The use of image-guided surgery in endoscopic sinus surgery: an evidence-based review with recommendations

Physician views of artificial intelligence in otolaryngology and rhinology: A mixed methods study

Objective

The study aimed to investigate otolaryngologists' knowledge, trust, acceptance, and concerns with clinical applications of artificial intelligence (AI).

Methods

This study used mixed methods with survey and semistructured interviews. Survey was e-mailed to American Rhinologic Society members, of which a volunteer sample of 86 members responded. Nineteen otolaryngologists were purposefully recruited and interviewed until thematic saturation was achieved.

Results

Seventy-six respondents (10% response rate) completed the majority of the survey: 49% worked in academic settings and 43% completed residency 10 or fewer years ago. Of 19 interviewees, 58% worked in academic settings, and 47% completed residency 10 or fewer years ago. Familiarity: Only 8% of survey respondents reported having AI training in residency, although 72% had familiarity with general AI concepts; 0 interviewees had personal experience with AI in clinical settings. Expected uses: Of the surveyed otolaryngologists, 82% would use an AI-based clinical decision aid and 74% were comfortable with AI proposing treatment recommendations. However, only 44% of participants would trust AI to identify malignancy and 53% to interpret radiographic images. Interviewees trusted AI for simple tasks, such as labeling septal deviation, more than complex ones, such as identifying tumors. Factors influencing AI adoption: 89% of survey participants would use AI if it improved patient satisfaction, 78% would be willing to use AI if experts and studies validated the technologies, and 73% would only use AI if it increased efficiency. Sixty-one percent of survey respondents expected AI incorporation into clinical practice within 5 years. Interviewees emphasized that AI adoption depends on its similarity to their clinical judgment and to expert opinion. Concerns included nuanced or complex cases, poor design or accuracy, and the personal nature of physician-patient relationships.

Conclusion

Few physicians have experience with AI technologies but expect rapid adoption in the clinic, highlighting the urgent need for clinical education and research. Otolaryngologists are most receptive to AI "augmenting" physician expertise and administrative capacity, with respect for physician autonomy and maintaining relationships with patients.

Level of Evidence

Level VI, descriptive or qualitative study.

Development of an optimized preoperative computed tomography imaging checklist for endoscopic sinus surgery utilizing a systematic review of the literature and the modified Delphi method

BACKGROUND

Critical review of computed tomography (CT) imaging is essential in preoperative planning for endoscopic sinus surgery. In this study, we used a systematic review and a modified Delphi method to develop a comprehensive checklist that facilitates preoperative review of sinus CT imaging.

METHODS

We performed a systematic review of PubMed, Embase, CINAHL, Cochrane, and Web of Science databases to identify existing checklists developed to evaluate sinus CT imaging. An inclusive list of items from these checklists was compiled and a modified Delphi methodology was used to assign ranked priority. The Delphi process involved 14 rhinologists and had three phases: an initial survey with Likert priority (scale of 1-9) and two rounds of live discussions followed by survey to confirm consensus.

RESULTS

Ninety-seven possible checklist items were identified from a systematic review and panelist input. On initial survey, 63 items reached a consensus score of 7+, and 13 items had near consensus scores between 6 and 7; two of these 13 borderline items were retained after subsequent panelist discussion. The resulting items were consolidated into an 11-item disease checklist and a 24-item anatomical checklist; the anatomical checklist was further divided into six subsections: nasal cavity, maxillary, ethmoid, sphenoid, frontal, skull base, and orbit. Additionally, panelists identified six core aspects of patient history to consider prior to surgery.

CONCLUSIONS

After establishing content validity through a systematic literature review and a modified Delphi method, we developed a comprehensive checklist for preoperative sinus CT imaging review; implementation and evaluation of validity among trainees will suggest overall utility.

Clinical and economic benefits of image-guided system in functional endoscopicsinus surgery: a retrospective chart review study in China

BACKGROUND

Image-guided system (IGS) has been gradually applied in the field of rhinology, making functional endoscopic sinus surgery (FESS) a truly minimally invasive and precise surgery. This study was based on real-world data from China hospitals and aimed to evaluate the clinical and economic benefits of the IGS navigation system in FESS.

METHODS

This was a two-center retrospective chart review of patients with chronic rhinosinusitis who underwent FESS, including open frontal sinus between July 1, 2018 and December 31, 2019 in China. The intervention group consisted of 100 patients who underwent FESS with the IGS navigation system (IGS group), and the control group consisted of 100 patients who underwent conventional FESS (Non-IGS group). Data were collected from surgical notes and hospital medical records. The primary endpoints for clinical effectiveness and safety were avoid rehospitalization due to bleeding, avoid reoperation due to bleeding, and avoid reoperation due to recurrence.

RESULTS

There were no cases of rehospitalization due to bleeding, reoperation due to bleeding, and reoperation due to recurrence in the IGS group, with an avoidance rate of 100%. In the non-IGS group, there were four cases of rehospitalization and reoperation due to bleeding, with an avoidance rate 96.00% (P = 0.121). No cases of reoperation due to recurrence were in the non-IGS group. The total hospitalization cost was 17,391.51 CNY in the IGS group and 17,742.41 CNY in the non-IGS group per patient, with no statistical difference between the two groups (P = 0.715). Compared with the non-IGS group, the IGS group had an overall cost saving of 350.90 CNY per patient. Although the procedure-related medical costs of IGS group were increased by 1,286.12 CNY compared with the non-IGS group, this was more than offset by other costs.

