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1 Research in Vestibular Science Vol. 11, No. 1, March 2012 Original Article pissn , eissn 전정유발근전위를이용한어지럼환자의전정기능평가 순천향대학교의과대학서울병원이비인후과학교실 이유재, 이찬구, 조상혁, 박영주, 김효진, 이권형, 이병돈 Vestibular Function Test of Dizziness Patients by Vestibular Evoked Myogenic Potential You Jae Lee, MD, Chan Goo Lee, MD, Sang Hyuck Cho, MD, Young Joo Park, MD, Hyo Jin Kim, MD, Koen Hyeong Lee, MD, Byung Don Lee, MD Department of Otolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Seoul, Korea Received Nov 9, 2011 R evised (1 st) Nov 17, 2011 (2nd) Dec 21, 2011 (3rd) Feb 7, 2012 Accepted Feb 16, 2012 Corresponding Author: Byung Don Lee, MD Department of Otolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul , Korea Tel: , 9360 Fax: bdlee12@schmc.ac.kr Copyright c 2012 by The Korean Balance Society. All rights reserved. Background and Objectives: Because the saccule, next to the cochlea, is the second most frequent site of hydrops formation, we evaluated whether vestibular evoked myogenic potential (VEMP) responses can reflect the diagnosis and the stage of Meniere s disease. And we studied about other vestibular disease such as vestibular neuritis and benign paroxysmal positional vertigo. Materials and Methods: Retrospectively, we analyzed the results of VEMP in 22 patients (12 men and 10 women) with unilateral definite Meniere s disease, 21 patients (5 men and 16 women) with vestibular neuritis, and 23 patient (4 men and 19 women) with benign paroxysmal positional vertigo (BPPV). All subjects underwent VEMP testing using ipsilateral 1 KHz-tone burst sound with 105 db nhl. Results: VEMP was present in 86% of Meniere affected ear. The latency of p13 of affected ears in patients with Meniere s disease, vestibular neuritis (VN), BPPV was not significantly prolonged than that of normal ears in the control group except left n23 latency in meniere s disease. In the patients with Meniere s disease, the amplitude-ratio was larger than that of the control group, statistically (p=0.006). And relationship was found in amplitude ratio among groups classified by the stage of Meniere s disease. Conclusion: This study shows that amplitude ratio of VEMP response is useful method to determine the severity