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B-II. 새로운내시경기법들 Room B 순천향대학교의과대학내과학교실 Endoscopy for Diagnosis and Treatment in Oropharyngeal Dysphagia Tae Hee Lee Department of Internal Medicine, Soonchunhyang University College of Medicine,

1 B-II. 새로운내시경기법들 Room B 순천향대학교의과대학내과학교실 Endoscopy for Diagnosis and Treatment in Oropharyngeal Dysphagia Tae Hee Lee Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea 서론구인두삼킴장애의진단과치료에서내시경의역할에대해서국내에서는활성화되어있지않다. 현재이비인후과또는재활의학과에서제한적으로구인두삼킴장애의진단목적으로내시경삼킴검사 (flexible endoscopic evaluation of swallowing, FEES) 를시행하고있는상태이다. FEES는 2012년에신의료기술위원회에서통과되어현재는구인두삼킴장애환자의평가에서급여로인정된상태이다. 이에반해국외에서는다양한 FEES관련서적들이출간되었고이와관련된논문도많이보고된상태이다. 본고에서는주로구인두삼킴장애의평가에서내시경을이용한진단, 즉 FEES에대해논하고자한다. 본론 FEES 검사란내시경으로인후두를관찰하고구인두삼킴장 애를진단하며삼킴장애의기전을평가함으로써향후식이및치료계획을수립하는데유용한검사이다. FEES의역사를보면 1968년에처음으로일본에서음성기능을평가하기위해시행되었고삼킴장애의경우 1988년 Langmore 등이이를적용하였다. 국내소화기내과분야에서는본원에서 2011년에처음으로구인두삼킴장애환자들에게 FEES를적용하였다. 1. FEES 검사의준비본원에서는비디오투시삼킴검사 (Video Fluoroscopic Swallowing Study, VFSS) 와동일한검사용식이로외경 6.5 mm의 GIF XP260 scope (Olympus, Tokyo) 를주로이용하여검사를시행하고있다 (Fig. 1). 검사용식이에서물의경우는관찰해상도를높이기위하여인디고카민 (indigocarmine) 을혼합해서사용한다. 비강으로내시경삽입시환자의불편감을최소화하고삼킴기능에영향을주지않도록반드시리도케인이첨가되지않은젤리를이용하고있다. Fig. 1. FEES 검사의준비. 제 51 회대한소화기내시경학회세미나 93

Grade 0 Grade 1 Grade 2 Grade 3 Fig. 2. 인두주위타액고임정도. 3. FEES 검사의우발증우발증으론대부분자연지혈이되는코피가대표적이며미주신경설실신이나후두경련이이론적으로거론되기는하지만그보고에대해선매우드물며기존의보고 1 나본센터의경험을보았을때매우안전하고환자들이큰불편감없이받을수있는검사이다.

FEES 와 VFSS 의비교 FEES는구인두삼킴장애에서인두기의이상소견을직접적으로평가가가능한반면에구강기의이상소견은간접적인평가가필요하다. 인두주위타액고임 (saliva pooling) 은구인두삼킴장애를시사하는소견이며심한경우흡인성폐렴의위험인자로알려져있는데이에대해평가가가능하다 (Fig. 2).

2 Grade 0 Grade 1 Grade 2 Grade 3 Fig. 2. 인두주위타액고임정도. 3. FEES 검사의우발증우발증으론대부분자연지혈이되는코피가대표적이며미주신경설실신이나후두경련이이론적으로거론되기는하지만그보고에대해선매우드물며기존의보고 1 나본센터의경험을보았을때매우안전하고환자들이큰불편감없이받을수있는검사이다. 본센터에서 4% 의환자에서코피를경험하였고이들은자연지혈이되었으며 94% 의환자에서는검사시불편감의정도가전혀없거나경미하다고호소하였다. 그외미주신경설실신등의우발증은관찰되지않았다. 4. FEES 검사의테크닉 Fig. 3. FEES 검사시내시경의비강통과경로. 2. FEES 와 VFSS 의비교 FEES는구인두삼킴장애에서인두기의이상소견을직접적으로평가가가능한반면에구강기의이상소견은간접적인평가가필요하다. 인두주위타액고임 (saliva pooling) 은구인두삼킴장애를시사하는소견이며심한경우흡인성폐렴의위험인자로알려져있는데이에대해평가가가능하다 (Fig. 2). FEES 검사에이용되는식이는 VFSS처럼바륨을혼합하지않기때문에진짜음식으로검사를할수있는장점이있다. VFSS에서는평가가어려운인후두부위의해부학적이상소견및일측소견의이상소견도평가할수있는장점이있다. 거동불편등의환자의상태로 VFSS가어려운환자에서도검사가가능하여침대옆에서도시행할수있으며검사비용 ( 본인부담 : 15,197 원 ) 이매우저렴하다. 그리고삼킴장애를진단하는데재활의학과에서시행하는 VFSS검사를기다리지않아도소화기내시경의사의처방하에즉각적으로시행할수있다는데매우큰매력이있다. 검사테크닉에서가장중요한것은내시경을비강에서구강으로넘기는것인데 Fig. 3에서보시면아래와가운데비갑개사이를통과시키는것이제일바람직하다. 5. FEES 검사의프로토콜 Table 1은 Langmore 등이제시한 FEES 검사의표준프로토콜로각기관별로약간의차이를보일수있으며동일기관에서도환자마다프로토콜에변형을줄수있다. 1부에서는해부학적및기도의흡입방지와관련된후두의기능을평가한다. 2부에서는음식을이용하여삼킴기능을평가한다. 6. Penetration Aspiration Scale (PAS) 흡인 (aspiration) 은식괴 (bolus) 가진성성대 (true vocal cord) 하방으로진입한상태를말하며침습 (penetration) 은식괴가후두부위까지도달은하였으나진성성대까지만진입상상태이다. 흡인이흡인성폐렴의위험인자라는것은분명하지만흡인의효과는다양하다. 즉어떤환자에서는흡인이발생하여도폐렴이생기지않는경우가있다. 이런차이는임상적측면에서호흡기, 구강및전신건강상태와관련이있다. 또한, 기침을해서잘제거하는지여부도흡인의효과를결정하는중요한인자 94 Korean Society of Gastrointestinal Endoscopy

