대한장애인치과학회지 9(1) 2013 고림프절과혈행을통해전파되어서생명을위협하기도한다 1,2). 치성감염의치료는원인균을명확히이해하고치성감염의발생기전과감염시확산될수있는해부학적인구조를알고치료계획을결정해야한다. 따라서우선감염의심각성정도를결정하고, 환자의병력과신체의방어기전상태를

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1 Korean Association for Disability and Oral Health 9(1) 증 례 다발성전신질환장애환자에서진행성치성감염에의한측두간극농양절개배농시창상주위봉합과배농술에의한과도한출혈조절 : 증례보고 손정석 오지현 유재하 * 연세대학교치과대학구강악안면외과학교실 ( 원주세브란스기독병원 ) Abstract BLEEDING CONTROL BY THE CIRCUMFERENTIAL SUTURE & DRAINAGE ON ACTIVE BLEEDING INCISION & DRAINAGE SITE OF TEMPORAL SPACE ABSCESS DUE TO ADVANCED ODONTOGENIC INFECTION IN A MULTIPLE MEDICALLY COMPROMISED DISABLED PATIENT : REPORT OF A CASE Jeong-Seog Son, Ji-Hyeon Oh, Jae-Ha Yoo* Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University(Wonju Severance Christian Hospital) The four principles of treatment of odontogenic infection are as follows : (1) removal of the cause, (2) establishment of drainage, (3) institution of antibiotic therapy, and (4) provision of supportive care, including proper rest and nutrition. A separate incision is required to establish drainage, especially in the case of extensive fascial space infections. There are four principle causes for active bleeding in the immediate incision & drainage phase; (1) vascular wall alteration (infection, scurvy, chemicals), (2) disorder of platelet function, (3) thrombocytopenic purpuras, (4) disorders of coagulation (liver disease, anticoagulation drug). If the hemorrhage from incision & drainage site is aggressive, the site must be packed with proper wet gauze and wound closure & drainage dressing are applied. The specific causes of bleeding may be associated with hypoxia, changes in the ph of blood & chemical changes affecting vascular contractility and blood clotting. This is a case report of bleeding control by the circumferential suture & drainage on active bleeding incision & drainage site of temporal space abscess due to advanced odontogenic infection in a multiple medically compromised disabled patient. [J Korean Dis Oral Health Vol.9, No.1: 30-35, Jun 2013] Key words : Active bleeding, Incision & drainage, Temporal space abscess, Medically compromised patient 교신저자 : 유재하 강원도원주시일산동 162 연세대학교원주세브란스기독병원치과학교실 Tel: , Fax: yun8288@hanmail.net Ⅰ. 서론감염성질환은치과임상에서다루기어려운질환들중하나로일반적으로국소화되어통상적인처치로치유가많이되지만, 진행되면근막간극을통하여인접조직으로파급되 원고접수일 : / 원고최종수정일 : / 원고채택일 :

그러나다발성전신질환장애환자에서치성감염이진행되면전신면역성의약화로, 관련의학과 ( 주로감염내과 ) 와의협진이필수적이고, 절개배농술등의국소적인치과 ( 구강악안면외과 ) 진료도시술자체가출혈과동통증가로매우위험해, 임상의와환자모두에게당혹감을주게된다 6,7).

