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Research in Vestibular Science Vol. 15, No. 4, December 2016 Original Article pissn 2092-8882, eissn 2093-5501 https://doi.org/10.21790/rvs.2016.15.4.121 수면자세가양성돌발성두위현훈의발생에미치는영향 서남대학교의과대학명지병원이비인후과 신용국, 박진우, 구자원, 송미현, 심대보 The Influence of Sleep Position on Benign Paroxysmal Positional Vertigo Yong Gook Shin, Jin Woo Park, Ja Won Gu, Mee Hyun Song, Dae Bo Shim Department of Otorhinolaryngology, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea Received Oct 11, 2016 Revised Nov 3, 2016 Accepted Nov 3, 2016 Corresponding Author: Dae Bo Shim Department of Otorhinolaryngology, Myongji Hospital, Seonam University College of Medicine, 55 Hwasu-ro 14beon-gil, Deokyang-gu, Goyang 10475, Korea Tel: +82-31-810-5451 Fax: +82-31-969-0500 E-mail: lovend77@gmail.com Copyright c 2016 by The Korean Balance Society. All rights reserved. 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. Objective: The purpose of this study was to identify the influence of sleep position on benign paroxysmal positional vertigo (BPPV). Methods: Four hundred sixty patients diagnosed as posterior or horizontal canal BPPV were analyzed retrospectively. All patients were asked about their preferred sleep positions among the following four choices: supine, right or left lateral, or no predominant side via questionnaire at initial visit and after 1month. Patients were classified into two groups: affected side group meaning that the patient preferred to sleep ipsilateral to the affected ear and other position group including all positions other than lying lateral to the affected side after treatment. We analyzed the change in the sleep pattern after treatment and compared the recurrence rate between the two groups. Results: Our study included 244 patients with posterior canal BPPV (PC-BPPV) and 216 patients with horizontal canal BPPV (HC-BPPV). Statistically significant correlation was demonstrated between sleep position side and the affected side by BPPV. The number of patients who slept on the affected side by BPPV decreased, while the number of patients who slept on the healthy side increased significantly after treatment. There was no statistically significant difference in the recurrence rate between the two groups. Conclusion: There was significant correlation between the sleep position side and the affected side in PC-BPPV and HC-BPPV. The patient had a tendency to avoid lying lateral to the affected side by BPPV during sleep after treatment, however the change in sleep position did not influence the recurrence rate of BPPV. Res Vestib Sci 2016;15(4):121-125 Keywords: Benign paroxysmal positional vertigo; Sleep; Position; Recurrence 서론양성돌발성두위현훈 (benign paroxysmal positional vertigo, BPPV) 은자세변화에따라반복적으로나타나는회전성어지럼을특징으로하는가장흔한재발성말초성전정질환이다. 