A-III. 놓치기쉬운내시경소견에대한집중토의 Room A 계명대학교의과대학내과학교실 Larynx and Pharynx Kyung Sik Park Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea 서론최근국가암검진사업의일환으로상하부위장관내시경의시술건수가빠른속도로증가하면서위장관에존재하는다양한전암성병변및악성종양들이조기에발견되는경우가많아수명연장이나삶의질향상에많은도움을주고있다. 또한치료내시경의발전으로인해많은수의조기병변들은개흉이나개복없이내시경으로일괄적인절제가가능하게되어상당한의료비의절감역시가능하게되었다. 내시경분야의이러한비약적인발전에도불구하고병변은대개이비인후과영역으로취급되는경우가많아위장관내시경을시행하는의사의입장에서의구조나내시경소견에관심을가지고시술을시행하는경우는흔하지않은것으로생각된다. 따라서대부분의병변은놓치기쉬운내시경소견의범주에들어간다고할수있겠다. 는상부위장관내시경삽입에있어반드시통과해야만하는구조물이므로이곳의정상구조를익히고내시경시술시조금만관심을가지고꼼꼼하게살펴본다면의외로다양한질환들을발견할수있다. 실제로그간상부위장관내시경검사시관찰할수있는병변들을연구한보고들에따르면전체검사건수의 0.9 3.5% 에서의이상소견이관찰되는것으로알려져있다. 1 7 그뿐아니라이제치료내시경의범위또한병변으로까지확대되고있다. 8 따라서이논문에서는부의정상적인구조및소견에대해간단히살펴보고통상적인상부위장관내시경으로관찰가능한병변들에대해살펴보려한다. 본론 1. 의구조및정상소견인두는비인두 (nasopharynx), 구강인두 (oropharynx), 후인두 (hypopharynx) 등세부위로나누어지는데연구개 (soft palate) 를기준으로상부가비인두, 연구개에서후두개 (epiglottis) 까지를구강인두, 후두개하부에서식도입구까지가후인두이며후인두는후두의뒤쪽에해당한다. 9 후두는성대를포함하는발성기관으로상부에는구강인두가, 하부에는기관 (trachea) 이, 뒤쪽에는후인두가위치한다. 통상적인상부위장관내시경에서는구강인두및후두가관찰가능하며최근개발된경비내시경으로는비인두를관찰할수있으나매우제한적으로이용되고있다. 내시경시술시이용되는마우스피스형태에따라차이는있으나흔히이용되는서랍자형마우스피스를통해내시경을진입하면연구개부터관찰이가능하다. 연구개에이어져있는목젖 (uvula) 및좌우측편도를관찰하고조금더진행하면후두개와설근주변의림프절들이관찰되며이어서후두의대부분과후인두의일부분을한시야에서관찰할수있다. 이곳에서성대, 후두개의내측면, 소각연골 (corniculate), 파열연골 (arytenoids cartilage), 이상동 (pyrifrom sinus) 등을관찰한다. 단이부위를관찰할때송기를하게되면분비물의기도유입으로인해심한기침이유발될수있으므로가급적송기를하지않도록하며짧은시간내에관찰하고필요하면식도, 위, 십이지장을관찰한후내시경을제거할때다시관찰하면된다. 50 Korean Society of Gastrointestinal Endoscopy
Table 1. Oral Lesions Observable During Endoscopy Tumors or lesions that mimic Squamous cell carcinoma Leukoplakia Melanoma Amalgam tattoos Fordyce spots Mucoceles Infections Candidiasis Herpes simplex virus Varicella zoster virus Coxsackie virus HIV infection Syphilis Aphthous oral ulcer (aphthae) Oral and genital ulcers Behcet s disease Complex aphthosis Lichen planus Connective tissue and autoimmune disease Systeminc lupus erythematosus Bullous pemphigoid Cicatrical pemphigoid Pemphigus vulgaris Erythema multiforme Miscellaneous lesions Black hairy tongue Geographic tongue Contact and irritant stomatitis Epidermolysis bullosa 2. 관찰할수있는병변들 1) 구강병변 구강의일부도관찰이가능한경우가있는데내시경시술시사용하는마우스피스로인해자세한관찰이가능한부위가많지는않으나연구개병변의경우조금만주의를기울이면의외로쉽게관찰되는경우도있다. 입술, 잇몸, 치아, 경구개, 연구개등구강내에발생할수있는질환들을표 1에정리하였으며양성혹은악성종양질환을포함하여각종감염성질환이나다양한원인에의한구강궤양, 결체조직질환등매우다양한질환들이포함된다. 병변이나타나더라도마우스피스에의해가려지는부위가호발부위인경우가많아실제내시경시술시발견하기가쉽지는않으나의심되는병변이발견되면조직검사를하던지이비인후과로의뢰하도록한다. 