The research team, led by Heng Li, Ying Cheng, Xiaotong Zhang and corresponding author Weijun Ma, reviewed 33 consecutive patients representing 35 operated ears treated between June 2018 and August 2024. Every patient underwent the same triad of assessments: audiologic testing to quantify the hearing deficit, temporal-bone high-resolution computed tomography with post-processing guided by the treating physicians, and exploratory tympanotomy, the surgical exploration of the middle ear that served as the definitive anatomic reference. Ossicular reconstruction was carried out whenever it was technically feasible and judged safe, which ultimately applied to all 33 ears for which hearing outcomes were analyzed.

What the surgeons found at the operating table was strikingly different from what a casual reading of hearing tests might suggest. Eight ears were diagnosed with otosclerosis, the abnormal fixation of the stapes footplate, and in every one of those ears the footplate was indeed immobile at surgery. The remaining diagnoses were dominated by congenital ossicular anomalies, which accounted for 25 ears, while traumatic ossicular discontinuity explained just two. That distribution underscores why imaging matters: congenital malformations of the middle ear bones can produce significant hearing loss behind an entirely intact tympanic membrane, and their anatomy varies from patient to patient in ways that directly shape the surgical plan.

The headline number from the study is a 97.0 percent patient-level agreement between the integrated preoperative diagnostic impression and the principal operative diagnosis, with the impression matching surgery in 32 of 33 patients. The authors are careful, and rightly so, about what this figure means. It reflects the combined weight of clinical examination, audiometry and CT findings, not the diagnostic accuracy of CT alone. The Wilson 95 percent confidence interval, ranging from 84.7 to 99.5 percent, also reminds readers that with a sample of this size the true rate could be somewhat lower. The single discordant case was a fibrous incudostapedial connection, a soft-tissue bridge between the incus and stapes that CT could not resolve.

That limitation is not a footnote; it is central to the study’s message. The authors explicitly note that stapes fixation and fibrous ossicular connections may remain occult on CT. Otosclerosis, in particular, is often a diagnosis of exclusion supported by audiometric patterns and surgical palpation rather than by direct visualization on a scan. Fibrous bands, being soft tissue of similar density to surrounding structures, sit below the resolution threshold of even high-resolution temporal bone protocols. Surgeons reading these images must therefore hold two possibilities in mind simultaneously: the anatomy the CT displays, and the pathology it cannot.

Where the imaging genuinely shines is in anticipating reconstruction requirements. Multiplanar reformation allows radiologists and surgeons to scroll through the ossicular chain in axial, coronal and sagittal planes, while three-dimensional reconstruction renders the malleus, incus and stapes as discrete, rotatable structures. For congenital anomalies, in which a crura may be absent, an incus may be fused or displaced, and the spatial relationships between ossicles and the facial nerve can be unpredictable, this preoperative map changes how the operation is approached. The study frames CT as providing anatomic information for integrated preoperative assessment and helping anticipate possible reconstruction needs, a formulation that respects both the power and the boundaries of the technique.

The hearing outcomes provide the most compelling evidence that this integrated approach translates into real benefit for patients. Mean air-conduction pure-tone average improved from 65.4 plus or minus 14.0 dB HL before surgery to 31.9 plus or minus 9.2 dB HL at three months, a mean paired improvement of 33.5 dB with a 95 percent confidence interval of 28.2 to 38.9. The air-bone gap, the standard measure of how much sound is being lost in the middle ear, fell from 40.9 plus or minus 13.1 dB to 12.1 plus or minus 7.3 dB, a mean closure of 28.8 dB. Both comparisons reached statistical significance at P less than 0.001.

Perhaps the most intriguing audiometric finding is that mean bone-conduction threshold improved by 4.7 dB, with a confidence interval of 1.7 to 7.7 dB and a P value of 0.003. Bone conduction bypasses the middle ear entirely, so an improvement in this measure after ossicular reconstruction is generally interpreted as a reduction in the masking effect of middle ear pathology, sometimes described as a correction of the air-bone gap’s contribution to measured bone thresholds, or as resolution of a mild sensorineural component that was masked preoperatively. Whatever the precise mechanism, the practical consequence is that patients did not merely close the conductive gap; their overall hearing function improved as well.

