Neural risks, protection, and monitoring in endoscopic sinus surgery: anatomy, imaging, outcomes, and emerging AI tools

Article information

J Neuromonit Neurophysiol. 2025;5(2):94-108

Publication date (electronic) : 2025 November 30

doi : https://doi.org/10.54441/jnn.2025.5.2.94

Yunsung Lee¹, Seung Hoon Woo^,1,2

¹Department of Medical Laser, Dankook University, Cheonan, Republic of Korea

²Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea

Corresponding to Seung Hoon Woo E-mail. lesaby@hanmail.net

Received 2025 October 31; Revised 2025 November 10; Accepted 2025 November 10.

Abstract

Introduction

Endoscopic sinus surgery (ESS) is now the preferred operative approach for chronic rhinosinusitis and many sinonasal disorders because it restores ventilation and drainage through minimally invasive corridors [1,2]. Despite its routine nature, the operative field sits millimeters from the orbit, anterior cranial fossa, the optic nerve, and the cavernous internal carotid artery [3,4]. Even rare breaches of these boundaries can cause devastating outcomes such as visual loss, cerebrospinal fluid (CSF) leak, stroke, or life-threatening hemorrhage [5]. Consequently, ESS must be executed with the same vigilance for neural safety that governs skull-base procedures.

Safety in ESS rests on three layers that reinforce one another. Accurate preoperative anatomical understanding, disciplined intraoperative technique, and judicious technology integration [6,7]. High-resolution computed tomography (CT) and, when indicated, magnetic resonance imaging (MRI) allow surgeons to anticipate individual hazards by revealing variants such as a low cribriform plate, Onodi cells abutting the optic nerve, dehiscence of the lamina papyracea, or sphenoid septations tethered to the carotid canal [6,8]. In the operating room, image-guided navigation refines situational awareness while structured checklists, clear team communication, and conservative instrument choreography reduce human-factor error [9]. This workflow and the accompanying checklist apply to both primary ESS and revision ESS. In revision cases, the system runs in a Revision mode with stricter guardrails that include mandatory image-guided surgery with repeated landmark checks, conservative instrument and energy defaults, lower proximity thresholds near the optic nerve and the internal carotid artery, and more frequent orientation verification.

Neural protection also benefits from targeted monitoring and emerging digital assistants. In selected high-risk cases, visual evoked potentials can warn of impending optic neuropathy and prompt reversible maneuvers before injury is fixed. Meanwhile, computer vision and augmented reality (AR) systems are beginning to overlay critical structure outlines directly onto the live endoscopic view, acting as a cognitive co-pilot for the surgeon without displacing the primacy of anatomy and tactile feedback [10,11].

This review synthesizes contemporary concepts in neural risk, protection, and monitoring for ESS and highlights the evolving role of artificial intelligence (AI). We organize the discussion along the clinical workflow, anatomy and variants, imaging-based prediction, preoperative planning and navigation, intraoperative protection and monitoring, complication-centered management, outcomes and follow-up, special populations, and the validation and ethics of AI. The intent is a concise, practice-oriented synthesis that surgeons and clinical neurophysiologists can apply immediately at the point of care (Figure 1).

Figure 1.

Endoscopic sinus surgery under indirect visualization. A rigid nasal endoscope advanced transnasally delivers the live operative view to the monitor, while the shaded areas indicate the paranasal sinuses and adjacent skull-base/orbital regions that frame the safe corridor.

Scope, Definitions, and Search Strategy

This review focuses on neural and neurovascular safety during functional and extended ESS in adults, with concepts flagged where they generalize to pediatric and revision surgery. Neural risk encompasses injury to the optic nerve, cranial nerve branches in the orbit and maxillofacial region, the olfactory epithelium and cribriform region, and indirectly, catastrophic vascular injury that compromises neural function [9,12]. We include orbital injuries that produce diplopia or vision loss and skull-base injuries that cause CSF leak or intracranial complications.

