뾰π대한방사선의학회지 1993; 29(5) : 9DI~9D6 Journal of Korean Radiological Society, September, 1993 염증성부비동질환의전산화단층촬영상 고려병원진단방사선과 - Abstract- 오원자 윤은경 이영욱 권혜수 Maj

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1 뾰π대한방사선의학회지 1993; 29(5) : 9DI~9D6 Journal of Korean Radiological Society, September, 1993 염증성부비동질환의전산화단층촬영상 고려병원진단방사선과 - Abstract- 오원자 윤은경 이영욱 권혜수 Major Pattems of Inflammatory Sinonasal Diseases on CT Won Ja Oh, M.D., Eun Kyung Youn, M.D., Young Uk Lee, M.D., Hye 800 Kwon, M.D. Departm eη t 01 Radiology, Koηo General Hosþital Paranasal sinus CT is known as the most effective imaging mod띠 it y in the evajuation of inflammatory sinonasaj diseases and can depict the distribution, causative lesions obstructing main drainge route, and associated findings. Recently, functionaj endoscopic sinus surgery has been widely used for the evajuation and treatment. Before operation, PNS CT has been routinely used to evajuate the paranasal sinuses and mucociliary drainage route. The authors an띠yzed the PNS CT findings of 3156 cases in 1578 patients with chronic sinusitis symptoms. Sinonasal inflammatory diseases were categorized into 5 patterns according to the obstruction sites. They were 1) infundibular (1 0%, 316/ 3156), 2) ostiomeatal unit (41 %, 1294/3156), 3) sphenoethmoidal recess (1 2 %, 379/3156), 4) sinonasal polyposis (30%, 946/3156), and 5) unclassifiable (6%, 190/3156) patterns The main causes for infundibular obstruction in order of frequency were inflammatory mucosa, enlarged ethmoidaj bulla and Haller s cell. With respect to the middle meatus obstruction, its main causes in the order of frequency were p이ypoid lesion, inflanunatory mucosa and mediajly deviated uncinate process. In particular, sinonasaj p이ypos i s showed one or more of the characteristic associated findings of infundibular enlargement, air-fluid level, ethmoidal sinus wall bulging and bony deossifìcation or sclel'osis as well as sinonasal p이yp o id change In conclusion, the inflammatory sinonasal diseases were c1assified into five patterns, and the causative lesions or anatomic variations were efficiently detected by the PNS CT. Furthermpre, it could provide a guid ance for proper management of the sinusitis including functionaj endoscopic sinus surgery. Index Words: ParanasaJ sinus, sinusitis Paranasal sinus, CT 서 론 (1 끼. 만성부비동염의치료에비내시경을이용한외과적치료 부비통의전산화단층촬영술 ( par a n asa l sinus computerized tomography, 이하 PNS CT 로약함 ) 은만성또는재발성부비동염에서병변의분포및동반되는소견을보여주는가장좋은영상진단법으로알려져있다 법이널리이용되면서 ( 1-3, 8-10) 수술전부비동과부비동의점막섭모성배출통로 ( mucociliary drainage route) 에대한정확한해부학적평가를위해 PNS CT가기본으로이용되고있으며, 그중요성이더욱강조되고있다. 최근 Babb e l등은만성부비통염을 5가지유형으로분류 이논문은 년 2 월 22 일접수하여 년 4 월 30 일에채택되었음

recess) 가막힘으로인해접형동과후사골동에병변이있 T 랩대한방사선의학회지 1993 ; 29 (5) : 90 1 ~ 906 하여보고한바있다 (1, 11-13). 저자들은이분류법을보완적용하여 PNS CT를통해부비동엽의유형을분류하고각유형에따른폐쇄원인을분석하여부비동염에대한이해를돕고 PNS CT 의유용성을검토하고자본연구를시도하였다. 유형 1V.

