Questions regarding imaging for patients with dental pain/infections.

[cdmOMR]

Cheers from the dental side of the world. I'm an oral radiology resident and I am trying to gauge how imaging is handled in your EDs for patients that present with dental pain/infection. First of, I want to say its unfortunate that this burden often falls on you. At my university it is all too common for patients with tooth pain/infections to be seen in the ED. That being said, my questions are:

1) What are your imaging protocols for patients with dental issues?

2) Who reads/interprets the imaging you order for dental issues?

Thanks!

---

Members don't see this ad.

 

[Apollyon]

I don't know of any hospitals where the ED has access to a panorex. For straightforward dental abscesses or dental pain, no imaging. If I can feel an abscess pocket, that's enough. Imaging for select peritonsillar abscess (once had a pt that had two, discrete, unconnected pus pockets - ENT couldn't believe it until he saw it), or possible cavernous sinus thrombosis. Also, possibly for facial trauma.

The regular radiologist reads them.

 

[RustedFox]

Imaging protocol for dental pain:

"Hey, patient... Imagine an image of the door that you walked through to get in here. Yep. Good work. Now walk back out through that same door."

 

[cyanide12345678]

Penicillin, ibuprofen and discharge usually.

Unless peritonsillar abscess or concern for ludwigs.

 

[Porfirio]

1) pain at mastoid process, concern for PTA/RPA/Ludwig

2) radiologist

 

[thegenius]

Are you doing a study or something?

This is a very odd, and somewhat suspicious, original post.

 

[cdmOMR]

I don't know of any hospitals where the ED has access to a panorex. For straightforward dental abscesses or dental pain, no imaging. If I can feel an abscess pocket, that's enough. Imaging for select peritonsillar abscess (once had a pt that had two, discrete, unconnected pus pockets - ENT couldn't believe it until he saw it), or possible cavernous sinus thrombosis. Also, possibly for facial trauma.

The regular radiologist reads them.

Ok interesting. We do have a panorex in our emergency room which are read by us on the dental side. I was curious how common it is to have one and was under the assumption it was relatively common but seems like it’s not. Appreciate the input!

 

[cdmOMR]

Are you doing a study or something?

This is a very odd, and somewhat suspicious, original post.

Haha I promise nothing nefarious or any study. My institution has a panoramic in the ED and the oral radiologists read those and help with dental issues. I was curious how it’s handled elsewhere with programs that do not have an affiliated oral radiology program (which are almost all). I’m curious mostly because I want to see if there is any demand out there for our services at EDs who do take routine dental imaging.

 

[evilbooyaa]

What in the world is an oral radiologist

 

[RustedFox]

I want to see if there is any demand out there for our services at EDs who do take routine dental imaging.

An ED should never take "routine dental imaging".
An ED should never take "routine" anything. That's what outpatient labs/rads are for.

 

[thegenius]

Haha I promise nothing nefarious or any study. My institution has a panoramic in the ED and the oral radiologists read those and help with dental issues. I was curious how it’s handled elsewhere with programs that do not have an affiliated oral radiology program (which are almost all). I’m curious mostly because I want to see if there is any demand out there for our services at EDs who do take routine dental imaging.

Ahh

I'd say about 1/50 people who present with dental pain have an emergency requiring admission and it's usually for a periapical abscess gone awry causing facial cellulitis or ludwigs angina.

The other 49 get discharged with Abx or get an I&D and then discharged with Abx.

Overall dental pain in the ED is a general nuisance. Occasionally I feel bad for the patient because they are in extreme pain and will literally do anything for pain relief. When I offer an inferior alveolar nerve block, most say "hell no! just give me some pills!" and I ignore them and discharge them, usually while they are complaining down the hall as the exit the ER. The few who say "yes I'll do anything for pain relief!" I'll happily do a block and give them some pills and Abx to go home with.

I remember this one woman had a grape sized buccal / periapical abscess around her mandibular premolar. She was screaming in pain she was saying stuff like "I would rather die..." and "God help me I'm going to pass out...." and "please shoot me now...." and she opened up and I numbed her alveolar nerve and like 2 minutes later was crying she was so happy to get pain relief. Then I cut into that juicy abscess and sucked out about 20 cc pus, and she felt even better. She was so happy that she gave me a hug and literally would have given me a million dollars if she had it.

