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1 KISEP Special Article 臨床耳鼻 : 第 17 卷第 2 號 2006 J Clinical Otolaryngol 2006;17: 후반고리관양성돌발성두위현훈의진단과치료 성균관대학교의과대학삼성서울병원이비인후과학교실 정원호 박계훈 iagnosis and Management of Benign Paroxysmal Positional Vertigo of Posterior Semicircular Canal Won-Ho Chung, M and Kye Hoon Park, M epartment of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea 서 양성돌발성두위현훈 ( 이하 BPPV) 은회전성어지러움을일으키는말초성내이질환중가장높은빈도를보이는단일질환으로, 어지러움클리닉내원환자중 18.3% 1) 를차지한다고보고되고있다. 흔히특징적인임상증상과안진소견으로진단이용이하고, 대부분의경우쉽게치유될수있는질환이다. 본질환의빈도는증상이자연소멸되는경우가많기때문에정확히평가하기어려우나, 대부분의보고에서 100,000 명당 10.7 명에서 64명으로보고되었으며, 2)3) 소아보다는중년이상의성인에서많이발생한다. BPPV 을일으키는기전은난형낭의평형반에서기원한유리부유물 (free floating debris) 이반고리관의내림프강내로들어가면서부유물에작용하는중력의영향으로머리움직임에따른내림프움직임의비정상적인항진효과를일으키게되어안진이발생되고어지러움이유발되는것으로설명된다. 원발성원인으로는미상 (idiopathic) 인경우가 50~70% 를차지한다. 이차성 (secondary) 교신저자 : 정원호, 서울강남구일원동 50 번지성균관대학교의과대학삼성서울병원이비인후과학교실전화 :(02) 전송 :(02) 론 BPPV 의원인으로는두부외상에의한 BPPV 의빈도가가장높으며 (7~17%), 이외에전정신경염, 만성중이염, 메니에르질환, 편두통, 중이수술등을원인으로들수있다. 침범되는반고리관은주로후반고리관이가장많고외반고리관과상반고리관의순으로발생한다. 이는해부학적으로누워있는자세에서후반고리관이가장아래부위에놓여있어, 생성된부유물이중력의영향으로후반고리관으로들어가기가용이하기때문이다. 후반고리관 BPPV 의진단 병력 (History) 환자는회전성어지러움의증상이갑자기발생하면서오심과구토를동반하게된다. 처음발생의시작은주로새벽에잠자리에서일어나거나몸을좌우로돌아눕는순간에발생하게된다. 이후계속되는어지러움은보통특정한머리의위치나움직임에의해유발되는특징이있다. 어지러움을유발하는가장흔한동작으로는잠자리에서눕거나일어날때, 선반에서물건을꺼내려고올려볼때그리고몸을앞으로구부릴때등이다. 환자들은종종어지러움을유발하는동작을기억하는경우가있어환측을예측하는데도움이되기도한다. 몇번의발작경험을하게되면, 환자스스로어지러움이발생되는자세와아닌자세를알수있기때문에어지러움을일으키지않도록행 174

2 정원호외 : 후반고리관양성돌발성두위현훈의진단과치료 A B Fig. 1. ix-hallpike maneuver (right ear). The patient is seated and positioned so that the patient s head will extend over the top edge of the table when supine. The head is turned 45 toward the ear being tested (position A). The patient is quickly lowered into the supine position with the head extending about 30 below the horizontal (position B). The patient head is held in this position and the examiner observes the patient s eyes for nystagmus. 동의변화를보이게된다. 어지러움의지속시간은전형적으로 30초에서 1분이내지만수분이상지속된다고말하는환자도있다. 이러한차이는어지러움발작이후에도지속적인비회전성의어지러움이동반되는경우가많기때문이다. 회전성의어지러움이외에많은환자들이쓰러질것같은느낌, 떠다니는느낌, 구역질나는느낌, 머리움직임에대한공포등을호소하기도한다. 특히회전성어지러움을처음경험하는환자는뇌에치명적인질환이나타난것으로생각하고심각한두려움을갖게된다. Frontal Sagittal 45 진단 (iagnostic maneuvers) 후반고리관형 BPPV 에대한 ix-hallpike 검사는 1952 년처음기술되었다. 4) 정확한검사를위하여다음과같은사항을유의한다. 1) 검사전에환자에게심한어지러움이발생할수있음을설명하고검사중에는눈을되도록뜨도록하고, 중앙의한점을주시하도록교육한다. 환자가한점을주시하지못하는경우안진의방향을기술하기어렵기때문이다. 2) 검사자의한손으로는최소한환자의한쪽눈이크게떠진상태로유지할수있도록한다. 3) 안진의잠복기가긴환자가있을수있으므로 30 초정도까지머리를낮춘자세를유지하고관찰한다. 