STEP 3

1. Anatomi sinus paranasal?

A sinus is a hollow, air-filled cavity. For the purposes of
this article, a sinus will referred to those hollow cavities
that are in the skull and connected to the nasal airway
by a narrow hole in the bone (ostium). Normally all are
open to the nasal airway through an ostium. Humans
have four pair of these cavities each referred to as the:
1. frontal sinus (in forehead),
2. maxillary sinus (behind cheeks),
3. ethmoid sinuses (between the eyes), and
4. sphenoid sinus (deep behind the ethmoids).
The four pair of sinuses are often described as a unit and
termed the "paranasal sinuses." The cells of the inner
lining of each sinus are mucus-secreting cells, epithelial
cells and some cells that are part of the immune system
(macrophages, lymphocytes, and eosinophils).
Fungsi sinus:
Functions of the sinuses include humidifying and warming inspired
air, insulation of surrounding structures (eyes, nerves), increasing
voice resonance, and as buffers against facial trauma. The sinuses
decrease the weight of the skull. If the inflammation hinders the
clearance of mucous or blocks the natural ostuim, the inflammation
may progress into a bacterial infection
http://www.medicinenet.com/sinusitis/page2.htm
Anatomi Sinus Paranasal
Ada empat pasang sinus paranasal yaitu sinus maksila, sinus
frontal, sinus etmoid dan sinus sfenoid kanan dan kiri. Sinus paranasal
merupakan hasil pneumatisasi tulang-tulang kepala, sehingga terbentuk
rongga di dalam tulang. Semua sinus mempunyai muara ke rongga
hidung.
Secara embriologik, sinus paranasal berasal dari invaginasi mukosa
rongga hidung dan perkembangannya dimulai pada fetus usia 3-4 bulan,
kecuali sinus sfenoid dan sinus frontal. Sinus maksila dan sinus etmoid
telah ada saat anak lahir, sedangkan sinus frontal berkembang dari dari
sinus etmoid anterior pada anak yang berusia kurang lebih 8 tahun.
Pneumatisasi sinus sfenoid dimulai pada usia 8-10 tahun dan berasal dari
bagian postero-superior rongga hidung. Sinus-sinus ini umumnya
mencapai besar maksila 15-18 tahun.

Sinus Maksila
Sinus maksila merupakan sinus paranasal yang terbesar. Saat lahir
sinus maksila bervolume 6-8 ml, sinus kemudian berkembang dengan
cepat dan akhirnya mencapai ukuran maksimal, yaitu 15 ml saat dewasa.
Sinus maksila berbentuk segitiga. Dinding anterior sinus ialah
permukaan fasial os maksila yang disebut fosa kanina, dinding
posteriornya adalah permukaan infra-temporal maksila, dinding medialnya
ialah dinding lateral rongga hidung dinding superiornya adalah dasar
orbita dan dinding inferior ialah prosesus alveolaris dan palatum. Ostium
sinus maksila berada di sebelah superior dinding medial sinus dan
bermuara ke hiatus semilunaris melalui infindibulum etmoid.

