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European Archives of Oto-Rhino-Laryngology (2022) 279:127–136
Assessing competence incochlear implant surgery using thenewly
developed Cochlear Implant Surgery Assessment Tool
MartinFrendø1,2 · AndreasFrithio1,2· LarsKonge2· SørenFoghsgaard1· PeterTrierMikkelsen3·
MadsSølvstenSørensen1· PerCayé‑Thomasen1· StevenArildWuytsAndersen1,2
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 
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.
Therefore, high-quality training and deliberate practice 
Traditional temporal bone surgical training consists of
preparation using human cadavers followed by supervised
practice in the operating room: apprenticeship learning .
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 , 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 ofOtorhinolaryngology, Head & Neck
Surgery andAudiology, Rigshospitalet, 9 Blegdamsvej,
2 The Simulation Centre, Copenhagen Academy forMedical
Education andSimulation (CAMES), The Capital Region
ofDenmark, Copenhagen, Denmark
3 Visual Computing Lab, The Alexandra Institute, Aarhus,