Photon-Counting Computed Tomography of the Paranasal Sinuses Improves Intraoperative Accuracy of Image-Guided Surgery

<b>Background:</b> Computed tomography (CT)-based image-guided surgery (IGS) is of great importance in functional endoscopic sinus surgery (FESS) and requires IGS-specific imaging protocols to ensure high intraoperative accuracy. This study aimed to compare photon-counting CT (PCCT), dual-energy dual-source CT (DECT), and spectral detector CT (SDCT) of the paranasal sinuses with respect to image quality, IGS accuracy and radiation dose. <b>Methods:</b> A formalin-fixed cadaver skull was examined using PCCT, DECT and SDCT at 100 kV tube voltage with descending tube currents (mAs). The setup of electromagnetic IGS was evaluated using a visual analog scale. Accuracy was analyzed endoscopically using defined anatomical landmarks. Diagnostic image quality as well as bone and soft tissue noise were assessed qualitatively using a 5-point Likert scale and quantitatively by determination of signal-to-noise ratio. Radiation dose was evaluated using the dose length product. <b>Results:</b> While PCCT datasets could be registered and navigated accurately down to 10 mAs (1.5 mm error at 10 mAs), both DECT and SDCT exhibited significantly increased inaccuracies below 40 mAs (4.35/5.15 mm for DECT/SDCT at 25 mAs). Using PCCT therefore enabled a 45% radiation dose reduction at the minimally required dose length product using PCCT. Quantitative and qualitative image quality were superior for PCCT compared to DECT and SDCT. <b>Conclusions:</b> PCCT provides excellent accuracy of anatomical landmarks in IGS with superior image quality of the paranasal sinuses in low-mA scans and substantially reduced radiation exposure.