Carotid artery and jugular vein invasion of oral-maxillofacial and neck malignant tumors: diagnostic value of computed tomography

OBJECTIVE: This study aimed to disclose the diagnostic value of computed tomography (CT) images in detecting carotid artery and jugular vein invasion by oral-maxillofacial and neck malignant tumors.Study design Forty-three patients (44 tumors) who had had enhanced CT examination before surgical treatment of oral-maxillofacial and neck malignant tumors were evaluated. The CT manifestations of all tumors were retrospectively compared with the surgical findings. RESULTS: Surgical findings recorded that the oral-maxillofacial and neck tumors adhered to 11 of 44 common carotid arteries (CCA) or internal carotid arteries (ICA) and 25 of 44 jugular veins (JV). The abnormal CT manifestations of the 44 oral-maxillofacial and neck malignant tumors with CCA, ICA, and JV involvement consisted of 6 types: type I, compression and deformation of CCA or ICA in 4 tumors and JV in 28 tumors; type II, obliteration of IJV on segmental axial CT views in 13 tumors; type III, displacement of CCA or ICA in 14 tumors and JV in 18 tumors; type IV, tumor encasement of greater than 180 degrees of the circumference of the carotid vessels in 5 tumors; type V, the segmental deletion of fat or fascial planes between tumor and CCA or ICA in 16 tumors and JV in 33 tumors; and type VI, ill-defined CCA or ICA wall in 7 tumors. The respective sensitivity, specificity, and accuracy were 36.4%, 100%, and 84.1% for compression and deformation of CCA or ICA; 84%, 63.2%, and 75% for compression and deformation of JV; 52%, 100%, and 72.7% for obliteration of JV in segmental axial CT views; 36.4% to 52%, 53.8% to 69.7%, and 61.4% for displacement of CCA or ICA and JV; 18.5%, 100%, and 50% for tumor encasement of greater than 180 degrees of the circumference of the carotid vessels; 90.9%, 81.8%, and 84.1% for partial fat or fascia deletion between tumor and CCA or ICA; 92%, 47.4%, and 72.7% for partial fat or fascia deletion between tumor and JV; and 36.4%, 90.9%, and 77.3% for ill-defined CCA or ICA wall. CONCLUSIONS: Various CT findings are of value in the diagnosis of oral-maxillofacial and neck malignant tumors that affect the carotid arteries and jugular veins. Comparatively, the signs of compression and deformation of the CCA or ICA, segmental obliteration of the JV, undefined CCA or ICA wall, and fat or fascial plane deletion between a tumor and the CCA or ICA may be valuable in diagnosing ICA and JV invasion, although accurate diagnosis of CCA or ICA involvement by the oral-maxillofacial and neck malignant tumors remains difficult.     

上颈部淋巴结恶性肿瘤影响颈鞘的CT评价

目的：评价上颈部淋巴结恶性肿瘤影响颈鞘的CT表现。方法：收集经手术和活检病理证实的上颈部淋巴结恶性肿瘤病例77例(83例病变),并对其在CT上显示的影响颈鞘及其内部血管的形式进行分类和评价。结果：CT上,病变对颈鞘及其内部血管影响的表现主要有：①颈鞘内血管受压变形者52例病变(颈内动脉1例;颈内静脉51例);②颈鞘内血管受压“消失”者13例病变(均为颈内静脉);③颈鞘内血管受压移位者67例(颈内动脉22例,颈内静脉50例);④淋巴结恶性肿瘤围绕颈鞘血管者15例。结论：上颈部淋巴结恶性肿瘤对颈鞘内部血管的影响主要表现为推移和受压变形。判断病变是否侵犯颈鞘及其内部血管,应综合考虑其CT影像表现。     

