POS0795 ULTRASOUND-GUIDED CORE NEEDLE BIOPSY: AN EFFECTIVE AND SAFE TOOL TO DIAGNOSE SJÖGREN`S SYNDROME AND LYMPHOMA OF THE MAJOR SALIVARY GLANDS

Background:

Histopathology is a cornerstone of diagnostics in Sjögren`s syndrome (SjS). The current widely accepted standard, minor salivary gland (lip) biopsy, is a surgical procedure with several disadvantages including permanent sensory loss of the lips as a well-known complication (reviewed in 1). Moreover, lymphoma of salivary glands cannot be excluded. Ultrasound-guided core needle biopsy (CNB) is an excellent diagnostic tool with good safety (2) and encouraging results as compared to open biopsy (3).

Objectives:

To retrospectively analyze safety and diagnostic outcome of ultrasound-guided CNB in patients with known or suspected SjS.

Methods:

A retrospective analysis of a case series of four patients with known or suspected SjS. All patients were treated at the outpatient clinic of the Department of Rheumatology & Immunology, and the Department of Otorhinolaryngology. All patients underwent ultrasound-guided CNB: We clean and disinfect the ultrasound transducer and the skin of the patient before and after the procedure. We use a sterile probe cover and gloves. Only sterile ultrasound gel or ultrasound compatible disinfectant should be used. Core-needle biopsy was performed using a 20 g needle (Bard). A Logiq S8 GE ultrasound device with a 6-15 MHz matrix linear transducer was used. We performed a local anesthesia at the entry point and a 2mm skin incision. The sampling length was set on 20mm. The CNB was performed at the most suspicious focal sonographic lesion. 2-3 needle passes were carried out through the same skin access.

Results:

Representative histopathological samples were obtained from all patients. In patient 1 (62y) with known SjS and parotid swelling, mucosa-associated lymphoid tissue (MALT) lymphoma was diagnosed (previous lip biopsy with no proof of malignancy). Also in patient 2 (35y) with known SjS and a 20-years history of parotid swelling, MALT lymphoma was diagnosed. In this patient a lip biopsy was performed in the previous year supporting the diagnosis of SjS, but without proof of malignancy. In patient 3 (64y) with SSc, anti-Ro/SSA positivity and dry eyes and mouth, the biopsy established the diagnosis of SjS. In patient 4 (59y) with SSc, negative anti-Ro/SSA antibodies and dry eyes/mouths, SjS could be excluded. In the corresponding ultrasound, all patients showed hypoechogenic lesions and inhomogeneous parenchyma of major salivary glands reflecting OMERACT grade II-III SjS ultrasound score (4). No safety signals were observed. Patients with prior lip biopsies perceived ultrasound-guided CNB as preferable.

Conclusion:

This pilot study suggests that ultrasound-guided CNB in SjS is a safe procedure with an excellent diagnostic yield allowing the diagnosis of lymphoma of the salivary glands, which is superior to lip biopsy. Given these encouraging results, we will now increase patient numbers for further validation.

References:

[1]Pijpe, J., et al., Parotid gland biopsy compared with labial biopsy in the diagnosis of patients with primary Sjogren’s syndrome. Rheumatology (Oxford), 2007. 46(2): p. 335-41.

[2]Kim, H.J. et al., Ultrasound-guided core needle biopsy in salivary glands: A meta-analysis. Laryngoscope, 2018. 128(1): p. 118-125.

[3]Zabotti, A. et al., Ultrasound-guided core needle biopsy compared with open biopsy: a new diagnostic approach to salivary gland enlargement in Sjögren’s syndrome? Rheumatology (Oxford). 2020.17:keaa441. Epub ahead of print.

[4]Jousse-Joulin, S., et al., Video clip assessment of a salivary gland ultrasound scoring system in Sjogren’s syndrome using consensual definitions: an OMERACT ultrasound working group reliability exercise. Ann Rheum Dis, 2019. 78(7): p. 967-973.

Disclosure of Interests:

Urs Borner: None declared, Lluis Nisa Hernandez: None declared, Adela-Cristina Sarbu: None declared, Lisa Christ Shareholder of: Roche, Grant/research support from: Gilead, Roche, Pfizer, Yara Banz: None declared, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Grant/research support from: Abbvie, Protagen, Novartis Biomedical Research and congress support from Pfizer, Roche, Actelion, mepha, and MSD. BM has a patent for mir-29 for the treatment of systemic sclerosis issued (US8247389, EP233143)., Marco D. Caversaccio Grant/research support from: Medel, Cochlear, Oticon, Storz, Florian Kollert Shareholder of: Roche, Consultant of: Actelion, BMS, Boehringer-Ingelheim, Pfizer, Grant/research support from: Gilead, Pfizer, Employee of: In the past at Novartis, currently at Roche

[Dizziness and vertigo in a tertiary ENT emergency department]

BACKGROUND

Although vestibular symptoms are amongst the most frequent reasons for seeking emergency medical help, many patients remain undiagnosed.

