副鼻窦和邻近结构PPT课件.ppt

1,ParanasalSinusesandAdjacentSpacesbyLaurieLoevnerandJenniferBradshaw,RadiologydepartmentoftheUniversityofPennsylvania,USAandtheradiologydepartmenttheMedicalCentreAlkmaar,theNetherlandsPublicationdate:25-2-2009副鼻窦和邻近结构,.,2,RoleofCTandMRISignalcharacteristicsofsecretions黏液的信号特征Pseudo-pneumatizedsinus假性气化的窦腔Enhancement增强ComplicationsofSinusitisBrainabscessMucoceleOrbitalCellulitisandAbscessComplicationofFESS(Functionalendoscopicsinussurgery)TumorandtumorlikelesionsEncephaloceleMucoceleInvertedpapillomaMalignanttumorsofthesinonasaltractMeningiomaKeratocystSilentsinusFibro-osseousLesionsFibrousdysplasiaOsteitisOsteomaMonitoringresponsetotherapy,3,RoleofCT,CTisofvaluefordetermininganatomiclandmarksandvariants.ThisinformationisofvitalimportancetotheENT-surgeon.Inaddition,weneedittoidentifyerosiveprocessesandacquireddevelopmentaldeficienciesofthebone.CT对于鼻腔鼻窦来说主要用于判定解剖标志和变异。这些信息对于耳鼻喉科医生是非常重要的。此外，我们还需判断病变对骨质的破坏以及骨的各种发育不良。,4,CTisalsoexcellentfordeterminingwhetherthereisintraorbitalextensionofsino-nasaldiseaseintheventral2/3oftheorbit.Whenpathologyapproachestheorbitalapex,anMRIstudyisnecessarytoassessspreadtothecavernoussinusandintracranialcompartment.CTisperformedwithoutcontrastmedium.Ifadditionalimagingisnecessary,orbitalMRIisthenextstep.CT也同样对于判断位于眼眶内侧3分之2的鼻腔鼻窦病变对眶内是否有侵犯非常有帮助。如果病变侵犯眶尖，那么需要进行MRI检查，以判断病变向海绵窦以及颅内腔的播散。,5,TherealvalueofunenhancedCTisthefollowing:ifyouseeanopacifiedsinuswithhyperdensecontents,itisusuallyasignofbenigndisease.Tumorisnothyper-dense.Thehyperdensityisduetooneoracombinationofthefollowing:inspissatedsecretionsfungusblood非增强CT的真正诊断价值在于：如果浑浊的窦腔内出现更高密度影，那么这个病变通常是良性的。肿瘤的密度不会很高。CT上的这种更高密度影主要由以下组成：浓缩的黏液；真菌；血液。,6,Ontheleftyouseeacasethatwasinitiallyinterpretedasatumor.Thehyperdensityisagoodprognosticsign,indicatingabenignprocess.Thisisanexampleofallergicfungalsinusitis.Usuallyitismoreanteriorlylocated.这是一张非增强的CT。我们最初认为是一个肿瘤。在右侧后组筛窦、双侧蝶筛隐窝、蝶窦和斜坡的病变内我们发现了更高密度影。这种更高密度影提示这可能是一个良性病变。最后证实这是一个过敏性真菌性鼻窦炎，通常位置靠前，这个病变靠后一些。,7,Allergicfungalsinusitis-unenhancedCT,Ontheleftanother,morecharacteristic,exampleofallergicfungalsinusitis.Thereisbilateralopacificationofthenasalcavities,usuallyasignofaninflammatoryprocessorpolyps.Notetheconcentriclamellatedappearanceofalternatinghyper-andhypodensityinthemaxillarysinusses.Thehyperdensityisduetoinspissatedsecretionsandfungalelements.Thehypodensityreflectscysts,mucosaldisease,andgranulationtissue.Intheethmoidalregionsomeofthehyper-densityreflectsperiostitisandneo-osteogenesisalongtheseptae.