HSC Section 8_April 2017

Reprinted by permission of Laryngoscope. 2016; 126(11):2574-2579.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Cost Analysis and Outcomes of a Second-Look Tympanoplasty-Mastoidectomy Strategy for Cholesteatoma

Matthew G. Crowson, MD; Vaibhav H. Ramprasad, BA; Nikita Chapurin, BA; Calhoun D. Cunningham III, MD; David M. Kaylie, MD, MS

Objectives/Hypothesis: To analyze cost and compare cholesteatoma recidivism and hearing outcomes with single-stage and second-look operative strategies. Study Design: Retrospective review and cost analysis. Methods: Adult and pediatric patients who underwent a tympanoplasty with mastoidectomy for cholesteatoma with a single-stage or second-look operative strategy were identified. Variables included procedure approach, residual or recurrent cholesteatoma, ossicular chain reconstruction frequency, and operative complications. Audiologic outcomes included pre-/ postoperative air bone gap (ABG) and word recognition score (WRS). Cost analysis included charges for consultation and follow-up visits, surgical procedures, computed tomography temporal bone scans, and audiology visits. Results: One hundred and six patients had a tympanoplasty with mastoidectomy for cholesteatoma, with 80 canal wall- up procedures (CWU) as initial approach. Of these, 46 (57.5%) CWU patients had a planned second look. Two (4.3%) CWU patients had recurrent cholesteatoma and 20 (43.4%) had residual identified at second look. Four (11.7%) single-stage CWU strategy patients developed recurrent cholesteatoma. There was no significant difference in pre-/postoperative ABG and WRS between second look and single stage ( P > 0.05). Compared to second-look patients, single-stage patients had significantly fewer postoperative visits (6.32 vs. 10.4; P 5 0.007), and significantly lower overall charges for care ($23,529. vs. $41.411; P < 0.0001). Conclusion: The goal of cholesteatoma surgery is to produce a safe ear, and a second-look strategy after CWU has his- torically been used to evaluate for recurrent or residual disease. The cholesteatoma recurrence rate at a second look after a CWU tympanoplasty-mastoidectomy is low. Costs of operative procedures are a significant proportion of healthcare resource expenditures. Considering the low rate of cholesteatoma recurrence and relatively high cost of care, implementation of a second-look strategy should be individually tailored and not universally performed. Key Words: Cholesteatoma, second look, tympanoplasty, mastoidectomy. Level of Evidence: 4. Laryngoscope , 00:000–000, 2016

INTRODUCTION Cholesteatoma is a potentially destructive epider- mal inclusion cyst of the middle ear. They can be acquired primarily through a retraction pocket in the tympanic membrane, secondarily through a tympanic membrane perforation, or develop as a congenital rest of squamous epithelium behind an intact tympanic mem- brane. If left untreated, the cholesteatoma can initiate local inflammatory cascades and osteoclast activation, resulting in erosion and destruction of the osseous struc- tures of the middle and inner ear that include the mas- From the Division of Otolaryngology–Head and Neck Surgery, Duke University Medical Center ( M . G . C ., V . H . R ., N . C ., C . D . C ., D . M . K .), Dur- ham, North Carolina, U.S.A. Editor’s Note: This Manuscript was accepted for publication February 2, 2016. Presented as an oral presentation at the Triological Society Com- bined Sections Meeting, Miami, Florida, U.S.A., January 22–24 2016. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Matthew G. Crowson, MD, Division of Otolaryngology–Head & Neck Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710. E-mail: matthew.crowson@dm. duke.edu

toid, ossicles, and semicircular canals. More serious sequelae include erosion of the tegmen, cerebrospinal fluid leak, encephalocele formation, and secondary infec- tion with intracranial extension. Management of cholesteatoma includes complete sur- gical removal of all cyst matrix, keratinaceous debris, and squamous epithelium. The surgical approach employed depends upon the extent of the disease. Small, well- contained cysts in the attic can be removed via a transca- nal tympanoplasty and atticotomy. In most cases, a tym- panoplasty with mastoidectomy is necessary for adequate exposure and removal of all disease. A mastoidectomy can be completed with either a canal wall-down or canal wall-up technique. Reported advantages of the canal wall-down technique include superior exposure of the middle ear and lower disease recurrence rates. 1–3 Advan- tages of the canal wall-up technique include preserved or improved hearing outcomes, preservation of the natural external ear canal wall, tympanic membrane position, and avoidance of a mastoid cavity. 4,5 However, the canal wall-up technique has a reported higher risk of residual and recurrent cholesteatoma. 6 The incidence of recurrent cholesteatoma at second-look surgery following primary canal wall-up tympanoplasty in contemporary literature

DOI: 10.1002/lary.25941

Crowson et al.: Second-Look Tympanoplasty-Mastoidectomy

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