Dari segi klinik yang perlu diperhatikan dari anatomi sinus maksila adalah
1.
Dasar dari anatomi sinus maksila sangat berdekatan dengan akar gigi
rahang atas, yaitu premolar (P1 dan P2), molar (M1 dan M2), kadangkadang juga gigi taring (C) dan gigi molar M3, bahkan akar-akar gigi
tersebut dapat menonjol ke dalam sinus, sehingga infeksi gigi geligi
mudah naik ke atas menyebabkan sinusitis.
2.
Sinusitis maksila dapat menyebabkan komplikasi orbita.
3.
Ostium sinus maksila terletak lebih tinggi dari dasar sinus, sehingga
drainase kurang baik, lagipula drainase juga harus melalui infundibulum
yang sempit. Infundibulum adalah bagian dari sinus etmoid anterior dan
pembengkakan akibat radang atau alergi pada daerah ini dapat
menghalangi drenase sinus maksila dan selanjutnya menyebabkan
sinusitus.
Sinus Frontal
Sinus frontal yang terletak di os frontal mulai terbentuk sejak
bulan ke empat fetus, berasal dari sel-sel resesus frontal atau dari sel-sel
infundibulum etmoid. Sesudah lahir, sinus frontal mulai berkembang pada
usia 8-10 thn dan akan mencapai ukuran maksimal sebelum usia 20 thn.
Sinus frontal kanan dan kiri biasanya tidak simetris, satu lebih
besar dari pada lainnya dan dipisahkan oleh sekret yang terletak di garis
tengah. Kurang lebih 15% orang dewasa hanya mempunyai satu sinus
frontal dan kurang lebih 5% sinus frontalnya tidak berkembang.
Ukurannya sinus frontal adalah 2.8 cm tingginya, lebarnya 2.4 cm
dan dalamnya 2 cm. Sinus frontal biasanya bersekat-sekat dan tepi sinus
berleku-lekuk. Tidak adanya gambaran septumn-septum atau lekuk-lekuk
dinding sinus pada foto Rontgen menunjukkan adanya infeksi sinus. Sinus
frontal dipisakan oleh tulang yang relatif tipis dari orbita dan fosa serebri
anterior, sehingga infeksi dari sinus frontal mudah menjalar ke daerah ini.
Sinus frontal berdraenase melalui ostiumnya yang terletak di
resesus frontal. Resesus frontal adalah bagian dari sinus etmoid anteroir.
Sinus Etmoid
Dari semua sinus paranasal, sinus etmoid yang paling bervariasi
dan akhir-akhir ini dianggap paling penting, karena dapat merupakan
fokus infeksi bagi sinus-sinus lainnya. Pada orang dewasa bentuk sinus
etomid seperti piramid dengan dasarnya di bagian posterior. Ukurannya
dari anterior ke posterior 4-5 cm, tinggi 2.4 cmn dan lebarnya 0.5 cm di
bagian anterior dan 1.5 cm di bagian posterior.
Sinus etmoid berongga-rongga, terdiri dari sel-sel yang
menyerupai sarang tawon, yang terdapat di dalam massa bagian lateral
os etmoid, yang terletak di antara konka media dan dinding medial orbita.
Sel-sel ini jumlahnya bervariasi antara 4-17 sel (rata-rata 9 sel).
Berdasarkan letaknya, sinus etmoid dibagi menjadi sinus etmoid anterior
yang bermuara di meatus medius dan sinus etmoid posterior yang
bermuara di meatus superior. Sel-sel sinus etmoid anterior biasanya kecilkecil dan banyak, letaknya di bawah perlekatan konka media, sedangkan
sel-sel sinus etmoid posterior biasanya lebih besar dan lebih sedikit
jumlahnya dan terletak di postero-superior dari perlekatan konka media.

Di bagian terdepan sinus etmoid enterior ada bagian yang sempit,

disebut resesus frontal, yang berhubungan dengan sinus frontal. Sel
etmoid yang terbesar disebut bula etmoid. Di daerah etmoid anterior
terdapat suatu penyempitan yang disebut infundibulum, tempat
bermuaranya ostium sinus maksila. Pembengkakan atau peradangan di
resesus frontal dapat menyebabkan sinusitis frontal dan pembengkakan di
infundibulum dapat menyebabkan sisnusitis maksila.
Atap sinus etmoid yang disebut fovea etmoidalis berbatasan dengan
lamina kribosa. Dinding lateral sinus adalah lamina papirasea yang sangat
tipis dan membatasi sinus etmoid dari rongga orbita. Di bagian belakang
sinus etmoid posterior berbatsan dengan sinus sfenoid.
Sinus Sfenoid
Sinus sfenoid terletak dalam os sfenoid di belakang sinus etmoid
posterior. Sinus sfenoid dibagi dua oleh sekat yang disebut septum
intersfenoid. Ukurannya adalag 2 cmn tingginya, dalamnya 2.3 cm dan
lebarnya 1.7 cm. Volumenya bervariasi dari 5-7.5 ml. Saat sinus
berkembang, pembuluh darah dan nerbus di bagian lateral os sfenoid
akan menjadi sangat berdekatan dengan rongga sinus dan tampak
sebagai indentasi pada dinding sinus etmoid.
Batas-batasnya ialah, sebelah superior terdapat fosa serebri media
dan kelenjar hipofisa, sebelah inferiornya atap nasofaring, sebelah lateral
berbatasan dengan sinus kavernosus dan a.karotis interna (sering tampak
sebagai indentasi) dan di sebelah posteriornya berbatasan dengan fosa
serebri posterior di daerah pons.
Kompleks Ostio-Meatal
Di meatus medius, ada muara-muara saluran dari sinus maksila,
sinus frontal dan sinus etmoid anterior. Daerah ini rumit dan sempit dan
dinamakan kompleks ostio-meatal (KOM), terdiri dari infundibulum etmoid
yang terdapat di belakang prosesus unsinatus, resesus frontalis, bula
etmoid dan sel-sel etmoid anterior dengan ostiumnya dan ostium sinus
maksila.
Fungsi Sinus Paranasal
Sampai saat ini belum ada kesesuaian pendapat mengenai
fisiologi sinus paranasal. Beberapa pendapat:
a.
Sebagai pengatur kondisi udara (air conditioning)
Sinus berfungsi sebagai ruang tambahan untuk memanaskan dan
mengatur kelembaban udara inspirasi. Keberatan terhadap teori ini ialah
karena ternyata tidak didapati pertukaran udara yang definitive antara
sinus dan rongga hidung. Lagipula mukosa sinus tidak mempunyai
vaskularisasi dan kelenjar yang sebanyak mukosa hidung.
b.

