Insight in to the Awareness of CBCT as an Imaging Modality in the Diagnosis and Management of ENT Disorders: A Cross Sectional Study (2024)

Validation of Questionnaire

The questionnaire was developed based on the applications of CBCT in the field Otolaryngology and reference of previous research study.

Face and content validation: The researchers comprehensively reviewed the initial draft of questionnaire during several meetings to ensure face and content validity.

Subject Validation: was performed by sending the drafted questionnaire to two subject experts in the field of Oral Medicine and Radiology. They suggested a few modifications which were incorporated in the questionnaire.

Content Validation-The finalised questionnaire was distributed amongst 20 ENT Surgeons as a part of the pilot study to check the feasibility of the survey. The obtained data was entered in Microsoft excel and internal consistency of the questionnaire was checked using Cronbach’s alpha value. The value obtained was 0.84 suggesting that items had good internal consistency.

The final questionnaire comprised of four sections. The first section was about demographic data: nationality, Age, gender, years of clinical experience, place and type of clinical practice. The second and third sections included questions about knowledge and practice of CBCT. The questions related to attitude of ENT surgeons towards CBCT imaging, were covered in the fourth section. The questions on knowledge and attitude were based on LIKERT scale—Strongly disagree, Disagree, Neither agree nor disagree and Strongly agree.

Self-prepared validated questionnaire was sent via email through the google form link and the responses were recorded. Information about the study was provided to each participant in English through Information Sheet explaining the aims, objectives and benefits of the study.

They were ensured about the confidentiality and privacy of their responses during the conduct of the study by administering anonymous questionnaire. Those willing to participate in the study provided their consent. The ethical standards were maintained during the conduct of the study following the guidelines of Helsinki Declaration by World Medical Association. The participation in this study was voluntary.

Statistical Analysis

The data of each participant was entered in Master chart prepared in Microsoft Excel sheet 2007. The collected data was then subjected to statistical analysis by using IBM SPSS Version 20.0 software. Descriptive statistical analysis was performed to calculate means, standard deviations and frequency distributions. The Chi square test was applied to know the difference in responses. Statistical significance was determined at p value less than 0.05.

Table 1

Descriptive statistics regarding demographic data

Table 2

Description of type of practice and number of years into speciality practice

Table 3

Assessment of practice

Table 4

Assessment of attitude

Table 5

Assessment of knowledge

^*Statistically significant ( p ≤ 0.05)

Indications of CBCT in ENT

Hodeza et al. [21] in their comprehensive review on applications of CBCT in ENT disorders proposed the use of CBCT in assessing inflammatory and infectious sinus pathology. Effusion, mucosal thickening, ostial obstruction and tooth sinus relation were clearly depictable, with precision similar or better than CT. Evaluation of maxillofacial trauma without associated neurologic or cranial extension can be performed with ease and rapidity. CBCT is an incomparable substitute for Ear imaging, with a lower radiation level and ideal for iterative examination, postoperative follow-up and paediatric examination [21].

The CBCT machines require certain modifications for imaging the temporal bone, middle and inner ear with a large field of view. These machines utilise a 200 × 25mm flat-panel detector at 650mm from the radiation source,360◦ rotation of the X-ray tube for 18 secs. Tube voltage is set at 110kV, with 19mA charge at the terminals. The major modification is a large FOV corresponding to a 12X 7.5cm diameter cylinder.

Paranasal Sinus Imaging

The last decade has established the strength of CBCT in precise visualization of the bony structures of the nose and paranasal sinuses [22]. The relatively low radiation dose, high quality bone definition, and compact design of CBCT has made it attractive for scanning paranasal sinuses [23].

