RESUMEN
BACKGROUND: The treatment of pediatric sinusitis continues to be a controversial topic. It has been recommended to treat pediatric chronic rhinosinusitis (CRS) with adenoidectomy before proceeding to more invasive techniques. There are concerns regarding side effects of endoscopic sinus surgery in pediatric patients. With the advent of balloon catheter dilation (BCD) as a minimally invasive technique, some authors are recommending up front adenoidectomy with BCD in order to maximize disease resolution while minimizing risk. PURPOSE: Our study examines the cost effectiveness of adenoidectomy alone versus adenoidectomy and upfront BCD for the management of pediatric CRS. METHODS: A decision tree analysis was created to determine the cost effectiveness of treating a pediatric patient who has failed medical management, using adenoidectomy versus adenoidectomy with up-front BCD. Three separate decision trees were made. The incremental cost effectiveness ratio (ICER) was calculated for each scenario and a sensitivity analysis was done to determine how different values impacted our results. RESULTS: Adenoidectomy as the sole first procedure was found to be more cost effective in all three decision trees. For tree 1, the adenoidectomy plus BCD arm was 0.03% more effective in the end, but with an $81, 431 incremental cost. CONCLUSIONS: Costs in addition to outcomes must be considered when comparing treatment modalities in our current health care environment. This study found that adenoidectomy as a first intervention before proceeding to more advanced techniques is nearly as effective and is a much more cost-effective algorithm for the treatment of pediatric CRS. However, the physician must advocate the best treatment for his or her own patients.
Asunto(s)
Adenoidectomía/economía , Cateterismo/economía , Dilatación/economía , Dilatación/instrumentación , Rinitis/cirugía , Sinusitis/cirugía , Cateterismo/instrumentación , Niño , Enfermedad Crónica , Análisis Costo-Beneficio , Árboles de Decisión , Humanos , Resultado del TratamientoRESUMEN
EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be able to recognize seeding as a form of treatment failure in transseptal resection of clival chordomas. OBJECTIVES: The purpose is to present a case of implanted metastases in the nasal septum after a transseptal approach for resection of clival chordoma and to compare it with other reported cases in the literature. STUDY DESIGN: Case report and literature review. METHODS: The clinical history, radiologic imaging, and pathology of a single patient are reviewed. RESULTS: A 35-year-old female presented with a left intranasal mass that completely occluded the left nasal passage. The patient had a history of clival chordoma treated at an outside institution with multiple partial resections via a transseptal approach and postoperative Gamma Knife radiotherapy. A 2.5 cm mass in the left nasal cavity as well as a 4 cm sellar mass was identified on MRI. Biopsy of the left nasal mass confirmed the diagnosis of chordoma, which was presumed to be secondary to seeding from a previous resection attempt. The patient received no further treatment due to multiple comorbidities. CONCLUSIONS: Recurrence of clival chordoma due to seeding along the surgical pathway is an infrequent mechanism of treatment failure, with only rare cases documented in the literature. When deciding on the appropriate surgical approach, the surgeon must consider the risk of septal seeding during a transseptal approach. The emergence of transnasal endoscopic skull base approaches may reduce the likelihood of surgical pathway tumor seeding.