2) 염증성병변 (1) 역류성후두염위 식도역류질환은식도증상뿐아니라다양한식도외증상이나합병증들을포함하는데역류성기침, 역류성후두염, 역류 Table 2. Reflux Finding Score (RFS) Subglottic edema Ventricular Erythema/hyperemia Vocal fold edema Diffuse laryngeal edema Posterior commissure hypertrophy Granuloma/granulation tissue Thick endolaryngeal mucus 1 = present 2 = partial 4 = complete 2 = arytenoids only 4 = diffuse 4 = polypoid 4 = obstructing 4 = obstructing 2 = present 2 = present 성천식, 역류성치아부식등은위산역류와의연관성이확인된질환들이고인두염, 부비동염, 폐섬유화, 중이염등은연관성이강력하게의심되는질환들이다. 10 역류 (laryngopharyngeal reflux, LPR) 라함은위산이나펩신등의위내용물이상부식도괄약근을지나로이동하는현상으로발성이상, 쉰목소리, 인두이물감, 연하곤란, 만성기침등의증상을나타낼수있다. 11,12 한편후두염은매우다양한원인에의해발생하는데원인과무관하게육안적으로비슷한양상으로나타나는경우가많으며 LPR 역시중요한원인이될수있고 LPR에의해발생한후두염을역류성후두염이라한다. LPR의진단에있어쉽게시행할수있으면서신뢰성이있는검사방법에대해서는논란이있을수있는데앞서언급한증상들과함께후두경이나내시경에서 LPR과관련가능성이높은이상소견들이보이는경우우선적으로고려할수있다. 이러한이상소견들로발적, 부종, 육아종, 협착등다양한양상들이있으나상부식도괄약근과의위치관계를고려할때피열연골의후방과피열연골사이의점막에발생하는발적과부종이가장흔한소견이다. 13 그러나이러한소견들이증상이없는일반인에서도높게는 70% 까지보고될정도로증상과의연관성이부족하고정상과이상소견을나누는기준이뚜렷하지못하다는점은심각한진단적제한점이될수있다. 14 16 24시간산도측정검사가 LPR의진단에가장우월하다는가 제 48 회대한소화기내시경학회세미나 51
정하에이루어진연구들이많으나 17 역시분명한기준이없고무증상건강인에서도 10 60% 의양성률을보일정도로증상과의연관성이높지않다는보고도있어모든환자에서추천되지는않는다. 18 최근 LPR 진단을표준화하기위해후두경에서관찰되는여덟개의항목을점수화하여표현한역류소견점수 (Reflux finding score, RFS) 가이비인후과영역에서제안되었다 (Table 2). 19 이체계는재현성과관찰자간및관찰자내일치도가상당히높게나타났으며역류성후두염의초기진단과치료후개선여부판정에도움이되는것으로보고되었다. 또한이점수와역류증상을점수화한설문을이용하여치료에대한반응을성공적으로조사한보고들이있어소화기영역에서도이용을고려해볼수있을것으로여겨진다. 20 22 (2) 부식성손상 의식이없거나의사소통불가능등특별한경우를제외하고는대개병력청취를통해예측할수있으며원인물질에따라다양한소견을보일수있으나주로급성기에는발적, 부종, 출혈등의소견을보이며시간이경과할수록부종과발적은줄어들면서섬유화에의한주변조직의변형이관찰되고만성기에는변형에의한협착이가장문제가된다. 23 (3) 칸디다증식도칸디다증에서와유사한백색막성물질들이구강점막이나부에관찰되며스테로이드사용, 만성질환등면역력이억제된상황에서흔히발생한다. 막성물질들을수산화칼륨염색을하여진단할수있다. 24 3) 종양성병변 (1) 후두암후두암은목소리의변성이있는환자에서특히의심하고관찰할필요가있는데성대와성대직상부에위치하고있어비교적쉽게관찰되는경우도있으나후두개와성대사이의함몰부위에위치하는경우는진단이쉽지않다. 다양한모양으로관찰되며내시경접촉시쉽게출혈을보이고조직검사시쉽게부서지는경향을보인다. 25 출혈에의한폐흡인이일어나지않도록조직검사시주의를요한다. (2) 후인두암내시경시술시내시경이좌측이상동 (pyriform sinus) 으로진입하게되므로좌측피열연골의후방에위치하는후인두암이간혹발견된다. 종괴가큰경우쉽게발견되기도하지만주의를기울이지않으면수차례내시경검사에서도발견되지않는경우도있다. 역시모양은매우다양하게나타나며육안적으로는거의구별되지않는데내시경접촉에의해쉽게출혈되는경향을보임으로써조직검사에의해진단되는경우도있다. 구강, 후두, 및후인두는조직학적으로식도와동일한편평상피로구성되어있으므로후두암이나후인두암은식도암과함께혹은시차를두고발생하는경우도있으며따라서식도암환자에서는후두나후인두를상세히관찰하여야하며역으로후두암이나후인두암환자에서는식도를자세히관찰하는것이필요하다. 최근들어활발히이용되고있는협대역영상내시경 (narrow band imaging) 등새로운영상기법들이조기에이질환을발견하는데도움을주고있다. 