ArticlePublisher preview available

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

To read the full-text of this research, you can request a copy directly from the authors.

Abstract and Figures

PurposeTo 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.ResultsThe 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.
This content is subject to copyright. Terms and conditions apply.
1 3
European Archives of Oto-Rhino-Laryngology (2022) 279:127–136
Assessing competence incochlear implant surgery using thenewly
developed Cochlear Implant Surgery Assessment Tool
MartinFrendø1,2 · AndreasFrithio1,2· LarsKonge2· SørenFoghsgaard1· PeterTrierMikkelsen3·
MadsSølvstenSørensen1· PerCayé‑Thomasen1· StevenArildWuytsAndersen1,2
Received: 1 September 2020 / Accepted: 20 January 2021 / Published online: 19 February 2021
© The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature 2021
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.
Keywords Cochlear implants· Medical education· Resident education· Virtual reality
Fifty years after the first electric stimulation of the human
auditory system, the cochlear implant (CI) has become the
key treatment of deafness and profound hearing loss [1]
with > 500,000 implantations worldwide. The CI procedure
comprises drilling of the temporal bone followed by an elec-
trode insertion through the round window or a cochleos-
tomy. Complex psychomotor skills are needed during the
procedure to avoid injury to the facial nerve and adjacent
structures, ensure sufficient and minimally traumatic elec-
trode insertion, and spare potential residual hearing[2].
Therefore, high-quality training and deliberate practice [3]
are essential.
Traditional temporal bone surgical training consists of
preparation using human cadavers followed by supervised
practice in the operating room: apprenticeship learning [4].
However, work-hour restrictions and patient safety concerns
have necessitated new ways of acquiring surgical skills such
as simulation-based training. In temporal bone surgery, vir-
tual reality (VR) simulation training is strongly supported
by evidence [5, 6] and allows the trainee to practice on an
unlimited number of virtual cases before advancing to train-
ing on cadaver temporal bones or supervised patient surgery.
Although a recent systematic review and meta-analysis con-
firmed the effectiveness of VR simulation training of the
mastoidectomy procedure [7], the simulation-based training
of cochlear implant (CI) surgery remains largely unexplored.
The primary reason is that until recently, no VR simulation
* Martin Frendø
1 Department ofOtorhinolaryngology, Head & Neck
Surgery andAudiology, Rigshospitalet, 9 Blegdamsvej,
2100CopenhagenØ, Denmark
2 The Simulation Centre, Copenhagen Academy forMedical
Education andSimulation (CAMES), The Capital Region
ofDenmark, Copenhagen, Denmark
3 Visual Computing Lab, The Alexandra Institute, Aarhus,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... In temporal bone surgery, virtual reality (VR) simulation training is strongly supported by educational evidence (Lui and Hoy, 2017;Wiet et al., 2017), and simulation-based training is increasingly integrated into training curricula (Frithioff et al., 2018). For CI surgery, training has previously been limited because none of the available VR simulation platforms supported the simulation of the electrode insertion part of the procedure (Frendø et al., 2021a). However, from version 3.0 of the Visible Ear Simulator (, a flexible CI electrode can now be inserted into the cochlea, which along with the possibility of drilling with force feedback, allows for a comprehensive simulation of CI surgery. ...
... The primary outcome was the performance of CI electrode insertion assessed using the CISATa newly developed structured assessment tool for evaluation of CI surgical performance (Frendø et al., 2021a). The assessment tool consists of 11 items: 6 concerning drilling (for example use of an appropriate drilling technique and if exposure of the round window is appropriate) and 5 on CI electrode insertion (for example use of a correct insertion vector and if the insertion of the electrode into cochlea is satisfactory). ...
... VR simulation training of CI surgery is a novel (Frendø et al., 2021a(Frendø et al., , 2021b and valuable training tool as proper surgical techniques are important for good surgical outcomes (Carlson et al., 2014;Chakravorti et al., 2019;Finley et al., 2008;Lazard et al., 2012). The availability of cadavers as well as CI electrodes for surgical training is limited (Frithioff et al., 2018) and consequently, such materials should be saved for more advanced training after basic skills have been acquired for example using VR simulation. ...
