HSC Section 8_April 2017

The Laryngoscope

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 (

0.05). Compared to second-look patients, single-stage patients had significantly

fewer postoperative visits (6.32 vs. 10.4;

0.007), and significantly lower overall charges for care ($23,529. vs. $41.411;

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:

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-

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.

The incidence of recurrent

cholesteatoma at second-look surgery following primary

canal wall-up tympanoplasty in contemporary literature

From the Division of Otolaryngology–Head and Neck Surgery,

Duke University Medical Center (

.), 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

DOI: 10.1002/lary.25941

Crowson et al.: Second-Look Tympanoplasty-Mastoidectomy

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