Cost-Effectiveness of Open vs. Endoscopic Repair of Zenker's Diverticulum

OBJECTIVE

To evaluate the cost-effectiveness of open versus endoscopic surgical repair of Zenker's diverticulum.

METHODS

In this study, an economic decision tree was utilized to compare the cost-effectiveness of open surgery compared to endoscopic surgery. The primary outcome in this analysis was the incremental cost-effectiveness ratio (ICER) that was calculated based on the economic decision tree. The probability of post-operative esophageal perforation complications, revision rates, and effectiveness of each procedure along with associated costs were extracted to construct the decision tree. Univariate sensitivity analysis was then utilized to determine how changes in esophageal perforation rate affect the cost-effectiveness of each surgical approach.

RESULTS

The ICER of open surgery for Zenker's diverticulum was $67 877, above most acceptable willingness to pay (WTP) thresholds. Additionally, if the probability of esophageal perforation with endoscopic surgery is above 5%, then open surgery becomes a more cost-effective option. Probabilistic sensitivity analysis using Monte Carlo simulations also showed that at the WTP thresholds of $30 000 and $50 000, endoscopic surgery is the most cost-effective method with 83.9% and 67.6% certainty, respectively.

CONCLUSION

Open surgery and endoscopic surgery are 2 treatment strategies for Zenker's diverticulum that each have their own advantages and disadvantages that can complicate the decision-making process. With no previous cost-effectiveness analysis of open versus endoscopic surgery for Zenker's diverticulum, our results support the endoscopic approach at most common WTP thresholds. Particularly with the current focus on rising healthcare costs, our results can serve as an important adjunct to medical decision-making for patients undergoing treatment for Zenker's diverticulum.

Functional and Aesthetic Outcomes of Extracorporeal Septoplasty: A Systematic Review and Meta-Analyses

OBJECTIVE

The safety and efficacy of extracorporeal septoplasty (ECS) has long been debated. Our objective was to determine this technique's functional and aesthetic outcomes and complications through a systematic review of the literature.

DATA SOURCES

PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases were evaluated for studies detailing functional or aesthetic outcomes of ECS.

REVIEW METHODS

Bias was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-randomized Studies (MINORS) score. Aesthetic and functional outcomes in addition to complications were evaluated using subjective and objective measures. Meta-analyses were performed when appropriate.

RESULTS

Seventeen studies encompassing 1418 patients were included. The average MINORS score for observational studies was 9.2. Overall there was a significant improvement in subjective nasal function with a preoperative average Nasal Obstruction Symptom Evaluation (NOSE) score of 75 (±16) decreasing to 19.5 (±16.5) postoperatively for a mean difference (MD) of -55 (95% confidence interval (CI): -60 to -49.5). In terms of objective nasal function, at 6 months postoperatively, there was an improvement of nasal flow measured by rhinometry ranging from 70 to 71% across studies. Anthropometric measurements were utilized for objective aesthetic outcomes. There was a significant improvement in I-shaped deviations (MD: -2.7°, 95% CI: -5.6 to -0.16) and C-shaped deviations improved by 11.9° (95% CI +2.8-+21.2). Complication rates ranged from 0 to 18%.

CONCLUSION

ECS can achieve significant improvements in the subjective and objective function of the nose. The associated complication rate is low but variable between surgeons.

Adverse Events in Facial Implant Surgery and Associated Malpractice Litigation

Importance

Facial implants represent an important strategy for providing instant and long-lasting volume enhancement to address both aging and posttraumatic defects.

Objective

To better understand risks of facial implants by examining national resources encompassing adverse events and considerations facilitating associated litigation.

Design, Setting, and Participants

A cross-sectional study reviewed complications following facial implants. The procedures reviewed were performed on patients at locations throughout the United States from January 2006 to December 2016. Data collection was completed in March 2017. The Manufacturer and User Facility Device Experience database, which contains medical device reports submitted to the US Food and Drug Administration (FDA), was searched for complications that occurred from January 2006 to December 2016 involving facial implants made by Implantech, MEDPOR, Stryker, KLS Martin, and Synthes. Furthermore, the Thomson Reuters Westlaw legal database was searched for relevant litigation.

Main Outcomes and Measures

The complications of facial implants were analyzed in relation to the location of implant and severity of complication. Litigation was analyzed to determine which factors determine outcome.

