pissn: eissn: Allergy Asthma Respir Dis 6(3): , May ORIGINAL ARTICLE 학령전기폐쇄수면

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1 pissn: eissn: (3): , May ORIGINAL ARTICLE 학령전기폐쇄수면무호흡증과재발성부비동염 윤형호, 안영민, 김현정 을지대학교을지병원소아청소년과 Factors associated with chronic and recurrent rhinosinusitis in preschool children with obstructive sleep apnea syndrome Hyung Ho Yun, Young Min Ahn, Hyun-Jung Kim Department of Pediatrics, Nowon Eulji Medical Center, Eulji University, Seoul, Korea Purpose: Obstructive sleep apnea syndrome (OSAS) in young children is frequently caused by adenoid and/or tonsillar hypertrophy. Adenoidectomy is the first operative method for childhood chronic rhinosinusitis (CRS). We investigated factors associated with recurrent rhinosinusitis in preschool aged children with OSAS to determine the association of 2 common diseases. Methods: One hundred forty-six children aged 2 5 years who were diagnosed as having OSAS after polysomnography between December 2003 and April 2016 were enrolled in this study. Children were divided into 2 groups with and without CRS. The 2 groups were compared in the severity of OSAS and allergy diseases and were evaluated for recurrent rhinosinusitis during the follow-up period, 1 year after diagnosis. Results: Among 108 patients with OSAS who were followed up, 81 patients (75%) were diagnosed with CRS. There were no significant difference clinical and allergic characteristics between groups with and without CRS. However, bronchial asthma and otitis media was significantly more prevalent in patients with CRS than in those without (P = and P = 0.000, respectively). Bronchial asthma and adenotonsillectomy was significantly associated with recurrent rhinosinusitis (P= and P= 0.04, respectively) during the 1-year follow-up. Conclusion: Approximately 75% of preschool children with OSAS have suffered from CRS. Bronchial asthma is associated with CRS among OSAS children. Recurrent rhinosinusitis is decreased after adenotonsillectomy, and bronchial asthma is an associated factor for recurrent rhinosinusitis after a follow-up. This close relationship childhood OSAS and recurrent rhinosinusitis/bronchial asthma needs further studies to investigate their role in the association. ( 2018;6: ) Keywords: Obstructive sleep apnea, Asthma, Rhinitis, Sinusitis 서론 폐쇄수면무호흡증 (obstructive sleep apnea syndrome) 은소아에 서비교적흔한질환으로학동전기소아의 10% 25% 에서코골이 증상이있을수있고, 2% 3% 에서폐쇄수면무호흡증을보인다. 1 소 아의폐쇄수면무호흡증은편도와아데노이드비대가주된원인이 고, 병력청취나진찰소견만으로진단이어려워확진을위해수면 다원검사 (polysomnography) 가권장된다. 