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1 The Korean Journal of Gastrointestinal Endoscopy Room A 내시경의사를위한구강및인후두의해부와생리 홍현준 연세대학교의과대학이비인후과학교실 Anatomy and Physiology of Oral Cavity and Laryngo-Pharynx for Endoscopist Hyun Jun Hong, M.D. Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea 서론 1970년대초반굴곡형상부위장관내시경검사가임상진료에도입후에내시경검사는위장관질환의진단, 평가및치료에필수적자리를잡아가고있다. 최근들어진단용으로만이용되던내시경시술이점차치료의영역까지확대되고있는실정이다. 여러분야에서기술적발전과더불어다양한내시경의제작기술이향상되고발전되어개복수술보다는일차적으로내시경시술로치료를시도하고있다. 이에보다많은의사들이위식도내시경술기에익숙해지기를원하고있다. 위식도내시경술기를처음시작하는의사는일반적으로시행되는진단적위식도내시경술에서만나게되는해부구조와생리학적특징을숙지하는것이무엇보다중요하다고할수있다. 특별히접근로로지나가게되는구강, 구인두, 하인두는경험이많지않은내시경의사에게는익숙하지않은구조물이다. 초보내시경의사들은익숙하지않은구조와숙련되지않은술기로인해상기도에손상을주는입는경우가생길수있다. 또한숙련된내시경의라하더라도구강, 구인두, 하인두및후두의병변이있는경우를간과하고지나치는경우가발생하기도한다. 이에위식도내시경에서꼭알고있어야하는구강, 구인두, 하인두및후두의해부구조와생리에관하여논하고자한다. 이비인후과 - 두경부외과해부구조 1. 얼굴 (Face) 과피부 (Skin) 2. 코 (Nose): 외비 (External nose) 3. 비강 (Nasal cavity) 1) 비전정 (Nasal vestibule) 2) 비강상벽 (Roof of nasal cavity) 3) 비중격 (Nasal septum) 4) 비강저 (Floor of nasal cavity) 5) 비강측벽 (Lateral wall of nasal cavity) (1) 하비도 (Inferior meatus) - 하비갑개 (Inferior turbinate) (2) 중비도 (Middle meatus) - 중비갑개 (Middle turbinate) (3) 상비도 (Superior meatus) - 상비갑개 (Superor turbinate) 4. 부비동 (Paranasal sinus) 1) 전두동 (Frontal sinus) 2) 상악동 (Maxillary sinus) 3) 사골동 (Ehtmoid sinus) 4) 접형동 (Sphenoid sinus) 5. 구강 (Oral cavity) - 7 subunits 1) 구순 (Lip) 2) 구강설 (Oral tongue): 주의! 설근부 (Base of tongue) 는구인두 3) 구강저 (Floor of mouth) 4) 치은 (Gingiva) 5) 협부점막 (Buccal mucosa) 6) 후구치삼각 (Retromolar trigone) 7) 경구개 (Hard palate): 주의! 연구개 (Soft palate) 는구인두 6. 인두 (Pharynx) 1) 비인두 (Nasopharynx) 2) 구인두 (Oropharynx) 3) 하인두 (Hypopharynx): 3 Ps (1) 이상와 (Pyriform sinus) (2) 하인두후벽 (Posterior wall of HPx) (3) 후윤상 (Postcricoid) 7. 후두 (Larynx) 1) 성문상부 (Supraglottis) (1) Epiglottis (2) Aryepiglottic fold (3) False vocal cords (4) Ventricle (5) Arytenoid cartilages (6) Cuneiform cartilages 2) 성문부 (Glottis) 44 The Korean Journal of Gastrointestinal Endoscopy

3) 성문하부 (Subglottis) 8. 기관 (Trachea) 및기관지 (Bronchus) 9. 식도 (Esophagus) 10.

침샘 (Salivary gland) 1) 이하선 (Parotid gland) 2) 악하선 (Submandibular gland) 3) 설하선 (Sublingual gland) 4) 기타침샘 (Minor

구강의경계는구순또는순홍부 (lip) 가앞쪽경계를이루고, 경구개와연구개의경계부위가상후방경계, 유곽유두 (circumvallate papilla) 가하후방경계를이룬다.

