DOI:10.5125/jkaoms.2011.37.1.81 김지연 김성민 명훈 황순정 서병무 이종호 정필훈 김명진 최진영서울대학교치과대학구강악안면외과학교실 Abstract (J Korean Assoc Oral Maxillofac Surg 2011;37:81-5) The treatment of obstructive sleep apnea patient using extended uvulopalatal flap: a case report Ji-Youn Kim, Soung-Min Kim, Hoon Myoung, Soon-Jung Hwang, Byoung-Moo Seo, Jong-Ho Lee, Pill-Hoon Choung, Myung-Jin Kim, Jin-Young Choi Department of Oral and Maxillofacial Surgery, School of Dentistry, Seoul National University, Seoul, Korea The uvulopalatal flap (UPF) technique is a modification of uvulopalatopharyngoplasty (UPPP) for the surgical treatment of obstructive sleep apnea. In the UPF technique, an uvulopalatal flap is fabricated and sutured to the residual mucosa of the soft palate to expand the antero-posterior dimensions of the oropharyngeal inlet. In the extended uvulopalatal flap (EUPF) technique, an incision at the tonsillar fossa is added to the classical UPF technique followed by the removal of mucosa and submucosal adipose tissue for additional expansion of the lateral dimension. The EUPF technique is more conservative and reversible than UPPP. Therefore, complications, such as velopharyngeal insufficiency, dysphagia, dryness, nasopharyngeal stenosis and postoperative pain, are reduced. In the following case report, the patient was diagnosed with obstructive sleep apnea and treated with the EUPF technique. The patient s total respiratory disturbance events per hour (RDI) was decreased to 15.4, the O2 saturation during the sleep was increased, and the excessive daytime sleepiness had disappeared after the surgery without complications. The authors report this case with a review of the relevant literature. Key words: Extended uvulopalatal flap, Obstructive sleep apnea, Uvula, Treatment outcome, Surgical flaps [paper submitted 2010. 9. 28 / revised 2010. 12. 15 / accepted 2011. 1. 12] Ⅰ. 서론 폐쇄성수면무호흡증 (obstructive sleep apnea, OSA) 은상기도폐쇄로인해수면중호흡정지가일어나는병증으로, 수면장애호흡 (sleep-disordered breathing) 에속하는질환이다 1-3. 아직까지한국성인의폐쇄성수면무호흡증의빈도에대해통계자료가보고된바없지만, 무호흡 - 저호흡지수 (apnea-hypopnea index, AHI) 가 5 회이상의폐쇄성수면무호흡증유병률이중국에서는성인의 20.39%, 미국에서는성인남자의 24%, 성인여자의 9% 로보고되어, 주요한공중보건의료문제중하나로인식되고있다 4,5. 성인에서폐쇄성수면무호흡증의 1 차적인치료법은지속적기도양압술 최진영 110-749 서울특별시종로구연건동 28 서울대학교치과대학구강악안면외과학교실 Jin-Young Choi Department of Oral and Maxillofacial Surgery, School of Dentistry, Seoul National University 28 Yeongeon-dong, Jongno-gu, Seoul, 110-749, Korea TEL: +82-2-2072-3992 FAX: +82-2-766-4948 E-mail: jinychoi@snu.ac.kr (continuous positive airway pressure, CPAP) 이다. 하지만, 이치료는환자의장기간지속적인협조도가치료결과에큰영향을미치며, 지금까지보고된환자들의순응도는 50% 정도에그친다는단점이있다 6. 따라서비강, 구강및하인두부에발생한협착, 폐쇄된부위의정확한해부학적위치가진단되었다면, 이에대한외과적치료가종종효과적인대안책이될수있다 1,2. 