头颈部副神经节瘤64-MSCT、CTA及DSA诊断和手术治疗

目的：通过对10例头颈部副神经节瘤患者诊断及治疗回顾性分析,探讨64排螺旋cT（64-MSCT）、CT血管造影（CTA）及数字减影血管造影（DSA）在头颈部副神经节瘤诊治中的作用及手术过程。方法：自2003年1月至2007年12月我科收治的10例头颈部副神经节瘤患者,其中6例为颈动脉体瘤,3例为颈静脉球瘤,1例为迷走神经副神经节瘤,对其分别进行了64-MSCT、CTA或DSA检查,对其影像学进行分析,对于手术情况进行总结。结果：64-MSCT、CTA及DSA图像清楚显示头颈部副神经节瘤的位置、大小、边界、肿瘤特征性表现及与颈动脉的关系,可为手术提供重要的信息。64-MSCTA重建图像清晰,可直观、立体、多角度的显示肿瘤与颈动脉的关系。对10例患者成功地实施了手术,除1例患者偶有头晕,1例患者术后偶有呛咳外,其他8例患者恢复良好。结论：64-MSCT、CTA及DSA影像可为头颈部副神经节瘤的诊断、术前准备、危险性评价及手术提供重要的信息。术前准备完善、术中操作严谨是手术成功的关键。     

咽旁间隙区肿瘤的临床特征及其诊断与治疗-附115例报告

目的　探讨咽旁间隙区肿瘤的临床特征及其诊断和治疗。方法　对收治的115例咽旁间隙区原发性肿瘤的临床表现、病理类型及诊治方法等进行了回顾性分析和研究。结果　本组115例咽旁间隙区原发性肿瘤中良性 99例,恶性16例。最常见者为腮腺深叶肿瘤(46例)及神经源性肿瘤(42例)。临床多表现为颈部或咽侧包块并伴有不同程度的吞咽、呼吸或语言功能障碍。CT或MRI能清楚显示肿块的大小、形态、位置、与周围结构的关系及继发改变;超选择性颈动脉造影能揭示肿瘤与血管系统的关系。本组肿瘤均经颌后-颌下径路切除。术后随访1~10年,2 例死亡,18例失访,余均治愈无复发。结论　CT、MRI或颈动脉造影对咽旁间隙区肿瘤的术前诊断及治疗设计有重要意义。经颌后-颌下径路切除咽旁间隙区肿瘤简易、安全而有效。     

血管纵向缩缝联合显微血管吻合术重建颈内静脉

目的 探讨晚期口腔癌患者颈部转移淋巴结累及双侧颈内静脉时血管的处理新方式。方法 采用显微血管吻合术和血管纵向缩缝术相结合的方法重建颈内静脉。当晚期口腔癌患者的双侧颈内静脉均与周围可疑癌转移的淋巴结粘连紧密时,可以节段性切除颈内静脉,采用颈外静脉重建颈内静脉,或仅切除部分颈内静脉血管壁;同时对颈内静脉的近心端和远心端纵向缩缝,使静脉管径均匀变化。选择5例接受双侧根治性颈淋巴清扫手术治疗的口腔鳞状细胞癌患者,采用该方法重建颈内静脉,观察手术效果。结果 5例患者术后均未出现因静脉回流不畅导致的面部水肿、咽喉部水肿、脑水肿、颅内高压等严重并发症,未出现颈内静脉栓塞。术后随访5~19个月,采用多普勒或CT血管造影等检查颈内静脉的通畅情况,均未发现栓塞。5例患者的1年生存率为60%（3/5）。结论 血管纵向缩缝联合显微血管吻合术是一种有效的处理颈部转移淋巴结累及双侧颈内静脉时的新方法,该方法具有良好的效果及可行性。     

64-MSCT及CTA对颈动脉体瘤和神经鞘瘤的诊断意义

目的:通过影像学分析,探讨64排螺旋CT(64-MSCT)、CT血管造影(CTA)在颈动脉体瘤和神经鞘瘤诊断和鉴别诊断中的应用。方法:对2006-03—2008-07来我院就诊的5例颈动脉体瘤和11例颈部神经鞘瘤患者进行64-MSCT及CTA检查,并对其影像学特征进行分析。结果:64-MSCT、CTA图像可清楚显示颈动脉体瘤和神经鞘瘤的影像学特征。64-MSCTA重建图像清晰,可直观、立体、多角度地显示肿瘤与颈内、外动脉的关系。颈动脉体瘤位于颈动脉分叉处,肿瘤使颈内、外动脉移位,颈内、外动脉夹角变大,呈典型的"杯口状"影像。神经鞘瘤位于颈动脉的深面,肿瘤使颈动脉向前、外移位,颈总动脉分叉角度无明显改变,肿瘤与颈动脉无粘连。结论:颈动脉体瘤与神经鞘瘤具有不同的影像学特征,64-MSCT、CTA在颈动脉体瘤及神经鞘瘤诊断与鉴别诊断中具有重要的临床价值。     