Operational terms are defined for clarity. Image-guided surgery (IGS) refers to stereotactic navigation that registers patient anatomy to preoperative CT/MRI and tracks instruments in real time. Intraoperative neuromonitoring (IONM) denotes electrophysiologic techniques, such as visual evoked potentials or extraocular muscle electromyography, used selectively when risk to the optic apparatus or orbit is material [13,14]. AI tools include machine-learning models for CT segmentation and risk mapping, video-to-CT registration for AR overlays, and real-time proximity alert engines that estimate tool-to-hazard distance [15].

To ground recommendations, we synthesized recent guidelines, large series, and technology studies identified via database queries for terms including ESS complications, sinonasal anatomy variants, navigation accuracy, visual evoked potentials, AR in surgery, and deep learning for paranasal sinus CT [16]. Because the submitting author will insert specific citations, statements are presented without in-text references but aim for balance, practicality, and clarity. The section sequence mirrors the surgical timeline so readers can map safeguards to each phase of care.

Finally, scope includes systems and human-factors elements that are often underemphasized in surgical texts. Checklists, briefings, and debriefings convert knowledge into team behaviors, the goal is to make high-risk steps predictable for everyone in the room. Where new tools are proposed, navigation upgrades, AR overlays, or monitoring, this review emphasizes how they should change actions at the bedside rather than focusing solely on engineering details.

Neurovascular Anatomy Relevant to Endoscopic Sinus Surgery and Anatomic Variants

The ethmoid labyrinth is bounded superiorly by the fovea ethmoidalis and cribriform plate [17]. The vertical depth of the olfactory fossa, summarized by the Keros classification, determines how much lateral lamella stands between instruments and the anterior cranial fossa. Deeper grooves leave thinner bone and narrower safety margins. Asymmetry between sides is common, a side-to-side Keros mismatch can lull the surgeon into a false sense of security if technique on the deeper side follows habits from the shallower side [18]. The anterior ethmoidal artery traverses the roof and may cause troublesome bleeding if avulsed, recognizing its bony canal and limiting superior traction reduce risk [12,19].

Laterally, the lamina papyracea forms a paper-thin medial orbital wall. Iatrogenic violation permits orbital fat prolapse that obscures the field and risks traction on the medial rectus with subsequent diplopia [19,20]. Haller cells that narrow the infundibulum can foreshorten the safe working corridor and shift the lamina medially. Conversely, a robust basal lamella offers a tactile boundary, staying medial to its plane during ethmoidectomy limits lateral drift toward the orbit [6].

Posteriorly, the sphenoid sinus abuts the optic nerve superiorly and the cavernous internal carotid artery laterally [21]. Bony canals may be thinned or frankly dehiscent, and intrasinus septations commonly insert asymmetrically on these canals. Aggressive twisting of such septa risks transmitting force directly to the optic nerve or carotid wall [8,22]. An Onodi cell can enfold the optic nerve or chiasm, reorienting landmarks and creating a trap for the unwary when entering posterior ethmoids [8,23].

Olfactory mucosa in the cleft and along the cribriform is vulnerable to cautery and mechanical stripping. Where disease control allows, preserving mucosa and minimizing thermal injury in the olfactory corridor support olfactory outcomes. Trigeminal branches, particularly the infraorbital nerve (V2) coursing in the maxillary roof, may be irritated by overzealous antrostomy or drilling near the canal, leading to temporary paresthesia [24,25]. A mental map that links these structures to stepwise ESS tasks is the substrate for safe decision-making.

Finally, venous pathways and microanatomy deserve mention. The ophthalmic veins and ethmoidal venous plexuses can engorge with positive pressure or head-down positioning, narrowing corridors and increasing bleeding risk [6,26]. Gentle head elevation, avoidance of excessive insufflation, and meticulous nasal preparation mitigate these dynamic contributors to neural risk by preserving a clean, spacious view as delicate structures are approached [27].

Imaging-Based Risk Assessment

High-resolution noncontrast CT is the primary risk-stratification tool for ESS. Coronal and sagittal reconstructions reveal Keros depth, the angle of the skull base, the height and thickness of the lamina papyracea, Onodi and Haller cell prevalence, and sphenoid septal insertions [28,29]. Thin-slice bone algorithms expose dehiscence or pronounced protrusion of the optic and carotid canals. A structured review protocol, moving from the nasal valve posteriorly and superiorly, reduces omissions and anchors the surgical plan to specific landmarks.

