Estimated Costs Associated With Management of Otosclerosis With Hearing Aids vs Surgery in Europe.

Importance: Surgery and hearing aids have similar outcomes in terms of hearing acuity but differ in terms of cost, aesthetics, and patient quality of life. The cost-effectiveness and budget impact of otosclerosis treatments have never been studied in Europe. Objectives: To compare the estimated mean costs per patient over 10 years of surgery vs hearing aids for the treatment of otosclerosis and to estimate the budget impact of an increase in the proportion of patients receiving surgical treatment. Design, Setting, and Participants: This economic evaluation analyzed French and European epidemiological data on the surgical management of symptomatic otosclerosis and compared them with data from the literature to build economic models. The analysis was conducted in January 2021. Exposures: Two care pathways were considered in the treatment of otosclerosis, either hearing aid or surgery. Main Outcomes and Measures: Costs were studied over 10 years using Markov models of the 2 care pathways (hearing aid vs surgery). The budget impact analysis was performed over 5 and 10 years, assuming a 1-percentage point yearly increase in the proportion of patients receiving surgical treatment. Results: Over 10 years, the estimated mean cost per patient was significantly lower in the surgery group compared with the hearing aid group (€3446.9 vs €6088.4; mean difference, -€2641.5; 95% CI -€4064.8 to -€1379.4 [US $3913.4 vs US $6912.4; mean difference, -US $2999.0; 95% CI, -US $4614.9 to -US $1566.1]). Increasing surgical treatment by 1 percentage point per year for 10 years would lead to overall savings of €1 762 304 (US $2 000 798) in France, with an increase of €1 322 920 (US $1 501 952) at 10 years for the public health insurance system and a decrease of €3 085 224 (US $3 502 750) at 10 years for patients and private health insurers. Sensitivity analyses showed that these results were robust. Conclusions and Relevance: These results suggest that in France, treating otosclerosis surgically is slightly less expensive over 10 years than using hearing aids, when considering all payers. The proposed models developed in this study could be adjusted to perform the same analysis in other countries.

Anaesthesia for ear surgery in remote or resource-constrained environments.

BACKGROUND: The successful provision of middle-ear surgery requires appropriate anaesthesia. This may take the form of local or general anaesthesia; both methods have their advantages and disadvantages. Local anaesthesia is simple to administer and does not require the additional personnel required for general anaesthesia. In the low-resource setting, it can provide a very safe and effective means of allowing middle-ear surgery to be successfully completed. However, some middle-ear surgery is too complex to consider performing under local anaesthesia and here general anaesthesia will be required. CONCLUSION: This article highlights considerations for performing middle-ear surgery in a safe manner when the available resources may be more limited than those expected in high-income settings. There are situations where local anaesthesia with sedation may prove a useful compromise of the two techniques.

Clinical and cost utility of an intraoperative endoscopic second look in cholesteatoma surgery.

OBJECTIVE/HYPOTHESIS: This study aimed to determine the clinical and cost-effectiveness of endoscopes during cholesteatoma surgery. More specifically, this study hypothesized that endoscope use would reduce cholesteatoma recurrence rates and cost. STUDY DESIGN: Case series involving the prospective enrollment of 110 consecutive cholesteatoma patients over a 2-year period. METHODS: Patients underwent cholesteatoma surgery with microscopy. During dissection, the location of the cholesteatoma was assessed. At the end of dissection and before reconstruction, the same subunits were visualized with straight and angled endoscopes for residual cholesteatoma. Hearing was analyzed before surgery and at the last possible examination. Costs were analyzed using Medicare reimbursement rates from the Centers for Medicare and Medicaid Services. RESULTS: Intraoperative endoscopic surveillance was able to detect residual cholesteatoma in 18 patients. With a 0° endoscope, residual cholesteatoma was noted in the epitympanum (two patients), sinus tympani (one patient), and the supratubal air cells (one patient). With a 45° endoscope, residual cholesteatoma was noted in the epitympanum (three patients), sinus tympani (nine patients), the supratubal air cells (two patients), and the mesotympanum (two patients). From a cost analysis, endoscopic surveillance ($6110.36 per patient) are less expensive than second look surgeries ($11,829.83 per patient), observation ($7097.20 per patient), and observation with annual magnetic resonance imaging studies ($9891.95 per patient). The patients hearing improved after surgery, consistent with previous studies. No complications were noted from the use of endoscopes. CONCLUSIONS: Intraoperative endoscopic surveillance reduced recurrence in our series of 110 patients. Endoscopes are particularly useful in evaluating the epitympanum, mesotympanum, sinus tympani, and supratubal air cells. Moreover, endoscopic surveillance is cost-effective. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2867-2871, 2018.

