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1 Research in Vestibular Science Vol. 10, No. 2, June 2011 Original Article pissn , eissn 어지럼을주소로응급실에내원한환자의임상적고찰 한양대학교의과대학이비인후 - 두경부외과학교실 김기용, 민현정, 이승환, 박철원 Clinical Review of Dizziness Patients Who Visited Emergency Room Ki Yong Kim, MD, Hyun Jung Min, MD, Seung Hwan Lee, MD, Chul Won Park, MD Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea Received Mar 25, 2011 Revised (1st) May 4, 2011 (2nd) May 15, 2011 Accepted May 16, 2011 Corresponding Author: Seung Hwan Lee, MD Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, 17 Haengdang-dong, Seongdong-gu, Seoul , Korea T e l: Fax: shleemd@hanyang.ac.kr Copyright c 2011 by The Korean Balance Society. All rights reserved. Background and Objectives: As most dizziness symptoms are vaigue, and misdiagnosis of central dizziness can be life threatening, diagnosis of the dizziness is difficult. Especially, in the emergency room with a restricted environment, it must be more difficult. The aim of this study is to find out and correct the aspects requiring a modification for diagnosis in patients of dizziness who visited emergency room. Materials and Methods: The authors retrospectively have reviewed the charts of 458 patients with dizziness who visited the emergency room at Hanyang University Guri Hospital from April 2008 to March 2009 and researched the various informations such as diagnosis, clinical feature, physical findings, present illness, past history, consulted department, and visiting season, etc. Results: The average age of patients was 61 years old. Even though there was a difference at the diagnosis distribution between age groups, non specific dizziness and benign paroxysmal positional vertigo was the most frequent diagnosis. Checking the dizziness characters like whirling sense, autonomic symptoms and progressing features was important. And vestibular function tests such as nystagmus test and rotatory test like post head shaking or head thrust test were helpful for differential diagnosis of dizziness in emergency room. Patients with central vertigo were older (71.2 year) and had more past medical histories. But there was no seasonal frequency difference of