这是一个非常典型的过敏性真菌性鼻窦炎的病例。双侧鼻腔浑浊，通常提示炎症或息肉。需要注意观察的是在上颌窦内可以看到高低密度同心层状排列的征象。那么这里的高密度主要是由浓缩的黏液和真菌组成。低密度反映的是囊肿，粘膜疾病和肉芽组织。筛窦内的一些高密度还可以反映骨膜炎和沿着鼻中隔的新生骨形成。,8,Signalcharacteristicsofsecretions,MRIisextremelyhelpfulincomplicatedsinonasaldisease.MRIcandiscernsecretionsandmucosafrommasses.Whenyouunderstandthesignalcharacteristics,youarereadilyabletodistinguishsofttissuesmassesfrominspissatedsecretions.Thesignalintensityofsecretionscanvaryandmainlydependsontheratioofwatertoproteinandtheviscosity.DifferentproteincontentsresultindifferentsignalintensitiesonT1andT2W-images.Fungususuallyhasahighproteincontentofmorethan28%andcanmimicanaeratedsinusbecauseitislowonT1-andT2WI.YouneedCTtomakethedistinction!黏液的特征：MRI对于复杂的鼻腔鼻窦病变是非常有帮助的。MRI可以区分肿瘤与粘液、粘膜。如果掌握了黏液的信号特征，那么是可以将软组织肿块与浓缩黏液进行区分的。黏液的信号可以多样，主要取决于水和蛋白质的比例以及粘滞度。不同的蛋白成分可以导致黏液在T1和T2上信号的不同。真菌的蛋白含量通常超过28%，因此在T1和T2上信号非常低，是鼻窦腔看上去像含气的空腔。此时，需要做的是建议CT。,9,Thesignalintensityofsinussecretionsdependsontheproteincontent不同蛋白含量导致信号不同,10,MRIisalsousefulfordetermininginvasionoftheskullbase.InvolvementoftheskullbaseisseenasreplacementofthehighsignalofthefattymarrowonT1WIbyhypointensesignalofthetumor.Alsolookforforaminalextension,whetherbyperineuralspreadordirectinvasionofthetumor.MRIisalsothestudyofchoicefordetectingintracranialextensionofsinonasaldisease.MRI同样对于判断鼻腔鼻窦病变对颅底的侵犯非常有帮助。信号改变主要表现为：T1上颅底诸骨髓腔内脂肪的高信号被肿瘤的低信号取代。也可以观察肿瘤沿着颅底孔道的播散，不论是沿着神经还是直接侵犯。MRI同样也是判断鼻腔鼻窦病变颅内侵犯的首选。,11,RoleofCTandMRISignalcharacteristicsofsecretions黏液的信号特征Pseudo-pneumatizedsinus假性气化的窦腔Enhancement增强ComplicationsofSinusitisBrainabscessMucoceleOrbitalCellulitisandAbscessComplicationofFESS(Functionalendoscopicsinussurgery)TumorandtumorlikelesionsEncephaloceleMucoceleInvertedpapillomaMalignanttumorsofthesinonasaltractMeningiomaKeratocystSilentsinusFibro-osseousLesionsFibrousdysplasiaOsteitisOsteomaMonitoringresponsetotherapy,12,Pseudo-pneumatizedsinus假性气腔,OntheleftaT2W-imageinanimmuno-compromisedpatientwithfever.InitiallyaMRIwasperformedtoruleoutsinusitis.Noticethelowsignalintensityoftheleftsphenoidsinus,whichalsohadalowsignalintensityontheT1W-image(notshown).ContinuewiththeCT.免疫缺陷患者，发烧。最初的T2像是为了排除鼻窦炎。需要注意的是蝶窦内的低信号，患者的T1上此处也为低信号（没展示）。