1 병태생리학적소견으로는난형낭반에위치한이 석이탈락되어반고리관내에유리결석형태로들어가피스톤역할을함으로써팽대부릉정이움직이는반고리관결석설과반고리관의팽대부릉정에결석이붙음으로써중력방향에따라팽대부릉정이움직이게되는팽대부릉정결석설이있다. 2,3 BPPV는확인될수있는원인의유무에따라일차성과 121

Res Vestib Sci Vol. 15, No. 4, Dec. 2016 이차성으로나뉘며, 이차성원인으로는두부외상 (8.5%), 전정신경염 (0.8%), 메니에르병 (0.6%) 등이있으나, 대부분의경우원인이알려져있지않은일차성 (70% 내외 ) 이다. 1,4,5 BPPV는수면전후자세변화와함께증상이시작되는경우가많고, 특히수면후아침에침대에서일어날때자주증상이발생하는데, 이를통해수면이 BPPV의발생에영향을줄수있다는추정이가능하다. 6 실제로최근수면중머리방향자세와이환되는반고리관의방향간에상관관계가있다는연구들이발표되고있다. 7-9 그러나대부분의관련연구들이제한된수의적은표본수를대상으로하거나후반고리관환자들만을대상으로하고있고, 수면자세가 BPPV의재발률에미치는영향에대해서도연구자간에상반되는결과를보이기도한다. 10-12 이에저자들은후반고리관뿐만아니라수평반고리관 BPPV 환자들의수면자세와 BPPV 발생과의관련성을확인하고, 첫진단후수면자세의변화양상에따른 BPPV 재발여부를알아보고자하였다. 대상및방법 2012년 1월부터 2014년 12월까지본원이비인후과로내원한 posterior canal BPPV (PC-BPPV) 와 horizontal canal BPPV (HC-BPPV) 로진단된환자들을대상으로후향적으로설문지및의무기록을검토하였다. 모든환자에서신경학적검사를통해중추신경계의질환여부를확인하였고, 여러반고리관에이환된환자, BPPV에영향을줄수있는다른귀질환 ( 만성중이염, 전정신경염, 돌발성난청, 메니에르병 ) 을병변측에함께갖고있는환자, 그리고난치성 BPPV 환자들은연구대상에서제외하였다. BPPV의진단은 2008년미국이비인후과학회에서제시한진료지침에따라체위성검사를통해각이환된반고리관을결정하였다. 13 비디오안진검사에서 Dix-Hallpike 검사와수평면에서의머리회전검사 (supine head roll test) 를통해 BPPV를진단하였다. 안진의확인은 video Frenzel goggle system (SLMED, Seoul, Korea) 을사용하였다. 이환된반고리관의종류와방향은다음검사에의해유발된안진에따라분류하였다. Dix-Hallpike 검사에서짧은잠복기를가지면서지속시간은 60초이내로강해졌다가약해지며사라지는형태의특징적인회전성상향안진이관찰되면 PC-BPPV 로진단하였다. HC-BPPV의향지성아형 (geotropic HC-BPPV, HC-BPPV[Geo]) 은 Supine head roll test 시전형적인향지성 방향의방향전환성두위안진 (direction changing positional nystagmus, DCPN) 을확인하고 Supine head roll test시강한안진을나타내는방향을병변측으로진단하였다. HC-BPPV 의원지성아형 (apogeotropic HC-BPPV, HC-BPPV[Apo]) 은 Supine head roll test시전형적인원지성방향의방향전환성두위안진을확인하고, 약한안진이유발되는방향을병변측으로진단하였다. HC-BPPV의 2가지아형을진단할때, 양측안진의세기가같은경우에는 bow and lean test를통해병변의방향을결정하였다. 14 처음내원할때, 환자들은수면시작시의선호자세에대한설문지를작성하였다. 환자들은수면시선호하는자세에대하여 (1) 똑바로눕는자세, (2) 우측으로눕는자세, (3) 좌측으로눕는자세, (4) 특정한선호자세없음의 4가지종류로응답하였다. 1주뒤다시내원한환자들은이석정복술이후자세변화에따른유발안진이없음을확인하였고다시방문하지못한경우에는전화설문을통하여어지럼재발유무를확인하였다. 이후환자들에게 1개월, 6개월 12개월마다어지럼증재발유무에대한전화설문및수면자세에대한설문을반복하여시행하였다. 수면시눕는자세와 BPPV의이환방향에대한상관관계는 Pearson 2 test, Fisher s exact test를통해분석하였다. 치료전과치료후에환자들의병변측또는건측방향에대한수면자세변화의차이를 Pearson 2 test를통해분석하였다. 수면자세에따른 BPPV의재발간의관계는첫설문시우측또는좌측으로눕는자세라대답한환자들중 BPPV의병변측방향과같은방향인환자들을 1년뒤수면자세에따라두개의군으로나누어두군간의재발률을분석하였다. 두군은 (1) 치료후병변측으로수면을유지한군과 (2) 병변측이외의수면자세로변화한군으로나누었으며, 두군에서 BPPV의재발률을 Kaplan-Meier method with log rank test 를시행하여비교하였다. 통계학적분석은 PASW ver 18.0 (SPSS Inc., Chicago, IL, USA) 을사용하였으며, p값이 0.05 미만일때통계적으로유의하다고판정하였다. 결과본연구의대상이된 BPPV환자 460명중남자가 115명 (25%), 여자가 345명 (75%) 이었고, 평균연령은 55.1±14.8세 ( 범위, 17 89세 ) 였다. 어지럼의발병부터 BPPV의진단까지의기간은평균 5.4±10.1일이었다. 반고리관의분포를살펴보면, PC-BPPV환자는 244명 (53%), HC-BPPV (Geo) 환자는 122

