醫(yī)學影像學課件：涎腺疾病的影像學診斷

1、涎腺疾病的影像學診斷 病史檢查影像學細針吸活檢唾液流率生化Imaging diagnosis of salivary diseases introduction病史涎腺疾病相關癥狀疼痛腫脹，腫塊口腔干燥唾液過多味覺異常全身疾病/用藥史/手術史/放射治療Imaging diagnosis of salivary diseases introduction檢查視診腫脹神經損害情況口腔粘膜導管口捫診腺體大小、質地、壓痛腫塊Imaging diagnosis of salivary diseases introductionWhich group of diagnoses have to be tak

2、en into consideration?Additional examination required?Which examinations should be carried out? In what sequence?What extra information can be obtained? And how useful?Is the value of this information worthwhile in view of any contraindications, discomfort to the patient, or financial consequences?I

3、maging diagnosis of salivary diseases introductionImaging diagnosis of salivary diseases introductionImaging modalitiesplain radiographssialographyscintigraphysialoendoscopyultrasoundComputerized tomographymagnetic resonance imagingX線平片結石相關骨改變Imaging diagnosis of salivary diseases introduction唾液腺造影

4、Rontogen1895discovery of X ray Carpy1902injection of mercury into Stensens duct in vitro Arcelin1913injection of bismuth into Wartons duct in vivo for investigation of sialolith Sicard & Forestier1921lipiodol as a contrast medium Barsony1925for the investigation of duct dilation/metal canula Wiskovs

5、ky1925Sialodochographie Jacobovici1926sialographie Rutney & Shapsio1950rubber catheterRubin, Holt, and Blatt1957secretory sialography/polyethylen canula Gullmo & Book Henderstrom1958hydrostatic sialography Liliequist & Welander 1969subtraction technique Ferguson, Evans, and Mason1977continuous infus

6、ion pressure monitored sialography digital subtraction sialography tomographic sialographyCT sialography MR sialography .Imaging diagnosis of salivary diseases Sialography顯示導管系統(tǒng)的形態(tài)以導管系統(tǒng)改變?yōu)橹饕憩F的疾病復發(fā)性腮腺炎口干綜合征阻塞性炎癥唾液腺瘺發(fā)育異常治療作用水溶性造影劑油溶性造影劑禁忌證局限：造影劑的使用，患者不適，插管困難，影像重疊約21%的腮腺標本可見副腺體Imaging diagnosis of sal

7、ivary diseases SialographyScintigraphy in 1960, Richards was the first to suggest that technetium-99m might have useful medical applications the first article dedicated to salivary gland scintigraphy with Tc-pertechnetate was published by Borner in 1965 remains the only procedure with which the func

8、tional status of all major salivary glands can be studies simultaneouslyImaging diagnosis of salivary diseases ScintigraphyImaging diagnosis of salivary diseases Scintigraphy正電子發(fā)射型斷層計算機(Positron emission tomography, PET)PET-CT功能代謝成像和解剖成像同機融合放射性示蹤劑18F-氟脫氧葡萄糖(18fluorine-fluorinedeoxyglucose, 18F-FDG)腫

9、瘤細胞增殖迅速，代謝旺盛，葡萄糖利用高于正常組織1931年Warburg報告腫瘤細胞攝取高于正常組織腫瘤惡性程度與攝取呈正相關明確原發(fā)灶早期、準確確定腫瘤位置和局部淋巴結轉移準確度88%，敏感度100%，特異度77%腫瘤分期劃定放療靶區(qū)，提高精確性觀察療效、復發(fā)、轉移18F-FDG不是腫瘤特異性顯像劑炎癥肉芽組織唾液腺組織腮腺良性腫瘤費用超聲檢查唾液腺位置表淺，適于超聲檢查成像原理高頻換能器，近場分辨率好，穿透能力差唾液腺腫瘤的首選檢查方法唾液腺結石主要優(yōu)點：無輻射，無創(chuàng)傷，無痛苦，易于反復檢查，操作簡便正常表現Imaging diagnosis of salivary diseases ul

10、trasound正?；芈暠憩F，橫切面與縱切面，換能器頻率CT軟組織分辨率好可觀察相關骨質改變及鈣化空間分辨率高多方向觀察，三維重建顯示病變位置、范圍、與周圍組織結構的關系成像速度快強化掃描可顯示血管影像和病變的強化特征輻射造影劑偽影組織HU腦脊液、水0脂肪100軟組織5060血液3550腮腺1030下頜下腺3060舌下腺6090骨1000肺850氣體1024鈣化150200灰質3540PK Jacob，2008腮腺密度1030HU，高于脂肪，低于肌肉，隨增齡有改變CTA觀察血管結構術前觀察病變的血供情況制定手術計劃，減少出血，是否需要術前栓塞CTSMRI 軟組織分辨率優(yōu)于CT 強化掃描有助于增