2 부비동염은비점막및부비동의염증으로빈번하게진단되는질 Correspondence to: Young Min Ahn Department of Pediatrics, Nowon Eulji Medical Center, Eulji University, 68 Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Korea Tel: , Fax: , aym3216@eulji.ac.kr Received: September 12, 2017 Revised: October 26, 2017 Accepted: October 28, 2017 병중하나이며편도와아데노이드비대, 아토피, 알레르기비염과 기관지천식이소아에서재발성및만성부비동염의위험인자이다. 3 Gozal 과 Kheirandish-Gozal 4 은폐쇄수면무호흡증의진단에반복 되는중이염과호흡기감염을부진단기준에포함하였다. 폐쇄수면 무호흡증에서저산소증과아데노이드비대에의한섬모운동감소 및아데노이드에세균집락으로인해부비동염이동반될가능성이 크다는보고가있다. 5 이렇듯폐쇄수면무호흡증과부비동염은연 관성이있을것으로생각되지만실제두질환의연관성에대한직 접적인연구는거의없고, 어떤인자가폐쇄수면무호흡증과부비동 2018 The Korean Academy of Pediatric Allergy and Respiratory Disease The Korean Academy of Asthma, Allergy and Clinical Immunology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (

2 윤형호외 폐쇄수면무호흡증과부비동염 염의연관성에영향을미치는것에관한연구도아직적고알려진바가별로없다. 이에저자들은학동전기폐쇄수면무호흡증환아들에서만성부비동염의동반빈도를알아보고어떤인자가부비동염의재발에연관이있는지찾아보고자하였다. 대상및방법 1. 대상 2003년 12월부터 2016년 4월까지본원소아청소년과에수면호흡장애가의심되어수면다원검사를시행한 2 5세환아들중두개안면증후군, 신경근육질환, 정신질환등을가진환아들을제외한 146명을대상으로하였다. 수면다원검사는 Somnologica (Medcare, Denver, CO, USA) 를사용하여기록하였고, 미국수면학회 (American Academy of Sleep Medicine) 의소아수면다원검사측정기준에따라폐쇄성무호흡 (obstructive apnea) 은지속적인호흡노력에도불구하고 2회이상의호흡주기동안호흡진폭이기저호흡진폭에비하여 90% 이상감소되어있는것으로정의하였고, 저호흡 (hypopnea) 은최소한 2차례의호흡주기동안호흡진폭이기저호흡진폭에비하여 30% 이상감소되고혈중산소포화도가 3% 이상감소된경우로하였다. 6 폐쇄수면무호흡증의진단은미국수면학회와미국소아과학회 (American Academy of Pediatrics) 의기준에따라수면중에코골이, 무호흡등의수면무호흡증의임상증상이있고중추무호흡지수 (central apnea index) 를제외한무호흡-저호흡지수 (apnea-hypopnea index) 가시간당 1 이상인경우로정의하였다. 2,6 수면다원검사상폐쇄수면무호흡증으로진단받은환아들을대상으로 2006년알레르기및임상면역학저널 (Journal of Allergy and Clinical Immunology) 부비동염기준에따라후비루, 안면압통또는코막힘, 후각의감소중 2가지이상의증상이존재하는경우부비동염으로진단하였고, 7 만성부비동염은지속되는기침, 콧물또는코막힘증상을동반하며 12주이상부비동의염증이지속되는경우로하였다. 7,8 재발성부비동염은적어도 10일간증상이없으면서한달이내부비동염이재발하는경우로보았다. 8 만성부비동염과재발성부비동염으로진단된환아를합쳐서부비동염호발군으로분류하였고, 2012년소아알레르기호흡기학회비염그룹의논문정의에맞추어만성부비동염군으로표에는지칭하였다. 3 전체폐쇄수면무호흡증환아를부비동염호발군과호발하지않는군으로구분하여각군의알레르기질환, 중이염, 체질량지수, 피부단자시험, 호산구, 혈청총 IgE를비교하였다. 1년이상외래경과관찰한환아를대상으로재발성부비동염군과재발하지않은군에서알레르기질환, 중이염, 아데노이드편도절제와의관련성을확인하였다. 알레르기비염은콧물, 재채기, 비강가려움증, 비폐색등의증상중 2가지이상의증상을동반하며피부단자시험에서양성반응을나타내는경우로정의하였다. 기관지천식은상기도감염없이 1년간 3회이상반복되는기침, 천명, 호흡곤란등의전형적인천식증상, 천식약물의사용, 과거병력을통해진단하였다. 9 아토피피부염은소양증을동반한피부질환으로홍반과인설등의주증상 3가지, 부증상 3가지이상을만족하는경우로분류하였다. 수면호흡장애분류는수면다원검사상무호흡-저호흡지수에근거하여수면호흡장애중증도분류를하였다. 수면다원검사결과에서무호흡-저호흡지수가 10 이상인경우중증 (severe), 10과 5 사이는중등도 (moderate), 1과 5 사이이면경증 (mild) 폐쇄수면무호흡증으로분류하였다. 수면다원검사시환아의신장과체중을측정하여체질량지수 (body mass index) 를측정한후측정결과를 2007 년한국소아및청소년표준성장도표중체질량지수의성장도표백분위수에대입하여 95 백분위수이상인경우를비만으로정의하였다. 