CONCLUSION

The results of the study indicated that the IGS may avoid occurrence of rehospitalization and reoperation due to postoperative bleeding. Although the use of navigation technology increased the cost of surgery, its clinical effectiveness brought other medical cost savings, resulting in no significant difference in the overall cost of navigation surgery compared to conventional surgery. The IGS should be considered cost-effectiveness in the treatment of FESS.

Olfactory Neuroblastoma: Surgical Treatment Experience of 42 Cases

Objective

Our purpose was to estimate the safety and effectiveness of the endoscopic endonasal approach (EEA) in olfactory neuroblastoma (ONB) and determine whether preservation of the dura and olfactory bulb could be considered in selected patients.

Methods

We retrospectively reviewed patients diagnosed with ONBs between July 2010 and June 2021 at our institution, and collected data on demographic, disease stage, surgical approach, overall survival (OS), disease-free survival (DFS), and postoperative complications.

Results

The study sample included 42 patients (8 treated for recurrence and 34 initial cases), 28 of which were men and 14 were women with a median age of 47.19 years. The mean duration from the beginning of treatment and follow-up time was 8.91 and 51 months, respectively. Among the 42 patients, 32 had unilateral lesions, and the rest had bilateral lesions. Patient symptoms were predominantly nasal, and four patients presented without any symptoms. The modified Kadish staging was A in three patients, B in 14 patients, C in 17 patients, and D in 8 patients. According to the preoperative examinations, five patients had cervical lymph node metastasis, and no patients had distant metastases. EEA was used in 38 patients, cranioendoscopic approach in 3, and open craniofacial approach in 1. The 5-year OS and DFS rates were 89.1 and 79.2%, respectively. The 2-year OS and DFS rates were both 89.1%. The overall surgical complication incidence was 9.52% (one cerebrospinal fluid rhinorrhea, one cervical hematoma, and two epileptic seizures).

Conclusion

The present results support the importance of earlier treatment for advanced ONB and the fact that it is safe and efficacious to treat ONBs via EEA. The preservation of the dura can be considered for select patients—specifically those without skull base involvement and who underwent postoperative comprehensive therapy.

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

Is There a Role for Intraoperative Navigation During Cochlear Implantation in Patients With Aural Atresia?

OBJECTIVE

Concurrent bilateral congenital aural atresia (CAA) and profound sensorineural hearing loss are rare. While not a contraindication, temporal bone and cochleovestibular abnormalities are an important consideration for cochlear implantation (CI) candidacy. Intraoperative image-guided surgical navigation may play a role during CI surgery in patients with complex anatomy, such as CAA.

PATIENT

One patient with bilateral CAA, cochlear dysplasia, speech delay, and profound sensorineural hearing loss underwent candidacy evaluation for cochlear implantation.

INTERVENTIONS

Cochlear implantation using intraoperative image-guided navigation.

MAIN OUTCOME MEASURES

(1) Registration accuracy, (2) surgical outcomes, (3) audiometry.

RESULTS

A four-year-old girl with complete bilateral CAA and profound sensorineural hearing loss successfully underwent a right transmastoid approach for CI using intraoperative image-guided navigation with sticker fiducials. Bony landmarks included the mastoid tip, tympanomastoid suture line, helical root, zygomatic root, and lateral brow. A registration accuracy of 0.9 mm was achieved. There were no intraoperative or immediate postoperative complications. Postoperatively, Neural Response Imaging was confirmed on 9 electrodes and behavioral testing demonstrated Ling-6 access at 30 dB. On most recent follow-up, she has demonstrated gains in language development, vocalizations, and uses total communication in a hearing-impaired educational environment.

CONCLUSIONS

Children with CAA and profound sensorineural hearing loss may be candidates for cochlear implantation, with successful outcomes in the setting of complex anatomy. Surgical navigation may play a role corroborating intraoperative landmarks.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Augmented reality-enhanced navigation in endoscopic sinus surgery: A prospective, randomized, controlled clinical trial

OBJECTIVE

Endoscopic sinus surgery represents the gold standard for surgical treatment of chronic sinus diseases. Thereby, navigation systems can be of distinct use. In our study, we tested the recently developed KARL STORZ NAV1 SinusTracker navigation software that incorporates elements of augmented reality (AR) to provide a better preoperative planning and guidance during the surgical procedure.

METHODS

One hundred patients with chronic sinus disease were operated on using either a conventional navigation software (n = 52, non-AR, control group) or a navigation software incorporating AR elements (n = 48, AR, intervention group). Incidence of postoperative complications, duration of surgery, surgeon-reported benefit from the navigation system and patient-reported postoperative rehabilitation were assessed.

RESULTS

The surgeons reported a higher benefit during surgery, used the navigation system for more surgical steps and spent longer time with preoperative image analysis when using the AR system as compared with the non-AR system. No significant differences were seen in terms of postoperative complications, target registration error, operation time and postoperative rehabilitation.

CONCLUSION

The AR enhanced navigation software shows a high acceptance by sinus surgeons in different stages of surgical training and offers potential benefits during surgery without affecting the duration of the operation or the incidence of postoperative complications.

LEVEL OF EVIDENCE

1b.