2 recess) 가막힘으로인해접형동과후사골동에병변이있 T 랩대한방사선의학회지 1993 ; 29 (5) : 90 1 ~ 906 하여보고한바있다 (1, 11-13). 저자들은이분류법을보완적용하여 PNS CT를통해부비동엽의유형을분류하고각유형에따른폐쇄원인을분석하여부비동염에대한이해를돕고 PNS CT 의유용성을검토하고자본연구를시도하였다. 유형 1V. Sinonasal polyposis patt e rn ( 이하 SNP patte rn로약함 ) : 비강과부비동전반에염증성용종들이있으면서사골누두확대, 사골동벽의측면팽대, 공기 - 대상및 방법 수면상또는주변골의탈골화 ( de oss ifi ca tion) 나경화 (s c1 ero s i s) 등의소견이일부또는전부동반된경우. 유형 V. Unc1assifiable pattern : 정상점막섬모성배 출통로의막힘과관계없이부비동에정체낭종 ( r e tention 년 2월부터 199 2년 11월까지 2년 1 0개월간만성부비동염이의심되어고려병원에서 PNS CT 를촬영한 1 578명의환자를대상으로하였고, 각대상환자에서오른쪽과왼쪽에서일어나는병변을각각별개로구분하여 3 156예를대상으로하였다. 연령분포는 8세부터 7 6세까지였으며, 남자가 997명여자가 58 1명이었다. PNS CT촬영전가능한한항생제치료를하여급성부비동염의요소를제거하였고, 촬영직전에코를푼후시행하 였다. 사용한 CT 촬영기기는 GE-CT / T Quick Hilight 였고, 부비동부위를횡단및관상주사하였다. 횡단주사는앙와위상태에서하안와외이도선에평행하게경구개로부터전두동상단까지 5mm 절편두께및간격으로연속주사하였고, 관상주사는환자를복와위로하여목을과신전시킨상태에서횡단주사변에수직이되게전두동전연에서후사골동전연까지는 3mm 절편두께및간격으로, 후사골통전연부터접형동후연까지는 5mm 절편두께및간격으로연속주사하였다. 특히관상주사영상을통해부비동구-비도단위 (osti omeatal unit, 이하 OM unit로약함 ) 를자세히관찰하기위하여 bone algorith cyst), 점액류 ( muc o cel e ), 또는점막비후가있는경우이 다.? 걱 E 크 각유형별빈도는 T able 1 과같으며, 이 예 (41%) 로가장많았고, 로 9 46 예 (30%) 이었으며, OMU pattern 다음이 SNP p a tt e rn 으 그외 SER, infundibular 그 러고 unc1assifiable p a tt ern 순이었다 ( F ig. 환자중 10 8 명에서정상소견을보였다. 1-7). 전체 PNS CT 를통해 그폐쇄부위및원인을찾는데큰어려웅은없었다. 각 유형별원인을보면, 1nfundibular p a t te rn 에서사골누두의폐쇄원인으로는 m 을사용하였다. 이러한방법으로얻은 PNS CT 영상 을통해폐쇄부위및질병분포양상에중점을두고분석 하여다음과같이다섯가지유형으로만성부비동염을분 류하였다. 유형 1. 1nfundibular pattern : 사골누두 (ethmoidal infundibul um ) 가막힘으로인해동측의상악동과전사골 동의전부또는일부에병변이있는경우. 유형 11. Ostiomeatal unit pa t te rn ( 이하 OMU pattern 로약함 ) : 사골누두, 중비도그리고전두와봉소 (frontal recess) 가막힘으로인해동측의전두동, 상악 동그리고전사골동의전부또는일부에병변이있는경우로, 세개의부비동모두에서병변이있을때는 complete type, 세개의부비동중두곳에만병변이있을때를 partial t yp e 이라하였다. 유형 III. Sphenoethmoidal recess p a tt e rn ( 이하 SER pattern 로약합 ) : 접사함요 (sphenoethmoidal a b Fig. 1. a,b. Infundibular pattern: Coronal CT scans show narrowing of the left infundibulum by mucosal thickening leading to inflamrnatory mucosa thickening in the left maxillary sinus. Note patent middle mèatus and no significant ethmoidal disease 902 -

