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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
39
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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 on Rhinosinusitis andNasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;
41
T t t id d d ti f
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Treatment evidence and recommendations for
children with acute rhinosinusitis EPOS 2012
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 on Rhinosinusitis andNasal Polyps 2012. Rhinol Suppl . 2012 Mar(23): 1-298.;
43
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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.;
44
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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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THANK YOU