1 Introduction

Surgery provokes anxiety in many patients and the experienced perioperative anxiety can even influence the patients postoperative pain (Kain et al. 2000). A high level perioperative anxiety can lead to delays in work processes of the medical staff before or during surgery. In surgeries performed under local anaesthesia, a high level of anxiety in patients can also distract the surgeon’s focus intraoperatively, as the surgeon has to deal with calming down the patient; if the surgeon is unsuccessful in doing this, the patient could face even higher levels of anxiety in a subsequent surgery. Thus, it would be advantageous to find a method that, on the one hand, comforts the patient and, on the other hand, demands as little involvement and focus from the surgeon as possible.

1.1 Related work

Various attempts have been made to influence patients’ anxiety through non-pharmacological methods. It has been shown that listening to music can have a calming effect on patients (Lee et al. 2012; Sadideen et al. 2012). In addition to the influence of music, visual distractors such as television have proven to reduce patients’ pain perception (Marsdin et al. 2012). While simple audiovisual distraction methods like music or television can be advantageous, the immersive character of virtual reality (VR) offers a higher level of distraction. VR technology allows users to immerse themselves in a “virtual world” through three-dimensional impressions- a stark contrast to two-dimensional television (Mladenovic and Djordjevic 2021). The immersive aspect of VR is enhanced by the fact that users are visually cut off from their environment by wearing the fully covering headset and can no longer see what is happening around them. This can be particularly helpful during medical interventions, as patients tend to focus on the displayed content rather than the surgical procedure taking place.

The immersive aspect, in turn, aids the intention to distract patients from the surgery and shifts attention from unpleasant stimuli such as the hospital environment to the more pleasant VR content. In addition, VR headsets have the practical advantage over a television that they are more mobile, can be easily transported from one room to another and can be used in multiple operating positions, as the patient’s direction of view is not dependent on a television screen. This provides the surgeon a higher level of flexibility.

It has already been demonstrated that VR can positively influence patients’ well-being and reduce pain not only before but also during the procedures (Wiederhold et al. 2014). A randomised study with 117 patients also showed that patients wearing a VR headset during transcatheter aortic valve implantation under local anaesthesia had lower postoperative anxiety than the control group. The procedure time was also estimated to be shorter in the VR group than in the control group. These results suggest another application of VR: it could also be used in longer procedures where patients at risk for anaesthesia receive a non-drug therapy method for anxiety during procedures under local anaesthesia (Lind et al. 2023). Similar studies explored the influence of VR during hand surgery under local anaesthesia (Hoxhallari et al. 2019): Among patients who reported high pre-existing anxiety, those who wore a VR headset had lower scores on pain and anxiety scales compared to patients who did not wear a VR headset. However, not all studies have shown that VR has positive effects. A non-randomised controlled trial observed that patients undergoing a vasectomy under local anaesthsia, who used a VR headset, presented with higher levels of anxiety than that of the control group. The authors state, that the benefit of a VR headset may be influenced by the field of surgery (Dings et al. 2020).

Research on the use of VR during procedures in the head area is currently focused on investigations in the dental and maxillofacial area. For instance, a study investigated the anxiety of patients undergoing a third molar extraction under local anaesthesia using a visual analog scale (VAS) before and during the treatment between a group wearing a VR headset and a control group. It was found that anxiety levels decreased in the VR group and increased in the group without a VR headset (Yamashita et al. 2020).

Further, many procedures in the ears-nose-and-throat (ENT) field are performed under local anaesthesia. There are currently only a small number of studies investigating the use of VR in head and neck surgery. In a randomised crossover study by Gray et al. (2021), 82 adult patients were recruited who were undergoing two office-based postoperative nasal endoscopy and debridement procedures. The patients received a VR headset at either the first or second postoperative nasal endoscopy. The patients who had already had a VR headset at their first visit, did not get a headset at the second visit and vice versa. Patients who had a VR headset at their first appointment had significantly less anxiety and fewer reflexive head movements than the control group. Patients who did not have a VR headset at their first visit but had them at their second visit had significantly decreased pain, anxiety, and reflexive head movements at their second visit. No significant difference in procedural time between VR group and control group was observed in both visits (Gray et al. 2021). Another study investigated the impact of VR on laryngeal and tracheal injections, biopsy, or laser ablation in a total of 16 patients. The VR group demonstrated lower values in subjectively perceived stress but not in perceived pain and procedural satisfaction. Additionally in this study, there was no difference in the average procedure time between the VR group and the control group (Chang et al. 2021). This is an important aspect, as it means that the placement and adjustment of the VR headset does not significantly prolong the perioperative process, even though the surgical site is close to the VR headset.

