Cost-Effective Evaluation and Management of Cranial Neuropathy

It may just be a ‘sign of the times’, but I did feel a bit uncomfortable with the opening of the title of this book. I would have been happier with ‘Best Practice in’ or ‘Evidence-Based Management of’. ‘Cost-Effectiveness’ as a subtitle rather than the emphasis of the book would have appealed more to my Bolshevik nature. And yet, we have to face such issues. I looked forward to reading whether every anosmic patient, with normal nasal examination findings, merits a magnetic resonance imaging (MRI) scan. Does a mild audiometric asymmetry in a 75-year-old warrant imaging or just serial audiometry?

The contributors are exclusively US-based, but it is notable and encouraging that otolaryngologists very much dominate the authorship. There is then a very brief Foreword, Preface and introductory chapter, with two short paragraphs on cost-effectiveness, before we are introduced to the I–XIIth cranial nerves.

The olfactory nerve chapter I did eagerly anticipate, and it does provide a good coverage of management of anosmia. Alas, ‘the literature regarding cost-effectiveness is mixed’. The authors cite a study of costs of the multiple MRI scans required in order to diagnose the one patient with an intra-cranial tumour. This total cost proves to be one-fifth of the cost of a malpractice suit for failure to diagnose. Ultimately, the conclusion is that ‘the routing [sic] use of imaging…is not cost-effective in patients with idiopathic olfactory dysfunction’, however.

I then did enjoy the chapter on the IInd cranial nerve and visual disorders, if only because it was all new to this ageing ENT surgeon and really well illustrated. However, cost-effectiveness has little mention other than a table of ‘Medicare Allowable’ costs of diagnostic procedures, and boxed ‘recommended’ and ‘not recommended’ comments for each condition, even if the basis for this is largely unspecified. How welcome this format would have been throughout the book. The next chapter on oculomotor disorders was written by medical students and ophthalmologists, so there is no coverage of Gradenigo’s syndrome or nasopharyngeal carcinoma. The trigeminal nerve chapter I was sure would be a ‘hot topic’ for discussion of cost-effectiveness, with so much over-investigation of facial pain. In practice, the discussion relates solely to trigeminal neuralgia, and this in only four pages of text. The facial nerve chapter seems slightly longer, but does carry more tables and illustrations. Fortunately, national guidelines were quoted regarding the management of Bell’s palsy (including the use of acyclovir).

The chapter on hearing disorders better meets the challenge of the book title, especially on hearing aid provision and screening for that vestibular schwannoma. The comment ‘in a litigious society such as that found in United States, gadolinium-enhanced T1-weighted MRI remains the standard of care’ is then balanced against T2 screening, or even simple patient counselling and involvement in decisions to monitor serial audiometry. This is a particularly worthwhile chapter, looking at the costs of a successful stapes surgery versus a lifetime of hearing aid provision, the benefits of cochlear implantation at any age or the bone-anchored hearing aid. The vestibular chapter very much concentrates on countless laboratory tests, with only a single mention of costs (a rotary chair vs videonystagmography).

The cranial nerves and dysphagia merited a very brief chapter, with uninterpretable images of an endoscopic larynx appearance and a modified barium swallow. Cost is never mentioned. A dysphonia chapter has better content. The poor old accessory nerve gets only three pages of text, but that is more than the hypoglossal, which is never covered in isolation. A final chapter, almost an afterthought, is on radiology in cranial neuropathy, and obviously repeats much of the earlier content (although with very nicely presented illustrations). Table 12.1 is amusing in listing imaging techniques and offering for each ‘a fair price’, a ‘low end’ and a ‘high end’ price (the difference is staggering).

At 120 pages of text, this is a slim book to cover such a vast topic, but it is relatively inexpensive. There is an inconsistency in the chapter style and in the quality of content, as contributors have varied in adherence to the book’s title. There is actually a true ‘final chapter’, of one-third of a single page, which concludes: ‘despite the increased focus on minimizing cost, one must remain vigilant of being too cost conscientious when human lives are at risk’. That was encouraging. Cranial neuropathies are obviously of great relevance to our specialty. Do not be too deterred by the title and its obvious trans-Atlantic relevance, as cost-effectiveness is a relatively minor issue in this book.

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