Cost of closure: Comparing success and spending of fat graft myringoplasties with and without hyaluronic acid.

INTRODUCTION: Myringoplasties are common pediatric procedures used to surgically close a perforated tympanic membrane. While a wide variety of graft materials are available to surgeons, the cost effectiveness of these different techniques is not well studied. OBJECTIVES: To compare the cost effectiveness of the fat graft myringoplasty (FGM) with the hyaluronic acid fat graft myringoplasty (HAFGM). METHODS: Retrospective chart review of patients ages 31 days to 18 years who had undergone either FGM or HAFGM from 2006 to 2016. RESULTS: We identified 85 patients who had undergone FGM and 51 patients who had undergone HAFGM. The two groups were statistically similar in age (CI -0.51, 1.9; p = 0.23), sex (CI 0.3, 1.4; p = 0.27), and history of prior tympanostomy tube placement (CI -0.07, 0.07; p = 0.69). Both groups had a similar number of total comorbidities (40.0% of patients in the FGM group and 27.5% of patients in the HAFGM; CI -0.04, 0.29; p = 0.19). The FGM and the HAFGM procedure did not have statistically significant differences in perforation closure rates, 82.4% and 92.2% respectively (CI 0.81, 7.3; p = 0.13). In comparing the total surgeons' cost of closing a tympanic membrane deficit, the FGM incurred a greater cost per perforation. The cost/tympanic membrane perforation closure for the FGM totaled $3011.88 per deficit, whereas the HAFGM totaled $2742.98. CONCLUSION: As financial stewardship becomes more important for medical decision making, it is imperative that providers consider cost and outcomes data together when comparing similar treatment options. The FGM and the HAFGM have statistically similar rates of success in closing tympanic membrane perforations. In this study, the FGM cohort consumed more health care dollars per perforation secondary to the need for revision surgeries. As such, this study offers that the additional use of a hyaluronic disc does not increase overall cost to the healthcare system when performing a fat graft myringoplasty over a large cohort of patients.

Clinical and audiometric outcomes of palisade cartilage myringoplasty under local anesthetic in an office setting.

OBJECTIVE: Assess clinical and functional outcomes of a modified palisade cartilage-perichondrium graft myringoplasty under local in an office setting. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care facility. PATIENTS: Patients with a tympanic membrane perforation presenting between March 2013 and October 2017. Inclusion criteria included age ≥ 7 years, entire perforation margin visualized through a transcanal view, and the ability to lie supine for up to 45 min. Exclusion criteria included a conductive hearing loss larger than expected, and presence of active infection. INTERVENTION: In-office modified myringoplasty technique under local anesthesia without sedation. MAIN OUTCOME MEASURES: Complete perforation closure rate and audiometric outcomes. RESULTS: 250 patients underwent the procedure, of whom 13 had bilateral sequential procedures (total 263 ears). Of those, 197 were primary and 66 revision. Average age was 46.3 years. Perforation sizes were categorized as small (32), moderate (109), large (78), and subtotal (44). Complete perforation closure was evident in 219 of the 250 cases (88%). Preoperative mean air pure tone average (PTA) was 56.7 dB and mean bone PTA was 27.5 dB (pre-operative ABG 29.2 dB). AC-PTA significantly improved to 35.0 dB (p < 0.0001), and ABG to 9.6 dB (p < 0.0001). Only subtotal perforations showed a statistically significant negative relationship with outcome (p = 0.04). CONCLUSION: The modified palisade cartilage-perichondrium graft myringoplasty under local anesthetic is a highly successful procedure well tolerated by adult and pediatric patients with variable perforation sizes. This may have significant potential patient benefits, as well as cost savings to the health care system.

Comparison of the medical costs and effects of large traumatic eardrum perforations treatment.

