online ML Comm Clinical Review Korean J Otorhinolaryngol-Head Neck Surg 2015;58(10): / pissn / eissn

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1 online ML Comm Clinical Review Korean J Otorhinolaryngol-Head Neck Surg 2015;58(10): / pissn / eissn Pediatric Chronic Rhinosinusitis Hyun-Jin Cho and Hyo Yeol Kim Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 소아만성비부비동염 조현진 김효열성균관대학교의과대학삼성서울병원이비인후과학교실 Received February 23, 2015 Accepted June 5, 2015 Address for correspondence Hyo Yeol Kim, MD, PhD Department of Otorhinolaryngology- Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel Fax siamkhy@gmail.com Pediatric rhinosinusitis is a common complication of viral upper respiratory infection (URI). According to the previous clinical researches, it has been found that more than 5 percent of children who suffered from URI might be diagnosed with rhinosinusitis. Especially, it might be challenging to clinicians for managing the children with high risk such as, presenting with severe symptoms, younger than 2 years, attending daycare facilities, or who are suspected antimicrobial resistance. Recently, evidence-based guidelines for the diagnosis and treatment of pediatric rhinosinusitis were introduced by the international societies comprising experts of otorhinolaryngology, pediatrics, and infectious disease. In this review, the authors would like to focus on the diagnosis and management of pediatric chronic rhinosinusitis to update and summarize the consensus from these guidelines and recent researches. Korean J Otorhinolaryngol-Head Neck Surg 2015;58(10): Key WordsZZChildren ㆍ Rhinosinusitis ㆍ Saline ㆍ Surgery. 서 론 해알아보고자한다. 소아의경우평균 1년에 6~8회이상감기에걸리게되며이중 5~10% 에서비부비동염으로이환된다. 1,2) 이러한감염은놀이방이나유치원등공동생활을하는아이들에서더흔하며, 최근여성의사회진출이활발해짐에따라아이들이공동생활을할기회가많아져점점그감염의기회가늘고있어, 이러한소아비부비동염의병태생리나진단, 치료에대한정확한지식이있어야할것으로생각된다. 최근미국과유럽에서는비부비동염의진단및치료를위한가이드라인이각각발표되었으나, 소아비부비동염의진단및치료에는아직까지도규명되지못한부분들이많다. 3,4) 저자들은본종설에서이러한소아비부비동염, 특히만성비부비동염의진단과치료에있어흔히지나치기쉬운쟁점들이나논란의여지가있는부분에대한현재까지의연구결과들과최근의국제적가이드라인에서권장하는지침에대 본론 동반질환또는위험인자들만성비부비동염은염증으로인해부비동의입구가막히게될경우발생하게된다. 이는비강내분비물의저류와환기장애를일으켜점막내로의산소의흡수및음압상태를야기시킨다. 따라서비강또는비인두에있는분비물의역류가부비동내로일어나게되며바이러스감염이있을경우, 이또한섬모운동의장애를일으켜세균의증식이일어나기쉬운상태가된다. 이러한바이러스감염외에도비부비동염을일으키기쉬운인자들로서는알레르기비염이나천식, 아데노이드증식, 담배연기등의대기오염물질들, 놀이방등의공동생활, 위식도역류, 면역기능이상등이있으며비부비동의구조적이상은별연관이없는것으로알려져있다. 4) Copyright 2015 Korean Society of Otorhinolaryngology-Head and Neck Surgery 667

