1. rinosinusitis pit idi 2015

8/18/2019 1. Rinosinusitis PIT IDI 2015

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Irwan Kristyono

Dept/SMF Ilmu Kesehatan THT-KL

Fak Kedokteran Universitas Airlangga/RSUD Dr Soetomo

Surabaya

RHINOSINUSITIS


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! NAMA : IRWAN KRISTYONO,dr,SpTHT-KL(K)

! TMP/TGL LAHIR : Surabaya, 31 Desember

! ALAMAT : Perum Griya Semampir. Jl Medokan Baru IV/34Surabaya

! PENDIDIKAN :! 1988: Lulus FK UNAIR

! 2004: Lulus Sp.THT-KL FK UNAIR

! 2014: Konsultan dibidang Rinologi

! RIWAYAT PEKERJAAN :! Kepala Puskesmas Sarmi, Kab Jayapura, Irian Jaya (1989-1990)

! Kepala Seksi P2M Din Kes Kab Jayapura, Irian Jaya (1990-1995)

! Pjs Kepala Dinas Kesehatan Kab Jayapura, Irian Jaya (1995-1996)

! Pjs Kepala Kantor Dep Kesehatan Kab Jayapura, Irian Jaya (1995-1997)

! Staf Medis RSUD Langsa, Kab Aceh Timur, NAD ( 2004-2005)

! Staf Medis RSUD Dr Soetomo, Surabaya (2005- sekarang)

! PEKERJAAN/JABATAN :! Staf medis SMF/Dep Ilmu KesTHT-KL RSUD Dr Soetomo/FKUNAIR

! Kepala URJ THT-KL RSUD Dr Soetomo

! Ketua Divisi Rinologi SMF/Dep Ilmu KesTHT-KL RSUD Dr Soetomo/FKUNAIR

! Ketua PERHATI-KL Cab JaTim Utara periode 2013-2016

!Anggota Kodi Rinologi PERHATI-KL

! Anggota PP PERHATI-KL Periode 2013-2016

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RHINOSINUSITIS in dults

! Inflammation of the nose and the paranasal sinuses characterised by 2

or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge

(anterior/posterior nasal drip):

! + facial pain/pressure

! + reduction or loss smell

And either

! Endoscopic signs of:

! Nasal polyps, and/or

! Mucopurulent discharge primarily from middle meatus and/or

! Oedema/mucosal obstruction primarily in middle meatus

And/or

! CT scan:

! Mucosal changes within the ostiomeatal complex and/or sinus

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RHINOSINUSITIS in Children

! Inflammation of the nose and the paranasal sinuses characterised by 2 or

more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior

nasal drip):

! + facial pain/pressure

! + cough

And either

! Endoscopic signs of:

! Nasal polyps, and/or

! Mucopurulent discharge primarily from middle meatus and/or

! Oedema/mucosal obstruction primarily in middle meatus

And/or

! CT scan:

! Mucosal changes within the ostiomeatal complex and/or sinus

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Duration of the Disease in adult and children

! Acute :

! < 12 weeks

! Complete resolution of symptoms

!

Chronic :! > 12 weeks symptoms

! Without complete resolution of symptoms

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Classification of RS

! Common cold/Acute viral Rhinosinusitis: duration of symptoms

for less than 10 days

! Acute post viral rhinosinusitis: increase of symptoms after 5 days

or persistent symptoms after 10 days with less than 12 weeks

duration

! Acute bacterial rhinosinusitis (ARBS): suggested by the presence

of at least 3 symptoms/signs of:

! Discoloured discharge (with unilateral predominance) and purulent

secretion in cavum nasi

! Severe local pain (with unilateral predominance)

! Fever (>380 C)

! Elevated ERS/CRP

! Double sickening

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Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper on

Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;


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Severity of the disease in adult and children

! Based on total severity Visual Analogue Scale (VAS) score(0-10 cm)

! MILD : VAS 0-3

! MODERATE : VAS > 3 – 7

! SEVERE : VAS > 7 - 10

Not troublesome worst thinkable

troublesome

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! Sino-Nasal Outcome Test 20 (SNOT 20)

!

20 multiple choice question! Score: 0-5

! Lund & MacKay Score

! Based on CT scan

!6 parts: frontal sinus, maxilla sinus, anterior ethmoid sinus,posterior ethmoidal sinus, sphenoid sinus and osteomeathal

complex

! Right and left

!

