J Korean Med Ophthalmol Otolaryngol Dermatol 2018;31(3):26-38 pissn 1738-6640 eissn 2234-4020 http://www.ood.or.kr http://dx.doi.org/10.6114/jkood.2018.31.3.026 Original Article / 원저메니에르병의침치료에관한최근임상연구동향 이규영 홍철희상지대학교한의과대학안이비인후피부과학교실 ( 교수 ) Recent Clinical Research Trends on Acupuncture Treatment of Meniere's Disease Kyou-Young Lee Chul-Hee Hong Department of Opthalmology and Otolaryngology and Dermatology, College of Korean Medicine, Sangji University Abstract Objectives : The purpose of this study is to investigate the possibility of applying acupuncture to the treatment of meniere's disease, which has no definite treatment methods, by analyzing the latest clinical researches about acupuncture treatment of meniere's disease. Methods : A and Randomized Controlled Trial (RCT) related to the acupuncture treatment of meniere's disease were searched using domestic and international thesis search engines including OASIS, CNKI, J-STAGE, PubMed. This study include acupuncture treatment and acupuncture combined with other treatments such as herbal medicine. The search was limitied to the publication date from 2000 to 2018 with free full text. Results : 17 cases were selected. There were 7 case studies in Korea, 5 case studies in China, and 5 RCT papers in China. All 12 cases reported improvement in meniere's disease and all RCT studies showed significantly higher treatment effects in the experimental group than in the control group. Conclusions : Acupuncture treatment showed significant effects for meniere's disease when applied alone or in combination with other treatments. In the future, various systematic studies should be conducted only for acupuncture treatment. Key words : Meniere's disease; Acupuncture; Case study; Randomized controlled trial c 2018 the Society of Korean Medicine Ophthalmology & Otolaryngology & Dermatology This is an Open Access journal distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/license/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 26
이규영외 1 인 : 메니에르병의침치료에관한최근임상연구동향 Ⅰ. Introduction 메니에르병 (Meniere's disease) 은반복적으로나타나는어지럼증과청력감소, 이명, 이충만감을주증상으로하는특발성내이질환이다 1). 유병률은국가별로 10만명당 4.3~157 명까지다양하게보고되고있으며 2), 30-50세에서최고발병률을보인다 3). 성별에따라여성대남성의발병비율은 2:1 정도이며 4,5), 가족력과도관련이있을것으로추정된다. 원인은아직까지명확하게밝혀져있지않으나여러가지원인으로유발된내임파액의흡수장애에기인한내임파액수종으로보고있다. 유발원인으로는체질적소인, 알레르기, 내분비장애, 자율신경긴장이상, 신진대사장애, 체내의 Na + 의저체, 갑상선기능저하증, 병소감염, 영양장애, 스트레스, 월스감염등이있다. 또한해부학적인요인으로는내임파액의흡수와관계되는전정수도관이나내임파관의이상이관련된다 6). 메니에르병은아직까지발병기전이불분명하여치료법이뚜렷하게규명되지않았으며, 증상완화를위해보존적치료로저염식및이뇨제를포함한약물요법, 수술적치료등이시행되고있으나대증요법에지나지않고그효과와부작용에대해서도논란이많은실정이다 7). 