2 대한장애인치과학회지 9(1) 2013 고림프절과혈행을통해전파되어서생명을위협하기도한다 1,2). 치성감염의치료는원인균을명확히이해하고치성감염의발생기전과감염시확산될수있는해부학적인구조를알고치료계획을결정해야한다. 따라서우선감염의심각성정도를결정하고, 환자의병력과신체의방어기전상태를평가하면서, 외과적시술을통하여절개배농술이나항생제등의약물요법과수액영양요법등을시행하게된다 3-5). 그러나다발성전신질환장애환자에서치성감염이진행되면전신면역성의약화로, 관련의학과 ( 주로감염내과 ) 와의협진이필수적이고, 절개배농술등의국소적인치과 ( 구강악안면외과 ) 진료도시술자체가출혈과동통증가로매우위험해, 임상의와환자모두에게당혹감을주게된다 6,7). 특히치성감염이악화되어서일차성근막간극을지나 2차성근막간극 ( 교근간극, 익돌하악간극, 측두간극 ) 까지파급된경우는진정요법과국소마취하에절개배농술시행시감염조직의과도한충혈과혈관의미란 (erosion) 등으로과도한출혈이발생되어, 생명을위협하는저혈량성쇼크에까지이를수있으므로, 매우주의가요망된다 8-10). 이에저자등은고혈압, 당뇨병, 뇌졸중, 빈혈, 천식, 신장질환등다발성전신질환이있던 74세남환에서하악구치부치성감염이측두근막간극농양까지진행된증례에서, 감염내과입원하에충분한수액약물요법으로전신상태가호전된것을확인하고, 진정요법과치과용국소마취시행하에측두간극농양부에절개배농술을실시하던중과도한출혈이발생되어, 황급히습윤압박거즈적용, 추가적국소마취시행, 절개배농창상주위봉합술 (circumferential suture) 및배농재료 (rubber & iodoform gauze drain) 삽입술과지속적압박드렛싱으로지혈과감염조절을달성했던치험을보고한다. 하, 천식, 당뇨, 뇌졸중이확인되어서 (Table 1), 수액약물요법 ( 항생제와소염진통제, 영양제등 ) 을실시했고, 절개배농술준비를위해 3일간항응고제인플래비스 (plavix) 를신경과협진으로중지시킨후에감염내과동의하에본치과 Fig. 1. Initial facial view. Fig. 2. Initial panoramic view. Ⅱ. 증례보고 74세남자환자로약 30년전부터고혈압과당뇨병을앓아왔고, 약 10년전에는뇌졸중으로쓰러지셔서한방병원과지방대학병원에서경구투약 ( 플래비스등 ), 재활치료등을받아오시던중, 약 1주일전부터우측턱주위안면부의종창과동통이있어, 지방의료원 ( 과거도립병원 ) 에서항생제 (vancomycin, cifrofloxacin) 치료를받았지만, 증상이악화되어본원으로내원했다 (2012년 4월 25일응급실로내원했고, 고혈압과미열이있어감염내과로입원하심 ). 구강악안면검사결과하악우측대구치부 ( 치식 :#46, 47) 금속관내부충치와치주염에서치성감염이시작되어하악골수염, 골막염, 악하간극, 협간극, 안와하간극, 측두하간극, 천측두간극농양까지진행된상태였고 (Fig. 1), 방사선사진검사에서도골파괴가관찰되었다 (Fig. 2). 임상병리검사등전신검사에서는빈혈, 전해질불균형, 신장기능저 Table 1. Initial major laboratory data & normal range WBC (4.0~10.0) RBC 3.64 (4.2~5.7) Hemoglobin 9.2 (13.5~17.0) Hematocrit 28.0 (40~53) Platelet count 288 (165~360) P.T (9.5~12.8) P.T.T (27.9~37.8) E.S.R. 75 (1~20) Na 129 (136.0~145.0) K 3.6 (3.5~5.1) Cl 101 (98.0~107.0) BUN 31 (.~< 20.0) Creatinine 1.66 (.~< 1.4) Glucose 74 (80~115) SGOT 30 (.~< 40) SGPT 14 (.~< 40)

최초 10 cc를주입하고나중 10 cc 추가주입함 ) 으로정신안정을유도하고서, 2% lidocaine HCl (1:10만 epinephrine 포함 ) 2 ampules로우측천측두간극농양부에국소마취를시행했다.