Surgical interventions in children also take on a special role, as children are less likely to understand the need for surgery and therefore require more perioperative attention and treatment. An integrative literature review from 2022 showed that studies supported the efficacy of VR in the handling of procedural pain and anxiety in paediatric patients (Addab et al. 2022). Whether VR is a suitable tool to distract children in this situation and to reduce the fear and pain during the procedures is still debated. In 2021 a randomised study attempted to explore this question. 53 paediatric patients between 7 and 17 years underwent nasal endoscopy; it was found that patients in the VR group experienced significantly less anxiety and pain. An increase in procedural satisfaction was also observed. In comparison to the VR content presented to the adult patients in most of the studies described above, patients in this study played a VR game in which they had to aim at and hit oncoming objects in outer space. The children were able to do this using a controller in their hand (Liu et al. 2021). However, a VR game was only used in certain studies (Gray et al. 2021). The majority of the studies presented patients’ VR programs with different natural landscapes such as beaches (Chang et al. 2021), forests, mountains (Wiederhold et al. 2014; Mladenovic and Djordjevic 2021), icelands (Chan and Scharf 2017), underwater or similar peaceful scenery such as historic cities (Hoxhallari et al. 2019).

As described above, there are differences in the results of the studies that have been conducted so far and the VR headsets have been used in only a small number of different operations in ENT field. This shows the need to investigate the effectiveness and possible uses of VR in head and neck surgery in more detail. Therefore, the aim of this study was to explore whether and to what extent the use of VR in the head and neck region has an influence on patients’ anxiety and pain. Another aspect was to investigate whether certain surgical areas in the ENT field were more suitable for VR than others.

2 Methods

2.1 Patient cohort

A non-randomised prospective study was conducted between October 2021 and June 2022 at a German university medical center. The study protocol was approved by the local ethics committee (#323/21).

A total of 95 patients participated in the study, of which 67 patients were in the VR group and 28 patients in the control group. The patients were divided into a VR group who received a VR headset during surgery and a control group who did not receive a VR headset or any other alternative distraction during the procedure. The allocation to the VR group was based on the suitability of the surgical site and the availability of the VR headset.

The gender distribution in the VR group was 55.2% male patients and 44.8% female patients and in the control group 50% male patients and 50% female patients. So, both groups were sex-balanced. The patients in the VR group had a mean age of M = 52.7 years (SD = 19.6). The range was between 12 and 89 years. The patients in the control group had a mean age of M = 43.6 years (SD = 20.9) with a range between 18 and 84 years. With regard to the distribution of age and gender, the groups are similarly distributed.

It is important to mention here that a total of 46 patients (28.4%) out of 162 patients who were screened for the study, refused to wear a VR headset during the surgical procedure. Of these patients, 65.2% were male and 34.8% female. The average age was M = 63.2 years (SD = 20.3), which is 10.5 years older than the patients in the VR group. Of these patients, three patients had requested the use of the VR headset preoperatively, but then refused to use them in the operating room. 6/46 (13.0%) of the patients justified their decision by arguing that they „did not need a VR headset as a support“. 2/46 (4.4%) said that they were not feeling well and therefore did not want the headset. Another 2/46 (4.4%) refused the headset because they experienced severe dizziness before the operation. 2/46 (4.4%) had very poor knowledge of German or English, which may have been the reason why the benefits of the VR headset could not be communicated.

