Cost-Effectiveness of Diffusion Weighted MRI Versus Planned Second-Look Surgery for Cholesteatoma.

OBJECTIVE: To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma. METHODS: A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY. RESULTS: Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations. CONCLUSION: Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized. LEVEL OF EVIDENCE: V.

Effect of Insurance Type on Postoperative Tympanostomy Tube Follow-up.

OBJECTIVE: Bilateral myringotomy with tube insertion (BMT) is a common procedure performed in children. Appropriate follow-up is necessary to ensure management of postoperative sequalae. The objectives are to investigate (1) the relationship between insurance type and postoperative follow-up attendance and (2) the effect of follow-up on need for further care after BMT. STUDY DESIGN: Retrospective cohort study. SETTING: The study included patients <3 years of age undergoing BMT for recurrent acute otitis media at a tertiary care children's hospital within a single year and followed for 3 years. Patients were excluded if they had received a prior BMT; underwent a concurrent otolaryngologic procedure; or had a syndromic diagnosis, craniofacial abnormality, or any significant cardiac or respiratory comorbidity. METHODS: Number of follow-up appointments, demographics, socioeconomic status, and postoperative outcomes were analyzed. RESULTS: A total of 734 patients were included with mean (SD) age of 1.4 years (0.50). The majority of patients had private insurance (520/734, 70.8%). Patients with public insurance attended fewer postoperative appointments (1.5 vs 1.8, P < .001) and had a higher incidence of BMT-related emergency department (ED) visits (10.3% vs 3.8%, P = .001). There was no significance found when different insurance providers were compared. An adjusted multivariate regression analysis showed that patients with private insurance were more likely to attend postoperative appointments (odds ratio, 3.52 [95% CI, 2.12-5.82]; P < .001) and less likely to have a BMT-related ED visit (odds ratio, 0.42 [95% CI, 0.20-0.89]; P = .024). CONCLUSION: Insurance type is related to outcomes after the treatment of recurrent acute otitis media with BMT. Future studies that survey individuals will help identify barriers that contribute to patient absence at follow-ups and need for subsequent ED visits.

Racial Disparities in Pediatric Endoscopic Sinus Surgery.

OBJECTIVE: To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS). STUDY DESIGN: Cross-sectional cohort study. SUBJECTS AND METHODS: Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS. RESULTS: A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37). CONCLUSION: This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E1369-E1374, 2021.

Comparison of the Fisher Anatomical Subunit and Modified Millard Rotation-Advancement Cleft Lip Repairs.

BACKGROUND: When analyzing cleft lip repair techniques, the modified rotation-advancement repair is most widely used; however, the anatomical subunit approach is gaining popularity. The purpose of this study was to compare the outcomes of these two surgical techniques performed by the same surgeon. METHODS: Anthropometric measurements were performed on postoperative photographs of cleft lip repairs performed by a single surgeon. As described by Rossell-Perry, four parameters were measured: lip height, lip width, vermilion height, and alar base width. An aesthetic ratio of cleft to noncleft sides for each measurement was used as a quantitative measure of outcome. Qualitative analysis of cleft lip repair was evaluated using the Steffensen criteria. RESULTS: TWELVE: modified rotation-advancement repairs and 10 anatomical subunit repairs were analyzed. A one-sample t test was used to assess the difference of each aesthetic ratio from the perfect ratio of 1.00. For repairs involving an incomplete cleft lip, statistically significant asymmetry was detected in vermilion height for the rotation-advancement repair and no measurements in the anatomical subunit approach. For repairs involving a complete cleft lip, statistically significant asymmetry was detected in lip height, vermilion height, and alar base for the rotation-advancement repair and in lip height for the anatomical subunit approach. CONCLUSIONS: THE AUTHORS': findings show that when separating the complete and incomplete cleft lips, the rotation-advancement technique seemed to have asymmetry in more parameters than the anatomical subunit approach. This seems to suggest that the outcomes of the anatomical subunit technique are less dependent on cleft lip severity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Down Syndrome as an indicator for pediatric otolaryngologic procedures.

