The survey was electronically distributed to a total of 654 otolaryngologists across Canada, of which 158 responded (response rate 24.2%).

Responses were received from all provinces in Canada, with the majority coming from Ontario and Quebec (37.3% and 22.8%, respectively) (Fig. 1). The years of practice was distributed relatively evenly among the respondents (Fig. 2); 25.3% of respondents had > 20 years of experience, followed by 15–20 years (21.5%), 10–15 years (19.6%), 5–10 years (15.8%) and 0–5 years (17.7%) of experience. The majority of respondents had a community practice (60.8%) with the remaining divided equally between an academic practice and a mixed practice. The majority of respondents did not have subspecialty training (61.4%). Of those with subspecialty training (38.6%), the majority were in rhinology and skull base (36.1%) followed by head and neck surgery (23.0%), then pediatric otolaryngology (19.7%), facial plastics (14.8%), otology and neurotology (13.1%) and laryngology (9.8%).

Geographic location of survey respondents

Number of years respondents have been in practice

Respondents were asked to quantify their experience with sinus and skull base surgery. The majority of respondants performed routine sinus surgery regularily (70.9% > 2 cases/month) (Fig. 3). Regarding complex or revision sinus surgeries, 34.2% of respondents do not perform any of these types of surgeries per month, 44.9% perform 1–2 complex/revision cases per month, 11.4% perform 2–5 cases per month, 6.3% perform 5–10 cases per month, and 3.2% perform more than 10 complex/revision cases per month (Fig. 3). Anterior skull base surgery was less commonly performed among respondents; 85.4% of respondents do not perform any anterior skull base surgeries, 8.2% perform 1–2 cases per month and 6.3% perform 2–5 cases per month (Fig. 3).

Comparing the number of cases per month respondents are performing routine sinus surgery, complex/revision sinus surgery, and anterior skull base surgery

Just over half of the respondents have access to IGS at their hospital (56.3%). Of those with access to IGS, 73.0% had access only one IGS available at their hospital. 21.3% have two systems available, 3.4% have three systems available and 2.2% have more than 5 systems available. The most common IGS available is from Medtronic (84.3%) (Fig. 4). The majority (76.4%) used an electromagnetic IGS and 32.6% used an optical IGS (Fig. 4). The surgical service that is the primary user of IGS was Otolaryngology, Head and Neck surgery (77.5%) followed by Neurosurgery (21.3%) and Orthopaedic/Spine surgery (1.1%). Regarding usage of IGS for ESS (not including skull base surgery), respondents reported using it for almost all cases (28.1% use for > 90% of cases) or for few cases (36.0% use it 0–20% of cases) with the remainder distributed between (Fig. 5).

Type of image guidance system used by respondents

Percentage of endoscopic sinus surgeries respondents are using image guidance systems (not including skull base surgery)

Of the respondents without access to IGS, 85.5% would use it if it was available. Financial (capital cost) was identified as the most important barrier in obtaining IGS by 76.3% of respondents. Other factors such as lack of support from health region and other capital needs that are higher priority were also identified as the most important or major factors (by 57.6% and 61.0% of respondents, respectively) (Fig. 6). A large majority of the respondents (83.1%) without access to IGS mentioned that lack of access to IGS prevented them from performing surgeries that they would otherwise undertake.

Barriers for obtaining an image guidance system (for respondents without access)

To gain more insight about he 85.5% of respondents without IGS access and expressing interest, a subgroup analysis looking at the amount and type of sinus surgergies they perform was assessed. The majority of these respondents mention performing at least two to five routine surgeries per month (47.5%) and one to two complex/revision sinus surgeries per month (54.2%) (Fig. 7).

Number of cases per month community otolaryngologist are performing routine sinus surgery, complex/revision sinus surgery, and anterior skull base surgery

Another subgroup analysis using the type of practice and access to IGS demonstrated that 40.6% of community otolaryngologist have access to IGS and 71.0% of those working in a mixed practice also have access to IGS. Despite having an academic practice, two respondents from Ontario and one from Quebec mentioned not having IGS access. The rest of the academic otolaryngologists (90.3%) mention having access to IGS (Fig. 8). A provincial breakdown of community otolaryngologist with IGS access revealed that British Columbia have the most access (87.5%) while Quebec have the lowest amount of access (10.0%) (Fig. 9).

Comparing access to image guidance based on hospital setting/practice type

Comparing community otolaryngologist access to image guidance based on province

Regarding potential drawbacks of using IGS, capital cost and disposable cost were identified as the most important barrier to IGS use (65.2% and 44.3% of respondents, respectively) (Fig. 10). Regarding potential benefits of using IGS, completeness of surgery and safety were identified as the most important benefits of IGS use (86.7% of respondents for each factor, respectively) (Fig. 11).

Potential drawbacks identified by all respondents for using image guidance

Potential benefits identified by all respondents for using image guidance

Indications surrounding the use of IGS were also asked. 29.7% of respondents mentioned its indication in primary sinus surgery; 87.3% in both revision sinus surgery and cases with distorted sinus anatomy of development, postoperative, or traumatic origin; 75.3% in cases with extensive sinonasal polyps; 80.4% in cases with pathology involving the frontal, posterior ethmoid, and sphenoid sinuses; 73.4% in cases with disease abutting the skull base, orbit, optic nerve or carotid artery; 63.9% in both CSF rhinorrhea or conditions where there is a skull base defect, and benign and/or malignant sino-nasal neoplasms (Fig. 12).

Indications for image guidance systems identified by all respondents