dizziness. Conclusion: As at emergency room, the differential diagnosis of dizziness is important but difficult, integrated medical knowledge of several departments associated with dizziness is required. Research in Vestibular Science 2011;10(2):56-62 Key Words: Dizziness; Emergency room; Diagnosis 서론신체평형은주변환경에대한정보가내이미로, 시각기, 근육과관절의심부지각기등을통해뇌중추에서통합되고여기서나오는원심성지령이안구운동계와사지운동계의근육긴장도를반사적으로조절함으로써유지된다. 말 초혹은중추전정질환, 안과질환등의환자는이러한평형반사회로에혼란이발생되므로어지럼증상을호소하게된다. 그러나어지럼증상은신체평형과무관한심장질환, 소화기질환등에서도비특이적으로발생하므로다양한진료과목의료진의협진에도불구하고원인을찾아내지못하는경우도있다. 1 어지럼은환자의주관적증상을비특이적 56
2 김기용외 3 인. 어지럼을주소로응급실에내원한환자의임상적고찰 으로함축한단어로환자는회전감, 동요감, 암흑감등의다양한표현법으로본인의어지럼증상을설명하므로어지럼진단에있어서어지럼증상의성질과발작양상및경과, 동반증상과기왕력등을정확히확인한후필요한이학적, 신경학적검사를시행하는것이무엇보다중요하다. 2-4 그러나관련과목의모든의료진들이각기이러한방식으로시간을소요하면서진료한다면중복되거나불필요한진료등으로응급치료가필요한환자의치료시기를놓칠수도있다. 5 따라서저자는어지럼을주소로응급실에내원하는환자의인구역학적분석에서부터환자의증상양상그리고응급실이라는제한된상황에서도시행가능한어지럼검사법등을검토하여응급실에서의어지럼환자진료가보다효율적이고정확하게진행되는데도움이되고자본연구를시작하였다. 또한이연구를통해응급실로내원한어지럼환자의진료에있어서문제점을유추하고이에대한개선방안을강구하고자하였다. 대상및방법 2008년 4월부터 2009년 3월까지한양대학교구리병원응급실에내원한총 13,141명의환자중, 어지럼을주소로내원한만 15세이상성인환자 458명의차트를후향적으로검토하였다. 응급실당직의가문진을포함한초진을먼저시행하고이후연락을받은해당과목의사가추가검사, 진단및치료를진행하였기때문에당시이들에의해작성된의무기록을통해진단명을먼저확인하였다. 그러나응급실에서진단되지않았거나외래추적진료에서진단이변경된경우에는외래당시의최종진단명으로대체하였다. 먼저대상군을문진결과에따라현훈성어지럼군과비현훈성어지럼군으로나누었고이들을다시각각중추신경계관련어지럼 ( 중추성어지럼 ) 과말초전정기관련어지럼 ( 말초성어지럼 ), 그리고내과적, 안과적, 심인성, 진단미상의어지럼등의기타어지럼세군으로세분하여분석하였다. 의증인경우진단명에포함시켰으나전정기능검사상중추성어지럼이의심되더라도방사선학적으로확진될수있는질환의경우는이를통해확인된경우만포함하였다. 말초성어지럼중양성돌발성두위현훈의경우는안진이없더라도두위변화에의한현훈증상력이있었고증상이수분이내에회복되고반복되는양상이었을경우는진단에포함하였다. 또한메니에르증후군은미국이비인후과학회에서 1995년정의한진단기준에따라 definite 이상의경우만포함시켰 다. 어지럼감별진단에도움이될만한단서로연령및성별, 어지럼의증상양상및증후, 병력, 방문계절, 진료과목등을고려하였고이들변량의분포와진단과의상호관계를살펴보았다. 특히진료과목의경우여러과에연락되어협진된경우는가장진단에접근된과에서담당하였다고가정하였다. 분석은 SPSS ver (SPSS Inc., Chicago, IL, USA) 프로그램을이용하여 Chi-Square test와독립 T-test를이용하였고 p값이 0.05 미만인경우를통계학적으로유의한것으로판정하였다. 결과 1. 대상군분포 2008년 4월 1일부터 2009년 3월 31일까지어지럼을주소로응급실로내원한환자는 458명으로전체응급실내원환자 13,141명의 3.4% 의비율을차지하였고여자가 270명 (58.9%), 남자가 188명 (41.1%) 로여자가남자보다약간더많았다. 평균연령은 61세 ( 범위, 세 ) 로연령대별내원환자수는 60대가 93명 (20.0%) 으로가장많았다 (Figure 1). 2. 어지럼증상양상어지럼의증상양상중회전성여부에따라현훈성어지럼과비현훈성어지럼군으로분류하였고다시이들을각각중추성어지럼, 말초성어지럼, 기타어지럼의세군으로세분하였다 (Figure 2). 현훈성어지럼이 192명으로 42%, 비현훈성어지럼이 266명으로 58% 를차지하였다. 특히현훈성어지럼중에서말초성어지럼의경우는 151예로전체말초성어지럼환자의 78.6% 를차지하였고반면중추성어지럼은 6예로전체중추성어지럼환자의 11.1% 를차지해회 Figure 1. Age distribution of dizziness patients at emergency room. 57
