KISEP Original Articles 臨床耳鼻 : 第 14 卷第 1 號 2003 J Clinical Otolaryngol 2003;14:92-99 부비동모형에서하비갑개의구조적변화와비중격의천공이상악동환기에미치는효과 동아대학교의과대학이비인후과학교실, 1 의공학교실

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1 KISEP Original Articles 臨床耳鼻 : 第 14 卷第 1 號 2003 J Clinical Otolaryngol 2003;14:92-99 부비동모형에서하비갑개의구조적변화와비중격의천공이상악동환기에미치는효과 동아대학교의과대학이비인후과학교실, 1 의공학교실 2 정용수 1 강명구 1 김동영 1 정인호 1 김재룡 1 이태훈 1 정동근 2 The Effects of the Structural Changes of Inferior Turbinate and Septal Perforation on Maxillary Sinus Ventilation in Model Experiment Yong-Soo Jung, MD 1, Myung-Koo Kang, MD 1, Dong-Young Kim MD 1, In-Ho Jung, MD 1, Jae-Ryong Kim, MD 1, Tae-Hoon Lee, MD 1 and Dong-Keon Jung, MD 2 1 Department of Otolaryngology-Head and Neck Surgery and 2 Medical engineering, College of Medicine, Dong-A University, Busan, Korea - ABSTRACT - Background and Objectives:Inferior turbinectomy has been known to have the possibility of inducing sinusitis. The perforation on septum occurs mostly by septal surgery, and its effect on the ventilation of sinus has not been known. The aim of this study is to measure the changes of maxillary sinus ventilation in conditions of inferior turbinate hypertrophy, inferior turbinectomy or septal perforation. Materials and Methods:From a healthy volunteer with no evidence of sinonasal pathology, one millimeter-thickness axial images of computed tomogram of paranasal sinuses were obtained. Margins between soft tissue and air density in each images were expressed with lines using computer programs, and one millimeter-thickness acrylic plates were cut according to these lines with computerized laser cutting system. They were attached sequentially to make a complete model. The conditions of inferior turbinectomy or septal perforation were expressed with a drill, and the hypertrophy of inferior turbinates was made with silicone. It was fitted with pressure sensors in left nasal cavity, maxillary, sphenoid and frontal sinuses, and with a sensor for oxygen concentration in left maxillary sinus. The pressure changes of each sinonasal cavities and the changes of the oxygen concentration in left maxillary sinus were measured during respiration with 600 milliliter tidal volume and at the rate of 15 times per minute. Results:The alternation of positive and negative pressures was observed according to respiration in the sinonasal cavities. The differences between highest and lowest pressures were increased in the model representing inferior turbinate hypertrophy, and diminished in the models representing inferior turbinectomy and septal perforation. And the times required for the decrease in oxygen concentration were increased in the models of inferior turbinectomy and septal perforation. Conclusion:Extensive resection of inferior turbinate causes the decrease of maxillary sinus ventilation, and it is strongly suggested that septal perforation can reduce the sinus ventilation. This model study is helpful in understanding the influences of the structural changes in sinonasal cavities upon the ventilation of sinuses. (J Clinical Otolaryngol 2003;14:92-99) KEY WORDS:Paranasal sinus Ventilation Model Inferior turbinectomy Septal perforation. 서론 92

2 모형의제작 대상및방법 - 93

J Clinical Otolaryngol 2003;14: 92-99 모형의 하부에서 좌측 하비도 후단과 좌측 상악동으 마찬가지로 직각으로 뚫어 압력 감지장치(Deltran Ⅱ 로 직경 2 mm의 검출구를 직각으로 뚫었고, 모형의 상 disposable

8 mm의 나사 구멍을 뚫은 후 산소 농도 감지장치(Class R-17Med, Teledyne Analytical Instruments, California)를 밀폐되도록 설치하였으며, 비인두에는 파형도관(corrugated tube)을 연결하였다

호흡은 안정상태에서 분당 15회로 C 20회 실시하였다. 비강과 연결된 검출구에 압력 감지장 D 치를 연결하여 압력 변화를 측정하였고, 휴식시간을 가 Fig. 1. Process of construction for the sinonasal model.

B Marginal line between soft tissue and air density area of A.

D Acrylic plates attached each other sequentially with acrylic resin. 지면서 3회 반복하여 측정하였다. 각 부비동의 압력 변화 측정도 동일한 방법으로 시행하였다.

version 2.0, 동아대학교 의 과학 연구소, Korea)을 통해 그래프로 정량화하였다. 압 력 파형 주기는 수동적으로 판독하여 최고 양압과 최저 음압을 검출하였다.

B 상악동 환기의 측정 산소농도 감지장치를 산소농도 측정기(MiniOX I oxy- C D gen analyzer, MSA medical products, Pittsburgh)에 E Fig. 2.

perforation of septum. A Dashed line 1 represents the hypertrophied both inferior turbinates.

