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Mri for undescended testis
218
CLINICAL RADIOLOGY
volumetric changes in the thyroids of patients with post-partum thyroiditis (PPT). Women with anti-thyroid auto-antibodies are at increased risk of developing acute auto-immune thyroiditis during the post-partum period. This may present as transient hyperthyroidism, hypothyroidism or both. Biochemical abnormalities are most marked 4 to 6 months post-partum and the process is usually self-limiting. Unlike De Quervain's thyroiditis, post-partum thyroiditis is usually painless and there is no associated pyrexia. On ultrasound examination the thyroid in these patients may appear generally hypoechoic or there may be multifocal hypoechoic areas. We have also documented marked reduction in thyroid volume during the recovery period, similar to that recently described in De Quervain's thyroiditis. We agree that ultrasound may have a useful role in the evaluation of acute thyroiditis. However, the sonographic features are non-specific and we emphasize that they must be interpreted in conjunction with the clinical, biochemical and immunological status of the patient.
SIR We thank Professor Sherwood and Mr Whitaker for their comments. We believe that modern imaging can locate the posiiion of impalpable undescended testes in most cases and direct the surgeon accordingl~ Magnetic resonance imaging should prove particularly useful in the l'i to 20% of testes which are intra-abdominal. We hope the days of the blind exploratory laparotomy will SOonbe over and feel that diagnostic imaging is the best way to start this particular ball rolling!
Department of Radiology Caerphilly District Miners Hospital Caerphilly Mid Glamorgan CF8 2 W W
SIR - Following Dr J. A. Fielding's valuable paper (1990) it may be helpful to describe the system employed in Harrogate for the past 12 years. Specially designed, selfcarboning flimsy report forms are used. These are pre-printed with a list of possible 'A and E' examinations on the left hand margin. The top half of the remainder of the form is for a record of the casualty officer's findings and includes a small box marked 'NBI'. The bottom half is for the Radiologist's report and includes a small box 'Findings Agreed'. The Radiographer writes the patient's name and rings the examina. tion on the form. In addition a line is put through 'NBI' if a fracture is spotted. The casualty officers have been officially notified that this is informal and of no legal significance. The form is then returned to the A and E Department with the film packet in a clear cellophane 'unreported' sleeve. On receipt of the films the casualty officer records his or her own name on the form and writes down the film interpretation acted on. In the majority of cases this involves only ticking the box labelled 'NBI'. The films and form are then returned t o the Radiology Department for reporting. At this stage the Radiologist has a flimsy report showing the casualty officer's name and opinion and is able to write the definitive report beneath it. In the great majority of cases this involves only ticking the box labelled 'Findings Agreed' and signing the form. Where there is disagreement this is immediately obvious and the A and E Department notified. The completed form then becomes the official report and copies are affÉxed to the request card, the report sheet with the films, and included in the patient's notes. No typing is involved and a great deal of secretarial time is preserved. The system has stood the test of time in a busy department with no junior staff and a stretched secretarial service. It may be relevant to others in a similar position and if anyone is interested, I should be pleased to send them an example of the flimsy report form that we use.
H. A D A M S M. C. JONES
Reference Birchall, IWJ, Chow, CC & Metreweli, C (1990). Ultrasound appearances of De Quervain's thyroiditis. Clinical Radiology, 41, 57 59. SIR- I am grateful to Drs Adams and Jones for their interesting information about the sonographic features of post-partum thyroiditis. Naturally, I would agree that the result of any imaging investigation must be tempered by knowledge o f the clinical status of the patient. As we explained, in a patient presenting with an acutely painful thyroid gland but without signs of infection, ultrasonic examination will usually suffice to differentiate between de Quervain's thyroiditis and other diagnoses (haemorrhage into the thyroid parenchyma or a nodule, and invasive malignancy), without resorting to other biochemical or immunological tests. I. W. J. BIRCHALL
Department of Radiology Bristol Royal Infirmary Marlborough Street Bristol BS6 8HW
MRI FOR UNDESCENDED TESTIS SIR - The interesting paper by Troughton et al. (1990) describes findings in six adults; the summary conclusions in the last paragraph and flow diagram go very much further. 'The use of diagnostic imaging for nonpalpable undescended testis is very controversial' (Friedland et al., 1990). Reviewing various published series, the authors suggested that 'no imaging examination currently available can help the surgeon decide whether to operate, nor can the r e s u l t s . . , be used to alter the surgical approach' (Friedland and Chang, 1988). In keeping With our experience that imaging does not represent a critical decision node for children with undescended testis, we do not subject all these boys to a ritual imaging work-up. T. SHERWOOD R. H. W H I T A K E R
Addenbrooke's Hospital Hills Road Cambridge CB2 2QQ
References Friedland, GW, Devries, PA, Nino-Murcia, M, Cohen R & Rifkin, M D (1990). Specific disorders of the urinary tract: developmental and congenital disorders. In: Clinical Urography, ed. Pollack, H. M., p. 764. W B Saunders Co., Philadelphia. Friedland, GW & Chang, P (1988). The rose of imaging in the management of the impalpable undescended testis. American Journal of Roentgenology, 151, 1107 1111. Troughton, AH, Waring, J, Longstaff, A & Goddard, P R (1990). The role of magnetic resonance imaging in the investigation of undescended testes. Clinical Radiology, 41, 178 181.