앉은자세에서환자의머리를환측으로 45도돌리고 (A) 환자 Fig. 2. Side-lying test (right ear). The subject s head is turned with the nose pointing 45 away from the side to be tested (The head is turned left). Then, the subject is briskly laid on the side being tested. The examiner is not shown, but supports the subject s head. Arms are crossed to prevent the patient from inadvertently stopping the motion. 를눕히며머리를뒤로젖혀검사대보다 30도정도머리가낮은위치를유지한후 (B) 안진을관찰한다. 특징적인안진은잠복기가 1~5 초이며지속기간은 30초이내이 175

3 J Clinical Otolaryngol 2006;17: 다. 안진의발생시에는환자가회전성의어지러움을동시에느끼게된다 (Fig. 1). 검사테이블이좁거나, 노인, 경추부에문제가있는경우 S L I Rt. M IO IV SO III MLF Slow Phase SR MLF IR IV Lt. Excitability Inhibitory Fig. 3. Excitation of the right posterior semicircular canal causes contraction of the ipsilateral superior oblique muscle and the contralateral inferior rectus muscle. The result will be left-rotatory and downward vertical movement of eyes. To overcome this movement, right-rotatory and upward vertical nystagmus is appeared. S:superior vestibular nucleus, L:lateral vestibular nucleus, I:inferior vestibular nucleus, M:medial vestibular nucleus, III:oculomotor nucleus, IV:trochlear nucleus, MLF:medial longitudinal fasciculus. SR:superior rectus muscle, SO: superior oblique muscle, IR:inferior rectus muscle, IO: inferior oblique muscle. The dotted lines mean excitatory, and the solid lines mean inhibitory. III 에서는검사시에테이블보다머리가낮은자세를취하기어렵다. 이런경우에는 ix-hallpike 검사보다는 sidelying 검사를시행하게된다. 검사방법은환자를검사테이블에앉히고머리를추정병변반대측으로 45 도돌린후추정병변쪽으로빠르게눕히면된다 (Fig. 2). 5) 특징적인안진의방향은대체로빠른성분의안진이상방향으로나타나는상향안진이보이면서, 안구최첨부가바닥으로향하는회전성안진이동반된다. 이는후반고리관이흥분되면동측의상사근과반대측의하직근의수축이일어나기때문이다 (Fig. 3). 그러나, 안진의방향은환자가주시하는방향에따라조금씩달라질수있다. 이는상사근활차 (trochlea) 의축이 X축과약 51 도정도각을이루고있기때문이다 (Fig. 4A). 즉, 지면쪽을주시할때는주로회전성의안진이보이며 (Fig. 4B) 지면과반대쪽을주시할때는상향의수직안진이강조되고 (Fig. 4C) 정면을주시할때는두가지성분이다나타난다 (Fig. 4). 환자를다시앉은자세로하면안진의방향이반대가되고반복해서검사하면피로현상을보여안진의강도가약해진다. 팽대부릉정이석 (cupulolithiasis) 의경우에는 ix- Hallpike 검사에서잠복기가짧고안진이비교적오래지속되며피로현상이약하게보이므로진단에도움이된다. Action plane 51 X axis 39 Rotational axis SO Y axis LR SR A B C Fig. 4. Rotational axis and action plane of right superior oblique muscle and direction of nystagmus on eye positions. A: The eye movements by superior oblique muscle are internal rotatory and downward vertical through the influence of the trochlea. The axis of trochlea forms about 51 with X axis. When gaze is directed about 39 laterally, only internal rotatory movement occurs because of the right angle between the rotational axis and the action plane of superior oblique muscle. But when gaze is directed to the nasal side, mainly downward movement occurs. The