By the conventional surgical benchmark of a postoperative air-bone gap below 20 dB, 28 of the 33 reconstructed ears, or 84.8 percent, achieved a successful outcome. For a cohort dominated by congenital ossicular anomalies, which are among the most technically demanding middle ear reconstructions, that success rate is notable. It suggests that when surgeons enter the operating room with a detailed three-dimensional understanding of the patient’s unique anatomy, they can select appropriate prostheses, plan their approach and anticipate complications before the first incision.

The study, supported by the National Natural Science Foundation of China and the Shaanxi Provincial Science and Technology Program, carries the usual caveats of a retrospective, single-center, selected surgical series. The patients all came to exploratory tympanotomy, meaning the cohort is enriched with cases where imaging and audiology pointed to surgically correctable disease. The authors themselves caution against over-reading the 97.0 percent correspondence as a statement about CT in isolation. Still, for a condition in which the eardrum looks normal, the audiogram shows a gap, and the cause remains a mystery, the message is clear: modern temporal bone imaging, wielded with clinical judgment, turns much of that mystery into a map, while honestly acknowledging the soft-tissue shadows that remain beyond its sight.

Subject of Research: Preoperative CT imaging and 3D ossicular reconstruction for diagnosing conductive hearing loss with an intact tympanic membrane

Article Title: Preoperative high-resolution computed tomography and three-dimensional reconstruction of the ossicular chain in conductive hearing loss with an intact tympanic membrane: a retrospective imaging-surgical case series

Article References: Li, H., Cheng, Y., Zhang, X., & Ma, W. (2026). Preoperative high-resolution computed tomography and three-dimensional reconstruction of the ossicular chain in conductive hearing loss with an intact tympanic membrane: a retrospective imaging-surgical case series. BMC Medical Imaging. https://doi.org/10.1186/s12880-026-02910-2

Image Credits: AI Generated

DOI: 10.1186/s12880-026-02910-2

Keywords: conductive hearing loss, high-resolution computed tomography, three-dimensional reconstruction, ossicular chain, otosclerosis, congenital ossicular anomalies, exploratory tympanotomy, tympanic membrane, hearing outcomes, temporal bone imaging, ossicular reconstruction, BMC Medical Imaging

The research, conducted at Shohadaye-Khalije-Fars Teaching Hospital in Bushehr and published in BMC Infectious Diseases, examined the medical records of 428 hospitalized patients with RT-PCR-confirmed SARS-CoV-2 infection admitted during 2020, all of whom underwent at least one chest HRCT scan during their stay. Across this cohort, a total of 463 HRCT examinations were performed. The researchers, led by Atefeh Esfandiari and Hedayat Salari of Bushehr University of Medical Sciences, judged each scan against the indications laid out in the Iranian national COVID-19 guidelines, using a structured checklist to extract clinical data from the charts. By these criteria, 188 of the 463 scans, or 40.6 percent, were classified as inappropriate.

The distinction between appropriate and inappropriate imaging rests on well-established principles of radiological stewardship. Reverse transcription polymerase chain reaction remains the reference standard for diagnosing SARS-CoV-2 infection, detecting viral RNA with high specificity. HRCT is meant to serve as a complementary tool, reserved for situations such as diagnostic uncertainty, suspected complications, or significant deterioration in a patient’s respiratory status. When a scan is ordered outside these documented indications, the patient absorbs ionizing radiation without a corresponding benefit, and the health system absorbs the cost. The American College of Radiology and similar bodies worldwide have long warned that indiscriminate imaging of this kind erodes both safety and economic efficiency.

To understand why so many scans fell outside guideline recommendations, the team turned to multivariable logistic regression, a statistical technique that isolates the independent effect of each potential predictor while controlling for the others. The results were striking. The strongest driver of inappropriate ordering was symptom duration of seven days or less at the time the scan was requested, with an adjusted odds ratio of 47.15 and a p-value below 0.001. In practical terms, patients scanned very early in the course of illness were dramatically more likely to have been imaged without a guideline-supported reason, a pattern consistent with clinicians reaching for CT before the disease’s characteristic radiological evolution had even had time to develop.

