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์ตœ์†Œ ์นจ์Šต ๋‚ด์‹œ๊ฒฝ ์ ‘๊ทผ์„ ํ†ตํ•œ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์˜ ์น˜๋ฃŒ

Abstract

Background and Objectives

In treating attic cholesteatoma, traditional microscopic approach provides limited exposure to the attic space. Recently, the use of endoscope has emerged as a new treatment option for attic cholesteatoma. The aim of this study is to report the preliminary results of transcanal endoscopic removal of attic cholesteatoma and to evaluate the feasibility of endoscopic approach to attic cholesteatoma.

Subjects and Method

Six patients with attic cholesteatoma were enrolled in this study from Sep 2014 to Oct 2015. Cholesteatoma was removed via transcanal endoscopic approach. We analyzed the clinical characteristics, surgical management and treatment outcomes.

Results

All patients had attic cholesteatoma in the epitympanic space with scutum erosion. However, the disease was restricted to the epitympanic space in three patients, whereas a limited extension of cholesteatoma to the aditus ad antrum was observed in two patients, and mesotympanum was involved in the remaining one patient. All of the patients suffered from conductive or mixed hearing loss with mean air-bone gap of 17.4 dB, and underwent endoscopic transcanal removal of cholesteatoma and scutoplasty. In three patients, the incus and malleus head were removed due to ossicular erosion, and a second-stage ossicular reconstruction was planned. No residual or recurrent diseases were noted during the follow-up period (mean: 13 months). No surgical complications were observed postoperatively, and favorable hearing outcome was obtained in all patients.

Conclusion

Transcanal endoscopic approach was successfully performed in patients with limited attic cholesteatoma. Further studies involving a large number of patients with long-term follow-ups are necessary to prove the clinical efficacy of transcanal endoscopic approach in managing limited attic cholesteatoma.

์„œ ๋ก 

์ค‘์ด๊ฐ• ๋‚ด์— ์ƒ๊ธฐ๋Š” ์ง„์ฃผ์ข…์€ ์ƒํ”ผ์กฐ์ง์˜ ๊ณผ์ฆ์‹, ๊ณผ๋ถ„ํ™”๋ฅผ ํŠน์ง•์œผ๋กœ ํ•˜๋Š” ์งˆํ™˜์œผ๋กœ ์„ ์ฒœ์„ฑ ์ง„์ฃผ์ข…๊ณผ ํ›„์ฒœ์„ฑ ์ง„์ฃผ์ข…์œผ๋กœ ๋‚˜๋ˆŒ ์ˆ˜ ์žˆ์œผ๋ฉฐ, ๊ตญ๋‚ด์—์„œ ์‹œํ–‰๋œ ๊ตญ๋ฏผ๊ฑด๊ฐ•์˜์–‘์กฐ์‚ฌ์—์„œ ์ค‘์ด ์ง„์ฃผ์ข…์€ 1.18%์—์„œ ๊ด€์ฐฐ๋  ์ •๋„๋กœ ๋น„๊ต์  ํ”ํ•œ ์งˆํ™˜์ด๋‹ค[1]. ํ›„์ฒœ์„ฑ ์ผ์ฐจ์„ฑ ์ง„์ฃผ์ข…์€ ๊ณ ๋ง‰ ๋‚ด์˜ ์ฒ˜์Œ ๋ฐœ์ƒํ•œ ์œ„์น˜์— ๋”ฐ๋ผ ์ƒ๊ณ ์‹ค(epitympanum) ์ง„์ฃผ์ข…๊ณผ ์ค‘๊ณ ์‹ค(mesotympanum) ์ง„์ฃผ์ข…์œผ๋กœ ๋ถ„๋ฅ˜ํ•œ๋‹ค. ์ด ์ค‘ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์€ ์ƒ๊ณ ์‹คํ•จ์š”(Prussackโ€™s space)์—์„œ ์‹œ์ž‘ํ•˜์—ฌ ์ƒ๊ณ ์‹ค ํ›„๋ฐฉ, ์ƒ๊ณ ์‹ค ์ „๋ฐฉ์œผ๋กœ ์ง„ํ–‰๋˜๋ฉฐ ๋‹ค์–‘ํ•œ ๊ฒฝ๋กœ๋กœ ํŒŒ๊ธ‰๋˜์–ด ์œ ๋Œ๋™๊ตฌ(aditus ad antrum)๋ฅผ ํ†ตํ•˜์—ฌ ์œ ์–‘๋™์œผ๋กœ ์ด๋ฅด๊ธฐ๋„ ํ•˜๊ณ  ์ƒ๊ณ ์‹คํ•จ์š”์˜ ํ›„ํ•˜๋ถ€๋กœ ๋‚ด๋ ค๊ฐ€์„œ ์ค‘๊ณ ์‹ค์˜ ํ›„๋ฐฉ์— ๋„๋‹ฌํ•˜์—ฌ ๊ณ ์‹ค๋™, ์•ˆ๋ฉด์‹ ๊ฒฝ์™€(facial recess)๋ฅผ ์นจ๋ฒ”ํ•˜๊ธฐ๋„ ํ•œ๋‹ค. ํ›„์ฒœ์„ฑ ์ง„์ฃผ์ข…์˜ ์ง„ํ–‰๊ฒฝ๋กœ๋Š” ์ƒ๊ณ ์‹ค ํ›„๋ฐฉ์ด ๊ฐ€์žฅ ํ”ํ•˜๋ฉฐ, ๋‹ค์Œ์œผ๋กœ ์ค‘๊ณ ์‹ค ํ›„๋ฐฉ, ์ƒ๊ณ ์‹ค ์ „๋ฐฉ์˜ ์ˆœ์„œ๋กœ ํ”ํ•˜๋‹ค[2,3]. ๋‚ด์‹œ๊ฒฝ์€ ์ง์„  ์‹œ์•ผ๋ฅผ ๊ฐ€์ง€๋Š” ๊ธฐ์กด์˜ ํ˜„๋ฏธ๊ฒฝ๊ณผ๋Š” ๋‹ฌ๋ฆฌ ๋” ๋„“์€ ์‹œ์•ผ๋ฅผ ๊ฐ€์ง€๊ณ  ์žˆ๋‹ค๋Š” ์žฅ์ ์ด ์žˆ๊ณ  ๋˜ํ•œ ๋‹ค์–‘ํ•œ ๊ฐ๋„์˜ ๋‚ด์‹œ๊ฒฝ์ด ํ™œ์šฉ ๊ฐ€๋Šฅํ•˜๊ธฐ ๋•Œ๋ฌธ์— ์ค‘์ด๊ฐ• ๋‚ด์™€ ๊ฐ™์ด ์‚ฌ๊ฐ ์ง€์—ญ์ด ๋งŽ์€ ๋ถ€์œ„์—์„œ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•˜๋ฉด์„œ ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๊ธฐ ํŽธ๋ฆฌํ•˜๋‹ค. ๋‚ด์‹œ๊ฒฝ์„ ํ™œ์šฉํ•˜์—ฌ ์ด๊ณผ ์˜์—ญ์˜ ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๊ณ  ์ข‹์€ ๊ฒฐ๊ณผ๋ฅผ ๋ณด๊ณ ํ•œ ์—ฌ๋Ÿฌ ๋…ผ๋ฌธ[4-9]์ด ์žˆ์œผ๋‚˜ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์— ๋Œ€ํ•œ ๊ฒฝ์™ธ์ด๋„ ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ๋ฒ•์„ ํ†ตํ•œ ์น˜๋ฃŒ ๊ฒฐ๊ณผ์— ๋Œ€ํ•œ ์—ฐ๊ตฌ ๋ฐ ๋ณด๊ณ ๋Š” ๋“œ๋ฌผ๋ฉฐ ๊ตญ๋‚ด์—์„œ๋Š” ๋ณด๊ณ ๋œ ๋ฐ”๊ฐ€ ์—†๋‹ค[10]. ๋”ฐ๋ผ์„œ ๋ณธ ์—ฐ๊ตฌ๋Š” ๊ตญ๋‚ด์—์„œ ์ตœ์ดˆ๋กœ ์‹œ๋„๋œ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์˜ ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ์„ ํ†ตํ•œ ๋‚ด์‹œ๊ฒฝ์  ์น˜๋ฃŒ ๊ฒฐ๊ณผ์— ๋Œ€ํ•œ ์ž„์ƒ์  ๊ณ ์ฐฐ์„ ํ†ตํ•˜์—ฌ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•œ ์ตœ์†Œ ์นจ์Šต์  ์ˆ˜์ˆ ์˜ ํšจ์šฉ์„ฑ ๋ฐ ์ดˆ๊ธฐ ์น˜๋ฃŒ ๊ฒฐ๊ณผ ๋“ฑ์„ ์•Œ์•„๋ณด๊ณ ์ž ํ•˜๊ณ  ํ–ฅํ›„ ์ง„์ฃผ์ข… ์ˆ˜์ˆ ์—์„œ ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ์˜ ์ ์šฉ ์˜์—ญ ํ™•๋Œ€๋ฅผ ์œ„ํ•œ ๊ธฐ์ดˆ์ž๋ฃŒ๋กœ ์‚ผ๊ณ ์ž ํ•œ๋‹ค.

