Sialadenitis: Difference between revisions
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==== The comparison table for diagnostic studies of choice for sialolithiasis ==== | ==== The comparison table for diagnostic studies of choice for sialolithiasis ==== | ||
The [[Sensitivity (tests)|sensitivity]] and [[Specificity (tests)|specificity]] of CT scan and ultrasonography in a patient with | The [[Sensitivity (tests)|sensitivity]] and [[Specificity (tests)|specificity]] of CT scan and ultrasonography in a patient with sialadenitis is given below:<ref name="pmid28457224">{{cite journal |vauthors=Thomas WW, Douglas JE, Rassekh CH |title=Accuracy of Ultrasonography and Computed Tomography in the Evaluation of Patients Undergoing Sialendoscopy for Sialolithiasis |journal=Otolaryngol Head Neck Surg |volume=156 |issue=5 |pages=834–839 |year=2017 |pmid=28457224 |doi=10.1177/0194599817696308 |url=}}</ref> | ||
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Revision as of 02:21, 8 February 2018
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| Micrograph showing chronic sialadenitis. H&E stain. |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]
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WikiDoc Resources for Sialadenitis |
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Articles |
|---|
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Most recent articles on Sialadenitis Most cited articles on Sialadenitis |
|
Media |
|
Powerpoint slides on Sialadenitis |
|
Evidence Based Medicine |
|
Clinical Trials |
|
Ongoing Trials on Sialadenitis at Clinical Trials.gov Clinical Trials on Sialadenitis at Google
|
|
Guidelines / Policies / Govt |
|
US National Guidelines Clearinghouse on Sialadenitis
|
|
Books |
|
News |
|
Commentary |
|
Definitions |
|
Patient Resources / Community |
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Patient resources on Sialadenitis Discussion groups on Sialadenitis Patient Handouts on Sialadenitis Directions to Hospitals Treating Sialadenitis Risk calculators and risk factors for Sialadenitis
|
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Healthcare Provider Resources |
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Causes & Risk Factors for Sialadenitis |
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Continuing Medical Education (CME) |
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International |
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Synonyms and keywords:
Overview
Sialadenitis is a condition of inflammation of a salivary gland. The causes of sialadenitis include bacterial and viral infections such as mumps and HIV, obstruction from stones or radiation, and autoimmune disorders such as Sjogren's syndrome. The complications of sialadenitis include recurrence, abscess, and chronic sialadenitis. Sialadenitis must be differentiated from other diseases that cause swelling in salivary glands, such as sialolithiasis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren's syndrome. History from the patient will reveal symptoms of sialadenitis that include fever, and difficulty in opening the mouth. The diagnosis of choice is a high resolution CT scan. Sialoendoscopy can be used in the diagnosis of small stones and differentiate them from polyps. Conservative treatment is the first line of therapy in the most patients and it involves Hydration, applying moist heat, massaging the gland, duct milking, discontinuation of medication that decrease the saliva flow, such as the TCAs because of their anticholinergic effects, and antibiotics usage for the infection. Preferred regimen Dicloxacillin 500 mg q 6h PO for 7 to 10 days or Cephalexin 500 mg q 6h PO for 7 to 10 days.
Historical Perspective
The historical perspective of sialadenitis is as follows:[1]
- In 17th century, major salivary gland ductal system in anatomical human studies was first reported.
- In 1990, , Konigsberger et al. performed the first successful salivary endoscopy.[2]
- In 2004, Zenk et al. reported the use of semirigid sialendoscope in different types of obstructive salivary disorders.[3]
- In 2006, Nahlieli et al. described sialendoscopy in the management of radioiodine sialadenitis.[4]
Classification
- There is no established system for the classification of sialadenitis, but may be classified according to location of the stone.[5]
| Gland | Percent of stones |
|---|---|
| Submandibular glands | 80 to 90 |
| Parotid glands | 6 to 20 |
| Sublinguals or minor salivary glands | 1 to 2 |
- Submandibular stones can be classified further as anterior or posterior in relation to the mandibular first molar teeth.
- Stones may be radiopaque, where they be visible on radiographs or radiolucent where they will not show up on radiography
- Stones may also be symptomatic or asymptomatic.
