Virtual reality in rhinology

Virtual reality in rhinology – a new dimension of clinical experience
Ear Nose Throat. 2016; 95(7): 23-28 (CC)
Ivica Klapan, PhD, MD1,4; Pero Raos, PhD, MEng2;
Tomislav Galeta, PhD, MEng2; Goranka Kubat, MD3
1University of Osijek, School of Medicine, Osijek, Croatia, EU
2University of Osijek, Mechanical Engineering School in Slavonski Brod, Slavonski Brod, Croatia, EU
3Sunce Polyclinic, Radiology Division, Zagreb, Croatia, EU
4Klapan Medical Group University Polyclinic, Zagreb, Croatia, EU
Ivica Klapan
Klapan Medical Group University Polyclinic
Ilica 191A, HR-10000 Zagreb, Croatia, EU
Pero Raos
Mechanical Engineering Faculty in Slavonski Brod
Trg I. B. Mazuranic 2, HR-35000 Slavonski Brod, Croatia, EU
Phone: +385 35 493 428
Tomislav Galeta
Mechanical Engineering Faculty in Slavonski Brod
Trg I. B.Mazuranic 2, HR-35000 Slavonski Brod, Croatia, EU
Phone: +385 35 493 439
Goranka Kubat
Sunce Polyclinic, Radiology Division, Zagreb
Trnjanska cesta 108, HR-10000 Zagreb, Croatia, EU
Phone: +385-1-304-6666
Keywords : virtual reality, CAS, Tele-CAS, rhinosurgery, navigation surgery, rapid prototyping




The need of a more precise identification of the pathologic process extent as well as of the fine elements of intracranial anatomic features is often experienced in diagnostic process and during many operations in the nose, sinus, orbit and base of the skull region. In two case reports, the methods used in diagnostic work-up and surgical therapy in the nose and paranasal sinus region are described. Besides baseline x-ray, multislice computed tomography and magnetic resonance imaging scans, the techniques of operative field per viam imaging by use of rapid prototyping model, virtual endoscopy, and patient head 3D-imaging (3D-Doctor) were employed with differential coloration of all substantial head tissues (different tissues visualized in different colors), their anatomic inter-relations, and the extent of pathologic tissue within the operative field. This approach has not yet been used as a standard preoperative or intraoperative procedure in otorhinolaryngology. In this way, we tried to understand the new, visualized 'world of anatomic relations within the patient's head' by creating an impression of perception (virtual perception) of the given position of all elements in a particular anatomic region of the head, which does not exist in the real world (virtual world). This approach was aimed at upgrading diagnostic work-up and surgical therapy by ensuring a faster, safer and above all simpler operative procedure. In conclusion, every ENT specialist, i.e. any member of our surgical team, is able to provide virtual reality (VR)-support in implementing surgical procedures, with additional correct control of all risks, within the limits of surgical normal tissue, without additional trauma to the surrounding tissue in the anatomic region undergoing surgical treatment, while having an impression of the presence in virtual world, navigating through it and manipulating with virtual objects.
1. Introduction
Virtual endoscopy (VE) is a new method of diagnosis using computer processing of 3D image datasets (such as 2D-multislice computed tomography (MSCT) and/or magnetic resonance imaging (MRI) scans) to provide simulated visualization of patient specific organs similar or equivalent to those produced by standard endoscopic procedures1,2. Visualization avoids the risks associated with real endoscopy, and when used prior to performing an actual endoscopic examination, it can minimize procedural difficulties3, especially for endoscopists on training, which was proved in Croatian 3D computer assisted-functional endoscopic sinus surgery (3D-CA-FESS) performed on June 3, 19944, our first Croatian Tele-3D-CA-FESS in October, 19983,4, as well as in our ongoing surgical activities (Fig. 1.).

Fig. 1. Virtual endoscopy of human head in different projections. Visualization of all paranasal sinuses and surrounding regions from different 3D aspects4.
Modern Tele-3D-computer assisted surgery (Tele-3D-CAS)4,5 should enable less experienced surgeons to perform critical surgeries using guidance and assistance from a remote, experienced surgeon. In telesurgery, more than two locations can be involved; thus less experienced surgeon can be assisted by one, two or more experienced surgeons, depending on the complexity of the surgical procedure. In our activities, 3D-CAS4 and Tele-3D-CAS6 also provide the transfer of computer data7 (images, 3D-models) in real time during the surgery and, in parallel, of the encoded live video signals4. Through this network, the two encoded live video signals from the endocamera and OR camera have to be transferred to the remote locations involved in the telesurgery/consultation procedure8,9.
Comparative analysis of 3D anatomic models with intraoperative findings, in any kind of CAS and/or CA-telesurgery, shows the 3D volume rendering image to be very good, actually a visualization standard that allows imaging likewise the real intraoperative anatomy10,11. The mentioned technologies represent a basis for realistic simulations that are useful in many areas of human activity (including medicine), and can create an impression of immersion of a physician in a non-existing, virtual environment12,13 . Such an impression of immersion can be realized in any medical institution using advanced computers and computer networks that are required for interaction between a person and a remote environment, with the goal of realizing tele-presence (Fig. 2).

