Case Report Rsk Group 14303 Revisi_terakhir

Chronic Rhinosinusitis

Presenter: 14303 GroupArief Yunan P.Nik Muh. Toriq

Audesia AlvianitaKemal Luthfan H.

Theodora Caroline S.Michael Hartono

Moderator: dr. Dika

Rhinosinusitis become one of burden disease.

20% western population be involved with rhinosinusitis (Hellgren, 2008).

Classification Rhinosinusitis (based on duration of sign and symptoms) :1. Acute 2. Subacute3. Chronic4. Reccurent acute

Background

Chronic rhinosinusitis may cause high prevalence and more threatening complications leading to significantly worsen a patient’s quality of life.

Chronic rhinosinusitis was found in 15.5% of total United States populations (second place of all chronic disease prevalence).

Higher incidence for women than men (Collins, 1997).

Prevalence increase in a line with the increase of age: 2.7% increase for people 20-29 years old and 6.6% increase for people 50-59 years old (Chen, 2003).

Background

LITERATURE REVIEWCHAPTER 2

Anatomy of Nasal

Ostiomeatal Complex

The OMC build by :-proc. Uncinatus-infundibulum ethmoid-hiatus semilunaris-ethmoidal bulae-agger nasi-ressesus frontal.

OMC helps drainage and ventilation from anterior sinus like maxila, ethmoid and frontal sinus.

Sinusitis is defined as inflammation of one or more of the paranasal sinuses. The most common cause of sinusitis is infection. It has been suggested that the term sinusitis be replaced by rhinosinusitis.(JTFPP 2005)

Definition

Acute sinusitis: symptoms for less than 4 weeks consisting of some or all of the following: persistent symptoms of an upper respiratory tract infection, purulent rhinorrhea, postnasal drainage, anosmia, nasal congestion, facial pain, headache, fever, cough, and purulent discharge.

Subacute sinusitis: (unresolved acute) symptoms from 4 to 8 weeks

Chronic sinusitis: symptoms for 8 weeks or longer of varying severity consisting of the same symptoms as seen in acute sinusitis.

Recurrent sinusitis: 3 or more episodes of acute sinusitis per year. Patients with recurrent sinusitis might be infected by different organisms at different times. (JTFPP 2005)

Classification

Etiopathophysiology of Chronic Rhinosinusitis

History/Symptoms

Similar to ARS but may be milder or less dramatic and variable in presentation.

Prolonged duration of rhinosinusitis symptoms (more than 8-12 weeks)

A decreased sense of smell is identified

Chronic RhinosinusitisPhysical Exam/Signs

Presence or absence of the following: (1) Nasal Polyps(2) eosinophilic or

other inflammatory features

(3) fungal hyphae in sinus mucus.

Standard radiographyCaldwell and Waters the frontal and maxillary sinusesLateral views the sphenoid sinus and adenoids in children

Computed tomographyExtent of disease and the degree of ostiomeatal complex obstructionDelineate pathologic variations and anatomic structures

Magnetic Resonance ImagingImaging of soft tissues

Imaging Studies

Imaging Studies

The aim of CRS management are:◦ Accelerate healing◦ Prevent further complication◦ Prevent deterioration

• The principal is opening the obstruction in ostiomeatal complex, so the drainage and ventilation of the sinuses could restore

Management of CRS

First line: Penicillin Second line: amoxi-clav For 10-14 days

Appropriate for gram negative and anaerob bacteria

Antibiotic

CASE REPORTCHAPTER 3

Name : Ms. S W Age : 30 years old Address : Sengon, Prambanan,

Klaten Occupation : Employee No MR : 86 13 19

PATIENT’S IDENTITY

Chief complaint : Nasal blockage

Anamnesis

About 1 year ago, patient complains nose blockage along with runny nose, usually happens in the early morning. According to the patient, the nasal discharge started as clear with thin consistency and change to be yellowish with unpleasant odor from the left nose. Patient also complains of facial pain especially in the morning, fever, and smelly breath.

Anamnesis - HPI

She took over-the-counter drugs, but the symptoms still persisted. 3 weeks ago ,patient went to Puskesmas, was given 4 type of medication, the symptom was relieved for a few days but the complaint still remains.

1 week ago patient started to sneeze, heavy head, lost the ability to smell, and fever. Patient went to Puskesmas again but was referred to the RSST, Klaten. At the time of examination the pasien still complaint of cough, runny nose, left side facial pain, and headache, and fullness in both ears.