颌面颈部恶性肿瘤侵犯颈动脉的CT诊断

目的　研究颌面颈部恶性肿瘤侵犯颈动脉的CT诊断价值。方法　共收集记录完整、经手术切除治疗的颌面颈部恶性肿瘤 5 3例 (5 5侧病变 )。所有病例均在术前行横断面增强CT检查 ,并与其手术结果对照。结果　CT检查显示颈动脉的异常表现形式有 5种类型 :Ⅰ型 :动脉受压变形(6侧病变 ) ;Ⅱ型 :动脉移位 (15侧病变 ) ;Ⅲ型 :肿瘤围绕颈部血管超过 180°(8侧病变 ) ;Ⅳ型 :位于肿瘤和颈动脉之间的脂肪带或筋膜部分或完全消失 (2 5侧病变 ) ;Ⅴ型 :动脉壁缘模糊 (12侧病变 )。手术记录显示 :2 0侧颌面颈部恶性肿瘤与颈动脉粘连 ,其中 14侧病变的CT异常表现呈多样性 (70 % )。对照手术记录 ,上述CT异常表现的敏感性、特异性和准确率分别为 :30 0 % ,10 0 0 %和 74 .5 % (Ⅰ型 ) ;2 0 .0 % ,6 8.6 %和 5 0 .9% (Ⅱ型 ) ;2 2 .2 % ,10 0 .0 %和 4 9.1% (Ⅲ型 ) ;90 0 % ,80 0 %和 83.6 % (Ⅳ型 ) ;4 5 0 % ,88.6 %和 72 .7% (Ⅴ型 )。结论　颌面颈部恶性肿瘤侵犯颈动脉的CT表现以多样性表现为主。尽管存在不足 ,但部分CT征象 (Ⅰ型、Ⅲ型和Ⅳ型 )对准确判断颌面颈部恶性肿瘤侵犯颈动脉仍具有一定的参考价值     

动态增强扫描在颈侧区肿块鉴别诊断中的应用

目的：研究利用颈侧区肿块在动态增强扫描的影像特征进行手术前鉴别诊断。方法：选择２１例颈侧区肿块患者，所有病例均最后行手术治疗并病理确诊。其中１７例作多层动态扫描，４例作单层与多层对比扫描，单层扫描时描绘时间—密度曲线。结果：时间—密度曲线对诊断血管性肿瘤具有重要价值；不同类型或性质肿块其增强扫描特征有明显区别；肿块与颈鞘及周围组织能准确显示。结论：动态增强扫描在鉴别颈侧区肿块及对手术方案的确立有指导意义。     

10例颈动脉体瘤的诊断和治疗体会

目的:探讨颈动脉体瘤的临床诊断和治疗经验。方法:对10例颈动脉体瘤患者的临床资料进行回顾。结果:10例颈动脉体瘤患者,男6例,女4例,均接受手术治疗。术前分别进行超声波、数字减影血管造影(digitalsubtraction angiography,DSA)、计算机X线断层扫描(computed tomography,CT)、磁共振成像(magnetic reso-nance imaging,MRI)及CT血管成像(computed tomography angiography,CTA)检查。术前行Matas试验2例,7例颈动脉体瘤被单纯剥离切除,2例行包括颈外动脉在内的瘤体切除术,1例行人工血管重建颈内动脉。术后1例出现暂时性舌下神经受累,1例交感神经受累,2例迷走神经受累,3个月后症状完全恢复。无偏瘫和死亡病例。结论:颈动脉体瘤患者术前完善检查和准备非常重要,CTA在诊断中具有良好作用。较小的肿瘤可以完整剥除;与颈外动脉包绕紧密的一并切除颈外动脉;与颈内动脉包绕紧密难以剥离的可以行人工血管重建。     

