RESUMO
OBJECTIVE: To evaluate the cost-effectiveness of tympanostomy tube placementvs nonsurgical medical management, with the option of tympanostomy tube placement in the event of treatment failure, in children with recurrent acute otitis media (AOM). STUDY DESIGN: A Markov decision model compared management strategies in children ages 6-35 months, using patient-level data from a recently completed, multicenter, randomized clinical trial of tympanostomy tube placement vs medical management. The model ran over a 2-year time horizon using a societal perspective. Probabilities, including risk of AOM symptoms, were derived from prospectively collected patient diaries. Costs and quality-of-life measures were derived from the literature. We performed one-way and probabilistic sensitivity analyses, and secondary analyses in predetermined low- and high-risk subgroups. The primary outcome was incremental cost per quality-adjusted life-year gained. RESULTS: Tympanostomy tubes cost $989 more per child than medical management. Children managed with tympanostomy tubes gained 0.69 more quality-adjusted life-days than children managed medically, corresponding to $520 855 per quality-adjusted life-year gained. Results were sensitive to the costs of oral antibiotics, missed work, special childcare, the societal cost of antibiotic resistance, and the quality of life associated with AOM. In probabilistic sensitivity analyses, medical management was favored in 66% of model iterations at a willingness-to-pay threshold of $100 000/quality-adjusted life-year. Medical management was preferred in secondary analyses of low- and high-risk subgroups. CONCLUSIONS: For young children with recurrent AOM, the additional cost associated with tympanostomy tube placement outweighs the small improvement in quality of life. Medical management for these children is an economically reasonable strategy. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT02567825.
Assuntos
Otite Média , Qualidade de Vida , Criança , Humanos , Lactente , Pré-Escolar , Análise Custo-Benefício , Recidiva Local de Neoplasia/tratamento farmacológico , Recidiva Local de Neoplasia/cirurgia , Otite Média/terapia , Otite Média/diagnóstico , Antibacterianos/uso terapêutico , Ventilação da Orelha MédiaRESUMO
OBJECTIVE: Tympanostomy is one of the most commonly performed surgical procedures in otolaryngology, and its complexity is challenging for trainee surgeons. Investing in medical education is a cornerstone of good patient safety practices. For trainees, use of simulators before operating on actual patients helps mitigate risks. This study aimed to develop a three-dimensional printed model simulator for myringotomy, tympanostomy and ventilation tube placement. METHODS: An articulated model with a detachable portion, base and plastic bag to simulate the external auditory canal, middle ear and tympanic membrane, respectively, was modelled and printed. RESULTS: The final simulator was made from acrylonitrile butadiene styrene polymer and measured 4 × 4 × 12 cm. It was designed to mimic the angulation of patient anatomy in the myringotomy position and simulate the texture and colour of the tissues of interest. The cost was low, and testing with an operating microscope and endoscope yielded satisfactory results. The advent of three-dimensional printing technology has made surgical simulation more accessible and less expensive, providing several advantages for medical education. CONCLUSION: The proposed model fulfilled expectations as a safe, inexpensive, reproducible, user-friendly and accessible surgical education tool that can be improved and reassessed for further research.
Assuntos
Endoscopia/educação , Microcirurgia/educação , Ventilação da Orelha Média/educação , Modelos Anatômicos , Impressão Tridimensional , Treinamento por Simulação , Adulto , Criança , Pré-Escolar , Competência Clínica , Humanos , Internato e ResidênciaRESUMO
ABSTRACT Objective: To discuss aspects of pre and post-operative otorhinolaryngology surgery in patients with glycogen storage disease type 1b. Case description: Description of three clinical cases with probable glycogen storage disease type 1b who underwent otorhinolaryngology surgery, showing the importance of multidisciplinary interaction to avoid episodes of hypoglycemia. Comments: Patients with glycogen storage disease type 1b present recurrent infections, including the otorhinolaryngology affections. When there is an indication for surgical treatment, the caloric intake should be carefully followed in order to prevent hypoglycemia. The way to ensure this is to perform the pre and postoperative period in the hospital ward. In the postoperative period, it is important to make a slow transition between the intravenous and oral routes and not suspend the infusion of glucose during the surgical procedure. The cases illustrate the need for the interaction of the otorhinolaryngologic surgeon with the anesthesiologist, the pediatrician and the gastro-pediatrician in the management of these patients, avoiding hypoglycemic episodes.
RESUMO Objetivo: Discutir aspectos de pré e pós-operatório de cirurgia otorrinolaringológica em pacientes com glicogenose tipo 1b. Descrição do caso: Descrição de três casos clínicos com provável glicogenose tipo 1b, que se submeteram à cirurgia otorrinolaringológica, mostrando a importância da interação multidisciplinar para evitar os episódios de hipoglicemia. Comentários: Pacientes com glicogenose tipo 1b apresentam infecções de repetição, incluindo as otorrinolaringológicas. Quando há indicação de tratamento cirúrgico, deve-se observar a garantia de aporte calórico para evitar hipoglicemia. A maneira de fazer isso é efetuar o pré e pós-operatório em enfermaria, tomando-se o cuidado, no pós-operatório, de realizar uma transição lenta entre a via endovenosa e a via oral e de não suspender a infusão de glicose durante o procedimento cirúrgico. Os casos ilustram a necessidade da interação do otorrinolaringologista com o anestesista, o pediatra e o gastropediatra na condução desses pacientes para que não desenvolvam hipoglicemia.