신용국외 4 인. 수면자세와 BPPV 발생사이의상관관계 100명 (21.7%), HC-BPPV (Apo) 환자는 116명 (25.2%) 이었다. 전체 460명환자중추적관찰이이뤄지지않은환자는 3명 (0.7%) 으로, 재발여부및수면자세의추적설문은 457 명 (99.3%) 에서시행하였다. 전체 460명환자들의수면자세분포는 BPPV 각아형별로 Table 1과같다. BPPV의병변측과수면자세와의상관관계는 PC-BPPV, HC-BPPV (Geo), HC-BPPV (Apo) 세가지아형모두에서통계적으로유의한상관관계를보였다 (p<0.001, p=0.001, p=0.005) (Table 2). BPPV 치료후의환자들의수면자세는병변측은감소 (187 명 [40.7%] 74명[16.2%]), 건측은증가 (80명[17.4%] 211명 [46.2%]) 하였다 (p<0.001). 똑바로눕는자세는증가 (110명 [23.9%] 112명[24.5%]), 특정한선호자세없음은감소 (83 명 [18%] 60명[13.1%]) 하였다 (Figure 1). 환자들의수면자세변화여부에따라분류한두군간최대 1년까지의재발률은유의한차이를보이지않았다 Table 1. The distribution of sleep positions in different types of BPPV Sleep position PC HC (G) HC (A) Right 71 (29.1) 26 (26) 34 (29.3) Left 74 (30.3) 30 (30) 32 (27.6) Supine 62 (25.4) 26 (26) 22 (19.0) None 37 (15.2) 18 (18) 28 (24.1) Total 244 (100%) 100 (100) 116 (100) Values are presented as number of patients (%). BPPV, benign paroxysmal positional vertigo; PC, posterior canal BPPV; HC (G), horizontal canal BPPV (geotropic subtype); HC (A), horizontal canal BPPV (apogeotropic subtype). (p=0.661) (Figure 2). 고찰본연구의전체환자들 460명중 PC-BPPV환자는 244명 (53%), HC-BPPV (Geo) 환자는 100명 (21.7%), HC-BPPV (Apo) 환자는 116명 (25.2%) 명으로기존의다른연구들에서보고된 HC-BPPV의비율 5% 33% 보다 15,16 높은 47% 를보였다. 이는본연구의환자들의어지럼증상발생후진단까지의기간이평균 5.4±10.1일로, 증상발현기간이짧은환자들에서 HC-BPPV의환자비율이높아진다는기존의연구를통해설명될수있다. 17 또본연구의전체환자들의수면자세분포는 PC-BPPV 와 HC-BPPV (Geo) 에서는우측으로눕는자세보다좌측으로눕는자세가더많은수를보였는데이는사람들이연령의증가에따라심혈관계상태로인해우측으로눕는자세를선호한다는 De koninck 등 18 의연구결과와는다르다. 19,20 이차이는본연구에포함된환자들의평균연령이 55.1±14.8 세 ( 범위, 17 89세 ) 로, 65세에서 80세사이의연령대환자를연구대상으로한 De koninck 등의연구보다젊은사람들이훨씬더많이포함된결과로보인다. PC-BPPV와 HC-BPPV 환자들모두에서이환방향과수 Table 2. Relationship between preferred position during sleep and affected ear in PC- and HC-BPPV Affected ear Preferred position during sleep Total Right Left p-value PC-BPPV <0.001 a) Right 50 (70.4) 21 (29.6) 71 Left 21 (28.4) 53 (71.6) 74 HC-BPPV (G) 0.001 a) Right 18 (72.0) 7 (28.0) 25 Left 8 (25.8) 23 (74.2) 31 HC-BPPV (A) 0.005 a) Right 28 (63.6) 16 (36.4) 44 Left 6 (27.3) 16 (72.7) 22 Values are presented as number (%). PC-BPPV, posterior canal benign paroxysmal positional vertigo; HC-BPPV (G), horizontal canal BPPV (geotropic subtype); HC-BPPV (A), horizontal canal BPPV (apogeotropic subtype). a) Pearson chi-square test. Figure 1. Sleep position distribution before and after treatment in