2 3) 성문하부 (Subglottis) 8. 기관 (Trachea) 및기관지 (Bronchus) 9. 식도 (Esophagus) 10. 경부 (Neck) 1) 경부림프절 (Cervical lymph node) 2) 경부정맥, 동맥, 뇌신경, 척수신경등 11. 침샘 (Salivary gland) 1) 이하선 (Parotid gland) 2) 악하선 (Submandibular gland) 3) 설하선 (Sublingual gland) 4) 기타침샘 (Minor salivary gland) 12. 갑상선 (Thyroid) 과부갑상선 (Parathyroid gland) 구강의해부 Figure 1. Nasal cavity and pharynx. 구강의경계는구순또는순홍부 (lip) 가앞쪽경계를이루고, 경구개와연구개의경계부위가상후방경계, 유곽유두 (circumvallate papilla) 가하후방경계를이룬다. 구강은다시구순 (lips), 구강설 (oral tongue), 구강저 (floor of mouth), 상ㆍ하치조능 (upper & lower alveolar ridge), 협부점막 (buccal mucosa), 후구치삼각 (retromolar trigone), 경구개 (hard palate) 등으로세분된다. Figure 2. Paranasal sinus (PNS), nasal cavity and pharynx. Vol. 41 (Suppl 2), 2010 (44-53) 45

구인두의해부 Figure 3. Oral cavity. 인두 (pharynx) 는후두상부에위치하고있는소화기관의일부로서두개저 (skull base) 에서부터시작해후두와식도에이르는근점막으로된공간으로서, 상부는두개저에단단히부착되어있으며하부는제6경추 (C6) 높이에해당하는윤상연골의하연높이에서식도입구 (esophageal inlet) 로이행된다.

3 구인두의해부 Figure 3. Oral cavity. 인두 (pharynx) 는후두상부에위치하고있는소화기관의일부로서두개저 (skull base) 에서부터시작해후두와식도에이르는근점막으로된공간으로서, 상부는두개저에단단히부착되어있으며하부는제6경추 (C6) 높이에해당하는윤상연골의하연높이에서식도입구 (esophageal inlet) 로이행된다. 인두의총길이는약 12.5 cm 정도로서, 두개저부위가전후직경이 3.5 cm 로가장넓고, 식도와연결되는부위가 1.5 cm로가장좁다. 인두는 2개의비강 (nasal cavity), 2개의고실 (tympanic cavity), 구강, 후두, 그리고식도등총 7개의공간과연결되어있다. 인두는비인두, 구인두, 하인두 3개부분으로구분된다. 비인두와구인두의경계는연구개의하연, 구인두와하인두의경계는후두개의상연이다. 이중구인두는구강에일치되는부분으로서하부경계는설골대각의높이에해당되는데, 대개설근부로보아도좋다. 전방부의구강으로통하는부위는좁아져서구협 (fauces) 이라한다. 구협의양측으로연구개가전후로분리되어전후구개궁 (anterior and posterior pillars) 을만들고, 그사이의함몰부는편도와 tonsillar fossa로서이곳에구개편도가있다. 설근부에는설편도가있고인두후벽은경추에경근막과소성조직으로부착되어있으며, 척추전근막 (prevertebral fascia) 과내장막 (visceral fascia), 협인근막 (buccopharyngeal fascia) 사이에만들어지는잠재적공간이후인두공간 (retropharyngeal space) 이다. 구인두의점막은중층편평상피로되어있 Figure 4. Orophaynx. 46 The Korean Journal of Gastrointestinal Endoscopy

고, 비인두는섬모상피로되어있다. 구인두에해당되는구조는다음과같다. 1. 연구개 (Soft palate) 2. 구개수 (Uvula) 3. 설근부 (Base of tongue) 4. 편도 (Tonsil) 5. 후두개곡 (Vallecula) 6. 구인두후벽 (Posterior pharyngeal wall) 하인두의해부하인두는 3개의인두중가장길이가길다.