3 오원자외 ; 염증성부비동질환의전산화단층촬영상분류 Table 1. Five Patterns of Sinusitis (n = 3156) Patterns No. of cases (%) Infundibular 316 (1 0) with maxilla 231 with ethmoid 108 Ostiomeatal unit 1294 (4 1) partial 537 complete 757 Sphenoethmoidal recess 379 (12) Sinonasal polyposis 946 (30) Unclassifiable 190 ( 6) Total 3125 점막비후가 228 에 ( 72% ) 로가장많았고 ( Fig. 1), 사골포 비대 (enlarged ethmoidal bulla) 126 예 (40%), Haller s cell 66 예 (21%), elongated uncinate process 57 예 (18%), long attenuated infundibulum 44 예 (1 4%) 순 으로나타났다 ( Table 2). OMU pattern 에서사골누두의폐쇄원인은 infun dibular pattern 과유사하나, 용종형병변에의해막힌 경우가좀더많이나타났다 ( Table 3). 중비도폐쇄의 원인으로는용종형병변이 893예 ( 69% ) 로가장많았고 (Fig.2), 그외에점막비후 ( Fig.3 ), 내측편위된구상돌기 (medially deviated uncinate proce;:;s), enlarged concha bullosa, paradoxical middle turbinate, 비중 격만콕증 ( septal deviation) 의순이었고, 여러원인들이 Table 2. Causes of Infundibular Obstruction in Infundibular Pattern (n = 316) Causes Inf1ammatory mucosa Enlarged ethmoidal bulla Haller s cell Elongated uncinate process Long attenuated infundibulum Polyp or polypoid lesion Concha bullosa Laterally bent uncinate process No. of cases (%) 228 (72) 126 (40) 66 (21) 57 (1 8) 44 (14) 13 ( 4) 6 ( 2) 3 ( 1) Table 3. Causes of Infundibular Obstruction in OMU Pattern (n=1294) Causes No. of cases (%) Inf1ammatory mucosa 1022 (79) Enlarged ethmoidal bulla 324 (25) Polyp or polypoid lesion 194 (1 5) Haller s cell 155 (1 2) Elongated uncinate process 78 ( 6) Concha bullosa 26 ( 2) Long attenuated infundibulum 15 ( 1) Laterally bent uncinate process 12 ( 1) Pneumatization of uncinate process 6 ( 0.4) 복합적으로작용하여폐쇄를일으키는경우가많았다 (Fig. 4) (Table 4) Fig. 2. OMU pattern: Right nasofrontal duct (arrow), maxilla까 ostium and infundibulum (large open arrow) and middle meatus (small open arrow) are totally obstructd by nasal p이yp Fig. 3. OMU pattern: Coronal CT scan reveals obstruction of the left OMU (*) and nasofrontal duct (*) by thickened mucosa and resultant inflammatorγ change of ipsilateral maxillaη, anterior ethmoid and frontal sinuses. Incidentallarge retention cyst or polyp is noted within the right maxillary sinus. Fig. 4. OMU pàttern: Mucoperiosteal thickening of both maxilla and ethmoid sinuses is caused by bilateral en larged ethmoid bullae (open arrows) obstructing the OMU

4 대한빙사선의학회지 1993; 29(5) : 901~906 SER pattern 에서접사함요폐쇄의주요원인은점막의 염증성변화와용종에의한경우가대부분으로 373 예 ( 98% ) 이며 (Fig.5), 그외에상비갑개의기포화 (pneu matization ) 에의한경우가 12 예 ( 3% ) 있었다. SNP pattern 은비강과부비동전반에염증성용종들 이있으면서특징적인동반소견을보였는데, 사골누두확 대, 공기 - 수면상, 사골동벽의측면팽대, 그리고주위골 조직의탈골화나정화등을보였다 ( Fig.6 끼 ( Table 5). 고 *> E므 Table 4. Causes of Middle Meatal Obstruction in OMU Pattern (n= 1294) Causes Polyp or polypoid lesion Inf1ammatory mucosa Medially deviated uncinate process Concha bullosa Paradoxical rrùddle turbinate Septal deviation Enlarged ethmoidal bulla No. of cases (%) 893 (69) 440 (34) 233 (18) 167 (13) 142 (11) 104 ( 8) 52 ( 4) 최근만성부비동엽의치료에비내시경을이용한치료법 Table 5. Associated Findings of SNP (n = 946) Fig. 5. SER pattern: Coronal CT scans show ob struction of left SER (*) with resultant opacification of posterior ethmoid and sphenoid sinuses Findings Infundibular enlargement Bulging of ethmoid wall Deossification ethmoidal trabeculae nasal septum cribriform plate lamina papyracea Sclerosis uoonate process rrùddle turbinate ethmoidal trabeculae nasal septum Air-fluid level No. of cases (%) 587 (62) 289 (30) 692 (73) 162 (17) 19 ( 2) 10 ( 1) 104 (11) 47 ( 5) 10 ( 1) 5 ( 0.5) 341 (36) 6a 6b 7 Fig. 6. SNP pattern: a. Coronal CT scan shwos bilateral nasal polyps and opacification of all the visible sinuses. Both iofundibula ( ) are widened and ethmoidal trabeculae are deossified by polypoid lesioos. b. Enhanced axial CT scaos reveal hypoattenuated nasal polyp and mucosal enhancement. Note air-f1uid level within the right maxillarγ sinus and lateral bulging of ethmoid walls Fig. 7. SNP pattern This SNP pat tern demonstrates sclerosis as well as deossification of ethmoid trabeculae. 904

