CASE DISCUSSION

SINUSITIS

Supervisor dr. H. Oscar Djauhari, Sp. THT-KL

Presentants Marcella Aprilia Lonatrista 2010.061.150 Arga Aditya 2008730006

Otolaryngology, Head and Neck Department Medical Faculty of Unika Atma Jaya Medical Faculty of Muhammadiyah Jakarta University R. Syamsudin, S.H. Regional General Hospital, Sukabumi
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26th November 2012 29th December 2012

CASE DISCUSSION
A. PATIENTS IDENTITY Name Gender Age Occupation Address B. HISTORY Chief Complaint recurrent common cold since 4 months before admission History of Present Illness A 28-year old woman came to ENT department at Syamsyudin hospital with a chief complaint of recurrent cold at the morning since 4 month before admission. The nose discharge had yellowish geen colour and smelled odour since 1 month before admission. She also complained had nasal speech. Fever and cough were denied. She had taken over the counter medication but she hadnt feel any improvement. No complainded on eyes. Additional Complaints : headache, located at the base of the nose History of Past Illness o History of right nose trauma with three times nose bleeding since 11 years ago o History of hypertension was denied History of Family Illness History of family illness was denied Habits o Recurrent cold o Does not smoke
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: Ms. I : Female : 28 years old : employer : Sukabumi

o Does not drink any alcohol substance. o Does not use any routine medication. o Does not use any narcotics. C. PHYSICAL EXAMINATION General condition Body weight Height Blood pressure Pulse Respiratory rate Temperature ENT Examination Ear Right ear - Auricle : normal : Appear calm : 45 kg : 156 cm : 110/90 mmHg : 80 beat per minute : 22 times per minutes : 36o C

- External auditory canal: hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (-) - Tymphanic membrane: Intact, hyperemic (-), retraction (-), light reflex (+)

Left ear - Auricle : normal

- External auditory canal: hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (+) - Tymphanic membrane: Intact, bulging (-), light reflex (+)
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Tuning fork test Rinne test : air conduction is being louder or louder than bone conduction on both ear Weber test Schwabach test : no lateralization : same with examiner on both ear

Nose Right nose - Mucous membrane: hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae - Septum - Air passage : eutrophy : no deviation : decreased

Left nose - Mucous membrane: hyperemic (+), edema (-), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae - Septum - Air passage : eutrophy : no deviation : normal

Oropharynx - Posterior pharynx : hyperemic (-) - Palatine tonsils - Uvula - Dental : T1 / T1, hyperemic (-), detritus (-) : symmetrical : no abnormatlities

Maxillofacial : symmetrical

Neck

: no lymphadenopathy

D. WORKING DIAGNOSIS Sinusitis

E. DIFFERENTIAL DIAGNOSIS Allergic sinusitis

F. WORK-UP Laboratory: 1. Routine blood count 2. Liver function test

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3. Blood glucose test 4. Renal function test 5. Bleeding time- clotting time

Chest X-ray PA position Paranasal Sinus X-ray Waters position ECG

G. TREATMENT Antral Wash Out dextra Ceftriaxone 2 x 1 gram vial Ketorolac 3 x 1 ampul (@30 mg/ml) Tranexamic acid 3 x 2 ampul (@ 250 mg/ml)

Laboratory Test Result Examination Hemoglobin Leucocyte count Hematrocryte Thrombocyte SGOT/ASAT SGPT/ALAT Ureum Creatinine Bleeding time Clotting time Blood glucose Normal value 12 -16 g/dl 4000 9000 / ul < 31 U/L/37 C < 36 U/L/37 C 20 -40 mg/dl < 0.9 mg/dl -1.1 mg/ dl 1-3 minutes 1-11 minutes < 180 mg/dl 11/9/2012 12,9 10.100 22,0 18,3 24,3 0,7 2 minutes 6 minutes 86 1 minute 6. 30 minutes 108 25/11/2012 11,9 7600 36,1 262.000

Paranasal Sinus X-ray: waters position (1/11/2012)

Interpretation

Right antrum wall thickened Opaque cloaking seen at right maxillary sinus Resume: sinusitis maxillary particularly dextra

Chest X-Ray (11/9/2012)

Interpretation Cor CTR> 50%, normal Hili, normal costophrenicus sinus Increase pulmonary vascular patern Resume: Cardiomegaly because of less inspiration, no pulmonary TB

Follow up 26/11/2012 S: Cold, pain at the forehead especially when she bows O: Nose Right nose - Mucous membrane: hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae - Septum - Air passage Left nose - Mucous membrane: hyperemic (+), edema (+), secretion (+), mass (-), laceration (-), crust (-) - Inferior conchae - Septum - Air passage A: Maxillary Sinusitis : eutrophy : no deviation : normal : eutrophy : no deviation : decreased