OBJECTIVE: Down Syndrome (DS) is the most common chromosome abnormality in humans. Due to the phenotype associated with DS, there are many disease states that require otolaryngologic procedures. Our goal is to use national data to study otolaryngologic procedures, their association with DS, and the degree of difference in risk profiles encountered with DS. METHODS: Data was obtained from the 2012-2015 American College of Surgeons' National Surgical Quality Improvement Program-Pediatric public use files. ENT procedure CPT codes were used to query the database and DS patients were identified using ICD-9 code 758.0. The ENT procedures were grouped into 18 categories and their frequency in DS patients as well as outcomes were analyzed. Postoperative outcomes were measured by complication rates, readmission rates, operation time, anesthesia time, and total length of stay. RESULTS: Results showed that DS patients are significantly (p < 0.05) over-represented in the following categories: Tracheostomy, Endoscopy, Laryngoscopy, Tracheoplasty, Myringoplasty, Tympanoplasty with Mastoidectomy, and Tympanoplasty without Mastoidectomy. DS patients are under-represented in the following categories: Abscess, Palatoplasty, Excision of Congenital Neck Cyst, and Cochlear Implantation. Logistic regression analysis showed that DS patients were significantly (p < 0.05) more likely to undergo procedures in the over-represented categories and were significantly (p < 0.05) less likely to undergo procedures in the under-represented categories as listed above. Outcomes analysis yielded no pattern of significance. CONCLUSION: Our data showed that DS may predispose patients to require certain procedures over others.

Clinical Indicators of Admission for Pediatric Cochlear Implant Procedures.

OBJECTIVES: A minority of children undergoing cochlear implantation (CI) are admitted overnight postoperatively, but there are little data on prognostic indicators. Our goal is to review national data to identify variables associated with admission and identify effects on outcomes. METHODS: We analyzed data from the 2012-2015 American College of Surgeons' National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) program use files. The CI patients were identified by CPT code. Demographics, comorbidities, anesthesia time, total operation time, 30-day complications, and 30-day readmission were compared between ambulatory and admitted patients. RESULTS: A total of 2943 CI patients were included, with 17.2% of these admitted post implantation. Single variable analysis revealed multiple factors associated with admission post implantation. Multivariable analysis showed patients with asthma were 2.2 times ( P < .001; odds ratio [OR] = 1.484-3.227) and those with structural central nervous system (CNS) abnormalities 2.1 times ( P < .001; OR = 1.584-2.706) more likely to be admitted. Younger age ( P = .002; OR = 0.995-0.999) and longer operation time ( P < .001; OR = 1.003-1.006) were weak predictors. Two hundred sixteen patients lacked any factors but were still admitted. They had similar outcomes to ambulatory healthy patients. CONCLUSION: We identified factors associated with admission post-CI and higher readmission rates. Asthma and CNS abnormalities are strong predictors of admission post implantation. Forty-two percent of admitted patients lack any of these factors and have comparable outcomes to corresponding ambulatory patients.

[Technetium TC 99m pyrophosphate myocardial scintigraphy in amyloidosis. Correlations with Doppler echocardiography]. / La scintigraphie myocardique au pyrophosphate technétié dans l'amylose. Corrélations avec l'échographie doppler cardiaque.

Technetium 99m cardiac scintigraphy as practiced at present for diagnosing amyloisodid only provides a visual semi-quantitative assessment of uptake of the isotope. To improve the diagnostic accuracy of the method, the authors evaluated prospectively a personal technique of scintigraphy quantification based on early images obtained at the 20th minute in 15 patients with neuropathic amyloidosis. Doppler echocardiographic studies indicated that 9 patients had cardiac involvement whilst 6 were free of cardiac amyloidosis. The index of isotopic uptake (ratio of cardiac/abdominal uptake) was 0.44 to 1.58 in the first group and 0.09 to 0.31 in the second group. The correlation between the scintigraphic index and interventricular septal or posterior wall thickness measured by echocardiography was poor. These results obtained in 15 patients with neuropathic amyloidosis suggest that the scintigraphic index measured at the 20th minute is discriminatory and allows identification of those patients with cardiac involvement. On the other hand, the correlations with echocardiographic wall thickness are poor. Technetium 99m cardiac scintigraphy with this technique of quantification is a useful tool for diagnosing cardiac amyloidosis, especially when echocardiography is difficult to interpret.