2. 통계분석통계분석은 SPSS ver. 17 (SPSS Inc., Chicago, IL, USA) 을이용하여실시하였고, 두군간의빈도비교는 Pearson chi-square test 를이용하였으며, 평균비교는 t-test를이용하였다. 만성부비동염, 재발성부비동염환아에서연령증가및무호흡-저호흡지수증가에따른경향분석은선형대선형결합을사용하여분석하였다. P- value 0.05 미만인경우통계적으로유의한차이가있는것으로보았다. 결과 1. 대상군의특징수면호흡장애가의심되어수면다원검사를시행한 2 5세까지환아는총 146명이었고, 폐쇄수면무호흡증으로진단되고 1년이상추적관찰된 108명을대상으로하였다. 전체환아 108명중에부비동염호발군 81명 (71.6%), 호발하지않은군 27명 (28.4%) 으로나누었다. 전체환아의평균나이는 3.54±1.08세였으며, 성별은남아가 77명 (71.3%), 여아 31명으로남아가더많았다. 평균체질량지수는 16.07±1.92 였고비만인환아는총 8명 (7.4%) 이었다. 성별, 연령, 체질량지수는두군간에유의한차이를보이지않았다. 혈청총 IgE, 호산구의수치는두군간에유의한차이를보이지않았다. 무호흡-저호흡지수는부비동염호발군에서유의하게높았고 (P = 0.04), 중이염은부비동염호발군에서호발하지않는군과비교해 3배가까이통계적으로유의하게높은빈도를보였다 (P = 0.000). 동반된알레르기질환비교에서아토피피부염의경우부비동염 169

3 Yun HH, et al. Rhinosinusitis and obstructive sleep apnea 호발군 31명 (38.3%), 호발하지않는군 7명 (25.9%) 으로호발군에서 1.5배가까이높았으나통계적으로유의한차이는아니었으며, 알레르기비염의경우에는두군간의비슷한비율을보였다. 기관지천식은부비동염호발군에서유의하게많았다 (P = 0.045). 피부단자시험을통한알레르기항원감작비교에서집먼지진드기, 동물털, 꽃가루에서뚜렷한차이는없었으며집먼지진드기항원의경우부비동염호발군 45명 (55.6%), 호발하지않는군 13명 (48.1%) 에서감작양성을보여다른알레르기항원에비해높은감작양성률을보였다 (Table 1). 4. 폐쇄수면무호흡증과재발성부비동염간의관련인자 1년이상외래경과관찰한 108명의환아에서재발성부비동염군은 34명 (31.5%), 재발성부비동염이동반하지않은군은 74명 (68.5%) 으로동반하지않은군이더많았으며, 각군의재발성부비동염관련인자를분석하였다. 기관지천식은다른알레르기질환에비하여재발성부비동염군에서유의하게높은빈도를보였고 (P = 0.005), 알레르기비염, 아토피피부염의경우에서는두군간의유의한차이가없었다. 아데노이드편도절제에따른재발성부비동염을비교해보면아데노이드편도절제를시행한군에서재발성부비동염이감소 2. 연령과부비동염호발군간의관계 전체 108 명환아중에 2 세 24 명 (22.2%), 3 세 27 명 (25%), 4 세 32 명 (29.6%), 5 세 25 명 (23.1%) 으로연령대별로고르게분포하였고, 연령 에따른부비동염호발군의비율을보면통계적으로차이는없었으 나, 연령증가에따라부비동염호발군의비율이감소하는경향을 보였다 (Fig. 1). 3. 폐쇄수면무호흡증의중증도와부비동염호발군의관계 폐쇄수면무호흡증의중증도분포는수면다원검사결과에서경 증 78 명 (72.2%), 중등도 14 명 (13%), 중증 16 명 (14.8%) 으로경증폐 쇄수면무호흡증이가장많은분포를보였다. 폐쇄수면무호흡증의 중증도에따른부비동염호발군의경향분석에서폐쇄수면무호흡 증의중증도증가에따라부비동염호발군이증가하는경향을보 였으나, 통계적으로유의한차이를보이지않았다 (Fig. 2). Table 1. Clinical characteristics of children with and without CRS Characteristic CRS (n= 81) Without CRS (n= 27) P-value Male sex 58 (71.6) 19 (70.3) Age (yr) 3.42± ± BMI (kg/m 2 ) 15.99± ± AHI (event/hr) 6.69± ± Otitis media 67 (82.7) 7 (25.9) Allergy disease AR 55 (67.9) 18 (66.7) BA 42 (51.9) 8 (29.6) AD 31 (38.3) 7 (25.9) Skin prick test House dust mite 45 (55.6) 13 (48.1) Animal dander 24 (29.6) 3 (11.1) Pollens 20 (24.7) 3 (11.1) Total IgE (IU/mL) 138± ± Eosinophil (%) 2.78± ± Values are presented as number (%) or mean± standard deviation. CRS, chronic rhinosinusitis and recurrent rhinosinusitis; BMI, body mass index; AHI, apnea-hyponea index; AR, allergic rhinitis; BA, bronchial asthma; AD, atopic dermatitis. Prevalence (%) Age (yr) Fig. 1. Linear-by-linear association of chronic rhinosinusitis and recurrent rhinosinusitis in obstructive sleep apnea syndrome according to age. Linear-by-linear association test indicates the prevalence of chronic rhinosinusitis and recurrent rhinosinusitis decreases not significantly as age increases (P for trend = and P for trend = 0.076, respectively). ReRS, recurrent rhinosinusitis; CRS, chronic rhinosinusitis and recurrent rhinosinusitis. Trend in proportions assessed with Linear-by-linear association test. Prevalence (%) ReRS CRS P for trend=0.051 P for trend=0.076 Mild OSAS Moderate OSAS Severe OSAS P for trend=0.292 Fig. 2. The proportion of chronic rhinosinusitis and recurrent rhinosinusitis in obstructive sleep apnea syndrome by obstructive sleep apnea syndrome severity. The proportion of chronic rhinosinusitis and recurrent rhinosinusitis in obstructive sleep apnea syndrome was not significantly rising trend with increasing obstructive sleep apnea syndrome severity (P for trend = and P for trend= 0.480, respectively). CRS, chronic rhinosinusitis and recurrent rhinosinusitis; ReRS, recurrent rhinosinusitis; OSAS, obstructive sleep apnea syndrome. Trend in proportions assessed with Linear-by-linear association test. CRS ReRS CRS ReRS P for trend=

4 윤형호외 폐쇄수면무호흡증과부비동염 Table 2. Comparison of associated factors between with and without ReRS Variable ReRS (n= 34) Without ReRS (n= 74) P-value AR 14 (41.2) 21 (28.4) BA 14 (41.2) 12 (16.2) AD 5 (14.7) 11 (14.9) OM 12 (35.3) 21 (28.4) AT 13 (38.2) 44 (59.5) Values are presented as number (%). ReRS, recurrent rhinosinusitis; AR, allergic rhinitis; BA, bronchial asthma; AD, atopic dermatitis; OM, otitis media; AT, adenotonsillectomy. 함을보였다 (P = 0.04). 그러나중이염은유의미한차이를보이지 않았다 (Table 2). 연령증가에따라서재발성부비동염분포는감소 하는경향을보였으나, 통계적유의성은없었고 (Fig. 1), 치료전폐 쇄수면무호흡증의중증도에따른재발성부비동염분포는증가하 는모습을보였으나, 유의한차이는없었다 (Fig. 2). 고찰 이번연구에서부비동염호발군에서기관지천식, 중이염이많았 고, 무호흡 - 저호흡지수가높았다. 1 년추적시아데노이드편도절제 후재발성부비동염이적게발생하였고기관지천식이동반된경우 재발성부비동염이많았다. 폐쇄수면무호흡증환아에서부비동염동반빈도에관한연구는 매우드물지만, Arens 등 10 은폐쇄수면무호흡증환아와정상대조 군을자기공명영상 (magnetic resonance imaging) 으로비교하여 폐쇄수면무호흡증환아 54 명중 32 명 (59%) 에서정상대조군에비 해부비동염과중이염소견이많이동반되었다고보고하였다. 성인 에서의만성부비동염에대한빈도나삶의질에대한연구는많지만 소아에서나이에따른만성부비동염의빈도를연구한논문은극히 드문데, 세에서일반아동의부비동염유병률연구에서 1,307 명중 87 명 (6.6%) 이부비동염으로진단되었고, 년조사에서 는 20 세미만소아에서 2.1% 5 세이하는 1.9% 로 11 이에비하여. 이 연구에서는폐쇄수면무호흡증환아 81 명 (75%) 이부비동염호발군 으로높은비율을보였다. 수면센터를중심으로한 Arens 등 10 의연 구에비하여이번연구에서부비동염비율이더높은이유는만성 호흡기증상을주소로알레르기클리닉을방문한나이가더어린 환아들을대상으로연구가이루어져차이가있을것으로생각된 다. 