10-11 김중헌

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1 Case Report 대한소아응급의학회지 2014 제 1 권제 1 호 Pediatric Emergency Medicine Journal Volume 1, Number 1, June, 2014 식도내잔류이물에의한지속적협착음을보인영아 1 례 김중헌 류정민 1 울산대학교의과대학아산병원소아청소년과, 응급의학과 1 Case of Infant with Persistent Stridor due to Residual Esophageal Foreign ody Jung-Heon Kim, M.D., Jeong-Min Ryu, M.D. 1 Department of Pediatrics, Children s Hospital, san Medical Center, Seoul, Korea, Department of Emergency Medicine, san Medical Center, Seoul, Korea 1 Esophageal foreign body could cause stridor. Stridor may be persistent due to residual foreign body even after removal of esophageal foreign body. We describe a case of a 10-month-old boy who experienced persistent stridor after initial removal of esophageal foreign body. He had been brought to the emergency department, and a foreign body had been removed by rigid bronchoscopy. Nevertheless, he had persistent stridor. computed tomography (CT) scan revealed residual foreign body with associated calcification in the prevertebral soft tissue (C3-C5 level). He has been on surgical observation with foreign body in situ. Key Words: Infant; Esophagus; Foreign odies; Respiratory Sounds 서 론 소아에게서식도에이물이걸려통증이나불편감이발생하는경우는, 6개월에서 3세미만의영유아에서가장흔하다 1). 식도내이물은흡인, 식도기관루, 출혈, 폐쇄, 천공은물론후두와기관을뒤에서압박하여기도폐쇄를유발할수있어조기발견하여제거하는것이매우중요하다 1-4). 그러나식도에이물이걸려도영유아의증상이뚜렷하지않은경우가많아서보호자가이물을삼키는장면을목격하지못하면진단이늦어지며, 위내시경이나컴퓨터단층촬영등의정밀검사를시행해서야발견되기도한다. Corresponding uthor Jeong-Min Ryu Department of Emergency Medicine, san Medical Center Children s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, , Republic of Korea Tel: Fax: qweynaver@naver.com Cevik 등 5) 은 18.3% 의환아에서 24시간이후에발견된다고보고하였다. 현재까지영유아연령의식도내잔류이물에의한호흡곤란에관한많은증례가발표되었지만 3,6-8), 저자들은이물을제거한이후에도지속적인상부기도폐쇄증세를보인영아의증례를경험하였기에이를보고하고자한다. 증례 10개월된남자환아가내원 2개월전부터지속된호흡곤란과고형식에대한삼킴곤란, 내원 3일전부터동반된발열로본원응급실을방문하였다. 환아는외부병원에서폐렴및모세기관지염추정진단하에입원하여항생제치료를받았으나호전이없었고, 흉부컴퓨터단층촬영 (Fig. 1) 에서양측폐실질에특이소견없었고, 기도에특이한병변은발견되지않았다. 과거력에서재태기간 41주에 3.6 kg으로정상자연질식분만으로출생하였고, 생후 1개 57

대한소아응급의학회지제 1 권제 1 호 2014 Fig. 1. Chest computed tomography (CT) scan performed at the other hospital. Fig. 1. () xial images showed no remarkable abnormality.

월에호흡기세포융합바이러스 (respiratory syncytial virus) 에의한모세기관지염을앓았던것외에특이사항없었으며, 가족력에서도특이사항없었다. 본원방문당시환자의활력징후는혈압 101/76 mmhg, 호흡수 28회 / 분, 심장박동수 130회 / 분, 체온 36.9 C, 맥박산소포화도 99% 였으며, 의식은명료하고전반적으로아파보이는상태였다.