Ear, nose, and throat surgical access for remote living Indigenous children: What is the least costly model?

RATIONALE, AIMS, AND OBJECTIVES: This costing evaluation compares three service delivery models for ear, nose, and throat (ENT) surgery for remote living Indigenous children to improve their hearing outcomes, with the aim to identify the least costly model. METHODS: The main outcome measure presented was the incremental cost difference between the base case (Model 1) and two alternative models (Model 2, 3). The costs in 2017 Australian dollars are assessed from two viewpoints: (1) health system perspective, and (2) patients and their families including travel out-of-pocket expenses, presented separately according to the funding source. RESULTS: Findings indicate that the least costly model offered low-risk ENT surgery from a state funded hospital in a remote setting, with high use of videoconference technology: TeleHealth (Model 3) could save $3626 to $5067 per patient, compared with patients travelling to a regional centre public hospital (Model 1). A federally funded scheme which allowed groups of patients to access a direct flight charter transfer to the private hospital in regional centre (Model 2) reduced the cost by $2178 to $2711 per patient when compared with standard care (Model 1). From a societal perspective, Model 1 required out-of-pocket patient expenses, with greater time away from home, and hence appears the least preferred option. CONCLUSIONS: The sensitivity analyses also demonstrate that Model 3 would be the more economical model for providing ENT surgery for remote living children. By proving an accurate assessment of the true costs of delivering these important ear and hearing health services, strategic health service planners may be better informed and sufficient budgets can be allocated to provide improved service delivery. The benefits of Model 3, over Models 1 or 2, would also incorporate improvements to patient safety as a result of reducing patient travel, which should in-turn, reduce failure-to-attend rates.

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.

Minimally Invasive Ponto Surgery compared to the linear incision technique without soft tissue reduction for bone conduction hearing implants: study protocol for a randomized controlled trial.

BACKGROUND: Over the last years, less invasive surgical techniques with soft tissue preservation for bone conduction hearing implants (BCHI) have been introduced such as the linear incision technique combined with a punch. Results using this technique seem favorable in terms of rate of peri-abutment dermatitis (PAD), esthetics, and preservation of skin sensibility. Recently, a new standardized surgical technique for BCHI placement, the Minimally Invasive Ponto Surgery (MIPS) technique has been developed by Oticon Medical AB (Askim, Sweden). This technique aims to standardize surgery by using a novel surgical instrumentation kit and minimize soft tissue trauma. METHODS: A multicenter randomized controlled trial is designed to compare the MIPS technique to the linear incision technique with soft tissue preservation. The primary investigation center is Maastricht University Medical Center. Sixty-two participants will be included with a 2-year follow-up period. Parameters are introduced to quantify factors such as loss of skin sensibility, dehiscence of the skin next to the abutment, skin overgrowth, and cosmetic results. A new type of sampling method is incorporated to aid in the estimation of complications. To gain further understanding of PAD, swabs and skin biopsies are collected during follow-up visits for evaluation of the bacterial profile and inflammatory cytokine expression. The primary objective of the study is to compare the incidence of PAD during the first 3 months after BCHI placement. Secondary objectives include the assessment of parameters related to surgery, wound healing, pain, loss of sensibility of the skin around the implant, implant extrusion rate, implant stability measurements, dehiscence of the skin next to the abutment, and esthetic appeal. Tertiary objectives include assessment of other factors related to PAD and a health economic evaluation. DISCUSSION: This is the first trial to compare the recently developed MIPS technique to the linear incision technique with soft tissue preservation for BCHI surgery. Newly introduced parameters and sampling method will aid in the prediction of results and complications after BCHI placement. TRIAL REGISTRATION: Registered at the CCMO register in the Netherlands on 24 November 2014: NL50072.068.14 . Retrospectively registered on 21 April 2015 at ClinicalTrials.gov: NCT02438618 . This trial is sponsored by Oticon Medical AB.

The economic impact of revision otologic surgery.