Background: Cochlear implantation requires excellent surgical skills; virtual reality simulation training is an effective method for acquiring basic competency in temporal bone surgery before progression to cadaver dissection. However, cochlear implantation virtual reality simulation training remains largely unexplored and only one simulator currently supports the training of the cochlear implantation electrode insertion. Here, we aim to evaluate the effect of cochlear implantation virtual reality simulation training on subsequent cadaver dissection performance and self-directedness. Methods: This was a randomized, controlled trial. Eighteen otolaryngology residents were randomized to either mastoidectomy including cochlear implantation virtual reality simulation training (intervention) or mastoidectomy virtual reality simulation training alone (controls) before cadaver cochlear implantation surgery. Surgical performance was evaluated by two blinded expert raters using a validated, structured assess- ment tool. The need for supervision (reflecting self-directedness) was assessed via post-dissection questionnaires. Results: The intervention group achieved a mean score of 22.9 points of a maximum of 44 points, which was 5.4% higher than the control group's 21.8 points (P = .51). On average, the intervention group required assistance 1.3 times during cadaver drilling; this was 41% more frequent in the control group who received assistance 1.9 times (P = .21). Conclusion: Cochlear implantation virtual reality simulation training is feasible in the context of a cadaver dissection course. The addition of cochlear implantation virtual reality training to basic mastoidectomy virtual reality simulation training did not lead to a significant improvement of performance or self-directedness in this study. Our findings suggest that learning an advanced temporal bone procedure such as cochlear implantation surgery requires much more training than learning mastoidectomy.
... Moving toward patient-specific simulators, Andersen et al. (2015;, Sieber et al. (2021), Frendø et al. (2022) developed a system which compares three segmentation methods to achieve the best result, namely manual, guided and automated segmentations, and employs the atlas-based algorithm. In the manual segmentation, a CT scan is segmented by the user using ITK-SNAP software. ...
... The system has been assessed in terms of its visual quality and anatomical validity. An extension of the use of the simulator to assess the surgeons' performance in a cochlear implantation is also explored by the creation of CI Surgery Assessment Tool (CISAT) (Frendø et al. 2022). The assessment tool is developed by four experts and has been clinically validated according to Messick's framework. ...
Full-text available
This paper presents a review of surgical simulators, developed to enhance the learning process of surgical procedures, that involves bones, ranging from musculoskeletal system (orthopedics) and the skull (ENT and neurosurgeries). The paper highlights the specific challenges in terms of the extended reality representation of surgical training along with its latest advances. The study gathers journal and conference proceedings from various database sources (bibliographic databases and online search engines) that fulfills a predetermined eligibility criterion. From the search, 185 journals were found but only 144 met the inclusion criteria. Surgical simulators emerge as a promising alternative to aid residents in surgical training. It encompasses surgical procedures done in the craniomaxillofacial, joints, limbs and spine section of the human body. The study was partially supported by internal grant STG/19/047 from KU Leuven.
... Compared with the traditional master-apprentice surgical education, VS-integrated surgical training can provide desirable alternative allowing an active, independent, repeated and safe learning for students to become familiar with procedures, instruments, and equipment before performing surgeries on patients. In particular, VS-based learning has been found to be conducive to the development of complex psychomotor skills, such as hand-eye coordination that endoscopic and robotic surgery sets particular demands on (64,65,97). A recently published article conducted by Petersen et al. (67) found no positive skill transfer from basic skills pre-training in a VR vitreoretinal simulator to the procedure-specific modules, suggesting that, compared than spending valuable training time on basic skills VS pre-training, proceeding directly to VS-based training of procedures was more meaningful for learners. ...
Full-text available
Virtual simulation (VS) as an emerging interactive pedagogical strategy has been paid more and more attentions in the undergraduate medical education. Because of the fast development of modern computer simulation technologies, more and more advanced and emerging VS-based instructional practices are constantly increasing to promote medical education in diverse forms. In order to describe an overview of the current trends in VS-based medical teaching and learning, this scoping review presented a worldwide analysis of 92 recently published articles of VS in the undergraduate medical teaching and learning. The results indicated that 98% of included articles were from Europe, North America, and Asia, suggesting a possible inequity in digital medical education. Half (52%) studies reported the immersive virtual reality (VR) application. Evidence for educational effectiveness of VS in medical students’ knowledge or skills was sufficient as per Kirkpatrick’s model of outcome evaluation. Recently, VS has been widely integrated in surgical procedural training, emergency and pediatric emergency medicine training, teaching of basic medical sciences, medical radiation and imaging, puncture or catheterization training, interprofessional medical education, and other case-based learning experiences. Some challenges, such as accessibility of VS instructional resources, lack of infrastructure, “decoupling” users from reality, as well as how to increase students’ motivation and engagement, should be addressed.
... Seven studies used more than 1 standard setting methodology with 4 studies comparing the results of the different methodologies. 29,35,57,85,86 Concordance was found for the contrasting groups' and Angoff methods in 3 studies 29,35,57 with the contrasting groups' method establishing standards at a higher level than the Angoff method. Goldenberg et al 85 established a pass-fail setting for flexible uretero-renoscopy using the borderline groups' method (examineebased method) and compared this to a crowd-sourced method where the assessors rated a pass or fail, as well as a global rating. ...
