Case ReportChronic Rhinosinusitis

Coass Group 15.1.07

Moderator: dr. Belinda Djimandjaja

Group Members Irfan Haris (14639) Atika Dwitama (14327) Rinda Rosmayanti (13164) Ulfah Fitriyani (14599) Singgih Setiawan (14561) Maruti Lintangsenjani (13467) Cresti Chandra Pradelta (14631)

LITERATURE REVIEW

Anatomy of the Nose and Paranasal Sinus

Chronic Rhinosinusitis

Definition Chronic rhinosinusitis is an inflammatory

process in the mucosa of the nose and paranasal sinuses with a duration of more than 12 weeks or 3 months.

Etiology Bacteria (Pseudomonas, Citrobacter,

Haemophilus, Propionibacterium, Staphylococcus, and Streptococcus)

Air pollution Active smoking Passive smoking Allergic rhinitis Gastropharyngeal reflux

Pathophysiology

Diagnosis

Major factor Minor factorFacial pain/pressurea HeadacheNasal obstruction Fever (all nonacute)Nasal discharge/discolored postnasal drip

Halitosis

Hiposmia/anosmia Dental painPurulence in examination FatigueFever (acute only)b Cough  Ear pain/pressure/fullnessa: The presence of facial pain / pressure without any other major symptoms and signs cannot be used to direct the diagnosis.b: The presence of fever in sinusitis / acute rhinosinusitis without any symptoms and signs another major, cannot be used to direct the diagnosis.

Table 1. Symptoms and Signs Associated With Rhinosinusitis(Rhinosinusitis Task Force in 1996 quoted from Bailey, et al,

2006)

The diagnosis of rhinosinusitis based on the above criteria is established when it is found that there are two or more major symptoms, or one major symptom accompanied by two minor symptoms.

Diagnosis Based on Task Force 2007, the chronic rhinosinusitis

is inflammation which twelve (12) weeks or longer of two or more of the following signs and symptoms: Mucopurulent drainage (anterior, posterior, or both) Nasal obstruction (congestion) Facial pain-pressure-fullness Decreased sense of smell

AND inflammation is documented by one or more of the following findings: Purulent (not clear) mucus or edema in the middle meatus

or ethmoid region Polyps in nasal cavity or the middle meatus Radiographic imaging showing inflammation of the

paranasal sinuses

Diagnosis Chronic rhinosinusitis, with or without nasal polyps in

adults is defined as: inflammation of the nose and the paranasal sinuses

characterised by two 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 of smell

for ≥12 weeks This should be supported by demonstrable disease. 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 changes: mucosal changes within the ostiomeatal complex

and/or sinuses (EPOS, 2012)

Management

Complications ► Local Complications

      - Mucocele      - Osteomyelitis (when occurs in frontal bone, known as Pott's puffy tumor)► Orbital Complications      - Preseptal cellulitis      - Orbital cellulitis      - Subperiosteal abscess      - Orbital abscess      - Trombophlebitis cavernous sinus► Intracranial Complications      - Meningitis      - Subdural abscess      - Epidural abscess      - Intracerebral abscess      - Cavernous sinus thrombosis / venous

CASE REPORT

Patient Identity Name : M Age : 25 years old MR : 73-XX-XX Sex : Female

Anamnesis Chief complain : runny nose History of present illness :

Since approximately 6 months before came to ENT clinic of RSUD Banyumas, patient had recurrent runny nose, stinky and yellowish-green colored discharge, and nasal blockage. Patient also complains about unpleasant odor in her nose and pain over right and left cheeks, and mucus on her throat. There are no complains about ear and throat. She never been treated before.

Anamnesis History of past illness :

She denies alergy, asthma, and toothache history. History of family illness :

Her family do not have diabetes mellitus, hypertension, and allergy.

Resume of Anamnesis Female patient with symptoms of rhinorrhea,

nasal congestion, foeter ex nasale, and mucous on her throat.

Physical Examination General status : good, compos mentis Vital sign

BP : 120/70 mmHg Respiratory Rate : 20 times/minute Temperature : 36,5˚C Pulse : 64 times/minute.

ENT Examination Right and left ears : within normal limit. Anterior rhinoscopy: hyperemic in right and

left nasal cavity, edematous inferior turbinate in the right and left nasal cavity, septum deviation (-), discharge (+), mass (-)

Posterior rhinoscopy: discharge (+), edematous concha (+)

Facial palpation and percusion: pain over right and left cheek

Oropharyngeal examination: palatine tonsils size are within normal limit, good gag reflex, post nasal drip (+)

Indirect laryngoscopy: within normal limit

Diagnosis Chronic rhinosinusitis without nasal polyp

Treatment Amoxicillin-clavulanate acid 625 mg every 8

hours Trifed (pseudoefedrin HCL 30 mg + tripolidine

20 mg) every 8 hours Ambroxol 30 mg every 8 hours

Problem Recurrency

Plan Control to ENT clinic for evaluation 1 week

later and skin prick test 1 week after the end of treatment.

DISCUSSION

This patient is diagnosed with chronic rhinosinusitis based on her signs and symptoms, which are recurrent rhinorrea, nasal congestion, foul-smelling and yellowish-green colored discharge. Patient also complains about unpleasant odor in her nose, pain over right and left cheeks, and mucus on her throat. There are no complains about ear and throat. She denies alergy, asthma, and toothache history.