3 Table 1. FEES 검사의표준프로토콜 2 Patient Name: Date: Examiner: I. Anatomic physiologic assessment A. Velopharyngeal closure Task: Ask patient to say "ee," "ss," other oral sounds; alternate oral and nasal sounds ("duh nuh") Task: Dry swallow Optional: Have patient swallow liquids. Look for nasal leakage. B. Appearance of hypopharynx and larynx at rest: scan around entire HP. Note any anatomic abnormalities that impact swallowing and any suspicious lesions requiring referral to specialist. Optional: Ask patient to hold breath and blow out cheeks forcefully (opens pyriform sinuses). C. Secretions and swallow frequency Observe amount and location of secretions and frequency of dry swallows over a period of 2+ minutes. Task: If no spontaneous swallowing noted, cue the patient to swallow. Go to ice chip protocol if secretions in laryngeal vestibule or if no ability to swallow saliva. D. Base of tongue and pharyngeal muscles 1. Base of tongue: Task: Ask patient to say "earl, ball, call" or other postvocalic "l" words 2. Pharyngeal wall medialization Task: Ask patient to screech/squeal; hold a high pitched, strained "ee" (Task: see laryngeal elevation task below) E. Laryngeal function 1. Respiration Observe larynx during rest breathing (respiratory rate; (adduction/abduction) Tasks: Ask patient to sniff, pant, or alternate "ee" with light inhalation (abduction) Phonation Task: Ask patient to hold "ee" (glottic closure) Task: Ask patient to repeat "hee hee hee" five to seven times (symmetry, precision) Elevation Ask patient to glide upward in pitch until strained; hold it (pharyngeal walls also recruited) Airway protection Task: Ask patient to hold breath lightly (true vocal folds) Task: Ask patient to hold breath very tightly (ventricular folds; arytenoids) Task: Ask patient to hold breath to the count of 7 Optional: Cough, clear throat F. Sensory testing Note response to presence of scope Optional: Lightly touch pharyngeal walls, epiglottis, aryepiglottic (AE) folds Optional: Perform formal sensory testing with air pulse stimulator Note: Additional information about sensation will be obtained in part II and formal testing can be deferred until the end of the examination. II. Swallowing of food and liquid: All foods/liquids dyed green or blue with food coloring if needed to visualize. Consistencies to try will vary depending on patient needs and problems observed. Suggested consistencies to try: Ice chips: usually one third to one half teaspoon, dyed green Thin liquids: milk, juice, formula. Milk or other light colored thin liquid is recommended for visibility. Barium liquid is excellent to detect aspiration, but retract the scope to prevent gunking during the swallow. Thick liquids: nectar or honey consistency; milkshakes Puree Semisolid food: mashed potato, banana, pasta Soft solid food (requires some chewing): bread, soft cookie, casserole, meat loaf, cooked vegetables Hard, chewy, crunchy food: meat, raw fruit, green salad Mixed consistencies: soup with food bits, cereal with milk, apple Amounts/bolus sizes If measured bolus sizes are given, a rule of thumb that applies to many patients is to increase the bolus size with each presentation until penetration or aspiration is seen. When that occurs, repeat the same bolus size to determine if this pattern is consistent. If penetration/aspiration occurs again, do not continue with that bolus amount. The following progression of bolus volumes are suggested: < 5 cc if pt is medically fragile and/or pulmonary clearance is poor 5 cc (1 teaspoon) 10 cc 15 cc (1 tablespoon) 20 cc (heaping tablespoon, delivered) Single swallow from cup or straw: monitored Single swallow from cup or straw: self presented Free consecutive swallows: self presented Feed self food at own rate The FEESR ice chip protocol Part I: Emphasize anatomy, secretions, laryngeal competence, sensation Note spontaneous swallows, cued swallow Part II: Deliver ice chips Note effect on swallowing, effect on secretions, presence of cough if aspirated. 이다. 그래서 Rosenbek 등 3 은기침과제거여부를감안하여 penetration aspiration scale (PAS) 을도입하였다. PAS1 에서 PAS8 로갈수록 aspiration pneumonia의 risk가높아진다. Table 2 는 PAS와본원에서사용하는변형 PAS이다. 7. 인두잔여물 (pharyngeal residue) 인두잔여물도반정량적인평가가가능하며일반적으로없음 (none) 과코팅 (coating) 상태는정상으로평가합니다. 인두잔여물은그양이많아질수록 (Fig. 4), 계곡와 (vallecular) 보다는이상와 (pyriform sinus) 에고인잔여물에서흡인의위험도가증가한다. 또한, 인두잔여물의양상을평가하면구인두삼킴장애의기전을예측할수있다. 가령설기저부위운동이약화되면식괴 제 51 회대한소화기내시경학회세미나 95

