Temporomandibular Joint Effusion Research Articles

OA08 A case of Recalcitrant Psoriatic Disease- should new treatment strategies be considered?

Introduction/BackgroundDespite the advent of numerous biologic therapies and small molecular drugs targeting specific immune pathways, at least 40% of PsA patients exhibit poor response.Given the complexity and heterogeneity of signalling pathways resulting in synovio-entheseal disease in PsA; new treatment strategies must be evaluated to induce deep and sustainable clinical responses in all the phenotypic domains.In patients who do not achieve remission in all disease aspects on biologic monotherapy or combination of a biologic therapy with an oral synthetic agent; dual targeted anti-cytokines strategies or combined biologic with a targeted oral small molecule are a possible treatment option.Description/MethodA 40-year-old attended our rheumatology department in 2010 with peripheral synovitis, dactylitis and scalp psoriasis. A clinical diagnosis of PsA was made and she was commenced on combination methotrexate and sulphasalazine.In 2011, therapy was escalated to include etanercept and methotrexate due to persistent active disease clinically and on nuclear medicine bone scan.Between 2011 to 2015, sequential bDMARD switches including certolizumab, infliximab and adalimumab, failed to put the disease in remission.Due to loss of effect, adalimumab was switched to secukinumab in early 2016. A few months later, while on secukinumab, she developed new onset Crohn’s disease and required treatment change to ustekinumab.In August 2018 following a prolonged flare, ustekinumab was stopped and tofacitinib was started. The disease went in LDA until September 2020 when hospital admission for a severe PsA flare was required. She had dactylitis of 3 digits, a left temporomandibular joint effusion on ultrasound and elevated acute phase reactants. A treatment change to abatacept resulted in primary failure and abatacept was replaced with baricitinib.In March 2021, she attended clinic with new nail changes, dactylitis of 3 digits and a large left knee effusion. She underwent a diagnostic arthroscopy of the left knee and wash-out in May 2021 which showed a macroscopic synovitis score and vascularity score of 100% respectively. Synovial histology showed evidence of chronic synovitis with abundant plasma cells.Following the arthroscopy and careful discussion, it was decided to initiate combination therapy with adalimumab biosimilar and tofacitinib in June 2021. The patient was assessed at 2 months following starting combination therapy and a dramatic clinical and biochemical was noted. CRP had improved from 139.9mg/L to 6.3mg/L. She was mobilising without an aid for the first time in years. Both her psoriasis and Crohn’s disease were also well controlled.Discussion/ResultsWhile the outcomes of patients with psoriasis have dramatically improved with monoclonal antibody therapies targeting IL-23 and IL-17A; achieving a measurable low disease activity state such as minimal disease activity (MDA) for musculoskeletal manifestations of psoriatic disease is infrequent. Due to the heterogeneity of disease in PsA, multiple cellular pathways are involved in the pathogenesis resulting in recalcitrant disease in a subgroup of patients. These patients, like our case, exhibit poor response to the current therapeutic paradigm in PsA.In such patients, treating one disease domain, one type of cell or a single pathway at a time is unlikely to result in meaningful disease control and remission may be unachievable thus subjecting patients to sustained joint inflammation and damage seen in PsA. Very little data exist regarding the safety of dual immunomodulator therapies for concomitant psoriasis and psoriatic arthritis. Safety concerns such as infectious risks are important considerations with such strategies; however, the targeted second-generation anti-cytokine biologics and targeted JAK-I have exhibited improved safety profiles with regards to infections.In this case, following careful discussion with our patient, she felt that the prospect of possible reduction in her musculoskeletal symptoms outweighed the potential safety concerns.Multiple cases are reported in the literature regarding the use combined biologic strategies in psoriatic disease; the most common combination reported being anti-TNF therapy and ustekinumab with varying degrees of response. Prospective, high-quality studies are needed to identify safe and efficacious dual strategies in PsA to pinpoint dosages, sequence and frequency of therapies.Key learning points/ConclusionThis case truly highlights the heterogeneity and complexity that accompanies psoriatic disease and as such, modulating a single pathway may not be sufficient to address all the phenotypic domains (skin, synovium, entheses, and axial).While physicians are often, understandably, hesitant to prescribe combined immunomodulatory therapies due to concerns regarding potential complications, such strategies should be considered in debilitating cases of psoriatic disease who fail to respond to conventional treatment as they have the potential to foster deep and long-lasting remission.Our case highlights that a patient-centred approach with patient involvement in clinical decisions regarding their disease is required. With such strategies, patients and clinicians, both, should balance the potential associated risks particularly infectious risk.Further studies are required to better determine the efficacy and safety profile of combined immunomodulatory therapies in psoriatic disease.

