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1 경희의학 : 제 30 권제 1 호 특 집 J Kyung Hee Univ Med Cent : Vol. 30, No. 1, 2015 특발성안면마비 : 구안와사 ( 口眼喎斜 ) Bell s Palsy 김종인 경희대학교한의과대학침구과교실 서 구안와사 ( 口眼喎斜 ) 는靈樞經筋篇에 足之陽明手之太陽筋急卽口目爲僻皆急不能卒視治皆如右方也 라고기재된 (1) 이래로역대여러한의학문헌에언급되어왔다. 口眼喎斜가입과눈에함께마비를보이는말초성안면마비를표현한것에반하여, 입주위만마비되는중추성안면마비는喎僻, 口僻, 口喎, 口急喎斜, 口禁眼合혹은口喎僻으로표현하여 (2) 역대의한의학문헌들도중추성과말초성의안면마비를구별하였다. 靈樞經筋篇은口眼喎斜의病機를 正氣가不足 하여絡脈空虛하고衛氣不固하여風邪가乘虛入中經絡하여氣血沮하고面部의足陽明經筋이失於濡養하여肌肉이縱緩不遂하여發病하게된다 고인식하였는데이를좀더현대적인의미로풀어본다면, 평소에체력저하로자극에대한저항력이약해진상태에서, 외부의병을일으키는어떤인자가몸에들어와風과같이급작스럽게얼굴의근육이마비된다는의미이다. 현대질환으로는스코틀랜드의해부학자이자외과의사였던 Charles Bell( ) 이기술한급성적으로온, 한쪽안면신경의기능이상으로인한특발성안면마비즉 Bell s palsy와일치한다. 론 책임저자 : 김종인, 경희대학교한의과대학침구과교실 Tel: , Fax: hann8400@hanmail.net 2013년건강보험통계질병소분류별입원다빈도상병급여현황전체에서보면국내안면신경장애발병환자는모두 7519명이고, 여자 4,244(56.4%) 가남자 3,275(43.6%) 보다약간높으며입원다빈도상병급여현황 ( 한방 ) 은특발성안면마비가속하는상병명인안면마비 (G51) 가진료실인원 5,090명, 진료비 4,796,133( 천원 ) 으로전체 13위를차지하고있다.(3) 본론 1. 감별진단 Bell s palsy는 72시간이내에한쪽얼굴근육이불완전하게혹은완전히마비되는원인불명의안면신경의마비이다. 안면신경은다른뇌신경들에비하여그주행이길고측두골내에서좁은골관을지나기때문에 Bell s palsy 이외에도, 대상포진바이러스, 중이및측두골의수술이나외상, 급만성중이염과진주종성중이염, 청신경종과수막종등종양으로인해서도안면마비가생길수있다.(4) 또한안면신경핵이하의중추성병변에서도이마의주름이소실되는말초성안면마비증상으로나타나기때문에주의를기울여야하며, 드물기는하나양측성마비를일으키는 Lyme disease와같은감염성질환이마비를일으키기도하므로감별진단을요한다.(5) Ramsayhunt syndrome은 herpes virus군의대상포진바이러스 - 9 -

2 경희의학제 30 권제 1 호 2015 Table 1. Etiologies and Clinical Features of Facial Paralysis [5] Condition Etiologic Agent Distinguishing Factors Autoimmune Guillain-Barre Autoimmune infectious Acute polyneuropathy; ascending paralysis; weakness of hands, feet progressing to the trunk Melkersson-Rosental syndrome Unknown Recurrent facial paralysis, swelling of face/lips, and fissures or folds in tongue Multiple sclerosis Unknown Abnormal neurologic examination with intermittent symptoms Sarcoidosis Unknown May be bilateral; laboratory abnormalities including angiotensin converting enzyme(ace) level Congenital Mobius syndrome Possibly viral Age(young), bilateral in nature, unable to move face or eyes laterally Endocrine Diabetes Microvascular disease Other signs and symptoms of diabetes, laboratory testing Idiopathic Acute facial nerve Unknown Classic Bell's palsy with other etiologies excluded paresis/paralysis Infectious Encephalitis/meningitis Fungal, viral, or bacterial Headache, stiff neck, cerebrospinal fluid abnormalities Herpes simplex Herpes simplex virus along axons of nerve residing in the geniculate ganglion Fever, malaise Human immunodeficiency virus (HIV) Lyme disease Human immunodeficiency virus (HIV) Spirochete borrelia burgdorferi Fever, malaise, CD4 count May be bilateral, rash, arthralgia Mononucleosis Epstein-Barr virus Malaise, difficult to distinguish Otitis media Bacterial