3 Korean Association for Disability and Oral Health 9(1) 2013 에서 valium(diazepam) 정주를이용한진정요법과치과용국소마취시행하에종창과동통이과도한우측천측두간극농양부에절개배농치료를계획했다. 병실에서거동할수없는환자를수술방이동용소침상으로옮겨서치과외래로이동시키고, 절개배농술을시행할창상 ( 우측측두간극농양주위로머리카락면도와소독시행 ) 부위에진정요법 ( 통상적인수액제인 5% Dextrose Solution 1,000 cc와종합영양제인카비벤페리액을설치한상태에서, valium 1 ampule과주사용증류수 20 cc를혼합한액체를서서히정맥주사로로주입시키되, 최초 10 cc를주입하고나중 10 cc 추가주입함 ) 으로정신안정을유도하고서, 2% lidocaine HCl (1:10만 epinephrine 포함 ) 2 ampules로우측천측두간극농양부에국소마취를시행했다. 약 5분경과후 #15 blade로절개배농술을시행하는순간감염창상내부에서과도한출혈 (active bleeding) 이관찰되어서, 부득이 4인치폭의습윤거즈 (wet gauze) 로황급히압박지혈을 20분간시행했는데, 그후에도계속출혈이과도해서 2인치폭의습윤거즈를길게말아서절개창상내부로압박시키는전색 (packing) 술을시행했고, 동통방지와출혈감소를위해, 절개배농창주위의천측두간극농양주위피부와피하조직에, 국소마취를추가적으로 4 ampules 침윤마취형태로시행했고, 또 30분간습윤압박거즈지혈을시도한결과지혈이달성되었다. 따라서절개배농창내부에전색시켰던 2인치폭습윤거즈를제거했고, 후출혈방지를위해절개배농창상주위로촘촘하게봉합술을추가했고, 나중국소마취가풀리고 2차적인혈관확장에의한추가출혈의방지와천측두간극농양강배농을위해, 고무배농재 (rubber drain) 를깊이삽입하고봉합한다음에, 절개배농창내사강 (dead space) 방지를위해요오드포름거즈 ( 상품명 Nu-gauze) 배농재를삽입하고서, 창상드렛싱을완료했다 (Fig. 3). 다음날구강외부천측두간극농양부의절개배농술부위의후출혈이없음을확인했고, 약 3주일간개구훈련을통해개구범위가 2.5 cm 정도되어서, 원인치아 (#46, 47) 발치와발치창상및구강내협부간극농양부절개배농술을실시했다 (Fig. 4). 그후통상적인드렛싱및전신면역성증진을위한수액약물 ( 영양 ) 요법을약 1개월간시행받은다음퇴원해, 통원가료를약 1개월간시행해완치가되었으며, 상실치아부의가철성국소의치장착도가능하게되었다. Ⅲ. 총괄및고찰치성감염은일반적으로항생제와소염진통제의약물요법, 수액요법, 절개배농술이나발치등국소적인외과적처치에의해치료될수있으나, 경우에따라서는악화되어서인접한근막간극으로파급되거나주위림프조직및혈행을따라전파되어서패혈증, 기도폐쇄, 해면정맥동혈전증, 종격동염등으로생명에큰위협이될수있다 1,4,11). 근막간극이란근막으로둘러싸여있으며, 소성결합조직과화농성삼출물에의해형성되는잠재성의공간으로, 치성감염에서직접이환되는일차성근막간극 ( 주로협부, 안와하, 측두하, 이하, 악하, 설하간극들 ) 과후방으로확산되어결과적으로이환되는이차성근막간극으로구분된다 3,5). 대표적인이차성근막간극에는교근간극, 익돌하악간극, 측두간극이있으며, 이보다더진행되면심층경부간극까지확산되어상기도폐쇄나종격동염같은합병증의발생으로이어질수있다 12). 치성감염치료의 4가지원리는 (1) 원인의제거, (2) 배농로의확보, (3) 수액약물요법 (4) 적절한휴식과영양관리로요약되는데, 초기치료는가능한한조기에수행되어야한다 5,9). 근관치료와발치는치수나치근단감염의원인을제거하는가장일반적인치료이며, 발치는자발적으로원인을제거하고배농로를제공한다. 근관치료는제한된배 Fig. 3. Incision & drainage view on the superficial temporal space abscess. Fig. 4. Teeth (#46.47) extraction, suture & intraoral drainage view

4 대한장애인치과학회지 9(1) 2013 농로를제공하므로, 만약배농이불충분하다면국소적인절개가인접연조직에필요할것이다. 감염이인접해부학적조직면의경계를넘어확장되면, 감염의전파가넓고빠르게인접간극으로파급되어서생명을위협하는상황이발생되는데, 이에는크게 3가지가능성이있다 (Table 2) 1,9). 본증례에서도하악우측대구치부위에서발생된치성감염이골수염과골막염을거쳐서협간극, 안와하간극, 측두하간극, 측두근막간극까지농양과봉와직염이파급된경우로, 좀더진행되면뇌막염, 뇌농양, 해면정맥동혈전증, 패혈증까지초래될수있는상황이어서상당한주의가요망되었다. 이에감염내과로입원하에신경과협진까지우선시행하고서, 전신상태호전후에치과진료를시행하게되었으며, 개구장애로발치는연기했고, 우선측두간극농양부절개배농술을먼저시행케되었다. 한편치성감염발생시면역반응은동시에진행되는 3가지방어기제에의존하는데, 여기에는체액성요소, 세포성요소, 국소요소들이관련된다 1,6,7). 