HSC Section 8_April 2017

demonstrated that magnetic resonance imaging (MRI) with diffusion-weighted imaging may be a more practical method for assessing for cholesteatoma recidivism com- pared to a second-look procedure. 17,18 High-resolution CT is also being investigated as a potential alternative to a second-look operation; however, with possibly less specificity, sensitivity, and positive predictive value com- pared to MRI. 19 Middle ear endoscopy has also arisen as a useful tool for reducing cholesteatoma recidivism. A recent investigation has shown that a progressive hybrid transcanal-endoscopic approach yields cholesteatoma residual rates comparable to the CWD. 20 A systematic review has also found that endoscopy has been used as both an adjunct to the microscope or as the sole visual- ization instrument for improved cholesteatoma localiza- tion or for clinic surveillance. 21 Prospective studies with comparisons to traditional microscopy will be needed to substantiate the reported benefits. Moreover, future for- mal cost-effectiveness analyses of the optimal surgical management of cholesteatoma should include considera- tion of these adjunctive technologies and techniques. If the surgeon is confident that no residual choles- teatoma remains, then an automatic second-look strat- egy is unnecessary and costly. If after an initial procedure the surgeon believes there is residual choles- teatoma despite best efforts, then a second-look strategy is likely worth the cost and risks of an additional proce- dure. Another reasonable indication for a second-look is if there is evidence of excessive inflammation in the mid- dle ear that may compromise primary ossicular chain reconstruction. Considering the low rate of cholestea- toma recurrence and relatively high cost of care, imple- mentation of a second-look strategy should be individually tailored and not universally performed. If we aim to narrow the scope of the second-look strategy and reap cost-savings in the management of cholestea- toma, further discussion is needed to achieve consensus on an acceptable cholesteatoma recurrence rate that bal- ances safety and cost-effectiveness. Acknowledgments The authors would like to thank Duke Financial Services for providing charge data and interpretations. We would also like to thank Amy Walker, Erika Juhlin, and Sunita Patel for continued administrative support—and Laura Ding for statistical support. BIBLIOGRAPHY 1. Smyth GD. Canal wall for cholesteatoma: up or down? Long-term results. Am J Otol 1985;6:1–2. 2. Mishiro Y, Sakagami M, Kitahara T, Kondoh K, Okumura S. The investi- gation of the recurrence rate of cholesteatoma using Kaplan-Meier sur- vival analysis. Otol Neurotol 2008;29:803–806. 3. Farrior JB, Farrior JB. Recurrent and residual cholesteatoma. Am J Otol 1985;6:13–18. 4. Kinney SE. Intact canal wall tympanoplasty with mastoidectomy for cho- lesteatoma: long-term follow-up. Laryngoscope 1988;98:1190–1194. 5. Wilson KF, London NR, Shelton C. Tympanoplasty with intact canal wall mastoidectomy for cholesteatoma: long-term hearing outcomes. Laryngo- scope 2013;123:3168–3171. 6. Tomlin J, Chang D, McCutcheon B, Harris J. Surgical technique and recurrence in cholesteatoma: a meta-analysis. Audiol Neurootol 2013;18: 135–142. 7. Barakate M, Bottrill I. Combined approach tympanoplasty for cholestea- toma: impact of middle-ear endoscopy. J Laryngol Otol 2008; 122:120– 124.

resources and expertise, supplies, and facility require- ments required for safe execution. As a result, operative procedures are a significant proportion of the healthcare cost burden. We found that the total charges of a second- look strategy are 76% higher than that of a single-look operative strategy, with arguably no benefit in recur- rence rate. Moreover, every surgical procedure carries an inherent risk of a complication. The most important risks of a tympanoplasty-mastoidectomy to consider are facial nerve injury, violation of the bony labyrinth, vas- cular injury, and dehiscence of the tegmen. These com- plications beget further procedures and ultimately add costs. In our study, we had a relatively low complication rate; however, after a second procedure, one patient developed an encephalocele and another developed a wound seroma. Although meticulous surgical technique is a cornerstone to optimal outcomes and avoiding com- plications, surgical complications are best reduced by the reduction of unnecessary procedures. Hearing preservation is a secondary goal of choles- teatoma removal because the risk of residual cholestea- toma outweighs the benefits of a conservative approach to removing components of the hearing apparatus. A purported benefit of utilizing a second-look strategy as a staged approach is reconstruction of the hearing appara- tus, if needed. However, we were unable to find firm evi- dence substantiating the benefit of this rationale. In our study, we found that there were no significant differen- ces in hearing outcomes between the second-look and single-stage strategies. In our opinion, ossicular chain reconstruction can be performed at the surgery if indi- cated, and need not be reserved for a separate operative procedure. Other investigators have also reported rou- tinely performing OCR at the primary surgery. 8 Our study has limitations that need mentioning. This is not a randomized control trial, so we cannot account for all possible confounding variables. We attempted to limit confounding variables and generate clean data by formulating strict inclusion criteria. This strict approach comes at the expense of being left with smaller cohorts of patients. We were also unable to account for the different surgical technique performed by our surgeons. Thus, we cannot explore if specific sur- gical techniques are responsible for our lower reported recurrent or residual cholesteatoma. We are also unable to characterize the severity of disease preoperatively. The initial burden of cholesteatoma may have an influ- ence on the surgical technique utilized, as well as on recidivism. Lastly, because this is not a formal cost- effectiveness analysis, we are unable to provide a conclu- sion regarding which strategy is more cost-effective. We hope this study serves as a basis for a formal cost- effectiveness analysis and are in the process of designing such a study. Considering the high cost of operative procedures and increased scrutiny on cost-effective care, the devel- opment of novel methods for evaluating for recurrent and residual cholesteatoma may gain traction. An emerging noninvasive modality for assessing cholestea- toma recidivism is with the use of specialized radio- graphic techniques. A recent systematic review has

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