pathogens Gradual onset, ear pain, fever, hearing loss Ramsay Hunt Syndrome Herpes zoster virus Pronounced prodrome of pain, vesicular eruption in ear canal or pharynx Syphilis Treponema pallidum Other neurologic and cutaneous manifestations Inherited Heritable disorders Autosomal dominant inheritance Neoplastic Facial nerve tumor, skin cancer, parotid tumors Multiple carcinomas of the head and neck Family history as high as 4%, may have other neurologic disorders May involve only select branches of the facial nerve or other cranial nerves and present as multiple cranial neuropathies Neurovascular Stroke Ischemia, hemorrhage Forehead sparing most often, extremities often involved Traumatic Injury to facial nerve Trauma, including forceps delivery Timing of injury coincides with trauma (Varicella zoster virus, VZV) 에의해발생하는데, 피부의감각신경을통해들어온바이러스가안면신경의후근신경절 (dorsal root ganglia) 에잠복하다가재활성화되어안면신경의피부절분포를따라통증및이상감각이초래되고외이도와이륜부에특징적인수포성발진이형성되는것이특징이다.(6) 그러나수포의발생이안면마비가생긴뒤수일에서수주후에지연되어나타나는경우도있으며, zoster sine herpete (ZSH) 바이러스가원인인경우에는피부에수포를형성하지않으므로주의를요한다 (Table 1). (7) 2. 증상안면신경은체성감각 ( 외이부의피부 ), 내장감각 ( 혀의앞 2/3와경구개와연구개 ), 수의적운동 ( 얼굴의모든표정근 ) 및부교감신경 ( 눈물샘, 침샘 ) 의 4가

3 김종인 : 특발성안면마비 : 구안와사 ( 口眼喎斜 ) Table 2. House-Brackmann Facial Nerve Grading System Grade Defined by 1 Normal Normal facial function in all areas. 2 Mild dysfunction Slight weakness noticeable only on close inspection. At rest: normal symmetry of forehead, ability to close eye with minimal effort and slight asymmetry. No synkinesis, contracture, or hemifacial spasm 3 Moderate dysfunction Obvious, but not disfiguring difference between 2 sides, no functional impairment; noticeable but not severe synkinesis, contracture, and/or hemifacial spasm. At rest: normal symmetry and tone. Motion: slight to no movement of forehead, ability to close eye with maximal effort and obvious asymmetry, ability to move corners of mouth with maximal effort and obvious asymmetry. Patients who have obvious but no disfiguring synkinesis, contracture, and/or hemifacial spasm are grade Ⅲ regardless of degree of motor activity. 4 Moderately severe dysfunction Obvious weakness and/or disfiguring asymmetry. At rest: normal symmetry and tone. Motion: no movement of forehead; inability to close eye completely with maximal effort. Patients with synkinesis, mass action, and/or hemifacial spasm severe enough to interfere with function are grade Ⅳ regardless of motor activity 5 Severe dysfunction Only barely perceptible motion. At rest: possible asymmetry with droop of corner of mouth and decreased or absence of nasal labial fold. Motion: no movement of forehead, incomplete closure of corner of mouth. Synkinesis, contracture, and hemifacial spasm usually absent. 