MRI complements CT when soft-tissue differentiation informs risk [30]. T2-weighted sequences distinguish encephaloceles from inflammatory mucosa at the skull base, contrast-enhanced imaging delineates tumor planes, orbital extension, or dural involvement [31]. Diffusion sequences may hint at invasive fungal disease where aggressive debridement may be necessary but also more hazardous. For routine inflammatory disease, MRI is selective, its chief role is in atypical or skull-base-adjacent pathology.

Translating imaging to action requires explicit linkage between features and intraoperative behavior. A high Keros grade cues deliberate superior limits and preference for blunt instruments under the skull base. A dehiscent lamina triggers angled visualization, limited suction traction, and readiness to decompress the orbit if needed [32]. Sphenoid septa tethered to carotid or optic canals are not twisted but drilled off under direct vision with diamond burrs, avoiding lateral leverage [33].

Digital tools increasingly transform CT into intuitive risk maps. Three-dimensional reconstructions and virtual endoscopy help learners anticipate blind corners. Emerging AI models segment the optic canal, carotid protuberance, and skull base to create hazard overlays with color coding [34]. Whether generated by humans or algorithms, these maps are most useful when paired with a simple, reproducible briefing that the entire team understands before incision.

Standardized reporting frameworks can further operationalize imaging. A one page synoptic report that lists Keros grade, the presence of Onodi cells and Haller cells, lamina thickness and any dehiscence, sphenoid septal insertions, and protrusion of the carotid canal or the optic canal, with a simple color code with three tiers in green, yellow, and red, helps nonexpert readers grasp risk at a glance and ensures that nothing critical is overlooked in handoffs or referrals [35].

Preoperative Planning and Image-Guided Navigation

Preoperative planning converts imaging into a stepwise operative script. Define disease targets, specify the minimal corridors needed to achieve them, and commit in advance to boundaries at the skull base, lamina papyracea, and sphenoid roof. Assemble contingency plans for rare events such as orbital hematoma, CSF leak, or carotid bleeding so that the team acts reflexively. Patient counseling should be individualized. When anatomy places vision or intracranial structures at higher risk, the discussion should explicitly address those possibilities and the safeguards in place [36].

IGS is an adjunct, not a substitute, for anatomical fluency. Registration accuracy should be verified at multiple landmarks and rechecked after head or bed repositioning. In revision surgery, distorted planes and absent septations increase the value of IGS. In extended procedures or operations near the skull base, navigation often becomes essential to maintain safe orientation [37]. A pragmatic rule is to use IGS to confirm rather than discover, corroborate what the endoscope and tactile feedback already suggest.

Navigation’s limitations, including occlusion of the line of sight in optical systems, electromagnetic drift, and residual registration error, mean that critical maneuvers must still be conservative. Keep the instrument tip in continuous view, prefer blunt exploration near danger zones, and delay power instrumentation until anatomy is unequivocal. When uncertainty arises, pause, clean the lens, regain hemostasis, and reestablish landmarks, the safest cut is often the one deferred until the field is perfect [38].

Preoperative rehearsal closes the loop between planning and execution. Walking through annotated CT slices with the entire team, pre-marking high-risk zones on a whiteboard, and agreeing on exact language for crisis triggers reduce ambiguity under stress [39]. A concise preincision briefing that lasts 1 minute can materially lower neural risk by aligning mental models.

Anesthesia planning based on risk is part of this preparation. Controlled hypotension during dissection in a narrow corridor, avoidance of nitrous oxide when a violation of the skull base is possible, and readiness for rapid transfusion in sphenoid work align the physiologic environment with surgical goals. Shared mental models between surgeon and anesthesiologist shorten the lag between an early warning and the physiologic correction that preserves neural function [40].