2 Korean J Otorhinolaryngol-Head Neck Surg 2015;58(10): 알레르기비염알레르기비염은소아만성비부비동염에서흔히동반되는질환이나, 두질환의연관성에관해서는아직논란의여지가있다. 먼저과거의연구들을살펴보면, 알레르기비염이비부비동염과연관성이높은것으로보고되고있으며정상군에서알레르기비염의유병률은 15~20% 정도인데반해비부비동염환아의 80% 정도에서알레르기비염에대한가족력이보고되고있고, 5,6) 보고에따라서는알레르기와천식이반수이상에서관찰되었다는보고도있다. 7) 알레르기염증에의해부비동염이발생하는원인으로서가장흔히생각되는것은부비동입구의폐쇄이다. 알레르기염증에의한점막부종이부비동입구의폐쇄를일으키고이것이점액배출과환기를방해하여점액의저류, 섬모운동의감소및세균의증식을일으킨다는가설이다. 8) 이외에도 Parsons와 Wald 9) 는부비동입구의폐쇄로인해발생하는음압의상승이비강내의세균들이부비동내로역류를야기시킨다고주장하였으나아직이를뒷받침하는데이터는보고되지않았다. 하지만실제로알레르기비염환자의 75% 이상에서알레르겐투여후상악동점막의비후가관찰된다는보고도있었고, 10) 정상인의경우 33.4% 에서 CT 상부비동의이상이관찰되나통년성알레르기비염환자의경우 67.5% 에서부비동의이상이관찰된다는보고도있어 11) 이러한가설들을어느정도뒷받침한다고할수있다. 하지만이와는반대로, Iwens와 Clement 12) 는 CT 상병변의정도는아토피유무와관련이없다고보고하였으며, 최근의보고에서는비부비동염환아와정상아사이에알레르기검사결과의차이가관찰되지않았다는보고도있어그인과관계는아직까지도확실하지않다. 4,13) 치료에있어서도아직알레르기비염의영향은그다지관찰되지않는다. 알레르기비염이비부비동염의원인인자라고하면치료에있어서도항히스타민의사용이비부비동염의치료에효과가있어야하지만아직까지이에대한명확한자료는없다. 오히려급성비부비동염에서의 placebo controlled trial 에서 1세대항히스타민의사용이대조군과차이가없다는보고도있다. 14) 하지만이실험에서는항콜린작용이강한 1세대항히스타민을사용하였으며, 이후생산된 2세대항히스타민의경우항콜린작용이적어알레르기비염이동반된비부비동염의경우사용을생각해볼수도있겠다. 천식성인에서보고된바와같이 15-17) 소아에서도만성비부비동염에천식이동반된경우가많다. 비록오래된연구이기는하지만천식과만성비부비동염이동반된환자에서부비동염에대한약물및수술적치료를시행할경우 80% 의환아에서 천식치료를줄일수있으며, 이환아들에서비부비동염이재발한경우천식도같이재발하였다는보고도있다. 18) 흡연중이염과마찬가지로흡연역시급, 만성비부비동염의발생에중요한역할을한다. 흡연은비점막의만성적인염증과염증매개물질의증가를일으키며비강및부비동점막의부종을일으켜만성비부비동염을야기시키게된다. 소아의경우직접적인흡연보다가정에서의간접적인흡연이문제가되는데간접흡연역시섬모운동을방해해비부비동염을야기시키며, 간접흡연이소아에서의비강면적을감소시킨다는보고도있으며, 1,19) 가정에서의간접흡연은호흡기감염의위험성을높이고 (OR 1.19), 엄마가흡연을하거나임신중흡연을한경우에는그위험성이더욱높아진다. 20) 또한소아부비동내시경수술의경우간접흡연이수술의경과를유의하게악화시킨다는보고들이나오고있어이에대한주의가필요하다. 21,22) 공동생활또다른비부비동염의원인인자는놀이방등의공동체생활이다. 5인이상의놀이방에서다니는소아의경우 upper respiratory infection 및비부비동염, 중이염의위험성이증가하며, 23) 항생제치료에대한내성률의증가도보고되고있어최근의미소아과학회 (American Academy of Pediatrics, AAP) 의가이드라인에서는이러한환아의경우고용량항생제를권장하고있다. 24) 위식도역류소아에서위식도역류와비부비동염과의관계에대해서는아직논란의여지가많지만적어도일부에서의가능성은인정되고있다. Suskind 등 25) 은위식도역류로치료를받은 82 명의환아중 17% 에서상기도이상을보고하였으며, Bothwell 등 26) 과 Phipps 등 27) 은만성비부비동염환자군에서위식도역류의발병률이높은것을보고하였다. 또한항생제치료에반응하지않는만성비부비동염환자에서위식도역류에대한치료를시행함으로써대상군의 90% 에서비부비동염에대한수술을피할수있었다는보고도있다. 26) 최근에는위식도역류가비부비동염에끼치는영향으로서위산에의한직접적인자극, 미주신경매개반사, H. pylori의역할등을제시하였으나아직까지이에대한연구는 evidence가부족한실정이다. 원인및병태생리소아만성비부비동염의정확한유병률은알려져있지는않지만, 나이에따른유병률의차이는있는것으로알려져 668

