ORIGINAL ARTICLE Korean J Clin Lab Sci. 2018;50(3):267-274 https://doi.org/10.15324/kjcls.2018.50.3.267 pissn 1738-3544 eissn 2288-1662 Korean J Clin Lab Sci. Vol. 50, No. 3, September 2018 267 Analysis of the Factors Affecting Canalith Repositioning Maneuver Treatment of in Posterior Canal Benign Paroxysmal Positional Vertigo of a Dizziness Patient Chul-Seung Kim Department of Clinical Laboratory Science, Mokpo Science University, Mokpo, Korea 뒤반고리관양성발작성두위현기증어지럼증환자이석정복술치료에영향을주는인자분석 김철승 목포과학대학교임상병리과 Posterior canal benign paroxysmal positional vertigo (PCBPPV) is the most common disease among patients who visited the st. Carollo hospital dizziness center with the head suddenly feeling rolling or rotational dizziness caused by head and body movements. Most patients showed improvements in symptoms after a single treatment. On the other hand, there are more causes requiring multiple treatments. This study examined the factors affecting the canalithiasis repositioning maneuver for symptom recovery of dizziness, which is posterior BPPV. Dizziness patients who visited the dizziness center of PCBPPV were classified. From March 2008 to November 2010, the cure rate of 165 posterior BPPVs patients was investigated. The success rate after the first, second, third, and further treatments was 57.6%, 17.6%, 10.3%, and 14.5%, respectively. The factors affecting treatment of PCBPPVs included traumatic, medical disease, cerebral infarction, small vessel disease, vestbro basilar artery insufficiency (VBI), cerebrovascular disease, brain disease, and vestibuloplasty (P<0.05). Vomiting, nausea, and syncope can be treated easily by considering the factors affecting these treatments. If the related diseases are combined with the treatment of the canalithiasis repositioning maneuver for symptom recovery of dizziness, the results will show an improvement in daily life that is free from painful dizziness. Key words: Canalith repositioning maneuver, Posterior canal benign paroxysmal vertigo, Post-traumatic, Vestbro basilar artery insufficiency, Vestibulopathy Corresponding author: Chul-Seung Kim Department of Clinical Laboratory Science, Mokpo Science University, 413-1 Yeongsan-ro, Mokpo 58644, Korea Tel: 82-61-270-2732 Fax: 82-61-279-8838 E-mail: hippo48@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2018 The Korean Society for Clinical Laboratory Science. All rights reserved. Received: August 13, 2018 Revised 1 st : August 28, 2018 Revised 2 nd : August 30, 2018 Accepted: August 30, 2018 서론뒤반고리관양성발작성두위현기증 (posterior canal benign paroxysmal positional vertigo, PCBPPV) 은어지럼중가장흔한질환으로팽대부릉이정상적인상태에서내임파액과동일한중력을기때문에회전가속도에서만반응하던반고리관이 생리학적변화를일으켜팽대부릉과내임파액의중력의차이가발생하여선형가속도에서반응하게된병적상태를말한다 [1]. 흔히일상생활하는도중빙빙도는느낌, 오심, 구토등의어지럼증을호소하는환자들이많은데대부분빈혈, 기립성저혈압, 뇌질환이라고생각하고약물치료만계속하면서어지럼증을계속호소하는경우가있다.
