Rhinologi(Sinusitis)& RA Dr.sph

7/28/2019 Rhinologi(Sinusitis)& RA Dr.sph

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Dr. Suprihati SpTHT. MSc.


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4 SINUS PARA NASAL1. Sinus Frontal

2. Sinus Sphenoid3. Sinus Ethmoid4. Sinus Maksila


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Air conditioning Keseimbangan kepala Menjaga suhu Resonansi

Fungsi normal sinus tergantung pd ventilasi &

drainase yg baik


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Terbesar, piramid Basis : dinding lateral rgg hidung Apek : proc Zygomatikus


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Batas2 : Anterior : permk fasial sinus maksila Posterior : fosa infra temporal &

Pterigomaksila Medial : dinding lateral hidung Superior : dasar orbita Inferior : proc alveolaris & palatum


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Anatomi klinik

Dasar sinus dekat dengangigi PM 1 & 2Batas superior dekat mataOsteum sinus lebih tinggi

dari dasarnyaDiameter ostium 1-3mm


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Terbentuk sejak lahirPada anak : dasar sama / > tinggi daridasar rongga hidungUkuran Sinus

Lahir : 7-8 x 4-6 mmDewasa : Medio lateral : 3-5 cm

Antero posterior : 2-5 cm

Volume : 15-30 mL


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Vaskularisasi : a. maksila interna a. sphenopalatina a. palatina mayor a. alveolaris anterior - posterior


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Sempurna usia > 8 tahun

Batas dengan orbita tipis

Muara di meatus medius

( bersama dg sinus maksila & sinus

ethmoid )


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3-16 Sel-sel ( sarang lebah )volume total 3 ml

Letak : bula ethmoid, diantara

konka media & ddng medial orbitaJumlah : 2 kelompok

S. Ethmoid anterior muara meatusmedia

S. Ethmoid posterior muara meatus superior


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Batas batasnya Lateral : Lamina papirasea ( mata) Superior : Lamina kribosa Posterior : Sinus sphenoid


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Letak : di dalam os sphenoidBatas batas : Superior : fosa cerebri media Inferior : atap nasofaring Lateral : sinus cavernosus &

a. carotis interna Posterior : Pons / fosa cerebri

posterior


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Komplek ostiomeatal

Celah sempit yg merupakan unit drainasefungsional ta :1. bula ethmoid,2. prosesus uncinatus,3. infundibulum ethmoid,4. hiatus semilunaris,

5. ostium sinus maksila,6. resesus frontalis


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Inflamasi pada satu atau lebih mukosa

sinus paranasal baik karena infeksi dannon infeksi dg gejala :* hidung buntu,* nyeri fasial dan ingus kental /purulen.


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American Academy of Otolaryngology Head and Neck

Surgery ( 1996 ) : Sinusitis Rinosinusitis

SINUSITIS

Alasan :

Mukosa hidung & sinus secara embriologis berhub

Pend sinusitis juga rinitis ( jarang yang tidak) Gjl pilek, hidung buntu, hiposmia ada pd keduanya CT pend C Cold inflamasi mukosa hdng & sinus

Kasus sinusitis lanjutan dari sinusitis

konsep one air one disease


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Morbiditas tinggi

AS : 30 juta penderita ( 1989 )90 % ke pelayanan primer

Indonesia : data epidemiologik : ( - ) dx dasar konfirmasi : x foto therapi tidak adekuat kronik

SINUSITIS


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Ketrampilan diagnosis sinusitisPemberian terapi tepat dan adekuat

Menurunkan : Morbiditas Angka absen Lama sakit

Biaya pengobatan

penting untuk :


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Dengan C.T. :- Struktur sinus

- Kompleks ostiomeatalSinusitis disertai kelainankompleks ostiomeatal

Sinus sehat : bakteri aerob dananaerob dlm sinus


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-Kelainan/ obstruksi komplek

ostiomeatal

- Bakteri dalam rongga sinus- Adanya faktor predisposisi

SIKLUS SINUSITIS


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Faktor predisposisi

Berbagai kondisi yang mengarah pada obstruksi

sinus : infeksi & alergi

Berbagai variasi anatomis : septum deviasi,konka bulosa, Kurvatura paradoksal konka media

Gangguan klirens mukosilia : sindrom diskinesia (

Kartegener, silia imotil ), fibrosis kistik.

