Paranasal Sinus Surgery

## **Chapter 6**

## Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant

*Daniel F. àWengen*

## **Abstract**

Nasal airway obstruction is a very common reason for reduced quality of life. For decades, nose surgeons have applied multiple techniques with little or partial success. Since 2003, the Titanium Breathe-Implant widens and stabilizes the internal nasal valve with a long-term success rate of 90% approval by the patients. Since 2017, the Titanium Batten Grafts widen and stabilize the external nasal valves. Combination of these grafts is possible. Quality of life improves, snoring is reduced, and acceptance of possible CPAP masks are proofs of the patient's widened nasal airway. Surgical techniques of open and closed rhinoplasty techniques are presented.

**Keywords:** titanium, Breathe-Implant, nose, nasal obstruction, functional rhinoplasty, internal nasal valve, snoring, obstructive sleep apnea

## **1. Introduction**

The nose is the most narrow part of the entire airway and the internal nasal valve is the most narrow part of the nose.

From the nasal tip to the lungs, the most narrow part of the entire airway is located within the lower third of the nose. The soft tissue of the lateral nasal wall is mainly responsible for the limitation of nasal airflow. It has been previously assumed that the internal structures of the nose, the nasal septum and the nasal turbinates, are the major causes for obstruction. Today, we know that half of all airway resistance and obstruction is caused by the soft lateral nasal wall, especially at the level of the internal nasal valve (INV). The older we become, the softer the nasal cartilages. This might lead to further weakening of the nasal nostrils with a tendency for collapse at the lateral nasal base.

If we want to provide our patients with better nasal breathing, we should carefully inspect our patients noses especially along the soft lateral nasal wall, and we should consider widening and stabilization of these structures.

Breathe-Implant was started in 2003 to open the patient's nose efficiently and permanently at the level of the internal nasal valve [1]. Since 2017, we also use this implant to widen and to stabilize the external nasal valve as Titanium Batten Grafts (TBG).

## **2. The internal and external nasal valves**

A valve is by definition the most narrow part in a flow system. In the nose, we have two valves. The internal and the external nasal valves.

#### **2.1 The internal nasal valve**

The internal nasal valve (INV) runs along the caudal border of the upper lateral cartilage (ULC) including the septum and the head of the lower turbinate (**Figure 1**). It is a three-dimensional space and not an angle (**Figure 2**).

The black line shows the bony piriform aperture. Upper lateral cartilage (ULC) (triangular cartilage) is in yellow. The red line marks the level of the internal nasal valve: along the caudal border of the ULC. The internal nasal valve is the most narrow part of the entire airway. We might therefore also define it as the **Isthmus** of the nose.

The external nasal valve includes all soft tissue of the lateral nasal wall and the septum caudal to the internal nasal valve. In precise anatomical terms, the zone 2 of Moubayed and Most consists of the vestibular valve and the external nasal valve. The latter is located at the level of the vestibular rim. To not further complicate this terminology, we include the vestibular valve into the term external nasal valve.

Both valves have a static and a dynamic property. In quiet breathing, the shape of structures causes a certain level of obstruction. In stronger breathing, the Venturi effect becomes stronger causing an inward movement of the soft lateral nasal wall exponentially increasing nasal resistance. This might even lead to total collapse with complete obstruction. The soft lateral nasal wall becomes even softer with age.

**Figure 1.** *Zones of lateral wall insufficiency: from Sami Moubayed and Sam Most [2].*

**Figure 2.** *The soft lateral nasal wall.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

Collapse of the lateral nasal wall is a frequent problem in elderly patients, especially in long and drooping noses.

#### **2.2 The isthmus of the nose**

In the literature, the internal nasal valve has sometimes been described as the angle between the septum and the lower edge of the upper lateral cartilage. Eugene Kern has described this angle of about 15 degrees. He may be considered the father of modern nasal valve surgery as he has recognized the influence of the internal nasal valve on nasal obstruction. Kern also applied the surgical technique of Dr. Fausto Lopez-Infante of Mexico City to cut out an inferior part of the ULC to widen the nasal airway. This ablative surgery has proven beneficial in an impressive number of patients. Today, we prefer to maintain our patient's cartilaginous framework for as much as possible. Instead of removal, we now reinforce and dilate the ULC by the Titanium Breathe-Implant (**Figure 3**). Eugene Kern has been very positive about Breathe-Implant and its procedure (personal communication) (**Figure 4**).

**Figure 4.** *The nasal isthmus.*

The nasal isthmus is due to the lateral nasal wall (internal nasal valve), the head of the turbinate, and the nasal septum.

Evaluation of the internal nasal valve and its effect on nasal obstruction should include not only the angle between septum and ULC but all parts of the nasal isthmus. According to Kern, this is a three-dimensional space. For the best possible deblockage of the nose, all parts of the isthmus must improve [3].

This includes **Septoplasty** where the upper third of the septum (under the nasal dorsum) is the most critical part and **Submucous Turbinoplasty** with preservation of the mucosal structure to prevent the formation of scar tissue.

## **2.3 Aerodynamic analysis of airflow in the nose**

Always observe the soft lateral nasal wall in its natural position and at in- and expiration. The dynamic valve instability is more important than the static instability. The nasal speculum has no place in the evaluation of the soft lateral nasal wall (**Figure 5**).

Air flows the fastest when entering the nose until it passes the internal nasal valve. Air speed then significantly slows down within the nose. The narrow area of the internal nasal valve is clearly seen in **Figure 6** as a notch. To improve airflow

#### **Figure 5.**

*Endoscopic inspection of the nose in the office: narrow airspace and an acute and partially obstructed internal nasal valve angle. Upper septal deviation to the right. Recurvature sign: the lateral end of the LLC points into the nose.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

within the nose, the most narrow part must be opened: the internal nasal valve. There is probably no method more efficient to dilate the internal nasal valve safely and securely than with the Titanium Breathe-Implant according to van den Broek et al. [4].

The anatomy of the nasal dorsum as well as the structure and function of the ULC are vitally important in understanding nasal airflow. The cartilaginous nasal dorsum of the middle vault consists of the medial structure of the septum and the lateral structures of both ULCs. The ULCs are connected to each other forming a canoeshaped nasal dorsum. The upper part of the canoe connects to the nasal bones. The lower point of the canoe connects to the lower lateral cartilages (**LLC**) in a variable connection termed the scroll area. This scroll area begins medially at the tip of the canoe and extends all the way laterally to the end of the ULC where they come close to the bony piriform aperture.

The scroll area is a major part of the internal nasal valve. If we plan to open the internal nasal valve, we must dilate the entire lower edge of the ULC (**Figure 7**).