Diagnostic Value of High-Resolution Ultrasound for the Evaluation of Capsular Width in Temporomandibular Joint Effusion.

Aim: The aim of this study was to evaluate if the increased temporomandibular joint (TMJ) capsular thickness, measured by ultrasound (US), is associated with the presence of effusion, diagnosed using MRI imaging. Materials and Methods: 102 patients with signs and symptoms of temporomandibular disorders were included in the study. Each patient underwent US and MRI examinations, 1 to 5 days following clinical examination. The US was performed with an 8–40 MHz linear transducer operating at 20 MHz. The MRI was performed using a 1.5 T MRI device. The ROC curve was analyzed to identify the optimal cut-off value for capsular distention, which can be interpreted as an indirect sign of TMJ effusion. Results: The capsular width values were found to be between 0.7 and 3.6 mm. The best cut-off value was 2.05 mm with a sensitivity of 55.9% and a specificity of 94.7%. The next optimal cut-off value was 1.75 mm with a sensitivity of 67.6% and a specificity of 82.4%. The area under the ROC curve was 0.78 (95% CI 0.68, 0.87, p < 0.05). Conclusions: Ultrasound-measured capsular width can be interpreted as an indirect sign of TMJ effusion. The critical cut-off for capsular width was 2 mm.

Magnetic resonance imaging assessment of temporomandibular joint effusion with limitation of mouth opening after arthroscopic lysis and lavages

Magnetic resonance imaging assessment of temporomandibular joint effusion with limitation of mouth opening after arthroscopic lysis and lavages

Effects of bruxism on temporomandibular joint internal derangement in patients with unilateral temporomandibular joint pain: The role of magnetic resonance imaging diagnostics

ABSTRACT Objective This study compared temporomandibular joint (TMJ) magnetic resonance imaging (MRI) findings between bruxism and control groups with unilateral TMJ pain as well as the TMJ MRI findings for the painful and non-painful sides of individuals in the two groups. Methods Clinical and MRI findings of patients seen at Uşak University, Dentistry Faculty, Department of Oral and Maxillofacial Surgery for unilateral TMJ pain between 2017 and 2020 were analyzed. Bruxism was diagnosed based on clinical findings and patient history. The MRI variables were disc/condyle relationship (normal, disc displacement with reduction, or disc displacement without reduction), disc structure (normal and abnormal), condyle degeneration type (normal, moderate, or severe), and joint effusion (absent or present). Pain was recorded based on a visual analog scale (VAS) numbered between 0 and 10. Statistical analyses were performed using IBM SPSS. The data were distributed non-normally according to the results of Kolmogorov–Smirnov tests. The Mann–Whitney U test was used to compare age and VAS. Chi-square tests were used to compare categorical variables. Statistical significance was defined as p < 0.05 Results This study assessed the MRI records of 558 cases of TMJ pain. No significant differences in disc/condyle relation, disc structure, condyle structure, or effusion were observed between the control and bruxism groups (p > 0.05). However, a significant difference in TMJ MRI findings was observed between the painful and non-painful sides of each individual in the control and bruxism groups (p = 0.001, p < 0.001 and p = 0.004, p < 0.001, respectively). Conclusion The results of this study established a relationship between the painful side for each patient and TMJ MRI findings. In particular, individuals with bruxism had a higher rate of TMJ internal derangement and effusion on the painful side.

