introduction to ent imaging - entpa.org

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Introduction to ENT Imaging

Barton F. Branstetter IV

Chief of NeuroradiologyUniversity of Pittsburgh Medical Center

University of Pittsburgh School of Medicine

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PAFourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Disclosure

• No commercial relationships to disclose

Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA


Objectives

• Suggest appropriate imaging studies for frequently‐encountered clinical scenarios in otolaryngology.

• Identify resources to assist in appropriate selection of imaging studies.

• Compare relative benefits and risks of cross‐sectional imaging modalities.

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Most important concept

• ACR appropriateness criteria

– Evidence‐based

– Panels of Clinical and Radiology experts

– http://www.acr.org/Quality‐Safety/Appropriateness‐Criteria/Diagnostic

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ACR appropriateness criteria

• Can be integrated into CPOE

– “Decision support”

• Alternative: call the radiologist


Which modality is best?

• Not always most expensive

–PET/CT > MR > CT > US

–No plain films

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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA

Choosing a ModalityMR vs. CT

• MR–Soft tissues–Multiplanar

–No radiation

• CT–Bones–Lower cost–Ubiquitous


Ultrasound• Good for thyroid

• Good for superficial nodes– Incomplete survey

• Good for image guidance

• Very safe

• Emerging in‐office role– Specific clinical situations


PET/CT

• Expensive test

• High‐end technology

• Nowadays, always PET/CT, not just PET

• Not all cancers

• Not all situations

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When to get a PET/CT

• Known malignancy

– FDG‐avid histopathology

• Staging

• Monitoring

• Surveillance

• Restaging

When NOT to get a PET/CT

• Suspected tumor– Undiagnosed neck mass

– Secondary symptoms

• Small tumors– Unlikely to metastasize

• Cured tumors– Outside usual recurrence window

• Non‐FDG‐avid tumors– Glandular tumors

Sample scenario: Hearing Loss

• SNHL

– Contrast‐enhanced MR of IACs

– Cochlear & retrocochlear pathology

– Specifically, vestibular schwannoma

• CHL

– Non‐contrast CT of temporal bones

– EAC, TM, ossicles, middle ear

• Mixed

– Contrast‐enhanced CT

– Specific diagnoses (otosclerosis)

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Sample Scenario:Bell’s Palsy

• When to image?

–Progression after 3 weeks

– Incomplete recovery at 6 months

–Recurrent ipsilateral

–Hyperkinesis

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Sample scenario:Dizziness

• Dizziness vs. Vertigo

• ACR criteria: MRI

• Recent literature: no imaging

– Exception: sudden onset; room spinning

• Usually Meniere’s, BPPD

– No imaging findings

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Sample scenario:Tinnitus

• Pulsatile vs. Continuous

– Pulsatile enhanced CT

– Continuous MR IAC

• Subjective vs. Objective

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Sample scenario:Thyroid nodule

• Discovered clinically

– Ultrasound to characterize and biopsy

• Discovered incidentally on imaging

– Depends on size and imaging findings

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Sample scenario: Sinusitis

• Acute bacterial sinusitis– Benefits from antibiotics

• All other sinusitis– Wastes antibiotics

• Distinguishable on CT– But is it worth it?

– Failed treatment

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Sample scenario:Head and Neck Cancer

• No entry in ACR criteria

– Not a complete list of all clinical scenarios

– Just most common imaging scenarios

– Focused on primary care

– At UPMC, PET/CT used in select circumstances


The art of not ordering tests

• Patient expectations

• Medicolegal threat

• Reduced uncertainty

• Convenience for doctor & patient

• Sweeping changes to the health care system?

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“Teach us how to read scans”

“Please condense 12 years of training into a one‐hour lecture”

Ice Cream Cone

Stapes

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Banana

Pancakes

Cherries

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Labyrinthine

Tympanic

Mastoid

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Snail


Summary

• Use the ACR Appropriateness Criteria

• Use PET/CT for– Documented malignancy

– FDG‐avid types

– Likely to metastasize

• Not every patient needs a scan

introduction to ent imaging - entpa.org

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