The airway of the nose is similar to an hourglass: the most narrow part, the internal nasal valve, limits the flow. This narrow shape has long been recognized in acoustic rhinometry. If we want to increase flow in an hourglass construction, we must open the most narrow part: we must dilate and stabilize the internal nasal valve. Breathe-Implant performs this task very efficiently.

By pulling the cheek laterally, the patient will open the nose in the internal and external nasal valve area. A positive Cottle sign is mandatory before implanting Breathe-Implant (**Figure 8**).

**Figure 7.** *Canoe-shaped nasal dorsum/hourglass/acoustic rhinometry.*

**Figure 8.** *Cottle sign.*

#### **Figure 9.** *Nasal strips.*

The Cottle sign can be tested unilaterally or bilaterally at the same time. Patients with narrow internal nasal valves will immediately respond in a positive way.

Another test that patients might use to evaluate the benefit of Breathe-Implant is the application of Breathe-Right Stickers (**Figure 9**). Septal deflections are responsible for about 20% of nasal obstruction, lower turbinates for about 30%, and the internal and external nasal valves for about 50%.

## **2.4 Preoperative testing**

The most informative clinical test to measure the effect of the soft lateral nasal wall is the peak nasal inspiratory flow (PNIF) mask test. With Breathe-Implant and/or Titanium Batten Grafts, values are often doubled compared to presurgical values.

## **2.5 Preparation of the nose for Breathe-Implant surgery**

The Titanium Breathe-Implant is a foreign body which incorporates a potential risk for infection. Our patients prepare their noses for 5 days of Mupirocin ointment to reduce bacteria in the nasal vestibule especially in the dome area.

## **2.6 Potential complications**

Patients might report a feeling of tension in their middle vault. If they do not get used to it, then the implant should be compressed from outside by the surgeon's thumb and index finger to slightly narrow the implant. This maneuver requires quite some pressure. The width of the implant should be as wide as the bony piriform aperture around it. This compression could be repeated several times. In thousands of patients, over a period of more than 19 years we have not seen or heard of a perforation through the skin. Direct trauma to the nose might bend the implant. The implant can be straightened in a small exposure in local anesthesia and be bent back into position.

Breathe-Implant will not trigger airport security checks.

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

#### **2.7 Potential removal/replacement of Breathe-Implant**

Breathe-Implant can be surgically removed in local anesthesia. Complication rate has been around 1–2%. Breathe-Implant has proven to be very stable.

#### **2.8 Opening the internal nasal valve: Breathe-Implant**

Starting in April 2003 after CE-mark by the European Committee, thousands of patients have already been successfully implanted with Breathe-Implant worldwide.

#### **2.9 What is Breathe-Implant? Sizes and sizers**

Breathe-Implant is manufactured in pure Titanium by the German company Heinz Kurz GmbH, Dusslingen (www.kurzmed.com) (**Figures 10** and **11**). The metal does not include nickel or chromium or other metals that might cause allergic reactions. To this date, allergy to Breathe-Implant has very rarely been a problem. In our patient population of close to 1500 patients, we have only removed two implants due to a local allergic reaction with red and thickened skin.

Breathe-Implant sits on the nasal dorsum like a saddle on a horse. It is placed on top of both ULCs. The intention is to strengthen and to widen the existing ULCs. There are six sizes of the Breathe-Implant (**Figure 12**):

To choose the right size, the surgeon measures the cartilaginous dorsum over the ULC in closed or open rhinoplasty with Breathe-Implant sizers (**Figure 14**). A set of all six sizers including a tray can be ordered by Heinz Kurz, Dusslingen, Germany, at www.kurzmed.com (**Figure 13**).

**Figure 10.** *Titanium Breathe-Implant has two rows of oval perforations for suturing.*

#### **Figure 11.**

*Positioning of Breathe-Implant on the ULC: 1 to 2 mm higher than the inferior edge. The correct positioning is a key to success: to avoid intranasal perforation.*

**Figure 12.**

*Sizes of Breathe-Implant: XS 3 mm, S 4 mm, M 5 mm, L 6 mm, XL 7 mm, and XXL 8 mm.*

**Figure 13.** *Breathe-Implant on the nasal dorsum.*

#### **Figure 14.**

*Breathe-Implant Sizer Box. In the Sizer Tray, all six sizes from XS to XXL are available to precisely measure the nasal dorsum.*

Sizers should always be used: one cannot judge the width of the nasal dorsum precisely enough in surgery and much less so before surgery through the skin. There is no rule as to what sizes would fit male or female patients. The width of the cartilaginous nasal dorsum dictates the size of the implant. In order to be ready for all possibilities, all six sizers and sizes of Breathe-Implant should be available in the OR.

## **3. Breathe-Implant in open rhinoplasty surgery: Surgical steps**

Spread your pointed scissors on the surface of the cartilaginous nasal dorsum. Feel the tips of the scissors gently scratching the surface of the cartilage. This is the level of the upper lateral cartilages (ULC) on which Breathe-Implant will be placed. At this point, one can also use cottonoids held in a clamp to push away the soft tissue from the nasal dorsum (**Figure 15**). This is one of the most gentle methods to expose the cartilaginous and the osseous nasal dorsum.

With the pointed scissors, follow the surface of the ULC all the way down to the bony piriform aperture (**Figure 16**). By spreading the branches, the soft tissue of the *Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

**Figure 15.** *Preparation of the ULCs.*

**Figure 16.** *Lateral exposure of the ULC.*

lateral nasal wall is released. Keep the ULC intact but stay in close contact to the surface of the ULC to allow full exposure and to avoid bleeding from the soft tissue. Expect some bleeding toward the piriform aperture. Use monopolar suction coagulation or bipolar coagulation for hemostasis. There must be perfect hemostasis before implanting Breathe-Implant. Do not remove the perichondrium of the ULC (**Figure 17**).

Identify the bony nasal dorsum and the bony piriform aperture before proceeding. Identify the scroll area: the connection zone between the ULC and LLC. There are variations to the scroll area. The LLC might be retracted gently to better identify this area. We must clearly see the inferior edge of the ULC in order to correctly place Breathe-Implant: one to 2 mm higher than the edge (**Figure 18**).

Use the six sizers for Breathe-Implant. They range from XS to XXL with incremental steps of 1 mm at the bridge area and longer flanges. Hold the sizer on both ULCs: correct position is 2 mm cranial of the inferior edge of the ULC.

**Figure 17.** *Full exposure of the cartilaginous nasal dorsum.*

**Figure 18.** *Measurement with the sizer.*

To judge the correct size, choose the size that is closest to the width of the patient's bony piriform aperture. The implant should not be wider than the bony sidewalls. In a patient with obstructive sleep apnea, one may choose one size larger to provide maximal endonasal dilatation.