Fig. 2. Virtual endoscopy during our 3D-CA-FESS in October, 1999.
In order to understand the idea of virtual reality (VR), it is necessary to recognize that the perception of the surrounding world created in our brain is based on the information coming from human senses and with the help of the knowledge that is stored in our brain8. The usual, well known definition says that the impression of being present in a virtual environment, such as virtual/tele-virtual endoscopy (VE/tele VE) of the patient’s head that does not exist in reality is called virtual reality. The otorhinolaryngologist, e.g., any member of our surgical team, has an impression of the presence in the virtual world and can navigate through it and manipulate virtual objects9,13.
2. Methods
2.1 Preoperative preparation
The real-time requirement means that the simulation must be able to follow the actions of the user that may be moving in the virtual environment8. The computer system must also store in its memory a 3D model of the virtual environment. In that case, a real-time virtual reality system will update the 3D graphic visualization as the user moves, so that up-to-date visualization is always shown on the computer screen. For realistic simulations it is necessary for the computer to generate at least 30-40 such images per second, which imposes strong requirements upon the computer processing power (Fig. 3)9. Virtual reality systems may be used for visualization of anatomic structures, virtual endoscopy, 3D-image-guided surgery, as well as of the pathology and/or anatomy during therapy planning14,15.

Fig. 3. Our 3D models of human head in different projections.
So, the basic goal is to develop methods for fast and realistic visualization of 3D objects that are in the VE. Advanced technologies of exploring 3D spatial models allow for simulation of endoscopic surgery and planning the course of the future procedure (VE) or telesurgery (Tele-VE).
2.2 Virtual endoscopy
Various 64 MSCT-scanners were used for image acquisition in our VE-activities. Recordings of VE images together with appropriate CT images in three major planes during fly-through were performed in real time.
In order to prepare virtual endoscopy for case studies presented in this paper, we used a specialized 3D-DOCTOR software16. MSCT and MR DICOM cross-sectional images were used as a starting point of the preparation and as an input for the software. Prior to interactive segmentation of tissues, several logical objects were prepared for corresponding tissue, e.g., for bones, flesh or pathology, but also for voids. Voids can also be rendered and presented in spatial form and so to provide additional significant information when internal anatomy is observed. Real-time 3D surface rendering done in software finally enabled full and detailed virtual endoscopy. Rendering also provided helpful capabilities to measure objects and to highlight or to hide particular regions and particular objects or tissues. Furthermore, when the 3D surface with tissues arranged by objects is obtained, it is possible to derive spatial cross-sections at selected cutting planes, thus providing additional insight into the internal regions observed.
Although the software provides fully automatic segmentation divided in a selected number of objects, in order to highlight and analyze the affected region, it is necessary to perform interactive segmentation. Interactive segmentation in the affected region should be manually constrained to this region of interest and segmentation has to be carefully performed regarding thresholds in order to avoid interleaving of objects. Due to the characteristics of medical imaging technique and segmentation algorithm, some objects are harder to segment. For example, orbital fat around the eye has similar intensity as the nearby tissue, so segmentation of orbital fat requires exhaustive and systematic work of the software operator during interactive segmentation with advisable supervision of an ENT specialist.
3. Case Reports
3.1 A 46-year-old male with chronic sinusitis and shadow intensity characteristic of a mucocele in the right orbital space and ethmoids was examined as the first case. MSCT (Siemens, 64 multislice) of the sinuses in coronal, sagittal and axial sections demonstrated a disease of the ethmoidal infundibulum on the right side, with homogeneous opacification and/or retention in the region of the right anterior and posterior ethmoidal cells and the orbit, as well as frontal sinus, with the sphenoid and the maxillary sinuses of normal transparency.
MSCT scanning of the orbit revealed a tumor like shadow, which partially protruded into the anterior and posterior ethmoidal cells, and partially into the orbit. The medial wall of the orbit, right medial rectus muscle, optic nerve and the eyeball were displaced laterally (exophthalmos). A huge inferior turbinate was noticed on the right. Pronounced chronic inflammatory changes with signs of ostiomeatal block were also observed in the region surrounding ethmoidal cells and frontal sinus (Fig. 4).

