RHINOSINUSITIS

Definisi• Inflammatory process involving mucosa of the nose and

one or more sinuses• Mukosa hidung-sinus merupakan kontinuum (inflamasi

mukosa hidung sinus)• Bentuk rhinitis akibat infeksi

(ARIA Update 2008)

Klasifikasi• Acute Rhinosinusitis (ARS)• Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)• Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP)

(EPOS 2012)

ACUTE RHINOSINUSITIS (ARS)

Mikrobiologi• Viral

• rhinovirus, coronavirus• influenza, parainfluenza, adenovirus, RSV, enterovirus

• Bakteri• S. pneumoniae, H. influenzae, M. catarrhalis• S. aureus

Patofisiologi

Acute Viral Rhinosinusitis

(Common Cold)

• Symptoms duration < 10 days

Acute Post-viral rhinosinusitis

• Increase of symptoms after 5 days• Persistent symptom after 10 days• Less than 12 weeks

Acute Bacterial Rhinosinusitis

•Discoloured discharge

•Severe local pain•Fever (>38)•Elevated ESR/CRP•“Double sickening”

Patofisiologi

Viral Infection

Mucosal edema

Epithelial disruption

Goblet cell increased

Cilliary cells decreased

Impairment in normal gas exhange

pH change

Impaired clearance of mucus and debris

Increased bacterial adhesion

Bacterial infection

Mucus accumulation

Followed by negative pressure built up due to impaired sinus

aeration

SymptomsLocal Symptoms

• Nasal blockage/congestion/stuffiness

• Nasal dicharge or postnasal drip

• Facial pain/pressure or headache

• Reduction/loss of smell

Distant Symptoms

Pharyngeal • Sore throat

Laryngeal • Dysphonia

Tracheal • Cough

General Symptoms

• Drowsiness, malaise, fever

Warning Symptoms• Periorbital edema/eryhtema• Displaced globe• Double vision• Ophtalmoplegia• Reduced visualacuity• Severe unilateral/bilateral frontal headache• Frontal swelling• Neurological signs• Reduced consciousness

Pemeriksaan Fisik• Temperatur• Rhinoskopi anterior inflamasi, edema mukosa, sekret

purulen, polyp, abnormalitas anatomi• Inspeksi dan palpasi sinus pembengkakan dan nyeri

pada daerah sinus• Oral post nasal discharge, infeksi gigi

Pemeriksaan Penunjang• Erythrocyte Sedimentation Rate/C-Reactive Protein• Bakteriologi tidak dibutuhkan (indikasi: penyakit severe,

rekuren, terdapat komplikasi)• Pencitraan (indikasi: penyakit severe, gagal terapi

medikamentosa, terdapat komplikasi, immunocompromised)

Diagnosis Banding• Viral Upper Respiratory Tract Infection (URTI)• Allergic Rhinitis

• Non-purulent rhinorrhea (vs. mucopurulent)• Nasal itching & sneezing (vs. pain)• Ocular symptoms• History of allergy/atopy, seasonal exposure pattern

• Orodontal disease

Kriteria Diagnostik ARS Dewasa

Sudden onset or two or more symptoms, one of which should be either nasal blockage or nasal discharge (anterior/posterior)• +/- facial pain/pressure• +/- reduction/loss of smell

For < 12 weeks

(EPOS 2012)

Kriteria Diagnostik ARS Pediatrik

Sudden onset or two or more of the symptoms• Nasal blockage• Discoloured nasal sicharge• Cough (daytime and nighttime)

For < 12 weeks

(EPOS 2012)

Tatalaksana ARS Dewasa

Tatalaksana ARS Pediatrik

Symptomatic Treatment• Analgesik golongan NSAID• Decongestant oral norephedrine, pseudoephedrine,

topikal oxymetazoline, xylometazoline• Irigasi hidung dengan saline

Antibiotik (AAO)• Primary (for mild symptoms, no previous treatment, low

resistance risk)• Amoxicillin 3 x 500 mg pc• Doxycycline 1 x 200 mg hari pertama 1 x 100 mg pc• Cefpodoxime 2 x 200 mg pc• Cefdinir 1 x 600 mg pc

• Secondary (for moderate-severe, prior treatment, high resistance)• Amoxicillin clavulanate 1 x 875 mg pc• Levofloxacin 1 x 500 mg pc• Moxifloxacin 1 x 400 mg pc• Ceftriaxone IV 1 x 1000 mg

CHRONIC RHINOSINUSITIS (CRS)

Patofisiologi• Superantigen hypothesis (disease modifier)

Staphylococcus mengeksresikan exotoxin, yang pengaruhi beberapa sel:• Th2 peningkatan aktivitas = pembentukan IgE polyclonal

• Treg inhibisi• Eosinophil peningkatan survival dan aktivitas • Sel mast peningkatan degranulasi

• Net effect untuk membantu mikroorganisme menghindari respon imun host

Staphylococcus aureus Superantigen

Patofisiologi• Immune barrier hypothesis

Defek barrier mekanis

Imunitas innate

Kolonisasi epitel dengan bakteri

Aktivasi sel epitel, limfosit B dan T

(Efek Superantigen)

Kompensasi imunitas adaptive

Respon Th2 meningkat

Pembentukan autoantibodi

Polyp• Translucent to pale grey• Pear shaped, smooth, soft, freely mobile• Lateral nasal wall• Inflammatory polyps are usually seen bilaterally• Fibromyxomatous stroma covered by respiratory

epithelium• Eosinophils and mast cells

(Ballenger Otorhinolaryngology, 2003)

Symptoms• ~ ARS, namun intensitas < ARS• Loss of smell > ARS (Ballenger Otorhinolaryngology,

2003)• Nyeri < ARS, kecuali eksaserbasi akut

• Minor symptoms: ear pain/pressure, dizziness, halitosis, dental pain

Kriteria Diagnostik CRS

Presence of two or more symptoms, one of which should

be either nasal blockage or nasal discharge

(anterior/posterior nasal drip)

• +/- facial pain/pressure

• +/- reduction/loss of smell

For > 12 weeks

Kriteria Diagnostik CRSwNP• Kriteria CRS• Bilateral, endoscopically visualise polyps in middle

meatus

Kriteria Diagnostik CRSsNP• Kriteria CRS• No visible polyps in middle meatus, if necessary

following decongestants

Tatalaksana CRS di Pelayanan Primer

Tatalaksana CRSsNP Dewasa

Tatalaksana CRSwNP Dewasa

Antibiotik (AAO)• S. aureus dan anaerob

• Clindamycin 4 x 150 mg pc atau• Amoxicillin clavulanate 1 x 875 mg pc atau• TMP-SMX 2 x 960 mg pc dan metronidazole 2 x 1000 mg

• Pseudomonas• Levofloxacin 1 x 500 mg dan metronidazole atau• Ciprofloxacin 2 x 500 mg pc dan metronidazole