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Purpose: Learning to use a surgical microscope is a fundamental step in otolaryngology training; however, there is currently no objective method to teach or assess this skill. Tympanostomy tube placement is a common otologic procedure that requires skilled use of a surgical microscope. This study was designed to (1) implement metrics capable of evaluating microscope use and (2) establish construct validity. Study design: This was a prospective cohort study. Methods: Eight otolaryngology trainees and three otolaryngology experts were asked to use a microscope to insert a tympanostomy tube into a cadaveric myringotomy in a standardized setting. Microscope movements were tracked in a three-dimensional space, and tracking metrics were applied to the data. The procedure was video-recorded and then analyzed by blinded experts using operational metrics. Results from both groups were compared, and discriminatory metrics were determined. Results: The following tracking metrics were identified as discriminatory between the trainee and expert groups: total completion time, operation time, still time, and jitter (movement perturbation). Many operational metrics were found to be discriminatory between the two groups, including several positioning metrics, optical metrics, and procedural metrics. Conclusions: Performance metrics were implemented, and construct validity was established for a subset of the proposed metrics by discriminating between expert and novice participants. These discriminatory metrics could form the basis of an automated system for providing feedback to residents during training while using a myringotomy surgical simulator. Additionally, these metrics may be useful in guiding a standardized teaching and evaluation methodology for training in the use of surgical microscopes.

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Purpose: To create a novel, multi-atlas-based segmentation algorithm of the facial nerve (FN) requiring minimal user intervention that could be easily deployed into an existing open-source toolkit. Specifically, the mastoid, tympanic and labyrinthine segments of the FN would be segmented. Methods: High-resolution micro-computed tomography (micro-CT) scans were pre-segmented and used as atlases of the FN. The algorithm requires the user to place four fiducials to orient the target, low-resolution clinical CT scan, and generate a centerline along the nerve. Based on this data, the appropriate atlas is chosen by the algorithm and then rigidly and non-rigidly registered to provide an automated segmentation of the FN. Results: The algorithm was successfully developed and implemented into an existing open-source software framework. Validation was performed on 28 temporal bones, where the automated segmentation was compared against gold-standard manual segmentation by an expert. The algorithm achieved an average Dice metric of 0.76 and an average Hausdorff distance of 0.17 mm for the tympanic and mastoid portions of the FN when segmenting healthy facial nerves, which are similar to previously published algorithms. Conclusion: A successful FN segmentation algorithm was developed using a high-resolution micro-CT multi-atlas approach. The algorithm was unique in its ability to segment the entire intratemporal FN, with the exception of the meatal segment, which was not included in the segmentation as it was not discernible from the vestibulocochlear nerve within the internal auditory canal. It will be published as an open-source extension to allow use in virtual reality simulators for automatic segmentation, greatly reducing the time for expert segmentation and verification.

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The gold standard method for visualizing the pathologies underlying human sensorineural hearing loss has remained post-mortem histology for over 125 years, despite awareness that histological preparation induces severe artifacts in biological tissue. Historically, the transition from post-mortem assessment to non-invasive clinical biomedical imaging in living humans has revolutionized diagnosis and treatment of disease; however, innovation in non-invasive techniques for cellular-level intracochlear imaging in humans has been difficult due to the cochlea’s small size, complex 3D configuration, fragility, and deep encasement within bone. Here we investigate the ability of synchrotron radiation-facilitated X-ray absorption and phase contrast imaging to enable visualization of sensory cells and nerve fibers in the cochlea’s sensory epithelium in situ in 3D intact, non-decalcified, unstained human temporal bones. Our findings show that this imaging technique resolves the bone-encased sensory epithelium’s cytoarchitecture with unprecedented levels of cellular detail for an intact, unstained specimen, and is capable of distinguishing between healthy and damaged epithelium. All analyses were performed using commercially available software that quickly reconstructs and facilitates 3D manipulation of massive data sets. Results suggest that synchrotron radiation phase contrast imaging has the future potential to replace histology as a gold standard for evaluating intracochlear structural integrity in human specimens, and motivate further optimization for translation to the clinic.