268 Chul-Seung Kim. Factors Analysis Affecting Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo 귀쪽에존재하는이석이라는소금덩어리가반고리관내에들어가평형반이약화되어어지럼증을나타나는경우가흔하다. 이러한대표적인질환이 PCBPPV 로서환자들은잠자리에눕거나일어날때, 선반에서물건을꺼내려고올려볼때, 몸을앞으로구부릴때지속시간이 30초이내또는수분이상지속적으로어지럼증을호소한다. 회전성어지럼증이외에많은환자들이쓰러질것같은느낌, 떠다니는느낌, 구역질나는느낌, 머리움직임에대한공포를호소한다 [2]. 위와같은증상을호소하는환자에대하여 Dix-Hallpike 검사로뒤반고리관형양성발작성두위현기증진단후 Figure 1과같은애플리이석정복술 (epley maneuver, EM) 을시행하였다 [3]. 국내보고에따르면변형된 EM을통하여 96 100% 의치료율을보고하고있으며 [4, 5], 그외에도많은연구에서이석치환술의효과를입증한바있다. 치료를끝내는시점은검사에의한눈떨림및어지럼증세가완전히사라졌을때이다 [6]. 이후항어지럼약물투여군, 이석치환술만행한군과약물투여와이석치 Figure 1. Epley maneuver (right ear). The patient is seated on a table as viewed from the right side. (A) Patient in norma Dix-Hallpike head-hanging position, then rotated toward the opposite side with the neck in full extension through position (B) and into position (C) in a steady motion by rolling the patient onto the opposite lateral side and then the patient sits back up to position (D) [3]. 환술을동시에행한군을비교한연구에서이석치환술군과약물과치환술을동시에행한군이약물만투여한군보다유의성있게치료율이더좋았으며치환술만행한군과약물과치환술을동시에행한군사이에는치료율의차이에유의성이없었다는보고가있다 [7]. 대부분양성발작성두위현기증에의한어지럼증환자들은어지럼증에의한극심한공포와제대로된일상생활을영위할수없을정도로어지럼증을호소한다. 양성발작성두위현기증에의한어지럼증으로진단될경우간단한치료방법으로바로어지럼증에서벗어날수있지만, 계속재발할경우가있고반고리관별로재발하는원인들이다양하다. 이에치료후에도어지럼증을재발되는원인분석을통해치료예후인자를고려한치료를통해많은어지럼증환자의치료에도움을줄수있을것이다. 재료및방법 1. 검사및진단방법 2008년 3월부터 2010년 11월까지전남순천성가롤로병원어지럼증센터내원한어지럼증환자에게비디오눈떨림검사를통해진단된 PCBPPV 환자 165명을대상으로치료횟수와양성발작성두위현기증과동반된질환에의한어지럼증지속여부상관성을분석하였다. PCBPPV 진단을위해 Dix- Hallpike 검사를시행하였고검사전에환자에게심한어지럼이발생할수있음을설명하고검사중에는되도록중앙을응시한채눈을뜬상태를유지하게하였다. 검사는앉은자세에서환자의머리를병변쪽으로 45 돌린상태로환자를눕히고머리를뒤로 20 정도낮게유지한후눈떨림을관찰한다. 뒤반고리관환자에서 Dix-Hallpike 검사시유발되어나타나는눈떨림의특징은잠복기는대부분 2 20 초정도이나드물게는 1분정도걸리는경우도있어눈떨림이나타날때까지자세를유지하고관찰하는것이좋다. 눈떨림의방향은상향이고눈동자의최첨부가바닥으로향하는회전양상의혼합성눈떨림이관찰된다. 또한눈떨림의강도는시작은약하게점차강도가증가하다다시약해지며사라지는눈떨림이특징이다. 눈떨림이발생하면환자는주관적인어지럼을느끼게된다. 일어나앉을때반대방향의눈떨림의역전과어지럼증이흔하게동반되고, 몸변환검사가반복될시눈떨림의강도가약해지고결국은관찰되지않는피로현상이관찰된다 (Figure 2) [8]. 또한몸이나머리의위치를변환시켜서반고리관내에존재하는이석이평형반을흥분시켜눈주위의근육을자극하여특이한눈떨림을감지하기위하여프렌즈안경을착용하게하였