๋Œ€์ƒ ๋ฐ ๋ฐฉ๋ฒ•

๋ณธ์›์—์„œ 2014๋…„ 9์›”๋ถ€ํ„ฐ 2015๋…„ 10์›”๊นŒ์ง€ ํ•œ ๋ช…์˜ ์ˆ ์ž์— ์˜ํ•ด ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์œผ๋กœ ์ง„๋‹จ๋œ ํ›„์— ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•˜์—ฌ ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ์„ ํ†ตํ•œ ์ œ๊ฑฐ๋ฅผ ๋ฐ›์€ 6๋ช…์˜ ํ™˜์ž ์ฆ๋ก€๋ฅผ ๋Œ€์ƒ์œผ๋กœ ์˜๋ฌด๊ธฐ๋ก, ๋ฐฉ์‚ฌ์„ ํ•™์  ๊ฒ€์‚ฌ ๋“ฑ์„ ํ›„ํ–ฅ์ ์œผ๋กœ ์กฐ์‚ฌํ•˜์˜€์œผ๋ฉฐ ์„ฑ๋ณ„ ๋ฐ ๋‚˜์ด, ์ดํ•™์  ์†Œ๊ฒฌ, ์ฒญ๋ ฅ๊ฒ€์‚ฌ ๊ฒฐ๊ณผ, ๋ฐฉ์‚ฌ์„ ํ•™์  ์†Œ๊ฒฌ(Fig. 1), ์น˜๋ฃŒ ๊ฒฐ๊ณผ, ์ˆ˜์ˆ  ํ›„ ํ•ฉ๋ณ‘์ฆ ๋“ฑ์„ ๋ถ„์„ํ•˜์˜€๋‹ค. ๋ณธ ์—ฐ๊ตฌ์—์„œ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•˜์—ฌ ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ์„ ํ†ตํ•œ ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๋Š” ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข… ํ™˜์ž์˜ ์ ์‘์ฆ์€ ์ธก๋‘๊ณจ ์ „์‚ฐํ™”๋‹จ์ธต์ดฌ์˜ ๊ฒฐ๊ณผ๋ฅผ ํ† ๋Œ€๋กœ ์ง„์ฃผ์ข…์ด ์ƒ๊ณ ์‹ค ๋ฐ ์ค‘๊ณ ์‹ค์— ๊ตญํ•œ๋˜์–ด ์žˆ๊ฑฐ๋‚˜, ๋˜๋Š” ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์ด ์œ ๋Œ๋™๊ตฌ ๋ถ€์œ„๋กœ ์นจ๋ฒ”์ด ๋˜์–ด ์žˆ๋”๋ผ๋„ ์œ ๋Œ๋™ ๋‚ด ์™ธ๋ฐ˜๊ณ ๋ฆฌ๊ด€์ด ์ด๋ฃจ๋Š” ๋ฐ˜๊ตฌ๊นŒ์ง€๋Š” ๋ฏธ์น˜์ง€ ๋ชปํ•˜๋Š” ์ฃผ๋กœ ์ƒ๊ณ ์‹ค ๋ถ€์œ„์— ๊ตญํ•œ๋œ ์ง„์ฃผ์ข…์œผ๋กœ ํ•œ์ •ํ•˜์˜€๋‹ค. ๋˜ํ•œ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์ด ์œ ๋Œ๋™ ๋‚ด๋กœ ์นจ๋ฒ”ํ•œ ๊ฒƒ์ด ์˜์‹ฌ๋˜๋Š” ๊ฒฝ์šฐ๋Š” ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ๋ฒ•์˜ ๋Œ€์ƒ์—์„œ ์ œ์™ธํ•˜์˜€๋‹ค.
์ˆ˜์ˆ ์€ ์ „์‹ ๋งˆ์ทจํ•˜์— ์ง„ํ–‰ํ•˜์˜€์œผ๋ฉฐ ํ™˜์ž๋ฅผ ์•™์™€์œ„๋กœ ํ•˜๊ณ  ๋จธ๋ฆฌ๋ฅผ ๋ฐ˜๋Œ€์ธก์œผ๋กœ ๋Œ๋ฆฐ ํ›„ ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ๋ฒ•์„ ํ†ตํ•ด ๊ณ ๋ง‰์™ธ์ด๋„ ํ”ผ๋ถ€ํŒ(tympanomeatal flap)์„ ๊ฑฐ์ƒํ•˜์˜€๋‹ค. ๊ณ ์‹ค์„ ๊ฐœ๋ฐฉํ•˜๊ณ  ์ค‘์ด ๋ฐ ์ƒ๊ณ ์‹ค ๋ถ€์œ„์˜ ๋ณ‘๋ณ€์„ ๊ด€์ฐฐํ•˜๊ณ  ๋ณ‘๋ณ€์„ ์ œ๊ฑฐํ•˜์˜€๋‹ค. ์ง„์ฃผ์ข…์ด ์ƒ๊ณ ์‹ค์˜ ์ „๋ฐฉ ๋˜๋Š” ์ƒ๋ฐฉ์œผ๋กœ ์ง„ํ–‰๋˜์–ด ์žˆ๊ฑฐ๋‚˜ ์œ ์–‘๋Œ๊ตฌ ๋ถ€์œ„๋กœ ์ง„ํ–‰๋˜์–ด ์žˆ๋Š” ๊ฒฝ์šฐ์—๋Š” ๊ณจ ์†ŒํŒŒ๊ธฐ(bone curette) ๋˜๋Š” ์ „๋™ ๋“œ๋ฆด์„ ์ด์šฉํ•˜์—ฌ ๊ณจ๋ฅœ(bony annulus)์ด๋‚˜ ํ›„์ƒ๋ฐฉ ์™ธ์ด๋„ ๊ณจ๋ฒฝ ์ผ๋ถ€๋ฅผ ์ œ๊ฑฐํ•œ ํ›„ ๋ณ‘๋ณ€์„ ๋…ธ์ถœ์‹œ์ผฐ์œผ๋ฉฐ ๋ณ‘๋ณ€ ์ œ๊ฑฐ ์‹œ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•œ ๋ฏธ์„ธ์ˆ˜์ˆ ์— ์ ํ•ฉํ•˜๊ฒŒ ๊ณ ์•ˆ๋œ ๋‹ค์–‘ํ•œ ๋„๊ตฌ๋“ค(Instrument Set for Endoscopic Ear Surgery, Karl Storz, Tuttlingen, Germany; Panetti Endoscopic Instrument Set, Spiggle & Theis, Overath, Germany)์„ ํ™œ์šฉํ•˜์˜€๋‹ค. ๋ชจ๋“  ๊ฒฝ์šฐ์—์„œ 0๋„, 30๋„ ๋ฐ 45๋„ ๋‚ด์‹œ๊ฒฝ์„ ์‚ฌ์šฉํ•˜์˜€์„๋•Œ ๋ณ‘๋ณ€์˜ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•  ์ˆ˜ ์žˆ์—ˆ๊ณ  ์ง„์ฃผ์ข…๋‚ญ์˜ ๋์„ ํ™•์ธํ•œ ์ƒํƒœ์—์„œ ์ „์ˆ ํ•œ ๋„๊ตฌ๋“ค์„ ์ด์šฉํ•˜์—ฌ ํ”ผ๋ง‰๊ณผ ์ฃผ๋ณ€์˜ ์œก์•„์กฐ์ง๋“ค์„ ์ œ๊ฑฐํ•  ์ˆ˜ ์žˆ์—ˆ๋‹ค. ์ง„์ฃผ์ข…์ด ์ด์†Œ๊ณจ ํŠนํžˆ ์นจ๊ณจ๊ณผ ์ถ”๊ณจ์˜ ๋‘๋ถ€ ๋ถ€์œ„์— ๋‹จ๋‹จํžˆ ๋ถ€์ฐฉ๋˜์–ด ์žˆ๊ณ  ์นจ๊ณจ๊ณผ ์ถ”๊ณจ์˜ ๋ฏธ๋ž€์ด ์˜์‹ฌ๋˜๋Š” 3์˜ˆ์—์„œ๋Š” ์นจ๊ณจ-๋“ฑ๊ณจ ๊ด€์ ˆ์„ ๋ถ„๋ฆฌํ•œ ํ›„ ์นจ๊ณจ์„ ์ œ๊ฑฐํ•˜๊ณ  ์ถ”๊ณจ ๋‘๋ถ€๋ฅผ ์ž๋ฅธ ํ›„ ์ถ”๊ณจ ๋‘๋ถ€๋„ ์ œ๊ฑฐํ•˜์˜€๋‹ค. ๊ทธ ํ›„ ์ƒ๊ณ ์‹ค๊ณผ ์œ ๋Œ๋™๊ตฌ ๋ถ€์œ„์˜ ์ž”์กด ๋ณ‘๋ณ€์„ 30๋„ ๋ฐ 45๋„ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•˜์—ฌ ํ™•์ธํ•˜์˜€๊ณ  ๊ณ ๋ง‰๊ธด์žฅ๊ฑด(tensor tympani tendon) ์ „๋ฐฉ์˜ ์ค‘๊ณ ์‹ค๊ณผ ์ƒ๊ณ ์‹ค์„ ์ด์–ด์ฃผ๋Š” ๊ณต๊ธฐํ†ต๋กœ๋ฅผ ํ™•๋ณดํ•ด์ฃผ์—ˆ๋‹ค. ๋งˆ์ง€๋ง‰์œผ๋กœ ์ด์ฃผ์—ฐ๊ณจ์„ ์ทจ๋“ํ•˜์—ฌ ์ƒ๊ณ ์‹ค ๋ฐ ํ›„์œค์ƒ๊ณจ ๊ฒฐ์† ๋ถ€์œ„๋ฅผ ์—ฐ๊ณจ์„ ์ด์šฉํ•˜์—ฌ ๋ง‰์•„์ฃผ๊ณ  ์—ฐ๊ณจ๋ง‰์€ ๊ณ ๋ง‰ ์ด์‹์กฐ์ง์œผ๋กœ ์‚ฌ์šฉํ•˜์—ฌ ์ˆ˜์ˆ ์„ ์ข…๋ฃŒํ•˜์˜€๋‹ค(Fig. 2). ์ˆ˜์ˆ ์‹œ ์‚ฌ์šฉํ•œ ๋‚ด์‹œ๊ฒฝ์€ 0๋„, 30๋„ ๋ฐ 45๋„ 4 mm ๋˜๋Š” 3 mm ๋‚ด์‹œ๊ฒฝ(Karl Storz)์ด์—ˆ์œผ๋ฉฐ ๊ด‘์›์€ LED nova 100(Karl Storz)์„ ์‚ฌ์šฉํ•˜์˜€๋‹ค.

