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.