CBCT-Based Image Guidance
for Sinus and Skull Base Surgery
Bradford A. Woodworth, Sri Kiran Chennupati,
and Alexander G. Chiu
Contents
27.1    Introduction  
27.2    Imaging in Otolaryngology  
27.2.1  Emerging Role of CBCT Imaging
in ENT  
27.2.2  Sinus Surgery  
27.2.2.1  Functional Endoscopic Sinus
Surgery  
27.2.2.2  Image-Guided Sinus Surgery  
27.3    Intraoperative Imaging for IGS  
27.3.1  Does IGS Increase Safety in Sinus
Surgery?   
27.3.2  Other Applications for IGS  
27.4    Future Directions  
Conclusion  
References  
B.A. Woodworth, M.D. (*)
Department of Otolaryngology—Head and Neck
Surgery, University of Alabama at Birmingham,
Birmingham, AL, USA
e-mail: bwoodworth@uabmc.edu
S.K. Chennupati, M.D.
Pediatric Otolaryngology, Division of Pediatric
Surgery, Lehigh Valley Health Network,
Allentown, PA, USA
e-mail: chennups@gmail.com
A.G. Chiu, M.D.
Department of Otorhinolaryngology—Head and
Neck Surgery, University of Kansas Medical Center,
Kansas City, MO, USA
e-mail: Achiu@kumc.edu
© Springer International Publishing AG 2018
W.C. Scarfe, C. Angelopoulos (eds.), Maxillofacial Cone Beam Computed Tomography,
https://doi.org/10.1007/978-3-319-62061-9_27
27
27.1 Introduction
1057
The field of otolaryngology—head and neck
1057
­surgery encompasses the diagnosis and treatment
1058 of a wide variety of disease processes involving
1059 the ear, nose, and throat (ENT). In particular, sur-
geries involving the paranasal sinuses and skull
1059
1060
base demand a high level of imaging accuracy
because of the complexity of the regional
1066
anatomy and intimate association with both
­
1067 neurovascular, ocular and cerebral tissues.
­
1068 Improvements in the field of diagnostic imaging
1069 have driven a number of technological advance-
ments in operative techniques, especially stereo-
1069
tactic surgical navigation. Image-guided systems
1069 (IGS) monitor surgical instruments relative to
known patient anatomic landmarks. This chapter
will discuss the origins and utility of this modal-
ity and highlight the particular use of in-office
and intraoperative CBCT imaging for endoscopic
paranasal sinus and skull base surgery.
27.2 Imaging in Otolaryngology
Multi-detector computed tomography (MDCT)
is presently the core modality of diagnostic imag-
ing in ENT applications. The fine bone detail pro-
vided by high-resolution MDCT scanners can
assist in determining the status of the inner ear
after temporal bone trauma and provide accuracy
paranasal sinus imaging necessary to develop a
1057
1058 B.A. Woodworth et al.

“road map” for sinus surgery. With the advent of
MDCT, direct coronal imaging for temporal
bones and sinuses are essentially examinations of
the past. Coronal and sagittal plane reconstruc-
tions from data obtained from fast MDCT scans
are exceptionally reliable (Phelps et al. 2000).
Magnetic resonance imaging (MRI), although
unsatisfactory for demonstrating the middle ear, is
now the imaging modality of choice for inner ear
lesions and their central connections. The cranial
nerves in the internal auditory meatus can be reli-
ably depicted as well as the contents of the scalae
of the cochlea (Phelps et al. 2000). Magnetic reso-
nance angiography is also a noninvasive modality
to demonstrate the major vessels of the head and
neck. MRI is particularly useful for tumors and
meningoencephaloceles of the skull base and
paranasal sinuses. MRI can identify brain paren-
chyma and CSF that have herniated into the sinus.
However, MRI lacks fine bony detail of the skull
base, which limits its accuracy in localizing cere-
brospinal fluid (CSF) leaks and characterizing the
bony paranasal sinuses needed for intraoperative
image guidance.
• Compact size. The overall size of in-office
units and the “C” arm configuration of intra-
operative units have an extremely small foot-
print compared to medical CT units which
provide greater physical constraints of the
operating environment.
• Low Dose. Although CBCT units do not have
dose modulation throughout the scan, they
operate at lower kilovoltage and mAs
providing up to 59% less effective dose
­
(Conley et al. 2011)
• High resolution. CBCT have higher sub-­
millimeter spatial resolution (range, 0.4–
0.83 mm) than MDCT (approximately
0.625 mm) (Conley et al. 2011).

