Guided placement of zygomatic implants in head and neck cancer patients: implant survival and patient outcomes at 1-3 years of follow-up.

Zygomatic implants (ZI) are a valuable option for supporting an obturator prosthesis after maxillary resection. This study was performed to assess the clinical outcomes of a digitally validated guided technique for ZI placement, followed by immediate prosthetic obturation. The primary objective was to evaluate implant survival, while the secondary objective was to assess patient-reported quality of life post-rehabilitation. Twelve patients treated for head and neck cancer received a total of 36 ZI after ablative surgery. The mean duration of ZI follow-up was 30.1 months. The survival rate of ZI placed in non-irradiated patients was 100%, while it was 85% in irradiated patients. Patient-reported outcomes were evaluated using the Liverpool Oral Rehabilitation Questionnaire (LORQv3) and the University of Washington Quality of Life Questionnaire (UW-QOL v4). Most patients reported satisfactory outcomes in the oral function domain of the LORQv3 (mean score 17.7 ± 4.5; possible range 12-48, with lower scores indicating better outcomes). Regarding the UW-QOL v4, the swallowing and chewing domains had the highest scores (mean 97.5 ± 8.7 and 95.8 ± 14.4, respectively; maximum possible score of 100). In conclusion, this treatment approach improves function and quality of life after maxillary ablative surgery. However, irradiated patients showed a noticeable trend of higher implant failure, and this was influenced by tumour position and size impacting the radiation dose to the zygomatic bone.

Planned dose of intensity modulated proton beam therapy versus volumetric modulated arch therapy to tooth-bearing regions.

BACKGROUND: Intensity modulated proton beam therapy (IMPT) for head and neck cancer offers dosimetric benefits for the organs at risk when compared to photon-based volumetric modulated arch therapy (VMAT). However, limited data exists about the potential benefits of IMPT for tooth-bearing regions. The aim of this study was to compare the IMPT and VMAT radiation dosimetrics of the tooth-bearing regions in head and neck cancer patients. Also, we aimed to identify prognostic factors for a cumulative radiation dose of ≥40 Gy on the tooth-bearing areas, which is considered the threshold dose for prophylactic dental extractions. METHODS: A total of 121 head and neck cancer patients were included in this retrospective analysis of prospectively collected data. We compared the average Dmean values of IMPT versus VMAT of multiple tooth-bearing regions in the same patients. Multivariate logistic regression analysis was performed for receiving a cumulative radiation dose of ≥40 Gy to the tooth-bearing regions (primary endpoint) in both VMAT and IMPT. RESULTS: A lower Dmean was seen after applying IMPT to the tooth-bearing tumour regions (p < 0.001). Regarding VMAT, oral cavity tumours, T3-T4 tumours, molar regions in the mandible, and regions ipsilateral to the tumour were risk factors for receiving a cumulative radiation dose of ≥40 Gy. CONCLUSIONS: IMPT significantly reduces the radiation dose to the tooth-bearing regions.

Multispectral optoacoustic tomography for in vivo detection of lymph node metastases in oral cancer patients using an EGFR-targeted contrast agent and intrinsic tissue contrast: A proof-of-concept study.

Oral cancer patients undergo diagnostic surgeries to detect occult lymph node metastases missed by preoperative structural imaging techniques. Reducing these invasive procedures that are associated with considerable morbidity, requires better preoperative detection. Multispectral optoacoustic tomography (MSOT) is a rapidly evolving imaging technique that may improve preoperative detection of (early-stage) lymph node metastases, enabling the identification of molecular changes that often precede structural changes in tumorigenesis. Here, we characterize the optoacoustic properties of cetuximab-800CW, a tumor-specific fluorescent tracer showing several photophysical properties that benefit optoacoustic signal generation. In this first clinical proof-of-concept study, we explore its use as optoacoustic to differentiate between malignant and benign lymph nodes. We characterize the appearance of malignant lymph nodes and show differences in the distribution of intrinsic chromophores compared to benign lymph nodes. In addition, we suggest several approaches to improve the efficiency of follow-up studies.