Temporomandibular joint dysfunction in some rheumatological diseases (case–control study)

Background The incidence of temporomandibular joint (TMJ) involvement in inflammatory arthritis, such as rheumatoid arthritis, is often underestimated. Noninvasive imaging modalities such as musculoskeletal ultrasound (MSUS) are used to evaluate the TMJ. Aim This study was conducted to determine the affection of TMJ in some rheumatological diseases using MSUS. Patients and methods The study included 50 participants divided into two groups: group I included 40 patients (80 TMJ joints) with four rheumatological diseases, and group II included 10 apparently healthy persons (20 TMJ joints) matched in age and sex with the patients, chosen as a control group. All patients were diagnosed clinically and through laboratory investigations. Thereafter, they were assessed for pain degree by visual analog scale (VAS); disease activity using disease activity score-28, systemic lupus erythematosus disease activity index, and Western Ontario and McMaster Universities Arthritis Index; functionally using Modified Health Assessment Questionnaire, and Fonseca questionnaire; and underwent imaging assessment using panoramic radiography and musculoskeletal ultrasonography. Results Erosions were detected in 12.5% of the examined TMJs by panoramic radiography, whereas they were detected in 32.5% by MSUS. TMJ effusion and disc displacement could not be detected by panoramic radiography, whereas effusion was detected by MSUS in 23.8% of the examined TMJs and disc displacement was detected in 27.5%. Conclusion MSUS is more sensitive in detection of TMJ affection than panorama x-ray. Radiographic pathological findings by MSUS and panorama x-rays were more in temporomandibular joint disorders of patients with rheumatoid arthritis followed by systemic lupus erythematosus and then osteoarthritis, and finally, psoriatic arthritis.

Correlation between joint effusion and clinical symptoms, magnetic resonance imaging and arthroscopic findings in patients with temporomandibular joint disease

ObjectivesThe aim of this study was to evaluate the relationship between temporomandibular joint (TMJ) effusions and clinical, magnetic resonance imaging and arthroscopic variables. MethodsWe designed a retrospective cohort study of patients attending our Department who presented temporomandibular joint disease according to the Research Diagnostic Criteria for Temporomandibular Disorders. According to the presence of effusion in magnetic resonance imaging, the sample was divided into 2 groups: patients with or without joint effusion. ResultsA total of 203 patients fulfilled the inclusion criteria, of which 99 (48.8%) showed no joint effusion and 104 (51.2%) presented effusion. We found no significant differences between clinical variables and joint effusion. However, patients without effusion showed significantly longer duration of symptoms that patients with effusion (mean = 34.8 months, standard deviation = 43.41 vs 20.25, 23.76; p = 0.005). We found no significant differences in magnetic resonance imaging and arthroscopic variables associated with the presence of effusions. For both groups, there were statistically significant differences in values of mean pain scores and mean maximum interincisal distance between the different times of examination (before surgery and 3, 6 and 12 months after surgery). ConclusionJoint effusion is not associated with clinical, imaging or arthroscopic variables, but may be a clinical characteristic of early stages of temporomandibular joint disease.

Characteristics of patients with temporomandibular joint osteoarthrosis on magnetic resonance imaging.

Temporomandibular joint (TMJ) dysfunction is a common condition that is best evaluated with magnetic resonance (MR) imaging. The aim of this study was to investigate the characteristics of the patients with TMJ osteoarthrosis on MR imaging. The MR images of 206 TMJs of 103 patients with temporomandibular disorders (TMD) were evaluated retrospectively in this study. The relationship between osteoarthrosis and age, gender, TMJ pain and MR imaging findings, such as disc displacement with or without reduction and TMJ effusion, was analysed. The patients with TMJ osteoarthrosis (mean: 51.6years) were significantly older than those without osteoarthrosis (mean: 44.8years, P=0.027). The incidence of the patients with TMJ osteoarthrosis was significantly different between with (10.0 %) and without reduction (57.0 %, P<0.001). Logistic multivariate regression analysis demonstrated that disc displacement without reduction was significant in patients with TMJ osteoarthrosis (odds ratio=12.285, P<0.001). This study suggests that characteristics of the patients with TMJ osteoarthrosis on MR imaging include older and disc displacement without reduction.