한의학에서는메니에르병을眩暈, 耳鳴, 耳聾의범주에서다루고있으며肝陽, 痰, 外邪등의實證病因과腎水不足, 氣血虛등의虛證病因으로나누어平肝潛陽, 消化熄風, 燥濕祛痰, 補益氣血, 健運脾胃, 補益腎精, 充養腦髓등의治法을활용한다 6). 현재까지메니에르병에대한한의학적연구로는증례보고 8편 2,4,8-13) 과메니에르병의현훈증상에대한침구치료를문헌적으로고찰한연구 1편 5) 및메니에르병의병리기전에대한현대의학의최신연구동 Corresponding author : Chul-Hee Hong, School of Oriental Medicine, Sangji University, St. 80, Wonju city, Gangwon, 26339, South Korea. (Tel : 033-741-9266, E-mail : hong7250@sangji.ac.kr) Recieved 2018/6/18 Revised 2018/7/26 Accepted 2018/8/2 향을분석하고메니에르병과관련된한의학연구를고찰한논문 1편 13) 에불과하다. 이에저자는메니에르병의침치료에관한국내및해외최신임상연구동향을분석하여뚜렷한방법이제시되어있지않은메니에르병의치료에침치료를대안으로적용할수있는가능성을모색하고자하였다. Ⅱ. Materials and methods 본연구에서는국내외논문검색엔진을활용하여메니에르병의침치료와관련된 와 Randomized Controlled Trial (RCT) 논문을검색하였으며연구대상논문선정은치료방법에서침치료및침치료와한약등의기타치료를병행한경우도모두포함하였으며, 2000~2018년에발표된논문중 free full text 가제공되는것을대상으로하여총 17편을선정하여조사, 분석하였다. 1. 국내저널검색 : 전통의학정보포털 (OASIS, Oriental Medicine Advanced Searching Integrated System, http://oasis.kiom.re.kr) 검색어 " 메니에르 ", "meniere" 로검색된국내한의학논문 10편중메니에르병과관련된문헌적고찰논문 2편과, 침치료를사용하지않은논문 1편을제외하고, 침치료를활용했던증례 7편을연구대상으로삼았다. 2. 중국저널검색 : (CNKI, China National Knowledge Infrastructure, http://search.cnki.net) " 梅尼埃病, 随机 " 로검색된 7편의논문중메니에르병의침치료와관련된 RCT 논문 2편을선정하였으며, " 梅尼埃病, 针 " 으로검색된 15편의논문중문헌고찰논문 3편, 개인적치료경험과관련된논문 2편, 중복되는논문 1편, 耳穴点刺放血치료와관련된논문 27
1편을제외하고총 8편의논문을선정하였다. 3. 일본저널검색 : (J-STAGE, Japan Science and Technology information Aggregator, Electronic, https://www.jstage.jst.go.jp) 검색결과선정조건에부합하는논문이존재하지않았다. 4. 영미권저널검색 : (PubMed, http://www.ncbi.nlm.nih.gov/pubmed) 검색결과선정조건에부합하는논문이존재하지않았다. Ⅲ. Results 연구형태별로는국내 7편, 중국 case study 5편, 중국 RCT 논문 5편이있었다 (Table 1). 1. Case study 1) 치료방법 Case study 12편중국내 7편, 중국논문 5편이었으며 (Table 2) 와같다. 침치료만시행한연구가 2편, 침과한약및기타치료를병행한연구가 9편, 침과뜸을사용한연구가 1 편있었다. 침치료방법은舍巖鍼을사용한연구가 4 편, 일반침을사용한연구가 3편으로그중 1편은복부穴位만자침하였다. 頭鍼을사용한연구는 2편으로 1편은일반침을병용하였으며, 그외八體質鍼 1편, 耳鍼 1편, 刀鍼 1편으로다양한鍼法을사용하였다. 사용된經穴은 (Table 4) 와같으며足三里 (ST-36), 百會 (GV-20) 가 5회로가장많이사용되었으며, 太衝 (LR-3) 이 4회, 太陽 (EX-HN5), 合谷 (LI-4), 大敦 (LR-1), 少府 (HT-8) 이 3회로사용되었다. 舍巖鍼法중脾正格이 2회로가장많이사용되었으며頭鍼治療와刀鍼療法에공통적으로暈聽區가사용되었다. 치료기간은 2~7일부터 2달까지다양하게나타났다. Table 1. Studies of Acupuncture for the Treatment of Meniere s Disease Published year First author Published country Journal Type of article Subject 2014 Lee MS Korea J Sasang Constitut Med A Case Study of a Taeeumin Patient with Meniere s Disease Treated with Cheongsimyeonja-tang 2008 Lee SY Korea The Korean J of joongpoong One Case of Meniere s Disease 2004 Lee SE Korea The J of Korean Acupuncture & Moxibustion Society Oriental medical treatment in Meniere s disease 2005 Lee KJ Korea J Korean Med Ophthalmol Otolaryngol Dermatol Two cases of Meniere s disease 2006 Park JY Korea J Korean Med Ophthalmol Otolaryngol Dermatol One case of Meniere s Disease 28