The accuracy of gap and step-off measurements in acetabular fracture treatment.

The assessment of gaps and steps in acetabular fractures is challenging. Data from various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. The aim of this study was to assess the accuracy of pelvic radiographs, intraoperative fluoroscopy, and computed tomography (CT) in detecting gaps and step-offs in acetabular fractures. Sixty patients, surgically treated for acetabular fractures, were included. Five observers (5400 measurements) measured the gaps and step-offs on radiographs and CT scans. Intraoperative fluoroscopy images were reassessed for the presence of gaps and/or step-offs. Preoperatively, 25% of the gaps and 40% of the step-offs were undetected on radiographs compared to CT. Postoperatively, 52% of the gaps and 80% of the step-offs were missed on radiographs compared to CT. Radiograph analysis led to a significantly smaller gap and step-off compared to the CT measurements, an underestimation by a factor of two. Approximately 70% of the residual gaps and step-offs was not detected using intraoperative fluoroscopy. Gaps and step-offs that exceed the critical cut-off indicating worse prognosis often remained undetected on radiographs compared to CT scans. Less-experienced observers tend to overestimate gaps and step-offs compared to the more-experienced observers. In acetabular fracture treatment, gaps and step-offs were often undetected and underestimated on radiographs and intraoperative fluoroscopy in comparison with CT scans. This means that CT is superior to radiographs in detecting acetabular fracture displacement, which is clinically relevant for patient counselling regarding treatment decisions and prognosis.

Immediate implant-retained prosthetic obturation after maxillectomy based on zygomatic implant placement by 3D-guided surgery: a cadaver study.

BACKGROUND: The aim of this study was to introduce a complete 3D workflow for immediate implant retained prosthetic rehabilitation following maxillectomy in cancer surgery. The workflow consists of a 3D virtual surgical planning for tumor resection, zygomatic implant placement, and for an implant-retained prosthetic-obturator to fit the planned outcome situation for immediate loading. MATERIALS AND METHODS: In this study, 3D virtual surgical planning and resection of the maxilla, followed by guided placement of 10 zygomatic implants, using custom cutting and drill/placement-guides, was performed on 5 fresh frozen human cadavers. A preoperatively digitally designed and printed obturator prosthesis was placed and connected to the zygomatic implants. The accuracy of the implant positioning was obtained using 3D deviation analysis by merging the pre- and post-operative CT scan datasets. RESULTS: The preoperatively designed and manufactured obturator prostheses matched accurately the per-operative implant positions. All five obturators could be placed and fixated for immediate loading. The mean prosthetic point deviation on the cadavers was 1.03 ± 0.85 mm; the mean entry point deviation was 1.20 ± 0.62 mm; and the 3D angle deviation was 2.97 ± 1.44°. CONCLUSIONS: It is possible to 3D plan and accurately execute the ablative surgery, placement of zygomatic implants, and immediate placement of an implant-retained obturator prosthesis with 3D virtual surgical planning.The next step is to apply the workflow in the operating room in patients planned for maxillectomy.

Augmented Reality Visualization for Image-Guided Surgery: A Validation Study Using a Three-Dimensional Printed Phantom.

