1 계명대학교의과대학동산의료원이비인후과학교실, 2 계명대학교의과대학동산의료원신경외과학교실 김지룡 1, 이예원 1, 김엘 2, 남성일 1 J Korean Skull ase Society 12 권 2 호 : 61~65, 2017 Transotic approach to the petrous bone cholesteatoma 종설1 종설2 원저1 원저2 증례1 증례2 증례3 증례4 증례5 증례6 증례7 증례8 증례9 1 epartment of Otorhinolaryngology, ongsan Medical enter, Keimyung University School of Medicine, aegu, Korea 2 epartment of Neurosurgery, ongsan Medical enter, Keimyung University School of Medicine, aegu, Korea Ji Ryong Kim 1, Ye Won Lee 1, El Kim 2, Sung Il Nam 1 To completely remove the petrous bone cholesteatoma (P) have been a surgical challenge for 교신저자 Sung Il Nam 논문접수일 : 2017 년 8 월 5 일논문완료일 : 2017 년 8 월 25 일주소 : epartment of Otorhinolaryngology, ongsan Medical enter, Keimyung University School of Medicine, 56, alseongro, Junggu, aegu 41931, Korea Tel : +82-53-250-7715 Fax : +82-53-256-0325 E-mail : entnamsi@dsmc.or.kr many years because of tight adhesion or invasion of the matrix into surrounding vital structures such as the labyrinth, middle and posterior cranial fossa dura, internal carotid artery, facial nerve canal or jugular bulb. The main factors influencing the surgical approach to choose are the inaccessible nature of the petrous bone, the extent of disease, the degree of facial nerve function, and the need for the prevention of cerebrospinal fluid leaks and the recurrence of the lesion. We present the case of a 55- year-old male presenting with right-sided facial palsy P treated by transotic approach. Facial palsy in the operated ear improved after surgery. We conclude that transotic approach is a safe and effective approach to the supralabyrinthine P region. Key Words petrous bone cholesteatoma, transotic, facial nerve, supralabyrinthine 61
INTROUTION 추체부진주종 (petrous bone cholesteatoma) 은측두골추체영 역의표피낭종을일컫는다. 이질환은모든추체부질환의 4%-9% 발병률을가진드문질환이다. [1] 서서히자라면서국소적으로파괴 적인병변을나타내기때문에안면신경이나미로를침범할때까지 는무증상으로지속되는경우가많다. 추체부진주종은일반적진 주종과는침범정도와방식에서약간의차이가있다. 즉, 서서히골 미로를침범하고경정맥구, 하추체정맥동, S 상정맥동, 내경동맥, 경뇌막, 안면신경관, 추체첨부, 두개저와내이도로침범하므로이 [2, 3] 주요구조물에접해있는진주종을완전한제거하기는어렵다. Sanna 등 [4] 은진주종의위치와침범정도에따라 5 개군으로분 류하였다. 즉 supralabyrinthine, infralabyrinthine, massive, infralabyrinthine-apical, 그리고 apical 로나누었다. [4] 최근우수 한영상기법의발달은측두골내의내이및내이도, 안면신경관의 주변구조로침범된병변의평가와다른양성종양과의감별진단을 용이하게해주었고, 지난수십년동안측면두개저수술접근법의 발전은추체부진주종치료에큰영향을미치고있음에도불구하고 수술후이환율은여전히높아해결해야될문제로남아있다. 저자들은측두골의추체부에서중이강일부까지진행한진주종 을경이 (transotic) 접근법을통해특별한합병증없이치유하였기 에문헌고찰과함께보고한다. 고와우, 반고리관및내이도를침범하여골파괴를보이는양상을보였다. 자기공명영상 (magnetic resonance imaging) 이미지상 T1 강조영상에서중등도신호강도를보이고, T2 조영증강에서고신호강도를보이는종괴가추체부에서관찰되었다 (Fig. 4). 영상학적검사상우측추체부진주종에의한안면마비로평가하고전신마취하에경이접근법으로개방형유양동삭개술및추체아전절제술을시행하였다 (Fig. 5). 개방형유양동삭개술을시행, 침 Fig. 1 Preoperative otoscopic finding of right tympanic membrane shows normal. SE REPORT Fig. 2 55세남자가내원약 20년전부터우측청력소실이있었으나특별한치료없이지내다가내원 4년전에안면마비가시작되었고, 내원 1년전부터는안면마비가점점심해져우측눈이감기지않고최근에간헐적어지럼이동반되어내원하였다. 