Working towards consensus in the management of pediatric chronic rhinosinusitis in cystic fibrosis

OBJECTIVE

The prevalence of chronic rhinosinusitis (CRS), defined by mucosal thickening on imaging, approaches 100% in the cystic fibrosis (CF) population. CRS is associated with significant morbidity in CF, including its ability to trigger pulmonary exacerbations. CRS in CF is typically managed by pediatricians, otolaryngologists and pulmonologists. This survey evaluates the variance in practice patterns of CRS in CF amongst specialists.

METHODS

This is a cross-sectional, electronic survey in which maximum variation purposive sampling was used by a multi-disciplinary group of pediatric, otolaryngology and pulmonology providers in order to select a survey population with expertise in CRS in CF patients. The survey was distributed to 381 practitioners from September to October 2019.

RESULTS

175 participants responded (45% response rate). Ten (of 54) statements achieved 75% consensus agreement. Consensus statements included: The decision to pursue surgical intervention for CRS in CF is a multi-disciplinary approach (94%; n = 146); maximal medical management should include nasal saline irrigation (93%; n = 142), topical steroids (75%; n = 117), maximal medical management should not include intravenous steroids (79%; n = 122); image guidance in surgery is necessary for all surgery involving the frontal sinuses (77%; n = 43), and all revision surgery(80%, n = 45); the appropriate setting for sinus surgery in a CF patient varies depending on patient presentation (89%; n = 133); post-operative regimen should include nasal saline (93%; n = 137); but does depend on the severity of disease discovered intra-operatively (84%; n = 124); post-operative antibiotics should be guided by intra-operative culture data (82%; n = 121).

CONCLUSIONS

There is a great deal of variation amongst specialists in the treatment of CRS in CF, however 10 statements met consensus criteria and should be considered when forming clinical care guidelines in this population.

Image-Guided Surgery and Intraoperative Imaging in Rhinology: Clinical Update and Current State of the Art

INTRODUCTION

Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes.

OBJECTIVES

Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies.

METHODS

English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advances.

CONCLUSIONS

As image guidance and intraoperative imaging systems have advanced, their applications in sinus and skull base surgery have expanded. Both technologies offer invaluable real-time feedback on the status and progress of surgery, and thus may help to improve the completeness of surgery and overall outcomes. Recent advances such as augmented and virtual reality offer a window into the future of IGS. Future advancements should aim to enhance the surgeon's operative experience by improving user satisfaction and ultimately lead to better surgical results.

Application of holographic augmented reality for external approaches to the frontal sinus

BACKGROUND

External approaches to the frontal sinus such as osteoplastic flaps are challenging because they require blind entry into the sinus, posing risks of injury to the brain or orbit. Intraoperative computed tomography (CT)-based navigation is the current standard for planning the approach, but still necessitates blind entry into the sinus. The aim of this work was to describe a novel technique for external approaches to the frontal sinus using a holographic augmented reality (AR) application.

METHODS

Our team developed an AR system to create a 3-dimensional (3D) hologram of key anatomical structures, based on CT scans images. Using Magic Leap AR goggles for visualization, the frontal sinus hologram was aligned to the surface anatomy in 6 fresh cadaveric heads' anatomic boundaries, and the boundaries of the frontal sinus were demarcated based on the margins of the fused image. Trephinations and osteoplastic flap approaches were performed. The specimens were re-scanned to assess the accuracy of the osteotomy with respect to the actual frontal sinus perimeter.

RESULTS

Registration and surgery were completed successfully in all specimens. Registration required an average of 2 minutes. The postprocedure CT showed a mean difference of 1.4 ± 4.1 mm between the contour of the osteotomy and the contour of the frontal sinus. One surgical complication (posterior table perforation) occurred (16%).

CONCLUSION

We describe proof of concept of a novel technique utilizing AR to enhance external approaches to the frontal sinus. Holographic AR-enhanced surgical navigation holds promise for enhanced visualization of target structures during surgical approaches to the sinuses.

The use and cost-effectiveness of intraoperative navigation in pediatric sinus surgery

OBJECTIVES/HYPOTHESIS

There are consensus statements about when to use intraoperative navigation (IN) in adult sinus surgery. However, no corresponding guidelines exist for pediatrics. Our objectives included: 1) assess the demographic and operative factors associated with IN use and 2) calculate the cost-effectiveness of IN use.

STUDY DESIGN

Retrospective chart review.

METHODS

One hundred nineteen pediatric patients undergoing sinus surgery between 2003 and 2016 were reviewed. Demographic and surgical factors were collected from medical records. Costs associated with use of IN were gathered from billing records.

RESULTS

Of the 119 patients, 60 underwent sinus surgery with navigation (wIN) and 59 underwent surgery without navigation (sIN). Children in the wIN group had more complex surgeries with more sinuses opened (P = .008). Individual attending surgeon and presence of trainee were associated with increased use of IN (P < .001 for both). IN resulted in a median of 31.5 minutes longer surgical time (P < .001). IN had an incremental cost/effectiveness ratio (ICER) of $22,378 for each year without revision surgery for patients with acute disease. However, for patients with chronic disease, the probability of undergoing a second surgery was the same between wIN and sIN groups, and navigation was not cost-effective (ICER of -$3,583).

CONCLUSIONS

IN use did not decrease complications or rates of revision surgery. It was used primarily as an educational tool or to increase confidence in intraoperative identification of landmarks. However, the use of IN added surgical time and was not cost-effective. Further research must be completed to determine when IN is indicated in pediatric sinus surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 2019.

