Cost-comparison analysis of diffusion weighted magnetic resonance imaging (DWMRI) versus second look surgery for the detection of residual and recurrent cholesteatoma

Cost-Effectiveness of Diffusion Weighted MRI Versus Planned Second-Look Surgery for Cholesteatoma

OBJECTIVE

To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma.

METHODS

A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY.

RESULTS

Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations.

CONCLUSION

Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized.

LEVEL OF EVIDENCE

V.

Canal-wall up cholesteatoma surgery with mastoid obliteration leads to lower rates of disease recurrence without affecting hearing outcomes

Objectives

The primary objective was to determine whether obliteration of the epitympanic area and mastoid cavity during canal wall up (CWU) cholesteatoma surgery reduces the rate of recurrent and residual cholesteatoma compared to not obliterating the same area. The secondary objective was to compare postoperative hearing outcomes between both techniques.

Methods

A retrospective cohort study was conducted in a tertiary referral center. One-hundred-fourty-three ears were included of patients (≥18y) who underwent a CWU tympanomastoidectomy for cholesteatoma with or without bony obliteration between January 2015 and March 2020 in the University Medical Center Utrecht. The median follow-up was respectively 1.4 (IQR 1.1-2.2) vs. 2.0 years (IQR 1.2-3.1) (p = 0.013).

Interventions

All patients underwent CWU tympanomastoidectomy for cholesteatoma. For 73 ears bone dust, Bonalive® or a combination was used for obliteration of the mastoid and epitympanic area, the rest of the ears (n = 70) were not obliterated. In accordance with the Dutch protocol, included patients are planned to undergo an MRI scan with diffusion-weighted imaging (DWI) one, three and five years after surgery to detect recurrent or residual cholesteatoma.

Main outcome measures

The primary outcome measure was recurrent and residual cholesteatoma as evaluated by MRI-DWI and/or micro-otoscopy and confirmed by micro-otoscopy and/or revision surgery. The secondary outcome measure was the postoperative hearing.

Results

In this cohort, the group treated with canal wall up tympanomastoidectomy with subsequent bony obliteration (73 ears, 51.0%) had significantly lower recurrent (4.1%) and residual (6.8%) cholesteatoma rates than the group without obliteration (70 ears, 25.7% and 20.0%, respectively; p < 0.001). There was no significant difference between both groups in postoperative bone conduction thresholds (mean difference 2.7 dB, p = 0.221) as well as the mean air-bone gap closure 6 weeks after surgery (2.3 dB in the non-obliteration and 1.5 dB in the obliteration group, p = 0.903).

Conclusions

Based on our results, a canal wall up tympanomastoidectomy with bony obliteration is the treatment of choice, since the recurrent and residual disease rate is lower compared to the group without obliteration. The bony obliteration technique does not seem to affect the perceptive or conductive hearing results, as these are similar between both groups.

Brain health measurement: a scoping review

OBJECTIVES

Preservation of brain health is an urgent priority for the world's ageing population. The evidence base for brain health optimisation strategies is rapidly expanding, but clear recommendations have been limited by heterogeneity in measurement of brain health outcomes. We performed a scoping review to systematically evaluate brain health measurement in the scientific literature to date, informing development of a core outcome set.

DESIGN

Scoping review.

DATA SOURCES

Medline, APA PsycArticles and Embase were searched through until 25 January 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they described brain health evaluation methods in sufficient detail in human adults and were in English language.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened titles, abstracts and full texts for inclusion and extracted data using Covidence software.

RESULTS

From 6987 articles identified by the search, 727 studies met inclusion criteria. Study publication increased by 22 times in the last decade. Cohort study was the most common study design (n=609, 84%). 479 unique methods of measuring brain health were identified, comprising imaging, cognitive, mental health, biological and clinical categories. Seven of the top 10 most frequently used brain health measurement methods were imaging based, including structural imaging of grey matter and hippocampal volumes and white matter hyperintensities. Cognitive tests such as the trail making test accounted for 286 (59.7%) of all brain health measurement methods.

CONCLUSIONS

The scientific literature surrounding brain health has increased exponentially, yet measurement methods are highly heterogeneous across studies which may explain the lack of clinical translation. Future studies should aim to develop a selected group of measures that should be included in all brain health studies to aid interstudy comparison (core outcome set), and broaden from the current focus on neuroimaging outcomes to include a range of outcomes.

