for the cochleostomy, attendings removed volumes closer to that determined in postoperative imaging. Trainees achieved a higher CISAT performance score compared with attendings (22.0 vs. 18.4 points) most likely due to lack of certain visual cues. CONCLUSION: We found that there were differences in performance of trainees and attendings in patient-specific VR simulation of CI surgery as assessed by raters and in comparison with actual drilled volumes. The presented approach of volume comparison is novel and might be used for further validation of patient-specific VR simulation before clinical implementation for preoperative rehearsal in temporal bone surgery. LEVEL OF EVIDENCE: n/a Laryngoscope, 134:1403-1409, 2024.

Gathering validity evidence for a 3D-printed simulator for training of myringotomy and ventilation tube insertion.

Objectives: This study aimed to gather validity evidence according to Messick's framework for a novel 3D-printed simulator for myringotomy with ventilation tube insertion for use in technical skills training of otorhinolaryngology (ORL) residents. Methods: The study included 15 junior ORL residents (trainees) and 13 experienced teaching otolaryngologists (experts). Experts and trainees first received an identically structured introduction to the procedure, simulator, and simulation setup. Five procedures performed by each participant were video-recorded and ordered randomly for blinded rating by two independent raters. The rating tools used were a global rating scale (GBRS) and a task-specific checklist. Validity evidence was collected according to Messick's framework. Differences in time consumption and performance scores were analyzed. Finally, a pass/fail standard was established using the contrasting groups' method. Results: Trainees used significantly more time per procedure (109 s, 95% CI: 99-120) than experts (82 s, 95% CI: 71-93; p < .001). Adjusted for repetition and rater leniency, experts achieved an average GBRS score of 18.8 (95% CI: 18.3-19.2) out of 20 points, whereas trainees achieved an average of 17.1 points (95% CI: 16.6-17.5; p < .001). In contrast to the task-specific checklist, the GBRS score discriminated between repetition number and participant experience. The pass/fail standard for the GBRS was established at 18.4 points. Conclusion: We established educational validity evidence for a novel 3D-printed model for simulation-based training of ventilation tube insertion and established a reliable pass/fail standard. Level of Evidence: 1b.

Retention of emergency cricothyroidotomy skills: A multicenter randomized controlled trial.

Objectives: Emergency cricothyroidotomy is the final approach to establishing a secure airway. The procedure is acute and highly infrequent, making it difficult to achieve and maintain competence in the clinic. Simulation-based training in emergency cricothyroidotomy is effective but it is unknown how often training should be repeated to maintain skills. This study aimed to assess novices' retention of technical skills in emergency cricothyroidotomy after completing SBT. Methods: Novices in emergency cricothyroidotomy completed a structured, simulation-based training program and were randomized to retention tests after 1, 3, or 6 months. Participants completed two emergency cricothyroidotomy tests at end-of-training and follow-up retention testing. Test performances were video recorded and evaluated by two experienced blinded raters using a structured assessment tool. Differences in the performances and the pass/fail rates were analyzed. Results: Eighty-two medical students from two different Danish universities were included from April 2021 to February 2022. Paired t-tests showed skills decay significantly after 1 month (mean loss 6.7 points, p < 0.001). The mean loss of points, representing the difference in global score points, from the end-of-training to retention test was 6.7 points (95% confidence interval [CI] 4.5-8.8) for the 1-month group, 8.2 points (95% CI 5.8-10.0) for the 3-months group, and 9.9 points (95% CI 8.1-11.7) for the 6-months group. Six participants in both the 1-month group (23.1%) and the 3-month group (24%) passed the first retention test, but no one in the 6-months group had a passing performance. Conclusions: Novices' technical skills performance in emergency cricothyroidotomy decay significantly already after 1 month. This initial loss of skill seems to be stable until 3 months, after which there is a further significant loss of skills. Recurring training should be implemented for the benefit of patient safety and outcomes.

3-D-Printed Models for Temporal Bone Training: A Validity Study.

