Stephen Nagler nagler at tinn.com
Tue May 19 00:24:45 EST 1998

audiologists at juno.com (Birmingham Otology) wrote:

>There was a discussion back in March about ABR vs. MRI, the differences
>between the two, and why MRI cannot replace ABR (although some insurances
>are trying to go this direction.)  I am facing this situation with the
>doctors with whom I work.  They feel that the ABR is no longer
>appropriate to rule out acoustic neuromas.  I disagree, but am having a
>difficult time arguing this.  One scenario offered by Ian Windmill was
>that  if the ABR is abnormal, refer for MRI.  If the MRI is negative then
>return to the findings of the ABR in an attempt to identify
>non-structural abnormalities.  What methods can be used to "identify
>non-structural abnormalities"?  And, how will the information learned
>>From this assessment change the direction of treatment?  I am in the
>position of having to defend the cost/benefit of such a test battery. 
>Any assistance is appreciated.
>David J. Coffin, M.A., CCC-A, FAAA
>Director of Audiology
>Birmingham Otology Center
>Birmingham, Alabama


Mr. Coffin -

I think your doctors and you are looking at this problem from two
different points of reference.

YOU know that in an individual with a symmetrical audiogram, an
acoustic neuroma is unlikely to begin with.  If the audiogram is
asymmetrical, but reflex, decay, and ABR is normal ... an acoustic is
still unlikely.  YOU know that this patient, if he/she does, indeed,
have an acoustic, it is very small.  YOU know that an MRI is warranted
in this setting only if the audiogram is deteriorating over time.

Here's what the doc thinks:
1)  He is not sure that the patient will be compliant and return for
another audiogram in a year.
2)  He knows that in 1998 even small acoustic neuromas should be (with
few exceptions) excised.
3)  He knows that - regardless of the circumstances - his ass is gonna
be sued if he misses an acoustic.  An even an unjustifiable suit is an
incredible nightmare.

So you are right as an audiological purist.  And the doc is right for
more basic practical purposes.

What do you do?  Depends (I guess) on who signs the paychecks at the
Birmingham Otology Center!


Stephen M. Nagler, MD, FACS
Southeastern Comprehensive Tinnitus Clinic
Atlanta, Georgia
(404) 531-3979

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