27.2.1 Emerging Role of CBCT

Imaging in ENT

The first application of cone beam computed

tomography (CBCT) outside the dento-­
maxillofacial region was as an in-office volumet-
ric scanner for ENT clinical situations (Fig. 27.1).
Portable CBCT units such as Xoran xCAT
(XoranTechnologies Inc., Ann Arbor, MI) and
Medtronic O-ARM (Medtronic Inc., Minneapolis,
MN) are now emerging for intraoperative use
(Fig. 27.2) (Conley et al. 2011).
CBCT imaging offers numerous advantages
over CT in ENT applications: Fig. 27.1  Volumetric cone-beam CT scanners acquire
multiple slices in one pass of the gantry. Office-based ver-
• Less expensive. The use of flat-panel detector sions, such as the MiniCAT™ (Xoran Technologies, Ann
Arbor, MI) shown here, allow convenient CT scanning in
technology in CBCT units rather than a detec-
a clinic setting. Preoperative CT scans are performed
tor array for MDCT reduces the cost of the expeditiously for download into any available image-­
equipment substantially. guidance system
27  CBCT-Based Image Guidance for Sinus and Skull Base Surgery
Fig. 27.2 Image-guided
surgical navigation
during endoscopic sinus
surgery (white arrow).
Stereotactic information
is portrayed in the
coronal, axial, and
sagittal planes
(BrainLab™, Munich,
Germany)
CBCT imaging provides data volumetrically
in one pass of the gantry, without translation, so
that patients can be scanned faster than on MDCT
scanners (Fig. 27.1). With the dramatic increase
in image processing and the ongoing develop-
ment of digital imaging, the use of volumetric
imaging is adding a previously unknown level of
diagnostic support to otolaryngologists
(Siewerdsen and Jaffray 2001; Sukovic 2003).
CBCT produces the equivalent of MDCT bone
window images at a greatly reduced radiation
dose (Aldrich et al. 2006; Cohnen et al. 2006) as
well as section thickness, and is on the verge of
revolutionizing CT imaging for otolaryngology.
27.2.2 Sinus Surgery
The origins of sinus surgery can be traced to
ancient Egypt (Reardon 2002). In the nineteenth
century, Caldwell and Luc independently
described techniques to specifically address
maxillary sinusitis. The Caldwell-Luc approach,
as well as other external approaches, aimed to
eradicate diseased mucosa of affected sinuses
1059
(Reardon 2002). In 1967, Messerklinger
described localized disruptions of mucociliary
clearance occurring in areas of mucosal contact
(Messerklinger 1967; Kennedy et al. 1985). He
felt that inflammation was most likely to occur in
the narrow channel of the middle meatus and
ethmoid air cells (Kennedy et al. 1985). With the
advent of high resolution optics and endoscopes,
functional endoscopic sinus surgery (FESS) was
developed as a means to correct the underlying
pathology of the osteomeatal unit (OMU)
(Kennedy et al. 1985). Zinreich et al. (1987)
noted that coronal computed tomography (CT) is
the best imaging technique to examine the
OMU. With the complimentary techniques of
nasal endoscopy and CT imaging, the anatomic
spatial relationships of the paranasal sinuses can
now be appreciated like never before.
27.2.2.1 F  unctional Endoscopic Sinus
Surgery
Functional endoscopic sinus surgery (FESS)
has now become one of the most common
­otolaryngologic surgical procedures in ENT (Wise
and DelGaudio 2005). The success rate of FESS
1060
has been reported to be as high as 80–90%
(Kennedy and Senior 1997). Endoscopic sinus
techniques have evolved from diagnosis and treat-
ment of inflammatory disease into approaches for
a variety of neoplastic and skull base lesions.
Endoscopic approaches are now widely utilized
for the management of mucoceles, skull base
defects, CSF leaks of the anterior skull base,
benign tumors, orbital and optic nerve decompres-
sion, and dacryocystorhinostomies. Furthermore,
the boundaries for the ­endoscopic approach to the
sinuses have been expanded to include the endo-
scopic resection of appropriately selected parana-
sal sinus malignancies and pituitary tumors. Basic
techniques for the treatment of inflammatory
disease have evolved as a result of increasing
­ axial, and sagittal planes.
­recognition of the importance of mucoperiosteal
preservation and improving knowledge with
regard to disease pathogenesis and management.
Because of the variability of the anatomy and the
critical relationships of the sinuses to the orbit and
brain, endoscopic surgical techniques require a
detailed knowledge of the anatomy and embryol-
ogy to avoid potentially disastrous complications.
Complications of Endoscopic Sinus
Surgery
Despite the increasing popularity of endoscopic
sinus surgery, the procedure is fraught with poten-
tial morbidity due to orbital and intracranial com-
plications. Complications of FESS are either major
or minor (Kennedy et al. 1994). Major complica-
tions include CSF leak or intracranial injury, orbital
hematoma, blindness, diplopia, extraocular muscle
injury, or death. Minor complications include naso-
lacrimal duct injury, adhesions, or hemorrhage.
While there is a less than 1% incidence of compli-
cations with FESS, it is one of the most commonly
litigated procedures in otolaryngology (Wise and
DelGaudio 2005). Ways to decrease complications
and improve surgical accuracy are needed.
27.2.2.2 Image-Guided Sinus Surgery
The development of new technologies for endo-
scopic sinus surgery has increased the ability for
the surgeon to maneuver safely through dis-
B.A. Woodworth et al.
eased or surgically altered sinus anatomy. In
particular, the development of image-guidance
or computer-­aided systems provides a method
for sinus surgeons to monitor surgical instru-
ments relative to a preoperative CT scan and
navigate skull base and orbital walls with more
precision (Fig. 27.2). Image-guided surgery
(IGS) links the patient’s radiographic and endo-