posterior and horizontal canal benign paroxysmal positional vertigo (BPPV). The number of patients who slept on the affected side by BPPV decreased, while the number of patients who slept on the healthy side increased after the initial treatment (*p<0.001). Affected side, sleep position toward the affected ear by BPPV. Healthy side, sleep position toward the healthy ear; Supine, supine position; None, no preferred sleep position; Tx, treatment (canalith repositioning procedure). 123

Res Vestib Sci Vol. 15, No. 4, Dec. 2016 Figure 2. Comparison of recurrence rate between the two groups according to the sleep position 1 month after the initial treatment. The Kaplan-Meier curve with a log-rank test shows no difference in the recurrence rate between the two groups classified according to the sleep positions 1 month after the initial treatment (p=0.661). 면자세와의상관관계에있어 BPPV 병변측으로눕는자세가건측으로눕는자세보다많은양상을보였는데이러한결과는기존의다른연구들과비슷한결과였다. 7-9,20 이는난형낭반에서이탈한이석이수면시머리의위치에따라중력에의해아래쪽에위치한귀방향의반고리관에들어가 BPPV가유발되는것으로추정된다. 7,8,20 BPPV 치료후, 환자들은병변측으로눕는비율이감소하고건측으로눕는비율은증가하였다. BPPV발생후환자들의수면자세에서병변측으로머리를향하는자세를피하는경향이생김을알수있다. 이는 BPPV 치료이후환자들의삶의질을다룬최근연구에서 BPPV를겪은환자들중에심리적인장애로인해활동의제한이생기는경우가있음을보고하였는데, 21 본연구에서도병변측으로누웠을때어지럼이생긴것을경험한일부환자들의어지럼재발에대한의식적또는무의식적인심리적두려움으로인한결과라생각된다. 그러나이석정복술후자세제한의필요성에대해서는논란이많다. 10-12,22 본연구에서치료후병변측으로수면을유지한군과병변측이외의수면자세로변화한군에서 1 년까지의 BPPV의재발률은유의한차이가없었고, 이는 BPPV의치료율과재발률에수면자세제한이큰영향을미치지못한다는다른연구들과비슷한결과를나타낸다. 10,11 이에반해, Cakir 등 12 은수면자세제한유무에따라 BPPV의치료에필요한이석정복술의횟수가의미있는차 이를보였다고발표했으며, 몇몇다른연구들에서도수면자세제한이치료에효과가있다는결과를보여주었지만연구표본대상환자수가적은제한점이있었다. 23-26 BPPV는치료후에도재발이 5% 50% 에이를정도로흔한질환으로, 20,27 중력에의해난형낭으로부터아래쪽으로떨어진이석의축적에의해 BPPV가발생할수있다는가설은 BPPV의치료와재발예방에있어수면자세에대해앞으로도계속충분히연구해볼이유가된다. 수면시머리자세변화에대한적절한모니터링장치의사용이연구의질을높일것으로생각되고, 또한머리자세변화에따른반고리관의정확한해부학적위치변화와이석의이동에대한연구도더진행되어야할것이다. 아울러수면자세에따른 BPPV재발예방의단기간및장기간효과비교및수면자세제한에따른환자의수면의질변화등은앞으로더수행될필요가있을것으로보인다. 결 PC-BPPV와 HC-BPPV 환자들에서수면시자세와 BPPV 의병변측사이에는유의한관계가있었다. 그리고치료후환자들의수면자세는의미있게병변측방향을피하고건측을선호하는양상을보였다. 그러나수면자세의변화가 PC-BPPV와 HC-BPPV환자들의 1년간의재발률에영향을미치지는않았다. 이연구결과는 BPPV 환자들의수면자세에대한앞으로의연구에도움이될것으로생각된다. 론 중심단어 : 양성돌발성두위현훈, 수면, 자세, 재발 CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Rhee CK. Benign paroxysmal positional vertigo. Korean J Otolaryngol-Head Neck Surg 2004;47:491-506. 2. Kim JS, Zee DS. Clinical practice: benign paroxysmal positional vertigo. N Engl J Med 2014;370:1138-47. 3. Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151-8. 4. Gordon CR, Levite R, Joffe V, Gadoth N. Is posttraumatic benign paroxysmal positional vertigo different from the idio- 124

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