OBJECTIVE: We investigated the medical costs and effects of ofloxacin drops (OFLX), gelatin sponge patches, spontaneous healing, and endoscopic myringoplasty on healing in large tympanic membrane perforations (TMPs). METHODS: In total, 100 patients with large traumatic TMPs involving >50% of the eardrum were randomly assigned to OFLX, gelatin sponge, spontaneous healing, or endoscopic myringoplasty treatment groups. Medical costs, closure times, and closure rates were compared among groups at 6 months. RESULTS: The closure rates in the OFLX, gelatin sponge, spontaneous healing, and endoscopic myringoplasty groups were 95.7%, 82.6%, 58.3%, and 91.7%, respectively (P = 0.05). The mean closure time was 13.73 ±â€¯6.14 days in the OFLX group, 15.89 ±â€¯4.95 days in the gelatin sponge group, 48.36 ±â€¯10.37 days in the spontaneous healing group, and 12 days in the endoscopic myringoplasty group (P < 0.001). The mean medical costs in US dollars were $15.53 ±â€¯3.15, $103.64 ±â€¯111.58, $11.17 ±â€¯1.33, and $715.90 in the OFLX, gelatin sponge, spontaneous healing, and endoscopic myringoplasty groups, respectively (P < 0.001). CONCLUSION: Although the gelatin sponge and myringoplasty treatments significantly shortened the closure time compared with spontaneous healing, the gelatin sponge patch did not significantly improve the closure rate, and the medical cost of myringoplasty was significantly higher than that of the other treatments. In contrast, OFLX significantly shortened closure time and had a higher closure rate than spontaneous healing, and the medical costs were lower than those of the gelatin sponge and myringoplasty procedures.

Clinical and economic evaluation of minimally invasive cartilaginous palisade myringoplasty.

OBJECTIVES: To test the clinical and audiometric efficacy of a minimally invasive myringoplasty technique, combining cartilaginous palisades while avoiding flap elevation, for small and wide perforations. METHODS: Over 4 years, this retrospective study included all patients over 6 years of age presenting an indication for myringoplasty. Several clinical and economic criteria were noted at 7 d, 2 months, 6 months and 2 years postoperative. The main outcome was the absence of perforation 2 years postoperative. The secondary outcomes were an audiometric gain at 6 months and the evaluation of the treatment cost. RESULTS: Thirty patients underwent the minimally invasive technique and 28 patients the technique with an elevation of the tympanomeatal flap. The minimally invasive surgical procedure was shorter (p = .001). At 2 years, the tympanic closure rate was equivalent (95% versus 89.5%, p = .77). The audiometric gain was similar between the two techniques (p = .09). From a medico-economic point of view, the minimally invasive procedure was the most effective because it was three times less expensive than the conventional technique with no reduction in efficacy (p = .02). CONCLUSION: This quick and easy technique could be developed in an ambulatory setting or even in conditions adapted to consultation.

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.

Fat-plug myringoplasty of ear lobule vs abdominal donor sites.

The purpose of this study is to compare the success rates of fat-graft myringoplasties harvesting adipose grafts from different donor sites (ear lobule vs abdomen). The clinical records of 61 patients (24 males and 37 females) who underwent fat-plug myringoplasty (FPM) were reviewed retrospectively. Fat from ear lobule (FEL) and abdominal fat were used as graft materials. The impact of age, gender, systemic diseases, topography of the perforation, utilization of fat graft materials of different origin on the tympanic membrane closure rate and the effect of FPM on hearing gain was analyzed. Our tympanic membrane (TM) closure rate was 82 %. No statistical significant difference was observed regarding age, gender, comorbidities (septal deviation, hypertension and diabetes mellitus) or habits (smoking). Posterior TM perforations had significantly lower healing rate. The change in TM closure rate considering different adipose tissue donor sites was not statistically significant. The hearing gain of the patients was mostly below 20 dB. Fat-plug myringoplasty (FPM) is a safe, cost-effective and easy operation for selected patients. Abdominal fat graft is as effective as ear lobe fat graft on tympanic membrane healing, has cosmetic advantages and should be taken into consideration when planning fat as the graft source.

[Cost-efficiency analysis of treatment of otitis media with effusion in children]. / Análisis de coste-efectividad del tratamiento de la otitis media serosa infantil.