Arthrocentesis as adjuvant therapy for conservative treatment of condyle trauma: a case report

Background: Despite the mandibular density and strength, condyle is a vulnerable anatomic region for fracture, frequently caused by indirect impact of an eventual mandibular trauma. Traditionally, the conservative treatment has excellent results when applicable. Nevertheless, it is painful and patient-dependent therapy. Recent studies introduced the concept that traumatic events also predispose damages to the soft tissue of temporomandibular joint (TMJ), including hemarthrosis, joint effusion and disc displacement. These events are related to mandibular movement restriction and severe pain. Thus, arthrocentesis has been also indicated to remove inflammatory components and improve the micro-environment of injured TMJ (Nogami et al., 2018).

The relationship between temporomandibular joint effusion and pain in patients with internal derangement

ObjectivesThe purpose of this study was to evaluate the relationship between temporomandibular joint (TMJ) effusion and joint pain in patients with internal derangement based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). MethodsA total of 240 TMJs from 120 patients with unilateral painful joints (103 females and 17 males, mean age 29.9 ± 12 years) were evaluated. Clinical assessments were carried out according to the DC/TMD guidelines. Magnetic resonance imaging (MRI) was used to evaluate the degree of effusion in each joint. The radiological and clinical findings were analysed for statistically significant correlations. ResultsAlthough the results indicated a statistically significant association between moderate joint effusion and disc displacement (p < 0,05), there was no statistically significant association between moderate effusion and joint pain (p > 0,05). There were, however, statistically significant associations between marked effusion and both disc displacement and joint pain (p < 0,05). ConclusionTMJ effusion is associated with both disc displacement and joint pain: the effusion increased in direct proportion to the severity of pain and disc displacement. The possibility that there are various aetiologies for the condition should also be considered.

Characteristics of the patients with temporomandibular joint effusion on magnetic resonance imaging

Background: Magnetic resonance imaging (MRI) is widely used in the region of temporomandibular joint (TMJ), particularly to examine disc position and configuration, posterior disc attachment, and mandibular marrow status and to assess the presence of TMJ effusion. Aims: The aim of this study is to investigate the characteristics of the patients with TMJ effusion on MRI. Materials and Methods: MR images of 98 TMJs of 49 patients with temporomandibular disorders were evaluated in this study. The patients with TMJ effusion were concerning age, gender, TMJ pain, disc displacement with or without reduction, and osteoarthrosis. Results: The incidence of the patients with TMJ effusion was significantly different between male (19.2%) and female (51.4%, P = 0.005) and between TMJ pain present (53.7%) and absent (29.5%, P = 0.024), respectively. Logistic multivariate regression analysis demonstrated that gender (odds ratio = 4.188, P = 0.012) and TMJ pain (odds ratio = 2.704, P = 0.027) were significant in patients with TMJ effusion. Conclusions: This study suggests that characteristics of the patients with TMJ effusion include female and TMJ pain.

Comparison of computed tomography and magnetic resonance imaging for the detection of mandibular condylar osteochondroma*

Abstract Objective The purpose of this study was to compare computed tomography (CT) and magnetic resonance imaging (MRI) for the detection of mandibular condylar osteochondroma. Methods Preoperative CT and MRI of 33 patients with unilateral condylar osteochondroma were reviewed. The morphology, location, continuity with the parent bone, cartilage cap, perichondrium of tumors, and changes in soft and hard tissues adjacent to the lesions were investigated by two reviewers. Data were analyzed using McNemar test. A P value &lt; 0.05 was considered significant. Results Among the 33 condylar osteochondromas, 11 were of the diffuse type, 10 were of the sessile type, and 12 were of the pedunculated type. Continuity with the cortex and marrow of the host condyle was observed on both CT and MRI. Both modalities had identical detection rates of surface reconstruction of the temporal bone joint, condylar dislocation, and pseudarthrosis formation. However, MRI showed significantly higher detection rates of the cartilage cap and perichondrium than CT (P &lt; 0.05). Furthermore, MRI showed ipsilateral and contralateral temporo-mandibular joint (TMJ) disc displacement in 4 cases and 6 cases, respectively, and ipsilateral and contralateral TMJ effusion in 20 cases and 14 cases, respectively. Conclusion CT can intuitively display the morphology and spatial location of condylar osteochondromas through three-dimensional reconstruction. MRI may be superior to CT in the detection of cartilage cap, perichondrium of the condylar osteochondroma, and changes in the TMJ and adjacent soft tissues.

