Canal Wall Up vs. Canal Wall Down: Symptom of a greater need?

This issue of ENT Today includes an article on the debate over canal-wall-up (CWU) versus canal-wall-down (CWD) tympanomastoidectomy (p. 5). I remember hearing the same arguments when I was a resident at UCLA, which was also the last time I drilled a mastoid bone; my practice focused on head and neck surgery and pediatric otolaryngology. Over the past 32 years, Drs. Bruce Gantz, Rick Chole (two of my otology colleagues on the Board of Otolaryngology), and other otologist friends have suffered through my semi-tongue-in-cheek comments on why otologists can’t agree on which procedure is better. Although the technology used in both procedures has evolved, the final product of the two procedures, a dry, safe ear, is, as best I can tell, the same as it was when I was a resident. I have been told that one of the main factors considered in the decision regarding which procedure to perform is where the otologist trained.

But CWU/CWD isn’t really the topic of this editorial. I just use it as an example of the problems involved in developing meaningful, evidence-based guidelines in our specialty as well as in medicine as a whole. It is quite clear that the payers, government and quality improvement groups all want to establish practice guidelines for laudable reasons—not just to control costs, but also to improve patient outcomes. The recently passed Patient Protection and Affordable Care Act includes funding for a Patient-Centered Outcomes Research Institute, which is charged with overseeing comparative effectiveness research (CER) that should move this process forward more rapidly. Regardless of your opinion of health care reform, it appears CER is here to stay.

If we physicians don’t work on developing quality improvement tools, someone else will, and I don’t think we will like that outcome.
—Robert H. Miller, MD

It is also clear in a number of specialties that the management of certain conditions varies dramatically across the country—with widely disparate costs. Yes, I understand some patients are better treated by taking the canal wall down, while others do well with the canal wall up. But shouldn’t the determination be based on evidence showing which patients should have which procedure? A surgeon’s preference is important, because it is advantageous for a surgeon to feel comfortable doing a procedure. But what if the outcome of the surgeon’s preference is not as good as another procedure? In that situation, the nod should go to what is best for the patient, not the surgeon. The surgeon should either become more facile with the better procedure or refer the patient to someone who is.