副鼻窦和邻近结构

1、精选ppt,1,Paranasal Sinuses and Adjacent Spacesby Laurie Loevner and Jennifer Bradshaw,Radiology department of the University of Pennsylvania, USA and the radiology department the Medical Centre Alkmaar, the Netherlands Publicationdate:25-2-2009 副鼻窦和邻近结构,精选ppt,2,Role of CT and MRI Signal characteristi

2、cs of secretions 黏液的信号特征 Pseudo-pneumatized sinus 假性气化的窦腔 Enhancement 增强 Complications of Sinusitis Brain abscess Mucocele Orbital Cellulitis and Abscess Complication of FESS (Functional endoscopic sinus surgery ) Tumor and tumorlike lesions Encephalocele Mucocele Inverted papilloma Malignant tumors

3、 of the sinonasal tract Meningioma Keratocyst Silent sinus Fibro-osseous Lesions Fibrous dysplasia Osteitis Osteoma Monitoring response to therapy,精选ppt,3,Role of CT,CT is of value for determining anatomic landmarks and variants. This information is of vital importance to the ENT-surgeon. In additio

4、n, we need it to identify erosive processes and acquired developmental deficiencies of the bone. 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。,精选ppt,4,CT is also excellent for determining whether there is intraorbital extension of sino-nasal disease in the ventral 2/3 of th

5、e orbit.When pathology approaches the orbital apex, an MRI study is necessary to assess spread to the cavernous sinus and intracranial compartment. CT is performed without contrast medium. If additional imaging is necessary, orbital MRI is the next step. 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

6、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。,精选ppt,5,The real value of unenhanced CT is the following: if you see an opacified sinus with hyperdense contents, it is usually a sign of benign disease. Tumor is not hyper-dense. The hyperdensity is due to one or a combination of the following: inspissated secreti

7、ons fungus blood 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。,精选ppt,6,On the left you see a case that was initially interpreted as a tumor. The hyperdensity is a good prognostic sign, indicating a benign process. This is an example of allergic fungal sinusit

8、is. Usually it is more anteriorly located. 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。,精选ppt,7,Allergic fungal sinusitis - unenhanced CT,On the left another, more characteristic, example of allergic fungal sinusitis.There is bilate

9、ral opacification of the nasal cavities, usually a sign of an inflammatory process or polyps.Note the concentric lamellated appearance of alternating hyper- and hypodensity in the maxillary sinusses. The hyperdensity is due to inspissated secretions and fungal elements. The hypodensity reflects cyst

10、s, mucosal disease, and granulation tissue.In the ethmoidal region some of the hyper-density reflects periostitis and neo-osteogenesis along the septae. 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。,精选

11、ppt,8,Signal characteristics of secretions,MRI is extremely helpful in complicated sinonasal disease. MRI can discern secretions and mucosa from masses. When you understand the signal characteristics, you are readily able to distinguish soft tissues masses from inspissated secretions. The signal int

12、ensity of secretions can vary and mainly depends on the ratio of water to protein and the viscosity. Different protein contents result in different signal intensities on T1 and T2W-images. Fungus usually has a high protein content of more than 28% and can mimic an aerated sinus because it is low on

13、T1- and T2WI. You need CT to make the distinction! 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。,精选ppt,9,The signal intensity of sinus secretions depen

14、ds on the protein content 不同蛋白含量导致信号不同,精选ppt,10,MRI is also useful for determining invasion of the skull base. Involvement of the skull base is seen as replacement of the high signal of the fatty marrow on T1WI by hypointense signal of the tumor. Also look for foraminal extension, whether by perineu

15、ral spread or direct invasion of the tumor. MRI is also the study of choice for detecting intracranial extension of sinonasal disease. 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。,精选ppt,11,Role of CT and MRI Signal characteris

16、tics of secretions 黏液的信号特征 Pseudo-pneumatized sinus 假性气化的窦腔 Enhancement 增强 Complications of Sinusitis Brain abscess Mucocele Orbital Cellulitis and Abscess Complication of FESS (Functional endoscopic sinus surgery ) Tumor and tumorlike lesions Encephalocele Mucocele Inverted papilloma Malignant tumo

17、rs of the sinonasal tract Meningioma Keratocyst Silent sinus Fibro-osseous Lesions Fibrous dysplasia Osteitis Osteoma Monitoring response to therapy,精选ppt,12,Pseudo-pneumatized sinus假性气腔,On the left a T2W-image in an immuno-compromised patient with fever. Initially a MRI was performed to rule out si

18、nusitis. Notice the low signal intensity of the left sphenoid sinus, which also had a low signal intensity on the T1W-image (not shown).Continue with the CT. 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）。,精选ppt,13,Pseudo-pneumatized sinus on MR. Beware of fungus!,The CT clearly shows the

19、 opacified sinus, which is slightly hyperdense. The signal characteristics on MRI and the attentuation on CT are a result of the high protein content of fungus. This is a good example of the pitfall of the pseudo-pneumatized sinus . So, when invasive fungal infection is suspected, start with a CT, t