4 고, 비인두는섬모상피로되어있다. 구인두에해당되는구조는다음과같다. 1. 연구개 (Soft palate) 2. 구개수 (Uvula) 3. 설근부 (Base of tongue) 4. 편도 (Tonsil) 5. 후두개곡 (Vallecula) 6. 구인두후벽 (Posterior pharyngeal wall) 하인두의해부하인두는 3개의인두중가장길이가길다. 하인두의위쪽경계는설골 (hyoid bone) 상부이며, 아래쪽경계는윤상연골의하연까지이고그밑으로는좁아지면서식도와연결되어있다. 앞쪽경계는, 중앙으로후두개와후두입구그리고후두의후벽이있으며, 그측면으로피열후두개주름 (aryepiglottic fold), 그리고더측면으로는주로갑상연골의내측점막으로이루어진이상와 (pyriform sinus) 가존재한다. 하인두의점막은비각질중층편평상피 (nonkeratinizing stratified squamous epithelium) 로덮여있다. 점막밑에인두수축근 (pharyngeal constrictor muscel) 이있으며, 이두층사이에인두기저근막 (pharyngobasilar fascia) 이존재한다. 인두기저근막은두개저에부착되어있고비인두부위에서는두꺼워서확인이가능하나, 하인두부위에서는확실한층으로확인하기어려울정도이다. 인두수축근은협인두근막 (buccopharyngeal fascia) 으로덮여있으며, 이층에서인두에분포하고있는신경과혈관들이총 (plexus) 을이루고있다. 1. Hypopharyx 3Ps 1) 하인두후벽 (Posterior wall of HPx): 상방으로는후두개의첨단에해당하는부위에서부터하방으로윤상인두근하부에해당하는부위까지의인두후벽을말한다. 외측으로는설골과갑상연골, 그리고이상와의외측벽에부착된다. 그러나하인두후벽의확실한해부학적경계와지표는없다. 2) 후윤상부 (Postcricoid area): 후윤상부란후두의뒤쪽중앙부위의외측후벽, 즉피열연골과윤상연골판 cricoid posterior lamina을후방에서덮고있는점막을말한다. 이역시확실한해부학적경계와지표는없다. 3) 이상와 (Pyriform sinus): 후두개의외측에인두의구인두와후두부의전측방경계부인인두후두개주름 (pharyngoepiglottic fold) 이존재한다. 양쪽의인두후두개추벽하측방으로갑상연골과후두사이를이상와라하며, 이는하방으로갈수록좁아져역피라미드모양을하고있다. 이상와의외측벽은갑상연골의내측점막이며, 내측벽은후두의외측점막이이루고있다. 역피라미드형의이상와의가장좁은아래쪽끝부분을첨부 (apex) 라하며, 첨부위치는윤상연골보다아래까지내려가있다. 이상와의전측방경계는인두후두개주름이고외측경계는갑상연골 (thyroid cartilage), 내측경계는피열후두개주름 (aryepiglottic fold) 과피열연골 (arytenoids cartilage) 이다. Figure 5. Hypopharynx. Vol. 41 (Suppl 2), 2010 (44-53) 47

cartilage) 등으로이루어져있다. 연골들은서로연결되어있는후두근육, 인대, 그리고막들에의해움직인다. 갑상연골과윤상연골, 그리고피열연골의대부분은초자연골 hyaline cartilage 로이루어져있는데, 갑상연골은 25 세를전후하여점차적으로석회화되기시작한다.

1) 갑상연골 (Thyroid cartilage) 2) 윤상연골 (Cricoid cartilage) 3) 후두개연골 (Epiglottis) 4) 피열연골 (Arytenoid cartilage) 5) 소각연골 (Corniculate cartilage) 6) 설상연골 (Cuneiform cartilage) 2.