Two other independent predictors emerged from the analysis. Requests originating from hospital-based general practitioners working in the emergency department carried an adjusted odds ratio of 9.64 for inappropriateness, compared with requests from subspecialists, suggesting that the ordering physician’s level of training shaped adherence to imaging criteria. Patient age also mattered: those younger than 30 years faced an adjusted odds ratio of 8.97 for receiving an inappropriate scan relative to patients older than 65. Younger patients with COVID-19 generally have milder disease and lower baseline risk, which may explain why imaging them often lacked a defensible clinical indication, yet the scanners were still frequently rolled out.

Repeat imaging added another layer of concern. Among the 35 repeat HRCT examinations performed during the study period, 12 were judged inappropriate. Serial chest CT is sometimes justified to track disease progression or response to therapy, but each additional scan compounds the cumulative radiation dose. In the context of a respiratory illness where many follow-up scans yield little actionable information, the finding underscores how easily a resource-intensive test can become routine rather than reasoned.

The economic analysis translated these clinical lapses into monetary terms, calculated from three distinct perspectives. The unnecessary financial burden attributable to inappropriate HRCT utilization was estimated at 56,047,000 Iranian rials, approximately 2,156 US dollars, borne by patients themselves. From the governmental healthcare system perspective, the burden rose to 182,360,000 rials, roughly 7,014 US dollars. Under the private tariff, the figure climbed to 328,812,000 rials, or about 12,646 US dollars. While these sums may appear modest in absolute global terms, they represent pure waste, expenditure on imaging that delivered no clinical value, and they scale rapidly when projected across the thousands of hospitals and millions of admissions that defined the pandemic era.

The study’s methodology deserves attention for what it reveals about health services research during public health emergencies. As a retrospective, analytical, cross-sectional investigation conducted in 2022, it reviewed records rather than prospectively guiding care, which means the findings describe practice as it happened rather than testing an intervention. Descriptive statistics and chi-square or Fisher’s exact tests were used to compare groups, and the appropriateness judgment depended on documented clinical indications in the chart, an approach that ties the assessment to the paper trail each ordering clinician left behind. The work was approved by the ethics committee of Bushehr University of Medical Sciences, with informed consent waived due to the retrospective design and all patient data fully anonymized.

Why does this matter beyond a single hospital in Bushehr? The pandemic placed unprecedented pressure on diagnostic infrastructure everywhere, and the temptation to image broadly, to see what the lungs looked like rather than to answer a specific clinical question, was felt in emergency departments across the globe. Guidelines from national health authorities and professional societies consistently urged restraint, recommending CT primarily when RT-PCR results were unavailable or discordant with clinical findings, or when complications were suspected. The Iranian data provide a quantified case study of what happens when that restraint slips: more than four in ten scans ordered without indication, a clear gradient of risk tied to early symptom duration, junior ordering patterns, and young age, and a measurable bill attached to every unnecessary exposure.

The authors conclude that strengthening adherence to evidence-based imaging indications could reduce unnecessary utilization without compromising clinical care. Their findings point toward practical remedies: decision-support tools embedded in electronic ordering systems, clearer escalation pathways that involve subspecialist judgment before advanced imaging, and audit-and-feedback mechanisms that show clinicians how their ordering behavior compares with guideline expectations. As health systems worldwide continue to digest the lessons of COVID-19, the Bushehr study offers a reminder that the cost of a pandemic is measured not only in lives and lockdowns but also in the quiet accumulation of tests that were never needed, doses of radiation that were never justified, and funds that could have strengthened care elsewhere.

Subject of Research: Clinical appropriateness and economic burden of high-resolution chest CT scanning in hospitalized COVID-19 patients

Article Title: Evaluating the clinical appropriateness of high-resolution chest CT scans in hospitalized patients with COVID-19 and the economic burden: a retrospective study in southern Iran

Article References: Esfandiari, A., Amiri, B., Abbasi, F., Esfandiari, S., & Salari, H. (2026). Evaluating the clinical appropriateness of high-resolution chest CT scans in hospitalized patients with COVID-19 and the economic burden: a retrospective study in southern Iran. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14582-y

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14582-y

Keywords: COVID-19, SARS-CoV-2, high-resolution computed tomography, HRCT, RT-PCR, medical imaging, imaging appropriateness, healthcare costs, radiation exposure, Iran, retrospective study, clinical guidelines