OBJECTIVE: 3-D printing offers convenient and low-cost mastoidectomy training; nonetheless, training benefits using 3-D-printed temporal bones remain largely unexplored. In this study, we have collected validity evidence for a low-cost, 3-D-printed temporal bone for mastoidectomy training and established a credible pass/fail score for performance on the model. STUDY DESIGN: A prospective educational study gathering validity evidence using Messick's validity framework. SETTING: Seven Danish otorhinolaryngology training institutions. PARTICIPANTS: Eighteen otorhinolaryngology residents (novices) and 11 experienced otosurgeons (experts). INTERVENTION: Residents and experienced otosurgeons each performed two to three anatomical mastoidectomies on a low-cost, 3-D-printed temporal bone model produced in-house. After drilling, mastoidectomy performances were rated by three blinded experts using a 25-item modified Welling scale (WS). MAIN OUTCOME MEASURE: Validity evidence using Messick's framework including reliability assessment applying both classical test theory and Generalizability theory. RESULTS: Novices achieved a mean score of 13.9 points; experienced otosurgeons achieved 23.2 points. Using the contrasting groups method, we established a 21/25-point pass/fail level. The Generalizability coefficient was 0.91, and 75% of the score variance was attributable to participant performance, indicating a high level of assessment reliability. Subsequent D studies revealed that two raters rating one performance or one rater rating two performances were sufficiently reliable for high-stakes assessment. CONCLUSION: Validity evidence supports using a low-cost, 3-D-printed model for mastoidectomy training. The model can be printed in-house using consumer-grade 3-D printers and serves as an additional training tool in the temporal bone curriculum. For competency-based training, we established a cut-off score of 21 of 25 WS points using the contrasting groups method.

3D-printing a cost-effective model for mastoidectomy training.

BACKGROUND: 3D-printed temporal bone models can potentially provide a cost-effective alternative to cadaver surgery that can be manufactured locally at the training department. The objective of this study was to create a cost-effective 3D-printed model suitable for mastoidectomy training using entry level and commercially available print technologies, enabling individuals, without prior experience on 3D-printing, to manufacture their own models for basic temporal bone training. METHODS: Expert technical professionals and an experienced otosurgeon identified the best material for replicating the temporal bone and created a cost-effective printing routine for the model using entry-level print technologies. Eleven participants at a temporal bone dissection course evaluated the model using a questionnaire. RESULTS: The 3D-printed temporal bone model was printed using a material extrusion 3D-printer with a heat resistant filament, reducing melting during drilling. After printing, a few simple post-processing steps were designed to replicate the dura, sigmoid sinus and facial nerve. Modifying the 3D-printer by installing a direct-drive and ruby nozzle resulted in more successful prints and less need for maintenance. Upon evaluation by otorhinolaryngology trainees, unanimous feedback was that the model provided a good introduction to the mastoidectomy procedure, and supplementing practice to cadaveric temporal bones. CONCLUSION: In-house production of a cost-effective 3D-printed model for temporal bone training is feasible and enables training institutions to manufacture their own models. Further, this work demonstrates the feasibility of creating new temporal bone models with anatomical variation to provide ample training opportunity.

Learning Curves in Directed Self-Regulated Virtual Reality Training of Mastoidectomy and the Role of Repetition and Motivation.

