Abstract
Objective
This study aims to evaluate the feasibility and utility of a novel, open‐source 3D printed simulator for practicing laryngeal surgery skills in the clinic setting.
Study Design
Device development and validation.
Setting
A tertiary medical center.
Methods
A laryngeal surgery simulator was created using computer‐aided design software and 3D printed. Ten otolaryngology residents completed exercises utilizing the simulator and a flexible video laryngoscope for visualization. The training involved 3 microsurgery tasks: (1) suture removal from simulated vocal cords, (2) removal of silicone vocal cord polyps, and (3) simulated flap creation by peeling a grape's skin. Participant demographics, task completion time, and video recordings were collected. Participants provided subjective feedback through 5‐point Likert‐style questions assessing content and face validity.
Results
Both novice and experienced otolaryngology resident physicians reported positive perceptions of the simulator and its efficacy as an educational device, with average agreement more than neutral (P < .01). Participants praised the simulator's utility for practicing microsurgery skills using a flexible video laryngoscope and for handling instruments such as Kleinsasser forceps and micro scissors (P < .01). Preliminary findings suggest improvements in task completion time with higher post‐graduate year. Participants also reported the need for greater realism.
Conclusion
This study of a 3D‐printed simulator for laryngeal surgery skills using a flexible video laryngoscope demonstrated promising utility as an educational device. Positive feedback reflects the potential value as a training tool for residents to practice fine motor skills required for laryngeal surgery. Further research with larger sample sizes is needed to validate these findings.
Keywords: microlaryngeal surgery, resident education, surgery simulation
Surgical education has widely incorporated simulations, task trainers, and practice instruments designed to simulate specific skills used in the operating room. 1 The field of otolaryngology has embraced both physical and virtual models for simulating common procedures, such as sinus surgery, pediatric airway surgery, and phonomicrosurgery. 2 , 3 , 4 , 5 , 6 , 7 , 8 These skill simulators have been validated as educational tools, allowing surgeons to practice surgical skills in a safe and controlled environment. 4 , 5 , 6 , 9 , 10
Microlaryngeal surgery, or phonosurgery, requires fine motor skills that are challenging to master. Usually, a single surgeon operates at a given time, using both hands to control surgical instruments with binocular vision. Given the limited space available within the surgical laryngoscope and the technical difficulty of these procedures, residents are generally unable to directly assist the attending surgeon without switching positions. Training in these skills is necessary to improve efficiency and minimize complications of laryngeal surgery, which include trauma to deeper vocal fold tissues. Among ACGME‐accredited otolaryngology programs, a recent study found that only 33% of programs offered hands‐on education in microlaryngeal surgery, and another observed that only 42% of PGY‐4 and PGY‐5 residents had participated in a laryngeal surgery laboratory. 11 , 12 A similar study in 2013 found that only 22% of otolaryngology residents in the United States and Canada were “very comfortable” with phonomicrosurgery. As such, residency programs must find innovative ways to provide more exposure and training in microlaryngeal surgery. 13
While simulators are an innovative avenue for training, the costs and hardware challenges of operating simulators for microlaryngeal tasks may be challenging to justify. Given the need for lower‐cost simulators in this subspecialty of otolaryngology, many groups have attempted to build low‐cost microlaryngeal skill trainers. 4 , 5 , 6 , 7 These simulators range from utilizing hardware store materials to constructs using custom electronics. 14 Novel simulators have been assessed for face, construct, and content validity to justify their use as a training tool. 2 , 4 , 5 , 6 , 7 , 9 , 15 , 16 , 17 Optimally, transfer validity can also show how effectively simulations translate to improved clinical ability. 18 While the literature contains many examples of laryngeal surgery simulators, these devices often use customized electronics, commercial manufacturing techniques, or require a microsurgery training laboratory. Although these features increase realism, they prevent practical use by trainees at other institutions. Few groups have openly released their designs, and reverse engineering represents a significant challenge.