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 four databases (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library). Original studies investigating simulation-based assessment of surgical procedures with 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, set-up, and expert level classification. The studies were appraised as having low and moderate evidence. Conclusion: Surgical education is shifting towards 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.
Objective 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.
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.
Full-text available
Purpose Virtual reality (VR) training of mastoidectomy is effective in surgical training—particularly if organized as distributed practice. However, centralization of practice facilities is a barrier to implementation of distributed simulation training. Decentralized training could be a potential solution. Here, we aim to assess the feasibility, use, and barriers to decentralized VR mastoidectomy training using a freeware, high-fidelity temporal bone simulator. Methods In a prospective, mixed-methods study, 20 otorhinolaryngology residents were given three months of local access to a VR mastoidectomy simulator. Additionally, trainees were provided a range of learning supports for directed, self-regulated learning. Questionnaire data were collected and focus group interviews conducted. The interviews were analyzed using thematic analysis and compared with quantitative findings. Results Participants trained 48.5 h combined and mainly towards the end of the trial. Most participants used between two and four different learning supports. Qualitative analysis revealed five main themes regarding implementation of decentralized simulation training: convenience, time for training, ease of use, evidence for training, and testing. Conclusions Decentralized VR training using a freeware, high-fidelity mastoidectomy simulator is feasible but did not lead to a high training volume or truly distributed practice. Evidence for training was found motivational. Access to training, educational designs, and the role of testing are important for participant motivation and require further evaluation.
Full-text available
Background and purpose — Orthopedic surgeons must be able to perform internal fixation of proximal femoral fractures early in their career, but inexperienced trainees prolong surgery and cause increased reoperation rates. Simulation-based virtual reality (VR) training has been proposed to overcome the initial steep part of the learning curve but it is unknown how much simulation training is necessary before trainees can progress to supervised surgery on patients. We determined characteristics of learning curves for novices and experts and a pass/fail mastery-learning standard for junior trainees was established. Methods — 38 first-year residents and 8 consultants specialized in orthopedic trauma surgery performed cannulated screws, Hansson pins, and sliding hip screw on the Swemac TraumaVision VR simulator. A previously validated test was used. The participants repeated the procedures until they reached their learning plateau. Results — The novices and the experts reached their learning plateau after an average of 169 minutes (95% CI 152–87) and 143 minutes (CI 109–177), respectively. Highest achieved scores were 92% (CI 91–93) for novices and 96% (CI 94–97) for experts. Plateau score, defined as the average of the 4 last scores, was 85% (CI 82–87) and 92% (CI 89–96) for the novices and the experts, respectively. Interpretation — Training time to reach plateau varied widely and it is paramount that simulation-based training continues to a predefined standard instead of ending after a fixed number of attempts or amount of time. A score of 92% comparable to the experts’ plateau score could be used as a mastery learning pass/fail standard.
Full-text available
Objective To investigate validity evidence, and strengths and limitations of performance metrics in mastoidectomy training. Methods A systematic review following the PRISMA guidelines. Studies reporting performance metrics in mastoidectomy/temporal bone surgery were included. Data on design, outcomes, and results were extracted by two reviewers. Validity evidence according to Messick’s framework and level of evidence were assessed. Results The search yielded a total of 1085 studies from the years 1947–2018 and 35 studies were included for full data extraction after abstract and full-text screening. 33 different metrics on mastoidectomy performance were identified and ranked according to the number of reports. Most of the 33 metrics identified had some amount of validity evidence. The metrics with most validity evidence were related to drilling time, volume drilled per time, force applied near vital structures, and volume removed. Conclusions This review provides an overview of current metrics of mastoidectomy performance, their validity, strengths and limitations, and identifies the gap in validity evidence of some metrics. Evidence-based metrics can be used for performance assessment in temporal bone surgery and for providing integrated and automated feedback in virtual reality simulation training. The use of such metrics in simulation-based mastoidectomy training can potentially address some of the limitations in current temporal bone skill assessment and ease assessment in repeated practice. However, at present, an automated feedback based on metrics in VR simulation does not have sufficient empirical basis and has not been generally accepted for use in training and certification. Level of evidence 2a.
Full-text available
Background The contrasting groups’ standard setting method is commonly used for consequences analysis in validity studies for performance in medicine and surgery. The method identifies a pass/fail cut-off score, from which it is possible to determine false positives and false negatives based on observed numbers in each group. Since groups in validity studies are often small, e.g., due to a limited number of experts, these analyses are sensitive to outliers on the normal distribution curve. Methods We propose that these shortcomings can be addressed in a simple manner using the cumulative distribution function. Results We demonstrate considerable absolute differences between the observed false positives/negatives and the theoretical false positives/negatives. In addition, several important examples are given. Conclusions We propose that a better reporting strategy is to report theoretical false positives and false negatives together with the observed false positives and negatives, and we have developed an Excel sheet to facilitate such calculations. Trial registration Not relevant.
