How cost- and clinically effective is the use of endoscopes during cholesteatoma surgery to reduce recurrence rates and cost?
Intraoperative endoscopic surveillance reduced recurrence, was particularly useful in evaluating the epitympanum, mesotympanum, sinus tympani, and supratubal air cells, and had significant cost savings.
Background: The goal of cholesteatoma surgery is to completely eradicate the disease and create a safe ear, where cholesteatoma is unlikely to recur. Using current microscopic techniques, recurrence rates for cholesteatoma range from 20% to 50% and occur almost exclusively in the middle ear space. Endoscope use allows surgeons to visualize difficult-to-access regions.
Study design: Case series of 110 consecutive cholesteatoma patients over a two-year period.
Setting: Vanderbilt University Medical Center, Nashville.
Synopsis: Of the 110 study patients, 68% were primary surgeries, and 85% had ossicular chain involvement. The most common cholesteatoma areas were the mesotympanum, epitympanum, sinus tympani, mastoid and hypotympanum, eustachian tube, and supratubal air cells. Cavity evaluation with 0° and 45° endoscopes identified residual disease in 14.6% of patients. Residual disease was identified in four patients using 0° endoscopes. The 45° endoscope detected further residual disease in the three patients with epitympanic cholesteatoma, two with mesotympanic cholesteatoma, and two with supratubal cell cholesteatoma. Overall, it took 2.8 minutes in additional setup time for the endoscopes. Significant improvement in airborne gap, improvement in postoperative air conduction pure tone average were noted, but no improvement in bone conduction pure tone average. The average Medicare fee per case was $5,914.92. At the Medicare rate of $18 per 15 additional minutes of operating, endoscopic use contributed to an average additional cost of $18. Overall cost savings of endoscope use during cholesteatoma surgery was $94,638.66 in preventing further procedures. Limitations included the lack of randomization and blinding, a two-year follow-up after surgery, and the lack of any other imaging techniques used.
Citation: Bennett M, Wanna G, Francis D, et al. Clinical and cost utility of an intraoperative endoscopic second look in cholesteatoma surgery. Laryngoscope. Published online ahead of print October 16, 2018. doi: 10.1002/lary.27258.