nystagums changes during ix-hallpike maneuver for posterior canal BPPV depending on the eye position. B:The fast component nystagmus is mainly rotatory when gaze is directed toward the lesion side. C:The fast component nystagmus is upward when gaze is directed to the normal side. :When the eyes are in the neutral position, the fast component nystagmus is both upward vertical and rotatory toward the lesion side. SO:superior oblique muscle, LR:lateral rectus muscle, SR: superior rectus muscle. 176

4 정원호외 : 후반고리관양성돌발성두위현훈의진단과치료 ix-hallpike 검사등의체위검사에서 Frenzel 안경을사용할수있는데진단률을높이지는않는다고한다. 6) 이론적으로 Frenzel 안경은환자의시고정을억제하여안진이잘나타나도록한다. 그러나대부분의환자는심한안진이나타나므로시고정에의해억제되지않으며, 특히, 회전성안진은시고정에의한억제효과가약한것으로알려져있다. 7) 결론적으로 Frenzel 안경의사용은육안으로관찰하기어려운미세한안진을진단하는데도움이될수있다. 전기안진검사는회전성의안진을기록하지못하므로안구의움직임을완전하게기록할수없다. 그러나, 최근에개발된적외선비디오전기안진검사장치 (Infrared videography) 는체위검사시직접적으로안구의움직임을관찰할수있어유용하다. 간혹 ix-hallpike 검사상특징적인안진을관찰할수없지만, 검사시환자는회전성어지러움을호소하고, 이러한주관적증상이잠복기와피로현상을보이는경우이를 subjective BPPV 라고한다. Haynes 등, 8) Tirelli 등 9) 과 Weider 등 10) 은이러한 subjective BPPV 환자에서다양한이석치환술을시행함으로써 76~93% 의환자가호전되었다고한다. 양성돌발성두위현훈환자에서 ix- Hallpike 검사로안진이유발되지않는이유로다음과같은이론들이제시되었다. 미세한안진을검사자가발견하지못하는경우, 이전의반복적인검사로이내피로현상이생기는경우, 어지러움은유발하지만전정안반사를자극하지못하는정도의경증의질환인경우 8) 등이다. 후반고리관 BPPV 의치료 비수술적인치료법후반고리관 BPPV 의치료법은질환에대한이해가깊어지면서지난 20년간많은변화가있었다. 예전에는어지럼증을유발하는두위를피하고, 증상조절을위하여약물처방만을하였던때가있었으나대부분효과가없는것으로증명되었다. 11) 다양한비침습적인치료법들이개발된것은 cupulolithiasis 와 canalolithiasis 의개념이도입되면서부터이다. Brandt 와 aroff 는 1980년도에 BPPV가후반고리관의팽대부에이석이달라붙기때문이라는가정하에달라붙은이석을작은조각으로부스러뜨리는운동법을소개하였다. 12) 이후같은가정하에 1988 년 Semont 13) 는 Fig. 5. Brandt-aroff exercises. Start sitting upright. Then move into the side-lying position, with the head angled upward about half-way. Stay in the side-lying position for 30 seconds, or until the dizziness subsides, then go back to the sitting position. Stay there for 30 seconds and then go to the opposite side and follow the same routine. 한번의치료운동으로팽대부릉정으로부터이석을떼어내는방법을고안하였다. 그러나획기적인치료법의도입은 1992년 Epley 14) 에의해이루어졌다. 그는팽대부릉정에붙어있는이석때문이아니라반고리관내의이석이 BPPV 의원인이된다는가설을바탕으로이석치환술을개발하였다. 이는현재까지도가장많이사용되고있으며치료효과를높이기위하여다양하게변형되어사용되고있다. Brandt-aroff 습관화운동 앉은자세에서어지러움이유발되는쪽으로갑작스럽게쓰러지고어지러움이없어진후 30초정도더누워있다가앉는다. 약 30초후반대쪽으로의운동을반복하며이와같은운동을하루수차례씩반복시행한다 (Fig. 5). 반복된운동으로점차유발되는증세가약화되어연속되는이틀간증세가유발되지않을때까지시행한다. 환자의증세가호전되는기전에대한설명은명확하지는않지만후반고리관의이석조각이떨어져나오고작은조각으로부스러져증세를유발시키지않게된다는것과반복되는자극에의하여중추에서적응이일어나기때문인것으로설명된다. 이러한운동법은환자가시행하기번거로움단점은있지만, 12)15) 팽대부릉정이석으로인해이석치환술의효과가크지않거나, 이석치환술로안진은없어졌지만주관적인어지러움을계속느끼고있는경우습관화운동을시행하면환자의증상을호전시킬수있다. 177