Korean J Clin Lab Sci. Vol. 50, No. 3, September 2018 269 Figure 2. Dix-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 eyes for nystagmus [2, 8]. Figure 3. Video nystagmus test. nystagmus detect the eyes movement by wearing french goggles, the front of sensor to detect and monitor the location of the vertical and horizontal position of the eyes to detect movement up, down, left and the side is represented by display in graphy. 고, 고글앞쪽의센서가눈동자의위치를감지하고두위의변환시어지럼이유발되는병력의환자가특징적인눈떨림이유발되고, 수직수평으로눈동자의위치를감지하여좌우상하로움직이는눈떨림을그래프로기록될시, 뒤반고리관양성발작성두위현기증을진단하였다 (Figure 3) [5]. 연구에참여한모든대상자의선정에윤리적인절차를거쳐연구자가직접연구의목적을설명하고연구방법및참여기간, 부작용및위험요소, 개인정보와비밀보장, 중도탈퇴할수있음에대한내용을공지하고각각의서면사전동의를얻어연구를수행하였다. 비디오눈떨림검사장비로검사를통하여뒤반고리관형양성발작성두위현기증을진단하였다. 2. 치료방법 PCBPPV로진단된경우 EM을시행하였고 (Figure 1), 어지럼증치료약물을처방하였다. EM을시행할때앉은자세에서 병변쪽으로 Dix-Hallpike 자세를취한후눈떨림을관찰한다. 이후천천히머리를반대쪽으로 90 돌리고, 고개는최대한신전된상태를유지한다. 이어서몸전체와머리를 90 반대쪽으로누운다음, 바로앉은자세를유지한채눈떨림을확인하다. 이때관찰되는눈떨림이초기 Dix-Hallpike 시와동일하다면, 이석이공통각을통하여타원주머니로가고있음을유추할수있고치료가성공적임을추정할수있다. 보통, 각단계별로자세를 1 2 분정도유지하거나, 눈떨림이사라지는시점까지자세를유지시켜야하고, 한번의치료가 5분정도의시간이걸리며, 치료후 24 48 시간동안눕지않을것을환자에게주지시켜야한다 (Figure 1) [2, 8]. 이석정복술후다음날부터는정상적인생활을하도록하였다. 환자는 2일에서 1 2 주후에다시내원하여어지럼증의주관적증상이있는지여부를확인하여비디오눈떨림검사를통해눈떨림유무를확인하였다. 특징적인눈떨림이소실한경우를치료성공으로보았다. 만약주관적어지럼증이존재하고비디오눈떨림검사를통해눈떨림이남아있는경우는다시이석정복술을시행하였고, 다시어지럼증이발생할경우방문하도록하였다. 입원환자의경우매일어지럼증유무를체크하여눈떨림이소실될때까지이석정복술을시행하였다. 어지럼증센터에내원할때마다비디오눈떨림검사장비로눈떨림유무를판정하여치료횟수를산정하였다. 3. 관찰항목임상양상분석은 PCBPPV의치료성적분석, 이석정복술후치료실패요인에대한분석을시행하였다. 관련예후인자별로외상유무, 뇌쪽질환유무, 메니에르및두통, 편두통, 중이염, 안뜰신경염, 당뇨, 고혈압의유무등을조사하였고, 치료전증상의
270 Chul-Seung Kim. Factors Analysis Affecting Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo 지속시간-치료성적에미치는영향을통계적분석인 SPSS version 18.0, SPSS Inc., Chicago, IL, USA를이용하여기술통계량 (descriptive statistics) 에서교차분석 (cross table) 을통해람다 ( ) 값을통해근사유의확률을구했다. 근사유의확률은 P< 0.05 미만일경우통계적으로유의하다고판정하였다. 결과 뒤반고리관양성발작성두위현기증을일으키는원인인자에대하여살펴보면원인이미상인경우가 79례 (47.9%), 머리등외상후 20례 (12.1%), 고혈압, 당뇨, 신부전등내과적인질환을동반한경우가 12례 (7.3%), 이명 4례 (2.4%), 청력소실, 중이염, 편두통, 두통, 연령이증가할수록뇌혈관의직경이조금씩줄어 Table 1. Factors analysis affecting treatment of posterior canal benign paroxysmal positional vertigo (N=165) Positional Diagnosis Treatment visits/no. of patients (%) Rt PCBPPV Lt PCBPPV Total (%) Idiopathic 40 (24.2) 39 (23.6) 79 (47.9) Post traumatic 13 (7.9) 7 (4.2) 20 (12.1) Medicine