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Program Number: B087
Session Name: Poster Session

The Advantages of Augmented Reality Navigation in Benign Head and Neck Tumor Visualization: An Illustrative Case

Karen K Hoi, MD¹; E. Brandon Strong, MS¹; Jared W Clouse, MD²; Cameron Sadegh, MD, PhD²; Alexander P Marston, MD¹; ¹Department of Otolaryngology-Head and Neck Surgery - University of California, Davis; ²Department of Neurological Surgery - University of California, Davis

Introduction: Fibrous hamartomas are rare, benign tumors that typically appear within the first two years of life, with up to 10% occurring in the head and neck. Surgical excision of infiltrative tumors requires an understanding of surrounding anatomy. We present a unique case illustrating the advantages of augmented reality (AR) navigation versus traditional navigation for benign head and neck tumor visualization.

Case Report: A 21-month-old male presented with a rapidly expanding posterior occipital neck mass since birth. MRI/CT demonstrated a 15x10x10cm infiltrative soft tissue mass centered in the posterior neck and occiput, involving the periauricular, parotid, carotid, paraspinal, and prevertebral spaces, with occipital osteolysis and extension into the posterior fossa abutting the dura and venous sinuses. Incisional biopsy suggested fibrous hamartoma. Due to the infiltrative nature and occipital osteolysis, conservative debulking to relieve occipital pressure followed by medical therapy was recommended over complete surgical excision. Virtual surgical plans were generated from preoperative imaging. Both traditional navigation (BrainLab) and a novel AR navigation platform (Xironetic) with a head-mounted display (Microsoft HoloLens 2) were utilized intraoperatively. The patient underwent debulking of the posterior cervical/occipital and infra-auricular aspects of the mass. No dural violation, CSF leak, or adverse facial nerve events were encountered and he was discharged on postoperative day 3. One month post-operatively, there was significantly decreased bulk of the mass, with a plan for further medical management.

Discussion: Navigation registration posed a challenge for both traditional and AR navigation due to poor quality pre-operative MRI/CT scans and the lack of posterior neck landmarks. However, AR registration accuracy in this case was still significantly improved compared to traditional navigation, which was ultimately not utilized in this case due to poor registration accuracy and the additional 3D spatial information provided by AR navigation. Even in cases with challenging registrations, 3D objects presented by AR navigation offer spatial cognition cues that can provide navigational value, which is not the case with 2D navigation. Furthermore, while traditional 2D navigation requires the surgeon to reference a separate screen (Figure 1A), the use of AR navigation allowed for real-time, patient-focused 3D visualization of the tumor and its relationship to nearby critical structures (Figure 1B), including dehiscent occipital bone, cerebral vasculature, and the facial nerve. AR navigation was particularly useful for planning the initial surgical incision to avoid incising over dehiscent bone, identifying areas of dehiscent bone to avoid dural violation during dissection, locating and marking out cerebral vasculature for safe dissection, and conceptualizing the location of the stylomastoid foramen and main trunk of the facial nerve surrounded by tumor during debulking (Figure 1C/D). 

Conclusion: Infiltrative head and neck masses may distort spatial conceptualization of complex anatomic relationships during surgery.  AR navigation offers enhanced visualization of 3D spatial relationships between tumor and surrounding anatomy, allowing for safe dissection, and has several advantages over traditional navigation.  While navigation is not typically employed by head and neck surgeons, we believe AR navigation may provide value by reducing a surgeon’s spatial-cognitive load, and may result in safer surgeries and reduced complications.

 

 

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