Cost-Effectiveness of Septorhinoplasty.

Importance: Septorhinoplasties are performed for functional, aesthetic, or a combination of these indications. As a nonvital intervention, cost-effectiveness may be questioned. Objective: To determine the cost-effectiveness of septorhinoplasty. Design and Setting: The literature was reviewed for revision rates (RRs) and health utility values (HUVs) for both septorhinoplasty and revision septorhinoplasty. Age-specific mortality rates and life expectancies were used. Costs were gathered from international settings and analyzed in an adapted Markov model. Intervention: Septorhinoplasty versus no intervention. Main Outcomes and Measures: Cost-efficiency was calculated for different willingness-to-pay thresholds in a probabilistic sensitivity analysis. The effect of different parameters (costs, RRs, HUVs, age, gender) were reviewed and addressed in a sensitivity analysis for an incremental cost-effectiveness ratio (ICER) willingness-to-pay threshold of $50,000/quality-adjusted life year (QALY). Results: The ICER for septorhinoplasty for a 40-year-old woman ranges from $1216 to $3509/QALY (depending on the country) in comparison with no intervention. Septorhinoplasty is cost-effective in 98.8% (for a $50,000/QALY threshold). The sensitivity analysis showed high robustness of the cost-effectiveness for various scenarios. Conclusions and Relevance: Septorhinoplasty is a highly cost-effective treatment.

The Role of Non-Echoplanar Diffusion-Weighted Magnetic Resonance Imaging in Diagnosis of Primary Cholesteatoma and Cholesteatoma Recidivism as an Adjunct to Clinical Evaluation.

INTRODUCTION:: The aim of this study was to analyze the sensitivity and specificity of non-echoplanar (non-EPI) diffusion-weighted (DW) magnetic resonance imaging (MRI) for the detection of cholesteatoma, with a focus on its value as an adjunct to clinical examination. METHODS:: In a prospective cohort study, 92 cases were divided into 2 groups: "clinically cholesteatoma" ( n = 79) and "clinically no cholesteatoma" ( n = 13). Non-EPI DW MRI was performed preoperatively in all cases. The presence of a cholesteatoma was assessed by clinicians otoscopically, by neuroradiologists on non-EPI DW MRI, by the surgeon intraoperatively, and finally by the pathologist postoperatively. Data analysis was performed for specificity, sensitivity, positive predictive value, negative predictive value, and interrater variability. RESULTS:: The sensitivity and specificity were 89.3% and 75%, respectively, in the "clinically cholesteatoma" group and 0% and 100% in the "clinically no cholesteatoma" group. Non-EPI DW MRI had a positive predictive value of 98.5% when cholesteatoma was suspected clinically and a negative predictive value of 84.6% when cholesteatoma was not suspected clinically. CONCLUSION:: If cholesteatoma is suspected clinically, non-EPI DW MRI is not necessary. If there is no clinical suspicion of cholesteatoma in second-look situations, sensitivity is low and serial follow-up MRI with long intervals is advised.

Early Timing of Thyroidectomy for Hyperthyroidism in Graves' Disease Improves Biochemical Recovery.

BACKGROUND: The role of thyroidectomy as an early treatment for hyperthyroidism has been poorly investigated. Our aim was to examine its success rates, particularly focusing on thyroidectomy as an early treatment. METHODS: Patients with thyroidectomy for hyperthyroidism between February 2008 and October 2014 were included. They were divided into two groups (early and delayed thyroidectomy), and patient characteristics, treatment indications, complications and time to biochemical recovery were analyzed. RESULTS: Ninety-nine patients met the inclusion criteria, of whom 65 (66%) suffered from Graves' disease, 25 (25%) from toxic goiters and 9 (9%) from amiodarone-induced hyperthyroidism. Structural abnormalities of the thyroid (39 patients, 39%) represented the most frequent indications for thyroidectomy. Forty-six patients (46%) underwent an early and 53 (54%) a delayed surgical approach. Patients with Graves' disease undergoing early thyroidectomy did not suffer more often from complications but had a significantly faster biochemical recovery after surgery than those with a delayed thyroidectomy, as judged by a shorter time to reach TSH (121 ± 24 vs. 240 ± 31 days, p = 0.007) and fT4 (91 ± 29 vs. 183 ± 31 days p = 0.015) levels in the normal range. As expected, there were no recurrences of hyperthyroidism. CONCLUSIONS: Early thyroidectomy was neither associated with permanent complications nor thyroid storm, but with a significantly improved biochemical recovery and therefore has to be recommended early in patients with Graves' disease.