2.2 Study design

Patients were screened via the operation schedule. The same senior physician (PS) selected operations that were suitable for interventions with VR. The deciding factor for the choice was the surgical area. All operations under local anaesthesia that were not in the direct anatomical area of the VR headset were selected, that is all operations that were not in the ophthalmic or nasal bridge region. It was decided not to test the VR headset in only one operation type for example nasal endoscopy, but in many different ones. This was done to investigate whether the area of operation plays a role in the use and influence of the VR headset. Surgical procedures, which were performed in this study are listed in Table 1.

Table 1 Surgical procedures performed during the study
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The patients were then asked by the same researcher (LT) in the waiting room whether they would like to participate in the study and were informed verbally and in writing about VR headsets, the advantages and disadvantages as well as the risks. The patients who did not know what VR headsets were received an explanation with particular emphasis on the fact that the headset closes off at the sides and one can only see what is shown in the headset, as this is a major difference to a regular TV. The VR headset was also used as visual aid during the explanations, so that the patient could see them in advance, albeit without turning on the headset. Afterwards, a medical questionnaire was filled out by the patients to minimise the risk of VR sickness. This manifests itself as discomfort, nausea, or headaches. It can also lead to movement instability. According to studies, VR sickness develops when the proprioception deviates from what is visually perceived. This deviation is interpreted by the vestibular system as a disturbance and produces the symptoms described. VR scenarios with many camera movements and actions, such as rollercoaster rides, lead to stronger irritations than calm scenarios Lawson (2014). Therefore, the questions were adapted to the contraindications of the VR headsets manual and were thus exclusion criteria for participation in the study. The following factors were asked: influence of alcohol, digestive problems, severe headaches, migraines, dizziness or severe earaches. In addition, it was determined whether the patients had experienced dizziness, epileptic seizures, convulsions, spasms of the eye muscles, unconsciousness in connection with flashes of light, TV, video games or virtual reality in the past. If this was the case, these patients were excluded from taking part in the study. In addition, patients were asked whether they wore a pacemaker, hearing aid or defibrillator. Once these aspects had been clarified, the patients in the VR group completed the STAI and the pain scales.

The patients in the control group were also asked in the waiting area whether they were willing to participate in the study and whether they would be willing to fill out the STAI questionnaire and the pain scales. The handling of the questionnaires and how to fill them out was explained to the VR group as well as to the control group. All patients gave their written consent to participate in the study. Patients who were minors were informed in detail and asked whether they would like to participate; written consent was given by the parents.

In the VR group, a total of 57 patients completed the questionnaires before and after surgery. Ten patients only completed the postoperative questionnaires and did not complete the preoperative questionnaire. 67 patients who wore a VR headset during surgery rated their VR experience after surgery. In the control group, 28 patients completed the questionnaires after surgery (Fig. 1).

Fig. 1
figure 1

Questionnaire procedure and group sizes

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Patients were given the VR headset in the operating room either before or after the injection of local anesthesia and before the surgical field was covered with sterile drapes (Fig. 2). The timing of putting on the VR headset in relation to the local anaesthetic injection was investigated, as fear of needle injection is a known challenge in medical interventions (McLenon and Rogers 2019). Therefore, it should be investigated whether there was any difference in the patients experienced intraoperative anxiety depending on if they saw the application of local anaesthetic (via needle application, as the VR headset was not yet on) or not (as the patient already had the VR headset on).

During the procedures, the VR headsets were connected to a tablet via Bluetooth through which the study team could monitor what the patient was seeing in real time. The CE certified VR headset (Pico G2 4 K) and the tablet were purchased from SyncVR (Utrecht, Netherlands), the VR software was purchased from HypnoVR (Strassbourg, France) (Fig. 3).

Fig. 2
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Patient wearing VR headset during neck surgery under local anaesthesia

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Fig. 3
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VR headset (Pico G2 4 K) and tablet used in the study

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At the beginning of the procedure, patients were able to choose between several programs. The programs were virtual tours through different animated landscapes, in which the user moved through the chosen scenery, similar to a walk. The patients were asked, prior to the procedure, which landscape they would like to see: a forest, a beach, an underwater landscape, a winter landscape, or a landscape which is called “4 seasons” by the manufacturer and changed accordingly from summer to winter.

