Discussion:
Otology as a surgical sub-specialty has seen several technological
advances recently, especially the emergence of minimally invasive
endoscopic techniques that have been applied to a wide variety of
otologic surgical procedures. Looking at similar trends in other
surgical subspecialties that have, to a large extent, adopted minimally
invasive techniques as the standard of surgical care, it is conceivable
that endoscopic techniques may well be the preferred surgical approach
in otology in the near future.
The trend in published evidence suggests that endoscopic management of
cholesteatoma is both safe and efficacious (1,2), with a recent
metanalysis reporting a significantly lower risk of recurrent
cholesteatoma with endoscopic removal of cholesteatoma compared to
microscopic surgery (6).
In addition to safety and efficacy, economics play a major role in
health technology assessments. Initial capital costs along with the
ongoing direct costs are major considerations when introducing a new
technology. This study demonstrates, in a British National Health
Service setting, a direct cost saving of £1463.22 per case of
cholesteatoma managed endoscopically. Similar cost savings have been
demonstrated elsewhere as well, with Patel et al. demonstrating a cost
saving of almost three thousand dollars in an Australian private
healthcare set up (4).The cost savings in our study may be attributed to
two main factors: surgical set up costs and operating theatre running
costs.
Surgical set up costs for microscopic surgery were higher primarily due
to the use of disposable surgical burrs, which comprised 39.8% of the
total. All our endoscopic procedures were carried out with removal of
bone using a curette, leading to a lower surgical set up cost. In
addition, operating theatre running costs for endoscopic ear surgery
were 31.7% lower, due to a shorter mean operating time. This may be
attributed to the reduced need for skin incision, soft-tissue dissection
and temporal bone drilling in the endoscopic approach. Similar trends in
cost comparisons were reported in the Australian healthcare set-up as
well (4).
Our study has a number of limitations. Ours was a retrospective study
with a relatively small sample size. Despite careful attempts at
case-matching in the endoscopic and microscopic groups, differences in
patient co-morbidities and extent of cholesteatoma may have influenced
the duration of surgery. The use of an atticoantrostomy microscopic
approach, as opposed to the combined approach tympanoplasty approach
that we follow in our institution, may influence duration of surgery as
well as number of surgical burrs used. Prospective data collection, with
larger numbers involving multiple surgeons in different institution
would help address these weaknesses in future studies.
Despite the limitations, the direct cost savings reported in this study
may under-represent actual total cost savings, due to exclusion of
indirect costs to both the healthcare system as well as the patient.
Although there is a paucity of published literature in this field, the
lack of need for extensive soft-tissue dissection, mastoid drilling or a
post-aural incision are likely to have an impact on the duration of
in-patient stay, the recovery time, as well as the subjective quality of
life, as was reported by Taneja et al in their review of 152 cases (7).
The economic impact of an early recovery and return to work along with
an improvement in quality of life were beyond the scope of the present
study, and form avenues for future prospective collaborative research.