Sebagai penahan suhu (termal insulators)

Sinus paranasal berfungsi sebagai penahan (buffer) panas,
melindungi orbita dan fossa serebri dari suhu rongga hidung yang
berubah-ubah.
c.
Membantu keseimbangan kepala

bila udara dalam sinus diganti dengan tulang, hanya akan

memberikan pertambahan berat sebesar 1% dari berat kepala, sehingga
teori dianggap tidak bermakna.
d.
Membantu resonansi suara
Akan tetapi ada yang berpendapat, posisi sinus dan ostiumnya
tidak memungkinkan sinus berfungsi sebagai resonator yang efektif.
Lagipula tidak ada korelasi antara resonansi suara dan besarnya sinus
pada hewan-hewan tingkat rendah.
e.
Sebagai peredam perubahan tekanan udara
misalnya pada waktu bersin atau membuang ingus.
f.
Membantu produksi mucus
jumlahnya kecil dibandingkan dengan mucus dari rongga hidung,
namun efektif untuk membersihkan partikel yang turut masuk dengan
udara inspirasi karena mucus ini keluar dari meatus medius, tempat yang
paling strategis.
THT FK UI
2. Mengapa pasien menguluh pilek tidak sembuh sejak 4 bulan yg lalu?
Retained mucus, when infected, leads to sinusitis. Another
mechanism hypothesizes that because the sinuses are continuous
with the nasal cavity, colonized bacteria in the nasopharynx may
contaminate the otherwise sterile sinuses. These bacteria are
usually removed by mucociliary clearance; thus, if mucociliary
clearance is altered, bacteria may be inoculated and infection may
occur, leading to sinusitis
The pathophysiology of rhinosinusitis is related to 3 factors:

Obstruction of sinus drainage pathways (sinus ostia)

Ciliary impairment
Altered mucus quantity and quality
Obstruction of sinus drainage
Obstruction of the natural sinus ostia prevents normal mucus
drainage. The ostia can be blocked by mucosal swelling or local
causes (eg, trauma, rhinitis), as well as by certain inflammationassociated systemic disorders and immune disorders. Systemic
diseases that result in decreased mucociliary clearance, including
cystic fibrosis, respiratory allergies, and primary ciliary dyskinesia
(Kartagener syndrome), can be predisposing factors for acute
sinusitis in rare cases. Patients with immunodeficiencies (eg,
agammaglobulinemia, combined variable immunodeficiency, and
immunodeficiency with reduced immunoglobulin G [IgG] and
immunoglobulin A [IgA]bearing cells) are also at increased risk of
developing acute sinusitis.
Mechanical obstruction because of nasal polyps, foreign bodies,
deviated septa, or tumors can also lead to ostial blockage. In
particular, anatomical variations that narrow the ostiomeatal
complex, including septal deviation, paradoxical middle turbinates,

