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1 Research in Vestibular Science Vol. 9, No. 3, September 2010 Original Article pissn , eissn 수평반고리관양성돌발성두위현훈의치료효과예측 : Gufoni 수기를이용한예비연구 충남대학교의학전문대학원신경과학교실 문정수, 신종욱, 김현정, 백인철, 오응석, 오지은, 이경재, 이지희, 김재문, 정성해 Prediction of Successful Repositioning of Horizontal Canal Benign Positional Vertigo in Gufoni s Maneuver: A Preliminary Study Jeong Soo Moon, MD, Jong Wook Shin, MD, Hyun Jung Kim, MD, In Chul Baek, MD, Eung Seok Oh, MD, Ji Eun Oh, MD, Kyung Jae Lee, MD, Ji Hee Lee, MD, Jae Moon Kim, PhD, Seong-Hae Jeong, MD Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea Received Aug 13, 2010 Accepted Aug 31, 2010 Corresponding Author: Seong-Hae Jeong, MD Department of Neurology, Chungnam National University College of Medicine, 33 Munhwa-ro, Jung-gu, Daejeon , Korea Tel: Fax: mseaj@hanmail.net Copyright c 2010 by The Korean Balance Society. All rights reserved. Background and Objectives: Although several methods of repositioning maneuver have been introduced for the benign paroxysmal positional vertigo involving horizontal canal (HC-BPPV), no study has investigated the nystagmus pattern during the repositioning maneuver and its correlation with the repositioning results. Therefore, we evaluated the predictive value of the nystagmus for successful repositioning by studying the nystagmus pattern during the position of the Gufoni s maneuver. Materials and Methods: Seventeen consecutive patients (age range=36~76 years, median age=64), with a diagnosis of HC-BPPV were recruited between July and August The Gufoni's maneuver for apogeotropic and geotropic nystagmus was performed. After 30 minutes, the treatment outcome was evaluated according to the nystagmus pattern at the individual stage of Gufoni s maneuver. Successful treatment was defined by the resolution of positional vertigo in geotropic HC-BPPV and nystagmus shifted from apogeotropic to geotropic in apogeotropic HC-BPPV. Results: In the successfully treated patients, 4 of 6 patients had the contralesional nystagmus between 1st and 2nd position of Gufoni s maneuver. Ipsilesional nystagmus in 1st position of Gufoni s maneuver was observed in 1 patient with apogeotropic nystagmus. And the other 1 patient with Geotropic HC-BPPV showed no nystagmus in 2nd position after contralesional nystagmus in 1st position of Gufoni s maneuver. Unsuccessfully treated 11 patients had a conversion of nystagmus direction in 2nd position after 1st step. Conclusion: During the 2nd position of the Gufoni s maneuver, a nystagmus toward unaffected side predicts a successful repositioning, whereas reversed nystagmus is suggestive of poor response to repositioning. Research in Vestibular Science 2010;9(3): Key Words: Positional vertigo; Nystagmus; Treatment 108

문정수외 9 인. 수평반고리관양성돌발성두위현훈의치료효과예측 : Gufoni 수기를이용한예비연구 서론양성돌발성두위현훈 (benign paroxysmal positional vertigo, BPPV) 은재발성어지럼의가장흔한원인으로서, 자세변환에의해유발되는발작성현훈을특징으로하며이중후반고리관성 BPPV가가장흔하다고알려져있다.