That's probably my only memorable, positive experience with dental pain. Most of the time it's just "I haven't seen a dentist in 12 years and I'm losing my teeth and I would rather spend money on meth and drugs than see a dentist. Please give me oxys and clindamycin."

 

[cdmOMR]

An ED should never take "routine dental imaging".
An ED should never take "routine" anything. That's what outpatient labs/rads are for.

I apologize I meant take dental imaging routinely, not for routine check ups. At our institution the ED takes several panoramics per day for patients coming in for dental issues and trauma. (Although the Panorex in the ED is actually also used by the hospital for pre-op TAVR dental clearance.)

 

[thegenius]

I apologize I meant take dental imaging routinely, not for routine check ups. At our institution the ED takes several panoramics per day for patients coming in for dental issues and trauma. (Although the Panorex in the ED is actually also used by the hospital for pre-op TAVR dental clearance.)

That is weird

What am I, as an ER doctor, supposed to do with a read from a radiologist (I presume it's a radiologist), that says "tooth fracture", or crown dislodgement or whatever else one can glean from a panorex?

Q: You know what would happen in our ER if word got out one could get a panorex xray?

A: The entire city of 240,000 people would be coming in every year to get their dental care.

 

[cdmOMR]

Ahh

I'd say about 1/50 people who present with dental pain have an emergency requiring admission and it's usually for a periapical abscess gone awry causing facial cellulitis or ludwigs angina.

The other 49 get discharged with Abx or get an I&D and then discharged with Abx.

Overall dental pain in the ED is a general nuisance. Occasionally I feel bad for the patient because they are in extreme pain and will literally do anything for pain relief. When I offer an inferior alveolar nerve block, most say "hell no! just give me some pills!" and I ignore them and discharge them, usually while they are complaining down the hall as the exit the ER. The few who say "yes I'll do anything for pain relief!" I'll happily do a block and give them some pills and Abx to go home with.

I remember this one woman had a grape sized buccal / periapical abscess around her mandibular premolar. She was screaming in pain she was saying stuff like "I would rather die..." and "God help me I'm going to pass out...." and "please shoot me now...." and she opened up and I numbed her alveolar nerve and like 2 minutes later was crying she was so happy to get pain relief. Then I cut into that juicy abscess and sucked out about 20 cc pus, and she felt even better. She was so happy that she gave me a hug and literally would have given me a million dollars if she had it.

That's probably my only memorable, positive experience with dental pain. Most of the time it's just "I haven't seen a dentist in 12 years and I'm losing my teeth and I would rather spend money on meth and drugs than see a dentist. Please give me oxys and clindamycin."

Yeah I honestly feel bad for you guys on that front. Most of the cases I see through the ED are clearly bombed out drug addicts. Our ED does take a panoramic on all of those patients though I assume mostly because of our affiliated program. Believe it or not though we've seen some pretty interesting pathology disguised as dental pain, pretty rare though.

 

[RustedFox]

I apologize I meant take dental imaging routinely, not for routine check ups. At our institution the ED takes several panoramics per day for patients coming in for dental issues and trauma. (Although the Panorex in the ED is actually also used by the hospital for pre-op TAVR dental clearance.)

Psst.
I know, amigo.
I'm having fun with you.
Have a laugh.

 

[RoyBasch]

Have worked at several different hospitals, panorex has never been available, so never routinely used in ER decision making. The vast majority of these patients get no imaging whatsoever. Most that have a benign exam get PO ABx, pain medicine, and dental follow up. If a patient has a clinical diagnosis of a dental abscess, then again, no imaging is indicated.

Situations where I image and protocol used:

-patient has a dental abscess/infection but severe enough to be admitted for IV Abx. -> CT maxface with IV contrast
-significant facial trauma with fractures suspected by exam and/or mechanism -> CT max face w/o contrast +/- CT head and CT cervical spine w/o
-significant orofacial infection suspected but unable to be clinically confirmed because of trismus, or other "red flag" symptoms suggesting a deep space infection (retropharyngeal abscess, extensive peritonsilar abscess, epiglottitis/tracheitis) not clinically apparent (stridor, significant dysphonia, drooling, unstable vitals) -> CT soft tissue neck/max face with IV contrast
-dental infection/sinus infection with suspected cavernous sinus thrombosis (very rare situation) CT max face with IV contrast + possibly MRI/MRV head with cuts through the orbits and upper face

edit: all of these CTs would be interpreted by a radiologist

 

[RustedFox]

That is weird

What am I, as an ER doctor, supposed to do with a read from a radiologist (I presume it's a radiologist), that says "tooth fracture", or crown dislodgement or whatever else one can glean from a panorex?