and Haller cells, make this area more sensitive to obstruction from
mucosal inflammation. Usually, the margins of the edematous
mucosa have a scalloped appearance, but in severe cases, mucus
may completely fill a sinus, making it difficult to distinguish an
allergic process from infectious sinusitis. Characteristically, all of the
paranasal sinuses are affected and the adjacent nasal turbinates are
swollen. Air-fluid levels and bone erosion are not features of
uncomplicated allergic sinusitis; however, swollen mucosa in a
poorly draining sinus is more susceptible to secondary bacterial
infection.
Hypoxia within the obstructed sinus is thought to cause ciliary
dysfunction and alterations in mucus production, further impairing
the normal mechanism for mucus clearance.
Impaired ciliary function
Contrary to earlier models of sinus physiology, the drainage
patterns of the paranasal sinuses depend not on gravity but on the
mucociliary transport mechanism. The metachronous coordination
of the ciliated columnar epithelial cells propels the sinus contents
toward the natural sinus ostia. Any disruption of the ciliary function
results in fluid accumulation within the sinus. Poor ciliary function
can result from the loss of ciliated epithelial cells; high airflow; viral,
bacterial, or environmental ciliotoxins; inflammatory mediators;
contact between 2 mucosal surfaces; scars; and Kartagener
syndrome.[16]
Ciliary action can be affected by genetic factors, such as Kartagener
syndrome. Kartagener syndrome is associated with immobile cilia
and hence the retention of secretions and predisposition to sinus
infection. Ciliary function is also reduced in the presence of low pH,
anoxia, cigarette smoke, chemical toxins, dehydration, and drugs
(eg, anticholinergic medications and antihistamines).
Exposure to bacterial toxins can also reduce ciliary function.
Approximately 10% of cases of acute sinusitis result from direct
inoculation of the sinus with a large amount of bacteria. Dental
abscesses or procedures that result in communication between the
oral cavity and sinus can produce sinusitis by this mechanism.
Additionally, ciliary action can be affected after certain viral
infections.
Several other factors can lead to impaired ciliary function. Cold air is
said to stun the ciliary epithelium, leading to impaired ciliary
movement and retention of secretions in the sinus cavities. On the
contrary, inhaling dry air desiccates the sinus mucous coat, leading
to reduced secretions. Any mass lesion with the nasal air passages
and sinuses, such as polyps, foreign bodies, tumors, and mucosal
swelling from rhinitis, may block the ostia and predispose to
retained secretions and subsequent infection. Facial trauma or large
inoculations from swimming can produce sinusitis as well. Drinking
alcohol can also cause nasal and sinus mucosa to swell and cause
impairment of mucous drainage.

Altered quality and quantity of mucus

Sinonasal secretions play an important role in the pathophysiology

of rhinosinusitis. The mucous blanket that lines the paranasal
sinuses contains mucoglycoproteins, immunoglobulins, and
inflammatory cells. It consists of 2 layers: (1) an inner serous layer
(ie, sol phase) in which cilia recover from their active beat and (2)
an outer, more viscous layer (ie, gel phase), which is transported by
the ciliary beat. Proper balance between the inner sol phase and
outer gel phase is of critical importance for normal mucociliary
clearance.
If the composition of mucus is changed, so that the mucus produced
is more viscous (eg, as in cystic fibrosis), transport toward the ostia
considerably slows, and the gel layer becomes demonstrably
thicker. This results in a collection of thick mucus that is retained in
the sinus for varying periods. In the presence of a lack of secretions
or a loss of humidity at the surface that cannot be compensated for
by mucous glands or goblet cells, the mucus becomes increasingly
viscous, and the sol phase may become extremely thin, thus
allowing the gel phase to have intense contact with the cilia and
impede their action. Overproduction of mucus can overwhelm the
mucociliary clearance system, resulting in retained secretions within
the sinuses.
http://emedicine.medscape.com/article/232670-overview#a4

Colds, bacterial infections, allergies, asthma, and other health conditions

can cause sinusitis.
Acute Sinusitis
Acute sinusitis usually is caused by a viral or bacterial infection. The
common cold, which is caused by a virus, may lead to swelling of the
sinuses, trapping air and mucus behind the narrowed sinus openings. Both
the nasal and the sinus symptoms usually go away within 2 weeks.
Sometimes, viral infections are followed by bacterial infections. Many
cases of acute sinusitis are caused by bacteria that frequently colonize the
nose and throat, such as Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis. These bacteria typically do not
cause problems in healthy people, but in some cases they begin to
multiply in the sinuses, causing acute sinusitis. NIAID supports studies to
better understand the factors that put people at risk for bacterial sinusitis.
People who have allergies or other chronic nasal problems are prone to
episodes of acute sinusitis. In general, people who have reduced immune
function, such as those with HIV infection, are more likely to have sinusitis.
Sinusitis also is common in people who have abnormal mucus secretion or
mucus movement, such as people with cystic fibrosis, an inherited disease
in which thick and sticky mucus clogs the lungs.
Chronic Sinusitis (Rhinosinusitis)