Pathophysiology
- Sialadenitis is a condition of inflammation of a salivary gland. [6]
- Swelling is usually present in this condition.
- Acute sialadenitis may be caused by viral or bacterial infection[7]
- Parotid and submandibular glands are more involved in acute sialadenitis. approximately 10% sialadenitis cases are related to involvement of submandibular gland.
- Chronic sialadenitis is caused by repeated episodes of inflammation and finally it progresses in to salivary gland dysfucntion.
Causes
Common causes of sialadenitis include the following:
Bacterial and viral infections[8]
- Mumps
- HIV
- Staph aureus
- Streptococci
- Pseudomona aeruginosa
- Escherichia coli
- Moraxella catarrhalis
- Tuberculosis[9]
Obstruction
- Stones
- Radiation
- Strictures
- Sarcoidosis
Autoimmune disorders
- Sjogrens
Differentiating sialadenitis from Other Diseases
- Sialadenitis must be differentiated from other diseases that cause swelling in salivary glands, such as sialolithiasis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren's syndrome.[10][11][12][13][14][15][16][17]
| Diseases | Symptoms and sign | Laboratory Findings | Other Findings | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Onset | Unilateral/Bilateral | Pain | Swelling | Tenderness | Purulent discharge | Common site of involvement | ESR | Leukocytosis | ||
| Sialolithiasis | Acute | Unilateral | + | + | + | - | Submandibular gland | ↑/NL | ↑/NL | Radio-opaque in X-ray |
| Acute bacterial sialadenitis | Acute | Unilateral | + | + | + | + | Parotid | ↑ | ↑ | Other sign of infection may be present |
| Chronic bacterial sialadenitis | Chronic | Unilateral | + | + | - | +/- | Parotid | ↑ | ↑ | Other sign of infection may be present |
| Viral sialadenitis | Acute | Bilateral | + | + | + | - | Parotid | ↑ | ↑ | Coryza symptoms |
| Human immunodeficiency virus | Acute | Bilateral | + | + | - | - | Parotid | NL | NL | Other systemic findings of HIV/ check ELIZA |
| Radiation sialadenitis | Acute | Unilateral | + | + | + | - | Depends on the treatment field | NL | NL | History of radiation in the salivary gland site |
| Salivary gland tumors | Subacute | Unilateral | - | + | - | - | Parotid | ↑/NL | ↑/NL | Advance age |
| Sarcoidosis | Gradual | Bilateral | - | + | - | - | Parotid | ↑ | ↑ | Systemic findings in other organs |
| Sjögren's syndrome | Gradual | Bilateral | +/- | + | - | - | Parotid or submandibular glands | ↑/NL | ↑/NL | Dry eye/dry mouth |
| Malnutrition | Gradual | Bilateral | +/- | + | - | - | Parotid | NL | NL | Systemic findings in other organs |
Epidemiology and Demographics
- The exact prevalence of submandibular sialadenitis is unclear.
- The incidence of acute sialadenitis is approximately 27.5 per 1,000,000 individuals in United Kingdom.[18]
- Patients of all age groups may develop sialadenitis.
- Sialadenitis commonly affects older, dehydrated patients.
Risk Factors
Common Risk Factors
Common risk factors in the development of sialolithisis which can lead to sialadenitis include:[19]
- Dehydration
- Diuretics
- Local trauma
- Sjögrens
- Gout
- Anticholinergic medications
- Smoking
- History of nephrolithiasis
- Chronic periodontal disease
- Head and neck radiotherapy[20]
Less Common Risk Factors
- Less common risk factors in the development of sialolithiasis include:
- Hypercalcemia[21]
- Being elderly[22]
- Renal impairment[23]
Screening
There is insufficient evidence to recommend routine screening for sialadenitis.
Natural History, Complications, and Prognosis
Natural History
- If left untreated, patients with sialadeitis may progress to develop secondary infection and chronic sialadenitis including gland atrophy.[24]
Complications
- Common complications of sialadenitis include:[25]
- Recurrence
- Abscess
- Cellulitis
Prognosis
- Prognosis is generally good with fluid management and antimicrobial therapy, but edema in the gland may persist for several weeks. [16]
Diagnosis
Diagnostic Criteria
Computed tomography
- High resolution noncontrast computed tomography (CT) scanning is the study of choice for the diagnosis of sialadenitis.[26]
- The following results are seen in acute obstructive due to sialolithiasis after administration of contrast:
- The gland may appear enlarged
- Hyperdensity of gland with stranding
- In chronic sialolithiasis, fatty atrophy and reduction in salivary gland parenchymal volume may be seen.