In an esthetic rhinoplasty, the size should suit the chosen width of the entire nose so it will not be visible (**Figure 19**).

Disinfection of the implant bed with a disinfectant solution (Octenisept or other) to provide an aseptic field. Then placement of Breathe-Implant 2 mm cranial to the lower edge of the ULC.

Use resorbable sutures to fix Breathe-Implant to the surface of the ULCs. Preferred suture is PDS 5–0 with the strong P-3 needle (**Figure 20**). This needle will bend less than the usual S-needle or other. The tip of the needle often has to palpate and search for an opening in Breathe-Implant (**Figure 21**).

Start the sutures toward the midline. The needle may start at the inferior edge of the ULC going through the tissue. A full bite of cartilage is preferred. The suture will not show in the nasal cavity (**Figure 22**).

```
Figure 19.
Width of Breathe-Implant according to the width of the bony piriform aperture.
```
**Figure 20.** *Suture material is PDS 5–0.* *Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

**Figure 21.** *First suture to fix the implant.*

**Figure 22.** *Second suture.*

The second suture starts near the inferior edge of the ULC. With the needle, find any suture hole in Breathe-Implant: first or second row is irrelevant. Only place one suture on the first side. Then switch to the other side. One is tempted to continue the sutures on one side. This will rotate the implant too far to one side and an asymmetric position might remain. Change of side after one lateral suture to continue on the contralateral side is crucial. The implant might have to be pulled down into the correct symmetrical position.

Suturing on the other side in the same manner: the needle can pass directly from the inferior edge of the ULC. Hold Breathe-Implant in its correct place using some forceps. The scroll area is marked in blue in **Figure 23**.

**Figure 23.** *First lateral suture on the other side.*

**Figure 24.** *Completion of three sutures on each side.*

For any suture, it is irrelevant whether it passes through the first or the second row of openings (**Figure 24**).

Breathe-Implant is now fixed in a symmetrical position on the cartilaginous nasal dorsum. The middle vault is dilated and stable. The thickness of only 0.5 mm will not show on the nasal dorsum. Breathe-Implant will remain lifelong. PDS will be resorbed after several months allowing the connective tissue to grow through all the openings in the implant securing its position. Initially, the patient might feel a slight poking sensation caused by the suture ends. This will pass within the first 3 months (**Figure 25**).

Never suture any parts of the LLC to Breathe-Implant. The LLC must be free to move in smiling or any other facial movement (**Figure 26**). Also, never place

**Figure 25.** *Completion of sutures.*

**Figure 26.**

*The LLCs are repositioned in their normal position. Breathe-Implant is covered by a large surface of the LLCs which recoil over the ULCs. Thus, the area that eventually comes into contact with the skin is fairly small. In the supratip area, the skin is quite thick.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

#### **Figure 27.**

*Immediate widening of the internal nasal valve by Breathe-Implant. The normally obtuse and narrow angle is widened and rounded off. There is probably no other surgical technique available today that is capable of this amount of the widening of the internal nasal valve in such a reliable way.*

**Figure 28.** *Position of Breathe-Implant deep to the skin: On top of both ULCs.*

Breathe-Implant on top of the LLC. The correct position the implant is on top of the ULC (**Figures 27** and **28**).

## **4. Breathe-Implant in closed rhinoplasty surgery**

Once the surgeon is familiarized with positioning of Breathe-Implant in open rhinoplasty, the closed rhinoplasty technique may be used. With some experience, this will become the standard procedure. It has proven to be very reliable and fast. In order to achieve a safe result, the following steps should be taken. Incision is through the LLC: a transcartilaginous incision. A strip of about 2 mm of the LLC is cut to be left attached to the scroll and the ULC. This cartilaginous strip will prevent endonasal exposure of Breathe-Implant which is the only potential complication that might occur over time (**Figure 29**).

By spreading the scissors, visualize the bright whitish surface of both ULCs that form the cartilaginous nasal dorsum. Stay deep to the soft tissue to avoid bleeding. Feel a slight scratching of the scissor's tips (**Figures 30**–**32**).

Stay on top of ULC until you touch the bony piriform aperture with your scissors. The transcartilaginous incision has not been completed yet. Insert a cottonoid in this pocket.

Cottonoid on top of both ULC and cartilagineous nasal dorsum to create a free pocket. This will be the space to accomodate Breathe-Implant (**Figures 33**–**35**).

#### **Figure 29.**

*The hemitransfixion and the transcartilagineous incision lines are combined. This is only necessary on one side. In case no septoplasty is needed, avoid the hemitransfixion. We almost always combine septoplasty with Breathe-Implant, because even subtle deviations in the upper half of the septum near the valve angle have a significant impact on nasal breathing.*

#### **Figure 31.**

*Endonasal incisions with a sharp insulated monopolar needle to avoid burn marks on the rim of the vestibule. Incisions can also be carried out with knife or scissors.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

**Figure 32.** *Preparation of the ULCs.*

**Figure 33.** *Creation of a pocket on top of the ULC.*

**Figure 34.**

*Full incision through the LLC only after placement of a cottonoid into the pocket between ULC and LLC as a space holder. This will prevent injury to the ULC.*

**Figure 35.** *Connection of both sides.*

The size can not be judged preoperatively (**Figure 36**). Have all sizers and all Breathe-Implant sizes ready for all male and female noses. The choice depends mainly on the width of the nasal dorsum and not on the general size of the nose. A big and high male tension nose might only need an XS, whereas a small and flat female nose might requre an XL or XXL. Implantation without measurement by sizer is not correct.

The surface of the ULC is more narrow before it is sutured to Breathe-Implant. This dilatation will open the internal nasal valve significantly (**Figure 37**).

Start suturing of Breathe-Implant to the cartilage in the middle with PDS 5–0 on a P-3 needle: to avoid a lateral displacement (**Figure 38**). After one suture on the left side, switch to the right side. The implant tends to rotate on the nasal dorsum. If we

**Figure 37.** *Breathe-Implant in its correct position.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

#### **Figure 38.** *First suture: to fix the implant to the midline.*

would put all three sutures of the left side in place before turning to the right side, the implant would be fixed too strongly to be rotated in a symmetric position. Sometimes, the implant must be pulled down into its correct position before being sutured to the ULC. Usually, we apply three sutures to each side. Try to grab the soft tissue of the lower lateral wall with the needle as far lateral as possible to stabilize most of the soft tissue (**Figure 39**).

After pulling down the implant into its correct position, we usually start the sutures medially. The needle may be inserted into the ULC right in the scroll area. Pass the needle under the ULC and do not worry about depth: the sutures almost never show endonasally.

