Comparative study of endoscopic and microscopic tympanoplasty performed by a single experienced surgeon.

PURPOSE: The use of endoscopes in otologic procedures has been increasing worldwide. This study aimed to compare the efficacy of microscopic tympanoplasty (MT) and endoscopic tympanoplasty (ET) for tympanic membrane and middle ear surgery. MATERIALS AND METHODS: We retrospectively analyzed 81 patients who underwent MT (n = 44) and ET (n = 37) for chronic otitis media with tympanic membrane perforation performed by a single surgeon between January 2013 and September 2019. The hearing outcomes, graft success rate, complications, operation time and hospital stay, and cost-effectiveness were recorded and compared between groups. Hearing outcomes were determined by pure tone audiometry. Cost-effectiveness was determined by the operation cost and total cost. RESULTS: There was no significant difference between the MT and ET groups regarding demographic characteristics, with the exception of the male:female ratio. There was no significant difference in the pre- and postoperative air conduction, bone conduction thresholds, and air-bone gap values between the two groups, but a significant audiologic improvement was observed in both groups (p < 0.05). In terms of recurrence of tympanic membrane perforation, postoperative otorrhea, and discomfort symptoms, there was no significant difference between groups (p > 0.05). The operation time and hospital stay were shorter in the ET group than in the MT group (p < 0.05). There were no significant differences in operation cost between the two groups (p > 0.05), but the total cost was significantly lower in the ET group than the MT group (p < 0.05). CONCLUSION: ET is as safe and medically efficacious as conventional MT, shortens the operation time and hospital stay, and is cost-effective.

Variation in Tympanoplasty Cost in a Multihospital Network.

OBJECTIVES: Identify costs and operative times for tympanoplasty, and evaluate factors influencing cost and time variation. STUDY DESIGN: Retrospective cohort study. SETTING: Multihospital network. PATIENTS: Patients undergoing tympanoplasty from 2008 to 2016. Subjects with additional procedures were excluded. INTERVENTIONS: A multihospital network's standardized activity-based accounting system was used to determine costs and operative times of tympanoplasty. MAIN OUTCOME MEASURES: Correlation between variable factors and cost was calculated by Spearman correlation coefficients. Statistical comparisons of cost and time were made between surgeons and hospitals using an ANOVA test (Kruskal-Wallis) followed by Dunn's test to correct for multiple comparisons. All providers or hospitals with single cases were excluded for statistical comparison. RESULTS: The study cohort included 487 tympanoplasties performed by 44 surgeons at 13 hospitals. Mean patient age was 18.2 ±â€Š17.4 years. Mean cut-to-close time was 85.8 ±â€Š56.7 minutes. Mean total encounter cost was $3491 ±â€Š$1,627. Substantial factors associated with total encounter cost were anesthesia cost (r = 0.8782; 95% CI 0.852-0.900, p < 0.001) and cut-to-close time (r = 0.7543; 95% CI 0.707-0.7949, p < 0.001). The total itemized supply cost was less correlated with total encounter cost (r = 0.3176; 95% CI 0.2128-0.4151, p < 0.001). Laser utilization (mean cost $541 ±â€Š$343) and artificial graft material (mean cost $199 ±â€Š$94) were the major supply costs. CONCLUSION: Significant variation in tympanoplasty costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste.

Cost-effectiveness analysis of endoscopic tympanoplasty versus microscopic tympanoplasty for chronic otitis media in Taiwan.