The comparison table for diagnostic studies of choice for sialolithiasis
The sensitivity and specificity of CT scan and ultrasonography in a patient with sialadenitis is given below:[27]
| Sensitivity | Specificity | |
|---|---|---|
| CT scan | 98% | 88% |
| Ultrasound | 65% | 80% |
History and Symptoms
A positive history of swelling of the affected gland and pain is suggestive of acute sialadenitis. The most common symptoms of sialadenitis include fever, and difficulty in opening the mouth.[25]
Common symptoms of chronic sialadenitis are similar to acute sialadenitis but with less intensity.
- A positive history of pain, swelling, overlying skin redness, and hard lump is suggestive of sialadenitis.
Physical Examination
Vital Signs
- Vital signs are usually normal, but fever may be seen in sialadenititis as a complication of sialolithiasis.[7]
HEENT
Normal salivary gland is spongy.
- Tenderness of the involved gland
- Palpable hard lump near the end of the involved duct or under the tongue in submandibular duct stone.
- Stones, sometimes may be felt smooth or irregular.
- In total obstruction, no saliva is being produced from the duct.
- Erythema of the floor of the mouth
- Pus discharging from the duct
- Stone in the minor salivary glands can be felt as a small nodule
- Stones are typically rock hard and small; they may be smooth or irregular. They are most commonly felt within the ductal system.
Neck
- Cervical lymphadenitis in cases of infection
Laboratory Findings
- There are no diagnostic laboratory findings associated with sialadenitis. In the case of superimposed inflammation and infection, high ESR or leukocytosis may be seen.
Electrocardiogram
There are no ECG findings associated with sialadenitis.
X-ray
- An x-ray may be helpful in the diagnosis of sialadenitis. Findings on an x-ray suggestive of sialadenitis include:[30]
- Radiopaque stones: 43-60% of the parotid stones and 80-95% of the submandibular stones are radiopaque and can be seen in x-ray.
Ultrasound
- Ultrasound may be helpful in the diagnosis of sialadenitis. Findings on ultrasound diagnostic of sialadenitis include:[31][32][33]
- Hyperechoic points or lines with distal acoustic shadowing.
- Small stones less than 2 mm may not have shadow
- Ultrasound can detect stones that are radiolucent
- In acute obstructive cases due to sialolithiasis, ther excretory duct may be dilated.
- Hyperechoic points or lines with distal acoustic shadowing.
- Ultrasound is done with intra oral probes.
CT scan
Head and neck CT scan is the study of choice for the diagnosis of sialadenitis.[26][27][30]
- The following results are seen in acute obstructive due to sialolithiasis after administration of contrast:
- The gland may appear enlarged
- Hyperdensity of gland with stranding
- In chronic sialolithiasis, fatty atrophy and reduction in salivary gland parenchymal volume may be seen.
MRI
- Magnetic resonance sialography may be helpful in the diagnosis of sialadenitis. Findings on magnetic resonance sialography suggestive of sialadenitisinclude:[34][35][31]
- Stones are visible as low signal regions outlined by saliva (high signal regions) on T2 weighted images.
- Acute from chronic obstruction can be distinguished by magnetic resonance sialography on T1 signals:
- In acute obstruction, enlargement of the gland and inflammatory changes may be seen as reduced signal compared to other side.
- In chronic cases, size of the gland is decreased and fatty atrophy may be seen as an increased signal compared to the other side.
Other Imaging Findings
Conventional sialography may be helpful in the diagnosis of sialadenitis. Findings on sialography suggestive of sialadenitis include:[31][36]
- Filling defect within the duct
- In complete obstruction, contrast can not pass beyond the stone
Sialography is contraindicated in active infection of the involved gland.
Sialography is replaced by CT scan and ultrasound.
Other Diagnostic Studies
- There are no other diagnostic studies associated with sialadenitis.