외과적수술요법은 2 단계수술들로나눌수있다. 첫번째단계의수술에는비부, 구개부축소술및설전진술또는축소술등위치특이적인치료방법들이있으며, 두번째단계의수술에는악교정수술을이용한상하악전진술 (maxillomandibular advancement) 등이있다. 통상적인치료순서는첫번째단계의수술시행후치료결과에따라두번째단계의수술을고려하게된다 1. Fujita 등 7 에의해수면무호흡증에처음으로적용된대표적외과적술식인구개수구개인두성형술 (uvulopalatopharygoplasty, UPPP) 은전, 후방측인두궁을절제및재배열하고구개수와구개후방부를절제하여후구개부기도를크게만들어주어폐쇄부를제거하는술식이다 1,7. 구개수구개인두성형술은경도및중등도폐쇄성수면무호흡증에서 40-50% 의높은성공률을가지고있으며, 구강악안면 * 이논문은 2010 년도정부 ( 교육과학기술부 ) 의재원으로한국연구재단의지원을받아수행된기초연구사업임.(2010-0009448) 81
J Korean Assoc Oral Maxillofac Surg 2011;37:81-5 외과의들이많이시행하고있는술식이다 8,9. 하지만, 구개인두폐쇄부전증 (velopharyngeal insufficiency, VPI), 연하곤란, 지속적건조증, 비인두협착증, 비인두역류등의합병증이발생할수있다는단점이있다 8,10-12. 이러한위험성을줄이기위해 Powell 등 13 은가역적술식인구개수구개피판술 (uvulopalatal flap, UPF) 을고안하였으며, 치료효과를높이기위해 Li 등 14 은이를변형한확대구개수구개피판술 (extended uvulopalatal flap, EUPF) 을고안하였다. 확대구개수구개피판술은구개수를부분적으로자른후구개수를당겨서연구개에중첩되는점막만을절개하여제거한후, 구개수피판을앞으로당겨봉합하여구인두를확장하는전형적인구개수구개피판술과함께, 구인두측벽의점막과점막하지방조직을같이제거하는술식이동반된것이다.(Figs. 1. A-C) 이술식은구개수구개인두성형술에비해비인두폐쇄부전의합병증발생을감소시킬뿐만아니라, 구개수구개인두성형술과달리구개부의자유말단부봉합이없기때문에술후통증을줄일수있으며, 반흔에의한구축이적어술후이물감이훨씬적은결과를보인다. 또한구인두측벽을구개수구개인두성형술및구개수구개피판술에비해더확장시키는장점이있기에대부분의환자증례에서구개수구개인두성형술에비해선호된다 1,2,14. 하지만, 구강과가장밀접하게연관되어있는구강악안면외과학분야에서는아직까지이의연구및고찰이이루어진것이거의없다. 이에본교실에서는확대구개수구개피판술을사용하여폐쇄성수면무호흡환자를성공적으로치료한경험이있기에이에대해보고하고고찰해보고자한다. 기상후두통등을호소하였다. 환자는동반된고혈압으로인해최근 10 년간약을복용하고있었다. 자가수면장애를확인하는설문조사를통해, 주간기면지수 (epworth sleepness scale, ESS) 15 가 12 로높은상태임을알수있었으며, 야간배뇨, 수면중무호흡에의한심한각성반응, 편두통등의증상이있음을또한확인할수있었다. 임상검사에서환자의구개위치는 IV 형으로, 입을가능한크게벌리고혀를구강내에서자연스럽게둔상태에서경구개만보이는상태였다. 편도크기는 1 형으로, 편도가전구개궁에가려보이지않는상태였다. 신체질량지수 (body mass index, BMI) 는 25.9 kg/m 2 로, 전체적으로종합하여볼때 Friedman 임상병기 stage III 였다 16.(Tables 1-3) 촬영한측두두개방사선사진에서계측결과, 안장점 (sella, S)- 비근점 (nasion, N)- 치상점 (supradentale, A) 을이루는각은 83 ( 정상치 : 82±2 ), 안장점 - 비근점 - 치하점 (infradentale, B) 을이루는각은 81 ( 정상치 : 80±2 ) 로두개골에대한상, 하악의위치는정상이었다. 반면, 각점 (gonion, Go) 과치하점을잇는연장선에서측정한후기도공간 (posterior airway space, PAS) 은 8 mm ( 정상치 : 11±2 mm), 후비극 (posterior nasal spine, PNS) 에서구개수첨단 (uvular tip, U) 을연결한연구개길이는 56 mm ( 정상치 : 39±4 mm) 로, 협소한후기도공간과긴연구개를관찰할수있었다 17.(Fig. 2) 수술전시행한수면다원검사에서호흡장애지수 (total respiratory disturbance events per hour, RDI) 는 24.3 으로중등도의폐쇄성수면무호흡을보였으며, 특히환자의총수면시간의자세중 1.4% 를차지하는앙와위로취한수면에서의 Ⅱ. 증례보고 45 세남자환자가수면장애호흡을주소로본과에내원하였다. 20 여년간심한코골이증상을보였으며, 수면중측와위가아닌앙와위에서는호흡장애로수면상태를유지할수없음을언급하였다. 