이학적소견상우측안면마비는 House-rackmann Grade VI 였고, 양측고막은정상이었다 (Fig. 1). 순음청력검사상우측은심도난청, 좌측은기도청력이 16 d, 골도청력이 11d로정상청력을나타내었다 (Fig. 2). 비디오안진검사에서는좌측으로향하는자발안진, 좌측을진동유발안진, 두진후에는좌측으로향하는자발안진이증가하는소견을보였고, 온도안진검사상 38% 의우측반고리관마비소견을보였다 (Fig. 3). 안면신경근전도검사에서탈신경전압은나타나지않았다. 측두컴퓨터단층촬영 (computed tomography) 상 2.2 1.2 1.7cm 크기의연조직음영을나타내는종괴가우측추체부를채우 Preoperative pure tone audiogram shows profound mixed type hearing loss on the patient s right side, otherwise normal hearing on the patient s left side. 62 JOURNL OF KOREN SKULL SE SOIETY SEPTEMER Vol. 12 No. 2
골을제거한뒤가측반고리관에서나온진주종을발견할수있었 다. 안면신경의주행을따라추체부내측과반고리관, 와우, 내이도 에위치한진주종을제거하였다. 안면신경의슬와신경부분에서일 부의직경이 60% 이상손상된것을확인하고신경절단후안면신 경고실분절과미로분절의단단문합을시행하였다. 수술직후시 행한뇌컴퓨터단층촬영상술전우측추체부에관찰되던진주종이 Fig. 3 Videonystagmography. () Spontaneous horizontal nystagmus toward the left side (2 /sec) was detected. () Vibration induced nystagmus toward the left side (5 /sec) was detected. () Head shaking nystagmus toward the left side (3 /sec) was detected. () aloric test shows 75% canal paresis on right ear. Fig. 4 E Preopeative temporal bone computed tomography shows 22 x 12 x 17mm sized nearly nonenhancing mass lesion in the right petrous bone, involving the right internal auditory canal and bony dehiscence of the basal turn of the right cochlea () and superior semicircular canal (), and magnetic resonance imaging shows shape of moderate intensity of T1-weighted imaging () and shape of high intensity of T2-weighted imaging () and PROPELLER diffusion-weighted imaging (E). 63
완전히제거되었음을확인하였다 (Fig. 6). 환자는수술후 9일째특별한문제없이퇴원하였다. 수술후 12개월까지의추적관찰에서안면신경마비의변화는 House-rackmann Grade IV였으며, 현재경과관찰중이다. ISUSSION 소실과안면마비, 어지럼이동반되어내원하였다. 진주종을감별하기위해여러가지방사선학적검사들이시행되고발전되어오고있다. 측두골컴퓨터단층촬영은진주종진단에매우중요한수단으로이용되고있으나민감도는 48%-54%, 특이도는 29%-41% 로보고된다. [9-11] 자기공명영상은컴퓨터단층촬영을보완해주지만민감도와특이도는각각 63%-71%, 50%-78% 추체부진주종의발생은배아기의표피세포의잔존에의한것으로설명되는선천성진주종이추체부에서발생하는것과만성진주종성중이염, 외인성혹은외상과동반되어중이와유돌부에서생긴진주종이이차적으로추체부까지침범하여생기는두가지기전이있다. [5] 추체부진주종은두개저외과수술의가진단하거나치료할때어려움에당면하게된다. 이질환은공격적인성향을지니고있어자주수반되는합병증들이있다. artels [6] 는 8명의추체부진주종환자모두에서안면신경관과미로를침범했다고보고하였다. Sanna 등 [4] 은 50명의추체부진주종환자중 23명 (46%) 에서안면마비가있었다고보고하였다. Tutar 등 [7] 은 34명환자에서호소하는증상으로난청 (95%), 이루 (63%), 안면마비 (59%), 두통 (24%), 이명 (9%), 이통 (9%), 어지럼증 (6%) 을보고하였다. Peron 과 Schuknecht [8] 는청력소실, 안면마비가가장흔한증상이고그외에현훈, 두통, 이충만감및기타뇌신경장애를보인다고보고하였다. 본증례에서는 20년전부터병소부위의서서히진행되는청력 Fig. 6 Postoperative brain computed tomography shows surgically removed previous mass lesion in the right petrous bone. Fig. 5 Intraoperative microsocpic findings. () Lateral semicircular canal originated cholesteatoma (arrow), incus absent. () holesteatoma in the petrous portion. () Facial nerve damaged (arrow). () Facial nerve was repaired with end to end anastomosis (arrow). 64 JOURNL OF KOREN SKULL SE SOIETY SEPTEMER Vol. 12 No. 2
로보고되고있다. [12, 13] Park 등 [14] 은프로펠러확산강조영상을이용하였을경우민감도, 특이도를각각 94.1%, 100% 로보고하였다. 본증례에서추체부에특징적인고강도의신호를관찰할수있었다. 추체부진주종의치료목표는추체부진주종을완전히외과적으로제거하는것이다. 수술적접근방식은수술전병변의해부학적위치와침범범위, 잔존하는청신경의기능, 안면신경의기능등을고려해가장적합한접근법을택하게된다. 접근방식으로는경이, 경와우 (transcochlear) 아전추체절제술 (subtotal petrosectomy), 경미로 (translabyrinthine), 경접형동 (transsphenoidal) 등이있다. 본증례는추체부 (supralabyrinthine) 의영역에진주종이발생하면서중두개와, 세반고리관, 와우, 안면신경관과내이도를침범하여서경이접근법을통해진주종을완전히제거한후심하게손상된안면신경을확인하고신경절단및단단문합을시행하였다. 경이접근법은추체부영역중 supralabyrinthine 영역을충분히노출시킬수있으므로수술시야가유용하게확보되어진주종을완전히제거할수있을것으로여겨진다. References 1. Omran, e enato G, Piccirillo E, Leone O, Sanna M. Petrous bone cholesteatoma: management and outcomes. Laryngoscope 2006;116:619-26. 2. Wright JL, olman H, onnor F. Massive acquired cholesteatoma of the temporal bone. J Laryngol Otol 1976;90:257-62. 3. Yanagihara N, Matsumoto Y. holesteatoma in the petrous apex. Laryngoscope 1981;91:272-8. 4. Sanna M, Zini, Gamoletti R, Frau N, Taibah K, Russo, et al. Petrous bone cholesteatoma. Skull ase Surg 1993;3:201-13. 5. Glasscock ME, 3rd, Woods I, 3rd, Poe S, Patterson K, Welling. Petrous apex cholesteatoma. Otolaryngol lin North m 1989;22:981-1002. 6. artels LJ. Facial nerve and medially invasive petrous bone cholesteatomas. nn Otol Rhinol Laryngol 1991;100:308-16. 7. Tutar H, Goksu N, ydil U, a t rk Tutar V, Kizil Y, akkal FK, et al. n analysis of petrous bone cholesteatomas treated with translabyrinthine transotic petrosectomy. cta Otolaryngol 2013;133:1053-7. 8. Peron L, Schuknecht HF. ongenital cholesteatomata with other anomalies. rch Otolaryngol 1975;101:498-505. 9. Thomassin JM, raccini F. Role of imaging and endoscopy in the follow up and management of cholesteatomas operated by closed technique. Rev Laryngol Otol Rhinol (ord) 1999;120:75-81. 10. laney SP, Tierney P, Oyarazabal M, owdler. T scanning in "second look" combined approach tympanoplasty. Rev Laryngol Otol Rhinol (ord) 2000;121:79-81. 11. Tierney P, Pracy P, laney SP, owdler. n assessment of the value of the preoperative computed tomography scans prior to otoendoscopic 'second look' in intact canal wall mastoid surgery. lin Otolaryngol llied Sci 1999;24:274-6. 12. Vanden beele, oen E, Parizel PM, Van de Heyning P. an MRI replace a second look operation in cholesteatoma surgery? cta Otolaryngol 1999;119:555-61. 13. Kimitsuki T, Suda Y, Kawano H, Tono T, Komune S. orrelation between MRI findings and second-look operation in cholesteatoma surgery. ORL J Otorhinolaryngol Relat Spec 2001;63:291-3. 14. Park SH, Lee YW, Park JW, Jang HJ, Nam SI. The value of PROPELLER diffusion-weighted image in the detection of cholesteatoma. Korean J Otorhinolaryngol-Head Neck Surg 2016;59:813-8. 65