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STOP-JIA

TMJ POCUS? Or Hocus POCUS?

By: Brian M. Feldman, MD, MSc, FRCPC | May 3, 2016 | What Caught Our Eye

Point-of-care ultrasound – with its clever acronym POCUS – has become a big thing in rheumatology, and in peds rheum. As someone who hasn’t received ultrasonography training, I find it highly mystifying, and I’m not sure on which side I fall. POCUS is seen, by some, as a natural evolution of the medical examination, and “with appropriate use, point-of-care ultrasonography can decrease medical errors, provide more efficient real-time diagnosis, and supplement or replace more advanced imaging in appropriate situations”(N Engl J Med 2011; 364:749-757). Some would even say that those who oppose POCUS are similar to those who opposed Laennec’s invention of the stethoscope. They were (presumably) saying that something would be lost from our medical skills – and doctor-patient relationship – if our ears didn’t have to be pressed against our patients’ chests.

However, there are others like Saurabh Jha who argue that we should forget the ultrasound and learn to do a proper history and physical instead. The argument here is that POCUS is plagued with false positives and that findings often “turn out to be giant balls of ‘nothingoma.’” Dr. Jha argues that, in the end, costs soar and patients get more exposure to radiation as false positives from POCUS are aggressively pursued.

I am personally sensitive to this argument because I know from colleagues’ recent work that we don’t know nearly as much as we thought we did about what’s normal for imaged joints.

Another thing that mystifies me is TMJ arthritis.

Like all of us, I see many patients with varying degrees of TMJ arthritis. It’s hard for me to get screening or frequent follow-up MRIs, and it’s hard for my patients too. Yet from what I understand from expert colleagues, that is what I’m meant to do.

The clinical exam for TMJ has several shortcomings. Wouldn’t it be wonderful if we could use POCUS for our JIA patients both to screen for and follow their TMJ course? Until recently, ultrasound has not been up to scratch, so it was with great interest that I read Edward Oberle’s abstract from the San Francisco ACR meeting.

The Oberle team examined 20 Milwaukee JIA patients and 20 dermatology clinic control patients. They received clinical exams, questionnaires, and TMJ POCUS. Ultrasound exams were later confirmed by a blinded ultrasonographer and radiologist.

What they found was a host of abnormalities on POCUS in their JIA patients: erosions, irregular contours, hyperemia, effusions and synovial prominence. Doppler, in particular, correlated highly with symptoms. POCUS indicated issues in patients where the history or exams were normal.

However, almost a quarter of the control patients had irregular TMJ contours, and some even had Doppler signal abnormalities. “Nothingomas?”

Without a gold standard, it’s hard to determine the place of POCUS in TMJ care. To me, it would be ideal if I could replace MRI with some of the newer ultrasound technologies, and so cool if it could be done at a clinic visit. It seems as though TMJ POCUS isn’t quite ready for prime time, but it certainly is an area that I’d like to see aggressively pursued.