BACKGROUND: Mastoidectomy is a complex procedure which can be trained on human cadaveric temporal bones or simulation models. The number of repetitions offered in most training curricula is considerably less than what is normally required for motor skills acquisition in crafts or sports. Directed, self-regulated virtual reality simulation training may provide unlimited repetitions but the effect on learning of extended but unsupervised training is unknown. This study recorded extended learning curves of novices in virtual reality simulation mastoidectomy training. METHODS: Six medical students used the visible ear temporal bone simulator at home for 100 repetitions. Virtual temporal bones were later assessed by 2 blinded experts on a 26-point modified Welling Scale. RESULTS: Four participants completed 100 procedures each and 2 participants completed 50 procedures. Learning curves and plots of time demonstrated great variation: one participant improved gradually during the first 50 procedures and sustained a high performance; another participant achieved only 16 points after 50 procedures; a third participant demonstrated mediocre performances between 10 and 15 points but only used about 5 minutes per procedure. The remaining 3 participants achieved high but fluctuating scores with very limited time use per procedure. Their score per time exceeds the performance of experienced otosurgeons and suggests the use of save/restore gaming strategies to inflate their performance. CONCLUSION: Deliberate learners may reach proficiency in virtual reality simulation of mastoidectomy after 50 repetitions. However, even 100 repetitions cannot guarantee proficiency if motivation fails. Creative "gaming" behavior must be considered and opposed by motivation, supervision, testing, and certification.

Pipeline for Automated Processing of Clinical Cone-Beam Computed Tomography for Patient-Specific Temporal Bone Simulation: Validation and Clinical Feasibility.

OBJECTIVE: Patient-specific simulation allows the surgeon to plan and rehearse the surgical approach ahead of time. Preoperative clinical imaging for this purpose requires time-consuming manual processing and segmentation of landmarks such as the facial nerve. We aimed to evaluate an automated pipeline with minimal manual interaction for processing clinical cone-beam computed tomography (CBCT) temporal bone imaging for patient-specific virtual reality (VR) simulation. STUDY DESIGN: Prospective image processing of retrospective imaging series. SETTING: Academic hospital. METHODS: Eleven CBCTs were selected based on quality and used for validation of the processing pipeline. A larger naturalistic sample of 36 CBCTs were obtained to explore parameters for successful processing and feasibility for patient-specific VR simulation.Visual inspection and quantitative metrics were used to validate the accuracy of automated segmentation compared with manual segmentation. Range of acceptable rotational offsets and translation point selection variability were determined. Finally, feasibility in relation to image acquisition quality, processing time, and suitability for VR simulation was evaluated. RESULTS: The performance of automated segmentation was acceptable compared with manual segmentation as reflected in the quantitative metrics. Total time for processing for new data sets was on average 8.3 minutes per data set; of this, it was less than 30 seconds for manual steps. Two of the 36 data sets failed because of extreme rotational offset, but overall the registration routine was robust to rotation and manual selection of a translational reference point. Another seven data sets had successful automated segmentation but insufficient suitability for VR simulation. CONCLUSION: Automated processing of CBCT imaging has potential for preoperative VR simulation but requires further refinement.

Are Video Recordings Reliable for Assessing Surgical Performance? A Prospective Reliability Study Using Generalizability Theory.

INTRODUCTION: Reliability is pivotal in surgical skills assessment. Video-based assessment can be used for objective assessment without physical presence of assessors. However, its reliability for surgical assessments remains largely unexplored. In this study, we evaluated the reliability of video-based versus physical assessments of novices' surgical performances on human cadavers and 3D-printed models-an emerging simulation modality. METHODS: Eighteen otorhinolaryngology residents performed 2 to 3 mastoidectomies on a 3D-printed model and 1 procedure on a human cadaver. Performances were rated by 3 experts evaluating the final surgical result using a well-known assessment tool. Performances were rated both hands-on/physically and by video recordings. Interrater reliability and intrarater reliability were explored using κ statistics and the optimal number of raters and performances required in either assessment modality was determined using generalizability theory. RESULTS: Interrater reliability was moderate with a mean κ score of 0.58 (range 0.53-0.62) for video-based assessment and 0.60 (range, 0.55-0.69) for physical assessment. Video-based and physical assessments were equally reliable (G coefficient 0.85 vs. 0.80 for 3D-printed models and 0.86 vs 0.87 for cadaver dissections). The interaction between rater and assessment modality contributed to 8.1% to 9.1% of the estimated variance. For the 3D-printed models, 2 raters evaluating 2 video-recorded performances or 3 raters physically assessing 2 performances yielded sufficient reliability for high-stakes assessment (G coefficient >0.8). CONCLUSIONS: Video-based and physical assessments were equally reliable. Some raters were affected by changing from physical to video-based assessment; consequently, assessment should be either physical or video based, not a combination.