Results

Thirty-nine instances of adverse events reported to the FDA were identified. Sixteen (41%) involved malar implants, followed by 12 chin implants (31%). The most common complications included infection (18 [46%]), implant migration (9 [23%]), swelling (7 [18%]), and extrusion (4 [10%]). Thirty-two patients (83%) had to have their implants removed. Infection occurred at a mean (SD) of 83.3 (68.8) days following the surgery. One-third of complications involved either migration or extrusion. The mean (range) time to migration or extrusion was 381.1 (10-2400) days. In 12 malpractice cases identified in publicly available court proceedings, alleged inadequate informed consent and requiring additional surgical intervention (ie, removal) were the most commonly cited factors.

Conclusions and Relevance

Infection and implant migration or extrusion are the most common complications of facial implants. Most of these complications necessitate removal. These considerations need to be discussed with patients preoperatively as part of the informed consent process, as allegedly inadequate informed consent was cited in a significant proportion of resultant litigation, and there were overlapping considerations among adverse events reported to the FDA and factors brought up in relevant litigation. Cases resolved with settlements and jury-awarded damages encompassed considerable award totals.

Level of Evidence

NA.

Traumatic Tympanic Membrane Perforations Diagnosed in Emergency Departments

Importance

Tympanic membrane perforations (TMPs) are frequent events leading to evaluation in the primary care and otolaryngology offices or the emergency department (ED). Despite specific warning labels on packaging of cotton-tipped applicators regarding the risk of injury to the ear canal with personal use, these products are commonly used to remove ear cerumen.

Objective

To analyze the mechanism of injury for traumatic TMPs among patients presenting to the ED.

Design, Setting, and Participants

Cross-sectional analysis of cases from 100 emergency departments in the United States. The National Electronic Injury Surveillance System was searched on April 3, 2015, for ear-related injuries with analysis information regarding patient age, patient sex, time and date of injury, specific injury diagnoses, and specific injury mechanisms that occurred across 5 years, from January 1, 2010, through December 31, 2014.

Main Outcomes and Measures

Diagnoses of traumatic TMP documented in the ED visit record as well as patient demographics, diagnoses, and other aspects of the injury, including mechanism of injury.

Results

There were 949 case entries in the database for traumatic TMP, which extrapolates to 4852 ED visits nationally. Of 949 patients evaluated, 568 (59.8%) were men and 381 (40.2%) were women resulting in a male to female ratio of 1.49:1. Most injuries occurred in patients 18 years or younger (602 of 949 [63.4%]) with children younger than 6 years most at risk (331 of 949 [34.9%]). Ear canal instrumentation including foreign bodies was noted in 581 of 949 cases (61.2%), with cotton-tipped applicators noted in 261 (44.9%) of these cases. While foreign body instrumentation represented the leading cause of traumatic TMP in patients aged 0 to 5 years (284 of 331 cases [85.8%]), 6 to 12 years (108 of 158 [68.4%]), 19 to 36 years (85 of 223 [38.1%]), 37 to 54 years (48 of 91 [52.7%]), and 55 years or older (22 of 33 [66.7%]), water trauma was the leading cause of TMP in patients aged 13 to 18 years (43 of 113 cases [38.1%]).

Conclusions and Relevance

Traumatic TMP represents a common reason for evaluation in the ED. Despite common warnings regarding risk of injury to the tympanic membrane with use of a cotton-tipped applicator, it is still a major cause of traumatic TMPs. Other injury mechanisms also play an important role in the teenage and young adult populations.

Craniofacial injuries related to motorized scooter use: A rising epidemic

OBJECTIVES

Over the last decade, there has been increased interest in utilizing motorized scooters for transportation. The limited regulation of this modernized vehicle raises numerous safety concerns. This analysis examines a national database to describe the yearly incidence of craniofacial injuries and patterns of injury related to motorized scooter use.

METHODS

The Consumer Product Safety Commission's National Electronic Injury Surveillance system was queried for craniofacial injuries associated with motorized scooter use. Patient demographics, injury type, anatomic location, injury pattern, and helmet status were extracted for analysis.

RESULTS

From 2008 to 2017, there were 990 recorded events for craniofacial injuries secondary to motorized scooters extrapolating to an estimated 32,001 emergency department (ED) visits. The annual incidence was noted to triple over that 10-year period. The majority of patients were male (62.1%) and the common age groups at presentation were young children 6-12 years old (33.3%), adolescents 13-18 years old (16.1%) and young adults 19-40 years old (18.0%). The most common injury pattern was a closed head injury (36.1%) followed by lacerations (20.5%). Facial fractures were only present in 5.2% of cases. In cases in which helmet use was recorded, 66% of the patients were not helmeted.

