Leroy Roberts

Clinical evaluation for sinusitis : making the diagnosis by history and physical examination

OBJECTIVE To identify the most useful clinical examination findings for the diagnosis of acute and subacute sinusitis. DESIGN Prospective comparison of clinical findings with radiographs. SETTING General medicine clinics at a university-affiliated Veterans Affairs Medical Center. PATIENTS Two hundred forty-seven consecutive adult men with rhinorrhea (51%), facial pain (22%) , or self-suspected sinusitis (27%) (median age, 50 years; median duration of symptoms, 11.5 days). MEASUREMENTS Patients were examined by a principal investigator (86%) or by a staff general internist, internal medicine resident (postgraduate year 2 or 3), or physician assistant, all blinded to radiographic results. All examiners recorded the presence or absence of 16 historical items, 5 physical examination items, and the clinical impression for sinusitis (high, intermediate, or low probability). The criterion standard was paranasal sinus radiographs (4 views), which were interpreted by radiologists blinded to clinical findings. RESULTS Thirty-eight percent of patients meeting entrance criteria had sinusitis. Sensitivity, specificity, and likelihood ratios were measured for clinical items. Logistic regression analysis showed five independent predictors of sinusitis: maxillary toothache (odds ratio, 2.9), transillumination (odds ratio, 2.7), poor response to nasal decongestants or antihistamines (odds ratio, 2.4), colored nasal discharge reported by the patient (odds ratio, 2.2), or mucopurulence seen during examination (odds ratio, 2.9). THe overall clinical impression was more accurate than any single finding: high probability (likelihood ratio, 4.7, intermediate (likelihood ratio, 1.4), low probability (likelihood ratio, 0.4). CONCLUSIONS General internists, focusing on five clinical findings and their overall clinical impression, can effectively stratify male patients with sinus symptoms as having a high, intermediate, or low probability of sinusitis.

Diagnosing sinusitis by X-ray: is a single Waters view adequate?

Objective:To determine whether a single Waters view (occipitomental) radiograph could be substituted for a four-view sinus series to diagnose sinusitis, and to determine the inter- and intraobserver variabilities for sinus radiography.Design:Radiographs were interpreted by radiologists blinded to the clinical history, and results were recorded on a standardized form.Setting:Veterans Affairs Medical Center.Participants:Staff attending radiologists, an attending radiologist with special training in skull radiology, and a senior radiology resident.Measurements and main results:The agreement between the Waters view and the four-view sinus series was moderate to substantial (simple agreement=75–84%, kappa=0.5–0.68). However, agreement varied by sinus and, after correction for chance agreement, was substantial only for the maxillary sinuses (kappa=0.72–0.87). Intraobserver agreement (kappa=0.72–0.84) was superior to interobserver agreement (kappa=0.49–0.59) for the four-view sinus series.Conclusions:Substituting a single Waters view for a four-view sinus series may be an acceptable strategy for diagnosing maxillary sinusitis.

Pancreaticobronchial fistula. Case report and review of the literature.

Fistulas between the pancreas and bronchial tree are uncommon examples of internal pancreatic fistulas. We describe a case of pancreaticobronchial fistula in which the diagnosis was made by bronchoscopy and biochemical analysis of respiratory secretions. Endoscopic retrograde cholangiopancreatography was confirmatory and guided treatment by internal drainage of the pancreatic duct. Ten other cases were found in the Western literature that emphasize the principles of diagnosis and treatment.

Scientific presentations. What to do and what not to do.

An effective scientific presentation requires skill, experience, and effort. In planning the presentation, a skilled speaker first forms clear conclusions through analysis of the data, then tailors the details of the proof of these conclusions to the interests and background of the audience. The facts and conclusions are presented in a practiced, specific, clear, and logical manner. It is not the topic or the data alone, but the sympathetic and strategic communication of the material to a particular audience that makes a meaningful presentation.

Computed tomography in the evaluation of severe facial trauma

Computed tomography (CT) is a simple, rapid, and safe method of evaluating patients with severe facial trauma. It has its greatest value in defining the extent of soft tissue damage as well as in assessing the skeletal disruption. In a group of 32 patients with severe facial trauma, CT outlined the degree of soft tissue and skeletal fracture. In 13 of these patients who also underwent conventional pleuri-directional tomography CT was determined to be just as effective in identifying all fractures. CT was also shown to be useful for follow up evaluation of patients with previous severe facial trauma.

An unusual presentation of thyroid papillary carcinoma: enlargement of a cervical intervertebral foramen.

Isolated enlargement of the cervical intervertebral foramen is frequently associated with dumbbell neurogenic tumors. We present an unusual case of isolated enlargement of a cervical intervertebral foramen in a 77-year-old male with an aggressive papillary thyroid carcinoma. To our knowledge, this represents the first case describing a thyroid process as a cause of foraminal enlargement.