University of Sriwijaya

Faculty of medicine
Block 4 2010

- SCENARIO 3 TUTOR GUIDE

Alergine, a 12-year-old girl is brought to the Department of Pediatrics RSMH hospital by her mother due to a
persistent headache she has been complaining for the past 2 weeks. Ten days ago her mother took the girl to an
ophthalmologist to find out the possibility of any eye problem. It appeared that her vision was normal and there
was nothing wrong in the eye and the orbit. The patient states that she has been in good health and that she
received a cat as a birthday present 1 month previously. Just three day ago she gets fever and stuffy nose. On
examination, she has a mild fever, the tympanic membranes appear normal. Her throat is mildly hyperemic but
otherwise looks normal. There is some tenderness of the right cheek and over the right orbit. Her father is
asthmatic while her older brother is allergic to aspirin.

What is the most likely diagnosis?

What is the most likely etiology for this condition?
What is the likely anatomical structures involved in this disorder?

Learning Objectives of Tutorial 2

After completing all of 3 tutorial sessions on the above vignette, the students should be able to:
1. Mention terminologies and their clinical significance related to the case.
2. Describe anatomy of the respiratory system, the eye, the pharynx and the middle ear.
3. Explain the relationship between allergy and infection in nose and paranasal sinus.
4. Tell about basic immunology and immunity.
5. State the differential diagnosis and rule out the unlikely ones.
6. Explain pathogenesis of any symptom and sign found in this case.
Learning issues
To achieve the above objectives, students should study:
1. The respiratory system with put more focus on the anatomy of the :
a. Nasal cavity
b. Paranasal sinus.
2. The Immunity system.
a. The basic concepts of immunology.
b. The pathophysiologic basic of allergic conditions.
c. The mechanism of infection of tissues following an allergic reaction.
3. Other related systems that might cause headache
a. Visual system (disorders of visus, intra ocular pressure, retina etc)
b. Auditory system, especially tympanic cavity..
c. Digestive system (oral cavity, tonsils, pharynx)
Summary:
The girl suffers from persistent headache.
Its likely that she is allergic to cats protein which causes allergic reaction in the nasal and sinus mucosa (allergic
rhinitis and allergic sinusistis).
Blockage of the sinus ostium causes a reduced air pressure inside the right maxillary and frontal sinus, hence the
headache ensues.
Inflammation of the sinus mucosal weakens the local immunity that leads to infection (most likely bacterial).
CLINICAL CORRELATION
Sinusitis is an inflammation of one or more of the six sets of paranasal sinuses, most of which are related to the orbits.
Inflammation may be caused by viruses, allergies, and bacterial pathogens. The sinuses are usually sterile cavities that are lined
by ciliated mucosa rich in mucous cells, and mucus drains directly into the nasal cavities through small openings, or ostia.
Edema of the nasal mucosa can easily occlude these openings and lead to secondary infection. The maxillary sinus is most
commonly involved, and sinus pain or pressure sensation is typical. Transillumination of the sinuses that demonstrates
opacification may be helpful on physical examination. Radiographs may also be helpful; CT imaging is usually reserved for
complicated cases. The recent acquisition of a cat by the patient suggests maxillary and frontal sinusitis caused by an allergy
rather than an infectious agent. Oral or topical (spray) decongestants, antihistamines, and/or nasal steroids are often helpful.
Antibiotics are not indicated until signs of bacterial infection becomes apparent, so the patient should be instructed to watch for
development of fever or an increase in tenderness. Complications include osteomyelitis, ocular cellulitis, and cavernous sinus
thrombophlebitis.
APPROACH TO THE BRACHIAL PLEXUS
Objectives
1. Describe anatomy of the respiratory system, the eye, the pharynx and the middle ear.
2. Explain the relationship between allergy and infection in nose and paranasal sinus.
3. Tell about basic immunology and immunity.

University of Sriwijaya
Faculty of medicine
Block 4 2010

4.
5.

State the differential diagnosis and rule out the unlikely ones.
Explain pathogenesis of any symptom and sign found in this case.

