HSC Section 8_April 2017

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.

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

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.

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.

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.

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.

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