6 Total paralysis Loss of tone; asymmetry; no motion; no synkinesis, contracture, or hemifacial spasm. 지성분의신경섬유로구성되어있다. 따라서특발성안면마비발생시에는입이한쪽으로삐뚤어지고, 눈을감을수가없으며, 이마에주름이지어지지않고, 귀뒤의통증이생기거나, 혀의맛을잘느끼지못하고, 얼얼한느낌이생길수있으며, 소리가과민하게들리기도하고, 눈물샘및침샘의분비에이상이생기게된다. 靈樞經筋篇에는風과寒의邪氣가虛를틈타얼굴의經筋을侵犯하여발생한다고하였는데임상적으로는피로등으로인해컨디션이좋지않다가며칠동안가벼운몸살이나감기증상후에얼굴마비가발생하는경우가많다. 또한 3개월에서 6개월사이에완전회복을보이지않았을때는안면근의이차적인구축 (contracture) 이일어나환측으로인중이치우치고안륜근의구축으로눈이작게보이며, 환측의경련이일어나며, 연합운동 (synkinesis) 이일어날수있다. 또한얼굴의표정은외모를판단하는데결정적인역할을 (8) 하므로표정근의이상은대인관계에도영향을주어삶의질뿐만아니라심할경우우울증에 (9) 이르기까지한다. 3. 전기진단학적검사안면신경손상의급성기에손상정도를알아보거나예후를알아보기위해시행하는전기신경검사는역치검사 (Nerve excitability test), 신경전도검사 (Electroneuronography), 침근전도 (Needle EMG), 안륜근반사검사 (Blink reflex test) 등이있다.(5) 손상으로인해생리적신경차단상태가된안면신경은축삭이보존되어있는경우자극의전도가가능한상태이나축삭절단이나신경절단이일어난안면신경은손상된원위부에서 Wallerian 변성이일어나전기적인유발자극을전달하지못하게된다. 신경전도검사는생리적신경차단과 Wallerian 변성을구분하여급성기에신경손상정도를전기생리학적으로분류할수있고전기자극에의해유발된근반응을객관적으로기록할수있으며이를정상측과비교할수있는장점이있다.(10) 신경전도검사시예후측정을위해서는 Wallerian 변성에의한원위부의이상을반영할수있는 72시간이후에검사를진행한다. 완전마비인

4 경희의학제 30 권제 1 호 2015 Table 3. Yanagihara s Unweighted Grading System Scale of five rating Scale of three rating At rest Wrinkle forehead Blink Closure of eye lightly Closure of eye tightly Closure of eye on involved side only Wrinkle nose Whistle Grin Depress lower lip 경우발병후 7일정도에신경손상이완성된다고알려져있다.(11) 유의할점은 14일이후의검사시에는신경재생이시작될수도있고변성부위주변의정상신경으로부터측부신경의신생이가능하기때문에신경손상을정확하게판단하는데어려움이있으므로발생후 3일이상 14일이내에검사를시행한다. 복합근활동전위가정상측에비해 10% 이상인경우완전회복혹은안면마비를거의인지하지못할정도로회복을보인다.(12-14) 김등의 (10) 보고에의하면 49명의한국인특발성안면마비환자중복합근활동전위가 20% 이하인경우 33% 만이완전회복을보였다. 침근전도검사는완전마비이면서신경전도검사상복합근활동전위가정상측의 10% 이하인경우에시행한다. 역치검사는검사역치의양측차가 3.5 ma 이상인경우에는불만족스러운예후를보이며,(15) 역치검사를시행하는시점이 3일이내인경우에는예후에관한정보를얻기어려운것 (16) 으로알려져있다. 4. 평가방법 (Grading system) 마비의정도를평가하는것은, 진단과치유과정그리고치료결과를판정한결과가의료인또는병원간정보교환에있어대단히중요한일이기때문에, 객관성과정확성이요구된다. 안면마비를평가할수있는많은분류법이개발되어사용되고있으며 Gold Standard 라고일컬어지는 House Brackmann 분류법 (H-B grade) 이보편적으로사용되고있다 (Table 2). H-B grade는안면마비연구에서대부분치료반응 을평가할때사용하는분류법으로 6단계로분류되어쉽고간편하게평가할수있다. 그러나 H-B grade는총괄법이므로 (gross scale) 각안면근육들의변화양상을상세히표시하는데에는어려움이따른다. 기존의연구들에서 H-B grade를이용하여치료반응을평가할때 Grade 1, 2에대해모두완치판정을내리고있는데김등의 (10) 연구에의하면 H-B grade 분류상 Grade 2는 Sunnybrook 척도상 96~58점으로다양하게분포하는것으로나타나마비정도를세밀하게분류하고등급간의균일함을나타내는데에제약이있다. Sunnybrook 척도는 (17) 1996년 Ross에의해만들어진분류법으로안정시와수의적인수축시근육의움직임정도및공동운동을각각점수별로표시할수있으며점수폭이 0~100점으로상세히연속적으로기술할수있다는장점이있다 (Table 3). 이분류법은기존의부위법 (regional grading system) 중많이쓰인 Yanagihara의척도가공동운동을고려하지못한단점을보완하였으나역시부위법의한종류이므로계산방법이복잡하여평가하는데많은시간이소요된다는불편한단점이있다 (Table 4). 또한, 안면마비가얼굴근육의마비뿐아니라정신적인영향을크게미치는점을감안하여 Facial Disability Index (FDI) 를개발하여사용하고있다. FDI는 (18) FDI-social score와 FDI-physical score의두개의 domain으로설문형식의 Likert 평가법이다. 특히 social score가있으므로안면마비의정신적영향을평가하는데있어유용하다 (Table 5)

