Cost-comparison analysis of diffusion weighted magnetic resonance imaging (DWMRI) versus second look surgery for the detection of residual and recurrent cholesteatoma.

BACKGROUND: Cholesteatoma is a destructive, erosive growth of keratinizing squamous epithelium in the middle ear cleft. Following treatment with a canal wall-up (CWU) tympanomastoidectomy, surveillance of residual and recurrent disease has traditionally been achieved through a second look tympanotomy following the initial procedure. Historically, MRI sequences have been inadequate at differentiating between granulation tissue, inflammation, and cholesteatoma. Recent literature has shown diffusion-weighted magnetic resonance imaging (DWMRI) to be a viable alternative to second look surgery for the detection of residual or recurrent disease. The goal of the present study was to perform a cost analysis of DWIMRI versus second look surgery in the detection of residual or recurrent cholesteatoma following combined approach tympanomastoidectomy. METHODS: A probabilistic decision tree model was generated from a literature review to compare traditional second look surgery with DWMRI. Cost inputs were obtained from the Ontario Case Costing Initiative, the Ontario Health Insurance Plan (OHIP) schedule of benefits. Costs were reported in Canadian dollars and a payer perspective was adopted. A probabilistic sensitivity analysis was performed. RESULTS: According to the probabilistic sensitivity analysis, mean cost difference of traditional second look tympanotomy versus echo planar imaging (EPI) DWMRI was $180.27CAD, 95%CI [$177.32, $188,32] in favour of second-look tympanotomy. However, mean cost difference of traditional second look tympanotomy versus non-EPI DWMRI was $390.66CAD, 95%CI [$381.52, $399.80] in favour of non-EPI DWMRI. CONCLUSIONS: Diffusion-weighted MRI, specifically non-EPI sequences, are a viable cost-saving alternative to second-look tympanotomy in the setting of detecting residual or recurrent cholesteatoma.

Diagnostic accuracy of intra-operative assessment of de-epithelisation of the malleus by the surgeon in type 1 tympanoplasty compared to histopathological examination.

OBJECTIVE: This study was undertaken to determine the accuracy of the surgeon's assessment in detecting epithelial remnants over the malleus after de-epithelisation in tympanoplasty. METHODS: Intra-operatively, the umbo was assessed for epithelial remnants with the microscope. The umbo was then resected and sent for histopathological examination to detect epithelial remnants. RESULTS: Out of 42 cases, microscopic examination findings for epithelium were positive in 16 cases and negative in 26 cases. Histopathology findings were positive in 13 cases. The surgeons' assessment was accurate only in two cases. CONCLUSION: Residents, with their limited experience, are more likely to leave residual epithelium. When the chance of residual epithelium over the umbo is significant, the surgeon has two choices: to place the graft medial to the umbo or to resect the umbo. It is our opinion that the malleus exteriorisation should be incorporated into tympanoplasty training, with the aim of preventing epithelial entrapment in the middle ear.

Direct cost comparison of totally endoscopic versus open ear surgery.

OBJECTIVE: Totally endoscopic ear surgery is a relatively new method for managing chronic ear disease. This study aimed to test the null hypothesis that open and endoscopic approaches have similar direct costs for the management of attic cholesteatoma, from an Australian private hospital setting. METHODS: A retrospective direct cost comparison of totally endoscopic ear surgery and traditional canal wall up mastoidectomy for the management of attic cholesteatoma in a private tertiary setting was undertaken. Indirect and future costs were excluded. A direct cost comparison of anaesthetic setup and resources, operative setup and resources, and surgical time was performed between the two techniques. RESULTS: Totally endoscopic ear surgery has a mean direct cost reduction of AUD$2978.89 per operation from the hospital perspective, when compared to canal wall up mastoidectomy. CONCLUSION: Totally endoscopic ear surgery is more cost-effective, from an Australian private hospital perspective, than canal wall up mastoidectomy for attic cholesteatoma.

Therapeutic Mastoidectomy in the Management of Noncholesteatomatous Chronic Otitis Media: Literature Review and Cost Analysis.