Cost-Effectiveness of Diffusion-Weighted Magnetic Resonance Imaging Versus Second-Look Surgery in Treating Cholesteatoma: A Modeling Study

OBJECTIVE

To evaluate whether canal wall-up (CWU) tympanomastoidectomy with diffusion-weighted magnetic resonance imaging (DW-MRI) is a cost-effective method of treating cholesteatoma compared with CWU with second-look surgery.

DESIGN AND SETTING

Cost-effectiveness analysis was conducted using a Markov state transition model. The simulation model adhered to the Panel Recommendations on Cost-Effectiveness in Health and Medicine established by the US Public Health Service. One-way and Monte Carlo probability sensitivity analyses were conducted for validation.

INTERVENTIONS

Tympanomastoidectomy with DW-MRI versus tympanomastoidectomy with second-look surgery.

MAIN OUTCOME MEASURES

Effectiveness and health utility were measured using quality-adjusted life years (QALYs). Costs were derived from Medicare reimbursement using the perspective of the payer. Probabilities for outcomes and complications were taken from existing literature. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio.

RESULTS

With base case analysis, the total cost was $15,069 when treated with CWU and second-look surgery versus $13,126 when treated with CWU and DW-MRI. The second-look treatment pathway yielded 17.05 QALYs, whereas the DW-MRI pathway yielded 16.91 QALYs in terms of health benefit accrued across the lifetime of the patient. The cost-effectiveness incremental cost-effectiveness ratio was $21,800/QALY. Using the conventional $50,000 willingness-to-pay threshold, second-look surgery was the more cost-effective approach 63.7% of the time by simulation.

CONCLUSIONS

Both treatment pathways were found to be cost-effective, with second-look surgery incrementally cost-effective 63.7% of the time. Assumptions were validated by one-way and Monte Carlo probability sensitivity analysis.

PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED

There is ample variation in treatment pathways regarding usage of DW-MRI and second-look surgery for cholesteatoma.

LEARNING OBJECTIVE

To evaluate the cost-effectiveness of DW-MRI and second-look surgery approaches, accounting for health-related quality-of-life outcomes and costs for the duration of the patient lifetimes.

DESIRED RESULT

To inform the discussion on the treatment for cholesteatoma given emergent noninvasive technologies.Level of Evidence: Level III.Indicate IRB or IACUC: Exempt.

[Diagnosis and treatment of congenital temporal bone cholesteatoma]

Congenital temporal bone cholesteatoma is a rare lesion in otolaryngology.The disease is locally invasive and may lead to significant complications,including hearing loss（conductive or sensorineural）, temporal bone destruction and intracranial invasion. This article reviews the characteristic symptoms of congenital temporal bone cholesteatoma, testing and imaging of the disease, stage and the current treatment options in order to promote awareness to this rare disease entity and perform early surgical treatment, effectively avoid the destruction of the temporal bone and its surrounding structures, thereby reducing the occurrence of complications. By improving the understanding of the disease and performing early surgical treatment, the destruction of the temporal bone and its surrounding structures can be effectively avoided, thereby reducing the occurrence of complications.

Updates in paediatric cholesteatoma

PURPOSE OF REVIEW

The management of paediatric patients with cholesteatoma is complex, as the disease process is more aggressive in children than adults. New technologies and practice adaptations currently help optimize the surgical management and monitoring of these challenging patients.

RECENT FINDINGS

Several options of surgical management are available and are associated with equal if not improved outcomes. Technologic advancements in endoscopic ear surgery, the discovery of chemical-assisted dissection of cholesteatoma and advanced imaging protocols have enabled surgeons to better care for patients with this complex disease process.

SUMMARY

The advances in endoscopic ear surgery, the discovery of Mesna as a chemically assisted dissection agent to improve recidivism rates and the use of specific diffusion-weighted MRI protocols enable the otologic surgeon to better care for these paediatric patients.