In chronic sinusitis, also known as chronic rhinosinusitis, the

membranes of both the paranasal sinuses and the nose thicken
because they are constantly inflamed. This condition can occur with
or without nasal polyps, grape-like growths on the mucous
membranes that protrude into the sinuses or nasal passages. The
causes of chronic rhinosinusitis are largely unknown. NIAID supports
basic research to help explain why people develop this chronic
inflammation.
Most people with sinusitis have facial pain or tenderness in several
places, and their symptoms usually do not clearly indicate which sinuses
are inflamed. The pain of a sinus attack arises because trapped air and
mucus put pressure on the membranes of the sinuses and the bony wall
behind them. Also, when a swollen membrane at the opening of a
paranasal sinus prevents air from entering into the sinuses, it can create a
vacuum that causes pain.
People with sinusitis also have thick nasal secretions that can be
white, yellowish, greenish, or blood-tinged. Sometimes these
secretions drain in the back of the throat and are difficult to clear.
This is referred to as post-nasal drip or post-nasal drainage.
Chronic post-nasal discharge may indicate sinusitis, even in people
who do not have facial pain.
However, facial pain without either nasal or post-nasal drainage is rarely
caused by inflammation of the sinuses. People who experience facial pain
but no nasal discharge often are diagnosed with a pain disordersuch as
migraines, cluster headaches, or tension-type headachesrather than
sinusitis.
Less common symptoms of acute or chronic sinusitis include the following:
1 Tiredness
2 Decreased sense of smell
3 Cough that may be worse at night
4 Sore throat
5 Bad breath
6 Fever
On very rare occasions, acute sinusitis can result in brain infection
and other serious complications.
3. Mengapa didapatkan hidung tersumbat dan batuknya tidak
berdahak?
Hidung tersumbat:

Sinus paranasal adalah bagian dari traktus respiratorius yang

berhubungan langsung dengan nasofaring. Sinus secara normal steril.
Dengan adanya obstruksi, flora normal nasofaringeal dapat dapat
menyebabkan infeksi.
Bila terjadi edema di kompleks ostiomeatal, mukosa yang letaknya
berhadapan akan saling bertemu, sehingga silia tidak dapat bergerak dan
lendirnya berhadapan akan saling bertemu, dan lendir tidak dapat
dialirkan. Maka terjadi gangguan drainase dan ventilasi di dalam sinus,
sehingga silia menjadi kurang aktif dan lendir yang diproduksi mukosa
sinus menjadi lebih kental dan merupakan media yang baik untuk
tumbuhnya bakteri patogen. Bila sumbatan berlangsung terus, akan
terjadi hipoksia dan retensi lender, sehingga timbul infeksi oleh bakteri
anaerob. Selanjutnya terjadi perubahan jaringan menjadi hipertrofi,
polipoid atau pembentukan polip dan kista.
4. Mengapa penderita sering mengeluh sakit kepala di sekitar mata?
Sinusitis is an inflammation of the membranes lining the paranasal
sinusessmall air-filled spaces located within the skull or bones of the
head surrounding the nose. Sinusitis can be caused by an infection or
other health problem. Symptoms include facial pain and nasal discharge,
or runny nose. Nearly 30 million adults in the United States are
diagnosed with sinusitis each year, according to the Centers for Disease
Control and Prevention.
The paranasal sinuses comprise four pairs of air-filled spaces:
1 Frontal sinusesover the eyes in the brow area
2 Ethmoid sinusesjust behind the bridge of the nose, between the
eyes
3 Maxillary sinusesinside each cheekbone
4 Sphenoid sinusesbehind the ethmoids in the upper region of the
nose and behind the eyes
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National
Institutes of Health National Institute of Allergy and Infectious
Diseases
https://www.niaid.nih.gov/topics/sinusitis/Documents/sinusitis.pdf
5. Mengapa didapatkan ingus kental?
Acute Sinusitis
Acute sinusitis usually is caused by a viral or bacterial infection. The
common cold, which is caused by a virus, may lead to swelling of
the sinuses, trapping air and mucus behind the narrowed sinus
openings. Both the nasal and the sinus symptoms usually go away
within 2 weeks. Sometimes, viral infections are followed by bacterial