OBJECTIVE: Despite evidence that therapeutic mastoidectomy does not improve outcomes in noncholesteatomatous chronic otitis media, it remains widely performed. An up-to-date systematic review is undertaken and conclusions drawn regarding the best evidence-based practice of its management. DATA SOURCES: PubMed, Google Scholar, Medline Embase, Cochrane, and Web of Science. REVIEW METHOD: A combination of the following words was used: chronic otitis media, chronic suppurative otitis media, COM, CSOM, mastoidectomy, tympanoplasty, atelectasis, retraction, tympanic perforation, and therapeutic. RESULTS: From 1742 studies, 7 were selected for full analysis with respect to the benefit of mastoidectomy in the management of active and inactive mucosal chronic otitis media. Most were retrospective studies, with 1 prospective randomized controlled trial available. Overall, there was no evidence to support routine mastoidectomy in conjunction with tympanoplasty in chronic otitis media. For ears with sclerotic mastoids, the evidence suggested that there may be some benefit as a staged procedure. Two studies were analyzed for the benefit of mastoidectomy in addition to tympanoplasty for the management of the atelectatic ear (inactive squamous chronic otitis media). The conclusion was also that mastoidectomy added no benefit. CONCLUSIONS: Examination of the available literature supports the notion that therapeutic mastoidectomy does not lend any additional benefit to the management of noncholesteatomatous chronic otitis media. This has implications for patient care, both clinically and financially. Further research, ideally in the form of a prospective, multi-institutional, geographically wide, ethnically diverse, randomized controlled trial, is needed to further support this notion.

Hearing loss assessment in primary and secondary acquired cholesteatoma, / Potenciais evocados auditivos de longa latência com verbais e não verbais

ABSTRACT INTRODUCTION: Acquired middle ear cholesteatoma can be classified as primary or secondary. Although both can result in hearing loss, it is still controversial whether there is an association between the type of cholesteatoma and the degree of hearing loss. OBJECTIVE: To analyze the association between hearing loss and the type of acquired cholesteatoma, and the status of the ossicular chain. METHODS: This was a cross-sectional historical cohort study involving patients diagnosed with acquired cholesteatoma who were surgically treated. Air and bone conduction thresholds, air-bone gaps and the status of the ossicular chain were analyzed for both types of cholesteatoma. RESULTS: Eighty patients aged 5-57 were included in the study. Fifty-one patients had primary cholesteatoma and 29 had secondary cholesteatoma. Both types of cholesteatoma determined greater air-bone gaps at 0.5 kHz. Secondary cholesteatoma determined greater hearing loss in all analyzed frequencies and higher air conduction and air-bone gap means. CONCLUSION: There was association between hearing loss and the type of cholesteatoma. Secondary cholesteatoma resulted in greater hearing impairment.

RESUMO INTRODUÇÃO: O colesteatoma adquirido de orelha média pode ser classificado como primário e secundário. Ambos podem ocasionar perda de audição, mas ainda há controvérsia quanto à relação dos tipos de colesteatoma com a perda auditiva. OBJETIVO: Analisar a relação dos tipos de colesteatoma e da erosão da cadeia ossicular com a perda auditiva. MÉTODO: Estudo de coorte histórica com corte transversal, envolvendo pacientes que receberam o diagnóstico de colesteatoma adquirido e foram submetidos à cirurgia otológica. Foram analisados os limiares ósseos, aéreos e a diferença aéreo-óssea, e suas associações com os tipos de colesteatoma e com a presença de erosão na cadeia ossicular. RESULTADOS: No estudo foram incluídos oitenta pacientes, com idade entre 5 e 57 anos, sendo 51 com colesteatoma primário e 29 com colesteatoma secundário. Ambos os tipos de colesteatoma determinaram maior diferença aéreo-óssea na frequência de 0,5 kHz. O colesteatoma secundário determinou uma perda auditiva maior em todas as frequências analisadas, e maiores médias do limiar aéreo e da diferença aéreo-óssea. CONCLUSÃO: Houve associação entre o tipo de colesteatoma e a perda de audição. O colesteatoma secundário determinou maior comprometimento da audição.

