{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T22:24:00Z","timestamp":1787264640618,"version":"build-2736575974"},"reference-count":35,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T00:00:00Z","timestamp":1787184000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T00:00:00Z","timestamp":1787184000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"National Hospital"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur Arch Otorhinolaryngol"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>To investigate the impact of anatomical variation (AV) on surgical skills acquisition, i.e., learning curves, and cognitive load (CL) during virtual reality (VR) simulation-based training (SBT) of mastoidectomy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A randomized, controlled educational trial. Trainees (medical students) were randomized to perform 12 virtual mastoidectomies on anatomically different temporal bones (intervention) or on the same temporal bone (controls). Training was organized as distributed practice. Mastoidectomy performances were evaluated by two blinded raters using the modified 26-points Welling Scale assessment tool and learning curves were established. CL was estimated by secondary task reaction time.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The intervention group (AV) improved from baseline performance by 80% compared with 59% in the control group (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.52). The intervention group reached 68%, and the control group of 65% of the maximum performance score. The groups had equal CL at the beginning of training (49% increase in reaction time for the intervention group vs. 47% for the control group). After the training program, CL had decreased by 11.6% and 10% from baseline for the intervention and control group, respectively.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Anatomical variation in SBT of mastoidectomy neither affected learning curves nor CL of novices compared to repeated practice on the same case. This suggests that AV is not needed for basic skills acquisition in complete novices. Nonetheless, AV and exposure to different anatomical variations could be valuable for more experienced trainees while other instructional designs might be more suitable for novice learners.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00405-026-10546-9","type":"journal-article","created":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T21:42:57Z","timestamp":1787262177000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The effect of anatomical variation on learning and cognitive load during simulation-based training of mastoidectomy\u2014a randomized, controlled trial"],"prefix":"10.1007","author":[{"given":"Martin","family":"Frend\u00f8","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karoline Abilds\u00f8","family":"Arnesen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mads S\u00f8lvsten","family":"S\u00f8rensen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven Arild Wuyts","family":"Andersen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2054-7639","authenticated-orcid":false,"given":"Andreas","family":"Frithioff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,20]]},"reference":[{"key":"10546_CR1","doi-asserted-by":"publisher","unstructured":"Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB (2013) Simulation in healthcare education: A best evidence practical guide. AMEE Guide 82\u2019 Med Teach 35(10). https:\/\/doi.org\/10.3109\/0142159X.2013.818632","DOI":"10.3109\/0142159X.2013.818632"},{"key":"10546_CR2","unstructured":"Klein G (1993) A recognition primed decision (RPD) model of rapid decision making"},{"key":"10546_CR3","doi-asserted-by":"publisher","unstructured":"Francis DMA (2009) Surgical decision making. https:\/\/doi.org\/10.1111\/j.1445-2197.2009.05139.x","DOI":"10.1111\/j.1445-2197.2009.05139.x"},{"key":"10546_CR4","unstructured":"Bjork EL, Bjork RA (2011) Making things hard on yourself, but in a good way: Creating desirable difficulties to enhance learning. Psychology and the Real World: Essays Illustrating Fundamental Contributions to Society pp. 56\u201364"},{"key":"10546_CR5","doi-asserted-by":"publisher","unstructured":"Cook DA et al (2013) Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis. Informa Healthc. https:\/\/doi.org\/10.3109\/0142159X.2012.714886","DOI":"10.3109\/0142159X.2012.714886"},{"key":"10546_CR6","doi-asserted-by":"publisher","unstructured":"Bjork RA, Bjork EL (2020) Desirable difficulties in theory and practice. J Appl Res Mem Cogn 9(4). https:\/\/doi.org\/10.1016\/j.jarmac.2020.09.003","DOI":"10.1016\/j.jarmac.2020.09.003"},{"key":"10546_CR7","doi-asserted-by":"publisher","unstructured":"Lamtara JC, Wijewickrema S, O\u2019Leary S, JM (2026) Determining the difficulty level of cases for temporal bone surgery training in virtual reality simulation. Acta Otolaryngol. https:\/\/doi.org\/10.1080\/00016489.2025.2602609","DOI":"10.1080\/00016489.2025.2602609"},{"issue":"S1","key":"10546_CR8","doi-asserted-by":"publisher","first-page":"S29","DOI":"10.1017\/S0022215116009233","volume":"131","author":"P Piromchai","year":"2017","unstructured":"Piromchai P et al (2017) Effects of anatomical variation on trainee performance in a virtual reality temporal bone surgery simulator. J Laryngol Otol 131(S1):S29\u2013S35. https:\/\/doi.org\/10.1017\/S0022215116009233","journal-title":"J Laryngol Otol"},{"issue":"8","key":"10546_CR9","doi-asserted-by":"publisher","first-page":"1034","DOI":"10.1097\/ACM.0000000000000681","volume":"90","author":"MV Pusic","year":"2015","unstructured":"Pusic MV, Boutis K, Hatala R, Cook DA (2015) Learn curves health professions education. Acad Med 90(8):1034\u20131042. https:\/\/doi.org\/10.1097\/ACM.0000000000000681","journal-title":"Acad Med"},{"issue":"2","key":"10546_CR10","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1097\/SIH.0000000000000477","volume":"16","author":"NM Howard","year":"2021","unstructured":"Howard NM, Cook DA, Hatala R, Pusic MV (2021) Learning curves in health professions education simulation research: a systematic review. Simul Healthc 16(2):128\u2013135. https:\/\/doi.org\/10.1097\/SIH.0000000000000477","journal-title":"Simul Healthc"},{"issue":"4","key":"10546_CR11","doi-asserted-by":"publisher","first-page":"907","DOI":"10.1002\/lary.26000","volume":"127","author":"SAW Andersen","year":"2017","unstructured":"Andersen SAW, Konge L, Mikkelsen PT, Cay\u00e9-Thomasen P, S\u00f8rensen MS (2017) Mapping the plateau of novices in virtual reality simulation training of mastoidectomy. Laryngoscope 127(4):907\u2013914. https:\/\/doi.org\/10.1002\/lary.26000","journal-title":"Laryngoscope"},{"issue":"10","key":"10546_CR12","doi-asserted-by":"publisher","first-page":"913","DOI":"10.1001\/jamaoto.2015.1563","volume":"141","author":"SAW Andersen","year":"2015","unstructured":"Andersen SAW, Konge L, Cay\u00e9-Thomasen P, S\u00f8rensen MS (2015) Learning curves of virtual mastoidectomy in distributed and massed practice. JAMA Otolaryngol Head Neck Surg 141(10):913\u2013918. https:\/\/doi.org\/10.1001\/jamaoto.2015.1563","journal-title":"JAMA Otolaryngol Head Neck Surg"},{"key":"10546_CR13","doi-asserted-by":"publisher","unstructured":"Van Merri\u00ebnboer JJG, Sweller J (2010) Cognitive load theory in health professional education: design principles and strategies. Med Educ 44(1). https:\/\/doi.org\/10.1111\/j.1365-2923.2009.03498.x","DOI":"10.1111\/j.1365-2923.2009.03498.x"},{"issue":"5","key":"10546_CR14","doi-asserted-by":"publisher","first-page":"371","DOI":"10.3109\/0142159X.2014.889290","volume":"36","author":"JQ Young","year":"2014","unstructured":"Young JQ, Van Merrienboer J, Durning S, Ten Cate O (2014) Cognitive load theory: Implications for medical education: AMEE Guide 86. Med Teach 36(5):371\u2013384. https:\/\/doi.org\/10.3109\/0142159X.2014.889290","journal-title":"Med Teach"},{"issue":"1","key":"10546_CR15","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1016\/j.jsurg.2015.09.010","volume":"73","author":"SAW Andersen","year":"2016","unstructured":"Andersen SAW, Mikkelsen PT, Konge L, Cay\u00e9-Thomasen P, S\u00f8rensen MS (2016) Cognitive load in mastoidectomy skills training: virtual reality simulation and traditional dissection compared. J Surg Educ 73(1):45\u201350. https:\/\/doi.org\/10.1016\/j.jsurg.2015.09.010","journal-title":"J Surg Educ"},{"issue":"2","key":"10546_CR16","doi-asserted-by":"publisher","first-page":"E74","DOI":"10.1002\/lary.25449","volume":"126","author":"SAW Andersen","year":"2016","unstructured":"Andersen