Score: paranasal sinus: 0: no lucency; 1: partly lucency;2: full lucency

osteomeathal complex: 0: no lucency; 2: lucency

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Bacterial Species Identified

! Most common bacterial species isolated

from maxillary sinuses of patients with

Acute Bacterial Rhinosinusitis (ABRS):

! Streptococcus pneumoniae

! Haemophilus influenzae

! Moraxella catarrhalis

! Less frequently:

! Other streptococcal spp.

! Anaerobic bacteria

! Staphylococcus aureus

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Symptoms and signs

Acute Rhinosinusitis:

4 Symptoms:

F Rhinorrhoea (nasal discharge)

F Nasal obstruction

F Facial pain or cephalgia

F Hiposmi/anosmi

F cough

F fever

4 Signs:- Mucopurulent discharge primarily from middle meatal

- Oedema & hyperemia on middle turbinate

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Symptoms and signsChronic Rhinosinusitis :

4 Symptoms: F Facial pain or cephalgia

F nasal obstruction

F Rhinorrhoea

F Hiposmi/anosmi

F Cough

F mouth breathing

F ear complaints

4 Signs:

- Mucopurulent discharge primarily from middle meatal

- Oedema & hyperemia on middle turbinate

- Polyps, multiple or singular, nasal cavity14


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Major Factors Minor Factors

! Facial pain/pressure * Headache

!

Facial congestion/fullness * Fatigue! Nasal obstruction/blockage * Halitosis

! Nasal discharge/purulence/ * Dental pain

discolored postnasal drainage

! Hyposmia/anosmia * Cough

! Purulence in nasal cavity on * Ear pain/pressure/fullness

examination

! Fever

The Task Force on Rhinosinusitis Outcomes Research of the American

Academy of Otolaryngology-Head and Neck Surgery

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Chronic rhinosinusitis

! When no earlier sinus surgery has been performed! CRS with nasal polyps: bilateral, endoscopically visualised in middle

meatus

! CRS without nasal polyps: no visible polyps in middle meatus, if

necessary following decongestant

! When sinus surgery has been performed

! Bilateral pedunculated lesions as opposed to cobblestoned mucosa >

6 months after surgery on endoscopic examination.

! Any mucosal disease without overt polyps should be regarded asCRS

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CRSwNP an CRSsNP

! A deficit of epidemiologic studies exploring the prevalence andincidence

! Approcimately 5-15 % general population in Europe and USA

!

Doctor diagnosed: 2-4 %! Many factors associated

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Factors associated with CRSwNP and CRSsNP

o Ciliary impairment

o Allergy

o Asthma

o Aspirin sensitivity

o Immunocompromised state

o Genetic factors

o Pregnancy and endocrine state

o Local host

o Biofilms

o Iatrogenic

o Environmental

o helicobacter pylori and LPR

o Osteitis

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Anatomical variation

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Inflammatory mechanisms in CRSwNP or CRSsNP

! Fungal hypothesis! Aspirin intolerance: defects in the eicosanoid pathway

! The Staphylococcal superantigen hypothesis

! The immune barrier hypothesis

! Biofilms

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Host inflammatory pathways in CRS

Mechanical barrier

Ephitelial cells

Dendritic cell and macrophages

Eosinophils

Neutorphils

Mast cell

Cells, Plasma cells and immunoglobulins

T cells and cytokins patterns

Remodelling

Elcosanoids and the arachidonic acid pathway25


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Stressmucosal Mucosal

Functionaldisturbance

Sinonasalphysiologydisturbance

Chronic Disease

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Complications of Rhinosinusitis

Local :

• Mucocele

• Osteomyelitisand Pott’spuffy tumor

Orbital :

• Preseptalcellulitis,

• orbitalcellulitis,

• superiostealabscess,

• orbital

abscess,• cavernous

sinusthrombosis

Intracranial:

• meningitis,

• epiduralabscess,

• subduralabscess,

• intracerebralabscess

• Superiorsagital sinusthrombosis

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L/1GL 1/3MLI1G!I/J

Mucocele

• Chronic

• cystic lesions that are lined with pseudostratified or low columnar epithelium

• Pathophysiologicmechanisms are still uncertain

• All sinuses could involved

• Most complaint: headache

• CT scan: hypodense and nonenhancing

• Treatment: open surgical or and endoscopic

Ostiomyelitis

• Most common: Frontal sinus (Pott’s puffy tumor)

• Can result acute and chronic sinusitis• Symptoms: headache, photophobia, swelling of the forehead, purulent / nonpurulent

discharge, and fever

• CT scan with contrast or MRI: hypodense collection of fluid external to the frontal bone with an enhancing rim that represent the thickened, displaced periosteum

• Treatment: endoscopic and external approaches29


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Chandler’s classification of orbital infection

