Computer Technology Boosts Rhinologic Surgery, but Poses Choices for Surgeons

PHILADELPHIA-Constantly advancing computer technology in rhinologic surgery leads to the possibility of better patient care, but also can mean difficult decisions for surgeons weighing whether to make an expensive purchase. Three surgeons gathered to discuss some of the nuances of the technology in a mini seminar at Rhinology World 2009.

Martin J. Citardi, MD, Professor and Chairman of the Department of Otorhinolaryngology-Head and Neck Surgery at the University of Texas Medical School at Houston, said that intraoperative scanning is a way to make computer navigation technology more useful.

Marvin P. Fried, MD, Professor and Chairman of the Otorhinolaryngology- Head and Neck Surgery Department at Albert Einstein College of Medicine in New York, and the panel’s moderator, said that computer simulation can be merged with computer navigation, making for an exciting area that can help with both training and with surgeons about to perform real-life procedures.

And Thomas Tami, MD, of the Cincinnati Sinus Institute, said that when it comes to choosing an image guidance system, it is fairly difficult to make a poor choice, as they all will accomplish the same tasks.

Importance of Intraoperative Scanning

In his remarks, Dr. Citardi drew attention to an inadequacy of image guidance systems: Changes to the anatomy during surgery are not reflected in the system.

Because the technology relies on preoperative imaging, it’s only as good as the preoperative imaging, and as soon as there are any surgical manipulations there’s no real-time update, he said.

That’s where intraoperative scanning comes into play, he said. If we can find ways to provide real-time information that reflects what’s going on at the time of surgery, and perhaps increase our surgical navigation accuracy, that would be deemed beneficial, he said.

Either CT or MR images can be used. CT images offer good bone detail, the system doesn’t take up too much space, it is less expensive (although not cheap), and the emergence of volume CT scanning offers surgeons a valuable tool, Dr. Citardi said.

The MR option offers good soft-tissue detail, but the system is much bigger and requires a dedicated operating-room suite, and it is expensive. I think there’s just too high of a real or perceived barrier for wide adoption, Dr. Citardi said about MR imaging.

Two studies have shown that intraoperative scanning can yield impressive results.

In a study by a University of Pennsylvania team released last year, CT scanning was done after endoscopic sinus surgery but before the operation was complete. In six of those cases, surgeons performed additional procedures based on the results of the intraoperative scans. Among the problems that needed to be fixed were residual uncinate process, a missed midline frontal sinus compartment, an incomplete frontal cell type 3 dissection, a residual sphenoethmoidal cell, and a residual posterior ethmoid partition. I think that if one out of four, or one out of three cases, are altered as a result of an intra-operative scanner, this may be a strong argument for adoption of the technology, said Dr. Citardi, who also reported that he is a consultant for Quest Medical and Medtronic ENT.