THE SEVEN JUMPS

Make sure that students follow the seven jumps approach in the discussion.
In Session 1 of tutorial
After reading the scenario, students should:
1. Clarify all of unknown or poorly understood terminologies and words (phrases or sentences). Let the students
identify all the words that they dont understand or need further clarification. Encourage the students to understand the
clinical significance of each word. Give a hint or direction when they fail to identify the following words :
1. Persistent headache
2. Ophthalmologist
3. Vision
4. Stuffy nose.
5. Mild fever
6. Normal tympanic membranes
7. Mildly hyperemic throat.
8. Tenderness of the right cheek and over the right orbit.
9. Her father is asthmatic
10. Allergic to aspirin
2.

3.
4.
5.

Identify problems. Problems are anything thats not normal. Clinical problems are presented as symptoms and signs.
For the sake of discussion, problems can be divided into :1) Main problem, 2) contributing problems and 3) chief
complain. Treating main problem would get rid off all other problems. In most cases, contributing problems are just
side-effects of other problems. Chief complaint is problem that make patient visit a doctor. Include also all other clinical
facts such as results of physical (clinical) examination and laboratory workups.
1. Persistent headache (chief complaint).
2. Stuffy nose
3. Mild fever
4. Tenderness over the right cheek and the right orbit.
5. Exposure to cats protein
6. Allergic history in the family
Analyze the problems. Direction of the analysis is toward 1) looking for relationship between all the problems
identified above, 2) Discussion of patho-physiological aspect of the symptoms and signs (see below).
Make a hypothesis. Hypothesis is actually a brief description of the chief complain and the main problems in this
patient.
- A 12 year old girl suffers from acute sinusitis secondary to nasal allergy caused by cats protein.
List learning issues. Make sure the followings are in the students list. Encourage them to study the learning issues
the best they can !!!!! Just in case they miss, give suggestion to the following list:
1. The anatomy of 1) the respiratory system, 2) the eye, 3) the pharynx and 3) the middle ear.
2. The relationship between allergy and infection in nose and paranasal sinus.
3. The basic immunology and immunity.
4. The pathogenesis of rhinitis allergic and sinusitis
5. A brief review of the clinical aspects of rhinitis allergic and sinusitis.

In Session 2
After studying the learning issues, students shoud:
6. Share all information they have studied and make a synthesis.
1. Let the students share what they have studied from the learning issues.
2. Review in brief brief about :
i. The anatomy of 1) the respiratory system, 2) the eye, 3) the pharynx and 3) the middle ear.
ii. The relationship between allergy and infection in nose and paranasal sinus.
iii. The basic immunology and immunity.
iv. The pathogenesis of rhinitis allergic and sinusitis.
7. Make a report to be presented on the plenary session. Encourage the students to make a report according to
all the previous jumps. Make a nice report and share it to others in plenary session.
A short review of the paranasal sinus
The paranasal sinuses are extensions of the nasal cavities into bones of the skull and are named for the bones in which
they are located. These spaces are lined with respiratory mucosa, decrease the weight of the skull, and probably assist in
humidifying inspired air. The sphenoid sinuses are located within the sphenoid bone, are variable in size and number, and open
into the sphenoethmoidal recess.
The ethmoidal sinuses consist of a series of sinuses positioned between the medial wall of the orbit and the nasal cavity (at the
level of the bridge of the nose). For descriptive purposes, they are divided into anterior, middle, and posterior ethmoidal cells,
and each has a separate opening. The posterior ethmoidal cells have their opening in the superior nasal meatus. The
middle ethmoidal cells elevate the ethmoid bone in the middle meatus, thus creating the ethmoid bulla on whose surface these
cells have their opening. Inferior to the ethmoid bulla is a groove, the semilunar hiatus. The anterior ethmoidal cells open into the
anterior portion of the hiatus, called the infundibulum.
The largest sinuses are the maxillary and frontal sinuses, and their relatively large openings also drain into the middle meatus.
The large maxillary sinus hollows the maxillary bone. The roof of the sinus, which also forms the floor of the orbit, is very thin and
at risk in direct trauma to the orbit that causes sudden increases in pressure. Such trauma may cause blow-out fractures of the

University of Sriwijaya
Faculty of medicine
Block 4 2010

orbital floor. The opening of the maxillary sinus is found in the semilunar hiatus. The frontal sinuses are found in the frontal bone
between the inner and outer tables and in the portion that forms the roof of the orbit. It is drained by the frontonasal duct, which
opens into the infundibulum, the anterior portion of the semilunar hiatus.