Hearing loss assessment in primary and secondary acquired cholesteatoma.

INTRODUCTION: Acquired middle ear cholesteatoma can be classified as primary or secondary. Although both can result in hearing loss, it is still controversial whether there is an association between the type of cholesteatoma and the degree of hearing loss. OBJECTIVE: To analyze the association between hearing loss and the type of acquired cholesteatoma, and the status of the ossicular chain. METHODS: This was a cross-sectional historical cohort study involving patients diagnosed with acquired cholesteatoma who were surgically treated. Air and bone conduction thresholds, air-bone gaps and the status of the ossicular chain were analyzed for both types of cholesteatoma. RESULTS: Eighty patients aged 5-57 were included in the study. Fifty-one patients had primary cholesteatoma and 29 had secondary cholesteatoma. Both types of cholesteatoma determined greater air-bone gaps at 0.5kHz. Secondary cholesteatoma determined greater hearing loss in all analyzed frequencies and higher air conduction and air-bone gap means. CONCLUSION: There was association between hearing loss and the type of cholesteatoma. Secondary cholesteatoma resulted in greater hearing impairment.

Residual cholesteatoma: prevalence and location. Follow-up strategy in adults.

OBJECTIVES: To assess prevalence and location of residual cholesteatoma following closed "canal wall up" tympanoplasty (CWUT). The evolution of follow-up strategy is discussed. PATIENTS AND METHODS: A retrospective study was run in adults operated on by CWUT for middle-ear cholesteatoma and who had undergone second look surgery and/or postoperative radiology (CT-scan, diffusion-weighted MRI). RESULTS: One hundred and nine patients (113 ears) underwent the procedure. Mean follow-up was 48 months (range, 24-96 months). Twenty-nine residual cholesteatomas were found (25%), including 11 located in the anterior attic (38%). Follow-up included 77 second look operations (70%), and 71 radiological examinations (62 CT-scans and nine diffusion-weighted MRIs). Second look surgery was without benefit for the patient (no residual, no ossiculoplasty) in one third of cases. CONCLUSION: Residual cholesteatoma in the anterior attic is a problem in CWUT. When postoperative auditory results are good, second look surgery should not be systematic but guided by high quality imaging.

A systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma.

OBJECTIVE: A systematic review to determine whether the diffusion-weighted (DW) magnetic resonance imaging scan can reliably detect residual or recurrent cholesteatoma after mastoid surgery. DESIGN: A systematic review. DATA SOURCES: Databases including EMBASE, MEDLINE, CINAHL, Web of Science, and Cochrane Review were searched for studies published without language restriction from the start of the databases. Additional studies were identified from cited references. SELECTION CRITERIA: Initial search identified 402 publications, of which 16 studies met the inclusion criteria for the systematic review. The DW imaging (DWI) scan was used to detect residual or recurrent cholesteatoma and subsequent second-look surgery was performed to correlate the findings. REVIEW METHODS: Studies were assessed for their selection of patients for radiologic investigations, imaging parameters, and subsequent surgery. Outcome measures included sensitivity, specificity, positive and negative predictive values of the DWI, and the incidence and size of residual or recurrent cholesteatoma. RESULTS: Two different modalities of DWI sequences have been described. Eight studies with 225 patients analyzed echo-planar imaging (EPI) and 8 studies with 207 patients described the "non-EPI" scanning techniques. Non-EPI parameters are more reliable in identifying residual or recurrent cholesteatoma with sensitivity, specificity, and positive and negative predictive values of 91%, 96%, 97%, and 85%, respectively. CONCLUSION: The available evidence suggests that non-EPI such as half-Fourier acquisition single-shot turbo spin echo sequences are more reliable in identifying residual or recurrent cholesteatoma. This is a promising radiologic investigation; however, we think further studies are required with more patients and long-term results to establish its place as an alternative to a second-stage surgery after canal wall up surgery.

Cholesteatoma imaging using modified echo-planar diffusion-weighted magnetic resonance imaging.