Treatment
=Medical Therapy
- Certain individuals with chronic bacterial infections not responding to appropriate conservative and antibiotic measures may require either radiation or removal of the affected gland to control its symptoms.The prognosis of acute sialadenitis is very good. Most cases are easily treated with conservative medical management, and admission is the exception, not the rule. Acute symptoms resolve within 1 week; however, edema in the area may last for several weeks
Conservative treatment is the first line of therapy in the most patients. The most commonly used treatment options are:[10]
- Hydration
- Apply moist heat
- Massage the gland
- Duct milking
- Using agents that increase the saliva flow, such as lemon drops.
- Discontinue of the medication that decrease the saliva flow, such as the TCAs because of their anticholinergic effects.
- Pain control with NSAIDs, or opioid analgesics, if needed.
- Antibiotics usage in the case of superimposed infection:
- Preferred regimen(1): Dicloxacillin 500 mg q 6h PO for 7 to 10 days.
- Preferred regimen(2): Cephalexin 500 mg q 6h PO for 7 to 10 days.
- If the patients clinics did not change in five days of using above antibiotics, change to:
- Preferred regimen(1): Amoxicillin/clavulanate 625 mg q 8h PO for 7 to 10 days.
- Preferred regimen(2): Clindamycin 300 mg q 8h PO for 7 to 10 days.
- Duct discharge should be used for culture.
- Many cases of sialadenitis can not be cured by using medical therapy alone; invasive, or open surgery methods can be used for salivary gland stones. The interventional methods are discussed in the sialadenitis surgery page.
Surgery
The mainstay of treatment for acute siladenitis is medical therapy. Surgery is not the first-line treatment option for patients with acute siladenitis. Surgery is usually reserved for patients with abscess that do not respond to medical therapy.[37]
Surgical resection of involved gland in chronic bacterial sialadenitis may be considered if it does not respond to medical therapy. [25]
Minimally invasive management
Sialoendoscopy
- Sialoendoscopy can be used in the diagnosis of small stones, and differentiate them from polyps.[38]
- In the case of no response to medical management, sialoendoscopy can be done. The treatment result using sialoendoscopy, mostly depends on the size of the stone.
Laser lithotripsy
- Can be used before sialoendoscopy in order to fragment salivary stones.[12]
Stone removal with wire baske
- Removal of stones using a wire basket extractor under fluoroscopic guidance.[39]
Surgical intervention
If all of above methods fails, surgical intervention can be used.[13]
- For the submandibular stones, a transoral approach can be used.
- In some proximal submandibular stones, a combination of sialoendoscopic and open intraoral techniques, may be used.
- For parotid stones, if sialoendoscopy did not worked, open surgery should be done.
Primary Prevention
- Effective measures for the primary prevention of sialadenitis include:[19]
- Healthy oral care regimen ( brushing teeth)
- Increased water intake
- There are no available vaccines against sialolithiasis
Secondary Prevention
Effective measures for the secondary prevention of acute sialadenitis include hygiene and repeated massaging of the gland when tenderness had subsided. [25][17][1]
- Prevention of dehydration
- Healthy oral care regimen ( brushing teeth)
- Treatment of underlying disease such as sjögrens, gout
- Avoid anticholinergic and diuretic medications
References
- ↑ Erkul, Evren; Gillespie, M. Boyd (2016). "Sialendoscopy for non-stone disorders: The current evidence". Laryngoscope Investigative Otolaryngology. 1 (5): 140–145. doi:10.1002/lio2.33. ISSN 2378-8038.
- ↑ Lydiatt, Daniel D.; Bucher, Gregory S. (2012). "The historical evolution of the understanding of the submandibular and sublingual salivary glands". Clinical Anatomy. 25 (1): 2–11. doi:10.1002/ca.22007. ISSN 0897-3806.
- ↑ Zenk, J; Koch, M; Bozzato, A; Iro, H (2004). "Sialoscopy—initial experiences with a new endoscope". British Journal of Oral and Maxillofacial Surgery. 42 (4): 293–298. doi:10.1016/j.bjoms.2004.03.006. ISSN 0266-4356.
- ↑ Nahlieli O, Neder A, Baruchin AM (1994). "Salivary gland endoscopy: a new technique for diagnosis and treatment of sialolithiasis". J Oral Maxillofac Surg. 52 (12): 1240–2. PMID 7965326.