and prognosis of Meniere s disease. We recommend VEMP to explain to the patient about severity of Meniere s disease quantitatively. Research in Vestibular Science 2012;11(1):37-43 Key Words: Vestibular evoked myogenic potiential; Meniere s disease; Vestibular neuritis; Benign paroxysmal positional vertigo 서론소리자극으로도어지럼이유발될수있다는것을 Tullio 가주장한이후, Bickford 1 는매우강한음성자극으로경부 근육에서근전위반응이나타남을보고하였으며, 1989년 Didier와 Cazals 2 는이반응이구형낭에서기원한다고추정하였다. 3 이후여러학자에의해이반응의기원이전정기관임이밝혀졌으며, 4,5 전정유발근전위 (vestibular evoked myogenic 37

2 Res Vestibul Sci Vol. 11, No. 1, Mar potential, VEMP) 로명명되었다. 현재어지럼의진단에주로사용하고있는온도안진검사와회전의자검사는대부분외반고리관의기능을평가하는반면 VEMP는구형낭을포함한일측의전정척수반사로의기능을평가할수있고, 또한측정과기록방법이기존의청성뇌간반응검사와유사하여추가장비없이손쉽게측정할수있다는장점이있다. 이에대한많은연구가축적되면서이석기능과하전정신경의실용적이고재현성있는평가로서인정되고있으며, 다양한말초전정장애의진단에적용되고있다. 6-8 메니에르병에서전기와우도검사의가중전압 (summating potential, SP) 과활동전압 (action potential, AP) 의비 (SP/AP ratio) 가진단및확진에널리활용되고있지만객관적인검사로인정되지못하고, 오직청력검사만으로진단되는현실정에서 9,10 새로운객관적인검사로서의가능성을확인하고자 VEMP의유용성에대한많은연구들이발표되고있다. 4,7,11 하지만현재까지메니에르병과전정신경염, 양성돌발성두위현훈등말초성어지럼질환에서의진단적가치, 진행의정도및경과에따른 VEMP의결과에대한연구는아직부족한상태이며국내에서말초성어지럼질환에대한 VEMP결과에대해종합적으로평가한연구가이루어지지않은상황이다. 이에본연구에서는전정신경염, 메니에르병, 양성돌발성두위현훈에서전정유발근전위의임상적가치에대해연구해보고자하였다. 1. 대상 대상및방법 2010년 9월부터 2011년 4월까지 8개월간병원에어지럼을주소로내원하여 VEMP를시행한 117명을대상으로하였다. 남자 39명, 여자 78명으로평균연령은 49세였다. 메니에르병은 American Academy of Otolaryngology- Head and Neck Surgery가제시한 definite 에합당한환자를기준으로하였다. 전정신경염은병력청취, 온도안진검사및비디오전기안진검사를이용하여특징적인회전성어지럼과함께양온교대온도안진검사에서일측성반고리관의마비가확인되고, 기타와우증상이없는 Cooper의진단기준을따랐다. 6 양성돌발성두위현훈은유발검사에서특이적안진소견에따라진단하였다. 정상대조군은현훈이나기타귀의질환등의기왕력이없는건강한남, 여 20대, 평균나이 26.3세로, 각각 20명씩 40귀에서시행하였다. 2. 방법 1) VEMP검사검사는 Viking IV (Nicolet Biomedical Inc., Madison, WI, USA) 로시행하였다. 먼저환자의외이도를검사하여귀지등이있으면제거하였으며, 편하게앉은자세에서활성전극은검사쪽흉쇄유돌근의상부 1/3 부위에, 기준전극은흉쇄유돌근의쇄골접합부위에, 접지전극은이마정중부에붙이고, 고개를검사쪽의반대편으로돌린후일정한힘을유지하도록하였다. 1.0 khz tone burst의자극음을 105 dbnhl 강도로삽입형수화기를통해초당 5.1회로주었고, 반대측은 65 db로차폐하였다. 좌측을먼저시행하였으며각각의검사사이에는 5분정도의시간을두어검사간의교차간섭을없도록하였고, 각각 2회반복하였다. 본연구에서후기파형은대상에서제외하였으며, 자극후의양성파형 p13, 음성파형 n23을측정하여, 각파형의잠복기 (latency) 와진폭 (amplitude) 을기록하였다. 좌우대칭을알아보기위해양이간진폭비 (amplitude ratio) 를구하였다. 양이간의진폭비는작은값이큰값의측에비해얼마정도로나왔는가하는값으로양이의각진폭건측이작을경우도상관없이작은값을분자로, 높은값을분모로놓아좌우의높고낮음을구분없이, 좌우양쪽이어느정도비대칭인지를나타내는값으로정의하였다. 2) 순음청력검사순음청력검사의청력역치는 4분법으로계산하였다. 