대한밤사선의학회지 1994 : 31 ( 3) %(52/ 1472 ) 의발생빈도를보였고이중 4 명 (8. 3% ) 이 양측성 (Fi g. 1) 이어서총 56 예이었다. 각나이군별로의발 생빈도는 30 대와 40 대에서각각 1 6 예로가장많았고 50 대

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1 대한방사선의학회지 1994 : 31(3) : 해부학적변이로서의지양판골결손과동반된 내측함몰 : 전산화단층촬영소견 1 나선영 이영욱 윤은겸 서상경 김동현 목적 : 해부학적변이로서의지앙판골결손과내측함몰의발생빈도및앙상을알아보기위해본연구를시도하였다. 대상및방법 : 만성부비동염증세가있었던환자 1472 명의부비동전산화단층촬영소견을후향조사하였다. 결 과 : 해부학적변이로서의지양판함몰은 3.5%( 52/ 1472 ) 의발생빈도를보였고이중 4 염이양측 성이어서총 56예이었다. 연렁증가에따른함몰빈도증가는통계적으로서로상관관계를나타내었다. 위치는기저층판의전방부합몰이후방부보다더많았다. CT상내측함몰된지앙판의변연은평활하였고전예에서나타난주변안와지밤조직의탈출과 19예 (3 4 %) 에서나타난안와내직근의내측만곡및비후외에는주위연조직이나골조직에이상소견이없었다. 결론 : 무외상성, 무증상의해부학적변이로서의지양판의골결손및내측함몰이 3.5% 에서나타났고이의발견및정도파악이사골동수술시여러안구합병증을방지하는데도움을줄것으로생각한다. 서 지양판은사골동의내측벽을이루는아주앓은골판으로 (1) 사골동염증이이곳을흥해안와내로파급될수있고 사골동수술시쉽게천공되어안와내합병증을일으킬수 있다 ( 2-4). 료응 - 이판은외상에의한안압증가로함몰되기도 하는데외상이나수술의기왕력이없는경우에도지양판 골결손이발견된다는보고가있다 (5-8). 최근만성부비 동염환자에서 CT 의이용이늘어남에따라우연히발견된 해부학적변이로서의지양판골결손과내측함볼의발생 빈도및양상을알기위해본연구를시도하였다. 대상및방법 1992 년 5 월부터 1993 년 7 월까지 15 개월동안만성부비 동염이의심되어본원에내원하여부비동전산화단층촬 영 (Computed Tomography, 이하 CT 로약함 ) 을시행한 환자 1472 명을대상으로후향조사를하였다. 남자가 912 명, 여자가 540 명이였고나이분포는 6 세에서 72 세사이였 으며평균나이는 32세였다. 이중지양판의골결손과내측 1 고려병원방사선과 이논문은 1994 년 5 월 3 일접수하여 1994 년 7 월 6 일에채택되었음 함몰을보인예를찾아서다시과거외상이나수술등의기 왕력및안구이상증세유무에대해조사하였다. 지양판의 함몰정도는임의로일측사골동의횡단면을삼등분하였 을때 1/ 3 이하의함몰언경우 mild, 1/ 3 에서 2/3 일때 moderate, 그이상일때를 severe 로분류하여대상군의연 령분포와비교하였다. 또한기저층판 (Basa l L ame lla) 을 중심으로전방부와후방부로나누어그호발부위도알아 보았으며다른동반된소견도관찰하였다. 사용한 CT 기종은 GE-CT /T Quick HiLight 였고부 비동부위를횡단및관상주사하였다. 횡단주사는앙와위 상태에서하안와 - 외이도선에평행하게경구개로부터전 두동상단까지 5mm 절편두께및간격으로연속주사하였 고관상주사는환자를복와위로하여목을과신천시킨후 횡단주사변에수직이되게전두동전변에서후사골동전면까지는 3mm, 후사골동전면부터접형동후연까지는 5 mm 절편두께및간격으로연속주사하였다. 횡단주사는 연부조직 algorithm 으로영상을얻었고관상주사는골 algorithm 으로영상을얻었다. 7 :f εe 1472 명중지양판의골결손과내측함몰을보인환자는 모두 6 1 명이었으나이중 9 명은안구외상의기왕력이있어 제외하였다. 따라서해부학적변이로서의지양판함몰은 과