infections. Many cases of acute sinusitis are caused by bacteria that

frequently colonize the nose and throat, such as Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
These bacteria typically do not cause problems in healthy people,
but in some cases they begin to multiply in the sinuses, causing
acute sinusitis. NIAID supports studies to better understand the
factors that put people at risk for bacterial sinusitis.
People who have allergies or other chronic nasal problems are prone
to episodes of acute sinusitis. In general, people who have reduced
immune function, such as those with HIV infection, are more likely to
have sinusitis. Sinusitis also is common in people who have
abnormal mucus secretion or mucus movement, such as people with
cystic fibrosis, an inherited disease in which thick and sticky mucus
clogs the lungs.
https://www.niaid.nih.gov/topics/sinusitis/Documents/sinusitis.pdf
6. Mengapa pasien setelah obatnya habis keluhan timbul kembali?
Karena pengobatanya hanya simpotamatis saja.
Untuk mengurangi gejalanya aja. Kerusakan sebenarnya belum
teratasi sehingga pas obatnya abis bisa timbul lagi keluhannya.
7. Mengapa ingus terasa keluar di tenggorokan?
Sistem mukosiliar:
Pada dinding lateral hidung terdapat 2 aliran transport mukosiliar
dari sinus.
Lendir yg bersala dr sinus anterior bergabung di infundibulum
etmoid disalurkan ke nasoparing di deoan muara tuba eustachii.
Lendir yg berasala dari sinus posterior bergabung di ressesus
spenoethmoidalis dialirkan ke nasoparing di postero superior muara
tuba eustachii.
Sinusistis didapati post nasal drip.
THT FK UI
8. Pemeriksaan fisik hidung yang dilakukan dan interpretasinya?
Pemeriksaan Sinus Paranasal
Untuk mengetahui adanya kelainan pada sinus paranasal
dilakukan inspeksi dari luar, palpasi, rinoskopi anterior, rinoskopi
posterior, transiluminasi, pemeriksaan radiologic dan sinuskopi,
Inspeksi
Yang diperhatikan adalah adanya pembengkakan pada muka.
Pembengkakan di pipi sampai kelopak mata bawah yang berwarna
kemerah-merahan mungkin menunjukkan suatu sinusitis maksilaris akut.
Pembengkakan di kelopak mata atas mungkin menunjukkan suatu
sinusitis frontalis akut.
Sinusitis etmoid akut jarang menyebabkan pembengkakan ke luar,
kecuali bila telah terbentuk abses.

Palpasi
Nyeri tekan pada pipi dan nyeri ketuk di gigi menunjukkan adanya
sinusitis maksila. Pada sinusitis frontal terdapat nyeri tekan di dasar sinus
frontal yaitu oada bagian medial atap orbita. Sinusitis etmoid
menyebabkan rasa nyeri tekan di daerah kantus medius.
Transiluminasi
Transiluminasi mempunyai manfaat yang terbatas, hanya dapat
dipakai untuk memeriksa sinus maksila dan sinus frontal, bila fasilitas
pemeriksaan radiologik tidak tersedia.
Bila terdapat kista yang besar di dalam sinus maksila, akan tampak
terang pada pemeriksaan transiluminasi, sedangkan pada foto rontgen
tampak adanya perselubungan berbatas tegas di dalam sinus maksila.
Transiluminasi pada sinus frontal hasilnya lebih meragukan. Besar
dan bentuk kedua sinus ini seringkali tidak sama. Gambaran yang terang
berarti sinus berkembang dengan baik dan normal, sedangkan gambaran
yang gelap mungkin hanya menunjukkan sinus yang tidak berkembang.
Pemeriksaan Radiologik
Bila dicurigai adanya kelainan di sinus paranasal,maka dapat
dilakukan pemeriksaan radiologik. Posisi rutin yang dipakai ialah posisi
Waters, P.A, dan lateral. Posisi Waters terutama untuk melihat adanya
kelainan di sinus maksila, frontal dan etmoid. Posisi posterior anterior
untuk menilai sinus frontal dan posisi lateral untuk menilai sinus frontal,
sphenoid dan etmoid.
Metode mutakhir yang lebih akurat untuk melihat kelainan sinus
paranasal adalah pemeriksaan CT-scan.
Sinuskopi
Pemeriksaan ke dalam sinus maksila menggunakan endoskop.
Endoskop dimasukkan melalui lubang yang dibuat di meatus inferior atau
di fossa kanina.
Dengan sinuskopi dapat dilihat keadaan di dalam sinus, apakah ada
sekret, polip, jaringan granulasi, massa tumor atau kista, bagaimana
keadaan mukosa dan apakah ostiumnya terbuka.
9. DD ?
Often, healthcare providers can diagnose acute sinusitis by reviewing a
persons symptoms and examining the nose and face. Doctors may
perform a procedure called rhinoscopy, in which they use a thin, flexible
tube-like instrument to examine the inside of the nose.
If symptoms do not clearly indicate sinusitis or if they persist for a long
time and do not get better with treatment, the doctor may order a
computerized tomography (CT) scana form of X-ray that shows some
soft tissue and other structures that cannot be seen in conventional X-rays
to confirm the diagnosis of sinusitis and to evaluate how severe it is.