26/11/2012 3.15 pm S: Patient awake 2 hours after AWO. Patient feel sore on the right nose, headache, nausea, blood taste inside the mouth, dry lips and thirsty O: tampon on right nose
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A: post-op sinusitis maxillaris dextra (AWO)

27/11/2012 08.00 am S: Patient getting better, but still feel sore on the right nose, headache, blood taste inside the mouth. Patient eat (liquid diet) and drink normally. O: theres still tampon plug on right nose A: post-op sinusitis maxillaris dextra (AWO)

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Chronic Rhinosinusitis
Chronic sinusitis is one of the more prevalent chronic illnesses in the United States, affecting persons of all age groups. It is an inflammatory process that involves the paranasal sinuses and persists for 12 weeks or longer. The literature has supported that chronic sinusitis is almost always accompanied by concurrent nasal airway inflammation and is often preceded by rhinitis symptoms; thus, the term chronic rhinosinusitis (CRS) has evolved to more accurately describe this condition. Most cases of chronic sinusitis are continuations of unresolved acute sinusitis; however, chronic sinusitis usually manifests differently from acute sinusitis. Symptoms of chronic sinusitis include nasal stuffiness, postnasal drip, facial fullness, and malaise. Chronic sinusitis may be noninfectious and related to allergy, cystic fibrosis, gastroesophageal reflux, or exposure to environmental pollutants. Allergic rhinitis, nonallergic rhinitis, anatomic obstruction in the ostiomeatal complex, and immunologic disorders are known risk factors for chronic sinusitis. Medical therapy is directed toward controlling predisposing factors, treating concomitant infections, reducing edema of sinus tissues, and facilitating the drainage of sinus secretions. The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining.

Anatomy
Knowledge of the anatomy of paranasal sinuses is essential for understanding the pathophysiology and management of chronic sinusitis. The 4 pairs of paranasal sinuses are
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lined with ciliated, pseudostratified columnar epithelium. Goblet cells are interspersed among the columnar cells. The mucosa is attached directly to the bone. Involvement of the surrounding bone and further extension of the infection into the orbital and intracranial compartments can result from inadequate treatment of sinusitis and specific types of sinusitis (eg, fungal sinusitis). The maxillary, frontal, and anterior ethmoid sinuses drain through their ostia located at the ostiomeatal complex lying lateral to the middle turbinate within the middle meatus. The posterior ethmoid and sphenoid sinuses open into the superior meatus and sphenoethmoid recess, respectively. The maxillary ostium is connected to the nasal cavity by a narrow tubular passage called the infundibulum, located at the highest part of the sinus; hence, drainage from the maxillary sinus flows against gravity via mucociliary clearance. Because the floor of the maxillary sinus is the tooth-bearing part of the maxilla, dental infections can easily extend to the maxillary sinus. Although the nasal cavity is usually colonized with bacteria, the sinuses are typically sterile. Pathophysiology Stasis of secretions inside the sinuses can be triggered by (1) mechanical obstruction at the ostiomeatal complex due to anatomic factors or (2) mucosal edema caused by various etiologies (eg, acute viral or allergic rhinitis). Mucous stagnation in the sinus forms a rich medium for the growth of various pathogens. The early stage of sinusitis is often a viral infection that generally lasts up to 10 days and that completely resolves in 99% of cases. However, a small number of patients may develop a secondary acute bacterial infection that is generally caused by aerobic bacteria (ie, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). Initially, the resulting acute sinusitis involves only one type of aerobic bacteria. With persistence of the infection, mixed flora, anaerobic organisms, and, occasionally, fungus contributes to the pathogenesis, with anaerobic bacteria of oral flora origin often eventually predominating. In one study, these bacterial changes were demonstrated with repeated endoscopic aspiration in patients with maxillary sinusitis. Most cases of chronic sinusitis are due to acute sinusitis that either is untreated or does not respond to treatment.

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The role of bacteria in the pathogenesis of chronic sinusitis is currently being reassessed. Repeated and persistent sinus infections can develop in persons with severe acquired or congenital immunodeficiency states or cystic fibrosis. Current thinking supports that chronic rhinosinusitis (CRS) is predominantly a multifactorial inflammatory disease. Confounding factors that may contribute to inflammation include the following:

Persistent infection (including biofilms and osteitis) Allergy and other immunologic disorders Intrinsic factors of the upper airway Superantigens Colonizing fungi that induce and sustain eosinophilic inflammation Metabolic abnormalities such as aspirin sensitivity All of these factors can play a role in disruption of the intrinsic mucociliary transport

system. This is because an alteration in sinus ostia patency, ciliary function, or the quality of secretions leads to stagnation of secretions, decreased pH levels, and lowered oxygen tension within the sinus. These changes create a favorable environment for bacterial growth that, in turn, further contributes to increased mucosal inflammation. Etiology Currently, etiologic studies of sinusitis are increasingly focusing on ostiomeatal obstruction, allergies, polyps, occult and subtle immunodeficiency states, and dental diseases. Microorganisms are more often recognized as secondary invaders. Any disease process or toxin that affects cilia has a negative effect on chronic rhinosinusitis (CRS). Bacterial involvement The bacteria presumed to be involved in CRS differ from those involved in acute rhinosinusitis. The following bacteria have been reported in samples obtained through endoscopy or sinus puncture in patients with chronic sinusitis.

