额窦黏液囊肿(Frontal sinus mucocele)CT病例图片影像诊断分析

鼻窦   2010-11-29

 【临床病史】:患者,男性,60岁,既往有双侧深静脉血栓和慢阻肺病史,现在出现右侧眼球突出,病人主诉眼眶骨痛,发热,视力异常。60-year-old male presents with a past history of bilateral DVTs and COPD. The patient now presents with new onset of right eye proptosis. The patient complains of orbital pain, fever, orbital discharge, and visual changes.

【影像图片】MRI图像


额窦黏液囊肿额窦黏液囊肿

额窦黏液囊肿额窦黏液囊肿

额窦黏液囊肿

【影像表现】:There is a large, expansile mass in the right frontal sinus (red arrow) crossing the midline, measuring 2.3 x 5.7 x 3.8 cm (AP, transverse, cephalocaudad dimensions). This mass extends inferiorly into the right orbit, pushing the right globe inferiorly and anteriorly. There is discontinuity of the ethmoidal margin (blue arrow). However, there is no definite extension of the mass into the brain parenchyma. These findings are consistent with a frontal sinus mucocele. Also noted is extensive sinus disease involving the other visualized paranasal sinuses.右侧额窦可见一大团状膨胀性肿块(红箭),跨越中线,大小月2.3×5.7×3.8cm,肿块向下扩展至右侧眼眶,向下前方推移右侧眼球,筛骨边缘不连续(蓝箭),然而,没有明显证据显示肿块扩展至颅内脑实质,这些表现符合额窦粘液囊肿。同时请注意其他副鼻窦广泛的病变。

额窦黏液囊肿

【影像诊断】:Frontal sinus mucocele额窦黏液囊肿

【诊断要点】:Mucoceles are encapsulated, expansile fluid collections in the paranasal sinuses which occur due to obstruction of a paranasal sinus ostium. 粘液囊肿是副鼻窦内一种包裹性,膨胀性囊性病变,是由于鼻旁窦窦口被阻塞所引起。

   Important complications include extension of the mucocele into the orbital or cranial cavity, resulting in various intracranial and ocular symptoms. 重要的并发症包括囊肿扩展到眼眶或颅内导致相应的颅内和视觉症状

   The treatment of choice is surgical, and long-term follow up for recurrence is important. 通常采用外科方式,长期的随诊以防止复发是非常重要的。

【讨论】:A mucocele is an encapsulated fluid collection which occurs due to obstruction of a paranasal sinus ostium. Obstruction of a sinus ostium can occur secondary to chronic sinus inflammation, trauma, surgery, chronic sinus polyposis and tumors such as an osteoma. In children, there may be a history of cystic fibrosis.粘液囊肿是副鼻窦内一种包裹性,膨胀性囊性病变,是由于鼻旁窦窦口被阻塞所引起。副鼻窦窦口阻塞可以是有慢性的副鼻窦炎、创伤、外科手术、慢性的副鼻窦息肉以及肿瘤如骨瘤等所引起,儿童可能会有囊性纤维化的病史。

   Mucoceles are important diagnoses to make due to their expansile nature. They have the ability to erode through adjacent bones, including the base of the skull to result in intracranial extension. Mucoceles can also involve the orbital cavity, resulting in proptosis and displacement of the globe. Orbital involvement may also affect branches of cranial nerve III. They can become inflamed and fill with pus (pyocele) or pus and mucus (mucopyocele). Clinically, patients experience symptoms which occur as a result of localized mass effect and inflammation. Depending on the extent of the mucocele and the paranasal sinus affected, patients may present with intractable headaches, orbital discomfort, decreased visual acuity, a visual field defect, and facial pain.

   由于其膨胀性生长的特性,确诊粘液囊肿是非常重要的。它们可以侵蚀邻近的骨质,包括颅底骨从而侵犯到颅内。粘液囊肿也可以累及眼眶,导致突眼及眼球移位,眼眶受累也可以影响到动眼神经的分支。它们可以发炎并充填以脓液或粘液。临床上,病人所表现的症状依据于局部的占位效应和炎性反应。根据粘液囊肿的扩展以及副鼻窦的受累情况,病人可以出现头痛、眼眶不适、视敏度下降、视野缺损以及面部疼痛。

   Plain film radiographs of the sinuses will reveal smooth, expansile enlargement of the affected paranasal sinus. The adjacent bone may also be thinned secondary to the expansile nature of the lesion. The sinus is typically completely opacified. Further work-up includes a CT of the maxillofacial bones, which will reveal a uniform non-enhancing, low-attenuating expansile mass in the paranasal sinus. There may be regions of hyperdensity within the lesion representing inspissated mucus. There may also be bone remodeling and thinning but without evidence for bone destruction. T1-weighted MR images depict mucoceles as an expansile and hyperintense abnormality of the affected paranasal sinus. T2-weighted MR images further characterize a mucocele as a hyperintense lesion with greater signal intensity than that seen on the T1-weighted images. The signal intensity will further depend on the state of hydration and contents within the mucocele (protein, hemorrhage, and calcification).

   鼻窦平片可以表现为受累的副鼻窦光整的膨胀性扩大。继发于病变的膨胀性特性,邻近的骨质可以变薄。通常整个副鼻窦的密度增高。更进一步的检查包括上颌骨CT扫描,表现为副鼻窦腔内均匀的无强化低密度的膨胀性肿块。病灶内的高密度区域可能代表浓缩的黏液。可以出现骨重塑和变薄,但不会有明显的骨质破坏。MRT1序列显示为膨胀性的高信号病变,T2显示的更有特征性,表现为高信号,且比T1序列上信号更高。黏液的内容物(蛋白、出血、钙化)以及水合程度对于信号的强度有更明显的影响。

    The preferred treatment of mucoceles is surgery with sinus reconstruction. Surgical treatment includes conservative options (marsupialization of the mucocele) and radical options (removal of the mucosa and obliteration of the sinus). If possible, it is important to re-establish sinus drainage to prevent mucocele recurrence. The resected mucosa may be normal or demonstrate areas of squamous metaplasia. Endoscopic sinus surgery has played a larger role in management of mucoceles in recent years. Despite surgery, mucoceles often recur, warranting long-term follow-up.

    粘液囊肿的首选治疗方式是外科手术并副鼻窦再造,外科手术包括保守的方式(粘液囊肿的造袋术)和激进的方式(黏液切除以及副鼻窦的重塑)。假如可能,需要重建副鼻窦的排出口以防止粘液囊肿的复发。切下来的粘液囊肿可以是正常的,也可以有部分的鳞状化生。在近几年,副鼻窦内窥镜手术扮演了一个更大的角色。即使是采用外科手术,粘液囊肿也常常复发,需要一个长期的随诊。

(参考来源:,ACR, February 10, 2009,作者:freemanpyw译)
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