A validation of register-derived diagnoses of interstitial lung disease in patients with inflammatory arthritis: data from the NOR-DMARD study

OBJECTIVE

There is a lack of knowledge concerning the validity of the interstitial lung disease (ILD) diagnoses used in epidemiological studies on rheumatic diseases. This paper seeks to verify register-derived ILD diagnoses using chest computed tomography (CT) and medical records as a gold standard.

METHOD

The Norwegian Anti-Rheumatic Drug Register (NOR-DMARD) is a multicentre prospective observational study of patients with inflammatory arthritis who start treatment with disease-modifying anti-rheumatic drugs. NOR-DMARD is linked to the Norwegian Patient Registry (NPR) and Cause of Death Registry. We searched registers for ILD coded by ICD-10 J84 or J99 among patients with rheumatoid arthritis, psoriatic arthritis, or spondyloarthritis. We extracted chest CT reports and medical records from participating hospitals. Two expert thoracic radiologists scored examinations to confirm the ILD diagnosis. We also searched medical records to find justifications for the diagnosis following multidisciplinary evaluations. We calculated the positive predictive values (PPVs) for ILD across subsets.

RESULTS

We identified 71 cases with an ILD diagnosis. CT examinations were available in 65/71 patients (91.5%), of whom ILD was confirmed on CT in 29/65 (44.6%). In a further 10 patients, medical records confirmed the diagnosis, giving a total of 39/71 verified cases. The PPV of a register-derived ILD diagnosis was thus 54.9%. In a subset of patients who had received an ILD code at two or more time-points and had a CT scan taken within a relevant period, the PPV was 72.2%.

CONCLUSION

The validity of register-based diagnoses of ILD must be carefully considered in epidemiological studies.

POS0925 HIGH LEVELS OF BOTH CCL2 AND CCL17 WERE ASSOCIATED WITH MORE SEVERE SSc-ILD

Background

Systemic sclerosis (SSc) carries a high risk for progressive interstitial lung disease (ILD). Several anti-inflammatory therapies have been used to treat SSc-ILD and recently the first antifibrotic therapy has been approved. Personalized treatment strategies are largely missing to date. The two chemokines, CCL2 (MCP-1) and CCL17 (TARC), have been shown to be markers of inflammation and fibrosis, respectively.

Objectives

To examine associations between ILD severity and serum levels of CCL2 and CCL17 in two different but complementary sources of biomaterial.

Methods

Sera from the prospective Oslo University Hospital SSc cohort (n=371) and healthy blood donor controls (HC; n=100) and lung tissue at the time of lung transplantation from UCLA SSc-ILD patients (n = 12) and healthy donors (n = 12) were analyzed for CCL2 and CCL17 by multiplex assays. CCL2 and CCL17 levels were defined in serum as high or low using 95% CI in HC sera as cut-off values. Paired pulmonary function tests and HRCT images were obtained at baseline and follow-up. ILD was diagnosed on HRCT and categorized by the extent of lung fibrosis as limited (<10%) or extensive (>10%) ILD. Cellular sources of CCL-2 and CCL-17 in lung tissues were determined by immunohistochemistry. Descriptive statistics were applied.

Results

CCL2 and CCL17 were increased in SSc in sera and in lung tissue compared to HC (Figure 1). High levels of CCL17 (>700 pg/ml) and CCL2 (>1000pg/ml) in sera were identified in 43/254 (17%) and 84/471(18%) of the SSc patients (Table 1 and Figure 1). High levels of both CCL17 and CCL2 were associated with lower FVC at baseline and higher extent of lung fibrosis on HRCT (Table 1). Of those with high CCL2 and CCL17, 67% had extensive lung fibrosis. Categorization of ILD into no ILD, limited or extensive ILD showed an association between high CCL17 levels and the extent of fibrosis (Table 1). Reactive epithelium and macrophages and plasma cells expressed TARC, while more AM and infiltrating mononuclear cells expressed CCL-2.

Conclusion

High levels of both CCL17 and CCL2 were associated with more severe ILD and expressed in end-stage kung tissue and may reflect an ongoing inflammatory and fibrotic processes in SSc-ILD. This may have an implication on treatment choices for SSc-ILD.