3 Res Vestibul Sci Vol. 10, No. 2, Jun Nystagmus classification Gaze nystagmus direction. Sp or Ga Po None Central Peripheral Etc Change + Change - Central Peripheral Visual fixation Rotatory test Fix + Shaking + Figure 2. Distribution of central, peripheral and Etc dizziness according to the true rotating sign. Fix - Central Peripheral Thrust + Central Peripheral Aggravate Continue Dissappear Sx changing pattern Central Peripheral Etc Auto Sx + Auto Sx - Autonomic Sx Central Peripheral Etc Figure 3. Distribution of central, peripheral and Etc dizziness according to the dizzy symptom changing pattern and autonomic symptom. Sx, symptom. 전성어지럼증상은통계적으로유의하게말초성어지럼과관련이높은증상이었다 (p=0.039). 총어지럼환자중오심, 구토, 안면창백등의자율신경자극증상을호소하는경우는 202예 (44.1%) 이었고비현훈성어지럼보다현훈성어지럼을보인환자에게서 (p=0.037), 중추성어지럼과기타어지럼군에비해말초성어지럼군에서통계학적으로유의하게자주발생하는증상이었다 (p=0.042). 응급실내에서의어지럼증상경과양상에따라환자를치료후호전되어귀가하는경우, 완전히호전되지않았지만진단된상태로귀가하는경우그리고악화되거나입원하게된세가지경우로분류할때현훈성어지럼과비현훈성어지럼군사이의통계학적차이는없었지만중추성어지럼군에서는통계적으로유의하게말초성어지럼군과기타어지럼군에비해악화되거나입원한환자의경우가많았다 (p=0.031) (Figure 3). 3. 전정기능검사 안진은총 458명의환자중 103명의환자에게서 (22.4%) 관찰되었다. 안진을보인 103명의환자중뇌경색환자 1명 Figure 4. Vestibular function test - nystagmus and rotatory test. Sp, spontaneous; Ga, gaze; Po, positioning; Fix, fixation; Shaking, post head shaking test; Thrust, head thrust test. 을제외한 102명의환자들은모두회전성어지럼을호소하여안진과회전성어지럼사이의상관관계는높게나타났다 (p<0.001). 자발안진이나주시안진의형태를보인경우가 63명 (13.8%), 두위변환안진 (positioning nystagmus test) 의형태를보인경우가 40명 (8.6%) 이었다. 특히자발안진이나주시안진을보인 63명의환자중 56명이전정신경염 46명, 메니에르증후군 6명, 돌발성감각신경성난청 3명, 내이염 1명의분포로말초성어지럼으로진단되었고, 두위변환안진을보인환자 40명의환자는모두말초성어지럼인양성돌발성두위현훈으로진단되어안진은말초성어지럼군에서중추성어지럼이나기타어지럼군보다통계학적으로유의하게자주나타나는증후였다 (p=0.012). 그러나자발안진유무와상관없이주시안진방향이주시방향에따라변경되었던 7명의경우는모두중추성어지럼으로진단되어주시안진의방향변화는안진관찰시반드시함께확인해야할사항이었다. 자발안진을보인 50명의환자중시선고정억제 (visual fixation suppression) 가시행된경우는총 34명이었고 28명에서시선고정억제양성소견을보였다. 말초성어지럼의경우시행된 31명중 28명에서시선고정억제에양성소견을보였으나중추성어지럼의경우시행된 3명모두음성소견을보였다. 진단별로는전정신경염환자의 95.8%, 메니에르증후군환자의 85.7% 에서자발안진이나타나안진이진단에도움이되기도하였으나양성돌발성두위현훈환자의경우 34.5% 에서만두위변환안진이나타나안진보다는증상의성질과발작양상, 경과등을통해서의증으로진단되는경우가더많았다. 자발 주시 두 58
