13 Conclusion and Discussion Points

As the previous chapters have demonstrated, cranial nerve disorders can be very complex to diagnose and treat. While there are dozens of diagnostic modalities available, the best approach to diagnosis begins with a detailed history and physical examination. A correct diagnosis is paramount and may require extensive testing. Oftentimes, a specialist with specific testing or tools (e.g., laryngeal endoscopy, audiogram, electroneuronography) is called upon to carry out the next steps in the diagnostic evaluation. Radiologic imaging plays a large role in many situations to confirm the diagnosis or to rule out life-threatening pathology such as intracranial masses or malignancy.

Treatment options also range from observation to surgery. For some self-limited benign conditions for which a spontaneous recovery is anticipated (e.g., a unilateral acute facial nerve paralysis), the medically appropriate decision to observe for recovery is also cost-effective. However, for certain conditions that manifest as a cranial neuropathy (e.g., slow-onset, progressive facial nerve weakness from a growing tumor in the cerebellopontine angle), the medically appropriate decision is surgical resection, which is costly. In this example, both situations involve unilateral facial nerve weakness. The details and time course of the clinical history are key differentiating factors that ultimately lead to correct diagnosis and appropriate treatment.

Obviously, an accurate diagnosis is necessary for cost-effective management decisions. The opposite is true: the least cost-effective action is a wrong treatment due to misdiagnosis. This is both costly and potentially harmful to the patient.

Finally, as discussed previously, despite the increased focus on minimizing cost, one must remain vigilant of being too cost conscientious when human lives are at risk.