Start inside through the lateral part of the LLC. This will bury the knot deep in the tissue to prevent suture exposure within the nasal vestibule (**Figure 40**).

**Figure 39.** *Sutures on the contralateral side.*

#### **Figure 41.** *Move suture ends upward.*

Before closure, all suture heads are pulled upward to within the metal openings (**Figure 41**). This will prevent any undue penetration and exposure within the nasal cavity. Please also note the rim of cartilage of the ULC that extends inferior to Breathe-Implant. This will protect the implant from endonasal erosion and exposure. Every human being picks the nose with fingers: a permanent danger if the implant would end directly at the inferior end of the ULC or even worse within the scroll area (**Figures 42**–**44**).

This is especially important in the nasal dome area to prevent infection around the implant. Always rinse the implant site with desinfectant before closing. A single shot

**Figure 42.** *Endonasal sutures: watertight wound closure of all incisions with fast resorbable sutures (Vicryl rapid 5–0).*

#### **Figure 43.**

*The effect of Breathe-Implant on the internal nasal valve is identical for closed and open techniques. The valve angle is dilated and rounded which will significantly increase nasal airflow.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

**Figure 44.** *The position of Breathe-Implant shown by this blue line is more cranial than would be suspected by the patient.*

of antibiotics is given before surgery. The previously acute nasal valve angle is now dilated and rounded.

## **5. With spreader grafts or spreader flaps**

Spreader Grafts will do little to the position or stability/instability of the lower edge of the ULC. Thus, Spreader Grafts will never be able to significantly open the nasal valve: a misconception since 1989 when Jack Sheen proposed Spreader Grafts [5]. He proposed them to provide structure to the middle vault of the nasal dorsum and not to improve airflow. The natural wide bow of cartilage of the ULCs and the septum is replaced by doubling cartilages that often extend too far into the airway [6] (**Figures 45**–**48**).

**Figure 45.** *Unnatural reduction of airspace by Spreader Grafts.*

#### **Figure 46.**

*Combination of Spreader Grafts with Breathe-Implant: before suturing. Spreader Grafts are for the nasal dorsum and Breathe-Implant for the lateral nasal wall. Combination is best.*

**Figure 47.** *Combination of spreader flaps with Breathe-Implant is also possible.*

**Figure 48.** *Difference between Spreader Grafts and Breathe-Implant.*

In many of our secondary cases, we also had to remove Spreader Grafts because they obstructed the valve angle.

## **6. Five-year unpublished study of our first consecutive 100 patients**

A 90% satisfaction rate after 5 years is significant. With septoplasty/turbinoplasty alone, we could not reach this result (**Figure 49**).

## **7. The external nasal valve**

In this CT scan reconstruction, the ULC and LLC are in dark blue: they only cover about half the height of the nose. The rest in light blue consists of skin and connective tissue. The external nasal valve includes all parts inferior to the ULC including the LLC and all the soft tissue of the nasal vestibule. Note the distance to the piriform aperture with no cartilage support at all. This area is addressed by the Titanium Batten Graft (TBG) that we have been using since 2017 (**Figure 50**).

The typical patient to complain of ENV instability is an elderly male patient. Cartilages and soft tissue structures become too soft and too weak to withstand the *Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

*Our 5-year retrospective study on the effect of Breathe-Implant: Breathing, sleep, snoring, mouth breathing, profit/ recommendation.*

**Figure 50.** *The soft lateral nasal wall.*

negative pressure by the Venturi effect. Typical inward movement of the nasal vestibule is in inspiration. The Cottle sign stabilizes the internal as well as the external nasal valves. Pay special attention to the lateral base of the nostril.

The external nasal valve can be stabilized by this new Titanium Batten Graft technique. Cartilage batten grafts do not help as they are too weak and too thick. They lack active elastic properties. They often compromise the endonasal airway instead of opening it. Long lateral crural strut grafts might help some of these patients. Not all patients appreciate these lateral crural strut grafts as they might be palpable in the nostril.

Toriumi et al. [7] proposed the implantation of cartilage in an effort to stabilize this soft wall [8]. Transplanted cartilage has very little or no active spring effect though. It merely acts as increased tissue in the lateral wall near the piriform aperture. Over time, transplanted cartilage invariable loses its elasticity to become more and more soft [9]. Surgeons then try to repeat the effect by implanting further cartilage batten grafts side by side with the idea to strengthen the wall again. As this procedure might be repeated several times, the lateral wall becomes thicker and thicker. Unfortunately, the skin of the nose is stronger than the lining of the nasal vestibule, so the implanted mass of cartilage will push inward and not outward as would be beneficial for the patient. Thus, paradoxically the airway becomes more and more narrow. We have found up to five layers of cartilage in these unfortunate patients.

The Titanium Batten Grafts (TBG) is quite different from cartilaginous Batten Grafts: they function as active springs. A Breathe-Implant XXL is bent in the surgeon's hands to follow the natural curve of the bony piriform aperture. The TBG are sutured lateral to the piriform aperture by two non-resorbable Prolen 4–0 sutures. The advantage of suture fixation over rigid fixation with screws is the partial mobility of the TBG: the patient can blow the nose and compress the lateral nasal wall medially. Upon release, the TBG will then regain its position due to the spring effect of this suture fixation. Drawbacks of TBG include discreet visual widening of the alar crease bilaterally, local sensation of thickness by the patient, and slight tenderness for about 3 months. The patient must agree to these sequelae before surgery. However, most of these patients have suffered for a long time and are quite willing to accept these minimal changes. Furthermore, the alar crease is often too deep creating a pinched nose effect. Any widening of the crease is thus beneficial not only in function but also in appearance (**Figures 51**–**61**).