5 후두의해부 1. 후두의골격 (Laryngeal framework) 후두의골격은갑상연골 (thyroid cartilage), 윤상연골 (cricoid cartilage), 후두개연골 (epiglottic cartilage), 그리고쌍으로된피열연골 (arytenoid cartilage), 소각연골 (corniculate cartilage) 과설상연골 (cuneiform cartilage) 등으로이루어져있다. 연골들은서로연결되어있는후두근육, 인대, 그리고막들에의해움직인다. 갑상연골과윤상연골, 그리고피열연골의대부분은초자연골 hyaline cartilage 로이루어져있는데, 갑상연골은 25 세를전후하여점차적으로석회화되기시작한다. 소각연골과설상연골, 그리고후두개연골과피열연골의일부는탄성연골 elastic cartilage로이루어져있기때문에석회화되지않는다. 1) 갑상연골 (Thyroid cartilage) 2) 윤상연골 (Cricoid cartilage) 3) 후두개연골 (Epiglottis) 4) 피열연골 (Arytenoid cartilage) 5) 소각연골 (Corniculate cartilage) 6) 설상연골 (Cuneiform cartilage) 2. 후두의관절 1) 윤상갑상관절 (Cricothyroid joint) 2) 윤상피열관절 (Cricoarytenoid joint): sliding and rocking movements 3. 후두강과점막 4. 후두근육 1) 후두내근 (Laryngeal muscles) 2) 후두외근 (Extrinsic laryngeal muscles): Strap muscles (1) 설골상근 (Suprahyoid strap muscles) 1 Digastrics muscle 2 Stylohyoid muscle 3 Geniohyoid muscle 4 Mylohyoid muscle 5 Stylopharyngeus (2) 설골하근 (Infrahyoid strap muscles) 1 Sternohyoid muscle 2 Sternothyroid muscle 3 Thyrohyoid muscle 4 Omohyoid muscle Figure 6. Larynx. Figure 7. The larynx: viewed from above. Figure 8. Normal larynx as seen during larynx examination or laryngoscopy: 1, vocal cords; 2, vestibular fold (false vocal cords); 3, epiglottis; 4, plica aryepiglottica (aryepiglottic fold); 5, arytenoid cartilage; 6, sinus pyriform; 7, base of the tongue. 48 The Korean Journal of Gastrointestinal Endoscopy

섭취작용 1) 저작운동 (Mastication) 2) 소화 (Digestion) 3) 연하운동 (Swallowing) 2. 미각작용 1) 미뢰 (Taste bud) 3. 구음작용 1.

6 Figure 9. Intrinsic muscles of larynx. 구인두의생리 1. 생체보호작용 2. 호흡기류의통로 3. 공명작용 4. 연하작용 1) 밸브기능 2) 압력형성 후두의생리 Figure 10. Passage of air and food. 구강의생리 1. 섭취작용 1) 저작운동 (Mastication) 2) 소화 (Digestion) 3) 연하운동 (Swallowing) 2. 미각작용 1) 미뢰 (Taste bud) 3. 구음작용 1. 후두의기능 1) 기도보호 2) 호흡 3) 발성 4) 연하 2. 후두반사 1) 점막반사 2) 관절반사 3) 근정지반사 4) 성문폐쇄반사 5) 호흡억제반사 6) 연하개시반사 7) 호흡반사 8) 후두분비촉진반사 9) 자율신경계의반사 Vol. 41 (Suppl 2), 2010 (44-53) 49

(Upper esophageal sphincter relaxtion) 4) 식도기 (Esophageal stage) 위식도내시경시접하게되는구강및인후두의소견 1. 구강및구인두 1) Mallampati classification 2.

7 하인두의생리 1. 하인두의기능 1) 호흡의보조 2) 연하작용 2. 연하작용의 4단계 1) 구강준비기 (Oral preparatory stage) 2) 구강기 (Oral stage) 3) 인두기 (Pharyngeal stage) (1) 구개인두폐쇄 (Velopharyngeal closure) (2) 후두거상 (Laryngeal elevation) (3) 후두페쇄 (Laryngeal closure) (4) 상부식도괄약근이완 (Upper esophageal sphincter relaxtion) 4) 식도기 (Esophageal stage) 위식도내시경시접하게되는구강및인후두의소견 1. 구강및구인두 1) Mallampati classification 2. 후두 1) 후두개낭종 (Epiglottic cyst) 2) 성대폴립 (Vocal polyp) 3) 성대결절 (Vocal nodules) 4) 후두육아종 (Layngeal granuloma) 5) 후두유두종 (Laryngeal papilloma) 6) 후두암 (Laryngeal cancer) 3. 하인두 1) 하인두암 (Hypopharyngeal cancer) 역류성인후두염 (Laryngepharyngeal reflux disease; LPRD) 의후두내시경소견 1. 가성대구증 (Subglottic edema; pseudosulcus) 2. 성대문폐쇄 (Ventricular obliteration) 3. 후두발적 (Erythema, hyperemia) 4. 성대부종 (Vocal cord edema) 5. 전반적인후두부종 (Diffuse laryngeal edema) 6. 후교련비대및점막비후 (Posterior commisure hypertrophy; Interarytenoid injection and thickening; pachyderma) 7. 궤양및육아종 (Contact ulcer, granuloma or granulation) 8. 진한후두점액 (Thick endolarygeal mucus) Figure 11. Mallampati classification. Figure 12. Laryngeal findings of Laryngepharyngeal reflux disease; LPRD. 50 The Korean Journal of Gastrointestinal Endoscopy