Anamnesis - HPI

History of Past Ilness:History of food allergy : (-)History of drug allergy: (-)History of Diabetes mellitus: (-)

History of family illness: History the same complaint in family: (-)History of asthma attack and atopic: (-)History of Diabetes Mellitus: (-)

Status Generalis

General status : well conscious, adequately nourished.

• Vital Sign BP : 110/70 mmHgPulse : 88 tpmRR : 20 tpmT : afebris

PHYSICAL EXAMINATION

NOSE AND PARANASAL SINUSES

DEXTRA SINISTRA

InspectionDeformity (-), hyperaemic (-), edema (-), discharge (-)

Deformity (-), hyperaemic (-), edema (-), discharge (-)

Palpation and Paranasal Sinus Examination

Maxilla pain (-), frontal pain (-) Maxilla pain (+), frontal pain (-)

Anterior Rhinoscopy

Septum deviation (-), hyperaemic (+), concha inferior & concha media visible, edema concha inferior (+), mass (-), discharge (+), yellow, mucoid.

Septum deviation (-), hyperaemic (+), concha inferior & concha media visible, edema concha inferior (+), mass (-), discharge (+), yellow, mucoid.

Posterior rhinoscopy

Septum deviation (-), hyperaemic (+), concha inferior & concha media visible, edema concha inferior (+), mass (-), discharge (+), yellow, mucoid

Septum deviation (-), hyperaemic (+), concha inferior & concha media visible, edema concha inferior (+), mass (-), discharge (+), yellow, mucoid

Edema concha nasalis (+) Hyperaemic (+)

Yellowish mucoid discharge (+)

Edema concha nasalis (+)Hyperaemic (+)

Edema concha nasalis (+)Hyperaemic (+)

Edema concha nasalis (+) Hyperaemic (+)

EARDEXTRA SINISTRA

Inspection Hyperaemic (-), edema (-)Discharge (-)

Hyperaemic (-), edema (-)Discharge (-)

Palpation Tragus pain (-), mastoid pain (-)

Tragus pain (-), mastoid pain (-)

Otoscopy

Cerumen (-)Hyperaemic in the wall of external auditory canal pars ossea (-)Intact tympanic membrane

Cerumen (-)Hyperaemic in the wall of external auditory canal pars ossea (-)Intact tympanic membrane

Cone of Light (+)Intact tympanic membrane

Hyperaemic(-), Edema (-)

MOUTH AND PHARYNGEAL

Structure FindingsLips Normal colorBuccal mucosa hyperaemic (-)Tongue and palatum hyperaemic (-), stomatitis (-)Gum and teeth Caries (+) in P1,P2,M1 upper leftUvula deviation (-)Tonsil and pharyng T1-T1, hyperaemic (-), Post

Nasal Drip (+)

Within normallimit T1

Post Nasal Drip (+)

Head X-Rays: Antero-posterior, Lateral, and Waters (occipito-mental)

Results: inhomogen opacity of the left maxillary sinus and left ehtmoid sinus (sinusitis of the left maxilla and left ethmoid sinus). Right nasal concha hypertrophy.

RADIO IMAGING

Odontogenic Chronic Rhinosinusitis of Maxilla Sinistra

Clinical Diagnosis

PROPOSED TREATMENTClindamycin 2x300 mgPseudoephedrine HCl 2x60 mgLoratadine 1x10 mg

Dubia ad Bonam

Prognosis

Evaluation after 7 days of treatment Education : Tooth extraction (refer to dentist) Good air circulation in house Oral and Teeth Hygiene Drinks 2 L of water/day

PLANNING

Drug of choice?

PROBLEM

DISCUSSIONCHAPTER 4

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

Anamnesis: presence of prominent symptoms of chronic rhinosinusitis (>2 Major Criteria)

Physical examination: hyperemia and oedema of concha sinistra, and yellowish mucopurulent discharge in the cavum nasi sinistra draining out from meatus nasi media (JTFPP 2005).

The type of chronic rhinosinusitis in this patient is odontogenic since there was a caries in upper left P1, P2, M1. This caries has led to an infiltration to the nearest sinus which is left maxillary sinus.

Patient symptoms: a nasal mucopurulent discharge in left nostril, facial pain, hyposmia

(Bailey et al 2006)

The general goals of therapy for this patient who is suspected for bacterial chronic rhinosinusitis is to control infection, disminish tissue edema, and reverse sinus ostial obstruction so the mucopus can drain out (Osguthorpe 2001).