11、強軟組織分辨能力功能成像動態(tài)增強MRI（DCEMRI）彌散加權成像（DWI）波譜成像（MRS）局限掃描時間長偽影禁忌Imaging diagnosis of salivary diseases腮腺在胚胎第六周開始發(fā)育起源于上下頜突分叉處的外胚層上皮頜下腺在胚胎第六周末開始發(fā)育起源于頜舌溝近外側的內胚層上皮舌下腺在第78周開始發(fā)育起源于頜舌溝近外側的內胚層上皮涎腺發(fā)育異常唾液腺先天缺失1885年，Gruber首次在尸檢中發(fā)現涎腺缺失全部大涎腺（腮腺和頜下腺）缺失，或部分缺失，有報告大、小涎腺均缺失(Otsuni PA, 1995)M/F=2/1家族史，可伴有其他畸形尸檢可見脂肪和疏松結締組織沒有

12、影像檢查手段以前，靠觸診、導管口、唾液分泌情況診斷CT (misdiagnosis resulting from the inclination of the scanning plane)、MRI、US、核醫(yī)學涎腺缺失應與以口干為主要癥狀的疾病鑒別 (serum studies and biopsy)靜止性骨腔（Stafne骨腔）1942年首次報告35 cases圓形、類圓形，邊界清楚單房，低密度下頜管以下下頜第一磨牙和下頜角之間位置恒定，形態(tài)具有特點多無癥狀男性多見，中老年人多見舌側骨板消失與頜下腺延續(xù)命名較多Aberrant or ectopic salivary glandStatic

13、 or latent or idiopathic defect, cavity, or cystMandibular salivary gland inclusionLingual mandibular bone cavity, concavity, or depressionStafne cyst, defect, or cavity發(fā)生率0.1% 0.48%唾液腺異位臨床可表現為腫塊、涎瘺，涎瘺可與進食有關垂體、中耳、外耳、下頜骨、甲狀舌管、甲狀腺、頸部（胸鎖乳突肌前緣）多可雙側發(fā)生兒童期就診，甚至出生時即可見與副腺體、鰓裂囊腫、腫瘤鑒別唾液腺結石病發(fā)生在唾液腺導管及腺體內的結石，繼發(fā)炎癥

14、改變下頜下腺80%，腮腺10%，舌下腺及小唾液腺10%早期無癥狀，腺體反復腫脹，與進食有關，進食后可緩解，導管口紅腫，膿性分泌，檢查可及結石，觸痛sialolithiasisplain radiographysubmandibular glandocclusal radiographposterior oblique occlusal viewlateral mandibular radiographparotid glandintraoral viewPAsialography (digital subtraction)Imaging diagnosis of salivary diseas

15、es sialolithiasisImaging diagnosis of salivary diseases sialolithiasisImaging diagnosis of salivary diseases sialolithiasisImaging diagnosis of salivary diseases sialolithiasisSialolithiasisecho-dense spotsposterior acoustic shadowingstones of 2 mm and largerImaging diagnosis of salivary diseases si

16、alolithiasis陰性結石 充盈缺損 filling defect 主導管擴張 frequently more or less dilated ductal system Imaging diagnosis of salivary diseases sialolithiasisImaging diagnosis of salivary diseases sialolithiasis鑒別阻塞性炎癥頜下區(qū)淋巴結鈣化血管畸形舌下腺腫瘤鑒別診斷Imaging diagnosis of salivary diseases fistula唾液腺瘺 fistula多數為獲得性：創(chuàng)傷，手術（醫(yī)源性），惡

17、性腫瘤，炎癥少數為先天性可發(fā)生于腮腺、頜下腺、異位腺體或副腺體可發(fā)生于耳周、頰部、口腔粘膜及頸部可伴有附耳等其它畸形臨床可見瘺口，口內瘺，口外瘺瘺口可見分泌，清亮或混濁，進食時明顯影像學：造影檢查，瘺道造影，唾液腺造影，可結合CTWK Moon, et al. Congenital fistula from ectopic accessory parotid gland: diagnosis with CT sialography and CT fistulography. AJNR 1995唾液腺炎癥性疾患流行性腮腺炎唾液腺結石病急性化膿性腮腺炎慢性下頜下腺炎慢性阻塞性腮腺炎放射性唾液腺炎唾

18、液腺結核俞光巖 馬大權：唾液腺病學 第二版 2014年Imaging diagnosis of salivary diseases inflammationER Carlson, RA Ord: Textbook and color atlas of salivary gland pathology 2008Infections of the salivary glandsBacterial salivary gland infectionsAcute bacterial parotitisChronic bacterial parotitisChronic recurrent juvenil

