Postoperative Recurrent Cholesteatoma in Rural Versus Urban Populations

Abstract

Objective: Chronic ear disease presents a unique challenge to otolaryngologists in both rural and urban settings. Cholesteatoma remains a difficult disease to treat in rural populations due to limited healthcare access and high risk of recurrence. The purpose of this study was to determine if there are differences in surgical outcomes among patients with acquired cholesteatoma residing in rural versus urban settings. Study Design: Single-surgeon retrospective case series with chart review. Setting: Tertiary care private otolaryngology practice. Patients: One hundred twenty-two patients presenting to the Kentuckiana ENT otology and neurotology practice from January 2011 to May 2017. Main Outcome Measures: Surgical outcomes including recurrence, air-bone gap improvement, ossicular integrity, and complications were reviewed and compared between the rural and urban cohorts. Results: Presence of postoperative residual cholesteatoma (OR = 8.667, 95% CI = 2.022–37.141, p = 0.008) and number of surgeries per patient (OR = 5.185, 95% CI = 1.086–24.763, p = 0.024) were significantly increased among patients in rural nonmetropolitan areas. No significant differences were found when comparing risk of recurrence, size of cholesteatoma, presence of complications, air-bone gap improvement, and ossicular chain integrity. There were significantly more second-look surgeries performed in privately insured patients (OR = 8.582, 95% CI = 1.937–38.017, p = 0.001). Conclusions: Patients in rural communities have an increased number of surgeries and postoperative risk for residual cholesteatoma compared to patients residing in urban settings. This study provides the basis for larger, multicenter, prospective examinations of outcomes among urban versus rural patients, which would enable a better understanding of difference in surgical outcomes between rural and urban cohorts. Level of Evidence: IV

Rural Otolaryngology Care Disparities: A Scoping Review

“…Four studies pertained to otologic conditions other than hearing loss. Kennedy et al 51 found that rural patients are more likely to have residual cholesteatomas postoperatively. Crowson et al 52 found ototopical antibiotics are prescribed by the same proportion of ear, nose, and throat (ENT) vs non‐ENT prescribers in both rural and urban settings.…”

Health Disparities in Otology: A PRISMA‐Based Systematic Review

“…Tinnitus was studied in 1 article with race/ethnicity as the disparity category (n = 1) and its risk factors in African Americans in particular 48 . Vertigo/dizziness and cholesteatoma were each associated with an article under the geographic/urban‐rural category 49 , 50 . Cholesteatoma was also associated with a comprehensive disparity article that discussed the relationship between factors such as race/ethnicity and income, as well as the choice of surgical procedures and postoperative complications 51 .…”

“…48 Vertigo/dizziness and cholesteatoma were each associated with an article under the geographic/urban-rural category. 49,50 Cholesteatoma was also associated with a comprehensive disparity article that discussed the relationship between factors such as race/ethnicity and income, as well as the choice of surgical procedures and postoperative complications. 51 52 Despite some progress within the past 30 years, this review identifies clear gaps in the literature that warrant further investigation regarding otology and health disparities.…”

Sociodemographic Factors and Health Care Utilization in Pediatric Chronic Suppurative Otitis Media

“…This is the first study to identify children from rural Appalachia having higher incidence of cholesteatoma at time of surgery. Several studies in the United States and Australia have identified associations between rural residence and development or recurrence of cholesteatoma, 33,34 but not all patients in these studies were pediatric patients. These studies do, however, bring rural residence as a significant risk factor for development and recurrence of cholesteatoma to the forefront.…”