Disclosure of Interests

Imon Barua: None declared, Vyacheslav Palchevskiy: None declared, Håvard Fretheim Shareholder of: non-financial support from GSK and

Actelion, outside the submitted work.,, Consultant of: Consultant of: Personal fees from Bayer and non-financial support from GSK and Actelion, outside the submitted work.,, Henriette Didriksen: None declared, Torhild Garen: None declared, Trond Mogens Aaløkken: None declared, Stephen Samuel Weigt: None declared, Øyvind Molberg: None declared, John Belperio: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche,, Consultant of: Actelion, ARXX therapeutics, Bayer, Janssen,, MSD, Lilly, Roche, Boehringer-Ingelheim, Medscape.,,, Grant/research support from: Boehringer Ingelheim

POS0065 INTERSTITIAL LUNG DISEASE ASSOCIATED WITH PRIMARY SJÖGREN’S SYNDROME IS FREQUENTLY PROGRESSIVE

Background

Interstitial lung disease (ILD) in primary Sjögren’s syndrome (pSS) has been reported to be present in 10-15% of patients, but pSS-ILD behavior over time is not well characterized.

Objectives

Assess the pattern of ILD in pSS, its disease behavior and factors associated with disease progression in a well-characterized pSS-ILD cohort.

Methods

All pSS patients from the Oslo University Hospital (OUH) were included if ILD was diagnosed on HRCT. Clinical characteristics, lung function tests including forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) and ILD pattern on HRCT assessed by a radiologist were evaluated. We determined ILD progression, defined as absolute FVC decline >5% or absolute DLCO decline >10% over 12 +/-6 months and increasing extent of ILD on HRCT over the observation period. Factors associated with disease progression were chosen based on expert opinion. Descriptive analyses were conducted

Results

Of 702 pSS patients followed at OUH, we identified 60 pSS patients with ILD with 33 (55%) having follow-up at 12 months (Table 1). Patients with pSS-ILD were characterized by high number of males (18%) and by frequent other extra-pulmonary organ involvement (48%) (Table 1). Mean time from pSS diagnosis to ILD diagnosis was 7.4 years. In 67% ILD was diagnosed after pSS, in 13% simultaneously, in 11% before pSS diagnosis and in 9% unknown. In total, 28 (47%) were diagnosed with lymphocytic interstitial pneumonia (LIP) and 32 (53%) with reticular pattern on HRCT. Over mean follow-up of 10.9 months (SD 4.2), 7/33 (21%) showed a FVC >5% decline, 9/32 (28%) a DLCO >10% decline and 12 (36%) had at least one of these defined lung function declines on standard of care treatment. Treatment was registered as ever used and by any indication. Over an observation period of 15.4 (SD 10.6) years, 27/47 (45%) showed any ILD progression on HRCT. HRCT pattern was not associated with risk of >10% DLCO decline or ILD progression on HCRT. >5% FVC decline occurred more frequently in patients with reticular pattern compared to LIP (6/17 (35%) vs 1/16 (6%), p=0.041). Factors significantly associated with ILD progression on lung function included higher baseline FVC (99% (SD16.4) vs 87% (SD14.9), p=0.032), higher DLCO (81% (SD13.1) vs 67% (SD17.4), p=0.020), increased CRP (2/10 (20%) vs 0/16 (0%), p=0.045) and presence of polyneuropathy (2/9 (22%) vs 1/17 (6%), p=0.045).

Table 1.

Clinical characteristics, demographics and outcome of pSS with ILD

pSS-ILD(n=60)Age at pSS diagnosis, y (SD)50 (21.9)Time from pSS to ILD diagnosis, y (SD)7.4 (8.9)Male sex, n (%)11 (18)Anti-SSA AB, n/50 (%)46 (92)Increased CRP, n/47 (%)7 (15)Low complements, n/49 (%)5 (10)Extra-pulmonary involvement, n/46 (%)22 (48)Deceased, n (%)10 (17)Pulmonary involvementFVC% predicted (SD)91 (18.7)FVC decline>5%, n/33 (%)7 (21)DLCO% predicted (SD)70 (20.7)DLCO decline >10%, n/32 (%)9 (32)ILD progression on HRCT, n/47 (%)27 (45)Treatment during follow upRituximab, n (%)11 (18)Any other immunosuppressive, n (%)20 (33)Hydroxychloroquine, n (%)16 (27)Nintedanib, n (%)1 (2)Lung transplant, n (%)1 (2)