- ↑ Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L (2007). "Modern management of obstructive salivary diseases". Acta Otorhinolaryngol Ital. 27 (4): 161–72. PMC 2640028. PMID 17957846.
- ↑ Loury, MC (2006). "Salivary gland disorder". Advanced Otolaryngology.
- ↑ 7.0 7.1 McKenna JP, Bostock DJ, McMenamin PG (1987). "Sialolithiasis". Am Fam Physician. 36 (5): 119–25. PMID 3318353.
- ↑ Maier H, Tisch M (2010). "[Bacterial sialadenitis]". HNO (in German). 58 (3): 229–36. doi:10.1007/s00106-009-2078-x. PMID 20204311.
- ↑ Maier H, Tisch M (2010). "[Bacterial sialadenitis]". HNO (in German). 58 (3): 229–36. doi:10.1007/s00106-009-2078-x. PMID 20204311.
- ↑ 10.0 10.1 Delli K, Spijkervet FK, Vissink A (2014). "Salivary gland diseases: infections, sialolithiasis and mucoceles". Monogr Oral Sci. 24: 135–48. doi:10.1159/000358794. PMID 24862601.
- ↑ Delli K, Spijkervet FK, Vissink A (2014). "Salivary gland diseases: infections, sialolithiasis and mucoceles". Monogr Oral Sci. 24: 135–48. doi:10.1159/000358794. PMID 24862601.
- ↑ 12.0 12.1 Capaccio P, Torretta S, Pignataro L, Koch M (2017). "Salivary lithotripsy in the era of sialendoscopy". Acta Otorhinolaryngol Ital. 37 (2): 113–121. doi:10.14639/0392-100X-1600. PMC 5463518. PMID 28516973.
- ↑ 13.0 13.1 Wallace E, Tauzin M, Hagan J, Schaitkin B, Walvekar RR (2010). "Management of giant sialoliths: review of the literature and preliminary experience with interventional sialendoscopy". Laryngoscope. 120 (10): 1974–8. doi:10.1002/lary.21082. PMID 20824782.
- ↑ Wallace E, Tauzin M, Hagan J, Schaitkin B, Walvekar RR (2010). "Management of giant sialoliths: review of the literature and preliminary experience with interventional sialendoscopy". Laryngoscope. 120 (10): 1974–8. doi:10.1002/lary.21082. PMID 20824782.
- ↑ Loury, MC (2006). "Salivary gland disorder". Advanced Otolaryngology.
- ↑ 16.0 16.1 Raad II, Sabbagh MF, Caranasos GJ (1990). "Acute bacterial sialadenitis: a study of 29 cases and review". Rev. Infect. Dis. 12 (4): 591–601. PMID 2385766.
- ↑ 17.0 17.1 Silvers AR, Som PM (1998). "Salivary glands". Radiol. Clin. North Am. 36 (5): 941–66, vi. PMID 9747195.
- ↑ Escudier MP, McGurk M (1999). "Symptomatic sialoadenitis and sialolithiasis in the English population, an estimate of the cost of hospital treatment". Br Dent J. 186 (9): 463–6. PMID 10365495.
- ↑ 19.0 19.1 Moghe S, Pillai A, Thomas S, Nair PP (2012). "Parotid sialolithiasis". BMJ Case Rep. 2012. doi:10.1136/bcr-2012-007480. PMC 4543829. PMID 23242089.
- ↑ Ship JA (2002). "Diagnosing, managing, and preventing salivary gland disorders". Oral Dis. 8 (2): 77–89. PMID 11991308.
- ↑ Paterson JR, Murphy MJ (2001). "Bones, groans, moans... and salivary stones?". J. Clin. Pathol. 54 (5): 412. PMC 1731434. PMID 11328848.
- ↑ Eigner TL, Jastak JT, Bennett WM (1986). "Achieving oral health in patients with renal failure and renal transplants". J Am Dent Assoc. 113 (4): 612–6. PMID 2945851.
- ↑ Sharma RK, al-Khalifa S, Paulose KO, Ahmed N (1994). "Parotid duct stone--removal by a dormia basket". J Laryngol Otol. 108 (8): 699–701. PMID 7930927.
