Outpatient ENT requires high levels of efficiency, a great attention to detail and a supremely talented surgical team with an in-depth knowledge of the instrumentation and technology these delicate cases require. If you're considering constructing a new ENT facility or remodeling an OR so you can host procedures from as basic as ear tube placement to as complex as image-guided sinus surgery, you'll need to invest in a couple key pieces of capital equipment: an image-guided system and a microscope. Here's what you need to consider.

Surgical navigation

Image-guided systems let surgeons move through the sinus cavity as if they're being directed by GPS, says Wayne Shaia, MD, an otologist and neurotologist who operates at Medarva Stony Point's surgery centers in Richmond, Va.

Computer-guided systems work off of pre-op MRI and CT scans of the patient's sinus anatomy that are loaded into the image-guided computer system, which projects anatomical landmarks of a patient's sinus onto a monitor in the OR. As surgeons operate, they can track how far they're progressing along a pre-planned surgical pathway and know exactly where their instruments are located as they maneuver around delicate structures in the sinus cavity.

Computer-guided systems come with 2 basic instrument options:

? Electromagnetic guidance. Surgeons don't need to maintain a direct line of sight between instruments and the image processor. They typically must use proprietary instruments, however, and the surgical team must keep metal items away from the patient in order to avoid interfering with the system's electromagnetic field.

? Infrared guidance. Passive systems have fiducial markers placed on the patient and instruments that reflect infrared light back to the system's camera. Active systems have infrared-emitting diodes on operating instruments that are actively tracked by an overhanging camera. With both types of infrared technologies, surgeons must maintain a clear line of sight between the instruments and the imaging unit.

"Electromagnetic instruments are more plug-and-play," says otolaryngologist Brett Scotch, MD, FAOCO, of the Select Physicians Alliance, a Tampa, Fla.-based practice of ENT docs that opened the Select Physicians Surgery Center in 2016. That's an important consideration, he says, because surgeons and staff shouldn't have to worry if the way they set up equipment and instrument tables in the OR occludes the line of sight that needs to be maintained when you use infrared systems.

The Select Physicians Surgery Center initially invested in 2 new computer-navigation units, which Dr. Scotch says are compact and easy to maneuver from room to room and a cinch to set up and break down between cases. A steadily increasing case volume is forcing the surgeons to consider adding a third unit. Don't ignore the importance of adding a platform with a small footprint, says Dr. Scotch, who points out that smaller units don't take up floor space in ORs or storage areas where every square foot is valuable real estate.

Dr. Shaia also says image guidance reduces the risk of wayward instruments breaking through the sphenoid sinus cavity and into the brain and helps surgeons steer clear of the eye socket.

The technology is pricey — about $80,000 to $100,000 — but it's a sound investment, according to Dr. Shaia. "If you want to bring in complex cases, it's getting more and more likely that you'll need image-guidance," he says. "If your ORs don't have the technology, surgeons will likely take their cases elsewhere."

Dr. Scotch agrees. "It's become the standard of care for complex sinus surgery, which we perform routinely," he says.

Dr. Scotch adds that the technology's high price tag is worth a line in your capital budget because it gives surgeons the confidence to perform delicate sinus surgeries faster, safer and more completely. "We can do a more thorough surgery as a result of the increased comfort level afforded by the image-guidance," he says.

Surgical microscopes

Dr. Shaia says standard, smaller ENT microscopes, which cost between $25,000 and $40,000, are best suited for general surgeries like removing foreign bodies from the ear, myringoplasty and endolymphatic sac surgery. But for more complex cases, like cholesteatoma surgery, he says surgeons need a microscope with high-end optics, which can push the cost of the scope to around $100,000.

The Select Physicians Alliance's surgeons spent about $50,000 to outfit each of the their 3 ORs surgical microscopes. They needed powerful and multifunctional surgical microscopes that could handle small cases such as tympanostomy tube insertions as well as complex ear surgery. Dr. Scotch says power zoom capabilities and interchangeable lenses let his group use the microscopes during complex laryngeal surgery, which requires lenses with different focal lengths.

Return on the investment

Outfitting a surgery center for ENT requires a large capital outlay, but it has the potential to generate a significant return in investment. A 10-minute ear tube surgery, for example, pays facilities about $800.

You also can't put a price on how much more patients are satisfied with their care when they go to an ENT specialty center where they're treated by a highly trained, dedicated staff and expert surgeons who use top-of-the-line equipment.

"ENT is all we do," says Dr. Scotch. "We do it every day, and we do it well." OSM