CHRONIC RHINOSINUSITISModerator : dr. Reni

INTRODUCTION Rhinitis and sinusitis usually coexist ->

the correct terminology “rhinosinusitis”

classification Rhinosinusitis (based on duration of sign and symptoms) :

1. Acute 2. Subacute3. Chronic

(Bailey,2006)

INTRODUCTION Chronic rhinosinusitis -> one of the

most common chronic illnesses in Americans under 45 years of age

> 30 million people suffer from chronic rhinosinusitis -> annual prevalence of 13% to 16% which has been increasing

Chronic rhinosinusitis can significantly worsen a patient’s quality of life

INTRODUCTION Chronic rhinosinusitis is a significant

health problem -> Therefore, an accurate, efficient, and accessible diagnosis of rhinosinusitis is required

OVERVIEW

External Nose

ANATOMY

OSTIOMEATAL UNIT

Adapted from: httpwww.noseandsinus.comnssfaqs603.html

A role in the pathogenesis of rhinosinusitis is certainly played by the ostiomeatal complex, a functional unit that comprises maxillary sinus ostia, anterior ethmoid cells and their ostia, ethmoid infundibulum, hiatus semilunaris and middle meatus, & process uncinate. The key element is the maintenance of the ostial patency.Fokkens WJ, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2007

OSTIOMEATAL UNIT

PARANASAL SINUSES

Adapted from: Brook, et al. Sinusitis From Microbiology to Management. 2006

ANATOMI HIDUNG & SINUS PARANASALIS

Adapted from: httpwww.noseandsinus.comnssfaqs603.html

Vascular SupplyArteries External nose : a. facialis(external carotid artery) & a.

opthalmica (internal carotid artery) Internal nose : terminal branches of the sphenopalatine

artery(from the maxillary artery) & the anterior and posterior ethmoid arteries(from the ophthalmic artery)

Veins Generally follow the arteries Veins that pass with branches from the maxillary

artery -> the pterygoid plexus in infratemporal fossa

Veins from anterior regions -> the facial vein

External Nose

INNERVATION Nerves that innervate the nasal cavities are: - The olfactory nerve of olfaction- Ophtalmic nerve(V1) - Maxillary nerves(V2)

Secretomotor innervations of mucous glands in the nasal cavities and paranasal sinuses is by parasympathetic fibers from the facial nerve (VII), which mainly join branches of the maxillary nerve (V2) in the pterygopalatine fossa

INNERVATION

Adapted from: Paganelli, R. Anesthesia, Nose. In: www.emedicine.com. 2009

Histology Nasal epithelium is a pseudostratified

columnar ciliated mucous membrane -> continuous throughout the sinuses.

The epithelium contains :- Goblet cells; which produce mucus- Columnar cells with mobile cilia projecting into

the mucus, beating 12–15 times a second. These mucociliary pathways ensure drainage

of the sinuses through their physiological ostium into the nasal cavity

MUKOSA RESPIRATORIK

Adapted from: httpwww.fess.com.auimportance_of_nasal_health.php

PHYSIOLOGY AND MUCOCILLIARY CLEREANCE

The nasal cavity & paranasal sinuses are lined by pseudostratified columnar ciliated epithelium.

Contains goblet cells and nasal glands -> of nasal secretions that keep the nose moist & form a “tapis roulant” of mucus.

Particles and bacteria can be caught in this mucus & rendered harmless by enzymes like lysozyme and lactoferrin-> transported down towards the oesophagus.

Cilia play an important role in mucus transport. All paranasal sinuses are normally cleared by this

mucociliary transport

MUCOCILLIARY CLEARANCEMucociliary clearance serves to transport trapped particles including pathogens out of the sinuses and nose.