Imunosupresi atau imun defisiensi


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Sekret kental

Perubahan met. gas mukosa

Silia & epitel rusak

Perbhn lingk. baik utk pertumbbakteri di rgg tertutup

Sekret yg tertimbun inflamasi jaringan

Infeksi bakteri dalam

rongga sinus

Penebalan mukosa sumbatan lebih lanjut

Ostium tertutup

Kongesti mukosa / obstruksianatomik hentikan aliran udara

dan drainase

Sekret terbendung


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Etiologi / penyebab sinusitis

Virus :Corona virus, Rhinovrus, Influenza A, RSV

Bakteria aerob:

Streptokokus pnemoni,H influenzae,Moraxella catarhalis,Streptokokus pyogenes,Staphylokokus aureus

Bakteri anaerob


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Anamnesis Sering dianggap pilek biasa yg tak

kunjung hilang Ingus kental, sepanjang hari Suara kadang sengau / nasolalia klausa Sakit kepala, sesuai lokasi sinus yang sakit Batuk, terutama pada anak Foetor ex nasi


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TANDA MAYOR1. Nyeri pada daerah muka2. Hidung buntu.3. Ingus berwarna.4. Gangguan penghidu.5.Sekret mucopurulen6.Demam

TANDA MINOR1. Batuk.2. tenggorok berlendir3. nyeri kepala4. nyeri geraham serta napas bau


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Nyeri ketok daerah pipi / dahi

Rinoskopi anterior :

* mukosa hidung edem, hiperemi

* sekret mukopurulen kental* warna kuning-kehijauan di kavum nasi dan

meatus medius

Pemeriksaan faring :

Drainase post nasal


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X foto sinus para nasalPungsi sinusCT Scan

Cairan dalam sinus


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Di i Kli ik i i i


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Kriteria Saphiro & Rachelefsky 1992

Rhinorhe purulen

Drainase post nasal Batuk

Mayor

demam

nyeri kepala dan sinus foetor

Minor

Sinusitis : 2 mayor

1 mayor + 2 / lebih minor

Diagnosis Klinik sinusitis :


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Task Forse AAOA dan ARS ( 1997)Gejala mayor :

Sakit pada muka ( pipi, dahi, hidung)Buntu hidungIngus purulenGangguan penciumanpem hidung : ingus purulen

Gejala minor :Batuk, demam ( yang akut )Nyeri kepalaNyeri gerahamHalitosisTenggorok berlendir

Dua gejala mayor atau lebih, atau

Satu gejala mayor disertai 2 gejala minor

SINUSITIS ?


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Sinusitis AkutAntibiotika spektrum luas

Dosis cukup, 10-21 hari

Dekongestan hidung ( topikal/ sistemik ) Mukolitik


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Sinusitis Kronik - Antibiotika sesuai hasil kultur- Dekongestan hidung- Mukolitik minimal 10-14 hari

tak terkontrol ?

* Irigasi sinus (maks 5x) tak sembuh ?FESS Operasi Cald-Well-Luc (CWL)


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The most prevalent of type I allergic dis.

The symptoms and signs caused by

mediators :

vessels, glands and nerves.

Classified as inflammatory disease.

ALLERGIC RHINITIS :


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Sign & symptoms : Itching nose Sneezing Rhinorrhea Nasal obstruction

Allergic salute


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Prevalence in ISAAC (Asher 1995) :0.8 14.95 % in 6-7 years old1.4 39.7 % in 13 14 years oldLow pervalence : Indonesia, Georgia, Greece

Semarang (2002) ISAAC phase 3, RA : 18,6%High pervalence : Australia, UK and Latin AmericIn adults : no equivalent to ISAAC studyNational survey : 5.9 % France and 29 % UK


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1. INTERMITTENT Less than 4 days a week, or Less than 4 weeks

2. PERSISTENT More than 4 days a week, and More than 4 weeks


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1. MILD means no one of the following itemsare present

Sleep disturbance Impairment of daily activities / sport Impairment of school / work Troublesome symptoms

2. MODERATE SEVERE, when one or more of

the symptoms are present


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MECHANISMS OF Allergic RHINITIS

Mast cell

Histamine

LeukotrienesProstaglandin'sBradykinin,PAF

Itch, sneezingWatery dischargeNasal congestion

allergen

Th 2 cell

B cell

eosinophils Nasal blockadeLoss of smellNasal hyperreactivity

IL4

IgE

IL 3, 5, GMCSF

Immediate rhinitis symptoms

Chronic ongoing rhinitis


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MAST CELL DEGRANULATION

Histamine, Heparin, Tryptase,TNF , TGF , IL 3, 4, 5, 13

Newly formed mediators

PLA2 AA + PAF

C.O 5 L.O

PGD2 LTC4 LTB

LTD4

LTE4

Yallergen

Preformed mediators

Y


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HISTAMINE

H 1-R

DEGRADATION( histamine methyl transfer

CNS Endothelium(Vascular Permeability)

Nociceptive Nerves

Itch.

Systemic ReflexesSneeze

Allergic Salute

Serous/Mucous Secretion Parasympathic ReflexesGlandular Exocytosis

HISTAMINE EFFECTS

Vascular wall

Vasodilatation

Diagram of DIAGNOSTIC PROCEDURES


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Diagram of DIAGNOSTIC PROCEDURES(1)

patients with AR symptoms( history of illness + physical exam.)

skin prick test

(+)

AR withcomplications /concomitant dis

AR withoutcomplication

eosinophil onnasal cytology

(+)

allergicRhinitis ?