I Inflammatory edema (preseptal) Lid edema, no limitation in ocular movementor visual change

II Orbital cellulitis (postseptal) Diffuse orbital infection and inflammationwithout abscess formation

III Subperiotseal abscess Collection of pus between medial periosteumand lamina papyracea, impaired extraocullar

movement

IV Orbital abscess Discrete pus collection in orbital tissues,proptosis and chemosis with ophthalmoplegia

and decreased vision

V Cavernous sinus thrombosis Bilateral eye findings and worsening of allother previously described eye finding

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Intracranial complications of rhinosinusitis

Sinus source Clinical presentation

Meningitis Sphenoid,

ethmoid

Acute and rapidly progressive; fever, headache, changes in

mental status, photophobia and meningismus

Epidural abscess Frontal Slowly expanding, indolent onset; headache, fever and local

pain and tenderness

Subdural abscess Frontal Rapidly progressive, neurosurgical emergency; headache, fever,

lethargy, meningeal signs, seizures

Intracerebral

abscess

Frontal Asymptomatic phase, followed by: headache, fever, vomiting

and lethargy, frontal lobe abscess, mood and behavioral changes

Cavernous sinus

thrombosis

Sphenoid,

ethmoid

Proptosis, ophthalmoplegia, chemosis, decrease visual acuity,

V1 and V2 facial anesthesia; involvement of the contralateraleye is a late finding

Superior sagital

sinus thrombosis

Frontal Extremely ill, high spiking fever, meningeal signs and

neurologic defects

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! Orbital complication: spread of infection directly via the

thin and often dehiscent lamina papyracea or by veins

! Intracranial/endocranial complication: can pass

through the diploic veins to reach the brain or by erodingthe sinus bones

Routes of Complication

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Clinical examination :

!

Rhinoscopy:! Nasal cavity: erythematous, yellow to greenish purulent rhinorrhoe, pus

in the middle meatus, turbinate swelling

! pharyngeal: erythematous, post nasal drip, hyperplasia of the

tonsils and adenoids! The cervical lymph nodes may be moderately enlarge

! Nasal endoscopy: rigid or flexible

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4 Microbiology assessment:

F Not necessary, accept with complication

F Indications:

4 Severe illness / toxic

4 Acute illness not improving with medical therapy within 48-72 hours

4 An Immunocompromised host

4 Suppurative complications (orbital cellulitis, intracranial)4 Imaging:

F Not necessary

F Indication are the same as those given for a microbiology specimen

and if surgery is being considered

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Treatment Rhinosinusitis

! Antibiotics

! Give with symptoms for as little as 10 days

! should be reserved for severe disease: toxic conditions with

suspected or proven suppurative complication, severe acute

rhinosinusitis and

! Amoxycillin, amoxycillin-potassium clavunate, cephalosporin,

azithromycin or clarithromycin

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!

Topical corticosteroid! Effective in reducing the cough and nasal discharge

! Topical or oral decongestan

4 Careful dosage, to prevent toxic manifestation

4 No additive effect

4 Xylometazoline and oxy metazoline

! Nasal douching

4 Eliminating nasal secretions and decrease nasal oedema

4Isotonic and at body temperature

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Surgical treatment

4 Goal: eliminated risk factor and to refunctional normal sinus

paranasal

4 Sinus irigation

4 Caldwell Luc operation

4 Functional Endosopic Sinus Surgery

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Management Chronic Rhinosinusitis

! Basic management:

! Reduce mucosal inflammation

! Control infection process

! Repair muccociliary clearance

! Individual

! Environment controll

! Medicamentosa: Corticosteroid, antibiotic, nasal saline

!

surgery

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Referral on CRS

!

Management CRS: ENT or non ENT! Indication: failure on therapy for 4 weeks, worse condition and

complication

! Referral Indication to ENT:

! Failure on therapy after 4 weeks therapy! Complication (intraorbital/intracranial/bone)

! No progression on therapy CRS without polyp for 3 months

! No progression on therapy CRS with polyp mild and moderate for 3

months or CRS with polyp severe for 1 month

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Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper on Rhinosinusitis andNasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;


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T t t id d d ti f


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Treatment evidence and recommendations for

children with acute rhinosinusitis EPOS 2012



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Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper on Rhinosinusitis andNasal Polyps 2012. Rhinol Suppl . 2012 Mar(23): 1-298.;

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Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper onRhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;

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Fokkens WJ, Lund VJ, Mullol J, BachertC, Alobid I, Baroody F, et al. European Position Paper on Rhinosinusitis andNasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;


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1. rinosinusitis pit idi 2015

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