3 Pediatric Chronic Rhinosinusitis Cho HJ, et al. 있으며, 나이가소아만성비부비동염의가장중요한단일위험요소로알려져있다. 실제, 만성비부비동염이의심되는환자의 63% 는 CT의이상소견이관찰되었고, 이는 2~6세환자군의 73%, 6~10 세환자군의 74%, 10세이상환자군의 38% 에해당한다는보고가있다. 7) 미생물학적요소소아만성비부비동염의원인균은 alpha hemolytic Streptococci, Staphylococcus aureus가가장흔하고, S. pneumoniae, H. influenzae, M. catarrhalis도비교적흔하다고알려져있다. 또한만성으로진행하면서혐기성균주도상대적으로증가한다. 28) Biofilm 또한소아만성비부비동염의원인으로거론되고있는데, 이는구조적, 유전적변화와함께균주들간의상호작용, 세포외기질의다양성등을특징으로하여항생제내성의발현에원인으로언급되고있다. 하지만, 소아의경우는추가적인연구를통한근거가필요한단계이다. 만성비부비동염에있어서아데노이드의역할아데노이드는해부학적구조상비강및부비동에인접해있으며, 과거부터약물에반응하지않는만성비부비동염의 1차적치료로서이용되어왔다. 아데노이드가만성비부비동염에영향을미치는기전은크게두가지경우로생각하고있으며그중한가지는아데노이드가박테리아의저장소역할을한다는것이다. 실제로여러연구에서만성비부비동염환아에서아데노이드의세균배양결과및 molecular typing 이중비도의그것과일치한다고보고되었으며, 29,30) 이러한만성비부비동염환아 (88~99%) 에서는대조군보다 (0~6.5%) 훨씬높은빈도로아데노이드의바이오필름형성이관찰되었다. 그리고만성비부비동염이동반된환아의아데노이드에서정상인에비해 IgA의분비가적다는보고도있다. 31) 그뿐아니라, IgA 발현빈도와 tissue-remodeling cytokines(tgf-β1, MMP, TIMP-1) 의발현빈도가비부비동염의유무에따라다르게나타났다는보고들도있어아데노이드가세균학적, 면역학적으로소아만성비부비동염에관여하고있음을알수있다. 하지만, 아데노이드의크기와비부비동염의심한정도는유의한차이가없어, 32) 결론적으로아데노이드는해부학적요인보다는세균학적, 면역학적으로소아만성비부비동염에관여하고있음을알수있다. 진단소아비부비동염의진단은몇가지면에서어른에비해어려운점이있다. 먼저소아의경우어른과달리본인의증상을명 확하게설명하지못하기때문에기침이나캑캑거림, 두통등의비특이적인증상으로표현되는경우가많고, 따라서알레르기비염이나감기, 편도및아데노이드비후등의다른이비인후과질환과혼동될위험성이있다. 따라서소아만성비부비동염의진단을위해서는기본적으로가족력과과거병력, 환아의증상에대한자세한질문을포함한병력청취와세밀한신체검사가필요하다. 특히, 비강에대한검사는내시경 ( 협조가힘든경우는전비경및이경을사용 ) 을통해중비도, 하비갑개, 전반적인점막의상태를확인하는것이중요하고, 구강에대한검사를통해농성분비물의유무, 편도의비대, 후인두점막의상태를확인해야한다. 또한소아만성비부비동염환아에서는알레르기비염이동반된경우가많으므로이에대한단자검사나혈액검사를고려하여야하며, 자주재발하거나, 약물치료에잘반응하지않고세균배양검사에서흔하지않은균이관찰될경우에는필요에따라면역결핍에대한검사를시행할수도있다. 농성분비물이심하거나약물치료에잘반응을하지않는경우세균배양검사를추가로시행하는것을고려해야한다. 4) 영상의학검사는 X-ray 검사보다는 CT를확인하는것이진단에도움이된다고알려져있다. 특히, 수술적치료를고려하고있을때는 CT를확인하는것이필수적이며, 만성비부비동염에의한합병증이의심될때는 MRI를통한병변의확인이중요하다. 방사선학적검사가진단에필요한가? 만성비부비동염의진단은대체로임상적으로이루어질수있으나, 약물에반응하지않고재발이잦은만성비부비동염에서는방사선학적인검사가필요하며, 이때가장적절한검사 (imaging modality of choice) 는 CT이다. 4,33) 과거수십년간비부비동염의진단에사용되어온단순방사선검사는, CT에비해가격이낮고유아의경우검사전진정제사용이필요하지않은면에서장점이있다. 