CONCLUSION

The incidence of motorized scooter related craniofacial trauma is rising, resulting in thousands of ED visits annually. Many patients are experiencing morbid traumatic injuries and may not be wearing appropriate protective equipment. This study highlights the importance of public awareness and policy to improve safety and primarily prevent craniofacial trauma.

Safety and efficacy of sphenopalatine artery ligation in recalcitrant pediatric epistaxis

BACKGROUND

Epistaxis is a common cause for emergency department visits for both children and adults. In particular, posterior bleeds can be difficult to identify and treat. In adults, endoscopic sphenopalatine artery (SPA) ligation has been shown to be safe, cost-effective, and curative. Conversely, very few studies have delved into the safety and efficacy of SPA ligation in children. This study aims to evaluate the feasibility of SPA ligation for treatment of recalcitrant epistaxis in children.

METHODS

A retrospective analysis of outcomes in pediatric patients who underwent SPA ligation at a tertiary academic center was performed. Patients with coagulopathies or other underlying conditions were excluded from the study.

RESULTS

Data obtained from 5 patients demonstrated 60% of the population were female, with ages ranging from 2 to 13 years. 7 SPA ligations were performed among the 5 patients, with 3 undergoing unilateral SPA ligation only. The remaining 4 underwent contralateral SPA ligation subsequently. No postoperative complications were observed, and all patients experienced resolution of significant epistaxis.

CONCLUSION

Although additional studies are necessary to further support our findings, SPA ligation in the pediatric population appears to be a safe and effective treatment to control persistent posterior bleeds.

Economic Analysis of Using Free Fat Graft or Acellular Dermis to Prevent Post-parotidectomy Frey Syndrome

A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of grafting techniques used to prevent Frey Syndrome. The authors performed a sensitivity analysis to calculate what the probability of preventing Frey Syndrome would have to be and maximum costs associated with using grafting techniques to warrant their use as more “cost-effective” choice than using neither. Decision pathways utilized were uses of (1) free fat graft (FFG), (2) acellular dermis, and (3) no grafting. The probability of developing Frey syndrome and costs were extracted from previous studies to construct the decision tree. The primary effectiveness was the ICER of FFG or acellular dermis to prevent Frey syndrome. The initial outcomes included preventing Frey syndrome (effectiveness = 1) or developing Frey syndrome (effectiveness = 0). Compared with not using a graft, the ICER of using FFG and acellular dermis were $10,628 and $50,813, respectively. Frey syndrome was found in 2.6% of patients postoperatively in FFG group, 9.8% of patients in acellular dermis group, and 30.7% of patients who did not have a graft. The ICER shows absolute dominance of FFG with lower cost and high effectiveness over acellular dermis. This economic evaluation strongly supports the use of FFG over acellular dermis as cost-effective approach for prevention of postparotidectomy Frey syndrome.

Management of Epistaxis in Children and Adolescents: Avoiding a Chaotic Approach

This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation.

Gender disparities in scholarly productivity within academic otolaryngology departments

OBJECTIVE

To examine whether there are gender disparities in scholarly productivity within academic otolaryngology departments, as measured by academic rank and the h-index, a published, objective measure of research contributions that quantifies the number and significance of papers published by a given author.

STUDY DESIGN AND SETTING

Analysis of bibliometric data of academic otolaryngologists.

METHODS

Faculty listings from academic otolaryngology departments were used to determine academic rank and gender. The Scopus database was used to determine h-index and publication range (in years) of these faculty members. In addition, 20 randomly chosen institutions were used to compare academic otolaryngologists to faculty members in other surgical specialties.

RESULTS

Mean h-indices increased through the rank of professor. Among academic otolaryngologists, men had significantly higher h-indices than women, a finding also noted on examination of faculty members from other specialties. Men had higher research productivity rates at earlier points in their career than women did. The productivity rates of women increased and equaled or surpassed those of men later in their careers. Men had higher absolute h-index values at junior academic ranks. Women academic otolaryngologists of senior rank had higher absolute h-indices than their male counterparts.

CONCLUSIONS

The h-index measures research significance in an objective manner and indicates that although men have higher overall research productivity in academic otolaryngology, women demonstrate a different productivity curve. Women produce less research output earlier in their careers than men do, but at senior levels, they equal or exceed the research productivity of men.