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Ding AS, Lu A, Li Z, Sahu M, Galaiya D, Siewerdsen JH, Unberath M, Taylor RH, Creighton FX. A Self-Configuring Deep Learning Network for Segmentation of Temporal Bone Anatomy in Cone-Beam CT Imaging. Otolaryngol Head Neck Surg 2023; 169:988-998. [PMID: 36883992 PMCID: PMC11060418 DOI: 10.1002/ohn.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/19/2023] [Accepted: 02/19/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE Preoperative planning for otologic or neurotologic procedures often requires manual segmentation of relevant structures, which can be tedious and time-consuming. Automated methods for segmenting multiple geometrically complex structures can not only streamline preoperative planning but also augment minimally invasive and/or robot-assisted procedures in this space. This study evaluates a state-of-the-art deep learning pipeline for semantic segmentation of temporal bone anatomy. STUDY DESIGN A descriptive study of a segmentation network. SETTING Academic institution. METHODS A total of 15 high-resolution cone-beam temporal bone computed tomography (CT) data sets were included in this study. All images were co-registered, with relevant anatomical structures (eg, ossicles, inner ear, facial nerve, chorda tympani, bony labyrinth) manually segmented. Predicted segmentations from no new U-Net (nnU-Net), an open-source 3-dimensional semantic segmentation neural network, were compared against ground-truth segmentations using modified Hausdorff distances (mHD) and Dice scores. RESULTS Fivefold cross-validation with nnU-Net between predicted and ground-truth labels were as follows: malleus (mHD: 0.044 ± 0.024 mm, dice: 0.914 ± 0.035), incus (mHD: 0.051 ± 0.027 mm, dice: 0.916 ± 0.034), stapes (mHD: 0.147 ± 0.113 mm, dice: 0.560 ± 0.106), bony labyrinth (mHD: 0.038 ± 0.031 mm, dice: 0.952 ± 0.017), and facial nerve (mHD: 0.139 ± 0.072 mm, dice: 0.862 ± 0.039). Comparison against atlas-based segmentation propagation showed significantly higher Dice scores for all structures (p < .05). CONCLUSION Using an open-source deep learning pipeline, we demonstrate consistently submillimeter accuracy for semantic CT segmentation of temporal bone anatomy compared to hand-segmented labels. This pipeline has the potential to greatly improve preoperative planning workflows for a variety of otologic and neurotologic procedures and augment existing image guidance and robot-assisted systems for the temporal bone.
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Affiliation(s)
- Andy S. Ding
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander Lu
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zhaoshuo Li
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manish Sahu
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Deepa Galaiya
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey H. Siewerdsen
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mathias Unberath
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Russell H. Taylor
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Francis X. Creighton
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Geiger L, Zuniga MG, Lenarz T, Majdani O, Rau TS. Drilling accuracy evaluation of a mouldable surgical targeting system for minimally invasive access to anatomic targets in the temporal bone. Eur Arch Otorhinolaryngol 2023; 280:4371-4379. [PMID: 37010602 PMCID: PMC10477231 DOI: 10.1007/s00405-023-07925-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE Minimally invasive cochlear implant surgery using a micro-stereotactic surgical targeting system with on-site moulding of the template aims for a reliable, less experience-dependent access to the inner ear under maximal reduction of trauma to anatomic structures. We present an accuracy evaluation of our system in ex-vivo testing. METHODS Eleven drilling experiments were performed on four cadaveric temporal bone specimens. The process involved preoperative imaging after affixing the reference frame to the skull, planning of a safe trajectory preserving relevant anatomical structures, customization of the surgical template, execution of the guided drilling and postoperative imaging for determination of the drilling accuracy. Deviation between the drilled and desired trajectories was measured at different depths. RESULTS All drilling experiments were successfully performed. Other than purposely sacrificing the chorda tympani in one experiment, no other relevant anatomy, such as facial nerve, chorda tympani, ossicles or external auditory canal were harmed. Deviation between the desired and achieved path was found to be 0.25 ± 0.16 mm at skulls' surface and 0.51 ± 0.35 mm at the target level. The closest distance of the drilled trajectories' outer circumference to the facial nerve was 0.44 mm. CONCLUSIONS We demonstrated the usability for drilling to the middle ear on human cadaveric specimen in a pre-clinical setting. Accuracy proved to be suitable for many applications such as procedures within the field of image-guided neurosurgery. Promising approaches to reach sufficient submillimetre accuracy for CI surgery have been outlined.
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Affiliation(s)
- Lena Geiger
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - M Geraldine Zuniga
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Ear Medical Group, San Antonio, TX, USA
- Tecnologico de Monterrey, Instituto de Otorrinolaringologia, Hospital Zambrano Hellion, TecSalud, San Pedro Garza Garcia, Mexico
| | - Thomas Lenarz
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Omid Majdani
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas S Rau
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Hajr E, Abdelsamad Y, Almuhawas F, Alashour A, Hagr A. Cochlear Implantation: The use of OTOPLAN Reconstructed Images in Trajectory Identification. EAR, NOSE & THROAT JOURNAL 2023:1455613221134742. [PMID: 36609169 DOI: 10.1177/01455613221134742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This study aimed to define the best electrode trajectory line in cochlear implant (CI) surgery using the OTOPLAN (otology planning software) reconstructed 3D model and to investigate the surgical distance of the retro-facial approach as a direct access to the round window. METHODS Computed tomography (CT) scans of the normal temporal bone were included for analysis in this study. OTOPLAN reconstruction was used to build 3D models with specific ear structures for study analysis. RESULTS Twenty-five scans were included; the average age at the time of CT scan was 6.8±12 years. Twelve scans (48%) were right-sided and thirteen (52%) were left-sided. The best trajectory line to the round window was identified in all scans. The retro-facial approach was the optimal approach for 52% of cases (13/25). In all scans, the safe distance from the facial nerve were in favor of the retro-facial approach (P = 0.0011). CONCLUSION The OTOPLAN reconstructed imaging provided a good analysis of the retro-facial approach and helped in planning the surgical trajectory line towards the round window. Additionally, calculation of the surgical distance can help the surgeon compare the retro-facial approach to the standard facial recess for preoperative planning. These findings may help in robotic surgery.
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Affiliation(s)
- Eman Hajr
- Department of Otolaryngology, Imam Mohammad Ibn Saud Islamic University, Saudi Arabia
- King Abdullah Ear Specialist Center (KAESC), College of medicine , King Saud University, Riyadh, Saudi Arabia
| | | | - Fida Almuhawas
- King Abdullah Ear Specialist Center (KAESC), College of medicine , King Saud University, Riyadh, Saudi Arabia
| | - Amnah Alashour
- Department of Otolaryngology, Imam Mohammad Ibn Saud Islamic University, Saudi Arabia
| | - Abdulrahman Hagr
- King Abdullah Ear Specialist Center (KAESC), College of medicine , King Saud University, Riyadh, Saudi Arabia
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Omari A, Frendø M, Sørensen MS, Andersen SAW, Frithioff A. The cutting edge of customized surgery: 3D-printed models for patient-specific interventions in otology and auricular management-a systematic review. Eur Arch Otorhinolaryngol 2022; 279:3269-3288. [PMID: 35166908 DOI: 10.1007/s00405-022-07291-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/24/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE 3D-printing (three-dimensional printing) is an emerging technology with promising applications for patient-specific interventions. Nonetheless, knowledge on the clinical applicability of 3D-printing in otology and research on its use remains scattered. Understanding these new treatment options is a prerequisite for clinical implementation, which could improve patient outcomes. This review aims to explore current applications of 3D-printed patient-specific otologic interventions, including state of the evidence, strengths, limitations, and future possibilities. METHODS Following the PRISMA statement, relevant studies were identified through Pubmed, EMBASE, the Cochrane Library, and Web of Science. Data on the manufacturing process and interventions were extracted by two reviewers. Study quality was assessed using Joanna Briggs Institute's critical appraisal tools. RESULTS Screening yielded 590 studies; 63 were found eligible and included for analysis. 3D-printed models were used as guides, templates, implants, and devices. Outer ear interventions comprised 73% of the studies. Overall, optimistic sentiments on 3D-printed models were reported, including increased surgical precision/confidence, faster manufacturing/operation time, and reduced costs/complications. Nevertheless, study quality was low as most studies failed to use relevant objective outcomes, compare new interventions with conventional treatment, and sufficiently describe manufacturing. CONCLUSION Several clinical interventions using patient-specific 3D-printing in otology are considered promising. However, it remains unclear whether these interventions actually improve patient outcomes due to lack of comparison with conventional methods and low levels of evidence. Further, the reproducibility of the 3D-printed interventions is compromised by insufficient reporting. Future efforts should focus on objective, comparative outcomes evaluated in large-scale studies.