부비동염호발군의연령에따른분포는 2 세부터 4 세까지감소 하는경향을보이다가 5 세부터는증가하는모습을보인다. 학동전 기는폐쇄수면무호흡증이가장자주발생하고상기도감염이호발 하는시기이다. 13 따라서학령기연령에서관련연구가더필요할것 으로보인다. 비만은사춘기이후폐쇄수면무호흡증의위험인자로알려져있 으며, 14 소아의경우는정상체중인경우가대부분이고성장장애로인한과소체중이있는경우도있다. 15 학동전기연령을대상으로한이연구에서는비만인환아는 8명 (7.4%) 으로학동전기폐쇄수면무호흡증에서대다수환아는비만하지않았고두군간의체질량지수의차이는없었다. 부비동염호발군에서중이염동반이높게확인된결과는중이염과부비동염의병태생리에편도와아데노이드비대가밀접하게관련되어있는이전결과들과동일하였고, 10,16 Gozal과 Kheirandish- Gozal 등 4 도잦은중이염을폐쇄수면무호흡증의부진단에포함시켰다. 이연구에서알레르기질환과의관련성을보면부비동염호발군에서기관지천식이동반되는경우가많았는데, 이결과는기관지천식환아 40% 60% 에서만성부비동염을동반한다는선행연구와일치한다. 17 알레르기비염환아는부비동염의위험이커진다고알려져있어, 18,19 폐쇄수면무호흡증소아에서도부비동염호발군에서알레르기비염이더많을것으로예상하였지만이연구결과에서알레르기비염동반이부비동염의위험인자로확인되지못하였다. 그러나 Kim 등 20 은 3 6세의일반아동을대상으로시행한알레르기비염의빈도에관한연구에서알레르기비염을 26.9% 로보고하였다. 이에반해이연구에서는부비동염호발여부에관계없이알레르기비염이 67% 정도로 2배이상높은비율을보여폐쇄수면무호흡증에서부비동염호발의위험인자로증명되지는않았지만아데노이드비대증상이알레르기비염증상으로오인되어차이가발견되지않을가능성도있을것으로생각한다. 부비동염의발생에서알레르기의역할에대한여러연구에서알레르기항원감작으로인한알레르기염증의악화는재발성또는만성부비동염에중요한역할을한다는보고가있으며, 3,21 이에반하여상반된연구결과도있다. 22 이에저자들은총 IgE 수치를비교하여부비동염호발군에서더높은경향을보였으나통계적차이를확인하지는못하였고, 피부단자시험을통한두군간의알레르기항원감작의차이를알아보았는데, 동물털감작에서만통계치에가까운결과를보였고, 다른항원에서유의한차이를확인할수없었다. 3 6세일반아동의감작률과비교해보면일반아동에서집먼지진드기 13%, 동물털 3.4%, 꽃가루 2% 인양성률에비하여, 20 부비동염호발군에서집먼지진드기 55.6%, 동물털 29.6%, 꽃가루 24.7%, 비호발군 48.1%, 11.1%, 21.3% 로일반아동에비해모두높은감작률을보여폐쇄수면무호흡증병인에알레르기의역할이있을것으로추정되며부비동염호발에는알레르기보다무호흡-저호흡지수가더영향을주는것으로확인되어많은환자나학동기아동들을대상으로한전향적연구를통해조사할필요가있다. 폐쇄수면무호흡증에서부비동염의발병기전을보면무호흡-저호흡지수중증도에따라비점막의산소포화도감소를일으켜미세조직의변화를가져오며상피의위축이발생하고, 5 섬모운동의 171

5 Yun HH, et al. Rhinosinusitis and obstructive sleep apnea 장애로부비동염의위험을증가시킨다. 또한아데노이드에세균집락은부비동염의원인이라고알려져있어, 23 부비동염과아데노이드비대와페쇄수면무호흡증은상호작용이있을가능성이크다. 이를뒷받침하는결과로폐쇄수면무호흡증성인환자들의추적관찰시정상대조군에비하여만성부비동염의발생위험률이 3배이상높다는연구가있다. 24 이번연구에서부비동염호발군에서비호발군에비하여무호흡 -저호흡지수가유의하게높았고, 통계적으로유의한차이는없었지만무호흡-저호흡지수중증도에따라부비동염이증가하는경향을보여부비동염발병에무호흡-저호흡지수와의연관관계를추정할수있다. 폐쇄수면무호흡증과기관지천식과의관련성에관한연구에서기관지천식과폐쇄수면무호흡증은저산소증과수면분절및상기도폐쇄에따른신경기계적효과 (neuromechanical effect) 에의해서기관지천식이있는군에서폐쇄수면무호흡증이나수면호흡장애가더많고, 폐쇄수면무호흡증환아의 1/3에서기관지천식이발병한다고알려져있다. 25 치료에서도기관지천식과폐쇄수면무호흡증은서로영향을미친다. Bhattacharjee 등 26 은아데노이드편도절제를받은경우기관지천식이호전을보인다는보고를하였다. 이번연구에서부비동염호발군과재발성부비동염군에서기관지천식의동반이많은결과는부비동염이기관지천식을악화시키고, 기관지천식이있을경우아데노이드편도절제후치료효과가떨어진다고보고된연구결과와동일하다. 27 재발성부비동염, 중이염등의상기도염증상태로인해상기도의만성염증이지속되면상기도에국한되는것이아니고, 상기도의염증질환인수면호흡장애와하기도의염증질환인기관지천식에영향을줄수있다. 상기도염증으로인한폐쇄는수면중저산소증과반복적인각성을통해수면의분절을유발하여기도개형 (airway remodeling) 이진행되어하기도의폐쇄도증가시킨다고알려졌다. 28 소아의만성부비동염치료에약물요법이효과가없다면, 아데노이드절제를먼저시행하고실패시내시경부비동수술이권장된다. 29 이연구에서는아데노이드편도절제를시행한환아 57명중에서재발성부비동염이 13명 (22.8%) 있었고시행하지않은군에서는 51명중 21명 (41.2%) 이었다. 이러한결과는아데노이드편도절제의비강호흡의호전과균집락의저장소로서의아데노이드감소를통한치료결과와일치한다. 