Conclusion

A substantial number of patients with pSS-ILD progressed during the time of observation. This highlights the importance of close monitoring and active consideration of treatment options in pSS-ILD. Recommendations for disease management including screening, diagnosis, disease monitoring and treatment for pulmonary involvement in pSS are lacking to date, but are highly needed.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Håvard Fretheim Consultant of: Bayer, Grant/research support from: Jansen, Phuong Phuong Diep Speakers bureau: Boehringer Ingelheim, Karoline Lerang: None declared, Helena Andersson: None declared, Øyvind Midtvedt: None declared, Torhild Garen: None declared, Mike Durheim Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim and Roche, Grant/research support from: Boehringer Ingelheim and Roche, Trond M Aaløkken Speakers bureau: Boehringer Ingelheim, Øyvind Palm: None declared, Øyvind Molberg: None declared

OP0174 SUBCLINICAL INTERSTITIAL LUNG DISEASE IS FREQUENT AND PROGRESSES ACROSS DIFFERENT CONNECTIVE TISSUE DISEASES

Background:

Based on the argument that symptoms define disease, physicians commonly apply the terms “preclinical” or “subclinical” disease to describe patients with disease-related findings but no accompanying symptoms for connective tissue disease associated interstitial lung disease (CTD-ILD). The term subclinical frequently applies to patients with mild ILD changes on high resolution chest tomography (HRCT), normal forced vital capacity (FVC), and without respiratory symptoms. Previous work in systemic sclerosis (SSc)-ILD did show that patients with even minor extent of ILD at baseline often progressed and had increased mortality risk, suggesting that it is not appropriate to define these patients as “subclinical.”

Objectives:

To identify the prevalence of subclinical ILD across CTD diagnoses, and assess the rate of progression of lung fibrosis compared to CTD without ILD and with clinical ILD.

Methods:

All CTD patients, including SSc, anti-synthetase syndrome (ASS) and mixed connective tissue disease (MCTD) from the Oslo University Hospital diagnosed before 2015 and assessed for the presence of ILD by HRCT were included. The year 2015 was chosen to secure an observation time of at least five years from ILD diagnosis to study end on 01.01.2021 or time of death. All patients fulfilled the respective CTD classification criteria. Subclinical ILD was defined as an ILD extent <5% by semi-quantitative assessment of baseline HRCT, preserved lung function with FVC >80% predicted and without respiratory symptoms. Clinical ILD was defined as >5% extent of ILD or <5% extent of ILD on HRCT with respiratory symtoms or FVC<80%. The outcome was ILD progression, defined as increasing extent of ILD from basline to follow-up HRCT by semi-quantitative assessment. Vital status was available in all patients and mortality was evaluated. Descriptive statistical analyses were conducted and time to ILD progression determined by Kaplan-Meier estimates.

Results:

We identified 525 CTD patients, including 296 with SSc, 135 with MCTD and 94 with ASS who had conducted a baseline HRCT. Of these, 227 (43%) had no ILD, 67 (13%) subclinical and 231 (44%) clinical ILD (Table). Of the 67 subclinical ILD patients, 45 (15%) had SSc, 13 (10%) MCTD and 9 (10%) ASS of thespecific cohorts. Over a median time of 4.5 years between baseline and follow-up HRCT, 95/395 (24%) showed progression of ILD, including 72 (26%) SSc and 23 (19%) MCTD patients. Disease progression frequently occurred in both subclinical ILD (38%) and clinical ILD (51%) patients (Figure). Age, gender, underlying CTD, and baseline lung function were not predictive for the progression of lung fibrosis. Progression was too infrequent to allow for meaningful multivariable regression analyses. After a median observation period of 12 years, 153 (29%) of the patients died. The 1-, 5- and 10-year survival rates in those without ILD, subclinical and clinical ILD were 97%/97%/99%, 88%/91%/82%, and 82%/85%/68% (p<0.001), respectively.