SAW, Mikkelsen PT, Konge L, Cay\u00e9-Thomasen P, S\u00f8rensen MS (2016) Cognitive load in distributed and massed practice in virtual reality mastoidectomy simulation. Laryngoscope 126(2):E74\u2013E79. https:\/\/doi.org\/10.1002\/lary.25449","journal-title":"Laryngoscope"},{"issue":"3","key":"10546_CR17","doi-asserted-by":"publisher","first-page":"343","DOI":"10.1002\/acp.1250","volume":"20","author":"JJG Van Merri\u00ebnboer","year":"2006","unstructured":"Van Merri\u00ebnboer JJG, Kester L, Paas F (2006) Teaching complex rather than simple tasks: Balancing intrinsic and germane load to enhance transfer of learning. Appl Cogn Psychol 20(3):343\u2013352. https:\/\/doi.org\/10.1002\/acp.1250","journal-title":"Appl Cogn Psychol"},{"issue":"8","key":"10546_CR18","doi-asserted-by":"publisher","first-page":"900","DOI":"10.1097\/MAO.0000000000003607","volume":"43","author":"KA Arnesen","year":"2022","unstructured":"Arnesen KA, Frithioff A, S\u00f8rensen MS, Andersen SAW, Frend\u00f8 M (2022) Mastoidectomy training: is anatomical variation needed? a randomized, controlled trial on performance and skills transfer from virtual reality to a three-dimensional printed model. Otology Neurotology 43(8):900\u2013907. https:\/\/doi.org\/10.1097\/MAO.0000000000003607","journal-title":"Otology Neurotology"},{"issue":"4","key":"10546_CR19","doi-asserted-by":"publisher","first-page":"484","DOI":"10.1097\/MAO.0b013e3181a5299b","volume":"30","author":"MS Sorensen","year":"2009","unstructured":"Sorensen MS, Mosegaard J, Trier P (2009) The visible ear simulator: A public PC application for GPU-accelerated haptic 3D simulation of ear surgery based on the visible ear data. Otology Neurotology 30(4):484\u2013487. https:\/\/doi.org\/10.1097\/MAO.0b013e3181a5299b","journal-title":"Otology Neurotology"},{"key":"10546_CR20","doi-asserted-by":"publisher","unstructured":"S\u00f8rensen MS, Dobrzeniecki AB, Larsen P, Frisch T, Sporring J , Darvann TA (2002) The visible ear: a digital image library of the temporal bone. ORL 64(6). https:\/\/doi.org\/10.1159\/000066089","DOI":"10.1159\/000066089"},{"key":"10546_CR21","doi-asserted-by":"publisher","unstructured":"Sieber DM, Andersen SAW, S\u00f8rensen MS, Mikkelsen PT (2021) OpenEar image data enables case variation in high fidelity virtual reality ear surgery. Otology & Neurotology (Publish Ahead of Print. https:\/\/doi.org\/10.1097\/MAO.0000000000003175","DOI":"10.1097\/MAO.0000000000003175"},{"key":"10546_CR22","doi-asserted-by":"publisher","unstructured":"Sieber D et al (2019) The OpenEar library of 3D models of the human temporal bone based on computed tomography and micro-slicing. Sci Data 6(1). https:\/\/doi.org\/10.1038\/sdata.2018.297","DOI":"10.1038\/sdata.2018.297"},{"key":"10546_CR23","unstructured":"Haahr M RANDOM.ORG: true random number service. Available at: https:\/\/www.random.org. Accessed 2 Feb\u00a0 2021."},{"issue":"10","key":"10546_CR24","doi-asserted-by":"publisher","first-page":"913","DOI":"10.1001\/jamaoto.2015.1563","volume":"141","author":"SAW Andersen","year":"2015","unstructured":"Andersen SAW, Konge L, Cay\u00e9-Thomasen P, S\u00f8rensen MS (2015) Learning curves of virtual mastoidectomy in distributed and massed practice\u2019, JAMA Otolaryngol. Head Neck Surg 141(10):913\u2013918. https:\/\/doi.org\/10.1001\/jamaoto.2015.1563","journal-title":"Head Neck Surg"},{"issue":"11","key":"10546_CR25","doi-asserted-by":"publisher","first-page":"960","DOI":"10.3109\/0142159X.2012.703791","volume":"34","author":"R Bloch","year":"2012","unstructured":"Bloch R, Norman G (2012) Generalizability theory for the perplexed: A practical introduction and guide: AMEE Guide 68. Med Teach 34(11):960\u2013992. https:\/\/doi.org\/10.3109\/0142159X.2012.703791","journal-title":"Med Teach"},{"issue":"2","key":"10546_CR26","doi-asserted-by":"publisher","first-page":"431","DOI":"10.1002\/lary.24838","volume":"125","author":"SAW Andersen","year":"2015","unstructured":"Andersen SAW, Cay\u00e9-Thomasen P, S\u00f8rensen MS (2015) Mastoidectomy performance assessment of virtual simulation training using final-product analysis\u2019. Laryngoscope 125(2):431\u2013435. https:\/\/doi.org\/10.1002\/lary.24838","journal-title":"Laryngoscope"},{"issue":"1","key":"10546_CR27","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1177\/0194599816670886","volume":"156","author":"R