,13,Pseudo-pneumatizedsinusonMR.Bewareoffungus!,TheCTclearlyshowstheopacifiedsinus,whichisslightlyhyperdense.ThesignalcharacteristicsonMRIandtheattentuationonCTarearesultofthehighproteincontentoffungus.Thisisagoodexampleofthepitfallofthepseudo-pneumatizedsinus.So,wheninvasivefungalinfectionissuspected,startwithaCT,thenmoveontoMRItoruleoutspreadtotheeye,cavernoussinusandintracranialcompartment!这位患者的CT清晰的显示了浑浊的窦腔，内见少量的更高密度。那么，在MRI上T1和T2都低以及CT上的高密度提示这是一个含有高蛋白的真菌性鼻窦炎。这就是一个很好的“假性气腔”的例子。因此，当我们怀疑患者有真菌感染的时候，首先需要进行的检查是CT，然后可以进行MRI检查以观察病变是否侵及眼部、海绵窦和颅内腔。,14,RoleofCTandMRISignalcharacteristicsofsecretions黏液的信号特征Pseudo-pneumatizedsinus假性气化的窦腔Enhancement增强的作用ComplicationsofSinusitisBrainabscessMucoceleOrbitalCellulitisandAbscessComplicationofFESS(Functionalendoscopicsinussurgery)TumorandtumorlikelesionsEncephaloceleMucoceleInvertedpapillomaMalignanttumorsofthesinonasaltractMeningiomaKeratocystSilentsinusFibro-osseousLesionsFibrousdysplasiaOsteitisOsteomaMonitoringresponsetotherapy,15,Enhancement,IngeneralbrightsignalonT2isasignofbenigndisease,sincefluidandmucosaldiseaseusuallyhaveahighwatercontent.Secretionsdonothavesolidenhancement.Ifyouhaveanenhancingmass,youmustruleouttumor.增强的作用：通常情况下在T2上比较亮的病变都是良性的，因为液体或粘膜的病变通常含水非常多。黏液不会出现实性强化。如果肿块出现强化，那么必须排除肿瘤性病变。,16,Ontheleftanexampleofinfectioussinonasaldisease.Onthepre-contrastscanyouseerelativelyhighsignalcontentofthemaxillarysinussesduetoproteineousmaterial.Aftertheadministrationofi.v.contrastthereisonlyenhancementofthecircumferentialmucosaandnosolidenhancement.T1上可见双侧上颌窦内的信号相对鼻腔内的要高一些，主要是由于其含有蛋白成分。增强之后可见只有环形的粘膜强化，没有实性强化。因此这是一个鼻腔鼻窦的感染性病变。,17,OntheCT-imagesthefindingsare:Softtissuemassinthemaxillarysinus(redarrow).Destructionofthesinuswall(yellowarrow).Remodellinganddestructionofthepterygoidbone(bluearrow).Largesofttissuemassinthemasticatorspace(asterisk).CT上可见左侧上颌窦内见软组织肿块（红箭头）。肿块对上颌窦壁有破坏（黄色箭头）。翼骨有膨胀及破坏（蓝色箭头）。在咀嚼肌区可见大的软组织肿块（星号）。,对于比较复杂的病例需要同时进行CT和MRI检查。这名患者肺移植术后出现发热，多发、快速发展的颅神经麻痹。,Theimageontherightismorecranial.Thereisopacificationofthesphenoidsinuswithdestructionandosteopeniaofthesphenoidbone.CTnicelydemonstratesthebonedestructionandsomeofthesofttissueinvolvement.ContinuewiththeMR-images.更上一张CT可见蝶窦窦腔浑浊，窦壁骨质吸收。CT清晰的显示了病变对骨质的破坏和累及的一些软组织。接下来看磁共振。,18,Thefindingsare:Fluidintherightsphenoidsinus(redarrow).Hypointensetissueintheleftsphenoidsinus(yellowarrows).Trackingalongtheduralmarginofthemiddlecranialfossa(bluearrows).Extensionintotheleftzygomatic-masticatorspace(largeyellowarrow).Followingcontrast,thereisnosolidenhancementofthetissueinthesphenoidspace.Continuewiththecoronalimages.与CT相应的MRI层面。可见右侧蝶窦内的液体（红箭头）。