대한두경부종양학회지제 23 권제 2 호 2007 online ML Comm Frey 씨증후군의진단에있어서 Thermography 의유용성 한림대학교의과대학이비인후-두경부외과학교실김현수 박범정 = Abstract = The Effectiveness of Thermography in Diagnosis of Frey s Syndrome Following Parotidectomy Hyun Su Kim, M.D., Bum Jung Park, M.D., Ph.D. Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Seoul, Korea Objectives and Backgrounds:After parotidectomy, some of patients complain gustatory sweating, facial flushing and discomfort in the same area. A series of these symptoms are supposed to be caused by the aberrant regeneration of the secretory parasympathetic fibers to sweat glands and blood vessels of the skin following parotidectomy. In this study, we want to compare the efficacy of thermography to the Minor s starch-iodine test for determining the presence of Frey s syndrome. Materials and Methods:48 patients who underwent total or superficial parotidectomy from March 2002 to December 2004 were selected for this study. A subjective clinical questionnaire and the objective Minor s starchiodine test were performed to evaluate the incidence of this syndrome. Total 21 patients were confirmed as positive Frey s syndrome and infrared thermography was performed for them. Result:Frey s syndrome occurred in 21 patients(43.8%). The average temperature of parotidectomy site and normal opposite area were 27.65 and 26.41 respectively. Thermography showed temperature difference in 20 patient(95.2%) and the difference of temperature was statistically significant above 1.0 (p<0.001). The severity of symptoms were related with the difference of temperature(p<0.05). Conclusion:Thermography is useful, non-invasive, simple and quantifying method to diagnose Frey s syndrome. Additionally, this geographic diagnosis is available to show the accurate area for botulinum toxin injection. KEY WORDS:Frey s syndrome Thermography Parotidectomy. 서 이하선절제술은이하선의염증성질환이나종양의치료목적으로비교적흔하게시행되는술식이다. 이하선절제술후발생하는잠재적합병증중하나인 Frey 씨증후군 (Frey s syndrome, auriculotemporal nerve syndrome, gustatory sweating) 은 1923년에 Lucja Frey(1889~ 교신저자 : 박범정, 431-796 경기도안양시동안구평안동한림대학교의과대학이비인후 - 두경부외과학교실전화 :(031) 380-3849 전송 :(031) 386-3860 E-mail:pbj426@hallym.ac.kr 론 1943) 가온기, 홍조, 발한, 그리고이상촉감등을포함한저작시발한을교감신경과부교감신경의신경분포에의한질환으로처음으로보고하였으며 1926년에 Higier 가 Frey 라는이름을처음으로알렸으며 1932 년에 Bassoe 가 Frey 씨증후군 이라명명하였다 1-3). 저작시발한 (gustatory sweating), 홍조 (flushing) 및동통 (pain) 이흔한증상인 Frey 씨증후군의발생기전은이하선에분포하는부교감신경이안면의한선 (sweat glands) 과주위의혈관에분포하는교감신경으로비정상적으로연결됨으로써발생하는것으로여겨진다 1-3). 이하선천엽이나심엽절제술을시행받은환자에서많게는 90% 이상에서 Frey 씨증후군이발생하였다는보고도있으며, 단지 - 142 -