Assuntos
Humanos , Feminino , Criança , Tonsilectomia , Ventilação da Orelha Média , Adenoidectomia , Doença de Depósito de Glicogênio Tipo I/cirurgia , Assistência Perioperatória/métodosRESUMO
OBJECTIVE: To discuss aspects of pre and post-operative otorhinolaryngology surgery in patients with glycogen storage disease type 1b. CASE DESCRIPTION: Description of three clinical cases with probable glycogen storage disease type 1b who underwent otorhinolaryngology surgery, showing the importance of multidisciplinary interaction to avoid episodes of hypoglycemia. COMMENTS: Patients with glycogen storage disease type 1b present recurrent infections, including the otorhinolaryngology affections. When there is an indication for surgical treatment, the caloric intake should be carefully followed in order to prevent hypoglycemia. The way to ensure this is to perform the pre and postoperative period in the hospital ward. In the postoperative period, it is important to make a slow transition between the intravenous and oral routes and not suspend the infusion of glucose during the surgical procedure. The cases illustrate the need for the interaction of the otorhinolaryngologic surgeon with the anesthesiologist, the pediatrician and the gastro-pediatrician in the management of these patients, avoiding hypoglycemic episodes.
Assuntos
Adenoidectomia , Doença de Depósito de Glicogênio Tipo I/cirurgia , Ventilação da Orelha Média , Assistência Perioperatória/métodos , Tonsilectomia , Criança , Feminino , HumanosRESUMO
OBJECTIVE: To analyze the incidence of otorrhea in the postoperative period of patients submitted to tympanotomy to place ventilation tube, and who did not protect the ear when exposed to water. METHODS: Open, randomized-controlled trial. Eighty patients submitted to unilateral or bilateral ear grommet tympanostomy were included and divided into two groups: Auricular Protection and Non-Protection to water during bathing and activities in water. RESULTS: In the first postoperative month, the Non-Protection Group presented a significant increase in the number of patients with otorrhea and in the incidence. Four patients of the Protection Group (11%) presented at least one episode of otorrhea in this period, representing an incidence of 0.11 (standard deviation ±0.32) episode/month, whereas in the Non-Protection Group there were 12 episodes (33%; p=0.045) and incidence of 0.33 (±0.48; p=0.02). Between the 2nd and the 13th postoperative months, there was no difference between groups. Seven patients in the Protection Group (20%) had at least one episode of otorrhea, representing an incidence of 0.04 (±0.09) episodes/month, while in the Non-Protection Group there were seven episodes (22%; p=0.8) and incidence of 0.05 (±0.1; p=0.8). CONCLUSION: Patients who underwent ear protection when exposed to water had a lower incidence of otorrhea in the first postoperative month than those who did not undergo protection. From the second month, there was no difference between groups.
Assuntos
Ventilação da Orelha Média/efeitos adversos , Otite Média Supurativa/etiologia , Otite Média Supurativa/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Água/efeitos adversos , Adolescente , Adulto , Banhos/efeitos adversos , Brasil/epidemiologia , Criança , Pré-Escolar , Dispositivos de Proteção das Orelhas , Feminino , Humanos , Incidência , Lactente , Modelos Logísticos , Masculino , Otite Média Supurativa/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Estatísticas não Paramétricas , Natação , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: To determine whether privately owned ambulatory surgery centers (ASCs) increase pediatric tympanostomy tube use in their surrounding communities. STUDY DESIGN: We studied children <5 years of age who underwent outpatient tympanostomy tube placement in New York or Florida in 2010-2014. Data came from the Healthcare Cost and Utilization Project State Ambulatory Surgery Databases, which include all outpatient surgeries in these states. Population characteristics came from the US Census' American Community Survey. Weighted conditionally autoregressive models were used to assess the association between the zip code-level proportion of tympanostomy tube procedures performed in privately owned ASCs and the rate of tympanostomy tube use. RESULTS: In 2010-2014, 106 privately owned ASCs in Florida and 29 in New York performed tympanostomy tube placement in young children. After accounting for zip code-level urban/rural status, socioeconomic status (SES), and the proportion of residents of non-Hispanic white race, children residing in zip codes in the top tertile of privately owned ASC use in Florida had 52% greater tympanostomy tube use than children from zip codes in the bottom tertile (P < .001). In New York, high-SES zip codes with any use of privately owned ASCs had 2.6 times greater tympanostomy tube use than other high-SES zip codes (P < .001). This association was not present in low-SES areas. CONCLUSIONS: The presence of privately owned ASCs is associated with increased tympanostomy tube use in young children.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Ventilação da Orelha Média/estatística & dados numéricos , Otite Média com Derrame/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Prática Privada/estatística & dados numéricos , Pré-Escolar , Bases de Dados Factuais , Feminino , Florida , Humanos , Lactente , Masculino , New YorkRESUMO