하지만검사의정확도는비교적낮은편이며, 부비동내의전체적인혼탁 (total opacification) 및공기액체층 (air-fluid level) 을기준으로할경우민감도는 54%, 특이도는 92% 였으며, CT와동시에단순방사선검사를시행한연구에서는 74% 에서두검사사이에차이가발생하였다고보고하여 34) 검사에대한판독시주의를요한다. 현재까지는급성비부비동염의진단에있어서방사선학적검사는불필요하다는것이대부분의의견이다. 2001년에미소아과학회 (AAP) 에서발표한가이드라인에서는 6세이하의소아의경우는비부비동염의진단을위해방사선검사를사용할필요가없으며 6세이상에서도선택적으로사용할것을권고하였다. 24) 이에대한근거로서소아의경우실제로 6세이하 669

4 Korean J Otorhinolaryngol-Head Neck Surg 2015;58(10): 의경우비부비동증상만으로도방사선검사이상의 88% 를예측할수있다고보고되었으며 35) 6세이상의경우에도 70% 를예측할수있다고보고되었다. 24) 또한미국방사선과학회 (American College of Radiology) 나 Sinus and Allergy Health Partnership의가이드라인에서도합병증이없는단순비부비동염에서방사선검사는필요하지않다고권고하였다. 27,34) 따라서급성비부비동염의경우에는방사선학적검사는대부분필요하지않으며, 이후약물치료에반응하지않거나수술을필요로하는경우등에서선택적으로사용하는것이좋으리라생각된다. 균동정을위한상악동천자가꼭필요한가? 약물치료에반응을하지않는경우균배양검사를시행하게된다. 과거에는이런경우상악동을천자하여균동정을시행하였으나, 여러논문에서중비도에서의균동정이상악동천자에서의결과와높은수준으로일치한다고보고하여, 통증에취약한소아에서상악동천자를꼭시행할필요는없다고생각된다. 36,37) 또한최근에면봉을이용한단순 swab culture (66%) 보다는 suction aspiration culture(87%) 가상악동천자의결과와일치도가높은것으로보고되었으나, 통증을야기할수있으므로나이가많은소아에서사용하는것이좋다고생각된다. 38) 내과적치료소아만성비부비동염에대한내과적치료는아직까지 consensus가확립되어있지않다. 2012년에발간된 European position paper on rhiniosinusitis and nsal polyps에서는식염수세척과비강스테로이드제제가효과가있다고보고하였으며, 단기항생제요법은효과가없는것으로보고하였다. 다만저용량장기간마크로라이드치료 (low dose long term macrolide, LDLT) 에대한가능성은열어두었다 (Table 1). 4) 항생제소아만성비부비동염의치료에있어항생제사용에대해 서는확립된근거가없다. 만성비부비동염에있어서는항생제사용군이기타생리식염수사용군이나배액및세척 (drainage and irrigation) 군에비하여장기적으로추적관찰하였을때, 치료성공의측면에서유의한결과를도출해내지못했으며, 39) 이후진행된연구에서도위약군에비해의미있는결과를보이지못했다. 40) 하지만소아만성비부비동염환자의많은수가잦은급성악화에의한발열, 화농성비루, 안면통등의심한증상을이유로치료를받게되며, 급성비부비동염이병발하는경우는대증적치료이외에도일차적으로항생제치료가요구된다. 일반적으로이러한항생제의사용빈도가지나치게높은경우나일반적인항생제치료에반응이없는경우적극적인치료혹은수술적치료까지도고려하게된다. 또한, 실제적으로는소아만성비부비동염환자에서급성비부비동염환자에서보다더장기간 ( 약 3~6주 ) 의항생제를사용하고있는경향을보이고있다 ) 일전에대한비과학회학술심포지엄에서실시한실시간설문조사에서도약 70% 정도의의사들이수술전 2개월이상의항생제를사용하는것으로보고하여상당히장기간항생제사용이이루어지는것을알수있었다. 여기서주의해야할것은광범위항생제보다는지역의호발균주와항생제내성을고려한최소한의항생제사용이우선되어야한다는것이다. 지금까지의데이터는소아만성비부비동염에서의단기간항생제사용을정당화할근거는없으며, LDLT의사용은비록그근거는낮지만사용해볼수있을것으로생각된다. 항생제의선택에있어우선생각할것이항생제에대한내성기전인데미국의경우에도 H. influenzae의 50% 와 100% 의 M. catarrhalis에서 beta-lactamase 가관찰되며이두세균의내성기전은이 beta-lactamase에의한다. 44,45) 따라서 amoxicillin-clavulanate 를사용할경우이두세균에대한치료성공률은거의 100% 에달할수있다고보고되었다. 