The programs had no specific duration. After 17 min of the play time an endless loop started. There were no sounds or music through the VR headset, so that the effect of the visual impression through the VR headset could not be influenced by the audio impression. In addition, it was possible for the patient to communicate with the surgeon for the whole duration of the surgery. The program could be stopped at any time depending on the duration of the operation, there was no set duration or fixed end of the program. The patients could also say at any time that they wanted the headset removed and this was done immediately.

Patients wore the VR headset between 4 and 77 min, with a mean of M = 25.7 min (SD = 20.1). The forest landscape was chosen most frequently by 33% (22/67) of the patients; the exact details are shown in Fig. 4.

Fig. 4
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Frequency of the selected VR scenarios

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Three patients had to have their headset removed during the operation due to dizziness, watery eyes or the headset falling off in the side position. The early removal of the headset before surgery completion occurred between 15 and 31 min after the surgery began. Accordingly, the patients had enough time to get an impression of the VR experience and to evaluate it. Therefore, patients who prematurely removed their headsets were not excluded from the study. In another patient, the headset slipped off during the operation, so that evaluation of the VR experience was not possible. With regards to the technical procedures and programs of the VR headset, no problems occurred during the operation.

2.3 Questionnaires

The preoperative and intraoperative anxiety and pain scores were recorded. Anxiety was measured using the State-Trait Anxiety Inventory for Adults [STAI-AD]. A score between 20 (lowest possible anxiety) and 80 (highest possible anxiety) could be achieved (Laux et al. 1981). The situational anxiety (state anxiety) and the anxiety as a trait (trait anxiety) were recorded. When preoperative or intraoperative anxiety is mentioned in the following, it always refers to the state anxiety at the particular time. When trait anxiety is mentioned, it is referred to as such. Pain was assessed using a pain scale (VAS) ranging from 0 (no pain at all) to 10 (highest possible pain). Here, the current pain intensity and the average pain intensity over the last 4 weeks were examined. The second question was added to enable a better interpretation of possible statistical outliers in the context of the pain intensity of the last 4 weeks. Finally, patients assessed their VR experience in terms of (1) helpfulness to be calm and to relax during the operation, (2) reduction of anxiety for a future operation when using a VR headset and (3) recommendation of a VR headset during an operation to others.

In comparison to other studies, not only the general satisfaction with the procedure (Gray et al. 2021) or the VR headset (Dings et al. 2020) but also more detailed aspects of the experience were examined. The aspect if (1) the patients perceived the VR headset as relaxing was surveyed, to evaluate whether there are correlations between the subjective assessment of the effect of the headset and the scores measured in the STAI. Aspect (2) referring to the reduction of anxiety for a future operation was added because other studies have already asked future-oriented questions regarding VR headsets in order to be able to draw conclusions about the evaluation of the VR experience (Chang et al. 2021; Chan and Scharf 2017). It can make a statement about whether the use of the headsets also could have an influence on future operations. Patients were able to rate certain statements to the mentioned aspects on a 4-point Likert scale from “not at all” to “very much”. This response scheme was chosen because the STAI also has 4 response levels, so that the patients did not have to adjust.

2.4 Data collection

Patients were given the preoperative anxiety questionnaires and the pain scales in the waiting area immediately before surgery. The intraoperative anxiety and pain score were collected postoperatively immediately after leaving the changing room. The patients were instructed to put themselves back in the situation of the operation again and to fill in the questionnaire according to their anxiety and pain during the operation. All patients were guided through the process by the same researcher (LT).