Revision otologic surgery places a significant economic burden on patients and the healthcare system. We conducted a retrospective chart analysis to estimate the economic impact of revision canal-wall-down (CWD) mastoidectomy. We reviewed the medical records of all 189 adults who had undergone CWD mastoidectomy performed by the senior author between June 2006 and August 2011 at Loyola University Medical Center in Maywood, Ill. Institutional charges and collections for all patients were extrapolated to estimate the overall healthcare cost of revision surgery in Illinois and at the national level. Of the 189 CWD mastoidectomies, 89 were primary and 100 were revision procedures. The total charge for the revision cases was $2,783,700, and the net reimbursement (collections) was $846,289 (30.4%). Using Illinois Hospital Association data, we estimated that reimbursement for 387 revision CWD mastoidectomies that had been performed in fiscal year 2011 was nearly $3.3 million. By extrapolating our data to the national level, we estimated that 9,214 patients underwent revision CWD mastoidectomy in the United States during 2011, which cost the national healthcare system roughly $76 million, not including lost wages and productivity. Known causes of failed CWD mastoidectomies that often result in revision surgery include an inadequate meatoplasty, a facial ridge that is too high, residual diseased air cells, and recurrent cholesteatoma. A better understanding of these factors can reduce the need for revision surgery, which could have a positive impact on the economic strain related to this procedure at the local, state, and national levels.

Retrosigmoid versus translabyrinthine approach to acoustic neuroma resection: A comparative cost-effectiveness analysis.

OBJECTIVES/HYPOTHESIS: Approach-specific economic data of acoustic neuroma (AN) resection is lacking. The purpose of this study was to analyze and compare adjusted total hospital costs, hospital and intensive care unit (ICU) length of stay (LOS), and associated factors in AN patients undergoing resection by translabyrinthine (TL) approach versus retrosigmoid (RS) approach. STUDY DESIGN: Retrospective chart review. METHODS: A total of 113 patients with AN undergoing TL (N = 43) or RS (N = 70) surgical resection between 1999 and 2012 were analyzed. Data including age, health status, preoperative hearing, tumor size, postoperative complications, hospital, ICU LOS, and disposition after discharge were collected from medical records and compared between both groups. Cost data was obtained from the hospital finance department and adjusted based on the Consumer Price Index for 2013. RESULTS: There were no significant differences in demographic data, preoperative hearing, preoperative health status, or postoperative complication rate. Total hospital LOS and ICU LOS were significantly longer in the RS compared to the TL group (4.3 ± 3.6 vs. 2.6 ± 1.1 days; P < 0.001, and 1.5 ± 1.1 vs. 1.0 ± 0.5 days; P = 0.015, respectively). Tumors were larger in RS compared to the TL group (2.1 ± 1.0 cm vs. 1.5 ± 0.7 cm, respectively; P = 0.002). When patients were stratified by tumor size < or ≥ 2 cm, the total hospital LOS remained greater in the RS group in both subgroups (< and ≥ 2 cm, P < 0.001, and P = 0.031, respectively). However, there was no difference in the total ICU LOS between both subgroups. The adjusted mean total hospital cost was higher in the RS compared to the TL group ($25,069 ± 14,968 vs. $16,799 ± 5,724; P < 0.001). The adjusted mean total hospital cost was greater in the RS group with tumor < 2 cm (P < 0.001) but not significantly different in patients with tumors ≥ 2 cm. Univariate analysis showed that greater tumor size, poorer preoperative health status, the presence of major postoperative complications, and the RS approach were independently significantly associated with higher total hospital LOS (P = 0.001, P = 0.009, P = 0.001, and P < 0.001, respectively) and a higher adjusted total hospital cost (P < 0.001, P = 0.002, P = 0.014, and P < 0.001, respectively). CONCLUSION: Hospital LOS and total adjusted costs are significantly less for patients undergoing translabyrinthine acoustic neuroma resection compared to the retrosigmoid approach. Many factors appear to influence these differences. Economic considerations in addition to tumor characteristics and surgeon preference should be considered in future acoustic neuroma resections. LEVEL OF EVIDENCE: 2c.

A break-even analysis of major ear surgery.

