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Innovations in ENT Surgery
What you need to know about middle ear endoscopy, virtual reality sinus navigation and a new sleep apnea surgery.
Daniel Cook
Publish Date: November 19, 2018   |  Tags:   ENT
BANG THE EARDRUM SLOWLY
Massachusetts Eye and Ear
BANG THE EARDRUM SLOWLY The light source at the tip of the endoscope provides a greater degree of transillumination of the middle and inner ear.

The latest innovations in ear, nose and throat surgery could put your facility head and shoulders above the competition. Here’s a rundown of 3 new developments in ENT surgery from leading head and neck surgeons.

1 Endoscopic ear surgery (EES)

ENT surgical microscopes, which provide illumination and visualization along a single line of sight, still have a place in today’s ORs, but endoscopic ear surgery (EES) is emerging as the future of inner ear interventions because surgeons who operate through the ear canal with an endoscope can see around bony corners. That’s a tremendous benefit when diagnosing and treating chronic ear infection conditions or finding and removing cysts that grow behind the eardrum, says Elliot Kozin, MD, an otolaryngologist at Massachusetts Eye and Ear in Worcester, Mass.

While visualizing and excising cysts with a surgical microscope often requires removing large amounts of bone through an incision made behind the ear, the endoscope lets surgeons see into the recesses of the inner ear where they could previously not see with a microscope, says Dr. Kozin, letting surgeons remove some growths directly through the ear canal with minimal bone removal.

Traditional instrumentation has been designed for line-of-sight surgery with microscopes, so new tools are being developed that fit alongside the endoscope in the ear canal.

“We’re going to see greater advances in EES as these ancillary instruments come online,” says otolaryngologist Aaron Remenschneider, MD, MPH, a colleague of Dr. Kozin’s at Massachusetts Eye and Ear.

VIRTUAL 3D PLANNING\
Stryker
VIRTUAL 3D PLANNING Stryker's Scopis Target Guided Surgery lets surgeons view surgical plans overlaid onto the endoscopic image with augmented reality.

Ultra-high-definition imaging has also helped surgeons overcome some of the visualization limitations associated with EES. “Past cameras didn’t have the quality to provide clear, crisp images of anatomy, which are essential to guide dissection,” says Dr. Kozin. “Now, with high-definition cameras and relatively small and angled endoscopes, we can see clearly throughout the middle ear space.”

The heightened interest in EES should lead to more doctors adopting the technique in the coming years, says Dr. Remenschneider. “A new generation of otolaryngologists that has trained with the endoscope will expect facilities to have the devices available,” he says.

Another benefit of EES: You can position endoscopic ear surgery to patients as a more minimally invasive procedure. “It makes more sense to patients, who are more informed and savvier about their treatment options than ever, to tell them you can perform surgery through the ear canal instead of making external incisions in order to operate with the microscope,” says Dr. Kozin. “Limiting soft tissue dissection results, at least theoretically, in less post-op pain. That’s a value-added benefit for patient care.”

2 Image-guided navigation for sinus surgery

You can perform endoscopic sinus surgery with 2 types of image-guidance modalities:

  • Infrared guidance platforms communicate with and track a surgeon’s own instruments through fiduciary markers you place on the tools and the patient. The surgical team must maintain a line of sight between the fiduciary markers on the instruments and the imaging unit.
  • Electromagnetic image-guidance platforms have traditionally required surgeons to work with the system’s proprietary instruments, which were often bulky and didn’t match the feel and performance of the devices they’re accustomed to using. Several manufacturers of electromagnetic image-guidance platforms have created small adaptors you can place on surgeons’ personal instruments.

“That’s a big deal,” says Brent Senior, MD, FACS, FARS, a professor of otolaryngology at the University of North Carolina Health Care in Chapel Hill. “Adaptors designed for use with standard instruments have led to some surgeons — and some major manufacturers of image-guidance systems — to transition away from using infrared guidance systems.”