BACKGROUND: Oral and maxillofacial surgery currently relies on virtual surgery planning based on image data (CT, MRI). Three-dimensional (3D) visualizations are typically used to plan and predict the outcome of complex surgical procedures. To translate the virtual surgical plan to the operating room, it is either converted into physical 3D-printed guides or directly translated using real-time navigation systems. PURPOSE: This study aims to improve the translation of the virtual surgery plan to a surgical procedure, such as oncologic or trauma surgery, in terms of accuracy and speed. Here we report an augmented reality visualization technique for image-guided surgery. It describes how surgeons can visualize and interact with the virtual surgery plan and navigation data while in the operating room. The user friendliness and usability is objectified by a formal user study that compared our augmented reality assisted technique to the gold standard setup of a perioperative navigation system (Brainlab). Moreover, accuracy of typical navigation tasks as reaching landmarks and following trajectories is compared. RESULTS: Overall completion time of navigation tasks was 1.71 times faster using augmented reality (P = .034). Accuracy improved significantly using augmented reality (P < .001), for reaching physical landmarks a less strong correlation was found (P = .087). Although the participants were relatively unfamiliar with VR/AR (rated 2.25/5) and gesture-based interaction (rated 2/5), they reported that navigation tasks become easier to perform using augmented reality (difficulty Brainlab rated 3.25/5, HoloLens 2.4/5). CONCLUSION: The proposed workflow can be used in a wide range of image-guided surgery procedures as an addition to existing verified image guidance systems. Results of this user study imply that our technique enables typical navigation tasks to be performed faster and more accurately compared to the current gold standard. In addition, qualitative feedback on our augmented reality assisted technique was more positive compared to the standard setup.?>.

Incidental findings during the diagnostic work-up in the head and neck cancer pathway: Effects on treatment delay and survival.

OBJECTIVES: As a result of the increasing number of diagnostic scans, incidental findings (IFs) are more frequently encountered during oncological work-up in patients with head and neck squamous cell carcinomas (HNSCC). IFs are unintentional discoveries found on diagnostic imaging. Relevant IFs implicate clinical consequences, resulting in delay in oncologic treatment initiation, which is associated with unfavorable outcomes. This study is the first to investigate the incidence and nature of IFs over the years and establish the effect of relevant IFs on delay. MATERIAL AND METHODS: This retrospective study compared two time periods (2010-2011 and 2016-2017), described associations between relevant IFs and delay in carepathway interval (days between first visit and treatment initiation) and assessed the effect of relevant IFs on overall two-year survival. RESULTS: In total, 592 patients were included. At least one IF was found in 61.5% of the patients, most frequently on chest-CT. In 128 patients (21.6%) a relevant IF was identified, resulting for the majority in radiologist recommendations (e.g. additional scanning). Presence of a relevant IF was an independent significant factor associated with delay in treatment initiation. The risk of dying was higher for patients with a relevant IF, although not significant in the multivariable model (HR: 1.46, p = 0.079). CONCLUSION: In diagnostic work-up for HNSCC patients, relevant IFs are frequently encountered. As the frequency of additional imaging rises over the years, the number of IFs increased simultaneously. These relevant IFs yield clinical implications and this study described that relevant IFs result in significant delay in treatment initiation.

Accuracy of fit analysis of the patient-specific Groningen temporomandibular joint prosthesis.

Total joint replacement (TJR) with a prosthesis can be indicated for patients with severe temporomandibular joint (TMJ) dysfunction. Surgical accuracy is necessary for correct translation of the preoperatively predicted functional outcome, wear, and biomechanical behaviour of the patient-specific TMJ-TJR prosthesis. This study describes the first clinical applications of the patient-specific TMJ-TJR prosthesis according to the Groningen principles (G-TMJ-TJR), which was developed and validated in a prior human cadaver test study. The aim of this study was to validate the accuracy of placement of the patient-specific G-TMJ-TJR in the clinical setting. It was hypothesized that a virtual surgical plan (VSP) combined with guided placement of the patient-specific G-TMJ-TJR would be performed as predictably and accurately as in the prior cadaver series. All patients who received a VSP-based patient-specific G-TMJ-TJR between December 2017 and March 2020 were included in this study. The accuracy analysis was based on postoperative cone beam computed tomography (CBCT) data. All 11 prostheses could be inserted using routine pre-auricular and retromandibular surgical approaches. Analysis of the VSPs and postoperative CBCTs showed an average three-dimensional deviation of 1.07mm (standard deviation 0.46mm, range 0.33-1.91mm) for all of the fossa and mandibular components. The patient-specific G-TMJ-TJR can be applied predictably and accurately in a clinical setting.

