Objective: The purpose of this study is to critically evaluate the typical cost of asymmetrical sensorineural hearing loss (ASNHL) workup, and to compare the positive predictive values from this common presenting symptom. Methods: We reviewed charts from patients presenting to New York Eye and Ear between January 1, 2006 to December 31, 2006 and the University of Minnesota between December 1, 2002 and November 30, 2007 with ASNHL. Diagnostic information included MRI and serum laboratory values (ANA, ESR, Lyme, RPR, and TSH). We calculated positive rate according to each item of diagnosis. To estimate cost-benefit, we further calculated average cost for identifying a patient with a positive result. Results: Total cost was $264,876 while average cost for identifying a positive patient was $2078. Total lab cost was $16,935 and total imaging cost was $246,600. Average cost for identifying a positive patient based on MRI was $61,650 and $1142 based on lab values. Of the 247 patients, only six patients (2.4%) - 1 patient with acoustic neuroma, 2 patients with syphilis, and 3 patients with Lyme - were identified with treatable pathology. Conclusion: A comprehensive ASNHL workup may not be applicable to all patients. The most valuable diagnostic tests were MRI for acoustic neuroma and serum test for syphilis and lime.