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Research in Vestibular Science Vol. 17, No. 3, September 2018 O riginal A rticle pissn 2092-8882, eissn 2093-5501 https://doi.org/10.21790/rvs.2018.17.3.90 현훈을동반한돌발성감각신경성난청환자에서의전정기능과예후 이세아, 김효준, 김보경, 이종대 순천향대학교의과대학부천병원이비인후과 Vestibular Function and Prognosis of Sudden Sensorineural Hearing Loss with Vertigo Se A Lee, Hyo Jun Kim, Bo Gyung Kim, Jong Dae Lee Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea Received Jun 1, 2018 Revised Jun 4, 2018 Accepted Jun 4, 2018 Corresponding Author: Jong Dae Lee Department of Otorhinolaryngology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 14584, Korea Tel: +82-32-621-5015 Fax: +82-32-621-5016 E-mail: ljdent@schmc.ac.kr ORCID code: https://orcid.org/0000-0003-2866-9841 Copyright c 2018 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. Objectives: Vertigo combined with sudden sensorineural hearing loss (SSNHL) is known as a poor prognostic factor. We investigated clinical findings and vestibular function tests in patients of SSNHL with vertigo to find the prognostic factors. Methods: We retrospectively evaluated data on the patients diagnosed with SSNHL with vertigo at Bucheon Soonchunhyang University Hospital from March 2009 to February 2018. We reviewed medical records and the results of vestibular function tests and audiometry. Results: Of the 68 patients, 30 (44.1%) showed profound hearing loss and 53 (77.9%) showed poor recovery. Age and the degree of initial hearing loss showed negative prognostic factor in hearing recovery. Abnormal results of cervical vestibular evoked myogenic potentials (cvemp) also showed significantly differences between good and poor recovery groups. Conclusions: In this study, most of the patients of SSNHL with vertigo showed poor recovery. Age, degree of initial hearing loss, and the abnormal result of the cvemp have a negative effect on the prognosis of hearing recovery. Res Vestib Sci 2018;17(3):90-94 Keywords: Sudden sensorineural hearing loss; Vertigo; Prognosis; Vestibular function 서론돌발성난청은일년에 10만명당 5 20명정도에서특별한원인없이갑자기발생하는감각신경성난청으로이명과현훈등의증상을동반하기도한다. 발병원인이나기전에대해서는아직명확하게밝혀지지않았으나, 바이러스감염, 혈관장애, 내이질환등이원인으로생각되고있다 [1,2]. 일반적으로돌발성감각신경성난청환자의자연회복률은약 32% 65% 정도로보고되고있다 [2,3]. 하지만, 소아나 40세이상의연령, 현훈, 고음역의청력소실, 어음명료도의저하등이동반된경우에는예후가불량한것으로알려져있다 [2,4,5]. 특히, 돌발성감각신경성난청환자의 30% 40% 는현훈을 90