One solution to the issues of reproducibility and cost is the use of 3D printing technology, which offers advantages such as easy modifications, accessibility, and cheap materials. 9 , 10 , 19 Several otolaryngology simulators have utilized 3D printing. In prior work, Lee et al created an open‐source simulator for percutaneous injection laryngoplasty training using injection‐molded silicone for soft tissue and 3D‐printed plastic for cartilage. 10 While open source, it requires a surgical microscope for visualization and only captures normal anatomy. Kavanagh et al developed a simulator for pediatric pathologies and compared various materials for anatomic realism, including silicone elastomer and common 3D printing filaments. 19 Saliba and Barros also created a device to simulate the surgical treatment of common vocal fold pathologies using both 3D printing and gelatin for anatomic structures. 9 However, both groups have proprietary designs that cannot be used externally or validated at other institutions. Given the advent of consumer‐grade 3D printers that cost a few hundred dollars, many medical institutions can now 3D‐print custom parts for academic departments. 20 A fully 3D‐printed and open‐source device would allow hospitals and otolaryngology trainees across the globe to create their own simulators and practice essential fine motor surgical skills.
We have developed a novel, low‐cost, entirely 3D‐printed microlaryngeal surgery simulator that is modular, simple to use, and easily transportable. This simulator can also be used outside of a microsurgery laboratory, allowing resident physicians to practice microsurgical skills in the clinical setting using a standard flexible video laryngoscope. 21 In this initial study, we present our phonosurgery simulator and examine residents' perceptions of this device.
Objective
This study evaluates the feasibility and utility of a novel, open‐source 3D printed simulator for practicing laryngeal surgery skills in an otolaryngology clinical setting.
Methods
Simulator Design and Creation
A 3D‐printed simulator for laryngeal surgery was designed using Autodesk Fusion360 software and printed with an Ender 3 Pro machine (Shenzhen Creality 3D Technology Co). Parts were printed using standard 1.75 mm polylactic acid (PLA) filament.
Simulator Evaluation
Ten otolaryngology residents completed several exercises utilizing the simulator and a Karl Storz flexible video laryngoscope with a Karl Storz video tele pack tower for visualization. The training involved 3 simulated microsurgery tasks: suture removal from simulated vocal cords, removal of vocal cord polyps, and microflap creation by peeling a grape's skin (Figure 1). For each task, participants were given freedom to use any available instrument, which consisted of Storz phonomicrosurgical instruments (Karl Storz): left and right curved scissors, 45° angled scissors, left and right curved alligator forceps, straight alligator forceps, and cutting forceps. Informed consent was obtained for each participant. Study protocols were approved by the MedStar Georgetown University Hospital institutional review board.
Figure 1.
Video view of simulation tasks as seen by participants. (A) Suture removal task. (B) Polyp removal task. (C) Grape skin microflap task.
Simulation Task Preparation
The suture removal task was created by stretching a standard 0.25‐inch width rubber band over a 3D printed task cartridge to create opposing bands mimicking vocal folds. A 2.0 prolene suture was knotted to each side of the simulated vocal folds, and a second suture was inserted into each side but left without a knot (Figure 1A). The task was defined as removing the sutures without tearing the rubber band material. The polyp removal task was created by adding a 2‐part silicone elastomer into a 3D printed polyp mold and allowing the silicone to cure for 8 hours. Silicone was prepared by mixing the 2 elastomer components before adding silicone oil and mucosa‐toned mica coloring to achieve the desired consistency and color. The polyp portions of the silicone vocal folds were painted using red lacquer paint (Figure 1B). The task was defined as removing the 2 polyps from the simulated silicone vocal folds without damaging the mucosa, which was defined as the area not painted red.
The grape skin microflap task was prepared by placing a standard supermarket red grape, approximately 2 cm in length and diameter, into the task cartridge and inserting wooden toothpicks through the cartridge to affix the grape (Figure 1C). The task was defined as removing at least 50% of the skin from the visible surface of the grape (under flexible video laryngoscopy) while minimizing damage to the underlying grape “parenchyma.”