The drug of choice is Clindamycin. It has been noted that antibiotic for rhinosinusitis cases should cover the gram negative and anaerobic bacteria group. Clindamycin has been reported to be effective for severe infections caused by anaerobic bacteria. In this case, there is also a radiologic finding of full sinuses indicating involvement of anaerobic bacteria infection.

Drug of Choice

Decongestant has a property of sympathomimetic agent that acts primarily on alpha adrenergic receptors, with some activity on beta-adrenergic receptors. The alpha agonist activity causes vasoconstriction of superficial blood vessels in the nasal mucosa, reducing edema, nasal congestion, and tissue hyperemia thus increasing nasal patency.

The main source of infection which is odontogenic must be specifically addressed. Tooth extraction with dentist was already planned to be done in the next day. Patient was also asked to come back to the clinic in the next seven days for treatment evaluation.

CONCLUSIONCHAPTER 5

A patient, female, 30 years old, and diagnosed with Odontogenic Chronic Rhinosinusitis of Maxilla Sinistra. The patient was treated with Clindamycin 2x300 mg, Pseudoephedrine HCl 2x60 mg, and Loratadine 1x10 mg. Patient was also referred to dentist for teeth extraction. Seven days follow up was expected to evaluate the treatment response.

Thank youPlease kindly give any suggestion

• Arterial Supply of the nasal cavity is form five sources :1. A. Anterior ethmoidal 2. A. Posterior ethmoidal 3. A. Sphenopalatine4. A. Greater palatine5. A. Septal branch of the superior labia

• 1 and 3 are the most important arteries to the nasal cavity• At the anterior nasal septum, there is the site Kisselbach area

of an anastomotic arterial plexus involving all the arteries.

Vascular Supply

From a. opthalmic

From a. maxillary

Superior part

Inferiror part

Arterial Supply

Drainage : • Nasal cavity : a rich submucosal venous plexus drains into the sphenopalatine, facial and

ophthalmic veins. This plexus is an important part of the body thermoregulatory system• External nose : drains into the facial vein via angular and lateral nasal veins

Nerve Supply

The nasal mucosa nerve supply can be divided into Superoanterior and posteroinferior portionns• Posteroinferior : Mostly n. Maxillary, n. nasopalatine to the nasal septum, n greater

palatine to the lateral wall• Anterosuperior : N. opthalmicus (also for the external nose) by way of n. anterior and

posterior ehtmoidal.Sensoris : n. olfactorius

NERVE SUPPLY

Nasal mucous sensoric, simpatic, parasimpatic

Simpatic and parasimpatic (enter nasal cavity from foramen sphenopalatina ):-Simpatic vasoconstriction and decrease sinonasal resistance -Parasimpatic vasodilatation and gland secretion

Sensoric: -Olfactory nerve → smell-Anterior ethmoidalis nerve (part of Opthalmicus nerve part of Trigeminus Nerve) → temperature, itch, touch, air flow

Respiratory Mucous

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

History/Symptoms

Suspect in Upper respiratory tract infection has persisted beyond 10 to 14 days

Prominent symptoms◦ nasal congestion◦ purulent rhinorrhea◦ facial-dental pain◦ postnasal drainage◦ Headache◦ cough

Less frequent symptoms include fever, nausea, malaise, fatigue, halitosis, or sore throat.

Acute Rhinosinusitis Physical Exam/ Sign

• sinus tenderness on palpation

• mucosal erythema• purulent nasal

secretions• increased

pharyngeal secretions

• periorbital edema.

PSEUDOEPHEDRINEPseudoephedrine is a sympathomimetic agent that occurs naturally in plants of the genus Ephedra; the drug acts directly on both α- and, to a lesser degree, β-adrenergic receptors.

Pseudoephedrine is used as a nasal decongestant for self-medication for the temporary relief of nasal congestion associated with upper respiratory allergy and to provide temporary relief of sinus congestion and pressure. The drug also has been used for self-medication in the symptomatic prevention of otitic barotrauma

The usual dosage of pseudoephedrine hydrochloride for adults and children 12 years of age or older is 60 mg every 4–6 hours with a maximum of 240 mg daily.Alternatively, some pediatricians recommend 4 mg/kg or 125 mg/m2 daily, given in 4 divided doses.

Adapted from: drugs info at www.emedicine-medscape.com

PSEUDOEPHEDRINEPseudoephedrine acts directly on α-adrenergic receptors in the mucosa of the respiratory tract producing vasoconstriction that results in shrinkage of swollen nasal mucous membranes, reduction of tissue hyperemia, edema, and nasal congestion, and an increase in nasal airway patency; drainage of sinus secretions is increased. Sympathomimetic effects of pseudoephedrine presumably also may occur in other areas of the respiratory tract, including the eustachian tube; these effects may improve or maintain eustachian tube patency and allow equilibration of middle ear pressure during external atmospheric pressure changes (e.g., during descent of an aircraft, underwater diving, hyperbaric oxygenation).