Delayed diagnosis of sinonasal lymphoma due to bilateral manifestation.

The objective of this study is to analyze the presenting symptoms, the time to correct diagnosis and outcome of a European patient cohort with sinonasal lymphoma focusing on unilateral vs. bilateral sinonasal involvement. In a retrospective setting in a European tertiary referral center, eleven patients (9 males, 2 females) with sinonasal lymphoma diagnosed between 2002 and 2015 were identified and divided into a unilateral and bilateral group according to their CT finding. Clinical findings on first presentation, the presence of B symptoms, the radiologic findings, overall survival and disease-specific survival were assessed. 55 % of the patients suffered from bilateral manifestation, which was associated with a delayed diagnosis (10 vs. 1.5 months, p < 0.05). B symptoms (67 vs. 0 %) and death of disease (50 vs. 0 %) were observed only in the bilateral group. Nasal NK/T-cell lymphoma was the most frequent diagnosis, followed by diffuse large B-cell lymphoma. Bilateral mucosal manifestation with B symptoms was shown to be common within the rare entity of sinonasal lymphomas and patients with bilateral sinonasal manifestation are at risk for a delayed diagnosis with worse outcome.

Detection of Helicobacter pylori in patients with head and neck cancer: Results from a prospective comparative study combining serology, polymerase chain reaction, and rapid urease test.

BACKGROUND: The purpose of this study was to evaluate prospectively the presence and impact of the gastric carcinogen Helicobacter pylori (H. pylori) in the upper aerodigestive tract. Previous studies suggested it could represent a risk factor for head and neck squamous cell carcinoma (HNSCC). METHODS: Serology, rapid urease test, and quantitative polymerase chain reaction (qPCR) for H. pylori were performed in patients with head and neck cancer (N = 56) and cancer-free controls (N = 90). Comparison between groups was done using logistic regression analysis. RESULTS: Rates of positive serology and rapid urease test did not differ between the 2 groups in logistic regression analysis (p = .677 and p = .633, respectively). Birth in a developing country and age above 50 years old were predictors of positive serology (p < .001 and p = .040, respectively). Using qPCR, no biopsy showed the presence of H. pylori. CONCLUSION: This study challenges the concept that H. pylori may be a risk factor for HNSCC.

Perineural Invasion in Squamous Cell Carcinoma of the Oral Cavity: Histology, Tumor Stage, and Outcome.

OBJECTIVES/HYPOTHESIS: To analyze the impact of different types of perineural invasion (PNI) in squamous cell carcinoma (SCC) of the oral cavity on overall survival and recurrence rate, with a special focus on histologic subtypes and tumor stage. STUDY DESIGN: Retrospective case-control study with clinicopathological analysis. METHODS: Seventeen patients who received primary surgical treatment for SCC of the oral cavity with PNI were matched to a control group. In a histologic review, PNI was classified into subtypes according to an adapted Liebig classification. The term type A was used to describe tumor invasion into the nerve, whereas type B was used to describe circumferential growth around the nerve. Clinical charts were reviewed, and a Kaplan-Meier survival analysis was performed. RESULTS: The recurrence-free survival rates were 47.1% versus 80.4% (PNI vs. matched control group, P < 0.05), 60.0% versus 94.1% (PNI in stage I and II disease vs. matched control group, P < 0.05) and 41.7% versus 73.5% (PNI in stage III and IV disease vs. matched control group, P < 0.05). In most cases (n = 9) of PNI, both histologic subtypes (type A and type B) were present. Five cases exclusively showed type A, and three cases exclusively showed type B. CONCLUSIONS: Perineural invasion in early disease oral carcinoma has a particularly high impact on survival. Both histologic subtypes showed a significantly worse recurrence-free survival rate when compared to the control group. LEVEL OF EVIDENCE: 3.

