Asymmetric sudden SNHL: Is all this screening necessary?

Asymmetric sudden SNHL: Is all this screening necessary?

Selena E. Heman-Ackah, M.D., M.B.A., Noel Jabbour, M.D., Ryan Dunn, B.S., Tina C. Huang, M.D.

Department of Otolaryngology ? Head & Neck Surgery, University of Minnesota Medical School, Minneapolis, MN

ABSTRACT

Objective: A number of factors have been identified that contribute to the presentation of asymmetric sudden sensorineural hearing loss (ASSNHL). Routinely patients presenting with ASSNHL undergo a battery of serologic testing and imaging in an attempt to determine a cause. The study will assess the utility of this diagnostic evaluation in elucidating a cause of an asymmetric sensorineural hearing loss. At the conclusion of this presentation, the participants should be able to: (1)understand the utility of diagnostic screening in the management of ASSNHL, and (2) evaluate the cost effectiveness of the diagnostic screening practices for ASSNHL.

Methods: The study design is a retrospective chart review. Charts from patients presenting to the otolaryngology clinic of a tertiary care facility between December 1, 2002 and November 30, 2007 with ASSNHL confirmed by audiometric evaluation were reviewed. Diagnostic tests included in the work-up of ASSNHL and test results were recorded. Percentage of positive tests was determined and compared to national data. Cost analysis of the diagnostic battery was performed.

Results: All patients presenting with sudden sensorineural hearing loss received one or more of the following serologic and radiographic tests: ANA, cholesterol, creatinine, DNA-ds, ESR, blood glucose, Lyme titer, rheumatoid factor, RPR, FTA-ABS, HSP, T3, TSH and MRI with gadolinium. The average cost associated with the full diagnostic evaluation is greater than $1,500. The positive rate for any of these tests was extremely low.

Conclusions: The utility of the comprehensive ASSNHL evaluation should be reconsidered. The choice of diagnostic evaluation should be directed by patient risk factors and exposures.

RESULTS

Figure 1. Number of Tests Performed Histogram

35

33

30 25

25

METHODS

?Retrospective chart review of patients evaluated in the Otolaryngology Clinic at the University of Minnesota between December 1, 2002 and December 31, 2007

?1762 charts were reviewed using the following ICD-9 codes: 12/1/2002 to 8/31/2006 ICD9 389.1, 389.11, 389.12, 389.14, 389.15, 389.16, 389.18 9/1/2006 to 12/31/2007 ICD9 389.15, 389.1

?Inclusion criteria: -Age > 18 years -Asymmetric sensorineural hearing loss defined as > 30 dB difference at >3 continuous frequencies -Sudden onset ( 1:40 dilution -Cholesterol > 200 mg/dL -Creatinine < 0.6 mg/dL, > 1.2 mg/dL -Anti-DNA antibody (DNA-ds) > 21% -Erythrocyte Sedimentation Rate (ESR) > 20mm/hr -Glucose< 70 mg/dL, > 120 mg/dL -Lyme Titer > 1:1600 (IgM) -Rheumatoid Factor (RF) > 20 IU/mL -Rapid Plasmin Reagin (RPR): reactive -Triodothyronine (T3) < 80 ng/dL, > 220 ng/dL -Thyroid stimulating hormone (TSH) < 0.4 uIU/mL, > 5uIU/mL -MRI of brain and internal auditory canals (IAC): lesion noted

Number of Persons

20

15

10

52 0

01

12

9

7

8

33 3

6 4

5

2 3 4 5 6 7 8 9 10 11 12

Number of Tests Performed Per Person

Figure 2. Analysis of Tests Performed

Clinical Test

Number Performed

Number Positive

ANA

70

2

Cholesterol

52

22

Creatinine

17

1

DNA-ds

61

0

ESR

66

1

Glucose

57

5

Lyme

68

1

RF

68

2

RPR

67

0

T3

49

1

TSH

63

1

MRI

103

0

Total

741

36

Average Cost $95 $73 $73 $83 $49 $19 $65 $70 $28 $58 $58 $2,100 $2,771

Total Cost $6,650 $3,796 $1,241 $5,063 $3,234 $1,083 $4,420 $4,760 $1,876 $2,842 $3,654

$216,300 $254,919

Figure 3. Tests Performed versus Tests Positive

DISCUSSION

The evaluation of asymmetric sudden sensorineural hearing loss poses a cost-effective conundrum. The extent of the work-up of patients with asymmetric sudden sensorineural hearing loss remains controverial1-4.

We reviewed 741 diagnostic tests performed on 120 patients. Thirty-six tests were positive. Twenty-seven of the positive tests were cholesterol and blood glucose analyses. This is consistent with reported rates in the literature5-7. Additionally, the ESR, a non-specific marker of inflammation, was positive in one patient. Aside from these tests, there were 8 positive tests in 4 patients. Two patients with a known history of Sjogren's syndrome presented with a positive RF and ANA. One patient had a positive Lyme titer. This patient was subsequently treated by the Infection Disease Service with doxycycline for Lymes diseases. Finally, one patient with severe diabetes and hypothyroidism had abnormal glucose, creatinine, T3 and TSH levels. In this series, there were no positive MRI examinations for intracanalicular lesions.

Over the study period, a total of $254,919 was spent on diagnostic evaluation of patients presenting with asymmetric sensorineural hearing loss. Of this cost, $216,300 is attributable to the cost of MRI evaluation and $38,619 attributable to serologic evaluations. The treatment management was impacted in only one patient as a function of this battery of testing. The rate of acoustic neuroma within this study is less than that previously reported in the literature of 1-3%. This may be due to the tertiary care nature of the setting of this study. Diagnostic evaluation of the patient presenting with ASSNHL should be directed by patient risk factors and exposures.

REFERENCES

1. Sabini P, Sclafani AP. Efficacy of serologic testing in asymmetric sensorineural hearing loss. Otolaryngology ? Head and Neck Surgery. 2000, 122: 469-476.

2. Daniels RL, Shelton C, Harnsberger HR. Ultra high resolution non-enhanced fast spin echo magnetic resonance imaging: Cost-effective screening for acoustic neuroma in patients with sudden sensorineural hearing loss. Otolaryngology ? Head and Neck Surgery. 1998, 119:364-369.

3. Weber PC, Zbar RI, Gantz BJ. Appropriateness of magnetic resonance imaging in suddent sensorineural hearing loss. Otolaryngology ? Head and Neck Surgery. 1997, 116: 153-156.

4. Cueva RA. Auditory brainstem response versus magnetic resonance imaging for the evaluation of asymmetric sensorineural hearing loss. Laryngoscope. 2004, 114: 1686-1692.

5. Arnett DA, Jacob DR, Luepker RV, Blackburn H, Armstrong C, Claas SA. Twenty-year trends in serum cholesterol, hypercholesterolemia, and cholesterol medication use the Minnesota Heart Survey, 1980?1982 to 2000?2002. Circulation. 2005,112:3884-3891.

6. Prince LA, Rodriquez E, Campagna J, Brown L, Fischer D, Grant WD. Hyperglycemia in ED patients with no history of diabetes. American Journal of Emergency Medicine. 2008, 26:532-536.

7. American Diabetes Association.

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