5 J Clinical Otolaryngol 2006;17: B A Particles in posterior canal Utricle C Cupula A B C Fig. 6. Semont liberatory maneuver (right ear). A:The patient is sitting with the head turned horizontally 45 to the healthy (left) ear. B:Moving to right side-lying position. C: Moving to left side-lying position. 이석유리술 (Semont liberatory maneuver) 환자는앉은자세에서환측의반대쪽으로얼굴을돌리고갑작스럽게환측으로고개를들고눕는다. 5분이지난후반대쪽으로얼굴이아래를향하여귀가닿도록빠르게눕는다. 환자는이자세를 5~10 분간유지한후앉은자세로서서히돌아온다 (Fig. 6). Semont 는이방법을통하여단한번의운동으로 84% 의치료효과를보았고, 1주후한번더시행함으로 93% 까지치료효과를높일수있었다고보고하였다. 13) 이후다른발표들에의하면 52~90% 의치료결과를보이며재발율은 29% 정도로보고되었다. 8)16-18) Herdman 등 18) 과 Cohen 등 19) 에의하면뒤에언급되는이석치환술과비교하여치료성적이유사하지만나이많고비만인사람한테적용하기어려운점이있고이석치환술에비하여더좋은결과를보이지는않는다고하였다. 이석치환술 (Modified Epley maneuver) 1992 년 Epley 는 5가지일련의동작으로이관내의이석을중력을이용하여난형낭내로재위치시키는방법을 고안하여높은치료성공률을보였다. 14) 그는운동시행전에환자에게안정제를투여하였고진동기 (mechanical skull vibrator) 를유양돌기부에작동하여이석의부양을유도하였으며증세가없어질때까지반복시행하였다. Parnes 등 20)21) 은이를변형하여안정제와진동기를사용하지않고 3가지자세변화를기본으로한번만시행하는변형 Epley 이석치환술 (modified Epley maneuver) 을제안하였고, 현재대부분의의사들은이방법을사용한다. 그는진동기의사용이오히려이석의탈출을조장할수있을것이라생각하였는데이는증명되지않았고최근의 Hain 등 22) 은진동기의사용여부와치료성공률은관련이없다고하였다. 방법은그림 (Fig. 7) 과같이앉은자세에서환측으로 ix-hallpike 자세를취한후안진을관찰한다 (B). 다음단계로천천히머리를반대쪽으로 90도돌리며이때고개는최대한신전된상태를유지한다 (C). 이어서몸전체와머리를 90도더반대쪽으로돌리고 (), 이자세에서안진 ( 이차안진 ) 을짧은시간안에다시확인한다. 첫번째보였던안진과동일한모양으로나타나면이관내이 178

6 정원호외 : 후반고리관양성돌발성두위현훈의진단과치료 90 Superior canal Utricle Cupula A Particles in posterior canal B C Fig. 7. Modified Epley maneuver (right ear). A:The patient is seated on a table as viewed from the right side. B: Patient in normal ix-hallpike head-hanging position. The patient s head is then rotated toward the opposite side with the neck in full extension through position (C) and into position () in a steady motion by rolling the patient onto the opposite lateral side and then the patient sits back up to position (A). 석이공통각 (common crus) 을통하여난형낭내로제대로들어가고있는것이다. 마지막단계로환자를앉도록한다. 각단계별로자세를 1~2 분정도유지하도록되어있으나, 안진의지속시간과이석이움직이는시간을고려할때안진이사라지는시점까지자세를유지시키면충분하리라생각한다 ( 약 30초 ). 이방법은시행하는데 5분정도면충분하고, 이석이제자리를잡고재발하지않도록시행후 24~48시간정도눕지말것을권고한다. 최근의연구에서는이석치환술을시행한후엄격하게앉아있는체위를일정시간유지하는것과유지하지않는것사이에치유율에는차이가없다는보고 17)23) 도있으므로환자의상태에따라유동적으로적용하여도무방할것으로보인다. 환자 1회방문시이석치환술시행횟수에는이견이있다. 정해진횟수만큼시행하는경우도있고, 22) 한번만시행하는경우도있다. 수차례이석치환술을반복시키는것은피로현상을초래하여결과판정이어렵기때문에 1 회만시행하고이석치환술시행중이차안진이나타나지않는경우와마지막단계인앉은자리로돌아올때역 안진 (reverse nystagmus) 이나어지럼증이나타나는환자에서선별적으로재시행하는방법 3) 등이있다. 치료성공률은저자마다추적관찰기간과시행횟수, 안정제와진동기사용등의차이가있어정확하게평가하기는어려우나약 30~100% 으로보고되고있다. 8) 저자들의경험에의하면후반고리관 BPPV 에서이석치환술을진단당시 1회시행하고, 1주일후에검사를시행하여치료판정을시행하였을때 82.2% 의치료성공률을보였다. 24) 수술적인치료법 BPPV 는양성질환으로수술적인치료는비수술적인치료법이효과가없거나자주재발하는경우에제한적으로사용된다. 그리고수술을시행하기전에 BPPV 와유사한증상을보이는중추신경계의질환이없는지를방사선학적인검사를통하여확인하여야한다. 단신경절제술 (Singular neurectomy) 후반고리관으로부터중추신경으로자극을전달하는유 179