Chronic eosinophilic pneumonia, or CEP, occupies a distinctive niche in pulmonary medicine. The disease is characterized by dense infiltration of the lung parenchyma by eosinophils, the white blood cells best known for fighting parasites and driving allergic reactions. It typically strikes middle-aged adults, shows a marked female predominance, and is strongly linked to asthma and atopic disease, with up to two-thirds of patients carrying a history of asthma before the lung disease declares itself. Clinically, CEP follows a subacute to chronic course, unfolding over weeks to months with cough, progressive shortness of breath on exertion, and constitutional symptoms such as weight loss and fatigue. The classic radiological picture is equally recognizable: bilateral consolidations and ground-glass opacities clustered at the periphery of the lungs, hugging the pleural surface in a pattern that experienced radiologists can spot from across the reading room.

The diagnostic architecture of CEP rests on a tripod of findings. Because no universally accepted diagnostic criteria exist, clinicians generally require a compatible subacute clinical course, characteristic peripheral-predominant pulmonary infiltrates on imaging, and evidence of eosinophilic inflammation, either in the blood or in bronchoalveolar lavage fluid, while systematically excluding secondary causes of pulmonary eosinophilia such as drugs, parasites, and systemic autoimmune disease. In typical cases, the lavage findings are dramatic. BAL eosinophilia is usually marked, often reaching 40 percent or more of the recovered cells, and peripheral blood eosinophil counts commonly exceed 1,000 cells per microliter. When the clinical picture, the imaging, and the cellular evidence all align, lung biopsy is generally considered unnecessary, reserved for the minority of cases in which features are atypical or inconclusive. That reserve clause, as this case demonstrates, is where diagnostic danger lives.

The patient at the center of the report was a 61-year-old ex-smoker who arrived with two months of progressively worsening breathlessness on exertion and two weeks of a productive cough that would not relent, accompanied by weight loss. His medical history included asthma, managed with inhaled fluticasone furoate and vilanterol, along with type 2 diabetes treated with empagliflozin and metformin and hyperlipidaemia controlled with simvastatin for more than a decade. He reported no recent travel abroad and no consumption of raw or undercooked food, closing off the most common routes to parasitic lung infection. On examination, doctors heard bilateral fine inspiratory crackles but no wheezing, and they found none of the peripheral stigmata, purpura, mechanic’s hands, Gottron papules, Raynaud phenomenon, synovitis, or neurological deficits, that would suggest a connective tissue disease or vasculitis masquerading as lung disease.

Laboratory testing initially seemed to confirm the suspicion of CEP. The patient’s peripheral blood showed eosinophilia of 15 percent, corresponding to 1,314 cells per microliter, comfortably above the threshold commonly associated with eosinophilic lung disease. Chest radiography revealed bilateral peripheral patchy opacities with an upper-lobe predominance, and high-resolution computed tomography went further, demonstrating multifocal peripheral consolidations and ground-glass opacities with a subpleural predilection, along with traction bronchiectasis indicating that the process had been smoldering long enough to begin remodeling the lung’s architecture. Taken together, the subacute course, the blood eosinophilia, and the textbook peripheral distribution of disease made CEP the leading diagnosis on admission, and a reasonable one by any standard.

Then the bronchoscope told a different story. Bronchoalveolar lavage of the patient’s lung returned a cellular differential that was 85 percent neutrophils and only 6 percent eosinophils, a profile that belongs to bacterial pneumonia, not to eosinophilic lung disease. Autoimmune serology, including antinuclear antibody, proteinase 3-antineutrophil cytoplasmic antibody, and myeloperoxidase-antineutrophil cytoplasmic antibody, came back negative, and the total IgE level of 289 kU/L offered no signal of an allergic driver. Urinalysis showed neither haematuria nor proteinuria, and renal function was normal, further arguing against a systemic vasculitis. Confronted with neutrophil-predominant lavage fluid, the clinical team reasonably pivoted to an infectious explanation and initiated empirical treatment with amoxicillin and clavulanate. The antibiotics failed. Symptoms persisted, radiographic abnormalities did not budge, follow-up lavage microbiological cultures were negative, cytological examination identified no parasitic organisms, and stool examination for parasites was also unrevealing.