Full-text available
Purpose: In otorhinolaryngology training, introduction to temporal bone surgery through hands-on practice on cadaveric human temporal bones is the gold-standard training method before commencing supervised surgery. During the recent decades, the availability of such specimens and the necessary laboratory facilities for training seems to be decreasing. Alternatives to traditional training can consist of drilling artificial models made of plaster or plastic but also virtual reality (VR) simulation. Nevertheless, the integration and availability of these alternatives into specialist training programs remain unknown. Methods: We conducted a questionnaire study mapping current status on temporal bone training and included responses from 113 departments from 23 countries throughout Europe. Results: In general, temporal bone training during residency in ORL is organized as in-house training, or as participation in national or international temporal bone courses or some combination hereof. There are considerable differences in the availability of training facilities for temporal bone surgery and the number of drillings each ORL trainee can perform. Cadaveric dissection is still the most commonly used training modality. Conclusions: VR simulation and artificial models are reported to be used at many leading training departments already. Decreasing availability of cadavers, lower costs of VR simulation and artificial models, in addition to established evidence for a positive effect on the trainees' competency, were reported as the main reasons. Most remaining departments expect to implement VR simulation and artificial models for temporal bone training into their residency programs in the near future.
Full-text available
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 ( I ² = 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.
Objective: Virtual reality (VR) simulation training can improve temporal bone (TB) cadaver dissection skills and distributed, self-regulated practice is optimal for skills consolidation. Decentralized training (DT) at the trainees' own department or home offers more convenient access compared with centralized VR simulation training where the simulators are localized at one facility. The effect of DT in TB surgical training is unknown. We investigated the effect of decentralized VR simulation training of TB surgery on subsequent cadaver dissection performance. Study design: Prospective, controlled cohort study. Setting: Otorhinolaryngology (ORL) teaching hospitals and the Danish national TB course. Participants: Thirty-eight ORL residents: 20 in the intervention cohort (decentralized training) and 18 in the control cohort (standard training during course). Intervention: Three months of access to decentralized VR simulation training at the local ORL department or the trainee's home. A freeware VR simulator (the visible ear simulator [VES]) was used, supplemented by a range of learning supports for directed, self-regulated learning. Main outcome measure: Mastoidectomy final-product scores from the VR simulations and cadaver dissection were rated using a modified Welling Scale by blinded expert raters. Results: Participants in the intervention cohort trained decentrally a median of 3.5 hours and performed significantly better than the control cohort during VR simulation (p < 0.01), which importantly also transferred to a 76% higher performance score during subsequent cadaver training (mean scores: 8.8 versus 5.0 points; p < 0.001). Conclusions: Decentralized VR simulation training of mastoidectomy improves subsequent cadaver dissection performance and can potentially improve implementation of VR simulation surgical training.
Hypothesis: To evaluate the insertion results of a novel straight array (EVO) by detailed imaging and subsequent histology in human temporal bones (TB). Background: The main focuses of modern cochlear implant surgery are to prevent damage to the intracochlear structures and to preserve residual hearing. This is often achievable with new atraumatic electrode arrays in combination with meticulous surgical techniques. Methods: Twenty fresh-frozen TBs were implanted with the EVO. Pre- and postoperative cone beam computed tomography scans were reconstructed and fused for an artifact-free representation of the electrode. The array's vertical position was quantified in relation to the basilar membrane on basis of which trauma was classified (Grades 0-4). The basilar membrane location was modeled from previous histologic data. The TBs underwent subsequent histologic examination. Results: The EVOs were successfully inserted in all TBs. Atraumatic insertion (Grades 0-1) were accomplished in 14 of 20 TBs (70%). There were three apical translocations, and two basal translocations due to electrode bulging. One TB had multiple translocations. The sensitivity and specificity of imaging for detecting insertion trauma (Grades 2-4) was 87.5% and 97.3.0%, respectively. Conclusion: Comparable insertion results as reported for other arrays were also found for the EVO. Insertion trauma can be mostly avoided with meticulous insertion techniques to prevent bulging and by limiting the insertion depth angle to 360 degrees. The image fusion technique is a reliable tool for evaluating electrode placement and is feasible for trauma grading.
This article presents a summary of the current simulation training for otologic skills. There is a wide variety of educational approaches, assessment tools, and simulators in use, including simple low-cost task trainers to complex computer-based virtual reality systems. A systematic approach to otologic skills training using adult learning theory concepts, such as repeated and distributed practice, self-directed learning, and mastery learning, is necessary for these educational interventions to be effective. Future directions include development of measures of performance to assess efficacy of simulation training interventions and, for complex procedures, improvement in fidelity based on educational goals.