左侧蝶窦内低信号的组织（黄箭头）。沿着中颅窝的脑膜蔓延（蓝色箭头）。延伸到左侧颧-咀嚼肌区。（大的黄色箭头）。增强之后，蝶窦内的组织没有出现实性强化。接下来看冠状位。,19,Lymphomaofsphenoidsinusandskullbase,Coronalimagesofthesamepatient:T1pre-andpost-contrast.NormalaspectoftherightMeckelscave,tissueintheleftMeckelscaveextendingintothecavernoussinus(bluearrow).Theredarrowpointstotheduralmarginofthecavernoussinus:thereisenhancementonbothsidesofthedura.Thediseasewrapsaroundthetemporallobe(greenarrow)andextentsdownwardintheforamenovale(yellowarrow)andintothemasticatorspace.Theasterixindicatesnormalnon-enhancingtissueinthemasticatorspace.该患者的冠状位T1和增强。右侧美克耳腔正常，左侧美克耳腔内的组织延伸到海绵窦（蓝色箭头）。红色箭头标出的是海绵窦的硬膜边缘，硬膜双侧都有强化。病变包绕颞叶（绿色箭头），并进入到咀嚼肌区域。星号指出咀嚼肌区正常的没有增强的组织。,20,Thispatienthadalymphoma.Nineoutoftentimesanimmunocompromisedpatientwillhaveafungalinfection,inoneoutoftenitwillbealymphoma.CTandMRhaveacomplimentaryroleinthiscase,butfinallyabiopsyiscalledfortodifferentiatebetweenthesetwodiagnoses,becauseofdifferenttreatment.这个患者最后确诊为淋巴瘤。虽然蝶窦内病变没有实性强化。免疫缺陷患者出现上述影像学表现时，10个人有9个人是真菌感染，剩下的一个人可能就是个淋巴瘤。虽然CT和磁共振可以很好的显示了这两个病变，但最终还是需要活检证实这两种不同的病变，因为采取的治疗不同。,21,RoleofCTandMR(4),Ontheleftimagesofa64-yrs-old,immuno-competentpatient,whohadafollow-upscanforleft-sidedvestibularneuroma.Ontheimageonthelefthypointensetissueisseeninthepterygo-palatinefossaandvideancanal(yellowarrow).Ontheimageontheright,whichismorecranial,thereishypointensetissueinthepterygo-maxillaryfissureandpterygo-palatinefossa.Continuewiththecontrast-enhancedT1W-image.64岁，免疫缺陷患者，这张片子是为了随访听神经瘤而拍摄的。T2像上右侧翼腭窝和翼管处可见低信号病变。右侧的是更上一张，在翼上颌裂和翼腭窝处可见低信号组织。接下来看T1增强。,22,Thereissolidenhancementoftheabnormality.Thedifferentialdiagnosisagainconsistsof2catagories:neoplasmandchronicinvasivefungalinfection.Inanimmuno-competentpatient,aneoplasmismuchmorelikely.ContinuewiththeCT-images.T1增强病变出现实性强化。那么鉴别诊断主要有2方面，肿瘤和慢性侵袭性真菌感染。如果患者没有免疫缺陷，那么更倾向于肿瘤。接下来看CT。,23,ThisisthecorrespondingCT,performednottomakethediagnosis,buttoassesstheconditionoftheadjacentbonystructures,especiallythesphenoidsinus.Also,itservestoguidetheendoscopistforintraoperativebiospy.Thereisextensivedestructionoftheskullbase.相应的CT层面。进行CT检查不是为了做出诊断，而是为了评估病变周围的骨结构，特别是蝶窦的。颅底的骨质有广泛的破坏。患者进行了经鼻内规镜下活检。,24,Thecoronalimageillustratesanormalforamenrotundumontheleft(yellowarrow),whichontherighthasbeenobliteratedbysofttissue.Thereisextensivebonedestruction,andapossibleareaforbiopsyisindicatedbythebluearrow.Atbiopsythediagnosisofaspindlecellcarcinomawasmade.冠状位CT显示左侧圆孔是正常的（黄色）。右侧圆孔被软组织充填。