BACKGROUND: Health care systems and physicians need to conform to budgets and streamline resources to provide cost-effective quality care. Although endoscopic tympanoplasty (ET) has been performed for decades, no studies on the cost-effectiveness of ET and microscopic tympanoplasty (MT) for treating chronic otitis media have been published. The present study aimed to compare the cost-effectiveness of ET and MT for treating chronic otitis media. METHODS: This study was performed using a Cohort-style Markov decision-tree economic model with a 30-year time horizon. The economic perspective was that of a third-party payer (Taiwan National Health Insurance System). Two treatment strategies were compared, namely ET and MT. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Probabilities were obtained from meta-analyses. Costs were obtained from the published literature and Taiwan National Health Insurance System database. Multiple sensitivity analyses were performed to account for data uncertainty. RESULTS: The reference case revealed that the total cost of ET was $NT 20,901 for 17.08 QALY per patient. By contrast, the total cost of MT was $NT 21,171 for 17.15 QALY per patient. The incremental cost effectiveness ratio for ET versus that of MT was $NT 3703 per QALY. The cost-effectiveness acceptability curve indicated that ET was comparable to MT at a willingness-to-pay threshold of larger than $NT 35,000 per QALY. CONCLUSION: This cost-effectiveness analysis indicates that ET is comparable to MT for treating chronic otitis media in Taiwan. This result provides the latest information for physicians, the government, and third-party payers to select proper clinical practice.

Outcome and cost analysis of bilateral sequential same-day cartilage tympanoplasty compared with bilateral staged tympanoplasty.

BACKGROUND: Few studies have compared bilateral same-day with staged tympanoplasty using cartilage graft materials. METHODS: A prospective randomised observational study was performed of 38 chronic suppurative otitis media patients (76 ears) who were assigned to undergo bilateral sequential same-day tympanoplasty (18 patients, 36 ears) or bilateral sequential tympanoplasty performed 3 months apart (20 patients, 40 ears). Disease duration, intra-operative findings, combined duration of surgery, post-operative graft appearance at 6 weeks, post-operative complications, re-do rate and relative cost of surgery were recorded. RESULTS: Tympanic membrane perforations were predominantly subtotal (p = 0.36, odds ratio = 0.75). Most grafts were harvested from the conchal cartilage and fewer from the tragus (p = 0.59, odds ratio = 1.016). Types of complication, post-operative hearing gain and revision rates were similar in both patient groups. CONCLUSION: Surgical outcomes are not significantly different for same-day and bilateral cartilage tympanoplasty, but same-day surgery has the added benefit of a lower cost.

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.

Cost analysis and outcomes of a second-look tympanoplasty-mastoidectomy strategy for cholesteatoma.

OBJECTIVES/HYPOTHESIS: To analyze cost and compare cholesteatoma recidivism and hearing outcomes with single-stage and second-look operative strategies. STUDY DESIGN: Retrospective review and cost analysis. METHODS: Adult and pediatric patients who underwent a tympanoplasty with mastoidectomy for cholesteatoma with a single-stage or second-look operative strategy were identified. Variables included procedure approach, residual or recurrent cholesteatoma, ossicular chain reconstruction frequency, and operative complications. Audiologic outcomes included pre-/postoperative air bone gap (ABG) and word recognition score (WRS). Cost analysis included charges for consultation and follow-up visits, surgical procedures, computed tomography temporal bone scans, and audiology visits. RESULTS: One hundred and six patients had a tympanoplasty with mastoidectomy for cholesteatoma, with 80 canal wall-up procedures (CWU) as initial approach. Of these, 46 (57.5%) CWU patients had a planned second look. Two (4.3%) CWU patients had recurrent cholesteatoma and 20 (43.4%) had residual identified at second look. Four (11.7%) single-stage CWU strategy patients developed recurrent cholesteatoma. There was no significant difference in pre-/postoperative ABG and WRS between second look and single stage (P > 0.05). Compared to second-look patients, single-stage patients had significantly fewer postoperative visits (6.32 vs. 10.4; P = 0.007), and significantly lower overall charges for care ($23,529. vs. $41.411; P < 0.0001). CONCLUSION: The goal of cholesteatoma surgery is to produce a safe ear, and a second-look strategy after CWU has historically been used to evaluate for recurrent or residual disease. The cholesteatoma recurrence rate at a second look after a CWU tympanoplasty-mastoidectomy is low. Costs of operative procedures are a significant proportion of healthcare resource expenditures. Considering the low rate of cholesteatoma recurrence and relatively high cost of care, implementation of a second-look strategy should be individually tailored and not universally performed. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2574-2579, 2016.