2.5 Data analysis

The aim of these investigations was to find out whether VR headsets influence patient’s anxiety and pain level during surgical procedures under local anaesthesia in the head and neck area. The data were analysed using SPSS Statistics (Version 28.0.1.0). Correlations were analysed by Kendall’s Tau, as all data are ordinally scaled. A paired sample t test was calculated for the examination of differences in intraoperative anxiety within the VR group from preoperative to intraoperative. To examine the differences in intraoperative anxiety between the groups, the t test or Mann-Whitney U-test was used, depending on whether the prerequisites of normal distribution and homogeneity of variance were fulfilled or not. To investigate whether the timing of the injection of local anaesthesia had an influence on the anxiety and pain level, these two were defined as dependent variables. The independent variables were the wearing of the VR headset during surgery and the time of putting them on. The prerequisites were fulfilled to conduct a t test to investigate this aspect. In the subgroup analysis of patients with pre- or intraopeative anxiety, patients with a pre- and/ or intraoperative state anxiety score of ≥ 39 were included. This cut point was set because a score of 39–40 was detected in literature to recognise clinically significant symptoms for the state anxiety scale (Knight et al. 1983; Addolorato et al. 1999).

To find out whether the intraoperative anxiety of the patients differed depending on the surgical area, group comparisons were conducted. The dependent variable was intraoperative anxiety, and the independent variables were the different surgical sites. Since the prerequisites for an ANOVA were not met, the Kruskal-Wallis test was performed to investigate if there were differences between the surgical sites.

There was a total of six items that could be summarised into the following three categories: (1) support to calm down and relax the patient during the operation through the VR headset, (2) reduction in anxiety for a future operation when using the VR headset and (3) recommendation of the VR headset during an operation to others. The exact items can be found in Table 2. Two items each could be summarised on the basis of the above-mentioned superordinate categories. This could be done due to sufficient Cronbach’s alpha values, which were all above the targeted value of 0.8 (Döring et al. 2015). The new variables were “relaxing influence” (α = 0.94), “anxiety reduction before future surgery” (α = 0.94) and “recommendation” (α = 0.97). All verbal or written statements made by the patients about the VR experience were documented and put into context with the quantitative results at appropriate points.

Table 2 Items of the VR questionnaire. The patiens had to rate each statement on a scale from [1] not at all to [4] very much. The instruction can can be found in line 1
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2.6 Exclusions

Before the final evaluation, 8 patients in the VR group had to be excluded because relevant data were missing or they filled out the questionnaires in such a way that the scores could not be reliably determined, despite prior explanation. To create better comparability between the groups, 13 patients were excluded in the control group at follow-up because the surgical site would not have permitted the use of the headset and 7 patients because they refused the VR headset in advance. After the exclusions described above, 95 patients remained for evaluation.

3 Results

3.1 Correlations

In the VR group there was a highly significant correlation between preoperative anxiety and trait anxiety with a medium to strong effect (rτ (50) = 0.40, p = .000). Furthermore, there was a highly significant correlation between trait anxiety and intraoperative anxiety with a weak to medium effect (rτ (52) = 0.26, p = .009). In addition, there was a highly significant correlation with a medium to strong effect between pre- and intraoperative anxiety (rτ (57) = 0.38, p = .000). In conclusion, patients who describe themselves as more anxious in the trait questionnaire tend to be more anxious before and during surgery. In addition, patients who are more anxious before the operation also tend to have higher anxiety scores during the operation.

Regarding pain, there was a highly significant correlation between preoperative pain and pain in the last four weeks before surgery with a strong effect (rτ (52) = 0.62, p = .000).

There were no correlations between state anxiety and age, pain, or duration of surgery. Nor was there any correlation between the subjectively rated VR experience and anxiety, age, pain or duration of surgery. In the control group, there were also no correlations between intraoperative anxiety, age, pain during surgery and pain in the last four weeks. The number of cases in the control group was too small for the evaluation of the preoperative anxiety scores (N = 2).

3.2 Anxiety before and during surgery in the VR Group

A paired t test (prerequisites satisfied) was performed to compare preoperative and intraoperative anxiety scores for patients who experienced VR content. The evaluation showed higher preoperative anxiety scores (M = 39.8, SD = 10.2) than intraoperative anxiety scores (M = 35.7, SD = 10.0, p = .002). This difference proved to be significant (t (57) = 3.31, p = .002). However, 20.9% (14/67) patients reported higher intraoperative tension than before surgery. Those patients who showed higher anxiety intraoperatively than preoperatively were 57.1% male and 42.9% female with a mean age of M = 50.1 (SD = 23.3).