Use of Mixed Reality Visualization in Endoscopic Endonasal Skull Base Surgery

BACKGROUND

Neuronavigation systems assist with spatial orientation during endoscopic transnasal skull base surgery, but they require a correlation of 3-dimensional (3D) views with 2-dimensional (2D) radiology studies.

OBJECTIVE

To outline an initial experience with a novel technology platform that provides intraoperative navigation using 3D reconstructions of patient anatomy for endoscopic surgery.

METHODS

A retrospective study of endoscopic anterior skull base and complex paranasal procedures was performed. Data from preoperative computed tomography and magnetic resonance imaging scans were fused to create 3D digital models of patient anatomy. Using the technology developed by Surgical Theater (Mayfield Village, Ohio), these reconstructions were designed to highlight particular anatomic regions of interest. The models were studied to guide the surgical approach and anticipate critical structures.

The reconstructions were linked with the navigational technology created by Brainlab (Munich, Germany) during endoscopic surgery. A dynamic image of the reconstruction was displayed alongside a matching endoscopic camera view. These 2 views could be overlaid to provide an immersive, mixed reality image of the patient's anatomy.

RESULTS

A total of 134 cases were performed. The pathologies included tumors of the anterior skull base or sinonasal cavity, inflammatory sinus disease, and cerebrospinal fluid leaks. Specific anatomic structures, such as the internal carotid arteries and optic nerves, were chosen for enhancement. Surgeons felt that the technology helped to guide the extent of bony dissection and to identify critical structures.

CONCLUSION

We describe the first clinical series of complex skull base pathologies treated using a novel mixed reality platform.

A prospective, feasibility study to evaluate the efficacy and usability of a novel drivable endoscope in patients with chronic rhinosinusitis

PURPOSE

To carry out a pilot study to evaluate the efficacy of a novel, drivable endoscope (the Peregrine™ Drivable ENT Scope), compared to standard rigid endoscopes in the access, visualization, and irrigation of the paranasal sinus anatomy.

METHODS

A prospective, multi-center, feasibility study was conducted on seventeen subjects who underwent primary functional endoscopic sinus surgery and were evaluated with the drivable endoscope and standard, rigid endoscopes (0°, 30° and 70°, as applicable). A CT scan was available for image guidance, as needed. The primary efficacy endpoint was the ability to access and visualize sinonasal anatomic landmarks. Secondary endpoints included device usability, as measured by a usability questionnaire given to surgeons postoperatively; the device's ability to irrigate the sinuses and patient reports of tolerability and pain during postoperative procedures.

RESULTS

The drivable endoscope success rate in visualizing all paranasal sinus anatomic landmarks was 55.6% better than the standard rigid endoscopes: 98.3% (178/181) versus 42.7% (76/178); p < 0.001. Surgeons rated scores of over 4 (on a 1-5 scale) for the usability of the drivable endoscope to enter the maxillary, frontal and sphenoid sinuses. The ability to irrigate the sinuses using the drivable endoscope was given a mean score of 4.3, and image quality was given a mean score of 3.4. The three patients evaluated postoperatively reported low pain and high tolerability scores with the drivable endoscope.

CONCLUSIONS

These preliminary results indicate that the drivable endoscope is effective, easy to use and highly tolerable in sinonasal endoscopy.

Perception enhancement using importance-driven hybrid rendering for augmented reality based endoscopic surgical navigation

Misleading depth perception may greatly affect the correct identification of complex structures in image-guided surgery. In this study, we propose a novel importance-driven hybrid rendering method to enhance perception for navigated endoscopic surgery. First, the volume structures are enhanced using gradient-based shading to reduce the color information in low-priority regions and improve the distinctions between complicated structures. Second, an importance sorting method based on the order-independent transparency rendering is introduced to intensify the perception of multiple surfaces. Third, volume data are adaptively truncated and emphasized with respect to the perspective orientation and the illustration of critical information for viewing range extension. Various experimental results prove that with the combination of volume and surface rendering, our method can effectively improve the depth distinction of multiple objects both in simulated and clinical scenes. Our importance-driven surface rendering method demonstrates improved average performance and statistical significance as rated by 15 participants (five clinicians and ten non-clinicians) on a five-point Likert scale. Further, the average frame rate of hybrid rendering with thin-layer sectioning reaches 42 fps. Given that the process of the hybrid rendering is fully automatic, it can be utilized in real-time surgical navigation to improve the rendering efficiency and information validity.

Applications of Augmented Reality in Otolaryngology: A Systematic Review

OBJECTIVE

Augmented reality (AR) is a rapidly developing technology. The aim of this systematic review was to (1) identify and evaluate applications of AR in otolaryngology and (2) examine trends in publication over time.

DATA SOURCES

PubMed and EMBASE.

REVIEW METHODS

A systematic review was performed according to PRISMA guidelines without temporal limits. Studies were included if they reported otolaryngology-related applications of AR. Exclusion criteria included non-English articles, abstracts, letters/commentaries, and reviews. A linear regression model was used to compare publication trends over time.

