xRead - Nasal Obstruction (September 2024) Full Articles

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more advanced sinus cases. 2133–2135 Regional variations in the usage of IGS are large, suggesting that factors other than case complexity determine its usage. 2136 IGS technology entails incremental costs. 2137 One study has proposed that IGS may reduce the overall cost of care, by reducing the need for revision surgery. 2104 From a medico-legal perspective, IGS has not been implicated as a factor in litigation for ESS-related complications. 2138 Recently, IGS systems have introduced new technology. IGS with virtual reality features has been described. 2139 Augmented reality features have been incorporated into IGS systems. 2140 Advantages of augmented reality-enabled IGS include more intuitive and more detailed imag ing data, which should reduce mental workload for surgeons. 2141 Interestingly, an IGS system offering 3 dimen sional modeling did not improve surgeon’s efficiency and workload in a cadaveric trial. 2142 In addition, microsensor electromagnetic tracking may be incorporated into con ventional instruments or sinus balloons. 2143 Use of Image Guidance for Sinus Surgery Aggregate Level of Evidence: B (Level 1: 2 studies; level 2: 1 study; level 3: 11 studies; level 4: 48 stud ies; Table XII-20). Benefit: Reduction in complications; improved surgical outcomes; more extensive surgery per formed under endoscopic visualization; surgeon satisfaction/stress. Harm: Increased operating time; IGS failure lead ing to inaccurate localization of instruments. Cost: Costs are related to greater operating time and the need for specialized equipment and tech nical expertise. Benefit-Harm Assessment: Preponderance of ben efit over harm in selected cases. Value Judgment: Image-guided surgery provides important localization information to the surgeon during ESS; such information may reduce com plications and improve outcomes. In addition, IGS may reduce operative morbidity by permitting endoscopic techniques for more complex surgical targets. Surgeon acceptance of the technology is high. Policy Level: Option in patients undergoing ESS, especially in the setting of anatomic complexity or the need for more advanced procedures. Intervention: Image-guided surgery may be per formed at the time of ESS.

extensive meta-analysis, concluded that IGS is indeed asso ciated with fewer complications. 2100 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 compli cations and severe hemorrhage. 2101 Both of these reports have been criticized because they cannot address the bias intrinsic to the underlying publications that they summa rize and review. 2102 While improvements in clinical outcomes associated with the use of IGS have been difficult to confirm, Javer et al. were able to show improved RSOM-31 scores in patients whose ESS was performed with IGS. 2103 Master son found a reduction in revision surgery among patients whose ESS was performed with IGS. 2104 In another retro spective study, Galletti et al., showed that IGS was associ ated with greater symptom reduction and decreased recur rence rates. 2095 Other studies have not demonstrated simi lar benefits of IGS. 2105–2108 Strauss et al. proposed a novel strategy for assessing the impact of IGS on surgical decision-making. In this clinical series, IGS was associated with changes in surgical tech nique and strategy, even for experienced surgeons. 2109 Pre sumably, the information provided by IGS, as captured in this study, translates to more complete/effective surgery and greater operative efficiency. Several studies have looked at the impact of IGS on surgeon stress levels. Survey data show that surgeons believe that IGS reduces their stress levels. 2078 In a prospec tive trial of trainees, IGS did not impact overall stress levels, although more experienced trainees did experi enced a decreased perceived workload with IGS. 2110 In a small study, physiological parameters for stress did not markedly differ if IGS was employed. 2111 Nonetheless, sur vey data show that surgeons report reduced stress levels with IGS. 2072 IGS has also been combined with intraoperative fluoroscopy, 2112 CT-MR fusion 2113,2114 and 3D CT angiography. 2115 These reports emphasize technical feasibility of these adaptations and explore potential clini cal applications. IGS with an imaging update provided by an intraoperative cone-beam (or volume) CT scanner has been associated with an alteration of the surgical plan in 30% of ESS cases. 2116,2117 Furthermore, IGS also has specific uses for frontal sinus surgery, 2118 orbital surgery, 2107,2119,2120 sphenoidotomy, 2121 skull base surgery, 2122 pediatric sinus surgery, 2123–2125 procedures with skull base erosion, 2126 trephination procedures, 2127 device placement, 2128 orbital surgery, 2107 mucocele marsupialization, 2129 and osteoplas tic frontal sinus surgery. 2130–2132 Surgeon surveys suggest greater availability of IGS tech nology in ENT operating rooms and confirm that most sur geons are comfortable with the technology, especially for