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Affiliation(s)
- Adam Omari
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen Hearing and Balance Center, Copenhagen, Denmark.
| | - Martin Frendø
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen Hearing and Balance Center, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR and Education, Region H, Copenhagen, Denmark
| | - Mads Sølvsten Sørensen
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen Hearing and Balance Center, Copenhagen, Denmark
| | - Steven Arild Wuyts Andersen
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen Hearing and Balance Center, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR and Education, Region H, Copenhagen, Denmark
| | - Andreas Frithioff
- Department of Otorhinolaryngology-Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen Hearing and Balance Center, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR and Education, Region H, Copenhagen, Denmark
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Hermann J, Mueller F, Weber S, Caversaccio M, O'Toole Bom Braga G. In Silico Assessment of Safety and Efficacy of Screw Placement for Pediatric Image-Guided Otologic Surgery. Front Surg 2021; 8:736217. [PMID: 34660679 PMCID: PMC8511321 DOI: 10.3389/fsurg.2021.736217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Current high-accuracy image-guided systems for otologic surgery use fiducial screws for patient-to-image registration. Thus far, these systems have only been used in adults, and the safety and efficacy of the fiducial screw placement has not yet been investigated in the pediatric population. Materials and Methods: In a retrospective study, CT image data of the temporal region from 11 subjects meeting inclusion criteria (8–48 months at the time of surgery) were selected, resulting in n = 20 sides. These datasets were investigated with respect to screw stability efficacy in terms of the cortical layer thickness, and safety in terms of the distance of potential fiducial screws to the dura mater or venous sinuses. All of these results are presented as distributions, thickness color maps, and with descriptive statistics. Seven regions within the temporal bone were analyzed individually. In addition, four fiducial screws per case with 4 mm thread-length were placed in an additively manufactured model according to the guidelines for robotic cochlear implantation surgery. For all these screws, the minimal distance to the dura mater or venous sinuses was measured, or if applicable how much they penetrated these structures. Results: The cortical layer has been found to be mostly between 0.7–3.3 mm thick (from the 5th to the 95th percentile), while even thinner areas exist. The distance from the surface of the temporal bone to the dura mater or the venous sinuses varied considerably between the subjects and ranged mostly from 1.1–9.3 mm (from the 5th to the 95th percentile). From all 80 placed fiducial screws of 4 mm thread length in the pediatric subject younger than two years old, 22 touched or penetrated either the dura or the sigmoid sinus. The best regions for fiducial placement would be the mastoid area and along the petrous pyramid in terms of safety. In terms of efficacy, the parietal followed by the petrous pyramid, and retrosigmoid regions are most suited. Conclusion: The current fiducial screws and the screw placement guidelines for adults are insufficiently safe or effective for pediatric patients.
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Affiliation(s)
- Jan Hermann
- ARTORG Center for Biomedical Engineering Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Fabian Mueller
- ARTORG Center for Biomedical Engineering Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Gabriela O'Toole Bom Braga
- ARTORG Center for Biomedical Engineering Research, Faculty of Medicine, University of Bern, Bern, Switzerland
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6
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Panara K, Shahal D, Mittal R, Eshraghi AA. Robotics for Cochlear Implantation Surgery: Challenges and Opportunities. Otol Neurotol 2021; 42:e825-e835. [PMID: 33993143 DOI: 10.1097/mao.0000000000003165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Recent advancements in robotics have set forth a growing body of evidence for the clinical application of the robotic cochlear implantation (RCI), with many potential benefits. This review aims to summarize these efforts, provide the latest developments in this exciting field, and explore the challenges associated with the clinical implementation of RCI. DATA SOURCES MEDLINE, PubMed, and EMBASE databases. STUDY SELECTION A search was conducted using the keywords "robotics otolaryngology," "robotic cochlear implant," "minimally-invasive cochlear implantation," "minimally-invasive mastoidectomy," and "percutaneous cochlear implant" with all of their synonyms. Literature selection criteria included articles published in English, and articles from 1970 to present. RESULTS The use of robotics in neurotology is a relatively new endeavor that continues to evolve. Robotics is being explored by various groups to facilitate in the various steps of cochlear implant surgery, including drilling a keyhole approach to the middle ear for implants, inner ear access, and electrode insertion into the cochlea. Initial clinical trials have successfully implanted selected subjects using robotics. CONCLUSIONS The use of robotics in cochlear implants remains in its very early stages. It is hoped that robotics will improve clinical outcomes. Although successful implants with robots are reported in the literature, there are some challenges that need to be addressed before this approach can become an acceptable option for the conventional cochlear implant surgery, such as safety, time, efficiency, and cost. However, it is hoped that further advancements in robotic technology will help in overcoming these barriers leading to successful implementation for clinical utility.
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Affiliation(s)
- Kush Panara
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
| | - David Shahal
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
| | - Rahul Mittal
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
| | - Adrien A Eshraghi
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
- Department of Neurological Surgery
- Department of Pediatrics, University of Miami, Miller School of Medicine, Miami, Florida
- Department of Biomedical Engineering, University of Miami, Coral Gables, Florida
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Wang J, Liu H, Ke J, Hu L, Zhang S, Yang B, Sun S, Guo N, Ma F. Image-guided cochlear access by non-invasive registration: a cadaveric feasibility study. Sci Rep 2020; 10:18318. [PMID: 33110188 PMCID: PMC7591497 DOI: 10.1038/s41598-020-75530-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/15/2020] [Indexed: 11/09/2022] Open
Abstract
Image-guided cochlear implant surgery is expected to reduce volume of mastoidectomy, accelerate recovery, and improve safety. The purpose of this study was to investigate the safety and effectiveness of image-guided cochlear implant surgery by a non-invasive registration method, in a cadaveric study. We developed a visual positioning frame that can utilize the maxillary dentition as a registration tool and completed the tunnels experiment on 5 cadaver specimens (8 cases in total). The accuracy of the entry point and the target point were 0.471 ± 0.276 mm and 0.671 ± 0.268 mm, respectively. The shortest distance from the margin of the tunnel to the facial nerve and the ossicular chain were 0.790 ± 0.709 mm and 1.960 ± 0.630 mm, respectively. All facial nerves, tympanic membranes, and ossicular chains were completely preserved. Using this approach, high accuracy was achieved in this preliminary study, suggesting that the non-invasive registration method can meet the accuracy requirements for cochlear implant surgery. Based on the above accuracy, we speculate that our method can also be applied to neurosurgery, orbitofacial surgery, lateral skull base surgery, and anterior skull base surgery with satisfactory accuracy.
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Affiliation(s)
- Jiang Wang
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Hongsheng Liu
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Jia Ke
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Lei Hu
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Shaoxing Zhang
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Biao Yang
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Shilong Sun
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Na Guo
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Furong Ma
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Ansó J, Dür C, Apelt M, Venail F, Scheidegger O, Seidel K, Rohrbach H, Forterre F, Dettmer MS, Zlobec I, Weber K, Matulic M, Zoka-Assadi M, Huth M, Caversaccio M, Weber S. Prospective Validation of Facial Nerve Monitoring to Prevent Nerve Damage During Robotic Drilling. Front Surg 2019; 6:58. [PMID: 31632981 PMCID: PMC6781655 DOI: 10.3389/fsurg.2019.00058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/09/2019] [Indexed: 11/30/2022] Open
Abstract
Facial nerve damage has a detrimental effect on a patient's life, therefore safety mechanisms to ensure its preservation are essential during lateral skull base surgery. During robotic cochlear implantation a trajectory passing the facial nerve at <0.5 mm is needed. Recently a stimulation probe and nerve monitoring approach were developed and introduced clinically, however for patient safety no trajectory was drilled closer than 0.4 mm. Here we assess the performance of the nerve monitoring system at closer distances. In a sheep model eight trajectories were drilled to test the setup followed by 12 trajectories during which the ENT surgeon relied solely on the nerve monitoring system and aborted the robotic drilling process if intraoperative nerve monitoring alerted of a distance <0.1 mm. Microcomputed tomography images and histopathology showed prospective use of the technology prevented facial nerve damage. Facial nerve monitoring integrated in a robotic system supports the surgeon's ability to proactively avoid damage to the facial nerve during robotic drilling in the mastoid.
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Affiliation(s)
- Juan Ansó
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Cilgia Dür
- Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Mareike Apelt
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Frederic Venail
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Montpellier, Montpellier, France
| | | | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Helene Rohrbach
- Vetsuisse Faculty, Veterinary Hospital, University of Bern, Bern, Switzerland
| | - Franck Forterre
- Vetsuisse Faculty, Veterinary Hospital, University of Bern, Bern, Switzerland
| | | | - Inti Zlobec
- Institute of Pathology, University of Bern, Bern, Switzerland
| | | | | | | | - Markus Huth
- Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
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9
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Morrel WG, Jayawardena ADL, M Amberg S, Dawant BM, Noble JH, Labadie RF. Revision surgery following minimally invasive image-guided cochlear implantation. Laryngoscope 2018; 129:1458-1461. [PMID: 30582165 DOI: 10.1002/lary.27636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 08/27/2018] [Accepted: 09/04/2018] [Indexed: 11/10/2022]
Abstract
Minimally invasive image-guided cochlear implantation (CI) research continues to progress. We previously performed the procedure in nine patients. Herein, we describe the first revision operation for device failure following minimally invasive image-guided CI. It was possible to reuse the original drill channel, obviating the need to convert to a wide-field mastoidectomy. Revision surgery, if required, can therefore be performed safely after minimally invasive image-guided CI. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1458-1461, 2019.