**Figure 51.** *Before and after TBG. Lateral crease partially filled up by TBG.*

**Figure 52.** *Narrowing of endonasal airspace by Cartilage Batten Grafts pushing inward.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

*Titanium Batten Graft formed from Breathe-Implant XXL and fixed to the piriform aperture by Prolen 4–0 sutures. Extension of the free part toward the lateral end of the LLC. The fixation of the lateral end of the LLC also corrects a possible recurvature problem within the nasal vestibule.*

**Figure 54.** *Incision in the right vestibular skin.*

**Figure 55.**

*Preparation of the piriform aperture before drilling with the suction elevator "Haraldson" form Medicon Germany.*

**Figure 56.** *Drilling of three holes at the piriform aperture with a 2-mm burr.*

**Figure 57.** *Titanium Batten Graft sutured lateral to the piriform aperture by Prolen 4–0.*

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

#### **Figure 58.**

*CT scan reconstruction with two Titanium Batten Grafts fixed to the piriform aperture and extending into the soft lateral nasal wall acting like a dynamic spring. (courtesy A-J. Tasman).*

**Figure 59.** *Before/after TBG: Lateralization of the soft lower lateral wall by TBG.*

**Figure 60.**

*Combination of Breathe-Implant and Titanium Batten Grafts: Widening and stabilizing the internal and external nasal valves simultaneously.*

## **8. Conclusions**

The internal and external nasal valves can be successfully widened and stabilized in these positions with the Titanium Breathe-Implant/Titanium Batten Grafts. In more than 19 years of observation, results have remained stable. Perforation through the skin has not occurred in several thousands of patients. These techniques have stood the test of time. They are the new gold standard in functional nasal surgeries. Instability of the soft lateral nasal wall should always be considered in patients with breathing problems. Septoplasty and turbinoplasty alone are often insufficient. Spreader Grafts do not improve breathing reliably enough, but the combination with Breathe-Implant will. These implants are the missing link in the treatment of nasal obstruction.

## **Acknowledgements**

The author wishes to acknowledge Mr. Uwe Steinhardt, previous Chief Engineer of Heinz Kurz GmbH, Dusslingen, Germany, for the production of this Titanium Breathe-Implant.

## **Conflict of interest**

The author is a consultant for Heinz Kurz GmbH, Dusslingen, Germany, and receives royalty for Titanium Breathe-Implant.

*Internal and External Nasal Valve Widening and Stabilization by Titanium Breathe-Implant DOI: http://dx.doi.org/10.5772/intechopen.108984*

## **Author details**

Daniel F. àWengen Facial Plastic Center, Binningen, Switzerland

\*Address all correspondence to: awengen@swissear.ch

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] àWengen DF. Titanium implants in the nose: State of the art. Facial Plastic Surgery. 2022;**38**(05):461-467

[2] Moubayed SP, Most SP. Evaluation and management of the nasal airway. Clinics in Plastic Surgery. 2022;**49**(1): 23-31

[3] Samra S, Steitz JT, Hajnas N, Toriumi DM. Surgical management of nasal valve collapse. Otolaryngologic Clinics of North America. 2018;**51**(5): 929-944

[4] Van den Broek SJAC, Van Heerbeek N. The effect of the titanium butterfly implant on nasal patency and quality of life. Rhinology. 2018;**56**(4): 364-369

[5] Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plastic and Reconstructive Surgery. 1984;**73**(2): 230-239

[6] àWengen DF. Alternatives to flaring spreader flaps and upper lateral advancement for the internal nasal valve. HNO. 2012;**60**(7):595-596

[7] Losquadro WD, Bared A, Toriumi DM. Correction of the retracted alar base. Facial Plastic Surgery. 2012; **28**(2):218-224

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[9] àWengen DF. Commentary on: Balanced cantilever graft for supporting the cartilaginous side wall of the nose. Aesthetic Surgery Journal. 2022;**42**(1): 28-30

## **Chapter 7**

## Training in Paranasal Sinus Surgery: A Review of Current Modalities and What the Future May Hold

*Karamveer Narang and Karan Jolly*

## **Abstract**

Pathology affecting the paranasal sinuses can have a myriad of negative effects on patients who suffer from chronic symptoms which may significantly impact their quality of life. In most patients who fail medical treatment, surgical options can be explored. Endoscopic sinus surgery has become a mainstay of managing paranasal sinus disease ranging from chronic rhinositis, nasal polyposis, and sinonasal tumours. Surgery in this anatomical area can be challenging due to the proximity to important structures and adequate training is needed. Trainees especially in the UK have less exposure to relevant cases due to time constraints, service provision and a shift towards consultant led care. Traditional methods of training such as cadaveric dissection and 2D simulators are still relevant but may not be the most effective in the modern day. Other alternative methods of learning and teaching using technology such as VR, AR/MR and telemedicine may provide a shift in the way paranasal surgical education is delivered. Future work is needed to develop these tools further and to validate them as effective tools for surgical trainees.

**Keywords:** paranasal surgery, endoscopic sinus surgery, FESS, simulation, cadaveric dissection, virtual reality, augmented reality, medical education

## **1. Introduction**

Paranasal sinus surgery plays an important role in addressing a myriad of nasal and sinus pathologies that can significantly impact patient's quality of life. Conditions such as chronic sinusitis, sinonasal tumours, structural abnormalities and persistent infections are among those than can be addressed with surgical management. Surgery offers individuals grappling with chronic symptoms such as nasal congestion, facial pain, and anosmia a glimmer of hope when medical management has failed.

Endoscopic surgery in all domains have continued to gain popularity due to the replacement of large incisions into non-invasive procedures. A better view of the anatomy and access to small orifices mean that endoscopic approaches can be better than traditional approaches to surgery. Additional benefits include improved patient safety, quicker post operative recovery, reduced operative times and lower costs. The use of endoscopy in paranasal surgery dates to the early twentieth century when a cystoscope was used to examine the sinuses [1]. However endoscopic sinus surgery was not regularly performed until the 1970s [2]. The use of external approaches using a headlight were routinely performed until technological advancements led to the modern development of functional endoscopic sinus surgery (FESS) which is now a mainstay of sinonasal and skull base surgery [3]. The main reason being the improvement in symptoms of patients undergoing FESS as well as the overall low complication rates when compared to traditional procedures [4].

The paranasal sinuses are situated within the bones of the facial skeleton and play a crucial role in respiratory function, immune response and maintaining the integrity of the skull. The interplay of various structures, such as the ethmoid, frontal, maxillary and sphenoid sinuses demand a comprehensive understanding of anatomy as well as the variations among these structures [5]. Performing any type of procedure within this domain requires precise knowledge but also the understanding of the challenges posed by the proximity of critical structures, the potential for complications and the variation in patient presentations [6]. Although complication rates are low in endoscopic surgery, they can be significant such as vision loss, CSF leak and haemorrhage.

The complexity of paranasal sinus surgery underscores the critical importance of well-trained surgeons. Effective training equips surgeons with the proficiency to navigate complex anatomical structures, make informed decisions during procedures, and anticipate potential complications [7]. As the demand for surgical expertise in this domain grows, it becomes imperative to explore the diverse training modalities available to aspiring surgeons and identify avenues for improving and innovating these methods.

This chapter aims to provide a comprehensive overview of the existing training modalities in paranasal surgery. We aim to outline traditional methods such as cadaveric workshops, while also exploring new modalities of learning such as virtual reality simulations, augmented/mixed reality, and telemedicine driven platforms. It is important to understand the current state of training in order to improve upon these methods to equip modern day surgeons with the tools they need to master the intricate art of paranasal sinus surgery.