이규영외 1 인 : 메니에르병의침치료에관한최근임상연구동향 Table 1. 계속 Published year First author Published country 2002 Lee HH Korea Journal Type of article Subject Korean J. Oriental Physiology & Pathology A Clinical report on 8 Constitutional Acupuncture Therapies for Treatment One Case of Dizziness Suggested Meniere s Syndrome 2012 Oh KC Korea The J of The Korea Institute of Oriental Medical Diagnostics A Clinical Report on Episodic Vertigo with Meniere s Disease Treated by Saam Acupuncture Sojangjungkyuk 2013 Zhang KL China Chinese J of Otolaryngology Observation on the Efficacy of Acupuncture and Herbal Medicine in Treating Meniere's Disease in 30 Cases 2005 Bai RH China Shanghai J of Acupuncture and Moxibustion Abdominal Acupuncture with Moxibustion at Baihui for the Treatment of Meniere's Disease in 30 Cases 2004 Feng JP China JCAM. 2001 Liu SQ China Hebei J TCM 2004 Ling N China JCAM. Observation on Curative Effect of Scalp Acupuncture and Acupuncture on Meniere s Disease Scalp Acupuncture with Dangxiong Decoction for Meniere s Disease in 86 Cases Acupotomy Therapy of Meniere's Disease in 12 cases 2013 LI X China J of Practical Traditional Chinese Internal Medicine RCT Acupuncture Combined with Zhenwu Decoction Treatment of Meniere s Disease A Randomized Controlled Study 2014 Zhang LY China J of Practical Traditional Chinese Internal Medicine RCT A Randomized Controlled Trial of Modified Banxia Baizhu Tianma Decoction combined with Acupuncture in the Treatment of Meniere s Disease 2012 Chen WL China Research of Integrated Traditional Chinese and Western Medicine RCT Treatment of Meniere's Disease with Pharmacopuncture and Herbal Medicine in 128 Cases 2011 Wang X China JCAM. RCT 2013 Huang S China Shanghai J Acu-mox RCT Clinical Observation on Treatment of Meniere's Disease with Acupuncture and Herbal Medicine Clinical Observation on Scalp Micro-needling at Hairline in Treating Meniere Disease 29
Table 2. Summary of Case study 1 st Author Sample size Mean age or ranges (years) (Sex, M/F) Chief Complaint Treatment Treatment duration Scale Lee MS 1 33(0/1) vertigo, tinnitus, aural fullness A-Tx, H-med, W-med 7 w GAS Lee SY 1 34(1/0) vertigo, nausea, vomiting, tinnitus, hearing loss A-Tx, M-Tx, H-med 32 d change of symptoms Lee SE 2 63(1/1) M: vertigo, Lt. tinnitus, Lt. ear hearing loss F: vertigo, Rt. tinnitus, Rt. ear fullness, Rt. ear