30 아데노이드편도절제후알레르기비염동반시아데노이드비대가재발하고수면무호흡증이재발하거나잔존한다는연구 31 들과수면무호흡증환아에서부비동염이선행시수술효과가적었다는결과는 32 수술후에도부비동염에대한지속적관리의필요성및알레르기질환동반을폐쇄수면무호흡증치료시에고려해야한다. 이번연구의제한점으로는첫째후향적으로진행된연구로폐쇄수면무호흡증이없는정상대조군에서비교연구가이루어지지않았고둘째단일의료기간에서폐쇄수면무호흡증으로치료받은환 아를대상으로해서연구에포함된대상환자수가충분하지않았 다. 또한학동전기의아동을대상으로하여알레르기질환, 특히 비염의정확한진단에제약이있었다. 결론으로폐쇄수면무호흡증환아들에서예상한바와같이부비 동염이호발하였다. 부비동염호발군에서무호흡 - 저호흡지수가높 고, 아데노이드편도절제후재발성부비동염의호전을보여폐쇄수 면무호흡증에서부비동염의병인에연관성을보여주었다. 폐쇄수 면무호흡증환아에서알레르겐감작률도높은점과부비동염호발 군에서기관지천식의빈도가높았고 1 년후재발성부비동염에위 험요소로확인된것은알레르기염증이폐쇄수면무호흡증과부비 동염병발의병인에관여된다는것을시사한다. 알레르기비염과의 연관성은진단을분명히할수있고빈도가높아지는학동기대상 을통한전향적인후속연구가필요할것으로보인다. REFERENCES 1. Castronovo V, Zucconi M, Nosetti L, Marazzini C, Hensley M, Veglia F, et al. Prevalence of habitual snoring and sleep-disordered breathing in preschool-aged children in an Italian community. J Pediatr 2003;142: Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130:e Choi SH, Han MY, Ahn YM, Park YM, Kim CK, Kim HH, et al. Predisposing factors associated with chronic and recurrent rhinosinusitis in childhood. Allergy Asthma Immunol Res 2012;4: Gozal D, Kheirandish-Gozal L. New approaches to the diagnosis of sleepdisordered breathing in children. Sleep Med 2010;11: Deniz M, Gultekin E, Ciftci Z, Alp R, Ozdemir DN, Isik A, et al. Nasal mucociliary clearance in obstructive sleep apnea syndrome patients. Am J Rhinol Allergy 2014;28: American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, 2nd ed. Westchester (IL): American Academy of Sleep Medicine, Slavin RG, Spector SL, Bernstein IL, Kaliner MA, Kennedy DW, Virant FS, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005;116(6 Suppl):S Chandran SK, Higgins TS. Chapter 5: Pediatric rhinosinusitis: definitions, diagnosis and management--an overview. Am J Rhinol Allergy 2013;27 Suppl 1:S Pedersen SE, Hurd SS, Lemanske RF Jr, Becker A, Zar HJ, Sly PD, et al. Global strategy for the diagnosis and management of asthma in children 5 years and younger. Pediatr Pulmonol 2011;46: Arens R, Sin S, Willen S, Bent J, Parikh SR, Freeman K, et al. Rhino-sinus involvement in children with obstructive sleep apnea syndrome. Pediatr Pulmonol 2010;45: Kirk V, Baughn J, D'Andrea L, Friedman N, Galion A, Garetz S, et al. American academy of sleep medicine position paper for the use of a home sleep apnea test for the diagnosis of OSA in children. J Clin Sleep Med 2017;13: Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed up by primary care pediatricians. Arch Pediatr Adolesc Med 1998; 172

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar