Transcript Imaging diagnosis of salivary diseases

introduction
病史
疼痛
肿大/肿胀
口腔干燥
多涎
味觉异常
全身情况/既往史
病史
临床检查
影像学检查
细针吸活检
唾液流率
唾液生化
Diseases associated with salivary gland enlargement
Nutritional deficiency
hypovitaminosis A
Generalized malnutrition
Pellagra
beriberi
Hormonal abnormalities
diebetes mellitus
hypothyroidism
testicular atrophy
menopause
pregnancy, lactation
(cont’d)
metabolic disorders
bacillary dysentery (Japanese dysentery)
celiac disease
ancylostomiasis 钩虫病
cardiospasm 贲门痉挛
obesity
alcoholic cirrhosis
others
carcinoma of the esophagus
SS
sarcoidosis
Uremia
Drugs affecting salivary glands
analgesics
iodine
anticonvulsants/antispasmotics
muscle relaxants
antiemetics/antinauseants 止吐药
CNS depressants
antihistamines
dibenzoxepine derivatives
antihypertensives
monoamine oxidase inhibitors
antiparkinsons
phenothiazine derivatives
antipruritic 止痒剂
tranquilizers/sedatives
appetite suppressants
expectorants 化痰剂
digitalis 洋地黄
decongestants 解充血药
diuretics 利尿剂
introduction
临床检查
视诊
肿大
神经损害
口腔粘膜/舌
导管口

病史
临床检查

影像学检查 细针吸活检

唾液流率
唾液生化
扪诊
腺体大小
质地
压痛
肿物
introduction
平片 plain film
初步印象?
是否需要辅助检查?
检查方法及检查顺序?
可望获得哪些信息? 是否有助于诊断和治疗?
权衡利弊?
造影 sialography
核素 radionuclide
超声 ultrasound
CT
MRI
PLAIN FILM
RADIOPAQUE SIALOLITH
阳性结石
BONE INVOLVEMENT
涎腺疾病导致骨改变
Sialography
SIALOGRAPHY
INDICATION
CONTRAINDICATION
DUCT SYSTEM
Acute inflammation
OBSTRUCTION
Allergy to iodine
fistula
RECURRENT PAROTITIS
AUTOIMMUNE DISEASES
OTHER NON-NEOPLASTIC DISEASES
Sialography
Sialography
Sialography
Digital subtraction
vascular tree
nonvascular application
laryngography
dacryocystogrphy
sialography
DSS of 7 cases first reported by JB Lightfoote et al
in 1984
superiority
subtraction of overlying structures
dynamic images
simpler, faster, and less radiation than CT
intervention
Imaging diagnosis of salivary diseases Scintigraphy
核素
 1960年Richards 首先报告 technetium-99m 的医学应用
 涎腺检查 1965年由Borner首先报告
 定量评价大涎腺功能状态的唯一方法
Scintigraphy
Radionuclide imaging
动态功能曲线
摄取指数
分泌指数
Imaging diagnosis of salivary diseases ultrasound
超声
高频换能器
涎腺肿瘤的首选检查
成象原理
高频换能器
近场分辨率好
穿透能力差
Imaging diagnosis of salivary diseases ultrasound
高频电流
声波-电信号
压电晶体
诊断用超声5-10兆赫
声波在声学界面反射形成回声
受检组织
1895年 伦琴发现“X射线”
1917年
JH Radon根据透射测量法提出重建断面图像的数学基础
1963年
AM Cormack提出计算人体放射吸收分布特性的技术方法
1972年
GN Hounsfield和J Ambrose进行第一次临床CT检查
1974年 共安装60台临床CT
美国GeorgeTown医学中心Ledley设计出第一台全身CT
1974年
1979年
Hounsfield和Cormack获诺贝尔医学奖
1989年
WA Kalender 和P Vock 进行第一次螺旋CT临床检查
1992年双螺旋CT问世
1998年4层螺旋CT
2004年64层螺旋CT进入市场
256层螺旋CT样机已进入实验室
MRI
MRI
1930年代，物理学家伊西多·拉比发现原子核与磁场以及外加射频场相
互作用。拉比于1944年获得了诺贝尔物理学奖
NMR nuclear magnetic resonance
The experimental foundations of magnetic resonance were laid by Block
and Purcell more than six decades ago (1945), work for which they were
awarded a Nobel Prize in 1952
MRI magnetic resonance imaging
Lauterbur and Damadian introduced MRI in the early seventies
Lauterbur and Mansfield were awarded a Nobel Prize in 2003
excellent contrast resolution
直接作出横断面、矢状面、冠状面和各种斜面的体层图像
不需注射造影剂
无电离辐射，对机体没有不良影响
空间分辨率不及CT
价格昂贵
Contraindication
claustrophobic
those not fully cooperative
patients with cardiac pacemakers or insulin pumps,
intracranial ferromagnetic clips or hemoclips on cerebral
aneurysm
带有心脏起搏器的患者或有某些金属异物的部位不能作MR的检查
涎腺发育异常
先天缺失/发育不全
导管发育异常
异位/迷走涎腺
sialolithiasis
SIALOLITHIASIS 涎石症
plain radiography 平片
submandibular gland 頜下腺
occlusal radiograph
lateral mandibular radiograph 頜下腺側位
parotid gland 腮腺
intraoral view 口内片