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A thorough understanding of the relationship between local hemodynamics and plaque progression has been hindered by an inability to prospectively monitor these factors in vivo in humans. In this study a novel approach for noninvasively reconstructing artery wall thickness and local hemodynamics at the human carotid bifurcation is presented. Three-dimensional (3D) models of the lumen and wall boundaries, from which wall thickness can be measured, were reconstructed from black-blood magnetic resonance imaging (MRI). Along with time-varying inlet/outlet flow rates measured via phase contrast (PC) MRI, the lumen boundary was used as input for computational fluid dynamic (CFD) simulation of the subject-specific flow patterns and wall shear stresses (WSSs). Results from a 59-year-old subject with early, asymptomatic carotid artery disease show good agreement between simulated and measured velocities, and demonstrate a correspondence between wall thickening and low and oscillating shear at the carotid bulb. High shear at the distal internal carotid artery (ICA) was also colocalized with higher WSS; however, a quantitative general relationship between WSS and wall thickness was not found. Similar results were obtained from a 23-year-old normal subject. These findings represent the first direct comparison of hemodynamic variables and wall thickness at the carotid bifurcation of human subjects. The noninvasive nature of this image-based modeling approach makes it ideal for carrying out future prospective studies of hemodynamics and plaque development or progression in otherwise healthy subjects.

A thorough understanding of the relationship between local hemodynamics and plaque progression has been hindered by an inability to prospectively monitor these factors in vivo in humans. In this study a novel approach for noninvasively reconstructing artery wall thickness and local hemodynamics at the human carotid bifurcation is presented. Three‐dimensional (3D) models of the lumen and wall boundaries, from which wall thickness can be measured, were reconstructed from black‐blood magnetic resonance imaging (MRI). Along with time‐varying inlet/outlet flow rates measured via phase contrast (PC) MRI, the lumen boundary was used as input for computational fluid dynamic (CFD) simulation of the subject‐specific flow patterns and wall shear stresses (WSSs). Results from a 59‐year‐old subject with early, asymptomatic carotid artery disease show good agreement between simulated and measured velocities, and demonstrate a correspondence between wall thickening and low and oscillating shear at the carotid bulb. High shear at the distal internal carotid artery (ICA) was also colocalized with higher WSS; however, a quantitative general relationship between WSS and wall thickness was not found. Similar results were obtained from a 23‐year‐old normal subject. These findings represent the first direct comparison of hemodynamic variables and wall thickness at the carotid bifurcation of human subjects. The noninvasive nature of this image‐based modeling approach makes it ideal for carrying out future prospective studies of hemodynamics and plaque development or progression in otherwise healthy subjects.

Black blood MRI has become a popular technique for measuring arterial wall area as an indicator of plaque size. Computer‐assisted techniques for segmenting vessel boundaries have been developed to increase measurement precision. In this study, the carotid arteries of four normal subjects were imaged at seven different fields of view (FOVs), keeping all other imaging parameters fixed, to determine whether spatial resolution could be increased at the expense of image quality without sacrificing precision. Wall areas were measured via computer‐assisted segmentation of the vessel boundaries performed repeatedly by two operators. Analysis of variance (ANOVA) demonstrated that the variability of wall area measurements was below 1.5 mm2for in‐plane spatial resolutions between 0.22 mm and 0.37 mm. An inverse relationship between operator variability and the signal difference‐to‐noise ratio (SDNR) demonstrated that semi‐automatic segmentation of the wall boundaries was robust for SDNR >3, defining a criterion above which subjective image quality can be degraded without an appreciable loss of information content. Our study also suggested that spatial resolutions higher than 0.3 mm may be required to quantify normal wall areas to within 10% accuracy, but that the reduced SNR associated with the higher resolution may be tolerated by semi‐automated wall segmentation without an appreciable loss of precision. Magn Reson Med 46:299–304, 2001. © 2001 Wiley‐Liss, Inc.

