igsinotology-neurotologyvancouverseptember28,2013
TRANSCRIPT
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Image Guided Surgeryin Otology/Neurotology Panel
ANS – Vancouver September 28, 2013
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IGS in Otology/NeurotologyModerator• Darius Kohan, M.D.
o New York University Langone School of Medicineo New York Head and Neck Institute
Panel• Samuel Selesnick, M.D.
o Weill Cornell College of Medicine• Robert Labadie, M.D., Ph.D.
o Vanderbilt University Medical Center• Hinrich Staecker, M.D., Ph.D.
o University of Kansas Medical Center• Daniel Jethanamest, M.D.
o New York University Langone School of Medicine
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Accuracy of Image Guided Surgeryin Otology/Neurotology
Darius Kohan, M.D.Chief of Otology/Neurotology
Lenox Hill Hospital/MEETHNew York City
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IGS Requirements for Otologic/Neurotologic Use
• Accurate anatomic roadmap (speculate within 1mm)• Distinguish pathology from surrounding
structures• Consistency throughout operative case
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IGS in Otology
• Registration– Links preoperative patient
imagery with the physical patient
– It is the greatest source of error in IGS
• Target Registration Error (TRE)– Reflects clinical accuracy and
is an actual measurement of distance between point of surgical interest in the image field and physical field.
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Zone of Accuracy
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Cadaveric Study Probe Superior SCC
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Literature ReviewHow Accurate is IGS in Otology/Neurotology?Year Author Subject Results
2001 Staecker H. Live Surgery 0.9 – 1.5 mm TB accuracy with LandmarX
2005 Coepland B.J. Cadaveric < 1 mm accuracy with BrainLab
2005 Labadie R. Cadaveric TRE – 0.73 +/- 0.25 mm with dental bite plate
2006 Rafferty M. Cadaveric ≤ 0.8 mm spatial resolution with IGS and Cone Beam CT
2009 Caversaccio M. Live Surgery 0.8 – 1.5 mm accuracy in aural atresia and cholesterol granuloma
2009 Hong J. Cadaveric TRE – 1.12 +/- 0.09 mm with hybrid registration and virtual intraoperative CT
2011 Kral F. Cadaveric TRE – Average 2.88 mm at lateral skull base improves to 0.72 +/- 0.28 mm if 0.5 mm HRCT combined intrinsic landmarks and superstructure registration
2012 Matsumoto N. Live Surgery Estimated TRE average 2.4 mm in CI surgery with STAMP registration
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Study Published – 2012• 13 patients• 15 procedures/7 years• Limited variables
• Fiducial location close to surgical field on bony prominences or stable anatomy unlikely to shift
• LandmarX system • Same radiologist – HRCT 1 mm cuts performed evening prior
to surgery• Same surgeon
• Target – measured accuracy at 11 landmarks in surgical field
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Study Criteria for LandmarX Image Guided Navigational Surgery in Adults Requiring Otologic Surgery
Inclusion Criteria:• Chronic otitis media with extreme disease such as cholesteatoma or neoplastic process with:
• CNS complications• Facial nerve involvement• Otic capsule erosion• Petrous apex disease• IAC compromise• Internal carotid artery involvement• Intracranial extension
• Extensive cholesterol granulomas of the petrous apex requiring surgery• Glomus jugulare tumors Grade C or D• Atresia surgical repair• Cochlear implants with anomalous anatomy• Encephalocele and/or CSF leakExclusion Criteria:• Uncomplicated chronic otitis media• Patient refusal (Lack of consent)• Emergency surgery
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Site of Navigational Probe Tip Placement During Surgery
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Intraoperative Estimated Accuracy of Navigational Probe Tip Location Versus Surgical Anatomic Landmarks
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Source of Registration Errors
• Localization of fiducials• In CT due to image distortion, noise, and resolution• In anatomic space
• Design of fiducial marker• Human error – probe placement• Plasticity at fiducial site – skin shift • Error in tracking system localization of probe
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Case OneHistory• 25 YOF with severe left otalgia for 10 days on antibiotics• AS – Cholesteatoma, Tympanomastoidectomy in Ireland at age 8• Age 23 – Meningitis with revision “ear surgery” also in Ireland
• Infection resolved but “lost” hearing
Physical Exam• AS – EEC red, tender, closed• Neuro – left F.N. – 2/6 paresis H/B – patient unaware• Audiogram
• Normal AD• Profound HL – AS – B Tymp.
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Case One – Axial CT
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Case One – Navigational Study Axial CT
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Case One – CT Coronal
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Case One – MRI Axial T1
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Case One – MRI Axial T1 SE/FAT/SAT
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Case One – MRI Coronal T2 with Flair
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Case TwoHistory• 61 YOF – Right progressive HL and constant pulsatile tinnitus – 5
years
Physical Exam• AD – anterior inferior erythematous pulsatile mass deep to
intact TM• Neuro – intact
MRA/V• AD – expansile hyperintense mass at petrous apex against IAC
and jugular bulb
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Case Two
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Case Two – Axial CTCyst Abuts Carotid Artery
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Case Two – Axial CT
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LandmarX Probe Lateral Surface of Cyst
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LandmarX Trajectory into Cholesterol Cyst
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Case ThreeHistory• 43YOF – Right progressive HL and nonpulsatile fluctuating
tinnitus – 3 years
Physical Exam• AU – WNL• Neuro – intact
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Case Three
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Case Three – Axial CT
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Case Three – Coronal CT
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Case Three – Coronal CT
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Case Three - MRI
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LandmarX Probe on Facial Nerve – Cholesterol Cyst
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LandmarX Probe in Center of Cholesterol Cyst
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Case Four - Atresia
28 year old male born with right aural atresia, maximum CHL, presents with a one year history of progressive right facial paresis
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Case Four - Atresia
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Case Four – Axial MRI T1 w/o C
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Case Four – Axial MRI T1 w/o C
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Case Four – Axial MRI T1 with C
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Case Four – Axial MRI T1 with C
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Case Four – Coronal MRI T1 with C
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Why IGS in Otology/Neurotology?
IGS…• Provides real-time data localizing extent of pathology relative to
a fluid surgical landscape• Prior procedures and pathology may have distorted or destroyed
anatomic landmarks • May help in complex otologic surgery• May be a good teaching tool in academic programs• Has potential to improve surgical outcome and patient safety• Robotic surgery?