Exploiting metabolic acidosis in solid cancers using a tumor-agnostic pH-activatable nanoprobe for fluorescence-guided surgery.

Cancer cell metabolism leads to a uniquely acidic microenvironment in solid tumors, but exploiting the labile extracellular pH differences between cancer and normal tissues for clinical use has been challenging. Here we describe the clinical translation of ONM-100, a nanoparticle-based fluorescent imaging agent. This is comprised of an ultra-pH sensitive amphiphilic polymer, conjugated with indocyanine green, which rapidly and irreversibly dissociates to fluoresce in the acidic extracellular tumor microenvironment due to the mechanism of nanoscale macromolecular cooperativity. Primary outcomes were safety, pharmacokinetics and imaging feasilibity of ONM-100. Secondary outcomes were to determine a range of safe doses of ONM-100 for intra-operative imaging using commonly used fluorescence camera systems. In this study (Netherlands National Trial Register #7085), we report that ONM-100 was well tolerated, and four solid tumor types could be visualized both in- and ex vivo in thirty subjects. ONM-100 enables detection of tumor-positive resection margins in 9/9 subjects and four additional otherwise missed occult lesions. Consequently, this pH-activatable optical imaging agent may be clinically beneficial in differentiating previously unexploitable narrow physiologic differences.

[Medicaments and oral healthcare. Adverse effects of medicaments: the 'Big Five' of bone healing]. / Serie: Medicamenten en mondzorg. Bijwerkingen van medicijnen: de 'Big Five' van de verminderde botgenezing.

the bone can still be present long after patients have stopped taking the medication. Patients are often able to report accurately what disorder(s) they have and certain disorders should cause dentists to be alert. Patients who can be defined as the Big Five users of bone-modulating medicaments are: 1. patients with osteoporosis, 2. patients who have been long-term users of glucocorticoids, 3. patients with solid tumours, 4. patients with multiple myeloma and 5. patients with congenital or hereditary bone disorders. These patient groups have an indication for bone-modulating medicaments. These are anti-resorptive medications (such as bisphosphonates and denosumab) or anti-angiogenic medications. By recognising the correct patient group, dentists can ask appropriate questions about the use of medicaments in the present or in the past. A dentist can recognise patients with a risk of medication-related osteonecrosis by using this method.

Splintless surgery using patient-specific osteosynthesis in Le Fort I osteotomies: a randomized controlled multi-centre trial.

The accuracy of orthognathic surgery has improved with three-dimensional virtual planning. The translation of the planning to the surgical result is reported to vary by >2mm. The aim of this randomized controlled multi-centre trial was to determine whether the use of splintless patient-specific osteosynthesis can improve the accuracy of maxillary translation. Patients requiring a Le Fort I osteotomy were included in the trial. The intervention group was treated using patient-specific osteosynthesis and the control group with conventional osteosynthesis and splint-based positioning. Fifty-eight patients completed the study protocol, 27 in the patient-specific osteosynthesis group and 31 in the control group. The per protocol median anteroposterior deviation was found to be 1.05mm (interquartile range (IQR) 0.45-2.72mm) in the patient-specific osteosynthesis group and 1.74mm (IQR 1.02-3.02mm) in the control group. The cranial-caudal deviation was 0.87mm (IQR 0.49-1.44mm) and 0.98mm (IQR 0.28-2.10mm), respectively, whereas the left-right translation deviation was 0.46mm (IQR 0.19-0.96mm) in the patient-specific osteosynthesis group and 1.07mm (IQR 0.62-1.55mm) in the control group. The splintless patient-specific osteosynthesis method improves the accuracy of maxillary translations in orthognathic surgery and is clinically relevant for planned anteroposterior translations of more than 3.70mm.