Intraoperative Neural Protection Strategies

Visualization is protection. Meticulous local vasoconstriction, atraumatic tissue handling, frequent lens cleansing, and timely use of angled optics maintain a stable horizon. Blood is the enemy of orientation, proactive hemostasis and a low threshold for packing restore clarity. When the corridor narrows, deliberate instrument choreography, one hand retracts and suctions while the other performs measured dissection, prevents blind advances [6,41].

To standardize these behaviors, we specify practical starting parameters. For soft tissue, a microdebrider can start at 5,000 rpm in oscillation, and continuous rotation should be avoided near the orbit or the skull base while the tip remains continuously visible [42]. For bony work adjacent to critical structures, use a diamond burr with continuous irrigation and maintain short, intermittent contact rather than sustained pressure. For hemostasis near thin skull-base plates or the optic apparatus, prefer low-power bipolar coagulation with brief activations, and avoid monopolar energy in these locations. IGS accuracy is re-verified at three or more anatomic landmarks after setup and after any head repositioning, and target registration error (TRE) is recorded when available [43].

Respect for planes prevents boundary violations. During ethmoidectomy, remain medial to the lamina, using the basal lamella as a guardrail. Under the skull base, exchange sharp for blunt tools and convert torque into piecemeal removal. In the sphenoid, begin inferomedially, enlarge under direct vision, and avoid prying on septa that insert on carotid or optic bulges [22]. Microdebriders are powerful but unforgiving, never run the blade outside the visual field and angle it away from the orbit and skull base.

Tactics specific to each structure reduce risk. Preserve a thin bone veneer over dehiscent optic or carotid canals rather than fully denuding them. When Haller cells crowd the infundibulum, debulk medially and inferiorly before approaching the lamina. In the frontal recess, balloon or limited drilling may achieve patency while minimizing superior fractures toward the anterior cranial fossa. In the olfactory cleft, favor cold instruments and avoid thermal injury whenever disease control allows [22,44].

Team behaviors serve as safety rails. Announce high-risk phases so the room quiets and attention peaks. Prime the anesthesiologist for controlled hypotension when bleeding threatens visualization and for immediate response to orbital signs, proptosis, tight lids, pupillary changes. Keep bailout kits accessible, lateral canthotomy set, carotid packing materials, and CSF repair grafts, so seconds are not lost when they matter most [45].

Ergonomics influences precision. Stable hand rests, neutral wrist angles, and predictable choreography for the scope holder reduce tremor and unintended motions near neural structures. When fatigue accumulates, a brief timed pause to reset posture and clean optics often repays itself by preventing a risky move made under stress. In training environments, dual console coaching and stepwise autonomy enable learners to develop judgment without exposing patients to undue hazard.

Intraoperative Monitoring and Artificial Intelligence Augmented Workflow

IONM is selectively applicable in ESS. The most pragmatic use case is visual evoked potentials when operating adjacent to the optic nerve, such as decompression or tumor resection abutting the canal [13]. Decrements in amplitude or increased latency can signal reversible compromise from traction, thermal spread, or hypotension, prompting immediate mitigation, pause, irrigate, ease retraction, or optimize blood pressure [46]. Limitations include anesthetic effects on signal quality, electrical noise, and the need for dedicated neurophysiologic expertise.

Most other cranial nerves at risk in ESS lack convenient real-time electrophysiology under general anesthesia. Extraocular muscle electromyography is feasible but rarely practical in routine sinus surgery [47]. Consequently, the principal intraoperative monitor remains visual. A constantly updated mental model validated by endoscopic landmarks and, when helpful, navigation. Nevertheless, the desire for earlier warning and cognitive support has catalyzed exploration of computer-assisted perception.

AI augmented workflows aim to elevate perception and predict peril. Computer vision models trained on endoscopic video can label landmarks, detect transitions to danger zones, and estimate the distance from the tool to the risk. Markerless video to CT registration enables AR overlays that outline the optic canal or carotid prominence within the live view. Alert engines can surface proximity warnings with thresholds tuned to minimize alarm fatigue while preserving sensitivity [11].