这个部分有广泛的骨质破坏，因此可以作为取活检的位置（蓝色）。最后病理证实是梭形细胞癌。,25,RoleofCTandMRISignalcharacteristicsofsecretions黏液的信号特征Pseudo-pneumatizedsinus假性气化的窦腔Enhancement增强ComplicationsofSinusitis鼻窦炎的合并症Brainabscess脑脓肿Mucocele黏液囊肿OrbitalCellulitisandAbscess眼眶蜂窝织炎和脓肿ComplicationofFESS(Functionalendoscopicsinussurgery)功能性鼻内窥镜术后合并症TumorandtumorlikelesionsEncephaloceleMucoceleInvertedpapillomaMalignanttumorsofthesinonasaltractMeningiomaKeratocystSilentsinusFibro-osseousLesionsFibrousdysplasiaOsteitisOsteomaMonitoringresponsetotherapy,26,ComplicationsofSinusitis,Whenassessingthecomplicationsofsinusitis,CTisexcellentforimagingofsubperiostialabscessesororbitalextensionintotheventral2/3oftheorbit.MRIisnecessaryforassessingintracranialcomplications,suchasbrainorepiduralabscesses,subduralempyemaorsinusthrombosis.CT对于评估鼻窦炎合并症的作用：对于判断骨膜下脓肿和向眶内侧3分之2的扩散非常有帮助。MRI对于评估鼻窦炎合并症的作用：主要评估颅内的合并症，例如脑和硬膜外脓肿，硬膜下积脓或者窦内血栓。,27,Brainabscess,Ontheleftimagesofapatientwasinitiallydiagnosedwithaglioblastomamultiforme.Thereareabnormalitiesinbothfrontallobes.Noticehowevertheabnormaltissueinthefrontalsinus(yellowarrow),subperiostealabscess(redarrow)andthefluid-fluidlevel(greenarrow)inthelargeintracraniallesionwhichhasringenhancement.这名患者最初的诊断是多形性胶质母细胞瘤。双侧额叶异常。值得注意观察的是颅内较大的病变，如额窦内的异常组织（黄色箭头），骨膜下脓肿（红色箭头），和液平（绿色箭头），都是环形强化的。,28,Brainabscess,Allabnormalitiesarecontinuousmeaningthereisfrontalbonydestruction.Therestricteddiffusionalsosupportsthediagnosisofbrainabscess.Thisisasubperiostealabscessandosteomyelitisofthefrontalbone,usuallywithasofttenderswellingoftheforehead.ThisisalsocalledPottspuffytumorafterSirPott,anEnglishsurgeonwhofirstdescribedthisentity.这些异常提示额骨有骨质破坏。弥散像上的表现也符合脑脓肿。额骨的骨膜下脓肿和骨髓炎，通常表现为前额质软、压痛的肿胀，也可以称为波特头皮肿瘤，最初是由一个叫波特的英国医生描述的。,29,Brainabscess(2),Ontheleftimagesofanotherpatient,whohadrecentlybeentreatedforsinusitisandnowpresentedwithaseizure.TheCTshowsanabnormalityinthelefttemporallobewithshaggythickrimenhancement,andalargeamountofvasogenicedema.Thisisalsoabrainabscess,mostprobablyduetorefluxofbacteriaintocranialveinsandthevenousplexusaroundthecavernoussinus.另外一个患者。曾经接受过鼻窦炎的治疗，现在出现了癫痫。CT显示出左侧颞叶的异常并有粗厚的环形强化，和大量的血管源性水肿。这个病变同样也是一个脑脓肿，最有可能的原因是细菌逆流进入海绵窦周围的颅内静脉和静脉丛。