DEFINITION Rhinosinusitis :

is an inflammatory process involving the mucosa of the nose and one or more sinuses with more than 12 weeks symptoms

(Epos,2007)

Viral Upper Respiratory Infection as a precursor

Microbial factors Sinus obstruction of the mucosal

edema Anatomic factors

• Osteomeatal complex obstruction• Allergies• Polyps • Occult • Subtle immunodeficiency states• Dental diseases• Fungal involvement

Acute

Chronic

ETIOLOGY

(Hwang, PH., et al., 2009)

CAUSATIVE AGENT Acute phase -> Viral infection Chronic rhinosinusitis ->

polimicrobacteria, aerobes & anaerobes :

- Staphylococcus aureus (36%)- Coagulase-negative Staphylococcus

(20%)- Streptococcus pneumoniae (17%).

Risk FactorsThe following conditions and risk factors predispose patients to the development of chronic rhinosinusitis:

• Anatomic abnormalities of

the ostiomeatal complex (eg

septal devation, concha

bullosa, deviation of uncinate

process, Haller cells)

• Allergic rhinitis

• Nasal polyps

• Tumoral obstruction

• Nonallergic rhinitis

• Nasotracheal and nasogastric intubation

• Immunologic disorders (eg common

variable immunodeficiency, IgA deficiency,

IgG subclass deficiency, AIDS)

• Cystic fibrosis

• Primary ciliary dyskinesia, Kartagener

syndrome

• Wegener granulomatosis

• Gastroeshopageal Reflux Disease

• Periodontitis/significant dental disease

(Brooke, I., et al., 2007)

Cont’dConfounding factors that may contribute to inflammation incude the following:

Persistent infection (including biofilms and osteitis) Allergy and other immunologic disorders Intrinsic factors of the upper airway Superantigens Colonizing fungi that induce and sustain eosinophilic

inflammation Metabolic abnormalities

(Ah-See,K., et al., 2008)

Patophysiology of Chronic Rhino-Sinusitis (CRS)

Adapted from Bailey 5th ed, 2014

Inflammatory state

Ventilation, protective, and drainage function was disturbed

Chronic Rhinosinusitis

Clinical Manifestation >12 weeks

Pathophysiology

Adapted from Bailey 5th ed, 2014

Underlying factors

PATHOGENESIS

Ostiomeatal unit patentcyDecreased PO2 and mucus statis

InflammationInfection, osteitis, allergy

autoimun disorder

Mucocilliary clearance

Cystic fibrosis, primary cilliar disorder, cigerrates, polutan/iritan

Bacterial growth

Immune deficiency

Adapted from: Brook, et al. Sinusitis From Microbiology to Management. 2006

DIAGNOSIS The symptoms : anamnesis Clinical findings of physical

examination Additional examination

SIGN AND SYMPTOMS ASSOCIATED WITH DIAGNOSIS OF RHINOSINUSITIS

(1996 RHINOSINUSITIS TASK FORCE)Major factors Minor factors

Facial pain/pressure* Headache

Nasal obstruction Fever (all nonacute)

Nasal discharge/ discolored post nasal

drip

Halitosis

Dental pain

Hiposmia/anosmia Fatique

Purulence in examination Cough

Fever (fase akut)* Ear pain/pressure/fullness

* Facial pain/pressure alone does not constitute a suggestive history for diagnosis in the absence of another major symptom or sign.*Fever in acute sinusitis alone does not constitute a suggestive history for diagnosis in the absence of another major symptom or sign. Adapted from: Bailey BJ, Johnson JT. Head & Neck Surgery-

Otorhinolaryngology. 4th ed, 2006

REQUIREMENTS FOR DIAGNOSIS OF CHRONIC RHINOSINUSITIS

(2003 TASK FORCE)Duration Physical findings

12 weeks of continous

symptoms (as described

by 1996 Task Force) or

physical findings

One of the

following must be

present:

1. Discolored nasal discharge, polyps, or

polypoid swelling on anterior

rhinoscopy (with decongestion) or nasal

endoscopy

2. Oedema or erythema in middle

meatus on nasal endoscopy

3. Generalized or localized edema,

erythema, or granulation tissue in nasal

cavity. If it does not involve the middle

meatus, imaging is required for

diagnosis.