5 김종인 : 특발성안면마비 : 구안와사 ( 口眼喎斜 ) Table 4. Sunnybrook Facial Grading System Summarized from Ross et al. Resting Symmetry of voluntary movement Synkinesis symmetry Movement No movement Slight movement Mild excursion Almost complete Movement complete None Mild Moderate Severe Eye Forehead Normal 0 Narrow 1 wrinkle Wide Eyelid Gentle 1 surgery eye Cheek (nasolabial fold) closure Normal 0 Open Absent 2 mouth Less pronounced 1 smile More pronounced 1 Mouth Snarl Normal 0 Corner Lip 1 drooped tucker Corner pulled 1 Up/out Composite score = 4 Voluntary movement score 5 Resting symmetry score 1 Synkinesis score Resting symmetry score : Voluntary movement score : Synkinesis score : Table 5. Facial Disability Index Physical function no difficulty How much difficulty did you haveusually did with a little difficulty some difficulty much difficulty usually did not do because for other of health reason 1) keeping food in your mouth moving food around in your mouth or getting food stuck in your cheek while eating? ) drinking from a cup? ) saying specific sounds while speaking? ) with your eye tearing excessively or becoming dry? ) with brushing your teeth or rinsing your mouth? Social functioning and well-being none of a little bit some of a good bit most of all of the time of the time the time of the time the time the time 6) How much time have you felt calm and peaceful? ) How much of the time did you isolate yourself from people around you? ) How much of the time did you get irritable towards those around you? ) How often did youwake up early or wake up several times during your nighttime sleep? ) How often has your facial function kept you from going out to eat shop or participate in family or social activities? *physical functioning score as percent functional ability = Total score(question 1-5) - (Number of questions answered) / (number of questions answered) * 25(%) ** Social functioning and well-being score as percent functional ability = Total score(question 6-10) - (Number of questions answered) / (number of questions answered) * 20(%)

6 경희의학제 30 권제 1 호 위험인자 Bell 마비의원인은특정할수없으나임신, 비만, 고혈압, 당뇨, 상기도의질병등이위험인자로알려져있다.(5) 발병연령은다양하나 15~45세사이에, 여성이남성보다빈발한다.(4) 242,000명의임신부를조사한후향적연구에서 42명 (0.017%) 이임신기간중 Bell 마비가발병하였으며임신중독증과관련이있다고보고하고있다.(19) 임상적으로寒이나風이위험인자로추정되는데미군을대상으로한연구 (20) 에의하면차가운날씨나기후가 Bell 마비의발병과관련이있다. 6. 눈의관리눈이불완전하게감기는경우눈의관리가필수적이다. 마비발생시안륜근의마비가동반되고눈물샘의기능이나눈물의생성에도이상이생기므로눈의자극증상과, 시리고, 가렵거나, 타는듯한느낌이나통증을호소하기도한다. 방치시각막의손상이나궤양이발생하기도하므로연고, 인공눈물의사용을권장하고테이프를이용하여눈을붙이고지내도록하며안과의의검진필요성을수시로점검하도록한다. 7. 부신피질호르몬 (steroid), 항바이러스제제 Bell 마비급성기치료에있어서부신피질호르몬과항바이러스제제에대해여러연구가있었고그치료효과에대하여여러논란이있었다.(21-24) 이들연구중근래에이루어진 Engstrom(22) 등의연구를살펴보면발병 72시간이내의 18세에서 75세사이의 829명의대상자를부신피질호르몬단독복용, 항바이러스제제단독복용, 스테로이드및항바이러스제병용혹은위약군으로무작위배정하여 1년동안관찰한결과부신피질호르몬을복용한 416명의환자는사용하지않은 413명의환자에비교하여완전회복에이르는회복율과걸리는시간에의미있는차이를보였다. 