hearing loss(transient) A-Tx, H-med 2 m FV, HT, FL, vertigo score, change of symptoms Lee KJ 2 39(2/0) 55 y: vertigo, vomiting, Lt. tinnitus, hearing loss. / 23 y: vertigo, vomiting, Rt. tinnitus, hearing loss(mild) A-Tx, H-med, N-Tx, Infra-red in progress/ 40 d HT, change of symptoms Park JY 1 37(0/1) Rt. tinnitus, Rt. ear hearing loss, vertigo A-Tx, M-Tx, N-Tx, H-med 49 d HT, change of symptoms Lee HH 1 34(1/0) vertigo, headache A-Tx, H-med 27 d change of symptoms Oh KC 1 64(0/1) vertigo, hearing loss, tinnitus, nausea, secretion of inner ear A-Tx, H-med 25 d VAS Zhang KL 30 38.19±4.75 (12/18) vertigo, tinnitus, aural fullness, hearing loss, nausea, vomiting, nystagmus auricular A-Tx H-med 10~30 d cure rate index Bai RH 30 38-62 (10/20) n.r. A-Tx, M-Tx n.r. change of symptoms, recurrence or not Feng JP 26 26-66 (12/14) n.r. Scalp A-Tx, A-Tx 2~7 d change of symptoms, recurrence or not Liu SQ 86 48 (54/32) vertigo, nausea, vomiting, aural fullness, tinnitus, hearing loss, nystagmus Scalp A-Tx, H-med n.r. change of symptoms, HT Ling N 12 21-63 (5/7) n.r. Miniscalpel A-Tx 20 d change of symptoms, recurrence or not F: female, M: male, A-Tx: acupuncture treatment, H-med: herbal medicine, W-med: western medicine, M-Tx: moxibustion treatment, N-Tx: negative treatment, y: year, w: week, m: month, d: day, GAS: Global Assessment Scale, FV: Frequency of Vertigo, HT: Hearing Threshold, FL: Function Level, VAS: Visual Analogue Scale, n.r.: not reported 30
이규영외 1 인 : 메니에르병의침치료에관한최근임상연구동향 2) 치료효과효과판정은대부분의연구에서증상변화또는증상의정도를점수화하는방법 (GAS, VAS), 청력역치, 재발유무를기준으로하였다. 일부연구에서는 FV(Frequency of Vertigo, 최근 6개월동안확실한현기증의 1달평균발작횟수 ) 를치료시작전과치료 2년후에각각평가하여그비율을 6등급으로나누어경과를평가하였으며, FL(Functional Level, 현기증에대한전반적인현재적응상태를평가하는방법, 6 단계 ) 과 Vertigo score( 현훈의심한정도를 5단계로나누어 0~4점까지점수화 ), 치료율을평가도구로사용하였다. 12편의증례보고에서모두메니에르병의호전이있었다. 2. Randomized Controlled Trial (RCT) 1) 연구방법 RCT 연구 5편은모두중국논문이었다 (Table 3). 침과한약 vs 한약을비교한연구가 1편, 침과한약 vs 양약을비교한연구가 1편, 약침과한약 vs 침을비교한연구가 1편, 침과양약 vs 양약을비교한연구가 1편, 頭鍼 vs 일반침을비교한연구가 1편이었다. 각각의연구방법이모두다르게나타났다. 효과를판정하기위한 scale 은모든연구에서총유효율을사용하였으며치료전 6개월과치료후 18~24 개월간의현훈발작빈도에대한비율을구하여총유효율산정에활용하기도하였다. 그외에완치율, 혈액학적지표들 ( 전혈점도, 혈장점도, 혈장섬유단백원 ) 이평가도구로사용되었다. 2) 치료방법실험군에서는주로침치료를시행하였으며사용된經穴은 (Table 4) 와같다. 百會 (GV-20), 風池 (GB-20) 가 4회로가장많이사용되었고太衝 (LR-3) 이 3회로사용되었다. 藥鍼치료는 654-2(anisodamine) 주사액 1ml에 5% NaHCO 3 주사액 4ml를가하여총 5ml 주사액을양쪽陽陵泉 (GB-34) 에 2.5ml씩주입하였다. 頭鍼치료는頭皮前, 後, 側髮際區頭穴과上焦穴點의총 12혈을사용하였다. 한약은진무탕, 반하백출천마탕등이처방되었다. 