The Utility of Image Guidance in Endoscopic Sinus Surgery

Abstract

IMPORTANCE More than a quarter-million cases of endoscopic sinus surgery (ESS) are performed annually in the United States. Most surgeons use image-guided systems as an adjunct during surgery in certain situations. Understanding the association of image-guided surgery (IGS) with surgical outcomes, complications, and surgeon factors is paramount.OBSERVATIONS Three systematic or evidenced-based review articles demonstrated no clear evidence that IGS improves surgical outcomes for chronic rhinosinusitis, including completeness of surgical dissection, patient-reported outcomes, or rates of revision surgery. Results from 2 systematic reviews suggest that major and total surgical complications may be decreased with use of IGS in certain cases, although bias may confound these findings. When complications were analyzed individually, there was no definitive evidence that IGS is associated with decreased rates of orbital, intracranial, or hemorrhagic complications. The rarity of complications in ESS, developing surgical experience, evolving training strategies, and selective use of IGS in more complex cases make future study on the association of IGS with complications challenging. Limited data on the influence of IGS on surgeon satisfaction and stress level suggests that more experienced surgeons might glean benefits in these realms, whereas junior surgeons may feel additional stress when using the technology.CONCLUSIONS AND RELEVANCE Level 2A evidence from systematic reviews suggests that in certain cases IGS may be associated with decreased major and total surgical complications, though the potential for bias and confounding exists in these conclusions. It is possible that, among more experienced surgeons, the use of IGS is associated with improvements in stress and satisfaction, although evidence in this realm is limited and there may be additional stresses associated with IGS for surgeons early in their career. The choice to use IGS in any endoscopic procedure remains best determined by the operating surgeon based on factors including case complexity and surgeon comfort.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

“…In a subsequent meta‐analysis, Vreugenberg et al, who focused on complex cases only, confirmed that IGS is associated with fewer total, major and orbital complications, but not minor complications and severe hemorrhage 2101 . Both of these reports have been criticized because they cannot address the bias intrinsic to the underlying publications that they summarize and review 2102 …”

Navigation and non-navigation CT scan of the sinuses: Comparison of the effective doses of radiation in children and adults

“…Navigation based surgery is a useful tool for the surgeon and has been widely used in sinus surgery [ 41 , 42 ]. The American Academy of Otolaryngology – Head & Neck Surgery has published a position statement regarding the appropriate indications for computer-guided sinus surgery.…”

“…The American Academy of Otolaryngology – Head & Neck Surgery has published a position statement regarding the appropriate indications for computer-guided sinus surgery. These indications include: (1) revision surgery; (2) distorted anatomy (developmental, traumatic or postoperative); (3) extensive sino-nasal polyposis; (4) pathology of the frontal, posterior ethmoid and sphenoid sinuses; (5) disease involving the skull base, orbit, optic nerve or carotid artery; (6) CSF rhinorrhea or other skull base defects and (7) benign or malignant sino-nasal neoplasms [ 41 ]. A surgeon’s choice to use 3D image guided surgery technology may rely on these official indications as well as his preference and comfort.…”

Image guidance for endoscopic sinus surgery in patients with chronic rhinosinusitis: a systematic review and meta-analysis protocol

“…There is a lack of robust scientific evidence to determine indications and recommend the use of IGS in CRS. Improvements in surgical efficacy and safety are believed to be relevant 21. This review seeks to analyse trials that compare ESS with and without IGS.…”