Dizziness case studies (with cost comparisons)

• Case 1: a common disease.  A woman in her 30s began experiencing brief episodes of spinning dizziness when she would lie down.  She was diagnosed with benign paroxysmal positional vertigo (BPPV, the most common cause of dizziness) involving the posterior canal (the part of the ear most commonly affected by this condition).  She was treated with the Epley maneuver twice per week for 15 months (at a cost of nearly $8100), with minimal improvement.  On our examination her eye movements showed that she had BPPV involving the lateral canal – which is not treated with the Epley maneuver.  After three treatments with the logroll maneuver, her symptoms finally subsided.  The cost of our evaluation and treatment was $835 (about 10% of the previous management).

• Case 2: an uncommon disease.  A woman in her 50s had an episode of severe spinning dizziness, nausea, vomiting and several right ear symptoms (fullness, hearing loss, roaring sounds) that improved after about a day.  It recurred about a month later, at which point she presented to an emergency room (evaluation cost $4100) where they performed a head CT (additional $950) then a brain MRI (additional $1580); she was diagnosed with labyrinthitis (inflammation of the inner ear) and treated with oral steroids ($29, with side effects of irritability and insomnia), so the total cost to this point was $6659.  However, the episodes continued to recur, with increasing frequency, and did not respond to repeated administration of steroids.  We were suspicious of the initial diagnosis, since it is uncommon for labyrinthitis to recur.  On our evaluation an audiogram showed right-sided low frequency hearing loss (whereas labyrinthitis more commonly involves high frequency hearing loss), and electrocochleography showed increased inner ear pressure on the right.  We diagnosed Meniere’s disease (total cost of evaluation and testing was $870, about 13% of the previous workup).  The patient was started on a low-sodium diet, and the frequency of her episodes went from twice per month to about once per year.

• Case 3: a rare disease.  An older man gradually developed chronic unsteadiness.  He spent >$37,000 consulting multiple specialists, getting multiple imaging studies (including invasive cerebral angiography twice) and other tests (including a lumbar puncture and a muscle biopsy), but still had no answer.  When we evaluated him, his eye examination showed a slow bouncing eye movement, and his palate oscillated rhythmically and in synchrony with the eye movement.  We diagnosed him with oculopalatal tremor; gabapentin stopped the symptoms.  The cost of our evaluation was $340 (less than 1% of the cost of his previous workup).  The prescription for gabapentin cost $40/month.

Securing the correct diagnosis not only paves the way to relieving the patient’s suffering, but is also cost-efficient.

Get on the fast-track to solving your dizziness in a cost-efficient way now!