양약은 betahistine mesilate tablets 6mg /time, 3 times/day를처방한경우와 betahistine hydrochloride sodium chloride injection 500ml + danshen injection 20ml /time, 1 time/day, sibelium capsule 10mg /time, 1 time/day, 취침전, anisodamine 10mg /time, 3 times/day, hydrochlorothiazide 50mg /time, 1 time/day를처방한경우가있었다. 치료기간은 3건의연구에서 10일로나타났고, 그외 3주, 6주가있었다. 3) 치료효과모든연구에서실험군이대조군에비해치료효과가유의하게높게나타났다. LI 14) 의연구에서침치료와한약을병용한군과한약만복용한군은총유효율이각각 93.55% 와 74.19% 로, 침치료를병행한경우유효성이더높게나타났으며 (P<0.05), Zhang 15) 의연구에서는침치료와한약치료를병행한군이양약치료를한경우에비해총유효율이 96.4% 로 82.1% 에비해유의하게높았다 (P<0.05). Chen 등 16) 의연구에서는藥鍼요법과한약치료를병행한군이침치료만시행한군에비해총유효율이 97.7% 로 90% 에비해유의하게높았으며 (P<0.01), Wang 등 17) 의연구에서는침치료와양약치료를병행한군의총유효율이 97.5% 로, 양약치료만시행한군의 85% 에비해유의하게높았고 (P<0.05), 각군의완치율은각각 47.5% 와 25% 로유의한차이가있었다 (P<0.05). Huang 등 18) 의연구에서는頭鍼치료군과일반침치료군을비교하였는데頭鍼치료군의총유효율은 80%, 침치료군은 75% 로통계적으로유의한차이가있었으며 (P<0.05) 혈액학적지표들 ( 전혈점도, 혈장점도, 혈장섬유단백원 ) 도치료후각군간에유의한차이를나타내었다 (P<0.05). 31
Table 3. Summary of Randomized Controlled Trial (RCT) 1 st Author Sample size (E/C) Mean age or ranges(years) (Sex, M/F) Intervention Control Treatment duration Scale Result LI X 62 (31/31) E: 42.71±13.73 (20/11) C: 43.36±17.29 (20/11) A-Tx(30min, daily) + H-med(Zhenwu Decoction, 1 doses of/d) H-med(Zhenwu Decoction, 1 doses of/d) 10 d total significantly efficiency more rate, effective than curative effect the control score group Zhang LY 112 (56/56) E: 41.5±4.2 (24/32) C: 39.2±4.1 (26/30) A-Tx(40min, daily) + H-med(Banxia Baizhu Tianma Decoction, 1 doses of/day) W-med(betahistine mesilate tablets 6 mg /time, 3 times/day) 10 d significantly more total effective than efficiency rate the control group Chen WL 228 (128/100) E: 18-71 (52/76) C: 19-70 (40/60) AI-Tx(every other day, total 5 times) + H-med(1 doses of/d) A-Tx (30min, daily) 10 d significantly more total effective than efficiency rate the control group Wang X 80 (40/40) E: 25-57 (21/19) C: 31-59 (17/23) A-Tx(30min, daily) + W-med(same as control) W-med(betahistine hydrochloride sodium chloride injection 500 ml + Danshen injection 20 ml /time, 1 time/d sibelium capsule 10 mg /time, 1 time/d, before sleep, anisodamine 10 mg /time, 3 times/d, hydrochlorothiazide 50 mg /time, 1 time/d) 6 w significantly full recovery more rate, total effective than efficiency rate the control group Huang S 80 (40/40) E: 55±2 (18/22) C: 55±2 (19/21) Scalp A-Tx(1 h, A-Tx(30min, daily, daily, total 3 total 3 session session 1 session: treatment 1 session: for 5 consecutive treatment for 5 days, rest for 2 consecutive days, days) rest for 2 days) 3 w total efficiency rate, indexes of significantly hemorheology more (whole blood effective than viscosity, the control plasma group viscosity, plasma fibrinogen) E: Experimental group, C: Conrol grup, AI-Tx: acupoint-injection treatment 32