3.3 Intraoperative anxiety and pain between VR and control group

The control group had a higher mean value (M = 42.1, SD = 12.9) and median (Mdn = 43.5) for intraoperative anxiety than the VR group (M = 35.6, SD = 9.6, Mdn = 33.0). The range of anxiety scores was also higher in the control group (Fig. 5). A Mann-Whitney U test was performed, as the prerequisites for a t test were not fulfilled. A significant difference between patients in intraoperative anxiety of the VR group (MRank = 43.9) and control group (MRank = 57.7) was found (U = 666.00, Z = -2.22, p = .026, r = − .228).

Fig. 5
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Distribution of intraoperative anxiety in the VR group and control group [STAI-AD]. The interquartile ranges and medians are shown

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When investigating whether there was a difference in intraoperative pain, no significant difference between patients in the VR group (MRank = 45.3) and the control group (MRank = 49.4) was found (U = 781.500, Z = − 0.689, p = .491).

3.4 Intraoperative anxiety and timing of the injection of local anesthesia

A t test (prerequisites fulfilled) was conducted to investigate the timing of putting on the VR headset in relation to the local anaesthetic injection. The evaluation showed slighty lower intraoperative anxiety scores in the group, in which patients already wore the VR headset during injection of local anesthesia (N = 31, M = 34.4, SD = 10.17) than patients who received the headset after injection of local anesthesia (N = 34, M = 36.6, SD = 9.26). The t test showed no significant result here (t (63) = − 0.88, p = .382). Similarly, no significant effect for intraoperative pain between the two groups was found (t (61) = − 0.51, p = .614).

3.5 Intraoperative anxiety and surgical site

When examining intraoperative anxiety in the VR group in relation to the surgical area, five anatomical areas were identified as shown by the categories in Table 1: Neck area, ear area, intraoral, intranasal, and other areas. The highest average intraoperative anxiety was in patients who underwent an intraoral procedure (N = 14, M = 39.3, SD = 9.44) and the lowest in patients who underwent intranasal procedures (N = 2, M = 28.0, SD = 7.1). Kruskal-Wallis test was used to investigate whether there was a difference in central tendency between the different surgical areas in intraoperative anxiety. This did not show a significant result (H (4) = 5.122, p = .275). In the control group, as well, the Kruskal Wallis test showed no significant result with regard to intraoperative anxiety (H (4) = 3.915, p = .418).

3.6 Intraoperative anxiety and different VR programs

Patients could choose between several VR scenarios. The distribution is shown in Fig. 4. Kruskal-Wallis test was used to analyse whether there was a difference in intraoperative anxiety between the different scenarios seen. No significant difference in the central tendency was observed between the different VR programs viewed (H (4) = 2.479, p = .648).

3.7 Analysis of patients with clinically signficant pre- and/ or intraoperative anxiety

It was found that 22/67 (32.8%) in the VR group and 17/28 (60.7%) in the control group experienced clinically significant anxiety during surgery. The gender distribution of these patients was balanced in both groups as shown in Table 3. In the VR group 29 patients had clinically signficant anxiety preoperatively and in 20/29 (69%) anxiety decreased from preoperative to intraoperative.

Table 3 Demographics of patients with clinically significant intraoperative anxiety
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Patient assessment of the VR experience.

Another important aspect was to find out how patients rated their VR experience subjectively regarding relaxation through the VR headset, reduction of anxiety for future surgeries if they knew they were going to receive a VR headset and recommendation of a VR headset to others.

The results showed that 47/67 (70.2%) patients selected a value of 3 or higher in the category “relaxing influence“ of the VR headset. Since this was a 4-point agreement scale, it can be concluded that these patients found the VR headset calming during the operation. In the category “anxiety reduction before future surgery”, 48/67 (71.7%) selected a value of three or higher. Finally, 58/67 (86.6%) patients selected a value of three or higher in the category “recommendation”, which means that these patients would be more likely to recommend the use of a VR headset during surgery (Fig. 6).