,30,RoleofCTandMRISignalcharacteristicsofsecretions黏液的信号特征Pseudo-pneumatizedsinus假性气化的窦腔Enhancement增强ComplicationsofSinusitis鼻窦炎的合并症Brainabscess脑脓肿Mucocele黏液囊肿OrbitalCellulitisandAbscess眼眶蜂窝织炎和脓肿ComplicationofFESS(Functionalendoscopicsinussurgery)功能性鼻内窥镜术后合并症TumorandtumorlikelesionsEncephaloceleMucoceleInvertedpapillomaMalignanttumorsofthesinonasaltractMeningiomaKeratocystSilentsinusFibro-osseousLesionsFibrousdysplasiaOsteitisOsteomaMonitoringresponsetotherapy,31,Mucocele,Ontheleftimagesofapatientwithacutesinusitisandethmoidaircelldisease.Hepresentedwithblurredvision.Firststudytheimages,thencontinuereading.Noticethefluidintheleftanteriorclinoidprocess.Theopticnerverunsmedialtoit.Continuewiththecoronalimages.这个患者患有急性鼻窦炎和筛窦气房病变。主诉是视力模糊。首先在T2上左侧前床突处可见液体，视神经在其内侧走行。接下来看冠状位。,32,Mucocele,ThecoronalT2WIshowsexpansionoftheclinoidprocess.TheT1WIshowslossofnormalfatcomparedwiththerightside,andextensionintotheorbitalapex(redarrow).Thisisamucoceleoftheanteriorclinoidwithsecondaryinvolvementoftheopticnerve.冠状位T2上可见床突的膨胀。T1上可见相较于对侧，左侧床突的髓内脂肪信号消失，并且病变延伸到眶尖（红色箭头）。这是一个前床突的粘液囊肿伴继发累及视神经。,33,RoleofCTandMRISignalcharacteristicsofsecretions黏液的信号特征Pseudo-pneumatizedsinus假性气化的窦腔Enhancement增强ComplicationsofSinusitis鼻窦炎的合并症Brainabscess脑脓肿Mucocele黏液囊肿OrbitalCellulitisandAbscess眼眶蜂窝织炎和脓肿ComplicationofFESS(Functionalendoscopicsinussurgery)功能性鼻内窥镜术后合并症TumorandtumorlikelesionsEncephaloceleMucoceleInvertedpapillomaMalignanttumorsofthesinonasaltractMeningiomaKeratocystSilentsinusFibro-osseousLesionsFibrousdysplasiaOsteitisOsteomaMonitoringresponsetotherapy,34,OrbitalCellulitisandAbscess,LeftisanaxialT1WI,rightisacoronalT2WI.Thereisanabnormalityontheleftside,buttoalesserdegreealsoontheright.Trytodeterminewhichstructuresareinvolved.Theyellowarrowspointtothenaso-lacrimalducts.Thenaso-lacrimalsacconnectswiththeduct,whichthendrainsintotheinferiormeatus.Ontheleftthereisperi-orbitalpre-septalsofttissueswelling.Onthecoronalimagethereisbilateralhighsignalatthejunctionofthenasolacrimalductandsac,indicativeofafluidcollection.左边是轴位T1，右边是冠状位T2。双侧鼻泪管处可见异常，左侧为著。黄色箭头所示的就是鼻泪管。需要考虑的是受累及的组织。鼻泪囊连接鼻泪管，引流至下鼻道。左侧T1上可见眶周眶隔前软组织肿胀。冠状位T2可见双侧鼻泪管和泪囊交界处的异常高信号，提示有液体积聚。,35,OrbitalCellulitisandAbscess,Post-contrastT1WI,axialandcoronal.Lateraltothenaso-lacrimalductsonbothsides,therearethefluidcollectionswhichnowshowperipheralenhancement.增强T1的轴位和冠状位。双侧鼻泪管的外侧积聚的液体表现为周围强化。,36,OrbitalCellulitisandAbscess,Theadditionalimages(T2WI)showmucosaldiseaseoftherightmaxillarysinusandafluidlevelintheleftmaxillarysinus,inadditiontoextensiveethmoidalandsphenoidalsinusdisease.Thispatienthadacutesinusitiswhichwascomplicatedbyorbitalcellulitisanddacrocystitiswithabscesses.Developmentalorinflammatorynarrowingofthenaso-lacr