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Medical Forum / Diseases and Disorders / Sinusitis / July 2006CT scans for sinusitis worse than we thought?
: J Otolaryngol. 2000 Jun;29(3):170-3. Related Articles, Links Is there a correlation between radiographic and histologic findings in chronic sinusitis? Cousin JN, Har-El G, Li J. Department of Otolaryngology, State University of New York, Health Science Center at Brooklyn, USA. OBJECTIVE: To determine if the degree of radiologic changes noted on computed tomography (CT) scan correlate with the severity of histologic changes. DESIGN: Retrospective analysis. SETTING: Academic tertiary care centre. METHODS: Sixty consecutive patients undergoing endoscopic sinus surgery for chronic sinusitis, with complete data obtained for 131 sinuses. MAIN OUTCOME MEASURES: Paranasal sinus CT scans and pathologic reports were examined. Respective findings were graded as mild, moderate, or severe, and the results were analyzed for agreement. CT scan grading was based on the extent of sinus opacification and pathologic grading was determined by the number of inflammatory cells found in the sinus mucosa. RESULTS: Of the 51 ethmoid sinuses, agreement between the radiographic and histologic grading occurred in 32 or 62.7%. In the maxillary group, a 57.1% (24 of 42) correlation was noted. Of the 20 frontal sinuses, agreement occurred in 8 or 40%, whereas a 22.2% (4 of 18) correlation was present in the sphenoid group. CONCLUSION: This study suggests that the severity of sinus disease based on preoperative CT scan does not correlate with the histologic degree of disease. PMID: 10883832 [PubMed - indexed for MEDLINE] It's even worse than I had previously thought: the numbers were about 70% sensitive/specific. Judy > x-no-archive: yes > [quoted text clipped - 28 lines] > > PMID: 10883832 [PubMed - indexed for MEDLINE] > It's even worse than I had previously thought: the numbers were about > 70% sensitive/specific. I never know who to believe about this stuff, since I keep seeing reports of sensitivity and specificity for Lyme testing, for example, that I've personally heard the researchers admit in private are completely false. Other abstracts had higher concordance, but lower for unilateral than bilateral disease, IIRC. Susan Your article was particulary interesting, because they looked at the scan and then actually got tissue. I've read other articles, but it's unclear what measure is used to determine if a person actually has sinusitis. I've had my ENT look with an endoscope, numerous times, when I knew I was infected, declare me "clear" and then I'll go home, and due to the vasoconstrictor, discover I'm actively infected. So, I think getting tissue is really a "gold standard". Lyme testing is a mess. Currently, in RI, we're seeing tons of it, and treating people clinically. Sometimes the antibodies and western blot help, but often just the classic rash and/or illness makes it clear that people are getting Lyme (and one case of babesiosis) like crazy this year--I think it's all the wet weather woke up the tick population. There's so much controversy with Lyme. I find it ironic that my dog gets Lyme vaccine, and my horse gets West Nile vaccine, but there's no vaccines for humans Judy > > It's even worse than I had previously thought: the numbers were about > > 70% sensitive/specific. [quoted text clipped - 8 lines] > > Susan > Your article was particulary interesting, because they looked at the > scan and then actually got tissue. I've read other articles, but it's [quoted text clipped - 3 lines] > due to the vasoconstrictor, discover I'm actively infected. So, I think > getting tissue is really a "gold standard". Ah, that makes sense, thank you. > Lyme testing is a mess. Currently, in RI, we're seeing tons of it, > and treating people clinically. Sometimes the antibodies and western > blot help, but often just the classic rash and/or illness makes it > clear that people are getting Lyme (and one case of babesiosis) like > crazy this year--I think it's all the wet weather woke up the tick > population. It's also the arrival of the Lone star tick up here; staying out of the woods and tall grass is no longer any protection, they don't care if it's dry, sunny, short grass, and they don't wait for you to brush past them, they hunt you down. Judy, there's so much disinformation and lack of information. For instance, the "classic" rash turned out to be the *least* common among all the culture positive EMs in the SKB LymeRix trials, according to Dr. Parenti, the lead investigator and his slides when I saw his presentation. Clusters of small vesicles, streaks, ovals, rectangles, blue, pink, red, you name it, occurred, and