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Diagnosztikus
képalkotó eljárások
anatómiája
2007.
Role of modern imaging
methods in maxillofacial
diagnostics
Department of Diagnostic Imaging
Semmelweis University, Budapest
FOK V.
09/04/2018.
SEMMELWEIS EGYETEM
Department of Radiology
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50 years old female
3 days ago accidentally was injected
with disinfectant instead of local
anesthetics, which caused tissue
necrosis
swollen, painful face
subfebrile
erythema on the neck
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MR vizsgálat
Which diagnostic method would
help here???
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Questions that could be
considered?
Extent of inflammation?
State of the organs in the region?
Crepitation- fluctuation?
Abscess formation?
Most important: is there any Abscess?
If so = surgery
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Specific examinations
Definite question – calls for a straight
answer
Step 1:
Ultrasound examination of he neck
Step 2:
crossectional imaging method – non contrast
and contrast enhanced CT
Abscess?
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US
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CT examination
Phlegmone (cellulitis).
No abscess.
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Diagnostioc Imaging methods
Ultrasound
Conventional X-ray (+ fluoroscopy) Non-contrast
Contrast enhanced
CT (Multislice, cone-beam) / MR
Angiography DSA
CT-, MR-Angiography
Molecular medicine scintigraphy
SPECT (single photon emission computed tomography)
PET (positron emission tomography), PET-CT
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Image is based on soundwave reflections
Bones and gases cannot be examined
solid ↔ cystic DD -excellent
Lower depth ↔ higher resolution
Flow related measurements (Doppler) Direction, speed → stenosis,
vascularization → inflammation, tumor
biopsy guidance (FNAB, core)
US
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Indications
face
Floor of the mouth
Superficial layers of the neck
Above bones
Main lymph node regions
US
Preparation
Jewelry needs to be taken off
Bandage removal
tracheostomy line if possible removed
Consent in case of contrast enhanced examinations or biopsies
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Extraoral
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Bucca
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Submandibular region
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Floor of the mouth
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Thyroid left lobe
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Lgl
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20
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Elastography
Qunatitatiove measurement of tissue characteristics: Inner stimulus or external compression the tissues
move
Elastic vs. Tough tissue
Tumors are tougher: less elastic
Color code
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Color Tissue Greyscale
Soft, elastic
…
…
tough
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indications: panoramic X-ray and dental X-ray
less valuable since CT: face bones, orbit, temporal
bone, sinuses
Preparation
Conventional X-ray
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Dental
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Conventional X-ray
w/ contrast
Swallow
Sialography (sialolithiasis)
Still valuable
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Conventional X-ray
Contrast enhanced Indications
FB -obstruction
Perforation
diverticulum
Sclerotic lesions
tumor – stenosis
Preparations
jewelry
empty stomach
cooperation
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Swallow x-ray
sialography
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nyelés rtg
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CT concepts
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CT concepts
DVT
CBCT
MSCT
DSCT
MDCT
HRCT
digital volumenography
cone beam CT
multislice CT
dual source CT
Multidetector row CT
high-resolution CT
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Uses X-ray
NC and CE + multiple rows of detectors
CTA – option
Better soft tissue resolution than X-ray, but
lower spatial resolution /512x512 px/
High dose of ionizing radiation
Non-contrast and
contrast enhanced CT
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Indications
tumor TNM
Deep spaces of the HN region
Bones (fractures, paranasal sinuses)
Suprahyoid regions - MR is more useful
Inrahyoid neck – very good;
Non-contrast and
contrast enhanced CT
Preparation
Remove metal pieces
Consent
Kidney function
iv. contrast– DM (metformin)
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Face CT MDCT
Helical
Resolution High
Collimation 16 x 0.75
Pitch 0.438
Rot. 0.75
FOV 200 / 150/ 100 mm
Filter D (bone)
kV 120
mAs 250
Sliceth/ rec 2mm/ 1mm
WC; WW 200/ 2000 HU
matrix 512
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MDCT primary planes
coronal
axial
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coronal
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Axial
coronal
„MPR”
Soft tissue
window
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natív CT postprocessing:
MPR = multiplanáris rekonstrukció
coronalis
sagittalis
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Submandibular gl. tumor
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sinonasal polyposis
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MD- vs. CBCT
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CBCT
NewTom 3G / i-Cat / ILUMA/ ProMax 3D
CB MercuRay / Dental CBCT / 3D Accuitomo / Sirona Gelileos
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kV mAs CTDIvol
(mGy)
Face MDCT 120 250 38.1
Face CBCT 110 7.91 1.06
MDCT CBCT
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Significantly lower radiation
max 100 μSv (↔MDCT kb. 1200-3300 μSv )
Panoramic X-ray 10-12 μSv (daily background radiation 8 μSv)
MDCT CBCT
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Advantages- Disadvantages MDCT CBCT
Tissue contrast Excellent Moderate
Density
measurement (HU)
precise Not reliable
„Windowing” Based on HU Brightness and contrast
FOV changeable Standard
Ionising radiation High (min. 10x) low
Voxel Isovolumetric 0.625mm Isovolumetric 0.125mm
Duration of the
examination
Irrelevant (10-30sec) Sensitive to motion
(<40sec)
Klausztrofóbia Not likely (vs MR) No
Space needed Larger Smaller
Metal artefacts stronger weaker
Expences High low
Covered by health
insurance
yes no
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CBCT clinical indications
implantiology
oro- and maxillofacialis diseases
TMJ
Surgical planning
fogszabályozás és orthognathia
impactált fogak
DMF
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Maps the Hydrogen atoms of tissues – best soft tissue
resolution
No ionizing radiation
More expensive, less available
Longer examination time (30-50 min)
Problematic next to metallic objects, bones harder to
assess
Non contast and
contrast enhanced MR
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Indications
Suprahyoid neck
Skull base (foramens)
Tumor extent
(scar tissue ↔recurring tumor)
Non contrast and
contrast enhanced MR
Preparation
Metallic objects removed
Consent
Contraindicated metallic prosthetics, pacemaker
claustrophobia
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MR T2W
MR T2W
MR T1W
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MR T2W MR T2W
US
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Digital X-ray + subtraction
High radiation, semi-invasive
Regional vascular structure
Problems are usually related to contrast agents
DSA
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Indications
Vascular structure of tumors – possible interventions (RFA-,
chemoembolisation, chemoablation, embolsation,
paraganglioma
glomus tumors
Digitális
szubtrakciós angiográfia
Preparation
Consent – empty stomach
Sterile environment
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Poor morphologic resolution
Good temporal / functional res.
Tc isotope Gamma camera (thyroid)
SPECT – single photon emission CT
FDG-PET F18 glucose – positron .
Tumor metastasis, primary malignancy or inflammation
PET-CT – fused images - better morphology
Molecular imaging
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Botos anita
MIBI 5 perc MIBI 120 perc
pertechnetát SPECT sagittal
Kontroll célzott UH
21 éves nő,
PTH: 58 pg/ml (!),
seCa: 2,85 mmol/l
adenoma
Ectopic parthyroid
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tu. rad. linguae +
met lgg. colli
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FDG-PET: metastasis