30% 정도만이주관적으로뚜렷한증상보고를보인다는보고도있다 4-6). Frey 씨증후군을진단하는방법으로는 Minor s starchiodine 검사가주로사용되어왔으나이방법은단지시각적인인지를통해 Frey 씨증후군의유, 무만을알뿐증상의심함의정도는알수가없는단순한방법이다. 이연구에서저자들은이하선절제술후발생할수있는 Frey 씨증후군을진단함에있어비침습적이면서보다간편하고객관적인적외선체열검사기 (infrared thermography) 를이용하여기존에 Minor s starch-iodine 검사를대체할수있고보다정량적인정보를줄수있는지를알아보고자하였다. 대상및방법 2002년 3월부터 2004년 12월까지본원에서이하선절제술을시행받은환자중발한에영향을미치는처치를받거나약물복용을한경우, 반대편이하선부위에수술적치료를받은경우와방사선조사를받은경우를제외한환자 48명중 Minor s starch-iodine 검사를통해 Frey 씨증후군으로진단된 21 례를대상으로하였다. 설문의내용엔환자가느꼈던경험을확인하기위하여식사때수술부위에땀이흐르는것을느낀적이있는지, 화장이지워진적이있는지, 후끈거리거나열감을느낀적이있는지의항목에서 예, 아니오 에표시하도록하였다. 이때 예 에표시한환자는술후얼마만의기간후에증상을느꼈는지를 술후즉시, 1 개월이내, 6개월이내, 그리고 6개월이후 로나누어선택하게하였고또증상이생활하는데얼마나불편을주었는지를 불편없음, 약간불편함, 불편함, 그리고 많이불편함 의항목중에선택하도록하였다. 추후증상의불편함정도는 불편없음 과 약간불편함 을경증군으로 불편함 과 많이불편함 을중증군으로나누어양측의온도차이와의관계를분석하였다. Minor s starch-iodine 검사는요오드용액 (iodine 3g, castor oil 20ml, absolute alcohol 200ml) 을이용하여환자의수술부위의안면에얇게바르고환자의안면부에서 50cm 떨어진거리에서 500 watt 조명등두개를약 5분간비추어요오드용액을완전히말린후, 그위에녹말가루를얇게바르고환자에게타액분비를유도하기위해레몬사탕을 10분간입에물게하였다. 검사당일환자는환부에연고등을바르지못하게교육하였고소염진통제나혈관확장제등을복용하지않도록하였다. 검사를시행받은부위의피부가암청색으로변하면양성으로정의하였다 (Fig. 1). 주관적설문지작성과객관적 Minor s starch-iodine 검사를통하여 Frey 씨증후군양성으로진단된환자 21례를대상으로하여적외선체열진단기 (Thermography, IRIS- 5000, MEDICORE, KOREA) 를이용하여 Frey 씨증후군측이하선부위와반대측정상부위의온도를측정하였다. 외부로부터빛과열이차단되고실내기류가일정한 22~25 의항온이유지된밀폐된검사실에서약 15분간검사실온도적응후에 Minor s starch-iodine 검사의경우와같이환자에게레몬사탕을 10분간입에물게한후적외선체열촬영을하였다. 적외선체열촬영후이하선절제술측온도와반대측정상부위의온도를측정, 비교하였다 (Fig. 2). 통계적유의성검증은대응표본 T 검정과 Fisher 의정확한 A Fig. 1. The results of Minor s starch-iodine test. A:Positive result in parotidectomy site. B:negative result in opposite normal site. B A B C Fig. 2. The results of infrared thermography. A:High temperature in parotidectomy site. B:Frontal view for comparing both sites. C: Low temperature in opposite normal site. - 143 -
Table 1. Sensitivity of infrared thermography compared with Minor s starch-iodine test Minor s starch-iodine test(+) Infrared thermography (+) 20 (-) 01 Sensitivity 95.2% Table 2. The results of thermography in Frey s syndrome Parotidectomy site Table 3. The relationship between thermal difference and symptom Thermal differences Total < 1.0 1.0 Mild 4 04 08 Symptom Severe 0 13 13 Total 4 17 21 Thermal differences are related with the severity of the symptom(p<0.05) 검정을이용하여확인하였다. 결 Opposite normal site 이하선천엽또는심엽절제술을받은환자군중발한에영향을미치는처치를받거나약물복용을한경우, 반대편이하선부위에수술적치료를받은경우와방사선조사를받은경우를제외한경우는 48명이었으며, 이중 Minor s starch-iodine 검사양성인환자군, 즉 Frey 씨증후군양성환자군은 21명 (43.8%) 이었다. Frey 씨증후군양성환자 21명을대상으로적외선체열진단기를이용하여검사하였다. 남자 8명, 여자 13명으로연령분포는 18~76(46.4±16.8) 세이었으며추적관찰기간은 6~27개월이었다. 병리학적으로는다형성종 (pleomorphic adenoma) 이가장많았다. Minor s starch-iodine 검사로진단한 Frey 씨증후군양성환자군에서적외선체열검사결과 Frey 씨증후군양성 ( 정상이하선부위에비해이하선절제술을시행받은부위의온도가 0.5 이상높은경우 ) 인경우는 20명이었으며민감도는 95.2%(20/21) 이었다. 적외선체열검사결과환부에나타난평균온도는 27.65 ±0.56 (26.70~28.90 ) 이었고반대측정상이하선부위의평균온도는 26.41±0.62 (25.50~28.20 ) 이었다. 이하선절제술부위와반대측정상이하선부위의온도차의평균은 1.24±0.39 (0.4~2.0) 이었으며대응표본 T 검정에의한 99% 신뢰구간에서양측의온도차가 0.99 이상일때의미있는차이가난다고볼수있었다 (p<0.001). 