Prevalence and hospital resource utilization in tympanoplasty and revision tympanoplasty: a population-based comparative study.

OBJECTIVE: To compare trends, risk factors, prevalence rates, and hospital resource utilization between tympanoplasty and revision tympanoplasty. STUDY DESIGN: Retrospective review. SETTING: All hospitals. PATIENTS: This study analyzed 58,038 tympanoplasty procedures and 953 revision tympanoplasty procedures performed in Taiwan from 1996 to 2007. MAIN OUTCOME MEASURES: Administrative claims data from the Bureau of National Health Insurance of Taiwan. Odds ratio and 95% confidence intervals were calculated to assess the relative change rate. Regression models were used to predict length of stay (LOS) and hospital treatment costs. RESULTS: The number of tympanoplasties performed per 100,000 patients was 22.97 in 1996. It gradually increased to 26.7 in 2001 and then gradually decreased to 16.61 in 2007. The number of revision tympanoplasties per 100,000 patients during the same period, however, was 0.29 to 0.48. During the study period, the LOS associated with both tympanoplasty and revision tympanoplasty decreased, whereas hospital treatment costs associated with the 2 procedures increased. Considerably decreased LOS and increased hospital treatment costs were associated with age, sex, number of comorbidities, hospital level, hospital volume, surgeon volume, and LOS. CONCLUSION: High-volume hospitals and surgeons obtained the largest improvements in tympanoplasty outcomes, particularly in LOS and hospital treatment costs. Health care providers and patients should recognize that hospital resource utilization may depend on hospital attributes as well as patient attributes.

The costs and quality of operative training for residents in tympanoplasty type I.

CONCLUSION: A teaching hospital would incur more operation room costs on training surgical residents. OBJECTIVE: To evaluate the increased operation time and the increased operation room costs of operations performed by surgical residents. As a model we used a very common surgical otology procedure -- tympanoplasty type I. SUBJECTS AND METHODS: From January 1, 2004 to December 31, 2004, we included in this study 100 patients who received tympanoplasty type I in Taipei Veterans General Hospital. Fifty-six procedures were performed by a single board-certified surgeon and 44 procedures were performed by residents. We analyzed the operation time and surgical outcomes in these two groups of patients. The operation room cost per minute was obtained by dividing the total operation room expenses by total operation time in the year 2004. RESULTS: The average operation time of residents was 116.47 min, which was significantly longer (p<0.0001) than that of the board-certified surgeon (average 81.07 min). It cost USD $40.36 more for each operation performed by residents in terms of operation room costs. The surgical success rate of residents was 81.82%, which was significantly lower (p=0.016) than that of the board-certified surgeon (96.43%).

Cost-utility analysis of tympanomastoidectomy for adults with chronic suppurative otitis media.

OBJECTIVE: To undertake cost-utility analysis for tympanomastoid surgery to analyze its cost-effectiveness in treating adult chronic suppurative otitis media (CSOM). METHODS: Seventy-seven patients with CSOM were evaluated with the Chronic Ear Survey (CES) before and 1 year after tympanomastoid surgery. Direct health care cost data during the 1st year after operation were retrieved. The utility gain was defined as change in the CES total score. The cost-utility ratio (CUR) was defined as cost per utility gain. Patients were stratified by disease type into wet-ear and dry-ear groups. RESULTS: The average total direct cost attributable to tympanomastoid surgery is (in New Taiwan dollars) 45,716.3 in the 1st postoperative year, and the average CUR is 1850.9 New Taiwan dollars. The lower CUR of 1280.9 New Taiwan dollars for the wet-ear group is due to the greater utility gain (37.6 +/- 3.4 versus 24.4 +/- 6.8, P < 0.05) despite its higher cost (48,163.2 New Taiwan dollars versus 38,419.7 New Taiwan dollars, P < 0.05). CONCLUSIONS: Treating continuously or intermittently draining ears is more cost-effective, as compared with managing a quiescent infection, because of its favorable utility gain.