disease 8 (4.8) 4 (2.4) 12 (7.3) Tinnitus 2 (1.2) 2 (1.2) 4 (2.4) Hearing loss 1 (0.6) 1 (0.6) 2 (1.2) Otitis media 1 (0.6) 1 (0.6) 2 (1.2) Migraine 2 (1.2) 0 2 (1.2) Headache 1 (0.6) 1 (0.6) 2 (1.2) Small vessle 4 (2.4) 2 (1.2) 6 (3.6) Cerebral infarction 5 (3.0) 2 (1.2) 7 (4.2) VBI 1 (0.6) 2 (1.2) 3 (1.8) Cerebral vessel 1 (0.6) 3 (1.8) 4 (2.4) disease Brain disease 4 (2.4) 0 4 (2.4) Vestibulopathy 7 (4.2) 3 (1.8) 10 (6.1) Transient cerebral 1 (0.6) 1 (0.6) 2 (1.2) ischemia Others 5 (0.6) 1 (0.6) 6 (3.6) Total 96 (58.2) 67 (41.8) 165 (100) The values are N (%). Abbreviations: PCBPPV, posterior canal benign paroxysmal positional vertigo; VBI, vertebro basilar artery Insufficiency. 드는환자 2례 (1.2%), 뇌혈관직경이좁아진환자 6례 (3.6%), 뇌경색 7례 (4.2%), 뇌혈관질환, 뇌손상 4례 (2.4%), 안뜰신경염 10례 (6.1%), 척추뇌바닥동맥기능부전증 3례 (1.8%) 등귀와관련된질환및중추성질환등에의해유발되었다 (Table 1). PCBPPV 165명환자를대상으로 EM 치료횟수를측정하였다. 1회치료성공률이 57.6% 로높은수치를보였고, 2회치료성공률이 17.6%, 3회치료성공률이 10.3%, 3회이상치료성공률이 14.5% 로조사되었다. 오른쪽이치료성공률이약간높았다 (Table 2). PCBPPV EM 치료횟수에영향을주는인자들을분석해보면 1회성공률은원인불명 47.8% 으로유의적으로가장높았고, small vessel, 뇌경색, 안뜰신경염을동반하면치료율이현저히떨어졌다. 그리고 3회이상의어지럼증이지속된경우가원인불명, 외상후, 뇌경색, 척추뇌바닥동맥기능부전증 (vertebro basilar artery insufficiency, VBI), 뇌혈관질환 ( 척추동맥좁아짐등 ), 안뜰신경염등이있었다. 통계적으로원인불명, 외상후, 내과적질환, 뇌경색, VBI, 뇌혈관질환, 뇌질환, 안뜰신경염등이치료횟수와상관성을보였다 (P<0.05) (Table 3). 주로안뜰계와관련된부분의질환에의해반고리관의기능약화로이석이발생한것으로보인다. 뇌경색경우중대뇌동맥협착으로인해반고리관으로혈류량이감소하여반고리관의기능이약화되고, 안뜰신경염인경우에는평형을담당하는기관인안뜰기관의반고리관에염증을동반할수있고이석치료가되더라도안뜰신경염을치료하지않으면계속적으로어지럼증을동반할수있다. 중추성질환을통한어지럼증을판단하기위하여뇌혈관자기공명영상 (magnetic resonance angiography, MRA) 를통해척추뇌바닥동맥 (veterbro-basilar artery, VA) 의기형을살펴본결과척추동맥또는뇌바닥동맥의기형에의해양성발작성두위현기증이나타났다. 특히척추동맥의기형에의한폐쇄나협착은숨뇌에영향을미칠수있기때문에어지럼증과밀접한관련성이있다. Figure 3은정상적인 MRA소견이고 Figure 4는척추동맥이 Table 2. Location of disease and number of treatment (N=165) Positional Treatment visits/no. of patients (%) 1 2 3 >3 Total P-value Rt PCBPPV 51 (53.7) 21 (72.4) 11 (64.7) 13 (54.2) 96 (58.2) 0.015 Lt PCBPPV 44 (46.3) 8 (27.6) 6 (35.3) 11 (45.8) 69 (41.8) 0.018 Total 95 (57.6) 29 (17.6) 17 (10.3) 24 (14.5) 165 (100) 0.009 The values are N (%). Abbreviation: PCBPPV, Posterior canal benign paroxysmal positional vertigo.