Fig. 4. Partial destruction of the middle part of the bony border between paranasal sinuses and the right orbit (orbital lamina), with dislocation of the rest of this bony borderline.
The patient also complained of difficult breathing, with additional headaches in the right fronto-ethmoidal region, and recurrent sinusitis with postnasal dripping (appropriate nasal discharge). Visual function was partially reduced on the right eye, with normal finding on the left eye. Postoperatively, antibiotic therapy with local corticosteroids was prescribed.
On diagnostic work-up, we used the standard 2D-MSCT-imaging sections, virtual endoscopy of the patient’s head model over a few applied travel sections through the patient's “virtual” head. Physical RP-models of the patient’s head showed clear demarcation (anatomic position) between the diseased and healthy tissues in the projection of the nose, paranasal sinuses and orbit. The patient underwent image guided CA-VE-FESS. Three months after the surgery, the patient was symptom-free. The VE-approach proved efficient not only for diagnostic localization of the radiologic soft tissue shadow in the region of anterior/posterior ethmoids and its identification within the orbital area, but also during the operation itself (Fig. 5).

Fig. 5. Basic contours of the pathologic process and the structures surrounding the orbit could not be visualized with certainty, nor it was possible to determine whether there actually were disparate, mutually connected fragments of the right orbital lamina, or a single bony wall partially destructed by pathologic tissue.
3.2 A 35-year-old male with a history of chronic frontal, ethmoidal and maxillary sinusitis with strong left frontal headaches and orbital pain, and postnasal dripping was examined as the second case (Fig. 6).

Fig. 6. 3D-model (back view) of the pathologic tissue and sinuses showed chronic rhinosinusitis with homogeneous transparency of all anatomic spaces of the whole frontal sinus, anterior and posterior ethmoidal cells, and maxillary sinus.
On diagnostic work-up, we used the same approach as in the first patient (2D-MSCT, VE). During the surgery, we had a very clear view of the size, shape and anatomic characteristics of the pathologic process and the status of all sinuses, as well as the sinus ostium, and especially of the sinus periosteum involvement in this case (Fig. 7).

Fig. 7. It is very easy to apply the minimally invasive approach to all sinus cavities, keeping in mind the patient safety and feasibility of the operation (postoperative hospital stay of several hours with rapid recovery within 3 days).
In our patient, the presence of inflammatorily changed mucosa of paranasal sinuses (left side), with “suspected protrusion of the cerebral tissue” into the left frontal sinus (as suspected/diagnosed by plain x-rays in another clinical institution), the basic diagnosis (per viam MSCT and VE) was quite easy to make, however, with highly reflective structures, especially in the borderline area toward the region of frontal sinus, skull base, and posterior ethmoidal cells. 2D-coronal and transverse sections were compared with 3D models16. At the same time, the static and dynamic 3D models and VE of the sinuses were used on surgery planning and were available to the surgeon in the operating room (OR) throughout the procedure. 3D models helped describe the expansion and the nature of the pathologic process8.
The density of the “questionable substance” in the frontal sinus was detected with a high level of certainty by use of MSCT sections of the orbit, paranasal sinuses and skull base/brain tissue, in axial and coronal sections, in comparison with soft tissue of the brain itself. Although it was known that a very suspected “unknown tissue” within the frontal sinus region could be visualized by MSCT scanning, vital anatomic soft tissue structures of the brain within the frontal sinus could not be definitely determined (index of transparency, 3D models). It was the reason for creating appropriate objects for matching tissues, e.g., for bones, flesh or for pathology, but also for voids, before the interactive segmentation of tissues. When rendered, voids can be presented as three-dimensional surfaces and so to provide noteworthy information when internal anatomy is observed. The real-time 3D-surface rendering performed in the 3D-DOCTOR software enabled full and detailed VE. Rendering also provided helpful capabilities to measure objects and to highlight or to hide particular regions and particular objects or tissues. Furthermore, when the 3D-surface with tissues arranged by objects was obtained, it was possible to derive spatial cross-sections at selected cutting planes, thus providing additional insight into the internal regions observed.
Thus, we were able to conclude that we had done the procedure correctly, within the limits of surgical normal tissue, without additional trauma of the surrounding tissue of the anatomic region undergoing surgical treatment (Fig. 8).