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Staphylococcus aureus (both methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA] strains) Coagulase-negative staphylococci H influenzae M catarrhalis S pneumoniae Streptococcus intermedius Pseudomonas aeruginosa Nocardia species Anaerobic bacteria (Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides , Fusobacterium species

In contrast with the well-established roles of microbes in the etiology of acute sinusitis, the exact roles of all of these microbes in the etiology of chronic sinusitis are uncertain. Various researchers disagree on the microbial etiology of chronic sinusitis. Much of the disagreement may be explained by methodology. Studies that have used adequate methods for recovery of anaerobes have demonstrated their prominence in chronic sinusitis, while those that did not use such methods have failed to recover them. When proper techniques are used, anaerobic bacteria can be recovered in 50-70% of specimens. The variable growth of microbes in samples may also be due to prior exposure of various broadspectrum antibiotics in patients involved in the studies. Jyonouchi et al successfully induced chronic sinusitis in rabbits via intrasinus inoculation of Bacteroides fragilis. The authors subsequently identified immunoglobulin G (IgG) antibodies against this organism in the infected animals. In addition, IgG antibodies to anaerobic organisms have been observed in patients with chronic sinusitis. These findings further support a role for anaerobes in chronic sinusitis. Microbiologic studies of chronic sinusitis often show that the infection is polymicrobial, with isolation of 1-6 isolates per specimen.

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In some cases, the baseline chronic sinusitis worsens suddenly or causes new symptoms. This acute exacerbation of chronic sinusitis is often polymicrobial as well, with anaerobic bacteria predominating. However, aerobic bacteria that are usually associated with acute sinusitis (eg, S pneumoniae, H influenzae,M catarrhalis) may emerge. Gram-negative facultative and aerobic bacteria, including P aeruginosa, are more often isolated in patients with chronic sinusitis who have undergone endoscopic sinus surgery. Fungal involvement The following fungi have been reported in samples obtained with endoscopy or sinus puncture in patients with chronic sinusitis:

Aspergillus species Cryptococcus neoformans Candida species Sporothrix schenckii Alternaria species

Epidemiology Chronic sinusitis is one of the more prevalent chronic illnesses in the United States, affecting persons of all age groups. The overall prevalence of CRS in the United States is 146 per 1000 population. For unknown reasons, the incidence of this disease appears to be increasing yearly. This results in a conservative estimate of 18-22 million physician visits in the United States each year and a direct treatment cost of $3.4-5 billion annually. Chronic sinusitis is the fifth most common disease treated with antibiotics. Up to 64% of patients with AIDS develop chronic sinusitis. International prevalence Chronic sinusitis is a common disease worldwide, particularly in places with high levels of atmospheric pollution. In the Northern Hemisphere, damp temperate climates along

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with higher concentrations of pollens are associated with a higher prevalence of chronic sinusitis. Rhinosinusitis in children Rhinosinusitis is more common in the pediatric population because this term includes both acute and chronic infection and both viral and bacterial disease. This is likely secondary to an increased frequency of exposure to upper respiratory tract infections in the pediatric population. Risk factors The following conditions and risk factors predispose patients to the development of chronic sinusitis:

Anatomic abnormalities of the ostiomeatal complex (eg, septal deviation, concha bullosa, deviation of uncinate process, Haller cells) Allergic rhinitis Nasal polyps Nonallergic rhinitis (eg, vasomotor rhinitis, rhinitis medicamentosa, cocaine abuse) Nasotracheal intubation Nasogastric intubation Hormonal (eg, puberty, pregnancy, oral contraception) Tumoral obstruction Immunologic disorders (eg, common variable immunodeficiency, immunoglobulin A [IgA] deficiency, IgG subclass deficiency, AIDS)

Cystic fibrosis Primary ciliary dyskinesia, Kartagener syndrome Wegener granulomatosis Repeated upper respiratory tract infections
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Smoking Environmental pollution Periodontitis/significant dental disease

History Patient history is extremely important in chronic rhinosinusitis (CRS) because of the broad overlap between sinus symptoms and other disease processes, as well as poor correlation between symptoms and endoscopic and radiographic findings. Chronic sinusitis manifests more subtly than acute sinusitis. Unless an appropriate history is taken, the diagnosis may be missed. The typical symptoms of acute sinusitisfever and facial painare usually absent in chronic sinusitis. Fever, when present, may be low grade. Patients with chronic sinusitis may present with the following symptoms:

Nasal stuffiness Nasal discharge (of any character from thin to thick and from clear to purulent) Postnasal drip Facial fullness, discomfort, and headache Chronic unproductive cough Hyposmia Sore throat Fetid breath Malaise Easy fatigability Anorexia Exacerbation of asthma
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Dental pain Visual disturbances Sneezing Stuffy ears Unpleasant taste Fever of unknown origin In pediatric settings, halitosis is reported more commonly by parents of younger

children. Nasal obstruction with mouth breathing and associated sore throat may be present. In some individuals with chronic sinusitis, parents may note occasional and painless morning eye swelling. Older children may complain of loss of taste due to associated nasal obstruction and anosmia. Nocturnal symptoms may include snoring and coughing due to associated postnasal drip. The patient history should focus on the following key factors, beginning with consideration of major and minor diagnostic criteria:

The presence of major symptoms (including purulent anterior nasal drainage, purulent-discolored posterior nasal drainage, nasal obstruction or blockage, facial congestion or fullness, facial pain or pressure, and hyposmia or anosmia)

The presence of minor symptoms (including headache, ear pain or fullness, halitosis, dental pain, cough, fever, fatigue)

Duration of symptoms Exacerbating and relieving factors History of previous nasal or paranasal sinus surgery Current medications Previous treatments and their duration Other confounding health problems (including asthma, allergy, and

immunocompromising disorders)
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Active or passive tobacco smoke

Physical Examination Physical examination in patients with chronic sinusitis may reveal various findings. It should include a complete head and neck examination (lymphadenopathy) to confirm the diagnosis and to rule out more serious disorders. Sinus palpation is performed to evaluate tenderness or swelling. Pain or tenderness on palpation over frontal or maxillary sinuses may be noted. Transillumination of maxillary or frontal sinuses may be useful; it lacks sensitivity but may have value in experienced hands. An oral cavity and oropharynx examination is used to evaluate the integrity of the palate and the condition of dentition and to look for evidence of postnasal drip. Oropharyngeal erythema and purulent secretions may be noted. Dental caries may be present. Anterior rhinoscopy, with the use of a nasal speculum, is used to evaluate the condition of the nasal mucosa and to look for purulent drainage or evidence of polyps or other nasal masses. Other contributing factors to CRS that can be evaluated are nasal septal deviation and turbinate hypertrophy. The nasal examination should be carried out both before and after the use of a topical decongestant. The nasal examination can be supplemented with the use of nasal endoscopy (if available). Endoscopic (rhinoscopic) examination findings include the following:

Nasal mucosal erythema, edema Purulent secretions Nasal obstruction due to deviated nasal septum or hypertrophied turbinates Nasal polyps Ear examination for the presence of middle ear fluid that may be the sign of a mass in

the nasopharynx is indicated. Ocular examination for spread of disease to the orbit and function of ocular musculature is indicated. Ophthalmic manifestations include the following:
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Conjunctival congestion Lacrimation Proptosis, extraocular muscle palsies, and visual disturbances (when complicated by orbital extension) Laryngeal examination is used to look for other confounding upper airway pathology

including laryngeal-pharyngeal reflux (LPR). Lung examination is performed to determine if coexisting lower airway disease is present. Cranial nerve examination is performed to look for underlying sinus malignancy or neurological disorder. Manifestations of fungal sinusitis Fungal sinusitis can manifest in different ways. Unlike acute invasive fungal sinusitis, which is observed in patients who are immunosuppressed or who have diabetes, chronic fungal sinusitis is usually observed in immunocompetent patients. Mycetomas or fungus balls may be asymptomatic or may manifest as chronic sinusitis. Allergic fungal sinusitis usually manifests as nasal polyps and allergic sinusitis. Fungal elements in the sinuses are the inciting allergens. Diagnostic Criteria In 1996, the American Academy of Otolaryngology-Head & Neck Surgery convened a multidisciplinary Rhinosinusitis Task Force (RTF). This group defined adult rhinosinusitis diagnostic criteria. These 1996 diagnostic criteria required 2 or more major factors or 1 major factor and 2 minor factors for the diagnosis of rhinosinusitis. Major factors included facial pain or pressure, nasal obstruction or blockage, nasal discharge or purulence or discolored postnasal discharge, hyposmia or anosmia, purulence in nasal cavity, and fever (for acute rhinosinusitis only). Minor factors were defined as headache, fever (for CRS), halitosis, fatigue, dental pain, cough, and ear pain, pressure, or fullness. Of note, facial pain requires another major factor associated with it for diagnosis (facial pain plus 2 minor factors is not deemed sufficient for diagnosis of rhinosinusitis).
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In 2003, the RTFs definition was amended to require confirmatory radiographic or nasal endoscopic or physical examination findings in addition to suggestive history.The 2003 diagnostic criteria for CRS require the above criteria for longer than 12 weeks or more than 12 weeks of physical findings. In addition, one of the following signs of inflammation must be present:

Discolored nasal drainage from the nasal passages, nasal polyps, or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy

Edema or erythema of the middle meatus or ethmoid bulla on nasal endoscopy Generalized or localized erythema, edema, or granulation tissue (If the middle meatus or ethmoid bulla is not involved, radiologic imaging is required to confirm a diagnosis.)