Statistical Analysis
Demographics, task completion time, and video recordings of the tasks were collected. Face and content validity were assessed by providing participants with a 5‐point Likert scale questionnaire. The surveys covered opinions regarding the simulator's realism, appropriate use of various instruments, and utility as an educational tool. The analysis was performed using GraphPad Prism (GraphPad Software) and Microsoft Excel (Microsoft Corporation).
Results
The simulator consists of 16 3D‐printed parts that are assembled using press‐fit or screw mechanisms (Figure 2). The modular device contains a tube‐like structure that houses the simulation tasks and is designed for future customization. The versatile structure can accommodate silicone laryngeal phantoms, cadaveric or animal larynges, and anatomical structures made from household materials. The design also allows for modifiable parts that can facilitate future improvements. The base structure includes a placement point for a 3D printed surgical laryngoscope, which contains a 6 mm diameter tunnel for insertion of a standard flexible video laryngoscope. The 3D printed surgical laryngoscope was designed to mimic the tapered shape of the standard rigid Kleinsasser laryngoscope with the channel positioned above the opening of the proximal end. It has nominal proximal internal dimensions of 18 mm × 24.5 mm, a minimum internal diameter of 18 mm distally, and a length of 139 mm. A flexible video laryngoscope can be inserted through the channel, enabling visualization of tasks without requiring an operative microscope. Alternatively, an operative microscope can also be used in the usual manner for visualization. The simulator further incorporates a raised stand to hold the flexible video laryngoscope handle in an upright position during use. The device is elevated to an operational level through modular supports that can increase in height with additional parts. This manuscript releases the components, schematics, and operational instructions to the public for replication and use through a Creative Commons Attribution 4.0 International License:
Figure 2.
Simulator for laryngeal surgery. (A) 3D printed assembly used for simulation. (B) Participant attempting grape microflap task using flexible video laryngoscope for visualization.
The simulator parts were produced using standard filament deposition 3D printing techniques, requiring a total print time of approximately 84 hours with PLA filament, completed over several batches. To test replicability, the associated Standard Triangle Language (STL) files were replicated by the simulation lab at our institution to create 2 additional copies. After printing, parts only required minor sanding for proper assembly. While not investigated, further optimization of print time and attachment mechanisms may be possible by altering print orientations and materials.
In total, 10 otolaryngology resident physicians at our institution, from post‐graduate year (PGY)‐1 to PGY‐5, completed the simulation trials. Four participants had performed more than 20 laryngeal surgeries in the past (Table 1). Face validity (Figure 3), content validity (Figure 4), and general impressions (Figure 5) demonstrated positive perceptions of the simulator and agreement regarding its utility for resident training. Higher PGY was associated with faster task completion times for the polyp (R 2 = 0.43) and suture tasks (R 2 = 0.45), but not grape (R 2 = 0.004) (Figure 6).
Table 1.
Study Participant Demographics (n = 10)
| Demographics | n (%) |
|---|---|
| Total participants | 10 (100) |
| Training level | |
| PGY‐1 | 3 (30) |
| PGY‐2 | 2 (20) |
| PGY‐3 | 1 (10) |
| PGY‐4 | 2 (20) |
| PGY‐5 | 2 (20) |
| Laryngeal procedures performed per year | |
| None | 1 (10) |
| Less than 5 | 2 (20) |
| 5 to 9 | 3 (30) |
| 10 to 20 | 0 (0) |
| More than 20 | 4 (40) |
| Laryngeal surgeries performed in lifetime | |
| None | 2 (20) |
| Less than 5 | 1 (10) |
| 5 to 9 | 2 (20) |
| 10 to 20 | 1 (10) |
| More than 20 | 4 (40) |
Figure 3.
Face validity, average score on a 5‐point Likert‐type scale for each questionnaire item (n = 10).
Figure 4.
Content validity, average score on a 5‐point Likert‐type scale for each questionnaire item (n = 10).