Differences in signal intensities of temporomandibular joint (TMJ) effusion on fluid-attenuated inversion recovery (FLAIR) images.

Joint effusion is demonstrated by high signal intensity in the upper and lower temporomandibular joint (TMJ) spaces on T2-weighted images. The fluid-attenuated inversion recovery (FLAIR) technique can be applied to analyze joint effusion in the TMJ. FLAIR signal intensity can be more sensitively influenced by the contents of joint effusion than T2-weighted signal intensity. The purpose of this study was to analyze the signal intensity of joint effusion on FLAIR images and to investigate the changes in joint effusion contents according to the status of TMJ disorders. A total of 48 joints (45 patients) with joint effusion were investigated by magnetic resonance (MR) imaging. Regions of interest were placed over the joint effusion and gray matter on FLAIR images. The joints were categorized as normal disk position (NL), disk displacement with reduction (DWR), disk displacement without reduction (DWOR), and osteoarthritis (OA). The signal intensity ratio of joint effusion was calculated using gray matter as the reference point. The Kruskal-Wallis test and Steel test were applied. A probability of less than 0.05 was considered statistically significant. The median signal intensity ratios of joint effusion differed significantly among the four joint categories (p = 0.02, Kruskal-Wallis test). The median signal intensity ratio of joint effusion in the OA category was significantly higher than that in the NL category (p = 0.04, Steel test). The present findings suggest that FLAIR images can demonstrate the changes in joint effusion contents according to the status of TMJ disorders.

Magnetic resonance imaging versus musculoskeletal ultrasound in the evaluation of temporomandibular joint in rheumatoid arthritis patients

Aim of the workTo evaluate temporomandibular joint (TMJ) affection in rheumatoid arthritis (RA) patients by magnetic resonance imaging (MRI) versus musculoskeletal ultrasound (MSUS) and to correlate the findings with clinical manifestations, disease activity and functional status. Patients and methodsTwenty RA patients (40 TMJ) were included in this study. Disease activity score 28 (DAS28) was assessed and functional status by modified health assessment questionnaire (mHAQ). The TMJs were assessed clinically and functionally according to the Fonesca’s questionnaire. Radiological assessment of the TMJ was performed using panorama X-ray, MSUS and MRI. ResultsThe patients mean age was 47.3±10.03 with a F:M 9:1. Out of 40 TMJs 27 (67.5%) were symptomatic; pain/tenderness in 67.5%, limited mouth opening in 65% and sounds in 47.5%. MRI was superior in detection of TMJ abnormalities compared with MSUS (82.5% vs 77.5%, respectively). The frequencies of TMJ erosions detected by MRI, MSUS and panorama were 80%, 57.5% and 27.5% respectively (p=0.0001). TMJ effusion and disc displacement were comparable by MRI and MSUS (67.5% and 62.5%; p=0.64 and 57.5% and 52.5%; p=0.5,respectively). Only the effusion and disc displacement significantly correlated with the DAS28 and mHAQ. Only the erosions detected by MSUS did not significantly correlate with the Fonesca’s questionnaire. ConclusionDetection of TMJ abnormalities tended to be higher by MRI than by MSUS yet with no difference between both modalities. TMJ erosions, effusion and disc displacement were common in RA patients as detected by MRI and MSUS. Also both were helpful in detecting subclinical TMJ radiographic abnormalities in RA patients.