Table 1.

Clinical characteristics, demographics and outcome

No ILD (n=227)Subclinical ILD (n=67)Clinical ILD (n=231)Age, y (SD)50 (15.4)51 (14.4)52 (15.3)Male sex, n (%)89 (39)22 (33)111 (48)Deceased, n (%)50 (22)12 (18)91 (39)Observation period, y median (range)13.7 (18.6)13.9 (17.9)11.5 (17.1)FVC% (SD)97 (18.6)99 (17.9)81 (20.9)FVC decline% (SD)-0.70 (11.1)-0.81 (16.5)-1.61 (15.9)DLCO% (SD)73 (19.4)73 (16.9)55 (17.4)Extent of ILD% (SD)0 (0)2.3 (1.5)19.3 (16.8)ILD progression% (SD)0.08 (1.0)3.1 (6.2)3.6 (9.9)ILD progressors, n (%)3 (2)20 (38)72 (51)Figure 1.

Time to ILD progression in CTD without ILD, with subclinical and clinical ILD

Conclusion:

Subclinical ILD is frequently present across CTDs and progresses over time in a substantial subgroup of patients, comparable to patients with clinical ILD. Our findings question the terms sub- and preclinical ILD, which may potentially lead to a suboptimal “watchful waiting management strategy”. Monitoring all CTD patients with any ILD is of high importance to identify disease progression early.

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Roche, Merck Sharp & Dohme, Lilly and Medscape, Consultant of: Actelion, Boehringer Ingelheim, Bayer, ARXX, and Medscape, Grant/research support from: Boehringer Ingelheim, Helena Andersson: None declared, Silje Reiseter: None declared, Håvard Fretheim Consultant of: Actelion, Bayer., Imon Barua: None declared, Torhild Garen: None declared, Øyvind Midtvedt: None declared, Ragnar Gunnarsson: None declared, Mike Durheim Speakers bureau: Boehringer Ingelheim and Roche, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Trond M Aaløkken: None declared, Øyvind Molberg: None declared

Chest abnormalities in juvenile-onset mixed connective tissue disease: assessment with high-resolution computed tomography and pulmonary function tests

BACKGROUND

Mixed connective tissue disease (MCTD) is associated with several chest manifestations. Only a few studies have focused on chest manifestations in juvenile-onset MCTD (jMCTD), and the true prevalence of pulmonary abnormalities on high-resolution computed tomography (HRCT) in these patients is unknown.

PURPOSE

To investigate the occurrence of pulmonary abnormalities in jMCTD with particular reference to interstitial lung disease (ILD), and to evaluate a possible association between pulmonary findings and disease-related variables.

MATERIAL AND METHODS

Twenty-four childhood-onset MCTD patients with median disease duration of 10.5 years (range 1-21 years) were investigated in a cross-sectional study by means of HRCT, pulmonary function tests (PFT), and clinical assessment.

RESULTS

Discrete ILD was identified in six patients (25%). Median extent of ILD was 2.0%, and all except one of the patients had very mild disease in which 5% or less of the parenchyma was affected. The CT features of fibrosis were mainly microcystic and fine intralobular. The most frequently abnormal PFT was carbon monoxide uptake from the lung, which was abnormal in 33% of the patients. PFT and disease duration were not significantly associated with HRCT findings of ILD.

CONCLUSION

The prevalence of ILD in childhood-onset MCTD patients was lower than previously believed. In most of the patients with ILD, the findings were subtle and without clinical correlation. The results suggest a low extent of ILD in childhood-onset MCTD, even after long-term disease duration.

Computed tomography enhancement characteristics of lymphomatous lymph nodes of the neck

OBJECTIVES

The objective of this study was to investigate prospectively CT contrast medium enhancement curves of lymphomatous lymph nodes of the neck.

MATERIALS AND METHODS

Eleven patients with biopsy-proven lymphoma had their enlarged cervical lymph nodes examined with dynamic CT and compared with a control group.

RESULTS

The mean contrast medium enhancement of the lymphomatous nodes was significantly lower than that of the control group in the time interval from 40 s to 180 s after injection.

DISCUSSION

The enhancement pattern previously suggested from studies of retroperitoneal lymph nodes was confirmed in this prospective study of cervical nodes.