P. G O D D A R D A. T R O U G H T O N
Department of Radiodiagnosis Bristol Royal Infirmary Marlborough Street Bristol BS6 8H~
IMPROVING ACCIDENT AND EMERGENCY RADIOLOGy
J. F. ROSE
Department of Radiology Harrogate District Hospital Lancaster Park Road Harrogate North Yorks
Reference Fielding, JA (1990). Improving accident and emergency radiology. Clinical Radiology, 41, 149-151. SIR - Dr Rose has a very useful system, involving both radiographer! and casualty officers in A and E radiology. At my own hospital the red dot system is in operation, and all A and E films are returned to the X" ray I)epartment with a written report from the casualty officer. The radiologist is therefore immediately alerted to any misdiagnosis an~ informs the A and E department, so that necessary action is taken. A! errors, and interesting cases are discussed at a weekly clinico-radiol0gl" cal meeting, with the A and E consultant and his staff. This method of audit raises the level of interest of all Concerned in A and E radiologY, and increases the film interpretation abilities of casualty officers. J. A. F I E L D I N G
Royal Shrewsbury Hospital Nort~ Mytton Oak Roat~ Shrewsbury SY3 8Bg
CLINICAL RADIOLOGY
volumetric changes in the thyroids of patients with post-partum thyroiditis (PPT). Women with anti-thyroid auto-antibodies are at increased risk of developing acute auto-immune thyroiditis during the post-partum period. This may present as transient hyperthyroidism, hypothyroidism or both. Biochemical abnormalities are most marked 4 to 6 months post-partum and the process is usually self-limiting. Unlike De Quervain's thyroiditis, post-partum thyroiditis is usually painless and there is no associated pyrexia. On ultrasound examination the thyroid in these patients may appear generally hypoechoic or there may be multifocal hypoechoic areas. We have also documented marked reduction in thyroid volume during the recovery period, similar to that recently described in De Quervain's thyroiditis. We agree that ultrasound may have a useful role in the evaluation of acute thyroiditis. However, the sonographic features are non-specific and we emphasize that they must be interpreted in conjunction with the clinical, biochemical and immunological status of the patient.
SIR We thank Professor Sherwood and Mr Whitaker for their comments. We believe that modern imaging can locate the posiiion of impalpable undescended testes in most cases and direct the surgeon accordingl~ Magnetic resonance imaging should prove particularly useful in the l'i to 20% of testes which are intra-abdominal. We hope the days of the blind exploratory laparotomy will SOonbe over and feel that diagnostic imaging is the best way to start this particular ball rolling!