RESULTS

Twenty-three articles representing 18 AR platforms were included. Publications increased between 1997 and 2018 ( P < .05). Twelve studies were level 5 evidence; 9 studies, level 4; 1 study, level 2; and 1 study, level 1. There was no trend toward increased level of evidence over time. The most common subspecialties represented were rhinology (52.2%), head and neck (30.4%), and neurotology (26%). The most common purpose of AR was intraoperative guidance (54.5%), followed by surgical planning (24.2%) and procedural simulations (9.1%). The most common source of visual inputs was endoscopes (50%), followed by eyewear (22.2%) and microscopes (4.5%). Computed tomography was the most common virtual input (83.3%). Optical trackers and fiducial markers were the most common forms of tracking and registration, respectively (38.9% and 44.4%). Mean registration error was 2.48 mm.

CONCLUSION

AR holds promise in simulation, surgical planning, and perioperative navigation. Although level of evidence remains modest, the role of AR in otolaryngology has grown rapidly and continues to expand.

Systematic Reviews and Meta-analysis in Rhinosinusitis: a Critical Review of the Reviews

PURPOSE OF REVIEW

There has been an explosion in the number of published systematic reviews on chronic rhinosinusitis in the last decade.

RECENT FINDINGS

While the aim of these reviews in facilitating evidence-based practice is laudable, poor quality reviews may contain significant bias that can mislead a non-discerning reader. Attention therefore must be given to review methodology before implanting findings. Organisations such as the Cochrane Collaboration promote high-quality reviews, but are limited in chronic sinus disease by heterogeneous outcomes and a paucity of randomised trials.

Registration and fusion quantification of augmented reality based nasal endoscopic surgery

This paper quantifies the registration and fusion display errors of augmented reality-based nasal endoscopic surgery (ARNES). We comparatively investigated the spatial calibration process for front-end endoscopy and redefined the accuracy level of a calibrated endoscope by using a calibration tool with improved structural reliability. We also studied how registration accuracy was combined with the number and distribution of the deployed fiducial points (FPs) for positioning and the measured registration time. A physically integrated ARNES prototype was customarily configured for performance evaluation in skull base tumor resection surgery with an innovative approach of dynamic endoscopic vision expansion. As advised by surgical experts in otolaryngology, we proposed a hierarchical rendering scheme to properly adapt the fused images with the required visual sensation. By constraining the rendered sight in a known depth and radius, the visual focus of the surgeon can be induced only on the anticipated critical anatomies and vessel structures to avoid misguidance. Furthermore, error analysis was conducted to examine the feasibility of hybrid optical tracking based on point cloud, which was proposed in our previous work as an in-surgery registration solution. Measured results indicated that the error of target registration for ARNES can be reduced to 0.77 ± 0.07 mm. For initial registration, our results suggest that a trade-off for a new minimal time of registration can be reached when the distribution of five FPs is considered. For in-surgery registration, our findings reveal that the intrinsic registration error is a major cause of performance loss. Rigid model and cadaver experiments confirmed that the scenic integration and display fluency of ARNES are smooth, as demonstrated by three clinical trials that surpassed practicality.

Next-Generation Surgical Navigation Systems in Sinus and Skull Base Surgery

Over the past 25 years, rhinologists have adopted surgical navigation technology for endoscopic sinus and skull base procedures. Navigation systems often produce a wide target registration error (TRE). Ideally, next-generation systems will include a leap in target registration error reduce TRE through innovative hardware and software. Incorporation of microsensors will be another important innovation. Future systems are likely to include augmented reality, which can project overlays of critical anatomy on real-world endoscopic images. Recent trends in surgical navigation suggest a phase of rapid evolution.

Role of surgical treatment for esthesioneuroblastomas: 31-Year experience at a single institution

OBJECTIVE

This study aimed to re-assess the outcomes of different surgical methods for esthesioneuroblastoma (ENB) in a single institution, with emphasis on changes in surgical treatment with regard to endoscopic approaches in patients with ENB.

SUBJECTS AND METHODS

We retrospectively reviewed the data of 35 patients with ENB treated over the last 31 years.

RESULTS

The 5-year overall and disease-free survival rates were 66.8% and 50.8%, respectively. Disease-free survival in the endoscopic surgery group was significantly higher compared to that of craniofacial surgery group (P = 0.035). In the endoscopic surgery group, nine of 10 patients did not exhibit local failure or regional recurrence over a mean followup period of 64.3 months, which was longer than the mean time to recurrence (22.0 months) observed in this study.

CONCLUSION

Given its significant survival outcomes and high rate of local control, endoscopic surgery could be preferred as a minimally invasive treatment with potentially low morbidity and possible oncological validity for the treatment of ENB.

Educational utility of advanced three-dimensional virtual imaging in evaluating the anatomical configuration of the frontal recess

BACKGROUND

Endoscopic sinus surgery represents a cornerstone in the professional development of otorhinolaryngology trainees. Mastery of these surgical skills requires an understanding of paranasal sinus and skull-base anatomy. The frontal sinus is associated with a wide range of variation and complex anatomical configuration, and thus represents an important challenge for all trainees performing endoscopic sinus surgery.

METHODS

Forty-five otorhinolaryngology trainees and 20 medical school students from 5 academic institutions were enrolled and randomized into 1 of 2 groups. Each subject underwent learning of frontal recess anatomy with both traditional 2-dimensional (2D) learning methods using a standard Digital Imaging and Communications in Medicine (DICOM) viewing software (RadiAnt Dicom Viewer Version 1.9.16) and 3-dimensional (3D) learning utilizing a novel preoperative virtual planning software (Scopis Building Blocks), with one half learning with the 2D method first and the other half learning with the 3D method first. Four questionnaires that included a total of 20 items were scored for subjects' self-assessment on knowledge of frontal recess and frontal sinus drainage pathway anatomy following each learned modality. A 2-sample Wilcoxon rank-sum test was used in the statistical analysis comparing the 2 groups.