Am I doing this right? Structured self-assessment during simulation training of mastoidectomy improves cadaver dissection performance: a prospective educational study.

PURPOSE: Temporal bone surgery requires excellent surgical skills and simulation-based training can aid novices' skills acquisition. However, simulation-based training is challenged by early stagnation of performance after few performances. Structured self-assessment during practice might enhance learning by inducing reflection and engagement in the learning task. In this study, structured self-assessment was introduced during virtual reality (VR) simulation of mastoidectomy to investigate the effects on subsequent performance during cadaveric dissection. METHODS: A prospective educational study with comparison with historical controls (reference cohort). At a temporal bone dissection course, eighteen participants performed structured self-assessment during 3 h of VR simulation mastoidectomy training before proceeding to cadaver dissection (intervention cohort). At a previous course, eighteen participants received identical VR simulation training but without the structured self-assessment (reference cohort). Final products from VR simulation and cadaveric dissection were recorded and assessed by two blinded raters using a 19-point modified Welling Scale. RESULTS: The intervention cohort completed fewer procedures (average 4.2) during VR simulation training than the reference cohort (average 5.7). Nevertheless, the intervention cohort achieved a significantly higher average performance score both in VR simulation (11.1 points, 95% CI [10.6-11.5]) and subsequent cadaveric dissection (11.8 points, 95% CI [10.7-12.8]) compared with the reference cohort, who scored 9.1 points (95% CI [8.7-9.5]) during VR simulation and 5.8 points (95% CI [4.8-6.8]) during cadaveric dissection. CONCLUSIONS: Structured self-assessment is a valuable learning support during self-directed VR simulation training of mastoidectomy and the positive effect on performance transfers to subsequent cadaveric dissection performance.

Ten Tips for Performing Your First Peer Review: The Next Step for the Aspiring Academic Plastic Surgeon.

Performing the first peer review of a plastic surgical research article can be an overwhelming task. However, it is an essential scholarly skill and peer review is used in a multitude of settings: evaluation of journal articles, conference abstracts, and research proposals. Furthermore, peer reviewing provides more than just the opportunity to read and help improve other's work: peer reviewing can improve your own scientific writing. A structured approach is possible and recommended. In these ten tips, we provide guidance on how to successfully conduct the first peer reviews. The ten tips on peer reviewing concern: 1) Appropriateness: are you qualified and prepared to perform the peer review? 2) Familiarization with the journal and its reviewing guidelines; 3) Gathering first impressions of the paper followed by specific tips for reviewing; 4) the abstract and introduction; 5) Materials, methods, and results (including statistical considerations); and 6) discussion, conclusion, and references. Tip 7 concerns writing and structuring the review; Tips 7 and 8 describe how to provide constructive criticism and understanding the limits of your expertise. Finally, Tip 10 details why-and how-you become a peer reviewer. Peer review can be done by any plastic surgeon, not just those interested in an academic career. These ten tips provide useful insights for both the aspiring and the experienced peer reviewer. In conclusion, a systematic approach to peer reviewing is possible and recommended, and can help you getting started to provide quality peer reviews that contribute to moving the field of plastic surgery forward.

Mastoidectomy Training: Is Anatomical Variation Needed? A Randomized, Controlled Trial on Performance and Skills Transfer From Virtual Reality to a Three-Dimensional Printed Model.