Quantitative 3D measurements of tibial plateau fractures.

Fracture gap and step-off measurements on 2DCT-slices probably underestimate the complex multi-directional features of tibial plateau fractures. Our aim was to develop a quantitative 3D-CT (Q3DCT) fracture analysis of these injuries. CT-based 3D models were created for 10 patients with a tibial plateau fracture. Several 3D measures (gap area, articular surface involvement, 3D displacement) were developed and tested. Gaps and step-offs were measured in 2D and 3D. All measurements were repeated by six observers and the reproducibility was determined by intra-class correlation coefficients. Q3DCT measurements demonstrated a median gap of 5.3 mm, step-off of 5.2 mm, gap area of 235 mm2, articular surface involvement of 33% and 3D displacement of 6.1 mm. The inter-rater reliability was higher in the Q3DCT than in the 2DCT measurements for both the gap (0.96 vs. 0.81) and step-off (0.63 vs. 0.32). Q3DCT measurements showed excellent reliability (ICC of 0.94 for gap area, 1 for articular surface involvement and 0.99 for 3D displacement). Q3DCT fracture analysis of tibial plateau fractures is feasible and shows excellent reliability. 3D measurements could be used together with the current classification systems to quantify the true extent of these complex multi-directional fractures in a standardized way.

Introduction of a three-dimensional computed tomography measurement method for acetabular fractures.

INTRODUCTION: Acetabular fractures consist of complex fracture patterns whereby bone fragments are displaced in different directions. Two-dimensional computed tomography (2DCT) gap and step-off measurements tend to underestimate the multidirectional features of these fractures. The aim was to develop a three-dimensional computed tomography (3DCT) measurement method for acetabular fractures and validate whether this method will provide an observer independent fracture characterization. MATERIALS AND METHODS: Sixty patients, operated for an acetabular fracture between 2007 and 2018, were included. The displacement was measured on the pre- and postoperative CT scans. Pre- and postoperative CT-based 3D models were made for each patient. Multiple 3D measurements, namely the 3D step-off, gap and the total gap area were introduced to quantify the preoperative and postoperative displacement. The Wilcoxon signed rank analysis was used to compare the 2DCT and 3DCT measurements. RESULTS: The preoperative displacement was significantly underestimated by 2DCT measurements in comparison with 3DCT measurements (2D vs. 3D; step-off 8 vs. 16 mm with P < 0.001; gap 19 vs. 21 mm with P = 0.001). The same applies to the postoperative residual displacement (2D vs. 3D; step-off 0 vs. 6 mm; gap 3 vs. 8 mm; P < 0.001). The total gap area, defined as the surface area between all fracture lines in the 3D model, was measured for each patient, resulting in a median value of 722 mm2 preoperatively and 168 mm2 postoperatively, with excellent inter- and intra-rater reliability. CONCLUSION: 2DCT measurements tend to underestimate the initial and residual displacement in complex acetabular fractures. A 3DCT analysis of these injuries was developed to overcome this and should be used in addition to the Judet/Letournel and AO/OTA classification systems, in order to provide an observer independent quantifiable fracture description and accurate assessment of the fracture reduction.

[Spontaneous numbness along with pre-existing deviations in the pigmentation of the lower lip]. / Een spontaan dove lip met reeds bestaande pigmentafwijkingen van de onderlip.

A 48-year-old man was referred for an evaluation of deviations in the pigmentation of the lower lip, intra-oral swelling and persistent numbness of the sensory area of the left mental nerve. In 2011, the diagnosis lentigo maligna of the lower lip was missed by histopathology of a biopsy performed elsewhere. In 2016, the numbness of the lower lip and chin was diagnosed by a neurologist as numb chin of unknown cause. A biopsy in 2017 showed lentigo maligna of the lower lip alongside a primary mucosal melanoma with significant local invasion. Treatment consisted of a hemimandibulectomy with a supraomohyoid neck dissection of the left side. This case shows the importance of the alarm symptom 'a numb lip' and the corresponding necessity of additional investigation. This article shows avoidable pitfalls that general practitioners, dentists and medical specialists need to be vigilant about.