청력에따른메니에르병의병기결정은 Committee on hearing and equilibrium의 Monsell 10 이제시한기준에따라 stage I 은 4분법에의한평균청력이 25 db 미만, stage II는 db, stage III는 db, stage IV는 71 db 이상으로구분하였다. 3) 온도안진검사 VNG ULMER (Synapsys, Marseille, France) 를사용하여안구운동을측정하였다. 냉온교대온도자극은개방회로온도안진기로냉수는 30, 온수는 44 의온도로각각의귀를교대로 30초간자극하여안진의최대완서상안구운동속도를측정하고, Jongnkee의공식으로편측마비가 30% 이상일경우양성반응으로정의하였다. 4) 통계학적분석통계적인분석은 SPSS ver (SPSS Inc., Chicago, IL, USA) 을이용하였고, 분석방법은 Mann-Whitney test와 Spearman 38

3 이유재외 6 인. VEMP in Dizziness Patients correlation test를사용하였으며, p값이 0.05 미만인경우통계적인의의가있다고하였다. 결과 1. 대조군 하였다 (p=0.001) (Figure 1). 진폭의비교에서 65세이상군에서비교적낮은수치를보였지만 ( 좌, 우 : p=0.108, p=0.272), 통계적으로유의하지않았고, 양이간의진폭비역시각각 0.758±0.197, 0.830±0.133으로유의한차이가없었다 (p=0.694) (Table 2). 또한남녀간의비교에서도잠복기및진폭비에서유의한차이가없었다 (p=0.199) (Table 3). 1) 정상대조군정상대조군으로건강한 20대성인남, 여각 20명에서좌측 p13 잠복기 13.37±0.57 ms, n23 잠복기 20.32±0.91 ms, 우측 p13 잠복기 13.47±0.59 ms, n23 잠복기 20.64±1.2 ms, 진폭비 0.83±0.17이었다. 정상대조군의남녀간의비교에서잠복기및진폭비모두에서유의한차이가없었다 (p>0.05) (Table 1). 2) 비특이적환자군어지럼을호소하지만전정기능의이상소견을보이지않는비특이적환자군은 51명 ( 남 :18, 여 :33) 으로, 65세미만 40명, 65세이상 11명이었다. 65세미만과이상의두군으로나누어비교하였을때좌측의 n23만이통계적으로유의 2. 메니에르병 1) 잠복기비교 메니에르병으로진단된남자 12명, 여자 10명의환자에서, 환측에서는 14% 인 3명의환자에서반응을보이지않 Table 2. VEMP of nonspecific dizziness patient (amplitude, amplitude ratio) Age <65 (n=40) 65 (n=11) p-value Lt. amplitude (μv) ± ± Rt. Amplitude (μv) 92.53± ± Amplitude ratio 0.758± ± VEMP, vestibular evoked myogenic potential. Table 1. Normal VEMP of control group Male (n=20) Female (n=20) p-value Lt. p13 latency (ms) 13.37± ± Lt. n23 latency (ms) 20.32± ± Rt. p13 latency (ms) 13.47± ± Rt. n23 latency (ms) 20.64± ± Amplitude ratio 0.82± ± VEMP, vestibular evoked myogenic potential. Table 3. VEMP in nonspecific patient (male vs. female) Male (n=18) Female (n=33) p-value Lt. p13 latency (ms) 13.32± ± Lt. n23 latency (ms) 20.82± ± Rt. p13 latency (ms) 13.70± ± Rt. n23 latency (ms) 20.73± ± Amplitude ratio 0.724± ± VEMP, vestibular evoked myogenic potential. Figure 1. VEMP of nonspecific dizziness patient (latency) (n, <65: 40, 65:11). VEMP, vestibular evoked myogenic potential. Figure 2. Meniere's disease. (n=19) vs. control group (n=40) (latency). disease. 39