2 대한소아응급의학회지제 1 권제 1 호 2014 Fig. 1. Chest computed tomography (CT) scan performed at the other hospital. Fig. 1. () xial images showed no remarkable abnormality. The highest level of axial images was at 5th cervical vertebra. () No abnormality was remarkable in both lung fields and the large airway. Fig. 2. Initial anterior-posterior view of chest x-ray. Fig. 2. There was no abnormal finding in both lung fields. 월에호흡기세포융합바이러스 (respiratory syncytial virus) 에의한모세기관지염을앓았던것외에특이사항없었으며, 가족력에서도특이사항없었다. 본원방문당시환자의활력징후는혈압 101/76 mmhg, 호흡수 28회 / 분, 심장박동수 130회 / 분, 체온 36.9 C, 맥박산소포화도 99% 였으며, 의식은명료하고전반적으로아파보이는상태였다. 환아는경미한호흡곤란및빈호흡과함께, 쉰목 소리, 기침, 콧물을보였다. 흉부시진에서흡기시흉골상수축 (suprasternal retraction) 소견이있었다. 청진에서는흡기시협착음 (inspiratory stridor) 이들렸으며, 천명음및수포음은들리지않았다. 심장박동은빠르고규칙적이었으며, 심잡음소견은없었다. 산소포화도는 99% 로잘유지되고의식도명료하여, 산소는투여하지않았다. 혈액검사에서 C반응성단백 (C-reative protein, CRP) 3.06 mg/dl로약간증가한것외에특이소견없었고, 호흡기바이러스중합효소연쇄반응 (polymerase chain reaction) 에서리노바이러스 (rhinovirus) 에양성을보였다. 심전도검사에서는정상동율동소견보였다. 본원에서시행한흉부방사선촬영에서양측폐야에특이소견없었다 (Fig. 2). 경부연조직측면방사선촬영에서하인두에방사선비투과성병변이보였고, 3~5번째경추앞공간 (prevertebral space) 에서연조직의심한비후와함께, 직선모양의방사선비투과성병변이보였으며, 후두개의비대는없었다 (Fig. 3). 당시방사선비투과성병변중하인두의병변은윤상연골 (cricoid cartilage) 로이해되었고, 척추앞공간의병변에대해서도이물이아닌다른종류의석회화병변으로이해되었다. 응급실진료후추정진단으로, 흡기시들리는협착음에대해후두염, 크룹, 이물에의한상부기도폐쇄, 후두연화증 (laryngomalacia) 가능성이, 환자의과거력과외부병원추정진단을근거로무기폐, 폐렴, 모세기관지염가능성이각각있다고보고입원치료하기로하였다. 호흡곤란에대해서는바이러스감염에의한크룹에준하여에피네프린분무투여및덱사메 58 Pediatric Emergency Medicine Journal

Neck computed tomography (CT) scan that was carried out at hospital day 3. Fig. 4.

3 식도내잔류이물에의한지속적협착음을보인영아 1 례 Fig. 3. Initial lateral view of neck soft tissue x-ray. Fig. 3. White arrows indicate normal epiglottis. () Circle indicates a radiopaque foreign bodies in the prevertebral space from 3rd to 5th level of vertebrae. () With magnified view, they could be easily recognizable. C Fig. 4. Neck computed tomography (CT) scan that was carried out at hospital day 3. Fig. 4. (-C) radiopaque foreign body with associated calcification in the prevertebral soft tissue (C3-C5 level) was recognized from axial, coronal and sagittal view. The lesion was seemed to be embedded in posterior wall of the hypopharynx and no lesion suggesting retropharyngeal abscess was found. (D) It is also recognized from the lateral view of neck soft tissue x-ray. White arrows indicate the lesion. D Pediatric Emergency Medicine Journal 59

대한소아응급의학회지제 1 권제 1 호 2014 Fig. 5. Follow-up lateral view of neck soft tissue x-ray that was carried out at 7 days after foreign body removal. Fig. 5. White arrow indicates the hypopharynx that shows clearance of the radiopaque lesion.

타손근주투여를시행하였고, 동반된세균성폐렴의가능성도배제할수없어경험적항생제로세포탁심을투여하였다. 입원기간동안의료진은응급실에서시작했던치료를지속하면서흡기시협착음과기침, 콧물은비슷한정도로유지되었고, 산소투여없이도측정법상산소포화도 99% 로유지되었다. 체온은지속적으로해열제투여하며 37~38 C로유지되었다.