Integration matters as much as algorithms. A usable system must keep latency low, tolerate blood and smoke, and fail-safe, suppress overlays and alarms when confidence drops. Figure 2 summarizes the intraoperative workflow. Preoperative CT segmentation and risk mapping, registration between markerless video and CT with an AR overlay controlled by confidence gating, tracking of the tool tip with continuous estimation of proximity, tiered alerts delivered in real time, and event logging for post hoc analytics. Performance should be judged not only by the segmentation Dice coefficient or by registration metrics such as TRE and latency, but also by fewer near misses, faster time to decision, and preservation of vision and olfaction [48]. Practical deployment should start with narrowly scoped pilots. For example, landmark labeling and proximity highlights can run in a mirrored display visible to an assistant who verbalizes cues to the primary surgeon. As trust and robustness improve, overlays can migrate into the surgeon’s heads up view. Throughout, opt out controls and adjustable alert thresholds are essential so that augmentation remains supportive rather than intrusive [11].

Figure 2.

Artificial intelligence-augmented intraoperative workflow (Primary & Revision ESS). Steps: (1) CT segmentation and risk map; (2) markerless video–CT registration with AR overlay; (3) tool-tip tracking and proximity estimation; (4) real-time alerts; (5) event logging and post-op analytics. Scope: the workflow applies to both primary and revision ESS. When Revision mode (R) is selected at input, guardrails tighten: image-guided surgery becomes mandatory with ≥3 landmark re-checks at setup and after repositioning, conservative instrument/energy defaults, lower proximity thresholds near the optic nerve and internal carotid artery, and denser orientation checks with enhanced event logging. Key metrics include Dice/HD95 (segmentation), TRE/latency (registration), AUROC/F1 (detection), alarm burden (alarms/min, time-to-warning), and all metrics are stratified by case type (Primary vs. R). Pre-op, preoperative; CT, computed tomography; MRI, magnetic resonance imaging; ICA, internal carotid artery; post-op, postoperative; AR, augmented reality; SLAM, simultaneous localization and mapping; IGS, image-guided surgery; TRE, target registration error; HUD, head-up display; Dice, Sørensen–Dice; HD95, 95th-percentile Hausdorff distance; AUROC, area under receiver operating characteristic curve; ESS, endoscopic sinus surgery.

Point estimates are presented with 95% confidence intervals for image, video, and sensor or signal-based metrics (Dice, HD95, TRE, latency, area under the receiver operating characteristic curve, F1). For each experiment, sample size, inclusion and exclusion criteria, the number of observers, and whether repeated measurements are present are specified [49,50].

Complication-Centered Synthesis: Predictors, Prevention, and Management

Although major complications are uncommon in ESS, preparedness requires a crisp understanding of mechanisms, predictors, and first line management. Orbital events arise from lamina papyracea violation or vascular injury. Fat prolapse obscures the field, medial rectus trauma causes diplopia, retrobulbar hematoma threatens vision. Early warning signs, rising intraorbital pressure, tense lids, afferent pupillary defect, mandate immediate decompression via lateral canthotomy and cantholysis while securing hemostasis endonasally [51]. Avoidance hinges on respecting the lamina plane and minimizing lateral traction.

Skull-base breaches produce CSF leakage and, rarely, intracranial injury. Risk increases with high Keros grades, revision scarring, and upwardly directed force under the fovea or cribriform. Management rests on prompt recognition, atraumatic margins, and a durable multilayer closure using free grafts and, when indicated, a vascularized flap. Postoperative care, head elevation, stool softeners, and avoidance of nose blowing, reduces pressure spikes that jeopardize the repair [52].

Vascular catastrophes are prevented by disciplined sphenoid technique. A carotid laceration is immediately life-threatening. The correct response is tight packing of the sphenoid and nasal cavity, activation of massive transfusion, blood pressure control, and rapid coordination with endovascular colleagues for definitive control. Smaller arterial injuries, ethmoidal or sphenopalatine branches, are managed with focused cautery, clips, or embolization when persistent. Across scenarios, pre-written crisis checklists reduce hesitation and improve outcomes [53].