4. Imaging confirming diagnosis (Plain

filmsa or CT-Scanb)

a A plain film without any of the other findings (1,2,or 3) is not a diagnosticb Magnetic resonance imaging (MRI) is not recommended for diagnostic

PERHATI-KL (Kelompok Studi Rhinologi), 2007

Case Report

Patient Identity Name : Mr. S Age : 52 y.o Job : Farmer Address : Ngampel, RT 02/04,

Purworejo Visit date: 12th December 2014

Anamnesis Chief Complaint : nasal blockage and swelling of the left eye

Current Disease History : › 3 Months Before Visit to the hospital the patient felt nasal blockage and

some serous discharge from the nose, especially at the night. Facial pain (-) . Fever (-)

› 2 Weeks Before Visit to the hospital the patient felt nasal blockage and rhinorrhoea with left cheek pain. Fever (-). And then patient went to a general practitioner -> diagnosed with sinusitis -> given some oral drug (not known) -> not resolute well. Two days later patient felt swollen in the periorbital area, pain (+), and difficult to open the eyelid, there is no visual disturbance.

› 1 Day Before Visit patient went to a Otolaryngologist (Sp.THT) in RS Palang Biru -> refer to RSUD Saras Husada Purworejo for incision - drainage plan and the following therapies.

› The day patient visit, he was admitted in the E.R RSUD Purworejo (with referral letter from RS Palang Biru) and admitted for incision - drainage plan (13/12/2014) with initial therapy : - Inf. RL 20 dpm (maintenance)- Inj. Ceftriaxone 2x1gr- Inj. Metronidazole 3x500mg- Inj. Ketorolac 3x30mg

Anamnesis Past Disease History :

› Similar symptoms was denied› History of sneezing in the morning (+), usually 5-7x

along with watery rhinorhea› Allergy or asthma history was denied› History Diabetes Mellitus or Hypertension was denied› History of malignancy was denied

Family Disease History :› Similar symptoms in the inner family was denied› History of Diabetes Mellitus: (-)

Resume Anamnesis Nasal obstruction (+) Rhinorrhea (+) Hiposmia (+) Post nasal drip (+) Left cheek pain (+) Pain and swollen in periorbital area (+) Difficult to open eye lid (+) Visual disturbance (-) Fever (-) History of food allergy (-) Hystory of asthma in family (-)

Physical Examination General status : well conscious,

adequatly nourished. Vital sign :

- Blood Pressure : 130/80 mmHg - Pulse : 84 x/min - Respiration : 20 x/min - Temperature : 36,8 0C

Otorhinolarygology examination

Ear examination : within normal limit Nose examination : Rhinoskopi anterior : hyperemia and

oedema conchae dextra et sinistra, discharge mukopurulen in the cavum nasi sinistra.

Rhinoskopi posterior: hyperemia and oedema conchae dextra et sinistra, discharge mukopurulen in the left side

Otorhinolarygology examination

Then we did lidocain and adrenalin pack Rhinohigrometri before pack: 3 cm/3 cm Rhinohigrometri after pack : 5 cm/6 cm Reexamination rhinsokopi anterior :

septum deviation (-) Orofarings : post nasal drip (+) Laringoskop indirect : within normal limit Cavum oris : caries dentis (+)right upper

molar II, calculus (-), fistula (-), gangrene radix (-)

Opthalmologist Consultation Results

Visus : ODS 6/6 Eye Movement : ODS Normal

a. Preseptal cellulitis(eyelid edema)b. Subperiosteal abscess c. Orbital callulius,d. Orbital abscesse. Cavernous sinus

thrombosis

Radiologic Imaging Performed CT scan of the SPN with 3mm

coronal sections Results : There are soft tissue mass with

inhomogene density in left supraorbita, cavum orbita sinistra, sinus frontalis sinstra, sinus ethmoidalis sinstra, sinus sphenoidalis sinistra, and sinus maxillaris sinistra, skeletal system is intact.