4 대한소아응급의학회지제 1 권제 1 호 2014 Fig. 5. Follow-up lateral view of neck soft tissue x-ray that was carried out at 7 days after foreign body removal. Fig. 5. White arrow indicates the hypopharynx that shows clearance of the radiopaque lesion. lack arrow indicates the residual edema and the other radiopaque lesion in the prevertebral soft tissue (C3-C5 level). Unfortunately, the latter was not recognized as a residual foreign body. 타손근주투여를시행하였고, 동반된세균성폐렴의가능성도배제할수없어경험적항생제로세포탁심을투여하였다. 입원기간동안의료진은응급실에서시작했던치료를지속하면서흡기시협착음과기침, 콧물은비슷한정도로유지되었고, 산소투여없이도측정법상산소포화도 99% 로유지되었다. 체온은지속적으로해열제투여하며 37~38 C로유지되었다. 환아는호흡곤란에동반된경미한경구섭취부전이있었으나, 무리없이식이진행하면서체중을 8.5 kg 정도로유지하였다. 제 1병일에시행한이비인후과검사에서인두뒤공간 (retropharyngeal space) 의종괴성병변이있어, 제 3병일에경부컴퓨터단층촬영을시행하였다. 그결과하인두의후방벽에이물이파묻혀있는소견을보였고, 농양을시사하는병변은보이지않았다 (Fig. 4). 이에제 5병일에위내시경을시행하여, 하인두에서상부식도로이어지는부위에서근육에쌓여있는장난감모양의이물을발견하였고, 이것이인두쪽으로튀어나온양상을보였다. 내시경적제거가어려운상황이었기때문에, 제 6병일에수술실에서전신마취후경성기관지경술 (rigid bronchoscopy) 을이용하여장난감플라스틱블록으로보이는이물을한개제거하였다. 이물제거이후 11일간경과관찰하는과정에서, 환아의협착음및호흡곤란은현저하게호전되었으나, 경한정도로지속 Fig. 6. Follow-up lateral view of neck soft tissue x-ray that was carried out at 4 days after discharge. Fig. 6. () White arrow indicates the hypopharynx that shows clearance of the radiopaque lesion. lack arrow indicates the residual lesion in the prevertebral soft tissue (C3-C5 level). () This lesion seemed to be more radiopaque than the last cut (Fig. 5) and it was recognized as a residual foreign body. With magnified view, they could be easily recognizable. 60 Pediatric Emergency Medicine Journal

식도내잔류이물에의한지속적협착음을보인영아 1 례 C D Fig. 7. Follow-up neck computed tomography (CT) scan that was carried out at 10 days after discharge. Fig. 7. (-C) radiopaque foreign body with associated calcification in the prevertebral soft tissue (C3-C5 level) was recognized from axial, coronal and sagittal view.

White arrows indicate the lesion. Fig. 8. Chest computed tomography (CT) scan outside the hospital. Fig. 8. radiopaque foreign body (white arrow) was recognized retrospectively from Chest CT scan that was carried out at the other hospital.

5 식도내잔류이물에의한지속적협착음을보인영아 1 례 C D Fig. 7. Follow-up neck computed tomography (CT) scan that was carried out at 10 days after discharge. Fig. 7. (-C) radiopaque foreign body with associated calcification in the prevertebral soft tissue (C3-C5 level) was recognized from axial, coronal and sagittal view. (D) ut shape of the foreign body was different from that in neck CT scan that was carried out during admission. It means that the radiopaque lesion was residual foreign body. White arrows indicate the lesion. Fig. 8. Chest computed tomography (CT) scan outside the hospital. Fig. 8. radiopaque foreign body (white arrow) was recognized retrospectively from Chest CT scan that was carried out at the other hospital. The formal report was bout cm sized residual radiopaque foreign body in the prevertebral soft tissue at C3-5 level. Please be sure that these images were entirely same with images of Fig. 1. Pediatric Emergency Medicine Journal 61

대한소아응급의학회지제 1 권제 1 호 2014 되었다. 이물제거 7일후시행한경부연조직측면방사선촬영에서하인두의석회화병변은소실되었으나, 척추앞공간의비후와방사선비투과성병변은남아있었다. 하지만이는이물제거후정상적으로남아있을수있는조직의부종과상세불명의석회화병변으로이해되었고 (Fig. 5), 환아상태가양호해외래에서경과관찰하기로하고제 17병일에퇴원했다.