3 J Clinical Otolaryngol 2003;14: 모형의 하부에서 좌측 하비도 후단과 좌측 상악동으 마찬가지로 직각으로 뚫어 압력 감지장치(Deltran Ⅱ 로 직경 2 mm의 검출구를 직각으로 뚫었고, 모형의 상 disposable pressure transducer, Utah medical pro- 부에서 좌측 전두동과 접형동에 동일한 직경의 검출구를 ducts Inc., Utah)를 설치하였다. 또한 좌측 상악동의 하단부에는 직경 15.8 mm의 나사 구멍을 뚫은 후 산소 농도 감지장치(Class R-17Med, Teledyne Analytical Instruments, California)를 밀폐되도록 설치하였으며, 비인두에는 파형도관(corrugated tube)을 연결하였다 (Fig. 3). A B 비강과 부비동의 압력 측정 정상 모형에서는 상악동, 전두동, 접형동의 검출구를 폐쇄한 후 비인두에 연결된 파형도관(corrugated tube) 을 통해 폐기능 검사상 1 회 호흡량이 600 ml인 지원 자가 호흡을 하였다. 호흡은 안정상태에서 분당 15회로 C 20회 실시하였다. 비강과 연결된 검출구에 압력 감지장 D 치를 연결하여 압력 변화를 측정하였고, 휴식시간을 가 Fig. 1. Process of construction for the sinonasal model. A Axial image of the paranasal sinus CT at the level of natural ostium (arrow) of maxillary sinus. B Marginal line between soft tissue and air density area of A. C An one millimeter-thickness acrylic plate cut with laser beam according to the line of B. D Acrylic plates attached each other sequentially with acrylic resin. 지면서 3회 반복하여 측정하였다. 각 부비동의 압력 변화 측정도 동일한 방법으로 시행하였다. 압력 감지장치의 전기신호는 Bridge-Amp(Sarotech, Korea)와 데이터 획득 시스템(P400, Sarotech, Korea)으로 증폭 및 디 지털 신호로 변환하여 개인용 컴퓨터에 연결하였고, 컴 퓨터 프로그램(PhysioLab version 2.0, 동아대학교 의 과학 연구소, Korea)을 통해 그래프로 정량화하였다. 압 력 파형 주기는 수동적으로 판독하여 최고 양압과 최저 음압을 검출하였다. 하비갑개의 비후나 절제술, 비중격 의 천공 모형에서도 동일한 방법으로 호흡에 따른 비강 A 의 압력변화를 측정하였다. B 상악동 환기의 측정 산소농도 감지장치를 산소농도 측정기(MiniOX I oxy- C D gen analyzer, MSA medical products, Pittsburgh)에 E Fig. 2. Expression of hypertrophy of both inferior turbinates, half and total volumetric resection of both inferior turbinates, and 5 mm and 15 mm perforation of septum. A Dashed line 1 represents the hypertrophied both inferior turbinates. Dashed line 2 and 3 represent the half and totally resected both inferior turbinates, respectively. B Dashed line 1 and 2 represents the 5 mm and 15 mm perforation of the nasal septum, respectively. C Silicone attached to both inferior turbinates to express hypertrophy of the inferior turbinate. D Totally resected both inferior turbinates with a drill. E Septal perforation cut with a drill. A B Fig. 3. Equipments for measurement of pressure in the nasal cavity, maxillary, frontal, and sphenoid sinus (A) and oxygen concentration in the maxillary sinus (B). 94

4 통계분석 결과 mmh2o N M F S 10 seconds Fig. 4. Tracing of the pressure in the left nasal cavity N, maxillary M, frontal F and sphenoid sinus S in normal model during controlled respiration. p0.01 compared with NL,p0.01 compared with HR,p0.01 compared with SP5. Table 1. Peak positive pressures PP, peak negative pressures PN and pressure differences PD of the left nasal cavity N, maxillary M, frontal F and sphenoid sinus S in normal model N M F S PP PN PD The values are presented as meansd mmh2o. 95