Phase-shift shadow-moiré topography is a noncontact optical technique for measuring the shapes of surfaces. Artifactual bands resembling isoheight surface contours are observed during measurement of small changes in shape by use of this technique. The shape-reconstruction algorithm used in shadow-moiré topography is based on a mathematical model of the fringe patterns generated on the surface to be measured. We hypothesize that the observed bands reflect systematic errors caused by ignoring height-dependent terms in the mathematical model of the fringe patterns. We test the assumption by simulating the fringe patterns for a virtual test surface by using a model that contains height-dependent terms and one term that is idealized by ignoring these terms. Small systematic errors in shape are observed only when the surface is reconstructed from fringe patterns simulated with a model containing the height-dependent terms. Shape-error curves are computed as a function of the surface height by the subtraction of the reconstructed shape from the known shape. Simulated shape-error curves agree with experimental measurements in that they show an increase in error with surface height, and both the experimental and the simulated shape-error curves contain ripples. Although the errors are small in comparison with the dimensions of the surface and are negligible in shape measurements and in most deformation measurements, they may show up as noticeable bands in images of small deformations.

In this work, three‐dimensional finite‐element models of the normal and surgically repaired cat middle ear were developed. The normal middle‐ear model was formed by adding explicit representations for the footplate and cochlear load to an existing model of the cat eardrum. The footplate was modeled as a thin plate with a thickened rim. The cochlear load was represented by springs attached along the footplate’s periphery. The model is valid for frequencies below 1 kHz and for physiological sound levels. Eardrum and manubrium displacements, and out‐of‐plane displacements of the footplate’s center, were found to compare well with experimental results. The normal model was modified to simulate the effects of two types of middle‐ear surgery, both of which are used to repair a discontinuous ossicular chain. Bulging of the footplate was found to occur when a prosthesis made direct contact with the footplate. The location of the prosthesis along the manubrium did not affect the motion of the footplate as long as the joints were all rigid. When the joints were flexible, the largest displacements occurred when the prosthesis was positioned near the upper end of the manubrium. © 1996 Acoustical Society of America.

Background: Despite significant anatomical variation amongst patients, cochlear implant frequency-mapping has traditionally followed a patient-independent approach. Basilar membrane (BM) length is required for patient-specific frequency-mapping, however cochlear duct length (CDL) measurements generally extend to the apical tip of the entire cochlea or have no clearly defined end-point. By characterizing the length between the end of the BM and the apical tip of the entire cochlea (helicotrema length), current CDL models can be corrected to obtain the appropriate BM length. Synchrotron radiation phase-contrast imaging has made this analysis possible due to the soft-tissue contrast through the entire cochlear apex. Methods: Helicotrema linear length and helicotrema angular length measurements were performed on synchrotron radiation phase-contrast imaging data of 14 cadaveric human cochleae. On a sub-set of six samples, the CDL to the apical tip of the entire cochlea (CDLTIP) and the BM length (CDLBM) were determined. Regression analysis was performed to assess the relationship between CDLTIPand CDLBM. Results: The mean helicotrema linear length and helicotrema angular length values were 1.6 ± 0.9 mm and 67.8 ± 37.9 degrees, respectively. Regression analysis revealed the following relationship between CDLTIPand CDLBM: CDLBM= 0.88(CDLTIP) + 3.71 (R2= 0.995). Conclusion: This is the first known study to characterize the length of the helicotrema in the context of CDL measurements. It was determined that the distance between the end of the BM and the tip of the entire cochlea is clinically consequential. A relationship was determined that can predict the BM length of an individual patient based on their respective CDL measured to the apical tip of the cochlea.

Background: Trainees in Otolaryngology–Head and Neck Surgery must gain proficiency in a variety of challenging temporal bone surgical techniques. Traditional teaching has relied on the use of cadavers; however, this method is resource-intensive and does not allow for repeated practice. Virtual reality surgical training is a growing field that is increasingly being adopted in Otolaryngology. CardinalSim is a virtual reality temporal bone surgical simulator that offers a high-quality, inexpensive adjunct to traditional teaching methods. The objective of this study was to establish the face and content validity of CardinalSim through a national study. Methods: Otolaryngologists and resident trainees from across Canada were recruited to evaluate CardinalSim. Ethics approval and informed consent was obtained. A face and content validity questionnaire with questions categorized into 13 domains was distributed to participants following simulator use. Descriptive statistics were used to describe questionnaire results, and either Chi-square or Fishers exact tests were used to compare responses between junior residents, senior residents, and practising surgeons. Results: Sixty-two participants from thirteen different Otolaryngology–Head and Neck Surgery programs were included in the study (32 practicing surgeons; 30 resident trainees). Face validity was achieved for 5 out of 7 domains, while content validity was achieved for 5 out of 6 domains. Significant differences between groups (p-value of < 0.05) were found for one face validity domain (realistic ergonomics, p= 0.002) and two content validity domains (teaching drilling technique, p= 0.011 and overall teaching utility, p= 0.006). The assessment scores, global rating scores, and overall attitudes towards CardinalSim, were universally positive. Open-ended questions identified limitations of the simulator. Conclusion: CardinalSim met acceptable criteria for face and content validity. This temporal bone virtual reality surgical simulation platform may enhance surgical training and be suitable for patient-specific surgical rehearsal for practicing Otolaryngologists.

