蝶窦膨出伴脑脊液漏(Pneumocele of the sphenoid sinus with CSF fistula)CT多平面重建病例图片影像诊断分析

鼻窦   2010-11-08

 【临床病史】:患者,男性,34岁,慢性鼻窦炎,头痛、间断性流清亮的鼻涕。34-year-old woman with history of chronic sinusitis, headaches and intermittent clear nasal discharge.

【影像图片】CT图像


【影像表现】:Figure 1: Axial CT in bone windows demonstrates expansion of an air-filled right sphenoid sinus with thinned and eroded walls. Pressure erosions at the base of the right pterygoid process (green arrow), medial wall of the right foramen ovale (red arrow), and anterior surface of the clivus (yellow arrow) are evident.

    图1 轴位的骨窗CT显示显示右侧蝶窦明显的充气膨胀,窦壁变薄受侵。右侧翼状突底部(绿色箭头)、右侧卵圆孔内侧壁(红色箭头)、斜坡的前面(黄色箭头)明显受压侵蚀



Figure 2: Axial CT in bone windows again shows the expanded air-filled right sphenoid sinus. Note that the wall of the right carotid canal is dehisced, leaving the right internal carotid artery (ICA) completely exposed (yellow arrow).

图2:轴位骨窗CT再次显示右侧蝶窦充气膨胀,注意右侧颈动脉管内侧壁受压消失,导致右侧颈内动脉完全暴露出来(黄箭)



Figure 3: Axial CT in bone windows shows narrowing of the right superior orbital fissure (green arrow) by the expanded right sphenoid sinus. Again seen is complete exposure of the right ICA (yellow arrow).

图3:轴位骨窗CT显示右侧眶上裂(绿箭)狭窄,再次注意右侧颈内动脉暴露(黄箭)



Figure 4: Reformatted coronal CT in bone windows demonstrates the expanded air-filled right sphenoid sinus eroding the base of the right pterygoid process and effacing the ipsilateral foramen rotundum (red arrow).

图4:CT冠状位重建像显示明显膨胀充气的右侧蝶窦,侵蚀右侧翼突的基底部并且使得同侧圆孔(红箭)消失。



Figure 5: Reformatted coronal CT in bone windows shows the expanded air-filled right sphenoid sinus eroding the base of the right pterygoid process and effacing the ipsilateral vidian canal (yellow arrow).

图5:CT冠状位重建像显示明显膨胀充气的右侧蝶窦,侵蚀右侧翼突的基底部并且使得同侧维杜斯管(黄箭)消失



Figure 6: Reformatted sagittal CT in bone windows shows the expanded air-filled right sphenoid sinus eroding the clivus (green arrow) and thinning the dorsum sellae (yellow arrow).

图6:重建的矢状位CT显示明显膨胀充气的右侧蝶窦侵蚀斜坡(绿箭),并使得鞍背变薄(黄箭)



Figure 7: Axial image from CT cisternogram demonstrates intrathecal contrast leaking into the expanded right sphenoid sinus along the septum (orange arrow).

图7:轴位CT脑池造影显示硬膜下造影剂沿着中隔渗漏到扩张的右侧蝶窦腔内。



Figure 8: Direct coronal image from CT cisternogram again shows intrathecal contrast leaking into the expanded right sphenoid sinus along the septum (orange arrow). (Note that the image is horizontally flipped).

图8:冠状位的CT脑池造影再次显示硬膜下造影剂沿着中隔渗漏到扩张的右侧蝶窦腔内(橙色箭头)。
 

【影像诊断】:Pneumocele of the sphenoid sinus with CSF fistula 蝶窦膨出伴脑脊液漏

【诊断要点】:Pneumocele is benign abnormal expansion of an air-containing sinus that distinguishes itself from pneumosinus dilatans (PSD) by wall thinning and erosion. 窦膨出是副鼻窦的一种良性异常含气扩张,这种扩张是超出了所谓的扩张性气化,伴有窦壁变薄、侵蚀。

    Clinical presentations vary depending on the sinus or sinuses involved and the degree of expansion and wall erosion. 临床表现依据受累的副鼻窦和窦腔以及扩张及窦壁受侵的程度不同而不同。