Figure 5.
General impressions for simulation (n = 10).
Figure 6.
Average task completion times for simulation tasks (n = 10).
Face Validity
When investigating value as an educational tool, the simulator performed appropriately (Figure 3). One hundred percent of the participants agreed or strongly agreed that the rubber band and the polyp tasks were valuable training exercises, with a mean Likert score of 4.4 and 4.8, respectively. For the grape microflap task, only 6 out of 10 participants (60%) agreed that the task was valuable with a mean Likert score of 4.0. For this question, 3 participants (30%) answered with “neutral” and 1 participant, a PGY‐2, answered with “disagree.” More generally, 90% of participants agreed that this simulator would be helpful for improving endoscopic laryngeal surgery skills, with 1 participant responding with “disagree.” All resident physicians agreed that the simulator would increase resident competency in endolaryngeal surgery, and 90% agreed that the simulator correlates with essential laryngeal surgery skills, with 1 “neutral” response.
Content Validity
The simulator also performed well in the category of content validity (Figure 4). All resident physicians agreed that the simulator helped develop hand‐eye coordination, fine motor skills, comfort with microlaryngeal instruments, and bimanual dexterity. Participants also agreed that the simulator helps develop the fundamental use of laryngeal scissors and Kleinsasser forceps, with mean Likert scores of 4.6.
Regarding each task, participants generally agreed that the rubber band suture removal task and the polyp removal task helped develop skills needed for vocal fold interaction and polyp removal, respectively, with mean Likert scores of 4.6 and 4.5. However, for the grape microflap task, only 6 participants (60%) agreed that the task was a valuable training exercise, with a mean Likert score of 4.0. Relating to realism, participants had more positive opinions about rubber band tissue characteristics compared to the silicone polyps and grape.
General Impressions
Regarding the overall use for practicing microlaryngeal surgery skills, participants generally agreed that it was helpful. All resident physician participants either agreed or strongly agreed that they would be interested in using the simulator for training and that the simulator can be used at a desk or table in a clinical setting. The greatest agreement was found in the question relating to the use of this simulator to increase resident competency before their first endolaryngeal surgery, with a mean Likert score of 4.9. A large majority (90%) also agreed that the simulator model was adequate for surgical training, with 1 participant responding with “neutral.” Altogether, participants had less agreement with phrases relating to improving knowledge, confidence, and ability to perform laryngeal surgeries, with mean Likert scores ranging between 3.5 and 3.9. Participants had limited agreement with phrases relating to the realism of the laryngeal anatomy, user experience, and video laryngoscope view compared to an operating room, with Likert scores less than 4.
Discussion
There is an unmet need for educational tools that enable otolaryngology trainees to acquire, practice, and fine‐tune microsurgery skills. 11 , 12 , 13 The laryngeal surgery simulator described in this study offers a modular, inexpensive, and replicable educational tool to practice phonosurgery skills in a clinical setting. Our novel simulator addresses specific gaps by enhancing affordability, accessibility, and customization. Unlike prior models that often involve complex and costly setups, our design leverages low‐cost 3D printing technology, making it feasible for a wider range of medical institutions. The designs for our simulator were created to balance fidelity and accessibility. The 3D printing allows for straightforward replication using relatively low‐cost machines. While designing the task portion to replicate the endolaryngeal anatomy could have provided greater anatomic realism, this feature would have limited possible use cases, such as replicating patient‐specific pathology. The simple tubular structure prioritizes the customization of tasks while allowing for compatibility with existing high‐accuracy cadaveric and silicone laryngeal models. 16 While additional task‐specific materials are required, the basic simulator requires few materials for its construction and can be modified for additional improvements and new surgical tasks. Importantly, the tasks chosen—suture removal, polyp removal, and microflap creation—are reflective of relevant skills in microlaryngeal surgery and are simple enough for repetitive training, ensuring that the simulator remains educationally valuable. These were chosen based on tasks used by Holliday et al in a similar study. The tasks incorporate simple materials and require sequentially increasing fine motor and microsurgical instrument skills. While greater anatomic realism could be created using techniques like silicone injection molding, these are difficult to incorporate for repetitive use. We believe that the low‐cost, modularity, replicability, and in‐clinic use features of our novel 3D‐printed laryngeal surgery simulator render it a feasible training tool for otolaryngology training programs.