๊ฒฐ ๊ณผ

๋Œ€์ƒํ™˜์ž์˜ ์—ฐ๋ น ๋ถ„ํฌ๋Š” 23์„ธ์—์„œ 51์„ธ๋กœ ํ‰๊ท  ์—ฐ๋ น 33.8์„ธ์˜€์œผ๋ฉฐ ๋‚จ๋…€ ์„ฑ๋น„๋Š” ๊ฐ™์•˜๋‹ค. ์ˆ˜์ˆ  ์ „ ์‹œํ–‰ํ•œ ์ดํ•™์  ๊ฒ€์ง„์—์„œ ์ƒ๊ณ ์‹ค์— ๊ตญํ•œ๋˜์–ด ๊ณ ๋ง‰์ด ํ•จ์ž…๋œ ๊ฒฝ์šฐ๊ฐ€ 3์˜ˆ, ์ƒ๊ณ ์‹ค ๋ถ€์œ„ ์™ธ์—๋„ ํ•จ์ž…์ด ๋™๋ฐ˜๋œ ๊ฒฝ์šฐ๊ฐ€ 3์˜ˆ ์žˆ์—ˆ๊ณ  ์ด ์ค‘ 1์˜ˆ์˜ ๊ฒฝ์šฐ ๊ณ ๋ง‰ ์ฒœ๊ณต์ด ๋™๋ฐ˜๋˜์—ˆ๋‹ค. ์ˆ  ์ „ ์‹œํ–‰ํ•œ ์ฒญ๋ ฅ๊ฒ€์‚ฌ์—์„œ ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๋Š” 7.5~30 dB๊นŒ์ง€ ํ‰๊ท  17.3 dB์ด์—ˆ๋‹ค. ๋ณ‘๋ณ€ ๋ฒ”์œ„ ๋ฐ ์ง„ํ–‰ ์ •๋„๋ฅผ ํŒŒ์•…ํ•˜๊ธฐ ์œ„ํ•˜์—ฌ ์‹œํ–‰ํ•œ ์ˆ  ์ „ ๊ณ ํ•ด์ƒ๋„ ์ธก๋‘๊ณจ ์ „์‚ฐํ™”๋‹จ์ธต์ดฌ์˜์—์„œ๋Š” ์ƒ๊ณ ์‹ค์— ๊ตญํ•œ๋œ ๊ฒฝ์šฐ๊ฐ€ 3์˜ˆ, ์œ ๋Œ๋™๊ตฌ(aditus ad antrum)๋กœ ํ™•์žฅ๋œ ๊ฒฝ์šฐ๊ฐ€ 2์˜ˆ, ์ƒ๊ณ ์‹ค์—์„œ ์ค‘๊ณ ์‹ค๋กœ ์นจ๋ฒ”ํ•œ ๊ฒฝ์šฐ๊ฐ€ 1์˜ˆ์˜€๋‹ค. ์ด์†Œ๊ณจ ๋ฏธ๋ž€์ด ๋ฐฉ์‚ฌ์„ ํ•™์  ๊ฒ€์‚ฌ์ƒ์—์„œ ์˜์‹ฌ๋˜๋Š” ๊ฒฝ์šฐ๊ฐ€ 3์˜ˆ์—์„œ ๊ด€์ฐฐ๋˜์—ˆ๋‹ค. ๋ชจ๋“  ์˜ˆ์—์„œ ์ „์‹ ๋งˆ์ทจํ•˜์— ์ˆ˜์ˆ ์„ ์‹œํ–‰ํ•˜์˜€์œผ๋ฉฐ ๋‚ด์‹œ๊ฒฝํ•˜์— ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ๋ฒ•์„ ํ†ตํ•˜์—ฌ ์ƒ๊ณ ์‹ค์„ ๋…ธ์ถœํ•œ ๋’ค ์ง„์ฃผ์ข…์„ ์ œ๊ฑฐํ•˜์˜€๊ณ  ์ˆ˜์ˆ ์žฅ ์†Œ๊ฒฌ์ƒ ์ด์†Œ๊ณจ ๋ฏธ๋ž€์ด ๊ด€์ฐฐ๋˜์–ด ์ด์†Œ๊ณจ์— ์ง„์ฃผ์ข…์ด ์นจ๋ฒ”ํ•œ ๊ฒƒ์ด ์˜์‹ฌ๋˜๋Š” 3์˜ˆ์˜ ๊ฒฝ์šฐ์—๋Š” ์ด์†Œ๊ณจ(์ถ”๊ณจ ๋‘๋ถ€ ๋ฐ ์นจ๊ณจ)์„ ์ˆ˜์ˆ  ์‹œ ์ œ๊ฑฐํ•˜๊ณ  ์ด์ฐจ ์ฒญ๋ ฅ๊ฐœ์„ ์ˆ ์„ ๊ณ„ํšํ•˜์˜€๋‹ค(Table 1). ์ง„์ฃผ์ข…์ด ์œ ๋Œ๋™๊ตฌ ์ž…๊ตฌ๋ถ€์œ„๋กœ ํ™•์žฅ๋œ 2์˜ˆ์—์„œ๋Š” ์ƒ๊ณ ์‹ค ๋ฐ ํ›„์œค์ƒ๊ณจ ๋ถ€์œ„๋ฅผ ์กฐ๊ธˆ ๋” ๋งŽ์ด ์ œ๊ฑฐํ•ด์•ผ๋งŒ ์ง„์ฃผ์ข…๋‚ญ์˜ ๋์ด ํ™•์ธ๋˜์—ˆ๋‹ค. ์ƒ๊ณ ์‹ค๊ณผ ํ›„์œค์ƒ๊ณจ ๋ถ€์œ„๋ฅผ ์ œ๊ฑฐํ•  ๋•Œ์—๋Š” ๊ณจ ์†ŒํŒŒ๊ธฐ์™€ ์ „๋™ ๋“œ๋ฆด์„ ์‚ฌ์šฉํ•˜์˜€์œผ๋ฉฐ ํŠนํžˆ ๋์ด ํฌ๊ฒŒ ํœ˜์–ด์ง€๊ณ  ํก์ธ๊ธฐ๊ฐ€ ๋์— ๋‹ฌ๋ฆฐ curved suction dissector ๋„๊ตฌ๋“ค์ด ์ง„์ฃผ์ข…๋‚ญ์„ ๊ณจ๋ฒฝ์—์„œ ๋ฐ•๋ฆฌํ•  ๋•Œ ๋งค์šฐ ์œ ์šฉํ•˜๊ฒŒ ์‚ฌ์šฉ๋˜์—ˆ๋‹ค. ์ˆ˜์ˆ  ํ›„ ์ง„์ฃผ์ข…์ด ์™„์ „ํžˆ ์ œ๊ฑฐ๋œ ๊ฒƒ์„ 0๋„, 30๋„, 45๋„ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•˜์—ฌ ํ™•์ธ ํ›„ ์ƒ๊ณ ์‹ค ๋ถ€์œ„์˜ ๊ฒฐ์† ๋ถ€์œ„๋ฅผ ์—ฐ๊ณจ์„ ์ด์šฉํ•˜์—ฌ ์žฌ๊ฑดํ•˜๊ณ (Fig. 3) ์ˆ˜์ˆ ์„ ์ข…๋ฃŒํ•˜์˜€๋‹ค. ์ˆ˜์ˆ  ํ›„ ์ถ”์ ๊ด€์ฐฐ ๊ธฐ๊ฐ„์€ ํ‰๊ท  13๊ฐœ์›”(์ตœ์†Œ 5๊ฐœ์›”~์ตœ๋Œ€ 26๊ฐœ์›”)์ด์—ˆ๋‹ค. ๋ชจ๋“  ํ™˜์ž์—์„œ ๋งˆ์ง€๋ง‰ ์ถ”์ ๊ด€์ฐฐ๊นŒ์ง€ ๊ณ ๋ง‰ ๋‚ด์‹œ๊ฒฝ ๊ฒ€์ง„์—์„œ ์ž”์กด ์ง„์ฃผ์ข… ๋˜๋Š” ์žฌ๋ฐœ์˜ ์†Œ๊ฒฌ์€ ๊ด€์ฐฐ๋˜์ง€ ์•Š์•˜์œผ๋ฉฐ, ์ดํ•™์  ๊ฒ€์ง„์—์„œ ๋ฐœ๊ฒฌ๋˜์ง€ ์•Š์„ ์ˆ˜ ์žˆ๋Š” ์žฌ๋ฐœ ์—ฌ๋ถ€ ํ™•์ธ์„ ์œ„ํ•ด ์ˆ˜์ˆ  ํ›„ ํ‰๊ท  9๊ฐœ์›”๊ฒฝ ์ธก๋‘๊ณจ ์ „์‚ฐํ™”๋‹จ์ธต์ดฌ์˜์„ ์‹œํ–‰ํ•œ 4์˜ˆ์—์„œ ์ง„์ฃผ์ข… ์žฌ๋ฐœ ์†Œ๊ฒฌ์€ ๊ด€์ฐฐ๋˜์ง€ ์•Š์•˜๋‹ค. ์ง„์ฃผ์ข…์˜ ์žฌ๋ฐœ์€ ๊ณ ๋ง‰ ๋‚ด์‹œ๊ฒฝ ๊ฒ€์ง„๊ณผ ํ•จ๊ป˜ ์ˆ  ํ›„ 9~12๊ฐœ์›” ์‚ฌ์ด์— ์ธก๋‘๊ณจ ์ „์‚ฐํ™”๋‹จ์ธต์ดฌ์˜์„ ์‹œํ–‰ํ•˜์—ฌ ํ‰๊ฐ€ํ•˜๋ฉฐ ์ˆ  ํ›„ 5๋…„๊นŒ์ง€๋Š” ์ตœ์†Œ 6๊ฐœ์›” ๊ฐ„๊ฒฉ์œผ๋กœ ๊ณ ๋ง‰ ๋‚ด์‹œ๊ฒฝ ๊ฒ€์ง„์„ ์‹œํ–‰ํ•˜๊ณ  ์žฌ๋ฐœ์ด ์˜์‹ฌ๋˜๋Š” ๊ฒฝ์šฐ์—๋Š” ์ธก๋‘๊ณจ ์ „์‚ฐํ™”๋‹จ์ธต์ดฌ์˜์„ ๋‹ค์‹œ ์‹œํ–‰ํ•˜๊ฒŒ ๋œ๋‹ค. ์ˆ  ํ›„ 3๊ฐœ์›”์งธ ์‹œํ–‰ํ•œ ์ˆœ์Œ์ฒญ๋ ฅ๊ฒ€์‚ฌ ๊ฒฐ๊ณผ์ƒ 4๋ถ„๋ฒ•(500, 1000, 2000, 4000 Hz)์œผ๋กœ ๊ณ„์‚ฐํ•œ ํ‰๊ท  ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๋Š” 9.8 dB, 6๊ฐœ์›”์งธ ์‹œํ–‰ํ•œ ๊ฒ€์‚ฌ ๊ฒฐ๊ณผ๋Š” 14.9 dB, 1๋…„์งธ ํ‰๊ท  ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๋Š” 8.6 dB๋กœ ์ˆ˜์ˆ  ์ „ ํ‰๊ท  17.3 dB๊ณผ ๋น„๊ตํ•˜์—ฌ ๊ฐœ์„ ๋œ ๊ฒฐ๊ณผ๋ฅผ ๋ณด์˜€๋‹ค(Table 2). ํŠนํžˆ ์ด์†Œ๊ณจ ์—ฐ์‡„๊ฐ€ ์ •์ƒ์ด์—ˆ๋˜ ํ™˜์ž ์ค‘ ์ˆ˜์ˆ  ํ›„ 1๋…„์งธ ์ฒญ๋ ฅ๊ฒ€์‚ฌ๊ฐ€ ๊ฐ€๋Šฅํ–ˆ๋˜ ํ™˜์ž ๋‘ ๋ช…์—์„œ๋Š” ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๊ฐ€ 0 dB๊ณผ 11.7 dB๋กœ ์ข‹์€ ๊ฒฐ๊ณผ๋ฅผ ๋ณด์˜€๋‹ค. ๋˜ํ•œ ์ˆ˜์ˆ  ์ค‘ ์ด์†Œ๊ณจ ๋ฏธ๋ž€์ด ํ™•์ธ๋˜์–ด ์ œ๊ฑฐํ•˜๊ณ  ์ด์ฐจ ์ฒญ๋ ฅ๊ฐœ์„ ์ˆ ์„ ๊ณ„ํšํ•˜์˜€๋˜ 3์˜ˆ ์ค‘ 2์˜ˆ์—์„œ ์ˆ˜์ˆ  ํ›„ ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๊ฐ€ 15 dB ์ด๋‚ด๋กœ ํ˜ธ์ „๋˜์—ˆ๊ณ (ํ™˜์ž No 3 & 4)(Table 2), ๋‚˜๋จธ์ง€ ํ•œ๋ช…๋„ ์ˆ˜์ˆ  ํ›„ 6๊ฐœ์›”์งธ ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๊ฐ€ 16.7 dB๋กœ ํ˜ธ์ „๋˜์—ˆ๋‹ค. ๋ชจ๋“  ํ™˜์ž์—์„œ ์ถ”์ ๊ด€์ฐฐ ๊ธฐ๊ฐ„ ์ค‘ ๊ณ ๋ง‰ ์ฒœ๊ณต, ์ด๋กœ ์ธํ•œ ์ด๋ฃจ๋‚˜ ์–ด์ง€๋Ÿผ์ฆ, ์ด๋ช…์ด๋‚˜ ๊ฐ๊ฐ์‹ ๊ฒฝ์„ฑ ๋‚œ์ฒญ, ์•ˆ๋ฉด์‹ ๊ฒฝ ๋งˆ๋น„ ๋“ฑ ํ•ฉ๋ณ‘์ฆ์€ ๋ฐœ์ƒํ•˜์ง€ ์•Š์•˜๋‹ค.

