Chronic

Rhinosinusitis
Presenter: 14303 Group
Arief Yunan P.
Nik Muh. Toriq
Audesia Alvianita
Kemal Luthfan H.
Theodora Caroline S.
Michael Hartono
Moderator: dr. Dika

Background
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.
2.
3.
4.

Acute
Subacute
Chronic
Reccurent acute

Background

Chronic rhinosinusitis may cause high prevalence

and more threatening complications leading to
significantly worsen a patients 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).

LITERATURE REVIEW
CHAPTER 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.

Definition

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)

Classification
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)

Etiopathophysiology of Chronic
Rhinosinusitis

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

Physical Exam/Signs

Presence or absence
of the following:
(1) Nasal Polyps
(2) eosinophilic or
other inflammatory
features
(3) fungal hyphae in
sinus mucus.

Imaging Studies

Standard radiography
Caldwell and Waters the frontal and maxillary
sinuses
Lateral views the sphenoid sinus and adenoids in
children
Computed tomography
Extent of disease and the degree of ostiomeatal
complex obstruction
Delineate pathologic variations and anatomic
structures
Magnetic Resonance Imaging
Imaging of soft tissues

Imaging Studies

Management of CRS

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

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

Appropriate for gram negative and anaerob

bacteria

CASE REPORT
CHAPTER 3

PATIENTS IDENTITY
Name
: Ms. S W
Age
: 30 years old
Address
: Sengon, Prambanan, Klaten
Occupation : Employee
No MR
: 86 13 19

Anamnesis
Chief complaint :
Nasal blockage

Anamnesis - HPI

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.

History
History of
History of
History of

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

History of family illness:

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

PHYSICAL EXAMINATION
Status Generalis

General status : well conscious,

adequately nourished.

Vital Sign BP : 110/70 mmHg

Pulse : 88 tpm
RR : 20 tpm
T : afebris

NOSE AND PARANASAL

SINUSES
DEXTRA

Inspection

SINISTRA

Deformity (-), hyperaemic (-), Deformity (-),

edema (-),
edema (-),
discharge (-)
discharge (-)

hyperaemic (-),

Palpation and
Paranasal Sinus Maxilla pain (-), frontal pain (-) Maxilla pain (+), frontal pain (-)
Examination

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
(+)

Edema concha
nasalis (+)
Hyperaemic
(+)

Yellowish
mucoid
discharge (+)
Edema concha
nasalis (+)
Hyperaemic
(+)

Edema concha
nasalis (+)
Hyperaemic
(+)

EAR
DEXTRA

SINISTRA

Inspecti
on

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

Hyperaemic (-), edema

(-)
Discharge (-)

Palpatio
n

Tragus pain (-),

mastoid pain (-)

Tragus pain (-),

mastoid pain (-)

Cerumen (-)

Cerumen (-)

Hyperaemic in the wall

of external auditory
canal pars ossea (-)

Hyperaemic in the wall of

external auditory canal
pars ossea (-)

Intact tympanic
membrane

Intact tympanic
membrane

Otoscop
y

Hyperaemic(-), Edema (-)

Cone of Light (+)

Intact tympanic membrane

MOUTH AND PHARYNGEAL

Within normal
limit

Structure

Post
Nasal
Drip (+)
T1

Findings

Lips

Normal color

Buccal mucosa

hyperaemic (-)

Tongue and palatum

hyperaemic (-), stomatitis

(-)

Gum and teeth

Caries (+) in P1,P2,M1

upper left

Uvula

deviation (-)

Tonsil and pharyng

T1-T1, hyperaemic (-), Post

RADIO IMAGING

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.

Clinical Diagnosis

Odontogenic Chronic Rhinosinusitis of

Maxilla Sinistra

PROPOSED TREATMENT
Clindamycin 2x300 mg
Pseudoephedrine HCl 2x60 mg
Loratadine 1x10 mg

Prognosis

Dubia ad Bonam

PLANNING
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

PROBLEM
Drug of choice?

DISCUSSION
CHAPTER 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).

Drug of Choice

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.

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.

CONCLUSION
CHAPTER 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 you
Please kindly give any suggestion

Vascular Supply

Arterial Supply of the nasal cavity is form five

sources :
1.
2.
3.
4.
5.

A. Anterior ethmoidal
A. Posterior ethmoidal From a. opthalmic
A. Sphenopalatine
A. Greater palatine
From a. maxillary
A. Septal branch of the superior labia

Superior part

Inferiror part

. 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.

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

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
Sensoric:
-Olfactory nerve smell
-Anterior ethmoidalis nerve (part of Opthalmicus nerve part
of Trigeminus Nerve) temperature, itch, touch, air flow
Simpatic and parasimpatic (enter nasal cavity from foramen
sphenopalatina ):
-Simpatic vasoconstriction and decrease sinonasal
resistance
-Parasimpatic vasodilatation and gland secretion

Respiratory Mucous

Adapted from:
httpwww.fess.com.auimportance
_of_nasal_health.php

Acute Rhinosinusitis

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.

Physical Exam/ Sign

sinus tenderness
on palpation
mucosal erythema
purulent nasal
secretions
increased
pharyngeal
secretions
periorbital edema.

PSEUDOEPHEDRINE
Pseudoephedrine is a sympathomimetic agent that occurs naturally
in plants of the genus Ephedra; the drug acts directly on both - and,
to a lesser degree, -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 selfmedication 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 46 hours with a
maximum of 240 mg daily.
Alternatively, some pediatricians recommend 4 mg/kg or 125 mg/m 2
daily, given in 4 divided doses.
Adapted from: drugs info at www.emedicine-medscape.com

PSEUDOEPHEDRINE
Pseudoephedrine acts directly on -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).
Adapted from: drugs info at www.emedicine-medscape.com

LORATADINE
Loratadine, 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

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

LORATADINE
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 24Hour) 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.
Adapted from: drugs info at www.emedicine-medscape.com

CORTICOSTEROID
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.

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

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

INDIKASI FESS
Rhinosinusitis rekuren
Rhinosinusitis Kronik
Rhinosinusitis karena jamur alergi
Rhinosinusitis Hipertrofi kronis (Polip)
Polip Antrokoanal
Mukokel dalam sinus

Adapted from: Modul Penyakit Sinus

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

ENDOSCOPIC (ENDONASAL)
SINUS SURGERY
Complications
Bleeding
Infection
Adhesions
Restenosis
CSF leak
Periorbital hematoma
Subcutaneous emphysema
Diplopia
Blindness
Epiphora
Adapted from: Brook, et al. Sinusitis From Microbiology to

Maxillary Sinus Surgery

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

Indications for Caldwell-Luc

Removal of mycotic fungus balls
Symptomatic multiseptate mucoceles of the maxillary sinus
Antrochoanal polyps
Biopsy and/or removal of neoplasms or other masses
Exposure to the pterygopalatine fossa (particularly for epistaxis
control)
Oroantral fistula repai
Adapted from: Brook, et al. Sinusitis From Microbiology to

Ethmoid Sinus Surgery

TYPE:
Endoscopic Endonasal Ethmoidectomy
External Ethmoidectomy

Sphenoid Sinus Surgery

TYPE:
Endoscopic Endonasal Sphenoidotomy
External Spenoethmoidectomy
Adapted from: Brook, et al. Sinusitis From Microbiology to

Frontal Sinus Surgery

TYPE:
Trephination
Lynch Procedure (External Frontoethmoidectomy)
Lothrop Procedure
Endoscopic Frontal Sinusotomy
Osteoplastic Frontal Sinus Obliteration

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