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Affiliation(s)
| | | | - Susan M Amberg
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Benoit M Dawant
- Department of Electrical Engineering and Computer Science, Nashville, Tennessee, U.S.A
| | - Jack H Noble
- Department of Electrical Engineering and Computer Science, Nashville, Tennessee, U.S.A
| | - Robert F Labadie
- Department of Otolaryngology, Nashville, Tennessee, U.S.A.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, U.S.A
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10
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Schieferbein V, Bredemann J, Schmitt R, Stenin I, Klenzner T, Schipper J, Kristin J. Influence of patient-specific anatomy on medical computed tomography and risk evaluation of minimally invasive surgery at the otobasis. Eur Arch Otorhinolaryngol 2018; 276:375-382. [PMID: 30554360 DOI: 10.1007/s00405-018-5249-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/12/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE With the increasing use of new minimally invasive approaches in temporal bone surgery, the need arises for evaluation of the risk of injury to sensitive anatomical structures. The factors that influence the measurement uncertainty (variation in representation of position and shape of anatomical structures) of imaging are of relevance. We investigate the effect of patients' anatomy on the measurement uncertainty of medical CT. METHODS Six formalin-fixed temporal bones were used, fiducial markers were bone-implanted, and 20 CT scans of each temporal bone were generated. Surgically threatened anatomical structures of importance were defined. Manual segmentation was performed to create 3D surface models, and different Gaussian filters were applied. Analysis points were established along the border of the superior semicircular canal to determine the deviation between the 3D images of the labyrinth. The standard uncertainty was calculated, and one-way analysis of variance was performed (significance level = 5%) to evaluate the effect of certain factors (patient, side, Gaussian filter) on the measurement uncertainty. RESULTS The influence of patient-specific anatomy on the measurement uncertainty of medical CT (p = 0.049) was demonstrated for the first time. The applied Gaussian filter (p = 0.622) and the patient's side (p = 0.341) showed no significant effect. CONCLUSION The applied method and the results of the statistical analysis suggest that the patient's individual anatomical conditions affect the measurement uncertainty of medical CT. Thus, the patient's anatomy must be considered as an important influencing factor during risk evaluation concerning minimally invasive and image-guided surgery.
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Affiliation(s)
- Vanessa Schieferbein
- Department of Otorhinolaryngology, University Hospital Duesseldorf, Duesseldorf, Germany.
| | - Judith Bredemann
- Laboratory for Machine Tools and Production Engineering WZL, Chair of Production Metrology and Quality Management, RWTH Aachen University, Aachen, Germany
| | - R Schmitt
- Laboratory for Machine Tools and Production Engineering WZL, Chair of Production Metrology and Quality Management, RWTH Aachen University, Aachen, Germany
| | - I Stenin
- Department of Otorhinolaryngology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Klenzner
- Department of Otorhinolaryngology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Jörg Schipper
- Department of Otorhinolaryngology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Julia Kristin
- Department of Otorhinolaryngology, University Hospital Duesseldorf, Duesseldorf, Germany
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11
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Ansó J, Scheidegger O, Wimmer W, Gavaghan K, Gerber N, Schneider D, Hermann J, Rathgeb C, Dür C, Rösler KM, Mantokoudis G, Caversaccio M, Weber S. Neuromonitoring During Robotic Cochlear Implantation: Initial Clinical Experience. Ann Biomed Eng 2018; 46:1568-1581. [PMID: 30051248 DOI: 10.1007/s10439-018-2094-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
During robotic cochlear implantation a drill trajectory often passes at submillimeter distances from the facial nerve due to close lying critical anatomy of the temporal bone. Additional intraoperative safety mechanisms are thus required to ensure preservation of this vital structure in case of unexpected navigation system error. Electromyography based nerve monitoring is widely used to aid surgeons in localizing vital nerve structures at risk of injury during surgery. However, state of the art neuromonitoring systems, are unable to discriminate facial nerve proximity within submillimeter ranges. Previous work demonstrated the feasibility of utilizing combinations of monopolar and bipolar stimulation threshold measurements to discretize facial nerve proximity with greater sensitivity and specificity, enabling discrimination between safe (> 0.4 mm) and unsafe (< 0.1 mm) trajectories during robotic cochlear implantation (in vivo animal model). Herein, initial clinical validation of the determined stimulation protocol and nerve proximity analysis integrated into an image guided system for safety measurement is presented. Stimulation thresholds and corresponding nerve proximity values previously determined from an animal model have been validated in a first-in-man clinical trial of robotic cochlear implantation. Measurements performed automatically at preoperatively defined distances from the facial nerve were used to determine safety of the drill trajectory intraoperatively. The presented system and automated analysis correctly determined sufficient safety distance margins (> 0.4 mm) to the facial nerve in all cases.
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Affiliation(s)
- Juan Ansó
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | | | - Wilhelm Wimmer
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland. .,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland.
| | - Kate Gavaghan
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Nicolas Gerber
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Daniel Schneider
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Jan Hermann
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Christoph Rathgeb
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Cilgia Dür
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Kai Michael Rösler
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
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Braga GPB, Gebrim E, Balachandran R, Noble J, Labadie R, Bento RF. Evaluation of the Facial Recess and Cochlea on the Temporal Bone of Stillbirths regarding the Percutaneous Cochlear Implant. Int Arch Otorhinolaryngol 2018; 22:260-265. [PMID: 29983766 PMCID: PMC6033613 DOI: 10.1055/s-0037-1606612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 08/04/2017] [Indexed: 10/30/2022] Open
Abstract
Introduction The literature shows that there are anatomical changes on the temporal bone anatomy during the first four years of life in children. Therefore, we decided to evaluate the temporal bone anatomy regarding the cochlear implant surgery in stillbirths between 32 and 40 weeks of gestational age using computed tomography to simulate the trajectory of the drill to the scala timpani avoiding vital structures. Objectives To measure the distances of the simulated trajectory to the facial recess, cochlea, ossicular chain and tympanic membrane, while performing the minimally invasive cochlear implant technique, using the Improvise imaging software (Vanderbilt University, Nashville, TN, US). Methods An experimental study with 9 stillbirth specimens, with gestational ages ranging between 32 and 40 weeks, undergoing tomographic evaluation with individualization and reconstruction of the labyrinth, facial nerve, ossicular chain, tympanic membrane and cochlea followed by drill path definition to the scala tympani. Improvise was used for the computed tomography (CT) evaluation and for the reconstruction of the structures and trajectory of the drill. Results Range of the distance of the trajectory to the facial nerve: 0.58 to 1.71 mm. to the ossicular chain: 0.38 to 1.49 mm; to the tympanic membrane: 0.85 to 1.96 mm; total range of the distance of the trajectory: 5.92 to 12.65 mm. Conclusion The measurements of the relationship between the drill and the anatomical structures of the middle ear and the simulation of the trajectory showed that the middle ear cavity at 32 weeks was big enough for surgical procedures such as cochlear implants. Although cochlear implantation at birth is not an indication yet, this study shows that the technique may be an option in the future.
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Affiliation(s)
| | - Eloisa Gebrim
- Department of Radiology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ramya Balachandran
- Department of Otolaryngology Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, United States
| | - Jack Noble
- Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, United States
| | - Robert Labadie
- Department of Otolaryngology Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, United States
| | - Ricardo Ferreira Bento
- Department of Otolaryngology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Caversaccio M, Gavaghan K, Wimmer W, Williamson T, Ansò J, Mantokoudis G, Gerber N, Rathgeb C, Feldmann A, Wagner F, Scheidegger O, Kompis M, Weisstanner C, Zoka-Assadi M, Roesler K, Anschuetz L, Huth M, Weber S. Robotic cochlear implantation: surgical procedure and first clinical experience. Acta Otolaryngol 2017; 137:447-454. [PMID: 28145157 DOI: 10.1080/00016489.2017.1278573] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION A system for robotic cochlear implantation (rCI) has been developed and a corresponding surgical workflow has been described. The clinical feasibility was demonstrated through the conduction of a safe and effective rCI procedure. OBJECTIVES To define a clinical workflow for rCI and demonstrate its feasibility, safety, and effectiveness within a clinical setting. METHOD A clinical workflow for use of a previously described image guided surgical robot system for rCI was developed. Based on pre-operative images, a safe drilling tunnel targeting the round window was planned and drilled by the robotic system. Intra-operatively the drill path was assessed using imaging and sensor-based data to confirm the proximity of the facial nerve. Electrode array insertion was manually achieved under microscope visualization. Electrode array placement, structure preservation, and the accuracy of the drilling and of the safety mechanisms were assessed on post-operative CT images. RESULTS Robotic drilling was conducted with an accuracy of 0.2 mm and safety mechanisms predicted proximity of the nerves to within 0.1 mm. The approach resulted in a minimal mastoidectomy and minimal incisions. Manual electrode array insertion was successfully performed through the robotically drilled tunnel. The procedure was performed without complications, and all surrounding structures were preserved.
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Affiliation(s)
- Marco Caversaccio
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Kate Gavaghan
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tom Williamson
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Juan Ansò
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Gerber
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Christoph Rathgeb
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Arne Feldmann
- Musculoskeletal Biomechanics, Institute for Surgical Technologies and Biomechanics, University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Martin Kompis
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Kai Roesler
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huth
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
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Ke J, Zhang SX, Hu L, Li CS, Zhu YF, Sun SL, Wang LF, Ma FR. Minimally Invasive Cochlear Implantation Assisted by Bi-planar Device: An Exploratory Feasibility Study in vitro. Chin Med J (Engl) 2017; 129:2476-2483. [PMID: 27748341 PMCID: PMC5072261 DOI: 10.4103/0366-6999.191787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: A single drilled tunnel from the lateral mastoid cortex to the cochlea via the facial recess is essential for minimally invasive cochlear implant surgery. This study aimed to explore the safety profile of this kind of new image-guided and bi-planar device-assisted surgery procedure in vitro. Methods: Image-guided minimally invasive cochlear implantations were performed on eight cadaveric temporal bone specimens. The main procedures were: (1) temporal bone specimens were prepared for surgery and fiducial markers were registered. (2) computed tomography (CT) scans were performed for future reference. (3) CT scan images were processed and drill path was planned to minimize cochlear damage. (4) bi-planar device-assisted drilling was performed on the specimens using the registration. (5) surgical safety was evaluated by calculating the deviation between the drill and the planned paths, and by measuring the closest distance between the drilled path and critical anatomic structures. Results: Eight cases were operated successfully to the basal turn of the cochlear with intact facial nerves (FNs). The deviations from target points and entrance points were 0.86 mm (0.68–1.00 mm) and 0.44 mm (0.30–0.96 mm), respectively. The angular error between the planned and the drilled trajectory was 1.74° (1.26–2.41°). The mean distance from the edge of the drilled path to the FN and to the external canal was 0.60 mm (0.35–0.83 mm) and 1.60 mm (1.30–2.05 mm), respectively. In five specimens, the chorda tympani nerves were well preserved. In all cases, no injury happened to auditory ossicles. Conclusions: This exploratory study demonstrated the safety of the newly developed image-guided minimally invasive cochlear implantation assisted by the bi-planar device and established the operational procedures. Further, more in vitro experiments are needed to improve the system operation and its safety.