먼저체액성요소는순환하는면역글로불린, 보체계단백질, 다른기질들이지속적으로동원을돕고염증가능성부위에면역시스템을집중시킨다. 보체계를따라면역글로불린은미생물과결합하여대식세포 (macrophage) 에의해식 균작용을유도하는옵소닌 (opsonin) 으로불리는단위들 (units) 을형성한다. 게다가면역글로불린 ( 특히, IgA) 은상피세포수용체와의접착을막아구강점막의미생물군락형성을막을수있다. 하지만, 감염시는다른화학적매개체가혈관확장과투과성을높여염증반응을지원한다. 또한세포성요소인식세포는미생물을사로잡아죽이는작용을작용을한다. 그러므로국소환경에서미생물을제거하고복제를막는다. 림프구는체액성방어를돕는물질, 림포카인 (lymphokines), 면역글로불린 (immunoglobulins) 을분비한다. 림포카인은포식세포의이주를막고림프구의재생산을촉진하고, 항체를죽이는다양한방법의활동을한다고여겨진다. 치성감염의면역에관련된국소요소들에는구강조직으로의풍부한혈액공급으로체액세포성반응이감염가능부위로의효과적인접근을얻도록하면서, 타액의물리적인자정작용, 타액에포함된분비 IgA, 부착세균과더불어높은상피교체와탈락등이있어큰도움이되고있다. 이를임상에적용해서, 전신질환이다발성으로연합된경우의치과진료시전신면역반응의효과를감소시키는요인들 (Table 3) 에대한철저한이해가필요하다 9). 본증례의환자도빈혈, 당뇨병, 뇌졸중등의전신질환이 Table 2. Common progression patterns of fascial space infections in the head and neck (1) Masticator space lateral pharyngeal space retropharyngeal space danger space mediastinitis (2) Submandibular space submental space contralateral submandibular space sublingual space Ludwig s angina airway obstruction (3) Canine space infraorbital space angular vein cavernous sinus thrombosis Table 3. Factors decreasing the effectiveness of the immune response Patient-related factors Decreased peripheral circulation Systemic disease (e.g., diabetes) Malnutrition (e.g., with alcoholism) Medications that depress the humoral/cellular response(e.g., chemotherapy, steroids, immunosuppressives) Diseases of immune system(e.g., leukemia, lymphoma, agranulocytosis) Xerostomia Microbial factors Selection for certain organisms by previous antibiotic therapy Virulence of specific organims Local factors Hematoma Traumatic surgery Pre-existing infection Chronic pericoronitis Anatomic location of infection(anaerobic environment vs, aerobic) Compromised vascular supply Necrotic tissue

5 Korean Association for Disability and Oral Health 9(1) 2013 Table 4. Classification of bleeding disorders 1. Nonthrombocytopenic purpuras 2. Thrombocytopenic purpuras 3. Disorders of coagulation a. Vascular wall alteration a, Primary-idiopathic a. Inherited (1) Scurvy b. Secondary (1) Hemophilia A (2) infections (1) Chemicals (2) Hemophilia B (3) Chemicals (2) Physical agents(radiation) b. Acquired b. Disorders of platelet function (3) Systemic disease(leukemia) (1) Liver disease (1) Genetic defects (4) Metastatic cancer to bone (2) Vitamin deficiency (2) Drugs (5) Splenomegaly (a) Biliary tract obstruction (a) Aspirin (6) Drugs (b) Malabsorption (b) NSAIDs (a) Alcohol (c) Excessive use of broad (c) Alcohol (b) Thiazide diuretics - spectrum antibiotics (3) Allergy (c) Estrogens (3) Anticoagulation drugs (4) Autoimmune disease (7) Vasculitis (a) Heparin and Coumarin (5) von Willebrand s disease (8) Mechanical prosthetic heart valves (b) Plavix (6) Uremia (9) Viral or bacterial infections (c) Aspirin and NSAIDs (4) DIC (5) Primary fibrinogenolysis 연합되어있어서면역기전에장애가많았고, 더욱이절개배농술을시행했을때과도한출혈이발생되어서 2차적인혈종 (hematoma) 형성에대한우려도많았으나, 감염내과에서수액영양약물요법을적절히시행해서, 추가적인출혈과혈종형성은없었다. 다만뇌졸중등의장애로전신상태가약화된환자에서는감염주위조직의만성저산소증 (hypoxia), 혈액수소이온농도지수변화, 화학적변화등으로혈관수축력 (contractility) 과응고 (clotting) 기전에문제가있으므로, 감염조직의절개배농술시행시출혈에상당한주의가요망되었는데, 예상대로과도한출혈이발생되어서, 절개배농창상내부전색 (packing), 습윤거즈압박술, 고무배농재 (rubber strip drain) 삽입과창상주위봉합술 (circumferential suture), 요오드포름거즈드레인삽입술등으로완벽한지혈을달성할수있었다. 출혈의원인에대해서는측두간극농양부절개부위에천측두동정맥의분지들이많은해부학적관점도있지만, 전신상태의약화에따른다양한원인들이작용하는만큼 (Table 4) 6,14-16), 이에대한전체적인대비가필요하다. 본증례에서도과도한출혈의원인은뇌졸중등에따른항응고제인플래비스 (plavix) 투약도문제가되지만, 측두간극농양부주위조직감염이더큰원인으로생각되는데, 감염조직의혈관충혈뿐만아니라혈행이많은혈관분지들에서혈관벽약화에따른미란 (erosion) 현상이과도했기때문으로사료된다. 이런경우경험이적은임상의가천측두동맥이나정맥분지절단으로생각하고혈관을잡아서묶으려는시도를할수도있는데, 이런처치는매우위험하며한두개혈관미란이나절단이아니므로자칫시간을끌면저혈량성쇼크의위험도있기에엄금할사항이라생각된다. Ⅳ. 결론저자등은치성감염이확산되어광범위측두근막간극농양까지진행된다발성전신질환장애환자에서감염내과와협진으로수액약물요법등을시행한후에, 진정요법과국소마취시행하에절개배농술을시도했다가과도한출혈이있어서, 절개창상내부에습윤거즈압박전색 (wet gauze packing) 으로우선지혈을시도한후에, 다시절개창상주위로촘촘하게봉합술을시행해지혈을달성한다음, 고무배농재와요오드포름거즈배농재로배농술을시행해양호한지혈과배농및창상치유를관찰할수있었다. 참고문헌 1. Topazian RG and Goldburg MH : Management of infections of the oral and maxillofacial regions. Philadelphia, WB Saunders , Kim GW, Kim KW, Kim SG et al : Oral & maxillofacial infection. Seoul, Jee Sung Publishing Co , Kang HS, Moon HJ, Song KH, Kim SG : Contemporary oral & maxillofacial surgery. Seoul, Ko Moon Sa , Korean Association of Oral & Maxillofacial surgeons : Textbook of oral & maxillofacial surgery, Second edition. Seoul, Medical & Dental Publishing Co , Peterson LJ, Ellis lll E, Hupp JR, Tucker MR :

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<C4A1B0FAB8B6C3EB2D3131B1C732C8A32E687770> 대한치과마취과학회지 :2011; 11: 177~182 증례 항응고제투여중인다발성전신질환자에서과도한발치창출혈부의진정요법과국소마취시행하에창상주위봉합과배농술통한출혈과감염조절 연세대학교치과대학구강악안면외과학교실 ( 원주기독병원 ), * 계명대학교의과대학동산의료원치과학교실 ( 구강악안면외과 ) 유재하 김종배 * Abstract Bleeding & Infection Control