Systematic review and meta-analysis of 3D-printing in otolaryngology education

Estimating Cognitive Workload Using Task-Related Pupillary Responses in Simulated Drilling in Cochlear Implantation

OBJECTIVES

Training of temporal bone drilling requires more than mastering technical skills with the drill. Skills such as visual imagery, bimanual dexterity, and stress management need to be mastered along with precise knowledge of anatomy. In otorhinolaryngology, these psychomotor skills underlie performance in the drilling of the temporal bone for access to the inner ear in cochlear implant surgery. However, little is known about how psychomotor skills and workload management impact the practitioners' continuous and overall performance.

METHODS

To understand how the practitioner's workload and performance unfolds over time, we examine task-evoked pupillary responses (TEPR) of 22 medical students who performed transmastoid-posterior tympanotomy (TMPT) and removal of the bony overhang of the round window niche in a 3D-printed model of the temporal bone. We investigate how students' TEPR metrics (Average Pupil Size [APS], Index of Pupil Activity [IPA], and Low/High Index of Pupillary Activity [LHIPA]) and time spent in drilling phases correspond to the performance in key drilling phases.

RESULTS

All TEPR measures revealed significant differences between key drilling phases that corresponded to the anticipated workload. Enlarging the facial recess lasted significantly longer than other phases. IPA captured significant increase of workload in thinning of the posterior canal wall, while APS revealed increased workload during the drilling of the bony overhang.

CONCLUSION

Our findings contribute to the contemporary competency-based medical residency programs where objective and continuous monitoring of participants' progress allows to track progress in expertise acquisition. Laryngoscope, 2024.

Multidisciplinary Advanced Surgical Planning for Slide Tracheoplasty Using 3D-Printed Models

OBJECTIVE

The objective of this study was to develop and assess multidisciplinary advanced surgical planning (ASP) sessions using three dimensional (3D) printed models for cervicothoracic slide tracheoplasty (CST). We hypothesized that these sessions would improve surgeon confidence, streamline intraoperative planning, and highlight the utility of 3D modeling.

METHODS

3D-printed patient-specific trachea models were used in pre-operative ASP sessions consisting of a multidisciplinary case discussion and hands-on slide tracheoplasty simulation. Participants completed a survey rating realism, utility, impact on the final surgical plan, and pre- and post-session confidence. Statistical analysis was performed via Wilcoxon and Kruskal-Wallis tests.

RESULTS

Forty-eight surveys were collected across nine sessions and 27 different physicians. On a 5-point Likert scale, models were rated as "very realistic", "very useful" (both median of 4, IQR 3-4 and 4-5, respectively). Overall confidence increased by 1.4 points (+/- 0.7, p < 0.0001), with the largest change seen in those with minimal prior slide tracheoplasty experience (p = 0.005). Participants felt that the sessions "strongly" impacted their surgical plan or anticipated performance (median 4, IQR 4-5), regardless of training level or experience.

CONCLUSION

3D-printed patient-specific models were successfully implemented in ASP sessions for CST. Models were deemed very realistic and very useful by surgeons across multiple specialties and training levels. Surgical planning sessions also strongly impacted the final surgical plan and increased surgeon confidence for CST.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3395-3401, 2024.

Dissecting human anatomy learning process through anatomical education with augmented reality: AEducAR 2.0, an updated interdisciplinary study

Anatomical education is pivotal for medical students, and innovative technologies like augmented reality (AR) are transforming the field. This study aimed to enhance the interactive features of the AEducAR prototype, an AR tool developed by the University of Bologna, and explore its impact on human anatomy learning process in 130 second-year medical students at the International School of Medicine and Surgery of the University of Bologna. An interdisciplinary team of anatomists, maxillofacial surgeons, biomedical engineers, and educational scientists collaborated to ensure a comprehensive understanding of the study's objectives. Students used the updated version of AEducAR, named AEducAR 2.0, to study three anatomical topics, specifically the orbit zone, facial bones, and mimic muscles. AEducAR 2.0 offered two learning activities: one explorative and one interactive. Following each activity, students took a test to assess learning outcomes. Students also completed an anonymous questionnaire to provide background information and offer their perceptions of the activity. Additionally, 10 students participated in interviews for further insights. The results demonstrated that AEducAR 2.0 effectively facilitated learning and students' engagement. Students totalized high scores in both quizzes and declared to have appreciated the interactive features that were implemented. Moreover, interviews shed light on the interesting topic of blended learning. In particular, the present study suggests that incorporating AR into medical education alongside traditional methods might prove advantageous for students' academic and future professional endeavors. In this light, this study contributes to the growing research emphasizing the potential role of AR in shaping the future of medical education.

Surgical Training Simulators for Rhinoplasty: A Systematic Review

Rhinoplasty training currently follows an apprenticeship model that is largely observational. Trainees have limited experience in performing maneuvers of this complex surgery. Rhinoplasty simulators can address this issue by providing trainees with the opportunity to gain surgical simulator experience that could improve technical competences in the operating room. This review amalgamates the collective understanding of rhinoplasty simulators described to date. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, OVID Embase, OVID Medline, and Web of Science databases were all searched for original research on surgical simulators for rhinoplasty education and reviewed by independent reviewers. Articles underwent title and abstract screening, and then relevant articles underwent full-text review to extract simulator data. Seventeen studies, published between 1984 and 2021, were included for final analysis. Study participant numbers ranged from 4 to 24, and included staff surgeons, fellows, residents (postgraduate year 1-6), and medical students. Cadaveric surgical simulators comprised eight studies, of which three were with human cadavers, one study was a live animal simulator, two were virtual simulators, and six were three-dimensional (3D) models. Both animal and human-based simulators increased the confidence of trainees significantly. Significant improvement in various aspects of rhinoplasty knowledge occurred with implementation of a 3D-printed model in rhinoplasty education. Rhinoplasty simulators are limited by a lack of an automated method of evaluation and a large reliance on feedback from experienced rhinoplasty surgeons. Rhinoplasty simulators have the potential to provide trainees with the opportunity for hands-on training to improve skill and develop competencies without putting patients in harm's way. Current literature on rhinoplasty simulators largely focuses on simulator development, with few simulators being validated and assessed for utility. For wider implementation and acceptance, further refinement of simulators, validation, and assessment of outcomes is required.