8 결론 진단적위식도내시경술에서접근로에서만나게되는구강, 구인두, 하인두및후두는내시경술기를익숙하지않은경험이부족한의사에게는친숙하지않은구조물이다. 이부위의해부구조와생리적인특징을잘숙지한다면상기도에손상을주는입는경우를피할수있을것이다. 또한구강, 구인두, 하인두및후두의의심되는이상병변이있는경우를간과하지않고기록한후에이비인후과-두경부외과의에진료를의뢰한다면환자의두경부암조기진단및관리에도움을줄수있으리라예상한다. 참고문헌 1. Beidler LM, Smallman R. Renewal of cells within taste buds. J Cell Biol 1965;27: Graney DO, Petruzzelli GJ, Myeres EN. Anatomy & Physiology. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology Head & Neck Surgery. 3rd ed. St Louis: Mosby-Year Book, Inc, 1998: Dantas RO, Dodds WJ, Massey BT, et al. Manometric characteristics of the glossopalatal sphincter. Dig Dis Sci 1990; 35: Farbman AL. Renewal of taste bud cells in rat circumvallate papillae. Cell Tissue Kinet 1980;13: Hollinshead. The jaws, palate, and tongue. In: Anatomy for surgeons vol.1. 3rd ed. Harper & Row: Publishers, Inc, 1982: Jacob P, Kahrilas P, Logemann J, et al. Upper esophageal sphincter opening and modulation during swallowing. Gastroenterology 1989;97: Kahrilas P, Dodds W, Dent J, et al. Upper esophageal sphincter function during deglutition. Gastroenterology 1988; 95: Kagrilas PJ, Lim S, Logemann JA, et al. Deglutitive tongue action: volume accommodation and bolus propulsion. Gastroenterology 1993;104: Kahrilas PJ, Lin S, Chen J, et al. Oropharyngeal accommodation to swallow volume. Gastroenterology 1996;111: Kahrilas PJ, Logemann JA, Lin S, et al. Pharygeal clearance durion swallow: a combined manometric and videofluoroscopic study. Gastroenterology 1992;103: Logemann JA. Evaluation and treatment of swallowing disorders. San Diego: Collage Hill, 1983: Logemann JA, Kahrilas PJ, Cheng J, et al. Closure mechanisms of the laryngeal vestibule during swallow. Am J Physiol 1992; 262:G Pouderoux P, Kahrilas PJ. Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology 1995;108: Shawker TH, Sonies B, Stone M, et al. Real time ultrasound visualization of tongue movement during swallowing. J Clin Ultrasound 1983;11: Clemente CD. In Anatomy of the human body. 30th ed. Philadelphia: Lea & Febiger, 1985: Daniels E. Embriology of the neck. In: Tewfik TL, Der Kalou-stain VM, eds. Congenital anomalies of the ear, nose and throat. 1st ed. New York: Oxford University Press, 1997: Sasaki CT. Postnatal descent of the epiglottis in man: a preliminary report. Arch Otolaryngol Head and Neck Surg 1977;103: Hirano M, Kurita S, Nakashima T. Growth, developement and aging of human vocal folds. In: Bless DM, Abbs JH, eds. Vocal fold physiology: comtemporary research and clinical issues. San Diego: College Hill Press, 1983: Meller SM. Functional anatomy of the larynx. Otolaryngol Clin North Am 1984;17: Fried MP, Meller SM. Adult laryngeal anatomy. In: Fried MP, ed. The Larynx. Boston: Little, Brown, 1988: Fink BR, Demarest RJ. Laryngeal Biomechanics. Harvard university press. Cambridge, Massachusetts, and London, England, 1978: Graney DO, Flint PW. Anatomy of the larynx. In: Cummings CW, Fredricson JM, Harker LA, et al, eds. Otolaryngology Head and Neck Surgery. 3rd ed. 1998: Lev MH, Curtin HD. Larynx. Neuroimaging Clin North Am 1988;8: Turker HM. The larynx. 2nd ed. New York: Thieme Medical Publishers, Inc., 1993: Hirano M. Morphological structure of the vocal cord as a vibrator and its variations. Folia Phoniatrica 1974;26: Hollinshead WH. Anatomy for Surgeons: Vol 1. The Head and Neck. 3rd ed. East Washington Square, Philadelphia, Pennsylvania: Harper & Row Publishers, Inc., 1982: Sanders I, Jacobs I, Wu BL, Biller HF. The three bellies of the canine posterior cricoarytenoid muscle: Implications for understanding laryngeal function. Laryngoscope 1993;103: Sanders I, Wu BL, Mu L, Biller HF. The innervation of the human posterior cricoarytenoid muscle: Evidence for at least two neuromuscular compartment. Laryngoscope 1994;104: Zaretsky L, Sanders I. The three belly of the canine cricoarytenoid muscle. Ann Rhinol Laryngol 1992;101: Garett JD, Larson CR. Neurology of the laryngeal systeme. phonosurgery: assessment and surgical management of voice disorders. In: Ford CN, Bless DM, eds. New York: Raven Press, Ltd., 1991: Kahane JC. Functional histology of the larynx. In: Cummings CW, Fredricson JM, Harker LA, et al, eds. Otolaryngology head and neck surgery. 3rd ed. vol 3. St Louis: Mosby Year Book, Inc. 1998: English DT, Blevins CE. Motor unit of laryngeal muscles. Arch Otolaryngol 1996;89: Rosen M, Malmgren LT, Gacek RR. Three dimensional computer reconstruction of the distribution of neuromuscular junctions thyroarytenoid muscle. Ann Otol Rhinol Laryngol Vol. 41 (Suppl 2), 2010 (44-53) 51