the airway Penetration 3 Material enters the airway, remains above the vocal folds, and is not ejected from the airway 4 Material enters the airway, contacts the vocal folds, and is ejected from the

4 Table 2. Penetration Aspiration Scale Original PAS Modified PAS used in our study 1 Material does not enter the airway Normal 2 Material enters the airway, remains above the vocal folds, and is ejected from the airway Penetration 3 Material enters the airway, remains above the vocal folds, and is not ejected from the airway 4 Material enters the airway, contacts the vocal folds, and is ejected from the airway 5 Material enters the airway, contacts the vocal folds, and is not ejected from the airway 6 Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway Aspiration 7 Material enters the airway, passes below the vocal folds, and is not ejected into the larynx or out of the airway 8 Material enters the airway, passes below the vocal folds, and no effort is made to eject Coating Mild Moderate Severe Fig. 4. 인두잔여물의반정량적평가. 인두에전반적인약화소견이있으면전반적으로잔여물이유발된다 (Fig. 5 D). A B 8. 식괴의흡인, 침습및인두잔여물진단의비교 4 6 본원에서시행한 FEES 검사와 VFSS 검사간의진단적일치도비교연구에서두검사간의침습및흡인의진단적일치도는 fair 수준이었다. 인두잔여물의경우는요플레는 substantial, 물은 fair 수준의일치도를보였다. 또한, VFSS 단독으로시행하는것보다는 FEES를병행했을때흡인, 침습및인두잔여물의진단율이의미있게증가되었다. 이런결과는최근에발표된 VFSS와 FEES 간의진단적일치도를평가한메타분석의결과와일치하였다. 결론 C D Fig. 5. 구인두삼킴장애에따른인두잔여물양상. 의후인두와의접촉이감소되어식괴의이동이감소하여계곡와에잔여물이유발된다 (Fig. 5 A). 일측성인두약화소견이있으면편측에인두잔여물이관찰된다 (Fig. 5 B). 후두의전상방이동이감소하거나상부식도조임근에기능적협착등의소견이있으면양측이상와에인두잔여물이발생된다 (Fig. 5 C). 소화기내과의사가 FEES를임상에서적극적으로적용하면많은구인두삼킴장애환자에서진단과치료계획을수립하는데매우도움을줄수있으리라기대된다. 참고문헌 1. Aviv JE, Kaplan ST, Thomson JE, Spitzer J, Diamond B, Close LG. The safety of flexible endoscopic evaluation of swallow- 96 Korean Society of Gastrointestinal Endoscopy

5 ing with sensory testing (FEESST): an analysis of 500 consecutive evaluations. Dysphagia 2000;15: Accessed on May 23, Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration aspiration scale. Dysphagia 1996;11: da Silva AP, Lubianca Neto JF, Santoro PP. Comparison between videofluoroscopy and endoscopic evaluation of swallowing for the diagnosis of dysphagia in children. Otolaryngol Head Neck Surg 2010;143: Rees CJ. Flexible endoscopic evaluation of swallowing with sensory testing. Curr Opin Otolaryngol Head Neck Surg 2006; 14: Leder SB, Murray JT. Fiberoptic endoscopic evaluation of swallowing. Phys Med Rehabil Clin N Am 2008;19: , viii ix. 제 51 회대한소화기내시경학회세미나 97

방사선학회 회장단 및 분과위원장

방사선학회 회장단 및 분과위원장 Myoyoung Jung, Namgil Choi, Jaebok Han, Jongnam Song, Weonjin Kim Dept. of Radiology, Dongshin University, Dept. of Occupational Therapy, Dongshin University 정묘영, 최남길, 한재복, 송종남, 김원진 동신대학교방사선학과, 동신대학교작업치료학과