腮腺少见肿瘤的增强CT表现及其病理基础

目的 探讨腮腺少见肿瘤增强CT表现特征与病理的相关性,以提高影像诊断水平。方法 对22例经手术病理证实的少见腮腺肿瘤进行回顾性分析,包括基底细胞瘤6例,肌细胞上皮瘤5例,脉管瘤4例,淋巴上皮囊肿及腮腺脂肪瘤各3例,软骨肉瘤1例。在增强CT图像上,从病变所在腮腺的位置、病变大小和形态、病变密度以及其与周围结构的关系进行总结分析。结果 基底细胞瘤发生在腮腺浅叶,边界清楚,病变内易囊变。增强扫描呈不均匀中度-明显强化肿块,边缘或内部可见结节状强化,可伴有增大的淋巴结。肌细胞上皮瘤多发于腮腺浅叶,易发生小囊变,少数病变内可有小点状钙化。实性部分增强后中度-明显强化,多有典型的动脉期强化结节和边缘显著强化。血管瘤为软组织肿块,病变较大可占据整个腮腺,密度均匀或不均匀,可见静脉石,突出于腮腺表面,增强后轻度-明显强化。淋巴上皮囊肿囊液较黏稠,CT值密度较高。软骨肉瘤以囊性为主的肿块,含边缘钙化、骨化成分的肿块。腮腺脂肪瘤可见脂肪密度肿块,边界清晰,无强化,病变内可见纤维分隔。结论 腮腺少见肿瘤的增强CT表现具有一定的影像学特征,可揭示其病理基础;增强CT是诊断腮腺少见肿瘤病变性质有效的影像检查手段。     

26例颈动脉体瘤的临床分析

目的　研究颈动脉体瘤的临床表现、诊断以及手术方法,为临床诊治提供参考。方法　回顾上海交通大 学附属第九人民医院1993~2004年收治的26例病理证实为颈动脉体瘤的手术病例,分析其年龄、性别、临床特点、 影像学表现、治疗和预后情况。结果　26例颈动脉体瘤患者,男女之比为1∶2·25,中位年龄为36岁;其中2例为双 侧颈动脉体瘤,1例为恶性颈动脉体瘤。21例患者术前行磁共振血管造影、数字减影血管造影及暂时性球囊阻断 试验(TBO)评价,其中6例为TBO阳性。11例行多普勒检查,9例行颈部CT,5例行磁共振成像。26例患者均采用 手术治疗,除切除肿瘤外,其中5例还行颈动脉人工血管重建,4例行颈动脉修补术,1例行颈总、颈内动脉吻合术,1 例切除部分迷走神经。所有病例均预后良好,无脑神经并发症发生,无死亡,随诊未见肿瘤复发。结论　血管造影 和多普勒检查在颈动脉体瘤的诊断中具有重要价值。颈动脉体瘤患者术前应常规行血管造影及TBO检查,进行系 统全面的颈动脉评价,并做好血管重建准备。确诊为颈动脉体瘤后,应尽早手术,根据肿瘤与颈动脉的关系选择适 宜术式。     

Contrast-enhanced conventional CT in patients after surgery for malignant tumors: evaluation of the optimal method of the administration of the contrast medium

