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preserve or improve hearing.
16
Cholesteatoma removal
can be a tedious undertaking, and there is a risk of
recurrence or residual cholesteatoma left behind,
despite best efforts. A second-look operative strategy
after CWU tympanoplasty with mastoidectomy has
been historically used to evaluate for recurrent or resid-
ual disease, as well as opportunity to perform OCR.
However, there are significant differences in opinion
among otologists regarding the optimal surgical strat-
egy.
15
Compared to previously published studies of
CWU and CWD approaches for cholesteatoma and
recurrence incidence at second-look, our recurrence
rate after CWU.
7–10
In our study, we found that choles-
teatoma recurrence rate after primary CWU
tympanoplasty-mastoidectomy in all patients is low at
2.5%, and 4.4% in the subgroup of patients who under-
went a second-look strategy. In patients with no second
look planned, 7.5% of patients required an unantici-
pated second-look procedure and recurrence was found
in all, and none had residual. The patients who we
included in our study had no prior otologic surgery. The
majority of surgical procedures were performed by
fellowship-trained neurotologists and were first
attempts at surgical management. The follow-up inter-
val was over 2.5 years for our single-stage cohort and
over 3.5 years for our second-look patients.
Considering the low recurrence rate, automatic
second-look procedures are not always necessary. In
approximately half of our CWU patients, the decision
not perform a second look was made due to high cer-
tainty that all cholesteatoma was removed at the origi-
nal surgery. A small group of these CWU patients
developed a recurrence, but none had evidence of resid-
ual cholesteatoma. We believe our follow-up time was
sufficient to allow for recurrence or residual disease to
declare itself. The other half of our patients had a
planned second look because the surgeon deemed there
was a high likelihood of incomplete resection at the orig-
inal surgery. We found a high residual cholesteatoma
rate in these patients. This indicates that performing a
second-look is justified when the surgeon is not sure
that all of the cholesteatoma was removed at the pri-
mary procedure.
We were not surprised that charges for the tympa-
noplasty with mastoidectomy procedure were the most
expensive component of care. In general, operative pro-
cedures are among the more costly healthcare interven-
tions owing to the substantial amount of human
TABLE II.
Charges for Individual Components of Care.
Mean (CI 95%), in $USD
Charges
Direct Cost
Total Cost
Consultation visit
737.
(612.–861.)
158.
(127.–189.5)
270.
(222.5–318.0)
Surgical procedure
16,032.
(14,707.–17,357.)
3,196.
(2.899.–3,494.)
4,598.
(4,672.–4,925.)
Postoperative visit
244.
(175.–313.)
38.
(27.–49.)
77.
(54.–99.)
CT temporal bone
2,231.
(1,987.–2,475.)
194.
(151.–238.)
375.
(319.–432.)
Audiology visit
833.
(743.–923.)
153.
(140.–165.)
282.
(259.–305.)
Each dollar figure rounded to nearest whole dollar.
CI
5
confidence interval; CT
5
computed tomography; USD
5
U.S. dollar.
TABLE III.
Cost of Care for Patients in Second-Look and No Second-Look Strategy Cohorts.
No Second Look
Second Look
P
Value*
Follow-up in days
916.0 (577.6–1254.5)
1312.6 (1018.4–1606.8)
0.08
Consultation clinic visits
1
1
–
Surgical procedures
1
2
–
Postoperative visits
6.32 (4.58–8.06)
10.4 (8.92–11.9)
0.0007
CT temporal bone, N
0.88 (0.56–1.2)
1 (0.73–1.27)
0.58
Audiology clinic visits
4.90(4.21–5.59)
3.88 (3.03–4.74)
0.07
Cost of care
$ 23,529
.
(22,512.–24,547.)
$41,411.
(40,590.–42,231.)
<
.0001
Each dollar figure rounded to nearest whole dollar.
*One-way ANOVA. Two-tailed
ANOVA
5
analysis of variance; CT
5
computed tomography.
Crowson et al.: Second-Look Tympanoplasty-Mastoidectomy
102