2 문정수외 9 인. 수평반고리관양성돌발성두위현훈의치료효과예측 : Gufoni 수기를이용한예비연구 서론양성돌발성두위현훈 (benign paroxysmal positional vertigo, BPPV) 은재발성어지럼의가장흔한원인으로서, 자세변환에의해유발되는발작성현훈을특징으로하며이중후반고리관성 BPPV가가장흔하다고알려져있다. 1 최근근거중심 (evidence-based) 연구결과후반고리관성 BPPV 의가장유용한치료법은 Epley에의해고안된이석정복술 (canalith repositioning procedure) 로인정받고있다. 2 또한, 이석정복술의과정중제2자세에서안진의역전현상이일어나는경우치료효과는떨어지는것으로보고되어후반고리관성 BPPV의치료법과효능에대해서어느정도표준화가되었다고할수있다. 양성돌발성두위현훈에관한국내연구결과를보면전체수평반고리관성양성돌발성두위현훈의빈도가다른나라에비해높아약 31.9~41.1% 로보고되고있다. 3,4 그러나수평반고리관성 BPPV (HC-BPPV) 에적용되는각정복술간의효과에대한비교연구는드물다. 최근국내의한연구에의하면원지성 (apogeotropic) HC-BPPV 환자를대상으로두진 (head shaking maneuver) 과 modified Semont maneuver를비교한연구결과반복적인두진을적용한경우치료효과가더높은것으로나타났다. 5 또한, HC-BPPV에적용되는각수기의치료성과를예측하는인자에대한연구역시부족하다. 이에본저자들은 HC-BPPV 환자들에 Gufoni 수기를적용시, 각시기별안진양상에따라치료결과에차이가있는지관찰하고자본연구를시행하게되었다. 로정하였다. 7-9 좌우안진의크기가유사하여편측화가어려운경우 head-bending nystagmus나 lying-down nystagmus를 대상및방법 2010년 7월부터 8월까지충남대학교병원신경과에어지럼을주소로내원한환자들중 HC-BPPV로진단받은 17명을대상으로하였다. HC-BPPV의진단은누운상태에서고개를좌우로돌려유발되는안진 ( 머리회전검사, supine roll test) 의양상에따라향지성과원지성으로나누었다. 머리회전검사상아래쪽에위치한귀쪽으로수평안진이발생하는경우향지성수평반고리관성 BPPV (GEO HC-BPPV) 로진단하였으며, 위쪽에위치한귀를향하여수평안진이유발될때원지성수평반고리관성 BPPV (APO HC-BPPV) 로진단하였다. 6,7 병변은원지성안진을보이는경우누운자세에서고개를돌렸을때안진이약하게유발되는쪽으로하였으며, 향지성안진을보이는경우강한안진이유발되는쪽으 Figure 1. The diagram of otolith and endolymphatic flow according to 4 positions of the Gufoni's maneuver for apogeotropic benign paroxysmal positional vertigo involving left horizontal canal. Position 0. The patient is seated. Position 1. The patient is quickly brought to the side-lying position on the affected side Position 2. The head of the patient is quickly turned 45 degree upward. Position 3. The patient returns to the seated position. A.The otolith is located in the anterior arm of horizontal semicircular canal. B. The ampullofugal endolymphatic flow is evoked by displacement of otolith toward posterior arm. C. As the otolith moves toward posterior arm, cupula is deflected toward ampulla by ampullofugal endolymphatic flow. D. The otolith is located in posterior arm of horizontal semicircular canal. 109

3 Res Vestibul Sci Vol. 9, No. 3, Sep 이용하였다. 7,8 진단된 HC-BPPV 환자들은각각다음과같은순서로 Gufoni 수기를적용하였다. APO HC-BPPV 환자 의경우 1) 고개를똑바로하고앉은자세에서환측방향으로신속하게옆으로눕히고원지성안진이끝나고나서 1 분동안이자세를유지한다 ( 자세 1, position 1, Figure 1B). 2) 환자의머리를신속하게 45 위로향하게한후 2분간유지한다 ( 자세 2, position 2, Figure 1C). 3) 환자를천천히앉힌다 ( 자세 3, position 3, Figure 1D). 10 GEO HC-BPPV 환자의경우 1) 건측방향으로신속하게눕히고 2분간유지한다 ( 자세 1, position 1, Figure 2B). 2) 환자의머리를신속하게 45 아래로향하게한후 2분간유지한다 ( 자세 2, position 2, Figure 2C). 