Table 1 consolidates a complication-centered checklist that links preoperative imaging predictors to concrete intraoperative prevention and monitoring steps and to outcomes that should be routinely tracked [54-58]. Using the checklist for briefing before the case and for auditing after the event transforms rare complications into structured learning, strengthens systems safety, and tightens the feedback loop between imaging, intraoperative behavior, and outcomes at the patient level.

Table 1.

Complication-centered checklist for neural safety in ESS

Institutions should track near misses, not only manifest injuries. A brief form free of blame, completed after cases and documenting moments when the team paused because of uncertainty near the orbit or the skull base, creates a dataset for targeted drills. Over time, this learning system clarifies which imaging predictors truly altered behavior and which steps most often preceded close calls.

Postoperative Functional Outcomes and Follow-Up

Most patients experience substantial symptomatic improvement after ESS, with better airflow, fewer infections, and higher disease-specific quality of life scores. From a neural perspective, the goal is preservation. No new visual deficit, stable ocular motility, intact sensation in V2 distributions, and maintained or improved olfaction. Because major neural complications are rare, routine outcome tracking should incorporate sensitive functional measures to detect subtle deficits and drive quality improvement.

Olfaction deserves special attention. Many patients with preoperative hyposmia due to mucosal disease recover partially or fully as obstruction clears and inflammation abates. Surgical technique influences this trajectory. Gentle handling of the olfactory cleft and avoidance of thermal injury correlate with better smell outcomes. When smell declines postoperatively, distinguishing transient edema from structural injury directs management and counseling [59].

Follow-up protocols that pair endoscopic debridement with patient-reported outcome measures and, when indicated, formal smell testing help sustain gains. Early detection and treatment of adhesions, infection, or persistent edema prevent secondary problems that might tempt riskier revisions. A brief neurological screen that covers vision, diplopia, and facial sensation should be part of routine review to capture rare late presenting sequelae.

Returning to function extends beyond the sinonasal domain. Simple, standardized questionnaires about visual symptoms, diplopia in gaze extremes, periorbital or infraorbital numbness, and smell and taste integrate neural safety into routine follow-up. Where concerns arise, early collaboration with ophthalmology or neurology prevents small deficits from becoming entrenched problems [51].

Documentation should be explicit and longitudinal. A brief note that pairs endoscopic findings with neural status, pupils equal and reactive, extraocular movements intact without pain or diplopia, symmetric light touch in V2, patient-reported smell on a simple 0, 10 scale, creates a traceable arc across visits. When a deviation emerges, earlier notes anchor timing and guide targeted evaluation, including imaging or specialty referral [60].

Special Populations and Challenging Scenarios

Pediatric ESS requires scaled down instruments, a slower tempo, and a lower threshold for navigation because bony boundaries are thinner and the sinuses are smaller. Growth considerations and the predominance of inflammatory polyposis shape conservative objectives. Communication with caregivers about risk and benefit is essential, emphasizing that neural safety dictates the limits of resection and that staging is preferable to clearance performed in a single stage when risk is high.

Revision surgery introduces scarred planes, missing landmarks, and altered geometry. Preoperative CT with three-dimensional review and a strict stepwise plan help restore orientation. Intraoperatively, expect more bleeding and slower progress, patience is protective. When anatomy remains unclear, staging the case rather than forcing a solution reduces neural and vascular risk and often improves outcomes by allowing inflammation to settle [61].

Extended procedures that encroach on the skull base or orbit, tumor resections, decompressions, encephalocele repairs, benefit from multidisciplinary collaboration. Combine ENT, neurosurgery, and ophthalmology expertise, add neuromonitoring where function can be measured, and agree in advance on abort criteria. In a monocular patient or one with contralateral visual compromise, escalation thresholds are even higher, and an AI augmented display should be tuned to maximize specificity to avoid alert fatigue [46].

Immunocompromised patients and those with invasive fungal disease present a different calculus. While disease control may necessitate assertive debridement, the surgeon must assume boundaries are thinner than they appear and that tissue planes are friable. Here, the threshold for staging, for navigation cross-checks, and for postoperative imaging surveillance is appropriately lower to guard against delayed neural complications [62].