OBJECTIVE: Virtual reality (VR) simulation-based training effectively improves novices' mastoidectomy skills. Unfortunately, learning plateaus at an insufficient level and knowledge on optimizing mastoidectomy training to overcome this plateau is needed. In this study, we aim to investigate how training on anatomically different temporal bone cases affects learning, including the effect on retention and transfer of skills. STUDY DESIGN: Randomized controlled trial of an educational intervention. SETTING: The Simulation Center at Copenhagen Academy for Medical Education and Simulation. PARTICIPANTS: Twenty-four medical students from the University of Copenhagen. INTERVENTION: Participants were randomized to practice mastoidectomy on either 12 anatomically varying (intervention group) or 12 identical (control group) cases in a VR simulator. At the end of training and again ~ 3 weeks after training (retention), learners were tested on a new VR patient case and a three-dimensional printed model. MAIN OUTCOME MEASURE: Mastoidectomy performance evaluated by blinded expert raters using a 26-item modified Welling Scale. RESULTS: The intervention and control groups' performance results were comparable at the end of training. Likewise, retention and transfer performances were similar between groups. The overall mean score at the end of training corresponded to approximately 70% of the possible maximum score. CONCLUSIONS: Simulation-based training using anatomical variation was equivalent to training on a single case with respect to acquisition, retention, and transfer of mastoidectomy skills. This suggests that efforts to expose novices to variation during initial training are unnecessary as this variation has limited effect, and-conversely-that educators can expose novices to naturally different anatomical variations without worry of hindered learning.

Simulation-based surgical training needs in otorhinolaryngology.

INTRODUCTION: This study aimed to conduct a targeted needs assessment to identify and prioritise technical skills and procedures suited for simulation-based training (SBT) in private otorhinolaryngology (ORL) practice in Denmark, including mapping the learning environment related to implementation of SBT. METHODS: A panel of trainers and trainees in private ORL practice was recruited. Using the Delphi method, three rounds of surveys were conducted. Round one consisted of a survey of the learning environment and a brainstorming phase. Round two quantified the frequency of procedures, ranked the importance of procedural competency, impact on patient safety and feasibility for SBT. In round three, panelists eliminated and ranked procedures for final prioritisation. RESULTS: A total of 26 of 57 invited trainers and trainees accepted participation. The educational environment was described and 136 skills were suggested in the brainstorming phase. "Non-technical" skills were removed, and the remaining 46 technical skills were grouped for appraisal in round two. In round three, panelists reduced these to eight technical skills and procedures which were maintained for final prioritisation for SBT with myringotomy with ventilation tube insertion ranking highest. Trainees and trainers indicated that close supervision and dedicated time for training were major strengths of the learning environment. CONCLUSIONS: Our findings extend the results obtained in a previous general needs assessment and may inform curricular implementation of SBT in private ORL practice. A structured "package" with SBT and assessment for the identified procedures are desired by trainers. This work is already in progress and implementation is facilitated by a positive attitude towards SBT among trainers and trainees alike. FUNDING: none. TRIAL REGISTRATION: not relevant.

The cutting edge of customized surgery: 3D-printed models for patient-specific interventions in otology and auricular management-a systematic review.

PURPOSE: 3D-printing (three-dimensional printing) is an emerging technology with promising applications for patient-specific interventions. Nonetheless, knowledge on the clinical applicability of 3D-printing in otology and research on its use remains scattered. Understanding these new treatment options is a prerequisite for clinical implementation, which could improve patient outcomes. This review aims to explore current applications of 3D-printed patient-specific otologic interventions, including state of the evidence, strengths, limitations, and future possibilities. METHODS: Following the PRISMA statement, relevant studies were identified through Pubmed, EMBASE, the Cochrane Library, and Web of Science. Data on the manufacturing process and interventions were extracted by two reviewers. Study quality was assessed using Joanna Briggs Institute's critical appraisal tools. RESULTS: Screening yielded 590 studies; 63 were found eligible and included for analysis. 3D-printed models were used as guides, templates, implants, and devices. Outer ear interventions comprised 73% of the studies. Overall, optimistic sentiments on 3D-printed models were reported, including increased surgical precision/confidence, faster manufacturing/operation time, and reduced costs/complications. Nevertheless, study quality was low as most studies failed to use relevant objective outcomes, compare new interventions with conventional treatment, and sufficiently describe manufacturing. CONCLUSION: Several clinical interventions using patient-specific 3D-printing in otology are considered promising. However, it remains unclear whether these interventions actually improve patient outcomes due to lack of comparison with conventional methods and low levels of evidence. Further, the reproducibility of the 3D-printed interventions is compromised by insufficient reporting. Future efforts should focus on objective, comparative outcomes evaluated in large-scale studies.