Fig. 8. MSCT of the nose and paranasal sinuses (fist line, prior to the operation, and MRI of the same region three months after the surgery).
4. Discussion
Using CA-surgery17 and/or tele-CA-system18, the possibility of exact preoperative, noninvasive visualization of the spatial relationships of anatomic and pathologic structures, including extremely fragile ones19,20, size and extent of pathologic process10, and to precisely predict the course of surgical procedure21, definitely allows the surgeon in any 3D-CAS or Tele-CAS procedure to achieve considerable advantage in the preoperative examination of the patient, and to reduce the risk of intraoperative complications, all this by use of VR or diagnosis (the surgeon and/or telesurgeon operates in the “virtual world”) . With the use of 3D model, the surgeon's orientation in the operative field is considerably facilitated10, including “patient location” and "location of the tele-expert consultant”22.
VR has many applications in CA-surgery. Using the computer recorded co-ordinate shifts of 3D digitalizer during the telesurgery procedure, an animated image of the course of surgery can be created in the form of navigation, i.e. the real patient operative field fly-through, as it has been done from the very beginning (since 1998) in our CA-telesurgeries.
Upon the completion of the CAS and/or tele-CAS-operation, the surgeon compares the preoperative and postoperative images and models of the operative field, and studies video records of the procedure itself. In otorhinolaryngology, especially in rhinology, research in the area of 2D and 3D image analysis, visualization, tissue modeling, and human-machine interfaces provides scientific expertise necessary for developing successful VR applications12. The basic requirement in rhinology resulting from the above mentioned refers to the use of a computer system for visualization of the anatomic 3D-structures and integral operative field to be operated on (Fig. 9).

Fig. 9. 3D-CA-surgery in rhinology, where we defined the precise relationships of the borderline areas that are important for the diagnosis of pathologic conditions in the patient’s head.
5. Conclusions
Different VR applications have become a routine preoperative procedure in human medicine, as we have already shown in our surgical activities in the last two decades, providing a highly useful and informative visualization of the regions of interest, thus bringing advancement in defining the geometric information on anatomic contours of 3D-human head-models by the transfer of so-called “image pixels” to “contour pixels”.
The physician has an impression of the presence in the virtual world and can navigate through it and manipulate virtual objects. A 3D-CAS/VR and tele-3D-CAS system may be designed in such a way that the physician is completely immersed in the virtual environment or tele-virtual-environment. We can conclude that the basic purpose of such medical and tele-medical systems is to create a sense of physical presence at a remote location. Tele-presence is achieved by generating sensory stimulus, so that the operator has an illusion of being present at a location distant from the location of physical presence8. A tele-presence system extends the operator’s sensory-motor facilities and problem solving abilities to a remote environment. A tele-operation system enables operation at a distant remote site by providing the local operator with necessary sensory information to simulate operator’s presence at the remote location8. Realization of VR systems requires appropriate software for running VR applications in real time6,9. Simulations in real-time require powerful computers that can perform real-time computations required for generation of visual displays.
VE or fly-through12,14 methods, which combine the features of endoscopic viewing and cross-sectional volumetric imaging, provided more effective and safer endoscopic procedures in the diagnosis and management of our patients, especially preoperatively, as already discussed (Fig. 10)8.
Fig. 10. Virtual endoscopy during our 3D-CA-endoscopic surgery
(with permission of Klapan Medical Group Polyclinic, Zagreb, Croatia).
Interactive display of correlated 2D and 3D data13,14,15 in the four-window format may assist the endoscopist in performing various image guided procedures. In comparison with real endoscopy, the VE is completely noninvasive. In the nasal or sinus cavity, VE can clearly display the anatomic structure of the paranasal sinuses17,23, nasopharyngeal cavity and upper respiratory tract, revealing damage to the sinus wall caused by a bone tumor or fracture8,24, and use the corresponding cross-sectional image or multiplanar reconstructions to evaluate structures outside the sinus cavity. A major disadvantage of VE is its inability to make an impact on OR performance, as well as considerable time consumption25 to evaluate the mucosal surface, or to provide a realistic illustration26 of the various pathologic findings in cases with highly obstructive sinonasal disease.
We would like to underline that ordinary, and occasionally even expert surgeons may need some additional intraoperative consultation (or VE/3D support), for example, when anatomical markers are lacking in the operative field due to trauma (war injuries)6 or massive polypous lesions/normal mucosa consumption, bleeding, etc. Now, imagine that we can substitute artificially generated sensations for the real standard daily information received by our senses8. In this case, the perception system in humans could be deceived, creating an impression of another 'external' world around the man (e.g., 3D navigation surgery). In this way, we could replace the true reality with the simulated reality that enables precise, safer and faster diagnosis, as well as surgery9. All systems of simulated reality share the ability to offer the user to move and act within the apparent worlds instead of the real world.




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The work presented in this paper was financially supported by the Ministry of Science, Education and Sports of the Republic of Croatia through the scientific research projects No. 108-1521473-0339 (Customized Implants) and No. 152-1521473-1474 (Advanced Technologies of Direct Manufacturing of Polymeric Products).