Laboratory tests that a healthcare professional may use to check for

possible causes of chronic rhinosinusitis include:
1 Allergy testing
2 Blood tests to rule out conditions that are associated with sinusitis,
such as an immune deficiency disorder
3 A sweat test or a blood test to rule out cystic fibrosis
4 Tests on the material inside the sinuses to detect a bacterial or
fungal infection
5 An aspirin challenge to test for AERD. In an aspirin challenge, a
person takes small but gradually increasing doses of aspirin under
the careful supervision of a healthcare professional.
Sinusitis (frontal, ethmoid, maksila,spenoid)
Sinusitis Maksila
Sinus maksila disebut juga antrum High-more merupakan sinus paranasal
yang terbesar.1,9 Saat lahir sinus maksila bervolume 6-8 ml, sinus
kemudian berkembang dengan cepat dan akhirnya mencapai ukuran
maksimal, yaitu 15 ml saat dewasa dan merupakan sinus yang sering
terinfeksi, oleh karena9:
1. Merupakan sinus paranasal yang terbesar.
2. Letak ostiumnya lebih tinggi dari dasar, sehingga aliran sekret
(drainase) dari sinus maksila hanya tergantung dari gerakan silia.
3. Dasar sinus maksila adalah dasar akar gigi (prosesus
alveolaris), sehingga infeksi gigi dapat menyebabkan sinusitis
maksila.
4. Ostium sinus maksila terletak di meatus medius, di sekitar hiatus
semilunaris yang sempit, sehingga mudah tersumbat.
Sinusitis maksilaris akut biasanya menyusul suatu infeksi saluran
nafas atas yang ringan. Alergi hidung kronik, benda asing, dan
deviasi septum nasi merupakan factor-faktor predisposisi lokal
yang paling sering ditemukan. Deformitas rahang wajah,
terutama palatoskisis, dapat menimbulkan masalah pada anak.
Anak-anak ini cenderung menderita infeksi nasofaring atau sinus
kronik dengan angka insidens yang lebih tinggi. Sedangkan
ganguan geligi bertanggung jawab atas sekitar 10 persen infeksi
sinus maksilaris akut.

Gejala infeksi sinus maksilaris akut berupa demam, malaise dan nyeri
kepala yang tak jelas yang biasanya reda dengan pemberian analgetik
biasa aspirin. Wajah terasa bengkak, penuh, dan gigi terasa nyeri pada
gerakan kepala mendadak, misalnya sewaktu naik atau turun
tangga11,15,16. Seringkali terdapat nyeri pipi khas yang tumpul dan
menusuk, serta nyeri pada palpasi dan perkusi. Sekret mukopurulen dapat
keluar dari hidung dan terkadang berbau busuk. Batuk iritatif non
produktif seringkali ada. Selama berlangsungnya sinusitis maksilaris akut,
pemeriksaan fisik akan mengungkapkan adanya pus dalam hidung,
biasanya dari meatus media, pus atau sekret mukopurulen dalam dalam
nasofaring.11,18
Signs dan symptoms sinusitis maksilaris kronis kongesti
hidung, sakit tenggorokan (dari postnasal), pada sekitar mata pipi
atau dahi sakit lunak dan bengkak, sakit kepala, demam, penciuman
berkurang, batuk, sakit gigi, susah bernafas, mudah lelah. Hal ini di
keluhkan lebih dari 1 minggu.
Sinusitis berdasarkan kausanya
Sinusitis berdasarkan waktu (akut atau kronis)
There are two basic types of sinusitis:
1 Acute, which lasts up to 4 weeks
2 Chronic, which lasts more than 12 weeks and can continue for
months or years .
3
https://www.niaid.nih.gov/topics/sinusitis/Documents/sinusitis.pdf
10.

Pemeriksaan penunjang apa yang disarankan?

11.

Terapi apa yang diberikan kepada pasien?

Acute Sinusitis
Medications can help ease the symptoms of acute sinusitis.
Healthcare providers may recommend pain relievers or
decongestantsmedicines that shrink the swollen membranes in
the nose and make it easier to breathe. Decongestant nose drops
and sprays should be used for only a few days, as longer term use
can lead to even more congestion and swelling of the nasal
passages. A doctor may prescribe antibiotics if the sinusitis is
caused by a bacterial infection.
Chronic Rhinosinusitis
Chronic rhinosinusitis can be difficult to treat. Medicines may offer some
symptom relief. Surgery can be helpful if medication fails.
Medicine