7 J Clinical Otolaryngol 2006;17: 일한후팽대부신경 (posterior ampullary nerve) 을자르는기법으로 1970 년대 Gacek 25) 에의하여처음보고되었으나감각신경성난청이발생할수있는부작용이있고기술적으로도어려워서좀더단순한후반고리관폐쇄법으로대체되고있다. 후반고리관폐쇄법 (Posterior semicircular canal occlusion) Parnes 등 26-28) 에의하여 1990 년제안된방법으로반고리관을눌러막으면내림프의순환이차단되고팽대부릉정이효과적으로고정되어정상적인각가속력에의한내림프의움직임뿐만아니라이관내의유리된이석이나팽대부의고정된이석에의해서도팽대부릉정이움직이지않게된다. 또한예전의침습적인내이수술에비하여후반고리관폐쇄법은청력저하를거의일으키지않는안전한방법이다. 수술은전신마취하 2~3시간정도걸린다. 5~6 cm 정도의후이개절개를가하고단순유양돌기절제술을시행하여후반고리관에접근한다. 드릴을이용하여골성후반고리관에 1 3 mm의창을내고 bone dust와 fibrinogen glue 로만든 plug 를밀어넣어서후반고리관을막는다. 수술이끝난후 2~3 일이면환자는퇴원할수있다. 수술후에환자는어지럼과평형장애를호소하나중추성보상기전에의하여수술후수일에서수주가지나면서회복된다. 이때전정운동을시행하여회복을도울수있다. Agrawal 등 29) 은 44예의후반고리관폐쇄수술에서모두성공하였고재발은 1예에서발생하였으며다른한예에서수술후 3개월에심도의돌발성난청이생겼다고보고하였다. 그외다수의연구에의해후반고리관폐쇄법은그안정성과효과가입증되었다 ) 중심단어 : 양성돌발성두위현훈 진단 치료. REFERENCES 1) Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol 2005;116: ) Froehling A, Silverstein M, Mohr N, Beatty CW, Offord KP, Ballard J. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991;66: ) Parnes LS, Agrawal SK, Atlas J. iagnosis and management of benign paroxysmal positional vertigo (BPPV). Cmaj 2003;169: ) ix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952;61: ) Cohen HS. Side-lying as an alternative to the ix-hallpike test of the posterior canal. Otol Neurotol 2004;25: ) Bronstein AM. Vestibular reflexes and positional manoeuvres. J Neurol Neurosurg Psychiatry 2003;74: ) Straumann, Suzuki M, Henn V, Hess BJ, Haslwanter T. Visual suppression of torsional vestibular nystagmus in rhesus monkeys. Vision Res 1992;32: ) Haynes S, Resser JR, Labadie RF, Girasole CR, Kovach BT, Scheker LE, et al. Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus. Laryngoscope 2002;112: ) Tirelli G, Orlando E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngoscope 2001;111: ) Weider J, Ryder CJ, Stram JR. Benign paroxysmal positional vertigo: analysis of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol 1994;15: ) McClure JA, Willett JM. Lorazepam and diazepam in the treatment of benign paroxysmal vertigo. J Otolaryngol 1980; 9: ) Brandt T, aroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106: ) Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988;42: ) Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107: ) Banfield GK, Wood C, Knight J. oes vestibular habituation still have a place in the treatment of benign paroxysmal positional vertigo? J Laryngol Otol 2000;114: ) Norre ME, Beckers A. Comparative study of two types of exercise treatment for paroxysmal positioning vertigo. Adv Otorhinolaryngol 1988;42: ) Nuti, Nati C, Passali. Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. Otolaryngol Head Neck Surg 2000;122: ) Herdman SJ, Tusa RJ, Zee S, Proctor LR, Mattox E. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 1993;119: ) Cohen HS, Jerabek J. Efficacy of treatments for posterior canal benign paroxysmal positional vertigo. Laryngoscope 1999;109: ) Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1993;102: ) Parnes LS, Robichaud J. Further observations during the particle repositioning maneuver for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1997;116: ) Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 2000;126: ) Marciano E, Marcelli V. Postural restrictions in labyrintholithiasis. Eur Arch Otorhinolaryngol 2002;259:

8 정원호외 : 후반고리관양성돌발성두위현훈의진단과치료 24) Chung YJ, Choe JY, Chung WH, Hong SH. Outcome of canalith repositioning maneuver in benign paroxysmal vertigo. J Korean Balance Society 2002;1: ) Gacek RR. Further observations on posterior ampullary nerve transection for positional vertigo. Ann Otol Rhinol Laryngol 1978;87: ) Parnes LS, McClure JA. Posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1990;99: ) Parnes LS, McClure JA. Posterior semicircular canal occlusion in the normal hearing ear. Otolaryngol Head Neck Surg 1991;104: ) Parnes LS. Update on posterior canal occlusion for benign paroxysmal positional vertigo. Otolaryngol Clin North Am 1996;29: ) Agrawal SK, Parnes LS. Human experience with canal plugging. Ann N Y Acad Sci 2001;942: ) Walsh RM, Bath AP, Cullen JR, Rutka JA. Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clin Otolaryngol Allied Sci 1999;24: ) Pace-Balzan A, Rutka JA. Non-ampullary plugging of the posterior semicircular canal for benign paroxysmal positional vertigo. J Laryngol Otol 1991;105: ) Hawthorne M, el-naggar M. Fenestration and occlusion of posterior semicircular canal for patients with intractable benign paroxysmal positional vertigo. J Laryngol Otol 1994; 108: ) ingle AF, Hawthorne MR, Kumar BU. Fenestration and occlusion of the posterior semicircular canal for benign positional vertigo. Clin Otolaryngol Allied Sci 1992;17: ) Anthony PF. Partitioning the labyrinth for benign paroxysmal positional vertigo: clinical and histologic findings. Am J Otol 1993;14:

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