3D printing as a pedagogical tool for teaching normal human anatomy: a systematic review

BACKGROUND

Three-dimensional-printed anatomical models (3DPAMs) appear to be a relevant tool due to their educational value and their feasibility. The objectives of this review were to describe and analyse the methods utilised for creating 3DPAMs used in teaching human anatomy and for evaluating its pedagogical contribution.

METHODS

An electronic search was conducted on PubMed using the following terms: education, school, learning, teaching, learn, teach, educational, three-dimensional, 3D, 3-dimensional, printing, printed, print, anatomy, anatomical, anatomically, and anatomic. Data retrieved included study characteristics, model design, morphological evaluation, educational performance, advantages, and disadvantages.

RESULTS

Of the 68 articles selected, the cephalic region was the most studied (33 articles); 51 articles mentioned bone printing. In 47 articles, the 3DPAM was designed from CT scans. Five printing processes were listed. Plastic and its derivatives were used in 48 studies. The cost per design ranged from 1.25 USD to 2800 USD. Thirty-seven studies compared 3DPAM to a reference model. Thirty-three articles investigated educational performance. The main advantages were visual and haptic qualities, effectiveness for teaching, reproducibility, customizability and manipulability, time savings, integration of functional anatomy, better mental rotation ability, knowledge retention, and educator/student satisfaction. The main disadvantages were related to the design: consistency, lack of detail or transparency, overly bright colours, long printing time, and high cost.

CONCLUSION

This systematic review demonstrates that 3DPAMs are feasible at a low cost and effective for teaching anatomy. More realistic models require access to more expensive 3D printing technologies and substantially longer design time, which would greatly increase the overall cost. Choosing an appropriate image acquisition modality is key. From a pedagogical viewpoint, 3DPAMs are effective tools for teaching anatomy, positively impacting the learning outcomes and satisfaction level. The pedagogical effectiveness of 3DPAMs seems to be best when they reproduce complex anatomical areas, and they are used by students early in their medical studies.

Comparing Feedback Techniques in Bilobe Flap Simulation Using 3D-Printed Facial Models

Objective

To compare live versus delayed feedback on trainee performance of bilobe flaps using 3-dimensional (3D)-printed facial simulators and determine whether these effects are sustained on repeat performance.

Study Design

Cohort study.

Setting

University of Arkansas for Medical Sciences.

Methods

3D-printed facial models with a nasal ala defect were provided to 18 subjects. Subjects were stratified and randomized based on their training level into 1 of 3 groups corresponding to live feedback (Group 1), delayed feedback (Group 2), and no feedback (Group 3). Subjects performed a bilobe flap following a structured lecture. Four weeks later, subjects independently repeated the exercise on the contralateral ala. Likert surveys were used to assess subjective parameters. Objective grading was performed by a plastic surgeon, which included a point system and score for the overall appearance.

Results

Following exercise 1, Group 1 reported a significant improvement in knowledge (P < .001), which was sustained after exercise 2 (P < .001); Group 2 reported a significant improvement after exercise 1 (P = .03) but was not sustained (P = .435). After the second exercise, Group 1 and Group 2 improved their confidence in bilobed repair (P = .001 and P = .003, respectively), but this was greater for Group 1. Group 1 showed a significant improvement in their design time following exercise 2 (P = .007). There were no significant differences between groups on total time for repair, total score, and appearance.

Conclusion

3D-printed models are valuable in teaching the bilobe flap for nasal defects, with live feedback providing the greatest level of improvement in self-reported knowledge and confidence.

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.

Using three-dimensional printed models for trainee orbital fracture education

BACKGROUND

Three-dimensional printing is an underutilized technology in ophthalmology training; its use must be explored in complex educational scenarios. This study described a novel approach to trainee education of orbital fracture repair utilizing three-dimensional (3D) printed models as a teaching tool.

METHODS

Ophthalmology residents and oculoplastic fellows from multiple training institutions underwent an educational session on orbital fractures, learning through four different models. Participants analyzed orbital fractures through computerized tomography (CT) imaging alone and then utilizing CT imaging with the aid of a 3D printed model. Participants completed a questionnaire assessing their understanding of the fracture pattern and surgical approach. After the training, participants were surveyed on the impact of the educational session. Components of the training were rated by participants on a 5-point Likert scale.

RESULTS

A statistically significant difference (p < .05) was found in participant confidence conceptualizing the anatomic boundaries of the fracture and planning the orbital fracture approach for repair of three out of four models on pre-test post-test analysis. On exit questionnaire, 84.3% of participants thought the models were a useful tool for surgical planning, 94.8% of participants thought the models were a useful tool for conceptualizing the anatomic boundaries of the fracture, 94.8% of participants thought the models were a useful tool for orbital fracture training, and 89.5% of participants thought the exercise was helpful.

CONCLUSION

This study supports the value of 3D printed models of orbital fractures as an effective tool for ophthalmology trainee education to improve understanding and visualization of complex anatomical space and pathology. Given the limited opportunities trainees may have for hands-on orbital fracture practice, 3D printed models provide an accessible way to enhance training.

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.