5 J Clinical Otolaryngol 2003;14:92-99 mmh2o T 1/2 sec NL HT HR TR SP5 SP15 Fig. 5. Pressure differences in the left nasal cavity of the normal NL, hypertrophy of both inferior turbinates HT, half resected state of both inferior turbinates HR, totally resected state of both inferior turbinates TR, 5 mm perforation of anterior nasal septum SP5 and 15 mm perforation of anterior nasal septum SP15 models. Oxygen concentration % Normal HT HR TR SP5 SP Time sec Fig. 6. Oxygen concentration decay curves of the left maxillary sinus of the normal NL, hypertrophy of both inferior turbinates HT, half resected state of both inferior turbinates HR, totally resected state of both inferior turbinates TR, 5 mm perforation of anterior nasal septum SP5 and 15 mm perforation of anterior nasal septum SP15 models. T1/2=21+791/2t/, p=0.015 compared with NL,p0.01 compared with NL,p 0.01 compared with HR,p0.01 compared with SP5. NL HT HR TR SP5 SP15 Fig. 7. The half-time of oxygen concentration decay of the left maxillary sinus in the normal NL, hypertrophy of both inferior turbinates HT, half resected state of both inferior turbinates HR, totally resected state of both inferior turbinates TR, 5 mm perforation of anterior nasal septum SP5 and 15 mm perforation of anterior nasal septum SP15 models. 고 찰 96

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7 J Clinical Otolaryngol 2003;14:92-99 결 론 중심단어 REFERENCES 1) Drettner B, Aust B. Pathophysiology of the paranasal sinuses. Acta Otolaryngol(Stockh) 1997;83: ) Pollei SR, Harnsberger HR. The radiologic evaluation of the sinonasal region. Postgrad Radiol 1989;9:242. 3) Proetz AW. Some intimate studies of nasal function: Their bearing on diagnosis and treatment. Ann Otol Rhinol Laryngol 1932;41: ) Ophir D, Shapira A, Marshak G. Total inferior turbinectomy for nasal airway obstruction. Arch Otolaryngol 1985; 111: ) Simmen D, Scherrer JL, Moe K, Heinz B. A dynamic and direct visualization model for the study of nasal airflow. Arch Otolaryngol Head Neck Surg 1999;125: ) Berenholz L, Kessler A, Sarfati S, Eviatar E, SegalS. Chronic sinusitis: A sequela of inferior turbinectomy. Am J Rhinol 1998;12: ) Lindemann J, Kuhnemann S, Stehmer V, Leiaker R, Rettinger G, Keck T. Temperature and humidity profile of the anterior nasal airways of patients with nasal septal perforation. Rhinology 2001;39: ) Nagoshi Y, Usui N, Unoki S, Ishizuka Y, Yamaguchi O. Ventilation of the paranasal cavity. Jibiinkoka 1970;42: ) Hahn I, Scherer PW, Mozell MM. Velocity profiles measured for airflow through a large-scale model of the human nasal cavity. J Appl Physiol 1993;75(5): ) Paulsson B, Dolata J, Lindberg S, Ohlin P. Factors influencing 133-xenon washout in a nose-sinus model. Clinical Physiology 2001;21: ) Wessely E. Die Druckverh?ltnisse in der Nebenh?len der Nase. Mschr Ohrenheilk 1921;55: ) Proetz AW. Applied physiology of the nose. 2nd ed. St. Louis; Annals Publishing Company; ) Aust R, Drettner B. The functional size of the human maxillary ostium in vivo. Acta Otolaryngol(Stockh) 1974;78: ) Müsenbeck K, Rosenberg H. Measurement of velocity of air flow in the sinus maxillaris. Rhinol 1979;17:13. 15) Rettinger G, Suess C, Kalender WA. Studies of paranasal sinus ventilation by xenon-enhanced dynamic CT. Rhinology 1986;24: ) Paulsson B, Lindberg S, Ohlin P. Washout of 133-xenon as an objective assessment of paranasal sinus ventilation in endoscopic sinus surgery. Ann Otol Rhinol Laryngol 2002; 111: ) Marcucci C, Leopold DA, Cullen M, Zinreich SJ, Simon BA. Dynamic assessment of paranasal sinus ventilation using xenon-enhanced computed tomography. Ann Otol Rhinol Laryngol 2001;110:

8 18) Kalender WA, Rettinger G, Suss C. Measurement of paranasal sinus ventilation by xenon-enhanced dynamic computed tomography. J Comput Assist Tomogr 1985;5: ) Aust R, Drettner B. Ventilatory studies of the maxillary sinus. Int Rhinol 1971;9: ) Jeong YS, Kim SR, Kim DH, Jung DK, Choi SS, Jung IH, et al. A model of human nose and paranasal sinuses for the study of sinus ventilation. Korean J Otolaryngol 1999;42:

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KISEP Original Articles 臨床耳鼻 : 第 14 卷 第 1 號 2003 J Clinical Otolaryngol 2003;14:92-99 부비동모형에서하비갑개의구조적변화와비중격의천공이상악동환기에미치는효과 동아대학교의과대학이비인후과학교실, 1 의공학교실

KISEP Original Articles 臨床耳鼻 : 第 14 卷第 1 號 2003 J Clinical Otolaryngol 2003;14:92-99 부비동모형에서하비갑개의구조적변화와비중격의천공이상악동환기에미치는효과 동아대학교의과대학이비인후과학교실, 1 의공학교실