PA 后前位
sialography (digital subtraction) 涎腺造影
sialolithiasis
Sialolithiasis
echo-dense spots
posterior acoustic shadowing
stones of 2 mm and larger
Sialographic findings
Filling defect
frequently more or less dilated ductal system
not normally indicated when a radiopaque stone revealed
fistula
fistula
Introduction
clinical
sialography
Imaging diagnosis of salivary diseases inflammation
Recurrent parotitis
juvenile
etiology: infection, immunology, dysplasia,
virus
clinical
sialectasia
adult
obstructive sialadenitis
etiology: calculus, stricture, mass, foreign body,
clinical
duct dilation
inflammation
Obstructive sialadenitis
left submandibular gland
tuberculosis
tuberculosis
clinical
sialography
US
tumors
ultrasound
Shape
regular
irregular
Border
well defined
ill defined
Internal echo
homogeneous
hetero-
Posterior enhancement
enhanced
attenuation, acoustic shadow
tumors
腮腺良性肿物
Pleomorphic adenoma
Imaging diagnosis of salivary diseases tumor
恶性肿瘤
边界不清，内部回声不均匀，
mucoepidermoid和acinic cell tumors 及较小的恶性肿瘤可呈良性表现
lymphoma 可呈良性肿瘤甚至囊性表现
tumors
Cross-sectional imaing
intra- and extraglandular tumours
adjacent structures
metastatic lymphadenopathy
contrast-enhanced CT scans
• deep lobe of the parotid and parapharyngeal space
• vascular and nodal structures adjacent to the gland
• dense parotid gland
Imaging diagnosis of salivary diseases tumors
CT sialography
stronge clinical suspicion of disease but negative
or equivocal with conventional CT scanning
possible mass lesions in submandibular gland
CT guided biopsy
tumor
Imaging diagnosis of salivary diseases tumor
Normal parotid
transaxial postcontrast CT
Imaging diagnosis of salivary diseases tumor
Imaging diagnosis of salivary diseases tumors
CT
characteristics
benign
round, well defined, calcification
malignant
lobulated or irregular in contour, heterogeneous
density or central necrosis
cervical lymphadenopathy
bone invasion
location
Pleomorphic adenoma
well defined
isodense with normal parotid tissue
usually homogeneous enhancement
indicators of malignancy
indistinct border
low density centres
thin enhancing rim
transaxial postcontrast CT
High-density rim in a pleomorphic
adenoma, caused by small calcification
Warthin’s tumor
most often the tumor is localized in
the inferior part of the parotid gland
can be multifocal in one or both
parotid glands
homogeneous with smooth margins
Lymphoma, sarcoidosis, or metastases also
may present as multiple mass lesions in or
both parotid glandds
Lipoma of the parotid gland
readily recognized on CT as low density lesions
well defined margins
Malignant tumours
painful
facial nerve involvement
fixed
ill defined margins
necrosis
local invasion
lymphadenopathy
retromandibular vein
Carcinoma of the parotid, transaxial postcontrast CT
Lymphomas
the majority due to intraparotid nodal involvement
an association with autoimmune diseases
dense infiltrative process on imaging
tonsils
Lymphoma of the intraparotid lymph glands
Imaging diagnosis of salivary diseases tumors
MRI
provide cross-sectional images in different planes without
repositioning the patient
produces images superior to those of CT for mass lesions
Major blood vessels depicted without the use of
intravenous administration of contrast medium
lesions in the deep lobe and the parapharyngeal space
identification of the fat plane between a normal
appearing gland and an extrinsic mass
facial nerve (?)