Objective assessment of stapedotomy surgery from round window motion measurement.

OBJECTIVES: As prostheses and techniques related to stapes surgery develop and improve, there is a need to assess the functional outcomes of the surgery objectively. This study provides a bench test method to assess the functional results of stapes surgery by measuring volume displacement at the round window (RW), which is closely related to pressure propagation of the travelling wave inside the cochlea and thus to hearing. DESIGN: Motion of the RW membrane in fresh temporal bones was measured using a scanning laser Doppler interferometry system for normal and reconstructed conditions, and the performance of the reconstruction with stapes surgery was quantitatively assessed by comparison of the volume displacements at the RW between the two conditions. To obtain optimal measurements, reflectivity of the laser beam of the scanning laser Doppler interferometry system was improved by retroreflective beads coated onto the surface of the RW, and orientation of the RW membrane relative to the laser beam was obtained using micro-computed tomography imaging. RESULTS: From measurements in 12 temporal bones, difference in the RW volume displacement between normal ears and ears reconstructed with stapes surgery was approximately 15 dB below 2 kHz and approximately 10 dB above 4 kHz, which was comparable with air-bone gaps in patients after stapes surgery. Two different sizes of the stapes prostheses were also tested (n = 3), and a tendency toward a better outcome with a larger diameter was found. CONCLUSION: The method developed in this study can be used to assess various prostheses and surgical conditions objectively in controlled laboratory environments. It may also have potential for providing ways to assess other middle- and inner-ear surgeries, and to study other aspects of hearing science.

The influence of prosthesis diameter in stapes surgery: a meta-analysis and systematic review of the literature.

OBJECTIVE: To analyze the influence of stapes prosthesis diameter on postoperative hearing results after stapedotomy without interposition in otosclerotic patients. DATA SOURCES: PubMed search from 1970 to 2009 using the key words stapedotomy or stapedectomy or otosclerosis or stapesplasty. STUDY SELECTION: Inclusion criteria to select articles and patient groups for meta-analysis and statistical analyses were as follows: otosclerosis as diagnosis, clear description of technique and prosthesis size, calibrated stapedotomy, and complete report of functional results. DATA EXTRACTION: Five controlled studies were found analyzing the influence of prosthesis diameter and reporting the results in a comparable way for meta-analysis (n = 590). Sixty-two studies not analyzing the influence of prosthesis diameter contained comparable subgroups with a total of 9,536 cases. These cases were pooled according to their diameter (0.3, 0.4, 0.5, 0.6,and 0.8 mm). The results of air conduction, bone conduction, air-bone gap (ABG), and success rate (closure of the ABG within 10 dB as percentage of the total cases) for all groups and frequency-specific ABG results were gathered. Furthermore, 12 clinical and experimental studies were reviewed that did not contribute to the statistical analysis. DATA SYNTHESIS: A meta-analysis performed for success rate of the 5 controlled studies showed favorable results for 0.6-mm over 0.4-mm prostheses (success rate, 67% versus 58%, p = 0.05). In the statistical analysis of the pooled data, the 0.6-mm prosthesis showed better results compared with 0.4 mm (p < 0.001) in the postoperative air conduction threshold (29 dB versus 35 dB), postoperative ABG (7 dB versus 11 dB), ABG improvement (25 dB versus 21 dB), and success rate (81.1% versus 75.1%). The frequency-specific analysis of the postoperative ABG showed no advantage for the small prosthesis in the high frequencies. There was no difference in postoperative change of bone conduction in the 0.6- and 0.4-mm groups. Statistically significant results could not be assessed for other prosthesis diameters because of the small number of cases reported. CONCLUSION: A 0.6-mm diameter piston prosthesis is associated with significantly better results than a 0.4-mm prosthesis and should be used if the surgical conditions allow it.