医学影像学课件：涎腺疾病的影像学诊断

1、涎腺疾病的影像学诊断 病史检查影像学细针吸活检唾液流率生化Imaging diagnosis of salivary diseases introduction病史涎腺疾病相关症状疼痛肿胀，肿块口腔干燥唾液过多味觉异常全身疾病/用药史/手术史/放射治疗Imaging diagnosis of salivary diseases introduction检查视诊肿胀神经损害情况口腔粘膜导管口扪诊腺体大小、质地、压痛肿块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线平片结石相关骨改变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显示导管系统的形态以导管系统改变为主要表现的疾病复发性腮腺炎口干综合征阻塞性炎症唾液腺瘘发育异常治疗作用水溶性造影剂油溶性造影剂禁忌证局限：造影剂的使用，患者不适，插管困难，影像重叠约21%的腮腺标本可见副腺体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正电子发射型断层计算机(Positron emission tomography, PET)PET-CT功能代谢成像和解剖成像同机融合放射性示踪剂18F-氟脱氧葡萄糖(18fluorine-fluorinedeoxyglucose, 18F-FDG)肿

9、瘤细胞增殖迅速，代谢旺盛，葡萄糖利用高于正常组织1931年Warburg报告肿瘤细胞摄取高于正常组织肿瘤恶性程度与摄取呈正相关明确原发灶早期、准确确定肿瘤位置和局部淋巴结转移准确度88%，敏感度100%，特异度77%肿瘤分期划定放疗靶区，提高精确性观察疗效、复发、转移18F-FDG不是肿瘤特异性显像剂炎症肉芽组织唾液腺组织腮腺良性肿瘤费用超声检查唾液腺位置表浅，适于超声检查成像原理高频换能器，近场分辨率好，穿透能力差唾液腺肿瘤的首选检查方法唾液腺结石主要优点：无辐射，无创伤，无痛苦，易于反复检查，操作简便正常表现Imaging diagnosis of salivary diseases ul

10、trasound正常回声表现，横切面与纵切面，换能器频率CT软组织分辨率好可观察相关骨质改变及钙化空间分辨率高多方向观察，三维重建显示病变位置、范围、与周围组织结构的关系成像速度快强化扫描可显示血管影像和病变的强化特征辐射造影剂伪影组织HU脑脊液、水0脂肪100软组织5060血液3550腮腺1030下颌下腺3060舌下腺6090骨1000肺850气体1024钙化150200灰质3540PK Jacob，2008腮腺密度1030HU，高于脂肪，低于肌肉，随增龄有改变CTA观察血管结构术前观察病变的血供情况制定手术计划，减少出血，是否需要术前栓塞CTSMRI 软组织分辨率优于CT 强化扫描有助于增

11、强软组织分辨能力功能成像动态增强MRI（DCEMRI）弥散加权成像（DWI）波谱成像（MRS）局限扫描时间长伪影禁忌Imaging diagnosis of salivary diseases腮腺在胚胎第六周开始发育起源于上下颌突分叉处的外胚层上皮颌下腺在胚胎第六周末开始发育起源于颌舌沟近外侧的内胚层上皮舌下腺在第78周开始发育起源于颌舌沟近外侧的内胚层上皮涎腺发育异常唾液腺先天缺失1885年，Gruber首次在尸检中发现涎腺缺失全部大涎腺（腮腺和颌下腺）缺失，或部分缺失，有报告大、小涎腺均缺失(Otsuni PA, 1995)M/F=2/1家族史，可伴有其他畸形尸检可见脂肪和疏松结缔组织没有

12、影像检查手段以前，靠触诊、导管口、唾液分泌情况诊断CT (misdiagnosis resulting from the inclination of the scanning plane)、MRI、US、核医学涎腺缺失应与以口干为主要症状的疾病鉴别 (serum studies and biopsy)静止性骨腔（Stafne骨腔）1942年首次报告35 cases圆形、类圆形，边界清楚单房，低密度下颌管以下下颌第一磨牙和下颌角之间位置恒定，形态具有特点多无症状男性多见，中老年人多见舌侧骨板消失与颌下腺延续命名较多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发生率0.1% 0.48%唾液腺异位临床可表现为肿块、涎瘘，涎瘘可与进食有关垂体、中耳、外耳、下颌骨、甲状舌管、甲状腺、颈部（胸锁乳突肌前缘）多可双侧发生儿童期就诊，甚至出生时即可见与副腺体、鳃裂囊肿、肿瘤鉴别唾液腺结石病发生在唾液腺导管及腺体内的结石，继发炎症