19、e parotitisCat scratch diseaseAcute bacterial submandibular sialadenitisChronic recurrent submandibular sialadenitisTuberculous mycobacterial diseaseNontuberculous mycobacterial diseaseViral salivary gland infectionsMumpsHIVCollagen sialadenitis兒童復發(fā)性腮腺炎Juvenile recurrent patotitis, recurrent acute p

20、arotitis兒童患者中第二位好發(fā)的唾液腺疾病，僅次于流行性腮腺炎，有時二者難于鑒別臨床表現：腮腺反復腫大，疼痛，與進食無關；可單側發(fā)生，也可以雙側發(fā)生，其中一側癥狀明顯；可見混濁或膿性分泌發(fā)病相關因素：導管發(fā)育缺陷，遺傳，病毒或細菌感染，過敏，自身免疫病的局部表現，多因素發(fā)病年齡平均最小最大3.8男3.35個月6女4.737O Nahlieli, 2004兒童復發(fā)性腮腺炎抗生素治療，唾液腺內窺鏡治療預防措施：局部按摩，chewing gum，促進唾液分泌，導管沖洗影像學檢查：唾液腺造影末梢導管擴張，主導管可擴張，副腺體可累及，排空功能遲緩，非癥狀側也可出現，73%可見對側腺體影像表現唾液腺

21、內窺鏡可見主導管管壁發(fā)白唾液腺造影可改善癥狀有自限性，部分遷延至成年期Imaging diagnosis of salivary diseases inflammation4歲到18歲10歲到15歲adult鑒別診斷流行性腮腺炎副粘液病毒全身癥狀重，發(fā)熱，乏力，頭痛，寒戰(zhàn)終生免疫兒童口干綜合征氣泡性腮腺炎淋巴瘤HIV阻塞性唾液腺炎唾液流出受阻引起腮腺反復腫脹etiology: calculus, stricture, mass, foreign body, infectionClinical反復腫脹，與進食有關咸味分泌導管口紅腫，分泌混濁或膿性Sialography：duct dilation

22、Imaging diagnosis of salivary diseases inflammation唾液腺結核 tuberculosis好發(fā)于腮腺，單側多見多見于腮腺淋巴結核，也可發(fā)生于腺實質結核菌感染，牙槽窩、扁桃體感染，導管系統(tǒng)多見于使用免疫抑制劑的患者診斷困難，切取活檢可發(fā)生慢性瘺口急性、慢性感染，與唾液腺炎癥、腫瘤不易鑒別可無癥狀，包塊，腺體腫大，瘺管，面癱ESR，FNAC影像：造影，超聲，CTImaging diagnosis of salivary diseases tuberculosisImaging diagnosis of salivary gland diseases:

23、 salivary gland tumors唾液腺腫瘤口腔頜面部腫瘤的23.9%，13人/10萬病理類型復雜臨床表現良性腫瘤：生長緩慢，無自覺癥狀，活動度好影像學檢查方法形態(tài)：CT、MRI、超聲波功能：核醫(yī)學，MRSSalivary tumors ultrasound形態(tài)邊界內部回聲后方回聲多形性腺瘤多形性腺瘤Warthins tumorBilateral parotid glands腺淋巴瘤橫紋肌肉瘤多形性腺瘤Imaging diagnosis of salivary diseases tumors粘液表皮樣癌CT良性腫瘤類圓形、結節(jié)狀軟組織腫塊邊界清楚，均勻強化或環(huán)形強化可有囊變及鈣化惡性

24、腫瘤形態(tài)呈結節(jié)狀或不規(guī)則形，邊界不清楚，脂肪、筋膜界面模糊消失密度不均勻頸部淋巴結骨破壞定位能力強化掃描可清楚顯示腫瘤范圍及強化特性，顯示腫瘤和血管及周圍結構的關系Imaging diagnosis of salivary diseases tumorsPleomorphic adenomawell definedisodense with normal parotid tissueusually homogeneous enhancementWarthins tumormost often the tumor is localized in the inferior part of the

25、parotid glandcan be multifocal in one or both parotid glandshomogeneous with smooth marginsLymphoma, sarcoidosis, or metastases also may present as multiple mass lesions in or both parotid glanddsLipoma of the parotid glandreadily recognized on CT as low density lesionswell defined margins惡性混合瘤Malig

26、nant tumourspainfulfacial nerve involvementfixedill defined marginsnecrosislocal invasionlymphadenopathy惡性混合瘤粘液表皮樣癌Lymphoma of the intraparotid lymph glandstonsilsLymphomasthe majority due to intraparotid nodal involvementan association with autoimmune diseasesdense infiltrative process on imagingMR