Imaging diagnosis of salivary diseases tumors
T1 weighted images
信号强度介于肌肉和脂肪之间，由于腮腺含有较多脂肪，在T1/T2均
呈高信号
Imaging diagnosis of salivary diseases tumors
T2 weighted images
•water has the most intense signal of all substances due to its long T2
• fat has a low signal intensity
Imaging diagnosis of salivary diseases tumor
良性肿瘤
T1加权像为低-等信号
T2加权像表现为强信号
信号变化特点与肿瘤内含有的浆液及粘蛋白物质有关
肿瘤边界在T2加权像或增强图像上显示较好
肿瘤内部信号均匀，边界清楚
Imaging diagnosis of salivary diseases tumor
Pleomorphic adenoma
transaxial T1 weighted MR T2 weighted MR
postcontrast T1 weighted MR
Imaging diagnosis of salivary diseases tumor
Pleomorphic adenoma
low signal intensity on T1
very high signal intensity on T2
homogeneous or inhomogeneous
correlate with the presence of myxoid and/or chondroid
or very cellular areas within the tumor
Imaging diagnosis of salivary diseases tumor
T1 weighted spin echo image
low signal intensity
homogeneous, lobulated tumor
Pleomorphic adenoma
T2 weighted spin echo image
very high signal intensity
homogeneous and lobulated tumor
Imaging diagnosis of salivary diseases tumor
Recurrent pleomorphic adenoma
multiple tumors
same signal characteristics as primary pleomorphic adenomas
easily depicted by MRI
exact localization correctly assessed
bright lesions
granulomas
cyst
isolated lymph nodes
Imaging diagnosis of salivary diseases tumor
Recurrent pleomorphic adenoma
T1 weighted image
T2 weighted image
Imaging diagnosis of salivary diseases tumor
恶性肿瘤
边界不规则
信号强度不均匀
周围组织受侵犯
颈淋巴结增大
低度恶性肿瘤（粘液表皮样癌/腺跑细胞癌）易与良性肿瘤混淆
高度恶性肿瘤多呈T!/T2低信号表现
根据肿瘤边界/均质性/信号强度定性不可靠
皮下脂肪受侵犯/淋巴结肿大可见于炎症
周围组织受侵犯（咽旁间隙/肌肉/骨）可靠
Imaging diagnosis of salivary diseases tumor
腮腺恶性肿瘤
临床有面瘫
增强前T1加权像
gadolinium DTPA增强像
Imaging diagnosis of salivary diseases tumor
Undifferentiated carcinoma, T1/T2 image
Imaging diagnosis of salivary diseases tumor
鉴别腺内外肿瘤
肿物与腮腺之间存在高信号的脂肪层，为腺外肿物
Imaging diagnosis of salivary diseases tumors
Sialograph
most authors nowadays agree that sialography is of limited
use in tumor diagnosis
duct system
acinar
bone
leakage
radionuclide imaging
Warthin’s tumours
increased activity on technetium scans
not wash out after a sialogogue
Imaging diagnosis of salivary diseases Sjogren’s syndrome
Sjogren’s syndrome
primary (sicca syndrome)
secondary: characterized by a clinical triad consisting
of dry eyes, dry mouth, and a connective tissue
disease, usually rheumatoid arthritis
clinical
salivary flow rate measurements
labial gland biopsy scores
scintigraphic/ sialographic changes
keratoconjunctivitis sicca
serological
Imaging diagnosis of salivary diseases Sjogren syndrome
sialography
delayed emptying
sialectasis (Robin P and Holt JF, 1957)
punctate early in the disease tiny collections of contrast
material are seen to be evenly distributed throughout the
gland
globular an apple tree in blossom image in a more advanced
stage
cavity the picture progresses to the presence of a few large,
irregular globules of contrast material
destructive the end stage reflects the total destruction of the
gland, characterized by bizarre pooling and puddling of
contrast material
atrophic
mass lesions
Imaging diagnosis of salivary diseases sialadenosis
Sialadenosis
endocrine
dystrophic-metabolic
neurogenic
associated systemic diseases
diabetes mellitus
hypothyroidism
cirrhosis
protein and vitamin deficiencies
anorexia nervosa
clinically reflected by the presence of a bilateral chronic or recurrent, painless
swelling
Imaging diagnosis of salivary diseases sialadenosis