Pulmonary involvement in patients with childhood-onset systemic lupus erythematosus

OBJECTIVE

Pulmonary involvement is a common finding in adults with systemic lupus erythematosus (SLE). The aim of this study was to investigate the frequency of pulmonary abnormalities in patients with childhood-onset SLE, with particular reference to interstitial lung disease (ILD), and to examine any association between pulmonary abnormalities and other disease-related variables.

METHODS

A cohort of 60 Norwegian patients with childhood-onset SLE was examined in a cross-sectional study by high-resolution computed chest tomography (HRCT) and pulmonary function tests (PFT). Median disease duration was 11.2 years. Disease activity, cumulative organ damage and immunological markers were also assessed.

RESULTS

Five patients (8%) had abnormal HRCT findings, including micronodules in four patients and bronchiectasis in one. None of the patients had radiographic evidence of ILD. PFT results were impaired in 37% of the patients, the most frequent pulmonary dysfunction was reduced carbon monoxide diffusing capacity (26%). HRCT findings, disease activity or serology did not correlate with PFTs. Reduced diffusion capacity was associated with smoking (p-value < 0.05).

CONCLUSION

Lung function was moderately impaired, while the frequency of pulmonary parenchymal involvement was low. There was no radiographic evidence of ILD, which is an unexpected finding given the high frequencies reported in adult SLE patients assessed with HRCT. The results suggests that PFT values are often abnormal, but these are infrequently associated with development of ILD or other substantial parenchymal alterations in childhood-onset SLE, and do not require further HRCT investigation in asymptomatic patients.

Multicenter evaluation of a new laser guidance system for computed tomography intervention

PURPOSE

To measure the accuracy of laser-guided punctures and to evaluate the usefulness of the developed laser-guided system.

MATERIAL AND METHODS

The study included 67 patients referred for computed-tomography-guided puncture. The majority of the punctured lesions were located in the chest (28 patients) or abdomen (19 patients). The mean diameter of the lesion was 3.1 cm, and the mean path length was 6.8 cm. The laser guide was movable along a horizontal or vertical rail and not physically connected to the CT unit. The angle of insertion was entered manually into the display of the unit by the interventional radiologist. A prospective multicenter trial was carried out.

RESULTS

A mean of 1.1 needle passes were necessary to reach the target, and in 55 (84.6%) of the patients the target was reached on the first needle pass. The mean deviation of the needle from the preselected angle was 1.8 degrees. The mean targeting time (from the initial localizing scan until the needle was in the target) was 15.6 min. In every case, both the usefulness and the ease of use of the laser guidance system were subjectively evaluated on a 5-point scale; the mean usefulness score was 4.5, while the mean ease of use score was 4.7.

CONCLUSION

Different users at four different centers found the laser guidance system useful and easy to use. A high level of accuracy of the puncture angle was obtained in most cases.

A new low-dose CT examination compared with standard-dose CT in the diagnosis of acute sinusitis

A low-dose CT of the paranasal sinuses was designed with few, thin sections, non-uniform intersection gaps, low milliampere settings and avoidance of direct radiation to the eye lens. The low-dose CT was prospectively compared with standard-dose CT in patients with suspicion of acute sinusitis. Forty-seven patients were examined with low-dose CT immediately after standard-dose CT. The effective dose and the lens dose were calculated and compared. Using standard-dose CT as a gold standard the sensitivity and specificity of low-dose CT was calculated for each sinus group. The effective dose and the lens dose of the low-dose CT were reduced to, respectively, 3 and 2% of the standard-dose CT. The diagnostic yield of the low-dose CT with regard to acute sinusitis was good with a high specificity (> or =96%) for all sinus groups. The sensitivity was also high (> or =95%) except for the frontal sinus where the sensitivity was 83%. Low-dose CT offers considerable dose reduction and should be the standard for imaging patients with suspected acute inflammatory paranasal disease.

Conventional sinus radiography compared with CT in the diagnosis of acute sinusitis

OBJECTIVES

To evaluate the value of plain film radiography in a prospective investigation of patients with clinical suspicion of acute sinusitis, using standard CT as a gold standard.