(-)

non allergicrhinitis

NARES

(-)


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1. Anamnesis Chief complain :

1. Itching nose2. Sneezing : morning >>3. Serous nasal secretion4. Nasal obstruction at night


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1. Anamnesis

The symptoms was environment related History of other allergic manifestation of

patients and other allergic familialmanifestations Duration of illness, severity of the disease

and the respond of the previous treatment


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2. Physical examinationShould be performed with appropriate lighting

and use of nasal speculum

normaloedema


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2. Physical examination Including :

1. Nasal passage ways2. Nasal mucosa

3. Turbinates4. Secretion5. Septum

6. Polyps ?7. Sinusitis ?


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3. Nasal cytology

Large number of eosinophils may aid todifferentiate AR & NARES from other Rhinitis

No consensus to routinely performed for evaluation of rhinitis


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4. Total serum Ig E

Neither very sensitive nor very specific

35 50 % AR Normal Ig E levels Poor correlation with symptom and skin

testing result


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5. Nasal provocation testing

Based on a history of AR symptoms

provoked by allergen exposure andconfirmed by skin testing It may be required for confirmation of

sensitivity to allergen in the work place


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6. Special diagnostic techniques

Upper airway endoscopy /

Rhinomanometry Standard radiographs CT MRI


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7. Testing for specific Ig E,

important for : Determining whether patient has allergic

rhinitis Identifying specific allergen for

avoidance measurement and allergenimmunotherapy


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8. Skin testing to allergen : Simple Ease

Rapid performance Low cost High sensitivity / spesificity

( Prick test )


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Skin prick test :

positive result

wheal > 3mm diameter


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AllergicRhinitis

O M E

Nasal

polyp

Sinusitis

U R T infection

Bronkhial

asthma


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US : sinusitis 30 Mill / year (1989 )sinusitis : 25 30 % AR

non sinusitis : 14 17 % AR Sinusitis ( dx CT ) Newman at all 1994 :

AR : 78 % Asthma : 71 %


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Non allergic rhinitis :Infectious : bacterial, viral, fungalDrug induced : aspirin & other medicationsOccupational rhinitis (allergy & non allergy)

Hormonal : puberty, pregnancy, menstruationand hormonal disordersOther causes : foods, irritants, emotions, NARESAtrophic RhinitisIdiopatic


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Objectives : relieving symptoms for improving QOL to avoid triggering factor

to avoid / to treat complication to change the natural history


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EDUCATION

Explain what is allergic rhinitis / reaction Explain the meaning of pos. allergic skin test Confirm whether there is correlation between

allergen contact & rhinitis attack Explain how to do allergen avoidance Encourage to avoid the allergens


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Globally important allergens

mites

pollen

mites sources

weed cockroaches

pets : dogs


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1. ANTIHISTAMINE First line Consider new antihistamine since :

Long acting more practicalNo sedating normal daily activityNo / less cardiac effectBroad spectrum effects

Except :Patient doesnt mind sedation effect It is not availableCan not be afforded

Classic antihistamine can be considered


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2. NASAL DECONGESTANTIndicated in patient with prominent nasal

obstruction complaintAs addition / combination with A H

Long term treatment Systemic nasal decongestant, be

careful in hypertension cases andglaucoma.

Topical : rebound effect


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3. INTRANASAL CORTICOSTEROID

Long term treatment safer than systemicapplication Effective to control AR symptoms

Note : Patients should be well informed how to use Symptoms relieve is not directly achieved In some places it is unavailable


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ASIT : effective for treating allergic rhinitis

Recommended in patients with : severe symptoms failed by pharmacological treatment positive correlation skin test & history agree & well informed about duration, schedule of

injection & expected results

Intermittent AR : Adults & children


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Is therapy needed ? If yes

Non-pharmacological therapy

Allergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/nasal AH or cromon

Nasalcorticosteroids

Nasal CS & oral/nasal AH

Add further symptomatictreatment

Or Short course oral CS

Or Consider IT

If inadequatecontrol

Persistent AR : Adults Is therapy needed ? If yes


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Non-pharmacological therapyAllergen avoidance measure

Environment control

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/ nasalantihistamine

Nasalcorticosteroids

Nasal CS &Oral antihistamine

If inadequatecontrol If resistent

I f resistent


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Nasal blockage

RhinorrheaAntihistamine and

Oral / nasaldecongestant

OrShort course oral

steroid

Nasal ipratropiumbromide

I f persistent

ConsiderImmunotherapy

I f inadequate control

Further examination &consider immunotherapy

OrSurgical turbinate reduction

Rhinologi(Sinusitis)& RA Dr.sph

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