이연구이후로 72시간이내의급성기 Bell 마비환자에게는스테로이드사용이권장된 다.(24) 또한 acyclovir와 valacyclovir 등의항바이러스제제를단독사용하는것은유효하지않으며, 부신피질호르몬과병용하여사용하는것은부신피질호르몬단독요법에비해효과적일가능성 (25) 을보이므로임상적으로판단한다. 72시간이후의부신피질호르몬의사용은그효과에대해논란이있으며부신피질호르몬의일반적인부작용을고려하여당뇨, 임신, 15세이하의환자에대해신중히투여한다. 8. 물리치료기기를활용한치료안면부의혈액공급을자극하고근육의긴장을유지하며안면근육의위축을예방하기위해경피신경전기자극요법을이용한전기자극, Kabat rehabilitation과 Mime therapy 등의 exercise 요법, Biofeedback, massage, thermotherapy 등다양한물리치료방법 (8, 26-29) 이사용되고있다. Exercise 등이연합운동에효과적이라는보고도 (29) 있으나, 임상효과에대해서는제한적이다.(30) 9. 한의학변증분류및치방구안와사에대하여東醫寶鑑과이를요약한濟衆新編, 方藥合編에서治方을논하고있다. 東醫寶鑑에서는風門의분류즉 中腑中臟中血脈의분류중에中血脈에속한다 하고治方으로는淸痰順氣湯을제시하였다. 아직한약처방에대한임상적근거를볼수있는연구들이없어雜病의분류방식을통해서분류한다. 1) 외감형外感型은구안와사와함께惡寒發熱혹은頭痛이나耳後의痛症이심하게나타나는경우이다. 구안와사가麻黃湯이나桂枝湯혹은桂麻各半湯과같은外感形의완전한表證의형태로나타나는경우는없으므로, 表와表裏間의兼病중좀더表證이많이나타나는경우이다. 이病位에서는陰證만있게되므로牽正散加味, 理氣去風散加味方을사용하고虛證인경우에는雙和湯류가사용된다

7 김종인 : 특발성안면마비 : 구안와사 ( 口眼喎斜 ) 2) 내상형內傷型은구안와사가발병초기라하더라도表證의증상즉痛症이나惡寒, 신체의不和感등이심하지않고병의진행이緩慢한경우이며, 역시表證의증상이있으나 ( 구안와사가있으므로 ) 좀더內位즉表裏間에病位가위치하는형태이다. 이경우에는잡병에준해서辨證施治하면되며이경우도治方은兼病의구조를갖추어야한다. 東醫寶鑑에四物湯에牽正散을合方하여사용하는경우나當歸補血湯合桃紅四物湯加減을사용하는형태이고熱證의경우銀花瀉肝湯加味, 荊防敗毒散加味方이주로사용된다. 3) 慢性型 ( 後遺症型 ) 구안와사는후유증의관리가중요하다. 질병의특성상虛證일개연성이많고또한심리적인증상을호소하는경우가대부분이므로주의를기울여야한다. 기존의구안와사를논하는한의서는대개급성기의치료만을대상으로하기때문에만성형의치료에는기존의치료방법만을생각하기보다는새로운시각을갖고辨證한다. 특히심리적인문제를해결하는데주의를기울인다. 10. 침구치료및다양한자극방법을이용한치료법 1) 침요법연구동향침요법의 Bell 마비치료효과에대해다양한의견들이있으며 (3) American academy of otolaryngology- Head and Neck Surgery에서 2013년에수립한 Bell 마비임상진료지침에서는 (5) 침요법을권고하지않고있다. 그러나한의약이보편화되어있는국내나동아시아에서는한의약치료에대한선호도가높은편이며,(3) 우수한안전성이있어,(31) 임상적근거창출을위한다양한연구들이활발하게이루어지고있다. Chen 등이 (32) 2010년에 537명의환자를대상으로하는 6개의무작위배정임상연구를분석한결과에따르면 4개의임상연구는약물치료를대조군으로하였고 2개의연구는물리치료를대조군으로하였 다. 5개의연구가침요법단독으로이루어졌고 1개의연구에서약물치료와겸용하여약물치료만한대조군과비교하여침치료군이유의한회복을보인다고보고하였다. 그러나침연구에있어서, 근본적으로가지게되는한계인 blinding과 control group 설정미비로질적수준이낮은임상연구들로인해신뢰할수있는결론을얻지는못하였다. 이에저자가시행한체계적문헌고찰 (Systematic review) 에서는 (33) 8개의임상연구들을분석하였는데침치료만을시행한 4개의임상연구 (463명) 에서부신피질호르몬을복용한대조군보다 7% 높은회복률을보였다. 이는치료효과가높다고해석하기보다는부신피질호르몬이가지고있는효과정도를보인다고도해석할수있다. 또한 6개의임상연구들 (512명) 에서부신피질호르몬과침을겸용한군과부신피질호르몬만을사용한군을비교한결과는겸용한군이 11% 더좋은회복율을보이는것으로나타났다. 그러나기존의연구들이가지고있는문제점외에도 Bell 마비가급성기, 회복기, 후유증기등의단계적변화를보임에도불구하고이를동일하게다루고있고, 손상정도를고려하지않았던결과로신뢰할수있는결론을얻을수는없었다.(33) 이러한침임상연구의결점을보완하기위한연구들을살피면 900명의참여자를대상으로 3개의중국임상센터에서병기에따라 5가지침구요법들을비교한결과마비발생 1~3주간에침치료가그이후의치료보다효과를보인다고보고하였다.(34) 저자가발병 6개월이상된 39명의 Bell 마비후유증환자를대상으로 2개월간주 3회, 총 24회의침치료임상연구를한결과 (35) 침치료를받은환자중 88% 가마비증상이 20% 이상호전됐고, 안면근육강직정도도치료전보다약 40% 줄어들었다. FDI social sore는 24%, physical score는 22% 개선되었다. 2) 혈위선택을비롯한침의질역대문헌이나임상연구들에서다양한穴位가치료穴位로제시되고있는데, 한의임상지침에서는 (3) 地倉, 頰車, 陽白, 翳風, 下關과健側, 合谷을권고등급