Nasal steroid sprays are helpful for many people, but most do not get full
relief of symptoms with these medicines. Saline (salt water) washes or
nasal sprays can be helpful because they remove thick secretions and
allow the sinuses to drain. Doctors may prescribe oral steroids, such as
prednisone, for severe chronic rhinosinusitis. However, oral steroids are
powerful medicines that can cause side effects such as weight gain and
high blood pressure if used over the long term. Oral steroids typically are
prescribed when other medicines have failed. Desensitization to aspirin
may be helpful for patients with AERD. During desensitization, which is
performed under close medical supervision, a person is given gradually
increasing doses of aspirin over time to induce tolerance to the drug.
Surgery
When medicine fails, surgery may be the only alternative for treating
chronic rhinosinusitis. The goal of surgery is to improve sinus drainage
and reduce blockage of the nasal passages. Sinus surgery usually is
performed to:
1 Enlarge the natural openings of the sinuses
2 Remove nasal polyps
3 Correct significant structural problems inside the nose and the
sinuses if they contribute to sinus obstruction
Although most people have fewer symptoms and a better quality of life
after surgery, problems can reoccur, sometimes even after a short period
of time.
In children, problems can sometimes be eliminated by removing the
adenoids. These gland-like tissues, located high in the throat behind
and above the roof of the mouth, can obstruct the nasal passages.
https://www.niaid.nih.gov/topics/sinusitis/Documents/sinusitis.pdf
Antibiotics:
d Amoxicillin often is the drug of choice for children
and adults. It is generally effective, inexpensive,
and well tolerated. Trimethoprim-sulfamethoxazole
can be used as an alternative drug in adults. Resistance
is more commonly seen in children, and it is
recommended that the clinician refer to their local
biogram profile of antibiotic resistance. For patients
who do not respond to amoxicillin, high-dose
amoxicillin-clavulanate (90 mg/kg amoxicillin and
6.4 mg/kg clavulanate, not to exceed 2 g every
12 hours) is recommended. For patients allergic
to or intolerant of amoxicillin, alternatives include
cephalosporins, macrolides, or quinolones.
d Acute sinusitis generally responds to treatment for
10 to 14 days. Some physicians continue treatment

for 7 days after the patient is well to ensure complete

eradication of the organism and prevent relapse.
It is important to instruct the patient to
complete the course of antibiotics.
d A reasonable approach would be to start the patient
on amoxicillin for 3 to 5 days and determine
whether the signs and symptoms are improving.
If the patients symptoms are improving, continue
this treatment until the patient is well for 7 days
(generally a 10- to 14-day course). If after 3 to 5
days the patient has not shown improvement,
switch to a different antibiotic, such as high-dose
amoxicillin-clavulanate or cefuroxime axetil.
Corticosteroids:
d The use of nasal corticosteroids might be helpful in
patients with acute and chronic sinusitis.
d Although efficacy has not yet been proved, the
short-term use of oral corticosteroids as an adjunct
in treating patients with acute sinusitis is reasonable
when the patient fails to respond to initial treatment,
demonstrates nasal polyposis, or has demonstrated
marked mucosal edema.
Saline-mucolytics:
d Saline nasal sprays or lavage might be a useful adjunct
by liquefying secretions and decreasing the
risk of crusting near the sinus ostia.
d There is no conclusive evidence that mucolytics,
such as guaifenesin, are useful adjuncts in treating
acute sinusitis.
a-Adrenergic decongestants:
d Topical decongestants (eg,oxymetazolinean dphenylephrine)
and oral decongestants (eg, pseudoephedrine)
reduce mucosal blood flow, decrease tissue
edema and nasal resistance, and might enhance
drainage of secretions from the sinus ostia.
d The use of topical decongestants beyond 3 to 5
days might induce rhinitis medicamentosa, with
associated increased congestion and refractoriness
to subsequent decongestant therapy.
https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF
%20Documents/Practice%20and%20Parameters/sinusitis2005.pdf
12.

Komplikasi ?

Sinusitis does not cause any significant mortality by itself. However,

complicated sinusitis may lead to morbidity and, in rare cases, mortality.

Approximately 40% of acute sinusitis cases resolve spontaneously without

antibiotics. The spontaneous cure for viral sinusitis is 98%. Patients with
acute sinusitis, when treated with appropriate antibiotics, usually show
prompt improvement. The relapse rate after successful treatment is less
than 5%.
In the absence of response within 48 hours or worsening of symptoms,
reevaluate the patient. Untreated or inadequately treated rhinosinusitis
may lead to complications such as meningitis, cavernous sinus
thrombophlebitis, orbital cellulitis or abscess, and brain abscess.
In patients with allergic rhinitis, aggressive treatment of nasal symptoms
and signs of mucosal edema, which can cause obstruction of the sinus
outflow tracts, may decrease secondary sinusitis. If the adenoids are
chronically infected, removing them eliminates a nidus of infection and
can decrease sinus infection.
http://emedicine.medscape.com/article/232670-overview#a7