When the Piedmont Outpatient Surgery Center in Winston-Salem, N.C., opened in 2012, it didn't have an ENT image-guided platform. That meant the center's surgeons had to perform all of their image-guided sinus surgeries at a nearby hospital-owned outpatient center.

A couple years later, Administrator Brandi Cunningham, RN, BSN, BA, MHA, MBA, decided to see what it would take to keep the cases in her facility. She first made sure the majority of the center's patients who were sent out for sinus surgery met the criteria to have their procedures performed at the ASC. They did. She then performed a cost analysis, which showed keeping the cases in-house would let the facility pay off an image-guidance system of its own within a year.

"We're really happy with the system we chose and it's worked well for us for the last 4 years," says Ms. Cunningham, who's constantly keeping tabs on new developments in image guidance so she's prepared for the inevitable technology upgrade. When it's time for her (and you) to shop for a new system, there are several cool new innovations to consider.

1. Augmented reality

"For a decade, there hadn't been much advancement in navigation systems for ENT," says Martin Citardi, MD, chair of the Department of Otorhinolaryngology—Head and Neck Surgery in McGovern Medical School at UTHealth in Houston and an attending physician at Memorial Hermann-Texas Medical Center. "But now there are 2 or 3 systems with new and competing technologies. It'll be interesting to watch how this new technology gets a foothold."

Dr. Citardi isn't just watching; he's used one of these new systems to perform the first U.S. sinus surgery using augmented reality (AR) for navigating the sinus cavity. AR merges the digital with the real world. "Five years ago, everyone was talking about virtual reality (VR), but that's faded," says Dr. Citardi. "AR is much more applicable to surgery."

The current standard in ENT navigation systems merges the pre-op CT scan with the location of instruments as the surgeon moves them through the surgical pathway. AR takes this approach a step further by merging the location of the instruments with the view through the surgeon's endoscope.

Distances to important structures are indicated right on the video monitor that is displaying the endoscopic view of surgery, so the surgeon can refer to the information without looking away from the action or switching between the CT scan and his camera view.

Critical anatomy that surgeons want to avoid like the optic nerve can be marked ahead of time and are then overlaid onto the camera view with their distances from the instruments updated in real time during surgery. Surgeons can also mark pathways to target sinuses and emphasize the anatomy around those pathways, adds Dr. Citardi.

This new system also lets the surgeon come up with a plan for the surgery before entering the OR. Using the CT scan, he can plot a surgical pathway and load it into the computer. Then during surgery, the pre-determined pathway shows up on the camera view as different colored rings. As an instrument moves inside the patient, it shows up in real time on the CT scan and lights up the rings as it "passes through" them.

Having the planned path and distances between the instrument and important anatomical structures marked and displayed on the surgeon's view is what makes AR an exciting advancement in ENT image guidance. "Even with traditional navigation systems, the surgeon must look at the navigation screen for positional information and the surgical field separately," says Dr. Citardi. "With AR, that information is unified into a single view, which could lead to faster and safer surgeries."

2. 3D Imaging

AR isn't the only thing shaking up how surgeons view their procedures. Ms. Cunningham's system uses 3D imaging by overlaying 3 different 2D images from CT scans of the patient. These images update during procedures to show where instruments are located in real time. The same company now offers a system that uses CT scans to generate 3D models of the patient's head and sinus and nasal anatomy. "This technology is closer to VR than AR," says Dr. Citardi.

3. Microsensors

Current image-guidance systems rely on electromagnetic or infrared sensors that are attached to or embedded into the handle of the instruments to track their locations during surgery.

"Our system has disposable trackers that surgeons pop onto the instruments they want to track," says Ms. Cunningham. But the sensors are fairly large, which means instruments they want to track have to be rigid in order to accommodate the sensors. Newer microsensors can be placed on non-rigid instrumentation, on areas other than the handle or incorporated into clamps that can be attached to any instrument, so surgeons can track their favorite tools.

These microsensors can also be placed on a guidewire, which surgeons can navigate through complex sinus anatomy to where they need to place a dilating balloon.

Dr. Citardi believes the ultimate image-guidance system will incorporate AR overlay of important clinical information, 3D anatomical models and novel microsensors into a single platform. There's no doubt the image guiding systems you will have to choose from in the future will offer a whole new view of ENT surgery. OSM