Korean J Clin Lab Sci. Vol. 50, No. 3, September 2018 271 Table 3. Treatments ratio of posterior canal benign paroxysmal positional vertigo (N=165) Diagnosis Treatment visits/no. of patients (%) 1 2 3 >3 Total (%) P-value Idiopathic 64 (38.8) 5 (3.0) 3 (1.8) 7 (4.2) 79 (47.88) 0.008 Post traumatic 14 (8.5) 1 (0.6) 2 (1.2) 3 (1.8) 20 (12.12) 0.014 Medicine disease 7 (4.2) 4 (2.4) 0 1 (0.6) 12 (7.27) 0.012 Tinnitus 1 (0.6) 1 (0.6) 1 (0.6) 1 (0.6) 4 (2.42) 0.128 Hearing loss 1 (0.6) 1 (0.6) 0 0 2 (1.21) 0.074 Otitis media 0 0 1 (0.6) 1 (0.6) 2 (1.21) 0.074 Migraine 0 0 1 (0.6) 1 (0.6) 2 (1.21) 0.074 Headache 1 (0.6) 1 (0.6) 0 0 2 (1.21) 0.074 Small vessel disease 1 (0.6) 3 (1.8) 1 (0.6) 1 (0.6) 6 (3.65) 0.062 Cerebral infarction 1 (0.6) 1 (0.6) 2 (1.2) 3 (1.8) 7 (4.24) 0.028 VBI 0 2 (1.2) 0 1 (0.6) 3 (1.82) 0.036 Cerebrovascular disease 0 1 (0.6) 2 (1.2) 1 (0.6) 4 (2.42) 0.036 Brain disease 2 (1.2) 1 (0.6) 1 (0.6) 0 4 (2.42) 0.029 Vestibulopathy 1 (0.6) 5 (3.0) 1 (0.6) 3 (1.8) 10 (6.06) 0.026 Transient cerebral ischemia 1 (0.6) 1 (0.6) 0 0 2 (1.21) 0.074 Others 1 (0.6) 3 (1.8) 2 (1.2) 0 6 (3.65) 0.012 Total 94 (57.6) 29 (17.6) 17 (10.3) 24 (14.5) 159 (100) 0.009 The values are N (%). Abbreviation: VBI, vertebro basilar artery insufficiency. 적인약물치료가필요했다. 고찰 Figure 4. Normal study of MRA angiography. Abbreviation: MRA, Magnetic resonance angiography. 정상축에서 3 mm정도굴곡된소견이다. 이환자의경우 2009 년 9월에내원하여빙빙도는느낌과구토를동반한현기증을호소하여비디오눈떨림검사결과오른쪽뒤반고리관양성발작성현기증으로진단되었고, 이석정복술로치료하였으나, 계속적으로어지럼증을호소하여뇌혈관촬영결과척추동맥의기형으로뇌혈류의안뜰기관유입에장애를가져와안뜰신경염을일으켰고이후양성발작성두위현기증을유발하였다. 이석정복술 2회이후이석치료는되었으나어지럼증이지속되어계속 PCBPPV는가쪽반고리관양성발작성두위현기증 (lateral canal benign paroxymal positional vertogo, LCBPPV) 과비슷하게어지럼증을일으키는질환중가장흔하다 [9]. PCBPPV 는잠자리에눕거나일어날때, 선반에서물건을꺼내려고올려볼때, 몸을앞으로구부릴때지속시간이 30초이내또는수분이상지속적인회전성어지럼증을유발하고, 쓰러질것같은느낌, 떠다니는느낌, 구역질나는느낌, 머리움직임에대한공포를호소한다 [2]. 