Q: You know what would happen in our ER if word got out one could get a panorex xray?

A: The entire city of 240,000 people would be coming in every year to get their dental care.

Yep.
They'd come at all hours because "it's free because its the EMERGENCY room."

 

[B52forU]

My academic hospital also has an panorex that we routinely order orthopantograms from the ED for as we do have an OMFS program. If they have a periapical lucency suggesting abscess, it involves a quick call to the OMFS team which usually will either a) come down and I&D +/- place a drain or b) give support in the discharge for augmentin/chlorhexidine rinses/close follow up.

 

[cdmOMR]

What in the world is an oral radiologist

Haha don't worry most dentists even know we exist either, there's only like 150 of us in the country. But for real, we're a board certified dental specialty like OMFS. With the rise of cone beam CT in private dental offices there's a demand for those to be read as dentists are not trained to read them. Sending them to a medical radiologist would be pricey/inefficient and medical radiologists are generally not as in tune with dental related issues/questions and I assume don't need any more workload. That's where we come in (plus academia).

 

[RoyBasch]

Haha don't worry most dentists even know we exist either, there's only like 150 of us in the country. But for real, with the rise of cone beam CT in private dental offices there's a demand for those to be read as dentists are not trained to read them. Sending them to a medical radiologist would be pricey/inefficient and medical radiologists are generally not as in tune with dental related issues/questions. That's where we come in (plus academia).

Honestly I didn't know this (outpatient dental offices with CT being interpreted by dental radiologists) was a thing either.

 

[Fox800]

Are you folks regularly imaging PTAs in well-appearing patients with stable vital signs? This is a new idea to me.

Edit: We did not in residency, but we would also use the endocavitary probe to visualize the abscess. I just realized that we don't have this probe available in the ED...I think it's locked up in the radiology suite somewhere.

 

[thegenius]

Are you folks regularly imaging PTAs in well-appearing patients with stable vital signs? This is a new idea to me.

Edit: We did not in residency, but we would also use the endocavitary probe to visualize the abscess. I just realized that we don't have this probe available in the ED...I think it's locked up in the radiology suite somewhere.

No!

I don’t even use a probe anymore to visualize. Can’t find it. I anesthetize the maximum area of fluctuance, and cut. Sometimes ill aspirate first. But I usually cut. And then take a qtip or Kelly forcep and probe around get more pus out.

Dont go too deep! Big red is close by ready to cause you real bad problems.

 

[cdmOMR]

That is weird

What am I, as an ER doctor, supposed to do with a read from a radiologist (I presume it's a radiologist), that says "tooth fracture", or crown dislodgement or whatever else one can glean from a panorex?

Q: You know what would happen in our ER if word got out one could get a panorex xray?

A: The entire city of 240,000 people would be coming in every year to get their dental care.

I presume its to help rule out any other pathology. Pretty uncommon but I've had cases presenting in the ED as tooth pain but ended up being something else (SCCs, ameloblastomas, OKCs etc). Nothing immediately life threatening but a panoramic can tell you a lot sometimes. But yeah 90% of the cases are people who've neglected their teeth for a couple decades and/or are searching for drugs.

 

[cdmOMR]

Honestly I didn't know this (outpatient dental offices with CT being interpreted by dental radiologists) was a thing either.

Yep! You can get a used CBCT for like $30k now a days. I think there's like 15k CBCTs in dental offices in the US.

 

[RoyBasch]

Are you folks regularly imaging PTAs in well-appearing patients with stable vital signs? This is a new idea to me.

Edit: We did not in residency, but we would also use the endocavitary probe to visualize the abscess. I just realized that we don't have this probe available in the ED...I think it's locked up in the radiology suite somewhere.

I do not I&D these, I call ENT and ask them what they want. Some want CT, some do not. I think either are reasonable. Sometimes ENT requests the patient be sent to their office for work in evaluation (business hours), sometimes they come to the ER to do a consult, sometimes they recommend admit to the hospitalist and they will evaluate the next day, sometimes they recommend go home and they will see in the office the next day. I think the dispo influences the desire to image a little bit, i.e. if the patient is going home for next-day follow up they like that a CT demonstrates the abscess is not too big or extensive.

