What is Navigation-Assisted Sinus Surgery?

Audio Transcript:

Dr. Smith:

Hi guys, welcome back to the We Knows Noses podcast. I’m joined here with Dr. Reddy, again, Dr. Smith. And we’re going to be talking about a second part of our little mini series on advances in sinus surgery. Last episode, we talked about packing and packingless surgery and the advent of some of these newer technologies that allow us to go without packing.

This time our episode we’re going to focus on another newer technology that’s been used probably for the last decade now, maybe a little bit longer, which is what we call navigation assisted sinus surgery. Dr. Reddy, do you want to talk a little bit about what navigation assisted sinus surgery is and what some people may call it in addition to that?

Dr. Reddy:

Sure. Almost always prior to any sinus surgery, it’s very routine to be getting a CAT scan of your sinuses. A CAT scan is basically a picture of your sinuses in three dimensions. And this CAT scan is typically viewed prior to the surgery by your surgeon to determine what sinuses need to be addressed during the surgery. And sinus anatomy, there’s some you know, some patterns that every patient typically has compared to other patients. But there’s also a lot of nuances and differences that are individual to that patient that’s different from an anatomic consideration to other patients. And so you have to take all of that into account when you’re doing the surgery because the sinuses are lined by critical areas. So you have your cheek sinuses, your forehead sinuses, and your eye sinuses.

And all of those areas are bordered by critical structures such as your eyes and your brain and other important, you know, vascular structures like your carotid arteries. And so it’s important to try to, during the surgery, try to safely open up the sinuses while not injuring those surrounding critical structures. And that’s where navigation kind of comes in.

Dr. Smith:

Right. And so historically to go over you know, why is this an advancement? Well, historically, you know, what we would do as sinus surgeons would be to take the printed CAT scan films and the patients would come in with a giant envelope full of these CAT scans, because there would be, you know, 100 or so pictures in there and maybe even three or four different orientations. And so you would look at these images and put them up at the time, one before surgery, but then also during surgery and you would put those up on these light boxes and look at the films. And so you would have to kind of look at the pictures, remember what structures or critical things might be at play or might be at risk. And some people have a different variation of how their skull base comes down, which is where the brain is housed. And so those things are extremely important to know how the skull base slopes or the, or the kind of the, where the openings going into some of these more difficult sinuses to reach are. And so you would look at those films and then you would go do your surgery. And if you had any questions, maybe you would scrub out and look at the films again, if there was an area of question that you were trying to look at. So with the newer navigation technology, do you want to explain kind of then how, how this is and what we use?

Dr. Reddy:

Yeah. So typically during these surgeries, you have one monitor and that monitor houses the endoscopic view from your camera. And that’s what you’re looking through with your camera into the person’s nose or sinuses. There’s a separate system next to it called the navigational system. And there’s different companies that do these navigational systems, including Striker. But basically these navigational systems take the CAT scan data that’s already been done on the patient’s CAT scan and it puts it up on a different monitor. And there’s a process called a registration process that occurs in the beginning of the case where a device is used to calibrate the patient’s anatomy to the CAT scan machine or the navigation machine so that ultimately when you’re moving an instrument like a pointer or a suction or some other instrument, that machine the tip of that instrument actually shows up on the three-dimensional portion of the CAT scan in real time. And so now when you’re looking at the during the surgery, not only are you getting the visual feedback from your camera system, but you’re also getting the visual feedback in real time of where your instrument is in relation to the CAT scan.

Dr. Smith:

Yep. So I usually tell patients I’m marrying the images basically your face to the images so I can see them during surgery. So the big benefit of that is, yep, we get real time visualization of where you are within the sinuses, within a relative degree of certainty. So we use that then as a safety tool, but also as I explain to patients when I tell them that I’m going to use this navigation equipment, it’s also another tool to ensure that we’re going to be as thorough as possible because especially if you’re trying to get in there and open up all the sinuses as high and deep as you possibly can, you want to make sure that you’re not leaving behind any blocked air cells or sinus cells. And sometimes it can look like you’re all the way to the back or all the way to the top and all the way lateral. And there might be one extra cell that you think might be there and you can kind of confirm that with the navigation equipment.

So it’s a safety tool, but also it allows us to be a little more thorough in opening up those sinuses so that hopefully in the future, prevents less recurrent cases and that need for future sinus surgeries. So it allows us to be more thorough safely and just review those images for the differences and the little nuances that each patient individually has in their sinus anatomy.

Dr. Reddy:

And we routinely use navigation CT, intropartive navigation systems for almost all of our sinus cases now, even for our routine cases. In the old days, it was only really used for, in the beginning, when I was first employed for very complicated sinus cases. Now we use it for everybody. And not only do we use it in the operating room, where, you know, it’s very commonly used, but we’re one of the first practices in the state of New Jersey to routinely use it in the office. every one of our balloon procedures, balloon sinuplasty procedures, or many sinus surgery procedures that we do in the office under local anesthesia, we use navigational systems. Can you talk a little bit about the transition from the operating room to the office?