8 경희의학제 30 권제 1 호 2015 A 로, 水溝, 四白, 觀髎, 巨髎, 列缺, 禾髎, 聽會를권고등급 B 로제시하고있다. 그러나임상연구설계시임상연구의특성상침치료처방은표준화과정을통해실제임상상황을반영하지못하는경우가대부분이고과학적이고체계적인연구설계에穴位선택을한질좋은임상연구가부족하다. 그러므로穴位선택을임상연구결과나진료지침에따라서만선택하는것이최선은아니며환자개개인의임상적특성에따라穴位선택이이루어져야한다. 치료부위만보더라도 東醫寶鑑 과歷代文獻은 右病左取左病右取 라하여巨刺法을제시하고있으나巨刺法을사용한임상연구는없다. 환자맞춤형치료방법을제시하고있는임상연구들도있으며,(32) 본저자는후유증환자들을대상으로하는임상연구에健側의地倉, 頰車, 患側의承泣, 魚腰, 絲竹空, 迎香, 兩側의翳風, 人迎, 手三里, 合谷, 足三里, 陽陵泉의 12개穴位를 25년이상 Bell 마비임상경험을가진경희의료원한방병원침구과교수 2명과의토론을통해결정하여사용하였다. 침치료의목적인得氣의유용성에대해得氣群 (167명), 非得氣群 (171명) 을대상으로하는 20회의침치료결과 (36) 6개월후완전회복률은得氣群이 9.8% 높은결과를보였으며圓方補瀉와提揷補瀉가다용된다. 비용대비효과측면에서중요한고려대상인침치료의횟수에관하여논하고있는문헌과임상연구는없다. 11. 다양한자극을이용한치료 1) 전침치료안면마비한방임상진료지침에서는 (3) 일반침치료단독시행보다는전침치료의시행을권고하고있으며 ( 권고등급 B), 이때파형의선택은소밀파 (Loose and dense wave) 보다는단속파 (Interrupted wave) 의적용을권고하고있다. 전침자극의유형및穴位는임상적으로고려하며소밀파의경우 2Hz~10Hz의교대적용이, 단속파의경우得氣와유사한감각을유발하기위해 1~5Hz 사이의주파수로 10~20분정도유침하여자극한다. 연결부위는안면근육의주요움직 임을고려하여贊竹 (BL2)- 絲竹空 (TE23), 四白 (ST2)- 下關 (ST7), 地倉 (ST4)- 頰車 (ST6), 水溝 (CV24)- 承漿 (CV26) 을選穴한다. 창 2) 뜸요법안면마비에뜸요법의적용은, 여타의일반질환과비교하면그용례및연구가적은데, 이는특히可燃性의치료도구가수반하는안면부의화상등의위험성때문으로보인다. Kwon 등이 (37) 灸管을이용하여地倉, 陽白뜸요법을병행시행하여높은호전율을보였으나통계적유의성이없었다. 치료선택시의이점에비해위험도가높은치료법이기때문에사용시각별한주의가요구된다. 3) 부항요법임상적으로안면마비증상자체의개선을위해부항요법을적용하는경우보다는, 주로이후통의경감을위해보조치료수단으로사용되는경우가많다. 이때에는患側의翳風에閃罐法혹은刺絡罐法을 3~5분정도적용한다. 4) 약침요법안면마비에대해蜂藥鍼 (Sweet Bee Venom), 紫河車藥鍼을중심으로中性瘀血藥鍼, 山藥藥鍼, 消炎藥鍼, 蜈蚣藥鍼등이시술되고있다. 蜂藥鍼은가장빈번하게시술되는데, 일정비율로희석된蜂毒藥液을주입하며, 患側의陽白, 顴髎, 地倉, 頰車, 翳風을중심으로한顔面部體鍼穴位를응용할수있다. 2~4 mm정도의깊이로한穴位당 0.01~0.05cc씩총시술량 0.1~0.3cc 사이에서적용할수있으나, 피시술자에따라다양한부작용 ( 쇼크, 시술시통증, 소양감, 현훈등 ) 에대한주의및이에따른시술용량조정에대해반드시고려해야한다. 사전에 0.05cc 정도를상완부穴位에주입하여반응을살피는 AST를반드시선행실시해야하며, 최초의시술시에는전신 즉시형과민반응및환자의불편을관찰하기위해 15~20분정도환자의상태를주의깊게살핀다. 紫河車藥鍼은 Lee의연구에서 (38) 일반한방치료와

9 김종인 : 특발성안면마비 : 구안와사 ( 口眼喎斜 ) 병행하여患側의陽白, 顴髎, 地倉, 頰車, 翳風, 絲竹空의穴位에대해각각紫河車藥鍼液 0.05cc씩총 0.3cc를주입한결과, 4주이상병행치료를하였을경우 Yanagihara score상유의한추가호전효과를나타내었다는결과가보고된바있다. 이외에도이후통을동반한안면신경마비의경우蜂藥鍼, 蜈蚣藥鍼, 消炎藥鍼을翳風에적용한연구들에의해유의한수준의통증강도및지속시간의감소를관찰, 환자의불편함을감소시켜주는효과가입증되었으나, 이것은안면마비증상자체에대한개선효과까지기대할수있는수준은아니다. 상기한다양한치료방법이외에도頭鍼療法, 耳鍼療法및發疱療法도사용되고있으나안전성에관한연구가충분하지않으므로각시술시에는임상의의신중한선택및주의가요구된다. 특히민간에서는안면마비에대해發疱療法의일환으로선피막이, 아주까리, 야생미나리등의약초를찧어서피부에붙임으로써살갗에火傷, 水疱를일으켜그자극으로치료를도모한다는서술이있으나이는직접적인치료효과가입증되지않았을뿐더러, 비위생적인환경에의한감염, 화상흉터발생등의부작용은현저하므로지양한다. 감사의글 우리병원안면센터가설립될수있는기초를닦아주신은사고형균, 김창환교수님께깊은감사의인사를드립니다. 또 다양한자극을이용한침요법항목의서술 에자료조사및기술에도움을준침구과전문수련의조대현선생님, 교정및 review를맡아준제자권효정박사와, 한국한의학연구원최지애선생님, 그리고부산대학교최준용교수님께감사드립니다. 참고문헌 1. 홍원식. 정교황제내경영추. 서울 : 동양의학연구원 1995; 김종인, 고형균, 김창환. 구안와사의평가방법에관한고찰 The Journal of Korean Acupuncture & Moxibustion Society 2001:18(2): EBM기반안면신경마비한의임상지침개발위원회 ( 한국한의학연구원, 대한침구의학회 ), 안면마비한의임상진료지침. 