이세아외 3 인. 현훈을동반한돌발성감각신경성난청환자의전정기능 호소하는데, 현훈이동반되는경우청력소실이심한경우가많고, 현훈이없는돌발성감각신경성난청환자와비교하면회복률이좋지않은것으로알려져있다 [6]. 예후가나쁘다고알려진현훈을동반한돌발성감각신경성난청환자에서온도안진검사, 양성돌발두위현훈, 경부전정유발근전위 (cervical vestibular evoked myogenic potential) 등다양한요인이청력회복에영향을미친다고보고자마다다르게보고되고있다 [7-9]. 따라서이번연구는현훈을동반한돌발성감각신경성난청환자에서의전정기능검사결과와예후와의연관성을알아보고자하였다. 대상및방법 1. 대상 2009년 3월부터 2018년 3월까지본원이비인후과에내원하여급성돌발성감각신경성난청으로진단받고치료받은환자중에서현훈을동반한환자를대상으로후향적의무기록을분석하였다. 돌발성난청의과거력이있거나, 중추성현훈이나메니에르병이의심되는경우, 중이염이있는경우, 내원하여시행한자기공명영상에서전정신경초종이있는경우는대상에서제외하였다. 경우불변 (no improvement) 로구분한뒤, 완전회복과부분회복을좋은회복 (good recovery), 경도회복과불변을나쁜회복 (poor recovery) 로보았다 [11]. 대상환자들은외래에서 frenzel goggle (Nagashima Medical Instruments, Tokyo, Japan) 을이용하여자발안진검사와체위성안진검사를시행하여자발안진유무와양성돌발두위현훈동반여부를확인하였다. 온도안진검사는환자를 60 o 눕힌상태에서외이도에섭씨 24 o C와 50 o C의공기로 1분간온도자극을주었으며, Jonkee 공식을이용하여반고리관마비를계산하였다. 반고리관마비 (canal paresis) 가 25% 이하를정상, 초과하였을때를비정상으로해석하였다. 경부전정유발근전위검사는 90 db의클릭음을헤드폰으로자극하였고, p13과 n23의잠복기와진폭차의비를구하여본원검사실정상치와비교하였다. 파형이없거나양이진폭차의비 (vestibular evoked myogenic potential asymmetry) 가 27.7을초과했거나, p13의잠복기가 15.07 msec을초과했을때비정상으로하였다 [12]. 통계는 IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA) 프로그램을이용하여환자의임상양상및전정기능의손상정도와청력회복과의관계는 Student t-test 와 chi-square test 또는 Fisher exact test를통해검증하였다. 통 2. 방법현훈을동반한급성돌발성감각신경성난청환자에서입원당시측정한순음청력검사, 자발안진검사, 체위성안진검사, 온도안진검사, 경부전정유발근전위검사등을분석하였다. 순음청력검사는 500, 1,000, 2,000, 4,000 Hz에대한주파수별청력손실을 4분법으로평균청력역치를계산하였다. 이환초기의난청의정도는 Hong 등 [10] 이분류한방법에따라 grade 1 (26 55 db), grade 2 (56 90 db), grade 3 (91 db 이상 ) 로분류하였다. 2개월간의추적관찰후청력회복을평가하였는데, 청력회복은 Sigel s criteria를기준으로 25 db 역치이내로청력호전이있는경우완전회복 (complete recovery), 15 db 이상청력호전이있고최종 25 45 db 범위의청력역치인경우를부분회복 (partial recovery, PR), 15 db 이상청력호전이있고최종 45 db 이상범위의청력역치인경우를경도회복 (slight recovery), 15 db 미만으로청력호전이있거나최종 75 db 이상범위의청력역치인 Table 1. Demographic and clinical characteristics of SSNHL with vertigo patients Demographic findings Value Age (yr) 49.46±15.17 Sex, male:female 35:33 (51.5:48.5) Hearing loss side, right:left 31:37 (45.6:54.4) Degree of initial hearing loss Grade 1 14 (20.6) Grade 2 24 (35.3) Grade 3 30 (44.1) Spontaneous nystagmus 15 (22.1) BPPV 7 (10.3) Canal paresis Normal 41 (60.3) Abnormal 27 (39.7) cvemp Normal 22 (32.4) Abnormal 46 (67.6) Values are presented as mean±standard deviation or number (%). SSNHL, sudden sensorineural hearing loss; BPPV, benign paroxysmal positional vertigo; cvemp, cervical vestibular evoked myogenic potential. 91

계학적유의수준은 p-value 0.05 미만으로하였다. 결 과 경부전정유발근전위검사결과는통계적으로유의한차이를보였다. 그외, 성별, 병변의위치, 자발안진과양성돌발두위현훈유무, 온도안진검사결과는유의한차이가없었다. 총 68명의환자를이번연구에포함하였다 (Table 1). 이들의평균연령은 49.46±15.17세였고, 성별에따라남자가 35명 (51.5%), 여자가 33명 (48.5%) 이었다. 이환초기청력소실정도는 grade 1이 14명 (20.6%), grade 2가 24명 (35.3%), grade 3가 30명 (44.1%) 이었다. 자발안진이 15명에서관찰되었고, 온도안진검사상비정상은 27명 (39.7%) 이었고, 경부전정유발근전위검사에서비정상소견은 46명 (67.6%) 이었다. 또한 7명에서병변측에양성돌발두위현훈이동반되었는데, 5명은후반고리관결석증, 2명은수평반고리관결석증이었다. 