Topic List Rhinosinusitis
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Transcript of Topic List Rhinosinusitis
Definisi• Inflammatory process involving mucosa of the nose and
one or more sinuses• Mukosa hidung-sinus merupakan kontinuum (inflamasi
mukosa hidung sinus)• Bentuk rhinitis akibat infeksi
(ARIA Update 2008)
Klasifikasi• Acute Rhinosinusitis (ARS)• Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)• Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP)
(EPOS 2012)
Mikrobiologi• Viral
• rhinovirus, coronavirus• influenza, parainfluenza, adenovirus, RSV, enterovirus
• Bakteri• S. pneumoniae, H. influenzae, M. catarrhalis• S. aureus
Patofisiologi
Acute Viral Rhinosinusitis
(Common Cold)
• Symptoms duration < 10 days
Acute Post-viral rhinosinusitis
• Increase of symptoms after 5 days• Persistent symptom after 10 days• Less than 12 weeks
Acute Bacterial Rhinosinusitis
•Discoloured discharge
•Severe local pain•Fever (>38)•Elevated ESR/CRP•“Double sickening”
Patofisiologi
Viral Infection
Mucosal edema
Epithelial disruption
Goblet cell increased
Cilliary cells decreased
Impairment in normal gas exhange
pH change
Impaired clearance of mucus and debris
Increased bacterial adhesion
Bacterial infection
Mucus accumulation
Followed by negative pressure built up due to impaired sinus
aeration
SymptomsLocal Symptoms
• Nasal blockage/congestion/stuffiness
• Nasal dicharge or postnasal drip
• Facial pain/pressure or headache
• Reduction/loss of smell
Distant Symptoms
Pharyngeal • Sore throat
Laryngeal • Dysphonia
Tracheal • Cough
General Symptoms
• Drowsiness, malaise, fever
Warning Symptoms• Periorbital edema/eryhtema• Displaced globe• Double vision• Ophtalmoplegia• Reduced visualacuity• Severe unilateral/bilateral frontal headache• Frontal swelling• Neurological signs• Reduced consciousness
Pemeriksaan Fisik• Temperatur• Rhinoskopi anterior inflamasi, edema mukosa, sekret
purulen, polyp, abnormalitas anatomi• Inspeksi dan palpasi sinus pembengkakan dan nyeri
pada daerah sinus• Oral post nasal discharge, infeksi gigi
Pemeriksaan Penunjang• Erythrocyte Sedimentation Rate/C-Reactive Protein• Bakteriologi tidak dibutuhkan (indikasi: penyakit severe,
rekuren, terdapat komplikasi)• Pencitraan (indikasi: penyakit severe, gagal terapi
medikamentosa, terdapat komplikasi, immunocompromised)
Diagnosis Banding• Viral Upper Respiratory Tract Infection (URTI)• Allergic Rhinitis
• Non-purulent rhinorrhea (vs. mucopurulent)• Nasal itching & sneezing (vs. pain)• Ocular symptoms• History of allergy/atopy, seasonal exposure pattern
• Orodontal disease
Kriteria Diagnostik ARS Dewasa
Sudden onset or two or more symptoms, one of which should be either nasal blockage or nasal discharge (anterior/posterior)• +/- facial pain/pressure• +/- reduction/loss of smell
For < 12 weeks
(EPOS 2012)
Kriteria Diagnostik ARS Pediatrik
Sudden onset or two or more of the symptoms• Nasal blockage• Discoloured nasal sicharge• Cough (daytime and nighttime)
For < 12 weeks
(EPOS 2012)
Symptomatic Treatment• Analgesik golongan NSAID• Decongestant oral norephedrine, pseudoephedrine,
topikal oxymetazoline, xylometazoline• Irigasi hidung dengan saline
Antibiotik (AAO)• Primary (for mild symptoms, no previous treatment, low
resistance risk)• Amoxicillin 3 x 500 mg pc• Doxycycline 1 x 200 mg hari pertama 1 x 100 mg pc• Cefpodoxime 2 x 200 mg pc• Cefdinir 1 x 600 mg pc
• Secondary (for moderate-severe, prior treatment, high resistance)• Amoxicillin clavulanate 1 x 875 mg pc• Levofloxacin 1 x 500 mg pc• Moxifloxacin 1 x 400 mg pc• Ceftriaxone IV 1 x 1000 mg
Patofisiologi• Superantigen hypothesis (disease modifier)
Staphylococcus mengeksresikan exotoxin, yang pengaruhi beberapa sel:• Th2 peningkatan aktivitas = pembentukan IgE polyclonal
• Treg inhibisi• Eosinophil peningkatan survival dan aktivitas • Sel mast peningkatan degranulasi
• Net effect untuk membantu mikroorganisme menghindari respon imun host
Patofisiologi• Immune barrier hypothesis
Defek barrier mekanis
Imunitas innate
Kolonisasi epitel dengan bakteri
Aktivasi sel epitel, limfosit B dan T
(Efek Superantigen)
Kompensasi imunitas adaptive
Respon Th2 meningkat
Pembentukan autoantibodi
Polyp• Translucent to pale grey• Pear shaped, smooth, soft, freely mobile• Lateral nasal wall• Inflammatory polyps are usually seen bilaterally• Fibromyxomatous stroma covered by respiratory
epithelium• Eosinophils and mast cells
(Ballenger Otorhinolaryngology, 2003)
Symptoms• ~ ARS, namun intensitas < ARS• Loss of smell > ARS (Ballenger Otorhinolaryngology,
2003)• Nyeri < ARS, kecuali eksaserbasi akut
• Minor symptoms: ear pain/pressure, dizziness, halitosis, dental pain
Kriteria Diagnostik CRS
Presence of two or more symptoms, one of which should
be either nasal blockage or nasal discharge
(anterior/posterior nasal drip)
• +/- facial pain/pressure
• +/- reduction/loss of smell
For > 12 weeks
Kriteria Diagnostik CRSwNP• Kriteria CRS• Bilateral, endoscopically visualise polyps in middle
meatus
Kriteria Diagnostik CRSsNP• Kriteria CRS• No visible polyps in middle meatus, if necessary
following decongestants