scopic images (Fried and Morrison 1998). High-
resolution preoperative axial images are
reformatted and registration links the space
defined by the virtual space of the reformatted
images (Fried and Morrison 1998; Wise and
DelGaudio 2005). These computer systems pro-
vide continuous information in the coronal,
History
Image-guidance has its origins within the field of
neurosurgery. In the 1970s, neurosurgeons began
to first use IGS to target specific areas of the brain
to eliminate tremors, drain abscesses, and treat
pain (Fried and Morrison 1998; Palmer and
Kennedy 2005; Wise and DelGaudio 2005). They
utilized rigid frame fixation of patients’ heads
and plain film radiographs for anatomic localiza-
tion. The bulky frames often obstructed access to
patients and made procedures cumbersome. In
addition, the use of two-dimensional plain radio-
graphs lacked precision. By 1976, the incorpora-
tion of CT with IGS resulted in a system that
allowed for improved three-dimensional visual-
ization of the paranasal sinuses and skull base.
Repeat CT imaging was performed using a
CT-dependent frame with diagonal rods that
served as fiducial markers for the computer
(Perry et al. 1980). Stereotactic ability was con-
veyed by the CT scanner itself so that repeat
scans could be obtained during surgery to con-
firm the position of the probe tip. Because of the
impractical nature of using large CT scanners in
the operating room and associated high radiation
exposures, intraoperative imaging was aban-
doned for one preoperative imaging sequence
that could be applied to a CT-dependent frame.
Subsequently, frameless stereotactic image-­
27  CBCT-Based Image Guidance for Sinus and Skull Base Surgery
guidance systems were developed and incorpo-
rated into neurosurgical procedures.
Because neurosurgical procedures ultimately
involve soft tissue, anatomic shift decreases the
utility of this technology for neurosurgical pur-
poses. However, the limits of dissection in endo-
scopic sinus surgery are the bony boundaries of
the skull base and orbit—stable structures with
no anatomic shift. Therefore, image-guidance
systems were aptly suited for this type of surgery.
Frameless, stereotactic image-guidance systems
were incorporated into endoscopic sinus surgery
for skull base and orbital wall navigation in an
attempt to make the procedure safer and more
complete.
Accuracy
The popularity of this image-guidance technol-
ogy has led to the development of many systems
which are now in common practice. Each sys-
tem has a method of anatomical point registra-
tion, a localization device, and a computerized
interface that will determine the anatomic accu-
racy of image-guidance during the procedure.
The incorporation of real-time endoscopic
views as part of the navigation screen is an
added benefit.
Despite these advantages, the accuracy of
image-guidance systems is the most crucial fac-
tor in an area where a few millimeters separate
the sinonasal cavity from the brain and eye
(Woodworth et al. 2005).
The accuracy of these systems has been stud-
ied by numerous investigators, with results
reporting accuracy within a few millimeters
(Kato et al. 1991; Anon et al. 1994; Fried and
Morrison 1998; Metson et al. 1998; Woodworth
et al. 2005). However, these systems are ulti-
mately dependent on registered anatomical ref-
erence points entered into the system.
Registration of patient landmarks is one of the
most important steps in using this technology.
Most techniques currently used are based on
either paired-point registration methods or
surface-based methods. Point-based methods
­ Fig. 27.3  Endoscopic image of juvenile nasopharyngeal
­determine spatial coordinates of corresponding
1061
points in different images and physical space and
calculate a geometric transformation between
the volumes (Schlaier et al. 2002). This method
usually uses extrinsic fiducial markers and an
electromagnetic tracking system. Surface-based
systems fit numerous points derived from con-
tours in one image set to surface models of coor-
dinates from the patient’s face or head. Since
accuracy typically degrades over the course of a
procedure by almost 1 mm (Maciunas et al.
1992), frequent intraoperative comparison of
known anatomic landmarks to the registered out-
put from the IGS system will ensure higher reli-
ability during the procedure.
Technology Innovations for IGS
Recent updates to this technology include the
integration of CT angiogram and CT/MRI
fusion techniques into computer-aided systems.
Because CT scans do not provide detailed
anatomy of the intracranial vasculature, the
­
incorporation of CT angiograms is a large
improvement in imaging technology for skull
base surgery. CT/MRI fusion facilitates delin-
eation of soft tissue tumors, while providing the
necessary bony anatomic boundaries and land-
marks for intraoperative navigation (Figs. 27.3,
27.4 and 27.5). Although some authors have
angiofibroma
1062
Fig. 27.4  Same patient as Fig. 27.3 (juvenile nasopha-
ryngeal angiofibroma) showing preoperative fusion of CT
and MRI (insert) images on image-guided software pro-
proposed MRI surgical navigation alone in both
sinus and skull base surgery (Pergolizzi et al.
2001; Suzuki et al. 2005), CT/MRI fusion tech-
niques are likely superior due to the ability to
combine the best aspects of each technology.
B.A. Woodworth et al.
gram. Superimposition of MRI image assists in distin-
guishing tumor from surrounding inflammatory disease
Historically, conventional image-guidance sys-
tems do not provide true real-time updated imag-
ing while the patient is still on the operating table.
Once data has been acquired for these navigation
systems, they do not provide the opportunity for
any modification of the data sets themselves.
27  CBCT-Based Image Guidance for Sinus and Skull Base Surgery 1063