LORATADINELoratadine, a derivative of azatadine, is a second generation antihistamine.

Loratadine shares the uses of other antihistamines, including the management of allergic rhinitis and chronic idiopathic urticaria. For additional information on these and other uses of antihistamines


For symptomatic relief of seasonal allergic rhinitis, the usual dosage of loratadine for self-medication in adults and children 6 years of age and older is 10 mg once daily. The usual dosage for self-medication in children 2 to under 6 years of age is 5 mg once daily as the syrup. When loratadine is used in fixed combination with pseudoephedrine sulfate in a twice-daily (12-hour) formulation for symptomatic relief of allergic rhinitis in adults and children 12 years of age and older, the usual dosage for self-medication is 5 mg of loratadine twice daily (every 12 hours). Alternatively, when the fixed combination containing loratadine with pseudoephedrine sulfate (Claritin-D® 24-Hour) in a once-daily (24-hour) formulation is used for symptomatic relief of allergic rhinitis in adults and children 12 years of age and older, the usual dosage for self-medication is 10 mg of loratadine once daily.

LORATADINE


Prolonged oral steroid use may result in muscle wasting and osteoporosis. Bone density scans should be considered in patients on long-term therapy. Extended use may also result in hypertension, redistribution of body fat stores, and may even induce long-lasting suppression of ACTH production, which can result in anterior pituitary and adrenal cortical atrophy. Because of these harmful side effects, steroids are tapered and given in short courses that may span three to four weeks.

CORTICOSTEROID

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

ENDOSCOPIC (ENDONASAL) SINUS SURGERY

‘‘Functional Endoscopic Sinus Surgery’’ (FESS) to describe a minimally invasive approach to improve drainage of the paranasal sinuses for the treatment of CR. Endoscopic endonasal surgery (EES) or endoscopic sinus surgery (ESS) are other terms commonly used to describe the same operation and can be used interchangeably.There are two primary goals of FESS. The first is to open up the narrow areas described above. The second is to perform the surgery in as atraumatic a manner as possible. Accordingly, sinus surgeons must remove the anatomical areas of obstruction without disturbing the surrounding healthy mucosa


INDIKASI FESS

Rhinosinusitis rekuren

Rhinosinusitis Kronik

Rhinosinusitis karena jamur alergi

Rhinosinusitis Hipertrofi kronis (Polip)

Polip Antrokoanal

Mukokel dalam sinus

Adapted from: Modul Penyakit Sinus Paranasalis- Sinusitis

KOMPLIKASI FESS Perdarahan intrakranial Terbentuknya sinekia Lateralisasi kokna media Stenosis & obstruksi ostium sinus dengan kekambuhan penyakit Terbentukya mukokel, khususnya sinus frontalis Empiema orbita Epifora Anosmia/Hiposmia Penyakit sinus menetap/kambuh Obliterasi resesus frontalis dengan penyakit frontal persisten/baru

Adapted from: Modul Penyakit Sinus Paranasalis- Sinusitis

ComplicationsBleedingInfectionAdhesionsRestenosisCSF leakPeriorbital hematomaSubcutaneous emphysemaDiplopiaBlindnessEpiphora

ENDOSCOPIC (ENDONASAL) SINUS SURGERY


Maxillary Sinus Surgery

TYPE:Antral Puncture and Lavage Inferior Nasoantral Window Endoscopic Middle Meatal Antrostomy Caldwell-Luc Procedure

Indications for Caldwell-LucRemoval of mycotic ‘‘fungus balls’’Symptomatic multiseptate mucoceles of the maxillary sinusAntrochoanal polypsBiopsy and/or removal of neoplasms or other massesExposure to the pterygopalatine fossa (particularly for epistaxis control)Oroantral fistula repai


Ethmoid Sinus Surgery

TYPE:Endoscopic Endonasal Ethmoidectomy External Ethmoidectomy

Sphenoid Sinus Surgery

TYPE:Endoscopic Endonasal SphenoidotomyExternal Spenoethmoidectomy


Frontal Sinus Surgery

TYPE:TrephinationLynch Procedure (External Frontoethmoidectomy) Lothrop Procedure Endoscopic Frontal SinusotomyOsteoplastic Frontal Sinus Obliteration


Case Report Rsk Group 14303 Revisi_terakhir

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