CBCT provides brilliant air-mucosa-bone contrast, permitting the visualisation of air cavity anatomy and ventilation. Effusion, mucosal thickening and ostial obstruction are perfectly visible, with precision equal to or greater than that of CT. Any inflammatory or infectious sinus pathology is accessible to cone-beam examination, with complete topographic exploration. However, as with CT without contrast injection, it is not possible to distinguish between simple mucosal thickening, mucosal cyst, polyp and retention [21]. The various indications include Chronic rhinosinusitis Aplasia, Hypoplasia Retention cyst, Polyp, Antroliths, Oroantral fistula and Benign cysts and Tumors [24]. Alspaugh et al. compared the spatial resolution obtained with CBCT scans of the paranasal sinuses with that of 16- and 64-section MDCT scanners. They concluded that 12line pairs per centimetre (lp/cm) isotropic spatial resolution could be obtained with an effective dose of 0.17mSv compared with a dose requirement of 0.87mSv for 11-lp/cm spatial resolution in a 64-section MSCT scanner [25].

Due to relative absence of metallic artifacts and good spatial resolution, CBCT enables detection of fine calcifications associated with fungal sinusitis like aspergillosis. Cone-beam imaging shows its advantages over CT in the study of tooth/sinus relations. High-resolution of (≤ 120 voxels) helps in visualising oral antral communications micro perforations of the sinus floor and Bucco sinus communications. This accuracy is lacking in conventional CT. The good spatial resolution helps us to assess fine bone remodelling, perforation of cortices, intraosseous fistula trajectories and thinning of walls. Mucosal calcification, along the wall by osseous metaplasia of Schneider’s membrane during subacute or chronic inflammatory processes, can also be detected Cone-beam imaging [23]. Due to low radiation intensity, CBCT can be used for postoperative follow-up of benign sinus lesion surgeries. In lesions extending to the cranium malignancies and deep fungal infections CT or MRI is preferred to CBCT [21].

In the present study 76.2% disagreed that CBCT images can be used in assessing pathologies of paranasal sinuses, which implies that the ENT surgeons are unaware of the usefulness of CBCT in sinus imaging.

Functional Endoscopic Surgery (FESS) and Sinus Endoscopy

FESS restores the mucociliary drainage pathways by resolution of infection from the Osteomeatal complex, secondary sites & sinuses. CBCT can be used as a preoperative assessment tool prior to FESS to analyse the anatomical variants and anomalous air cells, extent of disease in relation to the mucociliary pathways and identification of bony thickening suggesting chronicity or bony erosion/destruction. During intraoperative procedures CBCT provides high-quality definition of bony anatomy, augmenting the surgical strategy [26]. A cadaveric study conducted by Rafferty et al. [27] proposed the evidence of the application of C-arm CBCT imaging to FESS. They resolved that both spatial and soft-tissue contrast was appropriate to assist surgical navigation in the frontal recess. Batra et al. [28] performed a clinical study on 25 patients and discovered that residual bony partitions and stent locations could be envisaged with intraoperative CBCT scans, leading to surgical revision.

Of late CBCT has also been used to evaluate contrast delivery during sinus irrigation after FESS [29]. CBCT has been used in sinus endoscopy with same diagnostic accuracy. Due to the high accuracy of CBCT scanning, the CBCT findings are well correlated with sinus endoscopy findings. Considering its high accuracy and lower costs and radiation doses, CBCT may be a suitable alternative method for diagnostic sinus endoscopy in the assessment of Chronic rhinosinusitis in patients with a contraindication for sinus endoscopy [30]. Only 5.2% of the study participants agreed that CBCT can be used in FESS.

Maxillofacial and Nose Trauma

3D reconstruction, excellent spatial resolution, volume rendering and rapid protyping quality of CBCT aids in diagnosis of minute maxillo mandibular fractures involving the nasal bones, sinus or orbital walls or mandibular condyles. Zygomatico maxillary complex fractures at the level of cribriform plate are easily detected on coronal and sagittal CBCT [21, 31]. Kalaskar et al. reported the usefulness of CBCT in diagnosing four cases of tympanic bone fracture [32]. 78.1% of the respondents in the study agreed that CBCT is used in assessment of maxillofacial trauma.