46) 반면 S. pneumoniae의내성기전은 beta-lactamase 의생산이아니라 penicillin binding protein의변형에의한것으로서 clavulanate의작용보다는고용량의 amoxicillin에반응을하므 Table 1. Evidence and recommendations of medical treatment for children with chronic rhinosinusitis Treatment Evidence level Grade of recommendation Relevance Nasal saline irrigation Ia A Yes Therapy for GERD III C No Topical steroid IV D Yes Oral antibiotics (short term, <4 weeks) Ib(-)* A(-) No Oral antibiotics (long term) No data D Unclear Intravenous antibiotics III(-) C(-) No Evidence level and grade of recommendation refer to the EPOS guideline *level Ib study with a negative outcome, grade A recommendation not to use, level III study with a negative outcome, grade C recommendation not to use. GERD: gastro-esophageal reflux disease 670

5 Pediatric Chronic Rhinosinusitis Cho HJ, et al. 로고용량의 amoxicillin(amoxicillin component 80~90 mg/ kg and clavulanate 6.4 mg/kg in 2 divided doses) 을사용할수있다. 하지만내성균중일부는고도내성을보여고용량 amoxicillin에도반응하지않는다. 24,27,47,48) 특히이와같은고용량 amoxicillin 요법은 2세미만의환아, 증상이심할때, 보육시설에다니는경우또는최근의일반적항생제치료에반응이만족스럽지않은경우에권장된다. 49) 2005년국내에서발간된논문에따르면 pneumococcus에대한항생제감수성이 amoxicillin-clavulanate 의경우에는 32.5% 였으며, 반면 cefditoren 이나 ceftriaxone의경우각각 97.4%, 100% 에달해 amoxicillin-clavulanate 초치료에효과가없을경우고용량의항생제를사용하거나상기 cephalosporin계로바꾸는것도생각해볼만하다. 고용량의 amoxicillinclavulanate를사용시에도위장관계합병증의발생률은저용량에서와동일하다. 50) 약물치료를최대한하였는데도반응이없는만성비부비동염의경우항생제정맥요법이시행되기도하는데, 아데노이드절제술, 상악동세척 (irrigation) 등과함께사용되었을때, 89% 이상의높은장기치료율이보고된바있다. 51,52) 하지만아직까지항생제정맥요법단독의효과는확인된바없으므로이에대해서는주의하여야하겠다. 스테로이드아직까지소아에있어서비강내스테로이드제제의효과를입증한무작위연구는없지만국소스테로이드제제의사용시부비동염을호전시킬뿐만아니라수술의필요성을낮춘다는보고가있다 ) 또한성인에서이미그효과가증명되었고소아에서의안전성이증명된점을고려해보면소아만성비부비동염에서도 1차치료로사용될수있다고생각된다. 또한최근시행된무작위연구에서경구용스테로이드를항생제와 더불어사용한군에서그렇지못한군에비해기침, 코막힘, 후비루등의증상점수와 CT 중증도가유의하게좋아진것을보고하여, 56) 소아에서스테로이드의효과를예상해볼수있겠다. 식염수세척생리식염수를이용한세척및혈관수축제는만성비부비동염의호전에어느정도역할을할것으로생각되지만, 이에대한유의한결과를보여준비교연구는없다. 또한식염수세척은성인비부비동염에서는임상적으로많이사용되어왔지만소아는상대적으로시행하기힘들것이라는우려가많다. 하지만생리식염수세척은특별한부작용을일으키지않으며만성비부비동염의증상호전의측면에서이득이있다. 최근전체환아의 70% 이상에서식염수세척을잘시행하였다는보고도있으며, 57) 본교실에서도이에대해최근해외학술지에보고한바있다. 58) 저자는 2007년 1월부터 2010년 6월까지치료받은 77명의 13세이하의증상이심하여항생제및비강내스테로이드제치료에도호전되지않아, 수술여부를판단하기위해 CT를시행한소아환자를대상으로후향적환자-대조군연구를시행하였다. 