최종회복정도를분석했을때, 15명은좋은회복, 53명은나쁜회복에해당하였다 (Table 2). 좋은회복군의평균연령은 41세로나쁜회복군의평균연령인 52세보다유의하게낮았으며, 두군간의초기청력소실정도는나쁜회복을보인군에서보다높은경향성을보였고, 또한나쁜회복을보인군에서비정상적인경부전정유발근전위검사가흔했다. 두군간에환자의연력및초기청력소실정도, Table 2. The difference between good and poor recovery in patients of SSNHL with vertigo Findings Good recovery (n=15) Poor recovery (n=53) p-value Age (yr) 41.00±13.79 51.85±14.79 0.013* Sex, male:female 6:9 29:24 0.314 Hearing loss side, right:left 9:6 22:31 0.204 Degree of initial hearing loss 0.024* Grade 1 5 9 Grade 2 8 16 Grade 3 2 28 Spontaneuous nystagmus 2 13 0.492 BPPV 1 6 0.999 Canal paresis 0.568 Normal 10 31 Abnormal 5 22 cvemp 0.049* Normal 8 14 Abnormal 7 39 Values are presented as mean±standard deviation or number. SSNHL, sudden sensorineural hearing loss; BPPV, benign paroxysmal positional vertigo; cvemp, cervical vestibular evoked myogenic potential. 고찰돌발성난청은 1944년 De Kleyn [13] 이처음보고한이후현재까지도정확한원인이나예후에대해밝혀지지않았다. Noury와 Katsarkas [14] 은돌발성난청에서현훈이동반되면청력소실정도가농이거나고음역청력소실이동반되는경우가많다고하였고, Nakashima와 Yanagita [15] 의연구에서도비슷한결과를보였다. 이연구에서는현훈을동반한돌발성감각신경성난청환자를대상으로연구를진행하였다. 전체환자 68명의환자중에서 91 db 이상의청력소실을보이는환자가 30명 (44.1%) 이고, 나쁜회복을보이는경우가 53명 (77.9%) 이었는데, 현훈이동반된경우초기청력소실정도가심한경우가많고, 나쁜예후를보이는기존의연구결과와유사하였다. 예후에있어서초기의청력소실정도가연관성이있다고알려져있다. Sheehy [16] 은초기의청력손실이클수록예후가나쁘다고보고하였다. Hong 등 [17] 의연구에서초기청력소실이 100 db가넘는전체환자에서완전회복을보인환자는한명도없었고, 단두명만이부분회복을보였다. 이연구에서도이환초기의청력소실정도가좋은회복과나쁜회복을보인두환자군에서유의한차이를보였으며고도난청을보인환자들이많은영향이라고생각한다. 양성돌발두위현훈이동반된돌발성난청이청력회복에미치는영향에대해서는아직논란이많다. Lee와 Ban [18] 은돌발성난청환자에서동반된양성돌발두위현훈은미로의손상을보이는것으로, 돌발성난청의나쁜예후인자라고보고하였다. 반면, Kim 등 [19] 은양성돌발두위현훈이동반된돌발성난청환자가양성돌발두위현훈이없는돌발성난청환자와유의한차이를보이지않았고, 양성돌발두위현훈이주요예후인자로볼수없다고보고하였다. 이연구에서도양성돌발두위현훈은치료후회복과유의하지않은상관관계를보였다. 현훈을동반한돌발성감각신경성난청환자에서의전정신경검사와청력회복에대한다양한연구들이보고되었다. Iwasaki 등 [20] 은연구를통해온도안진검사와전정유발근전위검사의비정상소견과청력회복과의관계에대하여 92

이세아외 3 인. 현훈을동반한돌발성감각신경성난청환자의전정기능 보고하였다. 현훈을동반한돌발성감각신경성난청환자의 45% 에서온도안진검사상이상소견을보였고, 77% 에서전정유발근전위검사상파형의소실을보였는데, 온도안진검사상이상을보인환자중 50% 이상청력회복을보인환자는 20% 밖에보이지않았다. Shih 등 [21] 의연구에서는, 현훈을동반한돌발성난청환자중, 온도안진검사상비정상반응을보인경우, 정상반응을보인경우보다청력회복이나쁜경우통계적으로유의하게많음을보고하였다. 특히, 돌발성난청의예후와전정유발근전위검사와의연관성에대한연구들을살펴보면, Hong 등 [10] 의연구에서는전정유발근전위반응의비정상파형과청력회복의정도는유의한차이를보이지않았으나, Yun 등 [22] 의연구에서는전정유발근전위검사상정상과비정상두군간청력회복의차이를보여예후에영향을미치는것으로나타났다. 이연구에서는온도안진검사상에서는유의하지않았으나, 나쁜회복을보인환자군에서경부전정유발근전위반응의비정상소견을보인비율이 73.6% 로좋은회복을보인환자군과비교하여통계학적으로유의하게높은수치를보였다. 구형낭과와우의해부학적위치가가까워서소리에너지전달과정에서동시에손상이발생가능하다는점과둘다총와우동맥 (common cochlear artery) 에서혈액공급을받는다는점과연관이있다고생각된다 [23,24]. 이연구의한계점으로는현훈을동반하지않은군을조사하여비교하지않은점, 증례수가많지않다는점, 환자의전정기능을평가하는데있어수평반고리관과구형낭에국한되어있다는점이있다. 또한, 환자의청력도의양상에대한연구가이뤄지지않아청력도양상과돌발성감각신경성난청의예후와의관계를확인할수없었다. 