European Archives of Oto-Rhino-Laryngology

, Volume 276, Issue 1, pp 63–70 | Cite as

Three-dimensional force analysis of surgical manipulations at the long process of the incus

  • Attila ÓváriEmail author
  • Christoph Heckeler
  • Karsten Ehrt
  • Hans-Edgar Bernd
  • Hans-Wilhelm Pau
  • Albrecht Eiber



Surgical manipulation with application of inappropriate force may damage middle ear structures leading to hearing loss. This work analyzes the forces applied in simulated otosurgical exercises in a laboratory set-up by measuring the spatial components of applied forces with objective assessment criteria. With these criteria, the individual force characteristics applied by the surgeon can be quantified and an objective feedback can be given about their surgical maneuvers.


A natural size model of the human incus was mounted on a load cell to measure the spatial forces in all three directions during different manipulation tasks performed under the microscope by ten surgeons from our department having different levels of experience in otosurgery. The motions of the incus model and the instrument tip were recorded simultaneously with a video camera.


Independent of surgical experience, a three-dimensional force pattern could be detected with components transverse to the desired force directions. The measured forces applied by trainees showed larger variations in magnitude, in spatial distribution and in temporal course than those applied by experienced surgeons. A better repeatability of identical tasks, constancy of force patterns and low peak force values could be seen in the group of experienced surgeons.


The laboratory system presented in this study using simultaneous video and 3-D force registration allows the objective assessment of surgical manipulations, e.g., at the long process of the incus. Training with video and force feedback provides information about surgical techniques and skill development of surgeons and has the potential to shorten the learning curve and to diminish intra-operative risks to patients.


Otosurgery Ear ossicles spatial force measurement Trainees Training Exercises 



We acknowledge Prof. Robert Mlynski, director of the Department of Otorhinolaryngology, Head and Neck Surgery “Otto Koerner”, Rostock University Medical Center, Rostock, Germany for his help in critical reviewing of the manuscript.

Compliance with ethical standards

Ethical standards

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all individual participants included in the study.

Supplementary material

405_2018_5194_MOESM1_ESM.mp4 (1.6 mb)
Supplementary material 1 (MP4 1643 KB)


  1. 1.
    Óvári A, Neményi D, Just T, Schuldt T, Buhr A, Mlynski R, Csókay A, Pau HW, ValálikI (2016) Positioning accuracy in otosurgery measured with optical tracking. Plos One 30 11(3):e0152623. CrossRefGoogle Scholar
  2. 2.
    Owa AO, Gbejuade HO, Giddings C (2003) A middle ear simulator for practicing prosthesis placement for otosclerosis surgery using ward-based materials. J Laryngol Oto l117:490–492CrossRefGoogle Scholar
  3. 3.
    Clifton N, Kligmann C, Khali lH (2011) Teaching otolaryngology skills through simulation. Eur Arch Otorhinolaryngol 268:949–953CrossRefGoogle Scholar
  4. 4.
    Sowerby LJ, Rehal G, Husein M, Doyle PC, Agrawal S, Ladak HM (2010) Development and face validity testing of a three-dimensional myringotomy simulator with haptic feedback. J Otolaryngol Head Neck 39:122–129Google Scholar
  5. 5.
    Beleites T, Neudert M, Lasurashvili N, Kemper M, Offergeld C, Hofmann G, Zahnert T (2011) Evaluation of the Dresden tympanoplasty model (DTM). [in German] Laryngorhinootologie 90:672–673CrossRefGoogle Scholar
  6. 6.
    Bergin M, Sheedy M, Ross P, Wylie G, Bird P (2014) Measuring the forces of middle ear surgery; evaluating a novel force-detection instrument. Otol Neurotol 35:77–83CrossRefGoogle Scholar
  7. 7.
    Zahnert T, Hüttenbrink KB, Bornitz M, Hofmann G (2001) Intraoperative measurement of stapes mobility using a hand-guided electromagnetic probe [in German]. Laryngorhinootologie 80:71–77CrossRefGoogle Scholar
  8. 8.
    Nguyen Y, Mamelle E, DeSeta D, Sterkers O, Bernardeschi D, Torres R (2017) Modifications to a 3D-printed temporal bone model for augmented stapes fixation surgery. Eur Arch Otorhinolaryngol 274(2):729–736CrossRefGoogle Scholar
  9. 9.
    Sheedy M, Bergin M, Wylie G, Ross P, Dove R, Bird P (2012) Development of a surgical instrument for measuring forces applied to the ossicles of the middle ear. Australas Phys Eng Sci Med 35:503–510CrossRefGoogle Scholar
  10. 10.
    Lauxmann M, Heckeler C, Beutner D, Lüers JC, Hüttenbrink KB, ChatzimichalisM, HuberA, EiberA (2012) Experimental study on admissible forces at the incudomalleolar joint. Otol Neurotol 33:1077–1084Google Scholar
  11. 11.
    Linder TE, Volkan G, Troxler E (2015) Objective measurements of ossicular chain mobility using a palpating instrument intraoperatively. Otol Neurotol 36:1669–1675CrossRefGoogle Scholar
  12. 12.
    Bell B, Stankowski S, Moser B, Oliva V, Stieger C, Nolte LP, CaversaccioM, WeberS (2010) Integrating optical fiber force sensors into microforceps for ORL microsurgery. Conf Proc IEEE Eng Med Biol Sci 1848:51Google Scholar
  13. 13.
    Heckeler C, Lauxmann M, Eiber A (2010) The load of application of stapes prostheses on ossicle chain [in German]. GMS Curr Posters Otorhinolaryngol Head Neck Surg 6:Doc70. Google Scholar
  14. 14.
    Mlynski R, Dalhoff E, Heyd A, Wildenstein D, Rak K, Radeloff A, Hagen R, Gummer AW, Schraven SP (2015) Standardized active middle-ear implant coupling to the short incus process. Otol Neurotol 36(8):1390–1398CrossRefGoogle Scholar
  15. 15.
    Schraven SP, Mlynski R, Dalhoff E, Heyd A, Wildenstein D, Rak K, Radeloff A, Hagen R, Gummer AW (2016) Coupling of an active middle-ear implant to the long process of the incus using an elastic clip attachment. Hear Res 340:179–184CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Otorhinolaryngology, Head and Neck Surgery “Otto Koerner”Rostock University Medical CenterRostockGermany
  2. 2.Department of Otorhinolaryngology, Head and Neck SurgeryAsklepios St. GeorgHamburgGermany
  3. 3.Institute of Engineering and Computational MechanicsUniversity of StuttgartStuttgartGermany

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