26 (3) 기타양성종양들유두종 (papilloma), 낭종 (cyst), 성대결절 (vocal fold polyp), 지방종 (lipoma), 혈관종 (hemangioma) 등다양한양성종양들이후두, 후인두, 후두개, 구강등에서발견될수있으며 27 간혹국소적인백색반 (leukoplakia) 이다양한부위에서발견되기도하는데이병변은전암성병변이므로제거하는것이좋다. 4) 기타질환 (1) 기관삽관육아종전신마취나인공호흡등으로기관내삽관을시행했던환자에서기관협착, 기관 식도누공등의합병증들이발생할수있으며자극부위의섬유화에의해육아종이발생할수있다. 28 삽관기간이나삽관초기후두손상여부가육아종의발생을예측할수는없는것으로알려져있으며삽관제거후 7 10일이지나도록쉰목소리가지속되면육아종발생을의심하고검사를시행해보도록권장하고있다. 수술적제거가필요한경우가많다. (2) 부종기관내삽관상태나무리한내시경의진입후에후두부에부종이발생할수있어주의를요한다. 혹은토혈등으로짧은기간여러차례의내시경을시행하거나내시경시술중심한구역질을하였을때발생하기도한다. (3) 수술변형후두암이나후인두암으로수술을시행한후다양한변형이관찰되는데내시경시술전자세한병력청취를통해환자의수술력을확인할필요가있겠다. 수술후한쪽이상동이폐쇄되어있는경우반대쪽이상동을통하여진입하여야겠고동시성이나이시성병변이식도에존재하지않는지면밀한관찰이필요하다. (4) 베체트병단순아프타궤양과달리베체트병에의한구강궤양은잘치유되지않고자주재발하며성기등다른부위의궤양과동반된경우의심할수있다. 주로구강에발생하지만인두나후인두에관찰되는경우도있으며깊은궤양으로인해주변부의변형이동반되기도한다. 52 Korean Society of Gastrointestinal Endoscopy
(5) 점막변색 염증이나혈관이형성등으로인해점막이국소적으로변색되는경우가있으며궤양발생전후에점막의변색이관찰되기도한다. (6) 성대마비위산역류, 운동, 스트레스, 수술후, 신경질환등매우다양한원인에의해발생할수있으며목소리의변성에동반되는경우가많다. 요즈음은수면내시경이활발히이루어져관찰할수없는경우가많으며시술중환자에게발성을하게함으로써관찰할수있다. (7) 편도비대선천성혹은감염에의한편도비대는내시경진입시비교적쉽게관찰할수있다. 결론 이상에서일반적인상부위장관내시경검사시간과되기쉬우나주의를기울이면관찰할수있는구강, 부병변들에관해살펴보았다. 많은수의환자를짧은시간에검사를할수밖에없는현재의의료현실에비추어볼때이부위에존재하는병변들을내시경으로진단하는것이쉽지는않겠으나최대한가능한범위내에서주의를기울여자세히관찰한다면다양한질환들을조기에발견함으로써환자들에게많은도움을주고내시경의유용성을한층높일수있으리라기대된다. 참고문헌 1. Katsinelos P, Kountouras J, Chatzimavroudis G, et al. Should inspection of the laryngopharyngeal area be part of routine upper gastrointestinal endoscopy? A prospective study. Dig Liver Dis 2009;41:283 288. 2. Cammarota G, Galli J, Agostino S, et al. Accuracy of laryngeal examination during upper gastrointestinal endoscopy for premalignancy screening: prospective study in patients with and without reflux symptoms. Endoscopy 2006;38:376 381. 3. Raju GS. Value of screening the laryngopharyngeal area during routine upper gastrointestinal endoscopy. Nat Clin Pract Gastroenterol Hepatol 2005;2:22 23. 4. Mullhaupt B, Jenny D, Albert S, Schmid S, Fried M. Controlled prospective evaluation of the diagnostic yield of a laryngopharyngeal screening examination during upper gastrointestinal endoscopy. Gut 2004;53:1232 1234. 5. Yarze JC, Chase MP, Herlihy KJ. Laryngopharyngeal examination: an important but not so new role of upper gastrointestinal endoscopy. Ann Intern Med 2000;133:314 315. 6. Kozarek RA. Evaluation of the larynx, hypopharynx, and nasopharynx at the time of diagnostic upper gastrointestinal endoscopy. Gastrointest Endosc 1985;31:271 273. 