Fig. 27.5  Same patient as Fig. 27.3 (juvenile nasopharyngeal angiofibroma) showing marking technology to outline
the tumor seen on image fusion. The tumor is shaded in red

One such attempt to remedy this problem is
through the application of Eraser software
(BrainLab, Germany). This software provides the
ability to digitally erase sinus disease or tumor
from the preoperative CT scan based upon intra-
operative tracking of the surgical instruments
(Fig. 27.6). This technology is very useful if the
disease or tumor is confined by the bony anatomy
of the sinuses and skull base where the surgeon
obtains a virtual image update of the actual surgi-
cal progress. However, the utility of this software
decreases dramatically when surgery extends
beyond the bony boundaries of the sinuses into
soft tissue (i.e., pituitary surgery). Soft tissue col-
lapse and anatomic shift effectively limits this
technology. Therefore, updating the actual MRI
or CT images in the IGS could eliminate these
shortcomings (Figs. 27.7 and 27.8).
1064 B.A. Woodworth et al.

Fig. 27.6  An intraoperative endoscopic view with triplanar CT imaging of a patient with a left supraorbital ethmoid
mucocele and corresponding skull base erosion
27  CBCT-Based Image Guidance for Sinus and Skull Base Surgery 1065

Fig. 27.7  Same patient as Fig. 27.6 (supraorbital ethmoid mucocele). Upon entering the mucocele, the Eraser software
program begins to digitally “erase” the mucocele based on the path of the instrument
1066 B.A. Woodworth et al.

Fig. 27.8  Same patient as Fig. 27.6 (supraorbital ethmoid mucocele triplanar CT imaging with extensive digital simu-
lated “erasure” reveals the full extent of the mucocele beyond the skull base