Zygomatic Abscess with Temporomandibular Joint Effusion Complicating Acute Otitis Media

Zygomatic Abscess with Temporomandibular Joint Effusion Complicating Acute Otitis Media

TMJ arthritis is a frequent complication of otomastoiditis.

Septic arthritis of the temporomandibular joint (TMJ) is a rare condition known to result in significant morbidity if diagnosis is delayed. Acute otomastoiditis is a typical complication of acute otitis media but few cases of acute otomastoiditis complicated with TMJ arthritis have been reported in the international literature. Furthermore, otomastoiditis reports and studies rarely analyzed TMJ CT scans. The aim of this study was to determine the incidence of TMJ arthritis in acute otomastoiditis, based on the analysis of CT scans. We conducted a prospective study from 2014 to 2015, including all consecutive pediatric patients admitted to the Pediatric Otolaryngology department for acute otomastoiditis. A craniofacial injected CT scan was performed in all patients. The imagery was prospectively blind analyzed by two independent investigators screening for the criteria of TMJ arthritis. Finally, during the long-term follow-up we noted the number of patients presenting a clinical TMJ ankylosis. We included 45 patients. The analysis showed 15 patients with TMJ effusion. Of those, 6 (13.33%) had an abscess and 2 clinical ankyloses. This study showed a high rate of TMJ arthritis complicating otomastoiditis. Our results demonstrate that systematic TMJ analysis in the CT scan of patients with otomastoiditis is essential.

Parotid Lymphadenopathy Is Associated With Joint Effusion in Non-Neoplastic Temporomandibular Disorders

Lymphadenopathy often occurs in the setting of inflammation, with or without infection. We sought to elucidate any association of parotid lymphadenopathy with joint effusion in temporomandibular joint (TMJ) disorders. We performed a retrospective cohort study. We analyzed the magnetic resonance imaging studies of patients with suspected TMJ disorders performed from April 2006 to March 2007. The degree of joint effusion was graded on sagittal T2-weighted spin echo images according to a commonly used system. On axial short T1-weighted short inversion recovery images, the number and short-axis diameter of the parotid lymph nodes were recorded. We performed analyses of the cluster-correlated data using the Mann-Whitney U test and Spearman's correlation coefficients. P < .05 was considered to indicate significance. To assess the possible predictive value of certain variables, a generalized linear model (generalized estimation equation) was constructed, considering the multiple measurements. A total of 402 TMJ disorders were analyzed from 201 patients during the study period. The number and size of the parotid lymph nodes identified was significantly greater in the patients with TMJ effusion (P < .01) than in those without effusion. In the present study, we found an association between parotid lymphadenopathy and joint effusion in TMJ disorders. These findings indicate that lymphadenopathy should be considered as an inflammation condition commonly associated with joint effusion in TMJ disorders.

A special issue and a new look for Ultrasound.