## **2. Current training modalities**

#### **2.1 Training overview**

In the UK there are various routes into specialist otolaryngology training with the aim leading to consultancy. Typically the current training programme comprises of 2 years of foundation training after medical school. Following on from this there is a competitive national selection process to enter a 2 year 'Core Surgical Training' programme which can be themed based on the trainee's specialty of choice. This is then followed by a second competitive national selection process for specialty training which typically lasts for 6 years (ST3 – 8) but can be extended if any research, academia, fellowships or less than full time training occurs. The outcome then leads to a Certificate of Completion of Training (CCT) allowing appointment to consultant posts [8].

Surgical training in the UK is generally overseen by the Royal College of Surgeons in England or Edinburgh and Glasgow in Scotland. The Joint Committee on Surgical

*Training in Paranasal Sinus Surgery: A Review of Current Modalities and What the Future May… DOI: http://dx.doi.org/10.5772/intechopen.113297*

Training (JCST) via Specialty Advisory Committees (SACs) then provide and oversee the surgical curriculum as well as quality indicators for each specialty in order to monitor and assess trainees' progress [8, 9]. Trainees are then expected to complete work-based assessments (WBAs) and record them on the Intercollegiate Surgical Curriculum Programme (ISCP) portal [10] and log their operations on the eSurgical Logbook [11]. Trainees are then subjected to a rigorous assessment process via the Fellowship of the Royal College of Surgeons Exams which occurs in the latter stages of specialist training. A summary overview of the ISCP curriculum for paranasal surgery is provided in **Table 1** [10].

As outlined above, the training requirements for paranasal sinus surgery is extensive and one of the primary challenges in surgical training is ensuring trainees receive adequate exposure to a diverse range of cases. This allows the trainee surgeon to appreciate the variability in anatomy and pathology and allows a broad spectrum of experiences to develop their skill set. Not only are trainees able to perform procedures, but they are also able to observe experienced surgeons operate which can also help increase their knowledge base when faced with similar cases or challenges. Unfortunately ensuring adequate exposure can be problematic due to availability of suitable cases as well as time considerations such as the EWTD which was implemented in 2009 within the UK's healthcare. Trainees are limited to working 48 hours per week over a 6-month period with a change towards shift-based rotas [8]. The Temple report published in 2010 also identified concerns regarding the EWTD severely impacting training due to the reduced number of hours available for supervised learning [8, 12]. This has meant trainees have had to turn to other modalities of learning such as courses in order to gain knowledge and surgical skills such as via cadaveric dissection.

#### **2.2 Cadaveric dissection courses**

Cadaveric dissection has been the mainstay for anatomy teaching in the medical curriculum since the seventeenth century [13]. Human cadaveric dissection helps students understand the relationships between various anatomical structures when compared to textbooks and lecture-based learning [14]. Due to the unparalleled realism it offers, it has also been the mainstay of postgraduate surgical education. It offers trainees the opportunity to perform surgical procedures in a simulated environment where patient safety is not compromised [15]. Trainees can then apply what they have learned into an operative setting.

The opportunity to practice performing procedures on real human tissue helps to increase confidence and improve surgical skills to help them perform procedures independently. Trainers have been found to also have more confidence in their trainees and provide them with greater autonomy in the operating theatre [16]. Trainees who have been through cadaveric dissection courses were also found to have increased knowledge of procedural steps as well as a greater appreciation of complications which then contributes to a higher level of confidence when performing procedures [17].

In terms of paranasal sinus surgery, there are multiple courses that offer dissection—based learning for trainees globally. In the UK itself, courses such as these are funded by the training body and delegates are encouraged to attend in order to improve their technical skills. A multi-centre study surveyed 133 participants in seven centres across Germany, Switzerland and Australia regarding their experiences of endoscopic sinus surgery cadaveric dissection courses and almost all participants


#### **Table 1.**

*ISCP curriculum overview for paranasal surgery.*

#### *Training in Paranasal Sinus Surgery: A Review of Current Modalities and What the Future May… DOI: http://dx.doi.org/10.5772/intechopen.113297*

reported that the course had improved their anatomical knowledge and confidence [18]. The majority of participants considered infundibulotomy and anterior ethmoidectomy as the easiest step in the procedure while frontal sinus surgery appeared to be the most challenging regardless of their level of training. They identified that more emphasis on anatomy as well as self-directed learning during their surgical training years would be of greatest benefit [18].

Although cadaveric dissection courses have shown to be effective for training surgeons, there are certain factors that must be considered when running these courses. Cadaveric courses are expensive and require approval from the Human Tissue Authority in order to make sure cadavers are being used appropriately and safely [19, 20]. There are also ethical considerations involved and costs when handling cadavers related to donor consent, respect for human remains, and cultural sensitivities. Courses must be hosted in facilities that have the legal and health and safety requirements for cadavers. These factors not only increase the costs for running the course as well for attendees but also limits where and when courses can be run [21]. Balancing the educational value of cadaveric training with these ethical and financial concerns requires careful planning and consideration. Due to the issues highlighted above, the need for developing other means of training has been important such as using simulation or utilisation of phantom and animal models.

#### **2.3 Simulation in paranasal surgery**

Simulators have been widely used and developed in all domains of surgery. These systems all vary in their levels of realism, task specificity and training modality [21]. There are several simulators which have been developed for endoscopic sinus surgery reported in literature and these range from 'low fidelity' gelatine or 3D printed models to realistic 'high fidelity' anatomical models along with animal ovine models [22]. The fidelity of these simulations refer to the extent to which the models reflect real tissue properties and their anatomical accuracy of various structures. The simulators also vary in cost based on fidelity as well as the material used for production.

A detailed comparison of the various types of simulators available is beyond the scope of this chapter but it is interesting to observe that even with low-cost simulators, a significant improvement in skills has been noted [23]. This study utilised a low-cost sinus surgery task trainer to evaluate 52 medical students who had no sinus surgery experience by asking them to perform five specific sinus surgery tasks. Preand post-training videos were recorded of nasal endoscopy and surgical skills, and their performance was evaluated via a checklist and global rating scale. They found that even in novices, repeated practice using the skills trainer resulted in an improvement in performance [23].

Another study focused on assessing whether an intermediate fidelity FESS training model was effective and measured data comparing 12 medical students against 10 otolaryngology residents in the United States by asking them to perform distinct tasks on the simulator. They found that both groups were found to have gained a statistically significant improvement in skills and time taken to complete each task. They also found that the improvement was retained by testing them again after 2 weeks. Delegates were also found to have increased their accuracy in performing tasks through repetition which helped illustrate that practicing outside the operating theatre repeatedly can help improve surgical skills when performing FESS [24].