이규영외 1 인 : 메니에르병의침치료에관한최근임상연구동향 Ⅳ. Discussion 메니에르병은뇌신경계의기질적인병변과내이의미로에화농성질환이없이현훈, 이명, 저음성난청의특징적인 3대증상과이충만감, 압박감등이발작적으로반복되는질환이다 20). 어지럼은보통 20분이상지속되며 24시간을넘지않고발작빈도는주 2회에서연 1회까지다양하다. 초기에특징적으로저주파 에서변동성감각신경성난청이나타나나나중에는진행성청력악화가전주파수범위로확대되는경향을보인다. 병의말기에는발작성현기증은멈추지만경증평형이상감과영구적난청, 이명이지속되며, 환자들의약 40% 에서양측성이된다고보고되고있다 3). 치료방침은크게보존적요법, 약물요법, 외과적요법으로나눌수있다. 보존적요법에는저염식및술, 커피, 담배, 스트레스등을피하는방법들이제시되고있지만이들의효과에대한정확한연구보고는 Table 4. Acupoint Used in the Studies 1 st Author Acupoint Lee MS SP3( 太白 ), LU9( 太淵 ), HT8( 少府 ), LU10( 魚際 ), LU8( 經渠 ), LR4( 中封 ), LR2( 行間 ), ST36( 足三里 ) Lee SY GV20( 百會 ), GV23( 上星 ), GV26( 人中 ), CV24( 承漿 ), 太陽 (EX-HN5), Rt.: PC6( 內關 ), HT7( 神門 ), ST36( 足三里 ), SP9( 陰陵泉 ), SP6( 三陰交 ), LR3( 太衝 ), Lt.: TE21( 耳門 ), SI19( 聽宮 ), TE17( 翳風 ), LI11( 曲池 ), LI4( 合谷 ), SP10( 血海 ) Lee SE LI4( 合谷 ), LR3( 太衝 ), HT8( 少府 ), SP2( 大都 ), LR1( 大敦 ), SP1( 隱白 ) Lee KJ GB21( 肩井 ), SI10( 臑兪 ), GB20( 風池 ), TE17( 翳風 ), GV15( 瘂門 ), GV14( 大椎 ), BL12( 風門 ), BL11( 大杼 ), TE21( 耳門 ), SI19( 聽宮 ), TE20( 角孫 ), ST2( 四白 ), GV20( 百會 ), GV23( 上星 ), EX-HN5( 太陽 ), LI4( 合谷 ), LR3( 太衝 ), ST36( 足三里 ) Park JY HT8( 少府 ), SP2( 大都 ), LR1( 大敦 ), SP1( 隱白 ) Lee HH KI10( 陰谷 ), LU5( 尺澤 ), LR1( 大敦 ), LU11( 少商 ), LU8( 經渠 ), LR4( 中封 ), HT8( 少府 ), LR2( 行間 ), HT4( 靈道 ), HT9( 少衝 ) Oh KC SI3( 後谿 ), GB41( 臨泣 ), SI2( 通谷 ), UB66( 前谷 ) Zhang KL Auricular acupoints( 神門, 內分泌, 皮質下, 腦, 肝, 膽, 胃, 內耳, 心 ) Bai RH Feng JP Liu SQ Ling N 中脘 (CV12), 下脘 (CV10), 氣海 (CV6), 關元 (CV4), 商曲 (KI17, both), 氣穴 (KI13, both), GV20( 百會 ) for moxibustion Scalp acupoint: 1.5 cm above the apex of the ear pinna 2 cm before and after each( 暈聽區 ) GV20( 百會 ), EX-HN3( 印堂 ), EX-HN5( 太陽 ), PC6( 內關 ), ST36( 足三里 ), SP6( 三陰交 ), LR3( 太衝 ) Scalp acupoint: 暈聽區 GV20( 百會 ), ST36( 足三里 ), Scalp acupoint: 暈聽區 LI X GB20( 風池 ), GV20( 百會 ), LI4( 合谷 ), PC6( 內關 ) Zhang LY Chen WL Wang X Huang S Both: SI19( 聽宮 ), GB2( 聽會 ), TE17( 翳風 ), GB20( 風池 ) GV21( 前頂 ), GV19( 後頂 ) E: Both GB34( 陽陵泉 ) C: GV20( 百會 ), EX-HN5( 太陽 ), GB20( 風池 ), 中脘 (CV12), PC6( 內關 ), LI4( 合谷 ), GB34( 陽陵泉 ), LR3( 太衝 ) GV20( 百會 ), Both: 供血, SI19( 聽宮 ), TE17( 翳風 ) add LR3( 太衝 ), ST40( 風隆 ), ST36( 足三里 ) as needed E: Scalp acupoints: 頭皮前, 後, 側髮際區頭穴, 上焦穴點 total 12 points C: GV20( 百會 ), Both: GB8( 率谷 ), GB7( 曲鬂 ), GB20( 風池 ), ST36( 足三里 ), ST40( 風隆 ), LR3( 太衝 ), KI3( 太谿 ) 33