If the patient has severe trismus and you cannot really evaluate at all what is going on in the pharynx, then I would do the CT first. But if the patient can open their mouth and you see a distinct asymmetrical abscess or fullness in the oropharynx, I don't personally feel the CT is required as the clinical diagnosis has been made. There are some surgeons in my experience though that are very hesitant to do any procedure or cut into anything without imaging confirmation. Again, I don't think that's unreasonable. Sometimes the CT comes back phlegmon only and the patient never ultimately requires instrumentation at all, just ABx.

 

[RoyBasch]

Yep! You can get a used CBCT for like $30k now a days. I think there's like 15k CBCTs in dental offices in the US.

heh I don't know the first thing about the finances of a dental practice (or really any office-based practice, as an ER physician I have been exclusively hospital based my whole career) but if the prices of dental imaging are anything what they are in medicine, I imagine you could get a pretty good ROI on that type of hardware quickly. Whether or not this is good or helpful for patients is a different question though.

 

[cyanide12345678]

Ok interesting. We do have a panorex in our emergency room which are read by us on the dental side. I was curious how common it is to have one and was under the assumption it was relatively common but seems like it’s not. Appreciate the input!

Who cares if they have a bunch of cavities in the emergency department? It's not an emergency and doesn't require ER resources. Most patients that come to the ER have eroding teeth anyway so you don't need fancy xrays to see their dental issues

 

[cdmOMR]

heh I don't know the first thing about the finances of a dental practice (or really any office-based practice, as an ER physician I have been exclusively hospital based my whole career) but if the prices of dental imaging are anything what they are in medicine, I imagine you could get a pretty good ROI on that type of hardware quickly. Whether or not this is good or helpful for patients is a different question though.

Yeah its a rather interesting and recent phenomenon. Really only has gotten big over the last 5-10 years as prices of the tech has come down. Unfortunately ins companies are behind the times with payment on these so most patients pay a out of pocket for a scan (~$2-300). The ROI just based on the cost of the scan isn't all that great (as most new CBCTs are closer to $50-100k+). Without going into too many details its enormously useful diagnostically and for guiding for our routine procedures. The biggest value is in the improved diagnosis, more predictable treatment, and reduced failures which is good for everyone. Radiation dose is higher than conventional dental radiographs obviously but way less then a medical CT.

 

[thegenius]

I do not I&D these, I call ENT and ask them what they want. Some want CT, some do not. I think either are reasonable. Sometimes ENT requests the patient be sent to their office for work in evaluation (business hours), sometimes they come to the ER to do a consult, sometimes they recommend admit to the hospitalist and they will evaluate the next day, sometimes they recommend go home and they will see in the office the next day. I think the dispo influences the desire to image a little bit, i.e. if the patient is going home for next-day follow up they like that a CT demonstrates the abscess is not too big or extensive.

If the patient has severe trismus and you cannot really evaluate at all what is going on in the pharynx, then I would do the CT first. But if the patient can open their mouth and you see a distinct asymmetrical abscess or fullness in the oropharynx, I don't personally feel the CT is required as the clinical diagnosis has been made. There are some surgeons in my experience though that are very hesitant to do any procedure or cut into anything without imaging confirmation. Again, I don't think that's unreasonable. Sometimes the CT comes back phlegmon only and the patient never ultimately requires instrumentation at all, just ABx.

I must have an old school ENT where I work. He always wonders why we order unnecessary CT's for PTAs.

If someone has bad trismus, I pop in an IV, give toradol 15 mg IV and morphine 10 mg IV.

That usually does the trick. If it doesn't then I call ENT. But I think that has happened once to me the past 6 years.

 

[Apollyon]

I must have an old school ENT where I work. He always wonders why we order unnecessary CT's for PTAs.

If someone has bad trismus, I pop in an IV, give toradol 15 mg IV and morphine 10 mg IV.

That usually does the trick. If it doesn't then I call ENT. But I think that has happened once to me the past 6 years.

If they have a trismus, if you're not looking for retropharyngeal abscess, you are going to wish you had. (Ask me how I know. BTW, the guy lived.)