Non-echo Planar Diffusion-Weighted Imaging in the Detection of Recurrent or Residual Cholesteatoma: A Systematic Review and Meta-Analysis of Diagnostic Studies

We performed a systematic review and meta-analysis of patients with suspected recurrent cholesteatoma who underwent non-echo planar imaging (non-EPI) using diffusion-weighted magnetic resonance imaging (MRI), with surgery as the reference standard. We searched Medline, Google Scholar, and the Cochrane database for diagnostic test accuracy studies. The following prespecified subgroup analyses were performed: patient age, number of radiologists interpreting MRI, study design, and risk of bias. We used a bivariate model using a generalized linear mixed model to pool accuracies. Of the 460 records identified, 32 studies were included, of which 50% (16/32) were low risk of bias. The overall pooled sensitivity was 92.2% (95% CI 87.3-95.3%), and specificity was 91.7% (85.2-95.5%). The positive likelihood ratio was 11.1 (4.5-17.8), and the negative likelihood ratio was 0.09 (0.04-0.13). The pooled diagnostic odds ratio was 130.3 (20.5-240). Heterogeneity was moderate on visual inspection of the hierarchical summary receiver operating characteristic curve. Subgroup analyses showed prospective studies reporting higher accuracies (p=0.027), which were driven by higher specificity (prospective 93.1% (88.4-96.0%) versus retrospective 81.2% (81.0-81.4%)). There was no difference in subgroups comparing patient age (p=0.693), number of radiologists interpreting MRI (p=0.503), or risk of bias (p=0.074). No publication bias was detected (p=0.98). In conclusion, non-EPI is a highly sensitive and specific diagnostic test able to identify recurrent cholesteatomas of moderate to large sizes. This test can be considered a non-invasive alternative to second-look surgery.

The Clinical Role of Diffusion-Weighted MRI for Detecting Residual Cholesteatoma in Canal Wall up Mastoidectomy

OBJECTIVES

The purpose of this study was to assess the value of the diffusion MRI with the non-echoplanar imaging (Non-EPI) technique for follow-up the post-operative patients to detect residual cholesteatomas.

STUDY DESIGN

This prospective study was performed on 40 patients. All patients were at least one year after Canal Wall Up mastoidectomy surgery for cholesteatoma and scheduled for a second-look surgery.

PATIENTS AND METHODS

This prospective study was performed on 40 patients. All patients were subjected to Canal Wall Up surgery and planned for the second-look operation. After one year as removal of choleasteatoma is uncertain in first surgery. The study done at Tertiary referral centers (Ain shams, Mansoura, and Minia university hospitals), non-echoplanar diffusion MRI (NEP-DWI) technique for follow-up the post-operative patients to detect residual cholesteatomas, then second look surgery done 2 weeks after MRI.

RESULTS

Forty patients underwent MRI with Non-echoplanar diffusion-weighted imaging (NEP-DWI). Twenty-six patients had positive MRI results with the remaining 14 patients had negative results. These results were compared to operative findings. All positive MRI cases showed positive intra-operative findings. Ten of negative MRI cases showed negative intra-operative findings. Four of DWI-negative cases showed small cholesteatomas.

CONCLUSION

The use of NEP-DWI is a valuable tool in detecting residual cholesteatoma that could replace the second look surgery in many cases.

Accuracy of 2D BLADE Turbo Gradient- and Spin-Echo Diffusion Weighted Imaging for the Diagnosis of Primary Middle Ear Cholesteatoma

OBJECTIVE

To evaluate the diagnostic accuracy of 2D BLADE turbo gradient- and spin-echo diffusion weighted imaging (TGSE BLADE DWI) for primary middle ear cholesteatoma diagnosis, using qualitative and quantitative methods.

STUDY DESIGN

Retrospective case series.

SETTING

University hospital.

PATIENTS

Participants included those with suspected primary middle ear cholesteatoma after assessment by clinical otorhinolaryngologists combined with magnetic resonance imaging (MRI) examination. Finally, of the 85 ears from 65 patients enrolled in the study, 73 had cholesteatoma, and 12 had otitis media.

INTERVENTION

Two radiologists independently assessed images and measured apparent diffusion coefficient (ADC) values. Sensitivity, specificity and accuracy were evaluated. Kappa (k) statistics, the intraclass correlation coefficient (ICC), the Kolmogorov-Smirnov normality test, the independent t test, and receiver operating characteristic (ROC) analysis were used for statistical analysis. Pair-wise comparison of the area under the ROC curve (AUC) was also performed using the Delong test.

MAIN OUTCOME MEASURES

Imaging and histopathologic findings.