6 대한소아응급의학회지제 1 권제 1 호 2014 되었다. 이물제거 7일후시행한경부연조직측면방사선촬영에서하인두의석회화병변은소실되었으나, 척추앞공간의비후와방사선비투과성병변은남아있었다. 하지만이는이물제거후정상적으로남아있을수있는조직의부종과상세불명의석회화병변으로이해되었고 (Fig. 5), 환아상태가양호해외래에서경과관찰하기로하고제 17병일에퇴원했다. 이후환아의협착음및호흡곤란은지속되었고, 외래에서퇴원후 4일에시행한경부연조직측면방사선촬영에서 C3~C5 수준의척추앞공간연조직의방사선비투과성병변의음영이증가하였다 (Fig. 6). 이에잔류이물가능성있다고보고, 퇴원후 10일에다시경부컴퓨터단층촬영을시행하였다. 그결과 C3~C5 수준의척추앞공간연조직의방사선비투과성병변을재확인하였고, 의료진은이를잔류이물과이에동반된석회화소견이라고판단하였다 (Fig. 7). 이때외부병원에서시행한흉부컴퓨터단층촬영을다시판독한결과, 가장위쪽수준 (C5) 에서방사선비투과성을나타내는이물의심병변이발견되었다 (Fig. 8). 이에퇴원후 12일에위내시경을다시시행하였으나, 이물을발견하지못했고이전에이물이있던부위는상처없이치유된상태였다. 잔류이물에대한수술적제거필요성에대해흉부외과에의뢰하였으나, 이를제거하기위해근치목수술 (radical neck dissection) 이필요한것에비해 환자상태가안정적이어서, 일단 6개월간경과관찰하기로하였다. 이후에경미한협착음과반복적인상기도감염이반복되는상태로, 흉부외과추적진료후수술여부를결정할계획이다. 고찰 소아에서는식도이물에의한기도폐쇄가가능하다 1). 따라서상부기도폐쇄의임상증상을보이는환아에서상부기도내이물이발견되지않았다고하더라도, 경각심을늦추어서는안된다. 소아전문소생술 (Pediatric dvanced Life Support, PLS) 지침에의하면, 이물에의한상부기도폐쇄의경우두가지치료방안이제시된다 9). 첫째는완전한기도폐쇄의경우로, 기침, 호흡, 또는발성의감소가있는경우가이에해당하며즉각적인기도에대한응급처치가필요하다. 둘째는불완전한기도폐쇄의경우로위의사항에해당되지않는경우이며, 이경우어느정도시간여유를가지고병변에대한검사와기관지경술또는수술적제거를고려할수있다. 본증례의환아는앞서열거한완전한기도폐쇄의증상및징후가없었고이후에도뚜렷한임상증상악화가없었기때문에, 시간여유를가지고컴퓨터단층촬영검사및그결과에따라위내시경에의한 Fig. 9. difference of radiologic anatomy of the larynx between children and adults. Fig. 9. Lateral view of neck soft tissue x-ray of this patient () and 43 year-old female patient (). Partially calcified cricoid cartilage (white circle) is recognizable from, but not from. 62 Pediatric Emergency Medicine Journal