As evident in the literature, there are a multitude of simulators available to help trainees learn how to perform paranasal surgery and it is also interesting to observe that even though fidelity is important, it does not make a large difference when it comes to attaining skills in endoscopic surgery. In order to address the differences in fidelity and their effectiveness, 34 first year medical students were randomised into three groups and taught basic anatomy and instrumentation. Two groups were allocated to receive training with either a high-fidelity training model or a low fidelity training model with the last group serving as a control. The control group received no simulator exposure. The groups were then tested with cadaveric specimens and sessions were recorded and graded by an expert. It was interesting to note that there was no statistical difference in performance between the three groups in relation to identification of anatomy, endoscopic competency or completion of basic tasks however those who underwent training in either a high or low fidelity simulator did show improvement in time taken to complete various tasks [22].

In terms of validation of these simulators as an educational tool, a systematic review performed in 2018 aimed to analyse the evidence for validated endoscopic sinus surgery (ESS) simulation. They found that although several ESS simulators have been comprehensively validated, the majority lack standardisation in terms of outcome reporting which makes it difficult to compare the various types of simulators [25]. Despite the lack of uniformisation and standardisation of outcomes, literature has still shown that simulation is effecting in allowing junior trainees to acquire skills and practice in non-clinical environments where patient safety is not negatively affected [26]. Simulators in general allow the development of hand-eye coordination and dexterity when performing surgical tasks and are potentially a cost-effective means for teaching and learning surgical skills [27].

Although simulators have been shown to be effective, they are still not equivalent to cadaveric models in terms of immersion and realism which has been shown to be an important facet for skills acquisition [28]. A robust platform that is easily accessible to ENT trainees is also lacking and in order to address these differences and achieve the same level of realism as being within the operating theatre, virtual reality (VR) simulators have been in development over the last three decades [29, 30].

#### **2.4 Virtual reality simulation in paranasal surgery**

Advancements in technology have brought virtual reality and simulation to the forefront of surgical training. VR platforms create immersive environments where trainees can practice surgical techniques on realistic 3D models of the paranasal sinuses. One of the most popular simulators has been the ES3 developed by Lockheed Martin in 1997. This tool provides a virtual surgical environment where the trainee can manipulate an endoscope and other instruments inside the nasal cavity of a mannequin with varying levels of haptic feedback affordable via the surgical instruments [31]. The ES3 has been validated extensively as a learning tool and shown to be effective in addressing training needs in terms of procedural skills. In a prospective, multi-institute controlled trial, 12 ES3 trained novice ENT residents in the United States were compared with 13 novice residents who did not undergo training in the VR simulator. It was found that those who had used this training tool demonstrated more skill during instrument manipulation and made fewer technical errors when compared to the control group [32]. Although this tool has been extensively validated, it is no longer in production due to development costs making the simulator very expensive [31].

*Training in Paranasal Sinus Surgery: A Review of Current Modalities and What the Future May… DOI: http://dx.doi.org/10.5772/intechopen.113297*

Based on the effectiveness of the ES3, other VR simulators have also been in development, and these include the CardinalSim, VOXEL-MAN SinuSurg, Nasal Endoscopy Simulator (NES), Dextroscope, Virtual Endoscopic Simulation of Transsphenoidal Endoscopic Pituitary Surgery (STEPS), Flinders Sinus Surgery Simulator, NeuroTouch Endo, and the McGill Simulator for ESS [31]. Although many of these tools are validated, they are still faced with issues surrounding accuracy of anatomical models as well as the real-life applicability of the haptic feedback afforded from the surgical instruments used in each of the respective VR simulators [31]. Additionally, there are concerns around assessment and achievement of competence for trainees as there is no uniformity across various training programmes due to the affordability and accessibility of the various simulators [31]. It is also important to note that although the tools mentioned above are classed as VR simulators, they are not 'true' VR which we will cover in the next section of this chapter.

## **3. Potential future training modalities**

#### **3.1 'True VR'**

In 'true VR', a user is exposed to a computer-generated environment which is completely segregated from normal reality. Immersive VR (iVR) systems are different to the VR simulators described in the previous section due to the need for a head mounted display which then allows a 360° appreciation of the virtual environment. This differs from simulators such as the ES3 whereby the virtual environment is displayed on a screen display rather than offering true immersion.

Utilisation of 360° video also allows users to experience an immersive environment though unlike true VR, users are unable to move within or interact directly with objects in the virtual environment unless there are hotspots or clickable content added to the video [21, 33, 34]. With the user taken out of the real-world environment, they can be transported to any virtual environment that has been developed which allows for true immersion. This shift in visuospatial understanding is a major factor in how beneficial virtual 3D environments can be for learners.

A successful example of how 360 videos can be used for surgical education is the work and development done by Virtual Reality in Medicine and Surgery (VRiMs, vrims.net) and Brighton and Sussex Medical School (BSMS). They were the first medical school in the UK to have live streamed footage of cadaveric dissection using 360 videos [21]. Trainees across the UK were invited to attend a five-day course covering a range of specialities including ENT procedures. The delivery of content was via a combination of 360VR footage of clinical examination, assessment and surgical techniques as well as live streamed cadaveric dissection. The added benefit of the course was that content could be accessed via a smartphone and cardboard headset which made it cost effective. The course was accessed by over 500 trainees across the UK with 129 responding to the post course survey where 90% either agreed or strongly agreed that this training tool would be of value [21].

Although ENT operations were included within the 360° library, the majority of operations that were taught were emergency operations such as front of neck access and drainage of deep neck space infections. The positive feedback received in relation to 360° videos and their usefulness in surgical training should potentially be a basis for 360 video content creation in relation to paranasal surgery which has not yet been reported in the literature.

A further step in utilisation of immersive VR would be to develop simulations utilising 'true VR' and six degrees of freedom (6DOF). This technology forms the basis of gaming platforms offered by headsets such as Meta Quest 2 and Pro, Apple's Vision Pro, PICO 3 as well HTC Vive. Although not reported in the literature, there are ongoing developments by VR companies to push through medical simulations which include surgical procedures. Examples of these companies include Touch Surgery and Fundamental Surgery. The latter is already recognised by the American Academy of Orthopaedic Surgeons as well as the Royal College of Surgeons of England, but many simulations are focused on general surgery and orthopaedic procedures.

The benefit of utilising this technology would be to fully immerse delegates within an operative environment which not only helps increase the realistic nature of the simulation compared to real life, but also can mimic various surgical scenarios. Specifically, for paranasal surgery, a simulation that offers complications such as a catastrophic bleed, or CSF leak could allow trainees to learn how to correct these adverse events intra-operatively in a situation that mimics reality.