RESULTS

Most trainees (89%) believed that the virtual 3D planning software significantly improved their understanding of the spatial orientation of the frontal sinus drainage pathway.

CONCLUSION

Incorporation of virtual 3D planning surgical software may help augment trainees' understanding and spatial orientation of the frontal recess and sinus anatomy. The potential increase in trainee proficiency and comprehension theoretically may translate to improved surgical skill and patient outcomes and in reduced surgical time.

Advances in endoscopic surgery for small animal reproduction

Although endoscopic surgery entered its "golden era" in the mid-1980s, it is still advancing at a tremendous pace. Novel surgical techniques and devices are continuously developed and applied, and new indications (and/or contraindications) for the use of endoscopic surgery are routinely reported in the literature and subjected to systematic assessments. Although endoscopic surgery (laparoscopy in particular) has already become established as the gold standard in human medicine, it has yet to be proven as a viable alternative to open surgery in the field of veterinary medicine. The advantages of minimally invasive surgery include better intra-operative visualization, reduced postoperative pain, reduced scar formation and increased postoperative mobility. Therefore, it is reasonable to expect that the application of this will continue to expand. Small animal reproduction, a field within the broad discipline of veterinary medicine, has already recognized and begun to reap the benefits of endoscopic surgery. Herein, we retrospectively review the most recent successful novel applications of endoscopic surgery in the small animal reproduction system to provide small animal reproductive surgeons with important knowledge to help improve their own veterinarian medical practice.

[Transnasal endoscopic surgery of neoplasms in the children with the use of the CT-navigation systems]

The objective of the present article was to report the current literature data concerning the significance of and prospects for the application of the CT-navigation systems in transnasal endoscopic surgery of neoplasms localized in the nasal cavity, nasopharynx, paranasal sinuses, and the base of the skull in the children.

Current Trends in Sinonasal Imaging

As endoscopic sinus surgery (ESS) has evolved since its introduction to the United States, so has technology for imaging the sinonasal cavities. Although imaging is most frequently performed for evaluating chronic sinusitis refractory to medical therapy, its uses have expanded beyond inflammatory sinus disease. Multidetector Computed Tomography is the current workhorse for both diagnosis and preoperative planning in prospective ESS patients, while MR imaging remains a complementary tool for evaluating suspected tumors or intracranial and orbital complications of rhinosinusitis. In this article, the authors review current trends and potential future directions in the use of these modalities for sinus imaging.

Preventing and Managing Complications in Frontal Sinus Surgery

This review covers potential complications of frontal sinus surgical management and strategies for prevention of these complications. Accordingly, recent advances in frontal sinus surgical techniques are described, and the management of complications stemming both from these and traditional techniques are detailed.

Anatomic Considerations in Frontal Sinus Surgery

Comprehension of the complex anatomic variants comprising the frontal sinus outflow tract is essential for successful surgical intervention. Deviation from sound technique increases the potential for a variety of deleterious sequelae, including recurrent disease as well as catastrophic intracranial and orbital injury. Furthermore, incomplete removal of elements occluding the frontal recess can result in severe stenosis that can increase the difficulty of further interventions. This review covers anatomic considerations that should be kept in mind when performing frontal sinus surgery.

Utility of Image-Guidance in Frontal Sinus Surgery

The frontal sinus can present a challenging surgical dissection for the endoscopic surgeon. Image guidance as a surgical adjunct has become widely accepted for surgeries in this area. It can help verify vital structures and manage disorienting surgical conditions, improving surgeon confidence in performing safer and more complete surgery. It is relied upon heavily for placement of limited external frontal sinusotomies for disease beyond the endoscopic reach, and for mapping the frontal sinus for osteoplastic flap bony cuts. Its use has contributed to the expanding role of endoscopic surgical approaches for paranasal sinus inflammatory and neoplastic disease.

A Novel Augmented Reality Navigation System for Endoscopic Sinus and Skull Base Surgery: A Feasibility Study

Objective

To verify the reliability and clinical feasibility of a self-developed navigation system based on an augmented reality technique for endoscopic sinus and skull base surgery.

Materials and Methods

In this study we performed a head phantom and cadaver experiment to determine the display effect and accuracy of our navigational system. We compared cadaver head-based simulated operations, the target registration error, operation time, and National Aeronautics and Space Administration Task Load Index scores of our navigation system to conventional navigation systems.

Results

The navigation system developed in this study has a novel display mode capable of fusing endoscopic images to three-dimensional (3-D) virtual images. In the cadaver head experiment, the target registration error was 1.28 ± 0.45 mm, which met the accepted standards of a navigation system used for nasal endoscopic surgery. Compared with conventional navigation systems, the new system was more effective in terms of operation time and the mental workload of surgeons, which is especially important for less experienced surgeons.

Conclusion

The self-developed augmented reality navigation system for endoscopic sinus and skull base surgery appears to have advantages that outweigh those of conventional navigation systems. We conclude that this navigational system will provide rhinologists with more intuitive and more detailed imaging information, thus reducing the judgment time and mental workload of surgeons when performing complex sinus and skull base surgeries. Ultimately, this new navigational system has potential to increase the quality of surgeries. In addition, the augmented reality navigational system could be of interest to junior doctors being trained in endoscopic techniques because it could speed up their learning. However, it should be noted that the navigation system serves as an adjunct to a surgeon’s skills and knowledge, not as a substitute.