Standard Setting in Simulation-based Training of Surgical Procedures: A Systematic Review.

OBJECTIVE: This systematic review aims to examine the use of standard-setting methods in the context of simulation-based training of surgical procedures. SUMMARY OF BACKGROUND: Simulation-based training is increasingly used in surgical education. However, it is important to determine which level of competency trainees must reach during simulation-based training before operating on patients. Therefore, pass/fail standards must be established using systematic, transparent, and valid methods. METHODS: Systematic literature search was done in 4 databases (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library). Original studies investigating simulation-based assessment of surgical procedures with the application of a standard setting were included. Quality of evidence was appraised using GRADE. RESULTS: Of 24,299 studies identified by searches, 232 studies met the inclusion criteria. Publications using already established standard settings were excluded (N = 70), resulting in 162 original studies included in the final analyses. Most studies described how the standard setting was determined (N = 147, 91%) and most used the mean or median performance score of experienced surgeons (n = 65, 40%) for standard setting. We found considerable differences across most of the studies regarding study design, setup, and expert level classification. The studies were appraised as having low and moderate evidence. CONCLUSION: Surgical education is shifting toward competency-based education, and simulation-based training is increasingly used for acquiring skills and assessment. Most studies consider and describe how standard settings are established using more or less structured methods but for current and future educational programs, a critical approach is needed so that the learners receive a fair, valid, and reliable assessment.

Automated Calculation of Cochlear Implant Electrode Insertion Parameters in Clinical Cone-Beam CT.

HYPOTHESIS: Automated processing of postoperative clinical cone-beam CT (CBCT) of cochlear implant (CI) patients can be used to accurately determine electrode contacts and integrated with an atlas-based mapping of cochlear microstructures to calculate modiolar distance, angular insertion distance, and scalar location of electrode contacts. BACKGROUND: Hearing outcomes after CI surgery are dependent on electrode placement. CBCT is increasingly used for in-office temporal bone imaging and might be routinely used for pre- and post-surgical evaluation. METHODS: Thirty-six matched pairs of pre- and postimplant CBCT scans were obtained. These were registered with an atlas to model cochlear microstructures in each dataset. Electrode contact center points were automatically determined using thresholding and electrode insertion parameters were calculated. Automated localization and calculation were compared with manual segmentation of contact center points as well as manufacturer specifications. RESULTS: Automated electrode contact detection aligned with manufacturer specifications of spacing and our algorithms worked for both distantly- and closely spaced arrays. The average difference between the manual and the automated selection was 0.15 mm, corresponding to a 1.875 voxel difference in each plane at the scan resolution. For each case, we determined modiolar distance, angular insertion depth, and scalar location. These calculations also resulted in similar insertion values using manual and automated contact points as well as aligning with electrode properties. CONCLUSION: Automated processing of implanted high-resolution CBCT images can provide the clinician with key information on electrode placement. This is one step toward routine use of clinical CBCT after CI surgery to inform and guide postoperative treatment.

Assessing competence in cochlear implant surgery using the newly developed Cochlear Implant Surgery Assessment Tool.