20、hen move on to MRI to rule out spread to the eye, cavernous sinus and intracranial compartment! 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。,精选ppt,14,Role of CT and MRI Signal characteristics

21、 of secretions 黏液的信号特征 Pseudo-pneumatized sinus 假性气化的窦腔 Enhancement 增强的作用 Complications of Sinusitis Brain abscess Mucocele Orbital Cellulitis and Abscess Complication of FESS (Functional endoscopic sinus surgery ) Tumor and tumorlike lesions Encephalocele Mucocele Inverted papilloma Malignant tumor

22、s of the sinonasal tract Meningioma Keratocyst Silent sinus Fibro-osseous Lesions Fibrous dysplasia Osteitis Osteoma Monitoring response to therapy,精选ppt,15,Enhancement,In general bright signal on T2 is a sign of benign disease, since fluid and mucosal disease usually have a high water content. Secr

23、etions do not have solid enhancement. If you have an enhancing mass, you must rule out tumor. 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。,精选ppt,16,On the left an example of infectious sinonasal disease. On the pre-contrast scan you see relatively high signal conte

24、nt of the maxillary sinusses due to proteineous material. After the administration of i.v. contrast there is only enhancement of the circumferential mucosa and no solid enhancement. 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。,精选ppt,17,On the CT-images the findings

25、are: Soft tissue mass in the maxillary sinus (red arrow). Destruction of the sinus wall (yellow arrow). Remodelling and destruction of the pterygoid bone (blue arrow). Large soft tissue mass in the masticator space (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）

26、。,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。,The image on the right is more cranial. There is opacification of the sphenoid sinus with destruction and osteopenia of the sphenoid bone. CT nicely demonstrates the bone destruction and some of the soft tissue involvement. Continue with the MR

27、-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。,精选ppt,18,The findings are: Fluid in the right sphenoid sinus (red arrow).Hypointense tissue in the left sphenoid sinus (yellow arrows). Tracking along the dural margin of the middle cranial fossa (blue arrows). Extension into the left

28、 zygomatic-masticator space (large yellow arrow). Following contrast, there is no solid enhancement of the tissue in the sphenoid space. Continue with the coronal images. 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。,精选ppt,19,Lymphoma

29、 of sphenoid sinus and skull base,Coronal images of the same patient: T1 pre-and post-contrast. Normal aspect of the right Meckels cave, tissue in the left Meckels cave extending into the cavernous sinus (blue arrow). The red arrow points to the dural margin of the cavernous sinus: there is enhancem

30、ent on both sides of the dura. The disease wraps around the temporal lobe (green arrow) and extents downward in the foramen ovale (yellow arrow) and into the masticator space. The asterix indicates normal non-enhancing tissue in the masticator space. 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

31、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。,精选ppt,20,This patient had a lymphoma. Nine out of ten times an immunocompromised patient will have a fungal infection, in one out of ten it will be a lymphoma. CT and MR have a complimentary role in this case, but finally a biopsy is c

32、alled for to differentiate between these two diagnoses, because of different treatment. 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。,精选ppt,21,Role of CT and MR (4),On the left images of a 64-yrs-old, immuno-competent p

33、atient, who had a follow-up scan for left-sided vestibular neuroma. On the image on the left hypointense tissue is seen in the pterygo-palatine fossa and videan canal (yellow arrow). On the image on the right, which is more cranial, there is hypointense tissue in the pterygo-maxillary fissure and pt

34、erygo-palatine fossa. Continue with the contrast-enhanced T1W-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。,精选ppt,22,There is solid enhancement of the abnormality.The differential diagnosis again consists of 2 catagories: neoplasm and chronic invasive

35、fungal infection. In an immuno- competent patient, a neoplasm is much more likely. Continue with the CT-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。,精选ppt,23,This is the corresponding CT, performed not to make the diagnosis, but to assess the condition of the adjacent b

36、ony structures, especially the sphenoid sinus. Also, it serves to guide the endoscopistfor intraoperative biospy. There is extensive destruction of the skull base. 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。,精选ppt,24,The coronal image illustrates a normal foramen rotundum

37、 on the left (yellow arrow), which on the right has been obliterated by soft tissue. There is extensive bone destruction, and a possible area for biopsy is indicated by the blue arrow. At biopsy the diagnosis of a spindle cell carcinoma was made. 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

38、的位置（蓝色）。最后病理证实是梭形细胞癌。,精选ppt,25,Role of CT and MRI Signal characteristics of secretions 黏液的信号特征 Pseudo-pneumatized sinus 假性气化的窦腔 Enhancement 增强 Complications of Sinusitis鼻窦炎的合并症 Brain abscess脑脓肿 Mucocele 黏液囊肿 Orbital Cellulitis and Abscess 眼眶蜂窝织炎和脓肿 Complication of FESS (Functional endoscopic sinus s