Augmented reality for endoscopic sinus surgery with surgical navigation: a cadaver study

BACKGROUND

Augmented reality (AR) fuses computer-generated images of preoperative imaging data with real-time views of the surgical field. Scopis Hybrid Navigation (Scopis GmbH, Berlin, Germany) is a surgical navigation system with AR capabilities for endoscopic sinus surgery (ESS).

METHODS

Predissection planning was performed with Scopis Hybrid Navigation software followed by ESS dissection on 2 human specimens using conventional ESS instruments.

RESULTS

Predissection planning included creating models of relevant frontal recess structures and the frontal sinus outflow pathway on orthogonal computed tomography (CT) images. Positions of the optic nerve and internal carotid artery were marked on the CT images. Models and annotations were displayed as an overlay on the endoscopic images during the dissection, which was performed with electromagnetic surgical navigation. The accuracy of the AR images relative to underlying anatomy was better than 1.5 mm. The software's trajectory targeting tool was used to guide instrument placement along the frontal sinus outflow pathway. AR imaging of the optic nerve and internal carotid artery served to mark the positions of these structures during the dissection.

CONCLUSION

Surgical navigation with AR was easily deployed in this cadaveric model of ESS. This technology builds upon the positive impact of surgical navigation during ESS, particularly during frontal recess surgery. Instrument tracking with this technology facilitates identifying and cannulation of the frontal sinus outflow pathway without dissection of the frontal recess anatomy. AR can also highlight "anti-targets" (ie, structures to be avoided), such as the optic nerve and internal carotid artery, and thus reduce surgical complications and morbidity.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Stereotactic anatomical localization in complex sinus surgery: A systematic review and meta-analysis

OBJECTIVE

It is recognized that stereotactic anatomical localization (SAL) is a useful tool in endoscopic sinus surgery (ESS), but it may be most beneficial for complex rather than routine sinus procedures. This review sought to determine the safety and efficacy of SAL in complex indications for ESS.

DATA SOURCES

PubMed, EMBASE, Centre for Reviews and Dissemination, and the Cochrane Library were searched from inception up to April 4, 2014.

REVIEW METHODS

English studies comparing ESS with and without SAL in complex cases were included. Complex surgery included revision surgery, inverted papilloma, extensive sinus disease, or biopsy of tumors that are not exophytic. Safety outcomes included total, major, minor, orbital, dural, and major hemorrhage complications. Efficacy outcomes included operation completion, revision surgery, and patient-reported outcomes. Meta-analysis generated fixed-effects Mantel-Haenszel odds ratios (OR) and confidence intervals (CI).

RESULTS

A total of 2,381 studies were identified, of which nine met the inclusion criteria. Meta-analyses indicated a reduction in the likelihood of total (OR = 0.58; 95% CI, 0.37-0.92), major (OR = 0.36; 95% CI, 0.18-0.75), and orbital complications (OR = 0.38; 95% CI, 0.17-0.83). There was no demonstrated benefit of SAL at reducing revision surgery (OR = 0.64; 95% CI, 0.38-1.08), major hemorrhage (OR = 0.77; 95% CI, 0.29-2.06), or minor complications (OR = 0.85; 95% CI, 0.48-1.50).

CONCLUSION

Due to the rare outcomes under investigation, the included primary studies largely lacked the power to identify a statistically meaningful effect of SAL in ESS. However, meta-analyses of primary studies demonstrated a decreased likelihood of total, major, and orbital complications in complex ESS with the use of SAL.

Does Image-Guided Surgery Reduce Complications?

Image-guided surgery (IGS) is progressively used in endoscopic sinus surgery (ESS), and surgeon comfort with the technology has increased. It remains a challenge to determine if the use of IGS in ESS leads to a reduction in surgical complications and improved outcomes. Current literature does not show a clear reduction in surgical complications. The routine use of IGS in ESS as a deterrent to medicolegal liability is not substantiated by recent reported data. There are particular situations in which IGS may be helpful, but its use is likely not required for routine ESS and seems best left to surgeon discretion.

Pitfalls in Sinus Surgery: An Overview of Complications

There is a potential for significant complications from the medical and surgical treatment of rhinosinusitis because of the intimate relationship between the paranasal sinuses and surrounding vital structures. Familiarity with the complex anatomic relationships between the skull base and other critical structures and knowledge of pharmacologic properties of commonly used medical therapies are essential for preventing serious and harmful seqsuelae. The authors hope that this review represents a valuable addition to the otolaryngologist-in-training's therapeutic armamentarium, and also serves as a reminder of the potential pitfalls for the experienced sinus surgeon.

Complication rates after functional endoscopic sinus surgery: analysis of 50,734 Japanese patients

OBJECTIVE

The complication rates associated with different types of functional endoscopic sinus surgery (FESS) remain to be fully examined.

STUDY DESIGN

Retrospective cohort study.