RESULTS

The mean ADC value of cholesteatoma group (mean, 0.923 ± 0.246 × 10 -3 mm 2 /s) was significantly lower than that of noncholesteatoma group (mean, 1.744 ± 0.205 × 10 -3 mm 2 /s; p < 0.001). In ≤3 mm cholesteatoma group, the AUC of qualitative DWI was 0.846; the sensitivity, specificity, and accuracy for diagnosing cholesteatoma were 69.23%, 100%, and 84%, respectively; while the AUC of quantitative diagnosis was significantly increased to 1.0 ( p = 0.0209); and based on the optimal threshold of ADC, ≤1.352 × 10 -3 mm 2 /s, the sensitivity, specificity and accuracy improved to 100%. For >3 mm cholesteatoma group, there were no significant differences in diagnostic performance. Excellent interobserver agreement and ICC for the qualitative and quantitative evaluations (k = 0.90 and ICC = 0.80, respectively) was noted between reviewers.

CONCLUSION

TGSE BLADE DWI is useful for the detection of primary middle ear cholesteatomas, especially ≤3 mm lesions.

Detection of cholesteatoma: 2D BLADE turbo gradient- and spin-echo imaging versus readout-segmented echo-planar diffusion-weighted imaging

PURPOSE

This study is to compare the accuracy of 2D BLADE turbo gradient- and spin-echo imaging (TGSE BLADE) diffusion-weighted imaging (DWI) with that of readout-segmented echo-planar (RESOLVE) DWI in the detection of primary and residual/recurrent temporal bone cholesteatoma.

METHODS

The prospective study population consisted of 58 patients who were underwent magnetic resonance (MR) imaging for the evaluation of suspected temporal bone cholesteatoma. Two radiologists independently evaluated the two sequences. Kappa (k) statistics, the intra-class correlation coefficient (ICC), and a paired t test were used for statistical analysis.

RESULTS

Of the 58 patients included, all had histo-pathologically confirmed cholesteatomas. In ≤ 3 mm group (n = 13), TGSE BLADE sequence correctly identified all cases except one that was recorded as equivocal on both sequences because of high signal intensity on T1WI; while on RESOLVE sequences, 6 were positive, 4 were equivocal, and 3 were false negative. For > 3 mm group (n = 45), detection performance was similar between the two sequences. The mean ADC of cholesteatoma on TGSE BLADE DWI was 0.923 × 10^-3 mm²/s, and the mean ADC of cholesteatoma on RESOLVE DWI was 0.949 × 10^-3 mm²/s, with no significant difference in the mean ADC values of cholesteatoma measured on the two sequences (p = 0.9216).

CONCLUSION

TGSE BLADE outperforms RESOLVE in the detection of small temporal bone cholesteatoma ≤ 3 mm.

Optimal Duration of MRI Follow-up to Safely Identify Middle Ear Residual Cholesteatoma

BACKGROUND AND PURPOSE

Previous studies have demonstrated the usefulness of non-EPI DWI for detection of residual cholesteatoma. However, limited data are available to determine the suitable duration of imaging follow-up after a first MR imaging with normal findings has been obtained. The present study aimed to determine the optimal duration of non-EPI DWI follow-up for residual cholesteatoma.

MATERIALS AND METHODS

A retrospective, monocentric study was performed between 2013 and 2019 and included all participants followed up after canal wall up tympanoplasty with at least 2 non-EPI DWI examinations performed on the same 1.5T MR imaging scanner. MR images were reviewed independently by 2 radiologists. Sensitivity and specificity values were calculated as a function of time after the operation. Receiver operating characteristic curves were analyzed to determine the optimal follow-up duration.

RESULTS

We analyzed 47 MRIs from 17 participants. At the end of the individual follow-up period, a residual cholesteatoma had been found in 41.1% of cases. The follow-up duration ranged from 20 to 198 months (mean, 65.9 [SD, 43.9] months). Participants underwent between 2 and 5 non-EPI DWI examinations. Analyses of the receiver operating characteristic curves revealed that the optimal diagnostic value of non-EPI DWI occurred 56 months after the operation when the first MR imaging performed a mean of 17.3 (SD, 6.8) months after the operation had normal findings (sensitivity = 0.71; specificity = 0.7, Youden index = 0.43).