Patients after ablative surgery for malignant tumors require computed tomography (CT) examination of a wide area on the head and neck to follow-up for recurrence and lymph metastasis. The aim of this study was to determine a more effective method for the infusion of the contrast medium into post-operative patients undergoing conventional CT, based on the relationship between the method of administering the contrast medium and the contrast-enhancing effect in the internal jugular vein. First eleven images were selected from the existing contrast-enhanced and plain CT images in a manner such that the CT values of the internal jugular vein were distributed evenly in a range of 50-180. Seven experienced observers evaluated the contrast-enhancing effect of each image set at a window value of 40 and window widths of 120, 200, and 280. Secondly, the CT values of the right internal jugular vein were measured in a total of 10 CT images from the thyroid to maxillary sinus level from each of 60 post-operative patients. The injection needles and contrast-enhancing techniques used in the 60 patients were drip infusion using an 18G injection needle in 20, drip infusion using a 21G injection needle with bolus intravenous injection immediately before scanning in 20, and drip infusion using a 23G injection needle with bolus intravenous injection immediately before scanning in 20. A CT value of 100 or above, preferably 120 or above, in the internal jugular vein was needed for the contrast-enhancing effect of a CT image to be judged as clinically significant. Our results found that, when a conventional CT was used in patients after surgery for malignant tumors, drip infusion using a 21G or 23G injection needle should be combined with bolus injections immediately before the beginning of scanning, and at the glottis or submandibular gland level during the scanning. A sufficient contrast-enhancing effect can also be obtained by drip infusion using an 18G injection needle without bolus injection.     

兔同种异体颜面复合软组织瓣移植及组织瓣再血管化的研究

目的：建立兔同种异体颜面复合组织移植的动物模型,研究移植术后同种异体组织瓣的再血管化进程。方法：对日本大耳白兔和青紫蓝兔进行头颈部（主要是血管系统）解剖研究,并通过半侧颜面组织瓣的设计和移植,明确血管蒂所能营养组织块的最大范围,寻求最合适可靠的血管蒂,以最合适的血管蒂进行复合组织瓣移植。研究移植术后组织瓣的再血管化进程。结果：①兔头颈部的血管分支、走向与人相似,但颅内动脉及颅内、外动脉之间有丰富的交通吻合,结扎兔单侧颈总动脉,未引起偏瘫或死亡。②进行兔半侧颜面组织瓣移植最合适的血管蒂是颈外静脉和颈总动脉。③移植皮瓣的血管密度逐渐增加,约在术后10d达峰值,28d时移植皮瓣与受区相互吻合成网。结论：应用颈总动脉和颈外静脉为血管蒂进行兔同种异体颜面复合组织移植,可提高模型建立的成功率。移植后组织瓣与受区可达到良好的再血管化。     

Carotid sheath tumor--a diagnostic challenge

The tumor within the carotid sheath described in this article is unusual in that its clinical presentation mimicked a deep-lobe parotid tumor. Despite extensive investigation with conventional sialography, technetium pertechnetate scintigraphy, and computerized axial tomography, the correct preoperative diagnosis was not established. The value of CAT scanning in the diagnosis of parapharyngeal tumors is demonstrated.     

数字减影血管造影在颈动脉体瘤术前的应用

目的　探讨颈动脉体瘤术前数字减影血管造影 (DSA)的应用。方法　 7例颈动脉体瘤患者 ,行DSA瘤体造影 ,术前再次利用DSA行颈动脉体瘤滋养血管栓塞 ,并行健侧颈内动脉及颅内血管造影 ,观察大脑动脉环情况及血流侧支循环情况。结果　除颈动脉体瘤常见影像特征外 ,还发现另一种影像特征 :肿瘤将颈总动脉、颈内、外动脉推向前方 ,使颈动脉呈倒“Z”型 ,颈内、外动脉夹角变小。栓塞后可使术中出血量减少。颈内动脉及颅内血管造影 ,综合分析大脑动脉环情况及大脑侧支循环情况 ,可减少肿瘤手术切除的危险性。结论　DSA在颈动脉体瘤术前应用具有重要的临床价值     

颈动脉体副神经节瘤16例诊治分析

目的 总结16例颈动脉体副神经节瘤(CBP)的诊治经验。方法 本组共16例19个肿瘤，主要依靠B超和DSA检查确诊。12例共切除14个肿瘤，术前均经Matas训练，经动脉外膜下摘除肿瘤7例，切除肿瘤、修补血管6例，连同肿瘤一起切除颈总和颈内动脉1例。结果 DSA对CBP确诊率为100％，B超确诊率为89％。手术全部成功，没有严重并发症，证明术前Matas训练是有效的。结论 术前确诊CBP对围手术期准备至关重要，Matas训练对提高手术安全性非常有效，切除肿瘤、修补血管减少了术后严重并发症。     