순응도는나이가많은환아가더높을것이라는예상과달리 6~8세의환아에서비교적높은순응도를보였으며, 64% 의환아에서성공적으로지속적인식염수세척을시행할수있었다. 또한임상적측면으로보았을때, 치료순응도가높은군에서통계적으로유의한주관적, 객관적호전소견을보였으며, 결과적으로아데노이드절제술및기능적내시경부비동수술을시행받은환자들또한치료순응도가나쁜군에서많은것을확인할수있었다 (Fig. 1). 본연구결과로미루어보아, 소아만성비부비동염환자에서생리식염수세척은항생제나비강내스테로이드제와함께사용할수있는효과적인방법으로생각된 Total subjects: 77 patients Good compliance group: 49 patients (63.6%) Poor compliance group: 28 patients (36.4%) Improvement: 36 patients (73.5%)* No improvement: 13 patients (26.5%) Surgery: 8 patients (16.3%) Improvement: 14 patients (50.0%)* No improvement: 14 patients (50.0%) Surgery: 12 patients (42.9%) Fig. 1. Treatment outcomes according to compliance with nasal saline irrigation. Treatment outcomes including subjective and endoscopic improvements and the rate of surgery were significantly different between groups (*p=0.048, p=0.019)

6 Korean J Otorhinolaryngol-Head Neck Surg 2015;58(10): 다. 2007년발표된 Cochrane review에서도식염수세척이단독, 또는다른치료와함께사용하였을경우만성비부비동염의치료에효과적이라고보고하였다. 기타제제항히스타민제와항류코트리엔제또한알레르기비염의치료에서는효과가밝혀져있지만, 만성비부비동염에대한효과는밝혀진바없으므로알레르기비염이동반된경우에한해사용하는것이추천된다. 외과적치료-What to do and when do we operate? 수술의대상및시기소아비부비동염의치료에있어가장어려운결정은어떤환자군을언제수술하느냐하는것이다. 지금까지많은의사들이사용하는기준은안와합병증등합병증이있는경우를제외하고는최대한의내과적치료에도불구하고증상의호전이없는경우에수술을결정하게된다. 그러면과연이최대한의내과적치료는무엇을말하는것인가? 이는상당히주관적인용어로서아직까지이에대한객관적인결과들은없는실정이나여러연구결과들을미루어볼때항생제치료와비강스테로이드제제를기본으로 1) 알레르기및위식도역류가있는경우이에대한치료를모두시행하는것을의미한다고생각된다. 그러면이러한최대한의내과적치료의기간은얼마나될것인가? 아쉽게도이에대해서도아직까지공통된의견은없는실정이며저자들에따라경험적으로 3~6주정도를권장하고있다 ) 한가지재미있는연구는 2003년 Lieu 등 59) 은소아비부비동염환자를증상의심한정도에따라 4단계로나누어부비동내시경수술과내과적치료의성공률을비교하였는데 2, 3 단계증상을가진사람들에서는수술의호전율이내과적치료에비해훨씬높았는데 ( 각각 79% vs. 54%, 68% vs. 42%) 증상이가장경한 1단계와가장심한 4단계에서는오히려약물치료후호전율이수술에비해더높았다 ( 각각 38% vs. 56%, 43% vs. 67%). 또한저자가발표한연구에서도병변의중증도가수술후예후에중대한영향을미쳤다. 21) 이와같은결과로미루어볼때수술이필요하다고생각되는경우에는너무미루지않고조기에시행하는것이필요하다고생각된다. 수술의선택일단수술이결정되면어떤수술을시행할것인가하는것이다음과제가된다. 보통선택할수있는옵션으로는아데노이드절제술과부비동내시경수술이있으며각각의장단점이 있으나보통수술의간단함과상대적으로좋은효과, 그리고안면성장에문제가없을것이라는이유로아데노이드절제술을먼저시행하는경우가많으며, 2005년에미국소아이비인후과의사를대상으로한설문조사에서도만성비부비동염에수술적치료에있어아데노이드절제술을 1차적으로시행하는의사가 81% 였으며, 부비동내시경수술과동시에시행하는경우가 13% 로보고되었다. 60) 올해대한비과학회심포지엄에서시행한실시간설문조사에서는전체응답자의 56% 에서만성비부비동염에있어서아데노이드절제술을 1차적인수술로시행한다고응답하여, 우리나라에서도과거에비해부비동내시경수술을함께시행하는경우가늘어나고있는것을알수있다. 