Hostname: page-component-76fb5796d-zzh7m Total loading time: 0 Render date: 2024-04-25T18:53:50.279Z Has data issue: false hasContentIssue false
  • English
  • Français

Hear me out: rethinking internal auditory meatus magnetic resonance imaging in primary care. A cohort evaluation

Published online by Cambridge University Press:  20 August 2021

I M Sajid Open the ORCID record for I M Sajid [Opens in a new window]  and
K Frost
I M Sajid*
Affiliation:
NHS West London Clinical Commissioning Group, UK University of Global Health Equity, Rwanda
K Frost
Affiliation:
NHS Central London Clinical Commissioning Group, UK
*
Author for correspondence: Dr Imran Mohammed Sajid, West London Clinical Commissioning Group, 15 Marylebone Road, LondonNW1 5JD, UK E-mail: imransajid@nhs.net
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Imaging detects acoustic neuroma, a rare pathology associated with asymmetric sensorineural hearing loss and tinnitus, that is mostly managed conservatively. Scanning indication is debatable, without evaluation in primary care, despite the high burden of audiovestibular symptoms and commissioning of general practitioner imaging.

Method

Cohort evaluation of two years' internal auditory meatus magnetic resonance imaging in primary care.

Results

Of 200 scans requested by 77 general practitioners, only 33 per cent conformed to guideline indications. Most were referred to specialists, regardless of result. Only 10.5 per cent were appropriately imaged to rule out neuroma without specialist referral. One neuroma was detected (diagnostic yield 0.5 per cent) in a patient already referred. Incidental findings were shown in 44.5 per cent, triggering low-value cascades in 18 per cent. Whilst fewer than 1 in a 1000 imaged patients may improve through surgery, 1 in 5 can suffer negative imaging cascades.

Conclusion

Considering the bi-directional relationship between distress and audio-vestibular symptoms, anxiety-provoking imaging overuse should be minimised. In low-prevalence primary care, retrocochlear imaging could be limited to those with asymmetric sensorineural hearing loss. Alternatively, assessment and imaging could be shifted to audiologist-led settings, with a wider therapeutic offer, likely more beneficial and cost-effective than conventional surgical pathways.

Keywords

General PracticeNeuro-OtologyDiagnosisRadiologyOverdiagnosisMedical OveruseAcoustic NeuromaMRI Scans
Type
Main Articles
Information
The Journal of Laryngology & Otology , Volume 136 , Issue 1 , January 2022 , pp. 37 - 44
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Dr I M Sajid takes responsibility for the integrity of the content of the paper

References

Martinez, C, Wallenhorst, C, McFerran, D, Hall, DA. Incidence rates of clinically significant tinnitus: 10-year trend from a cohort study in England. Ear Hear 2015;36:e69–75CrossRefGoogle ScholarPubMed
Stockdale, D, McFerran, D, Brazier, P, Pritchard, C, Kay, T, Dowrick, C et al. An economic evaluation of the healthcare cost of tinnitus management in the UK. BMC Health Serv Res 2017;17:577CrossRefGoogle ScholarPubMed
Fortnum, H, O'Neill, C, Taylor, R, Lenthall, R, Nikolopoulos, T, Lightfoot, G et al. The role of magnetic resonance imaging in the identification of suspected acoustic neuroma: a systematic review of clinical and cost effectiveness and natural history. Health Technol Assess 2009;13:iii–iv, ix–xi, 1–154CrossRefGoogle ScholarPubMed
Sweeney, AD, Carlson, ML, Shepard, NT, McCracken, DJ, Vivas, EX, Neff, BA et al. Congress of Neurological Surgeons systematic review and evidence-based guidelines on otologic and audiologic screening for patients with vestibular schwannomas. Neurosurgery 2018;82:E29–31CrossRefGoogle ScholarPubMed
Basu, S, Youngs, R, Mitchell-Innes, A. Screening for vestibular schwannoma in the context of an ageing population. J Laryngol Otol 2019;133:640–9CrossRefGoogle ScholarPubMed
Mackeith, SC, Kerr, R, Milford, C. Trends in acoustic neuroma management: a 20-year review of the Oxford Skull Base Clinic. J Neurol Surg B Skull Base 2013;74:194–200Google ScholarPubMed
Trakolis, L, Ebner, FH, Machetanz, K, Sandritter, J, Tatagiba, M, Naros, G. Postoperative tinnitus after vestibular schwannoma surgery depends on preoperative tinnitus and both pre- and postoperative hearing function. Front Neurol 2018;9:136CrossRefGoogle ScholarPubMed
Coughlin, AR, Willman, TJ, Gubbels, SP. Systematic review of hearing preservation after radiotherapy for vestibular schwannoma. Otol Neurotol 2018;39:273–83CrossRefGoogle ScholarPubMed
Wang, JJ, Feng, YM, Wang, H, Wu, YQ, Shi, HB, Chen, ZN et al. Changes in tinnitus after vestibular schwannoma surgery. Sci Rep 2019;9:1743CrossRefGoogle ScholarPubMed
Kameda, K, Shono, T, Hashiguchi, K, Yoshida, F, Sasaki, T. Effect of tumor removal on tinnitus in patients with vestibular schwannoma: clinical article. J Neurosurg 2010;112:152–7CrossRefGoogle Scholar
Hoekstra, CEL, Prijs, VF, Van Zanten, GA. Diagnostic yield of a routine magnetic resonance imaging in tinnitus and clinical relevance of the anterior inferior cerebellar artery loops. Otol Neurotol 2015;36:359–65CrossRefGoogle ScholarPubMed
Papanikolaou, V, Khan, MH, Keogh, IJ. Incidental findings on MRI scans of patients presenting with audiovestibular symptoms. BMC Ear Nose Throat Disord 2010;10:6CrossRefGoogle ScholarPubMed
Cima, RFF, Mazurek, B, Haider, H, Kikidis, D, Lapira, A, Noreña, A et al. A multidisciplinary European guideline for tinnitus: diagnostics, assessment, and treatment [in German]. HNO 2019;67:10–42CrossRefGoogle Scholar
Sajid, IM, Frost, K, Paul, AK. ‘Diagnostic downshift’: clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2021. doi: 10.1136/bmjebm-2020-111629.CrossRefGoogle ScholarPubMed
iRefer: making the best use of clinical radiology, 8th edn, 2017. In: https://www.rcr.ac.uk/clinical-radiology/being-consultant/rcr-referral-guidelines/about-irefer [29 April 2020]Google Scholar
Tunkel, DE, Bauer, CA, Sun, GH, Rosenfeld, RM, Chandrasekhar, SS, Cunningham, ER et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg 2014;151:S1–40CrossRefGoogle ScholarPubMed
Waterval, J, Kania, R, Somers, T. EAONO position statement on vestibular schwannoma: imaging assessment. What are the indications for performing a screening MRI scan for a potential vestibular schwannoma? J Int Adv Otol 2018;14:95–9Google ScholarPubMed
Project documents. Tinnitus: assessment and management. NICE guidance [NG155]. In: https://www.nice.org.uk/guidance/indevelopment/gid-ng10077/documents [25 January 2020]Google Scholar
Hearing loss in adults: assessment and management. NICE Guideline NG98. In: https://www.nice.org.uk/guidance/ng98 [12 February 2020]Google Scholar
Royal College of Radiologists. Appropriateness of MRI IAM referrals for investigation of tinnitus. In: https://www.rcr.ac.uk/audit/appropriateness-mri-iam-referrals-investigation-tinnitus [21 May 2020]Google Scholar
El-Shunnar, SK, Hoare, DJ, Smith, S, Gander, PE, Kang, S, Fackrell, K et al. Primary care for tinnitus: practice and opinion among GPs in England. J Eval Clin Pract 2011;17:684–92CrossRefGoogle ScholarPubMed
Vattoth, S, Shah, R, Curé, JK. A compartment-based approach for the imaging evaluation of tinnitus. Am J Neuroradiol 2010;31:211–18CrossRefGoogle ScholarPubMed
Muncie, HL, Sirmans, SM, James, E. Dizziness: approach to evaluation and management. Am Fam Physician 2017;95:154–62Google ScholarPubMed
Das, AS, Regenhardt, RW, Vernooij, MW, Blacker, D, Charidimou, A, Viswanathan, A. Asymptomatic cerebral small vessel disease: insights from population-based studies. J Stroke 2019;21:121–38CrossRefGoogle ScholarPubMed
Mok, V, Kim, JS. Prevention and management of cerebral small vessel disease. J Stroke 2015;17:111–22CrossRefGoogle ScholarPubMed
Jang, E-Y, Yi, J-H. The role of psychological factors in tinnitus. Hanyang Med Rev 2016;36:92–8CrossRefGoogle Scholar