Our analysis demonstrates that junior trainees can learn basic instrument manipulation, coordination, and dexterity skills through the simulator. Participants' general impressions reveal agreement on adequate utility for surgical training and the ability to increase resident competency. While participant perceptions revealed a need for more realism compared to the operating room setting, a potential solution could involve injection‐molded silicone anatomy. 12
These results also highlight the initial construct validity of this simulator, which seeks to distinguish expert performance from novice performance. While the sample size in this study was limited, basic analysis of simulation task completion times demonstrated faster task execution among more senior resident participants in the polyp and suture simulation tasks (Figure 6). Further evaluation is needed to establish reliable construct validity, given the lack of completion time improvement across all tasks.
Despite the variety of published laryngeal procedure simulators, few of these models are published with detailed instructions for replication. 2 , 4 , 9 , 22 With the associated design files, the simulator was replicated to create 2 duplicates by our institution's Simulation Training and Education Lab with instructions only for the assembly of the parts. In this manuscript, we also include a citable repository of the associated design files, schematics, and detailed task‐specific protocols for our novel simulator. Given the importance of reproducibility, the release of these designs allows otolaryngology training programs to replicate the methods described. Furthermore, the instructions also allow future improvements relating to realism and operative relevancy.
Relating to cost, each simulator requires about 1 kg of PLA filament, equating to approximately $15 to $20, and printing the reusable parts requires about 84 hours using Ender 3 Pro machine, a household quality and accessible 3D printer. Task‐specific materials included 2‐part silicone, rubber bands, grapes, and toothpicks, which amount to approximately $0.50 per participant. The low‐cost materials allow for ease of repetition during resident training simulations. The tasks can be further improved with more realistic materials, such as animal larynges, or custom‐molded silicone replicas of laryngeal anatomy. Importantly, the flexible video laryngoscope (Karl Storz HD video rhino‐laryngoscope) utilized in our study allows for desk‐based use of the simulator, but if preferred, an operative microscope can also be used to view simulated anatomy through the 3D‐printed surgical laryngoscope. By removing the absolute need for a microsurgery laboratory, trainees can practice microlaryngeal surgery skills in the clinic setting and record their performance for coaching and feedback. This feature allows for flexible use in a variety of environments, improving accessibility.
As Barry Issenberg et al have described, an ideal, high‐fidelity task trainer includes characteristics such as providing feedback, allowing repetitive practice, offering individualized learning, and having defined outcomes, among others. 23 The simulator described here captures a majority of these qualities. It provides adequate feedback through defined tasks that can be repeated to improve skills for manipulating laryngeal instruments. The modular nature allows for tasks that can capture a range of difficulties, from simple suture removal to microflap creation. With the use of a flexible laryngoscope for visualization, the simulator can be used in a setting based on the learning needs of each individual. While curriculum use was not directly investigated in this study, the face and content validity results demonstrate adequate future educational potential.
Limitations of this study include the small sample size of trainees and the subjective nature of the survey‐based evaluation method. Furthermore, while the development was guided by a laryngologist, fellowship‐trained laryngologists were not participants in the evaluation of our simulator. Although residents were given a standardized set of microsurgery instruments, variations in participant use of specific tools may have influenced task completion times and choices on the validity questionnaire. Variations in the physical condition of the grape likely impacted participant opinions of this task and would benefit from refinement. Given the use of a flexible laryngoscope in this study, the simulation did not evaluate the ergonomics or skills of microscope usage for standard phonosurgery. Future improvements will include the evaluation of the simulator and tasks by fully trained laryngologists, analysis of participants' task videos, and a larger sample size. As the field of simulation‐based microlaryngeal training grows, the modular nature of this simulator provides an accessible platform for a microlaryngeal surgery task trainer.