 

[Groove]

Are you folks regularly imaging PTAs in well-appearing patients with stable vital signs? This is a new idea to me.

Edit: We did not in residency, but we would also use the endocavitary probe to visualize the abscess. I just realized that we don't have this probe available in the ED...I think it's locked up in the radiology suite somewhere.

I find myself ordering more of these at this stage in my practice compare to residency. Part of it has to do with losing ego and having greater mastery of the "disposition coefficient" as I like to call it. Do you need one? Nah, not for most.. but it's the best way to definitively visualize the abscess. If you've got a quick CT dept, you can get them completed relatively quickly. Sometimes, I'm surprised by how small the abscess is and don't have to waste time trying to drain it and can accurately document "too small to drain". Sometimes, I'm surprised at how large the abscess has become and encounter additional pathology and/or complications that allow me to punt to ENT (RPA, etc..). Sometimes, I waste time getting set up for an aspiration/I&D and I find the pt difficult and/or too much trismus and might bail...at which point I lose time by ordering a CT that I know ENT is going to want prior to the consultation.

As for I&D vs aspiration, I almost always aspirate these days. Last time I did a lit search, the outcomes seemed almost equal. I&D just gives you a lot of bleeding and pus in the pharynx and makes the pt gag if you can't suction it fast enough.

In residency, I would just stick based on exam or use a transvaginal probe but I rarely do that these days. In fact, I don't even have a transvaginal probe in my current ED.

 

[BoardingDoc]

Are you folks regularly imaging PTAs in well-appearing patients with stable vital signs? This is a new idea to me.

Edit: We did not in residency, but we would also use the endocavitary probe to visualize the abscess. I just realized that we don't have this probe available in the ED...I think it's locked up in the radiology suite somewhere.

Nope. CT is for diagnostic ambiguity, severe trismus, tripoding patient, etc. If you look in their mouth and they have a PTA, I have no idea why you would scan them. Drain them or don't. There's no need to irradiate them.

When I drain them I just have the patient nebulize lidocaine for a few minutes right before I go in, then go straight for it with a cut-capped 17 gauge needle, or hit them with hurricane spray first if I have it available, then needle.

 

[thegenius]

17 gauge needle?

They even exist?

I usually have some cetacaine / hurricane spray laying around. I spray the crap out of the back of the throat, then I actually infiltrate lidocaine with a needle (usually a spinal needle) right into the throat to get it nice and numb. Then I either aspirate and incise or just incise.

 

[Groove]

lol, I was thinking the same...what's this secret 17g needle that I've been missing my entire career?!

 

[pkwraith]

It really is amazing how wide the practice patterns in PTAs. At my current group, literally noone (young or old) does them, and everyone else jumps immeidately to CT, obs for antibiotics/steroids and ENT consult. All my APPs order CT Necks for r/o PTA and nurses/APPs are consistently confused that I'm doing my own drainage (cut capped 18 gauge needle) and DCing them,

 

[deleted547339]

It really is amazing how wide the practice patterns in PTAs. At my current group, literally noone (young or old) does them, and everyone else jumps immeidately to CT, obs for antibiotics/steroids and ENT consult. All my APPs order CT Necks for r/o PTA and nurses/APPs are consistently confused that I'm doing my own drainage (cut capped 18 gauge needle) and DCing them,

All our APPs order CTs on anything other than the most straightforward dental pain. I loved my training program - truly had sick patients at a rate not seen at many other places - but didn’t do a great job of fast track stuff. Didn’t do a bunch of splinting or dental pain stuff, so I’ve kind of had to figure this out as an attending. I figure if I can take care of a patient on 4 pressors (now 5 with AngII), I should be able to drain a small abscess in the mouth. I started doing these on my own as an attending with moderate success - seems like the data supports early drainage and relatively low rate of complications.

 

[Renaissance Man]

I must have an old school ENT where I work. He always wonders why we order unnecessary CT's for PTAs.

If someone has bad trismus, I pop in an IV, give toradol 15 mg IV and morphine 10 mg IV.

That usually does the trick. If it doesn't then I call ENT. But I think that has happened once to me the past 6 years.

I suspect 10 mg of IV Morphine would do the trick for most painful complaints, that's a ton!

 

[RustedFox]

I suspect 10 mg of IV Morphine would do the trick for most painful complaints, that's a ton!

Except that it's not.

