CASE REPORT Image guidance offers additional benefits in the endoscopic solution of extended cranio-facial malformations A case report Andor Hirschberg a, * , Zolta ´n Fent b , Ka ´roly Hraba ´k b ,O ¨ do ¨n Rezek b , Ron von Jako c , Ga ´bor Re ´pa ´ssy b a Department of Otolaryngology, Saint John Hospital, Dio´s a ´rok l-3, H-1125 Budapest, Hungary b Department of Otolaryngology, Faculty of Medicine, Semmelweis University, Budapest, Hungary c General Electric Healthcare-Surgery, Lawrence, MA, USA Received 9 January 2006; received in revised form 11 April 2006; accepted 17 April 2006 1. Introduction Computer-assisted endoscopic surgery (CAES) has already been successfully utilized in nasal and sinus surgery for more than a decade. A real-time loca- lization of the surgical instruments within the operative field is obtained with different tracking methods and a cross-hair mark serves for visualiza- tion on the patient’s reconstructed triplanar CT images. Ten years after launching CAES, Metson [1] demonstrated the most important lessons learned from the first 1000 cases. It is already accepted, that the accuracy of instrument localiza- tion must be within 2 mm when compared to International Journal of Pediatric Otorhinolaryngology Extra (2006) 1, 181—184 www.elsevier.com/locate/ijporl KEYWORDS Cranio-facial malformation; Choanal atresia; Computer-aided surgery; Navigation; Image-guidance Summary Computer-assisted endoscopic surgery (CAES) in combination with a transpalatal approach was applied in a 6-year-old girl with extensive cranio-facial malformation and bilateral nasal and choanal atresia. The GE Healthcare InstaTrak 3500 Plus surgical navigational system was used. The transnasal and choanal atresia was successfully opened and kept patent. The navigational system was able to point and localize orientations between the distorted anatomy, the instrument tip and in depth measurements for intraoperative planning. In extended anatomical malforma- tion of the nasal passages and the surrounding structures, where the anatomical landmarks are missing or definitely altered computer-aided navigation may facilitate the application of additional endoscopic surgery in combination with more radical surgical approaches. Development of special drills and curved suction devices mounted on the receiver and tailored for such anatomical malformations may offer a complete computer-aided endoscopic solution in similar cases. # 2006 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +36 30 9424 964; fax: +36 1 4584 597. E-mail address: hirschberg@t-online.hu (A. Hirschberg). 1871-4048/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2006.04.002