Supporting skill acquisition in cochlear implant surgery through virtual reality simulation

Feasibility of Using Inertial Measurement Units (IMUs) to Augment Cadaveric Temporal Training

OBJECTIVE

Insertional speed of cochlear implant electrode arrays (EA) during surgery is correlated with force. Low insertional speed, and therefore force, may allow for preservation of intracochlear structures leading to improved outcomes. Given the importance of low insertional speeds, we investigate the feasibility of using inertial sensors for kinematic analysis during EA insertion to augment otolaryngology-head and neck surgery training.

METHODS

Practicing otolaryngology surgeons were recruited and inertial measurement units (IMU; Metamotions+, MBIENTLAB Inc, San Jose, CA) consisting of accelerometers were used to measure hand speed during EA (Cochlear™Nucleus®CI522 cochlear implant with Slim Straight electrode, Cochlear Limited, Sydney, Australia) insertion into a cadaveric cochlea. A mixed regression model was utilized to determine differences in speed across trials within a surgeon.

RESULTS

A total of nine trials were performed by three surgeons. The highest mean ± SD speed obtained was 8.4 ± 1.7 mm/s, and the highest speed was 22.5 mm/s. Mean speed was not significantly different across trials within surgeons (p > 0.05).

DISCUSSION

IMUs are relatively inexpensive and relatively easy to use sensors that provide information on variables that may be of interest for otolaryngology resident training. The use of IMUs as part of advanced temporal training for cochlear electrode insertion can provide insight into hand speed, thereby allowing residents to train with specific regard to this variable. Future randomized-controlled trials can be carried out to determine whether IMUs are conducive to lower insertional speeds.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:1465-1471, 2025.

Virtual temporal bone simulators and their use in surgical training: a narrative review

OBJECTIVE

Temporal bone dissection is a difficult skill to acquire, and the challenge has recently been further compounded by a reduction in conventional surgical training opportunities during the coronavirus disease 2019 pandemic. Consequently, there has been renewed interest in ear simulation as an adjunct to surgical training for trainees. We review the state-of-the-art virtual temporal bone simulators for surgical training.

MATERIALS AND METHODS

A narrative review of the current literature was performed following a Medline search using a pre-determined search strategy.

RESULTS AND ANALYSIS

Sixty-one studies were included. There are five validated temporal bone simulators: Voxel-Man, CardinalSim, Ohio State University Simulator, Melbourne University's Virtual Reality Surgical Simulation and Visible Ear Simulator. The merits of each have been reviewed, alongside their role in surgical training.

CONCLUSION

Temporal bone simulators have been demonstrated to be useful adjuncts to conventional surgical training methods and are likely to play an increasing role in the future.

Intraoperative Measurement of Insertion Speed in Cochlear Implant Surgery: A Preliminary Experience with Cochlear SmartNav

OBJECTIVES

The objectives were to present the real-time estimated values of cochlear implant (CI) electrode insertion speed (IS) during intraoperative sessions using the Cochlear Nucleus SmartNav System to assess whether this measure affected CI outcomes and to determine whether real-time feedback assists expert surgeons in achieving slow insertion.

METHODS

The IS was measured in 52 consecutive patients (65 implanted ears) using the CI632 electrode. The IS values were analyzed in relation to procedure repetition over time, NRT ratio, and CI audiological outcomes.

RESULTS

The average IS was 0.64 mm/s (SD = 0.24); minimum and maximum values were 0.23 and 1.24 mm/s, respectively. The IS significantly decreased with each array insertion by the operator (p = 0.006), and the mean decreased by 24% between the first and last third of procedures; however, this reduction fell within the error range of SmartNav for IS (+/-0.48 mm/s). No correlation was found between IS and the NRT ratio (p = 0.51), pure-tone audiometry (PTA) at CI activation (p = 0.506), and PTA (p = 0.94) or word recognition score (p = 0.231) at last evaluation.

CONCLUSIONS

The estimated IS reported by SmartNav did not result in a clinically significant reduction in insertion speed or an improvement in CI hearing outcomes. Real-time feedback of IS could potentially be used for training, but its effectiveness requires confirmation through additional studies and more accurate tools. Implementation of IS assessment in clinical practice will enable comparisons between measurement techniques and between manual and robot-assisted insertions. This will help define the optimal IS range to achieve better cochlear implant (CI) outcomes.

What is the Current State of Extended Reality Use in Otolaryngology Training? A Scoping Review

OBJECTIVE

To map current literature on the educational use of extended reality (XR) in Otolaryngology-Head and Neck Surgery (OHNS) to inform teaching and research.

STUDY DESIGN

Scoping Review.

METHODS

A scoping review was conducted, identifying literature through MEDLINE, Ovid Embase, and Web of Science databases. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. Studies were included if they involved OHNS trainees or medical students who used XR for an educational purpose in OHNS. XR was defined as: fully-immersive virtual reality (VR) using head-mounted displays (HMDs), non-immersive and semi-immersive VR, augmented reality (AR), or mixed reality (MR). Data on device use were extracted, and educational outcomes were analyzed according to Kirkpatrick's evaluation framework.