3) 환자를앉힌다 ( 자세 3, position 3, Figure 2D). 11 Gufoni 수기시행후 30분간이자세를유지하게하고난후치료효과를판정하였다. 성공적인치료결과는 APO HC-BPPV 의경우 GEO HC-BPPV으로변화하거나증상과안진이소실된경우로정의하였다. GEO HC-BPPV의경우증상과안진이소실된경우로정의하였다. Gufoni 수기별자세에서안진양상을비디오프렌젤안경 (SLMED, Seoul, Korea) 을이용하여관찰하고기록하여치료결과에따른안진양상에차이가있는지분석하였다. 결 과 본연구에모집된총 17명의환자중 4명이남자로남녀성비는 1:3.25였다. 연령의분포는 36~76세였다 (median=64). 9명의환자에서는특별한원인을발견할수없었고, 일부환자에서외상 (1명), 편두통 (1명), 골다공증 (4명), 이전귀질환 (2명) 등의호발조건을가지고있었다. 총 17명의 HC-BPPV 환자중 10명의환자에서원지성안진 (10/17=58.9%) 을보였고, 7명의환자에서향지성안진을보였다 (7/17=41.1%). 1. 원지성수평반고리관성양성돌발성두위현훈 (APO HC-BPPV) Figure 2. The diagram of otolith and endolymphatic flow according to 4 positions of the Gufoni's maneuver for geotropic benign paroxysmal positional vertigo involving left horizontal canal. Position 0. The patient is seated. Position 1. The patient is quickly brought to the side-lying position in the unaffected side. Position 2. The head of the patient is quickly turned 45 degree downward. Position 3. The patient returns to the seated position. A. The otolith is located in the posterior arm of horizontal semicircular canal. B. The ampullofugal endolymphatic flow is evoked by displacement of otolith toward utricle. C. As the otolith moves toward utricle, cupula is deflected toward ampulla by ampullofugal endolymphatic flow. D. The otolith is repositioned in utricle. APO HC-BPPV로진단받은 10명의환자중 8명은 Gufoni 수기자세 1에서건측을향하는수평안진을보였고 Gufoni 수기자세 2에서는안진의방향이역전되었다. 나머지 2명중 1명에서는 Gufoni 수기자세 1에서유발된건측을향하는원지성안진이자세 2에서도지속되었다 (Table 1, patient 6). 다른 1명에서는 Gufoni 수기자세 1에서환측을향하는수평안진을보였으며, 자세 2에서안진의방향이역전되었다 (Table 1, patient 9). 상기환자들의치료결과를보면 Gufoni 수기자세 1에서건측을향하는수평안진을보이다가, 자 110

4 문정수외 9 인. 수평반고리관양성돌발성두위현훈의치료효과예측 : Gufoni 수기를이용한예비연구 Table 1. Characteristics of enrolled patients and nystagmus during repositioning maneuver Patient Sex Age Diagnosis Side Direction of nystagmus Before 1st position 2nd position 3rd position Treatment outcome 1 M 38 APO Right No Left Right No Fail 2 F 62 APO Right Right Left Right Right Fail 3 F 70 APO Left Left Right Left Left Fail 4 F 68 APO Left Left Right Left Left Fail 5 F 76 APO Left No Right Left Right Fail 6 F 36 APO Left No Right Right No Success 7 M 64 APO Left No Right Left Right Fail 8 F 76 APO Right No Left Right Left Fail 9 M 65 APO Left No Left Right No Success 10 F 50 APO Right No Left Right Right Fail 11 F 57 GEO Left No Right Left No Fail 12 F 70 GEO Left No Right Right No Success 13 F 54 GEO Left No Right Right No Success 14 M 67 GEO Right No Left Down Down