 

[thegenius]

It really is amazing how wide the practice patterns in PTAs. At my current group, literally noone (young or old) does them, and everyone else jumps immeidately to CT, obs for antibiotics/steroids and ENT consult. All my APPs order CT Necks for r/o PTA and nurses/APPs are consistently confused that I'm doing my own drainage (cut capped 18 gauge needle) and DCing them,

If I had the ability to admit PTAs I would probably do so. I don't like draining them and they take time to do, but obviously if needed I'll do it.

 

[Rekt]

From this thread, all I can say is I'm glad I didn't pick the huge academic center for training. Getting a panorex on dental pain and calling OMFS sounds like a complete waste of time. Imaging a straight forward PTA is crazy. I've done a few this year. It's a very easy procedure that seems completely unnecessary to have ENT involved.

 

[thegenius]

From this thread, all I can say is I'm glad I didn't pick the huge academic center for training. Getting a panorex on dental pain and calling OMFS sounds like a complete waste of time. Imaging a straight forward PTA is crazy. I've done a few this year. It's a very easy procedure that seems completely unnecessary to have ENT involved.

Totally agree brother. All but the most wicked ones which is extremely rare...just cut and d/c with follow-up.

I think Jerry Garcia agrees with you too.

 

[RuralEDDoc]

If I had the ability to admit PTAs I would probably do so. I don't like draining them and they take time to do, but obviously if needed I'll do it.

Yes what is this obs for consult concept? Foreign to me Local practice patterns are amazingly different, not just in who is willing to drain PTA but also which EDs or hospital systems are willing or able to hang onto these until a specialist is available to come in. In one of my early post residency jobs we routinely accepted PTA transfers since the sending docs didn’t have ENT on call. I thought I was in Oz.

 

[Brigade4Radiant]

Except that it's not.

People freak out over giving 10 of morphine will not look twice giving 1 mg of diluadid.

 

[deleted547339]

I suspect 10 mg of IV Morphine would do the trick for most painful complaints, that's a ton!

0.1mg/kg of morphine gets pain control on something like 1/2-2/3rd of patients. So if you have a 220lbs patient, up to half won’t be pain controlled following it.

 

[BoardingDoc]

lol, I was thinking the same...what's this secret 17g needle that I've been missing my entire career?!

It's what you get when you type quickly but not terribly accurately.

 

[Porfirio]

Odd, I am seeing more and more that ENT isn’t needling or cutting PTA. They are just giving antibiotics and follow up next week. They claim the literature reports 60-80% improve just with antibiotics. Anyone else seeing this?

 

[Dr Mantis Toboggan]

Yes. Good data supports strategy of IV ceftriaxone, clinda, dex then PO clinda if able to take PO etc. admission for this is also reasonable but hospitalists will not like it if there is no oto on call (which most hospitals do not have).


Otolaryngol Head Neck Surg. 2018;158(2):280. Epub 2017 Nov 7.

 

[littlejuan]

Odd, I am seeing more and more that ENT isn’t needling or cutting PTA. They are just giving antibiotics and follow up next week. They claim the literature reports 60-80% improve just with antibiotics. Anyone else seeing this?

Yup, I’ve had this conversation with my ENT colleagues and they tell me the same. Antibiotics first with follow up unless it’s this huge juicy looking one/causing significant distress.

 

[Apollyon]

Yes. Good data supports strategy of IV ceftriaxone, clinda, dex then PO clinda if able to take PO etc. admission for this is also reasonable but hospitalists will not like it if there is no oto on call (which most hospitals do not have).


Otolaryngol Head Neck Surg. 2018;158(2):280. Epub 2017 Nov 7.

So, if they need IV ceftriaxone, do they get admitted, or a PICC? Either way (obs admit, but might need 2 days, or PICC for only 2 days) seems unweildy. Or, is it just one IV dose, then go, if the dex worked that quickly?

 

[Dr Mantis Toboggan]

So, if they need IV ceftriaxone, do they get admitted, or a PICC? Either way (obs admit, but might need 2 days, or PICC for only 2 days) seems unweildy. Or, is it just one IV dose, then go, if the dex worked that quickly?

The latter. One dose rocephin and clinda both IV, one dose dex, 1 L NS too I think, home on PO clinda. Though it was a Kaiser study in SoCal so ENT f/u was guaranteed (not reality for most of us)