Cost-effectiveness of Canal Wall-Up vs Canal Wall-Down Mastoidectomy: A Modeling Study

Otolaryngol Head Neck Surg. 2022 Sep;167(3):552-559. doi: 10.1177/01945998221076051. Epub 2022 Feb 8.


Objective: To assess the relative lifetime costs, benefits, and cost-effectiveness between the 2 approaches, canal wall-up (CWU) and canal wall-down (CWD) tympanomastoidectomy, used in the treatment of cholesteatomas.

Study design: Markov state transition model.

Setting: Tertiary academic health system.

Methods: A Markov state transition model was used to simulate outcomes across the patient lifetime. Outcome and complication probabilities were obtained from the existing literature. Costs were calculated from the payer perspective, with procedure, hospital, clinic, and physician cost derived from Medicare reimbursement. Quality-adjusted life years (QALYs) were used to represent effectiveness and utility. One-way and probability sensitivity analyses (PSAs) were conducted.

Results: The base case analysis, assuming a 40-year-old patient, yielded a lifetime cost of $14,214 for a patient treated with the CWU approach assuming second-look surgery and $22,290 with a CWD approach. CWU and CWD generated a benefit of 17.11 and 17.30 QALYs, respectively. The incremental cost-effectiveness ratio for CWU was $43,237 per QALY. The Monte Carlo PSA validated the base case scenario. Using a standard $50,000 willingness-to-pay threshold, CWD was the more cost-effective approach and was selected 54.8% of the time by the simulation.

Conclusion: Both CWU and CWD were found to be cost-effective, with CWD being cost-effective 54.8% of the time at a WTP threshold of $50,000. The assumptions used in the analysis were validated by the results of 1-way and PSA.

Keywords: Markov model; canal wall down; canal wall up; cholesteatoma; cost-effectiveness; mastoidectomy.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Aged
  • Cholesteatoma*
  • Cost-Benefit Analysis
  • Humans
  • Male
  • Mastoidectomy* / methods
  • Medicare
  • Prostate-Specific Antigen
  • Quality-Adjusted Life Years
  • United States


  • Prostate-Specific Antigen