OBJECTIVE

In this cross-sectional study, we investigated the spectrum of vertigo and dizziness in a tertiary ear, nose, and throat (ENT) emergency department (ED). Furthermore, we investigated the attendant symptoms, clinical signs, and the diagnostic tests performed.

METHODS

We screened all ED reports from 01/2013 to 12/2013 for adult patients with vestibular symptoms referred to the ENT department.

RESULTS

In total, we found 2596 cases with reported vestibular symptoms in the ED as a main or accompanying complaint. Of these, 286 were referred to the ENT specialist directly (n = 98) or via other major medical specialties (n = 188). Benign paroxysmal positional vertigo (BPPV) was the most frequent diagnosis in our study (n = 46, 16.1%), followed by vestibular neuritis (n = 44, 15.4%), otitis media (n = 20, 7%), and 9 patients (3.1%) had an ischemic stroke or a transient ischemic attack. In 70 (24.5%) cases, dizziness was not further specified.

CONCLUSION

BPPV is the most frequent diagnosis seen in the ED; however, physicians need to document nystagmus more precisely and perform diagnostic tests systematically, in order to make an accurate diagnosis. To avoid misdiagnoses, ED physicians and ENT specialists should be able to recognize central signs in patients with an acute vestibular syndrome. Every fourth patient does not receive a definitive diagnosis. Diagnostic ED workup for patients with dizziness needs further improvement.

Radiation dose reduction in postoperative computed position control of cochlear implant electrodes in lambs - An experimental study

OBJECTIVE

Cochlear implants (CI) are standard treatment for prelingually deafened children and postlingually deafened adults. Computed tomography (CT) is the standard method for postoperative imaging of the electrode position. CT scans accurately reflect electrode depth and position, which is essential prior to use. However, routine CT examinations expose patients to radiation, which is especially problematic in children. We examined whether new CT protocols could reduce radiation doses while preserving diagnostic accuracy.

METHODS

To investigate whether electrode position can be assessed by low-dose CT protocols, a cadaveric lamb model was used because the inner ear morphology is similar to humans. The scans were performed at various volumetric CT dose-indexes CTDIvol)/kV combinations. For each constant CTDIvol the tube voltage was varied (i.e., 80, 100, 120 and 140kV). This procedure was repeated at different CTDIvol values (21mGy, 11mGy, 5.5mGy, 2.8mGy and 1.8mGy). To keep the CTDIvol constant at different tube voltages, the tube current values were adjusted. Independent evaluations of the images were performed by two experienced and blinded neuroradiologists. The criteria diagnostic usefulness, image quality and artifacts (scaled 1-4) were assessed in 14 cochlear-implanted cadaveric lamb heads with variable tube voltages.

RESULTS

Results showed that the standard CT dose could be substantially reduced without sacrificing diagnostic accuracy of electrode position. The assessment of the CI electrode position was feasible in almost all cases up to a CTDIvol of 2-3mGy. The number of artifacts did not increase for images within this dose range as compared to higher dosages. The extent of the artifacts caused by the implanted metal-containing CI electrode does not depend on the radiation dose and is not perceptibly influenced by changes in the tube voltage. Summarizing the evaluation of the CI electrode position is possible even at a very low radiation dose.

CONCLUSIONS

CT imaging of the temporal bone for postoperative electrode position control of the CI is possible with a very low and significantly radiation dose. The tube current-time product and voltage can be reduced by 50% without increasing artifacts. Low-dose postoperative CT scans are sufficient for localizing the CI electrode.

Limitations of balloon sinuplasty in frontal sinus surgery

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6 months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.

[Tracheobronchial foreign body in children. Is anamnesis alone enough to indicate tracheobronchoscopy?]

From 1989-1993 we performed rigid bronchoscopies in 86 children in whom foreign body aspirations were suspected. In 72 cases, foreign bodies were identified in the tracheobronchial tree. In the remaining 14, no foreign body was found. Boys outnumbered girls. The most common type of foreign body was a peanut. The predilection of the foreign body was to fall into the right main bronchus. If the history indicated foreign body aspiration, a chest x-ray was not found to be necessary except for forensic interest.

[Rare malignant laryngeal tumors]

Six rare malignant tumors were found in a group of 136 laryngeal malignancies accessioned between 1990 and 1992. The other 130 neoplasms were squamous cell carcinomas. One case each of an adenocarcinoma, a mucoepidermoid carcinoma and an undifferentiated carcinoma of nasopharyngeal type were of epithelial origin; a case of a malignant fibrous histiocytoma, a chondrosarcoma and a plasmacytoma were of mesenchymal origin. The clinical presentations, histological findings, and therapy employed in the six cases are discussed and the available literature reviewed.