Summary of the aspects of RHINOSINUSITIS

1.

Pathophysiology
1.

2.

2.

Initial
1.

Mucosal inflammation of paranasal sinuses

2.

Sinus ostia irritation and edema

1.

Sinus obstruction and stasis

2.

Subsequent sinus infection

Next

Epidemiology
1.

2.

Incidence
1.

United States clinic office visits: 1% (in Indonesia ?)

2.

Lifetime Incidence: 25%

Sinuses affected
1.

Maxillary sinus
1.

2.

3.

Frontal sinus
1.

Next most commonly infected in adults

2.

Absent in 10% population and very young children

3.

Higher risk for intracranial spread

Ethmoid sinus
1.

4.

Most commonly infected in adults

Most commonly infected in children

Sphenoid sinus
1.

Isolated infection is rare

University of Sriwijaya
Faculty of medicine
Block 4 2010

2.
3.

Types
1.

Acute Sinusitis
1.

2.

3.

Symptoms persist between 4 to 12 weeks

Chronic Sinusitis
1.

4.

Symptoms as long as 4 weeks

Subacute Sinusitis
1.

4.

Higher risk for intracranial spread

Persistent Symptoms beyond 12 weeks

Recurrent Sinusitis
1.

Four or more episodes per year

2.

Each episode lasts 7 days or more

3.

Symptom free intervals last greater than 2 months

Predisposing Factors
1.

2.

3.

4.

Environmental Factors
1.

Allergens (e.g. pollens, molds, animal dander)

2.

Nicotine or smoke exposure

3.

Air pollutants

Anatomic abnormalities
1.

Nasal Polyps

2.

Ciliary disorder

3.

Septal deviation

4.

Concha bullosa

Immune disorder
1.

AIDS

2.

Congenital (IgA or IgG subclas deficiency)

3.

Post-Transplant

4.

Chemotherapy

5.

Diabetes Mellitus

Inflammatory disorder
1.

Wegener's Granulomatosis

2.

Sarcoidosis

5.

Recurrent Upper Respiratory Infection

6.

Mucosal disorder
1.

Cystic Fibrosis

University of Sriwijaya
Faculty of medicine
Block 4 2010

5.

2.

Allergic Rhinitis and other hyperreactivity

3.

Nonallergic (Samter's triad)

1.

Asthma

2.

Nasal Polyps

3.

Aspirin sensitivity

Etiology:
1.

2.

Viral (10-15%)
1.

Rhinovirus (most common viral Sinusitis cause)

2.

Influenza

3.

Parainfluenza

4.

Adenovirus

Bacterial
1.

2.

Acute Sinusitis
1.

Streptococcus Pneumoniae

2.

Haemophilus Influenzae

3.

Moraxella

4.

Streptococcus Pyogenes

Chronic Sinusitis
1.

2.

3.

6.

Anaerobes (>50%)
1.

Bacteroides

2.

Anaerobic Gram Positive Cocci

3.

Fusobacterium species

Other less common causes

1.

Staphylococcus aureus

2.

Hemophilus Influenzae

3.

Pseudomonas aeruginosa

4.

Escherichia coli

5.

Beta-hemolytic Streptococcus

6.

Neisseria causes

Fungal (Immunocompromised or Diabetes Mellitus)

1.

Aspergillus

2.

Mucormycosis

3.

Fungus

Symptoms

University of Sriwijaya
Faculty of medicine
Block 4 2010

1.

Classic Sinus Symptoms

1.

Sinus "aching" pain or pressure

1.

2.

2.

3.

4.

2.

7.

Location
1.

Frontal: Frontal Headache

2.

Maxillary: Mid-face, dental (upper teeth) pain

3.

Ethmoid: Retro-orbital pain

4.

Sphenoid: Nonspecific pain radiates top of head

Provocative
1.

Pain increases on bending forward

2.

Pain increases in late morning

3.

Pain on mastication

Foul Nasal discharge or postnasal discharge

1.

Purulent yellow or green Nasal discharge

2.

Discharge color does not indicate bacterial cause

3.

Discharge for >10 days suggests bacterial Sinusitis

Associated Nasal Symptoms

1.

Decreased sense of smell (Hyposmia or Anosmia)

2.

Halitosis

3.

Snoring

4.

Mouth breathing

5.