Fig. 6
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Patient assessment (N = 67) of the VR experience

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When analysing those patients with clinically significant pre- and/ or intraoperative anxiety, it was found that in the categories “relaxing influence” and “anxiety reduction before future surgery” 24/35 (68.6%) selected a value of 3 and higher. In the category “recommendation”, 31/35 patients (88.6%) gave a score of 3 or higher.

Of those patients who did not rate their VR experience positively, meaning that on average they gave a score of less than three, four patients said that they did not like the scenarios they saw or noted poor quality. Three patients reported that they would have liked to have seen real landscapes rather than animated ones, although two rated their VR experience as rather positive. As mentioned earlier, there were no correlations between the variables for subjective evaluation of the VR experience with neither preoperative nor intraoperative anxiety, trait anxiety or intraoperative pain. Furthermore, five patients said that the headset did not fit properly, that they had to be readjusted intraoperatively or that they fell off. Two of these patients rated their VR experience as rather negative and one patient could not give a rating at all.

4 Discussion

This study investigated the intraoperative use of a VR headset as a method of distraction during operations under local anaesthesia in the ENT field. It was able to show that the use of VR is also feasible in the ENT field and is rated positively by the majority of patients. 86.6% of patients said they would recommend VR distraction during surgery and 71.7% said they would be less anxious about future surgery if they knew they would receive a VR headset. These results are in line with previous studies which have already shown that VR is well tolerated during operations under local anaesthesia in other fields, such as joint replacement surgery (Chan and Scharf 2017). In the case of head and neck surgery, the few studies that exist on this topic showed important results referring to the procedure satisfaction. Although there was no significant difference in procerdural satisfaction in either study, in the study by Gray et al. (2021) 69.51% of patients stated that they found it better wearing a VR headset during surgery under local anaesthesia than no VR headset. And also, in the study by Chang et al. (2021), 100% of the patients in the VR group stated that they would prefer VR again for a similar procedure in the future. Regarding anxiety levels, a significantly lower level of intraoperative anxiety was observed in the VR group compared to the control group in this study. This is consistent with the findings of Gray et al. (2021). It is noteworthy that there was no correlative relationship between the anxiety score (neither preoperative nor intraoperative nor trait anxiety) and the general evaluation of the VR headset experience. However, 88.6% of patients with clinically significant pre- and/or intraoperative anxiety stated that they would recommend VR during surgery. Thus, we conclude that VR headsets are not particularly suitable only for anxious patients, but that the majority of this subgroup rated them positively.

Lower intraoperative anxiety scores were found in the VR group compared to the control group, suggesting that the patients may have been distracted by the VR headset. The effectiveness of the distraction by the VR headset could be due to the three-dimensionality of the content that the patients saw. It made the landscapes appear less plane and hence more realistic. This supported the intended illusion of not being in a hospital situation and distracted the patients from the actual situation. This effect could be reinforced even more by the fact that patients wearing a VR headset could no longer see what was happening around them while wearing the headset. This may have enabled them to further immerse themselves into the content they were watching. In comparison to previous studies, the anxiety-reducing effect of the VR headset was shown even though these were single operations and not repetitive interventions. Thus, the patients did not know what to expect, which could have led to more stress, as suspected in a previous study (Dings et al. 2020).

In this study, there was no significant difference in intraoperative anxiety if patients were already wearing the VR headset during the local anaesthetic injection or not. One explanation could be that the fear of needles decreases with age and that women are more likely to be affected (McLenon and Rogers 2019). Since the sample of the present study was sex-balanced and the average age in the VR group was middle-aged (M = 52.7) rather than young, it is possible that this is the reason why the time at which the VR headset was put on did not make a decisive difference. For a sample similar to that of the present study, however, the results can be interpreted as an indication that the headset can be put on independently of the local anaesthetic injection, either during the preparation time before the injection as well as in the time between the injection and the beginning of surgery. Thus, the period to put on the VR headset is larger which provides a certain flexibility.