INTRODUCTION: Imaging of cholesteatomas can be useful especially in cases of recurrent disease. Computed tomography scans have been recommended before primary surgery, but cholesteatoma tissue looks similar to inflammatory tissue. Diffusion-weighted magnetic resonance imaging is both sensitive and specific in detecting cholesteatoma, which appears as a bright signal on a dark background. Non-echo-planar diffusion-weighted magnetic resonance imaging is superior to routine echo-planar diffusion-weighted magnetic resonance imaging as it minimises susceptibility artefacts; however, the addition of this facility involves expensive magnetic resonance scanner upgrading. METHOD: To avoid the cost of such upgrading, we modified our echo-planar diffusion-weighted magnetic resonance imaging parameters and then scanned 15 consecutive cases of suspected cholesteatoma or suspected recurrent cholesteatoma. RESULTS: Imaging results correlated well with clinical and/or operative findings. CONCLUSION: These results indicate that software adjustments can enable echo-planar diffusion-weighted magnetic resonance imaging to detect cholesteatomas reliably, and as effectively as non-echo-planar diffusion-weighted magnetic resonance imaging. This discovery has the potential to facilitate reliable delayed post-operative screening of canal wall up mastoidectomies, avoiding the need for a 'second look' procedure.

Quality-of-life assessment after primary and revision ear surgery using the chronic ear survey.

OBJECTIVE: To measure subjective outcomes after primary and revision surgery for chronic ear disease. DESIGN: Prospective questionnaire-based outcome study. SETTING: Tertiary referral center. PATIENTS: Adults with chronic otitis media with or without cholesteatoma. INTERVENTIONS: Primary or revision surgery for chronic ear disease. MAIN OUTCOME MEASURES: The Chronic Ear Survey, a disease-specific outcome survey, was administered preoperatively and at 1 year after surgery. We analyzed the total score and the activity restriction, symptom, and medical resource utilization subscale scores. Scores were averaged on the basis of the number of questions included in each category. Differences in preoperative and postoperative scores were analyzed within and between the 2 groups. We also assessed audiometry, postoperative complications, and the clinical condition of the operated-on ear. RESULTS: Twenty-one patients were enrolled in the primary surgery group, and 20 were enrolled in the revision surgery group. Significant improvements in the total score and each subscale score were observed in both groups at the 1-year postoperative survey. Improvements in the total score and symptom subscale scores were greater in the primary surgery group than in the revision surgery group (P < .05). The air conduction thresholds and any postoperative clinical problems were correlated with the total score and subscale scores in the primary group but not in the revision surgery group. CONCLUSION: Comparable objective outcomes are achieved after primary and revision surgery for chronic ear disease, but the improvement in quality of life is greater in the primary surgery group.

Contemporary assessment and management of congenital cholesteatoma.

PURPOSE OF REVIEW: Only 2-4% of cholesteatomas presenting to pediatric otologists are congenital in origin. Disease severity can range from intratympanic pearls to middle ear and mastoid obliteration. Recently, highlighted variations of this rare disorder warrant a systematic approach to disease assessment and surgical decision making. This review provides a comprehensive method to diagnose and manage congenital cholesteatoma based on current literature. RECENT FINDINGS: The holding theory of the origin of congenital cholesteatomas is that they arise from retained epithelial cell rest. Primary development can vary among sites within the middle ear and mastoid. 'Open' and 'closed' varieties have been proposed. However, disease severity depends on location, patient age, ossicular integrity, and number of anatomic sites involved. These variables have inspired the development of staging systems whereby appropriate surgical approaches can be designed. Computed tomography (CT) scans are necessary and continue to be the best radiographic tool for surgical planning. Over 30% of congenital cholesteatomas can be extirpated through a transcanal approach. Involvement of the posterior quadrant, over three anatomic subsites, or the mastoid cavity obligates standard canal wall-up techniques. Canal wall-down procedures are rarely required. SUMMARY: Congenital cholesteatomas frequently extend beyond the typically described anterosuperior location of the middle ear. Ossicular destruction, mastoid infiltration, and tympanic membrane rupture are encountered more frequently than previously thought. Advanced disease predominately occurs in older children and requires sophisticated assessment and surgical planning beyond removing a simple keratin cyst.