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Affiliation(s)
- Jia Ke
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Shao-Xing Zhang
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Lei Hu
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Chang-Sheng Li
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Yun-Feng Zhu
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Shi-Long Sun
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Li-Feng Wang
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Fu-Rong Ma
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
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15
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Ke J, Zhang S, Li C, Zhu Y, Hu L, Ma F. Application of bonebed-malleus short process registration in minimally invasive cochlear implantation. Comput Assist Surg (Abingdon) 2016. [DOI: 10.1080/24699322.2016.1240306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Jia Ke
- Department of Otorhinolarygology Head and Neck Surgery, Third Hospital Peking University, Beijing, China
| | - Shaoxing Zhang
- Department of Otorhinolarygology Head and Neck Surgery, Third Hospital Peking University, Beijing, China
| | - Changsheng Li
- School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Yunfeng Zhu
- School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Lei Hu
- School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Furong Ma
- Department of Otorhinolarygology Head and Neck Surgery, Third Hospital Peking University, Beijing, China
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A Neuromonitoring Approach to Facial Nerve Preservation During Image-guided Robotic Cochlear Implantation. Otol Neurotol 2016; 37:89-98. [DOI: 10.1097/mao.0000000000000914] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Kobler JP, Prielozny L, Lexow GJ, Rau TS, Majdani O, Ortmaier T. Mechanical characterization of bone anchors used with a bone-attached, parallel robot for skull surgery. Med Eng Phys 2015; 37:460-8. [PMID: 25771430 DOI: 10.1016/j.medengphy.2015.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/11/2014] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
Bone-attached robots and microstereotactic frames, intended for deep brain stimulation and minimally invasive cochlear implantation, typically attach to a patient's skull via bone anchors. A rigid and reliable link between such devices and the skull is mandatory in order to fulfill the high accuracy demands of minimally invasive procedures while maintaining patient safety. In this paper, a method is presented to experimentally characterize the mechanical properties of the anchor-bone linkage. A custom-built universal testing machine is used to measure the pullout strength as well as the spring constants of bone anchors seated in four different bone substitutes as well as in human cranial bone. Furthermore, the angles at which forces act on the bone anchors are varied to simulate realistic conditions. Based on the experimental results, a substitute material that has mechanical properties similar to those of cranial bone is identified. The results further reveal that the pullout strength of the investigated anchor design is sufficient with respect to the proposed application. However, both the measured load capacity as well as the spring constants vary depending on the load angles. Based on these findings, an alternative bone anchor design is presented and experimentally validated. Furthermore, the results serve as a basis for stiffness simulation and optimization of bone-attached microstereotactic frames.
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Affiliation(s)
- Jan-Philipp Kobler
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 Hanover, Germany.
| | | | | | | | | | - Tobias Ortmaier
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 Hanover, Germany
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Feasibility of using EMG for early detection of the facial nerve during robotic direct cochlear access. Otol Neurotol 2014; 35:545-54. [PMID: 24492132 DOI: 10.1097/mao.0000000000000187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
HYPOTHESIS Facial nerve monitoring can be used synchronous with a high-precision robotic tool as a functional warning to prevent of a collision of the drill bit with the facial nerve during direct cochlear access (DCA). BACKGROUND Minimally invasive direct cochlear access (DCA) aims to eliminate the need for a mastoidectomy by drilling a small tunnel through the facial recess to the cochlea with the aid of stereotactic tool guidance. Because the procedure is performed in a blind manner, structures such as the facial nerve are at risk. Neuromonitoring is a commonly used tool to help surgeons identify the facial nerve (FN) during routine surgical procedures in the mastoid. Recently, neuromonitoring technology was integrated into a commercially available drill system enabling real-time monitoring of the FN. The objective of this study was to determine if this drilling system could be used to warn of an impending collision with the FN during robot-assisted DCA. MATERIALS AND METHODS The sheep was chosen as a suitable model for this study because of its similarity to the human ear anatomy. The same surgical workflow applicable to human patients was performed in the animal model. Bone screws, serving as reference fiducials, were placed in the skull near the ear canal. The sheep head was imaged using a computed tomographic scanner and segmentation of FN, mastoid, and other relevant structures as well as planning of drilling trajectories was carried out using a dedicated software tool. During the actual procedure, a surgical drill system was connected to a nerve monitor and guided by a custom built robot system. As the planned trajectories were drilled, stimulation and EMG response signals were recorded. A postoperative analysis was achieved after each surgery to determine the actual drilled positions. RESULTS Using the calibrated pose synchronized with the EMG signals, the precise relationship between distance to FN and EMG with 3 different stimulation intensities could be determined for 11 different tunnels drilled in 3 different subjects. CONCLUSION From the results, it was determined that the current implementation of the neuromonitoring system lacks sensitivity and repeatability necessary to be used as a warning device in robotic DCA. We hypothesize that this is primarily because of the stimulation pattern achieved using a noninsulated drill as a stimulating probe. Further work is necessary to determine whether specific changes to the design can improve the sensitivity and specificity.
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Nau-Hermes M, Schmitt R, Becker M, El-Hakimi W, Hansen S, Klenzner T, Schipper J. Quality assurance of multiport image-guided minimally invasive surgery at the lateral skull base. BIOMED RESEARCH INTERNATIONAL 2014; 2014:904803. [PMID: 25105146 PMCID: PMC4106086 DOI: 10.1155/2014/904803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/28/2014] [Indexed: 11/17/2022]
Abstract
For multiport image-guided minimally invasive surgery at the lateral skull base a quality management is necessary to avoid the damage of closely spaced critical neurovascular structures. So far there is no standardized method applicable independently from the surgery. Therefore, we adapt a quality management method, the quality gates (QG), which is well established in, for example, the automotive industry and apply it to multiport image-guided minimally invasive surgery. QG divide a process into different sections. Passing between sections can only be achieved if previously defined requirements are fulfilled which secures the process chain. An interdisciplinary team of otosurgeons, computer scientists, and engineers has worked together to define the quality gates and the corresponding criteria that need to be fulfilled before passing each quality gate. In order to evaluate the defined QG and their criteria, the new surgery method was applied with a first prototype at a human skull cadaver model. We show that the QG method can ensure a safe multiport minimally invasive surgical process at the lateral skull base. Therewith, we present an approach towards the standardization of quality assurance of surgical processes.
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Affiliation(s)
- Maria Nau-Hermes
- Chair for Metrology and Quality Management, RWTH Aachen University, Steinbachstr. 19, 52074 Aachen, Germany
| | - Robert Schmitt
- Chair for Metrology and Quality Management, RWTH Aachen University, Steinbachstr. 19, 52074 Aachen, Germany
| | - Meike Becker
- TU Darmstadt, Graphisch-Interaktive Systeme, Fraunhoferstr. 5, 64283 Darmstadt, Germany
| | - Wissam El-Hakimi
- TU Darmstadt, Graphisch-Interaktive Systeme, Fraunhoferstr. 5, 64283 Darmstadt, Germany
| | - Stefan Hansen
- Hals-Nasen-Ohren-Klinik, Universitätsklinikums Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Thomas Klenzner
- Hals-Nasen-Ohren-Klinik, Universitätsklinikums Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Jörg Schipper
- Hals-Nasen-Ohren-Klinik, Universitätsklinikums Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
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Stenin I, Hansen S, Becker M, Sakas G, Fellner D, Klenzner T, Schipper J. Minimally invasive multiport surgery of the lateral skull base. BIOMED RESEARCH INTERNATIONAL 2014; 2014:379295. [PMID: 25101276 PMCID: PMC4101962 DOI: 10.1155/2014/379295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 06/02/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Minimally invasive procedures minimize iatrogenic tissue damage and lead to a lower complication rate and high patient satisfaction. To date only experimental minimally invasive single-port approaches to the lateral skull base have been attempted. The aim of this study was to verify the feasibility of a minimally invasive multiport approach for advanced manipulation capability and visual control and develop a software tool for preoperative planning. METHODS Anatomical 3D models were extracted from twenty regular temporal bone CT scans. Collision-free trajectories, targeting the internal auditory canal, round window, and petrous apex, were simulated with a specially designed planning software tool. A set of three collision-free trajectories was selected by skull base surgeons concerning the maximization of the distance to critical structures and the angles between the trajectories. RESULTS A set of three collision-free trajectories could be successfully simulated to the three targets in each temporal bone model without violating critical anatomical structures. CONCLUSION A minimally invasive multiport approach to the lateral skull base is feasible. The developed software is the first step for preoperative planning. Further studies will focus on cadaveric and clinical translation.