7. Lehman G, Compton M, Meadows J, Elmore M. Screening examination of the larynx and pharynx during upper gastrointestinal panendoscopy. Gastrointest Endosc 1982;28:176 178. 8. Choi JH, Park JJ, Jee JB, et al. Endoscopic Treatment of Benign Hypopharyngeal Tumors. Korean J Gastrointest Endosc 2005;31:306 310. 9. Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehabil Clin N Am 2008;19:691 707, vii. 10. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus G. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence based consensus. Am J Gastroenterol 2006;101:1900 1920; quiz 1943. 11. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA 2005;294:1534 1540. 12. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24 hour ph monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991;101:1 78. 13. Hickson C, Simpson CB, Falcon R. Laryngeal pseudosulcus as a predictor of laryngopharyngeal reflux. Laryngoscope 2001; 111:1742 1745. 14. Qadeer MA, Swoger J, Milstein C, et al. Correlation between symptoms and laryngeal signs in laryngopharyngeal reflux. Laryngoscope 2005;115:1947 1952. 15. Hicks DM, Ours TM, Abelson TI, Vaezi MF, Richter JE. The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers. J Voice 2002;16:564 579. 16. Branski RC, Bhattacharyya N, Shapiro J. The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease. Laryngoscope 2002;112:1019 1024. 17. Merati AL, Lim HJ, Ulualp SO, Toohill RJ. Meta analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux. Ann Otol Rhinol Laryngol 2005;114: 177 182. 18. Noordzij JP, Khidr A, Desper E, Meek RB, Reibel JF, Levine PA. Correlation of ph probe measured laryngopharyngeal reflux with symptoms and signs of reflux laryngitis. Laryngoscope 2002;112:2192 2195. 19. Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001;111:1313 1317. 20. Lien HC, Wang CC, Hsu JY, et al. Classical reflux symptoms, hiatus hernia and overweight independently predict pharyngeal acid exposure in patients with suspected reflux laryngitis. Aliment Pharmacol Ther 2011;33:89 98. 21.Reichel O, Dressel H, Wiederanders K, Issing WJ. Doubleblind, placebo controlled trial with esomeprazole for symptoms and signs associated with laryngopharyngeal reflux. Otolaryngol Head Neck Surg 2008;139:414 420. 제 48 회대한소화기내시경학회세미나 53
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