    Careful patient preparation and acquisition of direct axial and direct coronal images will optimize detection of CSF fistulas with CT cisternography.完善的准备,并通过获取直接的轴位和冠状位图像,将会优化CT脑池造影对脑脊液漏的检测。

【讨论】:The term pneumocele refers to an aerated sinus that is enlarged beyond normal anatomic margins and whose walls demonstrate focal or diffuse wall thinning or erosion. Pneumosinus dilatans also describes abnormal sinus expansion but with normal wall thickness and integrity. Several past articles on this topic have used the term pneumosinus dilatans to describe an abnormally expanded sinus with or without bony erosion, favoring a single term to describe what the authors believed to be variations of the same entity. We prefer to distinguish between the two entities based on the presence or absence of bony wall thinning or erosion. Nevertheless, both of these lesions can occur in any sinus, but the maxillary sinus is most commonly involved by pneumoceles, whereas the frontal sinus is most commonly affected by pneumosinus dilatans. In contrast, pneumocele of the sphenoid sinus is a rare lesion.

    术语“窦膨出“是指一个含气的窦腔异常的扩大,超过了其正常的解剖学边界,并且其窦壁显示局限性或弥漫性的变薄或侵蚀。而扩张性气化是用来描述异常扩张的窦腔,但窦壁完整,厚度正常。过去一些文献使用术语扩张性气化来描述窦腔异常扩张伴有或不伴有骨质的侵蚀,这些作者认为这两者是同一种病变的不同类型,我们更倾向于根据是否存在窦壁的变薄或侵蚀来区分这两者。尽管这两者病变都可以发生在任何的窦腔,但是窦膨出最常见于上颌窦,而扩张性气化最常见于额窦。相反,蝶窦的膨出是一种少见的病变。

    Pneumoceles may occur suddenly, presumably by a trap-valve mechanism or by rupture of a large mucocele. In contrast, pneumosinus dilatans tend to develop chronically. However, the etiology and pathogenesis of pneumosinus dilatans are still poorly understood. Proposed theories of sinus hyperpneumatization include infection with gas-forming microorganisms, hormonal influences, and congenital defects. Pneumosinus dilatans are usually incidental findings, but have been associated with various disorders including but not limited to fibrous-osseous dysplasia, Klippel-Trenaunay, hydrocephalus and arachnoid cysts. Pneumosinus dilatans of the sphenoid sinus may also be the first sign of a meningioma of the planum sphenoidale or tuberculum sellae.

    窦膨出可见突然发生,大概是一种滤网机制或者是一个大的黏液囊肿破裂所致。相反,扩张性气化通常是慢性的过程,然而,扩张性气化的病因学和发病机制目前尚不清楚,窦腔过度扩张的可能理论包括产气微生物的感染、激素影响,先天性缺陷。扩张性气化通常是偶尔发现,但是常常伴有多种异常,包括但不限于骨纤维形成不良,Klippel-Trenaunay综合症,脑积水和蛛网膜囊肿。蝶窦的扩张性气化也可能是蝶骨平面或鞍结节脑膜瘤的第一征像。

    The clinical severity of symptoms depends upon the sinus or sinuses involved and will guide patient management. Reported manifestations of pneumoceles, and similarly of pneumosinus dilatans, include but are not limited to headaches, frontal bossing, exophthalmos, vision loss, and CSF rhinorrhea. Based on the presumed etiology of a trap-valve mechanism, the surgical treatment of pneumoceles includes opening the affected sinus directly into the nasal cavity via transnasal endoscopic approach. In our case of sphenoid pneumocele with associated CSF fistula, the sphenoid sinus was packed with subcutaneous abdominal fat using transnasal endoscopic technique.

    临床症状的严重性取决于受累的副鼻窦或窦腔,并且也会影响病人的处理。窦膨出的临床表现,扩张性气化同样类似,包括但不限于头痛、额部隆起,眼球突出,视觉丧失,脑脊液鼻漏。基于滤网机制的假定理论,窦膨出的外科处理包括通过经鼻内窥镜检查将受累的窦腔开放并直接通向鼻腔。我们的病例采用经鼻内窥镜将腹部的皮下脂肪填充至蝶窦腔内。

(参考来源:,ACR Friday, May 22, 2009,作者:freemanpyw译)
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