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Affiliation(s)
- Igor Stenin
- Department of Otorhinolaryngology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Stefan Hansen
- Department of Otorhinolaryngology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Meike Becker
- Interactive Graphics Systems Group, Technical University Darmstadt, 64283 Darmstadt, Germany
| | - Georgios Sakas
- Interactive Graphics Systems Group, Technical University Darmstadt, 64283 Darmstadt, Germany
| | - Dieter Fellner
- Interactive Graphics Systems Group, Technical University Darmstadt, 64283 Darmstadt, Germany
| | - Thomas Klenzner
- Department of Otorhinolaryngology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Jörg Schipper
- Department of Otorhinolaryngology, University Hospital Düsseldorf, 40225 Düsseldorf, Germany
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Abstract
HYPOTHESIS A previously developed image-guided robot system can safely drill a tunnel from the lateral mastoid surface, through the facial recess, to the middle ear, as a viable alternative to conventional mastoidectomy for cochlear electrode insertion. BACKGROUND Direct cochlear access (DCA) provides a minimally invasive tunnel from the lateral surface of the mastoid through the facial recess to the middle ear for cochlear electrode insertion. A safe and effective tunnel drilled through the narrow facial recess requires a highly accurate image-guided surgical system. Previous attempts have relied on patient-specific templates and robotic systems to guide drilling tools. In this study, we report on improvements made to an image-guided surgical robot system developed specifically for this purpose and the resulting accuracy achieved in vitro. MATERIALS AND METHODS The proposed image-guided robotic DCA procedure was carried out bilaterally on 4 whole head cadaver specimens. Specimens were implanted with titanium fiducial markers and imaged with cone-beam CT. A preoperative plan was created using a custom software package wherein relevant anatomical structures of the facial recess were segmented, and a drill trajectory targeting the round window was defined. Patient-to-image registration was performed with the custom robot system to reference the preoperative plan, and the DCA tunnel was drilled in 3 stages with progressively longer drill bits. The position of the drilled tunnel was defined as a line fitted to a point cloud of the segmented tunnel using principle component analysis (PCA function in MatLab). The accuracy of the DCA was then assessed by coregistering preoperative and postoperative image data and measuring the deviation of the drilled tunnel from the plan. The final step of electrode insertion was also performed through the DCA tunnel after manual removal of the promontory through the external auditory canal. RESULTS Drilling error was defined as the lateral deviation of the tool in the plane perpendicular to the drill axis (excluding depth error). Errors of 0.08 ± 0.05 mm and 0.15 ± 0.08 mm were measured on the lateral mastoid surface and at the target on the round window, respectively (n =8). Full electrode insertion was possible for 7 cases. In 1 case, the electrode was partially inserted with 1 contact pair external to the cochlea. CONCLUSION The purpose-built robot system was able to perform a safe and reliable DCA for cochlear implantation. The workflow implemented in this study mimics the envisioned clinical procedure showing the feasibility of future clinical implementation.
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Minimally invasive image-guided access for drainage of petrous apex lesions: a case report. Otol Neurotol 2014; 35:649-55. [PMID: 24622019 DOI: 10.1097/mao.0000000000000328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In this case report, we present a novel, minimally invasive image-guided approach to drainage of a petrous apex lesion. PATIENT(S) A 34-year-old man diagnosed with a petrous apex lesion consistent with cholesterol granuloma. The granuloma was large and caused mild compression of the brainstem with associated neurologic symptoms and seizure-like activity. INTERVENTIONS Based on the anatomic location of the lesion, it was determined that the treatment plan would be to surgically drain the lesion via 2 linear paths-one after an infralabyrinthine approach and the other a subarcuate approach. Customized microstereotactic frames that mount on bone-implanted markers and constrain the drill along the desired path were used to accurately drill these desired paths and avoid damage to surrounding critical structures. After a simple mastoidectomy, the petrous apex was successfully reached without damage to vital adjacent structures by drilling the 2 linear channels using 2 custom microstereotactic frames. MAIN OUTCOME MEASURES Viscous brown liquid and debris was recovered by irrigating through one of the channels and suctioning through the other. RESULTS Drainage of the petrous apex was successfully performed via 2 linear channels without any complications. Custom microstereotactic frames were used to accurately drill those linear channels. Postoperative CT ensured no complications. Postoperative course of the patient was remarkable with normal hearing and normal facial nerve function. CONCLUSION We presented a successful implementation of an image-guided approach to drain petrous apex.
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Tuomi J, Paloheimo KS, Vehviläinen J, Björkstrand R, Salmi M, Huotilainen E, Kontio R, Rouse S, Gibson I, Mäkitie AA. A Novel Classification and Online Platform for Planning and Documentation of Medical Applications of Additive Manufacturing. Surg Innov 2014; 21:553-9. [DOI: 10.1177/1553350614524838] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Additive manufacturing technologies are widely used in industrial settings and now increasingly also in several areas of medicine. Various techniques and numerous types of materials are used for these applications. There is a clear need to unify and harmonize the patterns of their use worldwide. We present a 5-class system to aid planning of these applications and related scientific work as well as communication between various actors involved in this field. An online, matrix-based platform and a database were developed for planning and documentation of various solutions. This platform will help the medical community to structurally develop both research innovations and clinical applications of additive manufacturing. The online platform can be accessed through http://www.medicalam.info .
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Affiliation(s)
- Jukka Tuomi
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
| | - Kaija-Stiina Paloheimo
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
| | - Juho Vehviläinen
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
| | - Roy Björkstrand
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
| | - Mika Salmi
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
| | - Eero Huotilainen
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
| | - Risto Kontio
- Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | | | - Ian Gibson
- National University of Singapore, Singapore
| | - Antti A. Mäkitie
- Aalto University, Department of Engineering Design and Production, School of Engineering, Aalto, Espoo, Finland
- Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
- Karolinska Institutet, Division of ENT Diseases, CLINTEC, Stockholm, Sweden
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Rohani P, Pile J, Kahrs LA, Balachandran R, Blachon GS, Simaan N, Labadie RF. Forces and trauma associated with minimally invasive image-guided cochlear implantation. Otolaryngol Head Neck Surg 2014; 150:638-45. [PMID: 24468898 DOI: 10.1177/0194599813519747] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Minimally invasive image-guided cochlear implantation (CI) utilizes a patient-customized microstereotactic frame to access the cochlea via a single drill-pass. We investigate the average force and trauma associated with the insertion of lateral wall CI electrodes using this technique. STUDY DESIGN Assessment using cadaveric temporal bones. SETTING Laboratory setup. SUBJECTS AND METHODS Microstereotactic frames for 6 fresh cadaveric temporal bones were built using CT scans to determine an optimal drill path following which drilling was performed. CI electrodes were inserted using surgical forceps to manually advance the CI electrode array, via the drilled tunnel, into the cochlea. Forces were recorded using a 6-axis load sensor placed under the temporal bone during the insertion of lateral wall electrode arrays (2 each of Nucleus CI422, MED-EL standard, and modified MED-EL electrodes with stiffeners). Tissue histology was performed by microdissection of the otic capsule and apical photo documentation of electrode position and intracochlear tissue. RESULTS After drilling, CT scanning demonstrated successful access to cochlea in all 6 bones. Average insertion forces ranged from 0.009 to 0.078 N. Peak forces were in the range of 0.056 to 0.469 N. Tissue histology showed complete scala tympani insertion in 5 specimens and scala vestibuli insertion in the remaining specimen with depth of insertion ranging from 360° to 600°. No intracochlear trauma was identified. CONCLUSION The use of lateral wall electrodes with the minimally invasive image-guided CI approach was associated with insertion forces comparable to traditional CI surgery. Deep insertions were obtained without identifiable trauma.
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Affiliation(s)
- Pooyan Rohani
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Balachandran R, Reda FA, Noble JH, Blachon GS, Dawant BM, Fitzpatrick JM, Labadie RF. Minimally invasive image-guided cochlear implantation for pediatric patients: clinical feasibility study. Otolaryngol Head Neck Surg 2014; 150:631-7. [PMID: 24449796 DOI: 10.1177/0194599813519050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Minimally invasive image-guided cochlear implantation (CI) involves accessing the cochlea via a linear path from the lateral skull to the cochlea avoiding vital structures including the facial nerve. Herein, we describe and demonstrate the feasibility of the technique for pediatric patients. STUDY DESIGN Prospective. SETTING Children's Hospital. SUBJECTS AND METHODS Thirteen pediatric patients (1.5 to 8 years) undergoing traditional CI participated in this Institutional Review Board-approved study. Three fiducial markers were bone-implanted surrounding the ear, and a CT scan was acquired. The CT scan was processed to identify the marker locations and critical structures of the temporal bone. A safe linear path was determined to target the cochlea avoiding damage to vital structures. A custom microstereotactic frame was fabricated that would mount on the fiducial markers and constrain a tool to the desired trajectory. After traditional mastoidectomy and prior to cochleostomy, the custom microstereotactic frame was mounted on the bone-implanted markers to confirm that the achieved trajectory was safe and accurately accessed the cochlea. RESULTS For all the 13 patients, it was possible to determine a safe trajectory to the cochlea. Custom microstereotactic frames were validated successfully on 9 patients. Two of these patients had inner ear malformations, and this technique helped the surgeon confirm ideal location for cochleostomy. For patients with normal anatomy, the mean and standard deviation of the closest distance of the trajectory to facial nerve and chorda tympani were 1.1 ± 0.3 mm and 1.2 ± 0.5 mm, respectively. CONCLUSION Minimally invasive image-guided CI is feasible for pediatric patients.