With the non-invasive pathway exhausted, the team turned to video-assisted thoracoscopic surgery, resecting a wedge of the left lower lobe for histopathological examination. What the pathologist found rewrote the case entirely. The tissue demonstrated an organizing pneumonia pattern, defined by intra-alveolar proliferation of fibroblastic foci, the plug-like clusters of immature connective tissue known as Masson bodies, accompanied by active immature fibrosis. Critically, woven through the interstitial and peribronchiolar regions was a prominent eosinophilic inflammatory infiltrate, with plasma cells and scattered lymphocytes in attendance. The alveolar architecture was relatively preserved, and, importantly, a blood vessel examined in the specimen showed an intact wall with no histological evidence of vasculitis, excluding one of the most dangerous mimics. Integrating the clinical course, the peripheral eosinophilia, the radiological findings, the histopathological features, and a thorough assessment for secondary causes, the physicians made the diagnosis of chronic eosinophilic pneumonia.

Treatment followed the established playbook for CEP. Intravenous methylprednisolone was commenced at 40 milligrams daily, a dose equivalent to prednisolone at 1 milligram per kilogram of body weight per day, then converted to oral methylprednisolone before discharge and gradually tapered over approximately two months. The response was swift and convincing. Symptoms improved progressively, and a chest radiograph obtained after roughly one month of corticosteroid therapy showed resolution of the bilateral peripheral opacities that had dominated the initial films. The trajectory underscores why making the correct diagnosis matters so much: corticosteroids, which are useless against bacterial pneumonia and potentially harmful, are precisely the right weapon against CEP, and delays in reaching the diagnosis translate directly into prolonged symptoms and unnecessary exposure to antibiotics.

The case’s most instructive twist lies in what the lavage fluid did and did not reveal. Although BAL eosinophilia is usually prominent in CEP, the authors note that considerable variability has been reported across published series, with eosinophil proportions ranging from as low as 12 percent to as high as 95 percent. There is a technical reason for this scatter: bronchoalveolar lavage samples only a limited portion of the distal airways and alveolar compartment, a tiny and possibly unrepresentative window onto a patchy disease process. A normal or atypical BAL differential, the authors emphasize, does not exclude microscopic abnormalities elsewhere in the lung tissue. The cellular profile of lavage fluid should therefore be interpreted in conjunction with the clinical and radiological findings rather than wielded in isolation, and when the lavage results clash with the broader picture, surgical lung biopsy may be justified in selected patients to establish the diagnosis definitively.

The report also untangles a second source of confusion, the relationship between CEP and cryptogenic organizing pneumonia. The two conditions share several clinical and radiological features, including subacute respiratory symptoms, pulmonary consolidation, and ground-glass opacities, which can complicate their distinction even for experienced clinicians. Histologically, however, organizing pneumonia is a non-specific pattern of lung injury that may occur in a variety of pulmonary disorders, CEP among them. Although eosinophilic infiltration of the alveolar spaces and interstitium is the characteristic histopathological hallmark of CEP, foci of organizing pneumonia with intra-alveolar fibroblastic plugs may also be present within it. The presence of an organizing pneumonia pattern on biopsy, in other words, does not automatically signify cryptogenic organizing pneumonia. In this patient, the combination of that pattern with prominent eosinophilic infiltration, alongside compatible clinical, radiological, and peripheral blood findings, anchored the diagnosis firmly in eosinophilic territory. For clinicians navigating the eosinophilic lung diseases, the message is blunt: lavage fluid is a supporting witness, not the judge, and when the evidence conflicts, the tissue still holds the final word.

Subject of Research: Diagnosis of chronic eosinophilic pneumonia with atypical bronchoalveolar lavage findings and an organizing pneumonia pattern on lung biopsy

Article Title: Chronic Eosinophilic Pneumonia: A Diagnostic Challenge With Atypical Bronchoalveolar Lavage Findings and an Organizing Pneumonia Pattern

Article References: Chronic Eosinophilic Pneumonia: A Diagnostic Challenge With Atypical Bronchoalveolar Lavage Findings and an Organizing Pneumonia Pattern. (n.d.). https://doi.org/10.1002/rcr2.70780

Image Credits: AI Generated

DOI: 10.1002/rcr2.70780

Keywords: chronic eosinophilic pneumonia, bronchoalveolar lavage, organizing pneumonia, lung biopsy, eosinophilia, interstitial lung disease, corticosteroids, high-resolution computed tomography, cryptogenic organizing pneumonia, respiratory medicine, case report, differential diagnosis