만성비부비동염에있어서아데노이드의역할이확실하게밝혀지지는않았지만보통두가지로요약된다. 그첫째는아데노이드가만성비부비동염에있어서병원균의저장소역할을한다는것이다. 여러연구들에따르면아데노이드에서채취한세균집락수가비부비동증상점수와연관이있고 89% 에서중비도와아데노이드균배양검사의 molecular typing이일치하며아데노이드제거후비강내정상상재균이증가하고병원균이감소한다고보고되었다. 29,61,62) 다음으로비대한아데노이드가비강분비물이뒤로넘어가는것을막고정체시킴으로써또는아데노이드가비인두를막을정도로크지는않더라도계속된염증으로편평상피화가일어남으로써점액섬모운동이저하되어비부비동염이발생할수있다는것이다. 63) 소아만성비부비동염의수술적치료에있어아데노이드절제술의효과는 meta-analysis를통해잘밝혀져있다. 평균 5.8세환자를대상으로한 9개의연구를분석한결과 69.3% 의환자에서호전을보였다. 64) 또한 Ramadan과 Tiu, 65) Ramadan과 Cost 66) 는 7세이하이거나천식이동반된환아의경우아데노이드절제술의효과가떨어지며, 이차적으로부비동내시경수술이필요한경우가많다고보고하였다. 또한아데노이드절제술과함께중비도를통한부비동세척을시행하였을때, 아데노이드절제술을단독으로시행한환자군에비해높은호전율을보였다는연구결과도보고된바있다 (success rate 88% vs. 61%). 66) 따라서만성비부비동염의수술적치료에있어수술의간단함이나효과등을생각하면아데노이드절제술을 1차적으로생각하여야하는것은당연하다. 1,23) 또한수술시중비도나상악동에서균배양검사를시행함으로써이후항생제치료시도움이될수있다. 그렇다면만성비부비동염의치료에있어내시경수술의역할은무엇이며수술을필요로하는모든만성비부비동염환아에서아데노이드절제술을먼저시행하여야할까? 아데노 672

7 Pediatric Chronic Rhinosinusitis Cho HJ, et al. 이드의사이즈가크고수술을필요로하는어린소아의경우에는아데노이드절제술을먼저시행하는것에많은사람들이동의하지만나이가들어가면서아데노이드크기가작은소아에서도아데노이드절제술만을시행하느냐하는데에는아직논란의여지가많은실정이다. 이전의논문들에서는아데노이드의크기에관계없이아데노이드절제술을 1차적으로시행한다고보고하였다. 43,62,67) 하지만 Ramadan 68) 은천식이있거나나이가많은경우, CT score가높은경우에는아데노이드절제술만으로는만족스러운결과를얻지못한다고보고하였으며부비동내시경수술을함께시행할것을권고하였다. 기능적부비동내시경수술은최근 meta-analysis 에서소아만성비부비동염환자에서 88% 의성공률과낮은합병증빈도를보고하여효과적인수술적치료의방법으로생각된다. 69) 하지만앞에서도보다시피많은의사들이아직까지아데노이드절제술을 1차적으로시행하는경우가많으며, 여기에는많은이유가있지만무엇보다도소아에서부비동내시경수술을시행할경우가장먼저대두되는문제가수술이안면성장에영향을미칠수있으리라는우려때문이다. 이는 1990년대중반에발표된두편의동물실험에기초를두고있으며이논문들에따르면전사골동제거술과같은최소한의술식조차도안면골의변형을야기시킨다고보고하였다. 70,71) 하지만이후발간된임상논문들에서는이와반대의결과들을보고하였으며내시경수술후성형외과전문의의검진결과수술이안면성장을이상을일으키지않았다고보고하여, 72,73) 내시경수술로인한안면성장의장애는없으리라생각된다. 하지만소아의경우어른보다비강사이즈가작아부비동내시경수술을시행하기가불리한점이있다. 또한많은보고들에서성인과비슷한정도의유착등의합병증발생률을보고하지만이는이분야에서많은경험을쌓은의사들이며처음소아부비동내시경수술을시행하는의사의경우성인보다많은어려움을겪게된다. 74) 하지만이는경험을쌓으면서해결될수있는문제이며또한최근크기가작은 cutting forceps 등의발달로인해이전에비해수술이훨씬편리해졌다. 또한실제로수술후주합병증의빈도도 1% 이하로보고되어성인에서의부비동내시경수술에비해위험한편은아니다. 69) 최근에는 balloon sinuplasty가소아만성비부비동염에대한수술적치료의새로운선택사항으로사용될수있을지에대한연구들이진행되고있다. Balloon sinuplasty는 2006년미국식품의약기구 (Food and Drug Administration) 에서승인되어성인을대상으로한연구에서안전성및유효성을검증한이후에소아에사용되기시작하였다. 이후연구결과에따르면 balloon sinuplasty를이용한상악동확장및세척술 이아데노이드절제술단독시행군보다의미있는호전소견 을보였으나이것이 irrigation 에대한효과인지에대해서는 논란의여지가있다. 