companies commonly require a trial of corticosteroid nasal spray prior to authorizing nasal surgery, even in patients with severe to extreme anatomical nasal obstruction, despite lack of data supporting such medical therapy. OBJECTIVES To provide a model for the comparative analysis of medical vs surgical treatment for nasal obstruction to help maximize health care benefit per dollar spent and to explore the cost-effectiveness of corticosteroid nasal spray in patients with severe to extreme nasal airway obstruction on Nasal Obstruction Symptom Evaluation (NOSE) scores. DESIGN, SETTING, AND PARTICIPANTS A cost-efficiency frontier economic evaluation was performed. The economic perspective was that of the health care third-party payer. Effectiveness data were obtained from NOSE score questionnaires in 179 patients. An incremental cost-effectiveness ratio was determined from the cost and efficacy data. Comparative treatment groups were medical therapy with corticosteroid nasal spray vs surgical therapy for nasal airway obstruction. The study was conducted between January 1, 2011, and December 30, 2013. The time horizon included 1, 2, and 5 years. Data analysis was completed June 1, 2015. MAIN OUTCOMES AND MEASURES The primary outcome was cost per quality-adjusted life-year (QALY). A modified Markov decision tree model was used. Costs were obtained from the Medicare 2015 physician fee schedule, and the mean was determined (owing to geographic disparity) along with wholesale and generic pharmaceutical pricing. RESULTS Among 100 men and 79 women evaluated (mean [SD] age, 37.9 [12.9] years), surgical repair of severe nasal airway obstruction cost $6537 and produced a total of 1.15 QALYs at 1 year. Medical treatment involved a trial of corticosteroid nasal sprays, which cost $520 and produced a total of 1.03 QALYs. The surgical approach was markedly more effective but at greater short-term cost.

Objectives: (1) Ascertain the safety of topical mitomycin C in the prevention of recurrent keloid scars after surgical excision. (2) Determine the efficacy of mitomycin C in keloid prevention. Methods: This was a prospective pilot study of 10 patients. Between August 2009 and September 2011, subjects underwent surgical excision of keloids located in the head and neck region with a one-time, intraoperative, topical application of mitomycin C. Patients were followed for 12 months postoperatively. During this period, laboratory values reflecting complete metabolic profile and coagulation studies were drawn preoperatively and postoperatively (at 2 weeks and the first, second, and third months). Additionally, photo-documentation was obtained at regular intervals to ascertain the efficacy in prevention of keloid recurrence. Results: Twelve patients enrolled in the study. Nine patients completed the protocol. Three patients dis-enrolled prior to surgical excision. No patients were lost to follow-up. Analysis of variance performed demonstrating no statistical significance in the variance of the laboratory values. Additionally, no patient demonstrated abnormality of any laboratory value beyond the reference range. Next, clinical examination of the wounds demonstrated no evidence of necrosis or dehiscence. Finally, no wound demonstrated recurrence at the one-year follow-up visit. Conclusions: Mitomycin C appears safe for topical use after excision of keloids in the head and neck region. This study demonstrates no evidence of recurrence in all patients enrolled and followed for one year.

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