Fail 15 F 67 GEO Left Left Right Right No Success 16 F 61 GEO Left No Right Left No Fail 17 F 63 GEO Right Left Left No No Success Side, lesion side; APO, apogeotropic benign paroxysmal positional vertigo involving horizontal canal; GEO, geotropic benign paroxysmal positional vertigo involving horizontal canal; 1st position, first stage of Gufoni s maneuver; 2nd position, second stage of Gufoni s maneuver; 3rd position, third stage of Gufoni s maneuver. 세 2에서안진이역전된 8명의환자들은 Gufoni 수기이후에도증상과안진이여전히지속되었다. 반면에, Gufoni 수기자세 1에서건측을향하는수평안진을보이며 Gufoni 수기자세 2에서도안진이역전되지않은환자 1명과 Gufoni 수기자세 1에서환측을향하는수평안진을보이다가 Gufoni 수기자세 2에서안진의방향이바뀐 1명은 GEO HC-BPPV 으로변환되어성공적인치료결과를보였다 (Table 1). 2. 향지성수평반고리관성양성돌발성두위현훈 (GEO HC-BPPV) 17명의 HC-BPPV 환자중 7명 (41.2%) 에서 GEO HC-BPPV 로진단되었다. 이들중 4명의환자에서는 Gufoni 수기자세 1에서건측을향하는향지성안진이관찰되었고, 이중 3명은자세 2에서도안진의방향이역전되지않았고 (patient 12, 13, 15), 1명에서는자세 2에서안진이소실되었다 (patient 3). 나머지 3명에서는자세 1에서건측을향하는향지성안진이관찰되었으나자세 2에서안진의방향이변하였다 (Table 1). 수기를마친후치료결과를보면자세 1에서건측을향하는향지성안진을보이면서자세 2에서도안진의방향이변하지않고건측을향하거나안진이소실된환자군에서는 30 분이후시행한머리회전검사상증상과안진이소실되는성공적치료결과를관찰할수있었다. 반면에, 자세 2에서안진의방향이전환된경우에는증상과안진이지속되었다. 고찰본연구는하나의병원에서단기간동안소수의환자를대상으로한제한점이있으나, HC-BPPV 환자에서 Gufoni 수기에서관찰되는안진의양상에따라치료효과를분석한최초의연구이다. 연구결과 HC-BPPV 환자중 Gufoni 수기자세 1에서건측을향하는수평안진이자세 2에서지속되거나, 안진이소실된환자에서정복술이후성공적인치료결과가관찰되었다. 또한, 자세 1에서환측을향하는수평안진을보인 1명의 APO HC BPPV 환자 1명에서도 GEO HC-BPPV로변환되었다. 111

5 Res Vestibul Sci Vol. 9, No. 3, Sep Gufoni에의해제시된 APO HC-BPPV 이석정복술은관내부유하는이석이수평반고리관의 anterior arm에있다는가정에근거한수기로이석을 posterior arm으로이동시켜 GEO HC-BPPV로전환시켜 APO HC-BPPV의치료에이용되고있다. 10 APO HC-BPPV 환자가환측으로누울때 ( 자세 1) 이석은환측의수평반고리관의가장아래쪽으로이동하게되어팽대마루가팽대부쪽으로기울어져억제성신호를발생시키게된다 (Figure 1B). 이로인해자세 1에서는건측으로향하는원지성안진이발생하게된다. 이후머리를 45 위쪽으로향하게할때, 안진의방향이변하지않는다면이는이석이 anterior arm에서 posterior arm 쪽으로이동되어팽대부에서멀어지는내림프의흐름이지속되어환측의귀는억제성자극을받게되어이경우 APO HC-BPPV가 GEO HC-BPPV로전환된것을예측할수있다. 자세 2에서안진의방향이역전되는것은이석이여전히 anterior arm에위치하여, 팽대마루가전정으로기울어져흥분신호가발생하는것을의미하며, APO HC-BPPV가지속됨을의미한다고생각할수있다 (Figure 1C). 본연구에서 10명의환자중 Gufoni 수기이후증상이호전된 1명의환자가위의결과를반영한다고할수있다. 또한, 자세 1에서향지성안진으로바뀐경우이미이전체위변환검사등의과정에서 GEO HC-BPPV로변화한것으로추정할수있다. 10 나머지 8명에서는증상이호전되지않았고이들모두에서자세 1에서의안진의방향이자세 2에서역전되는결과를보였다. 이는자세 2에서도여전히이석이 anterior arm에위치하거나팽대부릉정에부착되어있다는것을의미한다고볼수있다. GEO HC-BPPV 환자의경우자세 1에서건측으로누울때이석이수평반고리관의 posterior arm을통해팽대부반대쪽으로이동하게되며팽대마루가팽대부쪽으로기울어져억제성신호를전달하여건측을향하는향지성안진이발생하게된다 (Figure 2B). 자세 2에서 45 아래로머리를회전할때팽대부에서멀어지는방향으로이석이이동하여여전히건측을향하는안진이지속되거나, 이석이난형낭으로이동하는경우안진이소실되기도한다 (Figure 2C). 자세 2에서이러한과정이일어나지않고안진의방향이역전되는경우에는이석이난형낭쪽으로이동하지않음을의미하고, 팽대부쪽으로내림프가흐르게되어흥분성자극이전달됨을시사한다 (Figure 2C). 