Erlandsson, SI, Rubinstein, B, Axelsson, A, Carlsson, SG. Psychological dimensions in patients with disabling tinnitus and craniomandibular disorders. Br J Audiol 1991;25:15–24CrossRefGoogle ScholarPubMed
Rauschecker, JP, Leaver, AM, Mühlau, M. Tuning out the noise: limbic-auditory interactions in tinnitus. Neuron 2010;66:819–26CrossRefGoogle ScholarPubMed
Carpenter-Thompson, JR, Schmidt, S, McAuley, E, Husain, FT. Increased frontal response may underlie decreased tinnitus severity. PLoS One 2015;10:e0144419CrossRefGoogle ScholarPubMed
Krog, NH, Engdahl, B, Tambs, K. The association between tinnitus and mental health in a general population sample: results from the HUNT Study. J Psychosom Res 2010;69:289–98CrossRefGoogle Scholar
Han, BI, Lee, HW, Kim, TY, Lim, JS, Shin, KS. Tinnitus: characteristics, causes, mechanisms, and treatments. J Clin Neurol 2009;5:11–19CrossRefGoogle ScholarPubMed
Hall, DA, Láinez, MJA, Newman, CW, Sanchez, T, Egler, M, Tennigkeit, F et al. Treatment options for subjective tinnitus: self reports from a sample of general practitioners and ENT physicians within Europe and the USA. BMC Health Serv Res 2011;11:302CrossRefGoogle ScholarPubMed
NHS Improvement. Proposed national tariff prices: planning for 2017/18 and 2018/19. In: https://improvement.nhs.uk/resources/proposed-national-tariff-prices-1718-1819/ [1 September 2020]Google Scholar
Starnoni, D, Giammattei, L, Cossu, G, Link, MJ, Roche, PH, Chacko, AG et al. Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section. Acta Neurochir (Wien) 2020;162:2595–617CrossRefGoogle Scholar
Kohno, M, Shinogami, M, Yoneyama, H, Nagata, O, Sora, S, Sato, H. Prognosis of tinnitus after acoustic neuroma surgery - surgical management of postoperative tinnitus. World Neurosurg 2014;81:357–67CrossRefGoogle ScholarPubMed
Gait, C, Frew, EJ, Martin, TPC, Jowett, S, Irving, R. Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness. Clin Otolaryngol 2014;39:22–31CrossRefGoogle ScholarPubMed
Zygourakis, CC, Oh, T, Sun, MZ, Barani, I, Kahn, JG, Parsa, AT. Surgery is cost-effective treatment for young patients with vestibular schwannomas: decision tree modeling of surgery, radiation, and observation. Neurosurg Focus 2014;37:E8CrossRefGoogle ScholarPubMed
Korenstein, D, Chimonas, S, Barrow, B, Keyhani, S, Troy, A, Lipitz-Snyderman, A. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. JAMA Intern Med 2018;178:1401–7CrossRefGoogle ScholarPubMed
Jacups, SP, McConnon, KM. Reducing ear, nose and throat (ENT) waitlists: implications of a referral audit. Health Policy 2019;123:333–7CrossRefGoogle ScholarPubMed
Mahalingam, S, Seymour, N, Pepper, C, Tostevin, P, Oakeshott, P. Reducing inappropriate referrals to secondary care: our experiences with the ENT emergency clinic. Qual Prim Care 2014;22:251–5Google ScholarPubMed
Chatrath, P, Frosh, A, Gore, A, Nouraei, R, Harcourt, J. Identification of predictors and development of a screening protocol for cerebello-pontine lesions in patients presenting with audio-vestibular dysfunction. Clin Otolaryngol 2008;33:102–7CrossRefGoogle ScholarPubMed
Bhargava, EK, Coyle, P, Wong, B, Masood, A, Qayyum, A. 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. Otol Neurotol 2019;40:S59–66CrossRefGoogle ScholarPubMed
Cadogan, SL, Browne, JP, Bradley, CP, Cahill, MR, Knottnerus, J, Pop, P. The effectiveness of interventions to improve laboratory requesting patterns among primary care physicians: a systematic review. Implement Sci 2015;10:167CrossRefGoogle ScholarPubMed
Fryer, AA, Smellie, WSA. Managing demand for laboratory tests: a laboratory toolkit. J Clin Pathol 2013;66:62–72CrossRefGoogle ScholarPubMed
Goldzweig, CL, Orshansky, G, Paige, NM, Miake-Lye, IM, Beroes, JM, Ewing, BA et al. Electronic health record-based interventions for improving appropriate diagnostic imaging: a systematic review and meta-analysis. Ann Intern Med 2015;162:557–65CrossRefGoogle ScholarPubMed
Obholzer, RJ, Rea, PA, Harcourt, JP. Magnetic resonance imaging screening for vestibular schwannoma: analysis of published protocols. J Laryngol Otol 2004;118:329–32CrossRefGoogle ScholarPubMed
Bayoumy, AB, De Ru, JA. Sudden deafness and tuning fork tests: towards optimal utilisation. Pract Neurol 2020;20:66–8Google ScholarPubMed
Kelly, EA, Li, B, Adams, ME. Diagnostic accuracy of tuning fork tests for hearing loss: a systematic review. Otolaryngol Head Neck Surg 2018;159:220–30CrossRefGoogle ScholarPubMed
Hoare, DJ, Gander, PE, Collins, L, Smith, S, Hall, DA. Management of tinnitus in English NHS audiology departments: an evaluation of current practice. J Eval Clin Pract 2012;18:326–34CrossRefGoogle ScholarPubMed
Gander, PE, Hoare, DJ, Collins, L, Smith, S, Hall, DA. Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff. BMC Health Serv Res 2011;11:162CrossRefGoogle ScholarPubMed
Abbas, Y, Smith, G, Trinidade, A. Audiologist-led screening of acoustic neuromas in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus: our experience in 1126 patients. J Laryngol Otol 2018;132:786–9CrossRefGoogle ScholarPubMed
Van Ravesteijn, H, Van Dijk, I, Darmon, D, Van de Laar, F, Lucassen, P, Olde Hartman, T et al. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns 2012;86:3–8CrossRefGoogle ScholarPubMed
Rolfe, A, Burton, C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med 2013;173:407–16CrossRefGoogle ScholarPubMed