Multi-modality 3D mandibular resection planning in head and neck cancer using CT and MRI data fusion: A clinical series.

OBJECTIVES: 3D virtual surgical planning (VSP) and guided surgery has been proven to be an effective tool for resection and reconstruction of the mandible. Currently, most widely used 3D VSP approaches to mandibular resection do not include detailed tumour information in the VSP. This manuscript presents a strategy where the aim was to incorporate tumour visualisation into the 3D virtual plan. Three-dimensional VSP of the mandibular resections was based on the fusion of CT and MRI data which was subsequently applied in clinical practice. METHODS: All patients diagnosed with oral squamous cell carcinoma between 2014 and 2017 at the University Medical Centre Groningen were included. The tumour was delineated on the MRI data, after which this dataset was fused with the CT bone data in order to construct a 3D bone and tumour model for virtual resection planning. Guided resections were performed and post-operative evaluation quantified the accuracy of the resection. The histopathological findings and patient and tumour characteristics were compared to those of a historical cohort (2009-2014) of conventional mandibular continuity resections. RESULTS: Twenty-four patients were included in the cohort. The average deviation from planned resection was found to be 2.2 mm. Histopathologic analysis confirmed all resection planes (bone) were tumour free, compared to 96.4% in the historic cohort. CONCLUSION: MRI-CT base tumour visualisation and 3D resection planning is a safe and accurate method for oncologic resection of the mandible. It is an improvement on the current methods reported for 3D resection planning based solely on CT data.

Patient-specific pre-contouring of osteosynthesis plates for mandibular reconstruction: Using a three-dimensional key printed solution.

PURPOSE: In mandibular reconstructive surgery, the osteosynthesis plates require contouring according to the patients' individual anatomical situation. These plates are frequently contoured around a three-dimensional (3D) printed model. However, the translation to the actual patient can introduce inaccuracies and unwanted rotations in the condyles and mandibular ramus, due to malpositioning of the pre-contoured plate. MATERIALS AND METHODS: This article describes an easy-access method for exact translation of the pre-contoured plate to the patient's mandible. This is done by using 3D printed guides that allow pre-drilling of screw holes in both the contour model and the patients' mandible. The accuracy of the Key Printed Solution was analysed by comparing the anatomical landmarks on both the 3D planned and post-operative models. RESULTS: The method was applied to 4 cases. All landmarks were identified on both the 3D planning and post-operative computed tomographic data. This showed an average deviation of 1.0 mm between planning and the post-operative result. The inter-observer variation was 0.6 mm (intra-class correlation, 0.75). CONCLUSION: This article presents an easy-to-use method for pre-bending the osteosynthesis plate and subsequent accurate translation of the intended contour with corresponding screw hole locations. The method was proved to be accurate and time-efficient.

Development of a patient-specific temporomandibular joint prosthesis according to the Groningen principle through a cadaver test series.

OBJECTIVES: Patients suffering from osteoarthritis, ankylosis (e.g. post-trauma or tumour) in the temporomandibular joint (TMJ) can present with symptoms such as severely restricted mouth opening, pain or other dynamic restrictions of the mandible. To alleviate the symptoms, a total joint prosthesis can be indicated, such as the Groningen TMJ prosthesis. This was developed as a stock device with a lowered centre of rotation for improved translational and opening capacity. This study aimed to improve the design of the prosthesis, and produce a workflow for a customized Groningen TMJ prosthesis, in order to make it more accurate and predictable. METHODS: The fossa and mandibular components of the Groningen TMJ prosthesis were customized. A series of five human cadavers was operated and bilateral TMJ prostheses were placed using custom cutting and drilling guides. Placement accuracy was evaluated based on post-operative CT data. RESULTS: A total of N = 10 prostheses were placed and analysed. The average Euclidean distance deviation from planned to actual position was 0.81 mm (SD 0.21). All prostheses were placed according to the routine surgical approaches and had an excellent alignment with the bony structures. CONCLUSION: The newly developed custom Groningen TMJ prosthesis can be placed with great accuracy and is the first step for improving TMJ total joint replacement surgery.