39、urgery )功能性鼻内窥镜术后合并症 Tumor and tumorlike lesions Encephalocele Mucocele Inverted papilloma Malignant tumors of the sinonasal tract Meningioma Keratocyst Silent sinus Fibro-osseous Lesions Fibrous dysplasia Osteitis Osteoma Monitoring response to therapy,精选ppt,26,Complications of Sinusitis,When asses

40、sing the complications of sinusitis, CT is excellent for imaging of subperiostial abscesses or orbital extension into the ventral 2/3 of the orbit. MRI is necessary for assessing intracranial complications, such as brain or epidural abscesses, subdural empyema or sinus thrombosis. CT对于评估鼻窦炎合并症的作用：对于

41、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。,精选ppt,27,Brain abscess,On the left images of a patient was initially diagnosed with a glioblastoma multiforme. There are abnormalities in both frontal lobes.Notice however the abnormal tissue in the frontal sinus (yellow ar

42、row), subperiosteal abscess (red arrow) and the fluid-fluid level (green arrow) in the large intracranial lesion which has ring enhancement. 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。,精选ppt,28,Brain abscess,All abnormalities are continuous meaning there

43、 is frontal bony destruction. The restricted diffusion also supports the diagnosis of brain abscess.This is a subperiosteal abscess and osteomyelitis of the frontal bone, usually with a soft tender swelling of the forehead.This is also called Potts puffy tumor after Sir Pott, an English surgeon who

44、first described this entity. 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。,精选ppt,29,Brain abscess (2),On the left images of another patient, who had recently been treated for sinusitis and now presented with a seizure. The CT shows an abnormality in the left

45、 temporal lobe with shaggy thick rim enhancement, and a large amount of vasogenic edema. This is also a brain abscess, most probably due to reflux of bacteria into cranial veins and the venous plexus around the cavernous sinus. 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

46、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。,精选ppt,30,Role of CT and MRI Signal characteristics of secretions 黏液的信号特征 Pseudo-pneumatized sinus 假性气化的窦腔 Enhancement 增强 Complications of Sinusitis鼻窦炎的合并症 Brain abscess脑脓肿 Mucocele 黏液囊肿 Orbital Cellulitis and Abscess 眼眶蜂窝织炎和脓肿 Complication of FESS (Functional endoscop

47、ic sinus surgery )功能性鼻内窥镜术后合并症 Tumor and tumorlike lesions Encephalocele Mucocele Inverted papilloma Malignant tumors of the sinonasal tract Meningioma Keratocyst Silent sinus Fibro-osseous Lesions Fibrous dysplasia Osteitis Osteoma Monitoring response to therapy,精选ppt,31,Mucocele,On the left images

48、 of a patient with acute sinusitis and ethmoid air cell disease.He presented with blurred vision. First study the images, then continue reading.Notice the fluid in the left anterior clinoid process. The optic nerve runs medial to it. Continue with the coronal images. 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

49、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。,精选ppt,32,Mucocele,The coronal T2WI shows expansion of the clinoid process. The T1WI shows loss of normal fat compared with the right side, and extension into the orbital apex (red arrow). This is a mucocele of the anterior clinoid with secondary involvement of the opti

50、c nerve. 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。,精选ppt,33,Role of CT and MRI Signal characteristics of secretions 黏液的信号特征 Pseudo-pneumatized sinus 假性气化的窦腔 Enhancement 增强 Complications of Sinusitis鼻窦炎的合并症 Brain abscess脑脓肿 Mucocele 黏液囊肿 Orbital Cellulitis and Absce

51、ss 眼眶蜂窝织炎和脓肿 Complication of FESS (Functional endoscopic sinus surgery )功能性鼻内窥镜术后合并症 Tumor and tumorlike lesions Encephalocele Mucocele Inverted papilloma Malignant tumors of the sinonasal tract Meningioma Keratocyst Silent sinus Fibro-osseous Lesions Fibrous dysplasia Osteitis Osteoma Monitoring re

52、sponse to therapy,精选ppt,34,Orbital Cellulitis and Abscess,Left is an axial T1WI, right is a coronal T2WI. There is an abnormality on the left side, but to a lesser degree also on the right.Try to determine which structures are involved.The yellow arrows point to the naso-lacrimal ducts.The naso-lacr

53、imal sac connects with the duct, which then drains into the inferior meatus. On the left there is peri-orbital pre-septal soft tissue swelling. On the coronal image there is bilateral high signal at the junction of the nasolacrimal duct and sac, indicative of a fluid collection. 左边是轴位T1，右边是冠状位T2。双侧鼻

54、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。,精选ppt,35,Orbital Cellulitis and Abscess,Post-contrast T1WI, axial and coronal. Lateral to the naso-lacrimal ducts on both sides, there are the fluid collections which now show peripheral enhanc

55、ement. 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。,精选ppt,36,Orbital Cellulitis and Abscess,The additional images (T2WI) show mucosal disease of the right maxillary sinus and a fluid level in the left maxillary sinus, in addition to extensive ethmoidal and sphenoidal sinus disease. This patient had acute sinusitis which was complicated by orbital cellulitis and dacrocystitis with abscesses. Developmental or inflammatory narrowing o