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Affiliation(s)
- Ramya Balachandran
- Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, USA
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Labadie RF, Balachandran R, Noble JH, Blachon GS, Mitchell JE, Reda FA, Dawant BM, Fitzpatrick JM. Minimally invasive image-guided cochlear implantation surgery: first report of clinical implementation. Laryngoscope 2014; 124:1915-22. [PMID: 24272427 DOI: 10.1002/lary.24520] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 10/23/2013] [Accepted: 11/11/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Minimally invasive image-guided approach to cochlear implantation (CI) involves drilling a narrow, linear tunnel to the cochlea. Reported herein is the first clinical implementation of this approach. STUDY DESIGN Prospective cohort study. METHODS On preoperative computed tomography (CT), a safe linear trajectory through the facial recess targeting the scala tympani was planned. Intraoperatively, fiducial markers were bone-implanted, a second CT was acquired, and the trajectory was transferred from preoperative to intraoperative CT. A customized microstereotactic frame was rapidly designed and constructed to constrain a surgical drill along the desired trajectory. Following sterilization, the frame was employed to drill the tunnel to the middle ear. After lifting a tympanomeatal flap and performing a cochleostomy, the electrode array was threaded through the drilled tunnel and into the cochlea. RESULTS Eight of nine patients were successfully implanted using the proposed approach with six insertions completely within the scala tympani. Traditional mastoidectomy was performed on one patient following difficulty threading the electrode array via the narrow tunnel. Other difficulties encountered included use of the backup implant when an electrode was dislodged during threading via the tunnel, tip fold-over, and facial nerve paresis (House-Brackmann II/VI at 12 months) secondary to heat during drilling. The average time of intervention was 182 ± 36 minutes. CONCLUSIONS Minimally invasive image-guided CI is clinically achievable. Further clinical study is necessary to address technological difficulties during drilling and insertion, and to assess potential benefits including decreased time of intervention, standardization of surgical intervention, and decreased tissue dissection potentially leading to shorter recovery and earlier implant activation.
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Affiliation(s)
- Robert F Labadie
- Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, U.S.A.; Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, U.S.A
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Wimmer W, Bell B, Huth ME, Weisstanner C, Gerber N, Kompis M, Weber S, Caversaccio M. Cone Beam and Micro-Computed Tomography Validation of Manual Array Insertion for Minimally Invasive Cochlear Implantation. Audiol Neurootol 2013; 19:22-30. [DOI: 10.1159/000356165] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 09/23/2013] [Indexed: 11/19/2022] Open
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Abstract
OBJECTIVES To report a novel modification of the cochlear drill-out procedure that uses customized microstereotactic frames as drill guides. PATIENT(S) A 34-year-old man with an 18-year history of profound bilateral hearing loss and completely ossified cochleae that underwent a previous unsuccessful conventional cochlear drill-out procedure in the contralateral ear. INTERVENTIONS Image-guided cochlear implantation using customized microstereotactic frames to drill linear basal and apical cochlear tunnels. MAIN OUTCOME MEASURES Transfacial recess cochlear drill-out procedure with full electrode insertion. RESULTS Two linear paths were drilled using customized microstereotactic frames targeting the proximal and distal basal turn followed by a full split array insertion. Postoperative imaging confirmed 2 cochlear tunnels straddling the modiolus with adequate clearance of the facial nerve and internal carotid artery. The patient received auditory benefit with device use and did not experience any surgical complication. CONCLUSION Successful cochlear implantation in the setting of total scalar obliteration poses a significant challenge. Image guidance technology may assist in navigating the ossified cochlea facilitating safe and precise cochlear tunnel drilling.
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An automated insertion tool for cochlear implants with integrated force sensing capability. Int J Comput Assist Radiol Surg 2013; 9:481-94. [DOI: 10.1007/s11548-013-0936-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/01/2013] [Indexed: 11/26/2022]
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Validation of minimally invasive, image-guided cochlear implantation using Advanced Bionics, Cochlear, and Medel electrodes in a cadaver model. Int J Comput Assist Radiol Surg 2013; 8:989-95. [PMID: 23633113 DOI: 10.1007/s11548-013-0842-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 04/09/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Validation of a novel minimally invasive, image-guided approach to implant electrodes from three FDA-approved manufacturers-Medel, Cochlear, and Advanced Bionics-in the cochlea via a linear tunnel from the lateral cranium through the facial recess to the cochlea. METHODS Custom microstereotactic frames that mount on bone-implanted fiducial markers and constrain the drill along the desired path were utilized on seven cadaver specimens. A linear tunnel was drilled from the lateral skull to the cochlea followed by a marginal, round window cochleostomy and insertion of the electrode array into the cochlea through the drilled tunnel. Post-insertion CT scan and histological analysis were used to analyze the results. RESULTS All specimens ([Formula: see text]) were successfully implanted without visible injury to the facial nerve. The Medel electrodes ([Formula: see text]) had minimal intracochlear trauma with 8, 8, and 10 (out of 12) electrodes intracochlear. The Cochlear lateral wall electrodes (straight research arrays) ([Formula: see text]) had minimal trauma with 20 and 21 of 22 electrodes intracochlear. The Advanced Bionics electrodes ([Formula: see text]) were inserted using their insertion tool; one had minimal insertion trauma and 14 of 16 electrodes intracochlear, while the other had violation of the basilar membrane just deep to the cochleostomy following which it remained in scala vestibuli with 13 of 16 electrodes intracochlear. CONCLUSIONS Minimally invasive, image-guided cochlear implantation is possible using electrodes from the three FDA-approved manufacturers. Lateral wall electrodes were associated with less intracochlear trauma suggesting that they may be better suited for this surgical technique.
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Three-dimensional histological specimen preparation for accurate imaging and spatial reconstruction of the middle and inner ear. Int J Comput Assist Radiol Surg 2013; 8:481-509. [PMID: 23633112 PMCID: PMC3702969 DOI: 10.1007/s11548-013-0825-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 02/27/2013] [Indexed: 11/02/2022]
Abstract
PURPOSE This paper presents a highly accurate cross-sectional preparation technique. The research aim was to develop an adequate imaging modality for both soft and bony tissue structures featuring high contrast and high resolution. Therefore, the advancement of an already existing micro-grinding procedure was pursued. The central objectives were to preserve spatial relations and to ensure the accurate three-dimensional reconstruction of histological sections. METHODS Twelve human temporal bone specimens including middle and inner ear structures were utilized. They were embedded in epoxy resin, then dissected by serial grinding and finally digitalized. The actual abrasion of each grinding slice was measured using a tactile length gauge with an accuracy of one micrometre. The cross-sectional images were aligned with the aid of artificial markers and by applying a feature-based, custom-made auto-registration algorithm. To determine the accuracy of the overall reconstruction procedure, a well-known reference object was used for comparison. To ensure the compatibility of the histological data with conventional clinical image data, the image stacks were finally converted into the DICOM standard. RESULTS The image fusion of data from temporal bone specimens' and from non-destructive flat-panel-based volume computed tomography confirmed the spatial accuracy achieved by the procedure, as did the evaluation using the reference object. CONCLUSION This systematic and easy-to-follow preparation technique enables the three-dimensional (3D) histological reconstruction of complex soft and bony tissue structures. It facilitates the creation of detailed and spatially correct 3D anatomical models. Such models are of great benefit for image-based segmentation and planning in the field of computer-assisted surgery as well as in finite element analysis. In the context of human inner ear surgery, three-dimensional histology will improve the experimental evaluation and determination of intra-cochlear trauma after the insertion of an electrode array of a cochlear implant system.
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Stayman JW, Dang H, Otake Y, Zbijewski W, Noble J, Dawant B, Labadie R, Carey JP, Siewerdsen JH. Overcoming Nonlinear Partial Volume Effects in Known-Component Reconstruction of Cochlear Implants. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2013; 8668:86681L. [PMID: 24949189 PMCID: PMC4060628 DOI: 10.1117/12.2007945] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nonlinear partial volume (NLPV) effects can be significant for objects with large attenuation differences and fine detail structures near the spatial resolution limits of a tomographic system. This is particularly true for small metal devices like cochlear implants. While traditional model-based approaches might alleviate these artifacts through very fine sampling of the image volume and subsampling of rays to each detector element, such solutions can be extremely burdensome in terms of memory and computational requirements. The work presented in this paper leverages the model-based approach called "known-component reconstruction" (KCR) where prior knowledge of a surgical device is integrated into the estimation. In KCR, the parameterization of the object separates the volume into an unknown background anatomy and a known component with unknown registration. Thus, one can model projections of an implant at very high spatial resolution while limiting the spatial resolution of the anatomy - in effect, modeling NLPV effects where they are most significant. We present modifications of the KCR approach that can be used to largely eliminate NLPV artifacts, and demonstrate the efficacy of the modified technique (with improved image quality and accurate implant position estimates) for the cochlear implant imaging scenario.