4 Res Vestibul Sci Vol. 11, No. 1, Mar 았고, 86% 인 19명의환자에서반응이있었으며, 건측에서는 22명모두에서반응이있었다. 메니에르병환자의잠복기를정상대조군과비교하여보았을때우측은모두유의한차이가없었으나, 좌측이환측인경우에 n23에서만통계적으로유의한차이가있었다 (p=0.000) (Figure 2). 2) 진폭비비교 VEMP 반응을나타낸 19명의메니에르병환자군에서의양이간진폭비는 0.573±0.27로서정상대조군에비해통계적으로유의하게감소되어있었다 (p=0.006). 메니에르병의병기는반응이나타나지않은 19명의환자들중 stage l 이 7명, stage ll 5명, stage lll 7명, stage lv가 1명이었다. 이들병기에따른양이간의진폭비비교에서는 p=0.51로통계적유의성은없었지만 r=-0.453으로음의상관관계를보였다 (Figure 3). 3. 전정신경염 1) 잠복기비교일측전정신경염으로진단된남자 5명, 여자 16명의 21명의모두에서환측, 건측이반응이있었다. 환자군의잠복기 를정상대조군과비교하여보았을때양측 p13, n23 모두에서통계적으로유의한차이는없었다 (p>0.05) (Figure 4). 2) 진폭비비교 21명의일측전정신경염환자에서양이간진폭비는 0.676±0.225로서정상대조군과비교하여통계적으로유의하게감소되어있었다 (p=0.047) (Figure 3). 안진의여부에따라전정신경염환자들의진폭비를비교해본결과, 자발안진이있는군 0.76±0.23 (n=8), 없는군 0.65±0.23 (n=13) 으로통계적으로유의한차이는없었다 (p=0.407) (Figure 5). 4. 양성돌발성두위현훈 1) 잠복기비교양성돌발성두위현훈으로진단된환자는남자 4명, 여자 19명이었다. 환자군은모두관내이석증이었으며침범된부위의경우후반고리관인경우는 16명, 외측반고리관인경우는 7명이었다. 23명의환자에서 VEMP는환측, 건측모든환자에서반응을나타내었다. 환자군의잠복기는좌, 우 p13, n23 모두에서정상대조군과비교하였을때유의한차이는없었다 (p>0.05) (Figure 6). 침범된반고리관에따른비교에서도유의성이없었다 (p>0.05) (Table. 4). 2) 진폭비비교양성돌발성두위현훈환자에서의양이간진폭비는 0.73±0.16으로서정상대조군과비교하여통계적으로유의한차이가없었으며 (p=0.281) (Figure 3), 진폭비를침범된반고리관에따라비교했을때도모두정상대조군과통계적으로유의한차이는없었다 (p>0.05) (Table. 4). Figure 3. Amplitude ratio of control group, Meniere's disease, vestibular neuritis (VN), and benign paroxysmal positional vertigo (BPPV). Figure 4. Vestibular neuritis (n=21) vs. control group (n=40) (latency). Figure 5. Amplitude ratio of vestibular neuritis with spontaneus nystagmus (n=8) and without spontaneus nystagmus (n=13). 40

5 이유재외 6 인. VEMP in Dizziness Patients Figure 6. Benign paroxysmal positional vertigo (BPPV) (n=23) vs. control group (n=30) (latency). Table 4. VEMP in BPPV patient (posterior and lateral canal type) Post. canal (n=16) Lat. canal (n=7) p13 latency (ms) 13.01±1.07 (p=0.589) 13.38±0.56 (p=0.461) n23 latency (ms) 20.07±1.45 (p=0.772) 20.71±0.82 (p=0.152) Amplitude ratio 0.764±0.131 (p=0.1) 0.608±0.187 (p=0.467) VEMP, vestibular evoked myogenic potential; BPPV, benign paroxysmal positional vertigo. 고 전정계는말초전정신경계, 중추전정신경계를거쳐전정안반사 (vestibulo-ocular reflex) 와전정척수반사 (vestibulo-spinal reflex) 로구성되는효과기 (effector organ) 로이루어져있다. 12, 년 Bickford 등 1 은강한음자극으로경부에서근전위가발생함을보고한이래, 이반응의기원및경로와임상적의미, 또한이런반응을유발하는자극의종류와강도, 특성등에대한연구가있었다. Murofushi 등 14 은하전정신경또는하전정신경이지배하는말단기관에병변이있는경우 VEMP가형성되지않는다고하였으며, 정상뇌간유발전위검사와온도안진검사를보이는청신경종양환자에서 VEMP가비정상적임을보고하여 VEMP는뇌간유발전위검사와온도안진검사로측정할수없는즉, 와우신경또는상전정신경이아닌하전정신경의기능을알아보는검사라고주장하였다. 