METHODS

47 consecutive patients were examined. Each patient underwent conventional X-ray and standard dose CT examinations on the same day. The sensitivity and specificity of the plain film examination were calculated.

RESULTS

The specificity of the plain film examination was high, but the sensitivity was low except for the maxillary sinus (sensitivity 80%). Thus, for maxillary sinusitis, plain film examination was reasonably accurate. A negative finding in the other sinuses could not be relied upon.

CONCLUSIONS

The sensitivity of plain film radiography for detecting sinus opacifications was unacceptably low for the ethmoid, frontal and sphenoid sinuses. The specificity was high.

CT appearances of unilateral cleft palate 20 years after bone graft surgery

PURPOSE

To describe CT appearances in patients with unilateral cleft lip and palate (CLP) 20 years after bone graft surgery.

MATERIAL AND METHODS

Eighteen consecutive patients with unilateral CLP were examined. All patients had been treated with primary closure, both in infancy and early childhood, supplemented with bone grafting at the age of around 10 years. The CT examination of the upper jaw included a dental CT program. The CT appearances of the cleft side were compared with those of the untreated non-cleft side.

RESULTS

Abnormal CT appearances included skew nasal aperture (n=17), nasal septal deviation (n=17), low floor of nasal aperture (n=15) at or towards the cleft side, and deviation of anterior nasal spine towards the non-cleft side (n=18). The posterior part of the bone cleft was visible in all patients, and the dental arch was V-shaped in 8.

CONCLUSION

Although adherence to the present treatment protocol is considered to give satisfactory functional and cosmetic results, certain abnormalities persist. A knowledge of these is a prerequisite for a complete and final evaluation of the surgical and orthodontic regimen.

CT appearances of unilateral cleft palate 20 years after bone graft surgery

PURPOSE

To describe CT appearances in patients with unilateral cleft lip and palate (CLP) 20 years after bone graft surgery.

MATERIAL AND METHODS

Eighteen consecutive patients with unilateral CLP were examined. All patients had been treated with primary closure, both in infancy and early childhood, supplemented with bone grafting at the age of around 10 years. The CT examination of the upper jaw included a dental CT program. The CT appearances of the cleft side were compared with those of the untreated non-cleft side.

RESULTS

Abnormal CT appearances included skew nasal aperture (n=17), nasal septal deviation (n=17), low floor of nasal aperture (n=15) at or towards the cleft side, and deviation of anterior nasal spine towards the non-cleft side (n=18). The posterior part of the bone cleft was visible in all patients, and the dental arch was V-shaped in 8.

CONCLUSION

Although adherence to the present treatment protocol is considered to give satisfactory functional and cosmetic results, certain abnormalities persist. A knowledge of these is a prerequisite for a complete and final evaluation of the surgical and orthodontic regimen.

[Resection of malignant tumors involving the anterior cranial fossa]

BACKGROUND

The craniofacial approach has greatly facilitated resections of tumours involving the base of the anterior cranial fossa when compared to either the transcranial or transfacial approach alone.

MATERIAL AND METHODS

This approach was used in 11 patients with malignant tumours localized to the ethmoid sinus, orbit and bone or soft tissue of the base of the anterior part of the skull. By combining a low frontal or frontolateral craniotomy with resection of the facial skull, en bloc resections were accomplished. A frontogaleal periostal flap or a muscle flap from the temporal muscle was used to replace resected bone and to seal the skull base.

RESULTS

There were no peri- or postoperative deaths. One patient died due to local recurrence, one patient is alive with residual tumour six years after surgery, and one is reoperated due to local recurrence. In addition one patient developed recurrence of a previously treated tumour of the maxillary sinus. Two patients developed meningitis and one pneumocephalus postoperatively. One patient has partial loss of vision and two patients underwent dacryocystorhinostomy due to epiphora.

INTERPRETATION

The planning and execution of this type of surgery requires close interaction in an interdisciplinary team, in particular between neurosurgeon and head and neck surgeon.

CT of the oral vestibule with distended cheeks

PURPOSE

To evaluate patient compliance in CT examination of the oral vestibule with distended, blown-up cheeks and to determine how often such images provided additional information when disease processes in this area were suspected.