ABSTRACT Objective To analyze the incidence of otorrhea in the postoperative period of patients submitted to tympanotomy to place ventilation tube, and who did not protect the ear when exposed to water. Methods Open, randomized-controlled trial. Eighty patients submitted to unilateral or bilateral ear grommet tympanostomy were included and divided into two groups: Auricular Protection and Non-Protection to water during bathing and activities in water. Results In the first postoperative month, the Non-Protection Group presented a significant increase in the number of patients with otorrhea and in the incidence. Four patients of the Protection Group (11%) presented at least one episode of otorrhea in this period, representing an incidence of 0.11 (standard deviation ±0.32) episode/month, whereas in the Non-Protection Group there were 12 episodes (33%; p=0.045) and incidence of 0.33 (±0.48; p=0.02). Between the 2nd and the 13th postoperative months, there was no difference between groups. Seven patients in the Protection Group (20%) had at least one episode of otorrhea, representing an incidence of 0.04 (±0.09) episodes/month, while in the Non-Protection Group there were seven episodes (22%; p=0.8) and incidence of 0.05 (±0.1; p=0.8). Conclusion Patients who underwent ear protection when exposed to water had a lower incidence of otorrhea in the first postoperative month than those who did not undergo protection. From the second month, there was no difference between groups.
RESUMO Objetivo Avaliar a incidência de otorreia no período pós-operatório em pacientes submetidos à timpanotomia para colocação de tubo de ventilação e que não realizaram proteção auricular quando expostos à água. Métodos Ensaio clínico controlado, aberto e randomizado. Foram incluídos 80 pacientes submetidos à timpanotomia para colocação de tubo de ventilação unilateral ou bilateral, divididos em dois grupos: Grupo Proteção e Grupo Não Proteção auricular da água durante o banho e as atividades aquáticas. Resultados No primeiro mês pós-operatório, o Grupo Não Proteção apresentou aumento significativo tanto no número de pacientes com otorreia quanto na incidência. Quatro pacientes do Grupo Proteção (11%) apresentaram ao menos um episódio de otorreia neste período, representando incidência de 0,11 (desvio padrão ±0,32) episódio/mês, enquanto no Grupo Não Proteção ocorreram 12 episódios (33%; p=0,045) e incidência de 0,33 (±0,48; p=0,02). Entre o 2º e o 13º meses pós-operatórios, não houve diferença entre os grupos. Sete pacientes do Grupo Proteção (20%) apresentaram ao menos um episódio de otorreia, representando incidência de 0,04 (±0,09) episódios/mês, enquanto no Grupo Não Proteção foram registrados sete episódios (22%; p=0,8) e incidência de 0,05 (±0,1; p=0,8). Conclusão Pacientes que realizaram a proteção auricular quando expostos à água apresentaram menor incidência de otorreia no primeiro mês pós-operatório do que aqueles que não a realizaram. A partir do segundo mês, não houve diferença entre os grupos.
Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Adulto , Adulto Jovem , Otite Média Supurativa/etiologia , Otite Média Supurativa/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Água/efeitos adversos , Ventilação da Orelha Média/efeitos adversos , Otite Média Supurativa/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Natação , Fatores de Tempo , Banhos/efeitos adversos , Brasil/epidemiologia , Modelos Logísticos , Incidência , Fatores de Risco , Resultado do Tratamento , Estatísticas não Paramétricas , Dispositivos de Proteção das OrelhasRESUMO
OBJECTIVE: To review an institutional experience with the surgical and clinical management of acquired middle ear cholesteatoma in patients with ectrodactyly, ectodermal dysplasia, cleft lip/palate (EEC) syndrome. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Eight patients with medical history significant for EEC syndrome who underwent surgery for acquired middle ear cholesteatoma between 1996 and 2016. INTERVENTION(S): Appropriate surgical interventions at the time of admission. MAIN OUTCOME MEASURE(S): History of ventilation tube insertion, status of the contralateral ear, surgical technique, cholesteatoma recidivism, presence of postoperative external auditory canal stenosis, pre and postoperative audiograms. RESULTS: Cholesteatoma was diagnosed in all patients, 3 (37.5%) unilateral and 5 (62.5%) bilateral, totalizing 13 ears. Six ears (46.2%) underwent a canal wall up mastoidectomy but required conversion to a canal wall down technique in a second procedure due to recurrent cholesteatoma. In the remaining seven ears (53.8%) a canal wall down mastoidectomy was performed. Of all meatoplasty performed, seven (53.8%) evolved with stenosis of the external auditory canal. CONCLUSIONS: Our results suggest that most patients with EEC syndrome and middle ear cholesteatoma should be considered for a canal wall down mastoidectomy due to extensive disease and a high rate of recidivism. In addition, a high percentage of postoperative stenosis of the external auditory canal was found in this group.