Temporal Bone

Imaging of temporal on CBCT was of particular interest by various authors. Explicit applications have been discovered, including postprocedural cochlear, middle and inner ear implant evaluation, visualization of the reuniting duct in the inner ear, and intraoperative temporal bone surgical guidance [33]. Preliminary studies were performed on cadaveric and postsurgical specimens. Table ​Table66 depicts the analysis of temporal bone on cadaveric specimens on CBCT. According to Gupta et al. [34] the lack of soft-tissue contrast in their assessments did not hinder the diagnostic accuracy due to the abundance of high-contrast structures housed in the temporal bone and the positive effect of higher spatial resolution on resolving some low-contrast structures such as the facial nerve. Dalchow et al. [39] subjected 25 patients with audiometry- confirmed conductive hearing loss to preoperative CBCT and concluded that CBCT could be accurate both in predicting the continuity of the ossicular chain and in detecting ossicular erosions. 86.5% of the study participant s disagreed that CBCT was useful in temporal bone imaging depicting their decreased cognizance.

Cochlear Implants

CBCT is increasingly used to assess the detailed dimensions of the cochlea and the position of cochlear implant electrodes in the inner ear, which is extremely important for maintaining the so-called ‘residual hearing’ [40, 41]. CBCT plays a key role in cochlear implantation in both planning implantation before surgery and quality control during surgery. In theCBCTimages, the electrodes were located in the scala tympani and near the lateral wall in all temporal bones It noninvasively depicts the electrode-modiolus relationship post-implantation [42]. 80% of the respondents disagreed that CBCT is useful in evaluation of cochlear implants.

Dacrocystography

CBCT is a safe and time-efficient modality for assessing the nasolacrimal duct system in patients with epiphora. Detailed images of the nasolacrimal drainage system, surrounding soft tissue, and bony structures are obtained in one diagnostic tour. It allows clear measurement of the bony nasolacrimal duct and displays image drainage lumen, improving the planning of therapeutic, interventional and surgical procedures [43, 44]. The decreased radiation dose and excellent bony detail make CBCT an imaging modality of choice as compared to CT and MRI respectively. 86.5% of the study population disagreed that CBCT can be useful in assessing the nasolacrimal duct blockade.

Obstructive Sleep Apnea (OSA)

CBCT is used in assessment of OSA to study anatomic abnormalities like micrognathia, Hypertrophic turbinate, and tonsils, elongated or posteriorly placed soft palate. Skeletal discrepancies are analyzed from a 3D aspect. CBCT generates 3D cephalometric images at low radiation dose to depict the maxillofacial anatomy [45,46].

Airway Analysis

CBCT is the choice of investigation in 3D analysis and visualization of upper airway. CBCT evaluates the airway volume, cross-section and width of the nasopharyngeal space and airway length with special sophisticated software. It is superior to 2D lateral cephalometry as it avoids anatomic superimposition and generates rapid 3D images at low radiation dose. In a study by Buchanan et al. [47] retrospective analysis utilizing existing CBCT scans were performed to evaluate the dimensions of the upper airway in OSA and control subjects. They concluded that OSA subjects have a smaller upper airway compared to controls.

87.7% disagreed that CBCT can be employed to detect OSA and for airway analysis. The reason regarding the decreased awareness could be due to the increased usage of polysomnography for diagnosing OSA by Otolaryngologists.

The most common indication for CBCT among the study participants was for maxillofacial trauma (7.1%) followed by TMJ disorders (3.2%). Therefore, this study demonstrated decreased knowledge, attitude and practice of CBCT imaging among the otolaryngologists of Gujarat region, India. The responses recorded highlighted the absence of complete and accurate information regarding CBCT. The reasons could be due to lack of standardised training programs and deficient teaching hours about CBCT imaging in the medical curriculum. The Oral and Maxillofacial Radiologists should initiate training programs regarding CBCT imaging and inculcate the habit of referral to Oral radiologists for ENT diseases.

CBCT images have certain limitations like poor soft tissue contrast precluding its use in lesions like glomus tympanicum, glomus jugulotympanic, vascular disease, diagnosis and staging of ENT tumors. CBCT is a valuable aid in maxillofacial trauma but there is a possibility of a missed soft tissue lesion including intra-cranial haemorrhage, Cerebrospinal fluid leakage, injury to the cranial nerves, septal hematoma, globe rupture, lens dislocation, muscle entrapment and vitreous haemorrhage [48]. Therefore CBCT.

Conflict of interest

The authors have no conflict of interest.

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