Sethia","year":"2017","unstructured":"Sethia R, Kerwin TF, Wiet GJ (2017) Performance assessment for mastoidectomy: state of the art review. Otolaryngology\u2013Head Neck Surg 156(1):61\u201369. https:\/\/doi.org\/10.1177\/0194599816670886","journal-title":"Otolaryngology\u2013Head Neck Surg"},{"key":"10546_CR28","doi-asserted-by":"publisher","unstructured":"Naismith LM, Cavalcanti RB (2015) Validity of cognitive load measures in simulation-based training: A systematic review. Academic Medicine. Lippincott Williams and Wilkins, pp S24\u2013S35. https:\/\/doi.org\/10.1097\/ACM.0000000000000893.","DOI":"10.1097\/ACM.0000000000000893"},{"issue":"1","key":"10546_CR29","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1007\/s40037-015-0160-5","volume":"4","author":"J Leppink","year":"2015","unstructured":"Leppink J (2015) Data analysis in medical education research: a multilevel perspective. Perspect Med Educ 4(1):14\u201324. https:\/\/doi.org\/10.1007\/s40037-015-0160-5","journal-title":"Perspect Med Educ"},{"issue":"1","key":"10546_CR30","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1186\/s41077-016-0025-y","volume":"1","author":"A Cheng","year":"2016","unstructured":"Cheng A et al (2016) Reporting guidelines for health care simulation research: extensions to the CONSORT and STROBE statements\u2019. Adv Simul 1(1):25. https:\/\/doi.org\/10.1186\/s41077-016-0025-y","journal-title":"Adv Simul"},{"key":"10546_CR31","unstructured":"Lang TA, Altman DG basic statistical reporting for articles published in biomedical journals: the statistical analyses and methods in the published literature or the SAMPL Guidelines\u2019. [Online]. Available: https:\/\/www.equator-network.org"},{"key":"10546_CR32","doi-asserted-by":"publisher","unstructured":"Vakharia VN, Vakharia NN, Hilll CS (2016) Review of 3-dimensional printing on cranial neurosurgery simulation training. World Neurosurg 88:188\u2013198. https:\/\/doi.org\/10.1016\/j.wneu.2015.12.031","DOI":"10.1016\/j.wneu.2015.12.031"},{"issue":"S1","key":"10546_CR33","doi-asserted-by":"publisher","first-page":"S29","DOI":"10.1017\/S0022215116009233","volume":"131","author":"P Piromchai","year":"2017","unstructured":"Piromchai P et al (2017) Effects of anatomical variation on trainee performance in a virtual reality temporal bone surgery simulator. J Laryngol Otol 131(S1):S29\u2013S35. https:\/\/doi.org\/10.1017\/S0022215116009233","journal-title":"J Laryngol Otol"},{"key":"10546_CR34","doi-asserted-by":"publisher","unstructured":"Wong W et al (2011) The Effect of cross-training with adjustable airway model anatomies on laryngoscopy skill transfer. Anesth Analg 113(4). https:\/\/doi.org\/10.1213\/ANE.0b013e3181fe758b","DOI":"10.1213\/ANE.0b013e3181fe758b"},{"key":"10546_CR35","doi-asserted-by":"publisher","unstructured":"Omari A et al (2026) Effect of case-specific 3D-printed models on surgical performance in cadaveric dissection\u2014a randomized controlled trial\u2019, European Archives of Oto-Rhino-Laryngology. https:\/\/doi.org\/10.1007\/s00405-026-10099-x","DOI":"10.1007\/s00405-026-10099-x"}],"container-title":["European Archives of Oto-Rhino-Laryngology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00405-026-10546-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00405-026-10546-9","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00405-026-10546-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T21:42:58Z","timestamp":1787262178000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00405-026-10546-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,20]]},"references-count":35,"alternative-id":["10546"],"URL":"https:\/\/doi.org\/10.1007\/s00405-026-10546-9","relation":{},"ISSN":["0937-4477","1434-4726"],"issn-type":[{"value":"0937-4477","type":"print"},{"value":"1434-4726","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,20]]},"assertion":[{"value":"9 April 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 August 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 August 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Dr. Andersen has consulted for Am bu A\/S. The remaining authors have nothing to declare.","order":1,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}