반면, LCBPPV 은갑자기일어나거나, 옆으로누울때빙빙돌면서오심이나타나고심하면구토를동반하는경우가있다. 이와같이증상별반고리관내이석유입부위가다르기때문에적절한이석정복술의선택이필수적이다. 이러한점을고려하여정확한임상진단과정이필요하고, 자세한문진을통해특징적인소견이나타나는지를알아본후눈떨림의관찰을통한이석위치를확인하는것이선행되어야할것이다 [1]. PCBPPV 가진단되면이석이반고리관또는팽대부릉정을자극하여평형리듬이깨지면서어지럼증이유발될수있고이석을제거하면다시평형의리듬이돌아오게된다. 이석정복술방법은 LCBPPV 치료방법인바비큐법 (Barbecue methode) 과달리 [3, 6, 9], EM법을시행한다 [3, 6, 8]. 이때관찰되는눈떨림이초기 Dix-Hallpike 시와동일하다면, 이석이공통각을통하
272 Chul-Seung Kim. Factors Analysis Affecting Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo Figure 5. BA abnormality in MRA. Deviation over twice the length of BA diameter from an imaginary line. About 3 mm aneurysm at basilar tip. Abbreviations: BA, basilar artery; MRA, Magnetic resonance angiography. 여타원주머니로가고있음을유추할수있고치료가성공적임을추정할수있다 [3]. 이러한이석정복술을통해이석이제거되면치료즉시어지럼증이호전되지만, PCBPPV 유발시키는인자들에의해이석정복술치료횟수가증가될수있다. 이석정복술의결과에영향을주는연구보고는많지않다. 양성발작성두위현기증환자에서효과적인치료법으로이석정복술이이용되고있으며, 이석정복술의 1회치료로실패한경우는 12% 에서 56% 로보고되고있다 [10, 11]. 본연구결과 57.6% 의어지럼증환자가 1회이석정복술로어지럼증이호전되었다 (Table 2). 다른보고와유사한성공률을보이였다 [10, 11]. BPPV 중 PCBPPV 을진단받은 165명의환자를대상으로 EM을시행한결과 1회치료로회복된경우가 57.6% 로높은수치를보였고 2회치료로회복된경우가 17.6%, 3회치료로회복된경우가 10.3%, 3회이상치료로회복되거나계속지속된경우가 14.5% 이었다 (Table 3). Kim 등 [9] 은 LCBPPV 환자 166명대상으로 1회치료성공률이 74.1% 로본연구와비교해서약간높은치료성공율을보였다. Chung 등 [12] 은외상후반고리관의변화로인해서이석정복술의횟수가증가하였다. So 등 [13] 은외상이있는환자와없는환자를비교했을때훨씬더외상이있는환자의치료횟수가증가한다는이유는외상이평형반을약화시켜서이석의발생횟수가증가하였다고보고하였다. 이석정복술시술당일취침전까지눕지않도록하고, 높은베개를사용하여수면을취하도록권장하였고, 다음날부터정상적인생활을하도록주의를시켰다. Kim 등 [9] 에의하면 LCPBBV 환자에게동반되어나타나는 15개질환을조사한결과는외상후, 내과적질환, 이명, 두통, 뇌혈관좁아짐, 뇌경색, 안뜰신경염등 7개인자였고, O Reilly 등 [14] 과 Baloh 등 [15] 도 PCBPPV에영향을주는질환에대하여비슷하게제시하였고, So 등 [13] 도치료에영향을주는인자로외상, 중이염, 안뜰신경염을제시하였다. PCBPPV 의이석정복술치료횟수에영향을주는인자들을분석해보면 1회성공률은원인불명이 47.8% 로유의적으로가장높았고, small vessel, 뇌경색, 안뜰신경염을동반하면치료율이현저히떨어졌다. 