Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKbH4TTImqenVA9Bu/kT98wMt8djJY+eEVUFZhB7lNRkh1kFamx/MjM0 on 12/22/2019 Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. Original Study To Scan or Not to Scan—A Cross-Sectional Analysis of the Clinical Efficacy and Cost-Effectiveness of Audiometric Protocols for Magnetic Resonance Imaging Screening of Vestibular Schwannomas Eishaan Kamta Bhargava, Paula Coyle, Billy Wong, Ajmal Masood, and Asad Qayyum Department of ENT, Peterborough City Hospital, Northwest Anglia NHS Foundation Trust, Peterborough, United Kingdom Introduction: Vestibular schwannomas (VS) are a rare cause of asymmetrical hearing loss, and routine screening with magnetic resonance imaging (MRI) can be costly. At present, no consensus exists on what qualifies as ‘‘asymmetrical sensorineural hearing loss’’ (ASNHL) and when a patient should be referred for screening. Objectives: 1) Evaluation of published audiometric protocols on the basis of sensitivity and specificity when applied to local clinical cohort of patients with ASNHL; 2) determina- tion of clinical risks of missing VS and potential wastes in screening ‘‘radiologically normal’’ cases; 3) assessment of the cost of MRI screening. Methods: Cross-sectional study with chart review in a 2-year (2015–2016) cohort of 1059 patients who underwent MRI screening and audiometry indicating sensorineural hearing loss. Fourteen previously published audiometric protocols were assessed for their sensitivity and specificity in guiding radiological diagnosis of VS, and cost analysis was performed. Results: 6/14 audiometric protocols had a sensitivity greater than 85%. Diagnostic specificity ranged from 22.91 to 82.76%, clinical risks from 0 to 50%, and potential wastes from 17.24 to 77.09%. Average annual cost of screening was £64,069. Application of proposed local screening protocol had a projected cost saving of 32.19%. Cost of screening patients that benefit from treatment was compared with a utility function that quantified expected benefit. Conclusions: Development of an easy-to-apply algorithm incorporating high-sensitivity audiometric protocols may result in significant cost saving, with minimal clinical risk of missing cases. There was disparity between screening costs and monetary ‘‘benefit’’ of hearing. Key Words: Audiometry— Diagnosis—Sensorineural hearing loss—Vestibular schwannoma. Otol Neurotol 40:S59–S66, 2019. Vestibular schwannomas (VS) comprise 80 to 94% of cerebellopontine angle (CPA) tumors, the most common tumors of the posterior fossa (1). To give an idea of the burden of disease in the UK, approximately two cases of VS are diagnosed per 100,000, with 1200 new cases diagnosed per year (2). The true prevalence of VS may be one in 200, with about 30,000 people living with VS at any given time in the UK, assuming a current population of 60 million (3). In the early 20th century, CPA tumors were notorious for being difficult to diagnose with a high morbidity and mortality associated with operative intervention (1). With advances in both diagnostic and therapeutic technologies, there is a trend towards early diagnosis and reduced morbidity and mortality from VS. Magnetic resonance imaging (MRI) is the investigation of choice for screen- ing patients with suspicious audiovestibular features (4). Despite improved diagnostics, the diagnostic yield for vestibular schwannomas is quite low, with published reports between 1.09 and 5.23% (5–12). To calculate a rough estimate of the financial burden of screening for VS, assuming the highest published diagnostic yield of 5.23% to screen 1070 patients for VS (6), and a national average MRI cost of £114, a total of £107,616 were spent on non-diagnostic MRIs. In addition to this financial wastage, ordering unnecessary scans leads to an increase in patient waiting times for MRI, which may have serious implications when this may lead to treatment delays for other neoplastic and non-neoplastic pathologies. Considering the relative rarity of the tumor and the cost implications of screening, a decision regarding ordering an MRI is usually based on clinical presentation and audio- metric findings. Due to a highly varied presentation, a patient’s clinical picture cannot be considered diagnostic, but may ‘‘increase the likelihood of this pathology (acous- tic neuroma) in the clinician’s mind’’ (13). Hence, a more Address correspondence and reprint requests to Eishaan Kamta Bhargava, M.S. (ENT), 33 Boleyn Avenue, Peterborough, Cambridgeshire, PE2 9RA, United Kingdom; E-mail: eishaan@gmail.com; eishaan.bhargava@nhs.net Disclosure of Funding: None to disclose. The authors disclose no conflicts of interest. DOI: 10.1097/MAO.0000000000002215 ß 2019, Otology & Neurotology, Inc.