๊ณ  ์ฐฐ

ํ›„์ฒœ์„ฑ ์ง„์ฃผ์ข…(primary acquired cholesteatoma)์€ ์ด๊ด€์˜ ๊ธฐ๋Šฅ๋ถ€์ „์œผ๋กœ ์ธํ•œ ์ค‘์ด ๋‚ด ์Œ์••์˜ ํ˜•์„ฑ์œผ๋กœ ๊ณ ๋ง‰ ๋‚ด ํ•จ์ž…์ด ์ง„ํ–‰๋˜์–ด ๋‚ดํ•จ๋‚ญ(retraction pocket)์ด ์ฃผ๋กœ ๊ณ ๋ง‰์˜ ์ด์™„๋ถ€์—์„œ ๋ฐœ์ƒํ•˜๊ฒŒ ๋˜๋ฉฐ ๋‚ด๋ถ€ ์ƒํ”ผ์„ธํฌ์˜ ์ด๋™์ด ์ €ํ•˜๋˜๊ณ  ์ผ€๋ผํ‹ด(keratin)์ด ์ถ•์ ์ด ๋˜๋ฉด์„œ ๊ณ ๋ง‰ ๋‚ด์˜ ๊ณต๊ฐ„์œผ๋กœ ํ•จ์ž…์ด ์ง„ํ–‰ํ•˜๊ฒŒ ๋˜์–ด ๋ฐœ๋ณ‘ํ•œ ์ง„์ฃผ์ข…์˜ ํ˜•ํƒœ๋ฅผ ์ผ์ปซ๋Š”๋‹ค[11]. Tos [12]๋Š” ํ›„์ฒœ์„ฑ ์ค‘์ด ์ง„์ฃผ์ข…์„ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…, ๊ณ ์‹ค๋™์ง„์ฃผ์ข…, ๊ธด์žฅ๋ถ€ ํ•จ๋ชฐ ์ง„์ฃผ์ข…์œผ๋กœ ๋ถ„๋ฅ˜ํ•˜์˜€์œผ๋ฉฐ, ์ด ์ค‘ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์€ ๊ณ ๋ง‰ ์ด์™„๋ถ€์˜ ํ•จ๋ชฐ์ด๋‚˜ ์ฒœ๊ณต์œผ๋กœ ์ •์˜๋œ๋‹ค. ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์€ ์ƒ๊ณ ์‹คํ•จ์š”(Prussackโ€™s space)์—์„œ ์ƒ๊ณ ์‹ค, ์œ ๋Œ๋™๊ตฌ(aditus ad antrum)๋ฅผ ํ†ตํ•˜์—ฌ ์œ ์–‘๋™์œผ๋กœ ์ง„ํ–‰๋˜๋ฉฐ ์™„์น˜๋ฅผ ์œ„ํ•ด ์ˆ˜์ˆ ์ ์ธ ์ œ๊ฑฐ๊ฐ€ ํ•„์š”ํ•˜๋‹ค.
์ด๋Ÿฌํ•œ ์ง„์ฃผ์ข…์˜ ์ œ๊ฑฐ์— ๋ณดํŽธํ™”๋œ ์ˆ˜์ˆ ๋ฒ•์œผ๋กœ๋Š” ์ดˆ๊ธฐ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์˜ ๊ฒฝ์šฐ ์ƒ๊ณ ์‹ค ๊ฐœ๋ฐฉ์ˆ ๊ณผ ์ƒ๊ณ ์‹ค ์žฌ๊ฑด์ˆ (attic reconstruction)์ด ๊ฐ€์žฅ ๋„๋ฆฌ ์‚ฌ์šฉ๋˜๋ฉฐ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์ด ์œ ๋Œ๋™๊ตฌ๋กœ ์ง„ํ–‰ํ•œ ๊ฒฝ์šฐ์—๋Š” ์œ ์–‘๋™์‚ญ๊ฐœ์ˆ ์„ ์‹œํ–‰ํ•˜๊ฒŒ ๋œ๋‹ค. ์ˆ˜์ˆ ์„ ํ†ตํ•ด ์ง„์ฃผ์ข… ๋ณ‘๋ณ€์„ ์™„์ „ํžˆ ์ œ๊ฑฐํ•˜๋Š” ๊ฒƒ์ด ์ค‘์š”ํ•˜๋ฉฐ ๊ทธ์™€ ๋”๋ถˆ์–ด ์ƒ์ด๊ด€์™€๋ฅผ ํ†ตํ•œ ์ƒ๊ณ ์‹ค ํ™˜๊ธฐํ†ต๋กœ๋ฅผ ํ™•๋ณดํ•˜๋Š” ๊ฒƒ์ด ์žฌ๋ฐœ ๋ฐฉ์ง€์— ํ•„์ˆ˜์ ์ด๋‹ค[13].
์ตœ๊ทผ ๋‚ด์‹œ๊ฒฝ์˜ ๋ฐœ๋‹ฌ์— ํž˜์ž…์–ด ์˜ํ•™์— ์ตœ์†Œ ์นจ์Šต์  ์ˆ˜์ˆ ์˜ ๊ฐœ๋…์ด ๋„์ž…๋˜์–ด ์—ฌ๋Ÿฌ ๋ถ„์•ผ์— ์ ์šฉ๋˜๊ณ  ์žˆ๊ณ  ๊ด€์‹ฌ์ด ์ฆ๊ฐ€ํ•˜๊ณ  ์žˆ๋‹ค. ์ด๋น„์ธํ›„๊ณผ์—์„œ๋Š” ๋ถ€๋น„๋™ ์ˆ˜์ˆ  ์‹œ ๋‚ด์‹œ๊ฒฝ์ด ํ™œ๋ฐœํžˆ ์ด์šฉ๋˜์–ด ์™”์œผ๋ฉฐ, ์•„์ง๊นŒ์ง€ ์ด๊ณผ ์˜์—ญ์—์„œ๋Š” ํ˜„๋ฏธ๊ฒฝ์„ ํ†ตํ•œ ์ˆ˜์ˆ ์ด ์ผ๋ฐ˜์ ์ด๋‹ค. ์ด๊ณผ ์˜์—ญ์—์„œ๋Š” ์ดˆ๊ธฐ์— ์ง„๋‹จ์ ์ธ ๋ชฉ์ ์œผ๋กœ ๋‚ด์‹œ๊ฒฝ์ด ์ฃผ๋กœ ํ™œ์šฉ๋˜์—ˆ์œผ๋‚˜ Nomura [14], Mer ๋“ฑ[15]์— ์˜ํ•ด ๊ณ ๋ง‰์„ ํ†ตํ•ด ๋‚ด์‹œ๊ฒฝ์„ ์‚ฌ์šฉํ•˜์—ฌ ์ค‘์ด๊ฐ• ๋‚ด๋ฅผ ํƒ์ƒ‰ํ•˜๋Š” ์‹œ๋„๊ฐ€ ์ฒ˜์Œ์œผ๋กœ ๋„์ž…๋˜์—ˆ๋‹ค. ๊ทธ ํ›„ Poe์™€ Bottrill [16]์— ์˜ํ•ด ์™ธ๋ฆผํ”„๋ˆ„๊ณต์˜ ์ง„๋‹จ์„ ์œ„ํ•œ ์ด๋‚ด์‹œ๊ฒฝ์˜ ํšจ์šฉ์„ฑ์ด ๋ณด๊ณ ๋œ ๋ฐ”๊ฐ€ ์žˆ๋‹ค. ํ•˜์ง€๋งŒ ์ตœ๊ทผ ๋ช‡ ๋…„ ์‚ฌ์ด์— ์ ์ฐจ ๋‚ด์‹œ๊ฒฝ์„ ํ™œ์šฉํ•œ ์ค‘์ด ์ˆ˜์ˆ ์— ๋Œ€ํ•œ ๊ด€์‹ฌ์ด ์ „ ์„ธ๊ณ„์ ์œผ๋กœ ์ฆ๊ฐ€ํ•˜๊ณ  ์žˆ๋Š” ์ถ”์„ธ[17]์ด๊ณ  ์‹ค์ œ ์ž„์ƒ์—์„œ ๋‚ด์‹œ๊ฒฝ์„ ๋‹จ๋…์œผ๋กœ ์ด์šฉํ•˜์—ฌ ์ค‘์ด ์ˆ˜์ˆ ์„ ์‹œํ–‰ํ•˜๊ณ  ์ข‹์€ ๊ฒฐ๊ณผ๋ฅผ ๋ณด๊ณ ํ•˜๋Š” ์—ฐ๊ตฌ ๋…ผ๋ฌธ๋“ค์ด ๋ฐœํ‘œ๋˜๊ณ  ์žˆ๋‹ค[8,18,19].