Interpretation : abcess in left supraorbita, cavum orbita sinistra, sinus frontalis sinstra, sinus ethmoidalis sinstra, sinus sphenoidalis sinistra, and sinus maxillaris sinistra

Diagnosis Chronic Rhinosinusitis sinistra with

periorbital abcess

Treatment Inf RL 20 dpm Inj Ceftriaxon 1 g/ 12 h Inj. Metronidazole 500 mg / 8h Inj Ketorolac 30 mg/ 8h Inj. Metylprednisolone 125 mg/ 12 jam Aldisa tab 2 x 1 PO Blood Glucose test Consult ophtalmologist

Problem Complicating to periorbital abcess

Planning Abcess incision and drainage Sinus Surgical terapy

Post-Operation Photo

13-12-2014

S: mass in regio periorbita(+), nasal discharge (+)O: KU : well nourish, Compos MentisMass in regio periorbita sinistra size 5x4 cm, fluktuatif, eritema, painful A: chronis rhinosinusitis with periorbital abscessP: - pro operasi sinus, insisi drainase abses periorbita

14-12-2014

S : pointed bleeding from nasal area (-)O : KU: well nourish, compos mentisAnterior solid tampon(+),A: chronic rhinosinusitis and abcess periorbita post sinus operation and incisi drainase periobrbital abcess day-1P : -aff tampon, verban replace everyday-inf RL 20 tpm-inj.ceftriaxon 1 gr/12 hour-inj. Metronidazole 500mg/8hour-inj.ketorolac 30mg/8hour-inj.ranitidin 50mg/8hour-inj.metil prednisolon 125mg/12hour

15-12-2014

S : pointed bleeding from nasal area (-)O : KU: well nourish, compos mentisAnterior solid tampon(+),A: chronic rhinosinusitis and abcess periorbita post sinus operation and incisi drainase periobrbital abcess day-2P : -verban replace everyday-inf RL 20 tpm-inj.ceftriaxon 1 gr/12 hour-inj. Metronidazole 500mg/8hour-inj.ketorolac 30mg/8hour-inj.ranitidin 50mg/8hour-inj.metil prednisolon 125mg/12hour

16-12-2014

S : pointed bleeding from nasal area (-)O : KU: well nourish, compos mentisAnterior solid tampon(+),A: chronic rhinosinusitis and abcess periorbita post sinus operation and incisi drainase periobrbital abcess day-3P : -verban replace everyday-inf RL 20 tpm-inj.ceftriaxon 1 gr/12 hour-inj. Metronidazole 500mg/8hour-inj.ketorolac 30mg/8hour-inj.ranitidin 50mg/8hour

17-12-2014 S : pointed bleeding from nasal area (-)O : KU: well nourish, compos mentisAnterior solid tampon(+),A: chronic rhinosinusitis and abcess periorbita post sinus operation and incisi drainase periobrbital abcess day-4P : -verban replace everyday-inf RL 20 tpm-inj.ceftriaxon 1 gr/12 hour-inj. Metronidazole 500mg/8hour-inj.ketorolac 30mg/8hour-inj.ranitidin 50mg/8hour-inj.metil prednisolon 125mg/12hour

18-12-2014 S : pointed bleeding from nasal area (-)O : KU: well nourish, compos mentisAnterior solid tampon(+),A: chronic rhinosinusitis and abcess periorbita post sinus operation and incisi drainase periobrbital abcess day-5P : -aff tampon, verban replace everyday-inf RL 20 tpm-inj.ceftriaxon 1 gr/12 hour-inj. Metronidazole 500mg/8hour-inj.ketorolac 30mg/8hour-inj.ranitidin 50mg/8hour-inj.metil prednisolon 125mg/12hour

Discussion The diagnosis chronic rhinosinusitis of

this patient was based on anamnesis, physical examination, and radiologic imaging.

According to Task Force 1996 and Task Force 2003, also EPOS 2007 this case can be diagnosed as chronic rhinosinusitis.

Discussion Chronic rhinosinusitis is a multifactorial

disease -> predisposing factors for CRS can be categorized into genetic or physiologic factors, environmental factors, and structural factors. (Bailey,2014)

The maxillary sinus, anatomically lying in an intermediate position between the nasal and oral cavities is vulnerable to invasion by pathogenic organisms through the nasal ostium or the mouth.