with greater overall frequency. The public health authorities should've blown up photos and they should be in offices and clinics everywhere! Dermatologists should be targeted for such info. Babesiosis is all over the map and only New Englanders are told to suspect it. It's nearly impossible to get a + test past the early acute phase. My child never tested +, so I can't say, but after 3 1/2 years of misery, was cured by atovaquone/zithromax. Symptoms and signs had been consistent with babesiosis, but we had a misdiagnosis of EBV/mono for months early on. Hasn't cured me, though. > There's so much controversy with Lyme. Here's the thing, Judy. Say you get a sinus infection, a bad one. The doc gives you 10 days of antibiotic and you still have all the same symtpoms but he tells you that you now have Post Sinusitis Syndrome and no more treatment is indicated. Controversy exists, and then craziness and paranoia (and some thorny truths, too) explode when folks *know* they're being lied to. The intensity of their frustration makes them so loony that authorities find it easy to dismiss them, even though the peer reviewed literature proves conclusively that they're right. I didn't get diagnosed here on Long Island despite a year of FUO, swollen knee, a decade of constant evanescent EMs and a poster child of a bullseye on my lower leg, not to mention all my neuro sx, which ultimately disabled me. I had to stop Lyme advocacy, too many nut jobs and unrelaible folks on both sides. But the academics know better and lie through their teeth in public; you should hear them talk off the record. > I find it ironic that my dog gets Lyme vaccine, and my horse gets > West Nile vaccine, but there's no vaccines for humans West Nile is pissing me off, so much TBD money has been diverted to an illness that rarely sickens people. Ticks are disabling so many every year. The vaccines were badly conceived and unsafe. Susan > It's even worse than I had previously thought: the numbers were about > 70% sensitive/specific. But when I studied probability and statistics in school, I learned the rule of thumb that multiple correlations tended to be higher than partial correlations, because more factors are combined. That is, in this case they separated out ethmoid disease, frontal disease, maxillary disease and sphenoid disease. And in diagnosing each type separately, the numbers were below the 70-80% accuracy for diagnosing sinus disease that we're we're used to. But that's not how real doctors do real diagnoses. They look at the entire CT scan to find evidence of sinus disease *anywhere* in the sinuses. And then the doctors will treat the entire osteomeatal complex. So even if the CT scan missed finding sinus disease in the sphenoids, it might pick up sinus disease in the ethmoids; even if it missed finding it in the frontals, it might pick it up in the maxillaries. And then the ENT can proceed with treatment or surgery. That was my personal experience too: From my CT scan, my ENT had found enough stuff wrong with my maxillaries to justify surgery. But when he operated on me he also found things wrong with my ethmoids that the CT scan had missed.  SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. >> It's even worse than I had previously thought: the numbers were about >> 70% sensitive/specific. > > But when I studied probability and statistics in school, I learned the > rule of thumb that multiple correlations tended to be higher than > partial correlations, because more factors are combined. Steven, they were testing for specificity, so combining all results wouldn't have been appropriate in this case. > That is, in this case they separated out ethmoid disease, frontal > disease, maxillary disease and sphenoid disease. And in diagnosing each [quoted text clipped - 14 lines] > operated on me he also found things wrong with my ethmoids that the CT > scan had missed. I think this was strictly an evaluation of the technology, not of how to make clinical decisions, though clearly it has implications. Susan > x-no-archive: Yes > [quoted text clipped - 7 lines] > Steven, they were testing for specificity, so combining all results > wouldn't have been appropriate in this case. I understand that. My point was that the numbers I usually have quoted in the past was that CT scans have about an 85% rate of correctly *detecting* sinus disease, not necessarily *pinpointing* the exact location of sinus disease. If a patient's CT scan shows obviously swollen linings and blocked ducts in his maxillaries, then it has detected sinus disease correctly. Even if it has missed some tiny little pocket of infection in some other sinus cavity. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. On 7/18/06 2:51 PM, in article 4i53f2F27ce2U1@individual.net, "Susan" <nevermind@nomail.com> wrote: > J Otolaryngol. 2000 Jun;29(3):170-3. Related Articles, Links > [quoted text clipped - 26 lines] > > PMID: 10883832 [PubMed - indexed for MEDLINE] But this study not based on 3-D digital CT. > On 7/18/06 2:51 PM, in article 4i53f2F27ce2U1@individual.net, "Susan" > <nevermind@nomail.com> wrote: [quoted text clipped - 31 lines] > > But this study not based on 3-D digital CT. Are there citations, with tissue samples taken, of the correlation of 3D digital CT and histologic findings that you can post? Susan Personally, the worst clinical experience I ever had was surgery at Mass Eye and Ear, by an "expert" based on a 3-D CT. I ended up with a post-op bone infection, which took a year to sort out, and the "expert" literally refused to see me back, because he never had bad outcomes. Using old technology: endoscopes, cultures and regular CT's, my local ENT performed two further surgeries to deal with multi-resistant pseudomonas osteomyelitis that had developed. When I called to Boston to report that things weren't going well, I was told "to stop obsessing about what came out of my nose." Actually, a piece of dead bone came out of my nose. My chairman, a true gentleman, kept telling me to report this to the Mass Board, but I was too sick to go that route. So, maybe 3-D CT's might be more sensitive, but I've never seen an article comparing them. MRI's are just as insensitive and nonspecific as CT's--they're slightly worse at showing "false positives". Imaging has limitations and that should be factored into making clinical decisions. Judy > x-no-archive: yes > [quoted text clipped - 38 lines] > > Susan On 7/20/06 10:27 AM, in article 1153416444.396217.183570@m79g2000cwm.googlegroups.com, "judy.n" > might be more sensitive, but I've never seen an > article comparing them. MRI's are just as insensitive and nonspecific > as CT's--they're slightly Actually MRI is much more sensitive, unfortunately it is TOO sensitive and picks up "disease" where it really isn't. We get MRI sinus disease referred regularly and we often have to reassure the patient that everything is normal.Howver because it is so sensitive, MRI of the sinus is useful in diagnosing various kinds of fungal disease. On 7/18/06 9:23 PM, in article 4i5qe6F28es5U1@individual.net, "Susan" <nevermind@nomail.com> wrote: > x-no-archive: yes > [quoted text clipped - 38 lines] > > Susan Just about every day we do surgery and correlate with digital 3 D findings in our practice. It certainly has helped our patients. The 3-D CT's make sense: after all, we're not two dimensional and knowing where you are with an endoscope is an art. My experience was just one bad one where the clinician was insensitive (bordering on negligent) and in this case embraced technology over patient care. I am skeptical about the tendency to embrace new technology, and then deal with the consequences: like the sinus balloon. I used to review "new technology" for a medicaid HMO, and found it was often put into practice with very little long-term patient experience. New isn't always better. I do understand that 3-D CT give a better picture, are more accurate and assist the surgeons: they're also considerably more expensive than traditional CT. Is the benefit worth the price? In my case, it wasn't. Judy > On 7/18/06 9:23 PM, in article 4i5qe6F28es5U1@individual.net, "Susan" > <nevermind@nomail.com> wrote: [quoted text clipped - 44 lines] > Just about every day we do surgery and correlate with digital 3 D findings > in our practice. It certainly has helped our patients. On 7/21/06 6:27 AM, in article 1153488448.644688.165680@i3g2000cwc.googlegroups.com, "judy.n" > they're also considerably more expensive than > traditional CT. In our area they actually cost less. There is no cost of film, or storage of film. Just the savings in X ray envelopes and storage alone brings the price down. All the info is in a standard CD disk. In our area all CT's and MRI's are on disk. I just had the experience of seeing a much higher charge for the 3-D CT on my EOB. It was a few years ago. Judy > On 7/21/06 6:27 AM, in article > 1153488448.644688.165680@i3g2000cwc.googlegroups.com, "judy.n" [quoted text clipped - 4 lines] > of film. Just the savings in X ray envelopes and storage alone brings the > price down. All the info is in a standard CD disk. > In our area all CT's and MRI's are on disk. I just had the experience > of seeing a much higher charge for the 3-D CT on my EOB. It was a few > years ago. Murray may've been referring to what they cost to perform, not what they cost the patient or insurance. Susan
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