11 따라서, HC-BPPV에서원지성수평안진을보인경우와향지성수평안진을보인두가지경우모두에서 Gufoni 수기자세 1에서건측을향하는수평안진방향이자세 2에서도그대로유지될때좋은치 료결과를예측해볼수있으며, 자세 2에서안진의방향이역전되는경우는치료예후가좋지않음을의미한다고볼수있다. 본연구에서 HC-BPPV의경우기존의연구에비해비교적낮은치료성적을보였다. 가능한이유로, Gufoni 수기적용후치료효과판정시점과수기시도횟수의차이를들수있다. 기존의연구에서는치료결과를치료이후하루이상경과된이후판정한경우가대부분이었고 2차례이상치료수기를시행하였다. 10,11 이에반해본연구는단 1회의 Gufoni 수기시행후 30분이후치료효과를판정한점등이본연구에서치료성공률을낮게한원인들로추정해볼수있다. 결 HC-BPPV에서 Gufoni 수기를시행하는경우자세 1에서건측을향하는수평안진방향이자세 2에서유지되거나소실되는경우성공적인결과를시사한다고할수있으며, 안진의방향이바뀌면치료에대한예후가좋지않음을시사한다. 향후이를입증할보다대규모의연구가필요하다. 론 중심단어 : 두위현훈, 안진, 치료 REFERENCES 1. Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology 1987;37: Oh HJ, Kim JS, Han BI, Lim JG. Predicting a successful treatment in posterior canal benign paroxysmal positional vertigo. Neurology 2007;68: Moon SY, Kim JS, Kim BK, Kim JI, Lee H, Son SI, et al. Clinical characteristics of benign paroxysmal positional vertigo in Korea: a multicenter study. J Korean Med Sci 2006;21: Jeong SH, Choi SH, Kim JY, Koo JW, Kim HJ, Kim JS. Osteopenia and osteoporosis in idiopathic benign positional vertigo. Neurology 2009;72: Oh SY, Kim JS, Jeong SH, Oh YM, Choi KD, Kim BK, et al. Treatment of apogeotropic benign positional vertigo: comparison of therapeutic head-shaking and modified Semont maneuver. J Neurol 2009;256: Baloh RW, Yue Q, Jacobson KM, Honrubia V. Persistent direction-changing positional nystagmus: another variant of benign positional nystagmus? Neurology 1995;45: Lee SH, Choi KD, Jeong SH, Oh YM, Koo JW, Kim JS. Nystagmus during neck flexion in the pitch plane in benign 112

6 문정수외 9 인. 수평반고리관양성돌발성두위현훈의치료효과예측 : Gufoni 수기를이용한예비연구 paroxysmal positional vertigo involving the horizontal canal. J Neurol Sci 2007;256: Koo JW, Moon IJ, Shim WS, Moon SY, Kim JS. Value of lying-down nystagmus in the lateralization of horizontal semicircular canal benign paroxysmal positional vertigo. Otol Neurotol 2006;27: Nuti D, Agus G, Barbieri MT, Passali D. The management of horizontal-canal paroxysmal positional vertigo. Acta Otolaryngol 1998;118: Appiani GC, Catania G, Gagliardi M, Cuiuli G. Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Otol Neurotol 2005;26: Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol 2001;22:

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<30322EBABBB9AE2E687770> Research in Vestibular Science Vol. 10, Suppl. 1, June 2011 Symposium pissn 2092-8882, eissn 2093-5501 가장흔한질환인양성돌발성두위현훈의여러아형에따른적절한이석정복술의선택과방법 아주대학교의과대학이비인후과학교실 정연훈, 임혜진 Management of Benign Paroxysmal