75) 결 론 결론적으로소아만성비부비동염의경우최대한의약물 치료를시행하였는데도호전이없을때, 수술적접근을고려 할수있으며, 병변이심하지않을경우에는아데노이드절제 술과부비동세척이우선적으로고려되어야하겠다. 그럼에 도불구하고증상의호전이없거나재발한경우, 병변이심하 거나천식등점막의염증성질환을동반할수있는질환이 있는경우에는기능적부비동내시경수술을선택하는것이 유리하리라생각된다. REFERENCES 1) Goldsmith AJ, Rosenfeld RM. Treatment of pediatric sinusitis. Pediatr Clin North Am 2003;50(2): ) Herrmann BW, Forsen JW Jr. Simultaneous intracranial and orbital complications of acute rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 2004;68(5): ) Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54(8):e ) Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps A summary for otorhinolaryngologists. Rhinology 2012;50(1): ) Shapiro GG, Rachelefsky GS. Introduction and definition of sinusitis. J Allergy Clin Immunol 1992;90(3 Pt 2): ) Shapiro GG, Virant FS, Furukawa CT, Pierson WE, Bierman CW. Immunologic defects in patients with refractory sinusitis. Pediatrics 1991;87(3): ) Nguyen KL, Corbett ML, Garcia DP, Eberly SM, Massey EN, Le HT, et al. Chronic sinusitis among pediatric patients with chronic respiratory complaints. J Allergy Clin Immunol 1993;92(6): ) Silviu-Dan F. Pediatric chronic rhinosinusitis: the old, the new, and the reasonable. Pediatr Ann 2011;40(4): ) Parsons DS, Wald ER. Otitis media and sinusitis: similar diseases. Otolaryngol Clin North Am 1996;29(1): ) Pelikan Z. The role of allergy in sinus disease. Children and adults. Clin Rev Allergy Immunol 1998;16(1-2): ) Berrettini S, Carabelli A, Sellari-Franceschini S, Bruschini L, Abruzzese A, Quartieri F, et al. Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 1999;54(3): ) Iwens P, Clement PA. Sinusitis in allergic patients. Rhinology 1994; 32(2): ) Leo G, Piacentini E, Incorvaia C, Consonni D, Frati F. Chronic rhinosinusitis and allergy. Pediatr Allergy Immunol 2007;18 Suppl 18: ) McCormick DP, John SD, Swischuk LE, Uchida T. A double-blind, placebo-controlled trial of decongestant-antihistamine for the treatment of sinusitis in children. Clin Pediatr (Phila) 1996;35(9): ) Dhong HJ, Kim HY, Cho DY. Histopathologic characteristics of chronic sinusitis with bronchial asthma. Acta Otolaryngol 2005;

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