없다. 약물요법은혈류개선제, 이뇨제, 스테로이드, 진정제등의경구투여와 aminoglycoside 고실내주입술등이있다. 급성기에는전정억제제와오심구토억제제를사용하여현기증치료를기대하며만성기의내과적치료에는 betahistine, 이뇨제, 스테로이드, calcium antagonist 등이사용되고있다. betahistine 이라는혈류개선제와이뇨제로부작용없이현훈을감소시키나이명이나이충만감은경감되지않으며이뇨제는내림프수종이라는병인에가장부합되는치료방법으로현기증에효과가있다는보고가많으나청력에대한장기효과는불분명하다. 스테로이드와혈류개선제는동물실험을근거로사용되고있지만객관적인증거는없다. 이들모두질병의자연경과를바꾸는효과는거의없는실정이다 2,10,21). 약물치료로호전되지않는환자에게는여러가지수술적치료법을고려할수있다. 외과적요법으로는내림프낭감압술, 전정신경절제술, 미로절제술등이있다. 이러한여러치법들이존재함에도불구하고현재까지는기능을보존하며어지럼발작을예방하고난청의진행을멈추게하는효과적인방법은없다고알려져있으며특히약물치료의효과에대해서는논란이많다. 약물이급성현기증의증상치료에효과적이지만청력보존에어떠한효과가있는지, 또한병의진행을어느정도막을수있는지는아직불분명하다 2,10). 메니에르병은한의학적으로는眩暈, 耳鳴, 耳聾의범주에서다루고있으며 6) 특히眩暈의병태와관련이깊다. 眩暈은역대醫書에頭眩, 眩冒, 眼運, 掉眩등으로기재되어있으며耳鳴, 耳聾, 惡心, 嘔吐, 汗出, 突然昏倒등의증상을수반한다. 眩暈의病因은다양하지만요약하면風, 火, 痰, 虛가주가된다 23). < 黃帝內經素問 > 에는 諸風掉眩皆屬於肝 이라하여風을, 張景岳의 < 景岳全書 > 에서는 眩運一症虛者居其八九而兼火 라고하여虛를, 朱震亨 < 丹溪心法 > 에서는 痰狹氣虛幷火治痰爲主. 無痰則不作眩痰因火動 이라하여痰과火를주요발병인자로보았다 2). 許俊은 < 東醫寶 監 > 에서원인과증세에따라風 熱 痰 氣 虛 濕暈으로분류하고있으며風 熱 痰 氣 虛 濕의병인에근거하여平肝潛陽, 補養氣血, 燥濕化痰, 利水健脾의치법을적용한다 10,23). 眩暈의치법으로朱丹溪 24) 는治痰을제시하였고, 張景岳 25) 은治虛를강조하며證에따라有火者는淸火, 有痰者는治痰, 有氣者는順氣를겸해야한다고주장하였다. 현재까지메니에르병에대한한의학적연구로는침구치료및한약처방을이용한증례보고 8편 2,4,8-13) 과메니에르병의현훈증상에대한침구치료를문헌적으로고찰한연구 1편 6) 및메니에르병의병리기전에대한현대의학의최신연구동향을분석하고메니에르병과관련된한의학연구를고찰한논문 1편 14) 등총 10편에불과하여국내연구는미흡한실정이다. 이에저자는메니에르병의침치료에관한국내및해외최신임상연구동향을분석하여서양의학적으로도명확한치료법이제시되어있지않은메니에르병의치료에침치료를대안으로적용할수있는가능성을모색하고자하였다. 메니에르병의침치료에관한논문은 12편, RCT 연구 5편이있었다. 는대부분침과기타치료를병행한연구였으며, 침치료만시행한연구 2편도頭鍼과體鍼치료를병용한논문 1편과刀鍼치료를시행한논문 1편으로다양한鍼法이활용되었다. 침치료방법중舍巖鍼을사용한연구가 4편으로가장많았으며, 그외일반침 3편, 頭鍼 2편, 나머지八體質鍼, 耳鍼, 刀鍼이각각 1편씩의연구에서사용되었다. 舍岩鍼은臟腑의氣순환이특별히잘나타나는五輸穴에木火土金水五行을배합하여, 臟腑의虛實에따른鍼灸補瀉法을상생계뿐만아니라상극계의원리를세워虛則補其母하고實則瀉其子하여子他經補瀉로疾病을치료하는鍼法이다 26). 舍巖鍼法중에서는脾正格이가장많이사용되었으며이는메니에르병에서현훈이심할경우동반되는오심, 구토의자율신경계증상과도관련이되며, 眩暈의病因중痰, 虛와관련되어消痰健脾하는작용을갖기때문인것으로 34
이규영외 1 인 : 메니에르병의침치료에관한최근임상연구동향 사료된다. 頭鍼療法은한의학의刺針方法을서양의학의大腦皮質區의기능과연관시켜頭皮의상응부위에刺鍼하여질병을치료하는방법이다. 頭鍼治療와刀鍼療法에공통적으로暈聽區가사용되었는데이는耳尖直上 1.5cm되는곳에서전후로각 2cm부위를그은 4 cm의선으로耳鳴, 眩暈, 메니에르병등을주치한다 27). 또한 에서는足三里 (ST-36), 百會 (GV-20) 가가장많이사용되었으며 RCT 연구에서는百會 (GV-20), 風池 (GB-20) 가가장많이사용되었다. 공통적으로百會 (GV-20) 가다용되었는데百會 (GV-20) 는巓頂의正中에위치하여, 手三陽, 足三陽, 督脈, 足厥陰이交會하는곳으로開竅醒腦, 淸熱熄風의효능이있어頭痛, 耳鳴등의치료에자주사용된다 28). 風池 (GB-20) 는頭部에위치하고足少陽膽經에屬하여疏散少陽風熱, 淸頭目, 利官竅하여頭痛, 耳聾등을치료하며外風외에도內風을막아熄風化痰安神하여眩暈등을치료한다. 足三里 (ST-36) 는機體强壯의要穴로益氣養血, 補益强壯, 扶正培元등의효능이있어頭暈, 耳鳴등瘦弱虛損의질환을치료하며足陽明胃經의合土穴이고自性穴 ( 土經의土穴 ) 이며四總穴의하나로肚腹을주관하여脾胃疾患에탁월한효과가있어惡心, 嘔吐등의치료에적용할수있다 29). RCT 연구에서대조군으로쓰인양약을살펴보면우선 anisodamine이있으며이는항콜린제 (anticholinergic) 및알파차단제 (α1 adrenergic receptor antagonist) 로서항콜린제는아세틸콜린수용체를차단하여그작용을하지못하게하는제제로혈압이떨어지고심장박동이느린환자의경우정맥을통해응급으로투여하면심장박동수를빠르게하고혈압을올려주는작용이있으며 30) 알파차단제는아드레날린작용제의 α-수용체에서의작용을특이적으로차단하는약으로임상적으로는말초혈관의순환장애나쇼크상태등에사용된다 31). 메니에르병에서는혈류순환을개선하기위한목적으로사용된것으로보인다. 