The additional benefit of utilising this technology would be the potential ability to measure competence. In traditional surgical training, an assessment is made by the senior consultant or attending on when a trainee is ready for the next step or first unsupervised steps when performing a procedure [35]. This is usually a subjective assessment, and it is difficult to standardise this across all trainees in various training programmes across the globe. Psychological fidelity is the extent or degree to which a simulation replicates the cognitive demands of the real task and eye tracking has been shown to be a potential assessment tool for this domain [21, 36]. Eye tracking tools are offered in the majority of new headsets and can measure gaze as well as other metrics such as fixation frequency, pupil dilatation and dwell time. The differences in these parameters have shown to help differentiate novices versus experts when performing tasks [21, 36, 37]. In one study focusing on endoscopic sinus surgery, 16 residents performed FESS training over 18 sessions which were split into three surgical steps. Eye movements were measured, and results indicated performance improvements in terms of completion time and surgical performance [35]. There was also a significant change in cognitive load and average fixation duration towards the last step of training [35]. Eye movements and cognitive load also differed between residents of different levels, and it was found that eye tracking is a helpful objective measuring tool in FESS.

True VR may potentially help solve some of the issues identified when using cadaveric dissection as there is no need for any human tissue to be obtained. It may also solve some of the issues with 2D VR simulators whereby standardisation and assessment have not been possible due to the differences in availability of various simulators across different units. There is also the added cost benefit where although the initial start-up costs can be significant, once a headset is obtained and programmed, simulations can be run repeatedly and potentially from a trainee's own home.

Although True VR may be a novel approach, it does not address the issue with the lack of appropriate haptic feedback which is where augmented reality and mixed reality solutions may be of benefit.

#### **3.2 Augmented and mixed reality**

Augmented reality is where a user is presented with a computer – generated image superimposed onto a part of normal reality. This is different to true VR described above as the user is not segregated from reality, but rather digital elements are

*Training in Paranasal Sinus Surgery: A Review of Current Modalities and What the Future May… DOI: http://dx.doi.org/10.5772/intechopen.113297*

overlayed onto the real world. Mixed reality on the other hand is where a view of the physical world is overlayed with digital elements, but these elements can interact with each other [21]. Within otolaryngology, this technology has most commonly been used to explore intra-operative guidance and surgical planning with minimal work done currently on procedural simulations [38].

One example of a mixed/augmented reality system that could be used for paranasal surgery training is the UpSurgeOn Transsphenoidal (TNS) Box which has been used in a neurosurgical setting for the endoscopic endonasal transsphenoidal approach to the pituitary fossa [39, 40]. The TNS box is a high-fidelity simulator and comprises of a nasal cavity with a 3D face overlay and is made of silicone via 3D printing. The model allows trainees to explore the nasal cavity, identify anatomical landmarks and resect pituitary tumours endoscopically. Currently there are no validated studies for this tool which led to a study looking at 15 neurosurgeons of which 10 were novices and 5 were intermediate and experts in their field. The participants were subjected to a survey as well as task specific technical skills and given a score. The results demonstrated that the model was a valid training tool as a simulator for the endoscopic endonasal transsphenoidal approach although improvements to the system could also be made [39]. These included the addition of neuro-vascular anatomy and arachnoid mater to stimulate bleeding vessels and CSF leak as well as improving the materials used to make the model more realistic.

Although the TNS box is tailored to paranasal approaches to access the pituitary fossa, there is the potential for further development of similar tools to simulate other paranasal surgical procedures. The TNS box also allows for haptic feedback whilst giving the user a superimposed image on their telephone mimicking an endoscopic view. Although initial costs may be deemed high, the repeatability of the simulation can possibly make this augmented/mixed reality simulator implementable across multiple training units across the UK and the globe.

#### **3.3 Telemedicine**

Telemedicine could be one method of adapting training methods considering the decrease in exposure to cases that are faced by trainees. Using technology to provide remote medical care and consultations remotely, this can be adapted to also provide teaching as well as access to real time learning experiences. Telemedicine allows trainees to remotely observe live surgeries by skilled surgeons across the world which allows further exposure to various techniques, approaches and patient scenarios. Vice versa, trainees could also perform procedures in a simulated or real life setting with ongoing observations from experts who can offer and comment on the techniques being performed which allows the trainee to learn in real time. Surgeons could potentially guide trainees through procedures, and provide step by step instructions, highlight critical landmarks, as well as offer immediate feedback. One such example is Proximie who are utilising their innovative platform to live stream operations or teaching sessions remotely while offering the educator the capability to annotate 'on screen' while trainees are watching the procedure being performed. Proximie's platform also allows for the editing of recorded content to be packaged into educational videos which can be accessed by trainees in their own time. Currently the platform has been used by several surgical bodies across the globe but it's application within paranasal surgery is not published in literature.

However, a successful venture to help facilitate remote training of FESS was completed in 2021 by a group based in Japan and Australia utilising novel 3D printed sinus models and telemedicine software [41]. Three otolaryngologists in Hokkaido, Japan were trained to perform frontal sinus dissections on 3D sinus models of increasing difficulty by two rhinologists in Adelaide, Australia. The models were printed using CT scans of patients with chronic rhinosinusitis. They utilised Zoom and the Quintree telemedicine platform to first lecture the Japanese surgeons followed by supervising them in real time as they performed the frontal sinus dissections. This teaching session was streamed to over 200 otolaryngologists worldwide. The Japanese surgeons were asked to complete a questionnaire afterwards and the time taken to complete the tasks were recorded. It was found that the time taken to identify the frontal sinus reduced significantly despite the increasing difficulty of the 3D models. Feedback was also mainly positive from the dissectors and the worldwide audience which may help illustrate how this can be implemented within surgical training.

## **4. Conclusions**

The landscape of surgical training is shifting towards alternative and novel methods to deliver education. These changes are driven by factors which can impact trainee's exposure to diverse cases due to time constraints as well as other factors such as service provision and a shift towards consultant led care. Traditional approaches such as cadaveric dissection and 2D simulation to learn how to perform paranasal surgery still have a place but other innovative approaches such as VR, AR/MR and telemedicine may prove to be effective in training surgeons of the future.

## **Author details**

Karamveer Narang1 \* and Karan Jolly2

1 Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom

2 University Hospitals Birmingham, Birmingham, United Kingdom

\*Address all correspondence to: karamveer.narang@nhs.net

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Training in Paranasal Sinus Surgery: A Review of Current Modalities and What the Future May… DOI: http://dx.doi.org/10.5772/intechopen.113297*

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## **Chapter 8**