OBJECTIVES: To determine variables which affect cost and profit for major ear surgery and perform a break-even analysis. DESIGN: Retrospective financial analysis. SETTING: UK teaching hospital. PARTICIPANTS: Patients who underwent major ear surgery under general anaesthesia performed by the senior author in main theatre over a 2-year period between dates of 07 September 2010 and 07 September 2012. MAIN OUTCOME MEASURES: Income, cost and profit for each major ear patient spell. Variables that affect major ear surgery profitability. RESULTS: Seventy-six patients met inclusion criteria. Wide variation in earnings, with a median net loss of £-1345.50 was observed. Income was relatively uniform across all patient spells; however, theatre time of major ear surgery at a cost of £953.24 per hour varied between patients and was the main determinant of cost and profit for the patient spell. Bivariate linear regression of earnings on theatre time identified 94% of variation in earnings was due to variation in theatre time (r = -0.969; P < 0.0001) and derived a break-even time for major ear surgery of 110.6 min. Theatre time was dependent on complexity of procedure and number of OPCS4 procedures performed, with a significant increase in theatre time when three or more procedures were performed during major ear surgery (P = 0.015). CONCLUSION: For major ear surgery to either break-even or return a profit, total theatre time should not exceed 110 min and 36 s.

How we do it: the absorbable gelatin sponge cube, an effective and economical approach to packing in ear surgery.

INTRODUCTION: There is currently a lack of robust evidence on the best form of packing for otological surgery. We describe the use of the absorbable gelatin sponge, a packing material that does not require removal and has the benefit of being considerably cheaper compared to other common forms of ear packing. METHODS: A comparison was made of the financial cost of several forms of packing for common otological procedures. In addition, a retrospective audit of complications was undertaken of all patients in whom the absorbable gelatin sponge was used over the past three years. RESULTS: The absorbable gelatin sponge was shown to be cheaper to purchase per unit and also more economical to use. It has been the exclusive form of packing used in 519 procedures over the past three years at the William Harvey Hospital in Ashford (UK), with very few complications noted at the follow-up review. CONCLUSION: We strongly advocate using the absorbable gelatin sponge, a packing material that is kinder to the patient, has similar efficacy to other forms of packing and is also much cheaper to use compared to other common forms of packing.

Malpractice in otology.

OBJECTIVE: (1) Analyze otologic procedural malpractice litigation in the United States of America. (2) Discuss ways to prevent future malpractice litigation. STUDY DESIGN AND SETTING: Case series with record review. METHODS: The study is a case series with review of court records pertaining to otologic procedures using the Westlaw legal database. The phrase medical malpractice was searched with terms related to otology and neurotology obtained from the AAO-HNS website. RESULTS: Of the 47 claims that met inclusion criteria, 63.8% were decided in the physician's favor, 25.5% were decided in the plaintiff's favor (average payment $446,697), and 10.6% were settled out of court (average payment $372,607). Cerumen removal was the most common procedure leading to complaint (21.3%) and the most likely procedure to lead to payment (50.0%). Hearing loss was the most common injury claimed among all cases (53.2%) and resulted in a high proportion of cases that led to payment (40.0%). Other common alleged injuries were facial nerve injury (27.7%), tympanic membrane perforation (23.4%), need for additional surgery (42.6%), and lack of informed consent (31.9%). In addition, cases resulting from acoustic neuroma or stapedectomy resulted in higher payments to the plaintiffs (average $3,498,597 and $2,733,000, respectively). CONCLUSIONS: Malpractice trials were resolved in the defendant's favor in the majority of cases. Cerumen removal was the most common procedure leading to complaint and the procedure most likely to result in payment. Hearing loss was the most common injury cited. Payment was highest in acoustic neuroma and stapedectomy cases.

High-fidelity, inexpensive surgical middle ear simulator.

HYPOTHESIS: A high-fidelity, inexpensive middle ear simulator could be created to enhance surgical training that would be rated as having high face validity by experts. BACKGROUND: With rapid prototyping using additive manufacturing technology (AMT), one can create high-resolution 3-dimensional replicas of the middle ear at low cost and high fidelity. Such a simulator could be of great benefit for surgical training, particularly in light of new resident training guidelines. METHODS: AMT was used to create surgical middle ear simulator (SMS) with 2 different materials simulating bone and soft tissue. The simulator is composed of an outer box with dimensions of an average adult external auditory canal without scutum and an inner cartridge based on an otosclerosis model. The simulator was then rated by otology experts in terms of face validity and fidelity as well as their opinion on the usefulness of such a device. RESULTS: Eighteen otologists from 6 tertiary academic centers rated the simulator; 83.3% agreed or highly agreed that SMS has accurate dimensions and 66.6% that it has accurate tactile feedback. When asked if performance of stapedotomy with the SMS improves with practice, 46% agreed. As to whether practicing stapedotomy with the SMS translates to improvement with live surgery, 78% agreed with this statement. Experts' average rating of the components of SMS (of possible 5) was as follows: middle ear dimensions, 3.9; malleus, 3.7; incus, 3.6; stapes, 3.6; chorda tympani, 3.7; tensor tympani, 4.1; stapedius, 3.8; facial nerve, 3.7; and promontory, 3.5. Overall, 83% found SMS to be at least "very useful" in training of novices, particularly for junior and senior residents. CONCLUSION: Most experts found the SMS to be accurate, but there was a large discrepancy in rating of individual components. Most found it to be very useful for training of novice surgeons. With these results, we are encouraged to proceed with further refinements that will strengthen the SMS as a training tool for otologic surgery.