ํŠนํžˆ ํ˜„๋ฏธ๊ฒฝ์€ ์ง์„  ์‹œ์•ผ๋ฅผ ๊ฐ€์ง€๊ธฐ ๋•Œ๋ฌธ์— ์ค‘์ด๊ฐ• ๋‚ด์˜ ๋‹ค์–‘ํ•œ ์‚ฌ๊ฐ ์ง€์—ญ์— ์œ„์น˜ํ•œ ๋ณ‘๋ณ€์— ๋Œ€ํ•œ ์‹œ์•ผ ํ™•๋ณด๊ฐ€ ์–ด๋ ค์šด๋ฐ ๋‚ด์‹œ๊ฒฝ์„ ํ™œ์šฉํ•˜๋ฉด ํ˜„๋ฏธ๊ฒฝ๋ณด๋‹ค ๋” ๋„“์€ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•  ์ˆ˜ ์žˆ์œผ๋ฉฐ ๋‹ค์–‘ํ•œ ๊ฐ๋„(0, 30, 45, 70๋„)์˜ ๋‚ด์‹œ๊ฒฝ์„ ๊ตํ™˜ํ•ด๊ฐ€๋ฉด์„œ ์‚ฌ๊ฐ ์ง€์—ญ์˜ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•  ์ˆ˜ ์žˆ๋‹ค๋Š” ์žฅ์ ์ด ์žˆ๊ธฐ ๋•Œ๋ฌธ์— ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข… ์ˆ˜์ˆ  ์‹œ ๋‚ด์‹œ๊ฒฝ์€ ํ˜„๋ฏธ๊ฒฝ์˜ ๋‹จ์ ์„ ๋Œ€์ฒดํ•  ์ˆ˜ ์žˆ๋Š” ์ข‹์€ ์ ‘๊ทผ ๊ธฐ๋ฒ•์œผ๋กœ ํ™œ์šฉ๋˜๊ณ  ์žˆ๋‹ค. ์ฆ‰, ํ˜„๋ฏธ๊ฒฝ์„ ํ†ตํ•ด ํŠนํžˆ ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ๋ฒ•์œผ๋กœ๋Š” ์‹œ์•ผ ํ™•๋ณด๊ฐ€ ์šฉ์ดํ•˜์ง€ ์•Š์€ ์ค‘์ด๊ฐ•์˜ ์ฃผ์š” ๊ตฌ์กฐ๋ฌผ์ธ ์ด์†Œ๊ณจ ๋ฐ ์ •์›์ฐฝ, ์•ˆ๋ฉด์‹ ๊ฒฝ, ๊ทธ๋ฆฌ๊ณ  ํ›„๊ณ ์‹ค์˜ ์•ˆ๋ฉด์‹ ๊ฒฝ์™€(facial recess), ๊ณ ์‹ค๋™(tympanic sinus), ์ƒ๊ณ ์‹ค[18,20]์— ์œ„์น˜ํ•œ ๋ณ‘๋ณ€์€ ์™„์ „ํžˆ ์ œ๊ฑฐ๊ฐ€ ์–ด๋ ค์›Œ ์ˆ  ํ›„ ์žฌ๋ฐœํ•˜๊ธฐ ์‰ฌ์šด ๊ฒฝํ–ฅ์ด ์žˆ๊ณ , ์ด ๋•Œ ์ง„์ฃผ์ข… ์ œ๊ฑฐ์— ๋‹ค์–‘ํ•œ ๊ฐ๋„ ๋ฐ ๋„“์€ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•  ์ˆ˜ ์žˆ๋Š” ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•œ๋‹ค๋ฉด ์ž”์กด ์ง„์ฃผ์ข… ์ œ๊ฑฐ ๋ฐ ์ง„์ฃผ์ข…์˜ ์žฌ๋ฐœ๋ฅ ์„ ๋‚ฎ์ถœ ์ˆ˜ ์žˆ์—ˆ๋‹ค๋Š” ์—ฐ๊ตฌ ๊ฒฐ๊ณผ๋“ค์ด ๋ฐœํ‘œ๋˜์—ˆ๋‹ค[19,21].
Marchioni ๋“ฑ[22], Tarabichi [20]๋Š” ์ค‘์ด ์ง„์ฃผ์ข…์˜ ์ผ์ฐจ ์ˆ˜์ˆ ๋กœ ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ๋ฒ•์„ ์„ ํƒํ•˜์˜€์œผ๋ฉฐ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข… ๋ณ‘๋ณ€์˜ ์™„์ „ํ•œ ์ œ๊ฑฐ์™€ ํ•จ๊ป˜ ์ด์†Œ๊ณจ์˜ ๋ณด์กด์ด ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ[4]์— ์žˆ์–ด์„œ ๋” ์šฉ์ดํ•จ์„ ๋ณด๊ณ ํ•œ ๋ฐ” ์žˆ๊ณ , Migirov ๋“ฑ[9]์€ ์ž”์กด ์ง„์ฃผ์ข… ํ˜น์€ ์žฌ๋ฐœ์„ฑ ์ง„์ฃผ์ข…์— ๋Œ€ํ•œ ์ด์ฐจ ์ˆ˜์ˆ ๋ฒ•์œผ๋กœ ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ์„ ๋‹จ๋…์œผ๋กœ ์„ฑ๊ณตํ•˜์—ฌ ์žฌ๋ฐœ ๋ฐ ์ž”์กด ์ง„์ฃผ์ข…์„ ์ œ๊ฑฐํ•œ ๊ฒฐ๊ณผ๋ฅผ ๋ณด๊ณ ํ•˜๋ฉฐ ๋‚ด์‹œ๊ฒฝ์˜ ํšจ์šฉ์„ฑ์— ๋Œ€ํ•˜์—ฌ ๊ฐ•์กฐํ•˜์˜€๋‹ค. Marchioni ๋“ฑ[22,23]์€ ์ค‘์ด ์ง„์ฃผ์ข…์ด ์ ‘๊ทผ์ด ์–ด๋ ค์šด ์œ„์น˜์— ์žˆ๋Š” ๊ฒฝ์šฐ(๊ณ ์‹ค๋™, ์ƒ๊ณ ์‹ค) ๋‚ด์‹œ๊ฒฝ์„ ์œ ์šฉํ•˜๊ฒŒ ์‚ฌ์šฉํ•  ์ˆ˜ ์žˆ๋‹ค๊ณ  ๋ณด๊ณ ํ•˜์˜€๋‹ค. ๋˜ํ•œ ์†Œ์•„ ์ง„์ฃผ์ข…์˜ ๊ฒฝ์šฐ์—๋„ ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ๋ฒ• ๋‹จ๋… ์‚ฌ์šฉ์€ ๋ณ‘๋ณ€์˜ ์™„์ „ํ•œ ์ œ๊ฑฐ๋ฟ๋งŒ ์•„๋‹ˆ๋ผ ์ตœ์†Œ ์นจ์Šต์ ์ด๋ผ๋Š” ์ธก๋ฉด์—์„œ ์ค‘์ด์— ๊ตญํ•œ๋œ ์†Œ์•„ ์ง„์ฃผ์ข…์˜ ์น˜๋ฃŒ์— ์šฉ์ดํ•œ ์ˆ˜์ˆ ๋ฒ•์ž„์„ ์—ฐ๊ตฌํ•˜์—ฌ ๋ฐœํ‘œํ•œ ๋ฐ” ์žˆ๋‹ค[7,23]. ๊ตญ๋‚ด์—์„œ๋Š” Jang ๋“ฑ[8]์ด ์œ ์–‘๋™์‚ญ๊ฐœ์ˆ  ์ค‘ ๊ธฐ์กด์˜ ํ˜„๋ฏธ๊ฒฝ์  ์ ‘๊ทผ์— ๋‚ด์‹œ๊ฒฝ์  ์ ‘๊ทผ์„ ๋ณ‘ํ–‰ํ•˜์˜€์„ ๊ฒฝ์šฐ ๊ณ ์‹ค๋™ ๋‚ด ์ž”์กด ํ˜น์€ ์žฌ๋ฐœ์„ฑ ์ง„์ฃผ์ข… ๋ฐœ์ƒ ํ™•๋ฅ ์„ ๋‚ฎ์ถ˜๋‹ค๋Š” ์ธก๋ฉด์—์„œ์˜ ๋‚ด์‹œ๊ฒฝ์˜ ํšจ์šฉ์„ฑ์— ๋Œ€ํ•˜์—ฌ ์†Œ๊ฐœํ•˜์˜€๊ณ  ๊ฒฝ์™ธ์ด๋„ ๋‚ด์‹œ๊ฒฝ ์ ‘๊ทผ๋ฒ•์„ ํ†ตํ•˜์—ฌ ๊ณ ์‹ค์„ฑํ˜•์ˆ ์„ ํ•˜์˜€์„ ๋•Œ ๋œ ์นจ์Šต์ ์ด๋ฉด์„œ ์ข‹์€ ๊ฒฐ๊ณผ๋ฅผ ๋ณด์ธ๋‹ค๋Š” ์—ฐ๊ตฌ ๊ฒฐ๊ณผ๋„ ๋ฐœํ‘œ๋œ ๋ฐ” ์žˆ๋‹ค[4].
ํ•˜์ง€๋งŒ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•œ ์ˆ˜์ˆ ์€ ๋‹จ์ ๋„ ์กด์žฌํ•˜๋Š”๋ฐ ๊ฐ€์žฅ ํฐ ๋‹จ์ ์€ ํ•œ ์†์œผ๋กœ ๋‚ด์‹œ๊ฒฝ์„ ๋“ค๊ณ  ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๊ธฐ ๋•Œ๋ฌธ์— ๋ชจ๋“  ์ˆ˜์ˆ  ์ ˆ์ฐจ๋ฅผ ๋‹ค๋ฅธ ํ•œ ์†์œผ๋กœ ์ง„ํ–‰ํ•ด์•ผ ํ•œ๋‹ค๋Š” ์ ์ด๋‹ค. ์ด๋Š” ์ถœํ˜ˆ์„ ์ ์ ˆํ•˜๊ฒŒ ์ˆ˜์ˆ  ์‹œ์•ผ์—์„œ ์ œ๊ฑฐํ•˜์—ฌ ๊นจ๋—ํ•œ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•˜๋Š” ๋ฐ ์ œํ•œ์ ์œผ๋กœ ์ž‘์šฉํ•˜๊ฒŒ ๋œ๋‹ค. ์ด๋ฅผ ๊ทน๋ณตํ•˜๊ธฐ ์œ„ํ•ด ๊ธฐ๊ตฌ ๋์— ํก์ธ์ด ๊ฐ€๋Šฅํ•œ ๊ตฌ๋ฉ์ด ๋‹ฌ๋ ค ์žˆ์–ด ํ•œ ์†์œผ๋กœ ์ˆ˜์ˆ ์„ ํ•  ๋•Œ์—๋„ ๊นจ๋—ํ•œ ์‹œ์•ผ๋ฅผ ํ™•๋ณดํ•  ์ˆ˜ ์žˆ๋„๋ก ๊ณ ์•ˆ๋œ ๋„๊ตฌ๋“ค์„ ์‚ฌ์šฉํ•˜๋Š” ๊ฒƒ์ด ๋„์›€์ด ๋œ๋‹ค. ๊ทธ ์™ธ ๋‹จ์ ์œผ๋กœ ๋‚ด์‹œ๊ฒฝ์˜ ๋์— ์œ„์น˜ํ•œ ๋ Œ์ฆˆ์—์„œ ๋ฐœ์‚ฐ๋˜๋Š” ์—ด์ด ๋‚ด์ด ๋ฐ ์•ˆ๋ฉด์‹ ๊ฒฝ์— ์†์ƒ์„ ์ค„ ์ˆ˜ ์žˆ๋‹ค๋Š” ์ ์ด ์žˆ์œผ๋ฉฐ ๋”ฐ๋ผ์„œ ๊ผญ ํ•„์š”ํ•œ ๊ฒฝ์šฐ๊ฐ€ ์•„๋‹ˆ๋ฉด ๋‚ด์‹œ๊ฒฝ์„ ๊ณจ๋ฅœ(bony annulus) ๋ฐ”๊นฅ๋ถ€์— ์œ„์น˜์‹œํ‚ค๊ณ  ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๋Š” ๊ฒƒ์ด ๊ถŒ์žฅ๋œ๋‹ค. ๋˜ํ•œ ๋‚ด์‹œ๊ฒฝ์€ ์ด์ฐจ์›์ ์ธ ํ‰๋ฉด ์‹œ์•ผ๋ฅผ ๊ฐ€์ง€๊ธฐ ๋•Œ๋ฌธ์— ์ˆ˜์ˆ  ์‹œ ์ •ํ™•ํ•œ ๊นŠ์ด๊ฐ์„ ๊ฐ€์ง€๊ธฐ ์œ„ํ•ด์„œ๋Š” ๋งŽ์€ ์—ฐ์Šต์ด ํ•„์š”ํ•˜๋ฉฐ ๋‚ด์‹œ๊ฒฝ์„ ์ค‘์ด๊ฐ• ๋‚ด์— ์œ„์น˜์‹œํ‚ค๊ณ  ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๋Š” ๊ณผ์ •์—์„œ ์˜ˆ๊ธฐ์น˜ ๋ชปํ•œ ํ™˜์ž์˜ ์›€์ง์ž„์— ์™ธ์ด๋„๋ฒฝ์˜ ํ”ผ๋ถ€๋‚˜ ๋˜๋Š” ์ค‘์ด๊ฐ• ๋‚ด์˜ ์ฃผ์š” ๊ตฌ์กฐ๋ฌผ๋“ค์ด ์†์ƒ์„ ๋‹นํ•  ์ˆ˜ ์žˆ๋Š” ์œ„ํ—˜์ด ์กด์žฌํ•˜๊ธฐ ๋•Œ๋ฌธ์— ์ด์— ๋Œ€ํ•ด ํ•ญ์ƒ ์œ ์˜ํ•˜๊ณ  ์ˆ˜์ˆ ์„ ์ง„ํ–‰ํ•˜๋Š” ๊ฒƒ์ด ์ข‹๋‹ค.