Problem in this case is recurrency Factors that contribute to recurrency of

chronic rhinosinusitis consists of: host factors (genetic factors, physiologic factors,

structural factors, defects in innate imunity, and defects in adaptive immunity);

environmental factors (allergy, smoking, irritants/pollution); and

microbial factors (bacteria, fungi, biofilms, and superantigens)

We think that the patient has allergy as the factors that contribute to recurrency of her chronic rhinosinusitis.

The relationship between allergic rhinitis with rhinosinusitis has been widely studied and recorded although a causal relationship cannot be state certainly.

In patients with chronic rhinosinusitis, allergic rhinitis prevalence ranged between 25-50% . In patients undergoing sinus surgery, the prevalence of positive skin test results ranged between 50-84%, the majority (60%) with multiple sensitivity.4

But how allergies can cause chronic rhinosinusitis, to this day is not known clearly. One hypothesis state that nasal mucosal edema in patients with allergic rhinitis that occurs in the sinus ostium can reduce ventilation even lead to obstruction of the sinus ostium, resulting in retention of mucus and infetion. However this is more directed to acute rhinosinusitis, while the extent of the development and persistence of state gives the effect of chronic rhinosinusitis, has yet to explain.

CONCLUSION

We report a 24 years old female patient with runny nose as a main complain; recurrent foul smelling and yellowish-green colored snot, and nasal blockage. since 6 months ago. Patient also complains about unpleasant odor in her nose and headache everytime she bents her neck, pain over right and left cheeks, and mucus on her throat. From anamnesis andphysical examination, we diagnosed chronic rhinosinusitis. The treatment for this case was Coamoxiclav 625 mg every 8 hours, Trifed (pseudoefedrin HCL 30 mg + tripolidine 20 mg) every 8 hours, and Ambroxol 30 mg every 8 hours a day. We ask patient to follow our advice, control her treatment regularly at ENT clinic of RSUD Banyumas, and skin prick test 1 week after the end or treatment.

REFERENCES

Kashani S, et al. Clinical Characteristics of Patients with Chronic Rhinosinusitis and Specific Antibody, Journal of Allergy and Clinical Immunology Volume 129, Issue 2, February 2012, Pages AB68

Brook, Itzak, et al. Sinusitis From Microbiology to Management. New York: Taylor and Francis, 2006.

Ballanger JJ. Hidung dan sinus paranasal. Dalam Penyakit Telinga, Hidung, Tenggorok, Kepala dan Leher Jilid 1 edisi 13, Binarupa Aksara 1994; hal 1-27.

Kristyono I, Selvianti. Patofisiologi, diagnosis dan penatalaksanaan rhinosinusitis kronik tanpa poli nasi pada orang dewasa, Karya Tulis Ilmiah, 2013.

Saladin K. Saladin: Anatomy & Physiology: The Unity of Form and Function. 3rd ed. New York: McGraw-Hill; 2003.

Vander AJ, Sherman JH, Luciano DS. Human Physiology: The Mechanism of Body Function. 8th ed. New York: McGraw-Hill; 2001

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology. 5th ed. Philadelphia: Williams & Wilkins, 2014.

Rhinology Study Group – PERHATI-KL 2007, Buku Saku EPOS 2007, PERHATI-KL, Jakarta.

Shah DR, Salamone FN, Tami TA. Acute & chronic rhinosinusitis. In Lalwani AK, eds. Current diagnosis and treatment in otolaryngology – head and neck surgery. New York: Mc Graw Hill, 2008; 273-281

Fokkens WJ, et al. 2012, European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinology 50; suppl. 23: 1-298.

Busquets JM, Hwang PH. Nonpolypoid rhinosinusitis: Classification, diagnosis and treatment. In Bailey BJ, Johnson JT, Newlands SD, eds. Head & Neck Surgery – Otolaryngology. 4th ed. Vol 1. Philadelphia: Lippincott Williams & Wilkins, 2006; 406-416.

Hamilos L Daniel, 2011, Chronic Rinosinusitis : Epydemiology and Medical Management, Journal of Allergy and Clinical Immunology Volume 128, Issue 4, October 2011, Pages 693-707

THANK YOU

BACK UP SLIDE

Tabel 2. Terms for Diagnosis Chronic Rhinosinusitis (2003 Task Force)

Duration Objective findings

Ongoing symptoms or clinical signs continuously for> 12 weeks in accordance with the criteria of the Task Force 1996

One of the criteria in addition to be found:

1. The presence of purulent secretions nasal cavity, polyps or polypoid growth in rhinoscopy examination (with dekongesti) or endoscopy

2. The presence of edema or erythema at the meatus media during endoscopic examination

3. The presence of edema, erythema, or granulation tissue either localized or difusa in the nasal cavity. If it does not involve media meatus, the imaging examinations required for diagnosis.

4. Imaging studies to confirm the diagnosis. (Plain photo or CT-Scanb)

a Plain without any other objective findings (1,2, and 3) can not be used for diagnosis.

b Magnetic resonance imaging (MRI) is not recommended for diagnosis.