또한주간활동시간중과다졸음과 Table 1. Classification of Friedman palate position 16 Palatal grade Observed anatomic sturectures I Allows the observer to visualize the entire uvula and tonsils II Allows the observer to visualize the uvula but not the tonsils III Allows the observer to visualize the soft palate but not the uvula IV Allows the observer to visualize the hard palate only The classification is based on visualization of the structures in the mouth when the mouth is opened widely without protrusion of the tongue. Fig. 1. A schematic diagram of the extended uvulopalatal flap technique. Table 2. Classification of tonsil size 16 Tonsil size Form of tonsils 0 Surgically removed tonsils 1 Tonsils hidden within the pillars 2 Tonsils extending to the pillars 3 Tonsils are beyond the pillars but not to the midline 4 Tonsils extend to the midline 82
Table 3. The modified Friedman staging system for patients with obstructive sleep apnea/hypopnea syndrome 16 Friedman palate position Tonsil size Body mass index (BMI) Stage I I 3, 4 <40 II 3, 4 <40 Stage II I, II 1, 2 <40 III, IV 3, 4 <40 Stage III III 0, 1, 2 <40 IV 0, 1, 2 <40 Stage IV I, II, III, IV 0, 1, 2, 3, 4 >40 All patients with significant or other anatomic deformities A Fig. 2. Preoperative and postoperative lateral cephalogram. A. Preoperative lateral cephalogram. The narrow posterior airway space and long soft palate was observed. The length of the soft palate (posterior nasal spine - uvular tip) was 56 mm. B. Postoperative lateral cephalogram. The x- ray was taken at 3 weeks after the surgery. The shortening of soft palate was observed. The length of the soft palate was changed to 38 mm. 호흡장애지수는 53.3 으로매우높은수치를보였다. 총코골이시간은총수면시간중 89.7% 에달하였다. 또한맥박산소측정에의한산소포화도는총수면시간중 0.2% 의시간동안 90% 이하로떨어졌으며, 가장낮은산소포화도수치는 88% 였다. 위검사들을바탕으로, 환자는연구개를포함하는구인두부폐쇄로인한중등도폐쇄성수면무호흡증으로진단되었다. 환자는보존적치료보다외과적수술을원하였으며, 상기도의해부학적폐쇄가확인되었기에, 전신마취로확대구개수구개피판을이용한구인두수술을시행하기로계획하였다. 확대구개수구개피판시행을위해, 먼저부분적으로구개수를절제해내고, 구개수를전방으로견인하여적절한연구개길이를확인하였다.(Figs. 3. A, B) 이때연구개와구개수를중첩시킬때중첩되는면의점막만절개하여박리후절제해냈다.(Fig. 3. C) 그리고형성된구개수피판을전방으로돌려봉합하였다. 또한양측편도와에절 B 개를가해점막및점막하지방조직의일부와편도를절제하고봉합하였다.(Fig. 3. D) 이와더불어치료효과의극대화를위해고주파를이용한설근부축소술 (tongue base reduction using radiofrequency) 또한같이시행하였다.(Fig. 3. E) 수술 1 주후의임상소견으로절제된연구개부및확장된후기도부가특별한합병증없이잘유지되고있었다.(Fig. 3. F) 수술 3 주경과후의측두두개방사선사진에서축소된연구개길이는 38 mm 로안정적으로유지되고있었다.(Fig. 2) 환자또한수술 2 주후에는앙와위로수면을취할수있고코골이가현저하게감소하였다고언급하였다. 수술 3 주경과후에는주간기면증상이많이사라졌으며, 피곤함또한많이감소하였다고언급하였다. 구개인두폐쇄부전증, 연하곤란등의합병증은관찰되지않았다. 술후 2 개월에시행한수면다원검사에서호흡장애지수는 15.4 로술전에비해현저히감소하였으며, 앙와위수면시간은총수면시간의 37.5% 로늘어난양상을보였고, 앙와위수면시간중호흡장애지수는 35.4 로술전에비해현저히감소한양상을보였다. 총코골이시간은총수면시간의 8.3% 에불과하였으며, 맥박산소측정에의한산소포화도는평균 96% 로, 총수면시간동안 92% 이하로떨어지지않았다. 현재환자는 6 개월째경과를관찰중이며, 특별한합병증없이치료결과가잘유지되고있다. Ⅲ. 고찰 구개수구개인두성형술시행시조직의과도한절제로발생할수있는구개인두부전증의예방을위해고안된확대구개수구개피판술은, 1) 근육은보존하면서지방층의광범위한제거가가능하고, 2) 후구개부공간, 특히측면공간을보다더크게확보할수있으며, 3) 연구개를절제하는것이아니라중첩시켜놓는보존적이며가역적인술식이라는점에서전통적인구개수구개인두성형술과구별되는장점을가지고있다 3,13,14,18. 뿐만아니라, 구개수구개피판술의비슷한치료결과를얻기위해서는수차례의재시술이필요한레이저구개수구개성형술 (laser-assisted uvulopalatoplasty, 83