Background: The BONEBRIDGE (MED-EL, Innsbruck, Austria) is a bone-conduction implant used in the treatment of conductive and mixed hearing loss. The BONEBRIDGE consists of an external audio processor and a bone-conduction floating mass transducer that is surgically implanted into the skull in either the transmastoid, retrosigmoid or middle fossa regions. The manufacturer includes self-tapping screws to secure the transducer; however, self-drilling screws have also been used with success. In cases where the skull is not thick enough to house the transducer, lifts are available in a variety of sizes to elevate the transducer away from the skull. The objective of the present study was to investigate the effects of screw type, lift thickness, and implant location on the sound transmission of the BONEBRIDGE. Method: Six cadaveric temporal bones were embalmed and dried for use in this study. In each sample, a hole was drilled in each of the three implant locations to house the implant transducer. At the middle fossa, six pairs of screw holes were pre-drilled; four pairs to be used with self-tapping screws and lifts (1, 2, 3, and 4 mm thick lifts, respectively), one pair with self-tapping screws and no lifts, and one pair with self-drilling screws and no lifts. At the transmastoid and retrosigmoid locations, one pair of screw holes were pre-drilled in each for the use of the self-tapping screws. The vibration of transmitted sound to the cochlea was measured using a laser Doppler vibrometry technique. The measurements were performed on the cochlear promontory at eight discrete frequencies (0.5, 0.75, 1, 1.5, 2, 3, 4 and 6 kHz). Vibration velocity of the cochlear wall was measured in all samples. Measurements were analyzed using a single-factor ANOVA to investigate the effect of each modification. Results: No significant differences were found related to either screw type, lift thickness, or implant location. Conclusions: This is the first known study to evaluate the effect of screw type, lift thickness, and implant location on the sound transmission produced by the BONEBRIDGE bone-conduction implant. Further studies may benefit from analysis using fresh cadaveric samples or in-vivo measurements.

Following publication of the original article [1], the authors identified incorrect ordering and incorrect files being used for Figs. 1, 2 and 3.

Background: Bone conduction implants can be used in the treatment of conductive or mixed hearing loss. The BONEBRIDGE bone conduction implant (BB-BCI) is an active, transcutaneous device. BB-BCI implantation can be performed through either the transmastoid or retrosigmoid approach with their respective limitations. Here, we present a third, novel approach for BB-BCI implantation. Objective: Describe the detailed surgical technique of BB-BCI implantation through a middle fossa approach with self-drilling screws and present preliminary audiometric outcome data following this approach. Methods: A single institution, retrospective chart review was completed for patients implanted with the BB-BCI via the middle fossa approach. Preoperative planning and modelling were performed using 3D Slicer. Audiological testing was performed pre- and post-operatively following standard audiometric techniques. Results: Forty patients underwent BB-BCI implantation using the middle fossa approach. Modelling techniques allowed for implantation through the use of external landmarks, obviating the need for intraoperative image guidance. The surgical technique was refined over time through experience and adaptation. Mean follow-up was 29?months (range 3–71?months) with no surgical complications, favourable cosmesis, and expected audiometric outcomes. An average functional gain of 39.6?dB (± 14.7 SD) was found. Conclusion: The middle fossa technique with self-drilling screws is a safe and effective option for BONEBRIDGE implantation. As a reference for other groups considering this approach, an annotated video has been included as a supplement to the study.