그후많은연구들을통하여 VEMP 반응은구형낭에서하전정신경 (inferior vestibular nerve) 을거쳐전정신경핵을경유하여경부의근육으로향하는전정척수로 (vestibulospinal tract) 를통한다고 찰 밝혀졌다. 15 VEMP 진폭에대해서 Sheykholeslami 등 16 은흉쇄유돌근중간부위에서반응이잘나타나며, Wu와 Murofushi 17 는자극음이 5회 / 초일때가, Colebatch와 Halmagyi 5 는 95 db NHL 이상의음에서규칙적이라고제안해, 본연구에서도 105 db NHL에서일정한강도로흉쇄유돌근에서측정하였고, Wu와 Murofushi 17 가제안한 VEMP의좌우양측의비대칭도를기준으로진폭비비교를이용하여정상대조군에서비교적안정된결과를얻을수있었으며, 이를환자와비교하여의미있는전정유발근전위의비대칭성을확인할수있었다. 정상적으로 VEMP는초기파형과후기파형으로나뉘는데, 초기파형은 13 ms에서주로관찰되는양전위의 p13과 23 ms에서의음전위인 n23으로구성되며, 후기파형은 n34 와 p44의두파형으로구성되어있다. 초기파형의기원은구형낭으로정상적으로모든경우에서관찰되나, 후기파형은와우기원의파형으로 5 모든경우에서관찰되지는않아, 본연구에서후기파형은대상에서제외하였다. 본연구에서정상군의잠복기와진폭비에서남, 여간의유의한차이는없었으며, 65세미만과 65세이상인두군간의비교에서연령이증가함에따라진폭이감소하는소견을보였는데이는노인화에따른근긴장도의감소, 전정척수로의신경전달능력저하등의원인으로생각되며, 11 연령에따른변화는양측이동시에진행되기때문에진폭을직접비교하는것보다는양이간의진폭비가일관성있는진단의지표로적합할것으로생각한다. 다양한전정질환에대한 VEMP의결과를확인하는데있어반응의유무, 역치, 잠복기나진폭의변화등을이용한다. Murofushi와 Curthoys 18 는메니에르병, 전정신경염, 전정신경초종, 다발성경화증환자에서 VEMP를측정한후정상대조군과비교하여일부에서반응이없거나진폭이감소하였고, 전정신경초종과다발성경화증환자에서 p13 파형의잠복시간이연장되었다고하였다. 15 본연구에서의결과를보면총 22명의메니에르병환자에서 14% 인 3명에서 VEMP 반응이없었으며, 나머지 19명의환자에서는반응을보였는데, 반응이없었던 3명의환자는메니에르병의하전정신경침범에따른근전위의미형성으로생각된다. 19 기존의보고에서일측의한가지파형의잠복기의연장이있었지만특별한의미를부여하지않았는데, 20 본연구에서도좌측의 n23이유의한차이가있었지만반대측환측이정상인점, 동측의 p13이유의한차이가없는점등을고려해볼때, 비특이적소견으로판단하였다. Lee 등 20 은메니에르병에서 VEMP의진폭차비가증가되 41

6 Res Vestibul Sci Vol. 11, No. 1, Mar 어있지만통계학적으로유의하지는않았다고하였는데, 이는환자수가적었다는점과메니에르병의활동기의일정한시기에검사가시행되지않았다는점이이러한결과의한계로고려되는데, 차후에이에대해보다광범위한환자를대상으로한연구가필요할것으로생각된다고하였다. 본연구에서는메니에르병에이환된환측의지표중양이간의진폭비가유의한차이를보였는데, 이것은메니에르병을진단하는데있어서유의성이있는검사로 VEMP의가치를입증한다고볼수있겠다. 문헌고찰에의하면 Young 등 19 은 40명의일측성메니에르병의환자를대상으로한연구에서파형의잠복기는정상과차이가없지만양이간진폭차가메니에르병의병기가높을수록의미있게커져순음청력검사와함께 VEMP 검사가또다른메니에르병환자의병기결정에유용한검사가될수있을것이라고보고하였다. 본연구에서도메니에르병의병기에따른진폭비또한통계적으로유의하지는않았지만병기가높을수록진폭비가감소하는음의상관관계를가지고있어, 환자의질환진행정도를판가름하는지표뿐아니라, 병기결정에유용한검사로추가가될수있을것으로생각한다. 일측성전정신경염환자를대상으로시행한본연구의결과는, VEMP의미형성이발견되지않았다. Murofushi 등 14 은연장된잠복기는내이병변보다는뇌간의병변, 특히전청척수로에병변이있는경우나타날수있는소견이라고하면서전정신경염이나메니에르병과같은전정신경이나미로질환에서잠복기의연장이발견되지않을수있다는이유를, 첫째, 전정유발근전위의경로인하전정신경의완전한손상이발생하여 VEMP의미형성이발생하거나, 둘째, 단지전정신경에만손상이있을경우 VEMP의잠복기연장을발생시키기에불충분하다 라고설명하였다. 하지만환측과반대측의진폭비를비교하여보았을때는전정신경염에이환된귀에서유의하게진폭이감소된결과로보아전정신경염을확진에이용할수는없겠지만, 병력과온도안진검사등을종합하면전정신경염을진단하는데도움을줄것으로생각된다. 본연구에서좌측의 n23이유의한차이가있었지만메니에르병에서와마찬가지로비특이적결과로판단하였다. 