과 Thermal difference Temperature( ) 27.65±0.56 26.41±0.62 1.24±0.39* *:Statistically significant thermal difference is above 0.99 (p<0.001) 환부와정상측과의온도차의정도와환자가느끼는증상의정도를비교해보았다. 우선환부와정상측과의온도차를통계적으로의미있는차이를보인 1.0 를기준으로그차이가 1.0 미만인군과 1.0 이상인군으로나누었고설문조사를통해환자가느끼는불편함의정도는경증과중증중선택하게하였다. 온도차이가 1.0 미만인군은 4례있었으며모두경증의불편함을호소하였고온도차이가 1.0 이상인군은 17례로그중 4례에서경증을 13례에서중증의불편함을호소하였다. Fisher 의정확한검정을통해환자가느끼는불편감과온도차이와의상관관계를검증한바로는온도차가 1.0 이상인군에서미만인군에서보다더불편함을호소한것으로나타났다 (p<0.05). 고찰 Frey 씨증후군은이하선절제술이나이하선부위의창상후발현될수있는합병증중하나로비록기전은명확히알려져있지않으나이개측두신경에대한손상으로인하는것으로여겨지며절후부교감신경섬유 (postganglionic parasympathetic fiber) 가피부한선및피하혈관의절후교감신경섬유 (postganglionic sympathetic fiber) 로의비정상적인연결로인해발생하는것으로설명되어진다 1-3). Frey 씨증후군에서나타나는주증상으로는저작시발한, 안면홍조, 그리고이환부위의통증이나불편감등이있으며발생률은 5~100% 로다양하게보고되고있다 1-6). 이러한 Frey 씨증후군발생률의차이는침분비자극후나타나는저작시발한과안면홍조를평가하는방법들간의차이때문이라고생각된다. 저자들의경우에총 48례의대상환자에서 21례에서 Frey 씨증후군이진단되어발생률은 43.8% 였다. 적외선체열진단은신체표면의온도분포를정량화할수있는진단방법으로적외선체열진단기 (IRT;infrared thermography), 액정체열진단기 (LCT;liquid crystal thermography), 그리고극초단파체열진단기 (MWT ; microwave thermography) 의세가지유형의진단기가있으며그중검체와접촉없이측정할수있는것은적외선체열진단기가유일하다 7). 임상적으로처음으로도입된것은 1970 년대초에사지의염증의위치와특징을확인한것이시작으로이후기흉의진단에도적용되었으며타액선의기능을확인하는방법으로도쓰였다 7)8). 이러한적외선체열진단을이용하면 Frey 씨증후군에서나타나는저작시혈관이확장된부분이정량적이며시각적으로열점 (hot spot) 의모습으로나타나기때문에진단에도움이된다 9). 체열측정을통한정상성인의안면부의좌, 우측의차이는 0.30±0.17 로보고된바있으며적외선체열진단기 - 144 -
를이용한기흉의진단에서 0.5 이상의온도차로확인할수있었다는보고도있었다 8)10). 본연구에서도적외선체열진단기를이용한측정에서 0.5 이상의온도차이를보이는경우에 Frey 씨증후군양성으로판정하였으며 Minor s starch-iodine 검사와비교해서민감도가 95.2%(20/21) 로확인되었다. 기존의 Frey 씨증후군을진단하는방법으로는 Minor s starch-iodine 검사가대표적이며이는저작시발한상태를시각적으로확인하는방법으로환자가검사시불편감을느낄수있으며검사가다소번거로운면이있다. 또한얇은막을안면에부착해발한된부위를확인하는검사방법도있으나이들방법들은증상의유무만을알수있을뿐으로그정도를정량적으로나타낼수는없는단점이있다 11). 그러나적외선체열진단기를이용하면온도차이로인한증상의경, 중을확인할수있다. 본연구에서도온도차이가 1.0 이상인군에서통계적으로유의하게중한증상을호소했음을확인할수있었다. 이러한 Frey 씨증후군을예방하고치료하기위하여여러가지내과적, 외과적방법들이사용되고있다. Frey 씨증후군예방을위해술중에시행하는외과적방법으로피부판을두껍게거상하는방법과이하선절제술부위와피부판사이에방벽 (barrier) 을삽입하는방법이보편적이다 12-15). 또한술후에시행하는내과적방법으로는국소적항콜린성 (anticholinergic), 항발한성 (antiperspirant) 제재의사용, 그리고보툴리눔독소 (botulinum toxin) 를주사하는방법이있으며이러한방법들중보툴리눔독소주입술은 Frey 씨증후군의치료에매우효과적이라보고되어있다 17-20). 저자들이시행한적외선체열진단기를사용하면온도차이에따라명확하게다른색으로표현되기때문에그동안제한적으로만알수있었던 Frey 씨증후군의병변부위와경중의정도와그범위를정확하게알수있다. 따라서보툴리눔독소주입술을시행함에있어주입범위와용량을결정하는데도움을줄수있다. 결론 이하선절제술후나타날수있는 Frey 씨증후군을진단함에있어기존의 Minor s starch-iodine 검사는다소번거롭고결과를객관적으로정량화할수없는단점이있었다. 하지만적외선체열진단기를사용하면비침습적이면서보다쉽고정확하게 Frey 증후군을진단하는것이가능하고증상이발현되는범위를보다시각적으로나타내며정량적으로확인할수있어치료를위한 botulinum toxin 주입술의범위를정하는것을보다용이하게할수있어진단뿐아니라치료적인면에서도많은이점이있을 것이라생각된다. 중심단어 : 프레이증후군 적외선체열진단 이하선절제술. References 1) Dunbar EM, Singer TW, Singer K, Knight H, Lanska D, Okun MS: Understanding gustatory sweating. What have we learned from Lucja Frey and Her predecessors? Clin Auton Res. 2002; 12:179-84 2) Moltrecht M, Michel O: The woman behind Frey s syndrome: The tragic life of Lucja Frey. Laryngoscope. 2004;114:2205-2209 3) Reich SG, Grill SE: Gustatory sweating: Frey syndrome. Neurology. 