Validation, Reporting Standards, and Ethics for Artificial Intelligence Tools

Clinical adoption of AI demands evidence that extends beyond bench metrics. External validation on diverse populations, prospective testing under operating room conditions, and demonstration of workflow compatibility are prerequisites. Outcome-linked endpoints, near miss reduction, decision timing, and complication surrogates carry more weight than Dice coefficients alone and should anchor evaluations.

Transparent reporting enables peer scrutiny and generalization. Datasets, annotation protocols, and failure analyses should be described with enough detail to reproduce results. Models should disclose confidence measures and abstain when uncertain. Continuous monitoring after deployment is essential to detect performance drift across software updates, new cameras, or different lighting and bleeding conditions.

Ethically, patient privacy, algorithmic bias, and responsibility boundaries are central. Video and imaging used for training must be deidentified and governed by consent frameworks. Bias audits should assess performance across anatomic variants and demographics. Surgeons remain the final decision makers, and AI should function as decision support with a clear human override. Logs that capture alerts and actions improve accountability and learning while respecting confidentiality [63,64].

Regulatory pathways will evolve as AI becomes embedded within surgical platforms. Developers should anticipate requirements for cybersecurity, audit trails, and post-market surveillance. Hospitals, for their part, need governance that evaluates algorithm updates like any other clinical change. With stakeholder input, sandbox testing, and clear rollback plans if performance deteriorates [65].

Knowledge Gaps and Future Directions

Because catastrophic events are rare, quantifying incremental safety gains requires large, multicenter datasets or federated learning across institutions. Harmonized definitions for complications and functional outcomes would enable pooled analyses and meta learning. Simulation platforms that faithfully render sinonasal anatomy, bleeding, and instrument physics could accelerate training and allow controlled testing of AI copilots before human use.

The next wave of safeguards will likely blend perception and constraint. Smart instruments may incorporate proximity sensing or force-limiting haptics that stiffen when approaching forbidden zones. Navigation could evolve from passive coordinates to active guards that modulate microdebrider suction or drill speed based on tool to risk distance, with surgeons retaining instant override [66].

Finally, implementation science deserves equal attention. Human factors studies should optimize alert design, panel layout, and teamwork choreography so that technology reduces rather than adds to cognitive load. Cost effectiveness analyses can identify which cases merit advanced augmentation. As evidence accrues, consensus statements can translate innovation into pragmatic, widely adoptable practice standards.

Looking farther ahead, multimodal data fusion, combining CT-derived risk maps, intraoperative video features, instrument kinematics, and physiologic signals, may enable predictive models that warn of loss of orientation before it is perceptible to the human eye. If implemented with restraint and transparency, such systems could function like aviation’s terrain-awareness alerts. Rarely heard, but decisive when conditions align toward harm [67].

Conclusion

Neural safety in ESS rests on the triangle of anatomy, technique, and technology. High fidelity preoperative imaging and disciplined intraoperative behaviors have already lowered major complication rates to very low levels. Yet the anatomic neighborhood of the sinuses, the orbit, and skull base, will always demand humility and vigilance.

Practical risk maps, structured checklists, and selective neuromonitoring convert knowledge into action, while image-guided navigation anchors orientation when landmarks are ambiguous [61]. Emerging AI systems promise to elevate perception with landmark recognition, augmented-reality overlays, and proximity alerts, their value must be proven in clinical reality and integrated without distracting the surgeon [15,37]. During early adoption, variability across devices and users is acceptable only when operating boundaries are prespecified, orientation is maintained, alerts remain actionable, patient safety is not degraded, and the system is configured to fail-safe with routine audit.

By coupling proven fundamentals with validated innovations, teams can further reduce the already rare neural complications of ESS while preserving or improving function, particularly vision and olfaction [16,61]. The organizing principle is simple. Treat the disease aggressively enough to help the patient, but never at the expense of neural integrity. That ethic should shape every plan, maneuver, and investment in the modern ESS suite. Measured against that standard, every innovation, analog or digital, should prove it helps surgeons keep patients safe while achieving durable relief of sinonasal disease [16,35].

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