RESULTS

Of the 1,434 unique abstracts identified, 40 articles were included. All articles reported on VR; none discussed AR or MR. Twenty-nine articles were categorized as semi-immersive, none used occlusive HMDs therefore, none met modern definitions of immersive VR. Most studies (29 of 40) targeted temporal bone surgery. Using the Kirkpatrick four-level evaluation model, all studies were limited to level-1 (learner reaction) or level-2 (knowledge or skill performance).

CONCLUSIONS

Current educational applications of XR in OHNS are limited to VR, do not fully immerse participants and do not assess higher-level learning outcomes. The educational OHNS community would benefit from a shared definition for VR technology, assessment of skills transfer (level-3 and higher), and deliberate testing of AR, MR, and procedures beyond temporal bone surgery. Laryngoscope, 133:227-234, 2023.

Modeling and simulation of cochlear perimodiolar electrode based on composite spring-mass model

This paper proposes, a method for the physical modeling of the perimodiolar electrode, particularly for the process of recovering its preset shape with the guide wire drawn out, based on the composite spring-mass model by employing the virtual-volumetric spring inspired from the traditional spring-mass model. Simulation experiments of modeling and virtual insertion of perimodiolar electrode were carried out. The results indicated that the mean and standard deviation of the difference between the local deformation angles of the simulated and measured sets of mass points, (1, 2, 3), (2, 3, 4), …, (13, 14, 15), were 6.34° and 5.98°, respectively. Additionally, the physical model of the perimodiolar electrode can reflect the overall morphological changes of the real perimodiolar electrode.

Cochlear implant surgery: Learning curve in virtual reality simulation training and transfer of skills to a 3D-printed temporal bone - A prospective trial

OBJECTIVE

Mastering Cochlear Implant (CI) surgery requires repeated practice, preferably initiated in a safe - i.e. simulated - environment. Mastoidectomy Virtual Reality (VR) simulation-based training (SBT) is effective, but SBT of CI surgery largely uninvestigated. The learning curve is imperative for understanding surgical skills acquisition and developing competency-based training. Here, we explore learning curves in VR SBT of CI surgery and transfer of skills to a 3D-printed model.

METHODS

Prospective, single-arm trial. Twenty-four novice medical students completed a pre-training CI inserting test on a commercially available pre-drilled 3D-printed temporal bone. A training program of 18 VR simulation CI procedures was completed in the Visual Ear Simulator over four sessions. Finally, a post-training test similar to the pre-training test was completed. Two blinded experts rated performances using the validated Cochlear Implant Surgery Assessment Tool (CISAT). Performance scores were analyzed using linear mixed models.

RESULTS

Learning curves were highly individual with primary performance improvement initially, and small but steady improvements throughout the 18 procedures. CI VR simulation performance improved 33% (p < 0.001). Insertion performance on a 3D-printed temporal bone improved 21% (p < 0.001), demonstrating skills transfer.

DISCUSSION

VR SBT of CI surgery improves novices' performance. It is useful for introducing the procedure and acquiring basic skills. CI surgery training should pivot on objective performance assessment for reaching pre-defined competency before cadaver - or real-life surgery. Simulation-based training provides a structured and safe learning environment for initial training.

CONCLUSION

CI surgery skills improve from VR SBT, which can be used to learn the fundamentals of CI surgery.

Augmented reality in neurosurgical navigation: a survey

BACKGROUND

Neurosurgery has exceptionally high requirements for minimally invasive and safety. This survey attempts to analyze the practical application of AR in neurosurgical navigation. Also, this survey describes future trends in augmented reality neurosurgical navigation systems.

METHODS

In this survey, we searched related keywords "augmented reality", "virtual reality", "neurosurgery", "surgical simulation", "brain tumor surgery", "neurovascular surgery", "temporal bone surgery", and "spinal surgery" through Google Scholar, World Neurosurgery, PubMed and Science Direct. We collected 85 articles published over the past five years in areas related to this survey.

RESULTS

Detailed study has been conducted on the application of AR in neurosurgery and found that AR is constantly improving the overall efficiency of doctor training and treatment, which can help neurosurgeons learn and practice surgical procedures with zero risks.

CONCLUSIONS

Neurosurgical navigation is essential in neurosurgery. Despite certain technical limitations, it is still a necessary tool for the pursuit of maximum security and minimal intrusiveness. This article is protected by copyright. All rights reserved.

Transfer of Automated Performance Feedback Models to Different Specimens in Virtual Reality Temporal Bone Surgery

Virtual reality has gained popularity as an effective training platform in many fields including surgery. However, it has been shown that the availability of a simulator alone is not sufficient to promote practice. Therefore, simulator-based surgical curricula need to be developed and integrated into existing surgical training programs. As practice variation is an important aspect of a surgical curriculum, surgical simulators should support practice on multiple specimens. Furthermore, to ensure that surgical skills are acquired, and to support self-guided learning, automated feedback on performance needs to be provided during practice. Automated feedback is typically provided by comparing real-time performance with expert models generated from pre-collected data. Since collecting data on multiple specimens for the purpose of developing feedback models is costly and time-consuming, methods of transferring feedback from one specimen to another should be investigated. In this paper, we discuss a simple method of feedback transfer between specimens in virtual reality temporal bone surgery and validate the accuracy and effectiveness of the transfer through a user study.