Augmented reality is also enhancing image-guided sinus surgery. Like a scene out of a video game, a virtual version of the optimal surgical pathway is superimposed over the endoscopic image surgeons view when operating. The virtual track appears brightly on the screen when surgeons move instruments through its center, says Dr. Senior, but the track darkens if the instruments begin to stray to one side or the other. Surgeons watch their progress along the virtual pathway and make adjustments on the fly as necessary to remain on the right (and safe) track. That real-time feedback provides surgeons with added reassurance as they manipulate instruments around the frontal sinus cavity, which is millimeters away from the brain and orbital cavities, says Dr. Senior.

Known as a pacemaker for the tongue, hypoglossal nerve stimulation therapy is a new way to prevent apnea in patients with OSA.

Clinical guidelines call for the use of the image-guided technology during revision sinus surgery or when operating on patients with complex sinus anatomy, but Dr. Senior says a growing number of surgeons are using the technology for routine endoscopic sinus procedures.

And although image guidance has not been proven to result in fewer complications or more efficient surgery, at least not in peer-reviewed journals, Dr. Senior believes there is tremendous value in investing in the technology.

“It provides surgeons with a tool they can use to operate more confidently,” he explains. “Plus, your facility can market image guidance to the growing number of patients who want to be operated on with cutting-edge technology.”

Of course, the $125,000 to $150,000 price tag can be a barrier to widespread adoption, but Dr. Senior says manufacturers are developing stripped down versions of the systems with smaller footprints and slimmer profiles to make the technology more accessible for facilities with limited capital equipment budgets.

3 Hypoglossal nerve stimulation

PACEMAKER FOR THE TONGU\E
Inspire Medical Systems
PACEMAKER FOR THE TONGUE The Inspire Upper Airway Stimulation system's surgically implanted pulse generator sends a signal to the hypoglossal nerve to control tongue movement through a stimulation lead.

In patients with obstructive sleep apnea (OSA), muscles in the throat and mouth relax during rest, causing the tongue and soft palate to slide against the back of the throat and obstruct airflow to the lungs. Continuous positive airway pressure (CPAP) devices deliver just enough pressure to keep the tongue and palate from falling back against the throat and custom-designed mandibular advancement devices, which keep the lower jaw pushed forward during sleep, are used to create more space for air to flow behind the tongue. Both options are often effective in patients with mild to moderate OSA.

For patients who don’t respond to those first-line treatment options, surgery has traditionally involved resection or repositioning some portion of the throat by tightening or removing muscles or resecting part of the tongue base. With advanced minimally invasive techniques, including robotic surgery, tissue cut or reshaped. Surgery is not an ideal treatment option, however, because it changes the throat’s normal form and function to create less airway obstruction during sleep.

Hypoglossal nerve stimulation therapy, also known as upper airway stimulation or a “pacemaker for the tongue,” is a new and possibly a better way to prevent life-threatening apnea in patients with OSA, says Michael Friedman, MD, an otolaryngologist–head and neck surgeon and medical director of Chicago (Ill.) ENT. Instead of removing tissue and muscle to prevent airway blockage, surgeons implant a small stimulator on the hypoglossal nerve, which controls motor function of the tongue. A sensor attached to the stimulator measures inspiration and expiration to determine when stimulation of the nerve is needed to keep the tongue from sliding against the back of the throat.

“Stimulating the hypoglossal nerve maintains tone in the palate and tongue when the patient is asleep — it essentially keeps the tongue awake,” says Dr. Friedman. “That makes a lot of sense because it keeps the throat open without cutting out healthy tissue or resecting muscle.”

The reversible procedure is a relatively simpler treatment option than the standard surgical options. The surgery involves making a small incision in the throat to place the electrode around the hypoglossal nerve. Although it’s a very delicate procedure, patients can go home the same day and recover quickly.

Although nerve stimulation is not a cure-all treatment for OSA — it’s reportedly effective in about 60% of patients — it has caused experts to reconsider the use of more invasive surgery to address the condition.

“The thinking will change when more studies show the long-term benefit of the procedure,” says Dr. Friedman. “It’s the better treatment option, but change is always slow to occur.”

Exciting times in ENT

Manufacturers have covered all of ENT’s bases with new advances for the ear (inner ear access), nose (virtual reality navigation for sinus surgery) and throat (sleep apnea implant). It all spells better patient care for your ENT patients — and exciting times for your head and neck surgeons. OSM

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