Conclusion
We have created a low‐cost, modular, and open‐source 3D printed simulator for practicing laryngeal surgery skills. Participants recognized the potential educational benefits of the simulator and expressed significant belief that it can increase resident competency. Overall, this study presents initial results that demonstrate the promising utility of our simulator as a training tool for otolaryngology programs and functions as a viable option for desk‐based phonosurgery skills practice.
Author Contributions
Alan Balu, conception, design, acquisition of the data, interpretation and analysis of the data, manuscript writing, manuscript editing; Hemali P. Shah, acquisition of the data, interpretation and analysis of the data, manuscript writing, manuscript editing; Sagar Vasandani, acquisition of the data, manuscript writing, manuscript editing; Nazaneen Grant, conception, design, acquisition of the data, interpretation and analysis of the data, manuscript writing, manuscript editing.
Disclosures
Competing interests
None.
Funding source
Funding for this project was received from Georgetown University School of Medicine.
Acknowledgments
We utilized technical expertise and 3D printing resources from the Georgetown University “Maker Hub.”
This article was presented at the AAO‐HNSF 2024 Annual Meeting & OTO EXPO; September 28‐October 1, 2024; Miami Beach, Florida.
References
- 1. Hammoud MM, Nuthalapaty FS, Goepfert AR, et al. To the point: medical education review of the role of simulators in surgical training. Am J Obstet Gynecol. 2008;199(4):338‐343. 10.1016/j.ajog.2008.05.002 [DOI] [PubMed] [Google Scholar]
- 2. Steehler MK, Pfisterer MJ, Na H, Hesham HN, Pehlivanova M, Malekzadeh S. Face, content, and construct validity of a low‐cost sinus surgery task trainer. Otolaryngol Head Neck Surg. 2012;146(3):504‐509. 10.1177/0194599811430187 [DOI] [PubMed] [Google Scholar]
- 3. Jabbour N, Reihsen T, Payne NR, Finkelstein M, Sweet RM, Sidman JD. Validated assessment tools for pediatric airway endoscopy simulation. Otolaryngol Head Neck Surg. 2012;147(6):1131‐1135. 10.1177/0194599812459703 [DOI] [PubMed] [Google Scholar]
- 4. Contag SP, Klein AM, Blount AC, Johns MM. Validation of a laryngeal dissection module for phonomicrosurgical training. Laryngoscope. 2009;119(1):211‐215. 10.1002/lary.20018 [DOI] [PubMed] [Google Scholar]
- 5. Yu P, Luan J, Cui X, Li X, Hu X, Sun G. Development and validation of a low‐cost and simple simulator for microlaryngeal surgery. Clin Exp Otorhinolaryngol. 2020;13(1):58‐63. 10.21053/ceo.2019.00556 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Bressler SE, Adkins LK, Dunham ME, et al. A modular surgical simulator for microlaryngoscopy using standard instruments and the carbon dioxide laser. Laryngoscope Investig Otolaryngol. 2022;7(4):1065‐1070. 10.1002/lio2.854 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Holliday MA, Bones VM, Malekzadeh S, Grant NN. Low‐cost modular phonosurgery training station: development and validation. Laryngoscope. 2015;125(6):1409‐1413. 10.1002/lary.25143 [DOI] [PubMed] [Google Scholar]
- 8. Dedmon MM, Paddle PM, Phillips J, Kobayashi L, Franco RA, Song PC. Development and validation of a high‐fidelity porcine laryngeal surgical simulator. Otolaryngol Head Neck Surg. 2015;153(3):420‐426. 10.1177/0194599815590118 [DOI] [PubMed] [Google Scholar]