현재의급성도등을판단하는자발안진유무와의비교에서는의미있는결과를보이지않아급성도와중증도등을평가하는검사로서는적합하지않은것으로생각한다. 양성돌발성두위현훈에서 VEMP의진단적가치에대해서는아직까지논란의여지가있다. 본연구에서양성돌 발성두위현훈은 VEMP의모든수치에서유의한차이를보이지않았는데, 이는양성돌발성두위현훈의병인론으로볼때이석으로자극되는전정신경과그의기능이정상이어야안진과어지럼이나타날수있으므로하전정신경의기능을평가하는 VEMP가정상이었던것으로생각된다. 최근파형의잠복기보다는파형을나타내는소리의역치가더많은정보를줄수있다는연구들이보고되고있다. 메니에르병에서 VEMP에대해 Rauch 등 21 은잠복기나양이간진폭차가아닌자극음의주파수에따른 VEMP 파형이나타나는역치를측정한역치동조곡선을이용하여정상인과일측성메니에르병환자에서의환측귀와건측귀에서의차이를비교하였는데, 메니에르병환자에서는정상인에서보이는 500 Hz에서의주파수동조현상이나타나지않았으며그역치가상승되어있었음을보고하였다. 본연구는역치에따른파형에대한검사는실시하지않았지만현재의잠복기및진폭의측정과더불어주파수에따른역치동조곡선의측정에대한보다많은연구결과가축적되고이를실제임상에적용한다면메니에르병환자의진단및예후예측에도움이될것으로생각한다. 본연구에서비특이적어지럼환자군들은 VEMP 결과가모두정상소견을보여 VEMP를시행하는것이진단및치료에도움을주지못하는것으로나타났다. 본연구에서는포함되지않았지만어지럼환자들, 특히만성재발성어지럼이나노인층의어지럼환자를정확히평가하는데있어서동적자세검사 (posturography) 를같이시행하여전정계뿐아니라시각계, 체성감각그리고운동계검사등을종합적으로평가함이반드시필요하다. 본연구에서는비특이적어지럼과메니에르병, 전정신경염, 양성돌발성두위현훈에서진단과병기에따른 VEMP 의임상적가치를알아본결과 VEMP 단독으로질환을확진할수있는특이소견을찾지는못하였다. 하지만다른검사와병력등을자세히조사한다면질병의진단및상태를판단하는데도움이될것으로생각한다. 좀더많은환자들을대상으로추적과정등에서 VEMP의변화및측정지수해석등에대해더많은연구가이루어져 VEMP의유용성을찾아가려는노력이필요할것으로생각된다. 결론모든검사가마찬가지지만, 확진이아닌진단에필요한보조수단으로서의역할과어지럼의진행에대해객관적인수치를기록하고제시할수있는검사로도움을줄수있으 42

7 이유재외 6 인. VEMP in Dizziness Patients 며, 일률적인전정기능검사에포함하기보다는충분한병력청취후에 VEMP 검사가의미있게나타날수있는질환을대상으로국한함이효율적이라고생각한다. VEMP가의미있는검사가될수있도록더많은노력이필요할것으로생각된다. 중심단어 : 전정유발근전위, 메니에르병, 전정신경염, 양성돌발성두위현훈 REFERENCES 1. Bickford RG, Jacobson JL, Cody DT. Nature of Average Evoked Potentials to Sound and Other Stimuli in Man. Ann N Y Acad Sci 1964;112: Didier A, Cazals Y. Acoustic responses recorded from the saccular bundle on the eighth nerve of the guinea pig. Hear Res 1989;37: Murofushi T, Curthoys IS, Topple AN, Colebatch JG, Halmagyi GM. Responses of guinea pig primary vestibular neurons to clicks. Exp Brain Res 1995;103: Ferber-Viart C, Dubreuil C, Duclaux R. Vestibular evoked myogenic potentials in humans: a review. Acta Otolaryngol 1999;119: Colebatch JG, Halmagyi GM. Vestibular evoked potentials in human neck muscles before and after unilateral vestibular deafferentation. Neurology 1992;42: Koo JW. Understanding of vestibular evoked myogenic potential and its clinical applications. Korean J Otolaryngol- Head Neck Surg 2004;47: Bae WY, Hwang CH, Heo SD, Lee TH, Jang YS, Ahn JK, et al. Vestibular evoked myogenic potentials produced by stimulation with 500 Hz-tone burst. Korean J Otolaryngol-Head Neck