2 대한밤사선의학회지 1994 : 31 ( 3) %(52/ 1472 ) 의발생빈도를보였고이중 4 명 (8. 3% ) 이 양측성 (Fi g. 1) 이어서총 56 예이었다. 각나이군별로의발 생빈도는 30 대와 40 대에서각각 1 6 예로가장많았고 50 대, 60 대에서 11 예, 3 예로다시감소하는양상으로나타났지만 통계적으로연령증가에따른발생번도의증가는상관관 계가있는것으로나타났다 ( p (0.05) (Table 1). 총 52 명에서 나타난 56 예의지양판내측함몰은우측이 27 예, 좌측이 29 예이었다. 각연령군에서함몰정도는 세, 세, 세는 rnild 가가장많았고 세, 6 0 세이상에서 는 mo de rat e가많았다 (Tabl e 2). 위치별로는기저층판의 전방부함몰은 32 예 (57% )(Fig. 2), 후방부함몰은 13 예 (23% ) 로전방부함몰이더많았고전후방부에걸쳐서나 타났던경우가 11 예이었다 ( Fi g. 3). C T 상함몰된지양판 의변연은매우매끄럽고평활했으며전예에서안와지방 조직이안으로탈출되어보였다. 안와주변근의내측탈출 은없었으나 19 예 (3 4%) 에서내직근이내측만곡을보이 Table 1. Incidence 01 Depressed Lamina Papyracea in Each Age Group Age ) 60 No. 01 patient 낀n i/ E rt nu 1, Total 1472 p(0.05 by the logistic procedure 4 8 없Ru )Cases 01 depressed I.amina papyracea (%) 0(0) 4 (1.0) 2 (0.8) 16 (5.1) 16 (8.4) 11 (6.0) 3 (3.5) 52 (3.5) 면서반대쪽과비교시비후된모양이었다 (Fi g. 3 ). Sinonasal p o l ypo sis 의 1 예에서는다른사골세포들은모두용 종성병변에의해팽창되어있는반면한사골세포는내 부의용종성변화에도불구하고그내측벽이골결손과함 께내측함몰을보이고있었다 (Fig.4). 고 지양판은라턴어의어원그대로종이처럼앓은판이고 찰 안와의내측벽을구성하는조직이며 ( 1) 골동의기포로덮여있고 ( 9) 중사골동과후사 안와주변과사골동을가르는 격막구실을한다 ( 3 ). 지양판의골결손은아주오래전두 개골해부상사골동의변형으로보고되었고그발생빈도 를보고한여러문헌에의하면부겸상 5-1 0% 의빈도를 보인다는예도있고 (10) M oulin 등에의하면 0.76% (5), Table 2. Relationship between Age Distribution and Degree 01 Severity Cases Age ) 60 Total Degree 01 depression(no. 01 cases) Mild Moderate Severe - J,, 33 ηζ 애l21 l 4l ng Iu J n4 nu 4l 4l 2 Total 머얘n 3 56 Fig. 1. Coronal CT scans shows depression 01 both lamina papyracea, mild degree on the right side and moderate degree on the left side. The depressed lamina papyracea is smoothly curved and depressed portion in lilled with isodense adjacent orbital lat Fig. 2. Axial CT scan shows medial depression 01 the left lamina papyracea anterior to the basal lamella

3 나선영오 해부학적변이로서의지앙판골결손과동반된내측함몰 a Fig year old male with sinonasal p이 yposis and medial depression with bony dehiscence of the right lamina papyracea: Serial coronal CT scans from anterior to posterior show outward expansion of lamina papyracea due to.multiple p 이 ypoid lesions occupying ethmoid air cells, however, disclose persistent medial depression of the right lamina papyracea at the site of bony dehiscence 이런합병증의빈도를 2.8% 내지 3.7% 로보고하고있다 (2). 이런사골동근처의감염경로는지양판의골결손을통하거나내직근과상사근사이로들어가는전사골동맥 (1 3) 과후사골동맥그리고전두, 사골경계부의신경공을통한파급이주원인으로되어있고그외드물게는상부와하부정맥총의판막이없는정맥을통한후향적혈행파급 b Fig. 3. a. b. The left lamina papyracea is medially depressed both anteriorly and posteriorly through the basal lamelia. The medial rectus muscle is mediaijy curved with focal thickening without significant herniation. Zukerkandle 등은 1.17% (6), Kozlov 등은 5.6%(7), Takahashi 등은 10%(8) 로보고하고있다. 본연구에서는지양 판의골결손을동반한내측함몰을조사하였고이는 3.5% 의빈도를나타내었다. 지양판골결손의임상적중요성은그주변부의해부학 적구조들과연관이있다. 지양판외측에는안와와그내용 물들이있고해변동과인접하고있으며 (11) 특히사골동 수술이나접형, 사골동수술등의비내시경수술시지양판 에근접한안와구조들즉, 전사골동액이나내직근, 상사 근등의외안근과안와주위지방조직등에영향을주어안 와합병증인안와혈종, 봉와직영, 안와농양, 해면동혈전 등의합병증이생길수있다 (2, 3, 4, 12). Stankiewicz 등은 으로오는경우가있다 (4). 또지양판내측함몰의경우그부위사골세포가매우작고측방이안와의지방조직으로차있으면서지양판자체는매우앓고결손되어있으므로비내시경수술시돌출된안와지방을사골동염증성병변으로오인하고제거하려고하여안와내합병증을일으킬수었다 (5). 지양판골결손의가능성있는원인으로는선천적변이, 외상, 감염등을생각할수있고특히심한용종성병변이나수술후빈도가높아진다는보고가있다 (1 4). 저자들의경우지양판결손만있고내측함몰이없는경우는포함시키지않았는데그이유는사골동염증이나용종에연해있는결손부위는이차적인변화로해부학적변이에포함시킬수없었고 CT상골결손이보인다하더라도아주앓아진골판인지실제골결손인지판단의기준이없었기때문이다. 특히한예에서는사골동에다수의용종이있어지양판의팽륜이기대되었음에도불구하고골결손과함께오히려함몰이있어서함몰자체가기존의해부학적변이임을시사하였다. 또한처음에는골결손만있다가시간이지남에따라이차적으로내측함몰이초래될가능 417

