September 2019 HSC Section 1 Congenital and Pediatric Problems

Reprinted by permission of Am J Otolaryngol. 2018; 39(4):418-422.

Am J Otolaryngol 39 (2018) 418–422

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Am J Otolaryngol

journal homepage: www.elsevier.com/locate/amjoto

A cost-e ff ectiveness analysis of the up-front use of balloon catheter dilation in the treatment of pediatric chronic rhinosinusitis Laura Kathryn House ⁎ , Andrea F. Lewis, Mary G. Ashmead 1 University of Mississippi Medical Center, Department of Otolaryngology, 2500 North State Street, Jackson, MS 39216, United States

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A B S T R A C T

Background: The treatment of pediatric sinusitis continues to be a controversial topic. It has been recommended to treat pediatric chronic rhinosinusitis (CRS) with adenoidectomy before proceeding to more invasive techni- ques. There are concerns regarding side e ff ects of endoscopic sinus surgery in pediatric patients. With the advent of balloon catheter dilation (BCD) as a minimally invasive technique, some authors are recommending up front adenoidectomy with BCD in order to maximize disease resolution while minimizing risk. Purpose: Our study examines the cost e ff ectiveness of adenoidectomy alone versus adenoidectomy and upfront BCD for the management of pediatric CRS. Methods: A decision tree analysis was created to determine the cost e ff ectiveness of treating a pediatric patient who has failed medical management, using adenoidectomy versus adenoidectomy with up-front BCD. Three separate decision trees were made. The incremental cost e ff ectiveness ratio (ICER) was calculated for each scenario and a sensitivity analysis was done to determine how di ff erent values impacted our results. Results: Adenoidectomy as the sole fi rst procedure was found to be more cost e ff ective in all three decision trees. For tree 1, the adenoidectomy plus BCD arm was 0.03% more e ff ective in the end, but with an $81, 431 in- cremental cost. Conclusions: Costs in addition to outcomes must be considered when comparing treatment modalities in our current health care environment. This study found that adenoidectomy as a fi rst intervention before proceeding to more advanced techniques is nearly as e ff ective and is a much more cost-e ff ective algorithm for the treatment of pediatric CRS. However, the physician must advocate the best treatment for his or her own patients.

1. Introduction

dysmotilities, bio fi lms, microbiome disruption, immunode fi ciencies, and gastroesophageal re fl ux can all contribute to development of chronic rhinosinusitis [ 6 ]. There are many treatment options. Antibiotics continue to be the mainstay of treatment for CRS in children, along with nasal steroids, allergy treatment, and saline irrigations [ 5 ]. When conservative man- agement fails, more invasive measures can be considered, including long term IV antibiotics, adenoidectomy, antral lavage, functional en- doscopic sinus surgery (FESS), and balloon catheter dilation (BCD). All of these interventions have been studied and shown to improve CRS in many patients. It has long been recommended to treat pediatric CRS that has been resistant to conservative management in a stepwise manner, starting with adenoidectomy before proceeding to more invasive techniques [ 7 , 8 ]. There has been concern in the literature that FESS may impede midface growth when performed in children, as well as a 0.6% risk of major complications [ 9 ]. With the advent of BCD as a minimally

The treatment of pediatric sinusitis continues to be a controversial topic, given that there are multiple treatment options. The majority of children with chronic rhinosinusitis (CRS) will resolve with medical management alone [ 1 ]. Pediatric chronic rhinosinusitis can be de fi ned as patients aging from 6 months to 19 years having two of the following symptoms: purulent rhinorrhea, nasal obstruction, facial pain or pres- sure, or hyposmia, for over 3 months with evidence of in fl ammation on computed tomography or nasal endoscopy [ 2 , 3 ]. It remains a poorly de fi ned, poorly understood illness, which is both di ffi cult to diagnose and di ff erentiate from other disorders. True evidence based guidelines are therefore challenging to create. Acute sinusitis is fairly ubiquitous, with approximately 5 – 10% of viral upper respiratory tract infection resulting in sinusitis [ 4 , 5 ]. It re- mains unclear why or how chronicity develops. It has been suggested that increasing prevalence of anaerobes, anatomic variations, ciliary

⁎ Corresponding author.

1 Present address: 1600 W. College Ave., Suite 270, Grapevine, Texas 76051, United States. E-mail addresses: lhouse@umc.edu (L.K. House), AFLewis@umc.edu (A.F. Lewis).

https://doi.org/10.1016/j.amjoto.2018.04.007 Received 11 December 2017 0196-0709/ © 2018 Elsevier Inc. All rights reserved.

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