๋ณธ ์—ฐ๊ตฌ์—์„œ ์ˆ˜์ˆ  ์‹œ ์ง„์ฃผ์ข…์— ์˜ํ•œ ์ด์†Œ๊ณจ ์นจ๋ฒ”์ด ๊ด€์ฐฐ๋˜์ง€ ์•Š์•„ ์ด์†Œ๊ณจ ์—ฐ์‡„๋ฅผ ๋ณด์กดํ•˜๋ฉด์„œ ์ง„์ฃผ์ข…์˜ ์ œ๊ฑฐ๊ฐ€ ๊ฐ€๋Šฅํ–ˆ๋˜ 3์˜ˆ์—์„œ๋Š” ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ 10 dB ๋‚ด์™ธ์˜ ์ข‹์€ ์ฒญ๋ ฅ๊ฒฐ๊ณผ๋ฅผ ์–ป์„ ์ˆ˜ ์žˆ์—ˆ๋‹ค. ๋˜ํ•œ, 3์˜ˆ์—์„œ๋Š” ์ด์†Œ๊ณจ ๋ฏธ๋ž€์ด ๊ด€์ฐฐ๋˜์–ด ์นจ๊ณจ ๋ฐ ์ถ”๊ณจ ๋‘๋ถ€๋ฅผ ์ œ๊ฑฐํ•˜๊ณ  ์ด์ฐจ ์ฒญ๋ ฅ๊ฐœ์„ ์ˆ ์„ ๊ณ„ํšํ•˜์˜€๋Š”๋ฐ 3์˜ˆ ๋ชจ๋‘์—์„œ ์ˆ˜์ˆ  ํ›„ ์ถ”์ ๊ด€์ฐฐ ์‹œ ๊ธฐ๋„๊ณจ๋„ ์ฒญ๋ ฅ์ฐจ๊ฐ€ 15 dB ๋‚ด์™ธ๋กœ ์˜ˆ์ƒ ์™ธ๋กœ ์ข‹์€ ์ฒญ๋ ฅ๊ฒฐ๊ณผ๋ฅผ ์–ป์„ ์ˆ˜ ์žˆ์—ˆ๋‹ค. ์ด๋ ‡๊ฒŒ ์˜ˆ์ƒ์น˜ ๋ชปํ•œ ์ข‹์€ ์ฒญ๋ ฅ๊ฒฐ๊ณผ๋ฅผ ์–ป์€ 3์˜ˆ์˜ ์ˆ˜์ˆ  ํ›„ ๊ณ ๋ง‰๋‚ด์‹œ๊ฒฝ ์†Œ๊ฒฌ๊ณผ ์ธก๋‘๊ณจ ์ „์‚ฐํ™”๋‹จ์ธต์ดฌ์˜์„ ๋ถ„์„ํ•ด ๋ณด๋‹ˆ 2์˜ˆ์—์„œ ์•ฝ๊ฐ„์˜ ๊ณ ๋ง‰ ํ•จ๋ชฐ์ด ๋ฐœ์ƒํ•˜๋ฉด์„œ ์ž์—ฐ์ ์œผ๋กœ ๊ณ ๋ง‰์ด ๋“ฑ๊ณจ์— ๋‹ฟ์•˜์„ ๊ฒƒ์œผ๋กœ ์˜์‹ฌ์ด ๋˜๋ฉฐ 1์˜ˆ์—์„œ๋Š” ์ƒ๊ณ ์‹ค ๋ถ€์œ„์˜ ๊ฒฐ์†์„ ์žฌ๊ฑดํ•˜๊ธฐ ์œ„ํ•ด ์‚ฝ์ž…ํ•œ ์—ฐ๊ณจํŒ์ด ์•ฝ๊ฐ„ ์•„๋ž˜๋กœ ์ด๋™ํ•˜๋ฉด์„œ ๋“ฑ๊ณจ๊ณผ์˜ ์—ฐ๊ฒฐ์ด ์ƒ๊ฒผ์„ ๊ฒƒ์œผ๋กœ ์ถ”์ •์ด ๋œ๋‹ค. ์•ฝ๊ฐ„์˜ ๊ณ ๋ง‰ ํ•จ๋ชฐ์ด ์žˆ๋Š” ํ™˜์ž๋“ค์€ ๋ชจ๋‘ ์ƒ๊ณ ์‹ค ๊ฒฐ์† ์žฌ๊ฑด๋ถ€์œ„๋กœ์˜ ํ•จ๋ชฐ์€ ๊ด€์ฐฐ๋˜์ง€ ์•Š์•˜์œผ๋‚˜ ์ด๊ด€์˜ ๊ธฐ๋Šฅ์ด ์ข‹์ง€ ์•Š์„ ๊ฒƒ์œผ๋กœ ์ถ”์ •๋˜๋ฏ€๋กœ ๊ณ ๋ง‰ ํ•จ๋ชฐ๋กœ ์ธํ•œ ์ง„์ฃผ์ข…์˜ ์žฌ๋ฐœ ์—ฌ๋ถ€๋ฅผ ์ง€์†์ ์œผ๋กœ ๊ด€์ฐฐํ•˜๋Š” ๊ฒƒ์ด ํ•„์š”ํ•  ๊ฒƒ์ด๋‹ค. ์ผ๋ฐ˜์ ์œผ๋กœ ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•œ ์ง„์ฃผ์ข… ์ˆ˜์ˆ  ์‹œ ์ด์†Œ๊ณจ์„ ์ œ๊ฑฐํ•œ ๊ฒฝ์šฐ์—๋Š” ๋ณธ ์—ฐ๊ตฌ์—์„œ์ฒ˜๋Ÿผ ์ด์ฐจ ์ฒญ๋ ฅ๊ฐœ์„ ์ˆ ์„ ๊ณ„ํšํ•  ์ˆ˜๋„ ์žˆ์ง€๋งŒ ์ˆ˜์ˆ  ์‹œ ๋ฐ”๋กœ ๋“ฑ๊ณจ๊ณผ ์ถ”๊ณจ ์‚ฌ์ด์— ์ด์†Œ๊ณจ ์—ฐ์‡„๋ฅผ ์žฌ๊ฑดํ•ด์ฃผ๋Š” ์ด์†Œ๊ณจ ์žฌ๊ฑด์ˆ ์„ ์‹œํ–‰ํ•  ์ˆ˜๋„ ์žˆ์œผ๋ฉฐ ๊ฐ ์ˆ˜์ˆ  ์ƒํ™ฉ์— ๋งž๋Š” ๊ฐœ๋ณ„์  ์ ‘๊ทผ์ด ํ•„์š”ํ•˜๋‹ค.
๊ตญ๋‚ด ์ตœ์ดˆ๋กœ ์‹œ๋„๋œ ๋ณธ ์—ฐ๊ตฌ์—์„œ๋Š” ํ”ผ๋ถ€์ ˆ๊ฐœ ์—†์ด ๊ฒฝ์™ธ์ด๋„์  ์ ‘๊ทผ์„ ํ†ตํ•ด ๋‚ด์‹œ๊ฒฝ์„ ์ด์šฉํ•˜์—ฌ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์˜ ์ œ๊ฑฐ์ˆ˜์ˆ ์ด ๋ชจ๋“  ์˜ˆ์—์„œ ์„ฑ๊ณต์ ์œผ๋กœ ๊ฐ€๋Šฅํ•˜์˜€๋‹ค. ๋˜ํ•œ, ๋ชจ๋“  ํ™˜์ž๋Š” ์ˆ˜์ˆ  ํ›„ ๋‹ค์Œ๋‚  ํ‡ด์›์ด ๊ฐ€๋Šฅํ•˜์˜€์œผ๋ฉฐ ์ด๋Š” ๋‚ด์‹œ๊ฒฝ ์ ‘๊ทผ๋ฒ•์˜ ๋˜ ๋‹ค๋ฅธ ์žฅ์  ์ค‘ ํ•˜๋‚˜๋ผ ์ƒ๊ฐ๋œ๋‹ค. ๋น„๋ก ์ถ”์ ๊ด€์ฐฐ ๊ธฐ๊ฐ„์ด ์งง์ง€๋งŒ ๋ชจ๋“  ์˜ˆ์—์„œ ์ž”์กด ๋ณ‘๋ณ€์ด๋‚˜ ์žฌ๋ฐœ์ด ๊ด€์ฐฐ๋˜์ง€ ์•Š์•˜๊ณ  ์ˆ˜์ˆ ๊ณผ ๊ด€๋ จ๋œ ํ•ฉ๋ณ‘์ฆ์ด ๋ฐœ์ƒํ•˜์ง€ ์•Š์•˜์œผ๋ฉฐ ์ฒญ๋ ฅ ๊ฐœ์„ ๋„ ์ธก๋ฉด์—์„œ๋„ ์šฐ์ˆ˜ํ•œ ๊ฒฐ๊ณผ๋ฅผ ๋‚˜ํƒ€๋ƒˆ๋‹ค. ์ฆ‰ ์œ ์–‘๋™ ๋‚ด๋กœ ์ง„ํ–‰ํ•˜์ง€ ์•Š์€ ๋น„๊ต์  ์ดˆ๊ธฐ์˜ ์ƒ๊ณ ์‹ค๊ณผ ๊ทธ ์ฃผ์œ„์— ๊ตญํ•œ๋œ ์ƒ๊ณ ์‹ค ์ง„์ฃผ์ข…์—์„œ๋Š” ๊ฒฝ์™ธ์ด๋„ ์ ‘๊ทผ์„ ํ†ตํ•œ ๋‚ด์‹œ๊ฒฝ ์ˆ˜์ˆ ์ด ์ง„์ฃผ์ข… ์ œ๊ฑฐ์— ์œ ์šฉํ•˜๊ณ  ํšจ๊ณผ์ ์ธ ์ˆ˜์ˆ ๋ฒ•์ž„์„ ํ™•์ธํ•  ์ˆ˜ ์žˆ์—ˆ๋‹ค. ํ–ฅํ›„ ๋” ๋งŽ์€ ํ™˜์ž๋“ค์„ ๋Œ€์ƒ์œผ๋กœ ์žฅ๊ธฐ๊ฐ„ ์ถ”์ ๊ด€์ฐฐํ•˜๋Š” ์ „ํ–ฅ์ ์ธ ์—ฐ๊ตฌ๊ฐ€ ํ•„์š”ํ•  ๊ฒƒ์ด๋ผ ์ƒ๊ฐ๋œ๋‹ค.