Welcome to this special issue on non-hepatic applications of contrast-enhanced ultrasound. The benefits of CEUS imaging in organs such as the heart and liver, for which it was originally licensed, are now well established, but new applications continue to be explored. This special issue brings together a collection of articles showing that CEUS can be a very useful additional imaging tool for assessing vascularity in the kidneys, spleen and testes as well as in the detection of endoleaks in post EVAR follow-up and DVT. Professor Paul Sidhu introduces this special issue overleaf in a guest editorial, charting the development of CEUS and highlighting new areas where it is being shown to be most useful. CEUS may become a practical alternative to contrast CT in many circumstances, avoiding the use of nephrotoxic contrast agents and exposure to radiation. You will have noticed by the time you reach this point, that Ultrasound has had something of a makeover. In collaboration with our publisher, SAGE Publications, we have redesigned the internal layout and cover to be more consistent with the recently rebranded BMUS website. The new internal format is also more consistent with industry standards for journals and helps to make content more discoverable through search engines. I do hope that you like the new look front cover. This will now be the same for each issue and will not show short titles for the content. We will also bid a fond farewell to the hand of a previous editor that has been a feature of the front cover for the last six years! As editor, I would like to think that the quality and content ofUltrasound has continued to improve. So I am delighted to be able to tell you that Ultrasound has been selected for inclusion in a new area of Web of Science called the Emerging Sources Citation Index. According to owners Thompson Reuters, this new index will extend Web of Science to include high-quality, peer-reviewed publications of regional importance and in emerging fields. The content will be visible in Web of Science, where it is searchable, discoverable and citable. I hope this development will give a new incentive to authors to send their work to Ultrasound for publication. For those of you who attended the excellent BMUS Annual Scientific Meeting in Cardiff in December, it probably now feels like a distant memory. However, I would like to encourage those who presented their work there as a lecture or poster to consider writing it up as an article for Ultrasound. Publishing your work in the journal ensures that a much wider audience can learn from your efforts, you will have a permanent record and your work will now be discoverable in Web of Science. If you need a little extra incentive, two of the articles that won journal prizes in 2015 started out as ASM presentations. For 2015, there were two joint winners and one runner up for the postgraduate paper prize. The winners were: Dr Neeraj Purohit for his article entitled ‘‘Ultrasound of lower limb sports injuries’’; and Katie Johnson for her article ‘‘Temporomandibular joint effusion and its relationship with perceived disability assessed using musculoskeletal ultrasound and a patient-reported disability index’’. The runner-up was Dr Anu Obaro for his article entitled ‘‘Benign liver lesions: grey-scale and contrast-enhanced ultrasound appearances’’. In addition, the inaugural Paul Allan prize for the best paper published in Ultrasound in 2015 was awarded to Dr Iain Willits for his article entitled ‘‘What proportions of focal liver lesions detected by unenhanced ultrasound are inconclusive?’’ I do hope that you find this special issue a useful educational resource and I look forward to seeing some article submissions from you! You can find author instructions and all you need to know on the journal website at: http://ult.sagepub.com.

A new CPD website for ultrasound.

Ultrasound publishes articles on a wide range of subjects relevant to those involved in medical ultrasound, including clinical applications, new technologies, professional issues and education and training. Although many of these articles are research reports, most issues include at least one review article aimed at providing basic education in one of these subject areas. Ultrasound is intended as an educational resource for ultrasound users worldwide including BMUS members, but BMUS members can now get more benefit from studying our educational articles. Our publisher, SAGE Publications, has commissioned its website designer to create a new CPD website for use in conjunction with the journal. BMUS members will be able to access this new site via the members’ area of the BMUS website and register with their name and email address. The site will give access to a selection of educational articles, each accompanied by a set of questions provided by the authors. After studying an article, members can then answer the questions, and if they achieve the 70% pass mark, be awarded a CPD certificate. Each registered user will have an account that records all CPD points earned in this way. The site is being launched with a small selection of review articles that have been published recently in Ultrasound. It is hoped that one or more articles per issue can be used as CPD articles, and that a broad collection of articles can be accumulated as new issues are published. Please log into the BMUS website members’ area to register your details and look for relevant CPD articles. Many BMUS members and non-members make valuable contributions to the BMUS Annual Scientific Meeting by presenting papers and posters or running practical workshops. Some presenters then go on to make a permanent record of their work by publishing it in Ultrasound. Now, all contributors can have a discoverable record of their work via the Ultrasound pages of the SAGE website. This May issue of Ultrasound is accompanied by an online-only supplement which contains all abstracts and titles from the Annual Scientific Meeting held in Manchester in December 2014. You can find the supplement at http://ult.sagepub.com We begin this May issue with a report from Willits et al. on a very large retrospective study of unenhanced ultrasound scans of the liver. It seems that many of these scans were able to detect, but not characterise, focal liver lesions (FLL). There were more inconclusive scans in the outpatient cohort than in the GP cohort, and almost 50% of FLLs detected in cirrhotic livers were inconclusive. The results of this research will inform future NICE diagnostics guidance on the use of contrast agents. Clements et al. report on a study aimed at developing ultrasound criteria for the assessment of the internal jugular vein. They show that body position (sitting or supine) has a large impact on cross-sectional area, time average velocity and reflux measurements. Katie Johnson et al. report on a study of the relationship between temporomandibular joint effusion and a patient reported disability index of the jaw. The strong correlation suggests that the index might be used in clinical assessments in place of ultrasound measurements. The previous issue of Ultrasound in February was a special issue devoted to education and training in ultrasound. You may have noticed that this special issue was larger than usual. In fact, it could have been much larger, because there were far more articles submitted than we could possibly publish in a single issue. So in this May issue, we include those education and training articles that were delayed. Parker and Byass describe the implementation of an audit tool based on case review by peers that helped identify the development needs of sonographers and monitor the quality of the scanning service. Diane Dickson reports on a study of how interactive educational technologies may help sonography students relate theory to practice. Grace Carolan-Rees describes a cost model for an ultrasound virtual reality training simulator. It seems that in most circumstances, cost savings can be made by using the simulator rather than traditional practical training methods. Returning to the use of contrast in the detection of liver lesions, Obaro and Ryan review the grey scale and contrast-enhanced ultrasound appearances of a range of benign liver lesions. Finally, a case report by Greenall and Drage demonstrates the ultrasound features of sebaceous carcinoma of the lip and describes the normal anatomy of this area.

