Imaging diagnosis of salivary diseases
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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