Previous studies have shown mixed results on the impact of VR on patients’ pain. A randomised trial with 50 patients undergoing tooth extraction under local anaesthesia found that the VR group had significantly less pain than patients in the control group (Sweta et al. 2019). Other studies using VR for head and neck surgery showed no significant difference in pain between the VR group and the control group (Gray et al. 2021; Chang et al. 2021). This is consistent with the results from this study, as no difference in pain was found here either. However, in the present study, this could also be due to the fact that many different operations in the ENT area were examined, of which some were more painful than others. Therefore, a direct comparison with other studies, which often investigated the same surgery, is not possible.

Another aim of the study was to find out whether certain surgical areas are more or less suitable for the use of a VR headset than others. Neither in the VR group nor in the control group could a difference be found with regard to intraoperative anxiety related to the anatomical surgical areas. It seems to have no influence on intraoperative anxiety whether the surgical site is close to the headset or further away. Thus, it can be concluded that the VR headset can be used for all areas in head neck and surgery that are not covered by the VR headset. It is important to ensure that the headset fits well so that it does not slip off when patients are lying on their sides. It also makes sense to use the smallest possible VR headset so that it covers as small an area of the face as possible and does not hinder the surgeon during procedures that are close to the headset. With even smaller VR headsets it would be possible to use them for more procedures.

Although the patients in the VR group had a lower intraoperative anxiety score than patients without a VR headset, 28.4% patients refused the headset in advance for various reasons. Therefore, VR headsets cannot be used as a generalised method of distraction for all patients. The results also showed that some patients who first wanted a VR headset changed their mind in the operating room. In addition, three patients had to have their headsets removed during the operation due to side effects. This emphasises how important it is to give the patient the opportunity to voice complaints during the whole VR treatment if side effects or discomfort occur and to communicate to the patient in advance that the headset can be removed at any time. Furthermore, if the VR headset is used in the operating room, where surgical procedure is sterile, the processes must be designed in such a way that if the headset needs to be removed earlier, a member of staff is available to do so. This underlines the importance of continuous patient contact and repeated patient consent to use the VR headset, as well as the need to think through the use of VR in terms of organisational processes.

5 Limitations

The present study is influenced by some methodological limitations. First, it should be mentioned that there was no randomisation in the allocation of the groups. Furthermore, there were different surgical procedures between and within the groups. Although comparable procedures were chosen in the VR group and the control group, these were not identical. This was done in order to find out for which areas of surgery the headset is particularly suitable, but it also leads to less comparability. When looking at the development of pre- and intraoperative anxiety scores it should be noted whether other factors may have influenced the patients’ anxiety at these two points in time. For example, the environment of the operating room or the presence of the surgeon could have influenced intraoperative anxiety. Therefore, it would be ideal to measure the preoperative and intraoperative anxiety scores in the same environment. In this study the intraoperative scores were collected postoperatively. Thus, this questionnaire was filled out in a different environment, namely directly after leaving the changing rooms and with a time difference of about 5–10 min after the operation. The questionnaires on the intraoperative scores could not be administered within the operating rooms due to the tight operating schedule. Although the patients were instructed to put themselves back into the situation of the operation, the change of environment as well as the short time difference could have led to a bias.

Looking at the development of anxiety scores it would be interesting to see whether the effect of reducing anxiety would also be present in a control group although one can already assume from the significantly lower intraoperative anxiety of the VR group compared to the control group that this would probably not be the case. Another factor that affects the comparability between and within the groups is that the patients were treated by several different surgeons.

The last point to be made is that previous experience with VR was not explicitly asked about. It was always asked in advance, during the first interview, whether the patients knew about VR and those who had used VR before mostly mentioned this, but it was not asked quantitatively in written form. Since a study showed that familarity with VR can have a moderating effect on the VR experience, this represents a limitation of the present study (Wei Wei et al. 2019).

6 Conclusion

It can be concluded that, in addition to a trusting surgeon-patient relationship and the use of sufficient local anaesthesia, the use of a VR headset as a method of distraction can further reduce the intraoperative anxiety of patients. Patients can benefit from using a VR headset independent of their preoperative anxiety level.