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Affiliation(s)
- J. W. Stayman
- Dept. of Biomedical Eng., Johns Hopkins University, Baltimore, MD USA 21205
| | - H. Dang
- Dept. of Biomedical Eng., Johns Hopkins University, Baltimore, MD USA 21205
| | - Y. Otake
- Dept. of Biomedical Eng., Johns Hopkins University, Baltimore, MD USA 21205
| | - W. Zbijewski
- Dept. of Biomedical Eng., Johns Hopkins University, Baltimore, MD USA 21205
| | - J. Noble
- Dept. of Electrical Eng. and Computer Science, Vanderbilt University, Nashville, TN USA 37232
| | - B. Dawant
- Dept. of Electrical Eng. and Computer Science, Vanderbilt University, Nashville, TN USA 37232
| | - R. Labadie
- Dept. of Otolaryngology, Vanderbilt University, Nashville, TN USA 37232
| | - J. P. Carey
- Dept. of Otolaryngology, Johns Hopkins University, Baltimore, MD USA 21205
| | - J. H. Siewerdsen
- Dept. of Biomedical Eng., Johns Hopkins University, Baltimore, MD USA 21205
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Williamson TM, Bell BJ, Gerber N, Salas L, Zysset P, Caversaccio M, Weber S. Estimation of tool pose based on force-density correlation during robotic drilling. IEEE Trans Biomed Eng 2012; 60:969-76. [PMID: 23269744 DOI: 10.1109/tbme.2012.2235439] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The application of image-guided systems with or without support by surgical robots relies on the accuracy of the navigation process, including patient-to-image registration. The surgeon must carry out the procedure based on the information provided by the navigation system, usually without being able to verify its correctness beyond visual inspection. Misleading surrogate parameters such as the fiducial registration error are often used to describe the success of the registration process, while a lack of methods describing the effects of navigation errors, such as those caused by tracking or calibration, may prevent the application of image guidance in certain accuracy-critical interventions. During minimally invasive mastoidectomy for cochlear implantation, a direct tunnel is drilled from the outside of the mastoid to a target on the cochlea based on registration using landmarks solely on the surface of the skull. Using this methodology, it is impossible to detect if the drill is advancing in the correct direction and that injury of the facial nerve will be avoided. To overcome this problem, a tool localization method based on drilling process information is proposed. The algorithm estimates the pose of a robot-guided surgical tool during a drilling task based on the correlation of the observed axial drilling force and the heterogeneous bone density in the mastoid extracted from 3-D image data. We present here one possible implementation of this method tested on ten tunnels drilled into three human cadaver specimens where an average tool localization accuracy of 0.29 mm was observed.
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Affiliation(s)
- Tom M Williamson
- ARTORG Center for Computer Aided Surgery, University of Bern, Bern, Switzerland.
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Abstract
This paper describes the design of a compact, lightweight CT-compatible, drill-press that is designed to be used in either a hand-held or stand-alone mode to assist with percutaneous bone based interventions. Previous medical drilling tools that have been developed have a metal structure and typically have one actuator for advancing the drill (feed) and another for rotating it (speed). After defining the device functional requirements and specifications, a deterministic design process was followed to generate several design concepts that were then evaluated based on their ability to satisfy the functional requirements. A final concept that uses a custom screw-spline to achieve helical motion of a shaft that is attached to a standard orthopedic drill was selected for prototyping. The design uses a single actuator to drive both the screw and spline nuts through two different gear ratios, resulting in a fixed ratio between the feed and speed. Apart from the motor which is placed away from the central drill axis, the device is largely made from plastic materials. A custom experimental setup was developed that enabled drilling into bone inside a CT scanner to be examined. Results showed that the device was successfully able to penetrate thick cortical bone and that its structure did not appreciably distort the medical images.
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Affiliation(s)
- Conor J. Walsh
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Cambridge, MA 02139; Massachusetts General Hospital, Department of Radiology, Boston, MA 02114
| | - Arjan J. H. Meskers
- Technical University of Delft, Department of Biomedical Engineering, Delft, 2600 AA, The Netherlands
| | - Alexander H. Slocum
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Cambridge, MA 02139
| | - Rajiv Gupta
- Massachusetts General Hospital, Department of Radiology, Boston, MA 02114
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Hiraumi H, Yamamoto N, Sakamoto T, Ito J. A minimally invasive approach for cochlear implantation using a microendoscope. Eur Arch Otorhinolaryngol 2012; 270:477-81. [DOI: 10.1007/s00405-012-2004-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 03/15/2012] [Indexed: 11/25/2022]
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Carlson ML, Driscoll CLW, Gifford RH, McMenomey SO. Cochlear implantation: current and future device options. Otolaryngol Clin North Am 2012; 45:221-48. [PMID: 22115692 DOI: 10.1016/j.otc.2011.09.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Today most cochlear implant users achieve above 80% on standard speech recognition in quiet testing, and enjoy excellent device reliability. Despite such success, conventional designs often fail to provide the frequency resolution required for complex listening tasks. Furthermore, performance variability remains a vexing problem, with a select group of patients performing poorly despite using the most recent technologies and processing strategies. This article provides a brief history of the development of cochlear implant technologies, reviews current implant systems from all 3 major manufacturers, examines recently devised strategies aimed at improving device performance, and discusses potential future developments.
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Affiliation(s)
- Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
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Balachandran R, Schurzig D, Fitzpatrick JM, Labadie RF. Evaluation of portable CT scanners for otologic image-guided surgery. Int J Comput Assist Radiol Surg 2011; 7:315-21. [PMID: 21779768 DOI: 10.1007/s11548-011-0639-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 02/23/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Portable CT scanners are beneficial for diagnosis in the intensive care unit, emergency room, and operating room. Portable fixed-base versus translating-base CT systems were evaluated for otologic image-guided surgical (IGS) applications based on geometric accuracy and utility for percutaneous cochlear implantation. METHODS Five cadaveric skulls were fitted with fiducial markers and scanned using both a translating-base, 8-slice CT scanner (CereTom(®)) and a fixed-base, flat-panel, volume CT (fpVCT) scanner (Xoran xCAT(®)). Images were analyzed for: (a) subjective quality (i.e., noise), (b) consistency of attenuation measurements (Hounsfield units) across similar tissue, and (c) geometric accuracy of fiducial marker positions. The utility of these scanners in clinical IGS cases was tested. RESULTS Five cadaveric specimens were scanned using each of the scanners. The translating-base, 8-slice CT scanner had spatially consistent Hounsfield units, and the image quality was subjectively good. However, because of movement variations during scanning, the geometric accuracy of fiducial marker positions was low. The fixed-base, fpVCT system had high spatial resolution, but the images were noisy and had spatially inconsistent attenuation measurements, while the geometric representation of the fiducial markers was highly accurate. CONCLUSION Two types of portable CT scanners were evaluated for otologic IGS. The translating-base, 8-slice CT scanner provided better image quality than a fixed-base, fpVCT scanner. However, the inherent error in three-dimensional spatial relationships by the translating-based system makes it suboptimal for otologic IGS use.
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Affiliation(s)
- Ramya Balachandran
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, 10450 Medical Center East, South Tower, Nashville, TN 37232, USA.
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Kobler JP, Kotlarski J, Öltjen J, Baron S, Ortmaier T. Design and analysis of a head-mounted parallel kinematic device for skull surgery. Int J Comput Assist Radiol Surg 2011; 7:137-49. [DOI: 10.1007/s11548-011-0619-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 05/10/2011] [Indexed: 11/29/2022]
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Campbell AP, Suberman TA, Buchman CA, Fitzpatrick DC, Adunka OF. Correlation of early auditory potentials and intracochlear electrode insertion properties: an animal model featuring near real-time monitoring. Otol Neurotol 2011; 31:1391-8. [PMID: 20856155 DOI: 10.1097/mao.0b013e3181f6c899] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this work was to assess electrophysiologic response changes to acoustic stimuli as an intracochlear electrode impacted cochlear structures in an animal model of hearing preservation cochlear implantation. The ultimate goal is to develop efficient procedures for assessing the status of cochlear physiology for intraoperative use. METHODS Sixteen gerbils and 18 ears were tested. A rigid electrode was inserted through a basal turn cochleostomy and directed toward the basilar membrane/osseous spiral lamina complex. We recorded acoustically evoked early auditory potentials including cochlear microphonics (CMs) and compound action potentials (CAPs) to a short stimulation sequence consisting of one stimulus frequency and intensity as the electrode was advanced. A microendoscope was used to visualize the electrode insertion progress and to identify the site of electrode impact. After each experiment, the site of intracochlear trauma was confirmed using whole mount preparations. RESULTS Electrophysiologic changes correlated well with the degree and location of trauma. We observed four distinct patterns. In addition, the endoscope in conjunction with the short recording sequence allowed for the detection of response changes that were reversible when the electrode was retracted. These cases were associated with less than full-thickness damage on histology. CONCLUSION The short recording sequence to obtain acoustically evoked intracochlear potentials and the microendoscope allowed us to detect various levels of cochlear trauma including minor and reversible damage. Recordings of this type are potentially available using current implant technology. Future improvements in the measurements can be expected to improve the efficiency of the recording paradigm to produce a clinically useful tool.
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Affiliation(s)
- Adam P Campbell
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7070, USA
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Development of an auditory implant manipulator for minimally invasive surgical insertion of implantable hearing devices. The Journal of Laryngology & Otology 2010; 125:262-70. [DOI: 10.1017/s0022215110002185] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To present the auditory implant manipulator, a navigation-controlled mechanical and electronic system which enables minimally invasive (‘keyhole’) transmastoid access to the tympanic cavity.Materials and methods:The auditory implant manipulator is a miniaturised robotic system with five axes of movement and an integrated drill. It can be mounted on the operating table. We evaluated the surgical work field provided by the system, and the work sequence involved, using an anatomical whole head specimen.Results:The work field provided by the auditory implant manipulator is considerably greater than required for conventional mastoidectomy. The work sequence for a keyhole procedure included pre-operative planning, arrangement of equipment, the procedure itself and post-operative analysis.Conclusion:Although system improvements are necessary, our preliminary results indicate that the auditory implant manipulator has the potential to perform keyhole insertion of implantable hearing devices.