Nasal or hyponasal speech

Generalized symptoms
1.

Fatigue

2.

Fever

Symptoms not correlating with Sinusitis

1.

Sore Throat (except with postnasal discharge)

2.

Sneezing

Symptoms: Red Flag (consider immediate ENT referral)

1.

High Fever over 102.2 F (39 C) or peristent fever

2.

Visual complaints (e.g. Diplopia)

3.

Periorbital edema or erythema

4.

Mental status changes

5.

Severe facial or dental pain

6.

Infraorbital hypesthesia

University of Sriwijaya
Faculty of medicine
Block 4 2010

8.

Signs
1.

Nasal Mucosa edema and erythema

1.

2.

Contrast with Allergic Rhinitis (pale, boggy mucosa)

Nasal exam to view pus discharge from lateral wall

1.

2.

3.

Instruments
1.

Nasal speculum (minimal visualization)

2.

Flexible Nasolaryngoscopy

3.

Rigid optical scope (Otolaryngology use)

Middle Meatus (hiatus semilunaris)

1.

Drains Maxillary, Frontal, and Anterior Ethmoid

2.

Consider local Topical Decongestant application

Superior Meatus (Rarely discharge is seen)

1.

3.

Turbinates enlarged

4.

Sinus tenderness to percussion

5.

Sinus Transillumination in darkened room

1.

9.

Drains posterior ethmoid sinus

Frontal and maxillary sinus

Diagnosis: Findings most suggestive of bacterial cause

1.

See Sinusitis Prediction Rules

2.

Symptoms persist beyond 10 to 14 days

1.

Under 10 days, viral Sinusitis predominates

2.

By day 10, 40% of Sinusitis resolves spontaneously

3.

0.5% of viral URIs develop into bacterial Sinusitis

1.

Low (1997) CMAJ 156:S1-S14

3.

Symptoms worsen after 5-7 days ("double sickening")

4.

Purulent Nasal discharge

5.

Maxillary tooth or facial pain (esp. if unilateral)

6.

Unilateral maxillary sinus tenderness

7.

References
1.

Hickner (2001) Ann Intern Med 134:498-505

2.

Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7

10. Labs
1.

Culture of nasal mucosa

1.

Not cost effective or helpful in management

University of Sriwijaya
Faculty of medicine
Block 4 2010

2.
2.

Does not correlate with sinus mucosa cultures

Endoscope directed micro-swab culture

1.

Swab of hiatus semilunaris

2.

Protected from nasal contamination

3.

Accuracy: 80-85% compared with antral puncture

11. Radiology
1.

Indications for Imaging

1.

Complicated Sinusitis

2.

Chronic or recurrent Sinusitis

3.

Sinusitis refractory to maximal medical therapy

4.

Imaging is not needed in routine cases

1.

2.

3.

4.

Empiric therapy for 1-2 courses is appropriate

Sinus XRay (Sinus CT preferred)

1.

Single Waters' View XRay is sufficient

2.

Indication (rarely indicated unless CT not available)

1.

Complicated Acute Sinusitis

2.

Suspected Chronic Sinusitis

Sinus CT (gold standard) Indications

1.

Osteomeatal complex Occlusion

2.

Chronic Sinusitis

3.

Recurrent Sinusitis

4.

Allergic Fungal Sinusitis

Sinus MRI
1.

No advantage over Sinus CT (and more false positives)

2.

Indications
1.

Suspected neoplasm

2.

Fungal Sinusitis

12. Complications
1.

Orbital Cellulitis

2.

Meningitis

3.

Extradural abscess

4.

Subdural abscess

5.

Brain abscess

6.

Osteomyelitis

University of Sriwijaya
Faculty of medicine
Block 4 2010

7.

Cavernous Sinus Thrombosis

13. Management
1.

See Acute Sinusitis Management

14. Referral Indications

1.

See Red Flag Symptoms above

15. Reference
1.

Giebink (1994) Pediatr Infect Dis J 13(suppl 1):S55-8

2.

Hadley (1997) Otolaryngol Head Neck Surg 117:S8-S11

3.

Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7

4.

Osguthorpe (2001) Am Fam Physician 63:69-76

5.

Slavin (1991) J Allergy Clin Immunol 88:141-146

6. Williams (1993) JAMA 270:1242-6