CONCLUSIONS

Repeat non-EPI DWI is required to detect slow-growing middle ear residual cholesteatomas. We, therefore, recommend performing non-EPI DWI for at least the first 5 years after the initial operation.

Non-EPI versus Multishot EPI DWI in Cholesteatoma Detection: Correlation with Operative Findings

BACKGROUND AND PURPOSE

Although multishot EPI (readout-segmented EPI) has been touted as a robust DWI sequence for cholesteatoma evaluation, its efficacy in disease detection compared with a non-EPI (eg, HASTE) technique is unknown. This study sought to compare the accuracy of readout-segmented EPI with that of HASTE DWI in cholesteatoma detection.

MATERIALS AND METHODS

A retrospective review was completed of consecutive patients who underwent MR imaging for the evaluation of suspected primary or recurrent/residual cholesteatomas. Included patients had MR imaging examinations that included both HASTE and readout-segmented EPI sequences and confirmed cholesteatomas on a subsequent operation. Two neuroradiologist reviewers assessed all images, with discrepancies resolved by consensus. The ratio of signal intensity between the cerebellum and any observed lesion was noted.

RESULTS

Of 23 included patients, 12 (52.2%) were women (average age, 47.8 [SD, 25.2] years). All patients had surgically confirmed cholesteatomas: Six (26.1%) were primary and 17 (73.9%) were recidivistic. HASTE images correctly identified cholesteatomas in 100.0% of patients. On readout-segmented EPI sequences, 16 (69.6%) were positive, 5 (21.7%) were equivocal, and 2 (8.7%) were falsely negative. Excellent interobserver agreement was noted between reviews on both HASTE (κ = 1.0) and readout-segmented EPI (κ = 0.9) sequences. The average signal intensity ratio was significantly higher on HASTE than in readout-segmented EPI, facilitating enhanced detection (mean difference 0.5; 95% CI, 0.3-0.8; P = .003).

CONCLUSIONS

HASTE outperforms readout-segmented EPI in the detection of primary cholesteatoma and disease recidivism.

Limitations of non-echo planar diffusion weighted magnetic resonance imaging (non-EPI MRI) in cholesteatoma surveillance after ossicular chain reconstruction. A prospective study

OBJECTIVE

Non-echo planar diffusion weighted magnetic resonance imaging is a reliable surveillance tool of residual cholesteatoma nowadays. It is not known whether the material of the ossicular chain prosthesis modifies the sensitivity and specificity of MRI in these cases. The aim of the study was to compare the sensitivity, specificity and a localization-specific accuracy of non-EPI DW MRI sequences for residual cholesteatoma in the following 3 subgroups: patients with titanium ossicular prosthesis (group T), with autologous cortical bone columella (group A) or without any reconstruction (group WR) of hearing bones.

METHODS

This prospective study covered 28 cases with cholesteatoma of the middle ear undergone second-look surgery, who had preoperative PROPELLER DW-MRI. Surgical findings were compared to the results of the DWI-MRI.

RESULTS

The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were: 0.76-0.8-0.76-0.8. Group T, group A and group WR sensitivity was 0.83-0.6-1, specificity: 0.75-0.75-0.85, PPV: 0.83-0.75-0.66, NPV: 0.75-0.6-1. Overall accuracy was 0.78. Size of missed cholesteatoma was 2-4 mm (mean: 2.66±1.15).

CONCLUSIONS

Various materials are suitable for ossicular chain reconstruction. The poor detectability of residual or recurrent cholesteatoma in the middle ears reconstructed with autologous bony prosthesis may still claim second-look surgery instead of the usage of non- EPI DWI sequences independently in these patients.

Novel Radiologic Approaches for Cholesteatoma Detection: Implications for Endoscopic Ear Surgery

Technological advancement in computed tomography (CT) and MRI has improved cholesteatoma detection rates considerably in the past decade. Accurately predicting disease location and extension is essential for staging, planning, and preoperative counseling, in particular in the newer approach of endoscopic ear surgery. Improved sensitivity and specificity of these radiological methods may allow the surgeon to confidently monitor patients, therefore avoiding unnecessary surgery. This article outlines recent advances in CT and MRI technology and advantages and disadvantages of the newer techniques. Emphasis on improving the feedback loop between the radiologist and surgeon will increase the accuracy of these new technologies.