5 오원자외 : 염증성부비동질환의전산화단층촬영상분류 이널리이용되어가는추세인데, 비내시경수술은 Messerklinger 등이주장한부비동점막의점막섬모운동과연 관된다 (1 5). 즉부비동점막의병변은대개회복가능하며 병변이며, 그외에점막비후, 내측편위된구상돌기, enlarged concha bullosa, paradoxical middle turbinate, 비중격만곡증, 거대사골포에의한경우가있을수 그자연공 ( natural ostium) 을통한충분한배농과환기 있다. SER pa tte rn 에서는점막비후나용종성병변이접 에의하여정상점막으로회복시킬수있기때문에치료 에있어병변을가지고있는비강및부비동의점막은가 사함요폐쇄원인의대부분이고저자들의경우기포화된 상비갑개가커서접사함요폐쇄를초래한경우도몇예있 능한그대로두고, 배출통로를막고있는원인만제거한 었다. 이상의 3 가지유형은부비동의환기통로폐쇄에의 다는데근거를두고있다. 한경우로, 비내시경수술에서폐쇄를일으키는원인제거 정상점막섬모성정화작용통로는크게두가지로대별되 어 ( ), 상악통, 전두통그리고전사골동은 OM unit 만으로부비동염의많은회복을가져온다 (1, 11 ). 그러나 SNP pattern 의경우는비강과부비동에전반적으로염 로향하게되는데, 이 OM unit 는상악동구에서사골누 증성용종들이있는경우로, 치료법도폐쇄성유형과다 두와반월열공을거쳐중비도로통하는좁은통로이다. 르게약물치료가원칙이며, 약물치료에반응이없을때광 접형동과후사골동은상비도및접사함요를통해환기된 다. 따라서, 어떤원인으로든이런통로에페쇄가생기면 범위한외과적치료를하는것으로되어있어수술전정확 한진단이중요시된다 ( 1, 1 2, 14 ). SNP patte rn 의진단 부비동에염증이생길수있으며, 원인에따른만성부비 에도움을주는통반된소견으로는사골누두확대, 사골동 동엽의분류는환자의치료방침을세우는데지침이될것 으로생각된다. 저자들의만성부비동염의유형별분류는 Ba b be l 등의 분류 ( 1, 11-13) 를적용보완한것으로, Babbe l 등이분류한 infundibular pattern 은사골누두가막험으로인해상악 벽의측떤팽대, 공기 -수면상의관찰, 주변골의탈골화나경화등을들수있다. 특히이 pattern 은과거에 Caldwe ll - Lu c씨수술이나용종제거술을받은후에도재발하는경우가많고임상적으로알레르기나아토피와관계가있을수도있으며 ( 1 2, 19 ), 원인분석과치료및추이관 동에만병변이있는경우로하였으나, 저자들은사골누두 찰등에많은시간과노력을요하는것으로알려져있다. 가막힘으로인해상악통뿐만아니라전사골동에도병변 이있는경우로하였으며, 해부학적구조와비교해볼때 도타당한것으로생각된다. 이러한 PNS CT 소견들은비내시경소견과도일치하였고, PNS CT 를통한부비통염의정확한원인과병변상태를 파악함으로써적절한치료로원인제거는물론불필요한 OMU pattern 의경우, 중비도가막힘으로동측상악 수술을막고, 예후를향상시킬수있는것으로생각된다. 동, 전두동그리고전사골동모두에서병변이생긴경우 결론으로, PNS CT 를통해만성부비동염의유형을분 는 complete t y p e 으로하였는데, 이는중비도가각부비동의공동배출통로임을입증해준다. 하지만, 각부비동의최종배출구의위치에는개인차가있고중비도나사골 류할수있었고, 각각의유형에서그원인분석이가능하였으며, 이러한분류는비내시경시술을포함한부비동엽의치료에지침이되는것으로생각된다. 누두가부분적으로막히게되면세개의부비동중일부에만 병변을일으킬수있는데이를 partial type으로분류하였다. 또한 Babb el 등이분류한 unclassifiable pattern 에는수술후의환자를포함시켰으나, 저자들의경우는광범위한부비동수술을받아해부학적구조를알기어려운몇예를제외하고는각각의유형분류에포함시켰다. 저자들의분류와 Babbel 등이분류한유형별빈도를비교해보면, 저자들의경우 OMU pattern과 SNP pattern 이많이나타났는데, 아마도환자들이병변이오랫동안진행된후에병원을찾은이유로생각된다. 각유형별폐쇄원인은비슷한소견을나타냈는데, 사골누두폐쇄의주요원인은대개점막비후이며, 그외에해부학적변이인거대사골포, Haller s cell, elongated uncinate process, long attenuated infundibulum등이원인이될수있다. 중비도페쇄의주요원인은용종성 참고문헌 1. Babble RW, Harnsberger HR, Sonkens], Hunt S_ Recurring patterns of inflamrnatory sinonasal disease demonstrated on screening sinus CT. A]NR 1992; 13: Babbel R, Harnsberger HR, Nelson B, Sonkens ], Hunt S. Optimization of techniques in screening CT of the sinuses. A] NR 1991; 12: Zinreich S], Kennedy DW, Rosenbaum AE, Gayler BW, Kumar A], Stammberger H. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 1987; 163: Thawleys, Gado M, Fuller T. Computerized to