Imaging modalities confirming the diagnosis include the following:

Computed tomography (CT) scanning demonstrating isolated or diffuse mucosal thickening, bone changes, or air-fluid levels OR

Plain sinus radiography revealing air-fluid levels or greater than 5 mm of opacification of one or more sinuses Magnetic resonance imaging (MRI) not recommended for routine diagnosis because of its excessive sensitivity and lack of specificity In general, plain radiography has low sensitivity and specificity. CT scanning is

considered the imaging standard for evaluation of chronic sinusitis. The latest executive summary on adult sinusitis has altered the definition for CRS to read 12 weeks or longer of 2 or more of the following symptoms:

Anterior or posterior mucopurulent drainage Nasal obstruction Facial-pain-pressure-fullness

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Decreased sense of smell In addition, inflammation must be documented by demonstrating one of the

following:

Purulent mucus or edema in the middle meatus or ethmoid region Polyps in the nasal cavity or middle meatus Imaging showing inflammation of the paranasal sinuses This is in contrast to recurrent acute sinusitis, which is present when 4 or more

episodes per year of acute bacterial rhinosinusitis without signs and symptoms of rhinosinusitis between episodes. Imaging Studies Plain radiography may show mucosal thickenings or sinus opacities. Air fluid levels are uncommon in chronic sinusitis. Ethmoid sinuses and the ostiomeatal complex are not visualized well on plain sinus radiography. Contrast-enhanced CT scanning is the current radiologic criterion standard for the evaluation of sinus diseases, although performing CT scanning in all patients with chronic sinus disease may be prohibitively expensive or medically unnecessary. CT scans are usually indicated after failure of maximal medical therapy, before surgical planning for evaluation of suspected complications, and when a neoplasm is a possibility. CT scan combined with endoscopic examination helps the surgeon to make operative decisions. Coronal CT scan of the sinus correlates best with the surgical approach, permitting visualization of the anatomy of the nasal cavity, ostiomeatal complex, sinus cavities, and surrounding structures such as the orbit, cribriform plate, and optic canal. Anatomic obstructions at the ostiomeatal complex and dental pathologies are visualized well. Specific entities in the sinus cavity, such as aspergilloma, are also visualized well. Most centers now offer limited sinus CT scans that consist of 5-12 coronal cuts. These limited or screening CT scans cost about the same as a plain radiography but provide more information.

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Magnetic resonance imaging (MRI) is generally reserved only for complex cases. Soft-tissue contrast is better with MRI. Neoplasms, orbital and intracranial complications, and fungal sinusitis can be better evaluated with MRI. Biopsy Biopsy samples from the maxillary sinus mucosa of patients with chronic sinusitis show basement membrane thickening, atypical gland formation, goblet cell hyperplasia, mononuclear cell infiltration, and subepithelial edema. The mononuclear cell infiltrate often predominantly demonstrates neutrophils in acute disease and eosinophils in chronic disease. Rarely, squamous cell metaplasia may be seen. Brush biopsy or turbinate biopsy Evaluation of cilia function with a brush biopsy or turbinate biopsy can be considered in cases of presumed cilia dysfunction. Endoscopic biopsy Specimens obtained from sinus openings via endoscopy correlate well with those obtained with endoscopic surgery or sinus puncture. These should be processed for cultivation of aerobic and anaerobic bacteria, as well as fungi. Specimens evaluated for anaerobic bacteria should be sent in proper transport media. Liquid specimens are preferred to swab specimens. Cultures Calcium-alginate tipped applicators are a readily available device that can be used to obtain a culture. Studies of chronic sinusitis have demonstrated no correlation between nasal flora and culture from the sinuses. Nasal swab cultures have no diagnostic value. Occasionally, an abundance of eosinophils in the nasal smear suggests an allergic etiology. In severe cases, blood cultures, including fungal blood cultures, may be helpful. Endoscopically directed middle meatal culture Recent literature has supported the use of endoscopically directed culture of the middle meatus (the primary drainage system of the anterior ethmoid, maxillary, and frontal
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sinuses) with the use of either a suction trap or a swab. Endoscopically directed middle meatal cultures had a sensitivity of 80.9% and a specificity of 90.5% in a recent metaanalysis. Maxillary sinus tap Traditionally, maxillary sinus tap via inferior meatal puncture was performed for sinus culture. Many otolaryngologists have moved away from maxillary sinus tap because of the discomfort of the procedure and the understanding that a culture of an organism from the middle meatus may be more accurate to determine the bacteria involved in the disease process. Symptomatic Treatment Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics. Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. Initial oral steroid therapy followed by topical steroid therapy was found to be more effective than topical steroid therapy alone in decreasing polyp size and improving olfaction in patients with chronic rhinosinusitis (CRS) with at least moderate nasal polyposis. Catalano et al evaluated balloon dilation for the treatment of chronic frontal sinusitis in 20 patients with advanced sinus disease in whom medical therapy had failed and therefore required operative intervention. Preoperative and postoperative CT scans were compared. There were no significant complications from balloon dilation, and there was significant improvement in patients with certain subsets of CRS. Antimicrobial Therapy An adequate antibiotic trial in CRS usually consists of a minimum of 3-4 weeks of treatment, preferably culture directed. Oral antibiotic regimens are generally used to treat chronic sinusitis, since this condition is primarily treated in an outpatient setting. For resistant cases, there may be a role for intravenous antibiotic therapy.