7 식도내잔류이물에의한지속적협착음을보인영아 1 례 이물제거를고려하였고, 결과적으로는경성기관지경술로제거하였다. 그리고잔류이물에대해서는수술적제거를고려하고있는상태이다. 영유아연령의식도내잔류이물에의한호흡곤란에관한많은증례를살펴보면, Sherrington 등 3) 과 Haegen 등 6) 은수술적제거를시행하였고, Tauscher 7) 와 Kim 등 8) 은내시경적제거를시행하였다. 본증례에서진단에대한일차적인단서는, 임상증상을제외한다면경부연조직측면방사선촬영소견이라고할수있다. 이검사는소아연령에서급성후두개염, 크룹, 이물에대한검사로많이시행되고있지만, 이를정확하게판독하는것은쉽지않다. 본증례에서이물을수술적으로제거한이후에시행한경부연조직측면방사선촬영에서방사선비투과성병변이지속적으로보였는데도조기에잔류이물을진단하지못한것에서경각심을가져야한다 (Fig. 3, 5, 6). 본증례에서하인두병변을석회화된윤상연골 (cricoid cartilage) 로오인할수가있지만, 윤상연골은피열후두개주름 (aryepiglottic fold) 의직하방에위치한다는점과윤상연골의석회화는 20세이후에시작된다는점을고려하면감별할수있다 (Fig. 9) 10). 또한척추앞공간연조직에서보이는선상의방사선비투과성병변은전종인대골화증 (ossification of the anterior longitudinal ligament, OLL) 과유사하게보인다. 경부방사선촬영에서 OLL의경부방사선촬영소견은, 4~5번경추전방의분절형또는연속형석회화병변이다 11). 사진만으로는이물과 OLL을명확하게구별하긴어렵기때문에단순히검사의판독에의존하기보다는환자의연령과임상증상에서단서를얻어야한다. 이물흡인을의심하게하는환자의병력과 OLL이고령에서발생하는퇴행성질환임을고려한다면 ), 감별진단이어렵지않을것이다 11). 대략적인이물의위치에따른적절한검사를시행하는것이중요하다. 이환아의경우에는상부기도폐쇄의임상증상을보였음에도불구하고, 초기에기관지내시경이아닌경부컴퓨터단층촬영과위내시경을시행하였다. 그이유는, 경부연조직방사선촬영결과 C3~C5 수준의하인두와척추앞공간연조직에서방사선비투과성이물을확인하 였기때문이다. 소아의식도에서이물이걸리는가장흔한위치는윤상인두근 (cricopharyngeus muscle, C6) 인데, 본증례의병변은이위치에근접한다 (Fig. 3) 2). 따라서주증상이호흡곤란과협착음이라고하더라도, 이물의위치가상부식도와그후방의척추앞공간연조직임을알수있다. 위험하지않은이물이라고하더라도식도에 24시간이상머물경우는응급내시경의적응에해당하고 4), 이물의심병변이방사선비투과성을보인다는점과척추앞공간연조직에위치한다는점을고려한다면컴퓨터단층촬영이좋은검사가될수있다 4). 물론이에따른방사선과조영제에대한노출에의한위험을고려해야할것이다. 컴퓨터단층촬영을한다면, 어떤부위를찍어야하는가하는것도경험이적은의사에게고민되는부분이다. 검사의프로토콜은각병원마다다양하지만, 본원의경우흉부컴퓨터단층촬영은 폐야 (lung field) 라고되어있고실질적으로 C5 수준이하가포함되며, 이는본증례의외부병원검사도같은범위를포함하고있었다. 병변이위치할가능성이높은부위, 즉 C3~C5 수준을충분히평가하지못함으로써, 외부병원흉부컴퓨터단층촬영에서이물을시사하는병변이포함되었음에도불구하고이를후향적으로발견하는데에그치고말았다 (Fig. 1, 8). 본원의경부컴퓨터단층촬영범위는 외이도 (external auditory canal) 에서흉곽입구 (thoracic inlet) 로, 이는머리뼈바닥 (skull base) 에서 1번흉추수준을의미한다. 본증례에서경추 3 번 ~5번수준의병변이 X선촬영에서확인되었기때문에, 이에대해추가로컴퓨터단층촬영을한다면경부에대한검사를시행하는것이타당하다. 식도내잔류이물은지속적인호흡곤란과협착음, 삼킴곤란을유발할수있지만, 임상현장에서는간과되기쉽다. 따라서, 다음과같은점을주의해야한다. 첫째, 식도내이물이상부기도폐쇄를유발할수있다는점을이해하고, 이에대한적절한응급처치가필요하다. 둘째, 경부연조직측면 X선촬영에서방사선비투과성병변의위치를파악할수있어야한다. 셋째, 병변의위치에따른적절한검사선택이필요하다. REFERENCES 01. Kliegman RM, Stanton F, St. Geme JW 3rd, Schor NF, ehrman RE. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: ELSEVIER; p Kay M, Wyllie R. Pediatric foreign bodies and their management. Curr Gastroenterol Rep. 2005;7: Sherrington C, Crameri J, Coleman LT, Sawyer SM. Stridor in an infant. Eur Respir J. 1999;14: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli s Emergency Medicine: Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; p Cevik M, Gókdemir MT, oleken ME, Sogut O, Pediatric Emergency Medicine Journal 63

8 대한소아응급의학회지제 1 권제 1 호 2014 Kurkcuoglu C. The characteristics and outcomes of foreign body ingestion and aspiration in children due to lodged foreign body in the aerodigestive tract. Pediatr Emerg Care. 2013;29: Haegen TW, Wojtczak H, Tomita SS. Chronic Inspiratory Stridor Secondary to a Retained Penetrating Radiolucent Esophageal Foreign ody. J Pediatr Surg. 2003;38:e Tauscher JW. Esophageal Foreign ody: n Uncommon Cause of Stridor. Pediatrics. 1978;61: Kim N, tkinson N, Manicone P. Esophageal foreign body: a case of a neonate with stridor. Pediatr Emerg Care. 2008;24: Chameides L, Samson R, Schexnayder SM, Hazinski MF. Pediatric dvanced Life Support provider manual. Texas: merican Heart ssociation; p Wakisaka N, Miwa T, Yoshizaki T, Furukawa M. Cricoid ossification mimicking an impacted foreign body. J Laryngol Otol. 2006;120:E Song J, Mizuno J, Nakagawa H. Clinical and radiological analysis of ossification of the anterior longitudinal ligament causing dysphagia and hoarseness. Neurosurgery. 2006; 58: Pediatric Emergency Medicine Journal

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±è¹ÎÁö 531 김민지 외: 미숙아에 발생한 의인성 식도천공과 기종격증 및 종격동염 A B C D E F Fig. 1. Chest radiographs and CT scans of a premature infant. Chest radiograph at 6 days after birth (A) shows left paravertebral radiolucency at the