选择性颈动脉造影在颈动脉体瘤诊断治疗中的应用

目的 :探讨X线颈动脉造影对颈动脉体瘤治疗方案选择的指导作用。方法 :分析 3 3例颈动脉体瘤术前颈动脉造影、术中所见及最终手术方式 ,探讨它们之间的相关性 ,总结造影结果对制定治疗方案的指导意义。结果 :颈动脉体瘤血管造影显示肿瘤血供丰富 ,颈动脉分叉张开 ,呈握球状改变 ;血管影像清晰、动脉被推移的病例 ,肿瘤对血管侵蚀轻 ,手术完整剥除肿瘤的可能性大 ;肿瘤包绕血管 ,血管显影不清晰的病例 ,说明肿瘤对血管壁破坏严重 ,剥除肿瘤困难 ,须做好颈动脉切除及重建的准备。对于肿瘤与血管染色混杂 ,无法分清各自结构与位置的病例 ,均需行颈动脉切除。术前的颈动脉压迫训练对减少或减轻术后并发症具有重要意义。结论 :术前选择性血管造影可以明确诊断 ,判断肿瘤对血管的侵蚀程度 ,评价阻断患侧颈动脉后健侧颈动脉对颅内 ,特别是对患侧脑的供血情况 ,有助于选择手术方案 ,对于颈动脉体瘤外科治疗和减少并发症是必要的。     

Computerized tomography and Trotter's syndrome in the diagnosis of maxillofacial pain

Trotter's syndrome is a clinical triad of unilateral deafness, neuralgia affecting branches of the trigeminal nerve, and defective mobility of the soft palate, which is caused by malignant tumors involving the lateral pharyngeal recess (Rosenmüller's fossa). It is an ominous presentation, which can masquerade as dental or masticatory pain. Computerized tomography (CT) can be used not only to explain the anatomic basis of Trotter's syndrome but also to determine the extent and distribution of the malignant tumor involved. The advantages of CT over conventional radiography are illustrated by a case of adenoid cystic carcinoma that presented as Trotter's syndrome. Perineural invasion by tumor is shown on the gross level for the first time with CT, and important diagnostic considerations, which may aid in the early diagnosis of future cases, are discussed.     

颈鞘内神经鞘瘤的诊治分析

目的:探讨颈鞘内神经鞘瘤的诊断与治疗方法。方法:回顾性分析2005～2010年收治的23例颈鞘内神经鞘瘤患者的临床资料。结果:彩超和CT-血管造影(CT-angiography,CTA)检查后对23例患者进行手术治疗,术后经病理检查确诊为神经鞘瘤,术后随访,无严重并发症发生,无复发病例。结论:术前CTA检查是诊断颈鞘内神经鞘瘤的有效方法,手术切除务求彻底,术中尽可能保存来源神经的完整性是治愈该病的关键。     

颈动脉体瘤的诊断和治疗

目的:探讨颈动脉体瘤的诊治经验,提高诊断准确率和手术成功率,降低并发症发生率。方法:回顾分析1996~2005年收治的30例颈动脉体瘤患者的临床资料。结果:30例患者均行DSA检查,均诊断为颈动脉体瘤;B超检查14例,12例诊断为颈动脉体瘤;CT检查20例,16例诊断为颈动脉体瘤;MR I/MRA检查16例,14例诊断为颈动脉体瘤。22例患者行TBO检查,8例为阳性。30例患者均行手术治疗,29例患者预后良好,1例发生永久性偏瘫,随诊期间无肿瘤复发。结论:DSA检查是诊断颈动脉体瘤的最佳方法,而MR I/MRA和BUS检查在颈动脉体瘤的诊断中具有重要价值。手术切除是治疗颈动脉体瘤的首选治疗措施。DSA和TBO同时检查,能为制定手术方案提供重要参考。应做好充分的术前准备,术前常规行M atas训练。术中精细的解剖可以降低术后并发症的发生。