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Initial choice of the appropriate antimicrobial(s) is usually empiric. Sinus cultures are not generally obtained for community-acquired infections unless empiric therapy fails to elicit a response. The agent(s) chosen should be effective against the most likely bacterial etiologies, including both aerobic and anaerobic pathogens. The likelihood of involvement by beta-lactamaseproducing organisms should be considered. If methicillin-resistant Staphylococcus aureus (MRSA) is a possible pathogen, coverage for this should be included. History of drug allergies (if any) and cost of therapy should be taken into account as well. In addition, if the patient has received antibiotics during the preceding 3 months, a different class of antibiotics should be used. Therapeutic regimens include the combination of a penicillin (eg, amoxicillin) plus a beta-lactamase inhibitor (eg, clavulanic acid), clindamycin, a combination of metronidazole plus a macrolide or a second- or third-generation cephalosporin, and the newer quinolones (eg, moxifloxacin). All of these agents (or similar ones) are available in oral and parenteral forms. Other effective antimicrobials are available only in parenteral form (eg, cefoxitin, cefotetan). If aerobic gram-negative organisms (eg, Pseudomonas aeruginosa) are involved, parenteral therapy with an aminoglycoside, a fourth-generation cephalosporin (cefepime or ceftazidime), or oral or parenteral treatment with a fluoroquinolone (only in postpubertal patients) is added. Parenteral therapy with a carbapenem (ie, imipenem, meropenem) is more expensive but provides coverage for most potential pathogens, both anaerobes and aerobes. Clindamycin as initial therapy provides coverage for MRSA and is effective against anaerobes. Alternatives include trimethoprim-sulfamethoxazole or linezolid, which are added to other regimens that cover anaerobes. Parenteral antimicrobials effective against MRSA include vancomycin, linezolid, and daptomycin. Ferguson et al performed a prospective observational study of 125 adults with classic symptoms of chronic rhinosinusitis who underwent nasal endoscopy and sinus CT. Severe symptoms occurred more often in younger patients with normal CT scans of the sinus than in those with positive CT findings. Improvement in response to antibiotics was similar for patients with positive CT findings and those with normal CT scans. The authors concluded that most symptoms considered to be typical for chronic rhinosinusitis proved to be nonspecific, and they suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if a prolonged course of antibiotics is being considered.

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Surgical Care Presurgical A preoperative antibiotic course may be administered in the weeks prior to surgery if an active infection is present. A preoperative steroid course may be administered if significant edema or polyps are observed on examination. In the preoperative holding area, nasal decongestion is begun with the patient receiving sprays of oxymetazoline. Following the commencement of general endotracheal anesthesia, the eyes are protected with eye ointment and thin strips of tape. The nasal passages are decongested with appropriate vasoconstrictors such as topical cocaine if not medically contraindicated. If septoplasty is to be performed, the septum should be infiltrated with 1% lidocaine with 1:100,000 epinephrine in the submucochondrial plane. Then, the patient is draped and prepared for surgery. A 4-mm 0- or 30-degree endoscope may be used, depending on the surgeon's preference. If septoplasty is to be performed, it may be done either before or after sinus surgery. Place the septoplasty incision in the unobstructed nasal passage to allow better visualization of the more obstructed side. Management of Chronic Maxillary Sinusitis Three main surgical options are available: (1) endoscopic uncinectomy with or without maxillary antrostomy, (2) the Caldwell-Luc procedure, and (3) inferior antrostomy (nasoantral window). Today, endoscopic maxillary antrostomy and uncinectomy are the standard for treatment for refractory chronic maxillary sinusitis. The Caldwell-Luc and inferior antrostomy approaches are reserved for rare circumstances, such as a case of severe allergic fungal sinusitis in which standard antrostomy alone does not allow complete extirpation of fungal concretions or complete drainage. Additionally, further FESS with mucosal-sparing techniques may be performed if additional disease is present within the ethmoid, sphenoid, and frontal sinuses.

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Endoscopic Maxillary Antrostomy Under endoscopic guidance, the middle turbinate may gently be moved medially, with care to avoid fracturing the turbinateskull base junction. At this point, the uncinate process should be within view, and it is injected with 1% lidocaine with 1:100,000 epinephrine. Local injections can be made using a 10-mL control syringe with a Luer lock 27-gauge needle attached. First, the root of the uncinate process is injected. Next, the inferior portion of the uncinate process is injected. The root of the middle turbinate is infiltrated as well. Finally, an injection is placed at the inferior junction of the basal lamella with the lateral nasal wall. This serves to vasoconstrict the sphenopalatine artery. Approximately 1-2 mL of local anesthetic is used at each injection site, with the bevel down (toward mucosa). An appreciable blanch of the mucosa should be observed with each injection. If using an image-guided system, it can be calibrated at this time (thereby giving time for vasoconstriction from the injections to take effect). Alternatively, the system may be calibrated prior to beginning the case. When using an image-guided system, checking the position of the guidance tracking in a few different known points and confirming the accuracy in 3 dimensions is important. Typically, for isolated chronic maxillary sinus disease, image-guided surgery is not necessary. After decongestion, uncinectomy is the next step. Uncinectomy can be performed in numerous ways. The following is the authors' preference. Under endoscopic guidance, a maxillary ostium seeker is insinuated just behind the uncinate process and used carefully to displace the free edge of the uncinate outwardly and anteriorly. To prevent lamina papyracea injury, care is taken to very gently manipulate only the uncinate process and not to penetrate deeply. Next, 90-degree upbiting forceps are used to grasp the free edge of the uncinate process. In a controlled push-and-pull fashion, staying parallel to the lacrimal duct, the uncinate process is then removed. Care is taken to engage the uncinate process parallel to the lateral nasal wall to prevent injury to the lamina papyracea. Any remaining uncinate process may be removed using a combination of microdebrider powered instrumentation and pediatric forceps. All portions of the uncinate should be taken down completely to permit
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visualization of the natural maxillary sinus ostium, roughly parallel to the inferior portion of the middle turbinate. Once the natural ostium is identified, an ostium seeker can be placed through the ostium and then carefully pushed posteriorly to widen the ostium. Using a through-cutting forceps, the ostium is enlarged, thereby completing a maxillary antrostomy. The maxillary sinus should be inspected with a 30- or 70-degree scope to ensure that no further disease is present within the sinus and that the natural ostium was included in the antrostomy. If either a microlith or a polyp is present, it may be removed using curved giraffe forceps or a curved suction. Further endoscopic work can be performed if disease is present in other sinuses. If lateralization of the middle turbinate is a concern and to allow easier postoperative examination of the maxillary antrostomy in the office, the controlled synechiae technique, as described by Bolger et al, may be used. Briefly, this involves abrading the opposing areas of mucosa from the medial middle turbinate and septum. With healing, the two roughened areas appose, thus medializing the turbinate for improved postoperative visualization of the maxillary sinus antrostomy. The middle meatus may be packed with various products if either postoperative bleeding or lateralization of the middle turbinate is a concern. Many packing materials have been described, ranging from rolled Gelfilm to Merocel packing. The authors' preference is for a latex-free, glove-covered, trimmed Merocel in the middle meatus. This should be removed at the first postoperative visit (3-5 d). Balloon catheters in endoscopic sinus surgery Balloon catheter technology has been used to dilate the maxillary sinus natural ostia without bone or soft-tissue removal. Early reports show sustained patient symptom improvement and sinus ostia patency. Further study and long-term outcomes with this technology will determine its role in endoscopic sinus surgery.