MATERIAL AND METHODS

Fifty-four patients were examined with CT of the oral vestibule with distended cheeks and 16 of them had diseases where oral vestibule affection was considered possible.

RESULTS

Fifty-three of 54 patients were able to perform cheek distension. Of 16 patients with possible disease involvement of the oral vestibule, additional information was thus obtained in 11 patients.

CONCLUSION

When lesions involving the oral vestibule or adjacent regions are suspected, CT examination with distended cheeks is recommended as a routine procedure. The oral vestibule separates the teeth and gingiva from the buccal mucosa of the lips and cheek. On CT images of the oral region, the buccal and gingival mucosa are not separated and thus difficult to define. Problems may arise in deciding whether or not a limited tumorous or infectious lesion of the gingiva also involves the buccal region and vice-versa. We observed that images with distended, blown-up cheeks could be useful in this respect, as the air separated the gingival from the buccomasseteric region and allowed a determination of buccal distensibility. The purpose of the present report was to establish how well the patients could co-operate in performing the CT examination with distended cheeks, and how often such images provided additional information in patients with disease processes which might affect the oral vestibule.

[High-resolution computer tomography of the lungs]

High-resolution CT (HRCT) is a technique developed over the last decade. It optimises spatial resolution and provides details similar to those obtainable from gross pathologic specimens. HRCT of the lungs provides an accurate assessment of the pattern and distribution of many disease processes that in the conventional chest radiograph are occult or non-specific. HRCT is an established technique and the method of choice for evaluating a variety of pulmonary diseases. In this review we describe the modifications in CT technique that are instrumental in obtaining HRCT, and we also give examples of normal and pathologic findings in general.

[CT combined with arterial portography. A sensitive method for evaluation of liver tumors]

During the period 1994-95, 22 patients were examined with CT during arterial portography for evaluation of hepatic tumours. The majority, 20 patients, had metastases from colon cancer. All patients were candidates for liver resection. In the series of patients described here, this process detected additional lesions in four more of the patients than found with any other imaging techniques. This supports that CT during arterial portography is the most sensitive method for detecting small malignant hepatic tumours, and for localizing them in relation to liver segments and major vascular structures. Optimal results are obtained in the absence of diffuse parenchymal disease and portal hypertension. Non-tumourous perfusion defects limit the accuracy of this technique, but such defects have characteristic locations and appearance. In difficult cases the technique should be correlated with ultrasonography and MR.

[Fulminant fasciitis in the head and neck region]

Deep interstitial infections of the head and neck are potentially life-threatening conditions because of the double threat of upper airway obstruction and production of bacterial toxins, which may result in spread of infection, sepsis and multiorgan failure. At an early stage the symptoms are rather diffuse. It is of critical importance however, to make an early diagnosis if a fatal outcome is to be prevented. We describe a patient with infection caused by group F streptococci, (Streptococcus anginosus or milleri), and discuss the diagnosis and treatment.

[Synovial chondromatosis]

Synovial chondromatosis is a rare monarticular condition in which cartilaginous masses are formed by metaplasia of the synovial membrane. These masses may calcify and ossify. The disease most commonly affects the knee, and the symptoms include pain, swelling, locking and palpable loose bodies. Although the clinical features are usually non-specific, the roentgenograms often provide important diagnostic information. Synovial chondromatosis is rarely a difficult diagnostic problem, but should not be confused with other disorders that give rise to loose bodies, such as degenerative joint disease and osteochondritis dissecans. Two cases are described and synovial chondromatosis is discussed in some detail, including radiological features and treatment.

[Salivary gland ultrasonography]

Many pathologic conditions of the salivary gland are diagnosed clinically. Until a few years ago, supplementary radiographic methods have only included plain film radiography and sialography. Both methods vary in usefulness, and the indications are controversial. During the last two decades other imaging methods, both radiographic and non-radiographic, have been used, and have provided clinically useful information. Probably the most useful of these is ultrasonography. Because the salivary glands are superficial structures they lend themselves well to ultrasonographic evaluation. Although sialography should still be the method of choice for some conditions, ultrasonography alone will often give the correct diagnosis. The purpose of this article is to describe the role of sonography for imaging pathologic conditions of the salivary glands.