[One-step rhinootosurgery. Clinical, economic and social aspects].

The objective of this work was to estimate from the clinical, economic, and social standpoints the efficacy of medical aid provided to the patients with chronic suppurative otitis media (CSOM) and concomitant pathology of the nasal cavity by means of the one-step surgical intervention. The study included a total of 208 patients presenting with CSOM of whom 108 ones were treated by the traditional multistage method and the remaining 108 by simultaneous rhinootosurgery. The latter approach was shown to be much more efficacious in terms of clinical, economic, and social considerations.

Clinical indication as an ethical appraisal: the example of imaging before middle ear surgery.

PURPOSE OF THE STUDY: Asking whether imaging is indicated before middle ear surgery requires us to examine the question of indication more generally. PROCEDURES: Clinical indication integrates different levels, which are distinguished in this paper. As deciding whether or not an intervention is indicated requires different approaches on each of these levels, these approaches are also explored. RESULTS: Even when sufficient data are available to determine whether an intervention brings some benefit, knowing whether or not this intervention is indicated still requires us to answer 3 additional questions: (1) Is the intervention sufficiently beneficial to be clinically relevant? (2) Is the intervention 'reasonable' in terms of its opportunity costs? (3) How are we to decide which interventions 'make the cut', and which do not? Although we may all have an informed opinion on this topic, the question of the thresholds we ought to apply to very marginal benefits is one where the best answer can only be the one we have all agreed on. This requires a guideline integrating elements of procedural fairness, developed in conditions of protection from the risks of conflicts of interests. CONCLUSION: Although some of these questions integrate considerations of costs, not all do. However, all integrate value judgements, making clinical indication in part a question of ethical appraisal.

Psycho-socio-economic outcomes in acoustic neuroma patients and their carers related to tumour size.

The objective was to explore psycho-socio-economic outcomes of a 2-year cohort of patients having surgery for an acoustic neuroma, and carers and their relationship to tumour size after surgery. The Wessex Patient Carer Questionnaire was designed in conjunction with Patients and Carers, to determine psycho-socio-economic outcomes. The results were juxtaposed against clinical profiles. The House-Brackman (HB) scale was used to assess facial function at 6 and 12 months after operation. The cohort contained 102 patients. There were 87% effective responders. Half were aged below 54 years and 30% had school-aged children. The majority (93%) of patients were operated via the translabyrinthine approach. Patients with large tumours, i.e. greater than 3 cm (28%), had most post-treatment physical problems, including hearing and balance difficulties, and 42% reported difficulty eating in public. Thirty-four per cent felt 'stressed' and 18%'depressed'. After 6 months, facial function was recorded as HB scale 5/6 in 21% of patients but by 1 year only 8% of patients were HB 5/6. Patients and carers were generally very satisfied with their in-patient neurosurgical care, but significantly dissatisfied with post-discharge care - particularly the shortcoming of the community services. The majority of families felt 'unsupported' and only 20% of patients had confidence in their General Practitioner's knowledge. Families faced severe socio-economic disruption and patients"time-off-work' was estimated to cost pound 954,000. Carers carried considerable post-discharge psychological burdens and costs to the public purse were calculated to be pound 52,000.

Cost-effectiveness of intraoperative facial nerve monitoring in middle ear or mastoid surgery.