4 대한방사선의학회지 1994 ; 31(3) : 성도있어서연령분포와이에따른발생빈도를비교한결 과연령증가에따라발생빈도가증가하는유의성을나타 내었으나 (p<0. 05) 3 1 세에서 40 세, 41 세에서 50 세사이에 각각 16 예로가장많다가 51 세이상에서 60 세사이에서는 11 예, 61 세이상에서는 3 예로숫적으로감소한것은모집단 의수가충분치못했기때문일것으로사료되었다. 자연적 으로생기는골결손의경우기저층판의전반부를침범하 고후방부는침범하지않는다는보고가있는데 (5) 저자들 의경우에는후방부침범을보이는골결손및함몰이 24 예 (43% ) 나되었다. 외상의기왕력이없이함몰된지양판의 경우그변연이분쇄나비틀림이없이매끄럽고주위연조 직에특별히증가된음영이나침윤병소가없다는점이외 상성함몰과구분할수있는점이라생각된다. CT 상지양 판에서간격을통해사골세포내로지방조직의탈출을보 이는데이지방조직이안와지방조직과연결되어있으면 서같은농도를갖는것을볼수있다 (5). Moulin등 (5) 에의 하면내직근이모두정상이라고보고하였는데저자들의 경우내직근의확실한탈출은없으나내직근자체의비대 나내측만곡을보인예가 34% 로나타났다. 결론적으로무외상성, 무증상의해부학적변이로서의 지양판의골결손및내측함몰이 3.5% 라는적지않은빈도 를보였고 CT 를통한이의발견및정도파악이사골동수 술시여러안구합병증을방지하는데도움을줄수있으리 라생각한다. ~~ C그 고 헌 3. Buus DR, Tse DT, Farris BK. Opthalmologic complications 01 sis surgery. Opthalmology 1990 ; 97(5) : Clary RA, Cunningham MJ, Eavey RD. Orbital complications 1 acute sisitis: comparison 01 computed tomography scan and surgical lindings. Ann Otol Laryngol 1992; 101 : Moulin G, Dessi P, Chagnaud C. et al. Dehiscence 01 the lamina papyracea 01 the ethmoid bone CT lindings. AJNR 1994; Zuckerkandl E. Normale und pathologische Anatomie der nasenhohle und ihrer pneumatischen anhange. Vol Bramuller, ed. Wien, Cited Irom Moulin G, Dessi P, Chagnaud C, et al. Dehiscence 01 the lamina papyracea 01 the ethmoid bone :CT lindings. AJNR 1994;15 : Kozlov VN. Anatomical data 01 the endonasal opening 01 the cells 01 the ethmoid labyrinth. Vestn Otorinolaringol 1975 ; Cited Irom Moulin G, Dessi P, Chagnaud C, et al. Dehiscence 01 the lamina papyracea 01 the ethmoid bone: CT lindings. AJNR 1994 ;15: Takahashi R, Tsutsumi M. Nasal cavity reconstruction. Otolaryngology(Tokyo)(Jibi Inkoka) 1969; 10: Cited Irom Moulin G, Dessi P, Chagnaud C, et al. Dehiscence 01 the lamina papyracea 01 the ethmoid bone : CT lindings. AJNR 1994 ; 15 : Malee MF. Endoscopic sis surgery: Role 01 the radiologist AJN R 1991 ; 12 : Yousem DM. Imaging 01 the sinonasal inllammatory disease. Radiology 1993 ; 188 : Maniglia AJ. Fatal and major complications secondary t nasal and sis surgery. Laryngoscope 1989 ; 99: Mattox DE, Delaney RG. Anatomy 01 the ethmoid sis Otolarygologic Clinics of the North America 1985 ; 18(1) : Rontal M, Rontal E. Studing Whole-Mounted sections 01 the paranasal sises to understand the complications 01 the endoscopic sis surgery. Laryngoscope 1991 ; 101 : Becker SP. Anatomy lor endoscopic sis surgery. Otol- 14. Teatini G, Simonetti G, Salvolini U, et al. Computed tomograaryngologic Clinics of North America 1989 ; 22(4) : phy 01 the ethmoid labyrinth and adjacent structures Ann 2. Stankiewicz JA, Maywood IL. Complications 01 endoscopic Otol Rhinol Laryngol 1987 ; 96: intranasal ethmoidectomy. Laryngoscope 1987 ; 97 :