그리고 3회이상의어지럼증이지속된경우가원인불명, 외상후, 뇌경색, VBI, 뇌혈관질환 ( 척추, 뇌바닥동맥좁아짐등 ), 안뜰신경염등이있었다. 통계적으로원인불명, 외상후, 내과적질환, 뇌경색, 척추뇌바닥동맥기능부전증, 뇌혈관질환, 뇌질환, 안뜰신경염등이치료횟수와통계학적으로상관성을보였다 (P<0.05) (Table 3). PCBPPV는주로안뜰계와관련된부분의질환에의해반고리관기능의약화로발생한것으로보인다. 뇌경색경우중대뇌동맥협착으로인해반고리관으로혈류량이감소하여반고리관의기능이약화되었고, 안뜰신경염인경우에도평형을담당하는기관인안뜰기관의반고리관에염증이동반될수있고, 이석치료가되더라도안뜰신경염을치료하지않으면계속적인어지럼증이지속적으로나타났다. 역시 Kim 등 [9] 에의한 LCBPPV 도 Meniere s disease( 메니에르병 ), 이명, 중이염, 편두통, 척추뇌바닥동맥기능부전증, 뇌혈관질환, 뇌질환, 뇌출혈을제외하고는양성발작성두위현기증과연관된인자와치료횟수가상관성이있었다. Lee 등 [16] 도두부외상환자 9명이모두어지럼증을호소하였으며, 5명이 PCBPPV 로진단하였고, EM으로호전되었고상관성을보였다. 그러나, 이석을유발하게하는 Meniere s disease( 메니에르병 ), 내림프수종 (endolymphatic hydrops), 미로염 (labyrinthitis) 등에의해 PCBPPV 가유발될경우, 치료후에도재발율이높다는보고도있다 [17]. 본연구와비슷한결과를나타냈다.
Korean J Clin Lab Sci. Vol. 50, No. 3, September 2018 273 중추성질환을정확히판단하기위하여뇌혈관자기공명영상 (magnetic resonance angiography, MRA) 을통해척추뇌바닥동맥 (Veterbrobasilar artery) 의기형을살펴본결과척추동맥또는뇌바닥동맥의기형에의해폐쇄나협착이생기면서연수에영향을미칠수있기때문에어지럼증과밀접한관련성이있다 (Figure 4, 5). PCBPPV 의 EM 치료횟수가증가하는원인은반고리관내이석이유입되게하는여러인자에의해어지럼증이발생한다. 이러한인자들에의해이석기관의기능이약화되어평형반에서쉽게이석이떨어져나와어지럼증이유발되고만약, 이러한원인인자가치료되지않으면이석정복술에의해반고리관내이석이제거되더라도다시이석이발생하여계속적인어지럼증을초래하게될것이다. 이런인자들의치료와이석정복술을병행하면치료성공확률이높아질수있을것이다. 뒤반고리관양성발작성두위현기증외에도본연구에서제시한인자들에의해어지럼증이유발될수도있고, 또이러한인자들에의해뒤반고리관양성돌발성두위현기증이더욱더악화될수도있으며, 만일이러한인자들이치료가되지않는다면치료횟수가증가되고, 계속적인재발로인해삶의질이악화되고, 불편한삶을살수밖에없을것이다. 또한, 어지럼증을호소하는 47.8% 가원인불명임에도불구하고, 반고리관내에이석이유입되어어지럼증을호소하고있는점을간과해서는안될것이다. 이와같은경우다른인자들에비해휠씬치료성공률은높았다 (Tables 1, 3). 비디오눈떨림검사를통해가쪽반고리관, 뒤반고리관등이석유입위치를확인하여야하고, 각각다른방법에따른치료가요구되고, 치료에영향을주는인자들에의하여많은환자들이겪고있는구토, 오심, 실신등의질환이발생할수있지만, 양성발작성두위현기증을유발할수있는질환치료와병행하고, 치료후주의사항을주지시키고, 지킨다면일상생활에많은불편함과, 고통을주는어지럼증에서호전될수있을것이다. 만약, 양성발작성두위현기증치료와상관성이떨어지는인자들이존재하고있으면여러번이석정복술을치료를반복하더라도, 재발확률이높아진다. 앞으로평형반을약화시킬수있는여러요인들의연구가필요할것이다. 요약순천성가롤로병원어지럼증센터에내원한어지럼증환자중뒤반고리관양성발작성두위현기증은머리나몸을움직일때갑자기빙빙도는느낌또는회전성어지럼증을호소하는가장흔한질환이다. 대부분환자들은 1회치료로증상이호전된 다. 