4 김기용외 3 인. 어지럼을주소로응급실에내원한환자의임상적고찰 위변환안진이모두관찰되지않거나불명확했던경우에는추가로두진후안진검사 (post head shaking test) 와급속회전검사 (head thrust test) 등의회전검사가응급실에서시행되었다. 안진이없었거나불명확했던 355명의경우만을분석할때, 두진후안진검사상양성소견을보였던경우는 17명으로이중에서 15명은말초성어지럼으로나머지 2명은중추성어지럼으로진단되었고급속회전검사의경우양성소견을보였던경우는 12명으로모두말초성어지럼군의환자였다 (Figure 4). 4. 진단별분포 진단별환자군분포를조사한결과상세불명의어지럼 167예 (36.5%), 양성돌발성두위현훈증 116예 (25.3%), 전정신경염 48예 (10.5%), 뇌경색18예 (4.0%), 부정맥 18예 (4.0%) 등의순서를보였다 (Table 1). 남녀를구분지어조사한결과에서도상위 4순위까지는전체진단분포와동일한순서를보였다. 연령군에따른질환분포차이를알아보기위해 30대미만, 30대와 40대, 50대와 60대, 70대이상으로환자를다시분류해보았다. 30대미만에서는기타상세불명의어지럼, 양성돌발성두위현훈증, 미주신경성어지럼, 편두 Table 1. Prevalence of dizziness according to the subgroups Subgroups of dizziness (%) Diagnosis (%) Central dizziness (11.8) Cerebral infarction (3.9) Migrane (2.6) Transient ischemic attack (1.1) Vertebrobasilar insufficiency (1.1) Cortical vertigo syndrome (1.1) Epilepsy (1.1) Cerebral hemorrhage (0.9) Peripheral dizziness (39.5) Benign paroxysmal positional vertigo (25.3) Vestibular neuronitis (10.5) Sudden hearing loss (2.0) Meniere s disease (1.5) Labyrinthitis (0.2) Etc. (48.6) Arrhythmia (3.9) Psychogenic dizziness (2.2) Vasovagal syncope (1.5) Gastrointestinal bleeding (1.1) Cervical vertigo (1.1) Anemia (0.9) Ophthalmologic disease (0.9) Coronary artery disease (0.6) Non specific dizziness (36.5) 통, 빈혈순이었고, 30대와 40대에서는기타상세불명의어지럼, 양성돌발성두위현훈증, 전정신경염, 심인성어지럼, 부정맥순이었으며, 50대와 60대에서는양성돌발성두위현훈증, 기타상세불명의어지럼, 전정신경염, 뇌척수기저동맥부전증, 뇌경색순이었고 70대이상에서는기타상세불명의말초성어지럼, 양성돌발성두위현훈증, 뇌척수기저동맥부전증, 뇌경색, 전정신경염순서를보여연령별로다소원인질환의분포차이를보였다 (Table 2). 현훈성어지럼군과비현훈성어지럼군의평균나이의차이는통계학적으로의미가없었지만, 중추성어지럼 54명의평균나이는 71.2세, 말초성어지럼 181명의평균나이는 58.8세, 기타어지럼 223명의평균나이는 60.3세로통계적으로유의하게중추성어지럼군의나이가많았다 (p=0.047). 환자과거력상어지럼과관련있을수있는상병으로고혈압 121예, 당뇨 56 예, 심질환 11예, 뇌혈관계질환이 20예있었고각각전체어지럼환자의 26.4%, 12.2%, 2.4%, 4.4% 를차지하였다. 상기과거력이있는경우에서없는경우보다중추성어지럼의비율이통계적으로의미있게높았다 (p=0.033) (Figure 5). 어지럼질환의월별분포를볼때중추성어지럼은가을인 9, 10, 11월에총 98예중 30예로가장많았고말초성어지럼은겨울인 12, 1, 2월에총 181예중 55예로가장많았으나계절별로나누어볼때중추성이나말초성어지럼이어느 Table 2. Prevalence of dizziness according to ages Age (yr) Diagnosis (%) <30 Non specific dizziness (32.3) Benign paroxysmal positional vertigo (15.7) Vasovagal syncope (10.0) Migrane (8.6) Anemia (3.2) Non specific dizziness (30.9) Benign paroxysmal positional vertigo (21.2) Vestibular neuronitis (13.2) psychogenic dizziness (5.4) Arrhythmia (4.6) Benign paroxysmal positional vertigo (30.2) Non specific dizziness (28.4) Vestibular neuronitis (15.4) vertebrobasilar insufficiency (9.7) Cerebral infarction (6.5) >70 Non specific dizziness (31.5) Benign paroxysmal positional vertigo (27.3) vertebrobasilar insufficiency (10.8) Cerebral infarction (10.1) Vestibular neuronitis (9.3) 59
5 Res Vestibul Sci Vol. 10, No. 2, Jun Consulted department (%) Central Peripheral Medical history histroy + Medical history - Figure 5. Distribution of central and peripheral dizziness according to medical history. Medical history: hypertension, diabetic mellitus, cardiac disease, neurologic disease. 특정계절에많다는가설은통계학적으로의미가없었다. 5. 진료시간및진료과목 ENT NR IM ED NS NP Figure 6. Consulted department for dizziness patients at emergency room. ENT, department of otolaryngology; NR, neurology; IM, internal medicine; ED, emergency department; NS, neurosurgery; NP, neuropsychiatry. 환자들은진단을위해평균 2.94 진료과목의료진의진료를받았다. 두과목이상의협진이필요했던환자가 262명 (57.2%) 이었고가장많은비율을차지한이비인후과역시타과목과함께진료를시행한경우가 144예 (60.2%) 이었다. 어지럼증상발생후응급실도착까지걸린시간을 3시간이내, 3시간에서 6시간이내, 6시간에서 1일이내, 1일에서 3일이내, 3일에서 1주일이내, 1주일이상의 6개의군으로나누어볼때 6시간에서 1일이내가 252예 (55.0%) 로가장많았고중추성어지럼군과말초성어지럼군의시간별분포양상은큰차이를보이지않았다. 응급실전체환자에서내원시간으로부터치료후퇴원하거나입원이결정되기까지걸린시간의평균이 168분이었던것에반해어지럼증환자의경우는평균 251분으로전반적으로진단및치료에있어서상대적으로많은시간이소요되었다. 응급실에내원한총 458명의환자중경과관찰 1년내에응급실을재내원한환자는 28명 (6.1%) 이었다. 동일상병으로재내원한환자가 25명이었고나머지 3명의환자는말초성어지럼에서중추성어지럼으로진단이바뀌었다. 또한응급실진료후입원치료를지속하거나퇴원후같은진단명으로외래에서다시진료를받은환자는 226명 (49.3%) 으로중추성어지럼환자의경우 87.0%, 말초성어지럼환자의경우 27.1% 를차지해통계학적으로유의하게중추성어지럼환자가말초성어지럼환자에비해응급실내원이후지속적인진료가이루어진경우가많았다 (p=0.023). 응급실당직의의초진후에연락되어주된진료역할을한과목은이비인후과 239예 (52.1%), 신경과 77예 (16.8%), 내과 69예 (15.0%), 응급의학과 41예 (8.9%), 신경외과 21예 (4.8%), 신경정신과 11예 (2.4%) 순이었다 (Figure 6). 어지럼 고찰어지럼증은모든연령대에걸쳐병원을찾게되는가장흔한증상중에하나로유병률이전체인구의 20-30% 정도이다. 6,7 남자보다는여자에서, 청장년층보다는고령층에서유병률이높다고보고되고있으며 8-10 특히 College 등 11 은나이가 5세증가할때마다어지럼유병률이 10% 씩증가한다고보고하였다. 그러나소아의경우어지럼증의빈도가낮을뿐아니라어지럼증자체보다는구역및구토등다른부대증상으로소아과진료를시행한경우가많아전체유병률계산에오류를일으킬가능성이높아보여본연구에서는조사도중제외하였다. 본연구에서어지럼을주소로응급실을내원한환자는전체응급실연인원의 3.4% 를차지하였고여자 58.9%, 남자가 41.1% 로여자가다소많았으며연령대별로분류할때 60대이상이 46.2% 로높은분포를나타내기존연구와유사한결과를보였다. 어지럼감별진단에서환자의증상에대한정확한문진과이에따른신체검사가무엇보다중요하다는보고가많다. 4,5 문진에는어지럼의성질, 시간적인경과양상, 수반증상, 원인인자가될수있는기왕력이반드시포함되어야한다고보고된다. 5 본연구에서도문진결과현훈성향을보이는경우, 시간경과에따라호전되는양상일경우, 그리고오심, 구토나안면창백과같은자율신경계증상이동반되는경우에는말초성어지럼의비율이의미있게높았고고령인경 60