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Inroads Toward Robot-Assisted Cochlear Implant Surgery Using Steerable Electrode Arrays. Otol Neurotol 2010; 31:1199-206. [DOI: 10.1097/mao.0b013e3181e7117e] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baron S, Eilers H, Munske B, Toennies JL, Balachandran R, Labadie RF, Ortmaier T, Webster RJ. Percutaneous inner-ear access via an image-guided industrial robot system. Proc Inst Mech Eng H 2010; 224:633-49. [PMID: 20718268 DOI: 10.1243/09544119jeim781] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Image-guided robots have been widely used for bone shaping and percutaneous access to interventional sites. However, due to high-accuracy requirements and proximity to sensitive nerves and brain tissues, the adoption of robots in inner-ear surgery has been slower. In this paper the authors present their recent work towards developing two image-guided industrial robot systems for accessing challenging inner-ear targets. Features of the systems include optical tracking of the robot base and tool relative to the patient and Kalman filter-based data fusion of redundant sensory information (from encoders and optical tracking systems) for enhanced patient safety. The approach enables control of differential robot positions rather than absolute positions, permitting simplified calibration procedures and reducing the reliance of the system on robot calibration in order to ensure overall accuracy. Lastly, the authors present the results of two phantom validation experiments simulating the use of image-guided robots in inner-ear surgeries such as cochlear implantation and petrous apex access.
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Affiliation(s)
- S Baron
- Institute of Mechatronic Systems, Leibniz Universität Hannover, Hannover, Germany
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Determination of the curling behavior of a preformed cochlear implant electrode array. Int J Comput Assist Radiol Surg 2010; 6:421-33. [PMID: 20665247 DOI: 10.1007/s11548-010-0520-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/02/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Accurate insertion of a cochlear implant electrode array into the cochlea's helical shape is a crucial step for residual hearing preservation. In image-guided surgery, especially using an automated insertion tool, the overall accuracy of the operative procedure can be improved by adapting the electrode array's intracochlear movement to the individual cochlear shape. METHODS The curling characteristic of a commercially available state-of-the-art preformed electrode array (Cochlear Ltd. Contour Advance(TM) Electrode Array) was determined using an image-processing algorithm to detect its shape in series of images. An automatic image-processing procedure was developed using Matlab and the Image Processing Toolbox (MathWorks, Natick, Massachusetts, USA) to determine the complete curvature of the electrode array by identifying the 22 platinum contacts of the electrode. A logarithmic spiral was used for a comprehensive mathematical description of the shape of the electrode array. A fitting algorithm for nonlinear least-squares problems was used to provide a complete mathematical description of the electrode array. The system was tested for curling behavior as a function of stylet extraction using nine Contour Advance Research Electrodes (RE) and additionally for nine Contour Advance Practice Electrodes (PE). RESULTS All arrays show a typical pattern of curling with adequate predictability after the first 2 or 3 millimeters of stylet extraction. Although non-negligible variations in the overall curling behavior were detected, the electrode arrays show a characteristic movement due to the stylet extraction and only vary minimally after this initial phase. CONCLUSION These results indicate that the risk of intracochlear trauma can be reduced if the specific curling behavior of the electrode carrier is incorporated into the insertion algorithm. Furthermore, the determination of the curling behavior is an essential step in computer-aided cochlear implant electrode development. Experimental data are required for accurate evaluation of the simulation model.
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Balachandran R, Mitchell JE, Blachon G, Noble JH, Dawant BM, Fitzpatrick JM, Labadie RF. Percutaneous cochlear implant drilling via customized frames: an in vitro study. Otolaryngol Head Neck Surg 2010; 142:421-6. [PMID: 20172392 DOI: 10.1016/j.otohns.2009.11.029] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 11/05/2009] [Accepted: 11/19/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Percutaneous cochlear implantation (PCI) surgery uses patient-specific customized microstereotactic frames to achieve a single drill-pass from the lateral skull to the cochlea, avoiding vital anatomy. We demonstrate the use of a specific microstereotactic frame, called a "microtable," to perform PCI surgery on cadaveric temporal bone specimens. STUDY DESIGN Feasibility study using cadaveric temporal bones. SUBJECTS AND METHODS PCI drilling was performed on six cadaveric temporal bone specimens. The main steps involved were 1) placing three bone-implanted markers surrounding the ear, 2) obtaining a CT scan, 3) planning a safe surgical path to the cochlea avoiding vital anatomy, 4) constructing a microstereotactic frame to constrain the drill to the planned path, and 5) affixing the frame to the markers and using it to drill to the cochlea. The specimens were CT scanned after drilling to show the achieved path. Deviation of the drilled path from the desired path was computed, and the closest distance of the mid-axis of the drilled path from critical structures was measured. RESULTS In all six specimens, we drilled successfully to the cochlea, preserving the facial nerve and ossicles. In four of six specimens, the chorda tympani was preserved, and in two of six specimens, it was sacrificed. The mean +/- standard deviation error at the target was found to be 0.31 +/- 0.10 mm. The closest distances of the mid-axis of the drilled path to structures were 1.28 +/- 0.17 mm to the facial nerve, 1.31 +/- 0.36 mm to the chorda tympani, and 1.59 +/- 0.43 mm to the ossicles. CONCLUSION In a cadaveric model, PCI drilling is safe and effective.
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Affiliation(s)
- Ramya Balachandran
- Department of Otolaryngology, Vanderbilt University, Nashville, TN, USA.
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Wanna GB, Balachandran R, Majdani O, Mitchell J, Labadie RF. Percutaneous access to the petrous apex in vitro using customized micro-stereotactic frames based on image-guided surgical technology. Acta Otolaryngol 2010. [DOI: 10.3109/00016480903194617] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Majdani O, Schuman TA, Haynes DS, Dietrich MS, Leinung M, Lenarz T, Labadie RF. Time of cochlear implant surgery in academic settings. Otolaryngol Head Neck Surg 2010; 142:254-9. [PMID: 20115984 DOI: 10.1016/j.otohns.2009.10.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 09/01/2009] [Accepted: 10/19/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Establish the time required to perform cochlear implantation (CI) in academic settings. STUDY DESIGN Historical cohort study. SETTING German and American academic centers. PATIENTS A total of 2639 patients underwent CI (1997-2007). We excluded patients receiving an experimental device or technique and those with abnormal cochlear anatomy or incomplete charts, leaving 2253 for analysis. INTERVENTION Unilateral, bilateral, and revision CI with devices approved in the U.S. and Europe. MAIN OUTCOME MEASURES Mean surgical time (ST) and total operating room time (TORT). RESULTS Mixed model analysis was used; estimated marginal means were calculated in minutes after adjusting for random effect of individual surgeon. There were no differences between unilateral (ST = 171, TORT = 245) and revision CI (ST = 160, TORT = 232), but bilateral procedures were longer (ST = 295, TORT = 377, P < 0.001). In unilateral surgeries, Cochlear Limited (CL) devices were implanted faster (ST = 165, TORT = 225) than Advanced Bionics (ABC) (ST = 183, P = 0.001; TORT = 240, P = 0.023) or MedEl (ST = 193, P < 0.001; TORT = 253, P = 0.002) devices. There were no differences for unilateral CI between ABC and MedEl devices. For revision CI, ABC devices (ST = 141, TORT = 219) were implanted faster than CL devices (ST = 181, P = 0.001; TORT = 266, P < 0.001). There were no differences by age group or between Germany and the U.S. ST and TORT were shorter for 575 CIs performed in the final two years of the study (unilateral CI: ST = 145, TORT = 209; bilateral CI: ST = 259, TORT = 330; revision CI: ST = 138, TORT = 205). For unilateral CI, ST and TORT decreased yearly (linear regression, P < 0.001) and inversely correlated with surgeon experience (linear regression, P < 0.01). CONCLUSIONS We report the time required to perform CI in academic settings-data that are vital for cost-benefit analyses and assessing new CI techniques.
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Affiliation(s)
- Omid Majdani
- Department of Otolaryngology, Medical University of Hannover, Hannover, Germany
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Labadie RF, Balachandran R, Mitchell JE, Noble JH, Majdani O, Haynes DS, Bennett ML, Dawant BM, Fitzpatrick JM. Clinical validation study of percutaneous cochlear access using patient-customized microstereotactic frames. Otol Neurotol 2010; 31:94-9. [PMID: 20019561 DOI: 10.1097/mao.0b013e3181c2f81a] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Percutaneous cochlear implant (PCI) surgery consists of drilling a single trough from the lateral cranium to the cochlea avoiding vital anatomy. To accomplish PCI, we use a patient-customized microstereotactic frame, which we call a "microtable" because it consists of a small tabletop sitting on legs. The orientation of the legs controls the alignment of the tabletop such that it is perpendicular to a specified trajectory. STUDY DESIGN Prospective. SETTING Tertiary referral center. PATIENTS Thirteen patients (18 ears) undergoing traditional cochlear implant surgery. INTERVENTIONS With institutional review board approval, each patient had 3 fiducial markers implanted in bone surrounding the ear. Temporal bone computed tomographic scans were obtained, and the markers were localized, as was vital anatomy. A linear trajectory from the lateral cranium through the facial recess to the cochlea was planned. A microtable was fabricated to follow the specified trajectory. MAIN OUTCOME MEASURES After mastoidectomy and posterior tympanotomy, accuracy of trajectories was validated by mounting the microtables on the bone-implanted markers and then passing sham drill bits across the facial recess to the cochlea. The distance from the drill to vital anatomy was measured. RESULTS Microtables were constructed on a computer-numeric-control milling machine in less than 5 minutes each. Successful access across the facial recess to the cochlea was achieved in all 18 cases. The mean +/- SD distance was 1.20 +/- 0.36 mm from midportion of the drill to the facial nerve and 1.25 +/- 0.33 mm from the chorda tympani. CONCLUSION These results demonstrate the feasibility of PCI access using customized microstereotactic frames.
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Affiliation(s)
- Robert F Labadie
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee 37232, USA.
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