ARS Position Statement: Criteria for Image-Guided Endoscopic Sinus Surgery

January 28, 2023

The American Rhinologic Society endorses the American Academy of Otolaryngology Head & Neck Surgery position statement on Intra-Operative Use of Computer Aided Surgery as visible below and available at:

The American Academy of Otolaryngology & Head and Neck Surgery endorses the intraoperative use of computer-aided surgery in appropriately select cases to assist the surgeon in clarifying complex anatomy during sinus and skull base surgery. There is sufficient expert consensus opinion and literature evidence base to support this position. This technology is used at the discretion of the operating surgeon and is not experimental or investigational. Furthermore, the American Academy of Otolaryngology-Head and Neck Surgery is of the opinion that it is impossible to corroborate this with Level 1 evidence. These appropriate, specialty specific, and surgically indicated procedural services should be reimbursed when used by qualified physicians regardless of the specialty.

Examples of indications in which use of computer-aided surgery may be deemed appropriate include:

  1. Revision sinus surgery.
  2. Distorted sinus anatomy of development, postoperative, or traumatic origin.
  3. Extensive sinonasal polyposis.
  4. Pathology involving the frontal, posterior ethmoid or sphenoid sinuses.
  5. Disease abutting the skull base, orbit, optic nerve or carotid artery.
  6. CSF rhinorrhea or conditions where there is a skull base defect.
  7. Benign and malignant sinonasal neoplasms.

Related/analogous terminology: image-guided sinus surgery, computer-assisted sinus surgery, surgical navigation systems, stereotactic-guided surgery, computer-guided surgery systems.


Metson R, Cosenza M, Gliklich RE, Montgomery WW. The role of image-guidance systems for head and neck surgery. Arch Otolaryngol Head Neck Surg. 1999 Oct;125(10):1100-4.

Neumann AM, Pasquale-Niebles K, Bhuta T, Sillers MJ. Image-guided transnasal endoscopic surgery of the paranasal sinuses and anterior skull base. Am J Rhinol. 1999;13:449-454.

Fried MP, Moharir VM, Shin J, Taylor-Becker M, Morrison P. Comparison of endoscopic sinus surgery with and without image guidance. Am J Rhinol. 2002 Jul-Aug;16(4):193-7.

Tabaee A, Kacker A, Kassenoff TL, Anand V. Outcome of computer-assisted sinus surgery: a 5-year study. Am J Rhinol. 2003 Sep-Oct;17(5):291-7.

Kacker A, Tabaee A, Anand V. Computer-assisted surgical navigation in revision endoscopic sinus surgery. Otolaryngol Clin North Am. 2005 Jun;38(3):473-82.

Wise SK, DelGaudio JM. Computer-aided surgery of the paranasal sinuses and skull base. Expert Rev Med Devices. 2005 Jul;2(4):395-408.

Tabaee A, Hsu AK, Shrime MG, Rickert S, Close LG. Quality of life and complications following image-guided endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2006 Jul; 135(1):76-80.

Smith TL, Stewart MG, Orlandi RR, Setzen M, Lanza DC. Indications for image-guided sinus surgery: the current evidence. Am J Rhinol. 2007 Jan-Feb; 21(1):80-3.

Citardi MJ, Batra PS. Intraoperative surgical navigation for endoscopic sinus surgery: rationale and indications. Curr Opin Otolaryngol Head Neck Surg. 2007 Feb;15(1):23-7.

Sindwani R. Image-guided surgery of the paranasal sinuses and skull base. Mo Med. 2008 May-Jun;105(3):257-61.

Parikh SR, Cuellar H, Sadoughi B, Aroniadis O, Fried MP. Indications for image-guidance in pediatric sinonasal surgery. Int J Pediatr Otorhinolaryngol. 2009 Mar; 73(3): 351-6.

Prulière-Escabasse V, Coste A. Image-guided sinus surgery. Eur Ann Otorhinolaryngol Head Neck Dis. 2010 Mar;127(1):33-9.

Justice JM, Orlandi RR. An update on attitudes and use of image-guided surgery. Int Forum Allergy Rhinol. 2012 Mar-Apr; 2(2):155-9.

Masterson L, Agalato E, Pearson C. Image-guided sinus surgery: practical and financial experiences from a UK centre 2001-2009. J Laryngol Otol. 2012 Dec;126(12):1224-30.

Ramakrishnan VR, Orlandi RR, Citardi MJ, Smith TL, Fried MP, Kingdom TT. The use of image-guided surgery in endoscopic sinus surgery: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013 Mar; 3(3):236-41.

Dalgorf DM, Sacks R, Wormald PJ, et al. Image-guided surgery influences perioperative morbidity from endoscopic sinus surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2013 Jul;149(1):17-29.

Vreugdenburg TD, Lambert RS, Atukorale YN, et al. Stereotactic anatomical localization in complex sinus surgery: a systematic review and meta-analysis. Laryngoscope 2016;126:51–9.

Galletti B, Gazia F, Freni F, Sireci F, Galletti F. Endoscopic sinus surgery with and without computer assisted navigation: A retrospective study. Auris Nasus Larynx. 2019 Aug;46(4):520-525.

Beswick DM, Ramakrishnan VR. The utility of image guidance in endoscopic sinus surgery: a narrative review. JAMA Otolaryngol Head Neck Surg. 2020;146:286–90

Govil N, Shaffer AD, Stapleton AL. The use and cost-effectiveness of intraoperative navigation in pediatric sinus surgery. Laryngoscope. 2020 Dec;130(12):E742-E749.

Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021;11:213–739.

Schmale IL, Vandelaar LJ, Luong AU, et al. Image-Guided surgery and intraoperative imaging in rhinology: clinical update and current state of the art. Ear Nose Throat J 2021;100:NP475–86

Nobre ML, Sarmento ACA, Nobre MG, Bedaque HP, Medeiros KS, Cobucci RN, Gonçalves AK. Image guidance for endoscopic sinus surgery in patients with chronic rhinosinusitis: a systematic review and meta-analysis protocol. BMJ Open. 2022 Apr 22;12(4):e053436.