Surg 2006;49: Welgampola MS, Colebatch JG. Characteristics and clinical applications of vestibular-evoked myogenic potentials. Neurology 2005;64: Kim YJ, Shin JE, Yoon TH. Clinical characteristics and diagnostic value of electrocochleography according to group of unilateral Meniere's disease. Korean J Otolaryngol-Head Neck Surg 2002;45: Monsell EM. New and revised reporting guidelines from the Committee on Hearing and Equilibrium. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg 1995;113: Suh MW, Kim JS, Koo JW. Influence of blood pressure manometer feedback on the parameters of the vestibular evoked myogenic potential test. Ann Otol Rhinol Laryngol 2009; 118: Park SH, Cha CI, Kim KH, Kim H, Hwang MG, Hong NP. The clinical significance of vestibular evoked myogenic potential evoked by click sound. Korean J Otolaryngol-Head Neck Surg 2001;44: Kim KS, Kim BY, Choi SH, Lee JW, Seo SY. Click evoked vestibular myogenic potentials in normal subjects. J Clin Otolaryngol Head Neck Surg 2002;13: Murofushi T, Matsuzaki M, Mizuno M. Vestibular evoked myogenic potentials in patients with acoustic neuromas. Arch Otolaryngol Head Neck Surg 1998;124: Robertson DD, Ireland DJ. Vestibular evoked myogenic potentials. J Otolaryngol 1995;24: Sheykholeslami K, Murofushi T, Kaga K. The effect of sternocleidomastoid electrode location on vestibular evoked myogenic potential. Auris Nasus Larynx 2001;28: Wu CH, Murofushi T. The effect of click repetition rate on vestibular evoked myogenic potential. Acta Otolaryngol 1999; 119: Murofushi T, Curthoys IS. Physiological and anatomical study of click-sensitive primary vestibular afferents in the guinea pig. Acta Otolaryngol 1997;117: Young YH, Huang TW, Cheng PW. Assessing the stage of Meniere's disease using vestibular evoked myogenic potentials. Arch Otolaryngol Head Neck Surg 2003;129: Lee JC, Yoon TH, Chung JW, Ahn JH, Kim JY, Kim YK. Clinical usefulness of vestibular evoked myogenic potential in unilateral Meniere's disease. Korean J Otolaryngol-Head Neck Surg 2007;50: Rauch SD, Zhou G, Kujawa SG, Guinan JJ, Herrmann BS. Vestibular evoked myogenic potentials show altered tuning in patients with Meniere's disease. Otol Neurotol 2004;25:

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