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10 73. Mansson I, Sandberg N. Oropharyngeal sensitivity and elicitation of swallowing in man. Acta Otolaryngol 1975;79: Kahrilas PJ, Lim S, Logemann JA, Ergun GA, Facchini F. Deglutive tongue action: volume accomodation and bolus propulsion. Gastroenterology 1993;104: Kahrilas PJ, Lin S, Chen J, Logemann JA. Oropharyngeal accommodation to swallow volume. Gastroenterology 1996; 111: Mc Connell FM. Analysis of pressure generation and bolus transit during pharyngeal swallowing. Laryngoscope 1988; 98: Logemann JA, Kahrilas PJ, Cheng J, Pauloski BR, Gibbons PJ, Rademaker AW. Closure mechanism of thelaryngeal vestibule during swallow. Am J Physiol 1992;262:G Kahrilas P, Dodds W, Dent J, Logemann JA, Shaker R. Upper esophageal sphincter action during deglutition. Gastroenterology 1988;95: Vol. 41 (Suppl 2), 2010 (44-53) 53

1548 Fig. 1. Laryngeal preparation for the laryngeal chemoreflex in puppy. Thyroid cartilage was retracted and bipolar, concentric needle electrode wa

1548 Fig. 1. Laryngeal preparation for the laryngeal chemoreflex in puppy. Thyroid cartilage was retracted and bipolar, concentric needle electrode wa KISEP Head and Neck Korean J Otolaryngol 1999;42:1547-54 강아지의후두화학반사에대한실험적연구 박한규 김광문 홍원표 김영호 김명상 김동영 Experimental Study of Laryngeal Chemoreflex in Puppies Han Q Park, MD, Kwang-Moon Kim, MD, Won Pyo Hong,