OBJECTIVES: Despite the utility of intraoperative facial nerve monitoring in reducing the risk of iatrogenic facial nerve injury during neurotologic surgery, its routine use during primary or revision surgery remains controversial. One of the major barriers to its acceptance is cost. This study evaluates the cost-effectiveness of intraoperative facial nerve monitoring during middle ear or mastoid surgery. RESEARCH DESIGN/METHODS: A simple decision analytic cost-effectiveness model and a societal approach were used to evaluate three cohorts of individuals who received (1) intraoperative facial nerve monitoring for both primary and revision middle ear or mastoid surgeries, or (2) facial nerve monitoring for revision surgeries only, or (3) no monitoring for any middle ear or mastoid surgeries. RESULTS: Our results strongly favored the use of intraoperative facial nerve monitoring in all patients undergoing middle ear or mastoid surgery, adding about $222.73 to $528.00 US dollars to the total cost. The strategy to monitor primary and revision surgeries had the greatest effectiveness and lowest cost, with an average quality-adjusted life-year (QALY) of 45.68 at an average cost of $238 US dollars. Facial nerve monitoring in revision patients only had similar QALYs (45.67) and higher costs ($292.1). Finally, the strategy not to monitor had the lowest QALY (45.65) and highest cost ($449.8). The analysis was robust across a wide range of changes in both costs and probabilities. CONCLUSIONS: Facial nerve monitoring is cost-effective, and its routine use should be adopted to reduce the risk of iatrogenic facial nerve injury during otologic surgery.

[Binaural cochlear implantation: general concept, surgical technique and electrophysiology]. / Implantation cochléaire binaurale.

Cochlear implant have been proven to be safe and cost-effective in deafened adults. Generally, a single cochlear implants is proposed providing monaural audition. Some teams have published interesting results in patients wearing two cochlear implants. The cost of the surgical procedure is greatly increased for bilateral implantation. In an attempt to provide patients with binaural hearing and a better chance to improve their capacity for frequency discrimination without an excessive increase in cost, we developed an new concept and design for binaural cochlear implants. The aim of the present study was to establish the surgical technique for binaural cochlear implantation with a single internal receptor-stimulator. We report descriptive data on surgical procedures performed in two cadavers and in two deafened adults. The special implant is composed of a single receptor-stimulator and two electrode arrays: a short one implanted into the ipsilateral ear and a long one in the contralateral ear. A specially designed tool for endoscopic facial lifting was used to create subcutaneous tunnels from the ipsilateral to the contralateral ear. Insertion into cochleas was unremarkable. Additional time for surgery (compared with mean operative time for routine adult surgery in our unit), and surgical details are discussed. Binaural cochlear implantation is feasible, easy and not very time consuming. Studies are in progress to determine patient benefit. Obtaining auditory brainstem evoked potentials electrically in patients with binaural cochlear implants is possible and provides an interesting mode for in vivo analysis of the long-term effect of profound/total deafness on neural transmission. In our patients, results have demonstrated that neural response properties in auditory pathways are negatively related to duration of deafness.

The otologic T-tube: a cost effective dacryocystorhinostomy stent.

Endoscopic endonasal dacryocystorhinostomy (EDCR) has established itself as a popular means of relieving post-saccal obstruction of the naso-lacrimal ducts. Soft tissue stenosis of the rhinostomy is a significant cause of long-term failure. We describe the technique of using a standard otological T-tube as a cheap and easy self-retaining stent to ensure a patent rhinostomy following EDCR.

The learning curve in vestibular schwannoma surgery.

OBJECTIVE: This study aimed to examine the effect of surgical team experience on facial nerve function and complication rate in vestibular schwannoma surgery. STUDY DESIGN: The study design was a retrospective analysis of a case series. SETTING: The study was conducted at a tertiary referral center. PATIENTS: One hundred sixty consecutive patients undergoing vestibular schwannoma excision participated. INTERVENTION: Surgical excision of vestibular schwannoma via a translabyrinthine, middle cranial fossa, suboccipital, or combined approach was performed. MAIN OUTCOME MEASURES: Facial nerve function (House-Brackmann score) and complication rates including cerebrospinal fluid leak and meningitis compared by groups of 20 patients were measured. RESULTS: There was a statistically significant improvement in the number of patients achieving a House-Brackmann grade I result between the first 20 patients (35% House-Brackmann grade 1) and the ensuing 7 groups of 20 patients (74% House-Brackmann grade 1) by chi2 analysis. When considering House grades I and II together, there was no statistically significant difference in facial nerve function in the first 20 patients (80%) compared to the last 7 groups of 20 patients (88%) by Tukey's pairwise comparisons (p = 0.245). Mean tumor size was not significantly different in the groups studied (p = 0.54). The total cost of patient care declined over the study period; however, the wide case-to-case variance made it so that this trend was not statistically significant (p = 0.448). CONCLUSIONS: A learning curve of 20 patients was demonstrated by this study to have been necessary for attaining acceptable standards in the surgical removal of vestibular schwannomas by a new surgical team. The findings of this study may have implications for patient care and surgeon training.