- ↑ Briffa NP, Callum KG (1989). "Use of an embolectomy catheter to remove a submandibular duct stone". Br J Surg. 76 (8): 814. PMID 2765834.
- ↑ 25.0 25.1 25.2 25.3 Chandak R, Degwekar S, Chandak M, Rawlani S (2012). "Acute submandibular sialadenitis-a case report". Case Rep Dent. 2012: 615375. doi:10.1155/2012/615375. PMC 3409526. PMID 22888457.
- ↑ 26.0 26.1 Ellies, Maik; Laskawi, Rainer; Arglebe, Christian; Schott, Anngrit (1996). "Surgical management of nonneoplastic diseases of the submandibular gland". International Journal of Oral and Maxillofacial Surgery. 25 (4): 285–289. doi:10.1016/S0901-5027(06)80058-5. ISSN 0901-5027.
- ↑ 27.0 27.1 Thomas WW, Douglas JE, Rassekh CH (2017). "Accuracy of Ultrasonography and Computed Tomography in the Evaluation of Patients Undergoing Sialendoscopy for Sialolithiasis". Otolaryngol Head Neck Surg. 156 (5): 834–839. doi:10.1177/0194599817696308. PMID 28457224.
- ↑ Hupp, James (2008). Contemporary oral and maxillofacial surgery. St. Louis, Mo: Mosby Elsevier. ISBN 9780323049030.
- ↑ Neville, Brad (2002). Oral & maxillofacial pathology. Philadelphia: W.B. Saunders. ISBN 0721690033.
- ↑ 30.0 30.1 Kraaij S, Karagozoglu KH, Forouzanfar T, Veerman EC, Brand HS (2014). "Salivary stones: symptoms, aetiology, biochemical composition and treatment". Br Dent J. 217 (11): E23. doi:10.1038/sj.bdj.2014.1054. PMID 25476659.
- ↑ 31.0 31.1 31.2 Jäger L, Menauer F, Holzknecht N, Scholz V, Grevers G, Reiser M (2000). "Sialolithiasis: MR sialography of the submandibular duct--an alternative to conventional sialography and US?". Radiology. 216 (3): 665–71. doi:10.1148/radiology.216.3.r00se12665. PMID 10966693.
- ↑ Witt, Robert (2005). Salivary gland diseases : surgical and medical management. New York: Thieme. ISBN 1588904148.
- ↑ Gritzmann N (1989). "Sonography of the salivary glands". AJR Am J Roentgenol. 153 (1): 161–6. doi:10.2214/ajr.153.1.161. PMID 2660533.
- ↑ Sumi M, Izumi M, Yonetsu K, Nakamura T (1999). "The MR imaging assessment of submandibular gland sialoadenitis secondary to sialolithiasis: correlation with CT and histopathologic findings". AJNR Am J Neuroradiol. 20 (9): 1737–43. PMID 10543651.
- ↑ Becker M, Marchal F, Becker CD, Dulguerov P, Georgakopoulos G, Lehmann W, Terrier F (2000). "Sialolithiasis and salivary ductal stenosis: diagnostic accuracy of MR sialography with a three-dimensional extended-phase conjugate-symmetry rapid spin-echo sequence". Radiology. 217 (2): 347–58. doi:10.1148/radiology.217.2.r00oc02347. PMID 11058627.
- ↑ Kalinowski M, Heverhagen JT, Rehberg E, Klose KJ, Wagner HJ (2002). "Comparative study of MR sialography and digital subtraction sialography for benign salivary gland disorders". AJNR Am J Neuroradiol. 23 (9): 1485–92. PMID 12372736.
- ↑
- ↑ Gallo A, Benazzo M, Capaccio P, De Campora L, De Vincentiis M, Fusconi M, Martellucci S, Paludetti G, Pasquini E, Puxeddu R, Speciale R (2015). "Sialoendoscopy: state of the art, challenges and further perspectives. Round Table, 101(st) SIO National Congress, Catania 2014". Acta Otorhinolaryngol Ital. 35 (4): 217–33. PMC 4731883. PMID 26824208.
- ↑ Drage NA, Brown JE, Escudier MP, McGurk M (2000). "Interventional radiology in the removal of salivary calculi". Radiology. 214 (1): 139–42. doi:10.1148/radiology.214.1.r00ja02139. PMID 10644113.