27.3 Intraoperative Imaging
for IGS
Intraoperative imaging acquisition with both CT
and MRI during sinus or skull base surgery is not a
novel concept (Fried et al. 1998a, b; Cartellieri and
Vorbeck 2000; Pergolizzi et al. 2001). Previously,
Cartellieri and Vorbeck (2000) published a report
of six patients who underwent intraoperative con-
ventional CT scanning during endoscopic sinus
surgery in order to provide an update to their
image-guidance system. Unfortunately, this study
required additional staff to operate the CT, the
operation to be performed on a CT table, and a
complete CT data set for updating the three-dimen-
sional navigation system. This resulted in pro-
longed anesthesia ranging from 20 to 60 min.
New compact, portable CT scanners (xCAT™,
Xoran Technologies, Ann Arbor, MI) can now
provide intraoperative CT scans of the sinuses
and skull-base for real-time update of image-­
guidance systems (Fig. 27.9).
This volumetric cone-beam CT scanner con-
tains an X-ray source and detector mounted on a
27  CBCT-Based Image Guidance for Sinus and Skull Base Surgery
Fig. 27.9 Intraoperative
CT with the xCAT—a
mobile cone-beam
scanner. A special head
rest allows rotation of
the gantry for image
acquisition. CT scans
are then transferred into
the surgical navigation
system of preference for
a real-time update of the
images
rotating scanning arm, a personal computer with
an integrated wide screen monitor, and an image-­
processing unit. During one rotation of the scan-
ning arm, the detector collects the flux of X-rays
that have passed through the patient. Cone-beam
CT scanners utilize a two-dimensional multi-row
detector, which allows for a single rotation of the
gantry to generate a scan of the entire head, as
compared to conventional, full body “fan-beam”
CT scanners whose multiple “slices” must be
stacked to obtain a complete image. Thus, this
system displays scans on its integrated monitor in
less than 3 min. Cone-beam technology utilizes
X-rays much more efficiently, requires far less
electrical energy, and allows for the use of more
compact X-ray components than fan-beam tech-
nology (Perry et al. 1980; Siewerdsen and Jaffray
2001; Sukovic 2003). The effective radiation
dose to the patient is as low as 0.25 millisievert
(mSV), while the radiation dose from a full-body
CT scanner is an average of 10 times higher
(Aldrich et al. 2006; Cohnen et al. 2006).
With the practicality of a mobile, CT scanner
and the ability to obtain slice thickness as little
as 0.2 mm, real-time updates of intraoperative
image guidance systems can be performed in as
little as 10 min. Numerous authors have reported
that this feature allows for endoscopic sinus
1067
s­ urgeons to check the thoroughness of surgery
to either extirpate sinus cells or fully resect bony
and soft tissue lesions of the sinuses and skull
base (Fig. 27.10). Jackman et al. (2008) showed
that intraoperative CT scanning performed at
the conclusion of FESS surgery lead to an alter-
ation in the surgical plan in 30% of patients.
Jeon et al. (2013) used intraoperative CT to
determine the extent of resection of tumor,
degree of hematoma removal, confirmation of
catheter placement, and monitoring unexpected
complications and found that overall 7% of sur-
geries required additional surgical procedures
based on imaging.
27.3.1 Does IGS Increase Safety
in Sinus Surgery?
Although IGS has been used in sinus surgery for
over a decade, the real value of IGS in sinus sur-
gery remains to be determined. Randomizing a
cohort of subjects to a therapeutic intervention
that could place them at an increased risk is
unethical. Thus, there are no randomized, con-
trolled trials on whether IGS contributes to the
safety of surgery. Furthermore, the quality of
information that is available is very poor and
1068
a b
Fig. 27.10  Intraoperative endoscopic view and triplanar
