Cost-Effectiveness Analysis of Intracapsular Tonsillectomy and Total Tonsillectomy for Pediatric Obstructive Sleep Apnea.

PURPOSE: We performed an economic evaluation using a decision-tree model to analyze the relative cost effectiveness from the United States Centers for Medicare and Medicaid Services (CMS) perspective of two different methods of tonsillectomy (traditional total tonsillectomy and partial intracapsular) for pediatric obstructive sleep apnea (OSA). MATERIALS AND METHODS: Procedural costs were drawn from published literature and Medicare values. Effectiveness and probabilities were drawn from medical literature. Primary intervention was monopolar-technique total tonsillectomy or microdebrider-assisted partial intracapsular tonsillectomy. Secondary interventions included operative control of hemorrhage, treatment of severe dehydration, or revision tonsillectomy. The decision model starts with pediatric patients with OSA, choosing between total and partial tonsillectomy. Outcomes were measured by costs (US dollars), effectiveness [quality-adjusted life year (QALY)], and a willingness-to-pay threshold of US$100,000/QALY. Base case analysis, probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses were performed. Primary outcome was incremental cost-effectiveness ratio (ICER) for each of the two tonsillectomy techniques. RESULTS: Base case analysis demonstrated that total tonsillectomy was more cost effective at US$12,453.40 per QALY gained. In PSA, 82.84% of the simulations show total tonsillectomy to be the more cost-effective strategy. Deterministic sensitivity analyses showed that when the rate of OSA recurrence is lower than 3.12%, partial tonsillectomy would be more cost effective. When the failure rate of partial tonsillectomy is below 1.0%, it is more cost effective even when total tonsillectomy is 100% successful. CONCLUSION: Study results suggest that overall monopolar-technique total tonsillectomy is more cost effective. However, with varying adjustments for disutility caused by procedural complications, intracapsular tonsillectomy could become a more cost-effective technique for treating pediatric OSA.

Semicircular canal dehiscence among idiopathic intracranial hypertension patients.

OBJECTIVES/HYPOTHESIS: The cause of superior semicircular canal dehiscence (SSCD) is unknown. Because of a demonstrated association with tegmental defects and obesity, some have suggested idiopathic intracranial hypertension (IIH) could contribute by eroding the bone over the canal and resulting in SSCD. However, an association between IIH and SSCD has not previously been evaluated. Our objective was to evaluate an association between IIH and SSCD. STUDY DESIGN: Retrospective cohort. METHODS: A retrospective study was performed of opening pressures for consecutive patients presenting at a lumbar puncture clinic between August 2012 and October 2015. Imaging for patients who also had thin-sectioned computed tomography (CT) imaging was reviewed for the presence of radiographic SSCD. Association between IIH and SSCD was evaluated using the Student t test and multivariate logistic regression. RESULTS: One hundred twenty-one patients had both a lumbar puncture performed and thin-sectioned CT imaging available, of which 24 patients (19.8%) met the criteria for IIH with an opening pressure >25 cm H2 O. The remaining 97 patients (80.2%) did not have elevated opening pressures and served as the control cohort. None of the 24 patients with IIH had radiographic SSCD, whereas eight of the 97 patients (8.2%) without IIH had radiographic SSCD. The average opening pressure in patients without radiographic SSCD was 20.2 cm H2 O compared to 19.3 cm H2 O in patients with radiographic SSCD (P = .521). In multivariate logistic regression controlling for age, body mass index, gender, and comorbidities (hypertension, diabetes, hyperlipidemia), opening pressure was not a significant predictor of radiographic SSCD. CONCLUSIONS: The results of this retrospective pilot study do not suggest an association between IIH and SSCD. LEVEL OF EVIDENCE: 3b. Laryngoscope, 128:1196-1199, 2018.

Bilateral osteomas and exostoses of the internal auditory canal.

Osteomas and exostoses are benign tumors of the bone that occur in the head and neck region but are rarely found within the internal auditory canal (IAC). In this report, we review the literature on bony lesions of the IAC and present two cases: one case of bilateral compressive osteomas and one case of bilateral compressive exostoses of the IAC.

Is partial laryngectomy safe forever?

OBJECTIVES: Over past decades, function-preserving surgery has been oncologically effective for specific types of laryngeal cancer. Although safe short-term swallow function has been reported, swallow safety during long-term survival has received less attention. The purpose of this report is to highlight potential consequences of late dysphagia and chronic aspiration after partial laryngectomy. METHODS: A retrospective case series was performed. The head and neck cancer database from Yale-New Haven Hospital identified 3 patients requiring completion laryngectomy due to chronic aspiration 11-15 years after oncologically successful partial laryngectomy. Demographics, presentation, treatment, and course are included. RESULTS: Primary treatment was open supraglottic laryngectomy with adjuvant radiation therapy (n=2) and vertical hemilaryngectomy (n=1). All patients demonstrated locoregional control and preservation of swallow function for >10 years postoperatively. Due to late dysphagia and chronic aspiration, two patients required completion laryngectomy 11 and 15 years postoperatively and the third patient will require this 14 years postoperatively. CONCLUSIONS: Successful swallowing after function-preserving laryngeal surgery may not last forever despite adequate control of cancer. Three patients presented with aspiration 11-15 years after partial laryngectomy and required definitive completion laryngectomy. This observation may affect preoperative counseling and consideration for longer post-operative follow-up. The data encourage a larger sample size.