5 나선영외 - 해부학적변이로서의지앙판골결손과동반된내측함몰 Journal of the Korea n Rad iological Society, 1994 : 31(3): Medial Depression with Bony Dehiscence of Lamina Papyracea as an Anatomic Variation : CT Evaluation Sun Young Na, M. D., Young Uk Lee, M.D., Eun Kyung Youn, M.D., Sang Gyung Suh, M.D., Dong Hyun Kim, M.D. Department of Diagnostic Radiology, Koryo General Hospital Purpose: To evaluate the incidence and CT findings of the medial depression and bony dehiscence of lamina papyracea as an anatomic variation Material and Methods: 1472 PNS CTs of the patients with symptoms of chron ic sisitis were retrospectively evaluated Results : The total incidence of depressed lamina papyracea as an anatomic variation was 3.5 % (52/1472) on PNS CT. There was a statistically significant correlation between the increasing age and the incidence of depressed lamina papyracea. Depression of lamina papyracea anterior to the basal lamella were more common than those of the posterior depression. Associated findings were herniation of adjacent fatty tissue in all cases and the medial bowing and hypertrophied configuration of the medial rectus muscle without significant herniation in 19 cases(34 %) Conclusion: Nontraumatic, asymptomatic depression with bony deh iscence of lamina papyracea as an anatomic variation is not uncommon with the incidence of 3.5 %. Recognition of its exi stence and degree may be helpful in avoiding various ocular complication during ethmoid surgery. Index Words : Paranasal sises, an atomy Paranasal sises, CT Address reprint requests to : Sun Young Na, M.D., Department of Diagnostic Radiology, Koryo General Hospital. 108, Pyeong 강 ong, Jongro-gu, Seoul, Korea. Tel Fax

6 1994 년도추계전공의연수교육일정표 E 므 l 시 : 년 10 월 23 일 09 : : 30 장소 : 서울대학교병원소아 1 강의실예정 이 E 므저 0 -'- 효 L 9: 05-9: 20 전공의생활중흔히만나는문제점들 ( 서울대병원 ) 김홍대 9: 20-9: 50 Computer 용어해설 ( 현대중앙병원 ) 이진성 9 : : 20 Spread sheet ( 현대중앙병원 ) 이진성 10 : : 50 Database ( 인천길병원 ) 김형 λ 1 10 : : 10 Slide making ( 부산동아대병원 ) 양승오 11 : : 00 방사선안전관리규정 ( 현대중앙병원 ) 오용호 2 시간 55 분 1 : 00-1: 20 Statistics ( 서울대병원 ) 한준구 1 : 20-1: 40 Tips in office automation ( 현대중앙병원 ) 송군식 1: 40-2 : 05 Literature search ( 삼성의료원 ) 김보현 2: 05-2: 30 3D reconstruction ( 서울대병원 ) 정진 1 r 2: 30-2: 55 Image database & archiving, scanner ( 상계백병원 ) 차 τ /ιr -;z 2 : 55-3 : 20 Multimedia, Computer based education ( 현대중앙병원 ) 송군식 3: 20-3: 45 Networking & ( 서울대병원 ) 김종효 3 : 45-4: 10 PACS & Teleradiology Basic concept, advantage, limitation ( 삼성의료원 ) 최혀 λ 1 4 : 10-4: 30 Radiology Dept. & Hospi tal information system ( 삼성의료원 ) 최형식 3 시간 30 분 -420-

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