Discussion Odontogenic sinusitis accounts for

approximately 10% to 12% of maxillary sinusitis cases.

Most infections from the maxillary teeth usually occur as sequelae of dental caries.

Odontogenic infections, if left untreated, perforate into the alveolar bone through the foramina at the apex of the tooth root tips. In the maxilla,infections from the teeth generally spread through the thin buccal alveolar bone and into the buccal soft tissue vestibule.

Discussion Although odontogenic infections are

extremely common, the incidence of sinusitis seen with these dental infections is extremely low.

Only rarely do odontogenic infections penetrate directly into the maxillary sinus or floor of the nose, probably because the floors of the sinus and nose are composed of dense cortical bone when compared with the lateral wall of the maxilla.

Discussion In some patients, however,

odontogenic infections can drain into the sinus, especially when the proximity to the maxillary sinus floor

Discussion The close proximity of the orbit to the paranasal

sinuses,especially the ethmoid sinuses, make it the most commonly involved structure in complications of sinusitis.(Bailey 2014)

Orbital involvement primarily results from a thrombophlebitis and interference with the venous drainage of the orbital contents.

(Bailey 2014) The superior and inferior ophthalmic veins are valveless,

allowing direct communication between the nose, ethmoid sinuses, face, orbit, and cavernous sinus. In addition, congenital or other dehiscences in the lamina papyracea, which separate the ethmoid sinuses from the orbit, expose the orbital contents to direct extension of sinusitis

Discussion The orbital periosteum, the periorbita, is an

important structure because it is the only soft tissue barrier between the sinuses and the orbital contents. It comprises loose fibrous tissue that can be easily elevated off the underlying bone.

The orbital septum is a reflection of the periorbita at the margins of the orbit and it passes centrally to fuse with the tarsal plates. The orbital septum lacks lymphatic channels and thus forms a barrier limiting infections from passing directly through the eyelids into the orbit

Discussion Chandler et al. (8) classified the orbital

complications of sinusitis into five groups: preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis

Based on clinical presentation and CT scan, orbital complication of this patient is preseptal abcess

Discussion Preseptal cellulitis can be a complication of ethmoid

sinusitis. Preseptal cellulitis manifests as eyelid swelling,

erythema, and tenderness. Occasionally these may progress to an eyelid abscess and can also be associated with edema of the orbital (postseptal) contents.

There are no limitation of extraocular movements and no impairment of visual acuity.

Sinonasal infection cause perioibital swelling due toimpaired venous drainage of the ethmoidal vessels that are obstructed by inflammation and pressure.

Discussion Most orbital infections respond to medical treatment. The

mainstay of medical treatment is intravenous (N) administrationof a broad-spectrum antibiotic followed by oral therapy. A nasal decongestant either topical or oral, mucolytics or saline irrigations may help promote sinus drainage.

Preseptal and orbital cellulitis generally respond to medical management. Preseptal cellulitis is treated with antibiotics, head elevation, warm packs, and management of the underlying cause.

Some patients with orbital cellulitis who are not responding to medical therapy, especially those with visual changes may also benefit from surgical drainage of their sinuses despite the absence of a discrete abscess.

Incision and drainage of a lid abscess is occasionally necessary.

Discussion In general, surgical intervention has

been recommended in cases when there is cr evidence of abscess formation, 20/60 or worse visual acuity is observed on initial evaluation, progression of orbital signs and symptoms occurs despite medical treatment, or lack of improvement is seen within 48 hours despite aggressive medical treatment.

Conclusion Have been reported a patient, male, 52

years old, and diagnosed as chronic pansinusitis sinistra with orbital complication. One of factors that interfere the complication is Diabetes Mellitus.

As the patient has caries dentis, the odontogenic cause can be considered as one of the etiologic factor of pansinuitis unilateral.

Patient has been treated with surgical therapy and pharmacology. Surgical therapy include abcess incision and drainage, and antrostomy. Whereas pharmacology therapy include antibiotic ( ceftriaxone injection and metronidazole), analgetic, mucolytic.

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