2005;65:24 4) Sood S, Quraishi MS, Bradley PJ: Frey s syndrome and parotid surgery. Clin Otolaryngol. 1998;23:291-301 5) Gordon AB, Fiddian RV: Frey s syndrome after parotid surgery. Am J Surg. 1976;132:54-58 6) Kornblut AD, Westphal P: The effectiveness of a sternomastoid muscle flap in preventing post-parotidectomy occurrence of the Frey s syndrome. Acta Otolaryngol. 1974;77:368-373 7) Lamey P-J, Biagioni PA, Al-Hashimi I: The feasibility of using infrared thermography to evaluate minor salivary gland function in euhydrated, dehydrated and rehydrated subjects. J Oral Pathol Med. 2007;36:127-131 8) Rich PB, Dulabon GR, Douillet CD, et al: Infrared thermography: A rapid, portable, and accurate technique to detect experimental pneumothorax. J Surg Res. 2004;120:163-170 9) Isogai N, Kamiishi H: Application of medical thermography to the diagnosis of Frey s syndrome. Head Neck. 1997;19:143-147 10) Uematsu S, Edwin DH, Jankel WR, Kozikowski J, Trattner M: Quantification of thermal asymmetry. Part I: Normal value and reproducibility. J Neurosurg. 1988;69:552-555 11) Eisele DW: Simple method for the assessment of Frey s syndrome. Laryngoscope. 1992;102:583-584 12) Hwang JH, Yang JM, Hong SK, et al: The effectiveness of sternocleidomastoid muscle flap in preventing Frey s syndrome following parotidectomy. Korean J Otolaryngol. 2005;48:778-782 13) Philip C: Frey s syndrome: A preventable phenomenon. Plast Reconstr Surg. 1992;89:452-456 14) Honig JF: Facelift approach with a hybrid SMAS rotation advancement flap in parotidectomy for prevention of scars and contour deficiency affecting the neck and seat secretion of the cheek. J Craniofacial Surg. 2004;15:797-803 15) Asal K, Koybasioglu A, Inal E, et al: Sternocleidomastoid muscle flap reconstruction during parotidectomy to prevent Frey s syndrome and facial contour deformity. Ear Nose Throat J. 2005; 84:173-176 16) Gooden EA, Gullance PJ, Katz M, Carroll C: Role of the sternocleidomastoid muscle flap preventing Frey s syndrome and maintaining facial contour following superficial parotidectomy. J Otolaryngol. 2001;30:98-101 - 145 -
17) Drobik C, Laskawi R: Frey s syndrome: Treatment with botulinum toxin. Acta Otolaryngol. 1995;115:459-61 18) Kreyden OP, Scheidegger EP: Anatomy of the sweat glands, pharmacology of botulinum toxin, and distinctive syndromes associated with hyperhidrosis. Clin Dermatol. 2004;22:40-44 19) Batniji RK, Falk AN: Update on boulinum toxin use in facial plastic and head and neck surgery. Curr Opin Otolaryngol Head Neck Surg. 2004;12:317-322 20) Kyrmizakis DE, Pangalos A, Papadakis CE, Logothetis J, Maroudias NJ, Helidonis ES: The use of botulinum toxin type A in the treatment of Frey and crocodile tears syndromes. J Oral Maxillofac Surg. 2004;62:840-844 - 146 -