6 김기용외 3 인. 어지럼을주소로응급실에내원한환자의임상적고찰 우나, 심혈관이나뇌혈관질환의위험요소로알려진기왕력이있는경우에는중추성어지럼의비율이높았다. 또한 Neuhause 12 나 Karatas 13 의연구에서와같이본연구에서도어지럼질환은연령별로분포차이를보였다. 그러나심혈관이나뇌혈관질환은추운겨울철에많이발생하고전정신경염, 미로염등의말초성전정질환등은봄이나환절기에높은빈도로나타난다는보고들과는달리본연구에서는중추성어지럼과말초성어지럼의계절별발병차이는없었다. 14,15 그러나이번연구가 1년기간동안만진행되었기때문에어지럼의계절별차이는더장기간의조사가필요할것으로생각된다. 본연구에서응급실에서시행할수있는전정기능검사로안진검사와회전검사가시행되었다. 자발안진이나두위변환안진, 시선고정억제에서양성반응을보이는경우는말초성어지럼에서보이는특징이고주시안진검사에서안진의방향이주시방향에따라변경되는경우는중추성어지럼에서나타나는특징임이응급실환자를대상으로한본연구에서도통계적으로유의한것으로확인되었다. 또한두진후안진검사나급속회전검사등의회전검사역시응급실에서의말초성과중추성어지럼감별진단에도움이되었다. 그러나이러한안진과회전검사등이진단에보다유용하게사용되기위해서는이비인후과와신경과, 안과등관련된과목들의정형화된안진검사법과회전검사의습득이우선시되어야할것으로생각된다. 16,17 저자는본연구를통해응급실에서의어지럼환자진료시개선되어야할사항을고려해보았다. 어지럼환자가응급실에내원하여진단및치료가이루어져귀가하거나입원치료가결정되어일차적인응급실진료를완료받기까지소요되는시간이타질환에비해오래걸렸던원인에대해생각해보았다. 물론어지럼환자진료의난해함때문에협진이필요한경우가많았던것도이유가되겠지만협진등으로많은진료시간을소요하였음에도확진되지않고상세불명의어지럼으로진료받은환자가 36.5% 로상당수를차지했다는것에대해서는다시생각해볼필요가있다. 또한 25.3% 의높은비율을차지했던양성돌발성두위현훈증환자도 65.6% 의경우에서두위변환안진검사를통한확진이아닌문진등을통해의증으로진단되었다는것도함께고려할문제로생각되었다. 이는의료진이응급실특성상중추성어지럼을배제하기위한검사들을우선적으로시행하고질환이환자의생명과직결되지않고진단이난해하다는이유로말초성어지럼군내에서는더이상의확진을위한 검사를진행하지않는경향이있었기때문이라생각된다. 특히진료시간지연및비용을염려하여환자가진단과정없이대증적치료만을원했던경우에이들환자의대부분이진훈제, 진토제등의대증적약물및수액치료만으로도호전되어귀가했던경과양상을고려해보면상세불명의어지럼의상당수가말초전정기능장애와관련된어지럼증이라고추정할수있다. 응급실어지럼환자진료에있어서질환의합병증을고려할때중추성어지럼의감별이무엇보다중요하겠으나, 적절한치료로보다좋은예후를기대할수있는말초성어지럼의정확한진단역시중요하다. 18 병원마다응급실어지럼진료에있어서주된역할을하는진료과목이다를수있으나어지럼증의감별진단에있어가장효과적인방법은제외에의한방법보다포함에의한방법이라고강조한보고 19 등을고려할때, 응급실어지럼진료는어지럼을통합적으로잘이해하고있는의사의정확한병력청취와신경, 이과적검진을통해이루어지는것이가장효율적일것으로생각된다. 그러나본연구는단일지역사회의단일병원에서이루어진검사로연구대상군의선택편위 (selection bias) 가작용되었을가능성이있고응급실환자만을대상으로하였기때문에일반어지럼환자에적용하는데는주의가필요할것으로생각한다. 결 응급실을방문한어지럼환자를정확하게진단하기위해다양한전문과목의협진이필수적이지만비효율적인협진은오히려중추성어지럼의치료시기를늦추게할수있으며, 확진후치료가능한말초성어지럼의진단을방해할수도있다. 병력청취와신경이과적검사는응급실에서의어지럼감별진단에있어서중요한단서를제공하므로어지럼환자진료에참여하는모든의료진들은이를놓치지않도록어지럼질환들의특성을포괄적으로고려한체계적인어지럼진단방법을함께정립하고습득해야할것이다. 론 중심단어 : 어지럼, 응급실, 진단 REFERENCES 1. Dieterich M. Dizziness. Neurologist 2004;10: Crespi V. Dizziness and vertigo: an epidemiological survey and patient management in the emergency room. Neurol Sci 2004;25 Suppl 1:S Turner B, Eynon-Lewis N. Systematic approach needed to 61
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