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Fig.ย 1.
Pre- and postoperative temporal bone computed tomography (CT) of case 1. Preoperative CT showed soft tissue density at epitympanic recess (*) (A and B). Postoperative CT which was performed 10 months after surgery showed clean middle ear cavity (C and D).
kjorl-hns-2016-17027f1.tif
Fig.ย 2.
Case 1. Operative endoscopic finding during tympanomeatal flap elevation. Tympanic membrane shows attic area crust (A). After elevation of a tympanomeatal flap and drilling out scutum, the structures in the epitympanum are exposed under direct vision. Attic cholesteatoma is discovered (B and C). Cholesteatoma was removed and no residual lesion in epitypanum (D). C: cholesteatoma, M: malleus, I: incus, RW: round window, Ch: chorda tympani, S: stapes.
kjorl-hns-2016-17027f2.tif
Fig.ย 3.
Illustration of endoscopic attic reconstruction with composite cartilage graft. After endoscopic transcanal removal of cholesteatoma, scutoplasty was performed in our cases (A). Postoperative endoscopic finding after transcanal endoscopic attic cholesteatoma removal (B).
kjorl-hns-2016-17027f3.tif
Tableย 1.
Clinical characteristics of patients
No. Age (yr) Sex TM Extent in imaging Surgery Operative findings Tympanoplasty Reconstruction graft
1 23 F Only attic pocket Aditus ad antrum Primary Cholesteatoma in epitympanum, extending to aditus ad antrum T1 Tragal composite graft
Ossicular chain intact
2 34 F Combined retraction Limited to attic Primary Cholesteatoma in epitympanum T1 Tragal composite graft
Ossicular chain intact
3 33 F Only attic pocket Aditus ad antrum Primary Cholesteatoma in epitympanum extending to aditus ad antrum T0 Tragal conposite graft
Malleus head, incus long process
4 51 M Combined perforation Mesotympanum Primary Cholesteatoma in epitympanum & mesotympanum (stapes tendon, malleus handle) T0 Tragal cartilage
Malleus head, incus body partial erosion
5 25 F Only attic pocket Limited to attic Primary Cholesteatoma in epitympanum T0 Tragal composite graft
Incus partially eroded
6 37 M Combined retraction Limited to attic Primary Cholesteatoma in epitympanum T1 Tragal composite graft
Ossicular chain intact

T0: tympanoplasty type 0, TM: tympanic membrane

Tableย 2.
Postoperative results of endoscopic attic cholesteatoma removal
No. F/U periods (m) Preop ABG* Postop ABG* (3 monthsโ€ ) Postop ABG (6 months) Postop ABG (12 months) Recurrenceโ€ก Complications
1 26 21.7 0 0 0 (-) (-)
2 15 17.5 14 18.3 11.7 (-) (-)
3 16 30 20 20.8 12.5 (-) (-)
4 14 13.3 10 15 10 (-) (-)
5 6 7.5 5 16.7 (-) (-)
6 5 14.2 (-) (-)
Average 13.66 17.36 9.8 14.16 8.55

* in pure tone audiogram,

โ€  follow up ABG 3 months after,

โ€ก follow up computed tomography image of temporal bone.

ABG: airbone gap

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