대전, 대한민국, Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002;122(549): Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg 2013;149(3 Suppl):S Kuhweide R, Van de Steene V, Vlaminck S, Casselman JW. Ramsay Hunt syndrome: pathophysiology of cochleovestibular symptoms. J Laryngol Otol 2002, 116(10): Furuta Y, Ohtani F, Mesuda Y, Fukuda S, Inuyama Y. Early diagnosis of zoster sine herpete and antiviral therapy for the treatment of facial palsy. Neurology 2000;55(5): Byrne PJ. Importance of facial expression in facial nerve rehabilitation. Current opinion in otolaryngology & head and neck surgery 2004;12(4): Valente SM. Visual disfigurement and depression. Plastic surgical nursing : official journal of the American Society of Plastic and Reconstructive Surgical Nurses 2004;24(4): ; quiz Ho-jung Kim B-jK, Seong-Beom Koh, Kun-Woo Park, Dae-Hie Lee, Seung Hwan Lee. The analysis of Treatment with Acyclovir and Prognostic Factors omn Idiopathic Facial Mononeuropathy Using Sunnybrook Scale. J Korean Neurol Assoc 2006;25(4): Tojima H, Aoyagi M, Inamura H, Koike Y. Clinical advantages of electroneurography in patients with Bell's palsy within two weeks after onset

10 경희의학제 30 권제 1 호 2015 Acta Otolaryngol Suppl 1994;511: Engstrom M, Jonsson L, Grindlund M, Stalberg E. House-Brackmann and Yanagihara grading scores in relation to electroneurographic results in the time course of Bell's palsy. Acta Otolaryngol 1998;118(6): Sinha PK, Keith RW, Pensak ML. Predictability of recovery from Bell's palsy using evoked electromyography. The American Journal of Otology 1994;15(6): Baba S, Kondo K, Kanaya K, Ushio M, Tojima H, Yamasoba T. Bell's palsy in children: relationship between electroneurography findings and prognosis in comparison with adults. Otol Neurotol 2011; 32(9): Laumans EP, Jongkees LB. On the Prognosis of Peripheral Facial Paralysis of Endotemporal Origin. The Annals of Otology, Rhinology, and Laryngology 1963;72: Campbell ED, Hickey RP, Nixon KH, Richardson AT. Value of nerve-excitability measurements in prognosis of facial palsy. Br Med J 1962; 2(5296): Neely JG, Cherian NG, Dickerson CB, Nedzelski JM. Sunnybrook facial grading system: reliability and criteria for grading. Laryngoscope 2010; 20(5): VanSwearingen JM, Brach JS. The Facial Disability Index: reliability and validity of a disability assessment instrument for disorders of the facial neuromuscular system. Phys Ther 1996; 76(12): ; discussion Katz A, Sergienko R, Dior U, Wiznitzer A, Kaplan DM, Sheiner E. Bell's palsy during pregnancy: is it associated with adverse perinatal outcome? Laryngoscope 2011;121(7): Campbell KE, Brundage JF. Effects of climate, latitude, and season on the incidence of Bell's palsy in the US Armed Forces, October 1997 to September American Journal of Epidemiology 2002;156(1): Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. Early treatment with prednisolone or acyclovir in Bell's palsy. The New England Journal of Medicine 2007;357(16): Engstrom M, Berg T, Stjernquist-Desatnik A, Axelsson S, Pitkaranta A, Hultcrantz M, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurology 2008;7(11): Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2009;7(4):CD Salinas RA, Alvarez G, Daly F, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2010;3:CD de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, Chen JM. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA 2009;302(9): Ross B, Nedzelski JM, McLean JA. Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope 1991;101(7 Pt 1): Mosforth J, Taverner D. Physiotherapy for Bell's palsy. Br Med J 1958;2(5097): Devriese PP. Treatment of sequelae after facial paralysis: a global approach. J Laryngol Otol 1998; 112(5): Beurskens CH, Heymans PG. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial. Aust J Physiother 2006;52(3): Ferreira M, Marques EE, Duarte JA, Santos PC

11 김종인 : 특발성안면마비 : 구안와사 ( 口眼喎斜 ) Physical therapy with drug treatment in Bell palsy: a focused review. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 2015;94(4): Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forschende Komplementarmedizin 2009;16(2): Chen N, Zhou M, He L, Zhou D, Li N. Acupuncture for Bell's palsy. Cochrane Database Syst Rev 2010(8):CD Kim JI, Lee MS, Choi TY, Lee H, Kwon HJ. Acupuncture for Bell's palsy: a systematic review and meta-analysis. Chinese Journal of Integrative medicine 2012;18(1): Li Y, Li Y, Liu LA, Zhao L, Hu KM, Wu X, et al. [Acupuncture and moxibustion for peripheral facial palsy at different stages: multi-central largeample randomized controlled trial]. Zhongguo zhen jiu=chinese acupuncture & moxibustion 2011;31 4): Kwon HJ, Choi JY, Lee MS, Kim YS, Shin BC, Kim JI. Acupuncture for the sequelae of Bell's palsy: a randomized controlled trial. Trials 2015; 16: Xu SB, Huang B, Zhang CY, Du P, Yuan Q, Bi GJ, et al. Effectiveness of strengthened stimulation during acupuncture for the treatment of Bell palsy: a randomized controlled trial. CMAJ : Canadian Medical Association journal = journal de l'association medicale canadienne 2013;185(6): Kwon SJ SH, Kim KH. The Influence of Moxibustion and Basic Compound Therapy on Peripheral Facial Paralysis. The Journal of Korean Acupuncture & Moxibustion Society 2000;17(4): Lee CW KH, Heo SW, Jung KK, Ahn CB, Song CH, Jang KJ, et al. The Clinical Study about Hominis Placenta Herbal Acupuncture on Facial palsy. Journal of Pharmacopuncture 2005;8(3):

13-09이성재

13-09이성재 대한응급의학회지제 23 권제 4 호 Volume 23, Number 4, August, 2012 원 저 응급실에내원한벨마비환자의스테로이드및항바이러스치료에대한임상적고찰 서울아산병원응급의학과 이성재 김형주 서동우 손창환 이재호 오범진 임경수 김원영 Analysis of Clinical Outcome and Effectiveness of Steroid and Antiviral