J Korean Assoc Oral Maxillofac Surg 2011;37:81-5 Fig. 3. A procedure of the extended uvulopalatal flap technique. A. The uvular and soft palate is retracted forward. B. The margin of the uvulopalatal flap is marked. C. The overlapping mucosa and submucosal adipose tissue are resected from the incision line to the uvular tip. D. The flap is folded and sutured to the residual mucosa of the soft palate. Also, the wound at tonsillar fossa for the removal of tonsils, mucosa and submucosal adipose tissue is closed. E. To achieve more effective expanding of posterior airway space, radiofrequency ablation of the tongue base is combined. F. At the postoperative one week, the shortening of soft palate and the expanding oropharyngeal inlet was observed. LAUP) 과는달리 1 번의내원으로수술이완료될수있다는장점이있어더유리하게사용되고있다 13,14. 하지만, 확대구개수구개피판술의좋은치료결과를얻기위해서는먼저정확한적응증을찾는것이중요하며정확한전신병력청취및정확한임상검사의선행이필수적이다. 전신병력청취에서는심혈관계, 호흡기계및신경정신과적질환등, 선행치료또는조절을요하는전신적합병증이있는지확인해야한다. 또한임상검사에서상기도폐쇄가가장많이일어나는세부분즉, 비부, 구개부 ( 구인두부 ) 및설기저부 ( 하인두부 ) 를검사하여, 확대구개수구개피판술적응증의적합여부를감별진단하여야할것이다. 비인두내시경및두개계측방사선사진, 컴퓨터단층촬영 (computed tomography, CT), 자기공명영상 (magnetic resonance imaging, MRI) 등의검사를통해상기도의구조와폐쇄여부를확인할수있다. 또한환자의수면상태및수면무호흡의심도를파악하고치료방향을결정하기위해수면다원검사 (polysomnography) 를시행하여야한다 1-3. 위증례환자의경우, 비대한연구개조직, 낮게내려앉은연구개등구인두부위의해부학적인폐쇄가직접관찰되었으며, 호흡장애지수가 20 이상인중등도이상의수면무호흡증으로심한주간기면증등을동반하고있었고, 환자가보존적치 료보다는수술적치료를원하였기에, 구인두수술의하나인확대구개수구개피판술의적응증에해당됨을알수있었다 3. 지속적기도양압술이폐쇄성수면무호흡증의 1 차적치료법임에도불구하고, 환자들이이상적으로지속적기도양압술을이용하였을경우, 평균무호흡 (mean apnea alleviation) 의대략 50% 정도가개선된것으로연구되었다 6. 따라서외과적성공은수술후호흡장애지수개선정도가지속적기도양압술을시행했을때와동등즉, 50% 이상의감소를보이는것으로정의되며, 지속적기도양압술을시행하지않았을경우에는, 수술후호흡장애지수가 20 미만으로개선되거나, 수술전호흡장애지수가 20 이하였으면수술전과비교하여 50% 이상감소하고동시에산소포화도가정상화되면서수면분절이개선되어야치료성공으로간주한다 3. 위증례의환자는 Friedman stage III 로구개수구개인두성형술등의외과적수술에대한예측된성공률이낮음에도, 정확한진단을통한적절한확대구개수구개피판술식을선택하였기에, 술전에지속적기도양압술시행없이호흡장애지수가술전 24.3 에서술후 15.4 로감소되어만족할만한치료결과를얻을수있었음을알수있다. 하지만, 모든수면무호흡환자에있어확대구개수구개피 84
판술이적응증이되는것은아니다. 앞서기술한바와같이, 구인두부폐쇄를동반한폐쇄성수면무호흡환자에서만확대구개수구개피판술치료의만족스러운결과를얻을수있다. 전체폐쇄성수면무호흡환자중대략 75% 정도에서구인두부폐쇄를동반한다는점에서구인두부의수술이폐쇄성수면무호흡증의대표적인수술치료임에는틀림없으나, 구인두부폐쇄를가지지않는 25% 의환자에서는증상의개선효과가미약할것이기때문이다 3. 또한확대구개수구개피판술은구개수구개인두성형술을사용할수있는대부분의증례에서우선적으로선택할수있지만, 심하게길거나두꺼운구개부를가진환자증례에사용할경우에는구개수의근육과구개부가중첩될때비정상적으로두꺼운구개부를초래하여이물감과연하곤란을일으킬수있기때문에술식사용을제한하여야할것이다 1,3,13. 또한확대구개수구개피판술시행후출혈, 혈종에의한피판분리, 감염등이합병증으로드물게발생할수있다. 하지만보고된증례의대부분의경우일시적증상으로술후지속적치료를통해완화되었다고보고되었다. 특히술후통증의경우구개수구개인두성형술에비해유의하게감소됨이보고된바있다 13,19. 최근치의학계에서폐쇄성수면무호흡의치료에대한관심이고조되고있다. 하지만그관심이대부분구강내장치를이용한보존적치료나제 2 단계수술적치료방법인상하악전진술에만머물러있다. 본증례및문헌고찰을통해확대구개수구개피판술은술식이간단할뿐아니라, 전통적인구개수구개인두성형술방식에비해보존적이며가역적인술식이기에합병증이유의하게감소함을알수있었다. 또한정확한진단을통해적절한증례에시술한경우그치료성적도훌륭함을알수있었다. 