水平（外側）半規管型BPPV クプラ結石症に対する新規治療法
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1 Equilibrium Res Vol. (3) BPPV New treatment strategy for the cupulolithiasis associated with horizontal canal BPPV, Head-tilt hopping exercise Toshiaki Yamanaka 1), Yachiyo Sawai 1), Takayuki Murai 1), Nobuya Fujita 2), Hiroshi Hosoi 1) 1) Department of Otolaryngology Head and Neck Surgery, Nara Medical University School of Medicine 2) Department of Otorhinolaryngology, Nara Prefectural Nara Hospital This study was performed to determine if a new treatment was effective for cases with benign paroxysmal positional vertigo (BPPV) suggesting cupulolithiasis of the horizontal semicircular canal as characterized by apogeotropic direction-changing nystagmus. We describe herein our head-tilt hopping (HtH) exercise designed to release and move otoconia adhesive to the cupula. Subjects were trained to hop with their heads tilted laterally. They completed 35 training sessions a day over a 4week period. Each session ended with a 20 -hop trial. HtH exercises were performed in 14 cases with intractable horizontal canal BPPV exhibiting persistent nystagmus beating toward the uppermost ear. The spine roll test was tested on all subjects before and immediately after the first trial, as well as after 1 and 4 weeks of the training to evaluate the effect of this treatment on the apogeotropic nystagmus. The nystagmus disappeared or decreased immediately after the first trial with the exercise in 3 and 2 of 14 cases, respectively. The number of subjects showing improvement as assessed by the disappearance or decrease of the nystagmus were in 9 (64.3%) and 11 (78.6%) of all cases tested at 1 and 4 weeks time, respectively. However the remaining 3 subjects were not affected by this treatment program after 4 week of the training. These results suggest that HtH exercises based on the concepts of release of otoconia from the cupula would appear to be feasible as a new therapy for cupulolithiasis associated with intractable horizontal canal BPPV Key words: horizontal canal, BPPV, new physical therapy, hopping exercise, cupulolithiasis ( 127 )
2 Equilibrium Res Vol. (3) BPPV BPPV BPPV AAO-HNS null position BPPV BPPV ( 128 )
3 Equilibrium Res Vol. (3) M/F:/ R/L:/ / # 1 73 M (R) 4 19 # 2 72 M (R) 6 9 # 3 68 F (L) 8 23 # 4 67 F (R) 3 15 # 5 53 F (L) 4 22 # 6 72 F (L) 7 11 # 7 56 F (R) 3 20 # 8 63 F (L) 10 7 # 9 66 F (L) 4 12 # F (R) 2 11 # M (L) 6 18 # M (R) 8 13 # F (R) 5 12 #14 60 F (L) 4 15 BPPV CCD ( 129 )