Dr. Smith:

Sure. you know, originally these systems were very large and cumbersome and required a lot of extra parts and things that were extremely expensive and cost prohibitive. So really only the bigger academic centers were able to afford these. And then little by little as the more more companies started coming out with these systems and, you know, Dr. Reddy alluded to Striker, you know, Medtronic and there are some other, Acclaren and some other systems that also have these systems that have kind of over the years have developed. So that competition has allowed these devices and these machines to get a little bit better and a little bit faster and a little bit smaller. And so every year they’ve developed more more compact units that are a little bit easier to use across the system. And now even in the office. And so these systems are, some of them are portable and can be set up very easily on a desktop. Some of them are a little bit larger and a tower type structure, but they are all extremely accurate within, you know, a millimeter, actually a fraction of a millimeter. And so it allows us to safely do that in the office. There’s no radiation or anything with it. A lot of them, most of them use electromagnetic and some of them use optical, but most of them now use electromagnetic fields to generate the signal between the instrument and the patient.

And so it allows us to do it easily, safely and cost effectively here in the office. so the insurance companies are slowly starting to come around to the fact that now that we have it in the office, we’re allowed, we were able to do more advanced sinus cases in the office. And so before you would only be able to kind of dilate or, or, or open up or do surgery on some of the you know, more simple routine sinus cases. But now, thanks to the navigation and the fact that it’s in the office, we’re able to do complex sinus cases, complex revision sinus cases, and both minimally invasive with balloon sinoplasty and some more minimally invasive traditional with, you know, microdegreeders and instruments that open up the sinuses fully.

So that’s a huge change that’s occurred probably in the last five years or so, but still not widely available and adopted by a lot of practices. And it’s, think in the future, something that ultimately a lot of sinus surgery will start transitioning to the office, thanks to the availability and accessibility of these navigation systems.

Dr. Reddy:
I mean, navigational systems for sinus surgery has been a big advancement for many different broad reasons, we’ve, a lot of it, which we’ve touched upon already, but broadly speaking, it’s helped the safety profile where surgeons are feeling more confident that they are not going to go past the borders of the dissection where the danger areas are. And it gives surgeons more comfort and confirmation that they’re clearing out all the disease that needs to be cleared out. It also helps with patient education where you can actually show a patient, know, even if they’re awake, even during the procedure, before the procedure, after the procedure, what actually has been done in your nose and sinuses. From a teaching perspective, it can be very helpful, right? If you’re teaching a resident, a junior surgeon or a medical student or student, you can show them the anatomy and you can show them what the plan, what the surgery is and the anatomy. There’s also some newer kind of technology with navigational systems called augmented reality that can actually help surgeons pre-plan their surgery prior to even getting into the operating room. So you can actually take a patient’s CAT scan, you can actually plan what you’re going to be doing even before getting to the operating room, almost like a video game in a way. And this gives surgeons more confidence that they are doing the surgery in the most effective way possible. Anything else, to add?

Dr. Smith:

The one thing you brought up, the resident education, which I was gonna touch on, which is perfect. I agree. I think when teaching newer generations of sinus surgeons, it’s an extremely effective and helpful tool for safety and education. The one big thing I think that we don’t often talk about though is the cost to the overall system. You would think, okay, well, this technology sounds really expensive. Like it’s gonna drive up the cost of my surgery if I have to have this fancy or newer technology. But in general, I think it’s really going to do the opposite. It’s gonna really decrease the cost to the overall system. You know, as we said, it allows you to be a little bit more thorough, safely. So, you know, the most costly things with sinus surgeries are having to do multiple sinus surgeries. And so if you can, you know, decrease the amount of sinus surgeries that a patient needs in their lifetime by using an equipment like this, or you can decrease a complication and so morbidity and mortality, those are things that you can never get back with a cost. But so those are, are, you know, cost savings to the system, but also to the patient that there’s an increased safety profile, a decrease for future surgeries. In general, it’s probably one of the biggest advances in sinus surgery in the past 15, 20 years. So I really think from a system-wide standpoint, it’s a no-brainer to use all the time.

Dr. Reddy:

Sure. Yeah, and the other thing is that when I was training navigational systems were looked down upon because it was thought that relying on this technology would almost dumb down the surgeon, that they wouldn’t maybe need to be as reliant on their anatomic learning and their studying of the anatomic landmarks for the surgeries. And I could certainly see that viewpoint. mean, I was trained essentially without navigation and then really employed it after training.

But the way that I kind of, this is somewhat analogous to the advent of smartphones and navigational systems in cars. You really need to have a surgeon that knows how to get from point A to point B, maybe being able to read a traditional map to get there, right? But you also have that additional navigation system in the car running as kind of like a confirmatory tool and as a comfort tool running in the background.

You may or may not use it, but it’s there and available. And if there’s a more efficient, effective way of getting there, can potentially update you in real time.

Dr. Smith:

Agreed. All right. All right. that’s been another episode of We Know’s Nose’s podcast. Make sure to like and subscribe and tune in next time for another advancement in sinus surgery. Take care.