- 9. Saliba TV, Barros RSM. Development and validation of a 3D laryngeal model in surgical skills training. Braz J Otorhinolaryngol. 2023;89(1):128‐135. 10.1016/j.bjorl.2021.09.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Lee M, Ang C, Andreadis K, Shin J, Rameau A. An open‐source three‐dimensionally printed laryngeal model for injection laryngoplasty training. Laryngoscope. 2021;131(3):E890‐E895. 10.1002/lary.28952 [DOI] [PubMed] [Google Scholar]
- 11. Balouch B, Alnouri G, Vontela S, Tipparaju P, Sataloff RT. Laryngology education in otolaryngology residency programs – a pilot study. J Voice. 2022;36(4):538‐541. 10.1016/j.jvoice.2020.07.020 [DOI] [PubMed] [Google Scholar]
- 12. Dhillon VK, Dailey SH, Akst LM. Microlaryngeal teaching courses: a national survey on prevalence, value, and barriers to implementation. Ann Otol Rhinol Laryngol. 2020;129(2):101‐109. 10.1177/0003489419876290 [DOI] [PubMed] [Google Scholar]
- 13. Klein AM, Gross J. Development and validation of a high‐fidelity phonomicrosurgical trainer: validation of a phonomicrosurgical trainer. Laryngoscope. 2017;127(4):888‐893. 10.1002/lary.26230 [DOI] [PubMed] [Google Scholar]
- 14. Santander MJ, Sepúlveda V, Iribarren J, et al. Development and validation of a laryngeal microsurgery simulation training system for otolaryngology residents. Otolaryngol Head Neck Surg. 2023;169(4):971‐987. 10.1002/ohn.376 [DOI] [PubMed] [Google Scholar]
- 15. Gallagher AG, Ritter EM, Satava RM. Fundamental principles of validation, and reliability: rigorous science for the assessment of surgical education and training. Surg Endosc. 2003;17(10):1525‐1529. 10.1007/s00464-003-0035-4 [DOI] [PubMed] [Google Scholar]
- 16. Nixon IJ, Palmer FL, Ganly I, Patel SG. An integrated simulator for endolaryngeal surgery. Laryngoscope. 2012;122(1):140‐143. 10.1002/lary.22441 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Richardson CM, Zopf DA, Ikeda AK, et al. A validated 3D printed laryngeal suturing simulator for endoscopic laryngeal cleft repair. Laryngoscope. 2023;133(4):785‐791. 10.1002/lary.30320 [DOI] [PubMed] [Google Scholar]
- 18. Kostas JC, Lee AS, Arunkumar A, et al. Validation of a 3D‐printed percutaneous injection laryngoplasty simulator: a randomized controlled trial. Laryngoscope. 2024;134(1):318‐323. 10.1002/lary.30878 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Kavanagh KR, Cote V, Tsui Y, Kudernatsch S, Peterson DR, Valdez TA. Pediatric laryngeal simulator using 3D printed models: a novel technique: pediatric laryngeal simulator: 3D printed models. Laryngoscope. 2017;127(4):E132‐E137. 10.1002/lary.26326 [DOI] [PubMed] [Google Scholar]
- 20. Hellman S, Frisch P, Platzman A, Booth P. 3D Printing in a hospital: centralized clinical implementation and applications for comprehensive care. Digit Health. 2023;9:20552076231221899. 10.1177/20552076231221899 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Gillespie AI, Shelly S, Tucker SJ, Hollister SJ, Tkaczuk A, Klein A. Development and validation of a 3‐dimensional flexible laryngoscopy training simulator. J Model Simul Mater. 2022;5(1):1‐6. 10.21467/jmsm.5.1.1-6 [DOI] [Google Scholar]
- 22. Kurashima Y, Hirano S. Systematic review of the implementation of simulation training in surgical residency curriculum. Surg Today. 2017;47(7):777‐782. 10.1007/s00595-016-1455-9 [DOI] [PubMed] [Google Scholar]
- 23. Barry Issenberg S, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high‐fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10‐28. 10.1080/01421590500046924 [DOI] [PubMed] [Google Scholar]