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Caldwell-Luc Procedure For patient comfort, this procedure typically is performed under general anesthesia. However, if medical comorbidities preclude general anesthesia, the procedure may be performed with local anesthetic and sedation. It may be performed in conjunction with nasoantral window (inferior antrostomy) to facilitate postoperative surveillance. Lidocaine, 1% with 1:100,000 epinephrine, is injected in the incision site, and time is allowed for vasoconstriction. Make a 3-cm incision centered over the canine tooth and first premolar while leaving about 0.5-1 cm of gingiva intact above the dentition to facilitate closure. Using electrocautery, dissection is carried down through the soft tissue and periosteum to bone. Next, a periosteal elevator is used to widely elevate periosteum from the anterior wall of the maxilla. Care is taken to identify and avoid injury to the infraorbital nerve, which is vertical and inferior to the midpupillary line. In the canine fossa, with mallet and osteotome, the maxillary sinus is entered through its anterior thin bone. Thereafter, rongeurs are used to enlarge the opening. Any pus from the maxillary cavity may be sent for culture. The disease within the sinus can be addressed appropriately. Next, the sinus is irrigated. The incision is then closed using 3-0 or 4-0 absorbable suture. Inferior Antrostomy Vasoconstriction is begun with topical oxymetazoline on pledgets. Next, 1% lidocaine with 1:100,000 epinephrine is injected under endoscopic guidance along the lateral nasal wall underneath the inferior turbinate. A 3-mL syringe with a 27-gauge needle facilitates the injection. Because the nasolacrimal duct lies approximately 1 cm anterior to the natural maxillary ostium, the injection and surgical antrostomy site is about one to two thirds of the distance back along the inferior turbinate. Next, the maxillary sinus is punctured in this region using a curved suction or trocar. This antrostomy should then be enlarged with through-cutting forceps. The maxillary sinus disease should then be extirpated as appropriate. Functional Endoscopic Sinus Surgery

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Surgical care is used as an adjunct to medical treatment in some cases. Surgical care is usually reserved for cases that are refractory to medical treatment and for patients with anatomic obstruction. Recent studies suggest that preoperative CT findings prior to sinus surgery may be poor predictors of surgical outcomes. The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining.

Recent advances in endoscopic technology and a better understanding of the importance of the ostiomeatal complex in the pathophysiology of sinusitis have led to the establishment of functional endoscopic sinus surgery (FESS) as the surgical procedure of choice for the treatment of chronic sinusitis. FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by establishing patency of the ostiomeatal complex, and causes less damage to normal nasal functioning. FESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80-90% of patients. Supportive medical treatment is instituted preoperatively and postoperatively. In children, surgical management is not as well established and should be reserved for complicated cases. Occupational exposure may affect FESS outcomes. Symptoms may persist with workrelated exposure to inhaled agents, and revision surgery may be required. Management of Fungal Sinusitis

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The preferred treatment for chronic fungal sinusitis is surgical debridement. Mycetomas or fungus balls are best treated by means of surgical removal. Allergic fungal sinusitis, which usually manifests as nasal polyps and allergic sinusitis, is treated by means of systemic steroids and surgical removal of polyps and mucinous secretions. Prognosis Because of its persistent nature, chronic sinusitis can become a significant cause of morbidity. If left untreated, it can reduce the quality of life and the productivity of the affected person. Chronic sinusitis is associated with exacerbation of asthma and serious complications such as brain abscess and meningitis, which can produce significant morbidity and mortality. Early and aggressive medical treatment for chronic sinusitis typically results in satisfactory outcomes. Functional endoscopic sinus surgery (FESS) restores sinus health with complete or moderate relief of symptoms in 80-90% of patients with recurrent or medically unresponsive chronic sinusitis. Chronic sinusitis is rarely life threatening, although serious complications can occur because of the proximity to the orbit and cranial cavity. Approximately 75% of all orbital infections are directly related to sinusitis. Intracranial complications remain comparatively rare, with 3.7-10% of intracranial infections related to sinusitis. Complications The most common complication of chronic sinusitis is superimposed acute sinusitis. In children, the presence of pus in the nasopharynx may cause adenoiditis, and a high percentage of such patients develop secondary serous or purulent otitis media. Dacryocystitis and laryngitis may also occur as complications of chronic sinusitis in children. Orbital complications include preseptal cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, and cavernous sinus thrombosis. Intracranial complications include meningitis, epidural abscess, subdural abscess, and brain abscess.

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Some studies have suggested a higher incidence of complications associated with fungal sinusitis. Untreated chronic sinusitis can lead to life-threatening complications, as in patients with cystic fibrosis. Other complications include osteomyelitis and mucocele formation.

Reference

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Adams L George, Boies L, et al. Boies Buku Ajar Penyakit THT edisi 6. Penerbit buku kedokteran EGC. Jakarta 1997 Brook, Itzhakm, et al. Chronic Sinusitis. Updated: Feb 15, 2012. Medscape. http://emedicine.medscape.com/article/232791-overview Patel, Ankit, et al. Surgical Treatment of Chronic Maxillary Sinusitis Surgical Overview . Updated: Mar 29, 2011. Medscape. http://emedicine.medscape.com/article/861886overview#aw2aab6b4 Soepardi, Efiaty Arsyad dan Nurbaiti Iskandar (ed.). 2003. Buku Ajar Telinga Tenggorok Kepala Leher. Jakarta : Fakultas Kedokteran Universitas Indonesia. Singh, Ameet, et al. Paranasal Sinus Anatomy. Updated: Jun 28, 2011. Medscape. http://emedicine.medscape.com/article/1899145-overview#showall

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