또한 sibelium capsule 도사용되었는데이는성분이 flunarizine 인 calcium antagonist 로전정계의기능성장애에의한어지러움등에처방되며 32) 칼슘길항제는칼슘이온의세포밖에서세포내로의유입을저해함으로써심근이나평활근의수축을억제하는약물로혈관확장등의작용을갖는다 31). 또한 betahistine 은히스타민 H 3 수용체의길항제이자히스타민 H 1 수용체의작용제로서주로내이의혈관에있는 H 1 수용체에작용하여국소적혈관확장과증가된투과성을일으키며, H 3 수용체에서강력한길항작용으로신경말단에서방출되는히스타민, 아세틸콜린, 노르에피네프린, 세로토닌및 GABA의수준을증가시켜혈관확장효과를나타낸다 33). hydro- chlorothiazide라는 thiazide계이뇨제도사용되었다. 모든 RCT 연구에서는평가 scale 로총유효율을사용하였는데, 3편의연구에서는완치, 현저한효과, 유효, 무효의 4단계로, 2편의연구에서는완치, 유효, 무효의 3단계로나누어전체치료중유효이상의효과를나타낸비율을구하여평가하였다. 또한혈액학적지표들 ( 전혈점도, 혈장점도, 혈장섬유단백원 ) 이평가도구로사용된점이특이했는데頭鍼치료군과일반침치료군모두에서혈액의점도와관련된지표들이치료후낮아졌으며頭鍼치료군에서보다유의한효과를나타냈다. 이는메니에르병의치료에각종혈류개선약물이사용되는것과도관련되며, 메니에르병의병리에혈액점도상승으로인한혈액순환장애가관련되어있을가능성을추정해볼수있어, 추후혈액학적으로추가적인연구가필요할것으로사료된다. 상기연구는메니에르병의침치료에관한국내외최신임상연구동향을분석하였으며, 연구결과들을통해메니에르병에서침치료가단독혹은다른치료와병행되었을때유의한효과를나타내는것과더불어다양한鍼法의효과도확인해볼수있었다는의의를갖는다. 하지만현재까지의메니에르병의침치료에대한국내연구는대부분 로증례수가적고관찰기간이짧다는한계가있으며 와 RCT 연구모두단일기관에서의연구로평가 scale 이 35
일관되지않고침치료외에다른치료가같이시행된경우가많아침치료만의객관적인효과판정에는어려움이있었다. 그리고연구안전성과관련된부작용이나이상반응에대한보고가 에서는없었으며 RCT 연구에서는 5편중 2편에서만이상반응이나타나지않았다고보고하였다. 또한 RCT 연구는 3 편이단일 session 연구이며나머지는각각 3, 6 session 으로연구기간이짧고치료후추적관찰평가가 3편에서만이루어졌으며연구대상자의선정 제외기준은 3편에서, 탈락기준은 2편에서만기재되었다는한계가있었다. 한편, 이번연구는 2000~ 2018년에발표된논문을대상으로하였지만최근연구는 2013, 2014년에이루어져최근 4~5년간은침치료를대상으로한연구가없었다. 반면메니에르병의병리기전등에관한논문은 2015년이후에도꾸준히발표되고있다. 이는메니에르병의기전및치료방법을밝히려는연구는계속되고있으나침치료에대한연구는부족함을시사하며향후이러한점들을보완하여침치료만을대상으로한다양한체계적인연구가이루어져야할것으로사료된다. Ⅴ. Conclusions 4. 의치료효과판정은대부분의연구에서증상변화또는증상의정도를점수화하는방법 (GAS, VAS), 청력역치, 재발유무를기준으로하였다. 5. 12편의증례보고에서모두메니에르병의호전이있었다. 6. RCT 연구 5편중침과한약 vs 한약을비교한연구가 1편, 침과한약 vs 양약을비교한연구가 1 편, 약침과한약 vs 침을비교한연구가 1편, 침과양약 vs 양약을비교한연구가 1편, 頭鍼 vs 일반침을비교한연구가 1편있었다. 7. 모든 RCT 연구에서효과를판정하기위한 scale 로총유효율을사용하였다. 8. RCT 연구의실험군에서는주로침치료를시행하였으며사용된經穴은百會 (GV-20), 風池 (GB-20) 가 4회로가장많이사용되었고太衝 (LR-3) 이 3회로사용되었다. 9. 모든 RCT 연구에서실험군이대조군에비해치료효과가유의하게높게나타났다. 10. 이상의결과를통해메니에르병에서침치료가단독혹은다른치료와병행되었을때유의한효과를나타내는것을확인할수있었다. 메니에르병의침치료에관한국내및해외최신임상연구동향을정리, 분석한결과다음과같은결론을얻었다. 1. 연구형태별로는국내 7편, 중국 case study 5편, 중국 RCT 논문 5편이있었다. 2. 는침치료만시행한연구가 2편, 침과한약및기타치료를병행한연구가 9편, 침과뜸을사용한연구가 1편있었다. 3. 에서는足三里 (ST-36), 百會 (GV-20) 가 5회로가장많이사용되었으며, 太衝 (LR-3) 이 4회, 太陽 (EX-HN5), 合谷 (LI-4), 大敦 (LR-1), 少府 (HT-8) 이 3회로사용되었다. References 1. Lee CG, Park MK, Lee JD, Park JY, Lee TK, Sung KB. Prognosis of hearing according to the presence of recurrent vertigo in Meniere's disease. Research in Vestibular Science. 2011;10(4):134-7. 2. Lee KJ, Nam HJ, Kim YB. Two cases of Meniere's disease. J Korean Med Ophtalmol Otolaryngol Dermatol. 2005;18 (3):158-64. 3. Adolfo MB, Thomas L. Dizziness:A practical approach to diagnosis and management. 36
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