GPS FOR ENT Surgical navigation systems give ENT surgeons a roadmap for procedures that require the utmost precision.

Image-guided surgery is not currently considered the standard of care in ENT. But should it be? To Jeffrey M. Gallups, MD, FACS, there's really no question.

"If I'm having sinus surgery of any sort, I'd want them to use navigation on me," says Dr. Gallups, the founder and medical director of The Ear, Nose & Throat Institute in Alpharetta, Ga., which has 13 locations throughout Georgia. "If I tell a patient, 'I'm going to use a device that tells me within 1 to 2 mm where I am at every moment in the sinus cavity,' they come to understand it's pretty important."

Sometimes likened to a GPS for the anatomy of the human head, ENT surgical navigation systems give surgeons a real-time roadmap so they know exactly "where they're going" when directing instrumentation. As a result, Dr. Gallups says surgeons tend to maneuver more efficiently and confidently even in the tightest of quarters, often within just a few hair widths of the brain, the orbital walls and other vital structures.

Although not necessary for more routine procedures, image-guided ENT has become increasingly popular for ENT surgeons, particularly in functional endoscopic sinus surgery (FESS), revision sinus surgery and cases marked by unusual anatomy. If you haven't yet made the investment, should you? Following are a few variables to consider.

• Functionality. In the past, an image-guided ENT system was an either/or scenario, meaning it worked off either an MRI or a CT scan taken before surgery. But today's newer systems have made it so you no longer have to choose between the two. In cases in which views of both bony and soft-tissue detail is essential — say, thinning of the bone between the sinuses and the brain or the eyes — CT scans, for bone detail, can be merged with MRIs, which offer superior soft-tissue detail, to offer a more comprehensive picture.

INVEST Consider the "high cost of admission" for image-guided ENT an investment in quality patient care.

Also, ENT surgeons used to have to choose between 2 types of surgical navigation: optical, which requires a clear line of sight to the instruments; and electromagnetic, which does not require a clear line of sight and registers CT and MR images without headsets or markers. Some vendors have developed hybrid systems that offer both options, which let surgeons choose whichever form best suits the specific needs of the procedure.

• Cost. These systems bear what Dr. Gallups refers to as "a high cost of admission." He puts the per-unit price tag at $200,000 to $350,000. Although the upfront investment is significant — and this does not include the ongoing costs associated with disposables, which he estimates at "hundreds of dollars per case" — image-guided ENT could very well be a billable item, depending on the insurance contract.

"The cost is acceptable, but what value can you put on a person's life?" he says. "It's an investment in quality patient care. It's also an insurance issue, because it shows you're taking steps to avoid complications."

Dare Underwood Meeks, RN, MSN, CASC, the administrator of Outpatient CareCenter in Birmingham, Ala., agrees that most surgical facilities invest in image-guided ENT for reasons other than financial. Her facility, which has 8 ORs and 1 procedure room, has 3 ENT surgical navigation systems.

"It's all about surgical performance," says Ms. Meeks. "Whether we use it for a specific case is up to the doctor's discretion, and there is a cost associated with it per case, so you have to weigh that along with reimbursement rates to ensure you stay solvent."

That having been said, the addition of a third surgical navigation system helped facilitate, if not drive up, her center's ENT case volume. The center added 2 ENT surgeons — one in 2014, the other the following year — thereby growing the surgical staff from 5 to 7. Before they came on board, ENT accounted for about 12% of the center's business. Now it accounts for as much as 15%.

"Those 2 surgeons were on the cutting edge of utilizing new technology," says Ms. Meeks. This included expertise in surgical procedures with which navigation systems are highly beneficial, including balloon sinuplasty, FESS and the placement of dissolvable sustained-release implants for patients with chronic sinusitis.

• Size and mobility. With OR real estate being as precious as it is, a number of vendors have responded by slimming down their units, with minimal footprints that don't compromise functionality. Dr. Gallups says The Ear, Nose & Throat Institute recently invested in a low-profile system that measures no more than 7 inches tall.

"The newer models are more size-conscious," adds Ms. Meeks. "We're in an old building from the 1980s, so there's never enough room for what you need in terms of storage."

Her center recently trialed a surgical navigation system with a dramatically smaller footprint than its existing system. In the end, though, the dependability of the existing system — not to mention the level of service from the vendor rep — won out.

WISH LIST
Advances in ENT Diagnostics and Navigation

SOUND ON Put the OR at ease with navigation systems equipped with high-fidelity sound systems.

ON THE FLY Low-dose CT scanners work in tandem with image-guidance systems.

"ENT is known as the specialty of gadgets," says Jeffrey M. Gallups, MD, FACS, the founder and medical director of The Ear, Nose & Throat Institute in Alpharetta, Ga. "If someone has a new product, I promise that they'll bring it to someone like me."

He's had more than his fair share of products to choose from in recent years, including some advances in diagnostics and surgical navigation. Here's a sampling.

• Portable low-dose CT scanners. These let ENT surgeons conduct intraoperative diagnostics while the patient is still under anesthesia. These CTs can then be uploaded to image-guidance systems to evaluate the completeness of surgery.
• Sound systems. Some surgical navigation systems come equipped with high-fidelity sound systems for your favorite playlists, making the OR just a little more comfortable — even if you prefer Metallica to Mozart.
• Ultra HD. Big, 55-inch screens with 4K ultra high-definition endoscopy mean ENT surgeons now have 4 times the resolution, with better light and a wider color spectrum to improve visualization for the entire surgical team.

— Bill Donahue

A guidepost in a place with no landmarks
Given the precision and assurance surgical navigation has brought to ENT, some surgeons may be scratching their heads, wondering: "How did I ever live without it?"

"In a complicated nasosinal case, where there are no landmarks whatsoever, I sometimes have that thought," says Dr. Gallups. "It's more efficient, I know exactly where the instrumentation is, and I can move with more confidence and speed. It takes all the guesswork out; there's no art to it. It also keeps the patient under anesthesia for not as long, and that's beautiful." OSM