PURPOSE: To develop and gather validity evidence for a novel tool for assessment of cochlear implant (CI) surgery, including virtual reality CI surgery training. METHODS: Prospective study gathering validity evidence according to Messick's framework. Four experts developed the CI Surgery Assessment Tool (CISAT). A total of 35 true novices (medical students), trained novices (residents) and CI surgeons performed two CI-procedures each in the Visible Ear Simulator, which were rated by three blinded experts. Classical test theory and generalizability theory were used for reliability analysis. RESULTS: The CISAT significantly discriminated between the three groups (p < 0.001). The generalizability coefficient was 0.76 and most of the score variance (53.3%) was attributable to the participant and only 6.8% to the raters. When exploring a standard setting for CI surgery, the contrasting groups method suggested a pass/fail score of 36.0 points (out of 55), but since the trained novices performed above this, we propose using the mean CI surgeon performance score (45.3 points). CONCLUSION: Validity evidence for simulation-based assessment of CI performance supports the CISAT. Together with the standard setting, the CISAT might be used to monitor progress in competency-based training of CI surgery and to determine when the trainee can advance to further training.

Cochlear implantation: Exploring the effects of 3D stereovision in a digital microscope for virtual reality simulation training - A randomized controlled trial.

In cochlear implantation (CI), excellent surgical technique is critical for hearing outcomes. Recent advances in temporal bone Virtual Reality (VR) training allow for specific training of CI and through introduction of new digital microscopes with ultra-high-fidelity (UHF) graphics. This study aims to investigate whether UHF increases performance in VR simulation training of CI electrode insertion compared with conventional, screen-based VR (cVR). METHODS: Twenty-four medical students completed a randomized, controlled trial of an educational intervention. They performed a total of eight CI electrode insertions each in blocks of four using either UHF-VR or cVR, in randomized order. CI electrode insertion performances were rated by two blinded expert raters using a structured assessment tool supported by validity evidence. RESULTS: Performance scores in cVR were higher than in the UHF-VR simulation although this was not significant (19.8 points, 95% CI [19.3-20.3] vs. 18.8 points, 95% CI [18.2-19.4]; P = 0.09). The decisive factor for performance was participants' ability to achieve stereovision (mean difference = 1.1 points, 95% CI [0.15-2.08], P = 0.02). DISCUSSION: No additional benefit was found from UHF-VR over cVR training of CI electrode insertion for novices. Consequently, standard cVR simulation should be used for novices' basic skills acquisition in CI surgery. Future studies should instead explore the effects of other improvements in CI surgery training and if the lacking benefit of UHF-VR also applies for more experienced learners. CONCLUSION: The increased graphical perception and the superior lifelikeness of UHF-VR does not improve early skills acquisition of CI insertion for novices.

Current Evidence for Simulation-Based Training and Assessment of Myringotomy and Ventilation Tube Insertion: A Systematic Review.

OBJECTIVE: Myringotomy and ventilation tube insertion (MT) is a key procedure in otorhinolaryngology and can be trained using simulation models. We aimed to systematically review the literature on models for simulation-based training and assessment of MT and supporting educational evidence. DATABASES REVIEWED: PubMed, Embase, Cochrane Library, Web of Science, Directory of Open Access Journals. METHODS: Inclusion criteria were MT training and/or skills assessment using all types of training modalities and learners. Studies were divided into 1) descriptive and 2) educational interventional/observational in the analysis. For descriptive studies, we provide an overview of available models including materials and cost. Educational studies were appraised using Kirkpatrick's level of educational outcomes, Messick's framework of validity, and a structured quality assessment tool. RESULTS: Forty-six studies were included consisting of 21 descriptive studies and 25 educational studies. Thirty-one unique physical and three virtual reality simulation models were identified. The studies report moderate to high realism of the different simulators and trainees and educators perceive them beneficial in training MT skills. Overall, simulation-based training is found to reduce procedure time and errors, and increase performance as measured using different assessment tools. None of the studies used a contemporary validity framework and the current educational evidence is limited. CONCLUSION: Numerous simulation models and assessment tools have been described in the literature but educational evidence and systematic implementation into training curricula is scarce. There is especially a need to establish the effect of simulation-based training of MT in transfer to the operating room and on patient outcomes.