결론적으로, 현훈이동반된돌발성감각신경성난청환자에서대부분이나쁜청력회복을보였고, 환자의나이, 이환초기청력소실정도, 경부전정유발근전위검사상비정상파형을보인경우에서청력회복에나쁜예후를보였다. 중심단어 : 돌발성감각신경성난청, 현훈, 예후, 전정기능이해관계 (CONFLICT OF INTEREST) 저자들은이논문과관련하여이해관계의충돌이없음을명시합니다. 감사의글 (ACKNOWLEDGMENTS) 이연구는순천향대학교연구기금의지원을받았습니다. REFERENCES 1. Chau JK, Lin JR, Atashband S, Irvine RA, Westerberg BD. Systematic review of the evidence for the etiology of adult sudden sensorineural hearing loss. Laryngoscope 2010;120: 1011-21. 2. Mattox D E, Simmons FB. Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol 1977;86(4 Pt 1):463-80. 3. Conlin AE, Parnes LS. Treatment of sudden sensorineural hearing loss: I. A systematic review. Arch Otolaryngol Head Neck Surg 2007;133:573-81. 4. Byl FM Jr. Sudden hearing loss: eight years' experience and suggested prognostic table. Laryngoscope 1984;94(5 Pt 1):647-61. 5. Mattox DE, Lyles CA. Idiopathic sudden sensorineural hearing loss. Am J Otol 1989;10:242-7. 6. Shaia FT, Sheehy JL. Sudden sensori-neural hearing impairment: a report of 1,220 cases. Laryngoscope 1976;86:389-98. 7. Park K, Chung JH, Min HJ, Lee SH, Park CW. Evaluation of vestibular function in idiopathic sudden sensorineural hearing loss. Korean J Otorhinolaryngol-Head Neck Surg 2010;53: 761-7. 8. Niu X, Zhang Y, Zhang Q, Xu X, Han P, Cheng Y, et al. The relationship between hearing loss and vestibular dysfunction in patients with sudden sensorineural hearing loss. Acta Otolaryngol 2016;136:225-31. 9. Park HM, Jung SW, Rhee CK. Vestibular diagnosis as prognostic indicator in sudden hearing loss with vertigo. Acta Otolaryngol Suppl 2001;545:80-3. 10. Hong SM, Byun JY, Park CH, Lee JH, Park MS, Cha CI. Saccular damage in patients with idiopathic sudden sensorineural hearing loss without vertigo. Otolaryngol Head Neck Surg 2008;139:541-5. 11. Siegel LG. The treatment of idiopathic sudden sensorineural hearing loss. Otolaryngol Clin North Am 1975;8:467-73. 12. Lee JD, Park MK, Lee BD, Park JY, Lee TK, Sung KB. Otolith function in patients with head trauma. Eur Arch Otorhinolaryngol 2011;268:1427-30. 13. De Kleyn A. Sudden complete or partial loss of function of the octavus-system in apparently normal persons. Acta Otolaryngol 1944;32:407-29. 14. Noury KA, Katsarkas A. Sudden unilateral sensorineural hearing loss: a syndrome or a symptom? J Otolaryngol 1989; 18:274-8. 15. Nakashima T, Yanagita N. Outcome of sudden deafness with and without vertigo. Laryngoscope 1993;103:1145-9. 16. Sheehy JL. Vasodilator therapy in sensory-neural hearing loss. Trans Am Laryngol Rhinol Otol Soc 1960;1960:570-602. 93

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