27、I軟組織分辨率好多方向、多層面顯示流空現象有助于大血管的顯示定位能力功能成像Imaging diagnosis of salivary diseases tumorsT1 weighted images 觀察組織器官的解剖結構 正常腮腺信號強度介于肌肉和脂肪之間 信號均勻 密質骨無信號T2 weighted images the normal gland has a more intense signal than the surrounding muscle tissue homoeneous water has the most intense signal of all substanc

28、es due to its long T2 fat has a low signal intensity多形性腺瘤Pleomorphic adenomalow signal intensity on T1very high signal intensity on T2homogeneous or inhomogeneouscorrelate with the presence of myxoid and/or chondroid or very cellular areas within the tumorT1 weighted spin echo imagelow signal intens

29、ityhomogeneous and lobulated tumorPleomorphic adenomaT2 weighted spin echo imagevery high signal intensityhomogeneous and lobulated tumorRecurrent pleomorphic adenomaT1 weighted imageT2 weighted imageParotid malignancy in a patient with a facial nerve palsyprecontrast transaxial T1 weighted MRMalign

30、ant tumours信號強度不均勻邊界不清楚，侵犯相鄰組織高度惡性腫瘤T1T2為低信號Undifferentiated carcinoma, T1 imageSialographmost authors nowadays agree that sialography is of limited use in tumor diagnosisduct systemacinarboneleakageImaging diagnosis of salivary diseases tumorsImaging diagnosis of salivary diseases tumors - scitigra

31、phyScintigraphythe mechanism of accumulation and retention of 99m Tc-pertechnetate by Warthins tumor has not yet been well elucidatedmost reports presumed that the increased accumulation of 99m Tc-pertechnetate by Warthins tumors was due to epithelium contained within this tumor extracting large ani

32、ons such as pertechnetate from the bloodWarthins tumour攝取99m Tc-pertechnetate與腫瘤上皮成分有關排空期放射性核素滯留Imaging diagnosis of salivary diseases tumors舍格倫綜合征 Sjogrens syndrome系統(tǒng)性自身免疫病多器官受累，外分泌腺破壞為特征原發(fā)性：不合并其它自身免疫病繼發(fā)性：合并類風濕性關節(jié)炎、系統(tǒng)性紅斑狼瘡女性多發(fā)，最常見的臨床表現為口干、眼干和唾液腺腫大口腔干燥猖獗齲腮腺腫大舌裂，舌乳頭萎縮念珠菌感染欲哭無淚Imaging diagnosis of sal

33、ivary diseases Sjogrens syndrome系統(tǒng)性表現皮膚：過敏性紫癜、結節(jié)性紅斑、雷諾現象骨骼肌肉：關節(jié)痛、肌炎腎：腎小管酸中毒、腎小球損害肺：間質性病變消化系統(tǒng)：萎縮性胃炎、肝損害、胰腺炎神經：周圍神經損害血液系統(tǒng)：淋巴腫瘤，血小板減少診斷方法淚腺功能Schirmer test角膜染色淚膜破裂時間唾液腺功能唾液流率唾液腺造影核醫(yī)學檢查活體組織檢查免疫學高丙種球蛋白血癥免疫球蛋白自身抗體干燥綜合征國際分類（診斷）標準2002年修訂版I 口腔癥狀：3項中有1項或1項以上每日感到口干持續(xù)3個月以上成年后腮腺反復或持續(xù)腫大吞咽干性食物時需用水幫助II 眼部癥狀：3項中有1項或1

34、項以上每日感到不能忍受的眼干持續(xù)3個月以上有反復的沙子進眼或沙磨感覺每日需用人工淚液3次或3次以上III 眼部體征：下述檢查任1項或1項以上陽性Schirmer I 試驗+（5mm/5分，不采用角膜麻醉方法）角膜染色+（4 van bijsterveld計分法）IV 組織學檢查：下唇腺病理示淋巴細胞灶1V 唾液腺受損：下述檢查任1項或1項以上陽性靜止唾液流率+（1.5ml/15分）腮腺造影+唾液腺同位素檢查+VI 自身抗體：抗SSA或抗SSB+（雙擴散法）原發(fā)性干燥綜合征：無任何潛在疾病的情況下，有下述2條則可診斷符合上述條目中4條或4條以上，其中必須含有組織學檢查和自身抗體眼部體征、組織學檢查、唾液腺受損和自身抗體4條中任3條陽性繼發(fā)性干燥綜合征：患者有任一結締組織病，有口腔癥狀或眼部癥狀中任1條，同時符合眼部體征、組織學檢查和唾液腺中任2條應除外頸頭面部放療史、丙肝病毒感染、AIDS，淋巴瘤、結節(jié)病、GV