METHODS

We extracted data from the Japanese Diagnosis Procedure Combination database on 50,734 patients (aged ≥ 16 years) who underwent FESS for chronic rhinosinusitis between 2007 and 2013. We focused on specific types of surgery and stratified the patients into three groups: group 1 (single sinus surgery), group 2 (multiple sinus surgery), and group 3 (whole sinus surgery). Patient characteristics and early postoperative complications including cerebrospinal fluid (CSF) leakage, orbital injury, severe hemorrhage, and toxic shock syndrome (TSS) that occurred during 1 to 2 weeks of each hospitalization were compared. Multivariable logistic regression analysis was performed to assess the association between overall complication rate and background characteristics, with adjustment for within-hospital clustering.

RESULTS

The overall complication rate was 0.50%; the rates of CSF leakage, orbital injury, hemorrhage requiring surgery, blood transfusion, and TSS were 0.09%, 0.09%, 0.10%, 0.18%, and 0.02%, respectively. Ethmoidectomy combined with sphenoidotomy was associated with higher overall complication rates (1.40%). The rate of orbital injury was highest in group 2, whereas that of other complications did not differ significantly among the groups. Extent of FESS showed no significant association with overall complication rate.

CONCLUSION

More extensive FESS was not associated with increased rates of postoperative CSF leakage, hemorrhage, or TSS. Multiple sinus surgery was associated with a higher rate of orbital injury. The extent of surgery did not significantly affect the overall complication rate.

LEVEL OF EVIDENCE

2b.

Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS.

METHODS

A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients.

RESULTS

This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators.

CONCLUSION

Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.

Clinical pearls in endoscopic sinus surgery: key steps in preventing and dealing with complications

Increasing prevalence of patients undergoing endoscopic sinus surgery (ESS) makes understanding methods to preventing complications important to otolaryngologists. This commentary details clinical pearls and perioperative strategies that may minimize complications and increase preparedness for appropriate decision making in the event of a complication. Preoperative preparation is an important factor in preventing adverse events in ESS. This includes ensuring the presence of objective radiographic findings before pursuing operative management, both for patients' safety as well as medicolegal reasons, and providing adequate preoperative patient education. Appreciating variants in skull base and orbital wall anatomy through preoperative imaging is crucial for avoidance of intracranial and orbital complications. The importance of optimal visualization intraoperatively and the appropriate role of CT-guided imaging are also discussed. Finally, strategies for dealing with postoperative sequelae of more common complications are noted. This article represents a brief review for introductory sinus surgeons and is not meant as an all encompassing review.

Image-guidance in endoscopic sinus surgery: is it associated with decreased medicolegal liability?

BACKGROUND

The use of image-guidance (IG) in endoscopic sinus surgery (ESS) has escalated over the last decade despite a lack of consensus that its use improves outcomes or decreases complications. One theoretical reason for using IG in ESS is its potential to minimize legal liability should an adverse outcome occur. In this study, we aimed to characterize the role of IG in ESS litigation, and further detail other factors in pertinent cases. A secondary objective was to characterize recent malpractice litigation for other relevant factors.

METHODS

Relevant cases from Westlaw were examined to determine whether the use of IG played a role in initiating litigation in ESS malpractice suits. Factors such as patient demographics and alleged cause(s) of malpractice litigation were examined.

RESULTS

Out of 30 malpractice cases from 2004 to April 2013, 4 (13.3%) mentioned the use of IG during ESS, although this did not appear to be a factor affecting the plaintiff's decision to initiate litigation, nor the case outcomes. In the 26 cases (86.7%) in which IG was not used, its non-use was not specified as an alleged cause of negligence. Eleven (36.7%) cases were resolved in the defendant's favor. Frequently-cited factors included iatrogenic injury (83.3%), permanent deficits (66.7%), needing additional surgery (63.3%), orbital and intracranial injury, and perceived deficits in informed consent (40.0%).

CONCLUSION

The use of IG was not found to be a factor in ESS litigation. This suggests that not using IG does not necessarily make one more vulnerable to malpractice litigation.

Image-Guided Surgery Influences Perioperative Morbidity from Endoscopic Sinus Surgery

Objective

Although image-guided surgery (IGS) is considered a valuable tool, its impact on perioperative morbidity for endoscopic sinus surgery (ESS) remains unclear. The evidence from reported literature is systematically reviewed with meta-analysis.

Data Sources

MEDLINE (1946 to September 14, 2012, week 2) and EMBASE (1974 to September 14, 2012, week 37).

Review Methods

MEDLINE and EMBASE were searched using a search strategy for publications on IGS during ESS that reported original data on perioperative morbidity. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed. Both comparative cohort studies with non-IGS cases and case series were included. Primary outcome was major and total complications. Secondary outcomes were specific orbital and intracranial injury, major hemorrhage, ability to complete the operation, and revision surgery. The incidence of these events was defined as dichotomous variables and expressed as a risk ratio (RR) in a fixed-effects model.

Results

In total, 2586 articles fulfilled the search, producing 55 included studies. Fourteen were comparative cohorts of IGS and non-IGS sinus surgical patient populations used for meta-analysis. Among the cohorts, major complications were more common in the non-IGS group (RR = 0.48; 95% confidence interval [CI], 0.28-0.82; P = .007). Total complications were greater in the non-IGS group (RR = 0.66; 95% CI, 0.47-0.94; P = .02). All other outcomes did not reach significance on meta-analysis.

Conclusion

Contrary to current review articles on the topic of IGS use during ESS, there is evidence from published studies that the use of IGS for sinus surgery, within selected populations, is associated with a lower risk of major and total complications compared with non-IGS sinus surgery.