6 대한방사선의학회지 1993 ; 29 (5) : 901"'906 mography in the evaluation of head and neck lesions. Laryngoscope 1978; 88: Kennedy DW, Zinreich S], Resenbaum AE, ]ohns ME. Functional endoscopic sinus surgery. Arch otolaryngol 1985; 111 : Bilaniuk LT, Zimmerman RA. Computed tomog raphy in evaluation of the paranasal sinuses. Radiol Clin North Am 1982; 20: 이영욱, 윤은경, 이영래, 권혜수. 만성및재발성부비 동염의전산화단층촬영. 대한방사선의학회지 1991 ; 27: Levine HL. Functional endoscopic sinus surgeη: evaluation, surgery, and f. 이 low-up of 250 pa tients. Laryngoscope 1990; 100: Chow]M, Mafee MF. Radiologic assessment preoperative to endoscopic sinus surgery. Otolaryngol Clin North Am 1989; 22: Rice DH. Endoscopic sinus surgery: results at 2- year follow up. Otolaryngol Head Neck Surg 1989; 101: Harnsberger HR. Babbel RW, Davis WL. The major obstructive inflammatory patterns of the sinonasal region seen on screening sinus computed tomography. Semin ultrasound CT MR 1991; 12: Drutman], Babbel RW, Harnsberger HR, Son kens ]W, Braby D. Sinonasal polyposis. Semin Ultrasound CT MR 1991; 12: Scuderi A], Babbel RW, Harnsberger HR, Sonkens ]W. 까le sporadic pattern of inflammatoiγ sinonasal disease including postsurgical changes. Semin Ultrasound CT MR 1991 ; 12: ]osephson ]S. The role of endoscopic sinus surgeη for the treatment of nasal p이yposis. Otolaryngol Clin North Am 1989; 22: Messerklinger W. Oll the drainage of the normal frontal sinus of man. Acta Otolarγngol 1967; 673: Babbel RW. Hansberger HR. A contemporaη look at the imaging issues of sinusitis: sinonasal anatomy, physiology, and computed tomography techniques. Semin Ultrasound CT MR 1991; 12: Becker SP. Anatomy for endoscopic sinus surgery, Otolaηngol Clin North Am 1989; 22: Schatz CJ, Becker TS. Normal CT anatomy of the paranasal sinuses. Radiol Clin North Am 1984; 22: Small P, Frenkiel S, Black M. Multifactorial etiology of nasal p 이 yp. Annals of allergy 1981; 46:

대한방사선의학회지 1993 ; 29 (3) : 373~377 와점막이상에관하여보고하고자한다. 탁까지를포함하였다. [~λ~ OJ t::jj 닙 ~ Od 7~ E 프 19 89년 6월부터 199 2년 6월까지부비동염이있거나, 의심되어부비동 CT를시행한환자 95명

대한방사선의학회지 1993 ; 29 (3) : 373~377 Journal of Korean Radiological Society. May. 1993 전산화단층촬영을이용한 Ostiomeatal unit 에영향을미치는 부비동의해부학적변이에관한연구 한국전력부속한일병원진단방사선과 - Abstract- 최성희 안재원 문정화 강진화 김 옥 Anatomical Variants