이에본저자들은이에대해보고하고추후많은구강악안면외과의의관심과연구를기대해보는바이다. References 1. Won CH, Li KK, Guilleminault C. Surgical treatment of obstructive sleep apnea: upper airway and maxillomandibular surgery. Proc Am Thorac Soc 2008;5:193-9. 2. Cho KS. Surgical management for obstructive sleep apnea. J Clin Otolaryngol Head Neck Surg 2008;19:168-76. 3. Rhee CS, Han DH. Surgical management of sleep-disordered breathing. Tuberc Respir Dis 2009;66:417-30. 4. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. 5. Huang SG, Li QY; Sleep Respiratory Disorder Study Group Respiratory Disease Branch Shanghai Medical Association. Prevalence of obstructive sleep apnea-hypopnea syndrome in Chinese adults aged over 30 yr in Shanghai. Zhonghua Jie He He Hu Xi Za Zhi 2003;26:268-72. 6. Grote L, Hedner J, Grunstein R, Kraiczi H. Therapy with ncpap: incomplete elimination of sleep related breathing disorder. Eur Respir J 2000;16:921-7. 7. Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomic azbnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981; 89:923-34. 8. Walker-Engström ML, Tegelberg A, Wilhelmsson B, Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest 2002;121:739-46. 9. Lee YK, Myung H, Hwang SJ, Seo BM, Lee JH, Choung PH, et al. Clinical study of surgical treatments for snoring and obstructive sleep apnea. J Korean Assoc Oral Maxillofac Surg 2008;34: 435-44. 10. Fairbanks DN. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 1990;102: 239-45. 11. Haavisto L, Suonpää J. Complications of uvulopalatopharyngoplasty. Clin Otolaryngol Allied Sci 1994;19:243-7. 12. Li HY, Chen NH, Shu YH, Wang PC. Changes in quality of life and respiratory disturbance after extended uvulopalatal flap surgery in patients with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2004;130:195-200. 13. Powell N, Riley R, Guilleminault C, Troell R. A reversible uvulopalatal flap for snoring and sleep apnea syndrome. Sleep 1996; 19:593-9. 14. Li HY, Li KK, Chen NH, Wang PC. Modified uvulopalatopharyngoplasty: the extended uvulopalatal flap. Am J Otolaryngol 2003;24:311-6. 15. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14:540-5. 16. Friedman M, Ibrahim H, Joseph NJ. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 2004;114:454-9. 17. Kim JH. Sleep apnea. In: Korean Society of Otorhinolayngology- Head and Neck Surgery, ed. Otorhinolaryngology-Head and Neck Surgery. 1st ed. Seoul: Ilchokak; 2002:1103-14. 18. Li HY, Li KK, Chen NH, Wang CJ, Liao YF, Wang PC. Threedimensional computed tomography and polysomnography findings after extended uvulopalatal flap surgery for obstructive sleep apnea. Am J Otolaryngol 2005;26:7-11. 19. Kim SW. Eun YG. Surgical therapy for obstructive sleep apnea. J Clin Otolaryngol Head Neck Surg 2005;16:193-206. 85