14、改变下颌下腺80%，腮腺10%，舌下腺及小唾液腺10%早期无症状，腺体反复肿胀，与进食有关，进食后可缓解，导管口红肿，脓性分泌，检查可及结石，触痛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阴性结石 充盈缺损 filling defect 主导管扩张 frequently more or less dilated ductal system Imaging diagnosis of salivary diseases sialolithiasisImaging diagnosis of salivary diseases sialolithiasis鉴别阻塞性炎症颌下区淋巴结钙化血管畸形舌下腺肿瘤鉴别诊断Imaging diagnosis of salivary diseases fistula唾液腺瘘 fistula多数为获得性：创伤，手术（医源性），恶

17、性肿瘤，炎症少数为先天性可发生于腮腺、颌下腺、异位腺体或副腺体可发生于耳周、颊部、口腔粘膜及颈部可伴有附耳等其它畸形临床可见瘘口，口内瘘，口外瘘瘘口可见分泌，清亮或混浊，进食时明显影像学：造影检查，瘘道造影，唾液腺造影，可结合CTWK Moon, et al. Congenital fistula from ectopic accessory parotid gland: diagnosis with CT sialography and CT fistulography. AJNR 1995唾液腺炎症性疾患流行性腮腺炎唾液腺结石病急性化脓性腮腺炎慢性下颌下腺炎慢性阻塞性腮腺炎放射性唾液腺炎唾

18、液腺结核俞光岩 马大权：唾液腺病学 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儿童复发性腮腺炎Juvenile recurrent patotitis, recurrent acute p

20、arotitis儿童患者中第二位好发的唾液腺疾病，仅次于流行性腮腺炎，有时二者难于鉴别临床表现：腮腺反复肿大，疼痛，与进食无关；可单侧发生，也可以双侧发生，其中一侧症状明显；可见混浊或脓性分泌发病相关因素：导管发育缺陷，遗传，病毒或细菌感染，过敏，自身免疫病的局部表现，多因素发病年龄平均最小最大3.8男3.35个月6女4.737O Nahlieli, 2004儿童复发性腮腺炎抗生素治疗，唾液腺内窥镜治疗预防措施：局部按摩，chewing gum，促进唾液分泌，导管冲洗影像学检查：唾液腺造影末梢导管扩张，主导管可扩张，副腺体可累及，排空功能迟缓，非症状侧也可出现，73%可见对侧腺体影像表现唾液腺

21、内窥镜可见主导管管壁发白唾液腺造影可改善症状有自限性，部分迁延至成年期Imaging diagnosis of salivary diseases inflammation4岁到18岁10岁到15岁adult鉴别诊断流行性腮腺炎副粘液病毒全身症状重，发热，乏力，头痛，寒战终生免疫儿童口干综合征气泡性腮腺炎淋巴瘤HIV阻塞性唾液腺炎唾液流出受阻引起腮腺反复肿胀etiology: calculus, stricture, mass, foreign body, infectionClinical反复肿胀，与进食有关咸味分泌导管口红肿，分泌混浊或脓性Sialography：duct dilation

22、Imaging diagnosis of salivary diseases inflammation唾液腺结核 tuberculosis好发于腮腺，单侧多见多见于腮腺淋巴结核，也可发生于腺实质结核菌感染，牙槽窝、扁桃体感染，导管系统多见于使用免疫抑制剂的患者诊断困难，切取活检可发生慢性瘘口急性、慢性感染，与唾液腺炎症、肿瘤不易鉴别可无症状，包块，腺体肿大，瘘管，面瘫ESR，FNAC影像：造影，超声，CTImaging diagnosis of salivary diseases tuberculosisImaging diagnosis of salivary gland diseases:

23、 salivary gland tumors唾液腺肿瘤口腔颌面部肿瘤的23.9%，13人/10万病理类型复杂临床表现良性肿瘤：生长缓慢，无自觉症状，活动度好影像学检查方法形态：CT、MRI、超声波功能：核医学，MRSSalivary tumors ultrasound形态边界内部回声后方回声多形性腺瘤多形性腺瘤Warthins tumorBilateral parotid glands腺淋巴瘤横纹肌肉瘤多形性腺瘤Imaging diagnosis of salivary diseases tumors粘液表皮样癌CT良性肿瘤类圆形、结节状软组织肿块边界清楚，均匀强化或环形强化可有囊变及钙化恶性

24、肿瘤形态呈结节状或不规则形，边界不清楚，脂肪、筋膜界面模糊消失密度不均匀颈部淋巴结骨破坏定位能力强化扫描可清楚显示肿瘤范围及强化特性，显示肿瘤和血管及周围结构的关系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恶性混合瘤Malig

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

27、I软组织分辨率好多方向、多层面显示流空现象有助于大血管的显示定位能力功能成像Imaging diagnosis of salivary diseases tumorsT1 weighted images 观察组织器官的解剖结构 正常腮腺信号强度介于肌肉和脂肪之间 信号均匀 密质骨无信号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信号强度不均匀边界不清楚，侵犯相邻组织高度恶性肿瘤T1T2为低信号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摄取99m Tc-pertechnetate与肿瘤上皮成分有关排空期放射性核素滞留Imaging diagnosis of salivary diseases tumors舍格伦综合征 Sjogrens syndrome系统性自身免疫病多器官受累，外分泌腺破坏为特征原发性：不合并其它自身免疫病继发性：合并类风湿性关节炎、系统性红斑狼疮女性多发，最常见的临床表现为口干、眼干和唾液腺肿大口腔干燥猖獗龋腮腺肿大舌裂，舌乳头萎缩念珠菌感染欲哭无泪Imaging diagnosis of sal

33、ivary diseases Sjogrens syndrome系统性表现皮肤：过敏性紫癜、结节性红斑、雷诺现象骨骼肌肉：关节痛、肌炎肾：肾小管酸中毒、肾小球损害肺：间质性病变消化系统：萎缩性胃炎、肝损害、胰腺炎神经：周围神经损害血液系统：淋巴肿瘤，血小板减少诊断方法泪腺功能Schirmer test角膜染色泪膜破裂时间唾液腺功能唾液流率唾液腺造影核医学检查活体组织检查免疫学高丙种球蛋白血症免疫球蛋白自身抗体干燥综合征国际分类（诊断）标准2002年修订版I 口腔症状：3项中有1项或1项以上每日感到口干持续3个月以上成年后腮腺反复或持续肿大吞咽干性食物时需用水帮助II 眼部症状：3项中有1项或1

34、项以上每日感到不能忍受的眼干持续3个月以上有反复的沙子进眼或沙磨感觉每日需用人工泪液3次或3次以上III 眼部体征：下述检查任1项或1项以上阳性Schirmer I 试验+（5mm/5分，不采用角膜麻醉方法）角膜染色+（4 van bijsterveld计分法）IV 组织学检查：下唇腺病理示淋巴细胞灶1V 唾液腺受损：下述检查任1项或1项以上阳性静止唾液流率+（1.5ml/15分）腮腺造影+唾液腺同位素检查+VI 自身抗体：抗SSA或抗SSB+（双扩散法）原发性干燥综合征：无任何潜在疾病的情况下，有下述2条则可诊断符合上述条目中4条或4条以上，其中必须含有组织学检查和自身抗体眼部体征、组织学检查、唾液腺受损和自身抗体4条中任3条阳性继发性干燥综合征：患者有任一结缔组织病，有口腔症状或眼部症状中任1条，同时符合眼部体征、组织学检查和唾液腺中任2条应除外颈头面部放疗史、丙肝病毒感染、AIDS，淋巴瘤、结节病、GV