4 Equilibrium Res Vol. ６９(3) ᡷༀ ᶖᄬ 䋨㪊 䋩 㪘㪅㩷 ᓟ ዋ 䋨㪉 䋩 ਇᄌ 䋨㪐 䋩 ᶖᄬ 䋨㪏䋩 㪙㪅㩷䋱ㅳᓟ ዋ 䋨㪈䋩 ਇᄌ 䋨㪌䋩 ᶖᄬ 䋨㪈㪇䋩 㪚㪅㩷㪋ㅳᓟ 㪇㩼 㪈㪇㩼 㪉㪇㩼 㪊㪇㩼 㪊㪌㪅㪎㩷㩼 ዋ 䋨㪈䋩 㪋㪇㩼 㪌㪇㩼 㪍㪇㩼 㪎㪇㩼 㪏㪇㩼 㪍㪋㪅㪊㩷㩼 ਇᄌ ᄌ 䋨㪊䋩 㪐㪇㩼 㪎㪏㪅㪍㩷㩼 㪈㪇㪇㩼 䋺ᶖᄬ ᡷༀ (%)䋽ᶖᄬ+ ዋ( 䋩/ ( 䋩㬍100 䋺 ዋ 䋨㗫ᐲ 㪌㪇㩷㩼䋩 䋺ਇᄌ 䋨㪌㪇㩷㩼䋼㗫ᐲ 㪈㪇㪇㩷㩼䋩 図３ 結石遊離法の効果 治療施行直後に３例 １週後に９例 ４週後には１１例が改善を示した ２ 実際に診察室で１セッション施行の直後に 眼振を観察すると 消失は３例 減少は２例に認 められ １４例中５例で改善を示し改善率は３５ ７ であった 図３ Ａ 消失した３例のうち 即座 に直接消失したものは１例で ２例はいったん下 ７ 向性に変化したが 頭位治療 Lempert 当科変法 を行うことにより直ちに消失した 図４ その 後 １週間の自宅トレーニングを行うと 消失例 はさらに５例増加して８例になり 減少１例と合 わせて改善例は計９例で６４ ３ の改善率を示した 図３ Ｂ さらに４週後には１４例中１１例が改善 を示したことにより 本療法による最終的な改善 率は７８ ６ に達した 図３ Ｃ しかし 残りの ３例 ２１ ４ は眼振に変化が認められず治療の 影響を受けなかった 眼振が１週で消失した後に 再発した症例が１例に認められたので 図２ これを含めると今回の検討で一度でも眼振が消失 したのは１１例でそのうち４例が下向性眼振への移 行を経由した 図４ また 眼振が消失するの に治療を要した期間を調べると ３例が１回施 行 ５例が１週間 ３例が４週間であり １１例中 ８例が１週以内に眼振の消失を示した 図４ なお 本研究では 転倒や捻挫などの有害事象は 全く認められず 治療によって新たなめまいを誘 ( 130 ) 発した症例もなかった 考 察 臥位頭位検査で持続する方向交代性上向性 背 地性 眼振が認められる場合 水平 外側 半規 管膨大部のクプラに結石が付着している病態にあ ることが多いと考えられている８ ９ 本病態はいわ ゆる水平 外側 半規管型 BPPV のクプラ結石 症と呼称されて一般に取り扱われている１ ２ が 診断に関しての基準は明確になっていない 今 回 水平 外側 半規管型 BPPV のクプラ結石 症に対する診断精度を高めるために 結石 重さ を有するクプラの位置と重力方向の関係によって 規定される頭位眼振の特徴を表す３項目を選んで 診断条件とした ひとつは通常の基準になってい る①臥位頭位検査で持続する １分以上 方向交 代性上向性眼振を示すこと であるが それ以外 に クプラ面が鉛直方向にあるとクプラは重力の 影響を受けず偏位しない特性から ②眼振が消失 ６ する頭位 null position が存在すること さら に 眼振の方向性はクプラに一定の重力が加わる 特定の頭位によって決定され 頭位変換の方向に 影響を受けない特徴から ③臥位での眼振の向き が左あるいは右下頭位どちらからの頭位変換でも 同方向であること を診断する条件として付加し
5 Equilibrium Res Vol. (3) 4 7 BPPV hopping jumping exercise ( 131 )
6 Equilibrium Res Vol. (3) Brandt-Daroff AAO-HNS BPPV BPPV Baloh RW, Yue Q, Jacobson KM, et al.: Persistent directionchanging positional nystagmus: Another variant of benign positional nystagmus? Neurology 45: , 1995 Bhattacharyya N, Baugh RF, Orvidas L, et al.: Clinical practice guidance: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 139: 4781, 2008 Equilibrium Res 68: , 2009 Bisdorff AR, Debastisse D: Localizing signs in positional vertigo due to lateral canal cupulolithiasis. Neurology 57: , 2001 ( 132 )
7 Equilibrium Res Vol. (3) BPPV Equilibrium Res 65: , 2006 Casani A, Giovanni V, Bruno F, et al. : Posiotional vertigo and ageotropic bidirectional nystagmus. Laryngoscope 107: , 1997 Equilibrium Res 65: , 2006 BPPV Equilibrium Res 65: , 2006 Brandt T, Daroff RB: Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 106: , 1980 Equilibrium Res 61: , 2002 Equilibium Res 59: , 2000 BPPV Nuti D, Vannucchi P, Pagnini P: Benign paroxysmal positional vertigo of the horizontal canal; a form of canalolithiasis with variable clinical features. J Vestib Res 6: , 1996 Equilibrium Res 55: , 1996 Equilibrium Res 64: , 2005 ( 133 )
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