title: Canal atresia: "surgery or implantable hearing devices? The expert's question is revisited".
abstract: OBJECTIVE
  (1) Evaluate hearing results in patients managed with external auditory canal reconstruction; (2) compare results to the expectations from treatment with surgical; placement of an osteo-integrated bone-conduction device (BAHA system); (3) assess complications of both interventions; (4) evaluate the medical cost-effectiveness of each avenue of management at 2005 rates for billings based upon relative value units (RVUs).
  
  
  METHODS
  (1) Retrospective chart review for 36 ears in 29 pediatric patients who underwent surgical canal reconstruction at a tertiary-care pediatric hospital in a major urban center with assessment of management techniques and surgical and audiologic outcomes. (2) Retrospective chart review of six pediatric patients who underwent BAHA placement in a major urban center with assessment of management techniques and surgical and audiologic outcomes. (3) Cost reassessment at 2005 billings rates based upon RVUs for canal reconstruction versus BAHA system and comparative analysis.
  
  
  RESULTS
  (1) The average post-operative hearing loss in the right ear was 34.3 dB left ear was 31.6 dB. The average gain per ear was 17.3 dB. (2) Twenty-seven (93%) of EAC reconstruction patients required some form of amplification post-operatively. (3) Data available for three of the BAHA patients reflected the predicted average gain in dB (predicted 34.3 dB, observed 31.8 dB). (4) Early complications of canal reconstruction included removal of the packing by the patient, post-operative bleeding and post-operative hematoma. (5) Late complications included recurrent canal stenosis, recurrent otitis externa, canal prolapse and canal cholesteatoma. (6) Uncomplicated external auditory canal reconstruction cost $51,505.98 or $2909.94/dB of hearing gain based upon billings fro RVUs. (7) Uncomplicated two-staged BAHA system placement cost $42,448.85 or $1237.57/dB of hearing gain based upon billings for RVUs. (8) Uncomplicated single-staged BAHA system placement cost $28,341.00 or $826.27/dB of hearing gain based upon billings for RVUs.
  
  
  CONCLUSIONS
  Study results indicate that even with significant investments in EAC reconstruction, most patients still required some form of amplification. There are also significant risks of early and late complications from the reconstructive procedure. Studies indicate and our results support that the osteo-integrated bone-conduction device (BAHA system) can achieve truly acceptable hearing (<or=15 dB) in school-aged children with normal bone curves, and it can match the bone-curves for children with sensorineural hearing loss. The two-staged BAHA system placement may be provided at almost one-third the cost to the medical system, on a decibel-for-decibel basis. The single-stage BAHA system placement yields even greater cost savings at just over one-quarter of the cost of surgical EAC reconstruction on a decibel-for-decibel basis. Additionally, there are fewer complications and fewer follow-up visits for the care of the implant system. This is an added value to the parents and patient for the savings in opportunity costs related to the lost time at work and school for office visits and peri-operative care. Overall, it appears that osteo-integrated bone-conduction devices may provide a higher quality of outcome for patients while resulting in significant economic savings.
authors.affiliation: Duke University Medical Center and Duke School of Medicine/Duke Children's Center, DUMC 3805, Durham, NC 27710, United States. adele.evans@duke.edu
authors.forename: Adele Karen
authors.initials: AK
authors.lastname: Evans
authors.forename: Ken
authors.initials: K
authors.lastname: Kazahaya
mesh_terms: D001844:Bone Conduction / Q000502:physiology; D002648:Child; D003251:Constriction, Pathologic / Q000209:etiology / Q000473:pathology / Q000517:prevention & control; D003365:Costs and Cost Analysis; D003710:Demography; D004424:Ear Canal / Q000002:abnormalities* / Q000473:pathology / Q000601:surgery*; D006310:Hearing Aids / Q000191:economics; D006311:Hearing Disorders / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D013517:Otorhinolaryngologic Surgical Procedures / Q000191:economics / Q000379:methods*; D011183:Postoperative Complications; D011474:Prosthesis Design; D019919:Prosthesis Implantation / Q000191:economics / Q000295:instrumentation / Q000379:methods; D012189:Retrospective Studies