Temporomandibular joint effusion and its relationship with perceived disability assessed using musculoskeletal ultrasound and a patient-reported disability index

The relationship between effusion of the temporomandibular joint (TMJ) and patient-reported disability is poorly researched. This pilot study explored the link between TMJ inflammation as measured by ultrasound and patient disability assessed by the Steigerwald Maher TMD Disability Index (SMTDI). The study design used a prospective correlational approach involving a sample with TMJ dysfunction (TMD). Twenty-four patients were recruited from the European School of Osteopathy and a Kent dental practice. Participants completed the SMTDI to determine the level of TMD (symptomatic score >20). A SonoSite SLA "Hockey Stick" [13-6 MHz] musculo-skeletal transducer was placed over the TMJ in a transverse direction and effusion was calculated indirectly by measuring capsular width. An upper left quadrant protocol was used throughout. A regression analysis was run with participants' gender, age and capsular width as predictor variables modelled against reported SMTDI. Larger capsular widths were found to be significant predictors of SMTDI scores (r = 0.803, p < 0.0001). The patient profile matched with the previous studies and the TMD sufferer population, indicating external validity. Results suggest that the SMTDI could be integrated into practice life as a quick, accessible and easy tool to monitor patients' progress and assess levels of inflammation, without the need for repetitive imaging. The study design proved reproducible and a larger scale study is indicated.

Effectiveness of treatment with viscosupplementation in temporomandibular joints with or without effusion

The objective of this study was to determine whether the effectiveness of viscosupplementation with hyaluronic acid (HA) in patients with temporomandibular joint (TMJ) degenerative disorders depends on the presence of intra-articular effusion. In this study of case–control design, two groups of 25 patients were recruited: patients with a clinical diagnosis of painful chronic TMJ osteoarthritis and magnetic resonance imaging (MRI) signs of TMJ degeneration, with (effusion group) or without (no effusion group) MRI evidence of TMJ effusion. All patients underwent five weekly single-needle arthrocenteses plus medium molecular weight HA and 6 months of follow-up. Several clinical outcome parameters were assessed. For all variables, analysis of variance (ANOVA) for repeated measures was performed to assess the existence of significant within-group and between-group treatment effects. Over time, both groups showed significant improvements in all outcome parameters, which were maintained at the 6-month follow-up (P<0.05). Between-group comparisons showed that the treatment effects did not differ significantly for either the primary outcome variable (pain levels: F=0.849, P=0.548) or secondary outcome variables (chewing efficiency: F=0.854, P=0.544; functional limitation: F=1.35, P=0.226; mouth opening: F=0.658, P=0.707). The null hypothesis that there are no differences in treatment effectiveness between patients with and without effusion could not be rejected.