CT imaging of a patient with bilateral nasal polyposis and
a right frontal recess cell extending into the frontal sinus
(type III) (a). During real-time update of image-guidance
l­imited to retrospective case series and expert
opinion. Practicing otolaryngologists gave their
views regarding image-guided sinus surgery in a
survey study published by Hepworth et al. (2006).
Approximately 75% of otolaryngologists stated
that IGS was used in all or some of their cases,
while the remaining 25% never used IGS. The
chief reason cited for not using IGS was cost
(34%). Although 80% of respondents felt that
IGS increased safety, this reflects an opinion and
does not indicate the actual impact of IGS on
safety outcomes during sinus surgery. Yet, despite
the differences in opinion, the overwhelming
majority (84%) believed that IGS had a role in a
subset of surgical cases.
Currently, the American Academy of
Otolaryngology-Head and Neck Surgery feels
B.A. Woodworth et al.
with the xCAT CT scan, it is possible to superimpose
images (boxes) (b) Clearance of polyps and bone in the
frontal recess is evident with the initiation of the type III
frontal cell dissection on the left hand image (arrow) (c)
there is sufficient expert consensus opinion and
evidence in the literature to endorse the use of
IGS in appropriately selected cases (Marple and
Setzen 2006). The Academy is also of the opinion
that it is impossible to corroborate this with Level
1 evidence. Appropriate indications purportedly
include revision surgery, extensive polyposis,
disease involving the skull base, post-traumatic,
benign or malignant tumors, and pathology
involving the frontal, posterior ethmoid and sphe-
noid sinuses.
27.3.2 Other Applications for IGS
Despite the acceptance and widespread use of
image-guidance in endoscopic sinus surgery, this
27  CBCT-Based Image Guidance for Sinus and Skull Base Surgery
technology has not been universally incorporated
into other fields within otolaryngology. In otol-
ogy and neurotology, image-guidance systems
have been used for middle cranial fossa surgery,
aural atresia, cochlear implantation, and
approaches to the petrous apex (Sargent and
Bucholz 1997; Caversaccio et al. 2003; Van
Havenbergh et al. 2003; Miller et al. 2006;
Rafferty et al. 2006). However, the use of these
systems is rare and not generally accepted as ben-
eficial for routine use by otologic and neuroto-
logic surgeons. Other applications within
otolaryngology have been limited to needle biop-
sies and facial trauma (Fried et al. 1998a, b;
Kokoska et al. 2003; Stuck et al. 2012). As
always, the system itself cannot be used in place
of detailed, thorough knowledge of head and
neck anatomy.
27.4 Future Directions
In the future, the development of compact, intra-
operative MRI scanners will provide real-time
up-to-date registrations for image guidance sys-
tems. This will be most beneficial in the fields of
skull base surgery and neurosurgery, because
the anatomic shift of soft tissue during proce-
dures will become a non-factor in the accuracy
of the system. Other future possibilities include
combined systems (CT with IGS, MRI with
IGS) as well as intraoperative imaging and IGS
applications for soft tissue surgery in the head
and neck.
Conclusion
While technological advances will continue to
increase the clinical utility of image-guided
surgery systems, the ultimate responsibility
for accuracy and anatomic localization in any
procedure lies with the surgeon. This technol-
ogy does not eliminate potential intracranial
or orbital complications and is no substitute
for expert knowledge of the anatomy and
sound surgical training. However, IGS does
provide additional information for intraopera-
tive decision-making, especially in the
absence of normal anatomic landmarks.
1069
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