Department of Radiology Caerphilly District Miners Hospital Caerphilly Mid Glamorgan CF8 2 W W
SIR - Following Dr J. A. Fielding's valuable paper (1990) it may be helpful to describe the system employed in Harrogate for the past 12 years. Specially designed, selfcarboning flimsy report forms are used. These are pre-printed with a list of possible 'A and E' examinations on the left hand margin. The top half of the remainder of the form is for a record of the casualty officer's findings and includes a small box marked 'NBI'. The bottom half is for the Radiologist's report and includes a small box 'Findings Agreed'. The Radiographer writes the patient's name and rings the examina. tion on the form. In addition a line is put through 'NBI' if a fracture is spotted. The casualty officers have been officially notified that this is informal and of no legal significance. The form is then returned to the A and E Department with the film packet in a clear cellophane 'unreported' sleeve. On receipt of the films the casualty officer records his or her own name on the form and writes down the film interpretation acted on. In the majority of cases this involves only ticking the box labelled 'NBI'. The films and form are then returned t o the Radiology Department for reporting. At this stage the Radiologist has a flimsy report showing the casualty officer's name and opinion and is able to write the definitive report beneath it. In the great majority of cases this involves only ticking the box labelled 'Findings Agreed' and signing the form. Where there is disagreement this is immediately obvious and the A and E Department notified. The completed form then becomes the official report and copies are affÉxed to the request card, the report sheet with the films, and included in the patient's notes. No typing is involved and a great deal of secretarial time is preserved. The system has stood the test of time in a busy department with no junior staff and a stretched secretarial service. It may be relevant to others in a similar position and if anyone is interested, I should be pleased to send them an example of the flimsy report form that we use.
H. A D A M S M. C. JONES
Reference Birchall, IWJ, Chow, CC & Metreweli, C (1990). Ultrasound appearances of De Quervain's thyroiditis. Clinical Radiology, 41, 57 59. SIR- I am grateful to Drs Adams and Jones for their interesting information about the sonographic features of post-partum thyroiditis. Naturally, I would agree that the result of any imaging investigation must be tempered by knowledge o f the clinical status of the patient. As we explained, in a patient presenting with an acutely painful thyroid gland but without signs of infection, ultrasonic examination will usually suffice to differentiate between de Quervain's thyroiditis and other diagnoses (haemorrhage into the thyroid parenchyma or a nodule, and invasive malignancy), without resorting to other biochemical or immunological tests. I. W. J. BIRCHALL
Department of Radiology Bristol Royal Infirmary Marlborough Street Bristol BS6 8HW
MRI FOR UNDESCENDED TESTIS SIR - The interesting paper by Troughton et al. (1990) describes findings in six adults; the summary conclusions in the last paragraph and flow diagram go very much further. 'The use of diagnostic imaging for nonpalpable undescended testis is very controversial' (Friedland et al., 1990). Reviewing various published series, the authors suggested that 'no imaging examination currently available can help the surgeon decide whether to operate, nor can the r e s u l t s . . , be used to alter the surgical approach' (Friedland and Chang, 1988). In keeping With our experience that imaging does not represent a critical decision node for children with undescended testis, we do not subject all these boys to a ritual imaging work-up. T. SHERWOOD R. H. W H I T A K E R
Addenbrooke's Hospital Hills Road Cambridge CB2 2QQ
References Friedland, GW, Devries, PA, Nino-Murcia, M, Cohen R & Rifkin, M D (1990). Specific disorders of the urinary tract: developmental and congenital disorders. In: Clinical Urography, ed. Pollack, H. M., p. 764. W B Saunders Co., Philadelphia. Friedland, GW & Chang, P (1988). The rose of imaging in the management of the impalpable undescended testis. American Journal of Roentgenology, 151, 1107 1111. Troughton, AH, Waring, J, Longstaff, A & Goddard, P R (1990). The role of magnetic resonance imaging in the investigation of undescended testes. Clinical Radiology, 41, 178 181.
P. G O D D A R D A. T R O U G H T O N
Department of Radiodiagnosis Bristol Royal Infirmary Marlborough Street Bristol BS6 8H~
IMPROVING ACCIDENT AND EMERGENCY RADIOLOGy
J. F. ROSE
Department of Radiology Harrogate District Hospital Lancaster Park Road Harrogate North Yorks
Reference Fielding, JA (1990). Improving accident and emergency radiology. Clinical Radiology, 41, 149-151. SIR - Dr Rose has a very useful system, involving both radiographer! and casualty officers in A and E radiology. At my own hospital the red dot system is in operation, and all A and E films are returned to the X" ray I)epartment with a written report from the casualty officer. The radiologist is therefore immediately alerted to any misdiagnosis an~ informs the A and E department, so that necessary action is taken. A! errors, and interesting cases are discussed at a weekly clinico-radiol0gl" cal meeting, with the A and E consultant and his staff. This method of audit raises the level of interest of all Concerned in A and E radiologY, and increases the film interpretation abilities of casualty officers. J. A. F I E L D I N G
Royal Shrewsbury Hospital Nort~ Mytton Oak Roat~ Shrewsbury SY3 8Bg