Otitis media with effusion is a common disorder in children, associated to hearing loss and recurrent acute otitis media. It has three basic treatments: Spontaneous resolution, oral antibiotics and surgery including adenoidectomy and/or grommets insertion. Through a sensibility analysis on a theoretical group of 1000 patients our aim is to study the cost-effectiveness of the different therapeutic options, evaluating direct and indirect costs, and identifying the most efficient option (cost-effective). We analysed effectiveness and variable costs of each arm of the decision tree, considering initial and rescue treatments. As expected, effectiveness grows up to the most through treatment, including adenoidectomy and grommets insertion, from 92% to 98% of children treated. Nevertheless, unitary cost of each child treated also increases, from 302 to 401 euros; that is, choosing the most cost-effective treatment enables to save approximately 100 euros per child. But, fixed costs, which are much higher (600 euros per child), will not change, limiting our management resources.

Análisis de coste-efectividad del tratamiento de la otitis media serosa infantil / Cost-effectiveness analysis of treatment of otitis media with effusion in children

La otitis media serosa (OMS) es una enfermedad muy frecuente en la infancia, estando relacionada con el desarrollo de hipoacusia y episodios de otitis media aguda de repetición. Las alternativas terapéuticas para la misma son básicamente tres: la evolución espontánea, el tratamiento con antibióticos orales, o la cirugía de adenoides y/o drenajes timpánicos. Mediante un análisis de decisión sobre un grupo teórico de 1.000 pacientes se pretende estudiar el coste-efectividad de las alternativas terapéuticas, valorando el coste directo y el coste indirecto de cada una, llegando a identificar la opción más eficiente (coste-efectiva). Se analiza la efectividad y el coste variable de cada rama del árbol de decisión, considerando el tratamiento inicial y el de rescate. La efectividad es creciente hasta la opción terapéutica más completa, que incluye adenoidectomía y drenajes timpánicos, desde el 92 por ciento hasta el 98 por ciento de los niños tratados. Sin embargo, también se incrementa el coste de cada niño que es curado con esta última opción, desde 302 euros a 401 euros; es decir, la elección del tratamiento más coste-efectivo de la OMS infantil permite un ahorro de unos 100 euros por niño tratado. No obstante, los costes fijos del proceso, que son mucho mayores (600 euros por niño), no varían, limitando nuestra capacidad de gestión (AU)

Otitis media with effusion is a common disorder in children, associated to hearing loss and recurrent acute otitis media. It has three basic treatments: Spontaneous resolution, oral antibiotics and surgery including adenoidectomy and/or grommets insertion. Through a sensibility analysis on a theoretical group of 1000 patients our aim is to study the cost-effectiveness of the different therapeutic options, evaluating direct and indirect costs, and identifying the most efficient option (cost-effective). We analysed effectiveness and variable costs of each arm of the decision tree, considering initial and rescue treatments. As expected, effectiveness grows up to the most through treatment, including adenoidectomy and grommets insertion, from 92% to 98% of children treated. Nevertheless, unitary cost of each child treated also increases, from 302 to 401 euros; that is, choosing the most cost-effective treatment enables to save approximately 100 euros per child. But, fixed costs, which are much higher (600 euros per child), will not change, limiting our management resources (AU)

Education, practice reviews needed to reduce surgical intervention, Quebec report says.

Clinical uncertainty may be the reason for large variations in the rates of tonsillectomy, adenoidectomy and myringotomy in Quebec, a report prepared for the provincial government states. Methods used in other jurisdictions, such as informing physicians about geographic differences in intervention rates and developing clinical practice guidelines, could reduce the variations and save millions of dollars, researchers suggest.

Homograft myringoplasty-controlled button technique: a preliminary report.

The successful outcome of homograft myringoplasty in small and medium perforation of the tympanic membrane was only 44.12 per cent. A better result was obtained in the small perforations (59.10%) compared with the medium ones (16.77%). We conclude that the procedure should be appropriate for repairing the incomplete healing of the tympanic membrane following standard tympanoplasty and removal of the tympanostomy tube. Furthermore this procedure is simple, safe, cost-effective and can be done in the out-patient department.