High sensitivity and negative predictive value of sentinel lymph node biopsy in a retrospective early stage oral cavity cancer cohort in the Northern Netherlands.

OBJECTIVES: In cT1-2N0, oral squamous cell carcinoma (OSCC) occult metastases are detected in 23%-37% of cases. Sentinel lymph node biopsy (SLNB) was introduced in head and neck cancer as a minimally invasive alternative for an elective neck dissection in neck staging. Meta-analyses of SLNB accuracy show heterogeneity in the existing studies for reference standards, imaging techniques and pathological examination. The aim of this study was to assess the sensitivity and negative predictive value (NPV) of the SLNB in detecting occult metastases in cT1-2N0 OSCC in a well-defined cohort. DESIGN: Retrospective study. The SLNB procedure consisted of lymphoscintigraphy, SPECT/CT-scanning and gamma probe detection. Routine follow-up was the reference standard for the SLNB negative neck. Histopathological examination of sentinel lymph nodes (SLN) consisted of step serial sectioning, haematoxylin-eosin and cytokeratin AE1/3 staining. SETTING: Two comprehensive oncology centres. PARTICIPANTS: A total of 91 consecutive patients with primary cT1-2N0 OSCC treated by primary resection and neck staging by SLNB procedure between 2008 and 2016. MAIN OUTCOME MEASURES: Sensitivity and negative predictive value. RESULTS: In all cases, SLNs were harvested. A total of 25 (27%) patients had tumour-positive SLNs. The median follow-up was 32 months (range 2-104). Four patients were diagnosed with an isolated regional recurrence in the SLNB negative neck side resulting in an 85% sensitivity and a 94% NPV. CONCLUSION: In our cohort, the SLNB detected occult metastases in early OSCC with 85% sensitivity and 94% NPV. This supports that SLNB is a reliable procedure for surgical staging of the neck in case of oral cT1-2N0 SCC.

Virtual 3D planning of tracheostomy placement and clinical applicability of 3D cannula design: a three-step study.

AIM: We aimed to investigate the potential of 3D virtual planning of tracheostomy tube placement and 3D cannula design to prevent tracheostomy complications due to inadequate cannula position. MATERIALS AND METHODS: 3D models of commercially available cannula were positioned in 3D models of the airway. In study (1), a cohort that underwent tracheostomy between 2013 and 2015 was selected (n = 26). The cannula was virtually placed in the airway in the pre-operative CT scan and its position was compared to the cannula position on post-operative CT scans. In study (2), a cohort with neuromuscular disease (n = 14) was analyzed. Virtual cannula placing was performed in CT scans and tested if problems could be anticipated. Finally (3), for a patient with Duchenne muscular dystrophy and complications of conventional tracheostomy cannula, a patient-specific cannula was 3D designed, fabricated, and placed. RESULTS: (1) The 3D planned and post-operative tracheostomy position differed significantly. (2) Three groups of patients were identified: (A) normal anatomy; (B) abnormal anatomy, commercially available cannula fits; and (C) abnormal anatomy, custom-made cannula, may be necessary. (3) The position of the custom-designed cannula was optimal and the trachea healed. CONCLUSIONS: Virtual planning of the tracheostomy did not correlate with actual cannula position. Identifying patients with abnormal airway anatomy in whom commercially available cannula cannot be optimally positioned is advantageous. Patient-specific cannula design based on 3D virtualization of the airway was beneficial in a patient with abnormal airway anatomy.