Canal Wall Up vs. Canal Wall Down: Symptom of a greater need?

This issue of ENT Today includes an article on the debate over canal-wall-up (CWU) versus canal-wall-down (CWD) tympanomastoidectomy (p. 5). I remember hearing the same arguments when I was a resident at UCLA, which was also the last time I drilled a mastoid bone; my practice focused on head and neck surgery and pediatric otolaryngology. Over the past 32 years, Drs. Bruce Gantz, Rick Chole (two of my otology colleagues on the Board of Otolaryngology), and other otologist friends have suffered through my semi-tongue-in-cheek comments on why otologists can’t agree on which procedure is better. Although the technology used in both procedures has evolved, the final product of the two procedures, a dry, safe ear, is, as best I can tell, the same as it was when I was a resident. I have been told that one of the main factors considered in the decision regarding which procedure to perform is where the otologist trained.

But CWU/CWD isn’t really the topic of this editorial. I just use it as an example of the problems involved in developing meaningful, evidence-based guidelines in our specialty as well as in medicine as a whole. It is quite clear that the payers, government and quality improvement groups all want to establish practice guidelines for laudable reasons—not just to control costs, but also to improve patient outcomes. The recently passed Patient Protection and Affordable Care Act includes funding for a Patient-Centered Outcomes Research Institute, which is charged with overseeing comparative effectiveness research (CER) that should move this process forward more rapidly. Regardless of your opinion of health care reform, it appears CER is here to stay.

If we physicians don’t work on developing quality improvement tools, someone else will, and I don’t think we will like that outcome.
—Robert H. Miller, MD

It is also clear in a number of specialties that the management of certain conditions varies dramatically across the country—with widely disparate costs. Yes, I understand some patients are better treated by taking the canal wall down, while others do well with the canal wall up. But shouldn’t the determination be based on evidence showing which patients should have which procedure? A surgeon’s preference is important, because it is advantageous for a surgeon to feel comfortable doing a procedure. But what if the outcome of the surgeon’s preference is not as good as another procedure? In that situation, the nod should go to what is best for the patient, not the surgeon. The surgeon should either become more facile with the better procedure or refer the patient to someone who is.

Some argue that guidelines are flawed because not all patients are the same (the “cookbook medicine” argument), which is absolutely true. Appropriate flexibility should be included in the guideline implementation process. And this is exactly why it is important for practicing otolaryngologists to participate in the development of guidelines. If we do not participate, then the guidelines will be developed by those not intimately familiar with the practice of medicine. That said, we must also remember that the guidelines are based on published data and not just someone’s opinion. Nevertheless, I think common sense input is important in the process, particularly when the guideline goes through the review process.

Another important role for guidelines is to provide a method for us to self-assess and improve our performance as doctors. Basic guidelines have been in place for many years in some specialties. Reviews of the use of beta blockers after myocardial infarction and disease screening (including mammograms) permit an analysis of what we are doing well and where we need to improve. Although the outcomes have not been perfect, this type of research has resulted in vastly improved care. This concept of following analysis with practice changes to improve outcomes is at the heart of Part IV of the American Board of Otolaryngology’s Maintenance of Certification (MOC) process. It may prove impossible to have guidelines for all conditions simply because patients with those conditions are so variable or rare that guidelines will prove meaningless. Nevertheless, I believe that many, if not most, situations in otolaryngology-head and neck surgery lend themselves to guidelines.

The American Academy of Otolaryngology-Head and Neck Surgery has been very active in the development of practice guidelines. Under the leadership of Richard Rosenfeld, the Academy’s Guideline Development Task Force has worked diligently to create meaningful, validated otolaryngology guidelines. As a member of this group, I have learned a great deal about the challenges of developing guidelines. These challenges include not only time and money but also the coordination of efforts with non-otolaryngology stakeholders whose input into the development process is critical. I encourage you to visit the AAO’s Web site at http://www.entnet.org/Practice/clinicalPracticeguidelines.cfm to learn more about guidelines and their development. The Academy is seeking partners to help develop their guidelines.

As in any quality improvement program, the loop needs to be closed by determining if the guidelines make a difference not only in costs but also in patient outcomes. Hopefully, Part IV of MOC will answer this question and help refine guidelines further.

So, which is better, canal wall up or canal wall down? As a non-otologist, I don’t have a clue, and this debate may go on for another 32 years. What I do know is that we must address the bigger issue, which is that health care quality improvement is staring us in the face. Guidelines are something that practicing otolaryngologists, working together, can create, implement and refine based on patient outcomes. If we physicians don’t work on developing quality improvement tools, someone else will, and I don’t think we will like that outcome.

Sincerely,
Robert H. Miller, MD, MBA

Physician Editor, ENT Today
Executive Director, American
Board of Otolaryngology