하지만, 세번이상여러번치료를요구하는경우도있다. 이석정복술에의한뒤반고리관양성발작성두위현기증환자의어지럼증증상회복에영향을주는인자을분석하였다. 어지럼증환자중어지럼증센터에내원한뒤반고리관양성발작성두위현기증환자를분류하였다. 2008년 3월부터 2010년 11월까지 165명의뒤반고리관양성발작성두위현기증환자치료율을조사하였다. 1회치료성공율이 57.6%, 2회치료성공율이 17.6%, 3회치료성공율이 3.6%, 3회이상치료성공율이 21.2% 였다. 뒤반고리관양성발작성두위현기증치료에영향을주는인자는외상후, 내과적질환, 뇌경색, 작은혈관질환, 척추뇌바닥동맥기능부전증, 뇌혈관질환, 뇌질환, 안뜰신경염이다. 위와같은치료에영향을주는인자들을고려한다면구토, 오심, 실신등을쉽게치료할수있을것이다. 또한, 어지럼증증상의회복을위한이석정복술과연관질환을병행치료하면일상생활에많은불편함을주고, 고통을주는어지럼증에서호전될수있을것이다. 앞으로어지럼증을유발하는많은인자들을조사하고, 분석할필요가있을것이다. Acknowledgements: None Conflict of interest: None REFERENCES 1. Byun JY, Ryu EW. Diagnosis and treatment of benign paroxysmal positional vertigo. Res Vestib Sci. 2010;9:55-64. 2. Lee HS, So YK. Diagnosis of vertical canal benign paroxysmal positional vertigo. J Korean Bal Soc. 2005;4:307-311. 3. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107:399-404. 4. Rhee CK, Benign paroxysmal positional vertigo. Korean J Otolaryngol. 2004;47:491-506. 5. Jeon HG, Song SH, Han GC, Huh JM. Analysis of factors that affect the result of vestibular rehabiliation in the treatment of benign paroxysmal positional vertigo. Korean J Otolaryngol. 2001;44:1259-1263. 6. Parnes LS, Robichaud J. Further observations during the particle repositioning maneuver for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1997;11. 7. Fujino A, Tokumasu K, Yosio S, Naganuma S, Yoneda S, Nakayama K. Vestibular training for benign paroxysmal positional vertigo. its efficacy in comparison with antivertigo drugs. Arch Otolaryngol Head Neck Surg. 1994;120:497-504. 8. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952;61:987-1016. 9. Kim CS, Choi HY, Kwon PS, Lee EP, Seo CW. Factor analysis affecting lateral canal benign paroxysmal positional vertigo.
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